Why Settle for Equity?

Abstract

The rurality gradient, in which health outcomes worsen the greater the distance from metropolitan locations, is well-established and enduring. This health disparity has maintained a strong hold on the attention of many politicians, policy- and other decision-makers and has been the focus of numerous policy imperatives and program and service innovations, all aiming to close the health gap. Yet, despite the best efforts of many talented and committed people, the health inequity gap remains.

Sometimes, when a problem is complex, intractable, even “wicked”, it can be helpful to step back and examine the construction of the concept that defines the problem. The concept in this case is health inequity or a health “gap”. Considering this gap in some detail may be instructive.

While there is appropriate sensitivity to “metrocentric” approaches in which programs and services are developed in metropolitan centres and then disseminated to non-metropolitan jurisdictions with little apparent regard for the importance of context, the same sensitivity does not appear to have been applied to the health inequity gap. It seems to be the case that metropolitan standards have become the default benchmark when considering health, education, and other statistics.

The Australian Institute of Health and Welfare [1] plays an important role in providing current statistics about rural and remote health. When reporting on age, we are informed that “On average, people living in Inner regional and Outer regional areas are older than those in Major cities.” For education, “In 2023, people aged 20-64 living in rural and remote areas were less likely than those in Major cities to have completed Year 12 or a non-school qualification.” There are also numerous health statistics in which metropolitan centres are presented as the comparison standard. In terms of chronic conditions, “people living outside Major cities had higher rates of arthritis, and mental and behavioural conditions, while chronic obstructive pulmonary disease was higher in Outer regional and remote areas compared with Major cities” [1].

How has the narrative arisen that metropolitan standards are those to which non-metropolitan areas should aspire? Comparisons similar to those prepared by the AIHW are offered in Queensland (QLD) Health's (2022) Rural and Remote Health & Wellbeing Strategy 2022-2027. For example, Queenslanders living outside metropolitan areas have one to 3 years less life expectancy than metropolitan residents and, in 2020, daily smoking prevalence was higher outside major cities [2]. A gap, however, necessarily has two sides. If some catastrophic city-based event were to occur so that people living in major cities started dying at a younger age, the life expectancy gap would close. Conversely, if the gap was flipped so that, due to a series of fortunate events, country people lived three to 4 years longer than city people, would there be concerted efforts directed towards the living conditions in cities?

Is achieving health outcomes that are the same as the city really what we are asking regional, rural, remote, and very remote citizens to settle for? The default position is reflected in ways other than the presentation of statistics. It is straightforward to find references to “metropolitan and non-metropolitan” locations but very uncommon to see the same distinction expressed as “non-rural and rural” locations. The city of Karratha has the wonderfully aspirational vision of being “Australia's most liveable regional city” [3]. Why, though, did the creators of this vision see it necessary to include the word “regional”. Could a regional jurisdiction not set a course to become, unapologetically, “Australia's most liveable city”?

Although the health inequity narrative can appear pervasive and consuming, there are exceptions. In Western Australia (WA), South Australia (SA), and Victoria (Vic), state legislation requires local shires and councils to develop their own public health plans. The plans are called Public Health Plans (WA), Regional Public Health Plans (SA), and Municipal Public Health and Wellbeing Plans (Vic). Time frames are specified for developing and reviewing the plans.

Perusing a small number of these plans is illuminating. Terms such as “health disparity” and “health inequity gap” do not appear in the plans and, where “equity” is referred to, it is discussed in the context of equity within the local jurisdiction not equity between the local area and a city. The plans provide information about the profile of the region and in these sections, comparisons are often made. The comparisons, however, are between the local area and national, state, or regional statistics. For example, 54% of the Kalgoorlie-Boulder City's population eats less than 2 serves of fruit daily whereas the prevalence is 57.4% for WA overall [4]. There are no comparisons in the Kalgoorlie-Boulder City Council's Public Health Plan between the Kalgoorlie-Boulder population and the Perth population. Similarly, in Mount Gambier, approximately 14% of 16-year-olds were not engaged in full-time secondary education compared with 17% in regional SA [5] and no comparable statistics with Adelaide are provided. In the Campaspe Shire Council, 46.2% of residents assessed their health as good or very good compared with 44.1% for Vic [6] but no comparison with Melbourne residents is offered.

It appears then, that local areas are interested in improving the living conditions for their residents without any hint that non-rural living conditions are the target they are aiming for. Instead, the plans explicitly describe the process they employed to develop their local priorities or focus areas (e.g., [7]) and extensive community consultation is a main component. Other sources of information were also used such as the priority areas specified in the state Public Health Plan and relevant policy and research documents.

This small number of public health plans from different rural areas across three Australian states indicates that closing the metropolitan non-metropolitan health inequity gap is not high on the agenda of country residents and decision-makers. This may create a tension for outside organisations (including universities) who do have addressing health inequity on their agendas. If they also have a priority for being community-led and assisting communities to address local priorities, then they might need to be prepared to follow rather than lead in terms of identifying the problems to be solved.

One area of expertise from outside organisations that may be of benefit to rural and remote jurisdictions is community consultation and the systematic collecting, organising, and analysing of information. Although the outside organisations will not know local residents or the context, if they are willing to be advised, they could assist with methods that promote a broad canvassing of ideas and priorities. For example, one framework that could be helpful in planning a multifaceted strategy considers a community (however that is defined) from the perspective of both its people and priorities.

In this example, therefore, there were two different people (someone from a health organisation and a local artist) with two different priorities (meeting KPIs and cataract surgery). It might also be recognised that, in any particular community at any given time there will be unknown people or priorities (or both). For example, 412 residents of Kalgoorlie-Boulder City completed a survey or participated in a conversation during the development of their current Public Health Plan. These residents listed crime and community safety, drug misuse and harm, and mental health wellbeing as their top three priorities [4]. In this situation then, some priorities are known but the people who hold these priorities might be unknown. Given that the population of Kalgoorlie-Boulder City was 30 679 in 2023 [4], there may also be many more priorities that are unknown.

Borrowing shamelessly from Donald Rumsfeld, therefore, it might be useful to think about communities in terms of known and unknown people and priorities [9]. So, in any community, there will be certain people (or groups of people) who are known and whose priorities are known; there might also be people or groups of people who are known but whose priorities are unknown. Then there could be certain priorities that seem obvious but without any clear indication of who the relevant people are who hold these priorities, and there might also be unknown people or groups of people in a community whose priorities remain similarly unknown. Perhaps when initiatives do not have the uptake and engagement that were anticipated, it is because one or more of these known-unknown combinations have been overlooked. Through community-led consultation and strategy development, different approaches for addressing the knowns and the unknowns could be devised to promote a more thorough acquaintance with the community and its priorities.

One way of addressing the health inequity problem could be to change the narrative of what the problem actually is. There seems to be no clear reason to assess a rural and remote jurisdiction's demographic and other statistics relative to metropolitan statistics. Why should it matter how many obese people are in the country compared to the city? Or why is it important if people in the country smoke and drink more than city residents?

Could that be the fundamental issue? To what extent do people love where they live? Perhaps more specifically, to what extent are people living the life they want (wherever they are living)? It need not be of concern as to whether people in Blackwater are living the life they want more (or less) than people in Brisbane. What can local, state, and national governments do to help people answer “a great deal” when asked about the extent to which they are living the life they want? It could be that pursuing answers to this question might lead to more effective, engaging, impactful, and sustainable solutions than trying to close a gap that is only present because of a metrocentric emphasis on the way life should be lived.

It is exciting beyond words to be able to announce that themes such as these will be pursued in an ambitiously innovative centre being created by CQUniversity. Originally positioned as the Centre for Health Equity in Regional and Remote Communities (CHERRC) it has generated interest across the university not only from talented researchers and educators in public health but also from areas such as Business and Law, Education, Emergency and Disaster Management, Information and Communication Technology, and Paramedicine. As a regionally based university with the most expansive reach of any Australian university, CHERRC aims to become a resource for regional, rural, remote, and very remote communities to access whenever they require help solving the problems they face in living well. The vision is very much looking beyond equity to establishing community standards and aspirations on local terms for a new narrative of what it means to thrive and flourish in country Australia.

Timothy A. Carey: writing – review and editing, writing – original draft, conceptualization.