The rate of Aboriginal and Torres Strait Islander people employed in health-related occupations increased from 96 to 173 per 10,000 between 1996 and 2016
The number of Indigenous Australians employed as medical practitioners increased from 155 to 363 between 2006 and 2017
Indigenous Australians made up 54% (4,255) of the employed full-time equivalent workforce in Commonwealth-funded Indigenous primary health-care organisations in 2017–18, of which 89% (3,769) were employed in Aboriginal Community Controlled Health Services
Why is it important?
Aboriginal and Torres Strait Islander people are significantly under-represented in the health workforce. This under-representation potentially contributes to reduced access to health services for the broader Indigenous Australian population. The accessibility of a health service goes beyond its physical availability and also encompasses other aspects, such as whether it is culturally safe (Scrimgeour & Scrimgeour 2008). The provision of culturally safe care is essential to meet the health care needs of Indigenous Australians effectively and requires health professionals to have considered power relations, cultural differences and patients’ rights (AHMAC 2016). Culturally safe health care includes the provision of services underpinned by Indigenous Australians’ beliefs and values (AH&MRC 2015). Recognition and understanding of the diversity of Indigenous cultures and regional variations is also vital to providing culturally safe care (Scrimgeour & Scrimgeour 2008). A key feature of Aboriginal Community Controlled Health Services (ACCHSs) is the provision of culturally safe care, and research has found the ACCHS sector to be a leading employer of Indigenous Australians (Campbell et al. 2018).
The Indigenous workforce is integral to ensuring that the health system can address the needs of Indigenous Australians. Indigenous health professionals can align their unique technical and sociocultural skills to improve patient care, improve access to services and support the provision of culturally appropriate care in the services that they and their non-Indigenous colleagues deliver (Anderson et al. 2009; West et al. 2010). While the Indigenous workforce plays an important role in the provision of culturally appropriate services, it is the responsibility of the health-care system to ensure that mainstream health services are culturally competent through high quality professional development and training, appropriate management where cultural respect is lacking, and staff developing awareness of their own unconscious bias (AHMAC 2016).
International studies have found that people prefer seeing health professionals from the same ethnic background and that improved health outcomes can result (LaVeist et al. 2003; Powe & Cooper 2004). Australian research has shown that Indigenous Australians want their health care to include Indigenous staff and clinicians (Lai et al. 2018). There can be a preference among Indigenous Australians for care by Indigenous health professionals, and qualitative research has shown that Indigenous health staff appeared to sustain better connection, rapport and trust with Indigenous patients (de Witt et al. 2018; Hayman N.E. et al. 2009) and reduce their anxiety and enhance communication (Freeman et al. 2014). There is evidence to suggest that Indigenous health workers may help to improve attendance at appointments, acceptance of treatment and assessment recommendations, reduce discharge against medical advice, increase patient contact time, enhance referrals and improve follow up (Jongen et al. 2019).
What does the data tell us?
Health workforce employment rates
An analysis of the 2016 Census of Population and Housing (Census) indicates that there were 11,161 Indigenous Australians aged 15 and over employed in health-related occupations. Between 1996 and 2016, the rate of Indigenous Australians aged 15 and over employed in health-related occupations increased from 96 to 173 per 10,000 (Figure 3.12.1). This was lower than the rate of employment for non-Indigenous Australians in 2016 (369 per 10,000) (Table D3.12.12).
Figure 3.12.1: Indigenous persons aged 15 and over employed in health-related occupations, by health-related occupation, 1996 to 2016
The 2016 Census found that 2.6% of the total Indigenous population aged 15 and over were employed in health-related occupations, a lower rate than the proportion of the non-Indigenous population aged 15 and over who were employed in the health workforce (approximately 4.1%) (Table D3.12.13, Table D3.12.14) (ABS 2018).
Health-related occupations with the largest number of Indigenous employees aged 15 and over were nursing (52 per 10,000, or 3,383), followed by nursing support and personal care workers (27 per 10,000, or 1,731), and Aboriginal and Torres Strait Islander Health Workers (19 per 10,000, or 1,253). The health-related occupations with the largest gap between rates of Indigenous and non-Indigenous employees were nurses, medical practitioners and allied health professionals (Table D3.12.12, Figure 3.12.2).
Figure 3.12.2: Employed persons aged 15+, by health-related occupation and Indigenous status, Australia, 2016
The rate of Indigenous Australians aged 15 and over employed in the health workforce varied from 93 per 10,000 in the Northern Territory to 221 per 10,000 in Victoria (Table D3.12.13). The highest number of Indigenous Australians in the health workforce was in the 25–34 and 45–54 age groups (2,677 and 2,710, respectively). Females accounted for 77% of the Indigenous health workforce, similar to the proportion of females in the total health workforce (76%) (Table D3.12.3).
Indigenous specific primary health care services
For Commonwealth-funded Indigenous primary health care organisations, Indigenous Australians made up 54% (4,255) of the workforce as at June 2018 (excluding visiting staff).
Of the 4,255 full-time equivalent (FTE) Indigenous staff, 3,769 (89%) were employed at ACCHSs. The occupation with the highest proportion of Indigenous staff was administrative staff (Table D3.12.15, Figure 3.12.3).
Figure 3.12.3: Number of Indigenous FTE staff employed by Commonwealth-funded Aboriginal and Torres Strait Islander primary health care organisations, by organisation type, 2017–18
Of all FTE staff in Commonwealth funded Indigenous primary health care organisations, the number of FTE staff who were Indigenous was highest in Outer regional areas (AIHW 2019).
The proportion of staff in all Commonwealth funded Indigenous primary health care organisations who were Indigenous was highest for Aboriginal and Torres Strait Islander Health Practitioners (98%), Aboriginal and Torres Strait Islander health workers (94%), outreach workers (88%) and drivers/field officers (88%). The professions with the lowest proportion of Indigenous staff were for medical specialists (0.4%), followed by general practitioners (7%), allied health professionals (12%), and nurses and midwives (17%) (Table D3.12.15).
Registered and employed health professionals
On 1 July 2012, the profession Aboriginal and/or Torres Strait Islander Health Practitioner was added to the National Registration and Accreditation Scheme, which regulates the registration standards of 16 health professions across Australia (AHPRA 2019). In 2018–19, there were 690 registered Aboriginal and/or Torres Strait Islander Health Practitioners in Australia, with the majority in the Northern Territory (223), followed by New South Wales (133), Western Australia (130), Queensland (123), South Australia (54), Victoria (21), Tasmania (3) and the Australian Capital Territory (3).
Data from the National Health Workforce Data Set, which collects data on registered health professionals, found that in 2017 there were 5,087 Indigenous Australians registered as health professionals. Of those, 70% (3,540) were employed as a nurse and/or midwife, 22% (1,130) as an allied health professional and 7% (363) as a medical practitioner (Table D3.12.1).
The rate of registered Indigenous health professionals was highest for those aged 45–54 and 55–64 (795 and 736 per 100,000, respectively). For non-Indigenous Australians, the rate was highest among those aged 35–44 and 45–54 (4,240 and 4,182 per 100,000, respectively) (Table D3.12.3).
Females accounted for 82% of registered Indigenous health professionals, which was higher than the proportion of non-Indigenous registered health professionals who were female (75%). Indigenous females were more likely than Indigenous males to be employed in most health professions; the exceptions were chiropractors (74% were males) and optometrists (56% were males). For Indigenous osteopaths, half were male and half were female (Table D3.12.2).
For Indigenous Australians, the registered health professional employment rate was highest in Major cities (859 per 100,000), followed by Inner and Outer regional areas combined (550 per 100,000) and Remote and Very remote areas combined (327 per 100,000) (Table D3.12.5, Figure 3.12.4).
Figure 3.12.4: Rate of Indigenous Australians registered in health professions, by remoteness area, 2017
Indigenous employment rate as a proportion of the Indigenous population
Of employed medical practitioners, 363 (0.4%) identified as being Indigenous. The proportion of medical practitioners that identified as Indigenous ranged from 0.2% (55) in Victoria to 1.7% (20) in the Northern Territory (Table D3.12.6). Between 2006 and 2017, the number of Indigenous Australians employed as medical practitioners increased from 155 to 363 (Table D3.12.7).
Of employed nurses and midwives, 3,540 (1.1%) identified as being Indigenous. The proportion of nurses and midwives that identified as Indigenous was lowest (0.5%, or 427) in Victoria and highest in Tasmania (2.2%, or 175) (Table D3.12.9). Between 2011 and 2017, the number of Indigenous Australians employed as nurses and midwives increased from 2,246 to 3,540 (Table D3.12.10).
In 2017, there were 1,130 employed Indigenous allied health professionals, which represented 0.9% of all allied health professionals. Aboriginal and Torres Strait Islander health practitioners were the largest category with 487 employed (representing 100% of all Aboriginal and Torres Strait Islander Health Practitioners), followed by psychologists (179, representing 0.7% of all psychologists). There were 89 Indigenous dental practitioners, representing 0.4% of this profession (Table D3.12.1).
What do research and evaluations tell us?
Indigenous Australians’ use of health services increases when they can receive culturally appropriate care (Roseby et al. 2019). In a Queensland clinic, Indigenous patient attendance increased markedly following the arrival of an Indigenous doctor and in response to other changes in the service designed to make it more welcoming. An Indigenous doctor was said to be ‘more understanding of their needs’ (Hayman N. 1999; Lawrence et al. 2009). Indigenous patients have identified the absence of Indigenous workers and adverse treatment by non-Indigenous health workers as barriers to the accessibility, quality and effectiveness of health care (Aspin et al. 2012).
Some Indigenous Australians reported scepticism of the ability of mainstream health services to deliver care in a culturally respectful way (Hayman N.E. et al. 2009). Aboriginal Medical Services (AMS) provide a culturally appropriate alternative to mainstream health services that can improve service uptake. Participants in a Brisbane study of government-controlled AMS and ACCHS reported marked health improvements in their communities due to the establishment of these services, and their important role in addressing the negative effects of discrimination on health (Baba et al. 2014). AMS provide holistic care that corresponds with the complex concepts of health shared by Indigenous Australians (Baba et al. 2014). ACCHSs are also the primary setting for employment and training of Indigenous Australians in Aboriginal Health Worker positions and offer pathways for tertiary education and professional training (Campbell et al. 2018).
In a study of census data over 2006–2016, Wright and others (2018) examined self-reported employment data to estimate the number of Indigenous health workers, using the Australian and New Zealand Standard Classification of Occupations category of ‘Indigenous health worker’ (Wright et al. 2019). They found growth in the number of Indigenous health workers to be incommensurate with population growth. This analysis also concluded that the Indigenous health workforce was ageing, and that there had been a reduction in the share of health workers who were male. The authors recommended that more effort is needed to improve recruitment and retention, particularly of younger age groups and males.
A review of strategies to strengthen the workforce in the Indigenous primary health-care sector found that the engagement and retention of Indigenous health professionals have been supported in a number of ways, including: co-worker support and peer mentoring; inclusiveness, workplace cultural safety and culturally competent human resources policy and practice; role recognition and clear definition of roles; job security and adequate remuneration; and support for expanded roles and career progression (Jongen et al. 2019).
The New South Wales Aboriginal Population Health Training Initiative (APHTI) was established in 2011 by the New South Wales Government to strengthen the Indigenous workforce with suitably trained and skilled public health practitioners (Li et al. 2017). The APHTI is a three-year public health training program for Indigenous Australians, in which trainees undertake a series of supervised work placements in population health and complete a Master of Public Health degree. A 2014 evaluation, and subsequent program outcomes, have shown the APHTI to be successful, with high retention and completion rates—noting that the program to date had involved a relatively small number of 18 participants. The APHTI’s success was attributed to: enabling trainees to stay within their communities; simultaneous work and study enabling trainees to develop skills and achieve competencies; and strong leadership and support from the New South Wales Government.
The Home Medicines Review (HMR) program aims to improve medication management and adherence. In 2009, the Danila Dilba Health Service in Darwin adjusted its HMR program to include an expanded role for a dedicated consultant pharmacist and an Aboriginal Health Worker to help identify patients for HMR referral, as well as coordination of the HMR process (Deidun et al. 2019). Involving Aboriginal Health Workers in the HMR process has been identified as an essential requirement for the success of Indigenous HMR programs. The in-depth community knowledge of Aboriginal Health Workers, strong relationships between Aboriginal Health Workers and pharmacists, and the provision of culturally appropriate medicines campaigns are key to effective use of medicines in Indigenous communities. A 2010 evaluation of the Danila Dilba Health Service HMR program found that general practitioners and pharmacists acknowledged the importance of Aboriginal Health Worker involvement in HMR activities and of them consistently accompanying the pharmacist. Access to, and the effectiveness of, HMRs were improved by including Aboriginal Health Worker assistance and having a culturally competent pharmacist conduct the HMR.
The Royal Australian College of General Practitioners (RACGP) established the Faculty of Aboriginal and Torres Strait Islander Health in 2010 to ensure GPs were well resourced and supported to provide culturally responsive patient-centred care for Indigenous Australians. In addition, the RACGP also developed Yagila Wadamba, a support program for Indigenous general practice registrars that provides individualised support to candidates to achieve success in their fellowship exams and other key aspects of their GP training. By the end of the 2018–19 financial year the RACGP had 55 Indigenous doctors in training and 65 Indigenous fellows (RACGP 2019).
The Australian Indigenous Doctors’ Association (AIDA) conducted a 2016 survey of members on bullying, racism and lateral violence in the workplace, with the results confirming the reality and prevalence of unsafe work environments, particularly for AIDA’s Indigenous members (AIDA 2017). The survey results inform AIDA’s mentoring program and ongoing collaboration with medical colleges, universities and government to improve cultural safety.
Growing the Indigenous medical workforce is a long-term process, and requires change at all stages of the medical education and training continuum (Gannon 2017). Programs at three medical schools in New South Wales, Western Australia and Queensland are based around alternative entry schemes that assess a student’s ability using a more comprehensive range of criteria than an academic score (Lawson et al. 2007). The programs entail various combinations of recruitment strategies, premedical preparation, academic, social and personal support during the course, and flexible pathways. A 2019 systematic review found that the most successful strategies by nursing, health and medical science faculties to improve Indigenous student retention include: comprehensive orientation and pre-entry programs; building a supportive and enabling school culture; embedding Indigenous content throughout the curriculum; developing mentoring and tutoring programs; flexible delivery of content; providing social and financial support; and ‘leaving the door open’ for students to return (see measure 3.20 Aboriginal and Torres Strait Islander peoples training for health related disciplines) (Taylor et al. 2019).
The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) develops and supports recruitment strategies aimed at Indigenous Australian nurses and midwives (CATSINaM 2019). CATSINaM has developed and distributed workplace resources to help improve the workforce experience of Indigenous nurse and midwife members, and runs the CATSINaM Mentoring Program which aims to reform the organisational culture of mainstream health services and improve communication in workplace and clinical contexts. Evaluations of the mentoring workshops suggest the mentoring program is helping to improve the workplace experience of Indigenous nurses and midwives.
The under-representation of Indigenous Australians in the health workforce places pressure on Indigenous health professionals. A systematic review of the available literature found that barriers to the retention of Indigenous health professionals include heavy workloads, poorly defined roles and responsibilities and wage disparity (Lai et al. 2018). Work environment was an enabler in workplaces with respect for Indigenous culture, but racism was reported as a major barrier in other work environments. The influence of community could be a strong personal motivator, or a source of stress due to work/life boundaries becoming blurred. A review of evidence by Topp and others (2018), on Aboriginal and Torres Strait Islander health workers’ governance arrangements and accountability relationships, found that the profession faces serious challenges in its implementation and governance (Topp et al. 2018). These include a lack of state or national scopes of practice resulting in pressure being placed on individual Indigenous health workers to meet ambitious expectations, and balancing community obligations with those of their clinical service managers. Such issues appear to be contributing to difficulties in recruitment as well as retention.
Increasing the number of Indigenous Australians in the health workforce is fundamental to improving health outcomes for Indigenous Australians. While numbers have increased in the past decade, Indigenous Australians remain under-represented in the health workforce and growth in the number of Indigenous health workers is not keeping up with population growth. In addition to recruiting more Indigenous Australians into the health workforce, supporting existing Indigenous health workers to remain in the workforce is essential. However, there is a lack of evidence on workplace strategies to improve retention, and of evaluations of such strategies, with more written about barriers than enablers (Lai et al. 2018). Timely data and research are needed to better understand retention and turnover rates, and the factors affecting pathways into health careers and retention of Indigenous clinicians in particular health fields (Lai et al. 2018). Improving opportunities for advancement also requires attention. Access to employment in a broad range of settings and occupations is needed to avoid under-representation in better remunerated, more skilled and managerial positions for Indigenous health professionals.
A number of initiatives are underway to address these challenges. The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework (2016–2023) provides a guide to assist planning, prioritising, target setting, monitoring and reporting of progress in Indigenous health workforce capacity building. A central aim of the framework is to improve recruitment and retention of Indigenous health professionals in clinical and non-clinical roles across all health disciplines, including through ensuring workplace environments are culturally safe for Indigenous health workers. The framework also suggests strategies for increasing the number of Indigenous Australians studying and completing qualifications in health. The National Aboriginal and Torres Strait Islander Health Workforce Plan 2021–2031, was informed by an extensive national consultation process. Consultations identified that improved recruitment and retention of Indigenous Australians requires a culturally safe health and education sector, and in order to successfully grow the Indigenous health workforce, barriers to education, employment and career progression need to be addressed consistently at both the national and jurisdictional level. For more information about the framework and the plan see Policies and strategies.
Training in cultural awareness is important for non-Indigenous health-care providers. The cultural awareness training programs that are currently offered, however, could be improved (Aspin et al. 2012). Indigenous cultural awareness training tends to homogenise Indigenous cultures, and position them as distinct from the ‘norm’. An increased emphasis on reflexivity and self-awareness in training could assist health workers to better understand their own values and beliefs, and how they shape the care that they provide. It is acknowledged that cultural education needs to be ongoing, and localised to the region in which health care providers are working (Kerrigan et al. 2020). There is, however, a need for more research and evaluation of training programs to understand what works (Downing et al. 2011).
Improving the representation of Indigenous Australians in the health workforce will require collaboration between the health and education sectors. Addressing educational disadvantages faced by Indigenous children can assist them to develop skills and be ready to pursue a career in the health sector (see measures 2.04 Literacy and numeracy and 2.05 Education outcomes for young people). Strategies to address barriers, highlight pathways into health careers, and strengthen support for Indigenous students and improve their rate of retention need to be implemented (see measure 3.20 Aboriginal and Torres Strait Islander peoples training for health-related disciplines).
The policy context is at Policies and strategies.
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