NACCHO Aboriginal health news: Bureaucratic overhaul, meaningful partnership can fix the Aboriginal health gap

Ian Ring

A bureaucratic overhaul and a more meaningful partnership with  Aboriginal people are essential changes according to Ian Ring who is a professorial fellow at the Australian Health Services  Research Institute at the  University of Wollongong.

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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Building better systems of care for Aboriginal and Torres Strait Islander people:findings from the kanyini health systems assessment


“Consistent with our theoretical understandings of kanyini, staff frequently commented on the obligations they felt to reach people and act in their best interests.

This need to hold and nurture people was most profoundly felt by Aboriginal Health Workers (AHWs).”

You can download the full report here


Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment.


Two theories informed the study: (1) „candidacy‟, which explores “the ways in which people‟s eligibility for care is jointly negotiated between individuals and health services”; and (2) kanyini or holding‟, a Central Australian philosophy which describes the principle andobligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed.


Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, andcommitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld.

Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is„tractable‟ and „navigable‟ to its users. Staff also described entrenched patient discriminationin hospitals and the need to expend considerable effort to reinstate care.


Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs „hold‟ their users and enhance their candidacy to health care.

Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.

Theme 1: AMSs are different from private general practice

At all sites staff emphasised the unique aspects of AMS service delivery when compared with private general practice. In particular, engagement with local Aboriginal and Torres Strait Islander communities was repeatedly affirmed as the main difference. Staff viewed the typeof care they provided to be comprehensive, responsive to community expectations and patient rather than business oriented. By contrast, private general practice was viewed as focussing on maximising business revenue and providing reactive rather than preventive health care. It was also felt to inadequately acknowledge the particular needs of Aboriginal and Torres Strait Islander people.

I suppose, as an Indigenous doctor, you often get (patients saying) “I‟m happy to talk to you about this, but I wouldn‟t really want to talk to the GP down the road about it…..If it’s something to do with emotional, cultural, spiritual stuff, then that really does need to be addressed. But, you know, mainstream practices might not see it as „true‟ medicine. (GP1, regional AMS2)

Although community linkages are known to be an important component to chronic care, the depth of community connection in AMSs goes beyond this. Even for the only noncommunity governed health service, staff stressed the importance of ensuring community input and that this is usually not appreciated in mainstream services.

Even though we’re a mainstream health service we do work really strongly with the community. There‟s nothing more important than having local people (on staff)…that liaise between the community and us…We still have that strong contact, especially with the elders… Normally mainstream health services never venture out in Indigenous health to actually work with thecommunity and not many (patients) come to them. (Clinical director, urban AMS1)

Consistent with our theoretical understandings of kanyini, staff frequently commented on the obligations they felt to reach people and act in their best interests. This need to hold and nurture people was most profoundly felt by Aboriginal Health Workers (AHWs). One AHW stated that her work „doesn‟t just stop when we finish work‟. These obligations constitute a powerful mechanism for enhancing the candidacy of Aboriginal and Torres Strait Islander communities to health care. For AHWs there was an unconditional quality to the care provided, subtly blending the more demarcated work responsibilities with diffuse personal obligations in the community. Whilst these obligations may manifest quite differently for non-Indigenous staff a similar dedication beyond the ordinary was apparent. This duty to reach people also helps explain why health promotion constitutes a key part of service activity. Bridging clinical services with activities that develop community capacity wereviewed as central to health service function.

Daniel (pseudonym), an Aboriginal project officer, works on a shared responsibility agreement with the football club.…I think that is a really good example of delivering health in a very different way and engaging thecommunity‟s strengths. Rugby league is a huge factor for a man and it shows in figures that men attending the clinic are still under represented….So this work has seen an investment of infrastructure in the community sector as well as furthering this clinic. (AHW project officer 1, urban AMS1

In order for an AMS t o „hold‟ and nurture its community, this engagement is needed at all levels of the organisation, not just with the governing board. The employment of local Aboriginal and Torres Strait Islander staff across a variety of positions allows this holding to be adequately enacted. It affirms community linkages and the consequent legitimacy of the organisation.

Being a community controlled service you not only have it (community control) at the board level but it should be reflected in the organisational structure right through to even the groundsmen…it gives the staff themselves a sense of belonging and knowing that it is owned by the community. We all live in this community so we’re a part of the organisation and we‟re working for it, showing to the wider community that we are able to work at all these different levels..(AHW1, regional AMS3)

A key component to enhancing candidacy to health care is that services are easily navigated by their users. Staff from all professional backgrounds particularly commented on the availability of transport services as a key component to a navigable health service. Rather than merely an ancillary support, transport was viewed as an integral part of health care itself.

Staff commented that health care standards were heavily influenced by the availability of transport and that its absence „ defeats the purpose of us being here‟. For the two remote services, transport was critically important. One service provided daily visits to homelands and transport to the major referral centre for acute or specialist care. This consumedsubstantial monetary and human resources. For the other remote site airplane transportservices were especially dire with long wait times and patients having to travel alone toattend appointments. This left many fe eling vulnerable when „stuck‟ without family in the referral centre. For some people this impacted greatly on future decisions to seek specialistcare.

Thus transport is a key mechanism by which people are supported to navigate the system

Download full report here