Governance:Urgent remedy needed for Aboriginal community healthcare

This opinion article is reproduced from The Australian

28 June 2012 for the information of NACCHO members

Selwyn Button is chief executive of the Queensland Aboriginal and Islander Health Council.

 Morgan Brigg is a senior lecturer at the University of Queensland.

THE community-controlled health sector can close the gap and deliver health improvements for Aboriginal people in ways that mainstream health services never have and never can. But the sector is in a crisis brought about by a failure of governance. This failure is not of the type popularly imagined and the solutions require urgent sector-led reform that will make many of the key players uncomfortable.

The mantra of “community control” has driven the Aboriginal community-controlled health sector for approximately 40 years, but insiders know that it needs a major overhaul. As services have grown to become complex multi-million dollar operations, they have not updated their governance models. Many organisations have become compromised as particular individuals and families come to exercise too much power. This is better described as “controlled community” than “community control”, with many Aboriginal people locked out of organisational membership by a powerful few.

In these circumstances it is impossible to keep organisations accountable, leading to systemic failures of governance. Without effective governance, funds are mismanaged and problems remain undetected until it’s too late.

 For several decades, governments have responded by attempting to improve corporate governance. Funders provide training on principles and mechanics of good governance and leadership and have tightened reporting requirements and increased monitoring and oversight. The efforts help, but they fail to address the problem. This is technical work, often undertaken by consulting firms with no expertise in Aboriginal health. They detect failure too late, displace local people by working only with the organisation, and divert resources and time from the core business of successfully delivering high quality healthcare to the country’s most disadvantaged populations.

The core of the problem is that corporate governance is in a battle with a compromised version of community control. Reform is necessary to prevent families from dominating boards and to avoid the conflicts of interest that plague the sector.

There is also a need for more expert and independent directors on boards. But such reform cannot be easily mandated by governments or technically administered. The answer, then, does not lie solely with corporate governance, although the highest of standards must continually be demanded in this area.

The sector needs to boldly reconfigure its approach to community governance as a key driver of good corporate governance. And there are already success stories. There are recent cases, following a crisis of corporate governance, where the community has stepped in and said enough is enough. As a result, governance has become more transparent and service provision and attendance have lifted.

Powerful individuals and families have been brought to heel by community pressure where they have not responded to consultancy firms and pressure from government funders. Unfortunately, though, this story is all too rare. Often crises lead to the closure of services or rolling problems.

Rethinking and reinvigorating community control can address the issues, but is not easy work. There is a need to explore and clarify where the values, principles and practices of community and corporate governance come from, and how they relate to the model of healthcare to be delivered. There is also a need to carefully think through the appropriate mix of Aboriginal and mainstream ideas and values that should be drawn upon. This type of work generates conflict, but it is necessary and can be transformative and valuable.

The upsides to rethinking governance in the sector and moving through conflict are big. One winner is Aboriginal control – Aboriginal people and Aboriginal values driving change on their terms. But equally important are the opportunities to better deliver the demonstrably effective health outcomes that are provided by community-controlled health services. This is crucial for closing the gap for an in-need population and for the responsible use of public funds.

Morgan Brigg is a senior lecturer at the University of Queensland. Selwyn Button is chief executive of the Queensland Aboriginal and Islander Health Council.