Medical specialist retention in non-metropolitan, low-population-density territories: a rapid realist review

This research project examines the attraction and long-term retention of medical specialists in non-metropolitan, low-population-density territories. These settings are understood functionally as areas characterised by demographic dispersion, distance from referral centres, limited access to specialist care, reduced institutional capacity, or comparable territorial constraints. The project is motivated by the persistent geographical maldistribution of medical specialists, which compromises timely access to care, continuity of services, referral capacity, and health equity. The central purpose of the project is to explain how, why, for whom, and under what contextual conditions different workforce strategies contribute to sustained specialist retention, unstable retention, or deferred exit. Rather than assuming that individual interventions produce uniform effects, the study adopts a realist perspective, according to which outcomes emerge when particular resources or strategies activate specific forms of professional reasoning within particular organisational, territorial, family, and institutional contexts. The first component of the project consists of a rapid realist review conducted in accordance with the RAMESES publication standards, with explicit adaptations for a rapid review process. The review examines educational, regulatory, financial, organisational, professional-development, family-support, and community-based strategies. Evidence is identified through systematic searches of Web of Science, Scopus, PubMed, Embase, LILACS, SciELO, the Cochrane Library, and Google Scholar, complemented by exploratory scoping, backward and forward citation searching, and targeted searches of institutional and grey literature. Documents are selected and appraised according to their relevance, methodological or argumentative rigour, explanatory contribution, and evidential directness rather than solely according to conventional study-design hierarchies. Data are analysed using context–mechanism–outcome configurations. The review seeks to determine how distributed training, territorial exposure, integrated incentive packages, professional development, career security, family liveability, compulsory service, organisational support, infrastructure, mentorship, referral networks, and institutional trust interact to influence specialist location decisions and long-term retention. Particular attention is given to differences between initial attraction, intention to remain, retention during mandatory service, post-obligation stay, and sustained long-term retention. The project is expected to generate a provisional middle-range theory of medical specialist retention in low-density territories. The principal anticipated outcome is an explanatory model describing the conditions under which multiple retention strategies converge into a coherent territorial career ecosystem. This model is expected to clarify why isolated financial or regulatory interventions may produce only temporary distribution gains, whereas integrated combinations of professional, organisational, family, and territorial supports may create more sustainable conditions for remaining. Additional expected outputs include a transparent and reproducible evidence corpus, complete database search strategies, a documented screening and appraisal process, a configurational extraction framework, an inventory of included documents and their provenance, a RAMESES reporting checklist, and graphical representations of the review process and explanatory model. These materials will be made available through the Open Science Framework to strengthen methodological transparency, auditability, and the potential reuse of the review methods and findings. The project is intended to inform health-workforce policy, particularly in rural, remote, peripheral, and non-metropolitan settings in Latin America and other regions facing comparable specialist shortages. Its expected policy contribution is to support multisectoral and place-sensitive planning by shifting attention from isolated incentives toward the combinations of educational, professional, organisational, institutional, family, and community conditions that make long-term specialist retention possible.