RTI International is a trade name of Research Triangle Institute Health Systems and the Governance...

RTI International is a trade name of Research Triangle Institutewww.rti.org

Health Systems and the Governance Building Block

Derick W. Brinkerhoff

Global Health Council, 37th Annual International ConferencePanel on Health Systems Building Blocks: How to Build Strong Health

Systems that Deliver Quality ServicesWashington, DC

June 15, 2010

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Where does governance fit in health systems performance?

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Defining governance

• Governance is about rules that distribute roles and responsibilities among societal actors and shape interactions among them. These rules can be:

– formal, embodied in institutions (e.g., democratic elections, parliaments, courts, sectoral ministries);

– and informal, reflected in behavioral patterns (e.g., trust, reciprocity, civic-mindedness).

• Governance encompasses authority, power, and decision-making in the institutional arenas of:

– civil society– politics– policy– public administration.

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Health governance model

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Health governance and power inequalities

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Governance levels

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Responsible health governance

• Responsiveness to public health needs and clients’/citizens’ preferences

• Leadership to address public health priorities• Inclusion of clients’/citizens’ voice• Clear and enforceable accountability• Transparency in policymaking, resource allocation, and

performance• Evidence-based policy and decision-making• Efficient, effective, and equitable service provision,

regulation, and management

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Entry points—voice & accountability: citizens facility

PAQs (Partenariats pour l’Amélioration de la Qualité) in Rwanda

Quality Assurance Partnership Committees (QAPCs) in the Philippines

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Entry points—responsiveness, accountability, transparency: central local, public private

• Transfer of resources, authority, decision-making, accountability

• Examples: – Devolution of health functions to

local governments, e.g., Philippines, Rwanda, Uganda

– Intergovernmental transfers, e.g., District Incentive Fund grants in Rwanda

– Hospital autonomy in sub-Saharan Africa

– Privatization, e.g, Family Group Practices in Kazakhstan

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Entry points—responsiveness, efficiency & effectiveness: MOH facility

• HRH planning, e.g., workforce planning in Egyptian governorates

• Financial incentives, e.g, pay-for-performance

• Non-monetary incentives, e.g., operations research in Swaziland on incentives for HCT performance

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Entry points—accountability, regulation, transparency: rule of law

• Medicines Transparency Alliance (MeTA), UN Convention against Corruption (UNCAC)

• Improved management control systems, e.g., electronic cash registers in Mombasa, Kenya hospital

• Performance-based monitoring, e.g., Global Fund accountability system and LFA oversight

• Citizen report cards on health services, e.g., India and Uganda

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A governance perspective on HSS helps to…

– Identify institutional factors influencing HSS at various levels (facility global)

– Recognize the role of power and politics– Clarify connections among HS actors– Connect the HS building blocks– Focus attention on incentives for

responsiveness and sustainable performance