The great health divide: Why rural Australians have poorer health outcomes than their urban counterparts
In mid-2009, an estimated 31 per cent of the Australian population (6 886 600 people) lived outside major cities – in regional centres, rural and remote areas.1
Australians living outside major cities have significantly poorer health and lower life expectancy than their urban counterparts.
National Health Performance Authority data show life expectancy at birth in 2011 ranged between 82.0 and 83.6 years in metropolitan catchments, 81.4 to 81.6 years across catchments in regional hubs and 78.3 to 80.6 years in rural areas. Moreover, there were an estimated 115 avoidable deaths per 100 000 people per annum in metro areas, versus 171 per 100 000/year in regional hubs and 244 per 100 000/year in rural areas.2
Lesley Barclay, Professor of Rural Health at the University of Sydney, wrote in a 2014 article in The Conversation that these stark differences are ‘driven by the distribution of health risk factors and how they interact with the nature of rural and remote places’.
Professor Barclay pointed to many factors that differentiate urban Australians and those living outside major cities, such as fewer years of education and lower incomes; higher rates of disability, smoking and risky alcohol consumption; poorer access to the internet and mobile phones; and relatively poor access to health professionals.
This article outlines the most important contributors to the discrepancy between urban and regional, rural and remote health in Australia, and looks at what is being done to bridge these gaps.
Chronic diseases such as diabetes, mental illness and cancer are responsible for nine out of 10 deaths in Australia, and substantially reduce many Australians’ quality of life.3 They are also economically significant: eliminating chronic diseases could increase the workforce and Australia’s productivity by 10 per cent.4
In 2007–08, people who lived outside major cities were 23 per cent more likely than their urban counterparts to have back pain, 20 per cent more likely to have asthma, and 27 per cent more likely to be deaf.1 They were slightly (8 per cent) more likely ever to have had a mental disorder.
Notably, people aged 16–85 years who lived outside major cities were 25 per cent more likely to have experienced a substance use disorder (overwhelmingly, alcohol) in their lifetime; this was driven almost entirely by greater probability among men.1
Tobacco smoking and risky alcohol consumption are key risk factors in the development of chronic disease, and both are more prevalent in rural and regional Australia. In 2007–08, people aged 15 years and older who lived outside major cities were 30 per cent more likely to be daily smokers, and 32 per cent more likely than their metropolitan counterparts to drink alcohol at levels deemed damaging to health in the long term.1 They were more likely
to experience alcohol-related harm through violence, acute and chronic health problems, and drink driving.5
Overweight and obesity
In 2007–08, women aged 15 years and older who lived outside major Australian cities were 19 per cent more likely to be overweight or obese than women in metropolitan areas. The corresponding figure for men was 8 per cent. 1 Interestingly, data from the Australian Bureau of Statistics show no significant difference in physical activity levels that might explain this gender difference.
On a positive note, people aged 15 years and older living outside major cities were 55 per cent more likely to consume fruit and vegetables in line with national recommendations than their urban counterparts.
Physical and environmental factors
People living outside major cities in 2008 were three times more likely to die because of a transport accident than those living in major cities.1 This is due in part to the relatively large distances non-metropolitan Australians must travel to work, shop and visit family and friends, but might also be attributable to higher average speeds on rural roads, poorer road conditions and longer waiting times for emergency services following an accident.
Long-term health conditions due to injury were 30 per cent more likely in non-metropolitan Australians than in those who lived in major cities – probably as a result of participation in agriculture, forestry, mining and other physically demanding industries endemic to rural and regional areas.1
Regional, rural and remote regions of Australia have higher proportions of Indigenous Australians than metropolitan areas, and Indigenous people continue to have poorer health on most measures than non-Indigenous people.
Life expectancy for Indigenous boys and girls born between 2010 and 2012 was 69.1 years and 73.7 years, respectively, compared with 79.7 and 83.1 years for non-Indigenous boys and girls.6
Indigenous Australians have higher death rates than non-Indigenous Australians across all age groups: over the period 2007–11, Indigenous people aged 35–44 years died at about five times the rate of their non-Indigenous counterparts.6 The gap in death rates is driven by circulatory disease (22 per cent of the gap), followed by diabetes and other endocrine, metabolic and nutritional disorders (14 per cent of the gap), which are five times more likely
to kill non-Indigenous than Indigenous Australians.6
Access to health services
Data from the Australian Bureau of Statistics show that, in 2009,
23 per cent of Australians living in outer regional and remote areas felt they waited longer than was acceptable for an appointment with a general practitioner (GP), compared with 16 per cent of those living in major cities.7 People living in outer regional and remote areas were also four and a half times as likely as those living in major cities to travel over one hour to see a GP.
- 58 GPs (versus 196 in capital cities)
- 589 registered nurses (versus 978 in major cities)
- 64 allied health workers (versus 354 in major cities).8
The National Strategic Framework for Rural and Remote Health (NSFRRH), released in 2011, aims to ‘improve health outcomes and return on investment for rural and remote Australians’ – meaning people living in all areas outside Australia’s major cities.9 It presents a strategic vision for health care for Australians living in regional, rural and remote areas, and supports a national approach to policy, planning, design and delivery of health services.
The goals of the NSFRRH are for rural and remote communities to have:
- improved access to appropriate and comprehensive health care
- effective, appropriate and sustainable health care service delivery
- an appropriate, skilled and well-supported health workforce
- collaborative health service planning and policy development
- strong leadership, governance, transparency and accountability.
The NSFRRH is a ‘vision’ document: it has no specific funding for its implementation, and was never intended to guide a coordinated stream of activity that could be monitored and evaluated. Nonetheless, numerous initiatives in rural health, designed to increase the size of the workforce and improve coordination, are aligned with the NSFRRH.
Primary Health Networks
Following a review of Medicare Locals, in 2014 the Australian Government began funding organisations to establish and operate 31 Primary Health Networks (PHNs) nationally. The grant for each PHN is based on a combination of population, rurality and socio-economic factors.
PHNs are designed to improve patient outcomes by reducing fragmentation of care. General practice is central to the PHN concept.10
PHNs, including those servicing rural and remote areas, must have GP-led Clinical Councils and representative Community Advisory Committees to report to their Boards on locally relevant clinical and consumer issues. They must work closely with public and private hospitals, Aboriginal Medical Services, nurses, allied health providers, health training coordinators, state and territory government health services, aged care providers and private health insurers.10
On 1 July 2015, Western Victoria PHN replaced Barwon, Grampians and Great South Coast Medicare Locals to cover the same geographical footprint as Western Alliance. Regional centres have been established in Ballarat, Geelong, Horsham and Warrnambool, and the PHN has identified as its principal focus the four strategic pillars of regional health planning, commissioning, GP and primary care development, health system integration and clinical services.
Incentives for rural GPs
The Rural Health Workforce Strategy (RHWS) includes the General Practice Rural Incentives Programme (GPRIP), which provides substantial financial incentives for GPs working in rural, regional and remote areas. GPs working in rural or remote areas, and in (or near) towns with populations up to 50 000 are eligible for payments on a sliding scale based on geographical remoteness/population size and years of service.
Like the GPRIP, the Bonded Medical Places (BMP) Scheme aims to increase the numbers of doctors in areas experiencing shortages. The BMP Scheme funds universities to offer 600 additional medical school places each year for students willing to commit to training and/or working in a district of workforce shortage (DWS).
Twenty-five per cent of all first-year, Commonwealth-supported medical school places are allocated to the BMP Scheme. Candidates commit to working in their chosen DWS area (outer metropolitan, rural and remote areas) after graduating, for a period of time equal to the duration of their medical degree.
The Victorian Health Priorities Framework 2012–2022, released in May 2011, is the foundation for the Rural and Regional Health Plan (RRHP). It promises better long-term planning across the health system, and to address health differences between rural Victoria and metropolitan Melbourne. Like the NSFRRH, the RRHP outlines a broad vision for rural health, but it also sets out many specific, funded initiatives, such as:
- an increase in the number of registered midwives in rural areas
- establishment of a GP – Rural Generalists Program
- support for dental practitioners to relocate to rural and regional communities
- recruitment of hundreds of new ambulance staff, enabling many rural and regional branches to be upgraded
- establishment of Mobile Intensive Care Ambulance units in major regional centres
- numerous expansion and infrastructure projects at regional hospitals. 11
These projects are currently underway.
Other RRHP priorities are being tackled by Victorian local governments under The Public Health and Wellbeing Act 2008 (which mandates that Councils must ‘seek to protect, improve and promote public health and wellbeing within the municipal district’12). Two examples from the western region follow.
Although Corangamite’s population reports substantially better health and wellbeing than the State average and performs well on other indicators such as unemployment, public safety and community engagement, the region has lower life expectancy than the Great South Coast and Victoria as a whole. It also has higher proportions of mental health clients and people reporting risky alcohol consumption, and higher rates of overweight and obesity.13
Corangamite Shire Council developed its 2013–2017 Municipal Public Health and Wellbeing Plan (HWP) in partnership with the four other Great South Coast Councils – Moyne, Warrnambool, Southern Grampians and Glenelg. 13
Corangamite’s HWP includes 80 actions, 79 of which were completed or commenced in 2014–15. These included:
- a community asthma awareness and prevention event in partnership with the Asthma Foundation
- an event designed to increase awareness of alcohol-related issues, in collaboration with the Youth Council
- continuing implementation of the KidsMatter Mental Health and Wellbeing Framework
- hosting training in the prevention of violence against women, in partnership with the Municipal Association of Victoria and Women’s Health and Wellbeing Barwon South West
- numerous initiatives aimed at increasing participation in physical recreation.14
Horsham Rural City
Horsham Rural City residents fare better than the Victorian average in many respects, such as self-reported wellbeing, citizen engagement and infant breastfeeding and immunisation rates. However, they fare worse with respect to educational attainment, meeting physical activity guidelines, violence against women and percentage of drug and alcohol clients.15
In response to these problems, Horsham Rural City Council’s HWP lists seven main priorities for action: social connection; physical activity; healthy eating; prevention of violence against women; healthy, safe and liveable environments; education and economic development; and public health and safety.
The City’s annual report for 2014–15 notes the following health-related initiatives.
- New provisions to support staff affected by family violence and training in the prevention of family violence in 2015–16. Strongly support and participation in White Ribbon, the world’s largest male-led movement to end men’s violence against women.16
- Participation in drug and alcohol awareness training and development of drug and alcohol management plans for the city.
- Leadership of a consortium involving the Victorian State Government, other Grampians councils and Grampians Tourism to develop the 100-kilometre Grampians Peaks Trail, a major resource for local recreation and tourism. Stage one of this long-distance walking trail opened in May 2015.16
New modes of health service delivery
More efficient and effective implementation of existing models that show evidence of success is obviously worthwhile, but innovation in health services must also play a part in improving rural health.
An initiative that could address several of the NSFRRH’s and RRHP’s priorities is the development of the role of physician assistant. Conceived in the United States in the 1960s specifically to improve access for people living in rural and remote areas to health care, a physician assistant is:
- a professional who works as a member of a multidisciplinary team under the delegation and supervision of a medical practitioner. The PA role is generalist in nature, with a focus on primary, emergency and preventative care. However, under delegated practice a PA may specialise, depending on experience and the scope of clinical practice of the supervising medical practitioner.17
As Professor Stephen Duckett wrote in The Conversation in 2014, the slowly growing numbers of physician assistants graduating from several Australian universities represent ‘an important step in improving access to care, especially in rural and remote Australia’.
However, the concept faces opposition from both the Australian Medical Association and the Australian Medical Students Association, which believe that physician assistants would compete with trainee doctors for scarce clinical placement and training positions,18 and that doctors should remain the primary focus of health workforce policy.19 Nevertheless, Queensland Health now allows physician assistants to prescribe, refer patients to specialists and order diagnostic tests.17 Other jurisdictions have yet to follow suit.
Support for the physician assistant concept and similarly novel service approaches to rural health has been building for some time. Professor Jane Farmer of La Trobe University (The Conversation, 4 September 2012) noted that ‘rural is not simply urban with trees and animals,’ arguing that ‘focusing on traditional doctors and nurses is outdated and unsuitable due to modern health needs and demographics’.
Professor Farmer’s work in Scotland showed that rural people want health practitioners who combine some of the skills of nurses, doctors and health promotion advisers; the professionals most resembling this ideal were physician assistants, nurse practitioners and paramedics.
Managing community participation in decision-making about rural health poses many challenges.20 Professor Farmer’s current research is helping rural people in Victoria and Queensland to design their own approaches to dental and oral health, and will recommend how the results can be translated into practice.
Whether physician assistants will ever play a major role in Australia is difficult to predict, but there’s little doubt that new modes of delivering services are needed if the rural health workforce is to be expanded and the health of rural and remote populations is to be improved. As the NSFRRH recognises, commitment and coordination at federal, state and territory levels will be crucial.
The role of research
Health and medical research generate vital new knowledge. In health care, research enables us to deliver the best possible, cost-effective patient care, and this is particularly critical in regional and rural/remote communities. Clinical research provides patients with access to new treatments, interventions and medicines. Research has other benefits, too: it enables better understanding or management of health conditions; provides opportunity for meaningful contact between patients and health professionals, and collaboration between clinical and academic researchers; can generate income for a practice or health service; and can provide an enhanced career path for health professionals seeking intellectual challenge and reward.
Improving the health and wellbeing of regional and rural communities is the principal focus of Western Alliance, which is supporting research through funding initiatives, education and training in research, facilitating collaboration between clinical and academic research, and highlighting quality research relevant to regional and rural/remote health. The Third Annual Symposium, to be held 8–9 September 2016 provides an opportunity to showcase health and medical research underway in the western region.
- Australian Bureau of Statistics (ABS) (2011) Health outside major cities, Australian Social Trends, March 2011. Cat no. 4102.0, Canberra: (ABS).
- National Health Performance Authority (NHPA) (2013) Healthy communities: Avoidable deaths and life expectancies in 2009–2011, Sydney: NHPA.
- McNamara K, Knight A, Livingston M, Kypri K, Malo J, Roberts L, Stanley S, Grimes C, Bolam B, Gooey M, Daube M, O’Reilly S, Colagiuri S, Peeters A, Tolhurst P, Batterham P, Dunbar JA and De Courten M (2015) Targets and indicators for chronic disease prevention in Australia, Australian Health Policy Collaboration (AHPC) technical paper No. 2015-08, Melbourne: AHPC.
- Business Council of Australia (BCA) (2011) Selected facts and statistics on Australia’s healthcare sector, Melbourne: BCA.
- Miller PG, Coomber K, Staiger P, Zinkiewicz L and Toumbourou JW (2010) Review of rural and regional alcohol research in Australia, Australian Journal of Rural Health, 18: 110–17.
- Australian Institute of Health and Welfare (AIHW) (2014) Australia’s health 2014.
- ABS (2011). Health Services: Use and patient experience. Australian Social Trends, March 2011. Cat no. 4102.0, Canberra: ABS.
- AIHW (2009) Health and community services labour force 2006. National health labour force series no. 42. Cat no. HWL 43. Canberra: AIHW.
- Commonwealth of Australia (2012) National strategic framework for rural and remote health.
- Australian Government Department of Health (2016) Primary health networks grant programme guidelines.
- Victorian Government (2012) Victorian health priorities framework 2012–2022: Rural and regional health plan.
- Victorian Government Department of Health (2013) Guide to municipal public health and wellbeing planning.
- Corangamite Shire Council (2013) Corangamite Shire health and wellbeing plan 2013–2017.
- Corangamite Shire Council (2015) Annual report 2014–2015.
- Horsham Rural City Council (2013) Health & wellbeing plan 2013–2017.
- Horsham Rural City Council (2015) Annual report 2014–2015.
- Queensland Health (2016) Physician assistant – Clinical governance guideline. Brisbane: Workforce Strategy Branch, Department of Health.
- MJAInSight (2011) Turf war over physician assistants.
- Australian Medical Students Association(2015) Policy document: Physicians assistants policy.
- Kenny A, Farmer J, Dickson-Swift V and Hyett N (2015) Community participation for rural health: A review of challenges, Health Expectations, 18: 1906–17.