Dr Lesley Russell Senior Research Fellow Australian Primary Health Care Research Institute Australian National University

Transcription

1 CLOSING THE GAP ON INDIGENOUS DISADVANTAGE: An analysis of provisions in the Budget and implementation of the Indigenous Chronic Disease Package Dr Lesley Russell Senior Research Fellow Australian Primary Health Care Research Institute Australian National University Research Associate Menzies Centre for Health Policy University of Sydney May

2 NOTE This paper presents the author s analysis of the Indigenous provisions in the Australian Government s Budget in the context of current and past strategies, policies, programs and funding support. It also looks at the implementation and impact of the Commonwealth s Indigenous Chronic Disease Package. This work has been done using only materials and data that are publicly available. The opinions expressed are solely those of the author who takes responsibility for them and for any inadvertent errors. This work does not represent the official views of the Menzies Centre for Health Policy, the Australian Primary Health Care Research Institute (APHCRI) or the Commonwealth Department of Health and Ageing which funds APHCRI. Lesley Russell T: E: Lesley.Russell@anu.edu.au Lesley.Russell@sydney.edu.au 2

3 Table of Contents Introduction... 5 National Partnership Agreements... 7 NPA on Closing the Gap in Indigenous Health Outcomes... 7 National Partnership Payments for Indigenous Health... 8 Support for Indigenous Education Budget Budget Initiatives Health and Ageing Attorney General s Education, Employment and Workplace Relations Families, Housing, Community Services and Indigenous Affairs Infrastructure and Transport Regional Australia, Local Government, Arts and Sports Progress in Closing the Gap in Health Tackling Chronic Disease Aboriginal and Torres Strait Islander Chronic Disease Fund Indigenous Chronic Disease Package Activities Supported Under the Indigenous Chronic Disease Package The Tackling Indigenous Smoking Initiative Helping Indigenous Australians to reduce their risk of chronic disease Local Indigenous community campaigns to promote better health Subsidising PBS medicine co payments Supporting Primary Care Providers to Coordinate Chronic Disease Management Care Coordination and Supplementary Services Measure Improving Indigenous Participation in Health Care Through Chronic Disease Self Management Increasing Specialist and Allied Health Follow up Care Monitoring and Evaluation Workforce Education and Training Expanding the Outreach and Service Capacity of Indigenous Health Organisations Engaging Medicare Locals to Improve Indigenous Access to Mainstream Primary Care Attracting More People to Work in Indigenous Health Clinical Practice Guidelines Primary Health Care Resource

4 Other Initiatives that are Part of the Aboriginal and Torres Strait Islander Chronic Disease Fund.. 44 Rheumatic Fever Strategy National Coordination Unit Closing the Gap: Improving Eye and Ear Health Services for Indigenous Australians training of Aboriginal Health Workers in ear health and monitoring and screening Other initiatives that are part of the Indigenous Chronic Disease Package Supporting primary care providers to coordinate chronic disease management

5 Introduction Total government expenditure on Indigenous health has risen significantly since the commencement of the National Partnership Agreement (NPA) on Closing the Gap in Indigenous Health Outcomes in and now represents about 5.1% of total government health expenditure. 1 This amounted to $4.7 billion in ; of this, the Commonwealth provided about one-third ($1.6 billion). 2 However while there is a significant effort underway to close the gap in Indigenous disadvantage and life expectancy, in most areas this effort has yet to show real returns on the investments. The disadvantages that have built up over more than 200 years will not disappear overnight, and sustained and concerted efforts are needed to redress them. Chronic diseases, which account for a major part of the life expectancy gap, take time to develop, and equally, it will take time to halt their progress and even longer to prevent their advent in the first place. Programs will need to be sustained over decades if they are to have an impact on improving health outcomes. On this basis, it is worrying to see that continued funding for the NPA on Closing the Gap in Indigenous Health Outcomes, as announced in April, will be less over each of the next three years than in At the same time, the Budget Papers show that expenses in the Aboriginal and Torres Strait Islander health sub-function will decline by 2.7% in real terms. This comes as states such as Queensland and New South Wales have made damaging cuts to health services and Closing the Gap programs. Education is a significant determinant of health status 3 so it is also concerning to see a reduced level of funding provided for Indigenous education over the next six years, especially when efforts to close the gap in education for indigenous students have stalled. These cuts in health and educations commitments cannot be justified by saying that Indigenous Australians can access mainstream programs. In many cases these are absent, inappropriate, or perceived as culturally insensitive, despite recent efforts to improve these deficits. It is a strength of the COAG commitment to close the gap on Indigenous disadvantage that it recognises that a whole-of-government approach is needed to deliver improvements in the lives of Indigenous Australians. However tackling disadvantage is about more than building houses, providing job training, implementing welfare reform, community policing and increasing access to health services; it requires that governments recognise and respect the complex social and cultural relationships that underlie the housing, economic, health and societal issues present in many Aboriginal communities and work with the communities to address these issues. 4 1 Indigenous Australians make up 2.6% of the population. 2 expenditure gap and indigenoushousing?0=ip_login_no_cache%3d54e45a2b073f701d2246d84b320acf43 5

6 There are several critical developments in 2013 that together will likely determine whether the goal of Indigenous health equality is achieved by These include the scheduled completion and implementation of a National Aboriginal and Torres Strait Islander Health Plan, 5 the renewal - with adequate funding from all governments - of the NPA on Closing the Gap in Indigenous Health Outcomes, 6 and the federal election that is scheduled for 14 September The Commonwealth has announced funding of $777 million / 3 years ahead of the expiry of the NPA on June 30, but the states and territories are yet to make their funding commitments. 6

7 National Partnership Agreements There are currently six Indigenous-specific National Partnership Agreements. (See Table 1) Table 1. National Partnership Federal funding and timing State / Territory funding Agreement Stronger Futures in the Northern $3.4 billion / 10 years (to 2022) $40 million Territory Remote Indigenous Housing $5.5 billion / 10 years (to 2018) - Closing the Gap in Indigenous $777million / 3 years (to 2016) TBD Health Outcomes Indigenous Childhood $564.4 million / 6 years (to 2014) - Development Remote Service Delivery $291.2 million / 6 years (to 2014) - Remote Indigenous Public Internet Access From Budget Paper No 3 $6.5 million / 3 years (to 2016) TBD NPA on Closing the Gap in Indigenous Health Outcomes In November 2008, the Council of Australian Governments (COAG) agreed to a $1.6 billion / 4 years National Partnership Agreement (NPA) on Closing the Gap in Indigenous Health to address the first Closing the Gap target (to reduce close the life expectancy gap within a generation). Within the NPA five priority areas were established: Tackling smoking; Primary health care services that can deliver; Fixing the gaps and improving the patient journey; Providing a healthy transition to adulthood; and Making Indigenous health everyone s business. The Commonwealth s contribution to this NPA is the Indigenous Chronic Disease Package (ICDP) which provided $805.5 million / 4 years, beginning in This contributes to the first three priority areas of the NPA; state and territory efforts contribute to all five priority areas. Each jurisdiction has developed implementation plans detailing the activities that will achieve the objectives of the NPA (although some of these from the States and Territories have proved difficult to find). On 18 April 2013 the Commonwealth announced continuing funding of $777 million / 3 years for the NPA which is due to expire 30 June. 7 This was described as an increase over 7 office/777 million renewed effort close gap indigenous health 7

8 previous per annum expenditure. That is true, but this statement ignores the fact that funding over the last four years was ramped up and in it was $317.9 million. So the reality is that funds for each of the next three years will be less than in The Government s media release says While this work is encouraging we know there is more to be done. We need sustained investment and effort to continue the momentum and ensure continued progress. And COAG said the improving opportunities for Indigenous Australians requires intensive and sustained effort from all levels of government. 8 The (important) recognition that these efforts will require sustained investment and effort is not backed by the actions of Australian governments. As of May 2013, none of the States and Territories had announced their contributions to the NPA. We await news of how these new federal funds will be allocated over the forward estimates (and which programs will be cut and where). The Budget provides no further information on this. The scheduled completion and implementation of a National Aboriginal and Torres Strait Islander Health Plan may provide the incentives for further Australian Government and COAG action. The Budget Papers provided some insights into Commonwealth expenses in this NPA, but this information has not been provided in the following years. At that time it was interesting to note that administrative expenses were high (estimated at $112 million in ) and they averaged 36% of expenditure over the forward estimates. National Partnership Payments for Indigenous Health In the Australian Government will pay $54 million to the States and Territories through National Partnership payments (NPs) for work in 12 areas of Indigenous health. (See Table 2) Of the $113.8 million provided of the four years to , over 50% ($68.8 million) is allocated to the Northern Territory. However expenditure drops considerably over the forward estimates

9 Table 2. NPs Sexual assault counseling in remote NT Accommodation related to renal services in NT CTG in the NT Improving ear services for Indigenous children Improving trachoma control services Indigenous early childhood development antenatal and reproductive health Reducing rheumatic fever in Indigenous children Renal dialysis services in Central Australia Stronger Futures in the NT Torres Strait health protection strategy Total From Budget Paper No 3 9

10 Support for Indigenous Education Under the National Education Agreement (NEA), which began on 1 January 2009, all Australian governments have committed to three targets for Indigenous education: Lift the Year 12 or equivalent attainment rate to 90% by 2015; Halve the gap for Indigenous students in reading, writing and numeracy within a decade; and At least halve the gap for Indigenous students in Year 12 or equivalent attainment rates by Several National Partnerships also contribute to achieving the NEA Indigenous objectives. These are: Early Childhood Education Indigenous Early Childhood Development National Quality Agenda for Early Childhood Education and Care Youth Attainment and Transitions Smarter Schools NPs: Literacy and Numeracy, Improving Teacher Quality and Low Socio-Economic Status School Communities A national Aboriginal and Torres Strait Islander Education Action Plan 9 which was endorsed by COAG in May 2011 and released in June 2011 commits all Australian governments to a unified approach to closing the gap in education outcomes between Indigenous and non- Indigenous students. It provides the priorities for collaborative work to be undertaken in the Government, Catholic and Independent school sectors until The Indigenous Education (Targeted Assistance) Act 2000 (IETA) is the Australian Government s major Indigenous specific education and training initiative. The objects of IETA are described under five themes: Involvement of Aboriginal and Torres Strait Islander people in educational decisionmaking; Equality of access to educational services; Equity of educational participation; Equitable and appropriate educational outcomes; and The development of culturally appropriate education services. For the period , a total of around $600 million was committed through IETA to fund a range of Indigenous education and training programs and projects. IETA funding is supplementary to mainstream funding, is targeted to areas of greatest need, and is intended for strategic interventions that will accelerate improvements in Indigenous student learning outcomes. In 2009, $173 million was allocated to the States and Territories. 10 This was split almost equally between government and non-government schools and educational bodies. 9 and torres strait islander education action plan rt_2009.pdf 10

11 The Budget allocates less funding to IETA initiatives over the forward estimates, providing $800 million / 6 years. This is concerning as efforts to close the gap in education for Indigenous students have stalled. 11 In 2012, for 14 out of the 20 National Assessment Program - Literacy and Numeracy (NAPLAN) indicator, the gap has widened compared to These results cast doubt on achieving the goal to halve the gap in literacy and numeracy skills between Indigenous and non-indigenous students by There is some good news in that the target to ensure that all Indigenous four-year-olds in remote communities have access to early childhood education within five years will likely be met in Data from the National Early Childhood Education and Care Collection shows that in August 2011, 91% of Indigenous children in remote areas were enrolled in preschool programs in the year before full-time schooling. However enrolment is not a sufficient measure for this target as data also show that in in 2009, Indigenous attendance rates ranged between 74-78% in remote and very remote areas. 14 There is also some possibility of meeting the target to halve the gap for Indigenous people aged in Year 12 attainment or equivalent attainment rates by In 2011, 53.9% of Indigenous Australians in this age group had achieved Year 12 or an equivalent qualification compared to 47.4% in Census data also show that education participation rates for Indigenous year olds have increased from 56.8% in 2006 to 61.6% in However continued rapid improvements will be required if progress towards meeting this target is to remain on track affairs/education/reforms failing to close indigenous schoolsgap/story fn59nlz ctg report_fa1.pdf 13 Ibid 14 rt_2009.pdf 15 ctg report_fa1.pdf 11

12 Budget The Budget claims $1.6 billion of new investment in Indigenous initiatives. Not included in this is the continued funding for the NPA on Indigenous Health ($777 million / 3 years) or the $6.5 million / 3 years committed as continued funding to the NPA for Remote Indigenous Public Internet Access Training and Maintenance. However it seems that this figure has been inflated by the inclusion of all of the $655.6 million / 18 months committed to the renewed NPA on Early Childhood Education 16 when in fact only a portion of these funds will go to Indigenous children. It also includes $127.5 million to extend the Youth Connections Program, the School Business Community Partnership Brokers Program and national career development initiatives but only about 20% of these funds go to Indigenous participants. 17 The actual figure is therefore estimated to be $903.3 million / 4 years ($1.05 billion / 6 years). (See Table 3) Almost of all of this is to continue or extend funding for existing programs. There is new funding of $24.5 million / 4 years for only four programs - $10 million for the Australian Indigenous Education Foundation; $12 million for additional scholarships through the Indigenous Youth Leadership Program (although this funding apparently comes from savings taken in this program in the Budget) ; $1.3 million for research into a vaccine for acute rheumatic fever (a disease that affects predominately Indigenous Australians); and $1.3 million to the Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait Islander People to help establish a parliamentary and community consensus on referendum proposals. Elsewhere in the Budget savings of $20 million / 4 years are taken from the National Rural and Remote Health Infrastructure Program and future grant rounds will focus on projects in remote or very remote areas or Indigenous communities. The failure of the Northern Territory Government to proceed with two projects to provide short term patient accommodation at Katherine Hospital and Gove District Hospital (which would have been largely used by Indigenous patients and their families) means that $10.8 million allocated to these projects, announced in the 2010 Regional Priority Round, is returned to the Health and Hospitals Fund. 16 See pages 4, 9 Budget Statement on Continued Investment to Close the Gap. 17 See page 14, Budget Statement on Continued Investment to Close the Gap 12

13 Table 3. Initiative Extended funding under the Indigenous Education (Targeted Assistance) Act. Australian Indigenous Education Foundation More scholarships under Indigenous Youth Leadership Program Extension of Cape York Welfare Reforms Extension of Municipal and Essential Services Program Continued funding Army Aboriginal Community Assistance Program Continued funding Aboriginal Hostels Limited Continued funding Remote Airstrip Upgrade Program Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait Islander People Continued funding National Congress of Australia s First Peoples Continued funding Reconciliation Australia Continued funding Longitudinal Study of Indigenous Children Continued funding for Youth Attainment and Transitions Continued funding for trachoma control Continued funding for mosquito control in Torres Strait Expanded funding Legal Assistance and Support Additional funding for Community Legal Centres Additional funding to Indigenous Visual Arts Industry Support Program Additional funding to Indigenous arts training organisations Expansion of Indigenous Languages Support Program Extended funding for the Community Development Financial Institutions pilot Research on development of acute rheumatic fever vaccine Total *20% of $127.5 million Funding level $659 million / 4 years 18 $10 million / 1year $12 million / 4 years $24.5 million / 2 years $44.1 million in $6 million / 1 year $6.2 million / 2 years $10 million / 2 years $1.3 million / 2 years $15 million / 3 years from $14.4. million / 4 years $1.3 million / 2 years $25.5 million / 1 year* $16.4 million / 4 years $3.9 million / 4 years $12 million / 2 years $10.3 million / 4 years $11.3 million / 4 years $1.7 million / 4 years $14 million / 4 years $3 million / 1 year $1.4 million / 2 years $903.3 million / 4 years 18 Note that in Budget Paper No 2 this is given as $800 million / 6 years 13

14 Budget Initiatives 1. Health and Ageing The Budget predicts that expenses in the Aboriginal and Torres Strait Islander subfunction will increase in but fall by 2.7% in real terms from to (See Table 4) Table 4. Estimates Projections Aboriginal and Torres Strait Islander health Total health 62,249 64,636 68,081 71,597 75,493 From Budget Paper No 1 In spending on Indigenous health initiatives includes: $380.8 million to improve the health and wellbeing of Indigenous people under the Stronger Futures in the Northern Territory package. $4.5 million in grants through the Indigenous Suicide Prevention program and an estimated $2 million from the Taking Action to Tackle Suicide package. 19 $10 million (estimated) through Bringing Them Home and Link Up Services. $65 million from the Substance Misuse Service Delivery Grants Fund will go to provide services in Indigenous communities. Acute rheumatic fever vaccine $1.4 million / 2 years is provided for early research into the development of a vaccine to prevent acute rheumatic fever. The New Zealand Government will also provide $1.4 million towards this effort. This was originally announced by the Prime Ministers of both countries as a $3million effort NHMRC Acute rheumatic fever is particularly prevalent among Aboriginal, Torres Strait Islander, Maori and Pacific Islander peoples. A recent AIHW report shows that almost all cases of acute rheumatic fever recorded in the Northern Territory between 2005 and 2010 were for Indigenous people (98%), with 58% of cases occurring in 5-14 year olds. These rates are among the highest in the world On 23 May 2013 the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy was released, together with additional funding of $17.8 million / 4 years. yr13 mb mb036.htm 20 office/joint statement prime ministers key and gillard february release detail/?id=

15 Improving trachoma control for Indigenous Australians $16.4 million / 4 years is provided to continue trachoma control activities. This funding is expected to improve eye health for 20,000 Indigenous Australians in up to 160 remote communities. Allocation over the forward estimates is not provided. This is renewed funding for provisions originally provided in the Budget. At that time $58.3 million / 4 years was provided for improved hearing and eye services. Of this, $5.3 million / 3 years went to four states (Queensland, NSW, Northern Territory and South Australia) under project agreements on improving trachoma control. The National Trachoma Surveillance and Reporting Unit was established in 2010 to improve the quality of trachoma data collection and reporting in Australia. The most recent report is for 2010 (released in September 2012). 22 The 2012 annual update on the implementation of The Roadmap to Close the Gap for Vision estimates that $70 million is needed to eliminate vision loss, which is 11% of the Indigenous health gap. 23 Mosquito control and cross border liaison in the Torres Strait $3.9 million / 4 years is provided to continue mosquito detection, control and elimination activities in the Torres Strait region. This funding goes to Queensland through a National Partnership on Health Services. 2. Attorney General s Expansion of funding for legal assistance $12 million / 2 years is provided to the Aboriginal and Torres Strait Islander Legal Services Attorney General s The Budget provided an additional $34.9 million / 4 years for Indigenous legal services (an average increase of $8.7 million per year). This brought the total Commonwealth funding to ATSILS to $ million in However ATSILS remains grossly under-resourced, lagging significantly behind the resource levels of mainstream legal aid service providers cdi3603b.htm 23 data/assets/pdf_file/0009/661869/2012_annual_update_roadmap.pdf 24 Information provided in Supplementary Budget Estimates,

16 3. Education, Employment and Workplace Relations Expansion and extension of Achieving Results Through Indigenous Education $4.4 million / 4 years (from ) is provided to extend and expand the Achieving Results Through Indigenous Education (ARTIE) program and support a two years extension to the end of Note that funding for this measure was included as a decision taken but not announced in the MYEFO. Extension of Indigenous Education (Targeted Assistance) Act 2000 $800 million / 6 years is provided to extend funding under the IETA to fund a range of Indigenous education and training programs and projects. This money flows through both the Department of Education, Employment and Workplace Relations and the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education. Breakout over the forward estimates is not provided in the Budget Papers. This is less funding than previously provided ($600 million / 4 years). Some indication of how funds will be split between initiatives, States and Territories, and public and private schools and education and training bodies can be found in the IETA Annual Report 2009 (which appears to be the most recent available). 25 From 1 January 2014, programs previously funded under IETA will move to an annual appropriation. The stated aim is to ensure greater transparency. Indigenous Education Scholarships $21.9 million / 5 years is provided for Indigenous education scholarships through the Australian Indigenous Education Foundation (AIEF) which receives $10 million in and the Indigenous Youth Leadership Program (IYLP) - which receives $11.9 million / 4 years DEEWR Since 2008 the AIEF has provided more than 400 Indigenous students with scholarships to 34 schools; 90% of these students finish Year 12. The funding provided this year is on top of $20 million provided in , which is supporting by matching funds from private sources. The new funding for IYLP will support 204 new scholarships for Indigenous students, providing scholarships for 68 students in 2014 in each of Years 7, 8 and 11. Since 2006, more than 1,500 secondary and tertiary students have been assisted under the IYLP. More than 86 per cent of students have been retained in the program or have completed Year 12. The Budget Papers state that this measure varies the Budget measure titled Stronger Futures in the Northern Territory Indigenous Youth Leadership program suspension which targeted students in Years 9, 10 and 11. In savings of $ rt_2009.pdf 16

17 million / 4 years were taken from IYLPto be redirected to support other spending on Indigenous priorities in the Government's Stronger Futures in the Northern Territory package. 4. Families, Housing, Community Services and Indigenous Affairs Cape York Welfare Reform $26.3 million / 2 years is provided to continue welfare reform initiatives in the Cape York communities of Aurukun, Coen, Hope Vale and Mossman George until 31 December $1.8 million of this funding is from redirection of savings taken in the Budget FaHCSIA DHS DEEWR Total In the Budget the Cape York Welfare Reform Trial was extended for 12 months with the provision of $11.8 million. In September 2012 the Queensland Government announced it was spending $5.7 million to extend this trial through to the end of The Cape York Welfare Reform (CYWR) aims to reverse the deterioration of social and economic conditions in Cape York Indigenous communities over recent decades. It is founded on the premise that this deterioration has been brought about by passive welfare dependence and the erosion of individual responsibility as the unintended effects of wellmeaning but misguided government welfare policies and service delivery. The 2012 Evaluation Report looked at the four-year period of implementation and modifications to projects between January 2008 and December 2011, with some data from early It found that most progress in implementation has been made in relation to the Social Responsibility and Education streams and the slowest progress in the implementation of the trial has been in relation to implementing projects under the Housing and Economic Opportunity streams. Income management in Western Australia $16.4 million / 2 years is provided to continue and expand income management in Western Australia. Of this, $11.8 million will continue the current trials in the Kimberley region and areas of metropolitan Perth for one year. $4.5 million / 2 years (provided from existing FaHCSIA / DHS resources) will expand income management into Laverton and Ngaanyatjarra Lands. This project commenced in April releases/ /budget funding to extend cape york trial.pdf 27 responsibilities/indigenous australians/publications articles/evaluationresearch/cape york welfare reform cywr evaluation report 17

18 DHS FaHCSIA Total A Background Paper produced by the Parliamentary Library in June 2012 concluded that, at that time, the evidence provided for or against income management was inconclusive. 28 A recent media article claimed that the scheme in the Kimberley was paternalistic and is being rolled out in a discriminatory fashion. 29 Funding for longitudinal surveys Funding of $4.3 million / 2 years is provided to continue three longitudinal surveys, including Footprints in Time, the Longitudinal Survey of Indigenous Children (LSIC). The Federal Budget provided the initial resources for the LSIC study. The first phase, from September 2003 to June 2004, involved extensive consultation with Indigenous peoples and communities about the study. The design and development of the study commenced in December 2005, with pilot testing continuing through 2006 and Funding of $12.0 million / 4 years to begin the surveys was provided in the Budget. The first wave of surveys commenced in This year LSIC will have completed 6 waves of surveys, with plans already in hand for further waves through Given this and the very nature of a longitudinal survey leads to questions about why at least 4 years of funding was not provided. It also appears that this Budget provides less funding than in the past for this important work. National Congress of Australia s First People $15.0 million / 3 years from is provided in continued funding to the National Congress of Australia s First People FaHCSIA [8.3]* [4.9]* *Funds from The Budget provided $29.2 million / 5 years (from ) to establish the National Congress of Australia's First Peoples /IncomeManagement

19 5. Infrastructure and Transport Regional Aviation Access Program airstrip upgrade $9.9 million / 2 years is provided to provide a further funding round for aviation safety upgrades at remote airstrips. This funding is provided on a co-funding basis, but up to 100% of funds will be available for work at priority remote Indigenous communities DIT The Regional Aviation Access Program was allocated $28 million / 2 years in the Budget for upgrading remote airstrips across Australia. This funding provided $22 million to Remote Airstrip Upgrades, with the expectation of matching co-funding, and $4 million that was specifically for further upgrades of aerodromes in remote Indigenous communities that currently receive a weekly passenger and freight air service subsidised under the Government s Remote Air Services Subsidy Scheme. 6. Regional Australia, Local Government, Arts and Sports The two provisions provide through DRALGAs are funding by raiding $12.2 million from the Indigenous Communities Strategic Investment (ICSI) Program Special Account which was established in This is not the first time this has happened: for example, in the Budget $29.2 million was taken from the ICSI to fund the National Congress of Australia s First Peoples. Creative Australia Indigenous Language Support $14.0 million / 4 years is provided to expand the existing Indigenous Language Program and to enable applications for funding from projects based in the Torres Strait Islands. FaHCSIA will provide $6.6 million for this measure form savings taken in the Indigenous Communities Strategic Investment Program DRALGAS FaHCSIA Total Additional funding for this work was a recommendation of the Standing Committee on Aboriginal and Torres Strait Islander Affairs 2012 report on the inquiry into language learning in Indigenous communities entitled Our Land Our Languages sia/languages2/report.htm 19

20 Before colonisation, 250 distinct Aboriginal and Torres Strait Islander languages were spoken on the Australian continent. Of these, only 18 or fewer languages are presently considered strong, in the sense that they are spoken by all generations of people within the language group. Of the 145 indigenous dialects currently spoken in Australia, 110 are at risk of being lost. 31 In August 2009, the Australian Government announced its National Indigenous Languages Policy to coordinate action among the agencies involved in the maintenance and revival of Indigenous languages, including government, Indigenous languages organisations and educational and research institutions. 32 In that year funding of $9.3 million was announced. In a total of 72 activities were support with funding of $9.9 million. 33 A recent study by the Australian Bureau of Statistics shows that young Indigenous people (15 24 years) who speak an Indigenous language are less likely to consume alcohol at risky levels, to report they had used illicit substances in the past 12 months or to have been the victim of physical or threatened violence. 34 Creative Australia Indigenous Visual Arts Industry Support $11.3 million / 4 years is provided to continue the Closing the Gap component of the Indigenous Visual Arts Industry Support Program. $5.6 million of this funding comes from existing FaHCSIA resources within the Indigenous Communities Strategic Investment Plan DRALGAS FaHCSIA Total The Budget provided $9.9 million / 4 years to increase operational funding for art centres and establish an Indigenous Australian Art Commercial Code of Conduct to guide ethical commerce in the sector. This commitment followed a report from the Senate Inquiry into the Indigenous visual arts sector, Indigenous art Securing the future final_0.pdf culture languages and visual arts funding/funding roundoutcomes inquiry

21 Progress in Closing the Gap in Health My own previous analyses 36 and those of others 37 indicate that it is still not possible to accurately assess whether progress towards the life expectancy target of closing the gap within a generation (by 2030) is on track. If current trends continue, the target to halve the gap in mortality rates for Indigenous children under five within a decade (by 2018) may be achievable, although more progress needs to be made on reducing the number and proportion of low birth weight babies if this is to occur. What is becoming apparent is that the problem is as much about the difficulty of measuring the impact of interventions as it is about the effectiveness of the interventions themselves. The 2012 Report on the Aboriginal and Torres Strait Islander Health Performance Framework makes this point that data quality limitations hamper our ability to monitor Indigenous health and the performance of the health system. 38 Indigenous life expectancy is estimated using a methodology adopted by the Australian Bureau of Statistics (ABS) in 2009 that relies on census data. Between now and 2030 there will be a census in each of the years 2016, 2021 and 2026, which provides only three points at which life expectancy can be assessed and programs adjusted as required. The COAG Reform Council has adopted seven supporting, or proxy, indicators for life expectancy: Mortality rate by leading causes Hospitalisation rates by principal diagnosis Rates of current daily smokers Average daily alcohol consumption and associated risk levels; rates of alcohol consumption at long-term risky to high risk levels Levels of obesity Level of physical activity Access to health care compared to need. To be effective, these require regular and timely data collection. The lag time is quite significant: the most recent report on the COAG Reform Council s website is for and this has data only for the first two of these indicators. 39 It found that in 2010 only five jurisdictions (NSW, Queensland, Western Australia (except for the years ), South Australia and the Northern Territory) had reliable data on mortality and that there were no significant changes in Indigenous death rates between 2006 and 2010 in any of these states and territories. Admittedly this is a short time frame. However in a wider time frame, from 36 See for example the gap another year of slow progress/ 37 CloseTheGapShadowReport 0212.pdf 38 hpf

22 , only Queensland and the Northern Territory showed significant decreases in Indigenous death rates. The report further noted that hospitalisation data are only briefly reported and are difficult to interpret. However it is encouraging to see that a recent AIHW report finds that an estimated 88% of Indigenous patients were correctly identified in public hospital admission records in There are additional data to show an improvement in deaths caused by circulatory disease (down 41% between 1997 and 2010) and respiratory disease. However there have been no improvements with respect to cancer deaths, kidney disease, injury and diabetes. It is disconcerting to see that there have been no significant changes in key risk factors such as smoking, levels of physical activity, obesity and high alcohol consumption. 41 Tackling Chronic Disease About 80% of the mortality gap for Indigenous Australian aged 35 to 74 years is due to chronic disease. The gap is caused by higher rates of chronic disease at younger ages as well as increased death rates associated with chronic disease. The major contributors are: Heart diseases; Diabetes; Liver diseases; Chronic lower respiratory disease; Cerebrovascular diseases, such as stroke; and Cancer. 42 While over the period 1998 to 2009 there has been a significant decrease in Indigenous chronic disease mortality rates there has also been a significant decrease in non-indigenous rates, resulting in no significant change in the gap. 43 Aboriginal and Torres Strait Islander Chronic Disease Fund The aim of the Aboriginal and Torres Strait Islander Chronic Disease Fund (ATSICDF) is to improve the prevention, detection, and management of chronic disease in Indigenous people to increase life expectancy and contribute to the target of closing the gap in life expectancy within a generation detail/?id= hpf 42 observatory chronic disease/ 43 report 1011 toc~1011part2~1011part2.4~1011outcome8 22

23 The majority of the funding for this Fund relates to grants programs from the Indigenous Chronic Disease Package. $834 million / 4 years (from ) has been allocated to the fund. Given that this does not include funding provided for higher utilisation costs for MBS and PBS, for subsidising PBS co-payments and for the Indigenous Health Practice Incentive Payment program, it can be inferred that at least $300 million of this $834 million is for continued funding of the included aspects of the Indigenous Chronic Disease package from July 2012 to June Initiatives that were consolidated into the Aboriginal and Torres Strait Islander Chronic Disease Fund from 1 July 2011 Indigenous Chronic Disease Package: National Action to Reduce Indigenous Smoking Rates; Helping Indigenous Australians Reduce Their Risk of Chronic Disease; Local Community Campaigns to Promote Better Health; Subsidising PBS Medicine Co-payments; 44 Care Coordination and Supplementary Services Measure; Improving Indigenous Participation In Health Care Through Chronic Disease Self- Management; Urban Specialist Outreach Assistance Program; Medical Specialist Outreach Assistance Program - Indigenous Chronic Disease; Monitoring and Evaluation; Workforce Training and Support; Expanding the Outreach and Service Capacity of Indigenous Health Organisations; Engaging Divisions of General Practice 45 to Improve Indigenous Access to Mainstream Primary Care; Attracting More People to Work in Indigenous Health; and Clinical Practice Guidelines; Rheumatic Fever Strategy - National Coordination Unit. Improving Eye and Ear Health Services for Indigenous Australians for Better Education and Employment Outcomes - Training of Aboriginal Health Workers in ear health and hearing monitoring and screening. The Practice Incentives Program (PIP) Indigenous Health Incentive funded under the Indigenous Chronic Disease Package has been consolidated into the Practice Incentives for General Practices Fund. The Higher Utilisation costs for MBS and PBS measure and special appropriation component of the PBS Co-payment measure funded under the Indigenous Chronic Disease Package are not consolidated in the ATSICDF as these are not grant programs. 44 Note that while this is included on this DoHA generated list (accessed at funds atsicdf toc~flexiblefunds atsicdf atta), this webpage also states that the special appropriation component of the PBS Copayment measure funded under the Indigenous Chronic Disease Package is not consolidated in the ATSICDF as it is not a grant program. This raises the issue of whether the funding for this measure ($88.7 million / 4 years) is included in the ATSICDF. 45 Now Medicare Locals. 23

24 Indigenous Chronic Disease Package The Commonwealth s Indigenous Chronic Disease Package, which commenced in 2009, was developed specifically to prevent and better manage chronic disease. Progress on implementing the provisions of this package is outlined in the following sections. Activities Supported Under the Indigenous Chronic Disease Package 1. The Tackling Indigenous Smoking Initiative Background Tobacco use is the leading risk factor contributing to disease and death among Indigenous Australians and is the single biggest contributing factor to the life expectancy gap between Indigenous and non-indigenous Australians. The great gains made in anti-tobacco campaigns in Australia in recent decades have not been reflected in Indigenous communities where smoking rates have not decreased over the past 15 years. Fifty-one per cent of Indigenous people smoke, compared with a 17% smoking rate across the general Australian population and in some communities rates are as high as 70-80%. Indigenous mothers are more likely to have smoked during their pregnancy than other mothers. Generally, Indigenous people take up smoking at an earlier age, smoke for longer and make fewer attempts to quit than non- Indigenous Australians. Tobacco use is responsible for 12.1 % of the total burden of disease and 20% of all Indigenous deaths. If the level of smoking among indigenous people were brought down to general Australian levels, health researchers say that 20 per cent of the life expectancy gap would close. 46 About this initiative Tackling Indigenous Smoking is a key initiative of the Indigenous Chronic Disease Package. Commonwealth, state and territory governments have committed a total of almost $200 million / 4 years ( ) to reduce the smoking rate and the tobacco-related burden of disease In Indigenous communities. This comprises $100.6 million from the Commonwealth Government and $98.09 million from the states and territories. This funding builds on the Commonwealth funds of $14.5 million / 4 years for 18 Indigenous tobacco-specific projects under the Indigenous Tobacco Control Initiative which was launched in March This initiative concluded at the end of June 2012 and an evaluation and review is underway. Fifty-seven regions have been identified and will generally receive one regional tobacco coordinator, three Tobacco Action Workers and two healthy lifestyle workers who will work as teams work on the ground in communities, developing programs that suit local needs and providing one-on-one support. The following federally-funded activities have been undertaken or are planned under the leadership of a National Coordinator for Tackling Indigenous Smoking:

25 A staged roll-out of tobacco action workers (TAW) and Regional Tobacco Coordinators (RTC) across 57 regions (to work as part of teams with the Healthy Lifestyle Workers (HLWs) who are being funded through another component of the Indigenous Chronic Disease Package); Training to support these positions (TAWs and RTCs) to deliver smoking cessation programs and supports in Indigenous communities; Training for the new and existing workforce in providing brief interventions in smoking; Training, funding and supports to the TAWs and RTCs to develop and implement localised anti-smoking social marketing campaigns; Quit smoking role models and ambassadors at the local level to assist other smokers to quit; An enhancement of Quitline services to be more accessible to and appropriate for Indigenous people; and Social marketing campaigns for Indigenous people. The aim is to halve smoking rates in Indigenous communities in urban, regional and remote areas by Progress to date The most recent report for the Indigenous Chronic Disease Package is from October 2011 for the year At that time: Regional Tackling Smoking teams had been rolled out to 21 regions and the ACT had also received a Tobacco Action Worker. 48 Over 200 health workers and community educators had received training in smoking cessation The Break the Chain advertising campaign Australia s first Indigenous-focused antismoking campaign - was launched in March 2011 on national media. This was described as a $4 million campaign. Two bursts of media activity occurred between 28 March and 26 June The initial burst of activity lasted for a total of 4 weeks from launch date and the second burst lasted from 22 May for a further 6 weeks. Both bursts of media activity included 40 TARPS, reducing to 30 TARPS in the final two weeks, with the media buy covering metropolitan and regional Australia, targeting areas with a high Indigenous population. An evaluation of the Break the Chain media campaign found that it resonated well with the Indigenous target audience and delivered a call to action to encourage Indigenous smokers to cut down or quit smoking and to encourage recent quitters to continue not to smoke and put pressure on others to quit resources/bibliography?page=5&q=closing%20the%20gap&q_exact=&q_author=&q_keyword=&sorter=year DESC&year_start=2011&year_end=2011&lid= The DoHA Annual Report states that 16 Regional Tackling Smoking and Healthy Lifestyle Teams were rolled out in , taking the total to 37 teams across Australia. e/doha% %20Annual%20Report.pdf 49 indsurvey execsumm 25