Introduction – The need for NACCHO
In mid 2006, the Indigenous population of Australia reached 500,000 , the number often quoted as the population prior to colonisation. The 500,000 milestone is both a symbolic and real victory for Aboriginal & Torres Strait Islander survival.
Australia now experiences an extraordinary paradox- while Aboriginal & Torres Strait Islander peoples make up more than 2.4% of the population and are a vibrant, integral part of Australian culture, there is compelling evidence of massive social and economic disadvantage experienced by Indigenous people. This disadvantage makes the excess morbidity and mortality of Aboriginal & Torres Strait Islander peoples utterly predictable. What Aboriginal & Torres Strait Islander people have always known – that racism and health are inexorably linked – is now supported by a number of research findings on the social determinants of health.
This has provided a significant body of evidence about how health is moulded by neighbourhoods, family and social connections, social marginalisation, and actual or perceived control over one’s life and workplace.
The unequal distribution of negative health-related behaviours adversely affects the already disadvantaged. Racially and ethnically biased clinical decision making has also been shown to contribute to poorer health care and outcomes.
Australia is alone among comparable developed nations in its failure to make significant inroads into the health status of its Indigenous population over the past 30 years. In particular, the massive excess of mortality among Aboriginal people in middle age is without comparison.
The evidence from North America and New Zealand is that a great deal can be achieved over relatively short periods of time. The fact that Aboriginal & Torres Strait Islander peoples comprise only 2.4 % of the population means that the necessary measures are eminently affordable.
Aboriginal community controlled health services and self determination
The first Aboriginal Medical Service (AMS) established at Redfern in 1971, following hot on the heels of the local service, was in part a reflection of the aspirations of Aboriginal people for self-determination in the intense, melting-pot environment of Redfern intellectual life.
Predating, Medibank, it was also a response to the urgent need to provide decent, accessible health services for the swelling and largely medically uninsured Aboriginal population of Redfern.
Aboriginal medical services (now known as Aboriginal Community Controlled Health Services’s to distinguish them from state government controlled services) are controlled by the local Aboriginal community via elected boards of management.
The primary health care approach adopted by Redfern and other early ACCHS’s was innovative. It mirrored international aspirations at the time for accessible, effective and appropriate needs-based health care with a focus on prevention and social justice (foreshadowing the 1978 WHO Alma-Ata Declaration on Primary Health Care).
The impact of ACCHS’s in the Aboriginal community came to be more than just an effective health service provision; through employment, education of staff, engagement, empowerment and social action, ACCHS’s became key strategic sites for Aboriginal community development.
The following goes some way to explaining their significance:
“Thing is that we own the bloody thing and it is something that we can’t, I can’t explain – about the ownership and the pride that it actually brings… we used to be blamed for being the same as the mainstream, well , I can tell you, the ACCHS service activity reporting has reflected that we’re nowhere near the same as mainstream. Mainstream would love to do some of this stuff, but they can’t. I don’t know why, but that’s why we’re here…”
The AMS Redfern funded NAIHO’s first national meeting. It was established to promote the principle of Aboriginal community control in Aboriginal people’s health and its holistic approach, and to lobby for the establishment of new services. The NAIHO was advocacy focused and many of its leaders were politically active in the broader sweep of Aboriginal issues. This was fully consistent with the interdependency between health and all determination of Aboriginal wellbeing.
New ACCH’s were being established in various parts of Australia through the 1970’s and by 1978 there were about 12. However, the minimal financial support offered by the government was to set a pattern for at least the next 15 years.
Most ACCHS’s initially had little or no specific funding, and began as fledgling services with donations and loans of staff from other AMS’s, notably those in Redfern, Melbourne and Alice Springs. Some were helped by international aid agencies (such as the West German organisation Brot Fur die Welt, which donated to the Broome AMS) and a few had Medibank income.
AMS Redfern received $20,000 as its first Commonwealth grant in 1973, around the same time that newly established mainstream community health services received Commonwealth funds under the Whitlam Government’s community health program.
However, it was not until the early 1980’s that significant Commonwealth funding was available to ACCH’s on a national scale.
In 1984, under a Federal Labour government, responsibility for all Commonwealth Aboriginal health programs (including the Health Department’s role in funding some ACCHS’s ) was consolidated within the Department of Aboriginal Affairs (DAA). It was thought that in line with primary health care approaches, there would be positive benefits in having all Aboriginal-related programs together in one portfolio.
The plan was that the DAA would directly fund Aboriginal primary health care programs via ACCHS’s and that the Aboriginal Development Commission would fund development issues.
This direct funding to ACCHS’s was not originally intended to be the sum total of Commonwealth Aboriginal Health investment – it was meant to help fill the gap and add value to what Aboriginal Australians obtained from mainstream health programs.
Overtime, however, the separation of Aboriginal health from the Commonwealth Health Department led to the reduction of the responsibility of mainstream health programs for Aboriginal health.
In the mid 1980’s, the Commonwealth increased its commitment to ACCH’s and made funding available to them using a range of strategies, which included diverting funding from state programs and finding some new funds. This had the effect of increasing the population covered by ACCHS’s. It also broadened the expertise and power of these services and gave Aboriginal people a much greater window into the government policy process.
Despite these positive developments, what ACCHS ‘s saw over the coming decade was Aboriginal people’s health being side-lined, with Aboriginal peoples in effect being excluded from programs initiated to meet the health needs of all other Australians – a pattern persisting to this day.
Political frustration increased, as it became increasingly clear that there would be no 10 year fix for Aboriginal health. Not only were the resources manifestly inadequate, but the health of Aboriginal communities was undergoing an alarming rise in chronic diseases, cancer and social pathologies.
Another landmark around this period was the Royal Commission into Aboriginal Death in Custody, initiated in 1988, with the final report published in 1991. The report comprehensively reviewed Aboriginal people’s health needs, government strategies and efficacy of existing programs. Its recommendations explicitly supported the implementation of the NAHS.
In 1990, the Federal Labour Government established the Aboriginal and Torres Strait Islander Commission (ATSIC) replacing the DAA and the Aboriginal Development Commission.
ATSIC was established as a government department answerable to both the Federal Minister for Aboriginal Affairs and an Aboriginal Board of Commissioners, the latter elected by Aboriginal communities throughout Australia. ATSIC assumed national responsibility for Commonwealth Aboriginal and Torres Strait islander programs, including health and the implementation of the NAHS.
The ACCHS sector continued to expand and collaboration and joint advocacy within the sector increased during the 1990’s. NAIHO having established its own secretariat in 1985 with an office in Melbourne, accepted government funds for the first time, having previously relied entirely on donated monies.
This name change reflected the fact that Torres Strait Islanders had embarked on their own campaign for self determination and wished to establish their own representative organisations.
Each jurisdiction now has an ACCHS representative body (known as NACCHO Affiliates).
Australian Government Health Iniatives to the Present
Increased advocacy capacity through NACCHO enabled considerable improvements in a number of health policies, with a key example being through the Keys Young evaluation of 1997.
These arrangements which provide clients of these services with access to PBS medicines from a community pharmacy without the need for a formal prescription form, and without charge, have revolutionised Aboriginal people’s access to the PBS. There is now evidence of increased PBS claims from remote areas (by 35%), which is directly attributable to the S 100 scheme.
The sector now plays a considerable role in primary health care service delivery, with over 1.4 million episodes of care delivered by these services in 2003-4 to Aboriginal people and Torres Strait Islanders. However there are major gaps in coverage : many towns and communities with significant Aboriginal populations, and some quite large geographical areas such as the Cape York Peninsula, lack an ACCHS.
There is considerable diversity within the sector, with significant differences in the levels of infrastructure and staffing, and consequently in the range of services offered. Only 197 full-time equivalent doctors are employed by ACCHS’s (2003-04), distributed among approximately 50 services.
The common factor that distinguishes these services is that they are governed by boards of management elected from the local Aboriginal community, and they deliver culturally appropriate comprehensive primary health care.
The boards oversee the policy and operations of the service, and appoint management staff. Around 64% of staff in the ACCHS sector are either Aboriginal or Torres Strait Islander Australians, and AHW s form a core component of the staff group. In contrast, an independent survey in 1995 reported that 64% of state health services did not employ Aboriginal people.
As a nation, Australia has not galvanised efforts to address health determinants or their negative health consequences, both of which have moved little in 30 years. Aboriginal affairs in Australia is characterised by myth and misinformation, denial of history, perennial jockeying over state and federal government responsibilities and incremental program responses, and sometimes huge about-turns in policy.
Governments have come and gone, departmental responsibilities have been reshuffled and their names changed ; there have been centralisation-regionalisation oscillations, fads in health financing reforms, numerous reports commissioned, all-of-government commitments and international covenants signed – truly a paradox of innovation without change.
We now see the re-emergence of a new paternalism and with it a failure of institutional memory of previous government health policies.