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

BackgroundMedical 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. MethodsA 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). FindingsWe 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. ConclusionsThis 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.