Dr. Abdelali Belghiti Alaoui comments our WHO Working Paper “Addressing Governance Challenges and Capacities in Ministries of Health”

In reaction to the launch of the WHO Working Paper “Addressing Governance Challenges and Capacities in Ministries of Health”, the Health Systems Governance Collaborative asked some seasoned health governance and policy persons to provide feedback. Herewith the reflections of Dr. Abdelali Belghiti Alaoui.

Full Working Paper here.

Question 1. Which are the most vital challenges in building governance capacities in Ministries of Health that occupy you today?

ABA: Let me say upfront: I carried senior responsibility and practiced decision-making for nearly 20 years within the Ministry of Health, including 5 years as deputy-minister (i.e. General Secretary of the MoH in Morocco). In all these years, this is the first time that I come across a structured document that seeks to put light on the black-box of the MoH and offers an alternative framework to the traditional politico-administrative approaches. From my long experience in the field, I consider capacity-building of the MoH at central and decentralized levels a major stake in health systems development. It conditions both the effectiveness of the actions of Ministers and stakeholders, and the improvement of the health system performance. I also consider the structuring of the contents of this report very relevant and I had no problem in appropriating it.

As to the challenges:

1. For me, the first challenge in the governance of the MoH is to restore trust with the population. Both politicians and the public sector have a bad press, and even when they make good decisions or do good things, citizens only see the negative side.
2. The second challenge, that could help solve the first one, is addressing how to bring all stakeholders together around a shared vision and common shared priorities. Political dialogue needs time to broaden participation and to capitalize on it. Likewise, changes in health systems need time, which goes beyond the regular political cycle (3 to 5 years). For this reason, the MoH needs a formal framework to conduct this dialogue beyond the ad-hoc forums. That can be through legislation, national charters, or otherwise. Otherwise, the dialogue may end up for the MoH in unsound recommendations, which are usually not accompanied by financial mobilization.
3. A third vital challenge is the lack of effectiveness of the actions of the Ministry of Health, which can have several causes. An MoH harbors a lot of people and skills that don’t necessarily work towards a common purpose. Nobody cares about motivation or building skills. This situation is compounded by the effects of political announcements which may often interfere and merely serve to fill the contents of political agendas. Under such circumstances, staff eventually breaks away from the MoH's mission.
4. A further challenge is related to the generation and management of knowledge and evidence in health. This is a role that only the MoH could and must play. It allows for political dialogue and strategic planning to be evidence-based and for the MoH to not waste time and money. Tools here are National Observatories, Health Knowledge Management Centers etc.

Question 2. From your daily experience, does the framework presented in the Working Paper make sense? If so, what general relevance could it have in your daily practice?

ABA: The framework allows for the analysis of MoHs, not merely as a legal entity (as we see in any politico-administrative approach) or as a component of government (executive power), but as a portfolio of assets, composed of resources and capacities. These resources and capacities make it possible, with a good national strategy, to improve the effectiveness of the MoH's actions and the general performance of the health system. So, the framework offers an alternative to the bureaucratic view of public administration by presenting the MoH as an instrument or lever of action that politicians seek to covet in order to act and turn their decisions into results.

In addition, the framework can be theoretically grounded in a strategic approach developed in the 1980s as part of business theories. I’m thinking of the so-called Resources and Competencies Approach[1]. This gives to this Framework a pragmatic scope and allows for research perspectives for health organizations in general and for the MoH in particular.

More concretely we can say that the proposed framework allows us:

• to value the MoH by taking it out of the shadow, to come up with a set of capacities. The proposed framework focuses on the internal capacities of the MoH and considers that a MOH can be strong with all the required capacities and can be vulnerable and that it requires capacity-building. The proposed framework also values the permanent staff of the MOH and acknowledges their different abilities and skills. The frame does not equate the MOH with an administrative machine but with a set of abilities and skills.
• to distinguish between the MoH and the political actors. The proposed framework gives the MOH a role independent of ministers. "The Ministry is not the Minister" as I announced in a workshop on political dialogue three years ago in Brussels. The MoH is an inimitable set of capacities based on know-how that is part of a continuity. The Minister is a political actor who drives actions and changes and who can be a mobilizing leader.
• to provide a framework for the analysis and capacity building of the MOH.

If not, what are you missing?

ABA: I think that the framework would gain further relevance and potential appropriation if it would further adapt to the practice of the actors for whom it is intended. As such, I make the following observations:

• I think that the capacities are not yet fully ‘tangible’ and that they are difficult to copy from one setting to another. The framework does propose 6 systematic capabilities for all MoHs in all countries, knowing that their stories, contexts, and environments are not the same. To remain consistent with the notion of "capacities", I think it is necessary to distinguish between common or general capacities, that would be observable in the majority of contexts, and specific capacities that would be more contingent.
• The 6 capacities proposed do not all have the same importance and therefore not the same weight for the governance of MoH. How can we prioritize between all the capacities observed or required for capacity building? I think that we need a tool or a method to identify among the capacities identified, those which are relatively important or strategic capacities. The attribute of "strategic capacities" of the MOH can vary over time and according to the contexts.
• In the description of the “performance capacity”, there is a confusion between capacities that correspond to tangible and mobilizable resources such as human and financial resources; and intangible abilities that are not similarly observable such as know-how, reputation, skills, etc. While both are necessary for performance, it is rather the intangible capacities that often guarantee performance. Also, according to the proposed model, the 6 types of capacities should all be required for performance. I think that it is better to propose another name (denomination) for this capacity.
• The usage of "role capacity" takes us back to the politico-administrative approach to which the proposed framework is supposed to offer an alternative. The notion “role capacity” is based on the assumption that the role of MoH is known, which is true if we consider the MOH as part of the government in charge of health affairs, but unclear if we assume that it is contingent on who defines the boundaries of this role? Are we talking about a role for the MoH or the Minister of Health? Does this ‘role’ have a constitutional basis or just a legal basis, etc.? Reading the description of this capacity, I consider it as a positioning capacity. The notion of ‘positioning capacity’ is more flexible. It does not refer to the politico-administrative approach and it has a history in strategy. Moreover, in section III on experiences of countries, the document refers to this capacity not as a role capacity but as a positioning capacity in the face of the change of national context (political transition, reforms, etc.). The document shows that the changes and the challenges can constitute both a threat of MoH (Mozambique, South Africa and Cambodia, post-socialist Sierra Leone Slovenia and Poland) and an opportunity (Afghanistan and East Timor) for strengthening the MoH. The notion of ‘role capacity ‘doesn’t reflect all these interpretations.
• The Ministry of Health often comprises a central administration, decentralized services (district, region) and agencies (or public institutions). Do the 6 capacities presented in the model apply equally to these three entities? If the answer is yes, it means that the 6 capacities are not specific enough. If the answer is no because they haven’t the same missions, then we must propose and further detail - in this work or another work - the required capacities of the decentralized services of the MOH. This needs to be further explored.
• On the issue of governance, the document speaks repeatedly of "mandated governance". This assumes a principal, who mandates. And a contract. It is not through a formal "mandate" that MoH governance is governed, but rather by legislation, executive (government) and leadership. I think that we can use MoH Governance of MoH without adding the term "mandated", knowing that it must also clarify the difference and the relationship between Governance of the MoH as such, and governance of the health system.

[1] For example, see the "RBV or Resource-based view" theory developed in the early 1980s and the dynamic capacity theory developed in the early 1990s.

Question 3. More specifically, could you see specific practical applications of the framework in your daily governance practice? What purpose could this framework fulfill there?

ABA: I could see, the proposed framework could be used to:

1. To analyze the functioning of the central administration of the MoH;
2. To identify the strengths and weaknesses of the MoH and its missing capacities;
3. To guide the development of regulatory texts (laws) on the missions and organization of the MoH.
4. To facilitate the development of capacity building strategies for the MoH;
5. To guide the development and implementation of a training plan for MoH staff.

What further elaborations would the framework need, seen from your practical experience, in order for it to have practical value for you and your colleagues and become ‘actionable’?

ABA: To facilitate the use of the framework proposed in this document, it is necessary, on the one hand, to facilitate its appropriation by the different actors of the MoH, and on the other hand to accompany its dissemination by tools for its practical application. As such, it would be useful:

1. to develop a practical guide to transition from the politico-administrative approach to the capacity approach promoted by this framework;
2. to develop a tool to assess the strategic dimension of the capacities of the MoH (as exists in the field of strategic business analysis: for example the VRIN or VRIO filter)
3. to elaborate a methodological support for the development of MoH capacity-building strategies.
4. to develop research on capacity approaches in health systems.

KEY QUESTIONS FOR FURTHER COLLABORATIVE DISCUSSION AND EXPERIENCE SHARING:

• The Governance capacities framework as a means to restore trust with population?

• The Governance capacities framework as ‘deliberative instrument’ in multi-stakeholder settings
• The Governance capacities framework as an instrument to create coherence in the actions of MoHs
• The Governance capacities framework as ‘alternative to the bureaucratic ways of public administration and as leverage of action
• The framework can help distinguish between MoH and political actors: that interface is very interesting!
• The general and the specific: the framework and working in different contexts
• Using the framework in decentralizing/decentralized settings and around  ‘mandate’ confusion
• Using the framework as a diagnostic: to identify the strengths and weaknesses of MoHs
• Using the framework in the development of real laws to deal with the mission and organization of MoHs
• Using the framework to facilitate capacity building strategies inside Ministries
• A range of further suggestions re-dissemination/appropriation actions around the framework which could be further developed.