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Corruption in public health 121experiment in India using cameras to record teacher attendance,which are tied to compensation bonuses resulted in a dramaticimprovement in delinquent behavior (Banerjee and Duflo, 2004). Itmay be that voice has less weight in influencing behavior than moreremunerative approaches combined with air tight monitoring. Ascellular phones become cheaper and more functional in rural areasphotos sent electronically offer another possible alternative meansof monitoring progress at the local level.While voice matters in many service delivery instances, its rolein health seems to be less straightforward. The specialized nature ofmedicine, the heterogeneous products of the sector and the statusof physicians in most societies complicates oversight by communities,and voting is a relatively blunt instrument for influencing thequality and responsiveness of health services.ConclusionsThe review of country evidence and the examination of the crosscountryfactors that influence performance (and to some extentoutcomes) in health care suggest that governance plays an importantrole. If the health system is not governed well, health workersare absent, patients pay illegal fees, and basic inputs are stolenwithout any consequences for those who mismanage or corrupt thesystem, performance of health services will be poor and populationhealth will suffer.Many health systems rely on anecdotal evidence to guide policy.What this paper has attempted to do is provide the evidence andoutline the major challenges facing health systems, dealing withissues typically ignored or unaddressed. Better country level datacan help in diagnosing the problem and some of the experimentshere may offer possible solutions.The second conclusion is that the returns to health investmentsmay be very low where governance is not addressed. Even with atime lag, investments such as those seen in Uganda, DominicanRepublic and Ethiopia, countries for which detailed data exist, will