study in Zimbabwe found that the top reason given for leaving the public health sector was the lack of equipment and medical supplies together with a poor work environment (USAID 2003). Similarly, in Ethiopia health workers cited a good work environment where drugs and medical supplies necessary to treat patients are available as one of the most important factors in raising performance (Lindelöw, Serneels, and Lemma 2005).

A lack of supervisor feedback and poor management are frequently reported by health workers as reasons for under-performance. In a 2007 study of mid-level professionals at four rural mission hospitals in Malawi, health workers expressed concern about management’s capacity, erratic implementation of policies, and absence of supervision (Bradley and McAuliffe 2009). In addition, of those interviewed, only 17 percent had written job descriptions but these often did not correspond to actual duties, and staff were frequently required to carry out tasks beyond their training and experience. While pay levels remained a concern, the lack of physical resources and better management were considered much more important for performance.

Opportunities to advance professionally and receive further education and training also emerge as important if sometimes overlooked factors in motivating health workers (Willis-Shattuck et al. 2008), however, the evidence is very limited. In Malawi, midlevel health workers in focus groups reported that one of the major reasons for their low performance was the lack of opportunities for career development and further education (Bradley and McAuliffe 2009). In a study of Cameroon and Ghana, 5-20 percent of skilled public sector health workers cited the main reason for leaving their country as the lack of professional training opportunities (Lehmann, Dieleman, and Martineau 2008).

The limited available evidence suggests that pay may not be as important a determinant of performance as the ability to hold health workers accountable for their performance. A study of Venezuelan public hospitals found that higher wages for purchasing managers were not associated with less corruption suggesting that higher pay alone does not necessarily control corrupt practices (Jaén and Paravisini 2001). Health workers in Uganda employed by non-profit, faith-based health facilities succeed in delivering higher quality health services than public sector facilities, even though the former pay similar, below-market salaries to their staff, and employ staff with similar levels of training (Reinikka and Svensson 2007). Evidence for Tanzania, Guatemala, and Honduras similarly finds that, on average, health workers in NGO health facilities provide better care than those in public sector facilities (Leonard and Masatu 2007; La Forgia 2005). Many of the reasons underlying this disparity in performance appear to be associated with differences in non-financial incentives, management authority to discipline poorly performing health workers, and ability to reward good performance, between public and NGO run facilities. Contracting of NGO management services dramatically improved quality (e.g. lower infection rates), efficiency, (lower per capita cost), and patient satisfaction in a sample of Brazilian hospitals (La Forgia and Couttolenc 2008).

Evidence from vignettes on physician performance from seven neighborhoods in Delhi find that physicians do less than what they could given their knowledge; physicians who know more do more; and that the gap between physicians’ knowledge and what they do 36