Dr. Manuel M. Dayrit 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. Manuel M. Dayrit.

Full Working Paper here.

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

MD: Before I go there, let me put a few general ideas upfront. First of all, an MOH is a multi-level, geographically-dispersed bureaucracy. Different types of decisions happen at various levels but they are all part of the organization’s ways of ‘governance’. Secondly, the functions and sub-functions of governance, do they apply at all levels of the bureaucracy? Are the functions executed at the central level? At the peripheral level? Both? This remains to be seen.

As to the three challenges, the first main challenge I observe, is whether an MOH can keep learning how to govern amidst discontinuous change?  There are constant time constraints. It is not easy to sustain efforts through discontinuous changes in the political leadership of MOH and the flux in resources, personnel, priorities. If in such circumstances leadership is dysfunctional, the organization becomes dysfunctional too. So it is vital to assess if leadership is taking the organization in the right direction. Leadership, however, can be a complex thing. It is not simply the management of a Ministry or Department of Health. Leadership can also comprise the DOH management and its various stakeholders, thus forming a “collective leadership”. Besides the Department of Health management, this could, for instance, also involve Congressional leaders, the President representing the Executive branch etc..

A second big challenge I see is raising governance capacity-building efforts to scale. This issue really has to do with the 4 capacities described in the MoH Working paper as the “operating capacities”: i.e. personal capacity, workload capacity, performance capacity and supervisory capacity. In moving to scale, the whole organization or bureaucracy would have to be refreshed, because everybody is only dealing with a part of things. This would boil down to re-tooling effectively and efficiently the MOH (or various parts of the MOH) in the wake of major new laws, such as - in the Philippines - the Generics Law, the Local Government Code, the Social Health Insurance or the recently passed Universal Health Care Law (2019). It would mean: strengthening the regulatory capacity, and that would apply to role capacity, personal capacity, and workload capacity all at once.

A third and final challenge for me is the deeper question whether good governance actually ensures good outcomes. How do we know? And how do we know this soon enough? Things take time to bear fruit. Often, there is no turning back once a law is passed, such as in our Philippines 1991 Local Government Code. It was a sea change, it took 25 years for this to really settle, and then it is not clear in the complexity of things, what exactly had what effect.

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? If not, what are you missing?

MD: Yes, it makes a lot of sense. It provides clear conceptual handles for thinking about ‘governance’ by an MOH!  It helps mapping the territory as it shifts.

3. Could you see specific practical applications of the framework in your daily governance practice? What purpose could this framework fulfill there? What further elaboration would the framework need, seen from your daily experience, in order for it to become actionable for you and your colleagues?

MD:  I would like to explore in what way the framework could be used to inform the effectiveness or ineffectiveness of UHC implementation. I would love to apply it to the current efforts of the Philippines Department of Health to implement the UHC Law of 2019. Could we, for instance, apply it in drafting the implementing of rules and regulations (IRR) for this UHC?

If I look at the ‘Role Capacity’ in the Working Paper,  I see this as the legal mandate provided by law or by executive order. For example: the UHC Law and its IRR spell out the role of the Department of Health, PhilHealth, Local governments (cities and provinces). But the private sector is not clearly delineated; we only speak about ‘contracting processes’ at the moment. We could use the tool to further advance this exercise.

Or if I think of the ‘Structural capacity’ mentioned in the Working paper,  I can see this as the organizational bodies/mechanisms for decision-making at various levels; the legal mandates and ‘roles’ of these bodies have to be clearly spelled out.

It is often in the operating capacities, where things break down. Currently, the structural capacities for our UHC Law are being created. For example, the Special Health Fund.  But the operational capacity still requires work:  this would combine the 4 four capacities described in the framework i.e. personal capacity, workload capacity, performance capacity, supervisory capacity. It would be very interesting to work this out in the context of our UHC law.

Any further comments?