Abstract
Background
To meet the health-related targets of the Sustainable Development Goals (SDGs), there is a pressing need to prioritise the quality of healthcare services, especially in low-income and middle-income countries (LMICs). The 2018 Lancet Global Health Commission on High-Quality Health Systems emphasised the importance of national health systems focusing on quality governance.
Aim
This thesis aims to analyse how the governance of the health sector influences the quality of healthcare in LMICs and identify strategies and interventions to govern healthcare quality effectively. The thesis pursued three research objectives.
Objective 1: To map the available evidence on governance strategies and interventions that are effective in improving healthcare quality in LMICs.
Objective 2: To elicit the opinions of stakeholders on effective governance strategies and interventions to improve healthcare quality in LMICs
Objective 3: To describe the enabling and constraining health governance factors impacting the quality of maternal healthcare services in Bangladesh.
Methods
Three studies were conducted sequentially to answer the research questions. First, a scoping review was undertaken to map the available evidence of the impact of health governance interventions on healthcare quality in LMICs. Second, a qualitative study was conducted with international stakeholders to elicit their views and opinions about health governance factors influencing healthcare quality. Third, a qualitative study was conducted to analyse the enabling and constraining health governance factors impacting the quality of maternal healthcare services in Bangladesh.
Results
The functions of health sector governance that impact healthcare quality are organised under three overlapping domains: steering, stewarding, and coalescing. Contextual factors and external influences significantly influence the governance environment in LMICs. The rules and relationships among the state actors, service providers and citizens influence governance relationships and impact healthcare quality. The analysis of health governance of maternal healthcare quality in Bangladesh identified a mix of enabling and constraining factors related to the policy environment, stakeholder engagement and mechanisms for accountability. The research highlighted the necessity of more rigorous investigations into the effects of governance interventions on healthcare quality in LMICs, employing comparable indicators and measurement approaches.
Conclusions
This thesis affirms that interventions to improve healthcare quality must go beyond the clinical and technical interventions and address underlying governance relationships among the various actors. The governance interventions are unlikely to show linear relationships with quality of care. There is a complex interplay of multiple functions of governance and governance actors that together impact healthcare quality. Considering the significance of contextual factors that shape the health governance of each country, the interventions to improve quality require a nuanced approach to suit the health system contexts of each country.