Why Australia needs a national college of Aboriginal and Torres Strait Islander health

The substantial continuing health and social inequalities faced by Indigenous Australians are increasingly well recognised and documented.1 The broad sociocultural influence on serious Indigenous health issues, such as diabetes and rheumatic heart disease, is also well recognised; poverty, lack of cultural security and a paucity of appropriate staff within health services for Indigenous people are evident contributors.2-4

Indigenous health policy development in Australia has been complicated by legal issues regarding Aboriginal land, through the Mabo and Wik decisions, and uncertainty about effective federal, state and local government strategies for dealing with health inequalities and their social determinants. The National Aboriginal Health Strategy, developed in 1989, emphasised the principle of Aboriginal self-determination in health, as well as increased coordination between Aboriginal community-controlled health organisations and federal and state governments.5 However, the transfer of health responsibility from the Aboriginal and Torres Strait Islander Commission to the Commonwealth Department of Human Services and Health in 1995 may have restricted the breadth of coordinated responsibility required to redress the inequitable social determinants and specific issues of health inequality. This issue has been further complicated by the significant challenge of service provision to an Indigenous population who are increasingly living in urban communities and regional centres, as well as remote locations, often with high mobility.6

The Howard Federal Government (1996–2007) appeared to lack a comprehensive strategic approach to the determinants of Aboriginal health outcomes, predominantly targeting initiatives against specific issues such as petrol sniffing, by the introduction of Opal fuel,7 and child abuse in the Northern Territory, via the Northern Territory Emergency Response.8 Although the Rudd Federal Government’s recent apology to Australia’s Indigenous peoples9 and current initiatives such as Close The Gap10 are welcome, the potentially long period needed to effect change may be significantly prolonged by electoral cycles and local political demands.

The current Australian Indigenous health policy environment has developed in parallel with increasing recognition of broader concepts of health that involve social determinants — including peace, education and social justice, and equity — as enunciated in documents such as the Ottawa Charter11 and repeated in Australian strategic documents such as the Ways forward blueprint for Aboriginal and Torres Strait Islander mental health.12 Unfortunately, the implementation of such strategies appears to be held back by a lack of coordination between federal and state governments and departments in terms of effective administrative responsibility for Aboriginal and Torres Strait Islander health and social determinants. In addition, public servants who manage and implement Indigenous health programs are often underprepared for dealing with issues of cross-cultural engagement involved in program delivery.6 The frustration of Indigenous Australians with the deficient overall strategic view is evidenced by recent calls from Indigenous health and human rights leaders for a national commitment to achieving health equality within 25 years.13

Evidence from overseas indicates that enlightened government policy and enhanced control of health-related socioeconomic factors by indigenous communities can lead to improved indigenous health outcomes. In New Zealand, recent strengthening of the Māori health workforce has led to a number of successes: interventions led by, focused on, and targeted to Māori; consistent investment in Māori health over a prolonged period; and an emphasis on the development of dual cultural and clinical competencies.14 In the United States, successful Native American health service development in the early 1990s appears to have been shaped by federal government administration, the separation of the Indian Health Service from other Native American affairs, and provision of an integrated health service.15 In both countries, recent reductions in overall death rates for indigenous people have been noted; in the US this relates to injury prevention, whereas in NZ it relates to fewer deaths due to circulatory conditions.16 Although it is not known whether improved health services for indigenous peoples in the US and NZ have a causal relationship with decreased mortality, the two appear to “travel together” well. In comparison, studies on community control by First Nations groups in British Columbia, Canada, suggest a direct correlation between increased cultural continuity within First Nation communities and reduced suicide rates.17 These are examples of health improvements for indigenous peoples that appear to have resulted from equality and partnership between the “mainstream” health services and indigenous community-controlled health services and programs.

The NSW Aboriginal Health Partnership Agreement18 is an example of an Australian program in which responsibility for and management of Indigenous health programs are shared between government and the Aboriginal community-controlled health sector. Comparable broadly based strategies aimed at dealing with indigenous disadvantage in Canada, administered through the Aboriginal Horizontal Framework in 2005,19 suggest that the need for partnership is being increasingly recognised as a means of ensuring continuity in any indigenous health program. The Framework, led from “front of government” by then Canadian Prime Minister Paul Martin, appears to place equal value on the “pillars” of health — health, lifelong learning, safe and sustainable communities, housing, economic opportunity, lands and resources, and governance and relationships.19 It has also been suggested that there has been an increased realisation in Australian policy that a broadly based approach is required across government departments to address health disadvantages faced by Indigenous Australians.20

With the realisation that “health” is more than the provision of medical and ancillary services to Indigenous Australians, any approach to health should be broadly based in a spirit of genuine and equal partnership with the Indigenous community. Adding a college of Aboriginal and Torres Strait Islander health to Australia’s medical colleges could help to continue stimulation and monitoring of such developments over a long timeframe. It could assist the Close The Gap10 strategy to develop a comprehensive long-term plan of action to address the challenges of Aboriginal and Torres Strait Islander health inequality. It could also ensure a high quality of health infrastructure with the full participation of Aboriginal and Torres Strait Islander health workers, health professionals and other interested organisations and individuals.

Australia’s medical colleges have traditionally performed a number of roles. For example, the Royal Australian and New Zealand College of Psychiatrists has performed the roles of a trade union, a scientific body and a professional council, and has recently increased its involvement in mental health policy.21 Similar roles could be performed by a national college of Aboriginal and Torres Strait Islander health.

Colleges have traditionally been based on exclusivity — enforced by a rigorous examination system — to maintain standards. This model would cause significant problems for a college aimed at emphasising partnership with the Indigenous Australian community because many of the Indigenous Australians who have a wealth of experience in health do not currently have formal educational qualifications that are comparable with those of non-Indigenous health providers. Also, given the significant cultural and demographic diversity of Indigenous Australians, a college of Aboriginal and Torres Strait Islander health would need to encompass their broad experience. In addition, it would need to provide for the broad interests of health professionals and administrative officials who may be interested in belonging to such a college. Such complexity may be suited to a layered model whereby college entry is open to a range of health professionals, Indigenous health workers, and Aboriginal and Torres Strait Islander people with significant life experience and activity in health. A further professional layer could then be available to members who complete approved education courses and pass an examination system. In Australia, a model similar to this is exemplified by the Australian College of Health Service Executives.22

Although there are a number of professional associations and courses that deal with Indigenous health at present, there does not appear to be any method of evaluating or compensating practitioners in terms of their suitability to provide culturally appropriate services to Indigenous Australians. Membership of a college could help to ensure that care provided to Aboriginal and Torres Strait Islander people in a range of localities is of a consistently high standard. Such a college could also have a range of other roles that benefit the progression and promotion of Aboriginal and Torres Strait Islander health issues in the current educational and policy climate (Box). Furthermore, it is hoped that it could provide an enduring basis for promoting and measuring Australian Indigenous health reform through direct participation with interested organisations such as the National Aboriginal Community Controlled Health Organisation, the Australian Indigenous Doctors’ Association, the Human Rights and Equal Opportunity Commission, and the Australian Medical Association.

A national college of Aboriginal and Torres Strait Islander health could contribute to the long-term strategy necessary to address the health disadvantages faced by Indigenous Australians. It could provide a mechanism for continuing advocacy for improved health, improved treatment, and the pursuit and monitoring of excellence in Aboriginal and Torres Strait Islander health care for generations to come.