ReviewA review of health governance: Definitions, dimensions and tools to govern
Introduction
Governance – either in terms of leadership, stewardship, regulation, oversight or governance itself – has repeatedly been asserted as a core function in theories and frameworks on health system [1], [2]. The World Health Organization (WHO) first framed the concept as ‘stewardship’ in the World Health Report 2000, defined as “the careful and responsible management of the well-being of the population” [3, p. 45]. Later iterations of WHO's systems-thinking [4], [5] and work from other dominant actors in health [6], [7], [8], [9], [10] has allowed for the function to mature and evolve, characterized at various stages as ‘stewardship’, ‘leadership’ and/or ‘governance’ [hereafter ‘health governance’]. Complemented by a continuously growing literature base, there is now clear and compelling consensus about the importance of the health governance function and its role in ensuring that priorities for population health and well-being are realized.1
While solidified in its importance, the health governance function itself remains an elusive concept to define, assess, and operationalize [11], [12], [13]. This has historically been attributed to an absence of conceptual thinking [11], [14]. However, the premise that ‘good’ governance will ultimately lead to improved health outcomes has been the presumption motivating the study of health governance with renewed vigor over the past decade [4], [6], [15], [16]. The conceptual chaos that has followed can be viewed as an effect of the lack of consensus on nomenclature, models and measures for governance in the health domain. In the absence of conceptual agreement, the comparability of literature and the extent to which findings obviously converge toward a common understanding of the concept has been compromised [11].
Adding to the conceptual challenges is the changing context of government and society, which has necessitated the continued evolution of the health governance function. Global trends – such as changing population demographics and epidemiology, widening social inequalities, and a context of financial uncertainty [7], [10], [11] – has influenced health system priorities and subsequently the setting of the health governance function. A shift in the general architecture of health systems can also be observed, as systems move toward increasingly decentralized structures, engaging diverse and heterogeneous networks of actors2 for generating resources, delivering services and financing care [7], [17]. The emerging consensus that health is a property of many complex systems and dynamic networks has demanded new and formal interactions with varied actors, found often beyond the domain of health itself [10].
Faced with such trends, the boundaries of the health sector appear to be less clearly defined and the collective interaction needed across ministries, including social services and education for example, is importantly realized. In effect, the health governance function has become increasingly diffused and the relationships between actors, largely ambiguous. A concerted effort is thus needed to resolve conceptual confusion on health governance, while also attempting to evolve earlier notions of governance to respond to health and health systems of the 21st century. Ultimately, a clearly (re)defined vision for the health governance function must be seen a means rather than an end in itself, to then address an arguably more pressing agenda: the needed arsenal of policy tools and instruments to then create the conditions for improving the health and well-being of populations [10].
Section snippets
Purpose and rationale
In this review, we aim to consolidate and align the literature on health governance by presenting an overview of governance literature pertaining to health since its initial introduction as ‘stewardship’ in the year 2000. Earlier literature on governance in the public and development sector is considered more generally, recognizing this as a starting point for much thinking on governance in the health domain. Consideration has been given exclusively from a national health systems perspective,
Methods
A restricted review of literature was conducted. The perspective of governance taken here is that of a national public steward and the governance function is framed according to this role. The work of international organizations in health governance was deemed most relevant for this perspective. While giving focus to the work of primarily international organizations has narrowed the breadth of literature, this inclusion criteria is felt merited by the unique mandate of such actors; supporting
Findings
In total, 39 publications were deemed relevant for review; 30 publications either defined the health governance (stewardship) function according to a discrete number of principles, dimensions, elements or attributes or to operationalize the function according to specific indicators and a further 9 publications defined governance (stewardship) within the public or development sector [18], [19], [20], [21], [22], [23], [24], [25], [26]. While outside of the health domain, these works were found
Discussion
Following the introduction of stewardship as a core health system function there has been an initially slow but steady increase of literature in this field. This is driven at present by the priority given to health system strengthening toward improved population health and well-being. Despite this interest and activity, there remains a persisting challenge to communicate with greater consensus a clear and actionable health governance function.
While not necessarily pursuing an ultimate,
Conclusion
Understanding the body of literature on health governance is necessary to effectively apply governance theories to contemporary government and society. This work has aligned the growing body of literature on health governance and related works of particular relevance in the development of this field from the perspective of national health stewards. In doing so, the challenges to define governance, characterize the function according to specific dimensions and catalog the available tools to
Acknowledgements
This paper was developed to support earlier health governance work of the WHO Regional Office for Europe and its partners by providing a review and synthesis of literature in this area of study and by extension, a common platform for more conceptual thinking and country applications. An earlier version of this paper was presented at an authors’ workshop convened by the European Observatory on Health Systems and Policies in Brussels (October, 2012) to stimulate discussions for a related project.
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