Improving access to sexual health services for youth in regional and remote NSW

Amy Tan, University of Sydney Faculty of Arts and Social Sciences, Y20 Global Voices Fellow 2024

Executive Summary

The systemic healthcare inequity in Australia continues to limit young people’s access to sexual healthcare, particularly in regional and remote areas. This disparity contributes to preventable hospitalisations and deepens the divide between rural and metropolitan communities. Young people in these areas have been found to experience higher rates of teenage pregnancy, sexually transmitted infections (STIs), and maternal death compared to their urban counterparts (Family Planning Australia, 2021). A conservative estimated cost of rural NSW’s preventable hospitalisations places the economic cost of this disparity at $300 million annually.

This policy explores several solutions including expanding access to telehealth services, improving training for medical professionals and deploying mobile sexual health clinics to underserved communities. This recommendation prioritises mobile clinics, which offer a direct, scalable and early prevention for rural youth – ultimately helping reduce the rate of preventable hospitalisations.

It is estimated that an initial roll-out would have an associated cost of $1 million to $5 million for five mobile health clinics to run for one year, servicing 30,000 (6000 (using IVF clinic numbers) x 5 (number of proposed mobile clinics)) rural patients per year. The funding for this clinic could be completely covered or subsidised by NSW Health.

Compared to the estimated $300 million annual cost of potentially preventable hospitalisations in rural NSW, even a fractional reduction in this figure, resulting from the implementation of the clinics, would represent a significant budgetary alleviation.

Potential risks include cultural stigmas around mental health and the adequate storage and protection of medical equipment. These may be mitigated by increasing targeted education campaigns and identifying more secure storage areas. Further, there may be some political tension in supporting the issue of sexual health. However, a decisive quantitative outcome would provide a compelling factor in persuading reluctant actors. 

Problem Identification

Inadequate healthcare infrastructure is the root cause of the higher rates of potentially preventable hospitalisations (PPH) and sexual health related illnesses experienced by young people in regional and remote areas, resulting in poor short and long-term health outcomes (Family Planning Australia, 2021). The systemic disparity in sexual health infrastructure results in rural young people experiencing higher rates of teenage pregnancy, sexually transmitted infections (STIs), and maternal death compared to their urban counterparts (Ibid). 

The Australian Institute for Health and Welfare (2024) found the disparity is further exacerbated by a shortage of healthcare professionals; rural areas have approximately 1,938 full time equivalent (FTE) per 100,000 people, far below the metropolitan average of 2,248 FTE per 100,000 people.

Financial and cultural constraints also play a role, with many youth in remote areas reporting that cost, and the cultural stigma or lack of privacy in small communities also pose a significant barrier in deterring young people from seeking the sexual healthcare help they need (Heslop, 2020; MacPhail & McKay, 2018).

Additionally, with telehealth appointments being limited in their current form, many young people in these areas face long travel distances to reach the nearest health facility, creating barriers to accessing timely and confidential care (Johnston et al., 2015).

The primary consequence of this poor access is higher rates of potentially preventable hospitalisations, which could have been avoided if preventative low cost interventions were sought earlier. The National Rural Health Alliance (2023) found the rate of preventable hospitalisations is 2-3 times as high in remote and very remote areas, placing a greater burden upon the already fragile healthcare system. 

Context

Background

Understanding how the healthcare system is delivered across federal and state levels is key to identifying where change is most needed and funds can be best allocated. In Australia, responsibility for healthcare is shared between the federal and state governments. However, the federal government is more focused on setting national policies and the funding of national initiatives such as Medicare. Alongside managing public and private hospitals, state governments are also responsible for public community-based and primary health services (including mental health, dental health, alcohol and drug services) (Australian Institute of Health and Welfare, 2016).

This policy proposal will specifically address this issue as it pertains to New South Wales, the most populous state of Australia (NSW Government, undated). The NSW Health Department receives on average the most health funding annually, being $13.8 billion in health facilities in the 2023-2024 Budget (2023), and has the highest comparative disparities between metropolitan and rural sexual health outcomes for youth. 

In 2016, the mean cost of a PPH was reported to be $20, 453, this number is likely to be higher now (Tran, 2016). The Australian Institute of Health and Welfare (2018) reported that the rate of PPHs increased with the remoteness of a persons’ place of residence with (25 hospitalisations per 1,000 people in major cities and 27 hospitalisations per 1,000 people in remote and very remote areas). 

The NSW Youth Health Framework (2017) noted poor health infrastructure as a structural issue defined by a lack of adequately trained medical personnel, availability of health outlets and low supply of medical equipment. Availability of health clinics also encompasses the geographical distribution of medical centres. This makes attending a health appointment an activity which can take up to most of a day, especially when public transport infrastructure is not as well supported as metropolitan areas, so youth will often have to resort to private transportation (Johnston et al., 2015).

Current Policy Landscape

The NSW Government budget for 2023-2024 allocated $3.8 billion to regional health facilities, primarily to existing hospitals, however this is not enough. Of this, $3.5 million (0.092%) was dedicated to funding reproductive and sexual health services for women. While this budget allocation goes to strengthening existing medical facilities in rural areas, there is a lack of future commitment in the budget to expanding beyond existing locations, exposing gaps within the budget allocation framework. To address the barriers outlined above, it is pertinent that sexual health infrastructure places an emphasis on reducing transportation, costs and other barriers to accessing care. 

NSW Health (2024) notes that there are some telehealth options such as the NSW Sexual Health Infolink, which is a free state-wide NSW Health sexual health service that provides the public with information on testing sites, general health, referrals and risk assessments. The service provides on average 10,000 calls a year. However, telehealth options are a preliminary early-stage solution which can only help with patients in initial stages of consultation. As the Royal Australasian College of Physicians (2015) states, addressing sexual health access requires more in-person contact and intervention. This is necessary to carry out tests and more accurate diagnoses. 

International Case Studies

There have been several successful attempts around the world to introduce telehealth and remote clinics targeting sexual and reproductive health to remote communities. However, it must be noted that the majority are run by non-governmental organisations (NGOs) and comprehensive government oversight has remained lacking. 

Peru Case Study - Mobile Clinics in the Andean region 

Numerous NGOs have begun successful initiatives providing mobile sexual and reproductive health services for locals living in the Andean region of Peru who struggle to access timely medical care due to the mountainous and remoteness of their location. The NGOs are run largely by volunteers and provide a range of services from diagnosis, STI screening and reproductive and sexual health education. They reported that while the initiative was ultimately successful in reaching patients, it did deal with a few challenges. Luque et al. (2016) reported a range of individual and cultural barriers such as a lack of knowledge of sexual healthcare, lack of support in healthcare seeking and stigma from friends and family. 

United States – Telehealth Sexual Health Programs in Appalachia

Programs like Planned Parenthood Direct and university-led initiatives have led the way in terms of providing greater access to sexual health to remote communities in Appalachian America. The services consist of sexual health education and virtual consultations. Local Initiatives Support Corporation (2020) reported that this led to a positive reception due to the reduced student absence, parental work disruption and unnecessary school nurse commuting.

Domestic Case Studies

The Australasian Society for HIV, Viral Hepatitis, and Sexual Health Medicine (ASHM) (2023) reports that the Deadly Liver Mob program, led by Aboriginal and Torres Strait Islander communities, aims to combat stigma and enhance health outcomes related to viral hepatitis and sexually transmitted infections (STIs). This initiative provides hepatitis C and sexual health education, along with referrals for testing and treatment specifically for Aboriginal and Torres Strait Islander individuals. The program, driven by Aboriginal and Torres Strait Islander workers, incentivises participation through a voucher system and promotes the sharing of health information by encouraging attendees to educate others about hepatitis C (ASHM, 2023).

Currently, Deadly Liver Mob operates at nine locations across New South Wales. During its initial year at a single site, the program engaged over 400 community members, with 300 referred for sexual health screenings, marking a 1,023% increase in access to these services. By 2020, Deadly Liver Mob had educated 1,787 individuals across all nine sites, with 74% participating in screening activities (ASHM, 2023).

This initiative is a robust initiative in the sexual health space. However, it does have its limitations, given its focus which is targeted specifically towards Aboriginal and Torres Strait Islander communities. A more expansive initiative will allow all youth in remote communities to benefit from such a vital service.

Similarly, in early 2024, the National Indigenous Australians Agency (NIAA), announced a program for mobile clinics in remote communities to service First Nations Australians. The program hopes to target diabetes prevention by providing education and podiatry outreach services. While this program does not specifically target sexual healthcare, this is a promising start to improving greater health mobility for rural patients. Until the end of 2024, the Federal Government had invested $456,000 into the NIAA mobile clinic program, which consists of a singular clinic (NIAA, 2024). The cost of servicing this singular mobile health clinic is estimated at $400,000 to $600,000 per year and is inclusive of staff funding. 

Mobile IVF clinics in the South Eastern Sydney Local Health District demonstrate comparative costs for these kinds of valuable health services. An analysis shows servicing 6,000 patients cost $1.1 million for two years; proving price stability at approximately $550,000 for one year (NSW Health, 2020). 

Policy Options

The success of the chosen program should be measured by a reduction in sexual health related PPHs amongst youth in regional and remote NSW. 

Several policy solutions that would be able to achieve this outcome have been analysed: 

1. Expanding access to online health services for sexual health consultations in remote NSW communities. 

   
   

   This option would be a time-effective way to begin offering increased access to sexual healthcare in rural and regional NSW youth. However, Al Khawaldeh (2022) notes some rural areas receive less internet servicing and connective issues so this potential solution could be less effective.  There is also a practical element that is neglected by the inherent format of telehealth appointments, which is the provision of sexual health services in an in-person capacity for services such as STI testing and assessment which would require the patient to attend the site in person. Although there may be an option to mail out STI kits, this may not be the most time effective method to detect illnesses. 

   
   

   Promisingly, in the 2023-2024 budget, the Federal government dedicated $3.5 billion in bulk billing incentives (Department of Health and Aged Care, 2023). This sought to cover many common GP consultations, including telehealth and videoconferences and could include sexual health appointments. In 2024, $5 million was committed to research into the impact of telehealth on health outcomes for Australians (Ibid). This appears to be an area which is well resourced and under development by the Federal government so may not be a preferable option.

   
   

2. Upskilling of existing healthcare staff in remote communities with the tools to increase their capacity to cater for sexual health appointments. 

   
   

   This option will allow healthcare professionals to be upskilled where needed, addressing a critical area of poor health infrastructure around sexual health. However, there is a disjunct between the stigma of sexual health within remote communities which is not adequately addressed by in-situ health professionals. Further, communities may struggle to increase the number of health professionals who may be able to assist with sexual health outcomes specifically due to existing workforce capacity limits.

   
   

3. Deployment of five mobile clinics for sexual health testing and treatment in remote and regional areas.

   This policy would allow implementable ‘on-the-ground’ action to be taken to address the shortage of health clinics in regional NSW. However, there are also significant challenges, primarily related to the operational logistics of implementing such a program. These challenges include the complexity of calculating the necessary resources and infrastructure, as well as the difficulty in quantifying the overall cost of implementation. The scale and rollout of the program would require careful planning and assessment, which can be difficult to manage effectively. This may help to overcome stigma associated with sexual health services given that services may be carried out by external providers, not local to the area.
   

Policy Recommendation

Considering cost, accessibility and urgency, Option 3, “Deployment of five mobile clinics for sexual health testing and treatment in remote and regional areas” emerges as the most viable and impactful solution. This paper recommends introducing five mobile sexual health testing clinics across regional and remote NSW to address ongoing barriers to youth sexual healthcare. These clinics would rotate through priority areas, providing testing, treatment, education and outreach, with focus on early prevention for young people.

Similar to the NIAA mobile clinic program, the five mobile health testing clinics would operate between three to five days of the week, servicing approximately 5,000 patients annually (NIAA, 2024). The clinic would also provide potential upskilling opportunities to remote health care workers through education and sexual health awareness. Educational awareness via the sexual health clinic would ideally focus on early intervention and awareness targeted towards youth. 

Location of the clinics

The following areas have been chosen according to the degree of remoteness and size of their populations. 

• Northern NSW Servicing areas such as Goodooga, Walgett, Coonamle, Brewarrna (1 x clinic)

• Inner NSW: Servicing areas such as Nyngan and Hilston (1 clinic).

• Southern NSW: servicing areas such as Ivanhoe, Hilston, Mungo and Menindee (3 x clinics) (ABS, 2021).

Source: Western New South Wales Primary Health Network (PHN) map – Australian Statistical Geography Standard (ASGS) remoteness area.

Budget and funding

Extrapolating from the NIAA and IVF clinic case studies using data targeted towards a singular mobile clinic to match the profile of the proposed plan for multiple clinics, is estimated that an initial roll-out would have an associated cost of $1 million to $5 million for five mobile health clinics to run for one year, servicing 30,000 (6000 (using IVF clinic numbers) x 5 (number of proposed mobile clinics)) rural patients per year. The funding for this clinic could be completely covered or subsidised by NSW Health.

Compared to the estimated $300 million annual cost of PPHs in rural NSW, even a fractional reduction in this figure, resulting from the implementation of the clinics, would represent a significant budgetary alleviation.

Measure of success

The program will be measured by the reduction of PPHs in the local health districts for sexually transmitted diseases. This evaluation will gather information from local health districts at the end of the year and will be collected by NSW Health in its annual evaluation.

Risks

Social and cultural 

Research by Queensland Health conducted in 2013 identified that there may be a crucial lack of understanding as to what the aim and objective of the mobile sexual health clinic is in regional areas. For example, there are traditional cultural stigmas within remote Aboriginal and Torres Islander communities which would present a barrier to discussions around sexual health. This may be derived from stigma and a lack of education around sexual health. In order to mitigate this and to create greater accessibility, community education can be conducted through postal messaging or creating a social media presence for the program.

Additional barriers could occur in practice, given the storage and ongoing usage of medical equipment which needs to be readily replenished, risks such as burglary or vandalism could pose serious roadblocks to the upkeep of the trailers. Further, access to fuel and mechanical breakdowns could result in lengthy or delayed trips. However, in the long term, these are minor issues which can be addressed through greater preventative measures, such as safe storage of the clinics in local community centres or well-patrolled areas. 

Political

Sexual health may be a politically controversial topic in these rural areas and this may impact the support of the initiative by the community (Horwitz et al., 2022). It is possible that some politicians may oppose the initiative given the priorities of the community, or that they may perceive the initiative as encouraging unwanted sexual behaviours. 

They may advocate or encourage the money to be allocated to other initiatives or funding existing health outlets (Schultz et al., 2023). This is especially as the funding allocation may be perceived as detracting from the existing allocation of NSW Health for rural NSW. It may be argued that other elements of the health infrastructure in NSW need the proposed funding more. This may also be mitigated through the aforementioned use of sustained visibility and increasing connection with the local community. Further, a focus on quantitative health outcomes and measuring the reduction of PPHs could be a decisive factor in increasing support for the initiative. This may build support in the local population. While these risks are justified, they can be mitigated through sustained community engagement and more active oversight of implementation. 

References

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Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. (2023). “Stakeholder pack – Budget 2023-24”. https://www.health.gov.au/sites/default/files/2023-05/stakeholder-pack-budget-2023-24.pdf

Australian Government Department of Health and Aged Care. (2018). Western New South Wales Primary Health Network (PHN) map – Australian Statistical Geography Standard (ASGS) remoteness area. Australian Government Department of Health and Aged Care. https://www.health.gov.au/resources/publications/western-new-south-wales-primary-health-network-phn-map-australian-statistical-geography-standard-asgs-remoteness-area?language=en.

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The views and opinions expressed by Global Voices Fellows do not necessarily reflect those of the organisation or its staff.