ࡱ> ` [bjbj RdtR1R1R181T14b22(F2F2F2444$Gh*B8c4"488BF2F2W:::8dF2F2:8::,F22 01R19($8,m0\ًB9ًpً4V5:67#444BB9R4448888b$ "Db "0tJ Social Justice Report 2005 CHAPTER 2 SUMMARY: Achieving Aboriginal and Torres Strait Islander health status and life expectation equality within the next generation This chapter sets out a campaign of achieving Aboriginal and Torres Strait Islander health status and life expectation equality within the next generation (approximately 25 years). There is no greater challenge to the Australian values of decency, fairness and egalitarianism than the inequality in health status between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population. It is a well known fact that a large gap in health equality exists in Australia. The gap in life expectation between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population is estimated to be 17 years. A major and underlying cause of health inequality is that Aboriginal and Torres Strait Islander peoples do not have an equal opportunity to be as healthy as non-Indigenous Australians in two key areas. Primary Health Care: Aboriginal and Torres Strait Islander peoples, in both remote and urban centres, do not enjoy equal access to primary health care. This is the essential foundation for health equality. Primary health care provides an immediate response to acute illness and injury; it protects good health through screening, early intervention, population health programs (such as antenatal care and immunisation) and programs to promote social and emotional wellbeing and prevent substance abuse. 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 in this context means high quality, integrated primary health care delivered by Aboriginal Community Controlled Health Organisations wherever possible in order to ensure these health services are physically and economically accessible to Aboriginal and Torres Strait Islander peoples and responsive to the different cultural needs. Health infrastructure: Aboriginal and Torres Strait Islander peoples do not enjoy the same standard of infrastructure necessary for health, including: safe drinking water, healthy food sources, effective sewerage systems, rubbish collection services and healthy housing. With these two foundation elements in place, concerted special measures programs to address specific health issues facing Aboriginal and Torres Strait Islander people and eliminate the gap in health status with the non-Indigenous population are possible and sustainable. As a nation, we have never been as well placed as we are now to turn the current health crisis faced by Aboriginal and Torres Strait Islander peoples around. In part, this is because the necessary commitments and mechanisms for whole-of-government coordination are now in place to achieve this. Traditionally, there has been a lack of coordination between the Commonwealth, states and territories, and between the health care and other relevant sectors in Australia. Since the National Aboriginal Health Strategy (1989) there has been a general agreement that whole-of-government and intersectoral integration and coordination mechanisms were a necessary first step towards any comprehensive response to the health crisis. These are now in place. Further, we have a historically large federal budget surplus, which could be used to fund dramatic improvements in Aboriginal and Torres Strait Islander peoples health status. With new agreement making processes, we have an unprecedented opportunity to engage and empower Aboriginal and Torres Strait Islander peoples to overcome existing health inequalities. And yet these opportunities are not being effectively harnessed. The human rights based approach to health Human rights provide a framework for addressing health inequality by providing a system to guide policy making and to influence the design, delivery, monitoring and evaluation of health programs and services. Crucially, the right to health requires governments to address issues of equality opportunity in health head on. It requires governments to address inequality of health services, particularly primary health care, as well as health infrastructure when it occurs. As such, it is directly relevant to the situation of Aboriginal and Torres Strait Islander peoples. The most important statement of the right to health is article 12 of the International Covenant on Economic, Social and Cultural Rights, which recognises the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. It is not to be understood as a right to be healthy, which cannot be guaranteed by governments. Instead, the right requires a state to ensure that its population enjoys the opportunity and an equal opportunity to be as healthy as possible - primarily by being able to access primary and other forms of health care and medicines when necessary, as well as enjoying a high standard of health infrastructure. The right to health is subject to the over-arching principle of progressive realisation. This means that governments must take steps that are deliberate, concrete and targeted as clearly as possible towards health equality and equality of opportunity in relation to primary health care and health infrastructure. Where health inequality and inequality of opportunity exists, governments must identify appropriate health indicators with achievable benchmarks, so that the rate of progress can be monitored and assessed. Setting benchmarks enables governments and other parties to reach an agreement about what rate of progress is adequate. Such benchmarks should be: specific, time bound and verifiable; set with the participation of the people whose rights are affected, to agree on what is an adequate rate of progress and set realistic targets; and Reassessed independently on their target date, with accountability for performance. The right to health also emphasises processes for achieving improvements in health, with the free, active and meaningful participation of Indigenous peoples critical in the design and delivery of health services, health infrastructure and health programs. A campaign for Aboriginal and Torres Strait Islander health equality within a generation The failure of the policies and programs over the past 20 years to achieve significant improvements in Aboriginal and Torres Strait Islander health status, yet alone reduce the inequality gap, reveals two things people can no longer accept from governments. We cannot accept the failure of governments to commit to an urgent plan of action. It is not acceptable to continually state that the situation is tragic and ought to be treated with urgency and then fail to put into place targets to focus policy making or to fund programs accordingly. 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 statement. Australian governments have proved unwilling to fund Aboriginal and Torres Strait Islander health programs based on need and as a result plans have failed. Programs and service delivery must be adequately resourced and supported so that they are capable of achieving their stated goals. The campaign the Social Justice Commissioners Office is proposing directly addresses these two failings. Time frames, targets and benchmarks Perhaps the most striking factor in the current response is the absence of a timeframe for achieving Aboriginal and Torres Strait Islander health equality. This absence promotes a lack of accountability of governments. The campaign recommends that governments commit to achieving equality of health status and life expectation between Aboriginal and Torres Strait Islander and non-Indigenous people within 25 years. This proceeds from a commitment to provide equality of opportunity in relation to health for Aboriginal and Torres Strait Islander peoples. Governments should commit to achieving equal access to primary health care and health infrastructure (including safe drinking water, effective sewerage systems, rubbish collection services and healthy housing) within 10 years for Aboriginal and Torres Strait Islander peoples. The goal of health equality and equality of opportunity should be supported by targets and benchmarks over the short and medium term. In many cases, the Overcoming Indigenous Disadvantage Framework, as well as the Aboriginal and Torres Strait Islander Health Performance Framework provide an appropriate basis for establishing targets and benchmarks with deadlines in the short and medium term across a variety of contributing areas. There is sufficient evidence to demonstrate that the improvements sought in Aboriginal and Torres Strait Islander peoples health status are achievable within the timeframes the campaign is proposing. For example, in the 1940s-50s in the United States, Native American life expectancy improved by approx. nine years; an increase in life expectancy of about 12 years took place in Aotearoa/New Zealand over two decades from the 1940s-60s. Figures demonstrate dramatic improvements in infant mortality in Australia (from 200 per 1000 in the mid 1960s in Central Australia to around 50 per 1000 by 1980) through the provision of medical services. A number of programs in Australia have also achieved rapid improvement in Aboriginal and Torres Strait Islander peoples health in response to specific program interventions. For example, death rates among Aboriginal and Torres Strait Islander people from pneumonia have dropped 40% since 1996 due to the rolling out of pneumococcal vaccinations; and the Strong Babies, Strong Culture program has shown that significant reductions in the number of low birth weight babies can occur within a matter of years. It is ironic that the government has committed to achieve the UN Millennium Development Goals by contributing to the international campaign to eradicate poverty in third world countries by 2015, but has no similar plans for Aboriginal and Torres Strait Islander Australians, in particular their health. Funding Only with funding commitments that are proportionate to the outstanding needs in the community will governments be able to meet the outstanding primary health care and infrastructure needs of Aboriginal and Torres Strait Islander peoples within 10 years. A Commonwealth initiative called the Primary Health Care Access Program (PHCAP) is the main vehicle for the expansion of existing primary health care services in communities and the establishment of new services. However, PHCAP has never been fully or appropriately funded. Not all zones have been rolled out and there are no plans to roll out further PHCAP zones in the Top End of Australia. Similarly, the Department of Health and Ageing has not provided estimates on the funding required to implement the PHCAP to the benchmark funding level in Aboriginal and Torres Strait Islander communities over the next five years. Medicare per capita underspend estimates have been used to assess the quantum of the Aboriginal and Torres Strait Islander primary health care shortfall. Factoring in greater health needs has created the following cost estimates: In 2003, the Australian Medical Association calculated there was a $250 million per annum shortfall in Medicare and related spending on Aboriginal and Torres Strait Islander peoples by the Commonwealth that, if made up, could be devoted to primary health care. In a report published in May 2004, Access Economics estimated there was a $400 million (approx.) per annum shortfall that should be devoted to an Aboriginal and Torres Strait Islander health program, including provision of an equitable distribution of primary health care. In 2004, the Costings Models for Indigenous Health Report estimated the cost of extending Indigenous specific universal primary health care to be between $409 million and $570 million depending on the quality of service offered. The Community Housing and Infrastructure Program (CHIP) has been set up to provide capital works infrastructure to communities. However, the CHIP is not a strategic plan to ensure that an equal standard of infrastructure is provided to Aboriginal and Torres Strait Islander communities. Funding is not linked to needs under this program. In 2001, it was estimated that at the current rate of funding it would take at least 20 years to achieve an equal standard of infrastructure in these communities. There is a danger that if infrastructure needs are not addressed expeditiously, the rapidly growing Aboriginal and Torres Strait Islander population may put such pressure on existing infrastructure that much of the good work of the past decade will be undone. Planning to address this historical lack of infrastructure is an essential joint step (with the provision of primary health care) if improvements to health are to be realised. However, there is no current overall plan to address these needs that meets with the human rights principle of progressive realisation (i.e. that inequality is steadily being reduced with the commitment of the maximum of available resources). While the estimated funds needed to address primary health care access and infrastructure provision is significant, it only represents about 1% of the current national per annum spending on health. Total expenditure on health goods and services, health-related services and capital formation in Australia in 200304 was estimated at $78.4 billion. This was an increase of $6.1 billion over the previous year. A federal budget surplus of $13.6 billion (as at 30 June 2005) suggests that resource availability is not the issue. How does the campaign fit in with existing approaches to Aboriginal and Torres Strait Islander health and the new arrangements? This campaign seeks to place a time-frames on the goal and aims of the National Strategic Framework for Aboriginal and Torres Strait Islander Health and the commitments of the Council of Australian Governments (COAG) to overcome Aboriginal and Torres Strait Islander disadvantage. It provides a long-term vision for government focussed activity. Governments have, after all, already made commitments to addressing Aboriginal and Torres Strait Islander health inequality as a major priority. In particular, there is now a joint commitment from all governments in Australia to coordinated service delivery with the objective of addressing Aboriginal and Torres Strait Islander disadvantage, including health inequality. Efforts towards this goal are to be guided by the COAG National Framework of Principles for Government Service Delivery. Progress in addressing these commitments is able to be measured against the COAG Overcoming Indigenous Disadvantage Framework on a biennial basis. Further, the National Strategic Framework for Aboriginal and Torres Strait Islander Health commits governments to work in a holistic, whole-of-government manner in partnership with Aboriginal and Torres Strait Islander peoples towards the goal of health equality. With the rolling out of the new arrangements for the administration of Indigenous affairs at the federal level over the past 18 months, the whole-of-government machinery necessary to implement the commitments of COAG is now in place. Processes have been put into place to administer this framework to achieve its goals and aims. This includes: the finalisation of bilateral health agreements between the Commonwealth and states and territories; the establishment of state-level health forums; the development of regional plans which identify needs and priorities; and the establishment of a national performance monitoring framework. There has been significant work to address many public health issues affecting Aboriginal and Torres Strait Islander peoples, notably commitments to environmental health workers, food and housing. However, there is no overarching strategic response to public health issues (notably health infrastructure) faced by Aboriginal and Torres Strait Islander peoples. The key outstanding issue for Aboriginal and Torres Strait Islander health is the need to implement the extensive commitments of governments and to ensure that the number and pace of activities is sufficient to achieve health equality. This campaign would address this failure by linking existing commitments to adequate funding and resources and setting the goal of health equality within a 25-year period. The new arrangements, with their emphasis on a whole-of-government response to Aboriginal and Torres Strait Islander disadvantage, are entirely compatible with such a campaign. Shared Responsibility Agreements (SRAs) in particular provide a significant opportunity to advance non-health sector issues which impact on Aboriginal and Torres Strait Islander health status. They are able to target social determinants of health, as well as support partnership approaches to addressing some issues relating to infrastructure provision and management within communities. However, there are limits on when SRAs should be used. In particular, it is not appropriate for primary health care to be delivered through SRAs. Overview of recommendations The Social Justice Commissioner has made the following recommendations to achieve long-term commitments to the goal of health equality for Aboriginal and Torres Strait Islander peoples within a generation. 1) 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. 2) Governments of Australia commit to achieving equality of access to primary health care and to an equal standard of health infrastructure for Aboriginal and Torres Strait Islander peoples within 10 years. This commitment could be achieved with agreement at the Australian Health Ministers Conference of a National Commitment to achieve Aboriginal and Torres Strait Islander Health Equality, with bi-partisan support from federal, state and territory parliaments. This commitment should: acknowledge the existing inequality of health status faced by Aboriginal and Torres Strait Islander peoples; acknowledge that this constitutes a threat to the survival of Aboriginal and Torres Strait Islander peoples and their languages and cultures, and does not provide Aboriginal and Torres Strait Islander peoples with the ability to live safe, healthy lives with full human dignity; confirm the commitment of all governments to the National Strategic Framework and the National Aboriginal Health Strategy as providing over-arching guidance for addressing Aboriginal and Torres Strait Islander health inequality; commit all governments to a program of action to redress this inequality, which aims to ensure equality of opportunity in the provision of primary health care services and health infrastructure within 10 years; note that such a commitment requires partnerships and shared responsibility between all levels of government, Aboriginal and Torres Strait Islander peoples and communities, non-government organisations and the private sector; acknowledge that additional special measures will be necessary into the medium term to achieve this commitment; Benchmarks and targets for achieving equality of health status and life expectation should be negotiated, with the full participation of Aboriginal and Torres Strait Islander peoples, and committed to by all Australian governments. Such benchmarks and targets should be based on the indicators set out in the Overcoming Indigenous Disadvantage Framework and the Aboriginal and Torres Strait Islander Health Performance Framework. They should be made at the national, state/territory and regional levels and account for regional variations in health status. Data collection processes should also be improved to enable adequate reporting on a disaggregated basis, in accordance with the Aboriginal and Torres Strait Islander Health Performance Framework. Resources available for Aboriginal and Torres Strait Islander health through mainstream and Indigenous specific services should be increased to levels that match needs in communities, and to the level necessary to achieve the benchmarks, targets and goals set out above. Arrangements to pool funding should be made with states and territories, matching additional funding contributions from the federal Government. Finally, the goals and aims of the National Strategic Framework for Aboriginal and Torres Strait Islander Health be incorporated into the operation of Indigenous Coordination Centres and the new arrangements for Indigenous affairs. The Social Justice Commissioners Office will follow up these recommendations with governments over the next 12 months, and further the campaign through consultation with Aboriginal community controlled health organisations and their representatives, Aboriginal and Torres Strait Islander peoples, the non-government and private sector.     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