Last week at the UHC Forum 2017 in Tokyo, the Health Systems Governance Collaborative and the UHC Partnership launched the Bold Moves Campaign and issued a manifesto calling for a “radical rethink” of governance and collaboration strategies. Emboldened and inspired by the manifesto, we decided right away to answer the call, and spin some ideas around how citizenship is conceived of within health governance.
In current health systems governance thinking (frameworks, interventions and action plans), attention has (rightly) gone to the multiplicity of governing actors and the distributive nature of power between those actors. However, governance does not only concern relationships between institutions, governing actors or power centres, but also relationships between citizens, the state and/or other actors. Health systems governance grounds much of its thinking on principal-agent theory (PAT), which rightly focuses on relationships between actors, institutions and their roles. However, the “principal” (the citizens in the relationship) remains a bit of an anaemic creature. While the onus (locus for change) is on institutions, the principal (i.e. citizens or communities) seems underdeveloped and somewhat instrumental. PAT does not appear to do sufficient justice to the creativity of collective action and the political agency of citizens and communities.
We argue here that a complexity-driven governance practice provides space for more creative, political collective action. Complexity science has been infecting governance research for quite some time and even the neo-institutional economist Elinor Ostrom, in her later work, adopted complexity in her study of adaptive environmental governance in social-ecological systems. More recently, the recent popular book “Doughnut Economics” from Kate Raworth throws old-school economic growth thinking out the window, to propose a complexity-driven economics, cognizant of climate change.
In the practice of governance at the national and sub-national health system levels, if we are to apply complexity thinking we will need to begin by acknowledging context and develop interventions accordingly instead of vice-versa (which is usually the case). This means that we must first begin with an appraisal of actual governance practices (what is actually happening right now) in health systems and communities instead of relying on starter assumptions on what governance should look like from other settings.
None of our health systems is a blank sheet in terms of governance. In fragile settings, people create their own practical governance solutions if there is a legal or a policy void, and in non-fragile settings rules are continuously adapted (or adjusted). Rules are grounded in social norms. Rightly the World Development Report 2017 on Governance and the Rule of Law points out that it really are the social norms, which give rise to power asymmetries and persistent inequity. Both are at the heart of accountability deficits/gaps. Therefore the effort should be primarily to influence these norms, which are really the mechanisms generating the “everyday” governance practices. If this is not done, actors will (find a way to) work around the rules.
Starting your intervention with what is actually happening on the ground also means that we will need to be “strategic rather than tactical”: when to use which governance instruments and how to combine them. We will need innovative ways to appraise the effects of our interventions, and to understand how they affect actor positions, which will transform the initial intervention. Much like chess play, strategies will need to be iterative and we will need to foresee and seize windows of opportunity by scanning the broader political and social context.
It does not stop there. If we want to tackle power and politics in the true sense of the word it is also time for a bit of “Global Health community reflexivity”, examining the political economy of our own work and the distribution of power therein. We need to question our own assumptions. Who are we as global health citizens, what are our values? Who do we want to be as (global) health citizens? What are our own incentives and how do we recognize and check those? What are our relative positions of power and how do we engage with differences? We could take our inspiration from radical democratic practice thinker Chantal Mouffe, that “talking truth to power” should also transform our practices as global health citizens – our ways of seeing, framing and working as researchers and practitioners.
Finally, (and central to the SDG endeavor and UHC 2030) is that health systems governance practice must be assessed based on its impact on equity, on “leaving no one behind”. Leaving no one behind in the context of health systems governance means that we will have to: (1) critically question legitimate representation, (2) explore how networked governance & self-organisation would lead to stronger democratic practice and public accountability in health, (3) explore how to enforce accountability towards those groups, (4) promote a more open view of what knowledge consists of in global health, (5) spur more “collaborative intelligence” and(6) a fine-grained representation of diversity.
In our role as researchers, it is also our responsibility to document existing practice – both successes and failures. Rooted governance practice does not necessarily appear in the form of experimentally tested interventions and often involves the work of grassroots activists and social movements over decades. Efforts at documenting these are required. New research and documentation on partnerships is required – what, for instance, do we know about cross-scale networks and responsibility sharing partnerships? Barriers of context and language need to be overcome in order to make those stories heard – and further open up space for learning. We can only be successful political agents in the global health community if (1) we manage to create new models that open up space for constructive dialogue; (2) if we manage to persuade others and link up networks and (3) if we legitimately represent and are accountable to those who are not being heard.
women talking in a community, Niger (2007)