Budget prophylaxis: the RACP pre-budget submission and Indigenous sexual health

The Royal Australian College of Physicians has released its pre-budget policy submission for the 2018-19 budget (link here). The RACP pre-budget submission includes sections on a range of key health issues including Indigenous health.

The May budget may appear to be over the horizon, but work will have already started within government on developing the budget. Agencies will have developed and costed proposals, Ministers will be sieving and choosing which proposals to take to the Expenditure Review Committee of Cabinet (ERC). The Department of Finance will shortly provide agencies and Ministers with various budget parameters and rules for considering the proposals. Cabinet may have set down the broad parameters within which proposals for new spending will be considered, including the levels of off-setting savings required for each proposal. And soon ERC will begin its more intensive rounds of meetings.

The bottom line is that there are no free lunches. Every program is vulnerable to be included on a Finance Department hit list of potential savings. Every budget proposal undergoes a process of multiple review and sieving, is critiqued by the Finance Department, and then more formally by ERC. To be successful, it needs to be rigorously developed, have identified offsetting savings, outshine competing claims from within the relevant agency, be supported by the relevant Minister, and then be supported by ERC which requires that it be aligned with the Government’s overarching budget and policy strategy.

The publication of pre-budget submissions by advocacy groups and peak bodies thus operate to raise the public profile of key issues, and can assist a minister in arguing for his or her new spending proposals by pointing to external support for particular initiatives. Unfortunately, too often these submissions come too late, or fail to be backed up with more intensive media follow-up by the authors. As a result, they can often be entirely ignored by government.

I thought I would use the release of this submission to draw attention to sexual health within the Indigenous community as a policy issue which demands greater attention and understanding both in the general community and within the Indigenous community. It is a topic I know very little about, but recognise as one which is of increasing significance and concern given the youthful demographic profile of the Indigenous population nationally.

The RACP pre-budget submission has this to say (footnotes excluded):

Sexual Health

There continue to be ongoing outbreaks of infectious syphilis across Australia affecting Aboriginal and Torres Strait Islander people, which has occurred in the context of increasing rates of other Sexually Transmitted Infections (STIs) and some Blood Borne Viruses (BBVs) in some Aboriginal and Torres Strait Islander communities. STIs are endemic in some regions; an unprecedented syphilis epidemic in Queensland began in 2011 and extended to the Northern Territory, Western Australia and South Australia.

Since 2011 there have been six fatalities in Northern Australia from congenital syphilis, and a further three babies are living with serious birth defects in the Northern Territory. In addition, there has been one reported case of congenital syphilis so far in 2017 in South Australia. Despite the existence of a number of Federal and state-level sexual health strategies, the situation remains dire.

Appropriate funding needs to be allocated to the implementation of the Fifth National Aboriginal and Torres Strait Islander Blood-Borne Viruses and Sexually Transmissible Infections Strategy and sexual health services; particularly to ensure sufficient capacity for the delivery of core STI/BBV services within models of care that provide comprehensive primary health care services (particularly Aboriginal and Torres Strait Islander community controlled health services). People should have access to specialist care when needed, through integration with comprehensive primary health care services to ensure sustainable and culturally appropriate service provision.

We welcome the plans to activate a short-term response across the state and territories on the continuing syphilis outbreaks, coordinated by the Federal Department of Health. However, whilst this Action Plan and short-term funding is urgently needed; the short-term activities need to be coordinated with and contribute to longer-term strategies and investments.

The RACP recommends [inter alia] that the Australian government:

• Allocate sufficient funding for the implementation of the Fifth National Aboriginal and Torres Strait Islander Blood-Borne Viruses (BBV) and Sexually Transmissible Infections (STI) Strategy.

• Fund the syphilis outbreak short-term action plan and coordinate this response with long term strategies.

 • Allocate long-term funding for primary health care and community- led sexual health programs to embed STI/BBV services as core primary health care (PHC) activity, and to ensure timely and culturally supported access to specialist care when needed, to achieve low rates of STIs and good sexual health care for all Australians.

• Invest in and support a long-term multi-disciplinary sexual health workforce and integrate with PHC to build longstanding trust with communities.

• Allocate funding for STI and HIV point of care testing (POCT) devices, the development of guidelines for POCT devices and Medicare funding for the use of POCT devices.

These recommendations appear sensible and quite modest, but also contain quite sobering information, which is made more concerning by the reality that the sexually active cohort of the Indigenous population is information poor. Yet with appropriate behaviour modification and/or treatment, most of these issues are or would be avoidable.

If I have a criticism of the RACP submission, it is that it provides no information on what the RACP would consider to be adequate funding for the various actions and initiatives it is proposing. There is a sense in which the RACP has abdicated the issue of funding adequacy to the government, and decided to focus solely on identifying issues which require prioritisation. I understand this as a pragmatic strategy, but remain sceptical that funding adequacy can be a victim of political rhetoric and spin.

Nevertheless, the RACP has done the public a service in identifying the health priorities it has. Their submission includes a range of other Indigenous related issues, as well as a larger number of mainstream health issues (many of which are highly relevant to Indigenous citizens’ health too). I recommend readers have a quick look at the RACP submission.

My suggestion is that it would be useful if post-budget, the RACP released a short assessment of the Government’s budget decisions in the health area along with a checklist of the RACP proposals and the relevant amounts allocated by the Government. I will try to have a closer look at this policy issue in future posts.

Finally I wish to acknowledge the NACCHO website for pointing me to the RACP pre-budget submission (link here).