Introduction
Over the past decades, health systems have experienced major transformation. The role of ministries of health has changed, progressively shifting from direct provision of health services to overall stewardship of the health sector, including financing and oversight of private providers.1 Health reforms have triggered that shift, fostering new institutions, such as national medicines agencies, public health agencies, disease control agencies (eg, National Cancer Agencies) or health financing organisations responsible for risk and fund pooling, purchasing of health services, or targeting the poor or vulnerable groups. Shocks such as political or financial crises, natural disasters or epidemics have also affected the governing of the health system in many countries. In this changing environment, exercising stewardship2 requires balancing the interest of a wide range of actors, particularly when decentralisation multiplies the number of actors involved in health services delivery, usually with greater autonomy.
Health systems processes must move from a top-down to inclusive policy, planning and implementation processes, increasingly adopting a people-centred approach.3 Democratic rights, human rights, equity and ethics values have become prominent in national policy debates. In response to this call, twenty-first century health systems need to be participatory, inclusive and pluralist, following Whole of Society and Whole of Government principles.3 4 People’s voice is a core driver of health systems’ performance towards Universal Health Coverage.5 In such a context, governance arrangements are changing and rely more on inclusion, participation and co-production.6
This paper presents a framework to help understand health systems governance; examine what we know about this important health system function, and what has been less explored, leaving an important gap in our health system knowledge and practice.
Conceptual framework
In this paper, we understand ‘governance’ as ‘ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system-design and accountability’.7 The framework proposed here (figure 1) is an adaptation of the governance triangle put forward in the World Development Report 2004,8 further adapted by Brinkerhoff and Bossert in 2008.9 The governance triangle reflects the set of arrangements that are the fabric of governance in practice by exploring key relationships between and within three categories of stakeholders: Policy-makers, Providers of health services and the People:
Policy makers: include different government organisations and agencies at the central and subnational levels, and the way they are organised in terms of hierarchy, delegations of authority and cooperative linkages, and so on. Actors in this sphere include the legislative and the executive branches, elected (politicians) and non-elected (bureaucrats) officials.
Health services providers: the different public and private (for and not-for-profit) clinical, paramedical and non-clinical health services providers (practitioners, clinical facilities and hospitals, pharmacies, laboratories, paramedical facilities, etc); unions and other professional associations (all cadres); networks of care or of services. Organisations responsible for supply of medicines as well as training of health professionals are part of the providers’ sphere, and so on.
People: citizens and residents, population representatives, patients’ associations, Civil Society Organisation (CSOs)/Non Governmental Organisations (NGOs), citizens’ associations protecting the poor or the elderly, the Media, and so on. Citizens become service users when they interact with health service providers.
We have purposively decided to replace the arrows of the original triangle by a series of gears, to picture the dynamic and interconnected nature of relationships linking stakeholders in health systems.
We also propose to unpack the governance triangle in more detail by examining six different spaces where governance function takes place:
Three spaces between the spheres: the relationships between the three spheres, formally or informally linking categories of stakeholders to each other.
Three spaces within the spheres: the relationships within the three spheres described above, formally or informally linking the variety of stakeholders within each sphere or category.
Relationships between the spheres
Between the Policy makers and Providers: Policy makers set objectives’ standards and rules and provide financial and non-financial resources in exchange for an agreed level and quality of services. Depending on the level of transparency of the system, providers and lobbies can sometimes use this space to exert considerable pressure on decision makers.
Between Providers and the People: This relationship is at the heart of the health system and refers to the organisation and delivery of promotive, preventive and curative health services. The ability for users to exercise their client power strengthens utilisation and quality of services and increases providers’ accountability to service users. Providers can also influence the behaviour of users through information dissemination.
Between the People and the Policy-Makers: The relationship is the exercise of voice, which consists of the expression of demands, needs and preferences of the population. This could be through processes such as elections, lobbying and advocacy, media, activism, formal population consultation processes in the health sector (eg, National Health Assemblies, national surveys, etc). However, practices like tokenism or distortion of the information disseminated (eg, through state-owned media) can undermine the impact of participatory processes. Political accountability ensures a certain level of participation and that voice is taken into consideration.
Relationships within the spheres
Within the Policy-makers sphere: Through a system of checks and balances, the legislative branch holds the executive power accountable and ensures reasonable use of power in accordance with the constitution. The Policy-makers sphere is also the arena of multisectoral engagement and power delegation. Relationships within this sphere include processes of delegation, of engagement between ministries (eg, Ministry of Health and Ministry of Finance), and of influence struggle between the different stakeholder groups such as parliamentarians, executive power and non-elected officials.
Within the Providers sphere: Relationships in the providers sphere are largely composed of those among the market of healthcare provision. Providers can choose to compete or cooperate and form networks of care, depending on the national policies regulating the sector. In this space workers can form associations and unions to hold their own members to account, according to professional charters; and to negotiate with health facilities for a fair work environment.
Within the People sphere: It is important to disaggregate the People sphere, as it comprises a wide diversity of stakeholder groups with very different vested interests. Relationships in that sphere involve different interest groups competing for their increased benefit in a finite pool of resources (eg, patient groups lobbying for inclusion in benefit packages, the elite and the poor negotiating for a balance between financial coverage and health taxes). Consensus among this group can be reached through vote, however small groups with important vested interests are more likely to influence the system while other groups that are less strongly affected are, therefore, less likely to organise actively and efficiently to defend their interests.10 The political process is typically influenced by the balance of power between the elite, the middle class and the poor. But other proximates of this balance can be found such as language, religion, and ethnic or geographical background. These relationships rely heavily on information and influence and are reflected in the behaviour of the media.
The key relationships between governance stakeholders that are the very fabric of the triangle can be divided into two categories: formal mechanisms and informal processes.