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Brief analytical summaries or syntheses #22

Governance in the health sector:

a strategy for measuring determinants and performance


Governance in the health sector: a strategy for measuring determiMany different strategies have been proposed to improve the delivery of health care services, from capacity building to establishing new payment mechanisms. Recent attention has also looked at whether improvements in the way health care services are governed could make a difference. These approaches ask which factors, such as rules and institutions, influence the behaviour of the system, its performance and outcomes. The paper proposes specific measures of governance determinants and performance and describes the instruments available to collect and interpret them.


While the term “governance” is increasingly being used to draw attention to a number of factors that affect the quality, effectiveness and reach of social services, no consensus has emerged on definitions, frameworks and, in particular, how it applies to the health sector. This paper draws on existing work from the health sector and broader governance literature to advance the discussion by providing a framework that should be both analytically and operationally useful. Such a framework will also make it possible to assess the usefulness of different measures of governance and identify promising alternatives.

A key difficulty in finding a consensus definition for governance in the health sector is that governance operates at many different levels. Governance can be analyzed at the broadest level in terms of political actors who establish each society’s particular public policies, but it can also be analyzed at the level of particular organizations such as hospitals.

Analysis and results

Three lessons can be drawn from the international literature on governance. First, governance can be measured. While many measures suffer drawbacks, advances in how measurements are made and how they are used (e.g. addressing bias, reporting errors) show that this is still a fruitful endeavor. Second, governance measures can be useful both for advocacy and analysis. Organizations like Transparency International show how creating an index can keep an otherwise vague issue like corruption visible as a public policy issue. At the same time, an extensive research literature is using governance indicators to further our understanding of how different aspects of governance affect a country’s performance. Finally, misuse and misinterpretation of governance measures are common. By recognizing particular errors related to misattribution of causality and considering particular mechanisms to be separable from their context, it should be possible to use these measures more effectively.

Defining governance

In light of these strands of the governance literature, this paper defines governance as the combination of political, social, economic and institutional factors that affect the behaviour of organizations and individuals and influence their performance.

This explicitly requires the identification of which organizations or individuals are the units of analysis and judges governance determinants against their impact. Fully characterizing any given governance determinant requires specifying the distribution of authority, the generation and use of information, and the ways actors are motivated. These concepts allow for the development of measurable governance indicators in the health sector.

Measures of governance performance in public health care provision can be gathered through facility and population surveys. Facility surveys can directly measure certain aspects of governance performance, such as rates of unjustified absenteeism. While population surveys are less direct, they can still elicit information about the performance of health facilities in terms of absenteeism or informal payments. The existing literature contains a manageable number of governance performance measures for public health care provision that could form the basis for a regular process of data collection that is comparable across countries, relevant, valid and reliable.

In contrast, measures of governance determinants are more difficult to choose and collect as these vary significantly across contexts. They are best conceived as hypotheses that require testing: does private ownership of health care services encourage better organizational performance? Does stakeholder participation improve policy-making? Do establishing formal procedures reduce corruption?


After reviewing the many ways governance has been used and studied, this paper argues for defining governance as the combination of political, social, economic and institutional factors that affect the behavior of organizations and individuals and influence their performance. Using this concept in applied research in the health sector requires a clarification of which organizations are the subject of analysis (e.g. health insurers, public health services, regulatory agencies) and how their performance is measured (e.g. what are their missions in terms of service provision or health outcomes). It also requires distinguishing governance determinants, such as ownership, decentralization, formal procedures and stakeholder participation, from governance performance (e.g. whether formal procedures are implemented, workers fulfill their responsibilities, or stakeholders have substantive input into decision processes).

Implications and recommendations

An eventual strategy could involve initiating a process of measuring governance determinants in the health sector and creating a large cross-country database.  These studies could be accomplished through a research process similar to that used in systematic reviews, one that clearly identifies the question about governance that is being asked, establishing quality criteria for data and evaluating results. This would make it possible to generate the type of evidence that decision-makers are looking for when trying to figure out how health services can be improved through better health care governance.

While it is possible to initiate a process of measuring governance determinants in the health sector and creating a large cross-country database, this paper argues instead for researching governance determinants with case studies followed by synthetic reviews. In this way, it is hoped that the advantages of case-study research can be emphasized while reaping the benefits of cross-country evidence in a synthetic review process.


Governance in the Health Sector - A Strategy for Measuring Determinants and Performance