mechanisms to hold officials to account. These shortcomings together also prevent effective management as those in charge are not empowered to ensure that performance reaches at least a minimum standard (e.g. that workers come to work or that informal payments are not required to receive care).

# **2. Good Governance in Health Care Delivery: Measuring Performance**

Measuring performance is critical to establishing benchmarks for efficiency, comparing performance across time and providers, and assessing effectiveness of public health expenditure. Accountability hinges on having adequate information about performance in health service delivery, which means having reliable indicators that help policymakers and program administrators improve service delivery. This is an area that has received little attention on the global health agenda, which has remained focused on general outcome indicators such as life expectancy, and infant and maternal mortality. Although helpful for setting strategic health priorities, these measures are infrequently updated and are strongly influenced by factors other than health care provision, making them less desirable metrics for tracking either performance or outcomes of health investments.<sup>5</sup> The incentives and accountabilities depicted in Figure 1 and explained in Box 1 are difficult to measure typically requiring use of proxy indicators. For indicators where there is no direct measure alternatives are required. For example, accountability cannot be captured directly so we rely on examination of arrangements that promote and demonstrate accountability. Having clear rewards and disciplinary actions for under- or non-performing staff and a track record that demonstrates that medical staff are indeed held to account suggests that there is accountability in the system but whether that process persists and expands to other aspects of service delivery is not assured. Thus, there may be accountability but this can only be inferred, not confirmed. Corruption may be easier to quantify but measures tend to be based on perceptions or reported behaviors, which have a large probability of error (see section 7). The performance indicators presented here are only a start and highlight the importance of additional work to develop viable performance measures for health care delivery. Before turning to specific indicators it is important to keep in mind that good governance is simply a means to building sound institutions, in this case in the health sector.

The indicators proposed here are generic enough to be adapted to different settings and can serve as a basis for cross-country and within country comparisons over time, and offer a menu of options. Some require information that can be relatively easily and frequently collected (e.g. type of provider payment system), others demand expensive data collection.<sup>6</sup> Thus, some indicators yield immediate insights into performance (e.g. absenteeism studies), and others, such as large surveys, provide a snapshot of performance that complements other measures of health care delivery performance. The

> 5 Infant mortality in the low income countries is often based on epidemiological models that project changes in infant deaths and other demographic factors based on data from the previous decade making it particularly unsatisfactory for tracking trends in the IMR.

> 6 See Vian (2008) for a discussion of some of these instruments and their applicability to the governance and anti-corruption agenda.

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