The role of corporate governance and boards in organisational performance

For more than two decades, successive UK governments have been concerned with modernising the delivery of public services and seeking performance improvements. As part of this drive, corporate governance arrangements across the sector have been reformed and much greater attention has been paid to the training, development and support of those serving on governing bodies and boards. An underlying assumption of these shifts in policy is that improvements in corporate governance arrangements, and in particular the working of boards, will lead to improvements in effectiveness. This chapter examines what evidence there is to support that assumption

Implementing Health Impact Assessment as a Required Component of Government Policymaking: A Multi-Level Exploration of the Determinants of Healthy Public Policy

It is widely understood that the public policies of ‘non-health’ government sectors have greater impacts on population health than those of the traditional healthcare realm. Health Impact Assessment (HIA) is a decision support tool that identifies and promotes the health benefits of policies while also mitigating their unintended negative consequences. Despite numerous calls to do so, the Ontario government has yet to implement HIA as a required component of policy development. This dissertation therefore sought to identify the contexts and factors that may both enable and impede HIA use at the sub-national (i.e., provincial, territorial, or state) government level. The three integrated articles of this dissertation provide insights into specific aspects of the policy process as they relate to HIA. Chapter one details a case study of purposive information-seeking among public servants within Ontario’s Ministry of Education (MOE). Situated within Ontario’s Ministry of Health (MOH), chapter two presents a case study of policy collaboration between health and ‘non-health’ ministries. Finally, chapter three details a framework analysis of the political factors supporting health impact tool use in two sub-national jurisdictions – namely, Québec and South Australia. MOE respondents (N=9) identified four components of policymaking ‘due diligence’, including evidence retrieval, consultation and collaboration, referencing, and risk analysis. As prospective HIA users, they also confirmed that information is not routinely sought to mitigate the potential negative health impacts of education-based policies. MOH respondents (N=8) identified the bureaucratic hierarchy as the brokering mechanism for inter-ministerial policy development. As prospective HIA stewards, they also confirmed that the ministry does not proactively flag the potential negative health impacts of non-health sector policies. Finally, ‘lessons learned’ from case articles specific to Québec (n=12) and South Australia (n=17) identified the political factors supporting tool use at different stages of the policy cycle, including agenda setting (‘policy elites’ and ‘political culture’), implementation (‘jurisdiction’), and sustained implementation (‘institutional power’). This work provides important insights into ‘real life’ policymaking. By highlighting existing facilitators of and barriers to HIA use, the findings offer a useful starting point from which proponents may tailor context-specific strategies to sustainably implement HIA at the sub-national government level

Exploring the role of health management information systems in improving accountability arrangements for primary health care delivery in less developed countries: a case of Northern Nigeria

Health management information systems (HMIS) are implemented in less developed countries (LDCs) with the expectation that they will contribute to improving primary health care (PHC) delivery. Information generated through these systems is conceived as an imperative for better decision making processes and strengthening accountability arrangements that underpin the delivery of PHC. Despite strong rhetoric and significant investments to support these systems, most HMIS implementation in LDCs face challenges of poor data quality and weak accountability arrangements that limit their impact on health status. This constitutes a divergence from the instrumentality of predetermined indicators measuring health status performance that do not necessarily reflect the complex reality underlying how poor communities define their health priorities. We therefore highlight that accountability for performance management may indeed detract from the objective of improving the health of the poor and needs to be understood more broadly. This study illuminates the challenges and potential of HMIS implementation through accountability arrangements that are socially embedded in institutions, interactions and interpretations of global and local actors. As such, our primary research question is, “To what extent can HMIS improve accountability arrangements of PHC delivery?” Employing an interpretivist research methodology, we provide perceptions of how interactions between citizens, service providers, bureaucratic and political agents dynamically construct, contest and navigate accountability arrangements underpinning the provision of health care. This understanding has hitherto been limited in the HMIS literature. As a central theme in ICT for Development literature, illuminating these interactions furthers our understanding regarding the potential of HMIS in improving the lives of the poor. National governments, donors and HMIS practitioners will benefit from the practical insights derived from this study especially in relation to reconceptualising HMIS analysis to incorporate contextual and developmental notions of PHC. With relatively limited HMIS research, Northern Nigeria as the empirical context of this study also constitutes a useful contribution to the body of knowledge

T.B. Direct Observation of Treatment, Short Course (DOTS) - Political Commitment, Policy Transfer and Adaptation in Papua New Guinea

This thesis examines the Tuberculosis Directly Observed Treatment, Short Course (DOTS) policy in Papua New Guinea. It specifically examines the 2006 PNG TB DOTS policy process and how the complex and particular policy context in PNG is addressed, and the role of international donors, in the policy agenda setting process and policy content. A particular focus is the meaning of TB DOTS Policy Component 1 – Political Commitment, and how this shapes the governance structures and health system governance in PNG which are a central part of the policy context for the implementation of a national TB DOTS policy in a country with a continuing high burden of disease from TB

Intersectoral Action for Health: Challenges, Opportunities, and Future Directions in the WHO European Region

Human health is shaped by public policy decisions made not only by the health sector, but numerous other sectors and actors that influence peoples social, economic, and cultural conditions. Therefore, national health ministries cannot solve the root causes of many health problems without also engaging non-health sectors to implement health-promoting public policies. For over three decades, the World Health Organization (WHO) has actively endorsed the concept of intersectoral action for health as a key approach to address the most pressing health challenges at the national and international levels. At the international level, the need to engage non-health sectors in health promotion activities has been repeated in nine outcome documents of the global health promotion conferences organized by WHO between 1986 and 2016. However, calls to promote health through greater intersectoral action have not led to wide-scale and systematic implementation by national governments and jurisdictions. The challenges and opportunities to intersectoral action for health are rarely identified in a systematic way in the existing research literature. To address the current gap in knowledge, this dissertation was based on three key research questions: (1) How do the expert informants within the WHO Regional Office for Europe understand the concepts of intersectoral action for health and governance for health?, (2) What do the academic literature and key informants identify as the challenges and barriers to intersectoral action for health?, and (3) Which factors facilitate the implementation of the intersectoral action for health and what are the opportunities to promote health through such action in the future? The methods of this study included an in-depth review of literature and primary data collection that involved 28 semi-structured interviews with WHO Programme Managers, Unit Leaders, Directors, and Technical Officers working at the WHO Regional Office for Europe in Copenhagen. A thematic analysis of the key informant interviews focused on the challenges and opportunities to intersectoral action for health. The aim of this analysis is to shed light on the factors that are relevant to the policy process and dynamics of intersectoral policymaking. The findings of this study draw on the perspectives that the informants had gained by working with many of the 53 countries that comprise the WHO European region. The analysis involved a computer-assisted coding process with NVivo software and led to ten thematic challenges/barriers and to ten thematic opportunities/facilitators. Overall, this dissertation increases understanding of the political, technical, institutional, and managerial barriers to intersectoral action for health. In addition, it presents a systematic analysis of the factors that can facilitate intersectoral action for health and considers the future of intersectoral approaches in health promotion. Based on the empirical findings, the concluding section includes eighteen recommendations for strategies to overcome the challenges and barriers to the implementation of intersectoral action for health in the future. These recommendations include various strategies such as ensuring high-level political support and a mandate for intersectoral action, mapping out co-benefits among sectoral partners, establishing permanent intersectoral mechanisms, ensuring adequate resources for implementation and monitoring, and increasing the capacity of the health sector to work with non-health sectors

Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa.

Recent global crises have brought into sharp relief the absolute necessity of resilient health systems that can recognise and react to societal crises. While such crises focus the global mind, the real work lies, however, in being resilient in the face of routine, multiple challenges. But what are these challenges and what is the work of nurturing everyday resilience in health systems? This paper considers these questions, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach. The paper presents evidence of the instability and daily disruptions managed at the front lines of the district health system. These include patient complaints, unpredictable staff, compliance demands, organisational instability linked to decentralisation processes and frequently changing, and sometimes unclear, policy imperatives. The paper also identifies managerial responses to these challenges and assesses whether or not they indicate everyday resilience, using two conceptual lenses. From this analysis, we suggest that such resilience seems to arise from the leadership offered by multiple managers, through a combination of strategies that become embedded in relationships and managerial routines, drawing on wider organisational capacities and resources. While stable governance structures and adequate resources do influence everyday resilience, they are not enough to sustain it. Instead, it appears important to nurture the power of leaders across every system to reframe challenges, strengthen their routine practices in ways that encourage mindful staff engagement, and develop social networks within and outside organisations. Further research can build on these insights to deepen understanding

From the Formulation of a National Policy to the Compilation of Social Protection Actions: A Case of ‘Non-design’ in Burkina Faso

To improve the social protection of its population, Burkina Faso adopted a national policy in 2012. This paper analyses the process whereby this policy was formulated, looking at the issue from the standpoint of ‘policy design’ (Howlett and Mukherjee, 2014). Conducted in accordance with an inductive qualitative approach, the collection and analysis of the data show that this process of formulation has led neither to reflecting on the problem to be solved nor to identifying the specific needs of the beneficiaries. Nor has it led to evaluating the potential outcomes of the proposed solutions in order to choose the most appropriate ones. The authors are thus led to an empirical observation of ‘non-design’. This policy boils down to a document whose all-encompassing content brings together every conceivable action of social protection, without any arbitration. Three factors have contributed to this non-formulation: (1) the lack of clear government direction to guide discussions; (2) a weakness of support and of political will, resulting in a low degree of involvement in the process on the part of high-level decision makers; and (3) conceptual and technical misunderstandings on the part of national stakeholders in social protection—so much so that they have simply relied on the advice of international bodies. The government announced its intention of playing a leading role in the process of formulating this policy, but this was a purely rhetorical declaration. The study shows that leadership and political will have been lacking, particularly when it has come to channelling the respective interests of the stakeholders and managing the contradictions that hinder the formulation of a coherent policy adapted to the needs of the population

Health reforms: a case study of Fiji

This research study is concerned with health policy analysis and its importance in the formulation, planning and implementation of health policy in Fiji . The project explores the influence of political institutions, and the significance of the political context and cultural and societal values in Fiji that influenced the implementation of the Fiji Health Management Reforms (1999-2004). The research has highlighted that health policy analysis is a necessary tool in developing countries that are undergoing health reforms

Moving forward health equity: implementation research on governance for health equity at local level.

286 p.BACKGROUND: Urbanization is one of the leading sociodemographic trends of the 21st century, which makes urban areas one the most important settings for tackling current and new global challenges. In fact, the importance urban health has been increasingly recognised for its central role shaping public health globally. In this context, an equity-promoting urban governance offers a window of opportunity not only to face these challenges, but also to be part of the solution. Policy coherence, accountability and social participation have been identified both as drivers of health equity and key dimensions of governance for health equity.OBJECTIVE: The fundamental question that underlies this research is how local health strategies can drive forward an equity-promoting urban governance for health. This thesis aims to describe the urban governance for health context in three urban case studies, and to appraise and comparatively analyse how the key dimensions of governance for health equity have been incorporated within local health strategies. Moreover, the thesis assesses the main barriers and facilitators of the implementation of equity-promoting local health strategies. ,METHODS: This is a qualitative-based implementation research, which employs a multiple case study method to in-depth examine the local health strategies of Bilbao, Barcelona and Liverpool. Participant observation, document analysis and 27 in-depth semi-structured interviews among technicians, managers, decision-makers and other local actors were conducted. The key dimensions of governance for health equity were assessed: 1. Policy coherence was analysed using an adaptation of the Storm's Maturity Model for HiAP; 2. Accountability was assessed using the Ebrahim and Weisband¿s proposal and the corresponding domain of the PAHO Equity Commission's rubric for accountability; 3. Social participation was analysed using the Health Canada¿s Public Involvement Continuum model. To assess the barriers and facilitators of the implementation processes the Consolidated Framework for Implementation Research was used. In addition, to contrast and validate the comparative analysis results, 16 experts in the field of governance for health, health equity and implementation science were interviewed.RESULTS: There were significant variations in the levels of maturity of policy coherence, accountability and participation across the local health strategies explored, being more developed in the cases of Barcelona and Liverpool, and somewhat more incipient in Bilbao. The heterogeneity of the governance for health strategies revealed that there is no one-size-fits-all type of strategy that fosters health equity. However, there are elements in common that can act as enablers of an equity approach.Regarding policy coherence, the results suggest that a democratic and socially progressive political environment supports the integration of health and equity as a shared value. Likewise, the establishment of legal and regulatory frameworks such as public health laws or strategic government plans can provide an umbrella for the institutionalization of a social model of health. Specifically with regard to local health strategies, these seem to be more operative when they involve multi-level policies, as they enable more easily the establishment of structures and resources for intersectoral action for health, the use of decision-support tools, and the development of individual and institutional capacities, which are key elements for its implementation. Building synergies with other programs and networks can also foster the implementation of policy coherence at the local level.With regard to accountability, a human rights-based approach to health combined with structures, mechanisms and processes for accountable governance can foster transparency and answerability, but also compliance and enforcement. Accountability in local health strategies can be operationalized through Public Health Observatories with a technical profile and a sufficient degree of autonomy from the political level. Ensuring continuous and inclusive monitoring and evaluation, an availability of openly available disaggregated local data as well as the generation and transfer of applied knowledge are also key enablers of accountability at the local level.Regarding social participation, a more horizontal model of governance involves promoting deliberative capacity and the decentralisation of power through the establishment of a variety of processes, mechanisms and instruments that encourage the participation of all social groups. It is key ensuring an inclusive and representative participation and incorporate social participation as an essential part of the whole policy circle. Local health strategies should strive for leadership by and for the community, including specific actions for the development of participatory skills and capacities for both the population and local government.CONCLUSION: The results highlight that progress in the implementation of equity-promoting local health strategies requires the inclusion of equity as a general value and as a specific policy objective through goals to reduce inequalities, but also through goals to strengthen and operationalise policy coherence, accountability and social participation. This implies moving from short-term, fragmented or isolated policies to a comprehensive set of policies that place equity at the centre. Effective policy action to respond to the global challenges cannot fit into low-cost policy options that fits within electoral cycles. Health inequalities will only be reduced as a result of substantial political change; moving forward policy coherence, accountability and social participation into local health strategies can foster the creation of arenas to challenge the distribution of power

An investigation into the qualitative characteristics of large infrastructure and project finance ventures in Southern Africa

A thesis submitted to the Faculty of Commerce, Law and Management, University of the Witwatersrand in fulfilment of the requirements for the degree of Doctor of Philosophy. Wits Business School 4 November 2016Sub-Saharan Africa faces severe infrastructure deficits including in power generation, water facilities, transportation, and telecommunications. These deficits compound the socio-economic challenges of the most impoverished region in the world. It is estimated that funding of US$ 90 billion per annum is required to address infrastructure deficiencies. Other developing regions including Asia, the Middle East, and South America, have with varying degrees of success utilised the project finance framework to address similar infrastructure deficiencies, and also develop other commercial ventures. Africa has lagged behind in this respect, and still accounts for less than 3% of international project finance flows. The ability to attract and access international and domestic project finance capital, and execute the underlying ventures is an important opportunity to address the challenges noted above. The study contributes to knowledge by deepening our understanding of project finance in South Africa, Mozambique, and Zimbabwe in the following ways. Firstly, it offers a model through which to monitor key contextual factors that influence the success, failure, and shaping of project and infrastructure ventures. Secondly, it interrogates the main capital structure theories including the static trade off and pecking order theories, and their applicability and relevance for project and infrastructure finance in the selected jurisdictions. It then compares capital structure theory with actual practice of capital structure formulation in the 7 cases studies investigated. This yields important insights as to the most important factors influencing capital structure in project finance in the three selected countries. In particular the constrained supply of capital is observed as the top factor determining capital structure. It further enhances our understanding of why ventures using project finance in these countries may have significantly lower leverage than other similar ventures in developed regions of the world. Thirdly, the study extracts key insights into how stakeholder interactions evolve in the projects by applying stakeholder agency theory to project sponsors, managers, contractors, state institutions, and community organisations. Collectively these insights should contribute to attracting increased capital to project finance in Sub-Saharan Africa, and arranging projects with greater prospects of operational success.MT 201