Governance in healthcare

Abstract

Jan. www.cgdev.org/content/ publications/detail/5967 Institutions and governance are critical to sound economic policies, income growth and development. To achieve the UN's Millennium Development Goals (MDG) of raising global living standards, governments in developing nations have invested heavily in education and health. However, poor governance and corruption impede achievement of MDG goals. Healthcare systems differ from one region to another. Therefore it is difficult to develop a single measure to assess quality. We have to rely on gross indirect measures such as life expectancy, mortality rates, spending levels, etc. In developing countries, even such data are often limited. Moreover, governments often fail to implement public policy to assure efficient delivery and adequate distribution of health resources. Many factors distort healthcare markets. The consumers (patients) cannot adequately assess the quality and appropriateness of their care. The poor and the uninsured, in particular, are generally sicker, most in need of care and have to rely on government-funded institutions. They are also the least able to voice their disaffection with public healthcare systems. Public healthcare systems involve capital (infrastructure, equipment, etc), labour (medical staff) and governance. Changes in capital and labour influence outcomes but governance can blunt or enhance the effects of the two. Measures to assess the performance of public systems, such as staff productivity, availability of drugs and supplies, condition of the physical structures and equipment, comprehensive medical records, etc, would allow us to evaluate efficiency and quality. Such data are simply not collected in developing countries. Governance in healthcare delivery Corruption reflects poor governance and can be used as one proxy measure. Good governance includes the capacity of governments to formulate and implement sound policies, manage resources and provide services efficiently; the process that allows citizens to select, hold accountable, monitor and replace governments; and the respect of government and citizens for the institutions that govern economic and social interaction. Measures of good governance include voice and accountability; political stability and lack of violence; government effectiveness; regulatory quality; rule of law; and control of corruption. Voice and accountability reflect the degree to which citizens can influence government decisions and be involved in decisions and oversight of healthcare services. Government effectiveness includes efficiency of the bureaucracy, roles and responsibilities of local and regional governments, the administrative and technical skills of the government, effectiveness of policy and programme formulation, governing capacity, and effective use of resources. Corruption can be defined as "use of public office for private gains." Control of corruption includes limiting the extent and nature of corruption among public officials, tracking the incidence of nepotism, cronyism and bribes among civil servants, irregularities in public purchasing and oversight, and the nature and extent to which governments manage corruption. Correlates of poor governance and public healthcare across countries Many investigators have shown a correlation between corruption indicators and child and infant mortality, immunisation, etc, even after controlling for mothers' education, healthcare spending and urbanisation. Thus, under-5 mortality has been shown to improve with additional funding only with good governance and low corruption. Therefore, improved per capita income is unlikely to improve public health indices unless it is accompanied by good governance. Corruption in public healthcare systems As corruption does not lend itself to straightforward data collection, perceptions of corruption provide the basis for assessing governance. In corruption surveys in 23 countries, health ranked amongst the top four in half the countries surveyed. Lack of transparency, accountability and monopoly were cited as the main reasons. In Uganda, for example, leakage of high demand drugs (eg anti-malarials) in public clinics was found to be as high as 94 per cent. In China, about 30 per cent of public drug supplies are expired or counterfeit. The constant need for drugs and supplies creates opportunities for petty theft. Misuse of funds often occurs in the process of tendering and payment. The contracting process for construction and the purchase of supplies is a rich source for kickbacks, over-invoicing or outright graft. seLeCteD sUMMARY Governance in healthcare