Rural hospital focus: defining rural

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The issue of defining 'rural' is something that has taken up much time at many meetings around the world. Usually it is very difficult to reach agreement, and different groups in different countries come up with and use different definitions. The key is what purpose the definition is used for.

Developed countries tend to define rural (and often remote at the same time) related to the size of communities (population) and, in terms of remoteness, distance. This is less useful in developing countries, where the size of the population bears little relationship to the degree of development, infrastructure and services. It is for this reason, perhaps, that the concept of the 'inhospitability index' was introduced by Nicholas Crisp some years ago (report for Deloite and Touche commissioned by Masa¹). The USA uses a Physical Quality of Life Index (PQLI), which is a computer-defined index, but this defines disadvantage more than 'rural'. Factors which need to be included in such indexes include the health service available, geography, demography, primary industry (agriculture), socio-cultural issues, schooling, recreational facilities, general services etc. Possible employment for doctors' spouses might be included. Academic contact/isolation would be important to include in such indices. However that is a cumbersome and complicated process to work out and does not actually define rural.

Another possibility is definition in terms of doctor-population ratios. The problem here is that there is not agreement on what ideal ratios are, and issues such as distance and transport infrastructure must affect these ratios - hence Australia has three different ratios for urban, rural and remote. The needs of different populations may vary. There are also methodological problems in establishing what the existing ratios are, related to the accuracy of population figures, defining the geographical area and defining the number of doctors². These are thus better used as ideals to be aimed for than as definitions.

Most definitions take issues such as service, access and remoteness (distance) into account. There are differences in definitions related to 'rural' versus 'rural practice' versus 'rural health care' versus 'rural development' etc. What is clear is that:

• rural cannot be defined as 'non-urban'
  
• rural and underserved are not interchangeable (some rural areas are not underserved, e.g. well known tourist areas, and some underserved areas may be in inner cities)
  
• 'rurality' is like beauty, which is in the eye of the beholder, and
  
• defining 'rural' is useful as a focus on which to build recommendations and policy, which will in turn impact on underserved areas.

But rural areas have particular challenges which make them different, beyond the key issue of workforce deficiencies, which is what defines underserved areas. (For this reason one definition proposed relates to the difficulty of evacuating critically ill patients.) Looking at services available is useful, but of course these change very quickly as human resources change, so it is probably better to work with a definition related to people providing the service.

For the purposes of this discussion, Working Party, I have looked at the definition of rural practice. The Royal Australian College of General Practitioners' Faculty of Rural Medicine defines rural practice as 'medical practice outside of urban areas where the location of practice obliges some general or family practitioners to have or to acquire procedural or other skills not usually required in urban practice'³. Jim Rourke from Canada defines rural practice as 'practice in non-urban areas, where most medical care is provided by a few GPs or family doctors with limited or distant access to specialist resources and high technology health care facilities'⁴.

I thus propose the following definitions, which draw on these and our own particular situation:

• Rural health care relates to the provision of health services to areas outside of metropolitan centres where there is not ready access to specialist, intensive and/or high technology care, and where resources, both human and material, are lacking. This service may be within hospitals, health centres, clinics or independent practices. It is best provided by a team of health care workers and is based on the principles of Primary health care.
  
  
• Rural medical practice is health care provided by generalist medical practitioners whose scope of practice includes care that would be provided by specialists in urban areas. It is appropriate technology health care, appropriate to the needs of particular communities that are served. It usually includes elements of family/general practice, public health, and extended procedural work, within the context of primary health care and the PHC team.

I would appreciate feedback on these definitions, as well as suggestions on how to define 'underserved', which is possibly an even more difficult task.

References

1. Deloitte and Touche. Human Resource Policy for Health. Report to the Medical Association of South Africa, 1994.

2. Hays RB, Veitch PC, Franklin L, Crossland L. Methodological Issues in Medical Workforce Analysis: Implications for Regional Australia Aust J Rural health 1998; 6: 32-35.

3. Working Group on Postgraduate Education for Rural Family Practice. Postgraduate education for rural family practice: Vision and recommendations for the new millennium. Canadian Family Physician 1999; 45: 2698-2704.

4. Rourke J. In search of a definition of rural Canadian Journal of Rural Medicine 1997; 2: 113-115.

Ian Couper
Chairman, RuDASA

Present address: Wits Medical School, University of the Witwatersrand
Parktown, South Africa
couper@lantic.net