How Does Governance Support Health Workers, Systems, and Outcomes?

How Does Governance Support Health Workers, Systems, and Outcomes?

{Photo credit: Rui Pires}Photo credit: Rui Pires

While at the World Federation of Public Health Associations meeting in India earlier this year, I met with a district health manager from Nigeria. He asked,

What is the value of having a District Health Council? It takes a lot of time to work with them; so what is the return on that invested time?

My Nigerian colleague is not the only one struggling to support the role of governing bodies. For years, governing bodies -– from district and provincial health councils to executive boards -– have been overlooked as valuable players in strengthening health systems.

“There are many examples of how investments in good governance lead to better health outcomes,” I said, “and many opportunities for supporting the under-supported leaders who govern through district health councils, hospital boards, or other governing bodies.”

We talked about how in the journey to stronger health system performance and greater health outcomes, it is not enough to have good leaders and managers to enable the talents of good health workers.

Strong health systems also need strong trustees serving on the organization’s governing body.

We determined that a good district health council -– or any good governing body –- amplifies the investment of time in at least three ways:

  1. Expanding resources (e.g. mobilizing more money!). Through relationships in the community and region, the governing body helps build the political capital needed to secure key resources (human resources, medicines, and money) for the mission of the organization.
  2. Enhancing legitimacy (e.g. listening, engaging, and informing). The governing body builds trust by ensuring that the plans and performance of the organization reflect the needs of the populations served, and that these populations are well informed about the plans and needs of the organization. This stakeholder engagement yields greater sense of ownership of the organization by its beneficiaries and hence expands the organization's legitimacy.
  3. Increasing transparency and accountability (e.g. monitoring resources better). Their oversight of and reporting on the plans and performance of the organization’s health workers, managers, and vendor relationships create a culture of openness and willingness for all to be held to account to the beneficiaries and citizens that the services and resources are being well used.

"Why the reference to ‘trustee’?" he asked.

“A trustee ‘holds in trust’ scarce resources that must be used to benefit the needs (in this case, health needs) of the beneficiaries,” I said, “particularly those that do not have the political or economic power or access to expertise to meet their own needs.”

These resources are not owned by the trustee, and must not be used to the benefit of the trustee. Rather, the trustee empowers managers and health workers to ensure that the resources bring value to the beneficiaries of the organization and its mission.

“In fact, great governing body members understand that their principal responsibility is to protect and support the mission of the organization in its drive to serve the needs of the organization’s beneficiaries.”

[The benefits of governance are far-reaching.] {{Figure from forthcoming "Leaders Who Govern" by: Management Sciences for Health}The benefits of governance are far-reaching.Figure from forthcoming "Leaders Who Govern" by: Management Sciences for Health

How can good governing bodies deliver on the promises of resources, legitimacy, and accountability?

We discussed five essentials for helping to unleash and nurture the effectiveness of a governing body:

  1. Define a clear, comprehensive “job description” or terms for the governing body and for each of its members;
  2. Ensure that the competency mix of people invited to serve on the body is diverse enough to reflect and champion the needs of the beneficiaries;
  3. Collaborate (manager and governing body chairperson) to ensure well-designed meetings and sufficient information so that governing body members know that their time and talents are well used by the governance decision making processes;
  4. Work sincerely (governing body and leadership team of the organization) at earning and nurturing mutual trust and open collaboration with each other, and, with, and for, the organization’s  beneficiaries; and,
  5. Commit to continuously improve strategic decision making on behalf of the mission of the organization.

Supporting Governing Bodies: An Investment Well Spent

“From over 30 years of working in health service delivery, health financing, and other areas of health systems strengthening, I’ve realized this,” I said, before we parted:

Health system performance and sustainable improvements in health outcomes require intentional governance at every level of the system. Your time supporting the members of the health council is well spent.

From the World Health Organization’s governance for health report, to a growing body of evidence and examples, the international community is understanding that  governing bodies need our support. To change the behavior of the health system, change the behavior of the institutions. To change the behavior of the institutions, change the behavior of the people who run it. To change the behavior of the people who run it, empower members of governing bodies, health workers, managers, and community leaders to understand and demand good governance.

Good governance will advance the mission of an organization or agency to deliver high-impact health services to individuals and communities, especially the most vulnerable populations.

{Figure from forthcoming "Leaders Who Govern" by: Management Sciences for Health}Figure from forthcoming "Leaders Who Govern" by: Management Sciences for Health


How are you struggling, or succeeding in supporting good governance? Share examples in the comments of this post. And stay tuned for a comprehensive exploration of good governance in two online learning formats this Summer: a forthcoming MSH book and digital resource, Leaders Who Govern; and a USAID-supported three-course governance program on Global Health eLearning Center.