Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce

Access to good-quality health services is crucial for the improvement of health outcomes, such as those targeted by the Millennium Development Goals (MDGs) adopted by the international community in 2000. For example, the reduction of maternal mortality by 75% in 2015 depends on access to skilled care at birth and during the pregnancy [1,2]. But often, services are not available at a reasonable distance; or they are available, but people cannot afford them. Or, they are not accessible for some organizational reason, such as limited hours of presence of staff, unfriendly behaviour towards users, cultural barriers, and so on. Accessibility of health services is a multidimensional concept [3] that refers to geographical, economic (affordability), organizational and cultural (acceptability) factors that can facilitate or hinder use of services.This article will focus on the geographical dimension of access and on one of its critical determinants: the availability of qualified personnel. There are many examples of poor countries that provide good coverage of their territory with health facilities yet limited access to services, because facilities lack the personnel needed to function normally. A well-balanced distribution of infrastructures needs to go hand-in-hand with a well-balanced distribution of health personnel to be worth the investment, let alone to have an impact on the health of the population.Unbalanced distribution of health personnel between and within countries is a worldwide, longstanding and serious problem. All countries, rich and poor, report a higher proportion of health personnel in urban and wealthier areas. In Nicaragua, around 50% of the health personnel are concentrated in the capital, Managua, which comprises only one-fifth of the country's population [4]. In Mexico, it is estimated that 15% of all physicians are unemployed, underemployed or inactive. Yet despite this apparent surplus, rural posts remain unfilled [5]. Indonesia's vast size and di