opening public agencies to stakeholder participation can distort decisions in favor of particular groups. Citizen representatives can influence decisions to their own benefit in ways that may be detrimental to others in the community. Similarly, union representatives might defend workers against legitimate disciplinary actions or lobby for benefits to their members even when they reduce the quality or quantity of available care. Professional associations can use their involvement in policy decisions to restrict the number of practitioners and boost incomes even when this might not be in the social interest.

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

- share of hiring decision bodies that include union representatives,

- share of facilities with citizen representatives on governing or advisory boards, and

- share of planning boards with representatives of planning associations.

These measures would give an indication of whether these three key stakeholders play a significant role in public health care provision. Nevertheless, they are only approximations and might miss a large number of alternative ways that stakeholders can participate. For example, unions might not have a formal role in hiring decisions, but they may exert public pressure effectively through strikes or political lobbying; citizens might be regularly interviewed or surveyed for feedback on service quality; or professional associations might not need formal representation to influence policy decisions. Therefore, a fuller characterization of stakeholder participation might require measurements like:

- dissemination of public expenditure data to the public,

- public advertising of jobs, selection criteria and outcomes of hiring decisions,

- share of representative bodies that file minutes, and

- numbers of meetings per year of representative bodies.

Additional indicators of stakeholder participation that have been proposed in other studies and that could be considered include:

- Active hospital health boards as indicated by number of meetings

- Participation in local health organizing committees

- Institutional arrangements for community and stakeholder participation

- number of regional coordinating meetings that are held each year (Ethiopia)

# **_Measuring the context for governance_**

Contextual Factors influence public health care provision in many ways, interacting with the governance determinants described above. Competition from private health care providers can sometimes motivate public health care providers to improve their services. Higher wages in the labor market, and specifically for health care workers, can make it difficult to recruit and retain qualified staff in the public sector. Furthermore, the scale and quality of professional training for health care workers can be an important constraint to public health care services and the general quality of public service institutions, whether courts, police, or public auditors, can influence the performance of public health care institutions.

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