Within the Governance theme, we have a particular interest in the relationships among frontline actors and mid-level management, and leadership in health policy implementation processes.

Governance is a central element linking and guiding the other health system building blocks including financing and health workforce. Good governance requires some level of accountability to the beneficiaries and the broader public; a policy process that engages and allows negotiation among stakeholders; sufficient state capacity, power and legitimacy to manage policymaking and implementation processes effectively; and engagement by non-state actors in policy processes, service delivery partnerships and in oversight and accountability.

A key challenge of governance research is the difficulty of disentangling the effects of changes in governance and accountability from those of parallel changes occurring in the health system; there is also potential for opposition to the research. As one strategy to address these challenges, we will work within Learning Sites located at sub-national level to: i) conduct action research to support local managers in taking action on issues prioritized by them and of relevance to RESYST; and ii) to investigate critical governance issues in real time, as health system policies are implemented.

Research questions

1. How can health system accountability be strengthened to support improved responsiveness?

In South Africa and Kenya, we will use Learning Sites to study community involvement in local health management groups. The research will also consist of reviews of community accountability mechanisms linked to peripheral health facilities and case studies. Detailed work within Learning Sites will be complemented by mapping of accountability mechanisms and their functioning in areas of Nigeria and Kenya.

2. What specific strategies can support effective implementation of new (financing and human resources) policies?

There is increasing international recognition of the importance of implementation research in generating better understanding of the gap between policy intentions and policy outcomes. In RESYST, we will conduct a detailed investigation of policy implementation experience through work funded a parallel project - Universal Coverage in Tanzania and South Africa (UNITAS), and by a qualitative evaluation of a national financing intervention in Kenya.

3. How can health system leadership capabilities be strengthened?

Learning sites in South Africa and Kenya will also be used to investigate specific leadership issues that arise and approaches to strengthening the leadership capabilities of health managers. A knowledge synthesis workshop will be held, drawing together health service managers and trainers to discuss what approaches to leadership strengthening have been applied.