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Corruption in public health 67
where governance represents some measure of institutional quality
or governance. Increases in labor and capital can improve outcomes,
but G may dampen or enhance these effects.
Labor encompasses management, physicians, nurses, other
medical staff. Capital is made up of infrastructure, equipment and
other fixed assets, as well as financing: government transfers for
local purchase, in-kind provision of drugs and supplies, and third
party and consumer payments. The functioning of the public system
is determined by the incentives facing the actors in the system, the
manner in which inputs are managed and the accountability
imbedded in the incentive structure.
While straightforward in concept, the production function itself
is far from simple and the market failures identified above plague
both private and public systems (i.e., principal agent and information
asymmetry problems), which undermine incentives and limit
the extent of accountability. Accountability can be to a central government,
local government, communities or patients, or some combination
of these.
Measures to assess performance of public systems are lacking.
Infant mortality, a readily available and commonly used measure of
outcome, better reflects more aggregate measures of well being
(such as income and education) rather than the health system,
although once the IMR drops below 25–30 per 1000 it better
captures the quality and extent of medical interventions. Monitoring
basic functions such as hiring, existence of appropriate policies,
purchase of drugs, building of clinics and procurement practices,
can be easily accomplished but only represents the identification of
inputs.
The more complex and important measures of health system performance
are such things as staff output, drug and medical supply
availability, regularity of funding transfers, state of physical infrastructure,
inventory and functionality of equipment, and existence
of patient records, factors which reflect whether health systems are
meeting minimal efficiency and quality standards. Utilization data
and patient satisfaction offer complementary metrics of health