This presentation was given at the 3rd RESYST annual meeting in Hanoi, Vietnam, 2013, during a workshop on Universal Health Coverage (UHC). It gives a background to RESYST research on Governance issues and how these relate to the UHC debates. The presentation was given by Professor Lucy Gilson from the Health Economics Unit at the University of Cape Town

1. Innovative approaches to
researching governance
issues for UHC
“International Experience on Provider
Payment Reforms for Universal Health
Coverage”, Hanoi 16th Sept 2013

2. Outline
1.Governance and UHC
1.Researching governance within RESYST

3. ‘It is more useful to think of UHC as a
direction, rather than as a destination’
Kutzin, 2013 p.604
…pursuing UHC requires coordinated policy
action & implementation, across system
functions and over time

4. Kutzin, 2013

5. Decisionmaking by
people is at
the heart of
health system
governance
De Savigny &
Adams, 2009

6. Governance issues for UHC
Governance
…of UHC and the health system
… and of change/reform itself

7. 1) The hardware: establish
frameworks of accountability &
spread power

8. Governance structures
• Develop a coherent network of ‘structures’
across the health system that spread power
for decision-making across actors
• Develop legislative frameworks that underpin
the structures and their power to act, and
hold them accountable upwards and outwards

9. 2) The software: enable the
responsible exercise of power by
system actors

10. ‘Governance is about the (formal & informal)
rules that distribute roles and responsibilities
among societal actors and that shape the
interactions among them (decision-making)’
Brinkerhoff & Bossert (2008)

11. Influencing decision-making?
• Through a combination of:
– values & principles
• Professional ethics
• Transparency
– leadership & role modeling
– relationships of accountability
– information
– financial incentives

12. 3) The governance of change: maintain
a consistent path and learn through
doing

13. Thai experience

14. Always important
• Sustained political leadership & commitment
to change
• Forming partnerships
• Engaging and managing stakeholders
• Sustained technical intensity & support

15. But also:
Expect the
unexpected
Encourage
learning
processes &
cultures
Plan - Do Study - Act

16. Understanding governance: the
Resyst approach

17. Governance as collective
organisational capacity
The hardware: e.g. a coherent network of ‘structures’ across the
health system that spread power; legislative frameworks that
underpin accountability; resource levels & distribution patterns
signaling value
Leadership
The tangible software:
The intangible software:
• Sets of human resources
• The informal rules,
communication patterns,
• Management knowledge &
values, norms that shape
skills
relationships and interactions
• Formal management
among actors (relative power,
processes
trust, civic-mindedness)
Leadership

18. RESYST governance focus
• The micro-practices of governance, and what
influences them
the decision-making practices of public sector
leaders working within the routines of the health
system
• And how these practices influence accountability,
policy implementation & health system change

19. Research challenges
• Micro-practices of governance are dynamic &
complex, hard to observe
• Difficult to disentangle governance effects from other
health system elements/changes
• Seek to inform and support continuing processes of
decision-making, rather than to identify a single policy
intervention

20. The job of the health system researcher
‘...is to illuminate the processes of change
and experience that they observe...
to make a contribution ... to the social process
of understanding or promoting change.’
Barnes et al., 2005

21. Research to support learning
Critical
reflection
Learning
through
doing

22. RESYST governance research
• Learning sites within the
‘District Health System’
• Continuous engagement
over time within a
context
• Focus on planning &
priority setting
• Understanding
implementing actors’
'theories of change’ for
system reforms
• Focus on specific UHCrelated reforms (South
Africa, Tanzania, Nigeria)
Encouraging reflection about decisionmaking practices through research

23. RESYST learning sites
Why focus on peripheral facilities?

24. Supporting distributed
leadership for UHC
‘Probably the most complex challenge in health
systems is to nurture persons who can develop
the strategic vision, technical knowledge,
political skills, and ethical orientation to lead
the complex processes of policy formulation
and implementation. Without leaders, even
the best designed systems will fail’ (Frenk
2010: 2)