Retention of physicians in rural Japan: concerted efforts of the government, prefectures, municipalities and medical schools.

CONTEXT: In post-war Japan, a number of factors lead to a general shortage of physicians by the 1950s, which became acute in rural areas and has continued until recent times. ISSUE: Teamwork among national, prefectural, municipal governments and public medical schools has addressed this shortage of physicians. The national government doubled the number of medical schools in the 1960s and 1970s; each of the country's 47 prefectures, whether rural or not, has at least one medical school. In rural areas where private hospitals are not profitable, municipal governments have funded public hospitals and physician recruitment from their own budgets. A cooperative project among Japan's 47 prefectural governments and the national government established Jichi Medical University (JMU), which conducts a bound medical education program followed by obligatory rural service. As a result, the number of 'non-physician communities' (muichiku) nationwide has decreased by 73%; however, the gap between physician concentrations in urban and rural areas has not changed. Therefore, the government has recently implemented a JMU-like contractual program as a form of 'rural quota' at other medical schools in all 47 prefectures. If all the replicated programs work as successfully as JMU, the impact on the geographic distribution of physicians will be substantial. LESSONS LEARNED: The Japanese public-sector-led rural physician securing system could also be effective in countries where rural healthcare provision is the responsibility of the public sector and close cooperation among levels of government is possible.