Opinion article Canberra Times

A recent episode of Q&A echoed traces of the widespread view  that much money has been spent on Aboriginal health and other matters, with  relatively little to show for it – and that the money must have been eaten up by  a bloated bureaucracy, was misdirected, or corruptly or incompetently used.

All of these may be true but only to a very limited extent. The reality is  that, until recently, the federal government, through its own programs, was  spending less per capita on Aboriginal health than it was on the rest of the  population – despite Aboriginal people being at least twice as sick

That changed with the introduction of the National Partnership Agreements  (NPAs) involving the Commonwealth and all state and territory governments, which  injected $1.6 billion into Aboriginal health and $4.6 billion over four years to  2012-13 into health, education, housing, employment and remote services as part  of the Closing the Gap programs. Australia went from having a degree of  international opprobrium because of its  neglect of Aboriginal issues to  becoming internationally competitive in terms of indigenous policy and  funding.

But what results have we seen from this allocation of additional funds? In a  four-year program, the funds start out at low levels in the first year and build  up progressively over the next three. The funds then need to be used to employ  people, who need to be recruited and trained, and then it takes more time for  the programs in which they work to become fully effective.

Taking the  $100 million allocated to smoking, for example, the very earliest  we could hope to see any kind of significant change in smoking would be picked  up by the next smoking surveys, the results of which will be available next  year.

Given the lag between smoking reduction and improvements in smoking-related  diseases, the earliest we could  see measurable changes in heart and lung  mortality may not be until 2020.

The apparent lack of progress from data currently available tells us about  the lack of progress before the additional $1.6 billion hitting the ground and  is just what we would expect to see at this stage rather than indicating  waste  of funds or misallocation of resource.

But was the money optimally allocated? Almost certainly not and for reasons  that are crying out to be dealt with by the Mundine review. The programs funded  by the NPAs all made sense individually but, collectively, they missed the point  and in no sense approximated the comprehensive long-term action plan promised in  the statement of intent. The problem was not in the policy determined by  governments, or in the funding, but in the bureaucratic implementation of those  policies.

The programs were determined by officials in state and territory governments  with insufficient genuine consultation with   the people who run the Aboriginal  community controlled health services (ACCHS).

Nobody seemed to have asked if we want to halve the child mortality gap in 10  years and the life expectancy gap in a generation, what services do we need to  achieve those goals?

And nobody seems to have wondered how it was possible to have healthy mothers  and babies and to get on top of chronic diseases without adequate provision for  mental health services.

The limited evidence available clearly shows that ACCHS  run by and for  Aboriginal people eclipse mainstream general practice in the identification of  risk factors, performance of health checks, care planning and the management of  Aboriginal and Torres Strait Islander patients.

So instead of asking  what services would produce the best return on  investment, the decision seems to have been taken to allocate new funds to  perpetuate current patterns of use between mainstream (GP) and ACCHS.

Too many senior officials still cling to the notion that in Australia’s  cities and towns mainstream services are the answer – in the absence of   evidence that  this is so and in the face of evidence that it isn’t. There is a  real risk that mainstreaming will be seen as some kind of solution, when the  reality is that there needs to be sensible arrangements for mainstream and ACCHS  services to work together, as in the Urban Indigenous Health Institute.

While current levels of indigenous health funding go a long way to redressing  the previous shortfall in health expenditure, estimated by health economists at  about $500 million a year, inequities in  the share of mainstream program  funding received by Aboriginal people is still an issue.

So what does this mean for the Mundine review and the new  government? Three  issues stand out.

First, bureaucratic reform is  essential. That means substantially fewer  public servants but those that remain need to have the requisite skills and  experience. There is broad agreement that the main functions of Aboriginal  health should remain with the Department of Health,  preferably led by an  indigenous official, but a small, high-level group in the Department of the  Prime Minister and Cabinet, to ensure the new Prime Minister’s requirement to  deliver for Aboriginal people, is an essential component of the new  arrangements.

Second, the recently formulated National Aboriginal and Torres Strait  Islander Health Plan isn’t really a plan in any meaningful sense but could  become one if the implementation plan foreshadowed in it is developed in genuine  partnership with Aboriginal people and involves officials with the requisite  skills, experience and training. But that implementation plan needs to also  include mental health and,  this time, to wrestle successfully with  mainstreaming.

Third, and most important, there seems to be an increasing recognition that  non-Aboriginal people really can’t make indigenous people healthy.  It is time  for Aboriginal communities to play a more central role in the design and conduct  of their own services, bearing in mind that  some of the best health services in  Australia are run by the ACCHS sector.

If the Mundine review and the Abbott government can successfully address  these issues,  Australia, in the not too distant future,  could complete the  long transition from international opprobrium to leading the world in indigenous  health.

• Ian Ring is a professorial fellow at the Australian Health Services  Research Institute at the  University of Wollongong.

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