Governance and leadership in health development are critically important for the achievement of the health Millennium Development Goals (MDGs) and other national health goals. Those two factors might explain why many countries in Africa are not on track to attain the health MDGs by 2015. This paper debates the meaning of 'governance in health development', reviews briefly existing governance frameworks, proposes a modified framework on health development governance (HDG), and develops a HDG index.
We argue that unlike 'leadership in health development', 'governance in health development' is the sole prerogative of the Government through the Ministry of Health, which can choose to delegate (but not abrogate) some of the governance tasks. The general governance domains of the UNDP and the World Bank are very pertinent but not sufficient for assessment of health development governance. The WHO six domains of governance do not include effective external partnerships for health, equity in health development, efficiency in resource allocation and use, ethical practises in health research and service provision, and macroeconomic and political stability. The framework for assessing health systems governance developed by Siddiqi et al also does not include macroeconomic and political stability as a separate principle. The Siddiqi et al framework does not propose a way of scoring the various governance domains to facilitate aggregation, inter-country comparisons and health development governance tracking over time.
This paper argues for a broader health development governance framework because other sectors that assure human rights to education, employment, food, housing, political participation, and security combined have greater impact on health development than the health systems. It also suggests some amendments to Siddigi et al's framework to make it more relevant to the broader concept of 'governance in health development' and to the WHO African Region context.
A strong case for broader health development governance framework has been made. A health development governance index with 10 functions and 42 sub-functions has been proposed to facilitate inter-country comparisons. Potential sources of data for estimating HDGI have been suggested. The Governance indices for individual sub-functions can aid policy-makers to establish the sources of weak health governance and subsequently develop appropriate interventions for ameliorating the situation.
An Editorial in the African Journal of Health Sciences delved into the 'The essence of leadership in health development' . However, there is often confusion between the terms 'leadership' and 'governance'. The Editorial argues that the Ministry of Health Headquarters, provincial medical officers of health, district medical officers of health, and officers-in-charge of health facilities are all leaders but they do not have the monopoly of leadership in health development. It concludes that all health workers and parents play public health leadership roles and their effectiveness could be enhanced through empowerment with appropriate leadership skills training. This paper debates on what governance in health development entails. It argues that unlike 'leadership in health development', 'governance in health development' is the sole prerogative of the Government through the Ministry of Health, which can choose to delegate (but not abrogate) some of the governance tasks.
The World Health Report 2000  delineated four functions of national health systems: stewardship, health financing, resource (input) creation and health services provision. The report uses terms 'stewardship' and 'governance' interchangeably. HarperCollins  dictionary defines a steward as a "person who administers another's property" (p.620). Since the Ministry of Health administers the public health system, it is a steward. Faith-based Organizations Health Associations, in their stewardship role, also oversees the running of church provided health services. The Board's of Directors of private-for-profit hospitals, in their stewardship role, oversees the operations of private hospitals on half of shareholders. This implies that the Ministry of Health does not have monopoly over stewardship of a national health system.
Unlike stewardship, governance is the sole prerogative of a national government, i.e. the executive policy-making body that exercises political authority over a country. A government through its system(s) rules or governs a country. HarperCollins  dictionary defines the word govern as "rule, administer, command, control (curb), direct, guide, handle, lead, manage, order, restrain, check, discipline, master, regulate, subdue, tame" (p.285). Thus, the scope of the governance role of government extends far beyond its stewardship role.
Overview of existing governance frameworks
The United Nations Development Programme (UNDP) five principles of good governance include: legitimacy and voice (participation and consensus orientation), direction (strategic vision), performance (responsiveness, and effectiveness and efficiency), accountability (and transparency), and fairness (equity and inclusiveness, and rule of law) .
The World Bank's three clusters (with six domains) of governance include: processes by which those in authority are selected and replaced (voice and accountability, and political instability and violence); ability of government to formulate and implement sound policies (government effectiveness and regulatory burden); and respect of citizens and the state for institutions which govern their interaction (rule of law and control of corruption) .
The World Health Report 2000  six domains of stewardship include: generation of intelligence, formulating strategic policy framework, ensuring tools for implementation (powers, incentives, and sanctions), building coalitions/partnerships, ensuring fit between policy objectives and organizational structure and culture, and ensuring accountability.
The slightly amended World Health Organization  health systems framework consists of six building blocks: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership/governance. The latter building block has six functions: policy guidance, intelligence and oversight, collaboration and coalition building, regulation, and accountability.
Siddiqi et al  framework for assessing governance of the health system has ten principles (and 22 domains): strategic vision (long vision, comprehensive development strategy including health), participation and consensus orientation (participation in decision-making process, stakeholder identification and voice), rule of law (legislative process, interpretation of legislation to regulation and policy, enforcement of laws and regulations), transparency (transparency in decision making and resource allocation), responsiveness of institutions (response to population needs and to regional local health needs), equity and inclusiveness (equity in access to care, fair financing of health care, disparities in health), effectiveness and efficiency (quality of human resources, communication processes, capacity for implementation), accountability (internal and external accountability), intelligence and information (information generation, collection, analysis and dissemination), and ethics (principles of bioethics, health care and research ethics). The framework assesses each of the 22 domains along three levels (national, health policy formulation, and policy implementation) and 63 questions (5 context related, 25 descriptive, 27 analytical/process related, and 6 outcomes related). Siddiqi et al  framework is the most comprehensive framework for assessing governance of health systems to date.
The governance domains of the UNDP and the World Bank are very pertinent but not sufficient for assessment of health development governance. That is understandable since they were developed for assessing general governance. The WHO six domains of governance do not include effective external partnerships for health, equity in health development, efficiency in resource allocation and use, ethical practises in health research and service provision, and macroeconomic and political stability. Siddiqi et al  also does not include macroeconomic and political stability as a separate principle, which is understandable because their framework is for assessing health systems governance.
In this paper we are arguing for a broader health development governance framework. Why? This is because of the fact that other sectors that assure human rights to education, employment, food, housing, political participation, and security combined have greater impact on health development than the health systems. For example, the significant negative impact of political and macroeconomic instability on health development has been starkly demonstrated in the diminished health indicators of the African countries that have undergone various forms of political and macroeconomic turmoil.
Siddiqi et al  does not propose a way of scoring the various domains to facilitate aggregation, inter-country comparisons and health development governance tracking over time. The following section suggests some amendments to Siddigi et al's framework to make it more relevant to the WHO African Region context.
Modified Framework for Health Development Governance
Table 1 presents a modified framework for assessing health development governance. This framework has ten functions and forty-two sub-functions of governance. First, public health leadership and management, which has five sub-functions, i.e. leadership responsibilities [8, 9], national health policy (NHP) , national health strategic plan (NHSP) , dissemination of NHP and NHSP, and implementation of NHSP . Siddigi et al  refers to this function as strategic vision. Second, rule of health-related laws function contains two sub-functions, i.e. existence of health-related legislations and their enforcement.
Third, community participation and responsiveness function has four sub-functions, i.e. participation in NHP and NHSP development process, participation in NHSP implementation, participation in tracking progress in implementation of NHSP, and responsiveness to community's legitimate non-medical expectations [12–14]. Siddiqi et al  principles of responsiveness of institutions and participation and consensus orientation are merged into one function of community participation and responsiveness. By assuring community participation in the planning, management and monitoring of health services, the institutions are partially being responsive.
Fourth, effective internal and external partnerships for health function has ten sub-functions, namely: inter-sectoral action [15, 16], public-private partnerships , alignment of aid flows to national health development priorities, strengthening capacity by coordinated support, use of country procurement and public financial management systems, strengthening national capacity by avoiding parallel implementation structures, more predictable aid, untied aid, shared analysis, and sufficient integration of global programmes and initiatives into NHSP . The need for inter-sectoral action with agriculture, animal husbandry, communications, education, employment, industry, food, housing, political participation, public works, security and transport sectors is critical for addressing all determinants of health development [15, 16]. Governments also have an important role in mobilizing, nurturing, coordinating and managing external support to maximize its impact on health development.
Five, horizontal and vertical equity in health systems function has three sub-functions, i.e. horizontal equity in access of health services [18–20], vertical equity in access of health services [16, 18–20], and fairness in financial contributions [18, 19]. Six, efficiency in resource allocation and use function has four sub-functions, i.e. allocative efficiency , technical efficiency [22–27], productivity growth [28–30], and institutionalization of efficiency monitoring . Seven, accountability and transparency in health development function has four sub-functions, i.e. existence of transparent results-oriented reporting and assessment frameworks; diagnostic reviews; use of information from diagnostic reviews; and publishing of audit reports for public consumption .
Eight, evidence-based decision-making function has four sub-functions, i.e. national health research systems [31, 32]; health knowledge management systems ; health management information systems ; publishing of audit reports for public consumption; and information, communication and technology connectivity . Nine, ethical practises in health research and service provision function, which has three sub-functions, i.e. international ethical guidelines for medical practice and health research, bioethics review system, and institutionalization of ethics training in all schools of medicine, nursing, public health and allied health sciences . This function is critically important to assure adherence to the international ethical principles of beneficence, non-malfeasance, autonomy, justice, dignity, truthfulness and honesty  even in settings, like Africa, where principal-agency relation in health-related biotechnology transfer is rather weak .
Ten, macro-economic and political stability function is divided into three sub-functions, i.e. link between national economic development plan (NEDP) , Poverty Reduction Strategy Paper (PRSP) and NHP/NHSP, existence of a medium-term expenditure framework (MTEF), and political stability [40, 41].
Health Development Governance Index
The health development governance (HDG) framework discussed above has 10 functions and 42 sub-functions. Each of the functions can be measured using a governance thermometer scale of 0% (very poor) to 100% (excellent) (Figure 1). The scale is authors' own construction. The Health Development Governance Index (HDGI) is the arithmetic mean of 42 indices, namely the index of each of the sub-functions in Table 2. All the indices are computed using the following general formula:
Where xi is the HDG indicator (sub-function) such as leadership responsibilities, existence of health-related legislation, inter-sectoral action, horizontal equity, allocative efficiency, existence of transparent results-oriented reporting and assessment frameworks, bioethics review system, national health research systems, etc.
For example, the Leadership Responsibilities index (LR) can be expressed as follows:
where LRI is the leadership responsibility index, Actual (LR) is the actual Leadership Responsibility score, Minimum (LR) is the minimum leadership responsibility score, and Maximum (LR) is the maximum leadership responsibility score. For example, assuming the global minimum leadership responsibility score and the global maximum responsibility scores are set equal to 0% and 100% respectively and the actual leadership responsibility score for a hypothetical country in Table 1 is 20%, the LRI can be obtained as follows:
The indices for each of the remaining 41 sub-functions can be calculated in a similar manner. And once individual sub-functions indices have been obtained, the overall Health Development Governance Index (HDGI) can be obtained using the following formula:
where is summation from sub-function 1 index to sub-function 42 index; HDGSFI is the health development governance sub-function index; N is the total number of sub-functions in the assessment framework. In the hypothetical example given in Table 2 the HDGI has been obtained as follows:
Since governance is measured on a scale of 0 (or 0%) to 1 (or 100%), the above HDGI of 0.35 implies that the health development governance in this hypothetical country is below average. If instead, the hypothetical country's HDGI was 50%, it would have signified average health development governance. The above formula is similar to that used by the United Nations Development Programme in calculating the Human Development Index . In reality, the scoring (using the thermometer scale) of the different sub-functions can be done by geographically representative national committees of informed persons.
The Governance indices for individual sub-functions can aid policy-makers to locate the sources of poor governance and then to develop appropriate interventions for ameliorating the situation. Those indices could be conducted every two or three years among all countries in the WHO African Region. Therefore, every two or three years, the WHO Regional Committee Ministers of Health from the African Region can have peer review. Since Regional Committee meets every year, there would be no additional cost for organizing the peer review sessions. Such peer review mechanisms would motivate countries to improve health development governance and also share good practises.
Possible sources of data for estimating HDGI
Countries that choose to estimate the HDGI may need to set up a national multi-disciplinary stakeholder Technical Working Group (TWG) to assess the current status of HDG. In addition, they might consider establishing a Steering Committee (SC) to oversee and facilitate the work. The TWG ought to be made up of appropriately qualified staff from all relevant sectors and programmes that deal with the ten functional domains of HDG. It is critically important for all relevant government sectors (especially those addressing various health determinants), health development partners, civil society organizations, and private health sector to be represented in both the TWG and SC. Wide participation will ensure that the results will be used to improve national HDG.
Table 3 shows the possible sources of data needed to assess the performance of each of the sub-functions of HDG. Public health leadership and management: Comprehensiveness of the NHP and NHSP can be assessed by reviewing the two documents against the WHO/AFRO guidelines . The data on leadership responsibilities and dissemination of NHP and NHSP can be obtained through a survey of stakeholders, e.g. civil society, health workers (in both public and private sectors) and partners. The level of implementation of NHSP can be assessed through appraisal of annual health sector review reports and other monitoring and evaluation reports. Annual reviews are often based on NHIS data and some times complemented with routinely gathered primary data.
Rule of law
Existence of health-related legislation can be assessed through review of existing health-related laws. The questions for assessing level of enforcement of health-related legislation may be included in the survey questionnaire for public health leadership and management.
Community participation and responsiveness
Firstly, data for use in assessing the level of community participation in formulation of NHP/NHSP and monitoring their implementation can be generated through administration of a questionnaire among parliamentarians and civic leaders or administrative leaders, e.g. chiefs. Secondly, responsiveness of health service providers to communities' non-medical expectations can be assessed through administration of responsiveness module of the World health survey questionnaire  among samples of clients exiting various levels of health facilities, e.g. tertiary, provincial/regional and district hospitals, and health centres.
Effective internal and external partnership for health
Firstly, data for assessing inter-sectoral action can be generated from in-depth interview with either prime minister's or president's office, depending on who chairs the cabinet. Secondly, review of health-related legislation and interviews with leaders of faith-based and private-for-profits health services providers can yield information on the extent to which legislative and policy environment fosters public-private partnerships.
Thirdly, interviews with Ministry of Finance and health development partners could yield information on percentage of aid flows for health development channelled through general government budget support. Fourthly, interviews with ministries of health would yield information on the existence of sector-wide approaches, multi-donor steering committees or equivalent donor coordination mechanisms.
Fifthly, the Public Expenditure and Financial Accountability (PEFA) initiative  reports contain information needed to assess extent of use of country procurement and public financial management systems, predictability of aid, whether aid is tied or not, and use of shared analyses. As at 7th March 2011, about 30 WHO African region countries had reports on the PEFA Secretariat website. Where such information does not exist, there may be need to conduct assessment using the PEFA framework .
Information on whether there has been sufficient integration of global programmes and initiatives into NHSP can be obtained by conducting interviews with Directors of Policy and Planning at Ministry of Health, health sector focal persons in Ministries of Finance, and country representatives of GAVI and GFATM.
The data needed for accountability and transparency in health development should be collected together with that on effective international and external partnership.
Horizontal and vertical equity in health systems
Estimation of health inequality requires data on health variables (e.g.) and ordinal living standards measure . Equity in utilization of health services or interventions entails data on utilization variables and ordinal living standards measure . Benefit-incidence analysis calls for data on health service utilization variables, ordinal living standards measure, and unit subsidies . Calculations of progressivity, catastrophic payments, or poverty impact of health financing require data on cardinal measure of living standards and user payments . Analysis of equity in health systems is best done using data from household surveys. Since household surveys can be very expensive to conduct, it is advisable to use data from existing household survey datasets, e.g., Living Standards Measurement Study (LSMS) , Demographic and Health Surveys (DHS) , Multiple Indicator Cluster Surveys (MICS)  and World Health Surveys . O'Donnell et al  is an excellent open access resource on how to analyze health equity using household survey data. The World Bank has also developed a free computer programme know as "ADePT-Health" for conducting health equity analyses .
Efficiency in resource allocation and use
Estimation of technical efficiency (TE) requires data on quantities of health system inputs, e.g. numbers (or time) of different cadres of health workforce, annual expenditure on pharmaceuticals, annual expenditure on non-pharmaceutical supplies, number of hospital beds; and volume of health service outputs, e.g. number of outpatient curative visits, outpatient preventive visits, community health outreach activities, inpatient admissions, inpatient discharges, and hospital deaths. In order to estimate allocative efficiency (AE), information on average inputs prices is needed in addition to data needed for TE. Calculation of productivity change requires all abovementioned input and output data for a number of time periods, e.g. a number of years. In the African region TE studies have been undertaken in Benin , Burkina Faso , Ethiopia , Ghana [22, 56], Kenya [24, 25], Namibia , Sierra Leone , South Africa [27, 58, 59] and Zambia ; AE studies have been conducted in Ghana  and Zambia ; and Malmquist total factor productivity analyses have been carried out in continental Africa national health systems , Angola , Botswana , Seychelles  and South Africa . Therefore, results from such studies can be used in computation of HDGI. However, in countries where no such studies exist, it will be necessary to collect relevant data and do the efficiency and productivity change analyses. Data needed for efficiency analyses can be found in NHIS database. If the data is not centrally available in NHIS database, there may be need to collate it from health facilities, using existing questionnaires [63, 64].
Evidence-based decision making
Firstly, the national health research systems analysis (HRSA) data can be obtained through review of existing HRSA reports. Where such data does not exist, it can be obtained through an assessment of national health research systems using HRSA toolkit [65–67]. Secondly, the health knowledge management systems (HKMS) data may be available in existing HKMS reports, and thus, a review of such reports might suffice. In countries where such reports do not exist, it will be necessary to conduct an assessment of HKMS using the "Research Matters" Knowledge Translation Toolkit . Thirdly, a review of existing NHIS reports may avail information needed in HDGI. However, if those reports do not exist, it may be necessary to do an assessment of NHIS using the Health Metrics Network tool . Lastly, the data for assessing ICT connectivity can be collected from health workers at various levels of national health system through use of the questionnaire mentioned earlier to gather information on dissemination of NHP and NHSP.
Ethical practises in health research and service provision
Data on dissemination of international ethical guidelines for medical practise and health research, bioethics review system, and institutionalization of ethics training should be collated simultaneously with that on HRSA (mentioned above) and using the same toolkit . The module entitled 'Module 7000: Research ethics and ethical processes' is specifically designed for this purpose.
Macroeconomic and political stability
Firstly, the linkage between NEDP, PRSP and NHP/NHSP can be ascertained through a review of those documents. Secondly, a review of Medium-Term Expenditure Framework (MTEF) document will help to determine whether it contains a clear health component derived from NHSP. Finally, a review of the national constitution and in-depth interview with chairperson of the national legal bar association can facilitate identification of the extent to which a non-violent process exists by which those in authority are elected and replaced. This information can be complemented with a review of data on the Economist Intelligence Unit Democracy Index  and the Ibrahim Index of African governance .
The weak governance and leadership in health development might explain why many countries in Africa are not on track to attain the health MDGs by 2015 [16, 70, 71]. This paper has attempted to review briefly existing governance frameworks and has proposed a modified framework on health development governance with a Health Development Governance Index. It has also suggested possible sources of data for estimating HDGI. The individual health development governance sub-functions indices can aid policy-makers to locate the sources of inadequate governance and then to develop appropriate interventions for ameliorating the situation.
One of the possible reasons for inadequate governance and leadership in health development in Africa is largely because many health leaders and managers, at various levels of national health systems, were never trained to govern and lead. Thus, whereas they may have had very good training on disease prevention and control, their curricula might not have featured training on governance and leadership. Therefore, there may be need to revise the curricula of schools of public health, medical schools, nursing schools and other schools of health sciences in Africa to reflect the recent developments in health systems performance assessment, including leadership and governance. In addition, leadership and governance should feature prominently in the continuing education programmes for medical and public health practitioners which are organized by the national professional associations (e.g. medical and nursing associations).
JMK has a PhD in economics (health economics specialization) from the University of York, UK; MA and BEd in Economics from the University of Nairobi, Kenya; and a Diploma in health economics from the University of Tromso, Norway. DGK holds a MPH from the London School of Hygiene and Tropical Medicine, UK; and a PhD in Public Health from the University of New South Wales, Australia. Currently, JMK works at the World Health Organization, Regional Office for Africa, B.P. 06, Brazzaville, Congo. DGK is CDC/WHO Consultant, P.O. Box 529, Freetown, Sierra Leone.
Household's capacity to pay
Demographic and Health Surveys
The Global Alliance for Vaccines and Immunization
Global Fund to Fight AIDS, Tuberculosis and Malaria
Health development governance
Health Development Governance Index
Health development governance sub-function index
Household expenditure on health
Health fairness in financial contribution
Health knowledge management systems
National health research systems analysis
Information, communication and technology
Leadership Responsibilities index
Living Standards Measurement Study
Millennium Development Goals
Multiple Indicator Cluster Surveys
Medium-term expenditure framework
National economic development plan
National health information system
National health policy
National Health Strategic Plan
Public Expenditure and Financial Accountability
Poverty Reduction Strategy Paper
Technical Working Group
United Nations Development Programme
World Health Organization Regional Office for Africa
- and WHS:
World Health Surveys
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We owe gratitude to the peer reviewers and the IAM Editorial Team for their suggestions that helped to improve the quality of our manuscript.
We are profoundly grateful to Jehovah Jireh for inspiration and sustenance in the entire process of writing this article. We dedicate the article to all the hardworking public health practitioners in Africa who continue to champion the cause of health development, at times, with hardly any formal training in leadership and governance.
This article contains the views of the authors only and does not represent the decisions or the stated policies of either the CDC or the World Health Organization.
The authors declare that they have no competing interests.
JMK and DGK contributed equally to the design, analysis and writing of various sections of the manuscript. Both authors read and approved the final manuscript.
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Kirigia, J.M., Kirigia, D.G. The essence of governance in health development. Int Arch Med 4, 11 (2011). https://doi.org/10.1186/1755-7682-4-11