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The Importance of Values in Shaping How Health Systems Governance and Management Can Support Universal Health Coverage

  • Giovanni Fattore
    Correspondence
    Address correspondence to: Giovanni Fattore, Università Bocconi, Via Röntgen 1, 20135 Milan, Italy.
    Affiliations
    Department of Policy Analysis and Public Management

    SDA Bocconi School of Management

    Research Center on Health and Social Care Management (CeRGAS), Università Bocconi, Milan, Italy
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  • Fabrizio Tediosi
    Affiliations
    Research Center on Health and Social Care Management (CeRGAS), Università Bocconi, Milan, Italy

    Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland
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Open ArchivePublished:November 16, 2012DOI:https://doi.org/10.1016/j.jval.2012.10.008

      Abstract

      In this article, we use cultural theory to investigate the nature of health systems governance and management, showing that it may be helpful in identifying key aspects of the debate about how to promote universal health coverage. Cultural theory argues that “how” we govern and manage health services depends on what we think about the nature of government organizations and the legitimacy of their scope of action. The values that are implied by universal health coverage underlie choices about “how” health systems are governed and their organizations are managed. We draw two main conclusions. First, the translation of principles and goals into practice requires exceptional efforts to design adequate decision-making arrangements (the essence of governance) and management practices. Management and governance, or “how” policies are decided and conducted, are not secondary to the selection of the best policy solutions (the “what”). Second, governance and management solutions are not independent of the values that they are expected to serve. Instead, they should be designed to be consonant with these values. Cultural theory suggests—and experience supports—the idea that “group identity” is favorable for shaping different forms of social life and public administrations. This approach should thus be a starting point for those who strive to obtain universal health coverage.

      Keywords

      Introduction

      The performance of health systems is still suboptimal in many countries with wide variations even at the same level of investment. Recent evidence regarding the consequences of poor health coverage on household economic conditions [
      • World Health Organization
      World Health Report 2010. Health Systems Financing, The Path to Universal Health Coverage.
      ,
      • Xu K.
      • Evans D.B.
      • Carrin G.
      • et al.
      Protecting households from catastrophic health spending.
      ] has shown that large unexplained variations might be due to different health systems’ organizational features and governance and management structures. As health systems are complex, dynamic, and adaptive systems, it has been noted that to improve their performance, all building blocks should be coherently strengthened [
      ,
      • Frenk J.
      The global health system: strengthening national health systems as the next step for global progress.
      ].
      In a recent article, we argued that the debate regarding universal health coverage (UHC) [
      • World Health Organization
      World Health Report 2010. Health Systems Financing, The Path to Universal Health Coverage.
      ,
      • WHO
      Department of Health System Financing. Achieving Universal Health Coverage: Developing the Health Financing System (Report No. 1).
      ,
      • World Health Organization
      Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action.
      ] largely focuses on health financing and efficiency issues but neglects other important aspects—in particular, health system governance and management [

      Fattore G, Tediosi F. Attaining universal health coverage: the role of governance and management. In: Missoni E. (ed). Attaining Universal Health Coverage: A Research Initiative to Support Evidence-Based Advocacy and Policy-Making. Milan: Egea, 2008.

      ]. Good health system governance and management practices are essential to actually implement effective policies to attain UHC [
      • McCourt W.
      • Gulrajani N.
      The future of development management: introduction to the special issue.
      ].
      When addressing the issue of “how” to implement policies, both “hardware”—structure, organization, technology, and physical and financial resources—and “software”—values, norms, and the relationships among the actors—of health systems are important. We believe that it is necessary to face what Frenk recently referred to as the “blackbox” misconception: “the belief that things are too complicated and we do not understand the intricate mechanisms of health systems, so we must simply get technologies and other inputs in place and then outputs will somehow walk their way” [
      • Frenk J.
      The global health system: strengthening national health systems as the next step for global progress.
      ].
      In this article, we draw from cultural theory and, in particular, from the work of Hood [
      • Hood C.
      The Art of the State: Culture, Rhetoric and Public Management.
      ] to highlight that the governance and management of health systems are shaped by values and principles and that these are relevant to the end goals of health systems and therefore to attaining UHC. The rest of the article is structured in four sections. The next section introduces the conceptual framework from cultural theory. The following two sections explore how the framework can help to show that governance and management are not neutral toward the values and aims of health systems. The last section discusses possible implications of our analysis for the debate on UHC and draws some policy conclusions.

      A Cultural Theory Framework for Categorizing Governance and Management

      The boundaries between management and governance may not be immediately obvious and are, indeed, controversial. And some might argue that there is no practical reason to keep the two distinct. For the sake of clarity, however, we refer to management as the variety of activities that are required to operate health care organizations according to their missions and goals. In contrast, we refer to governance as how policies are formulated, regulation is exercised, intelligence is generated, and accountability is upheld for all stakeholders [

      Lewis M. Governance and Corruption in Public Health Care Systems. 2006. Centre for Global Development. Working Paper Number 78, January 2006. Available from: www.cgdev.org. [Accessed November 6, 2012].

      ,
      • Loewenson R.
      Research Issues 3: Neglected Topics in Health Policy and Systems Research: Governance and Accountability.
      ,

      Balabanova DO-CV. Health Sector Governance and Implications for the Private Sector (Technical Paper 9: The Rockefeller Foundation—Sponsored Initiative on the Role of the Private Sector in Health Systems in Developing Countries: Results for Development). Washington, DC, 2009.

      ].
      Hood reframed the conceptual framework—that was originally formulated by the anthropologist Mary Douglas [
      • Douglas M.
      Cultural Bias: Active Voice.
      ]—that the many possible ways of managing and regulating organizations can be defined in two basic dimensions of human organizations: “grid” and “group” [
      • Hood C.
      The Art of the State: Culture, Rhetoric and Public Management.
      ]. Grid concerns the extent to which people’s lives are ruled and circumscribed. High grid means that the organizations in which individuals operate set detailed and penetrating rules about how people should behave. In contrast, low grid means that individuals can act freely. The other dimension is group, which denotes “the extent to which individual choice is constrained by group choice” [
      • Hood C.
      The Art of the State: Culture, Rhetoric and Public Management.
      ].
      Following Hood, combining the grid and group dimensions produces four potential approaches to (public) management and governance (see Fig. 1). High group and high grid denote the “hierarchist” style, in which individuals are constrained by organizational roles, rules, and processes; in contrast, low group and low grid denote the “individualist” style, in which individual preferences and choices override rules and collective perspectives. The “fatalist” perspective combines low group with high grid, producing a style in which individuals live in atomized societies that are constrained by routines and rules that disregard the social dimension of human life. Finally, high group and low grid characterizes a style of public management and governance in which the reference to public interest is strong and is coupled by a constant search for the empowerment and participation of citizens. This style is called “egalitarian.”
      Figure thumbnail gr1
      Fig. 1Four styles of public management and governance
      [
      • Hood C.
      The Art of the State: Culture, Rhetoric and Public Management.
      ]
      . Reprinted from The Art of the State: Culture, Rhetoric, and Public Management, Hood C, 1998, with permission from Oxford University Press.
      The hierarchist approach is based on the idea that there is a shared collective interest that overrides the individual perspective. Furthermore, this approach utilizes a broad spectrum of written and unspoken rules, procedures, and routines to coordinate people’s behavior. High grid calls for authority, structure, and a well-designed division of labor, as rules and authority structures are needed to avoid chaos and costly negotiations. Roles and rules also serve to ensure accountability because when things go wrong, those who do not comply with the rules can be blamed. High group means that individuals come second to the institutions or organizations to which they belong. Individuals should be ready to sacrifice themselves for supreme collective interests. These themes are the basic ingredients of an “enormously successful formula for human organisations, both at the level of whole society and of discrete institutions like churches, armies, and state bureaucracies” [
      • Hood C.
      The Art of the State: Culture, Rhetoric and Public Management.
      ].
      The individualist approach can be observed as a reaction to the hierarchist model of public management and governance. Culturally, it shifts the attention to a micro-level of analysis and contends that bureaucracies pursue the public interest (see, e.g., Niskanen [
      • Niskanen W.A.
      Bureaucracy & Representative Government.
      ]). Through different analytical lenses, a variety of authors have theorized that governments fail because they are captured by the private interests of the individuals who hold public positions. In this approach, low group means that organized action is shaped by individual behavior and interests. Normatively, the recognition of the individualistic nature of human behavior is encouraged for designing adequate incentive structures to govern public systems. Thus, the individualist approach requires that governance arrangements and management practices be designed to motivate individual actors to pursue collective goals. In the individualist style of management, low grid means that individuals must be liberated from rules, laws, codes, and routines to act freely to pursue organizational goals. Consequently, accountability is no longer assured by compliance to rules and laws but is based on ex-post evaluations of results.
      While the hierarchist and individualist approaches to governance and management are antithetic, as they contrast in both the grid and group dimensions, the other two ways of practicing management and governance are less clear-cut and more difficult to ascertain in the real world. The egalitarian approach is based on a strong sense of belonging to a group but a low level of behavior regulation, and strongly contrasts with bureaucracies and markets [
      • Hood C.
      A public management for all seasons.
      ]. Citizens’ accountability is not assured by market mechanisms, which are unavoidably discriminatory, or by politics, which has authoritarian and manipulative administrative bodies. Egalitarians believe in the virtues and functioning of self-managed organizations in which individuals cooperate without hierarchical structures. Typically, egalitarians also challenge professional dominance as a way to exert unjust power. In this respect, egalitarians call for wide community participation in the governance and even management roles of public services. They also consider mutuality, instead of competition or hierarchical control, as the desirable basis for coordination. Mutual surveillance and veto from peers are conceived as the main devices for respecting equality among individuals.
      Egalitarianism and individualism have a low grid feature in common. Both approaches challenge the use of rules, laws, and regulation for public management and governance. For the individualist, however, the aversion to rules and constraints mainly refers to management and supports the liberation of management practices by detailed regulations that hamper efficiency and effectiveness. For egalitarians, the main issues are participation and empowerment, and thus, the critique of the regulatory state concerns the emergence of relations of dominance (political, professional, and administrative). Participatory decision making, voluntarism, nonhierarchical forms of organization, and group self-management are observed as elements for building a just distribution of power between community members.
      The last approach to public management and governance, denoted by high grid and low group, is the opposite of the combination that characterizes egalitarians. Hood labeled this approach as fatalist, while Mary Douglas originally defined it as positional [
      • Douglas M.
      How Institutions Think.
      ]. It appears rather paradoxical to imagine approaches to management and governance that do not recognize a strong communitarian perspective while featuring detailed ways of thinking and behaving. Fatalist ideas, however, are indeed present in various cultures and conceptions of government. The idea that people are not in charge of their life because stronger forces shape their destiny is widespread and often implicitly (and sometimes cynically) assumed. According to Hood, the life in Montegrano, described by Banfield on the basis of an ethnographic study, exemplifies this fatalist attitude [

      Lo Scalzo A, Donatini A, Orzella L, et al. Italy: Health System Review. In: Health Systems in Transition. 2009.

      ]. In this little village in southern Italy, people and families were constrained by codes of conduct, old traditions, and long-established rivalries that fail to pursue public interest. These codes, traditions, and rivalries constrained people’s behavior in the present and condemn them to misery.

      Applying the Cultural Theory Framework to Governance and Management in Health Systems

      According to a hierarchist perspective, the governance of the health system is typically top-down, strictly associated with government decision making and based on a clear separation between politics and administration. The typical hierarchist perspective considers governance to be mainly a political issue. In democratic systems, this view implies that elected representatives hold all relevant health policy powers. In terms of public health systems, this perspective focuses on direct government control of resource collection—typically through taxes—and direct ownership of providers. Concerning management, this approach tends to see organizations as neutral, well-engineered machines with a limited degree of autonomy. The ideal type of this approach is the bureaucratic model, which tends to codify administrative processes and organize labor according to predefined sets of rules, processes, and routines.
      The bureaucratic model is a very popular form of organization; however, it was conceived and developed to deliver traditional public goods and services such as policing, justice, and defense rather than health services. This model clashes with key characteristics of the health sector such as the complexity of medical knowledge, professionalism, limited options for the standardization of practices, the need to coordinate the work of a number of different professionals because of interdependencies in individual patient care, and information asymmetries between professionals and patients. These characteristics make the bureaucratic model inadequate for health systems. Indeed, the practice of medicine is widely based on granting professional freedom and the limited scope of standardization makes rigid rules unsuitable for managing the practice of medicine. As a consequence, the hierarchist approach, while shaping public administration in a number of areas of government action, has had limited application in health care, where even integrated systems granted wide clinical autonomy to professionals. For example, the practice of management in the English National Health Service (NHS) from its foundation to the first reforms introduced by Margaret Thatcher in the early 1990s was likened to the practice of diplomacy because managers did not exert any substantial influence over professionals; instead, they had to support professionals’ activities and were asked to solve problems rather than to secure major changes [
      • Harrison S.
      Managing the National Health Service: Shifting the Frontier?.
      ]. Similarly, in the initial formulation of the Italian NHS, there was limited room for management as administrative departments had no management duties and the overall responsibility for managing health organizations rested with local politicians [

      Lo Scalzo A, Donatini A, Orzella L, et al. Italy: Health System Review. In: Health Systems in Transition. 2009.

      ].
      Interestingly, there are more elements of the hierarchist style in some recent health reforms. In England, the current approach to the management of professionals has been named “neobureaucracy” as it is characterized by formal, written rules and policies that reduce the autonomy of professionals and promote the use of surveillance, incentives, and sanctions aimed at securing compliance with the rules [
      • Harrison S.
      Medicine and management: autonomy and authority in the National Health Service.
      ]. The National Institute for Health and Clinical Excellence of England and Wales provides a major example of this neobureaucratic attitude as it acts as an independent, science-driven body guiding the NHS and providing scientifically legitimized rules to be used by policymakers and managers to govern professionals. The use of evidence-based medicine and health technology assessment to govern professionals is common in other tax-based systems and even in health systems where physicians have benefited from wider clinical autonomy, such as in France and Germany [
      • Sorensen C.
      • Drummond M.
      • Kanavos P.
      Ensuring Value for Money in Health Care: The Role of Health Technology Assessment in the European Union.
      ].
      Neoliberalist ideas and recipes, which are the essence of the individualist model, have vastly affected health governance and management practices around the world. International organizations have supported a number of health sector reforms, including the promotion of minimal government provision that restricts services to a “minimum” or “essential” package, with any additional services provided privately and being subject to user fees, and the encouragement of the establishment of various forms of health insurance [

      Lister J. Globalization and health systems change. In Labonte R, Schrecker T, Packer C, Runnels V, eds. Globalization and Health: Pathways, Evidence and Policy. New York: Routledge, 2009.

      ]. At the global level, there has been a dramatic fragmentation of global health governance and the proliferation of rather narrow global health initiatives, based on disease-specific goals.
      This trend was coupled with the implementation of performance management tools that often rewarded individuals and organizations for attaining specific targets. For instance, pay-for-performance or result-based financing schemes were implemented in high- and low-income countries in the last two decades [

      Shaffer RM. Pay for Performance (P4P) Programs in Health Services: What Is the Evidence? (World Health Report (2010) Background Paper, No. 31). Geneva, 2010.

      ,

      Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev 2012;Issue 2: Art No. CD007899.

      ] to boost the efficiency of individuals and organizations. Even the Millennium Development Goals, set by the United Nations Millennium Declaration, have been referred to as a consequence of “individualist” and narrow performance management techniques for measuring development and health outputs [

      Hulme D. The Making of the Millennium Development Goals: Human Development Meets Results-Based Management in An Imperfect World. Manchester, UK: Institute for Development Policy and Management, University of Manchester, 2007.

      ].
      In Europe, the distrust in command-control systems has prompted a search for a new policy, largely attributable to the individualist approach, since the late 1980s. The Italian quasi-market based on patient choice of public and private providers, funded according to a diagnosis-related group system introduced since the mid-1990s, the Thatcher reforms introducing purchaser-provider split and fund-holding in England, and the construction of a regulated health insurance market in the Netherlands are all examples of major reforms that have important elements attributable to an individualist model of governance. In these individualistic-type reforms, both “groupness” and “gridness” tend to be low, at least when compared with the traditional model of NHS, as designing appropriate economic incentives and promoting managerialism become major policy issues.
      Egalitarians share the low-grid mode with individualists. Egalitarians, as defined here, dislike detailed rules and routines because they constrain individual behavior and may be conducive to oppression and submission. Both individualists and egalitarians believe in the merit of decentralized authority, but the strong diversity between the two approaches in terms of “groupness” produces radically different perspectives about UHC. While egalitarians are strongly propoor and assume that a redistribution of resources is needed to foster communitarian values, individualists tend to be sceptical toward altruistic feelings. Egalitarians also differ from hierarchists because they consider equity concerns to be crucial for outcomes (universal coverage) and processes (fair and equitable participation in decision making). As a result, egalitarians favor decentralization arrangements and the variety of attempts to diffuse participation, empower patients, and prevent the dominance of medical professionals.
      Initiatives consistent with the egalitarian approach to governance and management can be found in several health systems; community participation, networked arrangements to secure the variety of stakeholders’ involvement in decision making, and the use of patients’ and citizens’ voice to control managers and professionals are major examples of these initiatives. For instance, the first changes introduced by the British Labour party in the late 1990s to the internal market of the NHS were aimed at shifting the focus from competition to cooperation, and the attempt to empower primary care in commissioning can be interpreted as a move to decentralize decision making and to make it closer to local conditions. In Italy, where radical decentralization has promoted the development of rather different regional health care models, some regions were driven by egalitarian principles to develop integrated health and social plans through participatory processes involving both local health authorities and municipalities. In the rest of Europe and in other continents, there have been countless experiences of involving local communities in health service planning, especially for primary health care. For example, the use of cooperatives both as financing mechanisms—such as the Chinese Cooperative Medical Scheme—and as delivery modality, the institution of patients’ juries to support priority setting in many countries, and even the increasing use of information technologies to empower patients and citizens are consistent with egalitarian principles.
      The fatalist approach combines low-group and high-grid attitudes toward government action. According to this view, humans live in atomized societies in which the behavior of individuals is strongly constrained by rules and codes that impede the pursuit of public interest. Given the pessimistic nature of this approach, it is difficult to identify policies overtly claiming to refer to this view. Still, such attitude is often behind the lack of government action to reform health systems and to address environmental threats.

      Governance and Management for attaining Universal Health Coverage

      Are all four cultural approaches to governance and management compatible with UHC? Are any of them more promising than others? We cannot provide a definitive answer to this question. On the basis of our analysis, however, we propose a few considerations that may inform the debate about UHC. First of all, UHC will not fit in any policy agenda if a fatalist approach is the dominant cultural view. The combination of low group and high grid offers no motivation and no means for the collective action required to achieve such an ambitious goal. The “universal” aim implies a collective attitude where solidarity and equity motivate individuals, which is incompatible with the low-group mode. In addition, the constraint on human action dictated by rules, beliefs, and rituals limits the possibility of universal coverage as the result of rational choices.
      For the other three approaches, the answer is less clear-cut. Both the hierarchical and the egalitarian approaches are consistent with the aim of UHC because of their group attitude. They both provide the underlying social motivation for the required social action. Both of them also provide a means of action, albeit of a different nature. Hierarchies are based on norms, rules, and also values, and thus strongly depend on the formidable resources required to have government functioning efficiently and effectively in societies that recognize a wider degree of freedom to individuals (as voters, clients, patients, etc.). In contrast, the egalitarian approach, which fully appreciates freedom and participation, often fails to provide actual solutions to major issues. Both approaches often fall short of meeting increasing expectations in terms of efficiency.
      The individualistic approach appears to be incompatible with the aims of UHC because it lacks the tendency toward “groupness.” And indeed some recipes inspired by neoliberalists have been shown to be in contrast with UHC such as the introduction of substantial user fees in poor communities or the private marketization of service delivery without any serious attempt to prevent its negative effects on the most poor and vulnerable parts of the population. There is not strong evidence, however, to argue that all the individualistic attempts to reshape health systems are in contrast with the pursuit of UHC—for example, there is little evidence that policies to increase patients’ choice, competition, and business-like management practices reduced the universal nature of health systems in Western Europe.
      Do these complex results mean that, at the end, cultural theory does not offer a valuable contribution to understand the nature of governance and management practices in the real world? First, there is no doubt that UHC finds a favorable environment in those cultures that are strongly inspired by the centrality of social ties and collective subjects. The strong reference to the community for human life provides a strong fabric to legitimize the pursuit of UHC. Both hierarchists and egalitarians, however, often fail to deliver solutions that fulfill their promises and thus are increasingly under social scrutiny. In addition, they suffer from the vagueness of the reference to “groups” in societies where the people belong to a variety of communities (from the local to the global). Second, more evidence is needed to understand whether the individualist approach may be valuable for attaining UHC. Some ideas on which it is based (e.g., the distrust in government action) may produce governance arrangements and management practices in contrast with the aim of UHC. At the same time, the centrality of individuals and their aspirations is present in policies that did not substantially challenge the basic reference to solidarity, inspiring tax-based systems. In conspicuous health policy reforms launched in England [
      • Le Grand J.
      Motivation, Agency, and Public Policy.
      ], Italy [
      • Fattore G.
      Cost containment and reforms in the Italian National Health Service.
      ], and even Nordic countries [
      • Martinussen P.E.
      • Magnussen G.
      Health care reforms: the Nordic experience.
      ], we would argue that elements of the individualistic approach have not weakened universalism. Nevertheless, despite the dramatic improvement in population health of the last decades, inequalities in health have been widening [

      Commission on Human Security. Human Security Now. New York, 2003.

      ], and this is likely to be correlated to the proliferation of approaches to develop health systems, in particular in low- and middle-income countries, based on individualistic principles.

      Discussion

      In this article we used cultural theory to investigate the nature of governance and management of health systems, showing that it may be helpful in identifying key aspects of the debate regarding how to promote universal coverage worldwide. Cultural theory argues that how we govern and manage health services depends on what we think about the nature of government organizations and the legitimacy of their scope of action. This view seems to be consistent with other macro-level analyses on health financing that show that the degree of solidarity of a community is related to the country’s willingness to adopt UHC [
      • Carrin G.
      • James C.
      Social health insurance: key factors affecting the transition towards universal coverage.
      ].
      Universal coverage requires a strong tie to equity and solidarity principles. Universalism implies a society beyond a simple aggregation of individuals and assumes that acting in the interest of all members of the community is legitimate and desirable. In this respect, promoting universal access to health and health care may be problematic when the individualist approach is dominant, even if the variety of policies that can be attributable to this approach is so broad that some of them may be consistent with UHC.
      More pragmatically, we could argue that the values that are implied by UHC matter in how health systems are governed and how their organizations are managed. Governance and management approaches are not indifferent to the values underpinning health systems goals, and thus, no approach is appropriate for every situation. For example, management practices that are successful in running private enterprises generally focus on efficiency and customer satisfaction. Although efficiency and user satisfaction are important for any health system, universal coverage is more likely to benefit from a strong commitment to the effectiveness of interventions and equity in access and financial contributions. Equity concerns tend to be small or secondary in private management but crucial in organizations that aim to provide universal coverage.
      The individualist approach to the governance and management of health systems, which has often prevailed in the last few decades, may not be consistent with the promotion of UHC. While the global community has recently endorsed the cause of UHC, global health governance is still fragmented by poorly coordinated institutions that are largely dominated by Western economies and individualists, or at least narrow approaches to health. This behavior is exemplified by the crisis of global public institutions, such as the World Health Organization, which have fragmented funding and narrow initiatives and partnerships. Our analysis would instead call for wider approaches to global health that have better coordination and that are focused on systemic approaches for strengthening health systems. This approach would also imply efforts to ensure a wider representation of citizens who are less likely to be covered and of all organizations that are involved in the decision-making processes.
      Most management practices and tools adopted in the health sector, particularly those of performance management, are underpinned by individualistic values. These tools are mostly targeted to individual performance and are rarely targeted toward collective objectives. They rarely include indicators of equity in access to care and financing aspects. To be consistent with UHC, administrative solutions should be designed following a different view of human action in which collective (rather than individual) responsibility is pivotal, and equity and fairness pervade management culture and practices.
      All these considerations emphasize the need for generating more knowledge regarding how governance and management approaches can be more conducive to attaining UHC. Research on these aspects would fit within the field of health policy and systems research [

      Gilson L. Health policy and systems research: a methodological reader. Available from: http://www.who.int/alliance-hpsr/resources/alliancehpsr_reader.pdf. [Accessed August 25, 2012].

      ,

      Hoffmann S, Rottingen JA, Bennet S, et al. Background Paper on Conceptual Issues Related to Health Systems Research to Inform a WHO Global Strategy on Health Systems Research. Geneva: Alliance for Health Policy and Systems Research, 2012.

      ]. This field recognizes the relevance of positivist, interpretativist, and constructionist paradigms of investigating how interventions and policies are implemented.
      In summary, we can draw two main conclusions from this analysis. First, the translation of cultural values and goals into practice requires exceptional efforts to design appropriate decision-making arrangements (the essence of governance) and management practices. Management and governance, or “how” policies are decided and conducted, are not secondary to the selection of the best policy solutions (the “what”). These issues include the architecture of decision making, the institutional organization of health systems, the design of information systems to support decision making at all levels, the way people are recruited and motivated to work, and the management culture of providers. Second, governance and management solutions are not independent of the values of the citizens that they are expected to serve. Instead, they should be conceived and designed consistently with these values.
      Cultural theory shows that “group identity” is favorable for shaping different forms of social life and public administration. This approach should thus be the starting point for those who strive to obtain UHC. In our opinion, the key issue in this approach is implementation. For egalitarians and hierarchists to pay more attention to “how” rather than “what” in government, that is to put governance and management issues at the center of the stage, is crucial as their main weakness concerns the translation of goals and objectives into feasible practical solutions. Concerning the individualist approach, it would be hazardous to conclude that it is always totally incompatible with UHC. It should be further investigated, theoretically and empirically, whether cultural movements that belong to this cultural approach can produce successful initiatives conducive to UHC.

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