At the recent Congress Lowitja in Melbourne, there was quite a bit of discussion about the adverse impact of government managerialism on the capacity of Aboriginal and Torres Strait Islander community health organisations.
Professor Ian Anderson from the University of Melbourne said that a mutual lack of trust between governments and Indigenous community organisations was leading to perverse outcomes, and suggested the need to build trust-based relationships.
Dr Mark Wenitong, from the National Aboriginal Community Controlled Health Organisation (NACCHO) and a former president of the Australian Indigenous Doctors Association, also raised concerns about the health impacts of public sector managerialism.
He suggested that discussions about Indigenous health should look beyond individual risk factors and the social determinants of health to the “political determinants of primary healthcare”.
In the article below, Professor Judith Dwyer from Flinders University and the Lowitja Institute (who chaired the conference session on “courageous questions”), investigates what progress has been made since The overburden report: Contracting for Indigenous health services of 2009.
While there has been some streamlining of the “reporting jungle”, she says there is still plenty of room for improvement.
Funding policy for Aboriginal Health Services: two steps forward…
Judith Dwyer writes:
You’re unlikely to read this in the mainstream media, but there is some good news about Aboriginal and Torres Strait Islander health – for example, the goal to halve the gap in infant and child mortality (0-5 years) by 2018 is on track (according to the latest Health Performance Framework report).
This and other signs of progress have many causes, but one of them is better funding for and attention to primary health care for Aboriginal and Torres Strait Islander people, a good proportion of it provided by Aboriginal community-controlled health services (ACCHSs).
Part of that story lies in back offices in health departments, where progress is being made on making the funding and reporting arrangements for the ACCHSs more stable and less onerous.
While it is routine that governments impose strict conditions in their funding contracts with the non-government sector, there is evidence that the ACCHSs experience the most complex web of funding rules and data requirements (sometimes overlapping and contradictory) when compared to other primary health care providers.
With colleagues, I have researched the relationship between government funders and ACCHSs for many years, and we have documented the extent of the problem.
None of the funders planned to make it so complicated, but the fact that ACCHSs we surveyed were funded on average from about 22 different programs and sources, each with its own reporting and accounting requirements, made for high costs in administration, and wear and tear on working relationships.
When the Overburden Report was released in 2009, the Office for Aboriginal and Torres Strait Islander Health (OATSIH) was already moving towards improvement, and our work was promptly acknowledged as an impetus for a major effort at streamlining that commenced in 2010.
However, partly because OATSIH is still only one of many funders, but for some other important reasons as well, it seems that this change hasn’t made a big difference on the ground. The reporting jungle has been thinned a bit, and there has been some shift towards more stable funding, but some underlying problems seem to be less amenable to change.
Why is it so?
It seems to me that one of the underlying reasons is concern about governance in Aboriginal organisations. I have never seen any hard evidence comparing the frequency or severity of governance problems in Aboriginal and mainstream organisations, but governments have a strong sense that there is a problem, and many community organisations and leaders acknowledge that there is room for improvement and are working actively to strengthen governance in the sector.
Some of the ‘red tape’ requirements of funders and regulators can be seen as an attempt to enforce good governance practice from the outside.
For example, one major funder specifies the risk management methods and tools the organisations must use as a condition of funding. At one level, this makes sense – a good risk management framework is helpful.
But good governance is a necessary foundation for accountability – it doesn’t really work the other way around. That is, you can’t create good governance by applying red tape (although the regulations and incentives that are part of the organisation’s environment matter).
Of course, accountability is more than what is measured with red tape. Aboriginal health organisations need to be accountable to their communities as well as to the broader tax-paying public.
While those two ‘accountability-holders’ may require many of the same things, they are not identical in their priorities or in how they judge success.
The Aboriginal health sector, OATSIH and the relevant Minister (Warren Snowdon) are working actively now on both community and corporate governance, through a working party and a major national project under the auspices of the National Aboriginal Community Controlled Health Organisation.
This important work needs to continue, and in the meantime, the real question for government funders is how could their policies and practices enhance rather than constrain good governance in this context? Two things are clear.
Firstly, as Professor Mick Dodson’s work has shown, there is no fundamental conflict at the level of principle between good corporate governance and good Aboriginal community governance. So the task of finding ways to make the two work together is feasible. Secondly, the solution will not be something that governments can impose.
Governments hold the responsibility for providing a strong regulatory environment (and in health services they do), and for funding essential health care.
But in the case of good governance, there is no choice other than to work with and support Aboriginal community organisations.
• Professor Dwyer and colleagues were funded by the Lowitja Institute and its predecessor the Cooperative Research Centre for Aboriginal Health, and she spoke about the impact of the research at the Lowitja Institute’s biennial congress held at the MCG earlier this month.