What is rural health and why does it matter?

There were over 620,000 people living in rural New Zealand in 2014, an increase of over 100,000 since the 1980s.¹ Our government has a target of doubling the value of our primary industry exports by 2025. It recognises that in order to achieve this 50,000 more people will have to be working in primary industries.² We need healthy vibrant communities throughout rural New Zealand to support and attract this workforce.

One of the core values that we aspire to as New Zealanders is social equality³ but we do not do well when it comes to translating what we say into action in the health sector.⁴ What do we know about the impact of living in rural New Zealand on health outcomes? Do we achieve equity across the urban-rural divide?

Health care services provided to people who live in a rural community can be accessed in their own home, in their local community or in regional and metropolitan centres at some distance from where they live. It is known that the further away people are from services, the less likely they are to use those services⁵ and we would expect this ‘distance decay’ phenomenon to have an impact on health outcomes in rural New Zealand as it does elsewhere in the world. It therefore came as a significant surprise when in a review of rural health services published in 2010 the National Health Committee identified only minor differences between the health status of urban and rural populations.⁶ The problem was compounded by the small number of studies that had been undertaken in rural New Zealand and issues around defining rurality.

We do know that rural Māori are worse off in many ways than urban Māori, having for example lower life expectancy and lower levels of health services utilisation than both urban Māori and rural and urban Pakeha. We also know that rural people have higher rates of mental health problems than urban people.⁷ We know that rural people present with more advanced cancer and use services such as radiotherapy less often.⁸ The reasons for these differences are likely to be multifactorial and complex, but two key contributing factors to problems of access are highlighted in papers in this month’s journal – cost and workforce.

David Fearnley, Ngaire Kerse and Garry Nixon demonstrate there are substantial costs incurred for rural people attending hospital services that may contribute to delayed presentation to hospital services.⁹ In another paper Deanne Wong and Garry Nixon show that the rural medical workforce in New Zealand is in a fragile state.¹⁰ Rural medics are older and more likely to retire in the next 10 years than their urban counterparts. Rural medics are working longer hours, and more likely to be involved in teaching. These authors make a strong plea for a clear and accurate way to analyse the impact of living in a rural community on health outcomes. A recent viewpoint article in the New Zealand Medical Journal discussed in depth the impact on research and outcome data from the lack of clarity around defining where people live and where they access services.¹¹ New Zealand has recently refreshed its Health Strategy¹² and if we are to fully understand what it means to provide services closer to home it seems obvious that we need to be able to accurately link where people live with where they access services.

Peter Drucker said ‘What gets measured gets managed.’¹³ If we are a country that values social equality, we need to measure more accurately the impact of living in rural New Zealand on health outcomes.