_I had the following experience. There was a pregnant lady who went for treatment. All the health workers were afraid to touch the woman and it was us who were helping her to move around. There is great fear and health workers are not willing to touch the clothes of some patients, let alone their body, even if wearing gloves; they do not trust the gloves._

## User in Addis Ababa

The concerns of health workers about HIV/AIDS risks are important in their own right, but they also have implications for the labor market. Health workers speak of a growing desire to steer their career away from clinical activities towards public health or administration. Some say that their move to the private sector is motivated by a concern with HIV/AIDS, as lower patient turn-over and better protective material and procedures lead to a lower risk of infection. New candidates may ultimately choose to stay away from the profession to avoid the risk of contracting HIV/AIDS.

_Many health workers who originally wanted to do clinical work now choose public health. Surgical training is more risky, while preventive care is seen as a relatively safer area._ Physician/health officer in Addis Ababa _I have a son who used to be very interested in joining the medical profession. Last year he got straight A’s in school but preferred to join another profession. His reason was that he had observed the risk his parents are exposed to—we are both working in the health sector... Everyday my 9 year old daughter asks me how I spent my day. She asks me ‘did you have any patient that bled? If so, please wash your hands with hot water and change your clothes.’_ Health assistant in a provincial town

# **4. SUMMARY AND CONCLUSION**

This paper reports findings from focus group discussions with health workers and users of health services in Ethiopia. The aim of the discussions is to generate insights into the nature and sources of performance problems of health workers, and the perspectives of health workers on career and labor market issues. In the first part of the paper we describe performance problems identified by both health users and health workers participating in the discussions. In the second part we present four structural reasons why performance problems arise, and how they relate to human resource policies.

The group discussions identify a number of problems, including absenteeism and shirking, pilfering drugs and materials, informal health care provision, illicit charging, and corruption. These problems have been documented in other studies from Ethiopia and elsewhere. However, in contrast to much previous work, the focus group discussions provide detailed insight into why the problems arise. The participants make clear that the problems are rooted in the ongoing transition from a command-and-control health sector, to a more pluralistic system. In this transition, human resource policies have not kept up with new realities. An inadequate policy and regulatory framework, combined with weak enforcement, has created new opportunities and altered incentives, while at the same time contributing to an erosion of trust and professional norms among health workers. On top of these health system 14