Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review.

BACKGROUND: Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action. OBJECTIVE: This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building. METHODS: This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems). RESULTS: The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%). CONCLUSION: This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries.

Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.

The Rural Clinical School Tracking Project: more IS better--confirming factors that influence early career entry into the rural medical workforce.

INTRODUCTION: This longitudinal tracking project by the University of Queensland Rural Clinical School (UQRCS) provides data on the early career pathways of alumni since its inception in 2002. Specifically we report on; (1) perceptions of the UQRCS regarding its influence on current career choice, (2) current speciality choices, and (3) factors that influenced these choices. METHODS: A retrospective web-based survey of all graduates who undertook clinical Year 3, Year 4 or Years 3 & 4 at UQRCS from 2002 to 2006. Associations with demographics, Year(s) at UQRCS, current workplace and speciality choice were assessed. RESULTS: Response rate was 69%, (N=180). Alumni who spent two years (Years 3 & 4) at UQRCS reported significantly higher degrees of encouragement to pursue a rural career. Alumni currently working in a non-urban location had spent two years at UQRCS and were significantly higher in desire to remain rural. 'Time spent at the UQRCS' contributed most to interest in a rural career. General practice and emergency medicine were most preferred specialities. CONCLUSIONS: Findings confirm that a longer rural clinical experience is more effective in eventual choice of workplace location and future interest in a rural career. This corroborates the positive impact of Australian rural clinical schools toward rural medical workforce improvement.

Evaluation of the ACRRM national radiology program for Australian rural and remote medical practitioners.

INTRODUCTION: In 2000, the Australian College of Rural and Remote Medicine (ACRRM) developed a national radiology quality assurance (QA) and continuing medical education (CME) program for rural and remote non-specialist Australian doctors. The program commenced on 1 January 2001. It required rural doctors to obtain 30 radiology QA/CME points over a 4 year period. At least 15-20 of these points had to be obtained by one of two mandatory options of the program, either: (1) film interpretation, report and review clinical audit activity; or (2) a radiology clinical attachment. METHOD: Doctors submitted their completed film review forms and clinical attachment logbooks to the program manager as confirmation of their educational activity to receive their professional development points. Data from film review forms and clinical attachment logbooks were de-identified and entered into two Microsoft EXCEL spreadsheets. The data were categorised and analysed in EXCEL. RESULTS: From 1 January 2001 to September 2004, 823 rural and remote doctors enrolled in the ACRRM radiology program. This included 281 locums who enrolled in the short-term locum option of the program and 563 doctors who enrolled in the full program. In September 2004, 419 doctors had completed a radiology film review with a radiologist and 41 doctors completed a radiology clinical attachment in 31 different public and private radiology practices. One hundred and ninety-five doctors completed the short-term locum activity. Ninety-two different specialist radiologists participated in the program and assisted rural and remote doctors to enhance their radiology knowledge, confidence and skills. This article describes results from the two mandatory activities. CONCLUSION: The evaluation of the ACRRM radiology program after its first 3 years and 9 months shows there are a large number of rural and remote Australian doctors undertaking professional development and quality assurance activities in radiology.

Whither rural health? Reviewing a decade of progress in rural health.

The problems associated with rural and remote health have been widely recognised by health workers, rural communities and health professions for some time. Yet it has only been in the past decade that any concerted effort has been made to address rural health issues. Today the state of health in rural Australia remains less than optimal. The tenth anniversary of the Australian Journal of Rural Health provides the opportunity to reflect on what progress has been achieved over the past decade, to recognise those factors that have contributed most to the implementation of policies designed to address the health needs of rural and remote Australians, and to discuss outstanding impediments and barriers to resolving rural health issues.

Educational needs of rural and remote Australian non-specialist medical practitioners for obstetric ultrasound.

OBJECTIVE: To determine the educational needs of rural and remote non-specialist Australian doctors for obstetric ultrasound. DESIGN: Survey design. SETTING: The study surveyed rural and remote doctors practising in a variety of settings including general practice, rural hospitals, Aboriginal communities and flying doctor organisations throughout Australia. SUBJECTS: Subjects included 314 solo and group practice rural general practitioners, rural hospital medical superintendents, senior medical officers, Aboriginal community controlled health service doctors, flying doctors, rural locums, registrars and two rural obstetricians. A total of 55% of the subjects were general practitioners in group practice. Respondents included 68 (22%) women and 246 (78%) men. RESULTS: The response rate was 32%. The highest priority areas of need for education included detecting foetal abnormalities and anomalies (19.1%), basic routine ultrasonography (17.17%), placental position (17.17%), dating (17.17%), foetal viability (12.88%) and morphology scan (12.26%). The main areas where doctors stated they lacked confidence included detecting foetal abnormalities (29.09%), basic routine ultrasonography (including machine use), such as, carrying out and interpreting obstetric ultrasound scans (27.27%), morphology scans (16.36%) and placental position (14.54%). CONCLUSION: The study showed there was a large unmet need for education in obstetric ultrasound among rural and remote non-specialist doctors. Information from the needs assessment was used to develop the Australian College of Rural and Remote Medicine national obstetric ultrasound professional development program. WHAT IS ALREADY KNOWN: The authors could not find any published work on the educational needs of Australian non-specialist rural and remote doctors for obstetric ultrasound. There is research about the outcome of obstetric ultrasound education for urban family physicians in the USA, but no information about rural doctors' educational needs or education outcomes. The study needed to be done so that obstetric ultrasound professional development program of the Australian College of Rural and Remote Medicine could be based on the real needs of the target group. WHAT THIS PAPER ADDS: As a result of this research, there is now information on the educational needs of rural and remote Australian non-specialist medical practitioners that can be used by education providers to develop quality education programs in obstetric ultrasound.

The influence of geographical location on the complexity of rural general practice activities.

OBJECTIVES: To examine the complexity of activities undertaken in general practice in relation to degree of rurality of the practice. DESIGN AND SETTING: National mail questionnaire survey across non-metropolitan Australia in July 2002. PARTICIPANTS: 1498 respondents out of 4406 GPs providing at least 375 Medicare-rebatable consultations in rural and remote locations during January-March 2002 (response rate, 35%). MAIN OUTCOME MEASURES: Responses to five sentinel measures of practice complexity. RESULTS: In general, the proportion of GPs providing complex services increases with increasing rurality or remoteness. Isolated rural and remote GPs manage myocardial infarctions to a higher level than GPs in larger rural and regional centres, are more likely to administer cytotoxic drugs, perform forensic examinations, stabilise injured patients pending retrieval, and coordinate discharge planning more often. CONCLUSIONS: The more rural or remote the area, the more likely a GP is to be regularly engaged in complex care. These findings have implications for the workload, responsibility, vocational satisfaction, need for professional education and support, and costs and remuneration of practice.