Governance in the health sector
Governance in health systems
Conceptualisation | Main governance aspects | Reference |
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Health System Performance | First emphasis on stewardship as a health system function | [52] |
Essential Public Health Functions | Strengthening public health regulation and enforcement capacity as one of the eleven essential public health function | [53] |
Control Knobs | Regulation as one of the health system control knobs to improve performance | [54] |
Strengthening Health Systems | Strengthening health system capacity by focusing on stewardship and regulation | [55] |
Health System Building blocks | Articulation of governance as one of the six major building blocks of the health system, and rephrasing stewardship into governance | [20] |
Health Systems Dynamics | Identifying stewardship and organizational arrangements as one of the four levers available to policy makers to achieve objectives and goals | [56] |
Maximizing positive synergies | Ensuring that governance along with the other six functions of a health system are driven by people to promote equity | [23] |
Systems thinking for Health Systems Strengthening | Links system thinking to health system building blocks, and conceptualizes governance across the building blocks. | [25] |
Monitoring Building Blocks of the Health System | Proposes indicators for monitoring governance and the other building blocks of the health system | [43] |
How has governance in health systems been conceived so far?
Governance element
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Reference
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WHO 2007 | Islam 2007 | Siddiqi et al. 2009 | Lewis & Pettersson 2009 | |
Accountability
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Effectiveness/efficiency
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Equity
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Ethics
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Existence of standards
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Incentives
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Information/Intelligence
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Participation/collaboration
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Policy/System Design
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Regulation
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Responsiveness
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Rule of Law
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Transparency
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Vision/Direction
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Towards a new approach to assessing governance in health systems
Example of an application
Governance Element | Building Block | ||||
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Financing Governance | Human Resources Governance | Information Governance | Medicines & Technology Governance | Governance | |
Participation
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Consensus Orientation
| Low participation from health workers in setting appropriate salary scales | Few ways of including community in health facility boards which provide oversight or advice to management. | Information on how community can participate in human resource decisions is not clear | Limited channels (such as health boards) for community or health workers to participate and have their voices heard | |
Strategic Vision
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System Design
| The system does not allow for incentives to be provided for working in less attractive areas; Salary increases not based on performance | No overtime payments structured in; Lack of performance appraisals; Distribution of staff is not based on service population making some environments more stressful | The design of the system does not require that data are regularly collected on staff attendance and transmitted to the district or above | Medicine delivery system is poorly designed leading to a lack of resources at health facility which make working environments less attractive as there are fewer resources available to staff. | System not designed to include sanctions that can be placed on health worker by management unit thereby reducing the ability to hold absent staff accountable |
Addressing corruption
| "Ghost" workers continually receive payments and are not identified by the system | Inability to replace ghost workers | Information on absenteeism is altered at health facility before it is transmitted, therefore hiding the problem | Absent staff may be taking publicly funded resources with them to sell in the private sector thus increasing incentive to be absent | Lack of supervision to ensure that health workers are present |
Being transparent
| Transparent information on salary scales and overtime payments is not available to staff | A list of staff who are supposed to be on call or at work is not available to the public | Information on staff attendance is not transferred to the authorities | Knowledge on future stock and flow is not transparent which could reduce the motivation for health staff to be present | Decisions made by health facility boards or management unit on hiring, promotions and firing are not made available to community |
Being accountable
| Ministry of Finance is not held to account when salary or bonus payments are late | Staff are not held to account when absent | No one is accountable for ensuring that regular, transparent data on staff attendance is collected and turned into information; Lack of information on sanctions options available to management unit to hold staff accountable | No one is held accountable if medicines go missing | Lack of enforcement options to hold absent staff accountable at the community or district level when staff are absent |