Submission to the Senate Economic References Committee

Inquiry into

Regional Inequali ty in Austral ia

28May2018

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CONTENTS

Page

AboutRDAA 2

ContactforRDAA 2ExecutiveSummary 3Recommendations 4Background 5KeyIssues 6ResponsetoTermsofReference 10Conclusion 14Endnotes 15

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ABOUTRDAA

CONTACTFORRDAAPetaRutherfordChiefExecutiveOfficerRuralDoctorsAssociationofAustraliaceo@rdaa.com.auP:0262397730M:0427638374

RDAAisthepeaknationalbodyrepresentingtheinterestsofdoctors

workinginruralandremoteareasandthepatientsandcommunitiesthey

serve.

RDAA’svisionforruralandremotecommunitiesissimple–excellent

medicalcare.

Thismeanshighqualityhealthservicesthatare:

• patient-centred

• continuous

• comprehensive

• collaborative

• coordinated

• cohesive,and

• accessible

andareprovidedbyaGP-ledteamofdoctorsandotherhealthprofessionals

whohavethenecessarytrainingandskillstomeettheneedsoftheir

communities.

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TIMETO‘THINKRURAL’

EXECUTIVESUMMARY

Australiais,byworldstandards,aprosperousnationwithahealthy,well-

educatedpopulation.Yetthereareanumberofpopulationgroupswithin

thiscountrythatarenotaswelloffasothers.Increasinginequalityof

incomeandwealthandawideninggapbetweenthetopandbottomofthe

socio-economicscaleisevident1.

Thishassignificantimpactinruralandremoteareaswherepeopleare

alreadyexperiencinghigherratesofpoverty2andsignificantlypoorerhealth

outcomesthanthosewholiveinmetropolitanareas.Manysocial

determinantsmarkers–includingforeducation,employmentandhousing–

indicatesignificantinequalitiesbetweenregions.Inequalitiesbeing

experiencedbyAboriginalandTorresStraitIslanderpeoplethoughwell

recognised,arepersistentandreflectedinunacceptablyhighratesofmany

preventableconditionsandmortalitygapsbetweenIndigenousandother

Australians.

RDAAbelievesthat:

• Thehealthofindividuals,families,communitiesandpopulationsis

bothanindicatorofandcontributortoregionalinequalityin

Australia.

• Inequitableallocationofhealthfundingandresourcesexacerbates

inequalityintheseareas.

Theinequitiesandinequalitiesinhealththatexistbetweenmoreurbanand

ruralandremotepeopleisantitheticaltothenationalcharacteristicsvalued

byAustraliansandmustbeacentralconcernofanyexaminationofregional

inequality.ThegoodhealthandwellbeingofruralandremoteAustralians

willalsobecriticaltoachievingandsustainingregionalgrowth.

Theroleofhumancapitalindeterminingeconomicgrowthisparticularly

importantindiscussionsaboutregionalinequalityandhassignificant

implicationsforthehealthsystem.Governmentsrecognisethattheyhavea

dutyofcaretoprovidehealthcareservicestothepopulationandoften

espousetheneedtoprovidetheseservicesclosetohome.However,adhoc

investmentatalllevelsofgovernment–afunctionofAustralia’stiered

healthfundingsystemandpoliticalexpediency–failstotranslaterhetoric

intoreality.Bipartisanstrategicandoperativeplanningunderpinnedby

adequatelevelsofinvestmentisessentialtoredressinequitiesandreduce

regionalinequalities.

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RDAAmakesthefollowingpolicyrecommendationstohelpaddress

inequalitybetweenregions:

• recognisethataddressinghealthandwellbeinginequitiesand

inequalitiesiscentraltoaddressingregionalinequalitymorebroadly

• analyseaccesstohealthservicesinAustraliausingtheModified

MonashModelremotenessscaletomoreaccuratelyreflect

communityaccess

• providebetteraccesstohealthservicesinruralandremoteareasby:

o investinginmodelsofcarewhichprovidecriticalservicesin

localcommunities,includingexpandingrenaldialysis

services

o allocatingsufficientfundingtodeveloptheNationalRural

GeneralistPathwaytoensureruralandremotepeoplehave

accesstodoctorswiththeadvancedskillstheyneed

o workingwithruraldoctorstoidentifyeffectivesupport

mechanismsforgeneralpracticesasprovidersofhealth

services,employersandcontributorstolocaleconomies

o developingspecificagreementsonruralhospitalfunding

throughtheCouncilofAustralianGovernmentsnational

healthagreementsprocessdirectedtomaintainingrural

hospitalservicesandprovidingincentivesforincreasing

services

o institutefundingmodelsthatsupportsustainablehealth

servicesandhealthworkforceretention

• furtherdevelopcross-governmentandcross-departmental

strategiestoimprovehealthoutcomes,particularlyinrelationto

childhealth

• developatransportpolicywhichalignswithhealthandeducation

needs.

RECOMMENDATIONS

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BACKGROUND

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Australia’sregional,ruralandremoteareascompriseadiverserangeof

communitieswitheconomiesbasedonactivitiessuchasagriculture,

forestry,fishing/aquaculture,miningandtourismthatmakeasignificant

contributiontothenation’swealthandprosperity3.However,this

contributionisnotrecognisedthroughequitablespendingonhealthinthese

areas.TheNationalRuralHealthAllianceestimatesaruralandremote

primaryhealthcaredeficitofover$2billioneachyear4.

Thisinequitableallocationoffundsisofsignificantconcern.Peoplelivingin

Australia’sruralandremoteregionsexperiencehighratesofpoverty5.

Socio-EconomicIndexesforAreas(SEIFA)mappingrevealslargeswathesof

ruralandremoteAustraliaareinthemostdisadvantagedcategorieswiththe

tenmostdisadvantagedhavingpopulationsofunder3700usualresidents

withintheLocalGovernmentArea6.

RuralandremoteAustraliansexperiencingthesedisadvantagesoften

interactwithmanydifferentareaswithinthehealthandhumanservices

systems,mostoftenindisconnectedways.Lackofaccesstoservicesisa

pervasiveproblem,whichbecomesmoredifficultwiththedegreeof

remotenessandcontributestogenerallypoorerhealthoutcomesas

evidencedbyhigherratesofmortalityandmorbidityandriskyhealth

behaviours.Risksofoccupationalaccidentsandinjuryarealsohigher7.

AlthoughtheprevalenceofmanymentalillnessesissimilaracrossAustralia,

suicideandself-harmratesaremuchhigher(especiallyformales)inrural

andremoteareas8.Accessingalltypesofhealthprofessionalsbecomes

increasinglymoredifficultwithremoteness,contributingtothesepoorer

healthoutcomes.Recruitmentandretentionofanappropriatelyqualified

healthworkforcecontinuestobedifficultinmanyareasresultingina

maldistributionofhealthprofessionals.

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KEYISSUES

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Clearly,thehealthprofileofruralandremoteAustraliaisindicativeof

regionalinequality.Healthdisparitiescompromisethecapacityofmany

ruralandremoteAustralianstoengageinsocialandeconomicactivities,

includingthosenecessarytogenerateincomeandwealth,andlimitthe

benefitsthathumancapitalcanprovide.Poorhealth,therefore,isalsoa

contributortootherregionalinequalities.

Thekeyissueimpactingonthissituationisaccess.Access–tohealthcare

andtootherservicesandopportunities–isacriticalfactorindetermining

thedesirabilityofalocationasaplacetovisit,tolive,towork,tobringup

childrenortoretireto.Accesstohighqualityhealthcare,includingtoa

generalpractitioner(GP),affectstheappealofaruralandremotelocationas

aplacetoliveregardlessofageorlifestage.

Theavailabilityofbirthingservicesinruralareasprovidesanexampleofthe

impactsthataccesstohealthcare,orlackthereof,canhaveonruralpeople

andcommunitiesastheyunderpinmanyactivitiesinthesecommunities.

Peoplewhochoosetoliveinruralandremotecommunitieshaverational

expectationsaboutwhatconstitutesreasonableaccesstohealthcare.For

manywomenaccesstobirthingservicesstronglyinfluencestheir

judgementsaboutthequalityofhealthservicesinacommunity.

Allhospitalservicesshouldbepreparedforanimminentbirth.As

communitiesincreaseinsize(andwithconsiderationgiventothedistanceto

thenextbirthingservice)ruralhospitalsmayincreasetheircapacityto

providebirthingservicesfromlow-riskdeliveriesstaffedbymidwivesand

RuralGeneralists,tobirthingserviceswhichhave24-houremergencyand

caesareancapabilitystaffedbymidwivesandRuralGeneralistswith

advancedskillsinobstetricsand/oranaesthetics.

However,birthingservicesarenotroutinelyprovidedinallruralhospitals.

Thosethatdonotprovidetheseregularservicesaredeemedtohave

significantrisksbyexpectantmothersandwomenintendingtohave

children.Ensuringthattheseservicesexistinlocalhospitalsalsoensuresthat

therearedoctorstrainedinobstetricsandmidwivesinthetownwhoare

abletoprovidethecontinuumofantenatal,perinatalandpostnatalcare.

Theclosureofabirthingfacilityrequireswomen(andtheirnewborns)to

travelforappointments.Itcanincreaseatwo-hourtriptoahospitalbirthing

centretohavetheirbabytofiveormorehoursforsomewomen.Theymay

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alsobe,andoftenare,askedtorelocatetoatownorcitywithabirthing

facilitytwotofourweeks(andsometimesmore)priortotheirduedate.This

placesconsiderablefinancialandotherimpostsonexpectantmothers,their

partnersandfamilies.Lackofaccesstobirthingservicescanforcewomento

permanentlyrelocatetoothertownstostartoraddtotheirfamilies

contributingtothesocialandeconomicdeclineofruralcommunities.

ItalsomeansthatmidwivesandtheGPobstetricianwilllikelyleavethe

communitytogowheretheycanusetheirtraining,furtherstrippingrural

communitiesofskills,opportunitiesforemploymentofsupportstaffand

incomederivedbyotherlocalbusinesses.

Ruralandremotedoctorshavealsoidentifiedarangeofotherfactorsthat

impactonwhethertheywillmovetoarurallocation.Theyareallindicative

ofregionalinequalityandarelikelytobeofsimilarconcernforothers.They

include:

• employmentissues

Employmentopportunitiesarefundamentaltothrivingruralandremote

communities.Youngpeoplearemorelikelytostayin,orreturnto,a

communitythatcanofferjobprospects.Othersaremorelikelytobe

attractedtoandretainedincommunitieswithsufficientopportunitiesto

meetnotonlytheirneedsbutalsothoseoftheirspouse/partner.

Employmentconsiderations,however,arenotjustaboutjobvacancies.Lack

ofaccesstopersonalandprofessionalsupport,tocontinuingprofessional

developmentandtocareerprogressionopportunitiescanalsodetractfrom

thedesirabilityofalocation.

• lackofaccesstohighqualitychildcare,schoolingandother

educationalopportunities

Accesstohighqualitychildcare,schoolingandothereducational

opportunitiesislimitedornon-existentinmanyruralandremote

communities.Accesstochildcarecanbeverydifficultforhealthcareworkers

who,throughmovingtoaruralorremotelocation,havereducedfamilyand

friendsupport.Theymayrequirechildcareoutsidebusinesshoursduetothe

24/7natureofmanyhealthcareservices.

Schoolingalsoposeschallenges,particularlyduringthesecondaryschool

yearswheretheavailabilityandchoiceofsubjectsandextra-curricular

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activitiestosuitindividualchildren,aswellaseducationalstandards,are

important.Sendingchildrentoboardingschoolbecomestheonlyfeasible

optionbutcanimpactonfamilyrelationshipsandisexpensive.

Lackofaccesstovocationalandtertiaryeducationopportunitiesmeansthat

youngpeopleoftenmovetowheretheseopportunitiesexist.Thisimpacts

negativelyonpopulationretentionandtheeconomicviabilityandsocial

vibrancyofruralandremotecommunities.Thiscontributestocontinuing

inequality.

• poortransportlinks

The“tyrannyofdistance”isawell-recognisedchallengeforthosewholivein

ruralandremotecommunities.Pooraccesstoqualityfreshfoodatan

affordablepriceisanongoingissue,asistheneedtotravelforhealth

services.Thesechallengescanbeaddressedtominimisethenegative

impactsofregionalinequalities.

Thereareexamples,suchasrenaldialysis,wherenewmodelsofservice

deliveryallowforservicestobedeliveredinruralandremotecommunities.

Withoutthislocalfacility,ruralandremoterenalpatientsmustendure

travellingtoadistantfacilitythreetimesaweek,whichhasasignificant

impactontheirphysicalandmentalhealth.Thisisonlyfeasibleifpatients

haveaccesstoprivatetransport.Relianceonpublictransportand/orair

travelsignificantlyincreasesfinancialcostsandtimeawayfromhome,

familyandcommunity.Airtravelmaynotbepossibleatallifthereisno

airportwithinareasonabledistance.

Forruralandremotecommunitiestobevibrantandthrivingtheymustbe

underpinnedbybetteraccesstohealthservices,employmentopportunities,

childcareandeducationalopportunitiesandtransport.Withoutthispeople

willeitherchoosenottoliveinthesecommunitiesortorelocatetomeet

theirpersonalandprofessionalwelfareneedsandthoseoftheirfamilies

furtherincreasingtheimpactsofregionalinequalityonthosethatstay.

Investmentbyalllevelsofgovernmentwillbenecessarytoavoidthis.

Regionaldevelopmentcanreducelevelsofinequalityinhealthinruraland

remoteAustraliathroughstrategicandoperativeplanning.Plansmustbe

mindfuloftheimpactsocial,culturalandenvironmentaldeterminantsof

healthhaveonpeopleandofthecomplexinterrelationshipofhealth

serviceswithothersocialandcommunityservices.Theymustacknowledge

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theroleofgeneralpracticeswithinthiscontextandbesupportedby

adequatelevelsofinvestment.

Investmentinhealthandsocialservicesadequatetoredresshealth

inequitiesandreduceinequalitycontinuestobeanissueforthosedelivering

theseservices,asarefundingarrangementsthatarecommonlybasedon

relativelyshort-termcycles.Sucharrangementsaredeleterioustothe

provisionofhealthcareandsocialservicesinruralandremoteareasleading

touncertaintyandworkforceinstability.Thisgreatlyincreasestheriskof

serviceclosureasitisfarmoredifficulttorecruitandretainqualified

personnelintheseareas.Healthfundingmechanismsthatrecognisethe

uniquechallengesthatexistinruralandremotecommunitiesareessential

forefficientandeffectiveplanning.

Ruralandremotegeneralpracticesarethecornerstoneofruralandremote

health,withGPsprovidingandcoordinatingteam-based,comprehensive,

continuousandlongitudinalcare,whichisbasedaroundtheneedsof

patients,familiesandcommunities.Theydeliverpre-conceptiontopalliative

agedcareandacuteandemergencyservicesinarangeofsettings,including

privatepractices,hospitals,agedcareandoutreachcentres.Theyarealso

smallbusinesses,providingemploymentwithinthelocalarea,supporting

otherlocalbusinessesandservicesandcontributingtothehighlyregarded

healthsystemthatisessentialtostrongtourismsector.

Investinginruralandremotegeneralpracticeswouldbebeneficialbothto

redressregionalhealthinequitiesandinequalitiesandtosupportlocal

economies.

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RESPONSETOTERMSOFREFERENCE

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• fiscalpoliciesatfederal,stateandlocalgovernmentlevels

Governmentshaveadutyofcaretoprovidereasonableaccesstohealth

servicestothepopulation:aresponsibilitythatcannotbeabrogated

becauseofbudgetarypressures.Spendingonhealthshouldnotbe

contractedsimplybecauseitisexpedienttodosoinfiscallychallenging

times.Whilevalueformoneymustbeaconsiderationforpolicymakersand

fundingproviders,healthexpendituremustbeseenasaninvestmentinthe

futureprosperityofthenation,notasacosttobeminimised.Governments’

healthexpendituremustbesetatrealisticlevelstoachievedesiredhealth

outcomes,notonlytosupportthegoodhealthandwellbeingofAustralians

butalsotounderpinthenation’seconomyandgrowth.

• improvedco-ordinationoffederal,stateandlocalgovernment

policies

AsdemonstratedbyAustralia’stobaccocontrolsuccesses,thebesthealth

outcomesarederivedfromco-ordinatednational,state/territoryandlocal

activities9buttherearefewreadilyavailableexamplesofeffectiveco-

ordinationinAustralia.

Thereare,however,manyexamplesofsiloedapproachesandfragmented

services.Australia’smentalhealthsystemisonesuchexample:Our“mental

healthsystem”—whichimpliesaplanned,unitarywhole—isinsteada

collectionofoftenuncoordinatedservicesintroducedonanoftenadhocbasis,

withnoclarityofrolesandresponsibilitiesorstrategicapproachthatis

reflectedinpractice10.

ThathealthsystemfundinginAustraliaistieredwiththefederal

governmentlargelyresponsibleforprimarycareandstate/territory

governmentsforhospitalsischallengingfortheruralandremotehealth

sectorandcontributestothesesiloedapproachestoissuesthatwouldbe

bestaddressedholistically,throughlongerterm,evidence-based,well-

consideredstrategicandproactiveplansthatprovidetheflexibilityforlocal

circumstancestoinfluenceaction.Inmanyareasitcreates“artificial”

divisionsthatarenotalwayswellunderstoodbypeopleinthecommunity.

Forexample,aruralpatientmayseekemergencytreatmentatthelocal

hospitalonlytofindthatitisprovidedbytheirregularGPwhoisaVisiting

MedicalOfficeratthehospital.

Thespan,scope,complexityandcircumstancesofruralandremotehealth

areoftennotfullyappreciatedbypolicymakers.Policyandfunding

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decisionstendtobemetro-centricinoriginandapplicationanddonot

adequatelyrecognisethatruralandremotehealthisacomplexand

interdependentweboflocalandfurtherafieldhealthpractitionersand

servicesfundedand/orprovidedbyalllevelsofgovernment,arangeofnon-

governmentagenciesandorganisations,privatecorporationsandindividual

healthprofessionalsoperatingassmallbusinesses.Ruralandremotehealth

servicesaredifferenttothoseprovideinmoreurbanareas

Thetwoissuesoftieredfundingandmetro-centricapproachesare

exemplifiedbySouthAustraliawhereruralhospitalswereonaveragebeing

funded30%lessthantertiaryhospitalsforthesameprocedureatthetime

whenthenewRoyalAdelaideHospital–whichransignificantlyoverbudget

andtimetoopening–continuedtoreceiveadditionalfunding.Fundingfor

ruralhospitalsisajurisdictionalresponsibility.Itisofgraveconcernthatitis

moreequitablydistributedinsomeStates/Territoriesthanothers.

• regionaldevelopmentpolicies

Regionaldevelopmentplanningofferstheopportunitytoidentifycommon

groundandunifyapproaches.Itiscriticalthatpolicymakerslearnfrom

previousexperiencetoavoidissuessuchastheendemiceffortstoshiftcosts

thatareafunctionofAustralia’stieredhealthsystemfundingmodel.

Addressingdisparitiesinhealthandeducationmustbecentraltoregional

developmentplanningashighlightedbytheRegionalAustraliaInstitutein

itssubmissiontotheSelectCommitteeonRegionalDevelopmentand

Decentralisation:Thefirstgoalistomoreeffectivelydevelopourruraland

remoteheartlands.Thisinvolvesdeliveringlocallytailoredservicesthatcan

narrowthelongtermdividesinhealthandeducationoutcomesandensuring

thatwehavethelocalpopulationandskillsnecessarytosustainablydevelop

ourvastnaturalresourceendowment11.

Regionaldevelopmentpoliciesmust:

o recognisethatthegoodhealthandwellbeingofruraland

remoteAustraliansisessentialtopersonal,communityand

nationalsocialandeconomicgrowth

o acknowledgethattheprovisionofhealthservicesiscriticalto

underpindevelopmentoutsidecapitalcities,anddeliverthose

services

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o becognizantofpossiblehealthimpactsandensureappropriate

riskmitigationstrategiesareinplace.Forexample,theclosure

ofabusinessthatemployslargenumbersofpeoplehasa

detrimentaleffectonthementalhealthofthoselosingajobin

anareawherefindingnewemploymentisdifficult.Lackof

mentalhealthservicesinruralandremoteareasmeansthat

ruraldoctorsbeartheburdenofincreasedhealthneeds

o supportmulti-disciplinaryapproachesacrosshealthandother

sectorstoprovidehighqualitycareandsafetyforpatientsand

professionals.

• infrastructure

Improvingthetechnological,physicalandcapitalinfrastructureinruraland

remoteareasiscriticaltoreduceregionalinequalities,redressinequitiesand

promoteregionalgrowth.Thehealth,socialandcommunityservicesand

educationsectorswouldallbenefitfrominvestmenttoimproveaccessto

broadband,upgradefacilitiesandprovideorreplaceoldequipment.Arural

hospitalshouldnothavetorunfundraisingcampaignstobuynew

ultrasoundequipmentforitsbirthingcentre.

There-establishmentofaninfrastructuregrantsprogramandinnovative

optionsforfundingandbetterutilisingruralhealthinfrastructureshouldbe

explored.

Reliableandfastdatastreamingisbecomingmorenecessitythan‘niceto

have’inourrapidlyevolvingtechnologicalworld.Itisneededtotake

advantageofinnovationsinhealthmonitoringandtelemedicineandto

improveaccesstotraining,continuingprofessionaldevelopmentand

supportforprofessionals,includingdoctors.

Improvedtransportinfrastructureinruralandremote,especiallyairports,

will:

o supportrecruitmentandretentionofworkforces,includingfor

health

o supportemergencyservices,includingretrievalofpatients

o improveaccessibilityshouldpatientsneedtotravelfor

treatment.

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• education;buildinghumancapital;enhancinglocalworkforce

skills;employmentarrangements

Ensuringtheavailabilityofappropriatelyqualifiedworkforcestodeliverthe

locallytailoredservicesthatarerequiredtoredresstheinequitiesinhealth

andeducationoutcomesischallenginginmanyruralandremoteareas.

Whilethereisthepotentialforregional,ruralandremotecommunitiesto

makegreatercontributionstoeconomicgrowthandprosperityofthe

nation,populationlosstourbancentresisasignificantconcern12.

Providinglocallyaccessibleopportunitiesforsecondaryandhigher

education,includingcontinuingprofessionaldevelopment(CPD)and

pathwaystoenhancetheknowledge,skillsandexperienceofindividualswill

benecessarytostemthislossandtoattractnewresidents.

Employmentarrangementscanbeacriticalfactorinrecruitingandretaining

qualifiedpersonnel.Forexample,ruralandremoteAustraliaisfacingthe

challengeofmatchingcommunityexpectationswiththatofdoctors.

Communitiesarenowhavingtorecognisethatyoungerdoctorshave

differentmobilityrequirementsandareunlikelytomakelifelong

commitmentstoacommunity.Employmentmodelsmustconsiderthese

requirements,theimpactofchanginglifecircumstances,possible

limitationstocareerprogressionduetolocation,educationand

employmentopportunitiesforspousesandaccesstochildcareamongother

things.

• decentralisationpolicies

Whiledecentralisationpoliciesmayimpactongovernmentemploymentand

expenditureinregions,anyassociatedincreaseinpopulationinregional

centresandthesmallerruraltownsthatsurroundthemwillalsoplacean

additionalburdenonexistinginfrastructureandhealthservices.If

decentralisationpoliciesareintroducedtheymustbeunderpinnedby

investmentinhealth,socialservices,education,housingandtransport.

Workforceneedsmustalsobeconsidered.

Otherconsiderationsarethelossofeconomiesofscaleandtheriskthatthe

greatercostswillbepassedontoconsumers;theimpactofvirtualisationof

servicesandtheneedforstrongdigitalinfrastructure,andtheriskofgreater

compartmentalisationofviewsbasedonregionsselected(Howwillservices

appeartootherlocalities?).

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CONCLUSION

Clearlyaddressingregionalinequalityiscomplexand,inrelationtoruraland

remoteareas,issuesofequitymustbeakeyconsideration.

Withoutgoodhealththecapacityofruralandremotepeopletoeffectively

participateineconomicandsocialactivity,andtocontributetothe

attainmentofregionaldevelopmentgoals,willbecompromised.Without

improvementsinregionalcapacitytoprovideimprovedinfrastructure,offer

educationalandemploymentopportunities,buildhumancapitaland

increaseworkforceparticipationredressinghealthinequitieswillbe

problematic.

Addressingregionalinequalitywillbevitaltothesustainabledevelopment

ofAustralia’sheartland.Itwillrequire:

• agreementacrosspoliticaldivides

• amulti-faceted,holisticapproachtoregionalpolicydevelopment

thatseekstoredressinequities

• acknowledgementoftheimportanceofhealthanditssocial,

culturalandenvironmentaldeterminantswithinthiscontext,and

• strategicandoperativehealthplanswithclearandattainablegoals.

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ENDNOTES

1 Figure A.14 shows that people living in the capital cities of Perth, Sydney, Brisbane, and to a lesser extent Melbourne, are more likely to be in the top 20% and less likely to be in the people living in the capital cities of Perth, Sydney, Brisbane, and to a lesser extent Melbourne, are more likely to be in the top 20% and less likely to be in the bottom 20%. Figure A.15 shows that people living outside capital cities tend to be found more at the bottom of the income distribution than at the top, except in Western Australia. Australian Council of Social Services (2015). Inequality in Australia. Sydney: ACOSS. p50. https://www.acoss.org.au/wp-content/uploads/2015/06/Inequality_in_Australia_FINAL.pdf Viewed 23 May 2018. 2 National Rural Health Alliance (2017). Fact Sheet: Poverty in Rural & Remote Australia. http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-povertynov2017.pdf Viewed 23 May 2018. 3 For example, the Department of Agriculture and Water Resources indicates that the food industry … consistently accounts for around 20 per cent of domestic manufacturing sales and service income. The overwhelming majority of food sold in Australia is grown and supplied by Australian farmers. We are able to export more than half of our agricultural produce, while more than 90 per cent of fresh fruit and vegetables, meat, milk and eggs sold in supermarkets are domestically produced. http://www.agriculture.gov.au/ag-farm-food/food 4 http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf Viewed 23 May 2018. 5 http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-povertynov2017.pdf Viewed 23 May 2018. 6 Socio-Economic Indexes for Areas (SEIFA) is a product developed by the ABS that ranks areas in Australia according to relative socio-economic advantage and disadvantage. The indexes are based on information from the five-yearly Census. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2033.0.55.001~2016~Media%20Release~Census%20shows%20our%20most%20advantaged%20&%20disadvantaged%20areas%20(Media%20Release)~25 Viewed 23 May 2018. 7 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. https://www.aihw.gov.au/getmedia/6d6c9331-5abf-49ca-827b-e1df177ab0d3/ah16-5-11-rural-remote-health.pdf.aspx 8 Bishop, L., Ransom, A., Laverty, M., & Gale, L. (2017). Mental health in remote and rural communities. Canberra: Royal Flying Doctor Service of Australia. p15. 9 http://www.quitnow.gov.au/internet/anpha/publishing.nsf/Content/submission-coa Viewed 23 May 2018. 10 National Mental Health Commission, 2014: The National Review of Mental Health Programmes and Services. Sydney: NMHC. p6. 11 Available at http://www.regionalaustralia.org.au/home/our-current-work/policy/ Viewed 23 May 2018. 12 Australian Bureau of Statistics mapping of POPULATION CHANGE BY SA2, Australia - 2016-17 shows a decline or relatively static population growth across most rural and remote regions. The combined population of Greater Capital Cities increased by1.9% between 30 June 2016 and 30 June 2017, accounting for 81% of Australia’s total population growth. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3218.0. Viewed 28 May 2018.