Living Soils: The Role of Microorganisms in Soil Health

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For significant service to medicine, particularly neurology, as a clinician, author and administrator, and to professional medical legal organisations. Upon touching these, the prey become entrapped by sticky mucilage which prevents their progress or escape. For significant service to the law and to the legal profession, both nationally and in the Asia-Pacific region, and to the community. Indigenous specific services in all areas provide the referral pathway to specialist and tertiary services, and support the providers in their responses to Indigenous patients. Fourth, it addresses Aboriginal and Torres Strait Islander health in a holistic manner reflecting both the social determinants of health inequality as well as the broader issues identified by Aboriginal and Torres Strait Islander people as impacting on their health.

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Known as the Overcoming Indigenous Disadvantage Framework , it reports on progress in addressing both the larger, cumulative or 'headline indicators' that provide a snapshot of the overall state of Aboriginal and Torres Strait Islander disadvantage such as life expectancy and a number of supporting 'strategic change indicators' to measure progress within the shorter term. Ultimately, the Framework is built on the vision that 'Indigenous people will one day enjoy the same overall standard of living as other Australians.

They will be as healthy, live as long, and participate fully in the social and economic life of the nation. In addition to these commitments to address Aboriginal and Torres Strait Islander disadvantage generally, specific commitments have also been made at the inter-governmental level to address Aboriginal and Torres Strait Islander health inequality.

This is through the development of a specific Aboriginal and Torres Strait Islander health policy framework and partnership process. The document itself presented problems in terms of implementation for example, it contained no recommendations. But as a statement of guiding principles, it enjoys broad support among all governments and Aboriginal and Torres Strait Islander peoples. The first Framework Agreements for Aboriginal and Torres Strait Islander Health were also completed and Aboriginal health planning forums were established during this period.

Through the National Strategic Framework , all governments recognise that progress in improving Aboriginal and Torres Strait Islander health status has been too slow and is unacceptable.

The foreword to the Strategy's Framework for Action by Governments states:. At the beginning of the 21st century, the devastating impact of poor health on Aboriginal and Torres Strait Islander peoples and communities cannot go on.

It is timely for us to commit to a long-term collaborative approach to addressing the health status of Aboriginal and Torres Strait Islander peoples as a matter of urgency. It is time for us to work together across governments and across portfolios in a spirit of bi-partisanship and in full collaboration with Aboriginal and Torres Strait Islander health leaders and communities to progress long-term strategies for sustainable outcomes.

The key commitments of the National Strategic Framework are set out in the text box below. The goal of the National Strategic Framework is 'to ensure that Aboriginal and Torres Strait Islander peoples enjoy a healthy life equal to that of the general population that is enriched by a strong living culture, dignity and justice'. The Strategy also lists the following specific aims to measure whether this goal is achieved:.

The Framework identifies nine 'key result areas' for achieving this goal and these aims. These relate to measures to:. The National Strategic Framework also commits governments to work in accordance with the following nine principles:.

An important commitment made was to develop a strategic framework for emotional and social wellbeing This was released in October The Framework aims to achieve for Aboriginal and Torres Strait Islander peoples 'three basic elements of care': Implementation will sit within the implementation, monitoring and evaluation arrangements of the National Strategic Framework and the National Mental Health Plan It was implemented in with initiatives in four complimentary areas: A review of the strategy in found that although there was much to commend in the strategy, year olds were not being effectively reached by it because of its focus on older, school-aged children.

The purpose of the Strategy is to highlight the additional priorities and special issues that are unique to the prevention and treatment needs of Aboriginal and Torres Strait Islander people. Other health-specific strategies and strategies that are committed to by the National Strategic Framework include:. The Agreements are intended to:. In accordance with these agreements and the National Strategic Framework , each government is required to develop its own implementation plan for addressing the goal and aims of the Framework.

This process, including qualifications on how the commitments will be met, is described in the foreword of the National Strategic Framework as follows:. This National Strategic Framework commits governments to monitoring and implementation within their own jurisdictions, working together at the national level and working across government on joint initiatives between health departments and other portfolios.

Through their Framework Agreement partnership structures, each jurisdiction will develop and publish a detailed Strategic Framework implementation plan including accountabilities for progressing the action areas, timeframes and reporting mechanisms.

Provision of financial resources to implement the Strategic Framework will depend on fiscal management strategies and competing funding priorities as determined by each jurisdiction's budget processes. An independent mid term review of progress against the implementation plan and outcomes achieved will be undertaken and published and an independent evaluation of the National Strategic Framework's outcomes will be conducted and published at its completion.

Health portfolios will report on progress annually to the Australian Health Ministers' Conference and biennial whole of government progress reports will be prepared and published. Governments have acknowledged that they have failed in the past to make good on their commitments to Aboriginal and Torres Strait Islander peoples in relation to health service provision.

Governments intend this National Strategic Framework for Aboriginal and Torres Strait Islander Health to inspire confidence amongst Aboriginal and Torres Strait Islander communities, organisations and leaders that we recognise the broader context of health disadvantage amongst Aboriginal and Torres Strait Islander peoples and have a long-term and bipartisan commitment to working with them to address it.

In correspondence with my Office, the federal Department of Health and Ageing has noted the progress in developing implementation plans in the past year:. During the Department developed the Australian Government Implementation Plan against the National Strategic Framework for Aboriginal and Torres Strait Islander Health and worked with jurisdictions on a reporting framework for the Implementation Plans that of all jurisdictions will replace the existing Framework Agreement reporting and assist in streamlining reporting.

They also note progress in finalising the Health Performance Framework for monitoring and evaluation progress under the National Strategic Framework:. This Framework has been developed to provide the basis for quantitative measurement of the impact of the National Strategic Framework for Aboriginal and Torres Strait Islander Health.

It will replace the existing National Performance Indicators from and will provide the focus for improvements in Indigenous health data in the longer term. Tier 1 Health Outcomes includes measures of health conditions, life expectancy and mortality.

Tier 2, Determinants of Health includes measures of socioeconomic factors, environmental factors and risk factors that all have an influence on final health outcomes. Tier 3, Health System Performance measures the effectiveness, capability and sustainability of the health system in relation to Indigenous health. It measures inputs and intermediate outcomes of the health system such as antenatal care, immunisation, screening, management of chronic illness etc where there is clear evidence in the literature of a linkage between health system activity and health outcomes.

The Health Performance Framework measures the performance of the whole health system in relation to Aboriginal and Torres Strait Islander health. The new Health Performance Framework is consistent with the COAG principles for service delivery and incorporates the majority of the health related performance measures from the National Reporting Framework on Indigenous Disadvantage and extends these to cover health outcomes more broadly such as health conditions, mortality by leading causes and health system performance beyond the issue of accessibility.

Despite this extensive system of monitoring, the National Strategic Framework does not require the setting of timeframes within which to achieve the goal and aims set out in the Framework. Within this implementation plan each jurisdiction will be responsible for determining its own specific initiatives, priorities and timeframes. This National Strategic Framework sets agreed direction for reform in Aboriginal and Torres Strait Islander health without imposing specific targets or benchmarks on the Commonwealth, State and Territory governments in recognition of the different histories, circumstances and priorities of each jurisdiction.

Therefore, reporting will record progress in areas consistent with the action areas detailed in each key result area and against the stated aims and, over time, chart each government's progress against their own baselines.

The National Strategic Framework does, however, indicate in general terms the type of results that can be anticipated over the life of the Framework:.

Some results of the National Strategic Framework for Aboriginal and Torres Strait Islander Health will be seen in the shorter term, such as the provision of enhanced primary care services under the Primary Health Care Access Program, outcomes of environmental health surveys, and outcomes of existing workforce capacity building initiatives.

In the medium term, it will be important to assess the aims of the key result areas to ensure that important initiatives are being implemented, including changes to service delivery, enhanced community participation and increases in the numbers of Aboriginal and Torres Strait Islander health professionals.

Some impacts on health outcomes may be expected in the medium term, such as changes to the health care provided to infants and young children and reductions in communicable diseases as a result of improved health information and immunisation programs. However, some results will take longer to achieve. Change in health outcomes must be monitored and the aim of reducing incidence, prevalence and impact of these disorders kept firmly in mind.

It currently operates under a Memorandum of Understanding signed by all Australian Health Ministers in February , for the period A number of national strategies and commitments in relation to environmental health workers, housing and the supply of food have also been developed. An overview of these frameworks is provided in the Text Box below. All require governments to work with Aboriginal and Torres Strait Islander communities to plan and deliver aspects of health infrastructure. However, there is yet to be developed an overarching strategy to address health infrastructure needs in communities in an integrated fashion.

It sets out establishing collaborative approaches and partnerships to address housing, adequate safe water, food supplies and waste disposal as priorities.

Eat Well Australia is the national public health nutrition strategy developed under the auspices of the NPHP. The National Steering Committee is focusing on two of the key action areas: Workforce and Food Supply. The Commonwealth Government, with the States, helps to fund Indigenous-specific public housing provided through Indigenous Housing Organisations. However, they share common features:. Indigenous Housing to BBF strategy is designed to guide the planning activities of Indigenous Housing Authorities and a whole of government approach.

BBF also considers environmental health, self management of communities, Aboriginal and Torres Strait Islander communities as partners in service delivery and the investigation of other forms of housing tenure to community housing including public housing, mainstream community housing and home ownership.

Aboriginal and Torres Strait Islander people throughout Australia will have:. The COAG commitments noted above and the health sector specific processes underway for Aboriginal and Torres Strait Islander health exist alongside newly introduced arrangements for the administration of Indigenous affairs at the federal level.

These new arrangements are intended to ensure:. The new arrangements apply to all federal government activity, including the delivery of health programs and services. It is also anticipated that the states and territories will align their service delivery processes with the new arrangements. This is asserted based on the agreement of the National Framework of Principles for Government Service Delivery to Indigenous Australians and the negotiation of bilateral agreements on Indigenous affairs based on these principles.

There is already an extensive focus within the health sector on the type of issues that the new arrangements are grappling with.

For example, the Framework Agreements on Aboriginal and Torres Strait Islander Health in each state and territory establish processes for advancing policy development, planning and resource allocation in a coordinated manner at the inter-governmental level and in partnership with Aboriginal and Torres Strait Islander communities through community controlled health organisations. The National Strategic Framework for Aboriginal and Torres Strait Islander Health notes that while a responsive health system is fundamentally important, 'action in areas such as education, employment, transport and nutrition is also required if sustainable health gains are to be achieved'.

The health sector can contribute to action on the agendas of other portfolios through research, advocacy, partnerships and linkages. Comprehensive primary health care services provide the infrastructure, and the Framework Agreements the partnership arrangements for intersectoral collaboration between the health sector, members of Aboriginal and Torres Strait Islander communities, other government agencies, the private sector and voluntary organisations.

Achieving such integration has been a central challenge for the health sector over the past decade. As discussed above, the evaluation of the National Aboriginal Health Strategy found that one of the reasons for the failure of that strategy had been the lack of engagement with the strategy by portfolios other than health. The new arrangements provide the opportunity to sharpen the focus of service delivery so that it addresses those related issues that impact on Indigenous health and to do so within an integrated framework.

The potential of the new arrangements to address these issues has been acknowledged by the Department of Health and Ageing.

In correspondence with my Office, they note:. In light of the changed arrangements in Indigenous Affairs, ICCs Indigenous Coordination Centres now represent the key mechanism that Aboriginal communities can use to contribute to the whole of government health planning and priority setting. They also acknowledge the potential to better utilise the existing processes set up in accordance with the framework agreements on Aboriginal and Torres Strait Islander health with the states and territories and under the Primary Health Care Access Program PHCAP:.

Under PHCAP, regional planning arrangements provide an important mechanism for promoting effective working relationships with Indigenous communities through the activities of joint planning forums, local regional steering committees and planning consultants. These planning processes enable direct engagement with Indigenous communities in the identification of key health needs and planning priorities.

The momentum gained through the planning processes and structures needs to be maintained after regional plans are completed in order to capitalise on the benefits of continued community involvement. The regional plans developed to date include a broad examination of health needs - including analysis of the underlying determinants of health such as the quality and availability of housing, environment issues e.

Specific recommendations emerging from the regional planning process could prove useful in the inter-agency negotiations conducted through the ICCs. As at 30 June , the arrangements for aligning activities in the health sector with those of ICC's, and more generally under the new arrangements, were as follows:. The clear recognition from the Department of Health and Ageing of the central role of ICCs in coordinating federal government activity at the regional level is also welcomed.

I acknowledge that the efforts to build the capacity of the Department of Health and Ageing to fully participate in the new arrangements are at an early stage.

It is also acknowledged that further improvements in coordination of activity will most likely be built into the Framework Agreements on Aboriginal and Torres Strait Islander Health when they are next renegotiated between governments. It must be recognised, however, that the COAG Principles for government service delivery to Indigenous Australians already require governments to work together to better coordinate their service delivery and so, strictly speaking, the alignment of health service delivery with the new arrangements is not dependent on the re-negotiation of the framework agreements.

Overall, it is fair to say that the Department of Health and Ageing has not played a significant role in the roll-out of the new arrangements for the administration of Indigenous affairs to date. In particular, the Department does not as yet have a significant presence in Indigenous Coordination Centres and has limited capacity to influence the strategic directions underpinning engagement at the regional level and through agreement making processes such as SRAs.

Similarly, the new arrangements have not sought to build on the significant progress and experience of the health sector. At this early stage, the new arrangements are yet to:. As a consequence, there is a disconnect between existing programs relating to Aboriginal and Torres Strait Islander health and the whole of government approach adopted through the new arrangements. This is despite the clear inter-connections between the issues. Even though there is recognition by governments that Aboriginal and Torres Strait Islander health outcomes require a holistic response in order to achieve lasting and sustainable improvements, in most instances issues are still being addressed separately.

So what can we ascertain about the existing policy environment for addressing Aboriginal and Torres Strait Islander health inequality? First, there has been significant work completed over the past 3 years to reinvigorate the commitments of governments to address Aboriginal and Torres Strait Islander health inequality through the National Strategic Framework.

This commits governments to work in a holistic, whole of government manner and in partnership with Aboriginal and Torres Strait Islander peoples. Second, processes have been put into place to administer the National Strategic Framework and through which to achieve the Framework's goal and aims. This includes through the finalisation of bilateral health agreements between the Commonwealth and states and territories; the establishment of state level health forums; the development of regional plans which identify needs and priorities; and the establishment of a national performance monitoring framework.

The 'whole of government' machinery necessary to implement the commitments of COAG is in place. Third, there has been significant work to address many public health issues affecting Aboriginal and Torres Strait Islander peoples, notably commitments in place in relation to environmental health workers, food and housing.

There is, however, an absence of an overarching strategic response to public health issues notably health infrastructure faced by Aboriginal and Torres Strait Islander peoples. Fourth, the specific commitments to address Aboriginal and Torres Strait Islander health inequality have progressed parallel to the agreement by COAG of commitments and processes to address Aboriginal and Torres Strait Islander disadvantage more generally such as through the establishment of the Overcoming Indigenous Disadvantage reporting framework and the principles for service delivery to Aboriginal and Torres Strait Islander peoples.

The health specific and Aboriginal and Torres Strait Islander disadvantage commitments are being progressed in a consistent manner, and are mutually reinforcing. However, both processes could benefit from better coordination of activities, including through building on the achievements and structures that have been established in relation to health.

Fifth, the more established approach in the health sector has not played a significant role during the first twelve months of these new arrangements for the administration of service delivery at the federal level. There remains much potential to learn from the achievements and structures of the health sector, particularly through its engagement with Aboriginal and Torres Strait Islander communities and assessment of need on a regional basis.

The health sector could be more actively engaged in progressing the new arrangements. This would also clearly benefit efforts to address health issues that are impacted on through the activities of other departments. Finally, the current processes recognise the urgency of the need to address Aboriginal and Torres Strait Islander health inequality. There is acknowledgement that efforts to address this in the past, such as those undertaken in accordance with the NAHS from to , were insufficient.

There is now a more sophisticated basis for planning activities and monitoring progress than in the past. There is also no broader agenda for setting a timeframe within which to achieve equality in health status or to match funding contributions and activities to the achievement of this goal. Accordingly, the key issue for Aboriginal and Torres Strait Islander health remains the need to implement the extensive commitments of governments and to ensure that the quantum and pace of activities is sufficient to achieve the goal of addressing Aboriginal and Torres Strait Islander health inequality.

Human rights provide a framework for addressing the consequences the health inequality experienced by Aboriginal and Torres Strait Islander peoples. This includes recognising its underlying causes as well as the inter-connections with other issues. Human rights require more than a rhetorical acknowledgement of the existence of inequality and general commitments to overcome this situation at some unspecified time in the future. Ultimately, human rights standards provide a system to guide policy making and to influence the design, delivery and monitoring and evaluation of health programs and services.

It is a system for ensuring the accountability of governments. This section of the chapter outlines the human rights based approach to health. While issues relating to health and human rights have been of international concern since the establishment of the United Nations, 'the actual linkages between health and human rights had not been recognized even a decade ago.

In the last few years human rights have increasingly been at the centre of analysis and action in regard to health and development issues. There are three main issues at the international level which are drawn on in setting out a human rights based approach to health. These are the application to the right to health of over-arching principles of non-discrimination and progressive realisation ; the emergence in international practice of the connection between human rights standards and participatory development processes ; and the content of the right to health itself.

The non-discrimination principle outlined above in Article 2 2 applies to all human rights. It establishes a baseline position that all people are entitled to be treated equally and to be given equal opportunities. The progressive realisation principle as outlined in Article 2 1 gives meaning to this principle where such equality does not exist for a particular group defined by race, sex or range of other characteristics.

There are two key features to the obligation 'to take steps' in Article 2 1. First, it allows governments to introduce specific measures to addressing the lack of equality experienced by a particular group within society. This includes a group defined by race, such as Aboriginal and Torres Strait Islander peoples.

Each of the main human rights treaties contains a provision which encourages and indeed requires governments to redress inequality in the enjoyment of economic, social, cultural or civil and political rights.

These provisions are sometimes referred to as 'special measures' provisions. This is because they are aimed at achieving substantive equality or equality 'in fact' or outcome. The rationale for such measures is that 'historical patterns of racism entrench disadvantage and more than the prohibition of racial discrimination is required to overcome the resulting racial inequality'.

They cannot, therefore, lead to the maintenance of separate rights for different racial groups and are not to be continued after the objectives for which they were taken have been achieved. Second, the obligation 'to take steps' in Article 2 1 also means that governments must progressively achieve the full realisation of relevant rights and to do so without delay. Steps must be deliberate, concrete and targeted as clearly as possible towards meeting the obligations recognized in the Covenant.

The High Commissioner for Human Rights has described this principle and its relevance to policy-making as follows:. Since the realization of most human rights is at least partly constrained by the availability of scarce resources, and since this constraint cannot be eliminated overnight, the international human rights law explicitly allows for progressive realization of rights While the idea of progressive achievement is common to all approaches to policy-making, the distinctiveness of the human rights approach is that it imposes certain conditions on the behaviour of the State so that it cannot use progressive realization as an excuse for deferring or relaxing its efforts.

First, the State must take immediate action to fulfill any rights that are not seriously dependent on resource availability. Second, it must prioritize its fiscal operations so that resources can be diverted from relatively non-essential uses to those that are essential for the fulfillment of rights that are important for poverty reduction.

Third, to the extent that fulfillment of certain rights will have to be deferred, the State must develop, in a participatory manner, a time-bound plan of action for their progressive realization. The plan will include a set of intermediate as well as long-term targets, based on appropriate indicators, so that it is possible to monitor the success or failure of progressive realization. Finally, the State will be called to account if the monitoring process reveals less than full commitment on its part to realize the targets.

The idea of progressive realization has two major strategic implications. First, it allows for a time dimension in the strategy for human rights fulfillment by recognizing that the full realization of human rights may have to occur in a progressive manner over a period of time.

Second, it allows for setting priorities among different rights at any point in time since the constraint of resources may not permit a strategy to pursue all rights simultaneously with equal vigour. This approach requires that governments identify appropriate indicators, in relation to which they should set ambitious but achievable benchmarks, so that the rate of progress can be monitored and, if progress is slow, corrective action taken.

Setting benchmarks enables government and other parties to reach agreement about what rate of progress would be adequate. Such benchmarks should be:.

My predecessor as Social Justice Commissioner elaborated on this rights-based approach in the context of addressing Aboriginal and Torres Strait Islander disadvantage. In particular, he identified five integrated requirements that need to be met to incorporate a human rights approach into redressing Aboriginal and Torres Strait Islander disadvantage and to provide sufficient government accountability.

There have been a number of developments at the international level in recent years which have seen a clearer understanding emerge of the relationship between human rights and development and poverty eradication. Past Social Justice and Native Title Reports have highlighted this work - such as the extensive focus on human rights by the United Nations Development Programme, including through its annual Human Development Reports; increased focus on the right to development; and also through the drafting of guidelines on human rights and poverty eradication by the High Commissioner for Human Rights and the United Nations Development Programme.

These have emerged largely as a result of the objective set in by the Secretary-General of the United Nations, Mr Kofi Annan, to mainstream human rights into all United Nations activities. This has been reaffirmed through the Millennium Declaration of and the commitment of all countries to achieve the Millennium Development Goals MDG' s by The focus of the MDG' s is very much centred on developing nations. The usual context in which the involvement of countries like Australia is discussed is in relation to international aid, technical assistance and debt relief.

But the implications of this focus on poverty eradication clearly relate to the situation of Aboriginal and Torres Strait Islander peoples in Australia. It is ironic that the Government has committed to contribute to the international campaign to eradicate poverty in third world countries by , but has no similar plans to do so in relation to the extreme marginalisation experienced by Aboriginal and Torres Strait Islander Australians.

One of the most significant outcomes of this focus on integrating human rights and development and poverty eradication activities has been the agreement among the agencies of the United Nations of the Common Understanding of a Human-Rights Based Approach to Development Cooperation. This document outlines the human rights principles that are common to the policy and practice of the UN bodies. The Common Understanding states that these principles are intended to guide programming in relation to health, among other issues.

The Common Understanding also identifies the following elements that are 'necessary, specific, and unique to a human rights-based approach' to development Other elements of good programming practices that are also essential under a human rights based approach include that:. These principles provide useful guidance for incorporating participatory development principles into domestic policies and programs relating to Aboriginal and Torres Strait Islander health. A detailed overview of the content of this right is provided at Appendix 4 of this report.

The key elements of this right are set out in the following text box. It reflects the understanding of the progressive realisation principle and participatory development practice as set out above. Governments give sufficient recognition to the right to health in the national political and legal systems, preferably by way of legislative implementation, and to adopt a national health policy with a detailed plan for realising the right to health. They ensure provision of health care and equal access for all to the underlying determinants of health, such as nutritiously safe food and potable drinking water, basic sanitation and adequate housing and living conditions.

Governments also take positive measures that enable and assist individuals and communities to enjoy the right to health, and undertake actions that create, maintain and restore the health of the population. Indigenous peoples have the right to specific measures to improve their access to health services and care.

These health services should be culturally appropriate, taking into account traditional preventive care, healing practices and medicines. States should provide resources for Indigenous peoples to design, deliver and control such services so that they may enjoy the highest attainable standard of physical and mental health. The vital medicinal plants, animals and minerals necessary to the full enjoyment of health of Indigenous peoples should also be protected.

The Committee notes that, in Indigenous communities, the health of the individual is often linked to the health of the society as a whole and has a collective dimension While the right to health has been recognised for some time, it is only in recent years that detailed consideration has been given to it.

This framework therefore offers a relatively new perspective on the factors necessary to address health inequalities and ensure to all people the right to the enjoyment of the highest attainable standard of health. It is timely to consider the existing health frameworks for Aboriginal and Torres Strait Islander people within Australia against this perspective.

This is particularly so given the slow pace of progress that has been made in recent decades in reducing Aboriginal and Torres Strait Islander health inequality and the opportunities that currently exist to address these issues in a coordinated, whole of government manner. This section notes the strengths and deficiencies of the current framework for Aboriginal and Torres Strait Islander health from a human rights perspective.

The following section then proposes how the existing health framework should be enhanced in order to achieve the goal of Aboriginal and Torres Strait Islander health equality within a generation. There are two aspects of the current health situation faced by Aboriginal and Torres Strait Islander peoples in terms of human rights compliance.

The first is that the extent of health inequality experienced by Aboriginal and Torres Strait Islander peoples raises issues of compliance with Australia's human rights obligations.

Both the International Covenant on Economic, Social and Cultural Rights Article 12 and the International Convention on the Rights of the Child Article 24 recognise the right of all people to the enjoyment of the highest attainable standard of health. By entering into these treaties, the Government has guaranteed the exercise of this right without discrimination. The extent of inequality experienced by Aboriginal and Torres Strait Islander peoples indicates that they do not enjoy this and related rights in a non-discriminatory manner.

The size of the inequality gap indicates the need for urgent attention to this issue. This has been acknowledged by successive governments in Australia. In September , the United Nations Committee on the Rights of the Child expressed concern at the level of inequality experienced by Aboriginal and Torres Strait Islander children, particularly in relation to health related issues. The Committee's comments included the following:. Furthermore, the Committee, despite recent studies suggesting that Indigenous infant mortality has declined in the past years, remains concerned at the disparity in the health status between Indigenous and non-Indigenous children and at unequal access to health care experienced by children living in rural and remote areas.

The Committee recommends that the State Party undertake all necessary measures to ensure that all children enjoy the same access to and quality of health services, with special attention to children belonging to vulnerable groups, especially Indigenous children and children living in remote areas.

In addition, the Committee recommends that the State party take all adequate measures to overcome, in a time-bound manner, the disparity in the nutritional status between Indigenous and non-Indigenous children. The Committee remains concerned that youth suicide rate is still high, especially among Indigenous children and that mental health problems and substance abuse are increasing.

The Committee is concerned at recent reports showing that the number of Indigenous peoples diagnosed with AIDS has more than doubled in the past four years. Despite the numerous measures taken by the State party's authorities, including the Indigenous Child Care Support Programme, the Committee remains concerned about the overall situation of Indigenous Australians, especially as to their health, education, housing, employment and standard of living.

The Committee recommends that the State party strengthen its efforts to continue developing and implementing - in consultation with the Indigenous communities - policies and programmes ensuring equal access for Indigenous children to culturally appropriate services, including social and health services and education. While noting the improvement in the enjoyment, by the Indigenous peoples, of their economic, social and cultural rights, the Committee is concerned over the wide gap that still exists between the Indigenous peoples and others, in particular in the area of employment, housing, health, education and income.

The Committee recommends that the State party intensify its efforts in order to achieve equality in the enjoyment of rights and allocate adequate resources to programmes aimed at the eradication of disparities.

It recommends in particular that decisive steps be taken in order to ensure that a sufficient number of health professionals provide services to Indigenous peoples, and that the State party set up benchmarks for monitoring progress in key areas of Indigenous disadvantage. The second issue to consider in terms of human rights compliance receives less attention - namely, whether the current processes in place to address Aboriginal and Torres Strait Islander health inequality comply with the key elements of the human rights based approach to health.

The human rights based approach to health is practical in that it acknowledges that inequality and discrimination may be the result of long term, perhaps even historical, treatment and cannot be overcome in the short term.

While a rights based approach does not excuse such inequality, it is primarily focused on considering the steps that are currently being taken by governments to address this situation. Accordingly, it is focused on determining the suitability of the steps being taken.

For example, do the steps taken by government respect, protect and fulfil the right to the highest attainable standard of health for Aboriginal and Torres Strait Islander peoples? Are programs and services accessible, available, appropriate and of a sufficient quality? Do they involve the full participation of Aboriginal and Torres Strait Islander peoples?

Do they target the systemic barriers faced by Aboriginal and Torres Strait Islander peoples? It is also focused on determining the adequacy of the steps being taken. For example, are they meeting core minimum obligations? Are they resulting in a progressive improvement in the realisation of the right to health for Aboriginal and Torres Strait Islander peoples?

Is the rate of progress sufficient, given the extent of the inequality? Do data collection, performance monitoring and evaluation processes exist which enable progress to be monitored? Are programs targeted, delivered and financed at a level that is capable of addressing the level of inequality? From this perspective, there are a number of aspects of the current approach to Aboriginal and Torres Strait Islander health that do meet the requirements of the human rights based approach to health.

But there are also aspects of the current approach that do not meet these requirements. The strengths and weaknesses of the current framework are identified in the two boxes below. The following aspects of the existing framework for Aboriginal and Torres Strait Islander health are consistent with the requirements of the human rights based approach to health. Despite these positives, there remain a number of concerns about the adequacy of the current framework for addressing Aboriginal and Torres Strait Islander health inequality.

Many of these concerns relate to the need for the key features of the current framework, some of which are acknowledged as positive developments above, to be extended so that they are more comprehensive and better linked to overcoming existing levels of inequality. This finding relates to both their shares of national health spending and the structure of health expenditures. Indeed, there have been only small changes since the first report for However, health expenditure for both Indigenous and non-Indigenous people has risen substantially.

What this chapter shows is that significant opportunities currently exist to make lasting inroads into the longstanding problem of health inequality for Aboriginal and Torres Strait Islander peoples. There is significant capacity in the health sector which can be built on. The new arrangements for Indigenous affairs at the federal level and associated commitments of COAG also provide perhaps unprecedented leverage for coordinating health programs with other departments and agencies.

We need to acknowledge these foundations and encourage them to achieve better compliance with the human rights based approach.

If we do not do this, we are unlikely to see improvements in Aboriginal and Torres Strait Islander health status. In fact, it is possible that by not providing sufficient attention and resources the inequality gap currently experienced by Aboriginal and Torres Strait Islander peoples could widen further.

Perhaps the factor that is most striking, in its absence from the current framework, is the lack of a timeframe for achieving Aboriginal and Torres Strait Islander health equality.

The human rights treaty committees quoted above express their concerns about Australia's progress in addressing Aboriginal and Torres Strait Islander health inequality. Their concern lies in terms of the need for governments to take adequate measures including through the allocation of adequate resources to overcome, in a time-bound manner, the disparity in rights experienced by Aboriginal and Torres Strait Islander peoples.

We should not be timid about setting a timeframe for when the solid commitments of government will be realised. The absence of such timeframes promotes a lack of accountability of governments.

It sends a tacit message that it is fine for things to simply drift along. But it is not fine. We are facing an urgent and emerging health crisis and all aspects of government activity should reflect this. The failure of the policies and programs of the past twenty years to achieve significant improvements in Aboriginal and Torres Strait Islander health status, yet alone to reduce the inequality gap, reveal two things that Aboriginal and Torres Strait Islander peoples and the general community can no longer accept from governments.

First, we can no longer accept the making of commitments to address Aboriginal and Torres Strait Islander health inequality without putting into place processes and programs to match the stated commitments. Programs and service delivery must be adequately resourced and supported so that they are capable of achieving the stated goals of governments.

Second, and conversely, we can also not accept the failure of governments to commit to an urgent plan of action. It is not acceptable to continually state that the situation is tragic and ought to be treated with urgency, and then fail to put into place bold targets to focus policy making over the short, medium and longer term or to fund programs so they are capable of meeting these targets. A plan that is not adequately funded to meet its outcomes cannot be considered an effective plan.

The history of approaches to Aboriginal and Torres Strait Islander health reflects this: Australian governments have proved unwilling to fund Aboriginal and Torres Strait Islander health programs based on the need and, as a result, plans have failed. The following description of Australia's human rights obligations to fulfil the right to health identifies the key issue that we presently face:.

In determining whether an action or an omission amounts to a violation of the right to health, it is important to distinguish the inability from the unwillingness of a government to comply with its obligations. A government which is unwilling to use the maximum of its available resources for the realisation of the right to health is in violation of its obligations. If resource constraints render it impossible for a government to comply fully with its obligations, it has the burden of justifying that every effort has nevertheless been made to use all available resources at its disposal in order to satisfy, as a matter of priority, the obligations.

The processes for implementing them also exist. But can it be said that government efforts are operating at the maximum of available resources? It is not credible to suggest that government efforts are being held back by an 'inability' to take action. Such action does, of course, need to be linked to the capacity of the health sector. The progressive realisation principle, however, requires that this be done in a time bound manner and as expeditiously as possible.

Resourcing should be increased to the maximum extent possible and rolled out in accordance with regional plans and benchmarks. The combination of the healthy economic situation of the country, the substantial potential that currently exists in the health sector and the national leadership being shown through the COAG process, means that the current policy environment is ripe for achieving the longstanding goal of overcoming Aboriginal and Torres Strait Islander health inequality.

Steps taken now could be determinative. As set out in the introductory sections of this chapter, I consider that we need to commit to a campaign for Aboriginal and Torres Strait Islander health equality within a generation. This final section of this chapter sets out some of the necessary elements that I consider need to be addressed for this to be achieved.

It also sets out how my Office will seek to broaden public debate on this issue over the coming year. This goal can be met. And it can be done by building on the existing National Strategic Framework , through the commitments and processes of COAG and in accordance with the new arrangements for Indigenous affairs at the federal level.

At the beginning of this chapter I set out my first recommendation for addressing Aboriginal and Torres Strait Islander health inequality. It provides a long term vision to focus government activity. A focus solely on such a goal would be impractical and difficult. The Overcoming Indigenous Disadvantage Framework recognises that changes in indicators such as life expectancy cannot be expected within short timeframes or as a consequence of a single policy intervention. Accordingly, the Framework also identifies seven strategic areas for action and strategic change indicators, which are designed to show progress over the shorter term.

They also allow us to identify progress on individual areas which have a cumulative impact on the larger and longer term indicators like life expectancy.

A commitment to achieve equality in life expectancy within a generation is not meaningless or problematic. It does, however, require that such a target be supported with the establishment of other, more detailed targets and benchmarks on a number of discrete, smaller indicators relating to health status and which exist over the short and medium term. The Overcoming Indigenous Disadvantage Framework , as well as the Aboriginal and Torres Strait Islander Health Performance Framework provide an appropriate basis for establishing time bound targets and benchmarks in the short and medium term across a variety of contributing areas that should ultimately contribute to the achievement of equal rates of life expectancy.

Such targets and benchmarks also need to be developed at a regional level and with recognition of the variations in health status between communities. Additional work is required to ensure that data collection methods can support such disaggregation and account for regional variations. A selection of these are set out in Table 1 below.

They indicate the type of targets that could be aimed for, with appropriate commitments of resources and effort to match. In addition, broader commitments at the level of the Council of Australian Governments COAG to address Indigenous disadvantage can also be considered an address to Aboriginal and Torres Strait Islander health to the degree they address the social determinants of health. In terms of medium term targets to support a commitment to achieve equality within 25 years, there are two clear areas of need which must be addressed to render such a commitment realistic.

These are commitments to ensure equal access to primary health care services for Aboriginal and Torres Strait Islander peoples, and equal access to health infrastructure. It is a simple fact that Aboriginal and Torres Strait Islander peoples still do not enjoy the same opportunities to be healthy as non-Indigenous Australians, due to the lack of equal access to primary health care and infrastructure provision.

If we compare the health situation of Aboriginal and Torres Strait Islander peoples with other Australians, there is some evidence to suggest that Aboriginal and Torres Strait Islander peoples today enjoy a similar state of health as non-Indigenous Australians did almost a century ago.

For example, life expectation for Aboriginal and Torres Strait Islander males in was estimated to be the same as the total male population in , while for Aboriginal and Torres Strait Islander females it is similar to the total female population in ; Adelaide was recorded as having an infant mortality rate of deaths per 1, live births at the end of the nineteenth century , similar to Aboriginal and Torres Strait Islander peoples in the s and s; trachoma was common in the capital cities of the late nineteenth century, as it is in some Aboriginal and Torres Strait Islander communities today.

What happened over the twentieth century is that the non-Indigenous population gained opportunities to be healthy that were not extended to Aboriginal and Torres Strait Islander peoples. As a result, life expectancy for Australian women increased A commitment to achieve equality of health status and life expectation between Aboriginal and Torres Strait Islander and non-Indigenous people within 25 years therefore requires commitments to address inequality of opportunity for Aboriginal and Torres Strait Islander peoples.

Accordingly, governments should also commit to achieving equal access to primary health care and health infrastructure within 10 years for Aboriginal and Torres Strait Islander peoples. This will require improving processes to ensure needs based assessment of resource allocations, as well as targets and benchmarks across a range of matters. The Aboriginal and Torres Strait Islander Health Performance Framework contains appropriate measures for access to primary health care.

These include proxy indicators such as access to Medicare and the Pharmaceutical Benefits Scheme, rates of hospitalisation from preventable diseases, rates of Sexually Transmitted Infections and so on. Ready access to local primary health care PHC is the foundation of a functioning health system. Primary health care provides an immediate response to acute illness and injury; it protects good health through screening, early intervention, population health programs such as antenatal care and immunisation and programs to promote social and emotional wellbeing and prevent substance abuse.

Critically for the Indigenous population, primary health care identifies and treats chronic diseases including diabetes, cardiovascular and renal disease and their risk factors.

Primary health care also acts as a pathway to specialist and tertiary care, and enables local or regional identification and response to health hazards; transfer of knowledge and skills for healthy living; and identification and advocacy for the health needs of the community. However, it must be emphasised that while many communities have a primary health care service, the quality of that service may not be adequate.

It is vital that these services are high quality and integrated that is services in which health promotion, screening and treatment for various conditions are coordinated to achieve lasting change in the health status of Aboriginal and Torres Strait Islander peoples. The most recent review of the Aboriginal and Torres Strait Islander primary health care system argues that:.

The Global Burden of Disease Study GBD provides a comprehensive assessment of all-cause and cause-specific mortality for causes in countries and territories from to These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.

We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD and GBD Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing.

We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model CODEm generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies.

First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index SDI , a summary indicator derived from measures of income per capita, educational attainment, and fertility.

Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality.

Finally, we attributed changes in life expectancy to changes in cause of death. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence.

Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders.

Age-standardised death rates due to injuries significantly declined from to , yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause.

Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI.

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