1. Richard M. Scheffler, PhD Distinguished Professor of Health Economics & Public Policy Director, Global Center for Health Economics & Policy Research School of Public Health University of California, Berkeley Health Workforce Allocation & Distribution The Rural-Urban Imbalance and Public Private Mix

2. Health Worker Labor Market (A) (B) Supply of Training Slots Cost of Training Number of Slots Types of Training Supply of Training Slots Cost of Training Number of Slots Types of Training Demand for HW: Demand for Health Care Wages offered Regulation Demand for HW: Demand for Health Care Wages offered Regulation Demand for Training Slots: Number of Applicants Cost of Tuition Expected Wages Demand for Training Slots: Number of Applicants Cost of Tuition Expected Wages Supply of Health Workers: Number of graduates Net migration Deaths and retirements Supply of Health Workers: Number of graduates Net migration Deaths and retirements Supply of HW: Wages Personal Preferences Supply of HW: Wages Personal Preferences HW Labor Market: Wages # of Health Workers Specialty Geographic area HW Labor Market: Wages # of Health Workers Specialty Geographic area (C) (E) (F) (D) Performance Productivity (G)(H)

3. Demand and Supply of Nurses

4. Private market for health workers

5. Public Market for Health Workers

6. Urban Health Worker Labor Market

7. Rural Health Worker Labor Market

8. Task-Shifting of Community Health Workers (CHW)

9. Productivity Function of a Health Worker

10. Measuring the Distribution Problem Density of health workers -rural urban gap -ratio of densities -benchmark -Lorenz curves and concentration indexes

11. Higher densities of health workers in urban areas

12. Using benchmark: No shortage in urban areas

13. Comparing Densities

14. Distribution of health workers per capita by cadre in all districts of Tanzania Source: Munga and Maestad 2009.

15. Measuring inequities in HRH

16. Why the Rural-Urban Imbalance? Demand factors Employment opportunities Funding Supply factors Preferences Cost of living

17. A rural and an urban market supplydemand labor co m pe ns ati on Comp U Urban HRH market supply demand Rural HRH market labor co m pe ns ati on Comp RU unemploymentshortage Urban employment and rural shortage situation

18. Supply 2 demand labor com pen sati on Comp URBAN Urban HRH market Supply 1 demand Rural HRH market labor com pen sati on Comp RURAL New level of unemploymentNew level of shortage Supply 1 New suppl Urban and Rural HRH Markets with Improved Information

19. labor Supply 1 demand Rural HRH market labor compensation Comp RURAL New level of shortage Supply 1 What can we do to influence the rural HRH labor market?

20. labor Supply 1 demand Rural HRH market labor compensation Comp RURAL New level of shortage Supply 1 Demand Interventions Pay more Comp RURAL

21. labor Supply 1 demand Rural HRH market labor compensation Comp RURAL New level of shortage Supply 1 Demand interventions Pay more, Increase Financing Comp RURAL

22. Public vs Private Sector Salary payment come from very different sources Private sector is not subject to some regulations Licensing Easier to hire and fire Payment and incentives are more flexible This leads to Different labor demand Another health worker decision (supply) 22

23. 23 In LICs 76% of all health spending is private and 70% is out of pocket Source: World Bank, WHO, 2007.

24. How Big is the Private Sector? 24

25. 25 Bangladesh Cameroon Ethiopia Honduras India Indonesia Papau New Guinea Peru Tajikistan Uganda Absemteesm Rates

26. Ban it and try to enforce through better monitoring India, Venezuela Increase pay (straight allowance or salary) Increase pay but based on performance Rwanda, Turkey Contract for specific hours Dominican Republic 20 hour contract Completely reform system Do not employ health workers – make them all private practitioners Policy Options – Dual Practice 26