While the Human Capital approach largely treats qualified labour as a private good, other perspectives are also possible. Economic theory describes purely private goods and purely public goods as two ends of a spectrum, with a number of hybrids in between. ‘Goods’ in the economic sense are defined as “anything that produces a benefit, be it a physical commodity or a service” (Woodward and Smith 2003, p.4). The classification of goods is mainly based on the economic criteria ‘subtractability’ and
‘excludability’ (see figure 1). Commons, or common-pool resources, as well as club goods, or toll goods, share some features of public and private goods. They are therefore sometimes called impure public goods.
Figure 1: Four basic types of goods Source: Ostrom 2005, p.24
26 Commons are also defined as “a natural resource (or durable facility of human design and construction) that is shared by a community of producers or consumers”
(Oakerson 1992, p. 41). Such shared resources can be fixed or fugitive, renewable or not, and more or less indivisible. Similarly to this definition, Ostrom (2005) emphasizes the aspect of communitarian use and also maintenance of the resource. Therefore, the social and cultural attributes of the community also form an important part in analyzing the commons. The major physical and technical attributes and the related economic concepts of commons are further described by Oakerson (1992):
• Subtractability (degrees of jointness): refers to the immediate non-availability to others of the resource share which is taken by one user. Different modes of usage of the same resource may be more or less subtractable. A second feature applicable to the commons is the reduced capacity of the resource over time to generate benefits. Commons are partially subtractable; their use becomes subtractible if a certain threshold is passed.
• Excludability: Originally refers to the ability of sellers to exclude potential buyers unless they pay a certain price. Applied to the commons, the interest lies in whether excludability exists on an individual user basis, or whether it is only applicable collectively to outsiders of the community. In the former case an increase in demand might stem from a rising number of users, in the latter the reason would be higher utilization levels within a closed user group.
• Indivisibility: Although physical boundaries of the resource are not always obvious, their identification is necessary at least for analytical purposes. This allows for investigating boundary conditions and determining the appropriate scale and measures for regulation. Divisibility determines whether a privatization of the resource is possible at all.
With commons, suboptimal aggregate use will lead to the depletion of the resource system. The economist Garret Hardin maintained that this ‘tragedy of the commons’ is unavoidable due to the incentive structures inherent in such a resource, which induce
‘free-rider’ behavior in independent gain-maximising actors (Hardin 1968). Fidler (2007) is applying the term ‘tragedy of the commons’ to the policy space of global health: “Political incentives, epidemiological evidence, technological advances,
27 globalization and funding have significantly lowered barriers to entry into global health activities, creating activities for more government actors and others to plan and implement projects” (p.244). Over-exploitation as the generally proclaimed core feature of this tragedy can be found in the “local and national capacities for public health and health care” (p.244), particularly in developing countries. This points to human resource capacities in a qualitative and quantitative sense. At the same time, Fidler states that fragmentation and lack of coordination in public health and health care systems lead to insufficient resource utilization for critical health issues.
“Technological fixes are not available for these challenges, as they are fundamentally political and governance problems” (Fidler 2007, p.244).
Health is often regarded as a public good, as individuals cannot be generally excluded from enjoying good health, and the health of one person does not subtract from the health of another. By contrast, Smith et al. (2003) state that individuals are the primary beneficiaries of their health and thus health is principally a private good, albeit with positive externalities to other persons. Eventually they prefer to simply view health as the ultimate goal of activities in the health sector and related fields, and instead focus on the goods that are necessary to reach that goal. These are called ‘access goods’, and they might be public or private in nature. Nevertheless, the authors argue that goods with considerable externalities in this context should be treated ‘as if’ they were public goods, meaning that they require collective action to ensure reciprocity, communication and enforcement mechanisms among actors. Private goods with positive externalities would otherwise be undersupplied, as private consumers and suppliers do not take these externalities into account (Smith et al. 2003).
Health is – among other social and economic determinants – maintained or re-established through health care systems. These fall into several sub-systems or building blocks, as outlined in the WHO framework for health systems strengthening (WHO 2007b):
1. Service delivery: packages; delivery models; infrastructure; management;
safety & quality; demand for care
2. Health workforce: national workforce policies and investment plans;
advocacy; norms, standards and data
28 3. Information: facility and population based information & surveillance systems; global standards, tools
4. Medical products, vaccines & technologies: norms, standards, policies;
reliable procurement; equitable access; quality
5. Financing: national health financing policies; tools and data on health expenditures; costing
6. Leadership and governance: health sector policies; harmonization and alignment; oversight and regulation.
It is clear from this WHO framework that human resources are nowadays considered to be a main field of action within health systems strengthening. Furthermore, they are neatly interwoven with the other health system components, as those all require specific skills and competences. HRH can therefore be considered an impure public good or access good, the sufficient provision of which requires collective action. While clinical and nursing services delivered on a personal basis are definitely dominating the global discourse on HRH, from a Public Health perspective it is also of interest how non-personal health services contribute to better population health. Powles and Comim (2003) introduce the concept of ‘Public Health infrastructures’, falling into three components:
• Institutional capacities (legal and regulatory framework, capacity to monitor and respond to changes)
• Staff education and training, and wider knowledge (vocational and research training, capacity to absorb latest Public Health knowledge)
• Physical infrastructures (concerning water and sanitation, food hygiene, housing, road safety, product safety, pollution control etc.)
Although Powles and Comim (2003) see some analytical benefits in viewing Public Health infrastructures from the perspective of ‘access goods’, they warn that such economic concepts may suggest that shortfalls could be solved if only the monetary investment was sufficient. Rather, the components named above are linked to a range of social institutions, which must be considered in devising coordination and transmission mechanisms for the provision of Public Health infrastructures.
29 Moreover, it should be noted that health care is not only provided as a formal professional service, but also includes informal measures at group level and self-care.
Those build on similar resources such as labour, knowledge and information, physical and monetary assets. Stubbs (2004) argues that individuals and families have always played a large role in producing welfare – which includes health –, and that this fact should be more acknowledged also in research and policy making. Social institutions of the larger Malawian society will therefore also play a role in the present study.
30 2.2 INSTITUTIONALIST VIEWS OF HUMAN RESOURCES
Public goods for health, as they have been outlined in the previous section, do not only comprise health systems per se, but may also consist in knowledge, policy and regulatory regimes (Woodward and Smith 2003). In the political sciences tradition, regulatory regimes – ‘the rules of the game’ – are usually referred to as institutions.
Influences from political economy as well as from sociological organisational theory have led to a New Institutionalism in political sciences, which has moved from historical description to systematic empirical research. Within this framework, institutions can be considered as dependent or as independent variables (Mols et al.
2006). While the New Institutional Economics emphasise the potential of institutions to reduce transaction costs, i.e. their instrumental value to reach organisational goals, New Institutionalism in organisational sociology is more concerned with the normative, cultural and cognitive nature of institutions, i.e. their explanatory value in organisational behaviour (Powell and DiMaggio 1991).
Mayntz and Scharpf justify the integration of rational choice views or game theory on the one hand, and institutionalist or structuralist views on the other hand: “What is gained by this fusion of paradigms is a better ‘goodness of fit’ between theoretical perspectives and the observed reality of political interaction that is driven by the interactive strategies of purposive actors operating within institutional settings that, at the same time, enable and constrain these strategies” (Scharpf 1997, p.36). Such a fusion is undertaken in their own approach known as Actor-Centered Institutionalism, but also in the Institutional Analysis and Development framework proposed by Ostrom and colleagues (Ostrom 2005). They understand institutions as rules and norms which affect the costs and benefits that an actor draws from a specific action. This is not only meant in a formalised, legal sense but also in terms of social norms which may be sanctioned by loss of reputation or withdrawal of cooperation (Scharpf 1997).
Organisational theory is generally dealing with circumscribed organisations and their goals, characterised by the interdependent actions of members and their internal division of work. Externally, organisations are also ‘players in the game’ of larger societal systems (or within markets, from the perspective of business administration).
31 Scharpf (1997) defines them as “social entities that are capable of purposive action”
(p.38). In the context of the research presented here, the term ‘organisation’ includes public administrative bodies, private firms and non-governmental organisations. It may also describe a profession in the sense of an association of professionals purposefully interacting with each other. However, professions are better understood as institutions which fulfil particular functions within a society.
Furthermore, professionals constitute a special category within the larger entity of experts. Uncovering expert knowledge may be the aim of interviewing people in exposed positions, possibly decision makers. This methodological approach is pursued for data collection in this study. Both the profession and the organisational affiliation are used as sampling criteria and for structuring the findings of the research. Chapters 2.2.1 and 2.2.2 outline some theoretical correlates of these ‘two sides’ of the experts interviewed.