Amongst other things, the Third National Aboriginal Health Summit in Darwin last week provided some examples of how the wider primary healthcare sector can learn so much from the Aboriginal community controlled health sector.
Presentations reviewing the history of the Central Australian Aboriginal Congress and the Aboriginal Medical Services Alliance Northern Territory (AMSANT) highlighted the diverse range of clinical, public health and political strategies that have been successfully employed to improve Aboriginal health in the NT.
Below are edited versions of speeches delivered by Donna Ah Chee, CEO of Congress, and Marion Scrymgour, chairperson of AMSANT, at the Summit, where the Federal and NT Governments and AMSANT signed a new five-year agreement.
Donna Ah Chee outlined the role of Congress, “one of the best examples in the world of a comprehensive primary health care service”, in contributing to significant gains in Aboriginal life expectancy in the NT, and in tackling gaps in early childhood development and services.
“We have largely got the health system right here in the NT but we must focus our efforts on early childhood development, pre-school and the early primary years if we want the gap to keep closing from here to 2031.”
Marion Scyrmgour told the Summit that the NT Aboriginal Health Forum, arising out of an agreement between AMSANT and the NT and Commonwealth governments in 1998, was enabling collaborative needs-based planning and crucial improvements to the health system throughout the NT.
With AMSANT the permanent chair of the Forum, she said: “For the first time, the Aboriginal community controlled health sector was at the table as an equal with government”.
She also warned that implementation of the new National Aboriginal and Torres Strait Islander Health Plan was at risk without a ten-year funding commitment and clear accountability mechanisms.
Take the time to read their speeches below: this is a recommended Croakey LongRead.
By Donna Ah Chee, CEO of Congress:
Aboriginal community controlled health services are key to Closing the Gap by 2031 and they are needed now, more than ever.
When we talk about community-control we are talking about more than 40 years of Aboriginal people working to set up, develop and maintain a dynamic and vibrant organisation.
The Aboriginal community set up Congress, it was not an act of government or any welfare agency. We controlled it from the beginning, and still do. In some ways, we had no choice our health status was very poor as can be seen from the infant mortality rate and Life Expectancy figures in 1973 when Congress started.
The mainstream health system had completely failed us – we had to do something new and different to get access to health care. We also had to take action on the broader social determinants of health, which the mainstream health system does not do.
Congress was the key organiser of the first Land Rights rally pictured here as the newly formed organisation was clear about the connections between health, control, land, culture, employment, shelter etc long before we started to use the language of Social Determinants of Health.
Born out of activism
In fact, the early years were a period of grass roots activism for health with many public rallies and street marches to fight for our rights in many different areas.
As things have improved, the need for this level of overt activism has declined as we now work in partnership with all levels of government and have been able to get a level of resources that is really making a difference to our health.
However, there is still much that needs to be done especially in the areas of early childhood development, education and employment and other social determinants of health beyond the health system.
With the growing level of inequality that is now occurring in Australia and the corresponding declining taxation revenue as a proportion of GDP, we may well be heading for a period where we need to return to grass roots community activism to achieve the changes that are needed for our people.
Congress was also instrumental in assisting many other Aboriginal communities to establish their own Aboriginal community controlled health services in Central Australia and beyond.
It is worth noting however that there has not been a new Aboriginal community controlled health service established in Central Australia for more than 25 years – we have got something wrong in recent times.
It seems the path that communities used to take has become too heavily regulated, bureaucratised and risk averse such that we have become somewhat crippled in the development of new Aboriginal health services. We need to get back to basics if we want to achieve more Aboriginal community controlled health services.
The Congress board has undergone some important changes to its constitution, which have created 3 specialist, non-member Director positions in primary health care, finance and governance and administration, and these positions are open to non-Aboriginal people. There are 6 positions that are Aboriginal identified and elected at the Annual General Meeting. This has greatly strengthened the governance of the organisation. At the same time there has been an independent review of the organisation’s management and administration structure and systems and this has led to a new Executive structure.
This is a breakdown of the core services and programs in our Services Division in Alice Springs.
It includes the main clinic which includes dental and our pharmacy, the Alukura women’s health service which includes the Olds Nurse Family Partnership program, Ingkintja our male health section, Child and Family Services – which includes an 8 week intensive Abecedarian program for children who are developmentally behind, and our Social and Emotional Well Being Section which treats people with mental illnesses including addictions of all types.
There are now well over 300 staff employed by Congress with many new services and program addressing the gap areas in the latest core services document.
Peak body matters
This growth in services and programs could not have occurred without the work that AMSANT has done in shaping the administrative arrangements for Aboriginal health. An effective peak body makes a difference to services on the ground.
Across all clinics in town and in the remote communities in which Congress provides services, there are very high levels of access each year for Aboriginal people. Given the relationship between access, quality care and the prevention of hospitalisations, this is a key mechanism through which the broad community acceptance of Aboriginal community controlled health services prevents more serious illness from developing.
The growth in the direct provision of pharmacy services is real testament to the success of the Section 100 initiative, which again was a policy solution to the lack of access to essential medicines for Aboriginal people advocated for by Congress and AMSANT and introduced in 1998.
Congress is accessing close to $3 million per year in PBS medicines and there can be no doubt that if medical care is to make a difference in peoples’ lives, then medicines must be accessed and taken. In 2014 our pharmacy provided 35 000 episodes of care which has continued the growth evident in this graph.
Next, I want to briefly highlight some of the important work that Congress has been able to do on key social determinants, including early childhood, alcohol and tobacco.
Focus on early childhood
The health transition that has occurred has meant that the challenge has moved from the high death rate of babies and children to the promotion of healthy development. Much of the trauma and harm caused by adverse social determinants are mediated to children through lack of responsive care and stimulation from parents in early childhood and this in turn leads to children who grow up more prone to both physical and mental health problems.
The Australian Early Development Index, now called Census, has revealed the extent of the disadvantage that Aboriginal children have in the language and cognitive domains as well as the emotional domain when they first enter school.
The next generation of young people who are likely to be impulsive, have unhealthy development leading to poor school performance, the development of alcohol and other drug addictions, violence, homelessness and incarceration are already there. We must do better at preventing this from occurring and early childhood is key.
Congress now offers some key social and preventive programs in the area of early childhood, which is arguably the most critical area that needs to be focused on to address intergenerational disadvantage. Children who are identified with developmental delays through routine health checks at age 3 are given an intensive 7-week program based on the Abecedarian program.
The data from 7 children who went through this program shows that they all improved their vocabulary by an average of 6 months based on Pea Body tests. This demonstrates that, even at this relatively late age for children who have been under stimulated, there is potential for rapid improvement prior to school.
Most importantly, children experience rapid improvement in development outcomes post enrolment in pre-school with age equivalent vocabulary, which is one of the most sensitive measures of cognitive development. At baseline, 52 children with an average age of about 48 months are well behind in their language development but they make very rapid progress once connected with pre-school.
As a result, these children will be much more school ready and able to understand what is being said to them in the classroom. This becomes a “bottom up” pathway to better school retention as these children are much more likely to want to be at school. Pre-school needs to be available for all 3 years olds as well. The Congress preschool program has seen enrolments and participation increase by about 70%.
Congress teamed up with Prof Collette Taylor, Prof Joseph Sparling and research fellow Isabel Brookes from Melbourne University to more robustly assess the impact that elements of the Abecedarian approach have on children’s development. This study was done with a sample of 12 Aboriginal children aged 22 – 35 months, ten in out of home care, all with language delay. All children attend Congress Child Care full time.
Children engaged in daily intervention sessions with trained educators for eight weeks. Intervention sessions ran for 15 minutes and include intentional, focused interactions to support children’s language development. Learning Games were used as provocations for interaction and Conversational Reading strategies were used during book reading. All sessions were video recorded for analysis purposes.
Assessments of language and joint attention were conducted at 3 time points – baseline, immediately following Intervention period 2, and three months after Intervention period 2. Mean dosage of the intervention was only approx. 7 hours per child over eight weeks of intervention.
Preliminary analysis of follow-up joint attention assessments show a 71% increase in children’s initiation of joint attention episodes, an important precursor to language development.
Preliminary analysis of follow-up language assessments suggest an average language development gain of 7 months in a 3.5 month period.
Early analysis suggests that the age related gap in comprehension and communication was closed significantly in only an 8-week period with a single daily intervention. Closing this gap is a key precursor to closing the Life Expectancy Gap.
We have largely got the health system right here in the NT but we must focus our efforts on early childhood development, pre-school and the early primary years if we want the gap to keep closing from here to 2031.
I want to briefly focus now on alcohol.
This slide shows the outcome of the advocacy that Congress has led through the Peoples Alcohol Action Coalition to increase the minimum price of alcohol.
In 2006 when the Alice Springs Liquor Supply Plan was introduced, shown on the top of the graph as LSP, the minimum price of alcohol doubled from 25 cents to 50 cents per standard drink shown by the sharp increase in the red line.
The effect was a nearly 20% decrease in per capita alcohol consumption shown by the black line in the graph.
The graph shows that there is a correlation between the decline in alcohol consumption, which came about with the introduction of the alcohol restrictions on October 1 2006 and hospital admission for Aboriginal women for assault.
The blue line is the projected rate if the trend prior to the introduction of the restrictions had of continued and the red line is what actually happened after the restrictions were introduced a very significant change.
This is a very objective indicator of a reduction of severe violence towards women as a result of the alcohol restrictions. Similar data is available for the impact of the former Banned Drinkers Register and for the current very effective Temporary Beat Locations strategy.
All of these strategies impact on reducing violence and promoting more healthy development for our children.
The need for a national minimum price on alcohol, photo licensing at the point of sale and a BDR as well as TBLs have been accepted by this report from the House of Representative Standing Committee on Indigenous Affairs. The report contains 23 recommendations and if these are fully implemented this will make a major difference in Aboriginal health towards 2031.
Congress has been part of advocacy for a whole range of measures to reduce smoking prevalence including increasing the price through taxation, banning smoking in restaurants and other public settings including in the Congress workplace, plain packaging, ensuring access to free Nicotine Replacement Therapy which has now been listed on Section 100 and implementing a social marketing and community based health promotion program employing local Aboriginal people as Healthy Lifestyle Workers.
All of this has seen smoking prevalence decrease from 58% to 48% over 4 years in Alice Springs. There is still a long way to go but improvement is finally occurring and we must aim to equalise smoking rates by 2031 as well.
Comprehensive primary health care is the amalgam of multidisciplinary primary clinical care with key social and preventative programs and public health action. The mechanisms and activities deliver outputs that then lead to medium and long-term outcomes. All this occurs in a social, political and economic context.
We draw your attention to the mechanism around promoting an economic paradigm consistent with public health because this was a key part of the original Alma Ata declaration on comprehensive primary health care.
A neoliberal economic paradigm with concepts such as deregulation, competitive tendering, user pays, privatisation, low taxes is often not consistent with promoting public health and there are many examples of Congress advocacy where were are working to promote regulation such as alcohol supply reduction, glucose taxes etc as well as needs based planning rather than competitive tendering. This is all part of primary health care along with the right mix of services and programs.
Congress is really one of the best examples in the world of a comprehensive primary health care service and we would not have been able to get to where we are today without the support and advocacy of AMSANT.
Life expectancy gains
Finally, I want to finish on the health gains that have been achieved. This graph from the COAG Indigenous Reform Council report shows clearly that the Aboriginal health gains in the NT are far greater that those occurring for Aboriginal people in other jurisdictions but starting from a much lower base.
Over this brief 3 year period the Life Expectancy gains for Aboriginal males have been 2.3 years and for women 2.1 years. This is one of the most rapid health transitions occurring anywhere in the world, although the latest report suggests that these gain have now plateaued.
While disappointing, this is not unexpected, as Congress and AMSANT have always argued that improving the health system alone will only address about a third of the gap and this is what has been achieved in the NT up to now.
If we are going to progress from here it will be primarily due to improved educational outcomes leading to secure, high income employment and greater control for our people and the key to this is early childhood.
Many more of our people are living into middle and older ages. This is good news indeed but we also want our people to be well and have good quality of life at the same time.
In a country as wealthy as Australia, this is not too much to hope for and if we are to achieve this we need comprehensive Aboriginal community controlled primary health care services – now more than ever!
By Marion Scrymgour, Chairperson, AMSANT
I would like to begin by acknowledging the traditional owners of the land on which we meet, the Larrakia people, and their elders past and present.
I would also like to acknowledge the Assistant Minister for Health, Senator the Hon Fiona Nash; Minister for Health, the Hon John Elferink; the Hon Jack Snelling; the Hon Helen Morton, and other distinguished attendees.
AMSANT is very pleased to co-host this summit with the Northern Territory Minister for Health, the Honourable John Elferink MLA.
It’s particularly significant for AMSANT, having last year marked 40 years of Aboriginal community controlled health services in the NT and 20 years since AMSANT was established.
This is an important opportunity for all of us working to improve the health and wellbeing of Aboriginal and Torres Strait Islander people, to share and collaborate on that journey for the important years ahead.
AMSANT’s Aboriginal community controlled member services provide high quality comprehensive primary health care to our communities across the Northern Territory. We are working with government to progressively transition further services to community control and to continue to build on our shared record of improved health outcomes.
We have achieved a steady and in many ways remarkable health improvement in the NT.
What I would like to do in my presentation is to briefly reflect the context and history of these health improvements that have laid strong foundations for the road ahead. And also some important lessons from what didn’t work.
An important precursor was the National Aboriginal Health Strategy, or the NAHS, developed in 1989. The NAHS outlined a way forward for Aboriginal health built on the foundation of Aboriginal community controlled comprehensive primary health care. Our sector took a leading role in its development.
It was a good plan with some significant outcomes, but ultimately let down in its implementation.
It resulted in the establishment of the Council for Aboriginal Health; State and Territory Tripartite Forums; a specialised health branch, the Office of Aboriginal Health; and a national Aboriginal community-controlled health organisation, which became NACCHO.
The Tripartite Forums proved to be an unwieldy and unsuccessful model for collaborative health planning, but other initiatives such as a specialised health branch and the establishment of NACCHO have been important developments.
Crucially, the NAHS was never properly funded. $232 million was allocated over five years: $171 million for housing and infrastructure, and $47 million nationally for Aboriginal health services. This was far less than the $3 billion estimated as necessary for full implementation of the NAHS, and states and territories failed to match the Commonwealth funding, resulting in a grossly under-funded health system.
At this time, in 1990, the Aboriginal and Torres Strait Islander Commission, or ATSIC, was established and assumed national responsibility for Indigenous health.
This proved to be a further mistake.
The resulting underfunding of Aboriginal health services meant Aboriginal health continued to languish.
In this era, our health services had to apply every year for their core funding from ATSIC. There were no three-year funding agreements and much uncertainty from year to year, making it very difficult to attract and retain staff. Very few new Aboriginal health services were set up as such services were not considered to be necessary to improve Aboriginal health.
The 1994 evaluation of the NAHS showed that, effectively, it was never implemented.
It was in this climate that AMSANT was formed in 1994 after a 3-day meeting of community controlled health services in Alice Springs. Its key objectives were: expanding community control; increasing resources; and improving training, salaries, and conditions for Aboriginal Health Workers.
AMSANT’s first major campaign, alongside other stakeholders, was to have administrative responsibility for Aboriginal primary health care transferred from ATSIC to the Commonwealth Health Department.
This was a very controversial move but was based on the carefully reasoned assessment that Aboriginal health funding would be forever constrained unless funds could be accessed from mainstream health funding, especially MBS and PBS.
There was also a need for a specialist department within the health department that understood and had special expertise in Aboriginal primary health care. The Office for Aboriginal and Torres Strait Islander Health Services, or OATSIH, was formed in 1995.
The impact of the transfer on access to increased funds has been very dramatic. In the year of the transfer, in 1995, there was only $70 million available to fund Aboriginal primary health care; however there has been a continuing increase in this funding since then to more than $1 billion per year for Aboriginal health.
Securing increased funding was complemented with a campaign to improve administrative arrangements for Aboriginal primary health care. Setting up a transparent and accountable planning structure was a key objective.
The signing of the Framework Agreement between AMSANT and the NT and Commonwealth governments in April 1998 saw the planning structure come into being—the Northern Territory Aboriginal Health Forum.
It is through the Forum that collaborative needs-based planning has occurred, enabling crucial improvements to the health system throughout the NT.
And for the first time the Aboriginal community controlled health sector was at the table as an equal with government. AMSANT is the permanent chair of the Forum.
However, inadequate and inequitable funding remained a key problem.
There was a need for a completely new funding model that combined pooled grant funding with access to Medicare and the PBS. AMSANT successfully campaigned for the Commonwealth Government to adopt a new Integrated Funding model as part of the new Primary Health Care Access Program or PHCAP. This required the pooling of all Commonwealth and Territory grant funds as well as access to MBS and PBS, and this mixed mode funding model remains the current way Aboriginal health services in the NT are funded.
AMSANT and Forum secured increased and more equitable program funding for Aboriginal primary health care through PHCAP, which divided the NT up into 21 health zones based on geographic, cultural and social affiliations.
Two successful regional health services were subsequently established through the Aboriginal Coordinated Care Trials: Katherine West Health Board in 1999 and the Sunrise Health Service in 2005. Due to the severe limitations of the Medicare “cash out” approach, these services transited to PHCAP funding agreements in order to help secure their sustainability.
These services demonstrated that regionalised community control can produce better services and improved health outcomes. Rolling out this model across the Territory remains a major objective of the joint planning process under Forum.
Effectively rolling out this agenda required a further critical development that needs mention. Because in order to allocate increased funds effectively and equitably there needed to be a clearer idea of what core services and programs should be funded in each health zone.
Forum set about developing the first version of the Core Functions of Primary Health Care in 2001, and this was used to direct the initial investment under the PHCAP. $30 million new investment over 5 years from 2001 to 2006 took the average investment from $600 per capita on average to about $1800. There was also a marked improvement in equity through the needs-based planning process of the Forum compared with the prior heavily politicised funding allocations.
An updated version in 2007 was used in negotiating new investment provided under the Expanded Health Services Delivery Initiative, or EHSDI, that accompanied the NT Emergency Response in July 2007. $50 million in new investment was provided in return for identified core services and corresponding core indicators. This took the system up to the current average of about $2500 per capita.
A third version, developed in 2011, is still to be implemented. In this version there are five domain areas of comprehensive primary health care under which there are more detailed descriptors of key services and programs.
The key gap areas that have been addressed in the third version are in early childhood, family support, alcohol, tobacco and other drugs, and aged and disability services. New funding coming into the NT in these areas is not currently being allocated under a core services approach or within the planning mechanism of the Forum.
The significance of having the NT Aboriginal Health Forum as an effective, high-level health planning body with the Aboriginal sector at the table cannot be understated.
It has delivered demonstrably better outcomes in the NT.
In 2009 an agreement was signed by the Forum partners, committing Government to transition all Aboriginal primary health care services in the NT to Aboriginal community control.
This was a landmark achievement.
And this year the Forum has established the Pathways to Community Control Working Group to progress the regionalisation process.
And in what is a kind of return to the future for AMSANT, we are revisiting one of our founding objectives in developing the Aboriginal Health Worker workforce, now, of course, referred to as Aboriginal Health Practitioners. However, this time it is in partnership with the NT Government through the Back on Track program and with the support of Forum.
AMSANT is greatly heartened by the continuing contributions and commitment of the NT and Commonwealth governments to Aboriginal primary health care and to the Forum.
And we are especially pleased by the launching of a new Framework Agreement for the NT that is coinciding with this Summit.
The national plan
The final message I want to leave you with concerns the new National Aboriginal and Torres Strait Islander Health Plan. It is a good plan, as was the National Aboriginal Health Strategy all those years ago.
History has shown that such plans fail at the implementation stage for three main reasons. Firstly, a lack of long-term commitment of funding. Secondly, a lack of commitment from states and territories to the concept of a national plan. And lastly, a lack of accountability.
We must learn from history and get this right. We need a ten-year funding commitment. We need the draft implementation plan to be endorsed by AHMAC. And we need key performance indicators that make everyone accountable. Annual reports on progress against these indicators should be tabled in Parliament as part of the Closing the Gap commitment.
Anything less would in our opinion be inviting failure.
And we simply can’t afford that.
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