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A Review of Health governance: definition, dimentions and tools to govern

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 Health Policy 116 (2014) 1–11

Contents lists available at ScienceDirect

Health Policy
journal homepage: www.elsevier.com/locate/healthpol

Review

A review of health governance: Definitions, dimensions

and tools to govern
Erica Barbazza ∗ , Juan E. Tello
WHO Regional Office for Europe, Marmorvej 51, DK-2100 Copenhagen, Denmark

a b s t r a c t
a r t i c l e i n f o
Background: The premise that good governance will ultimately lead to better health out-
Article history:
comes has been central to the proliferation of work in this area over the past decade.
Received 2 July 2013
Received in revised form Objective: To consolidate and align literature on governance by presenting an overview of
11 December 2013 efforts to define, describe and operationalize the health governance function.
Accepted 7 January 2014 Methods: A targeted review of governance literature.
Results: (1) A variety of terms have been assigned to precede health governance definitions.
These terms commonly describe governance ideals (e.g. good, democratic) or characteris-
Keywords: tics of the organization of actors in governance arrangements (e.g. hierarchical, networked).
Health governance (2) Dimensions of governance are defined from different perspectives and in varied combi-
Stewardship
nations, capturing values, sub-functions and/or outcomes of governance. (3) Tools used to
Health systems
govern remain to be cataloged, however, measures can be aligned according to dimensions
of governance or their ability to create specific relationships between actors.
Discussion: Resolving the conceptual confusion around health governance requires recog-
nition for the differences in the premise and approaches taken to defining governance, as
well as specifying core dimensions and aligning applicable tools.
Conclusion: Despite a growing literature base, a concerted effort is needed for a more acces-
sible understanding of health governance that is both practical at present and actionable
for policy-makers.
© 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction actors in health [6–10] has allowed for the function to

Governance – either in terms of leadership, stew-
ardship, regulation, oversight or governance itself – has
repeatedly been asserted as a core function in theories
and frameworks on health system [1,2]. The World Health
Organization (WHO) first framed the concept as ‘stew-
ardship’ in the World Health Report 2000, defined as “the
careful and responsible management of the well-being
of the population” [3, p. 45]. Later iterations of WHO’s
systems-thinking [4,5] and work from other dominant
∗ Corresponding author at: WHO Regional Office for Europe, DSP-HSD,
Marmorvej 51, DK-2100 Copenhagen, Denmark. Tel.: +45 45 33 69 09;
fax: +45 45 33 70 01; mobile: +45 91 67 96 57.
E-mail addresses: est@euro.who.int (E. Barbazza),
jet@euro.who.int (J.E. Tello).
mature and evolve, characterized at various stages as ‘stew-
ardship’, ‘leadership’ and/or ‘governance’ [hereafter ‘health
governance’]. Complemented by a continuously growing
literature base, there is now clear and compelling consen-
sus about the importance of the health governance function
and its role in ensuring that priorities for population health
and well-being are realized.1
1
A chronological account of health stewardship and governance has
been detailed in other literature (see [1,8]). Pertaining to the WHO, this
includes the endorsement of leadership and governance in its framework
for strengthening health systems in 2007 [4]. In the European Region, this
has also included an affirmed commitment to the stewardship function
in 2008 at a ministerial conference in Tallinn, Estonia. More recently, the
adoption in the European Region of the guiding policy framework, Health
2020, has prioritized improving leadership and participatory governance

0168-8510/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.healthpol.2014.01.007
2 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11
While solidified in its importance, the health gover-
nance function itself remains an elusive concept to define,
assess, and operationalize [11–13]. This has historically
been attributed to an absence of conceptual thinking
[11,14]. However, the premise that ‘good’ governance will
ultimately lead to improved health outcomes has been the
presumption motivating the study of health governance
with renewed vigor over the past decade [4,6,15,16]. The
conceptual chaos that has followed can be viewed as an
effect of the lack of consensus on nomenclature, mod-
els and measures for governance in the health domain. In
the absence of conceptual agreement, the comparability of
literature and the extent to which findings obviously con-
verge toward a common understanding of the concept has
been compromised [11].
Adding to the conceptual challenges is the changing
context of government and society, which has necessitated
the continued evolution of the health governance function.
Global trends – such as changing population demograph-
ics and epidemiology, widening social inequalities, and a
context of financial uncertainty [7,10,11] – has influenced
health system priorities and subsequently the setting of
the health governance function. A shift in the general
architecture of health systems can also be observed, as sys-
tems move toward increasingly decentralized structures,
engaging diverse and heterogeneous networks of actors2
for generating resources, delivering services and financing
care [7,17]. The emerging consensus that health is a prop-
erty of many complex systems and dynamic networks has
demanded new and formal interactions with varied actors,
found often beyond the domain of health itself [10].
Faced with such trends, the boundaries of the health
sector appear to be less clearly defined and the collec-
tive interaction needed across ministries, including social
services and education for example, is importantly real-
ized. In effect, the health governance function has become
increasingly diffused and the relationships between actors,
largely ambiguous. A concerted effort is thus needed to
resolve conceptual confusion on health governance, while
also attempting to evolve earlier notions of governance to
respond to health and health systems of the 21st century.
Ultimately, a clearly (re)defined vision for the health gov-
ernance function must be seen a means rather than an end
in itself, to then address an arguably more pressing agenda:
the needed arsenal of policy tools and instruments to then
create the conditions for improving the health and well-
being of populations [10].
2. Purpose and rationale
In this review, we aim to consolidate and align the liter-
ature on health governance by presenting an overview of
governance literature pertaining to health since its initial
for health as one of two main strategic objectives toward improved health
and well-being of populations [9].
2
Actors in health are broadly characterized here as those individ-
uals, organizations, groups or coalitions that have the capacity to exert
influence over policy or decision-making or are mandated with the
responsibility to carry out a particular aspect of a given health system
function [64].
introduction as ‘stewardship’ in the year 2000. Earlier liter-
ature on governance in the public and development sector
is considered more generally, recognizing this as a start-
ing point for much thinking on governance in the health
domain. Consideration has been given exclusively from a
national health systems perspective, seeing the purview,
potential influence and formal application of governance
tools taking a unique quality at this level, and thus, meriting
a targeted reflection. In chronicling the growing body of lit-
erature on health governance among leading international
organizations that have contributed to this field overtime,
we hope to contribute to an understanding of health gov-
ernance that is most meaningful and accessible to those in
a national stewardship role. This is seen here as a necessary
prerequisite to then position further study on health gov-
ernance that is also responsive to the context of the 21st
century.
To this end, the review attempts to consolidate the
findings around the following key questions: how is gov-
ernance defined; what dimensions are commonly used to
describe governance; and what are the common tools used
to govern?
3. Methods
A restricted review of literature was conducted. The
perspective of governance taken here is that of a national
public steward and the governance function is framed
according to this role. The work of international organiza-
tions in health governance was deemed most relevant for
this perspective. While giving focus to the work of primar-
ily international organizations has narrowed the breadth
of literature, this inclusion criteria is felt merited by the
unique mandate of such actors; supporting the process of
translating more conceptual thinking into policy tools and
instruments and with the work of such actors speaking to
an audience of policy-makers and system stewards with
national public officials as the target.
As the work of these organizations is primarily pub-
lished outside of academic literature, the websites of these
key actors were searched, namely: WHO and the works of
its Regional Offices, the World Bank, the United Nations
Development Programme (UNDP), the Organization for
Economic Cooperation and Development (OECD), the Euro-
pean Commission, the Council of Europe, Management
Sciences for Health (MSH) and the United States Agency
for International Development (USAID).
Additional searches were conducted using PubMed and
Google Scholar to identify scientific literature on gover-
nance in general and pertaining to health in particular.
Governance in the health domain was considered from
varied orientations, including the following: health gov-
ernance, stewardship or leadership and management;
governance of specific health system functions (e.g. gov-
ernance of medicines and technology); or frameworks
for overall health system strengthening. Online searches
included various combinations of the following key
words: ‘health’, ‘health systems’, ‘governance’, ‘steward-
ship’, ‘framework’, ‘mechanisms’ and ‘tools’. Experts in the
field were consulted in order to gain further access to rel-
evant sources of literature. The reference lists of literature
 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11 3

deemed relevant for analysis were each additionally con- Table 1

Governance frameworks reviewed.
sulted and relevant works distilled.
In selecting literature, preference was given to those Area of study Number (n = 39)
that have offered a definition of governance and/or have A. Health
described the governance function according to a dis- I. Stewardship 5
crete combination of dimensions. Attention was given II. Governance 13
here seeing these efforts as attempts to position a III. Health system function-specific 3
IV. Health system performance/strengthening 6
more operationalized governance function by making its
assessment
characteristics more accessible to those in stewardship V. Management 3
and leadership roles. While health governance has been
B. Public sector
informed by the study of related fields, such as the broader I. Stewardship 1
political sciences sphere, this review has aimed to remain, II. Governance 8
as far as possible, to work related to health and health sys-
Note: The publications considered here are exclusively those that were
tems. As discussions surrounding health governance are identified to have reviewed or defined a discrete number of governance
formally considered at the national level, we again take dimensions. This literature is felt to allow a unique synthesis of concep-
this orientation and have thus excluded work pertaining to tual thinking for defining and operationalizing the governance function.
Notably, this is to the exclusion of additional governance literature that
governance in the context of regional or local health care
has been reviewed and informs the findings and discussion to follow.
settings.
The process of data collection and review took place
engagement, accountability, power and institutional
between the months of September 2012 and March 2013.
authority, ownership, political stability and the rule of law
Aside from two exceptions [18,19] literature has been con-
– has posed a challenge to find a universally accepted def-
sidered from 2000 and onwards.
inition both within and beyond the health domain [36].
Despite the complexities and multidimensionality inher-
4. Findings
ent to governance, there does however appear to be general
consensus that the governance function characterizes a
In total, 39 publications were deemed relevant for
set of processes (customs, policies or laws) that are for-
review; 30 publications either defined the health gov-
mally or informally applied to distribute responsibility or
ernance (stewardship) function according to a discrete
accountability among actors of a given [health] system
number of principles, dimensions, elements or attributes
[4,6,13,14,19].
or to operationalize the function according to specific
Among international organizations, definitions of gov-
indicators and a further 9 publications defined gover-
ernance commonly frame these processes in terms of
nance (stewardship) within the public or development
strategies to reduce corruption and make government
sector [18–26]. While outside of the health domain, these
more efficient (Table 2). An initial departure from this gen-
works were found to have influenced the development
eral governance discourse to governance as it pertains to
and conceptualization of literature pertaining to health
health has been notably marked by the World Health Report
governance when considered chronologically. The objec-
2000 – retraced in a chronological account of health sys-
tives, how dimensions have been described and the specific
tems thinking as a response of WHO to calls for better
dimensions identified pertaining to each can be found in
governance from the World Bank [1]. The term ‘stew-
a web appendix (Table w1). The publications themselves
ardship’ was then introduced to define the steering and
should be further consulted to appreciate the specific def-
regulation role of national stewards within health systems
initions and the orientation taken.
toward improved performance and related gains in health
Supplementary material related to this article can be
outcomes [1,3]. This notion of health stewardship impor-
found, in the online version, at http://dx.doi.org/10.1016/
tantly distinguished health governance as a domain in itself
j.healthpol.2014.01.007.
which has since been refined and characterized through a
Additional publications were identified to take a nar-
number of efforts (such as [2,4,8,13,14,17,37–39]).
rower approach to governance, specifying an element of
The challenge to establish a universally accepted defini-
governance (e.g. accountability [27–30]), or the governance
tion of governance has been met with further confusion as
of a specific health system function (e.g. pharmaceuticals
to the distinction between the concept of stewardship from
[31,32] or human resources [33]). We could identify two
that of leadership and governance. While related, the par-
other reviews exclusively on governance applied to the
ticularities of each demand their specific use, despite their
health sector [34,35]. These works are felt to differ in con-
more common application as synonymous terms. Efforts
text and scope from that taken here, offering limited insight
to differentiate the stewardship function in the literature
into the congruence (or lack of) in prevailing approaches
appeal to its key element of direction – a central tenet to
taken to define and operationalize the health governance
the stewardship function that has been captured through
function overtime. A summary of the literature reviewed is
a number of images and analogies3 [8]. The task of system
found in Table 1.

4.1. How is governance defined? 3

The Institute for Government (2011) illustrates the stewardship func-
tion using an analogy to the game of football: like a steward, a football
The intrinsically broad concept of governance – manager sets an overall goal for the team [actors] to be guided by; a set of
encompassing systems of representation and citizen basic rules are put in place (e.g. do not use hands), defining the boundaries
4 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11
Table 2
Governance defined according to international organizations.
Organization Governance defined
European Commission “The rules, processes, and behaviour by
which interests are articulated, resources
are managed, and power is exercised in
society” [40, p. 3]
World Bank “The traditions and institutions by which
authority in a country is exercised. This
includes the process by which
governments are selected, monitored and
replaced; the capacity of the government
to effectively formulate and implement
sound policies; and the respect of citizens
and the state for the institutions that
govern economic and social interactions
among them” [19, p. 1]
UNDP “The exercise of political, economic and
administrative authority in the
management of a country’s affairs at all
levels” [18, Sec. Executive Summary]
USAID “The ability of government to develop an
efficient, effective, and accountable public
management process that is open to
participation and that strengthens rather
than weakens a democratic system of
government” [13, p. 1]
WHO Leadership and governance “involves
ensuring that strategic policy frameworks
exist and are combined with effective
oversight, coalition building, regulation,
attention to system-design and
accountability” [4, p. 3]
stewardship can then be said to include defining an over-
arching vision for the health system and establishing the
boundaries in which the system’s actors operate [41–43].
Characterizing stewardship according to its unique
quality of direction, the governance function then distinctly
describes the specific efforts and processes that are applied
to steer the system toward this given priority. This includes,
for example, the use of different tools to establish a set of
rules and incentives for a system of regulation [8]. Taking
this example further, the quality of leadership would then
characterize the capacity of the system to initiate, imple-
ment and monitor a regulatory system, as well as the ability
to organize and manage the alignment of all relevant actors
and actions engaged in processes pertaining to this.
Further discussion of common governance (stew-
ardship, leadership) definitions and their underlying
assumptions and implications has been addressed else-
where [12,13,35,39,43,44]. In place of this, consideration
is given now to common terms assigned to preface gov-
ernance definitions, characteristic of a prefix added before
the term to introduce a new meaning or concept. By first
cataloging the terms frequently used in combination with
governance, we then examine the basis on which each have
been derived and how the underlying premise of these
by which players [actors] must perform; the manager watches the game
to assess overall performance; and in response, the manager may change
the team’s tactics or formation. Analogies have also been drawn between
the stewardship function and the role of a steersman, using cybernetic-
systems (derived from the Greek word kybernetes – a steersman), whereby
stewards hold the responsibility for ‘steering the ship of state’ [41].
Table 3
Common values and descriptive terms preceding governance definitions.
Values Descriptions
Democratic [45–47] Horizontal (shared) [48,49]
Good [18,22,50–53] Networked [10,21,42,54]
Good enough [44] Hierarchical [21,41,42,55]
Smart [10,56] Market-based [21,42]
terms weighs on the interpretation of how governance is
defined. In doing so, we categorize these terms accord-
ing to two groupings: (1) values of governance (e.g. ‘good’
governance), depicting not what is governance, but rather
what governance ought to be; and (2) descriptions of gover-
nance, characterizing terms used to capture varied types of
arrangements in order to carry out the governance function
(e.g. ‘horizontal’ versus ‘vertical’ governance) (Table 3).
The use of values including ‘democratic’, ‘smart’ and
most frequently – ‘good’ – in defining governance, take a
similar approach to describe a governance ideal [44]. While
defining governance according to these values appears
common, the added value of the approach itself remains
contested. For example, Savedoff [39] noted definitions are
more useful analytically and for policy if assessed in terms
of impact on performance rather than a set of normative
principles. Similarly, as Grindle describes, the overwhelm-
ing agenda of ‘good’ governance fails to support priority
setting or practical efforts in defining a sequence of actions
and is ultimately limiting in the ability to separate “an ideal
state of good governance from one that is ‘good enough”’
[44].
These normative notions can be distinguished from
terms of a more descriptive quality, which are found
to connote a type or arrangement to approaching gover-
nance. This approach considers more so the architecture of
relationships, being attentive to the interactions between
actors (how authority and responsibility is distributed)
and the spaces between them (how authority and respon-
sibility is applied) [36]. The use of descriptive terms to
capture this structure appears increasingly common, as tra-
ditionally centralized, hierarchical notions of governance
do not sufficiently capture the context of contemporary
government and society [48]. ‘Horizontal’ or ‘networked’
governance for example, appreciate the need for gover-
nance arrangements that take into account multiple nodes
of power, interests and activity among an increasingly
diverse arrangement of actors [10,29,48]. This is in con-
trast to more traditional, linear notions of ‘hierarchical’ or
‘ministerial’ governance where decisions over policy devel-
opment and implementation were characterized by more
centralized processes [48].
As the governance function becomes increasingly
dynamic and diffused, the utility of more descriptive
terms capturing the numerous actors and the sophistica-
tion of their arrangement appears evident. However, as
Kettl [57] cautions, arrangements or approaches to gover-
ning are not mutually exclusive and require contextualized
interpretation. For example, while ‘horizontal’ governance
arranagements may be observed to a greater extent at
present, these relations have not necessarily superseded
more traditional, hierarchical governance arranagements
 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11
and rather, reflect the addition of hortizontal linkages to
those of more a top-down, veritical orientation [25,57].
4.2. What dimensions are commonly used to describe
governance?
The composition of the governance function within and
beyond the health sector has been conceptualized accord-
ing to a number of dimensions – synonymous here with
components, elements, principles or attributes of gover-
nance. Drawing on a subset of the literature reviewed, we
map those dimensions of governance most frequently cited
in the various attempts at characterizing the health gov-
ernance function (Table 4). Only those dimensions that
have been explicitly defined are shown, as the exercise has
given priority to understanding the aspects deemed most
inherent to the governance function. It is recognized that
a number of additional dimensions may be alluded to or
included in the context of others. However, capturing the
intricacies of more implicit dimensions was seen to extend
beyond the intended general overview across the litera-
ture. Thus, the table should be read as merely the discrete
dimensions of governance defined and further attention to
their respective definitions should be considered in order
to draw conclusions beyond the following observations.
From this mapping a considerable degree of variability
in the specific dimensions used to define the governance
function is clear. For example, some dimensions such
as ‘accountability’, ‘regulation’ or ‘formulating policy and
defining a strategic direction’ are included fairly consis-
tently across frameworks, while others, such as ‘rule of
law’, ‘conflict prevention’ and improvements in ‘quality’
or ‘sustainability’ are less so. Additionally, looking to the
frameworks themselves, the number of dimensions varies,
from a comprehensive arrangement of dimensions (e.g.
Council of Europe [17]; HealthGovMonitor [53]), to sim-
plistic groupings of three or four (e.g. Lewis and Pettersson
[38]; Smith et al. [42]).
At closer examination, further observations can be
made. Firstly, while arranged chronologically, the inclu-
sion/exclusion of dimensions appears variable, lacking
an accumulation of insights toward a refined number
and combination of governance dimensions at present.
However, attributing these fluctuations to differences in
the orientation or purpose of a given approach, there
then appears to be further consensus around what might
constitute ‘core’ governance dimensions from a given per-
spective. For example, in the 2009 framework of the WHO
Regional Office for the Eastern Mediterranean [14], ‘rule of
law’ is reintroduced as a dimension [principle] of gover-
nance, despite related earlier works excluding this same
principle, such as WHO [4] and WHO Regional Office for
Europe [8]. The inclusion of this dimension of governance
in the 2009 framework better aligns with the explicit con-
nection to more political dimensions similar to the earlier
work of the World Bank [19] and UNDP [18].
Secondly, the compatibility of grouping the dimen-
sions into one-like concept of governance appears to be
limited in recognition of fundamental differences in their
frame of reference or unit of analysis. This variability
in dimensions themselves and the importance of their
5
further classification to rectify qualitative differences has
been acknowledged in a number of works [2,12,17,39].
As Baez-Camargo and Jacobs argue, “categorizing these
dimensions and providing theoretically informed pre-
sumptions about causality links among them is a first step
to give governance analysis greater explanatory power
and to therefore increase its potential for having empirical
applicability” [12].
Across the literature, a number of categorizations have
been proposed, grouping dimensions of governance into
the following: governance inputs, processes, and outputs
[12,58]; principles of governance and core governance
concerns [21,22]; governance performance, governance
determinants and governance context [39]; enablers, out-
comes and core values of governance [17]. In keeping
with the characteristics of these earlier groupings, we have
aligned the common dimensions of governance identified
according to three distinct types: (1) those characterizing
the primary concerns of the governance function, serv-
ing as the guiding values or principles expected of ‘good’
governance; (2) those operationalizing the function of
governance itself, specifying subsidiary (sub-)functions as
actionable processes for which the system’s steward has
oversight; and (3) those specifying outcomes or goals of
strengthened governance, serving as potential indicators
for measuring improvements (Table 4).
Grouped in this way, the comparability across dimen-
sions is improved further and consensus on a subset of
core dimensions of governance – slightly strengthened.
For example, fundamental values of governance, such as
‘conflict prevention’ and ‘control of corruption’, while not
explicit in each framework, are arguably underpinning
‘good’ governance universally. Similarly, outcomes of gov-
ernance, such as ‘effectiveness’, ‘efficiency’, ‘quality’ and
ultimately ‘improved health’ can be viewed as implicit to
each of the definitions of governance, irrespective of how
they have been explicitly described. Sub-functions of gov-
ernance then uniquely describe the processes of governing
and related actions, such as enabling partnerships among
actors and ensuring organization adequacy or the appro-
priateness of the system’s design. Understanding further
the sub-functions of governance is then of great relevance
to governance strengthening, recognizing the operational
quality of these dimensions which lends itself best to a
practical assessment of current governance processes and
opportunities for improvement.
Finally, while an in-depth review of the specific dimen-
sions themselves has not been reflected in the mapping
of frameworks, we do observe variability in the scope
and core qualities of the dimensions themselves. Tak-
ing ‘accountability’ as an example, despite being one of
the most commonly cited dimensions of governance, an
equally common definition itself appears to be lacking.
Most simply stated, accountability is characterized as the
state of being answerable for one’s decisions and actions.
However, the institutional relationship of accountability
is described according to a variety of different compo-
nents. This has been found to include; (1) processes of
accountability, defined according to sequential steps such
as standard setting or delegation, resource allocation, per-
formance, investigation or information about performance,
 6
Table 4
Common dimensions of governance across literature reviewed.

Authors chronologically

World Bank (1999)

HealthGovMonitor
UNDP (1997) [18]

Smith et al. (2012)

Jacobs (2011) [12]

Wendt (2012) [58]

Council of Europe
WHO (2000)* [3]

Islam (2007) [21]

Mikkelsen-Lopez
Pettersson (2009)

Baez-Camargo &

MSH (2013) [45]

WHO (2007) [4]

Savedoff (2009)

Gleicher (2012)
et al. (2011) [2]
WHO/EURO

Siddiqi et al.

Kaplan et al.
Kickbush &
Travis et al.
(2002)* [6]

(2008)* [8]

(2009) [14]

(2011) [37]

(2012) [24]

(2013) [43]
Dimensions of governance

Lewis &
[20]

[22]

[23]

[10]

[39]
Fundamental values
Control of corruption

E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11

Democracy
Human rights
Ethics and integrity
Conflict prevention
Public good
Rule of law
Sub-functions
Accountability
Partnerships
Formulating policy/strategic direction
Generating information/intelligence
Organizational adequacy/system design
Participation and consensus
Regulation
Transparency
Outcomes
Effectiveness
Efficiency
Equity
Quality
Responsiveness
Sustainability
Financial and social risk protection
Improved health

Note: A shaded box is used to identify the explicit reference to a given element in the work of the corresponding author(s). The three groupings applied (fundamental values; sub-functions; outcomes) are the
authors’ own and therefore may not be explicitly used to characterize dimensions in the respective works.
*Refer to health stewardship.
 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11
and enforceability with rewards or sanctions [27,30,60];
(2) accountability arrangements, such as ‘horizontal’, ‘ver-
tical’, or ‘networked’ accountability [27,29,48,61–63]; and
(3) types of accountability, including financial, performance
and political/democratic [11,15] accountable-relations.
In seeking to operationalize the governance function
according to a discrete number of dimensions, there
remains work to define these variables and give greater
consistency to the scope and processes for each. Furthering
this practical aspect of health governance will additionally
require measurable indicators validated through first-hand
country experiences.
4.3. What are the common tools used to govern?
Actors of health systems do not behave in random
ways [64]. Their performance and interactions are indeed
shaped by strategic leadership and management. Those in
an oversight role must be equipped with applicable tools –
instruments, mechanisms, measures – that exist to enable
the governance function and to steer the system toward
defined goals [8,64]. These tools used to govern have been
characterized as catalysts that facilitate or rather, ‘enable
the conditions’ for aligned action by setting out a frame-
work and making explicit the ways in which actors of
the health system are expected to perform and interact
[6,8,65]. They do so, as described in the World Health Report
2000 [3], by defining the ‘rules of the game’ – the formal or
informal rules that determine the boundaries within which
the system’s actors operate [25].
Despite the growing literature base on conceptual
notions of health governance, thoughtful study of the tools
needed to govern remains underdeveloped. We find there
is then an absence of a clear, consistent evidence-base of
tools that is accessible to support health system stewards
in carrying out their role. Understanding the tools available
and their uses is of particular relevance for public stew-
ards in the context of modern health systems – a setting
of diffused, pluralistic relations with actors from different
sectors and levels and with varied interests and functions –
where new or different combinations of existing tools is
necessitated [10].
Nevertheless, varied tools can be identified in the lit-
erature, which are commonly applied when carrying out
the governance function. A non-exhaustive list is shown
in Boxes 1 and 2 where these tools to govern have been
aligned to distinguish two different orientations to thinking
of their use.
The first (Box 1) aligns tools according to the common
dimensions of governance that have been identified and
characterized here as ‘sub-functions’ (see Table 4). In doing
so, this approach recognizes that tools, as enablers for car-
rying out the governance function, vary according to the
processes of a given sub-function itself [8,17,29,64]. For
example, taking ‘participation and consensus’ as a dimen-
sion of governance, then the processes to carry out this
function may involve ‘generating dialogue’ and ‘receiv-
ing feedback’ among varied health system actors including
importantly, providers and the public [2,14,58]. The spe-
cific tools to generate participation along these lines may
then include national health forums [8], open meetings [10],
7
Box 1: Common tools used to enable sub-
functions of governance.
Accountability
Performance-based contracts [38]
Fair competitive elections, systems of judicial redress, procedures to
combat corruption [28]
Pay-for-performance techniques [8]
Partnerships
Inter-ministerial and interdepartmental committees [10,66,67]
Public-private task force [67]
Integrated budgets and accounting, co-funding arrangements or
earmarked grants [10]
Cross-cutting information education systems [10,58]
Common workforce training, qualifications, support and advice [10]
Ad-hoc, initiative-specific committees [68,69]
Formulating policy/strategic direction
National health plan [43]
National targets, goals and performance measures [43,70]
Multi-year strategic plan [7,70,71]
Policies, operational guidelines, training manuals, protocols [43]
Medium-term expenditure frameworks and national health accounts
[8,66]
Targets- and priority-setting techniques (e.g. WHO-CHOICEa ) [8]
Generating information/intelligence
Commissioned reports by independent researchers [64]
Interministerial fact-finding commissions or task force;
parliamentary investigations [5,59]
Periodic audits, public expenditure and performance reviews [6,17]
Health technology assessments [17]
Internationally recognized tools for conducting a situation analysis
(e.g. HMNb Health Information Systems Situation Assessment Tool)
[71]
Health impact assessment; environmental impact assessment;
geographic information systems, or health needs assessment [8,68]
Patient reported outcome measures (PROMs) [17]
Organizational adequacy/system design
Implementation or annual operational plan [72]
Monitoring and evaluation plan [7,58,71]
Training/personnel manuals [69,70]
Mission/vision statement, organizational chart [7,17,53,72]
On-the-spot training measures [66]
Peer-to-peer learning programs [73]
Participation and consensus
Open meetings, public workshops, national forums, citizen advisory
committees, citizen juries [10,59,69,71]
Satisfaction surveys [74]
Sector-wide approaches [8]
Consensus conferences [8,68]
National health forums [8]
Formal consultations in drafting legislation [68]
Regulation
Rules, procedures, decrees [6]
Codes of conduct [8,58,59,69]
Performance standards, accreditation, licensing/certification [7,69]
Statutory bodies (e.g. national regulatory agency) [32]
‘Hard laws’ (binding legislation); ‘soft laws’ (non-binding
recommendations) [68]
Transparency
Watch dog committees (facility boards, health authority,
ombudsman, parliamentary committees) [6,8,10,21]
Releasing performance information to providers and the public [8]
Inspectorates, fact finding commissions [64]
Publically available budgetary and financial information [10]
Citizen report cards [10]
Conflict-of-interest boards [10]
Note: The tools presented is a non-exhaustive list; tools may apply
to more than one of the noted dimensions, however, their inclusion
is shown only once to minimize repetition.
a
WHO-CHOICE: the WHO project on Choosing Interventions that
are Cost-Effective.
b
HMN: Health Metrics Network.
8 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11
Box 2: Common tools used to enable types of
relationships.
Control
Contracts [38]
Laws and declarations [10]
Market-based instruments (taxes, charges, fees) [10]
Regular internal/external audits (financial, clinical, quality)
Capacity to reward or sanction performance of individuals and
organizations [64]
Coordination
Common workforce training, qualifications, support and advice [10]
Professional advisory committees (national, regional, local and
institutional) [6,8,10,21]
Joint strategic planning [64]
Financial measures such as cost-sharing, resource pooling or
integrated budgets [7,10]
Collaboration
National partnership platforms [10]
Inter-ministerial and interdepartmental committees [10]
Co-funding agreements and earmarked grants [10]
Ad-hoc committees on specific initiatives [68,69]
Partnerships with civil society or NGOs [75]
Communication
Opportunities for public consultation or feedback [10,59,69,71]
User-friendly complaint system [17]
Satisfaction surveys [74]
Publically available budgetary and financial information [10]
Watchdog committees (political, non-governmental, mass media)
[10]
Consensus conferences [8,68]
Note: This Box reflects a sub set of the tools of Box 1 arranged
according to the relationships that may be enabled. This too is a
non-exhaustive list.
citizen juries [10], and consensus conferences [8,68], among
others.
A second orientation considers tools according to differ-
ent types of relationships or networks among actors that
they can be used to enable (Box 2). These are commonly
characterized in the literature as relationships of control,
coordination, collaboration and communication [10,29,64].
Relationships of control describe more authoritative, com-
mand and control interactions, whereby stewards have
direct capacity to enforce accountable-relations, for
example, through formal laws or administrative rules
[25,29]. Relationships of coordination (cooperation) share
in a similar use of more formal tools however, they
differ in that they do not require direct command and
control linkages. Rather, relations of coordination are often
intended to enable interactions that are supportive of the
joint management of activities through processes that are
formalized and built on mutual dependence [64]. Relation-
ships of collaboration may be established on shared values
and goals or mutual interests but without formalized mea-
sures that are characteristic of control and coordination
[29]. As a more informal interaction, it is recognized that
collaboration has less enforceability and maintaining such
interactions requires greater attention and use of tools
overtime [64]. Finally, relationships of communication
have been commonly characterized as the most informal
relationship between actors, intending to simply allow
dialog and improve the exchange of information.
In contemporary health systems, it is unrealistic that
one type of relationship will suffice. For example, solely
enabling relationships of control may create centralized
authority and contribute to inefficiencies. Similarly, think-
ing to tools for varied dimensions of governance, public
stewards have the challenge to identify the ideal combina-
tion of tools which, given the variability in their functions,
is no easy task. For example, as Travis et al. describe,
there is a delicate balance between ‘too much’ and ‘too
little’ formal, regulatory measures. Moreover, it is recog-
nized the same instruments can have different effects in
different settings [6,8,10]. There is also the potential for
conflicts and contradictions between tools used in com-
bination, thus demanding very strategic considerations to
ensure their agreement. Moreover, other tools may require
their combined use to achieve a given end (for example,
accountability arrangements may require both the gener-
ation of information through tools such as auditing but
also the enforceability of findings through tools such as
performance-based contracting).
Ultimately, the strategic and purposive use of tools
to govern is an essential component for carrying out
the health governance function and is central to the
effectiveness of the public stewardship role. From either
orientation – tools to enable specific dimensions of gover-
nance or tools to enable a given relationship – the steward
faces the same challenge to distinguish the ideal circum-
stances and boundaries for the system’s actors that will best
define their collective and aligned performance.
5. Discussion
Following the introduction of stewardship as a core
health system function there has been an initially slow but
steady increase of literature in this field. This is driven at
present by the priority given to health system strength-
ening toward improved population health and well-being.
Despite this interest and activity, there remains a persisting
challenge to communicate with greater consensus a clear
and actionable health governance function.
While not necessarily pursuing an ultimate, universal
model or definition to health governance – recognizing
varied worldviews and applications that may deem this
irrelevant – there does appear to be the important need for
improvements in the accumulation of insights by adopting
a shared frame of reference when speaking of definitions,
dimensions and tools to govern. For example, governance
defined as an ideal (e.g. ‘good’ governance) and governance
defined by the structure of its institutional relationships
(e.g. ‘networked’ governance) offer very different insights
into an understanding of the function. Acknowledging
these differences is necessary to resolve the chaos that pre-
vents health governance from becoming a more accessible
health system function for those in stewardship and lead-
ership roles.
Moving forward, with this understanding of where we
are in the current literature, we note the following points
for consideration in future study in the health governance
domain.
What is the utility of terms assigned to precede gover-
nance definitions? Further efforts to define governance must
acknowledge the fundamental differences in terms that can
be used as a prefix to introduce governance with greater
consideration given to the implications of each. This is of
 E. Barbazza, J.E. Tello / Health Policy 116 (2014) 1–11
particular importance when prescribing a value to describe
an ideal state of governance as the added value of this
remains contested. Reflecting on the differences in the
approach to definitions, it may then be possible to better
communicate their intentions and facilitate their accurate
interpretation.
How can governance dimensions be further classified? The
operational quality of the ‘sub-functions’ identified as com-
mon dimensions of governance are of particular relevance
for unpacking the governance function. However, the lack-
ing consensus within each of these dimensions regarding
their scope and purpose requires further attention and
refection on each to resolve if they are in fact mutu-
ally exclusive and their respective characteristics. Seeing
the function of governance as a process, there is also the
opportunity to consider a potential sequencing to core
dimensions of governance identified.
How can a common platform for the exchange of gover-
nance tools best be defined? Identifying tools to govern is
arguably the most needed effort to the study of health gov-
ernance in order to support public stewards in carrying out
the governance function [42,59,68,76]. To arrive at com-
mon denominator tools and instruments for governance,
a concerted effort is needed to best differentiate tools
and describe their application. Needed also are practical
assessment resources that allow a diagnostic assessment
of existing governance arrangements. This is necessary to
first develop an understanding of the existing institutional
context to then identify governance gaps – a misalign-
ment between the actions of actors across and within the
dimensions of the governance function – in order to be
in a position to strategize applicable tools that may rec-
tify this. Consideration must also be given to the variability
in tools at different levels (national, regional, institutions)
where the tools accessible may differ by the authority and
mandate of those in stewardship roles.
As a modest attempt to systematize the state of the
art on health governance, this review did not intend to
tackle debates like that of leadership versus stewardship.
Moreover, in taking the perspective of a national health
system steward, we have not given consideration to the
related concept of governance for health and well-being.
Nevertheless, this concept is of great importance to extend
thinking beyond the health system itself, calling for inter-
sectoral action to tackle the multifaceted determinants
of health and reduce persisting health inequities. While
related, the two concepts – health governance and gov-
ernance for health and well-being – remain distinct, giving
emphases to different dimensions of governance and appli-
cable tools. Through the continued refinement of the health
governance concept, aligned with the broader study of gov-
ernance for health and well-being, great strides can be
made to ensure both concepts are accessible to those in
leadership roles.
6. Conclusion
Understanding the body of literature on health
governance is necessary to effectively apply governance
theories to contemporary government and society. This
work has aligned the growing body of literature on health
9
governance and related works of particular relevance in the
development of this field from the perspective of national
health stewards. In doing so, the challenges to define gov-
ernance, characterize the function according to specific
dimensions and catalog the available tools to govern have
been noted. This review has attempted to give order to the
thinking behind the different approaches that have been
taken across these key aspects in the development of health
governance discourse overtime.
Moving from a state-centered governance function,
organized on vertical lines of accountability to increasingly
decentralized systems with multiple actors and levels of
authority, has given rise to an increasingly sophisticated
context for the health governance function. As a central
tenet to health system strengthening, a concerted effort
to resolve conceptual confusions and transform the gov-
ernance function to ensure its congruence in the context of
modern health systems is of great importance.
Acknowledgements
This paper was developed to support earlier health gov-
ernance work of the WHO Regional Office for Europe and
its partners by providing a review and synthesis of liter-
ature in this area of study and by extension, a common
platform for more conceptual thinking and country appli-
cations. An earlier version of this paper was presented at an
authors’ workshop convened by the European Observatory
on Health Systems and Policies in Brussels (October, 2012)
to stimulate discussions for a related project.
This work has been shaped by collaborations and
thoughtful discussions with the following experts: Claudia
Baez-Camargo (Basel Institute on Governance); Alejan-
dra Gonzalez (WHO Regional Office for Europe); Merilee
Grindle (Harvard University); and Maria Skarphedinsdot-
tir (WHO Regional Office for Europe). The authors would
like to thank Hans Kluge (WHO Regional Office for Europe),
Christine Brown (WHO European Office for Investment
for Health and Development) and Peter Smith (Imperial
College London) for their valuable review and detailed
comments. The authors thank also the reviewers of the
journal for their very constructive input that has impor-
tantly informed revisions to finalize this work.
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