Inequitable geographic distribution of physicians: systematic review of international experience

Liudvika Starkienė


Background. According to the World Health Organization, approximately one half of the global population lives in rural areas, but these are served by less than a quarter of total physician workforce. This is a global problem that affects almost all countries: some countries are affected to the higher degree and some to the lower degree. Over the last fifty years various attempts to solve this problem have been observed in different parts of the world.

Material and methods. We carried out systematic literature search of PubMed for studies describing intervention programmes aimed at improvement of recruitment and retention of physicians to geographically remote or rural areas. We used the following inclusion criteria: full-text articles, decribing programmes aimed at physicians and published in English in 2000-2013. In the initial search, we identified 922 articles, of which 856 were excluded as duplicates or based on their titles or abstracts. We conducted full-text reviews of the remaining 66 articles. Eighteen articles, which described 14 programs were included in the final review.

Results. Of the reviewed 14 programs, the earliest program was started in Chille in 1963 and the latest – in Senegal in 2006. Four programs were implemented in North America (three in the USA and one in Canada) and Asia (Philipines, India, Indonesia and Japan), two in Australia (nationally and in New South Wales) and Africa (South Africa and Senegal), one in Europe (Norway) and South America (Chille). The following types of programs were analysed: education programs, which train medical students for rural and remote areas (with scholarships and obligations), education programs, which train medical students for rural and remote areas (without scholarships and obligations), short-term oriented programs, professional support programs, and programs aimed at bringing international medical graduates to rural and remote areas. Programs, which were aimed at resolving physician shortage in short-term, usually included financial incentives and some included some other benefits (social benefits, free housing, etc.). These programs were successfull in retaining physicians for duration of contract (2-6 years), and so were international medical graduates-oriented programs. Education programs, which train medical students for rural and remote areas, show some promise, as their results were better compared to other programs. These programs contribute to solving the issue in long-term.

Conclusion. Even though different countries have implemented different intervention programs to address geographic maldistribution of physicians, the design of studies which were included in this systematic review did not allow to confirm whether any of the reviewed programs are effective or not. Rigorous studies are needed to evaluate the true effect of these programs to increase the number of physicians working in remote and rural areas.


physicians; geografic maldistribution; programmes; health policy

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