1. RTI International is a trade name of Research Triangle Institute www.rti.org Health Systems and the Governance Building Block Derick W. Brinkerhoff Global Health Council, 37 th Annual International Conference Panel on Health Systems Building Blocks: How to Build Strong Health Systems that Deliver Quality Services Washington, DC June 15, 2010

2. www.rti.org 2 Where does governance fit in health systems performance?

3. www.rti.org 3 Defining governance Governance is about rules that distribute roles and responsibilities among societal actors and shape interactions among them. These rules can be: –formal, embodied in institutions (e.g., democratic elections, parliaments, courts, sectoral ministries); –and informal, reflected in behavioral patterns (e.g., trust, reciprocity, civic- mindedness). Governance encompasses authority, power, and decision-making in the institutional arenas of: –civil society –politics –policy –public administration.

4. www.rti.org 4 Health governance model

5. www.rti.org 5 Health governance and power inequalities

6. 6 Governance levels

7. www.rti.org 7 Responsible health governance Responsiveness to public health needs and clients/citizens preferences Leadership to address public health priorities Inclusion of clients/citizens voice Clear and enforceable accountability Transparency in policymaking, resource allocation, and performance Evidence-based policy and decision-making Efficient, effective, and equitable service provision, regulation, and management

8. www.rti.org 8 Entry pointsvoice & accountability: citizens facility PAQs (Partenariats pour lAmélioration de la Qualité) in Rwanda Quality Assurance Partnership Committees (QAPCs) in the Philippines

9. www.rti.org 9 Entry pointsresponsiveness, accountability, transparency: central local, public private Transfer of resources, authority, decision-making, accountability Examples: –Devolution of health functions to local governments, e.g., Philippines, Rwanda, Uganda –Intergovernmental transfers, e.g., District Incentive Fund grants in Rwanda –Hospital autonomy in sub- Saharan Africa –Privatization, e.g, Family Group Practices in Kazakhstan

10. www.rti.org 10 Entry pointsresponsiveness, efficiency & effectiveness: MOH facility HRH planning, e.g., workforce planning in Egyptian governorates Financial incentives, e.g, pay-for-performance Non-monetary incentives, e.g., operations research in Swaziland on incentives for HCT performance

11. www.rti.org 11 Entry pointsaccountability, regulation, transparency: rule of law Medicines Transparency Alliance (MeTA), UN Convention against Corruption (UNCAC) Improved management control systems, e.g., electronic cash registers in Mombasa, Kenya hospital Performance-based monitoring, e.g., Global Fund accountability system and LFA oversight Citizen report cards on health services, e.g., India and Uganda

12. www.rti.org 12 A governance perspective on HSS helps to… –Identify institutional factors influencing HSS at various levels (facility global) –Recognize the role of power and politics –Clarify connections among HS actors –Connect the HS building blocks –Focus attention on incentives for responsiveness and sustainable performance