Governance for health

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Governance influences all other health system functions, thereby leading to improved performance of the health system and ultimately to better health outcomes.

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Governance for health

  1. 1. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatGovernance For Health‫الصحة‬ ‫الحوكمة من أجل‬ Dr. Ahmed-Refat A.G Refat Dr. Ahmed-Refat AG Refat Dec. 2012 1
  2. 2. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat “good governance is perhapsthe single most important factor in eradicating poverty and promoting development” Kofi Annan The former Secretary General of the United Nations, 2
  3. 3. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Contents Why GOVERNANCE for health? GOVERNANCE background Basic Concepts:  GOVERNANCE – Stewardship- Intersectoral action GOVERNANCE in health sector History of GOVERNANCE Health GOVERNANCE actors Principles of GOVERNANCE Current Framework of GOVERNANCE WHO –PAHO -World Bank UNDP Assessment approach 3
  4. 4. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatWhy Governance for Health ?The complex epidemiological, economic and socialissues confronting health systems around the world make it necessary for governments to adjust theirapproaches in order to manage these challenges and ensure the health of their populations and the prosperity of their countries. 4
  5. 5. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Why Governance for Health ?- conts In recent decades, knowledge development about what creates health and ill- health has made it clear that the only way to make real gains in populationhealth is to broaden strategies beyond the health care system, to include conditions in which people live, work and play. 5
  6. 6. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Why Governance for Health ?- conts Health systems must therefore subscribe to this broader vision, and the governments that produce them must consider population health as an issuethat concerns every sector and calls upon all actors of society. Governance influences all other health systemfunctions, thereby leading to improved performance of the health system and ultimately to better health outcomes. 6
  7. 7. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Determinants of Health 7
  8. 8. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Relationship between Governance indices and health outcomesKKM Index: Kaufmann, Kraay, Matruzzi Index (2005) 8
  9. 9. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Governance: Background Recent international WHO consensuses expressed inthe Bangkok Charter for Health Promotion (WHO, 2005) and the Commission on Social Determinants of Health (WHO, 2008), recommend that governments establish processes favouring a “whole of government approach”, which ensure more coherence among a government’smissions insofar as they touch on population health and wellbeing. 9
  10. 10. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Governance: Background -conts Other policy documents and declarations at Regionallevels have also strongly promoted this view, including, forexample, the WHO Health for all Update 2005 the recent Community strategy “Together for Health: a strategy approach for EU 2008-2013”. 11
  11. 11. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Governance: Background -conts The term “whole of government approach” refers to what is called a pan-governmental approach, that is, anapproach that calls for both horizontal (cross government) and vertical (across levels of government) management.Such an approach requires the establishment of various mechanisms allowing for coordination andcollaboration between various government actors and stakeholders from civil society or the private sector. 11
  12. 12. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Basic Concepts Stewardship GovernanceIntersectoral Action 12
  13. 13. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 1. StewardshipThe concept of stewardship was put forward by the World HealthReport 2000 as a central function for health ministers (WHO, 2000). It is“the careful and responsible management of the well-being of the population” (WHO 2000). and it refers to three broad tasks: 1._ Providing vision and direction for health systems; 2._ Exerting influence; 3._ Collecting and using intelligence on health system performance in order to ensure accountability and transparency. 13
  14. 14. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatThe function of stewardship is essentially to develop intersectoralwork processes in all sectors of the government and with its partnersto promote the implantation of health programs.The World health report 2000 proposed stewardship as one of the fourmain functions of the health system, along with financing, creating andmanaging resources, and service delivery . It recognized stewardship as the function of the government responsible for the welfare of thepopulation and concerned about the trust and authority with which its activities are viewed by the public http://www.euro.who.int/healthsystems/stewardship/20061004_1 14
  15. 15. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 2. GovernanceGovernance refers to  the challenge to take on the direction and coordination of a complex collection of organizations through a control system built upon many links.  The exercise of political, economic and administrative authority in the management of a country’s affairs at all levels. 15
  16. 16. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat  2. Governance-conts “the set of values, policies and institutions by which a society manages economic, political and social processes”. “the manner in which power is exercised in the management of a country’s economic and social resources for development”. 16
  17. 17. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 2. Governance-conts  "the exercise of political, economic and administrative authority in the management of a country’s affairs at all levels".  Governance comprises the complex mechanisms, processes and institutions throughwhich citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations. 17
  18. 18. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 2. Governance-contsThe key elements for good governance are: 1. _ The inclusion of several actors from both inside and outside the government; 2. _ The use of horizontal and vertical management; 3. _ Accountability and control mechanisms; 4. _ High-level political commitment; 5. _ Financial and human resources support; 6. _ Skills development; 7. _ The existence of knowledge production systems. 18
  19. 19. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 3. Intersectoral actionThe intersectoral action is the foundation for the practice ofstewardship and governance.Key elements of intersectoral actions : 1. _ Create an inspiring framework for health; 2. _ Ensure political support; 3. _ Engage key partners at the very beginning; 4. _ Ensure leadership and rewards; 5. _ Develop practical models, tools and mechanisms to support the implementation of intersectoral action; 6. _ Accountability frameworks; 19
  20. 20. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Governance in the health sectorThe concept of stewardship, or governance, in the healthsector is relatively new, and there is little guidance forcollection or standardization of information on this aspect ofthe health system.Evidence shows a positive relationship between governanceindices and measures of health performance and outcomes . 21
  21. 21. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Historyof Governance 21
  22. 22. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatFirst wave: intersectoral action and primary health careIn the Declaration of Alma-Ata (WHO, 1978), the participantsin the International Conference on Primary Health Care statedthat the role of governments in health, in all countries, bothdeveloping and developed, in the late 20th century should beredefined and strengthened and that intersectoral action is akey to better health.The Declaration called for a comprehensive health strategythat not only provided health services but also addressed theunderlying social economic and political causes of poor health. 22
  23. 23. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatSecond wave: health promotion and healthy public policyThe health promotion movement reinforced call to engageother sectors for health in the 1980s.The Ottawa Charter for Health Promotion (WHO RegionalOffice for Europe, 1986) introduced “build healthy publicpolicy” as one of the five action areas for health promotion,the others being “create supportive environments”, “strengthencommunity action”, “develop personal skills” and “reorienthealth services”. 23
  24. 24. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatThird wave: health in all policiesThe health in all policies approach considers the impacts of other policies on health through health determinants when policies of all sectors are being planned, decisions between various policy options are being made, and when implementation strategies are being designed. 24
  25. 25. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Health Governance Actors The first set of actors include politicians, policymakers, and other governmental officials The second set of actors is health service providersThe third set of actors contains beneficiaries, health services users and general public 25
  26. 26. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 26
  27. 27. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Elements of Good Governance1. Public Participation:2. Accountability and transparency.3. Respect for the rule of law and Human Rights4. Efficient and effective public sector management : 27
  28. 28. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatGovernance in Health System Building Blocks 28
  29. 29. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefatGovernance of the Health System: Principles Strategic vision Participation and consensus orientation Rule of law Transparency Responsiveness Equity and inclusiveness Effectiveness and efficiency Accountability Information and intelligence Ethics 29
  30. 30. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Current Frameworks forAssessing governance 31
  31. 31. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat The current frameworks for assessing governance are as follows: 1- WHO- domains of stewardship; 2- Pan American Health Organization’s (PAHO) essential public health functions (EPHF); 3- World Bank’s six basic aspects of governance; 4- UNDP’s principles of good governance.Siddiqi S et al., Framework for assessing governance of the health system in developing countries: Gateway to good governance HealthPolicy 90 (2009) 13–25 31
  32. 32. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 1- WHO- domains of stewardshipThe World health report 2000 recognizes stewardshipas a function of the health system similar to governance. Itidentifies several basic tasks of stewardship: Generation of intelligence Formulating strategic policy direction 32
  33. 33. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Ensuring tools for implementation: powers, incentives and sanctions Building coalition/building partnership EPHF 4 Social participation in health Ensuring a fit between policy objectives and organizational structure and culture Ensuring accountabilityhttp://www3.who.int/whosis/discussion papers/pdf/paper48.pdf. 33
  34. 34. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat2. Pan American Health Organization’s (PAHO) essential public health functions 34
  35. 35. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 35
  36. 36. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 3- World Bank’s (WB) six basic aspects of governanceThe World Bank has been among the leading agencies in raisingawareness of the importance of governance in economic development, indeveloping methodological approaches to its measurement and in rankingcountries on the basis of governance performance . TheWorld Bank’s governance indicators are organized into three clusters corresponding to the six basic aspects of governanceKaufmann D, Kraay A, Zoido-Lobaton P. Governance matters. Washington:World Bank policy research working paper no. 2196; 1999. 36
  37. 37. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 37
  38. 38. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 4- UNDP’s principles of good governanceThe UNDP enunciates a set of principles of good governanceforwhich there is evidence that these have a claim to universalrecognition . These five principles have been further elaborated intonine thematic areasUnited Nations Development Programme. Governance for sustainable human development: a UNDP policydocument. New York: UNDP; 1997. http://magnet.undp.org/policy/chapter1.htm. 38
  39. 39. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 39
  40. 40. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat Governance Assessment Approaches 41
  41. 41. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat I- USAIDS- 2002http://www.healthsystems2020.org/content/resource/detail/528/ 41
  42. 42. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 42
  43. 43. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat II-FrameworkFor Assessing Health Governance. 43
  44. 44. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 44
  45. 45. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 45
  46. 46. Governance For HealthDr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 46
  47. 47. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat II-FrameworkFor Assessing Health Governance Based Mainly on:Kirigia and Kirigia (2011). The essence of governance in health development .International Archives of Medicine p. 4:11 47
  48. 48. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 1. Public health leadership and management1.1 Leadership responsibilities:1.2 National health policy (NHP):1.3 National health strategic plan (NHSP):.1.4 Dissemination of NHP and NHSP:1.5 Implementation: 48
  49. 49. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 2. Rule of health-related laws2.1 Existence of health-related legislations:2.2 Enforcement of health-related legislations: 49
  50. 50. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 3. Community participation & responsiveness3.1 Participation in NHP and NHSP development:3.2 Participation in NHSP implementation:3.3 Participation in tracking of progress:3.4 Responsiveness to communities non-medicalexpectations: 51
  51. 51. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 4. Effective internal and external partnerships for health4.1 Intersectoral action:4.2 Public-private partnerships:4.3 Alignment of aid flows to national healthdevelopment priorities:4.4 Strengthen capacity by coordinated support:4.5 Use of country procurement and public financialmanagement systems: 51
  52. 52. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat4.6 Strengthen national capacity by avoiding parallelimplementation structures:4.7 Aid is more predictable:.4.8 Aid is untied:.4.9 Shared analysis:4.10 Sufficient integration of global programmes andinitiatives into NHSP: 52
  53. 53. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 5. Horizontal and vertical equity in health systems5.1 Horizontal equity:5.2 Vertical equity:5.3 Health fairness in financial contribution (HFC): 53
  54. 54. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 6. Efficiency in resource allocation and use6.1 Allocative efficiency:6.2 Technical efficiency:6.3 Productivity growth:6.4 Institutionalization of efficiency monitoring: 54
  55. 55. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 7. Accountability and transparency in health development7.1 Existence of transparent results-orientedreporting and assessment frameworks7.2 Diagnostic reviews:7.3 Use of information from diagnostic reviews:7.4 Publishing of audit reports for publicconsumption: 55
  56. 56. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 8. Evidence-based decision-making8.1 National health research systems:8.2 Health knowledge management systems (HKMS):8.3 Health management information systems:8.4 Information, Communication and TechnologyConnectivity: 56
  57. 57. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 9. Ethical practises in health research and service provision9.1 International ethical guidelines for medicalpractice and health research:9.2 Bioethics review system9.4 Institutionalization of ethics training: 57
  58. 58. Governance For Health Dr. Ahmed-Refat AG Refat ( ) www.SlideShare.net/AhmedRefat 10. Macroeconomic and political stability10.1 Link between national economic developmentplan, Poverty Reduction Strategy Paper andNHP/NHSP:10.2 Existence of a medium-term expenditureframework (MTEF):10.3 Political stability:Kirigia and Kirigia (2011). The essence of governance in health development .International Archives of Medicine p. 4:11 http://www.intarchmed.com/content/4/1/11 http://www.healthsystems2020.org/content/resource/detail/528/ 58

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