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Rural-proofing our health services

By Susan Stratigos - posted Tuesday, 28 March 2006


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 …

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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.

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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.

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Article edited by Ro Mueller.
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About the Author

Susan Stratigos is the Policy Advisor for the Rural Doctors Association of Australia. These are her views and not those of the organisation.

Creative Commons LicenseThis work is licensed under a Creative Commons License.

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