Governance and public health:
IDRC supports global initiatives

by Nasreen Jessani and Christina Zarowsky

In August and September 2005 a study on ‘good governance and corruption’ grabbed media attention in Senegal. Research on the Senegalese Health care system by Forum Civil – the Senegalese branch of Transparency International – explored the dynamics of corruption in the Senegalese health sector, particularly the effect on people seeking care.

The contentious project results triggered the publication of several articles in national Senegalese daily newspapers and initiated a flurry of political and civic activity. Doctors are disputing results; the government has promised to examine Forum Civil’s recommendations.

These Forum Civil caricatures translate results on health sector corruption simply but effectively, particularly for an audience that would not normally access or even hear about such research results. The cartoons are troubling and must be viewed with caution as they run the danger of reinforcing stereotypes.

Yet the reality is complex: health workers in Africa are systematically underpaid or at times even unpaid, but patients are not in a position to challenge requests for extra compensation in a moment of crisis. Publishing cartoons such as these can help to empower the patients, but they do not address the systematic under-funding of health services or empower health workers to claim a living wage.

Globalization and fragmentation of health care systems are fueling the need for more information as well as a desire to find effective strategies to rectify inequities in health, address the multitude of health determinants, develop effective financing mechanisms, and to encourage good governance.

‘Governance’ as a priority in the health sector is increasingly recognized as fundamental to achieving the Millennium Development Goals (MDGs). Commissioned by the World Health Organization (WHO) in 2004, the Task Force on Health Systems Research emphasizes the powerful contribution research on “governance, stewardship and knowledge management can make to achieving the MDGs.”

Canada’s International Development Research Center (IDRC)’s Governance, Equity and Health (GEH) Program Initiative is working to shift the way in which key actors such as decision-makers, researchers, donors, civil society organizations and others, think and operate so that political and governance challenges, equity concerns, and technical health and health policy questions are increasingly considered as integrally related. GEH supports research efforts that seek to better understand and redress health inequities facing the populations of Africa, Asia and Latin America and the Caribbean. Among the many possible interventions to increase equity in health, the program focuses on those that specifically relate to governance and health policy and systems challenges, in relation to particular local contexts.

Inherent to the pursuit of equitable health care delivery is understanding the complexities of governance concepts and mechanisms – whether they too are ‘good and just’ and whether a culture of trust and accountability is being nurtured.

IDRC/GEH supports the production and translation of evidence to support effective and accountable governance of plural health systems, with an emphasis on the stewardship role of the state and active civic engagement. But understanding and building ‘good governance’ requires much more than apportioning blame, as governance is not a straightforward ‘good’ or ‘bad’ condition. GEH projects have demonstrated the usefulness of understanding ‘governance’ as “the institutions, processes and traditions that determine how power is exercised, how decisions are taken, and how citizens have their say.” Starting from this non-judgmental definition allows actors to put taboo subjects on the table so that more open and equitable processes can be imagined and implemented.

Governance in relation to health occurs at all levels, from the global architecture supporting health research and health investments to the ways in which communities and households manage priorities and resources. The notion that positive governance in health systems can contribute to positive health outcomes is permeating all levels of political and social systems. Investigation into corruption, black markets and other, diversions of resources (such as patients selling their medication to buy food), decentralization and public-private partnerships offer prime possibilities for understanding and strengthening conditions for good governance.

Research in support of better health systems in Colombia is one example. In 1993, Colombia launched a profound reform of its social security system with a view to attaining universal coverage within a short period of time. The reform radically altered the health system but failed to fully deliver on its promise. Today, only 50% of the population is covered by the health insurance scheme, leaving an estimated 15 million without coverage.

For a developing country facing many urgent social and economic challenges, it is critical that debates aimed at reducing inequalities in health are informed by the best knowledge available. This action-research project developed a participatory process of policy formulation that makes use of state-of-the-art analytical tools and solid evidence. The project built on ongoing dialogue within two Colombian coalitions that bring together a cross section of interests and positions and enriched the groups' discussion by giving them access to simulations of alternatives for pro-equity reform of the health sector. The next phase intends to build further on these experiences, which demonstrated the need and strong Colombian support for going beyond experts. Phase II will consolidate and strengthen social participation mechanisms in evidence based health policy formulation in Colombia.

A focus on ‘plural health systems’ indicates placing importance not only in the formal health sector, but also in the relationships and governance of the broad range of actors, institutions and practices comprising the health system overall. The relationships among these various components (government, non-government, public, private, traditional, donor, insurance, unions, etc), together with the growing sense of urgency at all levels to produce visible results, creates multiple lines of accountability and, at times, perverse incentives for responsiveness to different stakeholders.

Research in this area will shed light on what is actually happening both at a policy level and ‘on the ground’, while also strengthening local and country relevance.

For instance, the introduction of anti-retroviral therapy (ART) in the Free State, South Africa is a prime example of establishing relations with key government and health officials amongst others in ‘researching the roll-out’ whereby aspects from infrastructure for storage of the medication to the impact on healthcare personnel are taken into account. The Public Sector Anti-retroviral Treatment project is the first large-scale and systematic research program supporting and evaluating a public sector roll-out of anti-retroviral drugs (ARVs) in Africa.

IDRC/GEH’s work on governance and the intersections with its work on health systems performance continues to inform broader debates on innovation and governance beyond the health sector. The health sector and health systems are important sites at which technological, biomedical, and social challenges and innovations converge. The responses of various actors in society to these challenges have implications beyond the concerns of the health sector itself. For example, the success of civil society movements such as the AIDS Treatment Action Campaign has reinforced interest at all levels in equity, civic participation and governance, particularly the stewardship role of the state.

While recognizing that health systems and equity changes must be grounded in specific contexts, IDRC/GEH continues to support analysis across projects to learn how and when to translate and adapt tools and strategies across contexts.

IDRC/GEH has therefore begun to support a range of activities aimed at ‘making research matter’ by developing analytic tools to help researchers and decision-makers understand ‘governance’ more thoroughly, with a view to increasing accountability, transparency, and effectiveness in achieving health equity goals.

IDRC/GEH has compiled a first edition of a Governance Toolkit for our research partners, and is supporting researchers at the University of the Witwatersrand to examine “Trust and Accountability in Health Service Delivery in South Africa”. Targeting policy-makers and researchers, this project aims to encourage innovative thinking about how to strengthen accountability by specifically considering the links between trust, responsibility and performance in the health sector.

The uniqueness of IDRC/GEH’s approach has been recognized and applauded both nationally and globally, as demonstrated by remarks and support from the WHO as well as other donor agencies such as CIDA, SDC and DANIDA. Comments made at the November 2005 WHO-Canada dialogue on health policy and systems research was a further demonstration of support and possible emulation of looking at health systems through governance and equity lenses.


Nasreen Jessani is Research Officer, Governance, Equity and Health with IDRC, where she has been involved in pilot public health schemes in Chitral, Pakistan and Dhaka, Bangladesh. Christina Zarowski is Team Leader, Governance, Equity and Health. A physician specialized in public health and a medical anthropologist, she has conducted research into the determinants of population health, the politics of humanitarian aid, and trauma and social reconstruction among Somali refugees.