If not now, when? Implementation failure of a rights- and value-based policy agenda for Aboriginal and Torres Strait Islander health

Aboriginal and Torres Strait Islander people sustain the oldest living culture on the planet. Yet our health is in a state of emergency. Health targets are not on track – our people die early from communicable and non-communicable diseases; they are not partners in their health; health systems do not meet needs; provide seamless patient journeys or quality patient-valued safe care. The Australian Charter of Healthcare Rights¹ espouses rights only a few Aboriginal and Torres Strait Islander people enjoy – access, safety, respect, communication, participation, privacy and comment. Despite health being a fundamental human right, Australia continues down the path of paternalism that breaches human rights standards. Ongoing experiences of racism, both personal and structural, have measurable negative impacts on our health. It is no secret that Australia lags behind other high-income nations in meeting the ‘minimum standards for the survival, dignity and well-being’ of Aboriginal and Torres Strait Islander Australians.²

This health crisis exists alongside policy and strategic intent developed to specifically meet the needs of Aboriginal and Torres Strait Islander people. From the landmark 1989 National Aboriginal Health Strategy to the Aboriginal and Torres Strait Islander Health Framework Agreements (1996–99), the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003–13, the National Aboriginal and Torres Strait Islander Health Plan 2013–23, the Cultural Respect Framework 2016–26, the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan, through to our most recent National Aboriginal and Torres Strait Islander Health Plan 2021–31 one finds long-term evidence of strategic direction but implementation failure. Our principles, values and philosophies are reflected historically and contemporaneously in our health policies and strategies. The current refreshed Health Plan emphasises quality care and the social and cultural determinants of health, takes a rights-based approach and considers the health effects of racism. It follows on from the bold vision of its previous iteration which envisions that:

The Australian health system is free of racism and inequality and all Aboriginal and Torres Strait Islander people have access to health services that are effective, high quality, appropriate and affordable. Together with strategies to address social inequalities and determinants of health, this provides the necessary platform to realise health equality by 2031 (p. 7).³

The key difference between the two Plans is that all levels of government are accountable for its implementation and ensuring progress on priorities and objectives. Yet, we still hear consistent stories of system fragmentation, racism, discrimination, access issues, lack of prevention and early intervention programs, health education, and poor-quality and inappropriate care. We will not meet the 2031 targets. We need substantial multilevel systemic reform, genuine investment and commitment to change in how the government develops and implements policy and does business with Aboriginal and Torres Strait Islander Australians. Reform opportunities exist in the National Agreement on Closing the Gap 2020.⁴ All Governments are signatories to four priority reform areas:

1. Formal partnerships and shared decision-making

2. Building the community-controlled sector

3. Transforming government organisations, and

4. Shared access to data and information at a regional level.⁴

Many people are putting their aspirations for real change in the Governments’ commitment. Many are sceptical. A dear friend repeatedly asks, ‘If you knew the end of a story, would you still want to hear it?’ Policy across generations has done little to change our life circumstances and health. We are but 1 million people. Yet successive governments fail us, and we live with untended consequences of policy failure.

The National Agreement goes part way, but a different investment is needed. Inconsistencies between intent and implementation characterise our health policies over time. Implementation fidelity is critical to successfully translating policy into practice; ‘policies do not succeed or fail on their own merits’ (p. 1).⁵ Overly optimistic expectations, implementation in dispersed governance, inadequate collaborative policymaking, and the vagaries of the political cycle characterise persistent policy failure (p. 2).⁵ Improving success means:

1. Comprehensive preparation – better policy design and understanding of the practicalities of implementation

2. Policy tracking – a central unit to monitor progress on policy implementation

3. Implementation support – managing and regulating, problem-solving and capacity building

4. Post-implementation review – evaluating policy objectives (pp. 5–10).⁵

Aboriginal and Torres Strait Islander issues have never been more overtly political, visible and open to reform. Governments are interested in the essential capabilities and preconditions for policy implementation to strengthen future performance; it is one of the primary responsibilities of government entities.⁶ We have unprecedented political commitment and a Referendum on an Indigenous Voice to Parliament looming late in 2023. The policy window is wide open.⁷ Can we get it right? If not now, when?