Governance in the health sector can be understood as a way of working on the framework conditions underlying the health system. By ensuring transparency, accountability or efficiency in procedures, decision-making processes and service delivery, it is expected that processes will improve and eventually convert into better health outcomes.
For example, corruption can have a devastating impact on the health sector: embezzlements of public monies, denied access to care through bribes and extortion, lack of public investments, lack of merit-based recruitment because of nepotism, etc. Those problems cannot be addressed with health-related tools. Governance principles translated into concrete measures, will help overcome those problems by changing rules, regulations, processes and mindsets.
For a development agency, two levels of governance intervention can be looked at:
- Health sector environment: The first level concerns how programmes and projects can have a positive impact on the health sector in general, and, conversely, how the health sector environment can/ does impact the programmes/projects. Addressing issues at this level can only be done iteratively.
- Project institutional set-up: The second level relates to the way the programme/project is constructed, from a governance perspective, which can have spill-over effects on the sector.
The five identified governance principles to be integrated in health activities are the following:
Accountability: refers to the control of the power exercised within state and society, as well as to the obligation for the people holding power to explain their decisions. In addition, it concerns the duty of the controlling agencies to reward good performance and to sanction abuses of power. Accountability presupposes clear definitions of the functions, duties, and rules for the scope of action of public and private institutions.
Transparency: implies that the public in general, or at least those directly affected, should obtain information from the state about the rationale underlying decisions, decision-making criteria, the intended manner of implementing a decision, and any insight into its effects.
Non-discrimination: means that no group may be excluded from power and resources. This implies that proactive public integration policies for excluded or marginalised groups need to be implemented. Non-discrimination policies have to be applied for the expressed purpose of reducing inequalities between men and women, urban and rural populations, and between different ethnic groups.
Participation: implies that all population segments need to be connected to the political and social processes that affect them. This means that public forums exist where different groups can express dissenting opinions and personal interests, and where these viewpoints are treated as serious input in the decision-making process.
Efficiency: implies that financial and human resources are used in optimal fashion (in other words, the target is fixed in relation to the resources, or the resources are adapted to the fixed target), without waste, corruption, or delays.
Those principles can translate, for example, concretely into the following measures:
1. Health sector environment
- accountability enhanced through instruments such as users satisfaction surveys, Joint Annual Reviews under SWAps, publications of audits and discussions on Medium Term Expenditure Frameworks with civil society
- demand for accountability and transparency increased through information on patients rights, that raise the level of awareness within the population which will, in return, ask more for results. Community participation in health
boards at district or facility level can also be effective. (Demand for accountability comes usually mostly from donors).
- non-discrimination addressed through changes in the health system (f.ex. basic-benefit package, per capita financing, awareness raising about quality standards for youth-friendly health services)
- Open and fair recruitment processes to avoid decisions regarding staff made on nepotism
- Transparency regarding prices of the various services in order to avoid patients being asked to pay bribes.
- Measures to improve vertical accountability within the Ministry of Health, including through quality assurance and management.
- Efficiency favoured through task shifting from doctors to nurses and focus on primary health care.
2. Project institutional set-up
The following elements shall be considered:
a. Publication of results and accounts of the project: to whom, how, how often? (accountability)
b. Internal decision-making processes : how is this regulated? Who is taking decisions formally? Who is taking decisions informally? (accountability)
c. Does the project involves giving incentives to stakeholders? On the basis of what? How is this made transparent? (accountability /Transparency)
d. Participation of stakeholders and beneficiaries : who participates in the project? At what level? For what purpose? (Participation)
e. Representation of minority groups in staff of projects : which groups are represented in the staff of the project? (Non-discrimination)
f. Power relations within the project : did you notice power relations which impede the smooth running of the project? (Non-discrimination)
g. Relations between means (financial and human) and goals : how do you assess the ratio between means and goals of the project (“value-for-money”)? (Efficiency)
h. Parallel structures: does the project work with a parallel structure (Project Implementation Unit (PIU) instead of existing structures)? If yes, how could this be avoidable in the future, for sustainability reasons? (Efficiency)
For more information, please read:
|Governance as a transversal theme, an implementation guide|
|Download (PDF, 757 KB): [en]|
|Vademecum Governance transversal for projects/sector|
|Download (PDF, 179 KB): [en]|
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