Countering failures of imagination: governance, human development and public health in low- and middle-income countries

Dramatic cuts in global aid have irrevocably changed the health funding landscape in Low- and Middle- Income Countries (LMICs), creating significant challenges for national governments. But there is a silver lining: these changes give national governments greater agency to set development goals. This moment of disruption demands bold thinking; it is an opportunity to place human development above sector-specific outcomes at the heart of national priority setting and reframe investments in public health accordingly. The social conditions that shape a person's health are the same conditions that shape their education, wealth, and a myriad of other outcomes within the social sector. Yet, despite strong momentum towards intersectoral collaborative approaches to governance, particularly in health, many government departments across the social sector continue to operate as siloes, neither prioritising nor implementing investments that target common or overlapping causes to improve outcomes across sectors. The dominant models of governance are insufficient to this task. We need innovations in governance that move beyond both traditional sector-specific approaches and newer intersectoral frameworks towards restructured government models that fundamentally transcend sectoral boundaries. We describe the limitations of current approaches, and explore how alternative governance structures might look in practice, and consider their implications for the health sector.