Increasing opportunities for Aboriginal and Torres Strait Islander people to undertake tertiary education in health disciplines and strengthening the quality of education in relation to Aboriginal and Torres Strait Islander health is vital, although there are many challenges in the way of achieving increased participation by Aboriginal and Torres Strait Islander young people, including family and financial barriers, and the attraction presented by trade-related occupations, particularly in the mining sector.
The 2012 Community Services and Health Industry Skills Council Environmental Scan highlights leadership, mentoring, prevocational training, vocational training and work experience as crucial in providing an appropriate Aboriginal and Torres Strait Islander health workforce and developing an appropriate broader health workforce to address Aboriginal and Torres Strait Islander health.122
Commonwealth health-related scholarships
Funding scholarships with a health-related focus is one way the Commonwealth encourages Aboriginal and Torres Strait Islander people to pursue a career in a health-related discipline. DoHA funds a range of scholarship programs targeting specific workforce needs.
Various submissions to the review indicated that there would be value in greater promotion of scholarships to students, raising awareness that Aboriginal and Torres Strait Islander people also have access to additional scholarship programs in the health-related disciplines. The Commonwealth health-related scholarships are more fully described in Chapter 3, but there are three scholarship programs dedicated to Aboriginal and Torres Strait Islander people studying in health, outlined below.
Puggy Hunter Memorial Scholarship Scheme (multidisciplinary)
The Puggy Hunter Memorial Scholarship Scheme provides scholarships to Aboriginal and Torres Strait Islander people who are undertaking study in a health-related discipline at Certificate IV level, undergraduate level or above. The scheme aims to address the under-representation of Aboriginal and Torres Strait Islander people in the health professions. In 2012, 155 scholarships were awarded as part of this scheme.
Australian Rotary Health Indigenous Health Scholarships Program
The Australian Rotary Health Indigenous Health Scholarships Program is a relatively small scheme in comparison to other Indigenous scholarship schemes. It provides scholarships to Aboriginal and Torres Strait Islander students in all health-related disciplines. Fifty per cent of the scholarship funding is provided by a local Rotary Club with Governments (Commonwealth or state and territory) contributing the remaining funding. Scholarship recipients also receive mentoring and other support by the different Rotary Clubs around Australia. In 2012, DoHA funding contributed to 40 scholarships.
Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme
The Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme aims to improve access to community pharmacy services by Aboriginal and Torres Strait Islander people by taking account of cultural issues in meeting health needs. The aim is to encourage Aboriginal and Torres Strait Islander students to undertake entry level studies at a university. Scholarships are offered preferentially to students who currently live, or have lived, in a rural or remote community.
Aboriginal and Torres Strait Islander undergraduate students
The Rural Clinical Training and Support (RCTS) and the University Departments of Rural Health (UDRH) programs have specific objectives in place to encourage and support Aboriginal and Torres Strait Islander people in pursuing a health or medical career (refer to Chapter 4).
While these existing initiatives are beneficial, many stakeholders have argued that given the demographics of the Aboriginal and Torres Strait Islander population, described above, it is inappropriate to include objectives and activity areas for health education and training for Aboriginal and Torres Strait Islander people as a subset of designated university “rural” training programs. Instead, these stakeholders have suggested that a separately funded program should be created targeting:
- higher student enrolments;
- curriculum development and evaluation;
- placements for students in Aboriginal and Torres Strait Islander health settings; and
- mentoring and support services to increase the number of Aboriginal and Torres Strait Islander students graduating from health courses.
Evidence supplied by the Australian Indigenous Doctors’ Association (AIDA) supports the view that while efforts to increase enrolments of Aboriginal and Torres Strait Islander medical students have met with increasing success in recent years, this will not necessarily translate into substantial increases in the number of new graduates. AIDA and some other Aboriginal and Torres Strait Islander health workforce stakeholders argue that universities need to enhance their focus on student support, both academically and in terms of cultural safety and personal support, to ensure that the trend in increasing medical school enrolments is matched by growth in graduates in coming years, and that Government programs need to support this by introducing mandatory targets for universities.
Figure 5.1 below, provided by AIDA (using data from Medical Deans Australia and New Zealand (MDANZ)) illustrates this situation.
Figure 5.1: Aboriginal and Torres Strait Islander medical student and graduate numbersD
This review’s consultation process identified the importance of mentoring mechanisms for Aboriginal and Torres Strait Islander health students undertaking tertiary education. Mentoring and support programs can significantly contribute to the recruitment and retention of Aboriginal and Torres Strait Islander students studying health-related disciplines. Consultations identified that mentoring and support programs need to occur along the entire educational pathway and continue into the workforce. The Indigenous Transitions Pathway(ITP) is an example of a support program which mentors Aboriginal and Torres Strait Islander students through their medical studies. It should be noted however that the ITP was developed specifically to support the NT Medical Program, which differs from other medical school programs and which operates within the particular geographic and other challenges of the Northern Territory.
Other support programs directed at Aboriginal and Torres Strait Islander health courses (including medical) currently in place in Australian universities should also be considered in terms of effectiveness and efficiencies. These models should be considered along with the ITP model. For example, the University of Western Sydney and James Cook University can claim success with less intensive models than the ITP.
If the ITP model is found to be effective and cost-effective, consideration should be given to applying the lessons from this program to other health disciplines, not only in rural and remote locations but also universities located in major cities
Indigenous Allied Health Australia (IAHA), the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) and the National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA) also administer programs around mentoring and support which focus on their respective health workforce members however these programs do have resource constraints.
Culturally appropriate curricula
Currently there is no standardised approach to incorporating Aboriginal and Torres Strait Islander health competencies as part of curricula in Australian universities. In many cases, it is left up to individual universities to incorporate these competencies into their programs. The attention given to Aboriginal and Torres Strait Islander health and cultural awareness appears to be variable between institutions. Developing Aboriginal and Torres Strait Islander health competencies and cultural competencies has the potential to improve the integration of Aboriginal and Torres Strait Islander health into health training.
This may assist Aboriginal and Torres Strait Islander people to access health services and improve health outcomes. Incorporating cultural understanding as part of health education and training programs was one of the key issues raised in consultations as part of the review.
Aboriginal and Torres Strait Islander health and cultural education should also be part of the ongoing training of all health practitioners in their formalised continuing professional development, not only in rural and remote areas but also in urban areas.
The Australian Nursing and Midwifery Accreditation Council (ANMAC) is one organisation which moved to strengthen Aboriginal and Torres Strait Islander health components within accreditation standards and criteria, having recently revised the standards and criteria for the accreditation of Australian nursing and midwifery courses. The revised standards and criteria have strengthened the requirement for undergraduate curricula to address Aboriginal and Torres Strait Islander health and culturally safe care by including a criterion that curricula must include a discrete subject specifically addressing Aboriginal and Torres Strait Islander peoples’ history, health, wellness and culture. While this is a valuable improvement, it will also be important to ensure that this component of nurse training is adequately assessed in the accreditation process.
Student targets for universities
As with curriculum development, there are no standardised Aboriginal and Torres Strait Islander health student targets in Australian universities. Currently, it is up to the individual universities to set their Aboriginal and Torres Strait Islander student admissions. Setting or incentivising targets would lead to growth in the Aboriginal and Torres Strait Islander health workforce more quickly, allow progress to be more easily measured, and increase accountability for outcomes.
A consultation process should be undertaken with Aboriginal and Torres Strait Islander peak bodies and other relevant stakeholders to consider appropriate Aboriginal and Torres Strait Islander student targets. It is important to take into account the capacity of jurisdictions and universities to provide education opportunities for Aboriginal and Torres Strait Islander people in different demographic areas.
This consultation process should also include a review to determine how faculties of health science in Australian universities are incorporating Aboriginal and Torres Strait Islander health into the curricula of health-related disciplines. It would be beneficial for the findings of such a review to report to an advisory/guidance group consisting of representatives from DoHA, the Department of Education, Employment and Workplace Relations (DEEWR), the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA), and the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education (DIICCSRTE), the Australian Health Practitioner Regulation Agency, Deans and Colleges. An advisory/guidance group focusing on Aboriginal and Torres Strait Islander health education would allow better collaboration.
It is essential that DoHA (across all divisions) engage with and work more closely with DEEWR, FaHCSIA and DIICCSRTE. This is consistent with research, undertaken by the Lowitja Institute, of the funding arrangements for Aboriginal community-controlled registered training organisations.
Amongst other findings, the researchers recommended that responsibility for core funding for registered training organisations should be allocated to a single funding agency, noting that DIICCSRTE and DEEWR is the logical ‘funding home’ for the sector.123 Closer collaboration within DoHA and other Government portfolios is also recommended by the Battye Review (the Battye Review is discussed in the final part of this Chapter).
Funding for Aboriginal and Torres Strait Islander health education
As identified above, supporting specific Aboriginal and Torres Strait Islander mentoring and support programs, student targets and standardised culturally appropriate curricula should be a central component of the Commonwealth’s Aboriginal and Torres Strait Islander health education and health workforce policy development. Currently there are various programs across the Health portfolio and other Commonwealth agencies which incorporate some of these elements into the program design.
For example, the Indigenous Chronic Disease Package (ICDP) has a workforce expansion and support component, with an aim of encouraging Aboriginal and Torres Strait Islander secondary students to pursue a career in health and to encourage health professionals to work in Aboriginal and Torres Strait Islander health. There are also mainstream programs and initiatives which have an Aboriginal and Torres Strait Islander health component linked to it, such as the RCTS program.
Increasing the enrolment of Aboriginal and Torres Strait Islander health students and more importantly, the number of new graduates, will in turn increase the Aboriginal and Torres Strait Islander health workforce. For this to be achieved, the Commonwealth should consider developing and implementing a new dedicated funding allocation to a more targeted health workforce program. Alternatively, there may be an opportunity to expand the workforce and support component of the ICDP, provided this can be re-designed with specific targets and enhanced activity areas.
In any case, a new funding allocation or an expansion to an existing program should also focus on the development and inclusion of culturally appropriate curricula into all health-related disciplines. This will complement the increase of the Aboriginal Torres Strait Islander health workforce by providing the current and future health workforce with increased understanding of how to deliver culturally safe and appropriate care.
A National Aboriginal and Torres Strait Islander Health Education approach would directly complement a key priority of the HWF by increasing the capacity of the Aboriginal and Torres Strait Islander health workforce and better equipping the broader health workforce to address the needs of Indigenous people.124
Currently, there are disparities between universities in their performance under the Aboriginal and Torres Strait Islander Health target of the RCTS program. Some universities focus more of their attention in this area as they have a larger cohort of Aboriginal and Torres Strait Islander people and/or potential student pool. If a new program model is introduced it is important to ensure that this does not disrupt the activities of those universities currently producing good outcomes. Potential redirection of funding in this way will also provide greater incentives for those universities to ensure a stronger focus on Aboriginal and Torres Strait Islander health education.
Any new program model should also complement the current activities of the ICDP. For example, ‘Health Heroes’ is an advertising campaign that commenced in 2011 to encourage Aboriginal and Torres Strait Islander secondary students to pursue a career in health and to encourage health professionals to work in Aboriginal and Torres Strait Islander health. It is important not to duplicate but rather expand on these existing activities. Further consultation between HWD and OATSIH is vital to the success of any new program or expansion of an existing program.
The cost of a new national program could be partially offset if a portion of the RCTS program was redirected and an individual program model focusing on increasing opportunities for Aboriginal and Torres Strait Islander students, as well as providing all health students with a comprehensive understanding of Aboriginal and Torres Strait Islander health issues was implemented. However, careful consideration would need to be given to the implications a redirection of funding would have on key stakeholders.
It is also important that a national program extends to all tertiary health professional courses (as opposed to medicine only). Program targets should have key performance indicators, such as percentage of students commencing and graduating that are of Aboriginal and Torres Strait Islander background relative to the Aboriginal and Torres Strait Islander population at either a national or geographic regional level. Implementing a new program across all health disciplines could not be fully funded by the redirection of RCTS funds alone, and would require additional support.
Possible mechanisms to achieve the program outcomes should be further explored including options for delivery of support to students such as virtual online resources and/or support units with physical office locations. Extending the Aboriginal and Torres Strait Islander support units which are currently in place in various universities should be considered rather than duplicating current efforts. Support units will need to vary from location to location, taking into account the service delivery environment and, where appropriate, encouraging collaborative regional support hubs. These regional support hubs should incorporate partnerships between universities.
As the RCTS program is a rural-focused initiative, any funding that is redirected to create a new funding stream should also have a rural parameter attached to it and reflect particular needs of Aboriginal and Torres Strait Islander populations in regional and remote locations. Inclusion of a rural parameter would ensure that a rural focus is maintained, whilst creating a broader Aboriginal and Torres Strait Islander health education and training initiative.
This will be important to ensure that valuable rurally focused Aboriginal and Torres Strait Islander health activities currently supported by the RCTS program can continue, noting that the health needs of rural and urban population groups differ. The proposed new funding stream should also include core performance indicators which may vary from location to location.
Consultation with key stakeholders to determine appropriate Aboriginal and Torres Strait Islander targets for any redirection of funding should be undertaken. Consultations should consider student intake targets for various health disciplines, curricula development and expanding Aboriginal and Torres Strait Islander academic positions.
Placements – cultural education
Incorporating later-year elective placements in Aboriginal and Torres Strait Islander communities appears to be an effective way to increase non–Aboriginal and Torres Strait Islander students’ ability to provide culturally safe care, provided students are well prepared in terms of cultural knowledge and have well-supported access to clinical training. Box 5.4 illustrates how the Commonwealth is allocating funding to support general practice training placements in Aboriginal Medical Services (AMSs) and Aboriginal Community Controlled Health Services.
Funding for the IHT is important given the significant role general practice plays in primary health care for Aboriginal and Torres Strait Islander people. Not only does the IHT increase the health workforce in AMSs, it also provides essential cultural educational training for medical practitioners. As mentioned earlier in this chapter, increasing health practitioners’ education and training in cultural aspects can assist in breaking down current barriers that impact on Aboriginal and Torres Strait Islander people accessing primary health care services. The training and education gained by the participating medical practitioner can be transferred to providing better informed health care to Aboriginal and Torres Strait Islander people in other general practice settings.
Aboriginal and Torres Strait Islander leadership is recognised internationally as a key factor in the development and sustainability of programs aimed at increasing Aboriginal and Torres Strait Islander workforce capacity, and influencing the non–Aboriginal and Torres Strait Islander health workforce to provide culturally safe and appropriate services. Aboriginal and Torres Strait Islander leadership is also relevant in guiding tertiary education for Aboriginal and Torres Strait Islander students and developing health courses that integrate Aboriginal and Torres Strait Islander health competencies.
Leadership support is provided through the Leaders in Indigenous Medical Education (LIME) Network of medical educators. The network seeks to support members in the delivery of quality Aboriginal and Torres Strait Islander health content within medical curricula and to encourage Aboriginal and Torres Strait Islander students to take up medical education. The LIME network and AIDA have been successful in working collaboratively with all medical schools to implement student support mechanisms and integrate Aboriginal and Torres Strait Islander health into the curriculum of medical and health science schools. However, AIDA has expressed the view that there needs to be better coordination between medical schools to decrease curricular variability. This is where leadership can play an important role.
To better support Aboriginal and Torres Strait Islander health education, the LIME network could adopt a more multidisciplinary approach and provide support to non-medical Aboriginal and Torres Strait Islander health students. This would require the current funding allocations to the LIME network to be reconfigured and potentially expanded. If this option is pursued by the Commonwealth it would be important to label the network accordingly to reflect its representation.
Alternatively, the activities of the LIME network could be adopted by other networks in their specified health discipline. This approach may be more appropriate as the LIME network is not a single body rather a network of students and educators located within each medical school with the aim of supporting students and enhancing the learning environment. The benefits and costs of either extending the LIME network or replicating it for the other health disciplines should be discussed with key stakeholders.
Aboriginal and Torres Strait Islander academic leaders/champions in all universities could also provide more of a focus on issues within health-related studies and help to provide advice to Government. However, this approach should be carefully considered as stakeholders have reported that it is difficult to fill Aboriginal and Torres Strait Islander academic positions in Australian universities. Consideration of the activities of the ‘Health Heroes’ (mentioned above) and the LIME network regarding Aboriginal and Torres Strait Islander leadership and knowledge should be explored as it is important to build on rather than duplicate current efforts.
Supporting education and training of nurses and midwives
DoHA supports a range of peak Aboriginal and Torres Strait Islander bodies to support and mentor Aboriginal and Torres Strait Islander health professionals, including the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN).
Nurses make up the greatest percentage of the health workforce; 40–50% globally and 55% in Australia125 126 As identified under the discussion regarding medical students (above), mentoring, culturally appropriate curricula, student targets and leadership are key underpinnings to building the Aboriginal and Torres Strait Islander nursing and midwifery workforce. In 2008 a review Blueprint for Action: Pathways to the health workforce for Aboriginal and Torres Strait Islander people (the Pathways Paper) was undertaken seeking to explore linkages between education and the health workforce. The Pathways Paper also underpins the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2011–15 and subsequently, jurisdictional and Aboriginal and Torres Strait Islander community‑controlled sector implementation plans. Key recommendations within the Pathways Paper include:
- The need to provide training in career guidance to Aboriginal and Torres Strait Islander education workers and roles to supplement those of existing careers advisors;
- Education institutions and Aboriginal and Torres Strait Islander health personnel and communities should work in partnership to develop a culturally‑inclusive Aboriginal and Torres Strait Islander health curriculum in a multidisciplinary manner; and
- Tertiary education providers should consult with Aboriginal and Torres Strait Islander communities on a whole-of-institution strategy to increase the number of Aboriginal and Torres Strait Islander students in health courses. Strategies should include student support and curriculum matters.127
In 2011, seed funding to establish a Leaders in Indigenous Nursing and Midwifery Education Network was approved to build on the Battye Review recommendations and the Pathways Paper. However, this approach has not proven feasible or practical, apparently due to the vast array of nursing education providers covering higher and vocational education systems and public and private providers.
An alternative avenue to enhancing nursing and midwifery education and support could be to enhance the role of CATSIN and existing established nursing peak bodies, by funding an Aboriginal and Torres Strait Islander Nursing and Midwifery Policy Adviser position within one of the nursing peak bodies. A policy adviser would inform the development of policy, policy analysis and organisational representation on Aboriginal and Torres Strait Islander nursing and related matters.
Establishing a dedicated policy adviser position in one of the peak nursing organisations would increase coordination and leadership, and raise the profile of Aboriginal and Torres Strait Islander health issues within nursing.
The policy adviser would consult and work with relevant organisations including, but not limited to, CATSIN, the Australian College of Nursing (ACN), the Australian College of Midwives (ACM) and the Australian College of Mental Health Nurses (ACMHN). A submission received as part of this review outlined key strategies, based on research findings with an aim of increasing the enrolment and graduation of Aboriginal and Torres Strait Islander people in university nursing courses.128 The strategies highlighted in the submission are supported in the discussion of this chapter and should also be considered not only for nursing but for all health-related disciplines.
Funding to Aboriginal and Torres Strait Islander health professional organisations and networks is vital to promote health careers, and for mentoring and supporting students throughout their studies. In addition to the funding provided through the Aboriginal and Torres Strait Islander Training Package (outlined below), HWD provides funding each year to a number of health workforce bodies to support a variety of operational activities of organisations.
Some of these organisations provide support through advocacy and/or program delivery. An example of this support is the Basic Emergency Care for Aboriginal and Torres Strait Islander Health Worker courses administered by the Council of Remote Area Nurses Australia (CRANAplus). (Refer to the stakeholder funding section in Chapter 9 for further information on this program.)
Commonwealth investment in Aboriginal and Torres Strait Islander health peak organisations is valuable. To increase the effectiveness of activities in this area, it may be worth considering one-off capital assistance for several of these agencies to co-locate to enable them to share administrative resources and enhance collaboration.
There may also be some merit in obtaining a current snapshot of funding provided to these agencies across DoHA and other Commonwealth agencies to reduce the potential for multiple contracts and funding agreements.
The Commonwealth should continue to encourage peak Aboriginal and Torres Strait Islander health education and workforce bodies to take a collaborative approach to their forums rather than continuing to run separate events.
The Commonwealth should also continue to consult with the National Congress of Australia’s First People’s National Health Leadership Forum (NHLF), which is the collective and consultative forum of peak Aboriginal and Torres Strait Islander health workforce bodies. A nationwide consultation with communities is now being undertaken by the NHLF, with the draft National Aboriginal and Torres Strait Islander Health Plan and recommendations due at the end of April. As consultations to date are understood to have raised numerous workforce development issues it will be important to keep faith with these communities and integrate ongoing implementation of strategies identified by those consultations (when accepted by government) with the implementation of recommendations arising from this review.
Engagement between the NHLF and cross-jurisdictional health workforce groups such as the Health Workforce Principal Committee could also be beneficial.
Without cutting across the role and work of the NHLF, to keep the momentum of implementation of operational initiatives, there may be merit in establishing a regular working group akin to those operating through the Coalition of National Nursing Organisations.
A greater focus should be placed on the interconnectedness within the education pathway, including secondary school education, VET training and university courses. Improving the number of Aboriginal and Torres Strait Islander people in the Australian health workforce requires collaboration across the entire education pathway. It is important to develop strategies for collaboration with key stakeholders involved in both the university and VET sectors to address the low participation rates of Aboriginal and Torres Strait Islander people in health-related disciplines.
Vocational education and training
The majority of Aboriginal and Torres Strait Islander health students are enrolled and complete their studies through the VET sector. It is therefore important to take into account the courses delivered and applicable students in the VET sector when considering Aboriginal and Torres Strait Islander leadership, mentoring, culturally appropriate curricula and student targets.
DoHA has a limited formal relationship with the VET sector. Nevertheless, it is a sector of enormous importance if the development of the Aboriginal and Torres Strait Islander health workforce is to be progressed. The most common health-related courses for Aboriginal and Torres Strait Islander VET students in 2010 were public health, followed by nursing. The lowest number of courses studied in the VET sector by Aboriginal and Torres Strait Islander people were pharmacy, optical sciences, dental and complementary therapies.129
Career pathways in health, from high school, through to the VET sector, and the need to enhance the support for these students, are consistent themes promoted by the peak bodies. This is of particular interest and recognised in reports such as the Review of Higher Education Access and Outcomes for Aboriginal and Torres Strait Islander People.130 Figure 5.2 below illustrates the financial arrangements and complexity of the VET sector and how it relates to the Aboriginal and Torres Strait Islander health workforce.
Figure 5.2: Financial arrangements and complexity of the VET sector and Aboriginal and Torres Strait Islander Health workforceD
122 Community Services and Health Industry Skills Council, Environmental Scan, CS&HIC, 2012, p. 8
123 A Martini., U Marlina, J. Dwyer, J. Lavoie, K. O’Donnell, & P. Sullivan, Aboriginal Community Controlled Health Service Funding: Report to the Sector 2011, The Lowitja Institute, Melbourne, 2011.
124 Department of Health and Ageing, Flexible Fund Guidelines – Health Workforce Fund, April 2012.
125 Productivity Commission, Australia’s Health Workforce, Research Report, Canberra,2006.
126 World Health Organization, The World Health Report 2006 - working together for health, WHO, 2006
127 National Aboriginal and Torres Strait Islander and Health Council, Blueprint for Action: Pathways to the health workforce for Aboriginal and Torres Strait Islander people, 2008
128 Roianne West, Indigenous registered nurses and midwives leading Australia’s health workforce in Closing the Gap, Submission to the Independent Review of Australian Government Health Workforce Programs, 2012.
128 Australian Health Ministers’ Advisory Council (AHMAC), Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report, AHMAC, Canberra, 2012
130 L. Behrendt, S. Larkin, R. Griew & P. Kelly, Review of Higher Education Access and Outcomes for Aboriginal and Torres Strait Islander People: Final Report, report to the Minister for Tertiary Education, Skills, Science and Research, Canberra, 2012.