Leadership and governance
The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. It is about the role of the government in health and its relation to other actors whose activities impact on health. This involves overseeing and guiding the whole health system, private as well as public, in order to protect the public interest.
It requires both political and technical action, because it involves reconciling competing demands for limited resources in changing circumstances, for example with rising expectations, more pluralistic societies, decentralization or a growing private sector. There is increased attention to corruption and calls for a more human rights based approach to health. There is no blueprint for effective health leadership and governance. While ultimately it is the responsibility of government, this does not mean all leadership and governance functions have to be carried out by central ministries of health.
Experience suggests that there are some key functions common to all health systems, irrespective of how these are organized:
- Policy guidance: formulating sector strategies and also specific technical policies; defining goals, directions and spending priorities across services; identifying the roles of public, private and voluntary actors and the role of civil society.
- Intelligence and oversight: ensuring generation, analysis and use of intelligence on trends and differentials in inputs, service access, coverage, safety; on responsiveness, financial protection and health outcomes, especially for vulnerable groups; on the effects of policies and reforms; on the political environment and opportunities for action; and on policy options.
- Collaboration and coalition building: across sectors in government and with actors outside government, including civil society, to influence action on key determinants of health and access to health services; to generate support for public policies and to keep the different parts connected – so called "joined up government".
- Regulation: designing regulations and incentives and ensuring they are fairly enforced.
- System design: ensuring a fit between strategy and structure and reducing duplication and fragmentation.
- Accountability: ensuring all health system actors are held publicly accountable. Transparency is required to achieve real accountability.
An increasing range of instruments and institutions exists to carry out the functions required for effective leadership and governance. Instruments include:
- sector policies and medium-term expenditure frameworks
- standardized benefit packages
- resource allocation formulae
- performance-based contracts
- patients' charters
- explicit government commitments to non-discrimination and public participation
- public fee schedules.
Institutions involved may include:
- other ministries, parliaments and their committees
- other levels of government
- independent statutory bodies such as professional councils, inspectorates and audit commissions
- nongovernment organization "watch dogs" and a free media.
This section of the health system profile is structured as follows:
Leadership and governance involves the responsibility of providing oversight across all national institutions through policy-making and health planning, organization and management, and regulation of health services. In all 46 countries of the WHO African Region, the ministries of health are mandated to provide this oversight function. Some country health policies contain additional mandates in respect of population and social welfare. Increasingly, in order to address upstream social and environmental key determinants of health, ministries of health work in close collaboration with other government sectors responsible for agriculture, water supply and sanitation, other environmental issues, education, and women’s empowerment.
The overall goal of health policy-making and health planning is to improve the performance of health systems, and the health status and trends of African populations, through application of primary health care principles. The process of creating health policy is becoming more evidence based and participatory over time, and therefore more responsive to differing population needs. National health policy will also take account of major international development agreements, goals or movements, aligning health and development policy to the extent possible in the interest of a unified governance approach. Further initiatives to acquire and use high-quality data for policy-creation purposes are desirable, and debates concerning the respective roles of international, national and subnational level data continue.
Many African countries are moving towards decentralized organizational models, bringing funding and services closer to the populations served. This circumvents many problems associated with the centralized approach, but places demands on district or local level services that current levels of local capacity may find challenging. Capacity to update and maintain the necessary regulatory and legislative measures in the area of health policy is also restricted, and monitoring and evaluation systems in the area of health governance are in very early stages of development.
However, what all health policies and strategies have in common is:
- the need to address themselves to the most commonly occurring causes of disease and to the most vulnerable sectors of the population;
- to ensure that all components of the health system function at their highest capacity.
Biannual reviews have become a commonly accepted governance method of monitoring and adjusting health policy and strategy. However, a major obstacle revealed through this process is an often conflicting series of health and related sector policies that hamper effective health leadership and reduce clarity of vision.
Context and background of the health system
Organization and functions of the ministry of health
Types of organizational structure vary across countries of the WHO African Region and most employ different guiding principles. These principles include the need to focus on:
- major diseases of public health concern
- the vulnerable and disadvantaged sectors of the population
- ensuring that the core functions of the health system are maintained.
The strength and size of departments, and units within departments, depends on the financial resources allocated and the degree of priority ascribed by the executive arm of the government.
Most African countries are organized around three main levels of management, namely national, regional and district. In a centralized system most funding is disbursed at central level, and the regional and district management teams focus on ensuring efficient use of the resources received. However, this system fails to react quickly to specific needs at district level. In a decentralized system, most resources are placed at district level and the district management teams are expected not only to ensure efficient use of the funds and supplies provided, but also to be able to prioritize, identify suitable markets, and ensure an effective procurement and logistics supply system.
Decentralization of the system
In a decentralized system, there are three main approaches: delegation, deconcentration and devolution. Devolution is the most advanced form of decentralization, where local authorities are contracted to carry out central level functions without any input from the central government except for the provision of funds through a contractual agreement. In the WHO African Region, almost all countries have embarked on some form of decentralization and it is not uncommon for a country to employ all three forms simultaneously. In the system of devolution, local governments are mandated to strategize, plan, implement and monitor the provision and use of health services at district or local level.
It is important to note that success in decentralization of the health sector depends heavily on two factors:
- whether other sectors are equally decentralized;
- an adequate level of local government being in place in order to debate and approve local budgets for local councils.
In addition, the executive arm of the local government has to be competently and effectively managed. Problems, particularly over funding allocations, can occur if efforts at decentralization result in the creation of parallel structures, rather than reductions in bureaucracy.
Policy making and health planning
All countries of the WHO African Region have both national health policies and national health strategic plans in place. However, as indicated in the table, 10 countries had undertaken to revise their national health policies by the end of 2010, while 27 countries should do so by the end of 2015. Similarly, 16 countries need to revise their national health strategic plans by 2010, while 38 countries will do so by 2015. The intended cycle for health policies ranges from 5 to 10 years, while the strategic plans are normally revised in 5-year cycles.
The most common policy and strategic directions include:
- defining an essential health package of services while attempting to ensure comprehensiveness, people centredness and continuity of services;
- decentralization of the management of health services at district and local levels;
- establishment and empowerment of health regulatory institutions;
- contracting out of services with other health service providers, especially the private sector;
- hospital autonomy through the establishment of hospital boards.
In terms of health financing, the major policies include determination of how revenues are collected and how funds are pooled, either through a sector-wide approach or a compact. The overarching goal is to improve health systems' performance using the principles of primary health care.
Health activity planning
There are three common planning levels related to health services provision and strengthening of the heath system. In almost all countries, the overarching national development policy and plan will determine the type of policies and plans developed within the health sector. National development plans may be influenced by global events that exert an influence on health. In past decades, for example the 1978 Alma Ata Declaration on primary health care and its subsequent renewal strongly influenced health policy.
The adoption of structural adjustment programmes to counter national economic difficulties and improve efficiency in resource allocation has led to poverty reduction policies and strategies at overall national government level. National poverty reduction strategy papers became key guidance documents for the formulation of sectoral policies, including national health policies. In some countries, governments have moved beyond poverty alleviation strategies alone, and have adopted growth and development strategies.
A national health strategic plan is usually a medium-term plan spanning 5 years. This strategic plan is used for the overall organization and management of the health sector as well as for resource mobilization. It lays out the national annual implementation plans that include detailed activities aimed at furthering the provision of relevant health services on a yearly basis. In addition, the strategic health plans form the basis for, and provide guidance to, the annual provincial, regional and district implementation plans.
The strategic plans reflect the priorities highlighted in the national health policy. The planning process requires the involvement of all stakeholders, with government leadership. At the district and provincial levels, plans take into account district, regional and provincial specificities, together with the need to contribute to national and global goals and targets such as the Millennium Development Goals, or the eradication of polio and measles.
Most countries continue to rely on national data rather than regional or district data to inform the planning process. This has the advantage of providing a common planning baseline, but also has the effect of generating targets and resource allocation that may not be in line with district realities. In addition, subnational data are rarely incorporated in measurements of progress towards long-term goals such as the Millennium Development Goals.
Community involvement may, in practical terms, be limited by factors such as:
- lack of knowledge and understanding;
- over-reliance on government
- limited capacity to implement community-level interventions towards attainment of national goals.
In their defence, communities may not always receive adequate support, either financial or technical, to ensure successful implementation of activities at local level. Community capacity in some areas can also be limited by difficulties in developing long-term vision and hence communities may rely on government measures rather than attempting to set the local agenda themselves and requiring government accountability in meeting locally set health targets.
Policy dialogue and decision-making process
The process of developing health policies and their related strategic plans is improving over time. Measures such as inclusive policy dialogue are now the norm, and content draws on comprehensive situation analyses reflecting country needs in relation to actual disease burden. In a decentralized system, the policy dialogue involves communities, civil society and all stakeholders who participate in the provision and use of health services. In many countries, policy coherence is achieved by circulating a draft policy to all government ministries and departments for their comments and suggestions.
It has been found beneficial for high-level government officials, and in particular the head of state, to launch the policy documents and for parliamentary scrutiny and approval to follow. This helps to ensure the relevance of health policies, as well as bringing them to the notice of other branches of government and the general population.
Regulation, monitoring and evaluation
Regulation - Legislation
From the regulatory perspective, improvements in health sector performance include the requirement to ensure technical competence through professional councils, public health policy and patients’ rights. The critical professional cadres such as nurses, clinicians, laboratory staff and pharmacists are governed by comprehensive codes of conduct governing aspects such as registration, professional ethics and professional advancement.
Public health policies are enacted through national laws commonly known as the Public Health Act. This is a comprehensive law covering all aspects that may result in conflict between health providers and those mandated with oversight, the international health regulations and health surveillance, and the recognition and setting of health sector boundaries. Most Public Health Acts were created during the colonial era and need revision and updating. However, capacity in this area is generally lacking in many African countries.
Monitoring and Evaluation
Monitoring and evaluation systems are essential to the governance and leadership functions of the health system. Monitoring needs to take place across all elements of the health system so that planned reforms are implemented synergistically. While monitoring of service delivery and disease outcomes are relatively advanced and have commonly agreed indicators, monitoring the performance of the health information system and of leadership and governance are still in their infancy. Insufficient use of currently available health information for policy, planning and regulatory purposes is hampering the effectiveness of governance and leadership reforms.
Countries of the WHO African Region regularly participate, with international partners, in the Demographic and Health Surveys as well as in other systematic surveys such as the Multiple Indicator Cluster Survey to evaluate various components of health status and systems. While morbidity, mortality and other health determinants such as education are adequately covered, the role of governance and leadership within the health system is rarely included in these surveys.
The Demographic and Health Surveys are carried out every 4–5 years, and the Multiple Indicator Cluster Survey takes place in intervening years. At international level, comparison of progress among countries cannot be accomplished using Demographic and Health Survey findings alone, due to variability of the intervals and the nature and number of indicators. Additional data and analyses are acquired through modelling. Reliance on modelling may explain why the development of national capacity in areas such as vital registration is low, and analytical skills and knowledge management need to be strengthened in many countries.
Policy is activated through implementation of the strategic plans. In many countries, especially those using the sector-wide approach, biannual health sector reviews have been institutionalized. Most results are obtained from routine data collected, collated, analysed and disseminated through the national health information system. These health sector reviews provide opportunities to assess progress towards set targets on an annual or biannual basis. As emphasized earlier, decisions taken during each review depend heavily on the quality and quantity of available data, and the level of analysis of the findings.
Challenges to effective review and decision-making include a multiplicity of potentially conflicting policies and strategic plans responding to diseases and health conditions of major public health concern. These may be contradictory to each other or to the central national health policy. For example, antiretroviral treatment and immunization services may be provided to the population through prepayment, while treatment for pneumonia and some cancers may be required through out-of-pocket expenditure by the same population in the same health facilities. Effective health leadership needs to ensure that contradictory policies are eliminated or minimized.
Priorities and ways forward
It can be argued that the leadership function of the health system is the most important, as it determines what the rest of the sector can achieve. It is therefore important to foster debate on how best to hasten the implementation of health leadership reforms. A related function of high importance is the strengthening of the regulatory and legislative aspects of the health sector. Team-building across all departments and sectors contributing to health status is highly desirable. Ways of institutionalize performance assessment on a team basis should be considered.
What works and why?
Inclusive dialogue, especially with the involvement of those sectors responsible for food production, education, women’s empowerment, water and sanitation, justice and human rights, public works and energy, is an optimal method of ensuring coherence in all policies promoting health throughout public sector policy documents. It also facilitates comprehensive strategic planning that has the capacity to move a country in the same direction, towards the attainment of a common and sustainable level of development. Systemic health financing, as opposed to the project approach, should prove flexible enough to address locally determined needs and priorities.