Writing about health system governance in low- and middle-income countries: reflections from an Indian perspective
In April 2016, the Collaboration for Health Systems Analysis and Innovation (CHESAI) and the Resilient and Responsive Health Systems (RESYST) Consortium convened a health system governance writing workshop. This workshop brought together health systems and policy researchers from Kenya, South Africa, India, Ghana and Argentina to discuss and develop papers on governance issues affecting low- and middle-income country (LMIC) health systems.
In the previous, very popular, edition of this blog, colleagues from Kenya wrote about their experiences and lessons from this workshop. We now complement this with the reflections of five colleagues working in India, who write about the workshop process, insights about new questions and methods, different understandings of governance, the cross-pollination of ideas and comparisons between the policy contexts of India and Africa.
Perhaps the most significant factor was the mix of formality and informality in the discussions and activities. The different groups we formed to discuss the papers were so unique: talking about methods in one group and concepts in another, carrying on to sessions on critically reviewing our papers. It was a stimulating process that stirred new thoughts.
I gradually came to appreciate how recognising the role of governance, and the processes through which it unfolds and impacts on health system outcomes, provokes new questions which ultimately lead to better analysis and inferences about the issue studied. More importantly, I realised how the rich toolkit of qualitative techniques can strengthen the predominantly quantitative empirical approaches I had used.
The biggest advantage, of course, was the vibrant crowd assembled. I could meet and have excellent, thought-provoking discussions with a range of very talented colleagues from across the globe, and listen to their experiences and ideas. The range of ideas - on different methods ranging from ethnography to case analyses, different definitions and understandings of governance, and how these played into diverse areas from infectious disease control to the training and posting of health workers - was remarkable. The proverbial icing was the excellent framework that blossomed out of the discussions, capturing diverse views and ideas, and knitting together how they interact to impact on the functioning and responsiveness of the health system.
Though I had read a lot about governance prior to the workshop, what I landed upon was a much wider range of perceptions that flowed between participants. I came to realise the complexity of a concept that I previously thought I already knew.
I realised that my paper was actually speaking to a very crucial element of governance, though one that is often neglected: relationships. I see governance now more as a kind of management (or governance) of relationships across actors involved in implementing policies within the health system.
Finally, the workshop prompted me to think of the relationships among researchers of the South: is there a need to 'govern' these relationships and how do we go about doing so, for bringing forward a richer understanding of health systems across LMICs?
During the four days of interactive learning, I came across diverse ways to understand governance and its component parts. Within this diversity of understanding, I realised that at a macro-level, governance is a decision-making process for policy formulation and implementation, including resource allocation, with the primary objective of treating disease while protecting communities from illness and health-related threats. At the same time at a micro-level, governance is a managerial tool for local and mid-level health system administrators to implement health programmes or policies with the wider purpose of creating a healthy community.
Applying my understanding of governance to research enabled me to reflect on methodological issues concerning long-term empirical health policy and systems research, such as the appropriateness of informed consent, the community’s expectations of the researcher, participant-researcher relations and the power dynamics concerning these.
There is so much to learn from one another. In India, policy processes often feel grindingly slow; hearing about the rapid decentralisation in Kenya and speedy implementation of National Health Insurance in Ghana caused me to more closely examine the benefits and the fallout associated with more nimble policy-making. Several African colleagues pointed out the remarkably different role of nurses in many African country health systems compared to India. African nurses tend to be seen as the heart of health systems and have quite powerful self-representation through unions. In contrast, India’s nurses have very little voice in any policy decisions and nursing organisations tend to be led by doctors. How did India’s nurses end up in this disempowered position? What mechanisms support the more powerful position of African nurses, which must be developed in India?
The workshop highlighted the fundamental humanity of health systems and policy research. This is a science about people and how we relate to one another and organise ourselves. Every actor in the system is seeking dignity, security and respect, and coping with stresses and pressures that are both highly personal and simultaneously universal, as they link to struggles of politics, gender and history. Relationships are at the heart of health systems and they make or break policies, programs - and even research studies.
The workshop was a great opportunity to understand the varied contexts in different parts of the South that prevent analytical approaches and policy solutions being directly transferred from one place to another. I was struck by the extent to which the history of each country - the hundreds of years of colonisation, struggles for independence, and subsequent attempts at decentralisation - has carved out similar trajectories, such that each country is struggling with remarkably similar challenges. Yet the ways in which we have been dealing with these challenges are unique, shaped by our specific socio-cultural and political contexts. Comparing India with some African countries, it seems that we have had a stronger civil society with greater emphasis on grassroots perspectives and value-based development, yet hierarchical relations across state and society appear more entrenched, with implications for how health systems can be developed. It was eye opening to understand the specific ways in which efforts at health system strengthening in India can have relevance for other places, and allowed me to appreciate the strengths and limitations of learning from other nations.