Access and equity in the provision of general practitioner services for women in Australia

OBJECTIVE: To assess geographical equity in the availability, accessibility and out-of-pocket costs of general practitioner (GP) services for women in Australia. METHOD: Data on general practice consultations during 1995 and 1996 for women aged 18-23 years (n = 5,260), 45-50 years (n = 7,898) and 70-75 years (n = 6,542) in the Australian Longitudinal Study on Women's Health were obtained from the Health Insurance Commission. A sub-study of 4,577 participants provided data on access to health services. RESULTS: Older women were more likely to have no out-of-pocket costs for their GP consultations, but in all age groups, the proportion was lower in rural areas than in urban areas (older age: 60% rural areas, 76% capital cities; mid-age: 24% rural areas, 40% capital cities; young age: 35% rural areas, 52% capital cities). Among mid-aged women, the median out-of-pocket cost per consultation ranged from $2.11 in capital cities to $6.48 in remote areas. Women living in rural and remote areas gave lower ratings for the availability, accessibility and affordability of health services than women living in urban areas. CONCLUSIONS: This study has shown a striking gradient in financial and nonfinancial barriers to health care associated with area of residence. IMPLICATIONS: The geographical imbalance in the supply and distribution of GP services in Australia has long been recognised but inequities in the affordability of services must also be addressed. Longitudinal survey data and Health Insurance Commission data provide a means to evaluate policies designed to improve access to health services in rural and remote areas.     

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability

STUDY OBJECTIVE: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. DESIGN: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. SETTING: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. PARTICIPANTS: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. MAIN RESULTS: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. CONCLUSIONS: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.     

Immigrants and equitable health-care delivery in rural areas

ABSTRACT: In response to settlement patterns in Australia, most immigrant specialist services and programs have been developed in metropolitan locations and large provincial cities. However, immigrants have also settled in smaller numbers in country locations. It is of concern, therefore, to consider how responsive and equitable health-care services can be delivered in country regions when immigrants do not reach the critical mass that would warrant the development of specialist services. This paper draws on a consultation conducted in South Australia to propose a way forward in linking country health services with local immigrant communities and immigrant specialist services in cities.     

headspace: National Youth Mental Health Foundation: making headway with rural young people and their mental health

Mental health is the number one health issue affecting young people in Australia today, yet only one in four of these young people receive professional help. Approximately 14% of 12- to 17-year-olds and 27% of 18- to 25-year-olds experience mental health problems each year. However, many do not have ready access to treatment or are reluctant to seek that help. These issues might be exacerbated in the rural and remote regions of Australia where sociocultural barriers such as stigma, lack of anonymity and logistic difficulties including cost and availability of transport can hinder young people accessing mental health services. headspace: the National Youth Mental Health Foundation has been funded to address these issues. headspace will provide funding for the establishment of communities of youth services across Australia, provide national and local community awareness campaigns and plans, establish a centre of excellence that will identify and disseminate evidence-based practice in addressing youth mental health issues, and translate findings into education and training programs that are targeted at service providers to work with youth mental health. The communities of youth services will build the capacity of local communities to identify early, and provide effective responses to, young people aged 12-25 years with mental health and related substance use disorders. Specific approaches in rural, regional and remote areas will be developed as well as specific programs to involve young Indigenous people.     

Key considerations in delivering appropriate and accessible health care for rural and remote populations: Discussant overview

Objective:  To provide an overview of papers discussing optimal service delivery models for rural and remote Australia.
Design:  A synthesis of overarching considerations guiding rural and remote health service policies.
Setting:  Small rural and remote communities in Australia.
Participants:  Invited delegates attending the Inaugural Rural and Remote Health Scientific Symposium in Brisbane 2008.
Main outcome measures:  Key issues underpinning health service provision for small rural and remote communities.
Results:  The formulation and implementation of effective health service provision policies must be underpinned by overarching health goals, agreed health service requirements, recognition of how rural and remote health contexts impact upon health service provision and the constraints limiting health service responses.
Conclusion:  Systemic change is required in order to ensure equitable access to health care services in small rural and remote communities.     

Health and the 1999 Regional Australia Summit

The Regional Australia Summit brought together 282 invited delegates from all parts of Australia. The aim of the Summit was to develop partnerships between the government, business and community sectors to deliver a better future for regional, rural and remote areas facing significant change. Health was one of 12 themes discussed at the Summit. Five key health priorities were identified; the need to change the dominant metropolitan mind-set, improve access to health-care services, improve service provision and workforce training, ensure equitable resource allocation, and adopt a population health approach. The ultimate success of the Regional Australia Summit will be gauged over time by the extent to which the health, wellbeing and prosperity of rural, remote and regional Australians has been improved, and existing problems and issues addressed. Nonetheless, the Summit is a significant event because it addresses issues at the highest level of government, emphasises coordination and the adoption of an intersectoral approach, and recognises the need to empower local communities and build partnerships between the government, corporate and community sectors.     

Rural health's demographic destiny

Demography is the study of the size and composition of populations. Populations change size through births, deaths and net-migration. Over time, mortality, fertility and migration patterns create populations that may be large or small, young or old, growing or declining. Rural and remote Australia has a unique demography that determines its health problems and health service needs. The tendency of young adults to leave rural and remote areas for cities means that they leave behind communities which are, on average, older than those found in the cities. Rural and remote women have slightly more children at significantly younger ages, but because of out-migration, the actual number of babies born outside of the cities is smaller than would be expected. Most rural and remote areas already have a high proportion of their population over 65 years old. Many communities with an older population are declining in absolute numbers but the need for health services may be greater than required for smaller, younger communities. In contrast to the trends in total population, the rural and remote Aboriginal and Torres Strait Islander population is growing rapidly. This is the result of a higher proportion of young people, higher fertility rates and lower rates of moving to cities. The health characteristics of rural and remote Australia increasingly reflects the higher morbidity of Indigenous and older people. Responding to this demographic destiny is the present and future challenge.     

Rating access to health care: Are there differences according to geographical region?

OBJECTIVE: To report on satisfaction with access to health care in Queensland focussing on regional differences. METHODS: A sub-sample of 4440 respondents with no history of cancer from the Queensland Cancer Risk Study who completed a self-administered questionnaire was used for this study. MAIN OUTCOME MEASURES: Perceptions of overall difficulty gaining access to health care and ratings of access to various health care services by region. RESULTS: Queenslanders living outside major cities reported less satisfaction with access to various aspects of health care services. Age was associated with more favourable ratings of health care access. CONCLUSIONS: Despite public health efforts to increase service provision throughout Queensland, health care access is still rated relatively less favourably by Queenslanders in regional and remote parts of the state. Implications: Identifying which services are difficult to access and why will assist public health policy makers in improving health service accessibility.     

国外社区双向转诊模式及其对我国的借鉴

由于医疗机构间缺乏行之有效的双向转诊制度,导致我国城市综合性医院承担了大量常见病、多发病的诊疗任务,而基层医院和社区医疗服务机构却需求萎靡,就诊量过少,严重浪费卫生资源。英国、美国、澳大利亚和巴西等国家转诊制度对我国社区医疗服务体系的建立和医疗机构问如何有效地进行双向转诊有着很强的借鉴意义。特别是其完善的全科医生制度和社区医疗服务体系是我国在大力发展社区医疗服务和建立顺畅的双向转诊制度中可以借鉴的有效模式。     

Mapping oncology services in regional and rural Australia

Objective: To map clinical oncology services in regional and rural Australia. Design and setting: A self‐administered survey was sent to 161 regional hospitals administering chemotherapy (RHAC) in Australia. RHAC were categorised by state, Hospital Peer Group and the Australian Standard Geographical Classification (ASGC) Remoteness Areas classification. Main outcome measure(s): Survey data provided percentage and aggregate figures about availability of medical, radiation and surgical oncologists, chemotherapy nurses, breast cancer nurses, palliative care physicians and allied health professionals according to remoteness and state. Chemotherapy prescribing practices, adherence to occupational health and safety guidelines and availability of multidisciplinary clinics were also explored. Results: A 98% survey completion rate was achieved. Significant deficiencies in service provision were identified in RHAC. Only 21% of RHAC reported a resident medical oncology service, 7% had a radiation oncology unit, and 6% had a resident surgical oncologist. Only 24% of RHAC reported a dedicated palliative care specialist and 39% identified a dedicated oncology counselling service. Other issues included administration of chemotherapy by nurses outside a recognised facility or by nurses without recognised oncology training, limited availability of funded breast care nurses and lack of multidisciplinary clinics. Conclusion: Survey data highlight marked cancer service deficiencies in rural and regional Australia. It is not unreasonable to conclude that these deficiencies might contribute to poorer outcomes for cancer patients living in these areas. The results suggest the need for short‐ and long‐term measures to improve access to best‐practice cancer services for patients living in regional, rural and remote areas of Australia.     

Harnessing the social capital of rural communities for youth mental health: an asset-based community development framework

In Australia, we are facing a period of mental health reform with the establishment of federally funded community youth services in rural areas of the country. These new services have great potential to improve the mental health of rural adolescents. In the context of this new initiative, we have four main objectives with this article. First, we consider the notion of social capital in relation to mental health and reflect on the collective characteristics of rural communities. Second, we review lessons learned from two large community development projects targeting youth mental health. Third, we suggest ways in which the social capital of rural communities might be harnessed for the benefit of youth mental health by using asset-based community development strategies and fourth, we consider the role that rural clinicians might play in this process.     

Perceptions of health care quality in Central America.

OBJECTIVES: To examine user perceptions of health care delivery in selected rural and urban areas of three Central American countries. DESIGN: Three focus group studies were conducted in 1997-98 in Honduras, Costa Rica, and Panama. In each selected region, 10 to 15 groups met to discuss health services available, access to and use of the services, satisfaction with different aspects of care and suggestions for improvement. SETTING: Regions chosen represented the poorest areas in each country and the dominant health care systems in Central America: the Ministry of Health system and the Social Security system based on mandatory contributions. PARTICIPANTS: 351 residents from rural and urban communities represented different genders, ages, occupations, health, and socio-economic status. RESULTS: Participants considered private care to be the best, but too costly. Their main preoccupations focused on prompt access to trusted physicians, effective and inexpensive medication, and quality attention in public hospitals. Hondurans favor the personal care offered in public clinics and rural hospitals, and hope for improved medical services. In Costa Rica and Panama, users prefer Social Security clinics for the medical specialties and perceived sophisticated technology, despite delays and poor attention. The rural poor, especially indigenous people, voice basic needs with little regard for quality. CONCLUSIONS: Health care quality is extremely variable in the three regions, requiring increased community participation to improve. Focus groups offered important, confidential and cost-effective information on quality and breadth of health care delivery and should be part of quality monitoring initiatives.     

Determinants of health provider selection in a West Dallas, Mexican-American community

The focus of health policy has shifted since the late 1970s from emphasizing "equal access" to now considering cost-efficiency in health care as vital. This paper analyzes factors related to the selection of a health provider in a low-income community in West Dallas, Texas. Specifically, it looks at two sets of characteristics (population at risk and health provision system) as they influence the choice of hospital outpatient services as a source of health care. When subjected to multivariate analysis, it was found that health system characteristics, and convenience measures in particular, had the greatest impact on consumers' choice of these services. The notion of "equity" for future health planners concerned with providing services to low-income communities will best be served by the more efficient use of existing hospital clinics rather than by continuing to provide health care systems that serve the poor exclusively.     

Health status differentials across rural and remote Australia

This paper describes mortality and disease patterns across five broad remoteness categories of Australia, with reference to the context in which those outcomes develop and are treated.
Health and its outcomes become worse as remoteness increases. Some of this phenomenon reflects proportionally greater numbers of Aboriginal and Torres Strait Islander people in remote areas coupled with their poorer overall health outcomes; however, mortality for non-indigenous people is clearly higher outside compared with inside major cities. Migration of people seeking services likely reduces the size of interregional health disparity.
Poorer health outcomes stem from worse risk factor profiles and average lower levels of income and of education, poorer physical and financial access to services, higher occupational and environmental risk, as well as factors unique to Aboriginal and Torres Strait Islander health. Little is known about the health benefits of living outside major cities.
Diseases of the circulatory system and injuries account, respectively, for 40% and 18% of the excess mortality outside major cities.
Death rates are declining over time in all (particularly remote) areas, but rates of death due to certain lung diseases in rural women are not, and rates of suicide have increased in remote areas.
Ostensibly, prevalence of mental ill-health appears roughly similar in all remoteness areas. Dental health is poorer and disability is more prevalent outside major cities, as are a range of infectious diseases.
Although pertinent, the effects on rural health of climate change and resource degradation generally have not been addressed in this paper.     

ANTHILL AND OTHER INJURIES: A CASE FOR MOBILE ALLIED HEALTH TEAMS TO REMOTE AUSTRALIA

ABSTRACT: Remote rural districts of Australia can continue to expect a loss of public services due to the low population density and migration loss. However allied health services such as physiotherapy, are cost-effective services that are in demand in remote Australia. This paper was derived from a report to the Rural Health Policy Unit of Queensland Health that granted funds for a mobile allied health team to visit the remote western shires of the Peninsula and Torres Strait health region. By presenting an outline of an unusual group of parochial occupational injuries it can be shown that there is indeed both a considerable demand for allied health services and these services can be provided to remote communities by a mobile remote outreach service for a reasonable cost.     

Improving transfer of mental health care for rural and remote consumers in South Australia

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.     

Improving equity in the provision of primary health care: lessons from decentralized planning and management in Namibia

This paper draws lessons from a review of primary health care services in Windhoek, the capital of Namibia, undertaken by a regional health management team. The review was carried out because of perceived increases in workload and inadequate staffing levels, arising from the rapid expansion of the city associated with inward migration. A survey of the utilization of government clinics was used to develop a more equitable allocation of primary health care services between localities. The survey revealed disparities between patterns of utilization of the services and the allocation of staff: the poorer localities were relatively underprovided. Decisions made centrally on resource allocation had reinforced the inequities. On the basis of the results of the review, the regional health management team redistributed nursing and medical staff and argued for a shift in the allocation of capital expenditure towards the poorer communities. The review demonstrates the potential for regional and provincial health management teams to make effective assessments of the needs of their populations and to promote the equitable delivery of primary health care services. In order to achieve this they need not only to become effective managers, but also to develop population-based planning skills and the confidence and authority to influence the allocation of resources between and within their regions and provinces.     

Critical health infrastructure for refugee resettlement in rural Australia: Case study of four rural towns

Objective: To explore the reported impact of regional resettlement of refugees on rural health services, and identify critical health infrastructure for refugee resettlement. Design: Comparative case study, using interviews and situational analysis. Setting: Four rural communities in New South Wales, which had been the focus of regional resettlement of refugees since 1999. Participants: Refugees, general practitioners, practice managers and volunteer support workers in each town (n = 24). Results: The capacity of health care workers to provide comprehensive care is threatened by low numbers of practitioners, and high levels of turnover of health care staff, which results in attrition of specialised knowledge among health care workers treating refugees. Critical health infrastructure includes general practices with interest and surge capacity, subsidised dental services, mental health support services; clinical support services for rural practitioners; care coordination in the early settlement period; and a supported volunteer network. The need for intensive medical support is greatest in the early resettlement period for ‘catch‐up’ primary health care. Conclusion: The difficulties experienced by rural Australia in securing equitable access to health services are amplified for refugees. While there are economic arguments about resettlement of refugees in regional Australia, the fragility of health services in regional Australia should also be factored into considerations about which towns are best suited to regional resettlement.     

The contribution of occupational therapy to the fabric of Australian rural and remote communities

Social justice has provided a basis for the underlying values of occupational therapy in Australia. In the 1990s, changes in health issues and delivery of services are causing occupational therapists to reconsider their values and the ways they deliver their services. By any measure, the health status of individuals in rural and remote communities of Australia is poorer that their urban counterparts. The issues associated with the poor health status of these communities will best be addressed through a combined strategic approach by governments, organizations and professional groups, including occupational therapy. Identification of some of the key issues affecting the supply of occupational therapists in rural and remote communities and how they might be addressed are discussed. It is proposed that the development of cohesive national strategies and actions aimed at enhancing the contribution of occupational therapy to rural and remote communities ought to include, among other things, adoption of the primary health care approach, fundamental changes in the education and preparation of practitioners for practice, and identification of competencies and standards for effective rural and remote practice.     

Differential effects on socioeconomic groups of modelling the location of mammography screening clinics using Geographic Information Systems

OBJECTIVE: To evaluate spatial access to mammography clinics and to investigate whether relocating clinics can improve global access. To determine whether any change in access is distributed equitably between different social groups. METHODS: The study was undertaken in Perth, Western Australia in 1996. It was an analysis of travel distances to mammography clinics, comparing distances to the pattern of existing clinics and modelled relocated clinics. The study population was the 151,162 women aged 40-64 years resident in Perth in 1991. RESULTS: Overall travel distances to the existing clinics was reduced by 14% when a GIS system was used to relocate them so as to minimise the travel distance for all women. The travel distance of the most disadvantaged groups fell by 2% and by 24% for the least disadvantaged group. CONCLUSIONS: GIS modelling can be used to advantage to evaluate potential locations for screening clinics that improve the access for the target population, however global analysis should be supplemented by analysis of special groups to ensure that no group is disadvantaged by the proposal. IMPLICATIONS: If new technology is not used to evaluate the placement of health services, population travel distances may be greater than necessary, with possible impacts on attendance rates.