Linking Governance Mechanisms to Health Outcomes: A
review of the literature in low- and middle-income
countries
Dana Karen Ciccone, Taryn Vian, Lydia Maurer, Elizabeth H.
Bradley
Accepted for publication in Social Science & Medicine, September
2014
1
Corresponding authors:
Dana Karen Ciccone, [email protected]
Elizabeth H. Bradley, PhD, [email protected]
Yale Global Health Leadership Institute2 Whitney Ave., Suite 401New Haven, CT 06510
2
Abstract:We conducted a synthesis of peer-reviewed literature to shed
light on links between governance mechanisms and health outcomes
in low- and middle-income countries. Our review yielded 30
studies, highlighting four key governance mechanisms by which
governance may influence health outcomes in these settings:
Health system decentralization that enables responsiveness to
local needs and values; health policymaking that aligns and
empowers diverse stakeholders; enhanced community engagement; and
strengthened social capital. Most, but not all, studies found a
positive association between governance and health. Additionally,
the nature of the association between governance mechanisms and
health differed across studies. In some studies (N=9), the
governance effect was direct and positive, while in others (N=5),
the effect was indirect or modified by contextual factors. In
still other studies (N=4), governance was found to have a
moderating effect, indicating that governance mechanisms
influence other system processes or structures that improved
health. The remaining studies reported mixed findings about the
association between governance and health (N=6), no association
3
between governance and health (N=4), or had inconclusive results
(N=2). Further exploration is needed to fully understand the
relationship between governance and health and to inform the
design and delivery of evidence-based, effective governance
interventions around the world.
4
Effective governance is recognized as a key component of
health systems (Kickbusch & Gleicher, 2012; Siddiqi et al., 2009;
World Health Organization, 2007). Governance encompasses
activities through which a society organizes itself to achieve
collective ends (Dodgson, Lee & Drager, 2002), implying agreement
among members to sacrifice some personal freedom and transfer a
measure of decision-making authority to a smaller governing body.
In principle, that decision-making entity reciprocally commits to
work toward a shared vision or goal, and accountability
structures help monitor and assure progress. Although ideally
commitments are reciprocal, the governing body and those governed
have different levels of power and authority to decide upon
overarching goals, strategies for attaining these goals, and
valuation of various outcomes. Governance principles apply to
actors across the health sector, including global aid mechanisms
(e.g. the Bill & Melinda Gates Foundation), intergovernmental
organizations (World Health Organization), and national
policymakers. With increasing calls for coordination,
accountability and results—as evidenced by consensus achieved on
the Paris Declaration on Aid Effectiveness—the international
5
community is pushing for more effective governance practices
(Chan, 2010; Easterly, 2002, Tucker & Makgoba, 2008; Transparency
International, 2006).
Governing institutions are most able to meet the needs of a
community when their processes are inclusive, transparent,
accountable to all stakeholders, and responsive to the demands of
the governed (Brinkerhoff, 2004; Buse, Drager, Hein, Dal, & Lee,
2009; Bartsch, Schneider & Kohlmorgen, 2009; Dodgson et al.,
2002; Vian, Savedoff, & Mathisen, 2010). Research has
demonstrated a correlation between national-level indicators,
such as control of corruption, and improved health (Witvliet,
Kunst, Arah, & Stronks, 2013; Gupta, Davoodi & Tiongson, 2002;
The World Bank, 2004), but the mechanisms facilitating this
association are not well understood. Although governing may take
different forms and many specific definitions of governance have
been proposed, most experts believe that sound governance
principles can improve health outcomes in low- and middle-income
countries (Andrews, Hay, & Myers, 2010; Savedoff, 2011; Lewis &
Pettersson, 2009; Marmot, Friel, Bell, Houweling, & Taylor,
2008). Despite endorsement of governance as essential to
6
improving health and health systems, to our knowledge, no one has
reviewed the literature connecting good governance mechanisms
with improved health outcomes—especially in resource-constrained
settings.
We conducted a systematic search of the peer-reviewed public
health and social science literature to determine the degree to
which governance activities in low- and middle-income countries
have been empirically linked to improved health outcomes.
Recognizing the vastness of existing literature on governance and
health in high-income settings (Batniji et al., 2014; Ferlie &
Shortell, 2001; Hefford et al,2005; Stuckler et al., 2009;
Veenstra, 2002), we focused where the gap in knowledge seemed
larger: in middle- and low-income settings. We acknowledge that
the effects of governance are context dependent, and our purpose
was to summarize what is known about the impact of governance on
and review the pathways by which good governance may influence
health outcomes in middle- and low-income settings. With this
focused scope, the findings from this study are most actionable
for helping shape governance efforts targeted at strengthening
health systems in low- and middle-income countries.
7
Methods
We searched for articles within databases likely to contain
literature on governance and health outcomes: Medline, Scopus,
Global Health, SSCI, and PAIS. We started with Medline to
determine appropriate search terms since Medline uses a
controlled vocabulary (MeSH terms). We then applied the Medline-
derived search strategy to other databases, for all available
years, up to and including March 2013.
Our search terms, which we selected to encompass a broad
literature related to governance, included: governance, governing
boards, decision making, democracy, health policy,
accountability, planning councils, participation, social capital,
stewardship, corruption, community monitoring, stakeholder, and
capacity building. For the health status construct, we used the
terms: health outcomes, health status, quality of care,
mortality, life expectancy, immunization rate, and essential
medicines. The governance construct search terms were combined
using "OR," as were the health status construct search terms.
Then, the governance and health status search results were
8
combined together using "AND." We filtered the results to isolate
studies written in English and conducted in low- and middle-
income countries.
After removing duplicates, the search generated 3,366
abstracts to screen for appropriate usage of the search terms to
describe some aspect or mechanism of governance and one or more
health outcomes. We removed commentaries, book reviews,
dissertations, and studies conducted in high-income countries.
Following the initial screening, 325 abstracts remained. Two
authors (DKC, LM) reviewed these and preserved 83 articles after
eliminating inappropriate studies by consensus. Three authors
(DKC, LM, EHB) reviewed the full texts and excluded articles
which had only casual referencing of governance and health
outcomes, but did not evaluate the association between them.
Based on this review, 28 studies were retained for data
extraction. An additional study not produced by the search
(Holmberg & Rothstein, 2011) was added by the authors because of
its relevance to the subject, and another was added during the
peer review process (More et al., 2012), yielding a final sample
of 30 papers (Figure 1).
9
Characteristics of the sample
Table 1 shows that only four studies involved a governance
intervention; otherwise, all other studies were cross-sectional
or descriptive. The most commonly examined health outcome was
under-five mortality rate (N=14), though it was often included
among an array of indicators like life expectancy, maternal
mortality, and immunization coverage.
Results
Associations between governance and health
Overview. Most, but not all, studies indicated significant and
positive associations between governance and health outcomes. The
nature of the association between governance and health, however,
differed across studies. In some studies (N=9), the governance
effect was direct and positive, while in others (N=5), the effect
was indirect or modified by contextual factors. In still other
studies (N=4), governance was found to have a moderating effect,
indicating that governance influences other system processes or
structures that improved health. The remaining studies reported
10
mixed findings about the association between governance and
health (N=6), no association between governance and health (N=4),
or had inconclusive results (N=2). See Tables 2-7. In this
section we describe the types of associates found, and in the
following section we describe the underpinning mechanisms.
Direct, positive relationship. Glatman-Freedman et al. (2010)
examined 35 GAVI Alliance-recipient countries and found that
combined governance score—using World Bank governance indicators—
was positively associated with the successful introduction of the
Hepatitis B and/or Haemophilus influenzae Type B vaccines. This
association remained significant when adjusted for other
contextual factors, including healthcare expenditure per capita.
Among a cross-sectional study of 120 countries, Holmberg and
Rothstein (2011) adjusted for national spending on health and
found a statistically significant, positive relationship between
quality of government (rule of law, government effectiveness, and
corruption perception) and better health in five indicators: life
expectancy at birth, child mortality, maternal mortality, healthy
life expectancy, and self-reported health status. Of these, the
most statistically significant relationship was found between
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quality of government and healthy life expectancy, which is the
average number of years that a person can expect to live without
suffering from disease or disability. The independent effect of
the government effectiveness variable was most evident among
countries where healthcare expenditure per capita was low. Burchi
(2011) examined 102 countries across 28 years and found that
countries with greater democracy, control of corruption, and
government effectiveness scores experienced fewer deaths during a
famine. Categorizing the countries as either 'democratic' or
'autocratic,' based on the political rights index, Burchi found
that among autocratic states, low values for voice and
accountability and political stability were significantly
associated with greater famine mortality. Olafsdottir et al.
(2011) found a significant association between governance
variables and under-five mortality in 46 African countries even
after adjusting for covariates reflecting the health care system,
e.g., financing, education, and physical infrastructure.
Moderating effects. One study (Rajkumar & Swaroop, 2008) of 91
countries found that two components of good governance—control of
corruption and strong institutions—modified the effect of public
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health spending on child mortality, showing that public spending
had a stronger effect on reducing child mortality in those
countries that have lower levels of corruption and high levels of
institutional capacity. A second study (Shandra et al., 2004),
examined infant mortality across 59 developing countries and
found that the detrimental effects associated with exports,
multinational corporations, and international lending
institutions have a more exacerbated effect on infant mortality
rates at lower levels of democracy than at higher levels of
democracy. In effect, higher levels of democracy safeguard low-
and middle-income countries against the unintended consequences
of unfavorable economic and trade policy, such as reliance on a
single export.
Inconsistent effects. Pushkar (2012) tested and found limited support
for the democracy advantage theory—that democracies deliver
better health outcomes than dictatorships—in India, a democratic
country that, at the time of the paper, ranked 134 out of 187 on
the global human development index. Pushkar examined infant
mortality rates across the country's 29 states for 1981 and 2009
and found that while democracy appeared to positively impact
13
health in some states, it had limited influence in others,
leading to increased disparity in infant mortality rates across
the country. In the wealthy state of Goa, infant mortality
dropped from 90 deaths per 1,000 births in 1981 to 11 deaths per
1,000 births in 2009, but eight of the poorest performing states
in 1981 continued to report infant mortality rates above 50 in
2009. Strand et al. (2008) examined eight governance measures,
alone and combined in the World Bank governance index, in 42
countries in sub-Saharan Africa and found that the governance
index could explain about one-third of the variation in ART
coverage for children—even when controlling for GDP per capita
and degree of ethnic fractionalization. In this same study, a
high governance score on the combined index, as well as
individual measures of voice and accountability and civil and
political freedom, were positively associated with school
enrollment and measles immunization coverage. Given the nature of
HIV/AIDS as a human rights issue, the authors were surprised to
discover that four democracy-related indicators had no
relationship with ART coverage: Polity Project's democracy index,
14
political competitiveness, political support for AIDS, human
rights in the AIDS approach.
Mechanisms by which governance may influence health
Below we highlight the four key governance mechanisms that
were found to have some association with improved health outcomes
in low- and middle-income settings: Health system
decentralization that enables responsiveness to local needs and
values; Health policymaking that aligns and empowers diverse
stakeholders; Enhanced community engagement; and Strengthened
social capital, with key data from all studies shown in Tables 2-
7.
Health system decentralization that enables responsiveness to local needs and
values. Six studies examining decentralization (conducted in
Bangladesh, Brazil, Egypt, India, Uganda, and Zambia) suggested
that the influence of decentralization on health outcomes may be
enabled by its responsiveness to local context.
Faguet and Ali (2009) conducted a mixed methods study on
decentralization in Bangladesh and reported divergent outcomes in
15
two upazilas (sub-districts): despite similarities in
administrative structures, one upazila, Saturia, performed
significantly better than the other (Rajnagar) in reducing under-
five mortality, maternal mortality and other indicators.
Implementation of the decentralized health system in Saturia
reinforced accountability to authorities at the district level by
frequent monitoring visits, and accountability to communities
through reporting on quality of services, while Rajnagar had no
such mechanisms. The study also found that in Saturia, strong
relationships had developed between health workers and citizens,
which seemed to improve awareness of positive health behaviors.
Compared with the population of Saturia, the population of
Rajnagar had greater reliance on traditional healers, greater
skepticism toward modern medicine and fear about prenatal
testing; factors which may have limited the decentralization
efforts in improving health outcomes. Conducting a survey across
45 local health systems, Atkinson and Haran (2004) found that
decentralization in the state of Ceará, Brazil was positively
associated with improved patient satisfaction, immunization
coverage, antenatal care attendance, clinical productivity, and
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service utilization. The success of decentralization in certain
municipios, however, was enhanced by the existence of informal
management practices not prescribed by the reform, such as
reliability of office hours, personal connections of the
community to the local health council, and ability of the local
leadership to relate to staff and patients. Data from Atkinson
and Haran (2004), consistent with findings of Faguet and Ali
(2009), suggested that implementing decentralization without
taking into consideration the local political culture, including
depth of community engagement and the existence of health-
compatible attitudes, may be ineffective.
Health policy-making that aligns and empowers diverse stakeholders. Six
studies examined a decision-making body’s ability to successfully
enact health regulation and found that the degree to which
policymaking leads to improved health was moderated by the
participatory, transparent and entrepreneurial nature of the
process. Harries et al. (2011) examined the translation of
research findings regarding Cotrimoxazole preventive therapy for
HIV-positive patients into national policy and subsequent scale-
17
up of an intervention leading to reductions in early mortality on
ART and increased TB cure rates. Effective policymaking and
policy implementation were catalyzed by several factors which the
researchers labeled as “policy entrepreneurship:” a willingness
to champion innovation, use of data in ministry-level decision
making, effective engagement of the necessary stakeholders,
alignment of public health priorities with national priorities,
and overall system transparency.Knippenberg et al. (1997)
conducted a case study of dramatic improvements to quality and
access of primary health care services in Guinea and Benin from
1986 to 1996—noting the increase in childhood immunization
coverage from 5 to 60 percent in Guinea and from 12 to 62 percent
in Benin. The authors posited that equity-promoting policies
enabled these improvements: design of a minimum health care
package, comprehensive supply system restructuring to improve
drug availability, successful outreach activities and continuity
of care to make service delivery more accessible, increased
engagement of nurses in decision making, ongoing transparent
monitoring, a revised and accessible comprehensive health
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information system, introduction of community financing schemes,
and creation of community health management committees.
Another case study (Taylor et al., 2009) compared the South
African government's response to the tobacco and AIDS epidemics,
crediting divergent outcomes to a difference in policy
approaches. Whereas South Africa successfully reduced national
per capita cigarette consumption by 40 percent from 1993 to 2006;
HIV/AIDS has continued to plague the country, accounting for an
increase of 170 percent in all-cause deaths in the 25 to 49 age
group from 1997 to 2006. South Africa swiftly passed legislation
banning advertising and sales to minors and increased excise tax
to raise the price of cigarettes 115 percent over a decade.
Additionally, the national coordinating body on tobacco
implemented an effective, multi-sectoral awareness-raising
campaign enlisting health workers, families and teachers. By
comparison, South Africa's response to HIV/AIDS was fragmented
and incremental. While overall awareness of HIV/AIDS had
improved, the authors argue that issues of gender inequity,
sexual violence, poverty, and stigma continue to obstruct
meaningful progress against the disease.
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The importance of alignment and empowerment in health
policymaking is further illustrated by Palmer et al. (2009) who
compared 170 countries’ ratification records for six human rights
treaties protecting the right to health, against HIV prevalence,
child mortality, and civil liberties indicators. Although 65
percent of countries had ratified all six treaties, their
citizens were no healthier than those of the other countries. In
fact, scores for infant and child mortality were lower for
countries that had signed all six treaties. This outcome
illustrated the gap between supranational and national
regulation, such that the populations – whose civil and social
rights the global community intends to protect through
international treaties – have not fully realized the benefits of
these agreements. In Cameroon, d'Almeida et al. (2011) examined
the national government’s policymaking through a partnership with
the Clinton Health Access Initiative to support the country's
2007 policy of universal, free access to HIV/AIDS treatments.
While 16 percent of patients living with HIV in Cameroon needed
second-line ART, only 1.9 percent received the therapy, despite
the partnership's commitment to cover the cost of the medicines.
20
The study found that implementation faced several obstacles
limiting its efficacy: the discrepancy between national- and
provincial-level estimates of demand, the prohibitive cost of
required testing to determine whether a patient qualified for
second-line ART, and a lack of coordination among supply chain
actors—particularly in terms of financing responsibilities. The
authors conclude that the well-intended policy was unrealizable
in practice due to failures in accountability, shared vision-
setting and infrastructure management.
Enhanced community engagement. Five studies examined community
engagement and health outcomes in Kenya, Nepal, Uganda, Burkina
Faso, Ghana, Nigeria, and India. Two pre-post intervention
studies and one cluster randomized controlled trial found that
participatory governance approaches with dialogue and
accountability mechanisms linking patients to providers led to or
were associated with improved health care quality and outcomes.
One study (Kaseje et al., 2010) found that increased
community-level participation in service delivery decision-making
in Kenya led to health improvements. The intervention included
21
development of committees to act as a linking structure between
service providers and consumers; training for community health
extension workers; village registers to monitor health-seeking
behavior; patient suggestion boxes; and provider sensitization on
the use of health management information system data. The study
found improvement in measles immunization coverage (91 percent in
intervention areas compared to 66 percent at control sites) and
increased use of insecticide-treated nets by women and children
(up 10 percent in intervention sites compared to -3 percent
observed in control communities). Improvements in water treatment
were also observed, ranging from 5 to 36 percent. The
intervention also led to improved documentation of facility plans
and outcomes, enhanced accountability among providers and between
providers and community members, improved staff morale, and an
increase in reported patient satisfaction. A similar study
(Manandhar et al., 2004) conducted in the rural Makwanpur
district of Nepal reduced neonatal mortality by 30 percent
through a community-based, participatory health intervention
involving community health worker facilitation of monthly
meetings with women of reproductive age.
22
Another intervention (Bjorkman & Svensson, 2009) used
community-based organizations (CBOs) as facilitators for a
community monitoring initiative across 50 rural communities in
Uganda. They collected data on health facility performance and
the opinions of service providers and community members, which
they summarized into a report card. The CBOs then held three
meetings: the first to disseminate the report card in each
community, the second to discuss the report card and the
community’s views with providers, and the third meeting bringing
together community members and health workers to develop a shared
action plan or “community contract” detailing what needed to be
done, when, and by whom. After one year, the communities that
implemented the intervention reported 33 percent lower child
death rates and 20 percent higher utilization of services.
Absence rates were lower, waiting time was lower, and drug stock-
outs were less frequent.
Strengthened social capital. Because citizens may feel engaged and
secure in a society with a functioning system of justice, a lack
of corruption and open government participation, interventions
23
that strengthen social capital may also function as health
governance mechanisms. Although the concept and measures of
social capital have been contested (Macinko & Starfield, 2001)
the literature demonstrates linkages between social capital—when
defined specifically according to connectivity and security--and
improved health.
One study of 1,680 pregnant women representing two cities in
Brazil (Do Carmo Leal et al., 2011) found that prenatal care use
above adequate levels was associated with a high level of social
capital, captured in the following indicators: social trust,
social control, empowerment, political efficacy, and neighborhood
security. In fact, higher aggregate social capital (calculated at
the city level) increased by eight-fold the odds of more than
adequate prenatal care. The authors suggest that social capital
may strengthen both the probability and impact of accountable
processes because in higher social capital communities,
reputations matter and shared values and goals likely exist.
Another study (Harpham et al., 2006) assessed social capital
across four dimensions—group membership, social support,
citizenship activities, and cognitive social capital (trust)--in
24
a survey of 2,000 one year olds and 1,000 eight year olds, and
their mothers, representing 20 sentinel sites in Vietnam. The
study found that social capital was associated with nutritional
status: mothers receiving support in formal or informal networks
had heavier children, and mothers with high cognitive social
capital had taller children. Similarly, one year olds of mothers
with high social capital were half as likely to be sick in the
previous 24 hours and eight year olds of mothers with high social
capital had reduced odds of suffering a life-threatening illness.
Discussion
Our review found significant associations between governance and
health in much of the literature, but not all of it. Many studies
show that the positive impact of governance mechanisms on health
is modified by the degree to which interventions are adapted to
local needs and values, the extent to which the existing economic
and political structures support the governance initiative, and
the presence of factors such as empowerment, accountability and
trust. Across the governance mechanisms studied, the literature
suggests that leveraging civic engagement and promoting tighter
25
accountability at all levels of the health system may be more
likely to improve health. Interventions to increase engagement
and accountability can be effective strategies in and of
themselves, as shown in the research on community engagement.
Many studies found that governance was linked with improved
health when culturally appropriate, equitable participation
exists, although experts (Taylor et al., 2009; Kalirajan et al.,
2012) have highlighted the challenges of accomplishing this with
health issues involving stigma or affecting very poor
populations. Inequity was found to limit the impact of governance
on improved health across the literature reviewed, although the
precise nature of its relationship with governance varied across
contexts and warrants deeper exploration. The findings on social
capital indicate that as general improvements in good governance
enhance individual feelings of trust, security and connectivity,
health improvements may be catalyzed, even in the absence of
health-specific governance interventions.
The literature sheds less light on the relative importance of
various governance mechanisms in improving health and how to
prioritize these when resources are limited. For example, we
26
found mixed results on the relative influence of the form of
government (democratic, autocratic) versus the nature of
institutions (bureaucratic, informal) on achieving better health
outcomes. Also, several studies conclude that strategies other
than governance may be an important influence on environmental
factors or processes leading to health improvement. In
particular, contextual factors, concurrent interventions and
structural elements that may trump the influence of governance on
health outcomes, such as the availability of foreign aid and the
penetration of interventions into rural areas. Hence, governance
by itself is not guaranteed to improve health, and its role in
the larger system of human development and health care delivery
deserves further research.
This review has identified substantial gaps in the available
research linking governance and health. Many of the studies in
our sample were conducted in Africa (N=13), with only eight
conducted in Asia, and two conducted in South America, thus
limiting opportunities for valuable learning across cultural
contexts and strategies. The study design employed in our sample
was predominantly either a national--level statistical analysis
27
(N=17) or a case study (N=7). Engaging in more mixed methods
evaluations would allow for effective multi-level analysis that
links information gained from national-level quantitative
indicators with community-level process descriptions and
perceptions. The studies we examined often had limited
longitudinal follow-up, insufficient consideration of other
factors influencing results, and ties to international
development assistance that narrowed the scope of research
results.
The conclusions drawn by this review should be interpreted
in light of several limitations. First, the definition of
governance is complex and widely debated. Our search terms,
intended to be as comprehensive as possible, are guided by our
interpretation of available research and will undoubtedly
conflict with or exclude some viewpoints. These terms were
generated after repeated explorations of Medline in order to
understand what subject categories and key words would yield the
broadest sample of literature that examines some aspect of
governance and health outcomes. Almost half of our sample (1188)
came from Medline, where the terms were subject headings rather
28
than text searches, meaning that they had been indexed using the
Medline-proprietary process. Although the field lacks consensus
on the ideal search terms for identifying governance literature,
we have been explicit about our search approach and believe that
any replication of our search methods would yield consistent
results.
Second, the empirical literature linking governance to health
is relatively sparse; our search yielded only 30 articles. Third,
the studies are diverse with each exploring a particular
governance mechanism and health outcome within a specific
context. Demonstrating the wide spectrum of available research on
governance, studies in our sample ranged from examining a
particular process or structure within local governance to
comparing national-level indexes of governance across countries.
Although we identified four governance mechanisms demonstrating a
relationship with health outcomes, replication studies would be
helpful to strengthen or refine the conclusions. Fourth, we
sought to evaluate the particular relationship of governance and
health in low- and middle-income settings. Finally, although we
recognize that the inclusion of gray literature would have
29
broadened the results of our search, we decided to limit the
scope to peer-reviewed literature only.
Although additional research to build a more robust body of
evidence concerning the nuanced ways in which governance
influences health is important, policy makers and program
managers can take action now to enhance the role of governance in
improving health by applying the enabling principles that have
already been found to improve population health around the globe.
While no single governance mechanism is likely to be effective in
all cases, building upon what we already know about the
relationship between governance and health in similar contexts
can catalyze new understanding and innovation for better
functioning health systems.
30
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Siddiqi, S., Masud, T. I., Nishtar, S., Peters, D.H., Sabri, B., Bile, K. M., & Jama, M. A. (2009). Framework for assessing governance of the health system in developing countries: Gateway to good governance. Health Policy, 90, 13-25.
Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., & McKee, M. (2009). The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. The Lancet, 374(9686), 315-323.
Vian, T., Savedoff, W. D., & Mathisen, H. (2010). Anticorruption in the Health Sector: Strategies for Transparency and Accountability. Sterling, VA: Kumarian Press.
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Transparency International. (2006). Global Corruption Report 2006: Specialfocus on corruption and health. London: Pluto Press.
Tucker, T. J. & Makgoba, M. W. (2008). Public-Private partnerships and scientific imperialism. Science, 320:1016-1017.
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Witvliet, M. L., Kunst, A. E., Arah, O. A., Stronks, K. (2013). Sick regimes and sick people: a multilevel investigation of the population health consequences of perceived national corruption. Tropical Medicine and International Health, 18(10), 1240-1247.
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World Health Organization. (2007). Everybody's business: Strengthening health systems to improve health outcomes: WHO's framework for action. Geneva: WHO Press. Available from http://www.who.int/healthsystems/strategy/everybodys_business.pdf.
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Appendix 1 – Final literature review sample
1. Atkinson, S., & Haran, D. (2004). Back to basics: Does decentralization improve health system performance? Evidence from Ceara in North-East Brazil. Bulletin of the World Health Organization, 82(11), 822-827.
2. Björkman, M., & Svensson, J. (2009). Power to the people: Evidence from a randomized field experiment on community-basedmonitoring in Uganda. The Quarterly Journal of Economics, 124(2), 735-769.
3. Blas, E., & Limbambala, M. (2001). User-payment, decentralization and health service utilization in Zambia. Health Policy and Planning, 16(2)(suppl), 19-28.
4. Burchi, F. (2011). Democracy, institutions and famines in developing and emerging countries. Canadian Journal of Development Studies, 32(1), 17-31.
5. Chilaka, M A. (2005). Ascribing quantitative value to community participation: a case study of the Roll Back MalariaInitiative in five countries. Public Health, 119, 987-994.
6. Croghan, T. W., Beatty, A., & Ron, A. (2006). Routes to betterhealth for children in four developing countries. The Milbank Quarterly, 84(2), 333-58.
7. d'Almeida, C., Essi, M. J., Camara, M., & Coriat, B. (2011). Access to second-line antiretroviral therapeutic regimens in low-resource settings: Experiences from Cameroon. Journal of Acquired Immune Deficiency Syndrome, 57, S55-S58.
8. do Carmo Leal, M., Esteves Pereira, A. P., de Almeida Lamarca, G., & Vettore, M. V. (2011). The relationship betweensocial capital, social support and the adequate use of prenatal care. Cadernos de Saúde Pública. 27(Suppl 2):237-253.
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9. Faguet, J. P., & Ali, Z. (2009) Making reform work: Institutions, dispositions, and the improving health of Bangladesh. World Development, 37(1), 208-218.
10.Glatman-Freedman, A., Cohen, M. L., Nichols, K. A., Porges, R.F., Saludes, I.R., Steffens K., . . . Britt, D.W. (2010). Factors affecting the introduction of new vaccines in poor nations: a comparative study of the Haemophilus Influenzae Type B and Hepatitis B vaccines. PloS One, 5(11):e13802.
11.Harpham, T., De Silva, M. J., & Tuan, T. (2006). Maternal social capital and child health in vietnam. Journal of Epidemiology and Community Health, 60, 865-871.
12.Harries, A. D., Zachariah, R., Chimzizi, R., Salaniponi, F., Gausi, F., Kanyerere, H., . . . Mpunga, J. (2011). Operational research in Malawi: Making a difference with Cotrimoxazole preventive therapy in patients with Tuberculosisand HIV. BMC Public Health, 11, 5930.
13.Holmberg, S. & Rothstein, B. (2011). Dying of corruption. Health Economics, Policy and Law, 6(4), 529-547.
14.Jepsson, A., & Okuonzi S A. (2000). Vertical or holistic decentralization of the health sector? Experiences from Zambiaand Uganda. International Journal of Health Planning and Management, 15, 273-289.
15.Kalirajan, K., & Otsuka, K. (2012). Fiscal decentralization and development outcomes in India: an exploratory analysis. World Development, 40(8), 1511-1521.
16.Kaseje, D., Olayo, R., Musita, C., Oindo, C. O., Wafula, C., &Muga, R. (2010). Evidence-based dialogue with communities for district health systems' performance improvement. Global Public Health, 5(6), 595-610.
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17.Knippenberg, R., Alihonou, E., Soucat, A., Oyegbite, K. Calivis, M., Hopwood, I., . . . Ofosu-Amah, S. (1997). Implementation of the Bamako Initiative: Strategies in Benin and Guinea. International Journal of Health Planning and Management, 12(S1), S29-S47.
18.Manandhar, D. S., Osrin, D., Shrestha, B. P., Mesko, N., Morrison, J., Tumbahangphe, K. M., . . . Costello, A. M. (2004). Effect of a participatory intervention with women's groups on birth outcomes in Nepal: Cluster-randomized trial. The Lancet, 364(9438), 970-9.
19.More, N. S., Bapat, U., Das, S., Alcock, G., Patil, S., Porel,M., . . . Osrin, D. (2012). Community Mobilization in Mumbai Slumsto Improve Perinatal Outcomes: A Cluster Randomized Controlled Trial. PLoS Medicine, 9(7):e1001257.
20.Nepal, B. (2007). Prosperity, equity, good governance and health: Focus on HIV/AIDS pandemic and its feminization. World Health & Population, 9(3), 73-80.
21.Olafsdottir, A. E., Reidpath, D. D., Pokhrel, S., & Allotey, P. (2011). Health Systems performance in Sub-Saharan Africa: Governance, outcome and equity. BMC Public Health, 11:237.
22.Osman, F. A. (2008). Health policy, programmes and system in Bangladesh: Achievements and challenges. South Asian Survey, 15(2), 263-288.
23.Palma-Solis, M. A, Diaz C. A. D, Franco-Giraldo, A., Hernandez-Aguado, I., & Perez-Hoyos, S. (2009). State downsizing as a determinant of infant mortality and achievement of Millennium Development Goal 4. International Journal of Health Services, 39(2), 389-403.
24.Palmer A, Tomkinson J, Phung, C., Ford, N., Joffres, M., Fernandes, K. A., . . . Mills, E. J. (2009). Does ratification
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of human-rights treaties have effects on population health? The Lancet, 373(9679), 1987-1992.
25.Pushkar. (2012). Democracy and infant mortality in india's 'mini-democracies': a preliminary theoretical analysis. Journal of South Asian Development, 7(2), 109-137.
26.Rajkumar A. S., & Swaroop, V. (2008). Public spending and outcomes: does governance matter? Journal of Development Economic, 86(1), 96-111.
27.Sayed, H. A. (1984). Community and family planning: a statistical analysis of Egyptian data. The Egyptian Population and Family Planning Review, 18(1), 1-32.
28.Shandra, J.M., Nobles, J., London, B, & Williamson, J.B. (2004). Dependency, democracy, and infant mortality: A quantitative, cross-national analysis of less developed countries. Social Science & Medicine, 59(2), 21-33.
29.Strand, P., Kinney, M., & Mattes, R. (2008). Politics and policy outcomes on children affected by HIV/AIDS in Africa. IDS(Institute of Development Studies) Bulletin, 39(5), 80-87.
30.Taylor, M., Meyer-Weitz, A., Jinabhai, C. C., & Sathiparsad, R. (2009). Meeting the Challenges of the Ottawa Charter: Comparing South African Responses to Aids And Tobacco Control.Health Promotion International, 24(3), 203-210.
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Electronic Database Search
Figure 1. Literature review schematic
● MEDLINE (n=1188)● Global Health (n=348)● Scopus (n=1359)
● SSCI (n=382)● PAIS (n=89)
Abstract Screening(n=3366)
Abstract Review(n=325)
Full Text Review(n=83)
Full Text Extraction(n=30)
References excluded based on abstract screeningReason for exclusion
● No mention of governance● No health outcomes● Editorial, commentary, book, or dissertation
References excluded based on abstractreview
Reason for exclusion
● Governance and health discussed but link between them not evaluated (n=49)
● Commentary/book/dissertation (n=5)
Reason for exclusion
● Health outcomes discussed but not tied to governance (n=77)
● Governance discussed but not tied to health (n=164)
References excluded based on full textreview
Added by authors(n=2)
Table 1. Characteristics of the literature review sample
Study location N=50+ countries 7Africa 13Asia 8South America 2
Scope of study N=Across many countries 12Comparison of two countries 2
Countrywide 8Within a country 8
Study design N=Quantitative 18Case studies 7Mixed methods 3Qualitative 2
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Table 2. Positive, direct association between governance mechanisms and health
Author Year
Location Governance construct Health construct Key findings
Bjorkman, et al.
2009
Uganda, nine districts
Community monitoring initiative to increase citizen-client ability tohold providers accountable.
Population health status: Nutrition status of infants, under-five mortality, service utilization rates, immunization rates
Community monitoring intervention led to significant increase in weight of infants, 33% reduction in under-five mortality, and 20% greater utilizationof outpatient services. Participating facilities saw improvements in immunization and examination procedures and reduced absenteeism.
Burchi 2011
102 countries
Degree of democracy: Political rights index. World Bank Governance Index: Voice and accountability,control of corruption, political stability, and government effectiveness.
Mortality rate associated with famine
Degree of democracy, control of corruption and governance effectiveness, are negatively correlated with famine mortality. Among autocratic states, voice and accountability and political stabilitywere negatively correlated with faminemortality.
Glatman-Freedman, et al.
2010
35 countries in AFRO region
World Bank Governance Index: Political stability, government effectiveness,rule of law, regulatory quality, control of corruption, and voice andaccountability.
Successful introductionof Haemophilus influenzae Type B and/or Hepatitis B vaccines.
High combined governance score was associated with successful introduction of one or both vaccines, independent of total and public-only health care expenditure.
Holmberg, et al.
2011
45 - 180countries
Quality of Government (QoG): Rule of law, government effectiveness, corruptionperception index.
Life expectancy at birth, child mortality rate, maternal mortality rate, healthy
All QoG variables were significantly correlated with all five health indicators; strongest relationship waswith healthy life expectancy.
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life expectancy, self-reported health status.
Kaseje, etal.
2010
Kenya, 6districts
Community engagement, through an evidence-baseddialogue model for service delivery improvement.
Population health status: Immunization coverage, ITN utilization, antenatal care attendanceSystem performance: Drug availability, staff availability, patient satisfaction surveys.
Intervention sites were found to have across-the-board improvements in health status and system performance. Study reported increased accountability, improved facilities, and strengthened community-provider relationships.
Knippenberg, et al.
1997
Benin, Guinea
Primary healthcare reformdemonstrating commitment to equity, sustainabilityand a focus on the poor.
Performance of primary health care services: Immunization rates.
Benin and Guinea strengthened primary healthcare despite a minuscule health budget, thanks to stewardship and strategies maximizing population benefit.
Manandhar,et al.
2004
Nepal, 1district
Community-based, participatory health intervention to promote healthy behaviors.
Neonatal mortality rates, maternal mortality rates
Participatory intervention led to 30% reduction in neonatal mortality. Maternal mortality was 80% lower amongintervention sites. Women were more likely to have antenatal care, take haematinic supplements, give birth in a health facility, and use a clean home delivery kit.
Olafsdottir, et al.
2011
46 countries in AFRO region
World Bank Governance Index: Voice and accountability,control of corruption, political stability, and government effectiveness.Ibrahim Index of African Governance: Rule of law,
Population health and health equity: Under-five mortality rate, under-five mortality rate averaged across poorestand richest quintiles.
Governance variables were all associated with lower under-five mortality. Of these, sustainable economic opportunities had the strongest association, even after controlling for other factors: health care; financing; education;
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transparency and corruption; sustainable economic opportunities.
infrastructure.
Sayed 1984
Egypt, 122 villages
Decentralization: Transfer of authority to local units at the governorate and village council level.
Contraceptive knowledge, use and practice.
A community-level governance structureand effective advocacy and accountability mechanisms together hada significant positive impact on contraceptive knowledge, use and practice.
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Table 3. Positive, indirect association between governance mechanisms and health
Author Year
Location Governance construct Health construct Key findings
Atkinson, et al.
2004
Brazil, state ofCeara
Decentralization reform System performance: Quality of care, patient satisfaction, percent of women attending antenatal care, child immunization coverage, percent attendance at facility.
Impact of decentralization reform on health was greater in those municipioswhere implementation was tailored to local needs, expectations, management style, and outreach activities.
do Carmo Leal, et al.
2011
Brazil, Rio de Janeiro state
Social capital: Social trust, social control, empowerment, political efficacy and neighborhood security. Contextual social capital: Part of societal structure.Compositional social capital: Resulting from networks.
Compliance with prescribed antenatalcare attendance.
Lower contextual and compositional social capital were associated with inadequate prenatal care utilization. Contextual social capital and social support were found to be social determinants for the appropriate use of prenatal care.
Faguet, etal.
2009
Bangladesh
Decentralization reform Population health status: Under-five mortality rates, maternal mortality rates, prevalence ofillness
Impact of decentralization reforms on health was greater in the upazila exhibiting reciprocal accountability, connectivity of citizens to health workers, and presence of health-compatible attitudes.
Harpham, et al.
2006
Vietnam,5 province
Mothers' social capital: Group membership, social support, citizenship activities, and cognitive
Child health status:nutrition (height and weight), mental
Children (one and eight year olds) were found to be healthier (heavier, lower rates of illness, better mental
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s social capital (trust). health, self-reported health status, recent illness.
health) when mothers had greater social capital.
Harries, et al.
2011
Malawi Successful translation of research on cotrimoxazole preventive therapy into national policy; subsequent implementation success
Health status of HIV-positive population: Rate of early mortality on ART, TB cure rate.
Process of catalyzing policy entrepreneurship to develop and implement national treatment guidelines based on research, led to reduced HIV-related mortality and increased TB cure rates.
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Table 4. Positive, moderating association between governance mechanisms and health
Author Year Location Governance construct Health construct Key findingsNepal 2007 100
countries
World Bank Governance Index: Voice and accountability, political stability, government effectiveness, regulatory quality, rule of law, control of corruption.
HIV/AIDS morbidity rate
Higher governance score was associatedwith lower size of HIV/AIDS epidemics,but relationship was not as strong as gender equity, wealth, and income equity. Governance appears to impact the extent of HIV/AIDS epidemics through its effect on equity and inclusion.
Rajkumar,et al.
2008 91 countries
Low levels of corruption, high quality bureaucracy (using the International Country Risk Guide).
Under-five mortality rates
As the level of corruption falls or the quality of bureaucracy rises, public spending on health becomes moreeffective in lowering child mortality.
Shandra, et al.
2004 59 developing countries
Degree of democracy (usingBollen Index): Freedom of the press, government sanctions, tolerance of political opposition, fairness of elections, methods of selecting executives, and methods ofselecting legislators.
Infant mortality rates
The level of political democracy was not found to have a direct relationship with infant mortality. The detrimental effect of multinational corporate penetration and commodity concentration increased with lower levels of democracy.
Palma-Solis, etal.
2009 161 countries
Freedom level: Freedom House index. Income equality: Gini indexNational fiscal policy: Government consumption per
Infant mortality rates
Countries best positioned to attain MDG 4 have the highest government consumption per capita, highest GDP per capita, greatest freedom score, and lowest Gini score.
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capita (government spending on goods and services), foreign direct investment, multinational penetration, commodity mix.
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Table 5. Mixed/inconsistent association between governance mechanisms and health
Author Year
Location Governance construct Health construct
Key findings
Jepsson,et al.
2000
Zambia, Uganda
Decentralization reform (health sector only, compared to national decentralization)
Infant mortality rate,life expectancy, access to waterand sanitation.
In Uganda, decentralization appeared to improve health, while in Zambia most indicators remained stagnant or worsened. Authors suggest that fragmentation caused by Zambia's health-sector-only reform prevented realization of intended benefit.
Osman 2008
Bangladesh
Demonstrated commitment to right to health and a pro-poorhealth system reform strategy.
Population health status: Child mortality, immunization rates
Case study concludes that despite some improvements, Bangladesh's health system reform failed to achieve its population health objectives due to a lack of regulation and absence of infrastructure touphold patient rights.
Taylor, et al.
2009
South Africa
Implementation of Ottawa Charter for Health Promotion: Healthy public policy, a supportive environment, community participation, development of personal skills, and re-orientation of providers to preventive care.
Tobacco use andrelated deaths;HIV/AIDS prevalence and related deaths.
Authors conclude that South Africa's use ofthe Ottawa Charter's five principles were pivotal in the success of its campaign to reduce tobacco use, but failed in addressing its HIV/AIDS epidemic.
Kalirajan, et al.
2012
India, 15 largest states
Decentralization reform Health disparity: Variation in infant mortality ratesand life expectancy
Decentralization has led to decreased health disparity among states in India, butbias toward urban populations has perpetuated health disparity within states,with lower health status in rural areas.
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between rural and urban populations.
Pushkar 2012
India Democracy, as characterized by a stable, open society based on free elections, political competition and civil activism.
Infant mortality rates
As India's democracy has matured, disparityamong state infant mortality rates has persisted, with significant improvement in some states and stagnation in others.
Strand, et al.
2008
Sub-Saharan Africa
Institutional quality: Control of corruption, government effectiveness.Degree of democracy: Voice and accountability, Political rights index, Press freedom, Political competitiveness (strength of opposition).AIDS Governance: AIDS Program Effort Index (API), OVC Policyand Planning Effort Index.
ART coverage, ART coverage for children, measles immunization coverage
Institutional quality was found to have thegreatest association with general ART coverage, ART coverage for children, schoolenrollment and measles immunization. Democracy did not impact ART coverage, but did have an association with measles immunization. Authors conclude that democracy and freedom may have an indirect impact on ART coverage.
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Table 6. No association between governance and health outcomesAuthor Year Location Governance construct Health construct Key findingsChilaka 2005 Uganda,
Ghana, Tanzania, Nigeria, Burkina Faso
Community participation, as experienced through theRoll Back Malaria Initiative.
Malaria control score: Malaria outpatient attendance (%); malariaadmissions (%) for 1998-2001.
Community participation was found to have no relationship with malaria control score. Small sample size, subjective nature of scoring, and lack of variation is scores, limit generalizability of results.
Croghan,et al.
2006 Bangladesh,Egypt, Ecuador, Indonesia
Political stability, control of corruption
This is a positive deviance case study, looking at countries with under-five mortality reductions ofmore than 40 percent.
While political stability and control ofcorruption did not hinder these countries from reducing under-five mortality, targeted health interventionsand access to foreign aid did appear to enable that achievement.
More, etal.
2012 India Community-based women'sgroups to lead a local initiative to improve perinatal care
Perinatal care, maternal morbidity, extended perinatal mortality
Cluster randomized controlled trial between intervention and control arms showed no significant effect of the use of these community-based women's groups on perinatal or maternal health outcomes.
Palmer, et al.
2009 170 countries
Demonstrated commitmentto the right to health via ratification of human rights treaties.
Population health status: HIV prevalence,maternal mortality rate, child mortality rate, infant mortality rate.
Treaty ratification was not associated with health improvements.
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Table 7. Association between governance and health could not be determinedAuthor Year Location Governance construct Health construct Key findingsBlas, etal.
2001 Zambia Decentralization reform Health service utilization rates, skilled birth attendance, immunization rates.
Decentralization was implemented at the same time as new user fee policies, so impact could not be isolated.
D'Almeida, et al.
2011 Cameroon Implementation of a policy to provide free second-line ART via a partnership among Cameroon, CHAI, and UNITAID.
Proportion of HIV patients in need of second-line ARVs who received them.
Authors conclude that policy effort failed due to absence of the following: consideration of testing costs, coordination of actors and effective monitoring.
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