Renata Danisevska is Digital Health Program Lead at Northern Queensland Primary Health Network (NQPHN). Renata is passionate about implementing digital health solutions that place consumers at the centre of their care and enable more efficient, appropriate and better quality healthcare for all. In 2016, Renata successfully coordinated regional teams to deliver the Federal Government’s My Health Record opt-out trial in north Queensland. NQPHN was one of only two nationally selected PHNs and the experiences gained by the team will inform any future national roll-out of this important digital health initiative. Before joining NQPHN, Renata was living in Sydney and she moved to Townsville to explore living in Far North Queensland after completing her Master of Business Administration. Her experience is predominantly in project management and management of higher education industry.
People living in rural and remote areas have reduced access to health services, greater distances to travel for medical attention, and generally have higher rates of ill health and mortality compared to those living in larger cities.
So when a rural and remote Primary Health Network was selected as one of only two regions in Australia to conduct the opt-out trial of the national My Health Record digital record system, it gave them the opportunity to improve the connectedness of care for their community, especially in improving health outcomes for Aboriginal and Torres Strait Islander peoples.
Their region, the fourth largest in geographical size in Australia, covers an twice the size of the UK. It is home to over 700,000 people, which includes more than 80,000 Indigenous Australians.
It was important to trial this initiative in this region due to a high burden of chronic conditions and complex needs, alongside the tyranny of distance between various communities, including remote Indigenous communities. The challenges in delivering connected healthcare in urban, regional and very remote areas are significant throughout this PHN’s footprint, and an electronic health record is a key enabler for sharing information in this environment.
This presentation will share the strategies and methods by which the PHN implemented the opt-out trial of the My Health Record on behalf of the Commonwealth Government, including:
Jill Davidson has had over 25 years' experience as a health executive. She has lead large and small hospitals and health services in Victoria, NSW and now South Australia. Currently CEO, SHine SA, she was previously CEO Primary Care Connect (Vic), Director Mountain Tracks Consulting, CEO of Dental Health Services Victoria and Orbost Regional Health as well as General Manager of Albury Base Hospital. Passionate about service planning for rural health, she spent 35 years in rural acute and community services with 13 years as CEO of a successful Multi Purpose Service in Far East Gippsland. She has overseen seven rural construction projects for improved service access in rural towns and co-designed a capital development project for rural medical student placement with Monash University in Gippsland. Jill has held senior positions in the Australasian College of Health Service Managers (ACHSM), is a Board Director at Adelaide Primary Health Network, member SA Public Health Council, the Ministerial Advisory Committee on BBV and STIs (MACBBVS), council member of the Australian Hospitals Association (AHHA) and has been previous Board Director of VAADA, GetGP Gippsland and member of the National Aged Care Alliance, Jill brings a comprehensive approach to the delivery of health services influenced by an exposure to policy development at state and national levels.
The LGBTI community has many challenges that they face above and beyond the everyday health issues that we confront in the general sexual and reproductive health stream. The statistics for the LGBTI population demonstrate that they have the one of the highest rate of suicide of any population in Australia. Research with the transgender population is even higher with some UK statistics of up to 50% of trans people having attempted suicide.
As a health executive leading a sexual and reproductive health organisation there are many challenges in meeting the population needs for the diverse LGBTI population and specifically the transgender population. On establishing a small response to the transgender population the organisation soon realised that the service demand was quickly outstripping the services available. This paper explores the service planning from a health administration perspective as well as the clinical needs of this population group and the challenges that are faced in establishing such a service in constrained financial environments.
As a state organisation the challenges then become how we extend our services to rural communities where LGBTI services are limited or non-existent. Rurality is a barrier to accessing health services generally but when it comes to highly specialised services for a transgender population, this challenge is heightened. A population service planning approach highlighted the need for 3 key services that would assist rural trans people to be supported. Firstly, general practitioners require clinical support and education to meet the needs of the transgender person. Defined education webinars and telephone support is an acceptable approach for the rural doctor. Secondly: providing counselling support through telemedicine so that people who are not wanting to leave their homes or cannot make the journey to a clinic, can gain assistance through teleconferencing sessions with a clinical psychologist and thirdly; peer to peer telemedicine support services where a trans person in a small country can speak with someone of the trans community who understands the personal challenges.
Dr Scott Davis is the Executive Director of the Greater Northern Australia Regional Training Network (GNARTN). Over the past 20 years, Dr Davis has held a range of Senior Executive leadership and practice roles within the health sector internationally and within Australia. Dr Davis academic interests include: health service drivers in social and economic development as an enabler of regional development, SODH and international public health. GNARTN is a cross-jurisdictional partnership established under agreement between the Directors General of the Health Departments in Western Australia, Queensland and the Northern Territory. Established in 2012 GNARTN focuses on delivering improved health outcomes for communities, by developing structures and processes that leveraged the existing health and education infrastructure and capability, to develop a fit-for-purpose health workforce. GNARTN has been involved in the development of allied health rural generalist strategies since 2013, and is committed to working with health service providers to address the maldistribution of the health work in regional, rural and remote Australia. Analysis of GNARTN methods and outcomes suggest that the network has enabled significant cost savings, productivity gains from leveraging existing capacity, relationships, and supported partners to find innovative solutions to shared issues.
Introduction: The merits of rural generalism as the basis for training, workforce and service models have been demonstrated in medicine and other professions. Implementing structured and supported rural generalist training pathways for the allied health professions is anticipated to provide similar benefits in terms of improved recruitment and retention, enhanced service capacity through use of professionals’ broad full scope and into extended scope of practice, and greater access for rural and remote consumers to high quality multi-disciplinary healthcare.
Methods: The development of rural generalist workforce and service models for seven allied health professions commenced in 2013 and has progressed through six stages:
The work has been lead and supported by a collaborative of health sector providers across Northern Australia with the addition of education sector partners in 2016.
Outcomes: Comprehensive profession-specific and skills shared clinical tasks for rural and remote practitioners in six professions have been published online.
Queensland Health has successfully trialled designated rural generalist training positions in six professions finding:
Education frameworks demonstrate significant consistency between non-clinical requirements of a range of disparate allied health professions including pharmacy, physiotherapy, podiatry, speech pathology, occupational therapy, medical imaging and dietetics. Combined with profession-specific clinical capabilities, the frameworks provide the basis of a formal training program.
Conclusion and the next steps: Collaboration between jurisdictions and health services is necessary to deliver sector-level implementation of an allied health rural generalist pathway. The addition of education partners in 2016 as the project enters its sixth stage is anticipated to produce the formal training program required to embed rural generalist practice models and improve the sustainability of the rural and remote allied health workforce.
Lyndall De Marco is the Executive Director of the Diamond Jubilee Trust and was instrumental in setting up Diamond Jubilee Partnerships Ltd when the Queensland Government donated $5 million for a diabetes and diabetes eye disease initiative. The IDEAS Initiative commenced operations in July 2013, focusing on substantially reducing avoidable blindness in Indigenous people in Queensland. A strong partnership with 19 Aboriginal Medical Services and 21 partners has been instrumental in the success of this initiative, which has impacted on 51 communities across Queensland. Lyndall is CEO of the IDEAS Initiative. Previously Lyndall enjoyed an international career as Corporate Director of Education for Pan Pacific Hotels & Resorts and most recently for the past eight years as the architect and leader of three global initiatives on behalf of HRH The Prince of Wales (Prince Charles) in London. Lyndall mobilised the private sector into action by inspiring industry leaders to move social responsibility and sustainability up the corporate agenda and respond with practical action. This was achieved through the three initiatives she designed across twenty three countries—Youth Career Initiative (YCI), International Tourism Partnership (ITP) and Digital Partnership. The Youth Career Initiative was founded by Lyndall in 1995 in Thailand as a program to combat the sexual exploitation of children. It continues today and has spread to thirteen countries. The YCI program has enabled thousands of disadvantaged young people the chance to lead fulfilling lives. Lyndall was a founding member of the World Council for the Protection of Children. When Lyndall returned to Australia she assisted Major General the Honorable Michael Jeffery in establishing the Diamond Jubilee Trust Australia, becoming a member of the board and its honorary Executive Director.
Dr Lucas de Toca MD MPH, is a doctor and public health expert focusing on health systems improvement and health equity. After graduating from Harvard University, he currently works in as the Chief Health Officer for Miwatj Health, the Regional Aboriginal Community-Controlled Health Service that provides universal comprehensive primary health in remote East Arnhem Land, Australia. Dr de Toca undertook medical training at the Universidad Autónoma de Madrid, Spain, with prolonged placements and electives at The University of Sydney. During medical school he took several leadership roles, including the presidency of the National Council of Medical Students of Spain (CEEM), a position he held for two terms. In that role he was a founding member of the Spanish Medical Profession Forum, a permanent stakeholder group of all major medical representatives in the nation. He then completed further postgraduate training at Harvard University, where he focused on health systems and leadership in health and human rights. This helped cement his understanding of large-scale health reform and effective availability of health services, fundamental for his role in Indigenous health. Since late 2013, Lucas has been based in Arnhem Land, a remote Indigenous region of the Northern Territory in Australia. He has been in charge of public health systems and programs and the management of Aboriginal primary health in the region. Miwatj Health delivers comprehensive primary health care services for over 6,000 Indigenous residents of North East Arnhem and public health services for close to 10,000 people across the region. Miwatj operates within a human rights framework, a rights-based approach, with self-determination at its core and the advancement of broader Indigenous rights and improvement of the social determinants of health as its ultimate mission. Addressing the underlying social determinants is the most effective way to improve a population’s health. Lucas is also an experienced medical educator, having held teaching positions at Harvard Medical School, Harvard School of Public Health, the University of Sydney and the University of Notre Dame Australia. He is currently a Lecturer at Flinders University and an Honorary Professor at the Autonomous University of Madrid.
Human beings have a tendency to categorise the world in distinct boxes where binary choices are often used. Jaded dichotomies like developed/developing countries or first/third world and more updated options like low and middle income Vs high and upper middle income countries are generally applied to describe different expectations for burden of disease and health system structures across nations. Health professionals in high income countries are often attracted to the different experiences that the perceived diverse disease profiles of low income economies offer. These international medical experiences are the main focus of a proportion of globally minded students on elective or young practitioners seeking adventure over more ‘mundane’ domestic placements. Remote Aboriginal Australia challenges all of this.
East Arnhem Land, a remote region of Australia, is a setting where the complex burden of poor social determinants of health (and plain old poverty) generates challenges akin to those of a low-income nation, while the fact that it remains part of the Australian society make it prey to the same overload of non-communicable diseases we see in other areas of the country. On the other hand, the strong culture, identity, push for self-determination and political ability of the sovereign Yolŋu people of that land and the availability of resources and sophisticated health systems of Australia as a rich nation offer a unique opportunity for meaningful, community-driven, effective change.
This rare mix of challenge and potential is the catalyst where bands like Yothu Yindi, statements like the 1963 Bark Petitions, leaders like Galarrwuy Yunupiŋu or Gatjil Djerrkura, and organisations like Miwatj Health Aboriginal Corporation emerged. Miwatj and other vibrant Yolŋu organisations in East Arnhem embody the think global/act local mantra. With highly diverse workforces attracting a majority Indigenous staff and a high proportion of committed non-Indigenous staff hailing from all parts of the world, these organisations help realise the quest for self-determination. In this setting, we see Yolŋu people at the helm embracing both worlds, old and new, mixing the strength of a living culture with the frameworks of evidence-based public health and international best-practice. In this presentation we analyse the contextual health challenges and the organisational and workforce model that Miwatj Health employs in its delivery of comprehensive primary health care in East Arnhem Land.
Used to providing telephone support and advice to elderly patients in her role as a Practice Nurse, Debi Dean now helps develop clinical services being delivered by videoconference across Torres and Cape Hospital and Health Service. Having trained at St Bartholomew’s Hospital in the City of London more than 36 years ago, Debi has swapped the delights of Liverpool Street and Hackney for the scenic beauty of the Cape York Communities. Working in these facilities provides many challenges but these remote locations are exactly where videoconference consultations can be most effective. By enabling Torres and Cape patients to be able to access specialist care from their community with the support of their family and friends, ensures that they receive timely health care, in a facility familiar to them without the stress of travelling. Debi is a passionate champion of clinical videoconference services and is keen to share her enthusiasm and experience.
Background: Medication misadventure is a serious issue with two to three percent of all hospital admissions being medication-related. The federally funded Home Medicine Reviews (HMRs) have provided an avenue for pharmacists to undertake medication reviews to reduce medication misadventure and they have been shown to be beneficial in improving quality use of medicines and overall health outcomes. The HMR program does not give reasonable access to medication reviews in Cape York due to accessibility and funding restrictions. A service model was required to address the challenge of providing medication reviews and to reduce the incidence of medication misadventure within the funding parameters.
Methods: A service model using telepharmacy was trialled in ten primary health care clinics throughout Cape York. The solution supported individualised, culturally appropriate medicine education/counselling, via telehealth to outpatients who had complex or extensive medication regimes or were recently discharged from hospital. Resources were developed to support the service model. A comparative analysis evaluated the outcomes of the state-funded telepharmacy service model to the HMRs using a cost analysis, clinical variables, patient safety factors and patient satisfaction.
Results: Telepharmacy delivery is a more cost effective way to deliver medication management reviews to remote communities than the current Home Medication Review funding model, which is not financially viable for remote communities. The safety evaluations indicated an improvement in service quality, safer use of medications and reduced hospitalisation due to medication misadventure. The comparative analysis has informed business model planning and provided a better understanding of cost difference for remote pharmacy medication review methods.
Discussion: The telepharmacy trial has increased access to services, developed clear process and increased the capacity to provide treatments closer to home. Phase two of the implementation will embed the service model within the rural and remote facilities.
Pascale Dettwiller is an adjunct Associate Professor and was the Director at the Katherine Campus of the Rural Clinical School Campus of the Flinders University NT Medical Program, Katherine, Northern Territory for the past four years. She is now a the EFN Regional Clinical Advisor for Pharmacy for country Health (SA). She holds a Doctor of Pharmacy from the School of Pharmacy, Joseph Fourier University, Grenoble (France) and several Bachelor and Diploma awards in Teaching, Business, Nutrition and Herbal Medicine. She has held Senior Clinical Pharmacist positions in regional health centres in New Caledonia, Tasmania and Victoria. Pascale has vast experience in teaching and mentoring of pharmacy, medical and nursing students in Tasmania, Victoria and Northern Territory, especially in rural medical schools and health practices. She is a member of 12 professional societies, including the Royal Pharmaceutical Society of Great Britain and the Society of Hospital Pharmacists of Australia. She has been a member of the Pharmacy Boards of Tasmania and Victoria and a member of Human Ethics and Research Committees in Tasmania and the Menzies School of Health Research in Darwin for the last seven years. Her major area of research is in medication management and safety, drug usage evaluation and education around medication and adherence. Her passion for health and Indigenous health has led her to initiate, implement and monitor the SELL project in speech pathology for Indigenous pupils in Katherine, which has contributed to close the health disparities.
The overview: Service learning is increasingly being recognised as an important part of health curricula and contributes to the community engagement of universities. International literature has recognised its contribution to community engagement and acknowledged its offering of a sustainable model to address gaps in health care services in rural and remote areas. Little is known in Australia, and this paper aims at covering some of this dearth.
The model and aims: The service learning program Speech Pathology for Living and Learning (SELL) located in Katherine (NT) has successfully generated a nexus between health and education in trying to address the health services gaps in speech pathology. For the last three years, the program has serviced primary school pupils, and this paper will present the results from quantitative measurements of pupils' improvements
In the context of the SELL program – Speech Pathology Student–led clinic in primary school - the study first objective was:
Method: A set of 112 individuals results was gathered over the seven cycles of student–led clinics at one primary school. Summary T-scores were calculated using a statistical package for the social sciences. T-scores are incrementally increasing with the pupils' progress. The interesting aspect of this mathematical translation to this study is drawn from the aggregation of attainment across individuals, and may be used for the entire cohort.
Findings: The pupils presented with measurable and significant improvement during one cycle over six weeks of therapy and the series of cycles. The positive and raised slope of the trend line demonstrates the overall progress the pupil cohort has achieved from seven cycles of six weeks block intervention over a three year period.
Overall, over 50% of Aboriginal students achieved their expected goals level with 70 % achieving above expected level.
Conclusion: This pilot study demonstrates that the application of criterion reference tools is appropriate for Aboriginal pupils in the Katherine context and has the potential to assist paediatric speech pathology.
Lyn Dimer is the Manager of the Aboriginal health program at the Heart Foundation in WA. Lyn is passionate about improving the health of her people; she works tirelessly to increase access to services and equality, which will lead to optimal care for her people who have, or are at risk of, cardiovascular disease. Lyn has dual qualifications in health and education, is a wife, mother and grandmother, her family is the most important blessing in her life, providing inspiration to remain true and loyal to the field of Aboriginal health sharing culture, health and wellbeing with people she meets.
Background: Cardiovascular disease remains the leading cause of morbidity in Aboriginal Australians, however only around 5% of eligible Aboriginal people attend cardiac rehabilitation (CR) heart health programs.
Through community consultation and strong collaboration between Heart Foundation, Karratha Central Healthcare (formerly Pilbara Health Network) and key stakeholder organisations in the West Pilbara a need was determined to provide culturally specific heart health programs for local communities in the region. These communities are Roebourne, Karratha and Onlsow.
Method: Consultation with local Aboriginal communities using snowball methodology, was followed by consulting with key community organisations/stakeholders. Oral interviews, were transcribed and fed back to all participating persons. Discussions included establishing community understanding and needs in relation to heart health logistics for program setup, recruitment of staff and aspects of implementation and sustainability. Yarning is an important part of Aboriginal culture, it was used throughout to discuss health messaging and support positive behaviour change through the diverse program activities and meetings.
Results: Since program commenced in September 2015, many changes have occurred including success in breaking down working in silos and establishing a more collaborative and partnership approach with stakeholder service providers the program can work alongside. Each town is different in size and access to service providers. Significantly through our program’s processes, participants have experienced empowerment over their own health. Outcomes include improved self-esteem, increase knowledge of the benefits of healthy eating, physical activity and mostly cardiovascular health knowledge. Cross cultural learning between staff and community people has been beneficial and the program continues to evolve.
Conclusion: To be effective as a health agency or as a practitioner when engaging in Aboriginal and Torres Strait Islander rural and remote locations, it is important to be able to engage, establish rapport and develop reciprocated relationships, built on trust. It is crucial to listen to the voice of the people. Not just listening but hearing and implementing where able. When working in rural and remote locations it is vital to consult with the local community to seek if there is a need for a program in the first instance, to establish relationships and to begin the process for ensuring sustainability.
Karen Dixon is the Manager Strategic Clinical Change for Country Health SA Local Health Network where a key aspect of her role is to identify and facilitate innovative opportunities for improving access to health services for people living in rural and remote South Australia. She oversees a range of programs and change processes while strongly advocating for country consumers and health workers. Karen seeks innovative ways to overcome the challenges faced by the tyranny of distance, with a recent example being the successful implementation of the Virtual Clinical Care Home Tele-monitoring program for people living with a chronic condition(s) in country SA. Karen has a background in occupational therapy and a strong commitment to reducing the disparities between health outcomes for people living in rural areas as compared to their city cousins as evidenced by the 15 years she has worked in rural health.
Recognising the growing need for improved access to timely and quality health services in country South Australia, coupled with the increased incidence of chronic disease in an ageing population and with dispersed resources over vast distances, innovative technological solutions were considered a vital enabler to strengthen existing services. The aim was to utilise emerging technologies to address the unacceptable inequity in health outcomes for people living in rural and remote South Australia compared to their metropolitan counterparts, through the provision of virtual clinical services.
This paper describes the key factors necessary for the successful implementation of technology-enabled solutions in rural South Australia. Examples of technology-based initiatives will be described, highlighting the key results, elements necessary for successful implementation and the challenges faced. These initiatives will include:
Technology has enabled this organisation to work in partnership with patients and other members of their health care team to provide high quality evidence-based care contributing to best practice patient outcomes. It is vital that technological initiatives are embedded with a foundation of local services thereby ensuring timely responsiveness to patient issues. Remote networks of support coupled with quality, accessible clinical data complement those local services providing a robust and sustainable framework in which to embrace new and emerging technology. Rather than technology driving innovation … the need for change in approaches to service delivery have necessitated the addition of technology to increase efficiency and improve access.
A platform was established through the network of videoconferencing, point of care testing and remote clinical support that can be added to over time.
The continued challenges of connectivity and equity in access to technology and gaps in IT literacy must be overcome to ensure we don’t inadvertently add to the disparities in health outcomes for people living in remote areas of Australia.
Heidi Drenkhahn grew up in the small coastal town of Eden on the Far South Coast of NSW. She studied Dietetics at the University of Wollongong and graduated with a MSc (Nutrition & Dietetics) in 2007. She worked for three years across many different clinical areas and hospitals throughout the Illawarra, then headed West to Broken Hill to take up the role of Community Dietitian in 2010 – filling the role of a previous placement supervisor of hers. Since being in this role Heidi has grown to love Broken Hill and it’s people and has developed a passion for rural health and ensuring regional and rural communities receive the same standard of care as their metropolitan counterparts. She likes to focus on the many positives that being in a smaller, isolated community can mean for health promotion—taking full advantage of local media, town squares and old-fashioned word of mouth promote her causes. Professionally her interests include health promotion, public health policy and chronic disease prevention. Personal interests are women’s AFL, good food and anything to do with the ocean.
Studies show around 4% of the Australian population is affected by eating disorders to clinically significant levels. For Broken Hill this would mean approximately 780 cases within the town. However current levels of referral to dietetics for these conditions are often limited to less than 5 a year and mental health services report low levels of diagnoses. This suggests a significant unmet need for those suffering from eating disorders within the community, who are likely still undiagnosed.
An online survey of local health clinicians and social services workers was undertaken to see what issues they faced with providing services to people with eating disorders. This revealed a low level of confidence and skills to work with eating disorders and limited knowledge of guidelines and online resources available. Additionally, in Broken Hill many health positions are filled by recent graduates who are new to not only their role but to their profession as well as the geographical area. This can lead to professional linkages between different professions or organisations being tenuous.
To address these issues the following interventions were implemented:
A post-intervention survey is planned for January 2017 to investigate how these initiatives have impacted on the confidence and skill of clinicians to identify, diagnose and treat people with eating disorders. It is hoped the improved co-ordination of care, access to education/resources and professional networking will lead to better clinical outcomes for patients as well as increased rates of diagnosis and evidenced-based treatment. This could be an achievable model for other rural areas to consider.
Avril Duck is a community theatre director and community arts and cultural development worker. She has been at the heart and foundation of two iconic Cairns community cultural events, both occurring annually: Shakespeare at the Tanks theatre productions and Shadows of the Past dramatised evening cemetery tours. For over 15 years Avril has led a wide range of theatre-based community projects and workshops in Far North Queensland. She builds partnerships with the community in collaborative creative work and has forged a practice of theatre making for social change. Avril grew up in regional FNQ in the small town of Herberton and after completing her Bachelor of Education at Melbourne University, studying Drama and Chinese, Avril returned to FNQ. She then gained a Certificate in Teaching English as a Foreign Language, which she has taught for over 20 years to support and compliment her theatre-making. Avril’s approach is always naturally inclusive because diversity is her aesthetic. She is known as a leader, a teacher, a creative and a doer in the community. Her work with people from diverse backgrounds was acknowledged in 2015 when she was awarded the Cairns Regional Council Australia Day Cultural Award.
An inspiring approach to using theatre as a community development tool.
When making theatre by, with and for the community, positive changes can happen for individuals and groups of people. Theatre is an umbrella art form requiring collective creative collaboration from a wide range of production areas as entry points: from acting and set making, to playing in musical ensemble or backstage and technical operators. In Avril Duck’s approach to community theatre-making over the last 15 years in FNQ, diverse individuals connect with and join in, on their own terms, self-selecting the areas they have strengths and interest in. This is Theatre Making for Social Change.
Focusing on the theatre production as the golden outcome combines everybody’s best efforts. There is no focus on “perceived lack”. In making theatre, nobody is being “fixed”, “cured” or “helped”—but everybody is being supported to shine in their moment as part of the theatre production. Through the collective wish to achieve a creative vision, along the way connections occur, voices are heard, skills are learned and social change occurs.
In 2016, a professional development program, led by Avril Duck asked key questions like:
The group of seven participants worked in various roles in collaboration within the Tropical Arts large-cast, inclusive theatre production of The Taming of the Shrew as part of the 9th annual Shakespeare at the Tanks season. They were engaged as actors, trainers, OHS officer, musicians, assistant directors and social change observers.
The aesthetic of Theatre Making for Social Change is premised on diversity. The audience is thrilled to see the local Cairns community on stage. Each is valued for their unique individuality. The varying abilities and experiences of the cast and crew means that “caring” is recognised as a core skill. Grounded and holistic, this theatre process ensures that all can speak for themselves, no one is not good enough.
This presentation discusses the concepts, process and the golden outcome—the production itself—and the social changes which have occurred within it.