Understanding shortages of sufficient health care in rural areas.

Health Policy 118 (2014) 201–214

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Health Policy journal homepage: www.elsevier.com/locate/healthpol

Review

Understanding shortages of sufficient health care in rural areas Ines Weinhold a,∗ , Sebastian Gurtner b,1 a

Technische Universität Dresden, Department of Business and Economics, Center for Health Economics, 01062 Dresden, Germany Technische Universität Dresden, Department of Business and Economics, Chair for Entrepreneurship and Innovation, 01062 Dresden, Germany b

a r t i c l e

i n f o

Article history: Received 18 October 2013 Received in revised form 7 July 2014 Accepted 25 July 2014

a b s t r a c t Background and purpose: Despite efforts to provide comprehensive health care services and reduce inequalities, most developed countries face serious challenges in achieving comprehensive health care delivery in rural areas. The purpose of this study is to characterize health care shortages in the rural areas of developed countries and to comprehensively explore the underlying reasons for these shortages. Methods and sample: To answer the research questions, we conducted a systematic literature review. The content analysis included 176 papers on the topic of rural health care. The thematic-analysis approach revealed key aspects of health care shortages in rural areas and evidence regarding the reasons for these shortages. Findings and conclusion: Shortages of sufficient health care in rural areas were clustered into the following five categories: provider shortages, maldistribution, quality deficiencies, access limitations and the inefficient utilization of health care services. The reasons for the occurrence of these shortage problems are manifold and are related to physical/infrastructural, professional, educational, social–cultural, economic and political issues. This paper contributes to a comprehensive understanding of the health care problems in rural areas by creating an integrated framework that examines several aspects of shortages in sufficient health care in rural areas as well as their underlying reasons. The results provide directions for future research and specific advice for policy makers. © 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction and motivation The comprehensive provision of quality health care services and the reduction of health inequalities are major priorities and objectives of the member countries of the Organization for Economic Cooperation and Development

∗ Corresponding author. Tel.: +49 351 463 33868; fax: +49 351 463 36883. E-mail addresses: [email protected] (I. Weinhold), [email protected] (S. Gurtner). 1 Tel.: +49 351 463 36873. http://dx.doi.org/10.1016/j.healthpol.2014.07.018 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.

(OECD) [1]. Even in developed countries, however, many regions face serious challenges in achieving comprehensive health care delivery in rural areas. Particularly in the face of an aging population, the need for both general and specialized health care services has steadily increased. Nevertheless, the supply of health care services in rural regions is declining for a multitude of interrelated reasons [2]. In previous decades, researchers have attempted to identify the reasons for this shortage and to provide practical solutions. Rural health research has rapidly expanded, particularly in the USA, Canada, Australia and the UK [3]. Despite their diversity, rural regions in these countries

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experience similar problems and developments. Communities have become progressively disempowered by the continuous centralization of services and the dismantling of infrastructures [4,5]. Migration and the rapid aging of the population [6–9] have fueled the socio-economic decline of many rural areas. Compared with citizens in urban areas, rural citizens are more often economically and socially disadvantaged [10,11]. Conversely, sufficient health care delivery requires sophisticated technology, is expensive and depends on a qualified workforce. Many restrictions also exist in rural areas, which leads to serious challenges regarding health care delivery [12]. Rural health policies should consequently be derived from the complex integration of multiple aspects. Accordingly, political actions must be based on rural data and research that explains a certain population’s specific needs and circumstances [13]. However, only a few studies have provided a broad approach to the various issues that contribute to the emergence of shortages in sufficient health care. Although existing studies have explored specific attributes of rural health or revealed certain inequalities, these studies do not delve into the reasons why these problems emerge. Furthermore, a significant amount of research has only considered the specific aspects that lead to shortages in rural health care supply. Therefore, it is necessary to examine the problem in a more comprehensive manner, thereby considering all complex influences that lead to regional provider shortfalls, as well as the numerous factors that contribute to access barriers for rural populations. Access to health care is influenced by factors that involve “where” (spatial factors) and “who” (non-spatial factors) [14]. Spatial factors are geographic and spatial behavior factors, such as distances, travel time or transportation modes [14,15]. Non-spatial factors are characteristics of the population subgroups that lead to differences and barriers in health care needs and access, such as demographic, socioeconomic, cultural and environmental variables [16,17]. Thus, it is necessary to consider the interactions between all aspects [16,18] and within the changing economic, professional, physical/infrastructural and socio-cultural environments [18,19]. By synthesizing the existing research, this article contributes to a comprehensive understanding of the problems in rural areas. Based on a systematic literature review, we propose and discuss an integrated framework that incorporates the various aspects related to shortages in sufficient health care in rural areas and the different underlying reasons. The results provide directives for future research, which will enable policy makers to better assess the problems in vulnerable areas and to channel their efforts to overcome these problems.

2. Conceptual background Prior to exploring and comprehensively outlining the relevant aspects of health care shortages in rural areas, two theoretical concepts must be discussed to ensure a common understanding of the key terms used.

Table 1 Definitions of rural areas. Country and institution

Definition of rural

OECD member states: OECD Directorate for Public Governance and Territorial Development

• Classified as predominantly urban, predominantly rural or intermediate • Predominantly rural: population density below 150 inhabitants per square kilometer [22]

Germany: Federal Office for Building and Regional Planning

• Classified as independent cities, urban districts, rural regions with urbanization tendencies and sparsely populated rural regions • Sparsely populated rural regions: share of population living in urban centers less than 50% and population density lower than 100 inhabitants per square kilometer [23]

USA: The United States Census Bureau

• Urban areas comprise densely settled cores and adjacent territory with a population density of at least 500 inhabitants per square kilometer • Urban Clusters: at least 2500 and less than 50,000 people • Urbanized Areas: 50,000 or more people • Any other area not included within an urban area is classified as rural [24]

Australia: Australian Institute of Health and Welfare

• Recommended classification: Australian standard geographic classification remoteness areas • Five categories of regions: major cities, inner regional, outer regional, remote and very remote • Calculation of remoteness scores based on the road distance to the nearest urban center [25]

2.1. The meaning of “rural” is not the same everywhere The term “rural” evokes many diverse images and associations, which range from small villages to vast landscapes, agricultural production, hard work and isolation. Differentiating between urban and rural is difficult because the virtual line that must be crossed when leaving a town is continuously blurred. Rural communities exist in varying scales and differ considerably in economic activity or population structure [20]. Despite increasing political attention and a growing body of literature focused on rural health care research, there is no common definition for the term “rural” [11]. In regard to defining rural areas, tremendous diversity prevails between countries and within states or even within smaller regional boundaries [21]. Classifications have primarily used measures of size, population density and proximity to urban areas to define geographic units as rural, as outlined in Table 1. The considerable diversity of taxonomies makes it difficult to generalize and compare scientific findings between countries or regions and hinders the development of an evidence-based understanding of rural health care [3]. The aim of this study is to conduct a broad exploration of shortage aspects and their emergence in developed


countries. With this objective in mind, we cannot commit ourselves to only one of the various classifications of the term rural. Thus, this study includes research that addresses “rural areas”, independent of the underlying definition. 2.2. Sufficient health care in rural areas In the context of health care, the term rural has also been associated with limited public transport, poor road infrastructure, long distances to health care service facilities and difficulties in recruiting and retaining professionals [3]. Consequently, there are significant implications for the provision of sufficient health care services. The provision of adequate health care and equitable access to technologies and services are one of the top priorities of countries across the world [26]. Scholars and politicians often claim that health care should be distributed according to need [27]. In Germany, an example of a developed nation, statutory health insurance and health care providers have to guarantee the equal and need-based provision of health care services [28]. In practice, these types of requirements raise several difficulties. First, there is no universal suitable concept to assess shortages in sufficient health care; second, need is a complex construct. From an objective point of view, the need for medical services represents the expert-suggested quantity of medical services that individuals should consume to maintain or improve their health [29]. Need must be distinguished from demand, which represents the amount of services that individuals want to consume. This quantity does not necessarily correspond to an objective medical need [30]. As a part of political health care planning and resource allocation, need can be estimated on the basis of service utilization, mortality, morbidity or socioeconomic conditions [17]. However, a multitude of subjective factors influence the objective planning regarding the need for health care services [31]. Thus, the identification of shortages based on need is not trivial [29]. Health policy decision makers often reduce this complexity and define underserved areas via spatial physician-to-population ratios. However, there is no general agreement regarding the specific number of providers required in a specific geographic unit [21]. Furthermore, high variability in international benchmarks that define physician shortage areas impedes a scientific and objective comparison. Because of the difficulties in objectively determining the aggregated need for health care services, it appears incongruous to define need as a physician-to-population ratio [32]. Important issues are often not adequately considered, such as physician productivity, the substitution effects of non-physician providers and patient-related aspects that influence the demand for health care services [33]. Additional aspects such as socioeconomic status, age, sex and ethnicity also influence access to health care services [17,16]. Consequently, health care might be insufficient even if an adequate supply of providers exists. Indisputable shortages of medical services exist in the rural areas of many industrialized countries, regardless of how these shortages are defined [33]. With the

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controversial discussion of terminology and thresholds in mind, this study conceived of shortages in sufficient health care in a broad sense as any state in which individuals do not receive the care that they objectively need. Within this conceptual background, we have compiled the primary aspects and reasons for the shortages that occur in rural areas. 2.3. Methodological approach It is difficult for practitioners and policymakers to utilize the large amount of current scientific knowledge, which is often contradictory [34]. To address this issue, a systematic literature review approach is appropriate to provide a coherent and reliable summary of current research and to derive specific recommendations for practice. Therefore, the objective of this study is to identify key aspects and research directions within the field of health care shortages in rural areas. After a presentation of descriptive information, the results of the reviewed studies are condensed, and the content is critically discussed. To gain a comprehensive understanding of this topic, the issues need to be broken down into core components [21]. In this study, these core components are defined by the following research questions: I. What main aspects characterize the shortages of sufficient health care in the rural areas of developed countries? II. What are the actual reasons that lead to the identified main aspects of shortages? 2.4. Data and sample The search for relevant studies included six databases (PubMed, Medline, ScienceDirect, EBSCO Academic Search Complete, EBSCO Business Source Complete and CINAHL) and covered research in business and economics, social science and medical disciplines. The search terms consisted of a combination of three main components derived from the research questions: (1) Health care and the provision of medical services, which were covered by terms such as health care, health service(s), physician(s) and supply or provision; (2) spatial aspects, which were covered by the terms rural or remote; and (3) shortage issues, which were covered by the terms such as underserved, shortage(s) or scarcity. To account for the topic’s growing relevance in the German-speaking part of Europe and to avoid a potential language bias, the search was supplemented by German search terms using the sources Thieme E-Journals and Springer Link. To obtain a comprehensive yet contemporary overview of the topic, this study included results from the past 15 years of publications (1998–2012). An extensive search process was necessary because research on the examined topic occurs in different fields. Relevant literature encompasses health care policy and management, medical disciplines and geographic and regional economics research. The conducted search initially resulted in a total of 4679 non-duplicated articles that were assessed in a stepwise

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Fig. 1. Cascading process of systematic literature review.

manner by title, abstract and full text. The final qualitative content analysis includes 176 articles. Two reviewers [IW and SG] screened the articles using preliminarily defined inclusion and exclusion criteria. If decisions regarding the inclusion of a study differed, the reviewers held discussions until a consensus was reached. This study applied the following criteria for the inclusion of articles. The set of formal restrictions covered language and region. The review only included studies in English or German that originated from developed countries. The general disempowerment and decline of rural communities are a pressing issue, particularly in industrialized countries, and the aging population confronts policy makers and practitioners with additional challenges [4–7,32]. Although this rural decline is also a severe problem in developing countries, the transferability of knowledge is limited by considerably different geographic, economic and demographic conditions [3]. Accordingly, we limited the scope of our analysis to developed countries based on the United Nations’ (UN) grouping, which includes North America, Europe, Japan, Australia and New Zealand [35]. The second category of criteria was related to the content of the studies. To be included, articles must address shortages in the provision of medical services, shortages in sufficient health care and/or access to health care in the

context of rural areas. Extraneous studies were excluded, as well as articles that did not strictly focus on the topic of interest (e.g., studies that considered shortage problems, but not in a rural context). We further excluded studies on specific diseases (e.g., hepatitis, epilepsy, asthma and diabetes) because this level of detail was beyond our scope. We also discarded several studies that analyzed rural–urban outcome disparities and thus could not contribute to answering our research questions. Finally, the literature sample only contains publications from peer-reviewed journals. Fig. 1 illustrates the review process and summarizes the reasons for discarding articles. 2.5. Analysis Because this review is not a meta-analysis, it includes several types of studies that differ considerably with regard to scope and methodology. This broad thematic framework was chosen to obtain a comprehensive understanding of the topic. The synthesis of diverse forms of evidence from qualitative, quantitative, mixed methods and conceptual papers is very complex and requires deviations from stringent methodological approaches [36]. We adopted a thematic-analysis approach [36] for the synthesis of evidence. Following this approach, the key issues were identified and the evidence was condensed


and narratively synthesized without applying statistical procedures. To facilitate the extraction of information from the sample, we used a preliminary extraction form, which was further developed throughout the analysis. Apart from bibliographic data, information that concerned specific aspects of service delivery (e.g., primary care or specialist care) and the applied methodology were extracted. With respect to content, the review structures the information in line with the research questions (the main aspects of shortages and underlying reasons). 3. Results 3.1. Descriptive analysis The analyzed body of literature in this review examines 12 different countries. The majority of research focuses on the USA (n = 83) and other large countries, such as Australia (n = 28) and Canada (n = 19). Twenty-seven studies analyze European countries, in which research on health care in rural areas has been less prevalent until recently. Countries such as Germany, Hungary and Finland have barely been the subject of published studies that identify and examine the reasons for health care shortages in rural areas [37–39]. One European exception in this regard is the UK, where rural health care is a more long-standing research issue. The only developed Asian country included is Japan, in which research on rural health care has only appeared recently (n = 7). Overall, the relevance of research in the field of rural health care is illustrated by the increasing number of industrialized nations that face similar challenges and address similar problems despite their vast diversity in other respects. Seventy-five different journals published the 176 studies included in the analysis. The journals examine health care management and policy (n = 14), social sciences and health (n = 8), public health (n = 11), medical sciences (n = 11), primary health care (n = 11) and specialist health care (n = 10). Some journals exclusively consider rural health care (n = 6) or primarily have a geographical focus (n = 4). These statistics demonstrate the interdisciplinary nature of the research subject and the diversity of problems and approaches related to rural health care. Several studies consider specific subtypes, including medical care for females (e.g., gynecology, obstetrics, or maternity care) (n = 13) and acute or emergency care (n = 12). The relevance of demographic change is also reflected by the 13 studies that specifically address topics including geriatric, chronic or palliative care. The analysis of the methodology applied in the sample shows that quantitative studies (n = 100) dominate, followed by conceptual approaches (including reviews) (n = 39) and qualitative research (n = 29) or mixed-method approaches (n = 15). However, the amount of qualitative research has increased in recent years. There are also a considerable number of systematic (n = 9) and narrative reviews (n = 13) that focus on issues specific to rural health care, such as the recruitment and retention of professionals and innovative health care models for rural areas.

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3.2. Content analysis The next section illustrates the details of the content analysis. Following the research questions, the content analysis first identifies the specific aspects of shortages that have been described in the literature. Second, the analysis is used to synthesize the underlying reasons for the shortage problems. 3.2.1. Aspects of shortage in rural areas Shortage areas are designated by the use of spatial physician-to-population ratios in each nation that appears in the sample. Notably, the examination of the literature clearly reveals that problems in rural areas extend far beyond inadequate ratios. Because shortages in sufficient health care emerge from a composition of various aspects, it is difficult to capture all aspects in a concise and comprehensible manner. For this purpose, we condensed the variety of problems and clustered them into five distinct categories as follows: provider shortage, maldistribution, quality deficiencies, access limitations and inefficient utilization of health care services. The following paragraphs describe the categories, explore the interrelations between them and elaborate the importance of the context in which a shortage problem is considered. The majority of studies (n = 94) examine the issue of provider shortages. The studies note a relative shortage of health care professionals in many countries [6,39–43]. Although the geography of these countries varies widely, the problem of unavailable health care is quite similar and is expressed in regional provider shortfalls [44–47], high rates of unfilled vacancies [39,48,49], understaffed rural facilities [50,51] and, consequently, a work overload of local professionals [47,52–55]. Moreover, scholars have discussed the problem of uneven distribution (maldistribution) of medical care providers (n = 53). Literature has described the uneven supply of rural providers [46,56] and analyzed the location and specialty decisions of medical graduates and actual providers [13,57,58,9]. Several studies have noted changes in the distribution of physicians over time [59], analyzed physicians’ movements into and out of rural counties [60] or predicted migration among physicians [61]. Another aspect of shortage is the deficient quality of health care in rural areas. The importance of the quality of care is rapidly increasing for all stakeholders within the health care sector [10]. The situational circumstances and local environments restrain the extent to which high-quality care can be achieved [62]. Thirty-three studies address quality problems to varying degrees. Quality deficiencies originate in the scope of services that rural providers offer and in the professional level of these services [13]. The majority of quality problems in rural areas emerge as deficiencies in the provision of comprehensive and continuous care. In the patient’s opinion, a continuous and trustful relationship with a provider is necessary to maintain quality care [63]. Concepts aimed at quality

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improvement, such as managed and coordinated care, are difficult to achieve in rural regions [10]; instead, health care is often highly fragmented [3]. As a result, ambulatory care is vulnerable, and basic services may be delayed [64]. Gaps also occur in the delivery of allied health services, e.g., physiotherapy or psychological care [65]. The elderly and patients with (multiple) long-lasting chronic conditions have been particularly affected [62]. A lack of integrated care management and support in cases of transition across different medical settings can constitute a serious problem for older rural individuals [66]. Rural health care frequently implies the management of complex and acute cases that potentially extend beyond a provider’s capacity and competency. Increasing numbers of emergency calls [67], the need to provide palliative care and supportive domiciliary services [68], and numerous limitations regarding time, distance and other resources [69] can lead to decreased quality of care. The fourth aspect of shortages in sufficient care represents access limitations, which constitute a considerable problem in rural regions. Access restrictions have been examined in 48 studies; specifically, geographic access is the most commonly assessed topic. However, the literature does not mention a specific distance that can be used to theoretically or empirically determine insufficient spatial access to care [70]. Research has examined various issues, such as access to transportation and its impact on health service utilization [63,71], the sensitivity of access to local physician densities [72], and the importance of geographic factors, such as distance [15,73,74] and travel time [75]. When the distance that must be overcome to obtain care is longer, inconvenient hours of services, difficulties in making appropriate appointments and long waiting times become more challenging [19,76,77]. Particularly in countries without obligatory health insurance, access to care is also considerably impaired by the nonaffordability of services or insurance premiums [76–78]. A considerable number of studies have focused not on single aspects but rather on several access restrictions, such as distance, non-affordability and inconvenience, because there are often considerable interrelations between them [19,69,79–81]. The final aspect of shortages in sufficient care in rural areas that has been analyzed in the literature is the inefficient utilization of health care. This aspect is mentioned often, but not exclusively, in 16 studies in connection with the previously described issue of access limitations (for example, limitations caused by socio-economic barriers). These aspects often cannot be clearly distinguished and sometimes overlap. However, we consider inefficient utilization to be a separate aspect of shortage because it is a problem that results from individual beliefs and awareness instead of (in)accessibility. To reduce deficiencies, it is necessary to understand how rural citizens use health services. In this respect, the urgency and seriousness of the perceived need for care emerge as a major factor. Because of multiple restrictions, rural patients tend to make trade-offs in meeting their medical needs [63]. Some services, particularly services related to prevention or mental health, are underutilized because of a lack of interest, a stronger focus on other needs

in rural communities [76,77,82] or the lack of a subjectively perceived need for the services [78]. Overall, a lack of engagement is prevalent in personal health management [83]. Occasionally, patients who require information and support for chronic conditions do not communicate their needs [84]. The inefficient utilization of services may also occur because of the rejection of offered services that conflict with the way of life and expectations regarding the service provision among rural dwellers [7]. Some rural patients choose not to visit local non-physician providers because of doubts regarding their competency and instead prefer to travel to urban physicians [85]. Notably, the avoidance of rural hospitals is a similar problem. Because rural facilities are often small and economically vulnerable, residents’ decisions to bypass them can send rural facilities into an accelerated downward spiral. This scenario, in turn, aggravates the health care supply for patients who are incapable of traveling to distant facilities [86]. Studies have indicated that rural providers from different regions complain about patients avoiding care or canceling treatments, especially in the fields of prevention and mental illness [69]. Instead of requesting preventive services or visiting their regular doctor, rural patients in some regions prefer to habitually utilize emergency care [77,83]. Other similar coping strategies include the delay of treatment, several self-care strategies and the preference to seek help from one’s personal acquaintances [77,78]. Moreover, patients in poor health delay or avoid care if they expect consequences, such as additional visits to urban clinics that turn into all-day activities, exhausting travel or unanticipated expenses [73]. 3.2.2. Reasons for the emergence of shortages The most pressing question regarding shortages in rural health care services is the reason why such shortages occur. Table 2 condenses the key findings of the studies analyzed in this review. The reasons for the shortage of health care services are divided into the following six groups: physical/infrastructural, professional, educational, social–cultural, economic and political reasons. However, it must be noted that these issues cannot be clearly distinguished from one another in practice because they are often interrelated and interdependent. Provider shortage and maldistribution aspects have almost exclusively been analyzed from the perspective of providers. Primary care physicians and general practitioners (GPs) constitute the largest group of providers [e.g., 13,57,87–90]. The reasons for the emergence of provider shortages have primarily been physical barriers and infrastructural deficiencies, such as those related to long distances and inadequate transport [55,65,70], communication infrastructure [91] and a lack of social and cultural facilities [20,92,93]. These circumstances of rural living explain a widespread unwillingness to practice in rural areas. Several socio-cultural reasons, such as resistance within a provider’s family [94], worries regarding social isolation [95] and an unsuitable work-life balance [96], intensify this unwillingness. The problems of provider shortages and their maldistribution are closely connected. In addition to physical


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Table 2 Summary of reasons for shortages of sufficient health care in rural areas. Reasons for shortage Physical/ infrastructural

- Impact of nature on inaccessibility and safety concerns [63,64,116] - Lack of transportation opportunities [4,71,79,80,84] - Burden of traveling for patients and providers, including time, money and inconvenience [19,65,69,72,79,84,91] - Inappropriate accommodation or poor local transportation and communication infrastructure [65,91,117] - Lack of social or cultural facilities [93,97]

Professional

- Higher workload and after-hour responsibilities [37,38,54,118,119] - More on-call coverage duties [41,44,49,61,92,120] - More home visits and frequent traveling, including country-specific needs to overcome large distances [65,97] - Excessive bureaucracy and paperwork [49,54,119,121] - Insufficient locum coverage [55,61,122] - Professional isolation, insufficient consultation opportunities among colleagues and insufficient access to hospitals [52,93–95,97,122,123] - Lack of continuous medical education and professional development opportunities [20,47,48,65,92,102,117,124,125] - Wide range of medical services must be provided [47,67,68,98,102,126] - Fear of being confronted with unfamiliar problems [10,103] - Lack of provider cooperation and integration, miscommunication in therapeutic planning and service inconsistencies [62,64–66] - Lack of resources and equipment [19,62,63,80] - Inefficient use of health care services because of personal preferences and a lack of trust [77,78,82,83,85,86,114,116]

Educational

- Few students with a rural background and a lack of targeted selection of students with a predisposition for rural practice [88,97,99,124,127–129] - Lack of rural orientation and commitment in medical education, including rural experiences and training [57,87,88,95,99,129–137] - Lack of rural role models [124,126,138,139] - Trend among medical students to specialize instead of generalize [40,99,136,140–144] - Lack of extended and structured qualification for rural providers; unsatisfactory programs [126,145,146]

Socio-cultural

- Unfamiliarity with rural lifestyle [85,89,128,135] - Social isolation of providers [20,91,95–96,125] - Inadequate educational infrastructure for children and lack of job opportunities for partners [20,61,91–93,97,103,122,125,147] - Family-unfriendly working conditions; unsuitable work-life balance [96,119,144,147,148] - Caring roles extend actual work, high community expectations and social control [69,97,117,122] - Need for special physician characteristics, such as high confidence in social skills and community orientation [87,149–152] - Confidentiality issues and lack of anonymity for patients and providers [69,114] - Greater responsibilities of rural providers for age and culturally diverse populations and more complex cases [52,63,66,73] - More frequent substance and alcohol abuse, tobacco use, and environmental threats to health [10,52,153] - Lack of patient’s knowledge regarding the availability of services and use of the medical system [65,66,76,80,81,110,114] - Rural dwellers’ attitudes and traits (e.g., stoic, self-reliant, and proud; stigmatizing illness) or expectations constrain the use of medical services [69,78,80,82,83,154,155] - Problematic service adequacy; care that is provided may not fit with patients’ expectations or culture [7,79,82,84,104,110,114,156] - Cultural barriers and miscommunication [62,78,113,114,154] - Inadequate cultural awareness of providers, including the level of education and language differences [65,69]

Economical

- Insufficient financial compensation and income; insufficient viability of services [7,49,54,61,86,117,119,121,128,157,158] - High rate of uninsured or underinsured individuals in rural areas [10,12,76,153] - Inadequate and expensive medical liability insurance [109,159,160] - Lack of insurance coverage and patient’s financial burden, including out-of-pocket costs [19,69,73,76,77,80,81,83,106,107] - Dependence on financially less-attractive patients [13,88,118,161]

Political

- Inefficiency and ineffectiveness of regulatory interventions; insufficient funding for rural facilities and providers [10,13,90,94,115,143] - Lack of supportive political environment; policy bias toward urban areas [21,55,84,162] - Contribution to inequalities because policy regulation conserves a suboptimal previous status quo of the provider’s distribution [32,163] - Providers lack knowledge regarding opportunities and administrative procedures to receive support [164] - Lack of scientific evaluations of political interventions and strategies [88,165,166] - Available services are tailored to urban criteria and are not sensitive to the needs and culture of rural communities [154] - Barriers to the integration of international medical graduates [42,167]

and socio-cultural issues, the most influential reasons for the emergence of provider shortages and provider maldistribution are summarized in the professional, educational and economic categories. From a professional point of view, unfavorable working conditions [54,55], professional isolation [94,97] and the lack of continuous medical education opportunities [98] deter many health

care providers. At the same time, medical education lacks rural orientation [57,99] and fosters specialization [100], which leads to provider maldistribution. Running a rural practice is also less attractive from an economic perspective [54]. The third aspect of shortage, which includes quality deficiencies, emerges to a large extent for professional

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reasons, many of which are related to problems that concern the coordination and continuity of care in rural areas [3]. The coordination of care and the trans-sectoral integration of providers are particularly difficult to achieve in rural regions [62]. Problems occur because of shortcomings in inter-professional communication [101], interruptions of therapy plans [66], impeded access to other health professionals or hospitals and a general lack of resources and the latest equipment [19,80,86]. The comparatively wide range of health issues [68,102] faced by rural provider also intensifies these challenges. Some professionals feel unprepared and unable to regularly confront unusual or unmanageable situations [103]. In the context of quality deficiencies, the number of articles that consider the patients’ views is considerably high. In addition to considering rural patients in general [104,105], several articles refer to subgroups that are particularly affected by quality problems because they need more specialized care or the services of several health care providers. Research on access limitations considers rural populations or communities together [16,74,106] or is concerned with more vulnerable groups that might suffer from restricted access to adequate services; these groups include children [107,108], the elderly or poor [8,72,75,80,109] and rural minorities [81,110]. To adequately consider access problems, it is necessary to understand that access not only indicates the physical availability of providers or services but also the accessibility from a spatial point of view and the organization of services in a manner that accommodates individuals (e.g., office or telephone hours). To ensure sufficient access, crucial prerequisites include the ability to afford health care, to accept providers and services and to eventually seek the necessary care [111]. However, access in rural areas is limited because of physical [15,75], socio-cultural [76,78] and economic [73,107,112] reasons. Cultural and language barriers [110,113] and a poor fit between provider and patient expectations [7,82,114] also represent obstacles to access. The inefficient use of medical services often occurs because of a lack of adoption or even a rejection of services. The problems of usage are primarily related to socio-cultural reasons. Studies from several regions have suggested that rural inhabitants’ attitudes and traits (e.g., stoic, self-reliant, and proud) pose considerable constraints to the use of medical services [78,84]. The stigmatization of illness sometimes generates a hidden burden, especially in the case of mental disorders [69]. A small set of articles considers the rarely analyzed yet important perspective of policy makers in this context, e.g., those focusing on effective health service provision policies and service models [7,84,115]. Some reasons that contribute to the problems of provider shortage, maldistribution and access limitations can be classified as political. The effectiveness of regulatory interventions, for example, is frequently doubted [90,100], and funding for rural providers is insufficient [13]. Table 2 summarizes the aforementioned physical/ infrastructural, professional, educational, socio-cultural, economic and political reasons and provides additional information for each category.

4. Discussion The purpose of this study was to perform a comprehensive analysis of research on health care shortages in the rural areas of developed countries. The two-part research question explored the different aspects of and the underlying reasons for these shortages. The analysis of the literature revealed the following five main aspects of health care shortages: provider shortage, maldistribution, quality deficiencies, access limitations and inefficient utilization. Although all aspects present essential challenges for health care providers, policy makers and patients, provider shortage remains the most widely recognized problem in the literature. Despite the ongoing discussion regarding the appropriate measurement of shortages, this aspect has been relatively tangible through the calculation of ratios. However, all aspects identified have significant interdependencies. An absolute or relative lack of providers can automatically lead to deficiencies in the quality of care because the few remaining providers experience a substantially higher workload and have less time for individual patients. To understand the problems of rural health care, the different aspects identified in this study must be analyzed on an individual regional level. The analysis of the underlying reasons for shortages revealed six major groups of factors. In addition to the spatial limitations of rural areas, which often relate to infrastructure, a variety of professional issues associated with socio-cultural, economic and political aspects were identified. The broad spectrum of reasons illustrates that one single policy or even one single player within the health care system will not be able to solve the root causes of insufficient health care in rural areas. Amid the ongoing depopulation and vulnerability of many rural regions and the tremendous cost pressure of health systems, infrastructural and economic issues will become particularly relevant, and the prevailing shortages of health care services will likely increase. Considering the perspectives addressed by the various studies, it becomes clear that the shortage in sufficient health care services is a multifaceted issue with several stakeholders. However, a multiple consideration of different perspectives has rarely occurred in research. While the perspective of the providers is the most common research focus, the perspective of rural residents on health care shortages has been under-researched for a long time. The focus on the provider perspective in traditional research is understandable because the providers themselves – their shortfalls, choices and preferences – appear to be one core problem. Recent research extends beyond the determination of factors that prevent physicians from working in rural areas and examines the in-depth role of extrinsic and intrinsic incentives [168] that motivate professionals. However, in order to assess a regional situation with regard to shortages in sufficient care, it is necessary to consider different perspectives. In particular new models of health care delivery must consider patient needs to be adopted successfully. The aggregated view in Table 3 shows that some groups of reasons affect certain aspects of shortages more


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Table 3 Aggregated view of shortage aspects and underlying reasons.

strongly than other groups. The shaded circles present a qualitative evaluation based on the literature review and illustrate how the aspects of shortages (columns) are related to specific reasons (rows). For example, if a regional analysis of the aspects of shortages, as previously proposed, shows that there is an overall provider shortage, it is very likely that physical/infrastructural reasons have caused this shortage. The aspect of maldistribution is more closely related to educational and economic reasons. Conversely, the insufficient utilization of health care services is unlikely to be caused by political reasons, but it has been related to social and cultural reasons. Stakeholders must jointly address the underlying reasons. For example, if quality problems appear to be the most pressing issues in one region, then the stakeholders must first examine the professional reasons for those problems and address the related topics, such as the need for focused provider business models for on-call duties, the reduction of excessive bureaucracy and the creation of new methods of (distant) continuous medical education for providers using online media.

5. Limitations This study shares limitations with numerous systematic reviews. The search covered only peer-reviewed journals, which may lead to a publication bias [169]. Furthermore, the heterogeneity of studies within the sample is a notable challenge. Because the evaluated literature covers multiple research settings and disciplines, as well as diverse samples and research methodologies, we used a meta-level approach to condense the large amount of findings within the content analysis. To enable a broad scope, this review made a trade-off to reduce the level of detail that concerned specific issues. Accordingly, certain subthemes (e.g., the types of access

restrictions) were only briefly discussed, and a more indepth analysis would be desirable. Moreover, the research included only developed countries and did not account for the geographic heterogeneity of regions. There are large differences in the spatial conditions that determine the extent of the outlined problems. Nevertheless, the study revealed that the problems are quite similar in different developed countries. The question of how to deliver adequate health care to rural and deprived regions is of high relevance.

6. Implications for research and policy As this study has illustrated, research on health care delivery in rural areas is manifold, complex and interrelated. Moreover, the local context, including individual perceptions and attitudes toward the situation in the community, is crucial. This context is particularly relevant in light of several changes that continue to occur in health care systems, such as the redesign of delivery models and services [170] and the increasing diffusion of ICTbased support tools [171]. Issues that have been raised by researchers include the levels of local service provision that individuals from different geographic regions consider acceptable. Evidence suggests that rural patients are more satisfied with their health care compared with urban patients [170,172]. This finding shows that lower expectations and social and cultural aspects positively influence satisfaction despite objective deficiencies. Furthermore, conclusive evidence on the effectiveness and efficiency of political interventions is very limited. Decades of research have focused on provider recruitment and retention, and various strategies have been implemented internationally. Financial incentives (e.g., scholarships and loan repayments) designed to persuade professionals to serve and remain in a region are

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a particularly prevalent strategy, despite existing evidence that professionals’ decisions are more influenced by socio-cultural conditions [88,173]. Other more promising examples include the targeted selection of students with predispositions toward rural service and rural medical education strategies [165]. However, the majority of those interventions still lack rigorous evaluation (e.g., by comparing a regional situation before and after an intervention and by discerning evidence regarding long-term effectiveness) [88,165,173]. To support political decisions and resource allocation, researchers must evaluate the success and sustainability of interventions that aim to provide sufficient delivery of rural health care while considering regional idiosyncrasies and community issues. The complexity of aspects and reasons for deficiencies in health care indicates that an integrated assessment is indispensable. However, the ideas presented in this paper have taken a very rational and objective approach, which, to some extent, neglects the wider problems of rural areas, such as depopulation and the aging of the rural population. Nevertheless, because of its broad scope and detailed insights, this review provides practical implications for health care service providers and policy makers to derive priorities for strategic action. Bearing in mind the different aspects of insufficient health care, policy makers on a local level as well as those on a broader, regional level should first analyze the situation in their respective areas. The next step would be a detailed analysis of the specific reasons related to the local shortage (see Table 2). A lack of social and professional support for providers, unrealistic patient expectations, and a lack of knowledge and (mis)communication between providers and patients can be addressed through targeted promotion, information, education and training. The acceptance of new models and services and the matching of actual needs can be achieved through early communication, shared political decisionmaking and the consideration of social and cultural issues. In response to the overwhelming focus on health care professionals in political strategies and research, studies must acknowledge the need to re-examine conventional health care delivery models. Additional efforts should be made in the development and implementation of teambased multidisciplinary health service models that (i) align to support health education, prevention and selfmanagement; (ii) are economically sustainable; and (iii) promote active community engagement and participation [166]. Innovative models foster the coproduction of health care and public services [174], such as community participation in defining local health priorities, the involvement of local volunteers for health improvement and basic service provision [175]; service delivery for older individuals by community social enterprises [176]; and the transfer of power and budgets to individuals to “personalize” and re-design traditional social care according to their needs [177]. Community participation, particularly community involvement, in the design of health services and participation in service provision are approaches that extend beyond informing and consulting in design processes [175]. The diversity of aspects of deficiencies in health care and the unbalanced consideration of perspectives highlight the

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