Governance and participation in health

In this open letter to the World Bank, a group of 110 international civil society organisations (CSOs) call on the Bank to play a truly progressive and transformative role in health by supporting countries to achieve universal health coverage (UHC). The World Bank is well-placed to be a vocal champion of UHC by deploying its knowledge and experience in health system reform, as well as its financial support. However, the Bank must reform the approach of its programmes and policy advice in order to deliver on this potential, and ensure it positively impacts poor and vulnerable populations. The CSOs call on the Bank to actively support countries to offer care that is free at the point-of-use for all people, as well as scale up investment in public health systems in developing countries, by supporting them to expand public financing, and by offering balanced policy advice that does not privilege private sector solutions over publicly financed and delivered health systems. The Bank can take further steps to promote UHC by ensuring all Bank programs benefit the poorest two quintiles in the countries where it works, actively supporting involvement of civil society in national health policy development, in order to improve democratic oversight and accountability for improved health outcomes, and collaborating with the World Health Organization and other global health institutions in the push for UHC.

Implementation of policies (decisions) in the health sector is sometimes defeated by the system’s response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes’. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper, researchers use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, they unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimise negative unintended effects.

When specifically viewed with Africa’s history in mind, administrative corruption, though rampant across Africa today, is an alien culture, argues the author of this article. Pre-colonial Africa, for the most part, was founded on strong ethical values sometimes packaged in spiritual terms, but with the end result of ensuring social justice and compliance. The author argues that colonialism introduced systemic corruption across much of sub-Saharan Africa, repudiating indigenous values, standards, checks and balances. The author makes several recommendations: restoration of indigenous values and institutions; improving access to formal, informal and non-formal education; promotion of the ‘African’ nation state; and strengthening of anti-corruption institutions. The author argues that African countries should not just seek the deceptive increment in Gross Domestic Product, but real development in terms of standard of living, with health, education, food security and infrastructural growth given prominence.

To address the research gap on health care leadership in low-income settings, researchers in this qualitative study documented the experiences of individuals in key health-care leadership roles in sub-Saharan Africa. They conducted in-person interviews with health care leaders in four countries in sub-Saharan Africa: Ethiopia, Ghana, Liberia and Rwanda. Individuals were identified by their country's minister of health as key leaders in the health sector and were nominated to serve as delegates to a global health leadership conference in June 2010, at Yale University in the United States. Five key themes emerged as important to participants in their leadership roles: having an aspirational, value-based vision for improving the future health of their countries, being self-aware and having the ability to identify and use complementary skills of others, tending to relationships, using data in decision making, and sustaining a commitment to learning. While current models of leadership capacity building only address the need for core technical and management competencies, skills relevant to managing relationships are also critical in the sub-Saharan African context, the authors argue. Developing such skills may require more time and a deeper level of engagement and collaboration than is typically invested in efforts to strengthen health systems.