What resources are needed? particular physicians, determine the use of other available inputs. An oversupply of physi cians will almost certainly mean an oversupply of the kind of services that physicians pro- vide. The high density of private physicians working in urban areas of many middle income countries, such as Thailand, usually correlates with frequent use of expensive equipment and laboratory testing, and with more services of sometimes doubtful value being provided to the urban population. In Egypt, the high ratio of physicians-for every occupied bed in Egypt there are two physicians-combined with extensive self-medication explain the very h use of drugs. According to estimates, the poorest households in Egypt spend over 5% of their income on drugs alone(2) Incentives and management related to human resources have an indirect impact on the use of other resources as well. For example, many payment systems provide physicians and providers with incentives to use more or less medical equipment, laboratory testing and medicines. In Bangladesh, physicians get 30-40% of the laboratory charges for each referral generated, creating a clear interest to expand the volume of such services(2). In both China and Japan, many physicians derive part of their income from the sale of drugs which they prescribe. In many countries, the use of branded drugs instead of generics is still common, and this can to a large extent be blamed on the incentives offered to physicians and phar- macists by pharmaceutical producers Lack of the skills needed to assess technology and control quality is an additional factor causing imbalances among resources Another difference between human and physical capital, which affects how people are managed, is that physicians, nurses and other health workers are not motivated only by present working conditions, income and management. They are also influenced by what they believe those conditions will be in the future, based on past experiences, views ex- pressed by others and current trends. If qualified staff believe that future payment, benefits and working conditions will deteriorate, their job-related decisions and motivation will reflect that belief. This "shadow of the future"can easily result in a continuing negative piral towards lower motivation and performance A first step to prevent such a development is to find a sustainable balance among the different types of resources and between investment and recurrent costs. Perhaps the most Box 4.2 Human resources problems in service delivery study of human resources in 18 specialist physicians in many coun- sional affiliation necessarily equates Nepal, only 20% of rural physician low and middle income countries, tries of eastern Europe and central with skill in dealing with specific posts are filled, compared to 96% one or more in each of the WHo Asia, or relative to geographical lo- problems. regions, indicates that most coun- cation. Distribution imbalances. Almost all Failure of past public policy ap- tries experience varying degree raining and skill mix imbalances. countries have some urban/rural proaches. Although progress has of shortages in qualified health Health care workers are often un- imbalances among their human re- been made in recent years to de- personnel. In sub-Saharan Africa in qualified for the tasks they perform sources and face problems in meet- velop national policies and plar particular, the limited training ca- because of a shortage of training ing the needs of specific groups for human resources for health, pacity and low pay for qualified opportunities, as in many African such as poor or handicapped peo- they are not fully implemented in health workers causes severe countries, or a mismatch between ple or ethn ities. It is almost most countries. Moreover, very problems in service delivery. Else- available skills and the needs and universally true that providers tend few countries monitor and e where, for example in Egypt, over- priorities of the health care system, to concentrate in urban areas. In ate the progress and impact of supply is a problem. Generally, as in eastern Europe and central Cambodia, 85% of the population policy implementation. ortages and oversupply are de- Asia. The number of physicians and live in rural areas, but only 13%of ned relative to countries in the other health personnel with a cer- the government health workers same region and at similar levels tain type of training or qualification, work there. In Angola, 65% live in of development. Oversupply, thus, however, tells only part of the story. rural areas, but 85% of health pro-
What Resources are Needed? 79 particular physicians, determine the use of other available inputs. An oversupply of physicians will almost certainly mean an oversupply of the kind of services that physicians provide. The high density of private physicians working in urban areas of many middle income countries, such as Thailand, usually correlates with frequent use of expensive equipment and laboratory testing, and with more services of sometimes doubtful value being provided to the urban population. In Egypt, the high ratio of physicians – for every occupied bed in Egypt there are two physicians – combined with extensive self-medication explain the very high use of drugs. According to estimates, the poorest households in Egypt spend over 5% of their income on drugs alone (2). Incentives and management related to human resources have an indirect impact on the use of other resources as well. For example, many payment systems provide physicians and providers with incentives to use more or less medical equipment, laboratory testing and medicines. In Bangladesh, physicians get 30–40% of the laboratory charges for each referral generated, creating a clear interest to expand the volume of such services (2). In both China and Japan, many physicians derive part of their income from the sale of drugs which they prescribe. In many countries, the use of branded drugs instead of generics is still common, and this can to a large extent be blamed on the incentives offered to physicians and pharmacists by pharmaceutical producers. Lack of the skills needed to assess technology and control quality is an additional factor causing imbalances among resources. Another difference between human and physical capital, which affects how people are managed, is that physicians, nurses and other health workers are not motivated only by present working conditions, income and management. They are also influenced by what they believe those conditions will be in the future, based on past experiences, views expressed by others and current trends. If qualified staff believe that future payment, benefits and working conditions will deteriorate, their job-related decisions and motivation will reflect that belief. This “shadow of the future” can easily result in a continuing negative spiral towards lower motivation and performance. A first step to prevent such a development is to find a sustainable balance among the different types of resources and between investment and recurrent costs. Perhaps the most Box 4.2 Human resources problems in service delivery Numerical imbalances. A recent study of human resources in 18 low and middle income countries, one or more in each of the WHO regions, indicates that most countries experience varying degrees of shortages in qualified health personnel. In sub-Saharan Africa in particular, the limited training capacity and low pay for qualified health workers causes severe problems in service delivery. Elsewhere, for example in Egypt, oversupply is a problem. Generally, shortages and oversupply are defined relative to countries in the same region and at similar levels of development. Oversupply, thus, may be absolute, as is the case for specialist physicians in many countries of eastern Europe and central Asia, or relative to geographical location. Training and skill mix imbalances. Health care workers are often unqualified for the tasks they perform because of a shortage of training opportunities, as in many African countries, or a mismatch between available skills and the needs and priorities of the health care system, as in eastern Europe and central Asia.The number of physicians and other health personnel with a certain type of training or qualification, however, tells only part of the story. Neither formal training nor professional affiliation necessarily equates with skill in dealing with specific problems. Distribution imbalances. Almost all countries have some urban/rural imbalances among their human resources and face problems in meeting the needs of specific groups such as poor or handicapped people or ethnic minorities. It is almost universally true that providers tend to concentrate in urban areas. In Cambodia, 85% of the population live in rural areas, but only 13% of the government health workers work there. In Angola, 65% live in rural areas, but 85% of health professionals work in urban areas. In Nepal, only 20% of rural physician posts are filled, compared to 96% in urban areas. Failure of past public policy approaches. Although progress has been made in recent years to develop national policies and plans for human resources for health, they are not fully implemented in most countries. Moreover, very few countries monitor and evaluate the progress and impact of policy implementation
The World Health Report important part of such a balance is to ensure that there are individual incentives to invest in human capital in the form of improved earnings, career opportunities and working condi- ions. Indeed, many low and middle income countries have increased pay or benefits as a key strategy for developing human resources and improving delivery of services to meet health needs and priorities(7). Public sector pay in Uganda rose by 900%(in nominal terms)between 1990 and 1999, which represents a doubling in real terms(8) In general there are no easy answers in the area of human resources development. Left unmanaged, human skills markets take years, even decades, to respond to market signals And, unlike physical capital, human resources cannot be scrapped when their skills no longer needed or obsolete; even laying off public sector health workers is often so diffi- cult that it can only be achieved as part of a broader policy to reform the civil service Public intervention to produce the required balance is thus essential to reduce waste and accelerate adjustment. Some successful experiences are summarized below but many problems remain(7) utilization levels, mix and distribution. The relative prices of different skill categories should guide decisions about their most efficient mix, where labour markets are function ing. There are no absolute norms regarding the right ratio of physicians or nurses to popu lation; rules of thumb are often used. Generally, shortages or ov the basis of need and priorities combined with comparisons with neighbouring countries or those at a similar level of development. Such assessment requires sou available human resources and their geographical and professional distribution: such in- formation is often lacking In Guinea-Bissau, 700"ghost "workers were removed from the payroll of the Ministry of Finance, following an inventory of the health care workforce. Cambodia's 1993 survey of health workers revealed a poorly distributed and largely unreg- istered workforce, with widely differing competencies(2) Three types of human resource strategy have been pursued with some success making more efficient use of available personnel through better geographical greater use of multiskilled personnel where appropriate; ensuring a closer match between skills and functions The latter strategy responds to a widespread problem. Formal training of health work ers, particularly for more highly skilled staff, too seldom reflects the actual tasks being per- formed. This is both wasteful and demoralizing ome success has been recorded with mandatory service and multiple incentives(fi nancial, professional, educational, etc. )to make otherwise unattractive technical or geo- graphical areas more appealing, as has been done in Canada and the Scandinavian countries to deploy staff in their northern regions. Countries such as Fiji, Oman and Saudi arabia have successfully recruited foreign workers to fill critical gaps, as an interim strategy. This strategy can, however, create other difficulties and tensions. Oman at present has a policy to recruit primarily a domestic workforce, as the pool of potential medical students has Intake training and continuing education. a clear case can be made for strong public sector involvement in training and in monitoring the quality of continuing education to stimulate the development of human resources in targeted areas. New public health schools have recently been established in Hungary and Jamaica to meet needs for professionals with skills in epidemiology, statistics, management and health education. They aim to inte- grate initial formal training, subsequent continuing education, and actual service provision
80 The World Health Report 2000 important part of such a balance is to ensure that there are individual incentives to invest in human capital in the form of improved earnings, career opportunities and working conditions. Indeed, many low and middle income countries have increased pay or benefits as a key strategy for developing human resources and improving delivery of services to meet health needs and priorities (7). Public sector pay in Uganda rose by 900% (in nominal terms) between 1990 and 1999, which represents a doubling in real terms (8). In general there are no easy answers in the area of human resources development. Left unmanaged, human skills markets take years, even decades, to respond to market signals. And, unlike physical capital, human resources cannot be scrapped when their skills are no longer needed or obsolete; even laying off public sector health workers is often so difficult that it can only be achieved as part of a broader policy to reform the civil service. Public intervention to produce the required balance is thus essential to reduce waste and accelerate adjustment. Some successful experiences are summarized below but many problems remain (7). Utilization levels, mix and distribution. The relative prices of different skill categories should guide decisions about their most efficient mix, where labour markets are functioning. There are no absolute norms regarding the right ratio of physicians or nurses to population; rules of thumb are often used. Generally, shortages or oversupply are assessed on the basis of need and priorities combined with comparisons with neighbouring countries or those at a similar level of development. Such assessment requires sound data about available human resources and their geographical and professional distribution: such information is often lacking. In Guinea-Bissau, 700 “ghost” workers were removed from the payroll of the Ministry of Finance, following an inventory of the health care workforce. Cambodia’s 1993 survey of health workers revealed a poorly distributed and largely unregistered workforce, with widely differing competencies (2). Three types of human resource strategy have been pursued with some success: • making more efficient use of available personnel through better geographical distribution; • greater use of multiskilled personnel where appropriate; • ensuring a closer match between skills and functions. The latter strategy responds to a widespread problem. Formal training of health workers, particularly for more highly skilled staff, too seldom reflects the actual tasks being performed. This is both wasteful and demoralizing. Some success has been recorded with mandatory service and multiple incentives (financial, professional, educational, etc.) to make otherwise unattractive technical or geographical areas more appealing, as has been done in Canada and the Scandinavian countries to deploy staff in their northern regions. Countries such as Fiji, Oman and Saudi Arabia have successfully recruited foreign workers to fill critical gaps, as an interim strategy. This strategy can, however, create other difficulties and tensions. Oman at present has a policy to recruit primarily a domestic workforce, as the pool of potential medical students has increased. Intake training and continuing education. A clear case can be made for strong public sector involvement in training and in monitoring the quality of continuing education to stimulate the development of human resources in targeted areas. New public health schools have recently been established in Hungary and Jamaica to meet needs for professionals with skills in epidemiology, statistics, management and health education. They aim to integrate initial formal training, subsequent continuing education, and actual service provision