Remote Australia Online

The Home and Community Care (HACC) program in Australia provides services which supports older people to live at home. Individual HACC organisations are generally responsible for initial assessment of eligibility and need of clients presenting for services. This paper reports on a project which aimed to develop an understanding of the various approaches to assessment of client needs in Central Australia. The majority of clients in this geographical area are indigenous. The project was initiated in recognition of the primary importance of assessment in determining service access and service delivery and of the particular challenges faced by service providers in remote areas. This paper discusses key project findings including the client group and services provided, initial needs assessment and care planning processes. Evident inconsistencies in practice reflect a variety of complex contextual factors. Staff in remote areas have an inadequate knowledge base to draw upon to assist them with assessment and care planning decisions, and further research and professional development is required.

OBJECTIVE: This paper reports on findings related to intersectoral collaboration stemming from an evaluation of a dementia awareness resource for use in remote Aboriginal communities*. The resource includes a DVD in English and three (3) Aboriginal languages of the Northern Territory. DESIGN: A qualitative evaluation was conducted in four Northern Territory Aboriginal communities/organisations where the resource had been implemented by external dementia educators. The method included five focus groups with Indigenous aged care workers, community members and aged care service users (n = 26), individual interviews with health care professionals and service coordinators (n = 5), and observation. Data were analysed thematically. RESULTS: Specific findings relating to intersectoral collaboration as a key enabling factor of effective dementia awareness and care are discussed in this paper. In addition to context variables such as understaffing and under-resourcing, there might be a lack of knowledge or interest on the part of some health practitioners concerning clients with dementia within remote communities. CONCLUSION: Dementia awareness in remote communities needs to be tackled from a 'whole system' perspective and not be the exclusive domain of the aged care services. Strategies that increase the critical mass of informed caregivers as well as health professionals will contribute to better services.

Introduction and Aims: We aimed to characterise motor performance in predominantly Aboriginal children living in very remote Australia, where rates of prenatal alcohol exposure (PAE) are high. Motor performance was assessed, and the relationship between motor skills, fetal alcohol spectrum disorders (FASD) and PAE was explored. Design and Methods: Motor performance was assessed using the Bruininks–Oseretsky Test of Motor Proficiency—Second Edition Complete Form, in a population-based study of children born in 2002 or 2003 living in the Fitzroy Valley, Western Australia. Composite scores ≥2SD (2nd percentile) and ≥1SD (16th percentile) below the mean were used respectively for FASD diagnosis and referral for treatment. FASD diagnoses were assigned using modified Canadian Guidelines. Results: A total of 108 children (Aboriginal: 98.1%; male: 53%) with a mean age of 8.7 years was assessed. The cohort's mean total motor composite score (mean ± SD 47.2 ± 7.6) approached the Bruininks–Oseretsky Test of Motor Proficiency—Second Edition normative mean (50 ± 10). Motor performance was lower in children with FASD diagnosis than without (mean difference (MD) ± SD: −5.0 ± 1.8; confidence interval: −8.6 to −1.5). There was no difference between children with PAE than without (MD ± SE: −2.2 ± 1.5; confidence interval: −5.1 to 0.80). The prevalence of motor impairment (≥−2SD) was 1.9% in the entire cohort, 9.5% in children with FASD, 3.3% in children with PAE and 0.0% both in children without PAE or FASD. Discussion and Conclusions. Almost of 10% of children with FASD has significant motor impairment. Evaluation of motor function should routinely be included in assessments for FASD, to document impairment and enable targeted early intervention.[Lucas BR, Doney R, Latimer J, Watkins RE, Tsang TW, Hawkes G, Fitzpatrick JP, Oscar J, Carter M, Elliott EJ. Impairment of motor skills in children with fetal alcohol spectrum disorders in remote Australia: The Lililwan Project. Drug Alcohol Rev 2016;35:719–727]

Aim: This study aimed to determine the gross motor (GM) performance of Aboriginal children living in remote Australia. The relationship between GM skills, prenatal alcohol exposure (PAE) and fetal alcohol spectrum disorders (FASD) was explored. Methods: A population-based observation study was conducted in 2011 to assess motor performance in children living in the Fitzroy Valley, Western Australia, using the Bruininks–Oseretsky Test of Motor Proficiency (BOT-2). BOT-2 data were retrospectively analysed using recently developed software enabling separation of fine and GM outcomes. Results: A total of 108 children (98.1% Aboriginal; 53% male, mean age: 8.7 years) were assessed. Half (52.2%) were exposed to at least ‘risky’ levels of PAE, and 21 (19%) were diagnosed with an FASD. The mean GM composite score of the cohort (47.0 ± 8.4) approached the BOT-2 normative mean (50.0 ± 10) and was similar between children with and without PAE (P = 0.27). This mean score, however, was significantly lower in children with FASD than without (mean difference: −5.5 ± 20.6; P = 0.006). Compared with children without FASD, children with FASD had significant impairment in subtests for running speed and agility (mean difference ± standard deviation (SD): −2.4 ± 8.1; P = 0.003) and strength (mean difference ± SD:−2.8 ± 9.9; P = 0.004) and (ii) a higher proportion than expected had overall GM impairment (≤2 SD: 9.5%; ≤1 SD: 23.8%). In groups with PAE, no PAE and no FASD, GM function approached expected population norms. Conclusions: A higher than expected proportion of children with FASD had GM scores that indicated impairment and need for therapy. Evaluation of GM performance should routinely be included in FASD assessment to determine strategies to optimise child development.

Aim: To identify soft neurological signs (SNS) in a population-based study of children living in remote Aboriginal communities in the Fitzroy Valley, Western Australia, born between 2002 and 2003 and explore the relationship between SNS, prenatal alcohol exposure (PAE), and fetal alcohol spectrum disorders (FASD). Method: The presence of SNS was assessed using the Quick Neurological Screening Test, 2nd edition (QNST-2), which has a total maximum score of 140. Higher scores indicated more SNS. ‘Severe discrepancy’ was defined as scores less than or equal to the fifth centile while ‘moderate discrepancy’ represented scores from the sixth to the 24th centile. Children were assigned FASD diagnoses using modified Canadian FASD diagnostic guidelines. Results: A total of 108 of 134 (80.6%) eligible children (mean age 8y 9mo, SD=6mo, 53% male) were assessed. The median QNST-2 Total Score for all participants was within the normal category (19.0, range 4–66). However, the median QNST-2 Total Score was higher in children with than without (1) PAE (r=0.2, p=0.045) and (2) FASD (r=0.3, p=0.004). Half (8/16) of children scoring ‘moderate discrepancy’ and all (2/2) children scoring ‘severe discrepancy’ had at least three domains of central nervous system impairment. Interpretation: SNS were more common in children with PAE or FASD, consistent with the known neurotoxic effect of PAE. The QNST-2 is a useful screen for subtle neurological dysfunction indicating the need for more comprehensive assessment in children with PAE or FASD.

OBJECTIVES: To assess the accuracy of point-of-care (POC) measurements of capillary blood glucose and glycosylated haemoglobin (HbA(1c)) levels in a remote Aboriginal community with high diabetes prevalence. DESIGN: Cross-sectional study comparing POC capillary glucose and HbA(1c) results with those from corresponding venous samples measured in a reference laboratory. PARTICIPANTS AND SETTING: 152 residents aged 11-76 years (representing 76% of population aged over 11 years) had POC glucose measurement in November 2003; 88 with POC glucose level > or = 5.0 mmol/L, or self-reported diabetes, had POC HbA(1c) and laboratory glucose and HbA(1c) measurements. MAIN OUTCOME MEASURES: POC fasting capillary levels of glucose (HemoCue Glucose 201 analyser, Medipac Scientific, Sydney) and HbA(1c) (DCA 2000+ analyser, Bayer Australia, Melbourne); correlation and mean difference between capillary POC and venous blood laboratory measurements of glucose and HbA(1c). RESULTS: Mean and median POC capillary glucose levels were 7.99 mmol/L and 6.25 mmol/L, respectively, while mean and median laboratory venous plasma glucose concentrations were 7.63 mmol/L and 5.35 mmol/L. Values for POC capillary HbA(1c) and laboratory HbA(1c) were identical: mean, 7.06%; and median, 6.0%. The correlation coefficient r for POC and laboratory results was 0.98 for glucose and 0.99 for HbA(1c). The mean difference in results was 0.36 mmol/L for glucose (95% CI, 0.13-0.62; limits of agreement [LOA], - 2.07 to 2.79 mmol/L; P = 0.007) and < 0.01% for HbA(1c) (95% CI, - 0.07% to 0.07%; LOA, - 0.66% to 0.66%; P = 0.95), respectively. CONCLUSIONS: POC capillary HbA(1c) testing, in particular, offers an accurate, practical, community-friendly way of monitoring diabetes in rural and remote clinical settings. POC capillary glucose results should be confirmed by a laboratory test of venous plasma if the results are likely to significantly influence clinical decisions.

Background To support antibiotic prescribing for both hospital and community-based health professionals working in remote northwestern Australia, a multidisciplinary Anti-Microbial Stewardship (AMS) Committee was established in 2013. This Committee is usually focused on hospital-based prescribing. A troubling increase in sulfamethoxazole/ trimethoprim (SXT) resistance in Staphylococcus aureus antibiograms from 9% to 18% over one year prompted a shift in gaze to community prescribing. What we did Finding a paucity of relevant research, we first investigated contextual factors influencing local prescribing. We also designed a systematic survey of experts with experience relevant to our setting using a structured response survey (12 questions) to better understand specific AMS risks. Using these findings, recommendations were formulated for the AMS Committee. What we learned Prescribing recommendations in a regional Skin Infections Protocol had previously been altered in December 2014. From 15 experts, we received nine comprehensive responses (60%) about AMS risks in community prescribing. If feasible, prescribing audits also would have been valuable. Ten recommendations regarding specific antibiotic recommendations were submitted to the AMS Committee. Strengthening AMS in remote settings As AMS committees in Australia usually focus on hospital-based prescribing, novel methods such as external expert opinion could inform deliberations about community-based prescribing. Our approach meant that this AMS Committee was able to intervene in the 2017 organisational review of the regional Skin Infections Protocol used by prescribers likely unaware of AMS risks. This experience demonstrates the value of incorporating AMS principles in community-based prescribing in context of a remote setting.

While a small body of literature focuses on various facets of aged care services delivered to Aboriginal and Torres Strait Islander Elders, very little is known about the support needs and preferences of Indigenous Elders who ‘return to country’. This article addresses this gap. It explores the support needs of Indigenous Elders who return to their communities after having lived elsewhere for prolonged periods of time. It provides an overview of the key themes emerging from group sessions and semi-structured interviews with 11 Aboriginal Elders and 12 representatives of regional health and social care providers conducted between 2012 and 2013. The article argues that the quest of Elders to strengthen traditional kinship systems should not be seen as a barrier but as an opportunity to develop aged care services that resonate with the needs of Indigenous Elders and with their kinship network. The findings presented in the article are structured around the themes of empowerment and choice; culturally appropriate care; enhancing program flexibility; case management; and systemic issues. The article recommends that (1) aged care services should work with and support Indigenous Elders in their efforts to strengthen traditional culture. (2) Aboriginal Elders eligible for home care packages should receive services that have the same flexibility and scope as those delivered under the National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NPFACP). (3) A relaxation of funding guidelines and particularly around the issue of income substitution should be considered for Indigenous Elders. (4) Agency staff should be up-skilled (i.e. cultural safety, culturally appropriate interventions, referral options) and given the authority to support Indigenous Elders to address grief and loss issues in a culturally appropriate fashion. (5) Elders and their communities should be central to the decision making process underpinning their support arrangements and have shared control over services.

Background: The patterns of health service use by rural and remote residents are poorly understood and under-represented in national surveys. This paper examines professional and non-professional service use for mental health problems in rural and remote communities in Australia. Methods: A stratified random sample of adults was drawn from non-metropolitan regions of New South Wales, Australia as part of a longitudinal population-based cohort. One-quarter (27.7%) of the respondents were from remote or very remote regions. The socio-demographic, health status and service utilization (professional and non-professional) characteristics of 2150 community dwelling residents are described. Hierarchical logistic regressions were used to identify cross-sectional associations between socio-demographic, health status and professional and non-professional health service utilization variables. Results: The overall rate of professional contacts for mental health problems during the previous 12 months (17%) in this rural population exceeded the national rate (11.9%). Rates for psychologists and psychiatrists were similar but rates for GPs were higher (12% vs. 8.1%). Non-professional contact rates were 12%. Higher levels of help seeking were associated with the absence of a partner, poorer finances, severity of mental health problems, and higher levels of adversity. Remoteness was associated with lower utilization of non-professional support. A Provisional Service Need Index was devised, and it demonstrated a broad dose–response relationship between severity of mental health problems and the likelihood of seeking any professional or non-professional help. Nevertheless, 47% of those with estimated high service need had no contact with professional services. Conclusions: An examination of self-reported patterns of professional and non-professional service use for mental health problems in a rural community cohort revealed relatively higher rates of general practitioner attendance for such problems compared with data from metropolitan centres. Using a measure of Provisional Service Need those with greater needs were more likely to access specialist services, even in remote regions, although a substantial proportion of those with the highest service need sought no professional help. Geographic and financial barriers to service use were identified and perception of service adequacy was relatively low, especially among those with the highest levels of distress and greatest adversity.

The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics.

Living in a rural or remote environment presents unique challenges for people with chronic conditions, mainly those created by limited health-care services and the physical and emotional isolation. Yet, research on how people self-manage their chronic conditions in such locations is limited. This study aims to contribute to research and clinical practice by describing the ways in which a diverse group of rural and remote people with a range of chronic conditions, and their unpaid carers, self-manage their conditions. Using semi-structured in-depth interviews, data was collected from a sample of 32 participants, residing in one of two regions of Australia: Mount Isa/North West region of Queensland and the Northern Rivers area of New South Wales. Our findings suggest that although self-managing in a rural and remote context requires many of the lifestyle changes necessary in urban areas, the uniqueness of the rural lifestyle and the limited availability of health care results in, at times, creative forms of self-management. Health-care professionals and policy makers need to be cognisant of the ways in which rural and remote residents modify self-management strategies to suit their needs, and help them develop self-management plans tailored to the realities of their rural environment.

Issue addressed: Injuries lead to more hospitalisations and lost years of healthy life for Aboriginal people than any other cause. However, they are often overlooked in discussion of relieving Aboriginal disadvantage. Methods: Four Aboriginal communities with diverse geography, culture and service arrangements participated in the Interplay Wellbeing project. In each community, Aboriginal researchers conducted focus groups and interviews arranged through Aboriginal organisations to explore wellbeing. A total of 84 participants contributed to 14 focus groups and eight interviews, which were recorded, transcribed and coded. This article reports on injury and possibilities for prevention, unanticipated themes raised in discussions of wellbeing. Results: Interpersonal violence, injury and imprisonment emerged as themes that were linked with employment and wellbeing. Employment in Aboriginal ranger programs provides meaningful activity, which strengthens people's identity and cultural integrity. This can avert interpersonal violence through empowering women and reducing alcohol access and consumption. Conclusion: Ranger programs may provide a much-needed opportunity to control escalating rates of injury for Aboriginal people in remote communities. So what?: The manifold benefits of Aboriginal ranger programs include reducing violence and its injury and criminal justice consequences.

Objectives: To determine the prevalence of dementia and cognitive impairment among older Indigenous Australians. Methods: A total of 363 Indigenous Australians aged over 45 years from the Kimberley region in the far north of Western Australia were assessed with the Kimberley Indigenous Cognitive Assessment (KICA). All those scoring less than 37 on the KICA and a percentage of those scoring 37 or more were reviewed by specialist clinicians and DSM-IV consensus diagnoses were obtained from two other specialists blinded to KICA results. Results: The prevalence of dementia was 12.4%, substantially higher than in the Australian general population. The prevalence of cognitive impairment not dementia was 8.0%. Conclusions: The prevalence of dementia among Indigenous Australians is substantially higher than that found in non–Indigenous Australians and all other studied populations. CIND=cognitive impairment not dementia; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, 4th edition; KICA=Kimberley Indigenous Cognitive Assessment.

Remote Area Health Corps: Nurses making a contribution to primary health services in the NT

BACKGROUND: Many older Australians now tour remote Australia (so called ‘grey nomads’). Anecdote suggests they place a burden on limited remote health services, however, this burden is poorly documented. METHODS: Two groups were approached to participate in the survey: travellers aged 50 years or over and staying in caravans, motor homes or tents at Fitzroy Crossing, Western Australia; and local primary health care providers. RESULTS: All 260 travellers approached responded. The prevalence of chronic diseases in those aged 65 years or over was 68%; 57% had sufficient chronic medications for the entire trip; 19% had a list of long term medications; and 9% of those with chronic diseases had a health summary from their usual general practitioner. Sixty-four local health providers responded: 95% rated health summaries highly (particularly if they included an active problem list, past history, current medications, and allergies). DISCUSSION: Older patients are poorly prepared for travel in remote Australia. They have a chronic disease rate no less than the national prevalence and could represent a drain on local health resources. Solutions might include GP review before travel, bringing sufficient medication for the trip, review of vaccination requirements, and a health summary.

Australians in rural and remote areas experience poorer health status compared with many metropolitan residents, due partly to inequitable access to primary health care (PHC) services. Building on recent research that identified PHC services which all Australians should be able to access regardless of where they live, this paper aims to define the population thresholds governing which PHC services would be best provided by a resident health worker, and to outline attendant implementation issues.

Hope For Health (HFH) is an Indigenous led nutrition project located on Elcho Island, East Arnhem Land, Northern Territory and is focused on preventing non-communicable diseases (NCDs). Sixty five years ago the Yolngu (aboriginal people of Elcho Island) were vital, healthy people. They now face an epidemic of NCDs such as diabetes, chronic kidney disease, cardiovascular heart disease and a life expectancy ten to fifteen years less than other non-indigenous Australians. A major contributing factor to this situation is poor nutrition. Due to complex cultural and political influences, the Yolngu diet has dramatically changed. No longer comprising purely of nutrient-rich, local food sources, today the Yolgnu diet is predominantly based upon refined and processed western food choices. These changes are contributing to nutritional deficiencies, multiple NCDs and high morbidity rates. The burden of these health consequences are not only felt by the health sector but also resulting in the loss of important cultural knowledge and disruptions to social order. The situation is further exacerbated by a lack of tangible, consultative, cross-cultural nutritional education. To overcome these challenges HFH has utilised their 40 years of cross cultural work in Arnhem Land to create a pioneering blend of methodologies towards community wide nutritional and lifestyle education. This includes experiential learning with short-term health retreats focused on acutely improving individuals with nutrient dense food, daily exercise and nutritional education. Participants are then supported back in community with regular, ongoing practical and theoretical nutritional workshops. HFH also focuses on removing challenges of continuity and on facilitating the sharing of their health education to families and community. The Yolngu culture has thrived for thousands of years. HFH’s unique methodology also empowers the local people to draw from their cultural wisdom. Essentials for the program’s successful integration into the community include a Yolngu steering committee; nutritional education workshops, exercise classes and resources all delivered in the local language, and program frameworks derived from traditional culture, diet and bush medicine. Using an integrated medical approach the programs efficacy is evaluated using both qualitative and quantitative data including pathology testing, measurable clinical examinations and naturopathic consultations. HFH is compiling data pre and post retreat. Results thus far that are demonstrating positive outcomes include participants, under medical supervision, reducing or eliminating pharmaceutical prescriptions.

Background/aim: Although previous research has demonstrated the benefits of targeting self-regulation in non-Aboriginal children, it is unclear whether such programs would be effective for Aboriginal children attending school in remote communities. Some of these children have been diagnosed with a fetal alcohol spectrum disorder (FASD) impairing their ability to self-regulate. The aim of this article is to describe a three phase formative process to develop and pilot a curriculum version of the Alert Program®, a promising intervention for improving self-regulation that could be used in remote community schools. This modified version of the program will be subsequently tested in a cluster randomised controlled trial. Methods: A mixed methods approach was used. Results: Modifications to the Alert Program®, its delivery and evaluation were made after community and stakeholder consultation facilitated by a senior Aboriginal community researcher. Changes to lesson plans and program resources were made to reflect the remote community context, classroom environment and the challenging behaviours of children. Standardised study outcome measures were modified by removing several questions that had little relevance to the lives of children in remote communities. Program training for school staff was reduced in length to reduce staff burden. Conclusions: This study identified aspects of the Alert Program® training, delivery and measures for evaluation that need modification before their use in assessing the efficacy of the Alert Program® in remote Aboriginal community primary schools.

The research investigated in detail how appropriate and sustained PHC service inputs contribute to direct and indirect health outcomes that ensure improved health status for all Australians. The CRERRPHC research helps to generate measures by which to link PHC models with improved efficiency, acceptability and appropriateness of care necessary to ensure sustainable improved health outcomes. Specific studies focused on sustainable models of aged care and mental health service delivery (two of the most important national priority areas relevant to under-served populations), and the role and importance of health knowledge and literacy in improving access to PHC.

In 2002/2003, the Queensland Government released a decision that Alcohol Management Plans (AMPs) were to be introduced to most Indigenous communities in Cape York, Australia, in an effort to address violence generally and specifically violence against women and children. By 2008, increased restrictions brought total prohibition in some communities and tightened restrictions in others. This project provides a pre-/postprohibition comparison and analysis of injuries, injuries that involved alcohol and verified police reported assaults. Supporting this are rich community survey data which together aim to elicit the effect restricting alcohol had on violent activity in the communities, particularly for women.

Introduction: The shortage of healthcare professionals in rural communities is a global problem that poses a serious challenge to equitable healthcare delivery. Both developed and developing countries report geographically skewed distributions of healthcare professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems. This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. Methods: A comprehensive search of the English literature was conducted using the National Library of Medicine’s (PubMed) database and the keywords ‘(rural OR remote) AND (recruitment OR retention)’ on 3 July 2008. In total, 1261 references were identified and screened; all primary studies that reported the outcome of an actual intervention and all relevant review articles were selected. Due to the paucity of prospective primary intervention studies, retrospective observational studies and questionnairedriven surveys were included as well. The search was extended by scrutinizing the references of selected articles to identify additional studies that may have been missed. In total, 110 articles were included. Results: In order to provide a comprehensive overview in a clear and user-friendly fashion, the available evidence was classified into five intervention categories: Selection, Education, Coercion, Incentives and Support - and the strength of the available evidence was rated as convincing, strong, moderate, weak or absent. The main definitions used to define ‘rural and/or remote’ in the articles reviewed are summarized, before the evidence in support of each of the five intervention categories is reflected in detail. Conclusion: We argue for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and educatio n policies, although incentive and support schemes may have value. There remains an urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to identify winning strategies for guiding future practice and policy.

Importance: Demand for Retinopathy of Prematurity screening, is increasing for infants born at rural and regional hospitals where the service is not generally available. The health system cost for screening regional/remote infants has not been reported. Background: The objective of this study is to evaluate the cost of Retinopathy of Prematurity screening at a large centralised tertiary neonatal service for infants from regional/rural hospitals. Design: This is a retrospective study to establish the cost of transferring regional/rural infants to the Royal Brisbane and Women's Hospital for ROP screening over a 28 month period. Participants: 131 infants were included in this study. Methods: Individual infant costs were calculated from analysis of clinical and administrative records. Main Outcome Measures: Economic cost of ROP screening for all transfers from regional/rural hospitals to Royal Brisbane and Women's Hospital. Results: The average economic cost of ROP screening for this cohort was AUD$5110 per infant screened and the total cost was AUD$669,413. The average cost per infant screened was highest for infants from a regional centre with a population of 75,000 (AUD$14,856 per child), which was also geographically furthest from Brisbane. No infant in this cohort transferred from a regional nursery reached criteria for intervention for ROP by standard guidelines. Conclusions and Relevance: Health system costs for ROP screening of remote infants at a centralised hospital are high. Alternative strategies using telemedicine can now be compared with centralized screening.

In this chapter, the author examines the Bawinanga Aboriginal Corporation located at Maningrida in Arnhem Land. Bawinanga is an Aboriginal corporation and for over 20 years it was also a Community Development Employment Projects (CDEP) organisation. It was established in 1979 and, during the first decade of the 21st century, it became one of the largest and most financially successful Indigenous corporations in Australia. Bawinanga succeeded in remote and difficult circumstances largely devoid of market opportunity where others, including the Australian colonial state from 1957, have failed. Its only serious competitor in the Maningrida region is the Maningrida Progress Association, a community-owned organisation that focuses on retail trade in the township of Maningrida. Much of Bawinanga's success can be linked historically to its productive deployment and reconfiguring of CDEP funding support from the Australian government. The focus of the chapter is on the relationship between CDEP and Bawinanga, as their life cycles are closely related; Bawinanga was established as a small community-based outstation resource agency two years after CDEP began. Both were new and innovative institutions in the 'Indigenous sector'. The author provides an account of the consequences of the demise of CDEP for Bawinanga, its members and the regional population more generally. Edited excerpts from publication.

The Community Development Employment Projects (CDEP) scheme is an unusual program for Indigenous people primarily underwritten by welfare entitlements. Currently there are 39,000 CDEP places and around 60,000 Indigenous people participate in the scheme each year. This paper discusses the roles that the scheme plays. First, the scheme provides flexible employment opportunities, often in remote contexts where there are no, or minute, labour markets. Second, it provides income security and the opportunity to earn additional income from employment and enterprise. Third, it provides opportunity for education and training. Fourth, and most innovatively, it acts as an instrument for economic and community development. This is especially so in remote and very remote Australia where people reside on the Indigenous estate and operate within an unorthodox ‘hybrid economy’ where customary (non market) activity looms relatively large. The customary sector has considerable economic value, both for Indigenous people directly and in spillover benefits to other Australians. The links between the CDEP scheme and the operations of the hybrid economy are explored.

There has been escalating media coverage of the view that Indigenous economic disadvantage and housing and infrastructure shortages are linked to communal title to land resulting from land rights and native title. A variety of powerful fi gures have been suggesting that privatizing or individuating this land might generate better economic and social outcomes for Indigenous people, especially in remote and very remote Australia. This Discussion Paper challenges this view in two ways; by reviewing the existing literature and by examining recently available statistics, especially on Indigenous housing need and affordability. The paper focuses most specifi cally on the situation in the Northern Territory for a variety of reasons. First, land rights are most deeply embedded and extensive in this jurisdiction. Second, there is no doubt that some of the most intractable development, housing and infrastructure issues facing remote Indigenous communities are evident in the Northern Territory.