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 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 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 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 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 coun￾tries experience varying degrees of shortages in qualified health personnel. In sub-Saharan Africa in particular, the limited training ca￾pacity and low pay for qualified health workers causes severe problems in service delivery. Else￾where, for example in Egypt, over￾supply is a problem. Generally, shortages and oversupply are de￾fined 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 coun￾tries of eastern Europe and central Asia, or relative to geographical lo￾cation. Training and skill mix imbalances. Health care workers are often un￾qualified 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 cer￾tain type of training or qualification, however, tells only part of the story. Neither formal training nor profes￾sional affiliation necessarily equates with skill in dealing with specific problems. Distribution imbalances. Almost all countries have some urban/rural imbalances among their human re￾sources and face problems in meet￾ing the needs of specific groups such as poor or handicapped peo￾ple 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 pro￾fessionals 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 ap￾proaches. Although progress has been made in recent years to de￾velop national policies and plans for human resources for health, they are not fully implemented in most countries. Moreover, very few countries monitor and evalu￾ate the progress and impact of policy implementation