NACCHO Aboriginal Health and Self Determination : How to improve health outcomes for Indigenous peoples in New Zealand , Canada and Australia by making space for self-determination #VoiceTreatyTruth

Indigenous public policy fails consistently. The research evidence is compelling. Across post-settler colonial societies like New Zealand, Australia and Canada, schooling is not as effective for Indigenous citizens, employment and housing outcomes are not as good, and health outcomes are worse.

In Canada, the government says the solution lies in stronger nation-to-nation relationships between the state and First Nations. In Australia, the federal government proposes stronger consultation to “close the gaps in Indigenous disadvantage”.

In New Zealand, the Treaty of Waitangi is broadly accepted as an agreement offering solutions to policy failure. It protects the Māori right to self-determination and obliges the state to ensure that public policy is as effective for Māori as it is for everybody else.

Last week, the Waitangi Tribunal affirmed both these general principles in respect to health policy, but in its comprehensive report on the primary health care system, it found that despite clear intentions, the state fails to deliver good outcomes for Māori. “

Associate Professor of Political Science, Charles Sturt University

From The Conversation

Lack of self-determination

In effect, the tribunal found the state fails because it does not stand aside to allow Māori self-determination to prevail. Self-determination is a right that belongs to everybody. Under the United Nations’ Declaration on the Rights of Indigenous Peoples, which New Zealand accepts as an “aspirational” document, self-determination means that:

Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, Indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions (Article 23).

Under the Treaty of Waitangi the right to self-determination may be expressed in at least two ways. Firstly, the treaty affirms Māori rangatiratanga, or chiefly authority over their own affairs. Secondly, it gives Māori the “rights and privileges of British subjects”.

The latter was a relatively meaningless status in 1840, when the treaty was signed by representatives of the Crown and Māori tribes. But in 2019, citizenship has replaced subjecthood as a substantive body of political rights and capacities for many New Zealanders, though not always for Māori.


Read more: Explainer: the significance of the Treaty of Waitangi


Proposal for Māori health authority

The tribunal’s Health Services and Outcomes Inquiry report is explicit. Poor Māori health persists because health policy doesn’t honour the treaty. Solutions, it says, lie in the treaty partnership between Māori and the Crown.

The idea of a treaty partnership is well established in New Zealand policy. But the tribunal report reinforces the idea that it is an unequal partnership, with the Crown acting as a senior party and crowding out space for Māori policy leadership. On the other hand, it makes at least two potentially transformative recommendations.

The first is that the Crown and Māori claimants in health care agree on a methodology for assessing underfunding of Māori health providers. The tribunal found that underfunding is in breach of the treaty and one of the variables that explains poor Māori health outcomes.

Secondly, the tribunal recommended the Crown and claimants “explore the possibility of a standalone Māori health authority”. This authority could become the principal funder of primary health services for Māori citizens. Māori health providers would make bids for contestable funding to the authority which, unlike District Health Boards, would have a predominantly Māori membership.

The authority would assess self-defined Māori health needs against established Māori cultural values. It could also have the capacity to commission research and contribute to national policy debate.

Māori at centre of policy decisions

This parallels a recommendation made to Kevin Rudd’s government in Australia in 2009 by a National Health and Hospitals Reform Commission.

Services would be purchased from Aboriginal community controlled health services, mainstream primary health care services and hospitals, and other services. The authority would ensure that all purchased services meet set criteria including clinical standards, cultural appropriateness, appropriately trained workforce, data collection and performance reporting against identified targets such as the national Indigenous health equality targets.

The proposal’s rejection was never fully explained. But it remains instructive to New Zealand as a way of making Māori policy work through self-determination.

Independent Māori decisions about which health programmes to fund, and from which providers, potentially brings Māori people and values to the centre of the policy process. It means that Māori people are not the subjects of state policy. They become its agents, exercising meaningful citizenship and the right to take responsibility for their own affairs. The concept of Māori as junior partners to the Crown is replaced by decision making authority.

An independent funding agency could also strengthen democratic accountability to Māori people who would not need to wait for an invitation to join the policy process, but would be at its centre. Liberal democracies exclude Indigenous people and perspectives as a way of protecting majority interests. But as the tribunal found, exclusion can explain why policy fails.

Meanwhile, Indigenous Australians have proposed a constitutionally enshrined “voice” to parliament, a truth telling commission and treaties between Indigenous nations and the state to acknowledge enduring Indigenous sovereignty. Victoria and the Northern Territory have started the process of treaty negotiation, but last year, a new government in South Australia “paused” the negotiations begun by its predecessor. It didn’t think that treaties could contribute to better lives for Indigenous people.

In Zealand, the treaty is not a panacea for better lives for Māori. But in 2019, it remains as the Māori government minister, Sir Apirana Ngata, put it in 1922.

[It] is widely discussed on all marae. It is on the lips of the humble and the great, of the ignorant and of the thoughtful.

Ultimately, the treaty’s transformative capacity depends on how it is interpreted, especially whether self-determination is allowed to trump partnership.

NACCHO Aboriginal Health #ClosingTheGap #NAIDOC2019 : @AIHW Key results report 2017-18 Aboriginal and Torres Strait Islander health organisations:

Findings from this report:

  • Just under half (45%) of organisations provide services in Remote or Very remote areas

  • In 2017–18, around 483,000 clients received 3.6 million episodes of care

  • Nearly 8,000 full-time equivalent staff are employed in these organisations and 4,695 (59%) are health staff

  • Organisations reported 445 vacant positions in June 2018 with health vacancies representing 366 (82%) of these
  • In 2017–18, nearly 200 organisations provided a range of primary health services to around 483,000 clients, 81% of whom were Indigenous.
  • Around 3.6 million episodes of care were provided, nearly 3.1 million of these (85%) by Aboriginal Community Controlled Health Services.

See AIHW detailed Interactive site locations map HERE

In 2017–18, Indigenous primary health services were delivered from 383 sites (Table 3). Most sites provided clinical services such as the diagnosis and treatment of chronic illnesses (88%), mental health and counselling services (88%), maternal and child health care (86%), and antenatal care (78%). Around two-thirds provided tobacco programs (69%) and substance-use and drug and alcohol programs (66%).

Most organisations provided access to a doctor (86%) and just over half (54%) delivered a wide range of services, including all of the following during usual opening hours: the diagnosis and treatment of illness and disease; antenatal care; maternal and child health care; social and emotional wellbeing/counselling services; substance use programs; and on‑site or off-site access to specialist, allied health and dental care services.

Most organisations (95%) also provided group activities as part of their health promotion and prevention work. For example, in 2017–18, these organisations provided around:

  • 8,400 physical activity/healthy weight sessions
  • 3,700 living skills sessions
  • 4,600 chronic disease client support sessions
  • 4,100 tobacco-use treatment and prevention sessions.

In addition to the services they provide, organisations were asked to report on service gaps and challenges they faced and could list up to 5 of each from predefined lists. In 2017–18, around two-thirds of organisations (68%) reported mental health/social and emotional health and wellbeing services as a gap faced by the community they served.

This was followed by youth services (54%). Over two-thirds of organisations (71%) reported the recruitment, training and support of Aboriginal and Torres Strait Islander staff as a challenge in delivering quality health services.

Read full report and all data HERE

This is the tenth national report on organisations funded by the Australian Government to provide health services to Aboriginal and Torres Strait Islander people.

Indigenous primary health services

Primary health services play a critical role in helping to improve health outcomes for Aboriginal and Torres Strait Islander people. Indigenous Australians may access mainstream or Indigenous primary health services funded by the Australian and state and territory governments.

Information on organisations funded by the Australian Government under its Indigenous Australians’ health programme (IAHP) is available through two data collections: the Online Services Report (OSR) and the national Key Performance Indicators (nKPIs). Most of the organisations funded under the IAHP contribute to both collections (Table 1).

The OSR collects information on the services organisations provide, client numbers, client contacts, episodes of care and staffing levels. Contextual information about each organisation is also collected. The nKPIs collect information on a set of process of care and health outcome indicators for Indigenous Australians.

There are 24 indicators that focus on maternal and child health, preventative health and chronic disease management. Information from the nKPI and OSR collections help monitor progress against the Council of Australian Governments (COAG) Closing the Gap targets, and supports the national health goals set out in the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.

Detailed information on the policy context and background to these collections are available in previous national reports, including the Aboriginal and Torres Strait Islander health organisations: Online Services Report—key results 2016–17 and National Key Performance Indicators for Aboriginal and Torres Strait Islander primary health care: results for 2017.

At a glance

This tenth national OSR report presents information on organisations funded by the Australian Government to provide primary health services to Aboriginal and Torres Strait Islander people. It includes a profile of these organisations and information on the services they provide, client numbers, client contacts, episodes of care and staffing levels. Interactive data visualisations using OSR data for 5 reporting periods, from 2013–14 to 2017–18, are presented for the first time.

Key messages

  1. A wide range of primary health services are provided to Aboriginal and Torres Strait Islander people. In 2017–18:
  • 198 organisations provided primary health services to around 483,000 clients, most of whom were Aboriginal and Torres Strait Islander (81%).
  • These organisations provided around 3.6 million episodes of care, with nearly 3.1 million (85%) delivered by Aboriginal Community Controlled Health Services (ACCHSs).
  • More than two-thirds of organisations (71%) were ACCHSs. The rest included government-run organisations and other non-government-run organisations.
  • Nearly half of organisations (45%) provided services in Remoteand Very remote
  • Services were delivered from 383 sites across Australia. Most sites provided the diagnosis and treatment of chronic illnesses (88%), social and emotional wellbeing services (88%), maternal and child health care (86%), and antenatal care (78%). Around two-thirds provided tobacco programs (69%) and substance-use and drug and alcohol programs (66%).

See this AIHW detailed Interactive site locations map HERE

  1. Organisations made on average nearly 13 contacts per client

In 2017–18, organisations providing Indigenous primary health services made around 6.1 million client contacts, an average of nearly 13 contacts per client (Table 2). Over half of all client contacts (58%) were made by nurses and midwives (1.8 million contacts) and doctors (1.7 million contacts). Contacts by nurses and midwives represented half (49%) of all client contacts in Very remote areas compared with 29% overall.

  1. Organisations employed nearly 8,000 full-time equivalent (FTE) staff

At 30 June 2018, organisations providing Indigenous primary health services employed nearly 8,000 FTE staff and over half of these (54%) were Aboriginal or Torres Strait Islander. These organisations were assisted by around 270 visiting staff not paid for by the organisations themselves, making a total workforce of around 8,200 FTE staff.

Nurses and midwives were the most common type of health worker (14% of employed staff), followed by Aboriginal and Torres Strait Islander health workers and practitioners (13%) and doctors (7%). Nurses and midwives represented a higher proportion of employed staff in Very remote areas (22%).

  1. Social and emotional health and wellbeing services are the most commonly reported service gap

Organisations can report up to 5 service gaps faced by the community they serve from a predefined list of gaps. Since this question was introduced in 2012–13, the most commonly reported gap has been for mental health and social and emotional health and wellbeing services. In 2017–18, this was reported as a gap by 68% of organisations.

 

NACCHO #ClosingTheGap Aboriginal Health and #UluruStatement #Makarrata : #NAIDOC2019 Week : #Voice #Treaty #Truth. Donna Ah Chee @CAACongress Let’s work together for a shared future

This NAIDOC Week we need to lift our gaze and consider the bigger picture reforms required to take the next step forward.

A Voice to Parliament; agreements or treaties; and a process to enable systematic truth telling.

All of this is achievable, and all requires deep listening from the Australian community and a commitment to action if we are to all move forward together as a single, unified nation.”

Donna Ah Chee CEO Congress ACCHO Alice Springs

Voice. Treaty. Truth. This is the theme for NADIOC Week 2019, and the words have never been more relevant; especially in Central Australia.

The movement for constitutional recognition culminated in 2017 in a National Constitutional Convention of Aboriginal and Torres Strait Islander people at Uluru. From this convention rose the Uluru Statement from the Heart. Put simply, this statement sums up where Aboriginal people see ourselves standing now and what we believe needs to be done to move forward for social justice; Voice, Treaty, Truth.

As Professor Megan Davis recently wrote “The Uluru Statement from the Heart was tactically issued to the Australian people, not Australian politicians. It is the people who can unlock the Australian Constitution for Aboriginal people, as they did in 1967, and the descendants of the ancient polities can unlock what is sorely lacking in this country, a fuller expression of Australia’s nationhood.”

Co-chair of the Referendum Council, Alywarre woman Pat Anderson said powerfully: “We need real change, because we, First Peoples, have something unique to offer this country. Our peoples have been here 65,000 years or more. Over these immeasurable periods we have developed a profound wisdom about this land and about what it means practically and spiritually to live here. We know this place. This is our place, and there is no doubt about it.”

Despite the enormity of the demands that Aboriginal people could make as peoples who never ceded sovereignty over the lands on which we now all live, our major demand is simply the right to be consulted about the legislation, policies and programs that are meant to help us.

The experience that Aboriginal people have had having been on the ‘underside’ of Australian history places us in a unique position from which to consider the laws and policies before Parliament and make suggestions for improvements that could make Australia a better place for all of us.

Having a constitutionally enshrined Voice in parliament would mean that the people who have actually experienced real poverty and hardship would finally be able to use this lens to consider the laws and policy decisions proposed in Parliament.

Just this week we heard from Kerry O’Brien on being inducted into the Logies Hall of Famefor his outstanding contribution to journalism, that “the failure to reconcile Indigenous and non-Indigenous Australia remained one big glaring gap in this nation’s story.” While lamenting the “awful racism this country is capable of”, he said that the Uluru Statement— which endorsed a constitutionally enshrined Indigenous representative body — offered hope for the future. Why is this seen by so many to be so important?

Relative to their numbers, Aboriginal and Torres Strait Islander people are politically marginalised in Australia. The seventy years following Federation saw not a single First Nations representative elected to any Australian parliament, only changing in 1971 when Neville Bonner entered the Australian Senate.

Since then only 38 Aboriginal and Torres Strait Islander people have been elected to any of the State, Territory or Federal parliaments; 22 of these being in the Northern Territory. Even today, the unprecedented four Aboriginal and Torres Strait Islander people we have seated in our national parliament only reflects 1.8% of all representatives.

A small number already, made even smaller when compared to the fact that Aboriginal and Torres Strait Islander people make up 3% of the Australian population, a number that is rising.

The systemic under-representation of Aboriginal people is mirrored in senior decision-making roles within public services across Australia. It is a powerful contributor to the lack of an accountable, informed, and sustained approach to Aboriginal issues, and the limited success in reaching the Closing the Gap targets.

Since the now famous Whitehall studies of the 1970s, ‘the control factor’ has been recognised as an important contributor to patterns of disease. The evidence shows that the less control people have over their lives and environment, the more likely they are to suffer ill health. Powerlessness is an identified risk factor for disease for Aboriginal Australians.

Aboriginal peoples’ lack of control of their lives is expressed at a national, systemic level through the absence of a national political representative institution; at a community level through their marginalisation from decision-making about programs that affect their own communities; and at an individual level through their experience of racism.

You only have to look at the poor implementation record of inquiry after inquiry into issues surrounding the health and wellbeing of the nation’s First Peoples for evidence of the absence of any real political influence.

Over the last three decades we have seen (most significantly) the National Aboriginal Health Strategy (1989), the Royal Commission into Aboriginal Deaths in Custody (1991) and the Bringing Them Home report (1997). They are among numerous other Royal Commissions and parliamentary inquiries into issues surrounding Aboriginal disadvantage resulting in recommendations that have not been fully implemented. I often think there needs to be a Royal Commission into the failure to implement so many Royal Commissions.

A genuine commitment to ‘Closing the Gap’ must include the establishment of a national representative body for Australia’s First Nations, as was recommended by the Referendum Council after extensive consultation with Aboriginal and Torres Strait Islander communities across Australia.

This must come alongside a Makarrata Commission to supervise a process of agreement-making and truth-telling between governments and Aboriginal and Torres Strait Islander peoples. Such changes, foreshadowed in the Uluru Statement from the Heart,have the support of the overwhelming majority of Aboriginal people and would provide the basis for substantive change in Aboriginal lives, as opposed to mere symbolic recognition.

This NAIDOC Week we need to lift our gaze and consider the bigger picture reforms required to take the next step forward. A Voice to Parliament; agreements or treaties; and a process to enable systematic truth telling. All of this is achievable, and all requires deep listening from the Australian community and a commitment to action if we are to all move forward together as a single, unified nation.

First published in the Centralian Advocate July 4 2019

NACCHO Aboriginal Health and #ClosingTheGap @nhmrc and @UniCanberra Project : Commissioning stronger evaluations of Indigenous health and wellbeing programs

 ” Billions of dollars are spent annually on Indigenous programs, services and initiatives yet, despite the need, there is limited evidence on what programs are effective for improving Indigenous health outcomes.

The Productivity Commission has called for ‘more and better’ evaluations of Indigenous programs and commissioning processes that engage Indigenous communities, organisations and leaders.

The commissioning of evaluations plays a significant role in the way program evaluations are carried out. It is through the commissioning process that the budget is set, the evaluators are identified, the aims and objectives of the evaluation are set, and many other aspects of the evaluation are determined.” 

See University of Canberra website 

This National Health and Medical Research Council funded project (GNT1165913) responds to a call from Indigenous leaders for opportunities to influence decision-making processes within the health system and across sectors for the commissioning of health programs to reflect their needs, priorities and views on program design, delivery and evaluation.

This project aims to identify how government (federal, state/ territory) and non-government (not-for-profit, corporate, foundation, philanthropic) commissioning practices can better support Indigenous engagement and leadership in the evaluation of health and wellbeing programs in Australia.

To achieve this aim, this project will address the following objectives:

  1. To characterise the spectrum of commissioning practices of government and non-government organisations in contracting evaluations for health and wellbeing programs particularly the role of Indigenous engagement and leadership during, and resulting from, the commissioning process.
  2. To identify the issues, challenges and opportunities for Indigenous engagement and leadership across the spectrum of commissioning practices from the perspectives of: (a) commissioners/policy makers; (b) service providers; and (c) the Indigenous community.
  3. To translate the findings into resources to support Indigenous engagement and leadership in the commissioning of program evaluations.

The project will be supported by an advisory group, chaired by Professor Tom Calma AO.

The project is funded until October 2022.

Research team

Contact

For more information on the project, please contact Margaret Cargo at margaret.cargo@canberra.edu.au.

NACCHO Aboriginal Health News : @pmc_gov_au Minister @KenWyattMP ( NIAA ) National Indigenous Agency Marks A New Era of Co-Design and Partnership to #ClosetheGap with Ray Griggs CEO

“Establishing this agency solely dedicated to the advancement of Australia’s First Nations is a significant opportunity for the Government to work with Aboriginal and Torres Strait Islander people on the ground to provide opportunities for growth and advancement, in education, employment, suicide prevention, community safety, health and constitutional recognition.

Over my life I have seen progress made but there is still more to do to find solutions and make a difference at the community level.

The NIAA will play a critical role in supporting me, as the first Indigenous Cabinet Minister and Minister for Indigenous Australians, to meet the changing needs of Aboriginal and Torres Strait Islander peoples, their leaders and communities

All of us must work together with State and Territory Governments to bring about change and close the gap in Indigenous communities.”

Minister Ken Wyatt

The National Indigenous Australians Agency (NIAA) was officially established today as an Executive Agency under the Prime Minister’s portfolio, marking a new era of co-design and partnership.

Minister for Indigenous Australians, the Hon Ken Wyatt AM, MP said the new agency represented a fundamental change in the way of doing business with Indigenous Australians by forming partnerships with Indigenous Australians at all levels, from children in remote communities to peak national organisations.

Minister Wyatt also announced that the inaugural Chief Executive Officer will be Mr Ray Griggs AO, CSC whose entire career has been in service to Australia and its peoples.

See NACCHO post for background

“NIAA is privileged to have such an experienced leader at the helm,” Minister Wyatt said.

“Ray Griggs will lead a dedicated team of some 1200 staff committed to making a significant contribution to an Australia that respects Aboriginal and Torres Strait Islander cultures and peoples.”

Chief Executive Officer Ray Griggs, said evolving the Indigenous Affairs Group of the Department of the Prime Minister and Cabinet into an Executive Agency in its own right was a natural progression.

“This change provides the opportunity to enhance the way we work across Government and ensure we have better coordination across the Commonwealth on matters that affect Indigenous Australians,” Mr Griggs said.

Minister Wyatt said he was looking forward to strong working partnerships with all levels of the team at NIAA to walk and work with Aboriginal and Torres Strait Islander peoples.

“Together we can build on our shared successes but also do many things differently, to deliver real change,” Minister Wyatt said.

 

NACCHO Aboriginal Health and #IndigenousEvaluationStrategy : The Australian Government has asked the @ozprodcom to develop a whole-of-government evaluation strategy for policies and programs affecting Indigenous Australians

 ” We are developing an evaluation strategy for Australian Government policies and programs affecting Aboriginal and Torres Strait Islander people.

 Better evidence about what works and why is needed to improve policies and programs.

The strategy will cover both Indigenous‑specific and mainstream policies and programs.”

 Romlie Mokak, Commissioner, Productivity Commission

Download the brochure HERE

indigenous-evaluation-about

Great ideas, engagement and interest in #IndigenousEvaluationStrategy workshop at #LowitjaConf2019 facilitated by Commissioner @RMokak and team members. Strong indicator of need for more attention on policy and program development and evaluation.

Evaluation can help policy-makers and communities determine:

  • whether government policies and programs are achieving their objectives
  • what influences whether government policies and programs are effective
  • how government policies and programs can be improved

We will engage widely across metropolitan, regional and remote locations.

We want to hear from individuals, communities and organisations.

  • How can Aboriginal and Torres Strait Islander knowledge, priorities and values be better integrated into policy and program evaluation?
  • What principles should guide Australian Government agencies’ evaluation efforts?
  • What should be the priority policy areas for future Australian Government evaluation efforts?
  • How can evaluation results be better used in policy and program design and implementation?

We are particularly keen to get input and advice from Aboriginal and Torres Strait Islander people, communities and organisations.

An issues paper will be released in June 2019.

Learn more about the project, or register your interest or call 1800 020 083

Indigenous Evaluation Strategy

Letter of Direction

Evaluation of policies and programs impacting on Indigenous Australians

I, Josh Frydenberg, Treasurer, pursuant to Parts 2 and 4 of the Productivity Commission Act 1998 hereby request the Productivity Commission to develop a whole-of-government evaluation strategy for policies and programs affecting Indigenous Australians. The Commission will also review the performance of agencies against the strategy over time, focusing on potential improvements and on lessons that may have broader application for all governments.

Background

A number of high profile reports have highlighted the need for more evaluation of policies and programs that have an impact on Indigenous Australians. For example, the Commission’s Overcoming Indigenous Disadvantage Report 2016found that only a relatively small number of programs have been rigorously evaluated.

Improving outcomes for Indigenous Australians depends on agencies with responsibility for policies and programs affecting Indigenous Australians undertaking meaningful evaluations. The Commission is to develop a strategy to guide that evaluation effort.

Scope

The Commission should develop an evaluation strategy for policies and programs affecting Indigenous Australians, to be utilised by all Australian Government agencies. As part of the strategy, the Commission should:

  • establish a principles based framework for the evaluation of policies and programs affecting Indigenous Australians
  • identify priorities for evaluation
  • set out its approach for reviewing agencies’ conduct of evaluations against the strategy.

In developing the strategy, the Commission should consider:

  • how to engage Indigenous communities and incorporate Indigenous knowledge and perspectives
  • ethical approaches to evaluations
  • evaluation experience in Australia and overseas
  • relevant current or recent reviews commissioned or undertaken by Australian, state, territory or local government agencies
  • the availability and use of existing data, and the further development of other required data and information
  • areas in which there may be value in the Productivity Commission undertaking evaluation
  • how to translate evidence into practice and to embed evaluation in policy and program delivery.

Process

The Commission should consult widely on the strategy, in particular with Indigenous people, communities and organisations (such as the Empowered Community regions), and with all levels of government. It should also consult with non-Indigenous organisations, and individuals responsible for administering and delivering relevant policies and programs.

The Commission should adopt a variety of consultation methods including seeking public submissions.

The Commission should provide the evaluation strategy and forward work program to Government within 15 months of commencement.

The Hon Josh Frydenberg MP
Treasurer

[10 April 2019]

 

Aboriginal Health and Indigenous Advancement Strategy : NACCHO CEO Pat Turner expresses her frustration that another ANAO report raises concerns about @pmc_gov_au management of #Indigenous Affairs.   

 ” It is very frustrating that we have another report from the Australian National Audit Office raising serious concerns about the Department of the Prime Minister and Cabinet’s management of Indigenous Affairs.  , 

In this case, it is the arrangements for the evaluation of the Indigenous Advancement Strategy which is a multi-billion dollar investment.  

The report tells us that five years after the introduction of the IAS, the Department is only in the early stages of implementing an evaluation framework and that there has been substantial delays.  

That is not good enough for the Department in charge of the Australian public service. ”  

Pat Turner NACCHO CEO

Listen to ABC World Today Interview Here 

Download the full ANAO report HERE

Evaluating Aboriginal and Torres Strait Islander Programs

The prime minister’s department acknowledged the findings of the audit report but said the strategy was set up within a “very challenging timeframe”.

It was “moving into a more mature phase of implementation that draws on lessons learned”.

The report made four recommendations, which the department agreed to and was already working to meet.

It intended to revise the strategy’s guidelines, and improve the application process and its own record keeping.

The Indigenous Australians minister, Ken Wyatt, said he “acknowledges the frustration we all share that we are not seeing quick enough progress on closing the gap between Indigenous and non-Indigenous Australians”.

“This is why Coag has agreed governments – both commonwealth and states and territories – and Aboriginal and Torres Strait Islander people will share ownership of and responsibility for a jointly agreed framework and targets and ongoing monitoring of the Closing the Gap agenda,” he said.

Labor, the Greens and peak Indigenous groups say the government must overhaul its Indigenous advancement strategy after a report found that the $5.1bn program was not being properly evaluated and did not align with the government’s policy objectives.

From The Guardian 19 June

Read full article 

After five years and $4.8 billion dollars, a new Auditor General’s report has revealed the Liberals and Nationals still can’t say whether their Indigenous Advancement Strategy is working.

Serious questions about the administration of the IAS have been swirling for years. Funding decisions have been notoriously opaque and the effectiveness of many programs is unclear.

This new report confirms the IAS has been operating for years without proper evaluation processes. Despite the former Minister being warned by his Department in 2016:

“At some point the current situation will become untenable as it is not sustainable to continue to fund activities that lack a good evidence base.”

[ANAO Report, p21, 2019]

Labor Response to ANAO report

Download Press Release Here

IAS Labor Response

Background

The Department of the Prime Minister and Cabinet (PM&C or the department) has been the lead agency for Aboriginal and Torres Strait Islander Affairs since 2013.

With the introduction of the Indigenous Advancement Strategy (IAS) in 2014, 27 programs were consolidated into five broad programs under a single outcome, with $4.8 billion initially committed over four years from 2014–15.

The Australian National Audit Office’s (ANAO’s) performance audit of the IAS (Auditor-General Report No.35 2016–17) noted that the department did not have a formal evaluation strategy or evaluation funding for the IAS for its first two years.

In February 2017 the Minister for Indigenous Affairs announced funding of $40 million over four years from 2017–18 to strengthen IAS evaluation, which would be underpinned by a formal evidence and evaluation framework.

In February 2018 the department released an IAS evaluation framework document, describing high level principles for how evaluations of IAS programs should be conducted, and outlining future capacity-building activities and broad governance arrangements.

Part 1 Pat Turner comments continued

It follows a string of bad audits starting with the audit of the IAS which found that the Department had not consulted properly in designing the IAS and rolling out a disastrous application process that led to many community controlled organisations losing their funding without reason.

Now the Government has decided to set  up a new executive agency, inside the Prime Minister’s portfolio but outside the Department of the Prime Minister and Cabinet to manage Indigenous Affairs.

It is good that a separate agency  for Indigenous Affairs is being re-established as it is one of the most important functions of the Commonwealth.

Aboriginal people and Torres Strait Islanders never asked or supported Indigenous Affairs being moved into the department of the Prime Minister and it is clear it has not done a good job on the IAS.

Whether setting up a new agency gets better outcomes remains to be seen.

Many say that the very disruptive shift of Indigenous Affairs into the Department of the Prime Minister and Cabinet has resulted in Indigenous Affairs being hollowed out and a loss of nearly all the capacity that it had before.

In the meantime, we are pleased that the Prime Minister has agreed to a new COAG  Partnership Agreement on Closing the Gap which includes agreement to an Indigenous led evaluation  of Closing the Gap progress after 3 years.

We think that bringing the representatives of Aboriginal and Torres Strait Islander peoples into the equation, and allowing them to share decision making about Government policy, programs and evaluation will improve outcomes.

It will allow us to hold agencies much more to account for what they are doing and not doing.

But we also have to commit to building up the community controlled organisations of Aboriginal and Torres Strait peoples to manage programs and deliver services to our people.

That is key to closing the gap and there are some signs that this is understood by the Coalition Government which committed in its election policy to increasing the Aborginal service sector.

That must go to giving them the responsibility for delivering programs and funding instead of public servants.

This audit shows that it is time for a radical shift away from governments and public servants to Aboriginal led delivery through their own community controlled organisations.

They will take responsibility for outcomes in a way that the public servants do not.

 

NACCHO Aboriginal Health and #LowitjaConf2019 Speech  : Donnella Mills Acting Chair NACCHO and John Paterson CEO AMSANT presents the Coalition of ACCO Peaks on #ClosingtheGap

 

We have started the task of determining an Aboriginal and Torres Strait Islander position on Closing the Gap. We know that Closing the Gap needs to be more than a set of targets. What we need is a radical shift to the way governments work with Aboriginal and Torres Strait Islander peoples at all levels of policy design and implementation. We also want to place Aboriginal Community Controlled Services at the heart of delivering programs and services to our people.”

Donnella Mills, the Acting Chair of the National Aboriginal Community Controlled Health Organisation or NACCHO, and John Paterson, the Chief Executive Officer of the Aboriginal Medical Services Alliance Northern Territory, an affiliate member of NACCHO, and convener of the Aboriginal Peak Organisations Northern Territory.

I wish to acknowledge the traditional custodians of the land we are meeting on. I wish to acknowledge and respect their continuing culture and the contribution they make to the life of this city and this region.

I would also like to acknowledge and welcome other Aboriginal and Torres Strait Islander people who may be attending today’s session and acknowledge their lands and culture.

We thank the Lowitja Institute for bringing us together again to think, speak and be First Nations solutions for global change, and for giving us the opportunity to speak with you today about the work of Aboriginal and Torres Strait Islander peak organisations across Australia on Closing the Gap.

Aboriginal and Torres Strait Islander peoples have historically been excluded from decision-making on the policies and programs that directly affect them and the communities in which they live. This is despite evidence which demonstrates that the only way to improve our people’s health and wellbeing is with their full participation in the design and delivery of services that impact on us. And despite our collective repeated calls over many years for full participation in decisions that impact on our lives.

Today we want to share with you how a group of Aboriginal community controlled organisations have exercised political agency by leading the way, challenging the possibilities and imagining a future of shared decision-making with governments on policies and programs that impact on our people and our communities.

You may remember that in 2007, the Council of Australian Governments (COAG), comprising leaders of federal, state and territory, and local governments, committed to ‘closing the gap’ in life expectancy between Aboriginal and Torres Strait Islander and other Australians. They also committed to a range of targets to end the disparity between Aboriginal and Torres Strait Islander peoples and other Australians in areas like infant mortality, employment and education.

This was the first time that Australian Governments had come together in a unified way to address the disadvantage experienced by too many Aboriginal and Torres Strait Islander peoples. The Commonwealth Government at the time also made an unprecedented investment in programs and services to ‘close the gap’.

Despite this unprecedented coming together of Australian Governments and investment, Aboriginal people were not formally involved in Closing the Gap, it was not agreed by us and it was a policy of governments and not for our people.

Many Aboriginal and Torres Strait Islander people felt that Closing the Gap presented the issue of our disadvantage as a technical problem built around non-Indigenous markers of poverty. This only served to hide the extent to which Aboriginal and Torres Strait Islander peoples’ disadvantage is a political problem requiring deep structural reforms.

Closing the Gap did not address the biggest gap that we face: the gulf between the political autonomy and economic resources of Aboriginal and Torres Strait Islander peoples and non-Indigenous people.

The policies and programs that then followed whilst making some difference to our peoples lives did not achieve their potential. Now ten years later we have not made the progress against the closing the gap targets that had been hoped.

In 2017 the Commonwealth Government embarked on a ‘refresh’ of the Closing the Gap framework and undertook a series of consultations. The consultations were inadequate and superficial. There was no independent report prepared on their outcomes. The lack of transparency and accountability surrounding these consultations were very disappointing, but not surprising.

As the ‘refreshed’ Closing the Gap strategy was being prepared for sign off by the Australian Governments, our dismay and disappointment galvanised a small group of community controlled organisations to come together to write to the Prime Minister, Premiers and Chief Ministers asking that it not be agreed.

We weren’t going away, and there were three important messages that we wanted governments to hear. These were:

  1. When Aboriginal and Torres Strait Islander peoples are included and have a real say in the design and delivery of services that impact on them, the outcomes are far better;
  2. Aboriginal and Torres Strait Islander peoples need to be at the centre of Closing the Gap policy: the gap won’t close without our full involvement; and
  3. the Council of Australian Governments cannot expect us to take responsibility and work constructively with them to improve outcomes if we are excluded from the decision making.

By staying strong and consistent in our messaging, our voices could not be ignored. In late October 2018, we were invited to meet with the Prime Minister, who acknowledged that the current targets were ‘government targets’ not ‘shared targets’, and that for Closing the Gap to be realised Aboriginal and Torres Strait Islander people had to be able to take formal responsibility for the outcomes through shared decision making.

On 12 December 2018, Australian Governments publicly committed to developing a genuine, formal partnership between the Commonwealth, state and territory governments and Indigenous Australians through their representatives on Closing the Gap and that through this partnership a new Closing the Gap policy would be agreed.

The initial fourteen organisations then became almost forty, as we brought together Aboriginal and Torres Strait Islander Peaks bodies across the country to form a formal Coalition to negotiate a new Closing the Gap framework with Australian Governments. We include both national and state and territory based Aboriginal and Torres Strait Islander Peaks representing a diverse range of services and matter that are important to us as Aboriginal and Torres Strait Islander peoples and to Closing the Gap.

As a first step and through our initiative, we negotiated and agreed a formal Partnership Agreement between the Council of Australian Governments and the Coalition of Aboriginal and Torres Strait Islander peak organisations which came into effect in March 2019.

The Partnership Agreement sets out that the Coalition of Peaks will have shared decision making on developing, implementing and monitoring and reviewing Closing the Gap for the next ten years. This is an historic achievement.

It is the first time that Aboriginal and Torres Strait Islander Peaks have come together in this way, to work collectively and as full partners with Australian Governments. Its is also the first time that there has been formal decision making with Aboriginal and Torres Strait Islander peoples and Australian Governments in this way.

A key commitment of the Partnership is the creation of the new Joint Council on Closing the Gap. The inaugural meeting of COAG’s Joint Council on Closing the Gap took place on 27 March. Noting that it is the first Council established by COAG that has representatives from outside government, it marked a historic step forward in the working relationship between Aboriginal and Torres Strait Islander peoples and governments.

It is not an easy path that we are on and there are many challenges.

The Coalition of Peaks are strengthening their own governance and it is not always easy coming together by teleconferences to work through our positions as we navigate our distances and the pace in which we need to work to stay in front of Australian Governments with their many resources.

We are committed to being transparent and accountable to each other through consensus-based decision-making. This has helped us build trust in each other, in our agreed processes of negotiation and representation, and has made us a strong and effective force to be reckoned with.

Australian Governments are also slow to change, and despite agreeing to the formal partnership with us, we are yet to see them fully embrace what it means to have us at the table and respond to our propositions.

We have started the task of determining an Aboriginal and Torres Strait Islander position on Closing the Gap. We know that Closing the Gap needs to be more than a set of targets. What we need is a radical shift to the way governments work with Aboriginal and Torres Strait Islander peoples at all levels of policy design and implementation. We also want to place Aboriginal Community Controlled Services at the heart of delivering programs and services to our people.

The Coalition of Peaks have also agreed with Australian Governments that they will lead consultations with Aboriginal and Torres Strait Islander organisations and communities across Australia on a new Closing the Gap framework later this year. This will be the first time that Aboriginal and Torres Strait Islander peak bodies will lead consultations with our own peoples on government policy.

Whilst the road is challenging, by presenting governments with alternative model for engaging with us, an historic new model of power sharing has been forged.

In conclusion, I’d like to share with you some of the key learnings of partnering for success and keeping governments accountable to community health priorities.

Throughout our negotiations with government, we learned the importance of staying strong and presenting a unified voice. Our membership may be large and reflective of very diverse organisations. But this diversity is also a strength, as long as we are willing to stay true to our common.

 

NACCHO Aboriginal #MentalHealth #SuicidePrevention @NMHC Communique : @GregHuntMP roundtable meeting to review investment to date in mental health and suicide prevention : #TimeToFixMentalHealth #TomCalma @AUMentalHealth @FrankGQuinlan @PatMcGorry @amapresident @headspace_aus

” Minister for Health, Greg Hunt, hosted a Government-led roundtable this week to review investment to date in mental health and suicide prevention, to hear from the sector on current gaps and priorities, to understand what is and is not working, and to advise on the upcoming national forum on youth mental health and suicide prevention.

Minister Hunt and Prime Minister Scott Morrison are committed to working towards zero-suicide for all Australians, including our youth.

From the National Mental Health Commission 6 June 

( The Indigenous ) Suicide rates are an appalling national tragedy that is not only depriving too many of our young people of a full life, but is wreaking havoc among our families and communities.

As anyone who has experienced a friend or family member committing suicide will know, the effects are widespread and devastating and healing can be elusive for those left behind.

It is time that we draw a line under this tragic situation that is impacting so significantly on Aboriginal and Torres Strait Islander communities  “

Noting Professor Tom Calma AO was a participant in the meeting via telephone link and opened the meeting with a discussion on Indigenous suicide. 

See this quote and 140 Plus Aboriginal Health and Suicide Prevention articles published by NACCHO in last 7 Years 

Those in attendance welcomed the Government’s commitment, with a number noting that suicide prevention needs to be a priority across all age groups, especially those groups with the highest suicide rates.

The conversation covered a range of key issues, challenges and opportunities for reform and action. Particular discussion points included:

  • Social determinants of mental health: there is a fundamental need to focus on the social determinants of mental health for all Australians, noting and emphasising the range of factors that contribute to distress in young Australians. This is an important factor for all young people and communities, with particular reference to the factors impacting on Aboriginal and Torres Strait Islander children and youth.
  • The impact of trauma and disadvantage: conversation centred on the impacts of trauma and disadvantage and the importance of supporting, for example, young people in out-of-home care, those living in poverty and individuals who are in the justice system.
  • Support for children and families: in order to improve the lives of young Australians, there is a need to better support children and families in the early years. This includes support for neurodevelopmental disorders. In the same way headspace has been developed for young people, there was a suggestion that mental health services focused on children and families could show real benefits.  There is strong support for a focus on prevention
  • Support for Schools: a continued need was highlighted around the role of, and support for, schools, including primary schools and early learning centres. Schools are a critical component of a ‘whole of community’ approach in building supportive environments for children and young people.   It was suggested that for families who may not seek services but who were in need a way of ‘connecting’ may be through digital tools, to identify and support children and parents in those families.
  • Impact on youth: young people can be seriously impacted and influenced by the suicide death of other young people who are their friends, peers, family members or celebrities. More timely and sophisticated data and comprehensive local responses are needed to assist in the reduction of risk for further lives being lost following a suicide.
  • Data: The importance of being able to collect, analyse and provide accurate data was highlighted.  This data is significant across mental health services and particularly for suicide prevention, treatment and support services.
  • Service reform: there is a need for service reform to better respond to people with mental health concerns that are too complex to be managed by a GP at a primary health care level but not so acute as to require specialist tertiary mental health services. While there are some good programs and services to build upon, there is a lack of equity across all regions and access remains a key issue for those requiring psychological and other services. We also need to integrate mental health services with drug and alcohol services.
  • Workforce development: there is an urgent need to focus on training and supporting the diverse professionals working with those at risk of or with mental health issues – health and allied health staff, drug and alcohol workers, school counsellors, psychologists, peer workers and many others. The role of peer workers was recognised as being a critical one and this must be included in all workforce development strategies and initiatives.
  • Peer and carer support: many families and peers supporting those who are in suicidal distress and/or living with challenging mental health and drug and alcohol concerns needed immediate and quality support themselves as they are also at risk for mental ill-health. Families and friends are the largest non-clinical workforce providing care and support for Australians and there is an immediate need to provide better supports for them.
  • Regional and national leadership: while attendees were supportive of regional planning and action, it was suggested that stronger guidance at a national level was needed in order to ensure equity and quality of service responses across the country, with a recognition of the importance of the role of Primary Health Networks.  Further work is needed to ensure that the roles and responsibilities of all governments were clarified, together with accountability. The Fifth National Mental Health and Suicide Prevention Plan, and particularly the Suicide Prevention Implementation Plan, are key drivers for clearer accountability and integrated and coordinated responses.
  • Funding models: there was discussion on how best to fund services across the range of needs, including the current review of Medicare and the role of private health insurance.

A collective agreement and strong commitment was reached that a collaborative approach is vital to achieving improved mental health outcomes for all Australians, including children and youth.

There is significant support for a 2030 Vision for mental health and suicide prevention, to be led by the Commission and to ensure that the systematic changes required to best service the community can be identified, prioritised and achieved. This Vision would be look beyond the current plans and strategies.

Attendees acknowledged the commitment to mental health and quality program responses in recent years, together with the increased funding in the 2019/20 federal budget for expanded youth and adult mental health services in the community, together with initiatives to strengthen the collection of critical data around suicide and mentally healthy workplaces.  They also noted the current enquiries being undertaken by the Productivity Commission and the Victorian Royal Commission.  However, there needs to be an increased focus on longer term systems reform.  The Commission has been tasked with taking a leading role in this and will work closely with the sector to develop a reform pathway.

Participants embraced the importance of hope, recognising not only the significant investment to date but that youth mental health services in Australia have been copied by other nations.  There is strong support for improvements in mental health and suicide prevention across all levels of government and community.

As outlined by the Minister for Health, this was an opportunity to review the current status and continue this important discussion.  It is one of many conversations that will continue with the sector at organisational, group and individual levels.

The Commission will provide updates in sector engagement and discussions as they occur.

Lucy Brogden

Chair, National Mental Health Commission

Christine Morgan

CEO, National Mental Health Commission

 

NACCHO Aboriginal Health Promotion #ClosingTheGap and the #AHW Workforce : Download Research : How can we make space for Aboriginal and Torres Strait Islander community health workers in health promotion ?

“Too many white Australians think the door opens to opportunity from the outside, when you’ve got to be let into the door from the inside’.

Noel Pearson, Aboriginal activist, The Australian, 7 May 2015. (Bita, 2015)

 “ The ‘AHW’ role was first established in the Northern Territory and recognized by the Western health system in the 1950s (Topp et al., 2018).

It was formally incorporated into Australia’s national health system in 2008 (National Aboriginal and Torres Strait Islander Health Worker Association, 2016).

Individuals can become an AHW if they are pursuing or hold a Certificate III, IV or higher degree diploma in, for example, primary health care, public health or a specific area of practice such as mental health.

In the mainstream health care sector, AHWs serve in ‘health worker’ or ‘outreach’ roles, providing clinical services, community outreach and education to improve access, health outcomes and the cultural appropriateness of services (McDermott et al., 2015).

Some also have specified AHW positions in prevention and health promotion. But the delivery of Indigenous health promotion in Australia is best exemplified by the work of Aboriginal Community Controlled Health Organisations (ACCHOs).

ACCHOs are primary health care services operated by the local Aboriginal community that they serve (NACCHO, 2018).

Their approach to providing comprehensive and culturally competent services draws on the cultural knowledge, beliefs and practices of their communities, and aligns with the Ottawa Charter principles aimed at enabling communities to take control of their own health care needs (WHO, 1986).

 AHW positions within ACCHOs may, therefore, reflect the full range of role types outlined in Table 1.

It is primarily within ACCHO-developed community programmes that other types of CHW roles and models for their delivery have been implemented, for example, lay-leader or peer-to-peer education models (McPhail-Bell et al., 2017).

 Yet many of these initiatives are only documented in programme reports within the ‘grey literature’ with much of the work undertaken in Aboriginal health promotion remaining under-researched and underreported ” 

Read over 290 Aboriginal Health Promotion articles published by NACCHO over the past 7 years 

Read this full research paper online HERE

Article Contents

Download the PDF Copy

Aboriginal Health Workers and Promotion

Photo top banner

 ” Mallee District Aboriginal Services health promotion co-ordinator Emma Geyer and MDAS regional tackling Indigenous smoking worker Nathan Yates are on the lookout for a local “deadly hero”. Picture: Louise Barker

MALLEE District Aboriginal Services (MDAS) is on the hunt for a “deadly hero” who will be the face of a campaign to encourage more Indigenous residents to visit the service for regular health check-ups.

MDAS regional tackling indigenous smoking worker Nathan Yates said the overarching aim of the campaign was to boost the health of the local indigenous population.

“Deadly Choices in our terminology is about making a good choice so for this it’s about making really healthy lifestyle choices because it’s all about trying to bridge the gap between life expectancy of indigenous and non-indigenous people,” Mr Yates said

Picture and story originally published Here

Abstract

Despite a clear need, ‘closing the gap’ in health disparities for Aboriginal and Torres Strait Islander communities (hereafter, respectfully referred to as Aboriginal) continues to be challenging for western health care systems.

Globally, community health workers (CHWs) have proven effective in empowering communities and improving culturally appropriate health services.

The global literature on CHWs reflects a lack of differentiation between the types of roles these workers carry out.

This in turn impedes evidence syntheses informing how different roles contribute to improving health outcomes.

Indigenous CHW roles in Australia are largely operationalized by Aboriginal Health Workers (AHWs)—a role situated primarily within the clinical health system.

In this commentary, we consider whether the focus on creating professional AHW roles, although important, has taken attention away from the benefits of other types of CHW roles particularly in community-based health promotion.

We draw on the global literature to illustrate the need for an Aboriginal CHW role in health promotion; one that is distinct from, but complementary to, that of AHWs in clinical settings.

We provide examples of barriers encountered in developing such a role based on our experiences of employing Aboriginal health promoters to deliver evidence-based programmes in rural and remote communities.

We aim to draw attention to the systemic and institutional barriers that persist in denying innovative employment and engagement opportunities for Aboriginal people in health.

Kirstin Kulka prepares fruit and salad wraps for children at Coen.

Selected extracts

Aboriginal and Torres Strait Islander cultures in Australia are acknowledged to be the oldest living cultures in the world (Australian Government, 2017a), maintaining thriving and diverse communities for over more than 60 000 years, and implementing land management practices that are exemplary in their sustainability and productivity (Pascoe, 2018).

Hereafter, we use the term Aboriginal to describe the many different clans that make up this diverse peoples, including those from the Torres Strait. Following the British invasion and subsequent colonization of Australia, Aboriginal people across the nation suffered a sudden and complete rupture to all aspects of life including kinship, language, spirituality and culture.

The resulting health disparities experienced by Aboriginal people since colonization, and the inequalities that contribute to them, are well documented (AIHW, 2015). Despite the preponderance of evidence as to these inequities there has been only marginal progress in implementing effective strategies to improve health (McCalman et al., 2016).

Not enough research has focused on how Aboriginal knowledge is reflected in health programmes and services, and there are continued calls for Aboriginal people to be leaders of health-promoting endeavours (National Congress of Australia’s First People, 2016; NHMRC, 2018).

However, combatting systemic racism and reorienting the institutions of the dominant non-Aboriginal culture—i.e. government, health care, education—to include Aboriginal people in decision making and to enable their leadership is proving to be an ongoing challenge in both global and local health settings (George et al., 2015). The opening quote of this paper draws attention to this often-contested issue.

Community ownership of decision making for health has long been recognized as key to addressing the social determinants of health that underlie health disparities (WHO, 1978). Internationally, community health workers (CHWs) enable community involvement in health systems—particularly among minority communities—and contribute to positive health outcomes in a variety of settings (Goris et al., 2013; Kim et al., 2016).

In the USA, for example, the Indian Health Service has funded American Indian ‘Community Health Representatives’ since 1968 (Satterfield et al., 2002).

These health workers provide links between communities and health services, and build trust, relationships and culturally appropriate education and care. Maori CHWs play a similar bridging role in New Zealand by linking community members with health interventions and clinical services, providing health education and also working alongside traditional healers and supporting tribal development (Boulton et al., 2009).

In Australia, CHWs are largely operationalized as Aboriginal Health Workers (AHWs), although there is considerable variation in the kinds of roles they perform. The result is that some AHWs experience inflated role expectations that can contribute to unmanageable workloads and stress, reduced job satisfaction, and barriers to integration with other members of the health workforce (Bailie et al., 2013; Schmidt et al., 2016).

Yet variations in role definition for CHWs, and the associated problems, are not unique to Australia (Topp et al., 2018) and are well documented in the broader global CHW literature (Olaniran et al., 2017; Taylor et al., 2017). This variation is problematic as it impedes research into how CHWs influence health outcomes.

In this paper, we explore the lack of differentiation in the global literature between the types of CHW roles both internationally and within the Australian context. Differentiating the various types of CHW roles has enabled us to articulate the need for a specific community health promotion role, one that is distinct from, but complementary to, that of AHWs in clinical settings.

The impetus for writing this paper came from the experiences of two of the authors (NT and JG), an Aboriginal and a non-Aboriginal woman, who have worked in partnership for more than 15 years delivering and evaluating health promotion programmes in Australia.

The challenges we experienced in creating Aboriginal CHW-type positions within two mainstream health promotion programmes caused us to question whether the focus on AHW roles had created unintended barriers to involving Aboriginal people in other opportunities to address health.

By detailing our experience in creating community-based, Aboriginal CHW positions in health promotion, we aim to draw attention to the systemic and institutional barriers that impede expanding employment opportunities for Aboriginal people wanting to work in health.

The National Tackling Indigenous Smoking Workers Workshop was held from Tuesday 2 April to Thursday 4 April 2019 in Alice Springs. This workshop was one of the largest gatherings of TIS workers, partners, experts and supporters of the TIS program.

CHWs AND AHWs

Broadly, CHWs are individuals who may or may not be paid, who work towards improving health in their assigned communities and who often share some of the qualities of the people they serve. These may include similar cultural, linguistic or demographic characteristics; health conditions or needs; shared experiences or simply living in the same area.

However, the degree to which CHWs demographic or experiential profiles ‘match’ the target population also varies. And while most bring cultural and community knowledge to the role, many CHWs have little or no training in Western medicine or in navigating its health systems prior to becoming CHWs (Olaniran et al., 2017).

There is less agreement on the specifics of the CHW role including what they do, how they are trained, how these parameters link to outcomes, and even the titles they are given. One review evidenced 120 terms used to describe CHW roles including variants of ‘lay health educators’, ‘community health representatives’, ‘peer advisors’ and ‘multicultural health workers’ (Taylor et al., 2017).

Syntheses of literature on CHWs illustrate that the tasks they undertake are highly varied but often inadequately or inconsistently defined (Jaskiewicz and Tulenko, 2012; Kim et al., 2016). These issues, coupled with a general lack of contextual information about the role of CHWs, make it difficult to determine patterns or predictors of success.

This lack of clarity is documented as an ongoing barrier to the sustainability of CHW programmes, sometimes causing negative impacts on the workers themselves including burnout due a lack of appropriate training and mentoring support (Jaskiewicz and Tulenko, 2012; Schmidt et al., 2016). One review concluded that ‘the [CHW] role can be doomed by overly high expectations, lack of clear focus, and lack of documentation’ [(Swider, 2002), p. 19].

Previous research has classified CHW roles into typologies of main tasks and activities performed (Olaniran et al., 2017; Taylor et al., 2017). These include providing: (i) social support, (ii) clinical care, (iii) service development and linkages, (iv) health education and promotion, (v) community development, (vi) data collection and research and (vii) activism.

In practice, CHW activities overlap substantially, and tasks regularly extend across categories—both formally and informally (Jaskiewicz and Tulenko, 2012). In Table 1, we present different CHW role types alongside the theoretical models that underpin each.

Linking roles to theory can help differentiate and specify the mechanisms by which CHWs are meant to influence health through the core tasks they perform, and the specific skills related to each task.