Strategic analysis of interventions to reduce physician shortages in rural regions

Alya Danish; Regis Blais; Francois Champagne

doi:10.22605/RRH5466

Review Article

Strategic analysis of interventions to reduce physician shortages in rural regions

AUTHORS

name here
Alya Danish¹ PhD, Postdoctoral Fellow *

name here
Regis Blais² PhD, Vice Dean, Academics and Professor

name here
Francois Champagne³ PhD, Professor

CORRESPONDENCE

*Ms Alya Danish

AFFILIATIONS

¹ Faculty of Medicine and Health Sciences, University of Sherbrooke, 150, place Charles-Le Moyne, C. P. 200 Longueuil (Québec), Canada J4K 0A8

^{2, 3} School of Public Health, University of Montreal, PO Box 6128, Station Centre-ville, Montreal, QC H3C 3J7, Canada

PUBLISHED

22 November 2019 Volume 19 Issue 4

HISTORY

RECEIVED: 4 May 2019

ACCEPTED: 13 August 2019

CITATION

Danish A, Blais R, Champagne F. Strategic analysis of interventions to reduce physician shortages in rural regions . Rural and Remote Health 2019; 19: 5466. https://doi.org/10.22605/RRH5466

AUTHOR CONTRIBUTIONS

This work is licensed under a Creative Commons Attribution 4.0 International Licence

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abstract:

Introduction:  Physician shortages in rural regions of OECD countries has led to the development of regulatory, financial, educational and tailored interventions designed to reduce physician shortages. Studies evaluating these interventions report weak or inconclusive results. The objective of this research is to examine the strategic relevance of the interventions by identifying and prioritizing the determinants of physician shortages and analyzing the interventions based on their ability to target the determinants.
Methods:  First, the determinants of physician shortages were identified and categorized using Mays et al’s 2005 method for reviewing qualitative literature. Second, the determinants were prioritized based on importance, severity and solvability, using Lehmann et al’s multilevel categorization of factors affecting attraction and retention. Third, the interventions were analyzed based on their ability to target the determinants through a document analysis as descriptive commentary from a policy analysis perspective.
Results:  Three individual and 10 contextual (work, rural or international context) determinants of physician shortages were identified. Non-rural background, inadequate training and inadequate incentive structure were prioritized as level 1. Lack of professional support, poor work infrastructure and personal interests were prioritized as level 2. Poor rural infrastructure, inadequate supply planning and cultural difference were prioritized as level 3. Non-minority background, geography and climate, global migration and aging population were prioritized as level 4. Establishing rural medical schools targets the greatest number of priority determinants, followed by financial interventions targeting practicing physicians and non-traditional health services delivery strategies. Curriculum changes, professional support strategies, selective admission to medical schools, financially targeting student physicians and coercive regulatory measures follow. Community support strategies target the fewest number of determinants and trickle-down economic regulation targets none.
Conclusion:  Strategic analysis demonstrates that most interventions designed to reduce physician shortages in rural regions are strategically relevant because they address the priority determinants of physician shortages. A link is established between the determinants of physician shortages and the interventions, thereby addressing an important concern expressed in the literature. An original contribution is made to health human resources literature by relying on established theoretical frameworks to achieve a strategic analysis of the interventions.

Keywords:

OECD, physician shortages, prioritization, rural regions, strategic analysis.

full article:

Introduction

Physician shortages in rural regions are prevalent across OECD member countries. Due to the central role occupied by the physician in improving the delivery of and access to essential health services by disadvantaged populations, OECD member countries have devised various interventions to attempt to mitigate the shortage of physicians in rural regions^1-3. Regulatory, financial, educational⁴ and tailored interventions are designed to encourage physicians to set up their medical practice in underserviced, rural or remote areas and at the same time discourage them from practicing in oversupplied, urban areas³. The interventions are subcategorized into 10 different strategies, described in Table 1.

However, no single intervention leading to a sustainable solution to the shortages of physicians in rural areas has been identified⁴. A recent OECD report describes policy responses as ‘largely conceived and implemented in the absence of evidence’³. One of the main critiques of existing interventions is that they rarely make reference to the determinants of physician practice location, so that interventions do not match the reasons why physicians may or may not practice in a given location^5-8. In the field of public health evaluation, this reported weakness of the interventions is referred to as strategic relevance, a criterion that describes the coherence between the activities of the intervention and the target problem⁹^,10. A corollary of the principle of intervention relevance is the idea that the causes of a problem are not equal; some may contribute more to the problem than others. The relevance of an intervention also refers to its consistency with the greater social context, and with an organization’s priorities and mandate¹⁰. For an intervention to achieve its intended results, it must be designed in a way that responds to the causes of the problem being addressed¹¹.

Table 1: A description of the interventions to reduce physician shortages in rural regions table image

The objective of this research was to examine the strategic relevance of the interventions to reduce physician shortages in rural regions of OECD countries, first, by identifying the determinants of physicians shortages; second, by prioritizing the determinants; and, finally, by analyzing the interventions that have been implemented across OECD countries based on their ability to target the determinants of physician shortages in rural regions.

Methods

Strategic analysis is a type of program evaluation used in the health and social services to rank and order public health problems and their solutions, based on which of them need to be addressed first and how they will be addressed, while taking into account the needs of the target population.

Strategic analysis is intended to be an accessible evaluation tool for policy makers and evaluators in a workplace setting and therefore uses priority-setting methods that rely upon existing documents and/or expert opinion as the primary sources of information¹¹. There are three main steps to conducting a strategic analysis. The first is to identify the set of problems that the intervention is intended to address. The second step is to prioritize the problems based on their relative importance and on the ability to intervene upon them. The third step is to analyze whether and how the intervention in question addresses priority problems¹¹.

Step 1: Identifying the problems

To identify the set of problems the interventions are intended to address, a literature review on the determinants of physician shortages was conducted. Publications were initially selected from the OECD and WHO research databases, using the key terms ‘causes/determinants’, ‘physicians/healthcare workers/healthcare personnel’, ‘geographic’, ‘distribution/shortage’ and ‘rural/remote/isolated/underserved/underserviced’. The citations of relevant publications were snowballed. This search was repeated in Medline including studies published between January 1995 and December 2014. Studies that examine non-OECD member countries were excluded, as well as those pertaining to non-physician health professionals. Studies pertaining to international medical graduates (IMGs) and associated regulation and procedures were also excluded because the use of IMGs is not among the interventions evaluated in this research (Table 1).

The method suggested by Mays et al in 2005 for reviewing qualitative evidence for management and policy in the health field was used to inform the inclusion of publications in the literature review¹². A purposive sampling approach was thus used to identify publications based on whether they refer to ‘internal’ (individual) determinants or ‘external’ (contextual) determinants influencing physician shortages¹²^,13. Purposive sampling makes use of large volumes of descriptive data, allowing for maximum variation, and the inclusion of studies that may otherwise be excluded from systematic reviews¹³^,14. The most information-rich studies were included until a theoretical saturation was reached: when incremental learning became minimal due to the same determinants of physician shortages being repeatedly identified in the literature¹⁴^,15. This was an iterative process involving all three authors, where disagreements or discrepancies were resolved by consensus.

Step 2: Prioritizing the problems

To prioritize the determinants of physician shortages three criteria were used: importance, severity and solvability^16-18. Importance refers to the size of a problem.Severity refers to the seriousness of a problem and its potential impact. Solvability refers to the potential for conceiving and implementing solutions to the problem; in other words, how well a problem can be solved, if at all¹⁶^,18^,19.

The importance of a determinant of physician shortages in rural regions was based on the number of published articles identifying it as such. The articles were categorized according to the strength of the evidence they provide, based on the Cochrane Collaborative’s grading system for the quality of a body of evidence²⁰. Descriptive studies or expert opinion were given a weight of 1, cohort or case control studies a weight of 2, and systematic reviews a weight of 3.

To determine the severity and the solvability of the determinants of physician shortages, a multilevel framework was relied upon (Fig1)⁶^,21. This framework has previously been used to further understanding of the factors affecting the recruitment and retention of healthcare workers, but in low- and middle-income countries rather than in OECD member states²¹. Multilevel frameworks depict how individual behavior is influenced by structured contingencies, opportunities and constraints, within several layers of contexts²²^,23. Higher-level or contextual factors enable and constrain lower levels, or individual factors, and are the drivers of interactions among lower-level phenomena such as attitude and behavior^24-27. This is a ‘top-down’ process referred to as embededness, where lower level factors take on the characteristics of and become aligned with the higher levels²⁷.

The severity and solvability scores are based on the position of a determinant in the multilevel conceptual framework. Determinants situated at the outermost level of the framework are most distal from the individual, and exhibit the most constraining properties, not just on the individual, but on all the layers embedded within them. They are thus the most severe. However, these determinants lie outside of the realm of public health intervention and are considered unmodifiable, therefore the most difficult to solve¹⁸^,28. The rural context is easier to intervene upon, followed by the work context, then individual determinants, which are considered the easiest to target through intervention programs^29-31. However, individual determinants are less severe because they lack the constraining properties of higher level contextual determinants.

For these reasons, determinants situated at the individual level received a 0 for severity, at the work context level a 5, at the rural context level a 10 and at the international level a 15. Individual-level determinants received a solvability score of 4, work environment level a 3, rural context level a 2, and international context level a 1. A total score for each determinant of physician shortages was calculated by multiplying the sum of importance and severity by solvability: (importance + severity) x (solvability)¹⁶. According to established methods of strategic analysis, the determinants of physician shortages were evenly divided into four categories based on their total scores¹¹. Priority level 1 determinants of physician shortages are those that should be targeted first through policy intervention, followed by priority level 2 determinants¹¹. Priority level 3 determinants are those requiring further research, while level 4 determinants are of secondary importance in terms of research¹¹.

table image Figure 1: Determinants of physician shortages in rural regions in OECD countries.

Step 3: Analyzing the interventions

Each intervention was analyzed based on whether and how it addresses priority determinants of physician shortages. The content of included studies was analyzed as descriptive commentary from a policy analysis perspective¹⁴. This approach is used by case study researchers and policy analysts to answer ‘how and why’ questions, and provides insight into collective actions, organizational dynamics and institutional structures through descriptive interpretation of documents¹⁴. This was an iterative process involving all three authors, where disagreements or discrepancies were resolved by consensus. The final analysis was presented to a panel of four field experts, a health economist, a demographer/epidemiologist with expertise in rural and remote health, an evaluation and health policy specialist and a family physician/health administrator. All suggested modifications were incorporated in the final manuscript.

Results

A total of 97 articles were included in the review,including 14 systematic reviews and six cohort studies. The remaining publications were descriptive studies. Publications covered a wide range of disciplines: public health literature accounted for 33 of the publications, while 24 articles came from rural health journals; 20 from medical journals; 11 from the social sciences including economics, geography and sociology journals; and nine from the organizational sciences. The review identified 13 determinants of physician shortages in rural regions of OECD countries. A detailed description of the determinants is presented in Appendix I.

The determinants were categorized based on Lehmann et al’s 2008 framework describing the different environments affecting attraction and retention, as shown in Figure 1⁶. The determinants were then prioritized according to the described method (Table 2).

Finally, the interventions designed to address the shortages of physicians in rural regions of OECD countries were analyzed based on their ability to target the priority determinants. This is displayed in Table 3.

Table 2: Prioritization of the determinants of physician shortages in rural regions

Table 3: Analysis of interventions to reduce physician shortages in OECD countries

Regulatory interventions

Trickle-down economics: Trickle-down economic strategies do not respond to any of the causes of physician shortages in rural regions. Increasing the supply of physicians to rural regions is thought to be accomplished by increasing the overall number of individuals entering into a medical career³². However, the economic assumption that the oversupply of physicians will ‘trickle down’ to underserviced areas has been refuted^33-35. Physician supply forecasting models have a limited ability to consider healthcare labour trends²⁸^,32^,36^,37.

Coercive measures: Intervention strategies that can bring the physician to a rural region may improve the chances that he or she will later choose rural medicine as a career. Several studies have noted a ‘dose–response’ relationship between the duration of exposure to a rural location and the likelihood of subsequently choosing rural medical practice²⁹^,38-41. Compulsory service in rural regions can result in a valuable learning experience serving disadvantaged communities, and a physician’s greater interest for rural health concerns and for primary care medicine⁴. Mandating rural medical service is a comparatively low-cost solution to increasing professional support for rural physicians³^,8.

Financial interventions

Targeting student physicians: Scholarship or loans repayment programs are offered in exchange for rural medical service, which exposes medical students to rural life. This experience may dispel some of the negative stereotypes associated with rural medicine³. Associating financial reward with rural medicine is a form of institutional recognition that can improve the perceived lower ranking of rural medicine and stimulate students’ personal interests³^,42. Students who participate in such programs receive more adequate training in rural medicine and are better prepared to practice⁴³^,44. Financial interventions are a relatively straightforward and quick method for relieving student debt and exposing students to rural medicine⁴^,5.

Targeting practicing physicians: This strategy addresses the determinants of physician shortages in a similar manner to targeting medical students, while addressing an additional four determinants. The inadequate incentive structure of rural medicine is targeted through pay increases for rural physicians as implemented in a number of OECD member countries to reduce turnover in underserviced areas²⁸. A variety of financial incentives are offered to differentiate rural physicians from their urban counterparts; these incentives include annual guaranteed minimum income, higher capitation payments, or premiums for regions with low patient volume³^,45^,46. Financing is offered to support locum programs and on-call duties, and for hiring nurses or physician assistants, which targets the lack of professional support⁴⁴^,46^,47. Financial strategies circumvent some of the inadequacies of rural practice infrastructure through payment of expenses for medical equipment, or reimbursement for the setup costs of private practice³^,46^,48. Providing rural physicians with reimbursement for travel expenses can help ease the burden of being geographically isolated from family and friends⁴⁹.

Educational interventions

Selective admission: Selective admission strategies target non-rural background. For example, ‘rural pipeline’ programs in Scotland and Japan recruit students directly from rural high school for entry into medical school³^,39. In Canada, Australia and the USA, medical schools screen for a student’s personal interest in primary care, which studies suggest is a proxy determinant for interest in rural medicine^50-52. The Rural Medical Scholars Program in Alabama, and similar interventions in Michigan and Missouri, screen for a student’s ‘humanitarian outlook’, and actively recruit students who have a demonstrated history serving the disadvantaged⁷^,39^,53^,54. Selective admission strategies are unique in their ability to target rural areas with a high concentration of minority and/or low socioeconomic groups, as well as students from disadvantaged or minority groups. University of Manitoba’s Northern Medical Unit actively selects Aboriginal students for premedical preparation, and Australia’s Flinders University targets Indigenous Australians, a visible minority group that is underrepresented in medical careers⁷^,55^,56.

Curriculum changes: Studies show that medical students enrolled in a rurally focused curriculum are more likely to work in underserved areas than those in conventional medical programs⁴⁶^,50. Specialized curricula allow physicians to acquire the broad skill set necessary to practice medicine in a rural setting and produce graduates with locally relevant competencies⁴^,50. Some medical schools in Canada, Australia, the USA and Belgium engage in partnership activities with rural health system personnel, thereby facilitating the creation of professional networks, collaboration and the increase of professional support for rural physicians⁵⁰^,56. Curricula that embed students early on in community and local clinics rather than in a university and hospital setting provide the type of hands-on experience that can increase interest in primary care, in rural medicine and in community service⁵⁵^,56.

Rural medical schools: Establishing medical schools, satellite campuses or ‘polyhealth’ clinics in rural regions is one of the costliest intervention strategies, because it involves an investment in infrastructure³^,57. However, evidence suggests that it is one of the most effective strategies to reduce physician shortages, in part by prolonging their rural experience and minimizing exposure to urban distractions²⁹^,39^,41. Rural medical schools eliminate, or greatly reduce, comparisons to urban practice, and expectations of urban teachers and staff, which can undermine a student’s rural inclination⁵^,31^,51^,55. Physicians are not expected to automatically transfer the skills acquired through a conventional urban medical education to the rural setting, where advanced technology, equipment and specialized support may be unavailable⁴. Rural medical schools, with their faculty, staff, and professional and community networks, improve professional support in rural regions³. A campus or clinic strategically placed in a rural or remote region can widely disperse medical services to hard-to-reach areas⁵⁷. This ‘medicalizes’ the region and makes it less isolated, in part by improving infrastructure⁸^,28. Developing rural infrastructure improves the medical practice infrastructure of rural regions by facilitating the acquisition of equipment and technological and human resources⁴^,57. Where research, training and partnerships are established between medical schools and local health systems, community engagement in health care increases, which helps to overcome the cultural difficulties that are sometimes reported by rural physicians⁴^,39.

Tailored interventions

Community support: Programs in Australia, Canada and the USA offer community mobilization activities to foster cooperation between an incoming physician and community members²⁸^,48. Some interventions offer ‘health and wellbeing’ support by linking physicians to community resources⁵⁸. Some OECD countries assist physician spouses to identify job opportunities²⁸. The Southern Rural Access Program in the USA helps rural communities to recruit a physician who is ‘the right fit’ for their needs as well as providing technical assistance towards the enhancement of local capacities⁵⁹.

Professional support: These intervention strategies encourage collaboration between rural health professionals and facilitate the creation of professional networks²⁸. Some countries have introduced ‘model practices’ in rural regions, where the delivery of health services is shared among multidisciplinary teams, allowing for more flexible work conditions and improving the practice infrastructure in rural regions³. Such initiatives have been shown to enhance the technical preparedness of rural physicians byincreasing opportunities for consultation, research and professional development to physicians³.

Non-traditional services delivery: Non-traditional health service delivery are beneficial for remote areas with a high concentration of minority and low socioeconomic groups. Programs in Canada and in Australia allow specialists to travel intermittently to isolated regions, or where the population base is too small to establish permanent clinics³^,4^,45. Web services allow rural physicians to connect with other health professionals, thereby reducing professional isolation. Many OECD countries are investing in improving broadband capacity in rural regions to effectively use advanced technology, an important step towards improving practice infrastructure³^,57. In Germany, rural physicians conduct ‘virtual visits’ with patients and communicate using e-health applications³. Studies suggest that telehealth networks in Canada have improved access to health care in Indigenous communities, who receive generalist and specialist consultations, and patient education through this intervention⁴⁵. A digital platform was established in some rural areas to cut down on commuting time for home visits, especially for chronically ill patients, making it an effective approach to providing health care to an increasingly aging population⁵⁷.

Discussion

This study presents a strategic analysis of the interventions to reduce physician shortages in rural regions of OECD countries by identifying the determinants of physician shortages in rural regions of OECD countries, prioritizing them and analyzing the interventions based on their ability to address the priority determinants of the problem. A link is therefore established between the determinants of physician shortages and the broad spectrum of interventions intended to mitigate them, addressing an important concern that has been expressed repeatedly in the literature^3-8.

This research demonstrates that establishing medical schools in rural areas is the most strategically relevant intervention because it targets the greatest number of determinants of physician shortages and functions at multiple levels, by contributing to rural infrastructure, by engaging local communities and by improving the day-to-day experiences of rural physicians, rural medical students and their families. Such is the case of the Northern Ontario School of Medicine in Canada, which distributes medical training to more than 70 teaching and research sites across Northern Ontario, and which has demonstrated positive results in keeping graduates in rural regions⁴⁵^,51.

Financial interventions are the most commonly implemented in OECD countries³^,48^,60^,61.This research sheds light on possible reasons for this: financial interventions target some of the most important, severe and solvable determinants of physician shortages. This study also reveals that financially targeting practicing physicians is strategically more relevant than it is to target medical students, who accrue greater benefit from educational strategies. Evidence suggests an important selection bias among students who participate in ‘return-of-service’ incentive schemes; these students would have chosen rural placements anyway⁸^,43^,50.

Non-traditional health services delivery strategies are shown to target a significant number of determinants of physician shortages at multiple levels, but outreach clinics have not been adequately documented in the literature and telemedicine has only recently gained attention as an important tool to improve health services delivery to rural and remote regions⁵^,8^,62.

Selective admissions policies are particularly useful in recruiting underrepresented groups into the rural medical pipeline, while community support strategies are the only interventions targeting the cultural differences that may deter physicians from accepting rural positions, or communities from welcoming new physicians. Professional support strategies target a small number of priority determinants of physician shortages, so may be best used in combination with strategies that target other determinants.

Regulatory interventions employing coercive strategies effectively target some of the determinants of physician shortages, but evidence suggests that they are disliked by both physicians and administrators⁸^,50^,63. Finally, laissez-faire regulatory strategies allowing market forces to dictate the geographic distribution of physicians have been shown to address none of the determinants of physician shortages and are therefore strategically irrelevant.

Two determinants of physician shortages are not addressed by any of the interventions: inadequate supply planning and global migration. A review of the tools and policies organizing physician labor supply and planning is required, as well as addressing the political opposition to innovative solutions to health services provision in rural regions, such as task sharing and skillmix⁶⁴. Further research and policy development are needed to address the need for infrastructure and services development, and the lack of amenities and basic life needs,which drives professionals away from rural areas.

This research makes an original contribution to the rural health human resources literature by functionalizing the multilevel frameworks prevalent in the literature⁴^,6^,21^,64^,65. To the authors’ knowledge, this is the first study to utilize this framework to categorize the determinants of physician shortages in OECD countries, and it is the first to use the framework as a basis for prioritizing the determinants, thereby achieving an evaluative exercise (strategic analysis}) rooted in theoretically established perspectives of a health human resources phenomenon.

An important contribution to the understanding of the determinants of physician shortages is made. As determinants move away from the individual level to more ‘distal’ levels of the framework, they become closer to being ‘fundamental causes’ of organizational or health phenomena⁶⁶. Interventions that tackle fundamental causes of public health problems by altering the social, economic and political contexts have a greater potential for achieving success in the long term, even though these interventions may be more difficult to implement⁶⁷^,68. Agentic interventions, which focus on an individual’s choice to act, may be easier to implement but are also ‘temporary and palliative’, producing only short-term gains⁶⁹. This point is worth noting when considering the persistence of physician shortages against the relative success of more complex, multilevel interventions, such as establishing medical schools in rural regions.

Limitations

The review of the literature is not a systematic review and is therefore not exhaustive. The aim was to achieve theoretical saturation in identifying the determinants of physician shortages in OECD countries. Although literature was deliberately selected from a wide range of disciplines, some relevant publications may have been excluded.

The prioritization method used to rank the determinants relied on the attribution of numerical values to represent the relative severity and solvability of the determinants. This was done to facilitate the calculation of a final score for each determinant. Further research is necessary to examine the validity of this scoring system.

Conclusion

Strategic analysis demonstrates that most interventions designed to reduce physician shortages in rural regions are strategically relevant because they address the priority determinants of physician shortages. A link is established between the determinants of physician shortages and the interventions, thereby addressing an important concern expressed in the literature. An original contribution is made to rural health human resources literature by relying on established theoretical frameworks to achieve a strategic analysis of the interventions.

Acknowledgements

We would like to thank Doug Angus, Barthelemy Kuate Defo, Jean-Louis Denis and Carl-Ardy Dubois for their valuable comments on this research.

references:

1 Dussault G, Dubois CA. Human resources for health policies: a critical component in health policies. Human Resources for Health 2003. DOI link, PMid:12904254

2 Kabene SM, Orchard C, Howard JM, Soriano MA, Leduc R. The importance of human resources management in health care: a global context. Human Resources for Health 2006; 4(20). DOI link, PMid:16872531

3 Ono T, Schoenstein M, Buchan J. Geographic imbalances in doctor supply and policy responses. Paris: OECD Publishing, 2014. DOI link

4 World Health Organization. Increasing access to health workers in remote and rural areas through improved retention. 2010. Available: web link (Accessed 15 September 2017).

5 Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bulletin of the World Health Organization 2010; 88(5): 379-385. DOI link, PMid:20461133

6 Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Services Research 2008; 8: 19. DOI link, PMid:18215313

7 Avery DM, Jr, Wheat JR, Leeper JD, McKnight JT, Ballard BG, Chen J. Admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in the Rural Medical Scholars Program. Journal of Rural Health 2012; 28(2): 128-136. DOI link, PMid:22458313

8 Wilson N, Couper I, De Vries E. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote Health 2009; 9(3): 1090. Available: web link (Accessed 15 September 2017).

9 United Nations Evaluation Group. UNEG handbook for conducting evaluations of normative work in the UN system. Geneva: United Nations Press, 2013.

10 World Health Organization. WHO evaluation practice handbook. Geneva: WHO Press, 2013.

11 Brousselle A, Champagne F, Contandriopoulos A, Hartz Z (Eds). Evaluation: concepts and methods. [In French]. Montreal: University of Montreal Press, 2011. DOI link

12 Mays N, Pope C, Popay J Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. Journal of Health Services Research and Policy Montreal. 1 July. DOI link, PMid:16053580

13 Mays N, Pope C. Rigour and qualitative research. British Medical Journal 1995; 311: 109-112. DOI link, PMid:7613363

14 Miller FA, Alvarado K. Incorporating documents into qualitative nursing research. Journal of Nursing Scholarship 2005; 37(4): 348-353 . DOI link

15 Eisenhardt KM. Building theories from case study research. Academy of Management Review 1994; 14(4): 532-550. DOI link

16 Pineault R. Health planning: concepts, methods, strategies. Ottawa: Éditions Nouvelles, 1995.

17 Baltussen R, Niessen L. Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Effectiveness and Resource Allocation 2006; 4(14). DOI link

18 Centers for Disease Control and Prevention. Prioritizing public health problems. GA2013. Atlanta, GA: Centers for Disease Control and Prevention, 2013.

19 Hanlon N, Halseth G, Ostry A. Stealth voluntarism: an expectation of health professional work in underserviced areas? Health Place 2011; 17(1): 42-49. DOI link, PMid:20605511

20 Cochrane Collaboration. Cochrane handbook for systematic reviews of interventions. Available: web link 2011. (Accessed 15 September 2017).

21 Araujo E. Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries: a guidance note. Washington, DC: World Bank, 2013.

22 Bronfenbrenner N The ecology of human development: experiments by nature and design. Cambridge, MA: Harvard University Press, 1974.

23 Glass TA, McAtee MJ. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Social Science and Medicine 2006; 62(7): 1650-1671. DOI link, PMid:16198467

24 Bamberger PA. From the editors: beyond contextualization: using context theories to narrow the micro-macro gap in management research. Academy of Management Journal 2008; 51(5): 839-846. DOI link

25 Costa PL, Graça AM, Marques-Quinteiro P, Santos CM, Caetano A, Passos AM. Multilevel research in the field of organizational behavior. SAGE Open 2013; 3(3): 1 July. DOI link

26 Festing M, Maletzky M. Cross-cultural leadership adjustment – a multilevel framework based on the theory of structuration. Human Resource Management Review 2011; 21(3): 186-200. DOI link

27 Rousseau DM, Aguinis H, Boyd BK, Pierce CA, Short JC. Reinforcing the micro/macro bridge: organizational thinking and pluralistic vehicles. Journal of Management 2010; 37(2): 429-442. DOI link

28 Organization for Economic Cooperation and Development. The looming crisis in the health workforce: how can countries respond? Available: web link (Accessed 15 September 2017).

29 Humphreys J, Wakerman J, Wells R. Improving primary health care workforce retention in small rural and remote communities: how important is ongoing education and training? 2007. Available: web link (Accessed 15 September 2017).

30 Pathman DE, Konrad TR, Dann R, Koch G. Retention of primary care physicians in rural health professional shortage areas. American Journal of Public Health 2004; 94(10): 1723-1729. DOI link, PMid:15451741

31 Rourke J. Increasing the number of rural physicians. Canadian Medical Association Journal 2008; 178(3): 322-325. DOI link, PMid:18227453

32 Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annual Review of Medicine 2012; 63: 435-445. DOI link, PMid:21888514

33 Bloor K, Maynard A. Planning human resources in health care: towards an economic approach – an international comparative review. Available: web link (Accessed 15 September 2017).

34 Matsumoto M, Inoue K, Bowman R, Noguchi S, Toyokawa S, Kajii E. Geographical distributions of physicians in Japan and US: impact of healthcare system on physician dispersal pattern. Health Policy 2010; 96(3): 255-261. DOI link, PMid:20236722

35 Zurn P, Dal Poz MR, Stilwell B, Adams O. Imbalance in the health workforce. Human Resources for Health 2004; 2(1): 13. DOI link, PMid:15377382

36 Dumont J, Zurn P, Church J, Thi CL. International mobility of health professionals and health workforce management in Canada: myths and realities. 2008. Available: web link (Accessed 15 September 2017).

37 Fournier M. Health workforce policies in Québec: a review. [In French]. Ruptures 2001; 7(2): 79-98.

38 Chan BT, Degani N, Crichton T, Pong RW, Rourke JT, Goertzen J, et al. Factors influencing family physicians to enter rural practice: does rural or urban background make a difference? Canadian Family Physician 2005; 51: 1246-1247.

39 Crump WJ, Barnett D, Fricker S. A sense of place: rural training at a regional medical school campus. Journal of Rural Health 2004; 20(1): 80-84. DOI link, PMid:14964931

40 Henry G. Beyond use: understanding evaluation’s influence on attitudes and actions. American Journal of Evaluation 2003; 24(3): 293-314. DOI link

41 Orzanco MG, Lovato C, Bates J, Slade S, Grand’Maison P, Vanasse A. Nature and nurture in the family physician’s choice of practice location. Rural and Remote Health 2011; 11(3): 1849. Available: web link (Accessed 15 September 2017).

42 Bilodeau H, Leduc N, van Schendel N. Analysis of attraction, recruitment and retention of medical practice in remote regions of Québec: final report. [In French]. 2006. Available: web link

43 Barnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: a systematic review. BMC Health Services Research 2009; 9: 86. DOI link, PMid:19480656

44 Fournier M, Contandriopoulos A, Diene CP, Trottier L. Attraction and retention of physicians in remote regions: policies adopted by Canadian provinces and other countries and lessons for Québec. [In French]. 2004. Available: web link

45 Pong RW, Russell N. A review and synthesis of strategies and policy recommendations on the rural health workforce. 2003. Available: web link (Accessed 15 September 2017).

46 Simoens S, Hurst J. The supply of physician services in OECD countries. 2006. Available: web link (Accessed 15 September 2017).

47 Kearns R, Myers J, Adair V, Coster H, Coster G. What makes ‘place’ attractive to overseas-trained doctors in rural New Zealand? Health and Social Care in the Community 2006; 14(6): 532-540. DOI link, PMid:17059495

48 Bourgeuil Y, Mousquès J, Tajahmadi A. Improving the geographic distribution of health professionals. 2006. Available: web link (Accessed 15 September 2017).

49 Viscomi M, Larkins S, Gupta TS. Recruitment and retention of general practitioners in rural Canada and Australia: a review of the literature. Canadian Journal of Rural Medicine 2013; 18(1): 13-23.

50 Grobler L, Marais BJ, Mabunda SA, Marindi PN, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas (Review). The Cochrane Library 2009; 1: CD005314. DOI link

51 Pong RW, Heng D. The link between rural medical education and rural medical practice location: literature review and synthesis. 2005 Available: web link (Accessed 15 September 2017).

52 Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. Academic Medicine 2008; 83(3): 235-243. DOI link, PMid:18316867

53 Porterfield DS, Konrad TR, Porter CQ, Leysieffer K, Martinez RM, Niska R, et al. Caring for the underserved: current practice of alumni of the National Health Service Corps. Journal of Health Care for the Poor and Underserved 2003; 14(2): 256-271. DOI link, PMid:12739304

54 Quinn KJ, Hosokawa MC. Factors contributing to the specialty selection, practice location, and retention of physicians in rural practice. Annals of Behavioral Science and Medical Education 2010; 16(1): 21-27. DOI link

55 Curran V, Bornstein S, Jong M, Fleet L. Strengthening the medical workforce in rural Canada: the roles of rural/northern medical education. 2004. Available: web link (Accessed 15 September 2017).

56 Murray RB, Larkins S, Russell H, Ewen S, Prideaux D. Medical schools as agents of change: socially accountable medical education. Medical Journal of Australia 2012; 196(10): 653. DOI link, PMid:22676883

57 Organization for Economic Cooperation and Development. Strategies to improve rural service delivery. 2010. Available: web link (Accessed 15 September 2017).

58 Wakerman J, Humphreys JS, Wells R, Kuipers P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia: a systematic review. BMC Health Services Research 2008; 8: 276. DOI link, PMid:19114003

59 Felix H, Shepherd J, Stewart K. Recruitment of rural health care providers: a regional recruiter strategy. Journal of Rural Health 2003; 19: 340-346. DOI link, PMid:14526517

60 Buykx P, Humphreys J, Wakerman J, Pashen D. Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy. Australian Journal of Rural Health 2010; 18(3): 102-109. DOI link, PMid:20579020

61 Sempowski IP. Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: systematic review of the literature. Canadian Journal of Rural Medicine 2004; 9(2): 82-88.

62 Gagnon MP, Duplantie J, Fortin JP, Landry R. Exploring the effects of telehealth on medical human resources supply: a qualitative case study in remote regions. BMC Health Services Research 2007; 7: 6. DOI link, PMid:17217534

63 Ono T, Lafortune G, Schoenstein M. Health workforce planning in OECD countries: a review of 26 projection models from 18 countries. Paris: OECD Publishing, 2013.

64 Dubois CA, Singh D. From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management. Human Resources for Health 2009; 7: 87. DOI link, PMid:20021682

65 Franco LM, Bennett S, Kanfer R. Health sector reform and public sector health worker motivation: a conceptual framework. Social Science and Medicine 2002; 54(8): 1255-1266. DOI link

66 Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 80-94. Available: web link (Accessed 1 September 2017).

67 Blakenship KM, Bray SJ, Merson MH. Structural interventions in public health. AIDS 2000; 14(S1): 11-21. Available: web link, DOI link, PMid:10981470 (Accessed 1 September 2017).

68 Blakenship KM, Friedman SR, Dworkin S, Mantell JE. Structural interventions: concepts, challenges and opportunities for research. Journal of Urban Health 2006; 83(1): 59-72. DOI link, PMid:16736355

69 McLaren L, McIntyre L, Kirkpatrick S. Rose’s population strategy of prevention need not increase social inequalities in health. International Journal of Epidemiology 2010; 39(2): 372-377. DOI link, PMid:19887510

70 Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004; 364(9449): 1984-1990. DOI link

71 Crossley TF, Hurley J, Jeon SH. Physician labour supply in Canada: a cohort analysis. Health Economics 2009; 18(4): 437-456. DOI link, PMid:18613317

72 Dauphinee WD. The circle game: understanding physician migration patterns within Canada. Academic Medicine. Academic Medicine 2006; 81(12 Suppl): S49-S54. DOI link, PMid:17086047

73 Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Human Resources for Health 2006; 4: 12. DOI link

74 Laurence CO, Williamson V, Sumner KE, Fleming J. ‘Latte rural’: the tangible and intangible factors important in the choice of a rural practice by recent GP graduates. Rural and Remote Health 2010; 10(2): 1316. Available: web link (Accessed 15 September 2017).

75 Lu DJ, Hakes J, Bai M, Tolhurst H, Dickinson JA. Rural intentions: factors affecting the career choices of family medicine graduates. Canadian Family Physician 2008; 54(7): 1016-1017.

76 Mullan F. The metrics of the physician brain drain. New England Journal of Medicine 2005; 353: 1810-1818. DOI link, PMid:16251537

77 World Health Organization. Human resources for health in Europe. 2006. Available: web link (Accessed 15 September 2017).

78 Pond B, McPake B. The health migration crisis: the role of four Organisation for Economic Cooperation and Development countries. Lancet 2006; 367(9520): 1448-1455. DOI link

79 Ricketts TC, Randolph R. Urban-rural flows of physicians. Journal of Rural Health 2000; 23(4): 277-285. DOI link, PMid:17868233

80 Vanasse A, Scott S, Courteau J, Orzanco MG. Canadian family physicians’ intentions to migrate. Canadian Family Physician 2009; 55(4): 396-397.

81 Bland CJ, Meurer, LN, Maldonado G. Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature. Academic Medicine 1995; 70(7): 620-641. DOI link, PMid:7612128

82 Cohen SA. A review of demographic and infrastructural factors and potential solutions to the physician and nursing shortage predicted to impact the growing US elderly population. Journal of Public Health Management and Practice 2009; 15(4): 352-362. DOI link, PMid:19525780

83 Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Affairs 2008; 27(3): w232-w241. DOI link, PMid:18445642

84 Cosgrove EM, Harrison GL, Kalishman S. Addressing physician shortages in New Mexico through a combined BA/MD program. Academic Medicine 2007; 82(12): 1152-1157. DOI link, PMid:18046118

85 Staiger DO, Auerbach DI, Buerhaus PI. Comparison of physician workforce estimates and supply projections. JAMA 2009; 302(15). PMid:19843902

86 Wayne SJ, Kalishman S, Jerabek RN, Timm C, Cosgrove E. Early predictors of physicians’ practice in medically underserved communities: a 12-year follow-up study of University of New Mexico School of Medicine graduates. Academic Medicine 2010; 85(10 Suppl): S13-S16. DOI link, PMid:20881694

87 World Health Organization. Human resources for health in Europe. Berkshire, England: Open University Press, 2006.

88 Cutchin MP. Physician retention in rural communities: the perspective of experiential place integration. Health and Place 1997; 3(1): 25-41. DOI link

89 Cutchin MP. Community and self: concepts for rural physician integration and retention. Social Science and Medicine 1997; 44(11): 1661-1674. DOI link

90 Hanlon N, Halseth G, Snadden D. ‘We can see a future here’: place attachment, professional identity, and forms of capital mobilized to deliver medical education in an underserviced area. Health and Place 2010; 16(5): 909-915. DOI link, PMid:20537935

91 Humphreys JS, Wakerman J, Wells R. What do we mean by sustainable rural health services? Implications for rural health research. Australian Journal of Rural Health 2006; 14(1): 33-35. DOI link, PMid:16426431

92 Laurent S. Rural Canada: access to health care. 2001. Available: web link (Accessed 15 September 2017).

93 Scott A, Witt J, Humphreys J, Joyce C, Kalb G, Jeon SH, et al. Getting doctors into the bush: general practitioners’ preferences for rural location. Social Science and Medicine 2013; 96: 33-44. DOI link, PMid:24034949

94 Weinhold I, Gurtner S. Understanding shortages of sufficient health care in rural areas. Health Policy 2014; 118(2): 201-214. DOI link, PMid:25176511

95 Campbell N, McAllister L, Eley D. The influence of motivation in recruitment and retention of rural and remote allied health professionals: a literature review. Rural and Remote Health 2012; 12(2): 1900. Available: web link (Accessed 15 September 2017).

96 Canadian Institute for Health information. How healthy are rural Canadians? An assessment of their health status and health determinants. Ottawa: CIHI, 2006. Available: web link (Accessed 15 September 2017).

97 Hancock C, Steinbach A, Nesbitt TS, Adler SR, Auerswald CL. Why doctors choose small towns: a developmental model of rural physician recruitment and retention. Social Science and Medicine 2009; 69(9): 1368-1376. DOI link, PMid:19747755

98 Martinez J, Pampalon R, Hamel D, Raymond G. Does living in rural communities rather than cities really make a difference in peoples’ health and wellness? 2004. Available: web link (Accessed 15 September 2017).

99 Veitch C, Grant M. Community involvement in medical practitioner recruitment and retention: Reflections on experience. Rural and Remote Health 2004; 4(2): 261. Available: web link (Accessed 15 September 2017).

100 Humphreys J, Wakerman J, Wells R. 'Beyond workforce’: a systemic solution for health service provision in small rural and remote communities. Medical Journal of Australia 2008; 188(8): S77. Available: web link, DOI link, PMid:18429743 (Accessed 1 September 2017).

101 Dieleman M, Hilhorst T. Governance and human resources for health. Human Resource for Health 2011; 9: 29. DOI link, PMid:22115191

102 Dunbabin JS, McEwin K, Cameron I. Postgraduate medical placements in rural areas: their impact on the rural medical workforce. Rural and Remote Health 2006; 6(2): 481. Available: web link (Accessed 15 September 2017).

103 Humphreys JS, McGrail MR, Joyce CM, Scott A, Kalb G. Who should receive recruitment and retention incentives? Improved targeting of rural doctors using medical workforce data. Australian Journal of Rural Health 2012; 20(1): 3-10. DOI link, PMid:22250870

104 Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. American Journal of Public Health 1997; 87(5): 817-822. DOI link, PMid:9184512

105 Henry JA, Edwards BJ, Crotty B. Why do medical graduates choose rural careers? Rural and Remote Health 2009; 9(1): 1083. Available: web link, DOI link, PMid:19257797

106 Leduc N, Vanasse A, Scott I, Scott S, Orzanco MG, Dogma JM, Malham SA. The career decision-making process of medical students and residents and the choice of specialty and practice location: how does postgraduate medical education fit in? 2011. Available: web link (Accessed 15 September 2017).

107 Mathews M, Rourke JT, Park A. The contribution of Memorial University’s medical school to rural physician supply. Canadian Journal of Rural Medicine 2008; 13(1): 15-21.

108 Matsumoto M, Inoue A. Long-term effect of the Home Prefecture Recruiting Scheme of Jichi Medical University, Japan. Rural and Remote Health 2008; 8: 930. Available: web link (Accessed 28 October 2019).

109 Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple predictors on generalist physicians’ care of underserved populations. American Journal of Public Health 2000; 90(8): 1225-1228. DOI link, PMid:10937001

110 Rourke JT, Incitti F, Rourke LL, Kennard M. Relationship between practice location of Ontario family physicians and their rural background or amount of rural medical education experience. Canadian Journal of Rural Medicine 2005; 10(4): 231-240.

111 Wilkinson D, Birks J, Davies L, Margolis S, Baker P. Preliminary evidence from Queensland that rural clinical schools have a positive impact on rural intern choices. Rural and Remote Health 2004; 4(4): 340. Available: web link (Accessed 15 September 2017).

112 Manusov EG, Livingston H, Stine C, Van Durme D. Toward a common framework for rural background. Canadian Medical Association Journal 2010; 42(10): 732-735.

113 Dhalla IA, Kwong JC, Streiner DL. Characteristics of first-year students in Canadian medical schools. Canadian Medical Association Journal 2002; 166(8): 1029-1035.

114 Laven G, Wilkinson D. Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Australian Journal of Rural Health 2003; 11(6): 277-284. DOI link, PMid:14678410

appendix I:

Descriptions of determinants^1-5^,7^,8^,21^,28-39^,41-57^,59-64^,70-89^,89-114 table image

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