A substantial body of evidence supports the beneficial health impact of an increase in primary care physicians for underserved populations. However, given that in many countries primary care physician shortages persist, what options are available to distribute physicians and how can these be seen from an ethical perspective?
A literature review was performed on the topic of primary care physician distribution. An ethical discussion of conceivable options for decision makers that applied prominent theories of ethics was held.
Examples of distributing primary care physicians were categorised into five levels depending upon levels of incentive or coercion. When analysing these options through theories of ethics, contrasting, and even controversial, moral issues were identified. However, the different morally salient criteria identified are of prima facie value for decision makers.
The discussion provides clear criteria for decision makers to consider when addressing primary care physician shortages. Yet, decision makers will still need to assess specific situations by these criteria to ensure that any decisions they make are morally justifiable.
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Bell S, Wilson K, Bissonnette L, Shah T (2013) Access to primary health care: does neighborhood of residence matter? Ann Assoc Am Geograph 103:85–105
Brooks RG, Walsh M, Mardon R, Lewis M, Clawson A (2002) The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med 77:790–798. doi:10.1097/00001888-200208000-00008
Busato A, Künzi B (2008) Primary care physicians supply and other key determinants of health care utilization: the case of Switzerland. BMC Health Serv Res 8:1–8. doi:10.1186/1472-6963-8-8
Daniels N (2008) Just health: meeting health needs fairly. Cambridge University Press, New York
German Medical Association (Bundersärztekammer) (2011). Eckpunkte zur Sicherstellung der hausärztlichen Versorgung. Beschlussprotokoll des 114. Deutschen Ärztetags vom 31.05–03.06.2011 in Kiel. http:/www.bundesaerztekammer.de/page.asp?his=0.2.23.9278.9427.9460.9461
Glinos I (2012) Worrying about the wrong thing: patient mobility versus mobility of health care professionals. J Health Serv Res Po. doi:10.1258/jhsrp.2012.012018
Godager G, Iversen T, Ma CTA (2009) Service motives and profit incentives among physicians. Int J Health Care Fi 9:39–57. doi:10.1007/s10754-008-9046-y
Gostin LO, Powers M (2006) What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Aff 25:1053–1059. doi:10.1377/hlthaff.25.4.1053
Guagliardo MF (2004) Spatial accessibility of primary care: concepts, methods and challenges. Int J Health Geogr 3:3. doi:10.1186/1476-072X-3-3
Habicht J, Kiivet RA, Habicht T, Kunst AE (2009) Social inequalities in the use of health care services after 8 years of health care reforms—a comparative study of the Baltic countries. Int J Public Health 54:250–259. doi:10.1007/s00038-009-8012-x
Hagopian A (2007) Recruiting primary care physicians from abroad: is poaching from low-income countries morally defensible? Ann Fam Med 5:483–485. doi:10.1370/afm.787
Koskinen S, Puska P (2009) From social determinants to reducing health inequalities. Int J Public Health 54:53–54. doi:10.1007/s00038-009-7069-x
Macinko J, Starfield B, Shi L (2007) Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv 37:111–126. doi:10.2190/3431-G6T7-37M8-P224
Mackenbach J (2005) Odol, Autobahnen and a non-smoking Führer: reflections on the innocence of public health. Int J Epidemiol 34:537–539. doi:10.1093/ije/dyi039
Nussbaum M (2006) Frontiers of justice: disability, nationality, species membership. The Belknap Press of Harvard University, Cambridge
Politzer RM, Harwick KS, Cultice JM, Bazell C (1999) Eliminating primary care health professional shortage areas: the impact of title VII generalist physician education. J Rural Health 15:11–20. doi:10.1111/j.1748-0361.1999.tb00594.x
Powers M, Faden R (2006) Social justice: the moral foundations of public health and health policy. Oxford University Press, New York
Puddu M, Demarest S, Tafforeau J (2009) Does a national screening programme reduce socioeconomic inequalities in mammography use? Int J Public Health 54:61–68. doi:10.1007/s00038-009-8105-6
Rabinowitz HK, Petterson S, Boulger JG, Hunsaker ML, Diamond JJ, Markham FW et al (2012) Medical school rural programs: a comparison with international medical graduates in addressing state level rural family physician and primary care supply. Acad Med 87:488–492. doi:10.1097/ACM.0b013e3182488b19
Rauprich O (2008) Utilitarismus und Kommunitarismus als Grundlagen einer Public-Health-Ethik? Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 51:137–150. doi:10.1007/s00103-008-0442-8
Rieselbach RE, Crouse BJ, Frohna JG (2010) Teaching primary care in community health centers: addressing the workforce crisis for the underserved. Ann Intern Med 152:118–122
Rosicova K, Geckova AM, van Dijk JP, Kollarova J, Rosic M, Groothoff JW (2011) Regional socioeconomic indicators and ethnicity as predictors of regional infant mortality rate in Slovakia. Int J Public Health 56:523–531. doi:10.1007/s00038-010-0199-3
Rothgang H, Staber J (2009) Ethik versus Ökonomie in Public Health? Zur Integration ökonomischer Rationalitäten in einen Public-Health-Ethik-Diskurs. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz 52:494–501. doi:10.1007/s00103-009-0836-2
Sade RM (1971) Medical care as a right: a refutation. New Engl J Med 285:1288–1292
Sade RM (2008) Foundational ethics of the health care system: The moral and practical superiority of free market reforms. J Med Philos 33:461–497. doi:10.1093/jmp/jhn023
Schlosberg D (2007) Defining environmental justice. Oxford University Press, New York
Schröder-Bäck P, Brand H, Escamilla I et al (2009) Ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the European Union. Cent Eur J Public Health 17:183–186
Starfield B, Fryer G (2007) The primary care physician workforce: ethical and policy implications. Ann Farm Med 5:486–491. doi:10.1370/afm.720
Starfield B, Shi L, Macinko J (2005) Contribution of primary care to health systems and health. Milbank Q 83:457–502. doi:10.1111/j.1468-0009.2005.00409.x
SVR (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen) (2009). Coordination and integration—Health care in an ageing society. Special Report. Abridged (English) version. Berlin
The Council of the European Union (2006) Council conclusions on common values and principles in European Union health systems. OJ C 146:1–3
Veatch RM (1981) A theory of medical ethics. Basic Books, New York
Walker KO, Ryan G, Ramey R, Nunez FL, Beltran R, Splawn RG, Brown AF (2010) Recruiting and retaining primary care physicians in urban underserved communities: The importance of having a mission. Am J Public Health 100:2168–2175. doi:10.2105/AJPH.2009.181669
WHO (1978). Declaration of Alma-Ata. In: Primary health care: report of the international conference on primary health care. World Health Organisation, Geneva, pp 6. http://www.planhealth.com.au/pdf/AlmaAta.pdf. Accessed 11 Nov 2012
WHO (2008). The world health report 2008: primary health care—Now more than ever. http://www.searo.who.int/LinkFiles/Reports_whr08_en.pdf. Accessed 11 Nov 2012
WHO (2010). The WHO global code of practice on the international recruitment of health personnel. World Health Organisation, Geneva. http://www.who.int/hrh/migration/code/WHO_global_code_of_practice_EN.pdf. Accessed 11 Nov 2012
The authors would like to extend their gratitude to the participants of “Explaining Health Inequalities: The Role of Space and Time” conference for their valuable comments and insight (Centre for Interdisciplinary Research, Bielefeld: Germany, 25–27 June 2012).
This article is part of the special issue “Explaining Health Inequalities: The Role of Space and Time”.
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Stapleton, G., Schröder-Bäck, P., Brand, H. et al. Health inequalities and regional specific scarcity in primary care physicians: ethical issues and criteria. Int J Public Health 59, 449–455 (2014). https://doi.org/10.1007/s00038-013-0497-7