Governing the Health Commons

Wikis > Governing the Health Commons

Elinor Ostrom.


For centuries, many communities have been successfully self-governing their day-to-day use (and abuse) of shared resources such as water for irrigation, grazing land for livestock, forests for heating and construction.

If health care resources can be usefully though of as common pool resources, as Jane Brock, M.D. has suggested from her analysis of  Grand Junctions, CO health system, then we should seriously consider designing our governance of ACOs or community health resources based on Elinor Ostrom’s eight principles:

Governing the Commons: an important book full of ideas for modern communities and the management of the limited resources for health and wellness along with illness. Here are Elinor Ostrom’s list of rules for successful governance of a common pool resource:

1. Clearly defined boundaries

Individuals or households who have rights to withdraw resource units from the CPR must be clearly defined, as must the boundaries of the CPR itself.

2. Congruence between appropriation and provision rules and local conditions

Appropriation rules restricting time, place, technology, and/or quantity of resource units are related to local conditions and to provision rules requiring labor, material, and/or money.

3. Collective-choice arrangements

Most individuals affected by the operational rules can participate in modifying the institutional rules.

4. Monitoring

Monitors, who actively audit CPR conditions and appropriator behavior, are accountable to the appropriators or or the appropriators.

5. Graduated sanctions

Appropriators who violate operational rules are likely to be assessed graduated sanctions (depending on the seriousness and context of the offense) by other appropriators, by officials accountable to the appropriators, or by both.

6. Conflict-resolution mechanisms

Appropriators and their officials have rapid access to low-cost local arenas to resolve conflicts among appropriators or between appropriators and officials.

7. Minimal recognition of rights to organize

The rights of appropriators to devise their own institutions are not challenged by external governmental authorities.

8. Nested enterprises

(CPRs that are parts of larger systems).
Inclusion/exclusion (Rule 1), appropriation/provision (Rule 2), monitoring (Rule 4), enforcement (Rule 5), conflict resolution Rule 6), and governance (rights & freedoms) activities (Rules 3 & 7) are organized in multiple layers of nested enterprises.