Delivering Primary Healthcare in Remote and Isolated Settings: A Global Review of Maritime, Offshore, and Rural Service Models

Abstract

Background. Primary healthcare in geographically remote and operationally isolated settings is organised very differently across rural, maritime and offshore domains, and the literatures describing these domains have developed largely in isolation from one another. Comparative accounts that read them together are scarce.

Methods. We conducted a structured narrative review, reported against the Scale for the Assessment of Narrative Review Articles (SANRA) and using PRISMA 2020 conventions to report search and selection. Eight bibliographic databases (MEDLINE, Embase, Scopus, Web of Science, CINAHL, LILACS, African Journals OnLine and the Cochrane Library) were searched from January 2000 to [month] 2025, supplemented by hand-searching of International Maritime Health, citation chaining, and targeted retrieval of regulatory and technical instruments from the International Labour Organization, the International Maritime Organization, the World Health Organization and national offshore safety regulators. Sources addressing the organisation, delivery, workforce, technology, governance or financing of first-contact healthcare in settings meeting a stated operational definition of remoteness were eligible. Included sources were assigned an explicit three-level rating of evidentiary strength. Synthesis was thematic, followed by framework comparison against a common extraction matrix.

Results. Included sources describe nine distinct service configurations across the three domains. Six mechanisms recur across all of them: a competent first-line responder positioned inside the isolated unit whose scope is set by protocol rather than profession; a system-level guarantee of access to distant clinical expertise; a pre-defined and resourced escalation pathway with a named destination; continuity of the clinical record across the escalation boundary; electrical power and communications treated as clinical rather than ancillary infrastructure; and supervision with periodic recertification as the mechanism sustaining delegated scope. Six features do not transfer: the logic of the population denominator, the demand profile, the source of regulatory leverage, the stability of time-to-definitive-care, the applicability of community participation, and the identity of the cost-bearer. Maritime and offshore capability is set by binding instruments attached to the flag State or the employer and can be raised by amending an instrument; rural capability is set by public budgets and has no equivalent lever.

Conclusions. The evidence assembled suggests that no single service model is universally transferable and indicates that transferability operates at the level of mechanism rather than of model. Remote primary healthcare is better designed as an integrated and adaptive system than as a collection of discrete interventions. Priorities include place-sensitive workforce strategies, dependable financing, strengthened referral networks, interoperable telehealth, resilient energy and communication systems, and cross-sector coordination. The maritime domain, and commercial fishing in particular, remains substantially under-researched relative to its occupational risk.