Health Financing: The Missing Piece to Universal Health Coverage

### **Chapter 14**

## Examining the Relationship between Access to Health Care and Socio-Economic Characteristics

*Oluwafunmiso Adeola Olajide*

### **Abstract**

The link between good health and the ability to work effectively to meet livelihood needs is established but the economic implications of the reverse have often not been estimated; also how this plays out for different gender and socio-economic groups is often not estimated. The chapter examines the health care access that rural households have and examine how it relates to their education and employment in various sectors. The study used Nigeria as a case study as such the General Household Survey Data for wave 4 was used. The data were analyzed using descriptive, and Tobit regression model. The results showed that labour hours worked (in agricultural, non-agricultural and non-household activities) has a negative relationship with health care access. Age and literacy (ability to read) is important in health care access and have positive relationships with it. The policy implication of the study is that educational infrastructure must be developed along-side health policy initiatives.

**Keywords:** health care accessibility, infrastructure, income, employment, livelihoods

### **1. Introduction**

A major target of the sustainable development goal three on good health and wellbeing includes achieving universal health coverage, which includes access to health services. This is relevant for developing countries and rural areas in particular where suffering and preventable diseases often lead to untimely death. Low insurance coverage, poverty and shortage of health care staff have been cited as deterrents to healthy lives in developing countries [1]; these can lead to increased out of pocket expenses which the vulnerable groups of the society may be unable to meet conveniently [2]. Hence, achieving the sustainable development goal three requires that the issue of access to health care and its socio-economic determinants like income, education, and gender be prioritized in policy and intervention strategy designs [1].

According to [3] access to health care means having "the timely use of personal health services to achieve the best health outcomes". Implicit in this definition is the thought that health facilities should be within the reach of all as at when needed; that it is utilized and positioned to render appropriate services from which users can achieve expected outcome. In reality many people lack access to adequate health care as a result of public policy failure which creates barriers such as poverty and other forms of inequality. On the other hand, there is the issue of self-selection as people show preferences for other 'medical' alternatives. However, health care system is a public policy issue and as such resources should be allocated to it to make it effective and efficient. Based on this, there is a need for empirical evidence that will support government planning and resource allocation with respect to the provider and the client.

To achieve this, appropriate definition of variables that define health care is important. In the literature [4, 5], some indicate that the ability to pay for services is a major determinant, in some case preferences indicated by clients' behavior in terms of perception of the illness, the options available are cited as playing important roles in health care access. There is also the gender dimension: poverty, religion, cultural values and norms are considered barriers to women's access [6]. Finally, there is the school of thought that lays emphasis on demographic and socio-economic factors as the determinants of health care access. The varied positions suggest the need to approach the question from a different perspective. This study defined an index for access to health care and used alternative set of variables which are particularly relevant to the clients' circumstance. The study focused on the rural areas of Nigeria and used hours worked, level of literacy as major covariates of health care access.

A focus on the rural area is apt because the poor are generally known to have less access to health care services. The continued disparity between the poor and the rich within the country, is the basis for research based evidence which will set the direction for approaches and interventions that will narrow the gap. Identifying the dimensions of healthcare deprivation in rural areas, the vulnerable and the hot spots for the disadvantaged can be a spring board for closing the gap. Based on this, the study examined the relationship between access to health care and socio-economic variables with the aim of suggesting evidence based policy options that will lead to improved personal health care system in rural Nigeria.

### **2. Methodology**

### **2.1 Conceptual framework**

Several organizations [3, 7] have given different definitions of health care access to include timeliness, coverage, a regular source of care and capable personnel. The word 'access' is also seen to have both quantitative and qualitative aspects which means that it may not be fully quantified while being evaluated. Some components used to assess and evaluate it in literature include 'being available', 'financial access', 'utilization', and 'barriers'. Part of the discourse on its measurement includes the capacity, demand [7] and geography or spatial dimension. But a common thread that runs through the literature is the need to have equity in health care access especially for planning and resource allocation at the macro level.

**Figure 1** shows the conceptual framework which underlies this study. The definition of access to health care is taken from Penchansky and Thomas [8]. Access is grouped into five As: Affordability, Availability, Accessibility, Accommodation and Acceptability. These characteristics of health care access are defined to reflect provider and client's expectations and characteristics; and the fact that these need to fit. The framework shows that there are aspects of healthcare access which are easily influenced by the socio-economic status of the respondent. For example, the income generated by the

*Examining the Relationship between Access to Health Care and Socio-Economic… DOI: http://dx.doi.org/10.5772/intechopen.109884*

### **Figure 1.**

*Framework for health care access. Source: Author's Concept based on Penchansky and Thomas, [8] cited in McLaughlin and Wyszewianski [9].*

client could influence not only the choice of the healthcare facility but also the ability to pay; also the resources of the facility especially in terms of personnel and technology may interact with the income level or socio economic status to determine health care access [10]. On the other hand, the level of access could impinge on the individual's continued ability to earn an income, improve the food security and livelihood status [11, 12]. Hence the relationships could be recursive in some cases. Also, the influence of external factors such as policies and institutions on elements of the framework can hamper or support clients' access to health care. The framework suggests the need for a holistic approach to improving rural people's access to healthcare so that it cuts across all socio-economic levels while not making any particular group worse off.

### **2.2 Analytical framework**

### *2.2.1 The relationship between health care access and socio-economic status*

The relationship of access to health care to socio-economic indices (Education, Income and Employment) was determined by first establishing an indicator of health care access. Rural people often have several health care options which may be formal or informal; also some combine different options in a bid to maintain a healthy life or restore themselves to health. This behavior reflects the different aspects of health care access, and may also be a reflection of what they feel comfortable with.

### *2.2.1.1 Measuring health care access*

Health care access has been measured in different ways. The IOM [3] identified two quantifiable areas: utilization and outcomes. Indicators for both were then identified which could indicate problem areas as well as show when problems occur; these permitted a level of measurement but access was treated as an intervening variable to health care utilization and outcomes. A conditional logit model was proposed by Jang


### **Table 1.**

*Indicators for the measurement of access to health care.*

[5]; the model combined a choice model with a Floating Catchment Area in such a way that the peculiarity of a client to use a hospital was captured. In this study, indicators were identified for each of the fives 'A's defined above. These were then used to generate an index using the Principal Component Analysis. The definition of the each A is relatively encompassing as such client and organizational peculiarities are included. The index generated was then used as the dependent variable in the regression model. The terms and the indicators are listed in **Table 1**. To examine the relationship between health care access and indicators of socio-economic variables [10], the people were classified as: (I) Able to read vs. Unable to read, (II) Male vs. Female (III) Hours worked in different jobs per week.

The PCA is a technique for reducing the dimensionality of large datasets, increasing interpretability but at the same time minimizing information loss [13]. It does so by creating new uncorrelated variables that successively maximize variance. Although for inferential purposes a multivariate normal (Gaussian) distribution of the dataset is usually assumed, PCA as a descriptive tool needs no distributional assumptions and, as such, is very much an adaptive exploratory method which can be used on numerical data of various types. Olajide, stated 'In mathematical terms, from an initial set of n correlated variables, PCA creates uncorrelated indices or components, where each component is a linear weighted combination of the initial variables. Mathematically, the transformation is defined by a set of *p*-dimensional vectors of weights or loadings (1) that map each row vector **X**(*i*) of **X** to a new vector of principal component *scores* (2) given by (3).

$$\mathcal{W}\_k = \begin{pmatrix} o\_1, \dots, o\_p \end{pmatrix} (k) \tag{1}$$

$$t\_{(i)} = \begin{pmatrix} t\_i, \dots t\_p \end{pmatrix} (i) \tag{2}$$

$$\mathbf{t}\_{k(i)} = \mathbf{X}\_{(i)} \bullet \mathbf{W}\_{(k)} \tag{3}$$

in such a way that the individual variables of **t** considered over the data set successively inherit the maximum possible variance from **x**, with each loading vector **w** constrained to be a unit vector [14].

For example, from a set of variables X1 through to Xn.

*Examining the Relationship between Access to Health Care and Socio-Economic… DOI: http://dx.doi.org/10.5772/intechopen.109884*

$$\mathbf{PC\_1 = \mathbf{a\_{11}X\_1 + \mathbf{a\_{12}X\_2 + \dots + \mathbf{a\_{1n}X\_n}}}} \tag{4}$$

$$\mathbf{PC\_m = \mathbf{a\_{m1}X\_1 + \mathbf{a\_{m2}X\_2 + \dots + \mathbf{a\_{mn}X\_n}}}}$$

Where:

amn represents the weight for the mth principal component and the nth variable [14].

### *2.2.1.2 Estimating the relationship between access to health care and selected indicators of socio-economic status*

Since an index was generated to summarize the individual's access to health care, it means that it can be subject to a censoring effect. As such in order to examine the relationships between the variables, the Tobit model is used to avoid having a biased coefficient estimates [15]. The model is designed to estimate linear relationships between variables when there is either left- or right-censoring in the dependent variable. The Tobit Model presents a simple relation:

$$\mathbf{y\_i}^\* = \mathfrak{B}\_0 + \mathfrak{B}\_1 \mathbf{x\_{1i}} + \mathfrak{e}\_i \tag{5}$$

$$\mathbf{y}\_{\mathbf{i}} = \mathbf{0}, \quad \text{if } \mathbf{y}\_{\mathbf{i}}{}^\* = \mathbf{x}\_{\mathbf{i}}{}^\dagger \mathbf{\beta} + \mathbf{e}\_{\mathbf{i}} \le \mathbf{0} \tag{6}$$

$$\mathbf{y} = \mathbf{y}\_i \overset{\*}{\ }=\mathbf{x}\_i \overset{\*}{\ }\mathfrak{\mathfrak{k}} + \mathfrak{e}\_i \text{ if } \mathbf{y}\_i \overset{\*}{\ }=\mathbf{x}\_i \overset{\*}{\ }\mathfrak{\mathfrak{k}} + \mathfrak{e}\_i > \mathbf{0} \tag{7}$$

The effect of the Xs on the probability that an observation is censored and the effect on the conditional mean of the non-censored observations are the same: β.

yi \* = HCA index (may be censored right or left).

β = Vector of parameters to be estimated.

x = Explanatory and control variables categorized into household head and household variables (sex, age, education, farm and non-farm income, employment type), household food security status. The model aimed at determining the partial effects of the x variables on the latent variable. The parameters of Eq. (5) are estimated by the maximum likelihood method. To examine the relationship between health care access and indicators of socio-economic variables, the people were classified as: (I) Able to read vs. Unable to read, (II) Male vs. female (III) Hours worked in different jobs per week.

### **2.3 Data**

The paper used the wave 4 of Nigeria General Household Survey (GHS) data collected by the National Bureau of Statistics and the World Bank. The survey panel is implemented in collaboration with the World Bank Living Standards Measurement Study (LSMS) team as part of the Integrated Surveys on Agriculture (ISA) program. The data is nationally representative involving about 5000 households, and contains comprehensive data on socio-economic characteristics and welfare indicators. The households were selected through a random sampling procedure which ensured the distribution of EAs across the 6 geo-political zones (and urban and rural areas within) in the nation. The GHS consists of three panel questionnaires: Household, Agricultural and Community, which were administered using Computer Assisted Personal Interview (CAPI) in post planting and post-harvest periods. This study focused on the rural sector as a case study not only because it is the agricultural base of the country but also because additional empirical evidence is necessary for

resource planning and policy implementation of improved health care delivery. It will also serve as a means of evaluating the current status of previously implemented rural programs in the nation. Individual level analysis was carried out using data for household heads in rural communities. All household heads were selected irrespective of sex leading to a total sample of 3433 individuals based in the rural areas but complete data for the variables of interest were found for 3217 people, so these were used in the analyses.

The Federal Republic of Nigeria is located in the south east of West Africa, with a coast at the Bight of Benin and the Gulf of Guinea. It lies between latitudes 4° and 14° N, and longitudes 2° and 15°E. It has a land area of 923,768 km2 and a population of 192 million people. It has a tropical climate with variable raining and dry season periods. Agriculture, which is the main means of livelihood in the rural sector, contributes about 23.4 percent of the GDP. Health care delivery is the joint responsibility of the three tiers of the federal, state and local governments in the country. Since the Bamako Initiative of 1987, the country has made significant improvement in health care delivery and access using the community based approach. However, the sector is witnessing increasing emigration of skilled workers to the west. The rural population is about 47% the World Bank World Development Report, over 35 percent work in agriculture, in an environment that generally has low social infrastructure [16].

### **3. Results and discussion**

### **3.1 Index generation**

The Principal Component Analysis (PCA) indicated that the most important components in the index generated were those associated with the first 4 As: Availability, Affordability, Accessibility and Accommodation. Component 1 was responsible for about 32 percent of the variance as such it was used in the regression analysis. **Tables 2** and **3** indicate the bases for the acceptance of the model and confirms that a PCA could be carried out on it.

### **3.2 Relationship between HCA index and socio-economic variables**

The HCA is the response variable predicted by the model. The tobit model was used because this response variable is censored. The tobit regression coefficients are interpreted in the same way as the OLS regression coefficients except that the linear effect is not on the observed outcome but on the latent variable. The expected HCA score or index will change for each unit increase in the corresponding predictors. As such an increase in hours worked is likely to reduce the probability of accessing health care while an increase in age could lead to an increase in health care access. The literacy status as a measure of educational level suggests that it could be a barrier to accessing health care. At p < = 0.005, labor hour in a week is the most significant variable, although negative, while Age and literacy status are significant at higher levels of the test statistic. Policy instruments that will encourage high literacy levels and create health care opportunities for the aged could increase personal access to health care in rural communities. Also, advocacy on the importance of balancing work with health could be necessary to encourage more visits even with a tight schedule (**Table 4**).

### *Examining the Relationship between Access to Health Care and Socio-Economic… DOI: http://dx.doi.org/10.5772/intechopen.109884*


*Rotation Method: Oblimin with Kaiser Normalization. a Rotation converged in 7 iterations.*

### **Table 2.**

*The component of the access to health care index.*


### **Table 3.**

*Data sampling adequacy.*


*Obs. summary: 2490 left-censored observations at HCA<=0*

*727 uncensored observations*

*0 right-censored observations*

### **Table 4.**

*Tobit regression results.*

### **4. Conclusion**

This study examined the relationship between health care access and some socioeconomic variables. To achieve this, an index was generated based on several variables. The index showed that availability, affordability, accessibility and accommodation are really important as such policies that would enhance these should be pursued in order to improve rural health care system in terms of utilization and outcome. The policies should combine rural healthcare infrastructure development with rural health insurance schemes. The results also showed that labour hours worked (in agricultural, non-agricultural and non-household activities) has a negative relationship with health care access. Age and literacy (ability to read) is important in health care access and have positive relationships with it. The policy implication of the study is that educational infrastructure must be developed along-side health policy initiatives.

### **A. Appendix**

### **A.1 Communalities**


### **A.2 Total variance explained**


*Examining the Relationship between Access to Health Care and Socio-Economic… DOI: http://dx.doi.org/10.5772/intechopen.109884*



### **A.3 Component Matrix<sup>a</sup>**

### **A.4 Structure Matrix**


### **A.5 Component correlation matrix**


*Extraction method: Principal component analysis. Rotation method: Oblimin with Kaiser normalization.*

### **Author details**

Oluwafunmiso Adeola Olajide Department of Agricultural Economics, University of Ibadan, Oyo, Oyo State, Nigeria

\*Address all correspondence to: preciousfunso@yahoo.com; funso.olajide@ui.edu.ng

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Examining the Relationship between Access to Health Care and Socio-Economic… DOI: http://dx.doi.org/10.5772/intechopen.109884*

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[2] Adogu PO, Egenti BN, Ubajaka C, Onwasigwe C, Nnebue CC. Utilization of maternal health services in urban and rural communities of Anambra state, Nigeria. Nigerian Journal of Medicine: Journal of the National Association of Resident Doctors of Nigeria. 2014;**23**(1): 61-69

[3] Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to Health Care in America. Washington, DC: National Academy Press; 1993 https://www.ncbi. nlm.nih.gov/books/NBK235882/

[4] Darin-Mattsson A, Fors S, Kåreholt I. Different indicators of socioeconomic status and their relative importance as determinants of health in old age. International Journal for Equity in Health. 2017;**16**:173. DOI: 10.1186/ s12939-017-0670-3

[5] Jang HA. Model for measuring healthcare accessibility using the behavior of demand: A conditional logit model-based floating catchment area method. BMC Health Service Research. 2021;**21**:660. DOI: 10.1186/s12913-021- 06654-3

[6] Puentes-Markides C. Women and access to health care. Social Science & Medicine (1982). 1992;**35**(4):619-626. DOI: 10.1016/0277-9536(92)90356-u

[7] Gulliford M, Figueroa-Munoz J, Morgan M, Hughes D, Gibson B, Beech R, et al. What does 'access to health care' mean? Journal of Health Services

Research & Policy. 2002;**7**(3):186-188. DOI: 10.1258/135581902760082517

[8] Penchansky R, Thomas JW. The concept of access: Definition and relationship to consumer satisfaction. Medical Care. 1981:127-140

[9] McLaughlin CG, Wyszewianski L. Access to care: Remembering old lessons. Health Services Research. 2002;**37**(6): 1441-1443. DOI: 10.1111/1475-6773.12171

[10] Saif-Ur-Rahman KM, Anwar I, Hasan M, Hossain S, Shafique S, Haseen F, et al. Use of indices to measure socioeconomic status (SES) in South-Asian urban health studies: A scoping review. Systematic Reviews. 2018;**7**(1):196. DOI: 10.1186/s13643-018-0867-6

[11] Melo A, Matias MA, Dias SS, Gregório MJ, Rodrigues AM, de Sousa RD, et al. Is food insecurity related to health-care use, access and absenteeism? Public Health Nutrition. 2019;**22**(17): 3211-3219. DOI: 10.1017/S136898001 9001885

[12] Ajayi OE, Adeola OO. Effect of healthcare accessibility on cocoa farmers' food security in Ondo State. Nigeria in Journal of Development and Agricultural Economics. 2021;**13**(3):248- 255. DOI: 10.5897/JDAE2021.1288

[13] Jolliffe IT, Cadima J. Principal component analysis: A review andrecent developments. Philosophical Transactions of the Royal Society. 2016; **A374**:20150202. DOI: 10.1098/ rsta.2015.0202

[14] Vyas S, Kumaranayake L. Constructing socio-economic status indices: How to use principal components analysis. Health Policy and Planning. 2006;**21**(6):459-468. DOI: 10.1093/heapol/czl029

[15] Austin PC, Escobar M, Kopec JA. The use of the Tobit model for analyzing measures of health status. Quality Life Research. 2000;**9**:901-910. DOI: 10.1023/A:1008938326604

[16] World bank. World Development Report 2021: Data for Better Lives. Washington, DC: World Bank; 2021. DOI: 10.1596/978-1-4648-1600-0

### **Chapter 15**

## Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities

*Min Jung Cho and Eva Haverkort*

### **Abstract**

Over the past twenty years, Uzbekistan's health system changed drastically from the inherited Soviet health system. This research aims to examine the main aspects of the Uzbek health financing system and policy process that led to out-of-pocket (OOP) health care expenditures by using a mixed-method case study approach. Qualitative findings reveal that the covered basic benefit package is limited. Health care evaluation methods and accessible information on health quality are lacking. This leads to inefficient use of resources and a risk of using unnecessary or low-quality health services. Quantitative findings reveal that especially the chronically ill have high OOP. Furthermore, alcohol use, health status of the household head, money saved in the past and place of residence proved to be significant factors. This research showed that the limited benefit package, lacking evaluation methods, and inaccessible information on health care led to high OOP. Policies remain inefficient at addressing OOP due to limited civilian participation, lack of data, and limited evidence-based decision making. This research suggests that the benefit package should be expanded to cover the chronically ill.

**Keywords:** out-of-pocket expenses, chronic diseases, household budget, catastrophic health expenditure, health insurance, primary health care, health equity, Uzbekistan, Central Asia

### **1. Introduction**

For a long time, the Uzbek health system was part of the Soviet health system, in which the state covered all health care services. After the Soviet Union's dissolution in 1991, Uzbekistan's government wanted to keep health care public [1, 2]. However, due to economic constraints, the state could no longer cover the use of all health care services. This meant that part of the health services had to be purchased directly by citizens: out of their own pocket. Hence the name, out-of-pocket expenditures (OOP) [3, 4].

Uzbekistan's large population of 33.6 million is struggling, both economically and health wise [5]. In 2013, 14% of the population lived under the poverty line. The fact that more recent data is not available proves one of Uzbekistan's challenges: there is a lack of monitoring and a lack of information management in their national statistical systems [6–9].

Furthermore, Uzbekistan is faced with double burden of infectious and non-communicable diseases, such as cancer and diabetes [5]. The average life expectancy in 2019 was 73 years for Uzbekistan compared to European countries' average life expectancy of 81 (in 2018) [10]. Infant mortality rate of 17 (in every 1000 children under five) in Uzbekistan compared to 5.11 in Europe also suggests a potential weakness in the health system. [11, 12].

OOP are a global phenomenon: all countries rely to some extent on OOP to fund their health care system. There are two general concerns about OOP. Firstly, the people with the greatest need and the people with the lowest income feel the financial burden the most. Secondly, patients may choose not to access necessary care to avoid this financial burden. Despite concerns, many countries have been shifting health care costs directly to patients [13].

This is also the case for Uzbekistan, which has been relying progressively on OOP [1, 3]. Between 2014 and 2018, the proportion of health expenditure that is paid out of pocket has been increasing from 45.41% in 2014 to 60.34% in 2018. Other Central-Asian countries have slightly different trends. Turkmenistan (76.34% in 2018) and Tajikistan (68.42% in 2018) have been gradually increasing their OOP proportion [14–16]. However, they have not experienced such a sharp increase as Uzbekistan. The Kyrgyz Republic's OOP proportion has been gradually decreasing, with a share of 52.44% in 2018. Kazakhstan seems to have been stabilising around 33%, much lower than the other countries [15, 16]. Thus, while other Central-Asian countries have alarming OOP rates, the sharp increase of Uzbekistan's OOP is concerning [17].

Trends may vary across Central-Asian countries because health financing reforms have also varied. Scholars have found that differentiation in success rates is, amongst other things, caused by variation in the type of pooling systems and the level of cooperation with international aid organisations [1]. Furthermore, the level of civilian involvement in policymaking and the level of evidence-based decision making may lead to varying success rates of health reforms. Uzbekistan, for example, has no national pooling system for health financing and limited international aid involvement [1, 3]. Furthermore, Uzbekistan stands out as a lower-middle income county. The average OOP of low-middle income countries is much lower than that of Uzbekistan. For years it has been around 36%, without many fluctuations [16].

Uzbekistan's government has implemented reforms targeting primary care, noncommunicable diseases and project management and evaluation improvement. While these efforts have been made, partly in an attempt to reduce OOP, challenges remain and financial protection is not achieved [4]. The current policies are not effective in reducing OOP. Existing studies have already established that economic health shocks contribute to poverty in low-middle income country settings [3, 5, 18–20]. Addressing OOP is vital for improving the health of the population because high OOP is one of the first issues citizens encounter when accessing health care.

Studies have analysed health financing both in high income and low-middle income country contexts [21]. However, there are only a few studies that focus on Central Asian context [13, 22–24]. This research is motivated by providing evidence into an important policy debate on health financing by analysing what causes high OOP through examining Uzbekistan's health financing system and policy process.

### **2. Background**

Uzbekistan is a democratic republic and has been independent of the Soviet Union since 1991. Since then, the public health care system is divided into three hierarchical

### *Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

levels: (1) the national (republican) level, (2) the regional (viloyati) level, and (3) the district (local tumanlar) levels. There are fourteen viloyati [1, 4]. Each viloyat exists out of smaller districts: cities or rural areas that are called tumanlar. The different hierarchical levels have different responsibilities in terms of regulation and financing of health services [25].

The formal actors in the public health sector are the President, the Cabinet of Ministers, the Supreme Assembly (Senate and Legislative Chamber), the Ministry of Health (MoH), the Ministry of Finance (MoF), viloyat health authorities and tuman (local) health authorities. In **Table 1**, presents an overview of all the actors and their tasks can be found.

The elected President, Shavkat Mirziyogyev (in power since 2016) determines the strategic course of health reforms in Uzbekistan [26, 27]. The direction for health care reform is co-determined by the Cabinet of Ministers and Parliament. They set priorities, formulate national health policies and determine means and sources of financing. The MoH and MoF are consulted before final policy documents are adopted, and they are involved in the policy development process [28, 29].

The MoH is also responsible for planning, organising and managing the health care system in general. It develops, implements and evaluates the policies, together with the Cabinet of Ministers. MoH also monitors the quality of care. Furthermore, it is directly responsible for managing and monitoring the national level hospitals, specialised medical centres, research institutions, medical schools and emergency care. The tasks of the Cabinet of Ministers and the MoH sometimes overlap, and they collaborate on many issues [30].

Subnational authorities have the responsibility to finance, manage and monitor sub-national hospitals, primary care units, sanitary-epidemiological services and ambulance services [4]. In general, the national government is more focused on specialised care, while the regional and local governments are more focused on primary care. Viloyat authorities are accountable to tuman or city health authorities and both are overseen by the MoH. Local governments can only implement policies that do not contradict national policies. Those are used as a regulatory tool [1, 4, 31].

Centralised decision-making remains mostly at the national level, but some administrative functions have been assigned to the viloyat, mostly budgetary responsibilities. There is to an extent cooperation between the different governmental levels, often those intersectoral approaches are donor-driven [30].

Although most health care is public, the private sector is gradually growing. The MoH has had to limit the private sector in the past due to unnecessary and unsafe care practices [4, 25]. However, the government has started to encourage private practices and clinics to mobilise resources and improve quality and efficiency. The private sector is now monitored better with unannounced inspections to private facilities [28]. Nevertheless, the private sector remains small.

It includes the supply of pharmaceuticals and other medical equipment. Moreover, some physicians have a private practice. Dental care is also privately provided. Many services cannot be provided in the private sector, either because the government does not allow it or because there are no private suppliers. Furthermore, government reimbursement is only possible in the public sector [32].

The role of international organisations and NGOs in the health system and policy process is small. Functions such as educational campaigns, free testing and treatment of AIDS/HIV are in many countries taken up by NGOs, but in Uzbekistan, the government has taken responsibility for this [2, 28]. Research has shown that many Central-Asian governments perceive NGOs to be politicising health care. Uzbekistan's government


### **Table 1.**

*Tasks of formal actors in the health systems decision making.*

has been pushing out most international donors and their projects since the mid-2000s. This is likely because they see non-state actors as a threat to state legitimacy [33, 34].

Local NGOs have been slowly growing and they have been trying to organise themselves better. Between 1999 and 2004, international donors have been helping to create a more autonomous NGO community with financial and technical support.

### *Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

Nevertheless, the government keeps hindering their full development. To avoid governmental resistance, the term "social organisations", instead of non-governmental organisations, is sometimes used. This term sounds less as if the organisation is against the government [33, 34].

Uzbekistan receives disproportionally low amounts of aid money considering the disease burden. This is caused by bureaucratic governance and the lack of governmentled aid coordination mechanisms. On top of that, aid actors are concerned with the "neglect of human rights issues, as well as cases of corruption" [29, 35]. Despite this resistance, President Mirziyogyev is slightly more willing to participate in international cooperation to improve his country's policies, as became appearant after his policy dialogue with the WHO [36]. Health reforms have targeted various areas of the health care system. Most recently, reforms have focused on improving primary care, reducing non-communicable diseases and improving project management and evaluation.

Furthermore, in 2019, the WHO has had policy dialogues with Uzbekistan to discuss the best practices for health financing reforms and effective policy instruments. Evidence-informed choices are in this way stimulated. Other topics discussed in this dialogue were establishing a single national pooling system for health financing, improving quality of health care, increasing equity and efficiency in resource allocation and designing a state-guaranteed benefit package with more clearly stated entitlements for recipients and obligations for care providers. These changes are aimed at achieving higher financial protection [36].

Finally, reforms have recently been made in the transparency of the policy process. The Parliament's visibility has been increasing, more fragments of their session are accessible, and the media covers the Parliament's work more often. Policy reforms suggested by the WHO are considered.

### **3. Methods**

This study has a mixed-methods case study approach. This means that a single case (Uzbekistan) is studied, and both qualitative and quantitative methods are used to collect comprehensive data on the case. The mixed-methods case study approach can be used to find answers to a specific question about the case. It is commonly used to answer questions about the effectiveness and feasibility of a particular treatment, intervention or program [37–39]. The research aims to examine the governance system and policy process and examine these systems' effectiveness and functioning. Thus, a mixed-methods case study approach is a good fit. This approach is beneficial when it is impossible to obtain a sizeable homogenous sample of cases in similar conditions. This type of research is mostly exclusively relevant for the studied case and thus has intrinsic value for that case. Generalizability does not have priority [38, 39]. This applies in Uzbekistan's case study: it is not relevant whether this case is generalizable because every country has unique circumstances. Thus, this research mostly has intrinsic value for Uzbekistan and its policymakers.

The qualitative component is a comprehensive literature review. We searched MEDLINE, Econlit, CINAHL, Scopus, and Embase (from inception to June 2021), and grey literature sources using keywords relating to health policy, health finance, and Uzbekistan. In addition, the snowball sampling method was used [40]. This is a repeated process to identify relevant articles in the reference list of other relevant articles. A total of 27 references were used in the literature review. The inclusion and exclusion criteria that were used in selecting the references are shown in **Table 2**.


### **Table 2.**

*Inclusion and exclusion criteria literature review.*

The quantitative part involves a linear regression analysis of cross-sectional secondary household survey data. The study was carried out using open data kit (ODK) in two districts- Olmalik and Kibray of the Tashkent province in Uzbekista. The lack of public statistics on the demographic, socio-economic, and health status of the population in the country made it challenging to stratify and randomise the sampling for the household survey. A simple random spatial sampling has been adopted to carry out a survey between July and October 2015. Further details of the study sampling strategy and survey data can be found in the Subramanian et al. (2018) study [41]. The study covered of 207 households in Olmalik and 200 in Kibray. Based on the survey responses, a linear regression analysis of each variable is performed. The software used to perform the statistical analysis is RStudio. Variables are considered significant when the p-value is lower than 0.05. Variables are considered significant if the p-value is lower than 0.05. After that, a model is proposed that includes all relevant variables and minimises the sum of squared errors. The objective is to predict the household OOPs based on a household's characteristics.

The variables in this expected model are based on what other studies into OOP have found to be significant. The response variable, health care expenditure in the last six months, is measured in Uzbekistan Sum, the local currency. Based on the exchange rate in 2015 and the average salary of an employed Uzbek citizen, the average proportion of household income spent on OOP is calculated.

Variables are considered significant if the p-value is lower than 0.05. To detect multicollinearity, a VIF test will be performed. Variables with a VIF between 5 and 10 are removed, as this is considered harmful.

The two methods provide comprehensive data on the constraints in the Uzbek health financing system and policy process. While the qualitative part provides a broader system overview, the quantitative part includes knowledge of what factors cause OOP on the household level and provides empirical evidence.

*Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

### **4. Results**

### **4.1 Basic benefit package**

Uzbekistan spends a relatively low proportion of gross domestic product (GDP) on health. In 2018, health expenditure, as a percentage of GDP, was 5.3% [42, 43]. This proportion has been increasing over the past decade, though it remains small. For comparison, countries in the European Union spent on average 9.9% of their GDP on health care. Almost half of Uzbekistan's total health care expenditure comes from private sources, such as OOP [15–17].

Funds for health financing are mostly raised at the sub-national level, mainly through taxes. In 2005, Uzbekistan received 87.7% of the government health expenditures from local taxes. Since there is variation in how much revenue sub-national units can raise, there is much geographical inequality. Moreover, the proportion of GDP spent on health care is higher in the richer than in the poorer areas. There is no national pooling system of health financing resources yet, although the WHO has organised policy dialogues with Uzbekistan to change that [2, 28, 32].

From the collected revenues, the government provides a basic benefits package. All citizens are covered. However, the range of benefits differs per group. For everyone, the package includes primary care, emergency care and care for socially significant and hazardous conditions. Uzbek's primary care includes initiatives in family, maternal and child health and preventive and sanitary-epidemiological activities [9, 28, 44]. The socially significant and hazardous conditions include specific respiratory, skin, intestinal, blood-borne infections (poliomyelitis, TB, leprosy, HIV/ AIDS, syphilis), cancer and mental health. Pharmaceuticals for inpatient care are also included, but pharmaceuticals for outpatient care are not. In principle, primary health care is free and universal. Nevertheless, some tests have costs and some pharmaceuticals need to be paid out of pocket [1, 44, 45].

For certain people, the basic benefit package also includes outpatient pharmaceuticals and specialised care (secondary and tertiary). People with specific diseases, such as HIV/AIDS, or people belonging to particular groups, for example, war veterans, are included in the extra benefit. **Table 3** shows everyone with the right to extra benefit. Some uncertainty exists about the extent of the extra benefit. Moreover, reimbursed care cannot be higher than 20% of the institution's total budget [1, 45].


### **Table 3.**

*Disease and population groups that receive extra benefit.*

For example, for cardiac care, the treatment's expensiveness can form an access barrier as cardiac patients constrain their daily consumption because of high medical expenses [46].

To finance primary care, there is an increasing use of capitation-based payments for. They are paid for the covered population, adjusted for age and gender as a lump sum per year [45, 47]. Capitation rates are calculated at the viloyat level. This helps to spread the risk evenly and reduce income inequality [48]. The rates are set annually and are dependent on the size of the viloyat health budget. No protocol dictates a particular share of primary care of the total budget [49–51]. Another way in which the state covers health care services is through user fees, amounts of money that are paid by the government to the providers after they have performed a specific health service. Those are mostly used in secondary and tertiary care institutions [51, 52].

### **4.2 Financing outside the basic benefit package**

For the largest part of the population, secondary and tertiary care, as well as outpatient pharmaceuticals, are not covered. Services that fall outside of the basic benefit package are expected to be paid for through other means, such as private health insurance, employer contributions, union funds and OOP [1, 3, 53]. In 2018, 60.3% of all health care expenses in the country were OOP, and this proportion has been increasing in the past years. Voluntary health insurance does not play a significant role. Nevertheless, it became more visible in recent years. Still, in 2012, it only accounted for 2.6% of total health ependiure [14, 16].

The government has been encouraging formal self-financing rather than the state budget. The price-setting process is regulated with price caps. The proportion of revenue coming from formally paid services has been gradually increasing in the past years [1, 54, 55]. Nevertheless, informal payments still occur, mostly in secondary and tertiary care [13, 56]. Despite self-financing options, physicians commonly accept informal payments to supplement their low income and keep care affordable to their patients. It is unclear if self-financing reforms have successfully [13, 56]. In 2007, a study showed that 42% of the respondents reported using informal expenditures [3]. Particularly the poor make informal payments: "patients from less affluent households are more likely to have to pay informal under-the-counter payments in health care settings" [57–59].

Informal payments are harmful because it is very hard to monitor the quality of care and manage data and information on informal services. Moreover, informal fees can become based on willingness to pay rather than on the service's quality. Furthermore, if informal payments make up a large part of the health care, it will formally seem like not many people need health care. This will result in lower investments in medical equipment or health care infrastructure [13, 24].

### **4.3 Consequences of OOP**

The basic benefit package only covers part of health care results in OOP, which leads to high inequalities and catastrophic expenditures for households. The extra benefits for specific groups are a good initiative, but including those groups is not based on income necessarily [2, 28]. The burden remains particularly high for poor people because an OOP service takes up a larger proportion of the household income

### *Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

for poor households than for more affluent families [2, 28]. Fear of high OOP leads to various suboptimal behaviours related to health.

To begin with, financial constraints may cause delayed diagnosis [60]. If people cannot access health care when they need it, their health complaints may develop into larger problems that are harder and more expensive to treat. The costs may be much higher than they would have been if health care was accessed immediately.

So, fear of OOP leads to late diagnosis and also to starting the treatment later [60]. A study on the drugs for tuberculosis found that of the 146 patients that were interviewed, 79% experienced financial problems to get the diagnosis and treatment for tuberculosis. Some patients mentioned having to sell livestock and crops to pay for the treatment, and one patient felt forced to sell his house to cope with the financial burden [55, 61–63].

The treatment is sometimes started with cheaper services and medication, reducing its efficiency. Mostly routine outpatient medicines can be a drain on the patient and their family's resources [44]. Financial concerns thus lead to selecting low-quality drugs, and the treatments are even cut short [60]. Short treatments could mean that health complaints will return and care needs to be purchased again and this is possibly harmful to the patient's health long-term. Some physicians, when aware of the financial status of the patient, prescribe expensive medication, but also provide a cheaper (less effective) medication or they limit the number of drugs prescribed [55, 61–63].

The transition to increasing use of self-financing schemes will likely enlarge the problems of accessing services for poorer households. It encourages inappropriate use of health services, leading to a waste of resources [1, 2]. This improper use is an attempt at avoiding costs by trying to receive health care through services that are covered by the state, even if those services are not the most efficient way of obtaining the required care. For example, the fact that emergency services are free of charge leads to overuse of those services, while specialised centres would be more efficient in addressing the health complaints. Apart from efficiency loss, this inappropriate use limits access for those who really need emergency care [64, 65]. Additionally, using health services that are not adequate for the patient's condition may lead to the worsening of the condition, leading to higher OOP long-term.

Furthermore, patients will try to stay in the hospital, even if outpatient care would be more suitable. The inpatient pharmaceuticals are for free, while outpatient medications are paid out of pocket. There is a lack of financial support to promote outpatient care, even for diseases that are supposed to receive extra benefit [66]. This suggests, again, that patients are not correctly informed about their rights to coverage or that the regulations around coverage for the people who have a right to the extra benefit (see **Table 4**) are flawed.

The problem of inappropriate health care use of inpatient or ambulatory services is worsened because there is no clear pathway for patients, and the referral processes at each level of care are poorly regulated. Patients can refer themselves to secondary or tertiary care easily. There is a weak link between primary and specialised care, and GPs do not have the financial incentive to take a gatekeeper role [17]. With self-financing, the connection between primary care and inpatient care has grown weaker because accessing specialised care became more expensive through the health care institution's fees. In the private industry there is even less regulation of referrals. Not being referred to the proper type of care can again lead to higher OOP, since unnecessary care might be accessed or care needs to be accessed again in a different level of care [5, 17, 47].


**Table 4.**

*Description of household characteristics using categorical variables.*

### **4.4 Caveats in health policy agenda setting**

On the policymaking level, a lack of civilian participation, unavailability of data, low analytical skills, poor communication at the implementation phase and inadequate evaluation procedures are underlying causes for the persistence of policies that are inefficient at lowering OOP.

Civilian participation is limited, as issues that are most important to citizens, such as high OOP, may remain unprioritized. Uzbek citizens do not play an active role in the health policy process as there is no specific frameworks are in place to ensure public participation in the planning, purchasing and organisation of health services [1, 67, 68]. The role of civil society organisations is limited due to Uzbekistan's selective policies towards NGOs [33, 34, 69]. Finally, access to health information is generally only available to government agencies and not to the public. This limited transparency makes it even

### *Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

harder for citizens to know which issues are most important to them. One of the main shortcomings is that citizens are uninformed about their rights: policies about coverage have been made, but patients do not always know what services they can access free of charge. Moreover, there is too little information on what services are high-quality. This may inhibit the implementation of modern health policies further. Weak communication in the implementation stage means that even if a policy is in theory adequate in addressing OOP, it will be inefficient in practice.

The data information system is fragmented: public health facilities must collect data, but all data collection systems work independently from other collection systems (e.g., the national programs' data is not connected to the sanitary and epidemiological data system) [9]. The WHO reports that in various provinces, patients' needs were not monitored frequently enough [2, 32]. The data collection system is primarily focused on structural data, and there is little effort to collect process-related and qualitative data. It is not clear if any data is pooled at the different levels of data collection. Furthermore, the MoH provides data reports and shares these with the viloyat authorities for decision and policymaking. Meanwhile, there is very little attention to the local and tuman levels. Information on income, education and ethnicity are not part of the policy process. Data collection is only done in the public system [9, 28, 32]. Finally, the available data is not as useful due to weakness in policy makers' capacity to utilise such data. The inadequate evaluation tools lead to the wrong conclusion on whether a policy should be maintained, succeeded or terminated.

### **4.5 Challenges of health financing at the household level: Olmalik and Kibray**

Olmalik is an old industrial township, and many households were small families or comprised of young migrant workers. On average, about three members (3.35) live in a household in this district compared to five members in Kibray (5.04). The socio-demographic characteristics are presented in **Table 4**. First, the majority of the households are male-headed in Olmalik (80.7) and Kibray (69.5). More than half (61.0% in Olmalik and 52.0% in Kibray) of the heads of household head have been educated up to secondary level and 13% do not have formal education. This shows the high level of literacy in the district as well as the educational requirement of the government. In Olmalik, most of the households (63.8) reported having no children in their homes, implying a worker population. Most of the households viewed themselves as being in the middle or above in terms of their income category (93.7% in Olmalik, 93% in Kibray).

The significant variables are 'number of household members with chronic illness', 'use of alcohol', 'saved money in the past', 'town of residence' and 'perceived health status household head'. The survey showed that none of the participants have health insurance. VIF statistics of the variables of the number of chronic disease, alcohol use, town of residence, money saved and perceived health status household head all turned out to have a value between 1 and 5 (average 1.054), which indicates a moderate correlation between the predictor variables, but not severe enough to require attention. Thus, the variables in the model do not create collinearity with the regression model. Finally, it was found that heteroskedasticity does not exist in the regression model above.

The adjusted R-squared of this model is 0.1099, with a p-value of 5.79e-10. This means that the model shows a significant correlation and the variables in the model explain about 11% of the variation in health care expenditures.

The variable 'perceived health household head' was significant. If the perceived health was 'good' the average OOP was 386,135 UZS, while if the health was considered fair, the average OOP was 655,000 UZS.

The mean amount of money spent by each household as out of pocket expenditures in the last six months is 418.373 UZS. Given the exchange rate, this would be 148,89 USD. Although there were far higher amounts reported too: 45 participants spent over a million (355,87 USD) in the last six months and the highest amount was 10 million (355,74 USD). For comparison, the GDP per capita in 2015 is 2.615,03. An Uzbek with a job earns 1307.52 USD in six months. In the sample population, 1.86 household members have a paid job. This means in 6 months there is an income of on average 2431,99 USD, with the average OOP, (355,87/2431,99\*100=) 14% of the household income is spent on health care expenditures.

The finding that chronic illness is a strong predictor for high out of pocket expenditures is in accordance with other studies that have looked at OOP predictors. For example, a study in Bangladesh also found that chronic diseases are a strong predictor of high household health expenditures [70, 71].

Alcohol use could be the cause of specific disease and thus create out of pocket expenditures. However, drinking alcohol could also be a coping mechanism of dealing with the financial instability of out-of-pocket payments. The association between alcohol use and health care expenditure is not conclusive since it is impossible to determine the direction of the association. Only a longitudinal study could determine the relationship, while this was a cross-sectional study [72, 73].

Infectious diseases or diarrhoea individually did not show a significant correlation with OOP. This is likely because various infectious diseases fall within the extra benefit package (e.g. HIV or leprosy). Moreover, most care for infectious disease and diarrhoea often falls under primary care, while many chronic conditions require specialised care, which is not covered by the state [44].

Saved money in the past likely showed significance for the simple reason that people with more money saved have more money available to spend on health care, while people with less money saved have less money available to spend on health care. The reason that perceived health status household had was significant is also straightforward: household heads with a health status that is considered 'good' need less health care than household heads with a health status that is only perceived to be 'fair'.

It is unclear how the significance of the town of residence is caused. One hypothesis is that Olmalik has very different living conditions. Olmalik is much more industrial, which causes various health complaints, especially related to low air quality. However, it would be expected that the industrial environment has more health hazard, but the OOP is lower in Olmalik. As shown in **Table 5**, there are higher infectious and chronic disease rates in Kibray, but it is unclear how this is caused. Future research would be needed to be conclusive about the correlation. Survey participants expressed concerns with access to health care as well as quality of care as low quality can lead to high OOP.


**Table 5.**

*Difference in disease occurrence between Olmalik and Kibray.*

*Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

### **4.6 Current progress on OOP reduction policy and universal health coverage**

As of 2018, the Uzbekistan government declared to implement a mandatory health insurance (MHI) to move towards universal health coverage. The Presidential Decree No. 5590 was approved in December 2018 under the name of "About complex measures for radical enhancement of health care system of the Republic of Uzbekistan", to introduce mandatory health insurance (MHI) for population coverage of essential health services and pharmaceuticals [74]. The decree states that the state will lay out mechanisms and stages of implementation for compulsory medical insurance. It also plans to determine the subjects of compulsory medical insurance as well as authorised entity on regulation for its legal scope, rights, and obligations. It also states the state will sought out sources of financing for programs of compulsory medical insurance. The Ministry of Foreign Affairs of the Republic of Uzbekistan planned to take measures for the organisation of interaction with the World Health Organisation and the international financial institutions for ensuring technical assistance in case of implementation of this Decree, including carrying out the feasibility statement on actions for implementation of compulsory medical insurance [74].

Departing from the existing health financing structure, as implementation of this new strategy was the introduction of a new single-payer state health insurance organisation: the State Health Insurance Fund. Amid the COVID-19 pandemic, in November 2020, Presidential Decree No. 4890 was approved to formally established the State Health Insurance Fund as a national purchasing agency to be financed through the central government budget to purchase health services defined in a new state-guaranteed benefits package, which will be available to the whole population [75]. Starting from June 1, 2021, in the Syrdarya region of Uzbekistan, a pilot project was launched to introduce a new model of healthcare delivery. Furthermore, the feasibility study by WHO (2021) recommended general taxation as the most effective way to pool funds and risks, to redistribute resources in an equitable manner and to support progress towards universal health coverage [76, 77].

Based on this recommendation, the State Medical Insurance Fund mainly receive funds from the state budget for basic compulsory medical insurance along with targeted deductions from excise taxes on tobacco products, alcohol, high sugar foods, trans fats and other products that are harmful to health (introducing the so called "sin taxes" as the first nation in Central Asia) as well as voluntary contributions and grants from international organisations. From 2023, state health insurance is planned to be introduced in Karakalpakstan, Tashkent, Samarkand, Navoi, Surkhandarya and Fergana regions, and from 2025 – throughout the entire Uzbekistan [78].

### **5. Conclusion**

The basic benefit package only covers primary care, emergency care and inpatient pharmaceuticals. Extra care is provided for some, but this selection is not necessarily based on income. The specialised care and outpatient pharmaceuticals need to be financed in other ways. Since there is almost no public or private health insurance, most care that is not in the basic benefit package needs to be paid out of pocket. The regression model suggests that having a chronic illness is an important factor in high OOP.

Additional aspects of the health financing system that lead to high OOP are a lack of qualitative, patient-centred evaluation methods. What is more, there is no publicly available information on quality, prices or types of health services. This large information asymmetry makes it easy for physicians to provide low-quality or unnecessary services. Moreover, the patient's referral pathways are poorly regulated. Attempts to avoid OOP lead to delay in diagnosis and delay in treatment. Furthermore, some patients seek informal care, where quality is even less regulated. These behaviours lead to higher OOP long-term.

The policy process is constrained by the limited civilian participation, which is partly due to socio-political factors such as resistance towards NGOs and the limited transparency of the policy process. In the implementation of policies, clear communication is lacking. Finally, the lack of qualitative data and analytical skills negatively impact almost all phases of the policy process. Uzbekistan is dealing with a capacity problem in data collection and analysis. Evaluation and information management is also important for improving the policy cycle. If more data is available and policymakers are additionally trained in analytical skills, evidence-based policymaking will become easier. Policymaking can be further improved by increasing civilian participation, for example, through civil society organisations. For meaningful civilian participation, more transparency about the policymaking is also needed.

Based on the findings, recommendations on improving the health (financing) system and policy process can be made. These are broad recommendations that need more research before they can be used in policies. In short, improving monitoring and evaluation procedures can help reduce the information asymmetry between the providers and citizens and between the providers and policymakers. Information on price, type and quality of services should be provided to patients. Additionally, patients should be made aware of their rights in terms of coverage. Finally, the benefit package should be expanded. This research suggests that expansion should include chronically ill. Uzbekistan has rolled out its pilot state funded compulsory health insurance for the first time in the nation [79, 80]. Based on the pilot project, it aims to design a benefits package of free medical services and medicines guaranteed by the state as well as to strengthen disease prevention, organising regular screening examinations of various categories of citizens [78]. Hence, prioritising health insurance coverage for the vulnerable as well as earmarking a coverage for chronic illness may be necessary.

Additionally, it would be relevant to understand what specific services were purchased with OOP by households. This could give insight into whether or not the guaranteed basic benefit package is serving the population's needs and what services outside of the package form the biggest drain on households. Finally, the examined variables in this research only explained 11% of the variation in OOP. Thus, future research should examine additional variables.

### **6. Limitations**

Most of the secondary data was not very recent and thus up-to-date information on the health system's financing status and policy process is lacking. The WHO and news articles provide more current information on certain issues such as ongoing reforms, but there is a lack of recent academic literature. Furthermore, while a combination of primary and secondary qualitative data would have been ideal, the time and COVID-19 pandemic-related constraints only made secondary data accessible.

### *Out-of-Pocket Health Care Expenditures in Uzbekistan: Progress and Reform Priorities DOI: http://dx.doi.org/10.5772/intechopen.110022*

The method of snowballing literature has a risk of neglecting relevant articles due to the exclusion of articles that are not relevant but form a useful connection to other papers [40]. Additionally, the inclusion and exclusion criteria, as well as terminologies used in health financing systems and health policy, overlap with other terminologies which may lead to different literature search results. Only English articles were included, meaning that Russian or Uzbek articles were not used, even if they would have contained a relevant approach or relevant information.

There is a limitation in the quantitative data collection because all participants came from the same region in Uzbekistan. While there were no other options due to resource constraints, it forms a limitation in nation-wide generalizability. Thus, if specific factors are found to be relevant, additional research is needed before recommendations to change nation-wide policy can be made. Nevertheless, the research can provide a broad view based on which detailed research can be recommended.

In this research, the range of aspects explored in the qualitative part may be broader than the range of aspects examined in the quantitative part. However, it should be noted that each part provides different types of information that complement each other. While the qualitative component may be able to point out broader aspects on a large-scale, the quantitative data can point out factors leading to high OOP that are experienced on the household-level.

### **Acknowledgements**

The authors are grateful to Dr. Saravanan Veluswami Subramanian for his support in concluding this research work.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Min Jung Cho\* and Eva Haverkort Faculty of Global Governance and Affairs, Global Public Health, Leiden University College, Hague, Netherlands

\*Address all correspondence to: m.j.cho@luc.leidenuniv.nl

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## Investing in Health Education to Reduce Rural Health Disparities

*Jean Ross, Samuel Mann and Kate Emond*

### **Abstract**

The global rural population accounts for almost half of the total global population. Access to health care for these rural populations is reduced, leading to increased health disparities. Nurses play a critical role in reducing health disparities but with limited models to guide their practice. The Community Health Assessment Sustainable Education model is a practical teaching and learning solution, which has been developed to engage student nurse learners in a health promotion philosophy for rural areas. Nurse learners assess and gather data to progress community development and navigate the holistic landscape of health. In this chapter, we describe how this approach integrates the sociopolitical, cultural, sustainable, economic, and environmental aspects of rural communities' health. Our focus is on preparing nurse learners to improve the health of rural populations globally and reduce health disparities. The CHASE model enables nurse learners to influence and change policy and legal responsibilities at local, national, and global levels, while community development aims to address nurses' role in advocacy that requires them to act on behalf of communities from a social justice perspective as they prepare for registered nurse practice.

**Keywords:** rural, health, education, CHASE model, nurses

### **1. Introduction**

Improving the quality of life in rural areas requires investment in rural health. While such investment often involves spending on physical infrastructure, we focus on the education of nurse learners in preparation for registered nurse practice in rural contexts. Nursing in rural areas is not the same as urban centers. Rural nurses must combine their clinical skills with that of community developers. In this chapter, we describe how the Community Health Assessment Sustainable Education (CHASE) model is used for introducing nurse learners to this complex nature of rural health [1, 2].

Rural nurses must be prepared for situations that are outside their usual lived experience and outside the textbook of clinical practice. Even for rural nurses who work in their home districts, we need them to be able to step back and look at the rural communities as if through the eyes of geographers or perhaps as strategic designers. These capabilities as community change agents will not come about through the usual clinically focused placements alone. We need to invest in the difference, that is, rurality. The CHASE model, therefore, enables nurse learners to influence and change policy and legal responsibilities at local, national, and global levels, while community

development aims to address nurses' role in advocacy that requires them to act on behalf of communities from a social justice perspective as they prepare for registered nurse practice.

After canvassing the challenges of rural health education, we outline the development and nature of the CHASE model. We then describe an international collaboration of investment in rural health education using the CHASE model. We commissioned the production of a film of the rural village of Bishop's Castle (Shropshire, UK) to enhance the learners' engagement and critical thinking and questioning of this community to enhance their community profiling and assessment.

The purpose of this chapter is to add to the growing debate of improving the provision of rural health care and equally rural workforce planning. Our focus is on preparing nurse learners to enhance the health of rural populations globally. To achieve this, we demonstrate the value of engaging with a research framework guiding our collaborations as we collaborate with rural communities. This project is explored using ethnographic reflections of the participating academics (authors), as we engage with an authentic teaching practice to consider the success of the CHASE model in preparing nurse learners for rural practice.

### **2. Background**

Nurses make up the largest segment of the global health care profession [3] and play a critical role in assessing the health care of rural populations while working collaboratively with rural community residents to reduce rural health disparities [4]. In consideration of nurses' positionality as community development practitioners, it is therefore imperative that an understanding of this joint role—of assessing and collaboration—is passed onto nurse learners. The demand of educating nurse learners for rural areas goes beyond the clinical, to provide them also with the opportunity to practice as community development practitioners a term derived by the International Association of Community Development (IACD) who note the inclusivity of all people whether in unpaid or paid work who offer their services to improve community welfare are considered community development practitioners [5].

The challenges of practicing within the contexts of rural geographical locations are numerous, which add to the complexity of practicing nursing in rural locations. Rural locations are widely dispersed and often isolated. Nurses practice health care in these contexts at times as solo practitioners, as a member of an intradisciplinary, interdisciplinary, or multidisciplinary teams in small hospitals, community venues, residents' homes, schools, recreation facilities [4] the outback, a village, the bush, or an open space [6]. Equally, these practitioners care for rural residents and visitors from birth to death and experience all manner of health care eventualities. In addition to the clinical practice of all nurses, the scope of practice of rural nurses includes the complexities of living rural, the economic factors, isolation; limited transportation and communication and the variety of occupations including engaging with nature; and agriculture and farm life, including animals; farmed space; domesticated; and wild [7].

The rural resident population accounts for 44 percent of the total global population [8]. People in rural areas experience similar rural health issues yet often suffer more than urban communities because of a lack of access to health care including affordability [9]. The provision of health care services in rural locations are under threat with centralization (hence urbanization) of services [10]. The provision of rural health care services is of global concern and has been recognized as such for

the past two decades [11–13]. Despite the huge differences between developing and developed countries, access to health care is the major issue in rural health around the world [14]. The provision of health care within rural communities remains a global challenge [15].

The state of rural health is one of the disparities and inequities [16]. This recognition acknowledges that the health of rural people experiences numerous health disparities and suffers more than their suburban and urban counterparts. A lack of access to health care is in turn related to the lack of health providers including the availability of specialists [9]. Further, the reduced numbers of rural health care practitioners have led to the lack of availability and recruitment of experienced health practitioners and a corresponding lack of rural planning and dedicated funding. Rural health care practitioners include doctors, nurses, midwives, and pharmacists, who make up most of current practicing rural professionals to improve access for the provision of health care and to highlight these issues to health planners, regulators, and governments, globally [17]. Rural nurses are one of the main contributors of this action [18].

Rural nurses need to have the capability of working with rural communities to gather and analyze population-level data, promote wellness and disease prevention, assist in adopting and disseminating best practices for population health, and identify patients who are at greater risk of disparities, necessitating greater outreach efforts [18]. Therefore, nurses need broad-based knowledge to succeed with this endeavor and more importantly to ensure that they are prepared and competent to practice successfully in rural contexts. There is no better time to engage with nurse learners about community development and the practice of "nursing a community" to improve health care. Student nurse learners can be immersed in community development, to enable them to develop the professional competence to contribute to solution-focused and sustainable health care. It is therefore imperative that nurse educators expose, facilitate, and provide their experience of practicing community development, for the future endeavors of rural health care as nurse learners prepare for registered nurse practice.

### **3. CHASE model**

The purpose of this chapter is to add to the growing debate of improving the provision of rural health care and equally rural workforce planning. Our focus is on preparing nurse learners to enhance the health of rural populations globally, in keeping with the vision of the Global Rural Nursing Exchange Network (GRNEN) [19] which is discussed in relation to the student nurse learners project grant, later in this chapter. To achieve this, we demonstrate the value of engaging with a research framework guiding our collaborations as we collaborate with rural communities.

The Community Health Assessment Sustainable Education (CHASE) model is used for introducing nurse learners to rural health [1, 2]. CHASE provides a consolidated structure that immerses nurse learners in community development practice and involves them to be active in their own learning in partnership with their team peer members, community organizations, community key stakeholders, and educational supervisors. CHASE guides learners through ethical, cultural, professional, and critical thinking, verbal and written communication, and visual presentations. CHASE enables nurse learners to influence and change policy and legal responsibilities at local, national, and global levels.

It is therefore imperative that student nurse learners experience community development work, as part of their primary health care clinical placements. Students are guided by the CHASE model to create opportunities for improved community health among rural population groups. Learners use both primary and secondary data collection to describe the community, map resources, uncover inequities, and listen to stories of community resilience. Health needs are identified between learners and community members, and sustainable responses evolved in the form of solution-focused strategies and resources and disseminated within the community to improve well-being.

### **3.1 CHASE engagement**

CHASE stands for Community Health Assessment Sustainable Education model. CHASE was developed in 2017 to assist nurse learners (as a component of their Bachelor of Nursing (BN) degree program from the School of Nursing, Otago Polytechnic, Dunedin, in New Zealand) to undertake community development projects. These projects related to clinical practice experience and received ethical approval in 2021–2024 to proceed by the School of Nursing, Ethics Committee, Otago Polytechnic, Dunedin, New Zealand, for learners to profile and assess the rural community, take action, and design and develop health promotion messages and resources to improve the health of the identified population associated with that rural community. CHASE consists of two preparatory stages: a pre-engagement stage and pre-orientation, an orientation stage and six phases [1].

The **pre-engagement** stage is extremely important, where the facilitator or the lecturer engages with the community.

The **orientation** stage offers learners the opportunity to become acquainted with team members (nurse learners) whom they participate with throughout this 4-week project, the supervising lecturers, and the rural geographical location to which they have been assigned to conduct the community development project.

**Phase one** commences with the planning stage to undertake the community assessment associated with the identified rural geographical location. The community assessment is guided by an adapted version of Anderson and McFarlane's communityas-partner wheel [20], which enhances the collection of both secondary and primary data including the demographics and social, political, and economic services aligned with the community. One of the outcomes is to "get to know the community better"; therefore, developing a film of the community was recognized as beneficial and could assist the students to experience visually, the community.

**Phase two** requires learners to prepare a draft written report for verbal and visual presentation in consultation with the supervising lecturers and community stakeholders and identify health disparities and health needs.

**Phase three** learners work in smaller teams and progress their individual component of the wider project. Additional consultation may occur with community members specific to the learners focus on the agreed (with the community) identified health need and population group. A detailed evidence-based literature review is completed related to this health need.

**Phase four** learners continue to work collaboratively and progress with their written report and engage with the Ottawa Charter [21] and design and develop evidencebased resources that match the health need for the identified population group.

**Phase five** learners present back to the identified community partners the final completed published written report, the health promotion resources, and presentation.

**Phase six** learners initially assessed the health promotion resources designed to improve the health of the identified population 3–6 months following completion of phase five.

### **4. Investment in action**

In the collaborative nature of rural practice, CHASE is not just a teaching device. The model is one of co-design, research, evaluations, education and ongoing and future collaborations, and community development. We illustrate this working research framework [22] with an example of a community development project connected to the rural community of Bishop's Castle, Shropshire, England, United Kingdom. This community development project commenced in February 2020, revisited in 2021 and 2022. We are showcasing the 2022 project in this chapter, while the community development projects 2020 and 2021 provide an informative background to the 2022 project. Our overall focus in this chapter is to share the collaboration between the Bishop's Castle community stakeholders, the educators from La Trobe Rural Health School, Victoria, Australia, (LRHS) the School of Nursing, Otago Polytechnic, Dunedin, New Zealand, and the funders of the GRNEN project grant. This GRNEN international learning grant partnered this collaborative venture between these education institutions, the rural community Bishop's Castle, Shropshire, United Kingdom.

This international project offered a platform for meaningful conversations and encouraged global diversity for rural student nurse learners to improve decisionmaking and progress on issues that matter most to rural nurses and rural communities around the globe. The goal for this endeavor was to advance nurse learners' community development practice and to provide an opportunity for learners to engage with each other to:


Beyond the community development goals and learning experiences for learners, the project had research goals to:

• **foster** interactive virtual global relationships and collaboration between nine New Zealand and nine Australian Year 3 BN nursing students, as they engaged with this interactive project and shared their knowledge from their own countries associated with rural community development and public health focused on the mental health of rural youth and COVID-19 lockdowns;


Thus, the project had the following objectives that integrated the educational, community development, and research goals:


*Investing in Health Education to Reduce Rural Health Disparities DOI: http://dx.doi.org/10.5772/intechopen.109766*

This project, therefore, provides an example of investing in nurse learners' education as a mechanism for addressing rural health disparities. The collaboration that occurs across stakeholders and education providers offers learnings and resources that would not otherwise be available to nursing students. Investing in nursing education with a focus on rural health and rural communities provides students with the opportunity to genuinely understand the health disparities that occur between metropolitan, regional, and rural areas. Engaging with rural communities is a key characteristic of building a sustainable health workforce [17]; therefore, incorporating this into undergraduate nursing curricula at a university rural health school is vital.

### **4.1 Investment in community story**

We engaged with a local professional filmmaker from Bishop's Castle to film the community. To achieve this, we set a task for the filmmaker to engage with a footsurvey template in looking at the different aspects of how the students were going to profile and assess this community. The foot-survey encourages students to review, for example, housing, roading, safety, transportation, education, recreation, economics, and health care services based on the original Anderson and McFarlane's communityas-partner wheel [20]. This assisted the filmmaker in creating the story line and then producing the film (**Figure 1**).

### **4.2 Investment in virtual platform**

A virtual platform is developed using a platform within a Learning Management System (LMS—"Moodle"). This Moodle shell allowed us to retain resources and information, offer direction and discussion, and support for teams of nurse learners locally, regionally, nationally, and internationally. The Moodle shell is a working space and resource for students and staff and in the future will accommodate community users. All relevant content organized into a cohesive Moodle course, including

**Figure 1.** *Rural community Bishop's Castle. Source: John Keeley (published with permission).*


### **Figure 2.**

*Moodle shell CHASE whiteboard animations. Source: Authors.*

downloading documents/materials including videos to include virtual conference rooms and whiteboard animations with narration (**Figure 2**). Interactive lessons outlining the platform and how to use Moodle and forums as required for student groups and community were provided. Technical support and ongoing revisions were also provided. The content and direction provided in the Moodle shell has showcased through numerous community case studies engaged by the learners, in which all CHASE model phases are exemplified. The CHASE model enhances collaborative relationships in the global landscape and further contributes to inform nursing curricula and teaching and learning pedagogy internationally. CHASE supports the community development project, and the LMS is the means to achieve this.

### **4.3 Engaging with rural health**

There was a total of 4 weeks of collaboration between the universities in New Zealand and Australia during 2021. The New Zealand students shared their community profile assessment and analysis presentation comprising phases one and two of CHASE of Bishops Castle in the United Kingdom to the Australian students. Following this, the New Zealand and Australian students discussed together using GRNEN virtual platform for student correspondence (a requirement of the GRNEN grant) and the mental health of youth and other members of the community from their own countries' perspective while critiquing and reviewing the literature related to the information that would be relevant to assist the United Kingdom of Bishop's Castle, youth community. The academic team invested time and communicated regularly with students to assess their progress, ensuring there was a strong alignment in their thinking and their progress of their piece of work with community needs, making sure that it was continually coming back to the information that they received about Bishop's Castle and the challenges and then lifting that up to think about the global context as well and what was going on in this community. There was an emphasis on mental health and appreciating where we were at in terms of the globe and coming out of the COVID-19 pandemic, and it is not surprising that

mental health was high on everyone's agenda and an area that was worth paying some attention to.

Nursing students from both Australia and New Zealand interacted with the virtual networking and collaboration tools that were created, and by using these platforms and engagement opportunities they were able to right from the commencement of the community development project, connect with each other, and share in different ways and at different points of time, through the project and also draw the project to completion.

### *4.3.1 Reflection on learning*

(First author reflection): *Community Assessment – Getting to know the community.* The film we created to assist the students to assess and get to know the community certainly had that desired effect. What we found was that the students who watched the film both from Australia and in New Zealand, could start to really understand the complexity of this medieval village. What we as lecturers and registered nurses are facilitating through this learning are the complexities of the landscapes of the village. The changing British seasons that the film identified included a snow scene; a spring scene and a summer scene, those changes in weather patterns, the trained eye of a registered nurse would consider, how these seasonal changes impact on the village residents which further stimulates the registered nurse to consider the services local to the village, for example is there an ambulance service? is there a hospital service?, how do people get from one place to the other, especially during seasonal changes which could impact the residents on accessing services. Being introduced to these complexities through the medium of image (film) we found that the students could ask more significantly in-depth questions to the community stakeholders (via Zoom meetings and emails) to gather and be able to develop a much better comprehensive assessment of the community, which enhanced their understanding as they progressed with the CHASE phases.

(Third author reflection): *Community Engagement – Increasing Awareness.*

Our nursing students did impressive work, and the feedback from them revealed they felt the CHASE model and engaging in this program was beneficial to their practice, in that it could be used to inform a health promotion message, or an event endorsed by health promotion to a real rural community, rather than exploring these concepts theoretically. They were pleased with identifying the strengths of the rural community and offer to build a health promotion message based on that strength [23]. Nursing students reported an enhanced understanding of the local-global connections, unique cultural relationships, similarities, and differences associated with rural locations and rural sense of belonging of rural communities, their people, and their health. At the completion of the project, they developed a mental health promotion recommendation for the community. This project increased their awareness and knowledge of mental health needs in rural communities and how important it is to engage communities in health promotion for sustainable outcomes.

(Third author reflection): *Collaboration – CHASE in Action.*

The information about the rural community via film was really important. The communication channel that was established between students and facilitators with time differences, had some challenges there but it was not something that we couldn't negate or overcome and that was part of the students' learning as well in terms of when you're collaborating with colleagues overseas. The skills developed in terms of teamwork stemmed from creating that sense of team in an online interface, and that's where the structure that's provided in the CHASE model gave the students a great sense of shared understanding of the point of collaboration and their role in what they were going to contribute.

### **5. Implications of the investment in rural health education**

We invested in the community development project by embedding it into curriculum. When learning opportunities are part of an undergraduate curriculum, the engagement of students is high [24].

Engaging with this global research project supported with the film of the rural village of Bishop's Castle enhanced the nursing students across international universities' engagement and understanding of the rural community. Nurse learners profiled and assessed this community's health and identified the health needs with a strong focus on mental health of the rural community (**Figure 3**).

(First and third authors reflections): *community Assessment – Film as Asset.*

We are keen to explore the possibilities of linking similar films of rural communities together in the future and even aspire to growing a regional, national and global network of rural communities and making sure that extends to student nurses and their learnings and how they've engaged with the CHASE model. This will enhance this way of working and could promote international collaboration, and unique learning opportunities, and also enable students to have global connections and foster relationships with other students but also then connect with the community case study. This is a focus on the work of GRNEN and we hope to collaborate further with them in this endeavor. This would also lend itself to being able to research the way that students are connecting and groups of nursing students and nurse educators relative to the healthcare discussions from their respective countries because it's been quite interesting in terms of what's been revealed.

**Figure 3.** *Screen shot introduction to film. Source: Authors.*

(Third author reflection): *creative Learning – Being Courageous.*

When learning opportunities are part of an undergraduate curriculum the engagement of students is high, so it was really important for us to be able to create an alternate assessment for nursing students and gain approval from La Trobe's Academic Board. This approval was a significant milestone because we weren't adding to students' work, this was part of their learning embedded in a third-year mental health subject. In terms of the implementation that the information about the rural community via video was really important and the communication channel that was established between students and facilitators with time differences, there were challenges there but it was certainly not something that we couldn't negate or overcome and that was part of the students' learning as well in terms of when you're collaborating with colleagues overseas, how do you actually create that sense of team and that's where the structure that's provided in this piece of work really gave the students a great sense of shared understanding of the point of collaboration and their role in what they were going to contribute.

In terms of monitoring, we were in touch and communicating regularly with students' progress and also making sure that there was a strong alignment in their thinking and their progress of their piece of work with community needs, so making sure that it was continually coming back to the information that they received about Bishop's Castle and the challenges, and then lifting that up to think about the global context as well and what was going on in this community.

### (Third author reflection): *collaboration – Responding Virtually.*

An interesting finding engaging in the project for students at that point in time coming out of the COVID-19 pandemic, was to think about collaboration using these online platforms, because the expectations of the students with working online via different online mediums was actually quite low because they have become so used to it over COVID, they're used to using technologies, they're used to working with other colleagues even within their cohort via Zoom and via different platforms, so in terms of where they were sitting with expectations they were really quite open to this way of learning. Feedback from the students was that they really enjoyed the experience, time zones, that was a bit challenging and we needed to think about our timeframe, appreciating that they're all enrolled in other subjects as well, so really making sure that we were providing resources in a timely manner and the expectations of participation were realistic; and the other thing too is it was really interesting for students at this point in time to think about collaboration using these platforms, because the expectations of the students with working online via different online mediums was actually quite low because they've got so used to it over COVID-19 lockdowns, they're used to using technologies, they're used to working with other colleagues even within their cohort via Zoom and via different platforms, so in terms of where they were sitting with expectations they were really quite open to this way of learning.

### **5.1 Implications of the project to improve health disparities**

Our approach to this project was cyclic, aligning with a quality assurance approach. The implications of undertaking community development as a component of the wider collaborative research project were evaluated between the two educational institutions and the community stakeholders of Bishop's Castle, Shropshire,

United Kingdom, who assessed that the project was meeting its goals and objectives (introduced above) on three monthly intervals and at the completion of the project.

### (First author reflection): *community Development – Improving Health Disparities.*

A positive impact of the project and engaging with CHASE was demonstrated by the students' commitment to improve health disparities. The students stayed in regular connect with the community stakeholders supported with regular facilitation and guidance by the lecturers. This was achieved through live virtual meetings such as Zoom and email correspondence they were able to update the community and liaise with them around the identified health issues and latterly as the project developed the health promotion messages and then in partnership with this community, they were able to focus on designing and producing the health promotion resource benefitting the health of the population of Bishop's Castle youth.

### (Third author reflection): *community Development – Working Together.*

La Trobe nurse learners offered a significant and a wonderful focus of mental health and youth within their own community to actually share with the students of New Zealand, and they focused on the Rainbow community.

The students from New Zealand presented their findings on Bishop's Castle by using nursing frameworks, they incorporated the framework of Te Whare Tapa Whā [25] which is the New Zealand indigenous population framework, into their presentation by using a holistic approach to discuss all four aspects of the health needs – physical, mental, social and spiritual [25]. They also used the framework of the community -as-partner wheel by Anderson and McFarlane [20] this allowed them to develop a comprehensive display of all relevant health issues disparities within the community, together with these frameworks enabled them to give the Australian students an extensive insight into the health needs of Bishop's Castle which they picked up on and it became evident that they successfully communicated this information after La Trobe students produced a presentation to the students of New Zealand in return which contained and expanded all that they had developed.

### (First author reflection): *community Development – Sustainable Practice.*

Developing and maintaining ongoing relationships, and model development partnership collaboration and communication are very important to maintain sustainability between the three groups and with GRNEN. Sustainability included meeting with the stakeholders where we could discuss with the local health professionals including general practitioners, and district nurses, and from our conversations we were able to reflect upon the position Bishop's Castle was in with the closure through COVID-19 pandemic of their community hospital and how it had affected health outcomes for those with more serious conditions and medical events that required very prompt medical response. Through this we discovered that there were five district nurses that covered 10 rural communities in the Shropshire region, and therefore there was an empathy towards those district nurses and how they were expected to work with the closure of that hospital and with the increase in social isolation of older people and the mental ill-health of youth.

### **6. Conclusion**

In this chapter, we have described how the CHASE model works to engage learners and provide benefits for rural community despite geographic separation. These students were positioned to act as community development practitioners with the aim to reduce health disparities in partnership with community stakeholders.

A challenge of educating nurses for rural health is directly related to the nature of rural health. The isolation, complexity, and diversity of health needs mean it is challenging to provide authentic learning experiences that cover the breadth of rural health. Added to this is the need for learners to experience and learn the integrated nature of clinical practice and what might be called community development needed for rural practice.

Herrington et al. [24] laid out a set of situated learning principles for authentic learning. Key elements include a real-world problem that is ill defined at the beginning; the learners need to incorporate multiple perspectives to first understand the problem, and then propose and select from a diversity of solutions that are seamless integrated into the real world. The development requires complex activities over time to deliver polished products that are whole and valued; and all takes the leaners outside their comfort zones, with work across subject boundaries and into diverse roles; and much of the learning is through reflection. The application of the CHASE model as a framework for rural-nurse learning meets all of these objectives. The learners engaged with a community without preconceived or predetermined ideas of what the problem is. They used the tools of CHASE to engage with the community to understand the health of the community as a system and to identify a pressing health need that could be addressed in the relatively short time available. The learners engaged with each other through virtual platforms and pitched their potential solutions to the community and delivered actual useful resources.

Thus, CHASE can be seen to be operating in a sweet spot. The model enables learners to navigate the complexity of learning rural practice. The project mirrors rural nursing practice; in that, it is unavoidably purposeful, collaborative, and relationship-based.

This has resulted substantial positive impact on improving the understanding, local-global connections, unique cultural relationships, similarities and differences associated with rural locations and rural communities, their people, and their health, among nine BN Year 3 students from New Zealand and nine from Australia. The use of the film to provide the context of the community and their health is new, as is the learners being part of an international collaboration with learners from two countries in partnership with a community in a third.

We intend to do further research on these aspects of collaboration between international nurse learners. Anecdotally, these discussions helped with the reflective process and helped learners with the challenges of identity formation as to what it means to be a rural nurse.

All three locations involved in the CHASE project described here are from the Global North (despite the southern positioning!). Previous applications of CHASE have involved rural communities in the Global South – primarily Small Island States in the Pacific (or "Large Ocean States") [26, 27], but with New Zealand as the source of nurse learners. It would be interesting to flip this and have LOS nurse learners.

Remote collaboration is enabled by virtual networking and collaboration tools. Further research will be to explore the value of a film as part of the CHASE model

and to enhance the collaboration tools within the networking environment. These international collaborations will foster global connections and deeper research as the groups of nursing students and nurse educator(s) will launch rural/remote health care discussions from their respective countries. We share a community of academics situated in Australia, New Zealand, and the United Kingdom who are involved in this project and are positioned to examine the process, outcomes, and evaluation of this initiative so that the results can be shared locally and globally through GRNEN.

Given the cost of producing films for every community, it would be interesting to explore whether we could link or group similar interactive films of rural communities together in the future, perhaps to grow a regional, national, and global network. Or would this defeat the purpose of an introduction to each specific rural community?

### **Acknowledgements**

The authors wish to acknowledge the Global Rural Nursing Exchange Network (GRNEN) learning grant which stimulated and supported this international learning protect. The authors also thank the community stakeholders and residents from Bishop's Castle, Shropshire, United Kingdom, for their time and engagement with the nursing learners. The authors also thank the Latrobe University, Victoria, Australia COIL Programme Funding, La Trobe Rural Health School, Victoria, Australia final-year Bachelor of Nursing students 2022 for their engagement, commitment, and feedback with this project work. The authors also thank the Otago Polytechnic, Dunedin, New Zealand Contestable Research Funding, and the School of Nursing, Otago Polytechnic, Dunedin, New Zealand Year 3 Bachelor of Nursing students' 2022 engagement with community development and virtual platform communication and learning. The authors also thank Associate Professor Mel Bish for her commitment to this learning project from its inception to completion.

### **Author details**

Jean Ross1 \*, Samuel Mann1 and Kate Emond2

1 TePukenga, Dunedin, New Zealand

2 La Trobe, Rural Health School, Victoria, Australia

\*Address all correspondence to: jean.ross@op.ac.nz

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Edited by Christian Rusangwa*

In this eye-opening exploration, the authors bring together years of research, onthe-ground insights, and a vision for the future of rural health. Through engaging narratives, data-driven analysis, and thought-provoking case studies, this book sheds light on the critical issues that affect the well-being of millions living outside urban centers. *Rural Health - Investment, Research and Implications* is an essential read for healthcare professionals, policymakers, researchers, and anyone passionate about the wellbeing of rural communities. It offers a roadmap to a brighter, healthier future for those often left in the shadows, highlighting the immense potential of rural America and the transformative power of investment and research in shaping a more equitable healthcare landscape. Join the conversation, be part of the solution, and uncover the untapped potential of rural health. This book is a call to action for a healthier, more inclusive future for all.

Published in London, UK © 2023 IntechOpen © zozzzzo / iStock

Rural Health - Investment, Research and Implications

Rural Health

Investment, Research and Implications

*Edited by Christian Rusangwa*