Integrating Politics, Policy, and Participation: Governance and Health Systems

Today, the international health community is seeing unprecedented levels of resources flowing to address health needs and diseases in the developing world. Yet there are serious concerns about the effectiveness of these investments and the sustainability of impacts due to the weaknesses in health systems and their governance. Developing country health systems confront daunting challenges. What resources and services are available, how they are allocated, and who accesses them constitute critical questions. Shaping the answers to these questions—which involve medical, policy, and political decisions—is governance. Health governance concerns the authorities, rules, institutions, and processes that form the nexus of state-society relations where government, health care providers, and citizens interact. This paper argues that without integrated attention to these elements of health governance, systems strengthening efforts are likely to fall short of achieving their intended outcomes. This attention requires looking beyond the standard interventions for service delivery and systems improvement to integrate democratic principles of representation, transparency, responsiveness, choice, accountability, and equity. The paper examines strategies and mechanisms that can improve health governance, assesses the conditions under which they are effective, and identifies constraints, drawing on both literature and ongoing field projects. The paper offers programmatic and policy recommendations for improving health governance that combine the standard supply-side capacity building with attention to demand-side measures that engage the public in health policy and service delivery decisions. Recommendations include:

• Provide multiple voice options for stakeholder input and accountability. • Develop systems that limit opportunities for corruption, institutionalize independent checks, and provide incentives for desired behavior. • Build skills among public health officials to reach out and involve stakeholders effectively. • Make transparent rights, responsibilities, legitimate expectations, and procedures. • Link inputs to expected performance outputs, outcomes, and results. • Increase citizen representation on governance structures.