Healthy Housing Programs

Acute rheumatic fever (ARF) is endemic in many Australian First Nations communities. Supporting these communities to develop innovative healthy homes initiatives can provide workable solutions to prevent new cases. Australia will need to spend at least $344 million in direct health care costs if no action is taken to eliminate ARF by 2031. National strategies in partnership with Aboriginal and Torres Strait Islander organisations are urgently needed to address ARF and its causes.

Australia has one of the highest rates of ARF in the world – a condition almost exclusively seen in its First Nations people. ARF is caused by Streptococcal A (Strep A) throat and skin infections that can trigger an autoimmune response, leading to an episode of ARF. Strep A infections are more common in crowded environments with limited access to health hardware.

Recurring Strep A infections and episodes of ARF can lead to valvular damage of the heart known as rheumatic heart disease (RHD).¹ RHD causes heart failure and premature death.

The burden of ARF is growing in Australia. The Australian Institute of Health and Welfare reports that the number and rate of notifications increased from 424 (60 per 100,000) in 2016, to 521 (69 per 100,000) in 2020.³

If no action is taken to eliminate ARF and RHD, more than 8,000 more people will develop RHD by 2031, accruing at least $344 million in direct health care costs.⁵ Improving housing and living environments has been prioritised by Aboriginal and Torres Strait Islander groups, communities, academics, and health experts as the key step to improving health outcomes.

Reducing overcrowded housing and improving access to functional health hardware (taps, showers, and toilets) can reduce high rates of Strep A infections and progression to ARF. These improvements are also likely to reduce the transmission of many other preventable infectious diseases, including COVID-19, and trachoma – an infectious eye disease that has been eliminated in several developing countries globally.⁶ A combination of economic development, policy, and regulatory change have been credited with reducing the burden of ARF and RHD in most developed countries.⁷

While there is the commitment, will, funding, policy, and strategy from governments to increase housing stock and reduce overcrowding in First Nations communities, there have been significant delays in delivering housing, particularly in the NT. These delays are the result of an ongoing dispute between the previous Australian and the current NT governments regarding the terms of the National Partnership Agreement for Remote Housing – Northern Territory (2018–2023). This has contributed to stasis in other areas of potential housing improvement. There are several place-based healthy homes and environmental health programs underway across Australia, and there are many other opportunities for locally relevant programs to be developed.

During my Churchill Fellowship,⁸ I discovered innovative co-design approaches for developing healthy housing initiatives have been used in New Zealand to reduce high rates of ARF in Māori and Pacific Islander communities.⁹ These approaches have produced a sustainable supply of housing interventions, improved program service delivery, and have prompted changes to government regulations, legislation, and minimum housing standards.¹⁰ These initiatives have also provided significant cost savings to the New Zealand health care system. However, current housing initiatives and future ones require ongoing support and funding from the Commonwealth, state, and territory governments to ensure their sustainability.

Consideration of the issues

Existing policy frameworks and commitments

Overarching Aboriginal and Torres Strait Islander health and housing policy in Australia

The Australian Government's Closing the Gap strategy has provided the overarching framework for Aboriginal and Torres Strait Islander health policy in Australia since 2008. In 2020, a new National Agreement was signed between the Coalition of Peaks and the Council of Australian Governments (COAG). The Closing the Gap strategy identifies healthy living environments and housing as priority areas, in reducing the many health risks associated with poor quality housing, overcrowding, and non-functional health hardware. One of the targets (target 9) outlined in the strategy is to ‘increase the proportion of Aboriginal and Torres Strait Islander people living in appropriately sized (not overcrowded) housing to 88% by 2031’.¹²

Health Policy and the Rheumatic Fever Strategy and RHD Endgame Strategy

The revised National Aboriginal and Torres Strait Islander Health Plan (NATSIHP) 2021 and Australia’s Long-Term Health Plan (2019) have also identified the elimination of ARF and RHD by 2031 as a key priority area.¹³ Priority 7 of the NATSIHP identifies health hygiene and healthy living infrastructure as key to ensuring safe and healthy environments for Aboriginal and Torres Strait Islander people. It also identifies supporting and growing the Aboriginal and Torres Strait Islander environmental health workforce to facilitate resourcing and ensure the development of locally responsive solutions.¹⁴

The Commonwealth’s Rheumatic Fever Strategy (RFS) was funded in 2009 to address high rates of ARF and RHD. The strategy includes a National Partnership Agreement with Queensland, WA, SA, and the NT. The strategy initially focused on register-based control programs and education and training resources. It more recently provided funding to the National Aboriginal Community Controlled Health Organisation to support RFS national coordination and implementation for community-led primary prevention and treatment projects.¹⁵

The RHD Endgame Strategy – a blueprint for eliminating Rheumatic Heart Disease by 2031 was launched in 2020. The strategy includes a framework with five priority areas for action. They include Aboriginal leadership, community based programs, healthy environments, early prevention, and care and support. The Endgame Strategy report sets out what is required to eliminate ARF and RHD in Australia. It was launched in 2021 and endorsed by 21 peak bodies, including Aboriginal and Torres Strait Islander organisations.¹⁶

Remote Housing Strategy

Remote housing policy remains in a state of flux. The National Partnership Agreement on Remote Indigenous Housing 2008-2018 was replaced by the Remote Housing Strategy in 2016 through an agreement between the Commonwealth, state, and territory governments. The agreement expired in 2018, with the Australian Government unable to reach an agreement with the jurisdictions on remote housing. In 2018 the NT Government reached an agreement with the Commonwealth through the National Partnership Agreement for Remote Housing Northern Territory – with a 50–50 funding arrangement. However, there had been an ongoing dispute between the previous Federal Government and the NT Government regarding responsibilities in this agreement.¹⁷

Lessons from New Zealand – using co-design to develop healthy housing programs and initiatives

In 2013, the New Zealand Government launched its Healthy Homes Initiative to reduce high rates of ARF in Māori and Pacific Islander communities. In 2015, the Ministry of Health engaged Auckland Council’s ‘The Southern Initiative’ and ‘Co-design Lab’ to undertake a co-design project to develop a sustainable supply of housing interventions and improve the program’s services.²⁰ The project used human centred co-design methods that engaged Māori and Pasifika with lived experiences of ARF and RHD, government agencies, non‑government organisations, and other service providers. This project also saw several policy and system improvements, including amendments to the New Zealand Residential Tenancies Act 1986 and the introduction of the Healthy Homes Guarantee Act 2017 and the Healthy Homes Standards.²¹

An outcomes evaluation of the Healthy Homes Initiative in 2019 found there were around 1,533 prevented hospital admissions, 9,443 fewer GP visits, 6,101 hospitalisations of reduced severity, and 8,764 less pharmaceuticals dispensed. These reductions are expected to result in savings in direct medical costs of $30 million in the third year after referral intervention. With a total program cost of $18.5 million, the expected return on investment for the New Zealand Government is likely to occur within two years.²²

Healthy Homes Initiatives in New Zealand that enlist local knowledge and expertise have played a critical role in reducing rates of ARF and other preventable infectious diseases. These initiatives have also provided savings in co-design costs that will see a return on investment for government. There is increasing evidence that place-based solutions are effective in addressing the housing needs of Aboriginal and Torres Strait Islander communities. Examples of current programs include Housing for Health (NSW) and Nirrimbuk Aboriginal Environmental Health Program (WA). These programs offer Aboriginal led placed based solutions that are tailored to a community’s needs, are locally relevant, and have produced promising results.²³

Exploring innovative approaches to policy reform and service delivery improvements will ensure that the Australian Government meets its targets for Closing the Gap on health disparities for Aboriginal and Torres Strait Islander people, along with the commitment it has made to eliminate ARF and RHD in Australia by 2031.

Stakeholder consultation

The policy recommendations below align with the RHD Endgame Strategy’s key priority area on accessing healthy housing and built environments²⁴ along with other priority areas, including Aboriginal leadership, community-based programs, and early prevention. The strategy was developed in consultation with and endorsed by 21 peak bodies, including Aboriginal and Torres Strait Islander peak organisations.

Aboriginal and Torres Strait Islander community controlled health services, especially in regions affected by high rates of ARF, household crowding, or poor quality housing were included in the consultation of co-designed community led initiatives as outlined in the RHD Endgame Strategy. The consultations recognised the valuable knowledge and expertise that these stakeholders hold about the problem, and the solutions that will work for their communities.

Consultations on the policy recommendations included in this paper have been conducted with key stakeholders, including the National Aboriginal Community Controlled Health Organisation and RHD Australia. Further consultation is needed with Aboriginal community controlled peak health and housing bodies in the NT, Queensland, WA, SA, and NSW to provide leadership and guidance on these issues locally.

Policy recommendations

1. That the National Indigenous Australians Agency (NIAA) and the Department of Health and Aged Care (DoHAC) lead the development of a national Aboriginal and Torres Strait Islander housing and environmental health strategy in partnership with First Nations communities and peak Aboriginal health and housing organisations that focuses on place-based housing solutions.

2. That the NIAA and DoHAC work in partnership with peak Aboriginal and Torres Strait Islander health and housing organisations, and communities with high rates of ARF to develop and implement sustainable healthy housing programs embedding environmental health into primary health care.

3. That the Commonwealth fund the National Aboriginal and Torres Strait Islander Housing Association (NATSIHA) to work with Aboriginal and Torres Strait Islander health and housing peak bodies, along with registered training organisations to:

• grow the Aboriginal and Torres Strait Islander environmental health workforce
• update and reintroduce the National Indigenous Housing Guide for endorsement by the Australian, state and territory governments to ensure minimum building standards and regulations for the construction of new housing and refurbishments in remote Aboriginal and Torres Strait Islander communities.

4. That state and territory governments fund and support the development of locally relevant healthy homes programs in their jurisdictions.

Acknowledgements

I would like to thank The Winston Churchill Trust and the Centre for Policy Futures at The University of Queensland for the opportunity to be part of the Policy Impact Program. I would also like to thank my policy peer reviewers Dr Rosemary Wyber and Ms Karrina De Masi, along with Vicki Wade, Director of RHDAustralia, Claire O’Neill, Acting Director RHD, and Nadine Blair, Director of Policy at NACCHO who provided invaluable expertise, advice, and insight through their reviewing of this article and for their support.

^{Published 29 November 2022}

Maida Stewart is a Wemba Wemba/Wergaia woman who has lived in the NT for the past 30 years. Maida is a Registered Aboriginal Health Practitioner with 20 years’ experience working in the Aboriginal Community Controlled Heath Sector, and extensive experience working with and caring for Aboriginal and Torres Strait Islander peoples living with acute rheumatic fever and rheumatic heart disease. Read more about Maida Stewart and her Churchill Fellowship.

References and endnotes

1. RHDAustralia. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research, 2020.
2. Milligan, L. ‘Heart Failure: An Investigation into the Hidden Killer in Remote Australian Communities.’ Four Corners. Australian Broadcasting Corporation, 7 March 2022. https://www.abc.net.au/4corners/heart-failure:-an-investigation-into-the-hidden/13787308
3. Australian Institute of Health and Welfare (AIHW). Acute rheumatic fever and rheumatic heart disease in Australia 2016–2020, catalogue number CVD 95, Canberra: AIHW, Australian Government, 2022.
4. Milligan, Heart Failure: An Investigation
5. Wyber, R, Noonan, K, Halkon, C, Enkel, S, Ralph, A, Bowen, A, Cannon, J, Haynes, E, Mitchell, A, Bessarab, D, Katzenellenbogen, J, Seth, R, Bond-Smith, D, Currie, B, McAullay, D, D’Antoine, H, Steer, A, de Klerk, N, Krause, V, Snelling, T, Trust, S, Slade, R, Colquhoun, S, Reid, C, Brown, and A, Carapetis, J.
   The RHD Endgame Strategy: The blueprint to eliminate rheumatic heart disease in Australia by 2031. Perth: The END RHD Centre of Research Excellence, Telethon Kids Institute, 2020.
6. World Health Organisation. ‘Trachoma.’ 7 March 2022. https://www.who.int/news-room/fact-sheets/detail/trachoma
7. Wyber, et al., The RHD Endgame Strategy
8. Stewart, M. The Bob and June Prickett Churchill Fellowship to examine healthy housing initiatives in the primary prevention of Acute Rheumatic Fever. Churchill Fellowship Report: The Winston Churchill Memorial Trust, 2020. https://www.churchilltrust.com.au/project/the-bob-and-june-prickett-churchill-fellowship-to-examine-healthy-housing-initiatives-in-the-primary-prevention-of-acute-rheumatic-fever/
9. Whaanga-Schollum, D, Wihongi, P, Tukua, L, Hoskins, R,
   Smit, K, Pilgrim, L, Fitton-Higgins, E, Charles, T, Forman, R, Mujica, A, Lock, G, Cameron, S, McFarlane, J, Solomon, S, and Child, A. Exploring the intersection of design and policy in Aotearoa NZ: 7 case Studies. New Zealand: Auckland Co Design Lab, 2018.
10. The Southern Initiative. Healthy Homes Initiative – Auckland: Co-design: Testing ideas to make homes warmer and drier: Report on stage two. Auckland: The Southern Initiative, 2018.
11. Milligan, Heart Failure: An Investigation
12. Closing the Gap. ‘Closing the Gap Targets and Outcomes.’ Australian Government, 30 January 2022.
    https://www.closingthegap.gov.au/national-agreement/targets
13. Wyber, et al., The RHD Endgame Strategy
14. Australian Government. National Aboriginal and Torres Strait Islander Health Plan 2021–2031, Canberra: Australian Department of Health, 2022. https://www.health.gov.au/sites/default/files/documents/2021/12/national-aboriginal-and-torres-strait-islander-health-plan-2021-2031
15. National Aboriginal Community Controlled Health Organisation (NACCHO). Rheumatic Fever Strategy (RFS) Joint Advisory Committee (JAC) Inaugural Meeting 24 February 2022 Communiqué. https://www.naccho.org.au/app/ploads/2022/06/24-February-2022-Joint-Advisory-Committee-Communique.pdf
16. Wyber, et al., The RHD Endgame Strategy
17. Wyber, et al., The RHD Endgame Strategy
18. Milligan, Heart Failure: An Investigation
19. Milligan, Heart Failure: An Investigation
20. Ministry of Health New Zealand. ‘Healthy Homes Initiative.’ New Zealand Government, 12 January 2022.
    https://www.health.govt.nz/our-work/preventative-health-wellness/healthy-homes-initiative
21. Whaanga-Schollum, Exploring the intersection
22. Pierse, N, White, M, and Riggs, L. Healthy Homes Initiative Outcomes Evaluation Service: Initial analysis of health outcomes (Interim Report). Wellington: Ministry of Health, 2019.
23. Standen, J, Morgan, G, Sowerbutts, T, Blazek, K, Gugusheff, J, Puntsag, O, Wollan, M, and Torzillo, P. ‘Prioritising Housing Maintenance to Improve Health in Indigenous Communities in NSW over 20 years.’ International Journal of Environmental Research and Public Health, 17, 16, (2020), 5946.
24. AIHW, Acute rheumatic fever

Key terms: First Nations, acute rheumatic fever, rheumatic heart disease, health hardware, co-design