Australian Indigenous Doctors’ Association
Submission to the ACT GP Taskforce
8 August 2009
Introduction
The Australian Indigenous Doctors’ Association (AIDA) welcomes the opportunity to
comment on the ACT GP Taskforce Discussion Paper Issues and Challenges for
General Practice and Primary Health Care (June 2009).
AIDA is a not-for-profit, non-government Aboriginal and Torres Strait Islander health,
education and workforce. There are approximately 129 Indigenous medical
graduates and a similar number of Indigenous medical students in Australia.
AIDA is represented on over 30 government and non-government health, education
and workforce groups, including the National Indigenous Health Equality Council, the
Indigenous Health Equality (Close the Gap) Campaign Steering Committee and the
Aboriginal and Torres Strait Islander Health Workforce Working Group.
AIDA works closely with Medical Deans Australia and New Zealand, the Committee of
Presidents of Medical Colleges and the Australian Medical Council to ensure that the
medical education and training system is inclusive of Indigenous health content, is
culturally appropriate and recruits, supports and graduates Aboriginal and Torres
Strait Islander people into medicine and medical specialties.
As Indigenous medical practitioners, we offer a unique combination of clinical and
cultural competence and expertise, and have a distinctive and central role in
advocating for, and improving the health and wellbeing of Aboriginal and Torres
Strait Islander people. We are keen to ensure that the needs of Indigenous
communities and their respective health needs are articulated, protected, advocated
for and respected.
Aboriginal and Torres Strait Islander Health Status
The poor status of Aboriginal and Torres Strait Islander health and the life
expectancy gap is well documented. The burden of disease experienced by
Indigenous Australians is estimated to be two and a half times greater than the
burden of disease in the wider Australian population.
Aboriginal and Torres Strait Islander people experience higher death rates than nonIndigenous Australians across all age groups, from all major causes of death1. This in a nation which in general, has one of the healthiest populations of any developed
country and which has access to a world-class health system - is unacceptable.
1
Australian Bureau of Statistics (ABS) 2008.
1
The 2008 AIHW Report Australia’s Health 20082 reports that the top five causes of
Indigenous deaths were (i) diseases of the circulatory system, (2) external causes of
morbidity and mortality (mainly accidents, intentional self-harm and assault); (iii)
neoplasms (including cancer), (iv) endocrine, nutritional and metabolic diseases
(including diabetes) and (v) diseases of the respiratory system.
Many of these conditions can be improved or prevented (and thus contribute to
closing the gap) through better access to primary health care, better preventative
measures and more effective transitions between levels of care for Aboriginal and
Torres Strait Islander people. Access to primary health care services continues to be
a barrier for Aboriginal and Torres Strait Islander people. The 2007 Australian
Medical Association (AMA) Report Card on Aboriginal and Torres Strait Islander
health attributes this to financial, geographic, personal and cultural barriers that
work against the delivery of an effective health system for Indigenous Australians3.
The Indigenous population is considerably younger than the non-Indigenous
population with the median age being 20 years for Indigenous people and 37 years
for the non-Indigenous population4. The Aboriginal and Torres Strait Islander
fertility rate is higher than that of the general population and the overall population
is expected to grow, whereas the general population growth is stagnant. This
differing demographic profile has considerable implications for the provision of
primary health care and population health programs to Aboriginal and Torres Strait
Islander people.
In addition, Aboriginal and Torres Strait Islander people ‘tend to be high users of
public hospitals’5 and ‘comparatively low users of medical, pharmaceutical and other
health services compared with other Australians’6. This means that health services
are provided in a reactive and/or emergency situation which limits the focus on the
full range of services needed to provide early diagnosis, clinical intervention,
prevention and promotion activities to address health risk and life opportunity
factors7.
Studies show that while Aboriginal and Torres Strait Islander people are more likely
to be hospitalised than other Australians, they are less likely to receive a medical or
surgical procedure while in hospital8 9. The reasons for this are not clear, but some
possible factors include communication and language difficulties, institutionalized
racism, the presence of co-morbidities, geography and presentation late in the
course of illness10.
With consideration of the appalling health statistics of Aboriginal and Torres Strait
Islander people, effective, culturally safe and timely access to comprehensive
2
AIHW 2008.
McConnachie, K; Hollingsworth, D & Pettman J 1988 in Australian Medical Association Report Card
Series 2007
4
AIHW 2008.
5
Ibid, p 209.
6
Ibid, p 209.
7
Ibid.
8
Cunningham J 2002, in MJA
9
Coory, M; Green, A; Stirling, J & Valery, P 2008 in MJA
10
ABS 2008.
3
2
primary health care is vital to reduce the disparity in life expectancy and improve
wellness.
The National Health and Hospitals Reform Commission recognises that ‘more of the
same’11 will not do and a new approach is required to drive innovation in the quality
and responsiveness of the whole health system for Aboriginal and Torres Strait
Islander people. Improving Aboriginal and Torres Strait health requires ‘a whole of
government commitment to address the social determinants of health, as well as
improving health services12.
Health and wellbeing from Indigenous perspectives
For Aboriginal and Torres Strait Islander people, health is not just the absence of
illness or disease. AIDA endorses the Australian Indigenous concept of health and
primary health care as outlined in the National Aboriginal Health Strategy (NAHS):
“Not just the physical well-being of the individual but the social,
emotional, and cultural well-being of the whole community. This is a
whole-of-life view and it also includes the cyclical concept of lifedeath-life.”
(National Aboriginal Health Strategy Working Party, 1989, x)
The “Ways Forward” definition:
“The Aboriginal concept of health is holistic, encompassing mental health and
physical, cultural, and spiritual health. Land is central to well-being. This
holistic concept does not merely refer to the “whole body” but in fact is
steeped in the harmonised inter-relations which constitute cultural well-being.
These inter-relating factors can be categorised largely as spiritual,
environmental, ideological, political, social, economic, mental and physical.
Crucially, it must be understood that when the harmony of these
interrelations is disrupted, Aboriginal ill health will persist.”
(Swan, P & Raphael, B 1995, 14)
The NAHS working definition of primary health care is:
“Essential health care based on practical, scientifically sound, socially
and culturally acceptable methods and technology made universally
accessible to individuals and families in the communities in which they
live through their full participation at every stage of development in
the spirit of self-reliance and self-determination.”
(National Aboriginal Health Strategy Working Party, 1989, x)
It is recognised that health and health care are cultural constructs arising from the
beliefs, values and assumptions about the nature of disease, the human body and
human society. AIDA embraces the philosophy that Life is Health is Life13 - a
11
National Health and Hospitals Reform Commission 2009, p 197.
Ibid, p 197.
13
Ibid, p x.
12
3
concept which includes the social, emotional, spiritual and cultural wellbeing of the
entire community.
Social and emotional wellbeing is an integral part of Aboriginal and Torres Strait
Islander peoples’ health. It should be understood within the holistic concept of
health and not seen as an issue separate from physical health. Issues of social and
emotional wellbeing cover a broad range of problems which can result from
unresolved grief and loss, trauma and abuse, inter-generational trauma, domestic
violence, issues associated with the removal of children, incarceration, family
breakdown, cultural dislocation, mental illness, racism, discrimination and social
disadvantage14. These issues sit within an historical and social context, and have
implications for poor health.
The development of an enhanced primary health care system would gain value from
a holistic approach to health and wellbeing as well as facilitate improved integration
with other services within and beyond the health sector.
Recommendation 1: The ACT Government take account of the holistic
view of Aboriginal and Torres Strait Islander health, and accept Indigenous
social and emotional wellbeing as central to health and wellbeing for
Indigenous people and communities.
Health Impacts of Racism
In recent years, a number of international reports have recognised that racism and
its effects have a significant impact on health status. More specifically, the
experience of racism by Indigenous people everyday can directly contribute to poor
physical and mental health15.
Research in Australia by Paradies, Harris & Anderson has suggested that racism
precedes ill health rather than vice versa. The most consistent finding in this body of
research is the association between racism and mental health conditions such as
psychological distress, depression and anxiety. Racism also appears to be
consistently associated with health risk behaviours such as smoking, alcohol and
substance misuse.
In relation to diseases of the circulatory system, it is important to note the evidence
regarding the link between heart disease and depression and ‘psycho-social stress’,
induced by social isolation, poverty, feelings of hopelessness and lack of
empowerment and control over life opportunities16.
Pathways from racism to ill-health may include17:
 Reduced and unequal access to the societal resources required for health (eg.
Employment, education, housing, medical care, social support),
 Direct impacts of racism on health via racially motivated physical assault,
 Stress and negative emotional reactions that contribute to mental ill health,
as well as adversely affecting the immune, endocrine and cardiovascular
National Strategic Framework for Aboriginal and Torres Strait islander Peoples’ Mental Health and
Social and Emotional Wellbeing (2004-2009)
15
Paradies, Y; Harris, R & Anderson, I 2008
16
Brown, A & Blashk, G 2006, p. 805-896. http://www.racgp.org.au/afp/200510/29470
17
Paradies, Y; Harris, R & Anderson, I 2008, p 9.
14
4

systems physiology; and
Negative responses to racism, such as smoking, alcohol and other drug use.
It is widely known that the cost of chronic disease on the Australian health system is
significant and will increase greatly in coming years. What is not easily measured is
the estimated cost of racism to society and on the health system.
“Racism accounts for a significant burden of Indigenous ill health.
Although international research has identified a range of factors that may
be implicated in the relationship between racism and Indigenous health,
there has been very little research on this topic in Australia. There is a
need to understand the role played by acute and chronic stress in the
relationship between racism and ill health. There is also a need to better
understand the effects of racist events early in life and the health
implications of cumulative racist experiences over the life course (as
exemplified by the experiences of the stolen generation)”.
(Paradies, Y; Harris, R & Anderson, I 2008, 10)
It is important to note the fundamental connection between country, spirituality and
health for Indigenous people. Unresolved issues regarding sovereignty and selfdetermination (including control of resources and cultural security) have been
recognised as contributing to illness and health inequity for Indigenous people in
international research. The landmark study by Chandler and Lalonde18 in Canada
showed that those First Nations communities that had more markers of cultural
continuity including some form of self government and settled land claims had lower
rates of youth suicide than those communities with fewer markers of cultural
continuity.
Key Factors in Primary Health Care Service Provision to Aboriginal
and Torres Strait Islander people
A Holistic Wellness Approach to Aboriginal and Torres Strait Islander
Health
Aboriginal and Torres Strait Islander people have historically advocated for a holistic
approach to primary health care. Holistic health care means that treatment does not
just focus on the disease, but that the disease is treated within the context of a
person’s individual health and wellbeing, and that of family and community. For
Aboriginal and Torres Strait Islander people, primary health care is not just about the
delivery of health services. Community engagement, relationships, translation of
health information and development of health behaviours are all part of the
connectedness around service delivery to Aboriginal and Torres Strait Islander
communities. The development of an enhanced primary health care system would
benefit from adopting this philosophy.
There is no magic bullet or one-standard model that can be applied across all
Aboriginal and Torres Strait Islander communities in remote, regional and
Chandler, M. J. & Lalonde, L 1998 in Canada’s First Nations Transcultural Psychiatry. Vol. 35
(20): p. 191-219.
18
5
metropolitan areas. Effective models include Aboriginal Community Controlled
Health Services (ACCHSs) such as our locally based, Winnunga Nimmityjah Aboriginal
Health Service, WuChopperen Health Service – 2006 Indigenous Governance Award
winner, and Inala Community Health Service. A range of proven, effective models
and projects in Aboriginal and Torres Strait Islander health have been identified and
evaluated19 20. These are commended to the GP Taskforce for consideration.
Core elements of effective models have been identified and need to be adopted at
the local level. These include21:
 Holistic, culturally safe, community-based care
 Aboriginal and Torres Strait Islander community consultation, development
and ownership
 Access to adequate and sustainable funding
 Access to skilled and culturally competent workforce across the continuum of
care and
 Partnerships with other service providers and hospitals
Recommendation 2: Existing, proven effective models and projects be
funded and promoted. Support the development and sustainability of
community-based programs and services within the primary health care
sector. Broader application and sustainability of these programs is critical to
ensure continued improvements in morbidity and mortality.
Access to culturally appropriate services across the continuum of care
Aboriginal and Torres Strait Islander people access health services across the
delivery spectrum – for example, general practitioners, hospitals, rehabilitation, drug
and alcohol, aged care, mental health and maternal and child health, as well as
comprehensive community-controlled health services. These need to be culturally
safe, responsive and focused on achieving the best possible outcomes22.
Both mainstream and Aboriginal and Torres Strait Islander specific health services
need to be enhanced in order to improve access to, and the impact of, primary
health care and linkages with services across the delivery spectrum. The National
Health and Hospitals Reform Commission propose the accreditation of health
services, requiring core Indigenous modules to ensure clinical quality and culturally
safe services23.
The mainstream health sector will better focus on the needs of Aboriginal and Torres
Strait Islander people and provide culturally safe services if government changes ‘the
way funds flow to all services and by strengthening the accountability of mainstream
services’24.
In addition, the non-Indigenous health workforce needs to be culturally competent,
knowledgeable and skilful with respect to Aboriginal and Torres Strait Islander
people and their health. Aboriginal and Torres Strait Islander people are more likely
19
Department of Health and Ageing (DoHA) 2001.
Cooperative Research Centre for Aboriginal Health (CRCAH) 2003.
21
AIDA Submission to the Review of Maternity Services 2008, p 8-9.
22
National Health and Hospitals Reform Commission 2009.
23
Ibid.
24
ibid, p 216.
20
6
to access and will experience better outcomes from services that are respectful and
culturally safe places.
Recommendation 3: The ACT Government support a broad range of
Aboriginal and Torres Strait Islander culturally safe health care programs and
services across the continuum of care.
Consultation and planning at the local level to determine culturally safe
services and design of models relevant to geographic differences
Aboriginal and Torres Strait Islander people experience poor health outcomes
wherever they live. ‘Aboriginality is a stronger predictor of life expectancy than place
of residence’25.
The ‘major underlying cause of health inequality in Australia is that Aboriginal and
Torres Strait Islander people, in both remote and urban centres, do not enjoy equal
access to primary health care or the same standard of infrastructure necessary for
health’ (such as safe drinking water, healthy food sources, healthy housing and
effective sewerage systems)26 27.
Improvements in the health and wellbeing of Aboriginal and Torres Strait Islander
people is achieved when health service providers work with communities to plan,
develop and implement programs, along with a program of community capacity
building. Primary health care services need to be based on local level health needs
and plans which have been identified through consultation with Aboriginal and
Torres Strait Islander communities.
In Australia, this relies on a partnership between ‘Indigenous communities and
health service providers; community involvement and capacity-building strategies;
links with institutional structures beyond the health sector (eg environment,
education, housing and food industries); and involvement of both mainstream and
Indigenous-specific health services’28.
Recommendation 4: All local service development, design and delivery
must consult with Aboriginal and Torres Strait Islander leaders, organisations
and communities.
Integrated, ‘joined-up’ services within the health system but also of
services outside the health sector
A comprehensive primary health care system is a prerequisite for effective hospital
and specialist service delivery. As Aboriginal and Torres Strait Islander people
experience poorer access to primary health services, this has serious implications for
integrated care across the primary, secondary and tertiary levels. In particular, it is
estimated that ‘health service provision can potentially contribute up to 70 per cent
to closing the gap’29.
25
National Health and Hospitals Reform Commission 2009, p 210.
Speech – Social Justice Commissioner Tom Calma, Indigenous rights watchdog challenges
governments to commit to health equality within a generation, 16 February 2006.
27
Ring. I & Brown. N in MJA 2002, 177 (11), pp 629-631.
28
DoHA 2001, p 11.
29
National Health and Hospitals Reform Commission 2009, p 197.
26
7
For Aboriginal and Torres Strait Islander people, primary health care is directly
related to the social determinants of health, that is, the ‘upstream’ factors that
influence health and contribute to the wellness of individuals, families, communities
and indeed, the nation. Health and illness do not exist in a vacuum. They are very
closely connected to the provision of adequate housing, clean water and sanitation,
proper schooling, having a job; access to transport and ability to communicate.
Integration and coordination of services can only be achieved at the local level with
the coordination of local service providers. This includes the identification and
establishment of effective linkages with health services in regional centres and major
cities.
It is well known that social determinants have a role in predetermining health – ie,
the social, economic, cultural and physical settings must be right. This in turn
requires genuine commitment, partnership and collaboration between sectors such
as education, housing, justice and employment. Importantly, inter-sectoral
commitment also requires governmental leadership to ensure that effective coordination occurs and to close the life expectancy gap.
Indigenous health is a whole of health system responsibility
Both Aboriginal and Torres Strait Islander community controlled and mainstream
services are needed by Aboriginal and Torres Strait Islander communities30. There
are currently some 141 Aboriginal community controlled health services across
Australia31. Not all Aboriginal and Torres Strait Islander people and communities
have access to an Aboriginal community controlled health service. In these cases,
health services are often accessed through community health provided by State
governments.
Mainstream general practice has the responsibility for providing health services to all
Australians. However, Medicare Benefit Scheme (MBS) statistics indicate that more
can be done by mainstream general practice to improve the health of Aboriginal and
Torres Islander people. For example, the number of Adult Health Checks (710s)
performed in 2007-2008 nationally totalled 15, 68432. The estimated Indigenous
population in Australia in 2006 was 517, 20033.
The Department of Health and Ageing found that ‘mainstream primary health
professionals are often not well equipped to work effectively in a cross-cultural
context, nor are they well equipped to deal with the complex multiple morbidities
and specific illnesses that are prevalent in Indigenous communities but not often
found in the non-Indigenous population’34. In this respect, State/ Territory
governments and mainstream general practice will benefit from partnering with local
Aboriginal and Torres Strait Islander organisations and communities to develop
better approaches to primary health care delivery.
30
HREOC 2005.
NACCHO website: http://www.naccho.org.au
32
Medicare Australia, Medicare Item 710 processed from July 2007 to June 2008, (accessed: 9 Feb
2009), http://www.medicareaustralia.gov.au
33
According to the 2006 Australian census, about 37 out of 100 Indigenous people were aged less than
15 years.
34
DoHA 2001, p 20
31
8
There is potential for mainstream general practice to work towards quality
improvement in the delivery of health services to Aboriginal and Torres Strait
Islander people. A range of strategic policy and program levers need to be
developed and established within primary health care programs for mainstream
general practice to work with Aboriginal and Torres Strait Islander organisations and
communities.
For example, the Australian Primary Care Collaboratives has scope to improve health
services to Aboriginal and Torres Strait Islander people through the ACCESS topic
area.
Additionally, the Practice Incentives Payments (PIPs) and Service Incentive Payments
(SIPs) offer the vehicle through which to provide financial incentives to general
practice to increase Aboriginal and Torres Strait Islander Adult Health Checks. PIPs
and SIPs are available to enable general practice to better manage patients with
asthma, diabetes, chronic conditions and cervical screening. There is scope for
better management of Aboriginal and Torres Strait Islander health through the range
of Adult Health Checks, Child Health Checks, and Older Person’s Health Check.
Recommendation 5: Specific Aboriginal and Torres Strait Islander
performance measures and financial incentives be developed and integrated
into mainstream general practice and primary care programs aimed at quality
improvement of clinical outcomes, such as the Australian Primary Health
Collaboratives, Practice Incentive Payments (PIPs) and Service Incentive
Payments (SIPs)35.
Preventive Health Care
Research by the Australian Institute of Health and Welfare shows that 32 per cent of
the burden of disease in Indigenous people is due to a number of risk factors which
can be reduced or prevented by lifestyle and personal behaviour – factors such as
smoking, obesity, physical activity, excess alcohol consumption and poor nutrition.36
Similarly, the National Health and Hospitals Reform Commission found that ‘chronic
illness is a major issue and is estimated to account for around 70 per cent of the life
expectancy gap between Aboriginal and Torres Strait Islander people and other
Australians - it has been calculated that 11 modifiable risk factors, including alcohol,
drug and tobacco use, physical inactivity, low fruit and vegetable intake, and high
blood cholesterol account for 37 percent of the burden of disease and for around 50
percent of the health gap carried by Aboriginal and Torres Strait Islander
Australians’37.
35
National Health and Hospitals Reform Commission (2009, 197) Reform 8.5 proposes that
accreditation processes for health services and education providers incorporate, as core, specific
Indigenous modules to ensure quality clinical and culturally appropriate services.
36
National Health and Hospitals Reform Commission 2009.
37
ibid, p 200.
9
It has become increasingly apparent that ‘improving the quality of chronic illness
care and preventive care will require reorientation of health care systems’38. There is
need for specific locally developed health promotion and prevention programs for
Aboriginal and Torres Strait Islander people, which target smoking reduction, alcohol
intake, healthy eating and physical activity. Preventive health assessments are
‘obviously needed earlier, given the occurrence of preventable chronic disease at
younger ages and higher rates than in other Australians, reducing the costs to the
health sector and enhancing health equity for Aboriginal and Torres Strait Islander
people’39. Investment in these at the local level will significantly increase the quality
of life and health of our communities.
AIDA also believes that Indigenous health and Indigenous illness prevention would
benefit from more support for a strengths-based, healing approach, one that
incorporates kinship care, which builds on the cultural networks and kinship
structures and can provide mentoring and role modelling for good health behaviours.
For example, Karpa Ngarrattendi - an Adelaide-based Aboriginal Health Unit
provides a cultural brokerage function between health professionals and Indigenous
Australian patients and their families. It recognises patient’s familial and kinship
relationships, attempts to accommodate language and gender needs, and
acknowledges that working with the familial unit often has better outcomes for
individual patients than working with the patient alone. The Unit takes a holistic
approach by working on a cultural, spiritual, psychological, social and physical level40.
Recommendation 6: The ACT Government support a broad range of
targeted Aboriginal and Torres Strait Islander culturally safe preventative
health activities aimed at reducing the risk factors.
Better Health Information and Accountability
AIDA is a lead partner in the Indigenous Health Equality Campaign to close the gap
in life expectancy between Indigenous and non-Indigenous Australians.
A number of significant developments have occurred in the past year in relation to
Indigenous health, and we draw these developments to the attention of the ACT GP
Taskforce.
In June 2008, the National Indigenous Health Equality Targets – Outcomes from the
National Indigenous Health Equality Summit, Canberra, March 2008, were handed to
the Australian Government. This document includes a set of targets relating to
primary health care41. Two of the high level targets include42:

Access to culturally appropriate comprehensive PHC services, at a level
commensurate with need and
Si, Bailie, Dowden, O’Donoghue, Connors, Robinson, Cunningham, Condon & Weeramanthri 2007,
p 453.
39
Mayers & Couzos 2004, p 531.
40
Mackean, L. 2008, Presentation to the Pacific Region Indigenous Doctors Conference, Hawaii.
41
Close The Gap National Indigenous Health Equality Targets: Outcomes from the National
Indigenous Health Equality Summit Canberra, March 18-20, 2008.
42
Ibid, p 20.
38
10

Mainstream services provided to Aboriginal and Torres Strait Islander people
in a culturally sensitive way and at a level commensurate with need.
AIDA commends the document to the ACT GP Taskforce in developing a sustainable
ACT response to primary health care delivery. Additionally, AIDA commends the
objectives outlined in the National Indigenous Health Equality Summit Statement of
Intent, which was signed by the Prime Minister, the Minister for Health and Ageing,
and the Minister for Indigenous Affairs, in March 200843.
AIDA proposes that the GP Taskforce comprise a core component of it’s strategic
direction and action in Aboriginal and Torres Strait Islander health.
Recommendation 7: The targets and benchmarks outlined in the
publication National Indigenous Health Equality Targets – Outcomes from the
National Indigenous Health Equality Summit be strongly considered by the
ACT Government in the development of sustainable responses to improving
the primary health care system.
The Interim Report from the National Health and Hospitals Reform Commission
proposes to increase awareness and understanding of health inequities by ‘public
reporting by governments, private health insurers and individual health service
providers on the health status, health service use and health outcomes of population
groups who are likely to be disadvantaged in our communities’44.
Aboriginal Community Controlled Health Services are required to report annually to
the Department of Health and Ageing through the Service Activity Reports (SARs) on
episodes of care provided and a range of other information. There exists however
limited information on the care provided by mainstream general practice.
National and local performance indicators are in place for general practice and the
Divisions of General Practice Network through the National Quality Performance
System (NQPS). The NQPS is designed to drive continuous improvement across the
Divisions network and identifies a number of changes to quality improvement and
accountability within the Divisions network45. While there is the opportunity to
develop specific Indigenous indicators at the local level, high level Indigenousspecific indicators are largely peripheral. Dedicated strategic and multi-levelled
Indigenous health measures need to be included in all reporting and data sets.
There will continue to be fracture coordination of care, planning and report if this
does not occur.
As general practice is the major provider of primary health care services and
Divisions are funded to support general practice to lead improved health outcomes,
greater accountability for Indigenous health needs to be embedded within the NQPS.
Recommendation 8: A specific set of Indigenous health performance
indicators be developed as part of the Access Domain within the National
Quality Performance System (NQPS) Divisions of General Practice program.
This will influence mainstream general practice to more proactively address
Close the Gap Indigenous Health Equality Summit – Statement of Intent, March 2008.
National Health and Hospitals Reform Commission 2009, p
45
Department of Health and Ageing website (accessed 23 Feb 2009), http://www.health.gov.au
43
44
11
Indigenous health.
Recommendation 9: Improve the collection and quality of data on
Aboriginal and Torres Strait Islander people. Health-related information
collection initiatives for improving the identification of Aboriginal and Torres
Strait Islander people need to be continued and strengthened. Indigenous
status must be recorded.
Workforce, Education and Training
Workforce shortages are experienced across the whole of the Australian health
system. The limited numbers of Indigenous and suitably trained and experienced
non-Indigenous health professionals exacerbates the limited provision of health
services provided to Aboriginal and Torres Strait Islander communities. The lack of
health service delivery, in turn, compounds the negative impact on health status and
wellbeing.
Aboriginal and Torres Strait Islander health professionals play a unique and critical
role in achieving positive health outcomes for Aboriginal and Torres Strait Islander
people and are currently significantly under-represented in Australia’s health
workforce46.
In 2006, the Aboriginal and Torres Strait Islander health workforce comprised of
some:
 100 Medical practitioners
 53 Midwives
 1107 Registered Nurses
 965 Aboriginal and Torres Strait Islander Health Workers47
A clinically qualified and culturally competent health workforce is essential for
ensuring that Australia’s health system has the capacity to effectively meet the needs
of Aboriginal and Torres Strait Islander people, close the life expectancy gap and
improve health outcomes. AIDA recognises the need for multi-disciplinary teambased models of care which have been operating in many Aboriginal and Torres
Strait Islander communities.
Australia relies on overseas-trained health professionals, particularly in regional and
remote areas where it is often difficult to recruit Australian trained professionals48.
Arkles, Hill & Jackson Pulver found that Aboriginal and Torres Strait Islander health
services are heavily dependent on overseas-trained doctors (OTDs). Indeed this
creates ‘another dimension of challenges for health service delivery in that ‘OTDs
must learn to negotiate multiple “cultural domains” – their own, the local Indigenous
culture and the broader Australian culture – when practicing in Indigenous health
services’49.
The chronic staff shortage is not only unacceptable to our regional and remote
communities, but it raises issues of professional ethics and efficacy due to
inadequate collegial and clinical support. The value of working with Aboriginal and
46
National Aboriginal and Torres Strait Islander Health Council 2008.
ABS-AIHW 2008.
48
National Health and Hospitals Reform Commission 2009, p 321.
49
Arkles, Hill & Jackson Pulver 2007, p 528.
47
12
Torres Strait Islander communities whether urban, regional or remote areas needs to
be acknowledged and remunerated appropriately.
Recommendation 10: The ACT Government focus attention on increasing
Indigenous medical student recruitment, support and graduation from ANU Medical
School.
Recommendation 11: The ACT Government allocate one GP scholarship to an
Indigenous Australian medical student or junior doctor, without compulsion for the
candidate to be ACT based given that there are no current Indigenous Australian
medical students or doctors in the ACT.
Aboriginal and Torres Strait Islander Health Workers play a central role in the
coordination of care and are often well placed to facilitate consultation with
community, and to design and implement strategies regarding health promotion and
prevention. Aboriginal and Torres Strait Islander Health Workers ‘have been an
important strategy for improving access to health care by Indigenous people’50. In
this respect, Aboriginal and Torres Strait Islander Health Workers are a vital part of
the workforce and need to be recognised through continued training, education and
investment in a nationally recognised professionally representative body.
AIDA strongly advocates the importance that Aboriginal and Torres Strait Islander
people are trained and recruited into all of the health disciplines.
Recently AIDA delivered a piece of work, on behalf of the (former) National
Aboriginal and Torres Strait Islander Health Council. The Pathways into the Health
Workforce for Aboriginal and Torres Strait Islander people: A Blueprint for Action
report outlines key recommendations for the development of an Aboriginal and
Torres Strait Islander health workforce. These include:
 student needs (including improving maths and science literacy)
 development of culturally safe learning environments
 enabling pathways (eg from secondary school to vocational education and
training, secondary to university; transitions between vocational, university
and workplace, etc.)
 health and education funding models and
 support for professional associations and professional development.
AIDA commends the report Pathways into the health workforce for Aboriginal and
Torres Strait Islander people: A Blueprint for Action to the ACT GP Taskforce51.
The National Health and Hospitals Reform Commission recently proposed additional
investment including the funding of strategy to build an Aboriginal and Torres Strait
Islander health workforce across all disciplines and the development of a workforce
for Aboriginal and Torres Strait Islander health52. AIDA strongly supports this
recommendation.
50
Murray, R & Wronski, I 2006, p 38.
The National Health and Hospitals Reform Commission (2009, p 318) supports the development of a
comprehensive national strategy to recruit, retain and train Aboriginal and Torres strait Islander health
professionals as outlined in the Pathways into the health workforce for Aboriginal and Torres Strait
Islander people: A Blueprint for Action.
52
Reform 8.6
51
13
Recommendation 12: Sustainable investment in the training and development of
the Aboriginal and Torres Strait Islander health workforce across all disciplines.
It is critical that the entire health workforce is equipped with both a fundamental
understanding of Indigenous health in Australia, as well has a high level of cultural
competence. These attributes facilitate better knowledge and understanding about
local Indigenous people and their communities and thus the most appropriate
strategies to engage in effective primary health care delivery.
AIDA advocates for systemic reform whereby core Aboriginal and Torres Strait
Islander health curriculum is included in all health discipline studies, hence providing
health graduates with a base level of cultural competency. For existing
professionals, AIDA advocates that continuing professional development (CPD) in
Aboriginal and Torres Strait Islander health be developed and implemented.
Recommendation 13: Development and implementation of Indigenous health
curriculum across all health disciplines, including continuing professional
development training for health professional graduates.
Funding and the Cost of Improving Indigenous Health
Australia is fortunate to be a wealthy nation with a world-class health system. It is
‘not credible to suggest that one of the wealthiest nations in the world can not solve
a health crisis affecting less than 3% of its citizens’53.
Currently, the Commonwealth provides funding to ACCHSs and a range of primary
health care programs and services for Aboriginal and Torres Strait Islander people.
States and Territories, in turn, also fund community health services and a range of
health services for Aboriginal and Torres Strait Islander people. These current
arrangements are not often coordinated, adequately funded or planned and provide
scope for duplication of services.
The National Health and Hospitals Reform Commission notes ‘that Aboriginal and
Torres Strait Islander people are under-serviced; therefore, greater investment is
needed to reach the underserved to ensure access to appropriate and responsive
care, to drive good practice, quality improvement, and the achievement of better
outcomes, and to influence action on the social determinants that affect health
outcomes’54.
Studies undertaken on the level of investment needed to improve health outcomes
and reduce the life expectancy gap for Aboriginal and Torres Strait Islander people
all conclude that significantly higher levels of expenditure are required55.
Eagar & Gordon sought to ‘calculate the level of public funding that will be required
to implement the transition to community control in Cape York and Yarrabah in a
way that achieves both increased utilisation and improved health outcomes across
53
HREOC 2005, p 7.
National Health and Hospitals Reform Commission 2009, p 197.
55
ibid.
54
14
the continuum of care’56. Four options for creating a funding pool were costed using
different sources: Cash- out, Equity of input, Equity of input adjusted for need, and
Equity of outcome.
Recommendation 14: In recognition of the burden of disease experienced
by Aboriginal and Torres Strait Islander people, primary health care funding
needs to be proportionate to health care need in order to achieve desired
outcomes57.
The reorientation of the health system requires greater funding investment in the
primary health care sector. AIDA recognises that reorienting the focus of the health
system will take some time and capacity is needed to be built within the primary
health care sector. A program of capacity building is required to assist service
provides to engage with and develop better relationships with Aboriginal and Torres
Strait Islander communities and organisations.
Reforms to the current Medicare items such as the Adult, Child and Older Person’s
Health Checks are moving in the right direction toward remuneration for general
practice to manage the holistic health and wellbeing of Aboriginal and Torres Strait
Islander people.
As previously stated however, there is limited data on the primary health care
services provided to Aboriginal and Torres Strait Islander people across the
continuum of care. In order to realise improved outcomes of Aboriginal and Torres
Strait Islander people, greater transparency and accountability needs to be
established across the whole health system to monitor health care performance and
outcomes.
Recommendation 15: A clear accountability framework articulating responsibility
and reporting across the whole of health system in relation to Indigenous health
services is established.
56
Eagar & Gordon 2008, p 1.
National Health and Hospitals Reform Reform 8.2 proposes an investment strategy for Aboriginal
and Torres Strait Islander people proportionate to health need, cost of service delivery, and the
achievement of desired outcomes.
57
15
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