Introduction

There is no question that male statistics feature more significantly amongst many of the major causes of mortality and morbidity than they should (Mathers:1995:1). While in the recent past there have been some improvements in male health, there is however, still substantial work that needs to be done to improve the health status of men in Australia. In 1996, the Australian Institute of Health and Welfare, pointed out that the average life expectancy for an Australian male was more than six years lower than that for women (AIHW:1998:10).

Australian men are many times more likely to die than women from health conditions such as cardiovascular disease, ischaemic heart disease, lung cancer and injury (principally suicide and car accidents) (Huggins:1996). These areas need close attention to reduce the health differential between men and women. While it is important that gender does not determine the level of health care provided, there are issues that need to be addressed in a gender specific context.

Males in Australia face many complex health problems and while few of these are no more or less complex than those experienced by women; it is reasonable to say that they are different. Many of the differences are highlighted in data on mortality and morbidity (Espaignet and Stevenson:1995).

These problems are particularly obvious when looking at specific sub-groups within the Australian male population. When examining the health of the Indigenous population for example, there is a marked disparity with the non-Indigenous population. We suffer a higher burden of illness and die at a younger age than non-Indigenous Australian’s. This statement is true for almost every type of disease or condition for which information is available (Anderson:unpub).The life expectancy of Aboriginal and Torres Strait Islander people is at least 14 to 18 years lower than that of the general population, the death rates for Aboriginal and Torres Strait Islander people are between 2 and 4 times greater, depending on the particular population (Mathers:1995:3).

One of the main problems in trying to determine the exact difference between the two populations is the lack of data. This is particularly accentuated when viewing the health of Indigenous men. There is a very real need to have more information on the health of this group. Anecdotal information suggests that Indigenous men’s health, for many conditions, is worse than that of Indigenous females. They appear to experience high levels of sickness, particularly in relation to mental illness, excessive use of alcohol and illicit drug use on top of poor levels of health service utilisation (Huggins:1996).

While there are many important health issues which need to be addressed to improve Indigenous male health status, health service utilisation is an issue that is foremost. There is a large amount of anecdotal evidence that suggests Indigenous male do not seek treatment for many forms of illness because of an unwillingness to attend health services, whether they be mainstream or community controlled. The barriers that exist for Indigenous men in many places are complex and not easy to identify or even to rectify. Smith and King make the point about Indigenous men that they rarely go to the health centre when they are sick…they wait until the problem is unbearable then they seek health care, at which time they often require emergency treatment because the problem has become so bad they need attention over and above what may be provided at the local primary health care service (1998).

At a population level, increased access to primary health care services has improved many aspects of Indigenous health in the past twenty years or so. However, anecdotal evidence suggests there are still many barriers to accessing health services for Indigenous males (Commonwealth:1996).

Aim of the paper

How can we begin to address some of these issues and reduce the barriers that exist for Indigenous males in Australia? This paper will explore key elements that are important in the development of a national policy framework that can strategically address access to health services for Indigenous males in Australia. It is, however, worth pointing out at this time that this is the beginning of the development process and there is still much work to be done to identify the more detailed issues, both at a national and regional level.

This framework will focus primarily on supporting those Indigenous males who use or who wish to use Aboriginal primary health care services. I use this term to describe both Aboriginal community controlled health services and state/territory run Aboriginal primary health care services. Its secondary focus will be on providing guidance to mainstream primary health services such as GPs and hospitals, to ensure that they do not maintain institutional barriers that reduce access for Indigenous males.

Elements of the National Policy Framework

Before I address the key elements of a national policy framework I would like to briefly outline the responsibilities of the Office for Aboriginal and Torres Strait Islander Health (OATSIH), these include:

• funding Aboriginal community controlled health services to deliver comprehensive primary health care to Aboriginal and Torres Strait Islander people;
• coordinating activity within the portfolio of Health and Aged Care, to promote policy and structural changes particularly to improve the access for Indigenous people to mainstream health care; and
• work to develop more effective health information and data systems in order to improve the quality and appropriateness of Indigenous health data.

The elements of a strategic framework that may begin to address some of the health access issues for Indigenous men in Australia, include:

• maximising the Aboriginal and Torres Strait Islander Health Framework Agreements;
• innovative approaches to health services infrastructure;
• utilising existing OATSIH programs;
• workforce strategies;
• use of the Service Activity reporting mechanism within Aboriginal community controlled health services; and
• promoting an evidence based approach to male health.

An important theme that underpins this strategic approach is effective partnerships. Key players in this partnership, include the National Aboriginal Community Controlled Health Organisation (NACCHO) and the State and Territory governments.

All State/Territory Governments have entered into framework agreements on Aboriginal and Torres Strait Islander Health that provide the basis for equitable health outcomes with the broader community. The framework agreements recognise that roles and responsibilities are not clearly separated between the Commonwealth and the State/Territories and that both levels of government are jointly responsible for responding to the needs of all Australians, this includes Aboriginal and Torres Strait Islander peoples.

An agreed national strategy will help to ensure consistent approaches across the country. While it is clearly recognised that Indigenous men and their needs differ greatly throughout Australia (remote, rural, urban, gay), it will be important to ensure that there are similar strategies to encourage health seeking behaviour when they move from one location to another.

The development of the national framework will require an effective mechanism for consultation with Indigenous men. However, we also need to have access to service providers and other key stakeholders who deliver of primary health care to Indigenous males. A specific mechanism is needed to bring together key people to provide advice and direction to the Office in relation to a range of health access issues for Indigenous males.

Innovative approaches to health services infrastructure

The challenge for the health system generally, and in particular Aboriginal primary health care sector, is to recognise and value the role of Indigenous men in the community. Part of this will be to allow men to take an active role in dealing with their own health care needs.

Mick Adams once said, "Indigenous men realise that they need to start taking hold of their responsibilities and control of their direction to improve their self-image and take up their rightful place within their communities and family structure". There are many reasons why the role of Indigenous men in the 1990s is so uncertain. Adams suggests that the path to excessive alcohol and drug abuse has been partly facilitated by a process of alienation that has displaced Indigenous men to the point that there is no clear sense of what it is to be an Indigenous male in today’s society. He goes onto say that if he (man) is well then the community benefits (1997).

Many Aboriginal primary health services have tackled this issue very successfully. One example that comes to mind is the approach to men’s health in East Arnhemland. This is by no means the only example.

With the support of the Miwatj Health Service and the Gapuwiyak Council, the Gapuwiyak men’s health program was established in 1997. The impetus for the program came from men in the Gapuwiyak area taking control of their health needs and making things happen. They essentially used existing infrastructure (a demountable unit) to set up a men’s sexual health clinic. Since its inception there has been at least a 600% increase in the number of males attending the clinic – at first for sexual health issues and increasingly for broader primary health care. I do not wish to understate the effort put in by the many people who helped set up the Gapuwiyak men’s clinic, but it was essentially a very simple process that used the available resources, some support from the local health services and a couple of male health workers (Guyula:1998:2).

This example demonstrates three things. Firstly, men’s health must be addressed through separate strategies to women’s health; secondly, when services are specific to male health issues, the men will attend; and third, the service was developed within the terms set down by local men. Other examples have also demonstrated that not only does there need to be specific strategies to address men’s health, but there also needs to be a recognition of men’s role in Indigenous society and how that has an impact on the health of men.

Utilising existing OATSIH programs

To make existing programs more responsive and reduce the possible duplication of programs and resources, one possible option is to ensure that the health of Indigenous males is a major theme running through all programs. This does not mean that men’s health will be relegated to second priority. Rather, it will help to ensure that men’s health gets addressed by all the specific health related programs including substance misuse, social and emotional well-being, sexual health and diabetes etc. In fact, this has already been happening. Examples include the establishment of a few men’s program within some of the Emotional and Social Well-being Regional Centres created under the Commonwealth’s Emotional and Social Well-being Action Plan. Similarly, there have been programs addressing men’s health under the National Indigenous Australians Sexual Health Strategy (1996-97 to 1998-99). Also the Substance Misuse Program has clearly identified men as a key target audience to help reduce the high levels of alcohol and drug overuse.

There are limited resources available to address broad population health issues within the Indigenous community. Therefore, it is important that services are effectively targeted without any unnecessary duplication. Where possible, OATSIH will seek to highlight the needs of Indigenous males and females as discrete groups, but at the same time take steps to promote the broad population health needs. In future years each of the specific OATSIH programs will be encouraged to address men’s health issues.

Workforce strategies

One of the key issues in improving men’s health access will be an increase in the number of men who work in the health sector. For example, the role of male health workers is an important factor in drawing Indigenous males to primary health care facilities and also to help address specific health issues of a sensitive and personal nature such as testicular and prostate cancer. Anecdotal evidence suggests that there are many fewer male than female health workers. Strategies to increase the number of male health workers within primary health care settings will be an important long-term approach to improving male health.

Not only will it be necessary to address issues relating to employment of this workforce but also education and training, course content and the use of exclusionary criteria based on gender in those courses.

Other strategies such as single-issue health worker positions may also be an important tool in increasing the number of male health workers. For example, in many parts of the country, male health workers only work in sexual health or social and emotional well being. It will also be important in the future to increase the number of Indigenous male doctors, nurses and males in Indigenous health policy.

The use of Service Activity Reporting within Aboriginal community controlled health sector

The Service Activity Reporting (SAR) process is a joint venture between the NACCHO affiliated community controlled health services and OATSIH to improve health data and information. The SAR only applies to services funded by OATSIH. The SAR will:

• contribute data and information to the policy and program development process;
• identify workforce issues; and
• total episodes of care by services – including a breakdown by gender.

The implementation of the SAR is not likely to affect the operation of the community controlled health services. In fact, the SAR is likely to provide valuable information in terms of levels of service activity and resource issues that need to be addressed. The first round of the SAR collected data on a range of health service delivery issues. Unsurprisingly, data indicated there were many more women than men accessing health services. These preliminary findings have not however been fully explored.

Promoting an evidence based approach to men’s health

Research is an important part of our overall understanding of men’s health issues and needs to play a key role in developing an evidence base to improve services. However, I am keenly aware of the problems that poor research practices have caused in the past. Notwithstanding this, research should not be excluded from the broad Indigenous men’s health agenda. Information collected through research can be very powerful if used properly. Indigenous men can use information to draw more attention to their needs. There are many things that we already know about Indigenous men’s health, however there are just as many issues that we know little about. We need to be strategic about how we use research.

What are the key principles for future research ?

Suggested principles that may underpin any future research in the area of men’s health include:

• Indigenous men having control any information collected and clear guidelines are established for its use;
• any research needs to bring health benefits the people under research and research reports should contain recommendations for interventions that are evidence based and feasible; and
• researchers and research institutions need to ensure there is transfer of research skills to the community.

Among the suggested issues that need further research that could be considered in this broad strategic approach are:

• how to integrate men’s health programs into existing Aboriginal primary health care centres;
• how to increase participation in the research process by Aboriginal and Torres Strait Islander men;
• the best method for targeting research directed at improving men’s health; and
• how best to improve access to health services for Indigenous males in urban, rural and remote areas.

Future research needs to be conducted in collaboration with Indigenous men so that sensitive issues can be handled with care and understanding. In a recent publication initiated by the Commonwealth, it was pointed out that of all the studies found on Indigenous men’s health, Aboriginal men were the subjects, but not the authors (Connell:unpub). This is a very pertinent point in the current debate. Research will play a vital role in understanding the health needs of Indigenous men.

Summary

There is a need to address the range of health access issues for Indigenous males not only in a strategic fashion but also in a sensitive and effective manner. There are many gender specific issues that need much consideration in the near future. This strategic approach is likely to help address some of these issues and support the current work by Aboriginal primary health care services in resolving some of the difficulties faced by Indigenous men. It also provides a framework for future activities.

There are many Indigenous male health issues that need to be addressed, among these are: the health status of Indigenous males in prison, injecting drug use amongst young Indigenous men, the alarming rate at which family violence is occurring as well as the continued high rates of suicide. Removing barriers to good quality health care is also a fundamental need that requires close consideration. If males are not healthy, and their role in society is diminished, many other issues cannot be addressed adequately.

In this presentation I have attempted to identify a process and key elements of a national strategic framework the Commonwealth is seeking to develop to address Indigenous male health in the near future.

The Commonwealth will work in partnership with key stakeholders to address some of the health access issues for Indigenous males. The Aboriginal and Torres Strait Islander Health Framework Agreements will be an integral part of this process. I have also pointed out that threading men’s health as a theme through all the existing OATSIH programs will focus attention on men’s issues and will reduce the possibility for duplication of services. Workforce, a reporting mechanism and a research agenda have also been identified as important parts of an overall men’s health access strategy. It is likely that other important issues will also be raised in the process of consultation.

Bibliography:

Adams.M (1997) A study into the delivery of service accessible to the needs of Aboriginal and Torres Strait Islander men’s health, Centre for Aboriginal Studies, Curtin University.

Anderson.I (unpub) A Strategic action plan for Aboriginal and Torres Strait Islander research, Discussion paper,

Commonwealth Department of Human Services and Health (1996) Draft National Men’s Health Policy, Commonwealth Department of Human Services and Health.

Australian Institute of Health and Welfare (1998) Australia’s Health, Australian Institute of Health and Welfare, Canberra.

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