Health Systems Stewardship, Governance, and Accountability: Issues of Public Health Ethics
Abstract and Keywords
This chapter argues that stewardship ought to be conceived as a particular form of governance that is the role of both governments and intergovernmental and extragovernmental bodies to carry out. Stewardship as ethically conscientious governance is grounded in an explicit normative commitment to the promotion of justice, including both consequentialist and deontological claims, as part of public health policy and practice. The justification of trade-offs and resolution of tensions among various objectives requires robust accountability mechanisms tied to ethical questions about defining the public good. This chapter describes a range of accountability mechanisms that can function for a variety of governmental and nongovernmental actors. It then explores issues of public health ethics regarding the ways in which specific health systems stewards—including states, the World Bank, and the World Health Organization (WHO)—are held accountable.
(p. 115) Stewardship in Relation to Governance and Government
The World Health Organization’s World Health Report 2000 includes stewardship among the four major functions of health systems, along with financing, resource generation, and service delivery (WHO, 2000). The WHO characterizes stewardship in terms of the functions undertaken by national governments as guided by health policy objectives; such functions may include crafting and implementing health-related policy and regulating the behaviors of actors like health insurers and providers (WHO, 2016). The WHO and others have envisaged stewardship as a particular form of governance that governments are responsible for carrying out (WHO, 2016; Saltman and Ferroussier-Davis, 2000; Travis et al., 2002).
On closer examination, however, governance includes not only the institutional functions of governments (legislation, regulation, enforcement) as formally constituted political authorities, but also a range of informal “values, norms, practices, and institutions” that are distinct from and complementary to governmental functions, and which, unlike governmental functions, typically exist at the international level as well as the (p. 116) national level (Weiss, 2009, 257). Even though the WHO’s explicit characterization of stewardship is limited to government, the World Health Report 2000 describes several stewardship roles that do not require the formal regulations or political authority of government and could just as well be functions of intergovernmental and extragovernmental bodies, such as “defining the vision and direction of health policy” and “collecting and using information” (WHO, 2000, xiv). Indeed, proliferating entities independently influence global public health primarily through governance—not government—including both intergovernmental bodies (e.g., the WHO and World Bank) and extragovernmental bodies such as civil society organizations (CSOs) and nongovernmental organizations (NGOs) (Ng and Ruger, 2011). These conditions suggest that expanding the explicit scope of stewardship as a form of governance, at least in the health domain, would be plausible. While others have argued that the scope of stewardship ought to include subnational authorities or even professional associations (Travis et al., 2002), defining stewardship only as the role of government or bodies sanctioned by governments obscures the influence of intergovernmental and extragovernmental actors who are not accountable to populations in the same way that governmental actors are.
This chapter conceives of stewardship as a particular form of governance that is the role of both governments and intergovernmental and extragovernmental bodies to carry out. The chapter discusses what stewardship means as a particular form of governance, describes accountability’s important role in stewardship, and outlines issues of public health ethics regarding the ways in which specific health systems stewards are held accountable.
Stewardship as Ethically Conscientious Governance
Stewardship can be understood as ethically conscientious governance (Saltman and Ferroussier-Davis, 2000; Kass, 1990; Armstrong, 1997). The obligations of stewardship thus understood present ethical tensions and trade-offs similar to those of public health ethics. As stewards of public health, institutions and organizations face ethical tensions between utilitarian goals of health maximization and deontological goals of protecting autonomy. Ideally, public health stewardship would involve balancing equity and efficiency in promoting health functioning and health agency for all.
Decisions about how to strike an ethically responsible balance, especially when governments employ coercive measures in pursuit of public health goals, must be justifiable. This requirement means that accountability in health systems stewardship is critical. Brinkerhoff (2004, 372) writes that “the essence of accountability is answerability,” which he argues entails providing both information and justifications regarding decisions and actions. Because health systems stewardship explicitly engages with ethical tensions and trade-offs regarding public health, strong accountability mechanisms help to ensure (p. 117) that the decisions and actions of the stewards are adequately justified to the public. The next section describes theories and mechanisms of accountability.
Accountability for Governments and Governance
Accountability implies the right of some actors to sanction others when they fail in their responsibilities under an agreed-upon set of standards (Grant and Keohane, 2005). Health systems stewardship requires accountability to justify decisions and behaviors influencing public health. If stewardship is a particular form of governance that both country governments and intergovernmental and extragovernmental bodies are responsible for carrying out, a useful theory of accountability must acknowledge the difference between government and governance and describe accountability mechanisms that can function for these varied actors.
Grant and Keohane (2005) distinguish between two models of accountability, differing primarily by who holds power-wielders (i.e., governments and intergovernmental and extragovernmental bodies) accountable. Under the participation model, all those who are affected by the power-wielders’ actions are entitled to hold them accountable. For example, in a direct democracy, the people enjoy and are permitted significant influence over individual government decisions through political participation, frequent elections, and substantial congruence on views and goals among representatives and the people. If a power-wielder strays too far from the collective preferences of those affected by its actions, the people are entitled to replace it.
Under the delegation model, those who entrust the power-wielders with certain powers hold them accountable, such as when national governments delegate certain health-related work to the WHO. Power-wielders are entrusted with the authority to act within the bounds of some office or to fulfill a general purpose. If power-wielders violate the relevant bounds or purpose, those who originally entrusted them with the power may remove them. Those who delegate to a power-wielder might not always be the same as those affected by the power-wielder’s actions. Under the delegation model, a power-wielder’s actions do not necessarily have to agree with the collective preferences of those affected, as long as the power-wielder acts according to the arrangement with the delegator.
Several accountability mechanisms—in addition to traditional democratic or electoral mechanisms—arise from these two models (Grant and Keohane, 2005), thus allowing us to make better sense of the ways in which both government and governance bodies may be held accountable. To be sure, nondemocratic mechanisms can operate to hold governments accountable, such as judicial checks on legislative actions, and extragovernmental bodies may incorporate democratic mechanisms, as represented by the WHO’s World Health Assembly. However, legal and other nondemocratic mechanisms (e.g., fiscal, market, peer, and public reputational) can also operate to hold intergovernmental and (p. 118) extragovernmental actors accountable. For example, budget restrictions are a form of fiscal mechanism through which individual or institutional donors can hold nongovernmental organizations accountable (more below).
Others have also identified nondemocratic mechanisms related to social or community accountability (Paul, 1992). Voice, understood as public participation in or protest of power-wielders’ decisions and actions, is an example of a peer or public-reputational mechanism. Exit is a form of market mechanism whereby consumers of some public service register discontent with one provider by choosing an alternative supplier. When there are no feasible means for exercising voice, exit can also be seen as an accountability mechanism; there have been instances, for example, of individuals refusing free vaccinations from the only possible supplier as a final attempt to protest a government failure to fulfill more basic needs, such as nutrition or education (Rubincam and Naysmith, 2009).
Theories that include multiple factors for accountability include the mutual collective accountability (MCA) framework (Ruger, 2012; Wachira and Ruger, 2011) and the framework presented by Grant and Keohane (2005). MCA calls for all actors working toward a common, specific health goal (e.g., the elimination of an insect vector for Chagas disease) to agree on respective roles and obligations needed to meet this goal. In MCA, institutions and organizations hold each other accountable through clear, transparent, and mutually agreed-upon standards, although transparent agreement regarding who is to do what can also enable those affected by the institutions’ work to hold those institutions accountable (Ruger, 2012). For example, an empirical study of MCA in the context of shared health governance evaluated several indicators: (i) goal alignment; (ii) knowledge and mutual understanding of key outcomes and principle indicators for evaluating those outcomes (consensus about the use of indicators and the statistics that measure these indicators and their implications); (iii) adequate levels of resources (human and financial); (iv) effective, efficient resource use for priority areas; (v) meaningful inclusion and participation of key global, national, and subnational groups and institutions; and (vi) special efforts to ensure participation of key vulnerable groups most affected by policy decisions (e.g., the poor, women, youths, persons with disabilities, and the elderly) (Wachira and Ruger, 2011).
Brinkerhoff’s work on health systems accountability, while important for its linking of accountability to stewardship and for its identification of linkages between health systems actors, ultimately fails to consider whether and how global organizations are held accountable. Like Travis et al. (2002), Brinkerhoff acknowledges the relevance of nongovernmental actors at a subnational level, but largely excludes intergovernmental and extragovernmental actors that operate globally (see Brinkerhoff, 2004, Figure 1).
Grant and Keohane (2005, 29) offer a framework that outlines several mechanisms through which institutions and those affected by the institutions’ work may engage in accountability practices. They argue that “conventional views of accountability”—typically rooted in representative democracy—might be appropriate as an ideal for states, but not for global institutions such as intergovernmental and extragovernmental bodies. Accountability, they state, “implies that some actors have the right to hold other (p. 119) actors to a set of standards, to judge whether they have fulfilled their responsibilities in light of these standards, and to impose sanctions if they determine that these responsibilities have not been met.”
Issues of Public Health Ethics in the Accountability of Health Systems Stewards
To promote ethically conscientious governance, health systems stewardship must grapple with the ethical tensions and trade-offs arising from the pursuit of often competing goals. Maximizing health across a population, for example, can conflict with individual agency. Accountability mechanisms can help justify decisions that make trade-offs between these alternative goals. The ethical justification for these decisions is tied to accountability in several ways.
Health systems stewards must be transparent about their ultimate goals and how they align with the public good. How the public good is defined remains an open question in public health ethics, so substantive clarity in goals is integral to the ethical commitment of transparency itself and in holding stewards accountable. A clear sense of what is expected of stewards is essential if they are to be held accountable. However, substantive goals may differ across populations. Thus, the procedure by which health system goals are specified and decided upon—who participates or decides, and by what process—is also of ethical importance.
Accountability mechanisms are such procedures. Given that various accountability mechanisms might allow different populations to hold power-wielders accountable, the substantive goals to which the power-wielders are held accountable might also differ. The question of who ought to decide what counts as the public good should therefore partially prescribe which accountability mechanisms are implemented to hold power-wielders accountable. For example, low-income countries (and the individuals who reside in them) cannot meaningfully participate in the fiscal mechanisms of accountability by which high-income countries wield substantial control over the WHO’s direction and decisions (more below). However, so far as the WHO’s actions affect low-income countries and their inhabitants, the conviction that these populations ought to exert control over its direction and decisions implies adopting a participation model of accountability and associated accountability mechanisms. Accountability mechanisms are therefore an important procedural link to substantive considerations about the public good in the health sphere.
To be sure, adopting the proper accountability mechanisms might not be sufficient to empower the populations whose conceptions of the public good ought to influence health systems stewards’ goals. Accountability, especially when leveraged through civil society organizations with privileged access to disadvantaged populations, can draw (p. 120) attention to existing health inequalities and enable health systems to better meet the demands of social justice. On the other hand, the populations most in need—precisely because of their disadvantage—might be the least likely to participate in even the best-intentioned accountability mechanisms. Relying on accountability mechanisms that ignore this concern might therefore fail to meet the demands of social justice.
Another concern is that the possibility of reaching substantive agreement regarding the public good diminishes as more numerous and diverse populations are invited to join in holding power-wielders accountable. However, adopting the “right” procedures, of which accountability mechanisms are an important part (Daniels, 2000) cannot ensure social justice, since it is imperative to achieve agreement regarding the public good.
Drawing on this overview, we discuss below some specific roles and accountability mechanisms pertaining to states and intergovernmental and extragovernmental bodies engaged in health systems stewardship. These examples are not exhaustive, but they highlight relevant issues of public health ethics related to stewardship and accountability.
A common view of determining the public good, including who ought to decide, holds that state boundaries define the “public” (Faden and Shebaya, 2015). Statists argue that national boundaries carve out discrete publics, and state health systems may justifiably limit the scope of public health practice to those living within their borders. So far as a state’s actions largely affect only its citizens and other residents, a participation model of accountability might not support the consideration of outside populations. Additionally, states are subject to elections or other democratic, legal, or fiscal accountability mechanisms available only to citizens and, sometimes, residents. The delegation model might therefore also justify this limited scope, given that the means of delegation are restricted in this way. However, Thomas Pogge (2002) argues that individuals of the developed world are in fact the cause of many global health inequalities beyond their nations’ borders. On this view, adopting the participation model would imply that national health systems ought to be accountable to individuals around the world and could therefore have duties to promote public health globally.
States typically have exclusive power to enforce compliance with regulations at an individual and institutional level. Enforcement powers limit the freedom of individuals and institutions, but they may be justified when the public benefit is large or a specific subgroup is benefited or protected. Accountability is important for ensuring that enforcement powers are tied to such goals.
What mechanisms of accountability are necessary to justify enforcement powers that ostensibly aim at the public good? One answer is that states are democratically accountable to their citizens, and that this accountability mechanism empowers those who (p. 121) ought to have influence over the state’s goals and provides the means with which they pursue these goals. However, states differ in the extent to which they are de facto democratically accountable. Some states resemble the participation model of accountability. For example, the Swiss electorate has veto power over federal laws. On the other hand, representative democracies more closely fit the delegation model, giving more influence to representatives than to all those affected by the state’s actions. Other countries, such as China, may lack democratic procedures altogether yet still enforce compliance, raising questions about whether these powers are aligned with the public good at all.
Tying the justification of enforcement powers solely to outcomes might be challenging, in that states can struggle to meet health-related goals despite their best efforts. Investigating more comprehensively who has decision-making power and how decisions are made within the state might better identify ethically troubling instances of enforcement. For example, enforcement powers that disproportionately impact disenfranchised populations, such as immigrants, can undermine justice.
The Work of Agencies or Ministries
The crafting and implementation of health-related policy relies on developing expert knowledge and regulations, accomplished largely by executive agencies or ministries. Agencies are typically directly accountable to funders, heads of executive branches, and local boards of health, but only indirectly accountable to communities (IOM, 2011), often through notice and comment periods, which can function as a form of “voice” for the public (Paul, 1992). Many agency or ministry leaders are appointed by executive branch heads and do not require outside approval. The delegation model, therefore, most appropriately describes how agencies or ministries are typically held accountable.
These actors are sometimes criticized for developing regulations that infringe on autonomy. Promoting the public good, however, often requires placing limits on individual autonomy. A lack of participation accountability could be ethically concerning if it prevents agencies or ministries from identifying and acting in the public good as determined by those affected by their actions. The interests of individuals or groups who cannot participate in the available accountability mechanisms might be overlooked, which is concerning from a justice perspective. Still, considering the interests of all individuals and groups might not ensure good outcomes, as a large body of research has demonstrated the many ways individuals fail to think and act rationally. According to this view, it is best to adopt a paternalistic approach and leave decisions about how best to promote public health to expert agencies or ministries.
As with other United Nations agencies, the WHO was established by consenting states via a treaty enumerating certain roles it is meant to fulfill. The delegation model of accountability therefore applies to the WHO, meaning the states entrusted the WHO (p. 122) with authority to act within the treaty’s bounds, and as delegators they may hold the WHO accountable if it fails to uphold its obligations. Are states the only bodies that should hold the WHO accountable? One objection is that the delegation model leaves the WHO unaccountable to individuals or to nonstate groups (Ruger, 2014). Can the WHO meet the demands of public health ethics without direct accountability to nonstate actors?
Transferred accountability through state members of the World Health Assembly (WHA), the legislative body of the WHO, could be sufficient. Where strong domestic accountability mechanisms exist, states should be best positioned to understand and advocate for their citizens’ interests. Unfortunately, many states are not adequately accountable to their citizens. Furthermore, over 75 percent of the 2014–2015 WHO budget consisted of voluntary extrabudgetary donations with donor strings attached (Butler, 2013). Certain states might therefore exercise disproportionate influence in the WHO despite the one-state–one-vote WHA. For example, the United States denied funding after the WHO proposed a new “essential drug program,” a move opposed by US pharmaceutical companies (Brown, Cueto, and Fee, 2006). Thus, the WHO might not always act in the best interests of individuals living in less influential countries, raising serious social justice concerns, and inadequate accountability mechanisms might result in greater disadvantages for those already the worst off. The WHO might also fail to maximize the good it achieves if its accountability mechanisms do not incorporate all relevant voices in its decision-making processes.
The World Bank
Representation on the World Bank’s Executive Board is unequal, with permanent seats only for large donor countries. Voting share is tied to state contributions, making the United States the only country with effective veto power. Funding for the International Development Association, which provides loans to developing countries, is renegotiated every several years in a process that has historically been co-opted for political ends; for example, the United States secured a World Bank promise during the 1970s that it would not lend to Vietnam (Clinton and Sridhar, 2017). These realities suggest that the World Bank might be primarily accountable to wealthier nations and elite interests through fiscal accountability mechanisms.
The legacy of the Bank’s structural adjustment programs, which have been criticized for not only failing to promote health, but also undermining it in some cases (Ruger, 2005; Stuckler and Basu, 2013), ground these concerns. The World Bank has responded to these criticisms. In 2010 the Bank began publishing data about its investment projects. While such reforms have improved decision transparency, they have not done enough to improve decision-making transparency (Clinton and Sridhar, 2017). The former is important for accountability in terms of substantive outcomes and determining if the Bank is effective, but little is known about the Bank’s rationale for choosing certain projects over others, or which interests it ultimately privileges. Procedural accountability might still be lacking.
(p. 123) Extragovernmental Bodies
Extragovernmental bodies include civil society organizations (CSOs) and nongovernmental organizations (NGOs), which can operate either within national boundaries or across them as international NGOs (INGOs). CSOs are typically nonprofit organizations established by citizens to promote health. Health-related NGOs typically focus on health services delivery, including preventive services, health education, and advocacy or lobbying.
These organizations have many advantages over states in promoting health. They might be devoted to a particular service (e.g., reproductive services), thereby providing an opportunity for social accountability through market “exit” (Paul, 1992), or to a particular population (e.g., adolescents), and thus have fewer populations to which they are accountable. Often operationally nimble, they can be more flexible and access remote communities. Given their on-the-ground work in communities, they can empower the most vulnerable through education or organization (OECD, 2009); NGOs played an important role in improving access to essential medicines following the implementation of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) (‘t Hoen, 2002). They can thereby fill a gap in accountability by giving voice to vulnerable individuals seriously affected by the actions of states and intergovernmental bodies, thus serving as “voice surrogates” (Paul, 1992, 1055). Insofar as a participation model of accountability does not obtain among intergovernmental bodies, CSOs may function to correct and check powerful interests and actors. For these reasons, CSOs are often described as more democratic than intergovernmental organizations, and they may help promote justice within health systems.
Of course, CSOs could also fail to check the actions of powerful states and organizations—as well as their own actions. For example, CSOs benefited from increased funding in the 1980s as structural adjustment led to reductions in state public health spending (Doyle and Patel, 2008). With much of this increased funding coming from Western donors, CSOs came to be seen as “passive agents of the neoliberal agenda” (Doyle and Patel, 2008, 1932). CSOs could thus in fact be accountable chiefly to powerful interests. Overall, many interests compete for the attention of CSOs, raising questions about whom these organizations are accountable to in practice, and whether trade-offs in meeting accountability demands are inevitable (Ossewaarde, Nijhof, and Heyse, 2008).
Other criticisms focus specifically on whether CSOs are more democratic than states or intergovernmental organizations. For example, CSO leadership is not typically the result of popular elections. CSOs are usually governed by a board, often composed of friends, with opaque decision-making procedures (Doyle and Patel, 2008). Moreover, CSOs might undermine efforts by states to bolster their own democratic accountability. Insofar as visibly delivering health services to populations in need is one way for states to build democratic accountability, CSOs acting independently of national governments could undermine these efforts.
(p. 124) Conclusion
This chapter argues that stewardship ought to be conceived as a particular form of governance that is the role of both governments and intergovernmental and extragovernmental bodies to carry out. Stewardship as ethically conscientious governance is grounded in an explicit normative commitment to the promotion of justice, including both consequentialist and deontological claims, as part of public health policy and practice. The justification of trade-offs and resolution of tensions among various objectives requires strong accountability mechanisms tied to ethical questions about defining the public good. Other chapters in this volume address related issues. Faden and Shebaya (this volume) ask whether the fundamental moral justification for public health activities is their importance for maximizing good health outcomes or their importance for promoting social justice, or whether it can be both. Achieving either goal is often so complex as to justify tasking expert institutions and organizations with the promotion of public health. Hecht, Arias, and Krubiner (this volume) ask about the relationship between stewardship and governance, stating that “stewardship and governance are separate concepts, though they overlap and entwine substantially.”
This chapter has described a theory of accountability that fits the conception of stewardship as ethically conscientious governance, and it has further explored issues of public health ethics in health systems stewardship by discussing specific roles pertaining to states and intergovernmental and extragovernmental bodies. This is not an exhaustive discussion, but it is intended to highlight salient issues and demonstrate how similar analyses might be extended to other health systems actors and functions.
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