10 years of preventive health in Australia. Part 2 – centring First Nations sovereignty

Since the 1788 invasion of Aboriginal and Torres Strait Islander (hereafter respectfully and collectively referred to as First Nations peoples) sovereign unceded lands, colonial policies and practices have introduced significant challenges for First Nations communities.^1–4 These colonial legacies persist within the health inequities of today, reflected in the stark disparities in life expectancy, infant mortality, and chronic disease prevalence.⁵ Current epidemiological discourse often racialises these disparities, framing Indigeneity as a risk factor for various lifestyle diseases rather than addressing the socioeconomic and historical contexts – such as colonisation and systemic racism – that underpin these outcomes.^5–9 Persistent disparities in health outcomes highlight the urgent need for consistent, targeted health policies that uphold self-determination and address the systemic root causes of poor health among First Nations peoples.¹⁰

This opinion piece offers a high-level critique of the implementation of the National Preventive Health Strategy 2021–2030 (NPHS) to date from the perspective of two First Nations individuals working in Australian public health (Khwanruethai, Wiradjuri and Ngemba-Wailwaan, and Alana, Truwulway from Lutruwita). We conclude with a series of recommendations that we strongly advocate for broad and immediate implementation across the public health policy landscape.

National Preventive Health Strategy

The NPHS seeks to improve the health and wellbeing of all Australians by taking a systems-based approach to prevention, addressing the wider determinants of health, reducing inequities, and lessening the overall burden of disease.¹¹ Although this vision is commendable, its implementation to date falls short of meaningfully addressing the complex and systemic challenges faced by First Nations peoples.

A key issue with this strategy is its treatment of racism, which is explicitly named as a root cause of poor health for First Nations peoples. Indeed, the NPHS acknowledges racism as a determinant of health but falls short of producing meaningful targets to address it, instead claiming that racism lies outside the direct control of the health system. This raises important questions: When will the health system be held accountable for the racism and discrimination-related barriers that prevent timely access to healthcare, particularly for chronic diseases and conditions in which premature death is preventable? Furthermore, colonial structures reinforce silos among ministries and services, leading to failure to collaborate effectively despite the need for coordinated action to resolve or mitigate health outcome gaps.⁸

The strategy’s focus on behavioural targets, such as smoking and obesity, neglects the broader historical and socioeconomic drivers of health disparities in First Nations communities, including colonisation, systemic racism, and intergenerational trauma. These disparities are not due to inherent medical issues but stem from systemic and political barriers. The ongoing impacts of colonisation, land dispossession, and intergenerational trauma have reinforced cycles of social, economic, and health disadvantage. Although the NPHS prioritises wider determinants of health, its lack of tailored solutions for First Nations peoples risks reinforcing a one-size-fits-all approach that deepens inequities instead of addressing them. The promise of a systems-based approach requires genuine investment in community-led initiatives and structural changes necessary to address these root causes.

As we critique the NPHS, it is essential to recognise that genuine progress cannot be achieved without a significant shift in approach across the Australian health system. This transformation must move beyond equity frameworks, which often fail to address the structural and systemic barriers that underpin health disparities. Although significant investments have been directed toward achieving health equity, the overemphasis on achieving equity alone has yielded little in terms of meaningful and sustainable improvements in First Nations health outcomes.¹²

The National Agreement on Closing the Gap,¹³ which came into effect in July 2020, outlines important goals for reducing health disparities, but progress has been limited. Recent findings from the 2024 Productivity Commission Review of the National Agreement on Closing the Gap (2020) further highlight the systemic barriers that persist in delivering equitable health outcomes.¹² With only 5 of the 19 targets on track, the Commission emphasises the need to address structural inequities, empower communities, and embed Indigenous Data Sovereignty in all facets of policy and implementation. The NPHS’s failure to align with the principles of the National Agreement on Closing the Gap highlights its inadequacy in addressing the unique needs of First Nations peoples.

Indeed, this reflects a broader pattern of ‘business-as-usual’ actions in health policy, particularly policy targeted at First Nations peoples.¹² Meaningful progress requires centring First Nations leadership, self-determination, and culturally grounded strategies to ensure policies are not just inclusive but truly capable of addressing the root causes of health inequities. Policies such as the NPHS must go beyond tokenistic inclusion and genuinely invest in the self-determination of First Nations communities to shape and drive preventive health initiatives.

Preventive health through a First Nations lens

Preventive health, as conceptualised through a First Nations lens, transcends the narrow biomedical focus typically employed in Western health policies. First Nations peoples’ approaches and understandings of health and wellbeing are holistic, encompassing not only the physical aspects of an individual, but the social, emotional and cultural wellbeing of the entire community.¹⁴ The health and wellbeing of First Nations peoples is therefore deeply connected to land/Country, community and culture.¹⁴ This perspective prioritises self-determination, calling for community-led strategies that are deeply rooted in First Nations knowledges and practices.¹⁴ The NPHS, however, neglects these principles, offering only superficial attention to First Nations health.

Health policies imposed on First Nations communities have often disregarded the communities’ traditional ways of knowing, being and healing.^8,15 Policies have instead favoured Western biomedical models and beliefs about health, and consequently, they uphold deficit-based approaches that undermine First Nations sovereignty and rights.^8,15 By dismissing First Nations healing practices, these policies perpetuate dependency, erode cultural identities and exacerbate health disparities. The failure to incorporate First Nations knowledge systems into health policies has resulted in solutions that fail to reflect the lived experiences of First Nations peoples. It is crucial that any health strategy, including the NPHS, recognises and values First Nations ways of healing as legitimate and effective approaches to health and wellbeing.

The National Aboriginal and Torres Strait Islander Health Plan¹⁶ and the National Agreement on Closing the Gap framework exemplify these efforts to embed culturally safe and community-driven approaches into health policy and service delivery. They emphasise the importance of addressing social determinants of health and prioritising First Nations perspectives, leadership, and traditional knowledge. These frameworks should be seen not only as progress, but also as a blueprint, or, at the very least, the bare minimum, for future policies aimed at improving First Nations health outcomes. They pave the way for moving beyond deficit models to systemic reform that supports self-determination and cultural safety. Future policies must build on these examples with sustained investment to ensure these principles are the status quo in Australian healthcare for First Nations peoples.

A First Nations perspective reveals that preventive health cannot be separated from the broader systemic context. It requires addressing racism, colonisation and systemic barriers to health while ensuring that First Nations voices and leadership are central to health policy development and implementation. Ultimately, preventive health from a First Nations lens is a call for transformation – one that demands that health systems and policies recognise the historical and systemic factors that have led to persistent health inequities.

Truth telling: a vital first step

Although striving for good health outcomes for First Nations peoples remains crucial, greater efforts are needed from systems and institutions to acknowledge their roles in the historical and ongoing subjugation and harm of First Nations peoples – a critical aspect of truth telling.¹⁰

The value in truth telling lies in its ability to elucidate the historical context of colonisation, forced displacement, land dispossession, and cultural suppression – all of which have significantly contributed to the prevailing health disparities faced by First Nations communities.¹⁰ The process serves to acknowledge the trauma embedded in these histories and the enduring consequences for First Nations peoples. The failure to address these issues through a social determinants of health lens – which includes inadequate access to culturally appropriate healthcare, housing, education, and employment – perpetuates poor health outcomes.¹⁷ Truth telling is indispensable not only for fostering healing and reconciliation, but also for empowering First Nations communities by strengthening their self-determination and sovereignty.

Although the apologies and statements made by peak health bodies represent important steps,^18–21 they are insufficient without meaningful and lasting change. True reconciliation requires continuous, evidence-based action that is accountable, measurable, and deeply committed to addressing the structural barriers that have marginalised and continue to marginalise First Nations peoples. As the health sector moves towards greater cultural safety and the decolonisation of healthcare practices, truth telling must serve as the foundation for real systemic transformation. Only through such efforts can we ensure that First Nations peoples can access healthcare that respects their sovereignty, culture, and dignity.¹⁰

Future directions: re-Indigenisation of ‘health’

True improvements in First Nations peoples’ health outcomes will require addressing these broader systemic issues, with an emphasis on First Nations-led solutions, self-determination, and the inclusion of traditional knowledges and governance. Until these root causes are addressed, the gap in health outcomes will remain entrenched.

Improving health outcomes for First Nations peoples demands policies to go beyond the Western assumptions of equity. It requires targeted efforts to address the systemic drivers of disadvantage. These approaches must extend beyond health services and encompass education, housing, employment, and social justice initiatives, with a holistic and intersectional lens.¹⁰ Emphasis must be placed on fostering self-determination and sovereignty within First Nations communities, ultimately promoting a more inclusive and authentic realisation of strong First Nations health.¹⁰

Recommendations for policymakers include the implementation of robust monitoring and evaluation frameworks, as highlighted by the 2024 Productivity Commission report.¹² Emphasising culturally sensitive and community-driven approaches can lead to more effective and sustainable outcomes.

Only through such holistic strategies can substantive improvements be achieved in First Nations peoples’ health outcomes. Indeed, the time for accepting sub-par policies founded on knowledges that does not align with First Nations worldviews is over; in order to see real change for First Nations peoples, we need to focus on the re-Indigenisation of the health system in Australia.