Deciphering Governance: Analysing constructs of governance, and how they facilitate attainment of health goals in a low- or middle-income country. A Case Study from Kenya

Challenges with ensuring effective governance persist in low- and middle-income countries in part due to lack of a common approach to interpreting and applying it by those responsible for providing direction and oversight of the health agenda. My study explores how to overcome this challenge. I document several theoretical, institutional or conceptual approaches to define the concept of governance. I postulate that through identifying a clear way to interpret and apply governance, health stewards and managers in low- or middle-income countries would be better able to plan, implement and monitor governance actions needed to facilitate attainment of their health results. To explore this through case studies involving forty-nine Key Informants in Kenya representing health stewards and managers at macro, meso and micro levels of oversight, plus public, faith based and private sector providers plus civil society organizations. Amongst these, I explored the various ways governance is understood, and factors needed from the health sector and other sectors. To ensure a depth of exploration, I deconstructed governance into its constituent constructs. I found that, these persons expected to implement governance actions understood these from the perspective of six primary characteristics. I also find that health sectors need to ensure a range of policy/legal, and structural (tangible) / process (intangible) based instruments and tools to facilitate the action of governance. Finally, other sectors need to focus on ensuring there are community transformation initiatives, processes to build social capital, participatory decision-making culture, systems to ensure equity and the right to health, governance improving processes and opportunities to expand devolved level decision space. My results have some elements that have been identified before in literature, and some which are new or not part of the mainstream thinking. I therefore build a reconstruction of governance through structuring and outlining the actions health stewards and managers need to focus on for effective influence on their health results. It would be worthwhile to explore how to make this construction of governance operational for health stewards and managers in low- or middle-income countries.