Prioritising Indigenous health policy

THERE’S a word Aboriginal and Torres Strait Islander people in Queensland use regularly to describe people or things that don’t really mean what they say – “gammon”. We say that about a lot of policy directed at us as well.

Since the bipartisan agreements for Australian governments to work together to ensure we have established Aboriginal and Torres Strait Islander health and social targets in the Closing the Gap (CTG) framework, there has been a myriad of health reforms.

The two main pieces of Aboriginal and Torres Strait Islander-specific national health policy remain the Council of Australian Governments’ CTG strategy and the federal Department of Health’s National Aboriginal and Torres Strait Islander Health Plan 2013–2023 (NATSIHP). These are good, well intentioned policies and strategies.

However, the impact of other major national issues, such as the increasing national budget deficit and the resource boom contraction, has led to cost-saving mainstream policy proposals to which health has not been immune.

• Related: MJA — Strengthening primary health care to improve Indigenous health outcomes
• Related: MJA — Primary Health Networks and Aboriginal and Torres Strait Islander health

As these policies are developed they may have very negative consequences for Aboriginal and Torres Strait Islander policy, and inevitably overshadow the specific Aboriginal and Torres Strait Islander issues.

As examples, the previously proposed Medicare co-payment changes, or increased pathology costs, actively work against both CTG and the NATSIHP, which were trying to increase access to primary health care for Aboriginal and Torres Strait Islander people.

These policy directions also worked against the policy intent of Aboriginal community controlled health services (ACCHSs) becoming increasingly more self-sustainable via Medicare.

In fact, for ACCHS business models, it has been almost impossible to forward-plan programs based on projected Medicare earnings as the proposed changes would have significant effect on the ability of services to self-fund, and most, if not all, of our ACCHSs will not pass on costs to patients.

This underscores a lack of coherence in national Aboriginal and Torres Strait Islander health policy development within the larger, mainstream health approaches. This is also apparent at state and territory health policy level, and it can be seen that, while ACCHSs are specifically documented as one of the most effective primary health care models in all of the major Aboriginal and Torres Strait Islander health policies, many jurisdictions still do not support them in practice.

Because of significant Indigenous affairs policy changes under the current government, and the increased role of the Department of Prime Minister and Cabinet (DPMC), the roll-out of health-related funding through both the Department of Health and the DPMC needs to be clarified.

The approach to health-related funding through the Indigenous Advancement Strategy via the DPMC was less than transparent and lacked good systems.

With the now revised health reforms rolling out health program funding via the Primary Health Care Networks (PHNs), there remains a lack of clarity on how these newer institutions should actively relate to CTG, the NATSIHP or ACCHSs.

While it can be useful to allow local flexibility and autonomy for these new organisations, there is also a need to ensure that Aboriginal and Torres Strait Islander-specific funds are much more targeted.

Potentially, more specific structural approaches within the PHNs are required to ensure effectiveness and strategic relationships between PHNs and ACCHSs. Couzos, Delaney-Thiele and Page have discussed this previously in the MJA.

Currently, under this “contestability” approach, the most effective primary health care approaches by ACCHSs are only one of the many health services or mainstream non-government organisations competing for Aboriginal and Torres Strait Islander health program dollars.

Local competition for funding does not result in organisations working well together. This will be even more evident in the roll-out of funding for the National Ice Action Strategy and new mental health programs.

As well as national and jurisdictional health policy that is better aligned with Aboriginal and Torres Strait Islander-specific policy, we need real clarity on which level of government has responsibility for specific parts of the health system such as Aboriginal and Torres Strait Islander primary health care, and where the PHNs fit in. While responsibility is often stated, this isn’t always the case for us in practice.

If Australia wants to get serious about policy reform and Aboriginal and Torres Strait Islander health outcomes, after this election there needs to be a fundamental shift in policy that includes a much higher level of policy influence and authority given to the National Aboriginal Community Controlled Health Organisation (NACCHO) and their state and territory affiliates, the National Health Leadership Forum (NHLF) – in which all of the Indigenous peak health bodies are represented – and the National Congress of Australia’s First Peoples (NCAFP).

• Related: MJA InSight — Closing the Gap: 10 years in
• Related: MJA InSight — Closing the Gap life expectancy target a distraction

Structures that hold the system accountable for this policy implementation need to be put in place.

Peak representative bodies such as the NACCHO, the NHLF and the NCAFP, provide the only real mechanism for national policy input from Aboriginal and Torres Strait Islander people and these peak bodies should be recognised as practical Indigenous leadership and policy development platforms.

They are also the best vehicle for ensuring that the social determinants of Aboriginal and Torres Strait Islander health are drawn together across portfolios — health, education, justice, housing, land, employment.

This would not be difficult to emulate at a regional level as well as through the Empowered Communities pilots or an alternative approach that ensures regional and local Aboriginal and Torres Strait Islander decision making across health, local councils, education and employment to address local social determinants.

An additional approach may be to establish, based on the original Kevin Rudd reforms, the Aboriginal and Torres Strait Islander Health Authority, which could provide specific program funding directly to ACCHSs. Such an approach could ensure that ACCHSs, mainstream health services and non-government organisations effectively use Aboriginal and Torres Strait Islander health dollars and take responsibility for the review of their health performance indicators. This is important in order to operationalise the policy and hold relevant agencies accountable.

Having a Prime Minister for Aboriginal and Torres Strait Islander people is laudable, but doesn’t help us if it’s just a 1-week trip to a remote community each year.

The clear policy learnings from these visits need to be taken back to the big end of town in Canberra to develop better policy, processes and outcomes, or the resources would be better spent on funding a remote social worker, GP, health worker or janitor.

Aboriginal and Torres Strait Islander-specific health policies need to maintain primacy and consistency within all national government policy in order to be effective, and not be seen as “gammon”.

Structures that are led by Aboriginal and Torres Strait Islander people and support the improvement of their health, need to be given authority and supported in order to develop, drive and implement effective policy.

Dr Mark Wenitong is an adjunct associate professor at James Cook University’s School of Tropical Public Health, and is medical advisor to the Apunipima Cape York Health Council

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