What sort of stewardship and health system management is needed to tackle health inequity, and how can it be developed and sustained? A literature review

This paper argues that stronger and values-based public sector management and leadership is essential in building health systems that better address health inequities. By considering evidence on the existing weaknesses of health system action to redress inequity it identifies a complex and inter-locking set of problems involving individuals, organisational culture and the ways in which wider political, economic and socio-cultural forces influence public sector organisations. From this base it then, first, examines the particular features of organisational culture in organisations judged to be better performing, and considers how change in organisational culture can be brought about. Second, it identifies the particular competencies of public sector managers and reviews evidence on how these competencies can be developed. Renewing the values base of public health system managers and professionals is an important requirement. Overall, the paper’s four key conclusions are that: 1. managerial action cannot be separated from the context in which it occurs; 2. strengthening public sector management will require efforts to generate organisational cultures that support and enable relevant managerial actions; 3. changing organisational culture involves multi-level actions focussed on individuals within organisations, the organisation and the wider system in which the organisation is embedded; 4. leadership training for senior and middle level public sector managers is an essential element of strengthening health system management. Management development initiatives cannot, therefore, simply be taken from sets of existing management strengthening tools and approaches. Instead they require careful, countryspecific reflection to identify: appropriate entry points, how to link training programmes with health system developments that themselves build capacity, the package of personal, organisational, professional and systemic-level interventions to adopt, and the flexible approaches to monitoring and evaluation that sustained these complex interventions.