Leadership and governance
The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. It is about the role of the government in health and its relation to other actors whose activities impact on health. This involves overseeing and guiding the whole health system, private as well as public, in order to protect the public interest.
It requires both political and technical action, because it involves reconciling competing demands for limited resources in changing circumstances, for example with rising expectations, more pluralistic societies, decentralization or a growing private sector. There is increased attention to corruption and calls for a more human rights based approach to health. There is no blueprint for effective health leadership and governance. While ultimately it is the responsibility of government, this does not mean all leadership and governance functions have to be carried out by central ministries of health.
Experience suggests that there are some key functions common to all health systems, irrespective of how these are organized:
- Policy guidance: formulating sector strategies and also specific technical policies; defining goals, directions and spending priorities across services; identifying the roles of public, private and voluntary actors and the role of civil society.
- Intelligence and oversight: ensuring generation, analysis and use of intelligence on trends and differentials in inputs, service access, coverage, safety; on responsiveness, financial protection and health outcomes, especially for vulnerable groups; on the effects of policies and reforms; on the political environment and opportunities for action; and on policy options.
- Collaboration and coalition building: across sectors in government and with actors outside government, including civil society, to influence action on key determinants of health and access to health services; to generate support for public policies and to keep the different parts connected – so called "joined up government".
- Regulation: designing regulations and incentives and ensuring they are fairly enforced.
- System design: ensuring a fit between strategy and structure and reducing duplication and fragmentation.
- Accountability: ensuring all health system actors are held publicly accountable. Transparency is required to achieve real accountability.
An increasing range of instruments and institutions exists to carry out the functions required for effective leadership and governance. Instruments include:
- sector policies and medium-term expenditure frameworks
- standardized benefit packages
- resource allocation formulae
- performance-based contracts
- patients' charters
- explicit government commitments to non-discrimination and public participation
- public fee schedules.
Institutions involved may include:
- other ministries, parliaments and their committees
- other levels of government
- independent statutory bodies such as professional councils, inspectorates and audit commissions
- nongovernment organization "watch dogs" and a free media.
This section of the health system profile is structured as follows:
The Government of the Gambia provides about 70% of the country's health needs for fairly low fees. Over the years these fees have become unrealistic, leading to a very low recovery for sustaining the services. Communities are involved in health care through the Bamako Initiative, as well as working with private and nongovernmental organization health providers.
There are about 15 nongovernment organizations involved in the delivery of health services in the country, through the signing of a memorandum of understanding with the Ministry of Health and Social Welfare. A few nongovernmental organizations, mainly faith-based organizations, provide social services such as institutional housing, feeding, and care for orphans and vulnerable children.
The Ministry of Health and Social Welfare is responsible for the overall coordination of health in the country as well as the management of the health sector, including:
- health services provision and regulation
- resource mobilization, including human resource development and health research.
Services are delivered through five directorates, namely:
- Health Services
- Planning and Information
- Social Welfare
- Public Health Laboratories and Food Safety
- Quality Hygiene Delivery Services.
The challenge has been frequent staff turnover, which leads to delay in implementation of programmes and plans.
The health system is being gradually decentralized with the formation of regional directorates that are mandated to distribute their staff, engage their communities in innovative health programmes and carry out activities funded directly by partners, both locally and internationally. However, the decentralization process needs to be accelerated in order to empower the communities and regional directors to function more effectively.
Health issues are articulated in plans and policies that are of national interest, such as yearly budget pronouncements, poverty reduction strategy papers, cabinet papers and the recently launched Programme for Accelerated Growth and Development.
Health data are collated from facility level through the regional directorates to central level. At the various levels, data entry clerks are deployed to help in the compilation of data that could be used at that level for necessary action. However, data are often not analysed at the collection points, leading to a delay in taking prompt remedial action when necessary. That said, the health management information system continues to provide useful data on various health issues for planning and public education purposes.
Health activity planning is not yet unified at the central level because the various programme areas are working with different funding partners. This sometimes leads to vertical programming and duplication of efforts.
The policy dialogue and decision-making process of health care delivery in the country is usually participatory. The various stakeholders in health, including the private sector and the community, are usually consulted and are actively engaged during the development and implementation of the health policy and strategic plan.
The central level of the Ministry of Health and Social Welfare is responsible for health policy formulation, setting standards and quality assurance at all levels of health care delivery.
The Gambia is a signatory to the International Health Regulations and works closely with the WHO Country Office and other partners for its implementation. Funding is sometimes a challenge in implementation of regulations.
The Directorate of Planning and Information is responsible for the monitoring and evaluation of the implementation strategies and, given the right staff mix, it should be able to guide the Ministry of Health and Social Welfare in the decentralization process as well as ensure efficient and effective use of resources. An effective quality assurance system within the health sector needs to be developed and introduced at all levels of health care delivery.
Context and background of the health system
Policy making and health planning
Regulation, monitoring and evaluation
Priorities and ways forward
Endnotes: sources, methods, abbreviations, etc.
- ↑ Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
- ↑ Programme for Accelerated Growth and Employment (PAGE) (2012–2015) (pdf 745.29kb). Banjul, Government of the Gambia, Division of Development Planning, Ministry of Finance and Economic Affairs