Urbanization and physician maldistribution: a longitudinal study in Japan.

Shinichi Tanihara,Hiroshi Une,Ichiro Kawachi,Yasuki Kobayashi

doi:10.1186/1472-6963-11-260

Abstract

BackgroundThe relative shortage of physicians in Japan's rural areas is an important issue in health policy. In the 1970s, the Japanese government began a policy to increase the number of medical students and to achieve a better distribution of physicians. Beginning in 1985, however, admissions to medical school were reduced to prevent a future oversupply of physicians. In 2007, medical school entrants equaled just 92% of their 1982 peers. The urban annual population growth rate is positive and the rural is negative, a trend that may affect denominator populations and physician distribution.MethodsOur data cover six time points and span a decade: 1998, 2000, 2002, 2004, 2006, and 2008. The spatial units for analysis are the secondary tier of medical care (STM) as defined by the Medical Service Law and related legislation. We examined trends in the geographic disparities in population and physician distribution among 348 STMs in Japan. We compared populations and the number of physicians per 100,000 populations in each STM. To measure maldistribution quantitatively, we calculated Gini coefficients for physician distribution.ResultsBetween 1998 and 2008, the total population and the number of practicing physicians for every 100,000 people increased by 0.95% and 13.6%, respectively. However, the inequality of physician distribution remained constant, although small and mostly rural areas experienced an increase in physician to population ratios. In contrast, as the maldistribution of population escalated during the same period, the Gini coefficient of population rose. Although the absolute number of practicing physicians in small STMs decreased, the fall in the denominator population of the STMs resulted in an increase in the number of practicing physicians per population in those located in rural areas.ConclusionsA policy that increased the number of physicians and the physician to population ratios between 1998 and 2008 in all geographic areas of Japan, irrespective of size, did not lead to a more equal geographical distribution of physicians. The ratios of physicians to population in small rural STMs increased because of concurrent trends in urbanization and not because of a rise in the number of practicing physicians.

Highlights

The relative shortage of physicians in Japan’s rural areas is an important issue in health policy
There was a bipolar trend in populations of secondary tier of medical care (STM): more heavily populated ones slightly increased their populations from 1998 to 2008; those with relatively smaller populations experienced the opposite tendency
All of the indexes reveal that the inequality of populations among STMs escalated in these years

Summary

Introduction

The relative shortage of physicians in Japan’s rural areas is an important issue in health policy. In the 1970s, the Japanese government began a policy to increase the number of medical students and to achieve a better distribution of physicians. Beginning in 1985, admissions to medical school were reduced to prevent a future oversupply of physicians. In the 1970s, the Japanese government introduced the policy of establishing at least one medical school per prefecture and increasing the total number of medical students. As a result, beginning in 1985, medical school admissions were reduced to prevent a future oversupply of physicians. In 1993, the numbers of those entering medical schools fell to 7725, or 7.7% fewer than in 1984. Since the target reduction was 10% from the number admitted in 1984, the cutback in entering medical students continued. In 2007, 7625 students were accepted for medical training, or 92% of the 1982 entering class

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Discussion

Conclusion