Transcript Framework for Assessing Health Governance in Developing Countries: Gateway to Good Governance Siddiqi S; Masud T I; Nishtar S; Sabri B Health System Metrics.

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
Governance Defined
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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)
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Frameworks for the Analysis of
Governance
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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
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
WHO’s Domains of
Stewardship
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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)
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
PAHO’s Essential Public
Health Functions
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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 5
Eastern Mediterranean Regional Office, World Health Organization, Cairo
(PAHO 2002)
World Bank’s Governance
Indicators
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Process by which those in authority are selected
and replaced
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Ability of the government to formulate and
implement sound policies
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Voice and Accountability
Political Instability and Violence
Government Effectiveness
Regulatory Burden
Respect of citizens and the state for institutions
which govern their interaction
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Rule of Law
Graft (control of corruption)
(Kaufmann 1999)
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
UNDP’s Five Principles of
Good Governance
Principles
Legitimacy and voice
Thematic areas
Participation
Consensus
Direction
orientation
Strategic vision
Performance
Responsiveness
Effectiveness
Accountability
and efficiency
Accountability
Transparency
Fairness
Equity
and inclusiveness
Rule of law
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
(UNDP 1997)
Contemporary Issues in the
Governance of Health Systems
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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
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Why the term –’Governance’?
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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
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Health Governance Principles
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Strategic vision
Participation and consensus orientation
Rule of law
Transparency
Responsiveness
Equity and inclusiveness
Effectiveness and efficiency
Accountability
Information and intelligence
Ethics
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Health Governance Analytical
Framework
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Governance principle
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Domain
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Broad question
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Specific questions / item
Level of Assessment
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National
MOH Policy
MOH Implementation
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
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
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Data Collection and Sources
of Information
Documents
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National budget document, report of the treasury,
state bank,
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Reports of ministry of economics, national
statistical organizations
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Policy documents from MoH, analysis by
international and NGOs
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MoH policy/ implementation reports, media
reports, external reviews
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Health budget reports, budget speeches
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Reviews of the health legislative process
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National information policy
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MoH policy/ implementation reports,
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Media reports, external reviews of health policy
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PRSP documents
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MoH contracting manual, rules and procedures
for civil servants
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National statistical reports, national health reports
Interviews
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National and MOH
policymakers,
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Mid- and senior
managerial staff of the
MOH or its component
departments,
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Civil society organizations
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International development
agencies,
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Academic institutions,
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Media personnel and
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Direct community
representatives
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Applying the Health Governance
Framework in a Country Setting
Health governance map of Pakistan – Strengths
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Central level
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MOH policy level
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Social safety nets for the poor and vulnerable;
Increasing role of the media and NGO’s in protecting people’s health.
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
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Increasing public-private interaction
Preventive programs, especially the LHW Program which has a strong
community as well as an equity dimension
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Health governance map of
Pakistan – Weaknesses
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Central level
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Lack of participatory decision making and culture of accountability;
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Parallel streams of bureaucracy and technocracy do not work in
unison
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Adherence to rules and procedures is considered as an end;
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Lack of consumer protection act delays or deny justice
MOH policy level
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Short-term objectives override the need for focus on health outcomes;
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Health equity is not high on the policy agenda;
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Mechanisms to monitor transparency of decisions do not exist;
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Decisions often tinged with personal preferences, not evidence-based;
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Legislation on minimum standards of care is absent with lax regulation
and enforcement capacity;
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Policy, planning, health information and surveillance units are weak;
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Delays in release and utilization of funds;
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Accountability systems focus on procedure instead of performance;
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Bioethics is not on the policy radar of MOH.
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Health governance map of
Pakistan – Weaknesses
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MOH implementation level
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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.
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Appraisal of the Framework
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Can health governance be improved without addressing
overall governance of a country?
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Health governance assessment framework relies on qualitative
approach and does not follow a scoring or ranking system
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A health governance map can be developed for each country
Contemporary issues in relation to health governance
included
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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?
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Health system reforms versus broader civil service reforms
Flexibility in the framework to integrate newer ones as they emerge
Health governance framework does not cover
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global health governance
clinical governance
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Policy Implications of
Assessing Health Governance
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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
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Eastern Mediterranean Regional Office, World Health Organization, Cairo
Thank you
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Eastern Mediterranean Regional Office, World Health Organization, Cairo