Towards a national primary health care strategy: fulfilling Aboriginal peoples aspirations to close the gap

The National Aboriginal Community Controlled Health Organisation (NACCHO) welcomes the Rudd Governments commitment to build a better primary health care system for all Australians through the development of Australia's first National Primary Health Care Strategy. In this submission we provide an important Introduction which sets the context and the definitions that underpin the recommendations for a national primary health care strategy that can best close the gap in life expectancy and health outcomes for Aboriginal peoples. The National Aboriginal Community Controlled Health Organisation believes that the success of a primary health care system should be judged by how effectively, those who are most needy are able to access quality care. The matter is not just about access per se, but also about who is accessing the health system. A strategy that supports health service provision to those who are already good users of the health system will not make gains in health outcomes for Aboriginal peoples. Access to primary health care is identified as a core obligation under the International Covenant for Economic Social and Cultural Rights (ICESCR). Within this core obligation is the understanding that Indigenous peoples have a right to design, deliver and control health services for them in order to achieve health gains. To this end, Australian Governments and non-government institutions have supported Aboriginal primary health care through Aboriginal Community Controlled Health Services (ACCHSs). The Rudd Governments definition of partnership means involving: "Indigenous people in the design and delivery of programs locally and regionally, and share responsibility for outcomes… This strategy is firmly based on the principle of working in partnership with the Aboriginal and Torres Strait Islander community-controlled health sector." The primary health care delivered by Aboriginal community-controlled health services is culturally appropriate because they are: 'An incorporated Aboriginal organisation, 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 Services that are not Aboriginal community-controlled, by definition, cannot deliver culturally appropriate primary health care. However, services that are not Aboriginal community-controlled can be encouraged to deliver healthcare that is culturally secure. A definition and program prepared by the ACCHS sector for the delivery of Aboriginal cultural safety training for mainstream health services should be supported. NACCHO wishes to impart the message that the Strategy affirm the critical role and impact that accessible and culturally appropriate primary health care can make to close the gap in Aboriginal health standards by 2018 (Rudd Governments Statement of Intent), and for the Strategy to support the required actions needed to realise that objective. In this regard, NACCHO provides numerous recommendations under each of the 10 elements of the Discussion Paper: Towards a National Primary Health Care Strategy. Principal of these recommendations is that ACCHSs are the preferred service model in the delivery of comprehensive primary health care to Aboriginal peoples across Australia. Unless ACCHSs are supported as the key providers in a strategy to close the gap, through an appropriately resourced Capacity Building Plan, the disparities in Aboriginal people's health status will not be alleviated. A systematic framework for working towards a primary health care system for Aboriginal peoples that maximises local community control (such as through a national plan aligned with the Northern Territory Aboriginal Health Forum 'Pathways to Community Control'1) should underwrite a 5 year Capacity Building Plan for ACCHSs. Resourcing pathways to community control for primary health care services will require pooling of all Aboriginal–specific primary health care funds currently being directed to State Governments, Divisions of General Practice and other private health care providers. This will maximize the potential of primary health care to close the gap in life expectancy for Aboriginal peoples. Such fund pooling should be governed by an appropriate mechanism, requiring the involvement of, and endorsement by, the NACCHO Aboriginal leadership. Capacity building will require capital and recurrent funding and workforce strategies to train, recruit and retain staff including measures to address the vast salary disparities which currently prevent staff recruitment within ACCHSs. It will require resourcing based on the model of the Primary Health Care Access Program (PHCAP). A systematic approach towards defining the core deliverables for Aboriginal primary health care services (ie what funding would buy with an acceptable per capita benchmark funding allocation) is needed. ACCHSs funding should be based on a weighted population basis, according to need. A resource allocation formula that reflects the actual cost of ACCHSs providing the agreed core services at particular locations must be agreed to by NACCHO and Affiliates. Progressing such a Plan will require a formalised partnership between the Department of Health and Ageing and the NACCHO leadership, particularly in the form of a new National Framework Agreement. The expert advisory group is encouraged to read the full evidence-based NACCHO submission, but in summary, we draw attention to the following core requirements in order to expand ACCHSs: 1. A long-term plan of action for the expansion of ACCHSs developed in partnership between the Department of Health and Ageing and NACCHO and Affiliates (see Element 1), which meets specified targets and is measured by the indicators identified at the National Indigenous Health Equality Summit (2008) (Element 5). 2. Joint governance of an expansion program based on a National Framework Agreement (see Element 3). 3. The plan to support the adoption of core functions for ACCHSs across Australia (see Elements 2 & 10). 4. A workforce support program (see Elements 2, 8 & 9). 5. An evidence-based, ethical and acceptable quality assurance and performance management program developed by ACCHSs and for ACCHSs (see Elements 5 &6) 6. A funding base for ACCHSs that utilises: • funding on a weighted population basis according to need • pooling of all Aboriginal-specific primary health care funds (including those to State Governments, Divisions of General Practice and other private providers). See Element 10