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Leadership and governance

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The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system.[1] 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.
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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 on the Leadership and governance is structured as follows:


Analytical summary

The health sector was one of the earliest sectors to start the process of decentralization in line with the Decentralization Policy of 1997. In 2004, health devolution guidelines were formulated taking into consideration the prevailing legislation, the policy framework and available local capacity for implementation of the decentralization process. The guidelines further identified the functions and activities to be devolved to district assemblies and defined:

  • the role of the central Ministry of Health in policy development;
  • standards setting;
  • monitoring and evaluating how the devolved functions are executed in line with the Ministry’s overall goals, overarching sectoral plans and policies.

Some of the key challenges with regard to decentralization, including weak coordination of decentralization at national level, underfunding of district implementation plans and high staff turnover within the health sector, tend to affect health services delivery at district level.

The Ministry of Health is responsible for:

  • the development, review and enforcement of health and related policies for the health sector;
  • spearheading sector reforms;
  • regulating the health sector, including the private sector;
  • developing and reviewing standards, norms and management protocols for service delivery and ensuring that these are communicated to lower-level institutions;
  • planning and mobilizing health resources for the health sector, including allocation and management;
  • advising other ministries, departments and agencies on health-related issues;
  • providing technical support supervision;
  • coordinating research;
  • monitoring and evaluation.

Other institutions are involved in provision of health and social services, including the Ministry of Local Government and Rural Development and the private sector. At community level, numerous nongovernment organizations, faith-based organizations and community-based organizations deliver health promotion services. The Christian Health Association of Malawi is the biggest partner for the Ministry of Health in the delivery of health services. The health sector also works with traditional healers through the Malawi Traditional Healers Umbrella Organization.

Health information is used in planning and priority setting, resource allocation, service delivery management, and monitoring and evaluation. For instance, data from the burden of disease study conducted by the College of Medicine in 2001 and revised 2011[2] and the 2009 Ministry of Health STEP survey[3] were used to identify priority diseases and conditions to be included in the Essential Health Package in the Health Sector Strategic Plan 2011–2016.[1]

In Malawi, the health activity planning process has been decentralized. While the Department of Planning and Policy Development at central level provides guidance to the lower levels on the development and implementation of the plans, preparation of such plans are done at national, zonal, central hospital and district levels. However, it is observed that the level of participation of people at community level or even at district level, including those in zone offices, in policy formulation is insignificant and unclear.

The Ministry of Health is strengthening collaboration with regulatory bodies in the development of a common code of practice for health professionals working in the public and private health sector, including international health institutions, research institutions and nongovernmental organizations. In this regard, the Ministry of Health works closely with the regulatory bodies in matters of professional regulation.

A monitoring and evaluation framework has been developed and core health performance indicators have been identified for monitoring the Health Sector Strategic Plan.[1] A Monitoring and Evaluation Technical Working Group with members from Government departments, nongovernmental organizations and development partners has been constituted as part of the sector-wide governance structure to provide technical input and advice on monitoring and evaluation issues in the health sector.

There is a need to strengthen leadership and governance structures in the health sector at all levels so as to enhance the implementation of the Health Sector Strategic Plan.[1] The following priority areas will be strengthened:

  • coordination of decentralization at national level;
  • collaboration through joint planning of interventions;
  • collaboration on monitoring of the implementation of the district implementation plans;
  • harmonization of the planning documents for the Ministry of Health and Ministry of Local Government and Rural Development.

Context and background of the health system

Ministry of health and other institutions involved in health and social services

Policy making and health planning

Regulation, monitoring and evaluation

Priorities and ways forward


Endnotes:References, sources, methods, abbreviations, etc.

  1. 1.0 1.1 1.2 1.3 Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. Burden of disease estimates for 2011 and the potential effects of the essential health package on Malawi’s health burden (Word 249kb). College of Medicine 2011
  3. Malawi national STEPS survey for chronic non-communicable diseases and their risk factors. Final report (pdf 1.45Mb). Lilongwe, Government of Malawi, Ministry of Health, and WHO 2010