Improving Indigenous patients’ access to mainstream health services: the Inala experience

Noel E Hayman, Nola E White and Geoffrey K Spurling
Med J Aust 2009; 190 (10): 604-606. || doi: 10.5694/j.1326-5377.2009.tb02581.x
Published online: 18 May 2009

Forced relocation, urban migration, poor education, lack of employment, low income, inadequate housing, lack of environmental infrastructure and a paucity of appropriate health service provision are important social determinants of ill health for Aboriginal and Torres Strait Islander people.1

Historically, health services have been absent or inappropriate for this community. For example, accommodation in the public hospital system was segregated until the 1960s.2 In the 2001–02 financial year, Medicare expenditure per person for Indigenous Australians was only 39% of that for other Australians.3 Cultural and financial factors and distance have been important barriers limiting Indigenous Australians’ access to mainstream services.4 It has been argued that low levels of access by Indigenous people to primary health care settings and inadequate government funding contribute to their continuing poor health status.5 Improved primary care access is vital for closing the gap for most health outcomes including chronic disease,6 cancer mortality,7 infant mortality,8 asthma admissions9 and immunisation coverage.10

Starting in Redfern, Sydney, New South Wales, in 1971, Aboriginal community-controlled health services (ACCHSs) began to be established to improve access. The principles underlying ACCHSs are essential to overcome barriers to effective health service delivery for Indigenous people.11 The National Aboriginal Community Controlled Health Organisation, the peak body supporting ACCHSs, has listed the main principles guiding the sector, including concepts of health as holistic, the right to self-determination, recognition of the centrality of kinship, recognition of different communities and needs, high-quality health care services, and equitable funding.12

In 1994, Queensland Health identified culturally appropriate service provision as one of seven key areas needing to be addressed to improve the health of Indigenous Queenslanders.13 A culturally appropriate service takes into account local language(s), beliefs, gender and kinship systems, thereby making service delivery settings more acceptable to the Indigenous community.

Despite the existence of primary care ACCHSs in many areas, mainstream services continue to be, numerically, the main source of health provision to Indigenous people. If Indigenous health is to improve, Indigenous people need to feel comfortable accessing mainstream health services.

The Inala context in 1994 to 1995

The suburb of Inala in south-western Brisbane is a low socio-economic area, with significant cultural diversity; many residents live in public housing. According to the 1996 census, 8% of the total Inala population (1063/13 284) was Indigenous, significantly more than the national proportion of 2.1% in the same year.14 The Inala Community Health Centre, a Queensland government-funded service established in 1977, aims to provide comprehensive primary health care, with very good access to allied health and specialist health teams operating under one roof.

In 1994, nursing staff members expressed concern that Indigenous people were grossly under-represented among the clinic’s patients — they could only identify 12 Indigenous clients who regularly used the Inala Health Centre General Practice. This led to the establishment, in 1995, of the Inala Indigenous Health Service (IIHS), which operated out of three rooms as part of the Inala Health Centre General Practice and was staffed by one Aboriginal doctor (N E H) and, shortly thereafter, one Aboriginal nurse (N E W). In July 1995, one of us (N E H) conducted a focus group and telephone interviews to evaluate poor attendance with the aim of improving access (Box 1). We used these findings to guide a series of changes to the service.

Following further community participation and feedback, five key strategies were developed and implemented:

Expansion (2006–2008)

In 2006, the IIHS was allowed to operate with an exemption from section 19(2) of the Health Insurance Act 1973 (Cwlth), which enables Medicare rebates to be claimed for state-remunerated primary health care services in certain circumstances. Bulk-billing payments have enabled the service to employ extra staff members, including two doctors, two nurses and two administrative officers.

In 2007, in conjunction with the refurbishment of the Inala Health Centre General Practice, the IIHS moved to a stand-alone clinic with four consulting rooms, a large procedural area with two beds for minor operations and emergencies, and a large non-clinical area for community-based staff. With additional staffing and space, the service was able to make maximum use of the newly launched Indigenous health checks, which now span all age groups. In the 2007–08 financial year, the IIHS performed 555 of 4819 Adult Health Checks (item 710) in Queensland; 238/3341 Child Health Checks (item 708); and 83/1150 Older Person’s Health Checks (item 704).16

In the same timeframe, use of Indigenous health checks and chronic disease Medicare item numbers contributed significantly to the employment of another doctor and registered nurse in 2007. In the same year, we added specialist services, such as a paediatric registrar (one session/week) and retinal photography. Indigenous and other community health workers in the service provide outreach immunisations, child playgroups, NAIDOC Week coordination, facilitation of local rugby league teams, and sexual health, nutrition and chronic disease self-management programs. Research activity has expanded, with the service participating in a number of projects funded by National Health and Medical Research Council (NHMRC) grants, as well as conducting research internally, often in collaboration with the Queensland Aboriginal and Islander Health Council’s Centre of Clinical Research Excellence and the Centre for Indigenous Health at the University of Queensland.

Increased attendance at the Inala Indigenous Health Service

Attendance data over the past 13 years are presented in Box 2. There were 3006 patients (96% Aboriginal, 3% Aboriginal and Torres Strait Islander and 1% Torres Strait Islander) registered in 2008 and about 900 medical consultations are completed monthly. The profile of patients is 61% female, 39% male; 38% are aged 14 years and younger, 56% are aged 15–54 years, and 6% aged 55 years and older.

By 2008, 22 full-time staff members were employed to cope with the increased demand on services. Other important factors relating to access are the low turnover rate of staff, which has provided continuity of care for patients, and the “one-stop shop” approach, with access to allied health services, mental health, alcohol and other drug services, and child health services.

The results of the census data for the Inala Indigenous population are also presented in Box 2, showing that this population was stable from 1995 to 2006. Clients accessing the service principally live in the local area, but significant numbers travel from surrounding suburbs. The improved access has led to many important community health gains.

Vision for the future

Within 1 year, the IIHS has outgrown its new clinic space. We envisage a Centre of Excellence in Indigenous Primary Health Care with the following objectives:

Progress towards closing the gap in life expectancy for Indigenous people is slow. New, innovative strategies are needed to improve health outcomes and increase life expectancy.

Vital to the success of this project were community consultation and participation of the local Inala Elders, employing Indigenous people and holding cultural awareness talks. Strong links with the Elders have been important in fostering trust in the community that has led to improved access, high participation rates of local Indigenous people in research, and more importantly, the development and implementation of community-based health activities, often conducted at the Elders’ building. However, the impact on access of energetic Indigenous leadership within the service cannot be understated. Under Indigenous leadership, the IIHS has been able to work more effectively with Indigenous organisations, including the ACCHSs, in addressing health issues and improving health outcomes.

The Australian Government and universities must ensure that more Indigenous doctors and nurses graduate and encourage them (but not oblige them) to work in delivering culturally appropriate services to their communities. Breaking down the barriers to access for Aboriginal and Torres Strait Islander people will increase the numbers attending mainstream primary health care services and result in significant improvements in Indigenous morbidity and mortality.

  • Noel E Hayman1,2
  • Nola E White2
  • Geoffrey K Spurling1,2

  • 1 School of Medicine, University of Queensland, Brisbane, QLD.
  • 2 Inala Indigenous Health Service, Inala Community Health Centre, Queensland Health, Brisbane, QLD.



We thank Raymond Gadd, Indigenous medical student, University of Newcastle, in conducting the 1998 survey, and the Inala Elders.

Competing interests:

None identified.

  • 1. Baum F. The new public health — an Australian perspective. Melbourne: Oxford University Press, 1998.
  • 2. Saggers S, Gray D. Aboriginal health and society: the traditional and contemporary Aboriginal struggle for better health. Sydney: Allen & Unwin, 1991.
  • 3. Australian Institute of Health and Welfare. Expenditures on health for Aboriginal and Torres Strait Islander peoples, 2001–02. Health and welfare expenditure series no. 23. Canberra: AIHW, 2005. (AIHW Cat. No. HWE 30.)
  • 4. Stamp KM, Duckett SJ, Fisher DA. Hospitals use for potentially preventable conditions in Aboriginal and Torres Strait Islander and other Australian populations. Aust N Z J Public Health 1998; 22: 673-678.
  • 5. Couzos S, Thiele DD. The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples? Med J Aust 2007; 186: 522-524. <MJA full text>
  • 6. Si D, Bailie R, Cunningham J, et al. Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia’s Northern Territory — use of the Chronic Care Model. BMC Health Serv Res 2008; 8: 112.
  • 7. Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncol 2008; 9: 585-595.
  • 8. Humphrey MD, Keating SM. Lack of antenatal care in far north Queensland. Aust N Z J Obstet Gynaecol 2004; 44: 10-13.
  • 9. Couzos S, Davis S. Inequities in Aboriginal health — access to the Asthma 3+ Visit Plan. Aust Fam Physician 2005; 34: 837-840.
  • 10. Menzies R, McIntyre P, Beard F. Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia, 1999 to 2002. Commun Dis Intell 2004; 28 Suppl 1: S1-S45.
  • 11. National Aboriginal Community Controlled Health Organisation. Proposal to increase access by Aboriginal people to appropriate primary health care. Canberra: NACCHO, 1998.
  • 12. National Aboriginal Community Controlled Health Organisation. Our guiding principles. (accessed Apr 2009).
  • 13. Queensland Health. Aboriginal and Torres Strait Islander Health Policy 1994. Brisbane: Aboriginal and Torres Strait Islander Health Policy Branch, Division of Policy and Planning, Queensland Health, 1994.
  • 14. Australian Bureau of Statistics. 1996 Census of Population and Housing. Canberra: Commonwealth of Australia, 2000.
  • 15. Deeble J. Expenditure on health services for Aboriginal and Torres Strait Islander People. Canberra: Commonwealth Department of Health and Family Services, 1998.
  • 16. Medicare Australia. Statistics. (accessed Jul 2008).


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