Features of effective primary health care models in rural and remote Australia: a case-study analysis

John Wakerman, John S Humphreys, Robert Wells, Pim Kuipers, Judith A Jones, Philip Entwistle and Leigh Kinsman
Med J Aust 2009; 191 (2): 88-91. || doi: 10.5694/j.1326-5377.2009.tb02700.x
Published online: 20 July 2009


Objective: To describe the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of primary health care (PHC) service delivery in rural and remote Australia.

Design: Case-study approach, including review of relevant literature, interviews with key informants, site visits and direct observation. Thematic analysis and template analysis were used with interview transcripts. An expert reference group provided feedback and advice on policy relevance.

Setting and participants: Six PHC services in small communities across rural and remote Australia were selected based on results of a previous systematic review; they reflected diverse rural and remote settings and PHC models, and the multidisciplinary nature of PHC. Sites were visited, and 55 individuals associated with the establishment and operation of these services were interviewed between July 2006 and December 2007.

Results: Independent and template analysis confirmed the usefulness of a conceptual framework, which identified three key “environmental enablers” — supportive policy; federal and state/territory relations; and community readiness — and five essential service requirements — governance, management and leadership; funding; linkages; infrastructure; and workforce supply. Systematically addressing each of these factors improves effectiveness and lessens the threat to service sustainability.

Conclusions: Evidence from existing effective rural and remote PHC services can inform the health care reform agenda, in Australia and other countries. The evidence highlights the need for improved governance, management and community involvement, as well as strong, visionary political leadership to achieve a more responsive and better coordinated health system which could help eliminate existing health status differentials between cities and rural areas. In Australia, establishment of a single national health system, operationalised at a regional level, would obviate much of the current inefficiency and poor coordination.

A third of Australia’s population lives outside major cities.1 Many residents of the 1500 rural and remote communities with fewer than 5000 inhabitants face significant health disadvantage and reduced access to health services.1 Despite a raft of specific rural health policies since the mid 1990s,2 the “inverse care law” still applies (ie, the availability of good health care tends to vary inversely with the need of the population served).3 In a wealthy country such as Australia, this inequity is unacceptable. However, empirical evidence to account for the failure of implementation of rural health policy,4 the lack of sustainability of rural primary health care (PHC) services,5 and the failure to generalise successful programs6,7 is lacking.

Our previous research described innovative models of comprehensive PHC (as defined by the World Health Organization8) in rural and remote Australia, a model typology, conceptual framework and resultant policy implications.6,9,10 This follow-up study describes the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of PHC service delivery in rural and remote Australia — issues about which little has been published to date.


Based on results of our previous systematic review,10 six identifiably sustainable PHC services were selected for detailed case-study analysis. The services were purposively selected to reflect a diverse range of rural and remote settings, PHC models, focus areas (health promotion, disease prevention, rehabilitation and clinical services) and national priorities (medical workforce supply, mental health and chronic disease care), as well as the multidisciplinary nature of PHC. Each service had been previously independently evaluated.11-16

The services were:

Between July 2006 and December 2007, we conducted in-depth interviews with key informants identified as having a significant role in the implementation or operation of each service by previous research,9 reference group members or snowballing. Those interviewed included:

Different combinations of two researchers visited each site, enabling direct observation of service facilities and informal interaction with staff. A national reference group provided feedback and guidance on the policy significance of findings.

Semistructured interviews were recorded and transcribed. Two interviewers documented summary themes and issues based on the recorded interviews and detailed notes. Using our previous framework10 as a template or coding frame,17 we identified and synthesised common themes. To validate the process and identify themes that fell outside the template, transcripts were independently thematically coded18 by a team member not involved in the interviews, and analysed for emergent themes using NVivo software (QSR International, Cambridge, Mass, USA).

Ethics approval was granted by the Monash University and Northern Territory Top End Human Research Ethics Committees.


Fifty-five individuals were interviewed. Although interviews covered diverse issues, clearly consistent themes emerged in the initial post-interview analysis and subsequent independent coding and analysis. We identified three key “environmental enablers” — supportive policy; federal and state/territory relations; and community readiness — and five essential service requirements — governance, management and leadership; funding; linkages; infrastructure; and workforce supply.

Environmental enablers
Supportive policy

In the recent national policy context, senior policy officers suggested that many rural health initiatives had resulted from a “liberation of ideas” within government in response to concerns from disaffected rural and remote electorates. In 2000, health formed a “budget centrepiece for rural and remote Australia” because supporting health and social data existed, funds could “flow and generate impact quickly”, and voters regularly interacted with health providers, such as doctors and pharmacists.

The policy context appeared to set the parameters for sustainability and generalisation of successful models. These were either supported by a policy (eg, KWHB, which was supported by the Coordinated Care Trial program) or a politically opportune source of funding (eg, NETPMHC, which was in the swinging seat of Bass in the lead-up to a federal election). A senior public servant described a three-tiered policy and funding hierarchy, comprising “mainstream programs”, such as the Medicare Benefits Scheme (MBS); “equalisation programs” for the bush, such as the Regional Health Services program and the Royal Flying Doctor Service; and “ad-hoc grants”, which cause sustainability problems for both grantees and granters. He considered that reliance on pilot projects worked against sustainability and commented that “pilotitis causes us indigestion”.

For effective models to be generalised to other contexts, there needs to be a political benefit for the government of the day. A number of service providers commented that, regrettably, high staff turnover and loss of corporate memory within the federal health department weaken the policy foundation from which to generalise successful pilot projects.

Service requirements

Although environmental enablers set essential parameters at the macro level, other micro-level requirements must be in place for the PHC model to be successful.

Governance, management and leadership

Effective governance, management and leadership were consistently identified as priorities for successful implementation of models, especially the NWQAHS, KWHB, RARMS and MTHCS models. Moreover, a strong PHC approach, encompassing community participation, multidisciplinary practice, a focus on disease prevention, and a shared leadership vision for the service, characterised these models.

Service “champions” at both the community and political levels were also important. A senior bureaucrat referred to the need for three types of key players: “visionaries” (leaders), “implementers” (managers) and “political runners” (experienced and committed officers who could pre-empt or overcome political barriers to implementation).

Governing committees or community boards contributed significantly to service sustainability. The leadership provided by key health professionals, themselves often community members, was also mentioned. This highlighted a dilemma for some small communities, where conflicts of interest can arise because a few key individuals perform multiple roles.

Service adaptability in a constantly changing environment required key managers capable of effective change management, so that services could take advantage of emerging opportunities and enhance sustainability. This was exemplified in several services, which adapted to chronic disease management through strategies that included better use of MBS items and information technology (IT), embracing a multidisciplinary approach, and ensuring adequate physical infrastructure to facilitate non-clinical interaction with patients. High-quality service evaluation also assisted with change and service improvement.

Localised management was also perceived as important. For example, NWQAHS adopted an explicit “place management” model that emphasised devolved management. Conversely, in services without strong local management or devolved authority, where management from a distance was not effective, or governance and management functions were not adequately distinguished, effectiveness and sustainability were threatened.


This study has confirmed critical environmental enablers and essential service requirements that underpin effective PHC service models in rural and remote areas. This evidence-based PHC models framework has proved to be a robust and useful tool in the development of these services.6,9,10 Moreover, effective PHC services were shown to systematically address all essential service requirements across a range of models, from discrete general practices to Aboriginal community-controlled comprehensive PHC services.

Currently in Australia, there are several significant policy reviews relating to primary health care, disease prevention and the broader health system. Internationally, there is renewed interest in PHC.19 Our study provides important evidence from exemplary PHC models that can inform policy development. As the case-study design may limit generalisability of the results, there is a need for rigorous, comparative studies based on this evidence that evaluate the effectiveness of different service models using both qualitative and quantitative methods.20

Good governance, visionary leadership and high-quality management skills are crucial attributes of effective services. PHC services require stronger recognition of managers as essential members of the PHC team, and appropriate management and governance training.

Genuine community involvement is fundamental to the initiation and sustainability of rural and remote PHC services, although the mechanism for participation will vary across different contexts and services. Given its importance, explicit funding and appropriate time are required to support community consultation and ongoing participation in planning and development.

At the same time, communities must be realistic about the range of services that can be expected. Catchment or community size is critical, as the population needs to be sufficiently large to support an appropriate range of services, but not so large that dedicated specialist or disease-specific programs would usually be provided.

Sustained political commitment is crucial to successful PHC reform. Changing political priorities remain a barrier to developing widespread, effective PHC services across rural and remote Australia. Each PHC service benefited from the existence of distinct, relevant “mainstream” or rural “equalisation” policies, with the exception of one that relied on pre-election activism in a key swinging seat before a national election. Policies abound when rural health is perceived to be a political problem, but ad-hoc and some equalisation policies may be at risk when there is no perceived problem. Over time, incumbent governments may eschew risks associated with generalising successful models into different contexts, instead favouring “innovative pilots”, which invariably have limited longevity. At the same time, federal–state relations remain complex and fraught, typified by fear of cost-shifting, with Commonwealth funding used to overcome state underservicing. Even positive strategies to overcome this divide, such as funds pooling, are difficult to implement.

Strong, visionary political leadership is needed to achieve a more coordinated approach to health service delivery, characterised by enhanced governance, management and community involvement. A national rural and remote health policy and plan is required to guide the ongoing development of health services. At a time when national health care reform is a priority, the establishment of a single Australian health system, operationalised at a regional level, would obviate much of the inefficiency and poor coordination that currently characterise health care in rural and remote areas, and contribute to eliminating existing health status differentials between cities and the bush.

  • John Wakerman1
  • John S Humphreys2
  • Robert Wells3,4
  • Pim Kuipers1
  • Judith A Jones2
  • Philip Entwistle1
  • Leigh Kinsman2

  • 1 Centre for Remote Health, Flinders University and Charles Darwin University, Alice Springs, NT.
  • 2 School of Rural Health, Monash University, Bendigo, VIC.
  • 3 Menzies Centre for Health Policy, Australian National University, Canberra, ACT.
  • 4 College of Medicine and Health Sciences, Australian National University, Canberra, ACT.


We are grateful to the Australian Primary Health Care Research Institute for its support of this study, and to the members of our reference group: Professor Ray Pong (Centre for Rural and Northern Health Research, Canada), Professor Martha Macleod (University of Northern British Columbia, Canada), Kim Snowball (Department of Health, Western Australia), Alma Quick (Office of Rural Health, Australian Government Department of Health and Ageing [DoHA]), Gordon Gregory (National Rural Health Alliance), Dr Ian Cameron (New South Wales Rural Doctors Network) and Mark Thomann (Office for Aboriginal and Torres Strait Islander Health, DoHA).

Competing interests:

None identified.

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