Strengthening medical specialisation policy in low-income and middle-income countries.

The availability of medical specialists has accelerated in low-income and middle-income countries (LMICs), driven by factors including epidemiological and demographic shifts, doctors' preferences for postgraduate training, income growth and medical tourism. Yet, despite some policy efforts to increase access to specialists in rural health facilities and improve referral systems, many policy questions are still underaddressed or unaddressed in LMIC health sectors, including in the context of universal health coverage. Engaging with issues of specialisation may appear to be of secondary importance, compared with arguably more pressing concerns regarding primary care and the social determinants of health. However, we believe this to be a false choice. Policy at the intersection of essential health services and medical specialties is central to issues of access and equity, and failure to formulate policy in this regard may have adverse ramifications for the entire system. In this article, we describe three critical policy questions on medical specialties and health systems with the aim of provoking further analysis, discussion and policy formulation: (1) What types, and how many specialists to train? (2) How to link specialists' production and deployment to health systems strengthening and population health? (3) How to develop and strengthen institutions to steer specialisation policy? We posit that further analysis, discussion and policy formulation addressing these questions presents an important opportunity to explicitly determine and strengthen the linkages between specialists, health systems and health equity.