Stewardship, sometimes more narrowly defined as governance, refers to the wide range of functions carried out by governments as they seek to achieve national health policy objectives. In addition to improving overall levels of population health, objectives are likely to be framed in terms of equity, coverage, access, quality, and patients' rights. National policy may also define the relative roles and responsibilities of the public, private and voluntary sectors - as well as civil society - in the provision and financing of health care.
Stewardship is a political process that involves balancing competing influences and demands. It will include: maintaining the strategic direction of policy development and implementation; detecting and correcting undesirable trends and distortions; articulating the case for health in national development; regulating the behaviour of a wide range of actors - from health care financiers to health care providers; and establishing effective accountability mechanisms. Beyond the formal health system stewardship means ensuring that other areas of government policy and legislation promote - or at least do not undermine - peoples' health. In countries that receive significant amounts of development assistance, stewardship will be concerned with managing these resources in ways that promote national leadership, contribute to the achievement of agreed policy goals, and strengthen national management systems. While the scope for exercising stewardship functions is greatest at the national level, the concept can also cover the steering role of regional and local authorities.
A key concern in many countries is to build the capacity needed to carry out stewardship functions effectively. This, in turn, requires a better understanding of what constitutes best practice when it comes to stewardship and how national leadership can be developed. It is increasingly recognized that the provision of development assistance needs to be geared to fulfilling these objectives.