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Innovative approaches to researching governance

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This presentation was given at the 3rd RESYST annual meeting in Hanoi, Vietnam, 2013, during a workshop on Universal Health Coverage (UHC). It gives a background to RESYST research on Governance issues and how these relate to the UHC debates.

The presentation was given by Professor Lucy Gilson from the Health Economics Unit at the University of Cape Town

Veröffentlicht in: Gesundheit & Medizin
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Innovative approaches to researching governance

  1. 1. Innovative approaches to researching governance issues for UHC “International Experience on Provider Payment Reforms for Universal Health Coverage”, Hanoi 16th Sept 2013
  2. 2. Outline 1.Governance and UHC 1.Researching governance within RESYST
  3. 3. ‘It is more useful to think of UHC as a direction, rather than as a destination’ Kutzin, 2013 p.604 …pursuing UHC requires coordinated policy action & implementation, across system functions and over time
  4. 4. Kutzin, 2013
  5. 5. Decisionmaking by people is at the heart of health system governance De Savigny & Adams, 2009
  6. 6. Governance issues for UHC Governance …of UHC and the health system … and of change/reform itself
  7. 7. 1) The hardware: establish frameworks of accountability & spread power
  8. 8. Governance structures • Develop a coherent network of ‘structures’ across the health system that spread power for decision-making across actors • Develop legislative frameworks that underpin the structures and their power to act, and hold them accountable upwards and outwards
  9. 9. 2) The software: enable the responsible exercise of power by system actors
  10. 10. ‘Governance is about the (formal & informal) rules that distribute roles and responsibilities among societal actors and that shape the interactions among them (decision-making)’ Brinkerhoff & Bossert (2008)
  11. 11. Influencing decision-making? • Through a combination of: – values & principles • Professional ethics • Transparency – leadership & role modeling – relationships of accountability – information – financial incentives
  12. 12. 3) The governance of change: maintain a consistent path and learn through doing
  13. 13. Thai experience
  14. 14. Always important • Sustained political leadership & commitment to change • Forming partnerships • Engaging and managing stakeholders • Sustained technical intensity & support
  15. 15. But also: Expect the unexpected Encourage learning processes & cultures Plan - Do Study - Act
  16. 16. Understanding governance: the Resyst approach
  17. 17. Governance as collective organisational capacity The hardware: e.g. a coherent network of ‘structures’ across the health system that spread power; legislative frameworks that underpin accountability; resource levels & distribution patterns signaling value Leadership The tangible software: The intangible software: • Sets of human resources • The informal rules, communication patterns, • Management knowledge & values, norms that shape skills relationships and interactions • Formal management among actors (relative power, processes trust, civic-mindedness) Leadership
  18. 18. RESYST governance focus • The micro-practices of governance, and what influences them the decision-making practices of public sector leaders working within the routines of the health system • And how these practices influence accountability, policy implementation & health system change
  19. 19. Research challenges • Micro-practices of governance are dynamic & complex, hard to observe • Difficult to disentangle governance effects from other health system elements/changes • Seek to inform and support continuing processes of decision-making, rather than to identify a single policy intervention
  20. 20. The job of the health system researcher ‘...is to illuminate the processes of change and experience that they observe... to make a contribution ... to the social process of understanding or promoting change.’ Barnes et al., 2005
  21. 21. Research to support learning Critical reflection Learning through doing
  22. 22. RESYST governance research • Learning sites within the ‘District Health System’ • Continuous engagement over time within a context • Focus on planning & priority setting • Understanding implementing actors’ 'theories of change’ for system reforms • Focus on specific UHCrelated reforms (South Africa, Tanzania, Nigeria) Encouraging reflection about decisionmaking practices through research
  23. 23. RESYST learning sites Why focus on peripheral facilities?
  24. 24. Supporting distributed leadership for UHC ‘Probably the most complex challenge in health systems is to nurture persons who can develop the strategic vision, technical knowledge, political skills, and ethical orientation to lead the complex processes of policy formulation and implementation. Without leaders, even the best designed systems will fail’ (Frenk 2010: 2)