Presentation titled "Governance in the Third Dimension: Science Fiction or Science Fact," given by HFG at 2015 USAID Global Health Mini-University on March 2, 2015. Session Description: Strengthening health governance can significantly improve the effectiveness and sustainability of reforms and, in turn, achieve better health system performance. Yet despite its importance, health governance investments are often overlooked. Health governance is frequently misunderstood by governments and the global health community, because governance in practice (vs. theory) is poorly defined and difficult to operationalize. In this session, participants will learn how Haiti has defined and is addressing dimensions of governance for health financing and human resource reforms. Participants will apply these dimensions of health governance to work/activities that they are involved in, and consider how addressing these dimensions can strengthen health governance in their countries and enhance the impact of health financing, human resource, and service delivery reforms.

1. Abt Associates Inc.
In collaboration with:
Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)
| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
Governance in the Third Dimension:
Science Fiction or Science Fact?
Elaine Baruwa, Awa Dieng, Jodi Charles, Matt Kukla
March 2, 2015

2. Outline
Definitions and the role of health governance
Overview of governance dimensions
Application to Haiti
Group breakout sessions
Discussion and lessons learned

3. Definitions of Governance
“The careful and responsible management of the well-being
of the population” (WHO WHR 2000 - stewardship)
“Health system governance concerns the actions adopted
by a society to organize itself in the promotion and
protection of the health of its population. This includes the
institutions – the formal and informal rules that shape
behavior – and the organizations that operate within these
rules to carry out the key functions of a health system”
(Siddiqi et al., 2009).

4. Health Governance and Us
 Step 1: How can we identify dimensions of health governance to strengthen?
 Step 2: How does strengthening governance impact our health performance goals?
Health System
Reform
Performance
Goals
Implementation
Governance
Step 1 Step 2

5. Governance Dimensions :
How do you know one when you see one?
Dimensions Identifying Questions
Decision-making Structures
 Are each governing entity’s formal roles and responsibilities
clearly defined and legally binding?
 Are mechanisms in place to resolve conflicts of
responsibility between governing entities and build
consensus?
Institutional Capacity
 Do governing entities have the resources and institutional
capacity to effectively fulfill their roles and responsibilities?
Monitoring & Evaluation
 Do feedback channels exist to ensure that reliable, clear, and
timely information is received and acted upon by governing
entities?
Sources: WHO (2012); World Bank (2008); Savedoff (2011); Mathauer & Carrin (2011); Mathauer (2009)

6. Governance Dimensions
& Sample Questions
Dimensions Identifying Questions
Transparency &
Accountability
 Are health policies publically available, easily understandable, and
legally binding?
 Are official and actual consequences of non-performance by
governing entities the same?
Stakeholder Voice
 Do governing entities effectively balance communicating with
stakeholders yet avoid capture?
Regulation &
Enforcement
 Are tools/instruments in place to ensure that health policies are
effectively enforced?
Stability
 Have fundamental governance roles, health system characteristics,
and performance objectives remained stable over time?
Sources: WHO (2012); World Bank (2008); Savedoff (2011); Mathauer & Carrin (2011); Mathauer (2009)

7. Governance Dimensions and Haiti
But are these governance dimensions
useful in the real world?
Let’s see how HFG applies this tool to their work in Haiti

8. HFG’s Haiti Accreditation Activity
Approximately 400 private nursing schools in Haiti
 High tuition for a poor country
 Low quality of schools  low state exam passing rates
 Students graduate without clinical experience
 Private nursing schools need two licenses in order to operate
but only 40-50 of 400 institutions have both licenses
 Accreditation “system” existed to monitor quality but
 Evaluation tool not based on quality standards
 Evaluation tool was old and poorly designed and only focused on
materials and infrastructure

9. HFG’s Haiti Accreditation Activity
Accreditation occurs when a neutral party evaluates a
private nursing institution’s:
 Strengths
 Weaknesses
 Possibilities for improvement
Evaluation team compares elements of the institution’s
education system against agreed upon quality standards:
 Curriculum
 Physical training facilities
 Teaching methods
 Techniques for grading students

10. Theory to Action
Key Questions HFG Intervention Dimension
• Do governing entities have the resources and
institutional capacity to effectively fulfill their
roles and responsibilities?
• Improve DFPSS capacity to oversee private
HRH training institutions with protocol
assigning R&R
Institutional Capacity
• Are tools/instruments in place to ensure that
health policies are effectively enforced?
• Develop accreditation process to ensure
minimum standards for training institutions
Regulation &
Enforcement (T&A)
• Are tools/data/instruments available to
monitor link between health policies,
governance responsibilities, and health
system performance?
• Develop online system to support
accreditation process
• Track and present data on student/teacher
ratios, national exam % pass rates
Monitoring &
Evaluation
• Do health system actors have a clearly
defined and equitable role in decision-
making?
• Include private sector entities and
professional bodies in design of accreditation
systems and jury process
Stakeholder
Voice
• All! • See above
Transparency &
Accountability
Does the accreditation intervention address any of the key governance questions?

11. Governance: Science Fact!
 Better education programs  More accredited nurses with better clinical skills  patients
get greater access to care and receive better quality of care
 Without accreditation – no oversight by government and no accountability
 Without including schools/professional bodies (stakeholders) in process design – no buy-in
Nursing school
oversight
Improved quality
and quantity of
nursing care
Accreditation
M&E
Reg. & enforce.
Inst. capacity
Stakeholder voice
Step 1 Step 2

12. Health Financing and Governance…
… and YOU!
 Review the activity described on the handout (page 1).
 Review the first dimension (page 2) and its questions
 For each dimension/question, assume the answer is “no”. Will that
impact the ability to implement a health financing strategy? How?
 What might we do to address that?

13. Better Implementation through
Stronger Governance
Key Questions HFG Intervention Dimension
• Are each governing entity’s formal roles
and responsibilities clearly defined and
legally binding?
• Has the level of decentralization been
accounted for in these decision-making
structures?
Help MSPP…
• develop roles and responsibilities of actors within HF reforms
• oversee flow of funding and resource allocation
• ensure that national level coordinates with department levels to
define HF roles, functions, and structures
Decision-making
Structures
• Do roles and responsibilities correspond
with decision-making power?
• Do governing entities have the resources
and institutional capacity to effectively fulfill
their roles and responsibilities?
Help MSPP…
• build institutional and technical capacity to implement HF
strategy
• strengthen their capacity to dialogue effectively with MoF
Institutional
Capacity
• Are health policies clearly defined, easily
understandable, and legally binding?
Help MSPP…
• Ensure HF strategies are understood by health system users
Transparency &
Accountability
• Do all health system actors play a clear
role in policy decision-making?
• Are procedures in place for stakeholders
to voice grievances?
• Is stakeholder participation equitable?
Help MSPP…
• identify stakeholders to work with on health financing strategy
• develop methods to include stakeholders in its development
• improve feedback channels and strengthen stakeholder
engagement
Stakeholder Voice

14. Abt Associates Inc.
In collaboration with:
Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)
| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
Thank you
www.hfgproject.org