introduction policy brief · policy brief february 2008 introduction country health officials and...

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rief

February 2008

INTRODUCTIONCountry health officials and donors

have increasingly realized that resourcesallocated to health will not achieve theirintended results without attention togovernance. Particularly as global programsinject huge amounts of funding targetingspecific diseases, weaknesses in healthsystem governance threaten to underminethe effective utilization of the funds.Corruption is perhaps the most dramaticgovernance-related threat, but in additionpoor accountability and transparency, weakincentives for responsiveness andperformance, and limited engagement ofcitizens in health affairs contribute to lowlevels of system effectiveness as well.

Health Governance:Concepts, Experience, andProgramming Options

Over the past decade, governance hasmoved to center stage in the internationaldevelopment agenda, marking a shift fromattention to achieving micro-level project-specific results to macro-level questions ofpolicymaking, politics, and state–societyrelations. As research findings demonstratedthe links among successful socioeconomicdevelopment, the enabling environment, andgood governance, donor agencies began to:i) emphasize targeting grants and loans tocountries with demonstrated performancerecords (see, for example, Dollar andSvensson 1998, Burnside and Dollar 2000),and ii) design and provide capacity buildingand technical assistance targeted atimproving governance. The popularity ofgovernance as a conceptual and practicalconstruct, however, has not led to clarityand agreement as to what it is or is not.

Governance has been the subject ofmultiple definitions and interpretations.Some definitions concentrate on technicalgovernment functions and how they areadministered. For example, the World Bank(2000) views governance as economicpolicymaking and implementation, servicedelivery, and accountable use of publicresources and of regulatory power. Otherdefinitions address how governmentconnects with other sectors and withcitizens. For example, the US Agency forInternational Development (USAID)considers governance to "pertain to theability of government to develop anefficient, effective, and accountable publicmanagement process that is open to citizen

Peru/PHRplus

Credit

This publication was produced for review by the United States Agency for International Development (USAID). It was prepared byDerick W. Brinkerhoff and Thomas J. Bossert for the Health Systems 20/20 project.DISCLAIMER: The authors’ views expressed in this publication do not necessarily reflect the views of the USAID or the United StatesGovernment.

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participation and that strengthens rather thanweakens a democratic system of government."1 TheUK's Department for International Development(DFID) describes it as "how institutions, rules andsystems of the state – executive, legislature, judiciary,and military – operate at central and local level andhow the state relates to individual citizens, civilsociety and the private sector" (DFID 2001:11). TheUnited Nations Development Program (UNDP1997) sees governance as "the exercise of economic,political and administrative authority to manage acountry's affairs at all levels."

All of these definitions emphasize policyimplementation, and most of them emphasizeaccountability. Some have a more normativeorientation, such as USAID's focus on democracy.Others tend toward the instrumental, focusing onefficiency and effectiveness. The latter definitionsexplicitly connect the political dimensions ofgovernance to the more technocratic elements ofmacroeconomic management and publicadministration operational capacity.

As sectoral specialists looked for answers toproblems of sustainability and systems strengthening,governance entered the vocabulary of environment,education, urban infrastructure, and health. In thehealth sector, the World Health Organization's(WHO's) World Health Report 2000 is generallyrecognized as paving the way for expanded attentionto health governance with its introduction of theconcept of "stewardship." Stewardship, as elaboratedby WHO, constitutes a set of six domains, which areclosely related to governance: generating intelligence(information and evidence), formulating strategicpolicy direction, ensuring tools for implementationthrough incentives and sanctions, building coalitionsand partnerships, developing a fit between policyobjectives and organizational structures and cultures,and ensuring accountability (see Saltman andFerroussier-Davis 2000, Travis et al. 2002). The PanAmerican Health Organization (PAHO) has carried

out a parallel analytic effort to reach agreement onessential public health functions, which has led to alist that overlaps somewhat with the stewardshipdomains and also reflects elements of the governancedefinitions.2 The stewardship domains relate moreclosely to the instrumental effectiveness definitions ofgovernance than to the political and normative ones.The essential public health functions, however,incorporate some of these latter governancedefinitions' features with the inclusion of participationand citizen empowerment and equity in the list offunctions.

USAID's Global Health Bureau, through a seriesof field assistance and applied analysis programs, hashelped countries address a range of governance-related issues within the framework of healthsystems strengthening. However, only recently hashealth governance become an explicit component ofthe Bureau's health systems agenda.3 To assist theBureau and Missions to understand healthgovernance and to develop intervention options thatincorporate it into programs, this paper provides anoverview with the following aims:

Clarify the meaning of health governance.Identify health governance issues and challenges.Develop a model for health governance thathighlights its practical dimensions.Review selected experience with interventions toimprove health governance.Propose options for health governance programmingthat can strengthen health systems and ultimatelylead to increased use of priority services.

1From <www.usaid.gov/our_work/democracy_and_governance/technical_areas/dg_office/gov.html>.

2 The list of essential public health functions includes: disease surveillance, healtheducation, monitoring and evaluation, workforce development, enforcement ofpublic health laws and regulations, public health research, health policydevelopment and management capacity, citizen participation and empowerment,service quality, equitable access, and disaster mitigation (see PAHO 2000).3 Health governance is accorded explicit attention in the Global Health Bureau'scurrent Health Systems 20/20 project. Other USAID health projects also includegovernance-related elements, for example: the Health Policy Initiative (HPI),Leadership, Management and Sustainability (LMS), and the Capacity Project.Predecessor projects that addressed some governance aspects include HealthFinancing and Sustainability, Latin America and Caribbean Health and NutritionSustainability Project, Data for Decision Making (DDM), Partnerships for HealthReform (PHR), and Partners for Health Reformplus (PHRplus).

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CLARIFYING GOVERNANCEAs the brief review of definitions presented above

reveals, governance encompasses authority, power, anddecisionmaking in the institutional arenas of civilsociety, politics, policy, and public administration.Governance is about the rules that distribute roles andresponsibilities among societal actors and that shapethe interactions among them. These rules can be bothformal, embodied in institutions (e.g., democraticelections, parliaments, courts, sectoral ministries), andinformal, reflected in behavioral patterns (e.g., trust,reciprocity, civic-mindedness). Table 1 illustrates thedifferent categories of rules in the institutional arenasof governance, and their functions.

In each of these arenas, the governance processesassociated with the functions create incentives thatcondition the extent to which the various actorsinvolved fulfill their roles and responsibilities, andinteract with each other, to achieve public purposes.Good governance results when these incentivesencourage and pressure both state and non-stateactors to be efficient, effective, open, transparent,accountable, responsive, and inclusive.

HEALTH GOVERNANCEGovernance in health systems is about

developing and putting in place effective rules in theinstitutional arenas outlined in Table 1 for policies,programs, and activities related to fulfilling publichealth functions so as to achieve health sectorobjectives. These rules determine which societalactors play which roles, with what set ofresponsibilities, related to reaching these objectives.Health governance involves three sets of actors. Thefirst is state actors, which includes politicians,policymakers, and other government officials. Clearly,actors in the public sector health bureaucracy arecentral, such as the health ministry, health and socialinsurance agencies, and public pharmaceuticalprocurement and distribution entities. However, otherpublic sector actors beyond the health sector haveroles as well. These can include, for example,parliamentary health committees, regulatory bodies,the ministry of finance, various oversight andaccountability entities, and the judicial system. Thesecond set of actors comprises health serviceproviders. Depending upon the particulars of a givencountry's health system, this set mixes public, private,

InstitutionalArena

Governance Functions

SocializingEnabling

AggregatingRepresentingLegitimizing

DistributiveRedistributiveRegulatoryConstitutiveAdjudicatory

ImplementingManaging

Focus of Rules

Civil society

Politics

Policy

Publicadministration

On shaping how citizens learn about and engagearound issues of public concern.On assuring access and facilitating participation ofsocietal groups.

On shaping how interests are combined by politicalinstitutions to contribute to policy.On structuring political institutions to represent andrespond to citizens' needs and demands.

On shaping how government institutions makepolicies that allocate benefits and costs, regulatebehavior, and adjudicate conflicts and disputes.

On shaping how policies are implemented, howgovernment is structured and organized, and howpublic agencies are managed.

TABLE 1. GOVERNANCE FUNCTIONS AND RULES BY INSTITUTIONAL ARENA

Source: Adapted from Hyden et al. (2004) and Brinkerhoff and Crosby (2002)


and voluntary sector providers. For example, the mixcan include hospitals, clinics, laboratories, andeducational institutions in all three sectors. Theprovider category also includes organizations thatsupport service provision: insurance agencies, healthmaintenance organizations, the pharmaceuticalindustry, and equipment manufacturers and suppliers.The third set of actors contains beneficiaries, serviceusers, and the general public. This set can becategorized in a variety of ways: for example, byincome (poor vs non-poor), by location (rural vsurban), by service (maternal and child health,reproductive health, geriatric care), and by disease orcondition (HIV/AIDS, tuberculosis, malaria, etc.). Box 1summarizes the defining parameters of healthgovernance.

A general consensus exists that health systemsshould achieve: i) improvements in health statusthrough more equitable access to quality healthservices and prevention and promotion programs, ii)patient and public satisfaction with the health system,and iii) fair financing that protects against financialrisks for those needing health care (WHO 2000,Roberts et. al. 2004).

These objectives reflect a particular set ofsocietal values, which many, though not all, countriesshare. In this sense, the general principles aboutgovernance that can contribute to good political,policy, and program decisions in support of healthsystem objectives have a normative dimension tothem. The following governance principles are widely,

although not universally, accepted.4 First, governancerules should ensure some level of accountability ofthe key actors in the system to the beneficiaries andthe broader public (see Brinkerhoff 2004).Accountability means that there need to be formalmechanisms by which patients and the broaderpopulation can hold key actors – politicians whomake general policy decisions, decision-makers infinancing institutions (social insurance and privateinsurance), providers of curative and preventiveservices – responsible for achieving the objectives ofaccess to quality services, satisfaction, and fairfinancing.5 Accountability mechanisms for holdingthese actors responsible include, for example, faircompetitive elections, systems of judicial redress,procedures to combat corruption, transparency ofinformation, advisory committees, community boards,and media access.

Second, health governance involves a policyprocess that enables the interplay of the keycompeting interest groups to influence policymakingon a level playing field. An effective process forimproving quality of services, satisfying demands ofpatients and the public, and equitable financingrequires some level of compromise among thevarious interests in the system – the differentproviders, insurers, administrators, and therepresentatives of different groups of beneficiaries.Again, an open policy-making process, accompaniedby fair rules of interest group competition, is neededto ensure the level playing field and to address thegovernance equivalent of "market failures" – reducingunfair lobbying practices, limiting corruption, andensuring responsiveness to underserved populations.In addition to these elements, the level playing fieldrequires checks and balances to ensure that the rulesof interest group competition are respected so thatall voices can be heard and adequate representationis achieved.

Box 1. Health Governance

Rules that govern the distribution of roles/responsibilities andthe interactions among:

Beneficiaries/service users,Political and government decision-makers, andHealth service providers (public, private, nonprofit)

That determine:Health policies pursued,Services provided,Health resource allocation and use,Distribution of costs,Recipients of services and benefits,Health outcomes to be achieved.

Source: Authors

4 These principles are grounded historically in Western political philosophy, whichconceived of state-society relations in terms of a "social contract" wherebycitizens cede their natural right of self-governance to the state in exchange forthe societal benefits derived from state sovereignty. The social contract shiftedthe balance of power away from the absolutist state, which ruled over citizens assubjects, toward government by consent of the governed. Not all countries sharethis governance heritage.5 These mechanisms reflect the operation of the principles of exit and voice thatdiscipline these actors, which Hirschman's frequently cited classic elaborates(1970).


Third, health governance requires sufficient statecapacity, power, and legitimacy to manage the policy-making process effectively, to plan and designprogrammatic interventions, and to enforce andimplement health policy decisions. Governance,whether in health or other sectors, depends uponthe operational capacity of government institutions tofunction effectively in providing public goods andservices, and in responding to citizens' needs anddemands (see, for example, Grindle 1997). At themost basic level, government needs the capacity toamass resources through tax collection and/or fromdonor agencies and to program and allocate thoseresources effectively.

Yet in many countries, the state in general, andparticularly the health ministries, lack the requisitecapacity. As Collins (2002: 136) notes,

Ministries of Health, or their equivalent, are notrenowned… for their strategic policy-making andpolicy implementation capacity. They tend to lackthe skills, systems and structures to allow them totake on the strategic change role. Neither do theypossess the authority within the government topromote change, being often one of the weakerministries or departments within the governmentalstructure.

Effective and responsive service delivery, whichdemonstrates to citizens that their government isconcerned for their welfare, contributes to statelegitimacy. Fragile states with highly corruptgovernments, which cannot or will not deliverservices, risk losing legitimacy. This loss is a well-recognized driver of conflict in fragile environments.Successful rebuilding in fragile states calls for capacitydevelopment that enables public sector institutionsto take on policy and service roles. This increasedcapacity can help to create government legitimacy inthe eyes of citizens (Brinkerhoff 2007a). A study ofDFID-funded health sector support in Afghanistan,Nepal, and Burma highlights this link between servicedelivery and state legitimacy (Berry and Igboemeka

2004). Health and education are two basic servicesthat all citizens want, so helping fragile states toprovide them is an important contributor toreducing fragility. Further, investments in health andeducation are fundamental to the human capitalcountries need to move beyond crisis to stability andincreased wellbeing.

Fourth, governance depends upon theengagement and efforts of non-state actors in thepolicy arena, as noted, as well as in service deliverypartnerships and in oversight and accountability.Effective engagement of these actors may call forstrengthening the power and capacities of societalgroups that may not necessarily have the resourcesand skills to participate in an open policy process, topartner with providers, or to fulfill accountability orwatchdog functions. For example, community groupsand local non-governmental organizations (NGOs)may be disadvantaged relative to organizations ofhealth professionals, or nurses' and doctors'associations. Participation is an essential element ofgovernance, in health and beyond, and is facilitatednot just by public structures and processes thatsupport and encourage it, but also by a vibrant civilsociety (see, for example, Burbidge 1997). In manydeveloping countries, measures to strengthen civilsociety are needed. In the health sector in particular,the development of social capital – trust incommunity members and local officials, knowledgeand information sharing, and greater participation involuntary organizations – has been shown tocontribute to improved health governance andservice delivery (e.g., Tendler and Freedheim 1995,Harpham et al. 2002). Such strengthening can buildcommunity-level capacities to work together tocontribute to health objectives at the local level, aswell as demand more services from other levels ofthe health system.

The principles outlined above constitute anidealized version of health governance. Few countries,developing or industrialized, have health systems thatfunction according to a full application of all of them.Table 2 illustrates some of the challenges healthsystems in developing countries face in the variousinstitutional arenas of governance.


HEALTH GOVERNANCE:A MODEL

As previously described, health systems containthree categories of actors: government, providers, andbeneficiaries/clients. Health governance involves therules that determine the roles and responsibilities ofeach of these categories of actors, and therelationships and interactions among them. Theseelements can be combined to create a model ofhealth governance, as illustrated in Figure 1, thatbuilds on work at the World Bank on service deliveryand accountability (2004, 2007). Several pointsregarding the model are important to note. First,although the figure could be interpreted as portrayingeach category of actors as having equal influence andpower, this is not the case. The degree of power is

differentially distributed among the three, with thestate and providers for the most part retaining thepreponderance of power, information, and expertiserelative to clients/citizens. Power distributions arealso influenced by political systems, with moredemocratic governance tending to give more poweroptions to clients and citizens than moreauthoritarian systems. Second, as the discussionbelow of context elaborates, the model should not beviewed as a closed system. The linkages among actorsin the state, provider, and client/citizen boxes arestrongly affected by external factors. These can rangefrom global issues beyond a given country's borders,such as avian influenza and global HIV/AIDS activism,to factors inside the country but external to thehealth sector, for example as just mentioned, theextent of democratization.

InstitutionalArena

Health Governance Issues

Civil society

Politics

Policy

PublicAdministration

Civil society groups are insufficiently organized and resourced to identify and aggregateinterests and exercise voice.Civil society does not effectively socialize and educate citizens to play a role in governance.Civil society stakeholders do not hold public and private health sector actors accountable.Citizens lack awareness of their rights and have low expectations of politicians and government.

Political systems systematically exclude the views and interests of poor and marginalized groups(e.g., people with HIV/AIDS) in health sector decisionmaking.Established health interests block reforms that threaten them.Health ministries and local governments do not have incentives and/or capacity to engagestakeholders in decisionmaking and priority setting.Health officials lack the technical and political expertise to argue effectively for resources, or toget health issues on the political agenda.

Policy processes are dominated by elites and technocrats.Health ministries plan and initiate programs that promise results but then are incompletelyimplemented or see funds diverted to other purposes.Health policy decisions are not made on the basis of evidence regarding needs and effectivenessof services.

Financial management practices in the government health sector are opaque, permittingcorruption and causing the unreliable delivery of critical inputs.Information on health sector planning, operations, and financing is unavailable, unreliable, orinaccessible thereby reducing accountability and service delivery effectiveness.Few and/or inadequate administrative mechanisms exist to enable citizen participation.Capacity for oversight of non-state service providers is weak.Weak leadership, limited management capacity, and insufficient human resources damageefficiency, undermining state legitimacy.Government health actors are oriented toward pleasing their superiors rather than respondingto citizens' needs.

TABLE 2. ILLUSTRATIVE HEALTH GOVERNANCE ISSUES BY INSTITUTIONAL ARENA

Source: Authors


LINKING THE STATE, PROVIDERS, AND CLIENTS/CITIZENS

The arrows characterize the general nature ofthe relationships among the various actors. Fromclient/citizens to state actors, the key feature of therelationship is the exercise of voice, that is, theexpression of needs, preferences, and demands topoliticians, policymakers, and public officials.Individuals can and do exercise voice – for example, acitizen can visit his/her mayor, or vote for aparliamentarian who has promised health reform –but in terms of health systems and governance, howindividuals come together in collective efforts tomake their voice heard around common interests is akey issue. Formal efforts through political parties andelections are one form of interest aggregation andexpression of voice; advocacy and public informationcampaigns are another, less-formal avenue. Citizenefforts to exercise voice and hold public officialsaccountable can be pursued through various means:for example, community initiatives to lobby localofficials, specialized civil society organizations thatdevelop expertise in budget monitoring and servicedelivery report cards, or cyber-activism that taps thepower of information technologies to expand voiceboth nationally and internationally.

From state actors to client/citizens, theoverriding health governance relationship isresponsiveness to client/citizen needs, preferences,and demands. This relationship varies in quality anddegree. In countries with authoritarian governments,political leaders and health officials may not be veryresponsive to the health needs of their citizens(although even authoritarian leaders need somepopular support), and/or they may respond throughpatronage networks to some citizens, but not to all. Indemocratic systems, health care is an issue that isoften of interest to politicians, because it touches thelives of almost all of their constituents. However, itcan be difficult to mobilize voters, whose attention tohealth concerns may be sporadic, and establishedinterest groups often resist changes. The establishedhealth interests may be better able to delivercampaign support and votes than the general public.So democracies are not immune from the patronageand clientelism that characterize politics inauthoritarian regimes. While health as a public good isnot so easy for political patrons to employ as areward to clients, the health sector resources theycontrol or influence can be amenable to clientelistexploitation. Rewards can take the form of, forexample, the allocation of disproportionatelygenerous funding to particular localities, the siting of

FIGURE 1. HEALTH GOVERNANCE FRAMEWORK

Source: Adapted from World Bank 2004, 2007


specific facilities, or tilting services in favor of certaingroups (e.g., urban elites, ethnic compatriots) overothers (e.g., the poor, disadvantaged, and politicallypowerless).

The governance relationships from stateactors to providers are encapsulated in the arrowlabeled "compact." This term seeks to capture thenotion of a contract-like connection in whichpolicymakers specify objectives, procedures, andstandards; provide resources and support; andexercise oversight relative to providers. In exchangefor the resources, providers carry out the agreed-upon desires and directives of the policymakers. Inessence, the compact is the sum of the rules thatdetermine the roles and responsibilities of thevarious parties to the agreement; these in turnestablish incentives for the actors involved.6 Healthsystem reforms that separate payment fromprovision of services have introduced major changesin the role of state actors relative to providers. Thesechanges have concentrated significant attention onthe accountability dimension of health governance.This accountability is of several types (see Brinkerhoff2004):

Political accountability, where politicians press thehealth ministry and other health-related agencies topursue objectives and employ resources so thatproviders respond to what citizens want regardinghealth care.7

Performance accountability, which focuses on thewide array of systems and organizations involved inregulating, overseeing, guiding, and disciplining healthservice providers.Financial accountability, which involves budgeting,accounting, and auditing systems that seek to ensurethat health service providers are using resources foragreed-upon and appropriate purposes, and toreduce corrupt practices.

Accountability is not the only health governancerelationship that connects the health ministry andrelated agencies to providers. There are linkages thatprovide knowledge and technical information, for

example, through medical education and in-servicetraining. And in some countries, clientelistrelationships between state actors and providersexist as well, where politicians and/or health ministryofficials channel resources and favors to selectedproviders in exchange for political support.

From providers to state actors, keygovernance relationships revolve around reporting:that is, the provision of information for purposes ofmonitoring and in fulfillment of the three types ofaccountability (political, performance, and financial).The particular features of provider payment schemes,for example, influence the nature of reportingrelationships between providers and payers, and theincentives created for providers. Pay-for-performancearrangements join financial and performanceaccountability, and increasing numbers of developingcountries are experimenting with them. Besidesaccountability, another important function of thegovernance link between providers and state actorsis to furnish data for policymaking. If healthpolicymakers are to pursue evidence-based policyformulation, then providers have a critical role as thesource of evidence.

As numerous analysts have noted, dealing withinformation asymmetries – service providers willalways know more about what they do or do not dothan those they report to – is an important piece ofmaking health governance effective. Providers'privileged position in terms of knowledge andexpertise also make the provider state linkage apolitical one. Providers are not neutral sources ofinformation; they have interests and exercise voiceand lobbying to influence state health policy andpractices. Another problem affecting the state actor–provider governance link is that of attribution. In thecomplex, multi-actor realm of the health system, it isdifficult to assess whose contributions made adifference, or whose efforts fell short. Healthoutcomes are the result of numerous factors, manyof which are outside of the control or influence ofproviders or health ministries.

The relationships between service users andproviders are the heart of health systems. In principle,clients/citizens convey their needs and demands forservices – and their level of satisfaction – directly toproviders, who in turn offer a mix of quality servicesthat satisfy needs and demands. Yet from agovernance perspective, the links from clients/

6 As the World Bank (2004: 51) defines it, a compact is "a broad agreementabout a long-term relationship."7 It is important to note the distinction between direct political accountability ofelected officials, and the more indirect accountability of public-sector healthofficials to political actors.


citizens to providers and from providers toclients/citizens are fraught with power andinformation asymmetries, capacity gaps, accountabilityfailures, and inequities. The compact between healthpolicymakers and providers cannot specify all therelevant factors for quality service delivery, and aneffective client provider link is necessary for systemfunctioning, quality of services, and service utilization;but the problems listed often weaken this leg of thegovernance triad substantially. As with the governancelink from clients/citizens to the state, the connectionto providers can be strengthened through collectiveaction, for example, civil society organizations thatexercise voice on behalf of beneficiaries, or villagehealth associations that participate with healthproviders in needs assessments and communitymobilization. Reforms that create health servicemarkets and introduce competition among providerscan enhance client power and increase provideraccountability to service users, who have the ability to

choose among providers, and/or whose views areincorporated into provider performance assessmentsthat inform funding decisions, for example, throughservice delivery surveys. Measures to reinforce thepurchasing power of particular societal groups – suchas subsidies for the poor, elderly, or HIV/AIDS-affected – are another example of offsettingimbalances between providers and service users.

UNPACKING THE BOXES

As with any model, Figure 1 is a shorthand for ahighly complex set of interactions among healthsystem actors and components. The above discussionhas concentrated on delineating the nature of thegovernance relationships among the three sets ofactors. Obtaining a full picture of governance in thehealth system calls for unpacking the contents of thethree categories of actors that are contained in thefigure: state, providers, and clients/citizens. Table 3provides a generic listing for each category.

Source: Authors

State: Politicians andPolicymakers Providers

Hospitals (public, private, nonprofit, faith-based)Clinics (public, private, nonprofit, faith-based)Doctors and doctors' associationsNurses and nurses' unionsInsurance claims and disbursementagenciesMidwives and traditional birth attendantsCommunity health workersTraditional healersMedical and nursing schools (public,private, nonprofit)Private insurance firmsFamily planning organizations (public,private, nonprofit)Nutrition organizations (public, private,nonprofit)Pharmaceutical suppliers andmanufacturers

Clients/Citizens

Health ministryHealth and social insuranceagenciesPublic procurement anddistribution agencies forpharmaceuticals, medicalsupplies, and equipmentParliaments andparliamentary committeesElected officials (national andsubnational)Decentralized units ofgovernmentRegulatory bodiesFinance ministryAnticorruption agenciesAudit agenciesLaw enforcement agenciesCourtsPublic employee unions

Community groupsVillage health associationsAdvocacy organizationsCivil society watchdogsElites (urban, rural)Middle class (urban, rural)Poor (urban, rural)Human rights organizationsHIV/AIDS support groupsLegal services NGOsThink tanksPolitical partiesBusiness associations

TABLE 3. HEALTH GOVERNANCE ACTORS


A few points of clarification are in order. First, asthe table illustrates, some providers are part of thestate: those that make up the public sector healthservice delivery infrastructure. In some healthsystems, state and non-state service providers aresubject to different governance regimes. For example,private insurance schemes that cover wealthy urbanpopulations operate under different rules from publichealth providers that serve the poor and uninsured.

Second, within each category various actors havegovernance links with each other, particularly relatedto accountability and checks and balances. Forexample, within the state category, parliaments canhold health ministry officials to account. State auditand anticorruption agencies can investigate the healthministry and its pharmaceutical and equipmentprocurement procedures. Courts can adjudicatehealth-related cases that involve state actors. Centrallevels of government can hold local levelsaccountable. Within the provider category, individualfacilities (hospitals and clinics) often have boards thatoversee policy and operations; in some cases theseboards include citizen representatives. Relatedly, inmany countries, medical practitioners' associationsexercise governance, certification, and quality controloversight of providers who are members. Thestructure of health labor markets can influencechecks and balances; for example, in countries wherethe state is the largest employer of healthprofessionals, their ability to take independentpositions on health issues may be limited.

TOWARD GOOD HEALTHGOVERNANCE

When the linkages illustrated in Figure 1 areoperational and effective, then the interactions amongstate actors, providers, and citizen/clients producegood health governance and fulfill the governanceprinciples discuss above (accountability, open policyprocess, state capacity, and engagement of non-stateactors). The key features of good health governanceare summarized in Box 2.

Good health governance rationalizes the role ofgovernment: reducing its dominance and sharing roleswith non-state actors; empowering citizens, civilsociety, and the private sector to assume new healthsector roles and responsibilities; and creatingsynergies between government and these actors.Health ministries redefine their roles as stewards of

the health system, with input from citizens, civilsociety, and the private sector; and establish oversightand accountability mechanisms. Policies incorporateevidence and analysis to allow assessment of progressand evaluation of effectiveness. Health insuranceagencies oversee providers to ensure effectiveservice delivery, respect for payment procedures, andabsence of fraud. Procurement agencies employtransparent and fair contracting and purchasingmechanisms to ensure that resources are well spentand to reduce corrupt practices. Civil society and themedia apply their skills and capacities to exerciseoversight and hold policymakers and providersaccountable. Health policymaking balances beneficiaryparticipation with science-based determination ofappropriate services.

Making this happy picture a reality is, of course,fraught with challenges, many of which have beenmentioned in the preceding discussion of the healthgovernance model. Health governance is a systems-level phenomenon, and pursuing changes that affectthe whole system are largely beyond the reach of anysingle group of reformers, whether country-based orfrom donor agencies. Yet strategies and interventionsthat address particular components of governance cansuccessfully promote improvements, withoutnecessarily taking on the whole. For example,comprehensive health reform experience fromcountries in the former Soviet Union offersencouragement that an integrated sequence ofdiscrete changes can lead to systemic change overtime (see O'Rourke 2001). Each of the componentslisted in Box 2 can be seen as entry points and

Box 2. Good Health Governance

Roles/responsibilities and relationships governed by:Responsiveness to public health needs and beneficiaries’/citizens’ preferences while managing divergences betweenthemResponsible leadership to address public health prioritiesThe legitimate exercise of beneficiaries’/citizens’ voiceInstitutional checks and balancesClear and enforceable accountabilityTransparency in policymaking, resource allocation, andperformanceEvidence-based policymakingEfficient and effective service provision arrangements,regulatory frameworks, and management systems.

Source: Authors


potential change levers for improving healthgovernance in the institutional arenas discussed above(civil society, politics, policy, and public administration).In practice, three major avenues have been pursued:one that addresses policymaking and the policyprocess, a second focusing on participation, and a thirdconcentrating on accountability, transparency, andreduction in corruption. The next section examinessome experience related to these three.

SELECTED EXPERIENCE INIMPROVING HEALTHGOVERNANCE

Interventions related to the three avenues notedabove have led to better health governance, although,because of the relative newness of thinking abouthealth sector reforms in governance terms, theirdiscussion in the literature does not always make thegovernance connections explicit. Here we highlightselected activities that have been pursued in:

Improving the policy process in the health sector –promoting more effective stakeholder engagement,including NGOs and beneficiary groups;strengthening ministries of health use of data andevidence, and providing information to the public ontheir rights and duties in health sector activities.Enhancing participation at a variety of levels – local tonational – to promote more effective governance ofhealth programs.Improving accountability and transparency andreducing corruption in the health sector.

Table 4 illustrates how these avenues relate tothe health governance framework presented above(Figure 1). Improving the policy process is associatedwith the linkages between the state and clients/citizens, and with those between the state andproviders. As the discussion below reveals, the firstcategory of linkages deals with creating more openpolicy processes where non-state actors have accessto policy debates, informed by the media, to increasethe voice of citizens vis à vis the state, and improvestate responsiveness to citizens. Illustrations of thesecond category, between state and providers, includeinterventions that increase the capacity of healthofficials to exercise evidence-based policy leadership,and to translate those policies into programs thatcommunicate appropriate incentives to providers sothat policy intent is achieved during implementation.

Enhancing participation concerns the linkagesbetween clients/citizens and the state, and betweenthem and providers. The examples provided belowillustrate that an extensive experience base exists oncommunity participation in health service provision,which links clients/citizens and providers. Healthsector decentralization, for instance, illustrates astructural intervention that, depending upon thescope of the responsibilities and authorities that aredecentralized, can increase citizen participation indecisions about health service mix, staffing, andoversight. This intervention relates to the connectionbetween clients/citizens and the state, as well asjoining them with providers.

TABLE 4. RELATING HEALTH SECTOR REFORMS TO GOVERNANCE LINKAGES

Client/Citizen <––> State State <––> Providers

Improving the policyprocess

Enhancing participation

Increasingaccountability,transparency,anticorruption

Client/Citizen <––> Providers


The third avenue – interventions to increaseaccountability and transparency, and to reducecorruption – connects to all three of the governancelinkages in the framework. Efforts to address voicefailures so as to push the state to be moreaccountable to the poor, for example, are associatedwith the linkages between clients/citizens and thestate. Procurement reforms, service deliveryproductivity improvements, and tightened regulationall illustrate interventions directly connected to howthe state interacts with providers. Mechanisms toexpand the role of community groups in oversightand assessment of frontline providers are concernedwith the governance linkages between clients/citizensand providers.

IMPROVING THE POLICY PROCESS

The literature on policymaking and the policyprocess is in general agreement that policy emergesfrom the intersection of the political context,evidence, and the links between policymakers andother stakeholders (see, for example, Court andYoung 2004). All three of these features of the policyprocess are important for health governance.Obviously, health policymaking is affected by thequality of a country's overall policy process,regardless of sector. The extent to which the policyprocess in general is: i) informed by independent andvalid research and analysis, and ii) open and accessibleto citizens and interest groups in ways that encourageequity, fairness, and responsiveness has implicationsfor health policy. So if, in a given country, policymakingtakes place from the top down, is determined largelyamong a closed circle of privileged elites, and isuninformed by policy-relevant research, then healthpolicymaking is likely to share these characteristics.

More directly, the roles, practices, attitudes, andcapacities of health sector actors involved in thepolicy process will condition the quality of healthpolicymaking. Those of the health ministry are central,though not exclusively, to the extent that otherhealth agencies are involved in policymaking. Healthpolicymakers are often ill equipped to argueeffectively for resources based on evidence, and tobuild constituencies within government or amongnon-state actors. Health sector officials often havelimited ability to counter the power and influence ofwell-organized providers, who influence health careregulation both by lobbying and by defining standards

of practice (see Rigoli and Dussault 2003). Ratherthan leading the policy process, they tend to operatereactively.

Thus, improving leadership capacity amonghealth sector officials is needed to enhance healthpolicymaking and fulfill the stewardship role (WHO2000). A special type of leadership is called for, onethat involves managing both the administrativeapparatus of service delivery and the political processof building legitimacy and political support for theinstitutions involved in health policy implementation(see Moore 1995, Heifetz 1994). According to Moore(1995), this leadership involves pursing a "strategictriangle" of objectives: I) substantive value (such asprotecting public health and improving equal accessand universal coverage); ii) legitimacy and politicalsustainability; and iii) operational and administrativefeasibility. To accomplish these objectives, healthsector officials must manage the policy process,particularly its political aspects – mobilizing supportfrom political actors, the media, interest groups, andoversight entities – and reengineer the operationalmanagement of the health bureaucracy to producegreater public value.

Of the many examples of interventions thattarget improving the policy process, most focus onthe evidence and linkage features. Efforts to increasethe quality and utilization of policy research havebeen undertaken in a variety of sectors besideshealth: economics, environment, sustainablelivelihoods, agriculture, trade, and so on. One

Côte d’Ivoire/Christine Ortiz


interesting example comes from Madagascar, wherethe MADIO project, between 1994 and 2001,supported local capacity building in economic,statistical, and social analysis, and diffusion of researchfindings in the media to encourage public debate on avariety of economic and governance policy issues(Razafindrakoto and Roubaud 2007).

In the health sector, improving the availability andquality of information for health decisionmaking hasbeen an objective for more than a decade. One of themost well known initiatives is the promotion ofNational Health Accounts (NHA), an analyticframework and methodology that provide acomprehensive picture of health expenditure by typeof service from all sources. From an early emphasison obtaining expenditure data and refining themethodology through donor-funded technicalassistance to small teams of technical staff, the NHAinitiative moved to creating regional networks toapply and promote the tool and to focusing onutilization of the data for policymaking. Currently, theconcern is to institutionalize NHA in country healthministries and/or health policy research and analysisunits. Institutionalization is one step toward ensuringNHA's contribution to improved health governance;another step is expanding the users of NHAinformation beyond state actors to include civilsociety. This latter step contributes to the linkageaspect of the policy process.

In some cases, the health sector has exercisedleadership in improving the policy process bystrengthening central ministries of health, often withsupport of donor projects. These efforts haveenlarged ministries' capacities in good healthgovernance. Charged with new roles as stewards ofthe health system, ministries of health have had toreengineer their structures and staffing skills todevelop stronger abilities to regulate both the publicand private sector providers, and develop politicalskills to lead changes in laws and regulation and topress other stakeholders to do their part inimplementation (WHO 2000). In Colombia, forexample, to implement its innovative health reform inthe 1990s, the Ministry of Health took the initiative tocreate the National Council for Social Security inHealth, a forum for participation of otherstakeholders that was led by the health minister. Italso created a separate unit for the implementation ofdecentralization, as well as a reform unit to lead the

political process of establishing details of regulationsand adjusting to changes in political landscape(Bossert et al. 1998).

Similarly, more recently in Mexico, under theleadership of Julio Frenk, the Ministry of Health ledthe process of developing stakeholder support for anambitious reform that has expanded coverage ofsocial insurance to the poor in many of the country'sstates. Carefully crafting coalitions of support bothwithin the executive and legislative branches, with anevidence-based approach for building strongpersuasive arguments, the ministry wove supportamong competing political and interest groups. Thiseffort was one of the most successful policy reformsof the Fox government, and demonstrates theeffectiveness of engaging ministries of health inbuilding alliances with pro-health civil society groups(Frenk 2006).

Evidence-based policymaking combined withbuilding strong advocacy packages, as in the Mexicancase, is another governance improvement strategythat seems to have been effective. These packages maybe designed to present persuasive evidence of majorhealth problems, such as health disparities, but alsomay be presented in ways that show the benefits ofpolicies for different interest and political groups.Several cases of changing national malaria treatmentpolicy offer good examples of how this strategy canwork. Drawing on cases from Malawi, Tanzania, SouthAfrica, Kenya, and Peru, Williams et al. (2004) discussthe challenges faced in altering national malariatreatment policy in the face of growing evidence ofchloroquine resistance across the globe. In each case,the consensus building process began early and withmany stakeholders, including the local pharmaceuticalindustry and district management teams. Theyinvolved standardized data collection and operationsresearch to develop compelling evidence that waspersuasive to the key stakeholders. In Honduras, asafe motherhood initiative was initiated with thedevelopment of systematic and high-quality data bysupporting maternal mortality surveys, which in 1990demonstrated that Honduras' maternal mortality ratewas nearly four times earlier reported levels(Shiffman et al. 2004).

In addition, mass media campaigns that informpatients of their rights in demanding better service ortheir duties in participating in, for example,


immunization campaigns are part of a health sectorcontribution to improved governance. Thesecampaigns can strengthen the voice of patients andthe public, and encourage their demands on the stateand providers. An example is the African BroadcastMedia Partnership Against HIV/AIDS (ABMP), whichwas launched in December 2006 with the aim ofincreasing the amount of HIV/AIDS-relatedprogramming by African broadcasters. 8 The five-yearpan-African HIV/AIDS public education campaignreceives support from a number of partners,including US and African foundations, mediaassociations, and private corporations. A similarinitiative unites the media in 23 Caribbean islandnations.9

Active engagement of advocacy groups in thepolitical process can be particularly effective inputting health problems on the policy agenda and ininfluencing the adoption and implementation of majornew health policies. The case of HIV/AIDS in Brazil isan excellent illustration of this strategy. Gómez(2006a) shows that involving civil societyorganizations depends on the openness of the regimeto bottom-up lobbying and advocacy, the reciprocalrelationship between civil society and policy elites,and international organizations (e.g., the Global Fundto Fight AIDS, Tuberculosis and Malaria [Global Fund]and the US President's Emergency Plan for AIDS

Relief [PEPFAR]). An example from Bangladeshreinforces these findings. In the mid 1990s, women'scivil society organizations advocated successfully forthe inclusion of gender equity in health policy reformand program design. However, during implementationthe government agencies responsible for the programgradually closed the door to civil society engagement,and with the coming to power of a newadministration in 2001, reform opponents were ableto block the reforms with little outcry from advocacygroups (Jahan 2003).

ENHANCING PARTICIPATION

There is a large literature on participation inhealth services reform and delivery, much of whichfocuses on community-level participation. Thecommunity-focused analyses note the relationshipbetween participation and targeting of services toaddress local needs, and the role of communities inextending the reach and effectiveness of healthsystems through co-management and co-financing.Related to governance, among the rationales for, andresults of, community participation is increasedaccountability.

For instance, the case studies in Cornwall et al.(2000) provide examples of village health committeesand local health councils where communities playedan integral role in increasing the responsiveness andaccountability of public health services to communityneeds. The case of Nepal's Baudha Bahunipati FamilyWelfare Program illustrates the evolution ofcommunity structures to sustain local participationto ensure responsiveness and accountability. Theprogram established community consultationprocesses that evolved into formalized health servicemanagement committees to incorporate local inputinto the health service mix, decide upon user fees,address procurement delays, and eventually takecharge of local service delivery in cooperation withthe public health system. Ultimately, several of themanagement committees constituted themselves asregistered local NGOs.

A well-recognized lesson of experience withcommunity participation in health (and other sectorsas well) is that its success depends upon communitymembers' skills, organizational capacity, social capital,commitment, and resources. El Ansari and Phillips(2001) document the importance of these factors in

8 See the ABMP website at: www.broadcasthivafrica.org.9 This is the Caribbean Broadcast Media Partnership on HIV/AIDS. Seewww.cbmphiv.org.

Ghana/Hirshini Patel


participatory community health projects in SouthAfrica. In a recent USAID project to develop socialcapital in Nicaragua, it was found that an interventionto develop leadership and management skills ofcommunity leaders was effective in a short period oftime in improving levels of trust among communitymembers in post-conflict communities that hadsuffered significant divisions among supporters of theSandinista government and the Contra rebels. It wasalso effective in improving some selected healthbehaviors. While it did not have a significant impact oncommunity-level participation in group meetings andactivities, it did have a major effect on civic andpolitical participation in elections and in advocacywith local officials (Bossert et al. 2003).

The empowerment dimension of participation isalso important, particularly if communities areexpecting to exercise oversight for accountability. Theeffectiveness of health committees, councils, andboard membership in empowering communities ismediated strongly by both expertise and politicalpower. A study of community involvement inhospitals in South Africa, for example, found thatcommunity members serving on hospital boards,ostensibly to increase hospital responsiveness tocommunity needs, were at a disadvantage in the faceof the superior technical authority and political cloutof the medical profession (NPPHCN 1998). In somecases, gender issues affect empowerment if womenface sociocultural impediments to participation, as isoften the case in the area of reproductive health (see,for example, Schuler 1999).

Governance linkages between citizens and thestate, and citizens and providers depend uponparticipation, but in many countries, significantbarriers exist. Capacity building is needed forcommunity groups to exploit organizationalmechanisms to inject their views and needs into thepolicy-making and service delivery process. A clearlesson from decentralization experience is thatcommunities, particularly disadvantaged ormarginalized groups, will not have greater access orcommand increased responsiveness solely as afunction of decentralization's ability to bring themcloser to local officials absent measures to countercooptation by local elites and to make communityparticipation both programmatically and politicallydesirable for those officials (Fung and Wright 2003).Institutional incentives, backed up by an openness

among health officials to engage with citizens, areneeded, as Golooba-Mutebi (2005) indicates in ananalysis of decentralized primary health care inUganda.

Besides incentives, however, public officials alsoneed capacities and structures that enable them toact on citizen inputs. For external participation to beeffective, local-level officials must be trained inparticipatory planning, negotiation, and consultativestructures, and processes need to be developed andemployed systematically to inject citizens' views intodecisionmaking.10 These skills contribute to leadership,discussed above, and to the ability of officials to usecitizen input to inform policy agendas, assess politicalfeasibility, and develop implementation strategies thatbuild support for reform (Moore 1992, Reich 1996).Such participatory leadership can help to mainstreamstakeholders' health priorities into decisionmakingregarding service mix, resource allocation, contractingand procurement, regulatory issues, and otherimportant questions. These structural and proceduralaspects of health governance extend beyond citizenparticipation, and are the topic of the next section.

INCREASING ACCOUNTABILITY AND

TRANSPARENCY, REDUCING CORRUPTION

Structural and procedural reforms in the healthsector to increase accountability and transparency,and to reduce corrupt practices, play an importantpart in improving health governance. As noted above,accountability falls into three main categories: political,performance, and financial. There are relatively fewexamples of health sector reforms that specificallytarget political accountability, althoughdecentralization efforts are an exception. Thestronger focus has been on performance and financialaccountability.

A unifying thread in accountability, transparency,and anticorruption reforms is attention to theavailability and quality of information. In many healthsystems, information flows are limited, procedures areopaque, and actors are unaccountable. Two types ofactions have been pursued: i) new management toolsand systems improvements internal to the health

10 For additional discussion of the need for health sector personnel to developskills to interact effectively with non-state actors to achieve health outcomes, seeBennett et al. (2005).


ministry, and ii) capacity building to exercise oversight.An example of the former comes from Afghanistan,where the health ministry, with donor assistance,employed a balanced scorecard to monitor progressin delivering a basic package of services (Noor et al.2007). An example of the latter is in Peters (2002),which documents oversight capacity building in Indiafor reproductive health services, and notes that itcalls for increased skills for other stakeholdersbesides public officials.

Problems of corruption have stood out as one ofthe most visible signs of poor and inadequate healthgovernance. The level of corruption in a country'shealth sector is reflective of the extent of corruptpractices more broadly. In countries where publicofficials fail to address citizens' needs, lackaccountability, and operate with impunity, andinstitutional checks and balances are weak ornonexistent, such practices affect the health sector aswell. Corruption is often defined as "use of publicoffice for private gains" (Bardhan 1997). Severalfeatures of the health sector make it particularlyfertile ground for corruption (Savedoff andHussmann 2006). The variety of stakeholdersinvolved in policy and programmatic decisions and indelivery of services (recall Table 3), the uncertaintiesinherent in health, and the pervasiveness ofinformation asymmetries in health markets all providefertile ground for corruption and fraud to take root.Manifestations of corruption in the health sectorinclude the purchase of public positions, leakage ofpublicly funded supplies and services (e.g., sale ofpublicly funded drugs in private markets, fraudulentinsurance billing practices), service- andprocurement-related soliciting of bribes and under-the-table payments, and absenteeism (Lewis 2006,Transparency International 2006). Small-scale,facilities-level abuses can result in greater perceptionsof system-wide corruption and loss of confidence inthe system. For example, a USAID-sponsoredcorruption survey conducted in seven EasternEuropean countries found that respondentsidentified doctors' solicitation of bribes as awidespread problem (Vitosha Research 2002).11

Three broad strategies in the health sector havebeen shown to help mitigate corruption and fraud. Afirst strategy involves dissemination of information onprocesses and performance. At the sectoral level,tools such as NHA and public expenditure trackingsurveys (PETS) are means of heighteningtransparency and accountability, and can – if theinformation reaches actors with oversightresponsibility and capacity – reduce the ability ofhealth sector actors to engage in fraudulent activities.These tools have been used to identify and curbleakage of financing. At the facility and provider levels,service delivery studies, and provider/institutionalreport cards can help curb more micro-level abuses.In Bolivia, for instance, one study found perceivedcorruption in the health sector to be lower inmunicipalities with relatively strong management ofstaff oversight, such as written evaluations ofperformance (Gatti et al. 2002). Argentina'sgovernment implemented a policy of tracking hospitalexpenses for medical supplies and disseminating thisinformation to them. The purchase prices for theseitems dropped by over 10 percent (suggestinglessened degree of fraudulent billing) but then roseonce enforcement of the policy waned (Lewis 2006,Transparency International 2006). The media have animportant role to play in information disseminationregarding service delivery performance and inexposing corrupt practices through both awarenessbuilding and investigative reporting (see Macdowelland Pesic 2006).

11 The Bulgarian firm, Vitosha Research, conducted a series of annual corruptionsurveys in Albania, Bosnia and Herzogovnia, Bulgaria, Croatia, Macedonia,Romania, and Yugoslavia (Serbia and Montenegro). The research usedrepresentative population samples of approximately one thousand people, andadministered opinion polls. See: http://www.vitosha-research.com/publications_en.php?bc=63&c=404.

Ethiopia/Leah Ekbladh


A second strategy involves establishment ofclear procedural rules (e.g., in contracting andprocurement) and use of authority to enforce thoserules (particularly use of audit and rewarding goodperformance/punishing abuses). At the macro level, astatistical analysis from the Philippines found that thefrequency of audit by central government as well asautonomy of local government increasedimmunization coverage (Azfar and Gurgur 2001). Anaudit of insurer registries of low-income subscribersby the Colombian Health Secretariat foundwidespread fraud in the form of ghost subscribers.Only after establishing a unified database andimproving monitoring was the government able toreduce millions of dollars of losses through fraud(Savedoff 2007). At the facility level, simple updating offinancing information systems can be effective inreducing employee theft. Establishment of acomputerized fee collection system in a Kenyanhospital reduced opportunity for embezzlement ofuser fees and resulted in a 50 percent increase inrevenues with no change in utilization patterns(Transparency International 2006). In Albania, theintroduction of simple computerized facility-levelaccounting and reporting systems led to reductionsin informal payments and increased service utilization(Hotchkiss et al. 2005).

A third strategy involves establishing greateraccountability through citizen oversight. Citizenoversight can take the form of heightened localcontrol. In Bolivia, active citizen health boards andsupervision of facility personnel helped reduceoverpayment for drugs by procurement agents(Gatti et al. 2002). In Uganda, community-representedhealth unit management committees were able toimpose accountability in the area of hospital drugmanagement (Transparency International 2006). Suchgovernance and accountability innovations, andothers such as provider report cards, can alsocontribute to improved quality of care (seeMcNamara 2006). In Latin America, Canada's IDRC issupporting a multi-country effort to assist healthpolicymakers, civil society organizations, and researchorganizations with health service delivery monitoringusing a "benchmarks of fairness" methodology (seealso Daniels et al. 2000). The purpose of themonitoring is to address inequities, increasetransparency and accountability, and improvegovernance.

Citizen oversight may also be more indirectthrough pressure on locally elected governments. InMexico, for instance, a National Survey onCorruption and Good Governance assessed theperformance of 38 different public services in 32states. The State of Chiapas responded to lowrankings by implementing an e-government programfor public service delivery; its ranking subsequentlyrose substantially, from 16th to 6th, in the nextsurvey round two years later (Savedoff 2007). Thiscase highlights the fact that some importantinterventions that can lead to improved healthgovernance lie outside the health sector. USAID'sdemocracy and governance programming recognizesthese linkages. Democratic governance programs canpromote sectoral synergies through, for example,strengthening checks and balances through legislativeoversight, reinforcing courts and judicial systems,building capacity in auditing and monitoring bodies("agencies of restraint"), strengthening localgovernment, supporting civil society, and introducingparticipatory mechanisms into policymaking andpublic administration (see Brinkerhoff 2000b).12 All ofthese can have positive pay-offs for healthgovernance.

CONTEXTUAL FACTORS

The previous section closed with the point thatinterventions beyond the health sector can affecthealth governance; the corollary is that contextualfactors beyond the sector can limit the options forsector-specific reforms to improve healthgovernance. This selected review of some illustrativeexperience should be balanced with a caution aboutthe need to take contextual factors into account indeveloping any health governance strategy. Whatworks in one socioeconomic context, for one type ofregime, or for one specific type of program may notbe feasible or advisable under different conditions.For example, policy processes tend to be restrictedin more authoritarian regimes, making it difficult andperhaps counterproductive to involve NGOs andgrassroots advocacy groups in the promotion ofparticipation in health policy and management

12 Among public administration mechanisms, participatory budgeting has receiveda significant amount of attention as a means of bringing community membersinto the budgetary process, strengthening responsiveness of government byinfluencing spending priorities, expanding information flows about governmentperformance, and matching citizen preferences to service provision. See, forexample, Baiocchi (2003) and Brautigam (2004).


(Gómez 2006b). For instance, the current Russiangovernment is relatively hostile to civil societyorganizations, making initiatives to combat HIV/AIDSdifficult to develop with bottom-up lobbying(McCullough 2005).

In another example of the impact of political andinstitutional context, Khan and van den Heuvel(2007) document how Pakistan's semi-authoritarianpolitical structures have limited broad participation inhealth policy making, and how changes ingovernments have disrupted health planning andimplementation. In a similar vein, Israr (2006)discusses how a World Bank project to developPakistan's district health management teams was notas effective as it could have been in part because itwas not able to change a "culture of rigidbureaucratic traditions and behavior."

In recent years, considerable attention has beenfocused on the importance of social capital – trustrelationships, social networks, civic and voluntaryorganizations – as a contextual factor that maycontribute to societal effectiveness in a variety ofareas, including better health behaviors and healthstatus, higher educational achievement, less violence,less poverty, more equity as well as more democraticpractices, and improved government performance(see, for example, Putnam 1993, James et al. 2001,Hardin 2001, Kawachi and Berkman 2000). While theamount of available social capital is often treated as acontextual factor that influences efforts to promotebetter governance and better health practices, arecent USAID project has attempted to targetbuilding social capital at the grassroots as a means ofimproving health behaviors and democraticgovernance in Nicaragua by strengthening localleadership to build trust and expand participation(Bossert et al. 2003).13

Specific features of a country's health system arealso a contextual factor. For example, forms ofcorruption that may be prevalent under a single-payer/publicly financed system (such as directkickbacks and graft in procurement) may be less of aproblem than those with a purchaser–payer split(where diversion of funds through fraudulent billingmight be more common). Thus, anticorruption

programs need to be carefully designed to take suchfinancing features into account. Further, the level ofpolitical will for tackling corruption is anothercontextual factor salient for the design andimplementation of interventions in the health sector(Brinkerhoff 2000a).

Fragile states pose one of the most challengingcontexts for health system improvement. As theliterature on failed and post-conflict states suggests,very weak states require special tailoring of projectactivities and humanitarian assistance in ways that areparticular to the multiple and often competingreconstruction objectives following conflict. In somecases, health programs are among the few organizedactivities that can form the basis for pushing forwarda peace process or for gaining legitimacy tostrengthen the state (Brinkerhoff 2007a,Waldman 2006).

Lubkemann (2001), for example, details the caseof post-conflict rebuilding of the health system inMozambique, where decentralizing health serviceswas seen as important for extending services to localcommunities and for increasing state legitimacy.However, the new government's desire to controlservice delivery and associated resources toreinforce its legitimacy led the state to discourage ordominate independent community mobilization thatcould lead to expanding local voice. Building localcapacity for responsive health service deliverychallenged the government's intent to consolidatepower and control local associational activity. From ahealth governance perspective, the outcomes weremixed; paradoxically, decentralized health servicedelivery reinforced local people's view of thegovernment as intrusive and domineering.Lubkemann concludes that, "if the state …is notencouraged to recognize the legitimacy of other localactors as participants in negotiating change, thepolitical culture may simply reinforce exit over voice"(2001: 103-104).

Even in developing countries that are not failed orpost-conflict states, there are limits to their ability toensure that the health sector can adhere to all theprinciples of good health governance discussed above.Little demand for better governance may be present.Given the salience of health to basic well-being, manyactors will opt for whatever access is available to them.

For useful details on social capital and health in developing countries anddiscussion regarding measurement see Harpham et al. (2002).


This is one of the lessons of efforts to reduce informalpayments. As Lewis (2007: 985) observes, "informalpayments allow patients to jump the queue, receivebetter or more care, obtain drugs, or simply any care atall." Donor expectations regarding country actors'interest in better governance are often out of touchwith citizens' desires to get the state to provideresources and services, through recourse to clientelistconnections if necessary (Brinkerhoff and Goldsmith2004). Entrenched interests on the part of providersare another force for maintenance of the status quo, asthe example of informal payments demonstrates. Inaddition, as noted in Table 2, citizens may have lowexpectations for government responsiveness to theirneeds. For example, in many African countries, largenumbers of people take their own responsibility forcovering health care expenditures out of pocket inrecognition of the public health system's weak capacityto meet their needs and politicians' limited interest intheir concerns.

The ability to pursue changes that will enhancehealth governance may be close to non-existent insituations of state failure and enduring civil conflict,where, for instance, the assumption thataccountability to patients and the public will result inachievement of the broader health system objectivesmay not hold. Citizens desperate for health serviceswill not accord priority to accountability when accessis problematic. Post-conflict governments, as theMozambique example cited above shows, may pursuehealth service objectives in ways that undermine andweaken good governance for purposes ofconsolidation of power.

In fragile states, then, donors will need to look foropenings to introduce elements of good healthgovernance, to the extent possible, as they provide theresources for post-conflict service delivery inanticipation of creating the architecture for a revivednational health system that both fits the countrycontext and reflects the principles of good governance.This approach is what is referred to as shadowalignment. For example, observers note some positiveexperiences in Haiti, Cambodia, and Afghanistan withintroducing limited forms of performance contractingfor health service delivery in fragile states, which, ifinstitutionalized through subsequent health ministryadoption of pay-for-performance modalities, could holdpromise for increasing provider accountability andresponsiveness (see Eichler et al. 2007, Palmer et al.2006, Ridde 2005).

PROGRAMMING OPTIONSThis overview has defined health governance

broadly, as consisting of the rules, roles, responsibilities,and institutional arrangements among the state,providers, and citizens, as illustrated in Figure 1. Healthgovernance takes place in four institutional arenas: civilsociety, politics, policy, and public administration. Interms of donor programming, the health governancelandscape, as noted above, offers numerous entrypoints and change levers at various levels, and it is notpossible to identify all options. This section begins witha review of several basic programming principles, andthen offers an illustrative set of options to help guidethinking about what can be done to strengthen healthgovernance and increase utilization of priority services.

BASIC PRINCIPLES

Three principles underlie the options offeredhere. These derive from accumulated evidence acrossa wide variety of country and sectoral cases on whatis necessary to implement reforms (see, for example,Brinkerhoff and Crosby 2002). They are: build andreinforce political will for reform; balance supply-sideinterventions with support for demand; and integratehealth governance with health systems operations,financing, and capacity building.

Ethiopia/Gilbert Kombe


Build and reinforce political will

The need to pursue objectives that are sharedby key decision-makers in the country that donorsare assisting is well recognized as a core principle ofinternational assistance, and is supported by researchon sustainability (see Bossert 1990). The aideffectiveness working group of the Organisation forEconomic Co-operation and Development'sDevelopment Assistance Committee identifiescountry ownership as central to achievingdevelopment results. While acting on this principle isnot always straightforward in practice, particularly inpost-conflict settings, sustainable change dependsupon mobilizing the political will of country actors atvarious levels to support change initiatives actively(see Brinkerhoff 2000a, 2007b). Reforms needchampions in order to succeed (Brinkerhoff andCrosby 2002).

One approach to fostering champions that hasbeen found to be effective in health reforms is thecreation of a "change team" of technocrats from bothwithin the health sector and in key ministries of thegovernment. This team is protected by higher politicalofficials and works together, often on an informalbasis, to fashion a technically feasible policy that hasthe potential for gaining sufficient support fromdifferent sectors of the state. These change teamswere created for the successful adoption of thereforms in both the authoritarian Pinochet period inChile and the democratic regime in Colombia(González-Rossetti and Bossert 2000, Kaufman andNelson 2004).

The main benefit of technocrat-led change teamsis that they are able to develop solutions to healthreform problems that are technically sound and likelyto reflect the best knowledge about what technicalfactors are necessary to achieve intended results. Thechallenge is making sure that the technical solutionsare acceptable to political leadership.

A cautionary tale on the limits of technocraticteams comes from Ghana's experience withreforming health insurance. Following the victory ofthe New Patriotic Party (NPP) in 2000 on a platformthat included the abolition of health user fees (whatGhanaians referred to as the "cash and carry"system), the newly elected political leadership asked a

team of health professionals to design an insurancescheme that would be nationally scalable, identifiablydistinct from the previous government's healthprograms, and implementable before the nextelection, in 2004. The design that the team oftechnocrats proposed, while technically sound, metnone of these criteria and was rejected. Seniorpolitical leaders brought in a new team of consultants,made up of trusted cronies, who designed a politicallyacceptable national health insurance act, which waspassed in 2003 and contributed to the NPP winningthe 2004 election. The insurance scheme that the actestablished led to increased service utilization, butsuffered from a host of operational and governanceproblems (e.g., overuse of services, mismanagement ofclaims, poor auditing, fraud and abuse), and accordingto some projections risks bankruptcy in the not-too-distant future. Among the lessons for change teamsare that while reforms create windows ofopportunity for change, they also open up potentialfor political opportunism, and technocrats need tobuild political feasibility into reforms if they are to besuccessful change agents and gain the support ofpolitical actors (Rajkotia 2007).

Another aspect to acting on this principle is toframe health governance objectives in terms thatcountry health officials can readily relate to theirconcerns and interests. This approach is likely to beeffective in building political will and commitment. Forexample, if health governance improvements can beplausibly linked to better HIV/AIDS or malaria

Ghana/Hirshini Patel


outcomes, then officials with responsibility for singlediseases/issues may take the lead in championingchanges. Or, for a politically loaded issue likecorruption, health officials may be more receptive tosupporting change if it is discussed in terms ofmanagement efficiency, good governance, systemsstrengthening, or accountability improvement.

Finally, the prospects for building political willoften depend upon timing. Changes of leadership canopen – or close – windows of opportunity forreform, as the Ghana national health insurance caseshows. Another example comes from Uganda, wherea 1987 health policy review commissionrecommended changes in the public private mix ofhealth care providers, including subsidies to missionfacilities, but senior health officials were notsupportive. A subsequent shift in health ministryleadership led to a reconsideration, and launched aseries of policy reforms that over time integratedprivate and nonprofit providers more closely into thenational health system (see Birungi et al. 2001).

Balance supply-driven improvements withsupport for demand

As with other change efforts, improving healthgovernance requires new policies and institutionalarrangements, improved skills and capacities, technicalassistance, and new resources. These constitute thesupply side of change. For example, good healthgovernance, as encapsulated in Box 2, calls for healthdecision-makers to reach out to stakeholders forinputs into decisions and to provide the informationand mechanisms for accountability. However, publicofficials often see stakeholder participation as time-consuming and unhelpful, and accountability as anunwelcome limitation on their discretionary power.So in the absence of effective legal mechanisms,coupled with external pressure, they have fewincentives to supply good governance. The demandside constitutes this pressure: stakeholdersexpressing their voice to provide input into decisionsand to hold those making decisions accountable.Incentives affect the demand side in that ifstakeholders perceive no receptivity to their input or

confront too many procedural roadblocks (e.g.,hearings announced with no lead time to allowinterested parties to attend), then their incentives toengage are weakened.

Health specialists tend to be more familiar, andcomfortable, with supply-side interventions thatfocus on various technical aspects of service delivery,health financing, and so on. As a result, often thetendency is to address health governance largelyfrom the supply side, without sufficient attention todemand. However, similar to the supply side, thedemand side also needs new organizationalmechanisms, skills and capacities, and resources to beeffective. Citizens and civil society groups must beable to exercise demand effectively, at the nationaland local levels. As public health officials, providers,and citizens gain confidence that more openapproaches can yield better decisions and services,incentives for shared responsibility for healthservices and outcomes will increase. More opennesson the demand side provides the incentive for morethoughtful participation by stakeholders in bothproviding input and in accountability mechanisms. It isimportant to recognize, however, that citizen demanddoes not necessarily lead to achieving desirable healthoutcomes, as in the case where curative services arepreferred over preventive, or where citizen supportgroups for particular rare diseases lobby forresources. Good health governance means givinggroups a voice, but not a veto, on health policies andservices.

Health education campaigns that provideinformation on the benefits of prevention, forexample, can lead to a shift in demand away fromcurative care alone. Policy forums and other venuesthat offer equal opportunities for multiple groups toexpress their views, accompanied by transparentprocedures for how policy decisions are made, canhelp to counter dominance by single constituencies.Legislative procedures that provide for notice-and-comment opportunities on draft legislation are oneexample of a governance mechanism that canincrease balanced expression of voice whenaccompanied by rules that are transparent and fair.


Integrate governance, financing, operations,and capacity building

The discussion in this paper has shown that therules, roles, responsibilities, and institutionalarrangements that comprise governance in aparticular health system serve to direct how thesystem is financed, how it operates, and whatcapacities it can exercise. A singular focus ongovernance will not be enough to ensure sustainableimprovements in the health system. Important forgovernance is operational and management capacityin public health service delivery and regulatoryagencies. Better leadership and management improvethe effectiveness of policy choices and increaseslegitimacy. Human resources are critical as well. Anintegrated approach to intervention offers thepotential for greater benefits than concentrating onone or the other of these systems-strengtheningelements alone (see Health Systems 20/20 2007).There may be situations where for various reasons –limited program funding, narrow access to key actors,or immediacy of need for services – an integratedapproach cannot be pursued. However, such targetedprogram interventions, further along in time, mayopen the door to an expanded orientation toencompass all four elements.

ILLUSTRATIVE HEALTH GOVERNANCE

PROGRAMMING OPTIONS

Clearly, the range of possibilities for interveningto improve health governance is extensive.Narrowing that range depends upon donor prioritiesand resources, the principles summarized above, andthe specific country situation. Table 5 is not meant toexhaust all possible interventions, but to provide anillustrative list of interventions according to the fourinstitutional arenas presented in this paper. Theprogramming options presented are categorized interms of which of the features of good health

governance, listed in Box 2, are their primary focus:responsiveness, sound leadership, voice, checks andbalances, accountability, transparency, evidence-basedpolicymaking, and efficient and effective servicedelivery and management. For any particular option, itcould be argued that it addresses more of thesefeatures than the table indicates. However, thepurpose of the table is to highlight whichinterventions relate most directly to one or more ofthe good governance targets as a way to identify whatoutcomes would most immediately result from agiven option. For example, the table demonstratesthat selecting one or more of the options in the civilsociety arena will yield primary results in voice,accountability, and responsiveness. While ultimately, asour governance model illustrates, such results willenhance efficient, effective, and equitable servicedelivery, the contributions of civil societyinterventions to these outcomes are somewhatindirect.

The options offered here can be used for avariety of programs. First, they could be pursuedeither individually or in some combination as stand-alone health governance interventions that addresscountry-specific opportunities or USAID Missionobjectives. Second, they could be integrated withother health interventions, to add a governancecomponent, for example, to health insurancedevelopment or to specific services (e.g., HIV/AIDS,maternal and child health, reproductive health). Third,they could add a sectoral focus to democracy andgovernance programs, for example, building ondecentralization or civil society strengthening. Andfinally, they could support improvements instructures and processes created through variousinternational health initiatives, for example, GlobalFund country coordinating mechanisms, GAVIAlliance inter-agency coordinating committees, orsector-wide approaches (SWAps) health sectorcoordinating committees.


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CONCLUSIONHealth governance encompasses a broad set of

features related to health systems. The modelpresented here demonstrates that good healthgovernance emerges from the actions and linkagesamong the state, providers, and citizens. Healthgovernance improvements – through their impactson rules, roles, responsibilities, and institutions – affectthe availability, quality, distribution, and utilization ofhealth services. We have reviewed a sampling ofefforts that have led to better health governance, wehave flagged some of the issues involved inundertaking governance improvements, and we haveprovided a framework to inform program designbased on health governance priorities and relatedinstitutional-arena interventions. In closing, we offerseveral caveats concerning health governance as wehave analyzed it here. First, any model that aspires tocoherence and utility must simplify real-worldcomplexity. Each of the boxes in the model (state,providers, and client/citizens) contains a vast amountof variety, both in terms of the actors involved (Box3) and of the institutional arrangements within whichthey operate. Second, because of the variety andcomplexity inherent in the model, the governancelinkages in health systems, and the outcomes theyproduce, are contingent rather than guaranteed. In

other words, as we noted above, the situation-specificcontext of a particular country's health systeminfluences what can be achieved from the design ofhealth governance strategies and the investments toimplement them. Thus, third, it is important tocontextualize health governance with regard to thelarger set of governance institutions that surround it,and to the social, political, cultural, and historicalterrain of which health governance is an integral part.

These caveats notwithstanding, we have arguedthat efforts to increase the quality of healthgovernance constitute worthwhile and effectiveundertakings for improving health systems functioningand for increasing the provision and utilization ofhealth services. The programming options we havesummarized constitute a source of ideas that can beused to develop interventions in four institutionalarenas to address specific targets associated with goodhealth governance. As noted, health sector reformershave only rarely used a governance lens through whichto design, implement, and assess programs. We hopethat this paper contributes to increased healthgovernance programming and to building the evidencebase for documenting both the effectiveness and thelimitations of health governance interventions andtheir relationship to increased service delivery andutilization.


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ABOUT THE AUTHORSDerick W. Brinkerhoff is Senior Fellow in

International Public Management at RTI Internationaland has a faculty associate appointment at GeorgeWashington University's School of Public Policy andPublic Administration. He is team leader for healthgovernance for USAID's Health Systems 20/20project.

Thomas J. Bossert is Lecturer on InternationalHealth Policy and Director of the International HealthSystems Program at the Harvard School of PublicHealth in Boston.


Health Systems 20/20 is funded by the U.S. Agency for InternationalDevelopment, cooperative agreement GHS-A-00-06-00010-00.

Abt Associates Inc. leads a team of partners that includes:| Aga Khan Foundation | BearingPoint | Bitrán y Asociados| BRAC University | Broad Branch Associates | Forum OneCommunications | RTI International | Training Resources Group| Tulane University School of Public Health

Health Systems 20/20

Health Systems 20/20, a five-year (2006-2011) cooperative agreementfunded by the U.S. Agency for International Development (USAID),offers USAID-supported countries help in solving problems in healthgovernance, finance, operations, and capacity building. By working onthese dimensions of strengthening health systems, the project will helppeople in developing countries gain access to and use prioritypopulation, health, and nutrition (PHN) services. Health Systems 20/20integrates health financing with governance and operations initiatives.This integrated approach focuses on building capacity for long-termsustainability of system strengthening efforts. The project acts throughglobal leadership, technical assistance, brokering and grant making,research, professional networking, and information dissemination.

Why Health Systems?

The delivery of all health services, including the priority PHN services,depends on the underlying health system. To combat malaria, TB, HIV, andmaternal and child health problems, the health system needs adequateand appropriately allocated financing, inclusive decision making andaccountability, and financial and human resource management systemsthat deliver inputs where and when needed. A smoothly functioninghealth system maximizes the delivery of effective and life-saving technicalinterventions.

How to Access Health Systems 20/20

USAID missions and bureaus can access Health Systems 20/20 byobligating funds to cooperative agreement No. GHS-A-00-06-00010-00.The project can accept all types of USAID funding, including PEPFAR, POP,CS, EFS, as well as funds through EGAT and D&G. As a Leader withAssociate mechanism, missions and bureaus can also negotiate and manageseparate Associate Awards for which they will designate a CTO.

For more information about Health Systems 20/20 publications(available for download) please contact Health Systems 20/20 at:www.healthsystems2020.org | e-mail: [email protected]

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