Developments in policy

If there is one message I want Governments to hear from this report it is:  Do not press the reset button! ... If we continue to start over again the foundations previously laid will be pulled up time and again, never allowing enough time or energy to build the structure required to close the gap on Indigenous disadvantage.^[121]

Brian Gleeson, the Coordinator General for Remote Indigenous Services

2.1 Proposed changes in Commonwealth-State relations and their impact on the Closing the Gap Strategy

The Closing the Gap Strategy aims to address Aboriginal and Torres Strait Islander disadvantage by achieving outcomes and equality across seven ‘building blocks’ or areas of life (early childhood, schooling, health, economic participation, healthy homes, safe communities, governance and leadership).^[122] This coherent and integrated approach is aligned with the holistic idea of health supported by Aboriginal and Torres Strait Islander peoples,^[123] and with social determinants of health theory.^[124]

The Closing the Gap Strategy is led by the Australian Government and involves the commitment of all the states and territories. As such, it also provides a national and consistent approach to closing the gap that can be sustained over the long term – until 2030. As the Department of Finance’s 2009 Strategic Review of Indigenous Expenditure noted, with these strong foundations in place the ‘key challenge from this point lies not so much in further policy development as in effective implementation and delivery’.^[125]

However, the Campaign Steering Committee is concerned that despite continued Australian Government commitment to closing the gap, broader structural reform to the federal system of the type that is currently being discussed could potentially have an adverse impact on the Closing the Gap Strategy.

(a) Reforms to the federal system

The Australian Government’s National Commission of Audit flagged structural reform to the federal system in its March 2014 report. It recommended clear delineation of respective roles and responsibilities and reform of the Commonwealth’s financial relations with the states and territories.

The Australian Government supports ensuring ‘that, as far as possible, the states are sovereign in their own sphere’.^[126] To that end, the Terms of Reference for the development of a White Paper on the Reform of the Federation (White Paper) were released on 28 June 2014.^[127]

This is intended to set out the Australian Government’s position on the practical application of what ‘the states being sovereign in their own spheres’ might mean for programme and service delivery, including in Indigenous Affairs.^[128]

Issues Paper 1 A Federation for Our Future was released in September 2014.^[129] This states that:

A major part of the [current] problem [with the federation] is that over time, the Commonwealth has become, for various reasons, increasingly involved in matters which have traditionally been the responsibility of the States and Territories.^[130]

This, of course, could include aspects of Indigenous Affairs. Reform along these lines then could potentially signal a break with the spirit of the 1967 referendum. In this, over 90 percent of Australians supported the potential for Australian Government involvement (and the Campaign Steering Committee believes leadership) in Indigenous Affairs. This was, at least in part, because of the failure of the states and territories to effectively address Aboriginal and Torres Strait Islander disadvantage and protect basic human rights since at least federation.^[131]

In relation to the Closing the Gap Strategy, the Issues Paper suggests:

In Australia, we should be particularly mindful of the difference in life chances that exist as a result of socio-economic disadvantage, especially in respect of Aboriginal and Torres Strait Islander peoples, and make it a priority to achieve governments’ commitment to Close the Gap in Indigenous life expectancy, child mortality, education and employment.^[132]

Later the Issues Paper acknowledges that ‘sometimes a national approach is more appropriate than pursuing different approaches across the States and Territories’ and cites addressing Aboriginal and Torres Strait Islander disadvantage as an example of such a national objective.^[133] However, other than this reference it does not significantly address the issue of what ‘clear delineation of responsibilities for different levels of government’ will mean for Aboriginal and Torres Strait Islander Affairs.^[134] Critically for the Campaign Steering Committee, all governments must ensure that actions are taken with clearly articulated responsibilities to address disadvantage.

Issues Paper 3 Roles and Responsibilities in Health, discusses Aboriginal and Torres Strait Islander health and health services at some length. It notes that there is a high degree of overlap between the Commonwealth and state and territory-level involvement in Indigenous health ‘but that the effect of this overlap on Indigenous health is unclear’.^[135]

Further, it discusses the role of the Australian Government in addressing health inequities:

Commonwealth involvement in a policy area is sometimes argued on equity grounds. While the Commonwealth may be best placed to address equity concerns in some circumstances, the States and Territories also work to improve and ensure equity for their communities. The States and Territories are closer to where services are being delivered and are often best placed to know how equity concerns can be addressed.^[136]

The Campaign Steering Committee supports the need for the clarification of roles and responsibilities among Australian governments to ensure the best health outcomes can be achieved for Aboriginal and Torres Strait Islander peoples.

The Campaign Steering Committee firmly believes that the Australian Government has the responsibility to lead the national approach to the Closing the Gap Strategy. Reform to the federal system should not adversely affect this.

(b) Continued national leadership of the Closing the Gap Strategy

In December 2013, COAG decided not to renew the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.^[137] The Campaign Steering Committee is not wedded to a national partnership agreement to further the Closing the Gap Strategy as it pertains to health. It is, however, concerned to ensure that the substitution of a national partnership agreement with tri-lateral Australian Government agreements with the states and territories and jurisdictional representatives of the Aboriginal and Torres Strait Islander health services, does not weaken or fragment the Closing the Gap Strategy. The tri-lateral agreements are being developed through AHMAC and existing Indigenous Health Partnership Forums.^[138]

As highlighted in the Campaign Steering Committee’s two previous reports,^[139] there have been significant cuts to mainstream health expenditure in Queensland,^[140] New South Wales^[141] and South Australia in recent years – particularly to preventative health programmes.^[142]

While not aimed at Aboriginal and Torres Strait Islander people, services or programmes, these cuts are likely to have disproportionate and detrimental impacts on preventative health efforts in these jurisdictions among Aboriginal and Torres Strait Islander peoples.^[143] One critic has highlighted the likelihood for increases in cardiovascular diseases, diabetes and mental health conditions over time.^[144]

As argued in last year’s report, the Campaign Steering Committee believe such jurisdictional health cuts demonstrate the need for greater Australian Government leadership to ensure a consistent national approach in the implementation of the Closing the Gap Strategy. They demonstrate the need for stronger and nationally consistent agreements (whether struck nationally or otherwise) to continue the Closing the Gap Strategy.

Maintaining a national and consistent effort under Australian Government leadership could, to some degree, help immunise the effort to close the health gap from the ever-turning wheels of state and territory-level political fortune.

 

2.2 The Indigenous Advancement Strategy and the Closing the Gap Strategy

The new policy framework developed by COAG (as reflected in the National Indigenous Reform Agreement and the Closing the Gap strategy) represents a comprehensive, coherent and ambitious agenda for reform. The key challenge from this point lies not so much in further policy development as in effective implementation and delivery.^[149]

Strategic Review of Indigenous Expenditure

The Indigenous Affairs priorities of the Australian Government are:

• Getting children to school;
• Getting adults to work; and
• Building safer Indigenous communities.^[150]

The Indigenous Advancement Strategy (IAS) is the vehicle for delivering these three priority objectives. The IAS commenced on 1 July 2014 and consolidated more than 150 individual programmes and activities into five broad-based programme streams that are being coordinated from the Department of the Prime Minister and Cabinet (PM&C). It does not include the bulk of health and mental health programmes that remain located in the Department of Health. The primary exception is the ‘Social and Emotional Wellbeing Programme’ which was transferred to PM&C.^[151]

The 2014-15 Budget, delivered in May 2014, detailed that the IAS consolidation will save the Australian Government $534.4 million over five years through programme rationalisation.^[152] The Campaign Steering Committee supports the reduction of red tape and duplication. However, the lack of detail on how these savings or cuts will apply and their impact on services and health outcomes is an ongoing concern.

The Campaign Steering Committee also notes that the IAS has been developed with minimal input from Aboriginal and Torres Strait Islander peoples and their representative organisations, apart from the Indigenous Advisory Council. This is despite the Australian Government seeking greater levels of engagement with Aboriginal and Torres Strait Islander peoples within the IAS itself. As noted by the Aboriginal and Torres Strait Islander Social Justice Commissioner:

The Federal Government has outlined its intention for a new engagement with Aboriginal and Torres Strait Islander people. To achieve this goal, surely it must at least have a discussion with us before proceeding with a radical re-shaping of government policy that so profoundly affects us? The Aboriginal and Torres Strait Islander leadership stands ready for this conversation with Government. All it takes is an assurance that we will be heard.^[153]

Without such engagement, these sweeping changes to programme funding have and continue to cause anxiety within Aboriginal and Torres Strait Islander organisations across the country. As further noted by the Aboriginal and Torres Strait Islander Social Justice Commissioner:

To give some idea of the magnitude of the changes confronting the Department of the Prime Minister and Cabinet is the rationalisation of approximately 150 programs and activities down to five. This affects about 1,440 organisations with just over 3,000 funding contracts. On top of this, the Department will have to manage a budget cut in the vicinity of $400 million over the next four years.^[154]

In November 2014, the Australian Government stated it would delay announcing the assessment of IAS applications until March 2015.^[155] This delay underlines the difficulties of the process and is a further cause of anxiety for Aboriginal and Torres Strait Islander organisations.

The five IAS programme streams are set out in the text box below.

 

Generational change takes time, commitment and a long-term strategic approach to ensure success. While we welcome the Australian Government’s IAS focus on improving employment, education outcomes and community safety, the Campaign Steering Committee believes the IAS needs to be coordinated within the national COAG Closing the Gap Strategy. Without such a national, coordinated approach, Indigenous Affairs is at risk of splitting along departmental and jurisdictional lines and becoming less effective and efficient.

Articulating and strengthening links between the IAS and the Closing the Gap Strategy will ensure that the IAS would achieve its goals. This is because a focus on health and wellbeing is fundamental to achieving improvements in school attendance, employment and safer communities.

As set out in the report of Mr Andrew Forrest, Forrest Review – Creating Parity, employment cannot be addressed in isolation, as:

A significant proportion of these [unemployed Aboriginal and Torres Strait Islander] individuals suffer from lifestyle and health conditions that pose considerable obstacles to employment...^[157]

The report of the Forrest Review also stresses the importance of maternal and early childhood health as key determinants of employment later in life.^[158]

The IAS could also be used to support the recruitment and employment of Aboriginal and Torres Strait Islander staff in health services. As discussed in the Campaign Steering Committee’s Progress and priorities Report 2014, the 2011 Census results show that health services (including, but not limited to, ACCHS) employ 14.6 percent of employed Aboriginal and Torres Strait Islander people. Health services are thus the single biggest ‘industry’ source of employment, which has expanded by almost 4,000 places since 2006.^[159]

Health services also provide pathways to employment for community members through internships and ‘in-house’ training. This reduces welfare dependency and connects individuals, families and communities to the wider economy. Flow-on benefits include the enabling of healthy norms and routines for community members and their families. Investment in health has a multiplier effect in communities beyond the critical improvements in health that they deliver.

The Campaign Steering Committee believes that connecting the IAS to the existing Close the Gap Strategy will bring advantages to both, contributing to a broader, holistic approach that includes health at the national level.

Another important finding of the Reeve study (discussed above) into the ‘diabetes gap’ was an association between lower levels of school education and higher prevalence of diabetes, possibly due to reduced capacity to access, interpret and act upon information.^[160] The study concludes:

If the significance of education is indicative of the capacity to access and act on health information, health promotion initiatives that provide information about healthy lifestyles and encourage increased engagement with primary care services should aid in prevention through earlier detection of pre-diabetes.^[161]

This again underscores the connectedness of education (an IAS priority) and health and the need to develop and expand the linkages between the IAS and the Closing the Gap Strategy for the enhancement of both.

2.3 Potential negative impact of proposed Budget measures

The Campaign Steering Committee is concerned about the potential negative impact of proposed measures contained in the 2014-15 Budget.

Reported cuts of up to $130 million over five years from the Tackling Indigenous Smoking programme are of particular concern. While this is now being explained in terms of a ‘freeze’ on recruitment of staff to the Tackling Smoking and Healthy Lifestyle Teams, which are central to delivery of the programme, it is still not clear what the long-term prospect for the programme is. Following a review, the future shape of the programme is due to be announced in early 2015.  The freeze on recruitment reduces the reach of the programme, undermines the momentum built to date, and erodes the programme’s goodwill developed with Aboriginal and Torres Strait Islander communities.

The reduction in Aboriginal and Torres Strait Islander smoking rates by 10 percent over the last decade, as well as the marked increase in the number of Aboriginal and Torres Strait Islander people not taking up smoking, demonstrates that efforts to cut smoking rates are working and that further gains are possible. As explored in Chapter 1, there is a clear link between smoking and poor outcomes in child mortality and life expectancy.

This recommendation requires not only maintaining current levels of funding, but increasing funding as the Tackling Smoking and Healthy Lifestyle Teams are fully established and start to consolidate and expand their activities.  Reducing smoking among Aboriginal and Torres Strait Islander mothers while pregnant should remain a particular focus, along with prevention of take-up by Aboriginal and Torres Strait Islander children and youth, through a population health campaign approach.

The Campaign Steering Committee is also concerned that the $89 million will be saved by slowing investments in primary health care funding prior to the implementation of the new funding approach and that funding in relation to activities under the expiring National Partnership Agreement on Indigenous Early Childhood Development will not be replaced.^[162]

As noted in the Forrest Review, reducing funding for early childhood programmes is short-sighted in terms of health outcomes among the resulting adult population. It is also an incredibly inefficient way of making cuts – a dollar saved in the early childhood years may result in many more dollars being spent later on:

If we get early childhood development and school education right, we don’t need to invest in or waste money by the billions in other areas as we do now. Measures relating to early childhood and school education are a long-term fix.^[163]

Recommendation 1 of the Forrest Review is for all governments to prioritise investment in early childhood, from conception to three years of age.^[164] While the Campaign Steering Committee has concerns with the Forrest Review including the breadth of its recommendations,^[165] nonetheless it wholeheartedly supports the recognition of the importance of early childhood development. At the time of writing this report the Australian Government was yet to respond to the Forrest Review.

The Campaign Steering Committee also notes the creation of the Indigenous Australians’ Health Programme and the new funding allocation methodology for Indigenous health grants.^[166] The Campaign Steering Committee supports a new funding formula for Aboriginal and Torres Strait Islander health services that is developed with the full and effective participation of Aboriginal and Torres Strait Islander peoples and their representative organisations.

The formula must be indexed for population growth and inflation, be geographically equitable and focus on areas with poor health outcomes and inadequate health services. Further, the evidence which demonstrates that ACCHS have inherent advantages as the provider of choice in terms of both better access and higher quality of service is to be utilised in developing this funding allocation.^[167]

The 2014-15 Budget and subsequent related developments also contains a number of proposed ‘mainstream’ measures that, if passed into law, will likely have a disproportionate impact on Aboriginal and Torres Strait Islander health. These include:

• The various proposed changes by the Australian Government regarding a co-payment for the Medicare Benefits Scheme (MBS) and the proposed increase to co-payments to the Pharmaceutical Benefits Scheme (PBS).^[168] The Campaign is firmly of the view that increasing out-of-pocket expenses for health care will further entrench existing barriers to equitable healthcare access for Aboriginal and Torres Strait Islander peoples.
• The cuts to preventative health programmes in the budget.^[169] Preventative health initiatives could also have significant impacts on Aboriginal and Torres Strait Islander peoples because of the negative effect this will have on addressing chronic disease. As outlined in Chapter 1 of this report chronic disease is a significant contributor to the health equality gap.
• The proposal to withdraw funding from hospitals.^[170]

In Chapter 3 the Campaign Steering Committee briefly considers the impact of proposed welfare reforms on Aboriginal and Torres Strait Islander youth.

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^[121] Coordinator General for Remote Indigenous Services, Final Biannual Report, 2014, p 4. URL http://www.papertracker.com.au/pdfs/cgris_report09.pdf.
^[122] Council of Australian Governments, above note 2.
^[123] See for example: National Aboriginal Health Strategy, 1989; Swan P and Raphael B, 'Ways forward': National Consultancy Report on Aboriginal and Torres Strait Islander Mental Health, 1995.
^[124] See for example: Wilkinson R and Marmot M (eds), Social Determinants of Health: The Solid Facts, 2nd ed, 2003.
^[125] Department of Finance and Deregulation, Strategic Review of Indigenous Expenditure, 2009 p 11. URL www.finance.gov.au/sites/default/files/foi_10-27_strategic_review_indigenous_expenditure.pdf.
^[126] Abbott Hon. T, White Paper on the Reform of the Federation, 28 June 2014, (Media Release). URL www.liberal.org.au/latest-news/2014/06/28/prime-minister-white-paper-reform-federation.
^[127] Abbott, above note 127.
^[128] Australian Government, A Federation for Our Future, Reform of the Federation White Paper, Issues Paper 1, 2014. URL https://federation.dpmc.gov.au/issues-paper-1.
^[129] Australian Government, above note 129.
^[130] Australian Government, above note 129, p vi.
^[131] Attwood B, Rights for Aborigines, 2003, pp 172-180.
^[132] Australian Government, above note 129, p 16.
^[133] Australian Government, above note 129, p 16.
^[134] Australian Government, above note 129, p 16.
^[135]Australian Government, Roles and Responsibilities in Health, Reform of the Federation White Paper, Issues Paper 3, 2014, p 15. URL https://federation.dpmc.gov.au/issues-paper-3.
^[136] Australian Government, above note 136, p 33.
^[137] Department of Health, Indigenous Health 2014-15 Budget – Questions and Answers, 2014. URL www.health.gov.au/internet/main/publishing.nsf/Content/596E9445127A4683CA257BF0001D7A79/$File/q&a%20indigenous%20health%20budget%20280514.pdf.
^[138] Department of Health, above note 138.
^[139]Close the Gap Campaign Steering Committee, Close the Gap Progress and Priorities Report 2014, 2014. URL https://www.humanrights.gov.au/publications/close-gap-progress-and-priorities-report-2014; Close the Gap Campaign Steering Committee, Close the Gap Shadow Report 2013, 2013. URL https://www.humanrights.gov.au/close-gap-indigenous-health-campaign#shadow.
^[140] Hurst D, ‘Healthy lifestyles program funding cut’, Brisbane Times, 24 September 2012. URL www.brisbanetimes.com.au/queensland/healthy-lifestyle-programs-funding-cut-20120924-26fsf.html.
^[141] ‘NSW Health told to find $3 billion In Savings’, ABC News, 14 September 2012. URL http://www.abc.net.au/news/2012-09-14/243-billion-squeezed-from-nsw-health-budget/4260814.
^[142] Wills D, ‘200 nursing positions to be cut from South Australian hospitals in health department savings blitz’, The Advertiser, 30 September 2013. URL http://www.adelaidenow.com.au/news/south-australia/nursing-positions-to-be-cut-from-south-australian-hospitals-in-health-department-savings-blitz/story-fni6uo1m-1226730350856?nk=b6848603ab8065ebb244f332d6086d67; ‘South Australian Government to cut health services’, ABC News, 9 August 2013. URL http://www.abc.net.au/news/2013-08-09/health-sector-cuts-jack-snelling-jobs-mental-health-report-/4875228.
^[143] These comments were also printed in our 2013 Shadow Report see: Hunter E, ‘Aborigines will bleed from cuts’, The Australian, 15 September 2012. URL http://www.theaustralian.com.au/national-affairs/opinion/aborigines-will-bleed-from-cuts/story-e6frgd0x-1226474433823.
^[144] Hunter, above note 144.
^[145] Australian Government, Budget Measures, Budget Paper 2 2014-2015, 2014, p 187. URL http://www.budget.gov.au/2014-15/content/bp2/html/index.htm.
^[146] Department of the Prime Minister and Cabinet, Portfolio Budget Statement 2014-2015, Budget Related Paper No. 1.14, 2014, p 25.
^[147] See the Close the Gap Clearinghouse website. URL http://www.aihw.gov.au/closingthegap/.
^[148] Australian Government, Mid-Year Economic and Fiscal Outlook 20145-15, 2014, p 171. URL http://www.budget.gov.au/2014-15/content/myefo/html/index.htm.
^[149] Department of Finance and Deregulation, above note 126, p 11.
^[150] Australian Government, above note 1, pp 2-3.
^[151] See Department of the Prime Minister and Cabinet, Indigenous Advancement Strategy. URL http://www.dpmc.gov.au/indigenous-affairs/about/indigenous-advancement-strategy.
^[152] Australian Government, above note 146, p 185.
^[153] Gooda M, ‘This budget could devastate Indigenous Australians’, The Drum, 20 May 2014. URL http://www.abc.net.au/news/2014-05-20/gooda-this-budget-could-devastate-indigenous-australians/5462748.
^[154] Gooda M, Engage with us, says Commissioner Gooda, 8 December 2014, (Media Release). URL https://www.humanrights.gov.au/news/opinions/engage-us-says-commissioner-gooda.
^[155] Scullion Hon. N, Indigenous Grant Round, 24 November 2014 (Media Release) http://www.nigelscullion.com/media-hub/indigenous-affairs/indigenous-grant-round.
^[156] Australian Government, Indigenous Advancement Strategy Guidelines, 2014, p 4. URL http://www.dpmc.gov.au/sites/default/files/publications/ias_guidelines.pdf.
^[157] Forrest A, The Forrest Review – Creating Parity, Commonwealth of Australia, 2014, p 121. URL https://indigenousjobsandtrainingreview.dpmc.gov.au/forrest-review.
^[158] Forrest, above note 158.
^[159] Australian Bureau of Statistics, New 2011 Census data reveals more about Aboriginal and Torres Strait Islander peoples, (Media release), 30 October 2012. URL http://www.abs.gov.au/websitedbs/censushome.nsf/home/CO-64?opendocument&navpos=620#industry.
^[160] Reeve et al, above note 6, p 464.
^[161] Reeve et al, above note 6, p 464.
^[162] Department of Health, Correspondence with Campaign Steering Committee regarding budget decisions, 22 May 2014.
^[163] Forrest, above note 158, p 20.
^[164] Forrest, above note 158, p 22.
^[165] Close the Gap Campaign Steering Committee, Submission in response to the Forrest Review – Creating Parity, 2014.
^[166] Department of Health, Portfolio Budget Statement 2014-2015, Budget Related Paper No. 1.10, 2014, p 103. URL http://www.health.gov.au/internet/budget/publishing.nsf/Content/2014-2015_Health_PBS.
^[167] See Panaretto K et al, above note 47.
^[168] See Australian Government, above note 146, p 133, 140; Abbott Hon. T; Dutton Hon. P, A Strong and Sustainable Medicare, 9 December 2014, (Media Release). URL http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2014-dutton111.htm?OpenDocument&yr=2014&mth=12; Ley Hon. S, Government to consult on Medicare reform, 15 January 2015, (Media Release). URL http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-ley002.htm.
^[169] Australian Government, above note 146, pp 138, 145.
^[170] Australian Government, above note 146, p 126.