Jichi, quota with scholarship, scholarship alone, and quota alone were effective in securing physician workforce in rural areas. The order of effectiveness was Jichi > quota with scholarship > scholarship alone > quota alone, and it became more obvious with the passage of time. This order is also held in terms of the results of physician license examination and compliance for obligatory rural service.
Figure 7 offers several reasons for this order. First, the degree to which the curriculum emphasizes rural health differs among programs. Jichi's curriculum is based on its special mission. Quota with scholarship is managed as a part of a medical school, so rural education is added as an extracurricular activity for quota students. Students of quota alone and scholarship alone usually do not have such a regular rural education. Second, the cohort effect created by classmates and similar-minded colleagues is different. In Jichi, all the students have obligatory rural service after graduation, so they can more easily maintain their motivation for the service, while students in quota with scholarship are a minority in the medical school class and so it is harder for them to remain motivated. Moreover, most of the students in quota alone or scholarship alone cannot benefit from this cohort effect, because they have no opportunity to meet regularly with their colleagues. Third, educational costs for each prefecture are different. The financial burden is heaviest in Jichi, for which prefectures must offer the whole budget to run a full-size medical school. For quota with scholarship and scholarship alone, each prefecture bears the cost only of scholarship and extracurricular rural education. Jichi graduates who breach the obligation must pay 23,000,000 yen (equivalent to US$219,000) though this refund still does not cover the full cost of their 6-year education [32, 33]. In contrast, graduates of quota with scholarship and scholarship alone must pay back 12,900,000 yen (US$123,000) on average, which is almost equivalent to the actual cost borne by the prefecture [18, 34]. Fourth, the strength of the obligation is different. Jichi graduates must spend about 5 years in rural areas of their home prefectures and usually are not permitted to have a deferral, compared to about 4 years with possible deferral for a few years for graduates of quota with scholarship. Graduates of quota alone do not have contractual, and, therefore, no legal, obligation to serve in any place. These differences might explain the inter-program gap in effectiveness shown in this study.
The chosen specialty is not different among programs. This is probably because these programs' main purpose is not to redress specialty distribution but to improve geographic distribution. Some prefectures restrict selectable specialties for Jichi and scholarship graduates or give an incentive to some specialties by exchanging them for rural service exemption. However, these initiatives are not large enough to change the specialty distribution of all graduates. As to the in-prefecture rate, Jichi and quota with scholarship were not different and both retained their graduates well in the designated prefectures. Reasons for a small number of graduates who worked in non-designated prefectures are, in addition to cases with a breach of obligation, cases with permitted leave due to marriage or specialty training.
The passing rate of those in quota with scholarship for the physician license examination was substantially higher than that of typical medical students, which are consistent with the results of a previous study [13]. This study also revealed that the passing rate of Jichi was even higher than that of quota with scholarship. This may be because the admission process in Jichi and many of the quota programs is a combined evaluation of the high school grade, extracurricular activity, recommendation letter, personal statement, interview and academic test score of the applicant, while in the usual admission process of medical schools the decision is based predominantly on the test score. The result suggests the personal aptitude for studying medicine assessed from multiple perspectives is better than that assessed solely based on the score of entrance examination, which casts doubt on the validity of the conventional admission process of Japanese medical schools.
Japanese health policy is rapidly shifting from the physician increase to the rectification of their maldistribution. The national government predicted a surplus of physicians, and is aiming to cut the enrolment capacity of medical schools [35], while declaring its intention to close urban–rural gap of physician supply by revising the Medical Care Act in 2019 [36]. This means that Jichi and quota with scholarship will be more important than before. In reality, the revised Medical Care Act requests each prefecture to provide a "career plan" so that the programs' graduates can balance specialty training and rural service, while authorizing the governor to participate in the decision making for the enrolment capacity of quota in a medical school. From a prefectural perspective, Jichi is a high cost/high return, quota with scholarship is a middle cost/middle return, and quota alone is a low cost/low return program. Each prefecture and medical school needs to understand the advantages and disadvantages of each program and use it rationally.
Many initiatives to recruit and retain physicians in rural areas are conducted around the world. In the United States, the federal government and state governments have return-of-service scholarship or loan forgiveness programs, such as National Health Service Corps (NHSC) [37,38,39]. There are many similar financial incentives in the world, and the estimated retention rate of the pooled subjects of these in contractual services was reportedly 71% in 2009 [27]. There are also many undergraduate programs for attracting medical students to rural practice in, for example, the United States, Canada, the Philippines, Thailand, Australia, New Zealand, Norway, and Scotland [25, 40,41,42,43,44,45]. These foreign programs usually focus on the preferential entry of students with a rural background and/or undergraduate primary care education in rural areas, and thereby attaining success in recruiting and retaining their graduates in rural areas. However, Jichi and quota with scholarship in Japan are different from these other initiatives in that they combine four elements: medical school admission, undergraduate rural-oriented education, scholarship, and obligatory rural service. Such a comprehensive education–scholarship initiative is also planned in South Korea. The South Korean government is planning to implement a special admission quota in medical schools to increase the number of medical students by 4000 (18%) over the next 10 years and send three quarters of them to rural provinces in exchange for tuition waivers and scholarships [20,21,22]. The results of this study will be a reference for the countries planning to introduce a new comprehensive education-scholarship program or to modify existing programs into more comprehensive ones. However, attention should be paid to the difference in the health system and culture when applying the results to societies outside Japan [46].
The nationwide and prospective nature of the data is an advantage of this study. Follow-up information is precise, because it derives from the legally enforced census data in case of quota and scholarship, and from the school institutional research data in Jichi. This study also covers almost 100% of potential subjects for analyses of passing rate for Physician License Examination and retention rate for the obligatory workforce.
There are some limitations to this study. Even though we accounted for 100% of Jichi graduates, we had 40% of graduates of quota with scholarship for geographic analyses. However, the timing of entry of the quota subjects to this cohort was 2 years before their actual placement to rural areas. It is, therefore, difficult to suppose that the response rate of potential subjects varies, depending on the rurality of their future workplace. In fact, a close look at the data shows that the response rate of each prefecture in 2014–2018 was not significantly correlated with its population density (Spearman correlation coefficient 0.000, P = 0.997.) Thus we consider the selection bias of study subjects is minimal.