From Principles to Practices · Sound Management. Transpar ent Governance. From Principles to Practices Roundtable on Governance for Health in Low and Middle Income Countries April-May,

LEADERSHIP, MANAGEMENT & GOVERNANCE PROJECTInspired Leadership. Sound Management. Transparent Governance.

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From Principles to PracticesRoundtable on Governance for Health in Low and Middle Income CountriesApril-May, 2012 A Call to Design Activities to Build the Capacity and Competencies of Those Who Govern in Low and Middle Income Countries (LMICs)

Inspired leadership, sound management, transparent governance

DISCUSSION BRIEF: GOVERNANCE FOR HEALTH ROUNDTABLE | 2

About the Leadership, Management, and Governance

Project (LMG)As the U.S. government enters a new era in international development through initiatives such as the Global Health Initiative and PEPFAR II, there is a strong emphasis on sustainability and country ownership within the health system strengthening framework. Development practitioners increasingly agree that improving the leadership, management and governance capacity of policy makers, health care providers, and program managers allows them to better imple-ment quality health services, and meet local citizens’ health needs. Funded by USAID, the Leadership, Management and Governance Project (2011-2016) collaborates with health leaders at all levels to improve leadership, management and governance practices to create stronger health systems and improve health for all, including vulnerable populations worldwide.

The LMG Project seeks to do the following:

■ Promote enhanced performance improvement processes driven by country leadership for individuals and teams through South-to-South dialogue and collaborative learning modules designed to increase organizational capacity

■ Develop senior leadership and governance capabilities using participatory processes and gender-aware approaches that enable health leaders and policy-makers to address their own challenges, and achieve results

■ Build and use evidence-based approaches by generating and disseminating evidence that shows how improved leadership, management, and governance contribute to health gains

Cover photo credit: Contributed by Management Sciences for Health

Prepared by

James A. Rice, Ph.D. and the LMG Project

Management Sciences for Health

Management Sciences for Health784 Memorial DriveCambridge MA 02139

3 | USAID LEADERSHIP, MANAGEMENT, AND GOVERNANCE PROJECT

Table of ContentsPurpose of Roundtable ................................................................................................................ 4

The Call for Assistance ................................................................................................................ 4

Context for Roundtable Discussions ........................................................................................... 5

Focus on Those Who Govern ...................................................................................................... 6

Ten Key Questions for Roundtable Discussion: ........................................................................... 7

The Evolving Model for Governance for Health in LMICs .......................................................... 8

Twelve Desired Attributes or Principles of Good Governance .................................................... 10

Four Essential Practices of Good Governance............................................................................. 11

MSH Results Model...................................................................................................................13

Appendix A

Insights From Those Who Govern, Perspectives from Kenya ...............................................15

Preface .................................................................................................................................. 15

Participants in Governance Workshop .................................................................................. 16

The Value of Good Governance in Health Sector .................................................................. 18

Addressing Factors Frustrating Good Governance: ................................................................ 19

Strategies for Smart Governance Practice .............................................................................. 21

Action Plan for Follow-up ..................................................................................................... 25

Appendix B

Insights From Those Who Govern, Ethiopia: Public Health Institutions..............................28

Preface .................................................................................................................................. 28

Factors that Frustrate Good Governance for Health (G4H): ................................................. 28

Factors that Facilitate Good Governance for Health (G4H): ................................................. 31


This short paper frames our discussion for the May 18, 2012 Roundtable on Governance for Health at the Brookings Institution. We welcome your participation, and hope you will invest time to consider the questions and background information provided here before you arrive at

the Roundtable.

Purpose of RoundtableConvene thought leaders to define key principles and practices of governance for improved health systems performance and outcomes in Low and Middle Income Countries (LMIC), in order to shape the next four years work of the US-AID supported Leadership, Management and Governance Project.

The Call for AssistanceIn Kenya on April 19, 2012, leaders from public and faith based hospitals gave examples of 15 factors affected by smarter governance for health (appendix 1).

In Ethiopia on April 25, 2012, leaders from several of the World’s Public Health Associations defined in key factors perceived to frustrate good governance and factors that can facilitate good governance (appendix 2).

During the first four months of 2012, we interviewed 25 key informants and surveyed 477 health leaders from 80 countries who govern and manage. They clearly stated that effective governance is critical for achieving favorable health outcomes for individuals and especially for populations. The top 10 factors that enable good governance and the top 10 deterrents to good health governance that they survey identified are below.

Top 10 Deterrents to good governance in health

1 Ineffective leadership2 Corruption3 Ineffective management4 Inadequate transparency5 Inadequate accountability6 Inadequate systems to collect, manage, analyze and use data7 Inadequate participation of community/ citizens/ clients/ consumers/ patients8 Political context9 Inadequate checks and balances10 Inadequate financial resources for governance


Top 10 Enablers to good governance in health

1 Ethical and moral integrity2 Competent leaders governing 3 A definite policy on measurement, data gathering, analysis, and use of information 4 Sound management of health sector5 Adequate financial resources available for governing in health sector6 Openness and transparency7 Client / community participation in decision making process8 Accountability to clients / community9 Governing based on scientific evidence10 Good Governance in sectors other than health

The requests from these leaders for practical insight about practices and tools to accomplish effective and sustainable governance for health are illustrative of the hunger in the field for fresh ideas and initiatives. The requests also call for investments in governing mechanisms that foster greater engagement of women in governing bodies and processes, as well as accessible evidence about the degree to which better governance yields better system performance and better health outcomes.

Context for Roundtable DiscussionsWe take as a point of departure for our Roundtable discussions the many useful resources on governance within the health sector developed over the past 20 years from WHO, World Bank, OECD and the growing body of knowledge within USAID.1

Recent interest in governance within the development community can be traced to the late 1980s as part of a desire among aid agencies to address the uneven performance of low and middle-income countries to macro-economic re-forms (Dia, 1993). The term good governance was introduced by the World Bank (1994) as an explanation for prob-lems being experienced in many countries, namely the weakness of public sector institutions and management, and as a basis for setting further lending conditional ties. In this context, governance is defined as “the manner in which power is exercised in the management of a country’s economic and social resources of development.”2

In today’s world of changing health risks and opportunities, the capacity for those who govern in LMICs to influence health determinants, status and outcomes cannot be assured through national actions alone because of the intensifica-tion of cross-border and trans-border flows of people, goods and services, and ideas. The need for more effective collec-tive action by governments, business and civil society to better manage these risks and opportunities is leading health sector leaders and development assistance agencies to reassess the rules and institutions that govern health policy and practice at the subnational, national, regional and global levels.3

1 See: Siddiqi et al, “Framework for assessing governance of the health system in developing countries: Gateway to good governance” in Health Policy 90 (2009) 13–25; and Governance for health in the 21st century: a study conducted for the WHO Regional Office for Europe, EUR/RC61/Inf.Doc./6 August 2011; as well as Important contributions on health sector governance is available from Management Sciences for Health in http://www.msh.org/projects/lms/Results/upload/Governance-Eval-four-pager-for-Intranet-for-Pager.pdf ; and from other USAID Implementing Agencies, see Health Policy Project at http://www.healthpolicyproject.com/index.cfm?id=ourWork; and the HealthSystems 20-20 Project at: http://www.healthsystems2020.org/section/topics/governance

2 Dia, M. (1993), A Governance Approach to Civil Service Reform in Sub-Saharan Africa, World Bank Technical Paper, No. 225, Washington D.C.

3 Global Health Governance, A Conceptual Overview, Department of Health & Development, World Health organization, Discussion Paper No. 1 2002, Nick Drager. A more detailed analysis of the institutional forms and mechanisms of international and global health gov-ernance is provided in Fidler D. (2002), “Global Health Governance: Overview of the role of international law in protecting and promoting global public health,” Discussion Paper No.3. 2 A more detailed analysis of the historical dimensions of global health governance is provided in Loughlin K. and Berridge V. (2002), Historical Dimensions of Global Health Governance, Discussion Paper No.2. See also the work of


Our work within the USAID supported Leadership Management and Governance Project 4 seeks to contribute to the growing global discussion about the principles and practices of health sector governance by moving beyond the traditional debate over concepts to focus on “Governance Practices” that hold promise to enhance:

■ the effective integration among three key ingredients for high performing health systems (management, leadership and governance);

■ the effective and efficient use of the time and talents of those who govern; and

■ Wise forms of technical assistance and related resources to help develop and unleash sustainable governance structures, mechanisms, and practices within the health sectors of (LMICs).

In broad terms, governance can be defined as the actions and means adopted by a society to promote collective action and deliver collective solutions in pursuit of common goals.5 This a broad term that is encompassing of the many ways in which human beings, as individuals and groups, organize themselves to prudently steward their use of scarce resources entrusted to those who govern to achieve agreed goals. Such organization requires agreement on a range of matters including “membership” within the co-operative relationship, obligations and responsibili-ties of members or stakeholders, the making of decisions, means of communication, resource mobilization and distribution, dispute settlement, and formal or informal rules and procedures concerning all of these. Defined in this way, governance pertains to highly varied sorts of collective behavior ranging from local community groups to transnational corporations, from labor unions to the UN Security Council. Governance within the LMIC health sectors thus relates to both the public and private sphere of human activity, and sometimes a combination of the two.

Governance for health concerns the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population. The rules defining such organization, and its functioning, can be formal (e.g. Public Health Act, International Health Regulations) or informal (e.g. Hippocratic Oath) to prescribe and proscribe desired behavior. The governance mechanism, in turn, can be situated at the local/subnational (e.g. district health authority), national (e.g. Ministry of Health), regional (e.g. Pan American Health Organization), and international/global (e.g. World Health Organization). Furthermore, health governance can be public (e.g. District Health Councils or Public Hospital Boards or the National Health Service), private (e.g. the growing number of CSOs and NGOs for health protection and promotion or bodies like the International Federation of Pharmaceutical Manufacturers Association), or a combination of the two (e.g. The Global Fund’s Country Coor-dinating Mechanism (CCMs) or the Malaria for Medicines Venture).

Focus on Those Who GovernIn our target countries, we are to help strength the performance of leaders engaged in a wide array of governing bodies, including: the ministers of health and the ministries/departments of health in a country and its provinces, the ministries other than health that have a bearing on health, the national and the state legislatures, CCMs, Ministerial Advisory Boards, Public and Faith Based Hospital Boards of Trustees, district councils and municipal councils, local and city governments, district or local community health committees, Maternal Child Health Proj-ect advisory councils, HIV-AIDS Coordinating Councils etc. We are to do this with a sharp focus on building the knowledge, skills and attitudes (competencies) of the people asked to govern and lead these diverse organizations and decision making processes.

Our mandate within the USAID Cooperating Agreement is also to develop tools, resources, and learning oppor-

4 USAID Cooperating Agreement No. AID-OAA-A-11-00015 with Management Sciences for Health September 2011 September 2016.

5 WHO, Nick Drager, Global Health Governance, op cit.,


tunities for those who manage, those who lead and those who govern public and private LMIC health systems. We are to build sustainable capacities in host country health services management training organizations; new profes-sional associations for the professionalization of health service managers; public and non-governmental organi-zations engaged in service delivery for communicable diseases; and evidence for the value of how integration of leadership and governance results in stronger health systems and greater health outcomes.

In short, we are to explore practical strategies, systems and technical assistance to build the capacity and successful performance of those who govern.

Ten Key Questions for Roundtable Discussion:To help ensure a productive set of conversations among the several participants in the one day roundtable, we sug-gest a focus on these key questions:

1. How should we invest to build the competency & confidence of those who govern in LMICs?

2. What competencies do they need in LMICs?

3. What is the purpose and work of those who govern?

4. How do these competencies vary by different types of governing bodies or entities or indi-viduals who govern?

5. What methods of training and learning are likely to be most suited for those who govern in the health sectors of LMICs?

6. What hinders and what enables effective governance in the context of health?

7. What systems and infrastructure are needed to enable and facilitate the work of those who govern?

8. How do we measure effective governance in the context of health?

9. How should we build evidence base that good governance results in stronger health systems and greater health outcomes?

10. What can be done to make governance in the context of health gender sensitive, gender responsive and gender transformative?

We anticipate a free flow of conversation by all participants, and have provided time not just for provocative keynote remarks for each of the four sessions, but reactors and opportunities for all of us to join in a lively discus-sion of how to (1) remove barriers to good governance, and (2) embrace strategies and systems that facilitate good governance.

You will see in the attached program that following short self-introductions by each participant, we have divided the day into four roughly equal blocks of discussion:

– Session 1: What are dimensions of and key drivers for governance within the health sectors of LMICs, and what are key aspects of the value of good governance for health system performance;

– Session 2: What are key barriers to or factors that frustrate the practice of good governance, and how can those who govern best develop competencies and systems to overcome them?


– Session 3: What are factors that enable or facilitate good governance, and how can those who govern best ensure the development and sustainability of these factors?

– Session 4: What are key activities the LMG Project, in collaboration with others working on Governance, should consider to follow-up and follow-through to both (a) develop technical assistance and resources to develop the capacity of those who govern, and (b) build an evidence base on the value of good governance practice to health systems strengthening and health outcomes.

The Evolving Model for Governance for Health in LMICsThe following draft is the result of consultation with frontline health sector leaders from 80 countries, the work of MSH over the past 10 years, and a continuing literature review.

This remains a work in process.

The Studies of Management Sciences for Health at the end of the USAID LMS project defined ten key lessons from work within low and middle income countries:

1. Although every context is unique, tools and approaches to strengthen good governance can be successfully transferred between sectors and from one country to another.

The executive dashboard first developed for the Global Fund in Nicaragua has now been transferred to Nigeria, Tanzania, Cote d’Ivoire and Zanzibar. Through the Grants Management Solutions Project (GMS), the dashboard as an oversight tool has been mainstreamed within the Global Fund as a recommended best practice. The Leadership De-velopment Program (LDP) has been used to strengthen governance in Peru, Afghanistan, and Cote d’Ivoire in vastly different contexts.

2. Good governance can be developed at all levels and degrees of complexity.

LMS applied basic principles and tools of management and leadership strengthening to very different levels of gov-ernance. Although governance is often conceived as a senior level function, the LMS programs in this portfolio were committed, as much as was allowed in their mandate, to an inclusive model of governance in which individuals at all levels have a part to play, and civil society is an equal partner with government

3. Good governance is a front-end requirement without which programs may not exist at all.

Capacity building in governance, like other forms of capacity building, requires asking the question, “Governance for what?” The ultimate desired end result is improved access to life saving health services and improved health. However, intermediate results in terms of improved governance structures, systems and performance are just as crucial to docu-ment. Without these tangible changes, programs risk losing their funding or not being funded at all.

4. Good governance is about people as well as systems.

LMS teams have helped developing country counterparts in public and NGO sectors to develop systems that promote transparency, social participation, and accountability. However, individuals and teams have limited capacity to support implementation. Developing good governance, like developing leadership capacity, is a process that takes place over time where people are challenged and given feedback and support.


5. Calls for good governance are not sufficient in the absence of supportive systems.

Health managers, whether at national, regional or district levels or in the public or civil society sectors, need strong systems to withstand political change and leadership and management skills and tools to exercise good governance. The following skills and tools are the basic building blocks of strengthened leadership and management, and of good gover-nance: scanning and assessment; planning; data use; participatory processes; simple oversight instruments; norms; stan-dards; policies; financial management guides; team building exercises; transparent monitoring and evaluation systems; and mechanisms for citizen voice and public access to information.

6. The process for strengthening governance should mirror the desired outcome.

If the desired outcomes of leadership and management strengthening are equitable, transparent, and accountable systems in which people feel empowered and responsible for assuring good health for the populations they serve, then the process to achieve these outcomes must also be empowering, participatory and independent of external expertise.

7. Governance is different from management and leadership.

Oversight of good governance differs significantly from management and from traditional M&E. Information tools developed for Global Fund Country Coordinating Mechanism (CCM) oversight developed under LMS highlight general progress and flag specific problems, but do not go to the level of detail required for routine management. Oversight also emphasizes action even more than information.

8. Good governance interventions can be paired with health system reform.

The empowering effects of the LDP, the Management and Organizational Sustainability Tool (MOST), and other tools for multi-sectorial governance are useful for fostering good governance in decentralized health systems in which all deci-sions were previously made at the central level of government.

9. Strengthening governance structures and systems is challenging, especially in unstable environments.

The barriers to strengthened governance mentioned by project managers of the programs reviewed in this portfolio were created most often by political instability. It is important to acknowledge up front that we are also witnessing a paradigm shift in technical assistance with models such as the Global Fund putting more and more power for good governance in the hands of the countries themselves, while at the same time requiring a degree of transparency and accountability that even developed countries can find hard to consistently achieve.

10. Champions for good governance exist and should be nurtured.

Health Systems 20/20 recently carried out an online survey of health professionals from developing countries that con-cluded that good governance practices were rare or existed on a very limited scale in many of the countries surveyed.1 However, the survey also uncovered a strong, almost passionate interest on the part of mid-level managers in addressing good governance to improve health services.


Twelve Desired Attributes or Principles of Good Governance6

1. Responsiveness

2. Leadership

3. Voice

4. Accountability

5. Transparency

6. Evidence-based decisions

7. Measurement and use of information for decision making

8. Efficiency and effectiveness

9. Equity and inclusiveness

10. Participation

11. Sustainability

12. Ethical and moral integrity

6 Adapted from the UNDP and developed from studies of USAID Health Systems 20/20 work in Rwanda (Brinkerhoff et al April 2009) and “Health Governance: Concepts, Experience and Programing Options” February 2008, p 10.


Four Essential Practices of Good Governance: (under development)

Key Governance Practice: Key Principles: Actions to Support Practice:CULTIVATE ACCOUNTABILITY

Foster a facilitative decision-making environment based on transparency and accountability

AccountabilityTransparencyLegal/ethical behaviorAccessibilitySocial justiceMoral capitalOversightStakeholder Legitimacy

Establish, champion and enforce codes of conduct that uphold the key governance principles and demonstrate the legitimate authority of the governance decision-making processes.Embed accountability into the governing institutions by creating mechanisms for the sharing of information and by rewarding behaviors that reinforce the key governance principles.Make all reports on finances, activities, and plans available to the public, and share them formally with stakeholders, public monitoring bodies, and the media.Demand that other stakeholders share similarly.Establish oversight and review processes (internal and external monitoring and evaluation by committees; judicial board) to continuously assess the impact and appropriateness of decisions made.Establish a formal consultation mechanism (open forums, special status at meetings, etc.) through which constituencies may voice concerns or provide other feedback.Sustain a culture of integrity and openness that serves the public interest.

ENGAGE STAKEHOLDERS

Identify, engage and collaborate with diverse stakeholders representing the full spectrum of interested parties

ParticipationRepresentationInclusionDiversityGender equityInput legitimacyConflict resolution

Empower marginalized voices, including women, by giving them a place in formal decision-making structures.Demonstrate input legitimacy by ensuring appropriate participation of key stakeholders through fair voting and decision-making procedures.Create and maintain a safe space for the sharing of ideas.Recognize the varying incentive structures that motivate each stakeholder and build in balancing measures to make negotiation across these differences feasible.Provide an independent conflict resolution mechanism accessible by all stakeholders and interested parties.Elicit, and respond to, all forms of feedback in a timely manner.Build coalitions, where feasible and necessary, and strive for consensus on achieving the shared direction.


Key Governance Practice: Key Principles: Actions to Support Practice:SET SHARED DIRECTION

Develop a collective vision of the ‘ideal state’ and a process for designing an action plan, with measurable goals, for reaching it

Aligned goalsLeadershipManagementOutput legitimacyAdvocacy

Demonstrate output legitimacy by overseeing the process for developing and implementing a shared action plan to achieve the mission and vision of the organization, community, or country.Advocate on behalf of stakeholders’ needs and concerns, as identified through the formal mechanisms above; making sure to include these in defining the shared direction.Document and disseminate the shared vision of the ‘ideal state.’Oversee the process of setting goals to reach the ‘ideal state.’Set up accountability mechanisms for achieving goals that have been set, using defined indicators to gauge progress toward goal achievement.Advocate for the ‘ideal state’ in higher levels of governance, other sectors outside of health, and other convening venues with a role to play in its realization.

STEWARD RESOURCES

Steward resources responsibly, building capacity

Financial AccountabilityDevelopmentSocial responsibilityCapacity buildingCountry ownershipEthicsResourcefulness

Protect and invest wisely those resources entrusted in the governing body to serve stakeholders and beneficiaries.Make evidence-based decisions on the use of resources, including human, financial and technical resources.Determine, and execute, a strategy for building the health sector’s capacity to absorb resources and deliver services that are of high quality, appropriate to the needs of the population, accessible, affordable, and cost-effective in their consumption of scarce resources.Champion the acquisition and deployment of resources to accomplish the organization’s mission and plans.Advocate for using resources in a way that maximizes the health and well-being of the organization and the public.

We will need to refine these practices, then take them out to the field to further test and enhance them.

These draft practices are intended to balance within the MSH Model for health systems strengthening; our work for country ownership enhancement and the WHO building blocks for enhance system performance.

We look forward to our time together next Friday May 18 in the Brookings Institution.


MSH Results Model: Leadership and Governance is Central

Leadership & Governance


Conceptual Model: Leading, Managing and Governing for Results

Those Who Govern |Roundtable Briefing paper May 18 2012 11

Leading• Scan • Focus • Align/Mobilize • Inspire

Managing

• Plan • Organize • Implement • Monitor/Evaluate

Governing

• Cultivate Accountability • Engage Stakeholders • Set Shared Direction • Steward Resources

People and teams empowered to lead, manage and govern

Enhanced work environment &

empowered health workers

Responsive health systems prudently

raising and allocating resources

Strong Management

systems

Increased Service Access

Expanded Service Availability

Better Quality

Lower Cost

Sustainable health outcomes and impact aligned with national

health goals and MDGs 4, 5 , 6

Improved health system performance

Conceptual Model: Leading, Managing and Governing for Results


Appendix A

Insights From Those Who Govern

Perspectives from Kenya

Governance Enhancement WorkshopStrathmore School of Business

Nairobi Kenya

April 19, 2012

Good governance enables and facilitates good Leadership and Management. Together they help ensure stronger health systems and greater health outcomes.Good governance does not just hap-

pen. We need to invest in its continuous development and enhancement.-James Rice, Ph.D.

PrefaceParticipants met April 19, 2012 for an intensive one day workshop on advanced governance for health systems perfor-mance enhancement organized by the USAID supported Leadership, Management and Sustainability (LMS) Project in cooperation with Strathmore School of Business and the Leadership, Management and Governance (LMG) Project from Washington DC.

This interactive program was designed to not only to share practical information and materials with senior health services executives and board members from Kenya, but to engage these leaders to help define and shape an agenda for enhanced board work in the rapidly evolving and decentralizing Kenyan health sector.

This paper provides a summary of the insights developed from the knowledge exchange between faculty and participants. It provides a strategic framework for an expanded program of educational opportunities and materials for health services delivery organizations in both the Public Health and Faith Based Organization’s health sectors.


Participants in Governance Workshop

Nane Sex Title Organization Email Telephone

1 Dr. Sylvester Kimaiyo M Chief of Pary AMPATH Plus [email protected] 0722-284916

2 Joe Mamlin M Field Director AMPATH Plus [email protected] 0722-374558

3 Patrcik Monyenye M HMC Chairman Kisii Level 5 Hosp. [email protected] 0724-005677

4 Bob Patrick Madanji M HMC Chairman Nyanza PGH [email protected] 0722-235620

5 Dr. Geoffrey Otomu M Med Supt Kisii Level 5 Hosp [email protected] 0722-274385

6 Moses Buyuka Obonyo M HMC Chairman Coast PGH [email protected] 0722-412451

7 Abrahim M. Siika M APM AMPATH Plus [email protected] 0721-280785

8 Dr. Tomohiko Sugishita M Chief Advisor JICA Kenya [email protected]

0729-696373

9 Mr. Eiichi Shimizu M Regional Project Formulation Advisor

JICA Kenya [email protected] 0718-769424

10 Dr. Jackson Songa M Head HSSF Secretariat

MoPHS [email protected] 0722-761885

11 Prof. Fabian Esamai M Principal CHS, Moi University

Moi University [email protected] 0724-400189

12 Salmon Owii M O. R Officer JICA CHS [email protected] 0722-833706

13 Dr. John Kibosia M Director, MTRH MTRH [email protected] 0725-200566

14 Makiko Kinoshita F Chief Advisor JICA/MoPHS [email protected] 0715-632754

15 Peter Waithaka M HRH Specialist USAID [email protected] 0714-606705

16 Jim Rice M Project Director MSH/LMG [email protected] 1-612-7034687

17 Dr. Tina Monique James F Technical Advisor CRS [email protected] 0735-628253

18 Dr. George Njenga M DVC Research Strathmore [email protected] 0717-363448

19 Judy Tuwei F Technical assistant Strathmore Governance Centre

[email protected] 0717-586483

20 Dr. A. Omar M Deputy Director MSH/LMS [email protected] 0722-607485

21 David Sperling M Research Professor Strathmore Unv. [email protected] 0733-758083

22 Karen Caldwell F Project Director MSH/LMS [email protected] 0737-470705

23 John Beku M Technical advisor MSH/LMS [email protected] 0733-456001


Nane Sex Title Organization Email Telephone

24 Mr. Nasoro Rashid M HMC Chair Kakamega PGH [email protected] 0722-863037

25 Dr. Javan Kouko M Ag. Med Supt Nyanza PGH [email protected] 0733-745952

26 Dr. Musa Mohammed M Med Supt Garissa PGH [email protected] 0722-650364

27 Zahara Ali F Board Chair Garissa PGH [email protected] 0722-461077

28 Besnson Macharia M Program advisor MSH/LMS [email protected] 0722-740077

29 John Cheruiyot M MSH/LMS [email protected] 0722-721917

30 Cavin otieno M Manager Health Care Program

SBS [email protected] 0738-288150

31 Luka Lukongo M CRT Manager SBS [email protected] 0721-396053

32 Josephine Mbiyu F Program Advisor MSH/LMS [email protected] 0722-113776

33 Magdalene Kamau F Health Service Coordinator

Archdiocese of Nairobi

[email protected]

0715-530333

34 Jeane Mathenge F Facilitator LeHHO SBS [email protected] 0731-507717

35 Wilkister Morara F Corporation Secretary

KNH [email protected] 0733-888811

36 Jacinta Mutegi F HSSO KEC [email protected]

0731-758249


The Value of Good Governance in Health SectorParticipants in the Governance Workshop were invited to share the most important reasons to have good governance within the Kenyan Health System. Their ideas and insights are share here in random order.

Please use their ideas as a catalyst for your local conversations about how these dimensions of good governance can add value to your situation, and help enable your leaders, managers, and clinical staff accomplish important gains in health system performance improvement and ultimately significant and sustainable gains in health outcomes among the people and communities you exist to serve.

Dimension of the Value of Good Governance:1. Those who govern have a fresh perspective on the value of good leadership, and the need to recognize that good

leadership is not intuitive for some clinicians. It needs to be intentionally developed

2. Board members and leaders are sometime “appointed” as if we had all the skills we need, but we often do not. They need to be developed

3. The devolution/decentralization of health services accountability and planning in Kenya places a high premium to have experienced board members, with the right set of knowledge and skills to do our board work. Without these skills we will have disorder and confusion from the top

4. Governance provides support for good leadership to perform better for our organizations (take sensible risks but to work harder for our patient’s needs)

5. Can help enhance coordination of faith based health care bodies with government

6. Guide improved stewardship of resources entrusted to us

7. Act as champion for us to gain more sustainable revenue sources

8. More likely to have efficient and fair/equitable utilization and mobilization (to both gather and manage) resources for health and health care that leads to the achievement of our care mandate and meeting the consumer’s expectations

9. Serve a sounding board and resources for managers to better serve our many stakeholders

10. Provide objective insights into the needs of our communities/publics, and to the degree that we are actually making progress to achieve our plans

11. More likely to receive objective accountability for service delivery

12. Strengthen our ability to earn trust among our public and stakeholders

13. Can help be our ambassador to the politicians and public that we are important resource for the overall well-being of the local economy and health status

14. Bring ideas from other parts of business or economy to shape smart use of scarce resources

15. Contributes to more predictable plans and activities for health delivery

16. Minimize conflicts among our many players to put patient first


17. Push for transparency in how we govern can inspire confidence and trust within our staff and thereby help improve their performance commitments and retention

18. Improve coordination between our organization and the many stakeholders

19. Others?

Addressing Factors Frustrating Good Governance:

Participants were polled to rank nine common obstacles to good governance:

1. Lack of good leaders to help boards

2. Board members lack experience

3. Not enough board education

4. Corruption and conflicts of interest

5. Role and responsibilities not clear

6. Lack good information for board work

7. Not enough time for good board work

8. Board not paid enough

9. Board work not reported enough to public

The top four factors expected to frustrate good health sector governance were defined to be:

1. Corruption and Conflicts of Interest among Board Members and the organization

2. Lack of good leaders to help boards

3. Roles and responsibilities not clear

4. Board members lack experience

Strategies identified to help remove, reduce or work around these frustration factors were defined in small groups of participants who suggested the following practical considerations:

Challenge 1: Corruption and Conflicts of Interest among Board Members and the organi-zation

1. While we know we have an obligation in our regulatory mandate to avoid conflicts and corruption, we have little orientation about what they are and how to avoid or manage them, especially in these areas of recruitment, tendering, and disclosure of possible business dealings

2. Policies should be clear we cannot participate in service delivery, recruitment of staff nor procurement of supplies or services with hospital

3. Members need to read policies and commit every quarter to acknowledge they are in compliance


4. Within short time after appointment, all required to go through formal orientation program on conflicts and how to avoid them

5. Obligated to affirm that we meet basic understanding of conflicts and that member and family are not in conflict

6. Celebrate those that are doing well to avoid conflicts. Or to disclose them before we discuss or take any actions

7. Be ready to apply penalties if there is abuse of the policy

8. Invest in continuous board member education programming both by in-house staff and with outside facilitators and resource people

9. Conduct technical audit by dedicated internal risk manager in larger organizations, or periodic review by outsider in smaller organizations

10, Others?

Challenge 2: Lack of good leaders to help boards1. Good leadership means, good CEO and good Board Chairperson. The role of Chairman and CEO are central to

good interactions and support for good board development and good governance practice. Each need specially orientation and training about how to develop good board work and best practices

2. CEO must see value of good board, not be threatened but actively work to help develop their board members

3. CEO must have integrity and strength to stand up to board as a respected peer and colleague

4. Board chairperson should deal fast and well with any board member behavior issues

5. Empower board to perform wisely and well while avoiding bringing their personal agendas in to board work

6. Involve outside experts and community leaders into advisory boards and committees to keep us stay focused and objective in our work and development

7. Participate in better board education and development about good board practices and policy frameworks

8. Remove political influence and interference by outsiders or politicians in our board work

9. Others?

Challenge 3: Roles and responsibilities not clear1. Review and understand our responsibilities with in our mandate from government (but several indicated that

these roles are not assertive or meaningful enough in terms of playing role in hire-fire of CEO or at least input into CEO performance plans and reviews. Our work can be second guessed and overruled by government

2. Each of should sign policy form that we understand the policies for our duties and we are following them

3. Need updated “Board Member Job Description” that shows ideal competencies good needed for good performance

4. Define the key decision-making processes we are to work in , and help us master the skills needed to do that work


5. Provide better and ongoing orientation programs and ongoing board educational opportunities

6. Others?

Challenge 4: Board members lack experience1. Make sure recruitment and appointment process is driven by ideal competencies of good board member

2. Allow for more autonomy of boards so we can attract and retain the best and brightest members

3. Define criteria we need in boards and board members

4. Make sure we balance big shots with average community leaders

5. Apply disciplined process for selection via interviews

6. Call for a new generation of boards that are more professionalized in their policies and board work.

7. Celebrate good members so we can attract more of them

8. Use annual board self assessments to sharpen our focus on good practices

9. Make sure there is effective use of our time and talents, by conducting good board education, mentorship and exchange with other boards with similar challenges

10. Others?

Strategies for Smart Governance PracticeParticipants in the governance workshop worked in small groups to identify practical actions that have the potential to strengthen our board work going forward. These proposed ideas and initiatives should be refined through meetings with board members and health sector leaders.

The areas in which good practices are important are suggested to be:

1. Smarter Meetings

2. Creating a Culture of Integrity and Ethical Governance

3. Champions for Quality

4. Champions for Financial Stewardship

5. Relations with Management

6. Human Resources Development

7. Creating Culture of Celebration

Smarter Meetings1. Each board member needs to appreciate the value of good meetings and help contribute to the quality of

discussion at these meetings to make effective and efficient decision making

2. Pre-meeting preparation is essential. Members need understand the expectation to come prepared on all agenda items


3. The board should develop and publish an 18 month calendar of future meets so that members and staff can anticipate the topics to be addressed and then facilitate attendance and scheduling of speakers or special presentations

4. Meeting agendas must be clear with a balance of presentations by staff, board members and possible speakers. Approximate time allocated for key topics, and occasionally flip order to allow for full discussion of strategic challenges and opportunities facing the organization

5. Meetings need good moderation by board chairperson and CEO cooperation to run agenda smoothly and efficiently. Invite all to participate and avoid one loud voice dominating

6. Presentations should be easy to follow and balance words with charts or graphs so all can see at a glance what the numbers are saying in terms of trends and conclusions

7. Others?

Creating a Culture of Integrity and Ethical Governance 1. Our roles need to be clear and our position descriptions very serious about performing our work in ethical

manner with high integrity

2. Establish and nurture a sense ‘that we are owners of this organization not for our benefit, but for the benefit of others. We have a role to be good stewards of assets and lives entrusted to us

3. We need values statement that expects us to work with these attributes:

– Recognize we work for better patient care, be patient or client centered in all we do

– Preach and walk the talk of Transparency & Truthfulness

– Open and honest in all communications

– Punctuality shows respect for others’ time and value

– Good moral training and underpinning of all our work

– Accountable for our behaviors,

– Coming well prepared to meetings and respecting rights of others

– Abhor and avoid conflicts of interest

– Condemn corruption which steals resources and rights of others for selfish interest or gain.

4. Earn trust and followers

5. Build more transparent feedback and reporting of our work to many stakeholders: government, clinicians, patients and public even the media

6. Develop formal policies of behavior in our job descriptions and post on “walls and websites”

7. Wrap our work in policy of patient quality and safety and service

8. Have frequent conversations in meeting and training programs about what is the spirit as well as the letter of


our regulatory roles and duties

9. Encourage and earn philanthropy

10. Base our work on health of patients and health of entire populations

11. Show how our decisions are good value for money returns of money entrusted to our use

12. Encourage Board Members and HMT to work for the love of their work more than money

13. Don’t be afraid to see how spirituality enters into our board work of service for others

14. Start at recruiting/selecting the right people that experienced, ethical and of good moral character

Champions for Quality1. Board members may not be expert in medical, quality or safety issues so plan on education about key factors that

drive patient quality and safety, and practical ways to ensure these factors can be well managed by physicians and staff

2. Board should ask for and expect staff to have formal policies, guidelines, and standard operating procedures (SOPs) to protect and improve quality in all three dimensions:

– Clinical outcomes

– Patient safety

– Patient satisfaction

1. Fair, transparent and fast review of performance of staff and physicians to meet quality guidelines must be linked to good enforcement of system flaws or behavior errors and celebration of positive accomplishments

2. Boards need to ensure staff provides continuous and accurate measurement of quality improvement processes and outcomes

3. There must be active feedback to the board on progress to achieve the quality goals

4. Ensure there are Investments in budget for staff training on quality

5. Periodically meet with staff to assess the quality attitudes and skills on the front lines and on the ground, practice governance by walking around and expect that management will be doing the same

6. Establish a culture oriented to quality that embraces teams. The patient comes first. Quality is first priority to serve the patient.

7. Report performance trends to stakeholders

8. Others?

Champions for Financial Stewardship1. Boards need high level measurements of the financial health of the enterprise. Each year there should be key

metrics for cash management, costs per units of services delivered, and progress in collections of revenues.

2. Schedule board education on organizational fiscal basics


3. Hire smart staff that is experienced and ethical

4. Establish and enforce financial management policies that expect ethical and cost effective decision making about the financial resources

5. Ask for monthly reports on financial picture, even if we meet quarterly

6. Report to stakeholders the trends in financial performance

7. Others?

Relations with Management1. The Board Chairperson and CEO need to have mutual respect and good communications

2. Even though most boards have little formal role to hire and fire CEO, the culture should be one of discussions before the fiscal year begins to define Board expectations of key performance measures for the CEO, and to provide input to the CEOs annual performance review

3. Common mutual courtesies of Board and CEO offering fair but firm reviews of each other’s respective performance, and expressions of thanks for work performed well

4. Should have periodic meetings with CEO between board meetings by Board Chairperson and committee chairs if we have them

5. Relationships should operate in spirit of no surprises

6. Trust building is essential. Hard to earn, easy to lose, difficult to rebuild once lost

7. Be clear on objectives, work plans to achieve objectives and agreed upon steps for follow-up and follow-through on commitments

8. Do joint training and travel to build and nurture rapport

9. Others?

Human Resources Development1. Ask what the organization’s policies and procedures are to recruit, retain and develop all staff

2. Ask about how staff morale studied, and expect annual reports on employee and physician opinions on quality, working conditions and performance planning and review

3. Expect policies and budgets for continuous professional education, development and capacity building

4. Ask how high performers are being recognized and rewarded

5. Transparently publish performance and morale results by service or department

6. Have board member education on modern human resources management and talent development

7. Expect good financial management so there is money available for fair compensation

8. Others?


Creating Culture of Celebration:1. Link high expectations of performance with training and support on how to achieve the goals.

2. When driving for high performance, look for and publish pictures, stories and reports on high performing staff and departments

3. Have quarterly recognition and reward events, even if we do not have much money so that frontline people know the board cares about the patients and the staff

4. Post on walls progress to quantitative and qualitative measures of great results

5. Celebrate results in different categories, for all areas of the organization, for example:

– Quality and safety

– Staff retention and longevity of service

– Superior service excellence by all departments from housekeeping to food to surgery and radiology

6. Show progress over time compared to ourselves, and to industry standards of similar organizations

7. Encourage a culture of constant feedback from clients/patients by relying on such initiatives as: suggestion boxes, exit surveys at discharge

8. Culture of measurement

9. Culture of continuous improvement, from bedside to boardroom

10. Others?

Action Plan for Follow-upAt the end of the workshop, all participants were invited to share their short list of actions that have the potential to strengthen governance in Kenyan health service organizations. To ensure good follow-through and follow-up on the exchange of practical ideas for smart governance, the participants’ recommendations are grouped into actions for the next 9 days, the next 9 weeks, and the next 9 months.

Please discuss their ideas and add your own for your organization’s unique situation

Actions for the Next 9 Days should be: ■ Call for board meeting to share and discuss the ideas that surfaced in this workshop

■ Send email distribution of the slides and notes from this meeting to others in our organization

■ Commit to manage meeting agendas and time more efficiently and wisely

■ Read and publish our board roles and responsibilities as a “job description”

■ Ask for group to review the government’s definition of board role to add more authority and how to avoid being second guessed by government

■ Arrange for board to meet with staff to define and discuss our vision and strategic plans

■ Ask ministry to develop good board education and orientation programs for types of health facilities


■ Learn more about good governance and how to establish cultures of high performing boards

■ Study how our organization can do more on celebration culture

■ Publish a n updated calendar of meetings and commit to have smarter board meeting agendas

■ Talk about how we can develop better communications between CEO and HMT

■ Read more about hospital quality

■ Others?

Actions for the Next 9 Weeks should be: ■ Try to have the SP draft finalized and approved at HMC level

■ Feedback with board on how we will do governance enhancement planning

■ Continue to share results of this meeting with other board members

■ Try the 20 minute standup meetings

■ Do board member competency map

■ develop a board self-assessment process

■ Experiment with new agenda styles

■ See how to develop board dashboards or report cards on organizational performance

■ Rely more on smart committee work

■ Ask for employee and patient satisfaction surveys to be routinely conducted and reported to board

■ Institute continuous monitoring and celebration of performance at all levels of organization

■ Maintain a culture of sustained improvement

■ Be sure we have budget for staff and board continuing education

■ Work with Ministries for Board development toolkits and educational modules

■ Encourage more conversations on results oriented programming with physicians, staff and even patients

■ Bring board and senior leaders together for ways day to explore plans and performance activities

■ Develop plan for stakeholder and community engagement and outreach

■ Others?

Actions for the Next 9 Months should be: ■ Establish a program for ongoing capacity building for our board members

■ Establish stronger system (paper and web based dashboards) for board monitoring of hospital performance

■ Establish ongoing staff celebration programming


■ Develop new policy and procedure manual for our board work that includes education, assessment and clear accountabilities

■ Establish board mentoring program

■ Establish new CEO performance planning and review process

■ Build patient care stories into some of our board meetings

■ Do one joint board education program a year with board members from another hospital

■ Expand our process to invite in community ideas and engagement in our planning and evaluation of performance

■ Others?

Thank you for all you do to enhance the governance of our hospitals in Kenya.


Appendix B

Insights From Those Who Govern

Factors that Facilitate and Frustrate Good Governance for HealthThe 13th World Congress of International Federation of Public Health Associations

Addis, Ababa, Ethiopia

April 25, 2012

Good governance enables and facilitates good Leadership and Management. Together they help ensure stronger health systems and greater health outcomes.Good governance does not just hap-

pen. We need to invest in its continuous development and enhancement.-James Rice, Ph.D.

PrefaceParticipants in the recent session on Trends in Governance for Health were invited to share their insights regarding factors expected to frustrate or facilitate good governance practices in health sectors of developing economies. Their comments are listed here in random order for you review and refinement.

As many nations explore decentralization of their public health systems as a means to improve the systems responsive-ness and performance, new forms of governing bodies are being formed. Thousands of community, civic, and clinical leaders are being asked to serve in these bodies. Unfortunately, too many of these people have little orientation nor support for their important governance decision making roles. To strengthen the effectiveness of these governing bod-ies, and to enhance the sense of pride among these servant leaders, we hope you will use the following comments from leaders working in over 20 countries as a catalyst for “Governance Enhancement Planning” in your unique organiza-tional and community context.

Factors that Frustrate Good Governance for Health (G4H):1. Too many participants in governance roles are not appointed for their competencies, but for political reasons, or are forced into body to appease a political rival. These players can work against the interest of the governing process and majority

2. Often those appointed to serve for political reasons bring selfish personal agendas that can conflict with the mission of the organization they are to be governing. Selfish leaders are ineffec-tive leaders.

3. Lack of clear governance model with modern definition of our roles, responsibilities, issues and ways to make good decisions

4. Lack of commitment to do good governance, and lack appreciation/celebration by managers, the public, the media or politicians when we do good work

5. Poor remuneration for the time required to do board work, and wasted time at inefficient meetings that do not focus on important issues


6. Context that does not attack corruption encourages it to persist, creates conflicts of interests that weaken our ability to serve our people in quality way

7. Many leaders do not know how to develop or guide their board to use best practices

8. Board members need more knowledge and experience about public health delivery, challenges and also how to be a good board member. We have had very little orientation nor education for us to grow our competencies

9. Board members do not understand what “accountability” means, and so rarely cause the govern-ing body to “render and accounting’ of how the decisions made by the board result in positive outcomes, there is poor reporting on the work of the board

10. Beneficiaries of the service organization or health enterprise are not allowed to participate in the governance decision making, or even to be aware of how the governance process is to work for them. The governing body therefore misses their wisdom to shape smarter goals and to help imple-ment the policies and plans from the board’s work

11. Board members do not do a good job of strategic thinking nor planning. Too often we drift into the future without building a clear road map to help us deal with both challenges and oppor-tunities critical to the vitality and performance of the organization or health district

12. Boards and leaders do not do periodic evaluations of the board’s work, so it is difficult for them to continuously improve their processes and results

13. Boards do not know how to relate to nor help do performance planning and review for the Managing Director/CEO, so both under perform

14. Health sector does not have enough political power in government, so we do not attract enough influential leaders into our boards

14. Lack of infrastructure (systems, staff, information, job descriptions) for governing bodies, espe-cially at district or local level to support smart and efficient governance decision making

15. Nepotism among politicians of even friends of management or other board members can frus-trate fair and objective decision making

16. Hard to keep talented board members because of our weak and bureaucratic decision making and poorly run meetings. It burns them out.

17. We are not transparent in our decision making: it is hard to know who is making what deci-sions, what is the timetable for decisions, what criteria is to be used, what is accuracy of informa-tion used for decision making, what are the results and what progress to the plans or programs or investments that came out of the governing processes

18. Poor participation of the community in governing activities, either not invited in, or when invited in, not given enough help to participate in substantive and effective ways. As a result, our reforms are not implemented well enough, or waste a lot of time and money, and do not accom-plish the desired goals

19. Weak monitoring and evaluation of governing bodies and their decision making process effi-ciency or effectiveness. Need more community engagement and smarter media oversight


20. Limited resources can force a survival mentality that does not encourage pursuit of creative governing

21. Unstable or hostile environment that distracts us from pursuit of good governance practices

22. Political gain emphasized more than our role to serve the public’s interest, to be good stewards of the resources entrusted to us

23. Other factors that frustrate good governance?


Factors that Facilitate Good Governance for Health (G4H):1. More international recognition that good governance is key to our accomplishment of the MDGs and local service plans

2. Those who lead and those who govern need to harmonize their work and decision making: One Plan, One Budget, One Report to the People we serve

3. People asked to serve in the governing body, have a clear understanding of the mission and strategic plan for the organization or health district

4. Board members have clear position description that defines expectations of our role, au-thorities, responsibilities and behavior expectations

5. Beneficiaries and our communities have sincere invitations to engage in our decision mak-ing processes, and are supported by staff to participate in meaningful and effective way

6. The governing process involves politically wise players so that decisions of board are lis-tened to and acted on fairly and promptly

7. Board leaders are skilled at stakeholder relationship building (listening, engaging, god two-way and communications)

8. Good leaders who value the work of board and help us make smart decisions about topics of importance to the mission and the people we exist to serve

9. Board members spend time preparing for each meeting, and to continuously develop their capacity to govern wisely and well

10. Boards rely more on well prepared committees, councils or task forces to add experience and expertise we need for governing

11. More political will to make difficult decisions

12. Plan and use the time and talents of governing participants better in our meetings

13. Assure much of the work of the board is in the open, there is transparency about how we do our work and make decisions

14. We do an annual self-assessment of how we are performing against good governance process and practices

15. We invest in ongoing board education and development

16. Other factors that could facilitate good governance?

These should be viewed only as a starting point for conversations in your situation about how you define good governance, the factors in your reality that get in the way of smarter governing work, and the factors that you should embrace to move your governing bodies to ever higher levels of performance, effectiveness and efficiency.

Thank you for your interest in good governance for health

The USAID Leadership, Management, and Governance project is a five-year cooperative agreement with a funding ceiling of $200 million and is able to accept funding from all accounts. Missions and bureaus may access these state-of-the-art services and receive technical oversight and leadership from LMG through field support or sub-obligations on an annual or multi-year basis.

The LMG Consortium is also engaging with private sector partners to increase the impact of our activities and interventions, in particular to strengthen the capacity of our local partners to serve as stewards of the health systems and institutions they lead.

For further information, and to explore options for requests to address criti-cal health leadership, management and governance challenges and needs in your country, please contact:

AOTR, Brenda Doe, GH/PRH/SDI202-712-1955, [email protected]

MSH Project Director Jim Rice612-703-4687, [email protected]

Documents

From Principles to Practices · Sound Management. Transpar ent Governance. From Principles to Practices Roundtable on Governance for Health in Low and Middle Income Countries April-May,