regional inequality in australia - productivity commission€¦ · inequality in these areas. rural...
TRANSCRIPT
Submission to the Senate Economic References Committee
Inquiry into
Regional Inequali ty in Austral ia
28May2018
APPENDIX B – PC inquiry into Mental Health
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CONTENTS
Page
AboutRDAA 2
ContactforRDAA 2ExecutiveSummary 3Recommendations 4Background 5KeyIssues 6ResponsetoTermsofReference 10Conclusion 14Endnotes 15
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ABOUTRDAA
CONTACTFORRDAAPetaRutherfordChiefExecutiveOfficerRuralDoctorsAssociationofAustralia
RDAAisthepeaknationalbodyrepresentingtheinterestsofdoctors
workinginruralandremoteareasandthepatientsandcommunitiesthey
serve.
RDAA’svisionforruralandremotecommunitiesissimple–excellent
medicalcare.
Thismeanshighqualityhealthservicesthatare:
• patient-centred
• continuous
• comprehensive
• collaborative
• coordinated
• cohesive,and
• accessible
andareprovidedbyaGP-ledteamofdoctorsandotherhealthprofessionals
whohavethenecessarytrainingandskillstomeettheneedsoftheir
communities.
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TIMETO‘THINKRURAL’
EXECUTIVESUMMARY
Australiais,byworldstandards,aprosperousnationwithahealthy,well-
educatedpopulation.Yetthereareanumberofpopulationgroupswithin
thiscountrythatarenotaswelloffasothers.Increasinginequalityof
incomeandwealthandawideninggapbetweenthetopandbottomofthe
socio-economicscaleisevident1.
Thishassignificantimpactinruralandremoteareaswherepeopleare
alreadyexperiencinghigherratesofpoverty2andsignificantlypoorerhealth
outcomesthanthosewholiveinmetropolitanareas.Manysocial
determinantsmarkers–includingforeducation,employmentandhousing–
indicatesignificantinequalitiesbetweenregions.Inequalitiesbeing
experiencedbyAboriginalandTorresStraitIslanderpeoplethoughwell
recognised,arepersistentandreflectedinunacceptablyhighratesofmany
preventableconditionsandmortalitygapsbetweenIndigenousandother
Australians.
RDAAbelievesthat:
• Thehealthofindividuals,families,communitiesandpopulationsis
bothanindicatorofandcontributortoregionalinequalityin
Australia.
• Inequitableallocationofhealthfundingandresourcesexacerbates
inequalityintheseareas.
Theinequitiesandinequalitiesinhealththatexistbetweenmoreurbanand
ruralandremotepeopleisantitheticaltothenationalcharacteristicsvalued
byAustraliansandmustbeacentralconcernofanyexaminationofregional
inequality.ThegoodhealthandwellbeingofruralandremoteAustralians
willalsobecriticaltoachievingandsustainingregionalgrowth.
Theroleofhumancapitalindeterminingeconomicgrowthisparticularly
importantindiscussionsaboutregionalinequalityandhassignificant
implicationsforthehealthsystem.Governmentsrecognisethattheyhavea
dutyofcaretoprovidehealthcareservicestothepopulationandoften
espousetheneedtoprovidetheseservicesclosetohome.However,adhoc
investmentatalllevelsofgovernment–afunctionofAustralia’stiered
healthfundingsystemandpoliticalexpediency–failstotranslaterhetoric
intoreality.Bipartisanstrategicandoperativeplanningunderpinnedby
adequatelevelsofinvestmentisessentialtoredressinequitiesandreduce
regionalinequalities.
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RDAAmakesthefollowingpolicyrecommendationstohelpaddress
inequalitybetweenregions:
• recognisethataddressinghealthandwellbeinginequitiesand
inequalitiesiscentraltoaddressingregionalinequalitymorebroadly
• analyseaccesstohealthservicesinAustraliausingtheModified
MonashModelremotenessscaletomoreaccuratelyreflect
communityaccess
• providebetteraccesstohealthservicesinruralandremoteareasby:
o investinginmodelsofcarewhichprovidecriticalservicesin
localcommunities,includingexpandingrenaldialysis
services
o allocatingsufficientfundingtodeveloptheNationalRural
GeneralistPathwaytoensureruralandremotepeoplehave
accesstodoctorswiththeadvancedskillstheyneed
o workingwithruraldoctorstoidentifyeffectivesupport
mechanismsforgeneralpracticesasprovidersofhealth
services,employersandcontributorstolocaleconomies
o developingspecificagreementsonruralhospitalfunding
throughtheCouncilofAustralianGovernmentsnational
healthagreementsprocessdirectedtomaintainingrural
hospitalservicesandprovidingincentivesforincreasing
services
o institutefundingmodelsthatsupportsustainablehealth
servicesandhealthworkforceretention
• furtherdevelopcross-governmentandcross-departmental
strategiestoimprovehealthoutcomes,particularlyinrelationto
childhealth
• developatransportpolicywhichalignswithhealthandeducation
needs.
RECOMMENDATIONS
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BACKGROUND
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Australia’sregional,ruralandremoteareascompriseadiverserangeof
communitieswitheconomiesbasedonactivitiessuchasagriculture,
forestry,fishing/aquaculture,miningandtourismthatmakeasignificant
contributiontothenation’swealthandprosperity3.However,this
contributionisnotrecognisedthroughequitablespendingonhealthinthese
areas.TheNationalRuralHealthAllianceestimatesaruralandremote
primaryhealthcaredeficitofover$2billioneachyear4.
Thisinequitableallocationoffundsisofsignificantconcern.Peoplelivingin
Australia’sruralandremoteregionsexperiencehighratesofpoverty5.
Socio-EconomicIndexesforAreas(SEIFA)mappingrevealslargeswathesof
ruralandremoteAustraliaareinthemostdisadvantagedcategorieswiththe
tenmostdisadvantagedhavingpopulationsofunder3700usualresidents
withintheLocalGovernmentArea6.
RuralandremoteAustraliansexperiencingthesedisadvantagesoften
interactwithmanydifferentareaswithinthehealthandhumanservices
systems,mostoftenindisconnectedways.Lackofaccesstoservicesisa
pervasiveproblem,whichbecomesmoredifficultwiththedegreeof
remotenessandcontributestogenerallypoorerhealthoutcomesas
evidencedbyhigherratesofmortalityandmorbidityandriskyhealth
behaviours.Risksofoccupationalaccidentsandinjuryarealsohigher7.
AlthoughtheprevalenceofmanymentalillnessesissimilaracrossAustralia,
suicideandself-harmratesaremuchhigher(especiallyformales)inrural
andremoteareas8.Accessingalltypesofhealthprofessionalsbecomes
increasinglymoredifficultwithremoteness,contributingtothesepoorer
healthoutcomes.Recruitmentandretentionofanappropriatelyqualified
healthworkforcecontinuestobedifficultinmanyareasresultingina
maldistributionofhealthprofessionals.
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KEYISSUES
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Clearly,thehealthprofileofruralandremoteAustraliaisindicativeof
regionalinequality.Healthdisparitiescompromisethecapacityofmany
ruralandremoteAustralianstoengageinsocialandeconomicactivities,
includingthosenecessarytogenerateincomeandwealth,andlimitthe
benefitsthathumancapitalcanprovide.Poorhealth,therefore,isalsoa
contributortootherregionalinequalities.
Thekeyissueimpactingonthissituationisaccess.Access–tohealthcare
andtootherservicesandopportunities–isacriticalfactorindetermining
thedesirabilityofalocationasaplacetovisit,tolive,towork,tobringup
childrenortoretireto.Accesstohighqualityhealthcare,includingtoa
generalpractitioner(GP),affectstheappealofaruralandremotelocationas
aplacetoliveregardlessofageorlifestage.
Theavailabilityofbirthingservicesinruralareasprovidesanexampleofthe
impactsthataccesstohealthcare,orlackthereof,canhaveonruralpeople
andcommunitiesastheyunderpinmanyactivitiesinthesecommunities.
Peoplewhochoosetoliveinruralandremotecommunitieshaverational
expectationsaboutwhatconstitutesreasonableaccesstohealthcare.For
manywomenaccesstobirthingservicesstronglyinfluencestheir
judgementsaboutthequalityofhealthservicesinacommunity.
Allhospitalservicesshouldbepreparedforanimminentbirth.As
communitiesincreaseinsize(andwithconsiderationgiventothedistanceto
thenextbirthingservice)ruralhospitalsmayincreasetheircapacityto
providebirthingservicesfromlow-riskdeliveriesstaffedbymidwivesand
RuralGeneralists,tobirthingserviceswhichhave24-houremergencyand
caesareancapabilitystaffedbymidwivesandRuralGeneralistswith
advancedskillsinobstetricsand/oranaesthetics.
However,birthingservicesarenotroutinelyprovidedinallruralhospitals.
Thosethatdonotprovidetheseregularservicesaredeemedtohave
significantrisksbyexpectantmothersandwomenintendingtohave
children.Ensuringthattheseservicesexistinlocalhospitalsalsoensuresthat
therearedoctorstrainedinobstetricsandmidwivesinthetownwhoare
abletoprovidethecontinuumofantenatal,perinatalandpostnatalcare.
Theclosureofabirthingfacilityrequireswomen(andtheirnewborns)to
travelforappointments.Itcanincreaseatwo-hourtriptoahospitalbirthing
centretohavetheirbabytofiveormorehoursforsomewomen.Theymay
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alsobe,andoftenare,askedtorelocatetoatownorcitywithabirthing
facilitytwotofourweeks(andsometimesmore)priortotheirduedate.This
placesconsiderablefinancialandotherimpostsonexpectantmothers,their
partnersandfamilies.Lackofaccesstobirthingservicescanforcewomento
permanentlyrelocatetoothertownstostartoraddtotheirfamilies
contributingtothesocialandeconomicdeclineofruralcommunities.
ItalsomeansthatmidwivesandtheGPobstetricianwilllikelyleavethe
communitytogowheretheycanusetheirtraining,furtherstrippingrural
communitiesofskills,opportunitiesforemploymentofsupportstaffand
incomederivedbyotherlocalbusinesses.
Ruralandremotedoctorshavealsoidentifiedarangeofotherfactorsthat
impactonwhethertheywillmovetoarurallocation.Theyareallindicative
ofregionalinequalityandarelikelytobeofsimilarconcernforothers.They
include:
• employmentissues
Employmentopportunitiesarefundamentaltothrivingruralandremote
communities.Youngpeoplearemorelikelytostayin,orreturnto,a
communitythatcanofferjobprospects.Othersaremorelikelytobe
attractedtoandretainedincommunitieswithsufficientopportunitiesto
meetnotonlytheirneedsbutalsothoseoftheirspouse/partner.
Employmentconsiderations,however,arenotjustaboutjobvacancies.Lack
ofaccesstopersonalandprofessionalsupport,tocontinuingprofessional
developmentandtocareerprogressionopportunitiescanalsodetractfrom
thedesirabilityofalocation.
• lackofaccesstohighqualitychildcare,schoolingandother
educationalopportunities
Accesstohighqualitychildcare,schoolingandothereducational
opportunitiesislimitedornon-existentinmanyruralandremote
communities.Accesstochildcarecanbeverydifficultforhealthcareworkers
who,throughmovingtoaruralorremotelocation,havereducedfamilyand
friendsupport.Theymayrequirechildcareoutsidebusinesshoursduetothe
24/7natureofmanyhealthcareservices.
Schoolingalsoposeschallenges,particularlyduringthesecondaryschool
yearswheretheavailabilityandchoiceofsubjectsandextra-curricular
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activitiestosuitindividualchildren,aswellaseducationalstandards,are
important.Sendingchildrentoboardingschoolbecomestheonlyfeasible
optionbutcanimpactonfamilyrelationshipsandisexpensive.
Lackofaccesstovocationalandtertiaryeducationopportunitiesmeansthat
youngpeopleoftenmovetowheretheseopportunitiesexist.Thisimpacts
negativelyonpopulationretentionandtheeconomicviabilityandsocial
vibrancyofruralandremotecommunities.Thiscontributestocontinuing
inequality.
• poortransportlinks
The“tyrannyofdistance”isawell-recognisedchallengeforthosewholivein
ruralandremotecommunities.Pooraccesstoqualityfreshfoodatan
affordablepriceisanongoingissue,asistheneedtotravelforhealth
services.Thesechallengescanbeaddressedtominimisethenegative
impactsofregionalinequalities.
Thereareexamples,suchasrenaldialysis,wherenewmodelsofservice
deliveryallowforservicestobedeliveredinruralandremotecommunities.
Withoutthislocalfacility,ruralandremoterenalpatientsmustendure
travellingtoadistantfacilitythreetimesaweek,whichhasasignificant
impactontheirphysicalandmentalhealth.Thisisonlyfeasibleifpatients
haveaccesstoprivatetransport.Relianceonpublictransportand/orair
travelsignificantlyincreasesfinancialcostsandtimeawayfromhome,
familyandcommunity.Airtravelmaynotbepossibleatallifthereisno
airportwithinareasonabledistance.
Forruralandremotecommunitiestobevibrantandthrivingtheymustbe
underpinnedbybetteraccesstohealthservices,employmentopportunities,
childcareandeducationalopportunitiesandtransport.Withoutthispeople
willeitherchoosenottoliveinthesecommunitiesortorelocatetomeet
theirpersonalandprofessionalwelfareneedsandthoseoftheirfamilies
furtherincreasingtheimpactsofregionalinequalityonthosethatstay.
Investmentbyalllevelsofgovernmentwillbenecessarytoavoidthis.
Regionaldevelopmentcanreducelevelsofinequalityinhealthinruraland
remoteAustraliathroughstrategicandoperativeplanning.Plansmustbe
mindfuloftheimpactsocial,culturalandenvironmentaldeterminantsof
healthhaveonpeopleandofthecomplexinterrelationshipofhealth
serviceswithothersocialandcommunityservices.Theymustacknowledge
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theroleofgeneralpracticeswithinthiscontextandbesupportedby
adequatelevelsofinvestment.
Investmentinhealthandsocialservicesadequatetoredresshealth
inequitiesandreduceinequalitycontinuestobeanissueforthosedelivering
theseservices,asarefundingarrangementsthatarecommonlybasedon
relativelyshort-termcycles.Sucharrangementsaredeleterioustothe
provisionofhealthcareandsocialservicesinruralandremoteareasleading
touncertaintyandworkforceinstability.Thisgreatlyincreasestheriskof
serviceclosureasitisfarmoredifficulttorecruitandretainqualified
personnelintheseareas.Healthfundingmechanismsthatrecognisethe
uniquechallengesthatexistinruralandremotecommunitiesareessential
forefficientandeffectiveplanning.
Ruralandremotegeneralpracticesarethecornerstoneofruralandremote
health,withGPsprovidingandcoordinatingteam-based,comprehensive,
continuousandlongitudinalcare,whichisbasedaroundtheneedsof
patients,familiesandcommunities.Theydeliverpre-conceptiontopalliative
agedcareandacuteandemergencyservicesinarangeofsettings,including
privatepractices,hospitals,agedcareandoutreachcentres.Theyarealso
smallbusinesses,providingemploymentwithinthelocalarea,supporting
otherlocalbusinessesandservicesandcontributingtothehighlyregarded
healthsystemthatisessentialtostrongtourismsector.
Investinginruralandremotegeneralpracticeswouldbebeneficialbothto
redressregionalhealthinequitiesandinequalitiesandtosupportlocal
economies.
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RESPONSETOTERMSOFREFERENCE
1
• fiscalpoliciesatfederal,stateandlocalgovernmentlevels
Governmentshaveadutyofcaretoprovidereasonableaccesstohealth
servicestothepopulation:aresponsibilitythatcannotbeabrogated
becauseofbudgetarypressures.Spendingonhealthshouldnotbe
contractedsimplybecauseitisexpedienttodosoinfiscallychallenging
times.Whilevalueformoneymustbeaconsiderationforpolicymakersand
fundingproviders,healthexpendituremustbeseenasaninvestmentinthe
futureprosperityofthenation,notasacosttobeminimised.Governments’
healthexpendituremustbesetatrealisticlevelstoachievedesiredhealth
outcomes,notonlytosupportthegoodhealthandwellbeingofAustralians
butalsotounderpinthenation’seconomyandgrowth.
• improvedco-ordinationoffederal,stateandlocalgovernment
policies
AsdemonstratedbyAustralia’stobaccocontrolsuccesses,thebesthealth
outcomesarederivedfromco-ordinatednational,state/territoryandlocal
activities9buttherearefewreadilyavailableexamplesofeffectiveco-
ordinationinAustralia.
Thereare,however,manyexamplesofsiloedapproachesandfragmented
services.Australia’smentalhealthsystemisonesuchexample:Our“mental
healthsystem”—whichimpliesaplanned,unitarywhole—isinsteada
collectionofoftenuncoordinatedservicesintroducedonanoftenadhocbasis,
withnoclarityofrolesandresponsibilitiesorstrategicapproachthatis
reflectedinpractice10.
ThathealthsystemfundinginAustraliaistieredwiththefederal
governmentlargelyresponsibleforprimarycareandstate/territory
governmentsforhospitalsischallengingfortheruralandremotehealth
sectorandcontributestothesesiloedapproachestoissuesthatwouldbe
bestaddressedholistically,throughlongerterm,evidence-based,well-
consideredstrategicandproactiveplansthatprovidetheflexibilityforlocal
circumstancestoinfluenceaction.Inmanyareasitcreates“artificial”
divisionsthatarenotalwayswellunderstoodbypeopleinthecommunity.
Forexample,aruralpatientmayseekemergencytreatmentatthelocal
hospitalonlytofindthatitisprovidedbytheirregularGPwhoisaVisiting
MedicalOfficeratthehospital.
Thespan,scope,complexityandcircumstancesofruralandremotehealth
areoftennotfullyappreciatedbypolicymakers.Policyandfunding
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decisionstendtobemetro-centricinoriginandapplicationanddonot
adequatelyrecognisethatruralandremotehealthisacomplexand
interdependentweboflocalandfurtherafieldhealthpractitionersand
servicesfundedand/orprovidedbyalllevelsofgovernment,arangeofnon-
governmentagenciesandorganisations,privatecorporationsandindividual
healthprofessionalsoperatingassmallbusinesses.Ruralandremotehealth
servicesaredifferenttothoseprovideinmoreurbanareas
Thetwoissuesoftieredfundingandmetro-centricapproachesare
exemplifiedbySouthAustraliawhereruralhospitalswereonaveragebeing
funded30%lessthantertiaryhospitalsforthesameprocedureatthetime
whenthenewRoyalAdelaideHospital–whichransignificantlyoverbudget
andtimetoopening–continuedtoreceiveadditionalfunding.Fundingfor
ruralhospitalsisajurisdictionalresponsibility.Itisofgraveconcernthatitis
moreequitablydistributedinsomeStates/Territoriesthanothers.
• regionaldevelopmentpolicies
Regionaldevelopmentplanningofferstheopportunitytoidentifycommon
groundandunifyapproaches.Itiscriticalthatpolicymakerslearnfrom
previousexperiencetoavoidissuessuchastheendemiceffortstoshiftcosts
thatareafunctionofAustralia’stieredhealthsystemfundingmodel.
Addressingdisparitiesinhealthandeducationmustbecentraltoregional
developmentplanningashighlightedbytheRegionalAustraliaInstitutein
itssubmissiontotheSelectCommitteeonRegionalDevelopmentand
Decentralisation:Thefirstgoalistomoreeffectivelydevelopourruraland
remoteheartlands.Thisinvolvesdeliveringlocallytailoredservicesthatcan
narrowthelongtermdividesinhealthandeducationoutcomesandensuring
thatwehavethelocalpopulationandskillsnecessarytosustainablydevelop
ourvastnaturalresourceendowment11.
Regionaldevelopmentpoliciesmust:
o recognisethatthegoodhealthandwellbeingofruraland
remoteAustraliansisessentialtopersonal,communityand
nationalsocialandeconomicgrowth
o acknowledgethattheprovisionofhealthservicesiscriticalto
underpindevelopmentoutsidecapitalcities,anddeliverthose
services
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o becognizantofpossiblehealthimpactsandensureappropriate
riskmitigationstrategiesareinplace.Forexample,theclosure
ofabusinessthatemployslargenumbersofpeoplehasa
detrimentaleffectonthementalhealthofthoselosingajobin
anareawherefindingnewemploymentisdifficult.Lackof
mentalhealthservicesinruralandremoteareasmeansthat
ruraldoctorsbeartheburdenofincreasedhealthneeds
o supportmulti-disciplinaryapproachesacrosshealthandother
sectorstoprovidehighqualitycareandsafetyforpatientsand
professionals.
• infrastructure
Improvingthetechnological,physicalandcapitalinfrastructureinruraland
remoteareasiscriticaltoreduceregionalinequalities,redressinequitiesand
promoteregionalgrowth.Thehealth,socialandcommunityservicesand
educationsectorswouldallbenefitfrominvestmenttoimproveaccessto
broadband,upgradefacilitiesandprovideorreplaceoldequipment.Arural
hospitalshouldnothavetorunfundraisingcampaignstobuynew
ultrasoundequipmentforitsbirthingcentre.
There-establishmentofaninfrastructuregrantsprogramandinnovative
optionsforfundingandbetterutilisingruralhealthinfrastructureshouldbe
explored.
Reliableandfastdatastreamingisbecomingmorenecessitythan‘niceto
have’inourrapidlyevolvingtechnologicalworld.Itisneededtotake
advantageofinnovationsinhealthmonitoringandtelemedicineandto
improveaccesstotraining,continuingprofessionaldevelopmentand
supportforprofessionals,includingdoctors.
Improvedtransportinfrastructureinruralandremote,especiallyairports,
will:
o supportrecruitmentandretentionofworkforces,includingfor
health
o supportemergencyservices,includingretrievalofpatients
o improveaccessibilityshouldpatientsneedtotravelfor
treatment.
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• education;buildinghumancapital;enhancinglocalworkforce
skills;employmentarrangements
Ensuringtheavailabilityofappropriatelyqualifiedworkforcestodeliverthe
locallytailoredservicesthatarerequiredtoredresstheinequitiesinhealth
andeducationoutcomesischallenginginmanyruralandremoteareas.
Whilethereisthepotentialforregional,ruralandremotecommunitiesto
makegreatercontributionstoeconomicgrowthandprosperityofthe
nation,populationlosstourbancentresisasignificantconcern12.
Providinglocallyaccessibleopportunitiesforsecondaryandhigher
education,includingcontinuingprofessionaldevelopment(CPD)and
pathwaystoenhancetheknowledge,skillsandexperienceofindividualswill
benecessarytostemthislossandtoattractnewresidents.
Employmentarrangementscanbeacriticalfactorinrecruitingandretaining
qualifiedpersonnel.Forexample,ruralandremoteAustraliaisfacingthe
challengeofmatchingcommunityexpectationswiththatofdoctors.
Communitiesarenowhavingtorecognisethatyoungerdoctorshave
differentmobilityrequirementsandareunlikelytomakelifelong
commitmentstoacommunity.Employmentmodelsmustconsiderthese
requirements,theimpactofchanginglifecircumstances,possible
limitationstocareerprogressionduetolocation,educationand
employmentopportunitiesforspousesandaccesstochildcareamongother
things.
• decentralisationpolicies
Whiledecentralisationpoliciesmayimpactongovernmentemploymentand
expenditureinregions,anyassociatedincreaseinpopulationinregional
centresandthesmallerruraltownsthatsurroundthemwillalsoplacean
additionalburdenonexistinginfrastructureandhealthservices.If
decentralisationpoliciesareintroducedtheymustbeunderpinnedby
investmentinhealth,socialservices,education,housingandtransport.
Workforceneedsmustalsobeconsidered.
Otherconsiderationsarethelossofeconomiesofscaleandtheriskthatthe
greatercostswillbepassedontoconsumers;theimpactofvirtualisationof
servicesandtheneedforstrongdigitalinfrastructure,andtheriskofgreater
compartmentalisationofviewsbasedonregionsselected(Howwillservices
appeartootherlocalities?).
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CONCLUSION
Clearlyaddressingregionalinequalityiscomplexand,inrelationtoruraland
remoteareas,issuesofequitymustbeakeyconsideration.
Withoutgoodhealththecapacityofruralandremotepeopletoeffectively
participateineconomicandsocialactivity,andtocontributetothe
attainmentofregionaldevelopmentgoals,willbecompromised.Without
improvementsinregionalcapacitytoprovideimprovedinfrastructure,offer
educationalandemploymentopportunities,buildhumancapitaland
increaseworkforceparticipationredressinghealthinequitieswillbe
problematic.
Addressingregionalinequalitywillbevitaltothesustainabledevelopment
ofAustralia’sheartland.Itwillrequire:
• agreementacrosspoliticaldivides
• amulti-faceted,holisticapproachtoregionalpolicydevelopment
thatseekstoredressinequities
• acknowledgementoftheimportanceofhealthanditssocial,
culturalandenvironmentaldeterminantswithinthiscontext,and
• strategicandoperativehealthplanswithclearandattainablegoals.
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ENDNOTES
1 Figure A.14 shows that people living in the capital cities of Perth, Sydney, Brisbane, and to a lesser extent Melbourne, are more likely to be in the top 20% and less likely to be in the people living in the capital cities of Perth, Sydney, Brisbane, and to a lesser extent Melbourne, are more likely to be in the top 20% and less likely to be in the bottom 20%. Figure A.15 shows that people living outside capital cities tend to be found more at the bottom of the income distribution than at the top, except in Western Australia. Australian Council of Social Services (2015). Inequality in Australia. Sydney: ACOSS. p50. https://www.acoss.org.au/wp-content/uploads/2015/06/Inequality_in_Australia_FINAL.pdf Viewed 23 May 2018. 2 National Rural Health Alliance (2017). Fact Sheet: Poverty in Rural & Remote Australia. http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-povertynov2017.pdf Viewed 23 May 2018. 3 For example, the Department of Agriculture and Water Resources indicates that the food industry … consistently accounts for around 20 per cent of domestic manufacturing sales and service income. The overwhelming majority of food sold in Australia is grown and supplied by Australian farmers. We are able to export more than half of our agricultural produce, while more than 90 per cent of fresh fruit and vegetables, meat, milk and eggs sold in supermarkets are domestically produced. http://www.agriculture.gov.au/ag-farm-food/food 4 http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf Viewed 23 May 2018. 5 http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-povertynov2017.pdf Viewed 23 May 2018. 6 Socio-Economic Indexes for Areas (SEIFA) is a product developed by the ABS that ranks areas in Australia according to relative socio-economic advantage and disadvantage. The indexes are based on information from the five-yearly Census. http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/2033.0.55.001~2016~Media%20Release~Census%20shows%20our%20most%20advantaged%20&%20disadvantaged%20areas%20(Media%20Release)~25 Viewed 23 May 2018. 7 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. https://www.aihw.gov.au/getmedia/6d6c9331-5abf-49ca-827b-e1df177ab0d3/ah16-5-11-rural-remote-health.pdf.aspx 8 Bishop, L., Ransom, A., Laverty, M., & Gale, L. (2017). Mental health in remote and rural communities. Canberra: Royal Flying Doctor Service of Australia. p15. 9 http://www.quitnow.gov.au/internet/anpha/publishing.nsf/Content/submission-coa Viewed 23 May 2018. 10 National Mental Health Commission, 2014: The National Review of Mental Health Programmes and Services. Sydney: NMHC. p6. 11 Available at http://www.regionalaustralia.org.au/home/our-current-work/policy/ Viewed 23 May 2018. 12 Australian Bureau of Statistics mapping of POPULATION CHANGE BY SA2, Australia - 2016-17 shows a decline or relatively static population growth across most rural and remote regions. The combined population of Greater Capital Cities increased by1.9% between 30 June 2016 and 30 June 2017, accounting for 81% of Australia’s total population growth. http://www.abs.gov.au/ausstats/[email protected]/mf/3218.0. Viewed 28 May 2018.