Governance is the interplay of various actors in a given ecosystem to achieve its core objectives. Health systems governance is to improve the health status of people, be responsive to their health needs, and reduce financial hardship in accessing healthcare in an equitable way. Governments in general and heads of the government, in particular, assume the role of leadership to govern the complex social systems.
Social systems evolve to serve the needs of people. Their elected representatives are required to evolve policies that address people’s needs and laws to enable their implementation. Public administrators are expected to implement these policies. Regulators are to oversee that the relevant laws are adhered to by all concerned actors. Researchers undertake studies to inform policy formulation and implementation, to assess systems and their components and their performance, and to understand disease burden and their trends. Healthcare providers cater to the promotive, preventive, curative, and palliative health needs of people. Health technology players undertake research & development and manufacture and supply various health goods. Health insurers offer financial protection products to meet unexpected medical expenses. Civil society organizations voice unmet people’s needs and bring them to the notice of others. In addition, each social system is interdependent and interconnected with other social systems.
The architecture varies subtly at global, regional, national, and subnational levels. Nations are represented as members in global multilateral bodies like United Nations (UN) and World Health Assembly (WHA). World Health Organization (WHO) acts as the directing and coordinating body of WHA. WHA passed international health regulations (IHR) that are binding on its member nations. Non-state actors include philanthropic foundations, global health academia, civil society organizations, multinational corporations, regional and other groupings like G7and G20, thinktanks, etc. Health is a national subject in some countries and subnational in others. Governments may be single-party or biparty or multiparty. They may be theocracies, monarchies, autocracies, democracies, and dictatorships. The supreme leader may be elected directly in a presidential system or by the elected representatives in a parliamentary system of governance. In most countries, governments play the leadership role in providing stewardship over other constituents of the ecosystem.
Government and its roles & responsibilities
The Ministry of Health generally is responsible for governing health systems. Health policy, financing, and regulation are the core functions of the government. It is responsible for monitoring & evaluation (M&E) of health systems performance. It is also responsible for information, education, and communication (IEC) of its policies, strategies, and programs across the system. It is responsible to build relationships through active engagement of non-governmental health system actors, of communities, with other health systems at different levels (global, regional, international, national, and subnational as the case may be), with other ministries that have relevance to health systems as part of ‘Whole of Government’ and ‘One Health’ concepts. The Ministry of Health itself is organized into departments that oversee healthcare provision function, health insurance function, public health functions supported by research, education & training, and regulatory institutions.
Non-governmental actors and their roles
The private sector accounts for a significant proportion of healthcare services, supply of health workforce, and health goods in many countries. It plays an important role in health R&D and health technology innovations. Medical and other health professional associations exhibit varying amounts of power across the globe in influencing health policies and health laws. Countries influence others through development assistance. Large philanthropies are playing an increasing role in global and national health systems through the power of their contributions. Regular and social media pervade across systems with the power to disseminate information, both right and wrong, at speed influencing the behavior of entire systems. Civil society organizations and social activists have influence over public policy. People, at the center of the systems, influence the health system through their electoral choices, their choice of providers and insurers, by participation in opinion polls, and by their lifestyle choices.
The interplay between various actors
Good governance requires mutual respect, transparency, ethics, coordination, collaboration, adherence to agreed rules and laws, and equitable distribution of resources and services. Since governments play the leadership role in many countries, the trust of people and other actors in their governments is a key factor in the effective performance of the systems. A balanced power play brings harmony amongst different actors. An imbalance in power destabilizes health systems and makes them ineffective and inefficient. It also leads to the malady of corruption in the government systems that exercise entrusted power irresponsibly.
There are no well-accepted assessment frameworks for governance. Financing and development assistance agencies have framed their own assessment systems of governance. Just as biological systems are assessed in terms of their anatomy (how the structural components are organized into functional units), physiology (the underlying processes that enable consistent and smooth functioning of various constituents), and pathology (the maladies that affect the structure or function or both leading to malfunction or disease), health governance should be assessed as to its architecture (anatomy), core functions and how they are undertaken (physiology), and the systemic afflictions (pathology) that impairs good governance. Good health system governance should improve the health status of the people they are responsible for, should be responsive to the health needs of people as to when, where, and how they receive needed healthcare and should remove financial hardships to all in seeking needed healthcare. These are the goals of well-governed health systems.
Governance ecosystems are assessed as to their institutional structures. These include the legislative structures – parliaments, assemblies, councils that formulate policies and pass laws and announce programs, and executive bodies – ministries and their departments that implement policies and programs, thinktanks that undertake research to inform policy formulation and implementation, autonomous or quasi-autonomous or controlled bodies that regulate, the judiciary that the laws are properly interpreted and applied, and the media that has the freedom to communicate differing views and expose misdeeds of various actors. There are no objective methods to assess the robustness of government structure. However, a map of the government structure provides a high-level view as to whether the structure is inherently strong or weak.
Governments are best assessed as to the processes involved in their functioning. How governments formulate and implement policies and pass laws is a good reflection of how they function. Mature governments involve all affected stakeholders while formulating a policy. Acknowledging differing views and perceptions while arriving at a broad consensus is a time-consuming process, but highly desirable. Arguments for or against should be supported by robust evidence generated through well-conducted policy research. Communicating formulated policy to all stakeholders affected by it in a way they understand it properly is as important as formulating policy. Policy implementation is the most challenging and iterative process for governments. Well-designed monitoring, evaluation, and learning system are critical in the successful implementation of a policy. Providing needed resources (financial, human, technological) for implementation and their efficient use is a vital responsibility. How governments build and maintain relationships with all the state and non-state actors across levels (global, regional, national, and subnational levels) determines a good from bad governance system.
Building ecosystems around shared purpose and values ensure that the systems perform effectively and efficiently in an enduring way. ‘Health for All’ was the shared purpose outlined in the Alma Ata declaration of the World Health Assembly. Following values are enshrined in good governance – accountability, participation, efficiency, effectiveness, equity, human dignity, inclusivity, respect for the law, consensus-building, responsiveness, and transparency. People trust their governments if they work towards a stated purpose and adhere to universal values.
A multiplicity of frameworks for governance is an indication of evolving nature of concepts and health and other social systems. However, we can perceive a consensus emerging around certain fundamental concepts. A clear distinction is apparent between government and governance. While there is a defined structure and function to government, governance is a diffuse power principle that operates between different actors in a system. When the governments are weak, the governance function shifts to other powerful actors of the system.
The concept of Leadership and Governance of complex health and social systems is still evolving. The role of leadership and governance in health systems became starkly evident during the ongoing Covid pandemic at global, national, and subnational levels. There is a need for global consensus on definitions, assessment frameworks, and measurable indicators of good health governance systems.
Dr Krishna Reddy Nallamalla,
Regional Director, South Asia, ACCESS Health International
(Views expressed are personal)
Photo Credits: –Sibenco