Newsletter 4
June 2018

Dear colleagues,

It’s been a busy and productive time for the Health Systems Governance Collaborative.
We’ve held two face-to-face meetings; one on complexity and governance in health systems and the other on definitions, frameworks and measurements of actionable governance in health systems.

With more and more members signing up, we’re building our communities of practice on our interactive web platform, with different themes and collaborations emerging.
The Collaborative will be also present at the Fifth Global Symposium on Health Systems Research in October 2018, organizing a satellite session on the morning of 8 October. Watch this space – more information to follow!

Unpacking complexity: a push from the field

On 19 March 2018, the Health Systems Governance Collaborative gathered 16 governance and complexity practitioners and researchers working at the interface of research and policy practice to unpack some key ideas on complexity and governance in health systems work.
Our aim is to foster health system reforms and support practices of governance that are better aligned with field realities, and we wanted to start the discussion on how actionable governance could be informed by complexity thinking.

How can we connect the principles of complexity to the understanding of everyday governance practices at the thick of health service delivery, policy and management?
Inspired by breakthroughs and applications from other fields, we examined the question of what actionable complex governance might look like and considered entry points in the health systems and policy research environment at every level, in practice and research, and in each phase of policy making.

Read more here...

Watch this short clip from one of our participants. 
Dr Aku Kwamie, University of Ghana, speaking about complexity and health systems governance.

Definitions, frameworks and measurements of actionable governance in health systems: missing links

Policy-makers, academics, global health agencies, representatives of patient organizations and other governance stakeholders gathered at the Rockefeller Foundation Center in Bellagio, Italy to discuss how to identify:
  1. Frameworks to arrive at actionable governance
  2. The best measurements to assess progress
Our aim was to establish the common ground on which ‘tools’ for ‘actionable governance’ (such as frameworks) can be more reliably and productively built, and address the systemic contexts, hurdles and missing links which currently make health systems governance such a challenging affair. 
While we are finalizing the meeting report, please see short reviews from each day:
Day one
Day two
Day three
You might also be interested to read some reflections about the meeting by one of the participants, Peter Smith, Emeritus Professor of Health Policy, Imperial College London.

“The Bellagio meeting was full of rich insights. But perhaps the most striking ‘missing link’ that emerged was the one between vital local engagement/the participation of local communities and the legitimate role of the state in overseeing the local use of national funds.”
Read more

Interactive web platform

Our health systems governance collaboration is growing day-by-day, and a warm welcome to those members who have joined recently.  
We currently have two themes on our website, each with specific 'collaborations' developing within them. 
1. Definitions, frameworks and measurements of health systems governance
2. Governance capacity and changing roles of ministries of health

A ‘collaboration’ is an opportunity to contribute to a particular topic on health systems governance via our interactive web platform and also other forms of face-to-face and virtual interactions.

Online you can upload events and documents, work jointly on documents and comment on other people’s documents. Through being a member of the Collaborative space online, you can interact with other members and make new connections with like-minded people.

On the website platform you can also access all our media from blogs to webinar recordings, stay informed about news and events and much more.

We hope many of you will actively engage.

We count on you. 
Sign In
Top publications
For this newsletter, we present some of the published governance frameworks that we debated in our Bellagio meeting. See here for the full list of 11 frameworks on our website.

Below you can find three selected three readings of interest; one of which is authored by Peter Smith, whose interview you can also read above.
1. Towards people-centered health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries 

Abimbola S., Nein J., Jan S., Martinuk A. 2014. Towards people-centered health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy and Planning 2014;29: ii29–ii39 

The components of the framework consist of three levels of Primary Health Care (PHC) governance, with complex interactions among them: 

Operational governance is the process by which individual local health system actors make decisions on the demand and supply of PHC services in their community. It refers to how individuals and health providers in the local health market make and implement practical decisions on day-to-day activities based on individual choices and market forces, or as allowed by communities and governments. 

Collective governance refers to collective action by community groups or representatives who bring communities into partnership with their PHC providers. The group may be made of users but may also be constituted as an intervention to stimulate support for PHC. These community groups may set, change, influence, monitor and enforce the rules guiding demand and supply. 

Constitutional governance refers to the actions and decisions of governments and similar bodies in setting, dictating and influencing the rules governing collective and operational actions and decisions. It is the level at which entities involved in collective and operational processes are defined and legitimized.
Constitutional governance could beat different levels, such as different tiers of government, and may arise from non-government actors such as traditional leaders, religious leaders, national and international NGOs and global health organizations. 
2. Leadership and governance in seven developed health systems 

Smith P., Anell A., Busse R., Crivelli L., Healy J., Lindahl A.K., Westert G., & Kene T. 2012. Leadership and Governance in seven developed health systems. Health Policy, 106 (1): 37-49. 
This framework for leadership and governance suggests three fundamental functions: priority setting, performance monitoring and accountability arrangements. Although simplified, this three-part model captures many of the essential issues in leadership and governance. It illustrates a representation that underlines the notion of performance feedback inherent in successful governance of the health system. This emphasises the function of ‘steering’ the system. 
The framework is combined with a semi-structured questionnaire to be administered as a survey to formulate a country case study. The questionnaire has four general questions and six specific questions for the agencies (whether it is a ministry of health or other national agency) responsible for the leadership and governance of the health system in developed countries
3. A framework to assess governance of health systems in low-income countries 

Baez-Camargo C. & Jacobs E. 2011. A Framework to assess governance of health systems in low-income countries. Working paper series No. 11. Basel Institute on Governance. 

This analytical framework divides components of good governance into three groups: 

Governance inputs: participation, consensus orientation, and strategic vision and policy design. 

Governance processes: accountability, transparency, and control of corruption. 

Governance outcomes: responsiveness of the health system to the needs of the population, equitable access of all groups to health services and efficiency in the use of resources.  

This framework suggests a problem-driven approach with the starting point for the analysis being a particular issue or concern related to health system performance. Thus, stakeholders mapping is needed but only to include those that have a direct link with the outcome of interest.  

The application of the framework involves three steps to compile and analyze information to evaluate governance inputs and processes 1/ Desk review, 2/First round of interviews to validate institutional and stakeholders mapping, 3/ Second round of interviews of actors situated in critical institutional junctions. 

The aim of interviews is to carry out a comprehensive assessment of the conditions necessary to hold key stakeholders accountable for their performance. The objective is to research different aspects that shape the incentives and constraints facing key stakeholders such as the formal components that are necessary for effective accountability to be enforced, and informal incentives to serve the interest of agents or constituencies other than the ones to which the agent should be formally accountable to. 

The example suggested for evaluation is the public sector medicine supply chain.
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