Service provision

About this topic

Australian governments, non-government and private organisations provide funding for mental health and suicide prevention-related services for Aboriginal and Torres Strait Islander (First Nations) people. Government-funded services include consultations with specialist medical practitioners, general practitioners and psychologists, residential care in hospital, and community mental health care services (AIHW 2018).

Australian governments provide 81% of all First Nations health expenditure, compared with 75% for non-Indigenous health care (AIHW 2023b). Non-government and other private-sector organisations also provide services to First Nations people, but data for these are neither nationally collected nor publicly reported.

Historically, First Nations people have experienced mistreatment by mainstream health services. Diagnoses of mental illness have been used to disempower marginalised groups, including First Nations people (Dudgeon et al. 2014). These historical factors have contributed to distrust and avoidance of mainstream health services (Canuto et al. 2018; Dudgeon et al. 2014).

There are also cultural differences in the understanding of mental health conditions, which may discourage First Nations people from seeking help from clinical services.

First Nations people and non-Indigenous Australians may have different understandings of the causes, expressions and treatments of mental health conditions, such as depression (Brown et al. 2012; Vicary & Westerman 2004). For example, spiritual healing from a cultural healer may be needed for a mental health condition that is seen to have a spiritual cause (Ypinazar et al. 2007). Services that do not recognise these issues may offer ineffective treatments that cause First Nations people to feel disempowered when seeking help (Bishop et al. 2012).

First Nations people must have access to culturally appropriate care. This can establish an environment that is responsive and respectful to any social, political, linguistic, economic and spiritual concerns of First Nations people (Kirmayer 2012; McGough et al. 2018). A First Nations mental health workforce can build trust in mental health services and improve mental health outcomes for First Nations people by enabling self-determination (Dudgeon et al. 2014).

In 2020, all Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations worked in partnership to develop the National Agreement on Closing the Gap- external site opens in new window (the National Agreement), built around 4 Priority Reforms. The National Agreement also identifies 19 targets across 17 socioeconomic outcome areas. Two of the Priority Reforms directly relate to service provision.

Access to services compared with need

First Nations people experience poorer health than non-Indigenous Australians, but they do not always have the same level of access to health services and do not share equally in the benefits of health care advances. First Nations people face barriers that other groups do not (AIHW & NIAA 2021). This can be due to remoteness and affordability (AIHW 2021a).

Defining and measuring access to health care is complex. Measures must consider the availability and supply of services as well as financial, organisational, social and cultural barriers that limit the use of services (Gulliford et al. 2002).

Levesque and others (2013) identified 2 main factors that affect access to health services:

• characteristics that facilitate access (approachable, acceptable, available, affordable and appropriate)
• the individual’s abilities to interact with services, such as the ability to perceive, seek, reach, pay and engage with services.

Cultural safety

In Australian research, there are various definitions of cultural safety and what it means in relation to the provision of health care.

The Cultural Respect Framework 2016–26 defines cultural safety as: ‘not [being] defined by the health professional, but is defined by the health consumer’s experience—the individual’s experience of care they are given, ability to access services and to raise concerns’.

The framework outlines the essential features of cultural safety, including:

• understanding one’s culture
• acknowledging difference, and requiring caregivers to be actively mindful and respectful of differences
• being informed by a theory of power relations
• appreciating the historical context of colonisation, the practices of racism at individual and institutional levels, and their effects on the lives and wellbeing of First Nations people, both in the present and past (AHMAC 2016).

The cultural safety of First Nations health care users cannot be improved in isolation. The structures, policies and processes across the health system all play a role in delivering culturally respectful health care. They require:

• organisational commitments to provide culturally safe care
• appropriate communication and services
• First Nations workforce development and training
• client and community feedback
• collaboration with Indigenous organisations.

The extent to which health care systems and providers are aware of and responsive to First Nations people’s perspectives determines health care outcomes.

Self-determination

Self-determination is the process by which communities control their destinies, particularly in relation to political status and economic, social and cultural development (AHRC 2010). For the people in those communities, this means the freedom to live well and according to their own values and beliefs (AHRC 2010).

In Australia, this is particularly important for First Nations communities, many of which have experienced destruction of traditional governance structures through colonisation and dispossession (Salmon et al. 2019).

Key statistics

This section focuses on mental health services.

First Nations people use some mental health services at higher rates than non-Indigenous Australians (AIHW & NIAA 2023a). However, it is difficult to assess whether this use matches the underlying need. Leading First Nations mental health researchers and advocates maintain that mental health care for First Nations people remains inadequate and inequitable (Dudgeon et al. 2020).

The data presented below are sourced from the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) 2018–19 and are for persons aged 18 and over. Estimates are calculated using a sample selected from a population rather than all members of that population. See the data tables in the Download data section for notes related to these data.

In 2018–19, 76% (132,800 out of 174,000) of First Nations people with a diagnosed mental health condition reported accessing/using health services for a mental health condition. This compared with 13% (38,600 out of 306,600) of people without a diagnosed mental health condition (Figure 1; Table S.1).

1. Data reported for persons 18 years and over.
2. Percentages may not sum to 100 due to confidentialisation and rounding.
3. Total excludes Unable to determine.
4. Data were collected from a survey sample and converted into estimates for the whole population. The overall coverage of the 2018–19 NATSIHS was approximately 33% of Aboriginal and Torres Strait Islander persons in Australia. The survey results were weighted to the projected Aboriginal and Torres Strait Islander population at 31 December 2018, which was 814,013.

The data below were sourced from the AIHW National Community Mental Health Care Database (NCMHCD) and National Residential Mental Health Care Database (NRMHCD). See the data tables in the Download data section for notes related to these data.

In 2021–22, First Nations people:

• had contact with community mental health care services at almost 4 times the rate for non-Indigenous Australians
• experienced episodes of care in residential mental health care facilities at more than 3 times the rate for non-Indigenous Australians
• presented to emergency departments for mental health-related diagnoses at more than 4 times the rate for non-Indigenous Australians
• had higher rates of same-day and overnight hospital separations for specialised psychiatric care than non-Indigenous Australians (AIHW 2023a, 2023d) (Table S.2).

The rate of community mental health care service contacts by First Nations people increased from 669 per 1,000 population (458,568 contacts) in 2010–11 to 1,273 per 1,000 population (1,076,528 contacts) in 2021–22 (Figure 2; Table S.3).

1. Data on Indigenous status should be interpreted with caution due to the varying quality of Indigenous identification across jurisdictions. Refer to the data quality statement of the relevant collection and collection period for detailed information.
2. For residential mental health care, prior to the 2012–13 collection period, the number of residents is likely to be overestimated, as residents who made use of services from multiple providers were counted separately each time. For the 2012–13 collection period onwards, patients who made use of services from multiple providers within a jurisdiction are only counted once in those jurisdictions that can uniquely identify patients.

The rate of residential mental health care episodes by First Nations people also increased from 2 per 10,000 population (121 episodes) in 2010–11 to 10 per 10,000 population (807 episodes) in 2021–22 (AIHW 2022a, 2023) (Figure 3; Table S.3).

1. Data on Indigenous status should be interpreted with caution due to the varying quality of Indigenous identification across jurisdictions. Refer to the data quality statement of the relevant collection and collection period for detailed information.
2. For residential mental health care, prior to the 2012–13 collection period, the number of residents is likely to be overestimated, as residents who made use of services from multiple providers were counted separately each time. For the 2012–13 collection period onwards, patients who made use of services from multiple providers within a jurisdiction are only counted once in those jurisdictions that can uniquely identify patients.

Data tables

Table number and title	Source	Reference period
Table S.1: Access/use of health services for mental health condition among First Nations people, by presence of mental health conditions, 2018–19	AIHW analysis of ABS NATSIHS	2018–19
Table S.2: Types of mental health care service use, by Indigenous status, 2021–22	AIHW National Community Mental Health Care Database (NCMHCD), National Residential Mental Health Care Database (NRMHCD), National Hospital Morbidity Database (NHMD) and National Non-Admitted Patient Emergency Department Care Database (NNAPEDCD).	2021–22
Table S.3: Specialised mental health care services, by Indigenous status, 2010–11 to 2021–22	AIHW National Community Mental Health Care Database (NCMHCD) and National Residential Mental Health Care Database (NRMHCD)	2010–11 to 2021–22

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Data tables: Service provision

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