The idea that rural PHUs should be granted additional resources to fulfill the mandated programmatic and performance expectations required of all PHUs, was discussed and supported by many informants as an important principle to consider in informing future directions around public health funding. Several informants proposed that rural PHUs require additional resources to deliver the standard set of health services that are mandated for all health units under the OPHS. Services such as public health inspections and vaccination/immunization in schools were identified as the key activities that require extra resources to deliver in rural jurisdictions. Justifications for rural PHUs requiring additional resources to meet the program expectations outlined under the OPHS, were oriented around distance-related time and costs attributable to vast landmasses and sparsely distributed community settlements (a common feature in rural PHUs). The limited availability and access to public transportation/infrastructural links for both community members and PHU staff were also suggested as key reasons for additional resource needs at a PHU level. Several public health professionals commented on this issue:
[Small rural health units] have no public transportation locally, so that affects staff and the public. Staff have larger distances to travel, so mileage rates are high. As well, they have to offer services in multiple sites, because [our] citizens can't easily get to one central location. [Staff in rural health units are] constantly going out to where [they] can - where we find people. So that's a challenge. (Participant 7)
We have [immunization/vaccination programs for] schools in rural areas… [a nurse and a supporting staff member] are gone for basically the better part of the day and yet they only see 18 kids. Where the nurse team in Toronto can go to one of the large public schools and
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[complete all immunizations in one day] - and of course because of Ontario Nurses
Association and labor costs, we still pay the same per hourly wage that the City of Toronto pays their nurses. We pay the same rate and yet, not only did it cost us more money… to see very few kids, we had to pay additional mileage on top of that and pay the nurse and her assistant lunch because they’re away from her home office… So, it becomes a way more expensive proposition than leaving a central city site and you could actually even take the subway. (Participant 13)
The trade-off between density and distance was another aspect of the discussion around rural PHUs requiring additional funding to meet the OPHS. Some informants felt that several urban or urban-rural mixed PHUs face many of the same challenges in service design and delivery as rural PHUs. The difficulty associated with balancing additional resource demands attributable to geography and rural dwelling with the resource needs of PHUs serving dense, heavily populated jurisdictions emerged as a key theme across many interviews. Several informants advised against the idea of additional ‘blanket-funding’ for rurally located health units, emphasizing that not all aspects of a rural health unit’s operations warrant additional resources:
How do you balance considerations of distance with density? That’s where you have something of a tradeoff. Toronto has the largest population of social housing of anywhere in the country, very high need. Now, the converse argument can be made in the far north, that the cost of delivery for remote [PHUs] where you might be carrying out, for example, inspections or outbreak investigations over an area the size of France… The appropriate balancing or weighting of distance and density related factors is extremely challenging and it’s very, very hard to reach a consensus on it. (Participant 9)
With respect to people that are isolated geographically or are residing in huge geographic areas, that doesn't necessarily mean it's a rural issue. I mean, you can go in the City of Toronto and you can find seniors there that are extremely isolated, just as socially isolated as people that live in rural areas. (Participant 14)
Simply awarding rural health units additional funding due to their jurisdiction type (i.e., rural, urban etc.) was cautioned against by some interviewees. Many public health professionals felt that striking a balance between providing rurally located health units with additional resources to deliver public health programs, and while encouraging rural PHUs to develop more cost-effective ways to deliver programs was identified as an important challenge in the practical application of this particular principle:
I totally understand that there are health units with enormous geographic distances that they have to cover in order to deliver programs… and that they would propose that there is a need for excess money to address that transportation or distance issue... It comes back to the problem of incentives… if you give a health unit extra money to address a transportation issue, it has no incentive to innovate and address that issue more efficiently. There are so many ways that technology could be used to address that transportation barrier… You can set up a video station. Instead of doing a home visit, you can do a Healthy Babies Healthy Children visit at a clinic that is set up with video monitor and you can monitor the interaction
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between the parents and the child, so you haven’t had to go out on a two hour drive to see them, right?... If you give them [rural health units] extra money… then they don’t have to think about how they might get around the transportation issue. (Participant 3)
And while there is continued pressure on all health units to restrict expenditure and deliver services within allocated budgets, some informants also suggested that with reference to rurally located PHUs and their associated challenges (geographic dispersion, limited transportation/public infrastructure etc.) a certain degree of cost-efficiency is to be expected and accepted as part of servicing populations in rural locations:
I think it’s so tempting to get caught up in the numbers game, right? We talk about equity and cultural sensitivity in terms of language, heritage, or ethnic group, but there is a real ‘rural culture’ [in some jurisdictions] and in order to service that culture I think you need to be a little bit inefficient. I mean, I think we should still do a flu clinic even though only 200 people may show up. So in a rural area, there’s a certain amount of built-in inefficiency just by virtue [of location] - if you’re going to provide equitable service, you’re going to be somewhat inefficient. (Participant 5)
Informants revealed a number of other factors that could lead to additional expenditures for rural health units. Costs incurred due to high staff turnover (i.e., hiring and training costs), fewer opportunities for collaborations with other municipal departments (e.g., social services) or other parts of the healthcare system i.e., primary care and family health teams etc. These types of collaborative (and often cost-shared) relationships (and potential cost-savings) were considered easier to establish and sustain in urban settings. In contrast PHUs in rural settings cannot rely on established healthcare networks/providers to share service delivery platforms and communication/media outreach etc.
Across interviews there appeared to be strong support for the provision of additional resources to rural PHUs for the delivery of the public health programs under the OPHS. Geography- related factors, i.e., low population density, high population dispersion and resulting travel costs were commonly mentioned as key justifications for the additional resource needs of rural PHUs. Some informants suggested that carefully examining the validity of density versus distance-related costs, and establishing appropriate incentives for rural PHUs to develop cost-effective methods for service delivery were key elements to address prior to integrating this principle into the distribution of resources across PHUs.
4.5.1.4 Principle 4: PHUs should receive annual increases that at least cover the cost of inflation