The Aboriginal Community Controlled Health Organisations (ACCHO) sector has a wealth of expertise in addressing the social and cultural determinants of health, responsive service development, and providing culturally safe care.
These are some of the findings from the work of The Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE), a collaborative enterprise between the National Aboriginal Community Controlled Health Organisation (NACCHO), Wardliparingga Aboriginal Research Unit, at the South Australian Health and Medical Research Institute (SAHMRI), and the University of Adelaide’s School of Public Health.
Below, Professor Alex Brown, a Chief Investigator, and Eddie Mulholland, CEO of Miwatj Health Aboriginal Corporation in East Arnhem and long-term member of the CREATE Leadership Group, explain why the wider health sector needs to gain a deeper understanding of the contributions of the ACCHO sector.
Alex Brown and Eddie Mulholland write:
The Closing the Gap Framework is getting a significant overhaul. It is the most significant change since the Rudd Government introduced the policy in 2008. The most substantial difference to the Framework has been claimed to be the power-sharing arrangement between the Council of Australian Governments (now replaced by the National Federation Reform Council) and the Coalition of Peaks.
The Coalition of Peaks, which is a representative body of around fifty Aboriginal and Torres Strait Islander community controlled organisations, suggests that engagement in the redevelopment will ensure Indigenous perspectives are embedded into the Framework and any subsequent strategies.
If realised, the importance of this proposed power-sharing arrangement extends beyond Closing the Gap; it will represent a critical moment for genuine engagement between Australian governments and Aboriginal and Torres Strait Islander people and Aboriginal Community Controlled Health Organisations (ACCHOs).
Yet much is required to ensure respectful and equivalent partnership.
There is a clear lack of understanding of the ACCHO sector, how it operates and why they are successful within the mainstream institutions of contemporary Australian society.
Significant history
ACCHOs have a long history in each state and territory in Australia. The first Aboriginal Community Controlled Health Organisation (ACCHO) was established in Redfern (Redfern Aboriginal Medical Service), New South Wales, in 1971.
Since then, over 140 independent ACCHOs operate across each state and territory, established by Aboriginal people to fill the unmet health, social and cultural needs within their communities.
Each of the 140-plus ACCHOs is run by and for Aboriginal and Torres Strait Islander people. The Board is drawn from its membership which consists of Aboriginal and Torres Strait Islander people from the community within which they provide services. As such, members are both the driver of and target for the service operations.
Despite this significant history and geographical spread, many people outside the ACCHO sector have very little understanding of why ACCHOs were established and the comprehensiveness and leadership that their primary healthcare model represents.
The lack of knowledge is despite the clear benefit and successes of ACCHOs and their state/territory peak bodies, and the national peak: National Aboriginal Community Controlled Health Organisation.
The “why” ACCHOs exist is evident to those who work in Aboriginal and Torres Strait Islander health: a history of racism in Australia which extended to the healthcare sector AND the need for culturally appropriate services to address the well-documented health disparity.
To increase understanding of ACCHOs, the Leadership Group of the Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE) determined to showcase the work of ACCHOs through a nationwide series of case studies.
CREATE is a National Health and Medical Research Council (NHMRC) funded research program dedicated to improving service delivery and health outcomes for Aboriginal and Torres Strait Islander peoples.
The CREATE research program consisted of systematic reviews of the evidence, capacity strengthening and knowledge translation activities alongside a nationwide series of case studies that served to highlight, celebrate, share and learn from leadership and success across the sector (Figure 1).
Figure 1 Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange research program
Key issues
The Leadership Group, whose members were from the ACCHO sector, identified several domains as focus areas for the research. These included health service delivery, governance, workforce, the social determinants of health, health promotion, aged care, funding, accreditation, continuous quality improvement and the role of national key performance indicators.
To ensure the findings are available to the ACCHO sector and well beyond, an online resource was developed: Aboriginal Community Controlled Health Organisations in practice: Sharing ways of working from the ACCHO sector. The resource showcases key findings drawn from ACCHO case studies, and is supported by systematic review evidence as appropriate, across the ten priority domains identified by the CREATE Leadership Group.
Ten key characteristics of ACCHO Comprehensive Primary Health Care Service Delivery are highlighted through this work.
Culture was found to be central to all ACCHO service delivery and related to nine other characteristics that included: self-determination and empowerment, community control and community participation, culturally competent and skilled workforce, holistic healthcare, flexible and responsive approaches to care, accessible health services, relationship building and advocacy, comprehensive health promotion and continuous quality improvement.
Three critical components of ACCHOs governance were identified: cultural, strategic and clinical governance. Cultural governance refers to the cultural guidance provided by Aboriginal and Torres Strait Islander community members, staff and Board of Directors to ensure the ACCHO follows cultural protocols and provides culturally-centred care.
Strategic governance refers to guidance and direction given to determine and achieve the long-term or overall aims and interests of the ACCHO. It comes from the Board of Directors who ensure the ACCHOs’ long-term strategic vision aligns with community priorities and who monitor the organisation’s financial management, risk management and legal responsibilities.
Clinical governance refers to the systematic monitoring and quality improvement processes undertaken by ACCHO workforce to promote safe and quality patient care in the delivery of ACCHO programs and services.
Workforce matters
Aboriginal and Torres Strait Islander workforce are critical to the foundational principles and operations of ACCHOs since they bring lived experience and community knowledge, community connection and engagement, and capacity across a range of professional disciplines and leadership roles.
The ACCHO workforce can be strengthened through targeted recruitment strategies, valuing and support, training and capacity building, and leadership pathways. ACCHOs face a range of challenges with growing their workforce, particularly concerning time, resources and sustainable funding.
It was clear throughout this work that ACCHOs do whatever is necessary to address the social determinants of health and meet the needs of their communities, recognising that health is a product of more than simply the absence of disease.
ACCHOs strive to create an accessible and culturally safe health service and employ a multidisciplinary workforce that walks side by side with clients to link them across sectors such as housing, employment, education, and family services.
They work to combat racism through cultural awareness training and mentoring and undertake extensive advocacy efforts to address inequitable features of the society we live in.
The work of ACCHOs to address the social determinants of health is enabled by community consultation and engagement, a highly skilled workforce, and respectful partnerships with external organisations.
In responding to community need, ACCHOs were seen to practise comprehensive health promotion across five action areas: primary healthcare designed by community, for community; providing and promoting culturally safe spaces; strengthening cultural pride and personal skills; strengthening, empowering and uniting communities; and building equitable public policy.
ACCHOs empower clients to manage their health with self-determination and provide culturally safe spaces where Aboriginal and Torres Strait Islander communities can access comprehensive primary healthcare.
They were seen to strive to strengthen and unite Aboriginal and Torres Strait Islander communities by providing a space where communities learn, grow, support, celebrate, heal and take action together.
Advocacy roles
ACCHOs also take a lead role in advocating for public policies that achieve equity for Aboriginal and Torres Strait Islander peoples, a role underappreciated within the policy setting landscape within Australia.
With Aboriginal and Torres Strait Islander people living longer lives, some ACCHOs directly provide aged care services. Key principles and values of aged care service delivery include connection with Elders and communities, respect for self-determination, culturally safe care, a focus on holistic wellbeing, tailored services, credibility and willingness to go the extra mile. This holistic approach is also consistent with the comprehensive primary healthcare model offered by ACCHOs.
While there are over 140 ACCHOs across the country, many Aboriginal and Torres Strait Islander people are still unable to access a community controlled service. Therefore, understanding approaches to funding of newly established ACCHOs is essential to growing the sector.
Newly established ACCHOs develop financial management strategies to maximise income and ensure operational expenditure is strategic in order to secure the financial position of the organisation into the future. Practical cost-saving strategies can include sharing IT expenses with other services and subleasing office spaces. Funding constraints facing newly emerging services can, however, limit the ability of services to support their communities through providing comprehensive care and addressing the social determinants of health.
ACCHOs, like other primary healthcare services, are required to undertake accreditation. Accreditation can be managed by a small group or large team of ACCHO staff, depending on the size of the service, though all staff contribute to achieving accreditation.
Representatives from external accrediting bodies visit the ACCHO to meet with staff and collect information. Accreditation benefits the ACCHO since it provides community, funders and partner organisations with the assurance that the ACCHO has systems in place to provide a quality and professional service.
Questions remain as to how other services, such as mainstream primary care providers, are assessed in relation to the way in which they provide care to Indigenous Australians.
A unique sector
The ACCHO sector also has a strong history of continuous quality improvement (CQI). The drivers of CQI include the inherited responsibility of ACCHOs to tailor services to the needs of local communities and external drivers such as accreditation, national Key Performance Indicators (nKPIs) and funding requirements.
Common enablers of CQI include community connection and engagement, effective corporate systems, a corporate culture that promotes CQI as an everyday whole-of-organisation process, staff commitment and participation in CQI, support from ACCHO state/territory affiliates, effective communication across the ACCHO, designated CQI Coordinators and resourcing.
The nKPIs were introduced by the Commonwealth Department of Health as part of the Closing the Gap Framework. The development and implementation of the nKPIs have been challenging for the ACCHO sector. Effective governance, internal communication and staff capacity enable ACCHOs to utilise relevant nKPIs in continuous quality improvement activities alongside other data. Considerable improvements could be made to the nKPIs to make them more useful for the ACCHO sector.
One of the tangible outcomes from the project findings were the number of policy level recommendations developed with the CREATE Leadership Group and case study sites. These will be used to advance advocacy efforts for the sector.
The findings from the CREATE case studies highlight the uniqueness of the ACCHO sector and demonstrate that how the model operates and needs to be better understood within healthcare policy settings to appreciate their value.
There is much to learn from the collective ACCHO experience that can inform and deliver benefits well beyond the Aboriginal and Torres Strait Islander community.
A greater appreciation of what ACCHOs have to offer will likely lead to genuine partnerships between Indigenous Australia and those who continue to manage our destiny. This isn’t simply important for us, but stands as a critical example to guide better health outcomes for all Australians.
Pictured below are the authors: (L) Professor Alex Brown is a Chief Investigator with The Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange, and (R) Eddie Mulholland, CEO of Miwatj Health Aboriginal Corporation in East Arnhem, is a long-term member of the CREATE Leadership Group
** The cover artwork in the feature image was collaboratively created by Alex Brown and Ella Brown and applied in the document design by Nicole Scriva.**
