Health systems across the world are facing huge challenges due to a number of demographic, ecological, and societal change. These include rising rates of communicable and non-communicable diseases, aging populations, rising inequality, spiraling healthcare costs, and climate change. To tackle these challenges, health system actors which are broadly defined to include public and private actors from different sectors, need to develop appropriate health policies and implement them to good effect. However, the effectiveness of policies is often hampered by a number of factors such as governance, political will, and resource and human-power constraint. Here, I'll explore governance, especially how the predominant theories and perspectives define and discuss the concept. The importance of governance is widely recognized. You might have heard of problems being blamed on a failure of governance or calls for good governance, especially in the international development field. The concept is complex and discussed differently across different disciplines. For example, in political science, governance is discussed in relation to how roles and responsibilities are shared and negotiated. In institutional economics, it is discussed in relation to how actors function within the constraint of societal norms and rules of engagement. In International development, good governance parameters are developed to inform decisions around development assistance and aid. Government which we're more likely to be familiar with, is the organization machinery or agency through which a political unit exercises authority and performs functions. Your government is the system of people, laws, and officials that define and regulate the country that you live in. Although governance which I'm now discussing in the context of health systems sounds a lot like government, they are not quite the same. The distinction is that, government involves some form of political authority while governance refers to any form of steering of collective action towards a common goal. You've previously learned about the evolution of health systems and how they are conceptualized. Most of the recent conceptualizations of health systems include the term governance or aspects of governance such as stewardship, regulation or oversight. For example, the framework by the Lancet Commission on high-quality health systems, describes governance as one of the five health systems foundations. Also, the WHO health system building blocks framework includes health system leadership and governance previously refers to us stewardship, as a building block and is about oversight and guidance of the whole system. The WHO defines governance as ensuring strategic policy frameworks exist and combined with effective oversight, coalition-building, the provision of appropriate regulations and incentives, attention to system-design, and accountability. You can also see how strongly it relates to each of the other building blocks. It is in a way like the mortar holding the blocks together. There has been a critic by many public health experts though, that this framework does not highlight the role of communities and service users. In the literature, you will see different definitions of governance. A recent systematic review by Thidar Pyone and colleagues has found as many as 16 different frameworks developed to assess governance of health systems. This in turn reflect the multi-disciplinary perspective studied from these models. As an example, I will highlight here one of the most common theoretical perspectives used, namely the principal agent theory. This theory demonstrates the relationship between principals and agents in delivering services, the principle contracts agents to perform certain acts. However, the relationship works both ways and often agents have specialist knowledge or access to information and hence have an advantage in this relationship. For example, although governments and other policy makers may instruct providers to deliver services, they are highly constrained for lack of specialist knowledge on health compared to health providers. Even more, the position of the public as clients is also quite limiting, as they are less likely to have the technical insights or the level of organization to enable them to oversee the provision of services. Governance shapes the capacity of the health system to cope with everyday challenges as well as new policies and problems. The quality of governance affects the ability of the health system to be sustainable, universal, and of high quality, and can generally affect the ability of a whole society to pursue social goods. There are also multiple actors that operate in health system which creates challenges for coordination and raises questions about the roles of various organizations, the rules by which they play, and who sets those rules. In summary, governance is a crucial concept that helps explain why and how different actors come together to pursue health system goals. There are multiple frameworks defining governance in various ways, and there are multiple ways of framing governance itself, which in turn reflects the multidisciplinary perspectives involved. It is widely recognized that the success of a health system to achieve its objectives, hinges on sound governance, approaches, and mechanisms.
