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| House of Representatives Standing Committee on Aboriginal and Torres Strait Island Affairs

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Chapter 3 Healthy stores, healthy communities

3.1                   Stores which promote and stock healthy food alternatives are an essential contributor to building healthy Indigenous communities in remote areas. This chapter provides an overview of the health status of Indigenous people living in remote areas, noting the links between health outcomes and nutrition.

3.2                   The chapter then considers how store managers, health workers, governments and communities themselves may contribute to developing the necessary policies, initiatives and incentives to promote healthy food preferences in remote Indigenous communities.

Health status of Indigenous people living in remote communities

3.3                   Indigenous people suffer disproportionately high levels of chronic diseases compared to the non-Indigenous population. Once rare, lifestyle diseases such as diabetes, heart disease, kidney failure and overweight problems now feature in many remote communities.

3.4                   In 2005–06, Indigenous people were hospitalised at 14 times the rate of non-Indigenous people for care involving dialysis, and at three times the rate for endocrine, nutritional and metabolic diseases (which includes diabetes). [1] The Department of Health and Ageing reported that:

n  approximately three times as many Indigenous Australians reported diabetes or high sugar levels as non-Indigenous Australians,

n  Indigenous Australian adults were twice as likely to be obese as non-Indigenous Australian adults,

n  the incidence of end-stage renal disease in remote areas of Indigenous Australians is 20 times as high as for other Australians —

In some parts of Australia we almost have a diaspora of people who cannot live in community any more. In some communities nearly everyone over the age of 50 who is alive is either in town or with their partner in town on dialysis,

n  of Aboriginal and Torres Strait Island people living in remote communities 14 per cent reported heart and circulatory conditions, compared to 11 per cent of those living in non-remote areas, and

n  cases of self-reported diabetes and high sugar levels are nine per cent for Indigenous Australians living in remote areas, compared to five per cent living in non-remote areas. [2]

3.5                   Figures on mortality rates in the ABS report, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, 2008 include:

n  life expectancy for Indigenous Australians was 59 years for males and 65 years for females, compared with 77 years for all males and 82 years for all females, a difference of around 17 years, and

n  the mortality rate for Indigenous infants and Indigenous children aged one to 14 years in the period 2001–2005 was around three times that for non-Indigenous infants and children.[3]

3.6                   The Australian Medical Association reported that compared with their non-Indigenous Australian counterparts, Indigenous children are:

n  two to three times more likely to die in the first 12 months of life, and 11 times more likely to die from respiratory causes,

n  more likely to be stillborn, to be born pre-term, to have low birth weight, or to die in the first month of life,

n  nearly 30 times more likely to suffer from nutritional anaemia and malnutrition up to four years of age,

n  at a much higher risk of suffering from infectious and parasitic diseases, diseases of the respiratory and circulatory system, hearing loss, rheumatic fever, dental caries, injuries, and clinically significant emotional and behavioural difficulties, and

n  cared for by significantly fewer adults, who are also at higher risk of premature death, serious illness, substance abuse, imprisonment, major social and emotional stress, lower household income, lower educational attainment, lower employment, and lower access to appropriate sanitary and household conditions, than other Australian adults.[4]

3.7                   The Committee notes that changes to the health profile of Indigenous people will not be seen in the short term; there are no quick-fix solutions. Long term health improvements are reliant on improvements to nutrition, diet and lifestyle. As John Tregenza, Mai Wiru Health Policy Coordinator suggested, ‘We cannot now change the health profile of anyone from five on.’[5]

Dietary change and current food preferences

3.8                   Indigenous people are relying more on the community store for food supply compared with the past. John Tregenza, who has been working in the Anangu Pitjantjatjara Yankunytjatjara (APY) lands for 35 years, told the Committee that in 1974, 90 per cent of diet was locally sourced from the bush and 10 per cent from store. Now the store is the primary place for people to get their sustenance.[6]

3.9                   Indigenous people across Australia do still regularly go hunting for foods for ceremonial purposes and as a healthy supplement to diet.[7] However, there has been a reduction in reliance on traditional hunting for a number reasons, including:

n  community gardens, fruit orchards and animal husbandry conducted in many communities disappeared with the missions and diet became largely based on non-perishable foods like tinned corned beef, tea, white flour and sugar, which are nutrient poor,[8]

n  the impact of environmental degradation and feral animals. For example, quandong trees, very high in Vitamin C, have been destroyed by the numbers of camels in the desert,[9]

n  quarantine regulations have affected the potential to grow and trade traditional foods and goods, for example, between Cape York, Papua New Guinea and between the Torres Strait Islands,[10] and

n  the high cost of fuel and management plans to sustain fishing resources have impeded the opportunity for people living in the Torres Strait to hunt dugong, turtle and fish.[11] The Committee notes that dugong and turtles are threatened and traditional hunting needs to be undertaken in a traditional way under a sustainable management plan. The Committee encourages the development of these plans where they are not currently in place.[12]

3.10               Sedentary lifestyle with increased access to attractive low nutrition foods has, in some circumstances, removed incentive and energy needed for traditional food gathering and hunting. The reliance on the community store in remote Indigenous communities has resulted in high consumption of nutrient poor and energy dense foods, a change from the traditional food systems which were largely nutrient dense but relatively low in energy and fat, sugar and salt.

Link between poor nutrition and health

3.11               Poor nutrition is a major contributor to the poor health outcomes and early death in remote Indigenous communities. The National Health and Hospitals Reform Commission reported in June 2009 that ‘Poor nutrition —particularly low fruit and vegetable intake—is an important determinant of the health gap among Aboriginal and Torres Strait Islander people’.[13]

3.12               Research indicates that low fruit and vegetable consumption accounts for five per cent of the life expectancy gap between Indigenous and non‑Indigenous people in Australia. Tobacco contributes 17 per cent. The burden of disease for Aboriginal and Torres Strait Islander people from low fruit and vegetable consumption is 1.6 times higher in remote areas than in non-remote areas.[14]

3.13               The National Aboriginal and Torres Strait Islander Health Survey 2004– 05 found that in remote areas, 20 per cent of Indigenous people aged 12 years and over reported no usual daily fruit intake and 15 per cent reported no usual daily intake of vegetables.[15]

3.14               Research points to maternal and early nutrition as important in a person’s health over their lifespan. The Department of Health and Ageing stated that health disparities between Indigenous and non-Indigenous Australians have their origins in early childhood development and continue to exert impact across the life course, leading to increased morbidity from chronic and preventable diseases with reduced life expectancy. The young mothers who are conceiving have poor nutritional status, the uterine environment for their children is poor and this contributes to an ongoing cycle of health problems.[16]

3.15               Nutritionists have discussed the importance of targeting child and maternal health because it allows good eating and exercise patterns to be established early.[17] The Prime Minister’s Science, Engineering and Innovation Council (PMSEIC) Working Group’s report into maternal and foetal health in Aboriginal and Torres Strait Islander Populations recommended ensuring access to healthy food at affordable prices in Indigenous communities as a critical step to close the gap in infant and maternal mortality and low birth weight in Aboriginal and Torres Strait Islander communities.[18]

Government initiatives on closing the gap in health

3.16               Two of the targets agreed to by the Council of Australian Governments (COAG) in October 2008 to close the gap were related to health:

n  close the gap on life expectancy within a generation, and

n  halve the gap on mortality rates for Indigenous children under five within a decade.[19]

3.17               Commonwealth Government initiatives to promote good nutrition and healthy eating among remote Aboriginal and Torres Strait Islander communities include:

n  The National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) was endorsed by the Australian Health Ministers Conference in August 2001. NATSINSAP was designed to build on existing efforts to make healthy food choices easier choices for Aboriginal and Torres Strait Islander peoples, irrespective of where they live. In 2004 a national project officer was appointed to provide coordination for the implementation for key components of the NATSINSAP. This position was funded by the Commonwealth Department of Health and Ageing.

A key achievement of the NATSINSAP was the collaboration between five state and territory jurisdictions and the completion in 2008 of the Remote Indigenous Stores and Takeaways Project (RIST). Nine resources have been developed, intended to establish and improve standards for ‘healthy’ remote stores. The RIST package includes:

§  Guidelines for stocking healthy food in remote community stores

§  Fruit and vegetable quantity spreadsheet

§  Marketing ideas for healthy food in remote community stores

§  Healthy Fast Food: A resource for remote stores and takeaways

§  Freight Improvement Toolkit

§  Checklists for the Store and Takeaway

§  Heart Foundation Buyers Guide for managers of remote Indigenous stores and takeaways

§  Guidelines for maximising the shelf life of fruit and vegetables

§  Keeping Track of Healthy Food—a monitoring and reporting tool (in Microsoft Access software format) that uses scanned sales data to assess a community’s consumption of key foods and nutrients. This information is indicative of a remote community’s food purchasing habits and nutritional issues.

n  The licensing of stores and income management in the Northern Territory were introduced as government interventions intended to improve the quality, quantity and range of groceries, including healthy foods and drinks in stores, and to increase healthy purchases. Store licensing and income management is discussed further in Chapter 7,

n  Outback Stores was established in 2006 as a non-government enterprise to improve the commercial viability of remote community stores, provide a better range of affordable healthy foods, provide consistency in delivering and supplying quality products, increase local employment opportunities for Indigenous workers, and establish more efficient and reliable stores. An assessment of the Outback Stores model is in Chapter 7, and

n  The Mai Wiru Regional Stores Policy (Mai Wiru), auspiced by the Nganampa Health Council, aims to improve the health and well-being of Aboriginal people living on the Anangu Pitjantjatjara Lands. It helps to ensure continuous access to safe, nutritious, affordable food through the stores. The Department of Health and Ageing funded the Nganampa Health Council to develop and implement Mai Wiru.

Stores—balancing the economic and health benefits

3.18               Health experts advise that the disproportionate amount spent on cigarettes, sweets and sugared drinks compared with water and fresh fruit and vegetables is having an impact on the health of remote Indigenous communities. Strategies must focus on increasing consumption of healthier products as well as discouraging the consumption of unhealthy products, such as sugared drinks.[20]

3.19               Community stores in the past have had a poor record on health promotion, with sales of sweets and nicotine products sustaining profits. The sale of cigarettes is of great concern. In 1995 a community with a population of 50 spent $5 824 on cigarettes in one month, whereas only $920 was spent on fresh fruit and vegetables.[21] At one store in Maningrida the monthly turnover was $600 000, with purchases of fruit and vegetables at $13 000 and cigarettes at $130 000. This was despite no advertising and the cigarettes not being on display.[22]

3.20               Several witnesses argued that remote community stores must operate as viable businesses before they can consider promoting healthy options. From a business point of view, selling nutritious foods carries a higher risk. High profit items, such as chocolate and lollies, can capitalise on some of the loss experienced through the loss of perishable fruit and vegetables. As accountant Craig Spicer, Remote Community Management Services, stated:

We like to try to get as much money on those [TVs] as we can. Obviously the lollies and all the sweets are high profit. We get flak from teachers and nurses about that, but the fact is that we cannot sustain these places without making money. Our vision is to have a commercial investment where we thrive without any grants or anything else. It goes to show that it can be done, but it is hard work.[23]

3.21               Joseph Elu, Mayor of the Northern Peninsula Area Regional Council (NPARC) and former Chairman of Indigenous Business Australia (IBA), agreed that every store should be run as a commercial enterprise and retail works when you supply what the community wants:

Retail is about people walking through the door because they know what they want and that is why they go to your store. If you are going to just sell them what you think they should be eating or what you think they should be buying they will quickly look for another place where they know the things they want are sold.[24]

3.22               Mr Elu believed the most important aspect of a viable store is that communities feel engaged and involved. Therefore the store becomes a focal point where people gather; it is not just about where they go to buy things. He stated that the original concept of Outback Stores was to, firstly, be commercially viable and secondly, supply quality healthy foods.

3.23               Outback Stores contended that, as a group, it needs to be viable to deliver services. According to Outback Stores, the approximate population size required is 200 for a store to be viable. Other factors which impact on viability include remoteness, access to transport and transient populations.[25] The Northern Territory Government’s strategy with its ‘Working Futures Package’ is that all store models must be viable businesses into the future.[26]

3.24               The Committee received counter arguments that community stores in remote communities provide a primary and essential service which should be subsidised.[27] Subsidies are further discussed in Chapter 5.

3.25               The Nganampa Health Council (NHC) sees the supply of affordable healthy food as an essential service: ‘a health issue, not a fiscal or an economic issue, in the sense of those stores’.[28] The NHC, the APY Council and the Ngaanyatjarra Pitjantjatjara Yankunytjatjara (NPY) Women’s Council together developed the Mai Wiru stores policy which applies to all stores in the APY lands and works to deliver affordable healthy foods. The NYP Women’s Council maintained that stores should be considered ‘essential services’ and receive government funding or subsidies in the same way a clinic or a school does. [29]

3.26               Free fruit and vegetables, particularly to children and young pregnant women, was advocated by FoodBank Western Australia.[30]

3.27               Encouragingly, several witnesses detailed approaches which delivered positive health as well as viable business outcomes. Darryl Pearce, Chief Executive Officer, Lhere Artepe Aboriginal Corporation stated that the health economy must be considered in conjunction with the cash economy of a community. For example in 1986, a store gave away fresh fruit and vegetables while still returning a profit of $45 000 to the community.[31]

3.28               The Arnhem Land Progress Aboriginal Corporation (ALPA)’s position is that a community’s store must be potentially commercially viable before it will consider managing it. ALPA’s consultancy service manages 11 stores owned by other community organisations. All are profitable and viable commercial enterprises, however they do operate with an emphasis on local employment and training, nutrition and range with best possible prices.[32]

3.29               Some communities have opted to operate at no profit or low profit in order to keep the margins on food as low as possible.[33]

Influence of store managers

3.30               Store managers can hold a very powerful position in determining the food supply, quality, pricing, freshness and promotion of goods, and this in turn impacts on the health outcomes of a community. Attitudes can influence the quality of the food supply and the turnover of healthy foods. In some circumstances, the success of a store is judged on profit or the amount of money the store can return to the community.

3.31               The tenure of managers can also be an issue: a health policy implemented by one manager may be discontinued by another manager.[34] The NPY Women’s Council stated that health outcomes have depended on whether store managers adhere to Mai Wiru: if a store manager is compliant the policy works, but if a store manager ignores the policy there are terrible health outcomes.[35]

3.32               Many witnesses asserted that the promotion of healthier purchases should not be the responsibility of the store. Store managers can spend long hours managing the store as a viable business and therefore are time and resource poor when it comes to considering health policies.[36] Dr Bruce Walker, Chief Executive, Centre for Appropriate Technology (CAT) stated that stores can make tactical responses but alone cannot create the demand for higher consumption of healthy food.[37]

3.33               Store managers are generally very conservative when it comes to stocking fruit and vegetables because once outside the cold-chain these have to be sold quickly or be thrown out, therefore creating a loss. ALPA links the sales of fruit and vegetables to the store manager’s performance targets and provides bonuses to encourage them to step out of their comfort zone and try increasing orders of fresh produce.[38]

Health and nutrition education

3.34               As discussed above health outcomes in the community do not, and should not, rely on store managers alone. Health units, nutritionists and community leaders need to work collaboratively with communities and store managers to develop health strategies for the store.[39] Nabeel Rasheed, Store Manager in Jilkminggan, noted that there was a doubling of fruit and vegetable sales after the Sunrise Health Service had nutrition demonstrations in the store.[40]

3.35               The Committee received other accounts of positive health outcomes in communities where nutritionists work. Ian McDowell, who had managed stores in remote communities in the Northern Territory and Queensland, surmised the high turnover of fruit and vegetables in Kowanyama was due to the nutritional education work of the health centre.[41]

3.36               The Queensland Government funds nutritionists to work with the stores in Cape York and the Committee observed the benefits of this first-hand during its visits to Bamaga, Aurukun and Kowanyama. Lesley Podesta, Department of Health and Ageing, referred to the benefits of nutritionists working in communities:

At the best, nutritionists that have been working in communities have made a big difference about being able to show people that substitution by nutrient-rich food of nutrient-poor food does not change taste… I know this will sound crazy, but a really good example is that a pie is a very popular item and one of the nutritionists had spent a lot of time identifying the best pies in terms of lower fat, high-protein content that was able to be shipped, had a longer shelf life …[42]

3.37               Nutritionists offer all sorts of advice to managers and community members to promote healthy choices, such as:

n  choosing nutrition enhanced foods, including intakes of key nutrients such as folate, iron and calcium during pregnancy,

n  preparing healthier takeaway food,

n  marketing and education programs combined can be effective in promoting healthy eating patterns,

n  labelling for health – identifying what is good food choice and what is poor food choice,

n  reducing or removing the sale of unhealthy items,

n  in store promotions and promotions in local media,

n  educating about brand or product attraction, and

n  appropriate placement on products on shelves and in fridges.

3.38               Armed with evidence based data, a nutritionist can help communities and managers understand what products are being bought from the store and the potential health effects.[43] A key component of Mai Wiru has been the monitoring of sales, whereby nutritionists demonstrate to community leaders the impact of sales on the health of the community. This has some influence on store committee decisions about what to stock in their store, and store managers must comply with these decisions. For instance, in Amata the nutritionist presented information about how much money was being spent on Coke and the community decided to remove it from the store.[44] The benefit of the point-of-sale monitoring tool is discussed below.

3.39               In many remote communities health units, charities, and businesses are collaborating with stores on health programs. Many stores support nutrition programs and supply fresh fruit and vegetables to schools and to other programs, such as meals on wheels.[45]

3.40               Under Queensland Health’s ‘Eat Well Be Active—Healthy Kids for Life’ project nutritionists work with schools to deliver a whole‑of‑community approach to improve child nutrition. The project is being trialled over three years in three locations and targets four key areas: mothers and babies, junk food reduction and healthy food consumption, improving family budgeting, and promoting activity. Tagai State College on Badu Island is the lead agency for the project in the Torres Strait. Project Coordinator Rita Kebisu told the Committee that baseline data for the project is gathered by routine screening and monitoring of all babies and children to 12 years. Funding for the project ends in late 2009.[46]

3.41               The Australian Red Cross and the Fred Hollows Foundation are delivering food nutrition and supply programs to remote Indigenous communities with the help of nutritionists and the stores.[47] The Red Cross has developed a national partnership with Outback Stores and has signed a Memorandum of Understanding to guide the partnership. The collaboration aims to ‘work towards making a positive impact on the health of remote Aboriginal people by partnering with Indigenous communities to deliver long term sustainable health outcomes’. Strategies include ensuring fruit is continually available for breakfast clubs, developing in-store nutrition promotion, and sharing sales data to inform ongoing development of food security policies.[48]

3.42               Oral health is another health area of great concern in remote Indigenous communities. Outback Stores is also working with Oral Health Services NT to provide oral hygiene products.[49]

3.43               Other health initiatives in communities aim to improve the capacity to store, cook and prepare food at home in remote Indigenous communities. There are programs operating out of health clinics about healthy food preparation and there was support for these programs from both women and men.[50] Cooking lessons in remote Indigenous communities is discussed further in Chapter 5.

3.44               The Committee notes there were many good examples of programs which provided services and education around food and nutrition, cooking classes and homemaker skills that were phased out by Government in the late 1990s.[51] Witnesses in Maningrida advised that funding for a nutritionist had been cut after six months. The need for staff was urgent as the clinic did not have the capacity to run nutrition programs in addition to seeing the 600 people on the chronic disease list every three to six months.

3.45               Following the Committee’s visit, Maningrida received funding for a nutritionist for two days a month. Witnesses in Maningrida called for longer term funding for anti-smoking and nutrition education.[52]

Indigenous health workers

3.46               Indigenous people represent one per cent of people working in health-related occupations in Australia.[53] In the Northern Territory Department of Health and Families there is one Indigenous nutritionist. Dr Julie Brimblecombe from the Menzies School of Health Research asserted the importance of Indigenous people conveying health messages to other Indigenous people and the need to train community people who can sit down with, empathise with, and understand their situation.[54]

3.47               The National Health and Hospitals Reform Commission recommended the government provide support for training for an Indigenous health workforce:

We must also strengthen the vital role of Community Controlled Health Services, train and recognise an Indigenous health workforce and a workforce for Indigenous health, and up-skill our health workforce to provide culturally appropriate services.[55]

3.48               NATSINSAP recognised that cross-cultural communication and awareness is essential to the development of effective health programs.[56] Dr Amanda Lee, member of the NATSINSAP Steering Committee, commented that the main factors for success in health interventions are engagement with the community and community control over the interventions that are trialled. This means a qualified nutritionist does not need to be in the community all the time. Rather, it is important that someone from the community with an understanding of nutrition communicates with the community:

A mother, a health worker, a community change agent, anyone in that community that has the respect of the community but is able to respond to community wishes and knowledge and build on that past understanding to enable them to influence the store, and the uptake of the food.[57]

3.49               The importance of a local person educating a community is well illustrated by the Jaywon land owners, east of Katherine, who have ten principal language groups but low English literacy levels with few people having an above primary school education. Family and kin obligations are paramount in the lives of residents; traditional systems of social and economic organisation prevail, as do traditional knowledge and beliefs. The Sunrise Health Service stated that the understanding, attitudes and practise about illness and health are often very different to those in non‑Indigenous health systems.[58]

3.50               The Dieticians Association of Australia (DAA) and the Public Health Association of Australia (PHAA) stated that a ‘well supported, funded and educated Aboriginal and Torres Strait Islander nutrition workforce is essential to attaining food security’. They were advocates of a cultural respect framework to ensure Aboriginal and Torres Strait Islander health workers are valued for local nutrition knowledge in conjunction with cultural processes and traditional knowledge.[59]

Developing healthy store policies

3.51               NATSINSAP regards the development, monitoring and reporting of nutrition policies for all remote stores as essential. NATSINSAP believes nutrition policies must include measurable targets on the sales of key indicator foods, such as fruit and vegetables and sugared drinks.[60]

3.52               The Central Land Council argued that all stores should adopt health principles:

All stores should have positive community health and nutrition principles included in their rules, so that the committee of the store is bound by those principles in its management role. Stores committees should be given assistance to review the current rules.[61]

3.53               The Committee was told that community generated health agreements are fundamental and attempts to merely impose health foods will fail. Rather, there needs to be choice and education is required so community members can make informed choices about the purchase of healthy foods and takeaways. Mai Wiru in APY lands demonstrates that supporting the stores and the communities, through knowledge and education, has resulted in the communities demanding and purchasing healthier food. Lesley Podesta from the Department of Health and Ageing recognised that Mai Wiru store is a ‘fantastic project’ which could be rolled out across other areas.[62]

3.54               There has been a range of health policies adopted by remote Indigenous communities across Australia. Health policies are briefly described below:

n  Outback Stores—The Outback Stores Nutrition Strategy focuses on improving nutritional outcomes, and improving sales of healthy food, through in-store promotion of fruit and vegetables, preferential pricing of key nutritional lines and basic foods, inclusion of nutritional options in takeaway menus, and selective sourcing of nutritional lines. Outback Stores employs nutritionists who help to develop the capacity of store managers and staff to focus on the health needs of the communities as part of their day-to-day work. They do this by spending time with the managers in the store and providing training. Nutrition strategies on store presentation include not selling confectionary at point-of-sale counters, bowls of fruit on counters, and not displaying tobacco.

Outback Stores set targets on the sale of fruit and vegetables at seven and a half per cent this year and 10 per cent in the future. (In most communities Outback Stores had entered fruit and vegetable sales were at two per cent, whereas in April 2009 fruit and vegetable sales were seven per cent across the organisation.) Outback Stores has set a target to reduce tobacco sales to 10 per cent.[63] Outback Stores used the RIST resources to inform them on developing their core range.

NATSINSAP advocated the need for Outback Stores to have a nutritionist on its governing board.[64]

n  Mai Wiru—The Mai Wiru (good food) policy, introduced in 2002, was developed jointly by the Nganampa Health Council, the NPY Women’s Council and the APY council as a result of work done in 1998 showing that people’s income was insufficient to allow them to access affordable healthy food.[65]

All eight communities under Mai Wiru have signed an MOU with the Mai Wiru Stores Policy Unit to implement the Mai Wiru policy. A steering committee, which is made up of the Chairs of each community governing body, signs off on strategies within the policy. The Unit has been funded by the Commonwealth Department of Health and Ageing and carries out necessary functions that stores do not have resources to do: organise preferred suppliers, training, staff recruitment and nutritional expertise. A public health nutritionist was recruited in April 2006 who helped with implementation and improvements to the diet of the community. In 2007 the Mai Wiru stores policy received the National Heart Foundation Award for community health initiatives.[66]

The Nganampa Health Council was investigating a future governance model on the APY lands, which would ensure that the Mai Wiru policy is enforced, yet managed by another management group. Consideration is being given to transitioning to management with Outback Stores. Under the Anangu Pitjantjatjara Yankunytjatjara Land Rights Act 1981, whereby traditional owners have the power to introduce by-laws, it would be possible to stipulate that the future manager of the stores would be governed by the Mai Wiru policy.[67]

n  ALPA Yolngu community owned and Australian Retail Consultancy (ARC) stores—In 1985 ALPA implemented its own nutrition policy and self-funded freight subsidy on fruit and vegetables in its stores to drive consumption.[68] The major objectives of ALPA’s 2004 Health and Nutrition Strategy include improving the health and nutrition of Arnhem Land communities, specifically targeting diabetes, kidney disease, heart disease, aged care and children’s health. ALPA employs a nutritionist and good food staff members in every store.

n  Other community owned stores—In many instances managers and store committees welcome collaboration with health clinics about what to stock or how to present stock in the store. For example, the two stores in Maningrida have received advice from the health clinic and nutritionists about stocking different products.[69] The Finke River Mission store manager works with a Northern Territory government funded nutritionist to develop strategies to encourage the consumption of healthier products.[70] A Healthy Store Policy was drawn up with managers, community members and the NPY Women’s Council in Tjukurla. A list of policy items includes stocking a minimum amount of healthy fresh food, stocking sugared drinks in small bottles only, and encouraging the sale of healthy foods by displaying good food posters and so on.[71]

n  Private owned and run: station stores and roadhouses—Health polices in these stores can be dependent on the priorities set by the manager.

n  Queensland Department of Communities—the Nutrition Policy for Remote Retail Stores and Take-Aways (2007) includes strategies to consistently stock a wide range of healthy and affordable foods including takeaways. Nutrition promotion, education and training of store staff are objectives with store participation in nutrition programs at least twice a year. The Retail Stores Unit seeks agreement to the policy from the local Aboriginal shire council. The implementation of the policy is monitored, reviewed and evaluated annually.[72]

n   Islanders Board of Industry and Service (IBIS) stores—the IBIS Healthy Food Policy includes a pricing policy that specials only healthy food and subsidises the provision of health foods. Integral to the policy is the ongoing availability of fresh fruit and vegetables. IBIS stores identify and highlight healthy food choices through signage, publication of recipes, advertising, and marketing. A nutritionist is employed by IBIS to promote healthy food choices in communities. The IBIS store on Thursday Island has a bakery which is selling low GI index, wholegrain, rye and multi-grain bread.[73]

3.55               Store committees and community representatives have self imposed a variety of mechanisms to improve health of their community. Some models are innovative and the Committee recognises that different communities require different approaches. Some examples of different community healthy store initiatives include:

n  Removal of the sale of Coke, Passiona, Gatorade and Disney poppers
— by the community of Amata. Diet Coke and Sprite was not removed. Data a year later showed there was an increase in orange juice and water sales,[74]

n  Displays of foods—stores managed by Ninti Corporate Services have lower mark ups on fruit and vegetables and display healthy foods near the checkout at eye and hand level. A basket of fruit is at the checkout and individual pieces are sold at 50 cents each,[75]

n  FOODcard—after recommendation from the Indigenous women of Gapuwiyak, ALPA developed the FOODcard to assist people with budgeting for healthy food throughout a pay cycle. The card was voluntary and was for food and essentials only, so articles like lollies, toys, takeaway fatty foods and soft drinks were excluded. A de facto labelling (green ticket) system also introduced indicated the products that could be purchased with the FOODcard,[76]

n  Encouraging hunting of nutritious foods—the people of Mapuru in north-east Arnhem Land made an active decision to go hunting and traditional food sourcing because it was impossible for them to get delivery of frozen produce. In the co-op the community could buy healthy foods and general household necessities. The co-op won the National Heart Foundation award for Small Rural and Remote Initiatives in 2004,[77] and

n  Cross subsidisation —Queensland Department of Communities stores subsidise the prices of healthy foods at the expense of less healthy items, including tobacco and high sugared drinks.[78]

RIST resources

3.56               NATSINSAP outlined in its submission the goals and objectives of the Remote Indigenous Stores and Takeaways (RIST) project. The goal of the project was to improve access to healthy food in remote Indigenous community stores and takeaways. Objectives of the project were to:

n  develop a common set of guidelines and resources that promote access to healthy foods, and discourage the promotion of energy-dense/nutrient poor food and drinks, and

n  implement and evaluate guidelines and resources across a number of remote community store and takeaway trial sites.

3.57               The core outcome of the RIST project was the development of a package of nine resources to assist remote stores and takeaways to stock, promote and monitor the sales of healthy foods. The RIST resources, referred to in paragraph 3.17, are a result of comprehensive research and development by NATSINSAP—a collaboration of five state and territory jurisdictions.

3.58               Queensland Health is currently leading a twelve month project to promote, distribute and train people in the use of the RIST resources and to design, conduct and report on an evaluation of these resources in Aboriginal and Torres Strait Islander communities across Queensland and the APY lands in South Australia. While this work is still ongoing, preliminary work in piloting these resources has demonstrated improvements in the sale of healthy foods when local level nutritionists worked in partnership with stores and communities to support their implementation.[79]

3.59               The NATSINSAP provided the Committee with a comprehensive submission and gave evidence at a public hearing in Canberra. The Committee was impressed with the work undertaken by NATSINSAP from a national perspective. During the public hearing NATSINSAP told the Committee:

The engagement of nutrition experts within store groups are a real[ly] important catalyst for change and influencing the supply and demand of healthy food. We would also like to see the promotion of these RIST resources in all remote stores across Australia. [80]

3.60               The Committee believes that NATSINSAP has carried out valuable work in the field of health and nutrition. The Committee also believes that the Queensland Government project to promote, distribute and train people in the use of RIST resources should be carried out by other jurisdictions such as the Northern Territory, Western Australia and South Australia.

3.61               The Committee strongly supports the distribution and use of the RIST resources with the support of nutritionists.

Recommendation 1

 

The Committee recommends the Australian Government fund the rollout of the Remote Indigenous Stores and Takeaways (RIST) resources to all remote Indigenous communities across Australia, in conjunction with the support required by a nutritionist.

Monitoring and evaluating health initiatives

3.62               With any intervention to improve health in remote Indigenous communities, testing must be done on whether these interventions work. There is currently no national mechanism for monitoring sales of food, and therefore the consumption of healthy or non-healthy food, in remote communities.

3.63               The RIST point-of-sale monitoring tool Keeping Track of Healthy Food can be modified to monitor any types of foods which stores or nutritionists may be interested in.

3.64               Outback Stores is using the RIST point-of-sale monitoring tool to measure the sale of key indicator foods.[81] The Queensland Health pilot project to report on and evaluate the RIST resources in Queensland and the APY lands was due to be completed in October 2009. [82]

3.65               Robyn Bowcock, a Public Health Nutritionist working in Western Australia, stated that the RIST point-of-sale monitoring tool is a ‘very strong tool to feed back and make change in the community store’ to the benefit of the health of the community.[83]

3.66               However, the RIST point-of-sale monitoring tool is only as effective as its operators. Store employees must be trained in the use of the tool and nutritionists are required to go onsite to check the point-of-sale system is working correctly. Also, each store must have the appropriate infrastructure setup to operate the monitoring tool.

Committee comment

3.67               The Committee has heard that tensions between health and business are not incommensurable in remote community stores. In many instances, a profitable store is the main source of income to a remote Indigenous community. That income is often put back into the community via a health policy in the store, such as subsidised fruit and vegetables.

3.68               Given the important contribution the store makes to the nutrition and health outcomes of a community, there should be the aim of ensuring that every store in a remote Indigenous community has a well-developed health policy and is able to deliver healthy foods regularly, reliably, in quantity and at a good price.

3.69               The Committee acknowledges that store managers often have very demanding workloads. They can be under pressure to produce a profit so may be reluctant to make changes which might threaten that profit. Incentives to change the practices of store managers and increase the stock of healthy foods must be matched with programs that aim to increase demand from communities for healthy produce.

3.70               Incentives, such as increases in pay or bonuses, may be a method of motivating store managers to attempt to stock and sell healthy produce, such as fresh fruit and vegetables.

 

Recommendation 2

 

The Committee recommends the Australian Government consider the development of an incentive scheme to influence store managers to sell healthy produce.

 

3.71               The Committee observed stores where nutritionists and health experts have had a positive influence on strategies to promote the consumption of healthy products. It is important that nutritionists working with communities and store managers in developing health policies are adequately resourced. Short term programs will only achieve short term results and longer term strategies are required to effect lasting lifestyle changes.

3.72               The Committee considers that the Outback Stores Board should include a nutritionist, as suggest by NATSINSAP. The Committee also strongly urges other Boards that oversee stores in remote Indigenous communities to include a nutritionist in their membership to assist in developing healthy community stores and so build healthy communities.

 

Recommendation 3

 

The Committee recommends that the Australian Government require that membership of the Outback Stores board include a nutritionist.

 

Recommendation 4

 

The Committee recommends that the Australian Government work collaboratively with state and territory governments, health services and remote store operators to ensure that nutrition education programs are available to all remote Indigenous communities.

 

3.73               The Committee stresses the importance of stores and people in remote communities having access to nutritionists and community health workers to inform their food choices and to provide skills for budgeting and food preparation that are compatible with the cultural, material and financial circumstances they live with.

3.74               In many instances there are advantages to health information being delivered by local Indigenous community members. The Committee urges federal, state and territory governments to increase their efforts to provide opportunities for Indigenous people to train as local health workers and assist in the delivery of local health care programs.

3.75               Ideally the Committee would wish to see every remote Indigenous community store with a healthy store policy in place. However given the diversity of store ownership and management structures, this can only be mandated for Government supported Outback Stores. Instead, the Committee recommends that assistance be provided to every remote Indigenous community and store to develop a healthy store policy, if they wish. The following chapter discusses access to other supply chain coordination assistance and the Committee recommends that this assistance be contingent on having a healthy store policy.

3.76               The Committee also encourages state and territory governments to require that a healthy store policy is established in consultation with each community for the stores it owns or operates.

3.77               Many communities have developed successful healthy store policies and interventions. These should be commended and in particular the Committee notes the success of Mai Wiru healthy store policy as an outstanding model.

3.78               The Committee also notes the importance of a healthy store policy being developed in consultation with the community and adapted to be appropriate to the traditions, preferences and needs of that community.

 

Recommendation 5

 

The Committee recommends that the Australian Government require all Outback Stores to develop, in consultation with local communities, a specific healthy store policy.

 

 

Recommendation 6

 

The Committee recommends that the Australian Government work collaboratively with all remote Indigenous community store owners, operators and communities to assist in the development and ongoing management of a healthy store policy.

 

3.79               To evaluate the impact of healthy store policies, the Committee considers a coordinated national system of monitoring food sales in remote communities is required. It should be mandated for Outback Stores, and funded and made available for use by other remote community stores. This monitoring system would provide data for policy development, coordination and review, program planning and evaluation and reporting against targets on a healthy store policy.

3.80               The Committee notes that the RIST monitoring and reporting tool Keeping Track of Healthy Food, which has been developed by the Menzies School of Health Research, is able to provide this data and may be able to be used or adapted for use to provide the appropriate point-of-sale monitoring.

3.81               Training should be provided on the operation of any monitoring tool and, once data is available, feedback should be provided to health workers, government programs and communities about the sale of products and the dietary and health implications.

 

Recommendation 7

 

The Committee recommends that the Australian Government work collaboratively with state and territory governments to fund and make available to all remote Indigenous community stores:

n  the Remote Indigenous Stores and Takeaways (RIST) or similar point-of-sale monitoring tool,

n  training for store employees on the operation of the tool, and

n  mechanisms to provide feedback to communities and governments about the sale of products from the store.

 

3.82               The Committee was impressed by ALPA’s FOODcard system—a voluntary budgeting tool to assist with healthy purchases—and considers a system similar to this could be offered for use across other communities. The Committee recommends that a similar healthy food card system be offered in all Outback Stores and that the Government consult with all other remote store operators to facilitate its introduction where desired. For this to be effective, the Committee recognises that delays in transferral of funds from the Basics Card to the ALPA card, recorded in evidence, should be addressed.[84]

 

Recommendation 8

 

The Committee recommends the Australian Government make available in all Outback Stores a system similar to the FOODcard established by the Arnhem Land Progress Aboriginal Corporation. The Committee also recommends that the Australian Government consult with other remote community store operators to facilitate more widespread introduction of this system for communities who are interested.

 

3.83               The Committee recognises the importance of a healthy diet for pregnant women and breast-feeding women as this has a significant impact not only the health of the mother and newborn but also on the infant mortality rate. Consequently the Committee recommends that consideration is given to a similar healthy food card system and be made available through local health services to all pregnant and breast feeding mothers in remote Indigenous communities.

 

Recommendation 9

 

The Committee recommends the Australian Government consider the optional introduction of a healthy food card system to pregnant and breast-feeding mothers in remote Indigenous communities.

 

3.84               To ensure that the nutrition needs of the growing child in remote Indigenous communities are met the Committee strongly supports the continuation of school nutrition programs, such as Queensland’s ‘Eat Well Be Active’ Project, funded by state and territory governments.

3.85               In view of the urgent need to foster Indigenous child health, the Committee also recommends that the Australian Government should support these programs under a national Primary Health Care initiative to provide healthy lunches and drinks at pre-schools and schools in remote Indigenous communities as need indicates.

 

Recommendation 10

 

The Committee recommends that the Australian Government establish a national Primary Health Care program to fund and coordinate supply of healthy lunches and drinks to children at pre-schools and schools in remote Indigenous communities where this need is identified.


Employment and training opportunities

3.86               Stores are one of the biggest employers of Indigenous people in remote communities. The Committee found that the majority of employees in remote community stores across the country were local Indigenous people.

3.87               The Northern Territory Government asserted that local jobs should be a condition of government support for store management models.[85]

3.88               One of Outback Stores’ four goals is to increase Indigenous employment opportunity through local recruitment and training. ALPA is one of the largest independent employers of Aboriginal people in Australia with over 300 non-subsidised staff. IBIS is employing about 134 Indigenous people across the region of Torres Strait.[86]

3.89               Store managers were usually employed from outside the community. The intention of some groups, however, was to train local Indigenous staff up to a level where they can manage their own store. Outback Stores has trained three Indigenous store managers and one is managing their own store. Two of the Island and Cape stores in the Torres Strait are managed by local Indigenous people. IBIS employs 14 store managers who are Indigenous Australians.[87]

3.90               As far as training is concerned, most stores offer on-the-job training in retail up to a basic level. However to become managers, people need to go away to major centres which generally they do not want to do.[88]

3.91               At Outback Stores there is a 12 day induction course which covers areas such as the company’s values, policies and procedures, safety, four-wheel driving, cross-cultural training, point-of-sale systems and dealing with customers. Employee training and store manager training is run in the store under the Australian apprenticeship training program. An accredited trainer goes to the stores to monitor progress of employees and managers.[89]

3.92               ALPA’s employees are trained locally in the store and at ALPA’s own registered training facility. ALPA is currently focusing on providing training in the participants’ first language. Alastair King, General Manager, ALPA, referred to the benefits of Aboriginal to Aboriginal training of staff:

One thing we have learnt over the years is that the Yolngu to Yolngu training—Aboriginal to Aboriginal training—is so much better than non-Indigenous to Indigenous training. It works so much better and you get the underpinning knowledge there rather than just the mechanics of what to do. They understand why they are doing it.[90]

3.93               Reverend Dr Gondarra, Chairman ALPA, referred to the company’s emphasis on self-sufficiency and self-management: their people are being paid for their work and are being educated to be able to run businesses.[91] The Maningrida Progress Association was also using the ALPA training course and on-the-job training for its employees.[92]

3.94               Island and Cape, operating in Queensland, is training local Indigenous people at the store about food security and is in negotiations with authorities in Cairns to get this type of training certified.[93] Irene Fisher, Chief Executive Officer, Sunrise Health Services, called for more varied training, such as in marketing, health promotion and management in the store for the Indigenous employees.[94]

CDEP

3.95               The Committee was told that the changes to Community Development Employment Projects (CDEP) Program would result in lower levels of employment and the loss of community sustainability.

3.96               It was claimed that in Djarindjin changes to CDEP have compromised the running of its community store. Djarindjin Aboriginal Corporation had run the store on a minimum profit basis to meet community needs. The Corporation had also managed the CDEP, which supported part-time jobs in the store. The store in turn funded a range of community run micro-businesses, foods, beauty products and bush medicines.[95] Through the CDEP the Jarlmadangah community built a shed, lined it and put in a fridge, freezer and cool room and it became the store.[96]

3.97               A number of stores employed part-time staff members through top-up under CDEP. This allowed on-the-job training and for people to participate in cultural ceremonies.[97]

3.98               There were, however, limits on CDEP top-up. Stephan Rainow, Nganampa Health Council, explained:

It also appears that there are restrictions placed on people on CDEP working more than 28 hours per week, which limits their capacity to earn money. And for people on Centrelink payments there is no WorkCover, which limits their capacity to earn extra income. These are major disincentives for people seeking to increase their income earnings capacity and as a consequence limit the cash turnover in the stores. There are limited or no checks and balances that regulate the remote economy on the APY lands within which people spend their income on a daily basis.[98]

3.99               At public hearings, FaHCSIA stated that CDEP would remain in remote Indigenous communities with some adjustments. Dianne Hawgood, Manager, Indigenous Remote Service Delivery Group, FaHCSIA, explained the changes:

There will be some new components to it, though, much more of a focus on CDEP being used as work experience, looking for opportunities for CDEP participants to get additional training so that they are ready for job opportunities that may come into the communities, for example through some of the new COAG investment in housing and other areas.[99]

3.100           Lynne Curran, Group Manager, Office of Indigenous Policy Coordination, FaHCSIA, also stated that, as commercial businesses, there is scope for stores in remote Indigenous communities to convert to market wage positions. There are a range of other employment reforms happening, including the Indigenous Employment Program, aimed to deliver better employment and training opportunities to remote Australia.[100]

Committee comment

3.101           On the job training and employment in stores contributes to the economic sustainability and health of remote communities. The Committee commends stores which have high levels of training and employment of Indigenous staff.

3.102           There are difficulties in attracting and keeping external managers, therefore it is logical that supporting the training of local people would benefit the community and the management of the store.

3.103           All stores should have a policy to employ local Indigenous staff wherever possible in the store. Training and development should be offered by the store to increase capacity of Indigenous store employees. Wherever possible, local Indigenous employees should be encouraged to step up to management roles.

 

Recommendation 11

 

The Committee recommends the Australian Government, in collaboration with educational institutions, investigate and develop:

n  the facilitation of training of Indigenous staff living in remote communities to store management levels, and

n  the certification of in-store training of skills such as health promotion and food supply and storage.

 

3.104           Remote communities that had managed themselves and their stores very well under the CDEP were concerned at the loss of the measure of self‑governance they had worked to achieve.

3.105           The Committee considers an assessment of the impacts the CDEP reforms will have on the viability and employment opportunities in remote Indigenous community stores is warranted.

 

Recommendation 12

 

The Committee recommends the Australian Government assess the impact that Community Development Employment Projects reform will have on the viability and employment opportunities in stores in remote Indigenous communities.

 

3.106           Improvements to the employment and health of Indigenous people in remote communities will go a long way to closing the gap in life expectancy.

3.107           However, Indigenous people living in remote areas require a more consistent and regular supply of quality nutritious food in order to maintain and enhance their health and well-being. The following chapter discusses challenges of providing fresh food to remote communities.

 

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