The Chapter describes health system governance as the aggregation of principles and normative values within the political system in which a health system functions. There is increasing appreciation of the central role of governance in influencing all elements of the health system. The five key governance principles or elements in health are strategic vision, participation, accountability, transparency, and rule of law. These, and other, governance principles have an influence strategic planning and decisionmaking, regulation, partnerships, and insurance in health. Multisectoral governance in health involves government and non-government agencies to address multidimensional challenges of differing levels of complexity across multiple sectors. Ministries of health need to assume new responsibilities in the 21st century and adopt roles that include – de jure governance processes, preparation for and response to change in context, relationship management, and values management. More work is needed to delineate the scope and influence on all health system functions, assessment tools and monitoring indicators, and to develop interventions for improving governance of the health system.