Inequalities in the distribution of rural primary care physicians in two remote neighboring prefectures of Greece and Albania.
BACKGROUND
Inequalities in the distribution of primary care physicians are of great importance in the provision of health care. This becomes more apparent mainly in the rural and remote areas of each country. The objective of the present study was to evaluate and compare the degree of inequality in the provision of primary care physicians in two rural and remote prefectures of neighboring countries. We studied the cases of Ioannina, Greece and Gjirokaster, Albania during 2001.


METHODS
In both prefectures, for all calculations made, we used the total number of physicians providing primary care in rural areas. This includes GPs, internal medicine specialists, non-specialised graduate physicians. All other physician specialties (eg. microbiologists) were excluded from the calculations of the present study. We calculated the population per physician ratio (PPR) for each health center in each prefecture. For the comparison of the inequality we used two relative inequality measures. We plotted the Lorenz curves and calculated the Gini coefficients for the distribution of physicians' workforce adjusted by population in the two districts. Finally, we calculated the difference in the inequalities in these distributions. The p values were two tailed and calculated for 95% confidence levels.


RESULTS
The PPR for the whole prefecture of Ioannina, Greece was 1222. The lowest PPR, which corresponds to higher supply of human resources, was 205, while the highest (worst) was 8166. In the case of Gjirokaster the PPR was 2376 for the whole prefecture. The lowest PPR was 1323, while the highest was 4546 inhabitants per physician. Because the two curves do not intersect we can assume with certainty that primary care physicians in the prefecture of Ioannina were more unevenly distributed than those in the prefecture of Gjirokaster. The Gini coefficient for the distribution of primary care physicians in Ioannina was 0.489 (SD = 0.045), while that of the Gjirokaster district was 0.186 (SD = 0.034). The difference between the two Gini indices was 0.303 (p < 0.001).


CONCLUSIONS
Primary care physicians in both prefectures were unevenly distributed. The inequality in the distribution of primary care physicians was significantly higher in the prefecture of Ioannina, Greece compared with that of the prefecture of Gjirokaster, Albania. Further investigations could be made using a need adjusted index instead of PPR. For this purpose, the number of physicians could be adjusted for mortality, morbidity of chronic diseases or limiting longstanding illness. Studying the inequality patterns in districts could be aided by the use of other disciplines, such as geographical information systems, giving a clearer picture of the situation of primary care provision in these districts. The results of the present study could be considered by health policy researchers. It seems that human resources' density and inequality in the distribution of health manpower are both needed as indicators for a more thorough investigation of health services, especially in the case of rural and remote areas. Furthermore, health policy makers should focus on the redistribution of the health manpower towards a more equitable situation, based on the results of similar studies. Finally, the documentation of inter-country differences would prove helpful in terms of international cooperation and sharing of knowledge by policy makers when the objective is the equality and quality of health services provision.
Theodorakis
Pavlos N
PN
State Mental Health Hospital of Chania, Crete, Greece. paultheodorakis@yahoo.com
Mantzavinis
Georgios D
GD
D000415:Albania; D006115:Greece; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D020380:Needs Assessment; D011320:Primary Health Care; D019035:Rural Health Services; D000078329:Workforce