Insufficient attention has been paid to understanding what determines the performance of health workers. The paper describe performance problems identified by both health users and health workers participating in the focus group discussions, including absenteeism and shirking, pilfering drugs and materials, informal health care provision and illicit charging, and corruption.

The overall message emerging from our findings is the need for a radical revision of human resource policies. The findings show that health workers respond strategically and purposively to policy and institutional changes, thus questioning the old assumption that health workers are passive actors, inherently competent and motivated to serve the public. Rather, health workers should be considered as economic actors, with clear preferences and making informed trade-offs. To design policies that are based on this approach, a deeper understanding is needed of how health workers make constrained choices, both in their career and in their day to day professional activities. This paper raises a multitude of topics on which further insights are needed.