Addressing Governance Challenges and Capacities in ...

AddressingGovernance Challenges and Capacities in Ministries of HealthAUTHORS: VEENA SRIRAM, KABIR SHEIKH, AGNES SOUCAT,

MARYAM BIGDELI

EDITOR: SANDY CAMPBELL

Addressing governance challenges and capacities in Ministries of Health/Veena Sriram, Kabir Sheikh, Agnes

Soucat, Maryam Bigdeli

ISBN 978-92-4-000541-9 (electronic version)

ISBN 978-92-4-000542-6 (print version)

© World Health Organization 2020

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ContentsAcknowledgements��iv

Introduction: Governance and the Ministry of Health ��1A Timeline of Change ............................................................................................................ 2Governance ...............................................................................................................................3Capacities ...................................................................................................................................4

1 MoH Governance: Definitions and Issues ��71.1 What do we mean by “governance”? ....................................................................81.2 In what ways does “governance” apply to an MoH? ........................................81.3 What are four major roles of MoH governance? ................................................9

2 MoH Capacity: Definitions and Issues �� 132.1 What do we mean by “capacity”? ......................................................................... 142.2 What governance capacities does an MoH require? .......................................15

3 The Governance and Capacity of a Ministry of Health: Country Examples �� 193.1 Around the world, what are the major challenges for MoH

governance capacities? ............................................................................................ 203.2 What are some specific governance roles for an MoH? ...............................253.3 How can an MoH uphold governance principles while ensuring

wide stakeholder participation? ............................................................................ 303.4 How can an MoH effectively manage governance relationships? ..............31

4 Strengthening MoH Governance Capacities: Examples ��374.1 Strategic planning and policy development. ................................................... 384.2 Procurement. ................................................................................................................ 384.3 Human and financial resource management. ................................................... 394.4 Evidence usage. ........................................................................................................... 394.5 Regulation...................................................................................................................... 394.6 Reform. ...........................................................................................................................404.7 Values. .............................................................................................................................404.8 Managing relationships. ............................................................................................40

5 Strengthening Governance Capacities: Observations and Recommendations �� 43Summary .................................................................................................................................44Lessons learned ....................................................................................................................44Recommendations ............................................................................................................... 45

References �� 47

IIIA D D R E S S I N G G OV E R N A N C E C H A L L E N G E S A N D C A PAC I T I E S I N M I N I ST R I E S O F H E A LT H 2 0 1 8 - 2 0 1 9

AcknowledgementsOur thanks to Benjamin Rouffy, Godelieve Van Heteren and Benjamin Lane with the

Health Systems Governance Collaborative for their leadership of the project, and the

members of the Core Group of the Collaborative for their feedback at various points

in the project. We are also grateful to the reviewers of the report for their constructive

feedback and suggestions. We also thank the Universal Health Coverage Partnership for

funding this work.

IV

Introduction: Governance and

the Ministry of Health

In addressing the big societal challenges of today – from containing communicable

diseases to offering health services at all levels – how equipped is a Ministry of

Health (MoH) to govern? This question occupies many health authorities around the

world. National health authorities occupy a central role in health system governance.

As Ministries or Departments of Health, these authorities have a unique mandate

over population health, charged with ensuring the health and wellness of millions.1

What kinds of capacities does an MoH require to govern responsibly and effectively?

How can we better understand the terms “governance” and “capacity” as applied to an

MoH? What are some strong country examples from which we can collectively learn?

And how can we better assess the ways in which an MoH changes and adapts to very

dynamic context?


In recent decades, the role of an MoH has shifted from that of funder and provider to

more of a steward of the entire health system. While states have always been tasked

with various degrees of “oversight,” current oversight measures for an ever-more

complex health sector require a distinctly outward-looking and inclusive multisectoral

approach to governance, and being better equipped to address increasingly pluralistic

systems [1, 2]. Notably, an MoH today often does not hold exclusive authority over

health, sharing that responsibility with sub-national actors – such as provinces, states

and districts – with supra-national actors – including global foundations and multi-

laterals – with legally empowered agencies, councils and institutions charged with

particular governance functions, and with citizens [3, 4]. Surrounding all these actors

are broader networks and structures that can include other parts of government, civil

society, researchers, professional groups, the private sector, including health sector

stakeholders and other industries, donors, and regional and international bodies.

Clearly, the governance context for any MoH has become highly complex and dynamic.

Many different actors – in some cases already part of the governance structure – now

advance their own interests. Particularly in low- and middle-income countries (LMICs),

1 Note that throughout this Working Paper, we will use the generic term “Ministry of Health” or “MoH” as a proxy for the major national health authority in any country, no matter its correct designation.

1A D D R E S S I N G G OV E R N A N C E C H A L L E N G E S A N D C A PAC I T I E S I N M I N I ST R I E S O F H E A LT H 2 0 1 8 - 2 0 1 9

a lack of resources may compound the complexity, as do the weight of other line

ministries exerting their own influence, or bureaucratic structures that may prove slow in

adapting to the fast-changing, modern environment [5].

The governance context for a modern MoH has become highly complex – and continually shifting.

In this WHO Working Paper, we seek to understand and illustrate this interplay between

governance and capacity in Ministries of Health across the world.

A TIMELINE OF CHANGE

As illustrated in Table One to the right, various pressures have combined to push and pull

on MoH governance abilities and capacities for decades. In most LMICs, MoHs emerged

from colonial systems and were often reconfigured in these newly independent states.

MoHs have also been shaped by global trends and milestones; for example, the Alma

Ata Declaration helped expand efforts around primary care and social determinants of

health. However, these trends were met with emerging fiscal constraints in the 1970s

and 1980s, which often squeezed MoH budgets [1, 6]. Other political, administrative

and/or fiscal reforms from the 1980s and 1990s onwards (e.g. diversifying purchasing

and provision of health services, decentralization measures) created new management

and organizational structures in Ministries, in many cases implemented without related

capacity-building efforts [1]. Furthermore, the rapid rise of market-based approaches

to health services in the last few decades has presented new oversight and regulation

challenges [7].

From the 2000s onwards, following increased global attention to health inequities

(for instance in the context of the Millennium Development Goals), Ministries engaged

with new stakeholders. This included new philanthropic foundations, private sector

corporations, new bilateral and multi-lateral agencies, plus a more diverse set of

international NGOs [5]. A cross-sectoral, “Health in All Policies” approach was

adopted [5]. And an increased focus on Universal Health Coverage – as reflected in the

Sustainable Development Goals [8] – supported calls for deeper systems thinking as part

of health systems strengthening [9] and demands for MoHs to actively engage citizen

voice across the health system [4].

2

Table 1. Historical context of evolving role of Ministries of Health

Timeframe Contextual factors in LMICs

1900s – 1980s Postcolonial reconfiguration of Ministries of Health in low- and

middle-income countries

1970s – 1980s Fiscal restraint imposed in response to economic crises, structural

adjustment programs etc.

1978 Alma Ata Declaration expands focus on primary health care, health

as a human right, and social determinants of health

1980s – 1990s Transition to multi-party democratic structures in some LMICs

trigger core MoH changes (e.g. expanded stakeholders, enhanced

role of sub-national actors, etc.)

1990s – Focus on health sector and/or civil service reform leads to staff

reduction, introduction of new forms of recruitment and pay,

and to decentralization

1990s – World Development Report highlights new reforms, including

purchaser- provider split; development of the sector wide

approach (SWAp)

2000 – 2015 Millennium Development Goals increase momentum for countries

to achieve targets in maternal and child health and certain

communicable diseases; World Health Report (2000) on health

system performance highlights the “stewardship” function of MoHs

2012 – Increased focus on Health in All Policies approach

requires Ministries of Health to take an active approach in

inter-sectoral coordination

2016 – Sustainable Development Goals promote a Universal Health

Coverage (UHC) and multisectoral action

Sources: [1, 2, 5, 6, 8]

As we see in this timeline, for an MoH the backdrop, the actors, the issues are all

continually changing. But what does this imply for an MoH’s capacities to govern?

Where does its governance remit begin and end? And – what exactly do we mean by

“governance” and “capacity”?

Where does governance begin and end for a Ministry of Health?

GOVERNANCE

Definitions of “governance” vary widely [10, 11]. The WHO has advanced its own

definition of “governance” as linked with leadership and stewardship, and focuses

on policy frameworks, harmonization, alignment, oversight and regulation [12].

Similarly, other approaches outline the responsibilities and tasks an MoH is expected

to fulfill, including strategic planning, policy development, coordination, convening

of stakeholders, regulation, performance, quality and equity assessment, monitoring

and evaluation, audit and inspection [5]. Beyond this, public policy and public

administration understandings of “governance” emphasize participation, transparency,

fairness and trust-building [11]. Emerging from this are governance needs that include


addressing corruption, failures of implementation, economic or ecological catastrophes,

the priorities of development partners – and managing those external priorities,

especially in an emergency setting.

CAPACITIES

Given these considerations, how do existing MoH capacities translate into specific

governance roles? Which capacities exist, which need strengthening, and which are

missing? In this WHO Working Paper, we explore different types of capacity and show

how each critically influences an MoH’s ability to govern. Importantly, this paper focuses

on organizational and individual capacities – and uses this lens to understand four key

governance roles, including how an MoH is equipped to perform its de jure governance

role; how an MoH can respond to changing contexts; how an MoH can manage

stakeholder relationships; and how an MoH can best uphold governance principles,

such as accountability and transparency.

Informed by a comprehensive scoping review [13], Section I of this paper asks: what

do we mean by “governance”? And in what ways does an MoH actually exercise its

governance responsibilities? In Section II we ask, what do we mean by “capacity”?

What capacities are required for an MoH to exercise its governance roles? How can we

“load” MoH capacity with governance roles to understand the strengths and challenges

for any MoH?

How do existing Ministry of Health capacities translate into specific governance roles? Which capacities exist, which need strengthening, and which are missing?

In Section III, we apply these questions to countries around the world. How have

MoHs demonstrated – or failed to demonstrate – capacity for governance, in varied

contexts and along different roles? What initiatives have strengthened MoH governance

capacities? Where does future work lie? We provide some examples of strengthening

governance capacities in Section IV and we conclude in Section V with some

observations, recommendations and thoughts on what comes next.

Our exercise has initially focused on low-and middle-income countries but carries

insights for all health authorities globally.

4

Section IMoH Governance:

Definitions and Issues7A D D R E S S I N G G OV E R N A N C E C H A L L E N G E S A N D C A PAC I T I E S I N M I N I ST R I E S O F H E A LT H 2 0 1 8 - 2 0 1 9

This section introduces some key concepts around “governance”. The term is

multifaceted, so what exactly do we mean by “governance”? And given the rapidly

shifting environment – globally, nationally and locally – in what ways does an MoH

actually interpret and exercise its governance responsibilities?

1.1 WHAT DO WE MEAN BY “GOVERNANCE”?

Generally, “governance” refers to accountability, representation, stewardship, ownership,

power, authority and the rule of law. It encompasses a “set of processes (customs,

policies or laws) that are formally or informally applied to distribute responsibility or

accountability among actors of a given [health] system” [10]. The WHO definition pairs

governance with leadership and stewardship, and stating that it involves “ensuring

strategic policy frameworks exist and are combined with effective oversight, coalition

building, regulation, attention to system-design and accountability” [12]. These

processes or rules “can be both formal, embodied in institutions (e.g., democratic

elections, parliaments, courts, sectoral ministries), and informal, reflected in behavioral

patterns (e.g. trust, reciprocity, civic-mindedness)” [14]. Importantly, governance implies

the transfer of “some decision-making responsibility from individuals to a governing

entity, with implementation by one or more institutions, and with accountability

mechanisms to monitor and assure progress on the decisions made” [15].

1.2 IN WHAT WAYS DOES “GOVERNANCE” APPLY TO AN MOH?

An MoH is typically mandated to “steer” health policy by regulating and monitoring

health functions in both public and private sectors, and in some cases, directly managing

health service delivery [16]. Ministries typically undertake an array of de jure roles,

including the formulation of a strategic vision for health, the balancing of centralized

and decentralized authority for decision-making, the management and implementation

of policies, programs and interventions, regulation and oversight, and monitoring

and evaluation, notably of performance, quality and equity [1]. As part of a broader

government system, Ministries engage with political leadership, other line ministries,

legislative bodies, sub-national state actors and political parties.

In recent decades, “governance” has evolved from being a state-centered concept to

one that is collaborative [2], with shared responsibilities across a range of actors at

multiple levels and various sectors. The increasingly complex challenges that society

faces demand that the state reach across boundaries, and become more inclusive,

strategic and agile in its approach [4].

Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system-design and accountability [12].

8 M o H G o ve r n a n c e : D e f i n i t i o n s a n d I s s u e s

1.3 WHAT ARE FOUR MAJOR ROLES OF MOH GOVERNANCE?

In this section, we explore four major roles of MoH governance:

• De jure governance processes;

• Preparation for and response to change in context;

• Relationship management; and

• Values management.

Role 1: “De jure” governance processes�

MoHs have certain de jure (by right, or based on laws and actions of the state)

governance roles pertaining to health [10, 16]. Over the last few decades, driven by

various factors, the focus of MoHs has shifted from service delivery to an emphasis on

stewardship, including policy development, strategic direction and oversight [1, 17, 18, 19].

Additional roles include citizen empowerment and responsiveness to needs; evidence

and knowledge management; resource management, including fundraising and financial

management; contracting and compliance; procurement and supplies management;

and quality, equity and performance monitoring. How effectively a Ministry can

implement its de jure governance responsibilities is a key performance area for any MoH.

Role 2: Preparation for and response to changes in context�

An MoH is increasingly required to prepare for and respond to fast-moving contexts

– within government and across society [2, 10]. Examples of changing contexts

include epidemiological shifts, crises, income inequality, urbanization, globalization,

the marketization of health, climate change, and the rise of citizens and consumers as

active participants in health sector governance [4, 16]. The speed and predictability of

these factors might also vary considerably, necessitating short-, medium- and long-term

perspectives to the response. This demands absorptive, adaptive and transformative

capacities when responding to rapidly changing contexts, as seen, for instance, during

the 2014 Ebola outbreak in West Africa [20] and illustrated in Figure 1 below.

An MoH is also a political actor, and as such is subject to sudden political shifts – not

only locally and nationally, but also globally, demanding Ministries engage with an

ever-wider range of actors [4]. The nature of reform in the health sector is also highly

context-specific, and dependent on the intersection of global, national and local actors

and trends. How swiftly and effectively an MoH can respond to the shifting context

underlines its resilience, relevance – and of course its capacity.


Figure 1. Ministry of Health Governance Roles and Performance Areas

• Policy development• Strategic planning and

prioritization• Regulation and standards

• Contracting and compliance• Promotion of innovation• Citizen empowerment

Implementation of de jure

responsibilities

Performance area

Resilience and relevance

Leadership and diplomacy

Values propagation and alignment

1. “De jure” governance processes

• Governance of systems reform• Crises management• Response to political

transitions• Response to macroeconomic

and social change• Response to global

phenomena

2. Preparation for and response to changes in context

• With the political leadership• With civil society• With the labour force• With the private for-profit

sector• With other ministries and

sector

• With international organizations

• With funders and development partners

• With parastatals and other health sector institutions

3. Relationship Management

• Accountability and transparency processes

• Participatory processes• Eciency processes

4. Values management

Role 3: Relationship management�

Ministries of Health must engage an array of stakeholders in governance, both within and

outside government. From a systems-thinking perspective, Ministries are embedded in

various overlapping systems, often playing a moderating or arbitrating role to manage

all the competing stakeholder interests [14]. For instance, citizen groups might not wield

similar power to that of organized labor. Or private sector actors might have direct

access to executive leadership allowing them to bypass the MoH. In this way, Ministries

must exert their leadership and diplomatic capacities to generate consensus and

manage stakeholder interactions [1].

Role 4: Values management�

In the end, as a governance body, an MoH must adopt and actively manage certain

values or principles [10]. Underlying these norms is the view that a shared approach

to governance, involving “whole of government” and “whole of society,” is preferable

to that of a narrow, overly centralized view of health and health governance [4].

This potentially includes processes that propagate values or principles such as

accountability and transparency, participation and efficiency.

10 M o H G o ve r n a n c e : D e f i n i t i o n s a n d I s s u e s

02

12

Section II MoH Capacity:

Definitions and Issues13A D D R E S S I N G G OV E R N A N C E C H A L L E N G E S A N D C A PAC I T I E S I N M I N I ST R I E S O F H E A LT H 2 0 1 8 - 2 0 1 9

This section explores various definitions and issues surrounding governance “capacity”

of Ministries of Health. This WHO Working Paper focuses on six capacities deemed

crucial in supporting MoH governance roles. Besides these capacities, a range of “soft

capacities” are equally important, as illustrated in Box 1 below.

Box 1: Soft Capacities

While the literature on “soft capacities” is growing [21], these capacities are not specifically included in

this paper. Such capacities include abilities to navigate complexity, to learn collaboratively, to engage

politically, and to be self-reflective and focused on building trust [22, 23]. These capacities “enable different

perspectives to be taken and … seek to better connect individuals to themselves, to others and to their social

environment” [23]. Future research in soft capacities will undoubtedly help make these abstract concepts

more tangible and directly actionable by stakeholders seeking to improve the governance roles of Ministries

of Health.

2.1 WHAT DO WE MEAN BY “CAPACITY”?

Capacity is a dynamic concept referring to both processes and outcomes [22, 24].

At an organizational level, capacity is the ability “to function as a resilient, strategic

and autonomous entity” [25], a combination of “individual competencies, collective

capabilities, assets and relationships that enables a human system to create value” [22].

Capacity is clearly central to health system performance. When applied across a system,

Rodriguez et al (2017) map capacity as individual competencies (e.g. indivudal mindsets,

skills and motivations), organizational competencies (e.g. “structures, practices and

resources” and systemic interactions (e.g. an enabling environment that promotes

stakeholder engagement) [26]. The effective combination of these capacities can greatly

improve health systems performance, and as a result, ensure improved health and social

outcomes. Importantly, this paper focuses primarily on individual and organizational

competencies, leaving systems-level issues for future research for future research.

Capacity includes individual competencies, organizational competencies, and systemic interactions [26].

14 M o H C a p a c i t y : D e f i n i t i o n s a n d I s s u e s

2.2 WHAT GOVERNANCE CAPACITIES DOES AN MOH REQUIRE?

In our current dynamic health settings, what specific capacities does an MoH need to

execute its governance roles effectively. Drawing on a typology developed by Potter

and Brough (2004)1, we present six categories of capacities, further illustrated in

Figure 2 [27].

Figure 2. Governance Roles and Capacities

Performance areaGovernance Roles Governance capacities

MOH capacities for governance framework

Resilience and relevance

Leadership and diplomacy

Values propagation and

alignment

1. “De jure” governance processes

Structural cap

acity

Ro

le capacity

Perso

nal capacity

Wo

rkload

capacity

Perfo

rmance cap

acity

Sup

ervisory cap

acity2. Preparation for and response to changes

in context

3. Relationship Management

4. Values management

Implementationof de jure

responsibilities

2�2�1 Structural Capacity�

Within an MoH, the “governance architecture” should be assessed. Are there,

for instance, appropriate ‘decision-making fora’, organizational flows, structures and

efficiences? [27] Are there relevant committees, task forces and commissions that can

greatly assist Ministries in responding to evolving contexts (e.g. response to disease

outbreak or implementing reform measures)? Task forces, networks, and fora are

also critical for an MoH to successfully manage relationships with other stakeholders,

both within and outside government. To ensure the application of broad governance

principles, participatory, transparent and efficient mechanisms must take root, including

public consultations and performance frameworks with a focus on citizens and

incorporating citizen voice.

2�2�2 Role Capacity�

Does the MoH have the appropriate authority or responsibility to make decisions and

undertake governance roles? “Role capacity” may refer to both formal and informal

ownership of particular decision-making roles and requires that an organization has

sufficient legitimacy and power to undertake those roles. Governments may consider

establishing stand-alone institutions (Ministry-led or multi-sectoral) to oversee and steer

efforts. Ministries might also strengthen their role capacity through legislative efforts

that synchronize or harmonize health sector governance roles, built upon comprehensive

1 Potter and Brough (2004) include three other capacities that were not included in this framework - facility capacity (Are facilities adequately sized, equipped, staffed and diversified to support the workload?), support service capacity (Are there sufficient support services to ensure that tasks may be implemented as required?) and systems capacity (Are there external linkages, such as those with the community and NGOs? Do financial and information systems function efficiently?) [27]. We acknowledge that these types of capacity overlap with those selected for our framework. Readers should also note that the original framework presented a “hierarchy of capacity needs” where capacities were sequenced in order to achieve systemic capacity building.


and clear legal frameworks. These frameworks can also support relationship building

across stakeholders, reinforcing good governance principles at the very center of the

health system, including citizen participation, transparency, integrity and accountability.

2�2�3 Personal Capacity�

Are staff sufficiently knowledgeable, skilled, and confident to perform their assigned

duties? [27] These competencies may be technical, managerial, inter-personal, or involve

other role-related skills. Ministry staff must have the appropriate skills and knowledge

for their positions and must be sufficiently motivated and confident to perform their

tasks. Individual competencies must be understood and targeted through needs

assessments, consensus building, learning by doing, and trial and error – and supported

by an enabling environment. Additional skills essential to managing relationships include

negotiation, conflict resolution, knowledge exchange and consensus building.

2�2�4 Workload Capacity�

Is there sufficient staff to perform the work? Is there an appropriate mix of educational

backgrounds and skills across the MoH workforce? Are there clear, practical job

descriptions with commensurate compensation? To perform its many roles, Ministry staff

must have a diverse and appropriate skillset – and the needed time and space. These

capacities allow staff to appropriately engage with other stakeholders (for example,

Ministries of Finance, professional associations or the public-at-large), and to engage in

negotiations or public relations.

2�2�5 Performance Capacity�

Are the necessary resources – the tools, infrastructure, finances, equipment and

consumables – in place to support MoH staff? MoH staff require the appropriate

physical infrastructure (buildings, rooms, etc.), office infrastructure (desk space,

internet connection, etc.), financial resources to fund salaries and routine activities,

and accessibility to knowledge resources (scientific literature, grey literature, etc.).

Performance capacity may also refer to resources required to manage crises or reforms.

2�2�6 Supervisory capacity�

Are there internal reporting and monitoring systems? [27] Accountability mechanisms?

Supervisory capacity also describes the availability of incentives and sanctions to

facilitate the delivery of functions. Accountability measures – including incentives,

sanctions, and reporting mechanisms – keep an MoH transparent and operating with

integrity. This demands mechanisms for feedback and input, frequent monitoring of

programs, and commissioned independent evaluations – all of which can promote a

learning by doing or a trial and error approach. Mechanisms that allow for external

stakeholders to obtain recourse for decisions, or to hold Ministry staff to account are

also important.

Another aspect of supervisory capacity includes the MoH’s management capacities.

How well do upper-level MoH staff ensure professional outcomes of staff under their

supervision? In which areas does an MoH require stronger supervisory capacity?

16 M o H C a p a c i t y : D e f i n i t i o n s a n d I s s u e s

Figure 3. Six Types of Capacity (Adapted from 27)

6Types of Capacity

Structural capacity

Role capacity

Performance capacity

Workload capacity

Supervisory capacity

Personal capacity

Decision-making fora, organizational flows,

structures and e�ciencies, committees, task forces and

commissions

Necessary resources, including tools,

infrastructure, money, equipment and consumables

to support MoH sta

Formal and informal authority, responsibility and legitimacy to make decisions and undertake governance

Knowledge, skills, motivation and confidence to perform assigned duties

Internal reporting, monitoring and

accountability systems alongside

available incentives and sanctions to

facilitate the delivery of functions.

Su�cient sta with diverse and appropriate skillset to perform the work

Now that we’ve reviewed the key terms of “governance” and “capacity,” including their

different dimensions and applications, we turn in Section Three to an appreciation for

how this interplay has influenced Ministries of Health around the world.


03

18

Section IIIThe Governance and

Capacity of a Ministry of Health: Country

Examples19A D D R E S S I N G G OV E R N A N C E C H A L L E N G E S A N D C A PAC I T I E S I N M I N I ST R I E S O F H E A LT H 2 0 1 8 - 2 0 1 9

In this section, we provide specific country-based examples of major governance and

capacity successes and challenges. In Section 3.1, we explore some of the challenges

created by change, and describe how different countries have responded to those

changes. In Section 3.2, we investigate how the roles for an MoH have shifted over time.

In Section 3.3, we examine how an MoH can uphold governance principles while ensuring

wide and inclusive stakeholder participation? And in Section 3.4, we explore the specific

dynamic of how MoHs have managed governance relationships.

A Note about Methods: The findings in Sections 3 and 4 draw upon a scoping

review [13] that we conducted to understand the governance capacities of Ministries

of Health. We included scientific articles, research or analytic reports, and official

presentations available from 1993 onwards. Our focus was primarily on LMICs, but we

drew upon certain high-income country examples for additional insights. In total,

115 resources were selected for analysis (78 scientific articles and 37 grey literature

resources) [13].

3.1 AROUND THE WORLD, WHAT ARE THE MAJOR CHALLENGES FOR MOH GOVERNANCE CAPACITIES?

MoHs work under rapidly changing contexts. These changes can arise internally (through

reform, crises, political trends and transitions), externally (through global policy shifts,

crises, and macroeconomic trends) – or through a combination of both [28]. Change

poses unique and distinct challenges for a Ministry’s governance responsibilities, for its

governance capacities, and for the long-term development of its capacities. Here,

we review some real-world examples of how change has posed distinct challenges for

the six MoH governance capacities outlined above.

Change poses unique and distinct challenges for a Ministry’s governance responsibilities.

As illustrated below, we address change in various countries in terms of political transitions, crises, reform, macroeconomic trends, global policy trends, and social movements and social change.

3�1�1 Political transitions�

Political transitions arise through the creation of entirely new political systems

(e.g. following conflict, or from military rule to democratic government), new economic

systems (e.g. shifts away from socialist towards market-based economies), or through

elections (e.g. pendulum shifts between ruling political parties). These transitions can

be extremely challenging for an MoH, with the transition sometimes exacerbated by the

relatively low power that institutions (like a line ministry) wield in the government [5].

20 T h e G o ve r n a n c e a n d C a p a c i t y o f a M i n i s t r y o f H e a l t h : C o u n t r y E x a m p l e s

In many parts of the world (e.g. sub-Saharan Africa, central and eastern Europe and

central Asia), the transition towards multi-party democracy in the 1980s and 1990s

brought with it an expanded set of stakeholders, including new political parties,

international donors, and the private sector. In many cases, this created new capacity

challenges for an MoH [18, 29, 30, 31]. In Mozambique, South Africa and Cambodia,

for instance, Walt et al (1999) report on the lack of consensus among civil servants and

new staff brought on by political liberalization directly influenced donor relationships,

which became cautious and even hostile [18].

This expansion of stakeholders following political transition had an immediate impact

on the role capacity of an MoH. For example, in post-socialist Slovenia, Albreht

and Klazinga (2002) report that new legislation made the MoH the primary system

administrator – but with considerable responsibilities devolved to new agencies

(including an independent national health insurance agency and a professional

chamber). This both fragmented and duplicated the MoH’s role and created conflict

between the MoH and the new professional chamber [30]. A variation on this theme

also appeared in Poland, where Sabbaat (1997) details how political transition resulted

in the MoH becoming increasingly fragmented, lacking a binding vision of health for the

country [32].

Post-conflict transitions offer a different set of challenges, often affecting an MoH’s

personal and structural capacities, and its ability to manage stakeholders – especially

external ones [33, 34]. Over 1991 to 1993, for instance, as described in Lanjouw, Macrae

and Zwi (1999), Cambodia had numerous struggles with its donor relationships. Against

the backdrop of a complex and crowded stakeholder environment, the structural

capacity of the MoH was too weak to coordinate the vast sums of aid flowing into

the country [35]. The coordination committees established to help coordinate aid

ultimately led to a focus on donor-prioritized projects, rather than on building MoH

capacity to manage the entire system. Another challenge here was the arguably

deliberate donor under-investment in coordination mechanisms, and the bypassing of

UN-led coordination mechanisms in favour of directly sub-contracting with (the now

proliferating) NGOs [35]. This situation has played out in many other countries as well.

In Siera Leone, Witter et al (2016) show how donor involvement stretched the MoH’s

already limited personal capacity to manage new stakeholder relationships [33].

Post-conflict transitions offer a different set of challenges, often affecting an MoH’s personal and structural capacity.

Interestingly, periods of political transition can also offer unique opportunities to build

MoH capacity. In post-Taliban Afghanistan, as described in Cross et al (2017) and Dalil

et al (2014), the MoH took an early stance on prioritizing its stewardship role – largely

through leading the development of the Basic Package of Health Services, and its

regulation of the private for-profit health sector [36, 37]. In Timor-Leste, Alonso and

Brugha (2006) illustrate how Timorese staff were involved in all decision-making with


the United Nation Transitional Administration for Timor-Leste. Progressive withdrawal

of international staff and timorization were seen as critical for building legitimacy of the

new MoH – despite resistance from international NGOs [38].

3�1�2 Crises�

Crises faced by an MoH are manifold, and can be political, ecological, financial or

epidemiological and/or health security crises. They often create major capacity

challenges. Political instability, as shown in the experience of Pakistan - described in

Ejaz, Shaikh and Rizvi (2011) and Khan (2007) - can contribute to wavering ownership

of policies and programs by successive governments [39, 40]. The low priority given

to health by various military regimes in Pakistan has also led, as in Siddiqi et al (2011),

to resource constraints, further weakening the MoH’s performance capacity, which in

turn deepened dependence on international donors [41]. Successive regimes and the

uneven democratic climate also resulted in non-participatory health policy development

and a vastly weakened structural capacity [41].

Capacity issues also emerge when the MoH is tasked with formulating or implementing

policy that emerges as a result of a political crisis. For example, in Lebanon, El-Jardali

et al (2014) show how a political crisis unrelated to health policy kickstarted health

insurance reforms [42]; and in Ghana, Agyepong and Adjei (2008) illustrate how a

political window caused by crisis also created strong momentum for health insurance

reform [43]. However, in both cases, despite the opportunity crisis created, the MoH

lacked structural and personal capacity to “steer policy in the desired technical

direction” [43].

Examples from sub-Saharan Africa highlight how political unrest can create critical MoH

challenges for its structural, role and workload capacity [44, 45]. As a consequence of

political unrest in Mali from 2012 onward, ties between donors and the MoH became

bifurcated. Two health coordination structures – one for development and one for

humanitarian needs – sowed confusion and directly affected structural capacity;

the competing coordination structures led to divergent planning processes and

timeframes [44]. As donors began to bypass the public system, the MoH lost personal

and workload capacity to coordinate and plan system-wide interventions, with the public

perception of the MoH consequently eroding.

Health crises, such as the 2014-15 Ebola epidemic in West Africa, also highlight

key capacity issues, as reported by Blanchet et al (2017) [20]. Liberia, Guinea and

Sierra Leone all exhibited weak MoH capacities that directly influenced disease

surveillance, partnership management, community engagement, financial management,

and international coordination [46]. MoH staff had to assume emergency roles and tasks

outside their regular mandate, complicating existing workload capacities to balance

emergency and routine functions [47].

In some Latin American countries, the debt crises of the 1970s and 1980s reduced

government spending in health and thus triggered health system reform, forcing

Ministries to rethink and reorganize their mandate and structure [1]. In Costa Rica, Chile

and Colombia, as observed in PAHO (2007), the governments displayed high-level

commitment to strengthening the MoH’s stewardship role and broader role capacity [16].

These legislative efforts highlighted the separation of functions within the MoH, focusing

on overall stewardship (including policy direction, financing and regulation) rather than

the provision of health services, while also clearly defining roles and responsibilities for

various government institutions. In Chile, an inter-ministerial committee, comprised of

Health, Treasury, Labor and the President’s Office, played a critical role in guiding the

reform [16].


3�1�3 Reform�

From a structural and role capacity standpoint, reform processes tend to create both

strong opportunities and tremendous challenges for an MoH. Some Ministries have

determined their capacities insufficient to manage reform and thus created new

structures or bodies to do so. These have included new health insurance agencies in

Nigeria, Ghana and Slovenia; a National Council of Social Security in Health in Colombia;

an insurance planning secretariat in Uganda; and the Health Promotion Foundation Act

in Thailand. While these structures have given legitimacy and capacity to reform efforts,

they have also complicated lines of authority and responsibility for the MoH.

In Thailand, this issue was successfully addressed, as in Adulyanon (2012), with the

Minister Minister of Health serving as the vice-chair for ThaiHealth [48]. Uganda

developed a new secretariat for insurance reform – but in the process, report

Colenbrander, Birungi and Mbonye (2015), did not consult with stakeholders in

developing a reform plan, which created opposition to proposed reforms [49].

In Colombia, however, as reported by Bossert et al (1998), the MoH dominated the

National Council of Social Security in Health and maintained considerable veto power,

creating an environment where consensus was “more imposed than forged” [1].

In some countries, the process of health sector reform has highlighted key role capacity

opportunities and challenges within Ministries and affiliated institutions. Sector-wide

approaches (SWAp)2 also placed more attention on improving planning functions within

the MoH. For example, in Bangladesh (as seen further in Box 2 below, and reported by

Ahsan et al (2016)), the capacity of the MoH to prepare and manage budgets – which

combines role capacity (more responsibility), structural capacity (relevant committees

and taskforces) and personal capacity (increased technical skills) – strengthened

considerably through the timely preparation of financial reports, the utilization

of treasury systems, and through audit committees and financial management

taskforces [50].

In some countries, the process of health sector reform has highlighted key role capacity opportunities and challenges within Ministries and affiliated institutions.

Capacity challenges within Colombia’s MoH, as seen in Bossert et al (1998), directly

complicated reform efforts [1]. There, insufficient personal and workload capacity to

support reform efforts created an overreliance on external technical experts. Frequent

changes within the senior leadership structure also significantly impeded reform efforts.

2 The Sector Wide Approach (SWAp) is, according to Foster (1999), a "method of working between Government and donors," the key characteristics of which are "that all significant funding for the sector supports a single sector policy and expenditure programme, [is] under Government leadership, [adopts] common approaches across the sector, and [progresses] towards relying on Government procedures to disburse and account for all funds" [125].


Box 2: Capacity evolution in Bangladesh’s MoHFW through sector-wide approaches

The 1998 introduction of the sector-wide approach (SWAp) for the health, nutrition and population sector in

Bangladesh created new capacities within the Ministry of Health and Family Welfare (MoHFW), as reported

in Ahsan et al (2016) [50]. The SWAp stimulated the MoHFW’s approach to donor coordination and

management, efforts further supported by development partners [51]. Capacity has since increased in:

• MoHFW control over the SWAp process, with better management of the annual program reviews and

mid term reviews from 2012-2014.

• MoHFW management, especially in the Directorates that perform administrative duties, using techniques

such as management capacity appraisal.

• MoHFW financial management, through the formation of an audit committee and a financial

management taskforce.

The MoHFW has shown significant progress in its structural capacity, supervisory capacity and personal

capacity. Additional capacity challenges remain, particularly regarding the overall MoHFW strategy for health,

its ability to coordinate various vertical programs, and a lack of clear sectoral boundaries (where, for instance,

urban health is the responsibility of the Ministry of Local Government).

The MoH has, in some cases, itself been the target of reform efforts. In Uganda, despite

high-level political and donor commitment, reform efforts were reportedly unable to

adequately address internal MoH power dynamics and territorial disputes [17]. In Costa

Rica however, the process of MoH reform was more successful, with PAHO (2007)

showing how legislation and broad consensus-building efforts strengthened structural,

role, performance and personal capacities [16].

3�1�4 Macroeconomic trends�

Countries transitioning to new economic models have created MoH capacity challenges,

especially in reconciling existing norms and structures to new market realities.

For example, in several countries, the MoH had challenges in overseeing and regulating

the rapidly increasing numbers of private health facilities. From a structural capacity

standpoint, in Kazakhstan, Chanturidze et al (2015), report that evidence and intelligence

systems were insufficient to capture the needed health system data [52]. In Viet Nam,

Fritzen (2007) illustrate how a similar insufficiency arose to track the emerging private

sector [19]. In Chile, as in Buchan (2004), the introduction of free-market policies

complicated the government’s ability to register health professionals [53]. Although

mechanisms existed for the Chilean MoH to observe voluntary professional associations,

there were no regulatory frameworks to clarify roles and responsibilities in the regulation

of health professionals, such as accreditation or registration.

Performance capacity may also be exacerbated by broader macroeconomic trends.

For example, in Tajikistan, increased donor funding reportedly buttressed a decline

in national funding [54]. However, in several European countries, as in Veillard et al

(2011), the 2008 financial crisis sharply reduced capacities to develop health systems

policies [28]. Similarly, in Pakistan, Siddiqi et al (2004) show how the unpredictability of

its macroeconomic situation gave the Ministry of Finance greater influence to determine

which policies and interventions of the National Health Policy would ultimately be

financed [41].


3�1�5 Global policy trends�

Many MoHs have experienced tremendous – and in many cases positive – shifts due

to global policy trends. From the 1990s on, global health initiatives focused on HIV/

AIDS, malaria, TB, tobacco control, and polio eradication, all of which radically changed

MoHs [18, 55]. The HIV/AIDS initiatives, for instance, have reportedly had a mixed impact

on Ministry capacity. They have directly increased performance capacity for priority

diseases and issues, but weakened capacity for intra-Ministerial coordination, planning,

and monitoring and evaluation [56]. Similarly, the increase in funding for tobacco control

in the 2000s resulted in increased structural capacity within Ministries [57]. Following

the ratification of the Framework Convention on Tobacco Control in 2004, in 2006 the

Turkish government – as found by Hoe et al (2016) – formed a National Tobacco Control

Committee, with the MoH successfully leading 130 individuals from various sectors to

develop the National Tobacco Control Programme and Action Plan [58].

3�1�6 Social movements and social change�

While perhaps not as prevalent, MoH capacity to engage with social movements and

social change has nonetheless become an increasingly important issue. In the United

States, the Department of Health and Human Services initiated an internal Lesbian,

Gay, Bisexual, and Transgender (LGBT) coordinating committee involving senior

representatives from multiple divisions. In 2016, the Department underlined this capacity

by creating a position titled Senior Advisor for LGBT Health [59]. In France, Faye (2017)

shows how the Modernization Act allowed for increased role capacity to strengthen

the participation of service users in health sector governance, while also mandating the

establishment of a national union of patient associations [60].

3.2 WHAT ARE SOME SPECIFIC GOVERNANCE ROLES FOR AN MOH?

How do governance capacity issues play out within specific MoH governance roles?

As indicated above, from the 1990s on, the MoH’s mandated governance roles have

evolved – from one focused to a large extent on health service delivery to one charged

with overarching strategy, quality and performance assessment, policy and planning

for the sector. From a role capacity standpoint, an MoH appears often insufficiently

capacitated to regulate key actors, especially private health providers [61]. Adding

further to this challenge is the organizational culture, especially in many LMIC MoHs

which still operate from a long history of centralized command-and-control [28, 62].

Favoritism, sectarianism and corruption have also long plagued MoHs and often

negatively influenced their mandated governance roles [34, 42].

As to personal, workload and supervisory capacity, Ministries often face considerable

challenges in implementing mandated goals. For example, Ministry staff tend to

have greater personal capacity leaning towards managing health services provision

and operations, rather than towards overall stewardship responsibilities [28, 63].

The organizational culture of Ministries in many LMICs is hierarchal [19, 52, 54, 64], often

coloured by an aversion to risk and a fear of retribution from superiors for perceived

decision-making inadequacies [54, 64]. Other human resource issues have exacerbated

the situation, including a lack of incentives for success, a lack of staffing profiles

or position descriptions, inconsistent or unpredictable performance evaluation or

promotion structures, limited motivation and enthusiasm, and low pay [65].

Several countries also struggle with externally driven pressures on their organizational

structure. Key issues include the frequent turnover of senior staff and limited training of


bureaucrats specific to health [17, 41, 53, 61, 66, 67, 68, 69]. In some countries, such as

Tajikistan, Ministry personnel issues are exacerbated by competition for staff with

international donors, as reported by Rechel and Khodjamurodov (2012) [70].

Here, we outline a number of key roles of Ministries of Health and how capacity issues

demonstrate themselves.

3�2�1 Strategic planning and prioritization�

A crucial role of most MoHs is their overall responsibility for strategic direction and

planning and prioritization [5, 10], often collectively referred to as “stewardship” [5, 28,

39, 55, 71]. One key challenge for this stewardship function lies with Ministers of Health

themselves. Ministers are often in office for a short and unpredictable period of time,

which does not serve either medium- or long-term planning [72].

Key facilitators supporting structural capacity for strategic planning tend to be

coordination committees with international donors. For example, as reported by

Rodriguez, Banda and Namakhoma (2015), in Malawi, the final Integrated Community

Case Management policy was produced by the Child Health Technical Working Group,

a group consisting of both MoH and donor stakeholders, with Ministry officials taking the

lead in policy formulation [73]. However - as reported by Seitio-Kgokgwe et al (2016) -

experience from Botswana suggests that structural capacity, without adequate personal

capacity, can result in “being led from the outside” (i.e. overly influenced by donor-

driven priorities) [61].

3�2�2 Evidence use, evidence generation and intelligence management�

Central to every MoH across the world is an ability to demand, generate, access, adapt

and apply research evidence in their policy-making and evaluation. This capacity

may exist internally in the form of professionals with requisite scientific expertise

(epidemiologists, social scientists, statisticians, etc.) or externally (for example, academic

or research institutions). A detailed conceptual framework for understanding evidence

use in MoHs was developed and tested across eight LMICs [26]. Organizational

capacities – “structures, practices and resources” – examined by Rodriguez et al

(2017) included creating organizational incentives for the demand and use of research,

to investments to access and assess research, to fora for sharing, discussing and

communicating research. In many LMICs, despite a high self-reported use of evidence of

inform policy-making, few institutional mechanisms are typically available at the Ministry

level – including sabbaticals to research institutions, or Memoranda of Understanding

with research institutions for commissioned research [74].

Personal capacity for evidence generation and use within Ministries is also a major

challenge. A 2013 assessment of MoH research units in 14 sub-Saharan African countries

found that only one country had a leader of an MoH research structure with health

research management training [75]. However, evidence generation and management

were also found to be key areas of personal capacity development in several

countries [74, 76]. Examples of activities include training workshops and programs,

policy retreats between researchers and policymakers, incorporation of evidence-to-

policy modules in postgraduate training programs, and regular seminars [76]. In Lao

People’s Democratic Republic, as illustrated by Jonsson et al (2015), developing the

personal capacity of policy-makers by instituting their involvement in operations

research projects was seen as a successful aspect of implementing the National Drug

Policy [77].


3�2�3 Policy development�

Strengthening personal capacity within an MoH to develop strategy and policy is

critical [16, 36, 52]. In Kazakhstan, a project by the MoH and UNDP to develop the MoH’s

policy-making capacity – as reported by Chanturidze et al (2015) – drew upon a formal

needs assessment of the strengths and weaknesses of self-reported organizational

capacities and individual competencies among MoH staff [52]. A clear success from this

capacity-building effort was the development of the Health Sector Strategy 2013-2017.

In Rwanda, as found by Fox et al (2010), technical capacity for policy-making was seen

as strong among a small group of committed MoH staff; however, these processes could

be strengthened with greater involvement from other stakeholders, particularly front-line

actors [78].

Some Ministries face capacity issues in terms of how they reconcile contested viewpoints

in the policy-making process [73, 79, 80]. For instance, in developing a National Health

Research Policy in Gambia, Palmer, Anya, and Bloch (2009) describe how a technical

successfully advocated for the policy, and for an inclusive approach to policy-making;

however, the policy stalled in the final process of Cabinet approval, primarily due to

the perception among senior MoH officials that the policy would weaken government

ownership [80]. In Malawi, the early stages of developing Integrated Community Case

Management policy saw challenges in securing internal agreement among various

vertical programs within the Ministry [73].

3�2�4 Citizen empowerment and responsiveness to needs�

Some MoHs have prioritized citizen voice in their policy-making efforts – and have been

proactive in engaging with citizens to ascertain their needs. In Brazil, as described by

Gragnolati, Lindelow and Couttolenc (2013), an ombudsman is appointed by the MoH to

the National Health Surveillance Agency to ensure public participation, accountability

and transparency – all supported by mandatory public consultations and open

dissemination of information through web platforms [81]. In Chile, PAHO (2007) show

how the MoH used various mechanisms to gather citizen feedback on an ongoing health

sector reform process; at nearly 300 community meetings, citizens discussed sectoral

problems, with an additional 200 meetings organized to discuss citizen feedback

on draft legislation on patients’ rights and duties, as well as on a reform intervention

plan [16].

3�2�5 Performance monitoring�

Information, evaluation and a broader understanding of performance is key to any

bureaucracy, especially an MoH. In Sri Lanka, as in Hornby and Perera (2002), ensuring

a flow of reliable information between federal and provincial structures was seen as a

key function of the MoH, and as a contributing factor to growing the MoH as a “learning

organization” [82]. In Senegal, Gueye Ba et al (2010), describe how the MoH adopted

performance monitoring mechanisms for a school health program through qualitative

stakeholder feedback, and through a quantitative analysis of school health facilities [83].

3�2�6 Procurement�

Issues around procurement appear to combine capacity weaknesses from both an

organizational and personal standpoint. For example, Palesh et al (2010) show how in

Iran, managing the flow and distribution of health technologies was a major challenge –

due to a lack of rules and regulations, and against the context of a highly active private


sector [68]. Furthermore, there was a major lack of internal and external coordination,

exacerbated by management instability within the Ministry, featuring frequent staff

turnover. In the example of Benin, procurement processes have reportedly been

highly politicized, and subject to corruption – further complicating the MoH’s role

capacity [84].

To deal with this issue, structural capacity interventions have included multi-stakeholder

boards and committees [16, 38, 84, 85]. For example, in Timor Leste and Sri Lanka,

Alonso and Brugha (2006) describe how boards and committees involving both health

and business stakeholders, in addition to other stakeholders, were developed to address

issues with access to medicines [38]. In Brazil, the national health authorities reportedly

played a key role in managing relationships with private drug manufacturers, civil

society, donors, and the public sector in order to strengthen national production of anti-

retroviral therapy pharmaceuticals [16].

3�2�7 Program planning and management�

Ministries across the world have persistent issues with role and structural capacity for

program planning and management. In many LMICs, MoH initiatives pertaining to non-

communicable diseases are often divided by disease- or risk-factors, which often results

in uncoordinated programs in response – with examples including programs for HIV/

AIDS, diabetes, cardiac disease, cancer, etc. [57, 86]. Global policy trends also influence

these structures. For instance, the increase in funding for tobacco control programs

in the 2000s reportedly led to increasingly separate tobacco control units within

Ministries [86]. Further, the mandate and functions of these units in terms of technical

advice, program management, and implementation are sometimes uncoordinated with

other structures within Ministries [57].

3�2�8 Personnel management�

Many countries face key role and structural capacity issues when implementing functions

related to human resources for health (HRH). These include the lack of clear mandates

for HRH units, multiple national and sub-national units responsible for the HRH function

without adequate coordination, little decision-making power within Ministries, and weak

coordinating powers with external actors [19, 66, 72, 87]. Coordination challenges

are exacerbated in the case of HRH policy as many stakeholders have “veto power,”

turning this policy space into one with a collective-action problem [19, 72]. Further,

HRH management may not align with other health policy and systems considerations.

For example, in Ghana, as argued by Koduah, van Dijk and Agyepong (2016b), the MoH

finds itself well situated to influence human resource policy given that 90-93% of the

government’s allocation to the health sector goes towards public-sector salaries; but,

as a result of this financing arrangement, the government has few resources to allocate

to other health priorities, allowing donors to promote and finance policies that satisfy

their own agendas [88].

3�2�9 Regulation and standards�

Reviews of health sector regulation in LMICs have found key capacity challenges with

the institutions tasked with these functions [89, 90], particularly in the context of

expanding private sectors [19, 89]. In terms of structural capacity, regulatory institutions

often lack the mechanisms to monitor the private sector [19, 89], including provider

abuses. Regulators also sometimes lack the structural capacity for information gathering

and sharing, which is necessary to ensure transparency in the system [91]. For example,


MoHs are often not in a position to gather information on the quantity and quality of

NGOs operating in the health sector due to inadequate rules and structures around

registration, information sharing, and so on [90].

From a performance capacity standpoint, regulatory institutions in many LMICs appear

to lack financial, human resource and logistical capacities. For example, in the United

Republic of Tanzania, Uganda, Papua New Guinea, and Liberia, as found by Janovsky

and Travis (2010), statutory bodies had “small, poorly funded secretariats with limited

IT capacity,” operating from restricted or insufficient office space [90]. In cases when

regulatory authorities are not well resourced by the government, scope for corruption

increases, as observed by Ma, Chen, and Tan (2015) in China [92].

3�2�10 Contracting and compliance�

Little has been documented about the capacities for an MoH to initiate, monitor,

and evaluate contracts with third parties, and to monitor compliance with rules and

regulations. In Viet Nam, compliance is reportedly weak in following the official mandate

that only those health professionals who have worked for five years in the public sector

may work in the private sector [19]. Research from Benin, as reported in Houngbo et al

(2017), found that the system for awarding contracts for health technologies was highly

politicized, and lacked accountability [84].

In Afghanistan, the MoH reportedly appeared to show strong supervisory capacity

for monitoring performance-based contracts through the Grants and Contracting

Management Unit [37, 93]. For example, contracts would be reviewed regularly, partners

were called in for meetings when necessary, and contracts were terminated when

necessary [37]. A contributing factor to the success of the Unit was the presence of

former NGO staff with important knowledge regarding NGO processes.

3�2�11 Resource management, including fundraising and financial management�

MoHs face several capacity shortages with regards to resource management [64, 94, 95].

From a personal capacity standpoint, there are challenges in planning, allocating and

executing budgets, and difficulties in managing and supervising funds [65, 94]. There

are also major structural and workload capacity challenges, particularly in the limited

number of Finance personnel within MoHs, and issues in coordinating with Ministry of

Finance staff [65, 95].

Some countries showed progress in building capacity at multiple levels around resource

management. In Thailand, ThaiHealth reportedly used sub-committees, such as audit

and fiscal policy, to monitor operational compliance and certify financial audits [101].

External, independent evaluations are also done on projects exceeding 20 million

baht (around US $700,000). These committees were found to be resource intensive,

but useful in the area of financial policy. In Bangladesh, as shown in both Ahsan et

al (2016) and Buse (1999), the process of managing the SWAp led to a considerable

improvement in the Ministry’s ability for timely financial reporting [50, 64].

Other countries, however, demonstrated a lack of performance and personal capacity in

resource management. Ministry officials in Uganda were reportedly more concerned with

expanding resources rather than managing inefficiencies within the system. For example,

as found by Colenbrander, Birungi and Mbonye (2015), the MoH was focused on

increasing wages for health workers, despite previous experience having shown that

such increases were ineffective [49]. In Malawi, despite playing a central role in steering

Integrated Community Case Management policy, Rodriguez, Band and Namakhoma

(2015) illustrate how the MoH was unable to secure internal resources, and depended


on inadequately coordinated donor funding, raising questions about the financial

sustainability of the program [73]. Finally, other articles raised the issue of Ministries not

always being able to absorb (i.e. appropriately spend) additional resources [37, 38].

3.3 HOW CAN AN MOH UPHOLD GOVERNANCE PRINCIPLES WHILE ENSURING WIDE STAKEHOLDER PARTICIPATION?

Beyond dealing with the technical dimensions of governance, upholding governance

principles – accountability and transparency, fairness, participation, integrity, prudence

and efficiency, and keeping the public’s welfare in mind – is a critical role for an MoH [5].

However, MoH capacity in this regard is typically ambiguous and/or limited [63]. Several

countries have developed interventions to directly strengthen an MoH’s ability to uphold

governance principles, including the promotion of accountability and transparency as

two core, overarching values. In this section, we provide examples of how countries have

incorporated such governance principles into MoH functions.

Ensuring the participation of a broad base of stakeholders – from both within and

outside government – is seen as a key governance objective for MoHs around the world.

And yet, despite this, MoHs have a decidedly mixed record on stakeholder engagement.

For example, capacity issues include broad MoH challenges with stakeholder negotiation

and mediation [30], a tendency to keep decision-making groups small [48, 78, 96],

the lack of formal stakeholder fora [97] and engagement with individuals rather than

networks due to weak systemic capacity [54].

In Ghana, despite the existence of stakeholder fora for a wide array of participants,

including civil society, government partners, and implementing actors, Koduah, van Dijk

and Agyepong (2016a) found that decisions tended to be made in closed meetings open

only to the MoH and donors [98]. In Brazil, participatory health councils were reportedly

mandated at each level of the health system – central, regional and local [81] – but

there is no legal authority for government to act on their recommendations, and further,

insufficient budgets limit the performance capacity of these councils [99]. Moreover,

these councils often lack trust among Ministry staff, professional representatives and

user representatives, and an inability to transform their proposals into action [100].

However, there were also several promising examples of MoHs broadening stakeholder

engagement. Some of the more successful attempts at this have been mandated by law,

strengthening role and structural capacity. For example, through the National Health

Act (2007), Rasanathan et al (2012) report that Thailand’s National Health Assembly

is organized annually by the National Health Commission Office with the purpose of

engaging a range of stakeholders from civil society, government and academia [101].

Further, ThaiHealth has developed several important mechanisms to improve capacity

for addressing accountability and transparency – examples include the involvement of

external experts in a Board of Evaluation, and the execution of a performance evaluation

that, in the ideal scenario, will lead to improved transparency and accountability [102].

In India, the advent of the National Rural Health Mission in 2005 evidently provided an

opportunity to broaden participation of civil society and citizens in the health sector;

stakeholders used the term “communitization” to describe the approach of increasing

public/citizen ownership of the health system [103]. To achieve this, Gaitonde et al

(2017) report that the Ministry formed an Advisory Group on Community Action,

and provided financial resources for this group to implement activities in certain states

to mixed effect [103]. A key lesson from this exercise was the need for expanded spaces

and strengthened institutional norms to build trust relationships between policymakers

and civil society.


In Afghanistan and Benin, Ministry units and technical committees were established

to monitor and evaluate contracts; in Benin, as whown in Houngbo et al (2017),

this was done explicitly to reduce corruption in the procurement system [84]. Other

countries, such as Kenya, have apparently struggled to improve transparency and

reduce corruption. An initiative to strengthen the capacity of the Kenya Medical

Supplies Agency (KEMSA), supported by development partners, was stymied by

conflict and tension among senior Ministry of Health staff with a key stake in KEMSA’s

operations [86]. Consequentially, KEMSA fell into further disarray, which in turn

expanded avenues for corrupt behaviour.

3.4 HOW CAN AN MOH EFFECTIVELY MANAGE GOVERNANCE RELATIONSHIPS?

Managing relationships with a wide range of stakeholders – within and outside

government – is a central governance function for an MoH [5, 10]. Capacities here

include the need to convene, build consensus, negotiate, mediate, problem solve,

and resolve conflict. In this section, we explore how MoHs have managed relationships

with, in no particular order, the private sector; with political leadership; with other line

ministries; with civil society; with organized labor groups; with donors – both generally

and within emergency contexts; and between the center and periphery.

Managing relationships with a wide range of stakeholders – within and outside government – is a central governance role for an MoH.

3�4�1 Managing relationships with the private sector�

The term “private sector” denotes a diverse set of stakeholders, including health

sector providers and facilities, industries (hospitals, pharmaceuticals, medical device

manufacturers, etc.) and industries from other key sectors that directly influence health

(for example, agriculture, food, beverages or manufacturing). Experience shows a mixed

record in the relationship between the MoH and the business community. As shown

in Omaswa and Boufford (2014), many Ministers of Health believe that business

stakeholders tend to promote their own business interests rather than national health

priorities; nonetheless, these Ministers often did see these companies as beneficial to

the overall objectives of the MoH [5]. In Botswana, the Ministry was reportedly seen

as lacking the role capacity to enforce rules with the private sector due to unclear

regulations (except in the case of HIV/AIDS). As found by Seitio-Kgokgwe et al (2016),

the MoH attempted a consultative committee with the business community; however,

the business community was represented by a trade group that had not developed its

own capacity to be productive in those meetings [61].

For most countries, building trust between the public and private sectors is essential

and constitutes an important dynamic. In Saudi Arabia, for Public-Private Partnerships

(PPPs) to be successful, Alonazi (2017) found that the business sector needs to have


trust-based relationships with the MoH, particularly around reimbursement [104]. To that

end, building capacity within the MoH around resource management and mobilization is

of paramount importance. Similarly, Afghanistan presents a successful example in trust

building. There, as shown in Cross et al (2017), the Minister chairs a quarterly forum with

private for-profit health sector actors – the Public Private Dialogue Forum – which has

resulted in greater levels of trust and collaboration, a regular flow of information, and the

resolution of several key issues [36].

3�4�2 Managing relationships with political leadership�

An MoH often has distinct challenges in engaging with political leadership or other

ministries - particularly challenging as, historically, an MoH typically has less comparable

power and influence. In Tajikistan, for instance, Mirzoev, Green and Van Kalliecharan

(2015) found that the MoH requires executive support or support from other Ministries

when initiating or approving policies [54]. In some countries, the “Minister of Health”

position was more a political than substantive post [1, 32, 54]; for example, in Poland,

Sabbat (1997) reported that the Minister of Health is typically the weakest political

coalition partner [32]. In some European countries, as argued by Veillard et al (2011),

MoHs lack the power and influence inside governments to define a government-wide

vision on health [28].

This lack of relative power can result in MoHs addressing policy demands from the

executive that may conflict with their professional judgment. In many places, political

decisions threaten to override technical decisions - with, further, those political decisions

often taken without sufficient time for effective MoH planning or implementation.

For example, MoHs in both Niger and Uganda reportedly had to actively manage the

political goals of the executive [105, 106], and donor concerns in another instance [49].

In Tajikistan, Rechel and Khodjamurodov (2010) show that the MoH was under pressure

from the executive to roll out a basic health services package, even though there was

insufficient involvement of local authorities, health professionals and the public [70].

Similarly, in Senegal, Mbaye and Ridde (2013) describe how the executive branch

unilaterally created a program for elderly care, giving the MoH limited time and ability to

plan and execute effectively – which ultimately limited the program’s success [107]. As a

consequence of all this, MoHs across the globe must find effective ways of inserting their

own perspective and experience into wider governmental decision-making processes

in government.

3�4�3 Managing relationships with other ministries�

Interactions among line ministries illustrate some clear issues in role capacity. Fuzzy

roles and responsibilities among ministries often - and predictably - lead to weak

coordination structures and habits [41, 61, 64, 65, 95]. In Botswana, as described in

Seitio-Kgokgwe et al (2016), a coordinating committee was set up between the MoH and

the Ministry of Local Government; however, the terms of reference were not constructed

properly, and there were no statutes guiding participation - ultimately resulting in the

committee's complete ineffectiveness [60]. Similarly, in Kenya, Tsofa, Molyneux and

Goodman (2016) show how a core team was organized to improve coordination across

the MoH and the Ministry of Finance, but a lack of clear leadership structures, terms of

reference or reporting responsibilities rendered the team ineffective over time [95].

From a personal capacity standpoint, high-level MoH staff in Uganda, Ghana and

Senegal were reportedly found in need to require further skill building in arbitration and

negotiation with Ministries of Finance, particularly to advocate for more funding [94].


However, Ministries of Finance in these countries did not exhibit flexibility and open

communication during budget discussions. Ministries of Finance were also found to

provide insufficient feedback to MoHs during budget preparation, and limited training

for MoHs regarding medium-term expenditure frameworks.

However, some positive examples highlight that intra-governmental collaboration can

indeed be built. In Afghanistan for example, Cross et al (2017) found that the Ministry

of Public Health worked closely with Finance and other legislative actors in developing

private sector regulations [36]. As in Galbally et al (2012), ThaiHealth initiated a small

unit to engage with Members of Parliament, providing them with updates and data

regarding health programs [102]. In another positive example from Chile, inter-ministerial

collaboration, in addition to high-level presidential support, evidently facilitated the

passage of multiple pieces of legislation that enabled health reform and strengthened

the stewardship role of the MoH [16].

3�4�4 Managing relationships with donors�

MoH capacity in coordinating aid relationships is complicated by the significant power

donors wield. In Tajikistan, for instance, where certain donors – such as the World Bank

– are more dominant than the MoH, Mirzoev, Green and Van Kalliecharan (2015) found

that there is limited capacity to build trust with donors, reconcile short-term projects

with long-term objectives, and influence knowledge production among donors [54].

Bangladesh apparently experienced similar weaknesses within the system to coordinate

aid, as reported by Buse (1999), including broad structural and personal capacity

issues [64]; however, the MoH also made significant progress in managing the SWAp

process and taking a coordinated approach to engaging with donors [50].

MoH capacity in coordinating aid relationships is complicated by the significant power donors wield.

MoHs have attempted other structural capacity efforts for engaging with donors, such as

special units charged with aid coordination [18]. However, these units have a mixed

record of success, due to issues of role capacity, or internal disagreements within the

MoH. Donors also sometimes bypassed these units to interact with the top decision-

makers at the MoH.

However, some Ministries did build capacity to engage more productively with as in

Rwangomba (2007), Rwanda took a holistic approach to aid coordination, focusing

on role, personal and structural capacities [108]. For example, role capacities were

strengthened through a Government of Rwanda aid policy, which provides a framework

for all aid negotiations, through the development of donor coordination groups,

and through stronger coordination across Ministries. Civil service reform has also helped

with improving personal capacity, through increased salaries, performance contracts and

intensive training programs [108].


3�4�5 Managing relationships with donors in an emergency context�

This MoH-donor relationship becomes even more stressed during times of crisis or

emergency. In particular, crisis can directly challenge the governance capacities of an

MoH. How, for instance, will MoHs coordinate inflows of additional external funding –

both to government and non-government actors? How will the MoH coordinate the

actions of various stakeholders (within government, across donor agencies, etc.) some

of whom are new to – and potentially ignorant of – the country context? How will

MoHs share data with international agencies? How will the MoH enforce transparency

among donors, creating a “comprehensive picture of monetary and in-kind pledges

and disbursements” to the crisis, while also demanding transparency among the NGOs

receiving donor funds [46]? And, perhaps most of all, given all of these new/urgent

inputs, how will emergency services be coordinated and effectively delivered?

Clearly, resource-poor health systems have limited capacities to manage a massive

infusion of external resources in responding to an emergency. However, the 2014-15

Ebola virus disease (EVD) epidemic in West Africa provides an important case study,

with Liberia’s governance response particularly notable. Despite systemic governance

inefficiencies before the outbreak, as shown in Nyenswah, Engineer and Peters (2016),

Liberia nonetheless successfully created an Incident Management System (IMS) within

the MoH. This allowed the country to establish a distributed leadership approach to

guide “strategic engagement with both local community leaders and international

stakeholders” [109]. Thematic teams within the IMS took leadership across the

health system in responding to the epidemic, with teams led both by Liberians and

international partners “so that the IMS did not have to deal separately with organizations

planning activities in the same thematic area, thereby avoiding duplication of functions

or activities… Decisions were taken and reviewed daily on the basis of available data

and communicated intensively within the health system, with the population, and with

international stakeholders” [109].

The global response to the 2005 Asian tsunami provides additional illustration on this

dynamic. In reviewing national and global responses to the disaster, de Ville de Goyet

(2007) calls for external expertise in an emergency so long as the MoH can employ

a “selective and closely coordinated use of this expertise, as was done in India and

Thailand” [110]. In Indonesia and Sri Lanka, by contrast, well-funded NGOs reportedly

had “little incentive” to coordinate with national governments or the UN [110]. Further,

de Ville de Goyet (2007) reported that international actors marginalized local actors

by restricting access to foreign assets, operating only in English, and frustrating the

role capacity of national authorities in Indonesia and Sri Lanka to “filter, coordinate,

or manage the overwhelming number of aid responders, or assume the technical lead in

adapting indicators and standards to local realities” [110].

3�4�6 Managing relationships between center and periphery in a decentralized system�

Managing national-subnational relationships can also be extremely challenging.

From the perspective of role capacity, many countries in Europe lack the appropriate

authority to ensure alignment between health system objectives and performance of

sub-national actors [28]. This issue takes on a different dimension in LMICs; in Kenya for

example, even though the MoH ought to involve sub-national counties in planning, Tsofa,

Molyneux and Goodman (2016) report that this tends not to happen in practice [95].

Brazil has experimented with several arrangements for improving coordination across

levels of government, including bilateral and trilateral committees; these committees,

as described in Gragnolati et al (2013), have been overly bureaucratic – and thus


new mechanisms are under consideration, including the establishment of a regional

coordinating level between the center and the municipalities [81].

In Uganda, additional resources reportedly supported the development of the Health

Planning Department; however, the strengthening of the Ministry appears to have come

at the expense of the districts, suggesting that power has been recentralized at the

central level and necessitating the need for structures to better engage the districts [111].

Conversely, in Pakistan, Pervaiz, Shaikh and Mazhar (2015) describe how the abolishment

of the federal MoH through the 18th Constitutional Amendment – in favor of devolution

of authority to the provinces – only underscored the need for role capacity for a federal

structure to coordinate with the provincial departments [112].

3�4�7 Managing relationships with civil society�

Similar to other types of relationships, there is a mixed record in terms of MoH capacity

to engage with civil society, particularly NGOs. In Kenya, despite the MoH having the role

capacity to engage NGOs through the annual planning process, such involvement has

been absent [95].

The South African National AIDS Council (SANAC) illustrates these important linkages

between an MoH and civil society. From a structural capacity standpoint, the existence

of SANAC is important; however, as raised by Powers (2013), there are valid questions

about who is involved, and whether there is an emphasis on those constituents with

biomedical expertise and/or engagement with transnational partnerships [113]. From a

performance capacity standpoint, this institution was only given limited resources by the

government – requiring SANAC to seek funding from private philanthropic sources [113].

Other countries have been more successful in engaging civil society. The autonomous

nature of ThaiHealth reportedly allows for more flexibility in the types of partnerships

pursued, resulting in increased civil society engagement in the health sector through

platforms such as the National Health Assembly [102]. In Timor Leste, Alonso and

Brugha (2006) report that NGOs are engaged in the government through a proposal

assessment process, and NGO proposals must align with key principles, such as equity,

gender and cultural sensitivity [38].

3�4�8 Managing relationships with labor�

Developing capacity to engage with organized labor is challenging, exacerbated in some

cases by weaknesses in role capacity, the diversity of professions, sectoral affiliations

(public, for-profit private and non-profit) and underlying power asymmetries. Physicians,

more than other types of health professionals, seemingly have more engagement and

access with Ministries. In Slovenia, as described in Albreht and Klazinga (2002), there

was good cooperation between professional groups and the MoH – including the

Slovenian Medical Society and the Association of Public Providers of Health Care – but

a more challenging relationship between the Ministry and the statutory professional

chamber [30]. In India, the Medical Council of India, the professional council for doctors,

is technically overseen by the Ministry of Health and Family Welfare; however, major

discrepancies in the accountability mechanisms between the two institutions have been

noted [91]. Similarly in Chile, Buchan (2004) reports that the MoH did not have a legally

clarified role in the regulation of doctors, such as through accreditation or registration

of their credentials – although such a system had existed prior to marketization of the

health sector [53].


04

36

Section IVStrengthening

MoH Governance Capacities: Examples


How can MoHs strengthen governance capacities?

In this section we briefly look at examples of specific measures countries have taken

to strengthen MoH governance capacities, including strategic planning and policy

development; procurement; resource management; personnel management; evidence

use; regulation; reform; values; and managing relationships.

4.1 STRATEGIC PLANNING AND POLICY DEVELOPMENT.

The MoH in Kyrgyzstan made strengthening its stewardship role a key goal during

multiple rounds of health sector reform. Some successful aspects of this reform effort

include consistency and commitment over several years, and the development of

technical capacity within and outside government through collaborative networks,

such as the Health Policy Analysis Centre [70, 114]. More specifically, as shown in

Ibraimova et al (2011), successful aspects of the initiative include the harmonization of

health sector legislation, delegation of tasks to other national health authorities and

non-state actors, the strengthening of relationships with other line ministries and the

executive leadership, restructuring and reorganization of the Ministry, and coordination

of the SWAp [114]. However, key challenges remain in sustaining these initiatives,

including the need for performance capacity funding and the broader challenge of

senior staff turnover.

The Government of Kazakhstan and UNDP also recognized the need to build the

capacity of the MoH in strategy development and policy-making [52]. As illustrated

by Chanturidze (2015), the program involved an eight-stage approach that focused on

strengthening both individual competencies and organizational capacities, including

stakeholder mapping, needs assessment, designing of capacity-building tools,

implementation, evaluation and facilitation of an enabling environment. In an effort to

strengthen capacity across the MoH, three of five departments were selected for the

intervention; activities included short courses, study tours, mentoring and coaching,

action learning, work placements and attachments, and training over both the medium-

and long-term. One measure of success for this program was that the Department of

Strategy Development within the MoH led the development of the Kazakhstan Health

Sector Strategy 2013-2017.

4.2 PROCUREMENT.

The MoH in Benin, as illustrated in Houngbo et al (2017), underwent an extensive

capacity-building exercise in reforming its health technology management system [84].

Using principles of good governance and applying the Interactive Learning and Action

(ILA) approach, the research team undertook a six-phased research and managerial

approach, involving preparatory analysis, shared analysis and visioning, priority setting

and planning, project formulation and implementation. The initiative appeared to have

several positive outcomes, including enhanced transparency for procurement processes,

participatory policy-making approaches that bridge the gap between technical and

political staff, establishment of technical committees to supervise contracts, and the

establishment of a separate directorate for medical devices, given stronger role capacity

through legislation. An evaluation of the initiative has yet to be conducted, but early

38 S t re n g t h e n i n g M o H G o ve r n a n c e C a p a c i t i e s : E x a m p l e s

successes include certain structural changes to the MoH’s functioning, and a reduction in

costs for health technologies due to improved contracting procedures.

4.3 HUMAN AND FINANCIAL RESOURCE MANAGEMENT.

As argued by Banteyerga et al (2011), Ethiopia appears to have successfully aligned the

Federal Ministry of Health, Ministry of Finance and Economic Development, and Ministry

of Capacity Building in applying management techniques to health sector budgeting,

accounting and fund utilization [115]. The government more broadly adopted the

approach of Business Process Reengineering (led by the Ministry of Capacity Building),

which has seen several positive outcomes from a governance standpoint, including

increased capacity to plan strategically for HRH, coordinate donors, and manage donor

funding [72]. This approach is under current evaluation, among other things assessing

whether this increases the centralization of policy decisions, and the related effects [115].

Ethiopia’s MoH has also demonstrated increased personal capacity in its abilities to cost

out the activities of the national HRH plan and actively monitor the program [72].

4.4 EVIDENCE USAGE.

In developing a conceptual framework to assess capacity for MoHs to utilize evidence,

Rodriguez et al. (2017) highlight the importance of taking broad constructs and

converting them into “discrete steps” that enable capacity strengthening [26].

Furthermore, this study underscores the importance of combining programs to

strengthen individual competencies with interventions at the organizational and systems

level. Similarly, Hawkes et al. (2016) found that in organizing capacity-building efforts for

supporting evidence use within four countries, country teams more frequently organized

initiatives for building individual competencies around data sources and evidence

assessment [76]. Organizational and institutional capacity-building initiatives, however,

were found to be more challenging to implement [76].

Structurally, there are a growing number of examples of new platforms to address this

issue. They stimulate building the capacities of policy-makers to interpret, assess and

evaluate evidence, and to articulate research needs. They also support strengthening

linkages between researchers and practitioners [116, 117, 118]. Countries such as Malawi,

Zambia and India are experimenting with such knowledge translation platforms,

all involving MoHs to different extents. From a performance capacity standpoint,

platforms in Malawi and Zambia have been largely funded by external agencies, while

the platform in India is funded by the government. From a broader organizational

capacity perspective, one study notes that “administrative and political will” allows for

flexibility, innovative partnerships, and documentation of practices and guidelines [119].

4.5 REGULATION.

The United Republic of Tanzania, as in Janovsky and Travis (2010), provides a strong

example of developing capacity in regulating pharmacies and drug stories. The MoH

initiated the Tanzania Food and Drug Authority, and piloted a collaborative approach,

including sensitization of key stakeholders, training, pre- and post-inspection visits,

and supervision. This pilot approach was then scaled across the country [90]. In China,

from 2000 onwards, Ma, Chen and Tan (2015) show that structural capacities began

to address challenges in health inspection, clarifying roles for various agencies at the

national, regional and local levels. A key form of building structural capacity is by using

the results of a nationwide audit of the health inspection system to understand the

strengths and weaknesses of the system and adapt accordingly [92].


4.6 REFORM.

The MoH in Saudi Arabia recently attempted to reform service delivery in the health

sector, specifically around quality of care [120]. As illustrated by Hassanain (2017),

the mechanism for this reform was public-private partnerships with private hospitals,

and the MoH established 15 key performance indicators as a way to keep track of

reform. The government also established a Performance Improvement Unit within

the MoH to apply six sigma principles to help improve the quality and performance

of hospital-based services. Despite some initial successes, an inconsistent six-sigma

training program (due to difficulties in securing legal approval for secured time-off for

training), leadership changes, resistance from civil service employees in the Ministry,

and inadequate follow-up, meant that the performance improvement processes were

unsuccessful, and indicators returned to baseline after nine months. Based on the

lessons learned from this experience, the Ministry plans to continue with the reform

efforts, but this time with the involvement of the Central Board of Accreditation of

Healthcare Institutions, and with more nuanced analysis for each hospital [120].

4.7 VALUES.

Some MoHs have explicitly focused on strengthening governance principles within

the Ministry. For example, since 2012, Ministers of Health from over 49 countries have

participated in Harvard’s Ministerial Leadership in Health program. An independent

evaluation of these programs has found that the program successfully supported

Ministers of Health in articulating a clear and ambitious legacy for their tenure [121].

Another outcome of this program saw a significant proportion of Ministers exhibiting

more confidence in building political support for public health strengthening, and in

negotiating for increased budgets with Ministers of Finance [121].

In Mongolia, through the Health Sector Development Program funded by the Asian

Development Bank, O'Rourke and Hindle (2017) found that workshops for MoH staff

focused on several topics, including how learning organizations can create openness and

reflection, and community focus [65]. Similarly, in Uganda, a learning-by-doing approach

was adopted by the Ministry to several aspects of health sector reform [55].

4.8 MANAGING RELATIONSHIPS.

The Brazilian Observatório on Human Resources in Health is an excellent example of

strengthening the capacity of an MoH to manage relationships across stakeholders [122].

From 1999 onwards, Campos and Hauck (2005) found that the MoH served as the

secretariat for the Observatório – a network of government, university and development

partner stakeholders focused on issues of human resources for health in Brazil.

The Ministry, with the support of PAHO, has played a key role in ensuring that the

network has adequate role and performance capacity. This support has also facilitated

the strengthening of technical capacity, alongside the soft capacities of trust building,

collaborative learning, flexibility and adaptability.

40 S t re n g t h e n i n g M o H G o ve r n a n c e C a p a c i t i e s : E x a m p l e s

05

42

Section VStrengthening

Governance Capacities: Observations and

Recommendations43A D D R E S S I N G G OV E R N A N C E C H A L L E N G E S A N D C A PAC I T I E S I N M I N I ST R I E S O F H E A LT H 2 0 1 8 - 2 0 1 9

SUMMARY

This WHO Working Paper aims to inform current and future efforts to strengthen

governance capacities in Ministries of Health (MoHs) across the world. By ensuring

and promoting health and wellness for their populations, MoHs hold responsibility for

a complex array of governance roles undertaken within a rapidly changing and often

volatile political, financial, ecological and health-related context. Despite growing

attention to the issue of health sector governance – in LMICs and elsewhere – there has

to date been little attention devoted to the capacities of Ministries to actually undertake

their governance roles. In focusing on four major dimensions of governance – performing

de jure governance roles, preparing for and responding to changing contexts, managing

stakeholder relationships and managing values – this WHO Working Paper explores

individual and organizational competencies, with the overall systems capacities requiring

greater attention in further research.

With attention to six relevant categories of governance capacity – structural, role,

personal, workload, performance and supervisory capacity – this WHO Working Paper

examines how MoHs deal with current challenges and changes, especially political

transition, crises, reforms, macroeconomic trends, global policy trends and social

movements/change – along with the resulting capacity gaps that emerge. Examples

from around the world reveal how these six governance capacities influence the current

execution of specific MoH governance roles, including strategic planning and monitoring,

evidence use and development, policy development, citizen empowerment, performance

monitoring, procurement, program management, personnel management, regulating

standards, contracting and compliance, resource management, fundraising and financial

management. This WHO Working Paper also addresses how MoHs work to uphold

governance principles while also ensuring inclusive participation, managing various

governance relationships with a rapidly expanding array of stakeholders.

LESSONS LEARNED

Given this focus, what lessons can we draw from this WHO Working Paper?

First, there are significant gaps in the knowledge base requiring further research and

commentary. These include:

• Relatively little research examines de facto, tacit or relational dimensions of

governance. Few interventions focus on MoH capacities to manage relationships,

uphold governance principles and/or navigate changing contexts.

• Despite the availability of more evidence regarding mandated governance roles

for MoHs, certain aspects, including regulation and the management of contracts,

remain relatively underexplored.

• There are few studies on the human aspects of capacity – including personal,

workload, and supervisory capacities – and how these interact with role and

structural capacity. Moreover, in the body of research on MoH capacity, there remains

a significant lack of precision on the types of capacity required.

• Insufficient attention has been paid to the concept of “soft capacities,” including

means of political engagement, and how to navigate complexity, build trust and

learn reflexively. Given the multiplicity of actors in the health sector and the cross-

cutting nature of health across all levels of government, the soft capacities of an

MOH are of crucial importance; as such, this is a core challenge moving forward.

44 S t re n g t h e n i n g G o ve r n a n c e C a p a c i t i e s : O b s e r v a t i o n s a n d Re c o m m e n d a t i o n s

• Few studies utilize theory-driven approaches to studying MoHs, with specific

attention here to the disciplines of sociology, public administration and political

science [123].

Second, this Working Paper suggests that role and structural capacity initiatives are

key mechanisms to strengthen an MoH and the other agencies in their task network,

particularly given the frequent confusion and ambiguity around roles and responsibilities

in the health sector. By clarifying laws, rules and regulations, particularly in terms of

the roles and responsibilities that various national health authorities are designed to

lead, share or delegate, and by giving other mechanisms (e.g. forums, committees,

assemblies and working groups) formal sanction, Ministries might find themselves

better positioned to exercise their duties. However, careful attention must be paid to the

implementation, monitoring and continuous improvement of these capacity reforms to

ensure their effectiveness.

Third, these findings underscore the need for major reforms and investments in personal,

workload or supervisory capacity at MoHs. Personal capacity initiatives are required

across a range of governance dimensions, and Ministries must actively recruit, develop

and maintain diverse, complementary workforces at multiple levels. Building sustained

networks and partnerships across state and non-state actors will also contribute

to developing capacity within MoHs and the systems in which they are embedded.

For such initiatives to be successful, stakeholders must promote organizational

cultures within MoHs that support innovation, collaboration and calculated risk-taking.

And at the same time, stakeholders must also find strategic ways of engaging with

external inhibiting factors such as relatively low power of MoHs across government,

and bureaucratic policies that often negatively impact MoH functioning, including

frequent leadership transfers.

Fourth, and finally, the sustainability of capacity-building programs demands further

attention. In many countries, performance capacity is largely dependent on donors –

with positive and negative consequences on MoHs. For example, while donors provide

critical funding that facilitates capacity development, the withdrawal of this funding

without detailed plans for transition and sustainability can be damaging [124]. Therefore,

careful preparation by governments and donors for the sustainability of capacity

building programs – such as developing political commitment, domestic funding and

monitoring and evaluation strategies – is essential. Medium-to long-term assessments

of these programs are also needed to understand their impact on MoH functioning and

health systems performance [36, 50].

RECOMMENDATIONS

The mandates of MoHs are continuously evolving, shaped by trends that more recently

include a growing focus on universal health coverage, citizen voice and multisectoral

collaboration. We strongly encourage further investigations and discussions on this

topic, including further research and theory development, as only increased attention to

this core issue will strengthen our collective efforts to build Ministry of Health capacities

in countries across the world. Specifically, we recommend:

• Continued investment in strengthening MoH capacities alongside the ongoing

documentation of these experiences to better capture the breadth of an MoH’s

organizational capacity, and its depth in terms of specific governance roles.

• Application of the framework in specific country contexts to map, assess or improve

MoH capacities for governance, and then incorporate lessons from those experiences

to further refine and improve the framework.


• Continued development and documentation of approaches to strengthen MoH

“soft capacities,” including navigating complexity, learning collaboratively, engaging

politically and being self-reflective.

• Creation of mechanisms for sharing best practices and cross-learning across MoHs

regarding governance and capacity.

• Identification of approaches to monitor, measure and/or assess the progression from

processes (governance roles) to outcomes (performance areas) for MoHs.

• Exploration and analysis of governance capacities at the sub-national level, and the

flow of capacities between national and sub-national levels.

• Advancement of rigorous, theory-driven research of MoH governance capacities,

including the utilization of concepts and methods from political science, sociology

and public administration.

This WHO Working Paper has examined the interface between governance and capacity

in MoHs, and presents both a multidimensional framework and results from a scoping

review of the literature. We encourage further reflection, research, and reform on this

critical topic, with the goal of contributing to lasting improvements in population health

and health equity for populations around the world.


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In addressing the big societal challenges of today – from containing communicable

diseases to offering health services at all levels – how equipped is a Ministry of

Health (MoH) to govern? Ministries or Departments of Health have a unique mandate

over population health, charged with ensuring the health and wellness of millions.


How can we better understand the terms “governance” and “capacity” as applied to an

MoH? What are some strong country examples from which we can collectively learn?

And how can we better assess the ways in which an MoH changes and adapts to very

dynamic context?

In this WHO Working Paper, we seek to understand and illustrate this interplay between

governance and capacity in Ministries of Health across the world, and offer a range of

practical examples and recommendations.

Addressing Governance Challenges and Capacities in ...

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