systems for health care professionals. The other two governance determinants that they mention are payment and accountability mechanisms for health care professionals and institutional health care providers – determinants that have demonstrated effects in the health care literature but which have never been measured on a system-wide basis (e.g., What share of payments to doctors are paid as wages, fee-for-service and capitations?).

As noted earlier, choosing which governance determinants to measure requires beginning with a set of hypotheses about a particular organization and so we will continue to focus on direct public health care provision. Reviewing WHO (2008), Lewis and Pettersson (2009) and other literature on governance of public health care provision in developing countries reveals at least five broad categories of hypotheses related to (1) ownership, (2) decentralization, (3) formal procedures, (4) stakeholder participation, and (5) contextual factors. From these governance determinants, it is then possible to derive a number of associated governance performance measures.

# _Ownership_

Ownership is a governance factor that has been analyzed extensively in the corporate governance literature and has entered health sector discussions primarily in debating the relative merits of private and public forms of health care service provision. Here we are considering its role within publicly financed health care services. When the public sector contracts and manages private health care services, the contractual relationship generally divides authority between responsibilities of the payer and payee, specifies information and how it will be used, and includes explicit incentives for fulfilling contract terms. By contrast, when the public sector directly manages its own health care services, public regulations and procedures may or may not explicitly establish clear lines of authority, information requirements and motivations for performance.

This characterization is, however, merely a hypothesis. It is reasonable to assume that a private health care provider whose capital is at risk will respond to financial incentives or competitors by raising productivity and quality, but providers may have a number of other ways to protect their incomes or not respond to incentives at all. Thus, we have reasons to expect that different forms of ownership will affect health care service providers‟ behaviors but still need to test the question empirically.

A first step to analyzing ownership as a governance determinant in public health care provision would be to measure:

- the share of public health care service expenditures used to contract private health care providers, and

- the share of publicly-financed consultations provided by private health care providers.

These measures would give a rough sense of the scale of public contracting in a given public health care service and could be compared with other systems to assess their performance. It is also necessary to distinguish between private health care providers that operate commercially, for-profit, and those which operate as non-profit institutions ______________________________________________________________________________________

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