Improving Aboriginal health: How might the health sector do things differently?

Jane Lloyd, University of New South Wales

Marilyn Wise, University of New South Wales

Tess Lea Bureaucrats and Bleeding Hearts: Indigenous Health in Northern Australia, Sydney, UNSW Press, 2008 (304 pp). ISBN 9-78192141-018-5 (paperback) RRP $49.95.

It is well known and widely reported that Aboriginal Australians are sicker and, on average, die much earlier than non-Aboriginal Australians (Australian Bureau of Statistics and the Australian Institute of Health and Welfare 2005; Close the Gap coalition 2008). There have been over three decades of inquiries, policies, programs and reviews into the health of Aboriginal Australians (Australian Indigenous Healthinfonet 2010). However, improvements in health outcomes have been limited.

The lack of progress in reducing the gap in health and life expectancy between Aboriginal and non-Aboriginal Australians points to the need for all sectors, including the health sector, to examine their structures, processes, policies and services and to identify and adopt the changes necessary to improve Aboriginal health outcomes. It is a truism, perhaps, to point out that one of the major ways that a health system influences the health of populations is through the implementation of policy ideas. However, policy ideas evolve and are adapted by the bureaucrats responsible for their implementation at a variety of levels within organisations and in communities or populations.

In the Australian health care system Aboriginal people access care through a variety of services. These services include mainstream, publicly funded health services that span primary, secondary and tertiary care (primary health care centres and hospitals), Aboriginal community controlled health services (which mainly provide primary health care and some specialist care), and private health care providers such as general practitioners.

In this essay we compare insights from Tess Lea’s ethnography of a mainstream health service’s workforce with the principles and practices of the Aboriginal community controlled health sector. This comparison raises questions about how things might be done differently to improve Aboriginal health in Australia.

HEALTH PROFESSIONALS AND ABORIGINAL HEALTH

Tess Lea conducted an ethnographic study of the publicly-funded mainstream Northern Territory health system and its workforce. The research, reported in Bureaucrats and Bleeding Hearts: Indigenous Health in Northern Australia, investigated the structures, roles, and methods used by the health workforce (the ‘bureaucrats’ of the title) to improve the health of Aboriginal residents of the Northern Territory. Lea’s work stands in contrast to much current research. She offers a different perspective, shifting the reader’s gaze away from examining Aboriginal people and their health, towards criticising the organisation of the mainstream health care system and the workforce employed to deliver health care and preventive interventions. Her descriptions of how the health professionals she calls bureaucrats think and behave sheds light on some reasons why the mainstream health sector has achieved only limited progress in improving the health of Aboriginal people and communities in the Northern Territory.

Public health bureaucrats are a talking and reflective profession.

Lea’s book comprises three parts: a description of the settings within which bureaucrats work; analysis of how bureaucrats learn and are socialised to work in these settings; and exploration of how work is carried out once bureaucrats are fully oriented into the system. The social dynamics of the bureaucratic setting are introduced using two case studies. The first describes the process of developing a corporate plan for the health department. The second describes an elaborate plan to privatise all public hospitals in the Northern Territory. Through this section we learn how bureaucrats justify, remember and rewrite history to make it more palatable, and to make the lost time and effort seem less wasteful. Survival is achieved by retelling the story in retrospect. The reader also learns why the health department’s structure and operations require co-ordination, and that the need for co-ordination is self-perpetuating. The act of co-ordinating results in greater fragmentation, which, ironically, only more co-ordination can solve.

Lea’s book reveals that public health bureaucrats are a talking and reflective profession. Workshops provide the primary platform for discussion. At first glance it may appear that public health bureaucrats use workshops as a way of solving problems. But Lea’s ethnography shows that, in fact, workshops are used, with the help of whiteboards and dot points, to normalise discussion. Complex discussions are recorded on the whiteboard as two or three word dot points. These dot points lose much of the complexity and layers of the discussion, and therefore limit the ability of the bureaucracy to generate a deeper and more nuanced understanding of the problem at hand. One of us also noted, reading Lea’s text, that the dot points tended to gravitate toward themes or ideas we have heard before. This process limits deeper insight and understanding and reduces the bureaucracy’s ability to do things differently. Although one of us enjoyed this part of Lea’s book, the other felt that the emphasis on the limitations of these discussions obscured an important prior problem: that underlying all the limitations of the bureaucrats and their ways of working has been the health sector’s lack of respect for Aboriginal leadership and direction. Until this is redressed, even though it might well be possible to have a nuanced discussion that addresses problems and solutions in more depth, if the wrong people are having the discussion in the first place, then the quality of that discussion becomes irrelevant.

Nonetheless, by building on observations and explanations of how agents of systems learn their roles and behave in practice, Lea’s work reveals glimpses of the inner voices of bureaucrats at work, engaging the reader as a first hand witness to ways health bureaucrats learn and survive in the health system. The book is an important addition to the literature. The focus on the workforce responsible for the implementation of public health policy (including health care services and preventive programs) is innovative and compelling, as is the focus on the organisational setting within which the workforce is employed.

Describing the problems is no longer sufficient.

In academic circles Lea’s text has been applauded (Rowse 2009; Sanders 2009). At the time of this review, no Indigenous perspectives on the text have been published. Lea’s work certainly helps us to understand some reasons why it is difficult to close the gaps in life expectancy and morbidity between Aboriginal and non-Aboriginal Australians. By describing what bureaucrats working in the mainstream health sector do and say, she highlights the significance of their roles in determining the actions taken by the health care system to implement health policy. This perspective is refreshingly different: rather than focusing on barriers to organisational change, or the cultural inappropriateness of health services or departments, Lea observes and explains the reasons for the actions the bureaucrats take ‘on the job’.

However, although the book offers new understanding of factors contributing to the slow progress in improving Aboriginal health, it does not move beyond describing the problem to offer constructive suggestions for change. It might be argued that this is not the role of an anthropologist or, alternatively, that better understanding a problem is always a first step in generating change. However, with the long standing and inequitable health gap between Aboriginal and other Australians and with the failure of decades of inquiries and policies to improve Aboriginal health—describing the problems is no longer sufficient.

We believe that Lea’s book does not pay sufficient attention to the potential for Western, ill-informed constructions of Indigenous Australians by health professionals and policy makers to compound the harm and poor health already present in many Aboriginal communities (Sherwood 2010). Perhaps this was a deliberate decision on the part of the author. It is a defensible decision in terms of the conduct of a discrete research project with limited time and resources. Nonetheless, there is danger that Lea’s work implies that there is no room for change within the existing bureaucracy—and that there is no alternative model of policy development and service delivery to mainstream services to serve Aboriginal people. In fact Aboriginal community controlled services constitute a significant component of the health care system for Aboriginal Australians and they provide a clear alternative with significant advantages.

WHAT LIMITS OUR ABILITY TO DO THINGS DIFFERENTLY?

Notwithstanding our concerns, Lea’s work has provided rare and valuable insights into the interaction between the ‘system’ in which policy is implemented and the workforce that is actually responsible for service delivery. Her work builds on that of Michael Lipsky (1980), who identified street-level bureaucrats—the public service workers who interact directly with ‘the public’. Many of the practitioners whose work Lea observed might be viewed as ‘street level bureaucrats’ who mediate the relationship between governments, their agencies and the public. Lea’s insights also add another dimension to work by Camara Jones (2000) on racism in health systems. Jones identified three ‘locations’ within which racism is perpetuated—institutions, their agents (often bureaucrats), and within the people who experience the racism, themselves.

There is danger that Lea’s work implies that there is no room for change.

Lea has, helpfully, explored ‘from the inside’ the views and perspectives of the agents—of the people who see, first hand, the positive and negative, unintended consequences of new policy and who act to modify it during implementation to make it ‘fit’ their particular circumstances. However, our own research found that the adaptation is, most commonly, not a response to community needs or circumstance (nor, even, to organisational demands). It is determined, principally, by the pre-existing knowledge and skills of the workforce (Lloyd, Wise & Weeramanthri 2008). Lea’s research confirms that no matter how well policy is focused and designed, the likelihood of its being implemented as intended is heavily influenced by ‘who’ is responsible for implementation and the organisational structure within which they are working. This means that the failure of policy makers and academics to fully understand the reasons for the decisions made by bureaucrats in the policy implementation process will result in further policy failure in improving Aboriginal health.

Lipsky’s, Jones’ and our own research confirms that there is need to do more than develop more effective policy responses to the health problems defined by Aboriginal communities and/or to develop more effective health care services and delivery systems. There is also a need, as Lea has done, to understand better how bureaucrats receive and integrate new ideas, and how they interact with the systems they work in to mould the new ideas to fit existing thinking and practices. It is important to recognise this, because similar policy ideas are shaped and moulded (and implemented) in very different ways by different systems that have different workforces, values and priorities (Pressman & Wildavsky 1984; Lloyd 2008).

A REAL ALTERNATIVE: SERVICES UNDER ABORIGINAL CONTROL

In Australia, the clearest point of comparison between systems is between the mainstream health system and Aboriginal community controlled health services (ACCHSs). ACCHSs were established in 1971 to address some of the barriers that had restricted the access of Aboriginal Australians to quality health care in mainstream Australia—miscommunication and lack of communication between non-Aboriginal providers and Aboriginal patients; mistrust of the mainstream health care system by Aboriginal people; and poor understanding on the part of many non-Aboriginal health professionals of the impact of their own cultures on the way in which they provide health care. In effect, ACCHSs are alternative structures and organisations with different workforces—and exemplify the differences in the style, type and range of care provided when policies and services are designed and delivered by organisations that are a practical expression of Aboriginal self determination in Aboriginal health and health service delivery (Hunter et al. 2005). The National Aboriginal Health Strategy Working Party (1989) described the differences in more detail. In short, the same national and state-wide policy ideas are implemented differently in the two structures by their two workforces (Larkin, Geia & Panaretto 2006). Policy, in and of itself, is not sufficient, on its own, to bring about the changes required to improve the health of Aboriginal people when the system through which it is to be implemented is ill-prepared to deliver the policy as intended.

Reading Lea’s work, one can see how little influence the design and practice of Aboriginal community controlled health services and their ways of working have had on the ‘mainstream’ health system. The ACCHSs were developed as an alternative to a mainstream health sector that manifested all of the challenges Lea identifies. They have provided vital leadership in defining the characteristics of systems (structures, processes, and the workforce) that more precisely meet the health needs of Aboriginal people and communities. There is evidence of the effectiveness of organisations that are under Aboriginal leadership and that have responsibility for employing their workforces, for developing new policies, for allocating resources, and for designing and delivering interventions and services (Sherwood 2010; Chandler & Lalonde 1997; Dodson & Sanders 2003). For example, there is a greater number of Aboriginal health workers employed in ACCHSs than in mainstream health services. Research shows that having more Aboriginal health workers involved in primary health care influences the nature of consultations, the time spent with patients, the number of problems that are managed, and the emphasis on public health (Larkin, Geia & Panaretto 2006).

New policy ideas are shaped by the systems and agents that implement them.

Despite this evidence, it has proven difficult for governments, which have jurisdictional authority over the provision of health services and are responsible for their funding, to ensure that both mainstream health services and the ACCHSs each make optimal contributions to improving Aboriginal health. The Overburden Report (Dwyer et al. 2009) recommended one way to increase the effectiveness of ACCHSs and of mainstream health services in providing the range and quality of care required to reduce the gap in mortality and morbidity between Aboriginal and non-Aboriginal Australians. That review proposed that ‘relational’ or ‘alliance’ contracting, rather than complex and fragmented contracts, would offer a way of improving accountability mechanisms and relationships between health authorities and ACCHSs (Dwyer et al. 2009). Alliance contracting is characterised by collective sharing of responsibilities and risks, under funding arrangements that are transparent without being overly bureaucratic. We support Dwyer’s recommendation for alliance contracting because we believe it is an example of one feasible, practical change that might better support and nurture the relationship between the government and ACCHSs.

Lea’s work illustrates how new policy ideas, no matter how relevant and evidence-based, evolve and are shaped by the systems and agents that are required to implement them (Lloyd 2008). The implication is that the failure to fully understand (and modify) how bureaucrats adapt policy at the point of implementation will lead to further failures to improve Aboriginal health. It is by understanding (and influencing) how health professionals shape and are shaped by the systems within which they have been educated, trained, and employed that it will be possible to develop more effective ways of working.

The history of colonisation and of government control over Aboriginal people has been institutionalised in the policies and practices of organisations and within the world views, education and training of health professionals (Jones 2000). Several changes are necessary to redress the problems that Lea’s research points to, including critical reflection on the membership, roles and work of the health bureaucracy in improving Aboriginal health; attitudinal change among non-Aboriginal Australians; and leadership and determination to do things differently. Most importantly, in 2011, in Australia, there remains a need for recognition and agreement that Aboriginal people need to have the authority to manage their own affairs—including, but not limited to, health services (Lavoie et al. 2010).

REFERENCES

Australian Bureau of Statistics and the Australian Institute of Health and Welfare 2005, ‘The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples’, Commonwealth of Australia, Canberra.

Australian Indigenous Healthinfonet 2010, ‘Major developments in national Indigenous health policy since 1967’ [Online], Available: http://www.healthinfonet.ecu.edu.au/health-systems/policies/reviews/health-policy-timelines [2011, Jan 31].

Chandler, M. & Lalonde, C. 1998, ‘Cultural continuity as a hedge against suicide in Canada’s First Nations’, Transcultural Psychiatry, vol. 34, no. 2, pp. 191–219.

Close the Gap coalition 2008, Close the Gap [Online], Available: http://www.closethegap.com.au/index.php [2011, Jan 24].

Dodson, M. & Smith, D. 2003, Governance for sustainable development: Strategic issues and principles for Indigenous Australian communities, CAEPR Discussion Paper No. 250, CAEPR, Australian National University [Online], Available: http://caepr.anu.edu.au/Publications/DP/2003DP250.php [2011, Feb 4].

Dwyer, J., O’Donnell, K., Lavoie, J. Marlina, U. & Sullivan, P. 2009, The Overburden Report: Contracting for Indigenous Health Services, Cooperative Research Centre for Aboriginal Health, Darwin.

Hunter, P., Mayers, N., Couzos, S., Daniels, J., Murray, R., Bell, K., Kehoe, H., Brice, G. & Tynan M. 2005, ‘Aboriginal community controlled health services’, in General Practice in Australia, Commonwealth Department of Health and Aging, Canberra.

Jones, C.P. 2000, ‘Levels of Racism: A theoretical framework and a gardener’s tale’. American Journal of Public Health, vol. 90, no. 8, pp. 1212–1215.

Larkin S.L., Geia L.K. & Panaretto K.S. 2006, ‘Consultations in general practice and at an Aboriginal community controlled health service: Do they differ?’, Rural and Remote Health, vol. 6, no. 560 [Online], Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=560 [2011, Feb 4].

Lavoie J.G., Forget E., Prakash T., Dahl M., Martens P., O’Neil J. 2010, ‘Have investments in on-reserve health services and initiatives promoting community control improved First Nation’s health in Manitoba?’, Social Science and Medicine, vol. 71, pp. 717–724.

Lipsky, M. 1980, Street-level Bureaucracy: Dilemmas of the Individual in Public Services, Russell Sage Foundation, New York.

Lloyd J. 2008, Implementing Aboriginal Health Policy, PhD thesis, The University of Sydney, Sydney.

Lloyd, J., Wise, M. & Weeramanthri, T. 2008, ‘Changing shape: Workforce and the implementation of Aboriginal health policy’, Australian Health Review, vol. 32, no. 1, pp. 174–185.

National Aboriginal Health Strategy Working Party 1989, A National Aboriginal Health Strategy, Australian Government Publishing Services, Canberra.

Pressman, J. & Wildavsky A. 1984, Implementation: How Great Expectations in Washington are Dashed in Oakland, University of California Press, London.

Rowse, T. 2009, ‘Bureaucrats and bleeding hearts: Indigenous health in Northern Australia’, Australian Anthropological Society, vol. 20, no. 6, pp. 154–156.

Sanders, W. 2009, ‘Writing Indigenous affairs: Diverse and innovative approaches’, Australian Journal of Political Science, vol. 44, no. 4, pp. 737–740.

Sherwood, J. 2010, Do No Harm: Decolonising Aboriginal Health Research, PhD thesis, University of New South Wales, Sydney.

POSTSCRIPT

We are disappointed that, in our search for responses and reviews to Lea’'s text, we missed an important and insightful review by Professor Ian Anderson of the University of Melbourne. It can be found online at: http://inside.org.au/bureaucracys-bleeding-northern-heart/. (J.L. and M.W., 7 March 2011)

Dr Jane Lloyd is a Research Fellow at the Indigenous Policy and Dialogue Research Unit at the University of New South Wales. Jane is currently working on an Australian Research Council Linkage Grant investigating the use of evidence in Indigenous policy.

Marilyn Wise is Associate Professor of Healthy Public Policy at the Centre for Health Equity Training Research and Evaluation (CHETRE), which is part of the UNSW Research Centre for Primary Health Care and Equity. She was one of the authors of the Health Impact Assessment of the Northern Territory Emergency Response conducted by the Australian Indigenous Doctors’ Association and CHETRE in 2008–09.