This handout is from the presentation titled "Governance in the Third Dimension: Science Fiction or Science Fact," given by HFG at 2015 USAID Global Health Mini-University on March 2, 2015. Session Description: Strengthening health governance can significantly improve the effectiveness and sustainability of reforms and, in turn, achieve better health system performance. Yet despite its importance, health governance investments are often overlooked. Health governance is frequently misunderstood by governments and the global health community, because governance in practice (vs. theory) is poorly defined and difficult to operationalize.

1. March 6, 2015 Page 1
Development of a Health Financing Strategy for Haiti
Background:
 Haiti is addressing the dual challenge of how to mobilize sufficient funds for health care and how to
efficiently manage and allocate those resources to provide quality care to the Haitian people.
 Currently, the health budget is developed on an annual basis; the vision for the health sector beyond
the one-year horizon is limited and not backed by an implementable plan with the necessary
resources.
 Haiti has an approved national health policy which addresses “what” is to be done but does not yet
have a national health financing strategy that outlines “where” resources will come from and “how”
they will be used to achieve the country’s health objectives.
Activity:
 HFG is working with the Ministry of Health through a health financing ‘task force’—including the
ministries of finance and social welfare—to develop a health financing strategy for the sector.
 Planning for a large health financing conference in April 2015 is underway. The conference will
include stakeholders from the government, private sector, and multilateral and bilateral donors.
Participants from Ethiopia and Ghana will share their experiences with health financing reform.
 HFG produced a situational analysis of Haiti’s current health financing situation with the following
findings:
o There are many actors in the health sector.
o A large portion of financial resources pass in the form of direct payments from the population to
private, for-profit contractors and NGOs.
o Funds are also passed directly to public facilities by means of co-payments, which are often set
arbitrarily without calculation of the actual costs.
o Foreign aid often falls outside the control of the Ministry of Health. Technical and financial
partners offer and negotiate projects and funds with the ministry, but the latter is not in a
position to refuse or realign these proposals or funds.
o Donor assistance is fragmented, and the Ministry of Health is not systematically informed of
foreign aid contributed.
o More than 70 percent of resources are focused on vertical programs targeting HIV and cholera,
even though the proportion of these patients to national morbidity figures is relatively low.
o Personnel salaries account for more than 90 percent of the government’s operating budget.
Proposed deliverable:
Haiti needs a health financing strategy and implementation plan that gives the Ministry of Health the
capacity to negotiate tangible increases in health financing using a specified mechanism to collect and
pool resources and purchase health services in a way that is technically sound and efficient.

2. March 6, 2015 Page 2
Health Governance
Dimensions
Key Questions
Decision-making
Structures
 Are each governing entity’s formal roles and responsibilities clearly defined and
legally binding?
 Do governing entities have informal roles, and do they negatively impact formal
decision-making structures?
 Are mechanisms in place to resolve conflicts of responsibility between governing
entities and build consensus?
 Has the level of decentralization been accounted for in these decision-making
structures?
Institutional Capacity
 Do roles and responsibilities correspond with decision-making power?
 Do governing entities have the resources and institutional capacity to effectively
fulfill their roles and responsibilities?
Monitoring &
Evaluation
 Do feedback channels exist to ensure that reliable, clear, and timely information
is received and acted upon by governing entities?
 Are tools/data/instruments available to monitor and evaluate the link between
health policies, governance responsibilities, and health system performance?
Transparency &
Accountability
 Are health policies publically available, easily understandable, and legally
binding?
 To whom are governing entities held accountable?
 Are official and actual consequences of non-performance by governing entities
the same?
 Are consequences of non-performance clearly defined and implemented?
 Is autonomy and accountability strong yet balanced for each governing entity?
Stakeholder Voice
 Do all health system actors play a clear role in policy decision-making?
 Are procedures in place for stakeholders to voice grievances?
 Is stakeholder participation equitable?
 Do governing entities effectively balance communicating with stakeholders yet
avoid capture?
Regulation &
Enforcement
 Are tools/instruments in place to ensure that health policies are effectively
enforced?
 Are rules on compliance and sanctions for health system actors clearly defined
and enforced?
Stability
 Have fundamental governance roles, health system characteristics, and
performance objectives remained stable over time?