Teaching Good Governance for Health


By: Dana Karen Ciccone, MIA

In this article, Dana Karen Ciccone gives a primer in how the Leadership, Management & Governance Project’s Senior Leadership Program is making health governance accessible to health leaders around the globe.

SLP Dana Ciccone

A key contribution of the Senior Leadership Program is the development of a curriculum that seeks to impart best practices for transparent, accountable and gender sensitive governance in the health sector. 

There are two primary challenges in teaching good governance for health. First is the fact that governance is a socially constructed idea, often difficult to define even among those who share a mother tongue.  Our preferences regarding power, authority and social structure are rooted in our heritage, our cultural history and our own experiences. All of these are deeply emotional and connected to our identity. The word ‘good’ is similarly subjective and imprecise. As educators, our task begins with a robust discussion of what good governance means to our participants, wherever they live and work. The very process of establishing consensus on the key principles and expectations that comprise ‘good governance’ is often novel in the contexts in which we teach. 

The second challenge is that while leadership and management are competencies that can be developed by an individual, governance is judged as a group decision-making process in an entire system. And it is often difficult to see how one individual’s action is linked to that system. Governance encompasses all the activities through which a community or group organizes itself and exercises authority to achieve particular collective ends. One person can influence a decision-making mechanism or process, but it takes many people working together to create a movement of social change. We assess governance according to how well the decisions made reflect the needs and wants of the people and agencies that are governed.  Hence, good governance is not achieved by enacting a series of recommended activities, but rather by creating a space and decision-making processes in which all relevant constituencies have meaningful participation in the policy making that impacts them.  What we must teach each participant, then, is to first understand his or her role in the larger governance architecture, and then, to identify process improvements that will increase accountability, transparency and effectiveness of the health sector or health services institution.

While each Senior Leadership Program is unique, there are a few broad guidelines we employ in the development and delivery of our governance modules.

1. Create a safe space for discussing controversial ideas

Our governance training begins with small group discussions about the “ideal community” that participants would create if they could. Each team then identifies a handful of concrete characteristics that they would be able to observe if they lived in this ideal community. By beginning with the hypothetical, we give participants a chance to voice indirectly the principles and practices that define good governance for them without assigning blame to aspects of their current system. We teach the governance practices of cultivating accountability, engaging stakeholders, setting shared direction, and stewarding resources, not as absolutes but rather landmarks across a spectrum of behavior. A similar approach can be used for an ideal institution.

2. Use appropriate, concrete examples

We know that the most profound learning happens not in the classroom, but in the act of applying knowledge gained. Because of this, the Senior Leadership Program is built around an assigned quality improvement project that participants must design, implement and evaluate before the final session.  Throughout this process we structure opportunities to apply good governance practices and principles, particularly in the development of a stakeholder mapping and an accountability plan for their project teams. A key teaching tool is the development of mini case studies, prepared with the help of local practitioners, describing typical scenarios across the health system in which a governance-related decision must be made. Participant teams discuss one of these scenarios for 30 minutes and together identify the governance issues at play. They then report back to the entire class on good governance principles that were demonstrated by the characters, as well as alternative decisions that could have been made to improve accountability, transparency and gender sensitivity in that situation.

3. Link recommended activities to desired outcomes

Because we have to start somewhere, our governance curriculum began with a model.  For months we researched, interviewed, debated and synthesized until we arrived at a series of practices, principles and actions that we felt comfortable presenting as predictors of effective health governance. But our model represents a shared history and culturally relevant understanding of governance that is particular to those who crafted it.  When we are in the field, we take participants through a similar exercise, asking, “How do you know when good governance is happening?” We want them to start with the evidence; with a description of what they see, hear and feel in a system that is governed well. Once participants can articulate the artifacts of good governance, then the actions they would need to take to achieve/create them are usually obvious.

4. Listen to the ideas of participants and adapt

Despite how much we prepare from afar, we cannot fully anticipate how appropriate and meaningful our governance teachings will be until we see our participants react. Throughout the in-country sessions we endeavor to remain open and flexible so that we can adjust our approach to have the greatest impact.  We count on our facilitators to check in with their teams every day and assess whether the participants are receiving the material in the way we had intended. In this way, we lead by example, demonstrating that our program is only done well when we are held accountable to our key stakeholders.

 

This tenet of flexibility is essential to making our capacity building efforts both meaningful and sustainable. Just in the course of implementing one program, our thinking on governance has evolved, and it is sure to progress as we learn from new participants, unique environments and unexpected challenges. 

We recently delivered our first certificates of completion for Advanced Training in Leadership, Management and Governance to 28 of Rwanda’s district medical directors and five National University of Rwanda School of Public Health faculty members.  Our ongoing Senior Leadership Program in Ethiopia will graduate all 11 of the country’s Regional Health Bureau Curative and Rehabilitative Core Process Teams in September.  In August, a Senior Leadership Program to strengthen the capacity of physical rehabilitation centers for the International Committee of the Red Cross will launch in Tanzania, hosting country teams from Ethiopia, Sudan, Tanzania and Zambia.

By Dana Karen Ciccone, Project Manager, Yale Global Health Leadership Institute

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