Second, we introduce the concept of allocative efficiencies to the PHC quality improvement literature and use it to quantify losses due to provider misallocation. In our case, the misallocation takes the form of a very low correlation between a provider’s caseload and their competence: More- and less-competent providers were nearly equally likely to be underutilized. In combination with the variation in caseloads we observed, this means it was often true that large patient populations were handled by low-competence providers while facilities with high-competence providers reported few or no patients.

Combining caseloads and competence measures allowed us to determine that half of the countries in this study are experiencing substantial productivity losses from underutilization among high-competence providers, and could improve the quality of care by reallocating better providers to busier facilities (or making other similar allocative improvements). Such improvements were generally comparable to or greater than the impact of training additional providers to the level of local doctors, suggesting the availability of lower-cost and shorter-term paths to quality improvement.

At the same time, the other half of countries had severe shortages of high-competence providers, and therefore had little to no potential gains from reallocation. These countries also demonstrated substantial excess capacity across their workforce, but typically had fewer high-volume facilities where their few high-competence providers could attend to large numbers of patients. Furthermore, due to the very low overall competence of their workforce, these countries would also be unable to improve the quality of care by producing more providers under business-as-usual medical education, suggesting very serious underlying problems in the development of human capital.

Our findings therefore support a revision in perspective regarding the “human resources crisis in health”, at least at the primary case level. We find that this “crisis” is not consistent with a _general_ shortage of health care providers, as aggregate statistics and facility surveys both indicate that many providers in every context have substantial excess capacity. Instead, there are two different workforce crises at play, whose interaction offers a promising new approach to system-wide quality improvement.

The first crisis arises from substantial variation in utilization. When combined with the temporal clumping of patients, the few facilities where utilization is high can quickly develop long queues. If we take patient demand as fixed, such queues could be better managed by applying stochastic queuing theory as a standard tool in facility personnel management. This would require detailed time and motion studies as well as the development of appropriate administrative tools and protocols, but it does not require a fundamental reassessment of the health system’s human resources.

The harder question is why there is such variation in caseloads to begin with. Our results show that the variation in caseloads is not just a question of rural versus urban clinics, large versus small clinics, or clinics with more and less competent providers. It could be that caseloads reflect historical spatial patterns while circumstances have changed – for instance, clinics may represent relatively fixed investments while changes in population distributions or improvements in transportation networks have occurred rapidly. We do not have the scope here to pursue this further, although we note that contemporary research using data such as the geolocations of clinics, population density estimates, and

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