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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.
Leadership and governance.jpg

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 Leadership and governance is structured as follows:


Analytical summary

The Ministry of Health and Sanitation is the statutory body responsible for coordinating health interventions and actions in Sierra Leone. The Ministry has made several provisions to influence the overall policy framework in the country.[2][3]


In collaboration with development partners, the Ministry developed the Joint Programme of Work and Funding to operate the National Health Sector Strategic Plan in a more coordinated and effective manner by outlining the priority health interventions to be implemented over the period 2012–2014, their resource implications and financing situation.[4]

Recently, the Ministry and its partners signed a compact agreement for better coordination of the health sector.[5]

The Minister of Health and Sanitation is the overall head of the Ministry. There are three broad areas of responsibility in the Ministry: political, administrative and professional. The political head is the Minister, supported by Deputy Ministers. The professional head is the Chief Medical Officer, assisted by the Deputy Chief Medical Officer. These are followed in hierarchy by other directors and the programme managers of the various technical programmes. There is a Chief Nursing Officer as well as a Chief Pharmacist within the professional wing. The administrative head is the Permanent Secretary.[2]

At district level, the district health management team, headed by a District Medical Officer, oversees all primary health care activities delivered through the peripheral health units. A Medical Officer is responsible for clinical activities at the district hospital. At the provincial or national hospitals, a Medical Superintendent or Hospital Manager is responsible for administration and supervision.[2]

With the devolution of services through the Local Government Act 2004, the core functions of the Ministry remain as:

  • policy formulation, setting standards and quality assurance
  • resource mobilization
  • capacity development and technical support
  • provision of nationally coordinated services, for example epidemic control
  • coordination of health services
  • monitoring and evaluation of the overall sector performance and training.[2]

The Ministry has multiple leadership responsibilities, including policy formulation, setting standards and regulations, collaboration and coalition building, monitoring and oversight, and resource mobilization. In this regard, the Ministry provides leadership and coordinates the efforts of all health care providers and financers at all levels of care.

The Government has established health sector legislation and regulatory statutory bodies to assist the Ministry. These are:

The Ministry also contributes to the development of the International Health Regulation (2005).

The 2010 health sector performance assessment highlighted the following issues:[6]

  • The districts had a clear plan for developing the health of their people.
  • There was weak coordination of events within and between central and district health management team levels.
  • Supervision of district health management teams and facilities was uncoordinated and weak.
  • There were inadequate logistics for supervision.
  • There was limited involvement of district health management teams and hospital staff in procurement processes.
  • Referral systems were weak in all districts.
  • Maintenance culture was weak in all districts.
  • Capacity in the regulatory bodies was weak.
  • There was low community participation in facility management.
  • Most nongovernmental organizations did not work in collaboration with the district health management team, leading to inefficient use of resources.

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. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. 2.0 2.1 2.2 2.3 National Health Sector Strategic Plan 2010–2015 (pdf 1.09Mb) Government of Sierra Leone, Ministry of Health and Sanitation, 2009
  3. National Health Policy final 2002 (revised 2009). Government of Sierra Leone, Ministry of Health and Sanitation
  4. National Health Sector Strategic Plan 2010–2015 Joint Programme of Work and Funding (JPWF) 2012–2014 (pdf 2.79Mb). Government of Sierra Leone, Ministry of Health and Sanitation, 2012
  5. Health Compact (pdf 510.02kb). Government of Sierra Leone, 2011
  6. Performance report. Government of Sierra Leone, Ministry of Health and Sanitation, 2010