Notice Board

Photo: Courtesy of Di Wyatt

Around the world, the health status of people living in rural and remote areas is generally worse than that seen in people living in urban areas.

1.2 billion people - nearly a quarter of the world's population are poor. Forty-four per cent are in South Asia, 24% each in sub-Saharan Africa and East Asia, and 6.5% in Latin America and the Carribean. 75% of the people in these countries live and work in rural areas.¹

In terms of health indicators, 766 million people in developing countries lack access to health services and 503 million do not expect to survive to the age of 40.² In South Africa, infant mortality rates in rural areas are 1.6 times that of urban areas ³. There is evidence of higher levels of morbidity and mortality in rural areas; the rural poor, especially women, generally have higher age specific mortality rates than the non poor ⁴. In India 716 million people (72% of total population) live in rural areas. Half of these people have incomes below the poverty line, and yet about 75% of health infrastructure, medical manpower and other health resources are concentrated in urban areas where 27% of the population lives.⁵

Critical factors in the relationship between poverty and health are population and environmental issues. Rural areas consistently have lower levels of access to primary health care services, safe water and sanitation ⁶. Eighty per cent of the poor in Latin America, 60% in Asia and 50% in Africa live on marginal lands of low productivity and high susceptibility to degradation. This tends to encourage migration from rural areas to the cities. However, in the world's cities, more than one billion people live without facilities for garbage disposal or water drainage and breathe polluted air.⁷ There are Healthy Cities policies and programs aimed at addressing these problems. At times, it seems to be assumed that eventually everyone will move to the cities. MK Rajakumar, the great family practitioner/philosopher, former Wonca President from Malaysia, points out that, in the totality of human history, cities are a very recent and potentially "unnatural" phenomenon. He suggests that this helps to explain why so many urban people feel more at ease, somehow "at home", in the rural areas. It does raise the notion that there should be programs, which actively seek to halt the rural-urban drift.

With the concentration of poverty, low health status and high burden of disease in rural areas, there is a need to focus specifically on improving the health of people in rural and remote areas, particularly if the urban drift is to be slowed. The World Health Organization International Development Program has highlighted this with specific objectives for policies and action which promote sustainable livelihoods including access for people to land, resources and markets as well as better education, health and opportunities for rural people. These objectives seek to contribute to lowering child and maternal mortality, and to improve basic health care for all, including reproductive services. Achievement of this is linked to protection and better management of the natural and physical environment.

In the vast majority of developing and transitional countries, rural poverty (whether measured by income/consumption data or other indicators) has been and remains at higher levels than in urban areas" ⁸. In terms of social indicators and access to basic services, rural populations continue to experience higher levels of deprivation, despite general improvements over the last 30 years ⁹.

The emphasis on poverty as well as other social and economic factors has led to a tendency to focus on those issues rather than directly addressing health issues. The 10/90 Report on Health Research, 1999 presents a different view: "The global community should recognize that good health is a way out of poverty. It results in a greater sense of wellbeing and contributes to increased social and economic productivity. The impact of ill health on productivity affects not only the poor, but societies and economies as well" ¹⁰. There is a particular need to focus on the health and wellbeing in rural and remote areas so as to break out of the poverty - ill health - low productivity downward spiral.

The low health status and variable patterns of illness and injury in rural areas are related not only to poverty. In general, the rates of avoidable deaths in rural and remote areas are higher than in the cities. Generally work injuries are more severe and their consequences more serious in rural areas. To some extent this follows from the stoicism and the "too tough to care" mindset particularly amongst farmers and agricultural workers ¹¹. In Australia, the tractor is the most dangerous machine with which people work. Forty per cent of work injuries are associated with tractors even though 5% of the workforce actually work with tractors ¹². Similarly there are dangers in other rural pursuits like mining, fishing and forestry. In countries with established highway systems country people spend a lot of time driving at high speed and tend to have more serious injuries from motor vehicle accidents.

The peaks and troughs of the economic cycle tend to impinge more directly on rural communities with economic downturns often placing severe pressure on these communities. Consequently there are significant levels of stress in a situation where generally counselling, support groups and other mental health services are limited if available at all. Commonly in rural areas there is a higher alcohol and tobacco consumption and standards of nutrition vary when compared with the cities.

Access to health care is, universally, lower in rural areas. One of the factors in the complex causation of poverty in rural areas is certainly the failure to reach much of the population with basic services of even minimal quality. Experience and evidence indicate that the more rural and economically marginalized a community is, the more likely it is to have health services that are below standard when compared to national norms ¹³.

Despite the enormous differences in resources between developed and developing countries access to health care for rural people is a major issue for both groups of countries. People in rural areas in both developed and developing countries are generally poorer and have a lower health status than their urban counterparts.

Clearly with the concentration of poverty, low health status and high burden of disease in rural areas there is a need to concentrate world effort on improving the health of people in rural and remote areas in ways which complement other international policies and programs.

This was recognised by the Earth Summit, held in Johannesburg, South Africa in September 2002, which included in its action plan a commitment to the following:

"Strengthen the capacity of health care systems to deliver basic health services to all, in an efficient, accessible and affordable manner aimed at preventing, controlling and treating diseases and to reduce environmental health threats, in conformity with human rights and fundamental freedoms and consistent with national laws and cultural and religious values, taking into account the reports of relevant United Nations conferences and summits and of special sessions of the General Assembly. This would include actions at all levels to:

Success in this endeavour will not only reverse one of the major health inequalities on the planet, but also stem the drift of rural populations to urban areas. Empowered communities in rural and remote areas will not only be healthy and happy, but will also become major contributors to the social and economic well-being of nations.

The Wonca Working Party on Rural Practice was established in 1992, following the Wonca World Conference in Vancouver. Over the subsequent decade the Working Party has undertaken a number of projects and activities that have contributed to the growing understanding and knowledge base of rural health and rural health practice.

Since 1995 the Wonca Working Party on Rural Practice has been involved in the organization of a series of World Rural Health Conferences. Each of these Conferences has involved delegates from around the world. The Melbourne Conference held in 2002 attracted over 900 delegates from 47 countries. These Conferences have provided a forum for the exchange if ideas between rural family practitioners and other health professionals and have developed recommendations which have formed the basis for Wonca policies on rural health and rural practice.

The Wonca Working Party on Rural Practice has developed a series of Wonca Rural Policies these are incorporated in the table below.

WHO-Wonca 'Health for All Rural People' Conference, Traralgon, Australia.
5th Wonca World Rural Health Conference, Melbourne Australia.
The Melbourne Manifesto: A Code of Practice for International Recruitment of Health Care Professionals.Wonca Policy on Quality and Effectiveness of Rural Health Care.

The Second World Rural Health Congress (1997) in South Africa had a particular focus on rural health in the developing world. The Congress adopted: "Health for All Rural People: The Durban Declaration".¹⁵ This Declaration outlines a series of principles which was followed by a Call for Action renewing the "Health for All" initiatives and calling on WHO, UNICEF, Development Banks, such as the World Bank, and National Governments to work with local communities, doctors nurses and other health professionals working in poorer areas of the world, to make a success of the "Health for All" initiative. The Declaration called for a combined effort to redress the historical inequities facing rural and disadvantaged communities.

In 1999 the Wonca Working Party on Rural Practice published the Wonca Policy on "Rural Practice and Rural Health." This document provides a policy framework and outlines strategies to assist governments and professional bodies to ensure that real progress could be made towards the goal of improving the health of rural people. The strategies have been used in many countries and the experience derived has been presented at Wonca World Rural Health Conferences. A key philosophy underlying these initiatives is the principle that rural family doctors should be part of the solution in rural health, rather than part of the problem.

In 2002 the Wonca Working Party on Rural Practice published "The Policy onQuality and Effectiveness of Rural Health Care". This document provides the framework to encourage the development of direct and indirect targets of and measures of the quality and effectiveness of rural health care.

In August 1999, the WHO held an International Conference, "Toward Unity for Health: (TUFH) Challenges and Opportunities for Partnerships in Health Development" in Thailand. Subsequently, the WHO produced a working paper intended to further the TUFH project. The project intention is to study and promote efforts worldwide to create unity in health service organizations - particularly through a sustainable integration of medicine and public health, or in other words, of individual health and community health-related activities - and consider the implication for important reforms in health professions, practice and education. The working paper explored innovative patterns of services for integrating medicine and public health focusing particularly on reference population and geography. ¹⁶

Many of the issues raised in this working paper are particularly pertinent in rural and remote areas. There are many examples of rural practitioners having developed innovative models of health service delivery.

WHO developed a partnership with Wonca through a landmark Invitational Conference in 1994 at London, Ontario, Canada. Subsequently, Wonca and WHO established their 1998 Memorandum of Agreement, which includes the Rural Health Initiative.

The WHO-Wonca Memorandum of Agreement commitment to Rural Health Initiatives facilitated the conduct of a WHO-Wonca Co-sponsored Invitational Conference on Rural Health held at Traralgon, Australia in April 2002. The Conference was attended by eighty invited guests from around the world representing a broad cross section of groups and organizations with an interest in rural health including rural health practitioners, governments, health professional organizations, non-government organizations, academic institutions and community groups.

Over three days, Conference participants explored the major issues in rural health around the world, drawing on experience from 16 case scenarios of local rural health initiatives from a range of different countries. With the intention of developing this Action Plan, Conference discussions sought to articulate the critical factors necessary to ensure success.

The major themes, which emerged from the Conference were:

"Think Locally, Act Locally, then Spread Globally"

The emphasis is on fostering and achieving local success through local initiative. This local success is then transferred to other local settings so bringing about local change networked across multiple sites which provide the impetus for substantial global change. The Action Plan should clearly articulate the key principles and success factors required.

Sustainable Change Bringing Long Term Improvements in Rural Health:

The key focus is to build from the ground up. All key stakeholders have important roles at the local, national and international levels.

Horizontally Integrated Programs:

There should be strong emphasis on active collaboration and partnerships at the local level involving all key stakeholders. The form that "the local level" takes will be different in different contexts and vary from the village to the district. The key connecting influence is a sense of mutual benefit through collaboration. It may well be that the local level is a network of villages in one setting and a local government area in another.

Further, it was agreed that the Action Plan be based on the assumption that policies, programs and activities have a greater chance of success if the initial frame of reference is communities and individuals, they promote integration, encourage and facilitate partnerships and support capacity building.

The Conference agreed on the following guiding principles for the Action Plan:

• Consider health, not just medicine, in policy and strategic development
• Ensure equitable distribution of health resources and investment
  
• Use a systems approach which leads to better, more efficient and effective solutions
  
• Ensure all policy, planning and service delivery is people centred and guided by the community
  
• Seek better results through a collaborative team approach and inter-sectional cooperation· Ensure services are sustainable
  
• Build capacity and self reliance at the local level
  
• Support progress in Information Technology in rural environments
  
• Ensure outcomes are supportable in a global context
  

A new track of hope for improved health of all rural people can be developed. Rural communities around the world share more than just their disadvantage. They often have an integration that reflects the close interactions of people in such communities. On the whole, they are inclined to have well defined social structures, shared values and belief systems and have closer family ties within the community in which they live. This brings about a strong sense of commitment to the overall wellbeing of their community.¹⁷

Most of all rural communities know their own needs and with the right support and assistance will work closely together in partnership for the good of the community. Unfortunately in many countries the voices of rural people are not heard. Frequently, health service planning and decision making is centralized and in the hands of the urban policy makers who may not understand the rural context. Rural communities do have capacity through the resourcefulness of their people, which is often not recognized. What is required is a commitment by Governments and other key stakeholders to provide the policy framework and targeted resources, and to build capacity within communities to maximize the potential that exists. When Governments commit to the policies and resources then communities can form the partnerships and collaborative arrangements that will deliver the desired outcomes, as they will find locally workable solutions involving the key stakeholders who are members of the rural community.

• A new track of hope for improved health of all rural people includes:
• Public health measures such as clean water, proper sanitation and immunization
• Greater equity for rural communities in terms of resources for and access to health services· Integrated, flexible health services that respond to rural community needs
• A better distributed and more skilled rural health work force
• Rural health research partnerships that involve and support rural communities and their health work force

To develop this new track of hope, there is a need to Create Unity for Action: An Action Plan for Rural Health. The improvement to the health status of rural people will only be achieved when all key players form the necessary partnerships and working relationships required to establish and maintain sustainable health services delivery systems based on community needs.

Photos: Courtesy of Steve Kirkbright

There needs to be a real and sustained investment in primary health care, in its broadest sense. The principles that underlie this are those of justice, fairness and equity. Equity is a commonly used and accepted term, which refers to the distribution of financial and other resources on the basis of need, with equal resources being allocated for equivalent needs¹⁸ . Need in this instance refers to a population's need for health care and the costs of providing this care¹⁹. Many would argue that equity should go further, in that the most vulnerable and needy groups within any society require greater resources than healthier, wealthier communities. This would allow such groups to improve their health status at a more rapid rate and thus to close the gap that exists between the advantaged and disadvantaged. Indeed, the more disadvantaged a group, the less able it is to access alternative resources to improve health status and the more likely it is to fall further behind. It is thus essential in order to achieve health for all rural people that significant resources are invested in rural health care and the provision of services, such as water and sanitation, education, electricity, transport infrastructure, etc. This implies specific, targeted investment in rural areas, and a diversion of funds away from better-resourced, urban areas. Often it simply means resourcing the strategies and policies that already exist in order that they can be implemented in rural communities.

Equity demands that focused attention is given to rural areas so that they are not left behind in attempts to improve health outcomes. The prevailing theory seems to be that improving health services generally will lead to improvements everywhere, including rural areas (trickle-down approach). However, if there is not a specific attempt to address rural health, with targeted action and specific resources, the rural-urban gap inevitably widens.

Financial and human resources follow power - political, social or economic. Action for equity means deliberately focusing such resources away from centres of power in order to assist the health and development of rural communities which do not have easy access to power in any form. Even within rural areas, it must be done carefully in a way that does not simply benefit those with greater access, creating gaps within communities but targets those with greatest needs. Thus community empowerment and local solutions remain the basis for action.

All programmes must be judged by their contextual relevance and applicability. Vertical or stand-alone programs may be destructive, drawing attention and resources away from other vital health-related activities, and disempowering local health care providers. Development interventions should be part of integrated rural development approaches; similarly health care interventions must build into and support comprehensive health care approaches, and develop local capacity.

The Action Plan depends on local strategies and the successful negotiation of these at the local level. This can only happen in a supportive policy environment that encourages collaboration, innovation and a community perspective. However, often the existing policy environment is characterised by individual and separate imposed programs - acting like silos, isolated from each other and the local reality.

In a paper in The Lancet by McFarlane et al, ²⁰ comment that the Declaration of Alma Ata was followed by a series of northern-designed selective initiatives which are still being generated today. Selective vertical programs enable the International Aid Agencies to measure results and protect their investments from complicated long-term multi-sectoral and inter-departmental implementation. They comment, however, that non-government organisations and religious groups have found that holistic community-based health programs are generally undermined by narrowly selective interventions and that the sustainability of people-owned initiatives can be put in jeopardy.

Many communities have struggled in the past to implement siloed programs and to fit the various initiatives into a coherent whole. Some have succeeded in this environment, and will no doubt continue to do so, through stretching the boundaries, creatively interpreting the rules and opportunistically taking the openings as they. Many, however, have failed to jump these hurdles of imposed discrete programs resulting in abandoned facilities, idle technology, wasted money and dissatisfied communities.

In developing a suitable policy environment for rural health, specific rural initiatives need to be developed and general policy initiatives, often metro-centric and urban in origin, need to be tested for rural relevance.

This was well outlined by Judith Justice in her paper: "The Bureaucratic Context of International Health - A Sociologist's View"²¹. She commented that many Primary Health Care programs were ineffective because they reflect the perspective and needs of the health bureaucracies involved rather than those of the local villages receiving services. Often Primary Health Care is interpreted differently in different bureaucratic settings and adapted to bureaucratic needs but not necessarily adapted to the village cultures and conditions.¹¹

Therefore, to successfully implement the Action Plan a facilitative environment is required at several levels:

• A cohesive national rural health policy approach

• Policy review

A cohesive national rural health policy approach and implementation strategy is a basic prerequisite of good rural health care. It should outline the goals of rural policy and outcomes that need specifically to be addressed. These will include specific rural initiatives including such areas as infrastructure development, disease targets relevant to rural areas and workforce approaches tailored for the rural and remote environment. These policies should also include an approach that seeks to break down artificial barriers between health services and programs. Coordinated and cooperative use of funds supplied to the community funds and avoidance of duplication and waste should be encouraged in line with the Action Plan and seek to reflect community needs. Health initiatives in communities should not unfairly disadvantage local providers but should seek to build on their strengths. Local providers are often hard to attract and their continuance should be encouraged. Primary care programmes should not dismiss or exclude curative interventions and practicing clinicians - including them may be a key factor to success. A program in Nepal, the Nutrition Education Intervention Program which was evaluated some years ago, did involve some curative intervention. The evaluators found that the inclusion of curative activities in the program seemed to be a key factor in increasing the motivation of participants and acceptance by the community, so contributing to the success of the program.²²

Community initiatives should be encouraged to replace external visiting services or reorientate visiting services towards education and support of local services. Visiting services should have in their charter community empowerment and devolution ensuring flow-on community benefit.

Risk management has become a recent area of focus. Risk, as discussed by governments, is often defined in terms of risk to the health provider or administration rather than risk to the community member. Withdrawal of a maternity service may control the perceived risk to the service provider or administration but does not necessarily control the risk to the pregnant woman who may be unable to travel to a distant facility because of timing (premature labour), financial or family (other children to care for) reasons. Replacing emergency services with retrieval may be self-defeating as such services become overloaded and slow to respond. Appropriate rural facilities with multi-skilled staff are in best risk balance when the needs of communities and their members are considered.

Policy at a national level necessarily must reflect the needs of all the nation. In doing so, however, it must take into consideration the cultural and geographic needs of particular sectors - one such is rural. National decrees limiting working hours of health care providers need to be balanced against the logistics of service provision, up-skilling of staff need to be provided for in isolated locations and sustainable call schedules and adequate back-up services. Early hospital discharge needs to be balanced against the limited supports in isolated living. Rural facilities need to be used to their maximum. Entry criteria to health sciences based on academic criteria only that favour urban students must be balanced to provide an equitable rural-urban mix. Perfectionism and elitism have the potential to have all procedures done in large centralised locations while rural people die for want of transport or while in transport to these unreachable centres of supposed excellence. The evidence for such an approach has not been validated for rural areas.One approach has been to ensure that all policy is reviewed for rural relevance before implementation and preferably in the planning phase. South Africa is seeking to do this and "Rural proofing" has been introduced in the UK. Community obligations have been introduced with privatisation of services in Australia. The ultimate measure of government and private sector interventions is the Rural Impact Assessment - a developing concept analogous to environmental impact assessment that assesses the effect of policy on the rural sector. Complex systems such as rural communities are prone to disproportionate impact of single interventions and these need to be adequately assessed before implementation.

Action in rural health can only happen if rural communities are allowed to develop strategies that suit their circumstances. The restrictive siloisation common to (and possibly effective in) urban communities needs to be broken down in rural environments and appropriate outcome measures used. The best solutions for rural areas may not be the transplanted urban solutions but a rural friendly solution that may not align with the needs of urban areas.

Simplistic, monolithic and reductionist or siloed approaches need to be replaced by a system that encourages diversity and innovation.

Action Process This Action Plan aims to improve the health of all rural people by a three-step process:

1. Think locally - Review local capacity
2. Act locally - Build local success
3. Transfer globally - Implement enabling policy environment

Think locally - Act locally

This three step process involves the community:

• identifying its needs,
  
• developing actions to address them,
  
• identifying the resources required including the community's contribution.

The most beneficial changes to the health care of local communities come from solutions developed with active community involvement. Communities vary widely in their needs, resources and abilities, but local solutions are the most likely to be effective. Therefore, the policy framework and resource allocation process must contribute to enhancing community capacity to address problems locally. This must be based on the principle of equity.

Implementation of local solutions needs to be nurtured by a supportive policy environment in terms of each of the five components identified. This needs to be an iterative process where policies are assessed for the degree of local flexibility they provide and the degree to which implementation at a local level in rural communities is possible. Often development of local initiatives is facilitated by local champions supported by change agents who receive specific funding and draw on successful experience from other local settings. Meaningful investment of resources makes this possible.

All key participants, as members of a local community, need to consider how they contribute to finding and supporting local solutions. What are some key questions the community should ask if they are to Think locally to review local capacity and Act locally to build local success?

Transfer globally - implement enabling policy environment

The most critical factor in the implementation of local solutions is the policy environment and the will of the key stakeholders to commit to strategies to achieve outcomes in all five components of this Action Plan. Without a commitment to improve the health status of rural and remote people through specific policies and defined strategies integrated into comprehensive primary health care efforts, the concentration of poverty, low health status and high burden of disease in rural areas will remain. Fundamental to this is for sufficient resources to be allocated and distributed to implement these policies and strategies.

This Action Plan is built on the key principles of:

• community participation and empowerment,
• local networks,
• partnerships between key stakeholders,
• service integration and coordinated approaches to health care which are locally based.

It is a guide based on five essential components for consideration at both the local and policy level.

The essential participants in the implementation of this Action Plan include: Communities, Policy Makers, Health Professionals, Academic Institutions and Health Managers.

Support capacity building within communities at a local district and regional level

Community capacity building is a key issue in health reform and requires an integrated set of strategies across a number of key areas to ensure effective practice

Community Empowerment

Background

The Ottawa Carter has describes community capacity building as

The key components of community capacity building that supports improved health outcomes are:

A commitment to community capacity building increases the social capital in rural communities, which helps groups to perform tasks such as planning and coordinating health services and programs. Social cohesion is critical for development to be sustainable, poverty to be alleviated and improved health outcomes to be achieved. Community capacity building is a key issue in health reform and requires an integrated set of strategies across a number of key areas to ensure effective practice. To be most effective capacity building needs to work at a number of levels and use a combination of strategies from the key action areas of organizational development, workforce development and resource allocation.

It is the responsibility of all health professionals to take seriously their obligation to pass on skills to the local communities they serve.

Increased capacity for local identification of health problems and improved capacity to address them

Improved usage of limited resources

Increased local ownership of health services and patient satisfaction

Increased public awareness of rural health issues at all levels and increased empowerment of rural communities

Photo: Courtesy of Di Wyatt

• What skills do we need to enhance our role in improving the health of our community, what training do we need and who could provide it?
  
• What mechanisms do we need to establish to enable us to input into the planning and delivery of health services within our community and what information do we need?
  
• Who are the key players and what collaborative arrangements or partnerships do we need to establish?
  
• What local networks do we need to support this?
  
• What do governments need to do to create the policy framework to assist community capacity building?

Photo: Courtesy of Di Wyatt

Support the development of linkages between patient care and public health through Primary Health Care

The importance of partnerships and sharing cannot be overemphasized

Building Unity of Partners

Background

The narrow and parochial definition of health employed by health care professionals, providers and managers has in the past hindered the development of truly integrated and inclusive health care and health care delivery systems. The term health has often referred to the delivery of services rather than the attainment of "well being" by tackling the wider determinates of health such as poverty, poor education, employment, housing, public utilities and the environment.

Primary health care requires working together broadly across disciplines, sectors and agencies at a local level. It is also important that close cooperation and dialogue develops through the levels of health care management and governance. Care systems need to be seamless and responsive. Those working on the ground should be given flexibility to respond to local needs, while those in government must ensure that some of the barriers are removed to encourage effective partnerships at all levels

Collaborative partnerships will only be successful if all those involved understand each other's role and responsibilities. Education is important in achieving these objectives. The principles of team work, joint working and community development needs to be integrated into all levels of training and education of health care professionals in the future, recognizing that learning together encourages individuals to work together.

Health care training for primary care professionals has traditionally focused on patient and family centred care. It is also important that these professionals also develop public health and community development skills in order to assess need and plan services together with the communities that they care for.

Best practice models as beacons

Best practice models as beacons

Increased understanding of the roles, responsibilities and functions across disciplines that encourages individuals to work together

Photo: Courtesy of Berta Nunes

In 1982 Portugal established a network of primary health care centres that provide preventive, public health and preventative services.

They are staffed by family doctors, nurses and public health support personnel. Despite having an overall doctor shortage, Portugal has a very good distribution of physicians working in rural areas.

Bertoni Photo: Courtesy of Ian Couper

• How do we form the partnerships locally to enhance integration between patient care and public health providers?
• How do we strengthen the relationships between direct patient care and public health services at a local level?
• How do we monitor and evaluate outcomes?
• How do we develop multidisciplinary approaches to health care and promote teamwork in the provision of services?
• What education and training programs do we need to assist health professionals to work in a multidisciplinary environment?
• How do we establish partnerships that facilitate resource sharing to tackle health inequalities?
• How do we improve communication between the key players?
  

Improved health outcomes by enhancing quality of, and increasing access to, health services for people living in rural and remote areas of the world.

There is a desperate need to develop mechanisms to support both the development and dissemination of best practice models for rural h