Quality of Governance workshop
The biggest obstacles to meeting the health-related SDGs are neither medical nor technical, but rather organizational and political. Attention to governance issues is therefore essential. By developing a richer and more empirically founded understanding of the ways in which individual governing arrangements necessitate unique health policy interventions, we can greatly enhance the likelihood of success in meeting SDG targets.
Introductory film by Professor Göran Tomson
Introductory film by Professor Folke Tersman
Quality of Governance in the SDG era:
Linking SDG 16 “Justice and strong institutions” to SDG 3 “Health and wellbeing for all”
Working toward the SDGs will demand multipronged policy solutions with coordinated efforts among a range of organizations and actors, both governmental and private sector. For example, decreasing poverty requires addressing underlying issues such as low quality education, lack of security and employment opportunities, pervasive health risks, and other context-specific factors. The interrelations between the problems addressed in the SDGs also means that success in one policy area may depend on how it affects the others, as is illustrated by the connection between poverty and health. It has been shown, for instance, that health-related expenditures are one of the primary factors that push families into poverty.
Successful strategies have already been developed for addressing many pressing health-related problems and vulnerabilities, including basic pre-natal care, vaccinations, and sanitation. Significant progress can be made by simply extending the availability and coverage of those programs. This is partly what underlies the adoption of SDG16, on ‘peace, justice, and strong institutions,’ which relates to the increase of the extent to which government institutions serve the interests of the populations living under their power. In situations with government institutions with low capacity in terms of expertise, resources, and recognized and widespread corruption, the needs of the most vulnerable in society are unlikely to be addressed, and even undermines the success of interventions by international development cooperation actors.
SDG16 identifies a number of integral components of good governance where improvement is needed – the improved rule of law (16.3), increased transparency and accountability (16.6 & 16.10), responsive and inclusive decision-making (16.7), and mitigation of corruption (16.5). The first three of these targets relate to the underlying principles of political equality and equality before the law. Corruption in its various forms is one of the main factors that undermines the respect of those principles, resulting in governments that serve those with means at the expense of those at the margins. Where government corruption is prevalent, making progress on SDGs will be difficult, including in the area of health (SDG3).
Linking Quality of Governance to Good health and well-being
Corruption is generally defined as the “abuse of public power for personal gain.” It occurs globally and at all levels of society. Corruption can assume different forms – bribery, collusion, embezzlement, nepotism, clientelism – ranging from small bribes to kickbacks of considerable sums in conjunction with publicly funded infrastructure projects. It undermines citizens’ trust both for the state as well as the efficiency and quality of public infrastructure and services. Corruption has devastating effects on health sector performance and outcomes.
According to the World Bank, WHO and others, corruption is linked to higher rates of infant mortality, lower life expectancy, and higher levels of poverty (5). The WHO estimated that in 2008, out of 5.7 trillion USD spent on health worldwide, 415 billion USD (7,3%), were lost to fraud and abuse (2). Corruption impairs governments’ ability to raise revenues for health and other social sectors, as core functions such as tax collection and attracting investors and donors are weakened.
In the health care sector, corruption occurs in the form of fraud and abuse of health-care payments, procurement of low-quality health equipment and medicines, clinics that are funded but not built, absenteeism of medical professionals on public payrolls. In a more indirect sense, corruption undermines health emergency preparedness and the provision of infrastructure such as potable water and sanitation. Corruption can be seen as deviations from a system of rules, but it is also a system in and of itself, and one which is strongly self-reinforcing. Corruption undermines citizens’ willingness to get involved politically, and when they do, their low trust for government and other citizens may induce them to seek benefits for themselves primarily, even if they would be motivated by the common good if general compliance were ensured.
Policy initiatives to improve health services, infrastructure and facilities thus need to take the specifics of the local context into account, including norms and levels of trust. A considerable proportion of international or non-governmental policy interventions fall short of the desired effects because they do not fully consider the strengths and weaknesses of the local governing institutions (6). Accountability systems with multiple dimensions are required, including top-down audits in conjunction with community monitoring. It is also crucial that policy actors consider the primacy in such contexts of fairness/rule of law, as the potentially positive effects of promoting democracy and political participation may otherwise be hampered by underlying power inequalities (7).
In more developed countries, generally deemed to have less corruption, other governance issues may instead require attention. The influence of special interests may, for example, influence government regulation of health insurance and the health sector in a way that undermines the access of more marginalized populations to health care and medicine.
The underlying thought of the workshop may thus be summarized as follows. The biggest obstacles to meeting the SDGs in general and health-related goals, in particular, are neither medical nor technical, but rather organizational and political, and attention to governance issues is therefore essential. A more thorough and empirically founded understanding of how the quality and capacity of governing arrangements in a specific setting may necessitate different types of health policy interventions will significantly enhance the likelihood of success in meeting SDG targets.
Suggested references as background material for the QoG workshop:
- Ciccone, D.K. et al. Linking governance mechanisms to health outcomes: A review of the literature in low- and middle-income countries. 2014. Elsevier.
- Mackey, T. et al. The sustainable development goals as a framework to combat health-sector corruption. Bulletin WHO 2018;96:634-643.
- Ottersen, O.P Al. The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. The Lancet, 2014; 383:630-67.
- Rothstein, Bo. 2015. The Quality of Government Institute: Report for the first ten years of a Research Programme at University of Gothenburg.
- Effective institutions and the 2030 agenda for sustainable development. UNDP (https://www.effectiveinstitutions.org/media/Session_1_Background_note_SDG.pdf)
- Mansuri, Ghazala, and Vijayendra Rao. 2012. Localizing development: Does participation work?. The World Bank.
- Zinnbauer, Dieter. 2017. Social Accountability – Taking Stock of All the Stock-Taking and Some Interesting Avenues for Future Practice and Research. Available at SSRN.com