Frameworks to assess health system governance

By Thidar Pyone, Liverpool School of Tropical Medicine

Governance has previously been measured by assessing the performance of health indicators at the national level and has not been assessed at the sub-national level. There are various tools and frameworks for assessing governance, but no critical evaluation of these. Our primary aim of conducting this review was to identify a framework which we could use in our health system and policy research. This will also help us move forward the debate in this area by providing an overview of all available frameworks, their theoretical basis, and their usefulness for assessing governance at the sub-national level.

Governance is a neglected agenda in health system and policy research

Governance is a diffuse concept with the lack of clarity on what it comprises. Governance had originated from different disciplines before it was introduced into health systems research.

Before conducting this review, I viewed governance as a concept linked to international development; I may have been influenced by my professional as a medical doctor with several years of experience in public health. Doing this review helped me to realise that it may be beneficial to explore governance not only from the standpoint of international development but different disciplinary perspectives. Political science, new institutional economics and international development have all shaped the concept of governance and how it is interpreted in health systems research.

Which frameworks are available to assess governance in the health system?

In our Health Policy and Planning paper, we identified 16 frameworks in total, published between 2004 to 2014 and the first published application in the health systems research was in 2009. Most of the frameworks (9) originated from the discipline of new institutional economics (NIE) which focuses on the role of institutions and shape interactions among organisations within the system.

Which frameworks are the most commonly used?

The framework of Brinkerhoff & Bossert based on the “principal-agent theory” seems to be the most widely used one in assessing governance in health systems. The “principal-agent” theory was adopted in several studies to assess governance.

There are growing numbers of frameworks adopting qualitative research methods (interviews and focus group discussions) to provide an in-depth explanation of the governance. On the other hand, there are frameworks which offer quantitative measurement to assess governance across settings such as ranking or scoring governance principles which are usually presented as summary measures.

From this review, we believe that governance is so context-specific and we cannot recommend one unified framework as no single, agreed framework can serve all purposes.

What next in assessment of health systems governance?

In summary, governance is a “set of actions and processes” and needs to be operationalised by individuals at different levels in the health system. Governance is not an “apolitical” process, and there are no absolute principles that define governance; it is a diffuse concept that cuts across disciplines and borrows from a range of theories. However, whether it is applied to health systems or political science, governance is concerned with how different actors in a given system or organisation function and operate and the reasons for this.

In the context of health systems governance, based on our review, we think that governance can be assessed and should be approached by identifying what governance arrangements are considered appropriate for a particular context. So we believe a multidisciplinary approach to assessment is necessary.

What do you think? Have you tried to assess governance in the health system? What did you learn in the process?

The relevant paper can be accessed here:

Image credit: Blue Coat Photos


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