Guest Editorial

Nurses have a pivotal role to play as team members in the provision of rural healthcare. This focus edition aims to emphasise the importance of rural nursing care and some of the exciting innovations happening around the world.

In 1978, the Declaration of Alma-Ata (World Health Organization, 1978) was adopted at the International Conference on Primary Health Care held in Alma-Ata situated in the then USSR (now known as Almaty in Kazakhstan). The declaration stated that there was a need for urgent action by all governments, policy makers, health and development workers and the world community to protect and promote the health of all people. The declaration was the first international statement underlining the importance of primary healthcare as a key to the provision of services in order to achieve ‘Health for All’ people globally. So has ‘Health for All’ been achieved in these four decades since its inception? No, it has not, although great strides have been made over last four decades.

In 2018, the Declaration of Astana (World Health Organization, 2018) highlighted the key role that primary healthcare has to play in the future of global healthcare provision in order to ensure that everyone can achieve an attainable and acceptable standard of health. The four key areas that Astana highlighted were: make bold political choices for health across all sectors; build sustainable primary healthcare; empower individuals and communities; and align stakeholder support to national policies, strategies and plans. The declaration describes the primary care workforce as being multi-professional and multidisciplinary and stated that this should be reflected in future decision-making and planning. We need to move to considering a team-based approach rather than adhering to traditional individual roles. Future service planning must also take into consideration the local context and the needs of different communities, as one size will not fit all and much will depend on the availability of health professionals within a given area, especially in rural and remote locations. The future of rural healthcare will be in the development of flexible and dynamic teams of professionals working together and bringing their different skills and knowledge to meet the needs of their patients and communities.

Unfortunately, the World Health Organization (WHO) (Global Health Workforce Alliance and World Health Organization, 2013) has estimated that there is a global shortage of nearly 7.2 million health professionals due to long-term underinvestment in the healthcare sector. As things stand, this figure is projected to increase to 12.9 million by 2035. The International Labour Organisation (ILO) report ‘Universal Health Protection: Progress to date and the way forward, 2015’ (International Labour Organisation, 2015) demonstrated that the impact of the health workforce shortage is disproportionally greater in rural areas than urban counterparts. Despite the fact that 56% of the world's rural population cannot access basic healthcare (as opposed to 22% in urban areas) only 38% of the world's nurses and 24% of the world's doctors work in rural and isolated locations (currently 48% of the world's population is deemed to be rural).

In 2018, the WHO in collaboration with the International Council of Nurses (ICN) launched a global campaign ‘Nursing Now’ from 2018 to 2020, which sought to empower nurses to realise their potential to tackle the challenges and to contribute to achieving universal healthcare coverage (International Council of Nurses/World Health Organization, 2018). In addition, the WHO also designated 2020 as the international year of the nurse and the midwife, particularly to address global health inequalities and the need for universal health coverage as nurses and midwives constitute over 50% of the health workforce globally (World Health Organization, 2020a).

The World Organisation of Family Doctors (WONCA) represents family doctors/general practitioners in 131 countries and a global workforce of over 500,000 doctors (Wonca, 2020a). The WONCA Working Party on Rural Practice (Wonca, 2020b) is one of the most active and influential working groups within the organisation (WONCA Rural Health, 2020). WONCA Rural Health leads in the development of rural practice and rural healthcare provision working with other non-governmental organisations including the WHO. WONCA Rural Health is committed to meeting the needs of rural communities through the development of a multi-professional rural workforce that is appropriately trained, resourced and deployed. In many parts of the world, especially in low and middle income countries nurses are often the only health professionals accessible to rural and remote communities.

In 2019, at the 16th WONCA World Rural Health Conference, WONCA Rural Health together with rural nursing colleagues from around the world authored and endorsed the Albuquerque Statement to support, advocate for and promote nurses and midwives worldwide (Wonca Rural Health, 2019). The statement saw nurses as collaborative leaders impacting on health service delivery and nursing and midwifery practice in rural and remote areas around the world. Issues on rural healthcare were also included in ‘The State of the World's Nursing Report – 2020’ highlighting the crucial role played by nurses and midwives in health promotion, disease prevention and treatment. It emphasised the significant gaps that exist in the global rural nursing workforce and the need for investment to strengthen rural nursing around the world and achieve the goal of health for all rural people (World Health Organization, 2020b).

There is currently a paucity of rural nursing research and we must build an evidence base which will enable multi-professional and multidisciplinary practice in the future in order to improve global healthcare standards. Research evidence can identify how we can best configure future teams to address the needs of different communities and cultures, using everyone's potential to create the opportunities for skills and career development as well as improving the quality and availability of healthcare.

We have been fortunate in receiving papers on a range of topics that need to be addressed in rural communities for this focus issue. One of the international issues highlighted by the WHO is the lack of health professionals needed for the provision of even basic healthcare. How can we encourage school age children to study for a role in health? Kyle and colleagues in their research followed up students who had taken part in a pre-nursing scholarship programme while they were in school to prepare and support them into nurse education. The authors highlight the benefit of the programme to the students, and the improved recruitment into nursing education leading to an expanded workforce within rural and remote areas of Scotland. The importance of recruiting locally resonated with the commentator as many of such communities often solely rely on the services provided by nurses for all aspects of their healthcare.

We have previously mentioned the need for multi-professional and multidisciplinary practice to be able to address the needs of different communities. Widmer and colleagues, using a pedagogical fieldwork approach, have investigated students training for different professions in Western Bengal, India, using ethnographic methodology. The aim of this research was to investigate whether they could initiate new ways of thinking towards the provision of future health in rural communities. In order to make changes, they realised that it is important to promote inter-professional engagement and involvement as well as addressing the community’s cultural and health needs, promoting a bottom-up approach to inform future care provision. The commentator highlighted the importance of eliciting social epidemiology and local public health concerns that influence the uptake of services. In many of the studies, rural areas are known for having higher unemployment, poverty, lower educational levels and difficulty in accessing health and social services.

Consequently, there is an issue of training the rural workforce to improve care provision to ensure that it is ‘fit for purpose’. In a submission from Madhya Pradesh in India by Foss and colleagues, where the state government wanted to improve maternal health, a distance learning programme (DLP), followed up with face-to-face activities for auxiliary nurse midwives has been evaluated. The initial assessment showed that auxiliary nurse midwives had minimal knowledge of the normal pregnancy and childbirth process. However, this was improved after the DLP and the activity sessions.

Culture plays a role in all rural communities and it has to be considered when designing local services. A successful example has been described by Toohill and colleagues in the development of future maternity care in Aboriginal and Torres Strait Islander women in Australia. Crucially, when evaluating their current services and designing a decision-making framework, stakeholders including consumers of the services were involved. This ensured a sustainable change in services to enable the pregnant mother to build a relationship with a known midwife.

Generally, in rural communities everybody knows everyone else. The familiarity helps build functioning communities and social capital. However, this intimacy can have its problems, especially for children growing up with a parent who has mental health issues. The study reported by Dam and Hall of adults who in their childhood experienced life with a mentally ill parent demonstrated that this could have a positive and a negative impact. However, it concluded that there was a need for collaborative support for both the parent and the child.

A study undertaken in Indonesia by Sugiharto and Hsu evaluated the use of a self-care calendar for patients with diabetes to improve the maintenance of their condition in rural areas. The lack of self-care can have a devastating impact on the long-term health of the patient. This raises the issue of devising educational interventions and equipment to manage chronic conditions, especially when internet access is not available and/or affordable.

There is a drive for evidence-based practice and the development of models of practice based on evidence; however, Carrier argues that wrong decisions may be made if the local context is not taken into consideration in rural and isolated communities. The patient may not be able to afford to see the doctor or pay for the medications prescribed and they will still have to work to be able to feed themselves and their family. It is crucially important that in primary care there are means of communication between practitioners and their communities which will result in improved patient outcomes and health literacy. What might be considered to be best practice is not necessarily the best for the patient.

In their Perspectives piece, Nowlan et al. argue that there is a need for leadership at all levels (politically and locally) with investment in the development of recruitment and retention in rural communities to ensure improved patient access and outcomes. As a result, policy makers in Australia have established the position of a rural health commissioner, with the remit to address the agenda of health and access to healthcare. The Australian experience has demonstrated the importance of local leadership that drives forward all aspects of care provision: the administration, communication, education, clinical-practice experience, supervision, research and audit capabilities especially in rural and remote communities.

The clear message emerging from this issue is the lack of rural health professionals and time, inadequate investment, ineffective education and training, poor rural healthcare provision, and a significant need for a new strategic policy approach to ensure that the inequity that exists between rural and urban communities around the world is addressed if we are to achieve true rural universal health coverage. Universal healthcare coverage can only and will only be achieved through successful attraction, recruitment and training of nurses, doctors and other healthcare professionals working as adequately supported and resourced teams in and with the communities that they serve. Kenkre et al’s closing Perspectives piece makes this clear and proposes a way forward.

Biography

Joyce Kenkre is Professor of Primary Care at the University of South Wales and is Associate Director for PRIME Centre Wales. Joyce is a Council member of Rural WONCA.

John Wynn-Jones retired from clinical practice in 2016, having been a rural GP on the Welsh borders for 37 years. He is currently part-time Senior Lecturer in Rural and Global Health at Keele Medical School and past chair of the Rural Working Party of the World Organisation of Family Doctors (WONCA). John founded the UK Institute of Rural Health, the Welsh Rural Postgraduate Unit and was instrumental in creating the European Rural and Isolated Practitioner’s Association (EURIPA).