Governance for health

Governance For Health www.SlideShare.net/AhmedRefat ) ( Refat Refat AG-Dr. Ahmed

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Governance

For Health

Dr. Ahmed-Refat A.G Refat Dr. Ahmed-Refat AG Refat

Dec. 2012

الصحة الحوكمة من أجل


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“good governance is perhaps

the single most important factor in

eradicating poverty

and promoting development”

Kofi Annan The former Secretary General of the United Nations,


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Contents

Why GOVERNANCE for health?

GOVERNANCE background

Basic Concepts:

GOVERNANCE – Stewardship- Intersectoral action

GOVERNANCE in health sector

History of GOVERNANCE

Health GOVERNANCE actors

Principles of GOVERNANCE

Current Framework of GOVERNANCE

WHO –PAHO -World Bank UNDP

Assessment approach


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Why Governance for Health ?

The complex epidemiological, economic and social

issues confronting health systems around the world

make it necessary for governments to adjust their

approaches in order to manage these challenges and

ensure the health of their populations and the

prosperity of their countries.


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Why Governance for Health ?- cont's

In recent decades, knowledge development about

what creates health and ill- health has made it clear

that the only way to make real gains in population

health is to broaden strategies beyond the health care

system, to include conditions in which people live,

work and play.


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Why Governance for Health ?- cont's

Health systems must therefore subscribe to this broader vision, and the governments that produce them must consider population health as an issue

that concerns every sector and calls upon all actors of society.

Governance influences all other health system functions, thereby leading to improved performance of the health system and ultimately to better health

outcomes.


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Determinants of Health


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Relationship between Governance indices

and health outcomes

KKM Index: Kaufmann, Kraay, Matruzzi Index (2005)


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Governance: Background

Recent international WHO consensuses expressed in

the Bangkok Charter for Health Promotion (WHO, 2005)

and the Commission on Social Determinants of Health

(WHO, 2008), recommend that governments establish

processes favouring a “whole of government approach”,

which ensure more coherence among a government’s

missions insofar as they touch on population health and

wellbeing.


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Governance: Background -cont's

Other policy documents and declarations at Regional

levels have also strongly promoted this view, including, for

example, the WHO Health for all Update 2005 the recent

Community strategy “Together for Health: a strategy

approach for EU 2008-2013”.


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Governance: Background -cont's

The term “whole of government approach” refers to what

is called a pan-governmental approach, that is, an approach that calls for both horizontal (cross government) and vertical (across levels of government) management.

Such an approach requires the establishment of various

mechanisms allowing for coordination and collaboration between various government actors and

stakeholders from civil society or the private sector.


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Basic Concepts

Stewardship

Governance

Intersectoral Action


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1. Stewardship The concept of stewardship was put forward by the World Health

Report 2000 as a central function for health ministers (WHO, 2000). It is

“the careful and responsible management of the well-being of the

population” (WHO 2000). and it refers to three broad tasks:

1._ Providing vision and direction for health systems; 2._ Exerting influence; 3._ Collecting and using intelligence on health system performance

in order to ensure accountability and transparency.


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The function of stewardship is essentially to develop intersectoral

work processes in all sectors of the government and with its partners

to promote the implantation of health programs.

The World health report 2000 proposed stewardship as one of the four

main functions of the health system, along with financing, creating and

managing resources, and service delivery . It recognized stewardship

as the function of the government responsible for the welfare of the

population and concerned about the trust and authority with which its

activities are viewed by the public http://www.euro.who.int/healthsystems/stewardship/20061004_1


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2. Governance Governance refers to

the challenge to take on the direction and coordination of a

complex collection of organizations through a control system

built upon many links.

The exercise of political, economic and

administrative authority in the management of a

country’s affairs at all levels.


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2. Governance-cont's

“the set of values, policies and institutions by which a society manages economic, political and

social processes”.

“the manner in which power is exercised in the management of a country’s economic and social

resources for development”.


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2. Governance-cont's

"the exercise of political, economic and administrative authority in the management of a

country’s affairs at all levels".

Governance comprises the complex mechanisms, processes and institutions through

which citizens and groups articulate their interests, mediate their differences and exercise their legal

rights and obligations.


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2. Governance-cont's The key elements for good governance are:

1. _ The inclusion of several actors from both inside and outside the government;

2. _ The use of horizontal and vertical management; 3. _ Accountability and control mechanisms; 4. _ High-level political commitment; 5. _ Financial and human resources support; 6. _ Skills development; 7. _ The existence of knowledge production systems.


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3. Intersectoral action The intersectoral action is the foundation for the practice of stewardship and governance. Key elements of intersectoral actions :

1. _ Create an inspiring framework for health; 2. _ Ensure political support; 3. _ Engage key partners at the very beginning; 4. _ Ensure leadership and rewards; 5. _ Develop practical models, tools and mechanisms to

support the implementation of intersectoral action; 6. _ Accountability frameworks;


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Governance in the health sector The concept of stewardship, or governance, in the health

sector is relatively new, and there is little guidance for

collection or standardization of information on this aspect of

the health system.

Evidence shows a positive relationship between governance

indices and measures of health performance and outcomes .


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History of Governance


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First wave: intersectoral action and primary health care

In the Declaration of Alma-Ata (WHO, 1978), the participants

in the International Conference on Primary Health Care stated

that the role of governments in health, in all countries, both

developing and developed, in the late 20th century should be

redefined and strengthened and that intersectoral action is a

key to better health.

The Declaration called for a comprehensive health strategy

that not only provided health services but also addressed the

underlying social economic and political causes of poor health.


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Second wave: health promotion and healthy public policy

The health promotion movement reinforced call to engage

other sectors for health in the 1980s.

The Ottawa Charter for Health Promotion (WHO Regional

Office for Europe, 1986) introduced “build healthy public

policy” as one of the five action areas for health promotion,

the others being “create supportive environments”, “strengthen

community action”, “develop personal skills” and “reorient

health services”.


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Third wave: health in all policies

The health in all policies approach considers the impacts of

other policies on health through health determinants when

policies of all sectors are being planned, decisions between

various policy options are being made, and when

implementation strategies are being designed.


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Health Governance Actors

The first set of actors include politicians,

policymakers, and other governmental officials

The second set of actors is health service

providers

The third set of actors contains beneficiaries,

health services users and general public


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Elements of Good Governance

1. Public Participation: 2. Accountability and transparency. 3. Respect for the rule of law and Human Rights 4. Efficient and effective public sector management:


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Governance in Health System Building Blocks


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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


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Current Frameworks for

Assessing governance


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The current frameworks for assessing governance are as follows:

1- WHO- domains of stewardship;

2- Pan American Health Organization’s

(PAHO) essential public health functions (EPHF);

3- World Bank’s six basic aspects of governance;

4- UNDP’s principles of good governance.

Siddiqi S et al., Framework for assessing governance of the health system in developing countries: Gateway to good governance Health Policy 90 (2009) 13–25


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1- WHO- domains of stewardship

The World health report 2000 recognizes stewardship

as a function of the health system similar to governance. It

identifies several basic tasks of stewardship:

Generation of intelligence

Formulating strategic policy direction


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Ensuring tools for implementation: powers,

incentives and sanctions

Building coalition/building partnership EPHF 4

Social participation in health

Ensuring a fit between policy objectives and

organizational structure and culture

Ensuring accountability

http://www3.who.int/whosis/discussion papers/pdf/paper48.pdf.


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2. Pan American Health Organization’s (PAHO) essential public health functions


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3- World Bank’s (WB) six basic aspects of governance

The World Bank has been among the leading agencies in raising

awareness of the importance of governance in economic development, in

developing methodological approaches to its measurement and in ranking

countries on the basis of governance performance .

TheWorld Bank’s governance indicators are organized into three clusters

corresponding to the six basic aspects of governance

Kaufmann D, Kraay A, Zoido-Lobaton P. Governance matters. Washington:World Bank policy research working paper no. 2196; 1999.


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4- UNDP’s principles of good governance

The UNDP enunciates a set of principles of good governance

forwhich there is evidence that these have a claim to universal

recognition . These five principles have been further elaborated into

nine thematic areas

United Nations Development Programme. Governance for sustainable human development: a UNDP policy

document. New York: UNDP; 1997. http://magnet.undp.org/policy/chapter1.htm.

http://magnet.undp.org/policy/chapter1.htm


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Governance

Assessment

Approaches


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I- USAIDS- 2002

http://www.healthsystems2020.org/content/resource/detail/528/


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II-Framework For Assessing Health Governance.


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II-Framework For Assessing Health Governance

Based Mainly on:

Kirigia and Kirigia (2011). The essence of governance in health development .International

Archives of Medicine p. 4:11


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1. Public health leadership and management

1.1 Leadership responsibilities:

1.2 National health policy (NHP):

1.3 National health strategic plan (NHSP):.

1.4 Dissemination of NHP and NHSP:

1.5 Implementation:


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2. Rule of health-related laws

2.1 Existence of health-related legislations:

2.2 Enforcement of health-related legislations:


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3. Community participation & responsiveness

3.1 Participation in NHP and NHSP development:

3.2 Participation in NHSP implementation:

3.3 Participation in tracking of progress:

3.4 Responsiveness to communities non-medical

expectations:


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4. Effective internal and external

partnerships for health

4.1 Intersectoral action:

4.2 Public-private partnerships:

4.3 Alignment of aid flows to national health

development priorities:

4.4 Strengthen capacity by coordinated support:

4.5 Use of country procurement and public financial

management systems:


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4.6 Strengthen national capacity by avoiding parallel

implementation structures:

4.7 Aid is more predictable:.

4.8 Aid is untied:

.4.9 Shared analysis:

4.10 Sufficient integration of global programmes and

initiatives into NHSP:


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5. Horizontal and vertical equity in health systems

5.1 Horizontal equity:

5.2 Vertical equity:

5.3 Health fairness in financial contribution (HFC):


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6. Efficiency in resource allocation and use

6.1 Allocative efficiency:

6.2 Technical efficiency:

6.3 Productivity growth:

6.4 Institutionalization of efficiency monitoring:


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7. Accountability and transparency in health

development

7.1 Existence of transparent results-oriented

reporting and assessment frameworks

7.2 Diagnostic reviews:

7.3 Use of information from diagnostic reviews:

7.4 Publishing of audit reports for public

consumption:


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8. Evidence-based decision-making

8.1 National health research systems:

8.2 Health knowledge management systems (HKMS):

8.3 Health management information systems:

8.4 Information, Communication and Technology

Connectivity:


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9. Ethical practises in health research and service provision

9.1 International ethical guidelines for medical

practice and health research:

9.2 Bioethics review system

9.4 Institutionalization of ethics training:


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10. Macroeconomic and political stability

10.1 Link between national economic development

plan, Poverty Reduction Strategy Paper and

NHP/NHSP:

10.2 Existence of a medium-term expenditure

framework (MTEF):

10.3 Political stability:

Kirigia and Kirigia (2011). The essence of governance in health development .International Archives of Medicine

p. 4:11 http://www.intarchmed.com/content/4/1/11

http://www.healthsystems2020.org/content/resource/detail/528/

http://www.intarchmed.com/content/4/1/11

Health & Medicine

Governance for health