Writing about health system governance in low- and middle-income countries: concepts, methods and gaps
Within development debates and applied to national governments, "good governance" is often seen as a loaded term infused with political and value judgements. Yet health system governance is widely seen as a crucial leverage point to generate performance improvements.
But what is health system governance? The common focus on structural rules and regulations in health debates may defuse concern about value judgements, but at the same time ignores the importance of relationships among actors and the multiple institutional drivers of these relationships: history, experience, reputation, customs, beliefs, values. Indeed, governance demands concern for values in every setting.
While health system managers appreciate this, they are often too stretched to incorporate the relational aspects of governance in their day-to-day managerial practice – and so a key challenge for researchers is to think about how such aspects of governance can practically be infused into health systems.
This was one of the key insights from the April 2016 health system governance writing workshop convened by the Collaboration for Health Systems Analysis and Innovation (CHESAI) and RESYST. The workshop brought together health systems and policy researchers from Kenya, South Africa, India, Ghana and Argentina to discuss and develop papers on governance issues affecting low- and middle-income country health systems.
A first key strand of workshop discussion dealt with conceptual understandings. We acknowledged that health system governance understandings were often deeply rooted in professional backgrounds and that it was often understood differently throughout the various nested and inter-related layers of the system. Building on these points, we concluded that health system governance:
- Comprises a set of leadership and management processes within the health system;
- Involves a focus on hardware (e.g. structures) and software (e.g. relational) elements; and
- Is exercised across different layers of the system.
It was exciting to map out the terrain of our health system governance work by discussing the range of 28 papers being drafted. The papers focused on different health system levels and covered a wide range of themes, including decentralisation and accountability, policy processes and implementation challenges, health workforce management, and health system leadership and management. All the papers fitted into the three health system governance dimensions, and we generated ideas for strengthening governance processes at various system levels.
A second key discussion theme was the methodological approaches used to study health system governance. The draft papers addressed diverse questions and used a wide range of quantitative, qualitative and mixed methods. Key qualitative approaches included case studies, action learning, embedded approaches, ethnographies, and realist evaluations.
An important argument was that researchers should do more to recognize the similarities across these qualitative methods and to communicate their methodological approaches more clearly and simply to facilitate readers’ understanding, not create confusion. Researchers often present their findings in the complex technical language of specific research domains. This does not resonate with health system managers and policy makers, thus missing an opportunity to influence policy and practice. We also had interesting discussions about the role of quantitative methods such as econometric analysis. It was observed that quantitative methods were generally under-represented in health system governance research, despite complementing qualitative methods.
We agreed that the nature and range of health system governance questions often call for multiple and creative methodological approaches. There is clear value in engaging multi-disciplinary study teams to explore different questions and using embedded and longitudinal approaches as they present an opportunity for prolonged exposure and engagement, while simultaneously providing real-time feedback of research findings.
All-in-all, the week was rewarding and that could not have been possible without the ambience of the Mont Fleur venue and the unrivaled energetic facilitation skills of Lucy Gilson that ensured everyone was engaged throughout the whole week. In remaining faithful to our true Kenyan spirit, it goes without saying that our highest moment of the week was the tour to the Mont Fleur winery to sample some of the best wines of Cape Town!
This blog was originally published by CHESAI, a collaborative of health policy and systems researchers based in the Western Cape, South Africa. They work to provide systematic opportunities and environments for deepening the health policy and systems research knowledge base.