Widening disparity in the geographic distribution of pediatricians in Japan

Can a Multi-Component Intervention Improve Pediatric Service Delivery in Guangzhou?

Background: Accessible, equitable, and efficient pediatric service is critical to achieve optimal child health. This study aimed to evaluate the effectiveness of a multi-component intervention on the pediatric health system over two different periods in Guangzhou. Methods: Based on the World Health Organization (WHO) "six building blocks" model and Donabedian's "Structure-Process-Outcomes" framework, an intervention package was developed to increase financial and human resouce investment to strengthen basic health care and strive for a better quality of pediatric care. This multi-component intervention package was conducted in Guangzhou to improve the pediatric service delivery during two stages (2011-2014 and 2016-2019). The main outcome indicators were the changes in the allocation of pediatricians and pediatric beds, pediatric service efficiency, and the impact of pediatricians on child mortality. Results: We found that pediatricians per 1,000 children (PPTC) and pediatric beds per 1,000 children (PBPTC) increased from 1.07 and 2.37 in 2010 to 1.37 and 2.39 in 2014, then to 1.47 and 2.93 in 2019, respectively. Infant mortality rate (IMR) and under-5 mortality rate (U5MR) dropped from 5.46‰ and 4.04‰ in 2010 to 4.35‰ and 3.30‰ in 2014 then to 3.26‰ and 2.37‰ in 2019. The Gini coefficients of PPTC and PBPTC decreased from 0.48 and 0.38 in 2010, to 0.35 and 0.28 in 2014, then to 0.35 and 0.22 in 2019, respectively, representing the improvement of pediatric resources distribution according to service population. However, equalities in the spatial distribution were not improved much. The average efficiency of pediatric service fluctuated from 2010 to 2019. A unit increase in PPTC was associated with an 11% reduction in IMR and a 16% reduction in U5MR. Conclusions: Findings suggest this multi-component intervention strategy is effective, particularly on the reduction of child mortality. In future, more rigorous and multi-faceted indicators should be integrated in a comprehensive evaluation of the intervention.

Characteristics and Workload of Pediatricians in China

OBJECTIVES

Although it is widely believed that China is facing a major shortage of pediatricians, the real situation of the current national status of pediatric human resources and their working conditions has not been evaluated to date.

METHODS

We administered a survey to 54 214 hospitals from all 31 provinces in mainland China from 2015 to 2016. Hospital directors of all secondary and tertiary hospitals with pediatric services and a random sample (10%) of primary hospitals provided information on number of pediatricians and their educational levels, specialties, workloads, dropout rates, and other hospital characteristics. A data set of medical resources and socioeconomic information regarding each region (1997-2016) was constructed from the Chinese National Statistics Bureau. The Gini coefficient was used to describe the geographical distributions of pediatricians and hospitals.

RESULTS

There were 135 524 pediatricians in China or ∼4 pediatricians per 10 000 children. Pediatricians' average educational level was low, with ∼32% having only 3 years of junior college training after high school. The distribution of pediatricians was extremely skewed (Gini coefficient 0.61), and the imbalance of highly educated pediatricians was even more skewed (Gini coefficient 0.68). The dropout rate of pediatricians was 12.6%. Despite an increase in the Chinese government's financial investment in health over the last decade, physicians have been burdened with a greater workload.

CONCLUSIONS

Uneven development of the pediatric care system, inadequately trained pediatricians, low job satisfaction, and unmet demand for pediatric care are the major challenges facing China's pediatric health care system.

Future projection of the physician workforce and its geographical equity in Japan: a cohort-component model

INTRODUCTION

The geographical inequity of physicians is a serious problem in Japan. However, there is little evidence of inequity in the future geographical distribution of physicians, even though the future physician supply at the national level has been estimated. In addition, possible changes in the age and sex distribution of future physicians are unclear. Thus, the purpose of this study is to project the future geographical distribution of physicians and their demographics.

METHODS

We used a cohort-component model with the following assumptions: basic population, future mortality rate, future new registration rate, and future in-migration and out-migration rates. We examined changes in the number of physicians from 2005 to 2035 in secondary medical areas (SMAs) in Japan. To clarify the trends by regional characteristics, SMAs were divided into four groups based on urban or rural status and initial physician supply (lower/higher). The number of physicians was calculated separately by sex and age strata.

RESULTS

From 2005 to 2035, the absolute number of physicians aged 25-64 will decline by 6.1% in rural areas with an initially lower physician supply, but it will increase by 37.0% in urban areas with an initially lower supply. The proportion of aged physicians will increase in all areas, especially in rural ones with an initially lower supply, where it will change from 14.4% to 31.3%. The inequity in the geographical distribution of physicians will expand despite an increase in the number of physicians in rural areas.

CONCLUSIONS

We found that the geographical disparity of physicians will worsen from 2005 to 2035. Furthermore, physicians aged 25-64 will be more concentrated in urban areas, and physicians will age more rapidly in rural places than urban ones. The regional disparity in the physician supply will worsen in the future if new and drastic measures are not taken.

Board certification and urban-rural migration of physicians in Japan

Background

The board certification system serves as a quality assurance system for physicians, and its design and operation are important health policy issues. In Japan, board certification was established and operated independently by academic societies and has not been directly linked to reimbursement systems. The phenomenon of younger physicians seeking specialist careers has raised concerns about acceleration of the tendency of fewer physicians working in rural areas and the maldistribution of physicians. Little is known about the associations between physicians’ geographical migration patterns and board certification status changes or between the continuation of urban/rural practice and the maintenance of board certification. This study aimed to identify these associations and to discuss their policy implications.

Methods

We analyzed 2012 and 2014 data from the Survey of Physicians, Dentists, and Pharmacists, a national census survey. To analyze geographical migration patterns, transitions in practice location (rural, intermediate, and urban) were analyzed by board certification status change (new, lost, consistently certified, and consistently uncertified). Logistic regression analysis was conducted to assess whether the odds of migrating to more urban/rural municipalities were associated with board certification status changes, adjusting for covariates, and whether practicing in a rural area was associated with maintaining board certification.

Results

Among 18,726 newly board-certified physicians, 94.9% (13,435/14,150) of those working in urban areas before certification remained in urban areas, whereas 64.6% (393/608) of those working in rural areas stayed in rural areas. Those who were newly certified had higher odds of moving to more urban areas, adjusting for covariates. Those who stayed in rural areas showed lower odds of maintaining board certification, adjusting for covariates.

Conclusions

Newly board-certified physicians are more likely to migrate to other types of areas, particularly more urban areas, than other physicians. Allocating more training quotas to rural areas could be one option for leveling the distribution of specialists. It also appeared that those practicing in rural areas have difficulty maintaining their certification, so the need to establish a support system for already-certified physicians in rural areas should be emphasized.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3441-y) contains supplementary material, which is available to authorized users.

Examining changes in the equity of physician distribution in Japan: a specialty-specific longitudinal study

OBJECTIVES

In this longitudinal study, we examined changes in the geographical distribution of physicians in Japan from 2000 to 2014 by clinical specialty with adjustments for healthcare demand based on population structure.

METHODS

The Japanese population was adjusted for healthcare demand using health expenditure per capita stratified by age and sex. The numbers of physicians per 100 000 demand-adjusted population (DAP) in 2000 and 2014 were calculated for subprefectural regions known as secondary medical areas. Disparities in the geographical distribution of physicians for each specialty were assessed using Gini coefficients. A subgroup analysis was conducted by dividing the regions into four groups according to urban-rural classification and initial physician supply.

RESULTS

Over the study period, the number of physicians per 100 000 DAP decreased in all specialties assessed (internal medicine: -6.9%, surgery: -26.0%, orthopaedics: -2.1%, obstetrics/gynaecology (per female population): -17.5%) except paediatrics (+33.3%) and anaesthesiology (+21.1%). No reductions in geographical disparity were observed in any of the specialties assessed. Geographical disparity increased substantially in internal medicine, surgery and obstetrics and gynaecology(OB/GYN). Rural areas with lower initial physician supply experienced the highest decreases in physicians per 100 000 DAP for all specialties assessed except paediatrics and anaesthesiology. In contrast, urban areas with lower initial physician supply experienced the lowest decreases in physicians per 100 000 DAP in internal medicine, surgery, orthopaedics and OB/GYN, but the highest increase in anaesthesiology.

CONCLUSION

Between 2000 and 2014, the number of physicians per 100 000 DAP in Japan decreased in all specialties assessed except paediatrics and anaesthesiology. There is also a growing urban-rural disparity in physician supply in all specialties assessed except paediatrics. Additional measures may be needed to resolve these issues and improve physician distribution in Japan.

Accessibility to Tertiary Stroke Centers in Hokkaido, Japan: Use of Novel Metrics to Assess Acute Stroke Care Quality

BACKGROUND

Both the accessibility and availability of stroke specialists are major determinants of patient outcomes following acute ischemic stroke (AIS). The purpose of this study was to implement novel metrics to assess the accessibility of tertiary stroke centers as well as to evaluate regional disparities in stroke specialists.

METHODS

Using network analysis in a geographic information system, we calculated areas within 30- and 60-minute travel times to facilities providing intravenous recombinant tissue-type plasminogen activator and mechanical thrombectomy. We further evaluated the accessibility for the proportion of the population aged 65 years or older that resided outside of these areas. Uniformity in the geographical distribution of stroke specialists was then evaluated using optimal statistical analysis.

RESULTS

Accessibility varied widely from region to region, with low accessibility being concentrated in rural areas with low population density. Accessibility to facilities providing mechanical thrombectomy was especially low, and 17.8% of elderly individuals lived ≥60 minutes from treatment facilities. In addition, the distribution of stroke specialists was uneven compared with the distribution of hospital beds and full-time medical doctors.

CONCLUSION

The results of this study revealed regional disparities in the spatial accessibility to treatment facilities, as well as in the distribution of stroke specialists in Hokkaido. These findings provide useful information that could be employed to appropriately allocate resources toward the formation of a medical supply system for patients with AIS.

Distribution of health care resources in Mongolia using the Gini coefficient

BACKGROUND

Attaining the perfect balance of health care resources is probably impracticable; however, it is possible to achieve improvements in the distribution of these resources. In terms of the distribution of health resources, equal access to these resources would make health services available to all people. The aim of this study was to compare the distributions of health care resources in urban, suburban, and rural areas of Mongolia.

METHODS

We compared urban and rural areas using the Mann-Whitney U test and further investigated the distribution equality of physicians, nurses, and hospital beds throughout Mongolia using the Gini coefficient-a common measure of distribution derived from the Lorenz curve. Two indicators were calculated: the distribution per 10 000 population and the distribution per 1000 km² area.

RESULTS

Urban and rural areas were significantly different only in the distribution of physicians per population. However, in terms of the distribution per area, there were statistical differences in physicians, nurses, and hospital beds. We also found that distributions per population unit were equal, with Gini coefficients for physicians, nurses, and hospital beds of 0.18, 0.07, and 0.06, respectively. Distributions per area unit were highly unequal, with Gini coefficients for physicians, nurses, and hospital beds of 0.74, 0.67, and 0.69, respectively.

CONCLUSIONS

Although the distributions of health care resources per population were adequate for the population size, a striking difference was found in terms of the distributions per geographical area. Because of the nomadic lifestyle of rural and remote populations in Mongolia, geographical imbalances need to be taken into consideration when formulating policy, rather than simply increasing the number of health care resources.

Examining sufficiency and equity in the geographic distribution of physicians in Japan: a longitudinal study

OBJECTIVES

The objective of this study was to longitudinally examine the geographic distribution of physicians in Japan with adjustment for healthcare demand according to changes in population age structure.

METHODS

We examined trends in the number of physicians per 100 000 population in Japan's secondary medical areas (SMAs) from 2000 to 2014. Healthcare demand was adjusted using health expenditure per capita. Trends in the Gini coefficient and the number of SMAs with a low physician supply were analysed. A subgroup analysis was also conducted where SMAs were divided into 4 groups according to urban-rural classification and initial physician supply.

RESULTS

The time-based changes in the Gini coefficient and the number of SMAs with a low physician supply indicated that the equity in physician distribution had worsened throughout the study period. The number of physicians per 100 000 population had seemingly increased in all groups, with increases of 22.9% and 34.5% in urban groups with higher and lower initial physician supply, respectively. However, after adjusting healthcare demand, physician supply decreased by 1.3% in the former group and increased by 3.5% in the latter group. Decreases were also observed in the rural groups, where the number of physicians decreased by 4.4% in the group with a higher initial physician supply and 7.6% in the group with a lower initial physician supply.

CONCLUSIONS

Although the total number of physicians increased in Japan, demand-adjusted physician supply decreased in recent years in all areas except for urban areas with a lower initial physician supply. In addition, the equity of physician distribution had consistently deteriorated since 2000. The results indicate that failing to adjust healthcare demand will produce misleading results, and that there is a need for major reform of Japan's healthcare system to improve physician distribution.

[Trends for the Geographic Distribution of Radiological Resources in Hokkaido, Japan: Data Analysis Using Gini Coefficient and Herfindahl-Hirschman Index]

The aim of this study is to analyze the maldistribution and the trends in the geographic distribution of radiological resources in secondary medical areas of Hokkaido. The distribution was measured by combining the Gini coefficient (GC), which is an indicator of inequality of distribution, and the Herfindahl-Hirschman index (HHI), which is mainly used to assess market concentration. Data concerning the distribution of radiological resources, such as CT, MRI, radiotherapy facilities (RTF), radiological technologists (RT), and medical doctors were obtained from official publications. CT was more equally distributed, and RTF was more inequality than other radiological resources in 2014. Radiological resources excluded CT were higher degree of concentration than population distribution, and it showed that they were located relatively more intensively in urban areas than in rural areas. During the period 1999-2014, the GC for CT, MRI, RTF, and RT decreased, while the HHI increased. These trends indicated increased equality of distribution of CT, MRI, RTF, and RT and the concentration in urban areas. This study suggested that GC and HHI could be powerful indicators for allocation planning of medical resources with further analysis of the maldistribution of medical resources.

Differences in medical schools' regional retention of physicians by school type and year of establishment: effect of new schools built under government policy

Background

Physician maldistribution is an ongoing concern globally. The extent of medical schools retaining graduates within their geographical areas has rarely been explored in Japan or in other countries. This study aimed to investigate whether the proportion of medical school graduates practicing in the vicinity of medical school (retention rate) differs by the year of the school’s establishment and by the school’s funding source.

Methods

This cross-sectional study used a set of databases on medical institutions and personnel. We analyzed a sample of 168,594 clinically active physicians practicing in institutions as of May 2014, who passed the National Medical Practitioners Examination between 1985 and 2013. We assessed the retention rate and the schools’ establishment period and funding source (pre-1970/post-1970, private/public), using a hierarchical regression model with random intercept unique to each medical school. We used the following factors as covariates: gender, physicians’ length of professional experience, and the geographical features of the medical schools.

Results

The retention rate was widely distributed from 16.2 to 81.5 % (median: 48.4 %). Physicians who graduated from post-1970 medical schools were less likely to practice in the prefecture of their medical school location, relative to those who graduated from pre-1970 medical schools (adjusted odds ratio: 0.75; 95 % confidence interval: 0.62–0.90). Physicians who graduated from private medical schools were also less likely to practice in the prefecture of their medical school location, relative to those who graduated from public medical schools (adjusted odds ratio: 0.63; 95 % confidence interval: 0.51–0.77). In addition, the ability to retain graduates varied by school according to the school’s characteristics.

Conclusions

There was a considerable difference between medical schools in retaining graduates locally. The study results may have significant implications for government policy to alleviate maldistribution of physicians in Japan.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1240-2) contains supplementary material, which is available to authorized users.

Interventions for increasing the proportion of health professionals practising in rural and other underserved areas

BACKGROUND

The inequitable distribution of health professionals, within countries, poses an important obstacle to the optimal functioning of health services.

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing the proportion of health professionals working in rural and other underserved areas.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, including specialised register of the Cochrane Effective Practice and Organisation of Care Group; March 2014), MEDLINE (1966 to March 2014), EMBASE (1988 to March 2014), CINAHL (1982 to March 2014), LILACS (February 2014), Science Citation Index and Social Sciences Citation Index (up to April 2014), Global Health (March 2014) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (June 2013). We also searched reference lists of all papers and relevant reviews identified, and contacted authors of relevant papers regarding any further published or unpublished work.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-and-after studies and interrupted time series studies evaluating the effects of various interventions (e.g. educational, financial, regulatory or support strategies) on the recruitment or retention, or both, of health professionals in underserved areas.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and assessed full texts of potentially relevant studies for eligibility. Two review authors independently extracted data from eligible studies.

MAIN RESULTS

For this first update of the original review, we screened 8945 records for eligibility. We retrieved and assessed the full text of 125 studies. Only one study met the inclusion criteria of the review. This interrupted time series study, conducted in Taiwan, found that the implementation of a National Health Insurance scheme in 1995 was associated with improved equity in the geographic distribution of physicians and dentists. We judged the certainty of the evidence provided by this one study very low.

AUTHORS' CONCLUSIONS

There is currently limited reliable evidence regarding the effects of interventions aimed at addressing the inequitable distribution of health professionals. Well-designed studies are needed to confirm or refute findings of observational studies of educational, financial, regulatory and supportive interventions that might influence healthcare professionals' decisions to practice in underserved areas. Governments and medical schools should ensure that when interventions are implemented, their impacts are evaluated using scientifically rigorous methods to establish the true effects of these measures on healthcare professional recruitment and retention in rural and other underserved settings.

How the government intervention affects the distribution of physicians in Turkey between 1965 and 2000

Introduction

One of the main weaknesses of the health system in Turkey is the uneven distribution of physicians. The diversity among geographical districts was huge in the beginning of the 1960s. After the 1980s, the implementation of a two-year compulsory service for newly graduated physicians is an interesting and specific experience for all countries. The aim of this study is to analyse the distribution of physicians, GPs and specialists between the years 1965-2000 and the efficiency of the strict 15 year government intervention (1981-1995).

Methods

The data used in this study includes the published data by the Ministry of Health and The State Institute of Statistics between the years 1965–2000. Covering 35 years for total physicians, GPs and specialists, Gini coefficients are calculated so as to observe the change in the distribution. In order to measure the efficiency of government intervention, Gini index belonging to the previous 15 years (first period-1965 to 1980) and the last 15 years (second period) of 1981 when the compulsory service was enacted is also analysed including the statistical tests.

Results

In 1965, the Gini for total physician is quite high (0.47), and in 2000 it decreases considerably (0.20). In 1965, the Gini for GPs and the Gini for specialists is 0.44 and 0.52, respectively and in 2000 these values decrease to 0.13 and 0.28, respectively. It is observed that, with this government intervention, the level of diversity has decreased dramatically up to 2000. Regarding to regression, the rate of decrease in Gini index in the second period is higher for the GPs than that of the specialists.

Conclusion

The inequalities in the distribution between GPs and specialists are significantly different; inequality of specialist distribution is higher than the GP. The improvement of the inequality in the physician distribution produced by the market mechanism shows a long period when it is left to its own devices. It is seen that the compulsory service policy is efficient since the physician distribution has improved significantly. The government intervention provides a faster improvement in the GP distribution.