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Framework for Assessing Health Governance in Developing Countries: Gateway to Good Governance


Title: Framework for Assessing Health Governance in Developing Countries: Gateway to Good Governance Author: EMRO Last modified by: Ties Boerma Created Date – PowerPoint PPT presentation

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Title: Framework for Assessing Health Governance in Developing Countries: Gateway to Good Governance

Framework for Assessing Health Governance in
Developing Countries Gateway to Good Governance
  • Siddiqi S Masud T I Nishtar S Sabri B
  • Health System Metrics Technical Meeting
  • September 28-29, 2006
  • Montreux-Glion

Eastern Mediterranean Regional Office, World
Health Organization, Cairo
Governance Defined
  • The exercise of political, economic and
    administrative authority in the management of a
    countrys affairs at all levels.
  • Comprises complex mechanisms, processes and
    institutions through which citizens and groups
    articulate their interests, mediate their
    differences and exercise their legal rights and

(UNDP 1997)
Frameworks for the Analysis of Governance
  • WHOs domains of stewardship
  • PAHOs Essential Public Health Functions
  • World Banks six Basic Aspects of Governance
  • UNDPs Principles of Good Governance

WHOs Domains of Stewardship
  • Generation of intelligence
  • Formulating strategic policy direction
  • Ensuring tools for implementation powers,
    incentives and sanctions
  • Building coalition / building partnership
  • Ensuring a fit between policy objectives and
    organizational structure and culture
  • Ensuring accountability

(Travis et al 2001)
PAHOs Essential Public Health Functions
  • Monitoring evaluation and analysis of the health
  • Public health surveillance, research and control
    of risks
  • Health promotion
  • Social participation in health
  • Policies and institutional capacity for planning
    and management
  • Strengthening institutional capacity for
    regulation and enforcement
  • Evaluation and promotion of equitable access to
    health services
  • Human resource development and training
  • Quality assurance in personal and
    population-based health services
  • Research in public health
  • Reducing impact of emergencies and disasters on

(PAHO 2002)
World Banks Governance Indicators
  • Process by which those in authority are selected
    and replaced
  • Voice and Accountability
  • Political Instability and Violence
  • Ability of the government to formulate and
    implement sound policies
  • Government Effectiveness
  • Regulatory Burden
  • Respect of citizens and the state for
    institutions which govern their interaction
  • Rule of Law
  • Graft (control of corruption)

(Kaufmann 1999)
UNDPs Five Principles of Good Governance
Principles Thematic areas
Legitimacy and voice Participation Consensus orientation
Direction Strategic vision
Performance Responsiveness Effectiveness and efficiency
Accountability Accountability Transparency
Fairness Equity and inclusiveness Rule of law
(UNDP 1997)
Contemporary Issues in the Governance of Health
  • Role of the state vs. the market in health
  • Role of the ministries of health vs. other state
  • Actors in Governance public sector, civil
    society and the private sector
  • Static vs. dynamic health systems
  • Health Reform vs. Human Rights-based approach to

Why the term Governance?
  • Governance is better understood by those within
    the health system and those outside
  • International development agencies have
    delineated the principles of governance that are
    well understood
  • Performance of the health system is dependent on
    overall governance of a country

Health Governance Principles
  • Strategic vision
  • Participation and consensus orientation
  • Rule of law
  • Transparency
  • Responsiveness
  • Equity and inclusiveness
  • Effectiveness and efficiency
  • Accountability
  • Information and intelligence
  • Ethics

Health Governance Analytical Framework
  • Governance principle
  • Domain
  • Broad question
  • Specific questions / item
  • Level of Assessment
  • National
  • MOH Policy
  • MOH Implementation

Analytical Framework for Assessing Strategic
Governance principle - Strategic Vision Domain - Long term vision Governance principle - Strategic Vision Domain - Long term vision
Broad Question Specific Question
National level What are the broad outlines of economic policy of the government Where does health rank in the overall development framework by resource allocation, and as percentage of total government expenditure
MOH policy level Whether there is a long term vision (policy) for health Is there a national health policy/strategic plan available stating objectives, strategies with a time frame and resources allocated
MOH implementation level Whether the implementation mechanisms are in line with the stated objectives of health policy What priority programs are being implemented and how do they correspond to the policy objectives
Data Collection and Sources of Information
  • Documents
  • National budget document, report of the treasury,
    state bank,
  • Reports of ministry of economics, national
    statistical organizations
  • Policy documents from MoH, analysis by
    international and NGOs
  • MoH policy/ implementation reports, media
    reports, external reviews
  • Health budget reports, budget speeches
  • Reviews of the health legislative process
  • National information policy
  • MoH policy/ implementation reports,
  • Media reports, external reviews of health policy
  • PRSP documents
  • MoH contracting manual, rules and procedures for
    civil servants
  • National statistical reports, national health
  • Interviews
  • National and MOH policymakers,
  • Mid- and senior managerial staff of the MOH or
    its component departments,
  • Civil society organizations
  • International development agencies,
  • Academic institutions,
  • Media personnel and
  • Direct community representatives

Applying the Health Governance Framework in a
Country Setting
  • Health governance map of Pakistan Strengths
  • Central level
  • Social safety nets for the poor and vulnerable
  • Increasing role of the media and NGOs in
    protecting peoples health.
  • MOH policy level
  • Preparation of draft bills to update health
  • Emerging role of the Pakistan health policy forum
    as a civil society organization
  • Stable turnover of health policymakers during the
    last six years are positive elements
  • MOH implementation level
  • Increasing public-private interaction
  • Preventive programs, especially the LHW Program
    which has a strong community as well as an equity

Health governance map of Pakistan Weaknesses
  • Central level
  • Lack of participatory decision making and culture
    of accountability
  • Parallel streams of bureaucracy and technocracy
    do not work in unison
  • Adherence to rules and procedures is considered
    as an end
  • Lack of consumer protection act delays or deny
  • MOH policy level
  • Short-term objectives override the need for focus
    on health outcomes
  • Health equity is not high on the policy agenda
  • Mechanisms to monitor transparency of decisions
    do not exist
  • Decisions often tinged with personal preferences,
    not evidence-based
  • Legislation on minimum standards of care is
    absent with lax regulation and enforcement
  • Policy, planning, health information and
    surveillance units are weak
  • Delays in release and utilization of funds
  • Accountability systems focus on procedure instead
    of performance
  • Bioethics is not on the policy radar of MOH.

Health governance map of Pakistan Weaknesses
  • MOH implementation level
  • Minimal protection against hazards from personal
    health services
  • Gaps exist in policy and practice for
    recruitment, posting and promotion of staff and
    rules favor seniority over meritocracy
  • Instruments for evaluation of staff performance
    are improperly used
  • Responsiveness of public sector health services
    is not monitored
  • Physicians turned managers lack understanding of
    administrative matters while bureaucrats lack
    health orientation
  • Physicians and allied staff extensively engage in
    private practice outside and often within public
  • Support systems function inefficiently
  • Code of ethics exists with the professional
    associations but not practiced.

Appraisal of the Framework
  • Can health governance be improved without
    addressing overall governance of a country?
  • Health system reforms versus broader civil
    service reforms
  • Health governance assessment framework relies on
    qualitative approach and does not follow a
    scoring or ranking system
  • retains the richness of information collected
  • development of a scoring system is not precluded
  • Does the assessment framework allow for
    cross-country comparison of the governance
  • A health governance map can be developed for each
  • Contemporary issues in relation to health
    governance included
  • Flexibility in the framework to integrate newer
    ones as they emerge
  • Health governance framework does not cover
  • global health governance
  • clinical governance

Policy Implications of Assessing Health Governance
  • Raises awareness among policymakers about
    governance as a function of the health system
  • Provides an avenue for debate on a subject that
    is often pushed under the carpet
  • Assesses each governance principle and allows
    developing interventions to address them
  • Governance issues identified at three levels,
    allowing for measures at each
  • Improving health governance requires political
    commitment as well as financial resources

  • Thank you