Health systems governance: the missing links

The role of ministries of health has changed, progressively shifting from direct provision of health services to overall stewardship of the health sector, including financing and oversight of private providers.1 Health reforms have triggered that shift, fostering new institutions, such as national medicines agencies, public health agencies, disease control agencies (eg, National Cancer Agencies) or health financing organisations responsible for risk and fund pooling, purchasing of health services, or targeting the poor or vulnerable groups. Health systems processes must move from a top-down to inclusive policy, planning and implementation processes, increasingly adopting a people-centred approach.3 Democratic rights, human rights, equity and ethics values have become prominent in national policy debates. In response to this call, twenty-first century health systems need to be participatory, inclusive and pluralist, following Whole of Society and Whole of Government principles.3 4 People’s voice is a core driver of health systems’ performance towards Universal Health Coverage.5 In such a context, governance arrangements are changing and rely more on inclusion, participation and co-production.6 This paper presents a framework to help understand health systems governance; examine what we know about this important health system function, and what has been less explored, leaving an important gap in our health system knowledge and practice. Missing links The past decade experienced an increase of the literature on health system governance; various frameworks presenting attributes or dimensions of governance have emerged and define the nature and scope of this function.11 12 In a review published in 2014, Barbazza and Tello highlight the challenge of reaching a consensus and communicating a clear agenda on governance in health.10 They conclude that frameworks and tools defining governance have been developed independently, seldom building on strengths and weaknesses as well as practical applications of previous instruments; they lack a shared frame of reference which would enable governance to become a truly actionable health system function.