Effective governance is essential for ensuring that a government's priorities, principles and values are reflected in how a health system works. Effective governance is key to achieving health objectives: from the most encompassing – like Universal Health Coverage – to time-bound short-term objectives such as scaling up the COVID-19 vaccine rollout. Countries may miss the opportunity to maximise health goals if efforts to strengthen health system governance incrementally are overlooked.
However, efforts to strengthen health governance, and improve health system performance, suffer from conceptual confusion and from an absence of guidance on how to do governance. Here we aim to facilitate understanding and highlight a new governance operating model focused squarely on the policy issues posed by the private sector. We argue that applying this model in practice should involve incremental improvements to governance capability over time focused on the reality of country priorities and the acceptability of reforms (Gindle, M. 2004).
The governance and public policy literature acknowledge "considerable disagreements" on conceptual definitions, with few systematic efforts to operationalise concepts (or even agree on concepts) and measure them (Wu et al, 2018). The literature further notes a lack of agreement on the extent to which governance capacity differs from policy capacity. Given the lack of working definition, there is limited use of governance concepts (and related capacities, competencies, and capabilities) in practice. Within the health systems literature, health governance is often approached as one of six building blocks (WHO 2007).
Putting governance in a health system building block is conceptually tidy. However, governance doesn't fit neatly into a box. It affects all aspects of the operation of a health system from health financing to service delivery, health programs, hospitals and clinics, the health workforce, and control of access, safety and quality of inputs such as medicines and vaccines. Unpacking governance more, we see that health governance represents the exercise of authority not only at the national level but also upward (to the regional, transnational, intergovernmental, and global), downward (to the local, regional, and the metropolitan), and horizontally (to private and civil spheres of authority) (Levi-Faur, David (ed.) 2012).
Within the WHO’s Country Connector on the Private Sector in Health, we focus on this horizontal aspect (www.ccpsh.org). Particular attention to this aspect is required because the private sector is becoming is a growing prominent provider of health service delivery in many countries, but it often remains under governed (Clarke et al 2019). This poses a lost opportunity to harness private sector capacities and know-how and creates significant risks where the private sector activities clash with public health goals.
The prescription and instructions for fixing this governance gap can be found in a new governance operating model developed by the WHO’s Advisory Group on the governance of the private sector in health; the model focuses on the performance of six governance behaviours (WHO 2020).
Deliver Strategy. Government establishes the priorities, principles, and values for the health system, and works out how to translate these priorities, principles and values into practice.
A
lign structure. Government takes the required actions to align public and private structures, processes and institutional architecture.
Build understanding. Government facilitates information-gathering and sharing about all elements of service provision in the health system.
E
nable stakeholders. Government authorises and incentivises health system stakeholders to align their activities and further leverage their capacities, for national health goals.
F
oster relations. Government establishes mechanisms that allow all the relevant stakeholders to participate in policymaking and planning.
Nurture trust. Government leads the establishment of transparent, accountable and inclusive institutions at all levels to build trust.
Supporting the implementation of the governance behaviours at the country level is underway. We are approaching this work as a change management process that evolves a country's institutions and governance capabilities over time using a maturity model. This approach acts on knowing what is most important and achievable in a country, mindful of conditions and context (Grindle, M., 2007).
Building the capacity to perform effective governance is a journey, not a destination. It's a process that takes place over time as countries continuously and incrementally build their capacities to undertake more complex governance tasks for the benefit of their populations.
References
Clarke D, Doerr S, Hunter M, Schmets G, Soucat A, Paviza A. The private sector and universal health coverage. Bulletin of the World Health Organization. 2019. 97: 434–5.
Engaging the private health service delivery sector through governance in mixed health systems: strategy report of the WHO Advisory Group on the Governance of the Private Sector for Universal Health Coverage. Geneva: World Health Organization; 2020.
Gindle, M. (2004). Good Enough Governance: Poverty Reduction and Reform in Developing Countries. Governance: An International Journal of Policy Administration and Institutions 17(4):525-548.
Grindle, M., 2007, 'Good Enough Governance Revisited', Development Policy Review, vol. 25, no. 5, pp. 533-574.
Levi-Faur, David (ed.) 2012: The Oxford Handbook of Governance, Oxford: Oxford University Press.
Xun Wu, Michael Howlett and M. Ramesh, 2018. Policy Capacity and Governance: Assessing Governmental Competences and Capabilities in Theory and Practice. Studies in the Political Economy of Public Policy. http://www.springer.com/series/14465
World Health Organization (WHO). Everybody's business - strengthening health systems to improve health outcomes: WHO's framework for action. WHO; Geneva: 2007.