|Implemented in this survey?|
The Australian government's intervention in the Northern Territory (NT) is the largest whole of government initiative ever undertaken in Australia. The government set up the NT Emergency Response Taskforce to oversee the implementation of the emergency measures aimed at protecting children in Aboriginal communities and normalising services and infrastructure in a sustainable way. Health interventions form a small but important part of the Response, largely centering on child health checks.
The stated purpose of the overall policy is to implement emergency measures which have as their objectives:
The policy has been developed using a "whole of government" approach so that the reforms cover a wide spectrum of policy areas and services, including Welfare, Law and Order, Education, Social Services, Child and Family Health Housing and Land Reform.
This report will focus on the Child and Family Health initiatives. The key activities in this area of the Response are providing health checks and follow-up treatment and care for Indigenous children and expanding drug and alcohol treatment and rehabilitation services across the NT to support individuals and communities affected by the new alcohol legislation. (Since September 2007, the NT Liquor Act has been modified to ban the sale, possession, transportation, and consumption of alcohol on Aboriginal land and to monitor take-away sales in the NT. Some licensed premises are allowed to operate in Aboriginal communities but their operation has been closely examined and is being monitored).
All health services are provided free of charge at the point of delivery. Access to the services is on a voluntary basis. All Aboriginal communitues in the NT are affected as well as services provided to these communities. From the health perspective, this applies particularly to Aboriginal community-controlled health services (ACCHS) and the NT Department of Health and Community Services.
The objectives of the Child and Family Health activities included in the NT Intervention were to:
A total of more than $1,224.3 million has been allocated to the NT Intervention. This includes $83m for child and family health activities and $100m for additional health providers and specialist services. No information is available regarding the funding available for enhanced drug and alcohol treatment and rehabilitation services.
All services are provided free at the point of delivery. All communities have been visited by health officials (amongst others) and the objectives and activities of the Intervention have been explained; this might be seen as a form of coercion.
Aboriginal communities, Aboriginal controlled community health services, NT Department of Health and Community Services
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The whole of government approach to this intervention as well as its emergency flavour makes this an innovative approach - particularly as it has been implemented and is not just the subject of a report.
The sudden emergency aspect and the paternalistic tone of many of the mandatory reforms made the NT Intervention a very controversial issue. It was widely perceived as being high handed and ignoring the reforms that had been achieved as well as brushing aside any idea of consulting with Aboriginal communities about the initiative. A response to this might be that it was clear to policy makers and the government what needed to be done; much consultation has been undertaken with Aboriginal communities in the past and this has only resulted in delays to the implementation of policies.
The impact of the NT Intervention at the system level has been fundamental, at least initially. The question is, will it become an embedded system and have a long lasting impact? The experience of Aboriginal people and communities in other parts of Australia is not encouraging. It has been reported that despite the creaton of new Medicare items aimed at Aboriginal people, the take-up has been low. In 2008-09, only 556 Indigenous health checks were undertaken (out of a total of 294 million Medicare items) and 295 consultations with an Aboriginal health worker or other allied health worker were reported. Although Aboriginal people can access mainstream Medicare services, it has been suggested that many often cannot afford the out-of-pocket costs charged by GPs and allied health providers.
Initially, the initiative was debated publically at all levels of the Australian community. Its implementation has been less visible and the report of the process evaluation has not been commented upon in the popular media. Some aspects of the initiative which have remained controversial or not been successfully implemented have been the subject of public discussion, but this has not included the health-related activities.
This type of initiative could be transferred to any system where the level of public outrage and political will coincide over a particular issue as they did here with the "Little children are sacred" report into child abuse.
No information is available about the drug and alcohol initiative; therefore no comments are able to be made about this aspect of the initiative.
In Australia, the Northern Territory (NT) does not have the same degree of autonomy over its affairs as do the States. Although it is able to promulgate its own legislation in regard to non-Federal issues (in the same way as other States), unlike in other States, the Australian government is able to independently enact legislation which applies to the NT and is able to over-rule any legislation passed by the NT government. As such, the Australian government was able to legislate to implement the NT Intervention, affecting only Indigenous people living in the NT, when the problems it was attempting to address affect most Aboriginal communities to a greater or lesser extent, the majority of whom are not situated in the NT.
The former Australian Government initiiated the NT Intervention in response to a report about child abuse and neglect amongst Aboriginal communities entitled "Little children are sacred". This report is the latest in a long list of reports (all of which include compelling statistics regarding the dire state of Aboriginal health status and the lack of services to address the issues), whose recommendations have been largely ignored by successive national and State/Territory governments. Some commentators have suggested that, despite the government's rhetoric that has implemented the NT Intervention as a response to this report, in fact, few of its recommendations have been considered or implemented (Brown and Brown, 2007). Some have even suggested that the report is being used as a "shield" to impose the goovernment's "real" agenda including dismantling native title, collective rights and self-determination amongst Aboriginal people (National Indigenous Times, June 2007). The initial announcements were made with great fanfare and much emotion regarding the "Little children are sacred" report but in the following months, it became clear that not all the policies announced had been well thought through and a number of changes were made.
|Implemented in this survey?|
The overall initative was that of the then conservative government of Australia and was announced by the Minister for Aboriginal Affairs, Mr Mal Brough. The main purpose of the health aspect of the initiative was to monitor children's health in Aboriginal communities in the Northern Territory (NT), to provide specialist assessment and treatment, particularly for ear, nose and throat conditions, hearing problems and dental decay.
A second purpose was to provide increased drug and alcohol services in terms of support for drug withdrawal, treatment and rehabilitation. However, these measures were secondary to the modifications made to the NT legislation regarding the sale, possession, transportation and consumption of alcohol on Aborginal land (see above).
The Child Health Checks (CHCs) form the basis of the health initiative of the emergency response. However, these checks were not new; government funding for CHCs for all Indigenous children were announced in 2005 and implemented in 2006. The CHCs were aimed at standardising screening tools and providing funding for primary care doctors to conduct such screening for children from birth to 14 years. Approximately 1000 CHCs had been undertaken in the NT prior to the emergency intervention.
In addition, ACCHS in the NT have been collaborating for some time with both national and Territory departments of health to reform and expand the delivery of primary health services more generally in the NT.
Originally, the emergency response CHCs were announced as being mandatory and included a forensic examination to attain a level of sexual abuse. However, within a week of the initial announcement, the Minister announced that the CHCs would be voluntary, would be carried out by the procedure previously developed in 2005 and not include the examination regarding sexual assault. It was recognised that providers were already obliged to report sexual abuse if they suspected it.
The approach of the idea is described as:
renewed: Child Health Checks first implemented in 2006
The government stance towards discussion of the emergency response has been characterised as "you are either with us or against us"(Brown and Brown, 2007). This does not reflect the reality of the attitude of most medical/health experts or organisations or that of Aboriginal people generally. Most of these individual or groups were supportive of some aspects of the NT intervention whilst opposing or questioning other aspects. For example, the initial idea that CHCs would be mandatory was greeted with disbelief by doctors and other health workers - it was suggested that health care providers would not be able to do such checks without permission from a parent or guardian and would not wish to do so. They were also concerned that such an announcement would generate fear and mis-information about the health checks; some commentators have suggested that it has taken a great effort to convince Aboriginal communities that what was announced was an expansion of the CHCs which were already being undertaken by ACCHS (Boffa et al, 2007). However, the ACCHS have attempted to rise to the challenge of harnessing the intervention's CHCs and other new services to develop a more comprehensive primary health service for Aborginal communities in the NT.
The then Opposition, the Labor Party, was generally supportive of the initiative, although critical of some aspects. The health initiative, once it had been clarified as being voluntary, was supported by the Labor Party. Now in government, the Labor Party has continued the intervention, albeit with some modifications and has received and acted on some aspects of the initial evaluation (process evaluation).
|Australian government||very supportive||strongly opposed|
|NT government||very supportive||strongly opposed|
|Opposition parties||very supportive||strongly opposed|
|Medical organisations||very supportive||strongly opposed|
|Aboriginal people||very supportive||strongly opposed|
No formal legislation was required for the health aspect of the intervention.
|Australian government||very strong||none|
|NT government||very strong||none|
|Opposition parties||very strong||none|
|Medical organisations||very strong||none|
|Aboriginal people||very strong||none|
The national and NT governments together coordinated the process of implementation. Some volunteer administrators and health care providers were also drafted into assisting workers already on the ground.
The most critical aspect of the health activities was the availability of a trained and skilled workforce to undertake the CHCs and provide the drug and alcohol interventions. This is a major barrier to the success of the initiative as there is already a shortage of such workers in Australia, particularly in regional and remote areas.
The initial evaluation report (process evaluation) is complete. The results are reported below. The Taskforce which coordinated the implementation and process evaluation, has used the report to highlight the need for the CHCs to be incorporated into a comprehensive set of services which in turn need to be resourced adequately. It points out that the workforce aspect of the intervention is critical and that both primary and specialist follow-up is crucial. The report includes a series of recommendations including the need to:
Mid-term review or evaluation
By June 2008, CHCs had been undertaken in 70 Aboriginal communities, 47 by CHC (intervention) teams and 23 by ACCHS/NT government teams. The estimated number of completed CHCs was 11,000, representing a coverage rate of children of 64%. Hearing assessments have been completed for 699 children, 46 have received ENT surgery and 227 non-surgical ENT follow-up. Non-surgical dental services have been provided to 350 children and 40 children have received dental surgery in hospital.
No details are available about the implementation or utilisation of the package of drug and alcohol treatment and rehabilitation measures which have been developed and rolled out.
Most children in NT will ultimately be assessed using CHCs by the time the intervention is complete. These checks and an improved primary health care system are clear potential benefits of the intervention.
It is not clear whether the CHCs will continue as an annual activity or whether the initial follow-ups, whether by primary care or specialist services, will be able to be maintained. An evaluation of the pre-intervention CHCs showed that the existing systems were not providing for adequate follow-up of identified medical and social problems in remote Aboriginal communities. The authors concluded that without effective systems for follow-up, screening children for disease or adverse social circumstances will result in little or no benefit (Boffa et al 2008).
The way in which the intervention was announced, designed and implemented was generally regarded as disempowering for Aboriginal people; this could be a negative aspect of the intervention given the known link between control of life circumstances and health outcomes and the already wide gap in health outcomes between Aboriginal and non-Aboriginal Australians (eg 17-20 years lower life expectancy for Aboriginal compared with non-Aboriginal Australians). The link between discrimination and population health also needs to be considered in light of the wide-ranging welfare reforms and the forced prohibition of alcohol, which are widely perceived amongst Aboriginal communities as being racially motivated, given that they are not being applied to other disadvantaged groups within the non-Aboriginal community. Similarly, the issues around changes to employment schemes housing and education must take account of their well-known links to health at both the individual and population levels.
No-one, including Aborginal communities and experts in the area, has disputed the need for reform in these areas; however, they have questioned the effectiveness of the measures taken.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
As mentioned, the primary health care system in the NT has the potential to be fundamentally reformed by the resources made available from the initiative. However, the extent to which reform at this level is supported by similar reforms at the specialist level is yet to be understood. At the primary care level, there is no doubt that equity of access will be improved for Aboriginal communities, at least intially. Any health services delivered to children which prevent ongoing chronic health conditions and improve their potential to benefit from education will be efficient.
The government has moved to increase the resources for Aboriginal Community Controlled Health Services, recognising their crucial role in improving both health services and health outcomes for Aboriginal people.
Northern Territory Emergency Response - Final Report to Government. www.fahcsia.gov.au/sa/indigenous Accessed 11 September 2009.
Glasson W. The Northern Territory Emergency Response: a chance to heal Australia's worst sore. Medical Journal of Australia; 187(11/12):614-616, 2007.
Baille R, Damin S, Dowden M, Connors C, O'Donohue et al. Delivery of child health services in Indigenous communities: implications of the federal government;s emergency intervention in the Northern Territory. Medical Journal of Australia; 88(10):615-618, 2008
Boffa J, Bella A, Davies T, Paterson J, Cooper D. The Aboriginal Medical Services Alliances Northern Territory: engaging with the intervention to imporve primary health care. Medical Journal of Australia;187(11/12):617-618, 2007.
Brown A, Brown N. The Northern Territory intervention: voices from the centre of the fringe. Medical Journal of Australia; 187(11/12):621-623, 2007.
Ryan S. Medicare system failing Indigenous. The Australian July 27, 2009.
Smiles S. Equality push on Indigenous health- Government sets targets to improve services. The Age, March 20th, 2008.