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When More Doctors Can Do More Harm than Good

July 23, 2012

In 2006 the WHO estimated that there are not enough health workers to get around for everybody. The problem is more acute in some countries – particularly in Africa – where the gap amounts to 2.4 million. This shortage can be traced back to a variety of factors ranging from poor infrastructure to lack of financial incentives to retain workers in those countries. There is no easy fix for it. If a country does not have enough nurses or doctors, citizens of those countries stand a slim chance to obtain proper care. One can have the diagnostic tools in place to detect the disease, can dispose of the medicines for treatment but they are no use if there is not a doctor to detect and treat the disease. This is a problem which affects overwhelmingly poor countries. Other countries face exactly the opposite problem: too many health workers, concentrated in one area. If you are asking why that could be a problem think about demand and supply, and about how, in healthcare, the latter drives the former.

A Demand Driven By Supply: people who access health services be that a diagnostic test or visit to a physician do not have the knowledge to decide by themselves when and how many test they are supposed to get. To do so they rely on what the experts say: the doctor holds the knowledge. Imagine one lives in a city where there are a lot of physicians and wants to get checked for a back pain. The physician’s interest is to prescribe to the patients as many examinations and visit for which he or she gets paid for. More tests and visits are not a bad thing in itself, they are just not necessary. What drives the doctor’s decision to over-prescribe test and medication is that he or she will not get the chance to see many other patients soon because they could chose to go to other physicians. For that reason they decide, sometimes unconsciously, to maximize their gain in the present. The number of doctors in one areas can in this way influence the number of health services consumed. This is true for a variety of care services whose frequency of utilization is driven by the supply of that service. In areas where there is a higher concentration of hospital bed per capita for example, patients will be more likely to be hospitalized. The principle is that if the supply is there then it is expected to be utilized at its full capacity: in other words hospital bed, once built, will be used. Patients will rarely object to the decision to get hospitalized because they cannot distinguish when it is necessary and when it is not. The demand in other words will accommodate the supply.

The problem is that more care does not mean better health. Research in the US (see the link above) shows that people in areas with high density of care do not fare better than people living in areas with relatively fewer care services. Reason being that the health gain for some patients is more than offset by the health loss of other patients which results from mistreatment and misdiagnosis.

Whose Problem? One could think that this problem is exclusive to very rich countries. This is just not the case. Lebanon, a middle income country, face the same problem: an unnecessary demand induced by oversupply of health workers, hospital beds and sophisticated services. People pay for MRIs, physicians visits or other services they do not need. In its report the WHO identifies a threshold in workforce density: below that level a satisfactory coverage of essential services such as vaccination is very unlikely to materialize. The lessons from both high and middle income countries such as the US and Lebanon is that there is also a threshold in workforce density above which one gets the risk to get services one does not need: one pays more but in exchange does not gain real health benefit. Too many resources, but health does not improve. A lesson countries should keep in mind if citizens are not to be made paid more for nothing.

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