First in, Best Dressed - Unless you were here First: The Indigenous Healthcare Paradox
… Unsplash
Writing this article, I begin by acknowledging the Gadigal People of the Eora Nation as the traditional custodians of the land on which I live, learn and work. I pay my deepest respects to Elders past, present and emerging, and acknowledge their ongoing connection to Land, Sea and Sky. I extend my respect to all Aboriginal and Torres Strait Islander Peoples.
Australia loves some preeminence. Ranked 9th globally in 2023 for happiness,[i] Sydney and Melbourne are reigning premiers within the top ten most ‘livable cities’ in the world.[ii] With a healthcare system that renders applause transcending geographical boundaries, one would reasonably assume that Australia has wellbeing and health down to something like that of a scientific utopia.
Think again.
Aboriginal and Torres Strait Islander Peoples are one of the world’s oldest, continuous living cultures on earth; the Traditional Custodians of the land on which these gleaming hospitals reside, and these internationally celebrated facilities now operate. For this community, however, this renowned system contorts into something entirely different: a maze; a fortress. This is exactly what the Indigenous Healthcare Paradox is.
The concept of healthcare, when accommodating the Indigenous Peoples, transitions from an ad hoc to a bureaucratic fend-for-yourself structure in which every outcome leads to poorer health, a longer process, and more paperwork. This notion is abundantly clear, as the life expectancy of the average non-Indigenous person in Australia is 82.2 years, whereas that of an Indigenous person living in Australia is 73.8.[iii] 17% of Aboriginal and Torres Strait Islander People currently have relatively poor physical access to a General Practitioner, compared to 5% of non-Indigenous Australians,[iv] wherein discrepancies grow with remoteness. When we read these statistics, we think, how can a state recognised as ‘livable’ accommodate so poorly for its Indigenous population? Where’s the happiness in that!?
The health inequities between Indigenous versus non-Indigenous Peoples lie not in individual behaviour, or one-off policy failures; it lies in a deeper, structural history, with roots entangled amongst colonisation, dispossession, and institutionally entrenched exclusion and segregation. The inception of these systemic disparities can be traced back to January 1788, to Captain Cook’s invasion of Botany Bay. Cook's arrival in 1788 coincided with a prejudiced misjudgement: he perceived the Indigenous Peoples, due to skin colour, as numerically, intellectually, and technologically inferior,[v] signifying the dispossession of Indigenous Peoples from Country, coupled with the forcible partitioning of Indigenous Peoples. This ‘classic racism’ continued for about 170 years.[vi] A prime example is the Aboriginals Protection and Restriction of the Sale of Opium Act 1897 within Queensland. It racialised laws to control the lives of Aboriginal and Torres Strait Islander Peoples;[vii] required to work without a wage, forbidden to partake in any cultural activities, ultimately being subjugated within their society due to colonialist oppression.
Post-referendum era, the Australian government formally recognised Indigenous People within ss 51 and 127 of the Constitution of the Commonwealth, representing a landmark decision in the country’s history; finally, the idea of a national unity. Contrary to this perceived notion of societal progress, this led to a paradigm shift void of any substance and, in turn, a ‘second wave’ of discrimination.[viii] This was characterised by the expansion of federal power over Indigenous affairs via Aboriginal Community Controlled Health Organisations (ACCHOs), which, while intended to facilitate equality, simultaneously enabled the continuation of top-down, paternalistic policies in all sectors of government, excluding meaningful Indigenous participation and decision-making, reinforcing bureaucratic control over Aboriginal and Torres Strait Islander Peoples.
This second wave of racism has ingrained itself deep within institutional structures, continuing to surface in the practices and systems that shape Indigenous lives today. The discriminatory issue of chronic neglect is exemplified by the fact that 93% of ACCHOs lacked sufficient funding to maintain safe infrastructure, while 79% reported being unable to meet patient demand due to inadequate facilities and staffing.[ix] These ACCHOs provide over 3.6 million episodes of care annually to over half of the Aboriginal and Torres Strait Islander population.[x] However, they operate within fragmented and highly restricted systems that limit their ability to access or expand infrastructure. The result is a structural paradox; Indigenous-led services are tasked with addressing the most severe health inequities and are often the least resourced within the national healthcare system.
Evidently, the issue here is not capacity, but the resources at hand; ACCHOs consistently outperform mainstream services in improving Indigenous health outcomes; however, efficacy is diminished due to deteriorating facilities and unstable funding arrangements that prevent service expansion, ultimately contributing to the vast difference in Indigenous versus non-Indigenous health outcomes. This disparity, noted above in the introduction, is reflected in the nearly nine-year life expectancy gap between Indigenous and Non-Indigenous Australians, as well as in the higher proportion of Indigenous Australians with limited GP access, with 17% of Indigenous Australians experiencing limited access compared with 5% of Non-Indigenous Australians.
And so, we arrive back in the present. The remedies combatting the Indigenous healthcare paradox are not new; they have long been articulated by Indigenous communities themselves. Yet, much like the history that produced inequities in the first place, these recommendations and solutions are often too filtered through the exact institutional structures that created the problem, leaving Indigenous voices acknowledged in theory, but rarely ever empowered in practice; rather, silenced. What’s below are some of the remedies proposed to combat what is the Indigenous Healthcare Paradox.
ACCHOs operate under short-term, inadequate funding arrangements, undermining the workforce stability and long-term efficacy, stagnating the health outcomes of Indigenous populations via limiting service availability, continuity of care, and perpetuating barriers to timely access; once again, access is exacerbated by remoteness and insufficient local medical infrastructure. Shane D'Angelo, a descendant of the Kokatha People - the Traditional Custodians residing far-west South Australia - recommends flexible block funding, enabling the self-determination of ACCHOs and their programs and patient priorities.[xi] Expanded core funding, devolved governance, long-term agreements, and Indigenous-led funding will ‘decolonise’ the current system, obliterating the current ‘one-size-fits-all’ programs, meeting local needs and improving health outcomes.[xii]
A core obstacle to decolonisation, preventing ‘cultural safety’,[xiii] is persistent racism within contemporary, mainstream services; deficit views, blame, and rigid biomedical models all comprise what racism against Aboriginal and Torres Strait Islander people looks like today.[xiv] Encapsulating racism, most is a recipient of D’Angelo’s survey, who stated:
‘Most surgeons …[have] been educated on a very core level of, “… Aboriginal people have
contributed to their own health issues and so they don’t deserve my service.” (Aboriginal
participant, research)’
A ‘culturally responsive system’ would actively ensure cultural safety, mitigating discrimination and inequities.[xv] Indigenous communities have expressed the need for ‘Aboriginal and non-Aboriginal members of the health service management team to be visible to and partner with Elders’.[xvi] This would be completed by establishing pathways for Aboriginal Peoples to pursue professions in healthcare. Internships, staff retention programmes, elevated pay and recognition are ways the proportion of Aboriginal clinicians in hospitals can be improved.[xvii] The lack of such initiatives really disincentivises staff from remaining in the sector, limiting the availability of culturally safe care; Indigenous staff are ‘the backbone of the service’,[xviii] and without incentivisation, no one will value Aboriginality nor the issues at hand, prolonging the cycle of inequitable health outcomes.
So, here we are: a nation so divided, boasting world-class liveability and happiness ratings, yet Indigenous Peoples navigate a healthcare system more Kafkaesque than curative. Until finding stabilises, bureaucracy bends and Indigenous voices lead, the paradox remains. Just goes to show the facade Australia cloaks itself with; bragging rights and real health equality here remain awkward, superficial acquaintances, regardless of how gilded the cage is.
____________________________________________________________________________________________________________
References-
[i] Australia Trade and Investment Commission, Why Australia (Benchmark Report, 2024) 1, 55.
[ii] Economist Intelligence Unit, Ranking the world’s most liveable cities (The Global Liveability Index 2025, 2025) 1, 5.
[iii] Australian Institute of Health and Welfare, Deaths in Australia (Web Report, April 2025) <https://www.aihw.gov.au/reports/life-expectancy-deaths/deaths-in-australia/contents/life-expectancy>.
[iv] Michelle Wisbey, First Nations Healthcare Access Gaps Laid Bare, newsGP (online, 2 Aug 2024) <https://www1.racgp.org.au/newsgp/professional/first-nations-healthcare-access-gaps-laid-bare#:~:text=gaps%20laid%20bare-,Michelle%20Wisbey,respectively%20in%20very%20remote%20areas.>.
[v] Aileen Moreton-Robinson, The White Possessive: Property, Power, and Indigenous Sovereignty (University of Minnesota Press, 2015) 1, 112–13.
[vi] Niyi Awofeso, ‘Racism: A Major Impediment to Optimal Indigenous Health and Health Care in Australia’ (2011) 11(3) Australian Indigenous Health Bulletin.
[vii] Ibid.
[viii] Ibid.
[ix] Dechlan Brennan, ‘Report finds remote NT Aboriginal health services struggling due to chronic neglect’, National Indigenous Times (online, 31 October 2025) <https://nit.com.au/31-10-2025/21038/report-finds-remote-nt-aboriginal-health-services-struggling-due-to-chronic-neglect>.
[x] National Aboriginal Community Controlled Health Organisation, Annual Report (Report, 2025) 1, 4.
[xi] Shane D'Angelo et al, ‘Next Steps in Decolonising Aboriginal and Torres Strait Islander Primary Health Care Policy in Australia: An Analysis of Key Stakeholder Views’ (2024) 15(3) International Indigenous Policy Journal 1, 8.
[xii] Ibid 7.
[xiii] Ibid 6.
[xiv] Ibid 11.
[xv] Elizabeth E Austin et al, ‘Birang Daruganora: What do Aboriginal and Torres Strait Islander communities need in a new hospital?’ (2024) 14(5) BMJ Open 1, 5.
[xvi] Ibid 6.
[xvii] Austin et al (n 15).
[xviii] D'Angelo et al (n 11) 13.