Why is “wilful ignorance” holding back progress in Indigenous health?
Judith Dwyer, Professor of Health Care Management at Flinders University, offers some suggestions in the article below, which is republished from The Health Advocate, the official magazine of the Australian Healthcare and Hospitals Association.
Wilful ignorance: method of choice for implementation failure
Judith Dwyer writes:
Some smart philosophers have suggested that we could learn a lot about why things don’t work from studying the ways we conspire not to know about them.
Wilful ignorance, for example, underlies the long-standing practice (changing at last) of excluding women from clinical trials of new drugs and then treating them with the drugs anyway.
The practice allowed the thalidomide tragedy to happen, so it really does matter.
We’ve had an outbreak of such ignorance in recent months. You might recall Joe Hockey, in his role as Shadow Treasurer, saying that the government is wasting $100 million ‘duplicating’ anti-smoking strategies for Aboriginal communities. (And in the West Australian, newspaper of record, the website headline became ‘billions burned in quit campaign’).
I’m sure Mr Hockey now knows that tailored programs are used when particular population groups are not effectively served by mainstream approaches.
This is an important example, because if smoking rates among Aboriginal people were reduced to general population levels, that would wipe out one sixth (17 percent) of the health gap.
But success would not show up in cancer rates or mortality statistics before the next election, so the argument will probably remain unresolved in political and media circles.
Mr Hockey’s remarks were made in response to the publication of a Cabinet review of funding for Aboriginal programs, which was reported in the media as a story of ‘wasted billions’.
But the story is more interesting than that and there are two aspects that are important for the health system.
First, health programs were not found to be wasteful and OATSIH ’s achievements as an effective funder were recognised.
Of 42 health funding programs examined, it was recommended that 40 (95 percent) be either maintained as is or consolidated with related programs in the interests of coherence and streamlining.
Only two programs were recommended for full or partial termination, along with suggestions that three programs be transferred to states and territories in the longer term.
Journalists could perhaps be excused for missing this bit, as it starts on page 412.
The second important aspect is the failure to recommend solutions that seriously address the problems.
Up front in the report is the headline material. ‘Past approaches have clearly failed, new approaches are needed’; $3.5 billion spent annually with ‘dismally poor returns’; we need ‘effective implementation and delivery’ rather than new policy development.
Though not in the headlines, the authors argue for holding mainstream service providers accountable; and they call for engagement with Indigenous communities, whole-of-government approaches, local integration, coordination with states and territories etc.
Most of this makes sense on the face of it. The report as a whole is thoughtful about the problems and will be an important source of information for years to come.
But careful reading leaves a sense of wishful thinking, if not wilful ignorance, when it comes to solutions.
The whole-of-government idea is a prime case in point. Governments structure their business into ‘silos’ for (mainly) good reasons and then allocate budgets and accountabilities to those silos.
Attempts to address the resulting fragmentation of effort generally come down to exhorting relatively junior officers in the provinces to work with their peers in other departments to perform courageous acts of local integration and responsiveness, in spite of a set of rigidly siloed budget and portfolio accountabilities.
Heroic effort does occasionally produce amazing results, but on average it hardly ever works and never lasts.
The even more important issue is engagement with Indigenous communities and organisations.
Every such government-commissioned report I’ve ever read highlights the lack of active real engagement with Aboriginal communities as part of the problem.
But the recommendations for change effectively amount to business as usual, with an occasional nod in the direction of improving the skills of public servants in ‘doing’ engagement and ‘delivering’ solutions.
I suggest that it takes an effort of wilful ignorance to believe that business as usual approaches, even if well structured, endowed with clear program logic and generous time for ‘consultation’, are going to crack it.
If we can correctly describe the problems, it only requires logic to figure out that we can’t solve them by continuing to do the things that we know don’t work.
Maybe policy makers need to examine the reasons why logical solutions are ignored.
Real engagement, for example, will only happen if Aboriginal people and governments work together to design approaches to engagement, and to programs, that suit both sides.
It might be difficult, but the overwhelming evidence shows it is essential.
• This article first appeared in The Health Advocate: Issue 11 October 2011.