Aboriginal Health

Culture and Self Determination

The term Aboriginal refers to a person who is of Aboriginal or Torres Strait Islander descent, who identifies as such, and who is accepted as such by the community in which s/he lives. Aboriginality is a social term and has little to do with genetic factors.

Self determination is a process as well as a collective right exercised by peoples rather than individuals.

The right to self determination is the right to make decisions. The practical exercise of self determination is central to Aboriginal health. It underpins cultural, community, family and individual well being. Aboriginal self determination and responsibility lie at the heart of Aboriginal community control in the provision of PHC services.

Contemporary Aboriginal culture is extremely diverse. It is important that Aboriginal people be given choices where possible rather than non Aboriginal health service staff assuming that all Aboriginal people will share the same attitudes and opinions. Whilst an understanding of kinship systems, and language is important, not all Aboriginal people live within the confines of the kinship system, and some do not speak an Aboriginal language. Ask local people, especially Aboriginal staff, for advice when unsure about how to deal with issues.

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Aboriginal Community Control

Over the years AMSANT has advanced a clear definition of community control and what constitutes an Aboriginal community controlled health service (ACCHS). Essentially, community control is the process through which the community determines the nature of the service, and are able to participate in the planning, implementation, and evaluation of those services. This interpretation of ‘community-control’ is supported by the National Aboriginal Health Strategy’s definition which states that ¹:

“Community control is the local community having control of issues that directly affect their community”. Implicit in this definition is the clear statement that Aboriginal people must determine and control the pace, shape and manner of change and decision making at [all] levels.

According to the AMSANT Constitution a community controlled organisation must:

1. be incorporated as an independent legal entity
2. have a constitution which guarantees control of the body by Aboriginal people and which guarantees that the body will function under the principle of self-determination
3. have compulsory accountability processes including the holding of annual general meetings which are open to all members of the relevant Aboriginal community, and the regular election of health boards.

Community control has been widely accepted as a key requirement in strategies to overcome Aboriginal health disadvantage. Implicit in this is the understanding that much of the morbidity and premature mortality experienced by Aboriginal people are not amenable to medical or other interventions imposed from outside the community.

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Aboriginal Primary Health Care Services

Aboriginal community controlled health services (ACCHSs) in the NT were first established with the Central Australian Aboriginal Congress in 1973.

Read History...

Concern about Aboriginal people’s access to mainstream services, which were racist, discriminatory and expensive (where they existed at all) were the motivating factors behind this development² . ACCHSs initially began with little, if any, government funding.

The 1978 Alma Ata Declaration on PHC promoted comprehensive PHC as a means for achieving Health for All by the Year 2000³ . Clearly this has not been achieved, largely because implementation has focused on selective PHC that is top down, and leaves power relationships (a major determinant of health) intact. In recent years a new international health movement known as the Peoples Health Movement has been established in order to re-assert the principles of Health for All. It has developed a People's Charter for Health which AMSANT has endorsed.

At a national level, by 1987 there were 54 Aboriginal community-controlled organisations providing health services. These organisations formed a peak body, the National Aboriginal and Islander Health Organisation (NAIHO) in the 1970s. NAIHO collapsed due to lack of funding in the late 1980s and eventually a new peak body, the National Aboriginal Community Controlled Health Organisation (NACCHO) was formed in 1992.

In the NT there are twelve Aboriginal community controlled health services that are full members of AMSANT, their peak body. As well AMSANT has a number of associate members who are moving towards community control of their service.

In the NT there are three other ways health services are controlled:

• Northern Territory Department of Health and Community Services (NTDHCS) is a major provider of PHC services to Aboriginal communities. In these services much of the administration (eg payroll) is managed centrally. However, there are also local (clinic) administrative issues that are the responsibility of a senior staff member (usually a senior Aboriginal Health Worker (AHW) or nurse). It is expected that this manual will be useful at this level for the development of appropriate local policies and procedures.
• NTDHCS and the Office of Aboriginal and Torres Strait Islander Health (OATSIH) have entered into service agreements with some non-health organisations (often local community councils) that are responsible for the full administration of the health service. This manual is aimed at providing these services with a useful guide to health service management issues and responsibilities.
• In some communities there is a mixture of responsibilities with different agencies and/or private doctors involved in various aspects of PHC service delivery. Potentially this presents some confusion about roles and responsibilities of different players. Often the administration function in these situations is more complex. This manual aims to provide a useful guide to administrators to help clarify and simplify administrative functions.

In some of these types of services there are advisory health boards established in an effort to provide local direction to the health service. Information about the legislative and constitutional basis for health services may be useful in the further development of these bodies.

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Core Functions of Primary Health Care

One of the main purposes of a core functions of PHC framework is to provide a template for funding bodies so that their funding lines are clear and have a reasonable chance of supporting the development of effective and comprehensive community PHC in communites. It is also a useful guide for communities and services in assisting them to identify what services are needed and in planning to meet these needs. Part of this is to help to identify gaps that particular services have in achieving a comprehensive approach, and allow a measure of government performance. It is also a useful framework for local evaluation of services.

All of the aspects of comprehensive PHC detailed in Table 1 require resources, some directly to individual services and others through regional support structures.

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Table 1: Core Functions of PHC

Core Function	Programs	How
Clinical Services	Sick care services; Screening programs; Public health programs (eg immunisations)	Delivered by resident health care services in the community, visiting services, provision of medicine kits to designated holders, organised access to health advice via phone/radio.
Social Preventive Programs	Preventive programs requiring community ‘agency’ (ie action) addressing issues such as substance misuse, youth suicide, domestic violence, store policy.	Address the underlying non-medical causes of poor health - requires commitment, leadership and action from local community people.
PHC Support	Management/ administration; Program development & evaluation; Specialist/ allied health services; Staff in-service training/ education; Technical - maintenance of equipment, IT.	Delivered by local support; visiting specialist & allied health services; regional support.
Advocacy	Development of policy, lobbying for system change (equity and access to programs and resources for better health), negotiating with government.	Advocacy occurs from different levels – the community, through ACCHSs with policy capacity, peak bodies such as AMSANT. Vehicles include NT Aboriginal Health Forum established under the Framework Agreements.

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Clinical Protocols

The development of PHC services in the NT has depended on multidisciplinary health care with AHWs, nurses and doctors working together. As part of this process it is imperative that there is a standardised approach to the management of common illnesses. The mobility of people, and there use of services in different communities, further underlines the importance of standard practices. To this end the Central Australian Rural Practitioners Association (CARPA) has developed the CARPA Standard Treatment Manual which specifies clinical management standards to be applied, including which drugs are to be used. This has also determined which drugs are stocked in clinics. It is important that this standardisation be maintained. If practitioners are concerned about the appropriateness of any section of the manual, they should raise them with CARPA.

CARPA organises a 2 day conference twice a year and produces a newsletter in association with it.

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Aboriginal Health Planning

The Framework Agreement and Collaborative Planning Structures

In 1989 The National Aboriginal Health Strategy (NAHS)⁴ identified PHC as one of the key strategies for addressing Aboriginal health disadvantage. This included inter-sectoral collaboration as a means of achieving health outcomes dependent on the activities of the non-health sector (a key component of PHC in the Alma Ata Declaration of PHC⁵ ) and the need to develop more collaborative health service planning processes. Jurisdictional conflict and cost shifting have been identified as significant barriers in achieving Aboriginal health outcomes⁶. AMSANT continue to advocate for formal agreements between the Commonwealth, States/Territories and the community sector as a means of overcoming these barriers that have plagued Aboriginal health. In the late 1990s the then Commonwealth Minister for Health, Dr Wooldridge, successfully negotiated with State and Territory Ministers and the community controlled health sector to formalise arrangements about how Aboriginal health issues would be addressed. These are known as the Framework Ageements.

The NT Minister for Health, the Chair of ATSIC, the Commonwealth Minister for Health and the Executive Secretary of AMSANT signed the NT Framework Agreement in October, 1998. The Northern Territory Aboriginal Health Forum (NTAHF) was established shortly after in line with that Agreement. Initial partners in the Forum were NTDHCS, DoHA, AMSANT and ATSIC. The Central Australian Regional Indigenous Health Planning Committee (CARIHPC), and the Top End Regional Indigenous Health Planning Committee (TERIHPC), were also established to operate under the NTAHF. These forums were vehicles for the development of agreed roles and responsibilities between the parties, and to develop and implement agreed strategies. These committees were disbanded in 2003. Also ATSIC was abolished by the Commonwealth Government in 2005 and thus is no longer a partner on the Forum. The newly established Office of Indigenous Policy Coordination (OIPC) has been invited to participate as observers. WHislt the Framework Agreements have not been formally extended, the practical work of the NTAHF continues.

Figure 1 illustrates these collaborative relationships.

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Figure 1 Collaborative Planning Structures under the Framework Agreement

The Framework Agreement has since expired and has not been re-signed. However the principles of the framework agreements and the Forum which was established under the Agreement in the NT continues to function. AMSANT continues to advocate for governments to formally re-commit to a cooperative strategic approach to improving the health of Aboriginal people.

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Regional Planning

Regional planning studies (Central Australian Health Planning Study⁷⁾ and Top End Regional Aboriginal Health Planning Study⁸ ) have been conducted that inform the planning work of the NTAHF.

A major finding in both of these studies was the dispersion of small groups of people across vast areas of the Territory, and their high level of mobility. A challenging task of the Aboriginal PHC system is to address the health service needs of these people, along with the larger population groups. Being clinic based and bound does not provide the degree of flexibility demanded by such a dispersed and mobile population. Given the significance of out-station/homeland living to people’s health status it is important that health services support out-stations/homelands wherever possible.

The studies further defined the development of an Aboriginal health system based on principles of comprehensive PHC that are described above as the Core Functions of PHC. The studies recommended the development of a number of Health Service Zones (HSZ) that would serve to better focus planning of health services. These have been partly operationalised through the Primary Health Care Access Program (PHCAP).

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Developments in PHC Service Provision

AMSANT has worked closely with NTDHCS and OATSIH to develop ways of accessing MBS (Medicare) funds for Aboriginal health. As a result the PHC Access Program (PHCAP) has been developed that provides per-capita funding to populations of Health Service Zones at a rate of up to 4 times the national utilisation rates of MBS (2x for remoteness, and 2x for disease burden), to be pooled with current NTDHCS expenditure on PHC. These funds will then be utilised in accord with decisions of local health boards.

The NT Remote Health Workforce Agency (NTRHWA) now known as GPPHCNT has worked to increase the number of doctors working in remote communities and have developed systems of support in an effort to retain doctors in that work. This includes Continuing Medical Education, mostly delivered through the Central Australian Division of PHC and the Top End Division of General Practice and the organisation of family support programs for doctors.

In Central Australia, the collaboratively managed Central Australian Remote Health Development Services (CARHDS) provides training support to PHC services, mainly focused on the training of AHWs. NTDHCS also provide training support to nurses and AHWs through their pathways program, and community controlled services also provide orientation and in-service training.

Congress and Danila Dilba provide accredited AHW education programs.

The Commonwealth Intervention

In mid 2007 the Howard Government announced a major intervention into Aboriginal communities in the NT based on emergency response principles as a response to the Little Children are Sacred Report by Pat Anderson and Rex Wilde. This report (yet again) exposed the serious sexual and other abuse of children, violence, and the continuing alcohol problem in many communities. This intervention was controversial. Many supported the promise of increased funding for essential services, the protecion of children, increased policing and alcohol restrictions. However, the intervention also included scrapping the permit system and the Community Development Employment Program (CDEP) which many saw as having little to do with the protection of children. There was also concern by many that the 'quarantining' of welfare payments was universal regardless of how well a family was performing in looking after their kids, and that there was little consultation with communities.

The Central Land Council (CLC) produced a series of Fact Sheets on the intervention which give more detail for those interested.

In late 2007, a new Commonwealth Labor Government was elected, and have made early promises to continue the intervention but also to establish better consultative processes. They have also promised to reinstate the Permit System and CDEP.

We will update this section when more information becomes available.

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References

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