《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2000_Health Systems：Improving performance_4 What Resources are Needed?.pdf

The World Health Report 2000 training of doctors often comes under the ministry of education, and there may be private investment in facilities and equipment Capital is the existing stock of productive assets. Trained health workers and mobile clinics, as well as fixed assets, are part of the capital stock of the health system. Investment is any addition to this stock of capital, such as more pharmacists or additional vehicles.The typical productive lifetime of different investments will vary from as little as 1-2 years for certain equipment to 25-30 years or more for buildings and some kinds of professionals Technological progress influences the economic lifetime of a piece of capital: old invest- ments quickly become outdated as new and improved technologies emerge. The way in which assets are managed also affects their lifetime. With proper handling and mainte nance, buildings and vehicles lose their value more slowly. Without care and maintenance, health capital deteriorates rapidly. The planning of maintenance also needs to take the physical environment into account. For example, bad roads reduce the average lifetime of vehicles; so the planning of maintenance, operation and replacement of vehicles should allow for this Human capital can be treated conceptually in the same way as physical capital, with education and training as the key investment tools to adjust the human capital stock and determine the available knowledge and skills (1). Unlike material capital, knowledge does not deteriorate with use. But, like equipment, old skills become obsolete with the advent of new technologies, and human capital needs to be maintained too. Continuing education and on-the-job training are required to keep existing skills in line with technological progress and new knowledge. Human capital is also lost through retirement and death of individuals nvestment also refers, in a broader sense, to any new programme, activity or project. Capital investment costs are all those costs that occur only once(to start up the activity), while the recurrent costs refer to the long-term financial commitment that usually follows from such an investment. If the available medical technology is seen as"capital,", and re search and development as the investment tool to expand the technology frontier and develop new ideas, these concepts may also be applied to diagnostic equipment, medicines and the like Investment is the critical activity for adjusting capital stock and creating new and pro- ductive assets. Such adjustments typically occur gradually over time. Thus, the current physi- cal infrastructure of hospital buildings and facilities in many countries is the product of ar evolution that has taken many years. Among OECD countries, expenditures for invest- ment in buildings and equipment are typically not more than 5% of total annual hea care expenditures and are usually somewhat lower than they were 15 or 20 years ago: cost control has been enforced partly by controlling additions to capital In low income countries, however, there is greater variation. Investment levels can be substantially higher than the OECD figures, especially when physical infrastructure is be ing created or restored with the help of donor agencies. Countries such as Burkina Faso, Cambodia, Kenya, Mali and Mozambique report capital expenditures of between 40% and 50%of the total public health care budget in one or more years(2). A large percentage of the remaining recurrent budget usually pays for health care staff. This means that only a small fraction of the total budget is spent on the maintenance of physical and human capi tal and on consumable inputs, including pharmaceuticals. The balance between invest- ments and other expenditures is more critical in low income countries as there is little room for mistakes. In general, however, very little is known about health investments in low ncome countries, even in the public sector. For the private sector, the available national health accounts estimates often have no data, or present implausibly high ratios of invest-

76 The World Health Report 2000 training of doctors often comes under the ministry of education, and there may be private investment in facilities and equipment. Capital is the existing stock of productive assets. Trained health workers and mobile clinics, as well as fixed assets, are part of the capital stock of the health system. Investment is any addition to this stock of capital, such as more pharmacists or additional vehicles. The typical productive lifetime of different investments will vary from as little as 1–2 years for certain equipment to 25–30 years or more for buildings and some kinds of professionals. Technological progress influences the economic lifetime of a piece of capital: old investments quickly become outdated as new and improved technologies emerge. The way in which assets are managed also affects their lifetime. With proper handling and maintenance, buildings and vehicles lose their value more slowly. Without care and maintenance, health capital deteriorates rapidly. The planning of maintenance also needs to take the physical environment into account. For example, bad roads reduce the average lifetime of vehicles; so the planning of maintenance, operation and replacement of vehicles should allow for this. Human capital can be treated conceptually in the same way as physical capital, with education and training as the key investment tools to adjust the human capital stock and determine the available knowledge and skills (1). Unlike material capital, knowledge does not deteriorate with use. But, like equipment, old skills become obsolete with the advent of new technologies, and human capital needs to be maintained too. Continuing education and on-the-job training are required to keep existing skills in line with technological progress and new knowledge. Human capital is also lost through retirement and death of individuals. Investment also refers, in a broader sense, to any new programme, activity or project. Capital investment costs are all those costs that occur only once (to start up the activity), while the recurrent costs refer to the long-term financial commitment that usually follows from such an investment. If the available medical technology is seen as “capital”, and research and development as the investment tool to expand the technology frontier and develop new ideas, these concepts may also be applied to diagnostic equipment, medicines and the like. Investment is the critical activity for adjusting capital stock and creating new and productive assets. Such adjustments typically occur gradually over time. Thus, the current physical infrastructure of hospital buildings and facilities in many countries is the product of an evolution that has taken many years. Among OECD countries, expenditures for investment in buildings and equipment are typically not more than 5% of total annual health care expenditures and are usually somewhat lower than they were 15 or 20 years ago: cost control has been enforced partly by controlling additions to capital. In low income countries, however, there is greater variation. Investment levels can be substantially higher than the OECD figures, especially when physical infrastructure is being created or restored with the help of donor agencies. Countries such as Burkina Faso, Cambodia, Kenya, Mali and Mozambique report capital expenditures of between 40% and 50% of the total public health care budget in one or more years (2). A large percentage of the remaining recurrent budget usually pays for health care staff. This means that only a small fraction of the total budget is spent on the maintenance of physical and human capital and on consumable inputs, including pharmaceuticals. The balance between investments and other expenditures is more critical in low income countries as there is little room for mistakes. In general, however, very little is known about health investments in low income countries, even in the public sector. For the private sector, the available national health accounts estimates often have no data, or present implausibly high ratios of invest-

What resources are needed? hent to total spending, maintained over many years. Not to know how much is being invested, and in what kinds of inputs, makes it nearly impossible to relate capital decisions to recurrent costs or assure that capital is not wasted or allowed to drain off funds needed for other inputs Even less data are available on the size of annual investments in education and training These investment costs include medical and nursing schools, on-the-job training in differ- ent forms, and clinical research. Many players are involved and investments are often nei ther controlled by a single ministry nor guided by a common purpose. There is reason to believe that the sum of investments in human capital is far greater than investment in physical capital, at least in high income countries. As is the case for investment in physical capital, additions to human capital usually occur slowly over time. The training of a special ist, for example, can take 10 years or more of studies in medical school and on-the-job training. New investments in human capital also have long-term consequences, similar to investments in physical capital. The creation of a cadre of health workers with new skills, for example, will require a long-term investment in new curricula for basic and continuing ducation as well as a long-term commitment to paying their salaries HUMAN RESOURCES ARE VITAL Human resources the different kinds of clinical and non-clinical staff who make each individual and public health intervention happen, are the most important of the health system'sinputs. The performance of health care systems depends ultimately on the knowl dge, skills and motivation of the people responsible for delivering services Furthermore, the human resources bill is usually the biggest single item in the recurrent budget for health. In many countries, two-thirds or more of the total recurrent expendi tures reflect labour costs. But people would not be able to deliver services effectively with out physical capital-hospitals and equipment-and consumables such as medicines, which play an important role in raising the productivity of human resources. Not only is a work- able balance between overall health capital formation and recurrent activities needed, but the three input categories shown in Figure 4.1 should also be in equilibrium. What treatment alternatives should be used for a certain illness or medical condition? Should services be offered at hospitals or primary care facilities? What is the level of skills ind knowledge required to deliver this set of services? These questions have one thing in common. They are concerned with the degree of flexibility that exists in delivering health services,ie the possibility of substitution between one type of input and another, or the substitution of one form of care for another, all the while maintaining a constant level and ality of output. From a societal point of view, such positive substitution to achiev effective delivery of services should be encouraged. a balanced combination of the differ- ent resource inputs will depend on identified health needs, social priorities and people's expectations Health systems are labour intensive and require qualified and experienced staff to func tion well. In addition to a balance between health workers and physical resources, there needs to be a balance between the different types of health promoters and care-givers. It would be an obvious waste of money to recruit physicians to carry out the simplest tasks. As a particular health system input is increased, the value added by each additional unit of input tends to fall (3). For example, where there are too few physicians, the arrival of an- other physician will have a positive effect on health care; but where there are already too tany physicians, an additional physician is more likely to increase costs than improve care

What Resources are Needed? 77 ment to total spending, maintained over many years. Not to know how much is being invested, and in what kinds of inputs, makes it nearly impossible to relate capital decisions to recurrent costs or assure that capital is not wasted or allowed to drain off funds needed for other inputs. Even less data are available on the size of annual investments in education and training. These investment costs include medical and nursing schools, on-the-job training in different forms, and clinical research. Many players are involved and investments are often neither controlled by a single ministry nor guided by a common purpose. There is reason to believe that the sum of investments in human capital is far greater than investment in physical capital, at least in high income countries. As is the case for investment in physical capital, additions to human capital usually occur slowly over time. The training of a specialist, for example, can take 10 years or more of studies in medical school and on-the-job training. New investments in human capital also have long-term consequences, similar to investments in physical capital. The creation of a cadre of health workers with new skills, for example, will require a long-term investment in new curricula for basic and continuing education as well as a long-term commitment to paying their salaries. HUMAN RESOURCES ARE VITAL Human resources, the different kinds of clinical and non-clinical staff who make each individual and public health intervention happen, are the most important of the health system’s inputs. The performance of health care systems depends ultimately on the knowledge, skills and motivation of the people responsible for delivering services. Furthermore, the human resources bill is usually the biggest single item in the recurrent budget for health. In many countries, two-thirds or more of the total recurrent expenditures reflect labour costs. But people would not be able to deliver services effectively without physical capital – hospitals and equipment – and consumables such as medicines, which play an important role in raising the productivity of human resources. Not only is a workable balance between overall health capital formation and recurrent activities needed, but the three input categories shown in Figure 4.1 should also be in equilibrium. What treatment alternatives should be used for a certain illness or medical condition? Should services be offered at hospitals or primary care facilities? What is the level of skills and knowledge required to deliver this set of services? These questions have one thing in common. They are concerned with the degree of flexibility that exists in delivering health services, i.e. the possibility of substitution between one type of input and another, or the substitution of one form of care for another, all the while maintaining a constant level and quality of output. From a societal point of view, such positive substitution to achieve costeffective delivery of services should be encouraged. A balanced combination of the different resource inputs will depend on identified health needs, social priorities and people’s expectations. Health systems are labour intensive and require qualified and experienced staff to function well. In addition to a balance between health workers and physical resources, there needs to be a balance between the different types of health promoters and care-givers. It would be an obvious waste of money to recruit physicians to carry out the simplest tasks. As a particular health system input is increased, the value added by each additional unit of input tends to fall (3). For example, where there are too few physicians, the arrival of another physician will have a positive effect on health care; but where there are already too many physicians, an additional physician is more likely to increase costs than improve care

The World Health Report Some ways of dealing with imbalances among health care providers are outlined in Box 4.1 A health system can have plentiful human resources, with excellent knowledge and ills, but still face impending crisis if future health needs, priorities and available resources are not taken into account. For example, where the education and training for junior doc- tors and nurses functions poorly, or where senior staff lack adequate time and resources to update their knowledge and skills, future shortfalls can be expected. Similarly, a health system with a skewed age distribution among staff towards the point of retirement poses a real problem. Thus, a health care system must balance investments in human capital to cover future needs as well as present demands. Some of the most critical and complex input problems relate to human resources(see Box 4.2) Without functioning facilities, diagnostic equipment, and medicines, it does not matter if the knowledge, skills and staff levels are high. The delivery of services will still be poor.A lack of complementary inputs will also have a negative impact on staff motivation, a factor that influences the capacity of human resources. Motivation, however, depends not only on working conditions. Financial incentives and compensation, i.e. income and other benefits, re also important, as are the overall management of staff and the possibilities for profes sional advancement Inadequate pay and benefits together with poor working conditions ranging from work in conflict zones to inadequate facilities and shortages of essential medicines and consumables-are frequently mentioned in less developed countries as the most pressing problems facing the health care workforce(4). In some countries, for example Bangladesh and Egypt, a clear majority of all publicly employed physicians see private paying patients to supplement income from their regular jobs In Kazakhstan, "informal payments"are estimated to add 30% to the national health care bill (5). possibilities for doctors to work privately in public institutions are being offered in some countries to neutralize an ongoing brain drain of qualified staff from the public sector. This strategy is considered successful in Bahrain, but experiences from Ghana and Nepal show that such incentives can lead to the diversion of scarce resources from public services and can induce professionals to engage in independent private practice(6) r People, as thinking creatures, are very different from machines and human capital can- be managed in the same way as physical capital. First of all, human resources, and in Box 4.1 Substitution among human resources A large number of countries face cians. While limitin ons to may cost three times more than that and function may demand the an overall shortage of physicians. specialist training and changing in. of a nurse. As a result, training of creation of new cadres In Nepal Other countries that are following temship programmes is a long-term more nurses as well as other health an educational programme al- a long-term strategy to shift re- strategy to balance the professional professionals may be a cost-effec lowed health assistants and other sources to primary care find that distribution of physicians, the tive substitute for physicians In health workers in rural areas to they have too many specialists reorientation of specialists into family Botswana, training of more nurse train for higher professional and too few general practitioners. practice is a short-run substitution practitioners and pharmacists has postings. 3 Many are dealing with the prob- strategy being used, for example, in offset the lack of physicians in some lems by substituting among ari- central and eastem Europe ous health care-givers. Substitution for other health Introduction of new cadres. ensur- Reorientation of specialist physi- fessionals. The training of a physician ing a closer match between skill: ent report 1993-Imvesting in health. New York, Oxford University Press for The World Bank, 1993 ses n managing ces for health problems. Geneva, World Health Organization, 00(Issues in health services delivery, Discussion paper No. 2, document WHO/EIP/OSD/2000. 2). 3 Hicks V, Adams 0. The effects of economic and policy incentives on provider practice Summary of country case studies using the WHO framework. Geneva, World Health Organization, health services delivery, ment WHO/EIP/OSD/2000.8(in press))

78 The World Health Report 2000 Some ways of dealing with imbalances among health care providers are outlined in Box 4.1. A health system can have plentiful human resources, with excellent knowledge and skills, but still face impending crisis if future health needs, priorities and available resources are not taken into account. For example, where the education and training for junior doctors and nurses functions poorly, or where senior staff lack adequate time and resources to update their knowledge and skills, future shortfalls can be expected. Similarly, a health system with a skewed age distribution among staff towards the point of retirement poses a real problem. Thus, a health care system must balance investments in human capital to cover future needs as well as present demands. Some of the most critical and complex input problems relate to human resources (see Box 4.2). Without functioning facilities, diagnostic equipment, and medicines, it does not matter if the knowledge, skills and staff levels are high. The delivery of services will still be poor. A lack of complementary inputs will also have a negative impact on staff motivation, a factor that influences the capacity of human resources. Motivation, however, depends not only on working conditions. Financial incentives and compensation, i.e. income and other benefits, are also important, as are the overall management of staff and the possibilities for professional advancement. Inadequate pay and benefits together with poor working conditions – ranging from work in conflict zones to inadequate facilities and shortages of essential medicines and consumables – are frequently mentioned in less developed countries as the most pressing problems facing the health care workforce (4). In some countries, for example Bangladesh and Egypt, a clear majority of all publicly employed physicians see private paying patients to supplement income from their regular jobs. In Kazakhstan, “informal payments” are estimated to add 30% to the national health care bill (5). Possibilities for doctors to work privately in public institutions are being offered in some countries to neutralize an ongoing brain drain of qualified staff from the public sector. This strategy is considered successful in Bahrain, but experiences from Ghana and Nepal show that such incentives can lead to the diversion of scarce resources from public services and can induce professionals to engage in independent private practice (6). People, as thinking creatures, are very different from machines and human capital cannot be managed in the same way as physical capital. First of all, human resources, and in Box 4.1 Substitution among human resources A large number of countries face an overall shortage of physicians. Other countries that are following a long-term strategy to shift resources to primary care find that they have too many specialists and too few general practitioners. Many are dealing with the problems by substituting among various health care-givers. Reorientation of specialist physicians. While limiting admissions to specialist training and changing internship programmes is a long-term strategy to balance the professional distribution of physicians, the reorientation of specialists into family practice is a short-run substitution strategy being used, for example, in central and eastern Europe. Substitution for other health professionals. The training of a physician may cost three times more than that of a nurse.1 As a result, training of more nurses as well as other health professionals may be a cost-effective substitute for physicians. In Botswana, training of more nurse practitioners and pharmacists has offset the lack of physicians in some areas.2 Introduction of new cadres. Ensuring a closer match between skills and function may demand the creation of new cadres. In Nepal, an educational programme allowed health assistants and other health workers in rural areas to train for higher professional postings.3 1 World development report 1993 – Investing in health. New York, Oxford University Press for The World Bank, 1993. 2 Egger D, Lipson D, Adams O. Achieving the right balance: the role of policy-making processes in managing human resources for health problems. Geneva, World Health Organization, 2000 (Issues in health services delivery, Discussion paper No. 2, document WHO/EIP/OSD/2000.2). 3 Hicks V, Adams O. The effects of economic and policy incentives on provider practice. Summary of country case studies using the WHO framework. Geneva, World Health Organization, 2000 (Issues in health services delivery, Discussion paper No. 5, document WHO/EIP/OSD/2000.8 (in press))