Countries have proposed and implemented interventions to address this challenge, but little is known about the effectiveness of such interventions in the long run.

The International Social Security Association (ISSA) recently organized a webinar on Addressing the challenge of medical deserts – National strategies and responses. It gathered the experiences of ISSA member organizations in Austria, Belgium, France, Germany, Italy and Switzerland in combatting medical deserts, with a specific focus on what measures have worked in practice and why. Organised on the initiative of the National Health Insurance Fund of France (Caisse nationale de l'assurance maladie – CNAM), in collaboration with the ISSA European Network, the webinar provided an overview of the challenges, strategies and innovative solutions in a comparative perspective.

The experts shared their national strategies and innovative solutions − including regulation, incentives or telemedicine – that support policymakers and social security institutions in facing the challenges related to medical deserts. The webinar offered the opportunity to rethink incentives for health professionals to work in remote areas or develop new tools to access care in underserved regions. This article summarizes the key issues and innovative responses discussed in the webinar.

Definition, causes and concerns

The term medical deserts – “déserts médicaux” in the original French – came into widespread use during the past decade, even if it is more accurate to speak of regions that are underserved in terms of physicians. Two methods can be used to identify these areas: comparing either the local medical density with the average national medical density; or assessing the degree of imbalance between healthcare supply and demand.

The scarcity of doctors

Paradoxically, in Europe, the total number of doctors is growing in many countries. At the same time, the number of specialists is growing much faster than that of general practitioners (GPs). Despite this, there are still quite a high number of unfilled positions, partly due to the lack of candidates with the necessary qualifications. This phenomenon will intensify with the massive number of retirements projected for the coming years. On the other hand, the increase in part-time work means that a greater number of health professionals needs to be trained in order to replace the current workforce.

In general, healthcare professionals prefer to settle in urban areas for financial reasons and to enjoy better working conditions. In rural or remote areas, professionals may feel more isolated, which in turn can affect their work and patient follow-up. A new generation of doctors seek a more favourable work-life balance, preferring multi-professional practices and part-time positions. In France, the declining medical workforce – particularly in certain specialties (paediatricians, gynaecologists, psychiatrists, dermatologists, etc.) – combined with an uneven distribution across the country, are reported as the main causes of medical deserts.

In Germany, there is no general shortage, but an unequal distribution of doctors. In some urban regions and in the area of specialist care, there is even overcapacity. As long as there are opportunities to set up practices in attractive areas, there is little incentive for doctors to work in peripheral rural areas. Family doctors in particular have difficulties finding a successor. In 2019, 54.1 per cent of all German doctors were older than 55. In addition, the growing proportion of women doctors is leading to fewer full-time positions.

Austria has one of the highest physician densities in Europe. Nevertheless, in rural areas the challenge of ensuring a demand-oriented supply of medical care is increasing. Despite the fact that at present, only a small number of posts are unfilled and people can expect to be able to walk to their nearest general practitioner, who usually represents the backbone of care, there are problems ahead. In addition to stagnating birth rates and increasing life expectancy, this is also due to population decline in peripheral regions, expectations of young doctors and a high average age of contract doctors.

In Switzerland, medical density varies between regions (higher density in urban areas, lower density in rural areas), a situation that is intensified by the fact that rural areas often face increased medical demand in summer and winter due to seasonal tourism. While the overall situation in Switzerland is not problematic, potentially perceived shortages can also be counteracted due to the overall small size of the country, which allows covering gaps through generally short distances.

Migration of the healthcare workforce

Some countries have difficulty retaining their health professionals. Among all the professions combined, doctors are those who emigrate the most in Europe. Long working hours, difficulties managing the work-life balance, low pay and lack of quality infrastructure, push professionals to go practice in a different country. Migration from East to West and South to North increases the lack of doctors in certain countries.

Ageing population

Demographic trends indicate a deterioration of the situation with a twofold negative ageing effect: ageing physicians who announce their retirement and an ageing population in general, which increases the demand for healthcare. As the number of patients with multiple, chronic and complex diseases grows steadily, the overall demand for both long-term care and healthcare will rise steeply.

Concerns

Medical deserts can negatively affect the health of people living in underserved areas. Large geographical distances combined with decreased mobility of elderly people and fragile patients reinforce the problem of access. Long delays to get an appointment make people more likely to ignore symptoms or skip screening programmes, potentially affecting negatively their overall health and chances for recovery. Medical deserts also tend to generate an overload of hospital emergency services, particularly for care that can be provided by general practitioners.

Recent measures taken to promote access to care

Several countries have implemented actions to improve the geographical distribution of doctors. Examining the effectiveness of measures applied abroad provides evidence for future reforms. Among the measures taken are:

• Financial incentives
• Intervention in the university curriculum
• Creation of new professions
• Strengthening coordinated care and practice
• Leveraging eHealth and telemedicine

Financial incentives

In France, the 2017 “Access to Care” initiative and the 2018 “My Health 2022” strategy are recent examples of healthcare system reforms. Incentives were introduced to encourage doctors to settle in vulnerable areas, such as the public service commitment agreement (contrat d'engagement de service public – CESP).  Under the agreement, medical students are entitled to a monthly allowance until they complete their studies. In return, as soon as their training is over, they undertake to practice medicine in underserved areas. Although it is financially attractive, the success of the programme has been modest.

There are, in addition, tax breaks that supplement these schemes: physicians working in rural zones are exempt from income tax for several years under certain conditions. A doctor who settles in an underserved area will experience a higher workload, which justifies the additional financial incentive to facilitate his/her installation.

In Germany, measures also include subsidies for the investment costs of setting up a new medical practice, taking over a practice or establishing a branch practice as well as loans to finance the establishment of new practices and renting or building medical centres.

The effectiveness of these incentives is subject of debate. Indeed, financial assistance is not a decisive factor. Issues of proximity to family, practice conditions and coordinated practice determine primarily a physician's choice of location. Therefore, more structural reforms seem necessary to significantly boost the number of practices in underserved areas.

Intervention in the university curriculum

The transformation of medical studies and the elimination of access controls are expected to lead to more trained physicians.  In France, the Minister for Health and Solidarity has announced a 20 per cent rise in the number of selected students admitted to continue at the end of the first year of medical school. Still, the effects of this increase will only become visible after 10 years.

In addition, measures can be taken during medical school, such as reallocating medical residency in attractive medical specialties to regions that have difficulty attracting new medical residents. Finally, raising awareness amongst medical students about general practice in underserved areas can help to address the issue.

In Germany, the “Masterplan medical studies 2020” introduces new criteria expected to apply from 2023 onward, accelerating the reorientation of medical studies through new learning and examination objectives. Topics such as general medicine, inter-professional practical orientation and soft skills for the day-to-day work of young doctors will be given more weight. In addition, the German regions (Länder) can give up to 10 per cent of medicine study places to applicants who commit to work in general practice in rural areas.

Creation of new professions

To enhance cost-effectiveness and access to care, new professions are being created. The potential of non-physician health care professions in particular will be harnessed in the future. To this end, general practitioners and specialist practices can employ non-medical practice assistants to support them in the care of their patients – for example, during home and nursing home visits. In Germany, GPs who employ a non-medical practice assistant receive a subsidy. In France, the new profession of medical assistant will free up time and allow doctors to focus on medical aspects of care.

Strengthening coordinated care and practice

A better coordination between health care professionals can be a significantly positive step. Multi-professional medical centres aim to improve access to care and facilitate the coordination of health professionals in managing chronic care.

In Austria, measures consist of the creation of primary care units, including demand-oriented care contracts and corresponding remuneration models, based on interdisciplinary and multi-professional cooperation.  The new team-based (i.e. involving other health care professions) primary care units are a particular focus. These should not only offer patients a variety of advantages, but also respond to the work-related wishes of young doctors. A primary care unit can be established either as a centre or as a network of general practitioners or together with a paediatrician. Especially in the form of a network, it can bring many advantages in rural areas.

In Germany, cooperative forms of care such as medical care centres – legally independent medical care facilities – are encouraged and hospital outpatient departments can be considered as part of regional health centres, in the event of care insufficiencies in rural regions.

Leveraging eHealth and telemedicine

A great potential for facilitating access to care is offered by eHealth and telemedicine. The use of digital information and communication technology (ICT) can contribute to bring care to remote areas. However, most rural areas lack a stable and fast internet connection. It is also important to ensure that both the older generation and healthcare professionals acquire the necessary skills to properly use innovative tools for care delivery.

The pandemic has accelerated the existing trend towards the digitalisation of medicine and put a focus on advancing and streamlining telehealth capabilities. The fear of the coronavirus spreading has an impact on medical in-person consultations. In Germany, for instance visits have been declining in more than half of German medical practices. On the other hand, telephone inquiries are increasing, as a little more than half of the respondents stated.

Electronic medical records, measurement of health data via mobile applications, the use of artificial intelligence, communication between doctors and hospitals via digital platforms and the use telemedicine – all this will result in reducing the need for in-person care by doctors, bridging gaps and optimising the overall health care situation in underserved areas. Efforts have already been made in this regard but need to take into account data protection and data literacy issues.

Conclusions

In the context of ageing populations and urbanization, many countries are facing the challenge of how to ensure access to adequate medical services for all, and in particular for people living in rural and remote areas. As a consequence, measures are being implemented to improve the geographical distribution of doctors. These include, among others, financial-incentive programmes, intervention in the university curriculum, the creation of new professions, the development of coordinated practices and the increased use of eHealth and telemedicine.

Examining the effectiveness of measures applied by countries provides precious input for future reforms. However, more must be done in order to address a situation that is expected to become more challenging in the future. Tailor-made approaches to combat territorial inequalities that take into account different dimensions, both territorial and individual, seem most promising. In addition, various strategies in the area of prevention and early disease detection need to be implemented in order to decrease the overall burden of disease and the future health care demand.

The exchange of information among ISSA members will continue in upcoming ISSA webinars as well as articles, to identify paths for solutions and to ensure that adequate, effective and affordable health protection is available for all.

References and further reading