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 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, are 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). People, as thinking creatures, are very different from machines and human capital can￾not 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 re￾sources to primary care find that they have too many specialists and too few general practitioners. Many are dealing with the prob￾lems by substituting among vari￾ous health care-givers. Reorientation of specialist physi￾cians. While limiting admissions to specialist training and changing in￾ternship 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 pro￾fessionals. 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-effec￾tive 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. Ensur￾ing a closer match between skills and function may demand the creation of new cadres. In Nepal, an educational programme al￾lowed 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))