Why global health matters to rural England

In bringing together domestic and international health concerns ‘global health’ criss-crosses geographical, cultural, economic and linguistic boundaries. But what exactly is global health? Why does it matter? And how might it benefit rural communities across the UK? Jessica Sellick investigates.

What is ‘global health?’ According to the Government ‘global health’ relates to “the range of health issues influenced by factors that extend beyond state borders…This includes preparedness for pandemic influenza and emerging infections, climate change, international development and a worldwide healthcare industry” (page 3).

Academic Jeffrey P. Koplan, describes it as an area of study, research and practice that places a priority on improving health and achieving health equity for all people worldwide; whereas for Ilona Kickbusch the term provides a new context, awareness and strategic approach to matters of international health.

International organisations and charities explanations vary from where ‘everyone has access to comprehensive healthcare services delivered by highly trained and compassionate medical professionals in well-equipped facilities’ (Global Health Foundation) through to ‘providing prevention, treatment and care services to hundreds of millions of people, helping to revitalize entire communities, strengthen local health systems and improve economics’ (The Global Fund). For The World Health Organization (WHO), which coordinates international health within the United Nations system (working with some 194 Member States), global health is concerned with ‘combating diseases – communicable diseases like influenza and HIV, and non-communicable diseases like cancer and heart disease…We ensure the safety of the air people breathe, the food they eat, the water they drink – and the medicines and vaccines they need.’ ‘Grand Challenges’ concentrates its efforts on 14 major scientific challenges that, if solved, could lead to key advances in preventing, treating and curing diseases in the developing world.; and The World Bank is working with Governments to achieve universal health coverage by 2030.

This plethora of definitions varies from a concern with the broad determinants of health through to the threat of individual diseases. Taken as a collective they open up debates around where the boundaries lie between global health and ‘other’ disciplines (e.g. international health, public health and tropical medicine); between population-wide health interventions and individual health interventions; and the relationships (and interrelationships) between high, middle and low income countries.

If there is no international consensus on what, how and when to take a global health approach, why does it matter?

In September 2014, Public Health England (PHE) published its Global health strategy. This sets out PHE’s approach to global health from 2014 until 2019. In the strategy PHE describes how ‘health is a global public good, and that we should have the skills and expertise at our disposal to contribute towards addressing the global health challenges that we face and to reducing global health inequalities. In doing so we achieve our own domestic priorities, while contributing to the public health priorities of others. We will adopt the principle of co-development in our international activity, working in genuine partnership and recognising our shared learning and shared future’ (page 4). PHE has five strategic global health priorities: (1) improving global health security and meeting responsibilities under International Health Regulations; (2) responding to outbreaks and incidents of international concern; (3) building public health capacity in middle and lower income countries; (4) developing its focus on international aspects of health and wellbeing including non-communicable diseases; and (5) strengthening UK partnerships for global health activity. In 2016-2017 PHE launched the Public Health Rapid Support Team, established a Field Epidemiology Training Programme, supported the development of infrastructure (e.g. disease surveillance in Pakistan, Ebola laboratories in Sierra Leone) and provided technical advice to the United Nations and other bodies.

The mandate for much of this work comes from an Outcomes Framework developed by Government in 2011. The Framework focused on three areas for action: (a) global health security, (b) international development, and (c) trade for better health. Ten guiding principles underpin the Framework. Notably this includes a principle to ‘protect the health of the UK proactively, by tackling health challenges that begin outside our borders,’ and to ‘learn from other countries’ policies and experience in order to improve the health and well-being of the UK population and the way we deliver healthcare’ (page 5). Progress on achieving the twelve outcomes was to be monitored through Government Department’s own delivery plans.

More recently Defra has been working with the Department of Health and Social Care, PHE and the Veterinary Medicines Directorate to slow the growth of antimicrobial resistance; and with PHE to support the diagnosis, management and epidemiology of avian influenza; and produce a new One Health Report.

The All-Party Parliamentary Group on Global Health recognises the interdependency and interconnectedness of health issues and has carried out evidence based reviews of global health issues and provided briefings and reports on emerging global health issues: from overseas volunteering through to measuring the UK’s footprint on health.

In June 2017 Public Health Wales launched its International Health Strategy. The strategy contains three priorities: (1) to maximise applied international learning and support innovation for public health; (2) to develop globally responsible people and organisations; and (3) to strengthen Wales’ global health approach. The strategy was developed through a consultation process, literature review and mapping international work and collaborations across the organisation. In 2018 Public Health Wales is developing an implementation plan for the strategy.

The Scottish Global Health Collaborative (SGHC) is a multidisciplinary network chaired by Scotland’s Chief Medical Officer that works with the Scottish Government and partners in the wider health community to ‘promote effective and coordinated health sector involvement in global health.’ The network has been mapping Scotland’s global health work and consulting on a Scottish Global Health Framework.

In Northern Ireland, Queen’s University Belfast convenes an annual global health symposium, undertakes research and provides a taught postgraduate course.

Healthcare UK is an initiative of the Department for International Trade, Department of Health and NHS England that promotes the UK healthcare sector to overseas markets and supports the development of partnerships between the UK and overseas providers. Launched back in 2013, the initiative is currently focusing on identifying international opportunities for healthcare providers in clinical services, education and training, infrastructure, digital health and healthcare systems.

From these country policy perspectives global health matters because communicable and non-communicable diseases do not respect national/administrative boundaries; the threats, impact and response are truly global. Importantly, the UK has leading scientific expertise, data and insights in fields such as data, technology, surveillance and laboratory services which can be harnessed to work with high, middle and lower income countries. The Global Burden of Disease (GBD), for example, collects and analyses data on premature death and disability from more than 300 diseases and injuries in 195 countries. This information has been used by PHE to develop a Health Profile for England and to focus on areas which help people in early life and middle age so they have the best chance of living a longer and healthier life. At both individual and population health levels the outcome being sought through each of these strands of work are the same: to improve health outcomes for people. Finally, as a signatory to the WHO International Health Regulations 2005 (IHR) we are legally obliged ‘to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.’

Why does global health matter to rural communities?

Despite what may appear to be huge differences between low, middle or high income countries (developed and developing) we share common challenges and issues in providing health care in rural areas.

According to the Statistical Digest of Rural England (April 2018 edition), people born in mainly rural areas in 2013-2015 are expected to live two years longer than people born in urban with minor conurbation areas. Potential years of life lost (PYLL) from all causes of death was lower in predominantly rural areas than predominantly urban areas: the highest rate of PYLL was in urban with major conurbation areas at 475 years of life lost per 10,000 population and the lowest rate in mainly rural areas, at 372 years of life lost per 10,000 population (2012-2014). While some of the data suggests people living in rural communities live longer and are healthier, the Digest also reveals how people living in rural areas have lower overall levels of accessibility to key service locations compared to people living in urban settlements: 41% of people living in rural areas do not have access to their nearest hospital within one hour travelling by public transport, compared with 6% of users living in urban areas; and people living in rural areas have (on average) access to four GPs within a 15 minute car journey compared to nine GPs for people living in urban areas.

There is considerable variation in the average home-to-hospital distances by local authority: 1.6 miles for the London Borough of Camden and 21.3 miles for people living in the Eden District of Cumbria.

Defra’s Single Departmental Plan (updated on 23 May 2018) cites work with the Department of Health and Social Care to improve access to health provision in rural areas, including on distance and time parameters used for service delivery (section 4.2).

Similarly for mental health, the literature reveals a number of factors specific to rural areas (e.g. demography, access to services, social exclusion, deprivation) that may contribute to stress, anxiety and depression; highlights how some rural occupations – including farming – have high suicide rates; and how those that develop mental illness in rural areas seem less likely to seek treatment compared to their urban counterparts.

There is also the rural premium that exists in providing services (i.e., sparsity) that is not always recognised in funding arrangements.

These issues around funding, access to services, transport, distance and sparsity are well-rehearsed among RSN members but also common in rural areas in other countries.

While not every country has a Rural Urban Classification, there are commonalities framed around geography, remoteness and population density/community size. For example, Australia has an Accessibility/Remoteness Index; Canada has a four-fold definition that includes all territory lying outside population centres,; and in the United States the Census Bureau, Office of Management and Budget and U.S. Department of Agriculture all have definitions based on demography to fit programmes. While in other countries such as South Africa there is no standard statistical definition of rural.

Regardless of whether and how rural areas are classified (for they are not homogenous), similar issues around access to health care emerge.

In Australia, for example, there are 58 GPs and 589 registered nurses per 100,000 population in outer regional and remote areas compared to 196 GPs and 978 registered nurses per 100,000 in major cities. 23% of people living in outer regional and remote areas felt they waited longer than was acceptable for an appointment with a GP (compared with 16% of those living in major cities), with people in these areas four and a half times more likely as those living in cities having to travel over one hour to see a GP.

The National Center for Health Workforce Analysis (NCHWA) assesses health surveys and data on the supply, use, access, need, and demand for health workers across the United States. This includes data on the distribution of practitioners in 32 health occupations across urban and rural areas. This reveals how there are proportionately more providers in occupations that require fewer years of education and training i.e., there are more EMTs and paramedics per capita residing in rural areas compared to urban areas, and more physicians and surgeons per capita in urban areas as opposed to rural areas.

Two sectors have proportionately fewer providers in rural areas regardless of education and training: oral health (i.e., dentists, dental hygienists and dental assistants) and behavioural health (i.e., psychologists, social workers and counsellors). Academics at the Gillings School of Global Public Health are evaluating inpatient care in rural areas in the United States through tracking rural hospital closures (some 81 of the 2,200 rural hospitals have closed since 2010) and looking at solutions for areas with a dearth of hospitals and other health providers (e.g. rural freestanding emergency centres).This is part of a recognition that rural residents have further to travel to hospital compared to their urban counterparts and changes in acute hospital configurations (closure, downgrading) can have bigger impacts.

More broadly, the Economist Intelligence Unit’s Global Access to Healthcare Index measures how healthcare systems across 60 countries are working to offer solutions to the most pressing healthcare needs of their people. The Index seeks to answer the key question: ‘in a country, do people have access to appropriate health services?’ The EIU’s report not only reveals the 6 top performers (the Netherlands, Germany, Australia, the UK and Canada) and bottom 6 performers (Cambodia, Ethiopia, Uganda, the Democratic Republic of Congo and Afghanistan) but also how income levels are not a precursor to success in providing health: with middle-income countries such as Cuba, Brazil, Thailand, Colombia and Kazakhstan ranked ahead of some high-income countries. The report also highlights how public health providers have less of a presence in rural areas and limited resources.

If access to healthcare in rural areas is a key topic of discussion worldwide, these statistics open up debates around how the ‘provider to population ratio’ varies between rural and urban areas; how to recruit, retain and develop the health workforce in rural areas; the relationship between universal coverage and universal access; the level of investment needed in (rural) healthcare systems; and how the health infrastructure that exists in rural areas relates to health outcomes for rural residents.

If the rural health issues in different countries are similar, there may be good practice and collaboration that can be taken up to improve the health of all rural residents.

The term ‘frugal innovation’ has been used by academics for some time to describe the development of sustainable products and services that are ‘appropriate, adaptable and accessible solutions’. The term brings together the idea that more can be done for less for many more people, globally. It is viewed as a means of leveraging new approaches to offset escalating health expenditures and to improve health outcomes. Some successful examples include GE’s MAC 400 and Narayana’s $1500 cardiac surgery. The term ‘frugal technologies’ refers to cost effective technologies that are developed to cope in local conditions. A report by Nesta considered India’s potential as a laboratory for frugal innovations and the knock-on effects this could have in the UK and globally: from crowdsourcing drug discoveries to the Keralan approach to palliative care.

The term ‘reverse innovation’ is concerned with translating innovation in lower income countries into higher income country health systems. Some recent examples of this in the United States include: The Brazilian Family Health Strategy around community health workers; Singapore-based GeriCare@North use of telemedicine and Brazil’s Saude Crianca community involvement and citizenship programme. This thought paper from The Health Foundation also explores what the UK could learn from India – from the provision of clinical data to physicians in real time through to the Care Companion Programme to help patients recover in their local community.

While RSN members may not be taken with the terms frugal innovation and reverse innovation, they do open up dialogues around the relationship between innovation and need; the relationship between cost and frugality (low/no frills versus access); and the relationship between health care coverage and scale. What can we learn from approaches to rural health in low, middle and high income countries that could be applied to rural England (e.g. what medical devices, technologies, diagnostics, workforce and other services integral to health such as transport, pharmacies are used in other rural settings that could work in the UK)?

Jessica is a researcher/project manager at Rose Regeneration and a senior research fellow at the National Centre for Rural Health and Care. Her current work includes undertaking research on the health workforce landscape in rural areas; helping public sector bodies to measure social value; and evaluating a mobile sensory project. In her spare time Jessica sits on the board of a housing association. She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen

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