The shifting sands of language - And what do we really mean by governance, most of the time?

PHOs have been crucial actors in the governance of primary healthcare

An intriguing feature of language is how two words having the same root and that mean much the same thing can come to have opposite meanings.

Think of “terrific” and “terrible”, “awful” and “awesome”.

One example I constantly stumble upon is the distinction between “politics” and “policy”. Both derive from the ancient Greek word for city (polis), which was used to refer to “the people” of Greek city states such as Athens.

In this context, politics is about the processes by which the polis determines its collective destiny.

Around the middle of the 20th century, the two words began to take on opposing connotations.

In the post-war period, the prevailing common sense in academia was that the realms of facts and values were separate. Politics ended up on the value side of this conceptual distinction, and policy on the other.

Politics signified argument, debate and some groups exerting power over others, whereas policy was about the rational weighing of options to arrive at an optimal decision.

If you take the view that policy processes should be apolitical, then policy becomes something that is technocratic, with much of the policy process quarantined from any democratic input. We have seen this in the way the Reserve Bank sets interest rates, and in how Pharmac makes decisions about public funding of new drugs.

However, there has been a counter-movement in recent years, arguing that politics and policy are two words meaning the same thing, so any call to “take the politics out of policy” is self-contradictory.

The implication is that multiple opportunities for input into policy processes should be expanded and strengthened.

Another interesting pair is “government” and “governance”. Same or different? Again, the common root is Greek.

“Govern” derives from the word “kubernan”, which means to steer a ship. In English usage, both government and governance can be used as nouns denoting the way(s) in which organisations, professions or countries are steered.

Sometime in the 19th century, the term “government” also began to be used to denote something more concrete, such that it became commonplace to refer to “the government” as the entity having the right to wield authority over a territory.

In our own context, Te Tiriti o Waitangi predates the widespread use of the word government as something with authority, and this is reflected in the distinction between kāwanatanga (te reo translation of government) and tino rangatiratanga.

Throughout the 20th century, it was usual to distinguish between government and non-government, and between public and private. These distinctions became convenient ways of distinguishing types of organisations according to who owned them. In this version of the world, the big questions were “which activities should be within the realm of government”, and “how big or small should government be?”

One consequence of carving up the world this way was that use of the word “government” to refer to a process largely disappeared.

In the 1990s, the word governance filled the niche that had been vacated. The World Bank wanted to put the spotlight on processes and practices in lower and middle-income countries, so “good governance” came to mean having systems that minimised corruption. In the corporate world, increased shareholder activism focused the spotlight on boards of directors, and the skills necessary for corporate governance.

In my own field of political science, governance came to mean something different again.

It was mainly understood as the processes by which the whole range of participants in policy processes – including government agencies, interest groups representing businesses and professions, and advocacy groups of citizens – collectively steered policy.

Although all three uses have different connotations, the common denominator was that governance is not only something involving “the government”. Governance of many things often happens with minimal input from government. This sense of the word also underpins “clinical governance” and “professional governance”.

The shift of focus from government to governance is not simply a matter of semantics and ivory-tower theorising; it has real implications for the health sector and beyond. For starters, inter-organisational collaborations are ubiquitous (think public–private partnerships in road building, or district alliances in our health system). These somewhat blur the distinction between government and non-government, and public and private. Many organisations are neither fish nor fowl.

What matters is the value they add to the collective project of governance.

PHOs have been crucial actors in the governance of primary healthcare. If we use the 20th century understanding of government described earlier, PHOs are non-government organisations, but created by, and largely funded by, governments. This has led many to ask whether PHOs should be responsible for implementing government policies as part of a chain of accountability to the electorate.

When we think in terms of governance, however, these questions recede into the background. Instead, the main concern is how well the ship is steered, rather than whether the captain is obeyed. This emphasis is also apparent in how key Labour Party ministers are framing “co-governance” between Māori and non-Māori as a key principle of health-sector reform.

Opposition parties have already indicated they intend to make this a debate about who or what is government in the context of co-governance.

We won’t stop referring to something called “the government” any time soon. But there may well come a time when it no longer occupies the central role it has had in describing how our societies and our health systems operate.

If governance is here to stay, we are going to need to develop much clearer ways of understanding what good governance looks like.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland