Bridging the health equity gap with a strong rural resolve


By Joe Mihaljević, HDR Director of Health, NSW*
Wednesday, 08 February, 2023


Bridging the health equity gap with a strong rural resolve

The health sector is transforming at speed and scale. The need for more equitable, resilient hospital infrastructure and integrated health precincts underpinned by flexibility, technology and personalisation is reshaping the trajectory of our healthcare system and challenging many of our preconceived notions as health architects, designers and planners.

As a design firm, this presents us with a once-in-a-generation opportunity to think about healthcare delivery in a new way and leverage our specialist healthcare planning capabilities to re-address some of the current inequalities that exist across rural, regional and remote Australia. By continuing to challenge our thinking, we can lay the foundations for a new era of regional healthcare architecture — one that is community-driven and better connected to the healthcare equity gulf across our island nation.

An evolving landscape

Currently, around 7 million people — or 28% of the Australian population — live in rural and remote areas (ABS 2022). Sadly, COVID-19 has disproportionately impacted many of these communities who are, for the most part, already susceptible to unique challenges presented by their geographic location, whether that be accessibility to public transport, limited resources or lack of digital connectivity.

In a healthcare context, research indicates that people from these areas also have limited access to primary healthcare services, which in turn increases rates of hospitalisation, death and injury compared to metropolitan areas (Australian Institute of Health & Welfare).

As a result, in November 2021 the NSW Government committed $500 million to a rural health boost and, more recently, the state governments came together to sign a new Memorandum of Understanding with the Commonwealth that enables the continuation of Medicare bulk billing and increases funding for additional primary care services in rural and regional areas. This sets the stage for unparalleled regional healthcare growth and development to meet community needs now and into the future.

Social determinants of health

Moving forward, our capacity to design and deliver cutting-edge, equitable healthcare infrastructure will be largely defined by our understanding of the social determinants of health, defined by WHO as “the non-medical factors that influence health outcomes”.

This means that continued sector transformation is becoming increasingly dependent on the reversal and mitigation of some of the inequalities that exist today — whether that be health, education, income, transport, housing or employment — in order to create integrated, intergenerational and inclusive communities that can thrive in their own right.

As healthcare architects, if we can successfully overlay these ever-evolving drivers of health with environmental, social and governance practices, we will be well-placed to deliver life-changing infrastructure and improve population health across regional and rural Australia.

A rural resolve

As a global organisation with an interconnected knowledge exchange, we often look to our global counterparts for insights and lessons that can be applied locally and layered with our own geographical nuances. An example of this is when rural hospitals shut down across the US in unprecedented numbers in 2020, leaving 60 million people — nearly one in five Americans — without access to medical care in their communities.

Amid this crisis HDR Design Director Tom Trenolone conducted a global study, ‘Rural Resolve’, to explore how innovative design interventions could improve the health and wellbeing of rural hospital providers, patients and the wider community during challenging times.

The team of specialist designers and planners not only considered how new concepts in master planning could become a catalyst for reversing inequalities, but whether design interventions such as a reimagined main street could indeed be an economic engine to providing more convenient health services.

Eight ideas

In the book Rural Resolve, eight ideas were identified that, when considered in unison, could help to transform regional and rural communities.

  1. Reimagine the main street to include healthcare services alongside, or as an alternative to, isolated, edge-of-town hospitals.
  2. Redefine health care so it is not defined by a monolithic hospital but a series of social supports, with a healthcare provider at the centre, within a main street.
  3. Provide access to high-quality parks and recreation spaces adjacent to healthcare facilities, as a critical lifeline to patients.
  4. Rethink indoor amenities to increase visitor and community engagement, such as theatres, community halls, basketball courts and swimming pools, therefore incentivising traditional retail services to return to the town’s main artery.
  5. Transform streets and existing infrastructure to meet growing demand for open space and community activities, such as dining, farmers’ markets and art shows.
  6. Find ways to bring education and tourism into towns, such as inviting guest lecturers to visit a town’s schools or senior facilities to present about their fields or research.
  7. Reinforce intergenerational connections by relocating the town’s retirement facility to the town centre.
  8. Use places of worship as gathering places that provide opportunities for patient education about healthy living and disease prevention through seminars, or for free health screening.

These ideas have been applied to HDR-designed projects such as Grand Island Regional Medical Centre and Intermountain Spanish Fork Hospital.

From theory to practice

Transferring HDR’s global Rural Resolve from theory to practice and applying it to our own healthcare infrastructure here in Australia has been a challenging but rewarding feat — and demonstrates just how influential our borderless, global-meets-local approach can be to the design and delivery of innovative healthcare infrastructure.

The HDR-designed regional NSW hospital developments Dubbo Base Hospital Redevelopment and Western Cancer Centre Dubbo — are examples of this theory in practice and verify just how interdependent progressive healthcare design and thriving rural communities can be.

As part of the NSW Government’s rural health boost, our dedicated healthcare team provided specialist master planning and design to deliver industry-leading community healthcare facilities that integrate Connecting with Country design principles and bring First Nations knowledge and biophilic design to the forefront of our design outcomes.

In another example of bridging the healthcare gulf, we have recently been appointed to design and deliver two regional hospitals in the Murrumbidgee Local Health District. The Temora Hospital Redevelopment and Finley Health Service Redevelopment will collectively enhance the delivery of health care across the region and future-proof care for the local community.

Projects like these, as well as our Grafton Hospital Redevelopment with Woods Bagot, and the design and delivery of 10 community hospitals across Victoria in collaboration with DesignInc, not only mark a key milestone in the advancement of regional health care but allow us to apply our global study to address the social determinants of health and bridge the gap in health care across the east coast.

Care model innovations

New care model innovations are currently transforming the way regional and rural health care is being designed and delivered — and ensuring better access to specialist services normally only available to metro patients.

For us, designing for inclusivity and equity is becoming increasingly important, as is the need to embed telehealth and virtual care within hospital facilities to improve workflows, enable personalisation and promote value-based health care that extends beyond the walls of the hospital.

Looking ahead, if we continue to design hospitals that embrace notions of Rural Resolve, we will be well-positioned to build smarter, more resilient regional and rural areas that advance health equity and create happy, healthy communities for many years to come.


*Joe Mihaljević is a Registered Architect with almost 33 years of experience on major health projects in Australia and New Zealand.

Mihaljević's project leadership experience covers a diverse range of health projects in both private and public sectors. He has particular skills in managing User Group Consultations to deliver a schematic design layout and is adept in transitioning to managing consultant groups in a collaborative manner with health clients, project managers and contractors alike in delivering quality functional health facilities.

Images: Supplied

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