“If you want to sit on your butts you’ll get nothing!” Community activism in response to threats of rural hospital closure in southern New Zealand
Introduction
Internationally the viability of health services in rural communities has been threatened by a number of factors, including declining levels of population and economic activity, the desire to restrain public sector expenditure on health overall, problems of recruitment and retention of health professionals and, more latterly, an economic rationalist approach to the funding and provision of services. The consequences of these policies and circumstances have included closure of rural hospitals (James, 1999), shortage of rural practitioners (Hays et al., 1997) and a continuing cycle of rural disadvantage (Kearns and Joseph, 1997). Internationally there have been a range of responses to these problems, including the provision of alternative services and innovative recruitment strategies (Veitch et al., 1999).
This paper extends this literature on solutions by examining one specific strategy, community trusts, used in New Zealand to retain essential health services for rural communities. Community trusts are voluntary non-profit organisations, owned and controlled by local communities. They provide, or ensure the provision of, primary care or other local health services under contracts with health funding agencies. They are part of the ‘shadow state’ (Wolch, 1990; Milligan, 1998) and are significant because they represent the emergence of a new localised participatory model of health services provision. Community trusts emerged in the late 1980s in New Zealand as a response to threats to withdraw hospital services from rural areas, and developed in the 1990s, with some government support, as an alternative mechanism for the provision of services.
In order to place such developments in perspective, this paper briefly reviews recent international research on community responses to threat of hospital closure and outlines the issues for rural health services in New Zealand and the formation of community trusts. In Methods we outline our research relating to nine rural health trusts in southern New Zealand. Our analysis is based on the conceptual framework developed by Davies and Herbert (1993) and applied by Halseth and Williams (1999). We discuss the critical success factors underlying the retention of rural services and the costs and benefits to the communities concerned. Finally, we discuss some of the implications of the development of these new voluntary forms of provision.
Section snippets
Institutional and community responses to rural hospital restructuring
Across much of the developed world the neo-liberal response to the fiscal crises of the 1980s and 1990s included attempts to rationalise the funding and provision of hospital services. This was true across public, for profit and not-for-profit sectors, with an extensive body of research developing, particularly in the United States, on hospital closure. Much of this research focused on identifying factors which placed hospitals at risk (e.g. Mayer et al., 1987; McLafferty (1982), McLafferty
Rural hospital services in historical context
In New Zealand, 25% of the population resides in rural areas, including towns of <10,000 people (Creech, 1999). Since the mid-1980s, with the removal of agricultural subsidies and restructuring of public sector services, rural communities have experienced an economic downturn, declining population and the withdrawal of a range of rural services, such as post offices, schools and hospitals. Historically hospitals were locally funded from specially levied hospital rates with the early
Methods
This research involves a study of all nine trusts in the Otago and Southland districts of the Southern region formed by late 1998 (Fig. 1). Subsequently, three other trusts (Gore, Clyde (Dunstan) and Oamaru), serving somewhat larger populations, were formed but are outside this study. Our research strategy involved documentation from the contacts with both the regional funder and rural providers, in order to understand their differing points of view regarding the provision of rural health
Critical success factors
Since the trusts developed within the same geographic, economic and political context, understanding variation between them is important. All trusts emerged from a threat of the withdrawal of funding. All were located in isolated rural communities (only Milton was within 80 km of a large urban base hospital). All had experienced downturns in their rural economies and were affected by other forms of state restructuring (Pawson and LeHeron, 1996). Moreover, there were no distinctive political or
Community trusts—assessing outcomes of voluntarism
Some of the factors identified by Davies and Herbert (1993) can also be used to evaluate the outcomes of trusts. The following section, therefore, examines how key informants perceived both the benefits and problems of their new voluntary status in 1999.
Conclusion
The emergence of community trusts during the 1990s represents the presence of a new organisational form in the landscape of health services in rural New Zealand. For the first time since the early years of the twentieth century, when the viability of public hospitals was heavily dependent upon local revenues and inputs of expertise, there is a return to local voluntary involvement, strongly reminiscent of Wolch's view of the ‘shadow state’ (Wolch, 1990). One could argue that the growth of
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