As a Victorian provider of community-based primary health care, mental health and social support and health promotion, cohealth welcomes the opportunity to contribute to the Australian Government Department of Health and Aged Care consultation on the Role and Functions of an Australian Centre for Disease Control.
cohealth supports the establishment of an Australian Centre for Disease Control. We are pleased to see the commitment to reducing health inequities, in partnership with communities that too often have not been included in the policy making discussions that impact on them, as embedded in the draft mission statement:
The CDC will strive to achieve health equity with a focus on eliminating preventable health disparities, and will work in partnership with affected communities, particularly those experiencing greater inequity in outcomes, to ensure their voices are included in its direction, priorities and policies. This will include alignment with and incorporation of the Closing the Gap reform priorities in all aspects of the CDC’s work.1
Our responses about the role and function of an Australian Centre for Disease Control are drawn from our extensive experience providing community-based health care and health promotion to diverse communities, including specific responses during the COVID-19 pandemic.
cohealth is one of Australia’s largest community health organisations, delivering care from over 30 locations across the inner, north, and west of Melbourne as well as statewide services across Victoria. cohealth provides integrated general practice, medical specialist, dental, allied health, mental health, alcohol and other drug, counselling, family violence, and social support services to more than 50,000 people each year.
People using cohealth services typically experience social disadvantage and are consequently marginalised from mainstream health services or require a higher level of care and support – such as people who are experiencing homelessness, mental illness, people who use alcohol and other drugs, Aboriginal and Torres Strait Islanders, refugees and asylum seekers, recently released prisoners, LGBTIQ communities and people with chronic and complex health conditions.
cohealth has extensive experience in the areas of preventative health and health promotion. Our Prevention Team collaborates with communities to contribute to the delivery of the Victorian Health and Wellbeing Plan. Across the organisation, promoting good health is a fundamental lens to all our interactions with clients and communities.
cohealth played – and continues to play – a major role on the front line of the COVID-19 response given our footprint in areas most impacted in Melbourne, providing testing, vaccination, health and social support and community engagement. During 2020 and 2021 cohealth provided assessment, health care and support to more than 10 percent of all COVID cases in Australia. cohealth partnered with Royal Melbourne Hospital and the local PHN to deliver the COVID Positive Pathways program to provide medical, social and mental health supports for people who tested positive in the west of Melbourne, reducing the burden on hospitals and allowing people to safely isolate at home.2
Recognising that government messaging and services were not reaching diverse communities, cohealth built on our strong relationships with communities to ensure that culturally appropriate messaging and information reached all communities. This work was most effective when communities were supported to drive their own responses, particularly through funding to employ community members, and when organisations were resourced to take services into communities. Some programs cohealth delivered demonstrating this approach include:
Response to the consultation paper – Role and functions of an Australian Centre for Disease Control
cohealth welcomes the proposal to establish an Australian Centre for Disease Control. Australia has an excellent health system, and by many measures, is a healthy nation. However, significant health inequities exist, with some groups in the community experiencing poorer health, including people experiencing socio-economic disadvantage, people with disabilities and mental health conditions, Aboriginal and Torres Strait Islanders and people from refugee and asylum seeker backgrounds. Concerted and coordinated national effort is required to reduce these inequities and ensure everyone has the opportunity for good health.
Health inequities were exacerbated by the COVID-19 pandemic, where the effects were worse in communities already disadvantaged by social and economic drivers of poor health.3
The COVID-19 pandemic also highlighted the shortcomings of our devolved and fragmented health system. With primary care, aged care and disability care largely the responsibility of the Federal Government, and public health and hospitals primarily the responsibility of individual States and Territories, COVID-19 responses were often implemented differently in different jurisdictions. A lack of coordination contributed to inconsistent policies, approaches and outcomes across the country. The impact on disadvantaged and vulnerable groups of measures designed to protect public health too often did not fully consider the reality of their circumstances, placing them at greater risk – of exposure to the virus, or to greater socio-economic hardship. For example, people ineligible for COVID income support payments had little option but to continue working to support themselves and their families.
In this context, cohealth welcomes the proposals in the consultation paper, particularly:
Structure and governance
Extensive public health systems already exist at Federal, state and territory levels, many of which have been improved during the COVID-19 pandemic. It will be vital that the CDC builds on these existing systems and processes, by enhancing coordination, consistency and communication across jurisdictions, rather than creating duplication.
The CDC must be independent, providing evidence-based advice and coordination and not subject to political influence. As VicHealth CEO Sandro DeMaio has stated:
First and foremost, Australians need and deserve an agency that can make the tough calls and serve the long term health interests of our nation.
To achieve this, its independence will be key.
Governed by a representative group from the sectors it is established to serve, and working with – not for – the government, this independence would empower a CDC to make decisions with confidence, ensuring that outcomes are based on evidence and without political influence.6
To ensure that the CDC is attuned to the needs of groups with the poorest health the CDC governing body and internal structures such as sub-committees and advisory groups should include representatives from these communities, including First Nations, culturally and linguistically diverse, LGBTIQA+ and socio-economically disadvantaged communities.
Health promotion and communication
Health promotion and communication activities are currently undertaken by a wide range of providers, including Federal government, states and territories, and local government, along with not-for-profit organisations and private businesses. The CDC can play a role in coordinating consistent, evidence-based information and messaging on public health issues, particularly those of national significance. To avoid duplication and ensure best use of existing resources, the CDC could have a role in quality control, collection and national dissemination of locally developed health resources.
All health promotion work and communications need to be undertaken in partnership with diverse communities. The experience during the COVID-19 pandemic clearly demonstrated the value of these partnerships. In the first year of the COVID-19 pandemic there was inadequate engagement, and diverse communities did not receive accurate and timely information. Vital health messaging was not conveyed in community languages or in culturally appropriate ways. In contrast, Aboriginal Community Controlled Health Organisations successfully protected their communities by delivering culturally appropriate messaging and support. As the pandemic progressed there was improved engagement with culturally and linguistically diverse communities leading to improved health literacy and uptake of testing, vaccinations and supports.
Ensuring that Australia has the data necessary to identify and respond effectively to public health risks is essential. However, existing data sets often do not share definitions nor collect key demographic data. To assess health risks and impacts and design and communicate effective public health responses it is vital that the CDC and related public health bodies understand which groups in the community are affected. The CDC can play a key role in working to harmonise data collection, and identifying key demographic data collected, particularly that which reflects groups with the poorest health outcomes.
This includes socio-economic status, age, disability, First Nations background and culturally and linguistically diverse background. The minimum data set for CALD communities should be part of routine demographic data collected, and include the fields: country of birth, date of arrival, cultural background, need for interpreter and preferred language/s.
To ensure data is used appropriately members of these groups must be included at all aspects of data use. In particular, the collection and use of Aboriginal and Torres Strait Islander data should respect and operationalise the principles of Indigenous Data Sovereignty, and Aboriginal and Torres Strait Islander leadership and decision making must be embedded into all aspects of data collection, analysis, use and interpretation.7
While Australians receive most of their healthcare in primary care settings from general practitioners (GPs), there is limited use of the primary care data collected for purposes such as research, surveillance and quality improvements. There is also limited data linkage with other routinely collected data from hospitals, specialist and allied healthcare providers, social services and the like.8 This limits knowledge about the patient journey through the healthcare system and impedes efforts to improve health outcomes.
Enhancing primary care data sets, data linkages and usage will be important to design tailored preventative health strategies to those with the poorest health outcomes at national and local levels.
When considering workforce requirements the CDC must include emerging workforces that reflect the communities they work with. In particular, peer and lived experience workforces, including bicultural workers, that can provide culturally appropriate information and services in community languages. During COVID-19 it was clear that when communities were engaged in designing and delivering public health messaging, testing and vaccinations there was a significant improvement in understanding and uptake.
The CDC could also encompass oversight of registration and accreditation requirements to ensure they do not present overly onerous barriers to practice for overseas qualified practitioners.
Wider determinants of health
cohealth welcomes the inclusion of the wider determinants of health in the CDC role, and the focus on influencing and driving positive change in these to improve public health outcomes. While many wider determinants lie outside the health system – income, unemployment and working conditions, social security access and adequacy, housing, experiences of racism and discrimination – and have the biggest impact on health outcomes9, there is no current cross government framework to ensure that the health impacts of policies in these areas are incorporated into the policy making process. The CDC presents a significant opportunity to drive cross government collaboration and action on the wider determinants of health.
Despite the poorer health experienced by groups that experience disadvantage, they receive less health care than those who are least disadvantaged (the ‘inverse care law’10). In order to improve overall health outcomes, the CDC must clearly prioritise improving the health outcomes of groups who already experience poorer health to ensure that health inequities are reduced over time.
To achieve this it will be critical that the CDC works in partnership with the groups that experience poorer health, including First Nations peoples, culturally and linguistically diverse communities, people with disabilities and people from lower socio-economic groups and neighbourhoods. As was clear during the COVID-19 pandemic, and in many previous health campaigns, responses are most effective when designed and delivered in ways that are appropriate to diverse communities.11 The CDC should commit to the principle of ‘nothing about us, without us’,12 and ensure representatives of diverse groups are included across all levels of operation – from governance structures, research and data collection, to health promotion and emergency responses.
National medical stockpile.
The role of primary care in the frontline COVID-19 responses was initially limited by lack of access to adequate personal protective equipment (PPE). To enable rapid grass roots health responses, future planning through a CDC needs to include arrangements for the timely provision to primary care of the resources needed to respond to public health emergencies, including PPE, medications and equipment.
The functions of the CDC must be adequately and securely resourced. To effectively respond to the existing and emerging health issues facing Australia, the CDC must have long term funding certainty, and be able to operate across political cycles. Similarly, addressing the structural drivers of health will take time and commitment. Within the CDC it will be important to ensure clear budgets are maintained for functions such as health promotion and addressing the wider determinants of health to ensure these functions are not subsumed by the need to respond to crises, or the pressure from clinical/technical aspects of the CDC’s function.