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Commentary
Health systems governance: the missing links
  1. Maryam Bigdeli1,2,
  2. Benjamin Rouffy1,3,
  3. Benjamin Downs Lane1,3,
  4. Gerard Schmets1,3,
  5. Agnes Soucat1,3
  6. The Bellagio Group
    1. 1Health Systems Governance Collaborative, Geneva, Switzerland
    2. 2Morocco Country Office, World Health Organization, Rabat, Morocco
    3. 3Health Systems Governance and Financing, World Health Organization, Geneve, Switzerland
    1. Correspondence to Dr Agnes Soucat; soucata{at}who.int

    https://doi.org/10.1136/bmjgh-2020-002533

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      Summary box

      • Studies conclude that frameworks and tools defining governance have been developed independently, seldom building on strengths and weaknesses as well as practical applications of previous instruments.

      • However, these existing frameworks lack a shared frame of reference which may enable governance to become a truly actionable health system function. This conceptual challenge creates considerable gaps in the way we have appraised and applied governance in health systems.

      • We propose here an adaptation of the governance triangle put forward in the World Development Report 20048 exploring six governance spaces between and within three categories of stakeholders: policy makers, providers of health services and the people.

      • This paper uses the framework to further explore both formal and informal relations between stakeholders in the governance triangle and identify, as we reflect on our past investments in health system governance, a number of gaps or ‘missing links’.

      • These missing links relate to formal relations of accountability, relations of power, the exercise of population voice and collective action in health systems.

      • Exploring the missing links described in this paper will help us better understand governance mechanisms in health system and design and implement more effective health policies and interventions.

      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 …

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