In a recent edition of the Journal for Rural Health1, Thomas Ricketts cautioned rural health advocates to avoid being perceived as a special interest group seeking special advantages, but rather be known as advocates of policies that appeal to society's sense of fairness. Australia is known internationally for its sense of 'a fair go', so it may be an apt setting for a test case of Ricketts' assertion.
Earlier this week, five Australian rural health advocacy groups jointly released a collaborative policy document, a 10-point plan that aims to provide strategies towards better health in rural communities2. One test of fairness is whether there is good evidence to support the proposals. Examining the 10-point plan on the basis of this criterion may also be a useful way of determining the relevance of a Journal, such as Rural and Remote Health, to such policy development.
The first strategy advocates for small rural hospitals to become centres of quality health care and training and for policy makers to consider their impact on health outcomes and community sustainability, not just the financial bottom line. Walters et al.3 and Rosenthal et al.4 have shown how small rural hospitals can become centres of excellence in medical education in Australia, and Doekson and Schott5 have demonstrated how the health sector provided nearly 20% of the non-farm employment in a group of typical small rural counties in the USA.
The second strategy emphasises a strategic approach to support procedural rural medicine. This strategy's emphasis on the importance of appropriate training is supported by Levitt's6 comprehensive review of the literature on maintenance of procedural competency.
The third strategy emphasises enhanced linkages between visiting medical specialist services and high quality local practitioners. This was a key finding from Rankin's rural consumer focus groups7 and Greenwood and Cheers'8 study of female practitioners and can be seen as a cost-effective solution in communities that cannot be expected to provide the high level of infrastructure that Katekar9 identified as necessary to support resident specialist services.
The fourth strategy called for higher payments for rural doctors reflecting the increased complexity of medical services in this context. Recent Australian research strongly supports the notion that rural medical work is more complex than that undertaken by urban peers10 and Ryan-Nicholls'11 work shows historically how lack of adequate funding has incapacitated rural health services in Canada.
The fifth and sixth strategies call for greater support for collaboration with rural nurses and Aboriginal Health workers in primary health care teams. Brown's12 study of falls in rural communities has shown the value of a collaborative multi-disciplinary approach to preventative medicine and Shephard's13 work with an Indigenous community has shown the effectiveness of an Aboriginal Health Worker led approach to detection and management of renal disease. Battye and McTaggert's work would suggest that extension to collaboration with other allied health disciplines should also be effective14.
The seventh strategy suggests the creation of a locally managed recruitment fund to purchase practice facilities and suitable housing to attract doctors and their families. Veitch and Crossland15 have shown the importance of a sense of financial, social and professional security in retaining doctors in rural Australia, and Couper's16 observations of the South African recruitment environment are strongly supportive of the need for adequate accommodation for rural doctors and their families.
The eighth strategy emphasises the need for improved access to broadband services in rural communities, a strategy supported by Peterkin's17 work in Scotland and currently being advanced in Canada18.
The next strategy is for greater incentives, especially through bonded scholarships, to encourage medical students to choose rural medicine. Dunbabin and Levitt's19 international review, and Alkan et al's20 report from Kyrgyzystan, outline evidence of the influence of undergraduate initiatives on career choice, whilst Wilkinson21 has cautioned that there are still considerable gaps in the evidence base in relation to workforce policy and student initiatives. There will be great interest in following the students enrolled in such bonded schemes.
Finally, the tenth strategy moves to support the place of overseas trained doctors in the Australian health system through appropriate mentorship and supervision. This journal has highlighted the ethical dilemma22 of recruiting overseas trained doctors to work in wealthy countries, but given the reality of such doctors forming the overwhelming majority of recruits to Australian rural practice over the last 5 years, it seems only right to give them a 'fair go' and support them through the professional, bureaucratic and cultural challenges23 that they face.
Readers from outside Australia must remember that this most recent collaborative policy statement is made in the context of over a decade of substantial rural health policy developments, so these strategies are not intended to be seen as the first priorities for a de novo rural health policy. Some may also see them as inappropriate, or unachievable for their country. International debate on the priorities in rural health policy can only be collectively helpful, and Rural and Remote Health welcome such contributions and the debate they raise.
Collectively these ten steps do, however, demonstrate the principle that integration is a key to workforce policy. Integration across the disciplines and between generalists and specialists; integration across the varying needs at the different life-stages of medical practice; integration of education, clinical service and career choice incentives; the persuasiveness of an integrated approach from lobby groups to policy development; and a recognition of the integral link between the social, cultural and economic resources of rural communities and their success in recruiting and retaining a high quality health workforce.
This brief overview of these ten strategies also demonstrates the need for high quality research to underpin rural health policy development. Rural and Remote Health salutes the authors of the sited articles. Their work enlightens our understanding of this particular initiative, and reaffirms the Journal's commitment to providing an easily accessible, peer-reviewed international evidence base for rural and remote health. Whilst the need for better evidence remains, for both practice24 and policy21, it is reassuring to find that the body of published work is providing a quiet but useful voice of reason to support the fanfare of rhetoric that is required to move political systems to give rural communities a fair go. May this Australian experience be a catalyst for similar action around the world.
Paul S Worley
Rural and Remote Health
1. Ricketts TC. Arguing for Rural Health in Medicare: A Progressive Rhetoric for Rural America. The Journal of Rural Health 20: 43-51. (Online) 2004. Available: http://www.nrharural.org/pagefile/JRH-Current.html (accessed 30 March 2004).
2. Rural Doctors Association of Australia, Australian Local Government Association, Country Women's Association of Australia, Health Consumers of rural and remote Australia, National Farmers Federation. Good health to rural communities - a 10-point plan. (Online) 2004. Available: http://www.rdaa.com.au/uploaded_documents/ GOOD_HEALTH_TO_RURAL_COMMUNITIES_final.pdf (accessed 30 March 2004).
3. Walters LK, Worley PS, Mugford BV. Parallel Rural Community Curriculum: is it a transferable model? Rural and Remote Health 3, 236 & 262 [Correction]. (Online), 2003. Available from: http://rrh.org.au (accessed 30/3/04).
4. Rosenthal DR, Worley PS, Mugford B, Stagg P. Vertical integration of medical education: Riverland experience, South Australia. Rural and Remote Health 4, 228. (Online), 2004. Available from: http://rrh.org.au (accessed 30 March 2004).
5. Doeksen GA, Schott V. Economic importance of the health-care sector in a rural economy. Rural and Remote Health 3, 135. (Online) 2003. Available from: http://rrh.org.au (accessed accessed 30 March 2004).
6. Levitt LK. Use it or lose it: is de-skilling evidence-based? Rural and Remote Health 1, 81. (Online), 2001. Available from: http://rrh.org.au (accessed 30 March 2004).
7. Rankin SL, Hughes-Anderson W, House J et al. Rural residents' utilisation of health and visiting specialist health services. Rural and Remote Health 2, 119. (Online), 2002. Available from: http://rrh.org.au (accessed accessed 30 March 2004).
8. Greenwood G, Cheers B. Doctors and nurses in outback Australia: living with bush initiatives. Rural and Remote Health 2, 98. (Online), 2002. Available from: http://rrh.org.au (accessed 30 March 2004).
9. Katekar LV. Value of hospital-employed medical officers in rural Australia. Rural and Remote Health 3, 150. (online), 2003. Available from: http://rrh.org.au (accessed accessed 30 March 2004).
10. Humphreys JS, Jones JA, Mildenhall MPJD et al. The influence of geographical location on the complexity of rural general practice activities. Medical Journal of Australia 2003; 179: 416-420.
11. Ryan-Nicholls KD. Health and sustainability of rural communities. Rural and Remote Health 4, 242. (online), 2004. Available from: http://rrh.org.au (accessed 30 March 2004).
12. Brown M. Health-care choices - the right of all Australians. Rural and Remote Health 2, 162. (Online), 2002. Available from: http://rrh.org.au (accessed 30 March 2004).
13. Shephard MDS, Allen GG, Barratt LJ et al. Albuminuria in a remote South Australian Aboriginal community: results of a community-based screening program for renal disease. Rural and Remote Health 3, 156. (Online), 2003. Available from: http://rrh.org.au (accessed 30 March 2004).
14. Battye KM, McTaggart K. Development of a model for sustainable delivery of outreach allied health services to remote north-west Queensland, Australia. Rural and Remote Health 3, 194. (Online), 2003. Available from: http://rrh.org.au (accessed 30 March 2004).
15. Veitch C, Crossland LJ. Exploring indicators of experiential place integration in a sample of Queensland rural practitioners: a research note. Rural and Remote Health 2, 111. (Online), 2002. Available from: http://rrh.org.au (accessed 30 March 2004).
16. Couper ID. Recruiting foreign to South Africa: difficulties and dilemmas. Rural and Remote Health 3, 195. (Online), 2003. Available from: http://rrh.org.au (accessed 30 March 2004).
17. Peterkin GSD. Proposed telemedicine booth. Rural and Remote Health 2, 142. (Online). 2002. Available from: http://rrh.org.au (accessed 30 March 2004).
18. Ryan-Nicholls KD, Racher FE. Investigating the health of rural communities: toward framework development. Rural and Remote Health 4, 244. (Online) 2004. Available from: http://rrh.org.au (accessed 30 March 2004).
19. Dunbabin JS, Levitt L. Rural origin and rural medical exposure: their impact on the rural and remote medical workforce in Australia. Rural and Remote Health 3, 212. (Online) 2003. Available from: http://rrh.org.au (accessed 30 March 2004).
20. Alkan ML, Oztek Z, Akylbekov IK. Reforms on medical education: the case of Kyrgyzystan. Rural and Remote Health 2, 127. (Online), 2002. Available from: http://rrh.org.au (accessed 30 March 2004).
21. Wilkinson D. Evidence-based rural workforce policy: an enduring challenge. Rural and Remote Health 3, 224. (Online) 2003. Available from: http://rrh.org.au (accessed 30 March 2004).
22. Couper I, Worley PS. The ethics of international recruitment. Rural and Remote Health 2, 196. (Online) 2002. Available from: http://rrh.org.au (accessed 30 March 2004)
23. Couper ID. Working abroad. Rural and Remote Health 2, 197. (Online) 2002. Available from: http://rrh.org.au (accessed 30 March 2004).
24. Dunbar J. Evidence-based rural general practice: still the evidence is largely absent. Rural and Remote Health 1, 198. (Online) 2001. Available from: http://rrh.org.au (accessed 30 March 2004).