Maintaining good governance in health systems is key to improving health system performance and health service delivery. The USAID-funded Leadership, Management, and Governance (LMG) Project defines governance as (1) setting a shared strategic direction and objectives; (2) making policies, laws, rules, regulations, or decisions, and raising deploying resources to accomplish strategic goals and objectives; and (3) overseeing and making sure that the strategic goals and objectives are accomplished.
The LMG Project takes a people-centered approach to governance, believing that interventions based on principles of human rights, dignity, and equal partnerships are more likely to meet the needs and of their communities.
In 2013, the LMG Project conducted a pilot study in Afghanistan to identify areas of improvement in provincial and district health systems. We applied our people-centered governance practices: (1) cultivating accountability, (2) engaging with stakeholders, (3) setting a shared strategic direction, and (4) stewarding resources in a responsible way.
Three Provincial Public Health Coordination Committees (PPHCC) and 11 District Health Coordination Committees (DHCC) were guided through four 2-day workshops where groups discussed specific governance actions that could improve their work to meet the health needs and expectations of their communities. Using the four governance practices, action plans were designed to be implemented over a period of six months. Despite a short period of time, improvements were identified based on the steps taken to improve governance practices on the district and provincial levels.
Committees saw improvements when implementing their short-term activities during the 6 month period. Through focus group discussions, we learned about successes like more regular and more productive meetings; creation of subcommittees; dissemination of information through press conferences, newsletters, and social media; and even closing down pharmacies without legal documentation. Committees also recruited more women and installed suggestion/complaint boxes, in addition to increased community mobilization efforts to discuss the importance of vaccination with elders.
Overall, the members observed a better link between committees at the provincial and district levels, and communities began participating in health facility monitoring by giving feedback on the quality of health services. There was an improved focus on patient’s health problems at the community level, and a desire to address and define the community health needs. While there are many improvements that still need to be made, committee members have become more aware of their weaknesses and are committed to make the necessary changes.
Even in fragile states, improvements to health system governance can help ensure adequate health services. The four effective governing practices helped the coordination committees in Afghanistan perform their roles and responsibilities in a more effective, efficient, transparent, and accountable manner. As time goes on, this has the potential to positively influence patient care experiences, and more importantly, access to quality care and overall health outcomes for people and communities.