IF ONLY WE HAD OUR HEALTH

Most Australians can proudly enjoy a sense of dignity, equity and comfort from working toward and having access to necessary services and infrastructure. ‘Over the fence’, entrenched poverty and disadvantage is eminent among some Aboriginal communities. Treating side-effects with policing and school attendance continues the Colonial myopia of Indigenous people as Soverign Owners of Australia - never ceded. Reform for an autonomy-focused health policy ‘in our own backyard’ will take greater commitment, yet yield better results. For the first Australians to have a fair go, the government must invest in collaborative research and development into Indigenous-led, empowering, community-controlled, culturally appropriate health and welfare. This paper explores constraints in some Indigenous communities, the constitutional context for addressing this, previous attempts at a federal level to ‘close the gap’ with Indigenous and non-Indigenous people, submissions for improved health made by Australian social and medical organisations and finally, the potential reform imperatives to replace the Morrison government’s ‘devil-might-care’ management will be evaluated.

Arney, McGuiness, & Robinson, (2009) identified poor health, education, housing, alcohol and drug abuse, unemployment, gambling and sexual abuse as concerning issues indicated by the Northern Territory Government’s Board of Inquiry. Dodson, (2007) cited in NACCHO & Oxfam alludes to the collective impact on the marginalised people when he states: “The statistics of infant and peri natal mortality are our babies and children who die in our arms…The statistics of shortened life expectancy are our mothers and fathers, uncles, aunties and elders who live diminished lives and die before their gifts of knowledge and experience are passed on. We die silently under these statistics...” This illustrates the broader, indirect effect of Indigenous disadvantage on the national and global community. It is fundamental for Australia to enact improved health regimes through federal action for resolution. Under Section 51 of the Australian Constitution,

...The Parliament shall, subject to this Constitution, have power to make laws for the peace, order, and good government of the Commonwealth with respect to: (xxvi) the people of any race, other than the aboriginal race in any State, for whom it is deemed necessary to make special laws...

Since some Aboriginal communities are subject to extenuating circumstances, this provides grounds whereby suitable measures can be instilled to redirect flailing initiatives and rescue Aboriginal people from dire states of affairs. Furthermore, the matter should be diplomatically articulated as to be serving the entire community. Pearson (2013), cited in Karvelas, warned that the race power, Section 51 (xxvi), should not be used for matters of public welfare or government socio-economic aid. “These matters should be addressed not on the basis of indigeneity, but on the basis of individual and community need, this distinction should be made clear in the drafting”. Highlighting the concern in terms of national interest, rather than Indigenous aid would strengthen the community and diminish racial segregation.

Under the Howard government (and mostly continued under the Rudd leadership as well), the government instituted mostly paternal protocols for treating Indigenous problems such as; supplying additional police, health checks, restrictions on alcohol and pornography, acquisition of townships, removal of customary law from bail applications and sentencing in criminal cases, filtering welfare benefits and the abolishment of community education development projects (Nathan, 2013). Contrastingly, the Whitlam government developed a ‘self-determined’ policy whereby the Commonwealth supported decision-making of Indigenous communities. Under his leadership, Aboriginal consultations were initiated and Medicare provided essential access to healthcare for all citizens. Famously in Whitlam’s (1972) election campaign speech, he stated:

“I personally find quite unacceptable a system whereby the man who drives my Commonwealth car in Sydney pays twice as much for the same family cover as I have, not despite the fact that my income is four or five times higher than his, but precisely because of my higher income”.

If Australia is to genuinely represent the preamble in the Charter for Human Rights where a democratic and inclusive society prevails, disparages in economic circumstances should not create unlevelled access to medical treatment. Indigenous health continues to receive inadequate attention from all major parties in government and the mainstream media. Indigenous Australians continue to die nearly 20 years younger than the rest of the population (NACCHO & Oxfam, 2007). According to the Australian Association of Social Workers (2010), the current situation for Indigenous health in Australia includes the following indicators; Indigenous adults are twice as likely as non-Indigenous adults to report their health as fair or poor; Hospitalisation rates are higher for Indigenous Australians, particularly for conditions that are potentially preventable such as diabetes and kidney disease; Mortality rates of Indigenous people are almost three times the rate for non-Indigenous people in Queensland, Western Australia, South Australia and the Northern Territory, (the only jurisdictions for which coverage of Indigenous deaths were deemed sufficient to report); Indigenous adults are more than twice as likely as non-Indigenous adults to smoke regularly; More than half of Indigenous people are overweight or obese; Indigenous people face barriers in accessing health services, in particular primary health care; infant mortality is three times the rate of non-Indigenous Australians and more than 50 per cent higher than for Indigenous children in the USA and New Zealand; Aboriginal deaths from smoking are 20 per cent higher than the rest of the community; Indigenous women are three times more likely to die during pregnancy than the rest of the population due to poor health and diseases such as rheumatic heart disease (AASW, 2010). A limited number of submissions regarding Indigenous Health were made prior to the Federal Budget. The groups that made submissions were the Australian Medical Association (AMA), the Australian Council of Social Services (ACOSS), and the National Aboriginal Community Controlled Health Organisation (NACCHO); these organisations reveal costly, but viable, effectual propositions for positive Indigenous health outcomes. 

Additional funding is required to increase the wages of medical professionals, particularly General Medical Practitioners, working in Aboriginal Community Controlled Health Services, in order to achieve parity with professionals in mainstream services. Also, recurrent funding is needed to keep wages competitive improving workforce retention and recruitment in these services, this way Aboriginal communities are not so heavily disadvantaged by the fact that they have to compete with mainstream services which can offer higher wages to medical professionals (ACOSS, 2010). Following this, a number of practical measures to ‘close the gap’ in Indigenous Health have been highlighted. For example, strengthening the capacity of Aboriginal Community Controlled Services, as well as expanding the Indigenous Health workforce. It was recommended that the Federal Government provide an additional $440M per year over five years to Aboriginal primary care services, and $500M in each subsequent year. This extra funding is necessary to enhance infrastructure and services, as well as to increase the capacity to provide training and mentoring opportunities to medical students and trainees in order to expand the Indigenous Health workforce. Offering competitive wages and conditions to medical professionals working in Aboriginal medical services is needed. Addressing the cultural appropriateness of health service provision, by providing $100M dollars over six years to develop Indigenous specific medical training is also recommended. Similarly to ACOSS’ (2010) recommendation, the AMA (2010) suggest allocating an additional 430 medical professionals to work in the area of Indigenous health and finally, committing $100M over ten years, in the form of grants to community and non-government organisations for health-related capacity building, to reflect the realistic time frame is needed to reach improved health standards in Indigenous communities subject to suffering conditions.

The policy Briefing Paper released by NACCHO details six key proposals for addressing the Indigenous health crisis. To begin, improved access for Indigenous Australians to primary healthcare that is culturally appropriate, at a level that matches the need for these services; they estimate would cost approximately $460M per year. The organisation also recommend that the Federal Government address the current shortfall of health practitioners working in Indigenous health services, which includes a shortfall of over 400 doctors and over 600 nurses, suggesting the reason for this shortfall as the inability of Indigenous services to offer competitive salaries, due to funding constraints. It’s proposed that allocating $36.5M per year toward a ten-year training plan for Aboriginal and Torres Strait Islander health professionals, as well as an additional $10M per year to establish Training Centres of Excellence in primary healthcare is required, in order to address this personnel shortfall. The institution of mainstream health services and programs would better respond to the health needs of Indigenous Australians, specifically the Pharmaceutical Benefits Scheme (PBS). Thus far, initiatives to increase Indigenous people’s access to PBS in remote areas have been very successful, but need to be extended to non-remote areas to better represent the 73 per cent of Australia’s Indigenous population who live in remote areas. This point is underscored by the fact that PBS usage by Indigenous people in remote areas is twice that of Indigenous people in non-remote areas (NACCHO & Oxfam, 2010).

To correct the disparity in Indigenous health, the organisation also proposed that $85M be spent per year to introduce a national scheme, $10M per year to be allocated toward improving Indigenous people’s access to specialist services and increase funding for programs targeting maternal and child health, as well as for chronic and communicable diseases. It was also recommended that allocating $20M for culturally appropriate maternal and child health programs of the kind that have proven successful when trialled. Additionally, particular attention is needed for specific chronic and communicable diseases which disproportionately affect Indigenous people, to combat these, $50M per year should be implemented as national strategies targeting; problem drinking, smoking cessation, immunisation, rheumatic heart disease and rheumatic fever, and cancer prevention. AASW (2008) put forward that:

Funding and support is needed for the building blocks of good health such as awareness and availability of nutrition, physical activity, fresh food, healthy lifestyles, and adequate housing (p. 4).

The organisation points out that in remote locations the cost of food is significantly higher than in non-remote areas and that this needs to be addressed by government in order to begin to address the problem of growth failure in children in remote areas. Construction of new houses and associated infrastructure to address the severe shortfall of housing for Aboriginal people is proposed. Finally, setting national targets and benchmarks to measure progress toward health equality will ensure greater success (NACCHO & Oxfam, 2010). These submissions were not considered in the recent Federal Budget. Rather, Australians are witnessing a shift from traditional welfare policies to leaner, simplified strategies, whereby increasing responsibility is delegated to the state level. In this instance, state governments can seek to have discussions with existing social organisations that have researched knowledge of Indigenous needs and plans of redress to rectify disparity between Aboriginal and non-Aboriginal welfare. Political representatives of individual states may try to negotiate federal funding under Section 96 of the Australian Constitution which: “Provides the Parliament may grant financial assistance to any state on such terms and conditions as the Parliament thinks fit”. Although it’s probable that state objectives would not be congruent with those on the Federal level, reducing the state power to manage local health agenda.

The government’s chosen strategy to improve Indigenous health outcomes in this year’s budget [1] indicates the government has failed to formulate a clear, long-term strategy required for improving Indigenous health outcomes, opting instead for short-term measures that lack evidence of efficacy. Considering this, allocated funding could have been better spent elsewhere, such as collaborative healthcare regimes or Community Controlled health services. In light of recent changes to welfare services, Indigenous people will have to compete to a larger extent with mainstream services for piecemeal funding from grants to address their deficits (NACCHO, 2010). A politically stated commitment to improving Indigenous health outcomes is lacking, the media avoids reporting on the health crisis and compounding the problem, many Australian citizens are not aware of this issue. Therefore, there is little pressure for government to change. Requests from Indigenous rights and health groups to improve social circumstances are not considered by a single-plane government, unprepared to identify to alleviate those in the gaps. Dwyer, et al. (2011) offer an alternative to the constraints on public funding by suggesting relational contracting as it provokes local healthcare organisations and governments to be mutually accountable and autonomous; providing better services in advocacy and setting priorities that engages Indigenous people.

Relational Contracting offers a sound alternative framework for redesigning this critical sector of the Australian health system, with potential to reduce administrative costs, enable improved performance, manage political risk, and, ultimately, maximise the primary health care contribution to closing the health gap between Aboriginal and non-Aboriginal Australians (p. 43).

This appears promising as Aboriginal people may resist another top-down approach from administration, especially if attempts to improve Indigenous welfare are not approached in a relevant way. Peiris, et al. (2012) provides research that enables positive reception of welfare intervention among Indigenous people. The principles here outline how ‘candidacy’ and ‘Kanyini’ [2] enable practitioners to jointly negotiate needs and interests of all those involved in the healing process. Here, specialised training and understanding are required for quality, far-reaching benefits. Once established, there is potential for quality improvement programs and these skills would be transferable to other areas – a worthwhile investment in Australia’s health system. “We found that tractable and navigable health services have good governance structures, sound leadership, systems that welcome the ‘non-ideal user’, good patient transport systems, and a well-supported workforce” (Peiris, et al. 2012, p. 10). A positive direction for Australia would be to adopt methods like this since, the nation as a whole would grow tremendously with the positive input of all citizens. Segregation breeds contempt and without cooperation – national performance suffers. Similarly, MacLean, Warr & Pyett (2009), advocate for collaboration. If realistic objectives are clearly investigated, a functional health policy that caters to Aboriginal needs may result. 

Collaborative participatory research (CPR) approaches foster and sustain participation of disenfranchised communities in the processes of research. A significant ethical advantage of CPR is that it can be used to empower communities by offering opportunities to influence the design of research, to develop skills and to become involved in developing strategies to address social and health inequality (p. 407).

Utilising this function in existing tertiary health and social science programs would expand both qualifications of students enrolled in relevant courses and establish priorities for the Australian government in terms of Indigenous healthcare, whilst being economically viable. The current, repeated, patronising, funding scheme for Indigenous people has proven to be misdirected with little efficacy, therefore reflects more on the initiator’s incapability than the subjects to whom the policy is directed. For the most part, reluctance to administer meaningful long-term, improved health agenda among Aboriginal communities is due to costs entailed. Current governments recognise the need for investment in growing infrastructure with limited cost to implement and enforce. With scarce commonwealth resources, reorienting national autonomy-focused initiatives to ‘close the gap’ in relation to Indigenous affairs is complex, yet vital for Australia’s advancement.

The possibility for governments on all levels to create opportunity for more effective policy by fostering clear objectives for nurturing all citizens through clear communication of issues at hand, especially in Indigenous communities exists. Diplomatically and specifically articulating how these targets will, through time, benefit the national and international community on social, economic and environmental levels has no fiscal price. The state can incorporate the views of existing welfare organisations and delegate tasks accordingly; building greater cooperative projects will lighten liability on public funds and ensure more meaningful programs are instilled. Using strategic mechanisms such as incorporating university students into research and development programs would have limited costs and potentially many flow-on effects such as generating greater awareness and concern for Aboriginal communities; reducing racial tension and improving outcomes for overall well-being. Consulting with Indigenous elders, changing the discourse of health policy by establishing more creative, constructive, mutually agreeable recovery strategies in community-participatory regimes will ensure that not only all Australians at least have their health, but are empowered to help themselves and others, ultimately relieving pressure from the commonwealth and positively shaping a robust future for the nation.

[1] Indigenous specific expense measures outlined in the Budget

[2] Kanyini is ‘holding’, a central Australian philosophy which describes the principle and obligations of nurturing and protecting others.