Volume 10 Issue 1
Peer reviewed article
The complex interaction of behavioural risk factors, historical events, and social determinants of health, compounded by barriers to accesses for health services, have been recognized as the causes of gaps in Indigenous health. The relatively poor health status of Indigenous communities demands integration of conventional medicine with local perspectives and cultural values. This article puts forth perspectives of students from different health related disciplines for resolving problems of access to healthcare for Indigenous Australians. It is hoped that the accounts in this article will serve as a starting point for dialogue on the institution of multidisciplinary healthcare teams.
Indigenous health represents one example of community-based practice which demands for a marriage between conventional medicine and an appreciation of local perspectives and cultural values. Medical professionals should appreciate that the increasing levels of complexity means that help from experts from different industries could be fruitful. Hence, one solution is to create a multidisciplinary team comprised of people with medical and other expertise to tailor specific and sustainable solutions towards certain health issues. Multidisciplinary teams have been known to increase the levels of innovation as well as improving implementation in the scopes of knowledge, skills, and abilities.  The Royal Australian College of General Practitioners (RACGP) recognises that multi- disciplinary care is highly crucial to improve the primary healthcare services for Australians as it helps General Practitioners (GPs) to provide “continuous, close, and respectful therapeutic relationships with patients.” [2, p. 454] How- ever, according to the World Health Organization, the definition of multidisciplinary practice extends beyond the patients themselves. They explained the concept as the provision of the highest quality of care by working together with the patients, families, caregivers, and the surrounding communities.  The institution of multidisciplinary teams in healthcare practices has raised numerous questions regarding its efficacy, which is measured by patient satis- faction as well as the hospital admission and re-admission rates for those hospitalized at home. [4,5] The following will present Indigenous health access as a sample case study of how multidisciplinary teams can be utilized to generate some recommendations for the local communities.
The Aboriginal and Torres Strait Islander population, which makes up 3% of the total Australian population,  has been faced with numerous inequalities over the years, especially in the healthcare sector. Recent surveys show that the median age of Indigenous Australians is 21 years, which is 16 years less than the median age of non-Indigenous Australians.  Their life expectancy is also lower by 10 years as compared with non-Indigenous population. Furthermore, the low socioeconomic status of many Indigenous individuals increases their likelihood of engaging in practices that can elevate their risks of major health complications. The Australian Institute of Health and Welfare (AIHW) stated that Indigenous Australians are twice as likely to be daily smokers and 50% more likely than non-Indigenous population to drink alcohol at chronic high risk levels, which are two risk factors that predispose to cardio- vascular diseases, chronic kidney disease, and type 2 diabetes.  Despite the widespread passion for “Closing the Gap” advocated by the Australian government, the discrepancies in the health outcomes between Indigenous and non-Indigenous communities remain, which means that more work is needed in the area. 
Various studies illustrate the under representation of Indigenous people across the three tiers of Australian Healthcare System, [9-10] which encompasses preventative medicine, primary accesses represented by GP consultations, and accesses to hospital-based and further treatments. As an example, on the preventative side, the immunisation coverage of Indigenous children in 2009 aged 5 years (78.2%) was lower than that of their non-Indigenous counterparts (82.7%). [7,11] In terms of hospital access, 26% of Indigenous Australians aged 15 years and over are faced with difficulties in accessing these services due to their rural and remote residence.  Multiple factors, such as financial, linguistic, and cultural barriers also give rise to challenges in accessing primary health services as simple as GP consultations. [12-13]
These problems can be considered to be stemming from the differences between Indigenous communities and non-Indigenous health practitioners, especially in terms of cultural values and opinions of a good healthcare system. As an example, health workers and policy makers tend to focus on improving physical environment and the healthcare system, put- ting aside the issues of trust and respect, which are paramount for Indigenous patients.  It is hard not to consider how the historical and intergenerational trauma of the Half-Caste Act, and other historical Government policies, has contributed to Indigenous people’s dis- trust in health and welfare services.  Racial discrimination in policies, institutional structures and social networks has led many Indigenous people to live in closed, isolated communities. [16-17] Even after the National Apology of 2008 and affirmative actions to promote Indigenous health, many Indigenous Australians are being ‘caught between two worlds’ as they live with ambivalent identities. [18-19]
The complex interaction of behavioural risk factors, historical events, and social determinants of health, compounded by barriers to accesses for health services have been recognized as the cause of gaps in Indigenous health.  Together these issues raise the integral question of how can different perspectives from different disciplines be integrated to improve Indigenous health access? This article presents the various problems related to Indigenous people’s ac- cess to primary health care services. It builds on perspectives of students from different disciplines and considers an institution of multidisciplinary healthcare teams as an effective option for collaborative approach to problem solving. It is hoped that the following accounts from students of medicine, molecular biology, social work and business will enrich readers’ thinking about the various approaches to understanding and dealing with problems experienced by Indigenous people.
Problems of Healthcare Access – A Medical Perspective
For most Australians, primary and community health services represent the frontline of the health care system and are provided by GPs and allied health professionals. General practice services serve as a direct measure of access to primary care.  According to the Bettering the Evaluation and Care of Health (BEACH) survey over five-year period from 2001 to 2006, only 1.5% of total GP consultations were with Indigenous patients, even though they account for 2.5% of the total population as of 30 June 2006. In addition, a comparison study con- ducted in the Townsville Aboriginal Community Controlled Health Services (ACCHS) sector has showed GP cases in Indigenous population are more complicated and challenging compared to mainstream general practice. On average, 1.65 problems were managed per consultation in ACCHS, whereas 1.45 problems needed to be managed in mainstream GP. 
It is proposed that language and cultural differences have been the main barriers limiting Indigenous people’s access to GP services. [12-13] In 2008, 11% of the Indigenous Australians who spoke a non-English language at home had reported difficulty communicating with English speakers. This rate was markedly increased among older Indigenous people (aged 55 and over), which makes up 24% of the Indigenous population. 
Additionally, cultural barriers remain a prominent issue in relation to access to healthcare. Indigenous and non-Indigenous Australians hold different perspectives of health and wellbeing.  A research study found that non-Indigenous health workers believed that improving the physical environments and the healthcare system would be the most effective ways of breaking the cultural barrier. However, Indigenous Australians consider sincere and open interpersonal relationships that are based on trust and respect to be crucial in medical practice  This study concluded non-Indigenous doctors and Indigenous Australians hold very different opinions about health care and many doctors were misguided when it came to how to provide culturally appropriate health care for Indigenous patients. Fortunately, we now have more Indigenous people joining the health care profession  and they are a critical source in demonstrating to non-Indigenous health staff culturally appropriate practices.
One possible solution to address this issue of cultural differences is early in doctors’ during medical training. Medical schools should integrate this issue into their curriculums and implement Indigenous rotations to give medicals students more exposure to Indigenous health care. In fact, in 2004 the Committee of Deans of Australian Medical Schools (CDAMS) developed an Indigenous Health Curriculum Framework with the purpose to provide medical schools with guidelines for how to successfully implement and deliver indigenous health content in medical education. Specific strategies include recruiting more Indigenous people as medical educators; inviting Indigenous guest speakers; integrating Indigenous elements into case-supported learning (CSL) or problem-based learning (PBL) and community visits. 
In addition, continued education post-medical schools are equally essential. There are now a considerable amount of workshops and conferences pertinent to Indigenous health available to health professionals, given by organisations such as National Aboriginal Community Con- trolled Health Organisation (NACCHO).  Practising doctors should be encouraged and motivated to regularly attend these conferences that serve as a reminder on how to provide the best care for Indigenous population, as well as keeping them well-informed on the latest trends in Indigenous health care.
Over the past decades, through the employment of more Indigenous health workers and culturally competent non-Indigenous staff, health promotion campaigns specifically tailored for Indigenous Australians, and increased utilisation of interpreter services,  we are finally “closing the gap” in terms of GP service usage. In 2009-10, the number of GP services reimbursed by Medicare was similar between Indigenous and non-Indigenous populations (approximately 5,630 and 5,550 per 1000 population, respectively).  Nonetheless, this is only the tip of the iceberg. Indigenous Australians are still doing poorly in other sectors of the healthcare spectrum such as preventive and hospitalised care. The road ahead is still full of obstacles.
From empirical data to solutions: A molecular biology perspective
Even though Australia is a pioneer in molecular diagnostics and drug development technologies, there has been a grave paucity of such studies or ventures tailored to Indigenous Australians. This deficiency is particularly exacerbated in the case of genetic studies,  mainly due to Indigenous communities finding a lack of benefit and fearing risk of further persecution based on their genetic background, particularly in insurances. One such case was seen in New Zealand with the ‘warrior gene’ fiasco of 2006, which led to an unintended racial discrimination against the Maori community by media incorrectly labeling them as aggressive and prone to risk-taking.  Such debacles can how- ever be evaded by implementation of culturally sensitive ethical frameworks and protocols as recommended by Kowal et al.,  which can help adapt medical researches to benefit Indigenous Australians.
In addition, research focus and investments should be targeted towards the factors that can impact Indigenous health access and outcomes. For example, recent research has suggested that Indigenous people with mixed ancestry see increased incidence of rheumatoid arthritis as compared to persons with strictly non-Aboriginal ancestry.  In addition, a recent and record first genomic study of Indigenous people also reported a genetic risk for high body-mass index and type 2 diabetes in Indigenous communities.  The knowledge of such risk factors and trends in public health can be used to design specific treatment, as exemplified by Anderson et al.,  by discovery of specific genes found in affected individuals whose genomes they sequence. Each of these studies when combined together can be used to form short-term and long-term treatment goals by clinicians and associated organizations.
Problems of Healthcare Access – A Social Work Perspective
In terms of primary health services, it has been shown that racial discrimination plays a crucial role in hindering Indigenous people from med- ical consultations as 22% of them reported racism from health providers. [17,29] Hence, there is a need for healthcare providers to establish trust with Indigenous communities at different levels in the Australian healthcare system, which can be done by respecting their social values. As an example, medical and allied health professionals must appreciate Indigenous peoples’ strong association to land, [30-33] extended family/kinship networks and affiliation to local languages that collectively form important aspects of their identities. [32- 33]
Social work practice rests upon the multi- dimensional approach that appreciates the interactive nature between an individual and various aspects of their environments, such as psychological, spiritual, social, and cultural.  In addition, social work practice also encapsulates commitment to values of respect and social justice, which mandates the recognition of historic and racial disadvantages that can adversely affect behaviours, social determinants, access to health care services and health status of Indigenous populations.  For medical practices, social workers can facilitate groups engaging in critical reflection to encourage realisation of personal and culturally constructed biases, [36-38] which is deemed to prompt empathetic practice and modification of service protocols to address Indigenous needs.
The multiple identities of different generations of Indigenous people calls for working in partnership with them so that they can be included in defining their problems as well as identifying and instituting solutions. [20,34-35] Roles and responsibilities in teams are defined by legal and ethical boundaries, but they are highly influenced by social norms and situational realities.  Social workers can contribute by encouraging mutual aid in teams and driving efforts towards affirmative action for Indigenous communities.
Strategic Use of Indigenous Health Funding: A Financial Perspective
In 2008-2009, healthcare expenditure for the Indigenous population was 1.39 times higher than that for non-Indigenous people. However, high prevalence of certain health problems and geographical challenges raise questions as to whether more spending is required along with the need for a more strategic use of Indigenous health funding to improve health services and accesses for Indigenous Australians.  Professor Geoffrey Dobb, the Vice President of Australian Medical Association (AMA), high- lighted that it is now the responsibility of all the governments and health service providers to strategically target funding to ensure that Indigenous people get the access to the right health service in the right place at the right time. 
Decisions made by both the funders and the providers should be based on returns from investments, including individual and community health gain, equity, as well as the incorporation of cultural security, which is defined as “the delivery of health services of such a quality that no one person is afforded a less favour- able outcome simply because they hold a different cultural outlook”. [43, p.45] Moreover, to improve the priority setting process by the funders and the providers, there is a need to make use of better evidence and data, especially economic evaluations. It has been suggested that more education on the credibility of economic evaluation by training staff in health economics would improve the use of economic evaluation evidence. 
Contracts in the context of Indigenous health provision is defined as the arrangements which specifies the services or other activities the government funders are obtaining on the behalf of the community, including the amount of funding, reporting and other accountability required. The currently applied funding and accountability arrangements have been particularly criticised for being excessively fragmented and complex, especially in terms of administrative and reporting requirements.  The contracts should accommodate uncertainties, such as the possibility of sudden changes in service demand, while maintaining care quality and continuity. As opposed to the old-fashioned classical contracting, relational contracting recognises the contractor-supplier interdependence, and is characterised by greater flexibility and cooperation, as well as reliance on trust and mutual accountability. This approach can potentially reduce administrative costs and improve healthcare performance.  So far, the reformation progress from classical contracting to relational contracting has been slow, and it is also still too early to assess on outcomes. But on a positive note, the provision of community governance and delivery on the basis of negotiation and agreed standards represents an important milestone towards an authentic partnership approach between communities and governments. Moreover, it also opens the possibility of a better integration of healthcare provision by both the community-controlled sector and the mainstream health system in a more practical sense, rather than simply in the form of high policy principles. 
Access to primary healthcare for Indigenous Australians presents a complex problem and to yield sustainable and effective solutions, each of the factors contributing to the problems have to be considered by seeking advice from experts in different industries. The four accounts from different postgraduate students in medicine, molecular biology, social work and business, addressed a portion of the problem surrounding Indigenous healthcare access. However, it high- lights the varying perspectives and approaches that exist which are outside the scope of practice for medical practitioners. For example, it is important to acknowledge the roles of social worker in taking care of the patients’ wellbeing post-treatment and ensuring that they have the access to various supporting facilities crucial to their treatment. The roles of financiers and accountants are also important in providing financial access as well as creating cost-effective solutions that can be easily adjusted for different circumstances. Lastly, molecular biology represents an important part of science towards the health industry for specific targeted treatments that can be provided to patients quickly by knowing their underlying genetic predispositions, hence saving costs and time.
Access to primary healthcare for Indigenous Australians presents just one of the many health challenges that calls for experts from different industries to collaborate and formulate sustain- able solutions. This collaboration has the potential to create avenues for greater learning, re- flections, and knowledge transfer, and ultimately lead to better health outcomes for patients. We hope that the above accounts from students of different disciplines could be a starting point to appreciate the importance in integrating a multidisciplinary team in tackling ongoing local and global health problems.
Ayesha Aziz, Hadrian Pranjoto, Mingkun Guan, Nicolas Adrianto Soputro & Rahul Vivek Rane
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