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Women
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POLICY ON QUALITY AND EFFECTIVENESS OF
RURAL HEALTH CARE, 2002
Contents
Preface
The Wonca Policy on Quality and Effectiveness of Rural Health Care has
been developed by the Wonca Working Party on Rural Practice.
The goal is to provide
a framework to encourage the development of direct and indirect targets
for and measures of the quality and effectiveness of rural health care.
On behalf of the Wonca
Working Party on Rural Practice, we hope this document stimulates your
thoughts and assists you in working towards the WHO target of "Health
for all people" and the Durban Declaration "Health for all rural
people by 2020".
Professor James
Rourke
Professor Roger Strasser
Dr Chris Simpson
Editors
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1.
EXECUTIVE SUMMARY
This policy is a contribution to the discussion about the quality and
effectiveness of health care throughout the world. Following the World
Health Organisation (WHO) goal of health for all people, the Wonca Working
Party on Rural Practice maintains that providing effective high quality
rural health care is an enormous challenge in developed and developing
countries. Rural health, defined broadly, includes physical, mental and
social well-being. Rural health can be related also to the degree of connectedness
that the individual feels with family, friends, work and community.
Rural residents throughout
the world generally have reduced access to health care and less favorable
health status and outcome when compared to urban populations. Worldwide
measures of the quality and effectiveness of health care have not been
well described, developed or applied to the rural context. This Policy
outlines a framework for direct and indirect measures of rural health
care that can be applied to the target: "Health for all Rural People"
throughout the world. The framework measures include rural context, rural
health status, rural health care outcomes, rural health care services,
rural health care work force, rural health care work force education,
rural health care infrastructure and information technology, rural health
research, rural health funding, rural health care organization and rural
health consumer satisfaction.
A series of health
care vignettes from around the world are presented in order to underscore
health problems from a worldwide perspective.
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2.
INTRODUCTION
The World Organization of Family Doctors, (Wonca 1997) and the World Health
Organization, (WHO 1998) have both set ambitious targets of health for
all rural people in the 21st century. These goals are most difficult to
achieve in the rural areas of the world where the majority of the world's
people live. The advancement of rural people's health requires the promotion
of physical, mental and social well-being, following the broad WHO definition
of health. The quality of rural people's health is based on many broad
determinants including connectedness, not just the absence of diseases.
Connectedness is the relationship of the individual to his or her family,
friends, work and community environment. Producing healthy rural people
begins with the preparation of the next generation of parents for rewarding
relationships that provide the stable basis for bringing up girls and
boys to live, play and work productively with each other over their life-spans.
Improving rural people's health requires multidimensional cooperative
activity from all parts of our society. It requires attention to the environment,
economics, resources, education and health care.
Special needs groups
must be given high priority, with a special focus on the health needs
of indigenous, minorities and socially isolated rural people towards achieving
the same level of health status enjoyed by the rest of the population.
Providing effective high quality rural health care is an enormous challenge
in developed and developing countries. Compared to their urban counterparts,
rural people in most countries have reduced access to health care and
overall poorer health status and outcomes. Measures of the quality and
effectiveness of health care have not been well described, developed or
applied to the rural context. This policy paper provides a framework for
development and implementation of quality improvement initiatives in rural
health. It outlines and discusses both direct and indirect measures of
rural health care that can be applied to the Wonca target: "Health
for all People", and the Durban Declaration "Health for all
Rural People by 2020" (See Table). The quality and effectiveness
of rural health care can be measured directly using rural health status
and rural health outcomes. Indirect measures indicating available health
care services, workforce, organization, infrastructure, research and funding
are also important. Several vignettes are used to highlight the rural
health context and illustrate the challenge of achieving quality and effectiveness
of rural health care in both developed and developing countries throughout
the world.
Table
|
Target: "Health
for All Rural People by 2020"(Durban Declaration)
Direct and
Indirect Measures of Rural Health Care
|
| 1. |
Rural
context |
| 2. |
Rural
health status |
| 3. |
Rural
health care outcomes |
| 4. |
Rural
health care services |
| 5. |
a)
Rural health care work force
b)
Rural health care work force education |
| 6. |
Rural
health care infrastructure and information technology |
| 7. |
Rural
health research |
| 8. |
Rural
health funding |
| 9. |
Rural
health care organization |
| 10. |
Rural
health consumer satisfaction |
|
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3. DIRECT AND
INDIRECT MEASURES OF RURAL HEALTH CARE
3.1
Rural Context
Target: Understanding of rural contexts including rural/urban
differences and specific rural/rural differences so as to improve design
and delivery of rural health services and ultimately rural health outcomes.
Measures: Geography and demography of the rural population including
age-sex distribution; sociology and psychology including attitudes and
values; education level; per capita income poverty indicators; employment/unemployment
rates; occupational status; water, housing, sanitation and electricity.
Comments: Economic
and social factors are key determinants of health. Rural areas often have
a lower than national average education level, lower than national average
per capita income, higher than national average unemployment and relatively
low-income occupations. Also, rural people are often at high risk for
accidental injury and trauma, related to pursuits such as fishing, farming,
mining, forestry as well as motor vehicle accidents and environmental
disaster. There are some wonderful examples of healthy villages and rural
areas that have a variety of exceptionally positive outcome measures.
These areas need to be studied to understand and replicate their reasons
for success.
Definitions of rural
vary greatly from country to country and thus can make comparisons difficult.
In Canada for example, the rural population is now defined as residents
living outside census metropolitan and census agglomerate areas. Essentially
this definition covers rural areas, including small communities of up
to 10,000 people not contiguous to larger urban centers. Similar definitions
are used in other countries.
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3.2
Rural Health Status
Target: "Health for All Rural People"
Measures: Outcome measures include life expectancy tables and mortality
rates including infant mortality, perinatal mortality, maternal mortality,
and suicide rates. Disease incidence and prevalence, including infectious
diseases such as TB, HIV/AIDS, chronic diseases like diabetes and cardiovascular
disease and level of disability should distinguish rural vs. urban populations
for comparison. A specific subset of the same measures for indigenous
(Aboriginal/Native) peoples is important in many countries.
Comments: Morbidity
and mortality data provides the best direct measure of rural illness and
can be compared with national and international figures in order to highlight
particular health problems for rural populations. Rural/urban and rural/rural
analysis requires data collection in a form that allows this to occur.
Around the world, indigenous, minority groups and disenfranchised peoples
have generally poorer health status than other rural or urban people.
This poses a particular challenge for rural health care. (Wonca 1999)
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3.3
Rural Health Care Outcomes
Target: Comparable Outcomes for the Same Health Problems
Measures: Examples of outcome measures include morbidity and mortality
from diseases such as diabetes, cardiovascular disease and trauma.
Comments: How
do treatment outcomes for rural people compare to urban or national outcomes
for the same disease conditions? For example, does a rural patient with
cardiovascular disease such as myocardial infarction attain the same health
outcome as a person presenting with the same problem in an urban area?
How do trauma outcomes compare? Do premature babies have the same access
to advanced neonatal care? This is an important measure of the effectiveness
of specific components of rural health care delivery. Access to and quality
of primary, secondary and tertiary components of health care will impact
these measures. These measures can be used to target specific conditions
in need of better health care to bring rural health treatment up to national
and international benchmarks. Rural practice/clinic chart audits can be
a useful tool for continuing medical education and quality improvement.
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3.4
Rural Health Care Services
Target: Equivalent Access to and Utilization of Available
Services
Measures: Health clinic visits; family doctor/generalist visits;
antenatal care; medical specialist visits; surgical procedure rates; hospitalization
rates; preventive measures; i.e. immunization, Pap smears, mammography,
ambulatory care and resource and ambulatory care sensitive condition incidence
rates, access to and utilization rates for advanced diagnostics (i.e.
CT, MRI scan, genetic testing), use of telehealth and health informatics.
Comments: The
utilization of health care services is an important measure of the access
that the population has to health care. Equal populations, those with
the same age/sex distribution and incidence of disease would be expected
to have similar utilization of health care resources, provided that those
resources are fairly distributed and accessible. For example, the need
for, and use of primary health care/family doctor services would be fairly
uniform. The degree to which utilization differs often reflects barriers
of unequal access to these services.
Interpretation of
differing utilization rates for specific procedures and hospitalization
can be quite interesting. For example, the rate of appendectomy should
be the same for two similar population groups with similar diets because
the incidence will be the same, and surgery is non-elective and non-deferrable.
In contrast, the rate of cataract surgery or hip replacement surgery is
very dependent on access to advanced health care services. Higher hospitalization
rates for ambulatory care sensitive conditions such as complications of
diabetes or asthma may reflect lack of primary and secondary preventative
services resulting in higher complication rates. Interpretations of such
measures become even more complex when the populations' burden of illness
differs significantly.
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3.5
a) Rural Health Workforce
Target: Fair Distribution of Health Work Force to Meet
Health Care Needs
Measures: Physician/population ratios; FP/GP/population ratios;
some specialist/population ratios; nurse/population ratios; allied health,
e.g. physiotherapist/population ratios.
Comments: The
distribution of the primary health care workforce, including family physicians/general
practitioners and nurses, is an important measure since all populations
need primary and preventive health care. Effective functioning of multidisciplinary
rural healthcare teams is essential. There is an important role for the
family doctor/GP who knows his/her patients, is able to manage most of
their health problems and coordinate specialized investigation and specialist
care. The extent to which rural people have difficulty accessing specialist
care and specialized services is an important barrier to equitable distribution
of health care services. It is clear that a uniform distribution of specialists
is impractical as many specialist services treat low prevalence conditions
that only produce an efficient workload from large populations (e.g. neurosurgery)
and thus need to be centralized for efficiency. Regional specialists do,
however, play an important role in many rural areas. Visiting specialist
clinics can be an important part of the distribution of the rural health
workforce and provide rural health care providers an important connection
to consultants for questions and continuing medical education. In addition
some regionalization and ruralization can be done for relatively high-tech
specialty services. Cataract surgery, for example, has been successfully
decentralized in some countries by utilizing regional and mobile clinics.
The increase in telecommunication services throughout the world can make
referral and consultation a mouse click away. Alternate caregivers and
traditional tribal and herbal practitioners have a role in many parts
of the world and need to be scientifically studied for quality and effectiveness
(Wonca 2001).
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3.5
b) Rural Health Workforce Education and Training
Target: Education and training of a sufficient number
of suitably skilled rural doctors and other rural health workforce members
Measures: Recruitment of rural people into medicine and other health
care occupations correlating to the percentage of the population that
is rural; rural undergraduate medicine curriculum and experience provided;
postgraduate rural family medicine training streams provided; postgraduate
advanced training provided for rural family practice, i.e. GP anesthesia,
GP obstetrics, GP surgery, etc.; rural nurse and allied health education
correlating to the rural population.
Comments: Rural
practitioners provide a wider range of services, and carry a higher level
of clinical responsibility, practicing in relative professional isolation
when compared with their metropolitan counterparts.Practice in rural areas
where specialists and specialized services are limited or distant requires
specific rural-oriented medical education to produce sufficient numbers
of adequately trained physicians and other health care workers. Recruitment
of individuals from a rural background and rural-oriented medical education
have been found to increase the numbers choosing rural practice as a career
and to be effective in educating more physicians and other health workers
with the knowledge, skills and interest to pursue rural practice as a
career. (Wonca 1995)
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3.6
Rural Health Infrastructure and Information Technology
Target: Clinics/facilities/staff and supporting network
infrastructure to provide effective rural health care and maintain attractive
and sustainable working conditions for the rural health workforce
Measures: Clinic facilities, clinic support staff and structures;
regional hospital facilities; communication and transportation network
to provide access to specialized services for critically ill and seriously
injured patients; and information technology access and support.
Comments: The
organization of rural health infrastructure, information technology and
support are important contributors to rural health care. Without high
quality infrastructure support it is impossible for the rural health workforce
to deliver effective rural health care. In addition, lack of infrastructure
is a significant barrier to recruitment and retention of a rural health
workforce. (Wonca 2001)
Information technology
has the potential to add significantly to the rural health work force.
Knowledge, information access and Telehealth can enhance patient services
and education where direct consultation is not possible. Telehealth, however,
is not a substitute for the provision of direct primary or consultative
patient services. (Wonca 1998)
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3.7
Rural Health Research
Target: Effective Local and Major Rural Health Research
Projects
Measures: Local physician and other health worker involvement with
both design of and participation in local and major rural health research
projects with appropriate community involvement.
Comments: Rural
populations have specific illness, injury and disability patterns. Rural
health care delivery systems need research and development. Indigenous
peoples often have very specific determinants of health and usual disease
patterns. Effective health care is based on sound research into both population
needs and the best practice delivery of health care for that context.
An important component of this is the fostering of community research
by rural physicians and other rural health care workers.
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3.8
Rural Health Funding
Target: Equitable funding for health services in all
regions.
Measures: Rural health funding based on need. Equity can be assessed
by expenditure per person, based on documented comparative needs.
Comments: Rural
health funding needs not only to take into account the per capita utilization
of health services but also the more extensive infrastructure and support
required because of distances involved for rural health care. The effectiveness
to which rural health care funding is distributed is a major determinant
of the size of the rural health care workforce and supporting infrastructure.
This will contribute significantly to both the quantity and quality of
rural health care that can be delivered and has a major impact on the
health of the rural population.
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3.9
Rural Health Care Organization
Target: Effective Development and Management of Health
Care Resources to Meet the Needs of the Rural Population
Measures: Must be locally defined, based on local needs as well
as national and international models.
Comments: The
overall organization of health care directly affects the number and distribution
of doctors and other health care workers and access to medical services
as well as outcomes. The local and regional organization of health care
directly affects the quality and effectiveness of rural health care. Local
community participation in owning and managing rural health services is
a key to sustainability of rural health services. Strong organizational
policies and structures that specifically address rural health care needs
are therefore required at local, regional and national levels (Wonca 2001).
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3.10
Rural Health Consumer Satisfaction
Target: Sense of good health and quality accessible
health care.
Measures: Quantitative and qualitative personal measures of well-being
and the access to and quality of health care received.
Comments: Much
work remains to be done, based on the dimensions that patients find important.
Rural health care consumers need to be involved in all aspects of rural
health care, planning and delivery. Measures of their satisfaction (or
lack) can be a powerful tool in identifying needed improvements.
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4.
FUTURE
Health for All Rural People requires high quality and effective rural
health care. This remains a challenging target which demands a total society
approach to employment, education and connectedness within the community.
This will require local, regional, national and international leadership.
By all measures, in most countries around the world, a great deal of effort
and organization is required to bring the quality and effectiveness of
rural health care up to comparable urban standards. Measures of the quality
and effectiveness of rural health care include the rural context, rural
health status, rural health outcomes, rural health care services, rural
health care work force, rural health care workforce education, rural health
care infrastructure and information technology, rural health research,
rural health funding and rural health care organization. The Wonca Working
Party on Rural Practice strongly encourages using targets and measures
of quality and effectiveness of rural health care in the development and
evaluation of rural health programs.
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5.
REFERENCES
- WHO (1998). Health-for-all
policy for the twenty-first century, Fifty-First World Health Assembly,
Agenda item #19,World Health Organization, May 16, 1998. The World Health
Organization, Headquarters Office in Geneva (HQ), Avenue Appia 20, 1211
Geneva 27, Switzerland,
http://www.who.int/archives/hfa/ear7.pdf
- Wonca (1995). Training
for Rural General Practice, World Organization of Family Doctors, Policy
on Training for Rural Practice, 1995, World Organization of Family Doctors,
College of Family Physicians Singapore, College of Medicine Building,16
College Road#01-02, Singapore 169854
http://www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/training/WONCAP.htm
- Wonca (1997). Health
for all Rural People: The Durban Declaration, 2nd World Rural Health
Congress, World Organization of Family Doctors, Policy Statement, Durban,
South Africa, 1997. World Organization of Family Doctors, College of
Family Physicians Singapore, College of Medicine Building,16 College
Road#01-02, Singapore 169854
http://www.globalfamilydoctor.com/aboutWonca//working_groups/rural_training/durban_declaration.htm
- Wonca (1998). Using
Information Technology to improve Rural Health Care, World Organization
of Family Doctors, Policy Brief 1998, World Organization of Family Doctors,
College of Family Physicians Singapore, College of Medicine Building,16
College Road#01-02, Singapore 169854
http://www.globalfamilydoctor.com/aboutWonca/working_groups/write/itpolicy/itpoli.htm
- Wonca (1999). The
Health of Indigenous Peoples: The Kuching Statement, World Organization
of Family Doctors, Policy Statement, 3rd World Rural Health Congress,
Kuching, Malaysia 1999, World Organization of Family Doctors, College
of Family Physicians Singapore, College of Medicine Building,16 College
Road#01-02, Singapore 169854
http://www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/kuching_statement.htm
- Wonca (2001), Rural
Practice and Rural Health, Policy on Rural Practice and Rural Health,
World Organization of Family Doctors, 2000, World Organization of Family
Doctors, College of Family Physicians Singapore, College of Medicine
Building,16 College Road#01-02, Singapore 169854
http://www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/practice/Practi.htm
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6. CLINICAL VIGNETTES
VIGNETTE # 1 – CANADA
JA, a primarily healthy 75 year-old man presented to the rural hospital
emergency department with a massive MI. Despite rapid diagnosis and treatment,
he continued to deteriorate and required intubation which was successfully
accomplished. Both his family and the attending physician (a trainee in
cardiac surgery who was working in the rural emergency department that
weekend to spell off the overworked local rural doctors) felt that the
patient's chance of survival was dependent on transfer to the tertiary
care center 100 km away. Despite the stormy winter weather, the doctor
and nurse set out by land ambulance, only to crash in a white-out. The
patient died and all attendants (the doctor, nurse and ambulance crew)
suffered severe injuries (closed head injury, femur fractures) and all
were off work for several months. The risks of emergency and routine transportation
are often not sufficiently considered in decisions to seek advanced centralized
care.
VIGNETTE # 2 –
NEPAL
SH, a 48 year old female in Nepal developed right sided chest pain in
the breast region. Being a female and with the presence of pain in the
breast region, she traveled to consult a renowned gynecologist, who examined
her and advised consultation with a cardiologist immediately. The patient
hurriedly visited the cardiologist who, after examining the lady and after
a few investigations, suggested an NSAID and reassured her not to worry
about the pain. The pain continued and a GP was requested to see her.
The GP, after taking a history, immediately diagnosed this as a case of
cholelithiasis and did ultrasonography, which confirmed the diagnosis
and the patient was treated accordingly and relieved from the pain. She
later underwent cholecystectomy. This emphasizes the role of a GP in any
setting, but particularly in a developing country like Nepal.
VIGNETTE # 3 –
SOUTH AFRICA
A mother delivers a premature baby in an urban area. The baby is guaranteed
a place in the Neonatal Care Unit and has an excellent chance of getting
a ventilator if needed. If the same baby is delivered in a rural hospital,
it is unlikely s/he will be accepted in the tertiary institution (unless
the mother can afford private medical care). The only way to achieve this
is to transfer the mother prior to delivery, but the possibility of premature
labor can not always be predicted, and once labor has started, distances
and transport infrastructure can make transfer unsafe.
VIGNETTE # 4 –
SOUTH AFRICA
Severe malaria is common in some rural areas of South Africa. Rural doctors
in these places develop expertise in managing malaria that their urban
counterparts may not have, but there are no ICU facilities. A patient
who is at risk of complications, especially renal failure, should be transferred,
but the referral hospital is often reluctant to receive him/her, not being
fully aware of the danger. Once acute renal failure has set in, transfer
is logistically more difficult and dangerous.
VIGNETTE # 5 -
NIGERIA
MG, a 33 year old G4P3 alive, whose last confinement was 4 years ago,
lost her husband 30 months ago. She was being seen by her GP because she
claimed that her dead husband was tormenting her in her dreams for starting
a new affair. She became pregnant from her boyfriend who insisted on marrying
her. She has not attended the antenatal clinic this time around because
she is sure that her dead husband has promised to harm her and the expected
baby. She believes strongly that only prayers can save her.
Her church traditional
birth attendant (TBA) has placed her on a diet and prayer sessions, insisting
she deliver in the church, so that her dead husband could not harm her
and the expected baby.
She is term and has
presented in labor with a 48-hour history of intermittent contractions
and liquor drainage. Her presentation is face to pubes. The TBA cannot
cope and does not want both her and the church to lose face. She has requested
for her family physician to come to the church and deliver the baby. The
family physician obliged her and delivered her in the church after augmentation.
Taking the needs of
our patients into consideration saves lives.
VIGNETTE # 6 –
EGYPT
SM, a 63 year old farmer came from a village, 25 km away from the nearest
town and was admitted to hospital with 2 days of very high fever, prostration,
headache, severe body pain, abdominal pain with a few loose stools. Gave
the history of working barefoot in the wet paddy fields the previous week.
On examination he was mildly disoriented. Temp was 104 degrees F. and
pulse 120/minute. There was mild neck stiffness. Conjunctival congestion
was ++, BP was 110/80 mm Hg. There was diffuse muscle tenderness. Systemic
examination revealed no other significant abnormalities. Investigations
revealed mild polymorphonuclear leucocytosis, blood urea mildly elevated,
urine albumin +, serum bilirubin mildly elevated , SGOT mildly elevated,
CPK moderately elevated, chest x-ray mild, diffuse pulmonary infiltrates.
A clinical diagnosis of leptospirosis/septicemia was made.
Eight hours after
his admission the patient developed severe hyperpyrexia, tachycardia,
oliguria and auricular fibrillation. He was treated with Crystalline Penicillin
2 million units 4-hourly. 48 hours later he developed severe oliguria
and went into acute renal failure. Leptospiral antibody was positive.
He required five hemodialysis.
He is now fully recovered
and has no residual stigmata. Final diagnosis was Leptospiral septicemia
with cardititis, alveolitis and acute renal failure.
Comments: Combating
this requires community awareness of preventive health measures.
VIGNETTE # 7 –
UNITED STATES
CS is a 48 year-old female who was awakened with dull chest discomfort.
It lasted about an hour. It was associated with nausea and sweating. She
was left with some fatigue and a little short of breath. She thought about
going to the emergency room but was afraid that the hospital bill would
be too high and the wait too long. She had no health insurance. She did
not call an ambulance. She smoked a cigarette, took an antacid and decided
to lie down and rest before the children came home from school. Before
her children returned, she died of an acute myocardial infarction.
CF is a 48 year-old
female who awakened with dull chest discomfort. It lasted about an hour.
It was associated with nausea and sweating. She was left with some fatigue
and a little short of breath. She called 911 and an ambulance transported
her to the rural hospital. EKG and blood tests confirmed her myocardial
infarction. Advanced cardiac life support protocols were instituted. She
was air-lifted to the nearest cardiac center where emergency coronary
artery bypass graft was performed. She walked out of the hospital three
days later.
Comments: The US has
some of the most sophisticated health care available, yet, over 40 million
citizens lack health insurance.
VIGNETTE # 8 SOUTH
AFRICA
A child with a cloacal anus (opening into the vagina) was sent to the
pediatric surgeons in the tertiary care center, 5 hours from the rural
hospital. They said they would operate at 6 months, but in the meantime
we should dilate the anus twice weekly with a Hegar no. 8 dilator. This
child lived a 2-hour walk from our most outlying fixed clinic, which was
visited weekly by a doctor, and which did not have Hegar dilators. What
to do? After much discussion with the mother, the compromise reached was
that she would bring the child to the clinic every 2 weeks, and I would
make sure that the doctor visiting on that day (every second clinic visit)
would take the Hegar dilators from the operating theatre with him or her
on the visit. The child was sent back at the right time to the surgeons
and operated on successfully, none the wiser, apparently. Was this quality
of care?
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7.
Acknowledgements
Dr Robert Hall (Australia) contributed ideas, particularly regarding the
concept of connectedness, used in the development of this Policy.
Dr Ian Couper (South Africa)
Dr Steve Reid (South Africa)
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