“Better health in the bush”: why we urgently need a national rural and remote health strategy

What are the problems in rural health service delivery and what can we do about them?

For decades, the Australian Government has been wrestling with how to “fix the rural health problem”. Long‐standing problems of workforce shortages and maldistribution, difficulties with recruitment and retention, and inadequate access to, and availability of, appropriate services persist.1 These contribute to the poor health status of many non‐metropolitan Australians, especially Aboriginal and Torres Strait Islander populations, despite the fact that governments spend millions of dollars annually on specific rural and remote health programs.2

While these problems seem intractable, we contend that the lack of progress in improving rural and remote health outcomes results largely from the lack of an overarching strategy that draws on available evidence to guide its development, implementation and evaluation. Without an overarching blueprint, many current programs reflect often ad hoc, loosely articulated political responses to concerns of vested interests, constituents and other players.

Twenty‐five years ago, against a background of limited research evidence, the first National Rural Health Strategy identified the need for “innovative models of rural service delivery … to meet the diverse health care needs of rural communities”.3 Today, we have comprehensive evidence about what service models work in different contexts and why, but no national strategy using this knowledge to scale up local successes and guide national health system development.

Rather than pursuing more innovative services, we need to use existing evidence to inform a cohesive, whole‐of‐system approach to improve rural and remote health outcomes. Accordingly, we suggest that research evidence addressing five key questions provides the fundamental content basis for a national rural and remote health strategy, the implementation of which will result in greater equity of access to health care for all Australians and improved health outcomes. The five key questions are:

• How do we get health professionals to work in rural areas and retain them?
• How do we ensure that high quality, comprehensive primary health care (PHC) services are accessible locally?
• How do we ensure that these services are sustainable?
• How much should these services cost?
• How do we ensure that these services meet community needs?

Evidence‐based approaches to rural health problems

While health outcomes result from many social and economic determinants, our focus here is specifically with health system responses to rural health needs. Given the higher rates of hospitalisation and declining PHC use associated with increasing remoteness in Australia, the need to strengthen the PHC system in non‐metropolitan regions is irrefutable.2

Getting and retaining the right health workers in the right places are key to meeting workforce requirements and maximising the availability of efficient and effective PHC services.1 Two decades of rural medical workforce research clearly show that an integrated medical training pipeline — based on student selection with a focus on rural origin; early and continuing exposure to rural practice; vocational training based in rural areas, including rural generalist training appropriate to community needs; and professional and family support after take‐up of rural practice, including appropriate remuneration, professional development, locum relief, social support and other incentives — is effective in delivering appropriately trained doctors and retaining them.4,5,6,7

Access to core PHC services at times of need is essential to promoting and maintaining optimal health, especially in large geographical areas where populations are sparsely distributed. Australian research has identified these core services, shown how local delivery varies with population size and location,8 and described a typology of service models that, with competent regional governance, can optimise access to care in remote and rural communities.9

Sustaining high quality, comprehensive PHC services with the capacity to meet changing community health needs will only occur if, in addition to workforce, several other essential requirements are met: strong leadership, competent management and appropriate governance; adequate physical infrastructure, including accommodation and information technology services; and service coordination.10 When federal, state, territory and local government policies align, these requirements can more easily be met, thereby ensuring service viability and continuity of care.

Rural and remote communities in Australia generally exhibit lower socio‐economic status and a disease burden far above that of capital cities. Distance, population dispersion and disease burden result in higher costs of both providing and accessing appropriate PHC care compared with metropolitan areas. Underutilisation of Medicare, pharmaceutical and allied health services in the bush has been estimated at $2 billion.11 Overcoming this deficit requires a needs‐based funding mechanism that takes into account the real costs of service provision in sparsely populated areas, targeted loadings reflecting the different scope and contexts of practice (eg, rural generalist), the need for on‐call and locum relief, and ensuring succession planning. Evidence indicates that when these conditions are met, staff retention is optimised, and the savings associated with reduced reliance on fly in‐fly out and short term staffing are considerable.12

Only with strong community engagement in all aspects of health service provision will services be congruent with needs and expectations, especially in Indigenous communities, in which cultural safety considerations are foremost. Evidence from studies in remote Western Australia and rural Victoria demonstrated the health benefits of direct community involvement, and showed how a community‐led, culturally safe PHC service significantly increased access for both preventive and acute health needs.13,14

Policy implications for a national rural and remote health strategy

Extant evidence shows how to ensure an appropriate workforce and maximise access to viable, high quality, affordable, comprehensive PHC services that meet community needs. This evidence provides the basis for informing the key policy pillars of a national rural and remote health strategy.

First, we need integrated rural training pipelines for non‐medical health professions, together with an effective, flexible, bundled retention strategy,7 in order to prepare and retain a fit‐for‐purpose workforce.

Second, the diversity of rural and remote Australia needs to be reflected in an agreed set of core services that all communities should be able to access locally,8 agreed practice principles governing effective visiting services to communities lacking in situ services,15 a range of models appropriate for specific contexts,9 and a regional governance approach to optimise service coordination and integration.16

Third, sustainability of rural and remote PHC services is underpinned by adequate funding, including for workforce support; efficient financing mechanisms; good governance, inspirational leadership and effective service management; adequate physical and information technology infrastructure that enables ongoing monitoring and assessment of performance and quality; and service coordination.9

Fourth, a national, needs‐based funding mechanism is required for PHC delivery in rural and remote areas, which ensures equitable resource allocation and takes into account both different models of health care delivery and the complexity of existing financing mechanisms, including Medicare, capitated payments, salaried staff at Aboriginal Community Controlled Health Services and state‐funded PHC services.

Finally, effective PHC requires substantive community input into all aspects of the planning and provision of PHC services through regional governance structures, which take into account existing Aboriginal community‐controlled governance structures.

At present, despite this considerable evidence of what works well and where in rural and remote communities, risk‐averse governments have been reluctant to formulate a national strategic framework, preferring a patchwork of political responses, mostly without rigorous evaluation of their effectiveness. When an evidence‐based strategic approach has been adopted, such as in the development and implementation of the Modified Monash Model as the basis for resource distribution to rural and remote areas of Australia, there have been significant system efficiencies and benefits.17

Why we need a national rural and remote health strategy

Our five evidence‐based policy pillars could collectively underpin a national rural health strategy. Current evidence clearly indicates that a national rural and remote health strategy is required to “dam the trickle upstream rather than contending with the deluge downstream” by focusing on comprehensive PHC. Ensuring the provision of accessible, affordable, acceptable and sustainable PHC services is the key to minimising the unacceptable rural–urban health disparity.

An overarching national strategy is needed so that governments, health authorities and services can formulate their rural and remote health policies in a manner that is consistent with evidence of what works well where, and with agreed national priorities and goals. A comprehensive strategy provides a blueprint for the coordination of efforts across different levels of government. Furthermore, such a strategy will link the essential components that together contribute to the provision of effective PHC services in rural and remote Australia. The strategy will also systematise community participation in order to ensure responsiveness to changing community needs. Finally, a national strategic approach will provide a clearly documented basis for monitoring and evaluating the role and contribution of each policy intervention in order to maximise the effectiveness of PHC programs.

Conclusion

In summary, using available evidence, a national strategy can improve access to high quality, comprehensive PHC in a way that results in greater efficiency, improved equity and more effective service provision that will bring about improved health outcomes in rural and remote areas, which has been the quest of the Australian Government for the past 25 years.