Sustainable Health Gains from Good Governance of Hospitals and Health Systems Mini-University 2014 March 07, 2014 Mahesh Shukla, MD, DrPH, MPA Good Governance of Hospitals and Health Systems 1

2  Afghanistan  Benin  Bolivia  Bosnia  Côte d’Ivoire  Ethiopia  Cambodia  Cameroon  Georgia  Ghana  Haiti  Honduras  Kenya  Lebanon  Liberia  Libya  Moldova  Nicaragua  Nigeria  Pakistan  Peru  Rwanda  Sierra Leone  South Africa  Sri Lanka  Tanzania  Uganda  Zambia  Zimbabwe  Vietnam Where LMG Project Works Good Governance of Hospitals and Health Systems

3 Fill in the blanks. ________________ facilitate the work of _____________ who in turn facilitate the work of __________________.  Health providers and workers  Health managers  Leaders who govern

4 Fill in the blanks. Effective ________________ is essential for effective _____________ of ________________ which in turn is essential for effective __________________.  people, money, medicines and information  health service delivery  management  governance

Effective Health System Governance Good Governance of Hospitals and Health Systems 5 is essential for health system performance.

Focus of Presentation  Explore the link between good governance of health systems and their performance and health outcomes  Discuss five governing practices that influence the performance of health systems Good Governance of Hospitals and Health Systems 6

Evidence on impact of governance Björkman and Svensson 2009 Olafsdottir et al Maureen Lewis 2006 LMG’s pilot study in Afghanistan 7 Good Governance of Hospitals and Health Systems

Björkman and Svensson 2009  Randomized field experiment  Conducted in 50 rural communities in Uganda  25 in intervention group and 25 in control group  Community members monitored public dispensaries and health care providers  Community monitoring improved health outcomes at the end of one year  Relative to the comparison group, communities with intervention saw o significant increase in the weight of infants, and o 33 percent reduction in mortality rates of children under five years of age. 8

Olafsdottir et al Governance was seen to be inversely associated with under-5 mortality rate in 46 African countries. (after controlling for healthcare, finance, education, and water and sanitation) 9 Good Governance of Hospitals and Health Systems

Maureen Lewis 2006 Good governance is important in ensuring effective health care delivery. Returns to investments in health are low where governance issues are not addressed. 10 Good Governance of Hospitals and Health Systems

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Good Governance of Hospitals and Health Systems Governance is (1)setting strategic direction and objectives; (2)making policies, laws, rules, regulations, or decisions, and raising and deploying resources to accomplish strategic goals and objectives; and also (3)oversight monitoring to make sure that strategic goals and objectives are accomplished. (Based on evidence from our review of literature, surveys, and fieldwork in Kenya, Nigeria, Ethiopia and Afghanistan) Definition of Governance 12

Governance is robust when (1)the decisions are based on information, evidence, and shared values; (2)the process is transparent, inclusive, and responsive to the needs of the people the organization serves; (3)those who make and those who implement decisions are accountable; (4)the strategic objectives are effectively, efficiently, ethically, and equitably met; and (5)the vitality of the organization is maintained and its mission is served. Good Governance of Hospitals and Health Systems 13

Key Governing Practices for Good Governance of Health Systems (Based on evidence from our review of literature, surveys, and fieldwork in Kenya, Nigeria, Ethiopia and Afghanistan) 14 EnablersPractice  Effective leadership and sound management  Openness and transparency  Inclusion and participation  Gender-responsiveness  Intersectoral collaboration  Ethical and moral integrity  Pursuit of efficiency and sustainability  Measurement of performance  Use of information and evidence  Use of technology in governing 1. Cultivating accountability 2. Engaging stakeholders 3. Setting a shared strategic direction 4. Stewarding resources 5. Continuous Governance Enhancement (Assessing and enhancing governance)

Results of our pilot study in 3 provinces and 11 districts of Afghanistan  13 to 21% improvement in governance  20% increase in antenatal care visit rate in the pilot provinces 15

Governing bodies are being established at all levels and thousands of people are being invited to perform a governing role, often without adequate preparation Our work in Africa and Asia demonstrates growing recognition of the value to build the capacity of leaders who govern.

17 Kenya Hospital boards, distribution by region# of Hospital BoardsTotal number of board members 1. Coast Nairobi Western Rift Valley Eastern Nyanza North Eastern Central Sub Total 275 3,575 Primary health care facilities boards# of Primary facility boardsTotal number of board members Health Centers and Dispensaries 3,636 47,268 Government Semi-autonomous health institutions with functional boardsTotal number of board members 1. Kenyatta National Referral Hospital11 2. Moi Teaching And Referral Hospital13 3. Kenya Medical Training College18 4. Kenya Medical Supplies Agency (KEMSA)13 5. Pharmacy And Poisons Board9 6. Medical Practitioners And Dentists Board16 7. Nursing Council Of Kenya18 8. Hospital Management Services Fund13 9. Health Sector Services Fund (HSSF) National AIDS Control Council Kenya Medical Research Institute National Hospital Insurance Fund14 51,013 persons are serving on the governing bodies of 3,923 government health sector institutions

Governance Guides for Health Systems 18

LMG Governance Guides 19

20 Name the five effective governing practices.  Cultivating ________________  Engaging _________________  Setting a shared ___________ ________  Stewarding ____________  Continuous _____________ ___________

LMG Governance Handbooks 21

Good Governance of Hospitals and Health Systems Thank you for your interest! Please visit us at Q & A, Comments 22

23 Cultivating Accountability Your personal accountability Accountability of your organization to its stakeholders Internal accountability in your organization Accountability of health providers and health workers Managing performance Sharing information Developing social accountability Using technology to support accountability Smart oversight Engaging Stakeholders Sincere stakeholder invitations Sincere stakeholder engagement Build trust Engage with patients Engage with doctors, other clinicians, and health workers Collaborate with other sectors Gender-responsive governance Setting Strategic Direction Define the population health goals Establish a shared vision among key stakeholders Enable leadership in the organization Create a successful strategic plan Implement the strategic plan Report progress Stewarding Resources Responsibly Wisely raise and use resources Practice ethical and moral integrity Build management capacity Measure performance Use information, evidence, and technology in governance Eradicate corruption Continuous Governance Enhancement Cultivate governance competencies Build diversity in the governing body Governance orientation and education Governance assessments Effective governing body meetings Governance policies Governance technologies Continuous governance enhancement

24 Handbooks for Governance Leaders and Senior Managers of the Ministries of Health, Provincial and District Health Systems, and Hospitals and Health Centers Table of contents Learning Plan Instructions for Facilitators Introductory Session: Establishing rapport and understanding Session 1: Accessing Governance Resource Suite Session 2: Participants apply the Challenge Model to governance in their own setting Session 3: Roles and responsibilities of a governing body Session 4: Cultivating accountability Session 5: Engaging stakeholders Session 6: Setting a shared strategic direction Session 7: Stewarding resources Session 8: Assessing and enhancing governance Session 9: Competency-based governance Session 10: Infrastructure for effective governance Session 11: Governance enhancement planning Session 12: Evaluating the learning experience Appendix 1: Governance Development Plan Appendix 2: Case study for reflection

Good Governance of Hospitals and Health Systems 25

Good Governance of Hospitals and Health Systems 26 References Björkman M, Svensson J Power to the People: Evidence from a randomized field experiment on community-based monitoring in Uganda. The Quarterly Journal of Economics, 124(2), pp Olafsdottir A, Reidpath D, Pokhrel S, Allotey P Health systems performance in Sub-Saharan Africa: governance, outcome and equity. BMC Public Health, 11(1), pp Rajkumar AS, Swaroop V Public spending and outcomes: Does governance matter? Journal of Development Economics, 86(1), pp Lewis M, Pettersson G Governance in health care delivery: raising performance’. World Bank Policy Research Working Paper 5074.