Scarce clinicians, placed by ranking instead of evidence.

Under a fixed budget, every system faces the same question: where should the next clinician go, or which places should get an incentive, so the money helps most? Today that call is usually made by ranking places on a shortage score, by negotiation, or by habit, rather than by the measured effect of the help itself.

Data-rich systems

e.g. United States

Records are plentiful, yet clinicians are still placed largely by ranking a shortage score, and the real effect of a placement on local access is rarely measured well.

Data-scarce systems

e.g. Nigeria

Staffing and access must be pieced together from a registry, surveys, and maps. Migration and insecurity cloud what is seen, and incentives are spent with little evidence of impact.

Why the gap persists

Doctors gravitate to cities. The gap does not close on its own.

The map is not random. Physicians concentrate where the amenities, incomes, professional networks, and training hospitals are, which means large cities and affluent suburbs. Rural and less-populous places are left short, decade after decade, because the choice of where to practise follows careers and lifestyles rather than need. This is why a market left to itself does not fix the shortage, and why deliberate, evidence-based placement has value.

Dense cluster of city high-rise buildings

Cities draw the doctorsPhoto: Joel Filipe / Unsplash

A small medical building among trees in a quiet, low-density setting

Rural areas are left shortPhoto: Acton Crawford / Unsplash

20%

of Americans live in rural areas, but fewer than 10% of physicians practise there (HHS)

7.2%

of U.S. counties had no primary-care physician at all in 2023 (HRSA)

5.1 vs 8.0

primary-care physicians per 10,000 in rural vs urban areas (USDA ERS, 2020)

Incentive programs exist to counteract this, from loan repayment to shortage-area designations, but they are typically handed out by ranking a shortage score, not by where an extra clinician would help the most people. That is the gap ACWIS is built to close.

The economics

The gain is in where the workers go, not how many.

Health care is nearly a fifth of U.S. GDP and the largest single source of new jobs, so the sector’s scale is not in question. The economic case for ACWIS is about allocation, not size: the same budget and the same new clinicians produce very different amounts of health depending on where they land. A clinician placed where the marginal return is highest reaches more people and prevents more avoidable, costly illness; the same clinician placed by ranking or habit leaves that value on the table. Reducing that misallocation, the deadweight loss of putting scarce skill in the wrong place, is the return ACWIS targets.

18%

of U.S. GDP is health spending: $5.3 trillion in 2024 (CMS)

1 in 4

of all new U.S. jobs this decade are in health care (BLS, 2023–33)

2.2M

health & social-assistance jobs added by 2033 (BLS)

A surgical team gathered around an operating light

A growing workforce; the question is where it landsPhoto: National Cancer Institute / Unsplash

The fastest-growing jobs in America are in health care

Projected employment change, 2023–2033. Source: U.S. Bureau of Labor Statistics, Employment Projections. "All occupations" is the economy-wide average.

The chart shows where the new workers are; it does not decide where they go. That decision, made clinician by clinician and dollar by dollar, is where a limited budget either reaches the most people or does not, and where a healthier, working population is either supported or left to chance.