Primary health care
Primary health care (PHC) is typically the first contact an individual, with a health concern, has with the health system. A strong, accessible PHC system keeps people well and out of hospital by supporting them to manage their health issues in the community and at home. Adequate PHC can reduce the need for specialist services and visits to emergency departments.
The following initiatives aim to improve the provision of PHC for Aboriginal and Torres Strait Islander peoples.
Aboriginal Community Controlled Health Services (ACCHS) are incorporated organisations initiated and based in Aboriginal and Torres Strait Islander communities. They deliver a holistic and culturally appropriate health service to the community. ACCHS are important providers of comprehensive PHC services for Aboriginal and Torres Strait Islander peoples.
The objective of community control is to improve health outcomes through increased community engagement to ensure culturally appropriate, responsive and safe health care is provided to address local needs. It is understood that having self-determination (or a meaningful measure of control) over social and political issues both as an individual and as a collective, has a positive effect on health. The Australian Government has supported the transition of several Northern Territory Aboriginal Medical Services to Aboriginal community control where a community has demonstrated aspirations for self-determination. Three priority regions of West Arnhem, East Arnhem and Maningrida were identified by the Northern Territory Aboriginal Health Forum to be transitioned.
The Australian Government Indigenous Australians' Health Programme (IAHP), the National Aboriginal and Torres Strait Islander Health Plan 2013–2023 and associated Implementation Plan and state and territory initiatives can be found in the National and State and territories sections above.
The Australian Government will invest $4 billion in Indigenous specific health programs and activities between 2020–21 and 2023–24. This includes investment under the IAHP where the Australian Government has provided funding to PHC organisations and State and Territory governments to deliver comprehensive PHC services to Indigenous Australians that are locally responsive to health needs.
The Australian Government provides subsidised general practice (GP) services and cheaper medicines through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). The Practice Incentives Program (PIP) Indigenous Health Incentive supports Indigenous health services and GP services to provide better health care for Indigenous patients.
The following range of programs and special arrangements allow intervention at multiple levels to improve access to PBS pharmaceuticals for Indigenous Australians.
- Special supply arrangements administered under Section 100 of the National Health Act 1953, allow for PBS medicines to be provided to Indigenous PHC services in remote locations, at no cost, by a suitably qualified and approved health service professional, without the need for a prescription.
- The Closing the Gap PBS Co-payment Measure was introduced on 1 July 2010 and continues to help address the financial barriers Indigenous Australians may face in accessing PBS medicines in non-remote locations. These arrangements provide assistance with the cost of PBS medicines for eligible Indigenous Australians living with, or at risk of, chronic disease. The identification of Indigenous clients is an important step in reaching the target population.
- Medicines are listed on the PBS on recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC). Under the National Health Act 1953, the PBAC considers PBS listing applications having regard to the clinical effectiveness and cost effectiveness of the medicine for the intended medical use. Availability of PBS medicines is for all Australians but can vary, where some medicines can have restricted access. Under the relevant regulations, cost recovery fees for applications to the PBAC may be waived when the application is in respect of medicines for Indigenous Australians.
- In recognition of the specific health needs of Indigenous Australians, a range of over-the-counter medicines are subsidised through the PBS specifically for prescription to Indigenous Australians.
Under the Sixth Community Pharmacy Agreement (2015–20) the Australian Government provided funding to assist pharmacies operating in rural and remote areas through the Rural Pharmacy Maintenance Allowance. Programs specific to Indigenous health were also funded, through the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People program. The primary aim of this program is to improve medication compliance and quality use of medicines and consequently the health outcomes of Indigenous Australians that attend participating Aboriginal Community Controlled Health Services in rural and urban areas of Australia.
On 12 June 2020, the Australian Government announced the Seventh Community Pharmacy Agreement, which includes a commitment to enhance the Closing the Gap PBS Co-payment Measure to:
- enable Indigenous Australian patients to register for the Measure, regardless of where they live and their chronic disease status
- expand the range of health care professionals who can register patients for the Measure and issue Closing the Gap prescriptions.
Through the Community Pharmacy Agreement the Australian Government provides funding to address the health needs of the Indigenous community and the workforce needs of community pharmacies. The Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme (ATSIPSS) and Pharmacy Assistant Traineeship Scheme supports and encourages Indigenous Australians to choose a career in pharmacy.
The Pharmaceutical Society of Australia’s Guide to providing pharmacy services to Aboriginal and Torres Strait Islander people was released in 2014 to assist pharmacists and pharmacy staff to be responsive to health beliefs, practices, and the diverse cultural and linguistic needs of Indigenous Australians, families and communities. The guide encourages increased engagement with Indigenous health services and key Indigenous organisations. The guide also includes an overview of Indigenous specific medicine programs and a resource list from which pharmacists can gather more in-depth information.
After hours care
A review of after hours primary health care provision was conducted in 2014. This led to a number of changes including:
- a PIP After Hours Incentive payment to be available to eligible accredited GPs registered for the PIP
- funding to Primary Health Networks (PHNs) to support locally tailored after hours services
- the new after hours GP advice and support line to better support all Australians who do not have access to face to face GP services in the after hours period.
The PIP After Hours Incentive provides payments to accredited GPs that ensure their patients have access to quality after hours care. The PIP After Hours Incentive simplifies the funding process to encourage and support practices to provide after hours access. It builds on existing infrastructure and provides GPs with a nationally consistent, streamlined, less administratively burdensome way to receive funding for delivering after hours services.
PHNs are being funded to address gaps in after hours service provision, including where there is unmet need. PHNs will focus on access to care for ‘at-risk’ or vulnerable populations (including Indigenous Australians) and improving service integration, particularly where gaps exist due to a lack of access to GPs registered for the PIP After Hours Incentive.
In Victoria, the Supporting Self-determination: Prioritising funding to Aboriginal organisations policy is a key commitment under the Korin Korin Balit-Djak: Aboriginal health, wellbeing and safety strategic plan 2017–2027. This policy has the overall objective of supporting Aboriginal self-determination and improving the health, wellbeing and safety outcomes of Aboriginal Victorians. It aims to prioritise Aboriginal-specific funding to Aboriginal organisations who provide services that address their communities’ health, wellbeing, safety needs and aspirations.
As mentioned above, the provision of adequate and effective PHC can reduce preventable hospitalisations. However, when hospitalisation is not preventable, then the care and support Indigenous Australians receive in a hospital setting should be well resourced and culturally appropriate.
The Indigenous Australians' Health Programme (IAHP) funds activities and programs that focuses on the prevention, early detection, and management of chronic disease to help keep people out of hospital. The success of IAHP will be influenced and supported by the successful implementation of other Indigenous specific initiatives including early childhood reforms, broader health system changes, improvements in identification of Indigenous patients and measures to address the underlying social determinants of poor health.
The Australian Government aims to reduce avoidable hospitalisations through funding GP health assessments for Indigenous Australians under the MBS, and through providing incentive payments for improved chronic disease management, and cheaper medicines under the PBS.
The Australian Government through the National Aboriginal and Torres Strait Islander Health Plan 2013–2023 and associated Implementation Plan, has committed to reducing discrimination in the health system and improve the accessibility of health services for Indigenous Australians.
The AIHW has been funded by the Australian Department of Health to develop an online Aboriginal and Torres Strait Islander dashboard on measures related to cultural safety in health care. The project will assist in measuring progress in achieving cultural safety under the Cultural Respect Framework 2016–2026 for Indigenous health which commits the Australian and state and territory governments to embedding cultural respect principles into their health systems; from developing policy and legislation, to managing organisations, to the planning and delivery of services.
State and territory governments have responsibility for managing public hospitals including for the cultural safety of hospital care. They also deliver Indigenous specific services and community initiatives for Indigenous Australians, designed to encourage healthy lifestyles, prevent chronic disease and improve chronic disease management (see Initiatives addressing determinants of health section below). These activities are set out in strategic plans with a focus on Indigenous Australians, for example the WA Aboriginal Health and Wellbeing Framework 2015–2030, the Australian Capital Territory Aboriginal and Torres Strait Islander Health Plan 2016–2020, and the Korin Korin Balit-Djak: Aboriginal health, wellbeing and safety strategic plan 2017–2027 in Victoria.
Governance and cultural competency
The development and delivery of well-designed and implemented cultural safety training programs can assist in the aim of achieving a health system that is a safe environment for Indigenous Australians, and where cultural differences are respected.
The National Aboriginal and Torres Strait Islander Health Plan 2013–2023 draws attention to ‘the centrality of culture in the health of Aboriginal and Torres Strait Islander peoples and the rights of individuals to a safe, healthy and empowered life’. Achieving improvements in health outcomes for Indigenous Australians means working towards fulfilling the vision of the Health Plan —a health system that is free of racism and inequality and where all Indigenous Australians have access to health services that are effective, high quality, appropriate and affordable.
The Cultural Respect Framework 2016–2026 was developed by the Australian Health Ministers’ Advisory Council and provides a national approach to building a culturally respectful health system. It commits the Australian and state and territory governments to embedding cultural respect principles into how organisations are run, through to the planning and delivery of services.
The Indigenous Australians' Health Programme (IAHP) supports the delivery of high quality, comprehensive, culturally appropriate PHC services and facilities to Indigenous Australians and communities.
The National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP) funds organisations to provide culturally appropriate aged care to older Indigenous Australians close to home and community.
The Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander people (QUMAX) Program complements the PBS Closing the Gap Co-payment Measure, and provides funding to Aboriginal Community Controlled Health Organisations (ACCHOs) in rural and urban areas. Funded services include cultural awareness training for community pharmacies, transport for clients, quality use of medicines education for consumers and staff, and medicine dose administration aids.
The Remote and Aboriginal and Torres Strait Islander Aged Care Service Development Assistance Panel (SDAP) supports aged care providers to build capacity to become culturally appropriate. SDAP employs local solutions to address the challenges of maintaining and delivering quality aged care services.
Health workforce and training
The National Aboriginal and Torres Strait Islander Health Workforce Plan 2021–2031, was informed by an extensive national consultation process. Consultations identified that improved recruitment and retention of Indigenous Australians requires a culturally safe health and education sector. Further, in order to successfully grow the Indigenous health workforce, barriers to education, employment and career progression need to be addressed consistently at both the national and jurisdictional level.
Strengthened partnerships between the health sector, education stakeholders and employers was identified as an enabler to the development of clear and accessible pathways between school and higher education, particularly in regional locations, to support locally relevant careers. In addition, strengthening the role and recognition of Indigenous Australians and Indigenous professions within health care models, was identified as a key enabler of cultural safety within the workforce.
The Australian Government, in partnership with the Project Reference Group, is currently finalising the Health Workforce Plan. The Health Workforce Plan focuses on the attraction, recruitment and retention of Aboriginal and Torres Strait Islander people across all roles within the health sector and aims to implement activities that support the following six Strategic Directions:
- Strategic Direction 1: Aboriginal and Torres Strait Islander people are represented across all health disciplines.
- Strategic Direction 2: The Aboriginal and Torres Strait Islander health workforce has sufficient skills and capacity across all health disciplines.
- Strategic Direction 3: Aboriginal and Torres Strait Islander people are employed in culturally safe and responsive workplace environments that are free of racism across health and all related sectors.
- Strategic Direction 4: There are sufficient Aboriginal and Torres Strait Islander students studying for qualifications in health to meet the future health care needs of Aboriginal and Torres Strait Islander people.
- Strategic Direction 5: Aboriginal and Torres Strait Islander health students have a high level of completion and graduation from their courses.
- Strategic Direction 6: Information and data are provided and shared across systems to assist health workforce planning, policy development and evaluation/continuous quality improvement.
The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework (2016–2023) is a key document to guide national Indigenous health workforce policy and planning in relation to providing culturally safe and responsive health care. It has been developed within the overall policy context of the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
The Australian Government funds Aboriginal and Torres Strait Islander Health Professional Organisations (ATSIHPOs) to grow and develop the Aboriginal and Torres Strait Islander health workforce and assist in increasing the capacity of mainstream health care providers to deliver culturally safe and responsive care to Indigenous Australians.
The Leaders in Indigenous Medical Education Network promotes and supports effective teaching and learning of Indigenous Australian health in medical education, and best practice in the recruitment and retention of Indigenous medical students and trainees.
The Puggy Hunter Memorial Scholarship Scheme continues to provide scholarships for Indigenous students in most health disciplines.
The Australian Government is continuing to ensure high quality training is provided to GP registrars under the Australian General Practice Training program. The program focuses on building the cultural competency of registrars and improving access to appropriate and holistic care for Aboriginal and Torres Strait Islander people. At least 50% of all GP training is undertaken in rural and regional areas, with additional GP services provided to remote and isolated communities through placements with the Royal Flying Doctors Service.
The Remote Vocational Training Scheme, provides distance education to GPs and general medical services in Indigenous communities and rural and remote locations throughout Australia. The scheme supports the retention of doctors by allowing doctors to improve their clinical knowledge and skills without having to relocate to a major city for training.
Rural Health Multidisciplinary Training (RHMT) Program supports health students to undertake rural training through a network of rural clinical schools, university departments of rural health, dental faculties offering extended rural placements, and the Northern Territory Medical Program (Flinders University). The program also supports 26 regional training hubs tasked with building medical training pathways within a region and guiding students and trainees through these. There are 21 universities currently participating in the program across Australia. The program’s primary objective is to improve the geographic distribution of the health workforce through the delivery of rural training experience. One of the program’s goals is to provide rural training experiences for health professionals. The program also requires participating universities to have strategies in place to attract and enrol Indigenous students to health courses and support them through to graduation.
The Rural Health Workforce Support Activity (RHWSA) provides a range of activities to improve the access, quality and sustainability of the rural health workforce. Providers work with local practices, communities and other organisations such as Aboriginal Community Controlled Health Services to ensure that a skilled, well-supported health workforce serves rural Australia.
The Health Workforce Scholarship Program aims to increase access to health services in rural and remote areas that are experiencing skill shortages, by targeting health professionals committed to rural service.
The National Aboriginal and Torres Strait Islander Health Plan 2013–2023 tasked the Royal Australasian College of Physicians (RACP) with helping increase Indigenous Australians’ access to specialists. The RACP Medical Specialist Access Framework connects stakeholders involved in delivering specialist medical care, including patients, carers, communities, funders, facilitators, service providers and individual practitioners. The RACP Medical Specialist Access Framework also focuses on successful models of Indigenous Australians accessing specialist care through case studies, and encourages stakeholders to consider how these case studies can inform their own service and practice.
Under the Remote Area Health Corps (RAHC) urban-based health professionals are recruited, trained and deployed for short-term placements in Northern Territory Government and Aboriginal community controlled health providers in remote Indigenous communities in the Northern Territory. The RAHC is currently funded under the Indigenous Australians’ Health Programme (see the Primary Health Care section above).
The Australasian College for Emergency Medicine has developed a series of educational tools and resources designed for doctors to enhance culturally competent communication and overall care for Aboriginal and Torres Strait Islander patients in the emergency department.
The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives has developed an innovative, online cultural safety training course for nurses and midwives who deliver frontline health care to Indigenous Australians.
The Healing Foundation aims to build a workforce with increased capacity to recognise and respond to trauma, loss and grief.
In the aged care sector, the Indigenous Employment Initiative (IEI) Program subsidises the employment costs of Indigenous Australians providing non-clinical aged care services to older Indigenous Australians. It also subsidises accredited training to ensure Indigenous Australians providing these services have the necessary skills.
The Australian Government committed to delivering the Indigenous Health Workforce Traineeship (IHWT) program, commencing in 2020–21. The IHWT program aims to increase the number of skilled Indigenous Australians working in primary health care settings by funding the wages and training costs of trainees employed at eligible Aboriginal Community Controlled Health Organisations.
The Health Demand and Supply Utilisation Patterns Planning (HeaDS UPP) Tool is an instrument to map health needs, workforce capability and service capability. This tool will better inform workforce analysis and planning, and policy and program development, and enable informed collaboration across the health system.
The JobTrainer Fund, as a partnership between the Australian Government and state and territory governments, will provide up to 340,700 additional training places that are free or low fee, in areas of identified skills need for job seekers and young people, including Indigenous Australians. Under the JobTrainer Fund, funding will be available for nationally accredited qualifications and skill sets based on a list agreed between the National Skills Commission and state and territory governments. It is expected that this will include health care and aged care related training.
State and territory examples
The Tasmanian Department of Health’s eLearning Aboriginal Cultural Respect in Health Services has been updated with new modules and supporting resources. The Department continues to encourage face-to-face ‘on country’ cultural safety training provided by Tasmanian Aboriginal organisations.
The Tasmanian Department of Health provides pathways into the health workforce through the Ida West Scholarship, which supports Tasmanian Aboriginal people to undertake university and vocational study in health subjects. Oral Health Services Tasmania is developing an Aboriginal Employment strategy.
The Tasmanian Department of Health also maintains several Aboriginal identified health positions. For example, the three major hospitals each have an Aboriginal Health Liaison Officer to provide emotional, social and cultural support to Aboriginal patients and their families and help people access and fully benefit from care and treatment.
The Tasmanian State Service Aboriginal Employment Strategy 2022 aims to increase the number of Aboriginal employees in a range of occupations and levels across all State Service Agencies from 3% to 3.5%. A new Aboriginal employment portal has been established where tagged and identified positions are highlighted.
The Tasmanian Department of Health’s draft Health Workforce 2040 plan also includes actions to increase the number of Aboriginal health professionals in the Tasmanian workforce.
The Tasmanian Department of Health is finalising an Action Plan for Improving Aboriginal Cultural Respect Across Tasmania’s Health System 2020–2026 in response to the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016–2026.
The South Australia Health Aboriginal Workforce Framework 2017–2022 and the South Australia Health Aboriginal Cultural Learning Framework provide strategic priorities to increase the number of Indigenous Australians employed in the health workforce and South Australia Health’s cultural capacity.
The Australian Capital Territory Health Directorate and Canberra Health Services currently drives cultural competency through:
- capability learnings (an internal learning management system)
- monthly face to face training delivered by the Aboriginal and Torres Strait Islander Practice Centre
- development of a new Reconciliation Action Plan – “Innovate”
- implementation of the National Cultural Respect Framework 2016–2016 for Aboriginal and Torres Strait Islander Health
- implementation of the National Safety and Quality Health Service Standards for Aboriginal and Torres Strait Islander consumers.
The Western Australian Department of Health has implemented a range of key strategic employment initiatives including:
- Aboriginal employee targets to increase representation in the health workforce
- the Aboriginal Leadership Excellence and Development Program to identify, prepare and fast-track talented Aboriginal staff for senior and executive positions
- the section 51 Pilot Program to increase the number of Aboriginal employees in the Western Australian health system
- the employment of Aboriginal graduates through the GradConnect Program for nurses and midwives and Graduate Development Program
- funding for tertiary institutions and community-controlled health registered training organisations, to support students and promote health careers
- employment of Aboriginal university students in clinical and non-clinical roles as cadets across the Western Australian health system
- the Western Australia Country Health Services introduced the Aboriginal Entry Level Employment Framework to provide funding to support Aboriginal employees
- implementation of the WA Health Aboriginal Workforce Policy.
In Victoria, the Aboriginal and Torres Strait Islander cultural safety framework has been developed to help the Department of Health and Human Services and mainstream Victorian health, human and community services to create culturally safe environments, services and workplaces. The framework aims to help the department and mainstream health and community services to strengthen their cultural safety by participating in a process of continuous learning and practice improvement. The model is designed to guide the development of strategies, policies, practices and workplace cultures that address unconscious bias, discrimination and racism.
The Victorian Government also provides pathways into health sectors through the Aboriginal cadetship program for nursing, midwifery and allied health provides a transition to practice program for graduates in their first year of professional practice, designed to consolidate knowledge and skills and build confident, safe and accountable professionals.
In Victoria, Aboriginal clinical and therapeutic mental health positions are employed in ten Aboriginal community-controlled organisations across rural and metropolitan areas. The initiative aims to increase the workforce available to deliver culturally responsive, trauma-informed services that can address the social and emotional wellbeing and mental health needs of Aboriginal people in Victoria.
Health care standards
Listed below are initiatives and safeguards that are currently in place to ensure the health care system that Indigenous Australians access meets an acceptable standard.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) has incorporated into the National Safety and Quality Health Service (NSQHS) standards, six actions that health service organisations must implement regarding care for Indigenous Australians. These actions require organisations to:
- establish collaborative partnerships with local Indigenous communities and ACCHOs
- set strategic goals and targets for the health service organisation to improve care provided to Indigenous Australians
- implement strategies to achieve improvement goals and targets
- provide cultural training of its workforce
- work with local Indigenous communities to establish a welcoming environment for its Aboriginal and Torres Strait Islander patients
- invite all patients to identify as Indigenous.
The Healthy for Life (HfL) program builds continuous quality improvement (CQI) into clinical practice and service delivery within ACCHOs.
The Aboriginal Community Controlled Health Sector peak bodies support ACCHOs in implementing best practice clinical, governance and business systems, and to provide training and support to ACCHOs in the use of CQI to achieve improved clinical outcomes.
The Australian Government Department of Health has embedded funding for CQI in all Comprehensive Primary Health Care Funding Agreements granted through the Indigenous Australians’ Health Programme.
Indigenous Health Research Fund
In 2019, the Australian Government committed $160 million for the 10-year Indigenous Health Research Fund (IHRF) under the Medical Research Future Fund to improve the health of Indigenous Australians. The IHRF will support practical, innovative research into the best approaches to prevention, early intervention, and treatment of health conditions of greatest concern to Indigenous communities.
The IHRF’s first three flagship priorities aim to deliver rapid solutions to some of the biggest preventable health challenges faced by Indigenous communities. These are:
- ending avoidable blindness
- ending avoidable deafness
- ending rheumatic heart disease.
Medical Research Future Fund
The Medical Research Future Fund (MRFF) is a $20 billion long-term investment supporting Australian health and medical research. The MRFF aims to transform health and medical research and innovation to improve lives, build the economy and contribute to health system sustainability.
National Health and Medical Research Council
The National Health and Medical Research Council (NHMRC) is Australia's peak body for supporting health and medical research; for developing health advice for the Australian community, health professionals and governments; and for providing advice on ethical behaviour in health care and in the conduct of health and medical research.
The NHMRC’s Road Map 3: A strategic framework for improving Aboriginal and Torres Strait Islander health through research is a comprehensive 10 year strategic framework to improve the health of Indigenous Australians.