sustainable health gains from good governance of hospitals and health systems mini-university 2014...

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Sustainable Health Gains from Good Governance of Hospitals and Health Systems

Mini-University 2014March 07, 2014

Mahesh Shukla, MD, DrPH, MPA

Good Governance of Hospitals and Health Systems

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Afghanistan Benin Bolivia Bosnia Côte d’Ivoire Ethiopia Cambodia Cameroon Georgia Ghana

Haiti Honduras Kenya Lebanon Liberia Libya Moldova Nicaragua Nigeria Pakistan

Peru Rwanda Sierra Leone South Africa Sri Lanka Tanzania Uganda Zambia Zimbabwe Vietnam

Where LMG Project Works


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Fill in the blanks.

________________ facilitate the work of _____________ who in turn facilitate the work of __________________.

Health providers and workers Health managers Leaders who govern

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Fill in the blanks.

Effective ________________ is essential for effective _____________ of ________________ which in turn is essential for effective __________________.

people, money, medicines and information health service delivery management governance

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Effective Health System Governance


is essential for health system performance.

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Focus of Presentation

Explore the link between good governance of health systems and their performance and health outcomes

Discuss five governing practices that influence the performance of health systems


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Evidence on impact of governance

Björkman and Svensson 2009

Olafsdottir et al. 2011

Maureen Lewis 2006

LMG’s pilot study in Afghanistan


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Björkman and Svensson 2009

Randomized field experiment Conducted in 50 rural communities in Uganda 25 in intervention group and 25 in control group Community members monitored public dispensaries

and health care providers Community monitoring improved health outcomes at

the end of one year Relative to the comparison group, communities with

intervention saw o significant increase in the weight of infants, and o 33 percent reduction in mortality rates of children under five

years of age.

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Olafsdottir et al. 2011

Governance was seen to be inversely associated with under-5 mortality rate in 46 African countries.

(after controlling for healthcare, finance, education, and water and sanitation)


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Maureen Lewis 2006

Good governance is important in ensuring effective health care delivery.

Returns to investments in health are low where governance issues are not addressed.


12Good Governance of Hospitals and Health Systems

Governance is

(1) setting strategic direction and objectives; (2) making policies, laws, rules, regulations, or

decisions, and raising and deploying resources to accomplish strategic goals and objectives; and also

(3) oversight monitoring to make sure that strategic goals and objectives are accomplished.

(Based on evidence from our review of literature, surveys, and fieldwork in Kenya, Nigeria, Ethiopia and Afghanistan)

Definition of Governance

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Governance is robust when (1) the decisions are based on information, evidence, and shared

values; (2) the process is transparent, inclusive, and responsive to the

needs of the people the organization serves; (3) those who make and those who implement decisions are

accountable; (4) the strategic objectives are effectively, efficiently, ethically,

and equitably met; and (5) the vitality of the organization is maintained and its mission

is served.


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Key Governing Practices for Good Governance of Health Systems(Based on evidence from our review of literature, surveys, and fieldwork in Kenya, Nigeria, Ethiopia and Afghanistan)Enablers Practice Effective leadership and sound management Openness and transparency Inclusion and participation Gender-responsiveness Intersectoral collaboration Ethical and moral integrity Pursuit of efficiency and sustainability Measurement of performance Use of information and evidence Use of technology in governing

1. Cultivating accountability

2. Engaging stakeholders

3. Setting a shared strategic direction

4. Stewarding resources

5. Continuous Governance Enhancement (Assessing and enhancing governance)

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Results of our pilot study in 3 provinces and 11 districts of Afghanistan

13 to 21% improvement in governance 20% increase in antenatal care visit rate in the pilot

provinces

Governing bodies are being established at all levels and thousands of people are being invited to perform a governing role, often without adequate preparation

Our work in Africa and Asia demonstrates growing recognition of the value to build the capacity of leaders who govern.

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KenyaHospital boards, distribution by region # of Hospital Boards Total number of board members

1. Coast 23 299 2. Nairobi 5 65 3. Western 30 390 4. Rift Valley 62 806 5. Eastern 52 676 6. Nyanza 60 780 7. North Eastern 19 247 8. Central 24 312 Sub Total 275 3,575

Primary health care facilities boards # of Primary facility boards Total number of board membersHealth Centers and Dispensaries 3,636 47,268 Government Semi-autonomous health institutions with functional boards Total number of board members1. Kenyatta National Referral Hospital 112. Moi Teaching And Referral Hospital 133. Kenya Medical Training College 184. Kenya Medical Supplies Agency (KEMSA) 135. Pharmacy And Poisons Board 96. Medical Practitioners And Dentists Board 167. Nursing Council Of Kenya 188. Hospital Management Services Fund 139. Health Sector Services Fund (HSSF) 1310. National AIDS Control Council 1711. Kenya Medical Research Institute 1512. National Hospital Insurance Fund 14

51,013 persons are serving on the governing bodies of 3,923 government health sector institutions

Governance Guides for Health Systems

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LMG Governance Guides

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Name the five effective governing practices.

Cultivating ________________ Engaging _________________ Setting a shared ___________ ________ Stewarding ____________ Continuous _____________ ___________

LMG Governance Handbooks

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22Good Governance of Hospitals and Health Systems

Thank you for your interest!Please visit us at http://www.lmgforhealth.org/

Q & A, Comments

http://www.lmgforhealth.org/



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Cultivating Accountability Your personal accountability Accountability of your organization to its stakeholdersInternal accountability in your organizationAccountability of health providers and health workersManaging performance Sharing informationDeveloping social accountability Using technology to support accountability Smart oversight

Engaging Stakeholders Sincere stakeholder invitations Sincere stakeholder engagementBuild trustEngage with patientsEngage with doctors, other clinicians, and health workers Collaborate with other sectors Gender-responsive governance

Setting Strategic DirectionDefine the population health goalsEstablish a shared vision among key stakeholdersEnable leadership in the organization Create a successful strategic plan Implement the strategic planReport progress

Stewarding Resources ResponsiblyWisely raise and use resourcesPractice ethical and moral integrityBuild management capacityMeasure performanceUse information, evidence, and technology in governanceEradicate corruption

Continuous Governance Enhancement Cultivate governance competencies Build diversity in the governing bodyGovernance orientation and educationGovernance assessmentsEffective governing body meetingsGovernance policiesGovernance technologiesContinuous governance enhancement

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Handbooks for Governance Leaders and Senior Managers of the Ministries of Health, Provincial and District Health Systems, and Hospitals and Health Centers

Table of contents

Learning PlanInstructions for FacilitatorsIntroductory Session: Establishing rapport and understandingSession 1: Accessing Governance Resource SuiteSession 2: Participants apply the Challenge Model to governance in their own settingSession 3: Roles and responsibilities of a governing bodySession 4: Cultivating accountabilitySession 5: Engaging stakeholdersSession 6: Setting a shared strategic directionSession 7: Stewarding resourcesSession 8: Assessing and enhancing governanceSession 9: Competency-based governanceSession 10: Infrastructure for effective governanceSession 11: Governance enhancement planningSession 12: Evaluating the learning experienceAppendix 1: Governance Development PlanAppendix 2: Case study for reflection

Good Governance of Hospitals and Health Systems 25

Good Governance of Hospitals and Health Systems 26

References

Björkman M, Svensson J. 2009. Power to the People: Evidence from a randomized field experiment on community-based monitoring in Uganda. The Quarterly Journal of Economics, 124(2), pp. 735-769.

Olafsdottir A, Reidpath D, Pokhrel S, Allotey P. 2011. Health systems performance in Sub-Saharan Africa: governance, outcome and equity. BMC Public Health, 11(1), pp. 237.

Rajkumar AS, Swaroop V. 2008. Public spending and outcomes: Does governance matter? Journal of Development Economics, 86(1), pp. 96-111.

Lewis M, Pettersson G. 2009. Governance in health care delivery: raising performance’. World Bank Policy Research Working Paper 5074.

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