Australia is all too fond of pontificating about human rights to other countries. Yet it leaves itself open to the question that if Australia is really dedicated to human rights, why doesn't it do more for its own Indigenous people? And now, the Chinese government has indicated it is going to raise just that issue in international circles.
Of course there has been progress and, for the first time, Australia's First Nations people have a seat at the table at the highest levels of governments through the National Partnership - though the question of a Voice to Parliament still hangs in the air.
But Australia has always been much better at talking than doing in Indigenous affairs, and the Partnership has much unfinished business to tackle.
There is little doubt that Indigenous funding needs an overhaul. It really has been a something of a shambles: driven by history and bid-driven processes rather than need, rife with inequity within and between states and territories, and subject to stop-start policies. Much of the funding has been misdirected towards mainstream services rather than services run by and for Indigenous people - services which have been proven to produce better results.
We have operated in a world of magical self-achieving targets rather than a systematic examination of what actual services are required to achieve the targets, identification of current service gaps, and the costs of filling the service gaps. The National Aboriginal and Torres Strait Island Health Plan is full of fine words and lofty aspirations, but lacks funding, accountability, and evaluation - or actual implementation.
The bedrock of public policy has been that funding ought to be proportionate to need. In health, no one suggests that spending on the elderly should be limited to the same level as for their younger, much healthier counterparts.
Yet in Indigenous affairs, the approach seems to be to suggest that since the total expenditure is a big number and the results indifferent, the money must have been inappropriately splashed around. There is no analysis of what ought to be spent on a needs basis, when it is clear that in health, for example, the Commonwealth spends about half the needs-based requirements, and this shortfall in spending on critical primary healthcare services, for which the Commonwealth is responsible, makes a significant contribution to the threefold differential in preventable hospital admissions for which the states and territories have to pick up the tab.
What has been missing is any kind of formal policy planning, funding and evaluation cycle. In the real world, targets are not set in a vacuum without formal consideration of funding and service requirements to achieve the targets or goals.
Instead, a long-term goal is set and then one-, five-, or 10-year targets are set, which are specifically related to the services and funding which can and will be provided to achieve those targets and goals. Targets are not limited to desirable outcomes (e.g. lowered mortality) but also include the services, funding and workforce needed to achieve the goal.
This is where evaluation in the form of continuous quality improvement comes in. There needs to be formal monthly, six-monthly and annual reviews by service providers, funders and administrators of progress towards the targets, not with the view of pulling the pin if results aren't up to scratch, but always with the aim of understanding what is working and what isn't and why - and, most importantly, how to improve services in the future.
This is the lesson learnt by the Japanese car industry decades ago, a lesson which has spread to other industries and gone global. It is time for it to be finally taken up by those involved in Indigenous health.
MORE IAN RING:
Of course, Australia could go on setting targets without any consideration of what would actually have to be done to achieve the targets, failing to implement the services needed to achieve the targets and then being astounded that the desired outcomes have failed to materialise. Then it could cast around for someone or something to blame - the targets must have been wrong, the funds were misspent, there wasn't rigorous external evaluation and so on.
But if you want something to happen, you must actually do the things required to achieve the targets - not just talk about them. The Partnership between Aboriginal and government leaders is potentially a game-changer - but only if these other issues, particularly the funding issues, are addressed.
Firstly, public servants, administrators and service providers need to be trained in the basics of the policy planning cycle. Secondly, it is get-real time for the funding discussions between Indigenous leaders and heads of government.
The concept of needs-based funding is a must. If a population has more than double the burden of disease, for example, then funding which does not reflect that higher need will not cut it. Discussions need to focus on what services and funding would need to be provided to achieve the goals, and how much can be provided in specified time frames. There must be a passion for continuous quality improvement, and that passion needs to be translated into action.
The additional funds required for many, but not all, areas of Indigenous affairs may not turn out to be as much as might be feared, although the legacy of years of neglect of housing is likely to be considerable. The reality is that if we shifted from amateur hour to the approach that has been advocated by Indigenous leaders for years, major gains in relatively short time frames are possible, but only with a fundamental shift in approach.
This does not mean Australia should ignore issues of human rights in other countries. But it does mean that it urgently needs to put its own house in order.
- Professor Ian Ring, AO, is a professor of tropical health and medicine at James Cook University.