Partnership factors enabling co-planning of sustainable rural health models
Belinda O’Sullivan A B , Pam Harvey A , Catherine Lees A C D E , Mandy Hutchinson E , Trevor Adem F , Dallas Coghill G , Donna Doyle H Nerida Hyett
A C D *
A
B
C
D
E
F
G
H
Abstract
Strong partnerships are the cornerstone for effectively co-planning primary healthcare models that meet community needs, however, there are few examples specifically for rural areas where smaller health services cover a dispersed population and wide geography with limited resources (thin markets). This study aimed to explore the partnership factors enabling the co-planning of sustainable rural health models in thin markets.
A qualitative study drawing upon in-depth focus groups with eight partnership members covering a combined estimated resident population of 24,620 people across three local government areas with small rural towns (<5000 population) was undertaken. Verbatim transcripts were thematically analysed.
The overarching theme was that the partnership was valued and should continue. Four sub-themes included: the importance of the skilled and independent project lead to coordinate co-planning, the leadership and commitment of rural health service executives, strength and fragility of the project in the face of limited resources and staffing changes, and the importance of trust and relationships.
The research suggested that partnerships for co-planning of sustainable rural health models in rural thin markets are important. Independent and skilled leadership can assist small rural health services to engage with co-planning. This context also relies on committed rural health service executives who pay attention to building relationships and trust. Partnerships within this context are likely to be dynamic and require executives to spend time together to understand the range of problems and potential solutions as conditions change. With attention to these partnership factors, work on sustainable rural health models can be maintained.
Keywords: access, co-design, equity, model of care, participatory health research, partnerships, planning, primary healthcare, rural health.
Introduction
Community engagement is a global cornerstone of safe and comprehensive primary health care and community health services. The World Health Organization (WHO) depicts community engagement as the process of developing relationships that enable stakeholders to work together to address health and well-being issues (World Health Organization 2017). As a method of engaging community, ‘co-planning’ through partnerships can build strong and ongoing engagement around healthcare solutions. Co-planning involves people and local groups affected by services discussing problems and solutions, including how resources can be prioritised and efficiently used in the community (Hyett et al. 2024). It reduces the potential for siloed strategies to be imposed on communities by government, not appropriately tailored to place and context, which may fail as a result (Bautista-Gómez and van Niekerk 2022). Co-planning partnerships for locally contextualised solutions are very important in rural contexts where there is limited time, resources, and populations dispersed over wide geographies.
Many rural health services have limited means for addressing community needs on their own, which increases with service remoteness. They operate in ‘thin markets’, areas at risk of market failure because of small population size and relative geographic isolation. In these contexts, private healthcare markets are ineffective and public sector co-planning is essential to produce economies of scale for sustainable primary health care. Co-planning within health service partnerships is a way to draw limited resources and workforce around the nuanced priorities of rural communities (Ramsden et al. 2021; Gillespie et al. 2022; Cairns et al. 2024). Co-planning also assists with developing a shared vision and addressing concerns such as sustainability of rural healthcare systems (Levesque et al. 2013; Hyett et al. 2024). Sustainable healthcare models are considered more efficient and effective by mitigating the cost of higher staff turnover and the reliance on locum workforce (particularly in more remote locations) and help maintain service access and relationship-based care (Zhao et al. 2019). However, despite the relevance of co-planning partnerships to address rural thin markets, there is scant research about what enables such partnerships to thrive in this context.
The wider evidence about partnerships suggests that transformational and sustainable health service partnerships are enabled by local community leadership, openness to innovation, reputation and trust between partners, consistency of relationships, and timely equal sharing of power and information (Jones et al. 2018). Additionally, partnerships need to manage contextual factors (Hoon Chuah et al. 2018) and dedicate enough time to partnership building and engaging senior leaders (Lazo-Porras et al. 2020). Partnership approaches that address power dynamics and inequity through collaboration also assist health services to engage and co-lead gradual systems changes to traditional ways of working (Yadav et al. 2021; Conlin et al. 2024).
Australian health policy has increased its focus on rural partnerships to promote private and public healthcare integration, reduce fragmentation and duplication, and enable place-based planning (Department of Health 2021, 2022). However, there are few practical exemplars specific to thin markets in rural areas.
This paper explores a maturing co-planning partnership in a thin rural market (hereafter called a regional co-planning network) (Box 1). It involved multiple public healthcare organisations in three local government areas with a dispersed population of 24,620 people in mostly small towns (<5000 people). The regional partnership had already achieved positive outcomes from co-planning sustainable rural healthcare models including the design of prototype models for implementation trials (Supplementary material S1) (Hyett et al. 2024). As part of the reflection on and refinement of the model, there was interest in understanding the partnership factors enabling progress. This was considered an important area of exploration to further enhance the partnership and to inform other regions seeking to set up new partnerships for similar purposes (Leask et al. 2019). The study aim, therefore, was to explore the partnership factors enabling the co-planning of sustainable rural health models in thin markets.
| Box 1.Summary of the study context. |
| The partnership was a regional co-planning network, formed in 2019 from a group of executive officers (executives) of small independently-governed rural health services (towns mostly <5000 population) including public hospitals (state government funded) and a standalone community health service (non-government, not-for-profit) across three local government areas with a combined estimated resident population of 24,620 people (Australian Bureau of Statistics 2021; Department of Health 2023). It was formalised through a Memorandum of Understanding and a full-time independent project leader in 2021, who provided administrative, strategic, and operational support for the partnership and was responsible for evaluation and refinement. |
| The co-planning network had a vision ‘to improve access to high quality primary care for rural communities and bolster health system sustainability’ through partnership. The most urgent issues driving the partnership were the current and future general practitioner workforce succession planning and major service inefficiencies due to workforce shortages, situations projected to worsen over the next 5–10 years. |
| The co-planning network aimed to develop sustainable healthcare models and utilised participatory action research and developmental evaluation methodology informed by WHO building blocks (De Savigny et al. 2009). The work was incremental and planned to be expanded over time through wider collaboration, reflection, and learning (Levesque et al. 2013). The network met monthly and progressed an agenda around identifying shared problems and potential solutions which the independent project leader documented and progressed with collaborative input between meetings. Supplementary material S1 shows the dynamic co-planning process and topics covered by the meetings. |
Method
Study design
The study involved a qualitative data study and used participatory methods to include the members of the partnership (the end users) in aspects of the study design, delivery, and review (Jagosh et al. 2012; Wallerstein et al. 2017). It aimed to include place-based contextual knowledge in the action research process to improve the capacity to translate the results.
Data collection
Data collection was led by PH, a trained rural health researcher experienced in participatory research methods, who had been involved in the co-design research but was not a member of the co-planning network. All participants were provided with study information disclosing that they will identifiable due to the small number of network members and paper co-authorship. Risks and opportunities to withdraw were explained and voluntary informed consent was recorded by the researcher leading the data collection and analysis (PH).
Preliminary reflection about the co-planning partnership was drawn from the minutes of 12 co-planning network meetings (2022–2023) and an online survey adapted from two established co-design and partnership evaluation tools: the VicHealth Partnerships Analysis Tool (VicHealth 2011) and Public and Patient Engagement Evaluation Tool version 2.0 developed by McMaster University (2018) Canada. The minutes and the survey were used as a preparatory reflective activity and to inform the question topics for the focus groups/interviews (held between November and December 2023). Focus group and interview participants included all co-planning network members; including, the Primary Health Network (PHN) project leader, two other PHN executive leadership staff, and four rural health service CEOs, in line with participatory action research methodology.
The focus groups aimed to explore the partnerships factors enabling co-planning of sustainable rural health models and were conducted using a semi-structured interview guide (Supplementary material S2). Participants were also co-researchers and were invited by email to participate in the focus groups, according to their availability. The first focus group included PHN staff and the project lead and captured organisational perspectives. The second group included two co-planning network executive members, and two further interviews were conducted individually with the remaining two executives as they were not available to attend the focus group. The interviews followed the same format of questions as the focus groups.
A total of 148 min of audio-recording was obtained via Zoom™ or Microsoft Teams™, and transcribed using built-in artificial intelligence functionality. The transcripts were reviewed and edited by the interviewer for accuracy in the week following the interview before they were analysed.
Data analysis
The minutes and survey stimulated critical reflection and relevant discussion by the research team and informed the question topics. The focus group and interviews were thematically analysed using a mix of deductive analysis drawing from what is known from the literature, the meetings notes, and the survey results; and inductive analysis using a constructivist paradigm (Creswell and Clark 2017). Codes and themes were interpreted by PH, a qualitatively trained researcher, who reviewed the interview codes for patterns and meaning based on the perspective of participants and refined the coding framework as a result. The analysis and development of themes was continually informed by critical reflexive discussion by PH until a final set of themes was agreed. The inclusion of an independent qualitative coder and the reflexive group discussions to refine themes and sub-themes improved the depth of analysis and rigour.
Results
The material from the minutes and survey suggested strong progress with co-planning (Supplementary material S1) and that the partnership processes were well established. There was some uncertainty about partnership capacity building and skill development, organisational integration, management support, and access to resources, among other issues This informed the development of the focus group questions – see Supplementary material S2. The focus groups and interviews included five participants: three PHN staff (all female) and four health service executives (two female, two male). All local government areas of the network were represented.
The overarching theme was that the partnership was valued and worth continuing. Four sub-themes around partnership factors enabling co-planning are described below.
Importance of the independent project leader
Participants acknowledged the extensive role of the independent project leader employed by the PHN, and the importance of high-level communication and research skills to enable overall facilitation of co-planning in this context. They brought time and health systems, policy, and funding knowledge to the work, which helped when the health service resources were stretched:
It’s really difficult, especially we’re looking at an integrated health networks to facilitate ourselves, but we don’t have a lot of resource … that’s just an extra job for me then to be managing that project. (2)
The skill set of the project lead was acknowledged as
... essential because of the amount of operational activity, but also linking or operationalising strategic activity into reality. It takes time and extensive skill … maturity … you need the right person with the right skills and competencies. (5)
The project leader based in a PHN was ideal as this reduced perceived conflict of interest if the leader had been part of an involved health service: ‘there are risks with that because it means that [x] belongs to an organization that may or may not have the same vision’ (1). Their context was considered to bring fairness to the co-planning: ‘you are neutral, you’re not ever going to be seen to be favouring one organisation that you’re employed in over others’ (5).
Collaborative commitment of health service executives
Executives reflected that the extended workload related to being involved in co-planning the sustainable rural health model was countered by the opportunity to participate in networking with other leaders from nearby services. However, there was dependence on the executives to attend: ‘if I’m not available to attend and be across the work that’s happening for the (network), then no one from (my area) does’ (2).
The commitment was significant in these rural health services with limited resources: ‘the CEOs just do everything and so that’s a big commitment’ (7). It was considered a major factor in seeking to scale the co-planning process:
So if you (are) approaching other people to partner … have to be really honest and upfront about the kind of commitment that they need to put in. (7)
The value of the network and partnership spurred the executives to participate: ‘it’s actually been great to have another opportunity to discuss similar issues with CEOs that are experiencing the same type of challenges that we do’ (2), with flow on effects: ‘We’re now doing other things together’ (2). This collaborative outcome was an unexpected learning: ‘… the ability to share solutions was a benefit of the project not initially recognised as an objective’ (7).
Strength and fragility of the project
Good relationships were considered foundational for the strength of the project: ‘success in partnerships, you know, really does hinge on trust’ (3). However, where relationships changed, project continuation was considered fragile. During the project, one long-term CEO resigned and there was concern that the possible appointment of a person not known to the project team could create vulnerability or, at the least, uncertainty: ‘with different people coming on board, that can change the dynamic altogether. Hopefully not! Or to strengthen it’ (6). Another reflected:
The important thing is to not damage any relationships, so that it’s really important that we continue to be able to provide a level of safety for people if they decide to come into the project. (1)
The network identified that a new CEO could affect the health service board’s support of the project: ‘you know you hope that the commitment’s been genuine and the board of that organisation kind of directs the incoming CEO that we’re a part of this’ (3).
Lack of sustainable resourcing was also noted as a challenge. The collaborative work was reliant on short-term grant funding and capacity building of other staff for succession planning: ‘hopefully we will get the time we need to demonstrate the value of it’ (1).
Despite concerns about fragility, strengths were acknowledged: ‘the small pieces of the puzzle can be fragile, but that’s solid foundation in the middle’ (6). The opportunity to work together as a network produced solidarity: ‘I feel like we’re all very comfortable … with each other and what we do’ (4). Working together was seen as a key strength: ‘partnerships are the key to success, especially in rural areas because we just can’t do things by ourselves’ (1).
Trust and relationship building
Much reference was made to the time it takes to build trust and working relationships with potential partners for a shared project vision: ‘That beautiful, multidisciplinary vision that we can all see and dream of for our communities … And I think it takes time’ (3) and ‘… there needs to be trust in order for people to achieve that’ (1).
A collective understanding of each partner’s purpose and commitment to the project’s objective was reported as central:
So everybody’s been, you know, everyone’s important to this process and no one’s more important than anyone else. Everyone’s got a role to play. And I think that’s, that’s there’s a sense of equity around that as well, which I think it’s great. Great. (1)
The work of network partners to communicate with health providers in the region was also essential for consistent understanding of roles and alignment. (1) Brokering these elements was sometimes seen as a challenge, ‘people are wary about how (a different healthcare model) might unfold, and they don’t really have the relationships with the rest of the region that we have as service providers’ (2). Understanding of the rural context was also seen to take time, as explained by one participant describing the length of time it takes for healthcare providers to understand the ‘complexities of working in a really small rural community’ (4).
Discussion
This article adds emerging evidence about the partnership factors enabling co-planning of sustainable health care, specifically in thin markets in rural areas. This adds to the existing published literature about rural co-planning for place-based solutions, with a focus on how to enable and manage effective partnerships in lower resource contexts (Gillespie et al. 2022). The network was a small and busy group (indicative of many rural partnerships), and they valued the partnership and wanted it to continue. The partnership was a relational interorganisational collaboration, which has been shown to be important for a collective impact on the health system (Salignac et al. 2018). Our results also suggest that partnerships in distributed and thin market contexts may need the resources and time of a skilled project leader.
Other partnership factors in this study aligned with the wider literature, including having a shared vision, individual drive, a background of collaborating, and a supportive policy and legislative environment (McDonald et al. 2001). However, when contextualised to rural thin markets, there are a smaller number of executives whose work covers large distances. The relationships between these staff and their leadership of co-planning for sustainable health care could be essential to success. Our findings also suggest that co-planning in this context can be challenging to maintain and requires reflexive learning to constantly evolve.
A key feature enabling success of the partnership is the strong relationships needed to navigate transition periods such as one of the partnership members changing. Change and workforce is a key characteristic of rural thin market contexts, and our findings suggest that time invested in regular meetings, where all members of co-planning partnerships can contribute, are important. In this context, meetings needed to be flexible and have strong forward planning and commitment to shared resources. In rural thin markets, time is also precious, however, involving executives in establishing a shared proactive vision about sustainable health care across a region may build positive momentum for retaining existing executives and attracting new executives. The co-planning network had achieved substantive progress on sustainable rural health projects over their relatively short time working together. Working together was viewed as more efficient by reducing competition between services, towns, and population cohorts and instead, fostering a collaborative approach that leveraged pooled resources and scale.
Co-planning with power sharing through participatory action research is considered best practice. Our findings suggest there is value in reviewing the partnership factors enabling co-planning for ongoing development and partnership sustainability and strengthening. In rural thin markets, this is even more important because situations can regularly change, and the time and resources for action research may be a lower priority in resource poor settings. In the longer term, the project and partnership model may require wider evaluation to explore its sustainability, given the challenges in funding and staffing and the complexity of working in these thin markets.
Our study had limitations; it was small but included all of the participants involved in the co-planning network. This meant the data is relevant and appropriately contextualised for rural thin markets, but it might limit the depth of analysis and transferability of results. The inclusion of participant researchers in this study, although a normal part of participatory methods, could have influenced the interpretation of results, however, it can lead to more practice-oriented and rurally contextualised learnings (Wallerstein et al. 2017). Depending on whether different participants joined a focus group or interview may have influenced the group dynamic and the level of reflection and responsivity to questions. However, the interviewer used a question guide with consistent prompts for obtaining in-depth responses from all participants.
Conclusion
This descriptive study informs some of the considerations for co-planning partnerships in thin markets in rural areas, where there is a critical need for sustainable rural health care. An overarching theme was that the partnership is valued and there is support for its continuation. Enabling co-planning in this context relies on a skilled independent project lead, the collaborative commitment of rural health service executives, recognising the strength and fragility of the context, and the importance of trust and relationship building. The findings provide a foundation for wider considerations around establishing partnerships with strong vision, including regular meetings, reflexive planning, and sharing of resources.
Declaration of funding
This partnership evaluation was funded by Murray Primary Health Network as one component of the Sustainable Rural Health project.
Acknowledgements
Thank you to Clare Bullen for graphic design of the diagram in Supplementary material S1.
References
Australian Bureau of Statistics (2021) Census. Available at https://www.abs.gov.au/census
Bautista-Gómez MM, van Niekerk L (2022) A social innovation model for equitable access to quality health services for rural populations: a case from Sumapaz, a rural district of Bogota, Colombia. International Journal for Equity in Health 21(1), 23.
| Crossref | Google Scholar | PubMed |
Cairns A, Rodda D, Wymarra F, Bird K (2024) Healthy ageing in remote Cape York: a co-designed Integrated Allied Health Service Model. Australian Journal of Primary Health 30(1), PY23135.
| Crossref | Google Scholar |
Conlin M, McLaren D, Spelten E, MacDermott S (2024) Cultivating participatory approaches in health promotion planning, delivery, and evaluation: a case study of an academic-health service partnership in rural Victoria. Health Promotion Journal of Australia 35(3), 804-812.
| Crossref | Google Scholar |
De Savigny D, Adam T, Alliance for Health Policy and Systems Research & World Health Organization (2009) ‘Systems thinking for health systems strengthening.’ (Eds D De Savigny, T Adam) (Alliance for Health Policy and Systems Research & World Health Organization) Available at https://apps.who.int/iris/handle/10665/44204
Department of Health (2021) 2020–25 National Health Reform Agreement (NHRA). Available at https://www.health.gov.au/initiatives-and-programs/2020-25-national-health-reform-agreement-nhra
Department of Health (2022) Future focused primary health care: Australia’s Primary Health Care 10 Year Plan 2022–2032, pp. 1–71. Australian Government, Canberra. Available at https://www.health.gov.au/resources/publications/australias-primary-health-care-10-year-plan-2022-2032 [verified 27 July 2022]
Department of Health (2023) Modified Monash Model. Available at https://www.health.gov.au/health-topics/rural-health-workforce/classifications/mmm
Gillespie J, Cosgrave C, Malatzky C (2022) Making the case for place based governance in rural health workforce recruitment and retention: lessons from Canada and Australia. Social Sciences & Humanities Open 6(1), 100356.
| Crossref | Google Scholar |
Hoon Chuah FL, Srivastava A, Rajkumar Singh S, Haldane V, Choon Huat Koh G, Kee Seng C, McCoy D, Legido-Quigley H (2018) Community participation in general health initiatives in high and upper-middle income countries: a systematic review exploring the nature of participation, use of theories, contextual drivers and power relations in community participation. Social Science & Medicine 213, 106-122.
| Crossref | Google Scholar |
Hyett N, Hutchinson M, Doyle D, Adem T, Coghill D, Harvey P, Lees C, O’Sullivan B (2024) Rural community-centred co-planning for sustainable rural health systems. Australian Journal of Rural Health 32(5), 1-15.
| Google Scholar |
Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, Sirett E, Wong G, Cargo M, Herbert CP, Seifer SD, Green LW, Greenhalgh T (2012) Uncovering the benefits of participatory research: implications of a realist review for health research and practice. The Milbank Quarterly 90(2), 311-346.
| Crossref | Google Scholar | PubMed |
Jones D, McAllister L, Dyson R, Lyle D (2018) Service-learning partnerships: features that promote transformational and sustainable rural and remote health partnerships and services. The Australian Journal of Rural Health 26(2), 80-85.
| Crossref | Google Scholar |
Lazo-Porras M, Perez-Leon S, Cardenas MK, Pesantes MA, Miranda JJ, Suggs LS, Chappuis F, Perel P, Beran D (2020) Lessons learned about co-creation: developing a complex intervention in rural Peru. Global Health Action 13(1), 1754016.
| Crossref | Google Scholar | PubMed |
Leask CF, Sandlund M, Skelton DA, Altenburg TM, Cardon G, Chinapaw MJM, De Bourdeaudhuij I, Verloigne M, Chastin SFM, on behalf of the GrandStand, Safe Step and Teenage Girls on the Move Research Groups (2019) Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions. Research Involvement and Engagement 5(1), 2.
| Crossref | Google Scholar |
Levesque J-F, Harris MF, Russell G (2013) Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International Journal for Equity in Health 12(1), 18.
| Crossref | Google Scholar |
McDonald J, Murphy A, Payne W (2001) Ballarat health consortium: a case study of influential factors in the development and maintenance of a health partnership. Australian Journal of Primary Health 7(2), 75-82.
| Crossref | Google Scholar |
McMaster University (2018) Public and Patient Engagement Evaluation Tool v2.0. McMaster University. Available at https://ppe.mcmaster.ca/resources/public-and-patient-engagement-evaluation-tool/
Ramsden R, Davies S, Colbran R, Haigh A, Connors M, Nott S, Lowe E, Edwards M, Clegg R, Bagnulo S, Pit S (2021) Collaborative care: primary health workforce and service delivery in Western New South Wales—A case study. Australian Journal of Rural Health 29(5), 768-778.
| Crossref | Google Scholar | PubMed |
Salignac F, Wilcox T, Marjolin A, Adams S (2018) Understanding collective impact in Australia: a new approach to interorganizational collaboration. Australian Journal of Management 43(1), 91-110.
| Crossref | Google Scholar |
VicHealth (2011) The partnership analysis tool. VicHealth. Available at https://www.vichealth.vic.gov.au/sites/default/files/VHP-part-toollow-res.pdf
World Health Organization (2017) WHO community engagement framework for quality, people-centred and resilient health services. WHO, Geneva. pp. 1–56. Available at https://iris.who.int/bitstream/handle/10665/259280/WHO-HIS-SDS-2017.15-eng.pdf;jsessionid=D7746ED9FDBDD2CDA77BAD7C5D623809?sequence=1 [verified 1 March 2024]
Yadav UN, Lloyd J, Baral KP, Bhatta N, Mehata S, Harris M (2021) Evaluating the feasibility and acceptability of a co-design approach to developing an integrated model of care for people with multi-morbid COPD in rural Nepal: a qualitative study. BMJ Open 11(1), e045175.
| Crossref | Google Scholar | PubMed |
Zhao Y, Russell DJ, Guthridge S, Ramjan M, Jones MP, Humphreys JS, Wakerman J (2019) Costs and effects of higher turnover of nurses and Aboriginal health practitioners and higher use of short-term nurses in remote Australian primary care services: an observational cohort study. BMJ Open 9(2), e023906.
| Crossref | Google Scholar | PubMed |
