Strengthening Governance within Ministries of Health

By: Mahesh Shukla, MD, MPA 

Governing in the Context of Decentralization
Health leaders who work within ministries of Health in low- and middle-income countries across the globe are engaged in a variety of initiatives to strengthen their capacity to deliver services that protect, promote and restore health, even though they are faced with substantial human and financial resource constraints. One common strategy is to enhance the responsiveness and effectiveness of the Ministry of Health by investing in the decentralization of selected job roles and responsibilities to staff working at the provincial and municipal levels. To support public health professionals and managers in the implementation of these roles, there is an increasing interest among the leaders of these ministries to establish “governing bodies” (throughout their countries) that are given varying degrees of control over policy and program decision-making related to these changes.
Decentralized Health Governance Structures in Kenya
Thousands of community, civic, and clinician leaders are being asked to serve in these governance structures. In a recent study of governance structures in the public health sector in Kenya, more than 51,000 health leaders who have been invited to perform a governing role have been identified (See Table 1 below). These health sector leaders, from villages to the capital, need continuous access to insights into modern health sector governance work and effective governing practices.

Table 1: Decentralization drives growth in the number of leaders engaged in governance in Kenya

Source: USAID-funded Kenya LMS Project, 2012

The USAID-funded Leadership, Management and Sustainability (LMS)/Kenya Program, a sister project to the LMG Project, is currently working to strengthen leadership, management, and governance for sustained health programs in Kenya and is in dialogue with Kenyan health leaders to lend support to this decentralization process. From January 29-February 1, 2013, the LMS/Kenya project hosted Kenya’s first National Conference on Health Leadership, Management, and Governance with the following theme: “Toward Our Devolved Health System: Leading and Managing Change for Better Health.” The conference brought together local and international experts, leaders, managers and practitioners in the healthcare sector to contribute their knowledge and expertise to the challenges faced in the Kenyan health sector today, specifically concentrating on those challenges related to the decentralization of health services and decision-making, and the critical role that leadership, management, and governance play in improving the quality of health service delivery in Kenya.

Decentralization of Health Services and Decision-making in Afghanistan

Similar developments in decentralizing health services and decision-making have taken place in Afghanistan during post-war reconstruction of its health services. The Provincial Public Health Coordination Committees (PPHCCs) have been established about a decade ago in 34 provinces of the country. These committees have been functioning as an effective forum for the coordination and information sharing among various stakeholders of the provincial public health directorate and the provincial health system overall. They coordinate delivery of the Basic Package of Health Services, a Hospital Package of Health Services, and also a Prison Package of Health Services. They also perform a monitoring and supervision role.

Around the same time, community health shuras (i.e., consultative assemblies) were established at health post level, and health facility shuras were established at health center and district hospital level. A vast majority (three out of four) of these community and facility shuras actively meet on a monthly basis. Encouraged by the success of the PPHCCs and community health shuras, and with availability of donor assistance for positioning District Public Health Officers in about half the districts, the Ministry of Public Health has established District Health Coordination Committees (DHCCs) in these districts during the last three years to perform a role similar to that of PPHCC but at a district level.

Table 2: Active Health Shuras (Consultative Assemblies) in Afghanistan

Source: HMIS, Afghanistan. October 2012.

As seen from the Table 2 above, more than 100,000 individuals as members of various health shuras are currently preforming a governing role. Performed more effectively, their work can make a difference to the care delivered during 43 million patient visits to health facilities that take place every year in the provinces in Afghanistan.Source: HMIS, Afghanistan. October 2012.

In Afghanistan, the LMG Project is assisting the Ministry of Public Health to improve governance at all subnational levels (i.e., provincial district and community levels). It assists the PPHCCs, DHCCs, facility health shuras (consultative assemblies), and community health shuras to discharge their governing role so that they are able to influence access to health care, quality of care, and overall health outcomes for the people living in their jurisdictions. The project is well-prepared to provide similar assistance to governing bodies in other low- and middle-income countries.

For more details on these interventions, see article on “LMG Project’s Assistance to Health Governing Bodies in Afghanistan” on the LMG web portal.

Governing the Health Sector and Health Institutions Effectively

For readers who want to learn more about the four practices of good governance, and take practical steps in their own specific health context, we have a resource that can provide useful guidance called The eManager, which specifically focuses on governing in the health sector.

By Mahesh Shukla, MD, MPA, Public Sector Governance Senior Technical Advisor, Leadership, Management & Governance (LMG) Project.

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