Congress Lowitja 2014 – The Future of Indigenous Health

It’s not about the size of the department or how many there are or whether we have a dedicated Minister for Indigenous Health. It’s about the outcomes for Indigenous people.

Congress Lowitja 2014 – Many Mobs, One Vision: Creating a Healthy Future

The Lowitja Institute

19 March 2014

 

Opening Address by Nyunggai Warren Mundine:“The Future of Aboriginal & Torres Strait Islander Health”

Thank you Aunty Di Kerr for the Welcome to Country on behalf of the Wurundjeri Nation.

I too would like to acknowledge and pay respect to the traditional owners of the land on which we meet and also to acknowledge and pay respect to my own Bundjalung, Gumbaynggirr, Yuin and Irish ancestors.

I wish also to thank you the Lowitja Institute for inviting me to give the Keynote Address at this Congress and to Lowitja O’Donoghue for her introduction.

And thank you Deborah Cheetham and the Indigenous Dance Troupe, Koori Youth Will Shake Spear, for your terrific performances.

I also acknowledge the Deputy Chair of the Prime Minister’s Indigenous Advisory Council, Professor Ngiare Brown.

I am honoured to be here today addressing you.

The Future of Aboriginal & Torres Strait Islander Health? The short answer is the Prime Minister’s Indigenous Advisory Council sees a healthy and prosperous future for Aboriginal & Torres Strait Islander health. I see great leadership, innovation and vision when I look at the community controlled Aboriginal & Torres Strait Islander Medical Services and their national advocacy organisation, the National Aboriginal Community Controlled Health Organisation, and the Australian Indigenous Doctors’ Association.

As people would appreciate, after reviewing the recent “Closing the Gap” report there is much more work to be done.

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To get an understanding of the Council and the work of the Council I’ll give a brief outline.

The Prime Minister’s Indigenous Advisory Council was created to provide advice to the Federal Government on Aboriginal & Torres Strait Islander Affairs, with a focus on practical changes to improve the lives of Aboriginal and Torres Strait Islander people.

The Council provides ongoing advice to the Government on emerging policy and implementation issues related to Aboriginal & Torres Strait Islander Affairs covering, but not limited to:

  • improving school attendance and educational attainment
  • creating lasting employment opportunities in the real economy
  • reviewing land ownership and other drivers of economic development
  • preserving Aboriginal and Torres Strait Islander cultures
  • building reconciliation and creating a new partnership between black and white Australians
  • empowering Aboriginal and Torres Strait Islander communities, including through more flexible and outcome-focussed programme design and delivery
  • building the capacity of communities, service providers and governments
  • promoting better evaluation to inform government decision-making
  • supporting greater shared responsibility and reducing dependence on government within Aboriginal and Torres Strait Islander communities
  • achieving constitutional recognition of Aboriginal and Torres Strait Islander people.

The Council also has another role of being the Deregulation Committee for Prime Minister and Cabinet as part of the review by Parliamentary Secretary to the Prime Minister, Josh Frydenberg into deregulation including cutting red tape and addressing the overburden of compliance costs.

The Council is supported by a Secretariat based within Prime Minister and Cabinet.

The Chair meets at least monthly with the PM, currently I have weekly conversations with the Prime Minister, the Minister for Indigenous Affairs and other Ministers. The Council meets 4 to 6 times a year. Our 3rd meeting is being held in Sydney on the 2nd April.

As you can see, the Council has a broad Terms of Reference and is an independent body that gives advice. That means we give advice whether the Government agrees or not. A good example of this is the Anti-Discrimination Act Section 18C debate. Council members didn’t agree with the policy taken to the last election by the Coalition and we gave advice to the Prime Minister of our views not to repeal Section 18C. The Government and the general public are very aware of the Council’s view on this matter.

The Council is the Prime Minister’s advisory group not an elected representative body. It is an advisory group like the Commission of Audit, the Gonski Education Review, the Henry Tax Review, the Banking Inquiry Review and many such other bodies. So, when people say we are not an elected body, we don’t represent Aboriginal and Torres Strait Islander people – I say “correct”. We are a group of people who bring a range of expertise, skills and experiences together to advise the Prime Minister and Government. Council meetings are full of robust and frank discussion and new ways of thinking and that is reflected in the advice we give to the Prime Minister.

The Prime Minister wants the Council to focus primarily on the three areas of Jobs, Education and One rule for all. The third area is essentially around upholding community standards and the rule of law in all communities. My term for this is “social stability”.

Broadly, the Council operates within a reform agenda based with an economic and commerce focus. We want to see a focus on outcomes and on the experience of the people who receiving or relying on services; we look for innovative and entrepreneurial approaches; we want service delivery that is integrated and eliminates duplication; we expect service deliverers – including States and Territories – to be accountable and we will hold them to their accountabilities; we want to see less red tape more Bang for the Buck and efficiencies in cost and delivery; we also want to see investment in Indigenous communities. Above all, we want to see simple and practical approaches that really deliver.

That is the lens through which all or our deliberations and recommendations are made and it is the lens through which I will talk about the future of Indigenous Health this morning.

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In preparing this speech I received a detailed briefing with pages and pages of statistics on Indigenous health and health risk factors. And these were just a sample. I am all too familiar with the data which paints a dire picture of Indigenous health and wellbeing in Australia.

Of course, for Aboriginal and Torres Strait Islander people it’s not just about statistics; it’s about our family, friends and communities; it’s about our parents and our children and our own selves. It’s my sister who died at aged 50 from heart disease. It’s the man who was stabbed in front of me enraged with alcohol and drugs Musgrave Park when I was a youth. It’s the regular emails I receive letting me know about “sorry business”. It’s the fact that almost every Indigenous person I know over the age of 40 has Type 2 diabetes. It’s my own brush with death in 2012 from cardio-vascular disease.

Indigenous people live these statistics every day and we experience the real impact – not just on individuals and their specific health problems – but also on our communities and families who are being hollowed out by things like low life expectancy, chronic and communicable diseases, and mental health problems, alcohol related disease and assaults, Foetal Alcohol Spectrum Disorder, suicide and child mortality. These problems have an ongoing social, cultural and psychological impact on communities and families.

When it comes to Indigenous health policy and health services, the greatest challenge is bureaucracy, waste and red tape.

Health is one of the most governed of all the public services. Constitutionally, health services are provided by the States. However, the Federal government has considerable influence and control because it provides substantial funding.

Indigenous health policy and the delivery of health services to Indigenous people involves multiple administrators and decision makers at multiple levels. There are at least two portfolios – health and Indigenous affairs – in the Commonwealth and in each State and often other relevant portfolios such as community services and human services. Each portfolio has a Minister and a department and often Assistant Ministers or Parliamentary Secretaries as well.  All of this is before you get to the front line health services, such as State operated hospitals and other medical services and specialised Indigenous health services such as Aboriginal community controlled health services, each of which has their own administrative staff and obligations.

The previous Federal government also had a Minister for Indigenous Health. Prime Minister Abbott chose not to continue with this portfolio and these responsibilities have been rolled into the Department of Health and the Department of the Prime Minister and Cabinet which is responsible for Indigenous affairs.

Some people criticised this, arguing that not having a dedicated Indigenous health portfolio would set back Indigenous health policy and delivery. I disagree. One of the reasons we are spending billions on Indigenous people and not achieving material improvements in closing the gap is because the funding is poorly targeted and wasted on red tape and bureaucracy. The most recent Productivity Commission indicates that the majority of funding allotted specifically to Indigenous Australians is spent on bureaucrats, advisers, contractors and the like, many of whom are non-Indigenous. Shortly after the last election Minister Scullion and I did a preliminary review of the spending figures and we estimated that at least a third of Government funding for Indigenous programs doesn’t even make it past the front doors of office buildings in Canberra and other cities.

Every additional Minister and department or other entity involved in Indigenous health results in additional reporting, handoffs and intra-government dealings. The different groups have to consult and report to each other and handle demarcation issues and duplication. Inevitably this means funding must be being consumed by bureaucratic process.

I recently saw a rerun of an episode of Yes Minister called “The Economy Drive”. In it, Sir Humphrey, Permanent Secretary of the fictional Department of Administrative Affairs, must deal with Minister Hackett wanting to eliminate waste and improve efficiency. Explaining to the more junior public servant, Bernard Woolley, why this is a bad thing, Sir Humphrey explains:

“There has to be some way to measure success in the Civil Service. British Leyland can measure success by the size of their profits, or rather they measure their failure by the size of their losses. We don’t make profits or losses so we have to measure our success by the size of our staff and our budget. By definition, Bernard, a big department is more successful than a small one.”

Even though it is fiction and satire, the scary thing about Yes Minister is that people who have worked in Government very much relate to it.

Whenever funding cuts to Indigenous services or programs are made, the vocal protest and criticism simply assumes that defunding will undoubtedly lead to bad outcomes for Indigenous people. In doing so they are measuring success by the size of budgets and staffing. But if funding to date has not had a material positive impact on Closing the Gap statistics, we can’t simply assume that a funding cut will have an adverse impact. It depends whether what is being cut is actually contributing to improvements or if it is wasted spend. Knee-jerk reactions of outrage without regard to the actual outcomes (if any) the defunded services have achieved, ultimately weaken the voice of criticism.

To me it is a very simple proposition. The success of government service delivery in Indigenous health should be measured by the outcomes achieved.

It’s not about the volume of services or who provides them or how much the Government is spending or how many people are involved or how much activity occurring on a day to day basis. It’s not about the size of the department or how many departments there are or whether we have a dedicated Minister for Indigenous Health. It’s about the outcomes and results achieved for Indigenous people.

We need to get bang for our buck. I do not want to see a single cent of funding wasted on administration, bureaucracy, reporting or other red tape that isn’t contributing to outcomes. Every cent wasted is a cent denied to Indigenous people and not being used to close the gap.

In this country we pride ourselves on our universal health system – a system where everyone gets access to top rate medical treatment in public hospitals with delivery prioritised based on health needs, not on ability to pay or other factors. No one wants to see a two-tiered health system, one for Indigenous people and one for non-Indigenous people. Our health system should deliver the world class medical services to everyone and Indigenous people should benefit from that as much as everyone else. The purpose of special Indigenous health services and policy is to close the health gaps between Indigenous and non-Indigenous people.

In the current Federal ministerial structure we have one Health Minister who is responsible for the funding and funding arrangements for health for everyone.

The job of the Department of Prime Minister & Cabinet (which houses the Indigenous Affairs portfolio) is to focus on what is needed in addition to the mainstream health system to close the gap between Indigenous and non-Indigenous health. This may involve funding additional health services or bodies. It also involves looking at the totality of different services and resources that are targeted towards, or that impact, Indigenous health – including housing, sanitation – and holding States, Territories and other bodies to account to deliver real outcomes.

Groups like the National Aboriginal Community Controlled Health Organisation are critical to delivering health services that cater to the additional needs of Indigenous people and communities to close the gap and recognise the importance of having Indigenous involvement in health policy and service delivery. The Indigenous Advisory Council’s Deputy Chair, Professor Ngiare Brown, who is a doctor, is an Executive Research Manager at NACCHO.

Decades of Indigenous controlled health service delivery have seen the Aboriginal community controlled health sector become a leading provider of primary health care services and a significant employer of Aboriginal and Torres Strait Islander peoples. This sector has mature organisations with a depth of expertise and capabilities, particularly in remote and regional areas, surpassing the level of mainstream health services in some areas. I see no reason why organisations in these positions should not be able to leverage their capabilities and positioning to provide health services more broadly, thereby expanding their ability to generate extra income and funding. Opening the door to entrepreneurship, independence and self-sufficiency could present great opportunities.

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At one level, it is very easy to become overwhelmed by Indigenous health statistics, not only the data itself but also the immensely complex interconnectedness of health problems, health risk factors and social issues.

At another level, Indigenous health problems are not complex to understand at all. If you step back from the tangled web of data and statistics, what you are really looking at is poverty.

Across the world, the conditions under which people are born, grow up, live, work and age shape their health.  As the World Health Organisation points out: ‘the poorest of the poor have the worst health’. Most Indigenous people of my generation, and many of those in the generations after that, grew up in poverty or not far above it. Poverty is both a cause and a consequence of poor health.

It is estimated that socioeconomic disadvantage – in things like education, employment and income – account for one-third to one-half of the health gap between Indigenous and non-Indigenous Australians.

If we only achieved two things – eliminating poverty and eliminating smoking – we would close the gap in Indigenous health for good.

It is very important to remember this as we talk about Indigenous health service provision and health policy. Both are vitally important. But even the best policy and the best service provision will not close the gap if Indigenous people continue to live in poverty, or indeed if we make choices, like the choice to smoke, which damage our health.

The solution to poverty is not a mystery. Poverty is solved by economic development and commerce. Between 1990 and 2010 the number of people living in extreme poverty globally halved. That’s one billion people lifted out of poverty in just 2 decades. Two-thirds of poverty reduction comes from economic growth. The most astonishing example is China. Since it began economic reform 30 years ago its extreme-poverty rate fell from 84% to 10%.

For economic development we need our people to be educated and get into jobs and we need social stability in our communities or people will never invest in them.

So – the reason why I talk so much about economic and commercial development, about getting kids to school, about getting Indigenous people into real jobs and about safe communities, is because these are the key to eliminating poverty and therefore they are key to closing the gap in health. And therefore they are priority areas for the Prime Minister’s Indigenous Advisory Council and for the future of Indigenous Health.

Nyunggai Warren Mundine is Executive Chairman of the Australian Indigenous Chamber of Commerce

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