Pediatricians^|^rsquo; Practice Location Choice^|^mdash;Evaluating the Effect of Japan^|^rsquo;s 2004 Postgraduate Training Program on the Spatial Distribution of Pediatricians

Rie Sakai,G^|^Uuml;Nther Fink,Ichiro Kawachi

doi:10.2188/jea.je20130117

Abstract

ObjectivesTo explore determinants of change in pediatrician supply in Japan, and examine impacts of a 2004 reform of postgraduate medical education on pediatricians’ practice location choice.MethodsData were compiled from secondary data sources. The dependent variable was the change in the number of pediatricians at the municipality (“secondary tier of medical care” [STM]) level. To analyze the determinants of pediatrician location choices, we considered the following predictors: initial ratio of pediatricians per 1000 children under five years of age (pediatrician density) and under-5 mortality as measures of local area need, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. Basic comparisons of pediatrician coverage in the top and bottom 10% of STMs were conducted to assess inequality in pediatrician supply.ResultsIncreased supply was inversely associated with baseline pediatrician density both in the pre-period and post-period. Estimated impact of pediatrician density declined over time (P = 0.026), while opposite trends were observed for measures of residential quality. More specifically, urban centers and the SES composite index were positively associated with pediatrician supply for the post-period, but no such associations were found for the pre-period. Inequality in pediatrician distribution increased substantially after the reform, with the best-served 10% of communities benefitting from five times the pediatrician coverage compared to the least-served 10%.ConclusionsResidential quality increasingly became a function of location preference rather than public health needs after the reform. New placement schemes should be developed to achieve more equity in access to pediatric care.

Highlights

Physicians are a limited health-care resource, and optimizing the distribution of physicians is a major challenge to health systems in many countries
Figure shows the distribution of the change in the number of pediatricians in each secondary tier of medical care” (STM) before (1998–2002) and after (2006–2010) the 2004 reform
While the child population gradually declined over the period, the pediatrician supply increased substantially: from 1998–2002, there was a 3.5% increase in the absolute number of pediatricians, and from 2006–2010, there was an 8% increase

Summary

Introduction

Physicians are a limited health-care resource, and optimizing the distribution of physicians is a major challenge to health systems in many countries. The critical challenge in most settings has been that of recruiting physicians to rural areas, where physician coverage is generally low and child health often significantly poorer compared to urban areas. In this regard, Japan is no exception. In 2004, the Ministry of Health, Labour and Welfare (MHLW) in Japan initiated a new postgraduate medical education program to improve the quality of residency training. Prior to 2004, most of the graduating medical students in Japan underwent postgraduate training at a hospital affiliated with the university from which they graduated,[1] with university hospitals systematically placing medical residents in affiliated rural facilities under their supervision. The new program allowed residents to choose their training location directly through a national matching system, thereby reducing university hospitals’ ability to dispatch recent graduates to their rural, affiliated training hospitals

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Conclusion