Geographic maldistribution of physicians

The inequitable geographical distribution of physicians, specifically a shortage of trained doctors in rural areas and a relative surplus in urban areas, is recognised as a problem across the world.1 2 Among all health professionals, there is a particular shortage of physicians in rural areas. In Japan, the dire need for physicians in rural mountain areas and on small islands has been a persistent and serious health and political issue since the establishment of the modern healthcare system in the Meiji period (mid-19th century).3

Access to healthcare largely depends on economic and geographic barriers to visiting healthcare facilities. In Japan, universal health insurance coverage was achieved in 1961, so economic obstacles generally are not considered to be a significant issue.4 More serious and important are geographical barriers, mainly in rural areas, due largely to a lack of physicians in such areas.3 There is a 2-fold difference in the physician-to-population ratio across all the 47 prefectures of Japan, and more than a 10-fold difference among municipalities (cities, towns and villages) even within a prefecture.5

Jichi Medical University and regional quotas of medical schools as a solution to the rural physician shortage

Japan does not have a formal system to allocate physicians, nor any regulation or law that controls the number of physicians in each region. Thus, the government has tackled maldistribution through two unique policies: Jichi Medical University (JMU), which was founded in 1972, and chiikiwaku, regional quotas (RQs) for medical schools, which have spread nationwide since 2008. The structures of these two schemes are similar, and the latter was developed based on the former.

JMU is a medical school created solely for producing rural physicians. It is financially managed by the 47 prefectures of Japan. Two or three students from each of the 47 prefectures are accepted and educated for 6 years. The curriculum is tailored to prepare students for future rural practice. Tuition is fully funded by each student’s home prefecture. In exchange, each graduate, after completing a physician’s licence, is obliged to return to their home prefecture and work in the prefecture for 9 years, which usually include 2–3 years of training in large cities and 6–7 years of rural service. If a graduate refuses the obligatory service, the graduate must return, in a single payment, full tuition (¥23 million, equivalent to £126 805) to the home prefecture. Since its inception, JMU has produced more than 4000 physicians, who practise in rural regions throughout Japan.6

RQs are special admission quotas operating in 65 of the 82 medical schools in Japan. The quotas are designed to produce physicians who will serve in the prefectures in which the medical schools are located. Usually an RQ takes around 10–20 local students and educates them for 6 years plus some extra training tailored for future rural practice. Scholarships are given to RQ students for the entire period by the home prefecture. After obtaining the physician’s licence, RQ graduates are obliged to work in their home prefecture for 9 years including, on average, 4 years of rural service. If they do not complete the obligation, they must pay back the scholarship (on average ¥13 million, equivalent to £71 143) to the prefecture in a single payment.7 In addition, the government imposes career-related penalties on JMU/RQ students and graduates who buy out the scholarship/tuition without the prefecture’s agreement. Currently, the scholarship-aided RQ entrants nationwide comprise 960 students, or approximately 10.3% of all medical school entrants, which, when combined with JMU entrants, adds up to 11.6% of medical students nationwide.8

Studies have shown that both JMU and RQs have been effective in producing rural physicians.1 9 JMU and RQ graduates’ completion rates for the National Physician License Examination are significantly higher than the rate for other graduates. The obligation compliance rate is 98% for JMU and 90% for RQs 5 years after obtaining a physician’s licence.10 The distribution of JMU/RQ graduates is highly skewed to rural areas as compared with non-JMU/RQ physicians.10

JMU has been highlighted as a unique and successful policy for producing rural physicians by the WHO.1 Recently, China has launched its own medical school programmes similar to RQs, and their effectiveness is beginning to be reported.11 12 South Korea is planning to found a new medical school to produce rural physicians as JMU does, and also to establish medical school quotas similar to RQs.13 Scholarship and loan forgiveness programmes for medical students or trainee physicians in exchange for future rural service are also managed in some other countries.14 One of the largest is the United States’ federal National Health Service Corps (NHSC). The NHSC was founded in 1972 and since then, 65 000 health professionals have worked in rural areas as part of the programme.15

Ethical issues related with JMU/RQs

Some have pointed to ethical issues in these policies. One argument asks whether it is necessary and valid for the government to implement these policies through new laws and the use of tax money. In the 1970s, when JMU was founded, some in the mass media criticised it as a ‘waste of tax money’. A similar debate occurred recently when RQs were introduced. The validity of the government as the main body of implementing JMU/RQs is a fundamental issue that goes to the raison d'être for these policies. A second claim is that these policies restrict physicians’ freedom to reside where they wish and may violate basic human rights.16 17 Related criticism suggests that the age of medical school entrants is too young for them to sign a contract that limits their future career.17 Finally, the penalties the government imposes on JMU/RQ students and graduates who buy out their rural service have been described by some critics as ‘unethical’.17 18 We will discuss each of these criticisms in detail.

Ethical validity of government management of JMU/RQs

Physicians are a core occupational role in the development of human resources for health. As such, their distribution needs to be fair. Article 13 of the Japanese Constitution states that the people’s pursuit of life is of utmost importance to the state. Article 25 declares that all people have a right to live a healthy life and the government has a duty to provide one. In Japan, therefore, the fair provision of healthcare is a social justice principle, and the main organ for guaranteeing fairness is the government. Internationally, the United Nations and WHO promote fair health for all people.19 20 However, in Japan, as is the case in many other countries, physicians strongly incline toward urban areas. Studies have shown that no matter how much the total number of physicians is increased by national policies, the Pareto optimal distribution between urban and rural areas can never be achieved.21 22

Rawls, in his theory of justice, claims that primary social goods must be allocated equally (the greatest equal liberty principle) to all citizens regardless of their social, economic or geographical background, and that the opportunity to obtain primary social goods must be open to everybody (the equal opportunity principle). Rawls’ primary social goods include civil and political rights, liberties, income and wealth, etc, but do not include health.23 Daniels proposes that fairness in availability of healthcare be included as a part of Rawls’ equal opportunity principle because ill health impairs human function and deprives individuals of their fair share of primary social goods.24 Health is determined by various factors such as genetic predisposition and socioeconomic status. Among the determinants of health, healthcare occupies an exceptional status in that it is a public good that can be allocated equally or unequally. Based on Rawls’ and Daniels’ principles of distributive justice, healthcare must be allocated equally whether people live in urban or rural areas. This accords with the principles articulated in the Japanese constitution.

To increase the average level of health of all citizens, from a utilitarian perspective it is usually best to concentrate healthcare resources on those who are most underprivileged and underserved, such as those living in rural areas. Such people have the largest potential for health improvement.25 According to Marmot, the larger the health gap among populations, the worse a society’s overall health level.26 In this sense, distributive justice for healthcare as derived from Rawls and Daniels is not just a matter of justice and fairness, but also accords with utilitarianism, which pursues the greatest health for the greatest number.

On the other hand, some oppose the idea of ‘allocating physicians’ from the viewpoint of luck egalitarianism. According to luck egalitarianism, bad outcomes that result from brute luck need to be ameliorated but those that are the consequence of conscious choices do not need to be redressed.27–29 In the luck egalitarianist’s view, rural people chose to live in rural areas understanding the disadvantages of such areas, including a lack of physicians, in exchange for various advantages such as cheap housing and a rich natural environment. It is thus unreasonable for rural people to demand the right to have a physician in their communities.

The luck egalitarian claim can be rejected. The majority of rural people in Japan work in agriculture, fisheries and forestry, and are hereditary inhabitants rooted in the land and sea. It is practically impossible for them to reasonably choose a living place among many options. Because living in rural areas is not their choice, we cannot put on them the responsibility to tolerate the physician shortage.29 30 Moreover, rural people contribute to society as a whole through their work in food production and forestry management. Nobody can deny the fact that every day we eat the rice they grow. Even if the rural physician shortage is attributed to their responsibility derived from their own choices, their plight should be addressed as long as they support the daily lives of urban dwellers.29 30

Finally, consistency with the national health insurance system, which covers the whole population, matters. The insurance system compulsorily enrols all people living in Japan and collects insurance premiums every month, assuming that everyone can equally access healthcare services as they wish. The monthly premium is proportional to income, and geographic factors are not taken into consideration. Despite the same financial burden, rural residents face significantly greater challenges in accessing physician services compared with their urban counterparts. This is undoubtedly unreasonable and unjust.

We can say, from the standpoint of distributive justice, utilitarianism, luck egalitarianism and the integrity of national health insurance and the Japanese Constitution, that the government’s control of the distribution of physicians is indispensable and valid. It is thus permissible for the government to manage the only socially accepted system for allocating physicians, that is, JMU and RQs, using legislation and the national budget.

Issue of limiting the freedom of physicians

A further criticism pertains to how JMU/RQs restrict a physician’s freedom, even though the period is limited, claiming that such strictures are ethically and legally problematic. The Labour Lawyers Association of Japan claims ‘just as citizens have the freedom to choose their living places, so do physicians. Freedoms to quit a job, relocate residence, and choose a job are assured by Article 22 of the Japanese Constitution. So the restriction imposed on RQ physicians can be a violation of these rights’.16

As Sen notes, in order to achieve equal freedom in a certain aspect of social function, we need to permit inequality of freedom in another aspect.25 There is a trade-off between securing the freedom of all citizens to access healthcare and the freedom of physicians to choose their workplace. In the end, it is a political matter to strike a balance somewhere between the two.

Article 22 of the Japanese Constitution states that, ‘anybody, as long as he or she is not against the common good, has the freedom to relocate their residence and choose a job.’ Notably, the freedom to choose a living place is valid as long as the person is not acting ‘against the common good’. ‘Being not against the common good’ means not violating other basic rights stipulated by the Constitution, including people’s right to pursue life (Article 13) and the right to live a healthy life (Article 25). John Stuart Mill, in his theory of liberty, expounds that an individual possesses a freedom as long as that freedom does not violate another person’s interests, but if it does so, the person owes a responsibility to society.31 In the case of physicians, the argument is complicated due to their job’s direct relationship to the common good. If a part of the citizenry suffers serious life and health disadvantages due to physicians’ limitless exercise of their freedom, regulating their freedom in some form does not go against legal or ethical principles.

From the perspective of medical professionalism, it is justified to require physicians to prioritise a patient’s welfare over their own interests. Medical professionalism is a set of norms governing physicians originated in the Hippocratic Oath in Ancient Greece, and it recently has been widely accepted as a compulsory subject in medical education.32 33 Professionalism is considered to be a tacit contract between physicians and their society. Society guarantees physicians the exclusive right to conduct medical practice, professional autonomy, social status and financial reward in exchange for reliable clinical skills and high moral standards.34 35 Medical professionalism as defined by the American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine includes the ‘principle of primacy of patient welfare’, the ‘principle of social justice’ and the ‘responsibility of commitment to improving access to care’.36 The implication of these principles and responsibilities is that physicians should serve the underserved.

Above all, JMU/RQ students and physicians voluntarily accepted temporary limitations on their place of work for the common good. JMU/RQs provide informational material to prospective applicants about the JMU/RQ system such as leaflets, websites, and orientation meetings so that they will understand the JMU/RQ system before they apply. Understanding the system and having a desire to work for underserved people are prerequisites for admission to JMU/RQs. The financial incentive provided to JMU/RQ students is also not merely a form of lending but can be interpreted as a contract between admitted students and Japanese society to achieve the common good.37 Therefore, JMU/RQ physicians have a moral responsibility to serve the underserved, while in order to uphold its end of the contract, society must provide students/physicians sufficient education and career support.

Controversy on the age when entering into the contract

JMU/RQs, such as other Japanese medical schools, recruit students who are usually eighteen or nineteen years old. Some critics have suggested that JMU/RQs force young students, who may not know much about the reality of a physician’s job, to sign a contract that limits their career choices.17 The age issue has also been argued in relation to scholarship programmes in other countries.38

First, in Japan, 18 is defined by law as the age at which an individual is capable of judging themself and possesses legal rights and responsibilities; that is, an 18-year-old is deemed a legal adult. It should also be noted that many Japanese choose a career at the same age. In the Japanese university admissions system, high school students/graduates apply to university departments that are closely linked to their chosen future career such as medicine, dentistry, veterinary science, engineering, education, etc. Many other students’ career choices are thus made at the same age, and no one has raised ethical questions about this system. If the choice of occupation at the age of 18 is ethically valid, the choice of workplace should not be a problem. When 18-year-old exercise their judgement, it is quite implausible that they would have more knowledge about the realities of a job than the reality of the place they hope to live (usually their home prefecture). This means, at least in Japan, that age should not be seen as a major ethical issue in terms of choosing JMU/RQs.

Another important point to be noted is that other career options can be chosen even after admission to JMU/RQs. It is always possible for a JMU/RQ student to return the tuition/scholarship to the prefecture, quit medical school before obtaining the physician’s licence, re-enter medical school through the regular admissions process, or matriculate into a non-medical academic institution. No penalty is imposed on such a case. Even if the student faces financial difficulties in taking on a medical education, he or she can still attend a non-JMU/RQ medical course by using public loan programmes that are open to everybody with financial need. The loan must be paid back after graduation, and the payment period can be set for a long period. Considering that the average income level of Japanese physicians is quite high, it is unlikely that he or she would not be able to pay back the loans.

Penalties imposed on those who get the physician licence and buy out the tuition/scholarship

The government imposes penalties on graduates who enter medical schools through JMU/RQs, obtain the national physician’s licence, and then buy out the tuition/scholarship to free themselves from the obligation without a convincing reason. As for those who buy out before postgraduate clinical training, which all medical graduates must participate in for 2 years, the government shares information about the buy-outs with all the training hospitals in Japan, which is likely to have a negative impact on a hospital’s decision to hire the graduates. As for those who have completed postgraduate clinical training, the government cooperates with the Japanese Medical Specialty Board to disqualify them from board-certification for any medical specialty such as internal medicine, surgery or ophthalmology.

The social context behind these penalties is the fierce competition to be admitted to medical school. In Japan, physicians enjoy high social status and their average income is also much higher than average.39 In fact, competition for admission is the fiercest by far among all the academic departments of universities. For example, the ratio of applicants to available places at private medical schools is 12.7, while other departments usually average somewhere between 2 and 3.40 Once admitted to medical school, 97.5% of entrants graduate and take the national physician’s licence exam.8 Over 90% of the graduates pass the licence exam on their first try,41 and there is no limit on the number of times one can repeat the exam. It is thus common sense in Japanese society that the most significant barrier to becoming a doctor is gaining admission to medical school, rather than in subsequent stages. JMU/RQs offer seats on the condition that the applicants serve in the designated prefectures after obtaining the physician licence. Therefore, escaping the obligation after training and licensure is considered by many, including the government, to be unethical.42

This penalty issue is closely related to ethical debate on international-level brain drain among skilled health workers. The brain drain of skilled health workers from developing to developed countries is a serious issue, and there is much debate regarding it.43 Brock argues that the emigration of highly skilled workers such as physicians from a developing country should be limited by the government of the country for the following three reasons:

1. Loss of social resources, including tax money invested to educate the highly skilled emigrants.

2. Health-related disadvantages of people in the country who otherwise could have enjoyed the service the emigrants provide.

3. Damage to the institution-building assets and sustainability of the society as a whole.

Brock insists that the government of the country from which highly skilled workers emigrate has a responsibility and legitimate power to protect their citizens from these losses and damages, and thus should implement policies to restrain the emigration.44

The debate on the emigration of physicians can be applied to our JMU/RQ discussion when we replace the words ‘developing country’ with ‘rural areas’ and words ‘developed countries’ with ‘urban areas’.45 46 Following is the revised version of the reason list.

1. A huge amount of public funds is invested to educate and produce JMU/RQ physicians.

2. When JMU/RQ physicians refuse to provide the services they are contractually obliged to provide, the health status of rural people is damaged.

3. Loss of physicians decreases the institution-building capacity of the rural society, which leads to the loss of sustainability of the society.

In addition, in the context of obligation refusal by JMU/RQ physicians, there is another reason to be noted which Brock did not mention:

1. Loss of opportunity to become a physician of applicants who hoped to enter JMU/RQ but were not admitted because the future refusers were admitted instead.

For these four reasons, national and prefecture governments have good reason to impose some penalties on the refusers.

The most important point, when considering the penalties, is the balance among the following three factors: the total value of invested public resources for producing the physicians, the responsibility and duty of the physicians based on the investment, and the physicians’ freedom to change working or living locations. During the brain drain debate, Brock proposed a tax for emigration and/or a pre-emigration mandatory term of service within the country with a buy-out option, as solutions to create a fair balance among these three considerations.44

In the case of JMU/RQ, the balance is not so fair if the penalties do not exist. The price of the buy-out option is too small in proportion to the amount of resource the national and prefectural governments invest.

As figure 1 illustrates, the average public money invested in JMU, including funds from both the national and prefectural governments, is about ¥120 million (£661 594) per student for the entire 6-year medical education.47 In the case of RQ, about ¥13 million (£71 143) is for the scholarship in addition to about ¥50 million (£275 664) for the education.7 48 More importantly, JMU/RQ graduates receive the physician licence from the national government, which is recognised as highly valuable in society and can be used forever even if they refuse the contractual service. All of these financial and non-financial benefits are given to graduates under the condition that they complete the contractual in-prefecture and rural services. Applicants who do not promise the completion of the service can never be admitted to JMU/RQ because the promise is a requirement. Currently, if a JMU/RQ graduate refuses to serve, the price of buying out is ¥23.0 million (£126 805) for JMU and ¥13 million (£71 143), on average, for RQ.7 49 There exists a substantial gap between the value they receive and the price they pay. This gap makes the penalties related to their training and qualifications necessary and valid. Even so, according to a survey, Japanese physicians who consider the JMU/RQ penalties to be light considering the benefits they receive are more numerous than those who find them harsh.50

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Figure 1

Public funds invested in a JMU/RQ student and what governments can recover if the student buys out of the contract after being licensed.

One problem about the penalties is that the clinical training and specialty-board certification are a different matter than compliance with the JMU/RQs obligation. Using these qualification systems as a means of punishment has been criticised by some as unfair and illegal.51 Whether illegal or not, the penalties may be inconsistent with the institutional framework of JMU/RQ. We thus propose two alternative systems. Either of them, not both, should be implemented. The first proposal is for service refusers to pay a penalty charge in addition to the current buy-out charge. The price of the penalty charge should be set at the price which most Japanese citizens think appropriate based on the amount of their investment. This makes the investment–responsibility balance better than now, and society can recover, to some extent, the cost of investment from the refusers. This system will make applicants to and students of JMU/RQ better understand the value of their service from a financial perspective. Also, it would reduce the number of service refusers. The second proposal is for the national government to give JMU/RQ graduates a prefecture-limited physician licence, and when they complete the contractual service in the designated prefecture, they can change it to the conventional, geographically non-limited licence. This limited licence incorporates the terms of contractual service within its validity range, and thus further penalties are not necessary. Also, with this licence, the applicants and entrants of JMU/RQ will be better aware of what they have to do in the future. At the same time, this system does not get rid of the freedom of those who refuse the obliged service and move to another prefecture (although, of course, they cannot practice in the non-designated prefecture). These alternative policies will maintain a just balance among investment, responsibility and freedom, and also improve the internal consistency of the JMU/RQ system. These alternatives should be explained to potential JMU/RQ applicants prior to applying to JMU/RQ system. Until the alternatives are implemented, the current penalties must be maintained in order not to break the balance and make the system unsustainable.