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?
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