Ian Ring | Closing the Gap is possible with information government already has

So, you would have thought, the key question asked by all might be "Why has progress been so slow - and what needs to be done to turn that around?" Not a bit of it. Instead, recriminations, unfounded assumptions, misinformation and worse became the order of the day.

It's not for want of plans. There has been a string of plans since the first announcement of a new health plan for Aboriginal and Torres Strait Islanders by ministers Roxon and Snowden in 2011. These plans and accompanying implementation plans have generally been well intentioned and the current Closing the Gap Commonwealth Implementation Plan, released 2021, represents a very considerable advance on its predecessors.

But all these plans have struggled with the way in which governments and agencies deal with the basics of implementation. This latest Implementation Plan provides somewhat vaguely worded ("increase", "decrease") targets specifying funding, timeframes, responsibility and general indicators, but what is missing is the "how" the target is to be achieved - analysis of the services and resource requirements to achieve the targets, an adequate information base to assess progress, in built evaluation and quality improvement processes, and basic management skills - all key elements in a proper planning process.

The good news is that there are things that can and should be done right now that would change that. There are, for example, steps that could be taken that would put the targets for life expectancy and child mortality "on track". They are not unaffordable, do not require new knowledge and have been sought by Aboriginal and Torres Strait Islander people for a very long time. But they would require governments, and particularly the Commonwealth government to get its act together, heed the voice of Indigenous people, strengthen Indigenous leadership and conduct a root-and-branch overhaul and upskilling of key government agencies - and make proper use of information that has long been available to it.

Take child mortality for example. Most childhood deaths occur very early in life and are driven by birthweight. Having a healthy birthweight is important not just for outcomes in early life but for the development of chronic disease in later life. Healthy birthweight is much more likely in those who start to access antenatal services early in pregnancy and receive adequate care for a range of health conditions and effective health promotion strategies for nutrition, smoking and other important factors.

The Strong Mothers, Strong Babies, Strong Culture program, was first developed by Aboriginal women and health workers in the early 1990s and was followed by various adaptations of this approach. The Townsville Aboriginal and Islander Health service as far back as 2007 showed, with its Mums and Bubs program, that well run community controlled antenatal services could boost attendance of mothers in early pregnancy with consequent improvements in the birthweight distribution and a reduction in perinatal mortality.

In 2014 the Australian Institute of Health and Welfare described other programs that improved antenatal attendance, improved birthweight and lowered mortality. The Aboriginal and Torres Strait Islander Health Performance Framework says: "Evidence shows that models of care tailored specifically for Indigenous women result in quantifiable improvements in antenatal care attendance, pre-term births, birth outcomes, perinatal mortality, and breastfeeding practice. These models include culturally appropriate and safe care as well as continuity of care, collaboration between midwives and Indigenous health workers, and involvement of family members such as grandmothers."

Given this information, much of it from the Commonwealth's own publications and all of it widely known and readily accessible, it might have been expected that the Commonwealth would conduct a service inventory of existing Aboriginal and Torres Strait Islander Community Controlled Services (ACCHS) for mothers and babies, identified service gaps and then developed a forward plan to fill the service gaps across Australia. Sadly, that has not been the case and there has been no significant change in the Indigenous low birthweight rate between 2013-2019, and between 2010-2019 there was no significant change in the Indigenous child and infant mortality rates.

The Aboriginal and Torres Strait Islander Health Performance Framework tells us that the gap in age standardised death rates (a proxy for life expectancy). widened over the decade to 2019. Not surprising as there has been no significant change in the Indigenous avoidable (i.e., the deaths the health system can reduce) mortality rate in that period, and the Indigenous use of the Medical Benefits Scheme (MBS) is below the needs-based requirements and the use of the Pharmaceutical Benefits Scheme (PBS) is less per capita for indigenous people than for the rest of the population.

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Life expectancy improvements are driven in large part by reductions in mortality from chronic disease. It was shown as far back as 2003 that well run and adequately resourced programs, delivered by Aboriginal Health Workers, backed up by practice nurses and physicians, could halve the chronic disease death rate in three-to-four years - and were highly cost effective. Delivery of such programs is a core function of Primary Health Care (PHC) services, and it has also been shown that ACCHS outperform mainstream services in terms of identifying and managing health risk. Access to health services in general and ACCHS in particular, is absolutely crucial. It might have been expected that, in the face of the continuing lack of progress, there would have been a program to urgently identify and fill PHC service gaps i.e. areas with relatively high levels of avoidable deaths and low use of MBS/PBS, with ACCHS services. Sadly again, to this day that has not been done.

It needs to be clearly understood that there is absolutely no prospect of the national goals for life expectancy and child mortality being achieved until the relevant service gaps are identified and filled and, equally importantly, much greater progress achieved with housing, education and other social and economic issues.