2. Good Governance from Villages to Parliaments:
What Global Health Needs Now
by Jonathan D. Quick, MD, MPH on June 22, 2012
3. LMG’s Governance Studies
Research questions
– What is effective governance in the context of health
– What enables it and what hinders it
– What are practices of effective governance
– How to measure it
– What are the gender issues involved
– How leadership, management and governance interact to produce
better health outcomes
4. LMG’s Governance Studies
Targeted literature review
Surveys
– 2011 Governance Survey
– 2012 Governance Survey
►477 health leaders, governors and managers form 80 countries
Interviews
– 25 key informant interviews from 16 countries
Governance roundtable 18 May 2012
– 30 governance thought leaders, experts, practitioners,
donors and CAs
5. What is effective governance in the context of health
• The governance that leads to both an improvement in
health service and the health of individuals and
populations
• Predominant themes
Impact on health service and health of people
Transparency
Accountability
Participation
Inclusion
Ethical and moral integrity
Focus and vision
Efficiency and Equity
6. What enables it and what hinders it
# Deterrent # Enabler
1 1 Ethical and moral integrity
Ineffective leadership
2 Corruption 2 Competent leaders governing
3 3 Governing with a definite policy on measurement,
Ineffective management data gathering, analysis, and use of information for
policy making
4 Inadequate transparency 4 Sound management
5 5 Adequate financial resources available for
Inadequate accountability
governing
6 Inadequate systems to collect, manage, analyze 6 Openness and transparency
and use data
7 Inadequate participation of community/ citizens/ 7 Client/community participation in decision making
clients/ consumers/ patients
8 8 Accountability to citizens/clients
Political context
9 9 Governing based on scientific evidence
Inadequate checks and balances
10 Inadequate financial resources for governance 10 Good Governance in sectors other than health
7. Defining governing in practical terms
100%
6% 5% 8%
90% 8% 9% is not a part of governing
8% at all
17% 17%
80%
21% 26%
70%
25% 29%
is a slightly significant
part of governing
60%
50%
is a moderately
40%
75% 75% significant part of
67% 63% governing
30% 60% 58%
20%
is a highly significant
part of governing
10%
0%
To include To steer To regulate To collaborate To oversee To allocate
8. Practices of Effective Governance
Cultivate Accountability
Engage Stakeholders
Set Shared Direction
Steward Resources
9. Practice Principles
CULTIVATE ACCOUNTABILITY Accountability
Transparency
Legal, ethical and moral behavior/Moral capital
Accessibility
Social justice
Oversight
Legitimacy
ENGAGE STAKEHOLDERS Participation
Representation
Inclusion
Diversity
Gender equity
Conflict resolution
SET SHARED DIRECTION Stakeholder alignment
Leadership
Management
Advocacy
STEWARD RESOURCES Ethics
Efficiency
Effectiveness
Resourcefulness
Financial Accountability
Development
Social responsibility
10. Practices Principles Governing actions
G CULTIVATE Accountability 1. Establish, champion, practice and enforce codes of conduct
O ACCOUNTABILITY Transparency 2. Embed accountability into the governing institutions
Legal, ethical and moral 3. Make all reports on finances, activities, and plans available to the public
V Foster a facilitative behavior 4. Establish oversight and review processes
E decision-making Accessibility 5. Establish a formal consultation mechanism
R environment Social justice 6. Sustain a culture of integrity and openness that serves the public interest
Moral capital
N Oversight
I Legitimacy
ENGAGE Participation 1. Empower marginalized voices, including women
N STAKEHOLDERS Representation 2. Ensure appropriate participation of key stakeholders
G Inclusion 3. Create and maintain a safe space for the sharing of ideas
Identify, engage and Diversity 4. Provide an independent conflict resolution mechanism
collaborate with Gender equity 5. Elicit, and respond to, all forms of feedback
diverse stakeholders Conflict resolution 6. Establish alliances for joint action at whole-of-government and whole-of-
P society levels
SET SHARED DIRECTION Stakeholder alignment 1. Oversee the process for developing and implementing a shared action plan
R Leadership 2. Advocate on behalf of stakeholders’ needs and concerns
A Develop a collective Management 3. Document and disseminate the shared vision of the ‘ideal state.’
vision of the ‘ideal Advocacy 4. Set up accountability mechanisms for achieving goals
C state’ 5. Oversee the process of setting goals to reach the ‘ideal state.’
T 6. Oversee the process of realization of the shared goals and the desired
I outcomes.
STEWARD RESOURCES Financial Accountability 1. Champion the acquisition and deployment of resources
C Development 2. Protect and invest the resources to serve stakeholders and beneficiaries
E Steward resources Social responsibility 3. Collect, analyze and use information and evidence for making decisions
responsibly, building Capacity building 4. Build capacity to absorb resources and deliver quality services
S capacity Country ownership 5. Use resources in a way that maximizes the health and well-being of the
Ethics public
Resourcefulness 6. Inform and allow the public opportunities to monitor raising, allocation,
Efficiency and use of resources, and realization of the outcomes
12. Measuring governance
Process
Outcomes Health service attributes
Health outcomes
Both process and outcomes
Impact Health impact
Impact beyond health
• An overwhelming majority asserted that governance
must be measured by the result in terms of
improvement in health service and the health.
• A typical comment was — ―I think it is fundamental to
be able to show results.‖
13. Gender in governance
+ ++ +++
Gender — 0
perspective Exploitative Blind Aware Responsive Transform
of our key 8% 8% -ative
12%
informants maintain
gender 56%
gender do not
inequalities does not seek to clearly 16%
and influence responsive
stereotypes how challenge seek to
the status to different
decisions needs transform
are made quo based on gender
gender relations
Roles women play in a health system and
promote
Women in boardrooms or governing positions equity
Women in health workforce
Women as users of health care
— ―In a situation like that where governance basically is a male thing, then
women’s issues are likely to be forgotten…..‖
14. How L+M+G interact to produce better health outcomes
► Leadership, management and governance are
interdependent, intricately linked, and reinforce each
other.
► There is a clear overlap between the roles of leading,
managing, and governing.
► Leaders are critical to the governing process.
— Effective leadership is a prerequisite for effective
governance and effective management.
15. You may access the reports
of our governance studies
on the LMG web page
of the MSH external site at
http://www.msh.org/global-presence/lmg-project.cfm
Over to Karen for how
LMG can help enhance
governance in public,
private, not-for-profit
and civil society
organizations
in partner countries
18. Who are the potential clients for governance
strengthening?
• Public sector: parlimentarians, state
legislators, senior MOH officials, state
and local health departments, hospital
boards, state/province/ municipal/
district/village health boards, and
elected councilors
• Multi-sector bodies: CCMs, specific
councils for
AIDS, RH, TB, women, children &
others
• Civil society: CBOs, FBOs,NGOs
• Private sector: hospital boards;
company CSR programs
• Academia: Schools of
medicine, nursing, pub. health &
19. How can LMG help enhance health governance in
public, private and not-for-profit institutions in
partner countries?
• Training
• Technical Assistance
• Knowledge Exchange
21. Senior Leadership Program
• Who: Teams of 4-6 senior
people; from all sectors
• How long: 12-month process
with workshops at months 3, 6 &
12
• Content: effective governance
practices; strategic problem
solving; leadership development;
design, implementation &
evaluation of a strategy for a
priority health problem.
• Certificate: from Yale University
22. Leadership Development Program Plus
(new and improved LDP)
• Who: Managers and teams of
health workers who focus on a
specific health result
• How long: 6-8 months
• Process: Senior Alignment
Meeting chooses priority health
area; Technical Team identifies
indicators and interventions to
address Priority Health Area;
Improvement teams meet in 3
workshops to learn L+M+G
practices; On-Site Team
Meetings to address challenges;
2 Shared Learning Sessions
23. Effective Board Governance Training Program
• Who: Members of CSO Boards
of Directors & key Executive
Staff
• How long: One 2-3 day
workshop
• Content: L+M+G practices;
definition of
governance, accountability &
transparency; responsibilities of
Boards of Directors compared to
staff; board operations; risk
management; CoI; produces a
Governance Enhancement Plan
24. Effective Board Governance TOT Program
• Who: Trainers who will provide
governance training to CSO
boards of directors & staff
• How long: One 2-3 day TOT
workshop
• Content: L+M+G practices;
definition of
governance, accountability &
transparency; responsibilities of
Boards of Directors compared to
staff; board operations; risk
management; CoI;adult learning
techniques
25. Community Leadership, Management & Governance
Training Program
• Who: Community leaders in rural
communities
• Process: Five 2-day workshops
every 3-4 weeks
• Content: Values-based leadership
(personal, family & community);
participatory planning; project
monitoring; accountability &
transparency; reconciliation &
forgiveness; conflict resolution;
communication; commitment to
children; produces a community
health project putting leadership &
governance skills into practice
26. Integration of Governance, Leadership, &
Management into Pre-Service Curricula
• Who: Curriculum integration
teams & support staff
• Process: Three workshops,
including a final TOT
workshop; includes Pre-
Service Guide; can also be
delivered virtually
• Content: Local adaptation
and integration of action-
oriented, practical
governance, leadership and Pre-Service Guide provides 3
management content into sample curricula, facilitators’ notes,
the pre-service curricula & resources on logistics & roles
and responsibilities within the
curriculum integration process.
27. The Virtual CSO Board Governance Program (VCBG)
• Who: Teams of CSO board
members and staff
• Process: Eight-week virtual
training program
• Content: role of the board of
directors, elements of an effective
board of directors, transparency
and accountability. By the end of
the VCBG, participants develop a
draft policy on board transparency
and a governance improvement
plan.
29. LMG Governance Technical Assistance
Areas
• Governance
Responsibilities
• Board Member
Development
• Governance Performance
Assessment
• Governance Monitoring &
Adaptations are made in the TA Information
based on the context, i.e.
public vs. private sector, • Governance and Gender
governing individuals (ministers)
vs. a governing body, etc.
30. LMG TA Area 1: Governance Responsibilities
• Role of Governing Body with regard to: Strategic Visioning
and Planning, Quality Assurance, Fiscal
Vitality, Management, Stakeholder Relations, Interface
with Government, Governance Effectiveness
• Board Member Position Description and Performance
Expectations
• Role and Array of Committees and Advisory Bodies
• Committee Charges and Annual Work Plans
• Board Meeting Calendar for 18-month Period
31. LMG TA Area 1 : Governance Responsibilities (cont.)
• Board Meeting Agendas
• Board Chairperson Position Description and
Performance Expectations
• Committee Chairperson Descriptions and
Performance Expectations
• Board Policy Manual (including Conflict of Interest and
Code of Ethics)
• Governance Enhancement Plan for continuous
governance improvement
32. LMG TA Area 2: Board Member Development
• Board Member Competencies
• Competency Mapping Process to Guide Recruitment
and Board Development
• Board Member Orientation Program
• Board Member Customized Individual Education
Plans
• Board Education Plan and Budget
• Board Portal for 24/7 access to board materials
33. LMG TA Area 3: Board Member Development (cont.)
• Board Experience Exchange Process
• Digital Reference Library on Governance Concepts &
Practices
• eLearning resources
• Board Member Mentoring Program
34. LMG TA Area 3: Governance Performance Assessment
• Governance Overall Risk Assessment
• Board Overall Performance Self-Assessment
• Governance Overall Performance Self-Assessment Tool
• Board Member 360 Assessment
• CEO Performance Planning and Assessment
• Physician (or other specific HR category) Satisfaction
Survey
• Work Force Satisfaction Survey
• Middle Managers Performance Assessment
• Patient/Client Satisfaction Assessment
• Community Perception Survey
35. LMG TA Area 4: Governance Monitoring & Information
• Design of Board
Information System
(BIS)
• Governance Dashboard
Design and
Development
• Development of
Governance
Performance Indicators
& Metrics
36. LMG TA Area 5: Governance and Gender
What can be done?
• Enable more women to
participate in
governance and
empower them
• Change the governance
Purpose: Work with
institutions
governing boards, institutions
and individuals to make them themselves—making
more gender-aware, gender - them gender-
responsive and gender - responsive
transformative, internally and
externally for clients
• Change mindsets
38. Problem Statement Long-Term Outcome
Millions of people die each year due to lack of Knowledge Improved health behaviors and health
information and ill-informed health care outcomes through effective knowledge
services. Management management
Logic Model
Initial Intermediate
Inputs Processes Outputs Outcomes* Outcomes
Procedures Knowledge Health
• Best practice Used Systems
guides • Access
Performance
• After-Action • Awareness
Improved
Reviews • Assessment
Human and Capture Organization • Mentoring • Adoption
financial programs • Access
• Adaptation
knowledge
resources • Communities
/ Networks • Coverage
Share
KM Culture • Quality
Data and and Capacity Services
information • Efficiency
Strengthening • Help desk Individual and
Generation Synthesis Organizational
• KM training
• Workshops Performance
Infra-
Improved
structure
Products • Policy and advocacy
Equipment Assessment informed
• Publications
• Websites • Programs and
• eLearning practice
courses enhanced
• CD-ROMs • Training and
education
improved
• Research
strengthened
Monitor, Evaluate, and Learn
*Project achievements are measured at the initial outcomes level. Intermediate and long-term outcome levels are shown to illustrate how initial outcomes can contribute to these other
expected outcomes.
43. Governance Publications
Guide to Effective CSO Governance
What is it?
The Guide is a 34-page compilation of FAQs about
CSO governance.
How is the Guide Used?
The Guide is used as supplementary training material
for face-to-face or virtual training programs on CSO
governance. Also serves as a useful Internet resources
for persons seeking information on CSO governance.
44. Virtual Governance Seminars
• LMG can organize virtual seminars of any length on
any topic related to governance
• Seminar participants: cross-national, from a single
country, from single state or province
45. LMG Governance Team
Jim Rice
Project Director
jrice@msh.org
Mahesh Shukla
Senior Technical Advisor for Governance
mshukla@msh.org
Karen Johnson Lassner
Governance Officer
klassner@msh.org
Notas do Editor
All three roles interact in a balanced way to serve a purpose or to achieve a desired result.Nevertheless, each of the roles is relevant.
Slide adapted from IRC KM Framework. The cyclic KE process start with people talking to each other (Conversations) and executing activities (Activities). In the picture above this is depicted as the blue blocks in the middle. The multiple blocks indicatethat with a certain sector, multiple conversations / activities are or will be going on in parallel.The KEprocessis scalable from individual, via team, community, department or organisation, up to sector scale. Some examples:Individual learns a certain topic and makes the knowledge explicit (Document process)—resulting in an article stored in a library (Information repository). The article can be communicated (Versioning information) to readers, presented at a symposium, salient points “tweeted”,etc e.g. included in another Conversation / Activity.An organization plans a pre-test / pilot of an intervention; the process is documented (Document process) by means of focus group discussions resulting in information on success / failure / amendments and that information is fed back (Versioning information) to that organisation for evaluation (Conversation).Key sector players meet for a sector review and the result are communicated to the various government, NGO,and CBO organisations.