By John O’Malley
Social Service Provision in Rural Areas: The analysis by economists of social service provision in rural areas inevitably turns into a discussion of the trade off between efficiency and equity.
The provision of social services in rural areas is an ongoing debate with economists and urban dwellers highlighting the financial costs. The urban dwellers, because of the extra taxes imposed to deliver the services and economists because some services are not economic because of the low density of population being served. Rural dwellers argue that their management of the enviornment and food production is a necessity for the sustainability of the country as a whole. The social services provision in depopulated areas is the trade off and an economic balance of necessity?
Richard Wakeford, (2008), Chair of the Working Party on Territorial Development Policy in Rural Areas, OECD, stated people, food, energy, water, landscape,
biodiversity are but a few of the assets rural areas can utilise to compete in national and international markets and re-balance the urban-rural relationship and ‘Rural areas are not a parasite on the urban economy but a partner in a symbiotic relationship in which the whole is greater than the sum of its parts; a crucial partner for the world in addressing global challenges’.
The task will be addressed in part one by giving a brief historical account and then analysing the trade off between equity and efficiency. This will be evaluated primarily within the Irish context and will focus on just some of the services, education and health. Part two will give examples of the problems encountered by rural dwellers.
Social services usually refer to key areas such as education, health, social security and social care which are provided by central or local government. The health services were initially delivered in rural areas throughout the nineteenth century by the poor law guardians. This was achieved, by initially Workhouses and later the development of small local hospitals/ services run by Catholic religious orders and lay organisations. The voluntary sector played a key role, especially in maintaining the elderly in their own homes. The basing of a nurse in rural parishes also played a major role. The development of education in rural areas was achieved by the provision of national schools in a major drive in the late 1800s; schools were generally positioned so that no child would have to walk more than two miles to attend. Second level was only available to students that were adjacent to urban areas; this remained the norm until free transport was introduced in 1969 (unit 2), some research for module 18 is included.
The health services today have evolved to a more central base, especially specialised hospital care with services being transferred from the smaller hospitals. It is also important to acknowledge that specialist services that were only based in Dublin in the past are now being regionalised to major urban areas for example, Galway, Cork and Limerick. ‘In 2007 the West of Ireland Cardiothoracic Surgery Unit was introduced, this is a purpose-built unit based in University Hospital Galway at a cost of €20.45million’ (CROI 2009). The health sector is the largest public service employer in the State, with an approved employment ceiling of 96,000 employees at the end of 2002, as opposed to 68,000 in 1997. The state is spending close to the E.U. average on health care (per person) but ranked in 15th place in Europe for excellence (Department of Health, 2010). There is no reward for efficiency in the Irish system. All social service workers have there jobs guaranteed whether their services are required or not?
The new HSE Service plan 2012 was launched on January 13th with a reduction in overall expenditure. The Service Plan sets out the health and personal social services that will be delivered by the HSE within its current budget of €13.317bn. The total quantifiable cost reduction target in 2012 is €750m. ‘The new financial reality in which the health system is operating means that there is a greater need than ever before to drive change, innovate and implement efficiencies’ (Irish Government News Services, 2012).
The decline in the provision and access to social services in rural areas especially health would seem rational as it is not economically feasible to deliver specialised care in depopulated area. The recently well documented case of the closure of 24 hour A& E under utilised services at Roscommon Hospital is an example – The trade off in this situation was – ‘The minor injuries unit will be supported by medical assessment facilities and a new out-of-hours GP service. There will now be four ambulances based in the county, two in Roscommon town, as well as a 24-hour rapid response vehicle staffed by an advanced paramedic (RTE News Monday, 11 July 2011). Health is similar to other provisions and must apportion its financial resources on a broad range of health care and if not efficiently applied will have an affect in the overall provision of services. Efficiency requires how resources are best applied – ‘should the money be spent on a specialised cardiac unit or on a campaign to help people stop smoking, should the resources be used for health care for the elderly or the young’ (unit 1). The introduction of a cardiac care unit in Galway is an example of efficiency and also an attempt of equity and a trade off. Prior to the opening of this unit, west of Ireland patents had no choice but to attend the cardiac unit in Dublin. Basing the unit in Galway makes it generally assessable within a maximum of two hours for west of Ireland patents.
This is also an attempt of equity as it gives west of Ireland patents/families generally the same service as for example Leinster. It could also be classified as a trade off for closing some services in small hospitals in the western region. The main problem with efficiency, just because it delivers efficiently, does not mean delivering equity, which is a system of justice based on conscience and fairness (unit 1). For example an efficient service in a central location may not be fair/equitable to people living in a remote area that have not the same transport access as people living close to the services.
The provision of multiple small schools in rural areas at a time when transport and roads have improved is not efficient/economic, for example the vast majority of rural schools are two teacher and can retain both teachers at a ’pupil level of 14 (average 7). An urban school with ten teachers will require 257 or an average of 25’ (INTO, 2011). The extra cost of insurance and maintenance and extra teachers in the small schools are creating higher numbers in the urban schools. This could be regarded as an attempt of equity and a trade off because rural students/families have extra expense not incurred by many urban dwellers in attending urban based third level colleges. ’The financial efficiency/viability of small schools is also of particular interest to Russia where 70% of the country’s 67 000 schools are in rural areas. Conference participants agreed that cost efficiency, effectiveness and tradeoffs may conflict with service delivery frameworks that lack full understanding (OECD, 2008).
Rural dwellers constantly argue that they are not being equally treated and that equality is incorporated in the Irish constitution – ’All citizens shall, as human persons, be held equal before the law’ (Art. 40.1). (unit 6). The treatment of people as equal may sometimes be hard to define as equality would give everyone an equal amount of a particular service while an equitable distribution would perhaps give rather more of the service to the more needy.
But efficiency on the basis of excluding people because of their residence or creed/caste ’defined social exclusion, refers to the societal and institutional processes that exclude certain groups from full participation in the social, economic, cultural and political life of societies is not equitable. The concept goes beyond the focus on income deprivation as a cause for marginalization of individuals or social groups (Gore and Figueiredo, 1997). The travellers are an example as travellers in rural areas are usually in small numbers and are excluded by many from most social interactions. This is an example of – people can be poor without being socially excluded or excluded without being poor (based on personal knowledge/interaction with travellers).
It could be also argued that the medical health provision is not equitable because ’given the public/private mix of health care in Ireland, inequality of access is inbuilt within the system, with those who can afford it having quick access and greater choice than those who cannot’(unit 4). The private health care may also increase demand based on moral hazard (unit 1). An example, a rural dweller may travel in the region of 100 miles and be deprived of service because private health care patents effectively jump the queue.
’horizontal equity is concerned with equal treatment of equals. Equal treatment for equals is about equal treatment for equal need’(unit 6) there appears to be no trade off here as of now?
The development of infrastructure in rural areas would appear not to be efficient and equitable at a first glance. But infrastructure development is not for exclusive use of the rural dweller. It generates a network of communication which is paramount for a country like Ireland that is dependent on rural tourism. ‘A well-maintained road network is essential for the efficient transportation of goods produced in rural areas to and from markets as well as for linking rural residents to other regions.
Road density and road quality are key determinants to the rural populations access to services such as education and healthcare. ICT provides new ways to deal with the disadvantages of remote and peripheral areas. First it helps reduce the costs associated with physical distances. Second, it facilitates access to information and services. Third, it allows scale economies without proximity’ (OECD, 2008) Trade off, – rural dwellers are receiving improved levels of ICT and road works that are not economical justified but the reality, it is equitable as it is for everybody’s use. ‘It is an example of a public good once provided anyone can enjoy the benefits and nobody can avoid benefiting’ (unit3).
The decision to live in a depopulated region whether necessary or not will pose challenges for many people. The challenge for many younger people will be primarily financial decisions relating to transport, employment and education services. Most social services are provided in response to those ‘needs most commonly by the elderly, physically disabled, the mentally ill and children’ (unit 1).
The provision of health care means that there are fewer options for patents, as generally essential medical treatment requires travelling long distances. This is a financial challenge in many cases as patents are usually transported by family members. It may require the family member to take a day off work and in some instances an overnight stay.
The provision of care for the needy is another difficulty not visible in urban areas as carers are constantly losing time travelling from patient to patient. The necessity to provide even essential food services entails in many instances travelling several miles to nearby towns because the vast majority of the small village food stores are closing down.
‘There is increasing recognition that some rural older people may be at special risk of social exclusion, and that access to adequate transport is a major facilitator of social inclusion in rural areas’ (Manthorpe et al 2008; Wenger, 2001).
The provision of local national schools and bus services is an advantage not withstanding the long hours some students spend waiting for buses. The limitation of provision for children with special needs in many cases involves travelling or basing the children in urban areas as there are not enough children to generate a local service, is a financial burden on families. Possibly the greatest social/financial impact is third level education. The option of students in the main urban regions (or adjacent to) of attending third level education institutions while still living in their own homes is a choice not available to most rural based students. The financial constraints involved in accommodation and weekend travel, in many cases makes third level education unrealistic/affordable to many rural dwellers. This would appear to be supported by the OECD (2008) which states ‘evidence also indicates that more rural dwellers participate in adult training and vocational programs than urban dwellers because of the insufficiencies of formal education’.
The imbalance of population in depopulated areas is a serious problem for many especially the younger age category. There are not enough people in the various age categories for social interaction, for example meeting a partner is seriously restricted and will involve in any cases commuting to urban areas for social interaction – ’Problems of rural isolation have been exacerbated in many areas by the exodus of rural young people to urban areas, often leaving ageing parents behind’ (Greene 1984). This will also leave an inbalance of the aged which is increasing and will create a major challenge for the future – The people aged 65 or older living in Ireland today, will increase by three fold by 2036 (unit 2). There will be fewer people to provide for example home care.
The provision of equity, equality and efficiency is difficult to deliver within an urban or rural area because there will be different interpretations of how they impact on a given population at a given time. An informal discussion at a setting in relation to services in rural areas for this assignment discovered that people in general were satisfied with the level of services and trade offs. The overriding disadvantage was the distance from a major hospital and that was primarily highlighted by people over 40 years of age? It is also interesting to get the view of a polish academic now living in a rural area who was present – ’why are urban based people continually talking about isolation and lack of services in rural areas. I lived in a big city for ten years and that was the only time I felt isolated and loss of social interaction – its time for rural people to promote programmes for those poor urban folk’ he said.
The task was addressed by giving a brief history of service provision in Ireland. The trade offs between efficiency and equity were addressed by discussing services that are/were in the public domain. This focused on Roscommon Hospital and the provision of cardiac care in Galway Regional Hospital. Education highlighted the inbalance in national school numbers and the trade off. The inequality caused by the two tier system created by health insurance was also discussed. Part two gave examples of how reduced populations impact on social services. Examples were given in essential health care, isolation effects on residents caused by depopulation. Education highlighted how the trade off benefits at national school level but causes financial challenges at third level. The module readings, OECD presentations and research and from the World Wide Web were included in the assignment. Personal experience was also incorporated.
Note: A Connemara farmers definition of Pareto’s 20/80
An open fire in a house delivers 20% of the heat in the room and 80% goes up the chimney – if a stove is fitted (with a boiler) 20% goes up the chimney and 80% can be dispersed around the house. This can also be done equitably by delivering extra heat to the living area which requires more heat and delivering heat to the occupants of the rooms. This can be achieved with the exact amount of fuel (some would argue less). Extra heat can be efficiently delivered without extra expense – does Pareto’s quote hold true?
According to Pareto, an economically efficient (optimal) outcome in society is one under which it is impossible to improve the lot of any one person without hurting someone else.
CROI, 2009, Heart Surgery Unit opens in Galway, CROI, West of Ireland Cardiac Foundation, available at Heart Surgery Unit Opens in Galway | Croi, accessed January, 12th 2012.
Department of Health and Children, 2010, available at www.dohc.ie/ , accessed February 26th for module 18.
RTE News, 2011, ‘Emergency department closes in Roscommon’, RTE News Monday, 11 July 2011, available at Emergency department closes in Roscommon – RTÉ , accessed January 9th, 2012.
Gore and Figueiredo, 1997, p, 4, in Bonds and Bridges: Social Capital and Poverty
BY DEEPA NARAYAN*POVERTY GROUP, PREM WORLD BANK July, 1999, available at Bonds and Bridges: Social Capital And Poverty accessed January, 16th, 2012.
INTO, 2011, BUDGET 2012, Staffing Schedule 2012-2013 (pdf, 64 kb) available at Budget 2012, INTO – Irish National Teachers‘ Organisation – into.ie,
Accessed January 9th 2012.
Module 27 and 18 readings are included throughout the assignment.
OECD, 2008, Increasing rural access through ICT and transportation, available at innovative Service Delivery: Meeting the Challenges – OECD, accessed January 12th
Wakeford, R., (2008), p 4, Chair of the Working Party on Territorial, Development Policy in Rural Areas, OECD, Innovative Service Delivery: Meeting the Challenges of Rural Regions, available at innovative Service Delivery: Meeting the Challenges – OECD accessed January 15th 2012.
Manthorpe et al 2008; Wenger, 2001, and Green 1984 in Planning for Rural Areas, available at 4.1.5 PLANNING FOR RURAL AREAS | Ageing Well Network, accessed January 12 the 2012.