Part one: Close the gap – A shared national priority

(a) How did we get here?

It is not credible to suggest that one of the wealthiest nations in the world cannot solve a health crisis affecting less than 3% of its citizens.

Dr Tom Calma AO, Aboriginal and Torres Strait Islander Social Justice Commissioner, 2005^[10]

In 2008, the United Nations Human Development Index ranked Australia the third most developed nation in the world. Then, as now, we were an enormously wealthy nation with amongst the highest life expectancy attainable.^[11]

In the same year, Aboriginal and Torres Strait Islander Australians life expectancy was estimated to be up to 17 years less than the broad Australian population.^[12] It was a stark reminder of a great divide in the nation across education, income, housing, mental health, chronic disease, child and maternal health, access to health services, and more. It was the scar of an unhealed past and a stain on the reputation of the nation. For Aboriginal and Torres Strait Islander peoples, it was an immense and unnecessary burden of suffering and grief.

Further, the health gap was getting wider as non-Indigenous Australia continued to prosper. In 2008 it was clear that if the nation was to honour its core principles of a ‘fair go’ and a ’level playing field’, in other words, of providing equality of opportunity to all, the time had come to act. Significantly, poorer Aboriginal and Torres Strait Islander health as a status quo was no longer acceptable. New thinking was needed.

That new thinking emerged following the release of the then Aboriginal and Torres Strait Islander Social Justice Commissioner, Dr Tom Calma AO’s, Social Justice Report 2005.^[13] The report called for a national effort to close the gap that included all Australian governments committing to closing the health gap within a generation. This call fostered a groundswell of action. In March 2006, Dr Calma convened a workshop that brought together peak Aboriginal and Torres Strait Islander and non-Indigenous health bodies, health professional bodies and human rights organisations. Attendees agreed to work to achieve Aboriginal and Torres Strait Islander health equality by 2030 utilising key elements and principles as set out in the text box below.

 

 

These bodies later formed the Campaign Steering Committee which launched the Close the Gap Campaign (Campaign) in 2007. Reflecting his stewardship of the process, Dr Calma became the inaugural Chair of the Campaign.

The Campaign garnered immediate public support and in 2007, the first National Close the Gap Day was held. Today it has become the largest and highest profile Aboriginal and Torres Strait Islander health event in the country. Nine hundred and seventy two community events involving 140,000 Australians were held on National Close the Gap Day in 2013.^[14] Almost 200,000 people have formally pledged their support for the Campaign. ^[15]

The ambitious but realistic goal that the health inequality gap could be closed within a generation, united the Campaign Steering Committee and the supporters of the Campaign across the nation. It was a goal set in full awareness of the challenges involved. The Campaign Steering Committee firmly believed then, and do today, that with political will and multiparty support (critical for such a generational challenge), it is possible to close the gap over the next 16 years.

(b) A nation-building exercise that is above political affiliation

It is not a Labor project, it is not a Liberal project. If it is to succeed, it must be a national project.

The Prime Minister Hon Tony Abbott MP, in response to the 2013 Annual Report to Parliament on Closing the Gap

when Opposition Leader, 6 February 2013^[16]

Through leadership, investment, and partnerships built on trust and respect, we can meet the closing the gap targets and build on our achievements: there are now more Indigenous children than ever before participating in preschool or early education programs. I affirm my commitment to the Closing the Gap framework.

The Opposition Leader Hon Bill Shorten MP, January 2014^[17]

The Close the Gap Campaign’s framework was based on a clear assessment of responsibility between Aboriginal and Torres Strait Islander communities and government.

A bold assertion of Aboriginal and Torres Strait Islander peoples’ responsibility underpinned the Close the Gap Campaign. Australian governments on their own can never make Aboriginal and Torres Strait Islander people or their communities healthy^[18]

However, it was also clear that such responsibility could not exist in a vacuum. In fact, critical government support is required to empower individuals, families and communities such that responsibility can be meaningfully exercised. In other words, there has to be a maternity class or clinic operating in a community for a mother to attend one; or for a doctor to be available to provide the health check-ups.

Government responsibility in this context is to empower Aboriginal and Torres Strait Islander individuals, families and communities with the opportunities to exercise responsibility for their health. Critically, this includes ensuring that Aboriginal and Torres Strait Islander people have access to health programs and services, medicines, and health information through health promotion campaigns and preventative health activities (such as anti-smoking campaigns).

Further, it stands to reason that Aboriginal and Torres Strait Islander people must be empowered with the same opportunities as all other Australians to access doctors, medicines, allied health services and so on, if health equality is to be achieved. There can no longer be a racially defined ‘opportunity gap’ when it comes to health. This opportunity gap has not yet closed, and nor can the health gap be expected to close until it does. This remains the nation-building challenge ahead, and for the next 16 years.

Genuine partnership, with shared decision-making power, in planning processes at the national, jurisdictional and community level is an extension of that clear articulation of where responsibility lies. It also further empowers: enabling the voices of communities to be heard in policy, service and program design and delivery.

 

 

These core concepts were elaborated in the Campaign’s blueprint for action: the Close the Gap Statement of Intent - signed by the nation’s political leaders. In the years since, the majority of Australian governments have signed up to the blueprint for action in the document.

The signing of the Close the Gap Statement of Intent established once and for all that bringing a timely end to Aboriginal and Torres Strait Islander health inequality was part of the nation’s core business.

The national effort to close the gap is above politics. As a nation-building exercise it has been, and should continue to be, set apart from the day-to-day fray. Indeed, as noted in the media,^[24] it is to our nation’s leaders’ credit that in the past three years of a hung parliament, at no time was the national effort to close the gap politicised, or its fundamental features undermined.

Achieving Aboriginal and Torres Strait Islander health and life expectancy equality by 2030 is an ambitious yet achievable task. It is also an agreed national priority. With nearly 200,000 Australians supporting action to close the gap, it is clear that the Australian public demand that government, in partnership with Aboriginal and Torres Strait Islander people and their representatives, build on the close the gap platform to meet this challenge. They believe that we can and should be the generation to finally close the gap.

The Campaign Steering Committee calls on the new Australian Government to not only ensure policy continuity in critical areas of the national effort to close the gap, but to take further steps in building on and strengthening the existing platform as set out in part three of this report.

(c) Empowered communities

 

The national effort to close the gap is an empowerment-based approach to achieving health equality. Among its underpinning principles is that the existing strengths in Aboriginal and Torres Strait Islander individuals, families and communities can, and should, be supported to enable them to exercise responsibility for their health.

ACCHSs are one way in which Aboriginal and Torres Strait Islander communities have exercised responsibility for their members’ health. The first ACCHS was established in 1971 in Redfern, Sydney, by community members, for community members.^[26] There are currently over 150 ACCHSs. They are defined as ‘a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it, through a locally elected Board of Management’.^[27]

The ACCHS model is a good example of supporting a community to exercise responsibility for its health. The roll out and expansion of ACCHSs is a means of community empowerment and supports:

• increased accessibility to health services;

• cultural continuity; and

• increased employment and participation in education and training by community members.

The community development and control of ACCHSs fosters culturally competent services.^[28] In particular, the acculturating force of high numbers of Aboriginal and Torres Strait Islander people who work in ACCHSs has been demonstrated to increase the accessibility of such services by contributing to a sense of cultural safety.^[29]

ACCHSs can operate as ‘one stop shops’ for clients displaying complex presentations that touch on many areas of their lives – not just their physical health. They connect their clients to services that may operate outside the health sector, and in so doing, breaks down artificial walls between a health condition per se, and the health impacts of poverty, poor housing, or a lack of cultural support.

There has been a steady rise in the number of dedicated Aboriginal and Torres Strait Islander primary health care services (about 75% of which are community controlled),^[30] from 108 services in 1999–2000 to 235 services in 2010–11. From 2008-09, supported by additional funding from national partnership agreements, there has been an increase of 30 services overall, with an additional 400,000 episodes of care delivered.^[31] These services, enabled by the national effort to close the gap, are targeted at addressing and overcoming the opportunity gap discussed above.

 

 

ACCHSs (and indeed other Aboriginal and Torres Strait Islander community controlled services, such as legal services) provide a model for the community control of other health services and sectors as they expand. This includes community-controlled AOD services as described in the case study below. In particular, services dedicated to mental health and social and emotional wellbeing could be developed according to the ACCHSs model.

 

 

Health services are also channels for economic growth in communities. The Australian Bureau of Statistics (ABS) 2011 Census results show that health services (including, but not limited to, ACCHSs) currently employ 14.6% of employed Aboriginal and Torres Strait Islander people. Health services are the single biggest ‘industry’ source of employment, which has expanded by almost 4,000 places since 2006.^[36] Health services, including ACCHSs, provide pathways to employment for community members through internships and ‘in-house’ training. This reduces welfare dependency and connects individuals, families and communities to the wider economy. Flow-on benefits include the enabling of healthy norms and routines for community members and their families. Investment in ACCHSs has a multiplier effect in communities beyond the critical improvements in health that they deliver.

ACCHSs are supported by State and Territory representative bodies who have played a critical role in developing long-standing and highly effective partnerships with state and territory governments (as examples, the Queensland Aboriginal and Torres Strait Islander Health Partnership; the partnership arrangements in the Victorian Indigenous Affairs Framework; and the South Australian Aboriginal Health Care Plan Implementation Committee, as discussed in the Campaign Steering Committee’s 2012 Shadow Report).^[37]

A further notable example is the partnership established in 1997 between the Aboriginal Health and Medical Research Council (the peak body for the ACCHSs in New South Wales), and the New South Wales Government. In 2012, the partners developed the New South Wales Aboriginal Health Plan.^[38] This partnership, based on trust and mutual respect, has created an enduring platform for the robust interactions that are required when addressing complex situations such as Aboriginal and Torres Strait Islander health. It is an example of how working together in partnership with trust is a productive and essential exercise.

In turn, these state and territory level partnerships can provide an umbrella for regional partnerships following the administrative boundaries for health service delivery within a state or territory. Regional partnership bodies for health planning, such as Regional Closing the Gap Committees in Victoria, was also discussed in the Campaign Steering Committee’s 2012 Shadow Report,^[39] and is illustrated by our case study below. The launching of Medicare Locals in 2010 and the restructuring of the previous health regions provides further opportunities for such regional partnerships to develop to benefit ACCHSs and Aboriginal and Torres Strait Islander peoples.

 

 

In 1979, the peak body for the ACCHSs at the national level, now known as the National Aboriginal Community Controlled Health Organisation (NACCHO), was established.^[41] National Aboriginal and Torres Strait Islander health leadership bodies emerged for doctors,^[42] nurses,^[43] health workers,^[44] dentists,^[45] psychologists and psychiatrists,^[46] physiotherapists,^[47] allied health professionals.^[48] Self-empowered, they assumed responsibility for the position of Aboriginal and Torres Strait Islander people within their professions and institutions. These national organisations promote their cultural and other expertise in working in communities and have helped create employment pathways, resulting in the health sector being a significant employer of Aboriginal and Torres Strait Islander people.

In the Campaign Steering Committee these and other organisations and allies from the non-Indigenous health space and human rights organisations first spoke with a common voice.

In recent years, and with the addition of the National Congress of Australia’s First Peoples (Congress) and the Torres Strait Regional Authority, these bodies have begun working together collectively as the National Health Leadership Forum (NHLF) (as discussed in previous Close the Gap Campaign shadow reports^[49]) to partner with Australian governments to develop health policy. The NHLF worked closely with the Australian Government to develop the Health Plan.^[50]

The development of the Health Plan demonstrates that the capital in the knowledge (including cultural knowledge), leadership and lived experience of this leadership group should not be underestimated. In particular, the emphasis in the Health Plan on the importance of social and emotional wellbeing;^[51] culture;^[52] and the need to address racism as a negative social determinant of Aboriginal and Torres Strait Islander health;^[53] can be identified as unique contributions of the NHLF to this key strategic document in the national effort to close the gap.

(d) A holistic approach that encompasses social determinants of health

 

Through the COAG Closing the Gap Agenda, significant funding and other support reaches Aboriginal and Torres Strait Islander communities to address poor health, poverty, unemployment and lower educational attainment. At the heart of the Agenda is the NIRA which, along with the Close the Gap Statement of Intent, is a foundation document to the national effort to close the gap. Like the Close the Gap Statement of Intent, the NIRA represents a national consensus and commitment: all Australian governments have signed up to its program.

Key features of the NIRA are the six COAG Closing the Gap Targets, and the seven ‘building blocks’ or areas of particular focus: Early Childhood; Schooling; Health; Economic Participation; Healthy Homes; Safe Communities; and Governance and Leadership.^[55] Further, all the Aboriginal and Torres Strait Islander-specific national partnership agreements, in addition to the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes and the National Partnership Agreement on Indigenous Early Childhood Development are intended to contribute to better health outcomes.

Without the broader context of the COAG Closing the Gap Agenda, health programs and services operating on their own are likely to have, at best, an unsustainable short-term impact. While the

focus of this report is on health, the Campaign Steering Committee counsel that the COAG Closing the Gap Agenda cannot be cherry-picked, and health cannot be viewed in isolation from the social determinants of health. This broader, multi-dimensional approach to addressing health must continue. All ‘fronts’ of the health and disadvantage gap must be engaged simultaneously for life expectancy to improve, and the foundations and gains so far must not be squandered by failing to maintain momentum in relation to the social determinants of health.

 

 

(e) Conclusion

The national effort to close the gap is a response to the unnecessary death, grief and suffering experienced by Aboriginal and Torres Strait Islander peoples as a result of long-standing health inequality. It is a response to a great stain on our national character.

The national effort to close the gap is a nation-building effort, built on clarity and a new consensus about responsibility. So armed, this is the generation to close the gap. Empowerment, and the capacity and demonstrated ability of Aboriginal and Torres Strait Islander peoples to exercise responsibility for their health is one side of the closing the gap approach. The other is the responsibility of government to provide the necessary opportunity and support.

Health inequality diminishes us all and it is for this reason that the Australian public support the national effort to close the gap. It is clear that Australians demand that government, in partnership with Aboriginal and Torres Strait Islander peoples and their representatives, build on the national effort to close the gap. They believe that we can and should be the generation that finally closes the appalling life expectancy gap between Aboriginal and Torres Strait Islander and non-Indigenous Australians.

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^[10] Calma, T. (Aboriginal and Torres Strait Islander Commissioner), Social Justice Report 2005, Human Rights and Equal Opportunity Commission, 2005, p 12. URL: http://www.humanrights.gov.au/publications/social-justice-report-2005-home (Accessed 14 January 2014).

^[11] United Nations Development Program, Human Development Report 2007/8, 2007, p 229 (Table 1).

^[12] Australian Bureau of Statistics, Deaths 2006 (cat. no. 3302.0), Commonwealth of Australia, 2007, p 76.

^[13] See above note 10.

^[14] See above note 2.

^[15] See above note 1.

^[16] Abbott, T. (Leader of the Opposition), Statement on Closing the Gap, 6 February 2013. URL: http://www.naccho.org.au/download/aboriginal-health/Leader%20of%20the%20Oposition%20Tony%20Abbott.pdf (Accessed 14 January 2014).

^[17] Correspondence, Shorten B. (Opposition Leader) and the Close the Gap Campaign Steering Committee, January 2014 (on file).

^[18] See above note 10.

^[19] Correspondence, Fred Hollows Foundation and the Close the Gap Campaign Steering Committee, December 2013 (on file).

^[20] As above.

^[21] Taylor H., Anjou M., Boudville A., McNeil R., The Roadmap to Close the Gap for Vision: Full Report, The University of Melbourne, 2012. URL: http://iehu.unimelb.edu.au/publications/?a=538656 (Accessed 14 January 2014).

^[22] See above note 19.

^[23] As above.

^[24] Daley, P., Mind the gap, right the wrongs, Sydney Morning Herald, 10 February 2013. URL: http://www.smh.com.au/federal-politics/political-opinion/mind-the-gap-right-the-wrongs-20130209-2e4yt.html (Accessed 14 January 2014).

^[25] Strategic Review of Indigenous Expenditure, Commonwealth of Australia, 2010, p 13. URL: http://www.finance.gov.au/sites/default/files/foi_10-27_strategic_review_indigenous_expenditure.pdf (Accessed 14 January 2014).

^[26] See National Aboriginal Community Controlled Health Organisation, NACCHO History (undated web page). URL: http://www.naccho.org.au/about-us/naccho-history/ (Accessed 14 January 2014).

^[27] As above.

^[28] For further information on cultural competence see: Walker, R., & Sonn, C., ‘Working as a Culturally Competent Mental Health Practitioner’ in  Purdie, N., Dudgeon, P., Walker, R.,  (eds.) Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice, Commonwealth of Australia, 2010, pp 157 -180.

^[29] As above, pp 161-166.  

^[30] Australian Institute of Health and Welfare, Aboriginal and Torres Strait Islander health services report, 2010–11: OATSIH Services Reporting—key results, Commonwealth of Australia, 2012, p 38. URL: http://www.aihw.gov.au/publication-detail/?id=10737423052 (Accessed 14 January 2014).

^[31] Comparing data presented in: Australian Institute of Health and Welfare, Aboriginal and Torres Strait Islander health services report, 2008–09: OATSIH Services Reporting—key results, 2010. URL: http://www.aihw.gov.au/publication-detail/?id=6442468388 (Accessed 14 January 2014).

^[32] Dudgeon, P., Cox, K., D’Anna, D., Dunkley, C., Hams. K., Kelly, K., Scrine., C., & Walker, R., Hear Our Voices, Community Consultations for the Development of an Empowerment, Healing and Leadership Program for Aboriginal people living in the Kimberley, Western Australia, Commonwealth of Australia, 2012. URL: http://aboriginal.childhealthresearch.org.au/media/394426/hear_our_voices_final_report.pdf (Accessed 14 January 2014).

^[33] As above.

^[34] As above.

^[35] Correspondence, National Indigenous Drug and Alcohol Committee and the Close the Gap Campaign Steering Committee, December 2013 (on file). See also the Council of Aboriginal Alcohol Program Services, Services (undated web page). URL: http://www.caaps.org.au/services/ (Accessed 14 January 2014).

^[36] Australian Bureau of Statistics, New 2011 Census data reveals more about Aboriginal and Torres Strait Islander peoples (Media release), 30 October 2012. URL: http://www.abs.gov.au/websitedbs/censushome.nsf/home/CO-64?opendocument&navpos=620#industry (Accessed 14 January 2014).

^[37] Close the Gap Campaign Steering Committee, Shadow Report 2012 - On Australian governments’ progress towards closing the gap in life expectancy between Indigenous and non-Indigenous Australians, 2012. URL: http://www.humanrights.gov.au/close-gap-indigenous-health-campaign#shadow (Accessed 14 January 2014). For the Queensland Aboriginal and Torres Strait Islander Health Partnership, see p 24; for the Victorian Indigenous Affairs Framework see p 25; for the South Australian Aboriginal Health Care Plan Implementation Committee see p 33.

^[38] NSW Aboriginal Health Plan 2013-23, New South Wales Health, 2013. URL: http://www.health.nsw.gov.au/publications/Publications/NSW-Aboriginal-Health-Plan-2013-2023.pdf (Accessed 14 January 2014).

^[39] See above note 37, p 25.

^[40] Correspondence, Katherine West Health Board and the Close the Gap Campaign Steering Committee, December 2013 (on file).

^[41] Then known as the National Aboriginal and Islander Health Organisation. See above note 26.

^[42] Australian Indigenous Doctors’ Association, Our History (web page), 2014. URL: http://www.aida.org.au/history.aspx (Accessed 14 January 2014).

^[43] Congress of Aboriginal Nurses and Midwives, About us (web page), 2012. URL: http://catsin.org.au/about-us/ (Accessed 14 January 2014).

^[44] National Aboriginal and Torres Strait Islander Health Workers’ Association, Our history (undated web page). URL: http://www.natsihwa.org.au/about-us/our-history/ (Accessed 14 January 2014).

^[45] Indigenous Dentists’ Association of Australia, Indigenous Dentists’ Association of Australia (webpage), 2009. URL: http://www.idaa.com.au/IDAA/Home.html (Accessed 14 January 2014).

^[46] Australian Indigenous Psychologists’ Association, Background/history – the formation of AIPA (undated web page). URL: http://www.indigenouspsychology.com.au/page/2973/background-history (Accessed 14 January 2014).

^[47] National Association of Aboriginal and Torres Strait Islander Physiotherapists, About Us (undated web page). URL: http://naatsip.org/# (Accessed 14 January 2014).

^[48] Indigenous Allied Health Australia, History of IAHA (undated web page). URL: http://iaha.com.au/about-us/history-of-iaha/ (Accessed 14 January 2014).

^[49] See above note 37.

^[50] See above note 3.

^[51] See above, pp 9, 20-22.

^[52] See above, p 9.

^[53] See above, pp 14-15 in particular.

^[54] Mundine, W., The Baker IDI Central Australia Oration, 4 October 2013. URL: http://www.indigenouschamber.org.au/wp-content/uploads/2013/10/Published-Baker-IDI-Oration.pdf (Accessed 14 January 2014).

^[55] COAG Reform Council, National Indigenous Reform Agreement: Performance report for 2009-10, 2011. URL: http://www.coagreformcouncil.gov.au/reports/indigenous-reform/national-indigenous-reform-agreement-performance-report-2009-10 (Accessed 14 January 2014).

^[56] Correspondence, Lynn Short and the Close the Gap Campaign Steering Committee, November 2013 (on file).