《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?

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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Technological progress influences the economic lifetime of a piece of capital: old invest- ments quickly become outdated as new and improved technologies emerge.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))

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

What resources are needed? This has two potential benefits. It ensures that training has strong practical foundations, and it continually exposes service providers to new thinking and development. In countries with large rural populations several strategies have been used to recruit staff to rural areas Examples are intake of medical students from rural areas and training in the locations Arelated problem concerns the brain drain of trained staff from low income countries to wealthier countries or from the public sector to the private sector within a country. The more successful trainees often emigrate, tempted by higher standards of practice and living abroad. Many Jamaican nurses have migrated to the United States. Physicians migrate from Egypt and India to other countries in the Middle East and to the USA and Europe Inadequate pay and benefits rank as the most serious problem confronting the public sec- tor health workforce in many countries, with growing formal and informal private practice as a consequence. Service contracts that require a certain number of years in public service, especially when the training is state sponsored, have been implemented in the Philippine and the United Republic of Tanzania, and are common in Latin America but there are attendant difficulties. The staff concerned are usually junior, placements are short term and unpopular, mentoring arrangements are seldom adequate, and overall geographical im balance is little affected. Globalization has led to greater mobility of staff and opportunity for overseas training, and students who qualify abroad may wish to stay in the coun here they were trained ADJUSTING TO ADVANCES IN KNOWLEDGE AND TECHNOLOGY Growth in the available knowledge or advances in technology- such as new drugs or diagnostic equipment-can substantially increase the capacity of human resources to solve health problems, and thereby improve the performance of a health care system. New knowl dge is also a challenge to each countrys existing input balance, as relative prices chang and the efficient mix of resources alters (9). In the past few decades, revolutionary advances in medicine and technology have shifted the boundaries between hospitals, primary health care, and community care (10). Corresponding resource shifts in health systems have been much slower to emerge. Antibiotic drugs provide one example of new knowledge affecting cost structures. Since their introduction in the 1940s, patients suffering from a bacterial infection have most often been cared for at home or at outpatient clinics rather than in special hospitals, significantly reducing costs and improving outcomes. The recent growth of unregulated self-treatment and the increasing incidence of drug-resistant bacteria have compromised some of these gains. There is now a need for active stewardship to regulate the quality of diagnosis, pre- scribing and compliance. Vaccines have similarly altered the strategy and costs of tackling epidemic diseases such as measles and poliomyelitis, and new vaccines will continue to necessitate re-thinking to ensure an efficient mix of inputs in national health strategy All countries-nich as well as poor-need to find and maintain a reasonable balance tween inputs. The choices involved in finding this balance, however, vary depending on the amount of total resources available. In a poor country, the possibilities of investing in modern medical technologies or paying for modern medicines are very limited. Moving from the use of essential drugs to new and expensive dru would mean an enormous opportunity loss in terms of health outcome for a poor country. This difference in opportunities across countries also has an impact on the optimal balance

What Resources are Needed? 81 This has two potential benefits. It ensures that training has strong practical foundations, and it continually exposes service providers to new thinking and development. In countries with large rural populations several strategies have been used to recruit staff to rural areas. Examples are intake of medical students from rural areas and training in the locations where physicians will later practise. A related problem concerns the brain drain of trained staff from low income countries to wealthier countries or from the public sector to the private sector within a country. The more successful trainees often emigrate, tempted by higher standards of practice and living abroad. Many Jamaican nurses have migrated to the United States. Physicians migrate from Egypt and India to other countries in the Middle East and to the USA and Europe. Inadequate pay and benefits rank as the most serious problem confronting the public sector health workforce in many countries, with growing formal and informal private practice as a consequence. Service contracts that require a certain number of years in public service, especially when the training is state sponsored, have been implemented in the Philippines and the United Republic of Tanzania, and are common in Latin America but there are attendant difficulties. The staff concerned are usually junior, placements are short term and unpopular, mentoring arrangements are seldom adequate, and overall geographical imbalance is little affected. Globalization has led to greater mobility of staff and opportunity for overseas training, and students who qualify abroad may wish to stay in the country where they were trained. ADJUSTING TO ADVANCES IN KNOWLEDGE AND TECHNOLOGY Growth in the available knowledge or advances in technology – such as new drugs or diagnostic equipment – can substantially increase the capacity of human resources to solve health problems, and thereby improve the performance of a health care system. New knowledge is also a challenge to each country’s existing input balance, as relative prices change and the efficient mix of resources alters (9). In the past few decades, revolutionary advances in medicine and technology have shifted the boundaries between hospitals, primary health care, and community care (10). Corresponding resource shifts in health systems have been much slower to emerge. Antibiotic drugs provide one example of new knowledge affecting cost structures. Since their introduction in the 1940s, patients suffering from a bacterial infection have most often been cared for at home or at outpatient clinics rather than in special hospitals, significantly reducing costs and improving outcomes. The recent growth of unregulated self-treatment and the increasing incidence of drug-resistant bacteria have compromised some of these gains. There is now a need for active stewardship to regulate the quality of diagnosis, prescribing and compliance. Vaccines have similarly altered the strategy and costs of tackling epidemic diseases such as measles and poliomyelitis, and new vaccines will continue to necessitate re-thinking to ensure an efficient mix of inputs in national health strategy. All countries – rich as well as poor – need to find and maintain a reasonable balance between inputs. The choices involved in finding this balance, however, vary depending on the amount of total resources available. In a poor country, the possibilities of investing in modern medical technologies or paying for modern medicines are very limited. Moving from the use of essential drugs to new and expensive drugs for cardiovascular diseases would mean an enormous opportunity loss in terms of health outcome for a poor country. This difference in opportunities across countries also has an impact on the optimal balance

The World Health Report 2000 between resources(see Box 4.3) Some input prices are determined locally; others are set in international markets. In most countries, prices for human resources(incomes for physicians, nurses and other health are personnel)are determined nationally, and the general income level for each country or region will be an important determinant. Prices for such items as patented drugs and medical equipment, on the other hand, are determined in a global market. Although differences in income levels across countries will induce manufacturers and distributors of medicines and equipment to differentiate prices somewhat, stewards of individual country health syste are far less able to influence these prices than the prices of human resources International stewardship is needed to represent the interests of consumers in low income countries that face heavy burdens of infectious and parasitic diseases. This type of stewardship, led by agencies such as WHO and the World Bank, will assume increasing importance as globali zation of the economy continues and free trade agreements are implemented. PUBLIC AND PRIVATE PRODUCTION OF RESOURCES With the exception of skilled human resources, most inputs used for health services are produced in the private sector, with varying degrees of public stewardship over the level and mix of production, distribution, and quality. For example, local markets successfully produce most consumables and unskilled labour. Governmentintervention is needed mainly to ensure that quality and safety standards are met, that reliable information is available about the products, and that a fair competitive environment exists Other inputs, such as manufactured pharmaceuticals and specialized medical equip- ment, often face barriers to entry into the market in the form of patents and licensing requirements, manufacturing standards, large initial investment costs, expensive research, and long development periods. This gives the manufacturers of these inputs considerable market power to abuse by manipulating prices and demand. Strong policy measures are therefore needed, such as anti-trust legislation, limited formularies, generic drug policies, bulk purchasing and formal technology assessments (11-13). Furthermore, by procuring Box 4.3 A widening gap in technology use? A vast quantity of valuable of these diseases are more prevalent of HIv treatment by obliging insur- nological breakthrough would edical technologies and inno- in the poorest countries ers to cover its cost for members of also demand a new mix of re- vative clinical methods have Medicines are now available for insurance schemes sources, but only for those coun- een developed over the past Hiv/AIDS that can, at a huge cost, at Malaria transmission can be pre- tries that could afford the new decades and many more are on least postpone further development vented by means of house spraying, vaccine. he way. Unfortunately, the new of the disease. But treatment insecticide-treated nets, chloro- For tuberculosis the incidence of possibilities are not open to all terms and resource inputs for Hiv/ quine prophylaxis, and so on, but bacterial resistance to first-line income in some countries. Dis- in different countries. In poor coun- able to the people who need them concern, for example, in the Rus- eases that are treated effectively tries, HIV/AIDS is still a disease with- most. Several different projects to sian Federation. Lack of effective in rich countries by professional out treatment alternatives. The sick develop a malaria vaccine are under medical treatment and improper modern technology are mainly taken care of informally way. A breakthrough in this re- use of medicines continue to cre. d by unskilled staff or at home or in institutions with pre- search would present a tremendous ate obstacles to dealing with this at home in less devel- dominantly unskilled staff. South opportunity to improve quality of escalating problem. 2 oped countries. Moreover, some Africa has improved the availability life and prevent death Such a tech- 2 Global tuberculosis control WHO report 2000. Geneva, World Health Organization, 2000(document WHO/CDS/TB/2000.275)

82 The World Health Report 2000 between resources (see Box 4.3). Some input prices are determined locally; others are set in international markets. In most countries, prices for human resources (incomes for physicians, nurses and other health care personnel) are determined nationally, and the general income level for each country or region will be an important determinant. Prices for such items as patented drugs and medical equipment, on the other hand, are determined in a global market. Although differences in income levels across countries will induce manufacturers and distributors of medicines and equipment to differentiate prices somewhat, stewards of individual country health systems are far less able to influence these prices than the prices of human resources. International stewardship is needed to represent the interests of consumers in low income countries that face heavy burdens of infectious and parasitic diseases. This type of stewardship, led by agencies such as WHO and the World Bank, will assume increasing importance as globalization of the economy continues and free trade agreements are implemented. PUBLIC AND PRIVATE PRODUCTION OF RESOURCES With the exception of skilled human resources, most inputs used for health services are produced in the private sector, with varying degrees of public stewardship over the level and mix of production, distribution, and quality. For example, local markets successfully produce most consumables and unskilled labour. Government intervention is needed mainly to ensure that quality and safety standards are met, that reliable information is available about the products, and that a fair competitive environment exists. Other inputs, such as manufactured pharmaceuticals and specialized medical equipment, often face barriers to entry into the market in the form of patents and licensing requirements, manufacturing standards, large initial investment costs, expensive research, and long development periods. This gives the manufacturers of these inputs considerable market power to abuse by manipulating prices and demand. Strong policy measures are therefore needed, such as anti-trust legislation, limited formularies, generic drug policies, bulk purchasing, and formal technology assessments (11–13). Furthermore, by procuring Box 4.3 A widening gap in technology use? A vast quantity of valuable medical technologies and innovative clinical methods have been developed over the past decades and many more are on the way. Unfortunately, the new possibilities are not open to all because of the lack of available income in some countries. Diseases that are treated effectively in rich countries by professional staff using modern technology are handled by unskilled staff or informally at home in less developed countries. Moreover, some of these diseases are more prevalent in the poorest countries. Medicines are now available for HIV/AIDS that can, at a huge cost, at least postpone further development of the disease. But treatment patterns and resource inputs for HIV/ AIDS currently follow different paths in different countries. In poor countries, HIV/AIDS is still a disease without treatment alternatives. The sick are mainly taken care of informally at home or in institutions with predominantly unskilled staff. South Africa has improved the availability of HIV treatment by obliging insurers to cover its cost for members of insurance schemes. Malaria transmission can be prevented by means of house spraying, insecticide-treated nets, chloroquine prophylaxis, and so on, but such measures are not always available to the people who need them most. Several different projects to develop a malaria vaccine are under way.1 A breakthrough in this research would present a tremendous opportunity to improve quality of life and prevent death. Such a technological breakthrough would also demand a new mix of resources, but only for those countries that could afford the new vaccine. For tuberculosis, the incidence of bacterial resistance to first-line drugs is increasing. It is of major concern, for example, in the Russian Federation. Lack of effective medical treatment and improper use of medicines continue to create obstacles to dealing with this escalating problem.2 1 The world health report 1999 – Making a difference. Geneva, World Health Organization, 1999. 2 Global tuberculosis control: WHO report 2000. Geneva, World Health Organization, 2000 (document WHO/CDS/TB/2000.275)

What resources are needed? medicines and medical technologies on the intenational market, countries can ensure that local producers remain competitive(14, 15) ublicly subsidized production of consumables, pharmaceuticals and medical equip- ment often leads to low quality, lack of innovation, outmoded technology, inefficient pr duction modalities and distribution delays. The most striking example of this occurred in the former Soviet Union. Most countries that have followed this model have quickly fallen behind in productivity and production technology. Many Western firms that entered the pharmaceutical and medical equipment market in central and eastern Europe during the early 1990s found it cheaper and easier to build new factories than to convert and modern ize the old Decisions on physical capital, such as hospitals and other large facilities, require more lbic attention. Ambulatory clinics, laboratories, pharmacies, cottage hospitals, and other small clinical facilities often have small capital requirements, and private providers may be able to finance these themselves or through small personal loans in parallel to public in- vestments In the case of large hospitals, most countries have in the past relied heavily on public investments. Investment decisions in this area have consequences that may last for 30-40 years or more. Once built, hospitals are politically difficult to close. The need for strong public policies, however, does not necessarily mean the public financing of the en tire capital stock. Increasingly, many countries are looking to the private sector to support estments in their health system even when the resulting facilities will not have for-pI objectives, and the running costs will be publicly financed (19). Chapter 6 illustrates some pitfalls of developing joint venture investments, and the different skills required for compe- Box 4.4 The Global Alliance for Vaccines and Immunization (GAVI hildren die from diseases that ing gap of vaccine availability board, held during the World Eco- regions, have already provided could be prevented with currently between industrialized and devel- nomic Forum in Davos in February details of their immunization available vaccines, yet nearly 30 oping countries. Beyond the six 2000, the GAVI partners discussed tivities and needs Resources from million of the 130 million children basicvaccines of the Expanded Pro- policies for attaining the 80% im- the fund will primarily be used to orn every year are not receiving gramme on Immunization (against munization objective and an- purchase vaccines for hepatitis B, vaccinations of any kind. The great poliomyelitis, diphtheria, whooping nounced a multimillion-dollar Haemophilus influenzae type b majority of unreached children- cough, tetanus, measles and tuber- global fund for childrens vaccines. (Hib), and yellow fever, and safe 25 million-live in countries that culosis), newer vaccines, such as Governments, businesses, private injection materials haveless than USS 1000 per capita those for hepatitis B, Haemophilus philanthropists, and international It is envisaged that GAVi par influenzae type b(Hib), and yellow organizations are working together The Global Alliance for Vaccines fever are now widely used in indus- to manage these resources so as to collaborate with national govern- and Immunization(GAvi) is a coa- trialized countries a major priority provide the protection of immuni- ments to help close the gaps lition of public and private inter- is to see that all countries of the zation to children in all countries, identified in the country propos ests that was formed in 1999 to world achieve at least 80% immu- under the campaign title of " The als other than those directly re- ensure that every child is pro- nization coverage by 2005. Based on Children's Challenge Members of lated to the provision of vaccines. tected against vaccine-prevent- current assumptions of vaccine de GAVI argue that protecting the By placing more of the responsi- able diseases. GAVI partners livery costs it is estimated that an worlds children against preventable bility for providing the necessary include national govemments, the additional $226 million annually are diseases is not only a moral impera- information and commitment on of the countries themselves the Vaccine Program, the International age in the poorest countries with a healthy, stable global society. GAVI partners are hoping that re- Federation of Pharmaceutical the traditional EPlvaccines; to cover All countries with incomes of less sulting efforts will be more coun- Manufacturers Associations the same number of children with than $1000 per capita GNP (74 try-driven and therefore more (IFPMA), research and technical the newer vaccines, according to the countries worldwide, with the ma- sustainable health institutions, the Rockefeller guidelines adopted at GAVI's first jority in Africa)have been invited to oundation, UNICEF, the World board meeting, would require an express their interest in collaborat additional $352 million ing with GAVI in this

What Resources are Needed? 83 medicines and medical technologies on the international market, countries can ensure that local producers remain competitive (14, 15). Publicly subsidized production of consumables, pharmaceuticals and medical equipment often leads to low quality, lack of innovation, outmoded technology, inefficient production modalities and distribution delays. The most striking example of this occurred in the former Soviet Union. Most countries that have followed this model have quickly fallen behind in productivity and production technology. Many Western firms that entered the pharmaceutical and medical equipment market in central and eastern Europe during the early 1990s found it cheaper and easier to build new factories than to convert and modernize the old capital stock (16–18). Decisions on physical capital, such as hospitals and other large facilities, require more public attention. Ambulatory clinics, laboratories, pharmacies, cottage hospitals, and other small clinical facilities often have small capital requirements, and private providers may be able to finance these themselves or through small personal loans in parallel to public investments. In the case of large hospitals, most countries have in the past relied heavily on public investments. Investment decisions in this area have consequences that may last for 30–40 years or more. Once built, hospitals are politically difficult to close. The need for strong public policies, however, does not necessarily mean the public financing of the entire capital stock. Increasingly, many countries are looking to the private sector to support investments in their health system even when the resulting facilities will not have for-profit objectives, and the running costs will be publicly financed (19). Chapter 6 illustrates some pitfalls of developing joint venture investments, and the different skills required for compeBox 4.4 The Global Alliance for Vaccines and Immunization (GAVI) Every year, nearly three million children die from diseases that could be prevented with currently available vaccines, yet nearly 30 million of the 130 million children born every year are not receiving vaccinations of any kind. The great majority of unreached children – 25 million – live in countries that have less than US$ 1000 per capita GNP. The Global Alliance for Vaccines and Immunization (GAVI) is a coalition of public and private interests that was formed in 1999 to ensure that every child is protected against vaccine-preventable diseases. GAVI partners include national governments, the Bill and Melinda Gates Children’s Vaccine Program, the International Federation of Pharmaceutical Manufacturers Associations (IFPMA), research and technical health institutions, the Rockefeller Foundation, UNICEF, the World Bank Group, and WHO. GAVI is seeking to close the growing gap of vaccine availability between industrialized and developing countries. Beyond the six basic vaccines of the Expanded Programme on Immunization (against poliomyelitis, diphtheria, whooping cough, tetanus, measles and tuberculosis), newer vaccines, such as those for hepatitis B, Haemophilus influenzae type b (Hib), and yellow fever are now widely used in industrialized countries. A major priority is to see that all countries of the world achieve at least 80% immunization coverage by 2005. Based on current assumptions of vaccine delivery costs it is estimated that an additional $226 million annually are needed to reach this level of coverage in the poorest countries with the traditional EPI vaccines; to cover the same number of children with the newer vaccines, according to the guidelines adopted at GAVI’s first board meeting, would require an additional $352 million. At the second meeting of the GAVI board, held during the World Economic Forum in Davos in February 2000, the GAVI partners discussed policies for attaining the 80% immunization objective and announced a multimillion-dollar global fund for children’s vaccines. Governments, businesses, private philanthropists, and international organizations are working together to manage these resources so as to provide the protection of immunization to children in all countries, under the campaign title of “The Children’s Challenge”. Members of GAVI argue that protecting the world’s children against preventable diseases is not only a moral imperative but an essential cornerstone of a healthy, stable global society. All countries with incomes of less than $1000 per capita GNP (74 countries worldwide, with the majority in Africa) have been invited to express their interest in collaborating with GAVI in this campaign. Nearly 50 countries, from all WHO regions, have already provided details of their immunization activities and needs. Resources from the fund will primarily be used to purchase vaccines for hepatitis B, Haemophilus influenzae type b (Hib), and yellow fever, and safe injection materials. It is envisaged that GAVI partners at the country level will collaborate with national governments to help close the gaps identified in the country proposals other than those directly related to the provision of vaccines. By placing more of the responsibility for providing the necessary information and commitment on the countries themselves, the GAVI partners are hoping that resulting efforts will be more country-driven and therefore more sustainable

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