**In-kind supply leakages** are common in many health systems. Given the importance of in-kind drugs and consumables received by hospitals and clinics in lieu of funds to purchase these inputs the management of these goods from purchase to the end-user and at the point of use is central to good governance and effective service delivery. There are notable differences between drugs and medical supplies, with the former being a more variable and portable commodity, and certainly, more valuable. It is very difficult to directly assess the effectiveness of procurement processes, warehousing, and management. One very useful indicator sometimes available, which captures procurement mismanagement or potential fraud is the difference in price paid for similar medical supplies/equipment across health facilities that cannot be explained by other factors. Assessment of the types of procurement processes and warehousing systems in use can also yield information on potential governance problems.

# **_Individual Providers_**

Medical staff claims a large proportion of government budgets and pose a significant management challenge given the difficulty of allocating and supervising a large cadre of public workers. The indicators discussed below reflect the need for assessment of the hiring and supervision process. It is arguably more difficult to assess health worker performance.

**Job purchasing** refers to the purchasing of public positions, which bypasses hiring based on objective criteria. Such indicators are typically based on perceptions of the extent to which personnel hiring decisions are influenced by illegal payments, measured as the share of respondents who regard job purchasing to be common or very common, and in rare cases, the “cost” of a particular job. These perceptions often differ depending on the position of the respondent in the health system hierarchy making it important to use a cross section of individuals. Related to the purchasing of posts are **nepotism and favoritism** in hiring. The former is defined as the illegal preference given to a relative, the latter to any person, without consideration of relative merit or other objective factors. Mainly anecdotal and occasionally some perception-based evidence is available on the prevalence of nepotism and favoritism.

The existence and enforcement of **physician credentials** are important for health service provision. Although second best, having and enforcing licensing examinations that ensure basic knowledge, and require continuing education or refresher courses, indicate that clinicians have adequate clinical knowledge, which in turn influences their performance.

**Health worker absenteeism** captures the absence of providers at their location of employment during contracted hours. It can be defined as the proportion of physicians or nurses who are contracted to be working on site during the period(s) of observation but who are not present. Provider absence is a measure of underperformance of health service providers and, depending on the reason for absence, fraud associated with unexcused absences. Physician and nurse absentee data can be collected by various means: surprise visits, direct observation at health clinics or hospitals, attendance records kept by health facility administrators, or other methods that document actual and expected attendance (see Chaudhury et al. 2006; Lewis 2006; and Halsey and Vegas 2008 for overviews).

**Health worker performance** is notoriously difficult to reflect in a single indicator, especially since an individual’s performance depends not only on training, skill, and effort but also on that of co-workers, complementary inputs, and patient behavior. Some available indicators include adherence to treatment protocols and patient satisfaction ratings. Indirect measures including examination of the incentives and accountability mechanisms that providers face further help explain provider performance and are useful for designing improved arrangements.

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