Russell J. Roberts, A rural health governance model that is fit for purpose—It's not them and us: It's ‘we’ (2021)

Summary

An editorial by Russell J. Roberts in the Australian Journal of Rural Health (DOI 10.1111/ajr.12830), published in 2021, arguing from the premise that things have never been better for rural health in Australia. He lists a Rural Health Minister, a Rural Health Commission, the National Rural Health Alliance, and a $197m per annum rural health training and research program with 16 University Departments of Rural Health and 19 Rural Clinical Schools staffed by over 1300 clinical academics; an audit across 6 universities found 240 academic staff in mental health alone. The AJRH, in its 30th year and the Alliance's research journal since 1996 under Gordon Gregory, reaches over 10 000 institutions with about 850 article downloads a day. The editorial proposes a governance model built on that capability rather than on a divide between them and us.

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“Russell J. Roberts, A rural health governance model that is fit for purpose—It's not them and us: It's ‘we’ (2021).” Original at web.archive.org. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/russell-j-roberts-a-rural-health-governance-model-that-is-fit-for-purp-6341b5447a/, SHA-256 3ff68a8832c2972d807d5ec8c3297fcdc8368e252eff820a4d6ad146dd1f105b.

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DOI: 10.1111/ajr.12830

EDITORIAL

A rural health governance model that is fit for purpose—It's
not them and us: It's ‘we’

Things have never been better for rural health in Australia. universities conducting research and delivering degree
Our rural health infrastructure and capacity are world programs in allied health, nursing, public health and com-
leading. munity development. Although there are no published
data available, this would entail many more than 1000
full-time academics contributing to rural health. (A recent
1 | DO WE H AVE T HE audit across 6 of these universities revealed 240 academic
BE ST RUR A L HE ALT H staff in the area of mental health alone.)
I N F R A ST RUCT U R E IN T HE Our understanding of rural Australia is enhanced
WOR L D? by the authoritative work of the Australian Bureau
of Statistics (ABS) and Australian Institute of Health
At a recent Australian Journal of Rural Health (AJRH) and Welfare, which routinely produce reports on rural
International Advisory Board meeting, one of our overseas Australia and examine rurality factors in most of their
participants noted that Australian rural health is the envy general analyses and reports. These national data provide
of the world. This caused me to reflect on the state of rural important evidence to inform rural health advocacy, pol-
health in our nation. We have a Rural Health Minister, icy and planning.
a Rural Health Commission, the National Rural Health The AJRH, now coming into its 30th year, is one of
Alliance and a score of rural health professional and the most respected rural health journals in the world.
rural health representative organisations. Rural health is Supported by the editorial team and 100s of reviewers,
prominent in strategy and planning documents. We have who all contribute their time and expertise pro bono, the
had the Healthy Horizons1 rural health plan, National journal plays the important role in curating and dissem-
Strategic Framework for Rural and Remote Health2 and inating the scholarship emanating from our rural health
our Stronger Rural Health Strategy,3 and rural health is sector. Over 10 000 institutions can access its content,
prominent in most state and national health plans and with an average of 850 research articles downloaded every
workforce strategies. day, or put another way, an article download every 1 min-
Health services are primarily governed locally. While ute and 40 seconds. The recent Council of Australian
the Rudd ‘funded nationally, run locally’ health pol- University Librarians open access agreements,9 will result
icy directions never fully fledged, we now have local in a significant increase in AJRH downloads.
health districts/networks/services and Primary Health We should ponder on the previous paragraphs for a mo-
Networks, which, despite their challenges, are essentially, ment. That is a substantial capability! No wonder our in-
place-based. In addition, we have a widely dispersed rural ternational rural health colleagues hold Australia in such
health workforce in pharmacy, allied health and general high esteem. These advancements did not just happen.
practitioner small businesses supported by the Medical They result from decades of persistent, thoughtful advo-
Benefits Schedule (MBS), the Pharmaceutical Benefits cacy10 from the likes of Gordon Gregory, Lesley Barclay,
Scheme (PBS) and Medicare funding. John Humphreys, David Lyle and countless others. It was
The last 25 years have also seen remarkable growth in under the leadership of Gordon Gregory that the AJRH
rural health research and training capability. Australia's became the research journal of the National Rural Health
$197m per annum4 rural health training and research Alliance in 1996.
program has 16 University Departments of Rural Health Australia has superb foundations to develop the best
and 19 Rural Clinical Schools staffed by over 1300 clini- and most comprehensive rural health services in the
cal academics.5 We also have new initiatives proceeding world. We have the policy, organisational, research and
such as rural medical schools,6 rural health research in- training foundations in place, but these are only the foun-
sititute7 and significant targeted funding to develop rural dations. As I have argued in previous editorials, there is
research capacity.8 In addition, we have 11 rurally based still much work to do to better integrate,11,12 coordinate13

816 | © 2021 National Rural Health Alliance Inc. wileyonlinelibrary.com/journal/ajr Aust J Rural Health. 2021;29:816–820.
EDITORIAL | 817

and focus14 these elements. The next key step is to embed the field, across the road, across borders and seas to bring
effective governance mechanisms and processes to enable international expertise to local projects. What a profound
all these elements to come together to best support local transformation!
communities. Recent unanticipated transformations in
rural health have suddenly made this an achievable goal.
3 | THE ACC ELERATING
VITALISATION OF RURAL AND
2 | COV I D - 1 9 AN D ZOOM HAVE REGIONAL COMMUNITIES
BE E N T H E CATALY ST S FOR A
REVO LUT I ON IN WOR K AN D COVID-19 forced many people to work from home.
RU RA L H E ALT H CAR E As a result, many organisations have realised that staff
don't have to be physically together in a central office,
The storm that disrupts, sometimes clears a path but can effectively and productively work from home.20
Consequently, more Australians are choosing to live and
work in rural and regional communities.
COVID-19, zoom and soaring capital city real estate
COVID-19 has stress tested our health systems,15,16 prices all factor in the net migration from the cities to the
workers17 and leaders.18 In the process, some profound regions.21 In the last 12 months of reported data, the ABS
transformations have transpired. Tele-health and remote reported that 44 673 people migrated from the city to live
consultations suddenly became MBS billable in private in rural and regional areas.22 Internal migration from the
health services and routine in public health services. city to the country has been a consistent trend since before
Health providers invented creative ways to provide care to 2011, but the rate has doubled over the last 12 months22
all, including hard-to-reach and vulnerable populations. reflecting the increase in people working from home.20
Clinicians met virtually for case consultations, clinical su- This surge probably includes the migration of a profes-
pervision and clinical advice. Each of these initiatives has sional middle class into rural communities, with all its
profound implications for rural health. flow-on impacts. Currently, each day 122 people from
Online meetings are now an everyday occurrence. our cities migrate to live in rural communities, and with
Meeting participants no longer need to travel vast distances many of these from the middle class, the expectations and
for meeting attendance. Video conference apps have pro- demands on rural health services are increasing. This un-
liferated. Some health service planning, management and derscores the need to ensure effective local health service
support staff no longer travel at all because working from governance.
home is an option. Rural advocates champion equality
and equity. During the height of COVID-19 lockdowns,
a profound and new equality in meetings arose. All were 4 | LET A HUNDRED FLOWERS
equally at home. Rural participants were no longer travel- BLOSSOM (AND 50 DIE? ):
ling to meetings in capital cities. Better yet, they were no POTENTIAL PROBLEMS WITH
longer on the end of a teleconference phone line, where PLAC E- B ASED, CO - D ESIGN
they could not hear much of the discussion, and the chair
often completely forgot that rural participants were di- This revolution in work practice coincides with the rise of
alled-in at all. (RIP the phone teleconference!) Previously, the ‘place-based’ and ‘co-design’ imperatives. Ironically,
rural participants had difficulty hearing and having their this can augur an exclusionary tone of ‘you just give us
voices heard via the teleconference pods. Now, thanks to the money and we will decide what to do with it.’ This
video-link meetings, rural attendees, for the first time in approach risks the development of programs that are not
history, all have equal right to hear: ‘you are on mute.’ based on need, with no research evidence, out of step with
Puzzlingly, Canberra-based participants also now seem to best-practice and not aligned with national and interna-
lose connection due to poor bandwidth. Equality! tional policy imperatives. This method of ‘let a hundred
I remember in October 2019 needing to apply for a ‘spe- flowers blossom and a hundred schools of thought con-
cial’ university zoom account that allowed international tend…’ could also lead to a disconnected hotch-potch of
participants to access an online Equally Well19 meeting. approaches that are impossible to coordinate, evaluate
Two years later, remote health consultations are common- and learn from. In addition, it risks extensive unneces-
place and rural participants routinely meet with associ- sary planning and transaction costs, duplicating work that
ates from across Australia and the world via video link. has already been done elsewhere. As such, this is an over-
Rural researchers can seamlessly connect with experts in reaction to past examples of the central bureaucracy's
818 | EDITORIAL

unilateral declaration ‘this is the program: you have to provision is the foundation stone for better health for all
implement it in your community.’ of us.23
Working in partnership with the ‘technocracy’— So how should we operationalise inclusion in ways that
central planning, administration and policy expertise—is work for rural communities? We already have the organ-
important to ensure place-based expertise is combined isational infrastructure via our local health districts/ser-
and aligned with the evidence and policy base. Placed- vices/networks and Primary Health Networks. Firstly, we
based expertise is vital, but co-design must be with all should ensure our governance models include experts by
those who can make a valuable contribution. experience and place-based experts, as they should also in-
clude policy and planning experts. The research evidence
should be also be included in a way that is accessible and
5 | RUR A L VS CIT Y: T H E ‘ T HEM applicable. Processes should facilitate mutual respect and
A N D U S ’ M E ME IS TOXIC appreciation of others' expertise and perspectives and the
value this brings to legitimate governance.
To make the progress needed over the last 30 years, the
data demonstrating inequity of health service provision
and outcomes for rural Australians have been highlighted. 7 | WHAT ARE THE ESSENTIAL
This approach is necessary but risks the development of ELEMENTS OF RURAL HEALTH
a ‘them and us’ mindset. This is unhelpful for many rea- SERV IC E GOVERNANC E?
sons. It can reinforce the same mindset in centrally based
administrators. It therefore risks making rural the ‘other’ My colleagues and I have outlined our views on the es-
in the mind of centrally based policymakers, service pro- sential elements of good health service governance previ-
viders and clinicians. Rural should be an integral part of ously,24,25 but they bear repeating here.
‘the’ thing they focus on, not be an ‘other’ thing to focus on. Effective, legitimate rural health service planning and
For instance, when a major specialist service in a major delivery:
metropolitan teaching hospital gets funding to run a state-
wide service, they should not plan the new service or pro- • respects the (equal) rights of rural Australians to quality
gram and then think ‘now what about rural?’. Instead, the health care
mindset should be, how do we incorporate the core rural • incorporates the knowledge and skills of rural experts
aspect into our basic service provision model? The ‘them • integrates principles of citizen participation and commu-
and us’ approach creates a tendency to assign rural to an nity development
afterthought. This rarely ends well. • combines national and international technical expertise
Exclusion based on place of residence, social status, with local, place-based knowledge and expertise
gender or population group is not helpful. An inclusive • appreciates that power and control are key to rural health,
service philosophy should not only include ‘hard-to-reach’ and that the exercise of power is manifest through fund-
and marginalised groups, and it should also include city- ing, planning, and decision-making
based experts who can make a valuable contribution to • values the perspectives of rural communities in evaluating
rural health. Exclusion in all forms is bad for health. We health services and programs in rural areas
must provide the narrative that places rural as a core ele- • understands that critical mass requires effective artic-
ment of everyone's agenda. ulation of available city-based and rural-based service
capacity
• makes provision for sufficient time and effort for ongoing
6 | O P E RATIONALISIN G T H E communication, collaboration and partnership building
‘ WE ’ work25(p.20)

In leadership, the key question is, how do we convert as- Money is power, and it is important for funding to
piration to action? In this case, how to convert the ‘we’ be controlled locally.24 There are numerous proof-of-
aspiration to concrete actions and processes. If COVID-19 concept examples of how this has worked well. One of
infections and zoom meetings have taught us anything it these was a federally funded, locally managed and ex-
is, we are all interconnected and interdependent in more ternally evaluated integrated care trial.26 Another was
ways than we can imagine. This applies to all groups, a state-wide program to enhance older persons' ser-
those of different races, social status, gender, sexual orien- vices.27 The common key features of these programs
tations, lifestyles and places of residence. Creating inclu- were as follows: locally controlled funding, central-
sive health services at all levels of governance and service agency engagement, mutual accountability and rigorous
EDITORIAL | 819
8. Tudge A, Gee A. Enhancing research collaborations in re-
evaluation. Other shared characteristics of these pro- gional areas. Dept of Education, Skills and Employment; 2021.
grams were as follows: the inclusion of place-based ex- https://ministers.dese.gov.au/tudge/enhancing-research-colla
perts, lived-experience experts, local leaders, clinicians borations-regional-areas. Accessed November 5, 2021.
and researchers working respectfully together to guide, 9. Council of Australian University Librarians. Wiley and CAUL
monitor and manage the program. Sign Three Year Transformational Open Access Agreement
In Australia, the time is right for a new inclusive Represents Largest in the Region by Article Output; 2021.
model of health governance, where place-based, research, https://www.caul.edu.au/news/caul-a nd-w iley- s ign-t rans
formative-open-access-agreement-represents-largest-anz-regio
central-policy, administrative and lived-experience exper-
n-article. Accessed November 5, 2021.
tise all have a voice, and indeed, a powerful hand in rural 10. Barclay L, Gregory G. Alliances and evidence: building the ca-
health service planning, provision and evaluation. pacity and effectiveness of rural health advocacy in Australia.
‘We’ are all better together. Aust J Rural Health. 2018;26(5):308-311.
11. Roberts R. Rural health: better together. Aust J Rural Health.
STATEMENT OF INTEREST 2017;25(3):140.
Prof Roberts is a Chief Investigator on a grant awarded by 12. Roberts R. Integrating rural health care. Aust J Rural Health.
2017;25(1):4.
the Regional Research Collaboration Program.
13. Roberts R. Doing rural health collectively: amplifying impact.
Aust J Rural Health. 2019;27(2):116-117.
Russell Roberts PhD, Editor in Chief 14. Roberts R. Researching for better health for regional and rural
Australians? Aust J Rural Health. 2019;27(6):474-475.
Charles Sturt University, Bathurst, NSW, Australia 15. Roberts R. Free speech costs: public health policy and leader-
Email: rroberts@csu.edu.au ship matters. Aust J Rural Health. 2021;29(1):4-6.
16. Roberts R. Prevention pays: COVID-19 tells us it’s time for a
ORCID Sovereign Health Fund for disease prevention. Aust J Rural
Health. 2021;29(4):488-492.
Russell Roberts https://orcid.org/0000-0003-3442-8366
17. Roberts R, Wong A, Jenkins S, et al. Mental health and well-
being impacts of COVID-19 on rural paramedics, police, com-
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820 | EDITORIAL

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