Cultivating accountability

This session highlights the practice of cultivating accountability and what approaches can be taken to effectively enact the
practice. The approaches provide a menu of options that should be prioritized based on the specific needs, priorities, and
resources of a particular governing body.

Introduction to the key practices

A growing body of evidence demonstrates that effective governance improves health outcomes.

This course presents the five key practices for ensuring effective governance and practical strategies for how to apply the
practices of:

Cultivating accountability
Engaging stakeholders
Setting shared strategic direction
Stewarding resources
Continuous governance enhancement or improvement

These practices are highly interrelated and reinforce each other. The first four practices are reinforced through the
fifth practice of continuous governance enhancement—which includes periodically assessing and continuously improving
governance.
Applying these practices will help those who govern as well as those who manage health service organizations to achieve
their missions, ultimately improving health system performance and achieving better health outcomes.

Sources: Svensson and Björkman 2009; Olafsdottir et al. 2011

What is cultivating accountability?

Cultivating accountability is taking actions that will:

Promote the culture of accountability in an organization,

Make an organization accountable to its external and internal stakeholders, and
Make people governing, managing, and providing services in an organization personally accountable.

Cultivating accountability fosters a facilitative decision-making environment based on systems and structures that support
transparency and accountability. When accountability is strengthened, the opportunity for corruption is diminished, and
health system outcomes--such as responsiveness, equity, and efficiency--are positively affected.

Before you can take actions to cultivate accountability, you first need to have a clear understanding as to how
accountability relates to the other key practices of good governance. See the next page for more information.

Glossary Term:
transparency
accountability
corruption

What is accountability?

Accountability means that institutions—ministries, organizations, and health facilities—are responsible for meeting the needs
of the people whom they were created to serve and protect.

Accountability means ensuring that officials in public, private, and voluntary sector organizations are answerable for their
actions and that there is redress when duties and commitments are not met.

Accountability's relationship to the other key practices of good governance

Integrity, transparency, accountability, trust, and engagement are all linked and deeply intertwined, and form the
foundation for all five key practices of good governance. All of the elements of accountability, beginning with integrity and
transparency and embracing inclusion and trust, contribute to produce shared strategic direction and effective and
efficient use of resources.

Shared direction and the responsible use of resources, in turn, improve organizational performance. We will discuss these
practices in greater detail in the following sessions of this course.

Click on the elements of the accountability chain in the graphic below to learn about actions that you can take
to strengthen each.
Approaches to cultivating accountability
Now that you know what cultivating
accountability is and why it is important,
consider the following scenario:

As the CEO of a provincial hospital in Honduras, you and your governing body chairperson have decided to challenge the
hospital’s employees to improve the quality of the hospital services.

What are the characteristics, systems, and rewards and consequences that you will need to build for a culture in which all
staff act accountably to maximize gains in service excellence? How should the governing body and management best model
its own behavior for ethical and transparent decision making?

The CEO and the governing body chairperson should consider taking actions to:
 Cultivate personal accountability
Nurture accountability among stakeholders
Foster internal accountability within the organization
Support accountability of health providers and health workers
Measure performance
Share information
Develop social accountability
Use technology to support accountability
Provide smart financial oversight

The following pages will provide guidance on how to implement these approaches to cultivating accountability.

Cultivate personal accountability

Good governance in the health sector as in any other sector is a group process. For group decision-making to be
effective, each person must be personally responsible for her or his own work, behavior, and results.

Taking personal responsibility means you take ownership of situations, challenges, and strategies and see them
through to completion.

The CEO and the Hospital Community Board of the provincial hospital in Honduras described in the accountability
challenge began with themselves first. They started taking responsibility for their own actions by better familiarizing
themselves with the hospital's workflow processes and holding regular meetings with the hospital’s stakeholders,
especially community members, and health workers to hear their complaints and concerns and answer their questions.

In response to complaints about the long wait time, the CEO and board created a new absenteeism policy as well as
incentives to encourage supervisors to work more closely with staff to develop and test new policies and systems to
address the wait time as it related to workflow processes. They continued to seek feedback from stakeholders on these new
policies and systems that they were testing until they arrived at a mutually beneficial solution.

Key points

Accountability starts at the top.

Begin with yourself, not waiting for others to act.

 Measuring personal accountability

Here is a simple self-assessment form, which you could use to test how well you are performing on personal
accountability.

Source: MSH 2014

Cultivate internal accountability within your organization

Health care is a labor-intensive sector. People who
govern must create workplace conditions in
which internal stakeholders are proud of their
work and are enthusiastic in their willingness
to continuously improve access to high-quality
services.

Practicing accountable behaviors is everyone’s responsibility – the governing body, management, and health service
providers. The governing body’s role is oversight and to make sure that there is internal accountability in the organization.
For more on the role of the governing body, see the first course in this series, Governance and Health.

The CEO and Hospital Community Board of the provincial hospital in Honduras next started working on improving the
accountability within their provincial hospital. For internal accountability to take root, they made sure that these five
things existed in their provincial hospital:

1. Information flows freely internally in the organization,

2. Goals and tasks are clear to all employees,
3. Managers and staff have sufficient resources to succeed,
4. Performance and targets achieved are monitored in a transparent manner, and
5. There are consequences for nonperformance or underperformance as well as rewards for excellent performance.

Glossary Term:
After Action Review
Oversight

Key points

Work on internal accountability within the organization first.

It is difficult to have external accountability in the absence of internal accountability.

Additional ways to encourage internal accountability

Clarity your expectations

Reward what you want to see more of―and stop tolerating what you do not

Promote personal ownership

Institute regular reflection opportunities (such as after action reviews) to learn from mistakes
 Source: Grimshaw and Baron 2010

Cultivate external accountability

People who govern are not only responsible for their own personal behavior and commitments, they must also ensure that
their organization is accountable to its stakeholders, such as patients, communities, elected politicians, and public
and private purchasers and providers of health services.

The CEO and Hospital Community Board established formal stakeholder consultation mechanisms in which
stakeholders were given the opportunity to ask questions and/or provide inputs. This included patient satisfaction surveys,
community focus groups, and citizen advisory committees.

They also established a community scorecard to assess the quality of care, which remained suboptimal. They began
formally sharing information and reports on finances, plans, budget, and hospital performance with the public and
other stakeholders.

A performance measurement system was established in the hospital to assess performance of all categories of
personnel: people who govern, manage, and deliver services. Managers and service providers who fell severely short of
their performance goals were sanctioned. The Hospital Community Board also started assessing not only the CEO’s but
also its own performance. Results of these assessments were made available to the stakeholders.

Citizen Health Board in Bolivia

An evaluation study of 30 hospitals in Bolivia published in 2001 found that citizen voice, as measured by active participation
on citizen health boards, had a statistically significant effect on lowering informal payments for services that should be free,
and reducing overpayment for supplies, as measured through procurement price data. The citizen boards exposed bribery
and deterred informal payments and the overpricing of medical supplies. Citizen health board activism proved to be an
important deterrent of hospital corruption, whereas institutional controls such as administrative regulations and
procedures seemed to have little impact.

Source: Gray-Molina et a. 2001

Measure performance
Though measuring organizational performance is largely a management function, the role of governance is to make
sure that performance is transparently measured and reported to stakeholders.

Working with management, the governing body should ensure that:

An explicit measurement strategy to measure progress for all strategic and operational objectives is in place.
The health service user perspective is kept in mind in the measurement process.
Performance is measured and reported disaggregated by gender and other variables important from an equity
perspective, for example by wealth quintile.
The performance information is used to refine programs and policies.
The indicators to measure performance are set in advance and a specific time frame identified for data collection and
analysis in respect of these indicators.

Glossary Term:
micro-management
Equity

Avoid micro-managing

Those who govern should avoid the temptation to micro-manage. This can be addressed by management developing and the
governing body using “performance dashboards” or “balanced scorecards” that document how well the organization is
doing to achieve a handful of key indicators of success or essential measures of progress against plans. An example of a
governance dashboard is presented in the third course in this series, Infrastructure for Good Governance.

Use performance measurement information

CEOs and governing bodies can use information from performance measurements for eight purposes.
Source: Behn 2003

Share information
Governance decision-makers need information that
is accurate and timely, covering the right issues, and
presented in formats that are easy to understand and
use.

Effective governing bodies must establish a positive partnership with health managers and clinicians to define
exactly what should be the minimum dataset that will inform all concerned about how well the organization is
performing.

The CEO of the provincial hospital in Honduras began collecting data about the quality of health services delivered by the
hospital in a systematic manner. Technical assistance was sought from an expert for implementing the clinical quality
measures. The medical and nursing directors developed an effective plan for collecting and analyzing data in collaboration
with service providers.

The Hospital Community Board began exercising responsibility for quality oversight, regularly reviewing the performance
dashboard of critical quality indicators. The clinical outcome data was made available in the public domain so the
community served by the hospital could keep track of the progress made by the hospital.
 Oversight role: What does information have to do with it?

In addition to using information for decision making, the governing body has another important role related to information. In
its oversight role, the governing body is expected to make sure that there is free flow of information within the organization
and also timely dissemination of relevant information to external stakeholders.

Impact of sharing information

There are many studies in the published literature that document the beneficial impact of sharing information in a wide-
range of transparency and accountability initiatives.

In Argentina, the Ministry of Health created a price monitoring system that tracked prices paid by 33 public hospitals for
common drugs, sharing this data with the reporting hospitals. The effect of the transparency policy was that purchase
prices fell by an average of 12%, and stayed below the baseline for over a year.

In Uganda, an information strategy was used to reduce leakage of central government education grants to local
governments. This problem was first identified through a Public Expenditure Tracking Survey. Before the grant transfer
amounts were publicized in newspapers and posted in schools, only 13% of grant allocations reached the schools; after the
reforms, 80–90% of grant funds were reaching recipients. Publicizing findings of leakage in funds intended to flow
to schools in Uganda, significantly reduced the leakage.

In Afghanistan, the balanced scorecard has helped rebuild trust in health institutions and delivery of health services by
increasing transparency in the health sector and enabling health managers and policy-makers to identify and address areas
of weakness. It has been instrumental in enhancing transparency in the decision-making process, creating a
culture of accountability by policy leaders to manage performance-based contracts.

Source: Gaventa and McGee 2013; Schargrodsky et al. 2001

Did you know?

More than 80 countries have freedom of information laws in place – up from just 13 in 1990.

Develop social accountability

The governance of health systems owes a duty to engage with, inform, and be accountable to a broad array of external
stakeholders at the local, provincial, or national levels.

Effective governing bodies do not hide from public scrutiny; rather, they proactively design sensible engagement
strategies and performance reporting with these external groups.

Social accountability refers to a broad range of actions and mechanisms that citizens, communities, independent media,
and civil society organizations may use to hold public officials and public servants accountable.

Social accountability in the delivery of health services may be strengthened by using:

 Community scorecards and citizen report cards
Public hearings
Participatory budgeting and public expenditure tracking
Citizen charters
Community radio

See the next page for two examples from the field.

Key points

Social accountability mechanisms enable community members to express their assessment of the health services provided by
the health facility. These can also be used to inform community members about available services and to solicit their opinions
about the accessibility and quality of these services. They have a potential to increase public accountability and the
responsiveness of the health workers and facility staff.

Additional resources

For more details on each social accountability mechanism, see:

MSH's Cultivating Accountability for Health Systems Strengthening

Resources from the World Bank Group and the Global Partnership for Social Accountability

Social accountability in action

The Filipino Report Card on Pro-Poor Services assesses the performance of selected government services based on
client experience. These services are basic health, elementary education, housing, potable water, and food distribution.
The Report Card results throw light on the constraints Filipinos face in accessing public services, their views about the
quality and adequacy of services, and the responsiveness of government officials. They provide valuable insights on the
priorities and problems faced by the clients and how the various services may be better tailored to the needs of Filipinos in
general, and the poor in particular.

In Uganda, community radio broadcasting was used to promote accountability, transparency, and responsiveness of
water, sanitation, and hygiene services. The radio program allowed the communities that were denied services to voice
their issues publicly, while giving the service providers a chance to explain why the services were not available.

Between July and September 2010, a research team examined seven cases of technology interventions - in Brazil, Chile,
India, Kenya, and Slovakia - that attempted to increase the accountability of public and private organizations
through technological transparency strategies. The authors suggest that those considering harnessing the potential of
new technologies to increase accountability pay greater attention to the context in which it will be used. They suggest that
the greatest opportunities for using technology exist when it is used to amplify NGO and governmental strategies of
accountability. Interventions are more likely to succeed when those who create the technology are embedded in local NGO
networks and recognize opportunities to partner with government.

The next page provides more information on the use of technology to cultivate accountability.

Additional approaches employed to ensure social accountability

Transparency portals / budget websites

Social audits

Citizens’ juries

Local issue forums

Public opinion polls

Local oversight committees

Ombudsman
 Other possible tools for social accountability

Service Provision Assessment (SPA) surveys of the Demographic and Health Surveys (DHS) Program that measure client
satisfaction with health services at the facility level are another good example of a tool that facilitates establishment of social
accountability.

In addition to SPA surveys, governing bodies working closely with the community may seek to employ mystery shoppers.
For example, Bandung Institute of Governance Studies (BIGS) had typical citizens secretly record their experiences with
frontline service providers in an effort to document quality and reduce corruption in basic services.

Use technology to support accountability

New information and communication technologies (ICTs) support: (1) the engagement of internal and external
stakeholders; (2) a two-way flow of ideas, insights, and information among stakeholders for planning and performance
monitoring; and (3) the prompt celebration of progress to highlight the work and results achieved.

ICTs can help improve accountability in health care through health information management and its display on public
websites.

Use of mobile phones facilitates citizen-led public accountability and monitoring of health services, for example, SMS-
based applications can report on health worker attendance and absenteeism, waiting time at clinics, availability of
medicines and vaccines, medicine stock-outs, functionality of equipment, and so on.

Examples from the field

In South Africa, a number of national and international health service organizations launched a national Stop Stock Outs
Project to assist the thousands of health care users whose lives remain threatened by the chronic plague of medication
stock outs. Stock-outs can be reporting using an iPhone or Android application, by sending an email, or by filling out a form
on a website.

In Guatemala, members of the public submit SMS reports of drug stock outs, health worker discrimination against
indigenous patients, and other health care access issues to a public website known as Vigilancia.

UNICEF's U-Report SMS-based social media platform is being used by over 1 million young people in 15 low- and middle-
income countries, mostly in Africa, to engage them in issues that affect their lives and futures.

Glossary Term:
mHealth
eHealth_2

For more information on leveraging technology

See this 3-part field guide on leveraging technology to elevate governing board performance.

Provide smart oversight

Good governance is shaped by, and also shapes, good leadership and management of health systems,
organizations, and programs.
People who govern have a duty to monitor the organization’s plans and performance. This oversight role includes:

1. Monitoring the financial health of the organization

2. Looking at its financial sustainability
3. Building the organization’s long-term ability to mobilize and allocate sufficient and appropriate resources
4. Using actual financial and cost data for planning, oversight, and evaluation
5. Setting up and monitoring key financial and outcome indicators

Effective governance oversight is needed to achieve the mission of the organization and protect the assets entrusted to the
governing body or people who govern.

Glossary Term:
Sustainability
Oversight

More information

Oversight is one of the important governance functions. To learn more about oversight responsibilities of people who govern,
see other courses in this series - Governance and Health and Infrastructure of Good Governance.

Engaging stakeholders

In this session, you will learn about practical ways to engage with stakeholders to ensure better governance of a health
service organization, which will ultimately improve the organization's services and health outcomes by better meeting the
needs of the population that is being served.

Why engage with stakeholders?

Engaging stakeholders can help a governing body to gain better insights to define current challenges more accurately.
Participation in problem definition improves the quality of solutions and the willingness of stakeholders to help define
practical ways to implement the solutions as well as actively participate in the implementation of the solutions.

Stakeholder engagement helps advance the awareness and ability of stakeholders to hold decision makers accountable for
their decisions. It fosters ownership of the decision and willingness to measure and own results.

Your stakeholders may include:

Health service users

Youth and youth organizations
Women and women’s organizations
Health workers, physicians, nurses, and other health providers in the public sector
Private health sector (hospitals, doctors, nurses, midwives, pharmacists, etc. and their professional associations and
unions)
Public health experts from academic organizations
Community and religious leaders
Government leaders and elected representatives
Municipal leaders and officials
Ministry of Health and different ministries that impact health
Private businesses
Media
National and international NGOs and civil society organizations

Highlight

Remember the key practices of good governance are interrelated and reinforce each other. Engaging stakeholders is an
effective approach to cultivating external accountability as described in the previous session.

Importance of being inclusive

Being inclusive involves engaging all relevant stakeholders—across gender, age, religion, race and ethnicity,
socioeconomic status, health and disability status, and location—in the decision-making process.

This is not just an equitable thing to do, but also is smart because engaging these groups who will use, deliver, or support
your organization’s health services will improve the quality, quantity, and sustainability of the health services it
provides.
Inclusion and participation are vital to the achievement of health equity, where all men and women—young and
old—have opportunities to improve or maintain their health and well-being. For example:

Non-representation of women and youth in decision making deeply affects their access to health care because barriers
they face are not addressed.
Similarly, the perspectives of people with disabilities, the elderly, and the very poor are not adequately represented in
the governance decision-making process.

Glossary Term:
Equity
Approaches to engaging stakeholders
Now that you know why stakeholder
engagement is important, consider the
following scenario:

The governing council of an HIV and AIDS program wants to engage more with key populations in the governance
decision-making processes.

Who are other key stakeholders to involve; why should you involve these stakeholders, and how should you best engage
with them? What should be done to not only involve them now, but to have them be ready, willing, and able to sustain their
engagement over the next 3-5 years?

The governing council should consider taking actions to:

Extend sincere stakeholder invitations for engagement

Achieve meaningful stakeholder engagement
Build trust
Engage with health service users
Engage with service providers and other health workers
Collaborate with other sectors
Practice gender-responsive governance

The following pages will provide guidance on how to implement these approaches to engaging stakeholders.

Glossary Term:
Key Populations

Key point

These approaches provide a menu of options that your governing body should consider putting into place depending on its
particular circumstances. Regardless of the approach(es) taken, the key point is to engage your stakeholders regularly!

Additional resource

USAID-funded Leadership, Management and Governance (LMG) Project's Guide for Engaging Stakeholders
Extend sincere stakeholder invitations for engagement

Those who govern need the ideas, insights, experiences, money, and political influence of many stakeholders. To
secure these valuable resources from stakeholders, they must believe your invitation to participate is sincere.

The governing body, working with management, has a responsibility to engage stakeholders. It is also the governing body’s
role to support management in engaging stakeholders.

These are some of the actions you can take to engage with diverse stakeholders.

1. Empower marginalized voices by giving them a meaningful role in a formal decision-making structures.
2. Create a safe space for sharing ideas so that genuine participation across diverse stakeholder groups is feasible.
3. Regularly conduct open meetings, surveys, public comment, public workshops, public forums, and establish citizen
advisory committees.
4. Devote adequate time and resources to the stakeholder engagement process.
5. Build partnerships and alliances across ministries, sectors, and levels of authority.

Measuring stakeholder engagement

Use this simple self-assessment form to test how well you are performing on engaging stakeholders.

In addition, here are examples of indicators that can be used to measure the effectiveness of your stakeholder engagement.

Source: LMG Project's Training Facilitation Handbook for District Health Office Governance Leaders and Staff

Achieve meaningful engagement

These are five different ways of working with your organization’s stakeholders. The degree of shared decision-making
progressively increases as you advance from bottom to top in the figure below.
The example on the next two pages outlines considerations that should be taken when serving on a governing body of an
organization that is targeting services to key populations and how to collaborate and empower them.

Source: International Association for Public Participation

Engaging key populations: Key questions for consideration

Recall the scenario described earlier in this session. Key populations are
disproportionately infected with HIV compared to the general population.
UNAIDS estimates that between 40% and 50% of all new HIV infections
among adults worldwide occur among these key populations and their sex
partners. There is no way toward an AIDS-free future without engaging with
these highly marginalized and often hard to reach populations.

Coverage rates of effective interventions among these key populations are extremely low, while stigma and discrimination
– including gender-based violence – is high. Key populations, their partners, and clients of sex workers face alarmingly low
access to services as persistent societal barriers stand in the way. The implementation and scale-up of comprehensive
prevention and treatment interventions are needed to address the burden of HIV faced by key populations.

Key questions for the people who govern to address include:

What are the definitions of key populations being used by your organization?
Who is doing the training for health providers providing services to key populations?
What does the training consist of?
How are you consulting with key populations in designing programs to ensure acceptability and accountability?
How are you monitoring the quality of service delivery, non-discrimination, confidentiality, and veracity of service
delivery data?

Glossary Term:
Confidentiality
Gender-based violence
Discrimination
Stigma
 Additional resources on engaging key populations

PEPFAR Blueprint: Creating an AIDS-free Generation

PEPFAR Technical Guidance on Combination HIV Prevention for Men Who Have Sex with Men

PEPFAR Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance

Successful engagement of key populations in Cameroon

In 2014, the Community Action and Leadership Collaborative (CLAC)’s global networks and respective country-level
partners facilitated greater participation of key populations advocates and the development of high quality rights-based
and evidence-informed activities focused on meeting the needs of key populations and other vulnerable groups in
Cameroon. Their experiences can serve as a model for civil society organizations and advocates engaging in the Global
Fund country dialogue process.

This process, beginning with community consultations, proved an effective way to ensure active engagement of key
populations from the start, and to watchdog and hold stakeholders accountable.

This resulted in:

The selection of a key population leader on the Country Coordinating Mechanism.

The development and institutionalization of a task force of 25 key population advocates.
The submission of a concept note pertaining to key populations focused on activities related to gender, human rights,
and community system strengthening to the Global Fund.

Good practices from the Cameroon experience included:

Bottoms-up, grassroots engagement of key population advocates

Build their capacity to engage in dialogue process
Continue organizing and movement building to fully engage key populations in all stages, including monitoring
activities
Use of community experts to facilitate engagement

Source: The Global Forum on MSM and HIV (MSMGF)

Build trust
Trust among stakeholders in governance decision-making processes is an essential but fragile commodity. Trust must be
earned, is easily lost, and is difficult to regain. Those who govern must first be trustworthy, and then be prepared to
risk extending trust to others.

Facilitate the establishment of trust between health workers and providers and the governing body and management,
between the governance structure and communities, and between the community and health workers and providers.

These are some actions you can take to establish a relationship of trust with diverse stakeholders:

Begin with yourself and keep promises you make.

Hold yourself accountable before holding others accountable.
Create a culture in which tolerance and cooperation are valued.
Have diverse stakeholders participate in making decisions.
Deal with difficult issues with courage before they turn into major problems.

A study found that had community members, frontline health workers, and the broader health system developed a trusting
relationship prior to the Ebola outbreak in Guinea, important messages about the disease and how to stop its spread would
likely have gotten through to people much sooner and slowed the march of Ebola.

Sources: Covey 2006; Presentation at the 2014 annual meeting of the American Public Health Association

Remember

Trust is a key element of cultivating accountability as well. A lot of the approaches undertaken to strengthen accountability
will also assist in building trust among stakeholders.

Engage with patients and health service users

The end goal of good governance is a health system that serves the health needs of patients and their families and
communities. In order to serve the needs of patients and their families and communities, they must be engaged in:

1. Direct patient care, in which patients get information about a condition and answer questions about their
preferences for treatment. This form of engagement allows patients and providers to make decisions based on the
 medical evidence, patients' preferences, and clinical judgment.
2. Organizational design and governance, in which health care organizations reach out for health service users' input
to ensure that they are as responsive as possible to patients' needs.
3. Policy making, in which health service users are involved in the decisions that communities and society make about
policies, laws, and regulations in public health and health care.

Engagement with patients, families, and the community that you serve and building staff capacity to support patient-
centered care have been identified among several other factors that are critical to assuring quality of care and patient
satisfaction with care.

Patient engagement results in more appropriate care and improved patient and community outcomes.

Sources: The King’s Fund 2012; Carman KL et al. 2013

Highlight

Leaders who govern wisely and well understand the health needs of the people they exist to serve. Patient and community
engagement and patient satisfaction reinforce each other.

Additional resources for community engagement

Implementing strategies in consumer and community engagement in health care: results of a large-scale, scoping
meta-review

Partners in Health offers a great example of effective community health worker engagement

Engage with health workers and providers

Good governance acknowledges the value and
power of engaging and focusing the talent,
ideas, experiences, and energy of health
providers and health workers in the planning
and implementation of an organization’s health
services. This essential participation, however,
needs to be sincerely requested, listened to, and
acted upon.

Motivation is key to the success of health workers as well as the health institutions. Health workers can give their best
if they are motivated.

Consider taking the following actions to engage with health care providers:

Ask them to lead improvements in quality of patient care.

Ask them what they want to work on.
Make it easy for them to lead and participate, not wasting their time.
Recognize providers who lead, including the opportunity to present to the governing body.
Provide learning and professional development opportunities.

Source: Reinertsen et al. 2007

 Highlight

Both staff and patient engagement rest on values of openness, collaboration, seeing the world through the eyes of others, and
listening to and supporting each individual employee or each individual patient. Engagement needs to be seen through the
lens of the person who is being engaged (e.g., how they feel, what their experiences are, etc.).

Additional resources

Check out the last session of the Health Workforce Productivity course for possible interventions to improve health
workforce productivity, including strategies for improving health workers' motivation as well as accountability.

In addition, WHO's Global Strategy on Human Resources for Health: Workforce 2030 outlines key practices to ensure
the availability, accessibility, acceptability and quality of the health workforce.

Collaborate with other sectors

Health gains and improvements in health service delivery result from the influence of many factors outside the control of
the health sector. Health has many determinants, such as food, water, education, housing, poverty, crime, and
pollution.

Effective governance seeks to engage with policy makers and leaders from other sectors to make and implement
policies and programs for better health and health services.

Consider taking the following actions to achieve cross-sectoral integration:

Establish cross-sectoral governance structures, for example, committees and secretariats convening across sectors or
ministries.
Establish cross-sectoral committees in legislative bodies, for example, in parliament, state legislatures, and local
councils.
Establish funding arrangements to support actions taken across many different sectors to attain health objectives.
Develop multisectoral agreements on desired health goals and outcomes.
Implement multisectoral policies on the social and other determinants of health beyond health sector, and monitor,
measure, and evaluate progress on social determinants of health.

Source: McQueen et al. 2012

Improving nutrition through multi-sectoral collaborations

In June 2010, through a signed Memorandum of Understanding (MOU) on Malnutrition, the Albanian Ministry of Health,
the Ministry of Agriculture, Food and Consumer Protection, the Ministry of Education and Science, the Ministry of Labour,
Social Assistance and Equal Opportunities, and the Ministry of Finance committed themselves to take joint, inter-sectoral
action to:

Improve the nutritional status of the Albanian population to reach the MDGs,
Establish a national, sustainable, coordinating mechanism at the highest level of decision making with the
participation of the signatory parties, and
Work jointly in drafting and implementing a national Inter-sectoral Food and Nutrition Action Plan.

The Ministry of Health led the preparation and consensus agreement of the MOU by organizing meetings with
representatives from the other ministries bilaterally and in group meetings to discuss drafts of the MOU, the nutrition
problems to be tackled, and the possible solutions. After signing the MOU, focal points were nominated by the five
ministries to take part in an inter-sectoral, interministerial working group to evaluate the implementation of
the current plan and formulate a new Food and Nutrition Action Plan.

The USAID Multi-Sectoral Nutrition Strategy 2014-2025 is another example of cross-sectoral work and programming
by the Global Health Bureau and the Bureau of Food Security. With this strategy, USAID aims to decrease chronic
malnutrition, measured by stunting, by 20% specifically through the U.S. Government’s Feed the Future and Global Health
initiatives, the Office of Food for Peace development programs, resilience efforts, and other nutrition investments.

Source: WHO and European Observatory on Health Systems and Policies 2012
Practice gender-responsive governance

Women play three important roles in a health system as governance and management decision makers, health care
providers, and health service users.

Nevertheless, men often dominate governance structures in health systems and health institutions. As a result, issues
faced by women in leadership, governance, and senior management roles, in the health workforce and as users of services
are too often ignored.

It is the responsibility of everyone working in the health system, especially of the leaders who govern, to make
their institutions gender-responsive.

Gender issues are too often ignored or inadequately considered by those who govern. Women and other marginalized
populations are often the most in need of services that protect, promote, and nurture their health.

Women are also central decision makers about the health of families and communities and perform the majority of frontline
health care service delivery activities.

Governance as well as leadership and management must be gender-sensitive and gender-responsive. Gender-sensitive
refers to governing bodies, council, committees, and task forces having a significant proportion of female participants,
while gender responsiveness in governance has the potential to enhance positive health outcomes, not only for women but
also for the entire community. See the examples below for how you can demonstrate gender-responsiveness.

Increase the number of women in leadership, governance, and senior management roles.
Reinforce a safe, harassment-free work environment by upholding strict codes of conduct and zero tolerance for
discrimination.
Collect sex-disaggregated data and define gender-sensitive outcomes, whenever possible.
Give voice to women and youth in making and implementing policies that affect them.
Seek advice from women’s organizations, women leaders, and gender experts.

For more on how gender impacts the health system, please take the Gender and Health Systems Strengthening course.

Glossary Term:
Sex-Disaggregated Data
Gender-Sensitive Indicators

Gender in Governance Assessment Tool

 People who govern should periodically assess how gender-responsive they are when making governance decisions (i.e., while
making policies and regulations, setting organization’s strategic direction, or allocating resources). The LMG Project has
developed a simple tool based on the spectrum of gender responsiveness, which was tested among an online learning
community of health leaders and managers.

Setting shared strategic direction

In this session, you will learn about practical ways to set shared strategic direction - which heavily relies on a governing
body's ability to cultivate accountability and effectively engage and build trust with stakeholders.

As a result, there will be a little overlap with the previous session since the key practices of good governance build off of
and reinforce each other.

Why set a shared strategic direction?

One of the most important roles of the governing body is to work with the managers, health providers, and beneficiaries to
determine the organization’s strategic direction, and policies to accomplish its strategic vision and plans.

Shared direction comes from agreeing on the goals and objectives for the public or private entity.

One of the most effective practices to enhance the sustainability of the health services the organization provides is to
establish a strategic roadmap to guide the organization forward. Often, this strategic roadmap or plan charts a path
into a future that is uncertain, with rapidly growing demands for services from patients and often a shortage of resources
(human, financial, and technological). The decision-making process of designing and ensuring the implementation
of this roadmap is referred to in this course as setting strategic direction.

The governing body sets the strategic direction in collaboration with senior management and key stakeholders. Once the
direction is set, it is primarily the responsibility of management to realize it.

Approaches to setting a shared direction

Now that you know why setting a shared direction is important, consider the following scenario:

You know that diverse stakeholders help your governing body develop plans that are not only more likely to yield better
strategies, but also strategies that are more successfully implemented. What actions should the governing body take to
ensure the strategies for improving health services are better and more wisely implemented?

The governing body working with management should consider taking actions to:

Define the population health goals

Establish a shared strategic vision among key stakeholders
Enable leadership in the organization
Create a successful strategic plan
Implement the strategic plan
Report progress to the key stakeholders

Some of these approaches specifically related to engaging key stakeholders have already been discussed in the previous
session. This session will provide guidance on different techniques to employ depending on the circumstances of your
particular governing body.

Define the population health goals

Good governance in health systems or in health sector organizations strives to understand and enhance the health status of
the people served by the system/organization. Those who govern must first know the existing scope and nature of the
health service needs of the populations they serve, trends in disease and illness, and patterns of utilization of available
health services.

Effective governing bodies and their senior management team clearly define measurable health status improvement
indicators and how these goals are to be:
 Achieved with evidence-based health and medical care that protects, promotes, and restores people to their optimal
levels of health and well-being,
Measured in the most cost-effective way, and
Monitored to determine progress and how progress is reported in an understandable manner.

Use this worksheet to define measurable health service and health status improvement indicators.

Glossary Term:
Indicator

Additional resources

Take a look at the:

GHeL courses on M&E Fundamentals and M&E Frameworks for HIV/AIDS Programs for more guidance on
identifying and selecting indicators.

Recently published Global Reference List of 100 Core Health Indicators by WHO.

Additional related resources

Additional related resources include:

USAID Vision for Health Systems Strengthening 2015-2019

USAID Vision for Ending Extreme Poverty

Establish a shared strategic vision with key stakeholders

Governing bodies find that when they engage stakeholders in defining the organization's vision, the vision is more
likely understood and owned by the stakeholders. Since people usually support what they help create, try to develop a
vision that is owned by those who will need to work to realize it. The vision provides a picture of a desired future and
creates conditions for working toward that desired future.

To lead your organization to achieve results, start with creating the shared vision and identifying future measurable
results, then assess the current situation, and develop the priority actions and an action plan. This process helps to link the
present to the future.
The Challenge Model has proven to be a very effective tool in guiding this process. As a governing body or person who
governs follow the step by step guidance which includes:

1. Developing a collective vision of the “ideal state” working with your colleagues, health workers, community members,
and many other diverse stakeholders, articulate this vision, and inspire everyone in the system to achieve it.
2. Documenting and disseminating the shared vision of the ideal state.
3. Overseeing the process of setting goals to reach the ideal state, and planning, strategizing, and monitoring progress
toward that vision.
4. Overseeing the process for developing and implementing a shared action plan to achieve the mission and vision of the
organization.
5. Making policies and decisions, and raising and allocating resources to achieve the collective vision.

Once the shared vision is created, it should be translated into measurable results.

How well are you performing at setting shared strategic direction?

Complete this simple self-assessment to find out.

Source: MSH 2014

Additional resources

Example of a strategic visioning exercise and document: DFID's The Strategic Vision for Girls and Women

Example of a strategic planning process: World Bank's Strategic Planning: 10-Step Guide

Enable leadership in the organization

Leadership is essential to setting and achieving the strategic direction. Good leadership is a prerequisite for both good
governance and sound management.

The full potential of governance and management cannot be realized without strong and effective leadership. Good
governance, in turn, provides purpose, resources, and accountability in support of management.

In a health system, we need leadership at all levels:

Leaders who govern or governance leaders

Leaders who manage or senior managers
Clinician leaders
Leaders of health worker teams
Community leaders

It is the job of people who govern and governing bodies to strengthen leadership by investing in continuing education of
the management and health provider teams of their organizations. See the first course in this series - Governance and
Health - for more on the relationship between leadership, management, and governance.

Investments in Leadership Training Lead to Improved Health Outcomes

In Afghanistan, the Ministry of Public Health has reached out to more than 1,800 health managers in 13 provinces to
make them more aware of their role as leaders and stewards of the health system. Under a program supported by USAID,
these managers have increased vaccination coverage and access to family planning services, resulting in improved child
and maternal health. The most significant improvements were an increase of almost 70% in health facility births and a 28%
increase in family planning consultations.

In Brazil, the Secretariat of Health of Ceará adopted a new paradigm in government for selecting people to promote into
leadership positions by requiring public servants interested in advancement to be accepted into and participate in
leadership training before they could even apply for management positions, breaking the mold of automatic promotion. The
associated improvement in health results was significant; in one municipality, infant mortality dropped from 26 to 11
deaths per 1,000, while the percentage of women receiving prenatal care increased from just over 50% to 80%. Overall,
70% of the 25 municipalities that participated in the leadership development process reduced their infant mortality—some
by as much as 50%.

Sources: MSH eHandbook Health Systems in Action; MSH 2004

Glossary Term:
Managing

Leadership training resources

The Virtual Leadership Development Program (VLDP) and LeaderNet provide excellent opportunities for leadership
training.

Create a strategic plan

Working with senior management, the governing body should take the following steps in order to create a strategic plan
for their organization.

To convert the strategic plan into an operational plan, you and your team should meet to select the activities that will best
fulfill the strategic objectives, define indicators of accomplishment, and assign costs to each activity. You may want to seek
expert help in determining costs and preparing the budget.

Source: MSH eHandbook Health Systems in Action

Glossary Term:
Program-level output indicators
Outcome indicators
Monitoring and Evaluation (M&E) Plan

Examples of strategic plan documents

The Christie NHS Foundation Trust: Strategic Plan Document for 2014-19

The Oxford Health NHS Foundation Trust: Strategic Plan Document for 2014-19

Did you know?

Although strategic plans, operational plans, and business plans have different time spans and are developed and used at
different levels, they are not mutually exclusive. In particular, operational or annual plans should be based on the content and
strategic priorities outlined in the strategic plan.

Implement, monitor, and report progress

Statements and plans that set strategic direction are only words unless they are implemented. The strategic
direction needs to be operationalized and acted on by senior and middle managers.

Governing bodies and their members should make policies that create conditions in which managers are more
likely to want to and be able to implement plans that drive the organization toward the achievement of its mission and
vision.

As highlighted earlier, the governing body sets the strategic direction in collaboration with senior management and key
stakeholders. Once the direction is set, it is primarily the responsibility of the management to realize it. The oversight
responsibility of the governing body highlights its role in monitoring from a high level the progress being made in
implementing the strategic and operational plans to achieve the organization's strategic direction.

You will need to monitor the output and outcome indicators that you selected when you worked with management and
stakeholders to identify the population health goals as described earlier.

An organization’s “progress to plan” should not only be measured and monitored but also reported to all key
stakeholders. Leaders who govern must report objectively and transparently progress of the organization to citizens,
patients, media, and policy makers.

Source: MSH eHandbook Health Systems in Action

Glossary Term:
Program-level output indicators
Outcome indicators

Additional resources

For more training on monitoring and evaluation and using data effectively, see any of the courses in the Monitoring and
Evaluation Certificate Program.
Stewarding resources

Health sector leaders who govern effectively: (1) define the scope and nature of resources required to implement their
organizations’ strategic plans; (2) raise the needed resources from diverse sources; and (3) ensure that the resources are
carefully used by managers, clinicians, and health workers.

In this session, you will learn about practical ways to steward resources as a key practice for good governance.

Why steward resources?

Stewardship is the ethical and efficient use of resources of the organization in pursuit of desired health
outcomes.

Lack of ethical and moral integrity can occur in any area of the health sector, for example, in construction and renovation
of facilities; purchase of equipment, supplies, and medicines; education of health professionals; and provision of services
by medical personnel and other health workers. Lack of integrity can manifest itself through:

Bribes
Kickbacks
Poor performance
Refusal to uphold institutional policies
Absenteeism
 Informal payments
Theft of public resources

Waste, fraud, and abuse of resources in a health system result in higher costs and lower quality of care,
disproportionately affecting the poor if services become biased towards a society’s elite. For example, poor
women may not receive critical health care services simply because they are unable to pay informal fees. There is also a
risk of harm due to substandard medicines and equipment, inappropriate treatment, and inadequate training of personnel.
Patients and citizens lose faith and trust in the health system and in the government if health service delivery is riddled
with corruption. And, the government loses its legitimacy.

As discussed earlier, the practices of good governance are interrelated and reinforce each other, for example, setting
shared strategic direction helps in mobilizing resources, and responsible stewardship of resources helps the governing
body realize the strategic direction set for the organization.

Glossary Term:
Stewardship
Approaches to stewarding resources
Now that you know why the stewardship of resources is important, consider the following scenario:

As a physician, you are the recently appointed Director of a Provincial Health Department in Zimbabwe. You want to be a
good steward of limited resources for health improvement.

How can the governing body for your provincial health department earn more money from the national government,
foreign donors, and non-governmental sources by developing smarter and more compelling business and financial plans?
What are the relative roles and contributions of the staff compared to the governing body member?

The governing body of the provincial health department should consider taking actions to:

Wisely raise and use resources

Practice ethical and moral integrity
Build management capacity
Measure performance
Use information, evidence, and technology in governance
Eradicate corruption

The following pages will provide guidance on how to implement these approaches.

Wisely raise and use resources

It is the role of the governing body to ensure a stable source and responsible use of resources for your organization.
Effective governing body members should:

Learn about their organization’s historical patterns and trends regarding funding sources and determine whether the
funds are at sufficient levels.
Mobilize resources through new services/products/partnerships, user fees, grant writing and proposal development,
and fundraising campaigns.
Critically analyze existing services and human resources and technical costs to determine areas for realignment based
on your organization’s mission and strategic plan.
Update your strategic plan regularly so that it is always a real roadmap for the next three to five years and so that you
can forecast the need for resources, budget appropriately, and also measure your organization’s performance.

Glossary Term:
Communicable diseases
Non-communicable diseases

Sources of funding

Sources of funding can be diverse, for example:

Budget allocation from the Ministry of Health

 Revenue from public health insurance agencies

User fees charged at the point of service delivery

Philanthropy and donor contracts or grants

Innovative health financing in Rwanda

In recent years, Rwanda has rebuilt its health sector and made dramatic
progress on health indicators, implementing a variety of reforms aimed at
improving health service delivery and access to care, particularly for the
most vulnerable segments of the population.

Reforms to boost both the demand for and the supply of health services included:

1. Health micro-insurance (‘mutuelles’),

2. Performance-based financing (PBF), and
3. Fiscal decentralization.

Since 2000, health insurance has been progressively scaled-up at the national level through community-based health
insurance schemes with strong support from the Government of Rwanda. PBF was also scaled-up nationally. And, now both
public and faith-based health facilities are legal, autonomous entities, responsible for the management of financial
resources, health service delivery, and human resources for health.

PBF has led to the transfer of public funds—about US$1.8 per capita—from the Treasury directly to health facilities at the
basic health service level on the basis of a performance-based formula that included 22 key indicators. These funds are
flexible and may be used for facility expenditures, including performance-linked salary bonuses, partially substituting for
revenues from user fees.

As a result of fiscal decentralization reform, district transfers for health are commanding an increasing share of
government health expenditures.

Source: Sekabaraga et al. 2011

Glossary Term:
Decentralization
Performance-based financing
Practice ethical and moral integrity

Governing bodies need to ask their leaders and managers if the system or organization is receiving good “value for
money.” Are the contracts to hire people, purchase pharmaceuticals and supplies, invest in facilities and equipment being
established in fair, competitive, and ethical terms?

In addition to answering these questions, governing bodies, leaders, and managers should:
 Involve stakeholders and the public in the oversight of activities of your department or organization.
Make policies, practices, expenditures, and performance information open to stakeholder scrutiny.
Make all stages of plan and budget formulation, execution, and performance reporting fully accessible to the public
and stakeholders.
Make information about tender processes publicly available on the internet.
Introduce a code of conduct on ethics, conflict of interest rules, and whistleblower protections.

See the case study in the first course in this series to learn more about how an International Planned Parenthood
Federation (IPPF) country-affiliate civil society organization (CSO) overcame some of these challenges specifically related
to conflicts of interest.

These actions ultimately impact stewarding resources responsibly but reveal the importance of cultivating accountability
as well as engaging stakeholders to ensure the practice of ethical and moral integrity.

Glossary Term:
Ethical and moral integrity
Build management capacity

Poor or inefficient financial management has implications for quality of service delivery and overall health system
performance. Governing bodies need training in financial management to be able to fulfill their oversight role. They need
to invest in continuously developing the competencies of managers to perform the essential leading and managing
practices as well as in the tools, systems, and working conditions for employees to flourish.

In 2013, USAID-funded Leadership, Management, and Governance (LMG) Project conducted ten financial capacity
workshops for staff of the International Planned Parenthood Federation (IPPF) Member Associations in Cameroon, Ghana,
Kenya, Mozambique, and Uganda. With nearly 100 participants, the workshops trained staff on skills necessary to bid on
and manage USAID awards in order to strengthen IPPF and their member associations’ capacity to improve family
planning and reproductive health outcomes. After participating in the trainings and applying the skills learned
from them, the participants won a $72 million USAID-funded award for the IPPF Africa Region Office in 2014.

Source: MSH 2015

Ideas in action

Equipping a modern health workforce with necessary financial management skills is an important part of preparing health
workers to assume leadership and management roles during their careers, and strengthening their organizations’ ability to
deliver health services to traditionally underserved populations. The LMG Project, with support from Amref Health Africa, is
working with six universities in southern Africa to integrate leadership, management, and governance practices—such as
effective financial management—into health workers’ pre-service curricula.

Source: MSH 2015

Measure performance
The wise stewardship of scarce resources requires that their flow and use be carefully measured and accounted for.
Modern, disciplined, accurate, and ethical accounting and bookkeeping are essential to the infrastructure of well-governed
health systems.

Effective governing body members ask pertinent questions about patterns and trends in the costs and expenditures of their
organization.

There are several activities that can help ensure the achievement of this essential practice.

Build the skills of managers and health providers in selecting and using meaningful measures to support their decision
making.
Review your governance effectiveness at least annually. Regularly seek information and feedback on your own
governance performance. Pause periodically for self-reflection to diagnose your strengths and limitations and examine
your mistakes.
Measure participation of stakeholders in governance decision-making, your gender-responsiveness, openness,
accountability, and integrity, and improvements in health system and health service performance.

Check out this simple self-assessment to see how well you are performing on stewarding resources.

Source: MSH 2014

Use information, evidence, and technology in governance

Consider how best to support your organization’s managers to use information, evidence, and technology to facilitate
governance decision-making and for effective and efficient utilization of resources. Information and evidence should be
used to inform the use of technology, and technology can assist with the collection, monitoring, and use of information and
evidence.

Source: Adapted from MSH eHandbook Health Systems in Action

Examples of using information, evidence, and technology

Working to end counterfeit drugs in Nigeria

Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) has been able to bring down
unregistered and hence suspected-to-be counterfeit drugs in the market from 68% to 20% from 2001 to 2011. NAFDAC’s
war against counterfeit medicine has been going on for more than 20 years. The agency’s fight against fake drugs may
have saved hundreds of thousands of Nigerians from possible adverse effects such as treatment failure, drug resistance,
complications, and death.

Now, Nigerian consumers can report counterfeit drugs through mobile texting. Medicine packs have a small scratch strip
added to the packaging. A purchaser scratches the panel and sees a unique number or code. The consumer then takes out
a mobile phone and sends the code to a toll-free number. Within seconds, a message appears on his or her phone with the
word "YES" - a response meaning the drug is genuine. If the consumer receives the word “NO,” there will also be a local
number so they can alert the authorities about this encounter with a potentially counterfeit medicine. The national drug
regulators, mobile phone networks, and pharmaceutical companies have come together to make this consumer
participation possible. Every Nigerian who walks into a pharmacy store with a cell phone in hand is now a potential
consumer advocate and a supporter of the NAFDAC’s fight against corruption.

Increasing health resources in Bolivia

In Bolivia, 1996, 1997, 1998 and 2008 national health accounts information showed that the Ministry of Health (MOH) was
spending approximately 43% of its budget on hospitals alone. Based on this observation, the government decided to
increase its overall health budget and also spending on primary care while avoiding a reduction, in absolute terms, in
hospital spending—expecting future savings due to a gain in allocative efficiency. The share of hospital spending in the
MOH’s budget is now 35%.

Sources: Guardian newspaper; HS2020 database

Eradicate corruption
Corruption is the improper use of resources for personal gain or in such a way that the achievement of the organization’s
mission is compromised or jeopardized. Corruption, unfortunately, exists in the health sector of all nations. Good
governance does not hide from this painful reality.

Expressions of corruption vary and can be blatant like taking bribes or more subtle like helping a relative get a job.

Fraud is the use of deception of any kind with the intention of gaining an advantage, which could be
financial or something else. It is intentionally committed knowing the act is wrong (per organizational
policy and general moral values) and with the expectation that it will not be found out or punished. Fraud
can take on many forms, including forging a signature, hiring family members, and using organization’s
assets for inappropriate or personal tasks.

Theft is the act of stealing. It can also take on many forms, including using petty cash funds for personal
purchases, cheating on an expense report, and stealing cash or business equipment. Theft includes the
misappropriation of funds in connection with procurements, billings, cash and other assets, payments,
receipts, and dealing with contractors, suppliers, or customers.

Bribery is paying or offering to pay (either directly or through agents) anything of value to an individual
for the purpose of influencing them in the exercise of their duties.

A kickback provides (either directly or indirectly) any of the following: Money, a fee, a commission, credit,
a gift, a gratuity, a thing of value, or compensation of any kind. Whereas bribery relates to influencing
decisions such as policy making or permits, kickbacks are specific to the awarding of contracts.

Governing body members must ensure that they do not behave in unethical and illegal ways and should take
any necessary actions to protect the organization from all forms of corruption. See the next page for actions that
can be taken to prevent corruption.

Additional resources for further study

Overview of integrity assessment tools

The basics of integrity in procurement

Addressing corruption in the health sector: Securing equitable access to health care for everyone

Corruption in the Health Sector

Best practices in engaging youth in the fight against corruption

Gender, corruption and health

Impact of community monitoring on corruption

Actions that help prevent corruption
A number of approaches to cultivating accountability and engaging stakeholders can also have a positive impact in curbing
corruption. In addition, the following actions can be taken.

Ethics and Compliance Initiatives

Ethics or compliance officer

Code of conduct for governing body members and staff
Ethics training for governing body members and staff
Internal whistleblowing or ethics reporting mechanism
Public statements by senior management
Risk assessments
Incentives for a well-designed compliance program

Human Resources Management

Employee performance appraisal system

Changes to civil service to allow for prompt disciplinary action
Performance-based payment
Merit-based hiring and promotion system

Financial

Electronic cash registers (give itemized receipts, reconcile quickly with cash count, measure performance of
individual fee collectors/locations)
Video surveillance of areas where cash transactions take place
Train auditors and financial staff; increase quality and frequency of audits
Strengthen computerized accounting systems (including automatic payments of per diems into bank accounts of
employees)
Initiatives to reduce informal payments by paying staff well while at the same time increasing detection and
punishment
Voucher programs (to reduce informal payments)

Source: Vian 2013

Continuous governance enhancement

The fifth practice of good governance - continuous governance enhancement - ensures that the four other practices of good
governance described earlier in this course are regularly assessed and consistently applied.
Why continuous governance enhancement?

Good governance is not static; it is dynamic. Leaders who govern and senior management team need to consistently apply
practices of good governance to influence organizational performance. The governing body should always seek ways to
improve its practice of good governance. Those who govern must make individual and collective commitment to
continuously enhance their strategies, structures, and practice of good governance.

Good governance thus requires an interest in and commitment to improvement that is continuous. For this to happen,
it is necessary for the governing body to step back at least once a year and assess its own performance and that of its
committees, chair and committee chairs, and individual members.

The periodic assessment will motivate the governing body and its members to continuously improve their governance
performance. Governing body self-assessment process and the action plans created out of it enable the
governing body to identify critical gaps and fill them over time. Self-assessment process facilitates the development
of a governance improvement action plan with responsibilities, timeframes, and projected outcomes.

Assess how your governing body is doing

Now that you know why continuous governance enhancement is important, consider the following scenario:

You are a community leader and also a member of hospital community board asked to chair a special task
force to design ways to continuously improve the work of your governing body of the public hospital in a
state capital in Nigeria.

How would you establish policies and relationships to annually assess progress to governance best
practices, and then create the conditions in which annual plans for continuous governance process
enhancement actually happens? How could you tell if governance was improving?

As a first step, you may want to assess how well your organization is performing on continuous governance
improvement.

Source: MSH 2014

Actions for continuous enhancement & infrastructure for good governance

The actions for promoting continuous governance improvement include:

Cultivating essential governance competencies,

Building diversity in the governing body,
Establishing governance policies,
Governance orientation and education,
Regular governance assessments,
Conducting productive meetings, and
Using governance technologies, such as a dashboard.

These largely reflect the necessary infrastructure (that is, what is physically needed in terms of structures, people, policies,
meetings, and technologies/information systems) for establishing a well-functioning governing body.

If the infrastructure is not just in place but also robust, then the process of continuous improvement will be easier.

Due to the significant overlap between the actions for continuous governance improvement and the physical infrastructure,
it is strongly recommended that you continue your learning experience by taking the third course in this series,
Infrastructure for Good Governance.

Glossary Term:
Competencies
Governance learning resources
In addition to the two other courses in this series - Governance and Health and Infrastructure
for Good Governance, there are a number of learning resources that USAID’s Leadership,
Management, and Governance (LMG) Project has made available for your use.

Governance training facilitation handbooks

For the Ministry of Health Governance Leaders and Staff (English | French)
For Provincial Health Office Governance Leaders and Staff (English | French)
For District Health Office Governance Leaders and Staff (English | French)
For Hospital Governance Leaders and Staff (English | French)
For Health Center Governance Leaders and Staff (English | French)
The eManager: How to govern health sector and its institutions effectively (English | French | Portuguese |
Spanish)

The eManager: Good Governance in Civil Society Organizations (English | Spanish)

Chapter 3 of MSH eHandbook: Governance of health systems and health organizations (English)

Govern4Health app (Available at App Store and Google Play Store for download on iPhone or Android phone)

GovScore is an app to measure the governance maturity of an organization and guide the governance leaders to
improve their governance and organizational performance.

In addition, USAID's Health Finance and Governance (HFG) Project supports countries in their quest for stronger health
systems that deliver the life-saving services their citizens need, when and where they can access them, and at affordable
prices. They have a wide-range of useful health finance and governance and leadership resources, among others, available.

USAID's Health Policy Project (HPP) is building capacity around the world for improved health policy, advocacy,
governance, and finance. They offer a variety of governance-related resources.

Finally, there are the case examples that illustrate the nature and impact of USAID's investments in Health Systems
Strengthening - which includes a number of governance examples.