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Healthcare workforce distribution during multiple crises: a 12-year analysis of physician allocation, retention and
Eray Ontas1, Cavit Işık Yavuz2
1Ankara University Faculty of Medicine Department of Public Health Division of Epidemiology, Ankara, Turkey.
Background:
Health systems worldwide face compound crises that test workforce resilience and equity. Turkey's centralized healthcare system offers a critical case to examine how governance models perform under sustained, sequential shocks.
Objective:
To assess how Turkey's compulsory service-based physician distribution system responded to major crises over the past decade and to introduce a novel metric for evaluating workforce retention efficiency.
Methods:
This 12-year longitudinal ecological study (2013-2024) analysed Ministry of Health physician stock (active density) and flow (new appointments) data across 81 provinces. A "retention efficiency" metric (ΔStock/Flow) quantified system performance, and distributional inequality was assessed. Quasi-experimental methods, including difference-in-differences and interrupted time series analyses, assessed the impacts of the Syrian refugee influx, COVID-19 pandemic, and the 2023 earthquakes.
Results:
Physician density under MoH increased by 57 % (2013-2023), yet regional inequality worsened markedly (Weighted-Gini:0.079→0.116; +47 %). A "revolving door" dynamic was identified: western regions retained physicians efficiently(>0.95), while peripheral eastern regions suffered catastrophic retention inefficiency(<0.10), rendering compulsory service ineffective. Crisis response phenotypes varied significantly. The 2023 earthquakes triggered a "volatile surge" with dose-response characteristics: the 3 epicentre provinces showed +239 % increase (ITS: +36.4;95 %CI: 35.4-37.4), declining 58.3 % by 2024. In contrast, the Syrian refugee influx elicited an "integrated absorption" pattern, with no significant targeted response (DiD:0.80; p = 0.574) despite increased demand.
Conclusion:
Compulsory service enables short-term absorptive capacity but fails to ensure lasting equity. The retention efficiency metric exposes hidden inefficiencies that conventional density measures miss. Transitioning from coercive placements toward bundled incentives and investment in professional ecosystems is essential to achieve sustainable workforce resilience.
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