Good governance in health care matters at all levels of the health system—from communities to health facilities to governments. When a community HIV & AIDS association in Zanzibar grew from 40 members to more than 1,000, it needed better governance. When women in Senegal raised concerns about lack of privacy and poor security at a district hospital, it needed better governance. And when the national health insurance program in Kenya was underperforming even after efforts to address its management and leadership, it too needed better governance.
Until recently, governance was arguably the most tenacious but unspoken barrier to achieving widespread, large-scale, sustainable health impact. In the 1990s, global health programs focused on training health managers. In the 2000s, as management improved and the need for stronger leaders became evident, the focus expanded to leadership development. By now, we’ve developed robust practices for building the capacity of health managers and leaders at all levels of country health systems.
When it comes to building the capacity of those who govern—people who provide the stewardship and oversight for a society or organization—health programs have focused mostly on the national level. This is where poor governance, including corruption, have been most evident. But as we have learned what managers and leaders need to succeed, we have come to understand that they need good governance to be most effective, whether they work for the government or in a health facility or in communities. Good governance, which is ethical and cost-effective, is essential to unleash good management and leadership at all levels, from villages to parliaments.
The following examples, each from a different level of the health system, illustrate the importance of good governance.
A Community Organization
For more than a decade, the Zanzibar Association of People Living with HIV/AIDS (ZAPHA+) never had more than 40 members. Then the global expansion of HIV & AIDS resources reached Zanzibar, the stigma affecting people with HIV lessened, and ZAPHA+ grew to more than 1,000 members between 2004 and 2009. The organization’s founder, local artist Farooq Consolata, and his team knew AIDS. They knew nutrition. They knew income-generation. But they didn’t know how to run an organization with so many members. With MSH guidance and a small grant, ZAPHA+ established a board of directors to govern the association, which now includes district branches.
A District Health Facility
At Joal Health Center in Senegal, the district health officer, Dr. Mamadou Diallo, was concerned about underutilization of care, specifically the low numbers of pregnant women who delivered at the health facility. The local health committee, with leadership from women on the committee, carried out a survey to gauge client satisfaction and provider effectiveness. They found serious deficiencies, including a lack of privacy and security in a cramped maternity ward. Dr. Diallo and the health committee contacted the Deputy Mayor of Joal and other municipal leaders to help mobilize resources to improve the health center. Together they raised both local and overseas sister-city funding in just a few months. They also engaged the community in fundraising for improved sanitation and repairing ambulances. The collaboration between political and health leaders and community engagement led to a significant increase in the number of deliveries at Joal Health Center, with improved maternal and child well-being.
A National Institution
Kenya’s National Hospital Insurance Fund (NHIF) was widely viewed as a poorly performing national service. Donors believed the problem was poor management and assisted accordingly. Nothing much changed. Then they concluded the problem was weak leadership and worked with the government to change the fund’s CEO. Still nothing much changed. With further scrutiny, it became evident that the problem was governance: the board of directors was a small hand-picked group with no accountability to members, patients, providers, or other stakeholders. Eventually, Kenya’s NHIF Act of 1998 required that the board was reformed. Now the majority of the board comes from stakeholder organizations, such as associations representing teachers, farmers, trade unions, religious organizations, health care providers, and other health insurers. Today the fund has grown to nearly 9 million contributors and dependents with more than US $60 million in annual expenditures. The board of directors plays an active governing role.
Stepping Stones to Better Governance
In these examples, we can see that individual health managers and leaders throughout the health system need governing bodies and organizations that are responsive to their constituencies. Better governance at the community, district, and national levels engages more people, especially women, in support of the health system. This fosters not only accountability, but also sustainability and country ownership of health development and delivery.
At each stage of our expanding focus from management to leadership to governance, progress has happened through three steps: First, we gain evidence that what exists now is not good enough; we recognize the magnitude and nature of the challenge. Next, we identify practical actions to address the challenge, which helps ease the anxiety that comes with facing a big problem. Finally, because of the overwhelming evidence and the visible pathway for action, there is a fundamental shift of attitude that enables change in policies and systems. National leaders, the international health community, and other stakeholders overcome their fear and skepticism; they commit to actions that strengthen governance through improved stewardship and accountability.
The need for a comprehensive approach to governance for health has now become highly visible to both country leaders and the donor community. USAID’s new Leadership, Management, and Governance (LMG) Project, led by MSH, recently brought together 30 global health leaders to build momentum for practical collaboration on governance for health.
The Time Is Now
Effective management, inspiring leadership, and accountable governance are each vital for building strong health systems that achieve lasting local health impact. Over the last two decades considerable progress has been achieved in management and leadership. Countries and the global health community now have the evidence that good governance matters, from villages to parliaments. And we now know that practical action is possible, as the above examples illustrate. As a result, we are seeing attitudes change from the view that poor governance is an insurmountable problem to the view that we can and we must act.
Now is the time to support not only managers who lead, but also leaders who govern. Now is the time for effective governance at all levels.
Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.