Are physicians distributed equitably in Canada?

"Geographic distribution of physicians is a major health care issue. For developed countries, including Canada, there is a general belief that the overall supply of physicians is adequate but there is an uneven distribution of physicians, with rural, small and remote areas having an inadequate supply....

"....The second part of the present study (Chapter 3) is an empirical analysis of physician availability in Canada (although the FTE analyses are based on data from only eight provinces), using as a guide insights gained from the literature review. Since the emphasis is on the spatial distribution of physicians, geographic information systems techniques have been used to visually present some of the results in a series of maps. The major findings and 'lessons learned' are highlighted in point form as follows.

"In Canada, during the period from 1986 to 1996:

The number of physicians increased by 20.5%, while the overall population of Canada increased by only 13.9%;

'Head count' population-to-physician ratios have improved and recommended population-to-physician ratios were met for GPs/FPs and for most specialist physicians at the national and provincial levels;

FTE-based population-to-physician ratios also show improvement; but when these figures are used, fewer recommended ratios are met;

If the trends that have been observed for female and older physicians continue (i.e., together becoming an increasing proportion of the physician workforce; and both associated with lower average FTE values), it will be more difficult to reach many of those recommended population-to-physician ratios;

While national and provincial numbers of physicians are generally adequate (assuming the validity of the recommended population-to-physician ratios), significant regional variations existed and persist, leading to a 'maldistribution' of the physician resources in many parts of Canada;

'Maldistribution' in the form of decreases in the numbers of rural physicians relative to the population in those areas is apparent and can be displayed easily using simple cartographic techniques; in some instances the simpler technique of a dot map is more adequate than the plotting of population-to-physician ratios because of the large geographical units needed to adequately portray the ratios;

If administrative units are used to examine differences between urban/rural physician and population distribution and if one cannot generate the classifications, then the Statistics Canada urban/rural codes are highly recommended; however, they should be used with caution especially for time-series analyses as the administrative/census boundaries of communities can change and have changed considerably over the years;

Over the short period of time from 1991 to 1996, the proportions of physicians working in small town and rural areas of Canada decreased from 14.9% to 9.8% while the population rose from 19.2% to 22.2% (Note: these figures are approximate only and should be used with caution because of the boundary changes in census administrative units that occurred during this timeframe);

While the majority of Canadians live in close proximity (i.e., less than 5 km) to physicians and hospitals, the distance to these health personnel and facilities is increasing for rural residents as physicians and hospitals are increasingly concentrated in urban and urban fringe areas; and

When detailed location data are available, urban/rural dichotomies in terms of both physician and population distribution are best assessed and shown when the researcher is not constrained by pre-defined, and perhaps inappropriate, geographical areas such as census divisions or counties.

"What this study has accomplished is to show that there is more to the geographic distribution of physicians than population-to-physician ratios. We have tried to show that physician distribution can be understood and measured in different ways. Some of these approaches have been used in an empirical analysis of physician supply in Canada, which has yielded some useful results....

".... while it is possible to document the unequal distribution of physicians, it is much more hazardous to infer physician shortage, except in extreme cases. This is because designations of 'shortage' or 'maldistribution' have to be made against some standards of adequacy. Unfortunately, there are as yet no universally accepted standards. The recommended population-to-physician ratios we have reviewed, even if they are valid, tend to be national standards which may or may not be applicable at sub-provincial levels."

From: Roger Pitblado and Raymond W. Pong (1999). Geographic Distribution of Physicians in Canada. Sudbury, Ontario: Centre for Rural and Northern Health Research, Laurentian University.