Policymaking in a maelstrom: preliminary thoughts on the longer term implications of the current crises

This world to me is as a lasting storm

Pericles Act 4, scene 1

What are the implications of the current crises for Indigenous policy in the future? At a national level, the current health and economic crises exude uncertainty at multiple levels. Neither governments, their health and economic professionals, nor the citizenry at large have answers to key questions: how long will the crises endure, where will the impacts fall most severely, which demographic cohorts will be most severely affected; what will be the most effective strategies to ameliorate adverse impacts, how will the inevitable trade-offs between competing objectives be managed and determined, and so on and so on.

In this post, I don’t wish to focus on the immediate consequences, risks and even opportunities emerging as a result of the crises. Others are doing this, and I don’t have anything substantive to add.

On the health front, I would point interested readers to the NACCHO web site and their regular updates on the virus (link here). See also recent articles from The Conversation focussed on the health implications of the crisis  (link here) and some economic implications of the crisis (link here).

On the economic front, the Treasury web site has a succinct and accessible document outlining the economic consequences of the Covid19 pandemic and the Federal Government’s most recent response (link here) which they estimate at $189 bn over the forward estimates.

At the macro/mainstream level, governments have set in train a rolling program of ever stronger health related precautions, including constraints on immigration, internal movement, on assemblies in public places, and on non-essential businesses, and are likely to extend to school closures in the near future. These all have economic costs and consequences, and will over time lose their effectiveness as the virus spreads within the community. They are likely however to be difficult to remove once in place.

The economic measures are designed to counter the macro-economic contraction of demand within the economy and to support the resilience and capabilities of firms  who are being forced to lay off employees and reduce or cease trading activities.

While huge in historical terms, the size of this intervention is likely to rise over the coming months. For example, it seems likely that the Government will have to step in to further support or effectively nationalise some or all of the nation’s airlines.

It is clear that notwithstanding the government’s intervention, the nation is facing a recession this year. What is unclear is just how deep and how prolonged it will be. A prolonged recession will itself have severe social and health costs for the nation, including perhaps increased mortality over the ensuing years, although there will be no obvious link between economic contraction and individual morbidity and mortality outcomes. Intuitively, these hidden costs and ramifications are most likely to fall on the vulnerable within the Australian community.

What is also clear is that the nation’s policymakers have a gargantuan and once in a generation policy challenge on their plate. The politicians among them have an additional side dish of diabolical political challenges to manage. The next federal election is due in mid-2022 (link here), so there is a strong likelihood that the Prime Minister will not call the next election until the first half of 2022.

Given these sudden and largely unforeseen circumstances, the question I wish to explore is what does this mean for Indigenous policy into the future?

Perhaps we should first list the known changes and their likely consequences, before moving to list the potential policy outcomes.

Known changes:

Indigenous communities and citizens are more likely to be vulnerable to the virus, and to have higher adverse morbidity and mortality outcomes . This is particularly the case in remote regions, but urban and regional populations are also vulnerable. Offsetting this is the knowledge that the Indigenous population is comparatively young, with the median age in 2016 being 23 years compared to the mainstream population median age of 34 years (link here). The virus appears less dangerous to younger cohorts.

The economic changes announced to date will allocate an extra $10 bn or so into social security payments over each of the next two years. To the extent that Indigenous citizens are over-represented amongst social security recipients they will benefit more pro-rata than mainstream interests from these allocations. They are likely under-represented in small businesses and will thus benefit less pro-rata than mainstream interests. Without a detailed study, the ultimate incidence of the stimulus in relation to Indigenous interests is unclear; however it does not appear that economically vulnerable Australians including Indigenous Australians have been given preferential treatment in the stimulus package.

Potential policy changes:

The following points are largely speculative insomuch as the future is fundamentally uncertain, and in current circumstances, even more so. Nevertheless, there seems value in at least considering what might emerge from the current crises in the Indigenous policy domain.

In terms of the Federal Government’s existing (or perhaps more accurately pre-existing) policy agenda, there are three significant policy reform initiatives in train: the development of new Closing the Gap targets in conjunction with COAG and the Coalition of Peaks under a COAG Partnership Agreement (link here); the development of proposals for an Indigenous Voice to Government; and the implementation of a northern Australia policy agenda under the recently signed Northern Australia Indigenous Development Accord (link here). A fourth policy agenda with the potential for significant policy implications is the eventual Government response to the forthcoming Productivity Commission report on an Indigenous Evaluation Strategy (link here). The Commission’s draft report is now scheduled for May 2020 (it was initially to be released in February 2020), to be followed by a final report currently scheduled for October 2020.

So how will each of these policy agendas now play out? My own assessment is that there is likely to be delays across three of the four agendas. Policy reform momentum will stall. The reasons are two-fold: the difficulty in gaining policy attention from policymakers who will be consumed with handling the implications of the health and economic crises; and the difficulty of gaining attention from Indigenous citizens and others as they strive to survive in increasingly difficult circumstances. A third, more cynical, reason worth considering is that governments generally respond to pressure, and in the absence of pressure, prefer the status quo to change. In a crisis, pressure will shift from calls for medium and longer term reform to calls for more immediate action. For all these reasons, the political incentives on the Government will be to focus on managing short term measures, and this will work against finding the time and resources to develop longer term policy reforms.

The Closing the Gap targets may well be the exception; the federal Government has an incentive to substantially shift the policy goalposts this year to avoid the reiteration of ongoing and deep-seated policy failure highlighted in the annual presentation of the report to Parliament. Moreover, the process of policy redesign is well advanced (albeit the details of the discussion have not been made public) and has the support of the national Coalition of Peaks. The Coalition of Peaks will be pushing for the target changes to proceed if they are agreed and perceived to be substantive and positive reforms. In a recent media interview (link here),  Minister Ken Wyatt went on the record confirming that the process remains on track:

Patricia Karvelas: Very briefly, Minister, before we end - the 2020 Close the Gap campaign report has been released today, and it's warned that only systemic reform will make up for the harrowing failure of the last 12 years of government policy on Closing the Gap. It seems to me closing that gap is ever more important as we now deal with the Corona virus. Are you still working to deadline on changing those targets?

Ken Wyatt: Yes, we are. And whilst we're focussing on COVID 19 we're also continuing with business as usual. And this means finalising the targets and then looking at what systemic commitment and change must occur at all levels in order for us to close those gaps. We have to do things differently. [inaudible] Closing the Gap, led by Tom Calma and then endorsed by Prime Minister Rudd, was a great way forward, but we collectively have not seen the systemic reform that would help achieve those gaps and close them.

While both the Government and the Coalition of Peaks appear to see benefit in the refresh process, I am wary and see significant risks as well as opportunities (link here). To date, there is inadequate information in the public domain to enable a close assessment of the likely results of the refresh process.

The other three policy reform agendas appear much less likely to be advanced in a timely fashion.

The process established to develop a National (and locally constituted) Voice to Government (link here) appears cumbersome, with three separate committees tasked to consult and develop proposals over a two phase process. Those Committees will find it difficult to convene over the next three to six months, and even harder to consult communities on the ground. The current schedule suggests that advice will be provided to Government by the end of 2020, with no timeframe on the Government’s own internal deliberations regarding how to proceed. I will be amazed if the Committees advice is ready before mid 2021, and see little prospect of the Government prioritising legislation or executive action to establish such a Voice before the next election.

The Indigenous component of the Government’s northern Australia agenda has been extremely slow to emerge. The Indigenous Reference Group to the Ministerial Forum was appointed in December 2017, and in its most recent meeting communique (link here), noted inter alia,

The IRG provided the Ministerial Forum an update on the extensive work undertaken to investigate access to capital, reform of the northern Australia Indigenous institutional landscape, and improve opportunities to leverage and commercialise the northern Australia Indigenous estate. This will help ensure that Traditional Owners can fully use their land and rights holdings should they choose to support economic development.

While the details of that work are not yet in the public domain, there seems little evidence to date that the Government has been serious about the structural reforms necessary to reshape the institutional and policy landscape in northern Australia to deliver a step change in Indigenous economic development outcomes. The likelihood that this will change in the current crises seems remote, not least because the two ministers who designed this policy architecture (Matt Canavan and Nigel Scullion) are no longer in place. We may see some policy change at the margin, but this would be window dressing. A close analysis of the Northern Australia Indigenous Development Accord (link here), the centrepiece of the policy process to date, suggests that it is largely process oriented: compare the proposed outcomes in clause 15, with the detailed outputs in the attached Implementation Plan. It seems likely that the IRG will continue to meet and the jurisdictional parties to the Accord will continue to ‘scope options’ and ‘engage constructively’ in working parties and the like, but actual and tangible reforms are unlikely this side of the next election.

On evaluation of Indigenous policies, the Treasurer requested the Productivity Commission to

develop a whole-of-government evaluation strategy for policies and programs affecting Indigenous Australians. The Commission will also review the performance of agencies against the strategy over time, focusing on potential improvements and on lessons that may have broader application for all governments.

Policy and program evaluation is a complex area, and I cannot do it justice here. See this previous post (link here). I expect the Commission will produce a detailed and comprehensive report, but it seems unlikely that the Government will set aside the policy resources required to institute the far reaching reforms to evaluation practice required to improve policy and program performance across the board in a time of ongoing crises. Nor do I think it is likely that the current Government will mandate ongoing Productivity Commission reviews of all agencies evaluations strategies. Let’s wait and see what the Commission recommends. The more robust its recommendations, the more likely that the Government will sit on the report and do nothing or little. In such circumstances, the existence of interrelated health and economic crises will be the perfect excuse for inaction.

It is also worth considering some ‘blue sky’ Indigenous policy ramifications of the dual crises we currently face.

On Constitutional recognition, the Government has been consistently sceptical of anything with more than symbolic content. The likelihood of any constitutional change agenda emerging over the next two years appears close to zero. Indeed, the likelihood of a post-election / post-2022 constitutional reform agenda emerging must be assessed as much lower today than may have been the case two months ago.

In terms of broad policy focus in the Indigenous domain, the stars appear to be aligning for a shift towards a much greater focus on Indigenous health issues. The Minister, Ken Wyatt has a long background in the health sector. NACCHO, the peak body for Indigenous medical services is the most effective peak body and First Nations advocacy body in the nation, ably led by Pat Turner, an experienced ex-public servant, who herself has a strong background in health sector issues. And of course, the political prominence of the impact of the Covid19 virus will propel greater focus on wider health risks and issues for Indigenous citizens, particularly vulnerable cohorts within the Indigenous community.

Of course, the corollary of a shift towards health will be shift away form focussing on other non-health policy sectors (such as land rights / native title).

More speculatively, I suspect that the impact of the dual crises, combined with the changing demographic shape of the Indigenous population, will accelerate the importance of mainstream programs in the lives of First Nations citizens. To the extent that Indigenous specific policy agendas are left to languish, this will merely serve to reinforce this trend.

While Government rhetoric will not necessarily reflect this, the reality is that mainstream institutions (the social security system; the justice system; the child protection system; the disability support system; the education system; the telecommunications system; the health system and the nation’s finance system) already dominate and shape the lives of Indigenous citizens much more than Indigenous specific policies and programs. Indigenous advocacy is yet to appreciate this reality, and if, as I suspect, the current crises represent a critical juncture which strengthen radically the influence of mainstream institutions across the Indigenous policy domain, it will become even more important that Indigenous leaders and peak bodies build the capability to advocate across mainstream policy domains, and seek out common cause with like minded mainstream advocacy bodies.

It is worth reminding ourselves that these crises will inevitably have uncertain outcomes, and the policy responses of Governments, both in the short and medium terms, will have unanticipated consequences. At the micro level, the social and health costs of mental anguish will likely be significant across the whole community. At the macro level, the potential for social and political breakdown and unrest will rise. Vulnerable members of the community (among whom First Nations citizens are over-represented) will be particularly at risk in these uncertain times. The impacts of structural inequality and exclusion are magnified in times of crisis.

Finally, it would be remiss of me if I did not turn my gaze backward rather than forward. In particular, should governments have given more attention to the risks of a pandemic, and more generally to the regularity of crises. Or to put it another way, when I stated above that the pandemic was unforeseen, was that in fact a reflection of poor and ineffective governance in relation to a foreseeable and inevitable eventuality. Part of the issue is that public policies are most effective when they operate as a neutral arbiter between competing interests, including in relation to the risk of temporal trade-offs. To the extent that policy is captured by special interests, it becomes much less attuned to managing for wider societal risks.

In the Indigenous policy domain (and beyond), this is reflected in a shift over the past two decades to privileging corporate over community interests in terms of program delivery (eg in the realm of social security). In turn, this opens up service delivery gaps when markets fail (eg in the shallow coverage of providers within the disability sector).

One outcome of the current crises is that a much stronger light will be shone on the risks and failures of recent policy settings in Indigenous affairs (and beyond). Whether future governments will have the independence, vision and political will to change course seems to me to be a moot point. One of the comparative advantages First Nations communities and citizens have is that there is widespread acknowledgement amongst the wider community and policymakers that they do have particular and unique needs and aspirations. Looking forward, this is a cause for hope that policy reforms and necessary reversals may be considered, notwithstanding the myriad reasons for pessimism in what appears to be a once in a century social, health, economic and political maelstrom.

Opportunities and risks: Important developments related to Closing the Gap

Last week, on 12 December, the Council of Australians Governments (COAG) met in Adelaide. The meeting was path breaking for Indigenous affairs policy insofar as it outlined a new approach to the establishment of Closing the Gap (CTG) targets by governments at all levels.

The COAG Communique (link here) said it best. COAG is:

committed to ensuring that the finalisation of targets and implementation of the Closing the Gap framework occurs through a genuine, formal partnership between the Commonwealth, state and territory governments and Indigenous Australians through their representatives…

Today, COAG issued a statement outlining a strengths based framework, which prioritises intergenerational change and the aspirations and priorities of Aboriginal and Torres Strait Islander peoples across all Australian communities. The finalisation of this framework and associated draft targets will be agreed through a formal partnership.

Governments and Aboriginal and Torres Strait Islander representatives will share ownership of, and responsibility for, a jointly agreed framework and targets and ongoing monitoring of the Closing the Gap agenda. This will include an Aboriginal and Torres Strait Islander-led three yearly comprehensive evaluation of the framework and progress.

The arrangements of the formal partnership between COAG and Aboriginal and Torres Strait Islander representation will be settled by the end of February 2019, and will include a Ministerial Council on Closing the Gap, with Ministers nominated by jurisdictions and representation from Aboriginal and Torres Strait Islander peoples. The framework and draft targets will be finalised through this Council by mid-2019, ahead of endorsement by COAG.

The establishment of a formal partnership is extremely significant for three reasons.

First because Closing the Gap represents an overarching policy process, truly national in scope and focus, the proposed Partnership will provide a guaranteed mechanism for the inclusion of Indigenous perspectives in macro-level policy planning processes at both national and state and territory levels. Second, because once established, this Partnership will likely create an opportunity for Indigenous interests to influence other phases of the policy development process, and thus represents a new avenue or pathway for greater inclusion of Indigenous voices and perspectives in policy formulation.

Of course, the degree to which these opportunities are made concrete will depend on the design parameters of the partnership (how often the parties meet, how agendas are determined, etc.), and the relative bargaining strength of the parties in undertaking the internal negotiations within the partnership. One constraint which Indigenous interests will face is that COAG processes are generally based on the achievement of consensus amongst governments, which means that any differences of views between governments will limit the capacity of Indigenous interests to prevail in persuading COAG members to take on board indigenous views and perspectives. The inclusion of an evaluation function, presumably led by the newly appointed Indigenous Commissioner on the Productivity Commission will provide a welcome source of independent oversight and scrutiny over the effectiveness of the CTG framework, and thus by implication, of the Partnership’s effectiveness.

The third reason the establishment of such a Partnership is important is that it will likely lead to the creation of a new national ‘peak of peaks’ for the representation of indigenous interests in engagement with the executive arms of governments at national, state and territory levels. I see this as a positive development, as it reflects the reality that policy development is increasingly complex and Indigenous interests will only successfully engage with governments if they utilise the research and advocacy expertise and resources available within the various peak bodies. A potential downside which Indigenous interests will need to consider and if necessary address is that the varying structures of peak bodies may effectively filter out the direct experience and views of local and regional communities. If this were to occur, it would likely flow through to the policy formulation process.

COAG also released a related COAG Statement on the Closing the Gap Refresh (link here). This document is in my view more problematic and begins to suggest just how complex the CTG process may become. I recommend it be read in full as I cannot summarise it adequately here in the space available.

The Statement begins with a recitation of previous COAG decisions, including the proposed focus on a ‘strength based approach’. The Statement then notes:

COAG has now agreed draft targets for further consultation to ensure they align with Aboriginal and Torres Strait Islander peoples and communities’ priorities and ambition as a basis for developing action plans.

The Statement then sets out sections on partnerships, outlines a vision for the future, lists the Indigenous formulated community priorities for the next ten years, and acknowledges the existence of what it terms ‘cross system priorities’ which ‘require action across multiple targets’.

The core section for present purposes relates to ‘Refreshed Targets’. The Statement notes (emphasis added):

The Commonwealth, states and territories share accountability for the refreshed Closing the Gap agenda and are jointly accountable outcomes for Aboriginal and Torres Strait Islander peoples. COAG commits to working together to improve outcomes in every priority area of the Closing the Gap Refresh.

The refreshed Closing the Gap agenda will commit to targets that all governments will be accountable to the community for achieving. …

…While overall accountability for the framework is shared, different levels of government will have lead responsibility for specific targets. The lead jurisdiction is the level of government responsible for monitoring reports against progress and initiating further action if that target is not on track, including through relevant COAG bodies.

The refreshed framework recognises that one level of government may have a greater role in policy and program delivery in relation to a particular target while another level of government may play a greater role in funding, legislative or regulatory functions. Meeting specific targets will require the collaborative efforts of the Commonwealth, states and territories, regardless of which level of government has lead responsibility. Commonwealth, state and territory actions for each target will be set out in jurisdictional action plans, and may vary between jurisdictions. COAG acknowledges that all priority areas have interdependent social, economic and health determinants that impact the achievement of outcomes and targets.

Through a co-design approach, jurisdictional action plans will be developed in genuine partnership with Aboriginal and Torres Strait Islander communities, setting out the progress that needs to be made nationally and in each jurisdiction for the targets to be met. Action plans will clearly specify what actions each level of government is accountable for, inform jurisdictional trajectories for each target and establish how all levels of government will work together and with communities, organisations and other stakeholders to achieve the targets. Starting points, past trends and local circumstances differ, so jurisdictions’ trajectories will vary and may have different end-points…

My purpose in highlighting the text above in bold is to shine a light on the likely complexity of the arrangements currently envisaged. The greater the complexity, the more difficult it will be for governments to be held accountable, and thus for an appropriate policy response to be developed.

The Statement goes on to list out 15 draft targets, seven of which are Commonwealth-led and eight state-led. I don’t propose to undertake a detailed analysis of the targets but merely note that the proposed Commonwealth-led targets are overwhelmingly to be achieved by 2028. A detailed analysis would, inter alia, form a view as to the level of inherent policy challenge in each target. To take one at random, aiming for 60 percent of Aboriginal and Torres Strait Islander people aged between 25-64 years to be employed by 2028 appears too soft. In effect, it means that we are prepared to see 40 percent of the Indigenous work force unemployed after ten years of policy focus.

A key issue embedded within the COAG approach, which was perhaps implicit or nascent within the original 2008 CTG targets, relates to their fundamental purpose. At one end of the spectrum, they might be conceptualised as an incomplete selection of key indicators which taken together represent a proxy indicator for overall performance in addressing deep disadvantage within the Indigenous domain. At the other end of the spectrum, the targets can be conceptualised as a comprehensive selection of the most important policy areas requiring attention, and thus are accepted as the areas requiring prioritisation by governments to the exclusion of other policy issues. While there is no apparent acknowledgment of this issue in current policy documentation around CTG, the current refresh appears to have shifted perceptibly towards the ‘comprehensive list of priorities ‘ end of the spectrum, and this in turn raises important questions regarding the approach of governments to those policy issues which will not be included explicitly as targets. Accordingly, going forward, there is a case for a much clearer articulation of the COAG approach in relation to whether the targets are mere proxies, or a comprehensive listing of policy priorities.

I have four specific suggestions to make regarding the proposed targets, none of which appear to be reflected in the current draft.

First, the targets need to explicitly list the current mainstream level or baseline for each target and then propose a target level for Indigenous citizens. This ensures a level of transparency in terms of the proposed targets, and makes clear how ambitious the target is designed to be.

Second, the targets (and the mainstream comparisons) need to be broken down into two components: an urban and regional component and a remote/very remote component. Only if this is done will the CTG arrangements be effective in driving policy attention to those policy issues most in need of attention. Indeed, without such an approach, it is likely that the CTG process will actually facilitate and encourage policy aimed at ignoring remote citizens since the majority of the targets will be able to be met by focussing mainstream programs on the four fifths of the Indigenous population who reside in urban and regional Australia. Urban and regional indigenous populations have legitimate needs, but it would be a serious mistake to establish a CTG system that allowed targets to be ‘met’ while effectively ignoring the needs of remote citizens.

Third, each target needs to be separately broken down by jurisdiction so that it is clear what the current relevant mainstream, urban/regional and remote/very remote data are in each jurisdiction.

Fourth, given the imperative of designing a system which is both sophisticated, workable, and not overly influenced by political positioning between the Commonwealth and the states, I propose the Productivity Commission be tasked with developing a second set of Draft Targets, which would then form the basis for co-design discussions between Indigenous interests and COAG.

I see three enormous flaws that permeate the current CTG Refresh proposals and targets.

The first serious flaw I see with the current proposals is that the whole process will inevitably become bogged down in a complex and incomprehensible array of separate reports from eight jurisdictions, with differing formats, different action plans, and effectively no accountability. The result will be an absence of effective political accountability since when everyone shares responsibility and accountability, no jurisdiction will accept responsibility for poor progress.  While we live in a federal system with shared responsibilities and the potential for differing policy approaches, and under a constitution which provides for concurrent powers on Indigenous issues between the Commonwealth and the states, in political and policy terms, the Commonwealth is primus inter pares. The current proposals seek to avoid or fudge that reality and instead reflect the current Government’s determination to shift as much political and policy responsibility for Indigenous policy failure by government to the states and territories. This is an abdication of the Commonwealth’s longstanding role in Indigenous affairs, and is being undertaken without any open and up-front discussion of the Government’s policy intentions.

A second fundamental problem with the current proposals is that they do not address one of the core shortcomings of the original 2008 CTG targets. Namely, there is no attempt to square the circle, and ensure that Governments allocate adequate financial resources to meeting the identified targets.

A third and related flaw with the CTG process is that targets are set which are partial and lack ambition. This then becomes a circular process, where resources are not required because the targets are not ambitious. The inevitable result is that the CTG process becomes more rhetorical than substantive

We need to acknowledge the reality: this is a strategy in name only. It sets targets, it makes ‘commitments’, but it offers no guarantee that the financial and other resources required for effective implementation will be available. In fact, the emphasis on ‘sharing’ accountability with the states and the territories just magnifies this issue, as it allows the national government to lay blame for missed targets on the states and territories, and shifts any arguments about lack of financial commitment to a lower jurisdiction. If this were a serious strategy, COAG would allocate resources to implement targets directed to entirely removing the relevant gaps in socials indicators, and then decide what can be achieved with the available funds.

In my view, this refresh proposal is on a slow but inevitable road to failure. It is fundamentally dishonest because it is presented as a strategy for achieving a policy end (closing the gap) whereas it is primarily a mechanism to persuade the Australian public that governments are addressing issues of Indigenous disadvantage. This is poor policy because it raises expectations amongst Indigenous interests that are ultimately bound to be dashed, with unknown consequences for future social cohesion. In particular, it seeks to ‘partner with’, and thus implicate Indigenous interests in a process which is, on present indications, destined to fail. It suggests to the community at large that governments are actively and effectively addressing the challenges of Indigenous disadvantage when they are not, and it thus has the effect of increasing complacency in the community at large as to the nature of the challenges facing both Indigenous people and the nation as a whole (this was one theme in my submission to the CTG refresh process, published here). We deserve better from our governments.

I began by pointing to the positive developments inherent in the formal partnership proposals for Indigenous interests. Indigenous peak bodies have welcomed the new approach (link here to NACCHO’s media release). The risk that NACCHO and the other Indigenous peak bodies face is that in ten years’ time, the refreshed CTG process will not have overcome the deep-seated and informal structural exclusion of Indigenous interests in Australia and the consequential deep-seated disadvantage that permeates many Indigenous lives. The Indigenous peaks will need to step very carefully in terms of their engagement and ‘partnership’ with Australia’s governments.

The CTG process has potential, it can be made to work with the allocation of adequate financial and human resources by government, and technically proficient design of the targets, but it can also be the complex and extremely technical façade behind which governments hide as they pursue other more pressing national priorities.

The most important contribution that Indigenous interests can bring to the co-design of the CTG process is a two-fold insistence that COAG and its constituent governments focus on the underlying systemic and structural factors driving Indigenous disadvantage, and commit real financial and human resources to the complete elimination of Indigenous disadvantage. A good first step in fleshing out these fundamental pre-requisites would be for the Indigenous peak bodies and COAG to agree to an upfront Productivity Commission review outlining the scale of the challenge and the potential policy pathways which might be chosen to go forward in devising an effective policy strategy to substantively close the gap. Laying out such a policy baseline is the best strategy available to reduce the current extreme risk of failure.

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).