This analysis of AMS health systems provides a useful snapshot of staff perceptions of barriers and enablers to health care access and quality for Aboriginal and Torres Strait Islander people. Although our focus was on identifying better systems of care for chronic diseases, the findings that emerged appear to be indicative of much broader health systems issues. Candidacy and its sub-constructs provide a useful frame for describing and understanding health care access issues in this study. We found that tractable and navigable health services have good governance structures, sound leadership, systems that welcome the ‘non-ideal user’, good patient transport systems, and a well-supported workforce. Similar findings on navigation barriers and enablers have been noted in the international Indigenous health literature, particularly availability of transport
[26–30], minimal or no out-of-pocket costs for attendance and treatments
[27, 31–34], welcoming physical spaces
[30, 34–36] and the ability of a health service to serve as a social and community space
. The relevance of kanyini is different but complementary to candidacy. It helps to clarify the distinguishing features of health care provision in AMS settings when compared with mainstream government and private services. The findings highlight multiple strategies taken by AMSs to ‘hold’ people from childhood to old age. These include robust community governance, community representation on staff and linkages with other community organisations, strengths based health promotion activities, and most notably the extra-ordinary efforts to reach people who may not otherwise be able to access health care. The degree to which a person, family or community feels held may be a fundamental driver of whether care is viewed as ‘proper’
. Several findings from this study have implications for the implementation of policy initiatives under the Council of Australian Government National Partnership Agreement on Closing the Gap in Indigenous health outcomes (COAG NPA). These are related to AMS sector support and staffing initiatives, discrimination in hospital care, increasing candidacy to specialist care, and overcoming health service systemic barriers.
AMS sector support and staffing
The duty felt by AMS staff to properly ‘hold’ people is undermined by a substantial fear about the viability of the AMS sector. Despite the AMS sector having a stronger national presence than ever before, staff remain suspicious of government intentions. The COAG NPA has had mixed responses with many concerned that these initiatives are geared toward enhancing Aboriginal and Torres Strait Islander people’s access to private general practice services, and that they are neglecting the substantial role played by this sector
. Although our Health Systems Assessments were conducted prior to implementation of the COAG NPA, it is quite likely that these new initiatives would further compound rather than allay the feeling of being under threat. The findings also shed new understanding on why the employment and support of Aboriginal and Torres Strait Islander staff is a critical component in promoting candidacy to health care. Staff highlighted that Aboriginal Health Workers are one of the essential elements to ensuring that people are properly held by their health services. Other studies from North America and New Zealand have similarly highlighted the broad roles played by Indigenous health workers including working as clinicians and health promoters
, brokering better delivery of health information
[40, 41], and fulfilling responsibilities to patients as friends and family whilst maintaining professionalism and avoiding nepotism
[37, 42–45]. The COAG NPA has invested in several hundred new Aboriginal and Torres Strait Islander positions including tobacco workers, lifestyle workers, outreach workers and self-management workers
. Whilst such a large workforce commitment may be a sound investment there are cautionary aspects to this policy. The ability of an AMS to ‘hold’ its community is equally applicable to its staff, especially its Aboriginal and Torres Strait Islander staff. Given a large proportion of these new workforce positions will be based in mainstream primary health care organisations (known in Australia as Medicare Locals or formerly Divisions of General Practice), there is potential to shift existing AHWs away from the AMS sector into isolated organisational contexts. Further, there are important professional development needs that must be addressed. Despite a national Aboriginal and Torres Strait Islander workforce strategy being developed in 2002
, progress on implementation has been slow and barriers to improving workforce standards remain
[47, 48]. The recently created National Aboriginal and Torres Strait Islander Health Worker Association may help to address this with new national registration and accreditation standards. It is hoped that this agency will provide professional development opportunities that are flexibly delivered and recognise the diverse roles played by AHWs. Institutional supports such as these are an important mechanism to better ‘holding’ this workforce.
Discrimination in hospital systems
Whilst there were relatively minor frustrations about hospital systems (especially communication processes), the most concerning issue was the repeated accounts of perceived discrimination experienced by patients. Such discriminatory attitudes emphasise that Aboriginal and Torres Strait Islander people may be viewed a priori as ‘non-ideal’ users and treated in a hostile manner by the hospital system. Candidacy theory describes how this makes the hospital system highly intractable and helps explain the circumstances culminating in ‘leaving hospital against medical advice’ and ‘non-compliance’ with medical instruction
[49, 50]. These findings support those of others in which racism in health care is highly prevalent for Aboriginal people, impacting on personal health and eliciting a range of constructive and destructive coping strategies to manage its effects
. Dealing with these negative experiences appears to be a regular component of AMS health professionals’ work. A specified objective of the COAG NPA is to ‘fix the gaps and improve the patient journey’. One performance benchmark for this objective is that state and territory government implement strategies to improve cultural security and practice within public hospitals. Despite this being explicitly stated there are few implementation initiatives that appear to be addressing this. Discussion of institutional and interpersonal discrimination in hospitals is beyond the scope of this paper, but it is likely that conventional cultural awareness training workshops do little to address such a complex and highly pervasive issue. Some potentially instructive alternative strategies include anti-racism training
 and the development of tools that critically examine notions of culture, race and oppression
[53–55]. At an institutional level, New Zealand Māori advocates have called for organisational audits for compliance with Treaty of Waitangi principles
. In addition, several New Zealand district health boards have policies outlining tikanga best practice guidelines for respecting Māori principles in relation to hospital care
Improving specialist service access
On-site specialist outreach clinics appear to be a beneficial strategy to enhance the proper holding of people. Our findings complement those found in the evaluation of the Northern Territory Specialist Outreach Program
. Although such services are likely to meet the chronic care needs of a minority of clients, there are delivery system benefits beyond making services more permeable and navigable. On-site services foster increased trust and sound collaborating relationships between AMSs, government and private agencies. They enhance the ability of AMSs to hold clients in the system by better coordinating primary and specialist service delivery. The use of adequately supported and trained AHW coordinators can impart a strong nurturing component to these services. At a systems level, on-site services can enhance professional development opportunities for local staff (eg. via case conferences, journal clubs, and training in technical procedures), which can lead to a sustainable enhancement to workforce capacity. The federally funded Medical Specialist Outreach Assistance Program complements state and territory outreach specialist programs to rural and remote communities but specialist service support schemes remain piecemeal and fall considerably short of being systematic and comprehensive. Within the COAG NPA, increased funding is being provided to expand the program
. A key component of this expansion is to foster the development of multidisciplinary teams, but questions remain whether these initiatives are adequately resourced to meet demand. Our study findings support this policy decision and, if adequately financed, there is the potential to make an important contribution to improving the navigation of specialist care.
Overcoming health service systems barriers
In addition to the importance of kanyini and candidacy, we identified a number of systems barriers to uptake of federal policy initiatives. The use of Medicare incentives to promote better systems of chronic care is of particular relevance to the COAG NPA. Financial incentives are being provided to AMSs and private general practices for registering and providing a minimum number of Medicare services to Aboriginal and Torres Strait Islander people with or at higher risk of a chronic disease
. Low uptake of these Medicare items has been well documented in both the Kanyini Audit and elsewhere
[8, 60]. We identified several system issues in this study that might contribute to this, especially poor information management and inadequate staff resources. Perhaps more important, however, were the mixed views of the value of these Medicare items on patient care. Whilst the larger sites felt incentives could assist in providing comprehensive care and additional business revenue, at the smaller sites they tended to be viewed as a distraction from rather than a promoter of good health care. The National Aboriginal Community Controlled Health Organisation has voiced similar concerns that the use of Medicare incentives in the COAG NPA may create an ‘inverse care’ situation where those least in need of care will be more likely to receive these Medicare services and health services with the least capacity and those patients with more complex care needs may miss out
. Close monitoring is needed to identify if such uptake patterns emerge. Novel funding models to enhance Aboriginal and Torres Strait Islander people’s access to services have been proposed by the Australian National Hospitals and Health Reform Commission
. Similar to the Australian Department of Veteran Affairs model, eligible patients would receive universal entitlements to particular services. This would allow the patient to be the arbiter of which services to access and care providers would be able to claim benefits from this funding authority. Given the substantial restriction in choice of specialist provider and the accompanying financial and transport barriers discussed in this study, innovative models could address navigational barriers in the health system. Despite its recommendation, it does not feature at all in current government health reform discussions. The ICT/IM barriers we encountered are highly consistent with a major Office of Aboriginal and Torres Strait Islander Health review of health service views on reporting requirements
. The Aboriginal Health and Medical Research Council has also conducted a series of organisational audits on ICT/IM capacity in NSW AMSs
. This review found a considerable shortfall in budget allocation toward ICT/IM systems, low levels of ICT/IM governance, and poor computer literacy amongst staff members. These issues are again consistent with our study findings and warrant urgent attention. The COAG NPA includes a component for web-based reporting and monitoring tools for Office of Aboriginal and Torres Strait Islander Health funded organisations
, but there are few specific initiatives to address infrastructure barriers and staff support.
The potential role of kanyini and candidacy in future policy development
Incorporating kanyini and candidacy theories into a coherent health policy framework should not be viewed as an academic exercise. McCoy uses kanyini to explain the excellent educational outcomes that were achieved in one central Australian school
. The manner in which this institution ‘held’ people, honouring its obligations to nurture and ‘grow’ its students is compatible with a systems oriented approach. The 2008 Close the Gap National Indigenous Health Equality Targets, proposed by a coalition of over 40 leading non-government agencies, are well aligned to the principles of kanyini and candidacy
. There are five interlocking sets of targets with a focus on: (1) partnership with Aboriginal and Torres Strait Islander people in the design, delivery and control of health services to optimise access; (2) health issues responsible for the life expectancy and child mortality gaps; (3) health services required to address those health issues with an emphasis on capacity building and optimal access to support programs; (4) health service infrastructure investment especially in workforce and capital works; and (5) targets associated with upstream social determinants
. The ‘Close the Gap’ Coalition emphasised that all five sets of targets are required to ensure progress. Such targets could be viewed as practical implementation strategies that are highly consistent with kanyini and candidacy theory.