revenues increased sharply. The combined effect of a transparent system tying earnings to activity, sanctions for inappropriate behavior, and provision of professional opportunities, together changed the performance of the hospital. Ferreting out the marginal contribution of any of the reforms is difficult but the success of the effort in eliminating informal payments suggests that such efforts can improve performance in health care delivery while at the same time curbing corrupt practices.

## _Voice and informal payments_

Evidence on the effect of voice on informal payments is limited. A study of 30 municipal hospitals in Bolivia carried out in 1998 (Gray-Molina et al. 2001). The empirical analysis suggested that voice as measured by citizen health board participation, was significantly associated with lower informal payments.<sup>24</sup> However, “one complication is that voice is not sufficient for accountability; it may lead to answerability but it does not necessarily lead to enforceability” (WDR 2004: 79), and without knowledge of the exact role of communities on health boards (for example, did they have the authority to sanction providers charging informally) it is not possible to determine whether voice alone, or combined with authority, was responsible for the lower informal payments.

# **7. Corruption Perceptions**

As noted in the previous section, corruption reflects a breakdown in good governance and the undermining of service provision. Indeed, corruption brings into question the viability of the governance process summarized in Figure 1, and suggests that accountability of service providers is either not enforced or non-existent. Surveys that reveal corruption in the health sector provide feedback on how public health care delivery is perceived, although they cannot offer guidance on specific areas for policy or program intervention. The ability of government to deliver on its commitments in the sector is severely compromised where corruption is endemic. Corruption perceptions complement the performance indicators discussed above and highlight the extent to which attention needs to be focused on curbing illegal practices. The concepts in Box 1 apply here, but reaching acceptable performance where corruption is concerned requires considerably more effort since corruption tends to be invisible and difficult to measure, undermines incentives, and reflects a lack of authority and accountability. Thus, perceptions of corruption are useful for diagnosis and tracking progress over time but need to be complemented by more precise measures to identify levers that can help raise performance.

Perceptions of the health sector and of health service delivery provide a guide to how public services are performing. While perceptions of actual performance or corruption are not completely accurate, they can affect the behavior of both providers and patients. The ability to cover households as well as providers and the private sector make perception surveys useful. They also signal how well public investments in the sector

> 24 The availability of private health care options was also significantly correlated with lower informal payments but the effect was smaller than for voice.

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