and its goals, willingness to exert effort on behalf of the organization, and general job satisfaction.<sup>9</sup>

# Links between provAiders

Another potential motivation for health facility surveys is to examine the interactions between providers. This can include the interactions between different levels within the public system, and the interactions between public and private providers. In OECD countries, the impact of competition on provider behavior has received attention in recent years. For example, Propper (1996) and Propper, Wilson, and Soderlund (1998) explore the effects of competition on prices in the NHS hospital sector in the United Kingdom. Soderlund and others (1997) explore the effects of competition between hospitals on hospital costs (rather than prices). Some work on competition and strategic interaction in the health care market has also been carried out in the US. For example, the Center for the Study of Health System Changel' has carried out a number of "Community Tracking Studies", some of which address these issues. Similar research, which could clearly benefit from health facility surveys, appears to be very limited in the context of developing countries."

# Government-prTovdeir linkages

> In other cases, health facility surveys have been undertaken to examine the interface

> between government and providers. The Public Expenditure Tracking Surveys (PETSs), for

> example, have been motivated by a desire to be able to account better for the flows of public expenditures from central government to regions and districts and thence to providers in the

> periphery. These studies hence relate to recent research concerning the link between public

> spending and health outcomes. Cross-country evidence suggests that total public spending on

> health has had much less impact on average health status than one might expect (for a review,

> see Filmer, Hammer, and Pritchett 2000). Tracking surveys and related studies have argued that the negligible effect from social sector spending to human development outcomes is

> likely to reflect problems of _identification,_ broadly defined. In other words, more spending

> does not necessarily imply more or better public services (Pritchett 1996, Reinikka 2001, and Reinikka and Svensson 2001). From the supply side one can identify two general explanations. First, there may be low efficacy in the transfer of funds within the public sector; for example, leakage of funds may prevent spending from reaching the intended frontline

> service provider (for instance, the health unit). Second, there may be low efficiency in the

> production of frontline goods and services (even if funds reach the frontline provider).

The need for this type of tool has increased in recent years, in the wake of debtreduction initiatives and a move towards sector and budget support under a "country-owned"

> **9** See, e.g., Bennet et **al.** (2000). See also Mowday and Steers (1979) for an early approach. This line of investigation can also take a more clinical perspective, by looking at the determinants of health worker performance in the management of

> cases. Some of this research has highlighted the important role that caregivers and the "community" can have on, e.g., prescribing practices (Paredes and others 1996; Rowe and others 2001).

> 10 http://www.hschange.org/.

> X l There is some evidence on the link between providers in developing countnes. For example, Gertler and Molyneaux (1997) report an increase in fees in private sector providers in response to the demand effect of an increase In user fees in public facilities. However, in general, the surveys are not explicitly designed to address these issues.

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