Received: 25 November 2023 - Revised: 8 January 2024 - Accepted: 29 January 2024DOI: 10.1002/hpm.3782
R E S E A RCH AR T I C L E
Medical deserts in Spain—Insights from an
international project
Katarzyna Dubas‐Jakóbczyk1 | Ana Isabel Gonzalez2,3 |
Alicja Domagała1 | Maria Pilar Astier‐Peña4,5 |
Veronica Casado Vicente6,7 | Antonia‐Gema Planet8 |
Agueda Quadrado9 | Rosa Mari Serrano10 |
Isabel Serafina Abellán11 | Alba Ramos12 | Marta Ballester2,3 |
Laura Seils2 | Sorin Dan13 | Linda Flinterman14 |
Robert Likic15 | Ronald Batenburg14,16
Correspondence
Ana Isabel Gonzalez.
Email: aigonzalez@fadq.org
Funding information
European Union's Health Programme, Grant/
Award Number: 101018379; Polish Ministry
of Education and Science within the project
“PMW” in the years 2021–2024, Grant/
Award Number: 5176/HP3/2021/2
[Correction added on 27 February 2024,
after first online publication: In this version,
author Sorin Dan’s name and affiliation have
been updated.]
Abstract
Introduction: Medical deserts are a growing phenomenon
across many European countries. They are usually defined
as (i) rural areas, (ii) underserved areas or (iii) by applying a
measure of distance/time to a facility or a combination of
the three characteristics. The objective was to define
medical deserts in Spain as well as map their driving factors
and approaches to mitigate them.
Methods: A mixed methods approach was applied following
the project “A Roadmap out of medical deserts into sup-
portive health workforce initiatives and policies” work plan.
It included the following elements: (i) a scoping literature
review; (ii) a questionnaire survey; (iii) national stakeholders'
workshop; (iv) a descriptive case study on medical deserts in
Spain.
Results:Medical deserts in Spain exist in the form of mostly
rural areas with limited access to health care. The main
challenge in their identification and monitoring is local data
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
© 2024 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.
Int J Health Plann Mgmt. 2024;1–14. wileyonlinelibrary.com/journal/hpm - 1
availability. Diversity of both factors contributing to medi-
cal deserts and solutions applied to eliminate or mitigate
them can be identified in Spain. They can be related to
demand for or supply of health care services. More national
data, analyses and/or initiatives seem to be focused on the
health care supply dimension.
Conclusions: Addressing medical deserts in Spain requires a
comprehensive and multidimensional approach. Effective
policies are needed to address both the medical staff edu-
cation and planning system, working conditions, as well as
more intersectoral approach to the population health
management.
K E YWORD S
health care demand, health care supply, health planning, health
workforce, medical desert, medically underserved area
Highlights
� Existence of medical deserts have been a growing concern
among many European countries.
� In Spain they are mostly identified as rural, often isolated and/or
depopulated areas.
� Health care demand and supply characteristics define and in-
fluence medical deserts.
� Mitigating medical deserts in Spain requires a comprehensive
and multisectoral approach.
1 | INTRODUCTION
The unequal distribution of health professionals in Europe has been investigated for many years now.1,2 The term
“medical deserts” has become popular to describe the lack of primary care physicians in rural areas.3–5 However,
there is no uniform definition of “medical deserts”. In a recent literature review they are defined as (i) rural areas, (ii)
underserved areas or (iii) by applying a measure of distance or time to a health facility, or a combination of these
characteristics.6
In Spain, the issue of progressing depopulation of mostly interior, rural provinces, called ‘Empty Spain’ (España
Vaciada) has been on the national policy agenda for many years now.7 Due to the high concentration of people in
urban areas, many vast and unpopulated regions lack access to essential local services like health clinics, schools,
and supermarkets. According to a study by the Bank of Spain, citizens residing in rural provinces have to travel
longer distances to reach these services compared to those in other European Union nations.8 The migration of
young people to urban areas in search of employment and education opportunities contributes to the decline of
rural populations. These strongly impact the health workforce distribution.
Although, no direct deficit of medical professionals exists in Spain (the number of medical doctors per 1000
inhabitants is higher than in the majority of other European countries9), there is unequal distribution across the
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country regions (Autonomous Communities) as well as within the regions.10 As of June 2021, there were an average
of 3.0 practicing physicians per 1000 inhabitants in the Spanish National Health System (NHS). The number varied
by region, with Andalusia having the lowest at 2.3 and Asturias having the highest at 3.8. Interestingly, 63% of
active doctors were in just five out of the 17 Autonomous Communities.11 The issue of physicians' unequal dis-
tribution is especially visible within primary health care, where the number of family physicians and pediatricians
per 1000 inhabitants varies from 0.6 in Balearic Islands to 1.1. in Castilla y León.12
The objective of this study was to define medical deserts in Spain as well as map their driving factors and ap-
proaches to eliminate or mitigate medical deserts in the Spanish context. The study is part of multinational research
work conducted within the project: A Roadmap out of medical deserts into supportive Health Workforce initiatives
and policies (ROUTE‐HWF) co‐funded by the European Union's Health Programme (grant agreement no.
101018379).13
2 | METHODS
A mixed methods approach was applied following the ROUTE‐HWF project's work plan.13 The activities included:
(i) a literature review, (ii) an online survey, (iii) a workshop with national stakeholders, and (iv) a descriptive case
study on medical deserts in Spain, involving consultations with key informants. A scoping review of an international
literature was conducted to identify and map the empirical research on medical desert characteristics, contributing
factors and approaches to mitigate them.6 The results of the review were used to develop a questionnaire to be
distributed among health workforce experts from European countries to gain more insight into the national context
of medical deserts. The questionnaire covered three main parts (all focused on a given country and/or region): (i)
characteristics of medical deserts and criteria for their definition, (ii) reasons and causes of medical deserts, (iii)
approaches to eliminate or mitigate medical deserts. Results of both the review and survey were then used to
conduct stakeholders' workshops with health workforce experts in five European countries (partner countries of
the ROUTE‐HWF project: Spain, The Netherlands, Finland, Croatia and Poland). During the workshops, the par-
ticipants were i.a. asked to evaluate a list of criteria that can be used to define medical deserts in their country,
comment on the medical deserts driving factors, and discuss possible solutions. A purposive sampling was used for
choosing both the survey respondents and the workshop participants.
The above activities led to the development of the ROUTE‐HWF project's taxonomy to define and measure
medical deserts across European countries (Table 1). The taxonomy is based on a set of four objects: two of which
address the level of health care demand and two that address health care supply in a given area. These four in-
dications are measured in terms of the relative value for a NUTS‐2 (Nomenclature of Territorial Units for Statistics
level two) region, being either above or below the country average. Combining the four dichotomous variables, the
matrix indicates five types of medical deserts, where at least three of the four objects apply. The taxonomy was
applied and tested in descriptive case studies on medical deserts in chosen European countries (including Spain)
which were then consulted with country informants.
In the case of Spain, a total number of eight experts filled in the questionnaire between December 2021 and
February 2022, while 19 experts participated in the national workshop organised as online event in February 2022.
Both the survey respondents and workshop participants represented different backgrounds, including academia,
active medical professions and local health authorities. The consultations of the case study on medical desert in
Spain took place between April and May 2023. Three country experts received the invitations to participate in
consultation, of which two agreed. The country experts were purposively chosen based on their expertise in health
workforce issues. They received the case study draft text via email and participated in consecutive online con-
sultations with the case study leading author (KDJ) and the Spanish ROUTE‐HWF project representative (AIG).
During the meeting, the national experts were asked to comment on the appropriateness of the data presented in
the case study text as well as provide any relevant additional information.
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3 | RESULTS
3.1 | Defining medical deserts in Spain
In Spain, the term “medical desert” has no official definition, but the national experts identified it mainly as rural
areas with restricted access to health care. These areas are typically located in sparsely populated and isolated
regions. The experts suggested that definitions used in other countries, like France and the United States, can be
applied in Spanish circumstances. In these countries, medical deserts are often linked to the uneven distribution of
health care providers across regions and a shortage of family doctors, particularly in rural areas.
To define medical deserts in Spain, it is considered appropriate to use a complex set of factors rather than
relying on a single indicator. The national experts established the following order of relevance: (i) distance to a
health facility; (ii) characteristics of the area; (iii) characteristics of the population; (iv) characteristics of the health
workers; (v) size of the population. Distance to a health facility may be related to remote or rural areas, especially if
it exceeds 50 km to the nearest hospital. Geographical accessibility, such as in mountainous regions or islands, is
also important. Low socioeconomic status may affect the demand for health services and the presence of medical
deserts.
TAB L E 1 The ROUTHE‐HWF project taxonomy, defining five types of medical deserts.
Source: Deliverable 4.2. Second version of a definition and taxonomy on medical deserts. https://route‐hwf.eu/
results‐and‐publications/.
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When applying the ROUTE‐HWF project's taxonomy six autonomous communities met the definition of
medical deserts: Extremadura, Valencia, Castilla y León, Castilla‐la Mancha, Andalucía and Canarias (Table 2).
3.2 | Contributing factors and solutions to medical deserts
Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be
identified in Spain. They can be related to demand for or supply of health care services (Table 3).
3.2.1 | Factors contributing to medical deserts
In the case of contributing factors, issues related to population ageing, changing health need's structure and lack of
social support are intertwined with health system regulatory issues (i.e., inadequate workforce planning and
insufficient funding) as well as health workforce's difficult working conditions, especially in rural areas. Population
ageing is a global phenomenon. In 2021, the median age of the population in Spain was 44.7 years, which was
slightly above the EU‐27 average of 44.1 years. In the same year, the share of the population aged 65 years, and
more was 19.8% (the ratio value has increased by approx. 3% within the last 10 years).9 It strongly impacts demand
for health services in terms of both the volume of care needed as well as its structure. As one of the national
experts pointed out ‐ many primary care consultations for older patients are more related to social care needs
(loneliness, dependency, etc.) than to health problems.
The unequal distribution of health workers is partly related to different levels of regulation.14 The distribution
of doctors and nurses is influenced by the planning and redistributive policies of regional health authorities. Since
there is a high degree of autonomy among Autonomous Communities' health systems, differences in regional
approaches can also be significant. Health workforce planning is based on health maps, which define the “basic
health zones” in each Autonomous Community and are used as a basic geographical unit for the organization of the
work of primary care teams.15 However, these maps are not regularly updated, which means that in many cases
they do not reflect the true distribution of the workforce or the accessibility to primary care. According to the
national Primary Care Information System (SIAP), there are currently 30,301 family physicians in Spain, the vast
majority of whom cover population groups of 1000–2000 inhabitants (Table 4). At the country level, only 5.7%
family doctors cover population below 500 inhabitants. However, there are regions, in which a much higher share of
family doctors has less than 500 patients (28.2% and 18.2% in Castilla y and Aragón respectively).16
The distribution of pharmacists depends on public and corporate regulation, while the distribution of dentists is
mainly influenced by market forces, leading to even greater variation in their distribution between Autonomous
Communities.14 In 2020, the number of dentists per 1000 population ranged from 0.4 in Ceuta to 1.3 in Madrid.17
Budget reduction policies affected the migration of health workers during the financial crisis. There was an
increased out‐migration of doctors and nurses seeking employment abroad, while the inflow of doctors from other
countries, especially Latin America, decreased.14 In general, the demand for doctors in the Spanish health system is
closely linked to the current economic and political situation.18 Although the number of doctors and nurses has
increased over the last decade, temporary contracts have grown, with high workloads and lower salaries than
permanent positions, contributing to the growing dissatisfaction among health workers. Economic incentives also
play a crucial role in the distribution of the health workforce across the country. For example, Catalonia Region
experienced a decrease in registered doctors between 1997 and 2017, as approx. 30% of all doctors trained in
Catalonia chose to work in Valencia and the Balearic Islands.19
The difficult working conditions for health workers in remote, rural areas (e.g., long hours, large patient lists,
solitude, and lack of peers' support) are intertwined with the location choices of the health workforce and strongly
contribute to medical desertification in Spain. Family and Community Medicine is often perceived by young
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professionals as difficult and unattractive choice of specialisation. In 2018 only 1 out of 10 chose that field. In 2022
approx. 8.5% of post in Family and Community Medicine remained vacant.20 The lack of adequate planning has led
to an imbalance in the specialties, with excess places in some and shortages in others.21 Young people prefer
TAB L E 2 Application of the ROUTE‐HWF project taxonomy in Spanish context.
Region
Demand for health care Health care supply
Compliance
with medical
desert criteria
Proportion of
the population
aged ≥65
Percentage of
population at risk of
poverty or social
exclusion
Percentage of
population within
15 min of a hospital
Doctors per
100,000
inhabitants
Spain 19.8% 27.8% 71.0% 458.0 Not applicable
Spanish regions
Andalusia 17.7% 38.7%a 70.6%a 368.0a Yes
Aragon 21.8%a 20.0% 64.8%a 576.3 No
Principality of
Asturias
26.5%a 26.3% 84.6% 418.1a No
Balearic
Islands
16.2% 22.4% 79.2% 490.0 No
Canary Islands 17.0% 37.8%a 61.5%a 447.0a Yes
Cantabria 22.7%a 21.4% 76.1% 595.3 No
Castilla y León 25.7%a 23.1% 61.6%a 438.6a Yes
Castilla‐la
Mancha
19.0% 32.5%* 58.9%a 277.0a Yes
Catalonia 19.3% 22.3% 84.4% 468.7 No
Extremadura 21.1%a 38.7%a 54.6%a 370.4a Yes
Galicia 25.7%a 25.2% 60.7%a 463.7 No
La Rioja 21.4%a 21.3% 84.8% 327.0a No
Comunidad de
Madrid
18.1% 21.6% 96.9% 569.6 No
Region of
Murcia
16.1% 33.8%a 81.4% 423.1a No
Autonomous
community
of Navarre
20.1%a 14.7% 81.8% 640.7 No
Basque
Country
23.1%a 16.0% 90.6% 560.4 No
Valencian
Community
19.9%a 30.6%a 83.7% 450.7a Yes
City of Ceuta 12.8% 43.0%a 94.2% 871.7/ No
City of Melilla 11.3% 35.2%a 99.7% Not
applicable
No
aMore unfavourable value than the average for the country.
Source: Eurostat 2023/Ministry of Health 2023.
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specialties with better salaries and job prospects in large cities. Between 11,000 and 15,000 doctors work in rural
areas, and it is estimated that about 28% of them will retire in 2027.22 Consequently, in case of many retired
doctors, no young professional trained and willing to take their place will be available. A survey revealed that many
rural doctors travel more than 50 km a day to work, bearing the costs of transport to and from rural areas.22 Some
Autonomous Communities have implemented a remuneration system based on geographic dispersion, but if they
live outside the working area, doctors must pay transport costs. In general, labour characteristics, difficult
geographical conditions (isolated mountainous areas) and lack of adequate infrastructure (Internet access or public
transport services) contribute to the existence of medical deserts in Spain.
3.2.2 | Solutions applied to eliminate or mitigate medical deserts
Diverse policies aimed at improving the health workforce situation have been implemented in Spain at both central
and regional levels. Although they were not always directly focused on medical deserts, they have aimed at limiting
medical deserts or at least mitigating the factors contributing to their existence. These policies focused on both,
managing the demand for health care services as well as improving supply of health care provision, with the latter
being more intensified. Some initiatives addressed both dimensions simultaneously (Table 3). The specific policies
met different implementation obstacles, thus their success in mitigating medical deserts might also vary.
The Ministry of Health has gradually increased the number of graduate and specialised medical/nursing
training places. However, these increases have not been properly adjusted to address the specific specialties deficit
nor individual needs of the Autonomous Communities. For example, the priority access to primary care nursing
posts for specialists in Family and Community Nursing has not been guaranteed. At the regional level, new models
of care have been promoted to improve quality and efficiency, as well as to manage patient demand. These focused
on (i) implementing multidisciplinary primary care teams accompanied by skill‐mix and task shifting activities; (ii)
introducing coordinated/integrated care models, including disease or and case management projects; and (iii)
introducing diverse digital health solutions.
There are several examples of successful implementation of an advanced nursing model. In Navarra region it
was introduced for both low complexity problems and chronic disease management in community settings.23
TAB L E 3 Matrix of contributing factors and solutions to medical deserts in Spain.
Demand for health care Supply of health care
Factors contributing to
medical deserts
� Population ageing
� Changing health needs structure
� Lack of social/community support
� Depopulation
� Inadequate health workforce planning
mechanisms
� Insufficient funding
� Lack of investments in primary care
� Difficult working conditions of health
professionals
� Poor geographical accessibility
� Health workforce ageing
Solutions applied to eliminate
or mitigate medical deserts
� Innovative models of care focus-
sing on managing patients'
demand
� Programs focused on integrating
social and health care
� Increasing number of training places for
medical professionals (at both under‐ and
postgraduate level)
� Innovative models of care focussing on
improving efficiency and access to care
� Policies aimed at encouraging medical pro-
fessionals to work in rural areas (incl. Infra-
structural support)
Source: authors own compilation.
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Advance practice nurses are part of multidisciplinary teams. The model emphasises the importance of empowering
patients and promoting self‐care. Another example is the model of Acute Demand Nursing Management, which has
been progressively developed,24–26 has an established regulatory framework in Catalonia27 and has been extended
to many Autonomous Communities. Also, intermediate solutions implemented in Madrid, Galicia, and Catalonia,
involving advanced nursing practices in remote areas without medical professionals, represent a promising strategy
to address medical deserts in Spain.28–30 These models require strong scientific evidence to support their long‐term
effectiveness.
Among, diverse examples of digital solutions implementation, the Galician telemonitoring programme for
primary care patients have been recognized as best practice on an international scale.31 The telemonitoring project
was piloted in 2017 in Santa Comba, a rural population with a high percentage of elderly residents. The positive
outcomes and acceptance led to its expansion throughout all healthcare centres in Galicia by 2020. The system
utilises the existing electronic medical record infrastructure and allows healthcare professionals to remotely
monitor patients' health status. Patients can enter their health data using their smartphones, ensuring ease of use
and accessibility. The system also supports secure communication between patients and healthcare providers,
including asynchronous messaging, phone calls, and video consultations. Another example is the tele‐dermatology
TAB L E 4 Share (%) of the number of family doctors per population groups across Autonomous Communities.
Region Total number
Share of the number of family doctors per population groups
<500 501‐1000 1001‐1500 1501‐2000 >2000
Spain 30,301 5.67% 9.44% 49.78% 32.84% 2.27%
Spanish regions
Andalusia 5121 1.21% 8.59% 45.38% 42.43% 2.38%
Aragon 989 18.20% 14.16% 31.45% 35.89% 0.30%
Asturias 607 3.79% 15.98% 42.17% 38.06% 0.00%
Balearic Islands 596 0.00% 0.50% 10.07% 77.52% 11.91%
Canary Islands 1264 1.74% 3.64% 48.58% 43.75% 2.29%
Cantabria 367 1.63% 6.81% 61.85% 29.70% 0.00%
Castilla y León 2257 28.22% 23.13% 39.70% 8.95% 0.00%
Castilla‐la Mancha 1375 13.02% 15.93% 28.15% 42.11% 0.80%
Catalonia 4930 4.52% 7.59% 48.92% 35.76% 3.20%
Extremadura 821 11.08% 27.53% 37.88% 23.39% 0.12%
Galicia 1923 2.29% 13.47% 73.89% 10.35% 0.00%
La Rioja 217 7.37% 12.44% 43.32% 36.87% 0.00%
Comunidad de Madrid 3815 2.41% 2.94% 40.81% 47.08% 6.76%
Region of Murcia 941 0.11% 3.61% 77.26% 19.02% 0.00%
Navarre 431 4.18% 14.39% 53.60% 27.84% 0.00%
Basque Country 1416 1.69% 3.39% 69.49% 23.02% 2.40%
Valencia 3159 3.13% 7.15% 71.73% 17.92% 0.06%
City of Ceuta 72 0.00% 0.00% 8.33% 91.67% 0.00%
City of Melilla
Source: SIAP 2023.
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model, implemented in several Autonomous Regions, including for example, in Castilla y León since 2020.32 Family
doctors can request online consultation with the dermatologist, send photos of dermatological lesions, and the
dermatologist decides on the referral or provides diagnostic or therapeutic guidance to the family doctor.
Initiatives focused on strengthening community participation and better integration between health and social
care can also be identified in Spain. For example, The Spanish Society of Family and Community Medicine (semFYC)
promotes the Programme of Primary Care Community Activities – PACAP.33 It was launched in 1995 and
implemented in several regions (Aragon, Asturias, Catalonia, Navarra, Basque Country and Valencia). The pro-
gramme promotes a broad spectrum of community activities in the field of primary health care, including those
related to communities' social well‐being and enhancing the capacity of people and groups to address their
problems and needs.
Finally, as the major challenge in Spain is accessibility to medical care in rural areas there are several examples
of initiatives focussing on encouraging medical staff to work in rural and other sparsely populated areas. These
involve local training for medical students in rural areas; investing in rural health centres infrastructure; building
local strategic alliances between neighbouring health centres aimed at sharing limited resources.
4 | DISCUSSION
Our study showed that medical deserts in Spain are mostly identified as rural, often isolated and/or depopulated
areas with limited access to health care. However, to accurately identify and monitor medical deserts in Spain,
availability of reliable and regularly updated local data is crucial. These should include not only the current ca-
pacities, but also projection of both future heath care needs and health care services supply, considering related
demographic, geographical and structural variables. The identified factors contributing to medical deserts and
solutions applied to mitigate them can be classified into two broad categories: those related to demand or supply
side of health care provision. For both factors and solutions, more national data, analyses and/or initiatives seem to
be focused on the health care supply dimension.
The identified solutions were implemented at both national and regional levels. They can be broadly catego-
rized into those focused‐on education (at both under and post‐graduate level), introducing innovative models of
care and providing professional and infrastructural support. The Spanish experiences are therefore in line with
those from other Western countries, as indicated by Flinterman et al. (2023).6 Actions focused on attracting and
retaining physicians to work in rural and/or remote areas are urgently needed in Spain. A recent analysis, based on
European countries experiences comparison showed that these should cover various stages of professional life and
aim at improving medical workers' work‐life balance and reducing their professional isolation.34
Our study indicates, that in the Spanish context, more attention should be given to managing the demand for
health services. This could include: implementing a network approach to continuous, people‐centered care and
improving data management systems. Strengthening strategic multi‐sectoral partnerships, especially in the face of
an ageing population and changing health needs, is important. Integrated health and social care models have been
promoted for many years now as an effective approach to improve access to care and limit unnecessary care (e.g.,
the need for hospital readmissions), especially for the older population.35–37
Due to the general characteristics of the Spanish health care system ‐ existence of separate regional health
systems per each Autonomous Community, a strongly recommended action is launching a national knowledge
translation platform (KTP) focused on identifying, evaluating and sharing best practices in limiting medical deserts
across different regions. Such platforms can take a form of organization or network supporting evidence‐informed
decision‐making – that is making health policy decisions “informed by the best available evidence from research, as well
as other factors such as context, public opinion, equity, feasibility of implementation, affordability, sustainability, and
acceptability to stakeholders”38 (WHO 2022). Different regions and communities across Spain can learn from each
other when the examples of best practices are identified and strongly disseminated. The involvement of major
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stakeholders, including local authorities seems especially important in the Spanish context. Without strong and
continuous political support, any policy aimed at mitigating medical deserts can face planning and implementation
obstacles. Diverse consensus building actions can be taken to involve multiple stakeholders and ensure better
applicability and sustainability of health policies.39
The main limitation of our work is the is the potential impact of arbitrary and/or subjective factors while
gathering the data/opinions from the national stakeholders/key informants. Yet, this was mitigated by involving a
diversified group of experts and referring to relevant literature/national data sources whenever available. Also, we
were not able to provide a more detailed local data analysis across the six Autonomous Communities indicated as
meeting the criteria of medical deserts. That would require availability of updated and comparable micro data.
Regardless this limitation, we were able to identify and map factors contributing to medical deserts and solutions
applied to mitigate them. Our results provide numerous implications for further research (e.g., on evaluation of
specific solutions on access to care and population health outcomes) and policy actions (e.g., on building inter-
sectoral collaborations and multi‐stakeholders approach, developing local data systems).
5 | CONCLUSIONS
The ROUTE‐HWF project's taxonomy allows to identify and define medical deserts across different European
regions. Yet, the proposed framework of four objects, related to both demand for and supply of health care, can be
also applied at lower, local levels to steer policy actions aimed at mitigating factors contributing to medical deserts
and supporting adequate solutions. In Spain, medical deserts are mostly rural, often isolated and/or depopulated
areas with limited access to health care. They are driven by factors related to both health care demand and supply
dimensions. There is no single, individual solution to medical deserts that can be applied and be sustainable. Instead,
a comprehensive and multidimensional approach must be applied. Policies are needed to address: the medical staff
education (more training in family and community medicine, intensive cooperation between medical schools and
rural health centres) and planning system (projections of future needs and capacities), as well as working conditions
(better infrastructure, peers support, local strategic alliances, more flexible working arrangements) and more
intersectoral approach to the population health management (e.g., community involvement, patients' empowering).
AFFILIATIONS
1Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
2Avedis Donabedian Instituto Universitario‐UAB, Barcelona, Spain
3Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Madrid, Spain
4Centro de Salud de Universitas, Servicio Aragonés de Salud, Zaragoza, Spain
5Grupo H36_23D H36_23D Feminización y Ética de las Profesiones Sanitarias (FEPS), IIS_Aragón, Zaragoza, Spain
6Centro de Salud Universitario Parquesol, Sanidad de Castilla y León, Valladolid, Spain
7Unidad Docente Universitaria de Medicina Familiar y Comunitaria, Facultad de Medicina, Valladolid, Spain
8Unidad de Apoyo Técnico DA Noroeste y DA Centro, Dirección Técnica de Sistemas de Información, Gerencia Asistencial de
Atención Primaria, Servicio Madrileño de la Salud, Madrid, Spain
9Centro de Salud de Navas Del Rey, Navas del Rey, Servicio Madrileño de la Salud, Tres Cantos, Madrid, Spain
10Centre d’Atenció Primària Marià Fortuny, L’Entitat de Dret Públic Salut Sant Joan de Reus ‐ Baix Camp, CatSalut, Servei Català de
la Salut, Reus, Tarragona, Spain
11Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
12Punto de Atención Continuada Tres Cantos, Servicio Madrileño de la Salud, Tres Cantos, Madrid, Spain
13School of Management, University of Vaasa, Vaasa, Finland
14Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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15School of Medicine, University of Zagreb, Zagreb, Croatia
16Department of Sociology, Radboud University, Nijmegen, The Netherlands
ACKNOWLEDGEMENTS
The authors would like to acknowledge Dr Pablo Rivas who provided language help and writing assistance. This
work was part of the ROUTE‐HWF project, co‐funded by the European Union's Health Programme (2014–2020)
under grant agreement no. 101018379. The publication is co‐funded by the Polish Ministry of Education and
Science within the project “PMW” in the years 2021–2024; agreement no. 5176/HP3/2021/2.
CONFLICT OF INTEREST STATEMENT
The authors declared that there is no potential conflict of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are openly available in ROUTE‐HWF at https://route‐hwf.eu.
ETHICS STATEMENT
Not applicable.
ORCID
Katarzyna Dubas‐Jakóbczyk https://orcid.org/0000-0002-6368-2868
Ana Isabel Gonzalez https://orcid.org/0000-0001-7167-4211
Alicja Domagała https://orcid.org/0000-0001-6162-1810
Maria Pilar Astier‐Peña https://orcid.org/0000-0002-3192-7672
Veronica Casado Vicente https://orcid.org/0000-0002-0576-2827
Marta Ballester https://orcid.org/0000-0002-7803-8354
Laura Seils https://orcid.org/0000-0001-9878-7865
Sorin Dan https://orcid.org/0000-0003-0565-7282
Linda Flinterman https://orcid.org/0000-0001-7943-5274
Robert Likic https://orcid.org/0000-0003-1413-4862
Ronald Batenburg https://orcid.org/0000-0001-9453-481X
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AUTHOR BIOGRAPHIES
Katarzyna Dubas‐Jakóbczyk – MPh, PhD, Associate Professor at the Health Economics and Social Security
Department, Institute of Public Health, Jagiellonian University in Krakow, Poland. Health policy and health
economics researcher working in the field of organizational and financial reforms within health care sector
including capacity planning at both health system and providers levels.
Ana Isabel Gonzalez – MD, PhD, Senior Researcher working mostly in projects about enhancing patient
empowerment and healthcare management of persons with chronic diseases. She belongs to the Research
Network on Chronicity, Primary Care, and Health Promotion (RICAPPS). She is the operational responsible of
Innovation at the Madrid Health Authority and for the last 3 years has worked in the development of a
Roadmap to address medical deserts in European countries with Avedis Donabedian Research Institute.
Alicja Domagała ‐ MSc PhD, Associate Professor at the Health Policy and Management Department, Faculty of
Health Sciences, Institute of Public Health, Jagiellonian University Medical College, Poland. Lecturer and
researcher in the field of health workforce, healthcare systems and human resources management.
Maria Pilar Astier‐Peña – MD, PhD, Family Physician at Universitas Health Centre. Health Service of Aragon
(Spain). Chair of the Patient Safety Working Group of Semfyc (Spanish Society for Family and Community
Medicine) and SECA (Spanish Society for Healthcare Quality). Executive Board Member Wonca World (Global
Family Doctors).
Veronica Casado Vicente – MD, PhD, Family doctor who was recognized in 2018 by the World Organization of
Family Doctors (WONCA World) as the best family doctor in the world. From July 2019 until December 2021,
she was the head of the Health Department of the Junta de Castilla y León.
Antonia‐Gema Planet – RN, Primary Care Nurse. Nursing Manager at Rural Health Centre. Technician in the
Technical Support Unit of the Primary Care Management of the Community of Madrid. Continuing Care Nurse.
Agueda Quadrado – MD, Pediatrician in Colmenar del Arroyo, Madrid (Spain), a rural primary care practice.
Rosa Mari Serrano – MD, Family doctor and director of Maria Fortuny Heath Centre in Reus, Barcelona (Spain).
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Isabel Serafina Abellán – RN, Student Nurse at the Virgen de la Arrixaca University Hospital, Mallocar (Spain)
and currently Resident Internal Nurse.
Alba Ramos – RN, Nurse at La Cabrera, Madrid (Spain), a rural primary care practice.
Marta Ballester – BPS, Graduated in Political Science and Administration, with a specialisation in International
Relations from the Autonomous University of Barcelona in 2010. Project coordinator specialising in patient
empowerment, self‐care, integrated care, and continuous improvement in social services. Teacher in Master's
and Postgraduate programs in Quality and Safety Management in healthcare. Currently, working on a doctoral
thesis focussing on the implementation of innovations in social services through an international comparative
approach.
Laura Seils – PT Master's student, Scientific Assistant at the Avedis Donabedian Foundation and
physiotherapist.
Sorin Dan ‐ MPPA, PhD, Assistant Professor, School of Management, University of Vaasa, Vaasa, Finland. Public
management and healthcare reforms, Public sector innovations, Digital transformation.
Linda Flinterman – PhD, Senior researcher at the department of Professions in Healthcare and Manpower
Planning of the Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands.
Researcher in health workforce planning and regional differences in health workforce on both national and
European level.
Robert Likic – MD, PhD, Medical graduate with honours from Zagreb in 2001, specialised in internal medicine
and clinical pharmacology. He's a professor at Zagreb Medical School and a consultant at the University
Hospital Zagreb. His research includes medical education, health outcomes, and rational antibiotic use. Involved
in international collaborations, Dr. Likic was a visiting scholar at the University of Michigan in 2009 and
contributed to VOIP telephony in medical education. He's also recognized for his contributions to clinical
pharmacology and medical committees.
Ronald Batenburg – PhD, coordinator of the research programme Professions in Healthcare and Manpower
Planning of the Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands, and
endowed professor ‘Health workforce and organisation studies’, at the Radboud University, Nijmegen, the
Netherlands.
How to cite this article: Dubas‐Jakóbczyk K, Gonzalez AI, Domagała A, et al. Medical deserts in Spain—
Insights from an international project. Int J Health Plann Mgmt. 2024;1‐14. https://doi.org/10.1002/hpm.
3782
14 - DUBAS‐JAKÓBCZYK ET AL.
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