The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.

Background: Improving process quality remains a significant opportunity to improve outcomes in many low resource settings, however a continued focus on improving knowledge through increased training has proven ineffective. In this context, we introduce a methodology for diagnosing the causes of low quality care, including not only low knowledge, but also infrastructure and material as well as motivation.Methods: The Three-Gap Model uses four measures of performance — target performance, actual performance, the capacity to perform and the knowledge to perform — to define three gaps for each health worker: the gap between target performance and what they have the knowledge to do (the know gap); the gap between their knowledge and their capacity to perform (the know-can gap) and the gap between their capacity and what they actually do (the can-do gap).Results: Using data on pediatric care from hospitals in Liberia, we illustrate how the model can be used to investigate the potential for improvements in the quality of care from several possible policy interventionsConclusions: The analysis of the relationships between these gaps across health workers in a health system help to paint a better picture of the determinants of performance and can assist policymakers in choosing relevant policies to improve health worker performance.

The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.

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