The 8th Global Conference on Health Promotion held in Helsinki, Finland, 2013 set the agenda for Health in All Policies (HIAP). The HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions. It improves accountability of policy makers for health impacts at all levels of policy making for the achievement of health equity and the realization of health as a human right. The Helsinki Declaration was inspired by the actions and evidence by the Alma Ata Declaration on Primary Health Care (1978) and the Ottawa Charter as central elements for the promotion of health. Subsequent WHO global health promotion conferences cemented key principles for health promotion action. These principles have been reinforced in the 2011 Rio Political Declaration on Social Determinants of Health, the 2011, Political Declaration of the UN High-level Meeting of the General Assembly on the prevention and control of Non-communicable diseases, and the 2012 Rio +20 Outcome Document (the Future We want).
In addressing the big societal challenges of today from containing communicable diseases to offering health services at all levels, the fundamental question to ask is how equipped is the Ministry of Health (MoH) to govern? This question occupies many health authorities around the world. It has been noted by various scholars that National health authorities occupy a central role in health system governance. As Ministries or Departments of Health, these authorities have a unique mandate over population health, charged with ensuring the health and wellness of millions. The questions then arise, what kinds of capacities does MoH require to govern responsibly and effectively? How can we better understand the term “governance” as applied to MoH? How can we better assess the ways in which an MoH changes and adapts to very dynamic context?
In Botswana his Excellency the President Dr Mokgweetsi Masisi recently outlined his roadmap the “Reset “Agenda, based on 5 key priorities areas. The fundamental key questions to ask are, firstly the roadmap’s applicability to addressing health systems governance and what is that is needed to rebuild and strengthen Botswana’s health systems and lastly their alignment to the Helsinki Declaration and all other WHO frameworks, strategies and resolutions. In short the extent to which the Policy Transfer from Global to National is being implemented as a guiding principle.
In recent decades, the role of an MoH has shifted from that of funder and provider to more of a steward of the entire health system, which came as a result of colonial systems and were often reconfigured in the newly independent States. MoHs have also been shaped by global trends and milestones, for example, the Alma Ata Declaration helped expand efforts around primary care and social determinants of health. However, these trends were met with emerging fiscal constraints in the 1970s and 1980s, which often squeezed MoH budget as observed by Bossert et al, 1998 and Gillar et al, 2008. Other political, administrative and/or fiscal reforms from the 1980s and 1990s onwards (e.g., diversifying purchasing and provision of health services, decentralization measures) created new management and organizational structures in Ministries, in many cases implemented without related capacity-building efforts, according to Bossert et al, 1998.
While states have always been tasked with various degrees of “oversight,” current oversight measures for an ever more complex health sector require a distinctly outward looking and inclusive multisectoral approach to governance and being better equipped to address increasingly pluralistic systems, Bossert et al and Rasanathan et al observed. Notably, MoH today often does not hold exclusive authority over health, sharing that responsibility with sub-national actorssuch as provinces, states and districts with supra-national actors including global foundations and multi- laterals with legally empowered agencies, councils and institutions charged with particular governance functions, and with citizens, noted, Saltman R B et al, 2013 and Kickbusch et al, 2012. Surrounding all these actors are broader networks and structures that can include other parts of government, civil society, researchers, professional groups, the private sector, including health sector stakeholders and other industries, donors, and regional and international bodies.
Clearly, the governance context for any MoH has become highly complex and dynamic. Many different actors in some cases already part of the governance structure now advance their own interests. From the 2000s onwards, following increased global attention to health inequities as captured in the context of the Millennium Development Goals (MDGs), Ministries engaged with new stakeholders. This included new philanthropic foundations, glamour aid, private sector corporations, new bilateral and multi-lateral agencies, plus a more diverse set of international NGOs. A cross-sectoral, “Health in All Policies” approach was
adopted. And an increased focus on Universal Health Coverage as reflected in the Sustainable Development Goals supported calls for deeper systems thinking as part of health systems strengthening and demands for MoHs to actively engage citizen voice across the health system.
The timeline according to the literature with respect to governance and health systems strengthening can be described from different backdrops. But what does this imply for MoH’s capacities to govern? Where does its governance remit begin and end? And what exactly do we mean by “governance”?
Definitions of “governance” vary widely, according to [10, 11]. The WHO has advanced its own definition of “governance” as linked with leadership and stewardship, and focuses
on policy frameworks, harmonization, alignment, oversight and regulation. Similarly, other approaches outline the responsibilities and tasks an MoH is expected to fulfil, including strategic planning, policy development, coordination, convening of stakeholders, performance and equity assessment, monitoring and evaluation, audit and inspection. Beyond this, (11) stated that public policy and public administration understandings of “governance” emphasize participation, transparency, fairness and trust-building. Emerging from these are governance needs that include addressing corruption, failures of implementation, economic or ecological catastrophes, the priorities of development partners and managing those external priorities, especially in an emergency setting.
Given these considerations, how do existing MoH capacities translate into specific governance roles? Which capacities exist, which need strengthening, and which are missing? Is MoH equipped to perform its de jure governance role (by right or based on laws and actions of the state) how MoH can respond to changing contexts; how MoH can manage stakeholder relationships; and how MoH can best uphold governance principles, such as accountability and transparency.
In order to make an assessment of the “Reset” road map on rebuilding and strengthening of health systems and governance, I use the lens of global health policy and the application of health systems strengthening and governance borrowing from different scholarly activism in the discipline.
In recent decades, “governance” has evolved from being a state centred concept to one that is collaborative, with shared responsibilities across a range of actors at multiple levels and various sectors. Generally, “governance” refers to accountability, representation, stewardship, ownership, power, authority and the rule of law. It encompasses a “set of processes (customs, policies or laws) that are formally or informally applied to distribute responsibility or accountability among actors of a given [health] system”, as noted by [10]. The WHO definition pairs governance with leadership and stewardship and stating that it involves “ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system-design and accountability”. These processes or rules “can be both formal, embodied in institutions (e.g., democratic elections, parliaments, courts, sectoral ministries), and informal, reflected in behavioural patterns (e.g., trust, reciprocity, civic-mindedness)”. Importantly, governance implies the transfer of “some decision-making responsibility from individuals to a governing entity, with implementation by one or more institutions, and with accountability mechanisms to monitor and assure progress on the decisions made”.
MoH is typically mandated to “steer” health policy by regulating and monitoring health functions in both public and private sectors, and in some cases, directly managing health service delivery. Ministries typically undertake an array of de jure roles, including the formulation of a strategic vision for health, the balancing of centralized
and decentralized authority for decision-making, the management and implementation of policies, programs and interventions, regulation and oversight, and monitoring
and evaluation, notably of performance, quality and equity].
In undertaking the “Re set “agenda rebuilding and strengthening its health system, the MoHW must take into account its de jure responsibilities, governance roles pertaining to health. Over the last few decades, driven by various factors, the focus of MoHs has shifted from service delivery to an emphasis on stewardship, including policy development, strategic direction and oversight.
MoH is also a political actor, and as such is subject to sudden political shifts not only locally and nationally. The nature of reform in the health sector is also highly context-specific, and dependent on the intersection of global, national and local actors and trends. How swiftly and effectively MoH can respond to the shifting context underlines its resilience and relevance.
A closer look at Botswana’s response to COVID-19 clearly indicates that its challenges were more structural leading to clash of professional egos, at times just confusion and lack of understanding and adherence to the public administration ethos thus resulting in health governance deficiencies. Time is now to “Reset “and embark on a journey for rebuilding and strengthening health systems in the country. Time is now for Botswana to have a robust Centre for Global Health which will serve as the think tank and will also play an advisory role.
*Thabo Lucas Seleke is a Researcher & Scholar, Global Health Policy (LSHTM)
