The word “Governance” is difficult to define. It‘s use may be associated with a set of principles, the exercise of legitimate authority through law and regulation, or processes for ensuring accountability and managing risk within organizations
[1, 2]. There are complex relationships within and across local, national and global levels of governance
. Governance has dimensions which must be considered when evaluating governance practices. The three dimensions commonly cited are political, economical and institutional. The political dimension refers to the process by which governments are selected, monitored and replaced. The economical dimension refers to the capacity of the government to effectively formulate and implement sound policies, including management of public resources. The institutional dimension includes the respect of citizens and the institutions that govern economic and social interactions among them
Governance has been defined by the United Nations Development Programme (UNDP) as the exercise of political, economic and administrative authority in the management of a country’s affairs at all levels. Brinkerhoff et al., defined governance as the rules that distribute roles and responsibility among societal actors and that shape the interaction among them
. The United Kingdom Department for International Development (DFID) defined governance in terms of institutions, rules and systems of the state. The World Bank has taken the economical view of governance defining it as economic policy making and implementation with a focus on accountability and use of public resources
. Governance goes beyond government to include relationships and networks at various levels. It must be acknowledged that the concept of governance is not a coherent or agreed theoretical concept and there are debates about the nature of governance
Governance has been cited as a key determinant of economic growth, social advancement and overall development
. Research has shown that the modes of governance may influence health outcomes through their association with patterns of incentives and with regulatory and performance management regimes
. The achievement of millennium development goals is partly dependant on governance practices in low and middle income countries
Health system governance concerns the actions and the means adopted by a society to organise itself in the promotion and protection of the health of the population. The rules defining such organization and its functioning, can be formal or informal
Health systems contain three categories of actors: government, providers, and beneficiaries/clients. Health governance involves the rules that determine the roles and responsibilities of each of these categories of actors, and the relationships, structures, and procedures that connect them. Good governance in health reflects the application of a set of normative principles: accountability to patients and the broader public, an open policy process where competing interest groups operate on a level playing field, state capacity and legitimacy to manage the policy process and implement health policy decisions, effective and responsive service delivery, and the participation of civil society and private sector actors in both policymaking and service delivery
In its health system building blocks which include service delivery, human resources, health information, Medical supplies, finance and governance, WHO has emphasised governance or stewardship as crucial in health system strengthening. WHO acknowledges that governance is one of the most complex building blocks. It involves overseeing and guiding the whole health system, private as well as public, in order to protect the public interest. This requires both political and technical action, because it involves reconciling competing demands for limited resources. With increasing demands for transparency and accountability the role of health system governance has become even more important
Good governance should, in theory, lead to better performance. More accountability to beneficiaries can be an incentive for health officials and providers to improve services
Thus to achieve a system of good health governance, a number of areas need to be addressed. These include improving the policy process through ensuring policy‒making based on evidence and open, informed, fair and equitable involvement of key stakeholders. Community participation has to be enhanced through increasing local information and leadership, and institutional incentives and openness of officials. Corruption has to be reduced, through tracking financial flows and disseminating information, auditing and citizen oversight
Saddiqi et al., proposed 10 principles for assessing governance of the health system. These were strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency, accountability, intelligence and information and ethics
In 2007, Health Systems 20/20 conducted an Internet-based survey on the practice of good governance in the health sector in collaboration with the Health Systems Action Network (HSAN). The survey posed a set of good practices related to health governance and asked respondents to indicate whether their experience confirmed or disconfirmed those practices. 17 questions were subsequently distilled from the semi structured and qualitative questions that represented statements about good health system governance. The responders were mainly mid level managers and the focus was at national level rather than primary care
. These questions were also used to assess governance practices in Rwanda as part of health system strengthening intervention
. However, these statements have not been validated for regular use in evaluating health system governance especially in rural settings were the concepts of governance may be less clear. We applied the 17 governance statements and adapted the statements to fit the primary care health workers working in rural health facilities of Zambia. The aim was to establish whether the statements were valid for assessing governance practices at primary care level and to identify the latent factors or domains of governance that were captured in the 17 statements or items. This was done as part of the baseline study.
This work is part of larger study in Zambia known as Better Health through Mentoring and Assessment (BHOMA) which is a randomised step wedged community intervention that aims to strengthen the health system in three rural districts of Zambia. There are 42 target health facilities in the three study. The full methodology of the main study is described elsewhere
 (Personal communication). In this study we used the governance tool developed by the health system 20/20 for measuring health system governance in the 42 health facilities. It contains 17 semi structured statements about good governance practices
[9, 14]. The answers were graded between 1 and 4 (4 = Agree 3 = Some what agree 2 = Some what disagree 1 = Disagree).The target respondents were the health facility management team in the rural health centres of Zambia. These were mainly the health facility incharge, clinical officers, nurses, environmental health technicians, pharmacists and in some places Classified Daily Employees (CDEs) who are usually lay workers working at health facility either voluntarily or are on government payroll. After explaining the self administered tool to the team they were then allowed to sit on their own and read each statement and then graded the performance of the health facility on each statement. They were only to come up with consensus responses on each statement. The teams consisted of 2–10 members with an average of 3 members per health facility. The research team did not take part in the grading and did not sit in the room where the grading was being done. The tool was pre-tested in pilot facilities which had settings similar to the study sites.
Principal factor analysis with Varimax and Kaiser Normalisation was used to determine the latent governance factors captured in the 17 statements. After factor analysis 16 statements had a coefficient above 0.4 and thus were retained for further analysis. Reliability test for the 16 items was done using cronbach’s alpha.
The maximum possible score by each health facility was 64.These scores were converted to percentage for easy comparisons. The total district score was calculated by the sum of individual health facility scores. After identification of the latent factors these were analyzed separately as domains which made the overall governance score.
Ethical approval was obtained from University of Zambia Biomedical Research Ethics Committee and London school of Hygiene and Tropical Medicine.
All participants signed written consent before taking part in the study. Confidentiality was maintained during data collection and publication.
For the qualitative component of the study, nine health facilities were selected from the three districts. The selection criterion was that in each district one rural, one semirural and one urban health facility was to be included. At each facility, In-depth interviews (IDI) were conducted with the health centre in-charge, Chairman of the Neighbourhood health committee (NHC) and a pharmacist were interviewed. Around the catchment area of each health facility, two Focus Group Discussions (FGDs) were held with men and women. In total 30 IDIs and 18 FGDs were conducted.
Qualitative data was analyzed using Nvivo version 9. The full methodology and results of the qualitative study are reported elsewhere
. Here we report on two elements of governance: Community participation and Accountability for medical supplies.