characteristics of the managers, the systems they use to manage their key inputs, community support, competition, etc. Angeles and others (1999) address related issues in Paraguay by comparing performance (costs) before and after decentralization. A recent health facility survey in Uganda (Lindel6w, Reinikka, and Svensson 2001; Reinikka and Svensson 2000a) provide a detailed description of the complex relationships between facilities and the district administration. In this case, data concerning financing, support and supply systems, and supervision arrangements were collected both through interviews with both facility staff and district administrators. Related to this approach, public expenditure tracking studies have been implemented in a number of countries. Although the focus of these surveys has varied, the general principle has been to collect data on resource flows from central level to the service delivery unit, as well as on institutional arrangements and characteristics. Depending on the context and survey design, this permits not only an assessment of whether actual distribution is consistent with intended allocations, but also on how capacity and system weaknesses, information asymmetries, and local capture can impact on the budget execution process.41 These examples represent attempts to understand better what factors explain observed differences in performance by trying to measure variation in the institutional and organizational environment. They demonstrate the value in trying to look beyond the facility, but also illustrate the considerable conceptual and measurement challenges involved in moving this agenda forward.

RV. How Facefty Daft Haave Beeimn Used

# _lPlsanning and bdgefin_

Planning and budgeting in the health sector concerns decisions about the use of resources in the future - for example, in respect of mix of services or the location and means of provision. Although an inherently political process, information is a fundamental input in all the stages of planning and budgeting, including situation analysis, priority-setting, option appraisal, programming, implementation, and monitoring and evaluation. Much of this information will be generated by routing health information system. However, facility surveys can provide valuable non-routine information to support decision making.

First, facility surveys can provide a detailed picture of resource availability and adequacy and costs at facility level. The premise in assessing "resource adequacy" is that a certain range, quantity and quality of inputs is required in order to provide the intended service package. In this sense, resource or input adequacy can be assessed by analyzing how resource or input availability relates to resource requirements. The resource requirements are a function of the package of services that the respective facility should be delivering, as well as to the number of clients. Hence, in order to make a meaningful assessment of resource adequacy, a careful estimate must be made for each type of input on the basis of information about the service range and the activity level of the facility in question. For example, an assessment of staff adequacy may be based on a minimum standard for any facility, and on the patient load for staff (Hanson and Gilson 1996). Similarly, there are established methods for estimating drug requirements (WHO 1988). In addition to looking at specific inputs,

> 41 Evidence from PETSs are discussed below.

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