title: Health systems performance in sub-Saharan Africa: governance, outcome and equity.
abstract: BACKGROUND
  The literature on health systems focuses largely on the performance of healthcare systems operationalised around indicators such as hospital beds, maternity care and immunisation coverage. A broader definition of health systems however, needs to include the wider determinants of health including, possibly, governance and its relationship to health and health equity. The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance.
  
  
  METHODS
  Using cross sectional data from 46 countries in the African region of the World Health Organization, an ecological analysis was conducted to examine the relationship between governance and health systems performance. The data were analysed using multiple linear regression and a standard progressive modelling procedure. The under-five mortality rate (U5MR) was used as the health outcome measure and the ratio of U5MR in the wealthiest and poorest quintiles was used as the measure of health equity. Governance was measured using two contextually relevant indices developed by the Mo Ibrahim Foundation.
  
  
  RESULTS
  Governance was strongly associated with U5MR and moderately associated with the U5MR quintile ratio. After controlling for possible confounding by healthcare, finance, education, and water and sanitation, governance remained significantly associated with U5MR. Governance was not, however, significantly associated with equity in U5MR outcomes.
  
  
  CONCLUSIONS
  This study suggests that the quality of governance may be an important structural determinant of health systems performance, and could be an indicator to be monitored. The association suggests there might be a causal relationship. However, the cross-sectional design, the level of missing data, and the small sample size, forces tentative conclusions. Further research will be needed to assess the causal relationship, and its generalizability beyond U5MR as a health outcome measure, as well as the geographical generalizability of the results.
authors.affiliation: Centre for Public Health Research, Brunel University, West London, UK. anna@mikron.is
authors.forename: Anna E
authors.initials: AE
authors.lastname: Olafsdottir
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Reidpath
authors.forename: Subhash
authors.initials: S
authors.lastname: Pokhrel
authors.forename: Pascale
authors.initials: P
authors.lastname: Allotey
mesh_terms: D017954:Africa South of the Sahara; D046688:Child Mortality; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D008297:Male; D017063:Outcome Assessment, Health Care; D011787:Quality of Health Care; D012959:Socioeconomic Factors