Introduction by Croakey: As flagged at Croakey last week, the justifiable dismay at the failure of progress revealed in the recent Closing the Gap report, was tempered by cautious optimism that an agreement fostered between the Council of Australian Governments (COAG) and the Indigenous Coalition of Peaks might represent a turning point that will see health gaps start to close, if the partnership is “more than window dressing”.
In the post below, epidemiologist Dr Ian Ring, who has long experience working to improve health outcomes for Aboriginal and Torres Strait Islander people, provides further information on the enormity, yet the achievability, of the task ahead.
He writes that the rhetoric of gap closure has never really stood a chance in the face of poor target setting and planning, a lack of appropriate services, patchy workforce training, inadequate monitoring and management, and failure to learn the lessons of either failure or success.
But, writes Ring, we have the tools to change all this if only we will use them.
Meanwhile, it’s worth bookmarking and reading this article in the Medical Journal of Australia (MJA), from University of Queensland academics, Drs Chelsea Bond and David Singh.
The article was published on February 6 but you may have missed reading it, as access at the MJA’s Wiley site was subscriber only until MJA editorial staff intervened and convinced Wiley to honour the Journal’s longstanding policy of open access for all content pertaining to Indigenous health.
Bond and Singh write that the concept underpinning the Closing the Gap initiative is problematic partly because positing race as a risk factor along with modifiable risk factors for “lifestyle diseases” such as smoking and obesity has encouraged the idea that, “health inequalities are a product of Indigenous lack, morally and intellectually, rather than socially determined.”
They write that this position has led to health and social policy paternalism, and thus poorer outcomes for Indigenous Australians.
Write Bond and Singh,
We remain unconvinced that improvements in Indigenous health will come through refreshed numerical targets or greater financial investments in health research. What is required is a broadening of our intellectual investment in Indigenous health: one that invites social scientific perspectives about the social world that Indigenous people occupy and its role in the production of illness and inequalities. In this way, we would come to understand that race needs to be better conceptualised before we understand the ways it matters to health outcomes.”
Through this we might also come to realise the limitations of drawing too heavily upon a medical response to what is effectively a political problem, enabling us to extend our strategies beyond affordable prescriptions for remedying individual illnesses to include remedying the power imbalances that cause the health inequalities we are so intent on describing.”
This is something to keep in mind in all deliberations about “Closing the Gap,” including the excellent suggestions below.
Ian Ring writes:
That “Closing the Gap” was branded a failure after the release of the most recent report should not come as a surprise.
After all, it has been prosecuted in a magical world of self-achieving targets where no one asks what resources are required to achieve the targets, a National Aboriginal and Torres Strait Islander Health Implementation Plan which has no budget. and Commonwealth expenditure on Indigenous health which is approximately half the needs based requirements.
While recent initiatives for shared decision-making between governments and Aboriginal and Torres Strait Islander groups and building community-controlled services are welcome and long overdue, believing that local community success can offset national failure is simply illusory.
And a new set of targets won’t fare any better than the last set unless there is a fundamental shift in approach.
The good news however is that the gaps can be closed, but this requires capitalising on the opportunities presented by the COAG partnership with Aboriginal and Torres Strait Islander representatives, and a real world approach rather than one based on words and diagrams, unfunded policy and blind faith in amateurism.
Target setting – link with services and resourcing
Firstly, target setting is not simply a process of setting out what results would be desirable, but needs to take into account what actual services and resources would be required to achieve the targets, what services are available and what services are missing, and the investment required to fill the service gaps.
Targeting and budgeting must go hand in hand. Targeting without budgeting is simply a recipe for failure and disappointment.
Needs Based Funding
It is a cardinal principle behind government social policy that service provision should be related to need. For example, no one questions the fact that far more is spent on health care for the elderly than on the young who enjoy much better health.
In broad terms, the level of need for health care in Aboriginal and Torres Strait Islander people, based on the Burden of Disease studies, is approximately 2.3 times higher per person than for the rest of the population.
However, while the jurisdictions spend $2 approximately per capita on health for every $1 spent on the rest of the population, the Commonwealth only spends $1.21 per capita on Aboriginal and Torres Strait Islander people for every $1 spent on the rest of the population (barely half of the needs based requirements).
This is particularly important as the Commonwealth is largely responsible for the out-of-hospital services required to bring down preventable admissions and deaths. It is utopian and unrealistic to believe that gaps can be closed by spending relatively less on people with worse health.
This is not a plea for a special deal for First Peoples but rather for a level of expenditure that anyone else of the population with equivalent need would receive.
Focus on Services – Capacity Building Plan
Having identified the service gaps, the next step is to develop a capacity building plan for Aboriginal and Community Controlled services to fill these gaps, as the available evidence is that services run by and for Aboriginal and Torres Strait Island people outperform mainstream services in both access and outcomes.
National Training Plan
There is clear evidence that significant progress is possible using methods that are tried and tested, but Aboriginal health and related issues are not so simple that just anyone can tackle them effectively.
They are complex and require considerable skills and service delivery experience for effectiveness.
Health Planning, for example, is not static. It involves planning, developing and implementing the services required to achieve the agreed goals (including resourcing, workforce etc) and monitoring and improving outcomes via a continuous process.
It is a defined skill that requires specific training. Currently a manifest lack of planning skills lies at the heart of suboptimal Aboriginal and Torres Strait Islander service delivery.
Throwing clinical and other staff in at the deep end is inefficient, and not fair either to the staff or to Indigenous people.
A National Training Plan is required to ensure all involved – clinicians, administrators and public servants – are trained in the clinical and cultural issues specific to Indigenous people, and adequately equipped for their individual roles.
Similarly, board members for Aboriginal Controlled Community Health Services and those involved in Primary Health Networks would benefit from training in the administrative, legal, management, planning and other skills relevant for their roles.
It will not be possible to adequately realise on the investments involved in Indigenous service provision without appropriate workforce training.
Structured management
For many, the concept of management has been little better than sitting around and hoping that somehow, miraculously, next year’s results will be better. That is not how Gaps are Closed.
A formal, integrated, multilayered management system is required – supported by appropriate information and evaluation systems with formal review processes, at least mid-year and annually, to consider both process and outcome measures in relation to the specified targets – with a timeframe that is based on trajectories which set out what results can and should be expected at different points of time.
Continuous Quality Improvement
There is incontrovertible evidence that sizeable and rapid health gains are possible. But those gains require high quality services and are not achieved without proper systems for measuring, monitoring and improving the quality of services – systems which are standard throughout industry.
Learning from and building on success
There are many fine examples of Indigenous Health service delivery – and some of the best health services in the country are provided by the Aboriginal Community Controlled Health Services such as the Institute of Urban Indigenous Health in South-East Queensland.
There are similar examples of services for mothers and babies which reduce low birth weight rates and lower perinatal mortality. In the important field of chronic disease, it has been demonstrated that systematic application of current knowledge can achieve dramatic reductions in mortality in short time periods.
We know what to do, and have shown that impressive results can be achieved but, nationally, progress in both child health and chronic disease falls a long way short of what is required.
Similarly, successful programs like Housing for Health, have improved housing and consequently health, and doing so by training and employing local Aboriginal people. It beggars belief that programs of such obvious worth are not universally delivered across Australia, and that needs to be rectified as a matter of urgency.
In other fields, child development and justice reinvestment programs have been shown to be effective and cost effective, both in Australia and overseas, but are implemented on a piecemeal and patchy basis in Australia. That cannot continue.
Turning stalled progress around
None of the measures above are radical or untested or impossible to implement. Indeed, they are standard throughout much of the world. Not implementing them nationally in Australia has proved costly in terms of poor results and suboptimal returns on investment.
The time for amateurism is over and Australia needs to lift its game.
These measures, under First Peoples’ leadership, and in the context of the COAG partnership, can make a significant contribution to the achievement of Australia’s national Goals to Close the Gap.
The Gaps can and should be closed – but not with fine words and good intentions.
*Dr Ian Ring AO Hon DSc was previously head of the School of Public Health and Tropical Medicine at James Cook University. He was Foundation Director of the Australian Primary Health Care Research Institute at Australian National University and Principle Medical Epidemiologist Queensland Health.
