more homogenous villages, underlining the importance of supplementing corruption perception measures with more objective ones.

Another approach to capturing perceptions of health sector institutions and performance is patient satisfaction surveys at exit. Satisfaction surveys complement evidence on perceptions of and experience with corruption and public health service delivery performance. Recent survey data from Indonesia has been used to examine whether patient satisfaction surveys can guide policy. The findings suggest that perceptions data are not as useful for direct interpretation for policy as they are for providing insights to policymakers on the priorities of citizens, and on the acceptability and impact of specific reforms such as decentralization (Dasgupta, Narayan, and Skoufias 2009). This is broadly consistent with our views on corruption surveys and their usefulness to the policy debate on health.

Patient satisfaction surveys on hospital performance suggest that greater efficiency improves perceived quality, which may indeed reflect reality since greater efficiency is associated with shorter wait times, greater availability of inputs and overall better organization. In Central America, studies in two countries have examined the link between efficiency and patient satisfaction. In Panama, patients reported much higher satisfaction with the most efficient hospital that contracted out all services (shorter lengths of stay, lower unit costs, and highest productivity for surgery) as compared to two traditional, publicly staffed and managed facilities. In Guatemala, low income, rural patients preferred the more efficient contracted NGO services to those of the government (as measured by performance in delivering immunizations, prenatal care and micronutrients) (La Forgia 2005).

High scores on perceived corruption, and low scores on perceived institutional quality and performance all provide red flags and indicate the need to assess possible corruption and shortcomings in service delivery and financing. The objective is to use perception indicators to identify areas in the health sector where governance is poor, and use more detailed information to guide the design of public health policy, programs and projects.

# **8. Conclusions**

The role of good governance in raising health service delivery performance is important and provides a useful entry point for discussions of policy, programs, and implementation. Considerable work exists on how to design sound health service delivery programs – quality of inputs and budget and financial management for example. Much of that knowledge informs the countries’ health agendas. However, the challenge of translating those concepts and actions into functioning and effective health systems is a harder and more complicated step. It moves into the realm of political economy to align the interests of stakeholders and ensure that they face the appropriate incentives and accountabilites to perform as intended.

The gap between good ideas and evidence-based programs on the one hand, and health performance and outcomes on the other, is often significant. The governance agenda focuses on the elements of implementation, the factors that drive performance and make 58