1. Framework for Assessing Health Governance in Developing Countries: Gateway to Good Governance
Siddiqi S; Masud T I; Nishtar S; Sabri B
Health System Metrics Technical Meeting
September 28-29, 2006
Montreux-Glion
Eastern Mediterranean Regional Office, World Health Organization, Cairo

2. Governance Defined
The exercise of political, economic and administrative authority in the management of a country’s affairs at all levels.
Comprises complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations
(UNDP 1997)
Eastern Mediterranean Regional Office, World Health Organization, Cairo

3. Frameworks for the Analysis of Governance
WHO’s domains of stewardship;
PAHO’s Essential Public Health Functions;
World Bank’s six Basic Aspects of Governance;
UNDP’s Principles of Good Governance
Eastern Mediterranean Regional Office, World Health Organization, Cairo

4. WHO’s Domains of Stewardship
Generation of intelligence
Formulating strategic policy direction
Ensuring tools for implementation: powers, incentives and sanctions
Building coalition / building partnership
Ensuring a fit between policy objectives and organizational structure and culture
Ensuring accountability
(Travis et al 2001)
Eastern Mediterranean Regional Office, World Health Organization, Cairo

5. PAHO’s Essential Public Health Functions
Monitoring evaluation and analysis of the health situation
Public health surveillance, research and control of risks
Health promotion
Social participation in health
Policies and institutional capacity for planning and management
Strengthening institutional capacity for regulation and enforcement
Evaluation and promotion of equitable access to health services
Human resource development and training
Quality assurance in personal and population-based health services
Research in public health
Reducing impact of emergencies and disasters on health
Eastern Mediterranean Regional Office, World Health Organization, Cairo
(PAHO 2002)

6. World Bank’s Governance Indicators
Process by which those in authority are selected and replaced
Voice and Accountability
Political Instability and Violence
Ability of the government to formulate and implement sound policies
Government Effectiveness
Regulatory Burden
Respect of citizens and the state for institutions which govern their interaction
Rule of Law
Graft (control of corruption)
(Kaufmann 1999)
Eastern Mediterranean Regional Office, World Health Organization, Cairo

7. UNDP’s Five Principles of Good Governance
Thematic areas
Legitimacy and voice
Participation
Consensus orientation
Direction
Strategic vision
Performance
Responsiveness
Effectiveness and efficiency
Accountability
Transparency
Fairness
Equity and inclusiveness
Rule of law
(UNDP 1997)
Eastern Mediterranean Regional Office, World Health Organization, Cairo

8. Contemporary Issues in the Governance of Health Systems
Role of the state vs. the market in health
Role of the ministries of health vs. other state ministries
Actors in Governance – public sector, civil society and the private sector
Static vs. dynamic health systems
Health Reform vs. Human Rights-based approach to health
Eastern Mediterranean Regional Office, World Health Organization, Cairo

9. Why the term –’Governance’?
Governance is better understood by those within the health system and those outside;
International development agencies have delineated the principles of governance that are well understood
Performance of the health system is dependent on overall governance of a country
Eastern Mediterranean Regional Office, World Health Organization, Cairo

10. Health Governance Principles
Strategic vision
Participation and consensus orientation
Rule of law
Transparency
Responsiveness
Equity and inclusiveness
Effectiveness and efficiency
Accountability
Information and intelligence
Ethics
Eastern Mediterranean Regional Office, World Health Organization, Cairo

11. Health Governance Analytical Framework
Governance principle
Domain
Broad question
Specific questions / item
Level of Assessment
National
MOH Policy
MOH Implementation
Eastern Mediterranean Regional Office, World Health Organization, Cairo

12. Analytical Framework for Assessing Strategic Vision
Governance principle - Strategic Vision
Domain - Long term vision
Broad Question
Specific Question
National level
What are the broad outlines of economic policy of the government;
Where does health rank in the overall development framework by resource allocation, and as percentage of total government expenditure
MOH policy level
Whether there is a long term vision (policy) for health;
Is there a national health policy/strategic plan available stating objectives, strategies with a time frame and resources allocated
MOH implementation level
Whether the implementation mechanisms are in line with the stated objectives of health policy
What priority programs are being implemented and how do they correspond to the policy objectives
Eastern Mediterranean Regional Office, World Health Organization, Cairo

13. Data Collection and Sources of Information
Documents
National budget document, report of the treasury, state bank,
Reports of ministry of economics, national statistical organizations
Policy documents from MoH, analysis by international and NGOs
MoH policy/ implementation reports, media reports, external reviews
Health budget reports, budget speeches
Reviews of the health legislative process
National information policy
MoH policy/ implementation reports,
Media reports, external reviews of health policy
PRSP documents
MoH contracting manual, rules and procedures for civil servants
National statistical reports, national health reports
Interviews
National and MOH policymakers,
Mid- and senior managerial staff of the MOH or its component departments,
Civil society organizations
International development agencies,
Academic institutions,
Media personnel and
Direct community representatives
Eastern Mediterranean Regional Office, World Health Organization, Cairo

14. Applying the Health Governance Framework in a Country Setting
Health governance map of Pakistan – Strengths
Central level
Social safety nets for the poor and vulnerable;
Increasing role of the media and NGO’s in protecting people’s health.
MOH policy level
Preparation of draft bills to update health legislation;
Emerging role of the Pakistan health policy forum as a civil society organization;
Stable turnover of health policymakers during the last six years are positive elements
MOH implementation level
Increasing public-private interaction
Preventive programs, especially the LHW Program which has a strong community as well as an equity dimension
Eastern Mediterranean Regional Office, World Health Organization, Cairo

15. Health governance map of Pakistan – Weaknesses
Central level
Lack of participatory decision making and culture of accountability;
Parallel streams of bureaucracy and technocracy do not work in unison
Adherence to rules and procedures is considered as an end;
Lack of consumer protection act delays or deny justice
MOH policy level
Short-term objectives override the need for focus on health outcomes;
Health equity is not high on the policy agenda;
Mechanisms to monitor transparency of decisions do not exist;
Decisions often tinged with personal preferences, not evidence-based;
Legislation on minimum standards of care is absent with lax regulation and enforcement capacity;
Policy, planning, health information and surveillance units are weak;
Delays in release and utilization of funds;
Accountability systems focus on procedure instead of performance;
Bioethics is not on the policy radar of MOH.
Eastern Mediterranean Regional Office, World Health Organization, Cairo

16. Health governance map of Pakistan – Weaknesses
MOH implementation level
Minimal protection against hazards from personal health services;
Gaps exist in policy and practice for recruitment, posting and promotion of staff and rules favor seniority over meritocracy;
Instruments for evaluation of staff performance are improperly used;
Responsiveness of public sector health services is not monitored;
Physicians turned managers lack understanding of administrative matters while bureaucrats lack health orientation;
Physicians and allied staff extensively engage in private practice outside and often within public institutions;
Support systems function inefficiently;
Code of ethics exists with the professional associations but not practiced.
Eastern Mediterranean Regional Office, World Health Organization, Cairo

17. Appraisal of the Framework
Can health governance be improved without addressing overall governance of a country?
Health system reforms versus broader civil service reforms
Health governance assessment framework relies on qualitative approach and does not follow a scoring or ranking system
retains the richness of information collected
development of a scoring system is not precluded
Does the assessment framework allow for cross-country comparison of the governance function?
A health governance map can be developed for each country
Contemporary issues in relation to health governance included
Flexibility in the framework to integrate newer ones as they emerge
Health governance framework does not cover
global health governance
clinical governance
Eastern Mediterranean Regional Office, World Health Organization, Cairo

18. Policy Implications of Assessing Health Governance
Raises awareness among policymakers about governance as a function of the health system
Provides an avenue for debate on a subject that is often ‘pushed under the carpet’
Assesses each governance principle and allows developing interventions to address them
Governance issues identified at three levels, allowing for measures at each
Improving health governance requires political commitment as well as financial resources
Eastern Mediterranean Regional Office, World Health Organization, Cairo

19. Thank you
Eastern Mediterranean Regional Office, World Health Organization, Cairo