Interventions for increasing the proportion of health professionals practicing in rural and underserved areas

What was the aim of this review?

The aim of this Cochrane review was to find out whether strategies to increase the number of health professionals working in rural and underserved areas are effective. Researchers in The Cochrane Collaboration searched for all new studies that could answer this question, given that the previous review done in 2009 did not identify any high certainty evidence.

What did the review conclude?

We were only able to identify one new study with very low certainty of evidence. Therefore, we remain uncertain about the effects of these types of strategies. Well conducted interventional studies with appropriate control or comparison groups are needed to assess critically the impact of strategies to increase the number of health professionals working in underserved areas.

What was studied in the review?

All countries have areas that are relatively underserved by health professionals; mostly among rural communities and the urban poor. This problem is seen across the world, but is particularly serious in low- and middle-income countries.

While some health professionals choose to work in underserved areas, we need strategies to persuade more of them to do so. Different strategies have been used. For example, some medical schools try to recruit more students with a rural background or arrange for students to practice in rural settings in the hope that graduates will return to those areas to practice. Scholarships, grants, loan repayment schemes and higher salaries have been offered to attract health professionals to underserved areas, while countries also utilise mandatory redeployment strategies. Although some strategies have shown promise, there is a lack of well-designed studies to measure the short-term and long-term effectiveness of these strategies in a rigorous fashion.

What are the main results of the review?

This review found one new study that evaluated the effect of a National Health Insurance scheme on the distribution of health professionals in Taiwan. Before the implementation of National Health Insurance, people living in rural areas were less able to afford medical costs than their urban counterparts. The implementation of a National Health Insurance scheme made medical care more affordable for all Taiwanese citizens in both urban and rural areas. This may have led to better geographical distribution of health professionals. However, we assessed the certainty of the evidence to be very low. Therefore, we are uncertain about the effects of National Health Insurance schemes on the distribution of health professionals.

How up-to-date is this review?

The review authors searched for studies that had been published up to April 2014.

A summary of this review for policy-makers is available here

Authors' conclusions: 

There is currently limited reliable evidence regarding the effects of interventions aimed at addressing the inequitable distribution of health professionals. Well-designed studies are needed to confirm or refute findings of observational studies of educational, financial, regulatory and supportive interventions that might influence healthcare professionals' decisions to practice in underserved areas. Governments and medical schools should ensure that when interventions are implemented, their impacts are evaluated using scientifically rigorous methods to establish the true effects of these measures on healthcare professional recruitment and retention in rural and other underserved settings.

Read the full abstract...

The inequitable distribution of health professionals, within countries, poses an important obstacle to the optimal functioning of health services.


To assess the effectiveness of interventions aimed at increasing the proportion of health professionals working in rural and other underserved areas.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, including specialised register of the Cochrane Effective Practice and Organisation of Care Group; March 2014), MEDLINE (1966 to March 2014), EMBASE (1988 to March 2014), CINAHL (1982 to March 2014), LILACS (February 2014), Science Citation Index and Social Sciences Citation Index (up to April 2014), Global Health (March 2014) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (June 2013). We also searched reference lists of all papers and relevant reviews identified, and contacted authors of relevant papers regarding any further published or unpublished work.

Selection criteria: 

Randomised trials, non-randomised trials, controlled before-and-after studies and interrupted time series studies evaluating the effects of various interventions (e.g. educational, financial, regulatory or support strategies) on the recruitment or retention, or both, of health professionals in underserved areas.

Data collection and analysis: 

Two review authors independently screened titles and abstracts and assessed full texts of potentially relevant studies for eligibility. Two review authors independently extracted data from eligible studies.

Main results: 

For this first update of the original review, we screened 8945 records for eligibility. We retrieved and assessed the full text of 125 studies. Only one study met the inclusion criteria of the review. This interrupted time series study, conducted in Taiwan, found that the implementation of a National Health Insurance scheme in 1995 was associated with improved equity in the geographic distribution of physicians and dentists. We judged the certainty of the evidence provided by this one study very low.