Leadership, Governance, and Stewardship Notes

Introduction

Welcome to the lecture on leadership, governance, and stewardship within the health systems goals, functions, and actors module. This lecture discusses definitions, values, principles, goals, indicators, and measurement of governance.

Stewardship in the 2000 World Health Report

In the 2000 World Health Report, stewardship (oversight) was positioned in the upper-left corner of the health systems framework, highlighting its importance.

  • Stewardship is critical because it oversees the performance of other health system functions.
  • The report marked a milestone, addressing health systems at the core of health ministers' roles and reflecting new public management ideas for low and middle-income countries.
  • The concept was expressed as "rowing less, steering more," advocating for a division of competencies where the state focuses on:
    • Health policy formulation.
    • Intelligence (assessing performance and sharing information).
    • Regulation (setting fair rules and promoting entrepreneurial activity).

The Role of Government

The state should not necessarily provide care directly (e.g., hospitals run by the Ministry of Health) but should be responsible for:

  • Health policy formulation: Defining the vision and direction for the health system.
  • Intelligence function: Assessing performance and sharing information.
  • Regulation: Setting fair rules of the game, including promoting entrepreneurial activity.

Shift to Leadership and Governance

The stewardship function was renamed leadership and governance in the 2007 building blocks framework because stewardship did not fully capture the complexity of health systems and was associated with strong leadership alone

  • Governance involves more actors than just the government.
  • The new description ensures strategic policy frameworks combined with effective oversight, coalition building, regulation, attention to system design, and accountability.
  • The government plays a crucial role but builds coalitions with other actors (third-party payers, providers) for better governance.

Defining Governance

Governance includes state and non-state actors interacting to design and implement policies within formal and informal rules.

  • Governance is how societies make and implement collective decisions.
  • It extends beyond the executive branch to include the legislative and adjudicative branches, as well as formal and informal processes like parliament and the media.

Importance of Governance

Governance shapes the health system's ability to respond to challenges like demographic changes (aging) and affects policy selection and implementation.

  • Governance affects which policies are chosen and how well they work.
  • Problems during implementation can cause even the best policies to fail.

Examples of Governance Challenges

  • Privatization of state-owned hospitals:
    • Aims to allow the government to focus on steering and make hospitals autonomous.
    • Risks corrupt appropriation of assets if the agency lacks integrity and transparency.
  • Pharmaceutical policies:
    • May lead to expensive or dangerous drugs if there is opacity, lack of regulatory agency accountability, and poor information.
    • Conflicts of interest can influence decisions.

Complexities of Governance

Governance is complex because multiple actors are involved at various levels of government, applying to different policy areas with a range of values and principles.

  • Actors include:
    • Public sector
    • Private sector
    • Non-governmental organizations
    • Health service providers
    • Funders
    • Civil society.
  • Levels of governance include:
    • European level
    • National level
    • Subnational and regional levels
    • Community level.
  • Sectors to be governed:
    • Pharmaceutical market
    • Human resources
    • Pooling and spending of health expenditure
  • Values, principles, and goals:
    • Transparency
    • Anti-corruption
    • Effectiveness
    • Accountability
    • Rule of law
    • Ethics
    • Inclusiveness

Framework for Health Governance

Health governance involves fundamental values, sub-functions, and outcomes.

  • Fundamental Values: Control of corruption, democracy, human rights, ethics, conflict prevention, public good, rule of law (cornerstones for good governance).
  • Sub-functions (Principles): Accountability, partnerships, formulating policies.
  • Outcomes: Effectiveness, efficiency, equity, quality, responsiveness, improved health.

European Observatory on Health Systems and Policies: The TARPIC Framework

The European Observatory on Health Systems and Policies developed the TARPIC framework, which includes five dimensions or attributes of governance:

  • Transparency
  • Accountability
  • Participation
  • Integrity
  • Policy Capacity

Transparency

Institutions inform the public and other actors of upcoming and made decisions, including the processes and grounds for these decisions.

  • Transparency is a characteristic all actors should exhibit.

Accountability

Actors must inform others of decisions, explain them, and can be mandated and sanctioned.

  • Accountability includes informing and explaining decisions, as well as being held responsible for the appropriateness of the decisions.
  • Good accountability enables administrative discretion, allowing agents to experiment to achieve objectives.
  • Overly explicit regulations and accountability mechanisms may lead to bureaucratic rigidity, hindering innovation.

Principal Agent Relationships

Accountability in health systems is complicated by multiple principal-agent relationships because of asymmetric information.

  • Citizens employ sickness funds as agents to ensure access to quality healthcare.
  • Governments use agents (purchasers, regional planning authorities) to ensure health services exist.
  • Purchasers act as principals, bundling government and population roles, and oversee providers as agents.

Participation

Affected parties have access to decision-making and power, acquiring a meaningful stake in the institution.

  • Advantages include ensuring legitimacy and ownership and incorporating information into policymaking.
  • Involves participation of institutions (patient self-help groups) and the population (hospital boards).

Integrity

Integrity includes predictability, anti-corruption, ethics, rule of law, clear allocation of defined roles and responsibilities, formal rules, and stability.

  • Processes of representation, decision-making, and enforcement should be clearly specified.

Policy Capacity

Policy capacity includes the ability to develop policies aligned with resources in pursuit of goals.

  • Capacity encompasses financial, technical (IT infrastructure, evidence), human resource, and political capacities.

Strategies to Achieve Good Governance

Achieving good governance requires various strategies tailored to each attribute or dimension.

  • Transparency: Watchdog committees, reporting requirements, freedom of information provisions, public information efforts, etc.
  • Accountability: Standards and codes of conduct, performance measurement, independent audits, etc.
  • Participation: Public consultations, stakeholder engagement, patient representation, etc.
  • Integrity: Ethics training, conflict of interest policies, whistleblower protection, etc.
  • Policy Capacity: Adequate funding, skilled personnel, evidence-based policymaking, IT infrastructure, etc.

Assessing Policies Using the TARPIC Framework

When assessing a policy field, it's essential to determine if problems are due to governance issues.

  • Is it a governance problem or due to lack of finances? (Although lack of finances can be traced higher up to governance)
  • Could be a fundamentally bad idea.
  • Adopted policy does not resemble paper version.
  • Is there too little, too much, or the wrong kind of governance?
  • Address the question of what solution. Do we need more relevant data requirements to improve transparency, improve the human resource capacity?

Measuring Governance

Governance should be measured as an accountability, managerial, and research instrument.

  • Accountability: Ensure arrangements promote good quality service and efficient resource use.
  • Managerial: Help governments and insurers ensure services are delivered in line with intentions.
  • Research: Identify governance arrangements that promote the best use of scarce resources.

General Governance Indicators

  • Worldwide Governance Indicators
  • Bertelsmann Sustainable Governance Indicators

Specific Governance Indicators

  • Transparency International's Corruption Perception Index.
  • Eurobarometer or Afrobarometer data on corruption.
  • Measures of trust.

Worldwide Governance Indicators (WGI)

WGI measures the quality of governance based on three main strengths:

  • Process by which governments are selected, monitored, and replaced (voice and accountability, political stability).
  • Capacity of the government to effectively formulate and implement sound policies (government effectiveness, regulatory quality).
  • Respect of citizens and the state for the institutions that govern economic and societal interactions (rule of law, control of corruption).

Bertelsmann Sustainable Governance Indicators

Bertelsmann sustainable governance indicators are only done for OECD and EU countries. Indicators are organized into:

  • Democratic Governance
  • Governing with Foresight
  • Sustainable Policymaking

Transparency International’s Corruption Perception Index

Transparency International's Corruption Perception Index asks the population in various countries how do you perceive the degree of corruption in your country. Countries are then ranked.

Specific Indicators: Corruption

Experience of corruption is highly correlated with satisfaction.

  • Tajikistan, Moldova, Ukraine, Azerbaijan, Albania, Romania all have high corruption, and low satisfaction.

Eurobarometer Data on Corruption

In European countries, people were asked: Apart from official fees, did you have to give an extra payment or a valuable gift to a nurse or doctor to make a donation to the hospital?

  • The EU average across all countries is that 3% of respondents answered yes to this question.

Afrobarometer Data on Corruption

Across all African countries, the African average is 13% of respondents answered yes to this question.

Trust in Healthcare Systems

Trust is a multi-criteria concept and influences health behavior.

  • If people have a lack of trust in the health system, they also tend to listen to non-expert voices.

World Bank Health Organization Governance Toolkit

There are rules-based and outcomes-based indicators.

  • Rules-based indicators: Existence of an up-to-date national health strategy linked to national needs and priorities.
  • Outcomes-based indicators: Health worker absenteeism in public health facilities.

Conclusion

Governance is about how societies make and implement collective decisions and is a key determinant of health system performance.

  • Policies often fail due to governance problems: bad implementation, supervision, and regulation.

  • There are problems of governance: too little, too much, or the wrong kind.

  • Governance is difficult to measure, but there is a wide range of indicators available; and is shaped by contextual factors.

  • Governance is complex because of the multiple levels of government involved in regulating health care systems.