Building better systems of care for Aboriginal and Torres Strait Islander people: findings from the Kanyini health systems assessment

Abstract

BackgroundAustralian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment.MethodsTwo theories informed the study: (1) ‘candidacy’, which explores “the ways in which people’s eligibility for care is jointly negotiated between individuals and health services”; and (2) kanyini or ‘holding’, a Central Australian philosophy which describes the principle and obligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed.ResultsStaff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, and commitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld. Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is ‘tractable’ and ‘navigable’ to its users. Staff also described entrenched patient discrimination in hospitals and the need to expend considerable effort to reinstate care. This suggests that Aboriginal and Torres Strait Islander people are still constructed as ‘non-ideal users’ and are denied from being ‘held’ by hospital staff.ConclusionsSome new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs ‘hold’ their users and enhance their candidacy to health care. Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.

Acute Rheumatic Fever and Rheumatic Heart Disease

“…Although the data analyzed for this report did not allow us to quantify access to or acceptance of medical care, others have found many barriers to Aboriginal people receiving optimal medical and surgical care for chronic diseases, related to healthcare systems, remoteness, and cultural factors. 22,23 In the case of RHD, there is the added complication that cardiac surgery is not available in the NT, so surgical intervention involves travel to cities many thousands of kilometers away. If outcomes for RHD are to be improved in similar settings, healthcare services must improve the capacity of the health workforce, the availability of specialist care, the systems for delivering care to patients with complex, chronic diseases, and the mechanisms to address cultural impediments to uptake of Western medical care.…”

Effectiveness of a cough management algorithm at the transitional phase from acute to chronic cough in Australian children aged <15 years: protocol for a randomised controlled trial

“…Further, the CEA of the intervention will provide data critical to clinical and public policy decisions with respect to incorporation of the intervention into routine care at the primary and tertiary healthcare levels. Such decisions will be enhanced by our incorporation of direct and indirect costs to the family, the community and the healthcare sector, 60 particularly given the focus on resource allocation in Indigenous health in Australia, 61 and the different mechanisms for delivery of primary healthcare services compared with mainstream Australia. 62 We have incorporated microbiological components into the RCT as the role of infectious agents in the transition from ARI to chronic wet cough remains largely unknown.…”

Experiences and views of a brokerage model for primary care for Aboriginal people

“…Many of these issues relate to the themes of candidacy, in particular navigation and making services more permeable (5,6). The relationship between Aboriginal people and the staff at brokerage service is ongoing and dynamic.…”

“…In the published literature on access to health care and increasingly, in Aboriginal health research the concept of candidacy is discussed (5). The term candidacy arose from a systematic review and interpretive synthesis of access to health care by vulnerable people (6).…”