Health and healthcare in transition: dilemmas of governance

Our societies are changing. On one hand, unprecedented socio-demographic changes are underway: albeit unevenly across various settings, life expectancy continues to rise globally, facilitating the rise of numbers of people living with one or more chronic diseases. On the other hand, societies are undergoing major political transformations as well. Examples include the massive transition away from communism resulting from the dissolution of USSR and rise of participation societies in the EU, to name just a few.

In this shifting environment, the issue of health becomes particularly difficult to deal with. Current approaches to governing processes and structures that define people’s health often fall short in responding to the changing health needs of the populations and in being adequate to shifting societal conditions. How to ensure and improve the health of citizens in times of societal transitions? This course invites learners to explore this question using examples from multiple settings.

Aim
This course aims to equip learners with the knowledge and skills needed to assess, develop, and implement options for health policies, programs and services in ways that are responsive to changing population health needs and to societal contexts; and to provide learners with analytical insights into the interconnections between societal transformations, health, and governance to facilitate the development of more responsive and contextually adequate health and health governance approaches.

After completion of this course you will be able to:
1. Recognize dilemmas in the governance of health and healthcare and the origins of these dilemmas
2. To be aware of different approaches in governance of health and healthcare; identify the trade-offs in these approaches for particular cases
3. Recognize actors and structures pertaining to the governance of health and healthcare on different levels
4. Identify problems in policies, programs, structures, and practices pertaining to the governance of health and healthcare in specific settings
5. Formulate and justify combinations in approaches to health and health governance suitable to various applications in specific settings

This course was developed by a consortium of five universities: Maastricht University, National Research Tomsk State University, National University of "Kyiv-Mohyla Academy", National Pirogov Memorial Medical University, Vinnytsya, and Siberian State Medical University within the framework of BIHSENA project. BIHSENA stands for “Bridging Innovations, Health and Societies: Educational capacity building in the Eastern European Neighbouring Areas”. BIHSENA project has been funded with support from the European Commission. This course reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.

• Introduction to the course "Health and healthcare in transition: dilemmas of governance"
• Dilemma 1. Definitions: Governance vs Management vs Leadership in Health
• This course module focuses on the main challenges and global shifts in the healthcare sector, which, in turn, create a demand for more systemic approaches to governance, management, and leadership. It appears to be difficult to differentiate these concepts (governance, management, and leadership) clearly due to their interrelations and complexity. This module will introduce different ways of defining and relating these concepts in order to illustrate challenges to finding a consensus between such definitions. First, you will delve into discussions about definitions of governance and about how to understand good governance. You will then also explore different leadership approaches in healthcare and to discern from specific examples how effective management can improve the performance of a healthcare facility.
  
  
• Dilemma 2. Health as a Political vs Apolitical Concept
• Assessing health system governance and performance requires ethical reflection on the following questions: 1) Who is responsible for health? 2) Who are the beneficiaries? There are different approaches in seeking answers to these questions. Healthcare policies entail scientific data, technologies, and expert recommendations that can appear non-political, as well as cultural norms and respect to individual liberty. But, on the other hand, health can become political in the context of decision-making that entails the distribution of resources and the selection of priorities and modes of action. So, in this module we will delve into these complexities and will work to understand what stands behind health policy and governance decisions. We will take a look at different ethical concepts that may underpin political decisions on health governance, health care reforms, or demands for redistributive policies.
• Dilemma 3. Public Participation vs Top-Down Steering
• On the one hand, citizens’ engagement in governance of health and health care is important for the transparency and responsiveness of decision-making, as well as for ensuring trust and cooperation. Moreover, often citizens themselves demand direct engagement, as exemplified by health activism: from local action to addressing environmental health risks, to global action on HIV/AIDS, and access to medicine. On the other hand, critics suggest that laypersons can add inefficiency, irrationality, and incoherence to health policy decision-making. There can be undesirable features in governance models heavily dependent on public engagement like interest-group competition in rule-making and the professionalization of citizen participation, where not all citizens are necessarily equally empowered to make contributions. This week explores the dilemma between engaging and not engaging the public.
• Dilemma 4: Focus on Whole-of-Society vs Focus on Health Services Provision
• Health governance is a field where the search for best solutions is continuous in all corners of the world. Health systems increasingly struggle with rising costs, ensuring adequate numbers of health professionals and providing access to the best life-saving treatments and technologies. You will hardly find a country that would not attempt to improve health system performance through reforming the health sector and improving health care delivery. But people’s health depends on multiple complex factors (from employment and work to transport and housing) and relates to social processes of industrialization, urbanization and globalization and to differential exposures to risks. Drivers of human health are not constrained to the health care system. Therefore, new and wider approaches to health governance appear: they are based on the idea of extending health governance from sectorial focus to the whole-of-society and whole-of-government level. These approaches argue that the improvement of a population’s health necessitates engaging non-health sectors and actors through policies and initiatives at all levels of governance, with or without the involvement of the health sector itself. This creates a dilemma for health governance: should it be focused on improving health service provision only, or embrace the whole of society and all sectors of governance?
• Dilemma 5. De Jure and de Facto Dimensions of Healthcare Governance
• Quite often the identification of the gaps or problems in the health care system result in recommendations to change certain regulations, i.e. to adopt a new law, to make the changes in the existing law, to issue an order etc (de jure dimension). For example, authors and experts suggest improving anti-tobacco policies or introducing sanctions for misbehavior of medical doctors. Indeed, the suggestion to improve regulatory dimension can be seen as a systemic approach (discussed in Dilemma 4) because the behavior and practices take place within the specific existing structure. Therefore, regulations are seen as the efficient entry point that has an impact on the numerous practices.
  However, changing structures or policy development requires substantial resources, e.g. political support, time and expertise (as it has been illustrated in Dilemma 2). Also, the rule of law in some countries can be low, meaning that even if the law is adopted, it is not necessary that it will be reflected in actual practices. Sometimes the results are poor not because of lack of law, but because people may simply be lacking knowledge, skills, competences in, for example, organization management. Therefore, introducing new regulations (de jure dimension) is not always the entry point for the new (more healthy, more effective, more transparent etc.) practices (de facto dimension).
  Thus, we discuss a dilemma related to inconsistencies and imbalance between the structures on the one hand, and practices on the other hand, as well as the challenges that arise when only one perspective (de jure or de facto) is taken into account. In this module we explore the dilemma between de jure and de facto dimensions in health care governance.
• Dilemma 6. Change, Reforms and Stability in Health and Healthcare Governance
• The stability of healthcare systems can be equally as important as change, especially in systems that are performing relatively well. The issue of stability and change in sectors and institutions, including health care, is rooted in the socio-cultural and historical context of the country as well as in current capacities for change. We may see that some countries or systems are more inclined to change when compared to others. Indeed, health care reforms have occurred in most post-communist countries after the Soviet Union collapsed, however the healthcare systems of some of the ex-republics continue functioning as they were designed in the Soviet Union. Several decades ago stability was seen as one of the most essential values in this setting, while now nostalgic moods in some of the countries may partially explain difficulties in the implementing reforms.
  
  In this module we will illustrate the concepts of “stability” and “change” or “reform” by the case of changing tax-based and insurance-based mechanisms of health care system financing, and its performance under varying and transforming socio-cultural and health conditions. The transition in the post-communist countries of Central and Eastern Europe is taken as an illustrative context for the case.