Challenging health system inequity by practicing everyday governance

Governance of health systems is critical to their operation and performance, but the everyday realities and practice of governance in LMICs is rarely considered in academic inquiry – yet, influences their capacity to promote equity. A new thematic series from the International Journal for Equity in Health provides an empirical and embedded research perspective on governance and equity in health systems. Here to discuss this and highlight the importance of the series is the Guest Editor, Lucy Gilson.

The myth of governance

Governance, as it relates to the health care system, often seems to be more of a myth than an instituted practice. It’s a term we know is important in that every health system fundamentally runs on it, but it is often only discussed in theoretical or abstract terms.

Good governance, on the other hand, is a term sometimes imbued with strong political overtones, as something the global North has and to which the global South should aspire. Yet, current political challenges worldwide show the mythical status of that judgment.

To move beyond these myths, the Health Systems Governance Collaborative has been established to harness and strengthen relevant communities of practice to support progress toward Universal Health Coverage. While this is a step forward, we also need to consider deeper insight into real world governance in order to think through what can be done to strengthen health care systems.

Beneath the surface of governance processes

Such insights are provided in a new thematic series from the International Journal for Equity in Health. This is a series which is unusual in three ways.

  1. The series presents a set of empirical papers reporting on real world governance experiences from a range of African and Indian settings.
  2. The studies all focus on what we call the everyday practice of governance, or the daily decision-making and meaning-making that governs and influences how health systems work and how they develop.
  3. The studies are all authored by embedded researchers working in the settings from which they report.

Together, the unique set of manuscripts in this series offer insights into four core governance processes: decentralization, accountability, leadership, and policy implementation. More importantly, they dive beneath the surface of these processes to illuminate the multiple levels and multiple actors engaged in governance work. They highlight the critical governance roles of community, frontline and mid-level actors, as well as showing how these actors are influenced by relationships and wider institutional forces.

Such forces include the informal rules, norms, and values that guide stakeholder actions which have been argued as an important influence over inequity. Indeed, the way this intangible software, in combination with health system hardware, influences everyday governance practices is explicitly considered in this thematic series.

Such understanding can provide a foundation for thinking through how to take action and make progress toward health system equity goals.

Furthermore, through this focus, we offer insights into the routine decision-making and sense-making that maintains inequity or resists equity-promoting policy implementation – as well as those entailed in purposeful efforts to maintain decent health services even in the face of wider systemic stress, in efforts to promote equity or strengthen accountability. Such understanding can provide a foundation for thinking through how to take action and make progress toward health system equity goals.

In reporting empirical research, these studies offer insights into how to conduct sound research on governance, a long-acknowledged area of health policy and systems research weakness. We hope that the material presented in this thematic series encourages a wider and deeper inquiry into governance experiences, moving beyond the myths to engage with the everyday, real world.

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