_99affRercejgoins cand 1bevav or_ Notwithstanding the obvious importance of health worker behavior and motivation for both quality and efficiency, there are currently few examples of surveys that focus on<sup>these</sup> issues.<sup>36</sup> McPake and others (1999) comprise an important exception. They collect data on the informal economic activities of health workers in Uganda, where informal economic activities are defined as "...activities which yield income which fall outside<sup>official dutiesand</sup> earnings." On the basis of this definition, the study focuses primarily on drug and user charge leakage.<sup>37</sup> The survey team spent a full month in a small sample of facilities in order<sup>to permit</sup> health workers to get used to their presence. They use wide range of survey instruments, explicitly designed to address the sensitive issues involved. Structured interviews were carried out with both health workers and community members. In addition, key informant interviews and focal group discussions were perforrned to probe certain issues in greater detail. Finally, detailed record reviews and checklist instruments were administered at different<sup>stages to</sup> collect information on daily patient attendance, drug stocks and use, number of prescriptions, user charge and revenue information, expenditures financed by user charges, etc. Through<sup>the</sup> "triangulation" of information from different sources, it was possible to verify and crosscheck information on construct estimates of overcharging and the divergence between the amounts of drugs supplied to the facility and actually prescribed.

From a different perspective, Bennet, Gzirishvili, and Kanfer (2000) collect subjective data on health worker motivation and performance in hospitals in Georgia. Extensive research on this issue has been carried out in developed countries, in particular in non-health sectors. More recently, efforts have been made to design an appropriate methodology for developing countries (Bennet and Franco 1999; Kanfer 1999). It emphasizes motivational determinants<sup>at</sup> both individual, organizational (work context), and socio-cultural levels. Data are collected through contextual analysis and structured interviews, where individual assessments were designed to assess the determinants and outcomes of motivational processes. Specifically, self-administered questionnaires were completed by a sample of both health workers and supervisors. The questionnaires were based on psychometric scales used for studying<sup>work</sup> motivation in the US, which focus on individual perceptions about themselves, their work environment, and performance.

Both these studies are based on small samples and survey staff in considerable detail. They illustrate the inherent difficulty involved in measuring perceptions, behaviors, or outcomes. This is particularly the case when there are strong rules or norms prescribing or proscribing certain perceptions or behaviors. Yet, both studies point at the potential value of focusing on human resource issues in the health sector, either through in-depth studies and expanded facility surveys.

> 3 6 There is however some recent interest in the behaviour, motivation, and perceptions of public officials in general. See, e.g., Manning et al. (2002).

> 3 7 Drug leakage can arise from recording of ghost patients; recording of prescriptions for real patients that did not actually receive any drugs; removal of drugs from drug store without recording. User charge leakage can arise from nonrecording of revenues, or from a divergence between recorded revenues and expenditures that is not accounted for.

18