Partnership, trust and respect: NSW's response to COVID‐19 among Aboriginal people

Abstract

Aboriginal communities can celebrate gre%at success from navigating the COVID‐19 pandemic throughout 2020 and have demonstrated once again the immense strength and resilience of Aboriginal peoples. As of December 2020, the state of New South Wales (NSW) has had only 45 cases of COVID‐19 among people who identify as Aboriginal and/or Torres Strait Islander, and there have been no subsequent deaths. This represents 1% of all COVID‐19 cases in New South Wales where Aboriginal and Torres Strait Islander people (hereafter Aboriginal people in recognition of Aboriginal people being the First Peoples of New South Wales) comprise 3% of the population. This success contrasts with the experience of COVID‐19 among Indigenous Nations and minority groups internationally, 1 , 2 and with Australia's previous performance during the 2009 (H1N1) influenza pandemic, which disproportionately affected Aboriginal people and saw higher rates of infection, hospitalisation, intensive care admission and death for Aboriginal than for non‐Aboriginal people. 1 , 2 , 3 Early in the pandemic, Aboriginal Community Controlled Health Organisations (ACCHOs) and Aboriginal communities mobilised rapidly to reduce the risk of local COVID‐19 outbreaks, and this is a key reason for the success to date in keeping Aboriginal people safe from COVID‐19. 4 , 5 Supporting these efforts in New South Wales is a comprehensive partnership approach to COVID‐19 from the government health agency and the Aboriginal Community Controlled Health sector. The Aboriginal Health and Medical Research Council of NSW (AH&MRC) is the statewide representative body for the NSW Aboriginal Community Controlled Health Organisations (ACCHOs) and has 47 members across the state. The AH&MRC and NSW Health have a formal partnership agreement that is more than 20 years old. This partnership is coordinated by the AH&MRC and the Centre for Aboriginal Health, NSW Ministry of Health, through monthly meetings focused on agreed priorities. Both parties have increasingly prioritised a strong partnership as a way of ensuring both parties are able to deliver meaningful outcomes for Aboriginal people and communities. The partnership is built upon the principles of self‐determination and collaboration to achieve the shared vision of improving Aboriginal peoples’ health and wellbeing in New South Wales. 6 In 2009, during the (H1N1) influenza pandemic, the AH&MRC and NSW Health built upon their partnership to establish a coordinated response to priority issues, identify gaps in communication and develop and disseminate communication resources. Reflections on the Aboriginal health response to the 2009 pandemic revealed that localised responses, the use of Aboriginal health champions and humour in communication materials and addressing social and community support issues were needed to support Aboriginal communities during infectious disease outbreaks. 7 In addition, there were limited avenues for Aboriginal people and organisations to inform and lead national and statewide pandemic responses. This reflection provided important learnings for the 2020 COVID‐19 response. Partnership, including with non‐government organisations, is a World Health Organization guiding principle for emergency response. 10 Partnerships work when there is a history of collaboration, mutual respect and trust, a shared focus with clear roles, open and frequent communication and adequate resources to participate. 8 Partnerships between Aboriginal and other health services provide a range of potential benefits, including building cultural and clinical capacity, broadening initiatives to better respond to the social determinants of health and health literacy, addressing institutional racism, and facilitating an integrated health response for planning and patient experience purposes. 9 However, challenges can also exist, including power and resource imbalances, differing timelines and competing priorities and different prioritisation of the partnership activities. Here we outline how the AH&MRC and NSW Health used the partnership to deliver a well‐integrated, comprehensive public health response to COVID‐19. We will outline the key areas of focus and activities delivered through the partnership and reflect on the challenges experienced during the pandemic to date, and the strengths of working in partnership to keep Aboriginal communities in New South Wales safe during COVID‐19. Partnership approach In February 2020, when Australia was seeing the first few COVID‐19 cases on our shores, NSW Health and AH&MRC commenced regular meetings to discuss the current situation, potential risks to Aboriginal people in New South Wales and ACCHOs, and strategies for minimising risk. Since February, these meetings have ranged from twice each week to fortnightly depending on the stage of the pandemic and have involved the executive and senior leadership of both partners who were responsible for leading operational, policy, communication, logistical and financial responses. This close working relationship built on many years of establishing and maintaining trust between the organisations (through timely responses to new issues, maintaining open and transparent communication and joint activities). Importantly, Aboriginal leadership of both organisations and the shared centring of Aboriginal peoples’ expertise and experiences were instrumental to maintaining this trust and informing shared work. There were equal opportunities for either partner to inform the agenda, discussions and actions. Outside of formal meetings, there were many phone calls and emails, which ensured that both partners were informed at every stage of the pandemic, agreed on priorities and were prepared adequately to rapidly respond to the situation as it unfolded. As part of this, local partnerships between ACCHOs and Local Health Districts (LHDs) were encouraged and supported by partners to problem solve local issues and ensure appropriate local planning. Conversely, strong partnerships between some LHDs and local ACCHOs provided valuable advice and examples to inform statewide responses. Specific activities to minimise the risk of COVID‐19 on Aboriginal people in New South Wales can be broadly grouped into five categories. Key activities to respond to COVID‐19 1. Targeted communications campaign The partners worked rapidly early in the pandemic, and have continued a high level of activity, to ensure appropriate messaging around key topics was available to Aboriginal people and services. To ensure communication materials were able to be rapidly developed and disseminated, NSW Health developed resources targeting Aboriginal people, while the AH&MRC developed resources targeting ACCHOs. This meant that while NSW Health and AH&MRC were familiar with the key messages and approaches taken by the partner organisation, delays from requiring two organisational approval pathways were minimised. Communication materials targeted hand hygiene, physical distancing, maintaining healthcare, wearing masks, protecting elders and getting tested, and were across print, television, radio and social media platforms. 2. Support for Aboriginal Community Controlled Health Organisations to continue to deliver COVID‐Safe services Ensuring ACCHOs could continue to deliver necessary health services was a key priority for the partner organisations. Support for ACCHOs included guidance and resources on how to provide COVID‐safe health services, and assistance with procuring personal protective equipment, including direct provision where necessary, as well as providing flexibility in the use of funding and reporting requirements. 3. Increasing access to COVID‐19 testing NSW Health and AH&MRC closely monitored and shared information regarding the epidemiology of cases and potential risks for community transmission of COVID‐19. This assisted with identifying focus areas to support increased testing, either in an ACCHO or Local Health District setting, for sustained COVID‐19 testing or for time‐limited pop‐up clinics. NSW Health and AH&MRC also worked collaboratively with the Commonwealth Department of Health and the Kirby Institute to identify and support five ACCHOs to participate in the national COVID‐19 Point of Care Testing program ensuring rapid diagnosis of COVID‐19 in regional and remote locations. 4. Responding to public health orders, border restrictions and mass gathering events During the COVID‐19 pandemic, there have been ever‐changing legislation and guidance on border closures, travel to remote communities, industry and mass gatherings. The rapid turnaround times of changing guidance have required close and frequent communication between the partner organisations. A large state funeral required close engagement between the partner organisations and other stakeholders to develop and implement a comprehensive risk mitigation strategy involving increased testing capacity (including through point of care testing), enhanced communications, and provision of hand sanitiser, masks and health education material for around 1,000 attendees. No cases of COVID‐19 resulted from this event. 5. Informing the national response On 6 March 2020, the Aboriginal and Torres Strait Islander National Advisory Group on COVID‐19 was established by the Australian Government's Department of Health. This group was established to provide advice to the Australian Government to ensure public health responses to COVID‐19 were appropriate, proportional and focused on equity. Representatives from the AH&MRC and NSW Health have been members of this group from its inception and have contributed to informing key national strategies and activities such as GP respiratory clinics, national health promotion materials, regulations and workforce planning. Box 1: Key strategies to support Aboriginal communities to stay COVID‐free. Aboriginal‐specific communications campaign Clear consistent messaging from partners to ACCHOs and communities Support ACCHOs to provide testing through point of care, or pop‐up and longer term respiratory clinics Ensure reliable and adequate supply of PPE and other consumables through different stages of the pandemic to support business continuity and COVID‐19 testing Ensure national and statewide responses are informed by, and respond to the needs of, Aboriginal people Support local partnership for improved community access to testing, integrated supports for cases and contacts and culturally safe contact tracing Address critical food shortages and mitigate risk associated with mass gatherings John Wiley & Sons, Ltd. Outcomes COVID‐19 case numbers In total, there were 45 cases of COVID among Aboriginal people in New South Wales as of December 2020, which equates to less than 1% of the total number of cases in the state, with no deaths as a result of COVID‐19 in New South Wales’ Aboriginal people. The rate of confirmed cases among Aboriginal people for that period was 15.4 per 100,000 population. This is dramatically lower than the case rate among the non‐Aboriginal population, which was 47.8 per 100,000 population. COVID‐19 testing Aboriginal status for those receiving a COVID‐19 test is ascertained through linkage with other health information systems. Around 90% of tests can be assigned through this process as being for Aboriginal or non‐Aboriginal people. Overall, the rate of COVID testing across the state was higher among Aboriginal people than non‐Aboriginal people. From 1 April to 1 November 2020, the rate of testing in the Aboriginal population was 361.6 per 1,000 compared to the non‐Aboriginal population, where the rate was 353.5 per 1,000. Reflections on successes and challenges The existing and longstanding genuine partnership between the two organisations in no doubt contributed to an easy collaborative approach that enabled a high degree of effective activity. The trust and respect underpinning the partnership enabled open communication and collaborative work. This trust was reflected in the mutual respect framework in which the partnership operates with each partner respecting the expertise, stakeholders and sphere of influence of the other partner. Similarly, the principles and ways of working were known to each partner, so discussions on priorities and approaches were easily had and unsurprising. Furthermore, partners share the principle of valuing and prioritising Aboriginal ways of knowing and doing enabling appropriate, culturally informed responses led by Aboriginal people. Governance has been an important factor in the success of the response. In addition to the formal partnership agreement between the NSW Health and AH&MRC, coordination of a response to COVID‐19 among Aboriginal people across health sector partner organisations was supported by an AH&MRC Pandemic Toolkit and an NSW Health guideline on pandemic preparedness and response for Aboriginal communities, which helped both organisations define roles and responsibilities of key New South Wales stakeholders. The AH&MRC Pandemic Response Toolkit 12 aims to support ACCHOs to develop comprehensive preparedness and response plans and is designed to be complementary with a seasonal influenza toolkit, and advice and resources from state and Commonwealth health agencies. This toolkit and the NSW Health guideline provided a foundation to enable a series of statewide and local desktop scenario exercises requiring NSW Health and ACCHO collaboration to explore the COVID‐19 Aboriginal health responses and identify any gaps requiring addressing. These exercises were a key strategy in both ensuring COVID‐19 prevention and response strategies were culturally safe, but also to further build local partnerships between NSW Health services and ACCHOs. The ease with which the two organisations collaborated on the COVID‐19 response was at times at odds with other collaborations and partnerships required during the pandemic, particularly between organisations where no or little partnership existed. While the partnership between NSW Health and the AH&MRC enabled a broad range of COVID‐19 response strategies that contributed to low COVID‐19 case numbers and high testing rates, the success of Aboriginal communities during this pandemic is in large part due to Aboriginal people and communities. Aboriginal people and organisations have once again demonstrated strength and resilience, and the ability to keep their own mob safe. Looking ahead As we move into the next phase of the pandemic where vaccines will play a central role in the public health response, the partnership will focus on ensuring appropriate vaccine access for Aboriginal people. In addition, there are many lessons from our collective experience to date that will inform the ongoing partnership, our work with mainstream stakeholders and ongoing support to the community‐controlled health sector. Acknowledgements The authors would like to acknowledge all the staff at AH&MRC and the Centre for Aboriginal Health for their efforts during the COVID‐19 pandemic, in particular Dr Kate Armstrong and Dr Anthony Zheng, and our partners, the Aboriginal community‐controlled health sector and Aboriginal health units in Local Health Districts for their continued work to keep Aboriginal people healthy. We would also like to acknowledge the support and hard work of the broader COVID‐19 response to contributing to the overall success of the New South Wales response to date. This work was completed while Elizabeth Ellis was employed as a trainee on the NSW Public Health Training Program funded by the NSW Ministry of Health. She undertook this work while based at the Centre for Aboriginal Health.