International Experience and Enlightenment of Training Models for Health Talents in Rural and Remote Areas

CHEN Haoyang¹, ZHU Hong¹, DUAN Yanhan¹, XI Biao², WU Haijiang¹

¹Medicine-Education Coordination and Medical Education Research Center, Hebei Medical University, Shijiazhuang 050000, China
²Hebei Health Development Research Center, Hebei Medical University, Shijiazhuang 050000, China

Corresponding authors: XI Biao, Professor; E-mail: 13931984969@163.com
WU Haijiang, Professor; E-mail: haijianglaoqi@hebmu.edu.cn

Abstract

To address global geographical disparities in healthcare workforce distribution, various countries have implemented diverse talent training programs tailored to their specific contexts. Since 2010, China has introduced a policy for the free training of medical students under a rural-oriented scheme, aimed at alleviating the shortage of healthcare professionals in grassroots medical services. Despite years of implementation, there remains a significant gap in the availability of healthcare personnel at the grassroots level, highlighting the need to optimize and expand training models. This study draws on international experiences to provide valuable insights for China's grassroots healthcare talent cultivation policies. Utilizing content analysis, the study summarized and compared healthcare talent training policies across several countries focusing on rural and remote areas, identifying three primary models: targeted training, incentive-based models, and regional medical education frameworks. Each model was defined, characterized, and assessed for its limitations, while common reasons for the failure of certain programs were also discussed. Overall, while international experiences in training healthcare personnel for rural and remote regions are extensive and well-established, China predominantly relies on a targeted medical student system, resulting in a relatively narrow training pathway. Therefore, building on international experiences and considering the current situation in China, this study proposes multidimensional policy measures and practical recommendations to enhance the cultivation of healthcare talent in rural and remote areas, providing valuable references for improving healthcare services in these regions.

Keywords: Rural health; Training of health personnel; Rural and remote communities; Grassroots services; Experience; Model

1. Targeted Training Model

1.1 Model Overview

The targeted training model refers to formal agreements or legally binding contracts signed between participating students and relevant healthcare departments or schools in their hometowns. These agreements explicitly detail the services supporting students' education, such as scholarships and loans, and stipulate that after graduation, students must undertake compulsory health services in designated areas for a specified period. This model effectively promotes the cultivation of medical and health talents in rural and remote areas while providing participants with stable employment opportunities and broad career development platforms, creating a win-win situation for both parties. The specific practices of this model across different countries can be compared through typical project cases. This study selected four ongoing representative targeted training programs from various countries and analyzed them across multiple dimensions, including target participants, contracting parties, support policies, service duration, service locations, and breach of contract provisions (Table 1 [TABLE:1]).

1.2 Key Features

1.2.1 Strong Contractual Framework Defining Rights and Obligations: The agreements clearly specify both parties involved. On one side are students at various stages, including high school, undergraduate, and graduate students; on the other side are governments, medical institutions, and schools. Participants are typically required to have rural or remote area backgrounds and demonstrate strong interest in serving rural communities. The agreements also specify study content, duration, and corresponding support strategies. To ensure orderly program operation, targeted penalties are imposed for contract violations.

1.2.2 Clear Provisions for Directed and Timed Service: The targeted model emphasizes that medical graduates and other target groups undertake compulsory services in designated locations for specified periods. For instance, all targeted medical graduates in China serve in rural areas for six years (including three years of standardized residency training), while Thailand requires relevant graduates to return to their hometowns for 12 years of service. To ensure effective implementation, punitive measures are applied for failure to provide services as agreed or for early withdrawal. Australia and Japan primarily enforce compliance by revoking or reclaiming previously provided support measures. Due to such strong constraints, over 95% of Japanese medical students complete their service at designated locations, with the proportion practicing in rural areas being 13 times higher than that of non-targeted graduates, demonstrating significant effectiveness.

1.2.3 Diverse Support Policies to Protect Participants' Rights: In practice, diverse support strategies directly benefit students and other participants. Taking Thailand as an example, the "One District, One Doctor" project provides participants with comprehensive support throughout nearly their entire journey—from medical education opportunities and government scholarships to post-employment allowances. Support policies encompass various types, including appropriate educational training measures, robust welfare benefits, and scholarships, thereby safeguarding participants' entitled interests and facilitating smooth policy implementation. In terms of outcomes, graduates under Thailand's special programs achieve a retention rate exceeding 75% at the grassroots level, far surpassing that of ordinary medical graduates, with over half serving at the grassroots level for more than six years.

1.3 Model Limitations: Recruitment and Follow-up Policy Coordination Require Optimization

First, targeted medical students are admitted with lower scores due to policy preferences, raising concerns about student quality. Having signed employment agreements before enrollment and enjoying policy benefits without financial burden or employment pressure, these students exhibit limited motivation. Second, environmental factors contribute to low retention rates after contract completion. Research indicates that only 9% of medical students in some countries choose to remain in rural areas after completing their compulsory service, with reduced willingness to stay due to low grassroots salaries and poor working conditions.

2. Incentive Model

2.1 Model Overview

The incentive model encompasses both economic and non-economic incentives—one type employs conditional stimulus-response mechanisms, while the other stimulates intrinsic needs and motivations. This model emphasizes improving living and working conditions for target populations in rural and remote areas to attract healthcare professionals. This study selected four representative programs from Chile, the United States, Brazil, and Zambia, summarizing their strategic designs from both economic and non-economic perspectives (Table 2 [TABLE:2]).

2.2 Strategic Design

2.2.1 Substantial Economic Incentives Far Exceeding Opportunity Costs: During the career selection phase, opportunity costs are particularly significant in rural and remote areas, influenced primarily by low salary levels, increased commuting costs, and poor housing conditions. High opportunity costs become key factors in healthcare professionals' career choices. Economic incentives therefore focus on providing competitive salaries, transportation allowances, and housing subsidies. Zambia, for example, renovates housing units. In practice, the combined value of these economic incentives significantly exceeds the opportunity costs faced by target populations during autonomous career selection, thereby substantially promoting stable retention of local health talents and sustainable implementation of training programs.

2.2.2 Diverse Non-economic Incentives Demonstrating Humanistic Care: Non-economic incentives focus on enhancing career development opportunities, living conditions, and work environments for rural and remote area health workers. Diverse measures are implemented to respect and understand practitioners' actual needs while increasing their job satisfaction and sense of humanistic care. In practice, this includes providing rich training opportunities and health courses to optimize career ladders, as well as assigning mentors from higher-level hospitals to increase skills training and enhance practitioners' sense of achievement. Chile's Rural Practitioner Program, for instance, allows rural health workers to participate in one month of paid training annually at regional hospitals, where they can establish networks with hospital specialists. Consequently, nearly 100% of doctors participate in rural service, with over half serving for more than six years, effectively improving Chile's uneven distribution of health talent between urban and rural areas. Additionally, non-economic incentives emphasize infrastructure investment and construction, including updating medical equipment and renovating healthcare facilities, to optimize the work environment for grassroots health workers. Brazil's program implementation increased the number of practicing physicians per 10,000 residents in remote and impoverished areas from 2.3 to 4.5.

2.3 Model Limitations: Limited National Financial Support

The WHO stipulates that government health investment should account for approximately 5% of GDP, a threshold met only by a few developed countries. Developing countries often fall below this average, resulting in limited health investment capacity and two major issues: First, restricted development of facilities and equipment. Research indicates that rural facilities in Zambia face heavy workloads, yet limited finances make it difficult to balance physician allowances with facility construction and maintenance, affecting practitioners' satisfaction. Second, human resource management effectiveness is difficult to guarantee. For example, Brazil's program staff are categorized into multiple roles including material management, disease consultation, and treatment, requiring substantial personnel to ensure stable operation. However, insufficient departmental funding makes it challenging to maintain salaries for numerous staff, leading to increased turnover and vacancy rates, with regional health human resource imbalances requiring further attention.

3. Regional Medical Education Model

3.1 Model Overview

The regional medical education model aims to cultivate regional health talent by establishing regional medical schools or training centers in rural and remote areas, offering local health curricula, and increasing local internship opportunities. This approach enhances students' understanding and awareness of rural and remote areas, attracting them to choose these locations during career selection. This section presents four typical projects in this model, summarizing their elements based on project timelines, target participants, curricula, and other components (Table 3 [TABLE:3]).

3.2 Key Features

3.2.1 Teaching Arrangements Focused on Grassroots Service with Emphasis on Practical Skills Development: The regional medical education model comprises curriculum design and practical training. Regarding curricula, the model emphasizes strengthening focus on key grassroots health issues and adds courses in rural medicine and community health to build a theoretical medical system aligned with grassroots healthcare realities. For example, the UK has seen a tenfold increase in student numbers between 2011 and 2018 by focusing on local priority health programs while adding general practice courses. In terms of practical training, heterogeneous grassroots practice arrangements are implemented for students at different academic levels, emphasizing long-term and frequent grassroots service opportunities to cultivate and enhance practical skills through immersive experiences. Effective implementation of teaching arrangements relies on the parallel integration of two core elements: combining medical education knowledge with immersive grassroots experience.

3.2.2 Emphasis on Multi-stakeholder Collaboration to Strengthen Professional Identity: The regional medical education model focuses on multi-stakeholder collaboration, with local government agencies taking the lead to establish official communication mechanisms and promote close cooperation among grassroots healthcare institutions to build professional exchange networks. This creates a positive interactive professional environment that strengthens career identity and breaks professional isolation. Medical schools also play an active role by hiring local doctors as mentors to deepen students' understanding of the grassroots physician role through言传身教 (teaching by personal example), thereby enhancing professional identity. The UK's clinical apprenticeship system, for instance, employs local physicians as clinical consultants who guide students in grassroots clinical services, effectively improving training capacity for rural and remote areas.

3.2.3 Establishment of Regional Medical Education Centers to Enhance Training Infrastructure: Regional medical education centers consist of regional medical schools and practical training bases for health talent. Currently, medical education centers tend to be located in economically prosperous urban cores to optimize resource allocation. In contrast, the regional medical education model emphasizes establishing regional medical schools and training centers to strengthen the hardware foundation for regional health talent cultivation. This model also advocates close cooperation with local grassroots healthcare institutions, locating practical training within partner organizations to directly deliver quality health talent to the grassroots level. For example, Australia collaborates with aged care facilities, arranging student training directly within these institutions to effectively deliver health talent to grassroots aged care services, with nearly 90% of patients expressing satisfaction with medical students.

3.3 Model Limitations: Focus on Service Experience Exceeds Personnel Retention

The regional medical education model emphasizes regular and continuous grassroots health practice, focusing more on accumulating grassroots health knowledge during teaching practice. In attracting grassroots talent, it primarily achieves this through enhanced understanding and emotional connection. Medical education in the United States and other Western countries belongs to an elite education system, and the regional medical education model provides opportunities for students from diverse socioeconomic backgrounds. For instance, the US Rural Physician Shortage Area Program only provides grassroots training and practice opportunities for medical students without establishing mechanisms to guarantee their retention or local practice rights. Consequently, participating medical students typically serve at the grassroots level for only 2-4 years, resulting in adequate short-term supply but persistently low long-term retention rates.

4. Lessons from Failed Rural and Remote Area Talent Cultivation Projects

Since rural and remote area health talent cultivation is influenced by multiple factors and requires collaborative participation from multiple departments, successful cases demonstrate that single policy interventions cannot effectively achieve expected goals. Therefore, intervention measures under various models must be based on specific analysis of regional health human resources and relevant contexts to identify key factors affecting local physicians' career choices and retention. The following projects encountered problems during implementation, with some ultimately deviating from their original intentions and failing. How to effectively translate policy objectives into actionable measures requires careful consideration and research.

4.1 Unclear Policy Provisions Prevent Goal Achievement

Unclear policy provisions often lead to four problems: arbitrary initial screening, ambiguous definitions of mandatory and supportive policies in targeted models, misalignment between incentive measures and reality in incentive models, and unclear curriculum system boundaries in regional medical education models. These issues create loopholes during program operation, ultimately preventing goal achievement. For example, Ecuador's ambiguous urban-rural classification affected site selection for physicians' compulsory service, resulting in most doctors ultimately choosing to serve in urban areas. The US Non-Military Loan Assistance Program aimed to deliver internal medicine talent to rural and remote areas, but strict eligibility criteria meant that over half of internal medicine students only maintained interest in the program without further development or participation.

4.2 Mismatched Policy Backgrounds Undermine Long-term Sustainability

First, political background mismatches manifest as conflicts between program content and major provisions of the current healthcare system, making policy implementation difficult and hindering long-term program operation. Russia's policy providing one-time housing compensation for rural doctors, for instance, conflicted with the Semashko model's emphasis on unified salaries for health workers. This differential incentive clashed with unified arrangement principles, causing difficulties in distributing housing allowances and preventing the policy from achieving expected results. Notably, Russia's healthcare model originated from the Soviet Union, based on complete public ownership and extremely high government management levels, leading to long-term insufficient healthcare funding and low service efficiency that inevitably interfered with program implementation.

Second, economic background mismatches mean that limited national fiscal investment directly affects program effectiveness. Without adequate financial support, short-term issues include limited infrastructure development and persistently inadequate living conditions, while long-term insufficiency seriously affects incentive program stability and sustainability. For example, Uganda's Makerere University SPICES model required students to serve for one year at rural health facilities, yet over 75% of students reported low satisfaction with the service. As a typical low-income country, Uganda's limited financial investment could not support rural facility construction, preventing long-term guarantee of basic health equipment supply and greatly affecting member satisfaction and motivation.

4.3 Social and Cultural Differences Directly Affect Policy Outcomes

When medical students and other participants serve in rural and remote communities, lack of understanding and familiarity with local social culture directly increases their workload and affects their service motivation. Specifically, unfamiliarity with local languages directly affects effective communication between medical students and residents, reducing their sense of professional achievement. For example, South African medical students face language barriers during rural practice due to differences in isiZulu, isiXhosa, and other languages, hindering service provision and significantly reducing their sense of achievement and willingness to remain. Additionally, religious and cultural differences also affect service delivery to some extent. In the University of the Western Cape's rural service program, Muslim patients' preference for Muslim doctors directly increases the workload of the grassroots physician group. Therefore, from screening to training stages, participants need to understand and become familiar with local social culture to ensure smooth communication in grassroots services and improve service efficiency and effectiveness.

5. Recommendations for Optimizing China's Rural and Remote Area Health Talent Training

5.1 Optimize the Policy System and Improve Implementation Coordination

Current issues exist in the implementation of China's targeted medical student policy and coordination between central and local policies. First, local deviations occur in the process of receiving targeted medical students. The initial policy required targeted medical students to serve at the grassroots level for at least six years. However, with the implementation of standardized residency training, this period was shortened to three years, which clearly fails to meet talent service needs. Additionally, these institutions lack confidence in the sustainability of the targeted medical student training policy. Consequently, some regions have unilaterally extended service contracts to ten years or more, leading to frequent and increasing breach of contract incidents.

Second, higher medical colleges, secondary-level or above medical institutions, and township health centers—though organizational entities throughout the process—demonstrate loose and weak associative structures, especially regarding condition differences between residency training units and targeted placement units, which further weakens compliance willingness. Finally, provincial-level policies vary significantly in specific arrangements for contract management, working and living conditions, and position and professional title promotion, easily causing psychological imbalance among targeted medical students. This not only affects their willingness to fulfill contracts but also leads to unfair talent competition across regions.

Therefore, standardized residency training and contracted service fulfillment for targeted medical students should be better integrated to ensure policy coordination between training duration and service time, thereby achieving long-term support for grassroots medical resources. Policy should promote long-term cooperative relationships between residency training hospitals and targeted grassroots health centers, forming fixed training and output channels that allow residency hospitals to become effective professional development platforms meeting targeted medical students' learning and growth needs. Finally, it is recommended to gradually unify treatment and service standards for targeted medical students nationwide, especially regarding breach of contract mechanisms, while ensuring basic working conditions and salary levels do not vary significantly between provinces under appropriate consideration for remote areas, maintaining policy fairness.

5.2 Clarify Application Motivations and Expand Recruitment Scope

China's rural targeted medical student free training policy faces implementation challenges. First, some students' understanding of the program remains insufficient, and their willingness and interest in serving rural and remote areas require further consideration. Research shows that targeted medical students' primary application motivations focus on lower college entrance exam scores, parental wishes, and employment security, revealing that most students currently have insufficient cognitive understanding of the policy and that their motivations mainly stem from external factors rather than active choice based on cognition and interest.

Second, targeted medical students sign employment agreements before enrollment and enjoy policy benefits without financial burden or employment pressure, coupled with relatively low graduation requirements at some institutions, resulting in minimal academic and employment pressure that indirectly affects learning attitudes and performance.

First, considering that current targeted medical students mainly come from rural areas, county-level health commissions should strengthen cooperation with village committees and other local units. Through policy posters, lectures, and parent meetings, they should enhance families' understanding of the policy. It is recommended to utilize WeChat public accounts and integrated media to release latest information during critical periods such as college application. Second, programs like "Three Rural Services" should be used to strengthen students' understanding of grassroots service concepts, allowing them to deeply experience and practice professional spirit through hands-on participation and career experience, helping them correctly understand the relationship between "material benefits" and "value confusion" to clearly plan their career paths.

Addressing the current shortage of grassroots medical talent, China can learn from other countries' experiences. Thailand faced similar challenges in the 1990s when private hospitals attracted large numbers of doctors by paying breach-of-contract fees, causing talent drain in the public system. In response, Thailand implemented new recruitment strategies incorporating high school students into talent supplement programs to lock in potential talent for grassroots medical services early. The Australian National University Medical School optimized grassroots talent supplementation mechanisms by making medical students' cognition of and willingness toward grassroots healthcare important considerations. Based on this, China could expand the scale of talent cultivation for grassroots medical institutions to some extent, establish general practice majors not bound by agreements, and allow interested students to freely join or exit under specific conditions, while using their cognition of, willingness toward, and understanding of relevant policies regarding grassroots healthcare as selection criteria to ensure effective talent cultivation.

5.3 Increase Service Opportunities and Enhance Emotional Connection with Grassroots Communities

OGDEN et al. demonstrated that medical students' grassroots healthcare service experience during internships helps strengthen their emotional connection with grassroots communities and improves retention rates. Compared with relatively mature grassroots health talent training systems abroad, China primarily relies on the targeted medical student policy to cultivate grassroots health talent. However, this policy only covers some medical specialties and has limited enrollment. Moreover, its curriculum design fails to adequately address grassroots service realities, with few core courses such as general practice medicine. Most medical colleges also use unified clinical medicine textbooks for targeted medical students, lacking targeted and practical teaching for grassroots healthcare services, causing some targeted medical students to be unable to accurately diagnose common and frequent diseases after employment, simply referring patients for treatment instead of fulfilling the policy's original intent.

Additionally, Western countries encourage ordinary medical students to participate in grassroots services through relevant policies and increase grassroots service components during training. In contrast, China's ordinary clinical medical students mostly complete internships and rotations in tertiary hospitals affiliated with medical colleges, with limited connections to and understanding of grassroots levels. Although grassroots service teaching institutions exist, teaching conditions and mentorship systems limit their effectiveness, and the lack of dedicated grassroots practice bases further hinders grassroots education and teaching.

Therefore, China can learn from international experience in hiring local clinicians as mentors to establish and improve domestic mentorship systems, helping students better familiarize themselves with grassroots service positions and optimize immersive experiences to deepen emotional connections with grassroots communities and improve retention rates. Second, a characteristic general practice medicine curriculum system should be constructed based on principles of appropriateness and sufficiency, increasing general practice courses and class hours. For example, institutions should incorporate diagnostic and treatment protocols for common and frequent local diseases into teaching based on actual local conditions, enabling students to establish theoretical systems and practical skills adapted to grassroots services earlier and faster. Finally, a multi-stakeholder co-construction mechanism should be established to strengthen tripartite cooperation among universities, grassroots healthcare institutions, and local governments (health commissions), creating a virtuous cycle where grassroots institutions provide personnel and skill needs, universities conduct targeted cultivation, and governments strengthen process management and practical arrangements, thereby achieving a two-way empowerment system for grassroots health talent cultivation integrating education and production.

5.4 Enrich Incentive Strategies to Alleviate Employment Concerns

Domestic and international studies show that medical students' concerns during career selection focus on low grassroots salaries, poor working conditions, and relatively narrow career development space. These issues further exacerbate problems of limited family support, rising opportunity costs, and weak contract fulfillment among targeted medical students. Research indicates that generous salary bonuses and welfare subsidies, stable establishment positions, and harmonious, supportive family and marital relationships effectively improve targeted medical students' contract fulfillment and retention rates. Currently, foreign countries have formed relatively comprehensive incentives through salary increases, hardship subsidies, and career development optimization, achieving good results.

Therefore, localities should actively implement the "Notice on Employment Placement and Contract Management of Rural Targeted Free Medical Students," continuously stabilize and implement the grassroots service establishment system and targeted medical student graduation assignment system, introduce corresponding social security policies, and continuously improve hardware conditions in rural medical and health units to promote active and long-term employment of targeted medical students. Second, in developed countries, general practitioners' salaries generally range between 2.5 to 4 times the average social salary, but in China this ratio is only achieved in economically developed Beijing and Shanghai. Currently, salary levels for most targeted medical students after employment remain low, primarily because performance wages are limited by township health centers' total wage pools, and rigid performance assessment methods result in small salary variation ranges. Therefore, under the guidance of "two allowances," the total performance wage pool for grassroots medical and health institutions should be increased, and reference should be made to the UK's mixed payment system primarily based on "capitation fees" to reflect general practitioners' service value and promote reasonable income growth.

Finally, to address post-contract talent loss, first, targeted medical students' professional identity and sense of honor should be enhanced by strengthening contract spirit during training. "Contract scholarships" or "fulfillment funds" could be established to recognize and reward students who uphold contract spirit, with increased publicity and preferential professional title promotion for outstanding practice after graduation, leveraging role model incentives. Second, to reduce regional talent loss after contract fulfillment, county medical communities construction and targeted general practitioner retention strategies could be organically combined. After targeted graduates fulfill their contracts, they could be prioritized for inclusion in county hospital workforces based on assessment of their practice level and comprehensive abilities, utilizing their rich grassroots practical experience to provide professional guidance for medical staff in township health centers and village clinics, thereby encouraging more targeted medical students to devote themselves to and take root in grassroots levels, effectively improving overall grassroots healthcare service levels.

Conclusion

Targeted training, incentive, and regional medical education models provide effective solutions for grassroots health talent cultivation through their distinctive institutional designs and practical innovations, yet each model has inherent limitations. The mandatory contracts of targeted training models may suppress students' professional autonomy while ensuring talent supply; incentive models' financial dependence makes them unsustainable in economically underdeveloped regions; and regional medical education models, while enhancing professional identity, lack long-term retention mechanisms. Failed projects reveal the common problem of disconnect between policy design and implementation context. Therefore, cultivating health talent in China's rural and remote areas should not only draw on the strengths of international models to build a diversified, multi-level talent cultivation system that precisely matches the needs of different regions and stages, but also be rooted in China's national conditions, strengthen policy synergy and coherence, optimize policy implementation details, focus on resolving difficulties and bottlenecks in policy implementation, and gradually construct a grassroots health talent cultivation model with Chinese characteristics.

Author Contributions: CHEN Haoyang was responsible for conceptualization, research implementation, and manuscript writing; ZHU Hong was responsible for data collection, organization, and manuscript writing; DUAN Yanhan was responsible for literature collection, organization, and synthesis; XI Biao provided guidance for the article; WU Haijiang was responsible for quality control and review, and overall responsibility for the article.

Conflict of Interest Statement: The authors declare no conflicts of interest.

References

[1] GOW J, GEORGE G, MWAMBA S, et al. An evaluation of the effectiveness of the Zambian Health Worker Retention Scheme (ZHWRS) for rural areas[J]. Afr Health Sci, 2013, 13(3): 800-807. DOI:10.4314/ahs.v13i3.40.

[2] STURESSON L, ÖHLANDER M, NILSSON G, et al. Migrant physicians' conceptions of working in rural and remote areas in Sweden: a qualitative study[J]. PLoS One, 2019, 14(1): e0210598. DOI:10.1371/journal.pone.0210598.

[3] WHO guidelines on health workforce development, attraction, recruitment and retention in rural and remote areas[EB/OL]. (2021-10-13)[2024-06-20]. https://iris.who.int/bitstream/handle/10665/341139/9789240035508-chi.pdf.

[4] PARLIER A B, GALVIN S L, THACH S, et al. The road to rural primary care: a narrative review of factors that help develop, recruit, and retain rural primary care physicians[J]. Acad Med, 2018, 93(1): 130-140. DOI:10.1097/ACM.0000000000001839.

[5] LIU Xiaoyun, JIA Zonglin, LIU Min, et al. Analysis of the design, implementation, and future direction of China's rural targeted medical student free training policy[J]. Chinese General Practice, 2022, 25(22): 2691-2697.

[6] KATAOKA Y, TAKAYASHIKI A, SATO M, et al. Motives and factors associated with staying in medically underserved areas after the obligatory practice period among first-year Japanese medical students in a special quota system[J]. Rural Remote Health, 2015: 3547-3552. DOI:10.22605/rrh3663.

[7] Bonded Medical Program[EB/OL]. [2024-06-20]. https://www.health.gov.au/our-work/bonded-medical-program.

[8] ARORA R, CHAMNAN P, NITIAPINYASAKUL A, et al. Retention of doctors in rural health services in Thailand: impact of a national collaborative approach[J]. Rural Remote Health, 2017, 17(3): 4344. DOI:10.22605/RRH4344.

[9] SOMPORN P, WALTERS L, ASH J. Expectations of rural community-based medical education: a case study from Thailand[J]. Rural Remote Health, 2018, 18(4): 4709. DOI:10.22605/RRH4709.

[10] KATAOKA Y, TAKAYASHIKI A, SATO M, et al. Japanese regional-quota medical students in their final year are less motivated to work in medically underserved areas than they were in their first year: a prospective observational study[J]. Rural Remote Health, 2018, 18(4): 4840. DOI:10.22605/RRH4840.

[11] PEÑA S, RAMIREZ J, BECERRA C, et al. The Chilean rural practitioner programme: a multidimensional strategy to attract and retain doctors in rural areas[J]. Bull World Health Organ, 2010, 88(5): 371-378. DOI:10.2471/BLT.09.072769.

[12] RABINOWITZ H K, MOTLEY R J, MARKHAM F W Jr, et al. Lessons learned as Thomas Jefferson University's rural physician shortage area program (PSAP) approaches the half-century mark[J]. Acad Med, 2022, 97(9): 1264-1267. DOI:10.1097/ACM.0000000000004710.

[13] SANTOS L M, COSTA A M, GIRARDI S N. Mais Medicos Program: an effective action to reduce health inequities in Brazil[J]. Cien Saude Colet, 2015, 20(11): 3547-3552. DOI:10.1590/1413-812320152011.07252015.

[14] Ministry of Health, Directorate of Human Resources and Administration. Zambian Health Workers Retention Scheme Sustainability Strategy[EB/OL]. (2018-11-08)[2024-06-20]. https://pdf.usaid.gov/pdf_docs/PA00K486.pdf.

[15] LONGMAN J M, BARRACLOUGH F, SWAIN L S. The benefits and challenges of a rural community-based work-ready placement program for allied health students[J]. Rural Remote Health, 2020, 20(3): 5706. DOI:10.22605/RRH5706.

[16] KRUPA L K, CHAN B T B. Canadian rural family medicine training programs: growth and variation in recruitment[J]. Can Fam Physician, 2005, 51(6): 852-853.

[17] IAGO H, MCKIMM J. The Swansea RRHiME track: a new curriculum model for embedding rural and remote healthcare into undergraduate medicine programmes[J]. MedEdPublish(2016), 2019, 8: 2. DOI:10.15694/mep.2019.000002.1.

[18] PARK Y, RYAN M H, SANTEN S A, et al. Nurturing the student, sustaining the mission: 20 years of the international/inner-city/rural preceptorship program[J]. Fam Med, 2019, 51(10): 823-829. DOI:10.22454/FamMed.2019.358223.

[19] Australian Department of Health and Aged Care. Bonded Medical Program[EB/OL]. [2024-06-20]. https://www.health.gov.au/our-work/bonded-medical-program.

[20] GOODFELLOW A, ULLOA J G, DOWLING P T, et al. Predictors of primary care physician practice location in underserved urban or rural areas in the United States: a systematic literature review[J]. Acad Med, 2016, 91(9): 1313-1321. DOI:10.1097/ACM.0000000000001203.

[21] ROMERO-ALVAREZ D, LÓPEZ-CEVALLOS D F, TORRES I. Doctors for the people? The problematic distribution of rural service doctors in Ecuador[J]. Health Policy Plan, 2023, 38(7): 851-861. DOI:10.1093/heapol/czad040.

[22] HAN X X, PITTMAN P, KU L. The effect of national health service corps clinician staffing on medical and behavioral health care costs in community health centers[J]. Med Care, 2021, 59(Suppl 5): S428-S433. DOI:10.1097/MLR.0000000000001610.

[23] SHEIMAN I. Health workforce policy in the Russian federation: how to overcome a shortage of physicians[J]. Front Public Health, 2022, 10: 1023845. DOI:10.3389/fpubh.2022.1023845.

[24] NOYA F, CARR S, THOMPSON S. Social accountability in a medical school: is it sufficient? A regional medical school curriculum and approaches to equip graduates for rural and remote medical services[J]. BMC Med Educ, 2024, 24(1): 526. DOI:10.1186/s12909-024-05522-y.

[25] STRAUME K, SHAW D M P. Internship at the ends of the Earth—a way to recruit physicians[J]. Rural Remote Health, 2010, 10(2): 1398.

[26] MABUZA L H, DIAB P, REID S J, et al. Communities' views, attitudes and recommendations on community-based education of undergraduate Health Sciences students in South Africa: a qualitative study[J]. Afr J Prim Health Care Fam Med, 2013, 5(1): 456. DOI:10.4102/phcfm.v5i1.456.

[27] WANG Ying, XIE Mengqi, CUI Xiaoxuan, et al. Contract fulfillment intention of targeted medical students in Shandong Province and its relationship with application motivation, policy cognition, and career planning[J]. Chinese Health Resources, 2022, 25(2): 205-209. DOI:10.13688/j.cnki.chr.2022.210428.

[28] OGDEN J, PRESTON S, PARTANEN R L, et al. Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects[J]. Med J Aust, 2020, 213(5): 228-236. DOI:10.5694/mja2.50697.

[29] ZHANG Qiande, HE Shutong, GU Yu, et al. Practice and reflection on undergraduate talent training model for rural medical and health services in Jiangsu—taking Kangda College of Nanjing Medical University as an example[J]. Jiangsu Health Care Management, 2022, 33(4): 417-420.

[30] MA Nannan, MENG Lihua, WEI Futao. Innovation and practice of the targeted medical student education model under the background of new medical science—taking the General Practice School of Guangxi Medical University as an example[J]. Education Review, 2023, 12(4): 7-10. DOI:10.16070/j.cnki.cn45-1388/g4s.2023.04.021.

[31] SHEN Ying, HUANG Xing, YU Jia, et al. Qualitative study on the work status, long-term work intention, and influencing factors of rural targeted medical graduates in township health centers[J]. Chinese General Practice, 2021, 24(31): 3995-4002. DOI:10.12114/j.issn.1007-9572.2021.00.280.

[32] DU Chunjing, LOU Yiqun, SUN Jumei, et al. Study on the influence of targeted medical students' application motivation on potential breach of contract risk and countermeasures[J]. Chinese Health Service Management, 2021, 38(9): 694-697.

(Received: July 25, 2024; Revised: April 23, 2025)
(This article was edited by WANG Shiyue)