Achieving Aboriginal and Torres Strait Islander health equality within a generation – A human rights based approach
Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner, ‘The Right to Health of Indigenous Australians’ seminar, University of Melbourne Law School, 16 March 2006.
Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner
http://www.humanrights.gov.au/social_justice/sjreport05/index.html
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I would like to begin by acknowledging the Wurundjeri people, the traditional owners of the land where we meet today and to pay my respects to their elders. I would also like to thank the University of Melbourne and Di Otto for organising this event, and the Chair; and to acknowledge my eminent fellow panellists – Professor Ian Anderson, and Dr Papaarangi Reid.
In July 2004, I took up my appointment as the Aboriginal and Torres Strait Islander Social Justice Commissioner at the Human Rights and Equal Opportunity Commission or HREOC. This role was created in 1992 to provide an ongoing monitoring agency for the human rights of Indigenous Australians.
I undertake this role in a number of ways. In particular, I am required to report annually to the federal Parliament on the status of enjoyment and exercise of human rights by Indigenous Australians. This is called the Social Justice Report. The latest 2005 report was tabled in Parliament on 14 February and the front cover is reproduced on the slide above me. I have a limited number of reports with me that people are welcome to take home, but the report is also available on the HREOC website and the URL address can be seen at the bottom of the slide. I also produce a community guide that outlines the salient points in the Social Justice Report and a second annual report I produce called the Native Title Report and they are available to take.
Now, this year’s report spoke at length to the poor state of Indigenous health and health inequality (when compared to the non-Indigenous population) and the right to health.
Slide 2: Health inequality – a snapshot (1) See: Australian Bureau of Statistics, Australian Institute of Health and Welfare: The Health and Welfare of Australia’s
Aboriginal and Torres Strait Islander Peoples (2005) |
Slide 3: Health inequality – a snapshot (2) See: Australian Bureau of Statistics, Australian Institute of Health and Welfare: The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples (2005)
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Slide 4: Examples of health infrastructure needs Australian Bureau of Statistics - Housing and Infrastructure in Aboriginal and Torres Strait Islander Communities, 2001
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I am sure that many of you have some knowledge of Indigenous health inequality. For those who do not, the slide above me provides a snapshot. This snapshot is enough to show that significant inequality exists across a range of health indicators – from life expectation to chronic and communicable diseases, and across all age groups. Now what relevance does the right to health have to this situation?
I want to start by observing that at a general level, I think human rights have a bad reputation in Australia. It is unfortunate, but true, that we live in a time in which human rights are seen as the concerns of only the ‘chardonnay swilling set’ – as if human rights are the tool of some elite class or as wildly impractical, or at best symbolic, things.
In fact, human rights, and specifically the right to health, have very detailed content that ought to be guiding the development of policy and the delivery of programmes to Indigenous peoples. As I have argued in this years Social Justice Report, the right to health ought to form the cornerstone of policy development and programme design for Indigenous health.
So, what is ‘the right to health’? First, can I address a common misperception that it is some abstract ‘right to be healthy’. This is not correct - any such right would be meaningless. Human rights bring obligations to states and no state can guarantee the health of it citizens in an absolute sense against the forces of old age, natural disasters and incurable diseases, for example.
What the right to health does say, however, is that the state has an obligation to provide opportunities for its citizens to be as healthy as possible. What this means in practice is that the state provides two things:
- The first might be characterised as a foundation for good health – safe drinking water, hygienic conditions (with sewerage and garbage safely disposed of), healthy housing, and a supply of healthy food for a start. I refer to this as ‘health infrastructure’ in shorthand.
- The second are health goods and services. That is, hospitals and medicines for when people are ill and primary health care services that aim to prevent ill health or detect it at an early stage so that ill health is nipped in the bud. Health education and promotion is also vital. How many of us remember the famous ‘Life Be in It’ campaign or the anti-smoking drives of the past 2 decades? The impact of these campaigns has been of enormous benefit to the health of the overall population. Without this, individuals are not empowered to make health-supporting choices for themselves and their families.
Further, the right to health obliges a state to ensure that everyone – regardless of sex, race, age, sexuality and so on – has an equal opportunity to be healthy.
- This means that from a health perspective, communities across Australia (whether Indigenous or non-Indigenous) should enjoy a similarly healthy standard of drinking water, can access fresh vegetables, fruits and meat, and have their sewerage and garbage removed. It also means that they enjoy a similar standard of housing – from a health perspective. Now this doesn’t mean that we all should live in a mansion in Toorak. What it does mean is that we should all be able to take a shower, wash our clothes, keep our food refrigerated, and not live with 5 or 10 people to a room - conditions where diseases can spread rapidly.
- Further, it means that all people and communities should have equal access to health services. Access means:
- Physically accessible or reachable services,
- Affordable services,
- Non-discriminatory services, meaning – among other things – culturally tailored services for individual communities.
And of particular importance in relation to equality of opportunity to be healthy, is – logically - primary health care with its preventative emphasis. Since the well-known Declaration of Alma Ata was made by the World Health Organisation in 1978, it has been universally recognised that ensuring health equality among the various groups in a population will, to a great degree, depend on the access those groups have to primary health care services, as well as health education and promotion.
Now in case you are not already aware, Indigenous peoples in Australiado not enjoy the same opportunities to be as healthy as the non-Indigenous population in relation to primary health care and health infrastructure.
- For example - based on a national survey of general practitioners - it was estimated that in 2004, Indigenous peoples enjoyed only 40% of the per capita access of the non-Indigenous population to primary health care provided by general practitioners. Further research – based on Indigenous peoples’ use of Medicare - indicates that the primary health care shortfall in communities can be quantified at between $250 - $570 million per year. There are also identified gaps in relation to health promotion and education.
- Further, health infrastructure in many Indigenous communities, particularly remote communities, does not provide the same foundation for good health as in the rest of the country. Historically, contaminated drinking water supplies – situations where sewerage, garbage and water supplies were mixing - was a big cause of disease in communities. While I am happy to report real improvements to this situation over the past 15 years, there are still some areas of concern. For example, where hard water from bores is impacting badly on the kidneys of people suffering diabetes. However, perhaps the most pressing areas in this regard remain food supplies and housing - as highlighted in the slide above me.
Now I hope it is becoming clear as to how the right to health has immediate relevance to this situation. From a human rights perspective, enabling equality of opportunity in relation to health is identified as the challenge. While special measures in relation to certain diseases are also required by the right to health, equality of opportunity provides the foundation for sustainable improvements to health status to the point of equality. In that way the right to health is directly relevant to the improvement of Indigenous health in this country.
But the right to health does more than simply allow us to identify the problem. It also speaks as to how the inequality gap could be closed and it is this aspect of the right to health upon which the health equality campaign proposed in the Social Justice Report is based.
While there are many elements to the right to health, the principle I want to highlight here is the p rogressive realisation principle and how it applies to achieving equality of opportunity in relation to health. Broadly speaking, this is the obligation to ‘take steps’ (in the words of the economic, social and cultural rights covenant) towards equality of opportunity. Now these are not steps in an unqualified sense. For example, the current response of governments – the National Strategic Framework for Aboriginal and Torres Strait Islander Health, or the PHCAP or CHIP programs, could be characterised as ‘steps’, but as I will set out these do not count as steps in terms of progressive realisation.
Slide 5: Example of the progressive realisation principle applied to a situation of inequality TARGET: EQUALITY IN 20-25 YEARS
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Steps towards equality in terms of progressive realisation, as illustrated on the slide above me, are very specific. They require a state to:
- create a plan to provide equality within an ‘ambitious yet realistic time frame’ – that is, a plan that sets equality as a target, and the attainment of that target within a set time frame;
- commit sufficient resources to the plan; and
- be accountable to the plan by setting benchmarks. That is, if your overall time frame for equality is ten years, a benchmark might be to have reduced inequality by 50% within 5 years and have mechanisms in place to measure achievement, or not, of that benchmark . In that way, benchmarks allow governments to be made accountable and facilitate the maintenance of a focus on achieving equality over the long term.
In fact it is these very elements that are striking in their absence from the current response. There is, for example, no timeframe for achieving Aboriginal and Torres Strait Islander health equality in the National Strategic Framework. The absence of such timeframes promotes a lack of accountability of governments and it sends a tacit message that it is ok for things to simply drift along.
In fact, the failure of the policies and programs of the past twenty years to achieve significant improvements in Aboriginal and Torres Strait Islander health status, let alone to reduce the inequality gap, reveal two things that Aboriginal and Torres Strait Islander peoples and the general community can no longer accept from governments.
First, we can no longer accept the making of commitments to address Aboriginal and Torres Strait Islander health inequality without putting into place processes and programs to match the stated commitments. Programs and service delivery must be adequately resourced and supported so that they are capable of achieving the stated goals of governments.
Second, and conversely, we can also not 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 bold targets to focus policy making over the short, medium and longer term or to fund programs so they are capable of meeting these targets. 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: Australian governments have proved unwilling to fund Aboriginal and Torres Strait Islander health programs based on need and, as a result, plans have failed.
The Primary Health Care Access Program is an example. For those who do not know, PHCAP provides funding for the expansion of comprehensive primary health care services in communities through clinical care, illness prevention and early intervention activities and management support systems. PHCAP also provides for new services in areas identified as having the highest relative need and the community capacity to manage funding and service delivery. Now while it is to be welcomed, PHCAP is funded to the tune of approximately $60 million per annum, not the estimated 250 – 570 million dollars per annum of extra resources needed for primary health care on an annual basis. Further, there is no comprehensive strategy in place to meet health infrastructure needs in communities. (And although time does not permit me to speak to this more fully, I would be remiss not to at least mention in passing the importance of Indigenous community control of health services).
In the 2005 Social Justice Report I therefore recommended that governments of Australia commit to achieving equality of health status and life expectation between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians within 25 years. And that in order to achieve this goal, governments need to commit to achieving equal access to primary health care and health infrastructure within 10 years; and to fund programs based on need, not on an ad hoc or incremental fashion. A diagram illustrating the main features of the campaign is on the slide above me.
Slide 6: The campaign for Aboriginal and Torres Strait Islander health equality
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These commitments need to be accompanied by targets and benchmarks over the short, medium and long term. And I note that the Overcoming Indigenous Disadvantage Framework, for example, provides appropriate foundations for establishing achievable targets and benchmarks. And there is some evidence that Australian governments are becoming more open to the use of targets and benchmarks in health – for example, in relation to some chronic disease initiatives as announced in the recent COAG Communiqué.
However, although as my co-presenter Professor Anderson will discuss, there has been a limited use of targets and benchmarks in relation to Indigenous health in the past, the current response contains no such features. As an aside, can I reflect on how ironic it is that the Commonwealth Government has committed to achieve the UN Millennium Development Goals by contributing to the international campaign to eradicate third work poverty by 2015, but has no similar plan to do so in relation to Aboriginal and Torres Strait Islander peoples in Australia. My proposed 25-year campaign would see health equality in Australia attained in the 2030s.
I would like to conclude by stating that I believe that we have a unique window of opportunity at the moment to achieve Indigenous health equality. In fact, as a nation we have perhaps never been as well placed as we currently are to turn the health crisis faced by Aboriginal and Torres Strait Islander peoples around.
- We have the necessary commitments and mechanisms for whole of government coordination (for example, in Indigenous Coordination Centres now being rolled out across the nation, and the jurisdictional health planning forums) to achieve this. Now, as many of you will know, since the National Aboriginal Health Strategy of 1989, this capacity for a coordinated government response has been identified as crucial to any effective response to Indigenous health inequality.
- We also have a historically large budget surplus, just a small fraction of which could lead to dramatic improvements in Aboriginal and Torres Strait Islander peoples’ health status; and
- We have programs in place already such as:
- the Primary Health Care Access Program I have already mentioned;
- like the Community Housing and Infrastructure Program; and
- the overall National Strategic Framework for Aboriginal and Torres Strait Islander Health
that provide a sound programmatic response to the situation. The campaign I am proposing would simply link these policy responses to identified need and place them within a framework of targets and benchmarks. In short, I am not talking about reinventing the wheel, simply improving what is already in place.
- And, finally, we have an unprecedented opportunity, with new agreement making processes (such as Shared Responsibility Agreements and Regional Partnership Agreements), to engage and empower Aboriginal and Torres Strait Islander peoples to overcome existing health inequalities.
Now can I take a few minutes to comment on Shared Responsibility Agreements – agreements in which governments give to communities only if the community do something in return - and how they might be used in the context of the campaign I am proposing?
- First, I note that because health services and health infrastructure are the subject matters of a right – the right to health - they should not be the subject of negotiations. They are entitlements. This is only reinforced by the fact that we are talking here about an address to inequality and no one should have to bargain to be treated equally. In that regard, I welcome indications from the Australian Government that conditions will not be attached to the delivery of primary health and essential services to communities.
- However, I also note that – if we can quarantine off primary health care and health infrastructure – that such agreements can be used positively and appropriately to improve Indigenous health. For example, there have been agreements that:
- provide sports facilities to communities that – among other things – will benefit the health of community members, or
- support breakfast clubs in schools - ensuring that children get a healthy meal at least once a day, and
- conduct participation and information sessions at crèches on baby care, good food preparation and the hazards of smoking etc.
And yet many of these opportunities are not being effectively harnessed. While time tonight does not permit me to address how they could be harnessed, the Social Justice Report does set out how these opportunities can be more effectively utilised within the framework provided by the right to health.
The 40 th anniversary of the 1967 referendum will occur in May next year. Given that one of the main purposes of the referendum was to enable the Commonwealth to address the poor state of Indigenous health, I believe that the health inequality that is still with us; is unfinished business. This anniversary, I believe, would be the ideal time to launch the health campaign I am proposing.
And if we do not rise to the occasion, things could get worse. The Indigenous population is younger and growing faster that the non-Indigenous population. Unless we act now, there is the risk that this generation will inherit the burden of ill-health that fell to their parents and grandparents generations.
Now, in finishing, can I highlight that I have tonight only touched on the main features of the campaign set out in the Social Justice Report. I would urge you to read the Social Justice Report to gauge what the full campaign might look like. As noted, I have limited copies here however the report is available on line - the URL address is on the slide above me.
Thank you. Now, does anyone have any questions?
http://www.humanrights.gov.au/social_justice/sjreport05/index.html
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