On Governance for Health

Mahesh Shukla

Senior Technical Advisor for Public Sector Governance

A few weeks ago, the USAID-funded Leadership, Management, and Governance (LMG) Project celebrated five years of work and entered into its sixth and final year, and over this time, we have learned a lot about governance for health.

The LMG Project looks at governance as setting shared strategic direction and objectives; making policies, laws, rules, regulations, or decisions; raising and deploying resources to accomplish the strategic goals and objectives; and making sure that the strategic goals and objectives are accomplished.

Key Practices of Good Governance

As a result, the LMG Project frames governance work in health settings using these key practices of good governance:

  1. Cultivating accountability
  2. Engaging stakeholders
  3. Setting shared strategic direction
  4. Stewarding resources
  5. Continuous governance improvement

We distilled these key practices from our reviews of literature, surveys and key informant interviews; roundtable discussions; and fieldwork. Then, we evaluated the impact of these key practices in Afghanistan.

Governance for health does not happen in isolation. Instead, it happens within the broader social, cultural, political, and economic context. This context not only deeply influences governance but also determines how governance is structured and how it functions. Rules (formal institutions) and norms (informal institutions) are products of social, historical, political, and economic contexts and they shape the behavior of people and groups governing in the health sector.

I am often asked about the link between good governance and health system performance and health outcomes. There is a definite link. Good governance enables sound management, and effective and efficient management of people, money, medicines, and information enables reliable health service delivery.

The LMG Project's conceptual framework of governance for health.
The LMG Project's conceptual framework of governance for health.

Governance for Health

The LMG Project’s conceptual framework of governance for health recognizes that context matters, and that context influences the drivers of governance – economic incentives and political will – that shape the behavior of the people who govern, manage, and deliver health services.

Within the context and even with political will and economic incentives in place, governance will not be effective without four enablers:

  1. Leadership skills
  2. Ethics and integrity
  3. Performance measurement
  4. Use of information, evidence, and technology

With these in place, good governance enables sound management which in turn enables reliable service delivery. As a result, individuals with self-efficacy are able to use health services and adopt healthy behaviors and, leading to a healthier population.

When people who govern cultivate governing competencies, consistently apply practices of good governance, and establish the essential governance infrastructure, they become a powerful enabler of a domino effect that leads to healthier populations.

Governance Shifts

Take note of the following two governance scenarios – one of a present governance reality and another of the governance aspiration.

A cartoon boardroom with eight men sitting around a table trying to build a consensus. (Figure: MSH)

This is a scene that we too often see in a governance setting or a boardroom. The chair is standing in the middle, trying to marshal the assistance of his board colleagues (all men) to improve the organization’s services while the other board members all have their own thoughts. The second scenario is what we aspire to see.

A cartoon boardroom with eight women, young people, and men sitting at a table and working together to make decisions. (Figure: MSH)

First, notice several young people and women around the governing table. In this scenario, all of the board members are focused on collaborating to improve the organization’s performance.

If we aspire to see a transition from the first scenario to the second, certain attitudinal, behavioral, and institutional shifts are required. Three examples of these shifts are from governance as usual to pursuit of efficiency and sustainability, from opaque to transparent decision-making processes, and from exclusive governance to decision-making that is inclusive of diverse stakeholders like people with disabilities.

These governance shifts – and the many, many others – are easier said than done. Often the entrenched approaches to governing suit the governing elites and hence they are intractable to change.

Thinking and Working Politically

This is where thinking and working politically might be helpful, especially to the external entities wanting to catalyze a change.

Try to unpack local realities and local context, identify the main actors and their incentives, support reform agents, and mobilize reform coalitions.

USAID is increasingly adopting this approach in its work, and USAID’s Center of Excellence on Democracy, Human Rights and Governance has already begun its work on integrating PITA principles – participation, inclusion, transparency, and accountability – in cross-sectoral programming.

Ineffective governance does not need to keep hindering the health sector performance because the key practices of governance can be learned and applied by using the LMG Project’s array of governance tools, guides, handbooks, publications, eLearning courses, and apps. In particular, the LMG Project’s three eLearning courses on Governance and Health are already proving to be popular with the learners on the USAID Global Health eLearning Center. 

This blog post is the third in a series of three blog posts around the 4th Governance for Health Roundtable that was held in Washington, DC, on September 29, 2016.