AMA VICDOC Autumn 2024 - Magazine - Page 24
Most research focuses on the direct causes of
poor rural health: health professional shortage,
lower income and employment levels, lower
educational levels, higher average age, and a
lack of geographical healthcare access.
However, this research fails to look at the
original urban-centric policies that caused these
issues. In the 1980s, the Australian government
began to adopt neo-liberal policies that rolled
back its intervention in the market, emphasising
individual responsibility and prioritising the
free market. However, rural communities –
with their smaller businesses and populations –
were disadvantaged by this shift while urban
areas benefitted. This is for three main reasons:
a dynamic market for services is less likely to exist
in rural regions and hence competition is less
likely to result in more competitive businesses,
job losses have significant consequences in rural
communities as alternative employment prospects
are limited, and small businesses are unlikely to
achieve the economies of scale that competitive
markets favour.
One study for example shows how Australia’s
National Competition Policy (NCP) and
compulsory competitive tendering in Victoria
potentially led to “the economic hollowing of
country Victoria” (Ernst et al., 1998). Testifying
to this, a 1998 submission to the Productivity
Commission by the Grains Council of Australia
warned that, if the NCP were to continue without
any adjustments for rural Australia, Australia’s
grain industry would suffer and rural Australians
as a result. However, the NCP continued, and
a 1999 Productivity Commission review of the
NCP found that the program indeed favoured
metropolitan areas more than rural and regional
areas. A 2005 review at the program’s conclusion
found again that it had had negative influences on
economic activity and employment in a number
of smaller regional areas while those living in
major cities recorded the greatest increases in
incomes. The Commission bluntly acknowledged
that it was “inevitable” that reforms designed to
remove sources of inefficiency in the economy
would create “losers” and “winners” – with the
“losers” being regional areas who suffered job
losses and reduced incomes.
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In combination, these policies whittled
away rural incomes and resulted in an oftseen downwards spiral in rural regions, where
unemployment and reduced incomes made it even
harder for rural areas to attract new employers
or employees. Additionally, perceived lack of
opportunity in rural areas incentivised young
people to leave for Australia’s cities, and these
reduced populations reduced the availability of
amenities. It also reduced government support
for hospitals via the casemix funding model,
which funds hospitals based on the number of
patients treated and activities conducted. Reduced
hospital capability itself began a downwards spiral
that challenged hospitals’ viability as it meant
that complex patients were transferred to larger
hospitals – further reducing the need for funding.
This has resulted in the unattractiveness of rural
areas to health professionals that we see today.
These professionals commonly cite disincentivising
factors such as poor hospital infrastructure and a
lack of opportunities for children and partners.
A more insidious factor was also at play:
rural-urban power differentials. The longstanding
urban-centric narrative of Australia consisting
of powerful urban centres orbited by rural
communities discreetly led to the de-prioritisation
of rural Australia in Australian policy. Additionally,
economic restructuring in the late 20th century
from agricultural, mining and manufacturing
to service-based sectors, the deregulation of
the financial system, as well as the increasingly
market-based system gave metropolitan cities
further financial and labour-force advantages that
translated into power and influence. Concurrently,
rural capacity to advocate for increased funding
and services declined with growing disadvantage.
Urban health is ultimately linked to rural health.
An erosion in rural healthcare capacity ultimately
results in overloaded metropolitan cities and
hospitals. This is already happening in Canada,
where Ontario’s urban hospitals have become
overwhelmed by dislocated rural patients. A 1998
research paper on the decline of rural Australia
damningly predicted this very scenario, saying:
“metropolitan Melbourne and half a dozen regional
centres will in future service the needs of everdeclining rural populations” (Ernst et al., 1998).
