Health Governance

1. Health Governance Ilona Kickbusch Yale University HPH Florence, Italy May 2003 Ilona Kickbusch Florence 2003

2. Our debate reflects a larger issue • The debates on health, diversity and governance are part of a larger society wide process of social learning and exploration which initially was focused on • How do we manage existing systems better (Evidence, Efficiency, Effectiveness) • It now moves to a larger question and the search for a new rationale Ilona Kickbusch Florence 2003

3. Health New and expanded role of health in modern societies and in developing countries that are much less health care system centered Governance New approaches to governance in all societal systems and at all levels of governance that are much less state centered Two starting points of a new dynamic Ilona Kickbusch Florence 2003

4. Buon governo Mal governo Governance matters for health and quality of life: Ambrogio Lorenzetti Ilona Kickbusch Florence 2003

5. 21st century: Change in context • Intense economic transition • Demographic transition • Political transitions • New technologies • Disease Transitions • Trans-boundary flows of people, goods, ideas, services, infections, lifestyles • Temporal/spatial/cognitive shifts • A new global context Ilona Kickbusch Florence 2003

6. New realities for policy • Changing role of governments and institutions • Changing demands on leadership • New pluralism of interest • A new view of political and social responsibilities • Search for new models of organization and financing of social security, welfare and health Ilona Kickbusch Florence 2003

7. Health Policy Challenge • “Although responsibilities for health remain primarily national, the determinants of health and the means to fulfill that responsibility are increasingly global.” • (Jamison/Frenk and Knaul 1998) Ilona Kickbusch Florence 2003

8. 21st Century: Change in governance • 21st century governance characteristics: • public philosophy based on equity • participatory value base • new ecology of collaboration • OECD Report Ilona Kickbusch Florence 2003

9. Values and philosophy • What political philosophy and values drive the governance debate? • Anthony Giddens: Life politics • Amartya Sen: capabilities • Ralf Dahrendorf: Life chances Ilona Kickbusch Florence 2003

10. State, Society and Diversity • the key issue of governance is a new relationship between state and society which requires the constant reconstitution of social relationships under conditions of diversity – • it creates and recreates a pattern of power sharing and makes collaboration the new imperative Ilona Kickbusch Florence 2003

11. New ecology of collaboration • Chris Patten expressed in his 2000 Reith lectures on globalization and governance that the new challenges require • a“mosaic of institutions, policies and values. Mosaic may even be too static a word for what is required: it is really a political ecosystem that is needed…” Ilona Kickbusch Florence 2003

12. A (global) society of networks • The defining feature of contemporary society – basis for collective agency • Networks are consensus/inducement oriented organizations and institutions Ilona Kickbusch Florence 2003

13. In the center: The active citizen • Language of common citizenship frequently based on global values • Health as expression of citizenship • Citizenship within health care system • Goal: Enhance citizens capacities and competence as producers of governance and of health Ilona Kickbusch Florence 2003

14. Two big trends • Medicalization • Professionals • Health • Citizens Ilona Kickbusch Florence 2003

15. Mixed institutions:apply to HPH • Institutions practice distributed governance or a dispersion of decision making power over a wide variety of actors and groups • In particular institutions and organizations need the knowledge and the information that active citizens possess: they need to learn faster and mobilize the collective intelligence of the system Ilona Kickbusch Florence 2003

16. Model of policy making • Health promoting hospitals shifts the model of policy making “from above” to network management and a model of complexity management and • It allows an approach to network governance in order to create consensus among stake holders and to involve civil society Ilona Kickbusch Florence 2003

17. Loose governance Innovation Adaptability Learning capacity Soft and hard power Characteristic of HPH network Ilona Kickbusch Florence 2003

18. HPH governance principles • Value and goal driven: empowerment • Co production of health as a process that recognizes local diversity • Health of systems and populations • Health as quality of process and health gain outcome • Governance as learning • Governance as sharing power and responsibility between stakeholders Ilona Kickbusch Florence 2003

19. A HPH strategy implies significant change in governance • Develop capacity building and managerial tools for the turn around that a HPH strategy brings to an organization, in particular patient/citizen oriented processes • New core competencies • New business model • New organizational culture Ilona Kickbusch Florence 2003

20. The HPH • Must improve the • The means to learn • The incentive to learn • The capability to learn • The access to relevant knowledge Ilona Kickbusch Florence 2003

21. Strategic challenge:expand the territory • From inward to outward orientation: • Move into other networks • Go global • Explore both the public and the private sphere Ilona Kickbusch Florence 2003

22. Role of HPH at European level • Address the health value base • create a new "political space“ for health, • ensure horizontal subsidiarity, • increase ownership across European stakeholders, • Ensure transparency and accountability • Respond to diversity Ilona Kickbusch Florence 2003

23. In consequence • HPH network must consider how to involve and engage more stakeholders • For example • patient organizations through associate memberships Ilona Kickbusch Florence 2003

24. New good governance • Un avventura commune Ilona Kickbusch Florence 2003

25. Select references: • Beck, Ulrich: Risk Society. Cambridge: Polity Press 1992 • Castells, Manuel: The rise of the network society. Oxford: Blackwell 1996 • Cesati, Franco: The Medici. Story of a European Dynasty. Florence: Mandragora 1999 • Dahrendorf, Ralf: Auf der Suche nach einer neuen Ordnung. Muenchen C.H.Beck 2003 • Florini, Ann: The Coming Democracy.New Rules for Running a new world. Washington: Island Press 2003 • Giddens, Anthony: Modernity and Self Identity self and society in the late modern age. Cambridge Polity Press 1991 • Kickbusch, Ilona: Perspectives on health governance in the 21st Century. In: Health Targets in Europe. Polity, progress and promise. Edited by Marshall Marinker. BMJ Books London 2002, pages 206-229 • OECD: Governance in the 21st Century. Paris: OECD 2001 • Sen, Amartya: Development as Freedom. New York: Knopf 1999 • Underwood, Jim: Complexity and Paradox. Oxford:Capstone Publishing 2002 Ilona Kickbusch Florence 2003