“Medical specialists in LMICs; a systematic review and best-fit framework synthesis of the evidence on their roles and contribution to health systems”

Background Medical specialists are integral to the medical workforce and play a pivotal role in referral systems. However, in low- and middle-income countries (LMICs), there is perception specialists often fail to align with local health needs, system capacities, and Universal Health Coverage (UHC) objectives.

A systematic review was conducted in 2024 using a best-fit framework to assess the contributions of specialists to health systems and population health in LMICs. Searches covered eight databases and specialist journals, guided by an expert-validated a priori framework for data extraction and analysis. We used the Johanna Briggs Institute critical appraisal tools to assess the quality of the papers, and the PRISMA guidelines to report the findings. The study protocol was registered in the PROSPERO database (CRD42024572877). Findings We found and reviewed 89 studies, highlighting a critical shortage of specialists, particularly surgeons, anaesthesiologists, and psychiatrists. Evidence linked specialists’ availability to improved health outcomes such as lives saved through expanded surgical capacity, though broader health system contributions were less clear. Specialists were reported to play key roles in referrals, hospital management, mentoring, and research. Governance of their professions was found to be variable across LMICs, with wide differences in specialty types, training curricula, accreditation systems, and regulation of private-sector involvement. Reports frequently documented specialists’ engagement with private health markets, revealing blurred boundaries between public and private care. A dynamic market for specialists was also observed, driven by a sustained global demand for their services. However, few policies were found addressing shortages and improving governance, with existing strategies focusing on task-shifting, clinical training, and sharing responsibilities.

This review offers an evidence-based framework for understanding specialists’ roles and health system engagement in LMICs. We highlight the need to reconsider specialists’ deployment, prioritising alignment with UHC goals and enhancing governance to optimize their contributions to health systems. Competing Interest Statement The authors have declared no competing interest. Funding Statement This study received funding from the Medical Research Council UK - Grant reference: MR/R022747/1 Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data produced in the present study are available upon reasonable request to the author