Shining a Light on rural and remote health

Thursday, 15 August 2013

Election campaigns provide a good opportunity for putting issues of concern before political parties and the public. But it's a congested space - particularly at a time when both sides of politics are unwilling or unable to make any commitments which will result in net increases in spending.

In 2010-11 spending in Australia on health was a little more than $130 billion - or 9.3 per cent of total gross domestic product. It is important not to think of this amount as what is spent by the Australian Government. Its share was 44 per cent, with state, territory and local governments contributing 26 per cent and private health insurers 8 per cent.

Out-of-pocket payments by individuals provided over 18 per cent of total health spending - more than in many other developed countries.

Hospitals take 40 per cent of health spending, medical services 18 per cent, medicines 14 per cent, and dental services 7 per cent. Cardiovascular conditions account for 11 per cent of health spending, followed by oral health care (10 per cent) and mental health conditions (8 per cent).

In the context of these national figures, consider the following characteristics of rural and remote areas:

  • their people have lower incomes and fewer educational opportunities;
  • their people are, on average, older;
  • a greater proportion of them live with a disability;
  • the more remote the area, the higher the proportion of Aboriginal and Torres Strait Islander people - a group whose members experience very particular health and lifestyle challenges;
  • the health workforce is insufficient to meet need and poorly distributed, with shortages becoming worse with increasing remoteness;
  • health risk factors are higher: for instance people in rural and remote areas have higher rates of smoking, higher rates of risky drinking and higher rates of obesity; and
  • remote areas are places where market systems do not work well: the number of people is lower, information poorer, communications less effective and doctors fewer, so Medicare doesn’t work as well in the country as in the city.

Consider just two headline indicators.

  • A white man born in north-west New South Wales can expect 11 years less in life expectancy than his cousin born in a wealthy Sydney suburb.
  • Each and every year there is a primary care deficit of over $2 billion experienced by the people of rural and remote Australia. It is made up largely of the net balance between a large Medicare deficit, a PBS deficit and greater use made of hospitals.

For these reasons the Alliance believes that its case is just and urgent. That is why we seek a place in the priority considerations of the political parties in this election campaign and for the future.

The Vision of the National Rural Health Alliance is good health and wellbeing in rural and remote Australia. The Alliance has a particular commitment to equal health for country and city people by the year 2020.

We are working to meet this commitment in four ways:

  • by improving knowledge and understanding of the health and wellbeing of people in rural and remote areas;
  • by being an effective advocate on issues affecting the health of rural people;
  • by working in collaborative relationships, including with our 34 Member Bodies; and
  • by ensuring the Alliance continues to be an effective, sustainable and ethical organisation.

For the 2013 election campaign, the Alliance has chosen to Shine a light on seven domains related to rural and remote health and wellbeing. We are unapologetic about the strong emphasis we have on the social determinants. The seven are as follows.

1. Local health needs must determine rural service planning and delivery.

Through the needs assessment work of Medicare Locals, small area needs are now known for the first time. Local leadership on health services works well and leads to the efficient use of resources. For these reasons the Alliance strongly supports the principles embedded in Medicare Locals. We want local communities to be able to determine the mix of health services delivered locally. This will help lead to funds flowing according to health need - not according to location, or the ability to pay, or the availability of health professionals.

2. There must be integrated rural training pathways for rural and remote health professionals.

Integrated rural training pathways - including for Aboriginal and Torres Strait Islander Australians - can be built around the UDRHs, Rural Clinical Schools and regional universities. These pathways will deliver good value and rewarding rural practice to those who engage with them.

Establishment of such pathways for professionals in all disciplines will lead to a better distribution of the health workforce beyond the cities. Inter-professional learning will help. Training and supporting students who grew up in rural and remote areas to become health professionals will help. Special support for Aboriginal and Torres Strait Islander people to become health professionals will help. Providing good infrastructure and trained health service managers will help.

3. In aged and disability care, government should build on reform to enable rural people to live better.

Aged and disability care needs to build on recent reforms, through continued commitment to expenditure, building on local voices and providing necessary infrastructure.

All of us must be encouraged by the strong bipartisanship which exists in relation to DisabilityCare Australia and the new aged care legislation. From the point of view of rural and remote clients of these two sets of services, the new regimes promise additional resources, better access and improved care. So what we seek are two things: first, continued commitment to the foreshadowed expenditures in these areas; and second, a strong focus on listening to the clients who live in rural and remote areas and their families and acting on what is heard to ensure that the new systems work well for rural and remote clients.

4. There must be continued support and resourcing for the Close the Gap Campaign.

This must surely be one of the pre-eminent areas in which, for reasons of justice, conscience and good governance, there should be bipartisan political support. We are calling on governments to recognise ownership of the Close the Gap Campaign by the Aboriginal and Torres Strait Islander health sector and the vital complimentary work of COAG's Closing the Gap. With bipartisan support and holistic action across all three levels of government, Australia can commit successfully to fixing the shameful inequality in Aboriginal health.

It is unacceptable that remote Aboriginal infants start life so far behind and, as a consequence, exhibit complex chronic disease so early in their lives.

Aboriginal leadership works and the nation and the government must increase it and use it.

5. Funding must provide equitable education and health choices for rural people.

Good education is the platform for much economic, social and health benefit, and rural families have for too long been missing out. For this reason the principle that rural schools, like those elsewhere, will be funded on the basis of educational need secures the Alliance’s strong support. The Alliance believes that improved educational outcomes in rural areas will also underpin improved health literacy and pave the way for more effective health promotion and illness prevention in rural and remote areas. As the evidence on smoking shows, finding a way to improve the effectiveness of health promotion activity in rural and remote areas is a matter of great importance and urgency.

6. Government should lead development of fixed and mobile connectivity for rural living, prosperity and health.

Rural people value the social, economic and health benefits that can be delivered by access to fit-for-purpose high-speed broadband – whatever the means of delivery. Affordable connectivity, at the same price as in the major cities, is a prerequisite for equivalent wellbeing. In the health sector, mobile telephony often provides the platform for eHealth records, telehealth, personal communications and personalised apps for health information and managing health risks and conditions. Young professionals will not choose to live and work in rural and remote areas unless they have good connectivity.

7. Government should build the economic future of rural communities.

Economic development and education are the best medium term fixes for rural health and wellbeing. We will be scrutinising parties' commitments to the economic development of rural and remote areas. Where climate change is concerned, we are interested both in minimising and managing the adverse effects, and in capturing the economic opportunities that will be available in rural and remote areas. Diversification of Australia's economic base can be supported through the development of renewable energy industries and rural and remote areas will be their location.

In each of these areas there are a raft of specific proposals we hope the next government will adopt. Some of them can be implemented at low cost, while others will require new allocations. For instance:

Local control: We want improved capacity for Medicare Locals to fund salaried staff where needs analysis shows they are necessary. Rural and remote Australia may not always have the population to support private practice, and yet still needs allied health, pharmacists, GPs and nurse practitioners. Early intervention for the maintenance of good mental health for rural and remote youngsters is likely to be a priority in a number of areas.

Integrated training pathways: Provide internships for allied health, hospital pharmacy and midwifery to encourage graduates to consolidate and stay in rural areas after their clinical placements.

Disability and aged care: Establish and test models through FACHSIA to show how community workers or allied therapy assistants can provide rehabilitation and disability care in more isolated communities.

Closing the Gap: Invest in Regional Eye Health Co-ordinators based in Aboriginal Medical Services – ideally based on Aboriginal Health Workers trained to provide services.

Fixed and mobile connectivity: Commit to high speed broadband - 'the infrastructure of the century' - for the 7 per cent of homes and businesses that are hard to connect but in great need.

Improved rural educational outcomes: Set a COAG target for significant improvement in Year 12 completions for young people living in rural and remote areas and trajectory into tertiary or trade training.

Rural economic development: Commit to a plan for the economic diversification of regions identified as having a narrow economic base.

Let it never be said that the people of rural and remote areas want for specific ideas about how their wellbeing can be assured - or for the determination to play their full part in leading and supporting those ideas.

Lesley Barclay
NRHA Chairperson

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