Financial incentives for return of service in underserved areas: a systematic review

Of the 42 reviewed studies 33 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60-80%). Seven studies compared retention in the same underserved area between program participants and non-participants. Six studies found that participants were less likely to remain in the same underserved area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Twelve studies compared provision of care/retention in any underserved area between participants and non-participants. Ten studies found that participants were more likely to continue to practice in any underserved area (eight studies reported the difference to be statistically significant, while two studies did not provide the results of significance tests); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with aspects of their enrolment in financial-incentive programs; three studies examined the satisfaction of members of participants’ families with their lives in the undeserved area.