Picture above: CEO of Diabetes Australia, Greg Johnson with NACCHO CEO Lisa Briggs

“The importance of community empowerment and engaging Aboriginal and Torres Strait islander communities in the development of culturally appropriate diabetes prevention and management strategies” 

I begin by paying my respects to the elders past and present and the traditional owners of the land we are on today the Ngunnawal people.

 This forum is perfectly timed. This is an important year for the Aboriginal community controlled health movement to “Close the Gap” for better outcomes for our people.

 With a Federal election now locked in by the Prime Minister, Julia Gillard, for September 14, NACCHO, as the national authority in comprehensive Aboriginal primary health care will be ensuring that our voice is heard and that our movement continues to play a major role in shaping the direction of Aboriginal health in this country especially in the area of diabetes prevention and management.

In this 2013 election year there will be many new developments and challenges ahead includingnegotiating the National Aboriginal and Torres Strait Islander Health Plan (NATSIHP),monitoring the growth and influence of Medicare locals, and contributing to the National Primary Health Care Review.

 In my address this morning I will be giving you an overview on how NACCHO, as the national authority in comprehensive Aboriginal primary health care, is empowering and engaging Aboriginal and Torres Strait islander communities in the development of culturally appropriate diabetes prevention and management strategies. 

 Today’s keynote presentation consists of four components

1.The diabetes challenge ahead

 2. NACCHO shaping national health reform ( national policy and advocacy of diabetes)

1. Closing the Gap and whole of Government
2. How we support the National Congress and the National Health Leadership Forum?
3. The current draft National Aboriginal and Torres Strait Islander Health Plan (NATSHIP)

3.    NACCHO and  culturally appropriate diabetes prevention and management strategies 

4.    NACCHO’s key recommendation for Government to help address the diabetes epidemic.

THE DIABETES CHALLENGE AHEAD

The reason we have so many delegates here today is that all available data shows that the state of Aboriginal health remains appalling despite the introduction of many key initiatives to address chronic diseases such as diabetes.

Diabetes rates in Australia are high but its prevalence in the Aboriginal and Torres Strait Islander population is between three and four times higher than the rest of Australia.

We are fast running out of time to stop this disease from creating a national disaster.

As mentioned many programs have been implemented to address this but still the life expectancy for Aboriginal people remains 15 to 20 years below that of other Australians with death rates for adults 3 to 4 times higher than the non-Aboriginal population.  

We as a group recognise that it is time to make changes to our approach in addressing the negative impact that diabetes and its’ associated morbidity has on the Aboriginal and Torres Strait Islander people.

In a snapshot

• Aboriginal peoples and Torres Strait Islanders have the fourth highest prevalence of Type 2 diabetes in the world
• Aboriginal people are more likely to develop diabetes at a younger age than non-Aboriginal people. Our children have an increased incidence of Type 2 diabetes linked to obesity, insulin resistance and a positive family history of diabetes. We now have generations of the same family with diabetes.  
• Gestational diabetes is more common in Aboriginal mothers with rates 2-3 times that of non-Aboriginal mothers
• The first case of diabetes among Aboriginal and Torres Strait Islander people was recorded in Adelaide in 1923
• Records prior to this time showed that Aboriginal and Torres Strait Islander people were fit, lean, and did not suffer from any form of metabolic condition, which were largely believed to be a characteristic of European populations.
• The earliest detailed studies investigating the development of diabetes in Aboriginal and Torres Strait Islander populations were not undertaken, however, until the early 1960s.
• These and subsequent studies found a significant correlation between the development of a ‘westernized’ lifestyle and the levels of type 2 diabetes in the Aboriginal and Torres Strait Islander population.

• Since that time, Type 2 Diabetes has been recognized as one of the most important health problems for Aboriginal and Torres Strait Islander populations across Australia, with the overall prevalence likely to be around four times that of the general population.
  • The higher rate of diabetes in the Aboriginal and Torres Strait Islander population results from genetics, poverty and the lack of education and resources within this population, particularly in remote communities.
  • Evidence from the ‘70s work of Thomas McKeown and built on since by others, reiterates the importance of addressing the social determinants of health as well as providing quality health care services to address chronic health conditions such as diabetes. You need this two pronged strategy to provide improved health.
• With a history of displacement from land, disconnection from family, social disadvantage and high levels of incarceration, the Aboriginal and Torres Strait Islander people experience these factors which have contributed and will continue to cause the health issue of diabetes and other chronic health conditions.

Addressing these issues are the challenges that face everyone here today

• A strong primary health care system at a national level is associated with better health outcomes. Our community controlled sector is integral in delivering quality primary health care to the Aboriginal and Torres Strait Islander people.

• The National Aboriginal Community Controlled Health Organization (NACCHO) that I represent, is the elected national peak body representing over 150 Aboriginal Community Controlled Health Services in Australia.

• We have here today dedicated members of NACCHO such as Congress Alice  Springs who are delivering frontline comprehensive primary health care to communities across urban, regional and remote regions.

• Our  Community Controlled Health boards and staff come from different cultural backgrounds, histories, experience and knowledge – but we share a common commitment to our communities at the local, state and national levels and to improving the health and well being of Aboriginal peoples in Australia.

• Our member services form a network, but each is autonomous and independent, both of one another and of government.

• The integrated primary health care model is in keeping with the philosophy of Aboriginal community control and the holistic view of health that this entails.

• Why does community control work so well in addressing health conditions such as diabetes?

• Diabetes is a complex metabolic syndrome that requires lifestyle and environmental changes, in conjunction with medication and education to achieve improvements in blood sugar levels but more importantly in reducing the macrovascular complications of diabetes. To make these significant life changes and to maintain them long term requires a supportive community approach.

• Community control is the embodiment of this. The principals of community controlled primary health care were set out in the National Aboriginal Health Strategy in 1989 and remain today the gold standard approach to improving the health status of Aboriginal and Torres Strait Islander people.

• These principals encompass ;-

• A holistic view of health care which includes physical, social, spiritual and emotional health of people.

• Capacity building of community controlled organizations and the community itself to support local and regional solutions or health outcomes

• Local community control and participation

• Partnering and collaborating across sectors

• Recognizing the inter-relationship between good health and the social determinants of health.

Our services were practicing interprofessional and collaborative health care delivery before it became “fashionable” model of service delivery.

I would like to talk about the importance of focusing on our children to address diabetes and other chronic conditions. Pre-disposition to chronic conditions such as diabetes starts in-utero. The sector needs to address maternal health issues such as smoking, alcohol consumption, stress and mental health related conditions and nutrition.

The controversial data on maternal smoking from the recently released AIHW report suggests more needs to be done in this area.

The wider Australian community needs to facilitate the growth of our children in an environment free of racism, which acknowledges the historical mistakes made that caused a disconnection from land and family and work towards rectifying the long term impacts of those mistakes.

Environment can influence how genes express themselves resulting in a predisposition to diabetes. Epigenetics explains why Aboriginal and Torres Strait Islander people have such a high incidence of diabetes and it is only through addressing the environmental, social determinants of health that the situation will be rectified.

Education of our children and development of strong leadership will lead to generational change to our health status.

Robust, culturally appropriate screening for diabetes risk factors to assist in early diagnosis and interventions to reduce the progression of the illness are important.

NACCHO shaping national health reform (national policy and advocacy  of diabetes)

 So what is NACCHO’s strategic direction for its member services?  

It covers three central areas that are consistent with its constitutional objectives.

Strategic Direction 1: Shape the national reform of Aboriginal health .

Strategic Direction 2: Promote and support high performance and best practice models of culturally appropriate and comprehensive primary health care

Strategic Direction 3: Promote research that will build evidence-informed best practice in Aboriginal health policy and service delivery.

 The first, and the one we need to concentrate on today Shape the national reform of Aboriginal health’ makes it clear that we need to embark on a new process of reform at the national level.

The last major national reform was the transfer of responsibility for Aboriginal health to the Department of Health and Ageing back in 1995.

Our sector led the advocacy for this change and it was the springboard we needed to greatly increase the amount of funding now available for Aboriginal health service delivery. This included much better access to the MBS and PBS as well as grant funding.

Unfortunately, these funds have not systematically flowed into the creation of new or enhancing existing Aboriginal community controlled health services even though this is the best practice model agreed in the national strategic plan.

There are systemic barriers within government to transforming of the health system in favour of Aboriginal community controlled comprehensive primary health care. Risks to the community controlled sector include the distribution of funds to Medicare Locals for the provision of services to the sector without the inclusion and consultation of the sector.

NACCHO is committed to working collaboratively with Medicare Locals as partners in service delivery for the sector but there is the network of community controlled services with a consistent track record in improving health status of Aboriginal and Torres Strait Islander people who are now being denied direct to service funding as it is passed directly to a Medicare Local .

We do not want this to occur for programs that are designed to prevent and manage complex, multi-factorial conditions such as diabetes.

Once again, national reform is needed to address these barriers so that our people can access the highest quality, culturally safe community controlled health care in a way that builds our responsibility for our own health.

This requires existing health funds to be better invested to promote the quality and effectiveness of our services and for greater recognition that Aboriginal community controlled health services are the best practice model for Aboriginal people.

As the national peak body in Aboriginal health, NACCHO has taken a lead role in forming and advocating for our position within the National Health and Hospital Reform debate and influencing the government’s health reform agenda in Aboriginal health.

Our sector has grown stronger as we have worked together to forge a unified position on the health reform agenda.

We have been joined by many other stakeholders in Aboriginal health who are keen to work with us and support us such as the National Congress of Australia’s First Peoples

The National Congress of Australia’s First Peoples  has teamed up with NACCHO and ten other Aboriginal and Torres Strait Islander health groups to form the National Health Leadership Forum (NHLF).

The forum is lead by: Congress Co chair Jody Broun and NACCHO Chair Justin Mohamed.

The NHLF is a partnership that builds onto the strength and experience of NACCHO’s members’ views, experience and expertise in primary health care delivery.

Together with our partners we are shaping the national reform of Aboriginal health that primarily is driven by COAG.

In November 2008, COAG agreed to sustained engagement and effort by all governments over the next decade and beyond to achieve the Close the Gap targets for Indigenous Australians.

The National Indigenous Reform Agreement (NIRA) sets out the policy framework for Closing the Gap in Indigenous disadvantage. One of the Better Health Performance Benchmarks is to reduce the age adjusted prevalence rate for Type 2 Diabetes to 2000 levels (equivalent to the national prevalence rate of 7.1%) by 2023

There are other interlinked indicators that cover body weight and smoking rates that impact on diabetes incidence and morbidity.

The COAG commitment also included targeted initiatives for Indigenous Australians of $4.6 billion across early childhood development, health, housing, economic participation and remote service delivery through a number of associated National Partnership Agreements.

Health related Agreements include:

The National Partnership Agreement on Indigenous Early Childhood Development—with joint funding of $564 million over six years to June 2014, to address the needs of Indigenous children in their early years.

The National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes—with funding of $1.6 billion over four years to June 2013, centred on five priority areas:

• tackling  smoking
• providing a healthy transition to adulthood
• making Indigenous health everyone’s business
• delivering effective primary health care services
• better coordinating the patient journey through the health system.

Addressing issues in peri and neonatal health and early childhood have demonstrated long term health outcomes. The investment in primary health care has been shown to be a major contributor to improving these health outcomes.

The benefits of improvements in children today will only be noticeable in future generation’s reduced burden of chronic diseases such as diabetes .

 NACCHO and culturally appropriate diabetes prevention and management strategies 

The ACCHS model of care has a long history and a proven track record. It has achieved clinical outcomes beyond those of conventional health services through the use of a range of care approaches including proactive[approaches to diabetes and other chronic diseases care, incorporation of health promotion and prevention into primary health care; support of an Aboriginal workforce, multi-disciplinary teams, family involvement and holistic care.

Evidence supporting ACCHS as the best avenue for delivery of Aboriginal and Torres Strait Islander Health can be demonstrated by:

• The Assessing Cost-Effectiveness in Prevention (ACE-Prevention) Project suggests that up to 50% more health gain or benefit can be achieved if health programs are delivered to the Aboriginal population via ACCHSs, compared to if the same programs are delivered via mainstream primary care services.
• Aboriginal people prefer health care provided by Aboriginal community health services. A recent survey health in South Australia, conducted by the University of Adelaide for the South Australia Department of Health, found that 52.1% of Aboriginal respondents preferred an Aboriginal specific health service, while only 9.6% preferred a non-specific service.
• ACCHS are better at treating Aboriginal health problems than mainstream general practices according to the 2003 Bettering the Evaluation and Care of Health (BEACH) report which concluded that 1.4 per cent of consultations in mainstream general practice involved Aboriginal and Torres Strait Islander people. This number is significantly less than the proportion of Aboriginal and Torres Strait Islander people within the Australian community (2.2 per cent).
• Greater equity, leading to better health outcomes, in relationships between doctor and patient. When Aboriginal people attempt to access mainstream biomedical health care, power imbalances between the doctor and patient may result in the needs of patients being unmet.
• A recent review in the Medical Journal of Australia which found that the Aboriginal community-controlled sector is in the vanguard of clinical governance in Australia and that input from the sector should be sought from others in Australia to inform the implementation of clinical governance across all primary health care.”
• A recent BMC paper looked at the differences between ACCHS and private practice and noted the extra “care” taken on by the ACCHS services and their health professionals in moderating access and nurturing patients rather than just a simple service delivery model based on a business model.8

NACCHO key recommendation the Government should take to address the diabetes epidemic.

How is this best achieved?

We need to nurture our children from conception through their early lives. Addressing nutrition, social and emotional well being of the entire family and education to ensure they are afforded every opportunity to make healthy and informed choices.

The government must recognise that Medicare Locals and all other service providers including the tertiary hospital health care team will only be able to deliver on care to the sector if they work in partnership with Community controlled health services.

This is the best system to address the complex issues that cause diabetes and other chronic diseases. It is also the best way to co-ordinate care across the continuum.

We need funding and support for a strong Aboriginal health professional workforce. More doctors, nurses, health workers and allied health and pharmacy services provided in a culturally appropriate manner to Aboriginal people by Aboriginal people.

Provision and support for preventative health programs that address the underlying issues contributing to diabetes such as lifestyle and health literacy.

We need a streamlined uniform medication system for the sector that delivers across the tertiary to primary care environments and does not rely on who writes or where your prescription is written.

At the local community level our community controlled health services need to lead action to address these social determinants.

At the state and territory level our Affiliates need to lead action to address these determinants.

At the national level; this plan commits NACCHO to providing stronger leadership than even before – we must move forward more quickly and not accept the very slow pace of change. Australia can do better than this.

Finally, at the level of each and every Aboriginal person there is also a responsibility to join the struggle.

Together we can make a difference.