The Australian Indigenous Doctors’ Association
Yaga Bugaul Dungun
PO BOX 3497 MANUKA ACT
Ph: 02 6273 5013  Fax: 02 6273 5014
Email: aida@aida.org.au         Website: www.aida.org.au

   
SUBMISSION TO THE PRODUCTIVITY COMMISSION 
HEALTH WORKFORCE STUDY BY THE AUSTRALIAN INDIGENOUS DOCTORS’ ASSOCIATION

1. The Australian Indigenous Doctors Association
 
The Australian Indigenous Doctors’ Association (AIDA) is a not for profit organisation dedicated to the pursuit of leadership, partnership and scholarship in Aboriginal and Torres Strait Islander health, education and workforce. AIDA provides collegiate and professional support to Aboriginal and Torres Strait Islander medical graduates and undergraduates and maintains strong working partnerships with Australian medical schools, medical colleges and key health and education organisations. 
 
AIDA is also a key member of a number of national health or workforce bodies including the:
 
•	Aboriginal and Torres Strait Islander Health Workforce Working Group (ATSIHWWG);
•	Australian Medical Workforce Advisory Council (AMWAC), and;
•	National Aboriginal and Torres Strait Islander Health Council 
(NATSIHC). 
 
In October 2005, AIDA launched the landmark report Healthy Futures: Defining best practice in the recruitment and retention of Indigenous medical students. AIDA has also been a key driver of the CDAMS Indigenous Health Curriculum Framework.
 
As the leading organisation for Aboriginal and Torres Strait Islander medical workforce issues, AIDA is in a central and decisive position to provide comment on Australia’s Health Workforce Productivity Commission Position Paper, September 2005, and submit other relevant information.  
AIDA strongly believes that the Australian health system must respond fully and appropriately to the continuing poor state of health and address the needs of Aboriginal and Torres Strait Islander people.
 
While wider social and economic determinants are significant factors, workforce capacity is able to have major impacts on health improvement of Aboriginal and Torres Strait Islander people. The development and attainment of a highly competent workforce has two dimensions:

•	a skilled and culturally safe Indigenous health workforce (both Indigenous and non-Indigenous); and

•	increased numbers of Aboriginal and Torres Strait Islander people in health - Indigenous doctors, nurses, health administrators, health workers and other allied health professionals.
 
Reform is required at both macro and micro health systems levels to address recruitment, support and retention of the Indigenous health workforce. 

AIDA is strongly of the view that broad health workforce changes occurring in Australia can be led by Indigenous models and practice. Undergraduate health sciences and medical training can learn a lot from Indigenous ways. For example: the need for curriculum and teaching to be much more responsive to contemporary health needs and current health policy and strategy, rather than based on traditional training models of care.
 
Areas where Indigenous models can be applied that are reflective of the need to respond to workforce shortage include: multidisciplinary undergraduate training and multidisciplinary care teams, such as those developed in the Aboriginal Controlled Community Health Services (ACCHS). New innovations to respond to the health workforce shortage (such as Physician Assistants) need to include  training in Indigenous health and cultural respect and safety to ensure the highest quality care is provided to Indigenous people.
 
Population health and public health approaches to undergraduate training have increasing relevance to Indigenous models of health service delivery, as well as to mainstream services. Chronic disease management in undergraduate health curriculum needs to be developed to include a major emphasis on Indigenous populations.
 
As rural and remote health workforce issues impact significantly on Indigenous  communities and people in these settings, this needs to be better recognised in rural and remote health policy. However, this must not happen at the expense of a concurrent focus on the health of Indigenous people living in urban environments. 

 
2. Improving Indigenous health will require multi-faceted responses 
 
As noted in the position paper ‘improved educational attainment is … likely to encourage increased Indigenous participation in the health workforce – itself a contributor to better health outcomes. As well as being readily accessible and able to provide culturally sensitive care, Indigenous health workers typically play an important role in health care matters within their communities.’[i]
 
The implications of increasing the Indigenous medical and health workforce are much broader than simple health service delivery gains. The recruitment, training and graduation of Indigenous health professionals addresses many of the social and economic determinants of health. Achievement in education and successful attainment of health qualifications leads to employment – a transition from welfare to participating in the real economy. 
 
In particular, the health (as well as the education) sector is a significant employer of Indigenous peoples and may be the major employer in smaller Aboriginal and Torres Strait Islander communities.  Accelerating the achievement of these positive outcomes must be a major focus of all governments. At the Australian Government level this scenario supports each of The Ministerial Taskforce on Indigenous Affairs’ priorities  – early childhood development, safer communities and overcoming welfare dependency. 
 
2.1 Indigenous doctors
 
The positive effects of Indigenous doctors for Indigenous peoples physical, emotional and cultural wellbeing have long been recognised by government and 
other Indigenous and non-Indigenous stakeholders. These may include Indigenous 
doctors’: 
 
•	ability to empathise with Indigenous patients and their strong have a good understanding of the social/cultural context (i.e., knowing enough to ask the right questions, the priorities of patients and extended family obligations);
 
•	knowing family groups and having patients know who your “mob” is … often allows much more personal flow of information (i.e., trust that you now what they are talking about when they speak about family/culture issues); 

•	being seen as leaders and significant advocates by community, which puts them in a position to influence change within the health system;

•	ability to interpret western medicine into Indigenous understanding, so patients have better understanding of management;
 
•	ability to bring “Indigenous “ understanding and concepts of health to enrich the medical community/profession, including holistic concepts and 
spiritual attributes of health; and
 
•	Fulfilling the acting role of mentors and role models for our children.
 
However, as noted in the AIDA Healthy Futures report, some Indigenous doctors may feel pressured to pursue careers in Indigenous health. In this respect, a wider and more sophisticated appreciation of the value of Indigenous doctors needs to be encouraged, highlighting their value as role models, mentors and leaders in their community as well as their highly skilled, holistic and unique contribution to medicine in a range of areas. 

2.2 Indigenous medical workforce shortage
 
According the Australian Institute of Health and Welfare (2003) there were 80 Indigenous doctors compared to 40,095 non-Indigenous doctors in Australia in 2001 (AIHW, 2001 Census). Indigenous doctors account for .02% of the Indigenous population in comparison to non-Indigenous doctors who account for 21% of the non-Indigenous population.[ii] This indicates that:
 
•	twelve times the current number of Indigenous doctors are needed; and
•	there is a current shortfall of 968 Indigenous doctors in Australia 
 
The Australian Medical Association (AMA) 2004 Discussion Paper Healing Hands: Aboriginal and Torres Strait Islander Workforce Requirements states that:
 
… to improve the health of Aboriginal and Torres Strait Islanders it is critical to increase the proportional representation of this group employed within the general health workforce. To increase the proportion of Aboriginal peoples and Torres Strait Islanders working as health professionals to non-Indigenous levels 928 doctors … need to be trained.[iii]
 
Although the figures quoted are based on equal representation in the health 
workforce, there is possible validity in basing figures on the “morbidity and 
mortality” data for indigenous Australians which would give a higher figure. 

2.3 Indigenous medical education
 
Despite the need for more Indigenous doctors, only 102 Indigenous students were enrolled in medicine in 2003 (Department of Education Science and Training 2003). Furthermore, data from the Healthy Futures surveys (2004/05) indicates there has been no growth in Indigenous medical student enrolments in the past two years.[iv] 
 
Reasons for the under representation of Indigenous students in medicine are complex and include prior educational disadvantage, racism and discrimination and lack of Indigenous content in the medical curriculum. As stated in the Healthy Futures (2005) report: 
 
Sixty seven percent of Indigenous student support workers emphasised the importance of engaging with primary and secondary school students regularly and in a number of different ways
 
Sixty six percent of Indigenous medical students surveyed for [the Healthy 
Futures report] said that they experienced racism and discrimination
 
Almost all Indigenous medical students surveyed in [the Healthy Futures]  
project were disappointed with the lack of Indigenous content in the medical curriculum and the inappropriateness of that content

3. What health workforce-specific directions look most promising? 
 
A number of innovative strategies that ‘facilitate greater Indigenous participation in the health workforce through changes to training delivery, career pathways and remuneration structures’ and ‘enhance service quality through greater emphasis on culturally appropriate models and methods’[v] have recently been developed by AIDA and the Committee of Deans of Medical Schools (CDAMS). These are the:
 
•	AIDA Healthy Futures: Defining best practice in the recruitment and 
retention of Indigenous medical students framework, and;
•	CDAMS Indigenous Health Curriculum Framework.
 
The implementation of these frameworks is critical to increasing the number of Indigenous as well as culturally competent and non-Indigenous doctors working in Indigenous in the health workforce. 
 
However, while organisations such as AIDA can promote health sciences and medical careers for young Indigenous children and young people, commitment from the health and education systems and sectors is critical. Upholding their primary responsibilities for improving outcomes for our children must be taken seriously.  
 
An example of a useful model includes the Indigenous Adolescents in Medicine program - supported by AIDA and an ACCHS in Queensland - has lacked ongoing support from the education sector. This has led to under resourcing of an innovative model for health workforce recruitment.
 
3.1 CDAMS Indigenous Health Curriculum Framework
 
The CDAMS Indigenous Health Curriculum Framework provides medical schools with a set of guidelines for success in developing and delivering Indigenous health content in core medical education. The framework identifies ten principles with rationales, principles, strategies, examples and cautions for the implementation of Indigenous health content in to the medical curriculum. See Attachment A for the full framework. 
 
Comprehensive implementation of the framework by the medical schools requires significant resourcing to increase both the numbers and capacity of Indigenous medical academics and support structures for Indigenous students. Indeed, the development of an appropriate Indigenous medical academic workforce is critical to the implementation of the CDAMS framework.
 
Undergraduate Indigenous health training is well suited for students learning to work in a multidisciplinary team. However, the coordination of medicine, nursing, Indigenous health workers and allied health students studying together can be challenging and resource intensive. Further support and development of undergraduate training is needed to ensure students have learning opportunities 
in the ‘real world’ of health and medicine.
 
Consideration of the capacity of Aboriginal and Torres Strait Islander community based training organisations who regularly take on medical and health sciences students such as at ACCHS’s is also needed. Innovative models of Indigenous medical and health training include “Teaching Primary  Health Care Centres”, where there is an academic unit or staff is based at the ACCHO  to take on the teaching role for both the university and the ACCHO.   

3.2  AIDA Healthy Futures Report
 
The Healthy Futures: Defining best practice in the recruitment and retention of 
Indigenous medical students report provides a framework for Australian medical 
schools, governments and principal stakeholders to improve recruitment and 
retention strategies for Indigenous medical students. Three headline targets to 
be achieved by 2010 are also identified. See Attachment B for the full report 
and framework.
 
3.2.1 Framework
 
The Healthy Futures Framework provides a foundation for individual institutional 
responses that are locally relevant, flexible and action oriented. The successful implementation of this frameworks will clearly require additional and adequate resourcing. The framework is made up of five principles: 
 
Principle 1: All Australian medical schools have a social responsibility to articulate and implement their commitment to improving Indigenous health and education.
 
(This will require real financial and broader commitment by both medical schools 
and government, and collaboration by both) 
 
Principle 2: Make the recruitment and retention of Indigenous medical students a priority for all staff and students and show leadership to the wider university community.
 
(Effective recruitment requires the education sector to articulate with the health sector and prioritise health sciences as a career choice)
 
Principle 3: Ensure cultural safety and value and engage Indigenous Peoples in medical school business
 
Principle 4: Principal stakeholders adopt strategies, initiate and coordinate partnerships that open pathways to medicine from early childhood through to specialty practice/vocational training
 
Principle 5: Ensure all strategies for Indigenous medical student recruitment and retention are comprehensive, long term, sustainable, well resourced, integrative and evaluated

3.2.2 Headline Targets 

To begin to increase the number of Indigenous doctors to levels comparative to the non-Indigenous workforce, the Australian Indigenous Doctors Association state that by 2010 the following headline targets must be achieved:

Headline targets 
By 2010:

•	Australian medical schools will have established specific pathways into 
medicine for Indigenous Australians

•	CDAMS Indigenous Health Curriculum Framework will be fully implemented by Australian medical schools

•	There will be 350 extra Indigenous students enrolled in medicine

4. Wider scopes of practice and greater recognition of prior learning … and greater remuneration arrangements.
 
4.1 Postgraduate Indigenous health curriculum
 
Post graduate medical training needs to be more comprehensive and strategic at both post graduate (post graduate year one and post graduate year two) training levels and within the Colleges training programs. These need to be integrated vertically with the CDAMS Aboriginal and Torres Strait Islander undergraduate curriculum and be consistent with CDAMS (a good example is the Royal Australian College of Physicians Indigenous health curriculum)
 
Many of the specialist Colleges have approached AIDA for support to increase their Indigenous health curriculum. While our current capacity to address this is limited, AIDA is committed to having a central advisory role in this curriculum development.
 
International Medical Graduates (IMG) are a necessary part of our Australian workforce at present but have little consistent training in dealing with Indigenous people. Many IMGs work within  Indigenous communities as area of need placements. AIDA believes there needs to be a nationally accredited cultural training package for IMGs before they work in Aboriginal and Torres Strait Islander communities. 
 
4.2  Sub-specialty in Indigenous health
 
As noted by the Department of Health and Ageing in their submission to the Productivity Commission Health Workforce Study (August 2005) ‘there is a need to improve the attraction of practice in Indigenous health … many practitioners believe that they will receive less remuneration and become professionally isolated.’  

The development of a sub-specialty in Indigenous health for general practitioners and physicians, which is supported by the appropriate medical colleges, would provide added incentive and recognition to Indigenous and non-Indigenous doctors committed to Indigenous health. It would ensure that practitioners working in Indigenous health were appropriately acknowledged for their unique and specialised skills. Furthermore, it would ensure that practitioners intending to work with Indigenous populations receive adequate and appropriate training in Indigenous clinical, population health and cultural issues. 
 
This addresses the major issue of supporting and retaining the Indigenous health medical workforce and retaining this workforce (which is mainly non Indigenous doctors.) A  Medicare rebate attached to this sub specialty would help to redress the under-utilisation of Medicare by Indigenous people and the general under financing of Indigenous health.

5. General comments 
 
 5.1 Public health
 
A key area for improving in Indigenous health is via developing an effective public health trained workforce- this would include ensuring that there is comprehensive core Indigenous health curriculum in all MPH courses and in public health physician training in Australia.  The Public Health Education and Research Program must retain Indigenous health as a policy and funding priority. 
 
5.2 Scholarships
 
The provision of scholarships as an incentive to increase the recruitment of Indigenous people into postgraduate training such as public health and research. A successful example of this is in New Zealand, where public health scholarships are offered to increase Maori participation in this field. 

[i] Productivity Commission 2005, Australia’s Health Workforce, Position Paper 
(Canberra).(pp191)
[ii] Australian Institute of Health and Welfare Catalogue HWL 19, 1996 Census 
Data from: Health and Community Services Labour Force 1996. Table 9.
[iii] Australian Medical Association, Healing Hands: Aboriginal and Torres 
Strait Islander Workforce Requirements, Discussion Paper, Canberra: Aboriginal 
and Torres Strait Islander health 2004.
[iv] Minniecon, D & Kong, K, Healthy Futures: Defining Best Practice in the 
Recruitment and Retention of Indigenous Medical Students, Themeda
[v] Productivity Commission 2005, Australia’s Health Workforce, Position Paper 
(Canberra) .(pp193)