Priority Area One Under National Strategic Health Development Plan: Leadership and governance 

Governance in health is being increasingly regarded as a salient theme on the development agenda. Leadership and governance in building a health system involve ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design and accountability. The need for greater accountability arises both from increased funding and a growing demand to demonstrate results. 

Accountability is therefore an intrinsic aspect of governance that concerns the management of relationships between various stakeholders in health, including individuals, households, communities, firms, governments, nongovernmental organizations, private firms and other entities that have the responsibility to finance, monitor, deliver and use health services. Accountability involves, in particular: 

  1. delegation or an understanding (either implicit or explicit) of how services are supplied; 
  2. financing to ensure that adequate resources are available to deliver essential services; • performance around the actual supply of services; 
  3. receipt of relevant information to evaluate or monitor performance; 
  4. enforcement, such as imposition of sanctions or the provision of rewards for performance. 

Governance in health is a cross-cutting theme, intimately connected with issues surrounding accountability. In the context of health systems strengthening, it is an integral part of the health system components discussed in earlier. Despite consensus on the importance of leadership and governance in improving health outcomes, they remain inadequately monitored and evaluated. 

Indicators for measuring health system governance 

Two types of indicators have been proposed for measuring governance: rules-based and outcome-based.

Rules-based indicators measure whether countries have appropriate policies, strategies and codified approaches for health system governance. In the health systems context, these indicators include the existence, for example, of a national essential medicines list or a national policy on malaria control. They are part of a larger class of indicators called governance determinants. In addition to the existence of rules (called “formal procedures”), the determinants of health-care-provision governance include four other broad categories: ownership arrangements, decentralization, stakeholder participation, and contextual factors.  In this framework, determinants of governance are contrasted with governance performance. 

Outcome-based indicators measure whether rules and procedures are being effectively implemented or enforced, based on the experience of relevant stakeholders. For health systems, examples may include the availability of essential medicines in health facilities or the absenteeism of health workers. Since the outcome-based indicators relate directly to the functioning of other health system “building blocks”, only the rules-based indicators for measuring health system governance are discussed in this section.

When selecting indicators for measuring governance in health, a high value should be placed on their usefulness and relevance. Nevertheless, even the most suitable governance indicators may be unable to adequately predict whether developments in a country or sector can be attributed to a change in governance. Thus, in general, governance indicators should not be used in isolation when designing policy responses to health system performance issues. 

Sources of information on health system governance 

Measurement of rules-based health system governance indicators will, in most cases, rely on both expert analysis of available sources such as administrative records (including legal/regulatory documents) coupled with expert reviews of national health policies. Administrative records are the important main data sources for rules-based indicators of governance and include legal and regulatory documents, national health strategies, budget documents, and regulations and guidelines that relate to the management, organization and financing of the health sector. 

Administrative records can be obtained from government publications, legal and administrative document departments and official web sites. The outcome-based governance indicators, which are discussed in other sections of this handbook, are generated using various data sources, including facility surveys, public expenditure reviews or client assessments. 

Core indicators 

A composite governance policy index, comprising 10 rules-based indicators that cover health policies for different disease interventions and health system aspects, is presented. The index provides a summary measure of governance quality from a rules-based perspective. The indicators assess whether countries have policies, regulations and strategies in place to promote good leadership and governance in the health sector, but do not aim to assess enforcement. Each indicator is given a score of 0 if an adequate policy does not exist or cannot be assessed; and scored 1 if an adequate policy is available. The maximum score for the policy index is therefore 10.

These indicators include:

  1. Existence of an up-to-date national health strategy linked to national needs and priorities.
  2. Existence and year of last update of a published national medicines policy.
  3. Existence of policies on medicines procurement that specify the most cost-effective medicines in the right quantities; open, competitive bidding of suppliers of quality products.
  4. Tuberculosis—existence of a national strategic plan for tuberculosis that reflects the six principal components of the Stop-TB strategy as outlined in the Global Plan to Stop TB 2006–2015.
  5. Malaria—existence of a national malaria strategy or policy that includes drug efficacy monitoring, vector control and insecticide resistance monitoring.
  6.  HIV/AIDS—completion of the UNGASS (United Nations General Assembly Special Session) National Composite Policy Index questionnaire for HIV/AIDS.
  7. Maternal health—existence of a comprehensive reproductive health policy consistent with the ICPD (International Conference on Population and Development) action plan.
  8. Child health—existence of an updated comprehensive, multi-year plan for childhood immunization.
  9. Existence of key health sector documents that are disseminated regularly (such as budget documents, annual performance reviews and health indicators).
  10. Existence of mechanisms, such as surveys, for obtaining opportune client input on appropriate, timely and effective access to health services


World Health Organisation.

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