Chronic disease

The Indigenous Australians' Health Programme (IAHP) includes a strong focus on the prevention, detection and management of chronic disease as this is a driver of the life expectancy gap. The IAHP funds activities aimed at prevention of chronic disease, as well as chronic disease early detection and management.

Page last updated: 23 December 2015

Chronic disease prevention

Tackling Indigenous Smoking

The Australian Government is committed to reducing the high rate of smoking amongst Aboriginal and Torres Strait Islander people. 

Under the National Healthcare Agreement, the Council of Australian Governments has committed to halving the daily smoking rate among Aboriginal and Torres Strait Islander adults (aged 18 years or older) from the 2008 rate of 47.7%,1 by 2018.

The Tackling Indigenous Smoking programme is a targeted activity funded by the Australian Government under the Indigenous Australians' Health Programme to reduce smoking rates among Aboriginal and Torres Strait Islander people. The programme includes the following components:

  • Regional tobacco control grants to support multi-level approaches to tobacco control that are locally designed and delivered to prevent the uptake of smoking and support smoking cessation among Indigenous Australians;
  • A National Best Practice Unit (NBPU) to support regional tobacco control grant recipients through evidence-based resource sharing, information dissemination, advice and mentoring, workforce development, and monitoring and evaluation;
  • Enhancements to existing Quitline services and provision of frontline community and health worker brief intervention training;
  • Programme Evaluation and Monitoring which will include the design of an evaluation and monitoring framework to be used for the development of local and national performance indicators for grant reporting and to guide overall programme evaluation; and
  • Special projects in areas of significant disadvantage associated with high smoking rates, and within specific groups such as pregnant women and young people susceptible to taking up smoking.
Top of page

Chronic disease early detection and management

Care Coordination and Supplementary Services

The Care Coordination and Supplementary Services (CCSS) programme aims to improve access to coordinated multidisciplinary care for eligible Aboriginal and Torres Strait Islander patients with chronic disease. In particular, patients with diabetes, eye health conditions associated with diabetes, mental health conditions, cancer, cardiovascular disease, chronic respiratory disease and chronic renal disease. Priority is usually given to those most in need of care coordination services. The CCSS programme is delivered through Primary Health Networks in all states and territories.

Care coordination, provided by qualified health workers who are typically nurses and Aboriginal Health Workers, helps patients access the range of services needed to treat chronic disease.

A flexible funding pool (Supplementary Services) is available to Care Coordinators to expedite patient access to urgent and essential allied health or specialist services, certain medical aids and transport to services.

Medical Outreach Indigenous Chronic Disease

The Medical Outreach Indigenous Chronic Disease programme funds multi-disciplinary outreach services, including medical specialists, general practitioners and allied health professionals. Funding is managed by jurisdictional funds holders, and many of the services are delivered through Aboriginal Community Controlled Health Services.

Top of page

Chronic disease monitoring and evaluation activities

Monitoring and evaluation of the Indigenous Chronic Disease Package (ICDP) took place in 2009-13 through a variety of measures. These included:

  • The Indigenous Chronic Disease Package Monitoring and Evaluation Framework
  • The Framework was developed in 2009-10, and provided a guide for monitoring and evaluating the ICDP package. It consists of three parts: Volume 1, the introduction and overview; Volume 2, the programme logic and framework for individual elements; and Volume 3, the appendices.

  • Indigenous Chronic Disease Package Sentinel Sites Project
  • This evaluation was a place-based approach that examined the effectiveness of the ICDP implementation at 24 sites, with the aim of identifying enablers, barriers and early outcomes. The report is made up of three sections: the summary report, which outlines key findings, messages and policy implications; the final report, which provides detailed information about the findings, messages and policy considerations; and the appendices.

  • Indigenous Chronic Disease Package National Monitoring and Evaluation project
  • This evaluation examined the ICDP as a whole, assessing the initiative’s performance over its first four years. The evaluation is comprised of four reports: Volume 1, the main report, which contains the full assessment; Volume 2, which assesses the impact of the initiative on patient experience and service availability at the local level; Volume 3, which distils the main messages and provides a synthesis of findings; and Volume 4, which contains the appendices.

Top of page

Chronic disease activities funded by the Australian Government Department of Health, but not funded under the IAHP

These include:
  • Subsidies for medicines (PBS Medicine Co-Payments);
  • GP health assessments for Indigenous people (MBS Aboriginal and Torres Strait Islander Health Assessments) along with follow on care; and
  • Incentive payments for GPs (Practice Incentive Payment – Indigenous Health Incentive).

1 This is the age standardised rate from the Australian Bureau of Statistics 2014. Australian Aboriginal and Torres Strait Islander Health Survey: Updated Results, 2012-13 – Australia (Released 6 June 2014). Cat. No. 4727.0.55.066.  Table 1.3: Selected characteristics – 2001 to 2012-13, proportion of persons by Indigenous status


top of page