Aboriginal Health in Aboriginal Hands

Flinders University Southgate Institute for Health, Society & Equity

Aboriginal health in Aboriginal hands

Community-controlled Comprehensive Primary Health Care @ Central Australian Aboriginal Congress What this report is about . . .

omprehensive primary health care (PHC)—which focuses on the whole patient, C not simply a disease state—has been the global ‘gold standard’ for addressing community health problems since the 1970s, including in Australia. Ideals are rarely put to the test, however.

In 2010 the National Health and Medical Research Centre (NH&MRC) funded the Southgate Institute for Health, Society and Equity at Flinders University to investigate how well community health services in South Australia are conforming to the principles of comprehensive PHC and the reasons for their success or otherwise.

Six community health services were selected for intensive study over several years: 5 in South Australia and 1 in Alice Springs in the Northern Territory.

Of these six, the Central Australian Aboriginal Congress (‘Congress’) in Alice Springs best embodied the principles of comprehensive PHC—by a long way.

This is a remarkable achievement for an organisation that started in 1973 with nothing, struggled to keep funded in the bureaucratic ghetto of Aboriginal affairs for its first 20 years of operation, and only in 1996 was certified to receive support through federal- and state-level funding mechanisms (i.e., Medicare), like other Australian health services.

Congress has had to fight every step of the way in the most challenging circumstances this country has to offer, but they have succeeded. Although there is still far to go, this is an Australian story worth telling.

Flinders University Southgate Institute for Health, Society & Equity

CONGRESS IS . . . SOUTHGATE INSTITUTE IS . . . A community-controlled health service An internationally renowned research centre, that provides culturally respectful located in the School of Medicine at the comprehensive PHC to Aboriginal people Flinders University of South Australia, which living in or near Alice Springs, or visiting the is concerned with the social, economic, town from much farther afield. political and equity aspects of public health policy, planning and implementation. Today, Congress is one of the most Professor Fran Baum, the institute’s experienced Aboriginal PHC services in the director, served on the Committee on Social country, a strong political advocate of closing Determinants of Health of the United Nations’ the gap in Aboriginal health disadvantage World Health Organization (WHO), whose and a national leader in improving health 2008 report set global standards. outcomes for all Aboriginal people. An Australian story worth celebrating

MESSAGE FROM FRAN BAUM, AO ver my career in public health which by racism, the distribution of income, Ostarted in the mid-1980s I have wealth and employment and educational researched community health centres and opportunities. While a health service become an admirer of the ways in which can’t change those things they can take they have been able to put the principles account of their impact on individual’s of the WHO’s Alma Ata Declaration on lives and play a crucial lobbying role. comprehensive primary health care into They can also act to redress injustice and action. I have had the opportunity to health inequities through their style of observe primary health care in many service provision. settings around the world and it is evident Congress is a community-controlled that Congress is an extraordinary model model of comprehensive primary health of good practice. care that needs to be acknowledged The Aboriginal Community-Controlled and celebrated. This report summarises health service model pre-dated Alma Ata the research evidence which my team at and was one of the social movements the Southgate Institute is pleased to have which contributed to the original 1972 produced in partnership with Congress Whitlam Community Health Program. This staff. We are very grateful for their trust has been the only time that community in allowing us to conduct this research health has been at the front and centre of and congratulate the Board, community national policy on primary health care. and staff on their fine commitment to a truly comprehensive primary health care The genius of the Aboriginal community service. We would also like to acknowledge controlled model is that it is able to the National Health and Medical Research take the best of a strong medical model Council for funding the research (project of care and combine it with a social grant 535041), and the research team who health model. As a Commissioner on the worked on the study, and who are listed Commission on the Social Determinants on the inside back cover. of Health I saw the accumulated evidence that good community health care has to We hope the report highlights what be based on an understanding of and makes Congress and other community appropriate action on the social and controlled health services like it special. cultural determinants of health. Congress My vision is that every community in stands out as an Australian service that Australia would benefit from having has managed to do exactly this. such a service. National policy makers should pay close attention to its benefits People’s health is profoundly affected and achievements. by the political and economic structures shaping their everyday Fran Baum, AO lives. Opportunities for leading a Director, Southgate Institute healthy and flourishing life are affected

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 1 Forty years of achievement

MESSAGE FROM DONNA AH CHEE t’s been over 40 years since Congress been about a 30% decline in all cause Ifirst opened the clinic on Hartley Street. mortality for Aboriginal people in the NT. All the old people who fought for this We have been able to achieve this because service, who worked so hard in the face right from the start Congress was based of so much opposition to make this on PHC principles and understood the possible, would probably find it hard to need to address both access to quality, believe how far we’ve come. Not because multidisciplinary sick care and the social they doubted what our people could determinants of health, because the do, but because the social and political conditions of Aboriginal life clearly have a climate was so aggressively opposed to huge impact on Aboriginal health. what they were trying to do. A lot has changed. Not enough, mind you, but a lot. Aboriginal people are the most over- researched group in the country, but Congress is now a $40 million operation, this research conducted by Southgate with more than 300 staff who provide Institute for Health, Society and Equity more than 160 000 episodes of care was important to us. Increasingly, research each year to about 12,000 Aboriginal is becoming our ally in the struggle to people living in Alice Springs and in improve health as it is being done in six remote community clinics in Central accordance with the strategic priorities of Australia. organisations like Congress. Congress’s In addition to this, the clinics service policies and practices have always been over 4,000 visitors each year. One of evidence-based. Congress is appreciative the best indicators of the success of of the collaboration with the Southgate this comprehensive PHC approach is Institute which has helped to demonstrate the improvement that has occurred in so clearly what Congress is doing right. the health of children. When Congress I hope by reading this report both started infant mortality rates were Aboriginal health and the critical role that around 170 deaths per 1,000 live community controlled comprehensive PHC births and now they are around 12. Our plays in health improvement will be better babies are no longer dying from easily understood. preventable causes and the challenge has moved to the promotion of health Donna Ah Chee development. Since 2001, there has also CEO, Congress

2 A big catchment

t’s impossible to appreciate Congress’s both in the town and in the town camps. Teresa) and Amoonguna communities in Iachievements in delivering primary However, the catchment also includes the east—among which Aboriginal people health care without understanding how remote Aboriginal communities—from move and live. Finally, Aboriginal people large and varied its catchment area is. the Mutitjulu community at Uluru (Ayers from other regions passing through Alice Alice Springs and the network of town Rock) in the south to, Utju (Areyonga), Springs also use Congress’s services. camps in and around the municipality, Ntaria and Wallace Rockhole communities constitute the core. Aboriginal people live in the west and Ltyentye Apurte (Santa

CONGRESS LOCATIONS IN CENTRAL AUSTRALIA

CONGRESS LOCATIONS IN ALICE SPRINGS • Head Oce • Gap Road Clinic • Alukura Women’s Health Service • headspace Central Australia • Social & Emotional Wellbeing Service • Child & Family Service • Ingkintja Male Health Service ALICE SPRINGS

AMOONGUNA

NTARIA UTJU LTYENTYE APURTE

Remote Health Service locations

LOCATION WITHIN NORTHERN TERRITORY

ULURU

MUTITJULU

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 3 What’s inside ...... key points

For Congress rom its very inception Congress •• Nearly all staff surveyed (96%) Fembodied the core primary health reported collaborating with other care principle of both treating sick organisations in the course of it has always been people and making them well through their work during the previous year, multidisciplinary sick care while at the including (in order of proportion both treating sick same time addressing the underlying of contacts) hospitals, community socio-economic determinants of ill health services, NGOs, Centrelink, people and making health. For Congress it has always been schools, police, housing services, local ‘both / and’ and not ‘either / or’. government / councils, the education them well. department, other PHC services, the NT In the beginning it was about providing Medicare Local, private allied health, emergency shelter through a tent private GPs, professional associations, program, creating an accessible bank tertiary education institutions, divisions that enabled enrolment for vital transfer of general practice—even the media. payments following the referendum •• The vast majority of Congress clients granting citizenship as well as running rated the quality of care at Congress a clinical service with GPs and the first high or very high. Aboriginal Health Workers. Now, Congress •• In the diabetes case study, clients with sees approximately 10,000 urban clients type 2 diabetes were ‘enthusiastically each year, providing about 130,000 unique positive about the care they received’, episodes of care (see Figures 1 and 2). and demonstrated good levels of Congress has continued to combine the glycaemic control and blood pressure. provision of essential clinical services with •• Congress has helped Aboriginal action on the broader social determinants people in other areas of the country of health. The key points of this report are: to establish their own culturally •• Congress arguably represents the appropriate health services. Australian ‘gold standard’ for •• The Southgate Institute study community-controlled comprehensive concluded that, of the six health PHC that conscientiously addresses services investigated over five social determinants in everything it years, Congress ‘provides a model’ does, as it is able. for building into an organisation’s •• 90% of staff interviewed by the governing structure the means for Southgate Institute said they take community participation in decision- the social determinants of health into making and service planning. account in the course of their work.

4 What’s inside ...... key points

Figure 1. Congress unique urban clients (service area and visitors), by year

12000

10000

8000

6000 Visitors

4000 Health service area

2000 NUMBER OF CLIENTS OF NUMBER 0

2007 2008 2009 2010 2011 2012 2013 2014 2015 2013-14 2014-15 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013

Figure 2. All Congress urban episodes of care, by year

160000 140000 120000 100000 80000 Total 60000 40000

EPISODES OF CARE OF EPISODES 20000 0

2009 2010 2011 2012 2013 2014 2015 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 5 Primary health care ...... a global paradigm shift still gaining ground

The primary health care ALMA ATA DECLARATION (PHC) movement began The historical reference point for comprehensive PHC is the manifesto issued on 12 September 1978 at the end of a major international conference in Kazakhstan hosted in the early 1970s out of by the World Health Organization (WHO). concern to correct massive How PHC differs from traditional health care is easily understood in terms of‘before’ social and economic and ‘after’ the Alma Ata Declaration, which: inequalities between •• Articulated a new definition of health. •• Established health and access to health care as a human right. rich and poor countries, •• Included social, economic and political factors among those contributing to poor and between rich and health, meaning that solutions require a multi-sectoral approach, including the recognition that there was a need for ‘a new economic paradigm’ in order to achieve poor communities within ‘Health for All’. countries. •• Put responsibility on national governments for providing equal access to health care, and developing the health workforce to meet greater demand. As a social justice-based •• Advocated community participation in health care planning and implementation. community development More selective variants of PHC have been introduced since, but the Alma Ata Declaration remains the benchmark for comprehensive PHC. movement gained pace worldwide, it became clear Table 3. Conceptions of health care before and after the 1978 Alma Ata Declaration on Primary Health Care that inequalities in illness BEFORE PHC AFTER PHC and mortality rates result Definition of Hard to define. Generally, ‘A state of complete physical, mental from personal context within health the absence of disease or and social wellbeing, and not merely infirmity. the absence of disease or infirmity . . . ’ communities characterised (Drawing on the 1947 WHO Constitution) Focus of Symptoms of disorders A multifaceted individual who is unwell and by social, economic treatment or diseases exhibited in a is embedded in a context that may or may and political inequality, patient. not support heath. Status of health Public or privately Health is a socio-economic issue, and factors. That means some care funded services to which access to health care is a human right. individuals may or may communities and groups not have access. Approach Curative, rehabilitative. Health promotion, disease prevention, have much less chance for a curative, rehabilitative. healthy life than others. Temporal duration Short-lived intervention. ‘ . . . ongoing process of improving people’s lives . . . ’ This is especially so among Socio-economic Negligible. Critical. factors colonised Aboriginal and Government’s role Variable. Responsible for ensuring all citizens have Torres Strait Islander equal access to health care. Health care policy Variable. National policies are required. peoples. Traditional health Sectors involved Health and medicine. Health and medicine, education, food in health care supply and nutrition, water supply and services are ill-equipped sanitation, housing, family support and family planning, transport, public works, to address these social communication. determinants. Role of the Negligible. ‘ . . . People have the right and duty to community participate individually and collectively in the planning and implementation of their health care.’

6 Primary health care ...... a global paradigm shift still gaining ground

Runs on the board ‘A PHC approach is the most efficient and cost-effective way to organise a health system. International evidence overwhelmingly demonstrates that health systems oriented towards primary health care produce better outcomes, at lower costs, and with higher user satisfaction.’ — MARGARET CHAN, DIRECTOR-GENERAL, WORLD HEALTH ORGANIZATION (2007)

Evidence for the effectiveness of PHC has been collected three times for the Australian government in the past 15 years: the National Centre for Epidemiology and Population Health (NCEPH) ‘Legge Report’ 1992, the ‘Griew Report’ (2008) and Better Health Care (2001). All three reports conclude that comprehensive PHC PHC IN AUSTRALIA is the only strategy for addressing the overwhelming health problems faced by The principles of PHC began to be Aboriginal people with a realistic prospect of success. Some observations: formalised in Australia at a Monash •• The main conclusion of the NCEPH report was that if the Australian health University conference in 1972. The system was re-oriented in accordance with the principles of primary health care meeting, Better Health for Aborigines, that this would lead to greater health improvement. was convened by Basil Hetzel, inaugural •• ‘International experience has shown that a comprehensive approach to professor of social and preventive primary health care can contribute to significant improvements in health medicine at Monash; Yami Lester, a in developing countries and among Indigenous populations in developed Yankunytjatjara man; and Jim Downing, countries comparable to Australia.’ (BHC, p. 11) a Uniting Church minister. The first •• ‘Evidence from the [USA] and New Zealand suggest that primary health care Aboriginal community controlled health has contributed to narrowing the life expectancy gap between Indigenous service, Redfern Aboriginal Medical and non-Indigenous peoples in those countries . . . [and] that poorer access Service, had been set up in 1971. to primary health care is associated with a widening life expectancy gap.’ The topic was how to address shocking (Griew, p. 7) Aboriginal morbidity and mortality •• ‘Improvements in Aboriginal and Torres Strait Islander infant mortality rates, often referred to as ‘third world’. rates are consistent with better access to primary health care services’— The principles of PHC appeared to be the although they remain ‘almost three times greater than for other Australians, only way to approach health problems and significantly worse than for those for Indigenous peoples overseas.’ linked with such widespread disadvantage. (Griew, p. 7) •• ‘Changes in disease mortality patterns—including the shift from mortality In 1973 the National Hospital and due to infectious diseases to mortality due to chronic conditions’—are well- Health Services Commission introduced documented, especially in the Northern Territory, ‘and are plausibly related to a community health initiative the development and actions of primary health care services.’ (Griew, p. 7) incorporating PHC principles. Although short-lived, the program led to the incorporation of PHC principles in Australian health policy and accreditation criteria and a funding stream for community controlled health services. The Aboriginal community-controlled health sector of which Congress is an exemplar, continued to develop and grow. All of this took place before the Alma Ata declaration in 1978.

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 7 Social determinants of health ...... context (really, really) matters

‘Our children have DISCRIMINATIO URE N ULT GE C ND dramatically different life g E in R in ra GROG H , t O chances depending on h D U lt IET S a LY IN e I G where they were born . . . h M l, A a F i R c D o A In countries at all levels s R C , U I r G S e M t S

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P L O A C L I I differences in health T are . . . avoidable by reasonable action they care – which is designed to treat are, quite simply, unfair.’ HEALTH BEYOND THE INDIVIDUAL defined conditions according to certain —CLOSING THE GAP IN A GENERATION, therapeutic protocols. The medical model Every person who seeks help from WHO COMMISSION ON THE SOCIAL places responsibility for health squarely Congress—or any health service—is DETERMINANTS OF HEALTH (2008) in individual behaviour (e.g., smoking, embedded in a context of daily life that drinking, overeating, not exercising has multiple layers, all of which affect enough, following a doctor’s orders). health. The first layer involves immediate or ‘proximate’ factors known to impact While PHC principles recognise the impact health, many of which would be checked on health of factors beyond the control in most medical settings. (See diagram of the individual—e.g. housing, family, above.) education, income, culture, the availability of transport—it is increasingly recognised However, these proximate factors are that health is not simply socially affected embedded in a larger social, economic but socially determined. and political context that powerfully shapes the patient’s lived reality as well, How a society is structured politically, including health. If these environmental what sort of economic system it has, and factors are not addressed, they will how these two work together with culture continue to adversely affect health. to distribute not only public and private goods but also public and private Considerable lip service is paid to PHC goodwill—praise or blame, acceptance principles in health policy discussions or discrimination—also have a profound and drafting, but in reality most health impact on health, affecting different services worldwide run on a traditional populations in different ways. ‘medical model’, – primary medical

8 Social determinants of health ...... context (really, really) matters

Generally speaking, people living in something about it should be an ‘ethical poverty, lacking education opportunity, imperative’ worldwide. and disadvantaged ethnic minorities The Commission made 3 over-arching that tend to be both, tend also to have recommendations, which provided the the worst health in a society. In part backbone of the 2011 ‘Rio Declaration’ on due to the body’s automatic response to SDH produced by a world conference held psychological stressors, there is a cost in Brazil to discuss the findings. to health paid by people lower on the socioeconomic gradient that is not 1) Improve daily living conditions. incurred by people higher up. Especially concerning the wellbeing of girls and women; early childhood Aboriginal people remain the most development; education; and the socioeconomically disadvantaged conditions in which people live and work. Australians. 2) Tackle the inequitable distribution RIO DECLARATION (2011) of power, money and resources in the way society is organised, which produce Under the auspices of the World Health inequities in the social and material SDH A PRIORITY @CONGRESS Organization (WHO), the Commission on conditions of life. Social Determinants of Health (SDH) •• Website clearly sets out Congress’s collected and analysed global evidence 3) Measure and understand the problem, commitment to SDH. See: http://www. for the impact of SDH on health, and the and assess the impact of action. This caac.org.au/aboriginal-health/social- health inequities arising from them. includes making SDH a greater focus of determinants-of-health/ •• 90% of staff interviewed by Southgate In a 247-page report entitled Closing the public health research. Institute said they take SDH into account in Gap in a Generation published in 2008, the the course of their work. Commission concluded: ‘Social injustice •• 59% of staff said SDH are taken into is killing people on a grand scale.’ Doing account in Congress service planning. •• 67% of staff interviewed thought SDH are on the Congress policy agenda. •• Examples include Congress’s advocacy on WHO COMMISSION MODEL OF HOW SDH AFFECT alcohol supply through the People’s Alcohol POPULATION HEALTH Action Coalition, a preschool readiness program, a Men’s shed that provides job skill training, and collaboration with the SOCIOECONOMIC AND POLITICAL housing authority on housing issues. CONTEXT DISTRIBUTION OF •• Congress has long prioritised and carried • Social position • Material circumstances • Governance HEALTH • Social cohesion AND WELLBEING out research to ensure its approach to • Policy • Psychosocial factors health care is based on scientific evidence, (Macroeconomic, • Education • Behaviours Social, Health) • Occupation • Biological factors a key recommendation of the WHO • Cultural and • Income Commission. societal norms • Gender and values • Ethnicity / Race HEALTH CARE SYSTEM ‘Put simply, the social gradient

SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES in terms of housing, education, employment, access to justice and empowerment are directly linked to Source: Closing the Gap in a Generation (2008) the disastrous health outcomes we face.’ —REBUILDING FAMILY LIFE (CONGRESS)

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 9 Congress in context ...... zero to comprehensive in 40 years

Congress became a pioneer of comprehensive PHC out of necessity, not ideology.

Addressing the social determinants of health was the most rational response to the circumstances when Congress was created, not simply because it coincided with a worldwide movement.

Today, Congress arguably ongress is one of two organisations It also meant that, right from the Ccreated at an historic meeting of beginning, Congress was charged with represents the Australian Aboriginal people from many language looking after more than just Aboriginal ‘gold standard’ for groups on 9 June 1973 in Alice Springs. health. Health was just one piece in a multi-dimensional picture of deprivation. community-controlled The Central Australian Aboriginal Legal Aid Service (CAALAS) was established FOUNDING PRINCIPLES comprehensive PHC that first to help Aboriginal people with the conscientiously addresses legal troubles, and personal trauma, that Congress was founded on several flowed from life in a social, economic and principles that set it on a collision social determinants in political system alien to their culture, course with government policy. At the everything it does, as it which had taken their land, herded them time, policies discriminated between onto missions and reserves, and was ‘traditional’ and ‘town’ Aboriginal is able. designed, in many respects, to control people on the basis of how much so- their lives. Congress was the second. called ‘Aboriginal blood’ an individual possessed. Instead, the meeting declared, Just as the Congress Party founded by Congress would operate according to the Mahatma Gandhi gave voice to Indians’ following ideas: determination to be free from Great Britain, so Congress was established to •• Town and bush are one mob. be ‘the voice of Aboriginal people in •• Anyone who identifies as an Aboriginal Central Australia’—for a ‘fair go’ in every person is an Aboriginal person. other area of extreme disadvantage that •• Culture must be respected in all facets blighted Aboriginal life. of Congress’s operation and service. This included being forced to use health, •• Community control is non-negotiable. education and social services that were insensitive —if not downright hostile— to Aboriginal needs. The Alice Springs Hospital was desegregated only four years earlier.

10 Congress in context ...... zero to comprehensive in 40 years

STARTING WITH NOTHING A ‘pick-up service’ was also established as the best hope for improving the to get drinkers out of public spaces shockingly poor state of Aboriginal health. Congress had a mandate to tackle a wide range of problems, but no resources. before they were charged with public Based on his wide-ranging consultations This meant asking for help. Intersectoral drunkenness, a difficulty faced by the and PHC principles, Cutter drafted collaboration thus became another minority of Aboriginal people who drank a funding submission to establish a standard of Congress’s operations. alcohol as pubs had ‘dress codes’ to keep community health program as part of them out. The winter Congress was established was the new established organisation which, very wet, and many Aboriginal people Monash University graduate Dr Trevor together with the existing non clinical had no shelter. The ‘Tent Program’ was Cutter arrived in 1974 to consult with programs would create a new Aboriginal- Congress’s first venture, with the help people and advise on the establishment controlled health service in Alice Springs. of the Alice Springs Town Council and of a community health program. Cutter Both NT and Commonwealth health charities like Anglicare. This was clear and was well-versed in the principles of the departments opposed the application. urgent way in which social and economic emerging PHC movement, outlined at factors were affecting health. a ground-breaking workshop at Monash

FROM HARTLEY STREET (TOP) TO LEICHHARDT TERRACE

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 11 Congress in context ...... zero to comprehensive in 40 years

‘[By] worrying about the people, that’s how Congress got so strong . . . [O]h, it just amazed me how we used to get these other new programs goin’ . . . with no dollars, no dollars, absolutely no dollars.’

— MARGARET LIDDLE, SENIOR WELFARE WORKER (1970s)

‘BETTER HEALTH FOR According to a history of the period, managing chronic diseases may attend ABORIGINES’ Congress recorded about 4,000 medical the clinic up to four times per month. consultations its first year. The next year Despite this opposition, Congress officially From its earliest days, Congress became the number of contacts for all services opened its clinic in dedicated premises on a model of comprehensive PHC for 10 October 1975 in a converted house on more than doubled to 9,750. Within Aboriginal communities seeking to Hartley Street. a decade, the number had grown to establish their own health services, from 28,000 medical consultations, 1,200 the Anangu Pitjantjatjara–Yakunytjatjara Employment and training of Aboriginal dental consultations and 25,000 welfare (APY) Lands to Broome. Congress today Health Workers, to work as ‘cultural services—’approximately 190 people per directly supports regional health brokers’ alongside the doctor, was an early working day’. services at Amoonguna, Uluru (Mutitjulu), Congress innovation, as was a focus on Areyonga / Utju, Hermannsburg (Ntaria) staff development, to train Aboriginal It took two decades of dogged advocacy, and Santa Teresa (Ltyentye Apurte). people to take over administrative jobs. but in 1995 Congress finally joined the relatively secure funding stream of The remainder of this report shows In addition to the health clinic, Congress mainstream health services, including how—and how well—Congress meets operated a ‘welfare section’, which access to Medicare (1996) and the its continuing mission to deliver initially helped people apply for benefits, Pharmaceutical Benefits Scheme (1998). comprehensive PHC to Aboriginal held the cheques of those with no postal people in Central Australia. address, and ran a bank, as well as running the pick-up service. A PURPOSE-BUILT MODEL Today Congress occupies a purpose-built Over the years the welfare section facility on Gap Road, from which it has grew to encompass most of the social operated since 1988 and to which have determinants of health, including been added two adjacent blocks of land expanding access to housing, education and another block 5 kilometres away, as (school busing), nutrition (school programs and demand have expanded. lunches, food vouchers), employment (via CentreLink), transport, family support, During the Southgate study period childcare, disabled and aged services, (2009–2014), the number of individual dental services, remote outreach, and Congress clients grew 15%, from roughly alcohol rehabilitation—even assisting 8,600 to 10,000. Each client may be seen with organising funerals. many times per year. Congress clients

12 Congress in context ...... zero to comprehensive in 40 years COURTESY OF REDBACKGRAPHIX.COM.AU OF COURTESY

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 13 What we do ...... activities and programs

Congress has over OUR GOVERNANCE STRUCTURE 40 years’ experience THE CONGRESS VISION: providing comprehensive All Central Australians enjoy the same level of health Congress is an Aboriginal community-controlled primary CONGRESS primary health care for health care service. This means that we have a membership MEMBERS Aboriginal people in of community members who help us to keep informed about the needs of our people. Central Australia. OUR CORPORATE SERVICES Our services target the CONGRESS BOARD OF social, emotional, cultural Congress’s Board of Directors is comprised of six member DIRECTORS and physical wellbeing of Congress’s corporate services help and three non-member directors. The member directors are FINANCE to keep our business running so that elected by Congress members and the non-member directors are Aboriginal people. we can provide high quality services appointed by the member directors for their specialised skill to our people. in important areas of governance. CEO

COMMUNICATIONS EXECUTIVE OUR CLIENT SERVICES OFFICE

INFORMATION TECHNOLOGY & INFORMATION MANAGEMENT

ALUKURA SOCIAL & EDUCATION & WOMEN’S INGKINTJA MALE CHILD & FAMILY EMOTIONAL REMOTE HEALTH GAP ROAD CLINIC TRAINING HEALTH HEALTH SERVICE SERVICE WELLBEING SERVICES HUMAN SERVICE SERVICE SERVICE RESOURCES

INCLUDES: INCLUDES: INCLUDES: INCLUDES: INCLUDES: INCLUDES: INCLUDES: Dentist Women’s Clinic Male Clinic Healthy Kids Clinic headspace (youth) Amoonguna Aboriginal Health Medical Dispensary Young Women’s Men’s Shed Childcare Cultural and Social Health Service Practitioner (AHP) Training Traineeships PUBLIC HEALTH Chronic Disease Program Community Health Young Men’s Community Pre-school Readiness Program Support Program Ntaria Health Service Research Education Program Frail Aged and Health Education Program Intensive Family Therapeutic Program Mutitjulu Health Service Continuous Quality Disabled Program Family Partnership Program Violence Intervention Support Program Mpwelarre Health Centre Improvement (CQI) Acute Care Grandmothers and Program Targeted Family Utju Health Service Aunties Program Alice Springs Support Program Aer Hours GP Midwifery

14 What we do ...... activities and programs

OUR GOVERNANCE STRUCTURE THE CONGRESS VISION: All Central Australians enjoy the same level of health Congress is an Aboriginal community-controlled primary CONGRESS health care service. This means that we have a membership MEMBERS of community members who help us to keep informed about the needs of our people. OUR CORPORATE SERVICES CONGRESS BOARD OF Congress’s Board of Directors is comprised of six member DIRECTORS Congress’s corporate services help and three non-member directors. The member directors are FINANCE to keep our business running so that elected by Congress members and the non-member directors are we can provide high quality services appointed by the member directors for their specialised skill to our people. in important areas of governance. CEO

COMMUNICATIONS EXECUTIVE OUR CLIENT SERVICES OFFICE

INFORMATION TECHNOLOGY & INFORMATION MANAGEMENT

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 15 Multidisciplinary teamwork ...... key to quality care & client satisfaction

‘Staff are willing to listen and they help by putting you in touch with other places and services or programs available at Congress.’

—CONGRESS CLIENT

‘I find with Congress that they have access to a lot more here than elsewhere ENSURING QUALITY CARE •• 81% said quality care was ensured by explaining all the treatment and that I’ve been.’ As part of their evaluation of six primary lifestyle options and letting clients —CONGRESS CLIENT health care services, Southgate Institute make the best decisions for themselves, researchers surveyed 59 members of a practice reflected in clients’ Congress staff. Of those surveyed: evaluations of the service.

•• 91.5% rated multidisciplinary •• Nearly all staff surveyed (96%) teamwork—having several health reported collaborating with other experts with different skills and organisations in the course of expertise consulting on individual their work during the previous year, clients’ cases—as the main mechanism including (in order of proportion for providing high quality care. (See of contacts) hospitals, community diabetes case study opposite.) health services, NGOs, Centrelink,

SERVICE QUALITIES: MEETING A HIGH STANDARD Southgate identified several qualities comprehensive PHC services should have besides the ideals of efficiency and effectiveness shared by all health services.

•• Holistic. Treat the whole patient, not just disease symptoms. •• Mix of treatment, prevention & promotion. Community conditions and common behaviour leading to ill health also must be targeted. •• Used by those most in need. The most powerless tend to be those with the greatest health needs. •• Increases individual control. Client rights are clearly articulated. Individuals better understand factors that affect health. •• Responsive to the local community. Through governance and other means. •• Supports and empowers the community. Seeing change as a result of having input in turn changes attitudes. •• Culturally respectful. Affects service use and treatment. On a 5-point scale, Congress’s clients ranked their service very highly (between 4 and 5) on six of the nine factors.

16 Multidisciplinary teamwork ...... key to quality care & client satisfaction

schools, police, housing services, local CASE STUDY: DIABETES government / councils, the education Chronic diseases present the greatest societal burden in terms of health funding, department, other PHC services, the NT patient suffering and cost to the economy, and in recent years their treatment has Medicare Local, private allied health, taken priority in national health policy. As part of their study, the Southgate Institute private GPs, professional associations, looked at how each of the six health services handled these complex cases. tertiary education institutions and divisions of general practice. Congress saw 884 clients with diabetes in 2014–15, equating to a 14% prevalence in the service’s catchment population. Researchers received permission from 30 •• Over 90% said that they personally take diabetic clients to review their cases, of which 12 clients agreed to be interviewed. the social determinants of health According to the Southgate report, in comparison with the other services Congress: into account in developing treatment plans for clients to a great (67%) or ‘[E]mployed the widest range of disciplines and arranged for visiting professionals, moderate (23.5%) extent, and over half allowing Congress to act much closer to a one-stop shop for clients with diabetes (51.2%) said this was accomplished compared to the South Australian services.’ both through collaboration with other • Saw clients four times as often (on average 4 times a month, compared to once organisations and advocacy. monthly for the SA services), and monitored cases more closely. HIGH CLIENT RATINGS • Enlisted the greatest number of professions in case management: ‘all clients saw As Southgate Institute researchers found, at least 3 professions . . . with the majority (70%) seeing more than 5 professions.’ Congress clients tend to have a high Of these, the most common seen were GP, pharmacist, diabetes nurse, podiatrist, opinion of the service. Of 82 Congress and optometrist. clients surveyed: • Took the most comprehensive approach to accessibility, ‘with the provision of transport, Aboriginal Liaison Officers, phone support to clients, home visitation •• 35% rated Congress 5 out of 5 for the and outreach, including Nephrocare for clients on dialysis.’ overall quality of services provided, while 48% gave a rating of 4 out of 5. • Was more likely to refer clients to external health services for diagnostic tests. •• 72.5% said that staff explain Moreover, clients were ‘enthusiastically positive about the care they received’ and procedures, tests and results all of the described Congress workers ‘as ‘understanding’, ‘helpful’, ‘extremely informative’, time (37.5%) or often (35%). ‘extremely friendly’, ‘very compassionate’, ‘very professional in their attitude’, and •• 77% said they were provided with the ‘very thorough’.’ Clients also said workers gave ‘clear messages’ and were ‘supportive’. information they needed all the time Congress’s health centre report for 2015 shows the clinical benefits of this care for (51%) or often (27%). Only 3.7% said clients. About a third of the 1207 Congress clients with diabetes (32%) had good they got the information they needed glycaemic control (HbA1c ≤ 7%), which was equivalent to the Northern Territory rarely or never. average for Aboriginal PHC, and 25% had high blood sugar levels (HbA1c ≥ 10%) •• Nearly 3 out of 4 clients (74%) said which is less than the NT average. This glycaemic control is important in preventing Congress staff listened to and cardiovascular, eye, and other complications from diabetes, including amputations. respected their preferences often 54% of these diabetic clients also had good blood pressure control (< 130 / 80) (46%) or all of the time (28%). and this is also important in the primary prevention of heart disease and stroke. Outcome data such as this was not collected in the other services in the study. •• Over half of respondents (54%) said they received help from Congress staff Finally, Congress helped to develop a video-based resource called The Diabetes with issues not directly related to Story, which is aimed at clients with low medical literacy levels and comprehension a health complaint—e.g. transport, of written material and is available in three Central Australian Aboriginal languages access to benefits, housing, legal as well as English. matters, job training and childcare— while 32% said they received such help with more than one issue.

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 17 How we do it ...... governance & community participation

‘Having the evidence is COMMUNITY CONTROL: HELPING OTHERS TO HELP not enough; knowing HOW IT WORKS THEMSELVES Congress was created by a community, As one of the earliest community- what ‘best practice’ for a community, and has remained controlled PHC health services, is [is] not adequate. community-controlled for over 40 Congress has helped Aboriginal people years, often against powerful odds. in other areas of the country to establish The best of ideas, the Community participation, one of the key their own culturally appropriate best of our knowledge, characteristics of PHC, has long been health services. acknowledged as the source of 1973 Central Australian Aboriginal must come from a well- Congress’s strength. Congress, Alice Springs grounded base within Every person over 18 years of age in the 1977 Angarappa – later Urapuntja our communities . . . Congress catchment area who identifies Health Service, Utopia [T]he evidence says that and is recognised by the community as an 1977 Pitjantjatjara Homelands Health Aboriginal person is eligible to become Service – later (1984) Nganampa community control has a member of Congress. Membership Health Council, SA superior outcomes in is required to vote in elections for 1978–82 Lyappa Congress, Papunya Congress’s governing board. The 1978 Broome Aboriginal Medical primary health care than Congress website explicitly encourages Service (BRAMS) membership, which is free, and provides solutions imposed from 1982 Kalano – later (1990) Wurli everything necessary to apply. Wurlinjang Health Service, elsewhere.’ Every year the membership elects 3 Katherine —REBUILDING FAMILY LIFE (2011) Aboriginal members to the board of 6 1983 Pintupi Homelands Health members that governs Congress. The six Service, Kintore community board members then recruit 1983 Ngaanyatjarra Health Service and appoint 3 specialist members, who (WA) may be non-Aboriginal people, represent 1985 Anyinginyi Congress Aboriginal disciplines relevant to Congress’s Corporation, Tennant Creek activities: primary health care, finance, 1986 Imanpa Health Service and governance and administration. 1986 Mutitjulu Health Service, Uluru The board, together with the CEO and 2000 Ltyentye Apurte Community specialist members, meet every 6 weeks. Government Council Health After every meeting, the board issues Centre, Santa Theresa a communiqué summarizing the items 2002 Western Aranda Aboriginal discussed and decisions made, which is Health Corporation distributed to all members and is available 2003 Utju Health Service (Areyonga) to all staff on the intranet. 2003 North Barkly Health Board In addition, community members can (becoming part of Anyinginyi) raise issues through board members or 2003 WYN Health Board (handed back Congress staff. to the NT DoH)

‘[L]ook, we as a people in this community know that if we have an issue with Congress . . . we feel like we could go and tell them. It’s not a place that you’ve got to keep an arm’s length away.’ CHR—CONGRESS CLIENT

18 How we do it ...... governance & community participation

SOUTHGATE STUDY: ADDRESSING THE SOCIAL DETERMINANTS THROUGH CONGRESS IS A MODEL TRAINING AND EMPLOYING ABORIGINAL PEOPLE The Southgate Institute study concluded One of the important ways Congress addresses social determinants is through that, of the six health services investigated training and employing Aboriginal people. As of December 2015, Congress over five years, Congress‘provides a employed 309 staff in full-time, part-time, and casual roles. Of these a total of model’ for building into an organisation’s 144 staff were Aboriginal (47%). The table below shows the Aboriginal staffing governing structure the means for community level by division and by salary level. participation in decision-making and service planning—not just for Aboriginal people Division Aboriginal Non-Aboriginal Total but for community-based health services Executive / Public Health 15 (60%) 10 (40%) 25 more generally.

Business Services 7 (33%) 14 (66%) 21 Researchers found that health services run by non-governmental organisations have HR 4 (50%) 4 (50%) 8 ‘more mechanisms for accountability to Health Services 118 (46%) 137 (54%) 255 the community’—for example, through Salary level boards of management—than state-managed

Level 1–2: Entry level roles 21 (78%) 6 (22%) 27 PHC providers.

Level 3–5: Technical officer roles, 64 (81%) 15 (19%) 79 While community participation is mandated Childcare, AHPs and admin levels in state-managed PHC services, researchers found that it was ‘less noticeable in practice,’ Level 6–7: Front line supervisors, 46 (73%) 17 (27%) 63 experienced admin levels, new graduates and actual opportunities for community RN participation had contracted.

Level 8 and above: Management roles, 13 (9%) 127 (91%) 140 Community participation in state-managed GPs, tertiary qualified roles, allied health PHC services was ‘generally limited to staff, experienced RNs individual feedback on specific programs,’ TOTAL 144 (47%) 165 (53%) 309 for example, on a particular consultation or as part of a program’s means of assessment. The reduced proportion of Aboriginal staff at the highest salary levels highlights the challenges faced by a service like Congress in employing Aboriginal people at the higher professional levels given the continuing failure to close the gap in early childhood education and school education to ensure there are sufficient Aboriginal people qualified at these levels. There are jobs within a PHC service like Congress that require tertiary qualifications yet there are not enough Aboriginal people qualified for these types of positions. This is where the Congress traineeships, cadetships and study support initiatives are important, as this is a pathway to assist Aboriginal people into tertiary level studies so that Congress can employ them in the better paid roles.

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 19 Advocacy ...... collaborating to makes good things happen

Advocacy is an important characteristic of primary health care that addresses the social determinants of health, but it usually is not a primary characteristic of most health services. In Congress’s case, advocacy was its first mission—to be ‘the voice of Aboriginal people in Central Australia’—and advocacy has permeated MAKING THE VOICE HEARD Today, collaboration with other its activities ever since. By assuming responsibility for ensuring professionals and organisations the health of Central Australian Aboriginal is Congress’s principal way of people, Congress necessarily took on the task of promoting Aboriginal people’s fulfilling its mission. interests in many areas not traditionally associated with health. HOW IT WORKS For example, the Tent Program, initiated Individual advocacy means accessing soon after Congress was established the services needed, clinical and social, in 1973 during a very wet winter, to bring the whole patient back to immediately involved the organisation health, not simply to treat the symptoms in the lack of appropriate housing for of a disorder. This may involve liaison Aboriginal people in and around Alice with other doctors or the hospital, Springs as well as the lack of secure social services, employment agencies, tenure over land on which to build educational institutions, and organising such housing. transport. It also means following up with patients to ensure they have what they Because Congress started with nothing, need to attend appointments. from the beginning advocacy meant collaborating to bring about a In fact, 96% of Congress staff interviewed positive result. In the Tent Program, for by the Southgate Institute reported example, Congress got help from what collaborating with other organisations in is now Anglicare and the Alice Springs the course of their work. Town Council. Community advocacy addresses the Shepherding applications for welfare social determinants of health through payments through relevant departments support of land rights, adequate housing and organising receipt of cheques for and infrastructure, transport, education, distribution also forced Congress staff and employment opportunities, in right from the start to develop productive addition to community-based health relationships with public servants in promotion campaigns, for example, many areas. against smoking and domestic violence.

20 Advocacy ...... collaborating to makes good things happen

Government advocacy takes place at PEOPLE’S ALCOHOL ACTION COALITION: the local, territory, and federal level and TURNING DOWN THE TAP is often aimed at policy and funding. Congress has enjoyed great success in this area, long acknowledged by governments ‘Congress could never have done this on our own . . . I am quite and peers. The most important victory confident that we wouldn’t have got where we are now on the was bringing funding arrangements for issue of alcohol and getting the tap turned down if it wasn’t for Aboriginal health services under the Commonwealth department responsible the collaborative nature of the work . . . ’ for health. This massive shift, in 1995, — CONGRESS STAFF MEMBER brought Congress’s clinical activities under Medicare and the pharmaceutical benefits Statistics show that Aboriginal people Council, Uniting Church, Public Health scheme (like mainstream services), and are more likely than non-Aboriginal Association of Australia NT, Mental provided a level of funding security people to abstain from drinking alcohol, Health Association of Central Australia, unknown in Congress’s first 20 years. but Aboriginal people who do drink are local church groups and trade unions. more likely to drink to harmful levels. VITAL ROLE OF RESEARCH The focus of PAAC’s actions has been Where it is a major feature alcohol to restrict alcohol availability via Research is now internationally affects every facet of Aboriginal lobbying of the NT Liquor Commission to acknowledged as indispensable for family and community life—from introduce measures such as restricting providing a solid empirical basis nutrition, employment and educational trading hours, reducing the number for health practice and assessing performance to levels of violence, the (or opposing the expansion) of liquor the effectsof interventions. It is also condition of housing stock and health. outlets, increasing taxes on particularly necessary to provide evidence for This is why one of the first programs harmful classes of alcoholic drinks (e.g., advocacy. Congress was and continues to Congress established was a pick-up alcopops, flagons or cartons of cheap be a pioneer in this area as well, mainly service, to get drinkers out of harm’s way wine), reducing taxes on less harmful because it had to be. and prevent their arrest. classes (e.g., beer), and registers of When the first Congress clinic opened In Central Australia the history of banned drinkers at taverns, pubs, hotels in 1975, it followed a new approach to Aboriginal attempts to address alcohol and takeaway liquor outlets. health care—through comprehensive PHC misuse has been marked by hopeful One of the strongest, most consistent that addresses the social determinants of starts, dashed hopes and renewed research findings concerningalcohol health. Little research had been done effort. In 1995 a group was formed of consumption is its sensitivity to price in Australia relative to this new model, concerned individuals and organisations and availability. When prices are lower, and nothing in relation to Aboriginal long-experienced in dealing with the consumption is higher. When prices are people, so Congress took responsibility for harmful effects of alcohol. This group higher, consumption declines. When ensuring a scientific evidence base existed ultimately became the People’s Alcohol availability is greater, consumption is for its innovations and practices. Action Coalition (PAAC). greater. This is the case worldwide. As a result, qualitative and quantitative In addition to concerned community Under the slogan Turning down the tap research has always been an integral members, the PAAC includes official to bring down the harm, PAAC has had part of Congress’s activities, which is representatives from Congress, the some big wins and some losses but relatively rare among health care services Central Land Council, Aboriginal Medical since 2006 there has been a 28% decline Australia-wide. The current research Services Alliance Northern Territory, in per capita alcohol consumption (NT register outlining all of the projects Northern Territory Council of Social Government, 2015). The PAAC website that Congress is engaged in is publicly Services, Central Australian Youth Linkup (http://www.paac.org.au) provides the available through the Congress website. Service, Ngaanyatjarra, Pitjantjatjara latest news on these continuing efforts. and Yankunytjatjara (NPY) Women’s

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 21 comprehensivePHC@Congress ...... putting it all together

SOUTHGATE MODEL FOR MECHANISMS ACTIVITIES SERVICE QUALITIES ACTIVITY OUTCOMES COMMUNITY OUTCOMES COMPREHENSIVE PHC: SOCIAL JUSTICE & SOCIAL VIEW SERVICE, GOVERNANCE & LEADERSHIP HEALTH FOR ALL CENTRAL AUSTRALIAN OF HEALTH Service planning, monitoring, INDIVIDUALS ABORIGINAL CONGRESS • Accessible, locally delivered management, administration, • Community driven development, capacity building for (community controlled) remote health, research, continuous • Community participation The Southgate Institute • Mix of prevention, treatment quality improvement • Build capacity for remote PHCs SUSTAINABLE and rehabilitation HEALTH PROF. EDUCATION & TRAINING CPHCORIENTED developed this program • Multi-disciplinary teamwork AHW training, registrar program, HEALTH SYSTEM: (inc. AHWs) supporting medical, social work, • Full Aboriginal • Intersectoral and interagency • Local community health logic model to capture psychological services, midwifery, nurse, professionals employment at collaboration AHW students, supporting juniors and OS Congress • Stable, skilled workforce the ways in which a • Cultural respect doctors, encourage local doctors • Promote economic paradigm CPHC MECHANISMS • Achieved Aboriginal consistent with public health ADVOCACY & INTERSECTORAL ACTION EMBEDDED IN community-controlled health service (in this PHCs in all communities Support development of ACC PHCs, PROCESSES, SYSTEMS • Achieved change in SDH improve models of ACC PHCs, intersectoral AND STRUCTURES case, Congress) works, • Strengthened ACC PHC ﬁeld committees, e.g. AS Transformational Plan, the context in which PAAC, early childhood SKILLED, ACCOUNTABLE, CLINICAL SERVICES & PROGRAMS SATISFIED WORKFORCE • Reduced rates of disease and services are provided, GP, pharmacy, chronic disease, hearing, disability GOVERNANCE children’s programs, frail aged and

SOCIAL AND PREVENTIVE PROGRAMS • Reduced progress and impact of and their intended disabled, dental, specialists, disease and disability immunisation, health checks, sexual outcomes. Elements health, allied health, preschool program, • People feel cared for School Health/Trachoma Program, Renal of the environmental Outreach Program, Health Lifestyle IMPROVED HEALTH

FAMILY AND WELLBEING OF INPUTS / RESOURCES Program • Increased child and mental health context can help or limit INDIVIDUALS AND THE • Sta, FTE, Funding WOMEN’S HEALTH ALUKURA • Increased and promote women’s COMMUNITY: Antenatal care, birthing, sexual health, health a service’s ability to COMMUNITY CONTEXT SERVICES THAT ARE: • Improved quality of ANFP program, specialist clinic, • Encouraging of • Increased rate of healthy weight life in our community • Community’s needs,values dispensary, health checks, cultural individual and babies enact the principles of and cultural practices program, YWCHEP • Increased dignity of • Chronic disease epidemic community the community comprehensive PHC, which • Resources available for health MEN’S HEALTH INGKINTJA empowerment and (through true holisitic

CONTRIBUTES TO ACHIEVEMENT OF ACHIEVEMENT TO CONTRIBUTES • Reduced rates of STIs in community Health checks, drop-in centre, violence, dignity service that in turn shape the activities • Education disadvantage sexual health, Men’s Shed, hygiene, • Responsive to • Reduced rates of violence encompasses social, (including for employing sta) cultural program, Nungkaris, health community needs • Increased men’s health and emotional, self-worth, the service engages in, summits, community liaison • Holistic wellbeing empowerment) ORGANISATIONAL OPERATING the qualities the service ENVIRONMENT SOCIAL EMOTIONAL WELLBEING • Ecient and eective • Reduced avoidable • Physical work environment, Therapy, youth outreach and drop in, • Universal and used by premature mortality • Increased social and emotional infrastructure Safe and Sober, targeted family support, those most in need • Increased equity in achieves, and thus wellbeing in community • Complexity of interaction FWBP, suicide prevention, community • Culturally respectful health, housing, development, advocacy, Targeted Family the community health between Indigenous • Compassionate • Reduced rates of suicide income, employment knowledge and culture and Support Program, intensive Family and tertiary outcomes that are the Western styles of professional Support Program qualiﬁcations practice in the context of ADOLESCENT HEALTH • Increased health, wellbeing of organisation’s goals. 21st Century life Headspace, youth advisory group, GP, Aboriginal and non-Aboriginal • Resources available for health psychological services, community adolescents in community development • Education disadvantage (including for employing sta) REMOTE HEALTH Remote health services (direct and • Improved health, wellbeing access SOCIOPOLITICAL CONTEXT auspiced) including podiatrist, diabetic to health care in remote NT • Political environment nurse, nutritionist, GPs, nurses, AHWs, AOD

• Close the Gap DEVELOPMENT, CENTRED CARE, COMMUNITY AND FAMILY PERSON • Northern Territory CHILD CARE Emergency Response Long daycare COMMUNITY • Improved outcomes for children

This program logic model was developed in collaboration with the South Australian Community Health Research Unit (Flinders University) as part of the Comprehensive Primary Health Care in Local Communities project funded by the NH&MRC. For more information please visit http://bit.ly/CPHCproject

22 comprehensivePHC@Congress ...... putting it all together

MECHANISMS ACTIVITIES SERVICE QUALITIES ACTIVITY OUTCOMES COMMUNITY OUTCOMES

SOCIAL JUSTICE & SOCIAL VIEW SERVICE, GOVERNANCE & LEADERSHIP HEALTH FOR ALL OF HEALTH Service planning, monitoring, INDIVIDUALS • Accessible, locally delivered management, administration, • Community driven development, capacity building for (community controlled) remote health, research, continuous • Community participation • Mix of prevention, treatment quality improvement • Build capacity for remote PHCs SUSTAINABLE and rehabilitation HEALTH PROF. EDUCATION & TRAINING CPHCORIENTED • Multi-disciplinary teamwork AHW training, registrar program, HEALTH SYSTEM: (inc. AHWs) supporting medical, social work, • Full Aboriginal • Intersectoral and interagency • Local community health psychological services, midwifery, nurse, professionals employment at collaboration AHW students, supporting juniors and OS Congress • Stable, skilled workforce • Cultural respect doctors, encourage local doctors • Promote economic paradigm CPHC MECHANISMS • Achieved Aboriginal consistent with public health ADVOCACY & INTERSECTORAL ACTION EMBEDDED IN community-controlled PHCs in all communities Support development of ACC PHCs, PROCESSES, SYSTEMS • Achieved change in SDH improve models of ACC PHCs, intersectoral AND STRUCTURES • Strengthened ACC PHC ﬁeld committees, e.g. AS Transformational Plan, PAAC, early childhood SKILLED, ACCOUNTABLE, CLINICAL SERVICES & PROGRAMS SATISFIED WORKFORCE • Reduced rates of disease and GP, pharmacy, chronic disease, hearing, disability GOVERNANCE children’s programs, frail aged and

SOCIAL AND PREVENTIVE PROGRAMS • Reduced progress and impact of disabled, dental, specialists, disease and disability immunisation, health checks, sexual health, allied health, preschool program, • People feel cared for School Health/Trachoma Program, Renal Outreach Program, Health Lifestyle IMPROVED HEALTH

FAMILY AND WELLBEING OF INPUTS / RESOURCES Program • Increased child and mental health INDIVIDUALS AND THE • Sta, FTE, Funding WOMEN’S HEALTH ALUKURA • Increased and promote women’s COMMUNITY: Antenatal care, birthing, sexual health, health COMMUNITY CONTEXT SERVICES THAT ARE: • Improved quality of ANFP program, specialist clinic, • Encouraging of • Increased rate of healthy weight life in our community • Community’s needs,values dispensary, health checks, cultural individual and babies and cultural practices program, YWCHEP • Increased dignity of • Chronic disease epidemic community the community • Resources available for health MEN’S HEALTH INGKINTJA empowerment and (through true holisitic

CONTRIBUTES TO ACHIEVEMENT OF ACHIEVEMENT TO CONTRIBUTES • Reduced rates of STIs in community Health checks, drop-in centre, violence, dignity service that • Education disadvantage sexual health, Men’s Shed, hygiene, • Responsive to • Reduced rates of violence encompasses social, (including for employing sta) cultural program, Nungkaris, health community needs • Increased men’s health and emotional, self-worth, summits, community liaison • Holistic wellbeing empowerment) ORGANISATIONAL OPERATING ENVIRONMENT SOCIAL EMOTIONAL WELLBEING • Ecient and eective • Reduced avoidable • Physical work environment, Therapy, youth outreach and drop in, • Universal and used by premature mortality • Increased social and emotional infrastructure Safe and Sober, targeted family support, those most in need • Increased equity in wellbeing in community • Complexity of interaction FWBP, suicide prevention, community • Culturally respectful health, housing, development, advocacy, Targeted Family between Indigenous • Compassionate • Reduced rates of suicide income, employment knowledge and culture and Support Program, intensive Family and tertiary Western styles of professional Support Program qualiﬁcations practice in the context of ADOLESCENT HEALTH • Increased health, wellbeing of 21st Century life Headspace, youth advisory group, GP, Aboriginal and non-Aboriginal • Resources available for health psychological services, community adolescents in community development • Education disadvantage (including for employing sta) REMOTE HEALTH Remote health services (direct and • Improved health, wellbeing access SOCIOPOLITICAL CONTEXT auspiced) including podiatrist, diabetic to health care in remote NT • Political environment nurse, nutritionist, GPs, nurses, AHWs, AOD

• Close the Gap DEVELOPMENT, CENTRED CARE, COMMUNITY AND FAMILY PERSON • Northern Territory CHILD CARE Emergency Response Long daycare COMMUNITY • Improved outcomes for children

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 23 Ensuring the future

‘More than 200 years or the first half of its life, Congress Foperated in an atmosphere of of institutionalised continual uncertainty regarding funding dispossession, racism for its programs. The second half has been much more secure, but challenges always and discrimination have exist , in particular to: left Aboriginal and Torres •• expand programs to address the social determinants of health. Strait Islander people •• conduct research to ground programs with the lowest levels of and practices scientifically. •• preserve an atmosphere of education, the highest cultural respect. levels of unemployment, Although all are important, preserving the poorest health and the atmosphere of cultural respect that makes Congress a safe place for Aboriginal the most appalling people to attend is not only vital but also OLYMPIAN CATHY FREEMAN VISITS CONGRESS, 2012. housing conditions.’ the most likely to be challenged in the future, as governments look for ways to the needs of Aboriginal people and the — OXFAM AUSTRALIA cut health budgets or to competitively conditions of Aboriginal life. tender out services primarily on the Low levels of education and employment basis of cost rather than respect for also present barriers. Compared to 73% community control. of non-Aboriginal Australians aged 15–64, If they don’t feel comfortable Aboriginal only 44% of Aboriginal and Torres Strait people won’t attend a clinic, doctor’s Islander people have attained Year 12 or office or hospital until the problem is very Certificate level II or above (ABS, 2013). serious, and Aboriginal and Torres Strait Just over half (56%) of Aboriginal and Islander mortality and morbidity statistics Torres Strait Islander people in that age remain a national scandal. group are in the labour force, compared Aboriginal and Torres Strait Islander to 76% of non-Aboriginal Australians people die 10–17 years younger than (ABS, 2013). non-Aboriginal Australians (ABS, 2011). So long as racism continues to blight By contrast, in the USA, Canada and New Aboriginal life, Aboriginal living Zealand Indigenous people have a life conditions remain significantly deprived expectancy only 7 years shorter, according relative to the non-Aboriginal population, to Oxfam Australia. and Aboriginal health remains a national Moreover, a tendency exists for Australian embarrassment, so long will there policy-makers to make program and be a critical need for Congress and funding decisions based on research other Aboriginal community controlled from abroad, which often does not reflect health services.

‘You can have people on what’s a really expensive maintenance health program, that requires a high level of commitment to a healthy lifestyle . . . [and] you’ve got people who are homeless, or living in very overcrowded situations, with no ability to control their diet or fluid intake . . . and [these] are the key factors [determining whether] you do well on that program or not.’ — STAFF MEMBER, CONGRESS

24 Want to know more? Check it out . . .

WEBSITES http://www.caac.org.au http://www.flinders.edu.au/medicine/sites/southgate/ http://www.who.int/social_determinants/en/ http://www.who.int/publications/almaata_declaration_en.pdf https://www.oxfam.org.au/explore/indigenous-australia/our-aboriginal-and-torres-strait-islander-peoples-program/ http://www.paac.org

REFERENCES Reports Articles from the Southgate Institute Baum, F., Legge, D., Freeman, T., Lawless, A., Congress. (2011). Rebuilding Family Life in Alice research project Labonte R. & Jolley G. (2013). ‘The potential for Springs and Central Australia: the social and Freeman, T., Baum, F.E., Jolley, G.M., Lawless, multi-disciplinary primary health care services community dimensions of change for our people. A., Edwards, T., Javanparast, S. & Ziersch, A. to take action on the social determinants of Alice Springs. Central Australian Aboriginal (2016). Service providers’ views of community health: action and constraints.’ BMC Public Congress. http://www.caac.org.au/files/pdfs/ participation at six Australian primary health Health 13:460. Rebuilding-Families-Congress-Paper.pdf care services: Scope for empowerment and Baum, F., Freeman, T., Jolley, G., Lawless, A., challenges to implementation. International CSDH. (2008). Closing the Gap in a Generation: Bentley, M., Värttö, K., Boffa, J., Labonte R. Journal of Health Planning and Management, Health equity though action on the social & Sanders, D. (2014). ‘Health promotion in 31:E1–E21. determinants of health. Final Report of the Australian multi-disciplinary primary care Commission on the Social Determinants of Freeman, T., Baum, F., Lawless, A., Javanparast, services: case studies from South Australia Health. Geneva, World Health Organization. S., Jolley, G., Labonte, R., Bentley, M., Boffa, J. and the Northern Territory.’ Health Promotion & Sanders, D. (in press). Revisiting the ability International, 29:705–719. Griew, R., Tilton, E., Cox N. & D. Thomas, D. of Australian primary health care services to (2008). The link between primary health care Baum, F., Freeman, T., Lawless, A. & Jolley, G. respond to health inequity. Australian Journal and health outcomes for Aboriginal and Torres (2012). Community development: improving of Primary Health. Online Early, DOI: 10.1071/ Strait Islander Australians: A report for the Office patient safety by enhancing the use of health PY14180. of Aboriginal and Torres Strait Islander Health, services. Australian Family Physician, 41:424– Department of Health and Ageing. Robert Griew Freeman, T., Edwards, T., Baum, F., Lawless, A., 428. Consulting. June. Waverly, NSW. Jolley, G., Javanparast, S. & Francis, T. (2014). Freeman, T., Baum, F., Lawless, A., Jolley, G., Cultural respect strategies in Australian Oxfam Australia. (2007). ‘Close the gap! Labonte, R., Bentley M. & Boffa, J. (2011). Aboriginal primary health care services: Solutions to the indigenous health crisis facing ‘Reaching those with the greatest need: Beyond education and training of practitioners. Australia.’ A policy briefing paper from the how Australian primary health care service Australian and New Zealand Journal of Public National Aboriginal Community Controlled managers, practitioners and funders Health, 38:355–361. Health Organisation and Oxfam Australia. understand and respond to health inequity.’ Fitzroy, Victoria. Jolley, G., Freeman, T., Baum, F., Hurley, C., Australian Journal of Primary Health, 17:355–361. Lawless, A., Bentley, M., Labonte, R. & Sanders, Rosewarne, C., Vaarzon-Morel, P., Bell, S., D. (2014) ‘Health policy in South Australia Carter, E., Liddle M. & Liddle, J. (2007) ‘The Updates on the Southgate research on 2003-10: primary health care workforce historical context of developing an Aboriginal comprehensive PHC can be obtained from: perceptions of the impact of policy change on community-controlled health service: a social Dr Toby Freeman health promotion.’ Health Promotion Journal of history of the first ten years of the Central ([email protected]) or Australia, 25:116–124. Australian Aboriginal Congress.’ Health & History Project Director Prof Fran Baum 9:114–140. Anaf, J., Baum, F., Freeman, T., Labonte, R., ([email protected]) Javanparast, S., Jolley, G., Lawless A. & Bentley, Commonwealth Department of Health and M. (2014) ‘Factors shaping intersectoral action And by consulting the project website: Aged Care. (2001). Better Health Care: Studies in primary health care services.’ Primary Health http://www.flinders.edu.au/medicine/sites/ in the Successful Delivery of Primary Health Care and General Practice, 38:553–559. southgate/research/primary-health-care-and- Care to Aboriginal and Torres Strait Islander community-services/cphc/cphc_home.cfm Australians. Canberra.

RESEARCH TEAM Southgate Institute for Health, Society and Other Chief Investigators • Prof. Malcolm Battersby, Flinders University Equity • Prof. David Sanders, School of Public Health, • Dr Michael Bentley, Southgate Institute • Prof. Fran Baum (CI) University of the Western Cape, South Africa • Dr David Scrimgeour, Aboriginal Health Council • Dr Angela Lawless (CI) • Prof. Ronald Labonté, University of Ottawa, of SA • Dr Gwyn Jolley (CI) Canada • Ms Kaisu Värttö, SHine SA • Dr Toby Freeman • Prof. David Legge, LaTrobe University, • Ms Di Jones, Northern Adelaide Local Health • Dr Sara Javanparast Melbourne Network • Ms Tahnia Edwards • Dr Pat Phillips, Endocrinologist • Ms Zoe Luz Associate Investigators • Ms Cheryl Wright, GP Plus Health Care Centre • Ms Patricia Lamb • Ms Stephanie Bell, Dr John Boffa, Congress Marion • Ms Paula Lynch • A / Prof. Anna Ziersch, Southgate Institute • Ms Theresa Francis, Southern Adelaide Local • Ms Helen Scherer • Ms Catherine Hurley, Southgate Institute Health Network ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 25 Flinders University Southgate Institute for Health, Society & Equity

CONTACT CONGRESS: Central Australian Aboriginal Congress PO Box 1604 Alice Springs NT 0871 Telephone: (08) 8951 4400 Fax: (08) 8953 0350

HOW TO CITE THIS REPORT: Pamela Lyon (2016). ‘Aboriginal health in Aboriginal hands: Community-controlled comprehensive primary health care @ Central Australian Aboriginal Congress.’ Alice Springs. Central Australian Aboriginal Congress.

DESIGN AND PRODUCTION: Bruderlin MacLean Publishing Services