” I believe that the development of collaborative, integrated service models can provide innovative and effective solutions for addressing not only the overrepresentation of Aboriginal and Torres Strait Islander peoples in the justice system, but also the indefensible health gaps between Aboriginal and non-Aboriginal Australians.
Justice health partnerships provide a model of integrated service delivery that goes to the heart of the social determinants of health, key causal factors contributing to Aboriginal and Torres Strait Islander peoples’ over-exposure to the justice and health systems. In this way we are also focussing on the rights of our people.
Address the legal issues, and you will have better health outcomes.
In the health and justice areas the message is simple. Community-control works, cultural safety works and collaborative partnerships work.
With Aboriginal community control at the front and centre of service design, we can deliver both preventive law and preventive health for Aboriginal and Torres Strait Islander peoples. ”
Donnella Mills, Acting Chair NACCHO
Speaking at the Australian Public Health Conference, Adelaide Panel Plenary session titled ‘Human Rights’
I would like to acknowledge that the land on which we are meeting today is the traditional land of the Kaurna Nation. I respect the continuing culture of the Kaurna people and the contribution they make to the life of this important city.
You may wish to say ‘hello, how are you’ in the Kaurna language. If so, say:
“I understand that the traditional greeting in the Kaurna language is ‘Ninna Marni’.”
I am the Acting Chair of NACCHO, which stands for the National Aboriginal Community Controlled Health Organisation. For those of you who don’t know me, I am a Torres Strait Islander woman with ancestral and family links to Masig and Nagir islands.
You may also want to add ‘welcome’ in Meriam Mir. If so, “In the language of Masig Island, ‘Maiem’.”
Thanks are due to the Public Health Association of Australia for welcoming me here to speak today. I am delighted to be able to share ideas with you on a topic that is close to my heart. I am also honoured to be part of a panel with such two inspiring colleagues: Barri Phatarfod (Founder, Doctors for Refugees) and Mohammad Al-Khafaji (CEO, FECCA).
In this presentation I will look at Aboriginal and Torres Strait Islander justice issues and the role of NACCHO’s member organisations: the 144 Aboriginal Community-controlled health organisations (our ‘ACCHOs’).
It is always tempting to focus on problems. I could talk about the fact that our life expectancy is at the level of a Third-World nation: about ten years lower than the non-Aboriginal population.
I could talk about the unconscionably high rates of incarceration for Aboriginal and Torres Strait Islander people and our over-representation in state and territory gaols and institutions across the country. I could ask why nothing has changed since the Royal Commission into Aboriginal Deaths in Custody was initiated in 1988. But most of you are already very familiar with these topics and frustrations.
What I will focus on instead is the ACCHO model of health care, how it started and how it has evolved. Why? Because I think that our model of community control is a way forward. It gives Aboriginal and Torres Strait Islander people control. It gives our people the framework in which we can deliver our own health outcomes and develop our own solutions and are able to form genuine partnerships.
So, before we look forward, let’s look backwards for a moment, so that we can appreciate the context in which this model was forged.
NACCHO and the model of Aboriginal community control
The Public Health Association is celebrating 50 years since its foundation in 1969. Two years after that, in 1971, the first Aboriginal medical service was established at Redfern. It was a response to the urgent need to provide decent, accessible health services for the largely medically uninsured Aboriginal population of Redfern.
The mainstream was not working. So it was, that forty-eight years ago, Aboriginal people took control and designed and delivered our own model of health care.
Similar Aboriginal medical services quickly sprung up around the country. In 1974, a national peak organisation was formed to represent them at the national level. All this predated the huge Medibank reforms of 1975.
The ACCHO sector has been growing bigger and stronger every year since 1971. NACCHO – the national peak – now represents 144 ACCHOs across the country. Our members provide about three million episodes of care per year for about 350,000 people – that’s over half the Aboriginal and Torres Strait Islander population.
Collectively, we employ about 6,000 staff (the majority of whom are Aboriginal or Torres Strait Islander people), which makes us the single largest employer of Aboriginal or Torres Strait Islander people in the country.
It also shows the flow on effect of what we have been doing. In this case, that our health organisations are doing more to Close the Gap in Aboriginal employment than any government program or scheme.
There is a dangerous myth that Aboriginal and Torres Strait people receive ample funding. The Government’s own numbers show that, in real terms, health expenditure (excluding hospital expenditure) for Aboriginal people fell 2% from $3,840 per person in 2008 to $3,780 per person in 2016.
Over the same period, expenditure on non-Aboriginal people rose by 10%. How can Governments seriously expect to Close the Gap in health if funding is decreasing? The burden of disease for the Aboriginal and Torres Strait Island population is 2.3 times higher than for the rest of the population. The burden of disease can be six-times higher in remote areas.
Despite the funding shortfall, our ACCHOs continue to deliver excellent results.
The primary health care approach developed by Redfern and other early ACCHOs was innovative. It mirrored international aspirations at the time for accessible, effective and comprehensive health care with a focus on prevention and social justice. It even foreshadowed the WHO Alma Ata Declaration on Primary Health Care in 1978.
Just like we did in the 1970s, NACCHO has continued to play a leadership role. Some of you may be aware that, recently, NACCHO and almost 40 other peak Aboriginal and Torres Strait Islander bodies forced the nine Australian governments to get the Closing the Gap process back on track.
This is community control at the national level. It is the first time that Aboriginal and Torres Strait Islander peaks have come together in this way, to work collectively and as full partners with the nine Australian governments.
We need this sort of radical shift to the way governments work with Aboriginal and Torres Strait Islander people at all levels of policy design and implementation. We need a seat at the table and responsibility for making decisions about what governments do in our communities.
Another priority reform area is placing Aboriginal community-controlled services in all sectors – not just health – at the heart of delivering programs and services to our people. When we are in control and lead the design and implementation of services in our communities the outcomes are so much better.
We have also had some staunch allies along the way. ACOSS and the AMA, for example, continue to be a key friends in our sector. For example, the 2018 AMA Report Card was launched in November of last year. It highlighted research showing that the mortality gaps between Aboriginal and Torres Strait Islander people and other Australians are widening. NACCHO called for the immediate adoption of its recommendations.
Closing the gap on justice outcomes
Now that I have referred back to the history of the community-controlled model and where it is today, let me now switch the focus onto human rights and justice outcomes.
The World Health Organisation (WHO) sees the “highest attainable standard of health as a fundamental human right”. I agree with this statement.
Most of you here today know the shocking statistics. I have already mentioned that Aboriginal and Torres Strait Islanders have ten-years less in life expectancy than other Australians.
We must take a rights-based approach in addressing health inequities, if we are ever going to close the gap. This means that we need to address the social determinants of health, such as: education, housing, and other social and economic factors. This, of course, is a huge topic, so let’s just focus on justice outcomes.
Earlier this year it was reported that Aboriginal and Torres Strait Islander men are imprisoned at a rate almost 15-times greater than non-Aboriginal men, and for women the rate is even higher, 21-times worse than non-Aboriginal women.
Our women represent the fastest growing population group in prisons; their imprisonment rate is up 148% since 1991. Locking up our women affects the whole community. Children may be removed and placed in out-of-home care. Research has found there are links between detainees’ children being placed into out-of-home care and their subsequent progression into youth detention centres and adult correctional facilities. Communities suffer, and the cycle of intergenerational trauma and disadvantage is perpetuated.
Figures on the incarceration of our children and young people in detention facilities also reveal alarmingly high trends of overrepresentation. Our young people aged 10–17 are 26-times as likely as non-Aboriginal young people to be in detention on any given night. How can this be justified?
Governments’ inertia and lack of commitment to genuinely addressing the issues have contributed to a worsening situation. The National Indigenous Law and Justice Framework 2009-2015 was never funded, attracted no buy in from state and territory governments, and the review findings of the Framework were never made public.
It is encouraging to note that in its 2016 report of the inquiry into Aboriginal and Torres Strait Islander experience of law enforcement and justice services, the Senate committee recommended that the Commonwealth Government support Aboriginal-led justice reinvestment projects. In December 2017, the Australian Law Reform Commission recommended that Commonwealth, state and territory governments should provide support for:
- the establishment of an independent justice reinvestment body; and
- justice reinvestment trials initiated in partnership with Aboriginal and Torres Strait Islander communities.
Emerging out of these inquiries is a growing understanding that an improvement in justice outcomes must begin with a commitment to self-determination, community control, and cultural safety. These are three of the most critical elements of the community-controlled model itself.
Appropriately resourced community controlled services are essential for addressing these barriers. Best-practice solutions to preventable problems of our peoples’ exposure to the justice system must begin with enabling their access to trusted services that are governed by these three principles.
But let’s see some traction on the ground with these statements. The intentions are there, but now is the time to act.
Case study – Law Yarn
As a lawyer myself and the ex-Chair of the Cairns-based Wuchopperen Health Service, I have become aware of the need to provide better legal supports for my community. In conversations with local Elders and LawRight, Wuchopperen entered into a justice health partnership in 2016.
LawRight is an independent, not-for-profit, community-based legal organisation which coordinates the provision of pro bono legal services for individuals and community groups. The aim of the partnership was to improve health outcomes by enhancing access to legal rights and early intervention. Initially, it was decided that, as community member and lawyer employed by LawRight, I would provide the free legal services at Wuchopperen’s premises.
One of the challenges of health justice partnerships is ongoing funding, and in 2017 we were forced to close our doors for several months. We knew the partnership was addressing a real need in our community, so we submitted a funding proposal to the Queensland Government, and received funding of $55,000 to trial ‘Law Yarn’.
Law Yarn is a unique resource that supports good health outcomes in Aboriginal and Torres Strait Islander communities. It helps health workers to yarn with members of remote, regional and urban communities about their legal problems and connect them to legal help.
Representatives from LawRight, Wuchopperen Health Service, Queensland Indigenous Family Violence Legal Service and the Aboriginal Torres Strait Islander Legal Services came together and created a range of culturally safe resources based on LawRight’s successful Legal Health Check resources. A handy how-to guide includes conversation prompts and advice on how to capture the person’s family, financial, tenancy or criminal law legal needs as well as discussing and recording their progress.
Legal and health services throughout Australia have expressed interest in this holistic approach to the health and wellbeing of Aboriginal and Torres Strait Islander peoples. And we are hopeful that the evaluation findings will support the rollout of our model to ACCHOs across Australia.
In conclusion, I believe that the development of collaborative, integrated service models can provide innovative and effective solutions for addressing not only the overrepresentation of Aboriginal and Torres Strait Islander peoples in the justice system, but also the indefensible health gaps between Aboriginal and non-Aboriginal Australians.
Justice health partnerships provide a model of integrated service delivery that goes to the heart of the social determinants of health, key causal factors contributing to Aboriginal and Torres Strait Islander peoples’ over-exposure to the justice and health systems. In this way we are also focussing on the rights of our people. Address the legal issues, and you will have better health outcomes.
If the Government really wants to help vulnerable populations, don’t punish them with cashless welfare cards, with robo-debts or by sending them off to meaningless Work for the Dole activities. Work with us, not against us.
In the health and justice areas the message is simple. Community-control works, cultural safety works and collaborative partnerships work.
With Aboriginal community control at the front and centre of service design, we can deliver both preventive law and preventive health for Aboriginal and Torres Strait Islander peoples.