How can we do things differently in Aboriginal health? The same challenges seen through new eyes

There are currently about 156 000 Aboriginal and Torres Strait Islander people living in New South Wales (NSW), representing 2.3% of the total NSW population, and equating to 29% of the total Australian Aboriginal population.¹ In this special issue of the NSW Public Health Bulletin, in accordance with NSW Health policy, Aboriginal and Torres Strait Islander people are referred to as Aboriginal in recognition of the fact that Aboriginal people are the original inhabitants of NSW.

It is well known that Aboriginal people continue to experience poorer health than the general population. When the new state government took office in March 2011, they gave a commitment to continue to work on closing the gap in Aboriginal health inequity. This commitment specifically mentioned that the NSW Government would:

1. develop a 10-year Aboriginal Health Plan for NSW

2. hold an Aboriginal Health and Wellbeing forum in their first year of office

3. hold, each year, an annual progress meeting with Aboriginal community-based organisations and NSW Health representatives

4. produce an annual progress report that measures the performance of the health system against the Closing the Gap agenda.²

It is now a year since that commitment was provided. So where are we up to, what successes have we seen, and where do we go from here? This special issue of the Bulletin provides an opportunity to take stock, and offers a number of perspectives on working in Aboriginal health and doing it better in the future. We discuss the intentions behind the Aboriginal Health Plan that is currently in development and note the themes emerging from the consultation and how closely these mirror the themes in each of the papers presented in this issue.

Recent reviews on Aboriginal disadvantage and Aboriginal programs in NSW have concluded that there is a need for fresh approaches. The NSW Auditor General, when reviewing the former Two Ways Together – NSW Aboriginal Affairs Plan,³ noted that: ‘while there were some gains there remain significant challenges requiring redress.’⁴ The NSW Ombudsman, in the recently released report, Addressing Aboriginal Disadvantage: the need to do things differently⁵ indicated that

…simply directing additional funds to more Aboriginal programs and services is not the solution. Rather, it is time for major reform in this state in relation to the overall approach to overall Aboriginal affairs.

As a health system and service providers we must share the same sentiment for the need to reform and overhaul the way we do our business to ensure that it is culturally responsive and provides a high quality service to Aboriginal people, including people working in the sector.

An underpinning principle to the way we work in Aboriginal health in NSW is the importance of working together with Aboriginal people, communities and organisations. In particular, that includes the way the public health system works with the Aboriginal Community Controlled Health Services. The article by Sandra Bailey and Jenny Hunt describes the history of that partnership, and the role of partnerships with Aboriginal people in all aspects of our work. It is fundamental that we involve Aboriginal communities in the design of services, programs and policies through to the implementation, monitoring, reporting and evaluation of these initiatives, and that these collaborations are real partnerships that are mutually respectful. Many of the other articles in this special issue also identify the importance of partnerships to the success of the agenda to close the gap in health disadvantage for Aboriginal people.

As part of the government’s commitment, we’re now more than half way through developing a new 10-year Aboriginal Health Plan for NSW. The paper by Parter, Gassner, Atkinson and McKendrick describes the consultation process being used, and highlights the importance of the strong involvement of Aboriginal people and communities throughout the planning process. It also emphasises the need to think differently to shift commonly held values, beliefs and biases and to challenge the status quo.⁶

As well as planning to do good things, it is important to have processes to monitor progress, assess effectiveness and produce evidence of what works in the Aboriginal health context. This monitoring process should occur at every level of the system, for state, through regional and local services to individual programs and projects. All of the articles in this issue refer to the evidence that has informed their work, and many describe their approaches to evaluating work. The article by Stewart et al. takes a view from the Ministry of Health and details the development of a strategic approach to enhancing capacity for research and evaluation in NSW. The article by Maher et al. provides a program-specific example, assessing the data on rates of cataract surgery to identify barriers to access to eye health services for Aboriginal people in western NSW.

Of course, in seeking new solutions, we need to be careful not to abandon excellent work that is already underway. Other articles in this issue showcase some of the efforts occurring in NSW where people have already successfully embraced the need to do things differently. An example is the Aboriginal Maternal and Infant Health Service (AMIHS), now over a decade old. Evaluation of the AMIHS provided evidence of success and identified opportunities for further improvements, leading to recent expansions of and enhancements to the AMIHS. The article by Murphy and Best describes the history, the approach and the outcomes achieved by the AMIHS.

Another statewide program that has developed a specific model of care for Aboriginal people is described in the paper by Gordon and Richards. The Chronic Care for Aboriginal People program, like the AMIHS, shows the importance of partnerships, planning and evaluation, and the need for effective linking of services within and beyond the public health system, to support a smooth journey for Aboriginal people who must access many different providers over the course of their chronic illnesses.

At a more localised level, the paper by Alperstein and Dyer describes the development of a collaborative approach to child wellbeing in one region. Once again, the approach is based on meaningful partnerships (including intersectoral collaboration), uses careful planning, sets up regular monitoring and requires a long-term view.

And finally, the collection of snapshots of statewide programs offers a taste of the breadth of work required in order to close the gap in health inequity for Aboriginal people. It is only through multiple strategies that we can address the complexity of issues involved in Aboriginal health.

When approaching the development of the Aboriginal Health Plan, we asked ourselves why the unacceptable health gap between Aboriginal and non-Aboriginal people still existed and what should be done differently to make a change. Despite small gains, these questions remain fundamental in a health system and in health service provision that is not meeting the specific cultural and health needs of Aboriginal people and communities. The article from the Hunter New England Health Aboriginal and Torres Strait Islander Strategic Leadership Committee tells the story of a mainstream organisation that has set itself the task of improving its ability to meet the cultural needs of Aboriginal people at a whole of organisation level. Such organisational change requires a long-term commitment, a multitude of strategies and strong leadership. Once again, partnership is a key component for success.

All the articles in this special issue provide indicators to the future of Aboriginal health. Reforming the system in ways that increase our ability to close the health gap is a big vision and requires all of us to re-examine our thinking. We must continue to determine the challenges, examine and identify the key areas in Aboriginal health where a small shift can produce a large change. We must all move towards changing the way we think and work with Aboriginal people and communities by changing our systems, processes, procedures and practices. We can learn from the past, and spread the good ideas. We hope to see this changed approach reflected in our 10-year Aboriginal Health Plan when it is finalised later this year.

We hope that you enjoy this issue.