Bridging Theory and Practice of Health System Governance in Fragile, Conflict-affected, and Vulnerable States

Abstract

Governance is referred to as the ‘mortar’ that holds the health system building blocks together. This thesis explores health system governance in the context of health emergencies, and in fragile, conflict-affected, and vulnerable (FCV) countries, and how these systems can learn and achieve optimal service delivery while being equitable, efficient, and resilient. FCV countries typically have poorer health outcomes than non-FCV countries with those experiencing hot armed conflict responsible for over 70% of disease outbreaks. Understanding, firstly, what health system governance mechanisms work where, when and why, and, secondly, how countries experiencing different forms of fragility or health emergency learn before, during and after crises, is crucial to reducing mortality, morbidity, and stopping health emergencies early.

This thesis employs different theory-informed research methods to explore health system governance, while drawing on specific case studies in both theory and practice. It finds that optimising the impact of decentralisation on health systems performance requires a careful combination of centralisation, (e.g., the benefits of central coordination in improving efficiency), with elements of decentralisation (e.g., the benefits of local decision-making in improving equity and resilience). It also finds that defacto decentralisation may occur in FCVs during crisis to fill the void of central health system governance, with impact on health system performance. Lastly, it identifies how to optimise learning and finds Intra- and After-Action Reviews can support effective and, at times, transformational health system learning before, during and after outbreaks. The thesis’ theoretical and applied research fills ‘gaps’ and advances the literature on learning health systems, health system decentralisation, and health system governance.