Why the Nation Needs More Indigenous Community Controlled Health Organisations
The underlying causes of poor health in the Aboriginal and Torres Strait Islander population have been well documented.
They include dispossession, poor socio economic status and low levels of education, lifestyle factors, prejudice, and discrimination, substandard environmental conditions, inadequate and inappropriate service provision and a lack of involvement of Indigenous people in policy and decision-making processes (Shannon and Longbottom 2004).
Life expectancy at birth for Aboriginal and Islander Australians was estimated to be 59.4 years for males and 64.8 years for females compared with 76.6 years for all males and 82.0 years for all females for the period 1998-2000 (Australian Institute of Health and Welfare and Australian Bureau of Statistics).
The main stream primary health care system on the evidence to date has largely failed these groups of people with far poorer outcomes for Aboriginal and Torres Strait Islander peoples’ in the areas of life expectation, death age and rate, infant and child health, chronic diseases, communicable diseases, oral health, mental health and disability (Aboriginal and Torres Strait Islander Social Justice Commissioner HREOC).
What can be done to improve the health of Aboriginal and Torres Strait Islander People?
One response to this disadvantage has been a focus on developing Aboriginal community controlled health organisations to address the reality that mainstream services have not responded to community health needs. The need to further develop and enhance community controlled health services (CCHS) also needs to be coupled with improving the accessibility of the mainstream primary health care system.
What does community control mean?
Community control is the ability, for the people who are going to use health services, to determine the nature of those services and then participate in the planning, implementation and evaluation of those services. A community controlled health organisation is:
- An incorporated Aboriginal or Islander organisation;
- Initiated by the Aboriginal community;
- Based in an Aboriginal or Islander community
- Governed by an Aboriginal or Islander body which is elected by the local Aboriginal community:
- Delivering a holistic and culturally appropriate health service to the community that controls it.
The first Aboriginal Medical Service was established in Redfern in Sydney in 1971 and there are now over 130 community controlled health services in urban, rural and remote communities across Australia within the National Aboriginal Community Controlled Health Organisation. In Queensland 21 services operate across the state. These services provide Indigenous specific primary health care services and a number also provide substance misuse services and mental health services. Primarily, community controlled health services:
- Diagnose and treat illness and disease and make referrals as appropriate;
- Conduct population health programs;
- Provide emotional and social wellbeing services, such as counselling; and
- Provide advocacy and community support roles.
Community controlled health services also provide an established mechanism for increasing Indigenous control over management of primary health care services; they represent a major source of education and training and knowledge and expertise on Indigenous health and ensure that a range of primary health care services are available in one place (Shannon and Longbottom 2004).
What is the evidence to support better outcomes for Indigenous people from community controlled health services?
There is substantial evidence that community controlled health services are a highly effective process for the provision of primary health care. Reports and studies have found that community controlled health services can offer:
- Better communicable disease control through vaccination;
- Improved treatment of communicable diseases i.e. reduced rates of STIs and scabies;
- Increased screening for cancer i.e. cervical cancer screening;
- Early detection and reduced complications of mental illness;
- Improved child and maternal health outcomes;
- Reduced infant mortality and low birth weight babies;
- Reductions in social and environmental risks i.e. reduced alcohol consumption and ill-health resulting from injuries; and
- Increased access to primary and specialist health care including mainstream services and major gains in diabetes management. (Aboriginal and Torres Strait Islander Social Justice Commissioner HREOC).
Case Studies: Impacts and Outcomes of Indigenous Specific Health Services
Communicable diseases control through vaccination
- Increased childhood immunisation rates-to 91% of children in the Tiwi Islands and 100% in Wilcannia
- Aboriginal and Torres Strait Islander people who attend an Indigenous specific medical service are more likely to be appropriately vaccinated for neumococcal disease than Aboriginal and Torres Strait Islander persons who attend a general practitioner (76% versus 32% respectively).
Treatment of Communicable Diseases
By 1997-98 the prevalence of gonorrhoea in a region was reduced by 46% and chlamydia by 20%. Prevalence has since remained stable at 5% and 6% respectively. Approximately 70% of the adult population served by the Aboriginal controlled health service participate in an annual Sexually Transmitted Infection screen.
Cancer Screening
The Northern Territory Well Women’s Program, which operates in a region with a high proportion of Aboriginal women and has a long history of engagement with women and local Aboriginal Health Services, has achieved a high rate of cervix screening (61%) in the Alice Springs remote area, which is comparable to the rate for Australian women generally (62%).
Reduced Complications of Chronic Disease
In 1999 a trial to improve diabetes care in the Torres Strait Islands resulted in an 18% fall in hospital admission rates and a reduction of 41% in the number of people admitted to hospital for diabetes-related conditions. On follow-up in 2002 there was a continuing reduction in hospital admissions for diabetes complications (from 25% in 1999 to 20% in 2002). The proportion of people with good glyacemic control increased from 18% to 25%, and the proportion of people with well-controlled hypertension increased from 40% to 64%.
Improved Maternal and Child Health Outcomes
Since 1990 an antenatal program at Daruk Aboriginal Community Controlled Medical Service, Western Sydney has achieved increased awareness among Aboriginal women of the importance of antenatal care. Thirty six (36%) per cent of Indigenous women presented within the first trimester, compared with 21% at Nepean and 26% at Blacktown Hospitals’ antenatal clinics; and women attended more antenatal visits (an average of 10 at Daruk compared to 6 at Nepean and 9 at Blacktown).
Since 2002 the Townsville Aboriginal and Islander Health’s Services Mums and Babies Project increased the numbers of women presenting for antenatal care (from 40 to over 500 visits per month in one year). The number of antenatal visits made by each woman has doubled, with the number having less than four visits falling from 65% to 25%. Pre-natal deaths per 1,000 reduced from 56.8 prior to the program to 18 in 2000, the number of babies with birth weights less than 2,500 grams has dropped significantly; and the number of premature births has also decreased.
Improved Mental Health Outcomes
Following three suicide clusters between the mid 1980s and mid1990s the Yarrabah community in Queensland through the locally controlled Community Council and Primary Health Care Service established in 1995 the Yarrabah Family Life Prevention Program. This Program was a set of strategies for suicide prevention, intervention, aftercare and life promotion. Alcohol misuse especially as a source of self harm was also targeted. Between 2000 and 2004, there were three suicide deaths in Yarrabah, compared to 12 from 1992-1006 and none from 1997-1999. Incidents of self-harm have also reportedly fallen, as have hospital presentations for accidental trauma and police interventions for alcohol related problems.
The Apunipima Cape York Health Council and researchers at the University of Queensland adapted the Family Wellbeing Empowerment Program to the needs of remote Indigenous school children. The school based program was piloted in two schools in remote Indigenous communities in far north Queensland. The program focussed on developing the analytical and problem solving skills of the students to enhance psycho-social development and build personal identity and to encourage students to reach their future potential. The program evaluation noted the significant social and emotional growth for the participating students, greater ability to think for oneself and set goals, less teasing and bullying in the school environment, enhanced friendships and social relatedness.
Improved Oral Health Outcomes
The Wuchopperen Indigenous Health Service which provides care to approximately 20,000 Aboriginal and Torres Strait Islanders around Cairns has improved access to dental care through the creation of the Filling the Gap Indigenous Dental Program. The privately funded Program addresses the severe shortage of dentists which was limiting Wuchopperen’s dental service by supplying volunteer dentists from around Australia to assist at the two fully equipped dental rooms at the clinic in Cairns plus a mobile van to travel to outlying communities.
(Aboriginal and Torres Strait Islander Social Justice Commissioner HREOC and Key Indicators 2007 Report Steering Committee for the Review of Government Service Provision).