Framework for Assessing Governance of the Health System: Gateway to Good Governance

1. Framework for Assessing Governance of the Health System: Gateway to Good Governance Capacity building workshop on health system development for WHO staff Eastern Mediterranean Regional Office, World Health Organization Alexandria May 20-24, 2007 Eastern Mediterranean Regional Office, World Health Organization, Cairo

2. HEALTH SYSTEM CONCEPTUAL FRAMEWORK Social Determinants of Health GOALS OF HEALTH SYSTEM SYSTEM BUILDING BLOCKS Information Support Service provision Responsiveness Governance & leadership Coverage Health workforce Quality, safety Health Efficiency Medical products, technology Provider performance Financing Financial protection Equity

3. Governance, Stewardship, Leadership? Governance • The exercise of political, economic and administrative authority in the management of a country’s affairs at all levels. • Comprises complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations (UNDP 1997)

4. Governance, Stewardship, Leadership? • Stewardship • Function of a government responsible for the welfare of the population and concerned about the trust and legitimacy with which its activities are viewed by the citizenry WHR 2000 • Leadership • The art or process of influencing people so that they will strive willingly and enthusiastically towards the achievement of the group's mission www.lhfm.salford.ac.uk/Resources/Stratman/glossary_itom.htm

5. Why the term –’Governance’? • Governance is better understood by those within the health system and those outside; • Development agencies have delineated the principles of governance that are well understood • Performance of the health system is dependent on overall governance of a country

6. Relationship between Governance indices and health outcomes Lewis et al 2006 KKM Index: Kaufmann, Kraay, Matruzzi Index (2005)

7. Frameworks for the Analysis of Governance • WHO’s domains of stewardship; • PAHO’s Essential Public Health Functions; • World Bank’s six Basic Aspects of Governance; • UNDP’s Principles of Good Governance

8. WHO’s Domains of Stewardship • Generation of intelligence • Formulating strategic policy direction • Ensuring tools for implementation: powers, incentives and sanctions • Building coalition / building partnership • Ensuring a fit between policy objectives and organizational structure and culture • Ensuring accountability (Travis et al 2001)

9. PAHO’s Essential Public Health Functions • Monitoring evaluation and analysis of the health situation • Public health surveillance, research and control of risks • Health promotion • Social participation in health • Policies and institutional capacity for planning and management • Strengthening institutional capacity for regulation and enforcement (PAHO 2002)

10. PAHO’s Essential Public Health Functions • Evaluation and promotion of equitable access to health services • Human resource development and training • Quality assurance in personal and population-based health services • Research in public health • Reducing impact of emergencies and disasters on health

11. World Bank’s Governance Indicators • Process by which those in authority are selected and replaced • Voice and Accountability • Political Instability and Violence • Ability of the government to formulate and implement sound policies • Government Effectiveness • Regulatory Burden • Respect of citizens and the state for institutions which govern their interaction • Rule of Law • Graft (control of corruption) (Kaufmann 1999)

12. UNDP’s Five Principles of Good Governance (UNDP 1997)

13. Contemporary Issues in the Governance of Health Systems • Role of the state vs. the market in health • Role of the ministries of health vs. other state ministries • Actors in Governance – public sector, civil society and the private sector • Static vs. dynamic health systems • Health reform vs. human rights-based approach to health

14. Governance of the Health System: Principles • Strategic vision • Participation and consensus orientation • Rule of law • Transparency • Responsiveness • Equity and inclusiveness • Effectiveness and efficiency • Accountability • Information and intelligence • Ethics

15. Health Governance Analytical Framework • Governance principle • Domain • Broad question • Specific questions / item • Level of Assessment • National • MOH Policy • Policy Implementation

16. Analytical Framework for Assessing Strategic Vision

17. Documents National budget document, report of the treasury, state bank, Reports of ministry of economics, national statistical organizations Policy documents from MoH, analysis by international and NGOs MoH policy/ implementation reports, media reports, external reviews Health budget reports, budget speeches Reviews of the health legislative process National information policy MoH policy/ implementation reports, Media reports, external reviews of health policy PRSP documents MoH contracting manual, rules and procedures for civil servants National statistical reports, national health reports Interviews National and MOH policymakers, Mid- and senior managerial staff of the MOH or its component departments, Civil society organizations International development agencies, Academic institutions, Media personnel and Direct community representatives Data Collection and Sources of Information

18. Applying the health system governance framework to countries Health system governance matrix of Pakistan – Strengths • Central level • Social safety nets for the poor and vulnerable; • Increasing role of the media and NGO’s in protecting people’s health. • MOH policy level • Preparation of draft bills to update health legislation; • Emerging role of the Pakistan health policy forum as a civil society organization; • Stable turnover of health policymakers during the last six years are positive elements • MOH implementation level • Increasing public-private interaction • Preventive programs, especially the LHW Program which has a strong community as well as an equity dimension

19. Health governance matrix of Pakistan – Weaknesses • Central level • Lack of participatory decision making and culture of accountability; • Parallel streams of bureaucracy and technocracy do not work in unison • Adherence to rules and procedures is considered as an end; • Lack of consumer protection act delays or deny justice • MOH policy level • Short-term objectives override the need for focus on health outcomes; • Health equity is not high on the policy agenda; • Mechanisms to monitor transparency of decisions do not exist; • Decisions often tinged with personal preferences, not evidence-based; • Legislation on minimum standards of care is absent with lax regulation and enforcement capacity; • Policy, planning, health information and surveillance units are weak; • Delays in release and utilization of funds; • Accountability systems focus on procedure instead of performance; • Bioethics is not on the policy radar of MOH.

20. Health governance matrix of Pakistan – Weaknesses • Policy implementation level • Minimal protection against hazards from personal health services; • Gaps exist in policy and practice for recruitment, posting and promotion of staff and rules favor seniority over meritocracy; • Instruments for evaluation of staff performance are improperly used; • Responsiveness of public sector health services is not monitored; • Physicians turned managers lack understanding of administrative matters while bureaucrats lack health orientation; • Physicians and allied staff extensively engage in private practice outside and often within public institutions; • Support systems function inefficiently; • Code of ethics exists with the professional associations but not practiced.

21. Appraisal of the Framework • Can health governance be improved without addressing overall governance of a country? • Health system reforms versus broader civil service reforms • Health system governance assessment framework relies on qualitative approach and does not follow a scoring system • retains the richness of information collected • development of a scoring system is not precluded • Does the assessment framework allow for cross-country comparison of the governance function? • A health governance matrix can be developed for each country • Contemporary issues in relation to health governance included • Flexibility in the framework to integrate newer ones as they emerge • Health system governance framework does not cover • global health governance • clinical governance

22. Policy Implications of Health System Governance Assessment • Raises awareness among policymakers about governance as a function of the health system • Provides an avenue for debate on a subject that is often ‘pushed under the carpet’ • Assesses each governance principle and allows developing interventions to address them • Governance issues identified at three levels, allowing for measures at each • Improving health governance requires political commitment as well as financial resources

23. Thank you

24. Directly address public sector performance Capacity development Institutional review and strengthening Improved information and communication Management systems revamped Partnership and coalition Instill sense of greater accountability to populations Stakeholders monitor public sector performance Organized and empowered communities democracy, devolution Civil society and media have a 'watch dog’ function Academia Generate &synthesize evidence Communicate to decision makers Medical and paramedical associations Voice and accountability Revamped legislative and judicial system E.g. Medical negligence Interventions to tackle Governance of the Health System