Addressing the Rural HHR Challenge: A Decade of Canadian Experimentation

Joshua Tepper MD, CFPC, MPH, MBA

Declaration of Competing Interests

Representing only myself

No COI

About Canada

Canadian Health CareNational Health System since 1964

reaffirmed in Canada Health Act 1984

Provincial/Territorial administration

Approx. 30% of costs paid by individual

Slow privatization (Diagnostics and Surgery)

1.1M employed in health care

Approx. 149,000 Nurses, 75,000+ MD

A system in crisis (HHR, Cost/Value, Access)

Distance to Specialist Care

0.52 - 14.99

15.00 - 24.99

25.00 - 49.99

50.00 - 99.99

100.00 - 2005.72

Sparsely Populated Area

(KM)

Home to 22-30% of Canadians (50%+ of Aboriginal)

More likely to be obese, smoke, drink alcohol to excessive levels, be less physically active; have a disability; die from cancer, heart disease, suicide, homicide, have traumatic injury & death

More likely to have a lower level of income, education and employment

Health status and access to health services both decline with increasing remoteness.

Chronic Maldistribution of health workforce

Rural and Remote Canada

Home to 1/3 of Australians

More likely to be obese, smoke, drink alcohol to excessive levels, be less physically active; have a disability; die from cancer, heart disease, suicide

More likely to have a lower level of income, education and employment

Health status and access to health services both decline with increasing remoteness.

Maldistribution of health workforce

Remoteness Areas in AustraliaSource: ABS (2008) Australian Social Trends.

Rural and Remote Australia

Thanks to Tanya Lehman

“The success of our health care system as a whole will be judged not by the quality or services available in the best urban facilities, but by the quality of service Canada can provide to its remote and Northern communities”

- Jose Amaujaq Kusugak

“Canada may, in fact, have a very good health care system with health outcomes that are generally among the best in the world. But there are growing signs that this is not the reality for Canadians living in smaller or more isolated communities across the country.”

- Roy Romanow, 2002

Examples of Rural HHR Initiatives

CaveatsSnapshots not a comprehensive review

Many areas have similar initiatives

Does not speak to impact

Ontario Focus

Medicine focus

Impact needs to be studied

If you have seen one rural town…If you have been to one Canadian Province/Territory….

New Educational ModelsOntario

Comprehensive Approaches

British Columbia: Rural Retention Program

Rural Continuing Medical Education Fund

Recruitment Incentive Funding

Recruitment Contingency Fund

Isolation Allowance Fund

Rural Emergency Enhancement Fund

Rural Education Action Plan

Northern and Isolation Travel Assistance Program

Rural Locum Program (GP/GP-Anaethesia/Specialist)

http://www.health.gov.bc.ca/library/publications/year/2013/rural-guide-mar2013.pdf

Rural Education Action PlanUndergraduate Rural Participation ProgramUndergraduate Teacher’s StipendCME

Advanced Skills and Training ProgramFirst Year in Practice Enhancement ProgramRural Locum Service Upgrade ProgramUrban Skills Enhancement ProgramRural GP Locum CME Program (ACLS)Specialty Training Bursary Program (FM PGY3)

Comprehensive Approaches

British Columbia:

Regionalization & Service Closures:

Pan-Canadian

Saskatchewan closed 52 of 112 hospitals; 1993-1994

Ontario major restructuring Urban and Rural hospitals 225-150; 1996-2000

Surgery, Maternity, Labs, Mental Health and Emergency Departments

19

Primary health care

Specialized Models and Programs: Ontario

Ontario Rural Northern Physician Group Agreement (RNPGA)

Groups of physicians committed to providing core primary health care services in certain rural communities

The RNPGA provides a global payment to a group of physicians and ensures patients will receive a wide range of comprehensive primary care services in 38 northern communities. The RNPGA provides physician access to all people in the defined geographic area including residents in Long Term Care Homes, patients in hospital and emergency department coverage for communities with hospitals.

More than Doctors:Newfoundland

Aboriginal Health Human Resources Initiative

Increase capacity and number of education and training programs provided by Aboriginal institutions

Improving the contribution of mainstream education and training programs to the development of Aboriginal human resources

Improve Aboriginal students’ ability to pursue education and training through financial and other supports

Improving the cultural appropriateness and effectiveness of education and training programs to meet the needs of Aboriginal students and communities

Aboriginal Health Human Resources Initiative

The Role of TechnologyNunavut:

1/5 of Canada’s land mass; 27,000 people, 25 communities (148 to 7,000); only sea and air access

Ikajuruti Inungnik Ungasiktumi (IIU) Telehealth Network - ‘a tool to help people from far away’;

More than medical services: social services, educational, public health, administration

Live and ‘store and bring forward’

Four languages, Inuktituk, Innuinaqtun, French and English

Reflections on Rural HHR

JAMA 2012

Final ThoughtsHigh degree of variation – Pros and Cons

No ‘silver bullet’

Urban context has high degree of impact on rural HHR

Definition of rural is problematic but important

Major focus of initiatives is on medicine, some in nursing and not enough elsewhere

Addressing HHR Challenge in rural areas is a chronic challenge