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Australian Government - Department of Health

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Australian Government - Department of Health

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Programs & Initiatives

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A list of all Health programs and initiatives.

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Health Systems - Equity

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A characteristic common to groups that experience health inequities-such as poor or marginalized persons, racial and ethnic minorities, and women-is lack of political, social or economic power. Thus, to be effective and sustainable, interventions that aim to redress inequities must typically go beyond remedying a particular health inequality and also help empower the group in question through systemic changes, such as law reform or changes in economic or social relationships.

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Social Determinants of Health

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The World Health Organisation (WHO) defines the social determinants of health (SDOH) as the conditions in which people are born, grow, live, work and age [1]. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

Further background reading is available at the " Social Determinants of Health: The Solid Facts 2nd Edition" and " Social determinants of health inequalities" , while the relevance in Australia is discussed in Australia's Health 2016 .

But how much of the expression of a population's health is a consequence of these social determinants? According to the British Academy (reflected in material at WHO and at the Centers for Disease Control and Prevention ), social determinants, risk factors (like smoking and physical inactivity - which are themselves strongly influenced by social determinants), environment (eg housing and climate) and health services (eg access to primary health care services) account respectively for 40%, 30%, 10% and 20% of the expression of a population's health - although it is probably reasonable to assume that these proportions will vary depending on the population. SDOH have a powerful influence on health.

Source: Australia's Health 2014

Socioeconomic status (ie average incomes, educational levels, career choices, etc) declines with remoteness, and this lower socioeconomic status is frequently cited (along with higher prevalence of Aboriginal and Torres Strait Islander people and lower levels of access to services) as one of the main reasons for poorer health outcomes for people living in rural and remote Australia. The inference is that poorer health outcomes in rural and remote Australia has little to do with rurality and much to do with the lower socioeconomic status of the people living in these areas.

But this misses the point - that employment, career opportunities and consequently education in regional, rural and remote places are restricted precisely because of the nature of towns and communities in these areas. For example:

the percentage of the workforce engaged in primary production (including forestry and fishing) is negligible (<1%) in Major cities, rising to 18% in Outer regional areas and around 30% in remote areas, while;

the percentage working in finance and as professionals decreases from 6% and 9% in Major cities respectively, to less than 2% and less than 4% in rural/regional areas, and to less than 1% and around 2% in remote areas.

By way of occupation, the percentage of the workforce who are managers or professionals is around 40% in Major cities, around 30% in rural/regional areas and around 40% in remote areas while the percentage who are machinery operators, drivers or labourers is 14% in major cities, 20% in rural/regional areas and 23% in remote areas.

These inter-regional differences reflect the nature of available work in these areas, which in turn influences the educational status of people living and working there. The types of available employment in rural and remote Australia are often in industries that are less well remunerated than the available employment in major cities.

In addition to these occupational differences for people who are employed, unemployment rates (as expressed by the percentage of people receiving unemployment benefits in June 2014) increases with remoteness from 5% in Major cities to 7% in rural, regional and Remote areas, to 12% in Very remote areas; while the percentage of families with children classified as low income and welfare dependent increased with remoteness from 9% in Major cities, through 11%, 12% and 14% in regional and Remote areas, to 26% in Very remote areas[13].

Many of the issues related to the level of control over one's own life can become increasingly influential in rural, regional and remote areas. For example:

Rural economies, notwithstanding a broad economic base, frequently rely heavily on the quality of the season to ensure employment and a buoyant economy; but regional rainfall in Australia is notoriously variable from year to year, with greater variation developing as the climate changes.

Regional economies dependent on long term climate stability (eg those dependent on tourism reliant on snowfields and coral reefs), are likely to be increasingly adversely affected as temperatures and ocean acidity rise.

Economies reliant on mining are ephemeral by nature, with the need for community transformation when the resource is depleted.

Commodity prices (eg iron ore and wheat prices) and the cost of inputs (eg diesel and fertiliser) are subject to fluctuation beyond the control of rural and regional businesses.

Some communities experience unrest and violence issues and some population groups can experience discrimination and racism.

The health effects of income and educational disadvantage can be compounded in many communities by poor access to a range of goods and services including affordable healthy food, high-speed broadband, mobile phone coverage and public transport.

The Public Health Information Development Unit , Regional Development Australia's " Insight" and the ABS are all good sources of online regional data including those related to social determinants.

The 2017 Aboriginal and Torres Strait Islander Health Performance Framework report describes a substantial number of health (including social determinants) indicators for Aboriginal and Torres Strait Islander peoples, frequently by remoteness, typically showing greater disadvantage with remoteness.

The NRHA is a member of the Social Determinants of Health Alliance

A number of relatively recent NRHA factsheets relate to social determinants, including:

A number of relatively recent NRHA submissions relate to social determinants, including:

A number of priority recommendations from the 14 th National Rural Health Conference relate to social determinants - namely cultural safety, strong families, Arts in Health and access to Broadband.

Published 30/06/2017
Previous archived edition can be found here.

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The World Health Organisation (WHO) defines the social determinants of health (SDOH) as the conditions in which people are born, grow, live, work and age [1] . These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

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Social determinants and the health of Indigenous peoples in Australia – a human rights based approach

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Social determinants and the health of Indigenous peoples in Australia – a human rights based approach

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Workshop paper presented by Mr Darren Dick on behalf of Mr Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner

International Symposium on the

Social Determinants of Indigenous Health,

Adelaide, 29-30 April 2007

1. Introduction

Improving the health status of Indigenous peoples 1 in Australia is a longstanding challenge for governments in Australia. The gap in health status between Indigenous and non-Indigenous Australians remains unacceptably wide. 2 It has been identified as a human rights concern by United Nations committees 3; and acknowledged as such by Australian governments 4.

Social determinants theory recognises that population health and inequality is determined by many interconnected social factors 5. Likewise, it is a basic tenet of human rights law that all rights are interconnected and that impacting on the enjoyment of one right will impact on the enjoyment of others 6. Because of this synergy, human rights discourse provides a framework for analysing the potential health impacts of government policies and programs on Indigenous peoples. 7

Important determinants of Indigenous health inequality in Australia include the lack of equal access to primary health care and the lower standard of health infrastructure in Indigenous communities (healthy housing, food, sanitation etc) compared to other Australians. While fundamental to improving Indigenous health outcomes, these issues are not addressed in this paper. 8 Instead, this paper considers the social determinants of Indigenous health with reference to human rights principles.

Indigenous health policy in Australia is guided by the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013. One of the nine guiding principles of this is that Governments adopt a holistic approach: 'recognising that the improvement of Aboriginal and Torres Strait Islander health status must include attention to physical, spiritual, cultural, emotional and social well-being, community capacity and governance.' 9 This paper also highlights the inconsistencies between this guiding principle and the practices of Australian governments.

2. Indigenous health in Australia - key trends

The current status of Indigenous health in Australia can be briefly synopsized as follows:

The health status of Australia's Aboriginal and Torres Strait Islander peoples is poor in comparison to the rest of the Australian population.10 There remains a large inequality gap in Australia across all statistics. For example, there is an estimated gap of approximately 17 years between Indigenous and non-Indigenous life expectation in Australia11. For all age groups below 65 years, the age-specific death rates for Indigenous Australians are at least twice those experienced by the non-Indigenous population12.

Indigenous peoples do not have an equal opportunity to be as healthy as non-Indigenous Australians. 'The relative socioeconomic disadvantage experienced by Aboriginal and Torres Strait Islander people compared to non-Indigenous people places them at greater risk of exposure to behavioural and environmental health risk factors'13 as does the higher proportion of Indigenous households that 'live in conditions that do not support good health'.14 Indigenous peoples also do not enjoy equal access to primary health care and health infrastructure (including safe drinking water, effective sewerage systems, rubbish collection services and healthy housing).15

There has been very little progress in reducing this inequality gap between Aboriginal and Torres Strait Islander and non-Indigenous Australians over the past decade, for example in relation to long term measures such as life expectation.

While there have been improvements on some measures of Aboriginal and Torres Strait Islander health status, they have not matched the rapid health gains made in the general population in Australia. For example, death rates from cardiovascular disease in the general population have fallen 30% since 1991, and 70% in the last 35-years16 whereas Indigenous people do not appear to have made any reduction in death rates from cardiovascular disease over this period.17

The young age structure of the Aboriginal and Torres Strait Islander population means that the scope of the issues currently being faced is expected to increase in the coming decades. The increase in absolute terms of the size of the Aboriginal and Torres Strait Islander youth population will require significant increases in services and programs simply to keep pace with demand and maintain the status quo, yet alone to achieve a reduction in existing health inequality.

The inequality in health status experienced by Aboriginal and Torres Strait Islander peoples is linked to systemic discrimination. Historically, Aboriginal and Torres Strait Islander peoples have not had the same opportunity to be as healthy as non-Indigenous people. This occurs through the inaccessibility of mainstream services and lower access to health services, including primary health care, and inadequate provision of health infrastructure in some Aboriginal and Torres Strait Islander communities. The Royal Australasian College of Physicians describes these health inequities as 'both avoidable and systematic'.18 This legacy remains to be fully addressed and is a significant barrier to the full enjoyment of the right to health for Aboriginal and Torres Strait Islander peoples.

3. Indigenous health and human rights - Key principles

The International Covenant on Economic, Social and Cultural Rights (ICESCR) includes the right to the enjoyment of the highest attainable standard of physical and mental health (article 12); the right to an adequate standard of living, including adequate food, clothing and housing (article 11); and the right to education (article 13).

Article 2 of the Covenant requires that governments take steps, to the maximum of their available resources, with a view to achieving progressively the full realization of the rights recognized in the Covenant. It also requires that all rights be enjoyed on a non-discriminatory basis.

The right to health, and these related rights, have been recognised for some time. But it is only in recent years that detailed consideration has been given a rights based approach to health. This framework therefore offers a relatively new perspective on the factors necessary to address health inequalities and ensure to all people the right to the enjoyment of the highest attainable standard of health.

Overall, the human rights based approach to health has the following components. It:

emphasises the accountability of governments for socio-economic outcomes among different sectors of civil society by treating these outcomes as a matter of legal obligation, to be assessed against the norms established through the human rights system;

establishes fundamental principles to guide policy development - such as that Indigenous peoples are not discriminated against and are provided with equality of opportunity, including through recognising their distinct cultural status;

highlights that governments have immediate responsibilities to guarantee that the right to health will be exercised without discrimination of any kind, and to take deliberate, concrete and targeted steps towards the full realisation of the right to health;

recognises as legitimate, and as non-discriminatory, the establishment of specific programs for particular groups (such as based on race) which are taken with the purpose of addressing inequality;

establishes that the obligation of government is to respect, protect and fulfil the right to health, which requires a combination of responses ranging from refraining from committing harmful acts, introducing measures to prevent others from committing such acts, and taking positive steps to realise the right to health;

emphasises process for achieving improvements in these outcomes, with the free, active and meaningful participation of Indigenous peoples being critical;

establishes criteria against which to assess health policy and program interventions to ensure that services are appropriate, accessible, available and of sufficient quality, and that they also do not fall below a core minimum or essential level of rights;

requires governments, working in partnership with Indigenous peoples, to demonstrate that they are approaching these issues in a targeted manner, and are accountable for the achievement of defined goals within a defined timeframe; and

places the burden on government of justifying that it has made every effort to use all available resources at its disposal in order to satisfy, as a matter of priority, the right to health.

A rights based approach to health has begun to be operationalized throughout the United Nations structure through the Common Understanding of a Human-Rights Based Approach to Development Cooperation.19 The Common Understanding emphasises, inter alia, that:

People are key actors in their own development, rather than passive recipients of commodities and services;

Participation is both a means and a goal; and

Strategies should be empowering, not disempowering, and encourage active engagement of all stakeholders.

These human rights considerations are critical in addressing the social determinants of health.

Social determinants of Indigenous health in Australia
(a) Links between health status and socio-economic status / poverty
Indigenous peoples in Australia experience socio-economic disadvantage on all major indicators. For example:

At the 2001 National Census, the average gross household income for Indigenous peoples in Australia was $364 per/week, or 62% of the rate for non-Indigenous peoples ($585 per/ week) .20

At the 2001 Census, the unemployment rate for Indigenous peoples was 20%; three times higher than the rate for non-Indigenous Australians21.

Nationally in 2004, Indigenous students were also half as likely to continue to year 12 as non-Indigenous students22.

Research has demonstrated associations between an individual's social and economic status and their health. Poverty is clearly associated with poor health. 23 For example:

Poor education and literacy are linked to poor health status, and affect the capacity of people to use health information; 24

Poorer income reduces the accessibility of health care services and medicines;

Overcrowded and run-down housing is associated with poverty and contributes to the spread of communicable disease;

Poor infant diet is associated with poverty and chronic diseases later in life;25 and

Smoking and high-risk behaviour is associated with lower socio-economic status.26

Research has also demonstrated that poorer people also have less financial and other forms of control over their lives. 27 This can contribute to a greater burden of unhealthy stress 28 where 'prolonged exposure to psychological demands where possibilities to control the situation are perceived to be limited and the chances of reward are small.' 29 Chronic stress can impact on the body's immune system, circulatory system, and metabolic functions through a variety of hormonal pathways and is associated with a range of health problems from diseases of the circulatory system (notably heart disease) 30, mental health problems 31, violence against women and other forms of community dysfunction. 32
(b) Linkages between perceptions of control and chronic stress
In the National Aboriginal Health Strategy (1989), Indigenous peoples stated that their health status is linked to 'control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity' 33.

In making these assertions, Indigenous peoples anticipated developments in social determinants theory over the 1990s. It is now generally accepted that an individual's perceived lack of control over their lives can contribute to a burden of chronic, unhealthy stress contributing to mental health issues, violence and substance abuse 34.

This is the experience among Indigenous Australians. For example:

An indicator of chronic stress in a population group is high rates of high-risk health behaviour, notably substance abuse.35 In 2002, just under one-half of the Indigenous population aged15 years or over smoked on a daily basis36. One in six reported consuming alcohol at risky or high risk levels.37

High rates of mental health problems also indicate chronic stress in a population group. 38 In 2003-04, Indigenous people were up to twice as likely to be hospitalised for mental and behavioural disorders as other Australians.

Hospitalisation rates for assault or intentional self-harm may also be indicative of mental illness and distress. In 2003-04, Indigenous males were 7 times more likely, and females 31 times as likely as for males and females in the general population; hospitalisation rates for intentional self-harm was twice as high.39

Relatively permanent, negative features of the social environment trigger chronic stress: intergenerational poverty, racism, and so on. It can impact on the body's immune system, circulatory system, and metabolic functions through a variety of hormonal pathways and is associated with a range of health problems, particularly diseases of the circulatory system. 40 These are currently the biggest killer of Indigenous people in Australia.

The WAACHS found that the environmental safety and the emotional and social health of Indigenous children improved with isolation (that is, those in remote communities had better mental health). Children living in Perth had significantly poorer (in fact, five times worse) emotional and social health than those living in very remote communities. The report concludes that traditional cultures and ways are protective against poor environmental safety and emotional and social health. 41

To the degree recognising Indigenous peoples' right to self-determination supports communities to regain control of their lives, including through the maintenance of traditional cultures, it can be understood as having positive health impacts. It is also a stepping-stone to the goal of social and economic equality. Experience from overseas confirms that Indigenous communities' control over their own affairs can be crucial to their social and economic regeneration 42.
(c) Evidence of the health impact of Indigenous community control of health services
Aboriginal community controlled health services an excellent example of how communities can be empowered by exercising control of local services. While the fact of control may in and of itself be expected to bring broader health benefits, the ability of communities to decide on, and address, their own health priorities has been found to increase the impact of primary health care in communities. 43

For example:

The Northern Territory Well Women's Program, which operates in a region with a high proportion of Aboriginal women and has a long history of engagement with women and local Aboriginal Health Services, has achieved a high rate of cervix screening (61%) in the Alice Springs remote area, which is comparable to the rate for Australian women generally (62%). \

A mental health project at the Geraldton Regional Aboriginal Medical Service reduced psychiatric admissions of Aboriginal and Torres Strait Islander people to Geraldton Regional Hospital by 58%.

Since 2000 the Townsville Aboriginal and Islander Health Service's Mums and Babies Project increased the numbers of women presenting for antenatal care (from 40 to over 500 visits per month in 1 year). The number of antenatal visits made by each woman has doubled, with the number having less than four visits falling from 65% to 25%. Pre-natal deaths per 1,000 reduced from 56.8 prior to the program to 18 in 2000; the number of babies with birth weights less than 2,500 grams has dropped significantly; and the number of premature births has also decreased.

Since 1990 an antenatal program at Daruk Aboriginal Community Controlled Medical Service, Western Sydney has achieved increased awareness among Aboriginal women of the importance of antenatal care. Thirty-six (36) per cent of Indigenous women presented within the first trimester, compared with 21% at Nepean and 26% at Blacktown Hospitals' antenatal clinics; and women attended more antenatal visits (an average of 10 at Daruk compared to 6 at Nepean and 9 at Blacktown).
(d) Traditional ownership of land and health status
The right of self-determination includes the right of peoples to freely 'dispose of their natural wealth and resources' and that 'in no case may a people be deprived of its own means of subsistence'.

Native title and the title to communally owned land (through the various Aboriginal land rights legislation in Australia) is the 'natural wealth and resources' of Indigenous peoples.

As noted above, supporting traditional culture - including customary law and governance structures - is likely to help improve the health status of people living in remote communities. In practice, this also means ensuring Indigenous peoples have access to their traditional lands.

While Indigenous commentators have highlighted the social and culturally related health benefits of access to land, 44 many possible positive health impacts are likely including improved diet, exercise, and the reconnection of Indigenous peoples with their traditional economic bases.

The Kuka Kanyini project in Wattaru, South Australia in the Anangu Pitjantjatjara Lands illustrates these benefits.
(e) Social determinants as a contemporary reflection of historical treatment
Indigenous peoples are not merely 'disadvantaged citizens'. The poverty and inequality that they experience is a contemporary reflection of their historical treatment as peoples. The inequality in health status that they continue to experience can be linked to systemic discrimination.

In Australia, this has been vividly demonstrated by:

the Royal Commission into Aboriginal Deaths in Custody, which illustrated the links between socio-economic status and imprisonment; and

the National Inquiry into the Forcible Removal of Aboriginal and Torres Strait Islander Children From Their Families (or Bringing them Home), which illustrated the inter-generational problems for parenting, health, and care and protection of the removal of children during the assimilation period.

The following examples (both contemporary and historical) demonstrate the negative impact of social determinants on Indigenous peoples' health.

Racism is a stressor that has been reported to affect both mental and physical health. A 2003 review of 53 studies in the United States found a decline in mental health status as racism increased 46. Eight out of 11 studies found links between the elevated prevalence of high blood pressure in Afro-Americans and racism 47. There have been very few studies on the impact of racism on the health of Indigenous people in Australia, although experts agree that a correlation with the US studies is to be expected 48.

One such study is the Western Australian Aboriginal Child Health Survey 2001-02 (WAACHS). It reported than 21.5% of the Indigenous children under 12 surveyed experienced racism in the previous 6-months. This was associated with increased smoking, marijuana use and alcohol consumption in these under-12s 49.

Children removed from their families ('stolen generations')

The National Aboriginal and Torres Strait Islander Social Survey 2002 reported that 38% of respondents had either been removed themselves and/or had relatives who, as a child, had been forcibly or otherwise removed from their natural family. 50

The practice has intergenerational health impacts. The WAACHS reported that the effect on parents was that they had higher rates substance abuse and mental health problems. Their children were twice as likely to have emotional and behavioural problems, to be at high risk for hyperactivity, emotional and conduct disorders, and twice as likely to abuse alcohol and drugs. 51

Indigenous women as victims of crime

Research conducted by the Social Justice Commissioner on the circumstances of Indigenous women's prisoners in Australia found that Indigenous women are victims of a complex frame of dynamics upon their lives including violence, poverty, trauma, grief, loss, cultural and spiritual breakdown.

Indigenous women are particularly vulnerable to intersectional discrimination within criminal justice processes due to the following reasons:

the combination of socio-economic conditions faced by many indigenous women; including being more likely than non-indigenous women to be unemployed, to have carer responsibilities for children other than their own, to receive welfare payments and to have finished school at an earlier age; and to be a victim of violence and also more likely to live in communities where violence is prevalent. These factors combine to make Indigenous women particularly vulnerable and their needs more complex than others.

Second, due to the consequences of family violence in indigenous communities, and its impact on Indigenous women. This has not been grappled with appropriately by the criminal justice system. Policies and programs provide relatively little attention to the high rate of indigenous victimization, particularly through violence and abuse in communities. Indigenous women disproportionately bear the consequences of this.

There is a consistent pattern indicating that incarcerated Indigenous women have been victims of assault and sexual assault at some time in their lives. There was also a strong relationship between incarceration and experiences of violence, drug and alcohol abuse, with Indigenous women often entering custody with poor physical or mental health, and at higher risk of self harming when in prison and also soon after release from prison.

As a consequence, the rate of Indigenous women being imprisoned has increased most rapidly in Australia since 2000. Indigenous women also experience extremely high rates of recidivism.

In consultations to identify solutions to address this situation, Indigenous women emphasised the importance of healing to address grief and trauma as a major priority. Strategies need to respond to the circumstances of indigenous women holistically, which seeks to not only address offending behaviours but also focus on healing the distress and grief experienced by many indigenous women and their communities.

Text box 3 below contains a case study of a program that attempts to help heal the trauma experienced by survivors of the Stolen Generation, Indigenous women prisoners and other Indigenous people.

In 1991, Australia commenced a formal process of reconciliation with Indigenous peoples. The Council for Aboriginal Reconciliation made its recommendations to the nation in 2000. The federal government responded to these recommendations by emphasising the need to address 'practical' issues such as disadvantage, as opposed to 'symbolic issues' which they described as including recognition of rights, a treaty and a national apology to the Stolen Generations, and other forms of reparation.

'Practical reconciliation' rests on an artificial division between measures that are described as practical as opposed to symbolic. 52 But, as social determinants theory would suggest, no such clear distinction exists - there are interdependencies between many of the dimensions of Indigenous disadvantage; including how social and historical factors can influence contemporary Indigenous practical outcomes. At the moment a more lasting and meaningful reconciliation process is the task of future generations.
5. Recognising social determinants as a contemporary reflection of the impact of colonisation - international developments
Recognising the contemporary impact of colonization on Indigenous peoples globally remains a major challenge for the international community and the United Nations. It is also a major challenge for those seeking to understand the social determinants of health among Indigenous communities.

At the launch of the Second International Decade for the World's Indigenous People, Ms Mililani Trask vividly described this challenge. She stated:
Governments speak of 'poverty' while Indigenous Peoples speak of 'rights'. Within Indigenous territories, poverty is also defined by power deficits, lack of self-determination, marginalization and lack of mechanisms for meaningful participation and access to decision-making processes... Poverty alleviation must start from Indigenous Peoples own definitions and indicators of poverty...53
Applying the Millennium Development Goals to the situation of Indigenous peoples, she continued:

the effort to meet the targets laid down for MDGs could in fact have harmful effects for indigenous peoples such as the acceleration of loss of lands and natural resources or the displacement from those lands. (The MDG indicators need to be redefined to be relevant to indigenous peoples by taking into consideration)... culturally appropriate indicators, redefining the process of impoverishment caused by dispossession of ancestral lands, loss of control over natural resources and indigenous knowledge, devastating social and environmental impacts, impacts from militarization and conflict and forced assimilation into the mainstream society and integration into the market economy. 54

She concluded:

The human-rights based approach to development is essential to the achievement of the MDGs. The MDGs must therefore be firmly grounded on a rights-based approach, to have meaning for Indigenous Peoples. 55

The United Nations Permanent Forum on Indigenous Issues (PFII) have identified that to address these concerns there is a need for processes for indigenous peoples 'to identify gaps in existing indicator frameworks, examine linkages between quantitative and qualitative criteria, and propose the development of indicators that are culturally-specific, measure exclusion, and reflect the aspirations of indigenous peoples'. 56

The PFII convened a meeting in Ottawa in February 2006 to this end. 57 It identified numerous challenges at the national and international level in developing appropriate indicator frameworks and linking these to the Millennium Development Goals. They stated, inter alia, that:

Indicators must place significant emphasis on indigenous peoples' inherent values, traditions, languages, and traditional orders/systems, including laws, governance, lands, economies etc. Collection of data and development of indicators should, therefore, also represent indigenous peoples' perceptions and understanding of well-being. It was noted, however, that not everything relating to indicators development undertaken by governments is relevant to indigenous peoples and not everything that indigenous peoples perceive can be measured.

Indicators should also focus on the interplay between indigenous and non-indigenous systems (social, political and economic, colonization, industrialization) that result in a series of impacts, such as racism and discrimination, migration to urban centres, youth suicide and disconnection to land and culture.

Indicators that demonstrate inequities and inadequacies in government funding for indigenous peoples' programming and services should also be developed. This data can be illuminating by linking funding levels to mandated areas of government responsibility, assessing their accountability and projecting demand and other impacts into the future.

There should be a balance of comparative indicators to assess well-being among non-indigenous and indigenous peoples, and indigenous-specific indicators based on indigenous peoples' visions and understandings of well-being.58

The Workshop recommended that 'the United Nations should identify and adopt appropriate indicators of indigenous identity, lands, ways of living, and indigenous rights to, and perspectives on, development and well-being' and that these indicators should by applied in performance measurement and monitoring processes by the UN system, as well as its member states, intergovernmental organizations and other development institutions. 59

Accordingly, the Workshop proposed a series of indicators that could be further considered at the national and international level based on the two key themes of:

Identity, Land and Ways of Living; and

Indigenous Rights to, and Perspectives on, Development.

The Workshop noted that 'more exact indicators need to be developed in a measurable form, with full participation by indigenous peoples from all regions'. 60 The proposed indicators relate to the following issues:

Maintenance and development of Traditional Knowledge, Traditional Cultural expressions and practices;

Use and intergenerational transmission of indigenous languages;

Support of, and access to, bilingual, mother tongue, and culturally appropriate education;

Ownership, access, use, permanent sovereignty of lands, territories, natural resources, waters;

Health of communities - including community safety, community vitality, and support for safe and culturally appropriate infrastructure;

Health of ecosystems;

Patterns of migration;

Indigenous governance and management systems;

Free, prior, informed consent, full participation and Self-determination in all matters affecting indigenous peoples' well-being;

Degree of implementation/compliance with international standards and agreements relating to indigenous peoples' rights; and

Government funding for indigenous peoples' programs and services.61

6. Conclusions and lessons

This paper has addressed a broad range of issues. It seeks to demonstrate the connections between low socio-economic status and poverty, and health outcomes. It demonstrates that the social determinants of health for Indigenous peoples reflect more than just their relative disadvantage. It also reflects the non-recognition and non-enjoyment of their human rights and of their distinct cultural characteristics.

Indigenous peoples globally have actively noted the importance of a human rights based approach to addressing their disadvantage and to ensuring the survival of their cultures.

An approach to social determinants that fails to recognise the fundamental connections between health status and the enjoyment of human rights will fail.

Footnotes

[1] Throughout this chapter I refer to Aboriginal and Torres Strait Islander peoples as 'Indigenous peoples'. In doing so, I acknowledge the distinct cultures and societies of different Aboriginal peoples and Torres Strait Islanders. The term 'peoples' is also used to recognise the collective dimension of the livelihoods of Indigenous people, with distinct cultural beliefs that differentiate them as a group from other Australians.

[4] See, for example, the 2nd and 3rd periodic report of Australia to the Committee on the Rights of the Child (submitted 29 December 2004, UN Doc: CRC/C/129/Add.4, p5) and the 14th periodic report of Australia to the Committee on the Elimination of Racial Discrimination (submitted 1 April 2004, UN Doc: CERD/C/428/Add.2, paras 80-81.

[15] Communicable and water-borne diseases and parasites are indicators of poor health infrastructure. Infants and children are particularly vulnerable to these diseases.

[24] Fred Hollows Foundation, Literacy for Life, Australian National University, Canberra, 2004, pp10-12, available online at http://www.hollows.org/content/TextOnly.aspx?s=244 . See also the issues raised in: Malin, M, Is schooling good for Indigenous children's health?, Cooperative Research Centre for Aboriginal and Tropical Health & Northern Territory University, 2003, available online at: http://www.acer.edu.au/research/special_topics/ind_edu/report_papers.html.

[25] Wadsworth, M., Early Life, in (eds.), Marmot, M. and Wilkinson, R., Social Determinants of Health, Oxford University Press, New York, 1999, p44.Chronic diseases that have poor diet as a determinant include cardiovascular disease, Type 2 diabetes and renal disease. Connections have been made between poor foetal nutrition and the presence of chronic diseases later in life: National Health and Medical Research Council, Nutrition in Aboriginal and Torres Strait Islander peoples - An information paper, Commonwealth of Australia, 2000,p15.

[42] Cornell, S, 'The importance and power of Indigenous self-governance: Evidence from the United States', Speech, Indigenous Governance Conference, 3 April 2002, p1.

[44] See generally Burgess, P., and Morrison, J., 'Country' in Editors, Carson, B, Dunbar, T, Chenall, R, et.al., op.cit., pp177-196

[48] See generally Paradies, Y, 'Racism' Editors, Carson, B, Dunbar, T, Chenall, R, et.al., op.cit.,pp65-80.

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Social determinants and the health of Indigenous peoples in Australia - a human rights based approach

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Improving the health status of Indigenous peoples1 in Australia is a longstanding challenge for governments in Australia. The gap in health status between Indigenous and non-Indigenous Australians remains unacceptably wide.2 It has been identified as a human rights concern by United Nations committees3; and acknowledged as such by Australian governments4.

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Australian Institute of Health & Welfare

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Australian Institute of Health & Welfare

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Australia's Health 2016 - Social Determinants of Health

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Social Determinants of Health

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November 2017 - During the Fourth Global Forum on Human Resources for Health the National Health Workforce Accounts (NHWA) were launched with an aim to provide concise information on the health workforce situation and trends of a country; facilitate the standardization of a health workforce information system; as well as to support tracking Human Resources for Health policy performance towards UHC.

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What is Heath Equity?

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What is Health Equity? This three-minute motion graphic video explains how social, economic, and environmental conditions can create health inequities and how these inequities can affect health disparities. For more information and to download our infographic series visit: http://healthequity.sfsu.edu/content/infographic Motion graphic designed by Peter Wang, Department of Design and Industry, SF State.

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Global hands - Social Determinants of Health

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Global hands - Social Determinants of Health

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Global Hands - Social Determinants of Health

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James discusses four key ideas in health promotion, including the social model of health; the Ottawa Charter for health promotion; the 'causes of the causes'; and values in health promotion.

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Understanding Health Promotion - A Short Introduction

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Understanding Health Promotion - A Short Introduction

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Department of Health & Human Services

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Defining Health Promotion

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Health promotion is the process of enabling people to increase control over, and to improve their health.

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World AIDS Day Australia | World AIDS Day

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World AIDS Day is held on 1 December each year. It raises awareness across the world and in the community about the issues surrounding HIV and AIDS. It is a day for people to show their support for people living with HIV and to commemorate people who have died.

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Australian Government - Department of Health

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Australian Government - Department of Health

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Cancer Screening

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Cancer screening can help protect your health through early detection, even if you don't have any symptoms of the disease. Simple screening tests look for particular changes and early signs of cancer before it has developed or before any symptoms emerge.

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What is health promotion? - Australian Health Promotion Association

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Australia's peak health promotion body, the Australian Health Promotion Association is the only professional association in Australia specifically for people interested or involved in the practice, research and study of health promotion.

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Health for all, and all for health

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WHO: Promoting health, promoting sustainable development: 9th Global health promotion conference

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The world has many barriers to good health. To overcome them, governments, communities and individuals must do more to promote healthy practices. Health promotion is about enabling and empowering individuals, communities and societies to take charge of their own health and quality of life.

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9th Global Conference on health Promotion Shanghai, 2016

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9th Global Conference on health Promotion Shanghai, 2016

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WHO: Shanghai Declaration on Health Promotion

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The Shanghai Declaration on Health Promotion was issued on 21 November 2016 at the opening of the 9th Global conference on health promotion. The Declaration commits to make bold political choices for health, stressing the links between health and wellbeing and the United Nations 2030 Agenda for Sustainable Development and its Sustainable Development Goals.

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Health Promotion

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Health promotion: WHO health topic page on health promotion provides links to descriptions of activities, reports, publications, statistics, news, multimedia and events, as well as contacts and cooperating partners in the various WHO programmes and offices working on this topic.

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Ottawa Charter

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Health promotion is the process of enabling people to increase control over, and to improve, their health.

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VicHealth

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What is Health Promotion Programs & Initiatives | VicHealth

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What is health promotion and does it really work? Research and case studies provide convincing evidence that health promotion is effective. Read more today.

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Health Promotion and the Ottawa Charter - Creating Healthier Populations: