That "closing the gap" has been branded a failure should not come as a surprise. After all, it has been prosecuted in a magical world of self-achieving targets (in which no one asks what resources are required to achieve the targets), a National Aboriginal and Torres Strait Island Health Implementation Plan which has no budget, and Commonwealth expenditure on health which is approximately half the needs-based requirements.
While shared decision-making and community-controlled services are welcome and long overdue steps, believing that local community success can offset national failure is simply illusory. A new set of targets won't fare any better than the last set unless there is a fundamental shift in approach.
The good news, however, is that the gaps can be closed - but this requires capitalising on the opportunities presented by the COAG partnership with Aboriginal and Torres Strait Island representatives, and a real-world approach rather than one based on words and diagrams, unfunded policy and blind faith in amateurism.
Target-setting is vital
Firstly, target-setting should not simply be a process of setting out what results would be desirable. It needs to take into account what actual services and resources would be required to achieve the targets, what services are available and what services are missing, and the investment required to fill the service gaps. Targeting and budgeting must go hand in hand. Targeting without budgeting is simply a recipe for failure and disappointment.
It is a cardinal principle behind government social policy that service provision should be related to need. For example, no one questions the fact that far more is spent on healthcare for the elderly than on the young who enjoy much better health.
In broad terms, the level of need for health care in Aboriginal and Torres Strait Islander people, based on the Burden of Disease studies, is approximately 2.3 times higher than for the rest of the population. However, while the jurisdictions spend approximately $2 per capita on health for every $1 spent on the rest of the population, the Commonwealth only spends $1.21 per capita on Aboriginal and Torres Strait Islander people for every $1 spent on the rest of the population (barely half of the needs-based requirements).
This is particularly important as the Commonwealth is largely responsible for the out-of-hospital services required to bring down preventable admissions and deaths. It is utopian and unrealistic to believe that gaps can be closed by spending relatively less on people with worse health.
This is not a plea for a special deal for First Peoples, but rather for a level of expenditure that anyone else of the population with equivalent need would receive.
It beggars belief that programs of such obvious worth [as Housing for Health] are not universally delivered across Australia.
There is clear evidence that significant progress is possible using methods that are tried and tested. But Aboriginal health and related issues are not so simple that just anyone can tackle them effectively. They are complex, and require considerable skills and service delivery experience for effectiveness. Throwing staff in at the deep end is inefficient, and not fair either to the staff or to Indigenous people. Health planning, for example, is a defined skill and requires specific training. A manifest lack of planning skills lies at the heart of sub-optimal service delivery. A National Training Plan is required to ensure all involved - clinicians, administrators and public servants - are adequately equipped for their individual roles. It will not be possible to adequately realise on the investments involved in Indigenous service provision without appropriate staff training.
For many, the concept of management is little better than sitting around and hoping that somehow, miraculously, next year's results will be better. That is not how gaps are closed. A formal, integrated, multilayered management system is required - supported by appropriate information and evaluation systems with formal review processes, at least mid-year and annually, to consider both process and outcome measures in relation to the specified targets. A time frame, based on trajectories which set out what results can and should be expected at different points in time, is also required.
Continuous quality improvement
There is incontrovertible evidence that sizeable and rapid health gains are possible. But those gains require high-quality services and are not achieved without proper systems for measuring, monitoring and improving the quality of services - systems which are standard throughout industry.
Building on success
There are many fine examples of Indigenous health service delivery - and some of the best health services in the country are provided by Aboriginal Community Controlled Health Services such as the Institute of Urban Indigenous Health in south-east Queensland. There are similar examples of services for mothers and babies which reduce low birth-weight rates, and lower perinatal mortality. In the important field of chronic disease, it has been demonstrated that systematic application of current knowledge can achieve dramatic reductions in mortality in short time periods. We know what to do and have shown that impressive results can be achieved - but nationally, progress in both child health and chronic disease falls a long way short of what is required.
Similarly, successful programs like Housing for Health have improved housing, and consequently health - and have done so by training and employing local Aboriginal people. It beggars belief that programs of such obvious worth are not universally delivered across Australia. That needs to be rectified as a matter of urgency.
In other fields, child development and justice reinvestment programs have been shown to be effective - and cost-effective - both in Australia and overseas. But they are implemented on a piecemeal and patchy basis in Australia. That cannot continue.
Turning stalled progress around
None of the measures above are radical or untested or impossible to implement. Indeed, they are standard throughout much of the world. Not implementing them has proved costly in terms of poor results and sub-optimal returns on investment.
The time for amateurism is over, and Australia needs to lift its game. These measures, under First Peoples leadership and in the context of the COAG partnership, can make a significant contribution to Australia closing the gap. The gap can and should be closed - but it needs more than fine words and good intentions.
- Dr Ian Ring was the foundation director of the Australian Primary Health Care Research Institute at ANU. This article first appeared on Croakey.org.