# **Box 2: Authority, Information and Motivation Go Together**

A series of studies in Europe looked explicitly at the role of setting targets in national health policies within a scheme of good governance (Wismar et al 2006). Such targets “are viewed as a means of defining and setting priorities, creating high-level political and administrative commitment to particular outputs, and providing a basis for follow-up and evaluation.” (European Observatory 2006).

Targets can play an important role in defining, generating and collecting useful information for governing the health sector. However, without concomitant changes in authority and motivation, it is not clear what impact targets can have.

England‟s experience with setting health service targets in the mid-1990s was combined with changes in authority and motivation. For one thing, the National Health Service‟s targets were defined in terms of outcomes rather than operational activities. In addition, these targets were introduced with a range of associated financial incentives (motivation) and increased autonomy (authority). Performance on targeted measures of care improved in England compared to Scotland and Wales where such policies were not implemented and even though spending levels are lower in England.

The case study in Hungary demonstrated how target-setting has been accompanied by improved data collection over a 10-year period, including the ability to disaggregate health status data by important social and geographical categories. An important advance in this process came with the coordination of data collection between the country‟s national statistical office and its national public health system. While data collection and reporting continued to improve, it was not possible to demonstrate any impact on health policy, health service performance, or health outcomes. While the use of such data in national policy debates may eventually have some impact, this case suggests that efforts to improve information without accompanying changes in authority and motivation may not bear the desired results.

Source: European Observatory 2006.

In light of this definition of completeness for governance determinants, the share of private sector contracting is not a very complete measure. It can still be useful as a proxy for efforts to incorporate the private sector in publicly-financed service provision, but it is only indicative of what the underlying theory suggests. Rather, a series of questions would need to be answered regarding the authority of those who do the contracting (e.g. what discretion they have to issue contracts, what rules circumscribe their discretion); the information that is collected and transmitted (e.g. does the contractor provide administrative information on services provided or does an independent agent verify outputs?); and the motivation for fulfilling contractual obligations (e.g. what are the consequences of success or failure in delivering contracted services?).

Using the concepts of authority, information and motivation is useful for developing measures of governance determinants in several ways. First, if a variable does not have some bearing on authority, information, or motivation, it is not likely to tell us much ______________________________________________________________________________________

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