In July 2001, the Ministerial Advisory Council on Rural Health was established to provide advice to the federal government on how it can help maintain and improve the health and well-being of people living in rural, remote and northern areas of Canada.

Chaired by Colin Kinsley, the 21-member advisory council prepared the report titled Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities.

The following is the Executive Summary of Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities. Complete report is available on-line at website address shown at the end.



Executive Summary

"Healthy people living in healthy rural, remote, northern and Aboriginal communities"

The rural, remote, northern and Aboriginal communities which make up rural Canada have diverse social, geographic and economic characteristics.

People who live in these communities are tied to the land by historical and cultural traditions, by long-term economic investments and by their preference for living in small communities, closer to nature. Depending on which definition of rural is used, between 21 and 30 percent of the Canadian population lived in rural communities in 2001.

Most rural communities have large populations of older people and children, with relatively small populations of people of working age (those between 20 and 50 years old). This age distribution is a result of the aging of the rural population, the tendency of retirees to move to rural areas, large family sizes and the migration of rural youth to urban centres. The cultural and linguistic make-up of rural Canada includes official language minority communities, a small immigrant population and more than half of Canada's 1.4 million Aboriginal people - First Nations, Inuit and Métis people.

Rural Canada comprises all territory outside of major urban centres and constitutes 95 percent of the country's land mass; Canada's north occupies half of that land mass. The breadth of geography includes prairies, mountains and tundra with extreme climate variations. Rural economies are diverse, ranging from mixed-economy communities to single-industry communities that depend solely on agriculture, forestry, fishing, hunting and trapping, oil and gas, mining or tourism. In terms of economic status, there are prosperous communities located near urban centres and small, remote communities with high unemployment levels and few prospects for economic growth.

Generally, the health of people living in rural, remote, northern and Aboriginal communities is poorer than that of their urban counterparts; indeed, health status declines with distance from urban centres. Compared with urban residents, people living in rural communities have shorter life expectancies, higher death rates and higher infant mortality rates. Although the national aver-ages indicate that the difference in life expectancy between urban and rural populations is about a year, life expectancy between regions varies by as much as 16 years. In 1996, infant mortality rates in rural areas were 30 percent higher than the national average, while death rates from all causes were 9 percent higher than the national average.

The poor health status in rural areas is linked to a broad range of personal, social, economic and environmental factors and conditions that influence health, such as income, employment and working conditions, education, personal health practices and the environment. Most rural areas have lower personal incomes and higher unemployment rates than urban areas. As well, rural workplace conditions often pose serious health hazards. In the majority of rural communities, people have fewer years of formal education than their urban counterparts, and rates of smoking, heavy alcohol consumption, obesity and physical inactivity are higher than the national averages. Access to safe drinking water is also a concern in many rural areas.

Aboriginal people tend to have the poorest health status. The gap in life expectancy between Aboriginal people and the general Canadian population varies from 6 to 14 years. Moreover, the infant mortality rate for Aboriginal people is double that of the Canadian population overall. Aboriginal communities have a high prevalence of all major chronic diseases and high rates of suicide, fatal injuries, smoking and alcohol consumption. Low incomes, low levels of education, chronic unemployment, inadequate housing, exposure to environmental contaminants and the legacy of the residential school era have a strong influence on the health status of Aboriginal people.

Rural realities and rural health needs are different from those in urban areas, and people throughout rural Canada have expressed serious concerns about their inability to obtain the health services they need in a timely fashion and closer to home. A major problem for rural people is the distance they must travel to reach health services. More than two-thirds of residents in northern and remote regions live more than 100 kilometres from a physician. In the Arctic, people may have to travel up to six hours by plane for hospital-based services and harsh weather conditions often make travel dangerous or impossible for days.

There is a fundamental mismatch between the health care needs of people living in rural Canada and the availability of health care providers and health services. Physicians, nurses and other health care providers are concentrated in urban centres, where the healthiest people in the country live. In 2000, only 17 percent of family physicians, four percent of specialists, and 18 percent of registered nurses practised in rural, remote and northern communities, where up to 30 percent of Canadians lived.

With regard to rural health care services, there is an underdevelopment of health promotion programs, a lack of diagnostic services, poor access to emergency and acute care services, a lack of non-acute health care services and under-servicing of special-needs groups, like seniors and people with disabilities. As well, health care restructuring has centralized, reduced or eliminated hospital-based services without community-based services being enhanced.

"Healthy people living in healthy rural, remote, northern and Aboriginal communities" is the vision that guided the Ministerial Advisory Council on Rural Health in the preparation of this report. This report contains the Council's advice to the federal Minister of Health on a variety of issues affecting the health and well-being of people living in rural Canada. The recommendations in this report are grounded in a health determinants approach that recognizes that economic, social and environmental factors have a significant collective influence on health. The recommendations are intended to stimulate thinking, support existing work and offer new solutions. This report sets out the following seven broad strategic directions to address rural health challenges.

Communities play a vital role in the health and well-being of their members. Vibrant, healthy rural communities are built and nurtured by the citizens who live there, the private and non-profit sectors and all levels of government. Community capacity-building, an approach referred to as "Healthy Communities", involves strengthening the capacity of local citizens and communities so they are able to identify health challenges, set priorities, develop strategies and take action.

For Aboriginal communities, capacity-building also includes strengthening cultural identity and community life. Healthy communities are those that provide a safe environment, encourage community involvement, and have diverse economies, sustainable ecosystems and accessible health services.

Rural, remote and northern communities are ideally suited to improving health by building community capacity. The Council therefore recommends:

• developing programs and policies specific to rural, remote and northern communities;
  

• supporting the development of Healthy Communities models;
  

• establishing community capacity-building coalitions and networks;
  

• supporting opportunities for community capacity-building processes and coordination;
  

• establishing a nationwide Healthy Communities virtual library;
  

• disseminating the Healthy Communities approach;
  

• training health care providers in the Healthy Communities approach; and
  

• developing Aboriginal-specific Healthy Communities models.
  

Rural, remote and northern communities require resources and infrastructure to create their own solutions to their health challenges. The infrastructure capacity of most rural communities is generally limited, although there is considerable variation across communities.

The Council proposes developing a network of "rural health innovation centres" as the infrastructure for capacity building related to health care in rural communities. The rural health innovation centre model focuses on community development, facilitation and coordination and promotes the following elements: strengthening community capacity; fostering community health research; supporting generalist and community-based training; developing health information technology readiness and capacity; and devising recruitment and retention strategies.

It is important that the key elements of the rural health innovation centre model be integrated into existing provincial and territorial structures. Strong collaboration with provinces and territories is needed to advance the recommendation to:

• sponsor stakeholder workshops, integrate key elements of the rural health innovation centre model into existing structures, and, phase in the rural health innovation centres, establishing new structures where needed.
  

Strong intersectoral collaboration is neces-sary to address the complex factors and conditions that influence the health status of rural Canadians. This strategy calls for greater collaboration, both across sectors (e.g., housing and transportation) and across jurisdictions (i.e., federal, provincial, territorial and municipal).

Many stakeholders, including front-line health care providers, researchers, national Aboriginal organizations, municipalities and non-government organizations have an interest in the health of rural Canadians. These stakeholders need opportunities to network and collaborate to ensure comprehensive, integrated responses to the health challenges affecting rural, remote and northern communities.

The Council firmly believes in the need for greater collaboration on several fronts and recommends:

• fostering collaboration across jurisdictions and sectors;
  

• increasing collaboration among stakeholders; and
  

• establishing innovative jurisdictional partnerships for Aboriginal health services.
  

Rural health research is necessary to under-stand, forecast and positively influence the health of people living in rural, remote, northern and Aboriginal communities. Through research, health challenges can be examined and monitored, appropriate rural health policies can be developed, and the effectiveness of health programs and services can be evaluated. Rural health research helps communities and residents clarify health issues, take action and hold governments accountable for the health care they receive. Rural health research is also important because Canada is the second largest country in the world, with a sizeable rural land mass and population. It is important that Canada work toward becoming a global leader and innovator in rural health research.

The Council therefore recommends:

• enhancing national data collection and analysis on the health status of people living in rural, remote, northern and Aboriginal communities, and developing indicators on the health of rural communities;

• enhancing rural health research;
  

• building research capacity in rural and northern Canada;
  

• promoting community-based research;
  

• supporting research on Aboriginal health;
  

• developing, documenting and disseminating best practices and models of care; and
  

• supporting research on rural health models.
  

Information and communication technologies have the potential to improve both the health and health care of people living in rural Canada. They can be used directly in patient care, or indirectly, as a means of information-sharing about success stories and best practices among rural, remote, northern and Aboriginal communities. The purpose of health information technology is to share health-related information among various health care providers and health care settings and to deliver health services over large and small distances. Telehealth can also support the recruitment and retention of health care providers in rural communities.

The Council therefore recommends:

• seizing opportunities provided by broadband;
  

• creating a nationwide rural telehealth initiative with dedicated funding;
  

• improving community readiness for telehealth;
  

• protecting existing investments through a bridging fund; and
  

• building the knowledge base on telehealth for future investments.
  

Health care providers make a significant contribution to the health and well-being of their communities. Rural health care providers need to be highly skilled generalists, rather than specialists, and practise in ways that are community-centered, team-oriented, innovative and flexible. Rural, remote and northern communities face an acute and persistent shortage of health care providers. Smaller communities across Canada report difficulties in recruiting and retaining physicians, nurses and other allied health care providers.

To address the health human resources issues facing rural Canada, the Council recommends:

• developing a nationwide rural health human resources strategy;
  

• supporting a survey of post-secondary health care training programs;
  

• promoting health careers to young people in rural, remote, northern and Aboriginal communities;
  

• improving post-secondary health education opportunities for rural, remote, northern and Aboriginal students;
  

• developing rural health and Aboriginal health curricula;

• increasing rural community-based learning opportunities;
  

• improving working conditions and support for rural health care providers;
  

• maximizing distance education and continuing professional development; and
  

• supporting community innovation.
  

These recommendations require extensive collaboration with provincial and territorial governments and other stakeholders.

More than half of Canada's 1.4 million Aboriginal people -First Nations, Inuit and Métis people - reside in rural, remote and northern regions. Significant disparities exist between the health status of Aboriginal people and that of the general Canadian population.

To improve the health and well-being of all Aboriginal people, it is important to invest in and build on the strengths and capacities of First Nations, Inuit and Métis communities, in collaboration with provincial and territorial governments and Aboriginal partners. There is also a need to promote the rejuvenation of cultural and community life. Culturally sensitive and relevant programs and health services are prerequisites for improving the health and well-being of First Nations, Inuit and Métis people.

The Council therefore recommends:

• integrating traditional knowledge, medicine and healing practices into existing Aboriginal health services for First Nations and Inuit people and working with provincial and territorial governments with respect to other Aboriginal people, including Métis and non-Status Indians;
  

• supporting the work to preserve traditional medicine;
  

• building on the strengths and capacities of Aboriginal communities;
  

• improving Aboriginal health care services;
  

• supporting cultural and community renewal; and
  

• enhancing parenting and family supports.
  

Building healthy communities and reducing inequities in health status is a challenge for all Canadians. The recommendations in this report provide an important and exciting opportunity to significantly improve the health and well-being of people living in rural Canada. Through their implementation, the Council hopes to realize the vision of healthy people living in healthy rural, remote, northern and Aboriginal communities.



Source: Ministerial Advisory Council on Rural Health (2002). Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities. Ottawa, Ontario: Ministerial Advisory Council on Rural Health, Health Canada.

Rural Health in Rural Hands