ACCHSs: Torchbearers of Primary Health Care

Timeline ACCHSs: Torchbearers of Primary Health Care Dr Mick Adams Chair, National Aboriginal Community Controlled Health Organisation June 2008 40 years since 1967 Referendum 37 years since the first Aboriginal Medical Service (Redfern) established 34 years since NACCHO (NAIHO) established 32 years since ICESCR (1976) entered into force in Australia 30 years since the WHO Alma Ata Declaration for primary health care Early days till 1967 HOW &WHY ACCHSs WERE ESTABLISHED States were mainly responsible for health services There was high level of segregation to protect the white working race Freedom of movement by Aboriginal peoples was restricted Incompetence and neglect by health service providers was tolerated There was considerable variation in the quality of health services especially in the State-run missions Many country hospitals refused Aboriginal peoples Hospitals had native wings (often a tin shed out back) Fee-for service was unaffordable In Qld, pensions and wages of Aboriginal peoples were confiscated to pay for health services provided Health programs were imposed and changed rapidly with little reference to local peoples. Post 1967 Rapid changes, with increased urban fringe camps The Commonwealth increased its role (specific purpose grants were paid to the States) Medibank established The Community Health Program introduced to promote primary health care services. AMS Redfern Established in 1971, it foreshadowed the WHO Declaration A triumph of Aboriginal peoples selfdetermination: providing solutions to health problems through comprehensive primary health care A result of: blatant discrimination experienced in mainstream services; the ill health and premature deaths of Aboriginal people; and the need for culturally appropriate and accessible health services. 1

ACCHSs There was minimal funding for ACCHSs. Many were established from international donations, loans from staff and assistance from AMS Redfern, Melbourne, and Alice Springs. AMS Redfern received its first Commonwealth grant in 1973 NACCHO was established 1974 to promote the establishment of culturally appropriate and Aboriginal controlled primary health care services. There was a prevailing belief that Aboriginal organisations were not up to it. They were a direct challenge to State Government service provision (which was thought to be adequate). Policy context Evaluation Committee found the NAHS had 1970s: Multiple reports (saying the same never been effectively implemented and thing- dismal grossly underfunded health, by more all governments, funds but needed, organisations, more Aboriginal the in particular HOR Committee participation needed) HREOC led coalition States/Territories. of Aboriginal & non-aboriginal Primary health care funding had to compete with housing and funding. 1989: The Howard organisations 10 year Governments to Plan- Close Forums the National formalising Gap within policy Aboriginal a and planning other needs. response Health generation. comprised Strategy Rudd bureaucratic Government (NAHS) with NACCHO commits Affiliates to Close between State & confirmations the Gap of (and existing support efforts. Commonwealth and develop ACCHSs ) Health Departments. accountability 1991: and to limited. Royal ensure The PHC Commission Depts services There for no into Aboriginal national Aboriginal Framework Deaths peoples.. in are Custody capable of bridging Agreement. the gap in without an independent health Review. standards by 2018. 1994: NAHS 1995: State-level Framework Agreements 2000: House NAHS: of Representatives: Aboriginal led and dominated Health is Life Working Party- an Aboriginal Peoples Strategy incorporating: 2003: 10 year Plan- goals and NSFATSIH targets 2008: Close the intersectoral Gap: COAG/Statement responsibilities, and of Intent 19 Public Hearings, 98 Submissions, site National Strategic Framework for Aboriginal visits to 60 Aboriginal communities and and Torres Strait Islander Health- aimed to take over where the NAHS failed, but was drafted by acknowledged the need for more PHC the Department of Health. Main purpose was to enhance mainstream sector responsiveness to Aboriginal peoples health. No targets specified, Implementation Plan was revised early in 2007 community control of Aboriginal primary health care. What does this mean now? We keep saying the same thing but in different ways. The same recommendations remain unaddressed. [ie funding PHC commensurate with health needs]. Former Government s view Two key themes: No amount of health care sector spending can improve Aboriginal ill health. Aboriginal peoples culture perpetuates their own poor health. These days, the problem is rarely inadequate health services. [Abbott, 2007] The fundamental problem is not lack of spending but the culture of directionless in which so many Aboriginal people live. [Abbott, 2006] 2

The reality is Hard to reach populations are often blamed when conventional public health programs fail to improve their health status. Rather, they are often locked out of meaningful participation in more appropriate program design and development and there are many examples of this in Australian health policy. WHAT DO ACCHSs DO? Definition of ACCHS An Aboriginal Community Controlled Health Service (ACCHS) is a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it (through a locally elected Board of Management). To be a member of NACCHO and its affiliates an ACCHS must be: Initiated by a local Aboriginal community; Based in a local Aboriginal community; Governed by an Aboriginal body which is elected by the local Aboriginal community; & Delivering a holistic and culturally appropriate health service to the Community which controls it. Size of services Most services are small. Just under half of all ACCHSs are too small to employ at least one FTE doctor. Funding of ACCHSs ACCHSs funding does not offset the under spending in primary health care. Eg total primary health care spending from federal and state sources is only 1.2 times higher for Aboriginal peoples (2004-5), when it should be at least 2 times higher. Only $426 per capita was expended through ACCHSs by OATSIH (2004-05). Analysts commissioned (2006) by the Australian Government reported that funding for Indigenous-specific primary health care services should be of the order of $1244 per capita. Thus, the current level of resourcing ACCHSs is insufficient to ensure Aboriginal peoples reach the highest attainable standard of health. Staff 3

2004-05 Episodes of care The total estimated number of individual clients seen by Aboriginal Health Services (AHS) in Australia was 317,000 in 2004-05. In 2004-05 there were approximately 1.6 million episodes of health care provided by AHSs of which 90% were to Aboriginal and Torres Strait Islander clients. Episodes of health care in past data collections includes: 2003-04 - 1,600,000 2002-03 - 1,500,000 2001-02 - 1,415,000 2000-01 - 1,340,000 1999-00 - 1,220,000 1998-99 - 1,060,000 1997-98 - 860,000 2004-05 Clinical health care Eg Broome Aboriginal Medical Service provides an Aboriginal community controlled satellite dialysis unit for the Kimberley region. This includes home visiting programs for families needing help. 2004-05 Community support role Also includes trachoma screening and treatment programs 2004-05 Preventive health care ACCHSs in both remote and non-remote areas make arrangements for the provision of free essential medicines to clients that would not otherwise afford such medicines. Funeral support is a service provided by most ACCHSs 2004-05 Substance misuse services 2004-05 Mental health and SEWB Programs 4

Primary Health Care ACCHSs within Australia deliver the WHO defined core elements of PHC Education about health problems & solutions Adequate food supply & nutrition Safe water & basic sanitation Maternal & child care; reproductive health Immunization against major diseases Prevention & control of local endemic diseases Treatment of common diseases & injuries Provision of essential drugs QUALITY ASSURANCE AND RESEARCH Quality Assurance ACCHSs commenced computerised Quality Assurance activity in the late 1980 s (well before mainstream general practice). [Garrow S.Healthplanner, 1990] ~60% of ACCHSs with at least 1 FTE GP are mainstream accredited practices [AGPAL 2008]. By 2004-05: Research & Evaluation Aboriginal Health Data: Service Activity Reporting OATSIH Healthy for Life Surveillance data (needs negotiating) National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data (NAGATSIHD) Data Protocols: Participatory research principles and guidelines ( Blacktrakker - in development) National Data Principles (AHMAC endorsed, 2006) NACCHO Data Protocols (1997) NHMRC 1991 Interim Guidelines on ethical research Quality assurance: Indicators (in development by the Sector for internal QA) QUM training (Good Medicine Better Health project) External Evaluations: Submissions and tenders Peer Review: Medical Journal of Australia, NHMRC Research Literature Reviews National Guide to Preventive Health Assessment Epidemiological research: Surveys (asthma, tobacco control, prescribing practice, Medicare & PBS uptake) Clinical interventional research: Multicentre randomised controlled trial (eg NACCHO Ear Trial) Formal Research Collaborations Affiliate Collaboration Aboriginal HREC NACCHO AHMRC (NSW) National Centre for Immunisation Research and Surveillance (NCIRS) James Cook University National Centre for HIV Epidemiology and Clinical Research Burnet Institute Coalition for Research to Improve Aboriginal Health (CRIAH) Sax Institute NACCHO Board and Statebased AHMRC Ethics Committee 5

Affiliate Collaboration Aboriginal HREC AHCWA Kulunga Research Network WAAHIEC (WA) AMSANT (NT) TAHS (Tas) Winnunga (ACT) Centre for Remote Health (Flinders University) (No formal collaboration with CRC-AH) Nil National Centre for Epidemiology and Population Health AIATSIS Australian National University Nil Nil Nil Affiliate Collaboration Aboriginal HREC QAIHC (Qld) AHCSA (SA) VACCHO( Vic) Univ Qld (Centre for Indigenous Health) Monash University (School of PH) James Cook University Mater Mothers Hospital (Perinatal Research Unit) Sax Institute CCRE (with Flinders University) Melbourne University (Onemda & GP Training Unit) project agreements: Deakin & Monash &Latrobe University & NGOs QAIHC Board SAAHEC (AHCSA) VACCHO Research into practice Where is this research leading us? As the research capacity of ACCHS representative bodies increases, they are making substantial contributions to evidencebased policy reform. NACCHO examples (medicines access) Condition: Smoking Survey: Medicines access: Subsequent policy reform: 2X>smoking rates, GPs working in Aboriginal health settings (Black A, 2006) Poor Nicotine replacement therapy (NRT) too costly and not on PBS Zyban on the PBS but not used (unsuitable Rx, contraindications) Nicotine replacement therapy introduced into the PBS 2008 for Aboriginal peoples. Condition: Asthma Survey: Medicines access: Subsequent policy reform: Higher rates of hospitalisation, longer hospital stays. 30/50 ACCHSs (Couzos & Davis, 2005) Limited health promotion opportunities Poor take-up MBS 80% reported poor patient access to asthma spacer devices Established Asthma Spacers Ordering Scheme in 2006 (Provides subsidised spacer devices to ACCHSs). MBS item revised Asthma awareness campaign funded (Indigenous) Condition: Chronic Suppurative otitis media Randomised controlled trial: Medicines access: Policy reform: Massive public health problem, 25% children in some communities, causes hearing loss 8 ACCHSs (Couzos, Lea, Mueller, Murray, Culbong, 2003) Existing antibiotic: contraindicated (ototoxic through perforated tympanic membrane) PBS approved only for otitis externa New antibiotic: TGA approved 2006 PBS listed for CSOM from 2007 Antibiotic guidelines amended 2007 New Australian (ENT Surgeons) Position Statement for CSOM 2007 6

WHERE TO FROM HERE? Close the Gap The full potential of ACCHSs cannot be realised without supportive infrastructure: Capable and adequate workforce Capital works (for new & to existing clinics, equipment, transport, etc) Formal agreements between NACCHO and DOHA for policy development, analysis and evaluation to improve accountability. HREOC Goals & Targets There is a need to: Establish a national framework agreement to secure the appropriate engagement of Aboriginal people and their representative bodies Fund a 5-year Capacity Building Plan for ACCHSs (including governance, capital works and recurrent support) to provide comprehensive primary health care to an accredited standard and to meet the level of need. Quantum of funding necessary Additional grants to Aboriginal primary health care services of $150m, $250m, $350m, $400m, $500m per annum over 5 years. $500m sustained in real terms thereafter until the Indigenous Australian health gap closes. Expenditure provides for: staff salaries (doctors, nurses, Aboriginal Health Workers, allied health, dental, administrative/management and support staff) training, transport provision, ancillary programs and all other operational costs including the annualised cost of infrastructure, and housing for staff in remote areas. [Access Economics, 2004, updated 2008] Can Australia afford this? The cost of atorvastatin alone (one type of lipid lowering agent) exceeded $510 million in just one year (2005-06). ACCHSs stand firm ACCHSs are the antithesis of the suggestion of Aboriginal peoples being directionless. Have defined comprehensive primary health care within Australia. Utilise regional centres/hubs to expand to needy areas. Provide a major training ground for workforce. Innovators of IT quality assurance activity. Play an increasing role in PHC research & leadership. Exemplify consumer participation, control and accountability in health. 7

NACCHO is a living embodiment of the aspirations of Aboriginal communities and their struggle for self-determination. Thank you! NACCHO website www.naccho.org.au 8