Abt Associates Inc.

In collaboration with:

Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)

| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Governance in the Third Dimension:

Science Fiction or Science Fact?

Elaine Baruwa, Awa Dieng, Jodi Charles, Matt Kukla

March 2, 2015

Outline

Definitions and the role of health governance

Overview of governance dimensions

Application to Haiti

Group breakout sessions

Discussion and lessons learned

Definitions of Governance

“The careful and responsible management of the well-being

of the population” (WHO WHR 2000 - stewardship)

“Health system governance concerns the actions adopted

by a society to organize itself in the promotion and

protection of the health of its population. This includes the

institutions – the formal and informal rules that shape

behavior – and the organizations that operate within these

rules to carry out the key functions of a health system”

(Siddiqi et al., 2009).

Health Governance and Us

Step 1: How can we identify dimensions of health governance to strengthen?

Step 2: How does strengthening governance impact our health performance goals?

Health System

Reform Performance

Goals Implementation

Governance

Step 1 Step 2

Governance Dimensions :

How do you know one when you see one?

Dimensions Identifying Questions

Decision-making Structures

Are each governing entity’s formal roles and responsibilities

clearly defined and legally binding?

Are mechanisms in place to resolve conflicts of

responsibility between governing entities and build

consensus?

Institutional Capacity Do governing entities have the resources and institutional

capacity to effectively fulfill their roles and responsibilities?

Monitoring & Evaluation

Do feedback channels exist to ensure that reliable, clear, and

timely information is received and acted upon by governing

entities?

Sources: WHO (2012); World Bank (2008); Savedoff (2011); Mathauer & Carrin (2011); Mathauer (2009)

Governance Dimensions

& Sample Questions

Dimensions Identifying Questions

Transparency &

Accountability

Are health policies publically available, easily understandable, and

legally binding?

Are official and actual consequences of non-performance by

governing entities the same?

Stakeholder Voice Do governing entities effectively balance communicating with

stakeholders yet avoid capture?

Regulation &

Enforcement

Are tools/instruments in place to ensure that health policies are

effectively enforced?

Stability Have fundamental governance roles, health system characteristics,

and performance objectives remained stable over time?

Sources: WHO (2012); World Bank (2008); Savedoff (2011); Mathauer & Carrin (2011); Mathauer (2009)

Governance Dimensions and Haiti

But are these governance dimensions

useful in the real world?

Let’s see how HFG applies this tool to their work in Haiti

HFG’s Haiti Accreditation Activity

Approximately 400 private nursing schools in Haiti

High tuition for a poor country

Low quality of schools low state exam passing rates

Students graduate without clinical experience

Private nursing schools need two licenses in order to operate

but only 40-50 of 400 institutions have both licenses

Accreditation “system” existed to monitor quality but

Evaluation tool not based on quality standards

Evaluation tool was old and poorly designed and only focused on

materials and infrastructure

HFG’s Haiti Accreditation Activity

Accreditation occurs when a neutral party evaluates a

private nursing institution’s:

Strengths

Weaknesses

Possibilities for improvement

Evaluation team compares elements of the institution’s

education system against agreed upon quality standards:

Curriculum

Physical training facilities

Teaching methods

Techniques for grading students

Theory to Action

Key Questions HFG Intervention Dimension

• Do governing entities have the resources and

institutional capacity to effectively fulfill their

roles and responsibilities?

• Improve DFPSS capacity to oversee private

HRH training institutions with protocol

assigning R&R

Institutional Capacity

• Are tools/instruments in place to ensure that

health policies are effectively enforced?

• Develop accreditation process to ensure

minimum standards for training institutions

Regulation &

Enforcement (T&A)

• Are tools/data/instruments available to

monitor link between health policies,

governance responsibilities, and health

system performance?

• Develop online system to support

accreditation process

• Track and present data on student/teacher

ratios, national exam % pass rates

Monitoring &

Evaluation

• Do health system actors have a clearly

defined and equitable role in decision-

making?

• Include private sector entities and

professional bodies in design of accreditation

systems and jury process

Stakeholder

Voice

• All! • See above Transparency &

Accountability

Does the accreditation intervention address any of the key governance questions?

Governance: Science Fact!

Better education programs More accredited nurses with better clinical skills patients

get greater access to care and receive better quality of care

Without accreditation – no oversight by government and no accountability

Without including schools/professional bodies (stakeholders) in process design – no buy-in

Nursing school

oversight

Improved quality

and quantity of

nursing care

Accreditation

M&E

Reg. & enforce.

Inst. capacity

Stakeholder voice

Step 1 Step 2

Health Financing and Governance…

… and YOU!

Review the activity described on the handout (page 1).

Review the first dimension (page 2) and its questions

For each dimension/question, assume the answer is “no”. Will that

impact the ability to implement a health financing strategy? How?

What might we do to address that?

Better Implementation through

Stronger Governance Key Questions HFG Intervention Dimension

• Are each governing entity’s formal roles

and responsibilities clearly defined and

legally binding?

• Has the level of decentralization been

accounted for in these decision-making

structures?

Help MSPP…

• develop roles and responsibilities of actors within HF reforms

• oversee flow of funding and resource allocation

• ensure that national level coordinates with department levels to

define HF roles, functions, and structures

Decision-making

Structures

• Do roles and responsibilities correspond

with decision-making power?

• Do governing entities have the resources

and institutional capacity to effectively fulfill

their roles and responsibilities?

Help MSPP…

• build institutional and technical capacity to implement HF

strategy

• strengthen their capacity to dialogue effectively with MoF

Institutional

Capacity

• Are health policies clearly defined, easily

understandable, and legally binding?

Help MSPP…

• Ensure HF strategies are understood by health system users

Transparency &

Accountability

• Do all health system actors play a clear

role in policy decision-making?

• Are procedures in place for stakeholders

to voice grievances?

• Is stakeholder participation equitable?

Help MSPP…

• identify stakeholders to work with on health financing strategy

• develop methods to include stakeholders in its development

• improve feedback channels and strengthen stakeholder

engagement

Stakeholder Voice

Abt Associates Inc.

In collaboration with:

Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)

| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Thank you

www.hfgproject.org