Governance in Healthcare: Accountability as a Key Element in a Wide Range of Reforms

Governance has been defined in various ways. Other definitions include politics, public administration, its interaction with civil society and the private sector, and the impact of various institutions on socioeconomic outcomes. This definition includes many functions, activities, and interventions that apply and span all sectors.

Development agencies with health systems programs often have a governance component as well, and most health systems strategies include some activities and objectives of governance and leadership. These programs tend to treat governance interventions as 'means to an end for the achievement of health system goals, including UHC goals. Various programs and technical advice on health systems are addressed as “tight” governance of health financial institutions and health services institutions, including informal payments and corruption among service providers. Agencies that participate in sector approaches to the health sector and support the use of governance systems to manage their health development assistance often support activities and objectives within the broad definition of governance, with a particular focus on the development of government capacities and executive responsibility. lies in the branch of government and the public function. DFID, SIDA, Netherlands, AusAID, EU, and the World Bank often offer support in the administration and management of the public sector in these contexts.

Corruption reflects poor governance and can be used as an indirect measure. Good governance includes the ability of governments to formulate and implement sound policies, manage resources, and deliver services effectively; A process that allows citizens to elect, hold accountable, monitor, and change governments; And respect to the government and citizens for the institutions that govern economic and social interaction. Good governance measures include voice and responsibility, lack of political stability and violence, government effectiveness, rules of the law, etc. Voice and accountability reflect the degree to which citizens can influence government decisions and participate in the decisions and oversight of health care services. Government effectiveness includes the efficiency of the bureaucracy, the roles and responsibilities of local and regional governments, the administrative and technical expertise of the government, the effectiveness of policy and program development, management capacity, and the effective use of resources. Controlling corruption includes limiting the scope and nature of corruption in public officials, monitoring the incidence of nepotism, fanaticism, and bribery among public officials, irregularities in public procurement and oversight, and the nature and the degree to which the government manages corruption.

Many researchers have linked correlations between maternal education, health care costs, and the management of urbanization, as well as indications of child mortality, vaccines, and so on. Therefore, the mortality rate under the age of 5 has been improved only through good governance and additional financial support through less corruption. Therefore, an increase in per capita income is unlikely to improve the health indicator unless it is well-governed.

Governance is becoming increasingly important in international development, especially as the movement for 'good governance' in international aid continues. The World Bank has played a key role in putting the government on the development agenda, introducing the concept of 'good governance' to sustainable development in sub-Saharan Africa. The report called on donor countries to be 'elected' and to support countries with a 'good political environment'. In many ways, governance is used as a policy tool in international development, although it is often denied. With regard to health, the rule was introduced in the World Health Report in 2000 emphasis was on the need for a strategic policy framework. That the health system can be affected by transparent principles governed by effective monitoring and strong accountability. More recently, the governance of the health system has been described as a 'combination of basic values such as equality and transparency within the political system in which the health system operates.' As the health system and the delivery of health services have accelerated over the past few decades, governance has become increasingly important. Leading international development partners have identified governance as the 'most important factor' in tackling poverty and development.

Effective management has a strong foundation for decision-making, resource allocation, and prioritization that can create storms and unpredictable weather. Just as it is unwise to invest in high-end completion in a home with a very weak foundation to protect them, healthcare leaders should not manage around priorities to ensure that It is successfully implemented. The structure of governance will not be the same. However, with the right leadership, understanding of system-wide goals, appropriate rewards for working towards betterment, and strategic priorities, organizations can build the infrastructure needed to succeed in improving performance results.

A framework for reviewing health system governance (HSG) at the national and sub-national levels, which has been implemented in Eastern Mediterranean countries. When developing the HSG framework, the role of the state in the marketplace was also considered. The role of the Ministry of Health in relation to other government ministries. The role of actors in governance. Static vs. Dynamic Health System and health reform vs. human rights approach to health.

Four existing framework requirements were considered:

  • World Health Organization Responsibility Areas
  • The key role of the Pan American Health Organization (PAHO) in public health
  • World Bank's six basic aspects of governance
  • United Nations Development Programme (UNDP) principles of good governance.

The proposed HSG assessment framework includes the following 10 principles: Strategic Vision, Partnership and Consensus, Rule of Law, Transparency, Response, Equality and Inclusion, Effectiveness and Competence, Accountability, Intelligence and Information, and Ethics. The framework enables HSG to diagnose diseases at the political and operational level and identifies steps to improve them. In the case of Pakistan, where the framework was applied, a positive aspect was the increase in stakeholder participation and consensus, while weaknesses in strategic vision, accountability, transparency, effectiveness and efficiency, and rule of law were identified. When using the HSG framework, it must be acknowledged that principles are value-based and non-principled and must be viewed in a social and political context. This framework is based on a standard approach and does not follow any evaluation or rating system.

Accountability in Healthcare:

Accountability has become a major health care issue. Accountability includes the procedures and processes that parties use to justify and take responsibility for their activities. The concept of accountability has three main components. 

  1. Place of Accountability-Healthcare consists of at least 11 different parties who may be held liable or who can hold others accountable. 
  2. Areas of Accountability- In healthcare, parties may be held liable for up to six activities: professional competence, legal and ethical conduct, financial performance, adequacy of access, and public health. Promotion and non-profit. 
  3. Accountability procedures, including formal and informal procedures for assessing domain compliance and disseminating assessments and responses from responsible persons. 

Different models of accountability emphasize different areas, metrics, locations, and procedures. We characterize and compare three major models of accountability. 

  1. A professional model in which individual doctors and patients participate in co-determination and doctors are responsible for their professional colleagues and patients. 
  2. The healthcare market and the economic model in which accountability works are mediated by the consumer choice of the provider. 
  3. A policy model in which doctors and patients interact as citizen members of the community and the doctor is responsible for the board of directors elected from among the members of the community, such as the board of managed care plans. 

We argue that a single model of accountability for healthcare is not appropriate. Instead, advocate a stratified accountability model in which the professional model governs the doctor-patient relationship, the political model operates within managed care plans and other integrated health care networks, and economic and political models work in relationships between managed care plans and other groups Such as employers, government and professional associations.

Thus, the medical system accountability system provides a clear definition of missions in the form of specific goals and objectives, attribution of these missions to trained providers or organizations, and incentives to support relationships, and accountability improvements. We face many design challenges. The objectives relate to complex production functions (integration of care, care for multiple chronic diseases, improvement of the health of the population) and direct a wide range of capacities and knowledge on the part of government bodies and providers. And the ability to work together to improve care and service.

Although the responsibility to improve the health system is challenging and important, we do not have systematic research with this issue. Research in Ontario Healthcare System documents how a research paper has structured accountability towards various sectors and organizations. This collection of papers is invaluable, as it is the first to provide a detailed account of how accountability governance systems have been developed and designed (such as the hospital sector, the long-term care sector, and public health). In addition to the richness of the landscape description of accountability in the health system, this set of papers raises important issues around the subject of accountability. First, it shows that responsibility is still in its infancy - providers or organizations do not want to be held accountable or the governing bodies do not want to hold them accountable, but to establish appropriate mechanisms for identifying and accounting for the right goals. Using health resources is a complex task. Second, these papers mostly deal with their silos with an obligation regime within the current boundaries of the system. It says almost nothing about the challenges and promises of developing accountability systems in the context of networks or programs that go beyond current business or organizational boundaries. Ultimately, the collection of these papers refers only to the question of financial incentives, which appears to be a major verbally used question that the Board of Governors uses to influence the behavior of healthcare providers and achieve their goals.

Strategies that increase accountability can focus on reducing misuse, ensuring adherence to processes/standards, and improving performance/learning. In practice, efforts to increase accountability are likely to involve more than one of them. Reducing abuse is a pillar that supports the 'default' strategy and the other two goals; It focuses on the prevention of fraud, abuse, and corruption. The strategies for compliance with the procedures/standards include regulatory, supervisory, monitoring, and reporting requirements. Sources of sanctions include the country's legal framework and judicial system, administrative rules and operating procedures, markets and quasi-markets, professional standards and ethics, licensing and recognition, and socio-political values. Strategies for executive summary xiii often include better performance/learning: clarifying chains of responsibility and more precisely determining who is responsible for what, so that roles are more direct and timelier, to respond. Shortening and/or making more powerful chains to lift. The incentive for responsive performance. Strategies can select goals at three levels: health system, facility, and/or individual service provider.

All healthcare systems include different types of accountability and work with different degrees of success. For example, the Ministry of Health, insurance agencies, public and private providers, Congress, Treasury, regulators, and service establishment committees are all control, oversight, cooperation, and reporting networks. Often, the driving force behind change is the perception of failure or inadequate responsibility. This puts accountability at the forefront of improving the current healthcare system. There is a widespread need for stronger accountability to address the weaknesses of the global health system.

As many observers note, there are numerous challenges in the health sector in achieving these accountability goals. These include: Strengthening the relationship between healthcare providers, consumers, and regulators in terms of access to information, skills, and services. With regard to the information, central regulators may have difficulty monitoring suppliers' performance as providers often overlook the information required. In terms of access, providers can use the powers of key gatekeepers, for example, to find out who is receiving care despite official procedures. Health care providers, especially poor Individuals are vulnerable to this power. Second, there are often differences between public and private interests and privileges that can limit accountability efforts. Third, institutional capacity differences often limit or weaken efforts to increase accountability for all three purposes. Monitoring of healthcare facilities, budget, fee collection, purchase of drugs and equipment, vehicles and equipment, etc., and their lack of reporting would limit their ability and accountability for safety purposes. Is. It destroys the health system and can create fertile ground for corruption. In addition, the facility's poor ability to monitor performance and practitioners' performance aims to improve accountability are hampered. This capacity gap has been widened by the difficulty of isolating the participation of different healthcare actors in achieving performance goals.

It is clear that the Ministry of Health of the State (MOH) is indirectly central to accountability, both in terms of accountability for healthcare providers and accountability to other government agencies. To the citizens. MOH can manage many other parties. Healthcare providers in the public sector at various levels (central, regional, local). Private sector healthcare providers through monitoring and enforcement. Budget, logistics, facility, and equipment management unit. Purchase and contract of entities. Policy, planning, regulation, and quality assurance features. Etc. This broad supervisory obligation is often accompanied by severe penalties. Ability to hire, dismiss, and promote. The right to grant or terminate a contract. Authority to set and enforce policies, regulations, and performance standards. In many countries, MOH's ability to fulfill this mission is limited, and as a result, health system reforms may strengthen the organizational systems and procedures necessary for MOH to effectively perform its functions. Often the focus is on construction. Separating payments from service delivery, especially for the decentralization of responsibilities and functions best performed by other parties. For example, who’s management concept identifies accountability as one of the key areas of an effective healthcare system and MOH's primary responsibilities as key decision-makers and supervisors of the healthcare system.

Non-government actors are increasingly playing an important role in empowering the health sector. The reasons are varied: an increase in contracting for the delivery of health services, an increase in the number of public-private partnerships, and the involvement of NGOs in political networks. When NGOs are engaged in service delivery, the main focus is on financial responsibility and performance. Cross-sectoral service delivery adjustment creates ambiguity and potential conflict for responsibility, as it is difficult to know which artists are ultimately responsible for service level, quality, and results. One of the main sources of ambiguity is whether NGOs should be more accountable for service funding (i.e., for the government), or more accountable for service users (citizens). Democratic/political responsibility takes precedence when NGOs are engaged in monitoring the activities or representing the interests of their constituents/members through lobbying and advocacy activities. This raises questions about the representation and legitimacy of these actors in terms of their actors/members and the legitimacy of their actions assumed by the government. It also creates confusion in liability relationships because NGOs often provide services through grants or agreements with public agencies simultaneously and are involved in advocacy on behalf of constituents and service recipients.

To conclude, greater accountability is a key element in a wide range of reforms, from countrywide anti-corruption campaigns to national health reform programs, decentralized local health care delivery, and community health funds. One of the main reasons for the widening of this range has to do with the relationship between different types and objectives of accountability. The accountability landscape is filled with a wide range of actors with many connections; In some cases, these actors are accountable to the actors of one group while at the same time being accountable to the other group. These links form a multilevel network of accountability with varying degrees of autonomy and sources of control/monitoring. This leads to problems of interference strategy such as advantages or disadvantages of strengthening various nodes in the network. For example, if the Health Minister is not politically accountable, efforts to increase the authority and autonomy of hospital councils may be ineffective, sacking council members who are unhappy with them. 

01 August 2022
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