1. Introduction

The term governance has existed since ancient Greece and the Roman Empire; however, it was used ambiguously and sometimes as a synonym for governability. It was not until 2004 that the International Development Research Center (IDRC-CRDI), through the Governance, Equity and Health (GES-GEH) program, held a Workshop on Governance in Health in the city of Montevideo, Uruguay, where researchers in health policies and systems were convened to analyze the concept and correct use of governance in research in health policies and systems ⁽¹⁾.

It is important to emphasize that governance has two fundamental characteristics: an analytical one that makes it possible to describe and explain the interactions of actors, processes and formal and informal rules. Rules with which a society determines its behavior, makes and executes its decisions in the society in which governance is developed; and a normative one which is based on a value and is accompanied by a social postulate and prescription in relation to what is considered good or bad ⁽²,⁴⁾.

Governance has been used as a horizontal management model based on the co-responsibility present between government and private and public organizations. It is even a matter of debate whether it can become a form of privatizing political power. However, it should be taken into account that the governance of each geographical sector has particular characteristics, for example, the governance of Europe is different and difficult to adopt to the regions of South America. For the sociologist Renate Mayntz, governance in health is a new form of governance different from the traditional hierarchical control model in which a plurality of actors from public and private institutions share, participate and cooperate in the responsibility of defining public policies^{(3, p.104)}. However, this new form of governance requires a change from an ethical, social, cultural and economic point of view that demands new public spaces for participation in individual and collective decision-making processes ⁽⁴⁾.

Likewise, health governance should not forget the actions of the patient whose free and autonomous participation is based on access to information and the exercise of his or her right to informational self-determination. This leading to a transformation of the doctor-patient relationship to a model of deliberation and dialogue, to a relationship of equality with respect to the dignity of the person, to achieve horizontality, intersectoral policies and informational self-determination in order to exercise autonomy and shared responsibility in health. This model in the context of the information society is based on three postulates: 1) informative and symmetrical self-determination of information; 2) co-responsibility for the patient’s health -shared responsibility; 3) the egalitarian model of shared decision-making.

Governance in health implies a model based on autonomy and informative self-determination and co-responsibility in health, without neglecting access to the means and informative and deliberative training of society in general, this being difficult to apply in societies with diverse structural and cultural inequalities such as language, uses and customs and even access to opportunities ⁽⁴⁾.

It is crucial to know the differences between the concepts government, governance and governability; which were explained by the Inter-American Network of Alumni Associations based on the works presented by Joan Prats I Català ⁽⁵⁾ and Elkin Velásques M ⁽⁶⁾.

Government (governing) is the mechanical element that guides (orients and balances) the interaction between political and social actors.

Governance is a systemic field (or directly, a system/subsystem) with a structure analogous to that of an electromagnetic type. The different strategic actors interact and influence according to their own physical and vector and tensor magnitudes depending on the position in space (which territory) and in time (when and with what evolution) in the functioning of the rules, in the decision-making process and in the development of collective conflicts.

Governability is a cybernetic type of equilibrium found by the system to function in a stable and effective manner in which there is feedback between social demands (what society requires in its broadest sense, which we call inputs). The interaction between strategic actors, the action and development of conflicts and the decision-making procedure (which we call processing), and the implementation of the decision and its results (which we call output) ⁽⁷⁾.

Another definition of governance is the capacity of a socio-political system to govern itself in the context of other broader systems of which it is a part⁽¹⁾.

When there are no clear objectives, these are ambiguous or defined in broad terms and the person, who agrees, does not have the responsibility of execution. Decisions are made based on agreements on the “what” and not on the “how”. This leads to the fact that the actors participating in the governance and health system such as the government (main responsible), the Ministry of Health, the health departments, the health institutions, the providers and the related public servants do not have their functions well defined and therefore the execution of the same.

The proper structure of the health system is a necessary condition for its proper functioning, and the agents or actors in the health sector are the government and its health agencies (health secretariats, services or institutes) responsible for providing quality service. Therefore, the government must guarantee the good health of the assets and their correct disposition in order to fulfill the health care objectives. In this context, the presence of a professional with the ideal profile to carry out the function entrusted is necessary ⁽⁸⁾.

The Australian sociologist Elton Mayo, at the beginning of the 20th century, carried out a research based on the observation of the formal hierarchy of an institution, which does not necessarily correspond to the effective hierarchy and which is important and determinant of the relationships between employees in the work organization. Likewise, Ronald Coase (1937) refers to the reduction of transaction costs of an institution that motivates the creation of hierarchical organizations and that, in addition, when reaching a certain level of complexity, administrative costs increase and may exceed the benefit of this reduction. All this led to this type of study being carried out in different organizations such as universities and companies, including those involved in health governance.

2. Concept of governance in health

The concept of governance has several meanings such as good governance, democratic governance, social capital and empowerment.

Prats and Celedón (2003) point out that the terms governance and governability should be differentiated, since dictionaries present various concepts and uses that have accepted their differentiation, since their connotation is different to the extent that various actors such as government and society participate.

3. Governance and health systems

In 1998, the World Health Organization (who) defined governance in health systems as the participation of actors concerned with the definition and implementation of policies, programs and practices that promote equitable and sustainable health systems^{(9, p.2)}. Therefore, it is possible to consider that this definition is limited since it is associated only with the participation of actors and these are part of governance processes; the rules of formal and informal games and organizations are also essential elements of the process. Prats refers that governance is the interaction between strategic actors, mediated by the institutional structure that generates a capacity of the socio-political system to reinforce itself (i.e., governance) ⁽¹⁰⁾.

It is essential to identify the three levels of governance: 1) the strategic actors and the resources they possess and which come from various sources, 2) the regulations and laws in force that regulate the way they are carried out, 3) the power asymmetries between social actors, who use the aforementioned power resources to influence decision making. These levels of power asymmetries between actors can be economic, religious, political and bureaucratic in nature in mass media ⁽¹¹⁾.

Governance refers to all decision-making techniques and power relations that play an important role in its concept. The United Nations Development Program (UNDP) placed power as a cornerstone in the definition of governance, stating that governance includes all the methods, good or bad, that societies use to distribute power and manage public resources and problems⁽¹²⁾, this definition not being specific to health systems, but to development in general. On the other hand, within health systems, governance refers to decision-making that directly or indirectly affects the health system. It involves strategic actors and organizations that abide by rules and other procedures, and use power resources to influence decision-making ⁽¹³⁾.

Plumtre and Graham, according to their studies on governance, indicate that governance involves interactions between structures, processes and traditions in a vertical, horizontal and informal manner. They point out two visions for understanding power relations in decision-making: 1) power and its capacity to produce changes in societies; and, 2) understanding power in a dynamic way and not in a latent capacity, since any population group can, at a given moment, decide to exercise this latent power and convert it into active power ⁽¹⁴,¹⁵⁾.

On the other hand, the steering role is a structural function of competence of health systems exercised through the national health authority and is defined as the exercise of the substantive responsibilities and competencies of health policy in the context of a new scheme of relations between government and society in the modern State⁽¹⁶⁾.

Its main objective is to implement public decisions and actions to satisfy and guarantee the legitimate health needs and aspirations of all social actors. On the other hand, the health authority is the custodian of the public good in health and its main purpose is the protection and promotion of the health of the population, directing and leading people to the processes and resources to achieve the objective of improving health.

It is important to remember the dimensions of the health function: 1) sectoral leadership, 2) regulation, 3) modulation of financing, 4) guarantee of insurance, 5) harmonization of service provision, and 6) execution of the Essential Public Health Functions. This should be conducted from a vision of governance under the principles of strategic vision, participation and consensus orientation, normativity, transparency, responsiveness, equity and inclusiveness and efficiency, accountability, intelligence, information and ethics of care and research.

The relevance of governance in health systems focuses on the traditional institutions providing medical services that analyze the value that society and the State place on a healthy life and the priority it has within social demands and public policy-making, since health is a priority for the individual and society. Hufty proposes five fundamental analytical units of health governance: actors, problems, norms, processes and nodal points. He also considers that it should have five characteristics: realistic, interdisciplinary, generalizable, comparative, reflexive and operational ⁽²⁾.

It is therefore necessary to establish governance indicators for the interaction of actors with different interests that influence the formulation and implementation of health policies ⁽¹⁷⁾.

The performance of health services is a key element to ensure that the functions and objectives of the system are clear and that, in turn, the roles and responsibilities of the actors are defined and understandable, as well as to introduce a mechanism of incentives aimed at continuous improvement in the performance of an effective community-based administration or management.

Therefore, in 2008 who defined three types of indicators based on rules and norms: the first measures whether countries have appropriate policies, strategies and codified approaches to governance in health (political index). who defines a political index as the result of 10 indicators based on norms and standards that assess whether a country has policies, strategies or regulations to promote good governance in the health sector in low and middle-income countries. These indicators are: 1) Existence of updated national health strategies that correspond to health needs and priorities. 2) Existence of a list of essential drugs in the last five years and their annual dissemination. 3) Existence of drug procurement policies, specifying the most cost-effective drugs in adequate quantities. 4) Existence of a national strategic plan for tuberculosis. 5) Existence of a national strategy or policy for malaria. 6) Existence of a national HIV/AIDS strategy or policy. 7) Existence of a comprehensive reproductive health policy. 8) Existence of a multi-year, comprehensive and updated childhood immunization plan. 9) Existence of key documents for the health sector that are regularly published and disseminated (budget documents, annual performance reviews and health indicators). 10) Existence of mechanisms, such as user surveys on the timeliness, effectiveness and adequate access to health services.

The second type of indicators are outcome-based, which measure how well the norms and procedures have been effectively implemented or applied based on the relevant experience of stakeholders. Among these are markers that provide information on the effectiveness and application of standards developed at the policy level or whether they contribute to governance outcomes. 1) Human resources for health (absenteeism of workers in health facilities). 2) Health financing (proportion of government funds reaching district level facilities). 3) Health service delivery (lack of essential drugs in health facilities, proportion of informal payments within the public health care system). 4) Pharmaceutical regulation (proportion of drug sales corresponding to counterfeit drugs). 5) Voice and transparency (existence of effective civil society organizations voicing their concerns to governmental statutes).

Finally, the third indicator: CPIA (Country Policy and Institutional Assessment) offers an annual institutional and national policy assessment and provides a governance rating measure for all sectors (18).

It is worth mentioning that globalization is affecting the social cohesion of many countries, with the result that health systems, fundamental elements of the contemporary social structure, are not functioning efficiently. This causes discontent among the population due to the inability of health services to provide a level of national coverage that can meet the demands and needs of the population, and it is a reality that the services provided do not meet the expectations of users.

4. Ethical principles associated with health systems governance

Most countries recognize the right to health in their political constitutions. Health systems in Latin America and the Caribbean are based on the principles of equity and equality of opportunities and responsibilities before the law, as well as on those of solidarity and social participation. Within this context, governance is a decision-making process that directly or indirectly affects health; therefore, it is evident that the processes involved must be governed by the ethical principles of equity, equality, solidarity and participation. It is convenient and important to know how the decision-making processes are aligned with the aforementioned ethical principles and to take into account that these principles become social objectives for health systems, such as greater equity in access, financing of the health system, equal opportunities and responsibilities before the law, and greater social participation in public health policies. It is important to point out that, due to power relations, the existence of an ethical framework in public policies does not automatically guarantee or ensure their application in decision-making processes ⁽¹⁹⁾.

It is common to observe that the outcome of the decision-making process, in most cases, contradicts social goals, causing barriers to equity, solidarity and a deterioration in the efficient use and allocation of resources, among others. The norms, the particular interests of the actors and public or private organizations play a determining role and, therefore, the values, motivations, incentives and practices of the social actors involved in decision-making must be understood, and social groups in conditions of vulnerability, such as those conditioned by poverty, ethnicity, gender, etc., must be included.

5. Ethics in health institutions

It is convenient to observe the ethics applied in health institutions not as a compliance with laws but as a conscious responsibility of ethical principles by professionals individually and independently as a practice of the system. Organizational ethics in health institutions is committed to fostering autonomy and personal integrity, not only as an individual good, but as a service to the vision, mission and principles that identify the institutional system that presents itself as a collective moral agent of its own identity functioning as a complexity of requirements applicable to all activities of the institution.

Currently, society is immersed in the coexistence with people of different ethnicity, beliefs, ideology, culture and personal interests. In many occasions, neither principles nor moral values are shared, which can hinder communication, coexistence and tolerance. This is the reason why the organizational ethics of health services has fundamental bases in life, common good and solidarity, through which it provides health care services to the population with opportunity, current medical and ethical knowledge, predominating beneficence, quality of care, distributive justice and equity.

Nowadays, in Latin America, the implementation of institutional ethics in public and private organizations in which the dignity of persons, social justice, multicultural care, equality and equity must be respected is fundamental. It is a task, which must be carried out diligently since the circumstances of poverty, level of development, sustainability, quality of life, insufficient and inefficient health systems, lack of resources, poor public administration and the expectations of the population, have exceeded the protocols of care, programs and public health policies ⁽²⁰⁾.

When speaking of the social responsibility of institutions, a broader space should be given to reflection on the ethical dimension and the moral values associated with it. It has been questioned how and why social responsibility should be carried out in institutions and there are many reasons why it is decided to implement social responsibility policies, as well as different models and objectives, the main reason why institutions assume social responsibility being the ethical commitment, which goes beyond legal responsibility ⁽²¹⁾.

Cortina and Conill mention that human groups and institutions should be guided by moral values, considering humanism as a gauge to express the value of the goodness/quality of the activities that human beings carry out with excellence. Institutional health ethics is based on the fact that it is not an ethics of the masses and/or consumers but an ethics of persons and institutions that give meaning and purpose to solidarity, highlighting the bioethical principles of non-maleficence (institutional ethics), justice and beneficence (institutional quality models), autonomy and participation (ethical validity of health institutions) ⁽²²⁾.

6. Implications of Governance and Health in Latin America

Health is a fundamental right and a condition for the full enjoyment of other rights. The 2030 Agenda for Sustainable Development reflects this perspective by proposing a universal, integrated and indivisible vision that shows how health and human well-being are intertwined with economic growth and environmental sustainability. Health in the Americas+ 2017 manifests the following motivations: 1) Universal health, its values and strategic principles of action. 2) The most pressing health problems and challenges or those that impose the greatest strain on health systems and on the physical and social context. 3) The regional panorama, including an analysis of the health situation and its trends. 4) The future prospects for health in the region with several of the dominant aspects of a prospective vision ⁽²³⁾.

The right to health, equity and solidarity are the values underpinning universal health that is endorsed as a strategy in 2014 for the States of the Americas in document cd53/5 Rev. 2 of the Directing Council of PAHO. These values constitute the ethical foundation for the design and implementation of public policies. The concept of universal health integrates universal access and coverage as an object of right ⁽²³⁾.

Equity is another pillar of the universal health strategy. The realization of the right to health is inconceivable without a basis of equity that leads to a social dialogue on the factors affecting people’s well-being.

Other values such as solidarity, social activism and collective action have played a crucial role for decision-makers in public health policies ⁽²⁴⁾.

The fundamental elements proposed by who for the strategy towards universal health are: 1) Expanding equitable access to comprehensive and quality health services centered on people and communities. 2) Strengthening intersectoral coordination to address the social determinants of health. 3) Strengthening stewardship and governance. 4) Increasing and improving financing with equity and efficiency and moving towards the elimination of direct payment, which becomes a barrier to access at the time of service delivery ⁽²³⁾.

In Mexico, several studies have been carried out in relation to health governance. These including the work Gobernanza en sistemas de salud y participación social en México a partir de la reforma del sector (salud) by Arredondo López and collaborators. They conclude that for political actors the reform has not modified dependence on the central level, as well as evidenced the lack of knowledge of strategies and participation in the local management of resources to finance state health systems and the absence of a timely system of accountability in health at the municipal and state levels. This leads to the conclusion that health governance does not have sufficient mechanisms for participation and accountability to advance in the democratization of health and that there is a challenge in the process of health reform in Mexico ⁽²⁵⁾.

7. Conclusions

The term governance refers to a horizontal management model based on a shared responsibility between government and institutions, including the strategic actors involved in these instances who implement policies, programs and practices in favor of equitable, responsible and ethical health systems. Governance takes place in a space and time where it is important to ensure the correct functioning of the rules, regulations and laws in force that affect or regulate the decision-making process of these strategic actors and the proper development of collective conflicts that arise within the health systems.

Due to the present globalization that affects social cohesion, causing health systems not to function as they were designed. A radical ethical, social, cultural and economic change is necessary, demanding new public spaces for participation in the decision-making processes in these systems, thus avoiding population discontent and allowing health services to provide an adequate level of national coverage where the demands and needs of the population are satisfied.

It is proposed to continue with a health governance model based on the organizational ethics of health services. This based on the principles of equity and equality of opportunities and responsibilities before the law, distributive justice, solidarity, social participation, autonomy, informative self-determination, life and the common good, taking into account the structural and cultural inequalities that may arise in a given territory. All this in order to provide health care services to the population with timeliness, current medical and ethical knowledge, prevailing the principles of beneficence and non-maleficence, quality of care, distributive justice, equity, autonomy and participation.

It remains to reflect on the following in this regard: