Engaging the private sector to deliver COVID-19

tools and achieve Health for All

What are the key behaviors for

governance of health systems?

Module 3
LEARNING OBJECTIVES

By the end of this module, learners will be able to:

• explain the governance behaviours that WHO recommends governments perform to
ensure the effective governance of the private sector both in the short term for the
COVID-19 response and in the longer term as part of health system resilience and
Universal Health Coverage.

INTRODUCTION

The Strategy Report of the WHO Advisory Group on the Governance of the Private Sector in
Health, "Engaging the private health service delivery sector through governance in mixed health
systems" [1], introduces six governance behaviours that governments should perform to govern
health systems effectively: deliver strategy, build understanding, align structures, enable
stakeholders, foster relations, nurture trust.

The six governance behaviours seek to:

(1) Operationalise health systems governance, identifying specific governance actions,

capacities, behaviours and tools that can be implemented to achieve national public health
objectives and build more resilient health systems; and

(2) To change how governance is conceptualised as a driver for change of the entire health
system (both public and private sectors).

Overall, the governance behaviours provide the foundation for a well-governed health system
where public and private actors collectively deliver on the realisation of health objectives.

THE STRATEGY REPORT

In 2019, WHO convened the Advisory Group on the Governance of the Private Sector for
Universal Health Coverage. The Advisory Group was established to provide advice and
recommendations on how best to govern the private sector in health to ensure that objectives
promoted by WHO are upheld: notably equity, access, quality, and financial protection for the
population.

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In 2020, the Advisory Group published its Strategy Report "Engaging the private health service
delivery sector through governance in mixed health systems" [1] The Strategy Report
introduced the governance behaviours as a framework promoting a new way of doing
governance focused on the private sector.

Since the publication of the Strategy Report, WHO has continuously worked on operationalising
the governance behaviours. This brief contains a definition of each governance behaviour and
outlines practical actions to use those governance behaviours in the context of the COVID-19
pandemic.

DEFINING GOVERNANCE

For this course, governance is defined as the political processes by which decisions are
reached and upheld in a country's health system and the technical processes that inform and
implement those decisions.

Governance is essential to achieve health objectives

Effective governance is essential for ensuring that a government's priorities, principles and
values are reflected in how a health system works. Effective governance is key to achieving
health objectives: from the most encompassing – like Universal Health Coverage – to time-
bound short-term objectives such as scaling up the COVID-19 vaccine rollout. Countries may
miss the opportunity to maximise health goals if efforts to strengthen health system governance
are not addressed, even incrementally.

In all circumstances, strong governance is essential for health systems performance. But,
during times of health emergency, strong governance is especially critical because there is a
need to act quickly and efficiently to mobilise all resources, both public and private, and to
ensure alignment of the activities of all health system actors with national response efforts. In
this regard, the COVID-19 pandemic has served to underline the importance of governance of
the entire health system for an effective response. It has reinforced the need for a whole-of-
society and whole-of-government approach to governance, where resources from both the
public and private sectors are steered and optimised to respond to the pandemic effectively.

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Governance is foundational to health systems performance

Governance affects all aspects of the operation of a health system from health financing to
service delivery, health programs, hospitals and clinics, the health workforce, and access,
safety and quality of inputs such as medicines and vaccines.

Governance represents the exercise of authority not only at the national level but also upward
(to the regional, transnational, intergovernmental, and global), downward (to the local, regional,
and the metropolitan), and horizontally (to private and civil spheres of authority).

Governance of the whole health system is the responsibility of governments

Governments have a responsibility to execute the governance function as part of their

stewardship role to protect the health and wellbeing of their population. Governments exercise
this responsibility by:

• Providing vision and direction for the health system.

• Collecting and using data to measure performance and inform decision making.
• Providing the conditions for the exercise of stakeholder's voice.
• Exerting influence over the health system through regulation and other means.

DEFINING THE GOVERNANCE BEHAVIORS

There are six governance behaviours: deliver strategy, build understanding, align structures,
enable stakeholders, foster relations, nurture trust. The governance behaviours are intended to
be mutually reinforcing and complementary. When working with the governance behaviours, it is
necessary to pay attention to all the behaviours even when working on one specific behaviour.

Deliver Strategy Government establishes the

priorities, principles, and
Deliver strategy refers to the government's responsibility to values for the health
establish the priorities, principles and values for the health system, and works out how
to translate these priorities,
system, and work out how to translate these priorities, principles and values into
principles and values into practice. practice.

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In practice, this consists in (1) determining what the priorities, principles and values of health
systems are; (2) defining what activities are needed and the roles and responsibilities of various
actors in delivering strategy; and (3) ensuring organisational learning and innovation to ensure
continuous improvement.

In the context of the COVID-19 response, activities include (but not limited to):
1. Developing (if not already in place) a national public health emergency preparedness
and response plan.
2. Engaging non-state actors for the development of the plan.
3. Ensuring the plan envisions a role for non-state actors (e.g., private and civic actors).
4. Regularly reviewing the plan to adjust and adapt (e.g., through a mechanism for
organisational learning and change management), notably to include the latest learnings
and experiences.
5. Mapping resources from all stakeholders to the plan.
6. Outlining the benefits of engagement to the private sector.
7. Recognising the critical role played by the private sector in the response.
8. Using the COVID-19 window of opportunity for overall policy change and strengthening
governance capacity.
9. Enlisting the support from international organisations and intermediaries in developing
new strategies, policies and capacities.

Build understanding
Government facilitates
Build understanding refers to the actions governments information-gathering and
can take to facilitate information-gathering and sharing sharing about all elements of
service provision in the health
about all elements of service provision in the health system.
system.

In practice, this consists of strengthening the government’s ability to (1) collect more, better and
different types of data on the private sector in health; (2) analyze data on the private sector in
health; (3) use data on the private sector in health in policy design, strategy development and
planning; (4) routinely share information with all health system actors.

In the context of the COVID-19 response, activities include (but are not limited to):

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 1. Ensuring data and information are collected (e.g., through a reporting mechanism) and
available to all stakeholders (public and private) at all.
2. Researching to understand barriers and enablers to data sharing and information
exchange between sectors and health system levels.
3. Improving data quality and increasing the level of details collected (e.g., disaggregation
of types of the private sector), notably through strengthened mandate and cross-
sectoral reach of national health information systems.
4. Ensuring data and information inform policy and management decisions related to the
COVID-19 response.
5. Creating (if not available) a mechanism to enable information exchange between
sectors.
6. Leveraging digital tools to facilitate information exchange and monitoring and ensuring
stronger governance and digital tools through legal and regulatory provision.

Align structure
Government takes the required
Align structure refers to governments' actions to align actions to align public and private
structures, processes and
public and private structures, processes, and institutional
institutional architecture.
architecture.

In practice, this consists of:

(1) taking a resource-based approach, recognizing that assets exist in both public and private
actors;
(2) optimising all available resources' in keeping with defined roles for the public and private
sectors.

In the context of the COVID-19 response, activities include (but not limited to):
1. Strengthening the capacity and mandate of designated units within government to align
public and private entities (national and devolved), ensure resources are shared
efficiently, and actions of various service platforms are coherent or incorporate
innovation (e.g., digital health) within the response.
2. Mapping resources and capacities to contribute to the COVID-19 response in the public
and private sector.

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 3. Defining and aligning roles and responsibilities of the public and private sectors, with
regular reviews and adaptation, to improve the COVID-19 to surge in demand and
better leverage public and private sector resources and capacity.
4. Regularly review and adapt the relevant national legislation, policy frameworks and plans
to improve the COVID-19 response (and health resilience more broadly).
5. Monitoring potential adverse practices of stakeholders in their response to COVID-19.

Enable stakeholders
Government authorise and
Enable stakeholders refers to creating norms, tools incentivise health system
and mechanisms to authorise and incentivise health stakeholders to align their
activities and further leverage
system stakeholders to align their activities and
their capacities, for national
further leverage their capacities for national health health goals.
goals.

In practice, this consists of:

(1) developing the necessary laws, capacity, resources and expertise so that governments and
other stakeholders (e.g., private sector federations, civil society) can carry out their respective
roles;

(2) in the case of governments, establishing and enforcing regulatory and financing frameworks
to align the activities of various stakeholders to national health goals.

In the context of the COVID-19 response, activities include (but are not limited to):
1. Developing a “rule book” (framework) of regulatory and financing measures necessary
for the COVID-19 response to guide public and private sector entities' actions in the
response and facilitate regulatory certainty.
2. Ensuring that the development of the rule book includes proactive communication and
dialogue on the rule book with public and private sector entities.
3. Ensuring the regulatory and financing measures are implemented and monitored, with
adequate resources and authority for the government to facilitate enforcement.
4. Reducing the risk of regulatory failure by enforcing regulations and proactively
monitoring private sector/market activity (focusing on the most high-risk areas) as part
of the COVID-19 response.

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 5. Review the fair cost of COVID-19 services (including gendered cost analysis) and create
financial incentives for private sector participation using regulatory and payment levers.
6. Committing to easing the regulatory burden through the adoption and use of digital
technologies.
7. Reviewing temporary COVID-19 regulatory measures to determine if these can be
adopted in the long term to achieve more efficient regulatory systems.
Foster relations

Foster relations refers to the governments’ responsibility Government establishes

mechanisms that allow all the
to establish mechanisms that allow all the relevant
relevant stakeholders to
stakeholders to participate in processes including participate in policymaking and
policymaking and planning to facilitate a coordinated planning.

response.

In practice, this consists of

(1) establishing or strengthening communication, consultation and coordination mechanisms;

(2) building skills and competencies necessary for cross-sectoral networking;
(3) ensuring the representation of various stakeholders (e.g., from the private sector, civil
society) in the mechanisms mentioned above.

In the context of the COVID-19 response, activities include (but are not limited to):
1. Creating (if not already) a mechanism for communication and coordination of public and
private sector actors, ensuring representativity of diverse interest groups (e.g.,
accounting for differences in gender, disability, ethnicity, geographic location, and age,
among others) within the mechanism.
2. Including private sector representatives in ministerial planning/monitoring meetings to
report on their contribution to the response.
3. Optimising intersectoral and inter-organizational relationships through virtual
communication platforms and protocols
4. Facilitating the engagement of sub-sector constituencies and sub-group interests (such
as gender and diversity specific interests) through private sector inter-organizational
networks (e.g., federations, associations, councils, etc.).

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Nurture trust
Government leads the
Nurture trust refers to the governments’ responsibility to establishment of transparent,
ensure transparent, accountable and inclusive institutions accountable and inclusive
institutions at all levels to build
at all levels as a means to build trust. trust.

In practice, this consists of

(1) recognizing and managing competing and conflicting interests of public and private
stakeholders;
(2) agreeing on shared metrics of success;
(3) establishing mechanisms to capture data on various stakeholders’ activities;
(4) monitoring coordination and implementation of various stakeholders’ activities;
(5) creating a culture of transparency and accountability in decision-making and actions (e.g.,
with sources of independent scrutiny);
(6) ensuring continuous interactions and consistent communications.

In the context of the COVID-19 response, activities include (but not limited to):
1. Recognising, mitigating and managing competing and conflictive interests as part of the
COVID-19 response.
2. Recognising the critical role of PHC as the first line of essential services and pandemic
defence by integrating response functions within frontline structures (public, private and
civic).
3. Applying governance behaviours consistently (across public and private sector entities)
and constantly (over time).
4. Maintaining the centrality of patient/civic interests (e.g., gender, diversity, equity) in
private sector engagement (and the response in general).
5. Engaging in joint activities with the private sector to incrementally build trust.
6. Adopting certain attitudes: using a collaborative skillset, calling upon a neutral
intermediary, etc.

A COUNTRY CASE STUDY ON SOUTH KOREA

By many accounts, South Korea has been an exemplar of pandemic response, lauded for its
effectiveness, rapid and targeted nature [2]. Despite having the second-highest number of
cases globally in the first two months of the COVID-19 pandemic [3], South Korea successfully

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suppressed the disease; this was achieved without restricting movement or imposing extended
lockdowns [4]. Many reasons are cited for the success of South Korea’s response. These
include a tradition of strong central governance [5], administrative and social characteristics,
and prevailing market conditions [2].

The WHO’s Country Connector has developed a case study considering South Korea’s
governance of the pandemic response [6]. A brief account of the case study is provided in this
brief to showcase the use of governance behaviours in an emergency context.

Governance Preparedness Response

behaviours
Delivery Strategy South Korea learnt from the
failure of the response to the
MERS-CoV outbreak of 2015,
which led to a revision of the
Infectious Disease Control and
Prevention Act in 2016 and the
redistribution of responsibilities
and accountabilities within the
health system.
Align structure Following the MERS-CoV
outbreak of 2015, the health
system was restructured: the
autonomy and authority of
health professionals were
strengthened, health
infrastructures and capacities
were upgraded and expanded
through partnerships.
Build understanding Following the MERS-CoV
outbreak of 2015, the
government invested in
COVID-19 triggered a response
led by the Ministry of Health and
Welfare and the President’s
Office.
The response was modulated
depending on the crisis alert
level.
Public-private cooperation
frameworks were central and
allowed for an effective
response.
South Korea was endowed with
adequate infrastructure to
respond to the pandemic, with
systems in place to ensure the
private sector played an active
role in the response and to align
the response across sectors and
levels.
The government used multiple
channels to facilitate open

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 information and communication
systems, notably e-government
technologies.
Enable stakeholders Following the MERS-CoV
outbreak of 2015, the
government revised regulations
for and invested in the biotech
industry (e.g., a streamlined
approval process for test-kit
development and clinical trials).
Foster relations The MERS-CoV outbreak of
2015 highlighted the need for a
centralized coordination
structure: as a result, the
Ministry of Health and Welfare
was later entrusted with the
necessary authority over
regional governments,
the private sector, medical
practitioners, and the public.
Appropriate resources were
given to the Ministry to fulfil its
role.
Nurture trust Following the MERS-CoV
outbreak of 2015, the
government established a legal
framework to address the public
and media’s right to information
to reinforce public trust in and
cooperation with response
policies.
and transparent communication
of the COVID-19 situation and
adjustment of government
policies in response to the crisis.
The government modified its
regulation at the onset of the
pandemic to allow for rapid
testing and used a fast-track
approval process with pre-vetted
domestic biotech companies.
The Ministry of Health and
Welfare acted as a “control
tower” and modulated the
response to COVID-19 on a
national scale, collaborating with
multiple actors and ensuring a
clear understanding of the
COVID-19 response structure
and related roles and
responsibilities.
The government was transparent
in its communication regarding
the open competition for test kit
development, building public
confidence in the process.
Overall, the Ministry of Health
and Welfare ensured a strong
and consistent communication,
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 securing civic cooperation and
compliance.

CONCLUSION

Governments play a defining role in coordinating the response to COVID-19, including ensuring
the equitable and effective delivery of COVID-19 vaccines, diagnostics, and therapeutics,
including oxygen and personal protective equipment (PPE). To optimise the response,
governments must deliver strategy, align the structures and activities of non-state stakeholders
towards policy goals, foster state/non-state relations, build understanding grounded in data and
information, nurture trust in the response and enable stakeholders to fulfil their contribution.

The six governance behaviours are essential at any time. But during times of health emergency,
they are even more so. The more governments deploy these behaviours in the COVID-19 health
system response, the more successful that response is likely to be. This new way of 'doing'
governance can lay the foundation for stronger health systems as countries transition from
managing the pandemic response to building back better in its aftermath.

REFERENCES

[1] World Health Organization, "Engaging the private health service delivery sector
through governance in mixed health systems: strategy report of the WHO Advisory
Group on the Governance of the Private Sector for Universal Health Coverage," World
Health Organization, Geneva, 2020.
[2] T. a. J. C. Im, "Coordination, incentives, and persuasion: South Korea's comprehensive
approach to COVID-19 containment," Korean Journal of Policy Studies, vol. 35, no. 3,
pp. 119-139, 2020.
[3] J.-K. D. S. H. L. R. J. F. M. &. L. R. H. Juhwan Oh, "National Response to COVID-19
in the Republic of Korea and Lessons Learned for," Health Systems & Reform, 2020.
[4] S. Lee, "Steering the Private Sector in COVID-19 Diagnostic Test Kit Development in
South Korea," Front Public Health, vol. 8, pp. 563525-563525, 2020.
[5] B.-Y. An, "Lessons From COVID-19 Responses in East Asia: Institutional Infrastrcture
and Enduring Policy Instruments," American Review of Public Administration, vol. 50,
pp. 790-800, 2020.
[6] Country Connector on the Private Sector in Health, "South Korea: learning systems and
pandemic governance," 2020.
[7] World Health Organisation, "Private sector landscape in mixed health systems," 2021.
[8] S. Nishtar, "The mixed health system syndrome," WHO Bulletin, 2010.

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[9] Y. K. David Williams O, " The failure of private health services: COVID-19 induced
crises in low and middle-income country (LMIC) health systems.," Global Public
Health, 2021.
[10] World Health Organization, "Factsheet: Universal Health Coverage.," [Online].
Available: https://www.who.int/news-room/fact-sheets/detail/universal-health-
coverage-(uhc).

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