Asaad Ahmed Nafees ( Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. )
Parvez Nayani ( Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. )
Since the concept of stewardship in health care first appeared in World Health Report 2000 there has been very limited discussion in the academia about its implications. In the present paper we revisit this concept and review the literature that has been written about it. We have particularly focused on the role of stewardship in health policy of Pakistan. We also highlight the improvement that stewardship can bring about in the health policy of Pakistan and the possible constraints that might be faced during its implementation phase.
The literature available is on the concept of stewardship in health policy. The search was done through the database of PubMed with key words including; stewardship, health policy, governance, and role of state. A total of 22 articles were shortlisted and included in the review.
The concept of stewardship has a lot of potential to reinterpret and reinvigorate the role of the state in Public Health of nations across the globe, including Pakistan.
Keywords: Stewardship, Health policy, Governance, Role of state.
The concept of stewardship in health was described by the World Health Report in 2000, which gives four functions of the health system; service delivery, resource generation, financing and stewardship.1 Stewardship is the fourth in order and has been stated to be one of the most important functions of a health system. The report defines stewardship as the: \\\'careful and responsible management of the well-being of the population\\\' or \\\'Effective trusteeship of national health.\\\'
The concept of stewardship in healthcare has also been discussed in detail by Kass and Armstrong.2 According to Kass stewardship is the \\\'administrator\\\'s willingness and ability to earn public trust by being an effective and ethical agent in carrying out the republic\\\'s businesses\\\'. While Armstrong has given a more managerial definition which states that stewardship is the \\\'willingness to be accountable for the well-being of the larger organization by operating in service rather than in control of those around us.\\\'
A related term \\\'governance\\\' can be described as the process of decision making by which decisions are taken and implemented which involves different formal and informal actors.3 Although the terms good governance and stewardship are mostly comparable there are differences in the context in which they are generally applied; with the former being more politically oriented and latter more technically oriented.4 Stewardship theory tries to build on the concept of good governance making it more ethically informed, normative and distinct from the agency theory.2
Since the concept of stewardship in health care first appeared in World Health Report 2000 there has been very limited discussion in the academia about its implications. There is also lack of literature regarding its implications in the health policy of Pakistan.
In the present paper we revisit this concept and review the literature that has been written about it. We have particularly focused on the role of stewardship in health policy of Pakistan.
We also highlighted the improvement that stewardship can bring about in the health policy of Pakistan and the possible constraints that might be faced during its implementation phase.
We reviewed the literature that is available on the concept of stewardship in health policy. The search was done by using the database of PubMed, without any language restriction and with key words; stewardship AND health policy (96 searches), governance AND health policy (647 searches), role of state AND governance (144 searches), role of state AND stewardship (25 searches). Additional search was done on the internet through Google and by using database of Aga Khan University library which includes literature from various international and local sources. Out of all these searches, 22 articles were found which discussed the concept of stewardship in health in Pakistan and other developing countries. These articles were shortlisted and included in this review.
Although the concept of stewardship has recently made inroads into the Public Health literature, it has its roots in the major religions including Christianity, Judaism and Islam. In Genesis it is mentioned that God appointed humanity as the steward of creation and this view can also be found in the Holy Quran. The Holy Quran and the Old Testament also refer to the parable of Prophet Joseph where a steward is described as \\\'a selfless servant, who manages assets without owning them, anticipates future trends and devises grand plans\\\'. The New Testament builds on this concept and refers that \\\'when entrusted with something of value one has an obligation to improve it\\\'.2
In Islam this concept was further worked upon and during the Caliphate period (about 1400 years back) stewardship was considered a separate institution called the institution of Hisba whose sole purpose was \\\'to ordain good and forbid evil\\\'.1 This institution had two dimensions; moral and administrative. The functions of the head of this institution called Muhtasib, can be classified into three categories: those relating to the rights of God; those relating to the rights of people and those relating to both.1,5 Thus the regulation of health sector also fell within the domain of Hisba and some of the measures undertaken include\\\' professional exams for physicians; formation of essential instruments list for physicians; and the regulation of the pharmaceutical industry. Hisba also served as an effective anti-corruption system. The once well established institution of Hisba was modified over the years so much so that it has now become almost obsolete.
The concept of ecological/environmental stewardship also traces its roots from religion. Environmental stewardship is defined as \\\'the responsibility for environmental quality shared by all those whose actions affect the environment\\\'. This sense of responsibility is a value shared by individuals, communities, companies, and government organizations and envisages behaviour modification for the improved environment.6
Domains of Stewardship:
The term \\\'domain\\\' has been used to categorize and organize the essential functions of stewardship. Following domains of stewardship have been described by Travis et al;7 the gist of these domains is also discussed.
1. Generation of intelligence
2. Formulating strategic policy direction
3. Effective regulation
4. Coalition building and communication
5. Creating an enabling environment
6. Ensuring accountability.
1. Generation of Intelligence:
Stewardship has been identified as one of the five primary functions of a health research system which also includes, financing, knowledge generation, utilization and management of knowledge, and research capacity development.8 Therefore generation of intelligence is one of the core domains of stewardship. To be good stewards, the ministries of health need to have comprehensive knowledge of their health systems, and this knowledge is essential to guide and direct different actors within the system. Without ensuring the availability of relevant information when required, it will not be possible for any organization to fulfil the role of stewardship. Current and future trends in health system performance will need to be collected and this will include information regarding human resource, coverage, provider performance, resource generation, financing, etc. Trends in health of the nation will also be required including disease patterns, vulnerable group dynamics, and information on diseases which are endemic in an area. Important contextual factors and actors like the political, economic and institutional context, user and consumer preferences, and effects of other systems on the health care system in a country need to be evaluated. Information is needed on national and international evidence and experience such as information on the cost-effective interventions, and on different policy tools which have been implemented within the country or have been implemented in other countries but can be modified to fit in the local context. It has been shown that countries with poor governance are more likely to have larger prevalence of HIV.9 Therefore a dynamic disease surveillance system including national health management information system and a national data base created through periodic situation analysis surveys would be essential in this respect.
Although traditionally the state health agencies have had the primary responsibility for public health issues,10 besides them the local and international NGOs have a strong role to play as stewards for health research. They are close to communities and actively serve as advocates for the health issues of these communities. Thus these NGOs can play their role in terms of directing the health research towards relevant issues through advocacy, shaping research priorities and acting as watchdogs by ensuring adherence to ethical frameworks.11
The process of globalization has been defined as an intensification of cross-national cultural, economic, political, social and technological interactions that lead to the establishment of transnational structures and the global integration of cultural, economic, environmental, political and social processes on global, supranational, national, regional and local levels.12 It is a complex process with far reaching consequences, influencing the interdependence among nations and the state\\\'s sovereignty. Presently it has led to an asymmetrical distribution of gains, losses and power between rich and poor countries of the world.13 Therefore there is a need for a new global health governance structure14 and various organizations working in the global health arena can play an important role in this regard.
2. Formulating strategic policy direction:
This function is extremely important because good stewards need to form policies that are clear to understand and futuristic in nature. This ensures that the policies are adaptable according to changing circumstances in the future. Key factors to consider would be to make sure that policies are made while keeping in mind the local norms and values as well as based on data that is locally driven and reliable. Involvement of various actors in the policy process, a clear definition of their roles and the identification of the instruments required to achieve the desired goals is also needed to formulate strategic policies. At the same time incessant guidance should also be provided at each step in the policy process and implementation and continuous improvement should be incorporated into the policy document.
3. Effective Regulation:
For effective regulation, stewards will have to use wisely the power that has been vested in them by the parliament of a country. They will have to formulate tools which will measure whether rules are being followed equitably or not. They will have to make sure those roles and responsibilities of consumers are also determined and some sort of consumer protection system should be in place. No one should be allowed to take undue advantage at the expense of others. Non adherence to or violation of such rules should make perpetrators to be punished accordingly and the law of the land should take its natural course. Some of the key principles which have been advocated when the state is in the process of designing public health programmes include; Mill\\\'s harm principle, caring for the vulnerable, autonomy and consent.15 These principles are intended to guide the state so that there is a balance between public health interests and individual freedom.16
4. Coalition Building and Communication:
For the good functioning of state machinery, the health stewards will need to involve different interest groups or stakeholders during the policy formulation and implementation phases since there are powerful groups which can determine the success or failure of any policy. These could be the political, religious or different marginalized groups in a country, or these could be the various other systems or ministries who have influence on the health system. Thus Intersectoral collaboration will be required between health and other relevant departments like the education or the local municipal departments. Private health sector and relevant non-government organizations should also be the part of a network for interaction and collaboration. A monitoring system for such partners and a framework for public private partnership would be useful. These partnerships will need to be established on fair means and they should be sustainable.
5. Creating an Enabling Environment:
Stewards will need to work through the management culture and bureaucracy, and therefore they will need to promote policies which enable a healthy working environment within organizations. This means that emphasis should be given to policies that envisage structural changes rather than functional changes which is usually the case in most developing countries. However, it would require a lot of will and persuasion to change the mind set. Appropriate knowledge and skills building would be required.
6. Ensuring Accountability:
Accountability is a very important domain of stewardship. Most of the developing countries have suffered because of lack of accountability in their systems of governance. Besides intra-departmental accountability process, the parliament of the country should establish its own system for incessant accountability of public representatives and bureaucracy. For this purpose help could be taken from different NGOs, representatives of various interest groups, \\\'watch dog\\\' committees and other such organizations. This way the rights of the different groups in the country can be protected and fairness in services ensured. Accountability of stewards themselves will also need to be assessed and tools should be in place for this process.
With a population of over 160 million15 and a high annual population growth rate of 1.9%, Pakistan is currently the 6th most populous country in the world. Total fertility rate is 4.07.16 Life expectancy at birth for males is 62 years while for females it is 63 years. Most of the population (65%) is living in rural areas.16 Total expenditure on health as percentage of GDP (2005) is 2.1. Out of 177 countries Pakistan ranks 135 on Human Development Index.16 The burden of disease according to percentage of total number of DALYs lost show that 38.4% is due to communicable disease, 37.7% is due to non-communicable disease, 12.5% is due to maternal and perinatal conditions and 11.4% is due to injuries.17
The health care system in Pakistan is a combination of both vertical and horizontally run programmes which include the Federal Ministry of Health, the provincial health departments, private sector healthcare providers, NGOs, and other institutions. The role of the federal government (Ministry of Health) involves policy-making, coordination, technical support, research, training and seeking of foreign assistance. The provincial and district departments of health are responsible for the delivery and management of health services.18
Health care provision in Pakistan comprises public and privately delivered services. The private sector serves nearly 70% of the population,19 is primarily a fee-for-service system and comprises of both formal (modern scientific/allopathic physicians or Homeopaths) and informal sectors (traditional healers). The public health delivery system is a three-tiered system consisting of; outreach services (Expanded programme of Immunization EPI, Maternal & Child Health, malaria programme) along with Primary Health Care PHC units (comprising both the Basic Health Units, BHU and the Rural Health Centers RHC), Secondary care units (Tehsil or Taluka Headquarters Hospital), and Tertiary Care facilities (District Hospitals and large teaching hospitals). Although Pakistan has one of the largest public health delivery system in the world, it remains mostly underutilized.18 A process of devolution of power has been started in Pakistan by the promulgation of Local Government Ordinance in 2001. However the restructuring that is required for the changing roles at the federal, provincial and district levels is still not clearly defined.20
As is apparent, the main steward of health in Pakistan is the Ministry of Health with its functions of giving the overall vision, formulating policies, strategic planning, setting priorities and co-ordination between different sectors.21 Although provincial health departments have service provision as their main role, they are also important stewards of health within provinces and have to perform similar functions as the federal ministry but in the provincial context. These are the main stewards of health in the present scenario.18 Since the inception of the devolution process the district health departments have also been included into this loop. However private organizations and other international organizations also need to be involved so that they play their role as stewards in their own capacities thus making stewardship a reality. The process of devolution has itself suffered setbacks as the present government strives to undo the work done by its predecessors.22 Case studies from Pakistan have shown that governance issues are a major barrier to improving health in the country23 and that good governance and strengthened stewardship are the prerequisites for improving the present state of affairs.24,25
National Health Policy of Pakistan:
The national health policy of Pakistan 200126 lists down 10 key areas where reforms are needed in the health system of Pakistan, but stewardship is not included in any of these priority areas. No mention of governance is there in the priority list of the government. However in the key features of policy (bullet 1.3 page no 1) it is mentioned that \\\'good governance is seen as the basis of health sector reform to achieve quality health care\\\'. In the part on over all vision (bullet 2.3 page no 1) it is mentioned that \\\'…the federal government will continue to play a supportive and coordinative role in key areas\\\'. These functions are included in the domain of stewardship but still the report has not used this term anywhere. There is no reason given as to why governance is not mentioned in detail or even discussed anywhere in the priority areas when it has been mentioned in the overall vision in the beginning of the document.
The recently published National health policy 200927 however explicitly mentions good governance as one of the key principles. While describing the state of health in the country it is mentioned that overemphasis of the Ministry of Health towards national programmes has diminished its stewardship roles for quality of care and health care financing. Strengthening stewardship functions has been stated as one of the 6 main objectives in this policy. It is envisaged that this objective will be achieved through strengthening of the health system performance by focussing on service provision, equitable financing and promoting accountability and responsiveness. A critical review of this policy through the framework proposed by Walt and Gilson28 shows that the policy is contextually based with current and relevant data, the content covers most of the important aspects of health system, and process is described through policy actions for each objective. Furthermore various actors with stakes in the national health policy have been involved. It remains to be seen how far the policy is implemented in the coming years.
There could be many reasons why stewardship could not be implemented in our health system. One of the major reasons is that our policies are not based on evidence, and are rather based on experience, intuitions or on the political agenda of policy makers.21,29 Donor preferences also have their influence thus making policies which are not based on locally collected data and therefore fail to get implemented. Our policy makers have been mostly output driven, rather than outcome driven and this factor impairs their vision thus making them extremely myopic.21 Immediate output of different programmes is usually worked out but there has been no effort to ascertain the overall health impact of the nation. An additional factor could be the lack of incentives or rewards given to our health administrators and managers thus making it difficult to promote a healthy competition.21
Although the concept of stewardship is relatively new in healthcare but it has wide implications on the health systems of countries across the globe. The immediate effect will be on the policy process itself. With a stewardship concept of government in place, policies will need to be formulated with the involvement of stakeholders from different perspectives; general public will also need to be involved, thus with general consensus these policies will have a greater chance of getting implemented. Policies will also be based on contextual information so that they are rational and locally acceptable. The role of stewards will continue throughout the implementation and evaluation phases as well. This means that this is an on going process so that permanent national and regional stewards will have to be appointed by the government. Although government will have the main role to play as steward in health system, the private sector will also have to be involved so that it is not marginalized. The different international organization like World Health Organization, World Bank, United Nations, and others also have an important role to play as stewards of health especially since the world is fast coming closer to the concept of a global village.
With the advancement in technology and due to the changing political scenario across the globe, countries have become increasingly interdependent. Situation in one country often leads to effects in many countries of the region and even beyond. In such a scenario governments might not have the power they had a few decades back. Now foreign powers will play an important role in the policy process of many nations thus these countries might not be able to freely apply the stewardship model in their health system, which could become a major challenge for the implementation of this model. Other potential challenges include lack of well defined functions of stewards and although work has been done in order to develop framework for assessing health system governance in developing countries,26 there is still lack of well defined indicators to measure the degree of implementation and evaluation of this model in different countries.
The concept of stewardship is extremely pertinent to the health system in Pakistan. Since its inception the country has been experiencing frequent government changes which lead to policy change with every new government that comes to power. This adds to the lack of political will that is one of the major problems in our health policies. The concept of stewardship calls for a strong role of state in health care therefore a greater political will is inherent in this concept. Thus this concept is the need of the hour for Pakistan.20
In the new health policy of Pakistan the role of government is redefined with the inclusion of stewardship concept it is hoped that this move will have far reaching effects on the nation\\\'s health. This way the different actors in health system and the general public will be involved in policy process and the process would be rational and outcome driven thus leading to policies which have greater chance of being implemented. This was the problem with our previous policies which could not be implemented as these were not based on consensus building and neither based on local data. With stewardship model in place the state will take active role in implementation and evaluation phases so that the policy is followed by strategic planning and a continuous cycle of evaluation and improvement. Pakistan\\\'s previous health policies were never properly implemented, no evaluation was done to assess its outcome thus stewardship model could help us in that respect as well.
The concept of stewardship has a lot of potential to reinterpret and reinvigorate the role of the state in Public Health of nations across the globe. There has been very limited discussion of this concept by the academia due to which there are problems with practical application of this concept. Since this concept first appeared in World Health Report 2000, there have been only two research papers published which deals with concept and implication of stewardship.30 However with increasing debate this concept could be clarified further and indicators could be established which effectively quantify its implementation. Stewardship has been included as one of the key areas where research is needed for the attainment of Millennium Development Goals.31 If properly implemented and sustained, stewardship in health is bound to give us healthcare which is both efficient and equitable at the same time.
The concept of stewardship should be gradually introduced into Health System of developing countries including Pakistan.
A thorough ground work needs to be done for the readiness, implementation strategies and continuous evaluation for stewardship in Pakistan and other developing countries.
The concept of stewardship should be supported by policies which are evidence based and contextually driven.
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