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Health system governance

  • Page updated onMarch 10, 2025
Health system governance
Photo: Bruno Abarca

A government has the mandate and responsibility to guide all actors involved in a health system, whether public or private, corporate or not-for-profit, protecting the public interests and the right to health and health care of its population. This requires the development and implementation of policies, plans and regulatory frameworks, attention to system design and oversight, and ensuring adequate accountability, coalition building and coordination of actors.

Who's who in health system governance

The Ministry of Health and other health authorities

In most countries, the Ministry of Health plays a key role in the governance and leadership of the health system, with a very important stewardship mandate granted by the country's constitution and laws. Thus, Ministries of Health provide vision and direction to the health system, while regulating and managing essential public health functions. Some of the usual responsibilities of Ministries of Health in system governance include regulatory tasks, resource management, intelligence, citizen empowerment and the promotion of innovations, along with preparing for response to public health crises and emergencies, establishing and maintaining good relations with other actors, and ensuring health system values such as participation, transparency, accountability or efficiency.

However, not all health system governance and not all public health functions rest exclusively with the MOH; not even with the central government. Often the Ministry of Health assumes the overall leadership of the system, along with regulatory, legislative and public health insurance-related aspects -if any-. Meanwhile, decentralized authorities assume the planning and management of health services in their territory. In addition, at the state level, the Ministry of Health needs to relate to other state public bodies, such as the Ministry of Finance, insurance agencies, the parliamentary system, or the judicial system, which in turn have fundamental roles.

Health care providers, civil society, and the global health care system

It would be a mistake to understand that the only relevant actors in the health system are the authorities with the mandate to make decisions about it, without considering civil society and service providers. On the one hand, service providers are often not only the most visible face of the health system, but can also have a large share of power and control over resources. On the other hand, civil society is a population that goes far beyond "patients", whose inclusion and participation in the system must go far beyond their role as beneficiaries or public commitment to accountability. Considering civil society as a fundamental group of actors in the governance of the system is what can make it possible to advance towards its democratization, as well as towards equity and the right to health.

Finally, a country's health system is not watertight, but is related to other health systems, international and supranational organizations, just as it is affected by global health problems that develop beyond its borders.

Relationships between actors in the governance of the health system

The health systems governance model adapted by Brinkerhoff and Bossert posits system governance as the rules that determine the roles and responsibilities of three categories of actors (government, providers and civil society) and how they relate and interact with each other.

This scheme, despite its simplicity, helps to illustrate many ways in which system governance can fail, when power differentials and failures in overall health system design and stewardship lead to unfair or inappropriate relationships between actors that do not protect the public interest in health.

Relationships between stakeholders in healthcare governance
Brinkerhoff and Bossert, 2008.

The relationship between the citizenry and the government: an attempt to be heard

The two-way relationship established between the citizenry and the government is often marked by the possibilities of the population to make its voice heard by its authorities, collectively. This is sometimes done through public participation mechanisms, community initiatives to exert pressure, campaigns and advocacy actions organized by civil society organizations with sufficient technical capacity, or simply through voting. However, the asymmetry of power is clear, and in both democratic and authoritarian regimes (where, despite not having a vote, leaders also seek some popular support), the authorities often end up favoring particular interest groups, due to their economic capacity or political influence.

The relationship between government and service providers: an incentive-generating contract

A contract-like relationship is established between the government and the service providers. On the one hand, the authorities establish objectives, set procedures and standards, and grant certain resources (financial, material and human). In return, the providers deliver the agreed services in the agreed manner and provide the data and information requested.

The dynamics of this relationship (largely determined by the dynamics of health financing) produce economic (and other) incentives that are of key value in promoting efficient performance and quality services. The information that providers offer to authorities is fundamental to ensuring accountability, formulating public policy, developing essential public health functions related to intelligence and the health information system, and ultimately government accountability to the citizenry.

The relationship between citizens and service providers: asymmetry in supply and demand

A supply and demand relationship is established between citizens and service providers, which is often characterized by asymmetry of power. If the government is unable to adequately provide, regulate and incentivize providers, it ends up exposing the population to low-quality services that are difficult for the majority to afford, lack of information and obstacles to demand adequate accountability, and finally to inequity in access to essential services and the right to health.

International cooperation for health system governance

In complex humanitarian crises health system governance is further complicated. This is due to the direct impact of conflicts on the stewardship functions of the health system and the capacities of the institutions that govern it at the national or local level, the disruption of service delivery and population displacement, increased corruption (linked both to weak regulation and the introduction of new military, political and economic powers), and even the fragmented arrival in the country of new humanitarian actors, independent in their objectives, ways of operating and financing.

For this reason, humanitarian health interventions cannot be limited to the provision of health services. Humanitarian and cooperation actors also have an important role to play in supporting the institutions that play a steering role in the health system and service providers, in the development of public policies and a strong health regulatory framework, in improving information, transparency and accountability of the health sector, and in promoting citizen participation in governance. All this requires technical and financial support and advocacy actions, with a strong commitment to localization and community participation.

Supporting health authorities in their functions and development of public policies

A well-coordinated humanitarian action can help sustain the stewardship role of the MOH, for example, by supporting the country's own national response coordination and leadership mechanisms, or by including the MOH as a co-leader through its own humanitarian response coordination and governance mechanisms. The health cluster, where possible and feasible, should include the Ministry of Health as a co-leader, in addition to playing a role in supporting national authorities in emergency preparedness and contingency planning.

The involvement of cooperation actors in the development and implementation of public policies can be key to ensuring that these policies have a strong epidemiological and scientific evidence base, that they ensure the participation of citizens and civil society organizations, and that they respect the public interest rather than the interests of privileged subgroups or private interests.

Often, improving the transparency and accountability of a health system requires a combination of political advocacy and technical assistance. In many contexts there are obstacles linked to the lack of tools and procedures for information management and its public communication, but also major problems of corruption, in total opacity and developed with total impunity of those responsible. Transparency and accountability is not just another function, or an ethical dimension of the system, but may prove to be fundamental for there to be trust in the system and demand for its services.

In complex humanitarian crises, working in governance can be almost unfeasible

Not all of this is possible in a complex humanitarian crisis or in fragile authoritarian contexts where the space and freedom of movement of humanitarian actors is reduced. On many occasions, the international cooperation actors are forced to work in an environment where, beyond having an umbrella of humanitarian coordination, thinking about improving governance is only a long-term goal, once the crisis has passed its acute phase. Moreover, this may only happen in the hypothetical case that a certain political will for change, universal health coverage and the right to health exists or can be fostered.

It is also worth asking to what extent humanitarian actors can be involved in this challenge, given the difficulties they themselves have in transparency and accountability and the tasks pending in terms of empowerment of local actors and citizen participation in decision-making on humanitarian responses in their own territory. In addition, the implications that in some cases these actions may have on the humanitarian principles of neutrality and independence must be considered.

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