National Aboriginal and Torres Strait Islander Health Plan 2013–2023

Priorities—Health Enablers

Page last updated: 27 June 2013

"Clear evidence of inequitable access to necessary healthcare underlines the need for health system reform to better address the health, social and cultural needs of Indigenous"16

High quality health care must be accessible and appropriate for the needs of Aboriginal and Torres Strait Islander people acknowledging that those with disability may face additional barriers in accessing health care. Coordinated, culturally appropriate services across the health system -including primary health care, hospital care and aged care-will improve the patient journey and health outcomes for Aboriginal and Torres Strait Islander people and their families.


A culturally respectful and non-discriminatory health system

“Discussion about racism is difficult and highly charged in the Australian community and action should be focused on the development of respectful relationships and sanctioning of discriminatory behaviour, policies and practices, including within the health system”.17

Goal

All health care, whether government, community or private, is free of racism.

Context

Racism is a key social determinant of health for Aboriginal and Torres Strait Islander people, and can deter people from achieving their full capabilities, by debilitating confidence and self-worth which in turn leads to poorer health outcomes. Evidence suggests that racism experienced in the delivery of health services contributes to low levels of access to health services by Aboriginal and Torres Strait Islander people. 18

There are a number of pathways from racism to ill-health—experiences of discrimination, linked with poor self-assessed health status, psychological distress, depression and anxiety, and health risk behaviours such as smoking and alcohol and substance misuse.

Experiences of racism are compounded by the traumatic legacy of colonisation, forced removals and other past government discriminatory policies. The consequences of these events have been profound, creating historical disadvantage that has been passed from one generation to the next.19Top of page

Key Strategies to Achieve this Goal

    • Implement the National Anti-Racism Strategy 2010-2020.
    • Significantly improve the cultural and language competency of health services and health care providers.
    • Identify, promote and build on good practice initiatives to prevent and reduce systemic racism.

Health System Effectiveness and Clinically Appropriate Care

"The failure of mainstream services and Aboriginal and Torres Strait Islander people’s ability to access mainstream services, lies at the heart of continuing health disadvantage."20

Goal

The health system delivers clinically appropriate care that is culturally safe, high quality, responsive and accessible for all Aboriginal and Torres Strait Islander people.

Context

Effective health systems contribute to improved health outcomes. They need to be:
    • tailored to individual health needs;
    • clinically effective;
    • accessible and culturally competent;
    • integrated into a system of care where needs are complex; and
    • well governed, cost effective, evidence based and accountable.
Australia has a world class health system that is not accessed equally by all Australians according to need. The data shows that Aboriginal and Torres Strait Islander people access health services at 1.1 times the rate of non-Indigenous Australians even though their need for health services is estimated to be 2-3 times higher due to their poorer health status. Evidence also indicates that Aboriginal and Torres Strait Islander people are receiving fewer procedures and prescriptions than non-Indigenous Australians with the same health conditions.21Top of page

To reduce these inequalities, the next decade should continue to focus on improvements to clinical care, increased access to services, better use of evidence based guidelines and reduced systematic racism. There will continue to be a need for complementary targeted programs to address specific areas as well as investments in population-wide health interventions, such as strategies to reduce smoking rates.

Through the National Health Reform Agreement, the Australian Government and state and territory governments will deliver better health and better hospitals for the future, ensuring that all Australians can access the best health care where and when they need it. Health reform presents an opportunity to make the health system more responsive to the needs of all Australians, including Aboriginal and Torres Strait Islander people. This will make a significant contribution to our efforts to close the gap in Aboriginal and Torres Strait Islander life expectancy. As a result of many of the health reforms, health services will be more in touch with communities and tailored to meet local needs to deliver improvements in health care for Aboriginal and Torres Strait Islander people.

A focus on the patient journey which meets the clinical health care needs as well as cultural and social needs of Aboriginal and Torres Strait Islander people and their families will produce better health outcomes. This includes effective coordination and integration between health service providers.

The use of regional or placed-based approaches can also contribute to efficient and sustainable service delivery, based on economies of scale and sustainable service populations. This approach recognises the urban, regional, rural and remote diversity of Australia, particularly in those regions where geography, language, culture and behaviour may present obstacles to the effective access to and delivery of services.

The development of regional infrastructure is needed to allow for effective planning and coordination across services and the delivery of strategies targeted at local needs. Local services can potentially benefit from regionalised support for corporate support systems, quality and accreditation programs, and workforce development initiatives. In addition, effort to support transport options to health services is important, particularly in regional and remote communities.

Key Strategies to Achieve this Goal

    • Continue efforts under the Closing the Gap agenda and health reform to contribute to improved health outcomes.
    • Improve the clinical effectiveness of the health system for Aboriginal and Torres Strait Islander people to contribute to improved health outcomes.
    • Enhance health system performance in areas of access, coordination, integration, responsiveness and the use of technology where these encourage increased use by Aboriginal and Torres Strait Islander people, including those with a disability and those incarcerated.
    • Improve access to health information including eHealth, recognising that for many Aboriginal and Torres Strait Islander people, language or lack of transport may be an additional barrier to accessing health services.
    • Continue to fund and support improvement of Aboriginal and Torres Strait Islander community controlled health organisations as a critically important part of the health system.
    • Continue to give priority to the development of primary health care systems, but also grow the strategic focus on improving the quality of hospital care, specialist services and secondary and tertiary care.
    • Regional infrastructure supports service planning, coordination, governance, quality and accreditation processes, corporate services and workforce development.
    • Support robust governance and quality of care systems for Aboriginal and Torres Strait Islander people across the entire health system.
    • Implement cultural safety and quality of care agendas for Aboriginal and Torres Strait Islander people across the entire health system.
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Evidence-Based practice

“Research plays an important role in advancing Aboriginal health through investigation of emerging areas of concern, identifying protective and risk factors, developing and trialling interventions, and evaluating the implementation of programs and policy.”22

Goal

Health policies and programs are clearly evidence-based and informed by robust health research and data systems.

Context

High quality data and skilled professionals are required to develop evidence-based policy. Further effort is needed at the national, state and territory and local level to improve data collection, availability, quality and analysis.

Under-identification of Aboriginal and Torres Strait Islander people hampers the effective monitoring of health outcomes and more work must continue to be done to address these barriers. Health services and professionals need to foster culturally supportive and culturally safe environments to ensure Aboriginal and Torres Strait Islander patients feel comfortable identifying. This needs to be complemented by approaches to address systemic racism within the health system.

New and innovative mechanisms are enabling better access to information and resources that support evidence-based practice and decision making including data linkage methods, improved information management systems, the e-health infrastructure connecting the health system, patient-controlled electronic health records and web-based reporting of national Key Performance Indicators (KPIs) and other information. Further, many of these technologies place the individual at the centre of their own healthcare by enabling access to health information and engaging personally with their health management.

At the national level, mechanisms are in place to share important learning’s. The Closing the Gap Clearinghouse collects, analyses and synthesises research and evaluation on what works to close the gap in Aboriginal and Torres Strait Islander disadvantage. The Lowitja Institute, Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research, is dedicated to achieving equity in health outcomes through innovative, collaborative and inclusive research and knowledge transfer. Through the Clearinghouse and the Lowitja Institute, policy makers, service providers, academics and the public have access to a continually growing evidence base about addressing Aboriginal and Torres Strait Islander health and disadvantage.

Supporting skill development to enable Aboriginal and Torres Strait Islander people to actively participate in and conduct research relating to their own cultures is also important. It is recognised that many local services, including Aboriginal and Torres Strait Islander community controlled health organisations, already contribute to the evidence base through local research, cultural knowledge and data collection, analysis and evaluation.

Aboriginal and Torres Strait Islander people should feel respected and valued throughout research and evaluation activities and be provided with an opportunity to access research findings in a culturally appropriate and relevant manner. The research process should be regarded as an equal partnership recognising that the intellectual ‘input’ from communities is equally important as the intellectual ‘output’ by researchers.

Key Strategies to Achieve this Goal

  • Continue efforts to ensure the accuracy and consistency of Aboriginal and Torres Strait Islander data, including increased identification.
  • Implement data linkage strategies as a priority for those regions in which under-ascertainment of Aboriginal and Torres Strait Islander peoples in vital statistics and health data persist.
  • Implement the National Anti-Racism Strategy 2010-2020 to support Aboriginal and Torres Strait Islander patients to feel comfortable identifying.
  • Promote best-practice and innovative approaches guided by research, monitoring and evaluation activities.
  • Continue to expand continuous quality improvement programs in Aboriginal and Torres Strait Islander community controlled health organisations and mainstream health services and support the sharing of lessons for the improvement of patient services and outcomes, and the development of the health workforce.
  • Promote the development of research systems and infrastructure that build evidence and support the translation of evidence into policy and practice.
  • Promote the development of Aboriginal and Torres Strait Islander research leadership and the development of Aboriginal and Torres Strait Islander researchers.
  • Build a contemporary evidence-base on all aspects of health care including traditional healing and cultural models of care.
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Mental Health and Social and Emotional Wellbeing

“Mental health above all things in the Health Plan needs a clear articulation – a lot of people might not know what health and spirituality means to us.” 23

Goal

Aboriginal and Torres Strait Islander people have the best possible mental health and wellbeing. Social and emotional wellbeing strategies are integrated in all health care service delivery and health promotion strategies.

Context

Social and emotional wellbeing problems are distinct from mental illness, although the two interact and influence each other. Even with good social and emotional wellbeing people can still experience mental illness, and people with a long-term mental health condition can live and function at a high level with adequate support.24

Mental Health

The concept of mental health comes from an illness or clinical perspective and its focus is on the individual and their level of functioning in their environment.25

There is no single experience of mental health conditions. While some people have only ever had one episode of mental illness, others have recurrent illness. Where mental illness cannot be prevented, effective clinical and non-clinical interventions can assist individuals in maximising their wellbeing. 26

Mental health conditions are the principal reason for 7% of hospital admissions for Aboriginal and Torres Strait Islander people, with rates highest in the 25-44 year age group.27 The risk of developing a mental illness is higher when a person is socially excluded and isolated or experiences poverty, neglect, abuse or trauma; misuses drugs or alcohol; is in poor physical health; or has a physical or intellectual disability. 28

Alcohol and drug misuse can lead to violence or mental illness and also be a co-morbidity. Better supporting drug and alcohol treatment services and building their capacity to better identify and treat coinciding mental illness and substance misuse (co-morbidity) will help improve the health and social outcomes of Aboriginal and Torres Strait Islander people with substance use issues including aiding recovery and reducing homelessness or the risk of homelessness and violence.

The suicide rates of Aboriginal and Torres Strait Islander people for the period 2001-2010 were twice that of non-Indigenous Australians.29 Incarceration can have a harmful effect on rates of suicide and self-harm. Prisoners are at heightened risk of suicide and overdose death in the immediate post-release period and therefore greater support is required during this period.

While not all mental health illnesses are preventable, steps can be taken to reduce the likelihood that people at risk will go on to develop mental illness and that if they do, they will have better access to quality support and care.30 National policy should promote positive mental health and address the determinants and risk factors associated with poor mental health. It should also focus on building the mental health and social and emotional wellbeing workforce, including increasing the proportion of Aboriginal and Torres Strait Islander people working in this field, strengthening the Aboriginal and Torres Strait Islander community controlled health sector and developing the cultural competence of mainstream mental health services.Top of page

Social and Emotional Wellbeing

Social and emotional wellbeing is a holistic concept which recognises the importance of connection to land, culture, spirituality, ancestry, family and community, and how these affect the individual. Social and emotional wellbeing can be affected by the social determinants of health including homelessness, education and unemployment and a broader range of problems resulting from grief and loss, trauma and abuse, violence, removal from family and cultural dislocation, substance misuse, racism and discrimination and social disadvantage.31 It is important that policy approaches recognise the legacy of intergenerational trauma on social and emotional wellbeing.

Social and emotional wellbeing is the foundation for Aboriginal and Torres Strait Islander physical and mental health. It results from a network of relationships between the individual, their family, and their kin and community. A positive sense of social and emotional wellbeing is essential for Aboriginal and Torres Strait Islander people to lead successful and fulfilling lives. Social and emotional wellbeing provides a foundation for effective health promotion strategies.

Culture and cultural identity is critical to social and emotional wellbeing. Practicing culture can involve a living relationship with ancestors, the spiritual dimension of existence, and connection with traditional lands and languages. Individual and community control over their physical environment, dignity and self-esteem, respect for Aboriginal and Torres Strait Islander people’s rights and a perception of just and fair treatment is also important to social and emotional wellbeing.

For Aboriginal and Torres Strait Islander people in contact with the criminal justice, detention and care systems, incarceration can have a significant impact on health, particularly in regard to social and emotional wellbeing, with each period of contact interrupting education and employment opportunities, disrupting family life and confirming the normalcy of these outcomes. Issues with family separation and removal from one’s homeland and culture can also have a detrimental impact on wellbeing.

Improvement in Aboriginal and Torres Strait Islander people's social and emotional wellbeing requires effort from all levels of government and across sectors.

Services at the local level should recognise the protective factors of culture, and the strong connection between culture and positive wellbeing, to help improve Aboriginal and Torres Strait Islander people’s access to timely and culturally appropriate mental health care. Aboriginal and Torres Strait Islander families and communities should also be supported by services and programs that promote child development and effective parenting to foster healthy and resilient children. At the same time, it needs to be recognised that a person’s choices may be limited by environmental factors which have a dramatic and negative impact on the social and emotional wellbeing of and within communities.

Aboriginal and Torres Strait Islander people with poor social and emotional wellbeing are less likely to participate in employment consume higher levels of alcohol and other substances and are also less likely to access health services.

It is recognised that sport can play a role in strengthening an individual’s self-esteem and dignity and can assist in connecting people to their local community and improving social and emotional wellbeing.

For thousands of years traditional healers have nurtured the physical, emotional and social wellbeing of their people. To increase understanding and encourage collaboration with mainstream health services and the wider community, in some communities traditional healers have forged partnerships with health professionals and practitioners of western medicine. It is widely accepted that combining traditional treatments and western medicine is necessary for the wellbeing of the whole Aboriginal and Torres Strait Islander person, which leads to patients being more satisfied with the health services they receive.Top of page

Key Strategies to Achieve this Goal

  • Continue to implement the Roadmap for National Mental Health Reform 2012-2022, the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013 and the renewed Aboriginal and Torres Strait Islander Social and Emotional Wellbeing Framework.
  • Support initiatives that promote Aboriginal and Torres Strait Islander wellbeing through connections to languages and culture, and that help to keep Aboriginal and Torres Strait Islander languages and culture strong.
  • Continue support for counselling, health promotion and early intervention services to promote social and emotional wellbeing amongst Aboriginal and Torres Strait Islander people, including members of the Stolen Generations.
  • Promote links across mental health and drug and alcohol services and continue to increase community awareness and education about the range of options for dealing with the impact of the use of drugs, both licit and illicit, and alcohol and tobacco.
  • Implement strategies to prevent and address the harms caused by violence, self-harm and abuse.
  • Implement strategies to promote resilience, empowerment and positive mental health.
  • Effectively integrate a focus on social and emotional wellbeing in all aspects of health care delivery and health promotion strategies.
  • Build the mental health and social and emotional wellbeing workforce.
  • Increase family-centric and culturally safe services for families and communities.
  • Work towards reducing the overrepresentation of Aboriginal and Torres Strait Islander people in the criminal justice system through strategies such as the National Indigenous Law and Justice Framework.

Human and Community Capability

“Improving the health and wellbeing outcomes for Aboriginal people can be achieved by local Aboriginal people determining and owning the process of health care delivery. Local Aboriginal community control in health is essential to the definition of Aboriginal holistic health and allows Aboriginal communities to determine their own affairs, protocols and procedures”. 32

Goals

The capabilities, potential and aspirations of Aboriginal and Torres Strait Islander people are realised and optimise their contribution as individuals to the health workforce and to strategies to achieve Aboriginal and Torres Strait Islander wellbeing.

Institutional and organisational structures and processes harness human and community capability and enhance its potential.Top of page

Context

Human and community capability encompasses:
  • the need to invest in education, employment and other social determinants of health to create a more equal playing field;
  • systems that support communities and individuals to make informed choices and to participate in health planning and the delivery of services;
  • a focus on workforce development to the benefit of individuals and health services;
  • planning and governance structures and processes so communities can benefit and health services can work together to deliver improved outcomes; and
  • improved health literacy across the community.
Governance is one of the key ways in which human and community capability can be strengthened. It is important in improving service delivery in raising the health and prosperity of Aboriginal and Torres Strait Islander communities.33 Aboriginal and Torres Strait Islander community controlled health organisations are an important element of the health system and provide a mechanism for Aboriginal and Torres Strait Islander people to actively lead, develop, deliver and be accountable for culturally appropriate health services.

Community governance also helps shape communities. The capability of the community, and community members, will be strengthened by supporting community decision-making and control over health organisations, and building on people’s skills, personal and collective contributions, and shared commitment to governance processes, goals and identity. It is recognised that aspects of community governance vary in different settings and it is therefore important that differing traditions and cultures are recognised and accommodated in a way that contributes to good community governance.

There is strong leadership at the national level of Aboriginal and Torres Strait Islander representative groups and organisations. This includes the National Congress of Australia’s First Peoples, incorporating the National Health Leadership Forum. There is also strong capability and leadership at the national level in mainstream health groups and organisations and through key bodies such as the National Aboriginal and Torres Strait Islander Health Equality Council.

Aboriginal and Torres Strait Islander health professionals are essential to the delivery of culturally safe care, in primary health care settings with a focus on health promotion, health education, in specialist and other health services, and the engagement of Aboriginal and Torres Strait Islander people in their own health. The employment of Aboriginal and Torres Strait Islander health professionals also contributes to the development and maintenance of culturally safe workplaces and assists in addressing institutionalised racism. Further, all health professionals delivering health care to Aboriginal and Torres Strait Islander people have the capacity to influence health policy and health professional systems and contribute to health research and infrastructure. The Review of Higher Education Access and Outcomes for Aboriginal and Torres Strait Islander People has placed a high priority on the development of stronger and enhanced pathways for Aboriginal and Torres Strait Islander people into the professions, including the health professions.

According to the 2012 independent review of the Australian Government’s Health Workforce Programs, the most significant health workforce issue in some rural and remote areas is not one of total supply of health workforce but one of distribution of the workforce due to inadequate or non-existent service provision.34 Support for pathways to health careers in Aboriginal and Torres Strait Islander health, and in rural and remote areas, has multiple benefits including increasing the education and economic participation of Aboriginal and Torres Strait Islander practitioners and health workers and the cultural competency of services.

It is also recognised that this Health Plan, and contributions to the improvement of human capability within Aboriginal and Torres Strait Islander communities, also extends to the private and not-for-profit sectors. There is already much philanthropic and private investment underway in areas of Aboriginal and Torres Strait Islander employment, education and mentoring, and this Health Plan provides a framework for and encourages further future activity in this area.

Health literacy is fundamental if people are to successfully manage their own health. A person’s ability to make informed health-related choices is determined by their ability to understand health information and their ability to negotiate the health care system. Access to education, particularly early childhood education opportunities, improves health literacy in an individual, and therefore their family and community.Top of page

Key Strategies to Achieve this Goal

  • Improve workforce capability through the continued implementation of the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework, including supporting the take-up of health careers and support for people working in the health and healing professions.
  • Consider implementing the recommendations from the 2012 Review of Australian Government Health Workforce Programs in consultation with other government agencies and key stakeholders.
  • Implement the relevant aspects of the Review of Higher Education Access and Outcomes for Aboriginal and Torres Strait Islander People.
  • Facilitate and promote renewal and innovation in order to enhance individual and organisational capabilities.
  • Increase access to culturally appropriate health services through a combination of targeted programs for individuals and families and population health wide support.
  • Harness private sector and philanthropic opportunities for action that will improve the health and wellbeing of individuals, families and communities.
  • Support sustainable good governance through capacity building solutions which are community driven.
  • Enhance programs to support families and community members to understand health issues, have the opportunity to gain the skills to help them actively engage in the planning and delivery of health and wellbeing services, and manage their own health.
  • Support initiatives that encourage individuals to pursue employment and professional careers, including in the health sector.