The evolving face of Aboriginal and Torres Strait Islander health in rural Victoria

Most Australians take culturally safe and timely access to primary healthcare for granted. In 2021, Australia ranked at least fifth overall among 38 Organisation for Economic Co-operation and Development (OECD) member countries for life expectancy at birth and holds similar privileges with regards to disease burden.^1,2 Unfortunately, these benefits are not shared among our Aboriginal and Torres Strait Islander (hereby respectfully referred to as Indigenous) communities. Indigenous people comprise hundreds of groups, with their own distinct languages, traditions and histories, and internal diversity in lived experience and health status.³ Indigenous health outcomes have improved over the years, but a combination of historical factors, fragmentation of health systems and ongoing racism continues to hinder progress.^4,5 In 2023, an overwhelming referendum vote against an Indigenous Voice to Parliament is an example of this, despite the well-established evidence base for the role of self-determination in positive health outcomes.⁶ For these and other reasons, Indigenous health outcomes in Australia remain inexcusably poor, particularly in regional Australia.

Indigenous people hold a life expectancy at birth that is at least 8 years lower than that of other Australians, higher rates of chronic disease and overall lower access to primary healthcare.^7,8 An increase in the number of people living with multiple co-morbid conditions, and time pressures among a receding general practitioner (GP) workforce are expected to inflict the heaviest toll on Indigenous communities in rural Australia.^4,9 The convergence of historically entrenched discrimination and racism, culturally unsafe health practices, long distance to nearest service, limited transport availability and lack of trust in mainstream services contributes to poor Indigenous health outcomes.⁴ These outcomes are amplified by rurality, which is especially pertinent as approximately 61% of Indigenous people live among regional and remote communities.^4,5,10

Closing Victorian targets

Health policies that customise health services to culture facilitate better outcomes for Indigenous people by making services safe and empowering self-determination. Indigenous patients fare worse in both experience and health outcomes in mainstream health services, and are more likely to self-discharge from hospitals or seek help later in their disease course – consequences of colonisation, displacement, the forcible removal of children and repression.⁷ Aboriginal Community Controlled Health Organisations (ACCHOs) are supported by the Australian Government and represented by a national Indigenous health board (abbreviated as NACCHO). As not-for-profit health organisations with in-house GPs, they create safe spaces that support healthcare-seeking behaviour, offer primary healthcare that extends beyond the traditional biomedical model to address the social and cultural determinants of poor health, and help train Indigenous people to become health workers.¹¹ According to the 2021–22 National Aboriginal Community Controlled Health Organisation (NACCHO) annual report, 145 ACCHOs exist across Australia, 24 of which operate in Victoria.¹²

The importance of ACCHOs in Closing the Gap is widely accepted in the health community. The COVID-19 pandemic is an example of how ACCHOs are dynamic, cost-effective frontline health services. Given higher levels of comorbidity, overcrowding and pre-existing socioeconomic disadvantage, a higher number of cases and COVID-19-related complications were predicted among Indigenous communities.¹² The opposite was observed. NACCHO lobbied Australian governments to support closing remote Indigenous communities, assist with provision of personal protective equipment and COVID-19 testing, trained Indigenous health workers, created patient education videos and ensured that elders and those with serious illness had access to early vaccination.^12,13 The positive results of this Indigenous-led response was evident by October 2022, when the Australian Department of Health reported that 81% of Indigenous individuals were double-vaccinated against COVID-19, higher than the national average of 72%.¹⁴ Indigenous people reported a high level of trust in, and preferentially sought information and treatment from, their local ACCHO, making Australia a role model in COVID-19 mitigation for its Indigenous peoples.^13,15

For Indigenous Victorians, several state-based programs exist to support improvements in health outcomes. The 2017 Aboriginal Governance and Accountability Framework guides how these programs operate to ensure that Indigenous leadership and self-determination are embedded across all levels of decision making.¹⁶ The main programs include:

• Improving Care for Aboriginal Patients (ICAP) Program: delivered across 41 (of over 134) public hospitals across Victoria, aiming to accurately identify Indigenous patients, streamline access to hospitals and mental health services, support culturally safe healthcare and promote partnerships between Victorian hospitals and ACCHO GPs.¹⁷
• Victorian Aboriginal Palliative Care Program: a culturally safe palliative care pathway that provides Indigenous health worker training and education, develops culturally sensitive resources and provides patients with options for palliative care service delivery.¹⁸
• Aboriginal Spectacle Subsidy Scheme: seeks to address the stark inequalities in eye health. Indigenous Victorians are six-fold more likely to experience blindness compared to non-Indigenous Victorians over the age of 40 years, mostly relating to refractive error, cataract or diabetes. The program funds a patient pathways coordinator at the Royal Victorian Eye and Ear Hospital (located in central Melbourne, Vic) and subsidies prescription glasses with a patient contribution of $10.¹⁹
• Koori Maternity Services (KMS) Program: funds Indigenous maternal health workers to assist pregnant women in navigating antenatal services and exists in 11 (out of 24) ACCHOs across Victoria. Nine ACCHOs are also able to provide shared antenatal and postnatal care for Indigenous mothers and babies.²⁰

Regional challenges and ways to address them

Strong evidence supports the vital role that ACCHOs play in culturally responsive primary healthcare provision in line with Indigenous cultural values and definitions of health; however, not all rural communities are within easy access of an ACCHO or wish to receive healthcare services at an ACCHO.¹¹ For patients seeking to access an ACCHO, distance and transport availability are significant barriers. For those who do not, annual Indigenous health checks are Medicare funded through any ACCHO or bulk billing medical practice; however, uptake among rural communities is inconsistent. Barriers include length of time needed for the assessment to occur, failure to register Indigenous status, insensitive questioning, shame and general mistrust in local mainstream health services that ripples across communities.²¹ This is where the culturally aware mainstream GP can really shine.

Chronic disease is prevalent among rural Indigenous communities; however, successful chronic disease management in ACCHO-inaccessible areas requires cultural competence. In 2009, a partnership between government and a local Indigenous community in the Hume region of rural Victoria identified that building cultural competence in mainstream health services is a key priority to help bridge the health gap.²² This means that rural GPs have an intimate part to play in Indigenous primary healthcare; however, the complexity of Indigenous care is not always reflected in busy mainstream general practices. Indigenous Australians view health as an integration of social, spiritual, cultural, environmental and physical health. Unfortunately, Western medicine tends to overlook the significance of culture in contributing to the health and wellbeing of Indigenous people, even though it is strongly correlated to positive health outcomes.^11,22 Furthermore, rural communities typically host a small number of GPs, who are usually in high demand.²² When the focus of Indigenous government funding is primarily dedicated to tertiary services and their partnerships with ACCHOs, rural Indigenous communities risk getting left behind.

Many of the attributes of culturally competent general practice, such as good communication, being mindful of stigmatising language and respect, are inherent to all good GP–patient interactions.²³ More specific knowledge around common health issues among Indigenous peoples, Closing the Gap medication support for low-cost or free PBS medications and the local specialised services that Indigenous patients can access is also important.²⁴ GPs with experience in Indigenous health emphasise the importance of building relationships and trust, prioritising non-medical conversations and mindful body language over the doctor’s clinical agenda.²⁵ The exchange of clinical knowledge happens over time as trust is established. A practice commitment to culturally sensitive care through cultural awareness training, employing GPs with a special interest in Indigenous health and harnessing opportunities for cultural mentorship from local Indigenous members are some proven strategies to establish rapport and reduce communication pitfalls.²⁴ In the case of rural Australia, where practices are few and far in-between, this in-house commitment to improving the experience of its Indigenous patients has the power to address the community’s need for culturally safe primary care and, in doing so, significantly improve local Indigenous peoples’ health outcomes.

The importance of Indigenous-led policy reform

The discourse around closing the health gap is changing from one that was previously government-led for Indigenous people to one that empowers and supports Indigenous communities to close the health gap themselves.²⁶ For this to be effective in rural areas, a whole-of-government and community approach is truly needed, and applied to local communities.²⁷ A rural Indigenous health taskforce could support local collaboratives in streamlining access to primary care for Indigenous rural residents by identifying their specific community health needs. A broad definition of Indigenous health that includes the physical, social, environmental, cultural and spiritual elements might reduce existing disparities by addressing both biomedical and non-physical determinants of Indigenous health. Cultural safety is a key determinant for improved health outcomes and in encouraging patients to engage with health services.^4,11,16,22 This might include, but not be limited to, access to a community centre or space to support cultural connectedness and ensuring that rural Indigenous communities have practical public transport options to access their nearest ACCHO or primary healthcare centre of choice in their region. Of greatest importance is that these interventions are led by and co-designed with rural Indigenous leaders for their community. Caution must be taken to ensure that Indigenous people play an active role in designing Indigenous programs and that their position on the table is not tokenistic – power and funding continues to be concentrated in mainstream authorities. The effects of new policies and programs also need to be rigorously and strategically evaluated to ensure that funding continues to be meaningful and translates to positive health outcomes for rural Indigenous Australians.²⁸

Conclusion

Discussions around Indigenous health often focus on disadvantage. There is certainly much to be done in bridging the health gap, particularly among rural Indigenous communities. The approach to rural Indigenous health equity should capitalise on the strength, leadership and resources that exists within these Indigenous communities, heralding a new way forward of working with Indigenous Australians. Mainstream primary health services also need to be at the forefront of this movement. The reversal of the health gap with regards to some aspects of COVID-19 control within Indigenous communities is testament to outstanding Indigenous leadership, and what is possible by listening to local wisdom and enabling its application.

Key points

• Indigenous communities face ongoing health inequities due to historical, cultural and systemic barriers, but discussions around Indigenous health should focus on empowerment rather than just disadvantage.
• ACCHOs play a vital role in delivering culturally sensitive care. Local council initiatives that enable access are therefore important.
• Not all rural Indigenous communities have access to an ACCHO or wish to receive care from one – a commitment to cultural safety by mainstream GP practices can significantly improve health outcomes for rural Indigenous patients.
• Empowering Indigenous communities to lead healthcare initiatives in policy reform through local taskforces and co-designed policies ensures that policies effectively address Indigenous primary health needs.
• Shifting towards Indigenous-led, community-driven health policies that prioritise empowerment, Indigenous definitions of health and local collaboration will help achieve health equity in rural Indigenous communities