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Background During the long-lasting economic stagnation, the popularity of medical school has dramatically increased among pre-medical students in Japan. This is primarily due to the belief that medicine is generally a recession-proof career. As a result, pre-medical students today who want to enter medical school have to pass a more rigorous entrance examination than that in the 1980s. This paper explores the association between the selectivity of medical school admissions and graduates’ later career choices. Methods A unique continuous measure of the selectivity of medical school admissions from 1980 to 2017, which is defined as the deviation value of medical schools, was merged with cross-sectional data of 122 990 physicians aged 35 to 55 years. The association between the deviation value of medical schools and various measures of physicians’ career choices was explored by logistic and ordinary least square regression models. Graduates from medical schools in which the deviation value was less than 55 were compared with those from more competitive medical schools, after controlling for fixed effects for the medical school attended by binary variables. Results From 1980 to 2017, the average deviation value increased from 58.3 to 66.3, indicating a large increase in admission selectivity. Empirical results suggest that increasing selectivity of a medical school is associated with graduates having a higher probability of choosing a career in an acute hospital as well as having a lower probability of opening their own clinic and choosing a career in primary health care. Graduating from a highly competitive medical school (i.e., deviation value of more than 65) significantly increases the probability of working at typical acute hospitals such as so-called 7:1 hospitals (OR 1.665 2, 95%CI 1.444 0–1.920 4) and decreases the probability of working at primary care facilities (OR 0.602 6, 95%CI 0.441 2–0.823 0). It is also associated with graduates having a higher probability of becoming medical board certified (OR 1.294 6, 95%CI 1.108 8–1.511 4). Conclusion Overall, this paper concludes that increased selectivity of medical school admissions predicts a higher quality of physicians in their own specialty, but at the same time, it is associated with a lower supply of physicians who go into primary care.

© 2015 Dawson et al. Background: Despite considerable evidence showing the importance of the nursing and midwifery workforce, there are no systematic reviews outlining how these cadres are best supported to provide universal access and reduce health care disparities at the primary health care (PHC) level. This review aims to identify nursing and midwifery policy, staffing, education and training interventions, collaborative efforts and strategies that have improved the quantity, quality and relevance of the nursing and midwifery workforce leading to health improvements for vulnerable populations. Methods: We undertook a structured search of bibliographic databases for peer-reviewed research literature using a focused review question and inclusion/exclusion criteria. The quality of retrieved papers was appraised using standard tools. The characteristics of screened papers were described, and a deductive qualitative content analysis methodology was applied to analyse the interventions and findings of included studies using a conceptual framework. Results: Thirty-six papers were included in the review, the majority (25) from high-income countries and nursing settings (32). Eleven papers defined leadership and governance approaches that had impacted upon the health outcomes of disadvantaged groups including policies at the national and state level that had led to an increased supply and coverage of nursing and midwifery staff and scope of practice. Twenty-seven papers outlined human resource management strategies to support the expansion of nurse's and midwives' roles that often involved task shifting and task sharing. These included approaches to managing staffing supply, distribution and skills mix; workloads; supervision; performance management; and remuneration, financial incentives and staffing costs. Education and training activities were described in 14 papers to assist nurses and midwives to perform new or expanded roles and prepare nurses for inclusive practice. This review identified collaboration between nurses and midwives and other health providers and organizations, across sectors, and with communities and individuals that resulted in improved health care and outcomes. Conclusions: The findings of this review confirm the importance of a conceptual framework for understanding and planning leadership and governance approaches, management strategies and collaboration and education and training efforts to scale up and support nurses and midwives in existing or expanded roles to improve access to PHC for vulnerable populations.

Contemporary approaches to rural generalist medicine training and models of care are developing internationally as part of an integrated response to common challenges faced by rural and remote health services and policymakers (addressing health inequities, workforce shortages, service sustainability concerns). The aim of this study was to review the literature relevant to rural generalist medicine. A scoping review was undertaken to answer the broad question ‘What is documented on rural generalist medicine?’ Literature from January 1988 to April 2017 was searched and, after final eligibility filtering (according to established inclusion and exclusion criteria), 102 articles in English language were included for final analysis. Included papers were analysed and categorised by geographic region, study design and subject themes. The majority of articles (80%) came from Australia/New Zealand and North America, reflecting the relative maturity of programmes supporting rural generalist medicine in those countries. The most common publication type was descriptive opinion pieces (37%), highlighting both a need and an opportunity to undertake and publish more systematic research in this area. Important themes emerging from the review were: There were some variations to, or criticisms of, the definition of rural generalist medicine as applied to this review, although this was only true of a small number of included articles. Across remaining themes, there were many similarities and consistent approaches to rural generalist medicine between countries, with some variations reflecting environmental context and programme maturity. This review identified recent literature from countries with emerging interest in rural generalist medicine in response to problematic rural health service delivery. Supported, coordinated rural generalist medicine programmes are being established or developed in a number of countries as part of an integrated response to rural health and workforce concerns. Findings of this review highlight an opportunity to better share the development and evaluation of best practice models in rural generalist medicine.

Introduction Patient-centered care approach in multidrug-resistant tuberculosis care requires health worker safety that covers both being safe and feeling safe to conduct the services. Stigma has been argued as a barrier to patient-centered care. However, there has been relatively little research addressing the issues of safety and stigma among health staff. This paper explored the issue of being safe, feeling safe, and stigmatizing attitude among health staff working with multidrug-resistant tuberculosis cases in primary health care facilities in Indonesia. Methods Using a mixed methods research design, data was collected with structured questionnaires among 123 staff, observations of infection control in 17 primary health care facilities, and in-depth interviews among 22 staff. Results The findings showed suboptimal infection control infrastructures for the primary health care facilities. The knowledge and motivation to follow multidrug-resistant tuberculosis care protocols are suboptimal. Feeling unsafe is related to stigmatizing attitude in providing multidrug-resistant tuberculosis care. Conclusion Being safe, feeling unsafe, and stigmatizing attitude are challenges in providing patient-centered multidrug-resistant tuberculosis care in primary health care facilities in Indonesia. Serious efforts are needed on all levels to ensure safety and prevent irrational stigma.

Background Health reform in China since 2009 has emphasized basic public health services to enhance the function of Community Health Services as a primary health care facility. A variety of studies have documented these efforts, and the challenges these have faced, yet up to now the experience of primary health care (PHC) providers in terms of how they have coped with these changes remains underdeveloped. Despite the abundant literature on psychological coping processes and mechanisms, the application of coping research within the context of human resources for health remains yet to be explored. This research aims to understand how PHC providers coped with the new primary health care model and the job characteristics brought about by these changes. Methods Semi-structured interviews with primary health care workers were conducted in Jinan city of Shandong province in China. A maximum variation sampling method selected 30 PHC providers from different specialties. Thematic analysis was used drawing on a synthesis of theories related to the Job Demands-Resources model, work adjustment, and the model of exit, voice, loyalty and neglect to understand PHC providers’ coping strategies. Results Our interviews identified that the new model of primary health care significantly affected the nature of primary health work and triggered a range of PHC providers’ coping processes. The results found that health workers perceived their job as less intensive than hospital medical work but often more trivial, characterized by heavy workload, blurred job description, unsatisfactory income, and a lack of professional development. However, close relationship with community and low work pressure were satisfactory. PHC providers’ processing of job demands and resources displayed two ways of interaction: aggravation and alleviation. Processing of job demands and resources led to three coping strategies: exit, passive loyalty, and compromise with new roles and functions. Conclusions Primary health care providers employed coping strategies of exit, passive loyalty, and compromise to deal with changes in primary health work. In light of these findings, our paper concludes that it is necessary for the policymakers to provide further job resources for CHS, and involve health workers in policy-making. The introduction of particular professional training opportunities to support job role orientation for PHC providers is advocated.

BACKGROUND: In order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work. METHODS: A phenomenological approach was used to examine CHAs' experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach. RESULTS: Personal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs' ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs' ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA's self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs' ability to deliver services. CONCLUSIONS: Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.

Background Globally, abundant opportunities exist for policymakers to improve the accessibility of rural and remote populations to primary health care through improving workforce retention. This paper aims to identify and quantify the most important factors associated with rural and remote Australian family physician turnover, and to demonstrate how evidence generated by survival analysis of health workforce data can inform rural workforce policy making. Methods A secondary analysis of longitudinal data collected by the New South Wales (NSW) Rural Doctors Network for all family physicians working in rural or remote NSW between January 1st 2003 and December 31st 2012 was performed. The Prentice, Williams and Peterson statistical model for survival analysis was used to identify and quantify risk factors for rural NSW family physician turnover. Results Multivariate modelling revealed a higher (2.65-fold) risk of family physician turnover in small, remote locations compared to that in small closely settled locations. Family physicians who graduated from countries other than Australia, United Kingdom, United States of America, New Zealand, Ireland, and Canada also had a higher (1.45-fold) risk of turnover compared to Australian trained family physicians. This was after adjusting for the effects of conditional registration. Procedural skills and public hospital admitting rights were associated with a lower risk of turnover. These risks translate to a predicted median survival of 11 years for Australian-trained family physician non-proceduralists with hospital admitting rights working in small coastal closely settled locations compared to 3 years for family physicians in remote locations. Conclusions This study provides rigorous empirical evidence of the strong association between population size and geographical location and the retention of family physicians in rural and remote NSW. This has important policy ramifications since retention grants for rural and remote family physicians in Australia are currently based on a geographical ‘remoteness’ classification rather than population size. In addition, this study demonstrates how survival analysis assists health workforce planning, such as through generating evidence to assist in benchmarking ‘reasonable’ lengths of practice in different geographic settings that might guide service obligation requirements.