Showing posts with label AIHW. Show all posts
Showing posts with label AIHW. Show all posts

Friday, 21 May 2021

Maintaining our gaze: the ongoing Indigenous child protection crisis

 


Men's eyes were made to look, and let them gaze…

Romeo and Juliet, Act 3, scene 1

 

This week the AIHW released the report Child Protection Australia 2019-20 (link here).  Attached are a series of selective quotes from the report reporting extraordinary rates of over-representation of Indigenous children within the system. I have omitted the relevant graphs which accompany these quotes.

 

The number of children in out-of-home care rose by 7% between 30 June 2017 and 30 June 2020 (from 43,100 to 46,000). During this time the rate of children in out-of-home was relatively steady at 8 per 1,000 children.

Indigenous children continue to be over-represented among children receiving child protection services, including for substantiated child abuse and neglect, children on care and protection orders and children in out-of-home care.

…14,300 Indigenous children were the subject of a substantiation in 2019–20. The most common type of substantiated abuse for Indigenous children was emotional abuse (47%) followed by neglect (32%)…

1 in 18 Indigenous children (around 18,900) were in out-of-home care at 30 June 2020, almost two-thirds (63%) of whom were living with relatives, kin or other Indigenous caregivers. [page vi].

 

Of the children in long-term out-of-home care, 2 in 5 (42%) were Indigenous [page vi].

 

In 2019–20, 55,300 Aboriginal and Torres Strait Islander children received child protection services, a rate of 166 per 1,000 Indigenous children. This was almost 8 times the rate for non-Indigenous children (21 per 1,000 non-Indigenous children) [page 14].

 

The number of Indigenous children receiving child protection services rose between 2016–17 and 2019–20, from 49,200 to 55,300. This was reflected in the rate, which rose from 151 to 166 per 1,000 Indigenous children in the same period. For non-Indigenous children the rates declined slightly from 22 to 21 per 1,000 children, with minor fluctuations during the period [page 16].

 

Children from geographically remote areas had the highest rates of substantiations—children from Very remote areas (24 per 1,000 children) were more than 3 times as likely as those from Major cities (7 per 1,000) to be the subject of a substantiation... Of the children who were the subject of a substantiation from Remote and Very Remote areas, 88% were Indigenous. In Major cities 20% of children subject to substantiations were Indigenous [page 26].

 

In 2019–20, 14,300 Indigenous children were the subject of a substantiation. This is a rate of 43 per 1,000— almost 7 times the rate of non-Indigenous children (6 per 1,000)... This is consistent with findings for previous years... The reasons for the over-representation of Indigenous children in child protection substantiations are complex. Underlying causes include:

• the legacy of past policies of forced removal; • intergenerational effects of previous separations from family and culture; • a higher likelihood of living in the lowest socioeconomic areas; • perceptions arising from cultural differences in child-rearing practices.

Indigenous children are also over-represented in other areas related to child safety, including:

• hospital admissions for injuries and assault; • experiences of homelessness; • involvement in the youth justice system [page 27].

 

At 30 June 2020, about 18,900 Indigenous children were in out-of-home care—a rate of 56 per 1,000 Indigenous children, which was 11 times the rate for non-Indigenous children ... This difference between Indigenous and non-Indigenous children was evident across all age groups...

Rates for Indigenous children in out-of-home care varied by age groups. Indigenous children aged 10–14 had the highest rate of out-of-home care (63 per 1,000 Indigenous children), while those aged under 1 had the lowest rate (28 per 1,000) [page 54].

 

For Indigenous children in out-of-home care, rates rose between 2017 and 2020, from 51 per 1,000 children to 56 per 1,000 Indigenous children [page 58].

 

There is a risk of over-simplification selectively quoting from a report such as this. I recommend readers take some time to have a look at the report itself. Nevertheless, it is astounding to comprehend that 42 percent of the 46,000 children in out of home care across the nation are Indigenous. In 2019, Neil Westbury and I assessed the state of out of home care in NSW in our Policy Insights paper Overcoming Indigenous Exclusion (link here), and we noted then that there were 31,000 children in out of home care and 11,900 or 38 percent were Indigenous. While the AIHW notes that data adjustments mean that prior comparisons are not appropriate (see page vi), it is clear that the national situation is much worse than national policymakers realised just two years ago. Moreover, these data points are not point in time issues, but are indicators of ongoing reductions in children’s life opportunities, with ongoing human costs to the families concerned and social and financial costs to the broader community.

Moreover, what is not addressed in a report focussed on measuring children’s engagement with the child protection system are the multiple upstream issues for parents and families that have led to children being placed into care. Issues such as drug and alcohol abuse, domestic violence, incarceration, and so on. These too have huge personal, family and wider social impacts which are both ongoing and negatively synergistic.

On the positive side of the ledger, the new National Agreement on Closing the Gap (link here) provides for new child protection target (link here) aimed at reducing the rate of over-representation by 45 percent over the decade to 2031.

Yet as the report notes, the rate of Indigenous over-representation has increased in the last four years. Further, this is not a new problem; in our Policy Insights paper referred to above, we considered the experience of NSW, and in particular, the reviews conducted by the NSW Ombudsman in 2011, 2014, and the excellent review by David Tune. Megan Davis conducted a subsequent review focussed on Indigenous child protection issues in 2019 (link here). What is common to all of these NSW reports is that the previous responses by the NSW Governments have been inadequate and that the calls for structural reforms have been dismissed (either implicitly or explicitly). The NSW experience has been largely replicated in the other jurisdictions.

While child protection is a state and territory responsibility, the broad uniformity of the challenges particularly for Indigenous children and families across the nation, and the inability of state and territory governments so far to successfully address those challenges, suggests that there are deeper structural issues at play. These are issues that span both Commonwealth and state / territory responsibilities, and demand a combined approach led by the Commonwealth.

To date, however, there is very little evidence that the Commonwealth recognises that it has a responsibility to lead in this policy space, nor that without its leadership, the prospects of success are limited. There has been no response from the Minister for Indigenous Australians to the release of the AIHW report.

We await the publication in July of the first implementation plans arising from the new National Agreement, and the associated Commonwealth investment. My prediction however is that in relation to this particular target, the Commonwealth will stay with its longstanding script, and seek to place the entirety of the responsibility on the states and territories. For their part the states and territories will either put their heads in the sand and ignore the issue, or implicitly deny that a problem exists. They have form on this… On 16 September 2020, the nation’s Community Services Ministers met and were briefed by Minister Wyatt on the new Closing the Gap targets for children in out of home care. The communique of the meeting (link here) has a self-congratulatory tone overall, and mentions that child protection reforms were paused across the nation in March 2020 because of the pandemic, and had not then been resumed. Extraordinarily, the Communique stated (inter alia):

Minister Wyatt acknowledged the importance of governments working together to keep children safe and healthy by identifying and replicating best practice, in partnership with Aboriginal Community Controlled Organisations. Ministers noted that a number of states and territories had developed very strong practice in this area which was seeing clear gains in reducing the intake of Aboriginal and Torres Strait Islander children into out of home care and increases in family restoration (emphasis added).

Given the data outlined in the AIHW report, the impression left by the statement in bold is clearly just wrong, and it is extraordinary that neither Ministers Ruston nor Wyatt, who were both present at the meeting, sought to correct the record.

When rhetoric trumps reality, policy development becomes an exercise in doing the minimum required to avoid sustained criticism. When the life opportunities of children are involved, this is plainly not good enough.

What is required is a comprehensive and well-resourced plan to address the structural underpinnings of child safety in the broadest sense. This would require the development of a structural reform agenda plus targeted program initiatives; robust but simple coordination arrangements across jurisdictions; long term financial commitments; engagement with the relevant community controlled agencies; and the creation of a sophisticated and policy specific research and evaluation capability aimed at identifying the key leverage points to turn current trends around and monitoring progress in live time. See my previous March 2020 post on an earlier AIHW report (link here) for other similar policy reform suggestions.

Such an agenda appears ambitious, because it is ambitious. It also happens to accord with the principles laid out in the new National Partnership.  Anything less is unlikely to have the necessary policy heft and firepower to make a difference. It is time the nation got serious about addressing Indigenous disadvantage. This will require Commonwealth leadership and commitment.

A core proof of the existence of structural exclusion is the inability of those who are not excluded to recognise and actually ‘see’ an issue. As a nation, we are conscious that there is an issue with Indigenous child protection; we know it is there somewhere, we allow statisticians to write reports, and prepare graphs, yet we are incapable of keeping it in focus, of identifying with the real and tangible impacts on children and their families. In short, we are incapable of maintaining our gaze. To maintain our gaze is too difficult because it would reveal a truth about Australian society, and ourselves, that we cannot bear to acknowledge.

 

Wednesday, 27 February 2019

Closing remote children's dental health gap




The AIHW has recently (26 February 2019) released a report titled Northern Territory Remote Aboriginal Investment: Oral Health Program July 2012 to December 2017 (link here).

I don’t propose to attempt a comprehensive summary the report as it is very accessible and easy to read. A quick scan of the graphs and tables will give any reader a good sense of progress. Not unexpectedly, remote children appear to have higher levels of poor dental health than their mainstream counterparts.

In terms of service delivery, preventative services, primarily involving fluoride varnish treatments, appear to have grown consistently (off an almost non-existent base in 2012) over the past five years (see figure 2.2). In terms of fissure sealant services, numbers have decreased slightly since 2013 (figure 2.4) and in relation to clinical services, numbers of services peaked in 2013, fell dramatically in 2014 and 2015, and are still below the 2013 levels in 2017 (figure 2.6).

In terms of outcomes, while the proportion of Aboriginal children with tooth decay remains extremely high, over time those proportions appear to be reducing. So in the period 2009 to 2017, the proportion of 1-3 year olds with tooth decay went from 73% to 43%; for 8 year olds it went from 93% to 88%; for 11 year olds it went up from 69% to 75%; and for 12 year olds it went from 81% to 68% (see page 16). While this is positive news, it also suggests that it will be decades before we attain parity in dental health outcomes.

Two appendixes discuss a number of data issues and limitations. The report is not based upon a comprehensive survey of all dental services across the remote parts of the NT, and thus there is no guarantee that the data which this report is based on is telling us the full story.

Nevertheless, like most AIHW reports, this report appears to be well researched, thorough, and reasonably accessible notwithstanding a degree of social and bureaucratic complexity.

However, the report raises a number of policy issues that are beyond the AIHW remit, but nevertheless demand consideration and attention.

The program being assessed is a Commonwealth program that is limited to the NT. It is a direct descendant of programs begun as part of the NT intervention and the subsequent Stronger Futures era. This raises the immediate question: what is the state of play in other remote jurisdictions?  The short answer is that we don’t know. My guess is that the outcomes are likely to be similar or worse (unless there is a particular jurisdiction that is delivering outstanding dental services to remote communities).

A second issue that the report fails to mention relates to the causes of high levels of poor dental health. The discussion of preventative health in the report is limited to health related prevention (largely the application of fluoride varnish treatments). Yet it is widely understood that the causal links between consumption of sugar and high sugar drinks and tooth decay are crucial.

These issues thus raise two further significant and related issues for policymakers. First, are governments allocating enough financial resources to both preventative and clinical dental services in remote Australia? In addition, are the programs that exist effective?

Second, are there wider policy responses to poor remote dental outcomes that ought to be pursued, or pursued with greater vigour? For example, should there be tighter regulation or higher taxation on high sugar drinks?  And as a further aside, what are the soft drink manufacturers and retailers doing in terms of their corporate social responsibilities to diminish the impact of poor dental health on children?

These are not simple policy issues, and design of appropriate policy interventions require careful consideration. However, we appear to be in a largely policy free zone at present.

The PMC website includes a number of reports related to dental health of Indigenous Australians. One of the more recent, the Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report (link here) notes inter alia in a section on ‘Implications’:

Implications
Available data indicate that dental health is worse for Indigenous Australians than for other Australians, for both children and adults. Barriers to good oral health include cost of services (see measure 3.14), healthy diets on limited budgets (see measure 2.19), attending services for pain not prevention, insufficient education about oral health and preventing disease, public dental services not meeting demand, lack of fluoridation in some water supplies, and cultural competency issues with some service providers (see measure 3.08)...
Prevalence estimates for oral health conditions for Indigenous Australians are based on out-of-date and incomplete surveys—further data development is a priority for this performance measure.

In the 2018 Closing the Gap statement in the chapter on healthy lives (link here) the Government mentions efforts by Outback Stores (a government owned stores company operating in remote communities) to reduce sales of sugary drinks, and notes also that:

The Australian Government has developed a strategy to reduce the sales of highly sugared products sold in stores in remote Indigenous communities. The store is often the main - or only - source of food and drinks in remote communities, so a reduction the amount of sugared products sold in the store is an effective way of reducing the amount sugar products consumed. The strategy is being implemented in stages through until June 2020, focusing on sugary drinks and expanding to other high-sugar products such as confectionary.

In the 2019 Closing the Gap Report at page 137 (link here), there is mention of Outback Stores operating in 37 remote stores (the Outback Stores website refers to 38 stores), and provides further mention of its store based sugar reduction strategies. But no reference to a wider strategy applicable to all remote community stores, and no mention to widening the strategy to confectionary. Perhaps the reference in the 2018 report was just to the Outback Stores footprint, which is less than a quarter of all remote stores.

The Outback Stores Annual Report for 2017-18 (link here) provides further detail on their sugar reduction strategies, built upon a foundation of price incentives and a support grant from PMC of $500k. What is less clear is whether PMC is doing anything substantive beyond the Outback Stores footprint. The indications are that it is not.

To sum up, we have an excellent report from AIHW addressing only one of the five jurisdictions encompassing remote Australia. It outlines serious dental health issues affecting scores of thousands of children. Its focus on measuring the scale of preventive services is limited to health interventions. There is some indication that Commonwealth policymakers have been focussed on addressing other wider causes of poor dental health in remote communities, but only in an extremely limited way and only in a small proportion of remote communities.

To be blunt, in relation to levels of dental health across remote Australia, the available evidence indicates that we know there is a problem, we don’t know how extensive it is, and we aren’t prepared to do what is necessary to address the wider causes of the problem. Admittedly, probably another twenty health issues across the remote indigenous health domain require focussed attention.

But the question remains, how will we close the gap on remote Indigenous dental health let alone remote Indigenous health status generally when governments are focussed on signalling they are doing something, but are not prepared to devise, develop and implement the substantive policies which might make real inroads?