Rural-proofing our health services

Once upon a time it was certainly healthier to live in the country. Urban dwellers generally lived in conditions markedly inferior to those of their country cousins who enjoyed clean air, fresh food and a comparatively unpolluted environment. This reality has changed with the great public health measures of the last two centuries, and - at least in more developed countries - better economic conditions in big cities. Urban hospitals and public and private health services have all been available for a long time.

The pendulum has now swung the other way. Data shows that both Indigenous and non-Indigenous Australians who live in the bush experience worse health and die younger than their city counterparts. The reasons for this swing are diverse, although often inter-related: a rural culture which supports risky behaviours; industry (including agriculture) with the highest rates of injury; and low levels of education and income are all implicated. Less access to health services is obviously a factor too.

While some of these issues are not easily addressed through policy frameworks, the distribution of health services is - or should be. Although most rural health services (including the number and distribution of GPs and hospitals) just grew haphazardly in response to the inclinations or needs of individuals or specific communities, for some time now they have been subject to layers of federal, state and district authorities all of which would profess to operate within policy frameworks. These frameworks must be presumed to focus on optimising health and minimising illness.

So how is it that people who live in rural and remote Australia miss out when it comes to the programs which implement these policies? At present, the benefits of three major national health programs - Medicare, the Pharmaceutical Benefit Scheme (PBS) and the Private Health Insurance Subsidy - are not shared equitably between urban and rural Australia.

Shortfalls in the GP and specialist workforce resulting from short-sighted policies a decade ago, exacerbate other factors which constrain the recruitment and retention of rural doctors. The Australian Health Care Agreements which provide about half the funding for all public hospitals also do nothing to preserve local hospitals for rural communities.

Medicare is predicated upon equity. Yet the third of the population that lives outside the cities receives only 21 per cent of Medicare-funded services. Calculations based on 1999-2000 statistics suggest that while the average per capita Medicare benefit per annum paid in metropolitan areas was $125.59, it was $84.91 in other parts of the country.

Which means that about $221,009,162 of the Medicare levy collected in non-urban areas flowed back to subsidise metropolitan services. The figures will have changed since then, but not the proportions or the inequity. The main reason for this is the shortage of doctors available to provide services in the country. Similarly, rural access to medicines subsidised through the PBS is limited by the number of doctors available to prescribe them.

There is good international evidence that heavy reliance on private sector funding of health services results in higher overall public expenditure on health. Current public policies to support private health insurance are not only costly, and of doubtful effectiveness - if the aim is to support private hospitals in order to ease the load on public hospitals, they are downright unfair.

Private hospitals are naturally more likely to be located where there are large numbers of patients. Obviously this is not in smaller towns. Incomes are generally lower in rural areas and apart from the ever-rising expense of private health insurance, there is little point in taking it out when the chances of using it are slight. In 2003, it was estimated that regional and rural Australia received approximately $100 million less of the private health insurance rebate than it would have if federal funding had been allocated on a per capita basis.

So much for the uneven impact of the major funding programs. As anyone who reads a newspaper knows, there are not enough doctors in the bush. Canberra-based consultancy Access Economics has estimated that nearly half (44 per cent) of the rural population lives in an area of severe medical workforce shortfall.

Fertility rates are higher in rural Australia and state and federal governments are loudly supporting regional and rural sustainable growth which can only be done if the population of working (and reproductive) age people is retained and increased. Yet, over 120 rural maternity units have been closed in Australia over the last decade.

How does this happen in a nation where we love our sunburnt country and have enshrined a fair go for all in our policy rhetoric?

To begin with the basics, only a third of Australian voters live in the bush. Perhaps another conscience vote would allow state representatives of rural electorates to cross the floor to defend the rights of their constituents to an equitable share of healthcare funding. It seems that few decision makers, elected or otherwise, do much differential analysis that looks at the impact of wider measures on rural areas.

Second, health policy is often focused on current price rather than long-term cost, particularly when those costs may seem more social than financial. The opening paragraph of the health section of the recent COAG communiqué could only come from a political culture clinging to economic rationalism:

Preventing ill health and improving physical and mental health helps people to participate in work and makes them more productive when they do …

The waste and inefficiency of the federal-state division of power and responsibility is now debated almost daily. On at least one point, most Australians wholeheartedly agree with Federal Minister Tony Abbott: this unfortunate and inefficient system “annoys the hell out of” pretty well everyone. The estimated cost of the inefficiencies and duplication in the health sector is around $1.1 billion a year. The paralysing cost- and blame-shifting that that engenders is equally appalling.

Finally, these factors have combined with history and geography to create a maze of wicked problems and perverse incentives. We have come a long way from the somewhat mechanistic context in which Rittel and Webber formulated their concept of “wicked problems” in the ’70s, but there are several ways in which the unintended inequity of Australian healthcare policy fits their criteria. Certainly, it results from “a set of interlocking issues and constraints which change over time, embedded in a dynamic social context”.

In policy terms, the complexities of wicked problems are often further complicated by information gaps, un-coordinated possibly conflicting policy instruments, high resource needs, a lack of clear prioritisation, and decision making processes which pay little regard to local definitions of need or approaches to solutions.

These can all be seen by taking the survival of small rural maternity units as an example. The reasons for the epidemic of closures mentioned above are seldom transparent, but they usually cluster around three themes: safety, cost and workforce. Yet studies here and in Canada, the country where rural health conditions are most comparable to ours, have produced risk-adjusted data that shows small rural maternity units have obstetric outcomes that are as good as, if not better than, those in larger hospitals. Travelling on country roads to distant hospitals to give birth increases, rather than decreases, risks to mother and baby.

The savings made by the relevant health authority are often at the expense of people: the mothers and families who have to travel, the local communities from which spending is diverted and the bigger hospitals that seldom get an increase in resources commensurate with their increased workload.

Closing small maternity units contributes to workforce difficulties as local midwives and GPs are de-skilled. Obstetric work is a major source of job satisfaction to those country doctors who still deliver babies. Some of them give up rural practice altogether if they are forced to give that up.

Workforce issues also provide a prime example of conflicting policies. The Federal Government’s Strengthening Medicare initiatives included a welcome recognition of the role of rural doctors and provided subsidies to support their ongoing upskilling. This excellent measure was designed to keep procedural GPs - those who do obstetrics, surgery or anaesthetics - in the bush. By definition, these services are provided in hospitals. So at the same time as the federal, and some state governments, are working to support the procedural workforce, the maternity units and rural hospitals where they can use their skills are being closed by state authorities.

The federal share of the funding which supports these hospitals is transferred to the state through the Australian Health Care Agreements. These agreements include penalty clauses which allow money to be withheld if conditions, including maintaining levels of service delivery, are not met. As cutting funds back is hardly likely to increase service delivery, for practical as well as political reasons, these penalties are never imposed. No wonder Tony Abbott said he felt he had “the prerogative of the eunuch” when it came to these agreements. He has foreshadowed that the 2008 Agreements are likely to be very different.

We must all hope so. But in what way will they be different?  Things won’t change much for rural communities if metro-centric concepts and interests continue to dominate policy development. The UK-based National Health Service has developed a concept of rural-proofing which we could well adopt here. It involves rigorous and informed scrutiny of policy frameworks and models of service delivery to ensure they not only meet the needs of people who live in rural and remote areas but that first they do them no harm.