Bossert 2008). The latter approach is more consistent with our definition of governance. In fact, by focusing on roles and accountability, it is possible to move away from discussing aggregate systems and see that distinct parts of the health system are governed in significantly different ways, particularly between those that rely principally on political and market processes (Emmanuel and Emmanuel 1996).

Questions about governance, then, can be raised in any part of the health sector. Among health _system_ services, like assuring the quality of health care provision or addressing environmental health risks, some countries rely more on government agencies, while others rely more upon professional associations or private rating agencies. For health _care_ services, like hospital care, some countries rely primarily on government-owned and operated facilities, while others rely on private non-profit organizations, private for-profit firms, or hybrids (e.g. government-owned but privately managed facilities).

Choosing an appropriate unit of analysis is critical for interpreting measurements. First, interpretation will be facilitated by selecting units for which we have behavioral models or hypotheses. This suggests either choosing organizations that have coherent decisionmaking structures such as health facilities, insurance firms, and public agencies or choosing segments of the health sector that can be characterized as markets (e.g. private health care providers).

Relevance is another criterion for selecting units of analysis. An initiative to measure governance across countries could give greater weight to those health care services used by more people – in some countries this would imply giving greater emphasis to public providers while in other countries the emphasis would go to private providers. This would be an appropriate choice if the goal is to measure how overall population care is affected by national policy. An alternative approach might aim instead at understanding how a particular governance determinant affects performance, in which case, the share of provision is less relevant than the amount of knowledge that can be learned from analyzing that particular organization or segment of the health sector.

It is beyond this paper to propose governance measurements for all potential units of analysis. Therefore, the remainder of this note focuses on governance of direct public <u>provision of health care services because the experience of seeking governance indicators</u> for this segment is more extensive than any other part of the health system. This is not meant to imply that it is either the most important or even the central feature of a health care system. In fact, in many countries, direct public provision is quite marginal relative to social insurance plans or private providers. Similar exercises could be undertaken for the governance of public health insurance organizations (Savedoff and Gottret 2008), non-governmental or commercial health care providers, and public health regulation (e.g. of medical and pharmaceutical supplies, medical education).

# **4. What to Measure?**

A complete data collection effort on governance in the health sector requires gathering a range of standard information in addition to specific governance measures. Data on health service inputs and demographics are necessary for judging the constraints and ______________________________________________________________________________________

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