Introduction
Many health care services are not friendly to Indigenous people of Australia (Aboriginal and Torres Strait Islander) as compared to their non-indigenous counterparts. We can attribute several factors to high-levels of disadvantages in gaining access to health care services among Indigenous people. For instance, most Indigenous people live in rural areas, which have accessibility challenges. Most health care services are mainly available in cities. In some cases, health care services are not sensitive to cultural orientations and specific needs of the Indigenous people. Still costs of health care are also inhibitive to Indigenous populations. A study by Peiris, Brown, and Cass indicate that inequities in gaining access to health care exist in Canada, the United States, and New Zealand (Peiris, Brown and Cass, 2008). While many studies have identified such disparities, addressing such challenges have not been effective. Disparities in provisions of health care services are unacceptable. At the same time, disparities in gaining access to health care services also enhance cases of avoidable chronic health conditions.
Some organizations have identified factors that can facilitate provisions of health care services to Indigenous people. These factors include having Indigenous health care providers among facilities’ staff, increasing the number of Indigenous health care workers, creating health care campaigns that target Indigenous people, creating cultural awareness in provisions of health care, providing health care services in remote locations and ensuring adequate funding of health care services in order to reduce cost burdens among Indigenous people.
The study provides a detailed comparative analysis of the management and leadership models of two different Indigenous health care systems (Jimbelunga Nursing Centre and Kalwun’s Home and Community Care Program). It refers to differences between the Indigenous health care and mainstream sectors, funding systems and models, service delivery models, characteristics of the system, challenges or enablers for effective service delivery including barriers to gain access, governance models utilized in the Indigenous health sector and features of the workforce.
Differences between the Indigenous and mainstream sectors
Ong and colleagues concluded that the Indigenous health care delivery in Australia had significant differences with the mainstream general practitioner (GP) practices (Ong et al., 2012). The main difference is in the models of delivery in which the Indigenous populations use Aboriginal Community Controlled Health Services (ACCHSs) while the other Australians use the mainstream GP.
Indigenous people also reflect “low-levels of utilization of health care services as compared to non-Indigenous populations” (Gillies, 2003). At the same time, the rate of adherence is also low among the Indigenous group. As a result, Indigenous people face serious health problems than the general population of Australia.
The mainstream health care service in Australia uses the Medicare program since 1984. In addition, there are also private health care systems in Australia. The government funds the Medicare program. The provision of primary health care has been the responsibility of the Australian federal government. Medicare guarantees a free universal access to health care services and subsidized services in cases where health care services occur outside the hospital.
The health care system in Australia remains a fragmented system in a number of ways. For instance, Baeza and Lewis note that the fragmented nature of the system exists in the organization, financial, functional, and professional levels (Baeza and Lewis, 2010).
Some critics claim that financing and provisions of health care services in Australia are almost inexplicable due to fragmented and complicated nature of the system. Australian health care services cover the Commonwealth, state, and local governments. This system makes it difficult to identify which government is responsible for a given case. For instance, we cannot easily distinguish which government is responsible for the primary health care, models and modes of health care provisions, or a given group such as the Indigenous populations. However, we can still provide general differences to account for variations.
The Commonwealth government is responsible for the largest financial contribution to the health care provision in Australia. It focuses on medical, hospitals, and pharmaceuticals funding. The Indigenous people receive funding from the Commonwealth government. State authorities account for provisions of hospitals, medical services, and other services related to health of the masses. They also ensure regulation of the health sector. On the other hand, local governments focus on the provision of maternal, children, and home-based health care services. Therefore, this system has created confusion in the health sector because of overlapping, which results in confusion, a lack of accountability, and changes in costs and blame to other arms of the government.
Funding systems and models
Studies on funding of Australian health care services show that the mainstream GP practices allow for cost-effective health care among non-Indigenous Australians. On the other hand, the Indigenous people have to use the same services at high costs through ACCHSs.
The universal system of GP funded through Medicare has been the source of funding for the mainstream Australians primary health care (Gillies, 2003). Conversely, primary health care funding for Indigenous people continue to be complex. This is because of the three main sectors, which primary health care providers must work with in order to secure funding. These include “Indigenous community controlled services, state and territory funded or operated services, and general practices” (Couzos and Murray, 2003). At the same time, most Indigenous people do not have access to general practice, especially in the Northern Territory. This is where many Indigenous people live, which is mainly a remote area. Therefore, for effective provisions of health care services, Indigenous people must depend on services from community health care facilities like Jimbelunga Nursing Centre and Kalwun’s Home and Community Care Program.
Service delivery models
In Australian health care services, the Indigenous people have various ways of gaining access to health care services. We have the mainstream health care provider, which is a publicly funded health care that covers primary, secondary, and tertiary care, which consist of primary health care services and hospitals. There are also ACCHSs, which mainly offer primary health care services to Indigenous people and some specialized services. Finally, we have the private health care providers like the general practitioners.
Most Indigenous health care services, in state or territory or community controlled, cannot cater for many Indigenous people who require health care services. Therefore, we have increased rates of acute care services among Indigenous people. These health care facilities also have limited staff coupled with high rates of staff turnover. As a result, acute care has become a necessity among Indigenous people. In addition, ACCHSs must also cater for Indigenous people with chronic conditions.
Under the Commonwealth Home and Community Care (HACC) Program, the Commonwealth government offers funding services to support frail old people and their care providers. These Indigenous people still live in the community, lack abilities for independent living, and they are at risks of long-term admission to residential care facilities inappropriately. They are mainly older adults aged 65 years and over, and Aboriginal and Torres Strait Islander people aged 50 years and over. One of the centers is Kalwun’s Home and Community Care Program.
Kalwun provides various primary health care and community-based health care services to Aboriginal and Torres Strait Islander community in the Gold Coast area. According to current statistics, several Indigenous people require quality “health care services, health promotion, prevention and intervention workshops, dental and outreach services within this region” (Kalwun Health Service, 2013).
We also have private health care providers to cater for Indigenous people. In this case, we use Jimbelunga health care providers to illustrate that the private sector has also realized the need to cater for Indigenous people, who are in dire need of health care services. Since 1994, Jimbelunga has provided different health care and support services to the aged of Indigenous origin in Australia. The center offers its services under the Auspices of the Aboriginal and Torres Strait Islander Community Health Service in Brisbane. The center aimed to meet “the Cultural and Spiritual needs of Aboriginal and Torres Strait Islander people” (Jimbelunga, 2013) in provisions of health care and support services. This center has also extended to provide services and support to people from different cultural backgrounds. It is important to note that the center charges fees on services and support it provides to older people. However, there are also optional services. Jimbelunga operates in accordance with the law of the Aged Care Act 1997.
Characteristics of the system
Most studies portray provisions of health care services to Indigenous people in Australia has the poorest among Canada, the US, and New Zealand (Peiris, Brown, and Cass, 2008; Durey and Thompson, 2012). Several attempts to improve provisions of health care and support services have met many challenges. However, there are few notable improvements.
Peiris and colleagues note that various governments of Australia have embarked on ambitious initiatives in order to improve the health care provisions to Indigenous people (Peiris et al., 2012).
Health care providers for Indigenous people (ACCHOs) are independent and autonomous. The community takes full control of them while funding mainly comes from OATSIH (Office of Aboriginal and Torres Strait Islander Health) (OATSIH, 2013).
The main model of running ACCHOs is a partnership, collaborative, or integrated system in order to uphold the viewpoint of Aboriginal community control and the holistic perception of health.
These health care providers offer a wide range of services. They mainly work with Indigenous health care workers or nurses, who offer most primary health care services to Indigenous people. They also complement services with preventive education.
Some facilities reflect best practices in the provision of primary health care services to Indigenous people. These facilities have the best staff and resources. On the other hand, some of these health care facilities for Indigenous people have serious challenges with regard to resources and support. They experience challenges with regard to attracting and retaining the best staff, maintaining equipment and infrastructure. This is common in remote areas.
Indigenous health care facilities rely on many sources of funding, which result into administrative issues (Dwyer et al., 2009).
Private GP services also have well-equipped facilities for both mainstream and Indigenous people. These facilities promote best practices and provisions of quality health care services and support to Australians. However, some of these facilities do not cater for cultural, emotional, and spiritual needs of Indigenous people. This is because of limited staff with expertise in these areas. Still, health care services in these facilities usually focus on specific health issues rather than comprehensive services, which most Indigenous people require. In some cases, Indigenous people receive poor services in these facilities. This results into low utilization of health care services. Private health care facilities also do not engage in thorough consultation, visits, and outreach.
Most GP services and community health centers are far from local Indigenous people. However, the distance remains reasonable.
Indigenous populations have unmet health care needs because of challenges with services availability. Many Indigenous people are in remote areas while others are scattered across urban areas. Health care needs have risen in urban areas where Indigenous people may be. However, government efforts have targeted people in remote locations (Australian Medical Association, 2011).
Studies also indicate that many Indigenous populations lack adequate representation in the private general practice. In fact, Indigenous patients represent 1.6 percent in these facilities (Australian Medical Association, 2011). These GP facilities provide opportunities for health care services to Indigenous people in order to ease unmet health care needs of Indigenous people. However, we have to recognize that Indigenous persons are the minority among other patients, who seek services and support from private general practices and community health centers.
Challenges or enablers for effective service delivery including barriers
Statistics from Australian government show that Australian Indigenous people experience worsening health conditions (Australian Indigenous HealthInfoNet, 2012). However, the government has taken policy initiatives to improve provisions of health care services to Indigenous people. These policy initiatives aim to enhance identification of health care needs and promote efficient provisions of primary health care services among local people. The model aims to enhance integration and linkages between hospital services and primary care providers. We evaluate the success of these initiatives based on their impacts. We concentrate on how well they improve health provisions among Indigenous people. However, such positive outcomes depend on reforms and best practices provided.
Despite the availability of statistics to reflect disparities in health care services between Indigenous and non-Indigenous populations, various authorities have found it extremely difficult to “ensure that the mainstream health care services and ACCOHSs have significant contributions towards enhancing health of Indigenous people” (Russell, 2010).
According the Overburden Report, one method of enhancing the quality of health care service is to ensure that both ACCOHSs and the mainstream health care services have “a range and quality of care required for reducing the gap in mortality and morbidity between Aboriginal and non-Aboriginal Australians” (Australian Medical Association, 2011). At the same time, health care authorities should abolish fragmented and complex ways of delivering health care services. In this context, they should adopt relational, collaborative, or integrated model, which can provide accountability and improve relationships among stakeholders. This model ensures that there are collective responsibilities, decision-making, and transparency in funding. It also reduces bureaucratic tendencies of OATSIH (Rowse, 2009). According to Lea, the bureaucratic system in provisions of health care services has hampered growths in the Northern Territory (Lea, 208). Therefore, the author calls for coordination in provisions of health care services to Indigenous people.
Collaborative model is an aspect of improving health care provisions among Indigenous people because it is a feasible and practical approach that can support health care sector. It can also improve the relationship among stakeholders.
Cultural attributes can both facilitate or act as a barrier in provisions of health care services (Peiris, Brown and Cass, 2008). Stereotypical ideologies have hampered provisions of health care to Indigenous people due to simplistic approaches to their conditions. On the other hand, health care providers who embrace certain cultural aspects of Indigenous people can improve health care services.
Studies also indicate that historical policy contexts have negative repercussions on provisions of health care services. Peiris and colleagues note that power imbalances affect Indigenous people when they interact with health care providers. These authors attribute the view to non-compliant behaviors and dominance of biomedical paradigm, which result into poor health outcomes. On the other hand, if health care providers advocate for non-biomedical strategies by adopting “trust, reciprocity and shared decision-making, they can empower recipients and effectively deliver interventions to reduce the gap in health outcomes” (Peiris, Brown and Cass, 2008).
Another access barrier is miscommunication. Miscommunication manifests itself in language and literacy, communication challenges, and ineffective sharing of patients’ information.
Some factors of success for improving health care services among Indigenous people should be community-managed and initiated. This can enhance physical and nutritional levels of Indigenous people. At the same time, health care providers have to create health care promotional messages for Indigenous people (Wise, 2008). In this context, various scholars have recommended partnership approaches in provisions of health care services to Indigenous people. Such approaches recognize local conditions and improvement approaches in health care services.
Kalwun believes that employing competent staff and providing patients with exposure to a variety of clinical and non-clinical programs and an organized and responsive approach to the management of accidents, illnesses, and disease” (Kalwun Health Service, 2013) can enhance health care services among Indigenous people.
Governance models utilized in the Indigenous health sector
There are various governance models in the Indigenous health sector. However, most studies support collaborative models, which OATSIH uses to deliver health care support to ACCHSs.
Based on the current shortcomings in the provision of health care services to Indigenous people, the focus should be on what a collaborative model can improve among stakeholders. Indigenous people usually visit both community-based health care centers and general practices for health care services. Therefore, it is necessary to ensure that these different health care facilities have high quality services. This can only happen through coordination, information, resources sharing, cultural understanding, availability of local expertise, accessibility of remote areas, and goodwill to improve health care services. Health care providers and receivers must develop collaborative models, which can sustain demands from Indigenous people.
Collaboration models can only succeed under favorable conditions. Care providers must provide necessary resources for care facilities. This ensures that services offered meet best practices, which improve the level of health care services provided. Such resources must account for unique cultural, emotional, and spiritual characteristics of Indigenous people. Health care providers must also recognize that Indigenous people are minority groups when compared to other patients. Therefore, they need high-levels of best practices.
Collaboration models also ensure that complementary health care services from mainstream health sectors are beneficial to Indigenous people in primary care services. At the same time, Indigenous people must also enhance sharing of information, cultural beliefs, health problems, emotional, and spiritual aspects with both private general practices and ACCHSs. This enhances provisions of health care services to Indigenous people.
Features of the workforce
Most health care workers usually express unique aspects in service delivery when dealing with Indigenous people compared to GP practices. The difference emerged from the level of interaction with Indigenous people. Staff considered that they provided high-levels of comprehensive care, which was responsive to various needs of Indigenous people in a health care setting. The approach was not business-oriented.
Conversely, GP practice aimed at “maximizing profits and providing reactive rather than preventive health care” (Peiris et al., 2012). As a result, workers felt that GP practice did not adequately account for specific needs of Aboriginal and Torres Strait Islander people such as emotional, cultural, and spiritual needs.
Based on experiences with community-based centers, many Indigenous people felt that support providers were threats to their health care centers. This is because nurses faced challenges from bureaucratic systems of the funding agency. Therefore, they had to ignore some community needs in order to satisfy demands of the funding agency (OATSIH). The reporting system was complex. A governing board would be appropriate to facilitate reporting to OATSIH.
Given such experiences, workers have these health care centers have unique features. There are severe staff shortages in some facilities, inadequate role and support, and a lack of access to professional development.
Workers are not adequate in these facilities. Some critics have argued that a severe shortage of nurses has curtailed effective provision of health care services. A lack of adequate nurses contributed to burnout. At the same time, such insufficient staff could not meet needs acute and chronic care needs of patients.
The role and support of Indigenous health workers are crucial in delivery of health care services. These nurses make provisions of health care tractable among Indigenous people. They have unique abilities to expand care services and engage community members. This feature facilitates conventional health care provisions.
Some centers provide effective exposure to professional development and workplace orientation support. However, some centers lack mechanisms that can prepare nurses to work with Indigenous people. In fact, only state government offered training workshops for the new workforce on cultural awareness. However, some workers claimed that the workshop was simplistic and did not adequately prepare workers for challenges on the ground. Many workers acquired cultural skills through informal interactions. These experiences enabled them to improve provisions of heath care services.
Conclusion
There is no doubt that the provision of health care services to Aboriginal and Torres Strait Islander is critically worse than non-Indigenous Australian populations. Still, health initiatives have not achieved substantial outcomes in terms of reducing disparities between these two populations. We have to understand that several factors contribute to health care disparities in Australia. Therefore, a suitable approach for reducing the gap must be multifaceted.
There are indications that provisions of health care services to the Indigenous group can improve significantly if stakeholders adopt favorable models like collaborative, partnership, or integration. The models are feasible and promote coordination among stakeholders.
References
Australian Indigenous HealthInfoNet. (2012). Summary of Australian Indigenous health, 2011. Web.
Australian Medical Association. (2011). 2010-11 AMA Indigenous Health Report Card – Summary – Best Practice in Primary Health Care for Aboriginal Peoples and Torres Strait Islanders. Melbourne: AMA.
Baeza, J., and Lewis, J. (2010). Indigenous health organisations in Australia: connections and capacity. International Journal of Health Services, 40(4), 719– 742.
Couzos, S., and Murray, R. (2003). Aboriginal primary health care: an evidence-based approach. Melbourne: Oxford University Press.
Durey, A., and Thompson, S. (2012). Reducing the health disparities of Indigenous Australians: time to change focus. BMC Health Serv Res., 12(151), 1-11.
Dwyer J., O’Donnell K., Lavoie, J., Marlina, U., and Sullivan, P. (2009). The Overburden Report: Contracting for Indigenous Health Services. Darwin: Cooperative Research Centre for Aboriginal health.
Gillies, A. (2003). What makes a good healthcare system? Comparisions, values, drivers. Oxon: Radcliffe Medical Press.
Jimbelunga. (2013). Web.
Kalwun Health Service. (2013). Kalwun Health Service – Medical, Dental & Allied Health Services. Web.
Lea, T. (208). Bureaucrats and Bleeding Hearts: Indigenous Health in Northern Australia. Sydney: UNSW Press.
OATSIH. (2013). Aboriginal and Torres Strait Islander Health. Web.
Ong, K., Carter, R., Kelaher, M., and Anderson, I. (2012). Differences in primary health care delivery to Australia’s Indigenous population: a template for use in economic evaluations. BMC Health Services Research, 12(307), 1-11.
Peiris, D., Brown, A., and Cass, A. (2008). Addressing inequities in access to quality health care for indigenous people. Canadian Medical Association, 179(10), 985- 986.
Peiris, D., Brown, A., Michael, H., Bernadette, R., Tonkin, A., Ring, I.,….Cass, A. (2012). Building better systems of care for Aboriginal and Torres Strait Islander people: findings from the Kanyini health systems assessment. BMC Health Serv Res., 12(369), 1-15.
Rowse, T. (2009). Bureaucrats and bleeding hearts: Indigenous health in Northern Australia. Australian Anthropological Society, 20(6), 154–156.
Russell, L. (2010). Indigenous health checks: a failed policy in need of scrutiny. Menzies Centre for Health Policy: University of Sydney.
Wise, M. (2008). Health promotion in Australia: Reviewing the past and looking to the future. Critical Public Health, 18(4), 497-508.