INTRODUCTION: Jichi Medical University (JMU) is an experimental medical school established in 1972 by the Japanese Ministry of Home Affairs and all 47 prefectures in Japan (equivalent to the states of Australia) with a special mission to produce rural doctors and distribute them nationwide. The JMU has adopted a contract-based 'home prefecture recruiting scheme' in which students recruited evenly from all the 47 prefectures of Japan are required to work in their home prefectures for 9 years (including 6 years of rural service) after graduation in exchange for having their 6 years of undergraduate medical education tuition fees waived. Although the JMU system is now being partially adopted by an increasing number of other medical schools in Japan, the effectiveness of this equal distribution scheme is largely unknown. METHODS: A retrospective cohort study of 1255 graduates who had completed their contract by 2000 was conducted. Baseline data were collected at matriculation and graduation between 1972 and 1991. Workplace addresses were followed up in 2000, 2004, and 2006. Follow-up rates were 98.7% in 2000, 98.2% in 2004, and 98.0% in 2006. Data excerpted from the 2004 National Population Census including various demographic indicators (eg population, population density, and physicians/population ratio) for each of the 47 prefectures were merged, through prefectural identification codes, with the baseline and follow-up addresses of the subjects. RESULTS: Of all JMU graduates after contract, 69.8% settled in their home prefectures. The rates varied from 45.5% to 93.3% among the prefectures (p<0.001). The settlement rate tended to be higher in prefectures with a lower population density or physician : population ratio. Among prefectural demographics, the physician : population ratio and medical institution : population ratio were negatively correlated with settlement rate in the prefecture (correlation coefficient -0.34 [p=0.020]; and -0.35 [p=0.017], respectively). In short, prefectures with a relative shortage of physicians had higher settlement rates. In multivariable analysis of personal factors, female sex and physician : population ratio of home prefecture were negatively associated with settlement (OR 0.25 [95%CI 0.10-0.58] and OR for 1 SD increase 0.82 [0.71-0.94], respectively). Primary care specialty was positively associated with settlement (1.80 [1.35-2.39]). Mother's higher academic background was negatively associated with settlement (OR for university vs junior high school graduate 0.54 [95%CI 0.34-0.88]). CONCLUSIONS: The home prefecture recruiting scheme has attained its goal, particularly in medically underserved prefectures. The high retention rates indicate that the scheme would be beneficial for other medical schools in Japan, which are now beginning to implement programs similar to JMU, and also medical educators and policy makers in countries searching for effective political interventions to maldistribution of physicians.
CONTEXT: The number of studies on long-term effects of rural medical education programs is limited. Personal factors that are associated with long-term retention of physicians in rural areas are scarcely known. Purpose: The authors studied the outcomes of Jichi Medical University (JMU), whose mission is to produce rural doctors, and analyzed the characteristics of its graduates who engaged in rural practice even after their 9-year obligation of rural practice. METHOD: A retrospective cohort study was conducted including 2,988 JMU students who graduated between 1978 and 2006. Baseline data were collected at matriculation and graduation. Workplace addresses were surveyed in 2000, 2004, and 2006. Follow-up rates were 98.7%, 98.2%, and 98.0% respectively. FINDINGS: After their obligation period, JMU graduates were 4 times more likely than non-JMU graduates to work in rural areas. The higher proportion of JMU graduates in rural areas did not change significantly between 1994 and 2004. The rural recruitment rate of post-obligation JMU graduates was somewhat lower than rates reported for top rural medical education programs in the United States. In multivariate analyses, rural upbringing and primary care specialty were positively associated with having a rural address in at least one post-obligation study year (OR 1.89 [95% CI 1.27-2.81]; and 7.63 [4.37-13.34], respectively) and settlement (ie, having a rural address over multiple years) after the contract (1.90 [1.04-3.48]; and 32.07 [4.43-232.24], respectively). Graduation from a private high school had a negative association with recruitment (0.56 [0.33-0.96]). CONCLUSIONS: JMU was successful in increasing the number and retention of rural physicians. Rural origin and primary care specialty have a positive impact on both recruitment and retention after the rural obligation.
BACKGROUND: Mosvold Hospital is one of 5 district hospitals providing care for 555,000 indigent people in the Umkhanyakude district, northern KwaZulu-Natal. Recruitment of professional staff is an ongoing challenge for hospital management. An innovative, locally based scholarship scheme, the Friends of Mosveld Scholarship Scheme (FOMSS), was established in 1998 to: (i) identify and fund local scholars admitted to a tertiary facility to study health science courses; (ii) support these students at university or technikon; and (iii) ensure that graduates were integrated into the workforce within the district. OBJECTIVES: To determine the perceptions of FOMSS-supported graduates with regard to the factors leading to success at university/technical college. METHOD: All graduates from the 1999-2002 cohort of students awarded a scholarship by the FOMSS were invited to participate. Focus group discussions or free-attitude interviews were conducted, followed by a self-administered questionnaire. RESULTS: Twenty-four students from Umkhanyakude district supported by the FOMSS have graduated. Eighteen are working in the district, 1 has died, 2 have completed their contract time, 1 is doing further studies and 2 are completing their internships. Factors contributing to their success include personal motivation, support at university, and holiday work experience. CONCLUSIONS: Despite educational challenges, students from rural areas are able to succeed at tertiary institutions and will return to work in rural districts. District hospitals can play an important role in the selection and support of students of rural origin.
Recruiting sufficient health personnel for rural hospitals is an ongoing problem. The Friends of Mosvold Scholarship Scheme in northern KwaZulu-Natal is a locally based scholarship scheme that offers the local community a chance to develop its own human resources for health care. Students are required to work in the local hospital during their vacations and sign a contract to work back their scholarship year for year. Already 44 people from Ingwavuma are being supported to study for a variety of health professions. This concept is being extended to the Limpopo and North-West provinces through the Wits Initiative for Rural Health Education. The scheme provides a model for human resource development at a district level that could be usefully adopted by any tier of government.
Inequitable distribution of doctors with high concentration in urban cities negatively affects the public health objective of Health for All. Thus it is one of the main concerns for most health policy makers, particularly in developing countries. This paper aims to summarize strategies to solve inequitable distribution of human resources for health (HRH) between urban and rural areas, by using four decades of experience in Thailand as a case study for analysis.
CONTEXT: In the mid-1980s, states expanded their initiatives of scholarships, loan repayment programs, and similar incentives to recruit primary care practitioners into underserved areas. With no national coordination or mandate to publicize these efforts, little is known about these state programs and their recent growth. OBJECTIVES: To identify and describe state programs that provide financial support to physicians and midlevel practitioners in exchange for a period of service in underserved areas, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net. DESIGN: Cross-sectional, descriptive study of data collected by telephone, mail questionnaires, and through other available documents, (eg, program brochures, Web sites). SETTING AND PARTICIPANTS: All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physician assistants; and nurse midwives. We excluded local community initiatives and programs that received federal support, including that from the National Health Service Corps. MAIN OUTCOME MEASURES: Number and types of state support-for-service programs in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other practitioners in 1996; numbers in state programs relative to federal programs; and basic features of state programs. RESULTS: In 1996, there were 82 eligible programs operating in 41 states, including 29 loan repayment programs, 29 scholarship programs, 11 loan programs, 8 direct financial incentive programs, and 5 resident support programs. Programs more than doubled in number between 1990 (n = 39) and 1996 (n = 82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states' borders, an emphasis on primary care, and reliance on annual state appropriations and other public funding mechanisms. CONCLUSIONS: In 1996, states fielded an obligated primary care workforce comparable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their activities should be monitored, coordinated, and evaluated. State programs should not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access. JAMA. 2000;284:2084-2092.
This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.
The University of New Mexico Area Health Education Center was established in conjunction with the Navajo Health Authority to begin health manpower development immediately in the Navajo Nation and surrounding areas (a territory approximately the size of West Virginia). To this end, a student support program was established at the Navajo Health Agency to recruit and support Indian students with scholarships, to provide them with culturally based counseling, and to reinforce the students' intentions of ultimately returning to serve Indian people. No payback penalties or other forms of coercion were used in this program to encourage students to return to the underserved Indian areas.From October 1973 through September 1977, 124 students graduated with 125 degrees or certificates in all aspects of health care. Of these 124 students, 76 were employed. The remaining were continuing their education, unemployed, untraceable, or deceased. Of the 76 employed, 61 were from tribes within the Navajo Nation; of these 61, 56 returned to their area to serve Indians. This return rate to an underserved area is substantially better than anticipated from a review of programs that employ a variety of coercive methods to encourage recipients of loans to settle in specific underserved areas after the necessary training.
Jichi Medical University (JMU) is an experimental medical school established in 1972 by the Japanese Ministry of Home Affairs and all 47 prefectures in Japan (equivalent to the states of Australia) with a special mission to produce rural doctors and distribute them nationwide. The JMU has adopted a contract-based 'home prefecture recruiting scheme' in which students recruited evenly from all the 47 prefectures of Japan are required to work in their home prefectures for 9 years (including 6 years of rural service) after graduation in exchange for having their 6 years of undergraduate medical education tuition fees waived. Although the JMU system is now being partially adopted by an increasing number of other medical schools in Japan, the effectiveness of this equal distribution scheme is largely unknown.
METHODS:
A retrospective cohort study of 1255 graduates who had completed their contract by 2000 was conducted. Baseline data were collected at matriculation and graduation between 1972 and 1991. Workplace addresses were followed up in 2000, 2004, and 2006. Follow-up rates were 98.7% in 2000, 98.2% in 2004, and 98.0% in 2006. Data excerpted from the 2004 National Population Census including various demographic indicators (eg population, population density, and physicians/population ratio) for each of the 47 prefectures were merged, through prefectural identification codes, with the baseline and follow-up addresses of the subjects.
RESULTS:
Of all JMU graduates after contract, 69.8% settled in their home prefectures. The rates varied from 45.5% to 93.3% among the prefectures (p<0.001). The settlement rate tended to be higher in prefectures with a lower population density or physician : population ratio. Among prefectural demographics, the physician : population ratio and medical institution : population ratio were negatively correlated with settlement rate in the prefecture (correlation coefficient -0.34 [p=0.020]; and -0.35 [p=0.017], respectively). In short, prefectures with a relative shortage of physicians had higher settlement rates. In multivariable analysis of personal factors, female sex and physician : population ratio of home prefecture were negatively associated with settlement (OR 0.25 [95%CI 0.10-0.58] and OR for 1 SD increase 0.82 [0.71-0.94], respectively). Primary care specialty was positively associated with settlement (1.80 [1.35-2.39]). Mother's higher academic background was negatively associated with settlement (OR for university vs junior high school graduate 0.54 [95%CI 0.34-0.88]).
CONCLUSIONS:
The home prefecture recruiting scheme has attained its goal, particularly in medically underserved prefectures. The high retention rates indicate that the scheme would be beneficial for other medical schools in Japan, which are now beginning to implement programs similar to JMU, and also medical educators and policy makers in countries searching for effective political interventions to maldistribution of physicians.
