Establishing effective pathways for positive change – an analysis by the Campaign Steering Committee
The need for a long-term approach and bipartisan support across the political divide [for addressing Aboriginal and Torres Strait Islander disadvantage] was stressed by those attending consultations across Australia and in the hundreds of written submissions to the review. First Australians and those working with them are rightly cynical about new government reform and how long it will last. The fundamentals of the... Closing the Gap strategy have bipartisan support and give us solid ground to build on.
The Forrest Review
The Campaign Steering Committee, while sobered by the size of the task remaining, is heartened by small but significant absolute life expectancy gains reported in 2010-2012. Further, it is more convinced than ever of the imperative for patience and that a focus is kept on the long-term, generational impact of the Closing the Gap Strategy. Further a sustained and targeted focus improving access to appropriate services is required.
As discussed in our Progress and priorities report 2014, the life expectancy estimate for 2010-2012 is the first new estimate published within the lifetime of the Closing the Gap Strategy – just two and a half years after the July 2009 commencement of the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes and the Indigenous Chronic Disease Package. As we have noted, the 2010-2012 life expectancy estimate therefore should be considered as akin to a baseline life expectancy estimate against which to measure progress until 2030 and beyond.
As outlined in Chapter 1, New Zealand Maori life expectancy over the past two decades can be usefully compared to the gains made by Aboriginal and Torres Strait Islander peoples to assess the latter’s progress, as set out in Table 5. The table includes life expectancy estimates for Maori men and women in 2000-2002, 2005-2007 and 2010-2012.
Life expectancy comparisons between Australia and New Zealand should be approached with caution because of different methodologies to make estimates. Nevertheless the comparison is a useful indicator and suggests that the life expectancy of Aboriginal and Torres Strait Islander peoples today is about a decade behind that of the Maori.
Table 5: A comparison of Maori and Aboriginal and Torres Strait Islander life expectancy in 2010-2012, by gender
Aboriginal and Torres Strait Islander
As can be seen in Table 5 above, the comparison suggests what long term focused action towards achieving health equality for Aboriginal and Torres Strait Islander peoples can yield valuable results. In 2010-2012 the Closing the Gap health reforms associated with the Closing the Gap Strategy were just getting started.Because of this time lag, the Campaign Steering Committee believe that significant increases in life expectancy, like those seen among the Maori, should be expected before the early 2020s if the national effort to close the gap is maintained.
New Zealand efforts to close the Maori health equality gap
Since 1992, the New Zealand Government’s Maori health policy objectives have required regional health authorities and the Public Health Commission to be guided by an objective ‘to improve Maori health status so that in the future Maori will have the same opportunity to enjoy the same level of health as non-Maori’. By this, services must recognise the special needs and cultural values of Maori.
This objective was to form the basis of much of the growth and development of Maori health initiatives throughout the 1990s.A Maori health branch of the New Zealand Ministry of Health was established in 1993. In 2000, it became a directorate. A Maori Capacity and Capability Plan was released in 2001. The Plan sought to build Maori management and workforce capacity, and to strengthen the knowledge and awareness of Maori health issues across the entire health system, including within the Ministry of Health and Maori health directorate. Consultation on the He Korowai Oranga (the Maori Health Strategy) began in the same year.
The Public Health & Disability Act 2000 (NZ) now incorporates a number of significant references to Maori health. In particular, it requires district health boards to establish and maintain processes to enable Maori to participate in and contribute to strategies for Maori health improvement. Part 3 of the Act provides for the establishment of district health boards and sets out their objectives and functions. They include the objective of reducing health disparities by improving health outcomes for Maori and other population groups, and to reduce, with a view to eliminating, health outcome disparities between the various population groups.The Ministry of Health today continues to describe Maori health inequality as unacceptable, and continues to work towards equality as a priority.
The Campaign Steering Committee believes we will start to see reductions in cardiovascular disease, indeed all chronic disease, among Aboriginal and Torres Strait Islander people as the new services, health checks, preventative health campaigns and other initiatives take effect. Assessing the impact of these measures requires a realistic understanding of the lag times between the rollout of programmes and the availability of measurements to assess their impact. The same applies to the effort to close the gap should more broadly.
As noted, creating better connections between the IAS and Closing the Gap Strategy could strengthen existing responses to school attendance, employment and community safety and help improved health outcomes. The IAS could also provide a further building block – culture – to enhance the Closing the Gap Strategy. This is entirely consistent with the position of the Health Plan that asserts the central place of culture in affecting positive outcomes in the health of Aboriginal and Torres Strait Islander peoples.
Culture is not an ‘add-on’ but rather underpins effective service and programme delivery. The role of culture as an additional building block in an enhanced Closing the Gap Strategy is discussed in the text box below.
Culture, the Indigenous Advancement Strategy and an enhanced Closing the Gap Strategy
In the context of service and programme delivery, ‘culture’ refers to the cultural underpinnings of Aboriginal and Torres Strait Islander family and community life as well as cultural activities and other expressions of culture. A building block based on the importance of culture would make a decisive contribution to the Indigenous Affairs priorities of the Australian Government in ways which may not be currently considered explicitly by the IAS and the Closing the Gap Strategy. For example:
- A recent Australian National University study of Aboriginal and Torres Strait Islander child truancy by Biddle found that there were strong associations between family functioning and truancy. In fact, household stress, housing issues and family crises were the most important predictors of school non-attendance. Strengthening families, including by supporting the cultural underpinning of family life, is likely to result in improved school attendance.
- Dockery’s analysis of the 2008 NATSISS identified Aboriginal and Torres Strait Islander people with strong cultural attachment are significantly more likely to be in employment than those with moderate or minimal cultural attachment. Furthermore, Aboriginal and Torres Strait Islander people who participate in cultural activities and who speak Indigenous languages are more likely to be employed than those who do not. While the casual factors are the focus of continuing research, the data suggests that positive cultural participation will contribute to supporting employment outcomes.
- It should be noted that cultural industries provide economic opportunities for Aboriginal and Torres Strait Islander peoples. In fact, the practice and production of Indigenous visual arts and the employment it generates is a multi-million dollar industry. In 2006, it was reported that 12 percent of Aboriginal and Torres Strait Islander people in remote areas received payment for making arts or crafts; performing theatre, music, or dance; or writing or telling stories.
The COAG Reform Council closes its final report on the Closing the Gap Strategy questioning whether the indicators that the health and life expectancy gap is closing need to be reconsidered. In particular, it questions the utility of the exclusive focus on improved outcomes (when such outcomes may take many years to show themselves). In this context it proposes broadening them to include improved access to health services, specialists, medications and other indicators of increased opportunity to be healthy in addition to outcome measures.
This approach is in line with the Campaign Steering Committee’s often stated belief that it is improved access to health services that will, over time, translate into improved outcomes. Access to proximal, available and culturally appropriate services is prerequisite to improved health outcomes.
The COAG Reform Council notes that the current indicators give a good overview of health behavioural risk factors (smoking, obesity and alcohol consumption) contributing to the burden of chronic disease affecting Aboriginal and Torres Strait Islander people. It also measures the burden of death from chronic disease itself. However, as highlighted in Chapter 1, it critically fails to account for the fact that these conditions are also treatable and manageable conditions with effective assistance from appropriate health services. In other words, deaths as a result of both the risk factors and chronic conditions are not inevitable if appropriate interventions occur.
To illustrate this point, the COAG Reform Council highlights the difference in Aboriginal and Torres Strait Islander and non-Indigenous survival rates from cancer in 1999-2007 in New South Wales, Queensland, Western Australia, and the Northern Territory – as set out in Table 6 below.
Table 6: The difference in Aboriginal and Torres Strait Islander and non-Indigenous survival rates from cancer in 1999-2007 in New South Wales, Queensland, Western Australia, and the Northern Territory, all levels of remoteness
Aboriginal and Torres Strait Islander survival rate
Non-Indigenous survival rate
Breast cancer in women
The gap in survival rates can be explained by factors such as advanced cancer at diagnosis, reduced access to and uptake of treatment, higher rates of comorbidities, and language barriers.
The current indicators and targets do not account for access to health services. Access is a critical factor in closing the gap. Accessing health services and appropriate interventions on treatable conditions can and does prevent deaths and reduce the burden of disease.
And, despite the much higher health needs of Aboriginal and Torres Strait Islander peoples, the most recent comparable data suggests that their overall access to health services is only marginally higher than that of non-Indigenous people and considerably less than appropriate for the level of need.
The 2011 review of the National Indigenous Reform Agreement referred to work on an improved measure for access compared to need to the NIRA Performance Information Management Group. This reference found that available measures of access compared to need were too conceptually complex for public reporting under the Agreement framework (this work will shortly be published by the AIHW).
However, the Campaign Steering Committee supports the development of other proxy indicators to provide insights into how use and availability of health services affects Aboriginal and Torres Strait Islander life expectancy. These indicators should complement existing measures on behavioural risk factors as part of an enhanced Closing the Gap Strategy.
That proxy indicators are developed to provide insights into the impact of the use and availability of health services on Aboriginal and Torres Strait Islander health and life expectancy outcomes.
Decades of Indigenous controlled health service delivery have seen the Aboriginal community controlled health sector become a leading provider of primary health care services and a significant employer of Aboriginal and Torres Strait Islander peoples. This sector has mature organisations with a depth of expertise and capabilities, particularly in remote and regional areas, surpassing the level of mainstream health services in some areas.
Mr Warren Mundine, Chair of the Indigenous Advisory Council, 2014
It is essential to invest in those services which have been shown to perform best in the identification of risk factors, performance of health checks, care planning, and the management of Aboriginal and Torres Strait Islander patients. With their model of comprehensive primary health care and community governance, ACCHS have reduced unintentional racism, barriers to access to health care, and are progressively improving individual health outcomes for Aboriginal and Torres Strait Islander people.
In 2012-2013, 260 services delivered primary health-care, substance-use rehabilitation and treatment services, and social and emotional wellbeing (including Bringing them home and Link-Up counselling and family reunion) services primarily to Aboriginal and Torres Strait Islander people. They report to the Australian Government and these services’ reports are published regularly. Of these, 205 are defined as Indigenous-specific primary health organisations (ISPHO) including 175 ACCHS.
In their 2014 analysis of the performance of ACCHS, Panaretto and colleagues looked at the evidence supporting Aboriginal and Torres Strait Islander people’s relative use of ACCHS and general practice in Queensland by comparing ABS 2011 Census data and ACCHS service use data. They report that ‘access to services is critical and, where ACCHS exist, the community prefers to and does use them’. In addition the study found that:
[T]he number of Aboriginal patients making one visit in 2 years to... regional ACCHSs is higher than the resident Indigenous population... For 11 of 17 services, over 60% of Aboriginal people living in their catchments within a 30-minute drive had visited in the 2 years to September 2012... for six of these ACCHSs, all classified Remoteness Area 2 or 3, the data suggest up to 100% of the Aboriginal population living within a 30-minute drive are using their services, with many patients travelling longer than 30 minutes.
Also, as set out in the text box below, Panaretto and colleagues surveyed the literature to evaluate whether ACCHS performed better for Aboriginal and Torres Strait Islander people than general practices. This was particularly in relation to the prevention, detection and treatment of chronic disease. Their findings provide strong support for properly resourced ACCHS. The positive effectiveness of ACCHS has also been documented in recent Department of Health research.
Panaretto and colleagues compare the performance of Aboriginal Community Controlled Health Services in Queensland with general practice (extract, without references)
The medical literature has many reports of well-implemented research programs, often integrated with everyday care in ACCHS, showing improved health outcomes. Sexual health, maternal and child health, smoking cessation and cardiovascular programs have been successfully run and monitored in ACCHS.
Care delivered in ACCHS for prevention and chronic disease management appears to be equal to if not better than that delivered by general practices. Queensland Aboriginal and Islander Health Council... data show good performance in risk factor monitoring and the management of hypertension and chronic disease...
The Torpedo study, a randomised controlled trial of the use of an electronic decision-support system measuring absolute cardiovascular risk, shows ACCHS outperforming general practices in managing risk... Data collected in late 2011 show that the ACCHS sites had significantly more patients at high risk being prescribed best-practice medications than the general practice sites at baseline, and this gap was sustained through the intervention period.
Data from the Australian Primary Care Collaboratives (APPC) program, often not published, can examine performance between ACCHS and general practice clusters. Data for 2012, from Wave 2 of the APCC e-health program, show that ACCHSs in Queensland had more diagnoses coded (as opposed to use of free text) in medical histories and a higher proportion of medications on their current medication lists prescribed within the preceding 6 months than their general practice counterparts.
This pattern is similar to that reported for cardiac and diabetes care in 2013 and seen in recent years in the QAIHC Closing the Gap Collaborative, where ACCHS were the higher performers in identification of risk factors and
It is critical that ACCHS continue to be funded and expanded to ensure the Aboriginal and Torres Strait Islander population is able to access them. This becomes particularly important when considering the potential significant health gain to be made by the high proportions of treatable and preventable conditions that are not currently being addressed as shown in the NATSIHMS (discussed in Chapter 1).
A good start in developing the services use and access indicators we propose would be to link them to meeting existing services gaps within ACCHS. The two key advantages of ACCHS are better access and a more culturally appropriate, community-based holistic approach, which in many ways offers, in the long term, a better return on investment of the health dollar.
In 2012-2013, the most common service gaps reported by all 260 organisations in the service reports were around mental health and social and emotional wellbeing (62 percent of organisations). The existence of this gap provides support for an increased focus on mental health and social and emotional wellbeing services and programmes within an enhanced Closing the Gap Strategy.
But equally, a concerted effort is needed to ensure ACCHS and ISPHO are properly resourced to address chronic disease and services for mothers and babies. Nearly half of all 260 organisations reported alcohol, tobacco and other drugs (48 percent) and youth services (47 percent) as service gaps in 2012-2013. Prevention and early detection of chronic disease was reported as a gap by 45 percent of organisations.
Equally critical to the above is the training of an Aboriginal and Torres Strait Islander health workforce, and support for the Aboriginal and Torres Strait Islander professional bodies. These bodies are working hard to increase the number of health professionals in the various health professions to achieve employment/population parity within them.
Such a workforce will also assist to shape a culturally safe, high quality health care system that is capable of supporting real improvements in Aboriginal and Torres Strait Islander health outcomes. Further, the health sector as the largest employer of Aboriginal and Torres Strait Islander people provides an exemplar for creating sustainable jobs and career pathways. Investing in the Aboriginal and Torres Strait Islander health workforce, including professional bodies, has a multiplier effect, of improved health and employment outcomes and their associated benefits.
The text box below provides an example of these programmes, and in particular, the benefits of investing in Aboriginal and Torres Strait Islander youth.
Murra Mullangari – Pathways Alive and Well
In 2013, the Australian Indigenous Doctors’ Association (AIDA) auspiced the inaugural Murra Mullangari – Pathways Alive and Well programme. This national Aboriginal and Torres Strait Islander health careers programme was held in partnership with the following peer Indigenous peak health organisations: Indigenous Allied Health Australia; Congress of Aboriginal and Torres Strait Islander Nurses and Midwives; National Aboriginal Community Controlled Health Organisation; Australian Indigenous Psychologists Association; Indigenous Dentists’ Association of Australia; and National Aboriginal and Torres Strait Islander Health Workers’ Association.
Thirty students from years 10, 11 and 12 participated in the programme which aimed to:
- increase knowledge of health careers;
- increase knowledge of pathways into tertiary study; and
- build the aspiration and confidence of Aboriginal and Torres Strait Islander students to stay in the education pipeline and achieve a career within the health profession.
With funding from the (then) Commonwealth Department of Education, Employment and Workplace Relations, the programme was delivered in two components over a period of six months. The first component, a one-week residential workshop in Canberra, provided students with: information about pathways into vocational and higher education; knowledge of a broad range of health professions; the opportunity to network with Indigenous health professionals and leaders; and exposure to a range of national institutions. The second component, mentoring, allowed programme participants to build upon the experiences gained during the residential workshop by connecting the participant with an Indigenous mentor within their desired career.
An in-depth evaluation process of the Murra Mullangari – Pathways Alive and Well programme demonstrates that the programme achieved its aims and objectives. Programme participants reported an increase in their knowledge of the various health careers and pathways into university study and vocational education and training. They also reported an increase in their knowledge of the health issues impacting on Indigenous people. Students advised that the programme built their confidence and aspirations toward achieving a career within the health profession. Four programme participants who completed their schooling in 2013 have commenced tertiary studies in health disciplines since the completion of the programme.
There is an entrenched mental health crisis among Aboriginal and Torres Strait Islander peoples that must be addressed. Mental health problems, including self-harm and suicide, have been reported at double the rate of that of non-Indigenous people for at least a decade. Recent data suggests the situation is getting worse, as set out in the text box below.
- Psychological Distress: In 2012–13, 30 percent of respondents to the AATSIHS over 18 years of age reported high or very high psychological distress levels in the four weeks before the survey interview. That is nearly three times the non-Indigenous rate. In 2004-05, high and very high psychological distress levels were reported by 27 percent of respondents suggesting an increase in Aboriginal and Torres Strait Islander psychological distress rates over the past decade.
- Mental Health Conditions: Over the period July 2008 to June 2010, Aboriginal and Torres Strait Islander males were hospitalised for mental health-related conditions at 2.2 times the rate of non-Indigenous males; and Aboriginal and Torres Strait Islander females at 1.5 times the rate of non-Indigenous females. Rates of psychiatric disability (including conditions like schizophrenia) are double that of non-Indigenous people.
- Suicide: The overall Aboriginal and Torres Strait Islander suicide rate was twice the non-Indigenous rate over 2001-10. Around 100 Aboriginal and Torres Strait Islander deaths by suicide per year took place over that decade. In 2012, 117 suicides were reported. The OID 2014 Report shows that hospitalisations for intentional self-harm increased by 48 percent since 2004-2005.
The Campaign Steering Committee believes that strengthening social and emotional wellbeing, building resilience and reducing psychological distress is of direct importance to the Indigenous Affairs priorities of the Australian Government and the IAS, in the following ways:
- Among adults who reported high/very high levels psychological distress, 38 percent were unable to work or carry out their normal activities for significant periods of time because of their feelings in the NATSISS 2008. (Note that the AATSIHS data that would connect reported rates of high and very high psychological distress to inability to work in 2012-13 has not yet been published – hence the reliance on NATSISS 2008 data to indicate the connection between high and very high psychological distress and inability to work).
- In the NATSISS 2008, adults with high/very high levels of psychological distress were also more likely to drink at chronic risky/high risk levels (21 percent compared with 16 percent with low/ moderate levels of psychological distress) and to have used illicit substances in the previous 12 months to the survey (27 percent compared with 18 percent). Substance abuse is a community safety issue and is associated with violence, child maltreatment, high rates of imprisonment, and other challenges facing communities.
- Promoting social and emotional wellbeing and resilience should also contribute to improving school attendance and performance because it will support children to cope with bullying and racism.
As the Campaign Steering Committee argued in its 2014 report, a dedicated Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing plan is needed. The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing provides the basis for such a plan.
This should be developed and implemented along with the Health Plan, the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013 and the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy. A coordinated implementation process for all four will avoid duplication, be more efficient, and maximise opportunities in this space.
The Campaign Steering Committee notes the Commonwealth funding of a comprehensive evaluation of suicide prevention programmes for Aboriginal and Torres Strait Islander peoples and looks forward to reporting on the findings later this year.
The text box below provides an example of a successful strategy of targeting racism, a preventative measure for addressing mental health issues.
Stop. Think. Respect. Campaign – Using primary prevention to address racism as a social determinant of poor mental health
In 2014, beyondblue launched a national anti-discrimination campaign addressing the impact of racial discrimination on the mental health and wellbeing of Aboriginal and Torres Strait Islander peoples. In developing the campaign, beyondblue carried out extensive research and consultation with Aboriginal and Torres Strait Islander peoples. The campaign was also guided by an Advisory Group, comprising a mix of representatives from Aboriginal and Torres Strait Islander organisations, other organisations and individuals with specific knowledge and expertise.
The campaign focused on the harmful impacts of subtle forms of interpersonal discrimination, and encouraged everyone in Australia to check their behaviour. With over 3.74 million online views to date, ‘The Invisible Discriminator’ campaign advertisement has attracted significant community interest.
Preliminary independent evaluation results show that the campaign is having an impact on the target audience of non-Indigenous people aged 25-44 years. Awareness of the prevalence of discrimination increased by up to 7 percent when compared to the pre-campaign baseline survey, demonstrating increased awareness of the behaviours which constitute discrimination. There has been a statistically significant reduction in the proportions of people who do not consider that several of the campaign scenarios are discriminatory in nature. Seventy-five percent of people consider that the campaign is raising awareness of the mental health impacts of discrimination. One in five people thought about what they could do to reduce discrimination against Aboriginal and Torres Strait Islander peoples after seeing the campaign.These results show that investment in primary prevention campaigns can make a difference by tackling the social determinants of ill-health.
The Campaign Steering Committee also recommends that the Closing the Gap Strategy is enhanced by the development of targets to reduce rates of imprisonment and violence and that achieving the targets is funded by a justice reinvestment approach. In doing so we build upon a number of earlier recommendations calling for reform:
- Recommendation 1 of the Aboriginal and Torres Strait Islander Social Justice Commissioner’s 2009 Social Justice Report that the Australian Government, through COAG, set criminal justice targets that are integrated into the Closing the Gap Strategy.
- Recommendation 2 of the House of Representatives Standing Committee on Aboriginal and Torres Strait Islander Affairs’ June 2011 report, Doing Time – Time for Doing: Indigenous youth in the criminal justice systems that the Commonwealth Government endorse justice targets developed by the Standing Committee of Attorneys-General for inclusion in the Closing the Gap Strategy.
Justice reinvestment refers to policies that divert a portion of the funds for imprisonment to local communities where there is a high concentration of offenders. The money that would have been spent on imprisonment is reinvested into services that empower communities to address the underlying causes of crime. This could be a particularly useful way of funding much needed mental health services and programmes.
Of significant concern is the finding in the OID 2014 Report, that mental health (as indicated by rates of psychological distress) and rates of imprisonment and juvenile detention were getting worse over time. This approach could help address both.
As discussed in last year’s Progress and priorities report, the incidence of mental health conditions and substance abuse problems among the Aboriginal and Torres Strait Islander prison population is apparent. A 2009 survey of New South Wales prisoners found that 55 percent of Aboriginal and Torres Strait Islander men and 64 percent of women reported an association between drug use and their offence. In the same sample group, 55 percent of men and 48 percent of women self-reported mental health conditions. In an even more recent Queensland study, at least one mental health condition was detected in 73 percent of male and 86 percent of female Aboriginal and Torres Strait Islander prisoners; with 12 percent of males and 32 percent of females diagnosed with Post-Traumatic Stress Disorder.
The IAS could also be meaningfully connected to this approach. After all, a prison record can be a major barrier to employment and families with members in prison are put under tremendous financial and emotional stress with the major impact being felt by children – potentially affecting school attendance and performance. Effective implementation of a justice reinvestment programme will immediately reduce the number of victims and make our communities safer.
That Closing the Gap Targets to reduce imprisonment and violence rates are developed, and activity towards reaching the Targets is funded through justice reinvestment measures.
An analysis by AIHW suggests that the social determinants account for a larger proportion of the health gap between Aboriginal and Torres Strait Islander people and non-Indigenous Australians than behavioural risk factors. Individually, social determinants were estimated to be responsible for 31 percent of the gap, compared with 11 percent for behavioural risk factors. Interactions between social determinants and behavioural risk factors were estimated to account for a further 15 percent of the gap.
It is clear that Aboriginal and Torres Strait Islander health outcomes are significantly influenced by many determinants outside the direct control of the health sector. Consequently, it is imperative that policies from outside the health sector are developed considering their impact, positive or negative, on Aboriginal and Torres Strait Islander health outcomes. Unfortunately this is rarely the case.
The Campaign Steering Committee believes that the time has come to ensure that the Aboriginal and Torres Strait Islander health impacts are actively considered in all policies from design through to implementation. This would adequately reflect closing the gap as a national priority. Further work is required to ascertain the best mechanism and processes to achieve this goal.
One option to explore is Health Impact Statements which assess government or other activity for positive, negative and/or unintended health consequences of policy initiatives using the known evidence base, and where an initial assessment indicates a formal health impact assessment could take place. Aboriginal and Torres Strait Islander Health Impact Statements are already being issued in New South Wales, Western Australia, and South Australia but their scope is limited to health policy.
While the types of Health Impact Statements already adopted in Australia at the state-level are different, they all comprise a checklist that policy and programme-developers are required to complete and address. In summary, the issues that they are required address include:
- Policy development – Were Aboriginal and Torres Strait Islander stakeholders and representative groups consulted?
- Policy content – Have the effects on Aboriginal and Torres Strait health outcomes been identified and addressed? Is the effect disproportionate on Aboriginal and Torres Strait Islander peoples and communities? If so, what measures have been taken to address this?
- Implementation and evaluation – Will the policy be implemented and its effects evaluated with Aboriginal and Torres Strait Islander stakeholders?
The Campaign Steering Committee will undertake further work in this area in 2015.
The implementation of the Health Plan provides a significant opportunity to address many of the challenges to closing the health and life expectancy gap raised in this report. It has particular potential for improving Aboriginal and Torres Strait Islander access to appropriate health care. The Campaign Steering Committee believes effective implementation of the Health Plan is essential to achieving the goal of health and life expectancy equality by 2030.
The Health Plan was launched in July 2013 and marked the partial fulfilment of a major commitment by all signatories to the Close the Gap Statement of Intent – to develop a comprehensive, long-term plan of action. However the Health Plan is a framework document that requires further elaboration through an effective Implementation Plan to drive outcomes and help close the gap.
In mid-2014, the Assistant Minister for Health, the Hon. Fiona Nash, announced that the Australian Government was beginning work on such an Implementation Plan. The Australian Government is working with the National Health Leadership Forum (NHLF), comprised of national Aboriginal and Torres Strait Islander health peak and professional bodies whose core business is health, in this process.
The Campaign Steering Committee believes that the Implementation Plan requires the following essential elements:
- Set targets to measure progress and outcomes. Target setting is critical to achieving the COAG goals of life expectancy equality and halving the child mortality gap. The Close the Gap Health Equality Targets are the starting point for developing these targets;
- Develop a model of comprehensive core services across a person’s whole of life with a particular focus, but not limited to, maternal and child health, chronic disease, and mental health and social and emotional wellbeing;
- Develop workforce, infrastructure, information management and funding strategies based on the core services model;
- A mapping of regions with relatively poor health outcomes and inadequate services. This will enable the identification of service gaps and the development of capacity building plans, especially for ACCHS, to address these gaps;
- Identify and eradicate systemic racism within the health system and improve access to and outcomes across primary, secondary and tertiary health care;
- Ensure that culture is reflected in practical ways throughout Implementation Plan actions as it is central to the health and wellbeing of Aboriginal and Torres Strait Islander people;
- Include a comprehensive address of the social and cultural determinants of health; and
- Establish partnership arrangements between the Australian Government and state and territory governments and between ACCHS and mainstream services providers at the regional level for the delivery of appropriate health services.
The Implementation Plan is capable of driving progress towards the provision of the best possible outcomes from investment in health and related services. The Campaign Steering Committee believes if the Implementation Plan contains the essential elements outlined above it can drive significant, rapid and progressive inroads into health and life expectancy gaps.
 Forrest, above note 158, p 18.
 Australian Bureau of Statistics, above note 7, pp 8, 13; Statistics New Zealand, New Zealand Periodic Life Tables 2005-07, 2008. URL www.stats.govt.nz/browse_for_stats/health/life_expectancy/NZLifeTables_HOTP05-07.aspx.
Whäia te Ora mö te Iwi (Strive for the Good Health of the People) Maori Health Policy Objectives of Regional Health Authorities and the Public Health Commission, Department of Health, 1992; Health and Disability Services Act 1993 022 (NZ).
 Ministry of Health (New Zealand), Our history and current position, 2012. URL http://www.health.govt.nz/about-ministry/ministry-business-units/maori-health-business-unit/our-history-and-current-position.
 Ministry of Health (New Zealand), above note 175.
 Ministry of Health (New Zealand), above note 175.
Public Health & Disability Act 2000 (NZ), s 23(1)(d).
Public Health & Disability Act 2000 (NZ), ss 22(1)(e)-22(1)(f).
 Ministry of Health (NZ), Maori Health, 2014. URL http://www.health.govt.nz/our-work/populations/maori-health.
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 Biddle N, Developing a behavioural model of school attendance: policy implications for Indigenous children and youth, CAEPR Seminar Series, Working Paper 94 / 2014, 2014. URL http://caepr.anu.edu.au/Publications/WP/2014WP94.php.
 Dockery A, Culture and Wellbeing: The Case of Indigenous Australians, CLMR Discussion Paper Series 09/01, 2009. URL http://ceebi.curtin.edu.au/local/docs/2009.01_CultureWellbeing.pdf.
 Dockery above note 183.
 The Senate Standing Committee on Environment, Communications, Information Technology and the Arts, Indigenous Art—Securing the Future, 2007. URL http://www.aph.gov.au/binaries/senate/committee/ecita_ctte/completed_inquiries/2004-07/indigenous_arts/report/report.pdf.
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 COAG Reform Council, above note 3, p 86.
 COAG Reform Council, above note 3, p 86.
 The Royal Australian and New Zealand College of Radiologists, Planning for the Best: Tripartite National Strategic Plan for Radiation Oncology 2012-2022, 2012, p 111.
 Steering Committee for the Review of Government Service Provision, above note 4, pp 8.4 - 8.5.
COAG Reform Council, above note 3, p.87.
 Mundine W, ‘The Future of Aboriginal & Torres Strait Islander Health’, (Opening speech at Congress Lowitja 2014 –Melbourne, 19 March 2014). URL http://www.indigenouschamber.org.au/congress-lowitja-2014-the-future-of-indigenous-health/.
 Panaretto et al, above note 47.
 Australian Institute of Health and Welfare, Aboriginal and Torres Strait Islander Health Organisations, Online Services Report – key results 2012-2013, AIHW cat. no. IHW 139, 2014, p 1. URL http://www.aihw.gov.au/publication-detail/?id=60129548237.
 Australian Institute of Health and Welfare, above note 194, p 5.
 Panaretto et al, above note 47, p 650.
 Panaretto et al, above note 47, p 650.
 Thompson SC, Haynes E, Shahid S, Woods JA, Katzenellengogen, Teng T-H, Davidson PM and Boxall A, 'Effectiveness of primary health care for Aboriginal Australians'. Unpublished literature review commissioned by the Australian Government Department of Health, 2013 as cited in Mackey, P, Boxall, A-M, Partel K (2014) ‘The relative effectiveness of Aboriginal Community Controlled Health Services compared with mainstream health service’, Deeble Institute Evidence Brief, No 12.
 Panaretto et al, above note 47, pp 650-651.
 Australian Institute of Health and Welfare, above note 194, p 43.
 Australian Institute of Health and Welfare, above note 194, p 43.
 Australian Institute of Health and Welfare, above note 194, p 43.
 Information provided to the Close the Gap Campaign Steering Committee by AIDA.
Australian Bureau of Statistics, above note 57.
 Australian Bureau of Statistics, above note 57.
 Australian Bureau of Statistics, above note 57.
 Based on combined data from New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory. See: Australian Institute of Health and Welfare, Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses, AIHW cat. no. IHW 94, 2013, p.639. URL http://www.aihw.gov.au/publication-detail/?id=60129543821.
 Australian Institute of Health and Welfare, Psychiatric Disability Support Services. URL http://mhsa.aihw.gov.au/services/disability-support/.
 Australian Bureau of Statistics, Suicides, Australia, 2010, ABS cat. no. 3309.0, 2012. URL http://www.abs.gov.au/ausstats/abs@.nsf/Products/3309.0~2010~Chapter~Aboriginal+and+Torres+Strait+Islander+suicide+deaths?OpenDocument.
 Australian Bureau of Statistics, Causes of Death 2012, ABS cat. no. 3303.0, 2014. URL http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/3303.0main+features100002012.
 Steering Committee for the Review of Government Service Provision, above note 4.
 Australian Bureau of Statistic, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples Oct 2010, ABS cat. no. 4704.0, 2011. URL http://www.abs.gov.au/ausstats/abs@.nsf/mf/4704.0.
 Australian Bureau of Statistic, above note 212.
 Australian Bureau of Statistic, above note 212.
 Telethon Kids Institute, National Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project. URL http://aboriginal.telethonkids.org.au/centre-for-research-excellence-(cre)/suicide-prevention/.
 Information provided to the Close the Gap Campaign Steering Committee by beyondblue.
 Calma T, Social Justice Report 2009, 2010. URL https://www.humanrights.gov.au/publications/social-justice-report-2009.
 House of Representatives Standing Committee on Aboriginal and Torres Strait Islander Affairs, Doing Time - Time for Doing
Indigenous youth in the criminal justice system, 2011. URL http://www.aph.gov.au/parliamentary_business/committees/house_of_representatives_committees?url=atsia/sentencing/report.htm.
 Steering Committee for the Review of Government Service Provision, above note 4, p 48.
 Steering Committee for the Review of Government Service Provision, above note 4, p 25.
 Indig D, McEntyre E, Page J and Ross B, 2009 NSW Inmate Health Survey: Aboriginal Health Report Appendix of Results, 2010, p 69 (Table 5.6.33). URL www.justicehealth.nsw.gov.au/about-us/publications/inmate-health-survey-aboriginal-health-report-appendix.pdf.
 Indig et al, above note 221, p 81 (Table 6.1.2).
 Australian Institute of Health and Welfare, Australia’s health 2014, AIHW cat. no. AUS 178, 2014, p 336. URL http://aihw.gov.au/publication-detail/?id=60129547205.
 Australian Institute of Health and Welfare, above note 223, p 336.
 NSW Health, Aboriginal Health Impact Statement and Guidelines, 2007. URL http://www0.health.nsw.gov.au/policies/pd/2007/PD2007_082.html;
 Department of Health (WA), Aboriginal Health Impact Statement and Declaration for WA Health, 2014. URL http://www.aboriginal.health.wa.gov.au/docs/AboriginalHealthImpactStatementandDeclarationforWAHealth.pdf.
SA Health, Aboriginal Health Impact Statement Policy Directive, 2014. URL http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/about+sa+health/aboriginal+health/aboriginal+health+impact+statement+policy+directive.
NSW Health, above note 225; Department of Health (WA), above note 226; SA Health, above note 227.
 Nash Hon. F, National Indigenous Health Plan to Focus on Outcomes, 30 May 2014, (Media Release). URL http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2014-nash023.htm?OpenDocument&yr=2014&mth=05; Nash Hon. F, Another Step Towards Indigenous Health Equality, 24 June 2014, (Media Release). URL http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2014-nash030.htm?OpenDocument&yr=2014&mth=06.
 The NHLF members form the leadership group of the Campaign Steering Committee that supports the leadership of the Co-Chairs.
 Close the Gap Campaign Steering Committee, National Indigenous Health Equality Targets, 2008. URL https://www.humanrights.gov.au/publications/closing-gap-national-indigenous-health-equality-targets-2008.