Roundtable Summary 05 December 2013 handout...ImprovingGovernanceforHealthinLMICs !!! USAIDLeadership,!Management!&!Governance!Project,December!2013! 7" 1. Smart governance yields

Observations on Improving Governance for Health

in Low- and Middle-Income

Countries

A summary of the Roundtable Conference on Governance for Health in Low-‐ and Middle-‐Income Countries convened by the USAID Leadership, Management & Governance Project on August 15–16, 2013, in Washington, D.C.

Funding was provided by the United States Agency for International Development (USAID) under Cooperative Agreement AID-‐OAA-‐A-‐11-‐00015. The contents are the responsibility of the Leadership, Management & Governance Project and do not necessarily reflect the views of USAID or the United States Government.

Improving Governance for Health in LMICs USAID Leadership, Management & Governance Project, December 2013

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PREFACE Smart governance is now seen as an essential piece in strengthening health systems, and enhancing country ownership of health sector reforms supported by international donors. To explore trends and strategies for improved governance practice in the health sectors of low-‐ and middle-‐income countries (LMICs), a two-‐day roundtable was convened at Georgetown University’s McDonough School of Business in Washington, D.C. in August 2013. Over 30 international governance leaders were invited to participate by Management Sciences for Health (www.msh.org) with the USAID-‐supported Leadership, Management & Governance (LMG) Project (www.lmgforhealth.org). For a list of participants, please refer to Appendix 1. This paper summarizes a series of key observations from this second annual Roundtable Conference on Governance for Health that were distilled from a transcript of the event. The paper should be used as a resource for planning the establishment of smarter governance by health sector policymakers, managers, and funders of health system reforms in LMIC. A conversational style with a series of short, brash, numbered observations is intentionally used in this paper to provoke thought and discussion. Please refer to these observations as a framework to guide work in your organizations to foster bolder investments for enhanced health system governance. Short and mid-‐term actions to ensure follow-‐up by the event’s participants and the LMG Project team are shown in Appendix 2. We are interested in your recommendations; questions or comments may be directed to James A. Rice, project director, LMG Project ([email protected]).


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Contents Preface ......................................................................................................................................................... 3

Introduction ................................................................................................................................................. 6

1. Smart governance yields smart health system performance. ................................................................. 7

2. Women’s and Youth Leadership are Vital to Good Health System Governance ..................................... 9

3. Use of New Technologies for Enhanced Governance Decision-‐making ................................................. 12

4. Governing Decentralized Ministries of Health ....................................................................................... 14

5. Identifying and Reducing Corruption Related to Health Sector Governance ........................................ 17

6. Governance of Pharmaceuticals ............................................................................................................ 19

7. Measuring the Effectiveness of Governance Practices .......................................................................... 20

Conclusions ................................................................................................................................................ 22

About the LMG Project .............................................................................................................................. 23

Appendix 1: Participants in the 2013 Governance Roundtable ................................................................. 24

Appendix 2: Follow up actions ................................................................................................................... 27


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Introduction This summary is not written in the usual style of a USAID technical brief. It seeks to encourage crucial conversations about new ways to build the capacity of individuals and institutions engaged in better governance for health systems strengthening. The paper is organized around seven key conclusions from the Roundtable:

1. Governance enhancement yields health system performance enhancement, but only if intentionally designed and developed;

2. Women’s leadership is vital to good health system governance; 3. New technologies can enhance smart governance decision-‐making; 4. Governance practice must flourish in decentralized health systems; 5. Corruption must be attacked by those who govern the systems and institutions in LMIC health

sectors; 6. Governance for essential medicines is an important opportunity for health systems

strengthening; and 7. Investments are needed to support evidence-‐based governance.

Within each of the paper’s sections related to these conclusions, a series of short observations distilled from the many discussions between participants in the Governance Roundtable are provided. Some of the numbered observations are direct quotes from participants and others provide a summary of the essential conclusions of the group discussions.


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1. Smart governance yields smart health system performance.

From the insights exchanged in the Governance Roundtable, participants had these observations related to the positive role good governance plays for stronger health system performance:

1. Governance is about setting the rules of the game (played by policy makers, regulators,

managers, clinicians, and health workers) for health system strengthening. Governance is about creating a shared understanding of fairness in access to high quality health services, as well as the careful stewardship of scarce resources.

2. The participation of beneficiaries in governance is vital to improving it. Leaders who govern should therefore seek continuous feedback from beneficiaries regarding what they should be doing for better governance. Sustainability, improvement of quality, and participation of disadvantaged populations in the governance process are desirable goals and can be achieved through more planned and disciplined governance practices.

3. Participants concluded that governance is now seen as integral to accomplishing health systems strengthening and health enhancement objectives. They asserted that smart governance yields smart health system performance. Governance practices and related research, however, are complicated by the unusual adaptive-‐system-‐nature of the health sector and of its governance. Governance unfortunately has an underdeveloped theory of change about its impact on health systems results. Its impact is underrated and underfunded by health sector policy makers. New public and private investment is needed for smart governance to flourish.

4. Failures of governance and the rule of law are fundamental to the root causes of underperformance in the public sector.

5. To improve governance in the context of health, health sector leaders need to look at governance in sectors of education, business, and public administration. Good governance means engaging with other sectors that influence health, e.g. the social determinants of health. Smart governance means working with the government, civil society, and the private sector to build sustainable health systems.

6. Better governance in the Global Fund’s Country Coordinating Mechanisms (CCMs) helped unblock over $4 billion in funds that were frozen because of governance problems in CCMs. Roundtable participants were asked to imagine how many antiretroviral therapies and how many TB treatments would not have been possible if that $4 billion had remained stuck. Many people’s lives were saved by improved governance.

7. There is a constellation of groups interested in good governance. The relative power that each of those interest groups has in influencing the decision-‐making process is a function of what resources they bring to the table. We also must consider the ability, once a decision is made, of those interest groups to influence the implementation of whatever policy is adopted. The most under-‐represented interest groups are women and youth. Section 2 frames challenges faced by women and youth in participating in governance.


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8. Section 3 concludes that a lack of information hinders better governance. Information is critical

to better governance decision-‐making. Governance leaders should invest more in information technology for better decision-‐making at all health sector levels, from villages to parliaments. Information is also needed to conduct better on-‐boarding orientation for members of the governing bodies in the public and private health sectors and health institutions. Smart governance processes should be written and codified into the policies of ministries of health.

9. In Section 4, we observe that a smarter approach to governance within decentralized health systems will help achieve more significant and sustainable health gains. Good governance can also lead to accelerated implementation of health programs and improved service delivery in these decentralized systems.

10. In Section 5, participants highlighted the importance for those who govern to address health sector corruption. There is a disparity between what health leaders say and what they actually do. Participants called for ministry leaders and health workers to have governance, ethics, and leadership training built into their primary professional education. Poor governance is not only a challenge in low-‐ and middle-‐income countries; it can be found in all countries. However, poverty exacerbates the problem. Participants believed that corruption is a consequence of poor governance. Corruption is one of the biggest challenges for governance of health systems in Africa. It saps the strength and morale of organizations and their capacity to thrive. It drains resources from health systems and affects health service delivery. Corruption costs lives. To maximize the benefits from financial resources and ensure that the system is as effective and efficient as possible, good governance is needed to inoculate the health system from the scourge of corruption.

11. Good governance also enables and creates the conditions in which health leaders and managers can effectively play their roles in health system strengthening. This has been evident not only in the response to the HIV/AIDS epidemic, but in family planning and maternal child health programming. Section 6 summarizes the value of good governance for essential medicines for these health challenges.

12. Cultivating accountability, engaging stakeholders, setting a shared strategic direction, stewarding resources, and then continuously assessing and enhancing the infrastructure for wise governance are five effective governing practices. Section 7 frames the challenges of measuring the effectiveness of governance.


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2. Women’s and Youth Leadership are Vital to Good Health System Governance

Women and youth need to be supported to engage in health sector governance. During the Governance Roundtable, participants offered several observations related to the positive roles that women and youth can assume in health sector governance.

1. Governance is about decision-‐making, accountability, and giving voice to vulnerable and

marginalized populations. When you look at health systems, the majority of health workers are women. A majority of the system’s clients and users are women and children. A family’s contact with the health system is usually initiated by a woman. Her thoughts, her voice should be extremely important in the governance of the system. Also, if you look at the health system’s external customers, the patients tend to be women and children. Gender-‐sensitive governance is therefore critical.

2. Participants called for more research on gender dimensions in all studies and activities for health systems strengthening. Leaders must collect data; document the role of women in the workplace; explore the visible difference that they are making; and frequently celebrate their successes.

3. Gender with a focus on women is just one example of diversity. Diversity also includes

religious, cultural, regional, and lifestyle diversity. Participants therefore observed that diversity in governance is essential to avoid groupthink, and to achieve more innovative strategies that are responsive to vulnerable populations. More diversity in governance decision-‐making results in better health care delivery and better health care outcomes.

4. Unfortunately, women face many barriers to engagement in governance. Women tend not to

get opportunities to build their CVs to be eligible to move forward into governing positions. Health sector leaders should identify women who will make good board members, then mentor them so that they can enter and be effective in their governance positions. We should enhance women’s capacity to be effective in governance via continuing education.

5. There are now many more governing body positions than management positions. We should encourage women to enter governance positions if we want more women engaged in shaping, guiding, and leading health systems.

6. Leadership training for women is also essential to enable and empower their competencies,

identify their own style, and find comfort and confidence in using that style as they move into positions of leadership. We should link women in governance with other women at senior levels via mentoring and coaching relationships.

7. Good governance must focus on removing discrimination and barriers that women face at work

and also outside of work. Smart governance arrangements must support a better “work-‐life balance” for men and women. Women are struggling to find and then excel in their leadership


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jobs, while still living their roles of wives, mothers, sisters, and daughters. 8. Participants ask for more men and women to serve as champions supporting more women in

leadership and governance positions. In these roles, women can create more opportunities, develop systems, and encourage more women to enter and, more importantly, enable them to stay. LMIC health sectors must establish networks of champions so that women have an amplified voice. This voice needs to engage a mix of male and female champions for larger, faster, and more sustained impact.

9. More rapid advancement is judged likely when health systems set quotas for women to serve on

the governing boards, and then monitor to make sure it happens. Governing bodies should put in place an accreditation system that requires them to comply with gender-‐responsive governance standards. International Planned Parenthood Federation (IPPF) is an excellent example of this leadership. Apart from an accreditation system where IPPF reviews national member associations every five years, IPPF also requires an annual report in which each member association has to report how they are doing in terms of respecting the 50 percent women quota. And it’s not just women; IPPF also requires the national Member Association boards to have youth—20 percent of IPPF member association boards must be youth.

10. Initiatives by the international development community need to give youth a larger voice in health systems governance. In many developing countries, youth make up to 50 per cent, and in some places two-‐thirds, of the population. These youth are restless. They are hungry for systems that work to their advantage. They are impatient and likely to cause revolutions with Twitter feeds. They can dispute and disrupt what has gone before, and are incredibly underrepresented in governance. As highlighted in Section 3, new technology can provide opportunities to engage these youth at higher levels of frequency and quality.

11. There is evolving experience that we can improve the gender dimension of governance by using

hotlines and suggestion boxes. There are many strategies, technologies, and tools to help women who may not yet be placed within a governing body to still be able to make an impact. We must encourage women to participate in governance beyond leadership, in such arenas as: serving on task forces, committees and councils, as well as collecting information, disseminating information, taking part in the accountability mechanisms. This participation can help hold government and institutions accountable for expanded roles for women in governance.

12. Developing women for leadership and governance roles must being very early. Success is about how children, boys and girls, are brought up. Leaders must take a long-‐term view on cultivating opportunities for women and youth. Kids in school need mentoring, and have role models who make them aware of possibilities beyond their immediate barriers. We need to engage, enable, and empower women and girls, but also boys and men to support them to participate and share the burden of women’s tasks.

13. Health sector organizations and their leaders must have “gender-‐transformative policies.” It’s

particularly important during the early phases of expanded women’s participation that that there can be understanding that some failures and learning will be anticipated in the journey to gender equity.


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14. We can build gender equity into the standard operating procedures and job descriptions of public and private health sector organizations. Leaders must also ensure that women’s work environment is nonthreatening from the physical, social, and psychological perspectives.


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3. Use of New Technologies for Enhanced Governance Decision-making

Cellular and digital tools enhance good governance decision-making. During the Governance Roundtable, participants offered several observations about the expanding contributions that smart technologies can make for smart health sector governance.

1. Top-‐down and bottom-‐up approaches for governance, both are essential for change, and

technology is helpful in both. Technology can help us engage stakeholders and get more accurate and timely information to use to make sound decisions. When users, patients, physicians, and citizens get good information on plans and performance, they can hold leaders accountable for governance decision-‐making. Mobile phones and the Internet can support positive transformations in governance for health.

2. Using accurate information can empower people. A two-‐way flow of information is important for more effective and efficient governing processes. Mobile technologies provide opportunities for enhanced citizens and government interaction; however, participants cautioned against forcing such technologies onto people. Technology can help information and communication move from the organization to the governing board and from the board to the organization and other stakeholders.

3. The exploding use of cell phone applications (There’s an app for that.) encourages us to consider the unique persona for whom we want to build a technological application. Expert advisers on technology for decision-‐making observe that we must define the “personas” of the users. “Persona” is a term used in information technology planning to mean five or six key characteristics and information handling needs of those individuals who will use the technology. If we build empathy and “walk a mile in their shoes”, we are more likely to understand which technologies will work and which will not.

4. Governance and leadership should support choice in technologies, not a single approach. Technology planning for better governance must also focus on function. Governance leaders should take time to define desired outcomes and ideal functions; they shouldn’t get obsessed over the type of tablet or the model of devices. Take time to ensure that governance leaders feel comfortable and confident with information and the communication technology. The key is to identify what you want to do with technology, measure its impact, and then engage the users in a dialogue about practical uses of the technology.

5. Getting the information and data to where they need to be, and managing and synthesizing that

data are equally important. There are situations where governing bodies are going to have too much for anyone to reasonably manage. Technology is a tool to synthesize that data and to make it easier for the recipient to understand what the implications are. Imagine the dashboard of your car: you may not look at the gas you have in the tank, but when a dashboard red light goes on, you know only a small supply remains. These kinds of technology applications can be really useful to the health sector governance leaders.


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6. Technology can also level the playing field among powerful and marginalized populations. Leaders who govern can come from a broad cross section of the society that they are trying to represent, and their levels of education and experience with technology will vary. Invest in user training to ensure equitable and effective use of new governance decision-‐making support technologies.

7. Participants encouraged the LMG Project team to explore more innovative use of mobile

technology for hotlines and crisis lines. These can provide people with direct access to report health service needs, gaps in services, and weak health worker and institution performance. Enhanced mechanisms for information sharing can enable people to report corrupt practices, and to celebrate superior service performance.

8. Participants were asked to consider mobile phones as a tool for enhanced connectivity with

diverse stakeholders that they always wanted to have. They were encouraged to think through the possibilities of the information that needed to be communicated, and then start to experiment in pilot applications. Health sector leaders must ask partners, clients, and colleagues what their needs are. Think of ways those devices could provide an infrastructure that has not been there for a long time.

9. Mobile devices don’t yet have the recognition to secure enough good quality, robust data for

officials to use on a regular basis for decision-‐making. Health system leaders are encouraged to stop isolating data, stop isolating findings, stop living in fear that shared information will spotlight failure, and instead open up the information to the public. Mobile phones and mobile devices can help bridge information gaps for smarter governance engagement, program planning, and program evaluation.


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4. Governing Decentralized Ministries of Health Decentralized health systems demand smarter governance participants and processes.

Discussions during the Governance Roundtable generated several observations about growth in decentralized health systems and the need for smarter governance processes and structures to accommodate this trend.

1. Decentralized governing bodies play an important role in the success of health system

decentralization. When effective, they: cultivate accountability; set strategic direction based on community needs; champion good quality health services; steward resources in a responsible way; oversee the performance of health managers and health workers; and, finally, continuously improve their approach to good governance.

2. The global trend for decentralized health system governance, e.g., in Kenya and Afghanistan, is

opening up thousands of roles and positions for men and women to serve on the governing bodies of hospitals, health centers, and district and provincial entities. Unfortunately, they often do not have adequate preparation or support for these new roles. There is need for new strategies and materials to build the capacity of these people and their institutions.

3. Five strategies can help ministries of health while decentralizing: (1) define what functions to decentralize, and to what degree, (2) design an effective governance model, (3) develop the terms of reference of the governing body, (4) develop its capacity to deliver these terms of reference, and, finally, (5) measure and broadly report performance results of the governing body to the public and key stakeholders. (Please refer the LMG publication, Five Smart Strategies to Govern Decentralized Health Systems for more details.) It is very important to move the three essential components—authority, accountability, and resources—in tandem. Without any one of those three, it will handicap the decentralization process.

4. Most developing countries are undergoing some decentralization of their administrative,

political, fiscal, and service delivery authority. The degree and extent of decentralization varies across countries. The two most common forms we see are de-‐concentration (responsibilities are transferred to an administrative unit of the central government) and delegation (some authority and responsibilities are transferred, but a principal-‐agent relationship between the central and lower levels of government remains).

5. Health sector decentralization does not happen in a vacuum. Ministries of health generally

follow a government-‐wide policy of decentralization, and often they do not have their own decentralization policy. Decentralization in the health sector is not something that is independent; it is often dependent on other initiatives taking place within the wider government structure.

6. Decentralization within the health sector is not usually a planned process. Therefore, it becomes

challenging to manage a coherent health care system when you have multiple, vertical disease programs managed by the central government and also horizontal programs managed by local primary care teams. This challenge needs to be resolved.


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7. Effective governance enables successful decentralization and helps health leaders achieve better

health service performance. There are two conditions for decentralization to be successful in achieving its objectives: effective governance in the ministry of health (and other ministries of the government) and effective governance in the decentralized entities.

8. At the government level, the minister of health (and other ministers) needs to take at least

three actions: First, when transferring the responsibility to carry out a specific function they need to transfer three other things at the same time: accountability for results, administrative authority, and resources required to carry out that function. There must be clear responsibilities, authority, and resources allocated through law. The decentralized entities should be able to raise financial resources within a transparent financial system that incentivizes higher levels of performance. Second, consult, consult, and consult! Decentralization is hard to introduce and hard to maintain, and sustaining it over time requires continuous adjustment and adaptation. Regular consultation with leaders of the decentralized entities is essential. Third, effective channels of political participation and representation should be developed in the decentralized governance structures. The minister should be a champion and provide strong political support, and also carry out effective oversight of decentralized governance structures.

9. The permanent secretary and the entire ministry also need to faithfully follow the intent of the

minister. They should be willing to transfer functions previously performed by the ministry, and transfer adequate resources to the local entities for them to succeed. They need to be willing to build the capacity of local governments. They should also develop strong administrative and technical capacity within the central ministry to support the decentralized structures. They should allow flexibility in the local units so they can be innovative and conduct small-‐scale experimentation. To succeed, decentralization needs political commitment, significant financial resources, and technical expertise. Context counts and outcomes vary.

10. To increase the likelihood of successful decentralization, a few key principles should be followed

when designing the decentralized governance model. Within a centrally defined policy framework, decentralized governing bodies should be empowered to make the most of their own governing policies and processes. Their responsibilities, accountability, authority, and resources should be formalized through law or regulatory policies. Competent members should be recruited to the governing body. The body should periodically assess its own performance and revise its structure, policies, and processes based on these assessments. Finally, it should conduct effective oversight, rather than micromanage.

11. How much to decentralize and how far to take decentralization is a challenge in most countries.

The infrastructure in rural and local communities may be inadequate, making it impossible for them to effectively receive and use the accountability, the authority, and the resources.

12. Participants in the roundtable encouraged leaders to avoid a time lag between the

announcement that something is to be decentralized and implementation of the plan. Open, timely, accurate and complete communication is critical. The process of decentralization is a process of change, and when there is change, there is often miscommunication, confusion about who has what roles and responsibilities, and who has how much authority. That confusion can become an obstacle to health system performance.


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13. Governing arrangements must embrace clear indicators of performance, as well as

measurement that shape continuous governance process improvement. No one expects the decentralized systems to be great the first time. There is always room for improvement, so there should be a process of feedback and then adjusting. Expect a continuing process of adjustment and readjustment. Regularly revisit and adjust.

14. Make sure the process is transparent so that people understand why resources are being

moved, why accountability has been shifted, and why authority has been delegated. In those situations where the infrastructure is inadequate, the central government needs to invest in the local authorities to build their capacity and to make sure that the infrastructure is adequate for success as the responsibilities are decentralized.

15. Decentralized governing bodies need to collect data and information to inform their decisions.

This supports an exercise of accountability by the civil society and the community, i.e., holding the decentralized bodies to account. Think through how to engage the community in active and relevant ways. For example, Twitter, SMSs, and community town halls can help the community engage in accountability mechanisms once the actual services are decentralized. Have protective policies for whistle-‐blowers—they will need to have safeguards for community members who actually speak up about flaws in the system.

16. Certain services and decision-‐making roles may need to remain centralized. Make sure that not

everything is lost in a rush to decentralize. A centralized provision can be effective, for example if rapid action is needed, when services are easy to standardize, when the standardization of services across populations and regions is desirable, or if there are economies of scale. Good governance seeks to find a balance between centralized and decentralized functions.

17. Vertical and horizontal communication and continuity of care are a challenge, especially for

mobile or marginalized populations. Health leaders must ensure continuity of health care for these populations. We should have a coordinating mechanism for the decentralized bodies to communicate and share best practices to serve vulnerable populations.

18. There are positive examples of countries that have successfully managed the decentralization

process. One positive example is Brazil. Through the process of decentralization, they’ve created participatory mechanisms for stakeholders to take part in decision-‐making as well as decentralized finances that they actually have to make decisions about. Ethiopia has made necessary changes in the regulatory framework in order to decentralize, accompanied by management training for the existing health managers as well as academic training at university levels so that future managers have the appropriate education as they move into the decentralized system.

19. For sustainable governance effectiveness, civic education should become a core component at

all levels of the education system. Individuals don’t fight for their rights or speak up if they don’t know that they can or how they can. Leaders engaged in decentralized governance systems must be champions for enhanced consumer rights and participation.


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5. Identifying and Reducing Corruption Related to Health Sector Governance

Corruption must be eradicated by governing bodies and leaders who are transparent and accountable. Governance Roundtable participants generated comments regarding the challenge of corruption and the need for those who govern to be more assertive about its resolution.

1. Corruption is a function of risk and reward, where reward is high and risk is low. Increase the

risks of indulging in a corrupt practice and the rewards of ethical behavior. 2. We need more data on corruption in the health sector, its causes, its many forms, and its many

bad implications and consequences. 3. Citizen and patient enlightenment is the first step. We must dare to help people understand

their rights—their right to report and know that there is an agency or an ombudsman, and these things could be created with relatively few resources.

4. Many segments of the health sector are vulnerable to corruption—procurement of drugs and

supplies and construction of health facilities especially. Corruption is a critical issue to be addressed by good governance. It matters because corruption saps the energy and vitality of people working in the field. It matters because it steals scarce financial resources, which are necessary to get medicines and to post workers in the right place at the right time; and it steals medicines that are going to be essential for health status improvement and saving lives. For too long we have allowed these kinds of things to not be talked about.

5. Corruption can occur at the central, provincial, district, or community level. We can’t ignore it; it

must be talked about. Governance bodies must start taking action. It is a pervasive and important issue. Civil society organizations, private non-‐profits, and governments all have room for improvement in dealing with corruption.

6. To help inoculate health systems from the disease of corruption, we must find ways to enhance

stakeholder awareness and transparency, keep a bright spotlight on transactions and interactions, and pay attention to achieving more trained and ethical leadership and management. Strengthen ethics and compliance training, and self-‐regulation. We have to look at modifying behavior with ethical debates and discussion at all levels of a health system. At the same time, leaders must promote enforcement, detection, and prosecution of corruption.

7. Provide support to the law enforcement that punishes the perpetrators. Use incentives for

health providers to promote responsiveness and avoidance of corrupt practices. Those who govern must champion a living wage for health workers, and establish performance-‐based pay to minimize the temptation for corruption.

8. The health sector can benefit from taking a political economy approach and conducting a

“political economy analysis” of how health services and health systems operate from top to


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bottom. Facilitate media and support citizens in expressing their outrage. Work with journalists to train them to better report on governance issues, and also actually invite them into your institution and be more transparent with them. Investing in investigative journalism can make a difference. Coverage of fraud and corruption brings people’s attention to it. It has a shaming effect. Shame is a very powerful disincentive. Strong governance leaders mobilize communities to bring corruption cases to light.

9. The eradication of corruption requires health system leaders to think and talk about their

desired institutional norms and values. We must develop and nurture more “moral capital” within those who govern by fostering expanded education with faith-‐based organizations and secular ethics specialists. Increasing moral capital in health care will help reduce corruption.

10. Invest in risk assessment and build up appropriate financial management to address some of the

core issues of corruption. 11. It may be helpful to start anticorruption efforts centrally. This can give the governing board

or central government moral authority to evaluate and act. Protect the whistle-‐blowers in your health system.

12. We can talk about corruption in terms of theft or unauthorized payments, procurement issues,

or under-‐the-‐table types of dealings, but there is also a range of other corrupt behaviors, including unethical use of supplies, absenteeism from work, and favoritism in promotions.

13. Donors may contribute to the problem. Can we say who benefits from corruption? Are we

looking at corruption as a necessary price to pay for the donors to be able do the kind of work that they want to do? Maybe corruption is the price that they pay. Are they somehow okay with certain levels of corruption as long as it allows them to do their work? In some countries, corruption is pervasive and donors often send mixed signals about how to reduce it. Do we have a zero tolerance policy or not?

14. Finally, how much countries value their health workforce is relevant to fighting corruption. Services of health workers should be valued, not only in compensation but also culturally and socially. More professional pride and professionalism means less corruption.


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6. Governance of Pharmaceuticals Access to essential medicines in universal health coverage requires wise governance systems. Participants offered observations about the importance of smart governance for enhanced systems for essential medicines.

1. About a third of the world population lacks regular access to essential medicines.1 Weak governance is one of the reasons why. Pharmaceutical systems are quite susceptible to both unethical practices and mismanagement. Medicines have substantial economic consequences for governments and also for individual households. When essential medicines aren’t available, people have to buy them, and there can be substantial out-‐of-‐pocket payments. People lose faith in those who govern when their access to basic medicines and care is compromised by poor governance.

2. What can be done to improve governance in pharmaceutical systems? Governance leaders

should focus on developing sound policies and laws for wise supply chain management and medicine security. Implement a set of strategies that deals with strengthening organizational structures for decision-‐making and oversight, and implement a set of interventions that looks at human resource management.2

3. Over the years, we realized that if we want to have significant gains and sustained gains, and to enable and facilitate the work of clinicians, we need health managers that move resources—human, financial, and pharmaceutical. To enable and facilitate the good work of these managers, we need good health leaders. To enable and facilitate the work of all of those health leaders, we need those invited into governing roles to be ever more effective at smart governance.

4. Pharmaceutical governance leaders need to adopt a better approach to governance structures,

governance processes, governance competencies, and the selection of those who are invited into decision-‐making roles. They need to have transparent processes and checks and balances in place. They should engage civil society and the community in oversight of the pharmaceutical supply chain.

5. Either oversight committees don’t exist or, where they do exist, tend to focus on micromanaging rather than governing. Good oversight relies on information systems. You must have reliable and accurate information for decision-‐making, operations, and oversight. New information technologies are absolutely critical for making such information available to decision-‐makers across all dimensions of the pharmaceutical supply chain.

1 From the World Health Organization website: “Although the percentage of the world’s population without access to essential medicines has fallen from an estimated 37% in 1987 to around 30% in 1999, the total number of people without access remains between 1.3 and 2.1 billion people.” See http://apps.who.int/medicinedocs/en/d/Js6160e/9.html. 2 For an approach to pharmaceutical governance, see http://www.msh.org/sites/msh.org/files/sps_governance_pub_final_2011.pdf. For more information, please view the proceedings of the 2013 Universal Health Coverage and Medicines Conference at http://uhc-‐medicines.org/ and http://uhc-‐medicines.org/agenda/.


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7. Measuring the Effectiveness of Governance Practices

Continuous governance effectiveness must be informed by evidence-based governance. There was a lively call among the participants for a series of bold initiatives to study and document evidence of the value of good governance Leaders need to invest in staff and systems to explore literature and evidence across disciplines to generate new theories and best practices related to smart governance. We need to draw on the good work done and published by the World Health Organization and World Bank on measuring governance. We need more measurement and research into effective governance in the health sector. We also need a language and a theory of change. It is not easy. However our research and evidence can help us enable health leaders to continuously improve their governance practices. WHO-‐led Implementing Best Practices (IBP) Initiative is identifying and applying evidence-‐based and proven effective practices to improve reproductive health outcomes. We may also draw lessons from their experience. Here is what we’ve learned in the roundtable discussions:

1. Existing frameworks for interventions are nonlinear. These interventions occur in complex, dynamic, shifting environments, and there is no single, globally accepted framework for how governance interventions result in improved health systems or health service delivery.

2. Governance interventions are multi-‐layered. An intervention, for example, at the community

level can have an effect at the health facility level, which in turn can have an effect on the health system performance and on patient satisfaction levels. Indicators designed to measure change caused by a governance intervention need to reflect these layers and levels, so changes in individual behaviors, organizational practices, and system performance can all be tracked.

3. Governance interventions can vary greatly. Interventions range from community-‐level

interventions (with village communities) around community monitoring to interventions with boards of civil society organizations to interventions with parliamentary committees around financial governance.

4. Because interventions are varied, so are governance indicators. There are hundreds of

indicators that have been developed, but these speak to specific interventions. Indicators that measure national governance cannot be applied to community-‐level governance interventions. There is value in having these indicators identified and located for easy access and use.

5. Governance interventions borrow from various disciplines, sectors, and theories. They are

derived from public health, democracy, corporate governance, community mobilization, political theory, management theory, and innovation theory, to name a few. Measurement frameworks need to borrow and learn from best practices across these disciplines and theories.

6. There is limited evidence concerning the effectiveness of governance intervention. There is

some evidence around community engagement processes, community mobilization, and


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bringing networks of people together. Because of the nascent nature of the field, there are tremendous opportunities to design and study what changes governance can bring about, why, and how.


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Conclusions Smart governance is a journey, not a destination. This Governance Roundtable is a continuation of the LMG Project’s advocacy for governance as a means to stronger health systems through enhanced local stakeholder engagement and expanded country ownership. This summary of the participants’ observations make clear that they see governance as essential for health system performance improvement. They also acknowledge, however, that we need more evidence on its impact, and expanded investments into capacity building for those who govern, and their governance decision-‐making systems. Governance exercises its impact as a complex adaptive system, and that governance influences most aspects of the health sector, including its financing and management, which in turn influences how health care services are designed, developed, and delivered.

Discussions among the participants concluded that the context in which governance is to function is very important in shaping better understanding and practice of governance; governance in turn shapes the context. The context is not political economy alone. It is the change in demography, in epidemiology, and in the economic environment. It is the change in legal and regulatory regimes that are made by local, regional, or national governments—as well as an increasing number of international agreements—regarding pollution, disease, bioterrorism, national security, and trade. Economic environments, sociocultural environments, and the technological context are all important to our shared exploration of the principles and practices of wise governance. The two days of discussions emphasized the value of transparency and accountability of governance decision-‐making for future health system strengthening, specifically in relation to health sector corruption. The participants observed that most countries do not have the systems and institutions needed to detect and correct governance failures, especially in low-‐income countries. Governance will need to be more inclusive to earn the engagement in and support of system outputs by end users, especially the marginalized and vulnerable. The future agenda for governance capacity building must overcome the underrepresentation of women and marginalized people. Weak inclusion and lack of diversity in governance lowers the effectiveness and acceptance of governing body performance. Governance works better when we listen to diverse and well-‐informed stakeholders. Roundtable participants also concluded that future advances in smart governance will require consideration of political dimensions in the design of effective governance structures, and to have a better understanding of the values of those who govern and those who are governed. Values were acknowledged as key to shape culture, and culture was acknowledged to trump strategy. Individual leaders come and go, but institutions and systems stay. Investing to develop these governance institutions and systems will materially lead to more significant and sustainable health systems performance gains. Good governance, however, costs money. Poor governance costs even more. Health sector leaders were encouraged by the participants to define what it takes to fund a fully functioning governance system. Participants were convinced that smart governance yields substantial returns on these investments.


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Collaboration is now critical, so secure the evidence that affirms these observations. We also must find and celebrate role models and case studies of superior governance practice. We all must practice what we preach by setting an example in all areas of governance, including leadership, transparency, accountability, and ethics Our conceptual models are also being called to advance. Too often when we think about governance, we think about boards of directors, but it is really so much more than that. It is about getting accountability, authority, resources, and information all at the right levels of the system in order to move decision-‐making forward in a positive and constructive way.

Recommendations for the LMG Project

The LMG Project took the recommendations from participants at the Governance for Health Roundtable, and refined them. These are summarized in Appendix 2 in the form of actions expected to be taken within 9 days, 9 weeks, and 9 months. LMG Project Director Jim Rice will lead on ensuring that the 9-‐day, 9-‐week, 9-‐month actions continue to move forward. He, working with USAID AOR team, will systematically review, and prioritize the actions for implementation, and also follow through the implementation. Governance and Monitoring, Evaluation and Research teams in the LMG Project will assist him. Brown bag sessions, and governance panel discussions will be organized to disseminate the learning from the Roundtable. LMG will also produce communication products for this purpose over the next year. Progress in achieving these actions will be reviewed in the third Governance Roundtable proposed to be scheduled October 2014 in conjunction with the International Conference for Health Systems Research in Cape Town, South Africa. However, we would also like to hear from you now to further guide our work!

How can we best use these observations and recommendations to:

! Refine the policies and procurements of USAID and other international development partners?

! Guide the development of education programs and materials for leaders who govern the health sector and health institutions in low-‐ and middle-‐income countries?

! Advocate for more women in governance?

! Invest in more research and measurement of governance? As a health leader and practitioner, your knowledge and experience in the governance realm is valuable to us. Please send your thoughts, observations and recommendations to the LMG Project at: [email protected], or contact Project Director James A. Rice: [email protected].

*****

About the LMG Project Funded by USAID, the Leadership, Management & Governance (LMG) Project (2011–2016) is


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collaborating with health leaders, managers, and policymakers at all levels to show that investments in leadership, management, and governance lead to stronger health systems and improved health. The LMG Project embraces the principles of country ownership, gender equity, and evidence-‐driven approaches. Emphasis is also placed on good governance in the health sector—the ultimate commitment to improving service delivery and fostering sustainability through accountability, engagement, transparency, and stewardship. Led by Management Sciences for Health (MSH), the LMG consortium includes the African Medical and Research Foundation (AMREF); International Planned Parenthood Federation (IPPF); Johns Hopkins University Bloomberg School of Public Health (JHSPH); Medic Mobile; and Yale University Global Health Leadership Institute (GHLI).

Appendix 1: Participants in the 2013 Governance Roundtable Dr. Rifat Atun, Professor of International Health Management, Imperial College Business School and Faculty of Medicine, Imperial College, London


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Ms. Deirdre Dimancesco, Technical Officer, Medicines Policy, Information and Governance, WHO Department of Essential Medicines and Health Products, Geneva.

Dr. Delanyo Dovlo, WHO Country Representative, Rwanda.

Mr. Bob Emrey, Lead Health Systems Specialist, Office of Health Systems, Bureau of Global Health, USAID

Ms. Elisabeth Epstein, Social Media Director, Girls’ Globe

Dr. Peter Eriki, Director, Health Systems Strengthening, ACHEST, Kampala, Uganda

Mr. Jacob Hughes, Founder and CEO, Hughes-‐Development Inc.

Ms. Temitayo Ifafore, Health Workforce Technical Advisor, Service Delivery Improvement Division, Office of Population and Reproductive Health, USAID

Ms. Alisha Kramer, Program Coordinator and Research Assistant, Global Health Policy Center, CSIS

Ms. Laura Lartigue, Communications Manager, LMG Project, MSH

Mr. James Christopher Lovelace, Principal Associate, International Health Division, Abt Associates

Ms. Tessa Mattholie, Technical Advisor, DfID

Mr. Larry Michel, Vice President, Center for Leadership and Management, MSH

Mr. Maurice Middleberg, Executive Director, Free the Slaves

Dr. Nzomo Mwita, Training Specialist and Deputy Director Capacity Building, AMREF

Ms. Maeghan Orton, Africa Regional Director, Medic Mobile

Mr. Rebeen Pasha, Advisor for Health Systems and Country Ownership, Office of HIV/AIDS, Bureau of Global Health, USAID.

Ms. Susan Putter, Principal Technical Advisor, Systems for Improved Access to Pharmaceuticals and Services, MSH

Dr. Jonathan Quick, CEO, MSH

Dr. James Rice, Director, LMG Project, MSH

Ms. Susan Richiedei, Director, Leadership and Capacity Building, PLAN USA

Mr. Thomas Rottler, President and CEO, BoardEffect LLC

Dr. Mahesh Shukla, Public Sector Governance Advisor, LMG Project, MSH

Ms. Maura Soucy, Intern, MSH

Dr. Tomohiko Sugishita, Senior Advisor Kenya Program, JICA


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Mr. Mahugnon Togbeto, Head of Governance and Accreditation, IPPF

Dr. Göran Tomson, , Karolinska Institutet, Stockholm, Sweden

Dr. Reshma Trasi, Director, MER, LMG Project, MSH

Dr. Kate Tulenko, Director, CapacityPlus

Dr. Taryn Vian, Associate Professor of International Health, Boston University School of Public Health

Ms. Helena Walkowiak, Principal Technical Advisor, Center for Pharmaceutical Management, MSH


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Appendix 2: Follow up actions What actions should the LMG Project take to promote smart governance for health sectors in LMICs?

Actions in the Next 9 Days:

1. Constitute a group of people from the three Centers within Management Sciences for Health (CLM, CPM, and CHS) to define and leverage our international experiences in good governance

2. Develop work plan to collect evidence on impact of governance – with case studies and experiences from other sectors

3. Establish drop box for sharing of ideas and evidence among all participants 4. Develop strategy and assign staff for a collaborative communication network for those

present and other colleagues to maintain sharing on the topic of governance (e-‐newsletter, listserv etc.)

5. Distribute directory of emails for all participants to foster ongoing exchange and networking 6. Commit to develop a series of case studies on successful good governance in LMICs 7. Prepare and circulate a short summary of the Roundtable discussions 8. Distribute link to photo gallery from the Roundtable

Actions in the Next 9 Weeks:

1. Continue conversations among key CAs like: HPP, CapacityPlus, HFG, and LMG 2. Constitute a group of people from relevant USAID projects (HPP, CapacityPlus, HFG, and

LMG ) to work on health governance issues 3. Build more visible and effective platform for collaboration with global (including donor and

key country partner) stakeholders to set and advance health governance priorities 4. Create a short video (2 minutes) that illustrates what good governance is, and why it is

important to health systems strengthening 5. Publish plans for next Governance Roundtable in an Africa venue in 2014 6. Poll participants for ideas from the roundtable that have proven to be the most valuable for

future applications 7. Establish working groups/committees on the topics covered in the conference to promote

continued knowledge sharing, and to stimulate progress 8. Expand partnerships with academic institutions to promote research and knowledge sharing

on governance and health (For example, Boston University, Yale, Johns Hopkins, George Washington, Georgetown, and Imperial College in UK)

9. Publish comprehensive “Conceptual Frameworks on Theory of Good Governance” 10. Outline work plan for expanded development of “Good Governance Resource Suite” for

2014 11. Publish preliminary set of “Governance Indicators” throughout USAID and its implementing

partner organizations 12. Develop a resource bank on smart governance metrics and indicators 13. Publish an expanded compilation of evidence on the value of investing in good governance

practices, competencies and performance infrastructures 14. Secure support from MSH to publish series of Technical Briefs on Measuring Governance


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Impact

Actions in the Next 9 Months:

1. Support an expanded “Technical Working Group” (TWG) as a group people from other donors to expand global resources on governance for health

2. Work with other stakeholders to capture strategies and tools that are known to improve governance in different settings (stable countries and others emerging from conflict)

3. Publish guidelines for effective governance of decentralized health systems 4. Establish a detailed 2-‐3 year action plan for review and input from USAID leaders 5. Establish a web-‐based “Voices of Governance” with frontline people engaged in various

aspects of good governance for health 6. Assemble and publish relevant literature and theories regarding measurement of

governance practices (start with organizational, social and behavior theory from business) 7. Publish a web-‐based “Set of Cases Studies” of what is actually working or not in the LMICs 8. Provide USAID a series of materials that show evidence from the research 9. Design longer-‐term research agenda to continually advance knowledge on the evidence of

smart governance 10. Develop and publish “Theory of Change” type articles on what good governance is and how

it helps enable stronger health systems performance 11. Publish a detailed program and logistics for Governance for Health in Africa for 2014

Documents

Roundtable Summary 05 December 2013 handout...ImprovingGovernanceforHealthinLMICs !!! USAIDLeadership,!Management!&!Governance!Project,December!2013! 7" 1. Smart governance yields