Background


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The 4th International Conference on Public Health

Best Western Premier Hotel, Solo, Indonesia
August 29-30, 2018

“Reaching the Unreached: Improving Population Health
in the Rural and Remote Areas”

BACKGROUND
Access to healthcare services is critical to good health. Yet one billion people (15% of the world population) are unreached in terms of accessing to quality healthcare service. Most of the unreached people are from rural areas in developing countries (Ahmed et al., 2013). Residents in the rural and remote areas face a variety of barriers to healthcare services. People in the rural and remote areas might not be able to get to a hospital quickly in an emergency they need. They also might not want to travel long distances to get routine checkups and screenings (Medline Plus, 2018). In most rural and isolated areas, it can take hours to reach the nearest puskesmas (health centers) due to poor road condition, topography, and a lack of transportation. Particularly for countries with outstreched geographical areas like Australia, China, Canada, Ethiopia, and, Indonesia, ensuring access to timely and quality health care needed is a thorny issue. For example, villagers of Papua (Indonesia) have to make an extra effort to get medical services as the region has geographical challenges with low and highland forest areas (Figure 1).

ICPH 2018_Dani tribe

Figure 1  Dani tribe woman in their traditional outfits
walking in Ugem Village, Baliem Valley, West Papua,
Indonesia – circa February 2016. Source: Dreamstime, 2017

Remote and rural areas often face the lack of health workforce like nurses and midwives. Doctors, dentists, and specialists might be unavailable at all. Globally, approximately one half of the population lives in rural areas, but less than 38% of the nurses and less than 25% of the physicians work there (World Health Organization, 2018). Local puskesmas are often run by one nurse or midwife who is responsible for a population of several thousand residents. In effect the access to healthcare services in a country with thousands of islands like Indonesia and other countries with outstretched vast land like in Africa and Australia is vastly unbalanced. Many isolated areas do not have the standard health professional to people ratio. Figure 2 shows an inactive subhealth center in Dombu village, Marawola Barat, Sigi district, Central Sulawesi, due to the absence of health manpower (Kompas, 2015).

ICPH 2018_Sulteng

Figure 2   An inactive subhealth center in  Dombu village,
Marawola Barat, Sigi district, Central Sulawesi, Indonesia, due
to the absence of health manpower. Source: Kompas, 2015

Because it can be hard to get care, health problems in remote and rural residents may be more serious by the time they are diagnosed (Medline Plus, 2018). In turn, the critical shortages, inadequate skill mix and uneven geographical distribution of the health workforce pose major barriers to achieving the equitable distribution of population health. Most districts in Papua, like in Puncak district, Papua, are in need for supply of health care facilities and health workforce (Pademme, 2016).

On top of that, people in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services (Peters et al., 2008). Most villagers living in hard-to-access areas are commonly poor and near-poor, leaving them at risk as it is difficult for them to bear the costs of medical treatment. Getting necessary health services in these settings may lead to time off work and a loss of pay to look after ill relatives, paying transportation and medication costs and perhaps even taking out a loan to cover medical expenses (Wiradji, 2016). For example, due to proverty, sick villagers in remote area in Nias island, North Sumatera, Indonesia, are taken to puskesmas (health center) only after health condition become worse. The ship fare to get Sumatera mainland was Rp 100,000 per person, and the caring family must bear the lodging cost and other expenses. It took 3-6 hours inter-island travel from the farthest island to reach the health facilities (Khalikholic, 2009).

Challenges related to low income, poverty, lower levels of education and higher unemployment negatively affect health status of rural and remote citizens and place them at greater risk for poorer quality of life and poorer health than those living in urban areas. As a consequence, isolated areas lag behind other easy-to access areas when it comes to community health. Rural populations have poorer levels of health status than their urban counterparts (White, 2013).

For example, in Indonesian underserved isolated areas, the maternal and child mortality rate reportedly remaining high as children in particular are vulnerable to diarrhea, malaria and other infectious diseases (Wiradji, 2016). In rural Canada, in comparison to urban areas, rural areas tend to have higher disability rates, shorter life expectancy, higher infant mortality rates and higher death rates due to injuries, circulatory and respiratory diseases, diabetes and suicide (White, 2013).  Likewise, heart disease kills more regional, rural and remote Australians (HealthTimes, 2017).

Although a lack of financial resources or information can create barriers to accessing services, the causal relationship between access to health services and poverty also runs in the other direction (Figure 4). When health care is needed but is delayed or not obtained, people’s health worsens, which in turn leads to lost income and higher health care costs, both of which contribute to poverty (Peters et al., 2008).

In order for rural and remote residents to have sufficient healthcare access, it is essential to ensure that necessary and appropriate services are available and obtainable in a timely manner. As the Ministry of Health Regulation (Permenkes) Number 75 Year 2015 on Puskesmas (Health Center) states it, every puskesmas must have a doctor, dentist, nurse, midwife, public health worker, environmental health worker, laboratory technician, dietician, and pharmacist. However, a large number of puskesmas in the remote, country border, and isolated places of Indonesia are lacking in health workforce. About 5 percent of 9,731 puskesmas did not have any doctor in 2016 (Jamsos Indonesia, 2016).
In order to fill the shortage of health workers in remote areas, the Ministry of Health has launched “Tim Nusantara Sehat” program since 2015. In 2015 the Ministry of Health assigned “Tim Nusantara Sehat” in two phases. Phase 1 consisted of a total of 1, 143 health workers designated to 20 puskesmas in 9 provinces. Phase 2 comprised a total of 553 health workers allocated to 100 puskesmas in 14 provinces (Jamsos Indonesia, 2016).

In May 11, 2016, Ministry of Health signed a Memorandum of Understanding of “Nusantara Sehat” with 27 district governments from 16 provinces. It calls for the local government support for “Tim Nusantara Sehat” in each of their jurisdictions. The local governments are expected to guarantee the life safety of “Tim Nusantara Sehat” on duty, and to provide infrastructure and appropriate housing for the health manpower. The local governments are also expected to issue Surat Izin Praktik (Practice License) for the “Tim Nusantara Sehat” to be able to do clinical practice (Jamsos Indonesia, 2016).

Researchers and community development innovators have attempted to develop models on how to improve access to health care for people living in the rural and remote areas. White (2013) highlighted the need for population health data that describe not only the health status of the population, but also the social determinants of health and policies underpinning variations in rural and urban health. A population-based health promotion approach has been proposed, which features a pragmatic shift in thinking about population health with health status is determined by a wide range of factors, including income and social status, social support networks, education and literacy, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services and gender. All of these factors are influenced by whether an individual lives in a rural or an urban setting.

The broader way of thinking about rural and remote health shifts from the “medical model” that encompasses evidence-based medicine to one of community capacity-building for health that also emphasizes a rural health promotion response . This comprehensive population-based health promotion approach is believed to be effective as healthcare reform for the population health in the rural and remote areas (White, 2013).

White (2013) has carried out a literature review  of 30 papers to describe the development and application of an evidence-based Rural Health Framework from a population health approach to guide rural and remote health program, policy and service planning. From the literature the author identified six key elements for rural health population program planning and delivery that can be used to guide the development of rural health programs. These six key elements are adopted with an adjustment of the element order that can be used for rural and remote health population program planning and delivery, as follows (White, 2013):

1. Identify a rural and remote community
A rural and remote population health approach identifies rural and remote areas using a common definition. Each definition emphasizes different criteria such as population size, labour market context, population density, or settlement context and as such, has important implications for program planning.

2. Focus on a rural and remote health issue
A rural and remote population health approach uses evidence to assess the health status of the population and respond to identified needs. Evidence-informed practice uses population health assessments, surveillance, research and program evaluation to generate evidence. It answers the following questions: How healthy is the rural population? How do we know? What are the community’s priorities? Are there any emerging issues? What are the priority populations? How does the health of the population look over time? Is the population health status getting worse or better?

3. Identify the social determinants of health
A rural and remote population health approach considers a full range of factors that influence and contribute to health, including social environments, income and social status, education and literacy, employment/working conditions, physical environment, personal health practices and coping skills, culture, health services, healthy child development, biology and genetic endowment, social support networks and gender.

4. Identify community rural and remote health challenges and assets
A rural and remote population health approach calls for the identification of rural health challenges and assets using a framework based on the social determinants of health. Challenges are informed by population health assessment, surveillance, research, program evaluation and personal experiences. Examples of challenges are access to healthcare services, geographic and social isolation, and poverty. Assets are advantages and attributes within a rural community that are vital to sustainability and growth, such as physical infrastructure (buildings), green space, social aspects of community living, agriculture and volunteerism.

5. Address rural and remote health challenges and maximize assets using good practices for rural and remote program planning and delivery
A rural and remote population health approach involves addressing health challenges and maximizing assets using a framework based on the social determinants of health. This approach contributes in meaningful ways to the development and implementation of strategies to improve health and is based on good practices in minimizing rural health challenges and maximizing assets as identified in the literature review.

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Figure 3 An evidence-based Rural Health Framework from a population
health approach to guide rural and remote health program, policy and
service planning, based on White (2013)

6. Integrate multiple levels of community support
A rural and remote population health approach uses multiple levels of support from various sectors and levels that have a vested interest in the health of the target population in every phase of the project. Early collaboration is recommended and includes but is not limited to researchers, health professionals, community organizations, government and other key stakeholders.

Figure 4 depicts a conceptual framework that can be used to assess access to health services in remote and rural areas. This framework describes four main dimensions of access, each having a supply-and-demand element, and include the following (Peters et al., 2008):

  1. Geographic accessibility—the physical distance or travel time from service delivery point to the user
  2. Availability—having the right type of care available to those who need it, such as hours of operation and waiting times that meet demands of those who would use care, as well as having the appropriate type of service providers and materials
  3. Financial accessibility—the relationship between the price of services (in part affected by their costs) and the willingness and ability of users to pay for those services, as well as be protected from the economic consequences of health costs
  4. Acceptability—the level of responsiveness of health service providers to the social and cultural expectations of individual users and communities

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Figure 4 Conceptual framework for assessing access
to health services. Source: Peters et al., 2008

In Figure 4, quality of care is at the center of the circle of all four dimensions of access to health services, because it is an important component of each dimension and is ultimately related to the technical ability of health services to affect people’s health. To the left of the circle are sets of more distal determinants of health service access, shown at the policy or macroenvironmental level, as well as the individual and household levels (Peter et al., 2008).
Policy-makers in all countries, regardless of their level of economic development, struggle to achieve health equity and to meet the health needs of their populations, especially vulnerable and disadvantaged groups. As noted above, there are a number of challenges including a complex one to ensure people living in rural and remote locations to have access to trained and motivated health workers.

Based on the problem background described above, the 4th International Conference on Public Health is planned to be conducted in Solo, Indonesia, on August 29-30, 2018, to discuss these issues of remote and rural health. The scopes of discussion cover four areas of WHO recommendation with specific issues, as follows:

  1. Education:
    Targeted student admission policies, location of health professional schools, student exposure to rural and remote community experiences, revision of undergraduate and postgraduate curricula, design of continuing education and professional development
  2. Regulatory:
    Enhanced scope of practice to increase job satisfaction, thereby assisting recruitment and retention, introduction of different types of health-related workers, compulsory service requirements, provision of scholarship and other education subsidies
  3. Financial incentives:
    Use of a combination of fiscally sustainable financial incentives (such as hardship allowances, grants for housing, free transportation, paid vacations etc.) sufficient enough to outweigh the opportunity costs associated with working in rural and remote areas (as perceived by health workers) to improve rural retention.
  4. Personal and professional support:
    Improved living conditions for health workers and their families and investment in infrastructure and services, provision of a good and safe working environment, implementation of appropriate outreach activities to facilitate cooperation between health workers from better served areas and those in underserved areas, support for remote and rural career development programmes, support for the development of professional networks, adoption of public recognition measures.

Researchers have investigated the likely effective interventions to address health issues in rural and remote areas. For exmple, Verma et al. (2016) conducted a systematic review that aimed to evaluate interventions and strategies used to recruit and retain primary care doctors internationally. The authors identified several tested intervention that are of value for an improvement in recruitment and retention of health workers in rural and remote areas. These interventions, from the strongest to weakest evidence, are as follows: (1) Financial incentives; (2) Recruiting rural students; (3) International recruitment; (4) Rural or primary care focused undergraduate placements; (5) Rural or underserved postgraduate training; (6) Well- being or peer support initiatives; (7) Marketing; (8) Mixed incentives; (9) Support for professional development and academic opportunities; (10) Retainer schemes; (11) Re-entry schemes; (12) Delayed partnership; (13) Specialized recruiter or case managers.

A study by King et al. (2016) reported another evidence with different perspective on the retention of rural health workers in Australia. Through rural clinical schools (RCSs), medical students may undertake an extended block of clinical training in rural Australia. The premise of these placements is that meaningful rural exposure will facilitate rural career uptake. RCSs offer a range of supports to facilitate student engagement in the program. The study aimed to analyze RCS students’ perceptions of these supports and impact on intentions to work rurally. The results showed that student perceptions of supports offered by RCSs were generally very positive. Perceptions of financial support were not predictive of rural career intent. Although this does not negate the importance of providing appropriate financial supports, it does demonstrate that student wellbeing is a more important recruitment factor for rural practice.

Ahmed et al. (2013) introduced the application of information and communication technology (ICT) to solve the issues of insufficient healthcare facilities and unavailability of medical experts in rural areas. In line with the recent penetration of mobile phone in developing countries, Ahmed et al. (2013) has introduced a pervasive way to serve the unreached community for preventive healthcare using the ICT. The authors call it a “portable clinic” with a software tool “GramHealth” for archiving and searching patients’ past health records. In order to observe the local adoption of the technology, they carried out experiments in three remote villages and in two commercial organizations in Bangladesh by collaborating with local organization. The authors also monitored the usability of the portable clinic and verified the functionality of “GramHealth”. The mobile-phone based remote health consultancy system has some advantages and technical challenges.

REFERENCES:

Ahmed A, Nakashima N, Inoue S, Nohara Y (2013). Portable Health Clinic: A pervasive way to serve the unreached community for preventive healthcare. From book: Distributed, Ambient, and Pervasive Interactions: First International Conference, DAPI 2013, Held as Part of HCI International 2013, Las Vegas, NV, USA, July 21-26, 2013. Proceedings (pp.265-274)

Dreamstime (2017). Dani tribal people in Ugem Village. https://www.dreamstime.com/editorial-photo-dani-tribal-people-ugem-village-baliem-valley-west-papua-indonesia-circa-february-tribe-woman-their-traditional-outfits-walking-image74189396. Accessed in May 2018.

HealthTimes (2017). Remote Health.
https://healthtimes.com.au/hub/remote-health/52/. Accessed in May 2018.

Jamsos Indonesia (2016. 130 puskesmas daerah terpencil diperkuat. http://www.jamsosindonesia.com/newsgroup/selengkapnya/130-puskesmas-daerah-terpencil-diperkuat_9824. Accessed in May 2018.

Khalikholic (2009). Ribuan puskesmas di daerah terpencil tak ada dokter
http://khalikholic.blogspot.co.id/2009/03/ribuan-puskesmas-di-daerah-terpencil.html. Accessed in May 2018.

Pademme A (2016). Puskesmas Gome butuh penambahan fasilitas. http://tabloidjubi.com/16/2016/04/05/puskesmas-gome-butuh-penambahan-fasilitas-2/ Accessed in May 2018.

Peters DH, Garg A, Bloom G, Walker DG, Brieger WRr, Rahman HM (2008). Poverty and access to health care in developing countries. Ann. N.Y. Acad. Sci. 1136: 161–171

King K, Purcell R, Quinn S, Schoo A, Walters L (2018), Supports for medical students during rural clinical placements: factors associated with intention to practise in rural locations. Rural and Remote Health 2016; 16: 3791. Available: www.rrh.org.au/journal/article/3791. Accessed in May 2018.

Medline Plus (2018). Rural Health Concerns.
https://medlineplus.gov/ruralhealthconcerns.html. Accessed in May 2018.

Verma P, Ford JA, Stuart A, Howe A, Everington S, and Steele N (2016) A systematic review of strategies to recruit and retain primary care doctors. BMC Health Services Research. 16:126. DOI 10.1186/s12913-016-1370-1

White D (2013). Development of a rural health framework: implications for program service planning and delivery. Healthc Policy. 8(3): 27–41a.

Wiradji SM (2016). Addressing health issues among underserved communities in isolated areas. http://www.thejakartapost.com/adv/2016/10/26/addressing-health-issues-among-underserved-communities-in-isolated-areas.html. Accessed in May 2018.

World Health Organization (2018). Global policy recommendations: Increasing access to health workers in remote and rural areas through improved retention. http://www.who.int/hrh/retention/Executive_Summary_Recommendations_EN.pdf?ua=1. Accessed in May 2018.

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