This study explored the availability of Australian allied health, nursing, dental and medical university courses in regional, rural and remote areas for 2023 by conducting a desktop audit and using the MM classifications to categorise course location and identify courses delivered online. The findings illustrate there are relatively few options to study health courses outside metropolitan areas, particularly in medium and small rural towns (MM4 and MM5), and remote and very remote communities (MM6 and MM7). For example, in some disciplines, such as optometry, there are no courses in MM2-7 locations, no courses in MM3-7 locations for podiatry, dentistry and oral health, and only one pharmacy course in an MM3 location. These findings indicate that despite significant effort to develop the rural health workforce (Stewart, 2023), the fundamental strategy of providing higher education health courses in rural areas has been overlooked at the same time as it is being recommended as good practice in the World Health Organization’s [1] guidelines on health workforce development. The findings also identify equity issues for people living in regional, rural and remote areas who cannot afford or are not able to move to metropolitan areas to study specific health professions, particularly those not living in eastern Australian states or territories.
The lack of higher education health course offerings in some disciplines accessible in or from rural areas highlighted in this study has implications for the Australian rural health workforce and access to healthcare for rural communities. Having no optometry courses being provided in rural areas may be contributing to the long-standing maldistribution of the optometry workforce [18]. Kirkman and colleagues [19] suggested the rural pipeline approach, involving recruitment of rural health students and educating in a rural location, is needed to resolve the maldistribution for optometry. In other disciplines, such as speech pathology, occupational therapy, physiotherapy and podiatry, relatively few courses are offered in rural areas beyond MM3 communities. The lack of course availability in these disciplines is consistent with workforce maldistribution and further exacerbates the impact of the significant increase in demand for services in these disciplines due to the introduction of the Australian National Disability Insurance Scheme (NDIS) [16] and an ageing population particularly in rural areas [20].
Since the NDIS was introduced, demand for speech pathology services has increased [21]. Similarly, occupational therapy is the fastest growing registered health profession in Australia and is still struggling to meet service demand [22]. Significant delays in access to services offered by these professions are commonly experienced in rural and regional areas, affecting participation in daily life and continuity of care. Demand for speech pathology and occupational therapy services in rural areas is not expected to decrease, given increases in ageing populations [23]. The paucity of rural health professionals also contributes to overwork and burnout among those who remain [24, 25, 26]. Innovative solutions are required to ensure health course offerings are made more accessible to rural people to help address longstanding issues around workforce demands and timely access to healthcare for patients in rural areas.
The limited opportunity for people living in rural areas to study locally or remotely is problematic and exacerbates an existing equity issue. Relocating to metropolitan centres to study poses a significant barrier to entry, particularly for mature-aged students who may have family, carer, and work commitments [12, 27]. These are in addition to significant social and financial costs for individual school-leavers and their families [27, 28]. While studying online can provide access to higher education for students who otherwise could not participate, it can also pose limitations relating to the quality and experience of online learning [29, 30], internet connectivity [31] and reduce the sense of belonging and peer support crucial for completing high intensity study, especially for mature-aged students [32, 33].
As findings here illustrated, many health disciplines do not deliver courses online or even flexibly via intensive on-campus or residential block attendance. Hence, for most disciplines except for nursing, social work and psychology, online study is not an option for Australian rural students. More flexible delivery of courses, such as online and/or part-time study may increase the likelihood of rural students being able to participate in health courses while remaining in their rural communities. Such delivery is important for mature-aged students in rural areas (who are unlikely to re-locate for studies) and is crucial for building the rural health workforce capacity of people who are committed to staying in and contributing to their communities. Studying online can also enable students to manage financial demands through continuing existing employment [34].
Consistent with the Australian Universities Accord Final Report [9], the Australian Government may be looking to explore novel approaches to manage inequities of access to higher education health courses in rural communities, drawing from local and international examples. One international example from the United Kingdom is the National Health Service (NHS) degree apprenticeship program where nursing and allied health students can earn an income while studying by working part-time in junior or assistant roles [35]. In this approach, the NHS Trust works in partnership with a local university, which enables students to attend university classes two days per week and work three days per week for the Trust. For allied health disciplines, the program length is four years compared to the traditional three years full-time course in the United Kingdom.
Another example of a strategy to address higher education access inequity is the currently expanding Australian ‘Regional University Study Hub’ (RUSH) program [36], formerly known as the ‘Regional University Centres’ (RUCs) program. Funded by the Australian Government since 2018, RUSHs are physical hubs that tertiary students can access to study in courses delivered online by any university across Australia. These study hubs are learning centres with study facilities, equipped with computers and high-speed internet, and provide academic and pastoral support. There is currently a network of 46 RUSHs distributed around Australia [36].
One successful RUSH is in Geraldton, Western Australia, where a collaboration between the Geraldton Universities Centre (GUC) and the University of Southern Queensland has sought to respond to a community’s rural health workforce need. Since 2014, students located in the mid-west of Western Australia have been enrolled as external students in the Bachelor of Nursing program at the University of Southern Queensland, with access to their online learning platform. While formally enrolled as ‘external’ students, they benefit from attending face-to-face tutorials at the GUC facility, led by industry experts. Students also benefit from the other supports provided, such as assistance with administration and enrolment, access to tailored academic learning support, and the opportunity to attend a graduation ceremony locally. The students also undertake their nursing practical placements in the local community, as well their clinical residential schools. Without the GUC, they would have to travel to Queensland to complete placements and intensives. The GUC also has an Australian Nursing and Midwifery Accreditation Council accredited nursing lab, with simulation manikins and associated equipment. Recently, 20 nurses graduated and 19 of these were employed locally. Since the start of the partnership, approximately 152 students have successfully graduated as registered nurses, many of whom still work locally.
In locations where students may not have access to a regional university campus or a RUSH, communities and health services could explore establishing support for health students within their community by collaborating with local libraries, vocational education and training providers, schools and even community/neighbourhood houses [37]. Access to technology and internet connectivity is vital for students to access higher education and therefore developing collaborations to improve their access, as well as support, where they work and live would be beneficial.
Since conducting the audit of course offerings for this study, new allied health courses have commenced or will commence soon for occupational therapy, physiotherapy and speech pathology. Flinders University commenced courses at Port Pirie, Renmark and Mt Gambier Campuses in 2024 for occupational therapy, speech pathology and physiotherapy (https://www.flinders.edu.au/study/health/regional-allied-health-courses). Deakin University has commenced an occupational therapy course at their Warrnambool campus (https://www.deakin.edu.au/course/bachelor-occupational-therapy) and the Australian Catholic University has commenced occupational therapy at the Ballarat campus (https://www.acu.edu.au/study-at-acu/find-a-course/new-courses/bachelor-of-occupational-therapy-ballarat). The University of South Australia is now offering physiotherapy and occupational therapy at their Whyalla campus (https://www.unisa.edu.au/connect/unisa-regional/whyalla-campus/). The University of Tasmania is also commencing an occupational therapy course at their Launceston campus (https://www.utas.edu.au/study/postgraduate/allied-health), increasing access for students in Tasmania where there had not been an occupational therapy course despite long standing workforce shortages. Even though there are new offerings in some rural areas of Australia, more work is required to ensure higher education health courses are accessible for people living rurally.
Another finding from the audit is the issue of inconsistent terminology on university websites can create confusion and mislead prospective students. While the TEQSA Domain 7 of the Higher Education Standards Framework [38] requires universities to clearly articulate how courses are delivered, the audit found that this did not always occur. Some courses were advertised as online although they had additional requirements, such as participation in multiple face-to-face intensive programs. Other inconsistencies identified in the audit included limited information regarding courses availability on university websites, and difficulty determining part-time availability, or part-time availability only being available in early course years. Inconsistent terminology used to describe the nature of involvement in courses may confuse or miscommunicate what is expected of students. Rural students may use the information to make decisions about participation, and if the course requires residency schools not clearly articulated in the course information, they may start the course then withdraw after significant investment and subsequently not join the rural health workforce.
Limitations of this study included the possible lag in professional registration boards and associations posting or updating information on their websites relating to new courses or those being discontinued. To limit the likelihood of missing courses on offer for 2023, we checked university websites to identify current courses and those being discontinued; however, we were reliant on the accuracy of these websites. Although we initially audited the list of approved programs of study by the Psychology Board of Australia according to their website, given the large number of pathway courses for psychology, there may have been some courses included that may not be offered or offered using a different title leading to some inaccuracies.