Expanding the number of doctors was not the answer to solving the imbalance in regional medical care and human resource allocation between departments, even in Japan, which implements a regional enrollment quota system for medical schools.

That was part of Japan’s experience addressing the problem of doctors’ regional concentration, presented at a debate, “Is supplying doctors to medically vulnerable areas the only alternative?” co-hosted by Reps. Shin Hyun-young of the Democratic Party of Korea and Cho Myung-hee of the People Power Party at the National Assembly Wednesday.

In the debate, Professor Hideki Hashimoto of the University of Tokyo Medical School pointed out that the limitations of the regional quota system introduced to secure doctors working in local areas have recently been revealed.

Autonomous medical schools were established in 1972 with the joint investment of prefectural governments. Each prefecture allocates two to three students to the school and provides scholarships. In return, graduates are required to work in their respective communities.

"Autonomous medical schools have been recognized as successful in training local healthcare professionals. Shigeru Omi, chair of the Covid-19 government subcommittee, is also a graduate of such schools,” Professor Hashimoto said. “However, there is still a shortage of doctors at large regional hospitals. This demonstrates the limits of autonomous medical schools.”

The regional quota system, which allocates a portion of medical school quota to regions, has also been ineffective and even led to legal disputes due to its enforcement. Introduced in 2008, the regional quota system had only been implemented until 2020 due to concerns about an oversupply of doctors and has since been reorganized into a “regional quota admission test” for medical schools.

“According to the latest research, the number of doctors per population in a region has barely changed. Although it seems to have improved slightly, it is not because the number of doctors has increased but because the local population has decreased,” Hashimoto said. “Simply imposing an obligation to work in a region has not solved the problem of regional ubiquity. Some doctors have even filed legal suits, claiming that the system interfered with their freedom of labor.”

Opinion polls confirmed reasons for Japanese doctors’ reluctance to work in rural areas. In a 2017 survey of more than 25,000 doctors across Japan, more than 40 percent said they wouldn’t mind working in rural areas.

However, different generations gave different answers when asked why they were reluctant to work in rural areas. Doctors in their 20s were concerned about not being able to experience the skills needed to become a specialist. In comparison, those in their 30s and 40s were concerned about their children's education. Doctors in their 50s and older felt anxious that they might be unable to find suitable workplaces in rural areas.

Professor Hashimoto emphasized that to retain local doctors, it is necessary to shift to supporting doctors’ careers instead of forcefully stationing them in specific regions.

Recently, Japan has been pushing for a plan where not central but prefectural governments consider whether to introduce a regional quota system. A proposal to flexibly allocate doctors to areas with too many and too few doctors within the same prefecture is also under discussion. Suppose a doctor trained in one region moves to another. In that case, the two regions work together to support joint training, he added.

“To solve regional ubiquity of doctors, we should also discuss ways to support the careers of young doctors,” Hashimoto said. “The number of female doctors has increased recently, and we should strive to support their careers so that they do not face conflicts in balancing marriage, childbirth, childcare, and work.”

Hashimoto also noted that the ubiquity of doctors does not necessarily lead to regional health disparities.

“Not only in Japan but globally, studies have shown that medical resources, such as the number of doctors and medical facilities, do not significantly affect regional health disparities. Instead, prevention, including lifestyle, is a bigger factor,” he said. “Even as the population ages, studies show that the demand for medical care is decreasing as people live longer and require more caregiving.”

Regarding the rush of doctors to popular departments and the shortage of physicians in pediatrics, obstetrics, and gynecology, he said that expanding the number of doctors is not the right solution. Instead, the priority should be improving specialists’ productivity and managing the quality of treatment.

“In Japan, there is also a concentration of specialists in certain fields. In some departments with a surplus of specialists, there are complaints about specialists doing only simple work,” he said. “Instead of increasing the number of doctors, we need to create a good environment for doctors to work in and provide supporting staff to increase their productivity.”

“In Japan, we have made various efforts and are still trying to solve the problem,” he said. “Increasing the number of doctors or expanding the number of medical school students was one way, but if you ask me if that was the only solution, I will say no.”

Improving working conditions, empowering local government suggested as domestic solutions

The panel discussion continued with suggestions on how to improve the supply of medical services to vulnerable areas and secure medical personnel, considering Korean situations.

“We must provide training courses and continuing education for doctors and nurses in primary and community healthcare,” said Park Keon-hee, director of the Pyeongchang Healthcare Center. “We also must expand incentives for doctors and nurses to work in cities and medically underserved areas and create a ‘senior doctor manpower development company’ to match retired doctors with medically underserved areas.”

Kang Min-koo, head of the Korean Intern and Resident Association, said, “In countries like the United States, Australia, and Canada when foreign medical school graduates win their licenses, the governments obligate them to practice and serve in certain areas. Korea also needs to consider ways that can be applied to foreign medical school graduates.”

Park Hyung-geun, head of the Public Health and Medical Support Corps at Jeju Special Self-Governing Province, said local governments should be given the authority to utilize National Health Insurance Service (NHIS) funds and open medical institutions. “If local governments play the role of an insurer for NHIS, they can actively provide medical services by establishing new hospitals and recruiting staff, considering the medical needs of residents,” he said.

On the other hand, Woo Bong-sik, head of the Medical Policy Research Institute at the Korean Medical Association, said that existing resources could be fully utilized to solve the problem of medically disadvantaged areas. “I am skeptical about the role of local public hospitals in medically disadvantaged areas. If we can’t utilize the resources we have now, I'm concerned about the role of creating more national medical schools.”

Government officials said the issue of creating more public medical schools needs further discussion, adding that they must consider various factors to solve the problem of medically vulnerable areas.

There were suggestions (during the debate) for resolving regional healthcare imbalance, such as essential medical infrastructure, reasonable compensation, reimbursement for public healthcare, reimbursement for regional addition, improving working conditions, and improving the situation for female doctors, all of which I think are very important, said Shin Wook-soo, director of the Public Healthcare Division at the Ministry of Health and Welfare.

“Some say we need public medical schools to address regional disparities, and others say we should utilize existing medical schools. However, we need further discissions,” Shin said. “There is a shortage of manpower and delivery system issues, but reimbursement is also important. The second comprehensive health insurance plan will be released later this year, and it will include policies on reimbursement, too.”