Geographic Imbalances in Doctor Supply and Policy Responses
By Tomoko Ono, Michael Schoenstein, James Buchan
OECD Health Working Papers No. 69, April 3, 2014
Doctors are distributed unequally across different regions in virtually all OECD countries, and this causes concern about how to continue to ensure access to health services everywhere. In particular access to services in rural regions is the focus of attention of policymakers, although in some countries, poor urban and sub-urban regions pose a challenge as well. Despite numerous efforts this maldistribution of physician supply persists. This working paper first examines the drivers of the location choice of physicians, and second, it examines policy responses in a number of OECD countries.
The choice of practice location is complex, but across the examined OECD countries, several key factors have emerged in studies of doctors and medical students in recent years. First, the relative unattractiveness as places to live and work is the root of an unequal distribution of physicians across regions and areas. Second, the mode of employment and payment for physicians set the frame for their options for location choices. Third, while incomes for general practitioners in rural regions are higher than those in urban regions in some counties, it may not be sufficient compensation as they work for longer hours and in generally more difficult working conditions. Furthermore, professional prestige plays a role as more prestigious specialties tend to be concentrated in urban areas and by default making rural practice less attractive. Finally rural origins and experience in rural settings are influential factors as doctors who are from rural regions are much more likely to go and practice in rural setting compared to those with an urban upbringing.
While a truly comprehensive regional development policy is helpful to tackle the maldistribution of physicians across regions, policymakers in the health sector have three broad strategies to respond to imbalances in physician distribution.
* The first strategy is to target future physicians to maximize the pool of physicians available for practice in relatively underserved regions. This means increasing the number of qualified physicians who are interested in practice in underserved regions, and/or the number of working hours they are willing to provide. The crucial focal point of action for this strategy is the selection and education of medical students.
* The second strategy is to target current physicians to maximise the share of physicians in the health system who practice in underserved regions. This requires a suitable incentive system, which may include both “carrots and sticks”, i.e. not only financial incentives, but also suitable regulatory measures to influence physicians’ location choices.
* The third strategy is to do with less, i.e. accept that staffing levels will be lower in some regions and focus on service re-design or configuration solutions. This can be done through expansion of involvement in health service delivery by non-physician providers. Service delivery innovations can also make a difference, by the use of technology (e.g. through better use of telemedicine), better management of human resources and their workload, or a combination thereof.
Policymakers in most countries will have to blend a range of elements of these three strategies, and review this mix over time. The best mix of such strategies will depend on various factors: patient needs, demography of the population and the physician workforce, health system characteristics, the budgetary situation, and the overall health reform context. While broad characteristics of interventions can be identified, more robust evaluations are required to improve the evidence basis for these policies and strategies in order to support policymakers to make better informed choices.
http://dx.doi.org/10.1787/5jz5sq5ls1wl-en
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Comment:
By Don McCanne, MD
All OECD countries experience maldistribution of the physician supply. Of particular concern is the distribution of primary care physicians, especially the lack of their presence in underserved regions. This OECD working paper describes the problem and suggests some approaches to improve distribution.
Currently I am in San Francisco, participating in the National Conference on Primary Health Care Access presented by the Coastal Research Group. The chief of adult medicine of a highly respected California family medicine residency that is noted for training physicians who would more likely practice in community health centers in underserved communities told me that though their program is initially very successful, their graduates experience burn-out, typically after about three years of practice. This is a very serious problem that obviously requires the attention of public policymakers. This OECD report suggests some strategies that could help.
The fact that all OECD nations experience these problems indicates that the health care financing system alone cannot be expected to correct these deficiencies. However, a public financing system, such as single payer, should improve the flexibility to work with the health care delivery system to drive improvement in the distribution of health care professionals. Our current fragmented financing system provides little opportunity to incentivize strategies that might help.
We do need a single payer national health system, but also we need to elect public officials who believe in better health care for all. Although correcting maldistribution will always remain a challenge, there is much that can be done, but we need people in charge who will want do it.