Opinion: Rural focus needed for mid-term health reform review

The mid-term review of the National Health Reform Agreement Addendum (2020–2025) (NHRA) — an agreement between the Australian Government and all state and territory governments to improve health outcomes for Australians — is underway. The National Rural Health Alliance (the Alliance) has, like many others, been asked to provide input.

A key point the Alliance made in the review was the need for investment in primary health care in rural, regional and remote areas, so that people receive preventative health care and early diagnosis and treatment to ensure that they spend less time in hospitals.

This is well resonated in the recent findings by Nous Group, released by the Alliance, showing alarming statistics of the lack of funding to improving rural health care. The findings are based on the access of patients to health care.

The report, titled ‘Evidence base for additional investment in rural health in Australia’, reflects that despite the 1.4 times of high disease burden in rural populations, they experience a shortfall of $6.55 billion in health expenditure, translating to $848.02 less expenditure per person, per year.

The findings are astounding and place a mirror on the rest of Australia and policymakers to ensure that people who live in rural Australia have access to the same health care that their urban counterparts enjoy.

Need for a genuine partnership

Without the genuine partnership of the federal, state and local governments, as well as considerations for grass root developed solutions — as envisioned by the NHRA — Australia will continue to have an inequitable healthcare system. It will be a system where 30% of Australia’s population is a second-class citizen; receiving less, paying more (sometimes double or triple), purely because of the tyranny of distance, despite their economic contribution to Australia’s wealth.

We need a genuine and holistic approach to solve the rural health access crisis in Australia.

Most people living in rural, remote and regional Australia are impacted by a triple disadvantage.

 

Poorer access

The Nous report shows that the number of in-hospital, non-admitted patient encounters that include procedural clinics, diagnostics and outpatient clinics, increases with remoteness, with remote and very remote regions experiencing an average of 1.92 encounters per person, compared to major cities at 1.27 encounters per person. This is partly because rural and remote communities often do not have access to primary care and may wait until their health becomes worse before they see a clinician.

In 2022, nearly 60,000 people living in Australia did not have access to general practitioner services within a 60-minute drive from their residence. The figures demonstrate that patients arrive for treatment at a tertiary stage of disease, rather than having had preventative health care earlier. As such, per-capita, age-standardised, non-admitted patient care expenditure increases with remoteness to reflect this higher use and cost of health service delivery.

In non-admitted patient care, rural populations experience higher emergency department encounters per 1000 people compared to urban (423 vs 309). Consistent with other hospital expenditure, per-capita, age-standardised emergency department expenditure increases with remoteness, as shown in Table 5 of the report. Rural Australians also receive less expenditure per capita for use of private hospitals. This figure declines significantly with remoteness despite a percentage of rural people paying private health insurance as a safeguard.

Rural health care at the community level must be viewed from a whole-of-system perspective, ie, within a multidisciplinary healthcare approach given the limited resources, which allows locally led innovation and solutions which are not ‘withdrawn’ at the whim of policymakers or funders.

Stakeholder involvement

State and federal governments must work together with stakeholders at the local level, rather than communities being crippled by funding and governance mechanisms as well as red tape, which do not allow for planning that fits the community and geographic challenges and locally led options.

Rural communities need to see a commitment for real reform and funding of primary health care delivery and service access. It requires a willingness by governments to accept that rural primary care services need different models of funding outside of the city, to make them economically viable and functioning to meet community population health needs.

The Alliance noted in our response to the NHRA mid-term review that many rural hospitals and Aboriginal Community Controlled Health Organisations (ACCHOs) receive much needed block or support funding to keep them viable, as they work in regions where markets have failed or are thin.

However, this funding also needs to keep pace with the rising costs of fuel and energy, the tyranny of distance, food and clinical materials. More locum doctors are needed and their costs have increased dramatically in recent years. This has not been factored in when decisions are made on funding.

Employment conditions

Employment conditions for health professionals can vary dramatically across state- and government-funded as well as primary healthcare services.

Further work is needed to ensure transferability of employment conditions and equitable rates of pay so that one part of the health system is not competing with others, especially in rural communities where the human resource is scarce.

The mid-term review of the NHRA provides the opportunity for policy planners and all levels of government to identify gaps and prioritise funding measures to improving health care in rural Australia. This is taxpayers’ money, after all, and they deserve the funding regardless of who funds their health care. The Alliance calls on all stakeholders to not miss out on this opportunity to make real change so that rural Australians enjoy the same healthcare benefits as their city counterparts.