governance within a large state in Brazil has provided evidence useful for policy toward hospital governance throughout that country in ways that are more relevant than if the findings came from comparisons between different countries (see La Forgia and Couttolenc 2008).<sup>6</sup> Comparisons between countries are also useful, but require much more careful consideration of the package of institutional and contextual factors that are likely to support any given governance arrangement. For example, the independence of health insurance institutions can improve performance when it limits undue political interference and can worsen performance when it insulates the institution from accountability for results – the implications of this kind of independence are contingent on interactions with other factors which may vary significantly across countries (Savedoff and Gottret 2008).

Cross-country indicators are easier to identify for governance performance than for governance determinants because the former are more easily defined against an objective standard. For example, an objective standard for unexcused absences might be “below 3%” but a similar objective standard cannot be defined for the degree of decision-making autonomy for health facilities. A recent effort to select health governance indicators (Lewis and Pettersson 2009) implicitly confirms this observation by mostly citing crosscountry studies when proposing performance measures such as informal payments (Lewis 2006) and absenteeism (Chaudhury et al 2006), but citing case studies when discussing determinants such as community monitoring (Bjorkman and Svensson 2007), performance pay (Solon et al 2009), and autonomy (PATHS 2008). The evidence base for assessing governance determinants relies almost entirely on within-country comparisons – either between different governance arrangements or assessing changes over time that can be attributed to a particular governance reform.

# **_Choosing units of analysis_**

Regardless of whether we are looking at within or between country governance measures, it is necessary to identify which units of analysis will be addressed. Health sectors vary so much around the world that it is difficult to make comparisons, let alone conduct research, without defining the organization or system that is being analyzed.

Countries are the unit of analysis in many initiatives, including the Governance Development Initiative and WHO‟s _2000 World Health Report_ . Interpreting differences between countries, however, is complicated by the myriad institutional arrangements that characterize their health systems. Leading approaches for classifying countries may distinguish their health systems _functionally_ – separately analyzing stewardship, resource generation, financing, and provision (WHO 2000) – or in terms of _policy instruments_ – such as health system financing, provider payment, organization, regulation, and social marketing (Roberts et al 2004). Others try to classify them by _institutional arrangements_ , for example, distinguishing those with social health insurance from those with national health services. Another approach is to focus on _roles and accountability_ , identifying actors and how they interact with one another (World Bank 2004, Brinkerhoff and

> 6 Savedoff 1998 takes a similar approach, using within-country institutional comparisons.

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