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 health…

Providing Rural Health Services

Background

Improved health outcomes require improved access to care as well as better quality of care. Access is the major rural health issue in both developed and developing countries. Even in countries where the majority of the population lives in rural areas, the health care resources are concentrated in the cities. The development and delivery of health services in rural areas must be specific to the rural context and different from that in the cities. Unfortunately, urban based policy makers and health service planners often seem to think that the country is just like the city but with a different population distribution, and that it is possible simply to transplant modified urban health services to rural areas without accounting for the broader socio-economic and geographic factors that affect rural communities and impact on health care.

The provision of health services in rural and remote areas is significantly affected by limited funding and other resource constraints. In developing countries, there is considerable poverty and limited facilities and resources available for health care. In many developed countries, there has been the trend towards the reduction of funding and infrastructure support for health services in rural and remote communities.

To improve health outcomes for rural people requires an equitable distribution of health resources and investment between rural and urban areas. Internationally there is no agreement on or consistency in the collection, collation and analysis of data relating to health indicators of rural communities to inform planning decisions. The lack of comprehensive data sets to assist evidence based planning for rural health must be addressed if we are to use evidence appropriately to plan strategies and programs to improve the health outcomes of rural people. Governments and other key stakeholders who provide health services and programs to rural communities need to develop this capacity, as interventions need to be based on sound evidence. Information relating to the demographic, geographic and health statistics of rural communities should form the base of any health planning system. Of related concern is the limited availability of best practice models and benchmarks for service outcomes applicable to rural environments. There is a desperate need to develop mechanisms to support both the development and dissemination of best practice models for rural health care if we are to encourage the implementation of best practice solutions suited to rural communities own specific needs.

Local models of community accountability for quality of services

Photo: Courtesy of Ijaz Anwar

Increased understanding within governments of issues facing rural communities.

Development of strategies by governments to address rural health care needs.

Increased focus at a national level on rural health matters.

Share successful models and validate these in the rural setting.

Unhcr - Oru Refugee Camp, Oru, Ijebu-North Local Government of Ogun State in Western Nigeria
Photo: Courtesy of Allan Fatayi-Williams

Refugee camps are usually located in rural communities worldwide. Over five thousand refugees from war-torn areas of Africa notably Liberia, Sierra-Leone, the Democratic Republic of Congo, Sudan, Cameroon and Rwanda have been resettled in this camp about 2 hours drive from Lagos which was established under the auspices of the United Nations High Commissioner for Refugees.

The refugees are being successfully rehabilitated and are undergoing skills acquisition in such areas as hairdressing, catering, shoemaking and computer studies. Those with requisite qualifications and language skills are assisted to obtain registration with nearby institutions of higher learning.

Voluntary HIV screening has also been performed on selected refugees in this camp who in addition to the rest also have access to the camp clinic for Primary Health Care.

An agreed and consistent set of data used worldwide in health planning for rural communities

Effective collection and use of data in planning, resource allocation, infrastructure development and capacity building in rural communities

Improved knowledge of decision makers of major health issues in rural communities and the development of strategies to address them

Omeo TownshipFar East Gippsland, Australia Photo: Courtesy of Anske Robinson

• What are our local health needs?
• What evidence do we have of these needs?
• How are they best met?
• How do we ensure equity based on community need?
• What information do we need to assist with health service planning in our local community?
• How do we ensure our services are sustainable?
• How do we evaluate our health services?
• What models of rural health care can we learn from and apply?
• What evidence do we have for best practices in the delivery of rural health care?

Foster research to advance knowledge in the field of rural health

As rural health care grows around the world, both patients and providers will benefit from increased scientific understanding and knowledge

Action - oriented Research

Background

There is a need for high quality research, which provides clear and specific evidence about rural health and rural practice. If initiatives in education and training for rural practice are to be taken further, there is a need for research into what works best and evaluation of the outcomes. Rural health workforce recruitment and retention issues will only be addressed by further research monitoring workforce trends, evaluating current initiatives and pointing to the potential value of new projects and programs. Similarly, models of health service delivery require further study identifying the demands and requirements of rural and remote communities and evaluating the effectiveness of different models.

Currently, the worldwide research agenda for rural health and rural practice is replete with "holes" and with regions of inadequate data and analysis. Although much effort has been expended towards developing work-lists of research topics, much of the actual research work remains undone, and, in many areas, it is not even clear what research questions should be asked. As rural health care grows around the world, both patients and providers will benefit from increased scientific understanding and knowledge. Increased wisdom regarding rural health care will be dependent on developing data collection systems based in rural health care services, supported by analysis oriented research units focused on transforming this data into usable knowledge. Finally, the integration of this data into health care practice will depend on dissemination and communication systems that can effectively transmit data from the research and analysis sites to the rural clinics.

The systematic development and implementation of evidence based planning and best practice guidelines and their application in practice together with Information Technology development and skills training requires international collaboration and coordination.

Contribute to scientific understanding, which informs
rural communities, professional practice, education and
training programs, service delivery, policy development
and the implementation of rural health programs

Establish Rural Health Research Units supported through the WHO Collaborating Centre for Rural Health. The functions of the Rural Health Research Units would be as follows:

• To build partnerships with communities, health professionals, health managers, policy-makers, and academic institutions to do rural health research.
• To analyze data collected at rural health service sites;
• To develop electronic Internet based reports and publications for rural providers;
• To coordinate strategic plans to address research questions;
• To formulate rural health care research agendas;
• To seek and to develop funding to support rural health care research
• Establish a worldwide Rural Health Research Network, or a series of regional networks, consisting of rural health care services that will serve as research data collection sites.
• Develop a system, using both Internet based and appropriate print resources, to disseminate the rural health research findings to rural health service sites across the world.

Effective local and major rural health research projects

Involvement and support of rural communities and their health workers in all aspects of rural health research from design to dissemination.

Knowledge, which contributes to international understanding of rural health, issues and provides the basis for ongoing developments in rural health care.

Increased use of rurally applicable research findings to buttress worldwide rural use of evidence based medicine.

Rural Summer Studentship participant and Gold Medal graduate from The University of Western Ontario medical school Amita DayalPhoto: Courtesy of James Rourke

Beaming with Pride - information sharing in rural AlbertaPhoto: Courtesy of David Topps

Facilitation and coordination of the implementation of the Action Plan for Rural Health and leadership in the ongoing development of information and knowledge, skills and capacities necessary to improve the health care and outcomes for rural people.

Monash University AustraliaPhoto: Courtesy of Steve Kirkbright

• How do we as community members contribute to the scientific understanding of rural health and rural health practice?
  
• What sort of mechanisms do we establish to assist use in research activities at a local level?
  
• What information do we need to plan interventions?
  
• What evidence is there for the planned interventions?

Improve Education and Training for Rural Health Practice and support ongoing Rural Health Workforce Development

One of the current barriers to entry into rural practice is the lack of training that could prepare health practitioners for the unique requirements of rural care By providing better on-going training and support for existing rural providers, retention is enhanced and the shortages of rural health practitioners are decreased

Education and Performance of Health Professionals

Background

There is a current critical worldwide shortage of rural health practitioners. Too few health care practitioners locate in rural areas, and the tenure of health care practitioners in rural areas is frequently too short. In addition, those who do practice in rural areas are often not located in the areas that need them the most.

Research evidence from around the world shows clearly that the three factors most strongly associated with entering rural practice upon completion of education and training are:

(a) A rural upbringing
(b) Positive clinical experiences in the rural setting at the undergraduate or basic level
(c) Specific postgraduate or post-basic training for rural practice.

Most countries have severely limited opportunities for training health care providers in and for rural settings. If adequate numbers of training opportunities existed, with a special focus on the knowledge, skills, and attitudes required for rural health care, more health practitioners would enter practice in rural sites. One of the current barriers to entry into rural practice is the lack of training that could prepare health practitioners for the unique requirements of rural care. In order to increase the number of health care providers entering rural practice, there must be increases in the number, the size and the quality of training programs for rural practice.

A second set of problems that contributes to the scarcity of rural practitioners is the low retention rate and short length of employment found in many rural areas. As noted above, one of the prime reasons for this situation is that many rural providers begin practice with inadequate training. The resulting sense of being overwhelmed by the scope and complexity of rural health care leads to short tenures. There are many additional causes of retention problems, including social and professional isolation, limited access to continuing education, distance from family, and difficulty in earning an adequate living. By providing better on-going training and support for existing rural providers, retention is enhanced and the shortages of rural health practitioners are decreased.

Finally, when health practitioners do decide to enter rural practice, they sometimes locate at sites that are not the most needful of their services. While this may be understandable from the personal aspect of the individual provider, it does not result in an equitable distribution of these scarce practitioners based on local needs. In order to impact on regional and local shortages of practitioners, the question of distribution, both between urban and rural sites, as well as among rural sites, must be addressed.

Improved knowledge among educators and educational institutions of current strategies for recruiting students into rural health care courses.

Scholarship Scheme StudentsPhoto: Courtesy of Ian Couper

Objective 5.2 - Postgraduate

Improved knowledge among educators and educational organizations of current graduate/postgraduate training initiatives

Northern Ontario is a vast area with many remotecommunities accessible only by air

Improved knowledge of training needs of rural health practitioners in both developing and developed countries.

Improved Continuing Professional Education programs for rural practitioners, and improved accessibility of those programs.

Increased numbers of trained faculty capable of teaching the knowledge, skills, and attitudes needed for rural practice.

Increased numbers of rural practitioners who participate in teaching in education and training programs for rurally oriented health care students.

• How do we contribute to training students both at an undergraduate and postgraduate level to work in rural communities?
• What can we do to encourage them to come to a rural community to undertake their training?
• How do we support them in our community?
• How do we work with the education and training institutions in the promotion and support of rural practice training?
• How can we help recruit health professionals into our rural communities and what support can we provide to retain them?

Photo: Courtesy of Ian Couper

Dr Bruce Chater
Dr Roger Strasser
Dr Ian Couper
Dr John Wynn-Jones
Dr Charles Boelen
Dr Tom Norris
Ms Di Wyatt

On behalf of all members of the Wonca Working Party on Rural Practice, I would like to thank the HARP committee for all its work in the organization and conduct of the WHO-Wonca Co-sponsored Invitational Conference on Rural Health and their input to this Action Plan. I would also like to acknowledge the major contribution made by the members of the Writing Group in the production of this document.

Special thanks to Di Wyatt and Steve Kirkbright, Monash University School of Rural Health, for the development and production of this document.

Roger Strasser
Chair
Wonca Working Party on Rural Practice

Project 1: The South African Integrated Sustainable Rural Development Program

Provides an overview of the Integrated Sustainable Rural Health Development Program currently being implemented as part of the change process occurring in South Africa and addressers many of the challenges facing all key stakeholders involved in bring about these changes.

Contact:
Dr Tim Wilson
South African Department of Health
email: wilson@health.gov.za

Project 2: The Spanish Rural Health Model

Provides an overview of the changes that have taken place in rural health practice in Spain over the past decade and the introduction of a primary health care system to rural areas, which has brought about improvement in both the health of rural communities and rural practice.

Contact:
Dr Luis Garcia Burriel
email: lgarciab@meditex.es

Project 3: The "In Fine Fettle" Project Scotland

Provides an overview of the "In Fine Fettle" program, which is running across the Scottish Borders, trying to prevent heart disease, stroke and cancer by using a wide range of approaches to address a number of risk factors.

Contact:
Dr John Gillies Department of Public Health
email: j.gillies@borders.scot.nhs.uk

Project 4: The Ingwavuma Scholarship Scheme: South Africa

Provides an overview of the unique locally based scholarship scheme that is a partnership between the local community/Department of Education/ Department of Health/private funders and The Friends of Mosold Trust. The ultimate aim of the project is to provide high quality health services to the indigent population of Ingwavuma by the identification, training and support of local students who have the potential to become health care providers.

Contact:
Dr Andrew Ross Mosvold Hospital
email: rossa@nu.ac.za

Project 1: The General Practice Training Project in Nepal

Provides an overview of the three year, university based post graduate (Residency) program in General Practice/Family Medicine. The training program was started in 1982 with the first half of the training conducted at the University of Calgary, Canada and the later half in Nepal. By 1992, the entire three-year program was being conducted in various training centers in Nepal. The majority of candidates are working in rural areas of Nepal.

Contact:
Dr Shatendra Gupta
Tribhuvan University Teaching Hospital, Nepal
email: skgupta@healthnet.org.np

Project 2: The Safe Motherhood Project: Nepal

Provides an overview of the Safe Motherhood Project being implemented in a number of districts in Nepal. The project aims to bring about sustained increase in utilization of quality midwifery and basic and comprehensive emergency obstetric care.

Contact:
Dr Shatendra Gupta
Tribhuvan University Teaching Hospital, Nepal
email: skgupta@healthnet.org.np

Project 3: The Training and Recruitment Project: Pakistan

Provides an overview of the rural health-training program in Pakistan developed to increase the skills of doctors and paramedical staff working in the most isolated rural and remote areas.

Contact:
Dr Tariq Aziz Pakistan Society of Family Physicians
email: psfp@wol.net.pk

Project 4: Rural Communities as Partners in Teaching Rural Health; Australia

Provides an Overview of James Cook University School of Medicine implementation of a community-based model of teaching designed to meet the health needs and workforce needs of northern Australia. The paper describes the development of an eight-week rotation in a rural community.

Contact:
Dr Tarun Sen Gupta James Cook University School of Medicine
email: Tarun.Sengupta@jcu.edu.au

Project 1: Developing Family Medicine in Regions of Extreme Need

Provides an overview of the development of a family medicine project in rural Orissa, one of India's poorest areas and the further development of the model in both Cambodia and Vietnam. The aim of the project was to increase accessibility to health care to a large number of people with minimal set up costs, which would be vital to success and sustainability.

Contact:
Dr David Whittet
Waikohu Medical Centre, Te Karaka, Gisborne, New Zealand
email: davidwhittet@xtra.co.nz

Project 2: The Health of Rural Peoples in the Pacific Islands Project: Vanuatu

Provides an overview of the current health care system in Vanuatu and the development of partnerships between Vanuatu and developed countries to address health care issues including the shortage of health care professionals and vital equipment and medicines needed to provide services.

Contact:
Dr Derek Allen Vanuatu Government
email: derekallen@vanuatu.com.vu

Project 3: The Health of Indigenous Peoples Project: New Zealand

Provides an overview of the poor health status of the Maori peoples compared to non-Maori and provides details of the East Coast Ngati Porou project which aims to improve their health status by improvements in the way services are delivered and the development of appropriate choices to Maori clients.

Contact:
Dr Iain Hague
email: ihague@enternet.co.nz

Project 4: Towards a Global Immunization Policy

Provides an overview of the development of a childhood immunization protocol in consultation with the local people and traditional health practitioners in Orissa India. This has lead to an increase in uptake rates of leprosy vaccination by 65% and an increase in polio immunization by 72% in the project area.

Contact:
Dr David Whittet
Waikohu Medical Centre, Te Karaka, Gisborne, New Zealand
email: davidwhittet@xtra.co.nz

Project 1: Shoulder to Shoulder Project: Honduras

Provides an overview of the Shoulder to Shoulder non-profit partnership between the University of Cincinnati College of Medicine, the City of Cincinnati, the Ministry of Health Honduras and the poor isolated community of Intibuca in the Santa Lucia region of Honduras. During the 11 year of the partnership a 24 hour medical and dental clinic has been built, a feeding program for up to 800 school children per day established, a new water system developed and a range of educational programs implemented.

Contact:
Dr Tom Norris University of Washington School of Medicine
email: tnorris@u.washington.edu

Project 2: The WWAMI Project

Provides an overview of the WWAMI (acronym for Washington, Wyoming, Montana, Idaho) program, which aims to increase the number of generalist physicians in the region. The WWAMI program is a thirty-year success story in training rural primary care physicians.

Contact:
Dr Tom Norris University of Washington School of Medicine
email: tnorris@u.washington.edu

Project 3. Rural Internship Program and Brazilian Family Health

Provides an overview to the Rural Internship introduced to the medical curriculum at the Federal University of Minas Gerais, Brazil in 1978 and its impact on rural health and rural health practice.

Contact:
Dr Tom Norris University of Washington School of Medicine
email: tnorris@u.washington.edu

Project 4: The Alaska Family Practice Residency: A new start curriculum designed for rural and remote practice success

Provides an overview of the Alaska Family Practice Residency, which is a new-start residency and the first and only graduate medical training program in Alaska. This is a collaborative and deliberate effort to critique the evidence of what works in producing successful rural and frontier family physicians and to apply that body of knowledge to the design of a new community based academically affiliated training site.

Contact:
Dr Barb Doty
Alaska Family Practice Residency Program
email: bdoty@alaska.net