Table 1 Modified framework for assessing health development governance

1. Public health leadership and management

1.1 Leadership responsibilities: Extent to which the Ministry of Health gives direction and effectively communicates that vision to align people with it; protect the health system from external threats; clarifies the roles and responsibilities of various actors; manages conflict internally and externally; motivates and inspires health workers (and other stakeholders) by satisfying their basic human needs to sustain their focus on the health development vision; and shapes the norms (including challenges unproductive norms) [8, 9].

1.2 National health policy (NHP): existence of an updated national health policy based on a thorough situation analysis of health systems goals (health, fairness in financing and responsiveness to non-medical expectations) and functions (governance, health financing, resource creation and health service provision) and policy dialogue, and existence of clearly spelt out strategic vision for health development, guiding principles and underlying values, goals, health development priorities (based on rational criteria, e.g. cost-effectiveness analysis), implementation framework, resource mobilization mechanisms, and modalities for monitoring and evaluation [10].

1.3 National health strategic plan (NHSP): contain a background; situation analysis (socioeconomic context; health situation; state of health services supply and demand; strengths, weaknesses, opportunities and threats); strategic health development priorities (vision, mission, goal, guiding principles, objectives, targets, strategic thrusts, expected results/outcomes, activities and performance indicators); resource requirements, including human resources, building space, vehicles, equipment, materials and supplies, information, communication and technology (ICT); finance plan (containing prospective estimates cost, available funds, financing gap and ways of bridging the gap); implementation framework specifying the roles and responsibilities of various people, institutions and organizations involved in health development; monitoring and evaluation, including mechanisms, schedule and cost; conclusion; and appendices [10].

1.4 Dissemination of NHP and NHSP: the NHP and NHSP are widely available at national, provincial/regional, district and community levels in relevant local languages.

1.5 Implementation: Extent to which NHSP has been translated into results-oriented operational programmes and plans as expressed in medium-term expenditure frameworks and annual programme budgets [11].

2. Rule of health-related laws

2.1 Existence of health-related legislations: Existence of public health laws related to governance, health financing, resource/input creation (essential health technologies, human resources, and infrastructure), provision of personal and public health services, research for health, ethical practises [7].

2.2 Enforcement of health-related legislations: the extent to which various health-related laws are applied at all levels of health system (and government) to administer governance, health financing, resource/input creation (essential health technologies, human resources, infrastructure), provision of personal and public health services, research for health, ethical practises [7].

3. Community participation & responsiveness

3.1 Participation in NHP and NHSP development: Extent to which communities (either directly or through elected leaders) are involved in the health needs assessment, national health policy development, and planning of health development [12, 13].

3.2 Participation in NHSP implementation: Extent to which communities (either directly or through elected leaders) are involved in management of health services and other health enhancing services (e.g. water, sanitation, environmental pollution control).

3.3 Participation in tracking of progress: Extent to which communities (either directly or through elected leaders) are involved in monitoring and evaluation in the achievement of health development objectives and targets spelt out in the NHSP.

3.4 Responsiveness to communities non-medical expectations: Extent to which health systems exercise respect for persons (dignity, autonomy in choice of interventions and confidentiality) and are client-oriented (prompt, adequate basic amenities, access to social support networks, choice of provider) [14].

4. Effective internal and external partnerships for health

4.1 Intersectoral action: Existence of vibrant intersectoral committees for tracing progress on socioeconomic determinants of health [15, 16].

4.2 Public-private partnerships: Extent to which the legislative and policy environment forges partnerships with the faith-based organizations and private-for-profit sector in health financing, health systems input creation and health services provision to facilitate implementation of NHP and NHSP [17].

4.3 Alignment of aid flows to national health development priorities: (i) Percentage of aid flows for health development channelled through general government budget support [11].

4.4 Strengthen capacity by coordinated support: Percentage of technical cooperation flows implemented through coordinated programmes consistent with NHSP [11].

4.5 Use of country procurement and public financial management systems: Percentage of donor aid that flow through recipient/partner country procurement and public financial management systems [11].

4.6 Strengthen national capacity by avoiding parallel implementation structures: number of parallel health project implementation units in a country [11].

4.7 Aid is more predictable: Percent of health-related aid disbursed according to multi-year frameworks [11].

4.8 Aid is untied: Percentage of bilateral aid for health that is untied to donor conditionality [11].

4.9 Shared analysis: Percentage of health-related (a) field missions and/or (b) country analytic work undertaken jointly between the cluster of health donors and national government [11].

4.10 Sufficient integration of global programmes and initiatives into NHSP: Percentage of global programmes (e.g. Global Fund for Aids, Tuberculosis and malaria; GAVI) and initiatives supporting the implementation of NHSP [11].

5. Horizontal and vertical equity in health systems

5.1 Horizontal equity: Extent to which there is the allocation of equivalent resources for people with equivalent capacity to benefit from health enhancing health interventions and socio-economic interventions [16, 18–20].

5.2 Vertical equity: Extent to which there is allocation of different resources for people with different levels of capacity to benefit from health enhancing health interventions and socio-economic interventions [16, 18–20].

5.3 Health fairness in financial contribution (HFC): Extent to which the ratio of total contribution to health from each household through all payments mechanisms (HE) to that household's capacity to pay (CTP) - which is the effective non-subsistence income - is identical for all households, independent of the household's health status or use of the health system [19], i.e. HFC = HE/CTP.

6. Efficiency in resource allocation and use

6.1 Allocative efficiency: Percentage of various levels of fixed health facilities allocating health resources to their most highly valued uses [21].

6.2 Technical efficiency: Percentage of various levels of fixed health facilities using physical health systems inputs to produce either health services without waste [22–27].

6.3 Productivity growth: Percentage of various levels of fixed health facilities experiencing total factor productivity growth due to efficiency improvement and/or technological growth [28–30].

6.4 Institutionalization of efficiency monitoring: Extent to which economic efficiency monitoring has been institutionalized within the national health management information system [23].

7. Accountability and transparency in health development

7.1 Existence of transparent results-oriented reporting and assessment frameworks to assess progress against NHSP targets indicators [11].

7.2 Diagnostic reviews: Extent to which diagnostic reviews of national arrangements and procedures for public financial management, accounting, auditing, procurement, results frameworks and monitoring provide reliable assessments of performance, transparency and accountability of country systems [11].

7.3 Use of information from diagnostic reviews: Extent to which evidence from diagnostic reviews is used in the design of reforms to ensure that national systems, institutions and procedures for managing all health resources are effective, accountable and transparent [11].

7.4 Publishing of audit reports for public consumption: Extent to which reliable and timely budget execution and audit reports are transparently reviewed by relevant parliamentary committees and published in mass media for public scrutiny [11].

8. Evidence-based decision-making

8.1 National health research systems: Existence of a health research policy and strategic plans that are being implemented as evidenced in research outputs and their use in health policy, planning and decision-making [31, 32].

8.2 Health knowledge management systems (HKMS): Existence of a functional HKMS that does acquisition, creation (probably through research and practise), diffusion, application and evaluation/improvement of knowledge [33].

8.3 Health management information systems: Extent to which a country has legal and policy frameworks supported by sufficient human resources, financing and infrastructure; core health indicators identified covering determinants of health, health system inputs, outputs and outcomes; key data available from six main sources and standards for their use - for census, vital events monitoring, health facilities statistics, public health surveillance, population-based surveys and resource tracking; optimal processes for collecting, sharing and storing data, data flows and feedback loops; dissemination of information and effective use of data for policy and advocacy, planning and priority setting, resource allocation, and implementation and action [34].

8.4 Information, Communication and Technology Connectivity: (i) Existence of a comprehensive national policy and a legal and strategic framework to guide and nurture the growth of ICT, while at the same time protecting the welfare of its citizens. (ii) Extent to which the necessary investment in ICT infrastructure, including fixed phone lines installation, equipment (e.g. computers, servers, networks) and Internet connectivity in the entire health system, i.e. from the Ministry of Health headquarters down to the level of community-based public health programmes [35].

9. Ethical practises in health research and service provision

9.1 International ethical guidelines for medical practice and health research: Extent to which a country have adapted appropriately international ethical guidelines for medical practice (e.g., the International Code of Medical Ethics of the World Medical Association or the International Conference on Harmonization guidelines for Good Clinical Practice) and biomedical research involving human subjects, made them available to all national health and health-related research institutions and health facilities, and are being adhered to [36].

9.2 Bioethics review system: Existence of operational bioethics research review system, which includes national, regional, district and institutional (health facility) ethics committees for protecting the dignity, integrity and health safety of all its citizens participating in research and those consuming health services [37].

9.4 Institutionalization of ethics training: Extent to which a country has institutionalized training in ethics and human rights in relation to health at all stages of the education and training of all health workers, including medical, public health and nursing schools [37, 38].

10. Macroeconomic and political stability

10.1 Link between national economic development plan (NEDP), Poverty Reduction Strategy Paper (PRSP) and NHP/NHSP: Existence of NEDP and PRSP with a health component linked with the NHP and NHSP [39].

10.2 Existence of a medium-term expenditure framework (MTEF): Existence of a MTEF with a clear health component [39].

10.3 Political stability: Existence of non-violent processes by which those in authority are selected and replaced [40, 41].