Person:

Sakai, Rie

Objective: Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program. Methods: The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status. Results: The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584). Conclusion: The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.

Background: In industrialized countries, assessment of the causal effect of physician supply on population health has yielded mixed results. Since the scope of child vaccination is an indicator of preventive health service utilization, this study investigates the correlation between vaccination coverage and pediatrician supply as a reflection of overall pediatric health during a time of increasing pediatrician numbers in Japan. Methods: Cross-sectional data were collected from publicly available sources for 2010. Dependent variables were vaccination coverage for measles and diphtheria, pertussis, and tetanus (DPT) by region. The primary predictor of interest was number of pediatricians per 10 000-child population (pediatrician density) at the municipality level. Multivariate logistic regression models were used to estimate associations of interest, conditional on a large range of demographic and infrastructure-related factors as covariates, including non-pediatric physician density, total population, per capita income, occupation, unemployment rate, prevalence of single motherhood, number of hospital beds per capita, length of roads, crime rate, accident rate, and metropolitan area code as urban/rural status. The percentage of the population who completed college-level education or higher in 2010 was included in the model as a proxy for education level. Results: Pediatrician density was positively and significantly associated with vaccination coverage for both vaccine series. On average, each unit of pediatrician density increased odds by 1.012 for measles (95% confidence interval, 1.010–1.015) and 1.019 for DPT (95% confidence interval, 1.016–1.022). Conclusions: Policies increasing pediatrician supply contribute to improved preventive healthcare services utilization, such as immunizations, and presumably improved child health status in Japan.