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 on Leadership and governance health system profile is structured as follows:
At independence, Namibia inherited a fragmented health system based on racial segregation and marked by a concentration of infrastructure and services in urban areas. Since independence in 1990, a number of health sector reforms have taken place, including the restructuring and re-orientation of the health sector in line with the Primary Health Care (PHC) approach, which brought health services closer to the population.
The health system still faces challenges due to persisting inequities as well as the scattered nature of the Namibian population, with consequent difficulties in geographical access to health facilities. Structural and systemic issues within the Ministry of Health and Social Services (MoHSS) are also hampering the effective and equitable provision of health services.
Namibia has a pluralistic health system in which the MoHSS serves about 85% of the population, and the private sector serves the other 15%. There are 1150 outreach points, 309 clinics and health centres, 29 district hospitals and 4 intermediate and referral hospitals. One problem that needs to be addressed is that referral hospitals are not autonomous (MoHSS, July 2010).
There are 844 private health facilities registered with the MoHSS, among which are 13 hospitals, 75 clinics, 8 health centres and 75 pharmacies, mainly in urban areas of Erongo and Khomas regions. In addition, there are 557 medical practitioners, including dentists, psychologists and physiotherapists (MoHSS, August 2008).
Faith-based organisations (FBOs) and NGOs play a significant role in protecting and promoting the health and social welfare of the Namibian people, as well as operating services for the MoHSS on an outsourcing basis. The public health system has three levels. The central level consists of the Permanent Secretary, Deputy Permanent Secretary, three departments, and seven directorates (Primary Health Care, Developmental Social Welfare Services, Special Programmes, Tertiary Health Care and Clinical Support Services, Finance and Logistics, Human Resource Management & General Services, and Policy, Planning & Human Resource Development).
The central level is responsible for policy, planning, coordination of services, resource mobilization and allocation, technical support, standards, performance management, legislative responsibilities, regulation, and the overall stewardship of the health sector. (MoHSS and Macro, August 2008) Fragmentation and duplication of functions in a number of divisions within various directorates, as well as across ministries needs to be addressed.
There has been some de-concentration of planning and management to the regions and districts. At the regional level 13 directors head the District Management Teams. These teams provide leadership and management support to the entire region, and are responsible for implementation at regional level. There are 34 District Coordinating Committees which manage health activities at district level. (MoHSS and Macro, August 2008)
The Regional Director is a member of the Regional Development Committee assuring coordination between the Regional Council and the MoHSS. Decentralisation to the Regional Councils of various government sector functions and responsibilities has been underway for some years. The Regional Council is responsible for environmental health in the regions although there is also MoHSS environmental health staff deployed in the regions (MoHSS, July 2010).
Health activities in the regions are planned in alignment with the Ministry’s strategic plan and specific programme frameworks, which are also required to align with the Primary Health Care approach. The MoHSS is striving to fulfil its role as overseer of the whole sector in order to better coordinate the activities of partners in health, including donor agencies and NGOs.
To inform policy planning and implementation, information is generated through routine data collection, analysis and reporting at all levels. However, there are a number of challenges, such as the multiplicity of information systems, understaffing, lack of data from the private sector, and delays in producing reports from the Health Information System (HIS) to enable timely data gathering and analysis for improved decision-making. (MoHSS, 2008; MoHSS, July 2010)
Public/stakeholder participation is frequently sought for policy and decision making at various levels, both within the MoHSS and externally. For example, the National Health Policy Framework 2010-2020 was developed through participatory processes involving key stakeholder consultations at national and regional levels. Other sector-wide dialogue occurs around priority areas.
For example, the Maternal, Newborn and Child Health Management Committee is chaired by the Director of the Primary Health Care and comprises all programme managers, UN agencies, bilateral and multilateral organizations, NGOs, training institutions and local associations; HIV technical advisory committees consisting of MoHSS representatives, CSOs, UN and USG organisations inform the National AIDS Executive Committee; the National Alliance for Improved Nutrition brings together public, private, civil society and development partners under the auspices of the Office of the Prime Minister.
The National Health Policy Framework 2010-2020 was published in July 2010 and provides ‘the overall orientation for health and health actions in Namibia’. (MoHSS, July 2010) The MoHSS takes the lead in priority areas such as nutrition and HIV/AIDS, where a multi-sectoral approach is required. In other multi-sectoral areas such as Environmental Health, MoHSS policy provides a clear point of reference. The Public Health Act of 1919, which provides guidance for sanitation and hygiene, is in urgent need of revision. (MoHSS, 2008)
The private sector is regulated by the Hospital and Health Facilities Act of 1994 (Act No. 36), but adherence to government policies such as programme policies and reporting has been limited. (MoHSS, July 2010) There is a need for the development of regulations for food safety and, fortification. Important guidelines that are utilised at facility level include Clinical, ART, Cholera, Pharmaceutical, IYCF, School Health, Vitamin A, CBHC, ARI, EPI, RH, TB, Malaria, HIV, PMTCT, FP and Mental Health Guidelines. In addition the Namibia Standard Treatment Guidelines were published in 2011.
Traditional medicine is widely used in the community and is often the first port of call, but there is no regulation of the practice. A number of semi-autonomous bodies play a role in regulating the health sector. They include the Health Professions Councils of Namibia, and the Medicine Control Council, among others.
Namibia is party to the International Health Regulations (IHR) Act 2005 and is currently developing an IHR plan from which areas that require guidelines will be developed. Closely linked to this are the Integrated Disease Surveillance and Response (IDSR) guidelines, which are currently being revised.
Identified priorities in leadership and governance include the improvement of the information management system, ensuring responsive legislation and policies, devolving levels of decision making to appropriate levels, and building capacity for leadership at clinical, management and executive levels, as well as addressing fragmentation and duplication of functions. (MoHSS, February 2009).
In 2008 the Ministry began to participate in the African Public Health Leadership Initiative spearheaded by Synergos (international NGO), and embarked on restructuring in 2009, a process which is still ongoing.