Authors
 Ali Kazemi Karyani ^{1}
 Zhila Kazemi ^{2}
 Faramarz Shaahmadi ^{3}
 Zohreh Arefi ^{} ^{4}
 Sadegh Ghazanfari ^{} ^{5}
^{1} Department of health management and economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
^{2} Department of medical informatics, School of health management, Shiraz University of Medical Sciences, Shiraz, Iran.
^{3} Savojbolagh Health Center, Alborz University of Medical Sciences, Karaj, Iran.
^{4} School of Public Health, Kurdistan University of Medical Sciences, Sanandaj, Iran.
^{5} Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
Abstract
Introduction: The mortality rate of children is one of the most important indicators to measuring the development of countries. Equitable access to pediatricians is an important factor in reducing child mortality and promoting society health. The aim of this tudy was to investiget the Inequality and trend of geographic accessibility to Pediatricians in Iran in the period 2007 to 2013.
Materials and Methods: We used the Gini coefficient and the index of dissimilarity for investigating the geographic distribution of pediatricians in the period 2007 to 2013 in Iran. Also, a regression model used for detrminig time trend of inequality. Data about the number of pediatricians and number of live birth in each province were obtained from the Statistical Center of Iran (SCI).
Results: The Gini coefficient was 0.27, 0.24, 0.26, 0.23, 0.23, 0.23, 0.25 and 0.21 in 2007 to 2013, respectively. The dissimilarity index of pediatricians were 18.35, 17.4, 19.4, 16.73, 14.93, 14.66 and 11.99 during 20072013. The time trend analysis showed that inequality have been decreased during the studied period and it was not statistically significant (p>0.05).
Conclusion: The results showed that there are some inequality in Pediatricians distribution and most of Pediatricians are in developed provinces. Thus policy makers for improving child’s health in Iran should develop a comprehensive plan for equitable distribution of pediatricians.
Keywords
Introduction
Maintenance and promote the health of children as one of the most vulnerable part of any society has an important role in healthcare sector so that today childs mortality is one of the main indicators for measuring degree of development of countries. This focuse on the child health can be due to the importance of socioeconomic factors in decrease or increase of the child health indexes such as infant mortality rate[1, 2]. There was 6.3 millions under five child mortality in 2013 (17000 each day) [3]. Different studies in developing countries reveals that infectious diseases, asphyxia and congenital anomalies are most important factors in under five mortality. Acording to the Iranian ministry of health records, most common causes of under five mortality in Iran are infections and different congential anormalies[4].
Fortunately in recent years along with the expansion of healthcare services and promotion of communities public health, a significant reduction in child mortality rate occurred, for example in Iran under 5 mortality rate in 2000 was 7/34 per 1000 live births and in 2013 reduced to 16.8 per 1000 live births [5]. But, there is a great disparity in reducing child mortality rate in different parts of the world so that according to worldbanks database in 2013 under 5 mortality rate in Luxumburg was 2 and for Angola was 16.7 per 1000 live births[6]
Access to healthcare providers is one of the main factors that can eliminate this inequlity and promote public health [7]. As we know pediatricians have a fundamental role in childs health [8]. But unfortunately, despite increase in number of pediatricians, they distributed very unfairy between cities of Iran so that many of them are concentrated in the center of provinces and people who living in other cities dosen’t have adequate access to this group of health experts. Thus investigating pediatricians geographic distribution could be a good step toward childs mortality rate reduction and promoting child and society health[9].
Different studies on geographical distribution of health sector resources specially health workers have done in Iran. Rezaei and et al [10] KiaDaliri and et al [11] Karimi and et al[12] and Abolhallaje and et al[13] have been investigated the inequality in distribution of healthcare resources.
Previous studies on geographical distribution of health sector resources dosen’t investigate the geographical distribution of pediatricians. Therfore, there was no scientific evidence about the distribution of pediatricians in Iran. this study tried to investigate inequality and trend of geographic accessibility to Pediatricians in Iran during 2007 to 2013.
Materials and Methods
This study was performed for measuring inequality in geographical distribution of pediatricians in Iran provinces from 2007 to 2013. Data were obtained from Statistical Centre of Iran[14]. Two inequality measure of Gini coefficient and Dissimilarity index were used for investigating the geographical distribution of pediatricians from 2007 to 2013.
Gini coefficient
The Gini coefficient is commonly used to measure the inequality in the geographic distribution of human resources in healthcare[15, 16]. The value of Gini coefficient is between 0 and 1. Zero implies the perfect equality and one shows the complete inequality in geographical distribution of interested variable.
Figure 1 shows the Lorenz curve. The Gini coefficient is derived from the Lorenz curve using the following formula:
15G= AA+B'>
15G='> Gini Coefficient
15A='>Area between the Lorenz curve and the 45° line
15A+B='>The whole area under the 45° line
usual expression of Gini coefficient used [17]:
(1) 
Where:
G: the Gini coefficient, µ: the mean of the distribution, N: sample size, y_{i}: number of pediatricians in i^{th }province. The value of the Gini coefficient is between 0 (perfect equality) and 1 (perfect inequality) [18, 19]. It worth nothing that we considered the number of live births in each year as index of need to pediatricians in provinces.
We used Jackknife variance estimator for calculating variance of Gini coefficient and tested the hypothesis test of equal distribution of pediatricians between Iran provinces (H_{0}) using Student's ttest.
(2) 
Where:
V: variance estimator, G_{i}: value of the coefficient when the i^{th} observation is taken out of the sample [2022].
Index of dissimilarity indicates the percentage of all health variables, which would have to be redistributed across counties to achieve a situation of perfect equality. Value of this index is between 0 and 100. Value of ID shows the percent of available pediatricians in which should be redistributed between provinces[23]. in the current study, index of dissimilarity (ID) calculated by following expression[24]:
15ID=12i=1nxip xih'>
Where:
ID: index of dissimilarity, X_{ip}: i^{th} province’s live births share, X_{ih}: i^{th} province’s pediatricians share, N: total number of provinces.
Time trend in inequality
Time trend in inequality of pediatricians from 2007 to 2013 was examined by estimating a regression model. Dependent variable was Gini coefficient and independent variable was year as follows:
Y= β0+ βiX + εi
Where:
Y: Gini Coefficient for geographical distribution of pediatricians; X: years (from2007to 2013).
β coefficient captures the direction and magnitude of trend of geographical distribution of pediatricians in Iran [25]. Negative β shows Gini coefficient declined over time and distribution of pediatricians became more equal. Presence of heteroscedasticity in the fitted model was examined by BreuschPagan test. P_value less than 0.05 was considered statistically significant. Stata version 11 and DASP Plugin were used for data analysis.
Results:
Table 1 shows the number of Pediatricians per 1000 live births in Iran provinces in 2007 to 2013. Also this table declares the mean, standard deviation, minimum and maximum of the number of Pediatricians in Iran provinces between 2007 and 2013. The mean of Pediatricians per 1000 live births were 1, 1.01, 1.03, 1.10, 1.11, 0.95 and 1.03 during study period. The maximum of Pediatricians per 1000 live births in 2007 to 2013 were 3.05, 2.95, 2.26, 2.45, 2.61, 2.97 and 2.68, respectively. Zanjan had the maximum Pediatricians per 1000 live births in 2009 and Semnan had the maximum amount in other years. The minimum amount were 0.16, 0.25, 0.26, 0.27, 0.37, 0.14 and 0.34. Siatan and balochestan had minimum Pediatricians per 1000 live births in 2008, 2009, 2011 and 2013. The North Khorasan had minimum amount in two years, too. Mazandaran with 0.14 Pediatricians per 1000 live births had the minimum per capita in 2012.
Table1 the descriptive analysis of the number of Pediatricians per 1000 live births in Iran Provinces 20072013.
Province 
2007 
2008 
2009 
2010 
2011 
2012 
2013 
East Azarbaijan 
1.50 
1.51 
1.45 
1.52 
0.99 
0.98 
0.95 
West Azarbaijan 
0.73 
0.70 
0.71 
0.74 
0.63 
0.88 
1.12 
Ardabil 
0.52 
0.64 
0.80 
0.92 
1.05 
1.06 
0.97 
Isfahan 
0.92 
1.03 
1.22 
1.52 
1.44 
1.38 
1.36 
Ilam 
1.20 
1.21 
1.20 
1.40 
1.36 
1.47 
1.40 
Bushehr 
0.96 
0.94 
0.74 
0.84 
0.84 
0.89 
0.87 
Tehran 
0.51 
0.48 
0.45 
0.65 
1.24 
1.12 
0.90 
Chaharmahal and Bakhtiari 
1.28 
1.03 
0.80 
0.96 
1.48 
0.83 
1.03 
South Korasan 
0.63 
0.76 
0.67 
1.17 
1.24 
0.68 
0.86 
Razavi Khorasan 
1.05 
1.03 
0.93 
0.97 
0.98 
1.00 
0.97 
North Khorasan 
0.16 
0.34 
0.31 
0.27 
0.43 
0.49 
0.50 
Khuzestan 
0.93 
1.07 
1.03 
1.16 
1.25 
1.07 
1.02 
Zanjan 
1.47 
1.13 
2.26 
1.67 
1.54 
1.43 
1.12 
Semnan 
3.05 
2.95 
2.14 
2.45 
2.61 
2.97 
2.68 
Sistan and Baluchestan 
0.31 
0.25 
0.26 
0.38 
0.37 
0.36 
0.34 
Fars 
0.72 
0.74 
0.58 
0.70 
0.69 
0.70 
1.13 
Qazvin 
1.12 
1.10 
1.09 
1.38 
0.89 
0.85 
1.46 
Qom 
1.24 
1.16 
1.25 
1.17 
1.19 
0.49 
0.57 
Kurdistan 
1.14 
1.12 
0.65 
0.99 
0.55 
0.68 
0.68 
Kerman 
0.50 
0.80 
0.78 
0.58 
0.66 
0.52 
0.54 
Kermanshah 
0.70 
0.85 
0.66 
0.84 
0.58 
0.85 
0.66 
Kohgiluyeh and BoyerAhmad 
0.56 
0.55 
0.99 
1.00 
0.92 
1.13 
1.38 
Golestan 
0.87 
0.97 
0.96 
1.14 
1.07 
0.80 
1.10 
Gilan 
1.33 
1.16 
1.32 
1.50 
1.47 
1.74 
1.44 
Luristan 
0.62 
0.62 
0.62 
0.54 
0.89 
0.65 
0.87 
Mazandaran 
1.85 
1.89 
2.03 
1.77 
2.13 
0.14 
1.69 
Markazi 
0.90 
1.09 
1.02 
1.02 
1.47 
0.83 
0.77 
Hormozgan 
0.60 
0.60 
0.81 
0.81 
0.90 
0.56 
0.60 
Hamadan 
1.19 
1.17 
1.23 
1.16 
0.98 
0.99 
1.18 
Yazd 
1.42 
1.46 
1.88 
1.76 
1.61 
0.94 
0.89 
Mean 
1 
1.01 
1.03 
1.10 
1.11 
0.95 
1.03 
Std. Dev* 
0.55 
0.51 
0.51 
0.47 
0.49 
0.51 
0.45 
Max 
3.05 
2.95 
2.26 
2.45 
2.61 
2.97 
2.68 
Min 
0.16 
0.25 
0.26 
0.27 
0.37 
0.14 
0.34 
The Gini coefficient and dissimilarity index of Pediatricians distribution in Iran provinces in 20072013 have shown in table 2. As shown in this table the Gini coefficient against live births was 0.27, 0.24, 0.26, 0.23, 0.23, 0.23, 0.25 and 0.21 in the study period, respectively. The standard error of Gini coefficient was 0.03 in 2013. The t statistics for Gini coefficient were more than 1.96 for all years and therefore the hypothesis of equal distribution of Pediatricians was rejected. The dissimilarity index of Pediatricians were 18.35, 17.4, 19.4, 16.73, 14.93, 14.66 and 11.99 during 20072013. The number of Pediatricians in which should be redistributed for reaching equal distribution of this health resource showen in the table, too. As it shown 206 of available Pediatricians in 2007 should be redistributed, this amount was 139 Pediatricians for 2013.
Table2 the Gini coefficient and dissimilarity index of Pediatricians in Iran, 20072013.
Year 
Gini Coefficient 
Dissimilarity index 

Estimate 
STE* 
tstatistic 
Estimate 
No redist** 

2007 
0.27 
0.04 
6.7 
18.35 
206 
2008 
0.24 
0.04 
6 
17.4 
203 
2009 
0.26 
0.03 
8.6 
19.4 
223 
2010 
0.23 
0.03 
7.6 
16.73 
212 
2011 
0.23 
0.03 
7.6 
14.93 
200 
2012 
0.25 
0.04 
6.2 
14.66 
159 
2013 
0.21 
0.03 
7 
11.99 
139 
Time trend in inequality
The result of regression analysis for investigation of time trend of inequality is shown in table3.
As the table shown, the βcoefficient for the effect of time on Gini coefficient was 0.007 and this effect was not statistically significant (p>0.05). the BreuschPagan test for heteroskedasticity showed there was no heteroskedasticity in fitted model (chi^{2} = 0.20, p>0.5). the rsquared of the regression model was 0.52.
Table3 Time trend analysis of Gini coefficients for pediatricians in Iran 20072013.
βcoefficient 
Std. Err.* 
P 
0.007 
0.003 
0.06 
Rsquared 
0.51 

BreuschPagan test

Chi^{2}= 0.20 p = 0.65 
Discussion
According to millenium development goals that agreed by all world’s countrie , in less than one decade (until 2015) childs mortality rate most decreas to 75% of 1990 [26]. When factors that influence child mortality rate being determined and resolved then a country can easily reach to this goal. Access to health sector resources espicially health workers is one of the main factors on child health. Therfore, we investigated the Inequality and trend of geographic accessibility to Pediatricians in Iran in the period 2007 to 2013. According to the results pediatricians per capita rate had unequal distribution and high variance. But most of this variablity was in developing provinces ( Semnan and Zanjan ) and resident population of deprived provinces like Sistan and Baluchestan, Kerman and Hormozgan always had been some geoghraphical problems for accessing to the pediatricians. Simillar studies reveal that deprived provinces like Sistan and Baluchestan, West Azerbaijan and Hormozgan are deprived in term of access to health sector services[13, 2729]. this results could confirm this hypothesis that socioeconomic factors and health have direct correlation with each other.
Investigating Gini index trend in study period cleared that Gini index had decreased but most of this decrease is due to increase in pediatricians in developing provinces and deprived provinces still have serious problems for accessing to this type of health experts. For investigating this issue we surveyed pediatricians growth in different provinces in study period. As defined in table 1, Semnan, Zanjan and Mazandaran as industrial and toursit centers experinced a higher growth in number of pediatricians and Sistan and Baluchestan, North khorasan, Kerman and Hormozgan as deprived and border provinces experinced a less growth in number of this health resource. Thus despite of increase in the total number of pediatricians in Iran, there are some degrees of inequlity in access to pediatricians, yet and some of deprived provinces have serious problems in access to pediatricians. Also, Investigating dissimilarity index revealed that total geographical distribution of pediatricians become better during the studied period but further investigation is needed to determine the status of deprived provinces in term of access to pediatricians.
Some studies like Tanimura and Shima in Japan [9] revealed that unequal distribution of healthcare services could worsen public health status [3032]. In this study we investigate the geographical access to pediatricians that is one of the main factors that can improve public health but we don’t consider other factors such as financial barries, organizational and personal factors that can affect on services utilization. These factors could limit the utilisation of available healthcare services.
Overally, two used indeces of inequality, both Gini Coefficient and dissimilarity index showed that total inequality in distribution of pediatricians was decreased in provinces of Iran between 2007 and 2013 but deprived provinces need more attention and strategic plans for improving access to pediatricians services. Regard the vital role of pediatricians in decreasing the child mortality and improve the public health, equal distribution of these physicians could have improtant impact on improving health indicitaros and societies health and welfare, thus Iranian policy makers with startegic plannings must decrese inequlaity in access to pediatricians.
Conclusion
In this study we investigate the geographical distribution of Pediatricians in 6 years and results showed that there is unequal trend in Pediatricians distribution so that most of Pediatricians are in developed provinces. Thus policy makers for improving child’s health in Iran should develop a comprehensive plan for equitable distribution of Pediatricians.
Conflict of interests: None