# **_Health Facilities_**

**Facility provider payments,** that is, how health service providers are paid, is one of the most critical incentives for performance. Payment can be in the form of a base wage, wages with bonuses, earnings linked to production or performance, or lump sum payments for work either to be undertaken (e.g. pre-paid care) or that has been completed (e.g. pay for production or performance), or some combinations of these. It is an area that receives relatively little attention and most systems are straight wage-based arrangements. Simple hospital efficiency measures are among the easiest to collect and are important indicators of hospital performance. Average length of stay defined as the total number of days in inpatient or acute care institutions divided by the number of discharges or admissions, and bed occupancy rates defined as the percentage of hospital beds occupied over a given period of time provide a summary of performance and are important indicators of hospital performance. However, despite their usefulness these data are not routinely collected or used. Patient satisfaction ratings can provide further information though they are inadequate on their own.

# **_Informal Payments_**

**Under-the-table payments** to individuals are charges for health services or supplies meant to be provided free of charge, or that are paid informally to public health care providers to obtain specific favors or even basic services. Types of informal payments include but are not restricted to fees for treatment, drugs, expedited or extra services, and as an insurance to receive better care in the future from physicians, nurses, and other health workers. Although informal payments may provide incentives for providers to be on site, they introduce questionable practices that undermine the intent of collective financing and permits corrupt practices to flourish. Informal payments are often measured as the fraction of survey respondents reporting that they made payments to a public health entity for services intended to be free of charge. Household surveys, health facility exit surveys, and perception surveys of citizens and public officials are the most common sources of this information. More detailed evidence can be collected on the average value of payments made, who requested/received them, and for what specific service. Data on informal payments in health are relatively scarce but are increasingly being added to household surveys.

# **_Corruption Perceptions_**

In many countries the health sectors is perceived as corrupt and reflects to some extent the overall quality of institutions as it determines the ability to execute services. Such perceptions complement the measures discussed above. Aggregate measures of corruption and institutional quality are difficult to create given the breadth of relevant factors. Kauffman, Kraay, and Mastruzzi (2007) have developed general indices of corruption that integrate the results from multiple perceptions surveys (see Annex 1).

Health sector specific indicators of corruption and institutional quality exist. The World Bank’s Country Program and Institutional Assessment (CPIA) captures **institutional quality** and provides breakdowns by sector but includes a broad range of issues, some of which affect performance, and others that do not. **Perceptions of corruption** in publicly financed health care systems are generally reported by one of the following: the fraction of citizens, business people, or public officials perceiving corruption in the sector, or respondents’ ranking of corruption in the health sector relative to other sectors. While these indicators are imperfect they complement the objective indicators discussed above. Perceptions also matter as people may change their health seeking behavior based on these even if incorrect, and where perceptions are largely 11