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Paper - Health systems governance: the missing links

A paper by Maryam Bigdeli, Benjamin Rouffy, Benjamin Downs Lane, Gerard Schmets, and Agnès Soucat, published in BMJ Global Health


► Studies conclude that frameworks and tools defining governance have been developed independently, seldom building on strengths and weaknesses as well as practical applications of previous instruments.

► However, these existing frameworks lack a shared frame of reference which may enable governance to become a truly actionable health system function. This conceptual challenge creates considerable gaps in the way we have appraised and applied governance in health systems.

► We propose here an adaptation of the governance triangle put forward in the World Development Report 20048 exploring six governance spaces between and within three categories of stakeholders: policy makers, providers of health services and the people.

► This paper uses the framework to further explore both formal and informal relations between stakeholders in the governance triangle and identify, as we reflect on our past investments in health system governance, a number of gaps or ‘missing links’.

► These missing links relate to formal relations of accountability, relations of power, the exercise of population voice and collective action in health systems.

► Exploring the missing links described in this paper will help us better understand governance mechanisms in health system and design and implement more effective health policies and interventions.


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