NACCHO Aboriginal health news: Closing the Gap in NT Aboriginal health outcomes

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“An Aboriginal community controlled comprehensive primary health care service?

A bloody mouthful of a description, but nonetheless a symbol and practical evidence of what Aboriginal people and their supporters have achieved—and continue to achieve.”

Chips Mackinolty NT Aboriginal health legend (Ex AMSANT)

Photograph by Therese Ritchie

This is a guest post by Chips Mackinolty that was first published, in edited form, in the NT News on 7 September 2013

NACCHO would also like to acknowledge a pay tribute to the support Chips has given NACCHO over the years

Intro Bob Gosford Crickey

After more than 30 years in the Territory, Chips Mackinolty is taking a year off: for “a pre-pension gap year” as he describes it. After all, he says, “gap years are wasted on the young”.

Across most of that time he has worked for organisations which haven’t allowed him to have a public personal opinion. This has included working for Aboriginal organisations, writing as an interstate journalist for both Fairfax and Murdoch, designing for private enterprise clients, and even a stint as a Labor Party ministerial appointee. For the last four years he has worked for the Aboriginal Medical Services Alliance Northern Territory [AMSANT].

Apart from an irreverent political approach in his artwork, which has occasionally been touted by the NT News, Mackinolty has pretty much stayed out of the world of public opinion.

A day after quitting AMSANT, he writes an opinion piece for the NT News on an ongoing commitment: Aboriginal health. It is published on the day of the Federal election, but with no intent to influence votes. In his words, “that’s deliberate: whoever wins the election today must commit to the most successful bipartisan strategy in recent Territory history, closing the gap in Aboriginal health outcomes”. He tells a story that suggests that the Territory is hitting well above its weight.

But it’s not as simple as that, as he tells us.

Four or five years ago I made the decision to pretty much stop going to funerals. Of course since then I have been to many—too many. There came a time when it had got too much, with the vast majority of funerals for Aboriginal people. And the people were dying younger.

It was a difficult decision, for many were from the Katherine region. It might sound peculiar to readers, but Katherine was where I “grew up”. I got there in the early ’80s in my late 20s. An evening of fireworks for the third celebration of Self Government in Darwin then, bizarrely a day or so later for the final shoot in Mataranka of We of the never never with Aboriginal artists I then spent the next four years with.

But nevertheless it was a town, at that age, in which I “grew up”. Whatever I thought I had learnt on the streets of inner city Sydney were, frankly, SFA when it came to the Territory.

Most of that learning was with Aboriginal people across an area greater than Victoria: from Borroloola to Elliot; to Lajamanu and Kalkarindji and west to the Kimberley: Halls Creek, Kununurra and Wyndham. And then across via Timber Creek to Bulman, Numbulwar and Angurugu, south through Numbulwar to Ngukurr and back up through Jilkminggan, Barunga, Manyallaluk and Wugularr. It was an astonishing education in land, language and law. But it was a period I spent far too much time learning about death: the death of the artists I worked with, their families, and their children.

But I also learnt from whitefellas in Katherine: from the legendary Judy King and John Fletcher; from Francesca Merlan, Paul Josif, Mick Dodson and Toni Bauman, to Anne and John Shepherd and John O’Brien.

In different ways they, and many others, all taught me about living in the Territory.

In the late 1990s the CEO of the Jawoyn Association, the late Bangardi Lee, recruited me, Jawoyn woman Irene Fisher and Dr Ben Bartlett to put together a seemingly endless series of submissions that resulted—some years later—in the establishment of the Sunrise Health Service: an Aboriginal community controlled comprehensive primary health care service.

An Aboriginal community controlled comprehensive primary health care service? A bloody mouthful of a description, but nonetheless a symbol and practical evidence of what Aboriginal people and their supporters have achieved—and continue to achieve.

Across the NT, from remote clinics such as that run by the Pintupi Homelands Health Service to Danila Dilba in Darwin, the Aboriginal community controlled primary health sector serves roughly half our Aboriginal population, the rest through NT Government health services.

Over time, the process of privatising into the community controlled health sector will increase as services are devolved from government. It’s not been an easy process—and slower than many of us want. Nevertheless, it has had bipartisan support federally and locally for more than a decade. Famously, former CLP health minister Steve Dunham “rescued” the Sunrise Health Service in its early development stage when it met resistance from some health bureaucrats. His intervention saved what is now one of the NT’s great success stories.

The evidence, internationally, nationally and locally is that community controlled primary health care is more efficient and effective in delivering the goods.

According to recent data produced by COAG, the Northern Territory is the only jurisdiction in Australia on track to meet the closing the gap target of reducing the difference in life expectancy between Aboriginal and non-Aboriginal people. This is a good news story that has been barely reported in the NT outside the pages of this newspaper.

There are a number of reasons for this success. The last decade has seen a dramatic rise in hospital spending; more importantly greater resources have been distributed more equitably to the bush. The increased resources to primary health care through the Intervention, now known as Stronger Futures, has been a prime reason this has been possible.

But we are also doing it better—and in many instances better than anywhere else in the nation. For example, childhood immunisation rates in the community controlled sector is better than in many affluent suburbs down South.

And we are doing it smarter: led by the Aboriginal community controlled health sector, there has been an increased use of electronic data collection and analysis. Clinical Information Systems are used at the individual patient level to keep up-to-date, easily accessible health histories, as well as to alert clinicians to possible allergies, and efficiently prompt clinics to recall patients for regular checks as well as follow ups.

The data analysed can be tailored by individual health services, but all clinics in the NT now contribute the to Northern Territory Aboriginal Health Key Performance Indicators, which have a commonly shared set of clinical measures. Access to this data is strongly protected through privacy protocols.

The big picture of this is the capacity for these systems to allow for public health data to be analysed at a community and regional level, and for subsequent follow up. For example, a regular system of patient interaction through Child and Adult Health Checks has the capacity to identify “spikes” in particular conditions such as childhood and maternal anemia or otitis media in children.

This not only keeps an individual clinic alert to changes in local health, but also in ways to respond. This is achieved through a process called Continuous Quality Improvement [CQI], and is carried out by all clinicians at a service and the data collected is a key part of this process. For example, with otitis media it will guide individual treatment (are we always checking following the national guidelines? what evidence-based treatments are we giving? are we referring the patients to specialist diagnosis and care?), but also to the community as a whole (are we working with the council, school and families? what sort of other public health campaigns might we undertake?)

At regional level this data can be very powerful. As well as the regional Aboriginal Community Controlled Health Services we already have, such as Katherine West Health Board and the Sunrise Health Service, other regions are now working together through Clinical and Public Health Advisory Groups [CPHAGs]. The CPAHGS meet regularly and work cooperatively to share experiences and data, and ways to do things better. Some have identified particular regional health problems which would otherwise might be “lost” in large scale data bases.

The Northern Territory is the first jurisdiction in Australia in which all remote clinics now have electronic health records for their patients.

Further to this, our sector, along with government clinics, has pioneered the idea of a “shared electronic health record”. Over half the Aboriginal people in the NT have signed up to such a record, and we are in the process of readying the system so as to be part of a national network. This allows, with full permission from the patient or carer at every consultation to update their health record to a data base that can then be accessed by other clinics and hospitals. For example, a patient at Ngukurr may fall ill at another community, and get the appropriate treatment through their shared electronic health record. A hospitalisation will allow the clinicians to see someone’s record, know what medications they are on, and past conditions. After discharge from hospital, the health records are updated, and an electronic discharge summary is available to the home clinic.

These and many other innovations are behind the improved statistics—but there is a long way to go. It’s a welcome trend—but the good results will flatten out and perhaps reverse if we do not tackle the other social determinants of health. These include housing, education, early childhood development, substance abuse, food security, incarceration rates and social exclusion. It is reckoned that health services alone will only be able to deal with about 25 per cent of “the gap”: the rest is down to the other social determinants.

And that’s where governments of all stripes come in, and where the need for truly bipartisan approaches must prevail. Whatever the result of today’s election, Aboriginal health remains the Territory’s major challenge. Aboriginal children yet to be born will benefit if only our politicians are working, in the words of the AMSANT slogan, “together for our health”.

NACCHO health news:Healing the Fault Lines: uniting politicians, bureaucrats and NGOs for improved outcomes in Aboriginal Health.

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Prominent Aboriginal Territorian and the current CEO of Danila Dilba Health Service Olga Havnen argues that the “fault lines” between politicians, bureaucrats and NGOs and the Aboriginal Community Controlled Health sector must unite to make a real difference.

A little known positive aspect of the Northern Territory Intervention was a significant increase in resources to Aboriginal Comprehensive Primary Health Care.

This, along with parallel initiatives under Closing the Gap, gave some hope that the decades long demands from our sector for substantial extra resources in primary health care was at last being heard.

However, while we have been making some advances in the Northern Territory, we face the potential for a “race to the bottom” in Aboriginal health where the interests of politicians, bureaucrats and NGOs potentially outweigh the evidence of Aboriginal community control.

 Prominent Aboriginal Territorian and the current CEO of Danila Dilba Health Service Olga Havnen argues that the “fault lines” between these groups and the Aboriginal Community Controlled Health sector must unite to make a real difference.

Extract from the 16 pages speech which can now be download from NACCHO

I am currently the CEO of Danila Dilba Health Service in Darwin, which has not long ago celebrated its 20th anniversary. We are an Aboriginal Community Controlled Health Service—and part of a broader, national movement of community controlled comprehensive primary health care that has its origins in Redfern some 42 years ago.

At the core of what we have achieved over those many years has been an aggressive approach to basing our work on evidence. Our accumulated achievements have always been based on what works—in clinical as well as social practice.

At the heart of what we have strived to achieve is the development of a practice—both clinical and social—that displays our strong and central commitment to comprehensive primary health care.

This model was codified at an international level at Alma Ata in 1978, and subsequently endorsed by the World Health Organisation (WHO) and the United Nations:

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

Primary health care is socially and culturally appropriate, universally accessible, scientifically sound, first level care.

You can download  Olga Havnen full speech 16 pages here

PRESS Coverage below and picture from the Australian May 29

REMOTE indigenous communities are suffering from a government culture of “risk intolerance” which has diverted funding from community-led organisations, a leading Aboriginal figure has said.

Olga Havnen, the Northern Territory’s former co-ordinator general for remote services, last night attacked successive governments for choosing large non-government organisations for service delivery ahead of smaller indigenous-led organisations.

Ms Havnen said many community-led service delivery organisations had “disappeared” since the Northern Territory Emergency Response in 2007.

“Aboriginal control of service delivery in many areas has withered on the vine,” she said in the Lowitja O’Donoghue Oration at the University of Adelaide.

“Despite jurisdictional, national and international evidence that community control over service delivery achieves better results, with control being a key element in the social determinants of health, for example, we have gone backwards.”

 Ms Havnen, whose position in the Territory was abolished by the new Country Liberal Party government in October, said there had been a “massive expansion” of NGO involvement in service delivery with “many millions of dollars” flowing to non-indigenous NGOs and multinational NGOs, regardless of their effectiveness.

She said in the past decade, only one new community controlled health service had been established in the Territory and only two remote health clinics handed across to community control.

“It is a process which has allowed government agencies to quarantine themselves from what they too often ascribe as risk in funding Aboriginal organisations,” she said.

“By this I mean that nothing is done, or can be done, that might in any way shape or form come back to haunt politicians or bureaucrats at a Senate estimates hearing or their state and territory equivalents.”

Ms Havnen, who is now chief executive of the Danila Dilba Health Service in Darwin, an Aboriginal community controlled health service, said that there needed to be a fundamental change in the relationship between Aboriginal service delivery in the Territory and elsewhere, and politicians, bureaucrats and NGOs who were involved in the process.

“The politicians and public servants can be agents of innovation and change if they abandon risk intolerance,” she said.

“Similarly, the response of NGOs to the last decade or so of reaping the benefits of government funding into Aboriginal service delivery must also change.

“Risk intolerance cannot be part of Closing the Gap.”

Ms Havnen said she remained concerned about many elements of the 2007 intervention into Northern Territory communities, which would continue to have a psychological impact “for many years”.

What are the priorities of Aboriginal people and communities in alcohol control? A report from the NT summit

APO

Sarah Barr and Chips Mackinolty write:

Grog has long been a part of life in the Northern Territory—with the NT having a per capita consumption twice the rate of the rest of the nation.

For a summary of key messages and resolutions

The “rivers of grog” described by Pat Anderson, co-author of the Little Children are Sacred (PDF alert) report into child abuse, has barely abated since the release of that report in 2007. Grog, and its impact on Aboriginal communities—particularly women and children—led in turn to the Northern Territory Emergency Response in the same year.

The election of a new government in the Northern Territory, with a mandate to wind back on alcohol controls, and supportive of opening alcohol outlets in remote communities, sent a sharp message to the bush electorates that voted in the new government: unless they spoke out, their views on alcohol on communities might be wiped out.

In announcing the Grog Summit, North Australian Aboriginal Justice Agency CEO Priscilla Collins summed up the widespread fears about the devastating effects of alcohol on Aboriginal communities in the NT.

“The effects of grog on our people here in the Territory cannot be denied. It is reflected in the health of our people, in the levels of alcohol-related family and communal violence, and our encounters with the justice and jail systems,” she said.

“Yes, the so-called right to drink alcohol can be—and is—touted still as a civil rights issue. Our people still get refused service in pubs and clubs because of the colour of their skin.

“But missing from the debate is our peoples’ right, collectively and individually, to choose not to suffer the ill effects of grog.

“We believe that if we were to balance the scales of so-called drinking rights with the damage caused by ‘the rivers of grog’, we come out on the side of the women and kids.”

The Grog Summit is one of a series of forums being organised by APO NT, but one that was rushed ahead of schedule to get Aboriginal views in front of the public before key sittings of the new parliament.

APO NT holds the position that alcohol disproportionately affects Aboriginal families and communities. Those sittings involved the abolition of the previous Labor government’s Banned Drinkers Register, and laying the groundwork for the CLP’s proposals to establish mandatory rehabilitation “farms” to get drunks off the suburban streets of Territory towns.

June Oscar and Emily Carter of the Marninwarntikura Womens Resource Centre and Patrick Davies from the Fitzroy Crossing Men’s Shed travelled from Fitzroy Crossing in Western Australia to share their story. The group opened up about the appalling alcohol-related harm in their community. “There was a cloud of alcohol which prevented our community moving forward,” said Ms Oscar.

“Aboriginal families are most affected by the destructive impacts of alcohol. This includes domestic violence, suicide, and removal of children from their families in high levels.”

The Fitzroy mob described the positive impacts which alcohol restrictions had on their small community. They were, however, careful to point out that restrictions were just the start of their journey.

“The restrictions are just to start the healing, and act as a ‘circuit breaker’ to start conversations about alcohol,” said Ms Oscar.

“Restrictions are only one part of the approach in Fitzroy Crossing. But you also need programs to assist the community in recovery, healing and to get back in touch with culture.”

Fitzroy Crossing now has programs for men and boys, such as the run by Patrick Davies. The community also have improved relationships with police. The Police in Fitzroy Crossing have expanded their role to community policing, not just law enforcement.

June Oscar noted that: “There was a chronic over-supply of alcohol, and their community felt different after restrictions. The restrictions allowed for a bit of respite and grieving time to consider how they move forward.”

The theme of breaking the cycle—and not giving in to pressures to bring grog into Aboriginal communities—was strong through the Summit.

The problem of drinkers dominating discussions on alcohol was a recurring refrain. “Drinkers always out vote the non-drinkers,” said Samuel Bush-Blanasi from Wugularr, and a member of the Northern Land Council Executive. “Drinkers always win – and the kids and the non-drinkers are the ones being hurt. The kids don’t get to vote.”

A key resolution from the Summit was to ensure that community consultation processes are not dominated by drinkers but give voice to women, non-drinkers, elders and particularly children—and a push towards community control over the process.

Marius Puruntatameri from the Tiwi Islands spoke passionately about the need for Aboriginal community control.

“We need to empower our people to solve our own problems,” said Mr Puruntatameri.

“We need to include Aboriginal people – be genuine and engage Aboriginal peoples in these processes.”

“Aboriginal people know their communities and we need to resolve problems in our own way”.

This sentiment was echoed by Peter d’Abbs from the Menzies School of Health. Professor d’Abb has extensive experience of the alcohol problems in the NT. He conducted evaluations of alcohol management plans and other initiatives to reduce alcohol problems in Tennant Creek, Katherine, Groote Eylandt and Gove Peninsula.

He said: “Whatever Government does around alcohol must be done with Aboriginal people, not for them, for it to be effective.”

A strong theme running through the meeting was the need to consider children and future generations. As Helen Fejo-Frith from Bagot Community pointed out, “We need to think about our kids and the next generation.”

Dr John Boffa, Public Health Medical Officer at Central Australian Aboriginal Congress spoke about the importance of early intervention. “The scientific rationale for early intervention is overwhelming,” he said.

“Adults who had adverse childhoods showed higher levels of violence and antisocial behaviour, adult mental health problems, school underperformance and lower IQs, economic underperformance and poor physical health,” said Dr Boffa.

Dr Boffa described the Nurse Family Partnerships program operating at Congress. The program aims to improve pregnancy outcomes, child health and development and parent’s economic self-sufficiency. The program is already having positive results.

There are no easy solutions to the complex problem of alcohol in NT communities. What is clear is a new approach is needed. A key message from the Summit is that alcohol restrictions will break through the haze, but what happens next is vital. And whatever happens, Aboriginal people need to be in control.

The alternatives are unthinkable, according to Mildred Inkamala from Ntaria in Central Australia.

“Grog is killing our people,” she told the summit.

“It means people no longer show respect for each other and culture. Grog is affecting their brains, and connection to culture.”

A further Grog Summit will be held in Alice Springs in the new year.

alcohol, Indigenous health, rural and remote health                               , , , ,