Close the Gap - Part 3 Looking to the Future

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Essentials for Social Justice: Close the Gap

A speech by Mr Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner, IQPC Collaborative Indigenous Policy

Conference, Brisbane, 11 June 2008

I begin by paying my respects to the Jagera and Turrubual peoples, the traditional owners of the land where we gather today. I pay my respects to your elders, to the ancestors and to those who have come before us. And thank you for your generous welcome to country for all of us.

This speech is the fourth in a series of six that I will be delivering nationally outlining an agenda for change across all areas of Indigenous affairs. I have termed this series of speeches “Essentials for Social Justice”.1

The first speech in this series was titled “Sorry” and outlined an agenda for addressing the needs of the stolen generations and the delivery of a national apology. The second – “Reform” – focused on the need for structural reform within government so that government is capable of meeting its commitments and ambitions. The third – “Protecting Indigenous children” – focused on addressing family violence and child abuse and the NT intervention.
Today’s speech is titled “Close the Gap” – a title that is a lot more popular now than it was when I started using it a few years ago.

Remaining speeches in the “Essentials for Social Justice” series in the coming months will address the importance of land and culture in creating economic development; and a look back at the progress of the Rudd government over its first 8 months in office.

But today – Close the Gap. So, what then is the gap being referred to? And why does it need closing?

The gap is the big one between the health status and life expectation of Indigenous and non-Indigenous Australians. It is well known, for example, that there is an estimated difference of approximately 17 years between Indigenous and non-Indigenous Australians life expectation. To look at this another way, that means that 75% of Indigenous males and 65% of females will die before the age of 65 years compared to 26% of males and 16% of females in the non-Indigenous population. For all age groups below 65 years, the age-specific death rates for Indigenous peoples were at least twice those experienced by the non-Indigenous population.

In fact, there are a number of disturbing indicators and trends that reveal an entrenched health crisis in the Indigenous population that need addressing if this gap is to close:

High rates of chronic diseases such as renal failure, cardio-vascular diseases and diabetes. In 1999–2003, two of the three leading causes of death for Indigenous people in Queensland, South Australia, Western Australia and the Northern Territory were chronic diseases of the circulatory system and cancer.
High rates of poor health among Indigenous infants do not bode well for the future adult population. In 2000–02, babies with an Indigenous mother were twice as likely to be low birth weight babies (those weighing less than 2,500 grams at birth) as babies with a non- Indigenous mother.
High rates of unhealthy and risky behaviour, including an increased prevalence of substance abuse and alcohol and tobacco use in the Indigenous population.

With a significant proportion of Indigenous peoples in younger age groups, there is an additional challenge to programs and services being able to keep up with the future demands of a burgeoning population. Unless substantial steps are taken now, there is a very real prospect that the health status of Indigenous peoples could worsen and the gap get bigger still.

So that is the ‘gap’ I am referring to: a health status gap that divides the life experience of black and white Australians. I will not be the first to be observe that the situation it is something like having two nations in one: on one hand, the non-Indigenous population enjoying some of the best health in the world, and – at the other end – the Indigenous population being forced to settle for something far less.

And behind this gap, there are other divides. Most importantly a divide between the opportunities to be healthy presented to black and white Australians. And I think this is a vital point to realise – particularly for those who would blame Indigenous peoples for their own poorer health. For while it is true that we are all ultimately responsible for the choices we make that affect our health, it is equally true that for a variety of reasons Indigenous Australians have fewer choices to make for health than other Australians.

For example, given that Indigenous peoples’ poorer health status would indicate a greater need for primary health care services, it is disturbing that in 2004 it was estimated that Indigenous peoples enjoyed 40% of the per capita access of the non-Indigenous population to primary health care provided by mainstream general practitioners. In other words, many Indigenous peoples cannot make the same kind of choices to see a doctor when they are ill, be checked up, or take advice from doctors about healthy living. There are many reasons for this. Because a higher proportion of the Indigenous population live in rural and remote areas, the doctor shortage in the bush is having a greater impact on Indigenous peoples when compared to the non-Indigenous population, for example.

But even in the urban centres, where the majority of Indigenous Australians live, many choose against using mainstream primary health care even where it is otherwise available and physically accessible. This can be for many reasons including a lack of cultural ‘fit’, language barriers, or the perception that mainstream services are not welcoming to Indigenous peoples. Australian governments have long accepted the importance of maintaining distinct health services in urban centres for Indigenous people

as a consequence of this.

Per capita Medicare under spend estimates have been used to assess the quantum of the Indigenous primary health care shortfall. Estimates of the shortfall range from $250 million per annum to $570 million per annum depending on the quality of service offered. So in an era of record ten and twenty billion dollar budget surplus on top of record budget surplus, we are not talking big sums to close this particular divide.

Another area where there is a divide is in relation to health infrastructure, a term used here to describe all the things that support good health, but that are not health services. Examples include potable water supplies, healthy food, healthy housing, sewerage and sanitation, and so on.

The dominant feature of health infrastructure inequality in Australia relates to Indigenous peoples’ housing. Nationally, 5.5% of Indigenous households live in overcrowded conditions. The proportion of overcrowded households was highest for those renting from Indigenous or community organisations (25.7%). Among the jurisdictions, the proportion of overcrowded households was highest in the Northern Territory (23.7%).

In relation to health infrastructure, a century of neglect of health infrastructure in Indigenous
communities has left what could be a $3–4 billion project for this generation, but again – in the
scheme of things – these sums should not discourage us, particularly if one thinks of a ten year program, for example, over which the overall cost would be spread.

And, of course, a wide range of social factors (such as income, education and so on) also determine good or bad health in a population group. Research has demonstrated associations between an individual’s social and economic status and their health. In short, poverty is clearly associated with poor health. And as is well known, Indigenous peoples in Australia experience socio-economic disadvantage on all major indicators.

And there are other divides too. While poverty is an example of a social determinant that will impact on both Indigenous and non-Indigenous Australians, there are some social determinants evident in Australia that will only impact on Indigenous peoples.

The unfinished business of colonisation and ongoing second class status afforded Indigenous peoples in Australian society is an example. This includes the stalled efforts to reconciliation (hopefully reignited by the recently offered National Apology to the Stolen Generations), and the ongoing uncertainty surrounding the issues of land, control of resources, cultural security, the rights of self-determination and sovereignty.

Racism too is likely to affect the social and emotional (as well as mental and physical) health of Indigenous Australians in a way not experienced by most other Australians.
So the gap I am referring too, the gap in the health status and life expectation enjoyed by non- Indigenous and Indigenous Australians, can be conceived of as a manifestation of other divides that exist in areas like health services provision, health infrastructure and broader social and economic factors that narrow the choices for health that Indigenous Australians can make. And all these must be addressed if the health status and life expectation gap between black and white Australia is to close.

In my 2005 Social Justice Report, I argued that it was unacceptable for a country as rich as ours, and one based on the notion of the ‘fair go’ and the ‘level playing field’, to tolerate the gap, or the divides that underlie it.

The 2005 report set forth a human rights based approach to achieving Aboriginal and Torres Strait Islander health equality within a generation. It made three recommendations to this end.
The first recommendation was that the governments of Australia commit to achieving equality of health status and life expectation between Aboriginal and Torres Strait Islander and non-Indigenous people within 25 years.

The second recommendation set out a process for what would need to occur for this commitment to be met. It called for:

The governments of Australia to commit to achieving equality of access to primary health care and health infrastructure within 10 years for Aboriginal and Torres Strait Islander peoples;
The establishment of benchmarks and targets for achieving equality of health status and life expectation – negotiated with the full participation of Aboriginal and Torres Strait Islander peoples, and committed to by all Australian governments;
Resources to be made available for Aboriginal and Torres Strait Islander health, through mainstream and Indigenous specific services, so that funding matches need in communities and is adequate to achieve the benchmarks, targets and goals set out above; and
A whole of government approach to be adopted to Indigenous health, including by building the goal and aims of the National Strategic Framework for Aboriginal and Torres Strait Islander Health into the operation of Indigenous Coordination Centres regionally across Australia.

The final recommendation then recommended that the Australian Health Minister’s Conference agree to a National Commitment to achieve Aboriginal and Torres Strait Islander Health Equality and that bi-partisan support for this commitment be sought in federal Parliament and in all state and territory parliaments.

That was two years ago.

Since the release of the Social Justice Report 2005 I have been working with a growing coalition of organisations who have committed to working in partnership to see these recommendations implemented. It encompasses every major Indigenous and non-Indigenous peak health body in the country, as well as reconciliation groups, human rights organisations and NGOs. It is an extraordinarily committed group of organisations and individuals, across a vast array of different sectors of the community.

The campaign progressed over the past 2 years without any financial support from Australian
governments – it has been self-funded.

Overall, the campaign has been led by a leadership group comprising the National Aboriginal
Community Controlled Health Organisation, the Australian Indigenous Doctors’ Association, the Congress of Aboriginal and Torres Strait Islander Nurses, the Indigenous Dentists’ Association of Australia, Oxfam Australia and HREOC. ‘Close the Gap’ was the public title for the Campaign.

One of our primary aims at the time was to obtain the commitment of all Australian governments – through COAG – and of the Australian government in particular due to its significant responsibilities for primary health care – to commit to closing the gap on Indigenous life expectancy within a generation.

And it was to obtain this commitment on a basis of partnership and shared ambition with a wide range of sectors of the community.

As you will be aware, the Councils of Australian Governments did exactly that on 20 December 2007.

In their Communiqué they stated: COAG agreed the 17 year gap in life expectancy between Indigenous and non-Indigenous Australians must be closed.

COAG today agreed to a partnership between all levels of government to work with Indigenous communities to achieve the target of closing the gap on Indigenous disadvantage. COAG committed to:

Closing the life expectancy gap within a generation;
Halving the mortality gap for children under five within a decade; and
Halving the gap in reading, writing and numeracy within a decade.

The first stage of the Campaign culminated in the National Indigenous Health Equality Summit held in Canberra over 18 – 20 March, 2008. There were two streams of activity that took place at the Summit:

First, a series of Indigenous Health Equality Targets were extensively workshopped to provide the means by which commitments to close the gap can be met.
Second, the Commonwealth government and the Opposition were invited to formally recommit to achieving Indigenous health equality within a generation.

On 20 March 2008 the Summit concluded in the Great Hall of Parliament House with a formal

ceremony at which a Statement of Intent was signed by the Prime Minister, the Ministers for Health and Indigenous Affairs, the Opposition leader, and every major Indigenous and non-Indigenous health peak body across Australia. This Statement of Intent commits each of these bodies to a new partnership to close the gap.

It states:

We share a determination to close the fundamental divide between the health outcomes and life expectancy of the Aboriginal and Torres Strait Islander peoples of Australia and non-Indigenous Australians.

We are committed to ensuring that Aboriginal and Torres Strait Islander peoples have equal life chances to all other Australians.

We are committed to working towards ensuring Aboriginal and Torres Strait Islander peoples have access to health services that are equal in standard to those enjoyed by other Australians, and enjoy living conditions that support their social, emotional and cultural well-being.

We recognise that specific measures are needed to improve Aboriginal and Torres Strait Islander peoples’ access to health services. Crucial to ensuring equal access to health services is ensuring that Aboriginal and Torres Strait Islander peoples are actively involved in the design, delivery, and control of these services.

And accordingly, the signatories have agreed to the following commitments. I quote:

To developing a comprehensive, long-term plan of action, that is targeted to need, evidence based and capable of addressing the existing inequities in health services, in order to achieve equality of health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by 2030.
To ensuring primary health care services and health infrastructure for Aboriginal and Torres Strait Islander peoples which are capable of bridging the gap in health standards by 2018.
To ensuring the full participation of Aboriginal and Torres Strait Islander peoples and their representative bodies in all aspects of addressing their health needs.
To working collectively to systematically address the social determinants that impact on achieving health equality for Aboriginal and Torres Strait Islander peoples.
To building on the evidence base and supporting what works in Aboriginal and Torres Strait Islander health, and relevant international experience.
To supporting and developing Aboriginal and Torres Strait Islander community-controlled health services in urban, rural and remote areas in order to achieve lasting improvements in Aboriginal and Torres Strait Islander health and wellbeing.
To achieving improved access to, and outcomes from, mainstream services for Aboriginal and Torres Strait Islander peoples.
To respect and promote the rights of Aboriginal and Torres Strait Islander peoples, including by ensuring that health services are available, appropriate, accessible, affordable, and of good quality.
To measure, monitor, and report on our joint efforts, in accordance with benchmarks and targets, to ensure that we are progressively realising our shared ambitions.

This is a major development and one that we now need to work together to capitalise on. Many people see this as a watershed in Indigenous policy – so the time is now to realise our goals and seize this moment.

To progress this new partnership, the Summit also finalised a series of targets to close the health inequality gap. These targets note that the achievement of the COAG goals requires a far more effective approach to Aboriginal and Torres Strait Islander health and in particular, those factors which are major contributors to current gaps in child mortality and the life expectancy gap.

We have therefore developed an integrated set of Close the Gap National Indigenous Health Equality Targets. These targets are grouped under four broad headings:

Partnership Targets – to lock into place a collaborative approach to Indigenous health;
Targets that focus on specific priority areas of child and maternal health, chronic disease and mental health and emotional and social wellbeing;
Primary Health Care and other Health Services Targets; and
Infrastructure Targets.

We note that ‘cherry picking’ specific targets or illnesses will not achieve the COAG goals.
Instead, we place far more reliance on integrated approaches to achieve the goals of equal access for equal need and equal health outcomes.

We argue that it is of limited value to say a particular condition or factor is important unless it is clear what the health target is, how it is to be achieved, indicative expenditure required (both recurrent and capital), program, workforce and infrastructure requirements to provide the necessary services and the monitoring, evaluation and management processes required.

The integrated sets of targets are designed to deal with these requirements, and mark a turning point for Aboriginal and Torres Strait Islander services. In particular as agreed by COAG, a partnership approach is proposed, involving Aboriginal people and their representative bodies, health agencies, government agencies and the wider community. These targets should be seen as the first step in a continuing process, where their refinement and implementation can be conducted through a genuine partnership between government and Aboriginal and Torres Strait Islander and other organisations.

The details of the structure and processes of this partnership will have to be determined and are essential to the achievement of the COAG goals. A fresh Government approach to partnership and to its management, monitoring, evaluation and review processes is essential for the achievement of the COAG goals – a little bit more of the same will not close the gap.
These targets will be formally presented to the government and publicly released in the coming weeks.

We are currently working with COAG Working Groups to ensure that the targets can be integrated into the COAG reform agenda for Indigenous issues.

And so, I want to conclude by considering the essential components for Closing the Gap.
The first is a principle of broad application. That is the need for partnership. This is what the Statement of Intent for a new partnership is all about.

We can’t achieve health equality by treating this as an issue solely for government to address, or solely for Indigenous peoples.

I believe we have now reached a pint where people have begun to be convinced that achieving health equality is achievable. This is what the evidence tells us, even if we lost faith over the past decade.

So such partnership requires an honesty and integrity about what needs to occur and transparency about how we are travelling, and whether we are doing everything we can to achieve our longer term goal.

Secondly, we need to ensure the full participation of Indigenous peoples in policy making processes and health programs in particular. We need to adopt a proactive approach to Indigenous health that has a prevention focus and builds a comprehensive primary health care approach.

Third, and related to this, is that high quality, integrated primary health care should be prioritised.

A focus on primary health care interventions addressing chronic diseases can be expected to have a significant impact on Aboriginal and Torres Strait Islander peoples’ life expectation. Critically for the Indigenous population, primary health care identifies and treats chronic diseases (including diabetes, cardiovascular and renal disease) and their risk factors. Primary health care also acts as a pathway to specialist and tertiary care, and enables local (or regional) identification and response to health hazards; transfer of knowledge and skills for healthy living; and identification and advocacy for the health needs of the community.

There should also be continued support for Aboriginal community controlled health services. There is evidence that they are a highly effective process for the provision of primary health care. There should also be independent research conducted to determine the success factors and governance issues which contribute to achieving the most effective community controlled health services possible.

The expansion of community controlled health services must take place alongside efforts to improve the accessibility of mainstream services. It should also be accompanied by health care programs focusing on specific diseases. If, through these, early stage symptoms are detected not only can suffering be prevented, but cost savings made.

The fourth requirement, is that we integrate targets for health equality into policy and programs across all governments. The Prime Minister announced at the National Indigenous Health Equality Summit in March that a new National Indigenous Health Equality Council will be established and operate from July this year. Its role should include advising on the implementation of targets and benchmarks. This provides an opportunity to embed the targets into policy and practice nationally.

And this is very much a work in progress. The Steering Committee for the Close the Gap Campaign continues to work with COAG and Australian governments to progress the adoption of the targets, and their integration into the National Strategic Framework for Aboriginal and Torres Strait Islander Health and the Aboriginal and Torres Strait Islander Health Performance Framework as well as the Productivity Commission’s Overcoming Indigenous Disadvantage framework. It is hoped that in the near future these policy frameworks and indicators will be linked to benchmarks and targets to the
end of achieving Indigenous health equality by 2030 or earlier.

There is sufficient evidence to demonstrate that a targeted approach will work and that the
improvements sought in Aboriginal and Torres Strait Islander peoples’ health status are achievable. For example, a recent review of Aboriginal primary health care states that:

international figures demonstrate that optimally and consistently resourced primary health care systems can make a significant difference to the health status of populations, as measured by life expectancy, within a decade. For example, in the 1940s to the 1950s in the United States, Native American life expectancy improved by about 9 years; an increase in life expectancy of about twelve years took place in Aotearoa/New Zealand over two decades from the 1940s to the 1960s. Figures from within Australia demonstrate dramatic improvements in infant mortality (for example from 200 per 1,000 in mid 1960s Central Australia to around 50 per 1,000 by 1980) through the provision of medical services.

The fifth essential is the adequate resourcing of commitments to Indigenous health. Research
suggests that addressing Aboriginal and Torres Strait Islander health inequality will involve no more than a 1% per annum increase in total health expenditure in Australia over the next ten years. If this funding is committed, then the expenditure required is then likely to decline thereafter.

Only with funding commitments that are proportionate to the outstanding need in communities will it be feasible for governments to meet the outstanding primary health care and infrastructure needs of Aboriginal and Torres Strait Islander communities within 10 years.

This has been acknowledged in the Statement of Intent which talks of funding matching need to achieve equality.

Generally, primary health care is a responsibility of the federal government – but savings made here can prevent engagement of Aboriginal and Torres Strait Islander peoples with the secondary and tertiary systems, which are predominately responsibilities of the states and territories. The states and territories also have significant responsibilities for service delivery in areas which impact on health outcomes, such as housing.

In light of the comprehensive national frameworks and strategies in place, it would appear that there exists a solid basis for governments to work together to address the projected funding shortfall.

Additional funding to the states and territories could be made contingent on the agreement of states and territories to match federal contributions.

An equitable distribution of primary health care rests on a prior effort to increase the numbers of health professionals, and particularly Indigenous health professionals, to provide the services. Any substantive address must begin at school – students must not only complete school, but they must receive a thorough grounding in maths and science to enter medicine. Recruitment campaigns must start focusing on Aboriginal and Torres Strait Islander young people at an early age.

Finally, to support these commitments and proposed targets, further reform of health financing models and data collection methods is required.

There has been significant work done to improve health financing models towards processes that identify the level of need. For example, quantifying the Medicare Benefit Scheme spending shortfall on Aboriginal and Torres Strait Islander peoples has provided a basis for quantifying the primary health care shortfall and stimulated initiatives to ensure Aboriginal and Torres Strait Islander enjoy greater access to Medicare and the Pharmaceutical Benefits Scheme. Further work is required to quantify enable the level of need to be quantified nationally, as well as at a regional and sub-regional level for both primary health care access and health infrastructure provision.

Ultimately, there is no larger challenge to the sense of decency, fairness and egalitarianism that characterizes the Australian spirit than the current status of Aboriginal and Torres Strait Islander health.

Closing the Gap is not only a major human rights issue in Australia, but it should be a matter of pride for us all.

And “Closing the Gap” is not impossible, although it will require long term action and commitment.

Committing to a 2030 year time frame to achieve this is feasible. It is also a long time in which to accept that inequality would continue to exist.

But history shows us that an absence of targeted action and a contentedness that we are ‘slowly getting there’ is not going to result in the significant improvements in health status that Aboriginal and Torres Strait Islander peoples deserve – simply by virtue of the fact that we are members of the human race and of the Australian community.

We have an unprecedented opportunity to make this happen due to the recent commitments of Australian governments and the adoption of National Indigenous Health Equality Targets, but targets on their own will not suffice – we need action on many fronts to address the many divides that lay behind the gap. And we do need to augment current efforts.

The failure of the policies and programs of the past twenty years to achieve significant improvements in Aboriginal and Torres Strait Islander health status, yet alone to close the gap, reveal two things that Aboriginal and Torres Strait Islander peoples and the general community can no longer accept from governments.

First, we can no longer accept the making of commitments to address Aboriginal and Torres Strait Islander health inequality without putting into place processes and programs to match the stated commitments. Programs and service delivery must be adequately resourced and supported so that they are capable of achieving the stated goals of governments.

Second, and conversely, we can also not accept the failure of governments to resource programs properly. A plan that is not adequately funded to meet its outcomes cannot be considered an effective plan. The history of approaches to Aboriginal and Torres Strait Islander health reflects this.

The combination of the healthy economic situation (at least in terms of the surpluses) of the country, the substantial potential that currently exists in the health sector and the national leadership being shown through the COAG process, means that the current policy environment is ripe for achieving the longstanding goal of overcoming Aboriginal and Torres Strait Islander health inequality.

Steps taken now could be determinative. The gap – the Indigenous health equality gap – can be closed, and closed in our lifetimes. The foundations are in place, but none of us can afford to rest on our laurels – it is imperative that hold Australian governments to their commitments so that by 2030 any Indigenous child born in this country has the same chances as his or her non-Indigenous brothers and sisters to live a long, healthy and happy life.

Thank you.

Endnote

[1] These speeches can be found at: www.humanrights.gov.au/social_justice/essentials/index.html.

Note: This is the fourth in a series of six speeches outlining an agenda for change in Indigenous Affairs. The “Essentials for Social Justice” series will be presented between December 2007 and August 2008, and will be available online at: www.humanrights.gov.au/social_justice/essentials/index.html .