The World Health Organisation (WHO) European Office commissioned a study into ‘Governance for health in the 21st century’.  The primary purpose of the study is to inform the WHO European Region’s new policy Health 2020.  It was carried out by Ilona Kickbusch who I heard speak about the early stages of the study at the WHO European Healthy City Network annual meeting (Liege, June 2011).  The final version of the study formed part of the papers at the sixty-first session of the Regional Committee for Europe and is available here.

There are a couple of reasons why this paper interests me.  Firstly, part of my role is to coordinate Newcastle’s involvement in the WHO European Healthy City Network so it is kind of my job to look at it – well, at least the exec summary anyway.  Secondly, the paper describes the development of ideas around health and around governance which to me are fundamental shifts of paradigm.  It is this second reason that has made me spend time going through the paper – in short, it is the first document I have read that puts ideas I am familiar with from my studies of Development Management and Systems at the heart of the way we should manage, lead, govern (whichever verb you want to use) our work to improve wellbeing and health and reduce health inequalities.

But, my experience was of a dense, hard-to-read document – partly because of the use of some ‘new-to-me’ concepts and also because I found the structure hard to deal with.  So I thought I’d attempt to summarise out the key messages so I can work with them a little more.

Key distinction

The paper starts out by drawing a distinction between:

– health governance:  the governance of health service system and governance of actions to strengthen these (page 2).  In the English setting, I think I’d find it more appropriate to talk of ‘health and social care’ or even ‘health improvement, health care, social care and health-related services’.  It seems that this type of governance is primarily about ways of making sure the people who need them get good quality treatment, care and ‘wrap-around’ support.  It’s all about the world of care plans; care pathways; treatment regimes; service systems and so on.

– governance for health and wellbeing: this concerns the joint actions of all sectors and of citizens for a common interest (page vii).  The definition they give is “attempts of government or other actors to steer communities, countries or groups of countries in the pursuit of health as integral to wellbeing through both a ‘whole of government’ and a ‘whole of society’ approach” (page 3).  It seems that this is much more about an approach that embraces the social determinants and the need for social change, rather than a sole focus on services.

The study emphasises that both ‘health governance’ and ‘governance for health’ are important challenges facing European countries – but its own scope is primarily on the latter and ways of working when you embrace governance for health and wellbeing.

Study overview

The study outlines – sometimes explicitly, sometimes implicitly – a number of shifts in ideas that together create the contextual drivers for, and elements of, ‘governance for health’.  I’m going to describe these shifts here in the form of ‘From’ and ‘To’ but wish to emphasise that this should be seen as an ‘expansion’ of the ‘From’ position – not a rejection of it.  This was a key message I picked up when I heard Ilona Kickbusch speak at WHO European Healthy City Network conference (Liege, June  2011).

Contextual drivers – from the world of ‘health’

The first part of the study outlines three key drivers of contextual change that are particularly relevant to governance for health.

Shift 1: From focussing on individual countries to recognition of global interdependence.

Health needs to be recognised for its interdependence.  This is particularly apparent when there are ‘shocks’ such as hurricanes or earthquakes or in the case of pandemics.  However, there are also problems that have taken longer to gather momentum – demographic changes; ageing society; climate change and severe events; economic disparities – all these have an effect on wellbeing and health of populations.

Shift 2: From understanding health from the perspective of individual risk factors to understanding health from the perspective of health as “an outcome of a wide range of political, social and economic developments and as an asset linked to the capabilities and resources of individuals, communities and society as a whole” (page 9)

The study refers to Systems theories to explain these new understandings – Complexity; Complex Adaptive Systems; and, a touch of Systems Dynamics – and it suggests the need for a ‘systems perspective’.  In essence, there are countless interrelated and often interdependent variables and we need new ways of making sense of these (beyond linear cause and effect).

In terms of actions, the study says “most interventions are broad, structural and relate to policy rather than specific clinical interventions” (page 12) which is a key distinction between governance for health and wellbeing as compared to health governance.

Shift 3: From viewing citizens as simply recipients of services or beneficiaries of interventions to viewing citizens as co-producers of health.

This shift helps me think of citizens (myself included) as participants in, and creators of, social change – social change with the aim of health and health equity.  This is a “democratisation of health [and] is linked to new participatory features of modern democracy” (page 12).  There is a discussion of the role that new technologies play in enabling communication – an important factor in that shift.

The study (page 12) draws out two distinct but related dimensions of ‘co-production’:

– the ‘health governance’ lens leads to shared health and care – the relationship between individuals and their health and care producers.  Which to me evokes the familiar discussions of personalisation; self-directed support; self-care.

– the ‘governance for health’ lens leads to shared governance for health – incorporating the commitment to a ‘whole of society’ approach.

Effective co-production of health in both of these dimensions requires health literacy and access to information and communication.

The study particularly highlights that co-production of health requires the co-production of knowledge and increased recognition of lived experience and a range of perspectives, as compared to ‘expert opinion’.  This pluralistic, multiple perspectives approach is a feature of  anticipatory governance – which seems like it could be a whole blog topic in its own right – starting with this paper by Fuerth. I think the important aspect to home in on here is that the approach allows for both ‘fact’ and ‘values’ to be incorporated into deliberations… and it incorporates ‘foresight’ as a way of anticipating possible futures.

Contextual drivers – from the world of ‘governance’

The study then draws from literature about governance, starting with the following definition:

Governance is “the sum of the many ways individuals and institututions, public and private, manage their common affairs.  It is a continuing process through which conflicting or diverse interests may be accommodated and cooperative action may be taken.  It includes formal institutions and regimes empowered to enforce compliance, as well as informal arrangements that people and institutions either have agreed to or perceive to be in their interest”

Commission on global governance, 1995

In introducing this section, the study notes that:

Shift 4: Overall there is a shift from authoritarian mechanisms and institutions of governance to collaborative, participatory strategies of both policy-making and problem-solving.

And then goes on to describe how this shift is shaped by three key dynamics.

Shift 5:  From governance as a role of government to diffused governance

The new ‘knowledge society’ and the complexity of challenges, leads to new patterns of power-sharing.  Governance is diffusing both vertically – to sub-national and local – as well as horizontally – across traditional government departments.  This diffusion is what provides the basis for the ‘whole of government’ and ‘whole of society’ ethos in the description of governance for health.  So governance is horizontal, multi-level and multi-stakeholder.

There are varying views about what this diffusion means for the role and authority of the state.  However, the study emphasises the need to complement traditional, hierarchical forms (such as use of law for smoking bans) with multi-stakeholder approaches.

Shift 6: From representative democracy to monitory democracy

Citizens expect to be involved in new ways and to be better informed.  As information is more widely available so it becomes possible for citizens and power-scrutinising organisations to monitor the use of power.  Again this shift drives the shift from authoritarian to collaborative approaches.

Shift 7: From viewing businesses as having a role of philanthropy and social responsibility to the concept of shared value.

The paper draws on an article by Porter and Kramer in Harvard Business Review on Creating Shared Value.  There is a summary and interview with Porter on the HBR website.  The article defines shared value as:

“The concept of shared value can be defined as policies and operating practices that enhance the competitiveness of a company while simultaneously advancing the economic and social conditions in the communities in which it operates. Shared value creation focuses on identifying and expanding the connections between societal and economic progress.” [http://hbr.org/2011/01/the-big-idea-creating-shared-value, accessed 7 November 2011].

Shift 8: From a linear approach to policy to policy as a dynamic process

After covering the three shifting governance dynamics, the study then homes in on the changing nature of policy making, which it summarises as “it has become more complex as it attempts to address ‘wicked problems’ and systemic risks, confront multiple possible futures, include many players and stakeholders and reach agreement on course of action based on the understanding that the amount of evidence is always increasing and it is rarely final” (page 23).

The study highlights how this presents challenges to traditional bureaucracies which tend to be averse to risk, little incentives to take action outside their own specific objectives, have sectoral division of labour.  Traditional policy approaches have tended to be linear which limits the possibilities for interactivity and dealing with uncertainty.

So the move is to “policy-making through highly networked, multilevel, multistakeholder governance” (page 24) which is not necessarily a recent push but the need for it is gathering momentum.

The study also includes a box summarising ‘feaures of policy making in the 21st century’ (page 24):

Nine features required of policy-making in the 21st century

Forward looking: a long term view based on statistical trends and informed predictions of the possible impact of the policy

Outward looking: taking account of the broader context and communicating policy effectively

Innovative and creative: questioning established methods and encouraging new ideas; open to the comments and suggestions of others.

Using evidence: using the best available evidence from a range of sources and involving stakeholders at an early stage

Inclusive: taking account of the impact of the policy on the needs of everyone directly or indirectly effected

Joined-up: looking beyond institutional boundaries to the government’s strategic objectives

Evaluative: including systematic evaluation of early outcomes into policy-making

Reviewing: keeping established policy under review to ensure that it continues to address the problems for which it was designed, taking itno account associated effects

Learning lessons: learning from experience of what works and what doesn’t.

Source: Adapted from Government of Northern Ireland (1999)

The changes to governance and policy making requires governments to take on more diverse roles.  The study draws now on Dube et al, 2009 to identify six roles:

– regulator

– provider of goods and public services

– steward of public resources and investments

– partner in multi-sector collaboration

– enabler of social and business innovation

– enabler of whole-of-society action

The ‘whole of government’ approach requires all involved to consider wellbeing and health as a social goal that requires joint action.  The approach requires “building trust, a common ethic, a cohesive culture and new skills” (page 26).  This is not always about creating new, formalized structures but finding ways to work together more pragmatically and intelligently.

Multi-level governance needs to recognise that governance is an emergent property of interactions among a range of state and non-state actors.  It also places an important role on local governments.

The ‘whole of government’ approach “emphasises not only better coordination and integration of government activities but also focuses coordination and integration on the social goals that the government represents” (page 27)

A complement to the ‘whole of government’ approach is the ‘whole of society’ approach.  Addressing difficult social problems requires many stakeholders, especially citizens.  Taking action on shared social goals is very important.  This approach implies much greater capacity for communication and collaboration and all partners need to invest time and energy into this.  This is about mobilising a range of actors to work together.  Coordination in this approach is through normative values and trust-building – it is not about centralised or hierarchical prescription.

The journey so far – governance and health and wellbeing

The study highlights three waves of governance for health.

The first wave was characterised by intersectoral action and primary health care and marked the “efforts by the health sector to work collaboratively with other sectors of society to improve health outcomes”.

The second wave was characterised by health promotion and healthy public policy.  This marked the beginning of the concern for accountability for health impact within all policies.  So, for example, the Ottawa Charter emphasised  “health in the context of everyday life, where people live, love, work and play” (page 32).  There was also the rise of the ‘settings’ based approach – healthy schools, healthy prisons, healthy cities and so on.  The focus shifted from individual behavioural change to a realisation that the “problems had to be addressed at the causal level” (page 33).  Health impact assessments were promoted.

The third wave is the Health in all policies.  The study draws on Stahl et al, 2006 to describe this:

“The Health in all policies approach considers the impacts of other policies on health through health determinants when policies of all sectors are being planned, decisions between various policy options are being made, and when implementation strategies are being designed.  It also examines the impacts of existing policies.  The ultimate aim is to enhance evidence-informed policy-making by clarifying for decision-makers the links between policies and interventions, health determinants and the consequent health outcomes. (page 34)

(It is interesting how this ‘definition’ of health in all policies is not necessarily consistent with the changing way of policy making described in the earlier section…. it feels a bit linear and as if all evidence is neatly available.)

The study however emphasises that health in all policies is “a network approach to policy-making throughout government – a whole of government approach with a focus on health – based on acceptance of different interests in the policy arena and the importance of building relationships among policy-makers in order to ensure policy outcomes (page 34/35).  It is important to involve private sector and civic society in policy making – but government does has a particular role, especially in relation to unfair distribution.  A good whole of government approach makes the state well equipped to steer and collaborate with society.

Guiding values

The study then moves its concern to guiding value system for ethical governance and proposes four value orientations.

Health as a human right:  health can directly influence the enjoyment of human rights and lack of respect for human rights can have serious health conseqnences.

Health as integral to wellbeing:  as the emphasis in development shifts from an economic perspective to being more people centered, there is increasing use of ‘indices’ of wellbeing.  Health is integral to wellbeing (and is defined by WHO in terms of wellbeing) and is a core element of new measures of success (life expectancy, childhood development).  There is literally a shift in what we are (e)valu(at)ing.

Health as a global public good:  The study outlines that where ‘public goods’ are adequately provided, everyone benefits but if they are underprovided then everyone suffers.  Health therefore exists in the collective, as well as the individual domain.  The concept seems similiar to descriptions of ‘resilience’ and ‘assets’, I would paraphrase this to “health as a collective asset” (but I may be missing something!)

Health as social justice: This brings in the issue of health equity and the differences in wellbeing and health across the social gradient.  Often the determinants of health inequity and equity are interrelated with those linked to other complex issues – educational performance; inclusion; cohesion; poverty; resilience.

Relationship between values and evidence

The study then re-visits in more detail, an issue it touched on earlier when discussing co-production of health.  It draws on Kinke and Renn, 2006) in identifying three components of good governance in a knowledge society: knowledge; legally prescribed procedures; and, social values.

As governance processes get more complex and involve more stakeholders, then it is even more important to have common values.  Policy cannot be based solely on ‘evidence’ – production of ‘evidence’ is “always embedded within existing values and beliefs” (page 41).

They then (page 41) quote Ozdemir and Knoppers, 2011:

Social factors such as human values and ways of knowing – what we choose to know and how we know it – expressly impact what gets to be produced as scientific knowledge.  The choice and framing of scientific hypotheses, experimental methodology and interpretation of data can all be influenced by experts’ and their institutions’ value systems that often remain implicit in scientific decision making.

Ozdemir and Knoppers, 2011

Governance therefore needs people to be fully aware of the values that are inseparable from ‘evidence’ and it is important that these are debated as part of participative processes.

In responding to uncertainty, there has been a tendency to rely solely on evidence and overlook the ways in which social values shape that evidence.

It is therefore essential to bring values into discussions.  Thus ceasing the false separation between ‘science’ (e.g. evidence) and ‘social’ (e.g. values).

Now, we’ve had the build up – we can look at what is meant by ‘smart governance for wellbeing and health’.

The term, smart governance was coined by Willke (2007) as “an abbreviation for the ensemble of principles, factors and capacities that constitute a form of governance able to cope with the conditions and exigencies of the knowledge society” (cited on page 43)

Smart governance for health and wellbeing has five dimensions:

Dimension 1: Governing through collaboration

The study provides an outline of the literature and a number of case studies around governing through collaboration, recognising both ‘horizontal’ and ‘vertical’ relationships and imbalances of power and resources.  The Executive Summary highlights that is important to give “due consideration to the process and design of collaboration; the virtuous circle of communication, trust, commitment and understanding; the choice of tools and mechanisms; and transparency and accountability” (page viii).

Dimension 2: Governing through citizen engagement

The success of health improvement is only possible with the active engagement of citizens – whether that is as ‘patients’ or as citizens engaged in social change.  “Policy can no longer just be delivered: success requires co-production and the involvement and cooperation of citizens” (page 51).  Again the study outlines relevant literature and some case studies with a particular emphasis on the role of technology in governing through citizen engagement.

The Executive Summary pulls it together with these words:

“Successful governance for health requires co-production as well as the involvement and cooperation of citizens, consumers and patients.  As governance becomes more widely diffused throughout society, working directly with the public can strengthen transparency and accountability.  Partnering with and empowering the public are also crucial for ensuring that values are upheld” (page viii).

Dimension 3: Governing by a mix of regulation and persuasion

Smart governance does not mean a choice between ‘networks’ or ‘hierarchies’, it requires the appropriate use of both approaches.  As demonstrated by the combination anti-smoking legislation (regulation) with approaches aimed at changing social norms (persuasion).  This is about combining the use of ‘hard’ power with ‘soft’ power in an appropriate way – and the growing use of ‘nudge’ ideas to make the healthier choice, the easier choice.

Dimension 4: Governing through independent bodies and expert bodies

The study describes the shift to monitory democracy and different monitory mechanisms and once again gives examples.

Once again the Executive Summary provides a round-up:

“as in other fields of governance, independent expert bodies,…., are playing increasingly vital roles in providing evidence, watching ethical boundaries, extending accountability and strengthening democratic governance in health, as related to privacy, risk assessment, quality control and health technology and health impact assessments.” (page ix)

Dimension 5: Governing by adaptive policies, resilient structures and foresight

The study describes how ‘Systems approaches’ can lead to better governance for health and wellbeing (though there is a tendency to focus in on the Systems approaches that emphasise interdependent variables, as opposed to multiple perspectives and ethical judgements).  Approaches to governance for health need to mirror the complexity and allow for de-centralised decision making and self-organising networks.  It emphasises adaptive policy and provides some conceptual frameworks to guide adaptive policy making.  It also looks at having integrated, forward-looking analysis – with the possibility of different modelling techniques for forecasting.

New roles – with related new skills and capacities

The study then re-emphasises the different role that government plays in ‘governance for health in the 21st century’ – as “broker, catalyst, animator, educator and partner in participatory ‘flat’ processes”. (page 70)

This new role translates into new leadership skills – with a shift in emphasis from ‘hierarchical’ to ‘collaborative’ and ‘transformational’.   Individuals need to develop their systems thinking and practice – feel more comfortable with non-linear approaches and act appropriately to improve situations whilst accepting unpredictability and uncertainty.

Leaders could be seen as “policy entrepreneurs: they help understanding of an issue, they frame it and act as facilitators” (page 72).  This can come from organisations or social movements as much as individuals.

It is important to that health leaders are prepared for “the political nature of health and the highly politicised context in which health decisions are taken” (page 72).  Although not explicitly mentioned I am reminded of the idea ‘health diplomacy’ – the ability to convince, negotiate and inspire others to work together for wellbeing and health.

My reflections – relating to English context

The current Health and Social Care Bill progressing through parliament marks a major change in ‘governance’ in the domain of health in England.

It seems to me that the vast majority of these changes link to what the study describes as “health governance” – a re-design of the health system (in its broadest sense).  The language is very much that of ‘service provision’ – health care; social care; ‘health related services’; and ‘health improvement services’.  It also advocates a linear strategic process – do Joint Strategic Needs Assessment (JSNA), make strategy, commission services.

However, the Bill follows on from the public health strategy “Healthy Lives, Healthy people” which does emphasise the need to work on the social determinants of health, echoing much of the Marmot review of health inequalities in England.

When the Bill and associated government discourse brings in social determinants, it tends to ‘assume’ that it is just an add on to the “health governance” arrangements.  So whilst the role of Health and Wellbeing Boards, talks of ‘health improvement’, it then homes in on ‘health improvement’ service commissioning, just one dimension of ‘health improvement’.  Health and Wellbeing Boards can ‘choose’ to include work on social determinants but this is stated in a way that makes people think that this is just a few extra JSNA sections – not as this study emphasises a whole expanded approach to governance.

In addition, the description of ‘HealthWatch’, the proposed ‘patient’ involvement mechanism seems to restrict thinking to the ‘watching’ of services, although it does link to the newer shift in monitory democracy.   But HealthWatch will need a ‘split’ personality to be part of ‘governance for health’ too – as collaborators and co-producers of health.  In the language of critical systems heuristics – that makes ‘local people’ into customers, decision-makers, sources of expertise and witnesses.

My reflections – relating to Systems

There is so much in this document that resonates with concepts, ideas and approaches I have covered in my studies.  So much, I don’t know where to start.  Every paragraph I have written in this post (and many others in the study itself)  has sent me off on little thought tangents – into systems dynamics; viable systems model; critical systems heuristics; soft systems methodology; the notion of systemic change; managing systemic change; multi-stakeholder and social learning; bringing ethics and values into work; distinguishing systematic thinking and action from systemic thinking and action; recognition of duality; epistemological awareness.

The disappointment I have is that the study often confuses these – it does not give the same rigour in drawing from the discipline of Systems than it has done in drawing from the disciplines of public health and policy/governance studies.  For me that weakens the overall document – but I would say that wouldn’t I!

References:

World Health Organisation, Regional Office for Europe (2011), Governance for health in the 21st century: a study conducted for the WHO Regional Office for Europe, World Health Organisation European Office for Europe.  Available at http://www.euro.who.int/en/who-we-are/governance/regional-committee-for-europe/sixty-first-session/documentation/information-documents/inf-doc-6-governance-of-health-in-the-21st-century [accessed 11 November 2011]

All other references are cited in this study.