Enhancing Health System Governance


In the 21st century, global health is profoundly influenced by the dynamic interactions of biological and socio-political systems at large. The health outcomes are affected by a nexus of intersecting global challenges ranging from emerging endemics or pandemics, migration, climate change, migration and displacement to environmental degradation and globalisation. 

Policymakers and planners are still facing challenges to address the unmet health care needs of people who are poor, marginalised and vulnerable in the developing countries. For a health system to be well functional, it should have adequate trained and motivated human resources, good health infrastructure, a reliable supply of medicines and technologies, funding and evidence-based policies and plans to address public health threats such as the COVID-19 pandemic and other health emergencies. 

Priority agenda

Therefore, strengthening health system governance is a high priority agenda as it aims to address the ways in which health care is regulated, financed and delivered in the federal context. While attempts are made to ensure health equity and universal access to health care through multi-sector engagement and partnership, more consistent efforts are still needed to further advance evidence-based health agenda, wider social determinants of health, reforming regulation, funding and health care delivery at all levels.  

The National Health Policy-2019 and Nepal Health Sector Strategic Plan (2022-2030) aim to sufficiently lay out the national context, vision, objectives and spending priorities for health within the country's broader development context. They provide an important guidance for health institutions in delivering health outcomes which ultimately contribute to achieving health related Sustainable Development Goals (SDGs). However, health financing is particularly critical to effectively implement the health policy and strategic plan, and support the progress towards the universal health coverage and health related SDGs. 

Over the years, Nepal has experienced a new model of federal health system. This system largely aims to advance multi-sector coordination, leadership and inclusive governance that involve strategic policy frameworks for effective oversight, regulation, and social accountability at all levels. Considering the conventional health governance models, the linkages between health service providers and citizens should be further strengthened and scaled up to improve health system performance at local level.

The key priorities for strengthening health system governance are mainly to ensure evidence-based planning and effective implementation of health policies, strategies, and quality health service delivery. For this, it is essential to enhance the institutional capacity of local governments in participatory planning, implementation, monitoring and evaluation of basic health services. In addition, technical supervision and monitoring support from the federal and provincial health authorities is extremely important to implement the existing national guidelines, strategic frameworks, and tools for effective delivery of basic health services at the local level. 

Apart from this, the role and capacity of local governments need to be further enhanced for multi-sector engagement and partnerships. In this context, multi-sector coordination platforms need to be strengthened for joint planning and resource mobilisation at all levels. Harnessing public private partnership approach is a unique opportunity to ensure effective delivery of quality health services for better health outcomes. 

Additionally, the role of development partners, UN agencies, civil society organisations, private sector, and academia is crucial to strengthen the health system governance by supporting government’s efforts of improving health sector performance at all levels. Moreover, existing policy and strategic frameworks for health system development include a range of conventions, norms, provisions, socio-political dynamics, cultural traditions, funding landscape and other relevant mechanisms which have profound impacts on governance architecture and health system performance.

However, there are growing public demands for easy access to and use of new technologies, new medications and new models of care, as well as expectations of quality care. Therefore, existing models of health care delivery should be broadly people-centred and continued in an uninterrupted and coordinated way so that health care needs are adequately addressed and monitored across populations. 

In the federal context, governments, development partners and civil society are concerned about the needs of ensuring health policies which are more evidence-informed, intersectoral, and inclusive at all levels. More importantly, there are critical needs of enhancing social accountability and monitoring of health system performance at large. 

Health in all policies is a popular public policy approach that aims to increase the recognition of health and action on health, health determinants, and health equity across all sectors. However, there are limited efforts of implementing this approach which seeks to ensure synergies across relevant sectors for health equity. Therefore, it is necessary to harness the power of several institutional structures, mechanisms, and processes of health planning at all levels.  

Coherent legislation

Nepal has recently developed Health Financing Strategy (2021-2030) that largely aims to broaden the fiscal space as well as develop robust health financing systems to mobilise resources more effectively and efficiently. In this context, there is a need to ensure coherent and realistic health legislation, policies, strategies and plans, with strong links between federal, provincial and local governments for effective implementation.

In the recent years, e-Health is the most cost-effective use of information and communication technologies (ICT) that includes multiple interventions, including telehealth, telemedicine, mobile health (mHealth), electronic medical or health records and even artificial intelligence. While there are increasing needs to strengthen integrated health information systems at all levels, more emphasis is needed to enhance the institutional capacity for digital health governance, improve data quality, and generate reliable evidences for policy making.   

(PhD in global health, Bhandari writes on health and development issues. talk2jhabindra@gmail.com)

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