Bellagio Meeting - Day One

On this first day of our meeting on "Actionable governance: the missing links" -participants went right to  the heart of the matter. After a short introduction of the Collaborative, participants shared their personal trajectories and their motivation to join the discussion, after which a large part of the day was dedicated to reflect on the question of “reversals” in health systems governance to make governance actionable. By “reversals” we meant turning the tables, radically rethinking governance and profoundly changing the way we work.

The group discussed what reversals they proposed to prioritize and suggested to start with the notion that health is a human right and that governance should aim at transforming health system to keep this as a central principle.

With that in mind, the first reversal to consider is that improving governance is about deep transformation and renegotiation of priorities. This in turn raises the question of what is real transformation? Transforming is an uncomfortable process as it aims at challenging the status quo in meaningful ways, notably by addressing the relationships of power and the allocation of resources. It is not about minor tweaking (referred to by some as  “fake handbag” syndrome) and pretending that the dynamic has truly changed.

The second reversal is to recognise that governance requires reconsidering the time we allow for change to happen. The incentive to score political points by pursuing immediate gain is much higher than to engage in transformation for the long run. But governance is a long process ant it is critical to acknowledge that governance is a progressive realization, a collective path that leads to a system  where every actor group, even patients or service user groups, are ultimately accountable towards citizen.

The last identified reversal comes from the widely spread notion that one size doesn't fit all. Consequently it seems only natural to reevaluate the concept of best practices and replace it with the idea of "best fit". For example, the mandate of the local governance actors may be widely different from one context to another, but once clearly identified, we need to look at how these actors are accountable within this defined "best fit".

The discussion however also acknowledged that it is important to gather data as to evaluate how successful the process is. Data gathering implies a model of evaluation where the important questions are how to fit it into practice , how can "we" co-construct a governance knowledge base, and finally who is the "we." This introduces the idea that frameworks are useful indeed but raises two questions:

• What are the purposes of frameworks (frameworks for what?)
• Who are the frameworks useful for (frameworks for whom?) 

Those are questions for the second day of the meeting:stay tuned!