Innovative approaches to researching governance

issues for UHC“International Experience on Provider Payment Reforms for Universal Health

Coverage”, Hanoi 16th Sept 2013

Outline

1.Governance and UHC

1.Researching governance within RESYST

‘It is more useful to think of UHC as a direction, rather than as a destination’

Kutzin, 2013 p.604

…pursuing UHC requires coordinated policy action & implementation, across system

functions and over time

Kutzin, 2013

De Savigny & Adams, 2009

Decision-making by people is at the heart of health system governance

Governance issues for UHC

Governance

…of UHC and the health system

… and of change/reform itself

1) The hardware: establish frameworks of accountability & spread power

Governance structures• Develop a coherent network of ‘structures’

across the health system that spread power for decision-making across actors

• Develop legislative frameworks that underpin the structures and their power to act, and hold them accountable upwards and outwards

2) The software: enable the responsible exercise of power by system actors

‘Governance is about the (formal & informal) rules that distribute roles and responsibilities among societal actors and that shape the interactions among them (decision-making)’

Brinkerhoff & Bossert (2008)

Influencing decision-making?

• Through a combination of:– values & principles• Professional ethics• Transparency

– leadership & role modeling– relationships of accountability– information– financial incentives

3) The governance of change: maintain a consistent path and learn through doing

Thai experience

Always important

• Sustained political leadership & commitment to change

• Forming partnerships• Engaging and managing stakeholders• Sustained technical intensity & support

Plan - Do - Study - Act

But also:

Expect the unexpected

Encourage learning processes & cultures

Understanding governance: the Resyst approach

The tangible software:• Sets of human resources • Management knowledge &

skills • Formal management

processes

The intangible software:• The informal rules,

communication patterns, values, norms that shape relationships and interactions among actors (relative power, trust, civic-mindedness)

Leadership

Lead

ersh

ip

The hardware: e.g. a coherent network of ‘structures’ across the health system that spread power; legislative frameworks that underpin accountability; resource levels & distribution patterns signaling value

Governance as collective organisational capacity

RESYST governance focus

• The micro-practices of governance, and what influences them

the decision-making practices of public sector leaders working within the routines of the health system

• And how these practices influence accountability, policy implementation & health system change

Research challenges

• Micro-practices of governance are dynamic & complex, hard to observe

• Difficult to disentangle governance effects from other health system elements/changes

• Seek to inform and support continuing processes of decision-making, rather than to identify a single policy intervention

The job of the health system researcher

‘...is to illuminate the processes of change and experience that they observe...

to make a contribution ... to the social process of understanding or promoting change.’

Barnes et al., 2005

Critical reflection

Learning through

doing

Research to support learning

RESYST governance research

• Learning sites within the ‘District Health System’

• Continuous engagement over time within a context

• Focus on planning & priority setting

• Understanding implementing actors’ 'theories of change’ for system reforms

• Focus on specific UHC-related reforms (South Africa, Tanzania, Nigeria)

Encouraging reflection about decision-making practices through research

Why focus on peripheral facilities?

RESYST learning sites

Supporting distributed leadership for UHC

‘Probably the most complex challenge in health systems is to nurture persons who can develop

the strategic vision, technical knowledge, political skills, and ethical orientation to lead the complex processes of policy formulation and implementation. Without leaders, even the best designed systems will fail’ (Frenk

2010: 2)