Needs and strengths: supporting child health in remote Australia

“The failure to close the gaps in Aboriginal and Torres Strait Islander health inequality, and other measures of social and economic disadvantage, cannot be justified by more rhetoric or data in another report. For us, the harrowing failure to close the gap is felt through sorry business, the countless funerals of family and friends, the hospital visits and the coronial inquiries that we continue to painfully endure. So many of our losses were and are preventable – that is the failure and pain we carry. A sensible way of doing business is long overdue as, apart from small gains, the attempts to close the gaps in Aboriginal and Torres Strait Islander life expectancy, health and education have failed.” June Oscar (2021)

IN Australia, nearly 28% of the Indigenous population live in rural areas, one-fifth in remote or very remote settings (here, here).

The documented poor child health and wellbeing reflects the impacts of colonisation: intergenerational trauma, forced dispossession, stolen generations, and racism and other social determinants of health. Although some Indigenous child health outcomes (eg, child mortality) and determinants of health (eg, preschool attendance, year 12 attainment) have improved in the past decade, most have stalled (eg, reading, writing, numeracy), and some have never improved (eg, school attendance). Many child illnesses, injuries and deaths are preventable. Better access to high quality health services in remote areas is part of the solution but must be underpinned by simultaneously addressing the social determinants of health.

For over 10 years, we have worked in partnership with Aboriginal communities who have led efforts to support child and family health in the remote Fitzroy Valley of Western Australia and have observed many barriers to optimal health care. To inform our work, we have also reviewed existing health services and workforce for Indigenous children living in remote Australian communities; characteristics of effective health services; and models of care and solutions. Our review is published at MedRxiv and is currently undergoing peer review at an open access journal.

Remote health services in Australia have been described as “very chaotic”, “ad hoc”, “swallowed by acute needs”, and “going under”. Key concerns include insufficient support for Indigenous leadership and Indigenous health professionals, inadequate clinical workforce, and poor coordination of services. The COVID-19 pandemic has exacerbated the pressures on health systems, particularly in rural and remote communities.

Indigenous children are less likely than non-Indigenous children to use GP services, paediatricians, maternal and child health and allied health services, but more likely to be hospitalised (here, here). Children represent 38% of evacuations from remote communities that depend on the Royal Flying Doctor Service for their health care.

Strategies to improve health care for Indigenous children must include service plans that are led by, or developed and implemented in partnership with, community leaders.

Implementing systems-wide, formal developmental assessments for all children will enable early identification of children’s need for services and support. For Indigenous children, use of culturally appropriate assessment tools and availability of culturally competent staff will facilitate acceptable service delivery. Increasing the number of trained Indigenous health care workers and culturally informed services in remote communities is crucial.

No single health care model is universally applicable for remote settings; however, iterative improvements such as coordinating delivery of government, non-government organisations, specialist outreach and virtual care services will improve child health. Coordination between primary, secondary, and tertiary services is also important to improve patient- and family-centred care and reduce duplication (here, here, here, here).

Increasing financial, educational, and collegial support for health care workers of all backgrounds, as well as increasing the availability of accommodation for health workers in remote settings, is crucial to enable the delivery of face-to-face health care. Outreach and telehealth services improve access to health care and improve health outcomes in remote settings (here, here, here, here) and have been shown to be cost-effective.

To understand and improve remote services and kids’ health, we need objective and routinely collected measures that are culturally appropriate and agreed to be useful (here, here, here, here).

For example, the applicability of existing indicators of access to care are debated for remote areas. Similarly, measures of population health, such as obesity, smoking and diabetes, are less directly relevant to children. To better understand child health in remote settings, we also need data from primary care, including on prevention, and metrics such as infant mortality which derive from the hospital system. Essential too for understanding child health are data collected outside the health system, including from schools and other agencies.

Outcome measures for the effectiveness of a health service are typically lacking for remote child health services.

Wait times, equity of access, satisfaction with services and hospital admission rates are among measures that could feasibly and usefully be measured. Measures must incorporate social theories and Indigenous concepts of health. Standards should be established for the numbers and types of health care workers required in remote Australia and governance and funding put in place to ensure that positions are filled and there is workforce continuity. Aboriginal Community Controlled Health Services (ACCHO) providing holistic, wrap-around care are valued and must be supported and strengthened (here, here). ACCHOs are unique in their ability to deliver services flexibly, have positioned themselves as social and medical organisations that improve the social determinants of health as well as providing health care. ACCHOs are a major employer of Aboriginal people and there is evidence they provide good returns on investment.

Changing the social determinants of health will have more health and social impact in remote communities than any other strategy.

Social determinants of health including nutrition, housing, transport and education are high priorities for improvement. Advances in these determinants will likely improve health, social and emotional wellbeing, and decrease childhood trauma. In terms of health services, priority should be given to preventive care, including maternal and child health care, parenting programs, early infancy and childhood programs, primary care, and vaccination. Empowering Indigenous leadership and knowledge sharing are key to improving child health. Consulting young people about service development will increase health service access by adolescents. Increasing funding, training, employment opportunities, and accommodation for Aboriginal health workers, paediatric nurses and allied health practitioners is needed to improve child health. These professional groups play an important role in facilitating access to health services in remote communities yet are seldom discussed.

Greater funding is required to improve coordination between services and retention of clinical and administrative staff in remote areas and would increase efficiency in health service use, particularly through improved communication and scheduling. Physical infrastructure including internet access, computer hardware and high quality, integrated clinical software systems are also urgently needed and would minimise administrative pressures felt by clinicians.

The Kimberley Aboriginal Health Planning Forum addresses a wide range of health determinants and services. The forum supports a holistic approach encompassing coordination of health services, creation of local treatment protocols and training, the Kimberley standard drug list, local referral pathways and the School Entry Check for early identification of health and developmental problems. This model could be adopted by other remote Indigenous communities.

We acknowledge the strength and resilience displayed by Indigenous people despite the ongoing legacy of colonisation, including racism and disadvantage. Many recommendations have been made for models of care to improve Indigenous child health services, but implementation remains a challenge.

Guiding documents include the National Aboriginal and Torres Strait Islander Health Plan 2021–2031, the National Aboriginal and Torres Strait Islander Early Childhood Strategy, and the revised Closing the Gap Report 2020. A formal partnership established in 2019 between governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations will, for the first time, give Indigenous people opportunity for shared decision making on Closing the Gap targets and strategy. Indigenous organisations leading the way in embedding best practices into child policy include the National Aboriginal Community Controlled Health Organisation (NACCHO) and SNAICC: the National Voice for our Children.

Now is the time to transfer accountability and decision making to Indigenous people, to refocus remote service delivery on families and communities, to promote community development and to address the social determinants of health.

Professor Alexandra Martiniuk is a Professor of Epidemiology at the University of Sydney, Adjunct Professor at the University of Toronto and Honorary Senior Research Fellow at the George Institute for Global Health. She has Canadian Indigenous family and has worked in partnership with Aboriginal communities in the Fitzroy Valley since 2009.

Dr Philippa Dossetor is an anaesthetic registrar at Royal North Shore Hospital Sydney. She obtained her medical degree and a PhD on Aboriginal child health services at the Australian National University.

Ms Emily Carter is a Gooniyandi Kija woman from the central Kimberley region. She is the Chief Executive Officer of Marninwarntikura Women’s Resource Centre in Fitzroy Crossing.

Dr Joseph Freeman is a medical intern in Darwin, and a PhD candidate at the University of Sydney where he is studying models of wrap-around care for Aboriginal children in remote Australia.

Dr Kathryn Thorburn is Assistant Director and Translational Research Fellow at the Nulungu Research Institute at the University of Notre Dame Australia.

Ms June Oscar AO is a senior Bunuba woman from the Fitzroy Valley and Australia’s Aboriginal and Torres Strait Islander Social Justice Commissioner.

Professor Heather Jeffery is an Honorary Professor of International Maternal and Child Health, University of Sydney and until recently was a Neonatologist at Royal Prince Alfred Hospital, Sydney and Gates Foundation Clinical Trials Manager.

Dr David Harley is a Senior Medical Officer (Public Health Medicine) at Metro North Public Health Unit Queensland Health, Principal Research Fellow at the University of Queensland Centre for Clinical Research, and Adjunct Professor at Griffith University Medical School.

Professor Elizabeth Elliott is a Distinguished Professor of Paediatrics and Child Health at the University of Sydney and a Consultant Paediatrician at the Sydney Children’s Hospital Network, Westmead and has worked in partnership with Aboriginal communities in the remote Fitzroy Valley in WA since 2009.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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