by Kevin Hague
The West Coast is the most sparsely populated region in New Zealand. Just 31,000 people live in the narrow strip of land between the mountains and the sea, while the distance from Karamea in the North to Haast in the South is about the same as that from Auckland to Wellington. That’s a popoulation density just 10% of the New Zealand average, distributed over large distances. It can be a challenging environment to provide services in, particularly when those services are specialised.
Hollowing Out Rural NZ
Rural areas in general have sustained what I call “hollowing out”, where a vicious circle of service losses and population reductions has seen a dramatic shift in the viability of rural life. While we maybe associate this mostly with the wave of closures of banks and Post Offices etc in the 1980s, the trend has continued with school ‘rationalisations’ and so forth. One of the ideas was that technology would help overcome the tyranny of distance. Maybe. But then consider the Government’s roll-out of “super fast broadband”. In fact that will see the digital divide between town and country widen further still, as Rural Women and Federated Farmers have been saying, making rural life harder still (of course there are compensations!)
Rural Heath Services
In health services, rural DHBs have been focusing strongly on good public health services, intended to keep people well. No surprises there. That’s Green Party policy too. Then the focus is on primary care – those community-based services that people are able to access directly when they first seek treatment for a problem. There’s a big problem in recruiting and retaining doctors and nurses to fill these roles: traditional small business models of general practice are often unviable, access to support is thin, the skillset required for rural practice is broad and the after hours requirements can be arduous. Nonetheless the work suits some people, attention is being focused on the area, technology is helping, and it looks to me as if this is starting to turn around.
More at risk are specialist services, typically hospital-based, for rural areas. This last week saw yet another report published concerning the future of these services on the West Coast, which, as the most rural DHB, is at the sharp end of the difficulties faced in rural and provincial New Zealand. A quick glance at the report and I have a strong sense of deja vu – it closely resembles proposals I wrote around 5 years. It’s not surprising really because the issues haven’t changed.
At their heart these are issues around the employment of specialist doctors and surgeons. Not so long ago rural hospitals were staffed by generalists, who were able to work across a broad range of areas of work (the general surgeon would whip out your appendix, set your broken leg or deliver a baby by Caesarian section etc). Therefore rural hospitals didn’t need many of them. In the intervening years there has been a very rapid trend of specialisation (and sub-specialisation) in these professions. People work now to a much greater degree of skill and depth, but in a much narrower “scope of practice”. That means that a hospital needs more departments to adequately cover the range of health issues that may present. Each of these departments really needs 3 or 4 specialists, to ensure 24/7 acute (urgent) care, and provide cover for training, leave etc.
This is possible for progressively fewer and fewer hospitals. A further problem is that the cost of providing this capacity may well exceed (and over time will be more likely to) the hospital’s income, which is essentially proportional to the population served and services provided. Rural specialist care costs more.
The Two Options
In fact New Zealand stands at a crossroads on rural specialist care. Under current trends, rural (and then provincial) hospitals will be untenable, and replaced by super primary care centres with some beds for observation by GPs and nurse practitioners, and the ability to stabilise patients before shipping them out to city hospitals. This will be an efficient use of the specialists, and patients will have considerable expertise and backup available to them when they arrive in the city hospitals. However this option comes at some costs. For a start the travel by patients is effectively a significant cost-shifting to them, and may be a considerable and sometimes impassable barrier for them. But sometimes they won’t even make it. Sometimes the West Coast is effectively isolated from everywhere else, with aircraft unable to fly and passes blocked. And sometimes a patient’s condition won’t tolerate the further delay of transport – emergency Caesarian, cranial bleeding, torsion of the testes (have never looked into the detail of that one, and don’t think I want to!) If hospital services are further away, some people will die because of the delay in treatment. Probably not many, but some.
But if we don’t want this future of centralisation of specialist services to the main centres only, then we need to do some things very differently. We need to restart training generalists, who will be able to provide the 24/7 acute cover necessary in rural hospitals, and to do so in sufficient numbers. There are some positive signs with the great work done by the doctors from Dunstan Hospital, which has resulted in rural hospital medicine being recognised as a separate vocation, with its own training path and broad scope. The surgical equivalent will also be needed. We will also need different employment arrangements for specialists, to facilitate the provision of their expertise in multiple centres (if we are to maintain local access to specialist services in rural areas and to make the best use possible of the resources we have, then both specialists and patients will sometimes have to travel, for example to take advantage of operating theatres with spare capacity). It won’t make sense for the West Coast to have its own specialist departments, but rather to receive visiting services from the “South Island Regional Surgical Service”. Finally we also need Government to pay for the infrastructure to support this model, including hospital buildings and facilities that are fit for purpose. And as a microcosm of the the problem that rural areas need to be funded for capacity, rather than volume, these rural hospitals won’t stack up on a volume-based affordability test. They will cost more, and the more rural they are, the more they will exceed conventional affordability.
So that’s the choice in stark terms: one alternative will cost more in dollars, while the other will cost more in lives. As you might imagine, people on the West Coast get a bit nervous about earthquake risk. Much of the Grey Base Hospital doesn’t come anywhere near compliance with the new Building Code and, as a result, no changes at all can be made to the buildings without incurring a massive cost to bring the existing building up to compliance. At which point the DHB would have a compliant building, but one which has a layout and functionality designed to meet the way of providing hospital care in vogue some decades ago.
The DHB has submitted plans for a new hospital, designed to suit the needs of what is realistic for a rural hospital staffed by generalists and serviced by visiting specialists. These have been batted back by Ministers as “too expensive”. The Minister will have to choose one or the other. The clock is ticking. And rural and provincial New Zealand will be watching to see what our future holds.
Published in Environment & Resource Management by Kevin Hague on Mon, February 1st, 2010
Tags: Kevin Hague
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on the trolls and those who are unable to keep on topic
Have you read Morgan’s Health Cheque?
It’s pointless having hospitals in rural areas. Better to have clinics that can fit general needs, and bring people to specialist hospitals in major centers.
The bottom line is that we can’t afford local hospitals with a range of services. We can’t even get the staff, let alone the money.
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I certainly agree with Morgan that trying to provide specialist services in rural areas in the way we are doing it now (individual DHBs all trying to recruit to and maintain their own departments) is a fail. That’s why I propse another model.
Interestingly, while centralisation of all services in big cities is the logical conclusion of the present settings, this also will fail. Check the waiting times for even basic procedures in big city hospitals and we would probably agree that they are unacceptably long. Yet the waiting times for the same procedures in rural and provincial hospitals are much lower. So why don’t we send the city folk (and the surgeons if need be) to the country? We would make better use of fixed resources like theatres and wards, better use of surgeons (who currently risk standing around idle while they wait for theatres to become free, or enough work to do), and faster surgery all round.
Actually this was done on the West Coast around 10 years ago. Canterbury patients needing minor general surgery were put on the train to Greymouth, had their surgery and returned the next day. Big win for everyone. Oh, except those Canterbury surgeons who would otherwise have done these procedures in private because the public wait was too long.
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The waiting times are to do with cost. You’re advocating for better health services – well, who wouldn’t?
The only thing preventing short waiting times is money. We spend 9.3b more per year than we earn right now.
My understanding of the medical profession – I have friends who are doctors – is that medical professionals are not interested in rural locations. They regard the money and lifestyle options as poor. As for mobile services, it sounds interesting, but again I’d question the cost. Operating theaters are the cheap part. It’s the labour that costs a fortune.
So where is the money going to come from?
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Now I don’t know where you are, but I’m guessing it’s a city, and that your doctor friends are likely to be a somewhat biased sample in that they themselves have chosen to work in a city. However, they are correct that urban practice is generally favoured over rural practice, for a variety of reasons:
1. rural general practice has been out of vogue as a career option for doctors for decades, partly because fewer students from rural backgrounds go in to medical training and also partly because students have had almost no exposure to rural general practice in their training.
2. most young graduates (and not so young GPs) prefer to live in cities for personal reasons – like partner employment, more things for their kids to do, more choice of movies and restaurants etc etc (a familiar list)
3. GPs sometimes have professional reasons for preferring city practice, such as more back-up if things go wrong, more peer support for ongoing learning and development, less arduous on-call requirements
4. all of these rural factors are particularly extreme on the West Coast, so unless someone particularly wants to come and work here (for family reasons say) or wants as rural a position as they can get, then West Coast positions are likely to be the last filled
5. Where shortages exist or practices are stressed for other reasons (like small community muttering in the supermarket about long waiting times, or someone making a mistake) then these also act as disincentives to come to Coast practices.
6. West Coast practices mostly have populations that have a higher than usual rate of serious disease (typically chronic disease). This means that the work is harder on the Coast than elsewhere.
7. The Government’s rural bonding scheme might help in some locations, but in general a new graduate will not have sufficient experience to work in a Coast practice without close supervision and support.
8. Overseas-trained doctors need to be supervised by a NZ trained doctor (slight oversimplification). As we don’t have many NZ-trained GPs able to provide this supervision, we are restricted in the overseas-trained doctors who can be recruited to the Coast.
(that was a list I wrote for a West Coast journalist about why the West Coast has trouble getting enough GPs. The reasons for difficulty recruiting specialists is similar, but with the addition of the fact that there is no private work available)
Note, however, that my proposal doesn’t require doctors to live in rural areas. Some may choose to (and indeed they do now, for reasons like wanting to do outdoor pursuits, valuing the strong sense of community, thinking it’s a good place for their kids to grow up, opportunity to work broadly and be challenged) and that will be fine, but others can live in a city and rotate through rural areas for short visits. A well-built system would be flexible and have a network structure.
As for your question about money, this comes back between the two alternatives. This is more expensive, in financial terms, because it involves the capital and maintenance costs of rural hospitals, but less expensive in terms of illness and death. It’s not an easy decision for a Minister with a constrained budget. However, the same considerations apply in lots of other aspects of health care: the more expensive option is taken because it is safer.. And of course where the money comes from is the same for virtually every dollar spent on health. Most of us would say that healthcare is a legitimate use of public money. However I agree strongly with Morgan that there are some areas where it is possible to ensure much better value for money, which should be pursued. In particular we absolutely have to prioritise spending on public health programmes that keep people well (and this Government has cut funding to many of these) and primary care, and we have to engage in some sensible and deep national conversations about what services we will and won’t provide and how prioritisation decisions should be made.
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BP -
do you have any idea what kevin means in his final para above, when he mentions the cost of illness and death?
This is not just personal grief we’re talking about, but the actual community cost of the incapacitation of intelligent, contributing members of society, who once stricken with disability don’t continue to contribute at their former levels to employment, social networks, community organisations, charities, etc.
If their ailment is something that timely medical intervention could have ameliorated, why wouldn’t a sophisticated, civilised public health system try to do as much as possible to prevent that person’s loss to the economy and the community?
What we have now by default is a situation where some individuals, by virtue of their residential location, get better service than others, and might recover most of their functional abilities in the event of a major medical emergency (eg: a coronary event); and where some forms of illness/disability are better managed by social cohort groups and alternative (private) practitioners, than the Ministry of Health subsidised systems.
Clustering services around areas of high-density population may sound good on paper, but it is in the end a form of geographically-biased eugenics, making some assumption that rural residents are not as worthy of adequate healthcare as those who live within an hour’s radius of all the best specialist care options.
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I also know people in the Ministry, who back this up. There is a real problem getting staff in rural areas.
It’s an interesting idea, but it’s going to cost. The problem is not lack of facilities, it is lack of staff. It’s always going to be much easier, and cheaper, to move one patient than entire, specialised surgery teams.
Katie,
There is nothing to suggest they’ll die if transported out to the nearest city. Would it be better if each rural settlement had a team of heart surgeons on stand-by? For the patient, quite possibly. But there is no money for that. There is no staff for that.
It is impossible to provide the myriad of medical services one might require in a rural area. That’s one of the downsides of rural life – you don’t get the extensive range of goods and services you do in a city. Likewise, you can’t get huge space and rural tranquility in a city.
One makes their choices.
Oh, FFS.
Suggest you read Health Cheque.
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You just said it yourself -
ergo, anyone who lives in a rural area has less value than those (such as yourself) who live in an urban conurbation. And that is geographically-biased eugenics.
BTW, coronary disease was just a commonly understood example of acute medical intervention.
If you look at Kevin’s posts, you will see he has listed several conditions that need immediate responses, where transporting the patient is not a viable option; and several conditions under which transportation from the West Coast is not possible – and I expect there are other places in NZ with similar restrictions of access.
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Furthermore the logical extension of your ‘cost before all other considerations’ approach is that we should close the public health system down altogether as this would avoid all health expenditure and save us a fortune! This will always be your conclusion until you start to account for social & environmental costs in addition to financial ones.
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If he was your dad, Blue, how much?
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The centralised model of healthcare may well be more expensive for the NZ economy as a whole once the transport costs transferred to individual patients and relatives are accounted for. With transport costs likely to rise well above inflation over the medium-term future this model will also continue to be more & more expensive.
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“According to 2006 figures, New Zealand spends about $15 billion on health every year, with $12 billion of that coming from taxes and ACC levies.
More importantly, health expenditure is “growing at a rate that far outstrips our national income, or our population growth”.
“Over the last decade, the average increase in total health expenditure has been 6% per annum, at a time when economic growth has barely managed half of that,” the book says. While health costs have been increasing at that rate, per-capita income has been growing at about 2.4% per annum…In particular, the book suggests the most effective use of spending now would be on improving Maori and Pacific Island health. “Rather than throwing ever more money at old white people – where the marginal returns swiftly diminish – the numbers of Maori who would benefit from relatively simple investments in public health would be greater per dollar spent. Focusing on issues like vaccinations, infant mortality, smoking, obesity and lower injury rates tends to have very big pay-offs in terms of health improvements.”
“
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(As an aside, on particular reason for higher growth in health spending over the last decade is that the boundaries of what is paid for have been changing, so a comparison of spending now with spending 10 years ago isn’t apples with apples. Obviously this includes new treatments and technology, which probably is more effective, but especially includes a massive investment in primary care, effectively shifting the boundary between what the state pays for and what patients pay for)
Main point though: maternity and birth services are a good illustration of the central issue. If NZ were to centralise specialised services then pregnant women and their health professional supporters will have to make an assessment about how likely it is that specialist backup may be needed. To use the West Coast example again, in our region people are usually at least 3 hours’ drive away from a city hospital. That’s too far to rely on traveling when an emergency arises. So women will only stay on the Coast (or rural areas more generally)for their expected births if there is all-round confidence that the probability that specialist intervention is very small. That’s a minority of pregnant women in fact. The social and direct financial cost to these women and their families is great. Such a development will undoubtedly contribute to the rural “hollowing out”. Is that an acceptable cost?
If it is not, then we conclude that we must have obstetrician backup in rural areas, with anaesthetists and theatres and associated services for emergency caesarians. But then if we have those, then the marginal cost of doing other surgery is greatly reduced, and so on. That’s why the choice between the two options is so stark.
And to be clear, I think BP is summarising the case for one of those options well – just not the one I would choose if I were Minister.
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Quite possibly. It’s probably more efficient – and more green – for people to live in cities anyway. If people choose to live in small towns, then they must accept that not all services will be readily available, just as city people don’t expect to live on three acres for 200K.
As an aside, Morgan points out that our specialist health care demands are relatively recent. Even in the early 60s, there wasn’t much the medical profession could do if you had a serious heart condition. The doctor would give you an aspirin, tell you to rest, and hope you made it through the night.
Many didn’t.
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Whilst these days, people howl “eugenics” if high-tech specialist care is not provided at the farm gate.
Usually a little quiet on how that might be paid for, of course….
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This issue is of critical importance to small town NZ, it is actually about protecting what we are about as a nation. Quite frankly I think the quickest way to end NZ would be to urbanise the whole population, the West Coast should have a hospital as a matter of principal.
To many people are looking for ways to pull the plug, not make it work.
There is far more at stake here than most people realise.
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BP –
Just how do you propose the continuance of market gardening, forestry, dairy farming, energy production, steel milling, etc, if it only fits your model for the population to embark upon urban lifestyles?
Your arguments are strawmen, which is why, in the limited time I spend on the net, I’m not bothering too much about responding to your posts.
Kevin is doing a great job covering the facts and policy directions, and welcome aboard, S.Earnshaw, it’s nice to have commentary from someone who is actually doing what they talk about.
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So people recommend that when a household has a weekly budget of $100, then they simply must, as a matter of principle, buy Kobe beef. To not do so would deprive people of high quality meat.
No one is suggesting that small towns shouldn’t have healthcare. It’s the level of healthcare *immediately* available that is the question.
I do suggest you read Morgans book. There are a number of pressures, namely scarce medical professionals, the global market for such professionals, and the fact we aren’t living in a rich country. There are limited resources, so something must give.
Morgan suggests super clinics – glorified GP offices that offer a range of other services all aimed at achieving general wellness, complete with a couple of roving nurses. They run something similar in Kapiti, and it works very well.
Specialist services need to be centralised as it’s far too expensive to do it any other way. Nice to be able to provide it everywhere, but unless you figure out a way to add billions to the health budget, then it’s simply not going to happen.
Small towns won’t be gutted because people need to travel for some highly specialised services. It is just one of the inconviences people will accept for lower house prices and more space.
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I think it’s more because you lack a coherent argument.
How small does a town have to be before you think that having specialist services, like a heart surgery team, is uneconomic? 10,000? 1,000? 100? 10?
At what point do you start practicing what you term “eugenics”?
The high costs of medical services are real. The amount we make as a country are real. You can demand all the good things you like, but if you can’t pay for them, your solutions are simply childish wishful thinking.
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It seems to me Kevin and I agree on most of what Morgan wrote.
This one sticking point is about the immediacy of specialist care in small communities, and how to solve that problem, given a limited budget.
The budget seems to be of no concern to you. Why not? Where are you going to find the extra money, each and every year, given a rapidly greying population? What other services would you cut?
You can’t avoid that question. It is fundamental to any solution.
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I suggest for more clinics because budget is not an immediate solution given the situation. It would take time before budget is given to rural areas.
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I think the discussion here is getting a bit off track. No-one is realistically suggesting that every rural town should have on-site cardiac surgery or neurosurgery facilities. What is however essential for the continued viability of our many rural and provincial centres is ongoing support of a small number of essential emergency services including general surgery, orthopaedics, obstetrics and general medicine. These services are already provided at all of our provincial hospitals – we just need to continue to support their provision ( not spend billions of dollars of new money). If these core services are centralised in a small number of large centres, then rural new zealanders will die before they are able to get there.
There is also scope to develop new models of delivering these services, which could well involve specialists travelling to their patients rather than the other way round.
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BP -
to respond to your petulant shreaks, no I was not blocking my ears.
I’ve been out in the real world, unhooked from the internet.
The point you keep missing, which I have been trying to re-iterate, is that Morgan’s book is one source, but not exhaustive; and since he is an economist, without experience working in a hospital as a Doctor, nurse, anaesthetist, physiotherapist or even orderly, I prefer to prioritise the opinions on health policy of those who have had hands-on experience of the hospital as a workplace.
I have read a few peices of Morgan’s writing on economics, and I do have some respect for his point-of-view; but I’ll side with Kevin on this one and say that a purely economic rational view of health spending doesn’t cover all the bases for this policy area.
As S.Earnshaw says above, there are basic services that any community the size of the West Coast should reasonable expect to have competently provided. Or the workforce decamps, and suddenly there is nobody to create the produce that city-dwellers expect to see flooding into the Malls and Supermarkets.
It really is very easy for rural patients to have urgent needs left unmet, and for simple situations, routinely dealt with in big urban hospitals, to become life-or-death emergencies.
FWIW, there’s a small town called Ashburton in South Canterbury which appears to be stocked with the elderly (in multiple retirement homes) who have come from the farming communities further up in the hills. They can be seen by medical staff in the local hospital, or travel an hour on a very straight road to Christchurch Hospital.
It seems to be an option that the Canterbury squatocracy have sorted out for themselves, as some of them own or part-own the retirement homes their elderly rellies live in.
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I wasn’t talking about you, Katie. I was talking about the lurking down voters who disagree, but can’t bring themselves to say why.
I agree that basic services should be provided, as I stated above. There is already a model for this in Kapiti. You can provide many basic services with a clinic.
My point, which you keep missing, is that the cost of providing a multitude of local hospitals is prohibitive. That’s even assuming you could get the staff, which as the Ministry will tell you, is becoming a major problem.
It’s not enough to say we need this, therefore we must have it. We’re running a $9.3b deficit. The money for your demands must come from somewhere – so where, exactly?
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West Coast has one of the highest surgical intervention rates in the country. Are people really that sick on the West Coast compared to elsewhere? Provincial hospitals tend to over treat for the conditions they have capacity for, and under treat everything else. Supplier induced demand.
They are inefficient. City tax payers already cross-subsidise them.
The question is not “do you want your local hospital closed”, the question should be “do you want substandard healthcare at your local hospital, or would you be prepared to travel a bit further for the best”?
A healthcare provider in the rural US, spends less on hospitals and more on technology that monitors people in their own homes. This picks up problems before they happen. This has reduced admissions by 20%.
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The focus for rural communities – in fact in all communities – should be around prevention, not intervention.
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Rural hospitals including the West Coast are not overtreating their patients – they are providing a better and more efficient service for their population than their big city counterparts, who are undertreating. Waiting times are consistently higher in large city hospitals, and the numbers of patients referred back to their GP’s (refused treatment) by hospitals in the larger centers are much higher. In addition the rates of private surgery are much lower in rural areas (due to very much fewer people being able to afford private healthcare).
The results of treatment in smaller hospitals are often superior to those in big centers. It is a fact that my department (in a small provincial hospital) is one of the best perfoming in NZ and that our outcome data from the NZ joint registry are consistently better than the NZ average. If our local population were to travel to our nearest big center they would be travelling a bit further for substandard healthcare, rather than getting the best at their local hospital. Bigger does not always mean better (and in healthcare rarely seems to).
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The newer Rural Hospitals are in a rebuilding phase – the ones I’ve seen/been are great!
However the United Union of Doctors can be callous.
Beauracracies are unweildly by nature.
Our Local outpatients told me y’day I had two broken ribs and I had pleurisy in my lower left lung. Might have to go on a ventilator hey? hmmmmm
This is two years after I broke seven ribs in total – I waited 36 hours in Outpatients (6 different occasions, months of unbearable pain) while the same Hospital firmly refused me any treatment.
In the End a friend drove me to Palmy where 6 or 8 people worked around the clock to save my punctured left Kidney.
An hour apart and like two different countries…
Beware the hand that feeds….may also kill. The good old CYA (cover your ass) attitude reigns supreme.
Some medics are the Greatest Humans….and some strut like little Lords caring not who they Torture and Kill.
It is precisely why euthanasia should be Legal
Provinciality isn’t Geography – it is attitude.
Great Topic Kevin
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Evidence from Ireland suggests that the minimum population needed for an effective a&e unit is 200K. The full range of regional services requires 3000-350K. Supra-regional specialties require 750K-1M. (Medical Training Board Study, Future Of Medical Workers)
Following those numbers, we need roughly 12 a&e units (depending on geography). We currently have 35. Travel times can’t justify having three times the number of a&e units.
The void left by the closure of local hospitals would likely be filled by more sophisticated primary care, in the form of super-clinics. They can perform minor operations and provide beds.
Should a rural area have Paediatric Oncology? Even Wellington can’t support such a unit. How about Neurosurgery?
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BP – you left out a word:
Travel times can’t justify having three times the number of a&e units.
should be “travel times alone can’t justify…”
New Zealand topography is a bit different to Ireland’s. Apart from being long and narrow, so average distances are higher, we have a lot of mountains so roads in some areas are few and far between, and not straight. Throwing a patient around in the back of an ambulance rushing to the nearest a&e centre through a windy mountain pass is NOT the way to maximise their chances of survival. Then there is the very real possibility of the roads being cut totally.
Trevor.
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It’s not like the a&e function disappears, it gets taken over by the clinic for many of the cases. Air ambulance covers the rest.
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Anytime National wants to build a 2 billion $$ road or blow 1.5 billion on fibre optic cables to every home in wellington the money is not a problem!
It’s just a matter of priorities. BP your constant refrain of “where’s the money going to come from” is really lame
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Those are one-off infrastructure costs. Are you saying we don’t need infrastructure? How is you ambulance going to get to the hospital if the road has been washed away by rising sea levels? Isn’t telecommuting more green than real commuting?
Look at the numbers of people entering retirement over the next twenty years. Those costs are huge and on-going.
Specialist care at end of life will soon be a luxury. I suspect we’ll be doing a lot more palliative care in the future.
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BP, master of the straw man
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Nick Smith’s number of $250m per week in borrowing has been shown to be closer to $130m, so he can’t run the numbers. (bit of a worry for someone in his postition to not be able to count)
Agree with Rimu on fiscal priorities. No money for Community Education but $30m to private schools. No money for paying school workers a fair wage that recognises their skills but $25m to implement national standards and to also spend $250,000 and other costs telling parents why the standards will be good instead of testing them first.
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At the current rate of increase, the % of national income gobbled by health will double to 12% by 2050.
The question is not that rural dwellers should not be treated. The question is how best to treat them with the budget we have available. If we could treat rural dwellers better for the same cost, would you be for it?
You’ll only arrive at the solution once you run the numbers. The people I’ve been talking to have done so.
What numbers have you got?
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