The role of governance in promoting IHR implementation
WHO defines governance alongside leadership as ‘ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, attention to system design and accountability’.14 Governance is also defined as ‘developing and setting effective rules in the institutional arenas for policies, programmes and activities relevant to fulfil public health functions to achieve the objectives of the health sector’.15 Health systems governance is the ‘mortar’ which holds five other building blocks of health system: human resources, financing, health systems information, medicines, vaccines and technologies and effective health service deliveries.1 16 There is increasing evidence that governance is a critical building block for improving health system performance to achieve UHC.17 For instance, Ciccone et al18 showed how improved governance mechanisms have been associated with positive health outcomes. Lazarova highlighted that improved quality of regulatory capacity, rule of law and corruption control had reduced infant mortality rates.19 Other studies in sub-Saharan Africa have highlighted that, with good health systems governance, spending in health was twice as effective in reducing under-5 mortality and increased life expectancy.20 21 The importance of good governance is also reflected in the United Nations Sustainable Development Goals as Goal 16 comprises of the rule of law, accountability, participation and transparency.22
Evidence suggests that governance is the best lever to achieve IHR compliance as it is a cross-cutting framework.23 24 There are an increasing number of studies highlighting a positive association between good health system governance and health system outcomes/performance.17 25 For instance, good governance of public health agencies with a clear line of accountability, strong leadership and command system are critical for the effective performance of public health emergency operating centres (HEOC).26 Therefore, leveraging governance efforts can help achieve collaborative working within and across sectors. Collaboration and multisectoral working are vital to achieving IHR compliance as the prevention and control of public health risks are no longer the responsibility of a single ministry or department.7 Without coordination and engagement with other sectors such as animal health, transport, communication, education, foreign affairs, border and trade, IHR strengthening cannot be achieved. The Myanmar JEE explicitly highlighted that ‘the effective implementation of the IHR requires multisectoral/ multidisciplinary approaches through national partnerships for efficient and alert response systems. Coordination of nationwide resources, including the designation of a national IHR focal point, which is a national centre for IHR communications, is a key requisite for IHR implementation’.12
The Myanmar NAPHS includes intersectoral and multidisciplinary collaboration as a guiding principle and calls for a ‘One Health’ approach for collaborative working within and across different ministries. This includes partnership working with civil society organisations (CSO) and bilateral and multilateral organisations due to the ‘changing nature in increasing emergence and re-emergence of infectious, non-infectious and other PHEIC across the world’.13 Furthermore, fostering a culture of internal coherence and joint working between different departments of the MOHS as well as outside the ministry is recognised as vital. In this context, good governance is critical as without it collaboration and multisectoral working cannot be effectively achieved. However, governance is an abstract and diffuse concept.27 28 To promote governance in one single sector itself is challenging. Hence, promoting governance to strengthen IHR compliance where multisector collaboration is key to its success, is even more challenging. Among different principles of governance, three governance principles—accountability; inclusive participation; and enforcement of rules—are essential to strengthen IHR compliance in Myanmar (figure 2).
Figure 2Key governance principles essential in strengthening IHR compliance. IHR, International Health Regulations.
First, ‘accountability’ of key stakeholders for national capacity building is an important initial step to help strengthen IHR core capacities in Myanmar. These include relevant policymakers and implementers from the government, including central, state/region departments as well as bilateral and multilateral organisations such as WHO and non-state actors (CSOs, ethnic health organisations/EHOs). Accountability of policy-makers and implementers will promote ownership and sustainability of the IHR strengthening efforts through regular evaluation and assessment of core public health capacities to improve the identified gaps. Accountability includes both internal (within health system hierarchy) and external (to populations they serve). Indeed, promoting stakeholders’ accountability will enforce and change values in strengthening IHR compliance. For instance, Myanmar has drafted a National Public Health Emergency Preparedness and Response Plan (multihazards) and an HEOC plan. In 2019, Myanmar tested this HEOC plan through a functional simulation exercise at three HEOC facilities in Nay Pyi Taw with the assistance of WHO and Public Health England (PHE). The exercise was conducted as part of the capacity building of staff at both national and subnational level, focusing on familiarising the roles and responsibilities of a HEOC and an incident management structure. The exercise focused on testing the communication aspect of the HEOC plan to promote accountability as clear lines of communication, and an understanding of roles and responsibilities are essential building blocks to improve accountability. Furthermore, a surveillance system review was conducted in October 2019, composed of a stakeholders’ workshop with representatives from 17 state and regions. The workshop aimed to improve the collection and use of surveillance information and to develop simple integrated communicable disease control and laboratory testing guidelines for basic health staff. These examples illustrate different efforts of the MOHS to improve accountability within its public health system, which can further be promoted through development of relevant accountability mechanisms and associated action plans.
While promoting accountability, care should be taken to avoid ‘accountability overload’, resulting from multiple demands for accountability with competing interests and conflicting expectations.29 Furthermore, ensuring the accountability of non-state actors is critical. This includes CSOs, EHOs, bilateral and multilateral organisations, charities and corporations whose accountability is often unclear. Clarity is needed on who these organisations are accountable to, the Myanmar people, their universal rights and health system, the funders or their own agenda.30 Ultimately, accountability of those organisations should promote health system strengthening, not the interests of the organisations.30 Accountability of key stakeholders is highly influenced by health systems software factors such as stakeholders’ attitudes and perceptions, clear roles and responsibilities, and values and the culture of the health system in addition to health system hardware (ie, resources).31 Therefore, stakeholders could be convinced of the benefits of IHR strengthening by focusing on safety and well-being of health staff and their workplaces, which can be witnessed during the COVID-19 pandemic. Delegation of authority to mid-level managers and a widening of their decision-making space can also promote accountability, efficiency and build their creative thinking and initiatives.
Second, Myanmar IHR strengthening efforts will benefit from ‘inclusive participation’ of different stakeholders (public, private, non-state actors). The NAPHS highlights ‘participation and engaging community’ as one of the guiding principles.13 In addition to communities, engaging policy implementers from different states and regions will be instrumental as they are the key frontline workers realising the NAPHS into action. Furthermore, enhancing inclusive participation of key implementers and non-state actors at different health system levels will ultimately promote their accountability. With lessons learnt from the Ebola epidemics in Africa, the importance of communities and civil societies for strengthening IHR compliance cannot be stressed enough.3 4 As an example, PHEs ongoing work in Myanmar to strengthen IHR compliance with respect to chemical poisoning is engaging all levels of the health system.32 In the ongoing COVID-19 pandemic, the Myanmar MOHS also proposed a bill to update the 1995 Prevention and Control of Communicable Diseases law. The bill was published in state-owned newspapers in February 2020 to enable the public to comment and send suggestions to the Union Parliament office further demonstrating inclusive participation in policy-making.
The Myanmar health system could further benefit from systematic inclusive participation. All levels of the health system, including those from states and regions’ basic health staff should be considered, and collaborative working and data sharing between relevant departments should be facilitated. This was highlighted in the JEE as engaging clinicians (both public and private) in public health surveillance will improve the national surveillance system. Engaging other public sectors to enhance the culture of multisector working is an important step to be considered. Furthermore, identifying ways to integrate the private sector into the national health system will be important as 70%–80% of ambulatory care in Myanmar is provided by the private sector.33
Additionally, Myanmar’s health system should continue to leverage the country’s socially ingrained volunteer spirit through existing CSO. The most significant example of such leverage was during cyclone Nargis in 2008 as emergency relief efforts were mainly carried out and supported by individual well-wishers and CSOs across the country. EHOs should not be neglected as the second Annual Operational Plan of the National Health Plan (2017–2021) delineates roles and responsibilities of EHOs for the first time in an official document.34 Hence, Myanmar cannot neglect the ‘mesolevel bottom-up’ approach because it can help to ensure stronger response and better compliance from key stakeholders and communities during the time of crisis.24 Myanmar needs to think globally but act locally by listening to key implementers and communities and engaging them in the work of the IHR strengthening work. This can ensure effective embedding of IHR core capacities into the national health system.
Third, strengthening the ‘rule of law’ or ‘enforcement of formal rules’ and legislations relevant to the IHR is another important governance principle which can help improve IHR compliance. The Myanmar regulatory system should provide a legal basis for prevention and response to public health emergencies,7 through promoting the institutionalisation and enforcement of laws, legislations and regulations. Myanmar has several laws, regulations, guidelines and standard operating procedures underpinning key aspects of health preparedness and response.12 However, they are not formally described in the existing draft laws that are being prepared for parliament as most are in the draft stage, requiring finalisation and endorsement followed by implementation.12 For instance, Myanmar has developed the National One Health Strategic Framework and Action Plan, involving three key ministries in 2019. Myanmar also is the first Association of Southeast Asian Nations (ASEAN) country to draft a national Chemical, biological, radiological and nuclear action plan. These are important milestones, illustrating attempts for multisectoral collaboration. But they need to be enforced and transformed into actions through endorsement from Parliament. As Gustafsson denoted ‘institutions without enforcement are not institutions at all’, the outcomes of the IHR strengthening efforts will depend on how these rules are enforced within the system.35 Myanmar should also have independent regulatory organisations which are assigned to enact the prescribed law or policy. It will be essential to separate regulatory and public health functions within government departments to avoid ‘regulatory capture’.36
