Does global health governance walk the talk? Gender representation in World Health Assemblies, 1948-2021.

BACKGROUND: While an estimated 70%-75% of the health workforce are women, this is not reflected in the leadership roles of most health organisations-including global decision-making bodies such as the World Health Assembly (WHA). METHODS: We analysed gender representation in WHA delegations of Member States, Associate Members and Observers (country/territory), using data from 10 944 WHA delegations and 75 815 delegation members over 1948-2021. Delegates' information was extracted from WHO documentation. Likely gender was inferred based on prefixes, pronouns and other gendered language. A gender-to-name algorithm was used as a last resort (4.6%). Time series of 5-year rolling averages of the percentage of women across WHO region, income group and delegate roles are presented. We estimated (%) change ±SE of inferred women delegation members at the WHA per year, and estimated years±SE until gender parity from 2010 to 2019 across regions, income groups, delegate roles and countries. Correlations with these measures were assessed with countries' gender inequality index and two Worldwide Governance indicators. RESULTS: While upwards trends could be observed in the percentage of women delegates over the past 74 years, men remained over-represented in most WHA delegations. Over 1948-2021, 82.9% of delegations were composed of a majority of men, and no WHA had more than 30% of women Chief Delegates (ranging from 0% to 30%). Wide variation in trends over time could be observed across different geographical regions, income groups and countries. Some countries may take over 100 years to reach gender parity in their WHA delegations, if current estimated trends continue. CONCLUSION: Despite commitments to gender equality in leadership, women remain gravely under-represented in global health governance. An intersectional approach to representation in global health governance, which prioritises equity in participation beyond gender, can enable transformative policymaking that fosters transparent, accountable and just health systems.

Contributing to collaborative health governance in Africa: a realist evaluation of the Universal Health Coverage Partnership.

BACKGROUND: Policy dialogue, a collaborative governance mechanism, has raised interest among international stakeholders. They see it as a means to strengthen health systems governance and to participate in the development of health policies that support universal health coverage. In this context, WHO has set up the Universal Health Coverage Partnership. This Partnership aims to support health ministries in establishing inclusive, participatory, and evidence-informed policy dialogue. The general purpose of our study is to understand how and in what contexts the Partnership may support policy dialogue and with what outcomes. More specifically, our study aims to answer two questions: 1) How and in what contexts may the Partnership initiate and nurture policy dialogue? 2) How do collaboration dynamics unfold within policy dialogue supported by the Partnership?  METHODS: We conducted a multiple-case study realist evaluation based on Emerson's integrative framework for collaborative governance to investigate the role of the Partnership in policy dialogue on three policy issues in six sub-Saharan African countries: health financing (Burkina Faso and Democratic Republic of Congo), health planning (Cabo Verde, Niger, and Togo), and aid coordination for health (Liberia). We interviewed 121 key informants, analyzed policy documents, and observed policy dialogue events. RESULTS: The Partnership may facilitate the initiation of policy dialogue when: 1) stakeholders feel uncertain about health sector issues and acknowledge their interdependence in responding to such issues, and 2) policy dialogue coincides with their needs and interests. In this context, policy dialogue enables stakeholders to build a shared understanding of issues and of the need for action and encourages collective leadership. However, ministries' weak ownership of policy dialogue and stakeholders' lack of confidence in their capacity for joint action hinder their engagement and curb the institutionalization of policy dialogue. CONCLUSIONS: Development aid actors wishing to support policy dialogue must do so over the long term so that collaborative governance becomes routine and a culture of collaboration has time to grow. Public administrations should develop collaborative governance mechanisms that are transparent and intelligible in order to facilitate stakeholder engagement.

Normalizing the political economy of improving health.

Problem: Political economy factors are important in determining the adoption and implementation of health policies. Yet these factors are often overlooked in the development of policies that have the potential to influence health. Approach: Political economy analysis provides a way to take into consideration political and social realities, whether at the community, subnational, national, regional or global levels. We aim to demonstrate the value of political economy analysis and to promote its wider use in technical programmes of work. Local setting: We provide examples from across a range of World Health Organization areas of work, including participatory governance, health financing, health taxes, malaria prevention and control, capacity-building and direct country support. Relevant changes: Existing examples of how political economy analysis can be incorporated into technical support demonstrate the variability of this analytical approach, as well as its potential to support policy progress. Applying political economy analysis within the specified programmes of work has enabled more contextually relevant technical support to enhance the likelihood of advancing countries' health-related objectives. Lessons learnt: Embedding political economy into technical work has many benefits, including: enhancing voice and participation in health policies; supporting the adoption and implementation feasibility of technically sound policies; and building capacity to incorporate and understand political factors that influence health-related priorities.

People's Voice and Civil Society Participation as a Core Element of Universal Health Coverage Reforms: Review of Experiences in Iran.

Health governance challenges can make or break universal health coverage (UHC) reforms. One of the biggest health governance challenges is ensuring meaningful participation and adequately reflecting people's voice in health policies and implementation. Recognizing this, Iran's Health Transformation Plan (HTP) lays out the country's blueprint for UHC with an explicit emphasis on the 'socialization of health.' 'Socialization' is seen as a key means to contribute to HTP objectives, meaning the systematic and targeted engagement of the population, communities, and civil society in health sector activities. Given its specific cultural and historical context, we sought to discern what notions such as 'civil society,' 'non-governmental organization,' etc mean in practice in Iran, with the aim of offering policy options for strengthening and institutionalizing public participation in health within the context of the HTP. For this, we reviewed the literature and analysed primary qualitative data. We found that it may be more useful to understand Iranian civil society through its actions, ie, defined by its motivation and activities rather than the prevailing international development understanding of civil society as a structure which is completely independent of the state. We highlight the blurry boundaries between the different types of civil society organizations (CSOs) and government institutions and initiatives, as well as high levels of overlaps and fragmentation. Reducing fragmentation as a policy goal could help channel resources more efficiently towards common HTP objectives. The National Health Assembly (NHA) model which was first launched in 2017 offers a unique platform for this coordination role, and could be leveraged accordingly.

Health system performance assessment: a primer for policy-makers

This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation.

Policy dialogue as a collaborative tool for multistakeholder health governance: a scoping study.

INTRODUCTION: Health system governance is the cornerstone of performant, equitable and sustainable health systems aiming towards universal health coverage. Global health actors have increasingly been using policy dialogue (PD) as a governance tool to engage with both state and non-state stakeholders. Despite attempts to frame PD practices, it remains a catch-all term for both health systems professionals and researchers. METHOD: We conducted a scoping study on PD. We identified 25 articles published in English between 1985 and 2017 and 10 grey literature publications. The analysis was guided by the following questions: (1) How do the authors define PD? (2) What do we learn about PD practices and implementation factors? (3) What are the specificities of PD in low-income and middle-income countries? RESULTS: The analysis highlighted three definitions of policy dialogue: a knowledge exchange and translation platform, a mode of governance and an instrument for negotiating international development aid. Success factors include the participants' continued and sustained engagement throughout all the relevant stages, their ability to make a constructive contribution to the discussions while being truly representative of their organisation and their high interest and stake in the subject. Prerequisites to ensuring that participants remained engaged were a clear process, a shared understanding of the goals at all levels of the PD and a PD approach consistent with the PD objective. In the context of development aid, the main challenges lie in the balance of power between stakeholders, the organisational or technical capacity of recipient country stakeholders to drive or contribute effectively to the PD processes and the increasingly technocratic nature of PD. CONCLUSION: PD requires a high level of collaborative governance expertise and needs constant, although not necessarily high, financial support. These conditions are crucial to make it a real driver of health system reform in countries' paths towards universal health coverage.

Realist evaluation of the role of the Universal Health Coverage Partnership in strengthening policy dialogue for health planning and financing: a protocol.

INTRODUCTION: In 2011, WHO, the European Union and Luxembourg entered into a collaborative agreement to support policy dialogue for health planning and financing; these were acknowledged as core areas in need of targeted support in countries' quest towards universal health coverage (UHC). Entitled 'Universal Health Coverage Partnership', this intervention is intended to strengthen countries' capacity to develop, negotiate, implement, monitor and evaluate robust and integrated national health policies oriented towards UHC. It is a complex intervention involving a multitude of actors working on a significant number of remarkably diverse activities in different countries. METHODS AND ANALYSIS: The researchers will conduct a realist evaluation to answer the following question: How, in what contexts, and triggering what mechanisms, does the Partnership support policy dialogue for health planning and financing towards UHC? A qualitative multiple case study will be undertaken in Togo, Liberia, Democratic Republic of Congo, Cape Verde, Burkina Faso and Niger. Three steps will be implemented: (1) formulating context-mechanism-outcome explanatory propositions to guide data collection, based on expert knowledge and theoretical literature; (2) collecting empirical data through semistructured interviews with key informants and observations of key events, and analysing data; (3) specifying the intervention theory. ETHICS AND DISSEMINATION: The primary target audiences are WHO and its partner countries; international and national stakeholders involved in or supporting policy dialogues in the health sector, especially in low-income countries; and researchers with interest in UHC, policy dialogue, evaluation research and/or realist evaluation.

Priority Setting for Universal Health Coverage: We Need to Focus Both on Substance and on Process Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, not Just More Evidence on Cost-Effectiveness".

In an editorial published in this journal, Baltussen et al argue that information on cost-effectiveness is not sufficient for priority setting for universal health coverage (UHC), a claim which is correct as far as it goes. However, their focus on the procedural legitimacy of 'micro' priority setting processes (eg, decisions concerning the reimbursement of specific interventions), and their related assumption that values for priority setting are determined only at this level, leads them to ignore the relevance of higher level, 'macro' priority setting processes, for example, consultations held by World Health Organization (WHO) Member States and other global stakeholders that have resulted in widespread consensus on the principles of UHC. Priority setting is not merely about discrete choices, nor should the focus be exclusively (or even mainly) on improving the procedural elements of micro priority setting processes. Systemic activities that shape the health system environment, such as strategic planning, as well as the substantive content of global policy instruments, are critical elements for priority setting for UHC.

Population Consultation: A Powerful Means to Ensure that Health Strategies are Oriented Towards Universal Health Coverage.

BACKGROUND: We seek to highlight why population consultations need to be promoted more strongly as a powerful means to move health reforms towards Universal Health Coverage (UHC). However, despite this increasing recognition that the "population" is the key factor of successful health planning and high-quality service delivery, there has been very little systematic reflection and only limited (international) attention brought to the idea of specifically consulting the population to improve the quality and soundness of health policies and strategies and to strengthen the national health planning process and implementation. So far, research has done little to assess the significance of population consultations for the health sector and its importance for strategic planning and implementation processes; in addition, there has been insufficient evaluation of population consultations in the health sector or health-related areas. DISCUSSION: We drew on ongoing programmatic work of World Health Organization (WHO) offices worldwide, as most population consultations are not well-documented. In addition, we analyzed any existing documentation available on population consultations in health. We then elaborate on the potential benefits of bringing the population's voice into national health planning. We briefly mention the key methods used for population consultations, and we put forward recent country examples showing that population consultation is an effective way of assessing the population's needs and expectations, and should be more widely used in strategizing health. Giving the voice to the population is a means to strengthen accountability, to reinforce the commitment of policy makers, decision-makers and influencers (media, political parties, academics, etc.) to the health policy objectives of UHC, and, in the specific case of donor-dependent countries, to sensitize donors' engagement and alignment with national health strategies. CONCLUSIONS: The consequence of the current low international interest for population consultations probably has the most negative effect on resource-poor countries, as this analytical oversight comes with a high price. However, a population consultation has the potential to give more benefit and added value to contexts where resources are scarce and where planning processes pose a high extra burden, and should thus be promoted among international donor agencies.

A resource planning analysis of district hospital surgical services in the Democratic Republic of the Congo.

BACKGROUND: The impact of surgical conditions on global health, particularly on vulnerable populations, is gaining recognition. However, only 3.5% of the 234.2 million cases per year of major surgery are performed in countries where the world's poorest third reside, such as the Democratic Republic of the Congo (DRC). METHODS: Data on the availability of anesthesia and surgical services were gathered from 12 DRC district hospitals using the World Health Organization's (WHO's) Emergency and Essential Surgical Care Situation Analysis Tool. We complemented these data with an analysis of the costs of surgical services in a Congolese norms-based district hospital as well as in 2 of the 12 hospitals in which we conducted the situational analysis (Demba and Kabare District Hospitals). For the cost analysis, we used WHO's integrated Healthcare Technology Package tool. RESULTS: Of the 32 surgical interventions surveyed, only 2 of the 12 hospitals provided all essential services. The deficits in procedures varied from no deficits to 17 services that could not be provided, with an average of 7 essential procedures unavailable. Many of the hospitals did not have basic infrastructure such as running water and electricity; 9 of 12 had no or interrupted water and 7 of 12 had no or interrupted electricity. On average, 21% of lifesaving surgical interventions were absent from the facilities, compared with the model normative hospital. According to the normative hospital, all surgical services would cost US$2.17 per inhabitant per year, representing 33.3% of the total patient caseload but only 18.3% of the total district hospital operating budget. At Demba Hospital, the operating budget required for surgical interventions was US$0.08 per inhabitant per year, and at Kabare Hospital, US$0.69 per inhabitant per year. CONCLUSION: A significant portion of the health problems addressed at Congolese district hospitals is surgical in nature, but there is a current inability to meet this surgical need. The deficient services and substandard capacity in the surveyed district hospitals are systemic in nature, representing infrastructure, supply, equipment, and human resource constraints. Yet surgical services are affordable and represent a minor portion of the total operating budget. Greater emphasis should be made to appropriately fund district hospitals to meet the need for lifesaving surgical services.

Health service planning contributes to policy dialogue around strengthening district health systems: an example from DR Congo 2008-2013.

BACKGROUND: This case study from DR Congo demonstrates how rational operational planning based on a health systems strengthening strategy (HSSS) can contribute to policy dialogue over several years. It explores the operationalization of a national strategy at district level by elucidating a normative model district resource plan which details the resources and costs of providing an essential health services package at district level. This paper then points to concrete examples of how the results of this exercise were used for Ministry of Health (MoH) decision-making over a time period of 5 years. METHODS: DR Congo's HSSS and its accompanying essential health services package were taken as a base to construct a normative model health district comprising of 10 Health Centres (HC) and 1 District Hospital (DH). The normative model health district represents a standard set by the Ministry of Health for providing essential primary health care services. RESULTS: The minimum operating budget necessary to run a normative model health district is $17.91 per inhabitant per year, of which $11.86 is for the district hospital and $6.05 for the health centre. The Ministry of Health has employed the results of this exercise in 4 principal ways: 1.Advocacy and negotiation instrument; 2. Instrument to align donors; 3. Field planning; 4. Costing database to extract data from when necessary. CONCLUSIONS: The above results have been key in the policy dialogue on affordability of the essential health services package in DR Congo. It has allowed the MoH to provide transparent information on financing needs around the HSSS; it continues to help the MoH negotiate with the Ministry of Finance and bring partner support behind the HSSS.