A ‘whole of government’ approach needed on Indigenous health

Editorials A ‘whole of government’ approach needed on Indigenous health Ian Ring It has been argued that the current generation is not to blame for events that occurred in the past, and that may well be a reasonable point of view. However, we are all the beneficiaries of those events and it is only we, as the current generation, who can deal with the aftermath of those events. To chart a course and to help to develop a climate of public opinion to support such a course is, however, the role and responsibility of national leadership, and the public health movement should so advocate. zyxwvutsr zyxwvutsrq James Cook Universit)! Queensland zyxw zyxwv z zyxwvuts There is a sense of shared national embarrassment in Australia about the poor state of, and lack of progress in, Aboriginal and Torres Strait Islander health. This lack of progress needs to be considered in the context of the Wik debate and other current debates on Indigenous issues What are the specific areas that should be targeted? There are two main areas that need to be dealt with: health service needs and the environment in a broad sense. Health, dispossession and reconciliation Health services At the outset, there is a need to recognise where the root causes of the current health problems lie. Dispossession and forcible relocation are not unique to Australia and, indeed, a large part of the history of many countries is made up of a record of forcible dispossession and its consequences. What is unique about the Australian situation, however, is our failure, as a first world country, to grapple effectively with the consequences of forcible dispossession of an Indigenous people. The current health status of the Aboriginal and Torres Strait Islander population is symptomatic of that failure and there is ample material to document, for example, that the current gap between the expectation of life for Australia’s Indigenous population and that of the rest of the ]population is 16-20 years, as against a gap of 4-6 years in United States, Canada and New Zealand - the countries which are perhaps most like Australia. The stark findings about other aspects of the health and social status of Australia’s Indigenous population have been outlined in detail in a groundbreaking report launched by the Governor-General, I and need no further elaboration. Some argue that it takes generations to bring about changes in health and that the lack of progress in Indigenous health is symptomatic of the time required rather than a lack of effort. However, the evidence from indigenous populations in other countries is otherwise. In New Zealand, for example, the mortality of the Maori population in the 1970s. which was then about the level of mortality now experienced by ,4ustralia’s Indigenous population, fell by a third in a decade. The lack of progress in Australia is simply that, a lack of overall progress, despite a number of isolated examples of success. As to the underlying causes of the health status issues, it is difficult to discount the suggestion that the absence of a treaty has been fundamental. Treaties, no matter how loosely worded, have to a greater or lesser extent played a significant and useful role in the development of health services, and in addressing the social and economic issues for the indigenous populations of New Zealand, the United States and Canada. In the absence of such treaties, in every clash of interests, other interests are of necessity more powerful, more numerous and more important. That is evident in the current and recent debates in Australia - particularly over land. As far as health services are concerned, the key requirement is a set of health services that work, and that address the priority issues ofAboriginal and Torres Strait Islander health. These services need to be adequately resourced, staffed by people with the necessary skills, and should be community controlled. The initiatives in Indigenous health that Minister Wooldridge has been responsible for, need to be commended, and the issue is essentially one of scale. Activities on the current scale can make at best only a very modest contribution to health and, unless the scale issues are addressed, the current disparities are likely to remain for very many decades to come. The Deeble Report2 found that, taking all sources of expenditure in to account, public and private, spending on Aboriginal and Torres Strait Islander people on a per capita basis is 1.08 times higher than it is for the population as a whole. That would be fine if the level of health for the Aboriginal andTorres Strait Islander people was only 8% worse than for the population as a whole, but on most measures it is in fact at least three times worse. The current levels of spending are simply inadequate to deal with the current burden of illness, let alone to provide the preventive and primary care services that are required to break the cycle of ill health. In the circumstances ofAustralia’s unique failure as a first world country to make headway with the health of its Indigenous population, it is therefore almost beyond belief that, because of differential access to the Medical Benefits Scheme (MBS) and Pharmaceutical Benefit Scheme (PBS) schemes, the Commonwealth Government itself spends substantially less on the Indigenous population than it does on the population as a whole (on a per capita basis 63 cents for each Aboriginal and Torres Strait Islander for every $1 spent for the population as a whole2). It has been argued3 that the Aboriginal and Torres Strait Islander health services bill, while large, is essentially affordable - of the order of an additional $100 million a year from the Commonwealth and matched by an equivalent amount from the States. This should not be seen as any kind of special deal for Aboriginal and Torres Strait Islander people, but simply what is required for any group of people in the community with health that bad. The level of health spending that is recommended would go a considerable way to- What should be done? zyxwvutsrqponm zyxwvutsrqpo 1998 VOL. 22 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 639 Editorials zyxwvu zyxwvuts wards redressing the current imbalance which, contrary to popular opinion is against, rather than in favour of Aboriginal people when health need is taken into account. Three recommendations zyxwvuts zyxwvutsrq zyxwvutsrq Environmental issues It is now well established that the environment - factors such as housing, water, sanitation, education, income, land and a feeling of being in control of one’s life -has a profound influence on health, and on all of these matters there is much that remains to be done. The environmental bill to deal effectively with these matters, may well be somewhat larger than the health bill and the scale of resources required here is not a matter just for individual ministers, but for the Government as a whole. These issues are difficult but do-able.A more fundamental issue is how to better define the proper place ofAboriginal people within Australian society today. Is there to be a treaty and if not, how are the interests of Australia’s original inhabitants who, as approximately 3% of the total population, are too small a proportion of the population to exercise a significant political voice of their own, to be recognised and dealt with? The Government should make the resolution of this fundamental issue a major national priority. Why Australia should take action Australia’s unique failure as a first world country to deal effectively with the health of our Indigenous population speaks to us as a people and to the world at large as to what type of society we really are. Surely we do not see ourselves as a society which lacks the capacity and willingness to do what other similar countries have done. So, while this is on the one hand an issue of and forAboriginal and Torres Strait Islander people themselves, it is equally an issue for Australian society as a whole. We have to create a climate and a framework in which Aboriginal and Torres Strait Islander people can solve these issues. It is an issue that calls for national leadership to create that climate and to take the necessary action. 640 1. The development of a framework to deal with interest clashes when the interests of the Aboriginal and Torres Strait Islander population are always going to be outweighed by those of other sections of the population. This will not be easy, but perhaps what is achievable in the short term is to make health and education the centrepiece of reconciliation while the longer term framework evolves. 2. For health services, the current inequities in the MBS and PBS programs need to be addressed as a matter of urgency. The need here is for a staged program with annual increments of $20 million genuine new money per year from the Commonwealth and matched by the States for a period of five years, building up to an increase of $100 million a year over current levels of Commonwealth spending after a period of five years, and maintained at the level until the differentials are reduced. 3. As far as the environment is concerned, a ‘whole of Government’ approach is required. This could be a further development of the approach used by the Western Australian Government, which identifies the current status and proposed action in the fields of education, economic development, land, justice, sport and recreation, housing, local government, etc, etc. The Commonwealth Government should commence the process of building the climate and taking the necessary steps. There can be no larger issue for any country than its standing as a people in its own eyes and in the eyes of the world at large. zyxwvuts zyx zyx References 1. Australian Bureau of Statistics 1997. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. 2. Australian Institute of Health and Welfare 1998. Australia’s Health 1998: the sixth biennial health report of the Australian Institute of Health and Werfare. Canberra: AIHW, 1998: 38-40. 3. House of Representatives Standing Committee on Family and Community Affairs 1997. AMMPHA Submission to the Inquiry into Indigenous Health. V1: 47-58. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1998 VOL. 22 NO.6