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Investing in health system governance: collective action required!


In these turbulent times, many people will agree that to the question recently asked by Fryatt et al. “Health sector governance: should we be investing more?”, the answer is definitely yes. The big issue then is: what kind of investments will make the difference?

Back in 2007, the WHO proposed a six building blocks’ framework to categorize and analyse health systems  : health financing, human resources for health, medicines and technologies, health information, health service delivery and governance. In this framework, health system governance was defined as: “Ensuring strategic frameworks exist and are combined with effective oversight, coalition-building, attention to system design and accountability”.  Since then, other definitions of governance have entered the literature, but for sake of simplicity we will stick to this one here for a moment and try to unpack what this definition really means in practice and what kind of actions it should ideally trigger in health systems.

First, we must admit that for the past decade, we have paid much attention to the first part of this definition: “ensuring strategic policy frameworks exist”. Communities of experts, donors and practitioners working to strengthen health systems and improve their performance have dedicated a great part of their work and resources to strengthening national and subnational capacities for strategic planning and policy-making. And surely, modernizing this planning process to meet the demands of fast-changing and diverse societies has been a challenge in its own right. As a consequence, until today, many health systems have a tendency to adopt a top-down planning approach whereby a central government (with or without the help of consultants) produces more or less visionary or conservative health sector strategic plans with varying levels of details.

But strategizing for health should not be a top-down approach. More and more people are convinced that robust national health strategies, policies and plans are to be developed through an inclusive process involving the diverse stakeholders and should contribute to health systems strengthening – including the population. Inclusive and participatory policy dialogue is at the core of strategic planning and policy formulation. Hence, building capacity for evidence-based, participatory and bottom-up planning has been at the focus of most governance investments in the recent past. This investment has also been extremely critical in providing a more solid base for donor coordination, harmonization and alignment. National health plans are a pre-requisite for effective coordination of health system strengthening interventions; support to the national health strategy is one of the seven behaviours of effective development cooperation, while Joint Assessment of National Health Strategies (JANS) is a well-established tool that promotes shared accountability in health systems.

Secondly, without denying the critical importance of policy-making capacity and strategic planning processes in the health sector, we must also acknowledge the need to examine more closely the latter part of the governance definition put forward by WHO in 2007: that is “effective oversight, coalition-building, system design and accountability”. Much less has happened in this respect in the recent past, although some authors in the health system literature have ventured this less travelled route: a recent systematic review identifies 16 frameworks for health systems governance published between 1994 and 2014, but only five of them have been applied in practice and only three considered governance at multiple levels of the health system. When travelled, the route therefore remains vastly theoretical; it is difficult to grasp what are the concrete actions that could benefit health system governance and improve health system performance. Nonetheless, some authors have attempted to incorporate key contemporary issues in the governance of health systems in their discourse: the role of the state vs. health markets, the role of ministries of health vs. other ministries, the diversity of actors in governance – public, private and civil society, the need to acknowledge the dynamic or organic nature of health systems and the implication of this on resilience and adaptability, the perspective of a rights-based approach to health. And for sure, addressing these issues, or at least attempting to consider them in the way we devise health system strengthening interventions will require much more than national health strategies, policies and plans. They also demand putting some emphasis on the institutions whose strength and power will ensure implementation of these plans and accountability towards their objectives: these institutions include broader governance principles such as the rule of law or democracy; public policies such as public financial management or decentralization; and organizational entities that govern the health sector such as ministries of health, public health agencies or health insurance organizations. To use the “hardware” / “software” metaphor now common in health systems research, a focus on institutions for health system governance requires investing in building or strengthening structures of government as well as in generating virtuous circles and positive outcomes through formal and informal processes, rules and incentives that play a role in policy implementation. Structures of governments – especially ministries of health and other health agencies, as well as relations between health system actors are at the core of the latter part of our definition of governance: “effective oversight, coalition-building, system design and accountability”,

In short: Promising innovations, new partnerships, platforms for intersectoral actions, innovations in applied policy research, and above all opportunities for dialogues between actors of the society – including first and foremost people for whom and by whom health systems are made : these are all crucial requirements of health systems governance for Universal Health Coverage.

The Health Systems Governance Collaborative was born from this urgent need for new collective action. The Collaborative is set up to work as a global network, made up of participants from various backgrounds: technical experts, agencies, policy makers, and citizens’ representatives. It is open to all stakeholders seriously interested in advancing health systems governance.  It seeks to provide a reflexive context for articulating locally relevant governance problems, and building theory from action and local practices. It is committed to develop a bold vision of collaboration, drawing actively on existing networks and communities of practice. The Collaborative is connected to the UHC2030 platform as one of the latter’s participating networks, to guarantee maximum synergy between local and global experiences. Two initial topics will be explored in the coming year; they reflect critical questions put forward by both scholars and practitioners in the field:

  • The changing roles and governance capacities of ministries of health, as the main stewards of health systems in the 21st century, faced with multiple local, national and global challenges and opportunities
  • Frameworks, dimensions and measures of governance that will support an actionable governance agenda in the health system, similar to broader actionable governance indicators supporting advances in sustainable governance


This is a new initiative, but we hear it is much needed and we are committed to make it happen. So don’t hesitate to join the movement, together we are stronger!


About Maryam Bigdeli

Department of Health Systems Governance and Financing, World Health Organization, Geneva

About Gérard Schmets

Department of Health Systems Governance and Financing, World Health Organization, Geneva

About Agnès Soucat

Department of Health Systems Governance and Financing, World Health Organization, Geneva