Comprehensive Analysis: Community Health and Wellness, Chapter 2

This assignment analyzes Chapter 2 of Anne McMurray and Jill Clendon's "Community Health and Wellness," focusing on the intricate relationship between health and place. The chapter explores how geographical location, social interactions, and cultural factors shape individual and community health outcomes. It delves into the impact of globalization, migration, and cultural viability, highlighting the inequities and challenges faced by various communities. The analysis examines the role of health professionals as advocates for social, political, and professional change, emphasizing community empowerment and the need for sustainable solutions. The assignment covers key objectives, including the influence of global factors, urban life, rural lifestyles, FIFO lifestyles, social media communities, and the creation of healthy cities for migrants and refugees. It also discusses the effects of globalization on healthcare, including commodification and the casualization of the workforce. This analysis is designed to provide a comprehensive understanding of the complex issues surrounding community health and wellness.

 Anne McMurray
 and Jill Clendon
Community Health and Wellness, Chapter 2, 24-41
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Introduction
The notion of reciprocal determinism, whereby people affect and are affected by their
environments, epitomises the relationship between health and place. Place is important to
relative states of health because ‘it constitutes as well as contains social relations’ ( Cummins
et al. 2007 :1825). Having a geographically bounded ‘community of place’ where people
interact with others can help promote community attachment, cohesion and solidarity
( Kilpatrick et al. 2009 :285). As we know, certain places are more conducive to health and
wellbeing because of their physical features. But places also affect the social and emotional
aspects of health and wellbeing. People feel grounded in certain places, but these need not be
only defined by a particular geographic boundary or distance or proximity to others.
Interacting across multiple places has interesting effects on people's behaviour, particularly in
terms of power relationships that allow some people to negotiate access to services and other
resources, while constraining others' ability to have equal access. Resources and support
systems may also be more readily accessible to those with differing socio-demographic and
cultural factors, such as age, gender, employment status, ethnicities and religious beliefs
( Cummins et al. 2007 ). These factors are all integral aspects of the SDH. So in terms of
‘place’ the effect of older persons being at home rather than in the workplace may create a
differential health disadvantage or advantage, just as the neighbourhood may have differential
effects on an adult or a young child, depending on the extent to which they are able to spend
time in parks or other recreational facilities. In today's world, where there is an increasing
concern about our global and local places, there is a need to look more closely at the
intersection of health, place, and our personal geographies and how we transit through
multiple contexts in the pathways to good health.
One of the most important issues in relation to health and place concerns migration and
cultural viability. Just as land and water shortages have caused forced migration, wars,
urbanisation and poverty have driven people all over the world to assimilate into foreign
cultures. As a result, the world has lost languages and culturally diverse elements that have
historically maintained cohesion and trust. In some cases, the fear of protecting borders from
refugees and other migrants has had the effect of disempowering some cultures. This in itself
is a health hazard, as the disappearance of cultures and traditional ways of life have left

whole communities without an understandable means of sustaining health or avenues for
communicating with others. Their cultural disempowerment is therefore an important factor
in determining the extent to which they flourish in family and community life.
The challenge in all communities is to find local, sustainable solutions and a sense of control
or community comfort. As health professionals we assume an advocacy role, helping
communities construct pathways to change on different levels. As social advocates, we adopt
a respectful and culturally sensitive approach, shifting the balance of power to the
community. As political advocates, we bring knowledge about the health and welfare systems
to the table and help link people together to access resources. As professional advocates, we
have an obligation to stay abreast of new knowledge and strategies that will help us maintain
professional competence as well as solidarity with others. These processes are developmental
in that by working together, people's skills, knowledge and self-confidence are developed,
ultimately empowering them to go on to the next undertaking. Facilitating and enabling
community empowerment also helps develop the skills of the health professional. Each
community and the strategies it uses to strengthen capacity are unique, so every opportunity
to work with a community yields new information that the health professional can use to
consolidate and refine health promotion skills. In this respect, advocacy is a deliberate two-
way process of mutual development, beginning with the global community.
What's Your Opinion?
Health professionals act as social, political and professional advocates.
In what ways have you seen these differing dimensions demonstrated in your community?
Objectives
By the end of this chapter you will be able to:
 1
explain the relationship between health and place
 2
outline the global factors that influence community health and wellness
 3
identify the major aspects of urban life that affect the community
 4
analyse the pros and cons of rural lifestyles in relation to social capital
 5
explain the effects of FIFO lifestyles in terms of the social determinants of health

 6
explain how the health of young people is enhanced by the ‘layers’ of assets available
to them in their social media communities
 7
develop a planned approach to creating a ‘Healthy City’ that will help ease the
transitions for migrants and refugees.
The Global Community
As part of the global community we need to be mindful that what occurs in one country
affects all others. As mentioned earlier in the chapter, we depend on our natural ecosystems
to provide life support throughout the world, and this affects our health and that of our
communities ( Hancock 2011 ). The global community has a profound impact on our social
world, particularly in terms of economic capabilities and our ability to access the social and
cultural supports that help conserve our communities. Globalisation is therefore relevant to
family life across the age continuum and across generations, from birth and child care to
education, employment, recreation and a comfortable retirement. Our globalised world has
brought significant changes to community life, some more dramatic and far-reaching than
others. Global technology has enhanced knowledge for many people, providing instant
electronic access to a wealth of information, including health information and research data;
however, it has also created inequities.
The term ‘globalisation’ refers to integration of the world economy through the movement of
goods and services, capital, technology and labour ( Labonte & Schrecker 2007a ).
Integration of these economic capabilities means that economic decisions affecting people in
all corners of the world are influenced by global conditions. When we first encountered the
notion of globalisation in the 1980s it seemed a palatable idea. A globalised world held the
promise of increased markets for goods, porous borders through which people could pass
freely, greater sharing of cultures, and economies of scale where goods might become
cheaper because they could be bought and sold efficiently by large business concerns.
Economic arrangements since globalisation have added wealth to various nations, reducing
absolute poverty (the total number of people living in poverty). However, inequities have
become evident from the fact that global markets privilege the global elite, those in control of
trade relationships, who have profited enormously from worldwide commercial endeavours at
the expense of social, environmental and health concerns.
Globalisation
Integration of the world economy through the movement of goods and services, capital,
technology and labour.
Open full size image
The political environment that paved the way for globalisation was one that valued not only
free trade between nations, but deregulation of financial markets and a host of other financial
decisions that ultimately created the 2008–09 global financial crisis. The crisis occurred

primarily because too much power was vested in a small number of multinational global
organisations, dominated by the wealthiest countries in the world, whose leaders made
decisions that allowed them to control the lion's share of the global economy and world trade.
With global markets gaining control over products and services industrialised economies
have flourished, but many countries and communities have become impoverished in the
process, especially those who were already poor. In some cases, multinational companies
have destroyed the livelihood of entire farming communities by importing cheaper goods,
effectively reducing the incomes of workers producing domestic products ( Cushon et al.
2010 ; Labonte & Schrecker 2007a b ). Large investors now control agricultural products
throughout the world, which has created a food crisis in a number of developing countries
( Schrecker 2011 ). Because of competition and an inability to find markets for their food,
some developing countries have stopped growing crops, leading to a vicious circle of poor
nutrition, foregone education and ongoing illness among the most disadvantaged in society
( Navarro 2009 ). Other sources of production have become non-viable, as the products are
now constructed in countries where both labour and taxes are cheap. This system maximises
profits for the global company but erodes the local economy and its tax base that could have
been used to fund infrastructure and support systems for health ( Schrecker 2011 ). Workers
in these countries who are engaged in the new production processes are also exposed to new
workplace hazards and industrial pollution, which have been tolerated to increase labour
market position. Some have become deskilled, once again, magnifying inequalities between
rich and poor countries.
Large financial institutions have also played a part in eroding the local economy of small,
developing countries. Over the last twenty years the International Monetary Fund and the
World Bank provided loans to those nations that agreed to adopt ‘structural adjustment
policies’ to reorganise their economies, but this placed them in a precarious, disempowered
position. Because the loans were also provided indiscriminately to political leaders who had
no moral obligation to defend the legitimacy of their rule, many local communities were
deprived of democratic participation in decision-making. This type of non-inclusive,
autocratic decision-making allowed a number of despotic rulers to maintain their leadership
through repression ( Labonte & Schrecker 2007b ). To make matters worse, foreign loan
repayments have been shifted to safer, tax-free havens, which stripped many developing
countries producing goods of tax funding that may have been used to improve citizens'
quality of life ( Schrecker 2011 ).
Group Exercise
Globalisation and nursing
In groups of two or three, consider how globalisation may affect your practice. Consider the
implications of commodification on job opportunities for new graduates, the drive for
efficiencies and costs savings within health services, and the impact of globalisation on the
people you care for.
Add to your answers as you work through the chapter and report back your findings to the
wider group. If working online, start a discussion forum on each of the above questions.
Some African and Asian countries have experienced this type of inequity for many years.
People in Zimbabwe starve to death regularly. In Bangladesh, which is the poorest country in
the world, only a fraction of the food aid reaches the poor, the majority of it being given to

the government, which sells it at subsidised prices to the military, the police, and middle-
class families ( Navarro 2009 ). Such inequality is not confined to developing countries, as
there has been a parallel situation in many Western nations, where indiscriminate lenders
allowed people and institutions to borrow money from them without them having the means
or job security to repay their loans. This type of practice has led many families to the brink of
poverty, to ‘survival circuits’ of low wage jobs and a cycle of debt from which they cannot
recover ( Schrecker 2011 :205).
Because globalisation has changed the focus of institutions from providing locally
appropriate services to economically efficient services, health, education, transportation and
other services have become commodified. What this means for health care is that if a
particular service is seen as inefficient, it is typically downsized or removed, and people who
may have relied on the service have to travel to a central location, creating a burden on
people in many communities, particularly those at a distance from specialist services.
Investors' search for cost effectiveness has also resulted in the casualisation of the workforce.
Where a service is dominated by cost rather than continuity, job security and benefits are
often eliminated ( Cushon et al. 2010 ). A further layer of disadvantage has arisen through
privatisation of previously public services, which has led to user fees for health care and
education. In addition, multinational pharmaceutical companies now dominate the trade in
medicines, creating higher costs with no accountability to current and future generations in
relation to local development or any social or environmental damage they may cause ( Baum
2009 ; Labonte 2008 ; Schrecker 2011 ). The growing number of free trade agreements (for
example, the Trans-Pacific Partnership Agreement (TPPA) negotiated between the United
States, Canada, Mexico, Peru, Chile, Vietnam, Singapore, Malaysia, Brunei, Japan, Australia
and New Zealand, and the Regional Comprehensive Economic partnership (RCEP) between
the 10 ASEAN states, together with Australia, China, India, Japan, Korea and New Zealand)
further exacerbates these issues, placing the interests of global companies well above the
interests of local communities (see Box 2.1 ).
Box 2.1
The Trans-Pacific Partnership Agreement
The Trans-Pacific Partnership Agreement (TPPA) is a trade agreement under negotiation
between Australia, New Zealand, the United States, Canada, Mexico, Japan, Peru, Chile,
Vietnam, Singapore, Malaysia and Brunei. However, the TPPA is much more than just a
trade agreement. Instead of being simply about freeing up trade in goods and services
between countries, the main focus of the TPPA is to create an attractive environment for
overseas companies who want to operate in Australia and New Zealand. What this means is
Australian and New Zealand laws on environmental protection, public health, intellectual
property and economic regulation will be restricted to make it easier for foreign companies
who wish to invest in Australia and New Zealand. In particular, US-based pharmaceutical
companies are lobbying for provisions that will reduce government regulatory control of
pharmaceuticals threatening equitable access to medicines (Faunce & Townsend 2011). The
TPPA would also give foreign investors the power to sue the New Zealand or Australian
governments in secret tribunals if they think that changes in law or policy have caused a
substantial financial loss to their New Zealand or Australian investments. For example,
tobacco companies would be able to sue governments if plain packaging has a detrimental
effect on profits.

One of the most concerning aspects of the TPPA is that it is being negotiated in secret and
there is no opportunity for community members to have their say in whether the TPPA goes
ahead. And if it does go ahead, it will bind Australians and New Zealanders to a set of rules
designed in the interests of big business, not everyday people. More information on the TPPA
in New Zealand can be found at: www.itsourfuture.org.nz and in Australia at:
http://aftinet.org.au/cms/ .
How is this related to community health?
Commitment to communities requires vigilance and advocacy so that people are aware of the
layers of decision-making that affect their lives. In the context of PHC and the goal of social
justice it is important to question whether policy decisions are made with equity in mind.
There is widespread concern about our global community among those attempting to promote
the health of local communities. These concerns all converge on the centralisation of
decision-making and the effects of these decisions on health. Researchers cite the health
effects of excluding some nations from the global market, particularly the developing
countries, many of which are already suffering from communicable diseases such as
HIV/AIDS, tuberculosis, hepatitis and malaria ( Schrecker 2011 ). These diseases, and the
inequities of globalisation have affected women disproportionately, many of whom were
already disadvantaged by poverty and discrimination and who, in a competitive global
economy, have no hope of improving their situation ( Falk-Rafael 2006 ; Schrecker 2011 ). In
some developing countries the mass migration of health professionals has also eroded the
capacity of the remaining workforce to deal with the burden of illness or health promotion.
While many Western nations are happy to welcome migrant health professionals to fill
workforce shortages, the net loss of these health workers has caused the near collapse of
already fragile health systems in their home countries.
What's Your Opinion?
Globalisation has had a significant impact on individuals, families, communities and nations.
What negative and what positive impact has globalisation had on you as an individual, your
family and your community?
The politics of global health care is clearly an issue for all nations. The global financial crisis
of 2008–9 impoverished many people, sweeping the world with new claims on public monies
and alarming discussions about resource scarcity. Decisions taken by global leaders led to a
reduction in funding for HIV/AIDS, tuberculosis and malaria programs to the extent that in
2010 annual funding for these programs was cut in half to US$9.2 billion ( Schrecker 2011 ).
Yet US$1 trillion is spent globally each year on arms and armaments ( Schrecker 2011 ).
Surely there is an ethical and moral argument to be made for decentralised decision-making
that would allow each community to establish its own priorities based on local needs. In fact,
in recognising the need to decentralise their local economies, some developing countries have
seen the development of micro-financing at the neighbourhood level, aimed especially at
helping impoverished women start their own businesses. This approach has provided small
loans, savings, insurance and training to people living in poverty as a just and sustainable
solution to alleviate global poverty (10thousandgirl, Online. Available:
www.10thousandgirl.com/some-facts/how-microfinance-works/ [accessed 21 December
2013]). Although modest, some of these businesses have helped break the intergenerational

poverty chain, helping women become empowered through viable employment that also
helps ensure an education for their children. Micro-financing developments are one of the
positive outcomes of globalisation, for without global attention and support, poor countries
like India and some African countries would not have had these opportunities.
Despite the global attention to poverty in developing countries, another effect of globalisation
has been the loss of cultural identities, languages and the right to choice in securing the best
level of health for the most number of people. The reality is that even as countries of the
West celebrate new wealth, we are all aware that wealth is distributed unequally. So as the
global community has continued to develop, there have been greater disparities between rich
and poor countries, and between the rich and poor within most countries. Clearly,
globalisation has wreaked havoc with the SDH. As Navarro (2009 :440) declares, ‘it is not
inequalities that kill, but those who benefit from the inequalities that kill’. This includes the
decision-makers who engage in a form of ‘predatory capitalism’ ( Schrecker 2011 :205) to
control food and tobacco, pharmaceuticals, financial markets and health care ( Dickens 2011 ;
Schrecker 2011 ). The effects of their decisions cascade throughout society, affecting the
poor and vulnerable, including women workers, migrants, different cultural groups, and rural
and urban dwellers.
Urban Communities
For the first time in history half of the world's population (3.4 billion people) live in cities
( WHO 2011 ). Many of these city dwellers are at the lower end of the social gradient and
therefore subject to inequitable living conditions, but even middle-class urban residents can
be affected by inequities in relation to those who are better off because they enjoy full
employment ( CMAJ 2011 ). Across the global spectrum, many cities have experienced
explosive growth over the past two decades, either through personal choice, migration to find
employment or to escape wars and civil strife or environmental degradation ( Satterthwaite &
Mitlin 2011 ; WHO 2011 ). In most parts of the world, the major cities are bulging at the
seams, trying to accommodate the vast influx of new residents. With growth in numbers there
has been a growth in urban poverty, and research has shown that cities contain the largest
proportion of those who are malnourished, have poor living conditions, and high maternal
and infant mortality ( Satterthwaite & Mitlin 2011 ; WHO 2011 ). On the other hand, the cost
of providing clean water, sanitation, schools, education and health care is more affordable in
urban areas because cities enjoy better infrastructure than rural areas ( Satterthwaite & Mitlin
2011 ).
In the city, the layered dimensions of life are played out in daily exchanges of social life and
commerce, in celebrations and exploitative acts, through illness and wellness, and across the
lifespan from birth to death. Urban life is a microcosm of the many relationships between
health, social, cultural and environmental factors, portraying both visible and hidden aspects
of family and community life. As population density increases in the cities, the differential
effects on health and wellbeing for the rich and poor come into clear focus. For the
unemployed or disadvantaged by birth or illness, the risks and hazards of city living include
crowding, violence, virus infections, motor vehicle accidents, exposure to harmful
subcultures such as substance abusers, environmental pollution and social exclusion ( WHO
2011 ). Yet there is a close connection between what is occurring in rural communities and in
the cities. In some cases, the hopelessness seen in impoverished city dwellers reflects the
physical and social degradation of rural areas, which has brought many people to the city
without their previous support systems.

Up Side, Down Side to the City
 •
More services, more jobs, more people
 •
Higher costs, poverty
 •
Inequities
 •
Substandard housing, crowding
 •
Fewer family supports
 •
Crime, pollution
Life in the city is increasingly inequitable. As the rich get richer, the divide between the
‘haves’ and the ‘have nots’ becomes more entrenched, and this erodes social capital
( Hancock 2009 ; Kawachi & Kennedy 1999 ). For the ‘have nots’ life holds few
expectations, given the drift of wealthier citizens out of the city and into the suburbs, leaving
behind an inflated housing market that is out of reach of many of the working poor. The
wealthy also take with them the tax base that might have funded additional services in the
core of many cities. Because of declining commerce and conditions in the heart of the city
many economically disadvantaged people are relegated to lower paying jobs. At the same
time, most urban societies have an unprecedented need to support older citizens and other
family members, especially for migrant and refugee families. Many live their lives in
substandard housing, which places all family members, particularly children, at risk of ill
health. Homelessness, the ultimate marker of disadvantage and inequality in society, is a
particular concern, as inadequate shelters struggle to keep up with demand for food, clothing
or safety. Many homeless people are the mentally ill who have been left on the streets by
deinstitutionalisation and the inadequacy of mental health support services ( WHO 2011 ).
Among the homeless is a growing number of adolescents and young families whose wages
have not kept up with housing costs, a situation that has been worsened by the global
financial crisis. One short-term solution has been house sharing, which has become
increasingly common among low-income New Zealand families trying to cope with limited
budgets and rising costs. However, this solution has resulted in severe overcrowding, which
exacerbates the risk of infectious diseases such as rheumatic fever and respiratory infections
—both diseases with marked prevalence in New Zealand ( Sharpe 2012 ; Trenholme et al.
2012 ).

Reminder
The socio-ecological perspective argues that everything is connected to everything else.
For some, the vibrancy and energy of urban life serves as a life-sustaining force. For others,
city life is a rat race without respite, refusing to soothe the concerns of older or disabled
people or, for many workers, to counter the agitation of overwork. The influence of the built
environment is more challenging in the city than in rural areas primarily because of concerns
about transportation and mobility and the risk of violence in well-concealed spaces. Older
people living in cities may be disabled and unable to navigate to essential services. Even for
younger people, including workers, human interactions are dictated by streetscapes, and
travel to and from work involves difficult manoeuvres through crowded, regulated spaces.
However, cities also afford more opportunities to be resourceful in overcoming risks; for
example, by developing innovative ways of countering emissions through cycleways or
public transport, or cooperative strategies to provide adequate nutrition or to cope with
weather events or other effects of climate change ( Satterthwaite & Mitlin 2011 ).
Research to Practice
Access to healthy food in rural and urban New Zealand
Nutrition is one of the most important issues in dealing with population inequities, as some
people are disadvantaged by a lack of access to healthy foods. Poor nutrition is one of the
most significant risks for chronic illness, particularly diabetes and heart disease. A group of
New Zealand researchers sought to map the availability and accessibility of healthy food (low
sugar, low fat, high fibre), comparing rural and urban communities ( Wang et al. 2009 ). They
found that the weekly family cost of a healthy food basket was 29.1% more expensive than a
regular food basket, and the cost difference was greater in urban than rural areas. Their
findings concurred with previous studies in other countries, which have shown that healthier
eating is more expensive than unhealthy food habits. They concluded that in order to support
the NZ Te Wai o Rona: Diabetes Prevention Strategy there must be a vast improvement in the
food environment and better strategies to support people in adopting health food choices,
especially in the cities. Interventions such as fruit in schools and milk in schools are designed
to improve access for children to healthy foods and improve behaviours, but it is important
that these are carefully evaluated to provide an evidence base for health promotion. The fruit
in schools program shows some success in these areas ( Boyd et al. 2009 ) while the milk in
schools program has yet to be evaluated nationally.
So what does this tell us?
The implications of these findings are twofold. First, they indicate that place is very
important to health. However, this does not mean that we cannot overcome various obstacles
that may exist in one or another geographic location. The study also illustrates some of the
impacts of global markets, where suppliers are able to affect health through their purchasing
policies.
How would you go about changing the availability of healthy foods in urban centres, creating
more affordable choices, and ensuring sustainability of the food supply?
What Is … A Healthy City?

A city where people have choices that can help them reach their maximum potential.
The Healthy Cities movement
The Healthy Cities initiatives have foregrounded the importance of ‘place’ in health
( Hancock 2009 ). Supported by the WHO, since its beginnings in 1986 the Healthy Cities
movement has spanned the globe, drawing support from health professionals, representatives
of recreation, police, social services, voluntary organisations, and people of all ages. The
model of Healthy Cities is to create awareness of the importance of place in achieving and
maintaining health. Healthy Cities initiatives have instigated actions to reduce crime and
environmental degradation, increase recreational spaces, and promote connectedness between
people for health, education and quality of life. The movement now incorporates thousands of
cities worldwide, all with the common aim of using intersectoral collaboration and
community participation to respond to the compromises to health that flow from people's
everyday lives in the city, to promote a holistic view of health, and to inform policy
( Hancock 2009 ; WHO 1998 2011 ). A healthy city is one where people have choices that
allow them to reach their maximum potential (see Box 2.2 ).
Box 2.2
Features of a healthy city
 •
A clean, safe, high-quality physical environment, including adequate housing
 •
A stable and sustainable ecosystem
 •
Strong, mutually supportive and non-exploitative communities
 •
Public participation in and control over decisions affecting one's life, health and
wellbeing
 •
Meeting basic needs for all, including food, water, shelter, income, safety and work
 •
Access to a wide variety of experiences and resources within the possibility of
multiple contacts, interaction and communication
 •

A diverse, vital and innovative city economy
 •
Encouragement of connectedness with the past, with the cultural and biological
heritage and with other groups and individuals
 •
A city form that is compatible with and enhances the above parameters and
behaviours
 •
An optimum level of appropriate public health and sick care services accessible to all
 •
High health status and low burden of disease for community residents
(Source: WHO 1998 )
The sustainability of Healthy Cities programs relies on continuing political commitment and
support. Some cities have been relatively successful in achieving this level of dialogue and
health improvements, while others have become mired in inaction and intergovernmental
conflicts. The most effective seem to be those linked to other Healthy Cities networks or
municipalities in a way that promotes citizen engagement and mutual support. These
networks span the globe, involving municipal leaders in many countries who have pledged to
reduce health inequalities and poverty, to promote citizen influence and address social
exclusion ( Hancock 2009 ).
An extension of the Healthy Cities movement is the WHO Age-Friendly City concept,
designed to provide optimal opportunities for health, participation, security and quality of life
for older citizens ( WHO 2007 ). Several initiatives have seen these goals adopted in a
number of urban communities, all with a focus on accessibility of city life for people ageing,
with or without disabilities, ensuring liveable, walkable communities and ageing in place;
that is, in the person's home community rather than in an institution ( Plouffe & Kalache 2010
). Research indicates that older people are more likely to be socially engaged if the
neighbourhood has interconnected street layouts, wide, smooth footpaths, local services,
green spaces and opportunities to interact with others ( Burton 2012 ; Parry 2010 ). These and
other factors are being addressed in a number of research studies examining the features
necessary for maintaining healthy municipalities, cities and communities as the global
population continues to shift to urban environments ( Meresman et al. 2010 ). Each of these
strategies will need to be developed on a local or regional basis, to ensure they are responsive
to needs and resources of various geographical areas.
Rural Communities

Rural communities have a number of unique challenges that have left many people
disadvantaged by poorer health than city dwellers. The most glaring challenge is a lack of
appropriate services, and this is the case in both Australia and New Zealand. As we
mentioned in the discussion about globalisation, health service planning is no longer
undertaken on the basis of need alone; instead many decisions are made on the basis of
economic considerations, and this has seen a net outflow of services to those living in rural
and remote communities. Even in New Zealand where distances are not as vast as in
Australia, there has been a decline in the rural hospital network in favour of centralised
services ( Tranter 2012 ). In both countries, small and dispersed populations cannot compete
for resident medical, nursing, allied health and specialist services, when the funding for these
is based on ‘allocative efficiencies’; that is, decisions to allocate resources from revenues that
flow to the broader state, national and private health agencies. Yet the core function of health
departments under a PHC commitment should be to provide access to health care for all,
including preventative services, illness care and a supply of appropriate health professionals (
Farmer & Currie 2009 ; Perkins 2012 ).
Up Side, Down Side to Rural Life
 •
Strong sense of community
 •
Stable family home
 •
Few health, social services
 •
Social, cultural isolation
 •
Family burden of caring
 •
Few education, employment, recreational opportunities
 •
Declining economy
Although the issue of access to care in rural and remote areas has been addressed through a
number of innovations, in Australia these have primarily been aimed at flying in health
professionals who conduct clinics or community assessments, but are then not able to provide
the ongoing attention the community needs. As a result many rural people have less