NACCHO Aboriginal Health Research News : Download @LowitjaInstitut and @ourANU Aboriginal Health and Wellbeing Services – Putting community-driven, strengths-based approaches into practice

From the wide range of health and wellbeing practitioners we spoke to – which included nurses, midwives, Aboriginal health workers, therapists, caseworkers and more – there was clear sentiment that in a context of post- colonial power imbalance, Aboriginal people often experience inappropriate treatment in mainstream services.

There was agreement that community-driven, holistic and person-centred approaches are key to delivering better services, yet, increasingly, restrictive and metrics-focus funding regimes constrain what works. ” 

From Aboriginal Health and Wellbeing Services – Putting community-driven, strengths-based approaches into practice Report

Download 80 Page PDF here

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” Laynhapuy Health is responsive to a set of distinctly localised, Yolŋu ways of setting goals and priorities. The Traditional Owners, in combination with the local health workers, are effectively the ‘bosses’ of the Laynhapuy Health service.

They make broad decisions about the nature and pace of health delivery, in keeping with the broader self-determined ethos of the homelands movement (see the section on Laynhapuy Homelands self-determination movement).

The Aboriginal health workers, meanwhile, are responsible for the clinics in their communities (see the section Aboriginal health and wellbeing professionals).

Difficult decisions about local health are made in the first instance through adherence to Yolŋu conventions of reciprocity, relational obligation, custodianship and clan-based understandings of the right way to do things.

In the second instance, decision making in Laynhapuy Health is intercultural. The Laynha Health manager (and a range of other staff) regularly meet with community leaders, health workers and a wide range of community members on routine community visits, and the communities are the manager’s first point of contact for discussing new ideas or directions.

This is not always an easy task as it relies on subtleties beyond formal governance. The community needs to trust that the staff and clinicians of Laynhapuy Health will respect and adhere to the decisions made at a homeland level.

At the same time, the manager must ensure power in decision-making continues to reside with the Traditional Owners and the community, while also adhering to the clinical and bureaucratic conventions of biomedical systems.

As we explore here, time, communication and trust are crucial elements in making this work. However, at the heart of Laynhapuy Health’s model is a belief that the people of the homelands are best placed to make decisions about their own health care; in short, Yolŋu concepts of health create healthy Yolŋu.”

From page 32 Laynhapuy Health is an Aboriginal Community Controlled Health Service (ACCHS) operating in East Arnhem Land, Northern Territory (NT). It delivers comprehensive primary health care (CPHC) to Yolŋu people across the remote Laynhapuy Homelands

Executive summary 

This report explores strengths-based, bottom-up approaches to delivering Aboriginal health and wellbeing services.

It focuses on three case study organisations across two sites, all of which have reputations for maintaining highly positive relationships with their communities:

  • Laynhapuy Health is an Aboriginal Community Controlled Health Service (ACCHS) operating in East Arnhem Land, Northern Territory (NT). It delivers comprehensive primary health care (CPHC) to Yolŋu people across the remote Laynhapuy Homelands (see https://www.laynhapuy.com.au).
  • Waminda is an ACCHS that provides a range of health and wellbeing services to Aboriginal women and their families in the Shoalhaven region of New South Wales (NSW) and beyond. This includes general practice, antenatal and postnatal care, lifestyle programs, justice support, social enterprise programs and more (see waminda.org.au).

  • Noah’s is a community-based, not-for-profit organisation catering to children and young people with special needs and their families across the Shoalhaven. Their work includes National Disability Insurance Scheme (NDIS) services, childhood education, playgroups, and behaviour Noah’s has several programs specifically for Aboriginal clients (see https://noahs.org.au/).

Despite the substantial differences between the two field sites and the scope of the three organisations, there were strong commonalities between them in the approaches and challenges they raised.

For all three organisations, strengths-based approaches are inseparable from their community-driven, holistic design. The linking elements are their understandings of power structures and neo-liberal trends in a cross-cultural context in the Australian health and wellbeing sector.

This highlights that strengths always need to be understood in relation to constraints. For example, a narrow focus on strengths risks portraying individuals and communities as responsible for their situations, shading out wider relations of power and socio-economic inequality.

We found that all three organisations strike an important balance between confidence in the strengths of the communities they serve and represent, and consciousness of the constraints on their (and their clients’) room for manoeuvre in a post-colonial and increasingly neoliberal nation-state.

In many ways large and small, the organisations keep working at pushing those boundaries a little further – creating more room for autonomy and for strengths.

This report explores these dynamics, and, in the process, details the three organisations’ approaches and successes. This brings us back to many of the core issues that are well documented in relation to Aboriginal health and wellbeing, including the importance of community-driven design, holism, the social determinants of health, and person- and family-centred approaches.

This allows us to celebrate the organisations’ strengths and successes – highlighting ‘beautiful, big, positive’ stories, as one of our interviewees put it.

Throughout this report we have followed the terminologies of our case study organisations, participants, and/or source materials in our use of the terms ‘Aboriginal’, ‘Aboriginal and Torres Strait Islander’ and ‘Indigenous’.

The main section of the report details the organisations’ understandings of effective approaches in the sector, as they have sought to implement them. Although there is much overlap, we have divided this into three areas of focus:

Under the section What Works: Bottom-up approaches we explore broad, organisational issues relating to governance, program design and staffing.

  • Community-driven program design is fundamental to ensuring This requires building long- term relationships with communities that go well beyond superficial consultation.
  • Relationship building goes hand-in-hand with long-term learning based on local histories, culture and socio-economic
  • From these relationships and learning, innovative place-based services that are responsive to community needs and aspirations can
  • Crucial to these processes is having staff who are part of the community, but drawing on expertise and support from staff with a diversity of backgrounds can also help build robust structures and services and provide clients with a wider

Under the section What Works: Holism and wellbeing we then look at how the organisations think about health and wellbeing and what they incorporate within the scope of their work.

  • Much of the health sector treats illness in Aboriginal people, rather than promoting health and
  • Holistic health that addresses social determinants is preventative and protective. It can include supporting culture and language, connection to Country, spirituality, belonging and identity, strength of community and family, and empowerment and control.
  • Holistic health may seem broad, and therefore difficult to implement. However, because the organisations are in tune with community needs and aspirations, it is often clear to them which health-promoting services are most relevant in their context. For example, for one health organisation, enabling people to live and thrive in remote homelands communities is at the core of their work, while another explicitly promotes fitness, nutrition and career pathways among other things.

Under the section What Works: Delivering person- and community-centred care we narrow to a focus on effective approaches at the ‘clinical interface’ of the organisations’ work.

  • Much top-down intervention in the health care sector and beyond relies on externally identifying and seeking to fix Often systems operate based on practitioners’ ‘expert’ values and terms.
  • Person-centred care shifts the power balance and places clients’ needs, desires, goals, values and circumstances at the centre of the care
  • Related strengths-based approaches seek to shift the emphasis away from problems and negative labels through which a person’s or community’s identity can become defined, to instead recognising positive capabilities, goals and
  • All the case study organisations stressed the importance of their services being accessible on a regular and consistent basis. This was closely linked with making a long-term commitment to a place and a population, and building peoples’ familiarity with the service and their trust over
  • Consistency in service provision must be balanced with flexibility, adaptability and responsiveness based on community and client needs. In other words, consistently ‘being there’ for clients is important, but the form this takes need not be prescribed, rigid or
  • Brief consultation times, which are standard in the health care sector, are particularly sub-optimal in the context of Aboriginal health care for a range of reasons we detail. For example, building trust is essential,particularly in light of traumatic histories with institutional services and the prevalence of negative experiences in the health and wellbeing sector. However, building trust and rapport takes time.
  • All the case study organisations see brokering, advocacy and coordination of care as central to their work and success. This ranges from explaining to people the available services and talking them through what to expect, to (in the case of one organisation) escorting them on major hospital visits and translating between

While many of these themes are well-established ‘best practice’ in the health and wellbeing sector, the organisations had remarkably similar Challenges and Constraints in marrying bottom-up, holistic and person-centred approaches with top-down funding regimes.

  • Funding is typically for a specific purpose, falls within a siloed sector or assumes a certain set of realities. The purpose and scope of the funding is decided from the top down and it often assumes a compartmentalised approach to health and
  • Project and programme grants are also often relatively short-term. But, as noted, genuine community relationships take time to build, and many programs that address the social determinants of health are unlikely to show results in such timeframes. Even initiatives with a strong and consistent record of positive results over the long term can be defunded at short notice with little or no This is a threat to the consistency and regularity of services (factors that our participants identified as being so important). It is also a threat to staffing in a context where the organisations have strived to build up Aboriginal staff capacity and cross-cultural understandings, as it can result in the loss of long-term institutional knowledge and produce employment precarity.
  • The organisations are required to report on key performance indicators (KPIs). These are typically determined from the top down and are often strongly metrics-focused. There are frequent disconnects between what KPIs measure and what local organisations value, as well as frustrations that KPIs measure the ‘wrong’ things or fail to capture important successful activity. This is part of a broader international trend toward standardised statistical indicators, despite evidence that they often do not produce the desired

Drawing on the findings throughout the report, we make a range of recommendations for ways forward. These are targeted at funders, policy makers and associated stakeholders seeking to enable non- government organisations (NGOs) in the Aboriginal health and wellbeing field to work more effectively.

Funding that embraces holism, innovation and responsiveness

  • A prevalence of narrow, sector-specific funding may be impeding holistic health and wellbeing approaches, and those driven by community needs, values and More funding streams that allow organisations to define and respond to holistic health and wellbeing in their context are needed.
  • Designing bottom-up, holistic health and wellbeing services sometimes means innovating and taking risks. Funding streams that embrace innovation, but do not force it where it is unneeded, would benefit the

Longer term funding cycles

The availability of more long-term funding options will better allow organisations to design projects and programs from the bottom up. This includes organisations’ efforts to prioritise relationship building;

to address the social determinants of health; to ensure there is leeway for strategies to be tried and, if necessary, amended; to provide consistency of presence over time; and to help build a more skilled and stable workforce that includes training, learning and career development opportunities for Aboriginal and non-Aboriginal staff.

Co-designed KPIs

  • Funding providers should allow organisations the capacity to design or negotiate KPIs according to local realities and community-based aspirations, thereby allowing for greater local relevance, responsiveness and
  • Co-design of KPIs should be an ongoing, reflexive process, allowing for the mitigation of unintended consequences.

Narrative-based reporting

  • Reporting formats need to allow funding recipients the option and scope to detail progress, issues and outcomes in narrative/descriptive form. This may mean incorporating more open-ended questions in report
  • The capacity to integrate or attach multi-media (including videos, audio and photographs) is also merited.
  • Public servants and program managers need professional development in valuing and using qualitative information, and in the dangers of privileging statistical

Reducing over-reporting

  • It is incumbent on funding providers to ensure that reporting requirements and processes are efficient. This includes thinking carefully about how often reports fall due, how user-friendly the reporting templates are to complete, and whether the extent of what they ask applicants to produce is

Relationship building between funders and recipients

  • Policy makers and funders can gain a better understanding of the realities on the ground by talking directly to those implementing services in that Staff at funding institutions should be encouraged to view the funding relationship as a partnership, rather than as a hierarchicalrelationship in which the funder holds the power. It is, after all, usually the service provider that best understands the realities, needs and aspirations of the communities with which they work.
  • Organisations can feel that submitting reports on expended funding is like feeding information into a black hole; there is typically no engagement or feedback from the funding organisation and it is often unclear if or how the submitted information is (or might in future be) used. More transparency around the use of requested information is important, as is engagement with submitted reports.

Career public servants and time for learning

  • The Australian Public Service encourages professional mobility among its staff, but understanding Aboriginal Affairs requires relationship building, substantial cross-cultural knowledge, and comprehension of a range of complex and interrelated historical, socio-economic and political As such, there is strong merit in encouraging public servant stability and specialisation in Aboriginal Affairs.
  • Because knowledge of best practice, and cross-cultural understanding, are central to effective Aboriginal health and wellbeing policy, public servants need time for There is a vast amount of high-quality and accessible research and guidance material on these topics, as well as a plethora of other learning avenues such as courses and cultural immersions. It would be of enormous benefit for public servants to be encouraged to read such materials and to undertake learning opportunities on-the-job with allocated time to do so.

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