Geographic distribution of doctors

Access to medical care requires an adequate number and proper distribution of doctors in all parts of the country. Concentration of doctors in one region and shortages in others can lead to inequities in access such as longer travel or waiting times. The uneven distribution of doctors and the difficulties in recruiting and retaining doctors in certain regions is an important policy issue in most OECD countries, especially those with remote and sparsely populated areas, and those with deprived rural and urban regions.

The overall number of doctors per capita varies across OECD countries from around two per 1 000 population in Turkey, Chile and Korea, to above five per 1 000 population in Greece and Austria (see indicators on doctors in Chapter 8). Beyond these cross-country differences, the number of doctors per capita also varies widely across regions within the same country (Figure 5.9). In many countries there is a high concentration of physicians in capital cities; this is particularly evident in Austria, the Czech Republic, Greece, Mexico, Portugal, the Slovak Republic, and the United States. Between regions, the United States shows nearly a five-fold difference in physician density, while Australia, Belgium and Korea show only around a 20 percent difference in physician densities between regions.

5.9. Physician density, by level 2 regions, 2015 (or nearest year)
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Source: OECD Statistics Database 2017.

 http://dx.doi.org/10.1787/888933603260

The density of physicians is also consistently greater in urban regions, reflecting the concentration of specialised services such as surgery and physicians’ preferences to practice in urban settings. There are large differences in the density of doctors between predominantly urban and rural regions in Canada, the Slovak Republic and Hungary, although the definition of urban and rural regions varies across countries. The distribution of physicians between urban and rural regions was more equal in Japan and Korea, but there are generally fewer doctors in these two countries (Figure 5.10).

5.10. Physician density, rural vs urban areas, 2015 (or nearest year)
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Source: OECD Statistics Database 2017.

 http://dx.doi.org/10.1787/888933603279

Doctors may be reluctant to practice in rural regions due to concerns about their professional life (including their income, working hours, opportunities for career development, isolation from peers) and social amenities (such as educational options for their children and professional opportunities for their spouse). A range of policy levers can be used to influence the choice of practice location of physicians. These include 1) the provision of financial incentives for doctors to work in underserved areas; 2) increasing enrolments in medical education programmes of students coming from specific social or geographic backgrounds or decentralising the location of medical schools; 3) regulating the choice of practice location of doctors (for new medical graduates or foreign-trained doctors); and 4) re-organising service delivery to improve the working conditions of doctors in underserved areas.

Many OECD countries provide different types of financial incentives to attract and retain doctors in underserved areas, including one-time subsidies to help them set up their practice and recurrent payments such as income guarantees and bonus payments (Ono et al., 2014). A number of countries have also introduced measures to encourage students from under-served regions to enrol in medical schools. Japan established in 1973 the Jichi Medical University specifically to educate physicians for service in rural communities, which contributed to improving access to care in underserved rural regions (Ikegami, 2014).

The effectiveness and cost of different policies to promote a better distribution of doctors can vary significantly, with the impact depending on the characteristics of each health system, the geography of the country, physician behaviours, and the specific policy and programme design. Policies should be designed with a clear understanding of the interests of the target group in order to have any significant and lasting impact (Ono et al., 2014).

Definition and comparability

Regions are classified in two territorial levels. The higher level (Territorial Level 2) consists of large regions corresponding generally to national administrative regions. These broad regions may contain a mix of urban, intermediate and rural areas. The lower level is composed of smaller regions classified as predominantly urban, intermediate or rural regions, although there are variations across countries in the classification of these regions. The data on geographic distributions are from the OECD Regional Database.

References

Ikegami, N. (2014), “Factors Determining the Distribution of Physicians in Japan”, Chapter 7 in Universal Health Coverage for Inclusive and Sustainable Development: Lessons from Japan, World Bank, Washington, DC, available at: http://dx.doi.org/10.1596/978-1-4648-0408-3.

OECD (2016), Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264239517-en.

Ono, T., M. Schoenstein and J. Buchan (2014), “Geographic Imbalances in Doctor Supply and Policy Responses”, OECD Health Working Papers, No. 69, OECD Publishing, Paris, http://dx.doi.org/10.1787/5jz5sq5ls1wl-en.