Rural Proofing Principles Consultation
Over 900,000 New Zealanders, around 20% of the population, live in rural parts of Aotearoa.1 Compared to urban areas, this rural population has a greater proportion of older people and Māori. Rural populations also have poorer health outcomes, including higher mortality rates.2 This is particularly true for rural Māori.3 People living rurally, particularly Māori, are more likely to live in areas of high socioeconomic deprivation.4 Despite these higher health needs, and key differences in access to the social determinants of health (including telecommunications limitations), rural people are up to 37% less likely to have a hospital admission in a given year compared to people living in cities.5 This suggests poorer access to health services which is impacted by distance, travel times, and a range of associated direct and indirect costs.
Experiences of living rurally, and accessing and providing services, is nuanced and heterogeneous. There are degrees of rurality, with differing implications for people’s access to and experience of health services. Rural people living close to urban areas can have better access to services than those living in more remote areas. Remote rural practices, often with low enrolled populations, dispersed over wide areas, have higher operating costs and can lack efficiencies of scale.
For those living in rural and remote rural areas, the cost of travel, accommodation and lack of earnings to seek health interventions in urban areas can be a real barrier to early diagnosis and then ongoing treatment, even if services are free.6
Historically, our health services have been designed by those with an urban-biased, and often hospital-centric, world view.7 As a consequence, planning, delivery models and funding have not been flexible to ensure that the realities of rural health delivery have been considered. This has contributed to inequitable health outcomes for those living in rural areas.8, 9
With “considered design” rural health equity can be achieved. This can be done by carefully considering how every person, irrespective of their geographical location, can access a good, base level of health care. To ensure equitable health outcomes for all priority populations, there may need to be differential levels of service, planning or funding provided for certain targeted individuals or communities. 10, 11
A sector group has defined this approach of “considered design” in order to give the best possible equitable health outcomes for priority rural populations: “Rural-Proofing Health Decisions”.
The following Guiding Principles are provided to those making policy, funding and programme design decisions in order to help ensure that any outputs are the most appropriate for the rural context. These Principles are numbered for easy reference, but the numbers do not signify any relative importance. The context that they are considered for will make some Principles more important than others for that particular application.
The following Guiding Principles can be used to ensure effective Rural-Proofing.
1) The founding document of our country, Te Tiriti o Waitangi, is a binding contract between the Crown (NZ Government) and Māori as the Indigenous peoples of Aotearoa New Zealand. The Waitangi Tribunal determined, through a major report in 2019 (registered as WAI 2575),12 that health is a taonga of Māori and that the Crown has systematically contravened obligations under Te Tiriti across the health sector. Article Two of Te Tiriti guarantees iwi-Māori Tino Rangatiratanga over their taonga, while Article Three guarantees Māori equitable health outcomes.13-15 The Crown must continue to meet these commitments through Acts such as Pae Ora (Healthy Futures Act) and the Local Government Act, and their implementation through Crown Agencies.16, 17
2) Community involvement is vital. A key strategy, for the mitigation of the limitation of tools, efficacy of decision making and social acceptance of decisions, is the involvement of the rural community in all processes from design, to implementation and evaluation. The rural community includes providers, patients, iwi/hapū and wider community members. At all stages, techniques to ensure community voices are heard, that address the “tyranny of distance”, will need to be employed. All of this while remembering that every rural community is different and may require different approaches!
3) Continuity of care through ongoing relationships between the primary care team and whānau is the preferable health delivery system. Traditionally these relationships have been best achieved through in-person contact, but modern technologies can embrace different modalities to maintain these relationships including phone, video and text messaging between physical consultations. Continuity of care through these ongoing relationships with a primary care team has been shown to lower use of out-of-hours services, reduce acute hospitalizations, and lower mortality.18 For rural communities this will mean strategies to ensure access to a stable primary care team over the short, medium and long terms.
4) Every person in New Zealand, irrespective of where they live, should have equitable access to the healthcare and range of services they need.19, 20 Health outcomes should not show significant disadvantage due to factors such as rurality/distance, ethnicity, gender and socio-economic status. For rural people and communities, this may necessitate providing mobile, outreach and virtual options to reduce barriers. Where services can’t be delivered ‘close to home’, adequate travel subsidies must be in place to ensure equity of access. (Note: people living in rural communities know and accept that time for emergency response and treatment will never be equitable).
5) The most health disadvantage often occurs where the nexus, or intersection of factors, combine. Thus, identified populations or subgroups that are rural, identify as Māori and are also living in high socio-economic deprivation, are shown through research to have the worst health outcomes3, 8, 21 and therefore warrant the earliest interventions and largest proportional allocation of resource.
6) Where possible, empirical evidence should be used to prioritise decisions regarding the allocation of resource to provide health equity. (For example, if immunisation rates are lowest in remote rural communities, extra planning, services and funding should be directed to those areas to drive equitable health outcomes.).
7) The sustainability of rural health service providers is vital, because the rural communities who are recipients of those services rarely have alternatives if the provider fails – unlike peers in urban settings. “Sustainability” refers to a range of measures including finance and workforce (attract, train, retain).
8) There is no single universal definition of “rural” in New Zealand (or internationally). The concept of ‘rural’ is context specific and no one model or measure of rurality is universally applicable. The tools available all have limitations. Which particular tool, or combination of tools, should be applied to define rural inclusion in any commissioning process needs to be carefully considered to target specific outcomes of any initiative. Note: An analysis of different tools available to define ‘rural’ is attached for reference to this document. This analysis indicates that the Geographical Classification for Health (GCH)1 has been developed specifically to compare health differences between urban and rural populations and is the preferred tool when identifying rural people, whānau and populations.
9) Evaluation, review and accountability should be embedded in decision making. The variability of rural community context means that there will likely be unintended consequences of commissioning, investment and resource support across a range of rural communities. Embedding a process to assess consequences and iterate implementation is important to mitigate risk. All government, local bodies, NGOs and others should be held accountable by rural communities, and must have considered each of these principles in all of their work in servicing those communities.
10) No rural-proofing solution or decision will ever be 100% ‘right’. But that should not stop decisions being made that attempt to address rural health equity for the sake of those rural individuals, whānau and communities. Planning, service delivery and funding should be reviewed in an iterative process to fine tune any agreed solutions while minimising and mitigating any unintended consequences.
Thanks to the members of the Rural Definition Working Group who provided their skill, knowledge and judgement to this work over many months: Carol Atmore, Rachael Bayliss, Emma Boddington, Taima Campbell, Grant Davidson, Bill Eschenbach, Grahame Jelley, Talis Liepens, Michelle Meenagh, Rachel Pearce, Jo Scott-Jones, Jensen Webber, Jeremy Webber, Jesse Whitehead, Greville Wood.
References: [1] Whitehead J, Davie G, de Graaf B, et al. Defining rural in Aotearoa New Zealand: A novel geographic classification for health purposes. The New Zealand Medical Journal 2022; 135:22-38. [2] Whitehead J, Davie G, de Graaf B, et al. Unmasking hidden disparities: a comparative observational study examining the impact of different rurality classifications for health research in Aotearoa New Zealand. BMJ Open. 2023; 13:e067927. [3] Crengle S, Davie G, Whitehead J, de Graaf B, Lawrenson R, Nixon G. Mortality outcomes and inequities experienced by rural Māori in Aotearoa New Zealand. The Lancet Regional Health–Western Pacific. 2022; 28. [4] Whitehead J, Atkinson J, Davie G, et al. Comparison of the Sociodemographic Composition of Rural and Urban Aotearoa New Zealand: Insights from Applying the Geographic Classification for Health to the 2018 Census. New Zealand Population Review. 2024; 49:27-69. [5] Nixon G, Davie G, Whitehead J, et al. Rural-urban variation in the utilisation of publicly funded healthcare services: an age-stratified population-level observational study. New Zealand Medical Journal. 2024:33-47. [6] Fearnley D, Kerse N, Nixon G. The price of ‘free’. Quantifying the costs incurred by rural residents attending publically funded outpatient clinics in rural and base hospitals. Journal of primary health care. 2016; 8:204-9. [7] Fors M. Potato Ethics: What Rural Communities Can Teach Us about Healthcare. Journal of Bioethical Inquiry. 2023; 20:265-77. [8] Hauora Taiwhenua Rural Health Network. Rural Health New Zealand Snapshot 2024. 2024. [9] Fors M. Geographical narcissism in psychotherapy: countermapping urban assumptions about power, space, and time. Psychoanalytic Psychology. 2018; 35:446. [10] Reid P, Robson B. Understanding health inequities. In: Robson B, Harris R, (eds) Hauora: Māori Standards of Health IV A study of the years 2000–2005. Wellington: Te Ropu Rangahau Hauora a Eru Pomare, 2007; 3-10. [11] Whitehead J, L. Pearson A, Lawrenson R, Atatoa-Carr P. How can the spatial equity of health services be defined and measured? A systematic review of spatial equity definitions and methods. Journal of health services research & policy. 2019; 24:270-8. [12] Waitangi Tribunal. Health Services and Outcomes Inquiry. Edition., cited.Available from: https://waitangitribunal.govt.nz/inquiries/kaupapa-inquiries/health-services-and-outcomes-inquiry/ [13] Came H, O’Sullivan D, Kidd J, McCreanor T. The Waitangi Tribunal’s WAI 2575 report: Implications for decolonizing health systems. Health and Human Rights. 2020; 22:209. [14] Waitangi Tribunal. Hauora report on stage one of the health services and outcomes inquiry. Wellington, 2019. [15] Parliamentary Counsel Office. Treaty of Waitangi Act 1975. Edition., cited.Available from: https://www.legislation.govt.nz/act/public/1975/0114/latest/DLM435834.html?search=qs_act%40bill%40regulation%40deemedreg_local+government+act_resel_25_h&p=1 [16] Parliamentary Counsel Office. Pae Ora (Healthy Futures) Act 2022 – Public Act 6 Te Tiriti o Waitangi (the Treaty of Waitangi). Edition., cited.Available from: https://www.legislation.govt.nz/act/public/2022/0030/latest/LMS575483.html [17] Parliamentary Counsel Office. Local Government Act 2022. Edition., cited.Available from: https://www.legislation.govt.nz/act/public/2002/0084/latest/DLM170880.html?search=qs_act%40bill%40regulation%40deemedreg_local+government+act_resel_25_h&p=1 [18] Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. British Journal of General Practice. 2022; 72:e84-e90. [19] Minister of Health. Government Policy Statement on Health 2024 – 2027. Wellington: Ministry of Health, 2024. [20] Health MHMo. Accountability arrangements. Edition., cited.Available from: https://www.health.govt.nz/new-zealand-health-system/health-system-reforms/statutory-framework/accountability-arrangements [21] Nixon G, Davie G, Whitehead J, et al. Comparison of urban and rural mortality rates across the lifespan in Aotearoa/New Zealand: a population-level study. J Epidemiol Community Health. 2023; 77:571-7.
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