Aboriginal Community Controlled Health Services in a Challenging Policy Context

Fighting for health equity: Aboriginal Community Controlled Health Services in a challenging policy context

David Coombs

A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy

Indigenous Studies

Nura Gili Indigenous Programs

UNSW Sydney

September 2019

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Surname/Family Name : Coombs Given Name/s : David George Bennett Abbreviation for degree as give in the University calendar : Doctor of Philosophy (PhD) Faculty : Arts and Social Sciences School : Nura Gili Indigenous Programs Fighting for health equity: Aboriginal Community Controlled Health Thesis Title : Services in a challenging policy context

Abstract 350 words maximum: (PLEASE TYPE) This thesis explores the critically important work of Aboriginal Community Controlled Health Services (ACCHS) in New South Wales, Australia. It works from the premise that ACCHS enable Aboriginal self-determination in health. It evaluates the policies and practices of government agencies and non-Indigenous health actors, assessing the degree to which they facilitate or constrain ACCHS in this task. A critical evaluation of the policy context in which ACCHS operate is provided, analysing the political intent and community impact of recent reforms. Making use of political economic theories of settler-colonial domination and neoliberal governance, and policy theories that explain how and why governments deploy symbols and moral language for political purposes, an original explanation of the neo-paternalist market- fundamentalist turn in Indigenous affairs policymaking is presented. Drawing on new evidence gathered through interviews with ACCHS CEOs and managers, the thesis presents an account of ACCHS’ unique role in the health system. It offers a nuanced explanation of First Nations peoples’ health inequities, constructed from interviewees’ theoretical insights and relevant scholarly literature. A key research output is the detailed description and modelling of the ACCHS holistic approach to Aboriginal healthcare. This expands our understanding of what ACCHS do, how they do it, and why it is effective. This examination of the ACCHS model of care is of relevance to all healthcare providers in Australia, as it provides practical examples of how to operationalise the social elements of primary healthcare, such as community participation in service design, and the development and delivery of culturally safe health promotion and education activities. This body of work also identifies and critically analyses the key policy challenges that impede the effective and efficient delivery of services by ACCHS in New South Wales. Key challenges identified include funding shortfalls and restrictions, and severe power imbalances between government actors and “mainstream” health actors, on one side, and ACCHS on the other. An extensive list of practicable policy solutions has been developed, making this thesis a valuable and viable source of guidance for policymakers and professionals working in Indigenous health service delivery.

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Abstract This thesis explores the critically important work of Aboriginal Community Controlled Health Services (ACCHS) in New South Wales, Australia. It works from the premise that ACCHS enable Indigenous self-determination in health. It evaluates the policies and practices of government agencies and non- Indigenous health actors, assessing the degree to which they facilitate or constrain self- determination. A critical evaluation of the policy context in which ACCHS operate is provided, analysing the political intent and community impact of recent reforms. Making use of political economic theories of settler-colonial domination and neoliberal governance, and policy theories that explain how and why governments deploy symbols and moral language for political purposes, an explanation of the neo-paternalist market-fundamentalist turn in Indigenous Affairs policymaking is presented.

Drawing on new evidence gathered through interviews with ACCHS CEOs and managers, the thesis presents an account of ACCHS’ unique role in the health system. It constructs an explanation of First Peoples’ health inequities, using interviewees’ theoretical insights and relevant scholarly literature. A key research output is the detailed description and modelling of the ACCHS holistic approach to Aboriginal healthcare. This expands our understanding of what ACCHS do, how they do it, and why it is effective. This examination of the ACCHS model of care is of relevance to all healthcare providers in Australia, as it provides practical examples of how to operationalise the social elements of primary healthcare, such as community participation in service design, and the development and delivery of culturally safe health promotion and education activities.

This body of work also identifies and critically analyses the key policy challenges that impede the effective and efficient delivery of services by ACCHS in New South Wales. Key challenges identified include funding shortfalls and restrictions, and severe power imbalances between government actors and “mainstream” health actors, on one side, and ACCHS on the other. An extensive list of practicable policy solutions has been developed, making this thesis a valuable and viable source of guidance for policymakers and professionals working in Indigenous health service delivery.

Acknowledgments I want to acknowledge and pay my respects to the past, present and future Aboriginal Elders of the Darug, Bedegal and Cadigal Nations. They are the traditional custodians of the land on which this thesis was written. I want to extend that respect to all the Aboriginal peoples of New South Wales who welcomed me into their communities and shared their timeless knowledge.

This project would not have been possible without the generosity, support, advice and kindness of an entire community of people who have nurtured me. Thank you to Lisa Orcher, Auntie Sue Pinckham, Auntie Clair Jackson, Auntie Julie Janson, Dr Kevin Lowe and Paul Weir for your insightful guidance, sage advice and warm encouragement during this research journey. You have been a huge source of strength and motivation. Thank you to Fay Adamson, Kelly O’Brien, and Anthony Paulson for your interest in the project when it was still in its infancy. You gave me direction and confidence in those moments of disorientation and uncertainty. To the caring, resourceful, and resilient women of Baabayn Aboriginal Corporation in Mt Druitt, thank you for letting me into your world. You are an inspiration.

To my primary supervisor, teacher and dear friend Dr Diana Perche, I cannot thank you enough for all your help during this project. You went above and beyond the call of duty and your astute suggestions and empathetic counsel have elevated my work and writing to a standard I never thought possible. So much of what this thesis has achieved was inspired by you. To my associate supervisor Professor Alex Broom, thank you for keeping me grounded in the fundamental principles of qualitative analysis and academic work. You reminded me of the significance of this kind of scholarship and the depth of understanding it offers. Thank you also to Professor Stephanie Lawson for your considered advice and feedback.

To Associate Professor Reuben Bolt, Sarah Keech, Ben Kelly, Dr Johanna Perheentupa, Katrina Smith, Mary Pianka, Jason O’Neil, and the entire team at Nura Gili, you make turning up to work every day a joy and I am constantly learning from you all. Thank you for your support and friendship. Thank you to the Faculty of Arts and Social Sciences for funding this project and for creating valuable opportunities for me to present my work. Thank you also to the Aboriginal Health and Medical Research Council of New South Wales for your practical assistance making this research directly relevant to the lives, priorities and needs of First Nations. The ethics process helped me understand research from additional perspectives. To the Honourable Linda Burney, MP, thank you for you interest in this project and for supporting me. You are a shining example of how to live a life of leadership, advocacy and service.

I am so very fortunate to have such wonderful friends and family. To my mother Rosemary and father Roger, brother Steve, sister-in-law Caitlin, nephew Liam and grandmother Shirley thank you so much for your love, encouragement and much-needed practical assistance during this challenging and transformative process. To my friends in Sydney, Melbourne, Katherine, Brisbane, London, Mexico, Spain, France, Germany, Florence, Singapore and Vienna, thank you for filling me with happiness and making me the person I am today. My housemates Amanda, Dane and Jack, and wonderful friends Natalie O’Brien and Sam Skidmore deserve especial thanks for feeding me regularly and putting up with me during these final months of nerves and busyness. Thanks also to the remarkable Dr Elizabeth Ingleson for encouragement and solidarity and to Terry O’Brien for proof-reading.

A note on terminology In this thesis the terms ‘First Nations’, ‘Indigenous’ and ‘Aboriginal and Torres Strait Islander’ are used interchangeably. These terms refer to the Indigenous or First peoples, communities and nations of the Australian continent and the Torres Strait Islands. They are inclusive terms designed to encompass all the peoples and societies that existed before and continue to exist after the colonisation of the Australian landmass. In some cases, interview participants from Aboriginal Community Controlled Health Services in New South Wales use the term ‘Aboriginal’ as a synonym for ‘Indigenous’ when referring to the Aboriginal and Torres Strait Islander people that live in their communities and make use of their organisations’ services.

Glossary of acronyms

ABS – Australian Bureau of Statistics

ACCHS – Aboriginal Community Controlled Health Service(s)

AGC – Aboriginal Governance Committee

AGM – Annual General Meeting

AH&MRC – Aboriginal Health and Medical Research Council of New South Wales

AIATSIS – Australian Institute of Aboriginal and Torres Strait Islander Studies

AIDA – Australian Indigenous Doctors’ Association

AIHW – Australian Institute of Health and Welfare

AMIHS – Aboriginal Maternal and Infant Health Service

AMS(s) – Aboriginal Medical Service(s)

ANAO – Australian National Audit Office

ASIC – Australian Securities and Investments Commission

ATSIC – Aboriginal and Torres Strait Islander Commission

ATSIPO – Aboriginal and Torres Strait Islander Peak Organisations

ATSISJC – Aboriginal and Torres Strait Islander Social Justice Commissioner

CATSI Act – Corporations (Aboriginal and Torres Strait Islander) Act 2006

CEO – Chief Executive Officer

CPHC – Comprehensive Primary Health Care

DAA – Department of Aboriginal Affairs (Commonwealth)

DoH – Department of Health (Commonwealth)

FFT – Functional Family Therapy

GP – General Practitioner

HREOC – Human Rights and Equal Opportunity Commission

IAHP – Indigenous Australians’ Health Programme

IAS – Indigenous Advancement Strategy

IFBS – Intensive Family-Based Services

ITC – Integrated Team Care

LHD(s) – Local Health District(s)

MBS – Medicare Benefits Schedule

MOU – Memorandum of Understanding

NACCHO – National Aboriginal Community Controlled Health Organisation

NAHS – National Aboriginal Health Strategy

NAIDOC – National Aboriginal and Islander Day Observance Committee

NATSILS - National Aboriginal and Torres Strait Islander Legal Services

NCOA – National Commission of Audit

NGO(s) – Non-government organisation(s) nKPIs – national Key Performance Indicators

NPM – New Public Management

NSW – New South Wales

OATSIH – Office for Aboriginal and Torres Strait Islander Health

OOHC – Out-of-Home Care

ORIC – Office of the Registrar of Indigenous Organisations

PHN(s) – Primary Health Network(s)

PIP – Practice Incentive Program

PM&C – Department of Prime Minister and Cabinet (Commonwealth)

RDN - Rural Doctors Network

SDoH – Social Determinants of Health

SEWB – Social and Emotional Wellbeing

Contents Originality Statement...... 4 Copyright statement ...... 6 Authenticity statement ...... 6 Abstract ...... 7 Acknowledgments ...... 8 A note on terminology ...... 9 Glossary of acronyms...... 10 Chapter 1...... 18 Introduction: Indigenous health and policy in Australia ...... 18 Research problem: Indigenous health inequality...... 19 Tracing the emergence of ‘marketised’ Indigenous policy ...... 20 Understanding the dominance of neoliberal governance in Australia ...... 21 Competitive contracting for Indigenous services: implications for ACCHS ...... 22 Policy prescriptions to remedy Indigenous “deficit” ...... 23 Applying constructivist theories of the policy process to the case of Indigenous Affairs ...... 24 From ‘target populations’ to target organisations ...... 24 Overarching research question ...... 25 Three related research sub-questions for the thesis...... 25 Consistent calls for greater Indigenous self-determination ...... 28 Undermining Indigenous self-determination through competition...... 30 Methodology, ethics and foregrounding Indigenous perspectives ...... 31 Methods ...... 33 Thesis structure ...... 34 Chapter 2...... 36 The political and social context of First Nations’ health inequity ...... 36 Operationalising Aboriginal self-determination in healthcare...... 36 Creating space: Aboriginal Medical Services in hostile socioeconomic times ...... 37 Implementing comprehensive primary health care for Aboriginal community contexts ...... 39 Enabling health through social and community services ...... 41 Improving access to healthcare for marginalised peoples ...... 41 Providing high-quality clinical care ...... 42 ACCHS’ actions on the social determinants of health ...... 42 Linking material conditions to health outcomes ...... 44

Recognising the health impacts of global inequalities ...... 46 The social gradient and psychosocial determinants...... 47 Explaining the psychological pathways between social inequality and health ...... 48 Power and powerlessness: the undercurrents of the ‘social determinants’ agenda ...... 48 Autonomy and self-efficacy in the life-world ...... 50 Towards an Indigenous-centred model of health ...... 50 Ongoing racism and its implications for First Nations health ...... 52 Fostering anti-racism in the health system ...... 55 Implications for practice: overcoming political barriers to action on Indigenous health inequity .. 57 Conclusion ...... 58 Chapter 3...... 60 Literature review: neoliberal Settler-colonialism and the social construction of Indigenous ‘dependents’ ...... 60 Understanding neoliberal reforms in Settler-colonial contexts ...... 60 Racialisation and Settler dispossession of Indigenous lands ...... 63 Indigenous Affairs ‘policy paradigms’ as meso-theories of Indigenous-Settler relations ...... 67 Constructing policy problems: the role of ‘framing’ and ‘problematisation’...... 79 Neoliberal framings of the Indigenous sector ...... 84 Understanding the Settler-colonial logics of neoliberal policy frames...... 88 Conclusion ...... 90 Chapter 4...... 92 Marketising Indigenous policy (2014-19) ...... 92 A short history of Aboriginal health funding arrangements ...... 93 ACCHS access to Medicare funding ...... 94 A sample of ACCHS funding across different remoteness categories ...... 95 The Indigenous Advancement Strategy: rationale and effects ...... 98 Destabilising Aboriginal organisations and communities ...... 101 Tracing the financial effects of the IAS ...... 104 Financial impact of the IAS on the ACCHS sector ...... 106 Table 1: Breakdown of PM&C Indigenous Affairs funding before and after the Indigenous Advancement Strategy. Source: NACCHO (2015, 15) ...... 107 Indigenous organisations as target populations ...... 109 Restructuring Indigenous primary health funding ...... 112 Marketisation and healthcare: special considerations ...... 113

Primary Health Networks: political background, and economic logic ...... 116 Installing a new hierarchy in the health system ...... 118 Future Indigenous health funding strategies ...... 123 Conclusion: Indigenous Affairs experiments in NPM and marketisation ...... 124 Chapter 5...... 128 Methods: developing an account of Aboriginal Community Controlled Health Services in action ... 128 The ethics of doing research with Aboriginal Community Controlled Health Services ...... 129 Indigenous input in study design and research focus ...... 131 Conducting field work across New South Wales ...... 131 Participant recruitment ...... 133 Benefits of this research for ACCHS and Aboriginal communities ...... 134 Overview of the data set...... 135 Interview methods and thematic analysis ...... 135 Overview of interviewees and participating organisations ...... 138 Conducting research from a non-Indigenous standpoint ...... 140 Hearing Indigenous voices: turning abstract policy contexts into lived realities ...... 142 Chapter 6...... 144 The role of ACCHS: caring for families, the holistic view of personal and societal health, and recognising trauma ...... 144 A three-tiered theory of First Nations’ health inequity ...... 145 Layering and linking three tiers of theory: the causal cascade ...... 161 The holistic model of care: temporal, social, family and community understandings ...... 163 Treating the family as the unit of care...... 168 Community events as healthcare interventions ...... 170 Offering comprehensive and coordinated clinical services from a “one-stop-shop” ...... 171 Mitigating the health impacts of poverty through subsidised care and “emergency relief” ...... 173 Providing culturally appropriate healthcare ...... 174 Conclusion ...... 180 Chapter 7...... 182 Navigating corporate governance challenges while maintaining Community Control ...... 182 Defining governance in the ACCHS sector ...... 183 Setting the strategic direction of the ACCHS, in line with ‘what the community wants’ ...... 184 Mitigating against familial biases ...... 185 Can a community board act as a responsible steward of ACCHS business? ...... 186

Re-structuring ACCHS around business principles ...... 189 One board, two roles: balancing corporate and community governance ...... 192 “It’s empowered our communities”: ACCHS governance as localised self-determination ...... 194 Navigating corporate governance challenges: strategies and recommendations ...... 196 Conclusion ...... 202 Chapter 8...... 204 Follow the money: Aboriginal health funding, competitive contracting, and neoliberal austerity ... 204 Running an Aboriginal Medical Service “on a shoestring” ...... 204 Open tenders and contestable contracts: “everyone and their dog competing for the dollars” .. 206 Struggling with the increase in competitive tendering ...... 207 “Sucking the blood off Aboriginal programs”: new mainstream competitors in the Aboriginal service-delivery market ...... 208 Accountability deficits, mainstream health providers and Aboriginal health outcomes ...... 212 Grappling with “over the top” tender applications ...... 218 Inequitable processes “making the strong stronger and sometimes the weak stay weak” ...... 220 Organisational “stress” in an uncertain and fast-paced funding environment ...... 221 “Political football”: adjusting to new rules, responding to new requirements ...... 223 Medicare machines: maximising revenue to compensate for funding shortfalls ...... 225 Diversifying income streams to mitigate financial risk ...... 226 “The burden of reporting” ...... 227 “[N]umbers … not narratives”: the quantitative nature and clinical focus of reporting structures ...... 228 The cost of competition: losing health programs that “looked at the root cause” ...... 229 Overlooked areas of funding: capital works, wages and Social and Emotional Wellbeing ...... 231 ACCHS’ complex relations with government ...... 234 Conclusion ...... 234 Chapter 9...... 236 Swimming against ‘the mainstream’: strained relations and barriers to cooperation ...... 236 Defining the ‘mainstream’ ...... 238 Research participants’ knowledge of ‘mainstream’ health and other services ...... 239 ACCHS’ relations with mainstream service providers: mixed results ...... 240 Productive relations with external health providers ...... 243 Expanding services through referral networks ...... 245 Strained relations between ACCHS and mainstream organisations ...... 249

Explaining the inconsistent relationships: the role of luck and mainstream health managers’ personalities ...... 258 ACCHS’ relations with Primary Health Networks ...... 261 Unequal power: Mainstream organisations and norms dominate ...... 273 ACCHS’ desire for closer partnerships, self-determination and two-way learning ...... 275 Conclusion ...... 278 Chapter 10...... 280 Conclusion and policy recommendations: calling for greater Aboriginal Community Control ...... 280 Answers to research sub-questions...... 280 Recommendation 1: Cultural change: confront institutional racism ...... 283 Recommendation 2: Increase and stabilise funding: resource the ACCHS model of holistic care 285 Recommendation 3: Cede power: recognise ACCHS as leaders in Aboriginal health care...... 286 Recommendation 4: Simplify processes: streamline reporting and tender writing ...... 288 Recommendation 5: Monitor ‘the mainstream’: hold Local Health Districts and non-Aboriginal NGOs accountable for Aboriginal health ...... 289 Recommendation 6: Strengthen ACCHS governance against external and internal instability ..... 290 Providing new answers to enduring policy problems ...... 291 Central contributions of this research ...... 293 Future research directions ...... 294 Emerging sites of First Nations empowerment ...... 295 References...... 298 Appendices...... 340 Appendix 1: Interviewees and remoteness map ...... 340 Appendix 2: Interview questions ...... 344 Appendix 3: Participant Information Statement ...... 347 Appendix 4: Aboriginal Community Organisation Consent Form ...... 350 Appendix 5: Participant Consent Form ...... 353 Appendix 6: AH&MRC Ethics Approval Letter ...... 355 Appendix 7: Macquarie University Ethics Approval Letter ...... 357

Chapter 1.

Introduction: Indigenous health and policy in Australia

If it wasn’t for our board, or the Aboriginal Community Controlled Health Organisations, a lot of us would be in the ground by now. – Charlotte

Well, the thing is about Aboriginal Community Control is that it’s yours, in a way, you know? You make all the decisions for yourself, and for your community. – Roger

Aboriginal Community Controlled Health Services (ACCHS) are vitally important. As the above quote from Charlotte, the Aboriginal CEO of an outer-regional ACCHS explains, they provide essential health services to First Peoples, who suffer the worst health outcomes of any people in Australia. In doing this, ACCHS also allow Aboriginal communities to take control of their own health. This is an important structural difference between ACCHS and ‘mainstream’ health services. As the CEO of the Central Australian Aboriginal Congress, Donna Ah Chee, recently re-asserted, “no other way of governing services guarantees Aboriginal empowerment” (2019). The value of Aboriginal Community Control in health is also emphasised by Roger, the Aboriginal CEO of an urban-based ACCHS quoted above. Research has shown that self-determination and empowerment can produce substantial health benefits at the individual and community levels (e.g. Marmot et al. 1991; Wallerstein 2002; Chandler & Lalonde 1998). In simple terms, the available evidence is strongly supportive of the proposition that Aboriginal health outcomes are significantly improved when the ‘Aboriginal community’ is in control of the delivery of health programs.

Government policy also exerts significant influence over Aboriginal health and wellbeing. Because of Australia’s history of dispossession, racial discrimination, and socio-economic exclusion, contemporary government “policies, services and payments assume a disproportionate importance” in the lives of First Nations (Moran 2016, 6). This is especially so in ‘remote’ Aboriginal communities. Since the 1970s, many crucial services have been delivered by Aboriginal Community Controlled organisations that make up “the Indigenous sector” (Rowse 2005, 214), which rely on government funding and support in order to operate (Sullivan 2011). There is evidence that this support is now being withdrawn, which

18 could mean the disappearance of ACCHS, and the deterioration of Aboriginal health and wellbeing. This thesis is a response to that emerging policy threat.

This thesis evaluates three recent Commonwealth policies via a close reading of policy documents and in-depth interviews with key stakeholders in ACCHS. An original contribution of the thesis is its combination of deductive policy critique using theories of New Public Management (NPM) and neoliberalism, and inductive methods of data collection drawing on service providers’ lived experiences and practical knowledge of Aboriginal communities. In this way, the thesis refines our macro-political understandings of Indigenous Affairs policies in Australia by considering the micro-political experiences of grassroots Indigenous organisations. The project builds on the premise that ACCHS improve the health wellbeing of First Peoples by enacting self-determination at the local level. It offers an account from the frontlines of First Nations’ health service delivery, developing a cross-cultural critique of the policies and funding systems that impact upon Indigenous self-determination in health. It also proposes policy solutions to some of the most pressing challenges facing ACCHS, advocates closer partnerships between ‘mainstream’ health service providers and ACCHS, and urges governments to nurture ACCHS’ special qualities and contributions to the health system. The central argument of this thesis is that greater Aboriginal Community Control is critically important for improving First Nations’ health and wellbeing.

Research problem: Indigenous health inequality There is a glaring disparity between the health and social outcomes between Indigenous peoples and other Australians. This disparity has been well documented (e.g. ATSISJC 1996; HREOC 1997). The Productivity Commission’s most recent Overcoming Indigenous Disadvantage Report (2016, 13) reiterates that Aboriginal and Torres Strait Islander men are expected to live for 10.6 fewer years than non-Indigenous Australian men. Between Indigenous and non-Indigenous women, the life expectancy gap is only slightly smaller at 9.5 years (Productivity Commission 2016, 13). The 2019 Prime Minister’s Closing the Gap Report admits that Australia is not on track to meet its target to close the gap between Indigenous and non-Indigenous life expectancy by the year 2031 (Commonwealth of Australia 2019, 10). The persistence and severity of this “wicked” problem (Hunter 2008, 35) makes the federal government’s recent alterations to Indigenous health funding of pressing concern to First Nations. Moreover, the ongoing public debates about ‘the gaps’ and the lack of

19 significant progress in closing them demonstrates the political and policy currency of Indigenous health inequalities today (e.g. Mitrou et al. 2014; Grattan 2017; Conifer et al. 2017; Gordon & Hunter 2016). The severity of Indigenous health problems is widely known but government policymakers continue to ignore or insufficiently support the most promising and appropriate solutions to Indigenous health problems. This disjunction is discussed in Chapters 3, 5 and 8.

Tracing the emergence of ‘marketised’ Indigenous policy The policy measures contained in the 2014 federal budget are highly relevant to Indigenous health and signalled a significant shift in Indigenous Affairs policymaking. Sanders (2010) has shown that from the early 1970s to the mid-1990s Indigenous Affairs was influenced by ideas of self-determination, arguing that government policy was more supportive of indigenous difference. This thesis considers how this began to change with the election of the Howard government in 1996, and Indigenous policy was brought into line with ‘mainstream’ policy orthodoxy. Chapter 3 provides an assessment of the reasons why Indigenous Affairs was treated differently during the ‘self-determination’ policy era, when the Aboriginal Community Controlled sector first developed. It then offers an overview of the most recent changes in government policy which have placed these services under threat.

In the 2014 budget the conservative Liberal-National Coalition, under Prime Minister Tony Abbott, introduced three major Indigenous Affairs policy reforms: the Indigenous Advancement Strategy (IAS), the Indigenous Australians’ Health Programme (IAHP), and the replacement of Medicare Locals with Primary Health Networks (PHNs). These three policies promote competition amongst service providers, based on the premise that this will drive innovation and efficiency. The Abbott government’s first budget also pursued fiscal austerity, which is closely associated with neoliberalism (e.g. Schrecker & Bambra 2015). Handing down the budget, Federal Treasurer Joe Hockey, photographed that night with a fat cigar in hand, disclosed that more than half a billion dollars had been cut from federal Indigenous Affairs, including $165.8 million over four years from Indigenous health programs (Australian Government 2014a; Russell 2014). It was reported that $112,884 of this had come from cuts to ACCHS (NACCHO 2015). This was a significant reduction especially in light of the sector’s persistent funding shortfalls (Alford 2014; Couzos &

Delaney Thiele 2007, 523; Grant et al. 2008, 19). Funding for the National Congress of Australia’s First Peoples – the only representative national advocacy body for Indigenous Australians – was terminated. These budget cuts delivered on the Coalition’s election promise to reduce government spending and cut “waste” (Liberal Party of Australia 2013).

The IAS, IAHP and PHNs are broadly similar in their intent and all three policies have the potential to undermine the material and political security of the ACCHS sector. All include some level of competitive tendering for government grants and contracts, privilege corporate models of governance and accountability, and prioritise “value for money”, efficiency and effectiveness (PM&C 2014a; DoH 2016a). These are the concepts and techniques of NPM (Hood 1991, 4-5). The ideological roots of these market-inspired policies are examined in detail in Chapters 3 and 4. The IAS, IAHP and PHNs continued the federal government’s move away from Indigenous self-determination towards a preference for what could be characterised as ‘market determination’ (see Chapter 3). This thesis argues that these three policies introduced a new level of “marketisation” to the Indigenous health sector (Meagher and Goodwin 2015, 2). The logic underlying the marketisation of Indigenous policy is analysed in Chapter 3. Its specific effects on Indigenous organisations are detailed in Chapter 4.

Indigenous peoples and their representative and service delivery organisations have heavily criticised recent Indigenous Affairs policy developments such as the IAS (see, for example, NACCHO 2015; Senate FPARC 2016; ATSIPO 2016; ATSISJC 2016). The IAS, the IAHP and the PHNs warrant deeper consideration from health policy scholars and observers of Indigenous Affairs. This thesis provides one such consideration of the impacts and implications of a major governmental redesign of the Indigenous Affairs policy architecture.

Understanding the dominance of neoliberal governance in Australia The relationship between Australian governments and non-government service-delivery organisations has been radically transformed in recent decades (Goodwin & Phillips 2015, 97). The practice of governments ‘contracting out’ some of their responsibilities has become increasingly common in Australia since the 1990s (e.g. Considine and Lewis 2003, 133). Not- for-profit and for-profit non-government organisations (NGOs) now undertake a considerable amount of the face-to-face work with citizens who need to access government

21 services. The contracting out of public services takes place in healthcare, employment services, disability services and education, for example. This is what Rhodes (1996) has called the shift from governing to governance, where government agencies now concentrate more on steering the boat while letting others do the physical work of rowing it, to use Osbourne’s and Gaebler’s metaphor (1993). Australian governments’ withdrawal from direct service provision has coincided with the rise of neoliberal ideology within government circles (Halligan 2007, 220). As Pusey has argued (1991), ‘economic rationalism’ – the Australian version of neoliberalism – has taken hold in Canberra and governments are turning to the ‘rational’ logic of market forces when making decisions about funding public services or investing in public infrastructure. It is a style of governing that promotes “a wider range of service providers and a more market-oriented approach to management” (Stoker quoted in O’Flynn 2007, 254). Recent policy developments suggest that NPM principles are now being introduced to the Indigenous Affairs portfolio, as examined below.

Competitive contracting for Indigenous services: implications for ACCHS The IAS exposes the Indigenous sector to competition from non-Indigenous service providers. The National Aboriginal Community Controlled Health Organisation (NACCHO) contends that the IAS funding processes do not value the ACCHS sector’s unique Indigenous attributes (2015, 5). Moreover, Russell has argued that the 2014 budget cuts signalled that the government was “more interested in saving money than in delivering more effective programs” (Russell 2014, 6). It has also been argued that the IAS placed small Indigenous organisations such as ACCHS at a disadvantage, since they were made to compete against government agencies, powerful public institutions, major corporations and large faith-based not-for-profit organisations (Senate FPARC 2016; Inala Wangarra n.d., 3). This thesis suggests that marketisation via the IAS, PHNs and IAHP may have a homogenising effect on Indigenous health service providers if the funding models are not reformed to accommodate Indigenous cultural differences, as explored in Chapters 3, 4, 6 and 8. The unique characteristics of the Indigenous sector may disappear in a process of “mimetic isomorphism” (DiMaggio & Powell cited in Hood & Peters 2004, 278).

Like the IAS, the PHN’s policy rationale also follows a competitive market logic. Evidence from interviews with ACCHS CEOs, examined in Chapters 8 and 9, highlights that many ACCHS are concerned by the PHNs’ competitive tendering process, officially referred to as

22 commissioning. Analysis of Indigenous Australians Health Programme Guidelines reveals that competitive tendering is also the Department of Health’s preferred process for funding Indigenous health services (Department of Health 2015, 8). The literature on the effects of competitive tendering and contracting in non-Indigenous service contexts suggests that Aboriginal Community Controlled organisations, and the Indigenous peoples who rely on them, will have to navigate numerous points of tension and practical challenges if they find themselves in a new relationship with “the contract state” (Cordella & Willcocks 2010, 83; for contracting out see Van Slyke 2003; Schmid 2003; Grey & Sedgwick 2015; Eikenberry & Kluver 2004; and for an analysis of the NPM’s overall effectiveness see Hood & Dixon 2015). These dynamics are discussed in greater detail in Chapters 3 and 4.

As Chapter 4 shows, Aboriginal and Torres Strait Islander organisations are entering into a more “professional” kind of relationship with the government, based on formal contracts and “quasi-market” competition (Le Grand 1991, 1257). This altered relationship could potentially change the Indigenous sector’s modus operandi and activities. As Considine, O’Sullivan and Nguyen have shown (2014, 177) with respect to the contracting out of employment services in Australia, the application of market principles to social services can alter NGOs organisational culture. The use of market logics can push NGOs to become more focused on commercial skills rather than their links to community. Evidence from interviews conducted for this thesis suggests that this “mission drift” (Considine, O’Sullivan & Nguyen 2014, 169) is already occurring in some Indigenous sector organisations, as ACCHS CEOs attempt to ensure organisational survival in this more commercially skewed. This adaptation is discussed extensively in Chapters 6 and 7.

Policy prescriptions to remedy Indigenous “deficit” There is evidence to suggest that the Indigenous organisations are subjected to more surveillance and are required to demonstrate their competence more so than their non- Indigenous counterparts (Sullivan 2011, 62; Dwyer et al. 2011, 40; Lavoie et al. 2010, 670). Activity reporting is a routine aspect of the funding process, yet for small Aboriginal Community Controlled organisations with limited staff and resources it can be extremely burdensome (Dwyer et al. 2009; Silburn et al. 2016; Martini et al. 2011, 9-10). Moreover, the special powers afforded to the Office of the Registrar of Indigenous Corporations (ORIC), including the unique ability to appoint a ‘special administrator’ to control Indigenous

23 organisations through “early proactive regulatory assistance” (ORIC 2017, 13) indicates that the government perceives Indigenous organisations to be inherently risky, vulnerable or untrustworthy. The ramifications of this “deficit discourse” (Fogarty, Bulloch, McConnell & Davis 2018, 3) and the racial biases embedded in IAS funding conditions, are discussed further in Chapter 3.

Applying constructivist theories of the policy process to the case of Indigenous Affairs To understand the driving forces behind these recent policy shifts I draw on Schneider’s and Ingram’s work (2005; 1997) on the social construction of ‘target populations’. Taking a social constructivist approach to policy analysis (see for example Fischer 2003; Stone 2002; Bacchi 2012), these leading policy theorists explain the many ways that governments use public policy to place people into categories. These categories are based on pervasive socially constructed ideas about the level of deservedness and entitlement of different social groups. Ingram and Schneider explain that public policy can be understood as “the institutionalisation of bias” (2005, 19), telling us who matters and who does not, in our society. In Chapter 3 I consider the politically contested nature of First Nations’ demands for self-determination (Bradfield 2006), and the historically marginalised status of First Nations peoples in Australia (e.g. Grant et al. 2008; Broome 2010). An understanding of this political history makes the negative social constructions of Indigenous peoples through public policies more comprehensible.

From ‘target populations’ to target organisations Although Ingram’s and Schneider’s theory was initially developed to explain the unequal treatment of different kinds of citizens or service users, I contend that it is equally useful when studying the unequal treatment of different kinds of civil society organisations or service providers. In this case, the target population under consideration is the ACCHS sector. As is shown in Chapters 3 and 4, the federal government treats Indigenous organisations differently to non-Indigenous organisations, based on underlying judgements about their relative moral worth. This thesis argues that under the neoliberal “moral economy” (Fassin 2005, 365; Rivkin-Fish 2011, 187) values such as economic sustainability, moral fortitude, entrepreneurialism, contribution to the national interest, the generation of profit, financial responsibility and good governance are presented as universally relevant.

Within this ideological framework, government policy discourse problematises Indigenous organisations such as ACCHS, socially constructing them as dependents, and justifying market discipline by the state. This thesis argues that this fits into a longer historical trend where policy has framed Aboriginality as deviant or deficient in order to justify state control, oppression and elimination. These “degenerative politics” (Schneider and Ingram 1997, 6) and policy dynamics are discussed in more detail in Chapter 3. One of the central contentions of this thesis is that the unequal status of ACCHS in the health system can be understood as a reflection of the unequal status of Indigenous peoples in Australian society.

Overarching research question This research project responds to one overarching question. The question is based on the premise that ACCHS provide a working example of First Peoples’ empowerment in healthcare. The question directs investigation towards government policy makers, making it an action-oriented endeavour, and provides practicable policy solutions designed to enable ACCHS to further improve First Nations’ wellbeing. The answers provided to this overarching research question set out the most pressing political and policy challenges to Aboriginal self- determination in health and suggest ways of overcoming them. The guiding question of this project is:

In what ways might government policy be reformed to allow space for genuine Indigenous self-determination in health and enable ACCHS to improve First Nations’ health and wellbeing?

Based on available evidence and First Nations’ ongoing campaigns and advocacy for greater control over their own affairs, this thesis investigates how policy change could facilitate a greater degree of Indigenous self-determination in healthcare.

Three related research sub-questions for the thesis With these political and policy challenges in mind, this thesis providers answers to three research questions:

1. What are the features and guiding philosophies of ACCHS in New South Wales? 2. How are current policies, funding arrangements, and ‘mainstream’ norms and practices affecting ACCHS and Indigenous self-determination in health?

3. In what ways could governments change policies to allow space for greater Indigenous self-determination in health?

The first research question focuses on the specific characteristics of ACCHS. In answering that question this thesis details the range and design of ACCHS’ services and programs (see Chapter 6). This investigation is thus a response to the limited scholarly literature investigating ACCHS guiding philosophies and their understandings of Aboriginal health and wellbeing. There is a particular lack of qualitative studies into ACCHS’ operations. This aspect of the thesis responds to a gap in the literature.

ACCHS undertake a crucial cross-cultural task in the health system in that they deliver culturally appropriate healthcare to Indigenous communities (AH&MRC 2015; Durey 2010, S89; Panaretto et al. 2014; Brigg & Curth-Bibb 2017, 206). They are also able to partner with governments and mainstream health providers to improve and expand the health services available to Aboriginal and Torres Strait Islander communities (Brigg & Curth-Bibb 2017; AH&MRC 2015, 12; Campbell 2017). Given that ACCHS occupy a vital and unique space within the Australian health and social policy context, there is a need to know more about their model of care and how ACCHS staff understand and implement it (ATSIPO 2016, 14; Department of Health 2016, 2; Russell 2013; Couzos and Delaney Thiele 2009). This thesis provides a qualitative account of the ACCHS model of care, which builds on previous accounts of the model which have described it as “holistic”, “integrated” and “culturally appropriate” (e.g. Bell et al. 2000, 75; Campbell et al. 2017, C). This expands the findings of previous studies that have concluded that ACCHS do not only treat individuals or body parts but treat families and communities (Mackey et al. 2014, 2; Panaretto et al. 2014, 649).

ACCHS have achieved considerable success in raising the overall levels of health and wellbeing amongst Indigenous peoples in Australia. As Chapter 2 explains in great detail, ACCHS are more effective in many ways than mainstream health providers (Campbell et al. 2017; Panaretto et al. 2014; Calma 2007a; AH&MRC 2015; Hurley et al. 2010; Moran et al. 2016, 360; Alford 2014, 43-5; Ong et al. 2012, 8; Kelaher et al. 2014; Brigg & Curth Bibb 2017, 201). For example, there is evidence to suggest that ACCHS general practitioners (GPs) manage a higher number and more complex range of health problems than mainstream GPs, and that the clinical outcomes achieved by ACCHS are equivalent to or superior to

26 those achieved by mainstream services (Larkins et al. 2006; Thomas et al. 1998; Jan et al. 2004; Panaretto et al. 2005).

Other research (see Chapters 2 and 6) suggests that what makes ACCHS unique is also what makes them effective; their Aboriginal Community Controlled governance model links them to their communities and makes them responsive to their specific health needs (Davis 2013, 13; AH&MRC 2015, 9; Couzos & Delaney Thiele 2009). ACCHS’ ties to the Aboriginal communities in which they operate make them important sites of cultural knowledge and cross-cultural communication. ACCHS explain health programs and medical treatments in culturally appropriate ways using language and other communication tools that patients can understand (AH&MRC 2015, 8). ACCHS also facilitate communication in the other direction; they translate Indigenous community priorities and needs into programs and services that align with government priorities and fit into funding frameworks. As Brigg and Curth-Bibb explain (2017, 206), ACCHS are intercultural entities that make use of settler-colonial resources and governance systems while at the same time drawing on Indigenous values and ways of operating. No other group in the health system operates so effectively in both worlds. The ACCHS’ Community Controlled, culturally appropriate, holistic model of care is held up as the gold standard when it comes to addressing health inequity through the provision of healthcare (Russell 2013, 2; Ong et al. 2012, 2; Marmot 2008, 1665; Hurley et al. 2010, 149; Panaretto et al. 2014; Brigg & Curth-Bibb 2017).

The second research question is designed to elicit detailed information about the policy and political challenges facing the ACCHS sector. Many researchers and ACCHS-sector advocates have identified funding shortfalls and a lack of flexible yet secure funding for ACCHS (Alford 2015; Alford 2014; NACCHO 2015; Bartlett & Boffa 2005, 55; Couzos & Delaney Thiele 2007, 523; Grant et al. 2008, 19; Dwyer et al. 2011, 35; Russell 2013; Dwyer et al. 2009). The consensus around the importance of ACCHS, and the persistent concerns that they are being inadequately funded have prompted this investigation into current policy challenges facing the ACCHS sector. Since all governments in Australia have committed themselves to Closing the Gap (COAG 2008) in Indigenous health, the claims that Indigenous health services are being neglected warrant further investigation.

The third research question responds to longstanding calls for greater policy support for Indigenous self-determination in Australia. Self-determination has been a central goal of many Indigenous-rights activists over many decades (Foley 2011; Burgmann 2003; Edwards 2013). Many scholars have argued that ACCHS enact a level of self-determination through their Community Controlled governance structure (Davis 2013; Rowse 2002; Panaretto et al. 2014; Sullivan 2011; Mazel 2016; AH&MRC 2015). Several studies have made a link between enhanced individual autonomy or self-efficacy, and improved health outcomes (e.g. Marmot et al. 1991, 1390; Siegrist & Marmot 2004). There is also evidence to suggest that this link applies at the community level, not just the individual level (Wallerstein 2002; Wilkinson & Pickett 2010; Wallerstein 1992; Wallerstein 2006; Rappaport 1981; Labonte 1994). Two studies from Canada examine the relationship between First Nations’ control of health services and rates of hospitalisation (Lavoie et al. 2010) and suicide rates (Chandler & Lalonde 1998). Lavoie and colleagues found that transitioning to community control resulted in a 30% decrease in hospitalisation rates, and Chandler and Lalonde uncovered a strong association between increased community control and decrease in suicide rates.

In interviews conducted for this thesis, self-determination emerged as a core element of the Indigenous-led proposals for reform and health improvement (see Chapters 6, 8 and 9). Other Indigenous community representatives and organisations are also campaigning for enhanced self-determination, as discussed below. As the historic Uluru Statement from the Heart declared:

We seek constitutional reforms to empower our people and take a rightful place in our own country. When we have power over our destiny our children will flourish. They will walk in two worlds and their culture will be a gift to their country. (Referendum Council 2017)

Chapter 10 of this thesis provides detailed policy recommendations on how governments, mainstream health services and Indigenous sector organisations can collaborate more effectively to enable greater self-determination in health.

Consistent calls for greater Indigenous self-determination Every year since 2008, the Close the Gap Steering Committee (a coalition of Australia’s peak Indigenous and non-Indigenous health bodies, human rights organisations and NGOs) has

28 published a shadow Progress and Priorities Report. These reports scrutinise the findings and explanations contained in the Prime Minister’s annual Closing the Gap Report and assess national progress towards the targets. The 2016 the shadow report concluded that in order to close the gap in life expectancy, governments at all levels would need to spend more on Indigenous health programs, expand access to primary healthcare, and act to mitigate the effects of complex and interrelated social and economic determinants of health (Holland 2016, 10). In the 2017 shadow report the Steering Committee reiterated the importance of addressing social determinants, but also stressed the need for governments to begin a ‘new engagement’ with Indigenous communities, representative bodies and Aboriginal Community Controlled organisations (Wright & Lewis 2017). This report also reaffirmed the importance of eliminating systemic racism, particularly in health care settings, policies and funding regimes (Wright & Lewis 2017, 11). “Cultural misconnection” and persistent racism due to the ongoing impacts of colonisation were identified as important dynamics that underpin Indigenous health inequality (Wright & Lewis 2017, 25). This thesis attempts to evaluate government engagement with Indigenous-proposed solutions such as those of the Close the Gap Steering Committee.

Just before the 2016 federal election a coalition of Aboriginal and Torres Strait Islander representatives, service-delivery organisation and peak bodies released The Redfern Statement, an urgent call for government action (ATSIPO 2016). The National Congress of Australia’s First Peoples, National Aboriginal and Torres Strait Islander Legal Services (NATSILS), the NACCHO, The Lowitja Institute, and the Australian Indigenous Doctors’ Association (AIDA) were amongst the leading contributors. The Redfern Statement called for: self-determination; adequate resources for Aboriginal and Torres Strait Islander organisations; a recommitment by the Council of Australian Governments to Closing the Gap; and “addressing the unfinished business of reconciliation” through treaty and constitutional reform (ATSIPO 2016, 6). The statement outlined eight priority areas for Indigenous health policy reform, including: the restoration of Indigenous health funding cuts from the 2014 budget; making ACCHS preferred providers for Aboriginal and Torres Strait Islander people; establishing guidelines that mandate engagement between PHNs and ACCHS, with ACCHS taking a leading role; reforming the IAS; and the development of a “National Aboriginal and Torres Strait Islander Social Determinants of Health Strategy”

(ATSIPO 2016, 9). The Redfern Statement is an explicit Indigenous-community endorsement of a social-determinants explanation of Indigenous health inequity.

This research project follows the lead of Indigenous community organisations and peak bodies. The Redfern Statement, the Uluru Statement from the Heart and the annual Progress and Priorities reports make strident calls for Indigenous self-determination and action on the social determinants of Indigenous health and wellbeing. Governments across Australia also acknowledge the importance of ACCHS in the delivery of primary health care to Indigenous peoples (DoH 2016c; NSW Government and AH&MRC 2015), the centrality of the social and cultural determinants of Indigenous health (DoH 2017a). However, the policies, primarily at the Commonwealth level, that govern the work of ACCHS and the delivery of Indigenous-specific services and programs do not reflect a deep appreciation of the special attributes of Aboriginal Community Controlled organisations (AH&MRC 2015, 8- 9; Baum et al. 2013, 7-8). This thesis is an exploration of the political ideologies and social constructions that have led to the unequal and neglectful treatment of ACCHS by government.

Undermining Indigenous self-determination through competition Sanders has argued that managing Indigenous Affairs is an inherently cross-cultural exercise, making it more complex than other policy areas (Sanders 2013, 167; see also Martin 2005). The enduring impact of mistrust, trauma, stress and anger produced by historical and contemporary institutional racism makes Indigenous Affairs even more complex and sensitive (Durey 2010; Paradies, Harris & Anderson 2008; Kelaher, Ferdinand & Paradies 2014; Reconciliation Australia 2016, 14). But NPM does not allow for these cross-cultural or historical factors when making decisions about public services and funding. Chapters 3, 4 and 7 explore these accountability tensions, examining the possibility that NPM could erode the trust between Indigenous organisations and service users, disempower Aboriginal communities and silence a significant source of Aboriginal advocacy on health issues. The (il)logic of NPM has the potential to transform contracted non-profit organisations into proxy government agencies (Schmid 2003, 320). The implications of this autonomy-control tension are expanded upon in Chapters 3 and 4.

The IAS is the largest Indigenous Affairs funding process in Australia. Since its introduction, ACCHS are finding themselves adopting mainstream commercial practices in a bid to ensure their ongoing receipt of government revenue, as detailed in Chapter 7. One of the effects of the application of NPM to mainstream NGOs is that as they have become more business- like, the less they are connected to the needs and goals of their communities (see for example Van Slyke 2003; Schmid 2003, 315; Considine, O’Sullivan & Nguyen 2014; Eikenberry & Kluver 2004). In this way, NPM incentivises assimilation to dominant commercial practices and values. This recalls the logic of “domestication” that Bradfield has identified, where the state recognises but at the same time controls Indigenous efforts towards self-determination by monitoring and managing Aboriginal Community Controlled organisations (Bradfield 2006, 82; see also Schulte-Tenckhoff 1999). Comparing recent policy changes to historical patterns and reforms prompts a consideration of whether the IAS and other related reforms are a novel application of NPM principles, or if they are part of a longer process of ‘eliminating’ Indigenous presence and/or difference? (Wolfe 2016, 33). Perhaps they are something new entirely, which does not fit neatly into these theoretical schemas? These questions are examined in Chapters 3 and 4.

Methodology, ethics and foregrounding Indigenous perspectives The methodological approach of this thesis emerged from an ethical commitment to working in partnership with Indigenous communities in research. This aligns with some of the core principles of decolonising methodologies, which prioritise Indigenous participation in research about Indigenous peoples. Following Tuhiwai-Smith (1999), Sherwood et al. (2015) and Hart (2010), this thesis invites Indigenous communities to speak for themselves. Rigney calls this “privileging Indigenous voices” (1999, 166). Including and prioritising Indigenous perspectives in Indigenous health research is crucial because Indigenous voices have been persistently ignored or silenced in research about Indigenous lives (Stanner 1968; Anderson & Whyte 2008, 831; Hart 2010, 5; Wilson 2008).

Scholars articulating the decolonising or Indigenous-centred paradigm have emphasised the importance of valuing Indigenous perspectives, experiences and priorities in order to understand what is important to Indigenous communities (e.g. Wilson 2008; Hart 2010). This project seeks to better understand how Indigenous organisations experience and interpret government policies. Towards this end, it asks Indigenous organisations to

31 evaluate the policies that affect their daily work and lives. This is a project that asks: ‘How well do Indigenous Affairs policies meet the expectations of Indigenous community organisations?’. This understanding of the ethics of undertaking decolonising research led to the selection of interviews as the primary method of data collection.

This thesis used in-depth interviews in an attempt to mitigate some of the inherent limitations of research conducted from an “outsider” positionality (Rowe 2014, 628). While my positionality as a middle-class, White, Settler-Australian, male graduate student with limited experience working in Aboriginal community contexts is inescapable I have attempted during every contact with Indigenous people and ACCHS representatives to establish a collaborative contract of relationship equivalence, respect for knowledge and culture, and shared learning. This was vital not only for ethical reasons (discussed further in Chapter 5) but also to fill in some of my knowledge gaps as a researcher. Following Gillian Rose’s feminist and post-Marxist understanding of knowledge as situated and therefore partial (1997, 305) the research project prioritised interviews as a way of drawing on the knowledge of people who occupy a different positionality, and who are partially the objects of investigation. The privileging of interview data generated through conversation with “insiders” (Rowe 2014, 628) made “for a more complete analysis of the complexities of social world” (England 1994, 81), which in this case are the inner workings of ACCHS. Accepting the inevitability of the biases and blind spots occasioned by my own positionality, I selected a semi-structured interview method and engaged an Aboriginal Governance Committee (AGC) to advise me. It is further to be hoped that the flexible nature of the interview process, and the invaluable input of a team of Indigenous advisors allowed for the construction of a more complex if nevertheless ‘partial’ account of ACCHS and their interactions with governments and mainstream health providers. More detail on the interview process and fieldwork can be found in Chapter 5.

Much of the past research conducted on Indigenous peoples has benefited non-Indigenous researchers’ careers, generating little or no positive outcomes for Indigenous communities (Tuhiwai-Smith 1999; Simonds & Christopher 2013, 2185). To overcome this exploitative dynamic, research ethics processes now require researchers to undertake to deliver “net benefits for Aboriginal people and communities” (AH&MRC 2008, 4). An ethical approach to

Indigenous research involves responding “to the needs and interests” of First Nations peoples (AIATSIS 2012, 16). Therefore, a central goal of the thesis is to develop targeted policy recommendations that would improve Indigenous wellbeing. By following a decolonising methodology and prioritising the creation of research outputs that benefit Aboriginal peoples, this research has produced policy recommendations that if implemented, have the potential to improve Indigenous health.

As an exercise in cross-cultural policy evaluation, this project analyses the effects of recent Indigenous Affairs policy changes and health policy reforms. Specifically, it looks at how recent policy changes have impacted ACCHS, described as “crucial vehicles for improving Indigenous health outcomes in Australia” (Brigg & Curth Bibb 2017, 199). This investigation considers both Indigenous and non-Indigenous points of view; however, the project privileges the insights and priorities of the Indigenous sector. This is because Indigenous- sector organisations have often been ignored in policymaking and policy evaluation (Calma 2007b; Senate FPARC 2016; Nicholson et al. 2009). Additionally, the Indigenous sector is directly affected by recent policy and funding changes. A central contention of this thesis is that the greater investment in the ACCHS model of care, and the Aboriginal Community Controlled governance model has the potential to produce significant Indigenous health benefits, building on the ACCHS sector’s achievements to date.

Methods This project used semi-structured interviews to gather previously untapped perspectives from ACCHS staff. These interviews were conducted in their places of business. The majority of the interviewees in this study are Aboriginal and Torres Strait Islander people, as are ACCHS staff across the sector (NACCHO 2018, 43). However, both the ACCHS sector and the interview cohort include many non-Indigenous people (see Appendix 1 for more details on interviewees). Interviews lasted roughly 1–2 hours and were loosely structured around a list of 20 questions. The audio of the interviews was recorded and then transcribed to facilitate analysis. Interview transcripts were analysed using a process of thematic analysis (Ezzy 2003; Pope, Ziebland and Mays 2006; Gomm 2004, 184). This generated emerging and recurring themes and codes that then became concepts for analysis, critique and theorising. To analyse the core policy documents that outline the principles and structures that underpin the IAS, the IAHP and the PHNs, I drew on the insights of post-positivist or

33 constructivist policy analysis (Bacchi 2009; Kratochwil 2008; Fischer 2003; Stone 2002; Schneider & Ingram 1997). A more extensive explanation of the interview methods and data analysis is included in Chapter 5.

Thesis structure Chapter 2 is centred on the critically important role, functions and contributions of the ACCHS sector. This chapter canvasses the social determinants of health literature, weighing up the evidence and causal explanations it offers, and critically analysing the application of social determinants of health theories to Indigenous health inequality in Australia.

Chapter 3 contextualises neoliberal Indigenous policy in the longer historical process of settler colonialism (Wolfe 2016). It also surveys the literature on the emergence of NPM and neoliberal ideology around the world and in Australia, examining the evidence for and against its application to social welfare services. To conclude this chapter, I use Ingram and Schneider’s (1997; 2005) ‘Social Construction of Target Populations’ theory to account for the ongoing marginalisation of Indigenous organisations within the social policy system.

Chapter 4 explains and analyses three recent federal government policy initiatives that have had a significant impact on ACCHS: the IAS; the IAHP; and the PHNs. This chapter describes the policy context in which ACCHS currently operate. The background of these policies is outlined and the common thread that runs through all three – NPM principles – is detailed. NPM’s implications for Indigenous health and ACCHS are discussed and likely future policy directions are contemplated.

Chapter 5 outlines and explains the research methods that were used to gather analyses interview data collection. It includes detailed information about the interviewees, participating organisations and the involvement of an AGC. The ethics approval process is also explained in this chapter.

Chapters 6, 7, 8 and 9 are based on my analysis of the interview data. Chapter 6 concentrates on the first research question of the thesis and discusses the factors that contribute to Indigenous health and wellbeing outcomes. It explains how ACCHS act on these factors. Chapter 6 also presents a central contribution of the thesis: a three-tiered model of First Nations health inequity, which is built from interviewees’ explanations of

Indigenous health and wellbeing. This chapter is crucial for the overall contribution and argument of the thesis, as it sets out and explains what ACCHS do and why.

Chapter 7 is organised around an emergent theme from the interviews with ACCHS: accountability and governance tensions. Interview respondents described the constant need to manage diverse expectations – at the community level, within the organisation, and in dealing with governments – as one of the most difficult aspects of their work. This tension is borne out of what Rowse (2002, 236) calls “the rationalising cultural imperative” of the self- determination policies that led to the creation of the Indigenous sector. The effects of these structural tensions are analysed as is the extent to which recent policies ameliorate or exacerbate them. Self-determination, specifically in relation to ACCHS governance, is discussed and interviewees’ understandings of the importance of Community Control are explored.

Chapter 8 focuses on challenges associated with government funding arrangements and associated policies. This chapter is organised around the impacts of new funding structures introduced by the IAS, IAHP and PHNs. The chapter also analyses the way in which recent funding changes appear to exacerbate an existing bias towards funding medical interventions over preventive public health measures.

Chapter 9 focuses on a final theme from the interview data: ACCHS’ complex relationships and interactions with mainstream services. Interview respondents described instances of damaging miscommunication, uneven reward for effort, unrealistic expectations, and the challenges of integrating Indigenous and Western understandings of health and wellbeing. This chapter introduces the concept of ‘two-way learning’ as a strategy for improving relationships between mainstream health services and ACCHS.

Chapter 10 is a summary and conclusion in which I reflect upon the responses from ACCHS, the frustrations they have expressed and the policy recommendations they have proposed. I look at what they believe is working well and make specific policy recommendations on how to strengthen the ACCHS sector, enhance Indigenous self-determination in health, and improve the care that Indigenous patients receive in all health settings.

Chapter 2.

The political and social context of First Nations’ health inequity

This chapter outlines the historical emergence of the Aboriginal Community Controlled Health Services. It describes the challenging social, economic and political circumstances that precipitated their establishment by Aboriginal communities from the early 1970s. The chapter also reviews the relevant literature on the social determinants of health and health inequity. Drawing on relevant theoretical frameworks and empirical findings, this chapter explains Indigenous health inequity and how ACCHS, also known as Aboriginal Medical Services (AMSs), address its root causes. The literature on psychosocial health determinants receives special attention here, because of its relevance to the ‘Aboriginal Community Controlled’ governance model. The psychosocial health literature concentrates on perceptions and psychological effects of social and economic inequality (e.g. Siegrist & Marmot 2004). This chapter also explores the available literature on the specific determinants of Indigenous health inequity in Australia, concentrating on racism and the ongoing effects of ‘structural violence’ (Galtung 1969; Farmer et al. 2006; Maddison 2013). Building on an analysis of Indigenous health inequity as a consequence of colonial oppression and racism, I examine the various approaches to minimising racism in service delivery settings, focusing mainly on cultural safety.

A recurrent theme in this chapter is that power and Indigenous peoples’ ability to control their own affairs are of great significance to health equity. The exercise of colonial power and the powerlessness that it produced in First Nations are understood as the root cause of First Nations peoples’ inequitable health status. Community empowerment has been linked to more equitable health outcomes for marginalised communities across the world (Rifkin 2003; Wallerstein 2006), making ACCHS’ work critical to the success of campaigns to close the gaps in health and improve First Nations health and wellbeing.

Operationalising Aboriginal self-determination in healthcare ACCHS deliver comprehensive, and culturally appropriate healthcare to Aboriginal and Torres Strait Islander peoples. They also deliver a range of health promotion, illness prevention, and social programs, which are described in greater detail in Chapter 6. First

Nations peoples own, run, and oversee their ACCHS, which are governed by community- based boards of directors, elected by members of the health service (Grant et al. 2008, 8; Campbell, et al. 2017). ACCHS act as “local employment hubs” (Lovett 2014, 45) for First Nations peoples, directly addressing this key socio-economic determinant of health. The ACCHS sector is the largest single employer of Aboriginal and Torres Strait Islander peoples in Australia (Alford 2014, 11), employing over 3,300 First Nations workers in 2017-18 (NACCHO 2018, 43). 56% of the ACCHS workforce is Indigenous (NACCHO 2018, 43).

Scholars have argued that ACCHS are a practical embodiment of Indigenous self- determination (Davis, 2013; Rowse 2012, 101), giving Aboriginal people a say on what their health services do and how. As one of the Redfern AMS’s foundational members, Gary Foley, maintains, “the basic philosophical principle that guides our work is ‘self- determination through community control’" (1991, 4). One common factor across the ACCHS sector is the Aboriginal Community Controlled governance structure (Larkins, Geia and Panaretto 2006, 2), which is elaborated in Chapter 7. For a health service to be Aboriginal Community Controlled it must be initiated by and based in a local Aboriginal Community and be governed by an Aboriginal board of directors elected by that community (NACCHO 2011, 5). In addition, the services an ACCHS offers must be “holistic and culturally appropriate” (NACCHO 2011, 5). Aboriginal Community Control, holism and cultural appropriateness are at the heart of the ACCHS philosophy of healthcare.

Creating space: Aboriginal Medical Services in hostile socioeconomic times ACCHS emerged before Australia’s systems of universal public health insurance were established (Duckett and Wilcox 2015, 208). Medibank was introduced by the Whitlam Labor government in 1975, substantially curtailed by the conservative Fraser government in 1976, and Medicare was introduced in 1984 by the Hawke Labor government (Biggs 2004). Between the Second World War and 1975 some medical services were provided free-of- charge to those who could pass a means test in hospital outpatients departments and public wards, and from 1970 free health insurance was offered to low income earners and people on social security payments (Saggers and Gray 1991, 128). Many Aboriginal people would have qualified for free healthcare under these schemes; however, they were often deterred by the complex bureaucratic procedures involved in applying for this assistance, combined with the culturally unacceptable way that many health services were delivered, and the

37 racist attitudes of many health providers (Saggers and Gray 1991, 145-6). The lack of Aboriginal doctors, the overt racism experienced by Aboriginal people attending hospitals and the cash advances required for treatment meant that for many Aboriginal people in the early 1970s medical care was unobtainable (Foley 1991, 4). In these challenging material and social circumstances Aboriginal activists and their supporters were motivated to offer affordable and acceptable health care to Aboriginal people, who were largely medically uninsured and unable to access healthcare via the private sector (Grant et al. 2008, 7).

The Aboriginal activists who set up the first ACCHS sought to overcome these cultural and social barriers to healthcare for Aboriginal people. The first ACCHS was established in Redfern in 1971 as part of a broader pan-Aboriginal social movement for Aboriginal rights (Foley 1991, 4-6). Redfern’s Aboriginal activists were inspired by the international Black Power movement and local efforts to confront racism, such as the Freedom Ride organised by Charles Perkins and Reverend Ted Noffs in 1965 (Foley 2009, 14-16). The first AMS was a “self-help project, conceived, created and controlled by Indigenous people” (Foley 2009, 16) and was a response to institutional racism so severe that “in some cases … Aboriginal people would literally rather die than be subjected to degrading humiliating treatment at the hands of non-Aboriginal health workers” (Foley 1991, 4). The Redfern AMS initially relied on a roster of volunteer doctors and nurses, and Aboriginal field officer Shirley Smith (Foley 1991, 5). In the years to come Redfern AMS would loan its staff to other fledgling ACCHS that had few other sources of support (Grant et al. 2008, 8).

Other Aboriginal communities established their own ACCHS soon after the Redfern AMS was up and running. In 1973 the Victorian Aboriginal Health Service was opened in the Melbourne suburb of Fitzroy (VAHS n.d.), and in 1975 the Central Australian Aboriginal Congress founded an ACCHS in Alice Springs (Reid, Taylor & Hayes 2016, 160). By 1978 there were approximately 12 ACCHS across Australia (Grant et al. 2008, 8). While their expansion was initially limited by a lack of government funding and their reliance on donations (Foley 1991, 5; Grant et al. 2008, 8), their survival has been held up as a testament to Aboriginal resilience and ingenuity, “proving to the mainstream community that Aboriginal people could organise and raise funds” to meet their own healthcare needs (Reid, Taylor & Hayes 2016, 158). In 2018 the Australian Government reported that it funded 136 ACCHS to

38 deliver Indigenous primary health care services across Australia, including 38 ACCHS in NSW and the Australian Capital Territory combined, the highest of any state or territory (AIHW 2018, 24). NACCHO, however, reports (2018, 14) that it represents over 140 ACCHS, indicating that not all ACCHS receive federal funding. Available data indicates that ACCHS provide approximately 50% of all primary health care to Aboriginal and Torres Strait Islander peoples, and that overall, where ACCHS exist First Nations peoples do and prefer to use them (Panaretto et al. 2014, 650). For these reasons ACCHS are among the most important health service providers to Aboriginal people today.

In their first two decades of operation the ACCHS quickly accumulated experience and expertise in Aboriginal health policy and service delivery (Grant et al. 2008, 11-12). Following a meeting of health and Aboriginal affairs ministers in 1987, an Aboriginal-led working party was established, chaired by the director of the Redfern AMS, Naomi Myers, to develop a National Aboriginal Health Strategy (NAHSWP 1989, 1). The creation of this strategy has been described as “a defining moment” in the history of Aboriginal health (Grant et al. 2008, 12). The concepts that the 1989 NAHS set out, such as the definition of Aboriginal health, continue to inform ACCHS’ work to this day (e.g. NACCHO 2011, 5; AH&MRC 2008, 32). The Working Party reported that during its consultation with Aboriginal organisations “philosophical, political and public health issues were raised rather than specific disease problems” (1989, appendix I). This focus on broader determinants of health, related to values, power, and living conditions, was encapsulated in the Strategy’s definition of health as: “not just the physical well-being of the individual but the social, emotional and cultural wellbeing of the whole community” (NAHSWP 1989, x, emphasis added). This holistic definition of health also implies that healthcare involves much more than treating illness in individuals.

Implementing comprehensive primary health care for Aboriginal community contexts The ACCHS approach to healthcare closely aligns with the internationally recognised model of Comprehensive Primary Health Care (CPHC) (Reid, Taylor and Hayes 2016, 158). This model, outlined in the World Health Organisation’s 1978 Alma Ata Declaration, embodies a holistic and empowering health philosophy. The Alma Ata Declaration recommends, among other things, “promotive, preventive, curative and rehabilitative services”, as well as

“maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care” (WHO 1978, 2). The principle of community control is at the heart of the Alma Ata Declaration. The National Aboriginal Health Strategy (NAHS) Working Party built on the Alma Ata definition of primary healthcare (Bell et al. 2000, 77). The NAHS defined primary health care as:

practical, scientifically sound, socially and culturally acceptable methods and technology made universally accessible to individuals and families in their communities in which they live through their full participation at every stage of development in the spirit of self-reliance and self-determination. (NAHSWP 1989, x)

In both the Alma Ata Declaration and the NAHS identify the principles of community participation and self-reliance as essential elements of primary health care.

The parallels between the international model of CPHC and the ACCHS’ approach are unmistakable and have been noted many times before (e.g. Grant et al. 2008, 8; Taylor and Guerin 2010, 101). Moreover, a recent evaluation identified ACCHS as the organisations in Australia that most faithfully implement the Alma Ata model of Comprehensive Primary Health Care (Hurley et al. 2010). This is significant because Comprehensive Primary Health Care, or Universal Primary Health Care as it is sometimes called, has been identified by the World Health Organisation as the model of healthcare most likely to reduce health inequalities (CSDH 2008). This has been further confirmed in the Australian context in a recent study which has found evidence of a link between Aboriginal participation in health governance (i.e. decision making and implementation) and improvements in health equity (Kelaher, et al. 2014).

In practice, the ACCHS approach to comprehensive primary health care involves employing “multidisciplinary teams” on a salaried basis (Duckett and Wilcox 2015, 208) rather than being “general practitioner-focused” (Panaretto et al. 2014, 649) and relying on activity- based revenue streams. However, there is evidence that this funding focus is shifting, in response to policy changes, as detailed in Chapters 7 and 8. There is significant variation between ACCHS across Australia, reflecting the diversity of First Nations peoples, their histories, cultures and preferences (Reid, Taylor and Hayes 2016, 158). ACCHS’ diversity is

40 also a product of the unique health needs of each Aboriginal community (Campbell et al. 2017, B).

Enabling health through social and community services ACCHS deliver a range of clinical and allied health services and are also involved in community development and health promotion, acting as valued community hubs (Bartlett & Boffa 2005, 58). Most ACCHS employ GPs, while many also provide services for the diagnosis and management of chronic diseases, antenatal and postnatal care, counselling for social and emotional wellbeing (SEWB), and deliver substance abuse and tobacco management programs (AIHW 2018, 27). ACCHS also commonly provide access to dental care, specialist care, and allied health services, either on ACCHS premises or externally (AIHW 2018, 27). Some smaller ACCHS operate without medical practitioners, relying on nurses and Aboriginal health workers to deliver preventive programs and health education (Taylor and Guerin 2010, 149; Bell et al. 2000, 80). The ACCHS that participated in this study ranged from large multipurpose health centres that employ dozens of staff, to small outposts that rely on nurses, Aboriginal health workers and visiting service providers. Many ACCHS also offer transport for clients to and from appointments, overcoming this socioeconomic barrier to healthcare access (Davy et al. 2016; Ware 2013). More details of the range of services they offer are provided in Chapter 6 but suffice to say ACCHS provide much more than clinical healthcare.

Improving access to healthcare for marginalised peoples According to Australian Institute of Health and Welfare (AIHW) 17% of the Indigenous population in NSW usually goes to an ACCHS if they have a problem with their health (AIHW 2017a, 148). However, a higher proportion (32%) of the NSW Indigenous population prefers to attend an ACCHS, while only 50% has an ACCHS available to them (AIHW 2017a, 148). These figures indicate that more First Nations people in NSW would attend an ACCHS if they were able to access one. Similar patterns of service usage, preference and availability are reported at the national level (AIHW 2017a). Other studies suggest that First Nations people prefer to receive healthcare in ACCHS rather than mainstream settings. These studies focus on chronic disease management (Aspin et al. 2012; Govil et al. 2013; Jowsey et al. 2012), sexual health (Ward et al. 2013), and maternal and child health services (Jan et al. 2004;

Campbell and Brown 2004; Panaretto et al. 2005). Panaretto and colleagues calculated that, in regional areas, over 50% of the Indigenous population uses ACCHS (Panaretto et al. 2014, 649). A subsequent study led by the same author (Panaretto et al. 2017) found that for Aboriginal and Torres Strait Islander peoples in Queensland ACCHS usage was higher than Australian Bureau of Statistics data would suggest and concluded that ACCHS are valued by First Nations people in Queensland, particularly in areas outside major cities.

Providing high-quality clinical care The few studies that have compared the clinical outcomes achieved by ACCHS with those achieved by mainstream general practices suggest that ACCHS’ performance is equal or superior to that of mainstream services (Jan et al. 2004; Panaretto et al. 2005). There is evidence that ACCHS general practitioners (GPs) manage a higher number of health problems than mainstream GPs (Larkins et al. 2006), and that ACCHS consultations involve the management of more complex health problems (Thomas et al. 1998). There is also evidence that ACCHS provide more cost-effective care for Indigenous patients than mainstream health services, because of “higher Indigenous rates of utilization of health services and adherence to treatments delivered from ACCHS compared to mainstream GP practices” (Ong et al. 2012, 8). ACCHS deliver valuable health education (Baba, Brolan and Hill, 2014, 6) and support clients in their follow-up care and treatment (Panaretto et al. 2014). Campbell and colleagues (2017) have written a thorough review of the literature covering ACCHS’ contributions to the health system and Indigenous health overall. While the Australian government has collected data since 2012, measuring the performance of organisations delivering primary health care to Indigenous Australians (Duckett and Wilcox 2015, 208), in reporting this data the AIHW does not disaggregate it to make possible any comparisons between Aboriginal Community Controlled, government-run and mainstream non-government providers (e.g. AIHW 2018). This should be remedied in future publications, to make possible a comparative assessment of the relative contributions of different providers in the Indigenous primary health care system.

ACCHS’ actions on the social determinants of health While ACCHS’ clinical contributions are valuable and in need of greater study, ACCHS’ social, economic, cultural and political contributions are arguably of greater significance for both

Indigenous health and reducing health inequity. As a recent review highlighted: “ACCHS are notable for addressing the socioeconomic determinants of health” (Campbell et al. 2017, F). This is crucial work, given that the Australian Institute of Health and Welfare calculates that 39% of the health gap between Indigenous and non-Indigenous Australians is due to social determinants such as housing, education, employment, drug and alcohol abuse and smoking (AIHW 2018). ACCHS offer primary health care, which involves more than just clinical health services. It is a development-based service model which focuses on strengthening social ties and support networks to create more health-protective community environments (Duckett and Wilcox 2015, 187). Primary health care is an approach to wellbeing that emerged from the ‘social model of health’, which is both a philosophy about fairness and equity, and an understanding of health as something that is determined by social, economic, and environmental factors (Keleher 2016, 76). This social perspective on health challenges the biomedical perspective, which has been dominant in the Western world for the past 200 years (Foucault 1973).

The social model of health is of great relevance to the work of policy makers. As Geoffrey Rose explains (1985), the potential health benefits are greater if policymakers and health professionals focus on the underlying (social) causes of incidence in society rather than on the specific markers of susceptibility in individuals. The biomedical approach assumes a body/mind dualism and analyses and treats the immediate causes and manifestations of disease in isolation from the rest of the body and its social environment (Saggers and Gray 2007, 4). The biomedical model has delivered significant advancements in care for individual patients, but it has been criticised for obscuring and neglecting the underlying causes of disease at the population level, and prioritising research into cures rather than working on ways to prevent illness in the first place (Baum 2010, 36). Baum characterises the biomedical idea of health as “the body operating efficiently like a machine” (2015, 3).

In contrast, the literature (e.g. Atkinson 2011; Rogers 2008; McNeill and Reiger 2015) that uses the social model of health has sought to understand and address broader health- influencing factors in society. This social approach has become linked to ‘the social determinants of health’ framework (Wilkinson and Marmot 2006). The social determinants framework and its conceptual basis are fundamental to this study of Indigenous health

43 inequity and its exploration of ACCHS’ work. This thesis shows that Indigenous health inequity can be explained by First Nations peoples’ disadvantaged material conditions, their position on ‘the social gradient’ (Marmot 2005; Marmot 2011), and their specific experiences of racism, and structural violence. I address these social determinants in turn, discussing the historical emergence of the social model of health and explaining its conceptual strengths and relevance to Indigenous health.

Linking material conditions to health outcomes There is a long history of social science and epidemiological research linking everyday living conditions to health outcomes (Chadwick 1842/1965; Villerme 1840;́ Engels 1845/1968). Pioneering studies in the early nineteenth century, such as those by French surgeon and social researcher Louis-René Villermé, and by the English civil servant and lawyer Edwin Chadwick, established correlation between poverty rates and mortality, and noted class- based differences in life expectancy (Julia and Valleron 2011; Birn 2009). Writing around the same time, the political radical and pioneering social scientist Friedrich Engels (1845/1968) was the first to theorise that class-based health inequalities were caused by adverse social, environmental and economic conditions (see also Germov 2014, 10). Engels saw poverty, and the crippling material conditions associated with it, as a root cause of sickness and premature death. The medical doctor John Snow was another early public health investigator. He successfully traced the source of an 1854 cholera outbreak to a water pump in London’s Soho district (Baum 2015, 22). After ordering that the pump handle be removed and successfully containing the spread of the cholera outbreak, he proved that the quality of public utilities significantly impacts on public health, subsequently putting more responsibility for health onto governments and policymakers (Saggers & Gray 2007, 3). These early studies of health and its relationship to material living conditions contributed to an understanding of health as something not predominantly determined by biological advantages or moral fortitude, as was previously believed (Birn 2009, 170), but as a something largely determined by socioeconomic factors and government decision-making.

The above evidence demonstrates that since the mid-nineteenth century it has been known that social conditions and population health are related. However, the relative health impact of social factors compared with advancements in medical knowledge has remained

44 contentious until relatively recently. McKeown's controversial and critical analysis of the relative impact on mortality of medical interventions, public health initiatives and economic changes altered previous understandings of the causes of population health (Baum 2015, 26). In The Role of Medicine, McKeown contended that between the mid-19th century up until the book's publication in 1979, key public health measures (namely purification of water supply and improvements in sewage disposal) had brought about a one fifth reduction in the total mortality in England and Wales from all causes (McKeown 1979, 76).

McKeown showed that the rest of the decline in mortality for infectious diseases during this period was due to environmental improvements and economic shifts, which had improved living conditions, nutrition, water quality and sanitation in the British Isles. He argued that the overall contribution to the reduction of mortality rates made by medical interventions, such as vaccination programs and curative treatments, had been minimal compared to these earlier socioeconomic shifts. Although some other aspects of McKeown's thesis have been subsequently refuted, his contention that curative medical interventions played little part in the reduction in mortality that occurred prior to the mid-twentieth century has stood the test of time (Colgrove 2002, 728; Nettleton 2006, 4). Social, economic and environmental conditions play a substantial role in creating the health profile of a population, and studies such as McKeown's were front-runners in the social determinants literature, pointing out that medical care has not historically been the crucial variable when it comes to better or worse health for populations (Colgrove 2002, 725; Graham 2004, 105).

McKinlay developed a powerful economic and political critique (1975) of the conventional curative approaches to treating illness. He argued that rather than focusing on ways to get individuals to practise more healthy behaviours, public health campaigners needed to “refocus upstream” on the activities of powerful economic and political actors. McKinlay highlighted large corporations’ manipulative marketing strategies and their creation of artificial needs through advertising, practices which habituated large numbers of people to ‘unhealthy’ behaviours (1975, 8). McKinlay identified the “entrepreneurial activities of the manufacturers of illness” (i.e. corporations and other powerful economic actors) as the root causes of death and disease, and argued that public intervention, therefore, should be targeted at the structures of the political economy (1975, 13). McKinlay’s critique, like

McKeown’s, sought to re-frame health and illness as consequences of societal forces, rather than the result of individuals’ behaviours or medical care (see also Geoffrey Rose 1985; Kickbusch 2012). These ground-breaking scholars demonstrated the social provenance of health.

Recognising the health impacts of global inequalities More recently, the World Health Organisation’s Commission on the Social Determinants of Health argued that a country’s level of overall health and of health inequality is determined by “the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness” (CSDH 2008, iii). These circumstances, argued the Commission, are products of political, economic and social processes. The social determinants of health and health inequity will vary from country to country but in general greater health equity is associated with a fairer distribution of “power, money and resources” (CSDH 2008, 109; see also Wilkinson & Pickett 2010). In a separate work the Commission’s chair (Marmot 2015) linked inequities in these kinds of political and material conditions to the specific health issues experienced by First Nations in Australia. Marmot identified “disempowerment” and “community disruption” as root causes of Indigenous health inequities (Marmot 2015, 242). Indigenous health inequities, like health inequities experienced by other socially marginalised groups, are the result of “inequities in power, money and resources” (Marmot 2015, 243). Social determinants research, and the accompanying public health campaigns led by the World Health Organisation, are grounded in an ethical commitment to equity and fairness in health and addressing the societal conditions that produce health disparities within and between nations. By taking a holistic approach to primary health care that addresses social determinants, ACCHS attempt to optimise family and home environments to promote good health (Campbell et al. 2017, E).

It is now generally accepted that a combination of numerous social and economic factors, including education, health literacy, early life experiences, income, living and working conditions, nutrition, the natural and built environment, access to social security payments, and the quality and availability of health care all play a part in creating the health profiles of populations (Kickbusch 2008; Marmot 2006; Dahlgren and Whitehead 1991; Braveman et al. 2010; CSDH 2008; Wilkinson and Marmot 2003). Public health interventions and the amount of spending on health care are important, but so are other social institutions such as local

46 eating and drinking customs (Powles 2001), patterns of physical exercise (CSDH 2008, 1663), gender equality (Navarro 2007, 2) and social support networks (Wilkinson & Marmot 2003). Economic, social, political, geographic and cultural factors are all at work in determining the health of populations and different groups within populations. Socioeconomic inequality though, has been shown to be a reliable predictor of health inequality within a society and of lower overall levels of health for societies (Wilkinson and Pickett 2010; Nowatzki 2012).

The social gradient and psychosocial determinants While there is much evidence demonstrating that socioeconomic conditions affect health outcomes, this does not mean that there is a universal material baseline for good health. Researchers have identified a correlation between health outcomes and relative social position. Marmot, Shipley and Rose (1984) conducted a longitudinal study of the health outcomes of a group of British civil servants. They found that mortality and employment grade were inversely correlated. Those in the lowest employment category were three times as likely to die as those in the highest category (Marmot, Shipley & Rose 1984, 1003). One of Marmot and colleagues’ subsequent studies (Marmot et al. 1991) reaffirmed the relationship between employment grade and mortality, and also found that people in lower status jobs were more likely to be sick, to engage in unhealthy behaviours such as smoking and not exercising, and that they were more likely to have a lower self-perceived health status. The Whitehall Studies, as they are now known, found that the lower one’s position in the social and economic hierarchy, the more likely one is to suffer disease, risk one’s own health, feel unwell and die.

Marmot and his colleagues found evidence that health follows a social gradient. Their findings show that this gradient continues even after people have access to adequate material resources, such as housing, food, clothing, water and sanitation. In fact, all the research participants in the Whitehall studies were in stable, white-collar employment in London and earned adequate salaries (Marmot 2006, 38). None was living in a state of material scarcity yet there was a gradient in health according to employment grade. Many other studies have also found evidence of a social gradient in health (e.g. Costa et al. 2002) and this gradient has been observed, to varying degrees, across the industrialised world (Shaw, Dorling and Davey Smith 2006, 197; Robinson 2007). This unexpected finding led

Marmot and his co-investigators to surmise that health was affected by social factors other than economic and material deprivation. In attempting to explain the correlation between health status and social status Marmot and colleagues pointed to stress and other ‘psychosocial’ variables such as: control and demand in the workplace; requirements to work at a fast pace; options for work variation; and work satisfaction (Marmot et al. 1991, 1390). What all these factors have in common is that they relate, in a sense, to the power to control one’s own activities. They are related to autonomy. Indeed, other studies have also concluded that powerlessness is a major risk factor for disease (Wallerstein 2006; Wallerstein 2002; Wallerstein 1992; Siegrist & Marmot 2004; Murray et al. 2004; Rappaport 1981).

Explaining the psychological pathways between social inequality and health Consequently, psychosocial determinants of health have received increasing attention in the literature that deals with health inequality between population groups. Scholars have investigated how psychosocial factors such as stress (e.g. Brunner and Marmot 2006), social inclusion/exclusion (Wilkinson & Marmot 2003), and self-efficacy (Siegrist & Marmot 2004), affect health outcomes and behaviours, and contribute to the social gradient in health. Wilkinson (2006) contends that social status has an important psychosocial effect on health. He explains that lower social status is associated with lower levels of health, as is lower control over work activities and subordination in general (Wilkinson 2006, 342). He theorises that the gradient in health outcomes is affected by how much control and power people have in relation to others. Research such as Wilkinson’s on psychosocial factors has expanded the scope of health investigation beyond material factors.

Power and powerlessness: the undercurrents of the ‘social determinants’ agenda Theories of psychosocial health determinants add nuance to our understanding of First Nations health inequality in Australia. Their utility lies in their treatment of power and powerlessness. Powerlessness is a socio-political condition that motivates First Nations peoples’ ongoing struggles for self-determination. For example, the Uluru Statement from the Heart explains, in relation to Indigenous peoples’ high rates of incarceration and youth detention, and the high numbers of Indigenous children in out-of-home care, “[t]hese dimensions of our crisis tell plainly the structural nature of our problem. This is the torment of our powerlessness” (Referendum Council 2017, para. 7, emphasis in original). Similarly,

48 the former Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma notes:

Aboriginal and Torres Strait Islander peoples, like Indigenous peoples around the world, have long asserted that their health is linked to their collective ability to control their lives and cultures and the recognition of their rights. (Calma 2007, S6)

Calma also suggests that First Nations peoples’ “lack of collective control” might act as a determinant of poor Indigenous health and wellbeing (2007, S6).

Empowerment under the ACCHS governance model, discussed in more detail in Chapter 7, occurs through a system of local-level representative democracy. Through participating in elections members of each ACCHS vest board members with the authority to make decisions about the strategic direction of and services offered by the organisation. This study, though, does not interview board members or service members, concentrating instead on senior ACCHS management. Therefore, the findings related to empowerment will reflect the views of ACCHS CEOs and managers and may not necessarily align with the views of board members and/or service users. Further research is required in order to uncover how these groups about empowerment in ACCHS.

While more research is needed on the connections between collective empowerment and health outcomes, this thesis maintains that through empowering Aboriginal communities the ACCHS model of care and governance has the potential to deliver broad psychosocial health benefits (see Chapter 7). Empowerment’s utility as a health promotion strategy has been theorised by public health researchers (e.g. Wallerstein 2002; Labonte 1994). Community empowerment has been defined as "a social action process by which individuals, communities, and organizations gain mastery over their lives in the context of changing their social and political environment to improve equity and quality of life” (Wallerstein 2002, 73). Other academic disciplines, such as community health psychology also champion community empowerment for better health (Murray et al. 2004). This latter field of investigation aims to build community strength and challenge social oppression so that there is more “personal and political awareness of the social constitution of health and illness” (Murray et al. 2004, 331).

Autonomy and self-efficacy in the life-world Aboriginal community empowerment produces community-level benefits that are similar to the individual-level benefits that social health researchers link to feelings of self-efficacy and self-esteem (Marmot, Siegrist & Theorell 2006, 101). Self-efficacy refers to the psychological outcome of learning new skills, working to your potential and exercising autonomy and control over your work, and self-esteem results from, among other things, an appropriate balance between reward and effort in the workplace (Siegrist & Marmot 2004, 1465). Self- efficacy and self-esteem are measures of individual mental health that are most often used in studies focused on the health impacts of the work environment. It could be surmised that these relationships between effort and reward, control and autonomy and positive mental health outcomes must also operate at the community level.

It is also arguable that self-efficacy and self-esteem are comparable to the concept of community empowerment or capacity (Wallerstein 2002, 73) and something like community pride or a positive sense of cultural identity. Sullivan argues that Indigenous sector organisations like ACCHS are expressions of Aboriginal cultural identity (2010, 11). Community-efficacy and community-esteem are useful theoretical concepts that contribute to an understanding of the psychosocial benefits of community control over and involvement in the delivery of health and other services. Murphy’s (2014, 320) characterisation of self-determination as a “collective capability” that enhances Indigenous freedom and wellbeing is another theoretical approach to the links between empowerment and health. I argue that Indigenous peoples’ relatively disadvantaged position in the Australian social hierarchy is a fundamental determinant of their unequal health status. This theoretical understanding aligns with the principles of cultural safety for improving First Nations peoples’ experiences of healthcare, discussed below. It logically follows that a better resourced ACCHS sector, which empowers First Nations people to take control of their own wellbeing, would increase community efficacy and community esteem and generate health benefits for First Nations peoples.

Towards an Indigenous-centred model of health The social determinants literature provides us with a useful conceptual framework for understanding how social and economic conditions affect the health of individuals,

50 population groups and whole societies. However, this framework has been criticised for being ahistorical and tending to homogenise the causes of illness and health across peoples and places (Banerji 2007). Social-determinants approaches also frequently propose welfare- state policies and progressive taxation as the solutions to health inequalities (e.g. Schrecker and Bambra 2015; Marmot 2005; Marmot et al. 2012; Wilkinson and Marmot 2003), without considering the political struggles and social movements required to achieve these social policies (Birn 2009, 172).

Boulton, in his historical-anthropology of Indigenous growth faltering (2016), argues that we need to look beyond social-determinants explanations of health and illness if we are to understand the causes of Indigenous health inequality. Boulton contends that the social determinants framework focuses too closely on the proximal socioeconomic causes of health and illness, such as poverty and unhygienic living conditions, without considering how Aboriginal health has been deeply affected by “the historical and ecological disruptions” that occurred during the colonisation of Australia (2016, 209). Mitchell, for example, links Indigenous experiences of Australian colonial history, such as mass death from introduced diseases, and “two centuries of poverty” brought on by economic exclusion, to Indigenous ill-health presently (Mitchell 2007, 41). These ‘social determinants’ explanations of Indigenous health inequity focus on the biophysical pathways to illness, and ignore the collective, social and spiritual elements of wellbeing.

Boulton’s analysis centres on three political, social and ecological disruptions, explaining their effects on the fundamental “human prerequisites for parenting” (2016, 4). The first disruption Boulton describes is the collapse of the Aboriginal population in the wake of the colonial frontier. He details the demographic collapse that occurred during the first half of the nineteenth century and the subsequent population regeneration from around the 1940s (2016, 123-133). This has led, Boulton explains, to higher numbers of Aboriginal children across the population and fewer older Aboriginal people available to assist with parenting. The second disruption described is to food security. The introduction of European farming and grazing practices inflicted radical ecological disruptions at the colonial frontier (Boulton 2016, 186). This destroyed Aboriginal peoples’ food security and made them dependent on the nutritionally inferior rations handed out on missions, stations and reserves during the

51 protection era. This famine continues in the present day through Aboriginal peoples, particularly in remote communities, subsisting on store-bought processed food (Boulton 2016, 209). These two disruptions meant that multiple generations of Aboriginal children have gone without two of the prerequisites for growth and development: sufficient nutritious food, and support and guidance from multiple adult caregivers or “allo-parents”, such as aunties and grandmothers (Boulton 2016, 4). A third health-damaging factor is Aboriginal peoples’ and particularly children’s, exposure to violence. Boulton uses the concept of ‘structural violence’ to explain how overt violence at the colonial frontier was transformed and cemented into structured inequalities of power and status through successive policies, which have limited the life chances of generations of Aboriginal people (Boulton 2016, 13).

Boulton’s analysis links Australia’s specific history of colonisation to the lower life expectancy of Aboriginal and Torres Strait Islander peoples, explaining how structural violence, food insecurity and population collapse and rapid regeneration constrain Aboriginal parents’ ability to provide for their children. Boulton’s thesis explains how Australian settler colonialism’s particular political, social and ecological disruptions, and the structured power inequalities that it has produced, have impaired the life chances of multiple generations of Aboriginal people. An understanding of these historical determinants of Indigenous health and the importance of early life experience for health across the life-course (Wilkinson & Marmot 2003; CSDH 2008; Wadsworth and Butterworth 2006) illuminates how ACCHS’ health education activities, their focus on prenatal and child and maternal health, and their poverty-mitigation services (all discussed in Chapter 6) act on the fundamental determinants of Indigenous health and illness.

Ongoing racism and its implications for First Nations health Racism significantly impacts the health of First Nations peoples in Australia (Osborne et al. 2013; Larson et al. 2007; Durey 2010; Paradies, Harris and Anderson 2008; Paradies 2007; Paradies 2017; Awofeso 2011; Bourke, Marrie and Marrie 2018; Macdonald 2010). The international literature has also made a connection between racism and health (Williams, Neighbors and Jackson 2003; Nazroo 2003; Krieger 2012; Priest et al. 2013; Williams 2006). Racism is one of the ideological pillars on which colonial violence against of First Nations

52 was based (see Wolfe 2016) and its impacts continue to be felt, to varying degrees, by Aboriginal peoples in the present day (Paradies 2017). Historically, white supremacy and social Darwinist views about Aboriginal peoples being biologically inferior to Europeans underwrote the ‘doomed race’ theory that came to prominence in 1880s Australia and remained influential until at least the 1930s (Francis 1996; Mitchell 2007; Boulton 2016). This racist theory held that over time Aboriginal people would perish and be replaced by White people, who were assumed to be biologically superior. In this way the doomed race theory “naturalised” White dominance, giving it the appearance of scientific fact (Francis 1996, 91; see also Wolfe 2016). Mitchell describes how a “genocidal logic” served to normalise and make uncontroversial the widespread poverty, hunger and disease that Aboriginal peoples suffered during the colonial period (2007, 52). The doomed race theory also informed the systematic removal of Aboriginal children from their families, for their own ‘protection’ (Biddle 2012, 68).

Racism is still a major issue in Australian society, highlighting the ongoing need for culturally safe health care delivered by Aboriginal Community Controlled organisations. Chapter 9 presents interviewees’ accounts of some contemporary examples of racism directed at Aboriginal and Torres Strait Islander people. Interviewees explained that ongoing racism in the health system and in Australian society more broadly detracts from the quality of service provision to First Nations peoples and creates barriers to accessing health care. Some interviewees also gave evidence of how racism impacts other aspects of Indigenous peoples’ lives, such as preventing First Nations peoples from gaining employment (see Chapter 9).

The impact of historical racism on the structuring of power in Australia, and its subsequent health impacts, has been thoroughly analysed (see Wolfe 2016; Veracini 2015). However, the health impacts of contemporary instances of interpersonal racism have begun to receive attention from researchers only recently (Priest et al. 2013). Paradies defines racism in relation to the dual concept of oppression/privilege, which he describes as “a social system in which people are divided along socially constructed dimensions with power unevenly distributed (or produced) based on these dimensions” (2007, 67). Racism, according to Paradies’ definition, is a form of systematic oppression that results in the unequal

53 distribution of power and resources according to socially constructed racial hierarchies. These socially constructed racial hierarchies result in people who are socially constructed as inferior experiencing abuse and discrimination (Durey 2010; Paradies 2007; Paradies 2017). Many Aboriginal and Torres Strait Islander people directly experience interpersonal racism. For example, 33% of Aboriginal and Torres Strait Islander people reported in 2018 that they had experienced “verbal racial abuse” in the past six months (Reconciliation Australia 2018, 5). This has direct relevance for health because experiences of racism have been shown to be associated with physical and mental health conditions (e.g. Priest et al. 2013; Paradies 2007; Paradies and Cunningham 2012b).

The growing understanding of the prevalence and health impacts of racism has led to the creation of a number of anti-racism strategies and training packages for service providers. These are variously termed cultural awareness, cultural appropriateness, cultural safety and cultural security (Best and Fredericks 2014; Taylor and Guerin 2010; Coffin and Green 2017). These frameworks were pioneered by Maori nurses in New Zealand (Best 2014, 52), and the work of Ramsden (2002) has been particularly influential. Ramsden’s (2002, 117) process for developing cultural safety requires individual health practitioners to reflect on their identity, culture, and power, and to understand how these things are shaped by broad social practices and structures. For example, if a middle-class, white, male nurse were to acknowledge how his own positionality (Brooks, te Riele & Maguire 2014, 100) affects his worldview and everyday practices, this would help him better understand how patients with different positionalities, such as being working class, female or Indigenous, might view the world and experience healthcare differently. The recognition of one’s own cultural biases and the understanding of cultural differences are key elements of building cultural safety in healthcare (Ramsden 2002; Best 2014). Taylor and Guerin (2010, 15-16) outline the key elements of cultural safety. They highlight the need for health practitioners to be reflective on their own practice, to be conscious of and try to minimise power differentials between themselves and clients, and to engage in respectful dialogue with clients (2010, 15). Muller, in her theory of Indigenous Australian health and human service work (2014) also emphasises the importance of equal valuing of all people and respectful communication between healthcare practitioners and patients. Decolonising is also central to the practice of culturally safe care (Taylor and Guerin 2010, 15). This requires the flattening of hierarchies

54 of power, being mindful of Indigenous peoples’ experiences of colonisation and history and respecting and supporting their contemporary efforts to reclaim their languages and cultures (Taylor and Guerin 2010, 168-9). In essence, cultural safety is about empowering First Nations clients in health and creating comfortable, productive and respectful spaces for them to seek healthcare.

Racism has been identified as an institutional problem in the Australian health system (Paradies et al. 2008, 9; Durey 2010; Bourke et al. 2018; Henderson et al. 2007; Department of Health 2017, 8). Black Power activists and political scientists Stokely Carmichael and Charles Hamilton (1967, 4) first defined institutional racism as a covert form of racism. They contended that institutional racism “originates in the operation of established and respected forces in the society, and thus receives far less public condemnation” (Carmichael & Hamilton 1967, 4). In the context of healthcare delivery to Indigenous peoples and other minority groups, institutional racism can refer to systemic racial discrimination (Henry, Houston and Mooney 2004), and to the unconscious biases and norms that inform how health practitioners – respected forces in society – interact with and care for patients (van Ryan and Fu 2011). It can affect Aboriginal and Torres Strait Islander health in many ways. Institutional racism can deter Indigenous patients from accessing healthcare (Osborne et al. 2013; Baba et al. 2014; DoH 2017a, 23; Awofeso 2011) and make it less likely that Indigenous patients will receive appropriate medical care (Cunningham 2002; Hall et al. 2007; Moore et al. 2014). Experiencing racism in healthcare settings has also been associated with heightened levels of psychological distress amongst Indigenous patients (Kelaher, Ferdinand and Paradies 2014).

Fostering anti-racism in the health system As stated at the beginning of this chapter, ACCHS were established in response to perceptions of widespread racism and discrimination against Aboriginal and Torres Strait people trying to seek healthcare in the mainstream system. Following Paradies’ (2007) definition of racism, institutional racism in health systems can be understood as a function of the unequal power relations that characterise interactions between mainstream health staff and First Nations patients. Baba, Brolan and Hill (2014) explain that ACCHS, through their employment of Aboriginal staff, and the Community Controlled governance model,

55 overcome some of the barriers to healthcare experienced by Aboriginal and Torres Strait Islander patients through empowerment:

ACCHS offer a broader political empowerment to communities; as they are community driven, granting local people the ability to take control of their own health and the services that are provided to them. (Baba et al. 2014, 8)

Baba and colleagues emphasise that empowerment through localised political structures improves Indigenous healthcare. Implying a similar relationship between power and health, other studies have linked First Nations peoples’ experiences of racism to feelings of powerlessness and lack of control. Paradies and Cunningham (2012a, 1; 2012b, 165) found that “stress, lack of control and feeling powerless as a reaction to racism” were mediating factors in the relationship between Aboriginal and Torres Strait Islander peoples’ experiences of racism and the symptoms of depression and lower self-assessed health status that stemmed from them. These studies strengthen the evidence base that connects psychosocial determinants such as powerlessness to physical and mental health outcomes.

ACCHS minimise racism and promote cultural safety in healthcare settings by culturally guiding non-Indigenous staff members, including doctors, and by employing a high proportion of Indigenous staff, as Chapter 6 explores. It is commonly asserted that ACCHS deliver culturally appropriate, holistic health services (Baba et al. 2014; Durey 2010; Campbell et al. 2017). While some scholars have criticised the use of ‘cultural appropriateness’ because of its conceptual imprecision (e.g. Martin 2005), it has remained an important consideration for the delivery and design of Indigenous-specific health services (Osborne et al. 2013); and for making mainstream health settings more accessible for First Nations clients (Heyman, White and Spurling 2009; Downing, Kowal and Paradies 2011; Best 2014).

Phillips (2019, para. 2) recently emphasised that cultural safety is about “addressing racism and unconscious bias” in policy and service delivery for First Nations peoples. Training the health workforce in how to work respectfully and effectively with Aboriginal and Torres Strait Islander patients is part of this. However, Phillips argues that this training must be given structure by policy and funding frameworks that both enable equal power between

First Nations and non-Aboriginal people, and prioritise Indigenous self-determination (Phillips 2019). Cultural safety, according to Phillips, is about preventing racism and empowering First Nations. While there is scant research evaluating the effectiveness of cultural safety, cultural awareness, or culturally security training, cultural safety has been singled out as the most potentially beneficial model, because of its grounding in post- colonial theory and its focus on systemic rather than individualised changes (Downing et al. 2011, 254). Downing, Kowal and Paradies (2011), like Phillips (2019), emphasise that cultural safety in healthcare should be more concerned with redressing power imbalances and systemic biases rather than teaching health practitioners about or essentialising Indigenous cultures. While there appears to be little research assessing ACCHS’ application of cultural safety, the Community Controlled service model contributes to the empowerment of First Nations communities through involving them in the running of the service. This is another important political contribution of the ACCHS sector, and the health implications of this kind of empowerment are in need of greater study.

Implications for practice: overcoming political barriers to action on Indigenous health inequity If ACCHS are to be granted increased government funding and autonomy, a number of political and ideological roadblocks need to be removed. As was explained earlier in the chapter, the biomedical approach to health, which Baum terms “the biomedical imagination” (Baum 2010, 36), is still dominant in Australian healthcare and policy domains (Baum et al. 2013; Baum 2010). Additionally, researchers have concluded that there is evidence of inconsistent commitment from Australian federal, state and territory governments to the goal of reducing health inequity (Newman, Baum and Harris 2006). Policy action is also impeded by the complexity of social determinants of health-style policies (Baum et al. 2013). It seems that political actors are not yet persuaded by the arguments of social determinants researchers and advocates (Kickbusch 2012). The task of achieving health equity is made even more complex by the incessant marketing and lobbying efforts of global corporate actors, such as food and drink manufacturers and pharmaceutical companies, whose power has increased greatly (Kickbusch 2012, 428) since McKinlay (1975) brought their health-damaging practices into public discourse more than 40 years ago.

There is evidence that the power of these corporate actors is bolstered by Australia’s dominant ideology - neoliberalism. This is of great relevance to health policy and Indigenous wellbeing. Neoliberalism affects health because its policy prescriptions increase socioeconomic inequality. As Burns states, “neoliberal (market-oriented) political doctrines lead to both increased income inequality and reduced social cohesion” (2015, 109). There is substantial evidence that neoliberal politics is making us sick (Schrecker and Bambra 2015) and its continued dominance has serious implications for health inequity in Australia. The rationale and effects of neoliberalism is the focus of the next chapter.

Conclusion The central argument of this chapter is that ACCHS enact local-level Indigenous self- determination, empowering Indigenous communities to take control over their own health. The chapter outlined the history of ACCHS, examining the social, economic and political circumstances that they were (and still are) designed to overcome. It argued that Aboriginal activists established ACCHS in response to severe racism in the health system, and Aboriginal peoples’ dire need for affordable and adequate healthcare. In explaining the ACCHS model of care, the chapter detailed the many ways that ACCHS address the underlying social and economic, as well as the biomedical causes of health and wellbeing. With reference to the literature exploring the psychosocial health impacts of status, autonomy and self-esteem, the chapter suggested that ACCHS’ community empowerment function is connected to the overall health of First Nations communities. The chapter also discussed how racism, both contemporary and historical, contributes to ongoing health inequity experienced by First Nations peoples. Various approaches to mitigating the health impacts of institutional racism in health settings were explored, particularly the ‘cultural safety’ approach. This chapter’s analysis of the ‘culturally appropriate’ design and delivery of ACCHS’ services demonstrated some ways that ACCHS foster anti-racism in the health system. The chapter concluded that ACCHS are critically important in ongoing efforts to improve Indigenous health. Based on evidence from the available literature, ACCHS’ comprehensive, culturally appropriate and empowering approach to health appears to hold great potential for improving Indigenous wellbeing. This ‘holistic’ health philosophy is explored in greater detail in Chapter 6. The next chapter of this thesis examines the

Australian state’s deep structures and ideological paradigms that may be hindering and undermining ACCHS’ efforts to overcome the barriers to health equity.

Chapter 3.

Literature review: neoliberal Settler-colonialism and the social construction of Indigenous ‘dependents’1

This literature review investigates the political and policy contexts in which the Aboriginal Community Controlled Health Services (ACCHS) sector operates. The chapter discusses relevant theories on the material and ideological foundations of the Australian Settler- colonial state. In doing so, it crafts an analysis of how Settler-colonial structures affect Indigenous agency and constrict the ACCHS sector’s ability to exercise self-determination. This theoretical chapter explores the literature on the neoliberal state’s discovery and application of new techniques of control. The chapter uses this critical literature to construct an explanation of how the neoliberal state continues the assimilatory project of Settler-colonialism. The chapter also explores the reasons why governments in Australia have taken varied approaches to First Nations peoples during different policy eras. It does this by engaging with Sanders’ competing principles framework (2010; 2013) and other relevant literature on the history and politics of Indigenous Affairs. The analysis presented below illustrates a clear link between dominant ideological principles and the content and logic of Indigenous Affairs policies. The chapter also surveys the constructivist literature on policy analysis, developing an account of how public policy frames Indigenous organisations. The insights generated by engagement with this constructivist literature enhance understanding of how contemporary Indigenous Affairs policies reinforce enduring stereotypes of Aboriginal people. To conclude, using Schneider and Ingram’s theory of the social construction of deservedness (1997), the chapter shows how current policies delegitimise Indigenous organisations, constructing them as economic dependents through moralistic appeals to the neoliberal market values.

Understanding neoliberal reforms in Settler-colonial contexts In this chapter, drawing on Wolfe’s structural analysis of the Australian state and its intentions, I argue that the recent restructuring of Indigenous health policy can be

1 Some of the material in this chapter has been drawn from a recent publication (Coombs 2018), which has been acknowledged and detailed in the ‘Inclusion of Publications Statement’ for this thesis.

60 understood as a new iteration of a longer process of Settler-colonial coercion and “elimination” (Wolfe 2016, 33). Additionally, following Rowse, I posit that even during the so-called ‘self-determination era’ Australian government policy towards First Nations peoples has been prescriptive and coercive, and has been designed to make Indigenous peoples conform to the dominant modes of social organisation (2017; 2005b; see also Sanders 2010). I contend that the current suite of Indigenous Affairs policies continues along this same trajectory. I argue that contemporary policies are designed to ‘train’ First Nations peoples to work in an imposed political and economic order, that being the dominant neoliberal order.

Below I analyse the example of competitive contracting in Indigenous service delivery, concluding that it exemplifies a coercive neoliberalism, imposing market norms on Indigenous organisations and communities. I use Meagher’s and Goodwin’s (2015) critical investigation of ‘marketised’ social policy in Australia to explain the specific policy forms that have recently been implemented in Indigenous Affairs, tracing their origins to earlier neoliberal reforms in other policy areas, such as employment services. But in Indigenous policy there is a symbolic “racialisation” that is not present in other policy contexts (Wolfe 2016, 31). Indigenous subjects and organisations are “socially constructed” as especially in need of reform and tutelage (Schneider and Ingram 1997, 102). In the current policy context, policy makers “frame” (Rein & Schön 1996, 85) Indigenous political and cultural differences as problems to be solved, as moral deviations from dominant norms. By appealing to powerful symbols of national and cultural identity, such as individualism, competition and political egalitarianism, the neoliberal state delegitimises and disempowers Indigenous organisations and communities wherever they are found to be too politically activist, or for prioritising cultural, familial, or community obligations above neoliberal economic prescriptions. Indigenous organisations are deemed ‘uncompetitive’ or ‘unscrupulous’ and funding has been withdrawn and handed on to non-Indigenous corporations, government agencies and non-government organisations (NGOs).

Wacquant (2009; 2012) argues that the state’s policing of social and economic norms is a central strategy of neoliberal governance. He refers to this moral policing as the neoliberal state’s “symbolic mission of reasserting common values through the public anathemization

61 of deviant categories” (2009, 5). In analysing the internal mechanisms of recent Indigenous Affairs policy designs, I apply Schneider’s and Ingram’s theory of the “social construction of target populations” to connect the disadvantaged political and social status of Indigenous organisations to their negative treatment by policymakers (1997, 102). Using this theory, we can better understand and closely observe how First Nations’ place in Australian society is correlated with the coercive and assimilationist ways that they are treated by policy.

Settler colonialism as a meta-theory of state power This thesis is concerned with the logics, designs and effects of Indigenous Affairs policies. It also seeks to clarify the role of ideology in these policies. However, in order to understand specific policy mechanisms, their outcomes and their underlying drivers, it is necessary to assess the broader context from which they emerge, expanding the level of analysis to the meta level to study societal level values and power dynamics. One body of literature that is useful for understanding these broad political dynamics is Settler Colonial Studies. The Settler Colonialism literature focuses on power relations between Indigenous and Settler populations. Typical Settler-colonial societies include Australia, New Zealand, the United States and Canada, where Europeans have invaded and now outnumber Indigenous peoples. The racist history of invasion, war, frontier violence, segregation, institutionalisation and forced assimilation that typifies Settler treatment of Indigenous peoples in these places leads Settler Colonial Studies to concentrate on race relations between Settler and Indigenous societies. This literature is useful for this thesis because it highlights the enduring influence of certain hegemonic ideas about race, civilisation and land, and helps us analyse how they are mobilised to further certain ends in the present. These racial constructs perpetuate Settler dominance and the expansion of the Settler state. Settler colonial theory sets the historical stage on which contemporary Settler-Indigenous relations are played out.

Wolfe is commonly cited as being the founder of Settler Colonial Studies (e.g. Strakosch 2019, 115; Veracini 2015, 1). One of his central ideas is that Settler treatment of Indigenous peoples follows a “logic of elimination” (2016, 33; 1999, 96; 1994, 93-152). In order to secure land for the establishment of Settler colonies, Europeans attempt to eradicate all traces of Indigenous life. On this basis, Wolfe contends that “invasion is a structure, not an event” (2016, 33), evidenced by Settlers’ ongoing efforts to extend their dominance and

62 constrict Indigenous life (see also Veracini 2015; Strakosch 2019; Brigg 2007). Following Wolfe, Veracini emphasises “the contemporary relevance of Settler colonialism as a specific mode of domination”, highlighting the historical structures and power dynamics that continue to influence Settler-Indigenous relations (2015, 1-2). Theorists of Settler colonialism argue that “Settlers are made by conquest, not just by immigration” (Mamdani 1998, 1; see also Veracini 2011, 3). The overwhelming influx of Settlers onto Indigenous lands is a central pillar of their dominance. Maddison articulates Settlers’ ongoing efforts to displace and disempower Indigenous peoples as “structural violence”, arguing that this continues “to dominate the lived experience of … Aboriginal and Torres Strait Islander peoples in contemporary Australia” (2013, 288-9). Settler colonialism, according to these theorists, is a destructive and violent process.

Racialisation and Settler dispossession of Indigenous lands There is no escaping the fact that Indigenous peoples have borne the brunt of Settler colonial violence in Australia. In explaining why this has been the case, Wolfe (2016) has argued that Settler-colonial states such as Australia racialise (i.e. deem inferior on ‘scientific’ grounds) Indigenous people in order to legitimate Settler possession of Indigenous lands. He also contends that “colonised populations continue to be racialised in specific ways that mark out and reproduce the unequal relationships into which Europeans have co-opted these populations” (Wolfe 2016, 2). Brigg and Murphy contend that Settlers “asserted” their own “cultural superiority”, labelling Indigenous peoples “uncivilised”, “illiberal” and in need of tutelage (2011, 22). As Strakosch argues,

It is in the necessary, continuous problematisation of Indigenous lives that racism and racialisation (through the construction of subjects as inferior, incapable, passive and unruly) become structured into the settler colonial policy system. (2019, 124-5).

Settler-colonial studies draws our attention to the purpose and effects of racial constructs in specific historical projects, also identifying the material drivers underlying Settler-colonial processes. Race, under Settler colonialism, becomes an ideological framework that serves to justify the domination and dispossession of Indigenous peoples by Europeans (Wolfe 2016, 7; see also Marx & Engels 1970). Settler colonial ideology constructs Europeans as superior (and therefore more deserving of the land than Indigenous peoples) and constructs Indigenous peoples as inferior and in need of control.

There is an ongoing racialised power imbalance in Settler-colonial Australia. Indigenous peoples’ sovereignty is not recognised by the Australian government, and there are still no treaties with First Nations, although processes for treaty-making are being developed in some states and territories, notably Victoria. Moreover, as Maddison notes, “Australia’s parliaments remain fundamentally White institutions” (2010, 663). There are no seats reserved for First Nations representatives in any Australian parliament and the debate at the federal level about introducing an Indigenous Voice to Parliament has currently stalled (Taylor 2019). The only national representative Indigenous body – the National Congress of Australia’s First Peoples – is currently under external administration due to funding cuts, and in order to apply for future funding will be forced to “meet a range of strict conditions” (Allam 2019). Settlers possess a near monopoly of political power in Australia, a form of institutional racism that expects Indigenous peoples to engage with the Settler state on its terms.

Acknowledging Indigenous agency and resistance Simpson urges us to remember that the Settler-colonial project is not complete. Indigenous peoples still exist and resist, and they “will continue to push back on the Settler logics of elimination” (2014, 12). Even though the Settler state does not recognise Indigenous sovereignty in contemporary Australia, many First Nations maintain their connections to Country, care for their sacred sites and practise their cultures, enacting their sovereignty despite Settler recalcitrance. Like Simpson, Ford emphasises the “incompleteness of Settler states” through examining various instances of Indigenous agency (2012, 11). Ford offers a valuable critique of Wolfe’s logic of elimination thesis, tempering Settler Colonial Studies’ focus on the power of Settler structures. She highlights the cracks in the Settler-colonial edifice through which elements of Indigenous life can escape. Simpson and Ford both demonstrate how Wolfe’s portrayal of Settler-colonialism does not hold true for all cases. Their critiques offer hope that Indigenous agents will be able to navigate Settler contexts with some autonomy. However, the power imbalance between the Settler state and Indigenous peoples is obvious. Smith and Hunt state that Indigenous Australia “must constantly attempt to renegotiate the balance of domination, subordination and contestation in its interactions with the Australian state” (2008, 4). First Nations exercise agency but do so in extremely challenging political circumstances. The institutional

64 limitations encountered by ACCHS attempting to deliver innovative health programs to Aboriginal communities, discussed in later chapters of this thesis, are evidence of this structural challenge.

Understanding ‘elimination’ in post-frontier policy Historically, Settler authorities in Australia sanctioned massacres of Indigenous peoples Ongoing evidence of frontier massacres is being amassed by researchers at the University of Newcastle and compiled as an interactive digital map (Ryan et al. 2017). In contemporary Australia, though, racial violence and oppression of First Nations occurs more subtly, through assimilation. Wolfe argues that once Indigenous peoples have been effectively dispossessed, assimilation becomes the primary Settler strategy for neutralising “Native resistance” (Wolfe 2016, 37). Settler-colonial states seek to minimise the possibility that Indigenous peoples will reassert their claims to sovereignty. In order to finalise their projects of domination, Settler societies seek to dissolve all vestiges of Indigeneity into “the Settler mainstream” (Wolfe 2016, 39). Assimilation thus continues the Settler colonial “logic of elimination” (Wolfe 2016, 33). Rowse has argued that even the policies enacted during the so-called ‘self-determination era’, such as those that encouraged Indigenous people to form corporations, “continued the underlying task of ‘assimilation’: to train colonised people to function within an imposed political order” (2017, 280). Even when nominally empowering Aboriginal people to take control over their own affairs, the Settlers mould Indigenous peoples in their image. Bradfield takes this argument further, maintaining: “Even as a distinct Aboriginality is recognised, recognition only takes place to the extent that the State can maintain, and extend, its control over a separate Indigenous political identity” (Bradfield 2006, 96). Bradfield calls this governmental pattern of trying to control Aboriginal people “a logic of domestication” (2006, 96; see also Schulte-Tenckhoff 1998). Assimilation can be understood as the dominant strategy currently employed by the Australian Settler state in its ongoing attempts to eliminate Indigeneity.

Assimilating ‘the Indigenous sector’ This explanation of assimilation, in relation to the logic of elimination, can aid our understanding of the government’s current treatment of Indigenous organisations. The Indigenous sector (Rowse 2002; 2005a) resists Settler normativity in various ways. One example of this is the ACCHS’ Community Controlled ownership and management structure.

Even though not all organisations that make up the Indigenous sector are explicitly concerned with Indigenous land rights and sovereignty, by working in ways that acknowledge and enact Indigenous cultural difference, Indigenous organisations highlight the ongoing existence and potential political threat of First Nations cultures and values (Martin 2005; Sullivan 2011; Rowse 2002). The government’s introduction of more contestability in the funding process for Indigenous health services threatens the resources available to Indigenous organisations and thus suppresses public expressions of Indigenous difference. These organisations do in some ways connect Indigenous peoples to their pre- colonial cultures and sustain the public visibility of Indigenous cultural difference (Rowse 2002, 236), thus undercutting Settler claims to cultural and political hegemony. ‘Mainstreaming’ Indigenous health services, (see also Chapters 1 and 9) if viewed through Wolfe’s Settler colonial lens, becomes a governmental refusal to allow Indigenous community organisations to foster and perpetuate alternative forms of economic and social organisation; it is an act of colonial incursion into an Indigenous space of autonomy and self- determination. Mainstreaming siphons resources away from Indigenous organisations and constrains their expressions of political difference. Wolfe’s logic of elimination thesis holds that the government pursues mainstreaming in the hope that Indigenous difference will be minimised, thus guaranteeing further expansion of the Settler society’s systems and norms.

Settler Colonial Studies contextualises contemporary Settler-Indigenous relations within Australia’s racist history of displacing, killing, dispossessing, disempowering and forcibly assimilating First Nations. It draws our attention to the historical material processes that underlie Settler subjugation of Indigenous peoples, and the racial constructs that have been used to justify them. Settler colonial theory explains that ideas about Indigenous peoples’ racial inferiority have been structured into the workings of Settler colonial states, influencing government treatment of First Nations into the present and Settler imaginings of Indigeneity. Settler Colonial scholars identify an ongoing yet flexible logic of elimination whereby Settlers seek to supress Indigenous dissent through whatever means are politically practicable. In Australia this has led to a variety of policy approaches designed to solve “the Aboriginal problem” (NSW Protection Board cited in Read 1981, 3). It is to these policy approaches that this chapter now turns its attention.

Indigenous Affairs ‘policy paradigms’ as meso-theories of Indigenous-Settler relations The chapter now narrows its scope of analysis, focusing on the more recent era, and describing and analysing the main approaches to Indigenous Affairs policy that have been dominant at different times in Australia’s history. Hall calls such ideologically coherent and temporally bounded policy eras “policy paradigms” (1993, 275). Working at this “meso- analytical” level (Fenna 2004, 124) allows us to understand the political philosophies or ideological schemas that drive policy during certain time periods. The work of Sanders assists us greatly in this endeavour, focusing on guiding principles and dominant arguments. I return to his work below. This section of the chapter analyses the main Indigenous Affairs policy paradigms that have operated in Australia. By looking back and discerning the logics and dominant ideologies in operation during previous policy periods we are better able to identify and scrutinise the dominant logics informing policymaking in the present. I concentrate my analysis on the period after the 1967 referendum, the moment the federal government gained powers to legislate on Indigenous issues, given the focus of this thesis on federal government policies. The section begins with an overview of the way in which Indigenous Affairs policy approaches have been traditionally characterised in the Indigenous Affairs literature.

Sketching state treatment of Indigenous peoples: logics and eras In a broad sense, the historical, anthropological and political scholarship that deals with Australia’s colonial, state and territory, and federal policy treatment of First Nations tends to focus on four roughly bounded periods, ascribing them with one or another dominant logic or approach. An increasing number of scholars has begun to elaborate and analyse a fifth policy paradigm, which extends into the present. Below, I outline the five main policy paradigms. In general, scholars of Aboriginal policy have argued that:

• Indigenous policy between 1788 and 1850 was characterised by dispossession, invasion and “the civilising mission” (Broome 2010, 53; Reynolds 2006; Atkinson 2002); • government action between 1850 and the 1940s was guided by the idea of ‘protection’, which involved racial segregation and high levels of government control over First Nations (Rowse 2017, Chapter 3; McGregor 2011, Chapter 2; Sanders 2010, 315-318; Broome 2010, Chapter 10);

• from the end of the Second World War through to the late 1960s ‘assimilation’ became the guiding mantra for government treatment of Indigenous peoples (Bennett 1999, 60-61; Chesterman 2005; McGregor 2009; Sullivan 2011, 3; Rowse 2017, 222-4; Rowse 2005b) • between the early 1970s to the late 1990s government policy nominally prioritised and supported Aboriginal ‘self-determination’ (Sanders 2010, 316; Altman 2014, 116;; Reynolds 1996; Strakosch 2015, 1; see also Kowal 2008). However, other scholars have argued that in practice these policies only allowed for limited Aboriginal ‘self-management’, also contending that they were designed to integrate and assimilation Indigenous peoples rather than empower them (e.g. Hunt 2008, 27; Bradfield 2006; Perheentupa 2018, S15; Moreton- Robinson 2007) • a coercive ‘neo-paternalism’ is now the dominant Indigenous Affairs policy paradigm, rising to prominence since the end of the 1990s (Strakosch 2015; Howard-Wagner, Bargh & Altamirano-Jiménez 2018; Altman 2007; Altman & Hinkson 2007; Bielefeld 2016; Maddison 2009, 7-18).

From this bare-bones sketch of almost 250 years of policy, it appears that the overall historical trajectory of Indigenous Affairs policy has been to move away from the overt violence and coercion that characterised the early colonial period, and towards greater inclusion of and independence for Aboriginal and Torres Strait Islander peoples. However, as the above overview of the current policy paradigm alludes to, scholars have argued that governments are currently returning to a more coercive mode of Indigenous Affairs policy making.

‘Competing principles’ and ideological influence To make sense of this return to paternalism, I use Sanders’ competing principles framework (2010; 2013). In analysing the policy debates that have influenced and guided federal Indigenous Affairs policies since the 1930s, Sanders identifies three competing principles: equality, choice and guardianship (Sanders 2010, 313-18). In the ‘protection’ years, Sanders contends, guardianship dominated Indigenous policy debates. During the ‘assimilation’ era he argues that equality held sway. Under the policies of ‘self-determination’ or ‘self- management’ choice became a more prominent concern in Indigenous Affairs, although equality was still a highly influential policy ideal (Sanders 2010, 315-18). Sanders’ framework (2010, 317) highlights a re-emergence of the guardianship principle in Indigenous Affairs policy, beginning in the early 2000s, when the Howard government introduced coercive

68 policy measures in pursuit of socio-economic equality. The competing principles framework is useful for this study because it explains the relationship between Indigenous Affairs policies and dominant ideologies. By showing how changes to the dominant political belief system (or ideology) coincide with changes to the government’s approach to Indigenous policy, Sanders’ framework suggests that there is a fundamental connection between ideology and Indigenous policy.

Mapping a separate policy trajectory: Indigenous Affairs from 1972-1996 Following Sanders’ logic, one might expect Indigenous Affairs policy trends to follow the broader policy trends observable across the ‘mainstream’ policy areas, such as employment services, education, housing or health. However, Indigenous Affairs policy developed differently because of the unique relationship between First Nations and the Australian state, as was outlined in the beginning of this chapter, and because of Indigenous peoples’ political resistance and activism (Burgmann 2003). The contrast between Indigenous Affairs and mainstream social policy is particularly obvious during the latter years of the ‘self- determination’ era, because federal governments were investing heavily in services for Aboriginal and Torres Strait Islander peoples (see Sanders 2004), while at the same time retreating from direct service provision for the general population. The Hawke and Keating Labor governments (1983-1996) were heavily influenced by economic rationalist thinking and implemented a range of “free market” policies such as the reintroduction of user fees for tertiary education and the shrinking of social security to a more residual social “safety net” (Fawcett, Goodwin, Meagher & Phillips 2010, 69; Pusey 1991; Keating 2004, 79; Fenna 2004, 347). Free market thinking also influenced the subsequent Fraser government (1975- 1983), which wound back newly established public entitlements to healthcare, reducing coverage and introducing user fees (Fenna 2004, 343; Biggs 2003). It was during the Hawke- Keating years, though, that free-market thinking came to dominate economic and social policy after the abandonment of full-employment as a policy goal (Emy 1998, 10). As Battin explains, the Hawke and Keating governments worked from

an assumption that a free-market economy should be allowed maximum rein, and that social policy would be funded from a kind of largesse to be distributed after free market economic processes had, more or less, run their course. (1998, 96 emphasis in original)

These “New Labor” (Battin 1998, 96) governments had faith that market deregulation would increase productivity, which would allow the government to invest some of the additional tax revenue in social services for the sections of society most in need of assistance.

Free market thinking did not, however, dominate the Hawke-Keating government’s nor the Fraser government’s approach to Indigenous Affairs. These governments created novel, empowering policies that promoted some level of Indigenous self-determination and supported the growth of additional services for Indigenous peoples (Attwood 2003; Chesterman & Galligan 1997; Bennett 1999; Reynolds 1996; Rowse 2002; Howard-Wagner 2018a, 1336). Earlier, the Whitlam Government (1972 to 1975) had started investing in Indigenous-specific services, and introduced Northern Territory Aboriginal land rights legislation to parliament, an amended version of which was subsequently passed by the Fraser Government in 1976. Additionally, the Fraser Government (1975 to 1983) created Community Development Employment Projects in 1977, the Hawke Government (1983- 1991) established the Aboriginal and Torres Strait Islander Commission (ATSIC) in 1990 and instigated the Royal Commission into Aboriginal Deaths in Custody (ATSISJC 1996). The Keating Government (1991-1996) legislated Native Title in 1993 and Keating himself acknowledged some of the damage done to Indigenous peoples by Settler Australians through their governments, institutions and policies, in his landmark Redfern address (Keating 1992). Keating also set up the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families (HREOC 1997). During the ‘self- determination’ policy paradigm, governments shed some light on the darkest aspects of Settler treatment of Indigenous peoples and granted some Indigenous rights to land. This period also saw the expansion of Aboriginal-specific services run by Aboriginal corporations, including medical, legal and children’s services (see Rowse 2002; 2005a). As Perche has noted, “Indigenous Affairs thus remained out of kilter with dominant policy thinking, through the 1970s and 1980s, as economic rationalism began to take hold in Canberra” (Perche 2017, 41). In many ways the governments of the ‘self-determination era’ approached Indigenous Affairs as a unique policy area requiring unique policy approaches.

Why was Indigenous Affairs treated differently? In order to understand why Indigenous Affairs was guided by different policy principles to mainstream social policy, three factors are worth considering: social justice, Indigenous

70 socioeconomic inequity, and cultural difference. From the mid-1960s there was growing public acceptance for “special benefits to compensate for Aboriginal disadvantage” (McGregor 2011, 159-61). In the late 1960s and early 1970s Aboriginal people were pushed into a new period of social dislocation and economic insecurity. After the breakup of the Aboriginal reserves and missions, and the equal wages decision of 1966 (which ironically foreclosed a valuable source of unemployment for Aboriginal people when pastoralists decided to no longer hire Aboriginal stockmen) many Aboriginal people moved to the fringes of towns and cities (Perche 2017, 41). During this period Aboriginal peoples often lived in squalid conditions, depended largely on welfare payments, and alcoholism and other social maladies took hold (Sullivan 2011, 3; Peterson 2005, 11; see also Pearson 2009, 158-159). The Indigenous Affairs policies that were introduced in the three decades that followed can be understood as a form of compensation for these new forms of Aboriginal socio-economic “disadvantage” (McGregor 2011, 61; Sullivan 2011, 3). In acknowledging and introducing policies to improve Aboriginal and Torres Strait Islander peoples’ unequal social circumstances, governments of the ‘self-determination’ era were guided, in part, by a commitment to social justice.

In the 1970s, 80s and 90s there was also growing recognition of Indigenous cultural difference, in response to Indigenous assertions of sovereignty, distinct identity and what Rowse refers to as “customary political capacity” (2012, 17). This latter point amounts to a belief that Aboriginal societies have the internal capacity to govern themselves effectively, drawing on customary law (Rowse 2012, 25). But, as Sanders has argued (2010, 2013) dominant debates about the overarching goals of Indigenous Affairs policy swing between aiming for statistical equality or collective political empowerment. During the self- determination era, the principle of choice was dominant and Indigenous cultural difference and collective political capacity was recognised. Foley has argued that this recognition was brought about by sustained and strident activist campaigns led by Indigenous peoples (Foley 2009; 2011).

The literature discussed above suggests that Indigenous issues were regarded as unique during the ‘self-determination’ policy era. First Nations’ concerns were approached differently to mainstream social policy issues because of the severe levels of socio-economic disadvantage experienced by First Nations, because of a recognition of the need to

71 compensate Aboriginal people for the discriminatory, exclusionary and neglectful policy approaches of the past, and because of Aboriginal peoples’ increasing demands for self- determination, rights to land, and respect for their cultural differences. However, these issues were only partially resolved between 1972 and 1996, and after a change of government in 1996, Indigenous issues began to be brought into “the mainstream” (Behrendt 2005, 234). This marked the beginning of a new policy paradigm where Indigenous Affairs policies were brought into line with the prescriptions of the now dominant neoliberal ideology.

Reasserting ‘guardianship’: Indigenous Affairs from 1996-present Soon after the Liberal-National Coalition under John Howard took office in 1996 it signalled its intentions to change the course of Indigenous policy (Cunningham & Baeza 2005, 463). One of the first items of business was an audit of all Aboriginal organisations, putting the issue of financial risk at the heart of Indigenous policy (Sullivan 2010, 7). The enforcement of mutual obligation through ‘shared responsibility agreements’, which the Labor opposition also supported and later continued, was another example of neoliberal ideas being applied to Indigenous Affairs. Many scholars have argued that there was a coercive element to the Indigenous Affairs policies enacted during the years of the Howard government (Strakosch 2015; Howard-Wagner, Bargh & Altamirano-Jiménez 2018; Altman 2007; Altman and Hinkson 2007; Bielefeld 2016; Maddison 2009, 7-18). However, although these coercive policies were enacted by the Howard Coalition government, the Labor Party’s support of them is evidence of bipartisan commitment to ‘guardianship’ as the guiding principle of Indigenous Affairs.

The conservative Howard government (1996-2007) pushed back against the Indigenous Affairs policies of previous eras, arguing that self-determination had been an abject “failure” (Sanders 2008, 187). Disenchantment with existing forms of Indigenous self-determination was also expressed by the Labor opposition leader, Mark Latham In the lead up to the 2004 election. Latham committed his party, if elected, to replacing ATSIC with another forum for Indigenous self-governance (Sanders 2018, 117). Labor did not get this opportunity, with the Howard being returned to office. The Coalition subsequently began abolishing ATSIC in July 2004 and did not replace it with a similar representative or policy delivery body (Sanders

2018, 117). This marked the end of Australia’s most significant Indigenous representative body, and a shift away from Indigenous ‘choice’ as policy.

The Howard government launched a sweeping Indigenous affairs policy intervention in 2007. Its Northern Territory Emergency Response (the Intervention) has been viewed as the antithesis of the ‘self-determination’ approach to Indigenous policy and is held up as evidence of the transition into a new policy paradigm (Hunt 2008, Howard-Wagner 2018a; Altman 2007; Maddison 2009). The introduction of this suite of coercive policies was supported by the Labor opposition under Kevin Rudd, and subsequently expanded and extended by the Rudd and Gillard Labor governments (2007-2013). Jon Altman has argued that the approach to Indigenous Affairs of the Howard government was characterised by both assimilationist goals and paternalistic policy measures (2014, 117; 2007), signalling the return of the guiding principles from previous policy eras. The Howard government challenged the idea of separate Indigenous rights, and promoted what it called “practical reconciliation”, focusing on statistical parity between Indigenous and non-Indigenous Australians (Bradfield 2006, 94; Hunt 2008, 94). This period of Indigenous policy revision coincided with the increasing influence of neoliberal policy prescriptions and their extension to human or social services (Fenna 2004; 346-72; Cass 1998, 46). I argue, in line with Strakosch, that the Howard government’s hostility to ‘special’ Indigenous rights, and its neoliberal ideology culminated in “neoliberal Indigenous policy” (Strakosch 2015). That many of the Howard government’s defining Indigenous policy interventions were supported and even continued by the Labor Party, suggests that the development of neoliberal Indigenous policy was a bipartisan phenomenon.

The parallel development of neoliberalism and New Public Management The literature that examines the emergence of neoliberal ideology, and the associated policy reforms dubbed New Public Management (NPM), sheds light on the logic underlying the current Indigenous Affairs policy paradigm. This section sketches its broad ideological contours and tracks its application to social policy. In Australia neoliberalism is often termed ‘economic rationalism’. Pusey, in his seminal work Economic Rationalism in Canberra, famously linked the rise of neoliberal policymaking to the educational background of a generation of public servants who had been trained in neoclassical economics (Pusey 1991, 59-64). Harvey argued that neoliberalism is founded on the assumption that: “human well-

73 being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade” (Harvey 2005, 2; see also Mooney 2012, 34; Altman 2014, 122). Placing more emphasis than Harvey on how these ideas are applied to society, Povinelli characterises neoliberalism as the process of using the market to assess the worth and effectiveness of all “social activities and values” (2010, 21). Similarly, Sullivan posits:

The innovation of neoliberalism is to extend market relations into the social sphere, first by imposing markets on civil society and then by regulating families and individuals as if life itself is a commercial activity. (Sullivan 2018, 201-2)

Mudge also highlights the extension of market logic, identifying neoliberalism’s “ideological core” as “the elevation of the market – understood as a non-political, non-cultural, machinelike entity – over all other modes of organization” (2008, 705). For these theorists, neoliberalism is essentially market fundamentalism (see also Wacquant 2012, 68; Altman 2014, 123). The critical scholarship on neoliberalism outlines a concerted political project that seeks to de-politicise, and portray as both natural and scientific, the state’s promotion of market activity.

Reorganising the public sector around market ideals While neoliberalism is an ideology that concerns the workings of all elements of society, NPM is concerned predominantly with the public sector and its non-government partners. Proponents of neoliberalism developed a powerful critique of the welfare state (e.g. Hayek 1944), which led governments to rethink the operations and structures of the state itself (Maddison & Denniss 2009, 50-51). A related critique of bureaucracy, stemming from public choice theory, argued that the self-interest of public servants might lead them to implement policies in self-serving ways, undermining the policy capacity of legislators (Wanna, Butcher & Freyens 2010, 141). One proposed solution was the outsourcing of policy delivery to third parties, whom the government could monitor and regulate through contracts (Wanna, Butcher & Freyens 2010, 141). Contracting out and the use of internal markets and competitive tendering are now typical NPM management devices (McGuigan 2005, 236). In the 1980s the first wave of NPM reforms washed through the bureaucracies of the United

States and Great Britain involving cuts to public servant numbers and the partial privatisation of the public sector (Considine & Lewis 2003, 132).

Christopher Hood identifies NPM’s key elements as: the desire for explicit and measurable performance benchmarks; an emphasis on results rather than procedures; increased public- sector competition; budgetary austerity; and the use of private sector management styles (Hood 1991, 4-5). As Diefenbach explains: “[t]he basic idea of NPM is to make public sector organizations – and the people working in them! – much more ‘business-like’ and ‘market- oriented’, that is, performance-, cost-, efficiency- and audit-oriented” (2009, 893). NPM has been associated with the ideas and suggestions contained in Osbourne’s and Gaebler’s highly influential book Reinventing Government (1993). These authors recommended a new approach to governance which would involve less direct government involvement in the provision of services but more government management of programs, a process they likened to steering a ship rather than rowing it (see also Rhodes 1996). NPM has seen the involvement of increasing numbers of non-government actors in the provision of public services, and a heightened prominence of markets and competitive processes in public administration (Sullivan 2011, 59). The rise of NPM during the 1980s and 1990s saw public services redesigned around neoliberalism’s “incentive-based theory of internal organization” (Considine & Lewis 2003, 132).

Contracting out: effects and rationale In Australia, public organisations have been retreating from direct service provision since the 1990s (see Considine, O’Sullivan and Nguyen 2014 for a discussion of the case of employment services). At the same time, for-profit organisations and non-government not- for-profit organisations have been expanding their presence in the social services sector (Hancock 2006, 44; Meagher & Goodwin 2015, 12; Keen 2006, 27-8). In order to enter these lucrative public service markets, governments require NGOs, both charitable and for-profit, to demonstrate efficiency and effectiveness. Governments are now using measures developed in the private sector, such as cost-effectiveness and productivity, to evaluate the performance of the providers of public services (Goodwin & Phillips 2015, 102). NPM’s effects on service quality and efficiency, procedural fairness, equity and other social outcomes have been the subject of heated debate amongst policy scholars (e.g. Hood & Dixon 2015; Le Grand 2009; Hunter 2008). However, successive federal governments in

Australia have pressured the not-for-profit sector to be more businesslike via the use of competitive tenders for government contracts, output-based funding, mandating new standards for professionalisation, and extensive performance monitoring (Goodwin and Phillips 2015, 101-2). NPM is now having profound effects on the non-profit sector, as well as the public sector.

Neoliberalism as an expansion of state power and social control Central to the above descriptions of neoliberalism and NPM is the idea that governments are still in control of policy and governance, even where they devolve some responsibility for delivery. Keating, writing specifically about NPM in Australia, argues governments maintain their dominant position, even when they contract out services to the private sector. They do so by managing performance and retaining control over funding (Keating 2004). Wacquant (2009; 2012) goes further than Keating, arguing that neoliberalism involves the extension of state power through an expansion of its systems of social control. Similarly, Sullivan conceives of “contemporary public management as a coercive extension of the state” (2018, 202). He also contends that the Australian state favours marketisation (discussed below) – and other techniques of what terms “neoliberal public management” – because it “tightens social control” (Sullivan 2018, 203). An enhancement of government power is central to these scholars’ depictions of neoliberalism.

Moreover, Wacquant theorises that the “remaking and redeployment of the state” is what is ‘neo’ about neoliberalism (Wacquant 2012, 68 emphasis in original). In the service of market expansion, Wacquant concludes, the state incentivises the citizenry’s acquiescence to market rule. Meagher and Goodwin have identified a similar phenomenon in the Australian context, which they dub “marketisation” (2015). Central to their thesis is the contention that “market organisations and market logics” are becoming increasingly influential in the provision of social services in Australia (Meagher & Goodwin 2015, 1). Meagher and Goodwin show how successive Australian governments have used their financial and regulatory powers to promote competition between social service providers. The state justifies its market-inspired policy reforms on the economic assumption that competition, via contestable contracts, increases allocative efficiency and drives innovation (Meagher & Goodwin 2015, 15; see also Guinness & Gruen 2011, 143; Sullivan 2011, 58).

Marketisation is a central part of the shift to NPM (Meagher & Goodwin 2015, 4). The state champions competition as a force for social good, and promotes competition in traditionally non-competitive sectors of society, such as the bureaucracy and civil society. Meagher and Goodwin call this policy strategy “market discipline” (Meagher & Goodwin 2015, 4). Wacquant also places a strong emphasis on the neoliberal state’s disciplinary function. He outlines how the state uses both ideological and material means to normalise and enforce market logic (Wacquant 2009, 307). Ideologically, the state presents itself as favouring ‘small government’ and seeking to activate an entrepreneurial drive in individuals, encouraging work and “individual responsibility” (Wacquant 2010, 200). Materially, the state expands its punitive capacity to enforce market rule, using its penal arm to effect “disciplinary supervision over the precarious fractions of the postindustrial proletariat” (Wacquant 2009, 307). Meagher and Goodwin’s account of marketisation reveals the ideological character and favoured techniques of neoliberal governance in Australia. Wacquant’s account of the material and ideological facets of neoliberal statecraft (see Wacquant 2010, 210) helps us to understand the symbolic and material strategies being used to normalise and enforce market expansion, while at the same time bolstering state power and legitimacy. Neoliberalism has redesigned the social and economic purpose of the state. A core part of its new role and remit is to actively promote and enforce market logic (Wacquant 2010, 2010).

Ensuring government control through contract management One consequence of the neoliberal restructuring of the state is the proliferation of the use of contracts. This is particularly relevant to this thesis’ analysis of government treatment of Aboriginal organisations. Grey and Sedgwick (2015) use the term “contract state” to describe this new form of governance via proxy. They highlight how contracts can limit democratic debate and policy critique (Grey and Sedgwick 2015; see also Maddison and Hamilton 2007; Sullivan 2011, 58). The Australian government’s increased uptake of contracting-out has made NGOs crucial agents for service provision (Keen 2006). Rowse suggests that civil society organisations and Indigenous organisations can become so dependent on government funding and so involved in delivering government services that they become an arm of government (Rowse 2005a; see also Sullivan 2011, 56).

The entanglement of NGOs and the state, and the management of this relationship via contracts has threatened the independence of civil society organisations. Maddison and Carson (2017) have explained how NGOs now self-silence to avoid financial and political retribution from government funders. Explicit gag clauses in contracts and the perceived threat that funding could be cut if an organisation steps out of line have constrained NGO advocacy (Maddison & Hamilton 2007; Grey & Sedgwick 2015, 100; Maddison & Carson 2017). Many Indigenous organisations rely on government funding to operate. However, with funding comes a growing list of conditions and obligations, some of which limit their ability to comment on policy (Sullivan 2011, 62; Dwyer et al. 2009). Through a risk- management discourse, and the enforcement of contractual obligations, governments have silenced non-profit and Indigenous-sector voices. Moreover, Moran, Porter and Curth-Bibb (2016) argue that this kind of contracting also alters the lines of accountability, forcing them to turn away from their community base and respond to government priorities (see also Sullivan 2011, 58; Schmid 2003, 318). Governments can use funding and contracting to heavily influence the operations of civil society organisations.

Orchestrating new contests in the non-profit sector Marketisation and contracting out do not necessarily threaten the Indigenous sector. Indigenous-specific services have been contracted out to Aboriginal Community Controlled organisations for decades in response to community demand for self-determination and culturally appropriate services. However, contestable contracting, the specific form of marketisation that has been recently introduced to Indigenous Affairs, poses a serious threat to the Indigenous sector. As Gingrich (2011) has shown, marketisation varies across countries and the specific form of market mechanism that governments decide to introduce determines the distribution of resources, authority and accountability. Contestable funding processes use market-like incentives to increase competition amongst service providers. According to Australia’s Productivity Commission: “[c]ontestability means that a provider of human services faces a credible threat of replacement if it underperforms” (2017, 65). Under competitive tendering and contestable contracting the federal government retains control over funding, therefore it retains much of its power to influence service providers and determine what services are offered, to whom and how. Australian governments are embracing competition and contestability as policy strategies; they are the key elements of

78 this recent application of marketisation to Indigenous Affairs (Meagher & Goodwin 2015, 5; see also Thornton et al. 2012). Indigenous organisations’ funding is destabilised by contestable contracting and they must now compete with non-Indigenous service providers.

Presenting the market as the only available solution The new policy developments in Indigenous Affairs are part of a broader push to redesign the Australian state and society in the image of the market. Wacquant theorises that neoliberal states conceive of markets (or market-like mechanisms such as government- orchestrated competitive tenders) as the “universally optimal means for efficiently allocating resources and rewards” (Wacquant 2012, 72). The Indigenous Affairs literature suggests that since the election of the Howard government, Indigenous Affairs has been increasingly subjected to neoliberal reforms. Indigenous Affairs are now framed as economic issues, rather than social or political issues.

Indigenous dependence on government welfare has further been framed as a moral issue, in social and economic terms. The writings of the Indigenous lawyer and leader Noel Pearson have been very influential in reframing the policy debate (2009; 2007). Sanders has argued that Indigenous Affairs is a morally charged policy domain, but this does not necessarily lead to the conclusion that it is an economic domain (Sanders 2008, 188). It has to be “framed” as such by powerful policy actors (Fischer 2003, 144). But what is framing and how do policymakers use it to achieve policy change? This is the question that the third section of this chapter responds to.

Constructing policy problems: the role of ‘framing’ and ‘problematisation’ “Framing” is a term closely associated with the broad theoretical perspective of social constructivism, and post-positivist analyses of public policy (e.g. Goffman 1974; Fischer 2003). Berger and Luckman’s The Social Construction of Reality (1966), a constructivist text in sociology, established social construction as a key perspective in the social sciences. Constructivist investigations of the social world focus on how people interpret and conceptualise social reality, looking at the meanings that they construct about it through self-reflection and drawing on pre-existing cognitive frameworks and conventions (Kratochwil 2008, 81). Constructivist policy analysis sees policy work as involving the social construction of meaning and gives particular importance to “the process of problematisation” (Colebatch 2006, 9).

Problematisation refers, in part, to the process through which social phenomena are transformed into public policy ‘problems’. Kingdon (2003, 109-11) illustrates how “problem definitions” largely determine the eventual content of policy solutions. Kingdon highlights how policymakers are influenced by their value systems and ideologies when they are interpreting public problems, making sense of their causes and formulating appropriate policy responses based on their pre-existing cognitive biases (Kingdon 2003, 110-11). Constructivist policy scholars maintain that policymakers’ understandings of the root causes of pressing policy problems, such as unemployment, pollution, or obesity, will be heavily influenced by their world view. Stone, for example, focuses on how policymakers construct policy problems through rhetorical acts or the telling of “causal stories” (Stone 1989; 2002). She contends that policymakers use causal stories to attribute blame and label the root causes of public problems (Stone 1989; 2002). Stone argues that causal stories are an important political tool that policy makers use to persuade the public of the validity of their proposed policy solution.

Framing is another term that constructivists have used to explain the communicative processes through which actors (including policymakers) selectively construct reality and define problems. As Fischer explains, policymakers frame or give accounts of policy problems by drawing attention to some pieces of information at the expense of others (Fischer 2003, 144). The framing process draws on “familiar cultural symbols” to make policymakers’ constructions of policy problems readily comprehensible to the public (Fischer 2003, 144). Framing involves “sense-making; selecting, naming, and categorizing; and storytelling” (van Hulst & Yanow 2016, 92). Rein and Schön emphasise the “assumptional basis” that lies beneath the linguistic acts that give frames their outward appearance (1996, 88). Thus, framing is a subjective and political act influenced by policymakers’ assumptions about the nature of reality and the beliefs about the ideal state of society.

Dissecting the logics of problem representations One prominent approach to analysing policy frames and problem definitions is Bacchi’s ‘what’s the problem represented to be?’ method (2009; 2012). Bacchi urges policy scholars to scrutinise problem representations, in search of the underlying assumptions and “deep- seated conceptual logics” on which they rest (2012, 22). Her method is strictly constructivist, concentrating on the “meanings attached to social phenomena” (Lister 2010,

144). In drawing attention to the impact of framing and problem definition, constructivist approaches to policy analysis such as Bacchi’s, highlight the subjective and ideological aspects of policymaking. Constructivist policy scholars also highlight how policymakers use framing and causal stories to construct links between problems and policy solutions. Building on Stone’s insight that policymakers “choose causal stories not only to shift the blame but to enable themselves to appear to be able to remedy the problem” (1989, 297). In some cases, policymakers tell causal stories that depict certain population groups as the source of their own problems. In the process, these causal stories socially construct these same groups as ‘bad’ or ‘irresponsible’ people. Schneider’s and Ingram’s theory of the social construction of target populations concentrates on exactly this phenomenon (Schneider & Ingram 1997; 2005). It is a useful tool for understanding the social construction of cause and effect and the attribution of blame and responsibility through policy. The chapter now turns to the case of Indigenous Affairs funding reforms. Using Schneider’s and Ingram’s theory to examine the social constructions of Indigeneity, I show how assertions of Indigenous deviance and dependence are used to justify and reinforce specific policies.

Morality politics and the social construction of deservedness Schneider’s and Ingram’s (1997; 2005) constructivist theory of the policymaking process can aid our understanding of the Australian government’s treatment of Indigenous organisations such as ACCHS. This micro-level theory directs our attention to the specific ways that policies socially construct the moral worth of different groups in society. Schneider and Ingram refer to such acts of moral judgment as involving decisions about the “deservedness” of “target populations” (2005, 1). These theorists explain that populations are ‘targeted’ by policy not just in a material sense but in a symbolic sense as well. Policies, through the carefully crafted problem definitions and causal stories that underpin them, are designed to socially construct the deservedness and entitlement of social groups and populations (Schneider & Ingram 1997, 84-9; see also Rochefort & Cobb 1994; Stone 1989). Polices communicate to target populations how much they matter to the rest of society. Schneider and Ingram maintain that these powerful messages, located in policy frames, have radical societal implications for the distribution of benefit and burden, entitlement and disqualification (2005, 2). Their theory provides a method for discerning how policy can be used to reinforce political and social inequality.

Schneider and Ingram use a four-fold analytical schema to categorise target populations according to political power and social status. Target populations with high political power and social status are labelled “advantaged”. Doctors are an example of an “advantaged” target population because they possess considerable resources that can be used to influence policymaking and politics and they are also socially constructed in very positive ways by both policymakers and the general public (Schneider and Ingram 1997, 108). Politically powerful groups who are socially constructed in a negative way are termed “contenders”. “Contenders” possess significant political power to influence policy but are viewed with suspicion or contempt by the public and are therefore negatively constructed. An example of a contender would be a tobacco company or a bank (Schneider & Ingram 1997, 109).

Target populations who are politically powerless yet viewed positively by society are referred to as “dependents”. Dependents, as Schneider and Ingram explain, “are socially constructed as deserving in a moral sense” but they lack political power and are therefore “ignored as much as possible” (2005, 18). The moral dimension is a key element of this policy theory. The final target population in the analytical schema are the “deviants” who are both politically powerless and negatively socially constructed (Schneider & Ingram 1997, 108-9; Schneider, Ingram & deLeon 2014, 110-12). Criminals are one of the most obvious “deviant” population groups because they lack political resources and are socially constructed very negatively by policymakers and the general public (Schneider & Ingram 1997, 109). I contend that while ACCHS possess low levels of political power they are constructed as morally worthwhile organisations. This places them squarely in the category of dependents.

Historicising Aboriginal deservedness Social constructions are historically contingent (Jensen 2005; DiAlto 2005). Schneider, Ingram and deLeon contend that, over time, “policy cultures” can develop based on previous policy designs and their treatment of “target populations” (2014, 120). Moreover, some social constructions are more durable than others, and can be “anchored” or “legitimised” through policy (Schneider & Ingram 2005, 5). In Australia, for much of the period since colonisation began, policies have directly discriminated against, attacked, controlled, and neglected Aboriginal and Torres Strait Islander peoples. There are many

82 examples of negative social constructions of Indigenous peoples enduring for centuries and being reinforced by policy. Explicitly racist social constructions, such as the ideas that Aboriginal people were not fit to vote or care for their children, have been accompanied in Australia by entrenched and persistent policy discrimination against Aboriginal and Torres Strait Islander peoples (HREOC 1997; ATSISJC 1996; Broome 2010; McGregor 2011; Attwood 2003; Moses 2004). The social constructions of Indigenous incapacity and deviance “reached its nadir in the forced removal of Aboriginal children from their families without a court order and without parental consent” (Lea et al. 2011, 323). Governments have legitimised racial prejudice through policy, institutionalising Australian society’s negative impressions and stereotypes of Aboriginal people. Much of this was founded on scientifically baseless notions of racial hierarchies and social Darwinism (Francis 1996) that came to prominence at the end of the 19th Century (Rowse 2015a, 588), and paternalist ideas of protection and then “modernist” assimilation that have enduring influence (Sanders 2010; Maddison 2009, 5). Based on this policy history, it is a reasonable conclusion that there still exist vestiges of a policy culture that treats Indigenous peoples negatively or dismissively, categorising them as either dependents in need of assistance, or as deviants deserving punishment and reform.

Locating ACCHS within Australian policy’s moral field As observed above, within Schneider’s and Ingram’s analytical schema, ACCHS most closely resemble “dependents”. ACCHS possess relatively limited political power, they have a low public profile, and rely heavily on government funding. However, ACCHS are at times also closely associated with negative social constructions, such as ‘special treatment’ being given to Aboriginal and Torres Strait Islander peoples, and financial mismanagement and organisational incapacity (Sullivan 2010). As Smith notes: “the often unilateral imposition of the state’s sovereign powers are deemed to be necessary to ‘protect’ Indigenous people from the governance disabilities of their own culture” (2008, 77). This combination of a negative social construction and minimal political power locates ACCHS in the “deviants” category. However, ACCHS also have positive social constructions attached to them because their work delivering health services to socioeconomically marginalised Aboriginal families and communities is valued by some sections of society and government (e.g. DoH 2016c). This reading of ACCHS’ socio-political position locates them as quite positively constructed but relatively powerless.

The ACCHS sector’s dependent status explains why the sector is constantly struggling to secure ongoing government support and resources. As Schneider, Ingram and deLeon (2014, 112) explain, “dependents are viewed as ‘good’ people but considerably less deserving of actual investments than advantaged groups”. Dependents are the first to see their benefits cut in times of fiscal austerity and the last to receive a funding boost in times of economic prosperity (Schneider, Ingram and deLeon 2014, 112). ACCHS dependent status was evidenced in 2014 when the federal government cut the Indigenous Affairs budget by over $500,000,000 including significant budget reductions to Indigenous health. ACCHS are not on top of the government’s list of services and industries to fund, because they are dependents and do not contribute substantially to the creation of national wealth in a neoliberal economic sense (Schneider, Ingram and deLeon 2014, 112).

Neoliberal framings of the Indigenous sector As argued earlier in the chapter, the Australian government is using market logic to distribute benefits and burdens across society’s full spectrum of population groups, according to the neoliberal logic of NPM and marketisation. There is evidence that governments have accepted economists’ arguments about markets encouraging the most efficient allocation of resources (Pusey 1991; Edwards 2002) even though state intervention is often required to remedy some of the more egregious instances of market failure (Guinness & Wiseman 2011, 118). I argue that the precarious status of ACCHS in the broader health and public finance system can be understood as a product of the way policy, and society, constructs them as economic “dependents”.

Evidence suggests that Indigenous sector organisations are not receiving funding levels proportionate to the Indigenous population’s greater level of need for health and other services (Alford 2014; Alford 2015; Russell 2013; Couzos & Delaney Thiele 2007, 523; Dwyer et al. 2011, 35). The Close the Gap Steering Committee recently reiterated this point highlighting a “funding myth” that informs mainstream understandings of the value of Indigenous-specific services. Contrary to the popular belief that too much money is spent on Indigenous people, the Committee states:

The Aboriginal and Torres Strait Islander population have, on average, 2.3 times the disease burden of non-Indigenous people. Yet on a per person basis, Australian government health

expenditure was $1.38 per Aboriginal and Torres Strait Islander person for every $1.00 spent per non-Indigenous person in 2013-14.3. (Holland 2018, 5)

Thus, the supply of Indigenous health funding is not nearly keeping up with demand. This funding shortfall undercuts the federal governments ongoing rhetorical commitments to close the gaps in health. The government’s decision to direct minimal funding to Aboriginal organisations can be explained as a consequence of the social construction of these organisations as economic dependents.

As mentioned in Chapter 1, there is evidence that ACCHS are subjected to greater government scrutiny than non-Indigenous organisations. This sentiment was echoed by some ACCHS representatives interviewed for this thesis (see Chapter 9). Contributing to this perception of unequal treatment is the fact that the original Indigenous Advancement Strategy (IAS) guidelines contained a mandatory requirement that any Indigenous organisation receiving a grant of more than $500,000 per annum must incorporate under the Corporations (Aboriginal and Torres Strait Islander) Act 2006 (The CATSI Act). Organisations that incorporate under The CATSI Act are monitored by the Office of the Registrar of Indigenous Corporations (ORIC). Non-Indigenous organisations administering $500,000 or more were required to incorporate under the Corporations Act 2001 overseen by the Australian Securities and Investments Commission (ASIC). Crucially, Strakosch (2019, 125) notes that the regulations contained in the Indigenous-specific incorporation statute are more “onerous” than under the Corporations Act 2001. The IAS required any Indigenous organisation already covered by the Corporations Act, and which did not wish to transfer to the CATSI act, to apply to the Minister for an exemption (PM&C 2014a, 8).

Following advice from the Department of Prime Minister and Cabinet (PM&C), which argued that requiring Indigenous organisations to change their incorporation status “could be perceived as heavy-handed” (ANAO 2017, 24) the Minister removed the requirement in 2015. The government contended that the differential treatment of Indigenous and non- Indigenous organisations was designed to ensure that Indigenous organisations administering large IAS grants “have high standards of governance and accountability” (PM&C 2015, 19). The government also maintained that this kind of incorporation would offer Indigenous organisations benefits such as “access to training, advice, recruitment and

85 dispute resolution services” through ORIC (PM&C 2015, 19). The apparent assumption here was that Indigenous organisations require additional assistance to ensure that they administer large sums of government money appropriately; thus, steps must be taken to minimise the risk to government (Moran et al. 2016, 368).

Several organisations have noted the potentially racially discriminatory nature of the IAS’ incorporation requirements (Gooda 2015, 26; Oxfam 2017, 61; Strakosch 2019, 125; ANAO 2017, 24). This Indigenous-specific funding condition conforms to Moran, Porter and Curth- Bibb’s description of the Australian-public-finance management of Indigenous organisations as characterised by a “broad assumption of deficit” (2016, 368; see also Brigg & Curth-Bibb 2017, 203-4; Strakosch 2019, 125). This deficit discourse, based on assumptions of financial risk and Indigenous dysfunction (Strakosch 2015, 125), is of major concern to Indigenous organisations and communities. Based on this evidence, I argue that social constructions of Aboriginal deviance and ineptitude, framed in economic terms, pervade current Indigenous Affairs policymaking rationales and resultant surveillance.

Market discipline – a global process When combined with neoliberal imperatives for market expansion and profit generation, the position of “dependents” in society becomes even more insecure. Neoliberal governments, and neoliberal international institutions such as the World Bank and the International Monetary Fund prioritise investment in economically ‘viable’ or profitable industries and organisations, at the expense of non-profit organisations (for a discussion of how this affects global public health see Mooney 2012, 44-55). This creates a particularly destructive struggle for legitimacy, where dependents, such as charities and non-profits, seek to justify their legitimacy and highlight the public value of their work, while governments seek to build public support for their policy and funding decisions. This often plays out as follows: dependents criticise government policy as unfair and damaging to vulnerable citizens and the government responds by manipulating the social constructions attached to these dependents in order to “build support for the state and to continue the prevailing social structure” (Schneider & Ingram 2005, 33). Harsh treatment or neglect of dependents is often justified through appealing to social constructions that cast this target population as “in need of discipline” (Schneider & Ingram 2005, 17). For ACCHS this takes

86 the form of market discipline, enacted via obligatory reporting mechanisms built into their service-delivery contracts and the legislation that covers their incorporation status.

Economic risk discourse in Indigenous Affairs Aboriginal organisations are closely associated in Australia’s popular and political consciousness with the ideas of incompetence and “deficit” (Moran, Porter & Curth-Bibb 2016, 368). Sullivan has argued that the conservative Howard Government viewed Aboriginal organisations as a problem to be solved rather than as resource to be utilised (2010, 7; 2011, 59-60). Moran argues that during the years of the Howard Government “Indigenous organisations were recast as obstacles to progress” (2016, 179 emphasis added). There is evidence to suggest that the current Commonwealth government continues to treat Aboriginal organisations as risky investments and views Aboriginal people as needing especial oversight and management. Relatively recent policy decisions imply that ACCHS are undeserving of, and unentitled to government funding, such as the 2014 decision to cut $165.8m over four years from Indigenous health programs (see Chapters 1 and 4). Specific examples of such deficit thinking used by government are discussed in Chapter 4.

A financial risk discourse is prevalent in official discussions and media representations of Indigenous organisations (e.g. Neal 2018; McDonald & Besser 2016; Gibson 2000, 301). This occurred at the same time as governments were constructing an environment of continuous audit in pursuit of better management and organisational improvement (Head 2005, 48). Neoliberal Indigenous policies frame Aboriginal Community Control as just another way of running a business and attempt to quash the uniquely Indigenous political qualities of the Aboriginal Community Controlled governance model. The continuous suspicion surrounding Indigenous organisations’ financial management gives credence to Gibson’s assertion that “[t]wo of the weapons used in dispossession today are the economic tool of accounting and the rhetoric of accountability” (2000, 299). The incessant talk of financial risk undermines the legitimacy of Indigenous organisations and distracts public debate from the foundational source of national political tension: enduring Indigenous sovereignty and Settler-colonial dispossession.

Aboriginal Community Control as resistance to Settler hegemony Indigenous organisations frequently advocate for greater Indigenous self-determination. The Indigenous sector often openly challenges the government’s policy frames, its problem definitions and social constructions of Indigenous peoples. Advocacy is an important part of the Indigenous sector’s social and political function (Bartlett and Boffa 2005). The creation of ACCHS can be viewed as a strategy for resisting Settler colonial processes of elimination. Given that ACCHS were established to provide Aboriginal people access to the basic healthcare services needed to survive in Settler colonial Australia (Grant et al. 2008, 7-8), the formation of these organisations can be understood as an Indigenous survival tactic. Gradually, the ongoing operation of ACCHS also assumed the purpose of guaranteeing the continuity of Aboriginal cultures, worldviews and religions. This is explicitly acknowledged in the Aboriginal Health and Medical Research Council’s (AH&MRC) constitution (AH&MRC 2008, 9). The mere fact that ACCHS aim to provide ‘culturally appropriate’ healthcare implies that distinct Indigenous cultures continue to exist outside of the mainstream Settler culture.

Understanding the Settler-colonial logics of neoliberal policy frames Government attempts to undermine the Indigenous sector through funding cuts and increased competition can be understood as an attempt to manage political risk; they can be viewed as a “post frontier attempt to eliminate the obstruction presented by the persistence of Native sovereignties along with their attendant territorial counter claim” (Wolfe 2016, 15). Ongoing Indigenous sovereignty has the power to undermine popular understandings of Australian nationhood and the political hegemony that rests on them (Wolfe 2016). This is not to suggest that ACCHS represent sovereign Indigenous polities in the same way as Native Title groups or Local Aboriginal Land Councils. However, I argue that ACCHS are closely associated in the mainstream political imagination with Indigenous separatism and can therefore be framed as a political challenge to the status quo. Dwyer and colleagues argue that this political form of risk stems from the mistrust and sensitivity that surround Australia’s “foundational ideas of national identity” (Dixson cited in Dwyer et al. 2011, 40). To manage the political risks produced by vocal Indigenous organisations, such as ACCHS, Governments have sought to undermine Indigenous organisations by socially

88 constructing them as financially unaccountable and incompetent and therefore illegitimate, when assessed against dominant neoliberal values.

The Australian government’s rhetorical and policy treatment of Indigenous organisations implies a great deal about how mainstream Australia perceives Indigenous Australia. By pairing Wacquant’s (2009; 2012) explanation of the heightened surveillance and paternalism that occurs in neoliberal states with Schneider’s and Ingram’s (1997; 2005) theory of the social construction of deservedness through policymaking, we begin to see how in contemporary Australia, policymakers use the market as a way of sorting the undeserving Aboriginals from the deserving Settlers, distributing benefits and sanctions accordingly. This continues Settler colonialism’s logic of elimination (Wolfe 2016). As market logic is drilled deeper into social and health services, ACCHS are no longer shielded from the neoliberal Settler state’s demands for market expansion, efficiency maximisation and profit generation.

Neoliberalism involves new techniques of governance and social control and the extension of market logic to the social and bureaucratic spheres (Wacquant 2009; Meagher & Goodwin 2015). However, in relation to the Australian state’s treatment of Indigenous organisations, neoliberalism continues the underlying ‘logic of elimination’ (Wolfe 2016), where First Nations organisations are pressured into assimilating into dominant forms of social, political, and economic organisation and coerced into renouncing pre-colonial allegiances, values and sovereignties. That contemporary neoliberal policies act on Indigenous organisations differently to the historical policies enacted under the ‘protection era’ of Indigenous Affairs (see for example Broome 2010) is entirely consistent with Wolfe’s description of ‘race’ as a versatile ideology. Indigenous peoples, and in this case Indigenous organisations, are racialised in different ways over time in response to “particular historical agendas” and emergent political and economic priorities (Wolfe 2016, 10). The underlying intention remains the same, though, and policy perpetuates Settler displacement of First Nations and their representative organisations, “requiring either their removal or their transformation” (Wolfe 2016, 8).

Lloyd and Wolfe (2016) argue that that neoliberalism and NPM are just the latest manifestations of Settler-colonial expansion. We currently see this in Indigenous health

89 policy, where Settler approaches to healthcare, predominantly clinical ones, are being promoted at the expense of alternate Indigenous ways of caring. ACCHS are being politically neutralised so the neoliberal project of Settler expansion can continue. Thus, the neoliberalisation of the Indigenous sector can thus be viewed as part of the longer historical project of erasing Indigenous difference through assimilating Indigenous individuals and collectives to Settler paradigms.

The neoliberalisation process affects First Nations peoples in particularly insidious ways. It constricts Indigenous agency and hampers many projects for Indigenous self-determination. It does this by presenting engagement with the neoliberal market economy as the only acceptable way of living life (Edwards 2002, 16-18; Bielefeld 2016; Altman 2014; Rose cited in Bulloch & Fogarty 2016, 83-4). Moreton-Robinson’s concept of Whiteness is instructive here (2004). She explains that “deviant” behaviour is that which does not match up to the invisible White ideal that forms the moral backdrop of the nation (Moreton-Robinson 2004, 78). Whiteness in the neoliberal age normalises market logic and condemns alternate Indigenous forms of social, political and economic organisation.

Conclusion This chapter has theorised that consecutive Australian governments have been engaged in neoliberal statecraft through the application of NPM to all sectors of society, including the Indigenous sector. It has argued that NPM’s application to Indigenous Affairs continues the Settler-colonial logic of elimination by undermining the political legitimacy and material security of Indigenous organisations. Using social constructivist theories of the policy process this chapter has argued that the Australian government ‘frames’ the market as the universally optimal state of social and economic organisation. The chapter has also contended that current Indigenous Affairs policies delegitimise Indigenous organisations by socially constructing them as morally deficient economic dependents. The chapter has positioned NPM as a recent addition to the Settler state’s disciplinary repertoire, which it justifies by frequent appeals to neoliberal market logic. NPM can be understood as a contemporary policy mechanism that furthers the reach of Settler colonial normativity and control and undermines Indigenous attempts to reassert sovereignty. The next chapter analyses three contemporary Indigenous Affairs policies and assesses the ways in which they are affecting Indigenous self-determination and furthering neoliberal market logic.

Chapter 4.

Marketising Indigenous policy (2014-19) 2

This chapter traces the emergence of three closely related federal Indigenous Affairs policies, which have been implemented in the last five years of conservative Liberal-National Government. The policies under analysis are the Indigenous Advancement Strategy (IAS), the Indigenous Australians’ Health Programme (IAHP) and the Primary Health Network (PHN or PHNs). This chapter contends that all three policies are examples of New Public Management (NPM) being applied to Indigenous Affairs. This chapter documents the market logic that courses through the IAS, the IAHP and the PHN, focusing on the policy documents that structure their operation. These policy documents are also analysed in terms of the way they frame or socially construct First Nations, drawing on the post- positivist policy analysis literature that was introduced in Chapter 3. Public statements and explanations from federal ministers are also analysed in order to shed light on the current government’s overarching policy goals for Indigenous Affairs. The three policies that this chapter considers were predominantly developed during the Liberal-National Prime Ministership of Tony Abbott, but they have been continued by the subsequent Liberal- National Prime Ministers Malcolm Turnbull, and Scott Morrison. The chapter argues that this policy continuity is indicative of the ongoing neoliberalisation of Indigenous Affairs.

The chapter begins by setting the 2014 policy changes in historical context, offering an overview of previous funding arrangements for Aboriginal Community Controlled Health Services (ACCHS). It also details the funding sources of four ACCHS in New South Wales (NSW). These case studies illustrate the financial implications of recent policy and funding reforms for individual ACCHS in different remoteness categories. The chapter then analyses the IAS, charting its development before and during the 2013 election campaign and discussing in detail the findings of the 2016 Senate Inquiry into the IAS’ tendering processes. The IAS’ practical impact on service delivery organisations is the main concern of this section. Subsequently the chapter analyses the mooted changes to Indigenous primary

2 Some of the material in this chapter has been drawn from a recent publication (Coombs 2018), which has been acknowledged and detailed in the ‘Inclusion of Publications Statement’ for this thesis.

92 healthcare funding under the newly created IAHP. The potential for the IAHP to expand contestability in Indigenous primary healthcare funding is explored here. The final section of the chapter focuses on the emergence of PHNs, which are responsible for funding and supporting primary health service providers. Based on interview responses, the creation of the PHNs is one of the policy developments about which ACCHS sector representatives are most worried. The theoretical basis of the PHNs is outlined, and the operation of the PHNs in practice is scrutinised. The chapter illuminates the practical challenges that all three of these reforms present for the ACCHS sector. It concludes that the IAS, the IAHP and the PHNs destabilise the position of the ACCHS in the broader health system, raising the possibility that these vital Aboriginal services will disappear or be transformed beyond recognition.

A short history of Aboriginal health funding arrangements Since the inception of ACCHS in the 1970s, there have been many shifts in how these organisations have been funded. As mentioned in Chapter 2, early ACCHS such as the Redfern Aboriginal Medical Service (AMS) had very limited access to government funding and relied on donations from community members and volunteer labour from doctors, nurses and other staff (Saggers & Gray 1991, 148; Foley 1991, 5). Over time, though, Commonwealth funding became the ACCHS sector’s main source of income. This began in 1973, when the Whitlam Labor government made the first grant of funds to the Redfern AMS, however significant Commonwealth funding for ACCHS was not forthcoming until the early 1980s (Grant et al. 2008, 8). In 1984 the Hawke Labor government consolidated all federal responsibility for Aboriginal health programs under the Department of Aboriginal Affairs (DAA) (Grant et al. 2008, 11). Following this machinery of government change the Hawke government significantly boosted funding for ACCHS (NAHS 1989,32; Grant et al. 2008, 11). While this funding increase expanded the number of Aboriginal and Torres Strait Islander people with access to ACCHS, the relocation of Aboriginal health in the DAA meant it became an increasingly neglected policy area (Grant et al. 2008, 11). In the 1980s and early 90s ACCHS were “invariably under-funded in comparison with government health services” (Saggers & Gray 1991, 154).

In 1990 the Hawke government created the Aboriginal and Torres Strait Islander Commission (ATSIC), a new government department run by Aboriginal Commissioners

93 elected by Aboriginal people. ATSIC was responsible for Indigenous Affairs policies and programs. ATSIC replaced the DAA and assumed responsibility for Aboriginal health. As early as 1993, however, the ACCHS sector began advocating for the Aboriginal health portfolio to be transferred to the Commonwealth Department of Health (DoH) (Grant et el. 2008, 12). The ACCHS sector’s national peak body the National Aboriginal Community Controlled Health Organisation (NACCHO) was a leading voice in this campaign (Grant et al. 2008, 12). NACCHO and its ACCHS affiliates argued that the ‘mainstream’ DoH with its sizeable budget and powerful status, should be made to take responsibility for improving Aboriginal health outcomes (Grant et al. 2008, 13). This campaign was not a criticism of ATSIC but rather a recognition that only the mainstream DoH commanded the resources to improve Indigenous health outcomes (Bartlett & Boffa 2005, 56).

In response, the Hawke government transferred responsibility for the majority of Aboriginal health policy and programs, including funding and policy for ACCHS, from ATSIC to the Commonwealth Health Department in 1995 (Grant et al. 2008, 13). The Office for Aboriginal and Torres Strait Islander Health (OATSIH) was formed inside the Health Department, in an early act of Indigenous health policy ‘mainstreaming’. Martini and colleagues (2011) provide a useful historical snapshot of ACCHS funding during the OATSIH period. For the 2007-8 financial year they found that the Commonwealth government provided 72% of ACCHS funding, with state/territory governments contributing 27% of funding, and other sources making up the remaining 1% (Martini et al. 2011, 5). This analysis also found that ‘mainstream’ health departments were the largest funders at the state/territory and Commonwealth levels. DoH via OATSIH contributed 39% of ACCHS funding and state/territory health departments contributed 16% (Martini et al. 2011, 5). Another study asserts that the overall proportion of funding to come from Commonwealth sources was similar in subsequent years: “In 2010 ACCHS were funded through a myriad of programs, with the Commonwealth government contributing 73% of total funding and the state governments contributing the remainder” (Donato & Segal 2013, 235).

ACCHS access to Medicare funding Another important source of revenue for ACCHS comes from Medicare. In 1996 ACCHS were granted the ability to bulk bill under Medicare (Bell et al. 2000, 82). ACCHS’ access to Medicare funding was increased in 2001 when the Howard government made changes to

94 the Health Insurance Act 1973 allowing ACCHS to claim Medicare rebates in addition to receiving grant funding through OATSIH (Grant et al. 2008, 15). The addition of Indigenous- specific items to the Medicare Benefits Schedule, such as health checks and chronic disease care plans, has also seen ACCHS’ Medicare revenue increase (Moran, Porter & Curth-Bibb 2014, 21-2).

No contemporary data could be located giving a detailed national picture of Medicare funding allocated to ACCHS. However, Russell reported in 2014 that “Aboriginal Medical Services” received “about $700 million for Indigenous‐specific services plus a Medicare component of about $45‐50 million” (Russell 2014, 17). A conservative estimate of Medicare revenue then would put the figure at 6% of total Commonwealth funding for ACCHS. Additionally, the publicly available financial statements of several ACCHS suggest that the proportion of total ACCHS funding that is generated via Medicare billing may be increasing (see for example Awabakal 2018, 6; Bullinah AHSAC 2015, 14; Bullinah AHSAC 2014, 17-18; Maari Ma HAC 2014, 49; Maari Ma HAC 2016, 47; IUIH 2018, 10). Interview responses (see Chapter 8) also give this impression. This is an important development as Medicare revenue can be expended in a more flexible manner than grant revenue, as it is not tied to particular outcomes or activities once generated through service provision. The implications of using Medicare as a flexible funding source are explored further in Chapter 8.

A sample of ACCHS funding across different remoteness categories To comprehend the significance of the 2014 Commonwealth Indigenous Affairs funding changes it is necessary to understand the proportion of ACCHS funding that comes from various funding sources. While no sector-wide analysis of post-2014 ACCHS funding sources could be located, and it was beyond the scope of this thesis to conduct this kind of detailed accounting, it was possible to locate and analyse a sample of financial records from four ACCHS in NSW, one for each of the four remoteness categories covered by this study. While the financial records are drawn from two different financial years, they are consecutive years. The records for two ACCHS refer to the 2016 financial year and the other two cover the 2017 financial year. The annual reports for the urban-based and the remote ACCHS, from which the financial records were sourced, are publicly available online. However, the reports for the inner-regional and outer-regional ACCHS were given to me during fieldwork.

For this reason, no citation is given in order to protect the anonymity of research participants and participating ACCHS.

In the below analysis I work from the assumption that funding sources for these four ACCHS are typical of the ACCHS sector in NSW. The analysis is designed as an indicative sample only and no claim about statistical significance is made here. By calculating the proportion of funding that these organisations receive from various government sources, and assuming that the funding distribution is broadly similar across the ACCHS sector, it is possible to gauge the scale of the funding shifts that occurred after the introduction of the IAS, the IAHP and the PHNs. While this is a very small sample size, it offers some insight into the ACCHS sector’s contemporary funding context.

Below, I outline the funding sources of each of the four organisations and offer some interpretation of the funding distribution where possible. NSW government grants, Medicare revenue, and non-government grants, such as those from the Rural Doctors Network (RDN) are listed separately. ‘Commonwealth grants’ can refer to either IAHP funding, IAS funding, other funding from other federal government departments, or a combination of these sources. It is important to clarify that funding for the IAHP is administered by the Commonwealth Department of Health (DoH). PHN funding is also the responsibility of DoH, while IAS funding comes from the Department of Prime Minister and Cabinet (PM&C). PM&C only became a major source of Indigenous funding and policy after machinery of government changes that were implemented by the Abbott government in 2013-14.

Urban-based ACCHS: 2016-17 An urban-based ACCHS reported that in the 2016-17 financial year it received 41% of its income from Commonwealth government grants, 21% from Medicare revenue, 19% from NSW government grants, 13% from the regional PHN and 2% from the RDN. DoH was this ACCHS’ largest single funding partner, contributing 34% of the organisation’s revenue. The financial report did not list PM&C as a funding source but it is possible that PM&C funding constituted the difference between total Commonwealth grants (41%) and DoH grants (34%). If this were the case, PM&C funds would make up no more than 7% of the organisation’s total revenue. (Yerin AHSI 2017, 34)

Inner-regional ACCHS: 2015-16 An inner-regional ACCHS reported that in the 2015-16 financial year it received 29% of its total revenue from Commonwealth grants (26% from the DoH, 2% from PM&C and 1% from the Department of Social Services). 10% of its total income came from Medicare, 44% from the NSW government, 1% from the Local Health District (LHD) and the remainder from other sources including client contributions, interest, and training and wage subsidies. The reason that this ACCHS received such a high proportion of its revenue from the NSW government is because it provides Out-of-Home Care (OOHC) services for Indigenous children. OOHC funding accounted for 37% of the organisation’s total revenue.

Outer-regional ACCHS: 2016-17 An outer-regional ACCHS reported that in the 2016-17 financial year it received 45% of its income in Commonwealth government grants. DoH contributed 38% of the organisation’s total revenue and PM&C contributed 7%. 14% of this ACCHS’ income was generated via Medicare revenue. 6% of its revenue came from the NSW Ministry of Health, 3% from the LHD, 10% from the RDN, 3% from the regional PHN, and the remainder from other sources similar to those listed above for the inner-regional ACCHS. The DoH was the largest single funder for this organisation.

Remote ACCHS: 2015-16 A remote ACCHS reported that in the 2015-16 financial year 45% of its revenue came from Commonwealth government grants (40% from DoH, 5% from PM&C), 10% from Medicare revenue, 8% from NSW government grants (6% from NSW Ministry of Health), 9% from LHD grants, 5% from the RDN, and the remaining 23% from a range of other sources. (Maari Ma HAC 2016, 47-55)

For three out of four of these ACCHS, Commonwealth grants constituted the largest single source of revenue. If Medicare revenue, which is administered by DoH, is also categorised as Commonwealth funding then for these same three ACCHS Commonwealth funding constitutes more than 50% of their total revenue. DoH was also the largest single provider of funds for these three ACCHS. For the inner-regional ACCHS, Commonwealth grants primarily provided by DoH were the second largest source of revenue. PM&C delivered a relatively small although not insignificant amount of funding to all four ACCHS, contributing

≤7%, 2%, 7% and 5% to the urban, inner-regional, outer-regional and remote ACCHS respectively.

While only two of these organisations reported receiving funding from their regional PHN, that the urban-based organisation received 13% of its total funding from this source illustrates the importance of PHNs as fund holders for some ACCHS. This funding overview illustrates that changes to the way the Commonwealth government administers Indigenous grant funding, especially IAHP grants administered by DoH, have major implications for ACCHS in NSW. The above analysis also shows that since the introduction of the IAS in 2014 PM&C has become an important funding partner for some ACCHS. As statements from interviewees attest to, IAS funding is vital for ACCHS because it pays the wages of health workers who deliver social and emotional wellbeing (SEWB) and drug and alcohol programs to Indigenous clients (see Chapter 8).

The Indigenous Advancement Strategy: rationale and effects The IAS constitutes one of the most sweeping revisions of the federal government’s policy and funding arrangements for Aboriginal and Torres Strait Islander services in recent decades. It has dominated debate over Indigenous policy-making since its introduction and has been the subject of a Senate inquiry (Senate FPARC 2016) and two national audits (ANAO 2017; ANAO 2019). The IAS has been singled out by Indigenous peak bodies and representative organisations (e.g. ATSIPO 2016, 4) and by the Aboriginal and Torres Strait Islander Social Justice Commissioner (ATSISJC 2015; 2016) as a policy in need of reform. As mentioned in Chapter 1, the Close the Gap Steering Committee also identified the IAS as a policy area of which could negatively impact Indigenous health and wellbeing (Holland 2016, 39; Wright & Lewis 2017, 43). The federal government also positioned the IAS as its flagship Indigenous Affairs reform (Scullion 2014; Australian Government 2014a). For these reasons, and because it was the first of the three policies discussed here to be implemented, this chapter begins its analysis with the IAS. I argue that the IAS signalled the direction of the federal government’s reform agenda.

The Minister for Indigenous Affairs, Nigel Scullion, announced the IAS on 13 May 2014 as part of the Abbott Government’s first budget (Scullion 2014). The Minister contended that the IAS measures would improve outcomes by “getting children to school, adults into work,

98 and building safe communities” (Scullion 2014). On July 1, 2014, just six weeks later, the IAS consolidated more than 150 Indigenous-specific programs and services that were previously administered by several different government departments. Most Aboriginal and Torres Strait Islander-specific services were rolled into five new funding streams administered by PM&C. Judged at face value this consolidation seemed like a dramatic feat of streamlining, but closer analysis by Hudson (2016, 11) revealed that the number of Federal programs was closer to 50, with additional sub-programs and projects hidden within the five new programs.

The administration of Indigenous programs remains complicated. The new funding streams or programs are entitled: Jobs, Land and Economy; Children and Schooling; Safety and Wellbeing; Culture and Capability; Remote Australia Strategies (PM&C 2014a, 4). The first iteration of the IAS guidelines explained that:

The Strategy has been designed to reduce red tape and duplication for grant funding recipients, increase flexibility, and more efficiently provide evidence based grant funding to make sure that resources hit the ground and deliver results for Indigenous people. (PM&C 2014a, 4)

The Government characterised its new funding model as simple and efficient, contending that it would reduce administrative requirements and improve outcomes. Many service providers and policy observers, however, have since stated that the IAS did not adequately meet these expectations when implemented, and that it did not achieve the desired level of administrative streamlining and simplification. There was widespread confusion amongst service providers who had been caught off guard by the IAS’ surprise announcement and were struggling to understand how the new arrangements would impact their organisations (Senate FPARC 2016). These on-the-ground effects are discussed in detail in Chapter 6.

As well as trying to fit a sizeable number of diverse programs into a handful of funding streams, the IAS introduced a new funding allocation methodology to Indigenous Affairs. PM&C announced that “open competitive grant rounds” would be used to distribute the “bulk” of funds under the IAS (PM&C 2014a, 5). Other funding opportunities, namely restricted grant rounds, direct grant allocation and demand-driven grants, were also

99 allowed for (PM&C 2014a, 5). These alternate funding processes involved the Department directly approaching certain service providers to invite applications or came in response to community demand for services. Four years after the IAS was initially announced, PM&C’s grant reporting website lists all grants awarded via the Department’s flagship Indigenous Affairs program, totalling $4.46b. As of April 2018, the figures available on PM&C’s website (PM&C n.d. a; PM&C n.d. b) reveal that the ‘bulk’ of IAS funding was in fact distributed via non-competitive processes. The funds distributed during the 2014 open competitive grant round accounted for just 27% (or $1.22b) of total IAS funding (PM&C n.d. a). The department distributed 73% of total IAS funds (or $3.24b) via non-competitive processes (PM&C n.d. b) such as where the Department responds to “community led proposals” or directly approaches an organisation to offer it funding (PM&C 2016, 9). This non- competitive funding most likely also included ongoing funding commitments that preceded the announcement of the IAS.

The introduction of competitive tendering to Indigenous Affairs policymaking has not been as easy as the government might have hoped (for details of implementation issues see ANAO 2017; 2019). The Senate enquiry into the IAS’ tendering processes drew attention to the fact that small Aboriginal Community Controlled organisations had to compete for funds with mainstream non-profits, major companies and government departments (Senate FPARC 2016, 39-40). Many people working in the Indigenous sector view competitive tendering as an inappropriate way of distributing funds for Indigenous-specific services. Many ACCHS share this view, which is discussed in Chapter 6.

The underlying assumption that justifies competitive tendering is that competition for government service grants will drive costs down, increase choice and lead to innovation, thus improving service quality (Industry Commission 1996; Ernst 1998, 220, 223; Savas quoted in O’Flynn 2007, 356; Marquand quoted in Siltala 2013, 470). A belief in the innovative potential of market competition was a key part of the rationale that led to the introduction of the new arrangements under the IAS (NCOA 2014). In practice however, competitive tendering is not without its problems. It has been associated with diminishing numbers of service providers, and the organisational growth and expansion of the few remaining providers (Considine, O’Sullivan & Nyugen 2014, 177), thus reducing consumer

100 choice. There is also the potential that competitive tendering can instil a more businesslike approach within the organisational culture of a non-profit organisation, leading to ‘mission drift’ (Van Slyke 2003, 298) and a lessened focus on community values (Eikenberry & Kluver 2004, 136). When it is introduced with little warning, as it was by PM&C, competitive tendering can be a source of acute organisational stress (ATSISJC 2015). If staff members are inexperienced with the competitive grant writing process, the need to prepare a convincing application in a short timeframe can be tremendously taxing, because of the potential consequences for staff, clients and the organisation if funding is not secured. Given the small percentage of IAS funding that was able to be distributed via competitive processes, and the fact that half of all applications PM&C received for the competitive round were non- compliant (PM&C cited in Senate FPARC 2016, 42), open competitive tendering has not been particularly efficient way of reforming Indigenous Affairs funding.

Destabilising Aboriginal organisations and communities The move to restructure Indigenous Affairs funding processes followed the 2013 machinery of government changes wherein responsibility for most Indigenous policies, programs and services transferred to PM&C from eight other government agencies (PM&C 2014b). Some observers have worried that this consolidation has led to substantial loss of institutional memory and policy expertise (Perche 2018; Carey et al. 2016; Russell 2014, 6; Senate FPARC 2016, 29-30). Service providers have complained that the transfer of Indigenous Affairs to PM&C made adapting to the new grant application process even harder to manage because of the loss of established relationships and contacts in government (Senate FPARC 2016, 29- 30). The performance audit of the IAS, conducted by the Australian National Audit Office (ANAO 2017, 22), found that PM&C “developed a consultation strategy but did not fully implement the approach outlined in the strategy”. The IAS consultation strategy involved the Department seeking feedback from the government-selected Indigenous Advisory Council, and PM&C also conducted around 80 regional information sessions for stakeholders and potential grant applicants (ANAO 2017, 23). However, the ANAO reported that these sessions did not cover central issues such as how PM&C would involve Indigenous communities in the co-design and delivery of regional strategies to address needs (ANAO 2017, 23). Even more worrying is the ANAO’s finding that only 12% of the grant applicants interviewed for the audit said they had been consulted prior to the IAS’ commencement

101

(ANAO 2017, 23). The department’s inadequate consultation with Indigenous stakeholders likely contributed to the high number of complaints from Indigenous organisations about the lack of consultation and community engagement regarding the IAS and what it would entail in practice (ANAO 2017, 23; Senate FPARC 2016, 14). The restructuring of Indigenous Affairs administration was not done in partnership with Indigenous sector organisations, nor were the details of the reforms effectively communicated to key stakeholders.

PM&C argued that the rationalisation of funding streams would provide greater flexibility to service providers and Indigenous communities and simplify the funding application process (PM&C 2014a, 4). However, because of a lack of consultation with Indigenous communities, leaders and organisations in developing the IAS, the announcement of this ‘rationalisation’ came as a rude shock. Service providers had to scramble to familiarise themselves with new bureaucratic procedures and selection criteria (ATSISJC 2015, 2). Communication between PM&C and key Indigenous stakeholders was limited (NACCHO 2015). Details of the new arrangements were not forthcoming, timeframes for applications were short and the funding process was described by the Aboriginal and Torres Strait Islander Social Justice Commissioner (ATSISJC 2015, 2) and the Lowitja Institute (Mokak 2015, 5) as chaotic, inefficient and the source of significant stress for Indigenous organisations (see also Senate FPARC 2016, 13; ANAO 2017, 25; Chapter 8). Half of all applications made in the first round of IAS funding were deemed ‘non-compliant’ (Senate FPARC 2016, 43), suggesting that the new arrangements were overly complicated and/or poorly explained by the Department. In implementation, many Aboriginal Community Controlled organisations have not experienced any of the simplification or flexibility that the IAS promised, as Chapter 7 details.

It seems possible that meaningful consultation processes were not organised because the government had already decided, even before winning office, what its Indigenous Affairs reforms were going to look like. Many of the ideas underpinning the IAS were spelled out in a 2014 National Commission of Audit’s (NCOA) Phase One report that recommended “significantly consolidating and rationalising Commonwealth Indigenous-specific programmes” (NCOA 2014, 177). Many earlier government reports had also made similar recommendations for the consolidation and simplification of Indigenous programs and

102 funding streams (e.g. DoFaD 2010; ANAO 2007, 25; Morgan Disney & Associates 2006). The NCOA report also recommended the increased use of competitive tendering across government (NCOA 2014, 230). The NCOA report made recommendations for budget repair and suggested greater levels of private-sector involvement in the delivery of government services, based on the claim that “the private sector will often be better placed to deliver services more efficiently” (NCOA 2014, ii). Overall, the report prioritised fiscal restraint, was supportive of greater private-sector involvement in government work, argued for the benefits of markets, was sceptical of regulation as a solution to public problems, and promoted “value for taxpayers’ money” as a central objective of all government programmes (see, in particular ‘Principles of Good Government’ in NCOA 2014, iii-iv).

Given the professional backgrounds of the people leading the Commission of Audit, it was perhaps foreseeable that it would recommend fiscal restraint and privatisation. The Commission was chaired by former Business Council of Australia president Tony Shepherd, and included three former senior public servants, including Peter Boxall, a self-identified economic rationalist trained by the Chicago School of Economics (Altman 2014, 123), and the former Howard Government minister Amanda Vanstone. Prime Minister Abbott appointed the members of the Commission and they were all drawn from sympathetic sections of the public and private sectors. The NCOA was arguably established to find ways for the Abbott Government to justify and implement many of the policy promises that it had made in the election campaign. The Abbott Government, in setting the NCOA’s terms of reference, explained that the Commission had “a broad remit to examine the scope for efficiency and productivity improvements across all areas of Commonwealth expenditure” (Australian Government 2013a, 1) and stated that there was a need to “ensure taxpayers are receiving value-for-money” and “eliminate wasteful spending” (Australian Government 2013a, 1). These statements closely align with the Coalition’s election promises to “cut waste”, build “more efficient government” and “start delivering better value for money” (see Liberal Party of Australia 2013, 4-5 & 17). There is political precedent within the Liberal Party for using an ‘audit’ in this way, with the previous NCOA assembled in 1996 during the first year of John Howard’s Prime Ministership (Wright 2014).

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Importantly for our discussion of the overarching political and policy contexts in which the IAS was announced, the NCOA’s report contains concepts and recommendations consistent with neoliberal policy priorities such as downsizing government and privatising public services (Navarro 2012, ix). Moreover, prior to winning government the Liberal Party released a document entitled ‘Our Plan’ during the 2013 election campaign, which outlined “the Coalition’s top policy priorities” (Liberal Party of Australia 2013, 4). In this document the Coalition promised to “eliminate red tape and streamline programmes to move away from the complex web of overlapping initiatives that have failed to end disadvantage” (Liberal Party of Australia 2013, 43). This foreshadowed the NCOA’s recommendation that that the government consider “significantly consolidating and rationalising Commonwealth Indigenous-specific programmes, bodies, committees, councils and boards, and ensuring programmes and reporting are focussed on outcomes” (NCOA 2014, 177). This was then put into practice in the Abbott government’s attempts to streamline and simplify the administration of Indigenous Affairs programs and services under the IAS.

The NCOA delivered its Phase One report to government in February 2014. However, the government pre-empted the handing down of the Commission’s findings by announcing in January that it would be consolidating over 150 Indigenous specific activities and services into five or six broad policy areas, in the hope of saving “tens of millions of dollars” in administration costs (Karvelas 2014). This announcement, and the Coalition’s election campaign promise to streamline Indigenous programs, indicate that the IAS’ general form had been conceived well in advance of the NCOA handing its recommendations to government. These recommendations did, though, give the government more material with which to justify its decision after the fact. The IAS’ genesis in the 2013 election campaign underscores the top-down nature of the reform, driven by senior figures in the Liberal National Coalition with no meaningful consultation around First Nations’ priorities (Gooda cited in Senate FPARC 2016, 14). The IAS imposed ‘textbook’ economic solutions from above with little consideration of cultural fit or appropriateness. The IAS’ particular history indicates that ideology rather than evidence was the driving force behind this policy.

Tracing the financial effects of the IAS Once the IAS came to be implemented, it was reported that the competitive tendering for the open round of applications had resulted in most grants being allocated to non-

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Indigenous organisations (Morgan 2015, also Howard-Wagner 2018b, 219). Howard- Wagner, for example, reports that under the IAS 65 % of federal funding for Aboriginal and Torres Strait Islander service delivery went to “large, mainstream not-for-profit organisations and the commercial sector” with only 21 % going to Aboriginal Community Controlled organisations (2018b, 219). Although the Government has since stated that the proportion of Indigenous organisations now receiving grant funding has increased under the IAS (Scullion 2015), it is not clear if there has been an overall increase in the total number of Indigenous organisations to receive Commonwealth funding.

The Commonwealth government has also stated that of the $1 billion administered through the IAS’ open competitive round “Indigenous organisations received the largest slice of the grant round funding—55 % of the total” (Australian Government 2016, 2), indicating that Indigenous organisations were not as disadvantaged by the IAS’ competitive funding rounds, as was previously reported (Senate FPARC 2016, 21). However, the government’s statement does not explain how much or what percentage of IAS funding went to Aboriginal organisations in non-competitive funding rounds. This is a telling omission because the majority of IAS funding has been distributed via these non-competitive processes, and not under the competitive grant round. As was demonstrated earlier, non-competitive funding made up $3.2billion, or 73%, of the total IAS funding pool, as of April 2018 (PM&C n.d. b). Analysis of IAS funding conducted by Hudson (2016, 12), from the Centre for Independent Studies (CIS), adds additional caveats. She found that Indigenous organisations received only 32% of total grants. Additionally, the CIS investigation found that Indigenous organisations received only 24% of total IAS funding (Hudson 2016, 12). This contradicts the government’s claim that under the IAS’ non-competitive funding processes, which include community-led proposals, 50% of all funding went to Indigenous organisations (Australian Government 2016, 3). If the CIS funding breakdown is accurate, the Government’s claims that it is directing the majority of IAS to Indigenous organisations are misleading.

Based on available analyses of IAS funding (Hudson 2016; PM&C n.d. a; PM&C n.d. b; Howard-Wagner 2018b, 219) it appears that Indigenous organisations received approximately 31% of total IAS funding. Additionally, it was widely reported in the media that IAS funding cuts had led to the closure of several large ACCHS, cultural organisations

105 and drug and alcohol service providers (e.g. Sweet 2015; Alexander 2016; Bond 2015; Davidson 2015). The IAS seems to have diverted funding away from Indigenous organisations. This makes Prime Minister Malcolm Turnbull’s pledge to “do things with, not to” Aboriginal and Torres Strait Islander peoples seem hollow (The Mandarin 2018). The evidence suggests that overall effect of the IAS for Aboriginal Community Controlled organisations has been to strip them of vital resources. Some ACCHS representatives interviewed for this thesis also reported that a portion of their organisations’ funding had been cut as a result of the 2014 policy changes (see Chapter 8 for further details).

Financial impact of the IAS on the ACCHS sector As was noted in Chapter 1, aside from the reforms to funding procedures and the centralisation of decision-making, the Abbott government cut $534.4 million over five years from the Indigenous Affairs budget, including a $121.8m cut to the DoH’s budget for Indigenous services (Australian Government 2014a, 185; Gardiner-Garden 2014). The federal government explained this spending reduction as an efficiency-enhancing measure to “eliminate waste and duplication” (Australian Government 2014a, 185). In the area of Indigenous health, NACCHO’s analysis of PM&C funding to ACCHS before and after the IAS found that the 2014 budget cuts resulted in a 51.4% reduction of ACCHS funding from this government department (NACCHO 2015, 15). The government has claimed since that the funding cuts did not affect frontline service delivery (Australian Government 2016, 9). However, as Russell has noted, the 2014 budget removed funding for Indigenous-specific anti-tobacco programs, which “are surely frontline services” (Russell 2014, 21; see also Chapter 8).

Federal funding reductions in the Indigenous health sector also coincided with a redistribution of funds between different kinds of service providers. Based on NACCHO analysis (see Table 1 below), prior to the introduction of the IAS, the ACCHS sector and the charity sector received the largest segments of PM&C grant funding, receiving 30.1% and 15.2% respectively (NACCHO 2015, 15). After the IAS, the ACCHS sector saw its PM&C grant funding reduced in one budget year from over $1.2 billion to $8.2 million, making up just 3.9% of the 2015 IAS funding pool (NACCHO 2015, 15-16). Conversely, the IAS delivered increased funding to for-profit businesses and government departments, which became the highest funded categories of grant recipients, respectively receiving 27% and 14.5% of

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PM&C’s IAS grants (NACCHO 2015, 15). Prior to the IAS, the business for-profit sector received just 2.7% of PM&C grant funding, with government departments receiving slightly more at 6.5% (NACCHO 2015, 15). While IAS funding does not constitute the largest section of the ACCHS sector’s federal funding, it covers SEWB programs and drug and alcohol programs, which interviewees identified as crucial to the health of Indigenous families and communities, and integral to the ACCHS sector’s holistic model of care (see Chapter 6).

Table 1: Breakdown of PM&C Indigenous Affairs funding before and after the Indigenous Advancement Strategy. Source: NACCHO (2015, 15)

NACCHO’s analysis (2015) of the distribution of IAS funding between different kinds of service providers suggests that this funding process advantaged the for-profit sector in the first year of its operation. It is important to remember, though, that the majority of ACCHS’ funding remains under the control of the DoH, as the analysis in an earlier section of the chapter demonstrated (see also Senate FPARC 2016, 32). ACCHS’ base funding comes from the IAHP which is administered by the DoH. The 2014 Budget offered ACCHS a 12-month extension of their primary health care funding, up to June 2015 (Russell 2014, 17).

The distribution of funds between the five IAS funding streams illuminate some of the Abbott government’s funding priorities. By February 2015 nearly $2 billion of the $2.9 billion of committed IAS funding was directed to the Jobs, Land and Economy stream (PM&C 2015a), reiterating the government’s focus on economic development. The reallocation and

107 reduction of Indigenous expenditure under the IAS could be interpreted as evidence of a growing governmental preference for funding commercial enterprises and government departments over non-profit Indigenous-controlled organisations, when it comes to Indigenous-specific service provision. This would be entirely in keeping with the NPM’s promotion of private-sector involvement in the delivery of public services. It would also be consistent with the ‘mainstreaming’ of Indigenous services (Strakosch 2015, 5; Behrendt 2005). Tellingly, the most recent Indigenous Expenditure Report (2017) shows that the Commonwealth is increasingly channelling Indigenous funding through mainstream government departments and institutions. In 2015-16, Indigenous-specific services accounted for just 18% of overall expenditure on First Peoples, down from 22.5% in 2008-9 (Productivity Commission 2017a, xii). Over the same period, expenditure on Indigenous- specific services delivered by mainstream service providers increased from 77.5% to 82% of overall Indigenous expenditure (Productivity Commission 2017a, xii). These expenditure trends highlight the ongoing mainstreaming of Indigenous service provision at the Commonwealth level.

Also typical of NPM approaches is an explicit demand for measurable and demonstrable results (Head 2008). The language used to explain and justify the IAS is dotted with references to ‘outcomes’ and ‘results’ (PM&C 2014a; PM&C 2016), defined as quantifiable improvements in Indigenous peoples’ economic, educational and social conditions. Economistic language such as “value for money” (PM&C 2014a, 3) is employed in the government’s explanation of the IAS. Grant funding would be dependent on the “achievement of results and intended outcomes” (PM&C 2014a, 4). This indicates, as Rowse has observed (2013, 155), that Indigenous Affairs expenditure is still highly vulnerable to political review if quantifiable reductions of Indigenous ‘disadvantage’ cannot be demonstrated.

Statistical improvement in Indigenous socioeconomic indicators is the government’s stated goal for the IAS (PM&C 2014a, annexure 2; PM&C 2016, annexure 1). Delivering adequate returns on public investment, quantified in terms of Indigenous people’s socioeconomic outcomes compared against non-Indigenous outcomes, is one of the IAS’ core objectives. It is important to note, though, that the government’s desired outcomes and the methods

108 proposed for their achievement did not arise out of a cultural vacuum. The federal government uses a set of socioeconomic indicators based on the non-Indigenous average against which to measure policy success in Indigenous Affairs. As Altman has noted in reference to the government’s overarching policy of Closing the Gap (2009, 14; 2014; see also Jordan, Bulloch & Buchanan 2010, 340), the underlying logic of policies, such as the IAS, that focus their efforts on eliminating statistical gaps and differences between Indigenous and non-Indigenous Australians “assumes that adoption of Western economic institutions and norms will erase socioeconomic and health inequalities” (Altman 2014, 118). The IAS, when viewed through this lens, has an assimilatory intent.

Greater levels of engagement with the non-Indigenous economy and education system, and greater respect for the non-Indigenous legal system are held up as the solution to Indigenous health and social inequity. For example, one of the stated objectives of the IAS is to “Ensure that the ordinary law of the land applies in Indigenous communities” (PM&C 2016, 42, emphasis added). The implication here is that Indigenous communities are a law unto themselves and that what happens there would not be acceptable to the ‘ordinary’ people of mainstream middle Australia. This normalisation of dominant norms and can be understood as part of an invisible logic of “Whiteness” (Moreton Robinson 2004, 78), as mentioned at the end of Chapter 3. Whiteness has a long history in Australia (see McGregor 2009; 2011) and its logic expects that all members of society will behave in accordance with the values of the dominant (White) social group. In measuring Indigenous peoples against White standards, the IAS perpetuates a larger assimilatory modernisation project that sees Indigenous peoples being expected to live according to Western values and practices (Altman 2009, 14). The IAS promotes ‘mainstream’ measures, standards and practices. It does not engage with Indigenous cultural considerations, such as Community Controlled decision-making, Indigenous-specific rights, maintenance of languages, or community wellbeing. It thus continues the logic of elimination that has dominated the state’s treatment of First Nations since 1788 (Wolfe 2016; 1999).

Indigenous organisations as target populations As was argued in Chapter 3, public policies are important manifestations of how governments socially construct images and stereotypes of certain target populations. If we examine the ways that the IAS treats and describes ACCHS and other Indigenous sector

109 organisations it is possible to discern a social construction that frames them as less capable than non-Indigenous organisations. Specifically, the IAS’ incorporation requirement for Indigenous organisations administering large grants attaches a negative social construction to Aboriginal organisations; this requirement implies that Aboriginal run organisations need special support and surveillance to execute corporate governance acceptably. This Indigenous-specific policy requirement suggests that within PM&C there is a belief that Aboriginal organisations are less competent than non-Aboriginal organisations. It is important to note that the Government has since amended this section of the IAS guidelines after significant criticism from observers and the Indigenous sector (Australian Government 2016). This shows that social constructions are not fixed and that through organised agitation and criticism, policies that are clearly shown to be discriminatory can be altered.

Further evidence of the government’s negative construction of Indigenous organisations can be found in ministerial announcements. In May 2014, a press release from then Minister for Health (currently the Minister for Home Affairs, Immigration and Border Protection), Peter Dutton implied that Indigenous health services received sufficient funding to “provide services to those most in need” (Dutton 2014). In response to concerns that the government’s proposed $7 co-payment for GP visits would negatively impact Indigenous patients, Mr Dutton said: “Given the amount of money being administered by Indigenous health services I am keen to get a better understanding of the concerns being raised and of how the funding is being translated into front-line support” (Dutton 2014). The minister’s statement implies that Indigenous health services receive high levels of government funding, and fits a framing often used by conservative media commentators and White nationalist politicians such as Pauline Hanson (e.g. Hanson 1996). The statement can also be interpreted to imply that if needs are not being met, then Indigenous organisations must be inappropriately spending money on things other than “front-line support”. This statement casts suspicion over Aboriginal health services and associates them with notions of financial negligence and wasteful spending. Minister Dutton’s statement contributes to the social construction of Aboriginal organisations as risky investments.

The IAS, like all policies, necessarily involves government identifying a target population and then socially constructing it in a certain way in order to justify the treatment it receives.

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Within the very name of the IAS there is an implication that Indigenous peoples in Australia are in some way backwards or undeveloped. As Bulloch and Fogarty have observed, in naming their flagship Indigenous Affairs policy the Indigenous Advancement Strategy, the government socially constructs Indigenous peoples “as ‘behind’, ‘lacking’, and in need of ‘advancement’” (2016, 80). Thus, the IAS perpetuates the modern-primitive binary (Attwood 1992, iii; Hinkson 2002), implicitly linking all things Indigenous to the latter half of this socially constructed dyad. In this case Indigenous peoples are the target population, they are socially constructed as not advanced, and they are therefore offered “programmes” or funding opportunities for services that will increase mainstream economic and educational participation, make communities safer, promote “culture and capability”, and reduce social and economic disadvantage in remote locations (PM&C 2014a, 4). The IAS also implies that Indigenous communities are places where different rules and laws apply. This is clear from the policy’s stated objective: “[t]o ensure the ordinary rule of law applies in Indigenous communities” (PM&C 2014a, 15). This could be interpreted as a statement that Indigenous communities are lawless and undisciplined places that need government to take a firm hand and assert authority.

Indigenous people are being induced via economic and other incentives to become ‘productive individuals’ taking part in the mainstream economy (for a discussion of the government push towards Aboriginal individualisation see Bulloch and Fogarty 2016). For example, the 2014 Indigenous Advancement Strategy Guidelines state that this policy aims to improve outcomes for Indigenous people by: “Getting Indigenous Australians into work, fostering Indigenous business and ensuring Indigenous people receive economic and social benefits from the effective management of their land and native title rights” (PM&C 2014a, 3). Within the IAS there is an explicit focus on mainstream economic participation. Economic development has become the overarching Indigenous Affairs goal, and economic techniques are becoming the preferred methods for shaping the behaviours of Aboriginal individuals and organisations. This is consistent with the government’s overarching policy goal of supporting private enterprise, increasing economic participation and economic growth (see, for example, Hockey 2014; Hockey 2015; Morrison 2016; Morrison 2017).

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Restructuring Indigenous primary health funding Even though most of the Indigenous-specific health funding remained with the DoH and did not roll into PM&C under the IAS, a similar funding allocation methodology for health services was signalled in the 2014 budget (Russell 2014, 5, 15). In a move that mirrored the rationalisation of programs that occurred within PM&C, the government announced that the DoH would consolidate four existing Indigenous health funding streams3 into a single funding stream called the Indigenous Australians’ Health Programme (IAHP) (Russell 2014, 15). The Indigenous health budget was also significantly affected by the 2014 expenditure reductions, receiving a $121.8 million cut over five years. The IAHP commenced in the 2015- 16 financial year and applied to $2.4 billion over three years (DoH n.d. a, 5). The IAHP was a familiar combination of “open competitive funding rounds”, “targeted or restricted competitive funding rounds” and “demand-driven processes” (DoH n.d. a, 8-9). The DoH noted that it would “preference competitive rounds” except “[i]n areas of limited market access or specialist requirements (such as comprehensive primary health care[)]” (DoH n.d. a, 8). In these special circumstances non-competitive rounds would most likely be preferred. In all other cases a form of economic logic would determine the efficient allocation of resources in the ‘quasi-market’ (Dunleavy & Hood 1994, 9) created via a competitive tendering process. In this way, the IAHP and the IAS are consistent in their application of a set of NPM principles to the government’s funding of Indigenous health and related services.

Of particular relevance for ACCHS, the IAHP committed $1.4 billion for “culturally appropriate primary health care services” over the three-year period commencing in financial year 2015-16 (DoH n.d. a, 5). As part of this commitment, the Minister for Health Susan Ley and Assistant Minister for Health Fiona Nash announced that 112 ACCHS would have their funding agreements extended (Ley & Nash 2015, 1). However, this funding did not come without its challenges. ACCHS were initially sent a letter from the DoH inviting them to apply for funding. It was reported on the website Croakey (2015) that this letter

3 The funding streams that were consolidated were: “primary health care funding, child, maternal and family health programmes, the Health Implementation Plan of the former Stronger Futures in the Northern Territory National Partnership Agreement in the Northern Territory (Health) (now known as Northern Territory Remote Aboriginal Investment) and programmes covered by the Aboriginal and Torres Strait Islander Chronic Disease Fund” (DoH n.d. a, 3).

112 arrived in mid-April 2015 and organisations only had until 13 May 2015 to submit a funding proposal. This proposal was required to include a revised action plan and budget, and some explanation as to how a new Continuous Quality Improvement (CQI) requirement was going to be incorporated into the organisation’s work plan (Croakey 2015). Even though the DoH did guarantee some funding certainty for ACCHS under the IAHP, and Indigenous primary healthcare funding was not entirely opened up to competitive tender, ACCHS were still subjected to the organisational stress associated with drafting thorough proposals in short timeframes in response to government-determined criteria. This demonstrates that the DoH can exert significant influence over ACCHS, reflecting the relationship between government and the Indigenous sector in general (Martin 2005; Sullivan 2010; Sullivan 2011; Cunningham & Baeza 2005). The nature of the funding process also indicates that the Department makes decisions without consulting ACCHS.

In addition to the 2015 IAHP funding changes, ACCHS were also affected by the IAS because this policy change shifted responsibility for the Indigenous-specific SEWB programs and Indigenous-specific drug and alcohol programs from the DoH to PM&C (Australian Government 2014b, 110). This caused significant confusion within the ACCHS sector during the first round of grant applications under the IAS because of unclear departmental expectations (Senate FPARC 2016, 19). The reshuffle also meant that ACCHS had to compete with non-Indigenous organisations when applying for government funding for SEWB or substance-abuse treatment and prevention programs. Some ACCHS lost their SEWB and drug and alcohol program funding after the IAS was introduced (Davidson 2015) including one ACCHS that participated in this study (see Chapter 8). Non-Indigenous organisations, such as Mission Australia, are now providing these services in many regional areas of NSW. As is explored in detail in Chapters 5 and 8, there are significant issues with the delivery of Indigenous health services by non-Indigenous organisations because of the difficulty of establishing trust-based relationships between service providers and clients, and the specific skills required to create culturally appropriate and safe service contexts.

Marketisation and healthcare: special considerations The DoH’s new Indigenous health funding model, the IAHP, promotes contestability and competition between service providers. The department has a clear preference for competitive funding distribution processes:

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In areas of limited market access or specialist requirements (such as comprehensive primary health care and the Australian Nurse Family Partnership Program), the Programme is expected to preference non-competitive rounds. The non-competitive rounds will assess past delivery of services, the maintenance of continuity of care and strong local knowledge. Otherwise the Programme will preference competitive rounds to award grants. (DoH n.d. a, 8)

Aside from the opaque reference to “limited market access” and “special requirements”, the Department makes no mention of the potential for markets to work differently in healthcare. Nor does the department discuss the ideal conditions for market activity. The IAHP programme guidelines present limited evidence to justify the new focus on contestability but they make clear the Department’s default position to favour contestable funding processes.

For any government considering the expansion of markets in the health system there are several points of instability and inefficiency that ought to be considered. Firstly, as Hunter notes (2008, 108), the logic of the market may not apply when it comes to healthcare since patients are often incapacitated in some way. Patients are, therefore, often looking for guidance and support from professionals, rather than shopping around for the option that best suits their needs and budget. The specialised knowledge required for understanding many medical treatments, and the complexity of modern healthcare systems mean there are inherent limitations to the information available to consumers (Kuttner cited in Fenna 2004, 88). Hunter points out that the information asymmetry between patients and health professionals limits patients’ ability to exercise informed choice (Brown cited in Hunter 2008, 98). In most healthcare interactions a certain level of faith is required of patients.

Additionally, given patients’ often limited understanding of the information being presented to them in medical settings, their consent to be treated often relies on the trust they place in the ethical behaviour of doctors and medical professionals. The financial incentives of market competition may weaken medical professionals’ adherence to the Hippocratic Oath and may override moral incentives to improve care and health outcomes (Smith cited in Hunter 2008, 109). Maddison and Denniss explain that for markets to work well there are certain prerequisites, such as sufficient informed consumers to sustain multiple producers

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(Maddison & Denniss 2009, 68). In a market such as this, producers will be forced to compete against each other for business, which then theoretically leads to innovation and novelty, price reductions, improved quality and greater provider responsiveness to users’ needs and preferences (Productivity Commission 2017a, 64-5). In healthcare, though, there are some additional complications that make market failure more likely. One such problem is “adverse selection” (Fenna 2004, 83). This involves health providers targeting mostly healthy people with uncomplicated and inexpensive health needs (Pellegrino 1999, 256). This can produce serious equity-of-access concerns if sicker, poorer people are denied care where addressing their complicated health issues is deemed unprofitable. While the IAHP guidelines do not discuss these issues, they promote market-like competition amongst health service-providers nonetheless.

The healthcare information asymmetry means that health providers possess a much greater knowledge than their patients of both the likely health outcomes that will be generated by a treatment and the quality of healthcare options that are being made available (Boxall 2011, 37). This knowledge and hence power imbalance make it possible for doctors and other health professionals to encourage patients to undergo procedures and treatments “beyond what is optimal and necessary” (Boxall 2011, 37) in order to guarantee greater financial returns. Such “over-servicing” is even more likely when private health providers are involved, because of their increased economic incentive to maximise revenue by increasing billable episodes of care (Collyer, Harley & Short 2015, 283). Moreover, publicly accessible information on the activities of and outcomes delivered by competing healthcare providers is often non-existent or of poor quality (Boxall 2011, 37). This makes it almost impossible for even the most well-informed patients to compare and evaluate the different offerings of competing healthcare providers and weigh up the potential costs against the likely health benefits. By increasing the role of competition and market incentives in the healthcare system, it becomes more likely that healthcare professionals and organisations will exploit market failures to the detriment of both economic efficiency and the public’s health.

It has been recognised that there are certain sectors of the economy that are more prone to market failure than others. As Ernst concedes (1998, 223), competition is an important force in the economy at large; it can spur innovation, efficiency, choice and economic growth. But

115 competition does not necessarily produce the same results when injected into the health services sector. This is because competition necessarily: duplicates services to ensure choice; is exclusive, to protect against free riding and the loss of commercial secrets; divides in order to determine market share and competitive advantage (Ernst 1998, 223). Duplication, exclusion and division are principles that are the antithesis of the equitable and effective and efficient provision of health and welfare services (Ernst 1998, 223). Indeed, much of the work of the health and welfare sectors is done in response to the market failures and negative consequences of market competition (Ernst 1998, 223). It therefore seems illogical to promote more competition as a solution to the side-effects of competition.

It is unclear how the government plans to manage the significant risk of market failure associated with the marketisation of Indigenous primary healthcare services. The IAHP has introduced a level of competitive tendering into the ACCHS sector and there is now less focus on the Indigenous specific knowledge required to work effectively with Indigenous healthcare clients. Market mechanisms are being promoted as correctives to wasteful spending and duplication of services. One of the central goals of the IAHP is to maximise value for money regarding government funding. There appears to be very little acknowledgement within government that the ‘allocative efficiency’ upon which much faith in markets is based (Fenna 2004, 73) does not naturally occur in health systems. Therefore introducing competitive tendering based on the premises of laissez faire economic theory is likely producing a number of negative externalities and market failures in the healthcare system, which will have to be managed by government or the consequences borne by individuals and communities, in this case by Indigenous clients and communities.

Primary Health Networks: political background, and economic logic PHNs were created in 2015 and have been tasked with ‘commissioning’ primary health care services, with a focus on Indigenous health. The commissioning process involves each PHN conducting its own competitive tender processes using Commonwealth funding to purchase services on behalf of local communities. In this, the Department of Health prioritises value for money and is “encouraging competitive and non-discriminatory procurement/purchasing processes” (DoH 2016a, 10). In this kind of managed market, PHNs act as a proxy for the DoH in the sense that they are the purchasers of services but not the

116 end users or the service providers. Service users (i.e. the public) do not have any role in the commissioning process until the services have already been contracted out. The PHNs determine which services are purchased on citizens’ behalf. This increases the distance between service users and government and further blurs the lines of accountability that run between citizens and the government. This is a clear challenge to the traditional Westminster form of responsible government. The additional level of administration in the form of PHNs, creates more distance between the government and the public, who will only ever have direct interaction with the (generally) non-government service providers contracted by the PHNs.

The PHNs emerged after a government-commissioned review of Medicare Locals (Horvath 2014). In the 2014 budget the Commonwealth announced that PHNs would take over the planning and coordination of primary healthcare (Australian Government 2014b, 103). However, PHNs would not directly provide health services to the public, as many Medicare Locals had done, but would work with existing services to improve continuity of care (Henderson et al. 2017, 2). There are now 31 PHNs across the country, whereas there were 61 Medicare Locals. Ten PHNs cover NSW and their boundaries map onto the NSW health system’s LHDs. PHNs are funded by the Commonwealth DoH and are tasked with “increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes” and “improving coordination of care” (DoH 2016a, 7). The DoH contends that PHNs will achieve these goals by: gathering information on the health care needs and service gaps in their regions; providing practice support for GPs; ensuring high safety and quality standards in primary care; and assisting with the roll-out of eHealth (DoH 2016a, 7). PHN contracts were awarded in the 2014-15 financial year via an open competitive tender conducted by the DoH, in a process similar to the awarding of IAS contracts. The PHN policy rationale, drawing heavily upon the economic language of efficiency and coordination, bears some of the same hallmarks as those of the IAHP and the IAS. Also, the PHNs’ move away from direct provisioning is a continuation of the ‘contracting out’ that NPM promotes.

In justifying its decision to channel funding through PHN, the DoH uses the rational language of economics to make the commissioning process seem logical, scientific and

117 unquestionable. The focus on efficiency and value for money is in keeping with the fiscal austerity that characterised the thinking of the Abbott Government that established the PHN in 2015. This decision came in response to a review of the PHN's precursor, Medicare Locals, which was an initiative of the Gillard Labor government. Abbott’s Liberal-National government ordered the review upon taking power in 2013. The Health Minister at the time, Peter Dutton, stated that one of the review's goals was ‘reducing waste and spending on administration and bureaucracy’ (Dutton, 2013). This echoed the Coalition election campaign's emphases on small government and fiscal austerity. The Coalition’s message was that Medicare Locals were bureaucratic and wasteful. In practice though, PHNs are almost entirely bureaucratic and are only involved in direct service provision as a last resort. Moreover, the cost of winding up Medical Locals has been estimated to be as high as $200 million (Thompson, 2015).

Installing a new hierarchy in the health system The emergence of the PHN has changed the game dramatically. While they ostensibly replaced Medicare Locals, almost all PHNs are either consortia of former Medicare Locals or have a former Medicare local as lead partner (Thompson, 2015). PHNs function as “third party payers” (Wade, Smith, Peck, & Freeman, 2006, 3) in the primary healthcare system, offering funding and support to primary healthcare providers. Even though legally PHNs are independent non-profit companies, in a practical sense they are closely aligned with government. They rely entirely on government funding, and work towards government- determined priorities.

PHNs take a commissioning approach to the funding and management of primary health services including Indigenous health services. Commissioning is an umbrella concept that covers a range of public-service activities. These include needs assessment, procurement, purchasing, contracting, service delivery and performance management, all of which are interrelated yet distinct processes (Dickinson, 2014, 15). Sturgess (2018, 165) expresses commissioning's primary function as: “to design and manage the interface between policy/funding and delivery”. Tasked with improving the efficiency, effectiveness and coordination of services, commissioning organisations such as PHNs act as intermediaries between government funding decision-makers and service providers. Commissioners are responsible for the strategic design and ‘stewardship’ of service-provision systems (Sturgess,

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2018, 163), gearing their overall functioning towards the efficient achievement of government's strategic objectives. In theory commissioning improves on previous attempts to improve the purchaser-provider relationship because it acknowledges some of the complexities encountered at the service delivery coalface (Sturgess, 2018, 156). However, as Dickinson notes (2015), the definitional “fuzziness” around commissioning has meant that in practice the concept has been used ‘as a synonym for more contracting out or privatisation’.

The evidence on commissioning's effectiveness is mixed. A recent report written for the DoH laments the ‘limited evidence that links commissioning with quality improvement or cost containment’ (King's Fund et al. 2016, 4). However, some observers are hopeful that commissioning can deliver broad benefits if commissioners’ ‘softer skills’ can be strengthened (Dickinson, 2014, 17). Robinson and colleagues (2016, 10) have argued that the crux of the commissioning task is to accommodate multiple and sometimes divergent values, goals and practices. In this way, successful commissioners are those who achieve ‘a meeting of the minds’ amongst diverse stakeholders (Sturgess, 2018, 164). Booth and Boxall (2016, 3–4) contend that fostering reciprocal and trusting relationships between commissioners and providers is an indispensable component of successful commissioning.

Governments have long known that when commissioning for complex social services (of which Indigenous-specific comprehensive primary healthcare are a clear example), commissioners should assess how well providers ‘understand the human dimensions’ of the service contracts for which they are tendering (Sturgess, Argyrous and Rahman 2018, 466). Providers need time to develop this expertise and relational contracting allows for this. The evidence suggests that for commissioning to work well in Indigenous health, PHNs and ACCHS will need to foster close relationships.

Research on the policies and funding arrangements that apply to ACCHS as providers also highlights the importance of close and trusting relationships between purchaser and provider. This literature (e.g. Dwyer, Lavoie, O'Donnell, Marlina, & Sullivan, 2011, 43; Lavoie, Boulton, & Dwyer, 2010, 675–6) promotes relational contracting as the best way of funding ACCHS to maximise Indigenous health gains. Relational contracting involves purchasers and providers working closely together, under flexible long-term contracts, towards the achievement of shared goals.

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However, based on the testimony of ACCHS representatives, as presented in Chapter 9, PHN contracting and decision-making processes have been more hierarchical than collaborative. PHNs control both the needs-assessment and funding processes, inevitably compromising the space available for Aboriginal self-determination in health. This seems to follow from the DoH's vision of commissioning as “proactive and strategic”, where the PHNs decide what services should be offered, how, and by whom (DoH 2015a, 2).

Commissioning via PHNs allows the government to retain control of the primary healthcare system while also increasing contracting out and ‘contestability’, an increasingly common way of introducing competition and marketisation into the provision of social services (Productivity Commission 2017a, 65). Contestability is one of the main methods that governments use to increase the presence of market-like mechanisms in the provision of services. According to the Productivity Commission: “[c]ontestability means that a provider of human services faces a credible threat of replacement if it underperforms” (2017a, 65). This is because ongoing government funding to a service provider is conditional and only guaranteed for as long stipulated in the contract that underwrites it. When funding contracts expire other organisations can submit rival funding proposals to government and ‘contest’ for the right to deliver services on the government’s behalf. As observed above, contestability is also the principle that guides the competitive tendering processes that PM&C uses to distribute funding under the IAS. Moreover, DoH documents suggest that contestability through competitive tendering may also become more prominent in the administration of IAHP funding, as discussed in this chapter. Contestable contract arrangements create competition between service providers and proponents argue that this can deliver efficiency and innovation, reduce costs and improve service quality and effectiveness (Productivity Commission 2017a, 68). Critics of contestability and contracting out, however, argue that these policy instruments lessen public accountability, tend to favour for-profit providers, and that the associated pressure to cut costs reduces service quality and equity of access. By commodifying social services and promoting contestability governments have altered the values that underpin the public commitment to providing universal or needs-based access to these services.

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Under the PHN commissioning model the federal government retains ultimate control over funding decisions. Providers, who can be government agencies, commercial enterprises or not-for-profit community organisations, respond to the wants and needs of government through the intermediary of the PHN. PHNs determine the community’s health needs and then organise an “approach to market” where service providers bid for the contract and funding to meet those service needs (DoH 2016b, 18). In this “quasi-market” arrangement (Le Grand 1991, 1257) PHNs determine what services the community needs and who will be contracted to deliver them. The PHN’s structure, and the contracts that bind providers to the demands of the PHN as purchaser, ensures that it is the state that will ultimately control all new primary healthcare services commissioned under this process. This is a case of managed rather than free markets, which, as Keating has shown, Australian governments tend to prefer because they “create desirable incentives for individual economic participants to pursue the government’s objectives” (2004, 12). The PHN commissioning process promotes competition between producers but allows government to retain ultimate control funding.

Apart from the accountability and communication issues that arise when there is a separation between the purchaser and the provider of a service, the practice of contracting out to third parties creates perverse economic incentives. Under the PHNs’ purchaser- prover, or commissioning, model, the principal-agent relationship that shapes producers’ behaviour is different from that of a typical market setting because the commissioning model splits the principal in two. The government, or the PHN acting as its proxy, acts as ‘the payer’ of the service and the citizen consumer acts as ‘the user’ of the service. This differs in a typical market situation where the payer and the user are one and the same, and purchasing power is exercised unitarily. The separation between payer and user means that demand is coming from two different sources and therefore, the supplier will not always know whose demands they must satisfy (Gingrich 2007, 9). PHNs arguably add another level of complication in the supply chain because they are nominally independent non-profit organisations contracted to act in the best interests of providers and the government. The supply-and-demand relationship runs from citizens to providers, then from government to the PHN, then from the PHN to providers. However, because supply and demand are both

121 located inside government, providers respond to government priorities, and citizens have little or no influence.

The PHN funding model fits neatly into a NPM paradigm, emphasising economic incentives, the rational operation of markets and the efficiency-producing power of competition over resources. As a one-size-fits all policy framework, it does not acknowledge the particular “contribution and effectiveness of Aboriginal and Torres Strait Islander organisations” (Senate FPARC 2016, vii). This can be viewed as a form of institutional racism where funding models discount Indigenous approaches to health and service delivery (see Chapter 6). In interviews ACCHS managers and CEOs have expressed concern over the PHNs’ competitive tendering process and the way it pits small ACCHS with limited resources and staff against large NGOs with greater resources and grant-application-writing experience (see Chapter 8). They have also expressed frustration at the exceedingly complex nature of the PHNs’ tendering process that renders the PHN funding effectively inaccessible.

The government has made some effort to facilitate cooperation between PHNs and ACCHS. In March 2016 the DoH released Primary Health Networks (PHNs) and Aboriginal Community Controlled Health Organisations (ACCHOs) – Guiding Principles (DoH 2016c). This document outlined the need for ACCHS and PHNs to work together to improve primary health services for Aboriginal and Torres Strait Islander people. It urges collaboration in seven “key domains”: Closing the Gap; Cultural Competency; Commissioning; Engagement and Representation; Accountability, Data and Reporting; Service Delivery; and Research (DoH 2016c, 4-8). Additionally, the former Minister for Indigenous Health and now Indigenous Affairs Minister, Ken Wyatt encouraged the PHNs to broaden the range of organisations represented on their boards and make more use of ACCHS’ skills when designing health programs for Aboriginal and Torres Strait Islander people (Wyatt 2017). However, from the perspective of the ACCHS sector, the PHNs have not yet adequately integrated ACCHS’ skills and experience into their operations. In a March 2017 press release NACCHO stated that Aboriginal people had been calling for greater ACCHS input into the design of PHN programs and structures since their inception (NACCHO 2017). NACCHO also called on the PHNs to make ACCHS preferred providers of any Indigenous-targeted health programs that they commission, requested ACCHS representation on PHNs’ boards of

122 directors, and lobbied for the full implementation of the previously mentioned ‘guiding principles’ for PHNs-ACCHS collaboration (NACCHO 2017).

Future Indigenous health funding strategies The introduction of the three major policy initiatives already discussed in this chapter does not mark the end of the government’s reform agenda in this area. NPM principles are also on display in the mooted changes to the IAHP’s funding distribution methodology. In July 2020, the IAHP will move to a more activity-based funding model, a model commonly associated with NPM (Pollitt 1995, 134). Funding will be distributed amongst all Indigenous primary health care providers based on the numbers of clients enrolled at each ACCHS, and their reported episodes of care delivered (DoH 2017b, slide 9). Additionally, IAHP funding levels will be adjusted according to individual ACCHS’ performance against a set of national key performance indicators (known as nKPIs) (DoH 2017b, slide 12). The use of nKPIs focuses government attention on the measurable and quantifiable, often at the expense of the intangible, qualitative elements of care. Under activity-based funding models, ‘what’s measured is what matters’ (Bevan & Hood 2006). This is true for the government bureaucrats in charge of assessing the performance of public agencies and contracted third parties, but it is also true for workers and managers who must report on their organisation’s activities with reference to specified performance indicators. There is evidence that when funding is tied to activity and performance, public and contracted organisations will engage in ‘gaming’, ‘cherry-picking’ ‘or cream-skimming’, altering organisational practices in ways that will lead to more favourable performance scores as measured by the KPIs or activity measures (see, for example, Wharam et al. 2011, 239; Sheridan 2016; O’Reilly et al. 2014, 82; Baxter et al. 2015, 1105; de Jong 2017, 2; Wand 2014, 273; Van Slyke 2003, 301). Performance monitoring and tying funding to measurable work processes are key elements of NPM, although they operate according to slightly different incentive structures to competitive tendering. In the health sector, activity-based funding incentivises providers to carry out greater numbers of priority health care interventions or health assessments in less time and to service higher numbers of patients. The measures of performance and activity focus on doctor-patient interactions at the expense of the whole-of-community or family- centred approach favoured by ACCHS.

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The funding allocation methodology for the new IAHP incentivises ACCHS to deliver more episodes of care. This may be complicated by the fact that Aboriginal and Torres Strait Islander health needs are more complex than non-Indigenous health needs (Alford 2014). ACCHS operating under an activity-based funding model attempting to increase their episodes of care in order to generate revenue may struggle to do so because of their clients’ need for longer GP consultations. The benefits of ACCHS’ extended consultations are discussed at the end of Chapter 6. The IAHP funding model somewhat undermines this element of the ACCHS model of care.

The new IAHP funding model also gears ACCHS to focus more on clinical data collection and reporting, rather than resourcing them to respond to community needs and priorities, which may involve health promotion or programs for SEWB. Indeed, the nKPIs for Indigenous primary health care are based on clinical interactions, such as immunisation rates, blood pressure measurements and recording individual patients’ smoking status (AIHW 2017b). None of these indicators reflect a social and emotional understanding of health and wellbeing, nor do they capture information about the many non-clinical health services that ACCHS provide (see Chapter 6). KPIs have come to play a central role in monitoring ACCHS performance and future funding is allocated according to the activity that organisations report to government. In response to the changing demands of the IAHP funding model, ACCHS may alter their behaviours because of the need to secure ongoing revenue. Some ACCHS in NSW are already reorganising their services to generate activity-based revenue through the Medicare system, as Chapter 7 explores. When the IAHP moves to a more activity-based funding structure, the financial for ACCHS to prioritise quantifiable clinical care will be even higher.

Conclusion: Indigenous Affairs experiments in NPM and marketisation The IAS, IAHP and PHN policy initiatives coincide with the broader policy trend towards NPM and marketisation that have been developing in Australia since the early 1990s, as was explained in Chapter 3 (see Pusey 1991; O’Flynn 2007 and others). Under NPM policymakers have increasingly sought “market solutions to government failure” (O’Flynn 2007, 355). Marketisation is a policy technique that follows the competitive rationale of NPM. In Australia and other Anglosphere countries such as New Zealand and the United Kingdom, marketisation has involved the promotion of competition in the public sector and the use of

124 contracts to define relationships between purchasers (i.e. government departments) and providers (i.e. non-profit and for-profit NGOs) (O’Flynn 2007, 354-5). This process of reforming government bureaucracies and service delivery has been based on the idea that market competition and entrepreneurship drive economic efficiency and productivity (Hulkko cited in Siltala 2013, 470). However, after more than three decades of NPM there is minimal evidence showing efficiency dividends or higher public satisfaction with the quality of government services. This evaluation deficit is partially due to the complexity long-term nature of the NPM reform program (Pollitt 2007, 113). Hood and Dixon (2015) concluded that NPM in the United Kingdom in fact increased both the running costs of the civil service and the numbers of public complaints and legal challenges about the maladministration of government services. Other scholars have argued that NPM has corroded democratic values (Diefenbach 2009, 906) and demotivated public servants through its audit culture (Siltala 2013; Lapsley 2009). In Australia there is some evidence that NPM has demotivated health service providers through its strict management practices (Newman and Lawler 2009).

Following the example of these studies of the impact of NPM in other jurisdictions and policy areas, this thesis explores the impact of the imposition of marketisation and contestability on the Indigenous health sector, paying particular attention to the experience of those at the frontline of service delivery. ACCHS reside in this unstable funding environment. This chapter has argued that the IAS, the PHNs and the proposed new funding model under the IAHP all operate according to a clear market logic. Through a close reading of the policy documents that structure these three funding models, the chapter has highlighted the common goal in all three policies: ‘value for money’. It also showed that neoliberal economic theory informs the policy intent of the IAS, IAHP and PHNs, with competition and constestability being the primary policy techniques employed to generate economic efficiency. Drawing on the international and Australian literature on the impacts of ‘contracting out’, Chapter 4 highlighted some of the negative consequences that may ensue for ACCHS and the First Nations peoples who rely on them. The potential for market failure in healthcare was also discussed, concluding that in the case of Indigenous health services there is great potential for this to occur. Ultimately, the chapter suggests that the Commonwealth’s doctrinaire commitment to competitive service markets and contestable contracting risks reducing the quality of health services available to First Nations peoples in

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Australia. This hypothesis will be tested in Chapters 6, 7, 8 and 9 based on evidence from interviews with ACCHS CEOs and managers across NSW. The next chapter explains the methods used to collect and interpret interview data, and the decolonising methodology that guides this research.

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Chapter 5.

Methods: developing an account of Aboriginal Community Controlled Health Services in action

The thesis now turns its attention to the findings generated through interviews examining the political, community-based, societal and interpersonal challenges faced by CEOs and managers working in Aboriginal Community Controlled Health Services (ACCHS). This qualitative evidence, drawn from the frontlines of Indigenous health service delivery, forms the basis of the remaining chapters. Through engagement with this rich interview data, which policymakers usually have difficulty accessing, Chapters 6, 7, 8 and 9 explore how current policy frameworks and dominant social attitudes are impacting Aboriginal organisations and Aboriginal health in NSW. This chapter focuses on the methods that were used during fieldwork and data analysis. It explains how a decolonising approach fed into the specific techniques of data collection. It also details the qualitative and inductive analysis methods I used to interpret and make sense of interview responses for this thesis. Additionally, in order to make clear the normative and collaborative nature of this decolonising research project, this chapter outlines the ethics approval processes followed, highlighting the crucial role played of the Aboriginal and Torres Strait Islander governance committee. The chapter also explains the selection of interview locations, participating organisations and interviewees. To conclude the chapter, I reflect on how my identity as a non-Indigenous researcher influenced the research process, specifically in relation to Aboriginal community access, trust building, giving back, and interpreting findings.

As outlined in Chapter 1, a decolonising methodology guided this research project. These methodologies privilege Indigenous voices in research projects relevant to Indigenous lives and prioritise Indigenous oversight, input and co-design of such research projects. They also stipulate that Indigenous communities should benefit from research about and/or involving them. With these normative methodological considerations in mind, this research project sought to put Indigenous voices and perspectives at the forefront of its analysis and policy evaluation, using semi-structured interviews as the primary research method for gathering Indigenous-community perspectives. While I acknowledge that the predetermined nature of

128 the research topic limited this research project’s decolonising potential, and that ideally Indigenous communities would have contributed to the initial design of the research project, the input of Indigenous advisors and representatives from ACCHS at many stages of the research project shaped the findings and scope of this thesis. Through interviews with key Aboriginal community stakeholders working at the frontlines of Indigenous health service delivery, this thesis has generated insights into the current challenges faced by ACCHS, and developed target policy recommendations aimed at improving Indigenous health and wellbeing. Crucially, these insights were built upon first-hand knowledge provided by Indigenous community representative working inside Aboriginal Community Controlled organisations. The majority of interviewees identified as Aboriginal.

The ethics of doing research with Aboriginal Community Controlled Health Services To ensure interviews were appropriate, I undertook two separate ethics approval processes. The first was an internal ethics approval process at Macquarie University, where I commenced study for my PhD, and the second was an external, Aboriginal Community Controlled ethics approval process overseen by the Aboriginal Health and Medical Research Council of New South Wales (AH&MRC). For the Macquarie University ethics process I was required to outline my research protocol and give details of my strategies for mitigating any potential risks to participants. A key risk-mitigation strategy developed during this process was the de-identification of interviewees and participating organisations in all subsequent publications and use of interview data. I also developed a participant information statement (see appendix 3), which outlined the project, what was required of participants, and the study’s intended benefits to individual participants and Aboriginal communities. During this process I developed a concise research project summary which I sent to potential participants so they could understand what the project was concerned with. I devised consent forms for individual participants (see Appendix 5) and consent forms for organisations (see Appendix 4), which were required to be signed by relevant CEOs.

The Macquarie University ethics process also required an outline of how I planned to compensate research participants for their time and input. Interview duration ranged from 45 minutes to 3 hours, with the average interview being approximately 90 minutes. Through consultation with an Aboriginal cultural advisor, it was decided that gift cards to a major

129 retailer or supermarket would be an appropriate form of compensation for participants’ time. The Macquarie University ethics approval process provided a very useful opportunity for me to formulate strategies for mitigating risk and ensuring benefit to individual interview participants. I obtained ethics approval from Macquarie University’s Human Research Ethics Committee on the 6th of June 2016 (see Appendix 7).

The second ethics approval process through the AH&MRC was more focused on Aboriginal community engagement, co-design and governance. It was during this second ethics approval process that I established an Aboriginal and Torres Strait Islander Governance Committee (AGC). The AGC for this research project had six members consisting of four Aboriginal women, one Aboriginal man and one Torres Strait Islander man. All were highly respected members of First Nations communities. One of my advisors works as an Aboriginal cultural advisor in a university; another is an academic with a focus on education; another is an experienced researcher who has worked in education, health and the arts; another is a teacher, artist, playwright and poet; one is a manager working in the Aboriginal Health Unit of a major metropolitan hospital; and the final member is an ACCHS CEO. The members of the AGC provided invaluable cultural and practical advice on interview methods and suggested techniques and protocols for establishing connections and building trust with ACCHS. The AGC members reviewed my interview questions for cultural appropriateness and suggested valuable lines of inquiry and investigation. Their input ensured that the project remained focused on the issues of broad relevance to First Nations peoples, and that it was conducted in a culturally safe way. Part of their role involved enlightening me as to the most respectful and acceptable ways of navigating Aboriginal spaces as a non-Aboriginal researcher. I have been in regular contact with the members of the AGC for the duration of the project, providing them progress updates via email, speaking on the phone and occasionally meeting face-to-face. I sought their advice on any issues that came up during field work, and obtained feedback on drafts, presentations of findings and publications. This project would not have been possible without their input, guidance, wisdom and oversight.

As part of the AH&MRC ethics process, I established formal links with Aboriginal and Torres Strait Islander people working in Aboriginal health service delivery, specifically in Aboriginal Community Controlled contexts. This was important because of my limited prior experience

130 working with Aboriginal and Torres Strait Islanders peoples, and to ensure Aboriginal Community Control over this research project about Aboriginal health (AH&MRC Ethics Committee 2016). I travelled to meet with ACCHS CEOs and managers in their offices. We discussed the research project, its relevance to their work, and their interest in being involved. Through this process I established informal links with two ACCHS, and the CEO of another ACCHS whom formally joined the AGC for this project. This ensured that the project was overseen and co-designed by a representative from inside the Aboriginal Community Controlled Health Sector. After forming the AGC establishing links with ACCHS I obtained AH&MRC ethics approval on the 14th of March 2017. This approval was subsequently renewed on the 13th of April 2018 and the 19th of June 2019 (see appendix 6).

Indigenous input in study design and research focus The decolonising methodology that guided this research project led to the inclusion of new approaches to analysis and additional points of focus (see also Chapter 1). For example, during initial conversations with ACCHS CEOs I was made aware of the central importance of Primary Health Networks (PHNs) in the redesigned Indigenous health policy context post- 2014. I had not realised the full impact of the creation of the PHN, since it had been little discussed in the Indigenous policy literature and had received little attention in the media. Additionally, the semi-structured nature of the interviews gave participants the ability to steer the conversation towards issues that they judged to be of major importance. Through this process, the impact of institutional racism in the mainstream health system emerged as a major factor impacting on First Nations’ wellbeing. I had not given this point much consideration before interviews because I had been so focused on government policy. The inductive and decolonising approach of this research project led to the inclusion of new sites of policy analysis and addition research themes. Aboriginal people played a key role in determining the focus of this study, making it more relevant to the ACCHS sector and First Nations health.

Conducting field work across New South Wales New South Wales (NSW) was selected as the research site for several reasons. Firstly, NSW is the state with the largest Aboriginal and Torres Strait Islander population in Australia (ABS 2017, para 3). This makes the work of ACCHS in this state critical to overall Indigenous health outcomes and Commonwealth government efforts to achieve health equity. NSW is

131 also the state with the highest number of ACCHS (AIHW 2018, 24), making understanding the challenges faced by ACCHS in this state crucial to understanding the challenges faced by the ACCHS sector more broadly. ACCHS in NSW are also spread across urban, rural and remote locations, making the research findings applicable to a diversity of contexts. Additionally, as health policy is both a state and federal government responsibility, focusing this study’s analysis on a single state-government jurisdiction removed one element of policy complexity. By limiting the interview sites to NSW, it was possible to write specific policy recommendations targeted at the Commonwealth and NSW governments.

To represent some of the diversity of experiences and contexts of First Nations organisations across NSW, an interview schedule was designed that included organisations in urban, inner-regional, outer-regional and remote areas (see Appendix 1). This required me to travel to and develop genuine connections with ACCHS in a range of sites, many of which were far from my home base in Sydney. The project was designed to draw on and include the diverse (and often overlooked) experiences of Indigenous people living and working far from the cities, as well as seeking input from urban-based Aboriginal organisations. Initial contact with organisations was made by telephone, followed by a more formal email which also contained the relevant consent forms, participant information statements, and project summaries. Once I had secured the consent of participants and ACCHS CEOs, field work excursions were organised and I obtained funding from the university. All interviewees gave written consent to participate in the study and all were offered a $100 gift card as compensation for the time taken to conduct the interview. The CEO of each participating ACCHS gave written consent on behalf of the organisation.

I made several field-work excursions to different regions of NSW. I would often visit three or four Aboriginal organisations and communities in consecutive days, when it could be organised and was convenient for interviewees and organisations. I gained valuable access inside ACCHS and was frequently given a tour of the facilities and introduced to staff members. At some locations I spent only a few hours at the ACCHS; at others I spent up to two days shadowing the CEO on his or her daily routine. Several times I was invited to eat lunch with the team, giving me a view into the more informal elements of ACCHS day-to-day happenings. I was invited into ACCHS located on ex-mission sites, in what are now discrete

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Aboriginal communities. This gave me an invaluable insight into contemporary Aboriginal spaces in NSW, where few non-Indigenous people visit, and even fewer non-Indigenous researchers visit. Moreover, interviewees emphasised that my effort to travel to visit ACCHS on Country was an important demonstration of my genuine interest in their work and the challenges they encounter. Many also emphasised that very few policymakers or government representatives ever visit ACCHS. This makes this thesis a valuable source of policy-relevant information. My search of the literature did not uncover other data of this kind gathered in these places.

I experienced the welcoming atmosphere of ACCHS waiting rooms and observed the relaxed and warm interactions between ACCHS staff (including CEOs and managers) and their clients. I noted the Aboriginal-specific health information in the waiting areas and the expressions of cultural pride that adorned the walls. Aboriginal and Torres Strait Islander flags, First Nations artworks, pictures of community members and local events, and communal tea and coffee rooms gave many of the ACCHS I visited a distinctly Aboriginal character. These social and cultural elements confirmed interviewees’ descriptions of their organisations as much more than medical services (see Chapter 6). They appeared to me as community hubs where clients were treated with great care and respect.

Participant recruitment I used two main methods to recruit research participants. My initial method was purposive sampling, directly contacting services because of their location and characteristics (Morse 2004). I would search online to find details of ACCHS in different statistical regions of NSW, then telephone to find the email address of the relevant manager or CEO, and send a formal invitation via email. As I approached more services and sought more interviewees I also utilised the snowball sampling method (Crouse & Lowe 2018): by making use of the interpersonal and professional networks of earlier interviewees to identify and contact prospective interviewees, I was able to expand the number and range of interview locations.

While travelling across the different regions I took field notes, recording some elements I thought to be significant to settler-Indigenous relations, or to the status of First Nations peoples in those communities. I noted the appearance and state of repair of the buildings that housed each ACCHS and reflected on their location. Some were located in the heart of

133 major urban centres, but many were clustered around the fringes of towns, in close proximity to their Aboriginal clients’ homes, on the other side of a river to the main town, or in socio-economically marginalised areas or public housing estates. I recorded my recollections of conversations I overheard, attempting to document my experiences and learnings from field work in multiple forms. I also took photographs of the surrounding areas to capture visually some of the physical and geographical attributes of these communities. None of this informally collected data is presented in my thesis, but it did help to inform my analysis, which I understand to be an account from the frontlines of Aboriginal health service delivery.

Benefits of this research for ACCHS and Aboriginal communities The project is designed to give voice to the ACCHS, so that they can speak out about the effects of competitive tendering and contract-based grants. The study is an opportunity for ACCHS representatives to share their views on the way governments fund and interact with ACCHS. This was done to generate knowledge about how recent funding changes have affected ACCHS across NSW. Through interviews, this research project has been able to paint a clear picture of how recent policy changes are negatively impacting ACCHS. It also provides some ideas about what direction government is likely to go in the future and explains the ideas and motivations that underwrite these policy shifts. This project privileges the perspectives of grassroots Aboriginal organisations in order to advocate for a fairer and more effective funding model.

The research project’s findings are designed to be useful to ACCHS when they are advocating for increased governmental support. A key contribution of this project is its production of targeted policy recommendations and new research on the unique aspects of the ACCHS model of care. These policy recommendations are detailed in Chapter 10. Some of the findings of this research project have already been published in an open-access edition of The Australian Journal of Public Administration (Coombs 2018) which was publicised online by the National Aboriginal Community Controlled Health Organisation (NACCHO 2019a), indicating its interest in this research topic. I also presented a paper at an annual general meeting of the AH&MRC in 2019. In addition, I was also engaged as a consultant by AH&MRC to develop a member survey, designed to gather information from ACCHS representatives regarding their relationships with regional PHNs. I viewed this as

134 another way of giving back, sharing my findings, and ensuring that this research project benefits the ACCHS sector. I am currently in talks with AH&MRC about ways that I might collaborate with them in future research projects. In these ways, this research project has been a collaborative effort that has generated findings of great relevance and interest to the people who are the focus of investigation. This was a product of the decolonising methodology that guided me.

Overview of the data set The findings presented in chapters 6, 7, 8 and 9 are drawn from a series of 22 interviews, involving 29 individual participants at 18 ACCHS across NSW. Of the participating ACCHS, two were in remote areas, six were in outer-regional locations, another six in inner-regional locations, while three were in major urban centres, as defined by the Australian Bureau of Statistics (see Appendix 1). The relative ratio of remote, regional and urban ACCHS included in this study roughly reflects the spread of ACCHS across NSW, with most ACCHS in this state located in either inner-regional or outer regional areas (AIHW 2018, 22). While I make no claim that the findings here are statistically representative in a quantitative sense, the fact that the interview cohort is made up of people from a range of remoteness categories, and that there is good representation in four different remoteness categories attests to the robustness of the conclusions drawn and the diversity of views consulted. The findings therefore have broad relevance for ACCHS, mainstream health services and governments working on Indigenous health in remote, regional and urban areas in NSW.

Interview methods and thematic analysis The interviews were conducted between July 2017 and March 2018. Ten field trips were made, some of which involved extended periods of travel (up to six days) while others were day trips. In some cases, I returned a second time to the interview location after establishing contact and building a relationship subsequently with ACCHS representatives. Most locations were reached by car but in some cases it was necessary to fly.

21 interviews were recorded using a voice recorder, while one interview was documented by taking hand-written notes. Audio recordings of interviews were transcribed verbatim. I transcribed almost all the interviews myself, which allowed me to familiarise myself with the data and write notes to myself to highlight important ideas and issues as I transcribed. In

135 general, I asked open-ended questions and allowed for interviewees to divert the conversation towards issues and topics of interest to them. An indicative list of broad interview questions can be found in Appendix 2. Each interview produced slightly different content.

I employed thematic analysis to make sense of the interview transcripts, following Ezzy (2003), Gomm (2004, 184) and Pope, Ziebland and Mays (2006). I also used techniques of qualitative analysis that are closely associated with Grounded Theory, including memo writing (Charmaz 2006, 80) and axial coding (Strauss and Corbin 1990). My analytic process was concerned with the meaning being conveyed by the speaker, not specific words used or the structure of their speech, as in content analysis and some forms of linguistic/discourse analysis (Kvale 2007).

At the beginning of the period of focused data analysis, I broke the interviews down into four important kinds of relationships. They correspond with the primary foci of the four empirical chapters for this thesis. These four relationships are:

• ACCHS’ relations with Indigenous community members; • ACCHS’ internal relations and governance structures; • ACCHS’ relations with government; • ACCHS’ relations with mainstream service providers and society.

Chapters 6, 7, 8 and 9 are structured around these four relationships, in the above order. I also wrote ‘memos’ in the margins of the transcripts, suggesting theoretical possibilities, making linkages to other interviews, writing specific questions that needed answers, and drafting tentative explanations of the cause and effects of government policies in this space.

A more informal analytic process was conducted after I conducted the first four interviews, where I listened to the recordings and reviewed the transcripts. During this analysis of the initial interviews I attempted to identify the topics that elicited the most passionate or insightful discussion, the instances where I should have asked for more detail, the most effective phrasings of interview questions, and any unexpected or counter-intuitive responses that warranted further attention. This helped me to fine tune and restructure my interview questions and to recalibrate my approach as interviewer. During later interview

136 rounds I found that I said less, preferring to let interviewees guide the conversation to the issues that were most important to them, in line with decolonising methodologies that prioritise Indigenous agency in the research process (e.g. Tuhiwai-Smith 1999; Hart 2010).

After all the interviews were completed, I went through a process of open coding, following Ezzy’s method (2003, 88), reading through the interview transcripts and sporadically listening back to interview recordings to refresh my sense of the interviewees’ intonation, emphasis and silences. I began by coding only the sections of the interviews that were related to one of the four broad types of relations that ACCHS manage: with community members and clients; with board members and staff; with governments; and with the mainstream health sector. In this way I conducted the thematic analysis for each of the four empirical chapters separately. For example, as I moved through the community-relations sections of the interview transcripts, line by line, a set of categories or ‘codes’ describing the concepts and issues discussed in the interviews emerged. Some codes were renamed during the analytic process, as my understandings of their most important properties shifted or evolved. Some codes were discarded or became subsumed into broader categories (e.g. ‘taking a preventative approach’ was renamed ‘prevention, education, promotion, early intervention’ so that more kinds of health-conducing activity could be included in this category). Linkages between categories/codes were made throughout the coding process. This was done by colour-coordinating similar codes. All of this was done in Microsoft Excel. As the ‘community relations’ codes emerged I was able to identify four broad categories or meta-themes under which the more specific codes could be grouped. I named these meta- themes: ‘being a part of community’; ‘responding to community priorities’; ‘shaping services to meet community need’; and ‘accommodating external demands’. Through the open coding process I was able to interpret a logic in the interview responses. This then guided my thinking on how to explain ACCHS special characteristics and contributions to the health system.

After the open coding had been concluded I embarked on a process of ‘axial coding’. Following Charmaz’s (2006, 61) version of axial coding, I attempted to develop analytic categories and sub-categories and demonstrate the connections between them. Charmaz (2006, 63) explains that axial coding, when done well, “helps to clarify and to extend the

137 analytic power of your emerging ideas”. I found it to be a useful technique for connecting the disparate elements of a complex set of accounts. During the axial coding, similar codes were grouped together and analytical categories were “elaborated” (Liamputtong 2013, 229). These dominant codes were grouped together under ‘key themes’ to make the data more manageable and useful, which is similar to the coding process outlined by Pope, Ziebland and Mays (2006, 68).

The coding process I employed was iterative and driven by the data. Through interpretation, conversation, interaction and reengagement with the interviews I tried “to understand participants’ views from their perspectives” (Charmaz 2006, 47). Since this thesis is primarily concerned with what participants think of current Indigenous health policies, and the construction of bottom-up policy analysis, critiques and recommendations for reform, I concentrated on the experiences, insights and knowledge of people working in the Aboriginal Community Controlled Health Sector. In the interview data I looked for evaluations of current policy approaches, and suggestions and justifications for alternative policy directions that would nurture the uniquely Indigenous skills and approaches of the ACCHS sector. This inductive method of policy analysis and evaluation gave this thesis its grounded and cross-cultural quality.

Overview of interviewees and participating organisations In this thesis all interviewees and collaborating organisations are anonymised and provided pseudonyms. The decision to de-identify interview respondents was taken in order to prevent any adverse consequences for individual participants, ACCHS or communities. Much of the material contained in the interviews is highly critical of government agencies and key decision-makers. At other times, interviewees spoke candidly about the sensitive social and health problems facing their communities. Additionally, many interview respondents were quite scathing in their assessment of mainstream health and social service providers. In these cases, there exists the potential that identifying the interviewees who made these frank and critical comments would harm their relationships with key stakeholders in government, the mainstream service sector, and Aboriginal communities. Therefore I have devised an anonymised identification system that protects participants’ identities while still offering some key information about the speaker, their organisation, and their local community.

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A list of interviewees is presented in Appendix 1. It provides the following personal and professional information:

• whether they identify as Indigenous or not; • their level of experience in ACCHS and related fields; • their gender; • their job title.

Of the 29 individual participants, 21 were Indigenous and 8 were non-Indigenous. 16 were ACCHS CEOs, and 13 were ACCHS managers. 11 ACCHS CEOs are Indigenous, and nine ACCHS managers are also Indigenous people. The Indigenous identity of interviewees is relevant because it tells us a lot about the life experience of the speaker, particularly in relation to their insights into how the mainstream health system treats First Nations people on an interpersonal level. There were more women than men in the interview cohort (17:12), and there was a wide range of experience across the cohort, ranging from 40 years to three months. The interviewees had a combined experience of 404 years and three months. Interviewees’ average level of experience across the cohort was 14 years. I argue that the interviewees’ high levels of experience working in ACCHS and related fields makes them authoritative voices on issues related to Indigenous health and wellbeing.

The key characteristics listed for each participating organisation are:

• Remoteness Area, based on the Australian Bureau of Statistics’ Australian Statistical Geography Standard (ABS 2016a); This is relevant because it tells us about the local people’s access to vital services (including health services), and indicates employment and educational opportunities. • whether it is in a freshwater or saltwater community, which is relevant and important because of the cultural importance of water and Country for Aboriginal communities (Graham 2008); • whether they provide outreach services to other communities using the ‘hub and spoke’ service delivery model (Elrod & Fortenberry Jr. 2017); • the percentage of the community that identifies as Indigenous, based on 2016 census data (ABS 2016b).

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Of the two remote, six outer-regional, seven inner-regional, and three urban ACCHS, most are in freshwater Aboriginal communities (11:6). All but one of the participating ACCHS are in communities with higher than average Indigenous populations, according to ABS data (2016b). 2.9% of the NSW population identified as Aboriginal and/or Torres Strait Islander people at the last census, while the average Indigenous population across the interview locations was roughly 10.5%. This is not a precise statistical calculation, but it demonstrates that the ACCHS in the cohort are based in places with large Aboriginal communities.

Conducting research from a non-Indigenous standpoint During the entirety of this research project, but particularly during the collection of interview data via field trips, I have been conscious of the need to reflect on my own socio- cultural position as a relatively privileged non-Indigenous researcher from the city. My approach throughout the project was to assume the stance of a non-expert on all matters relating to Indigenous cultures, community life and politics. I have not lived at the “interface” between Western and Indigenous knowledges in the way that many Indigenous people have done (Nakata 2010, 56; 2007). My knowledge of Indigenous domains has been gained primarily through formal education. I was conscious that my strengths lay in the areas of political and policy analysis, academic writing and desk-based research, so I tried to remain humble and assume a learning mindset when engaging with Aboriginal community life and organisations, topics with which I have no lived experience. An Indigenous researcher would perhaps have been able to be more critical in engaging with these areas of the research project and data set, because of their lived experiences as an Indigenous person. This is important in the context of Indigenous standpoint theory and “the cultural interface” (Nakata 2010, 56; 2007).

Throughout the research process I reflected on the different forms of knowledge generation that operate in Indigenous and non-Indigenous communities. I was also conscious that there are certain Indigenous sources of knowledge that are unavailable to me, such as those that stem from Indigenous connections to Country, ancestral beings and the Dreamings (Moreton-Robinson 2013, 340). I was aware that these ontological and epistemological differences would influence the results of this research. Moreover, I was conscious that most of what I ‘know’ about Indigenous peoples, Indigenous health and wellbeing, and Indigenous relationships to government and public policy has been acquired in a university

140 context. As Nakata explains, “the way we come to know and understand, discuss, critique and analyse in university programmes is not the way Indigenous people come to know in local contexts” (2007, 8). The contexts in which I have learned about Indigenous peoples and their interactions with policy have been dominated by non-Indigenous epistemologies and people. I am conscious of the Western standpoint that influences my approach to the issues under study in this research project. However, I see this research project as contributing to self-reflexive and critical dialogue between non-Indigenous and Indigenous scholars and theorists, which Grande views as a vital process for advancing Indigenous self- determination and recovery (Grande 2004).

Where I lacked lived experience of Indigenous contexts I drew on the knowledge of my Indigenous advisors, friends and colleagues. In building trust with Indigenous communities, and to secure honest and unguarded interview responses, I tried to demonstrate to my collaborators and interviewees that I was genuinely committed to learning from them and telling their stories. I approached this task in good faith and interviewees responded with an overwhelming frankness, offering generous insights into the lived realities of Aboriginal organisations. They freely shared their knowledge and experiences of dealing with governments and mainstream society. I have been careful to nurture the trust that participants have given me and have treated the interview material that deals with Aboriginal community life in a respectful and non-judgmental manner.

I am also conscious that every story is a partial account of reality, and that people choose what to reveal and what to obscure when creating narratives about their lives. This stems from the social constructivist perspective that I use in this thesis (Kratochwil 2008; Fischer 2003; Bacchi 2009). Interviewees may have been somewhat more selective with their comments to me because of my ‘outsider’ status (see for example Milligan 2014; Thomas, Blacksmith & Reno 2000; Louis & Bartunek 1992; Breen 2007). However, I have no reason to believe that interviewees deliberately concealed pertinent information from me. I was frequently astounded at the frankness of responses offered by respondents who shared intimate details of their lives with me, a relative stranger. I am aware that some of the accounts given in interviews may be somewhat sanitised because I am not part of the Indigenous communities where interviews were conducted. Nevertheless, Indigenous and

141 non-Indigenous readers alike will notice the visceral and impassioned quality of the testimonies detailed in subsequent chapters. They attest to the gravely serious nature of the policy and social challenges faced by ACCHS in NSW. They also contain vivid details of some of the internal and family-based problems faced by Aboriginal communities. I have no doubt that other researchers, particularly Indigenous researchers, would have been offered different interview responses than I was if they had been conducting the same research project. They also would have interpreted the data in a different way. But that is the nature of qualitative research – the findings are not replicable, but they deepen our understanding of the subject matter. Similarly, my identity as a non-Indigenous researcher has shaped the content and results of this project but the findings are of great importance nonetheless.

Hearing Indigenous voices: turning abstract policy contexts into lived realities The thesis now turns to the interview data, bringing the analysis down from abstract analytical concepts and theories to grass-roots accounts of ACCHS in action. As has been noted previously, the privileging of Indigenous voices is a key strength of this project. By interviewing many CEOs and managers working in ACCHS in NSW, this research project has gathered a rich and broad new set of contemporary evidence that demonstrates how policy decisions in Canberra are negatively impacting Aboriginal health and wellbeing across this state. Interview responses also demonstrate the disproportionate power that non- Indigenous actors and interests exert over Indigenous health issues. The interview data speaks to four broad sets of challenges. They relate to four important types of relationships that ACCHS must maintain, as has been mentioned above. Chapter 6 is organised around the most important of these relationships, ACCHS’ relationships with local Aboriginal communities. This chapter details the range of services ACCHS offer and outlines their holistic approach to healthcare. Chapter 6 also develops an account of Aboriginal health inequity based on interview data, which is a key contribution of this thesis. Chapter 7 deals with a related but slightly more specific relationship: ACCHS’ relationships with their boards of community directors. This chapter is about internal ACCHS governance and the challenges of responding to external corporate governance pressures. Chapter 8 centres on the ACCHS sector’s complex and often counterproductive relationship with government agencies and funding bodies. It details the impact of recent funding changes and policy decisions, giving specific examples of what has changed for ACCHS since 2014. Chapter 9

142 focuses on the ACCHS’ relations with ‘mainstream’ or non-Indigenous society, focusing on their engagement with non-Indigenous health service providers and PHNs. A sense of frustration at the power imbalance characterising this mainstream-ACCHS relationship pervades this chapter. These empirically based chapters underscore the difficult social position that ACCHS occupy. Interview responses give a sense that ACCHS must respond to multiple stakeholders and imply that they are not in charge of their own destiny. Interviewees argued that the ACCHS sectors high levels of dependence on the mainstream health system for medical expertise and on governments for funding, limits their ability to be self-determining. The practical and political limitations of these unequal power dynamics are explored in the chapters to come. The policy recommendations detailed in the thesis’ final chapter are built on the evidence gathered in these interviews.

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Chapter 6.

The role of ACCHS: caring for families, the holistic view of personal and societal health, and recognising trauma

Natalie: In an Aboriginal community the holistic, the social and emotional, the spiritual wellbeing, looking at what’s happening in the families, what’s happening in the community, education, unemployment, –

Amanda: – past history of here –

Natalie: – all of those factors have an impact on your health, but the government’s just interested in who’s been immunised, how much does your baby weigh, who smokes…

This chapter is informed by evidence gathered at the frontline of Indigenous service delivery, in Aboriginal Community Controlled Health Services (ACCHS). Drawing on ACCHS representatives’ own explanations of what ACCHS do and why, this chapter outlines the logics of practice that inform the work of these important First Nations health organisations. There is very little information In the literature regarding the operations of ACCHS. This chapter seeks to expand this literature by providing a forum for leading voices from the ACCHS sector in NSW to describe and explain their organisations’ special purposes and attributes. Below, I present the narrative explanations, offered by ACCHS CEOs and managers regarding the critical importance of the ACCHS. This chapter also presents interviewees’ explications of how ACCHS differ from the rest of the health system. It is organised around three main data-derived themes: the centrality of trauma in structuring services; integrating the family as the unit of care; and recognising the health impacts of socio-economic disadvantage. The ACCHS interview respondents concentrated on the underlying causes of inequality rather than immediate symptoms of disease. This has shaped the tone of the chapter, which takes a social justice approach rather than focusing on disease symptoms or biomedical explanations of health inequalities.

Interviewees outlined three main accounts of Aboriginal health and the underlying causes of Aboriginal health inequality. In these grass-roots accounts of the historical, socioeconomic, and family-based determinants of First Nations health I identify a three-tiered theory of

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Aboriginal health, which I call ‘the cascade of causation’. This framework informs the chapter’s analysis of the comprehensive range of health, social and community services that ACCHS provide across NSW. I use the cascade metaphor to portray the multiple social, economic and historical challenges that ACCHS are working against. This chapter also analyses interviewees’ articulations of the principles and practices of ‘culturally appropriate’ healthcare. In line with the views of many participants, I contend that culturally appropriate care distinguishes ACCHS work from the health and social services delivered by ‘the mainstream’, as is further discussed in Chapter 9. The chapter begins by exploring interviewees’ understandings of the root causes of First Nations health and illness.

A three-tiered theory of First Nations’ health inequity Evidence from the interviews provides the contexts and causal factors that influence Indigenous health and wellbeing. Almost every interviewee commented on the root causes of Indigenous health inequity. Most interviewees constructed coherent “causal stories” (Stone 1989, 281; 2002) to explain the underlying causes of First Nations peoples’ health and social concerns. The interview responses contain a breadth of information about the historical, social, economic, and geographic circumstances that affect the health of ACCHS’ clients and communities. ACCHS representatives also detailed a range of health-relevant behaviours such as drug and alcohol abuse and family violence, that exacerbate Indigenous health and social problems in NSW. Interviewees’ considerations of the social, economic and historical factors underlying the health gaps are essentially theories of cause and effect, which also illuminate the ACCHS sector’s unique place in the health system. For example Dane, an Aboriginal man who is the clinical services manager of an inner-regional ACCHS, stated that his organisation is highly conscious of the local Aboriginal community’s experience of systematic discrimination, often referred to as ‘structural violence’ (Galtung 1969; Farmer et al. 2006):

So where [this AMS] is located, is the original Aboriginal mission. So you have an entire generation of people who couldn’t get mainstream jobs, weren’t allowed to get mainstream jobs, weren’t allowed to have an education, had to ask permission to do anything, so that still filters down constantly … (Dane, emphasis in original)

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Dane’s account, and others like it from the interviews, links the physical space of the AMS to the geographical locations where Aboriginal people were confined using the regulatory powers of the ‘protection’ era (Broome 2010). Dane also links local Aboriginal peoples’ experiences of discrimination to unequal education and employment outcomes – two commonly cited social determinants of health (see Chapter 2). In stating this, Dane implies that the local Aboriginal peoples’ historical experiences of structural violence are relevant for health providers assisting the community in the present day. Dane’s account introduces some of the historical and socioeconomic causes of Indigenous health inequity.

By examining ACCHS CEOs’ and managers’ theories of Indigenous health inequity it is possible to better understand the broad philosophical principles that guide the ACCHS sector. Each interviewee follows a particular rationale in seeking to implement what they describe as the ACCHS sector’s holistic and culturally appropriate model of care. They each expressed an understanding of the importance and impact of their work in unique yet related ways. In interviews, ACCHS CEOs and managers offered three main accounts of Indigenous health inequality. I have labelled the three prominent narratives ‘the historical trauma narrative’, ‘the family environment narrative’ and ‘the poverty narrative’. I address them in that order below.

Tier 1: Conceptualising the ongoing health impacts of historical traumas The historical trauma narrative occupies the uppermost position in interviewees’ three- tiered theory of Indigenous health inequality. Interviewees recounting the historical trauma narrative explained transgenerational trauma as the result of child removal policies, which resulted in what is now known as the stolen generation. They also linked trauma to dispossession of land, and loss of culture, language and identity. According to most research participants, the root causes of Indigenous health inequity are buried in Australia’s history of official discrimination and systemic racism. Trauma associated with these historical processes of colonisation, family separation and dispossession has been identified as a significant determinant of Indigenous health in Australia (Boulton 2016; Atkinson 2002; Atkinson, Nelson & Atkinson 2010; Healing Foundation 2017). Around one third of interviewees explicitly stated that child-removal policies had adverse effects on Aboriginal peoples’ health and wellbeing in the present day, with a minority of others implying this in their explanations of how “intergenerational trauma” affects Aboriginal wellbeing. Some

146 interviewees argued that dispossession and/or cultural loss were significant determining factors in people’s health. Several others mentioned the negative impact of official discrimination and/or racism.

For example, Sam, the Aboriginal CEO of an inner-regional ACCHS, details how discrimination in service provision directly produced some of the worst possible health outcomes for Aboriginal people:

My great grand uncle …he went to a local hospital, sat in the outpatients’ area for many hours while other non-Aboriginal people who came in after him were put in before him. And his appendix actually burst. He died, just waiting there. I think people would remember they had wards just for Aboriginal people. You know how they have pyjamas and other clothing in hospitals? Well the hospitals used to have garments with ‘Abo’ on it. ‘Aboriginal’. And there was an Aboriginal board [ward]. This used to be at the Kempsey District Hospital, a place where I said I worked ... (Sam)

The trauma of previous generations, as Sam’s recollection illustrates, is not forgotten.

Another Aboriginal ACCHS manager explicitly describes how the negative effects of institutional racism linger on, long after the events have taken place:

But look, the impact of racism is one negative experience from a mother or a grandmother or a father impacts everything down the line. So every time they talk about a hospital or a procedure or a location or a somewhere where they’ve experienced that [racism], there’s a negative connotation or a negative attachment to it. That just goes through, generation after generation, the hatred or the experience and it’s hard to undo. It’s really hard to undo… Aboriginal people don’t like that [mainstream] environment and once they’ve experienced it [racism in a mainstream setting] it’s really hard to undo because there’s no support in there as it is, let alone the additional support that’s going to be needed to try to undo it. (Adam)

Harry, a non-Aboriginal man who is the CEO of an inner regional ACCHS, communicated a similar understanding of how traumatic experiences are passed down through story-telling. He states:

To listen to some of their stories – those stories are being told to their grandchildren and to their children and so that trauma translates through that population. And I think it’s a huge

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issue because unless they’re dealing with that trauma, and trying to resolve it in some way, it’ll go to their children and to their grandchildren. It’s a huge issue. (Harry)

Historical trauma, as articulated by Harry and other respondents, can then manifest itself in “bad decision-making around health, bad choices around drug and alcohol issues or sexuality [sexual behaviour]” (Harry). This view is shared by Rosemary, the Aboriginal CEO of an urban-based ACCHS:

Rosemary: There’s a lot of people who are disconnected from their Aboriginality, from their culture. There’s a lot of impact from stolen generation, there’s a lot of people who have moved down here and who are disconnected from their families and extended families and feel isolated and look to drug and alcohol … [to] self-medicate really. Mental health issues: there’s a shit load of that here. And in the schools, kids who know they are Aboriginal but are not connected in any way outside of their family, we get lots of them… So schools are ringing up and saying ‘I’ve got a kid, he identifies as Aboriginal but he doesn’t know anything about his culture, he doesn’t know where his family’s from’. We could have a whole team just doing that and that’s why I think the drug and alcohol problems are massive here.

Me: And when you talk about mental health problems, what kind?

Rosemary: Depression, anxiety. And it’s all trauma-based. So apart from the stolen generation, our books are full of people who have suffered trauma: grief and loss, people dying in their family one after the other. Massive. Trauma is massive.

Rosemary’s account, and others like it, illuminate the multiple forms of trauma and loss that often underlie health-damaging behaviours and mental illness. According to Rosemary, and some other interviewees, younger generations of Aboriginal people are not only affected by the transgenerational trauma that stems from historical child removal policies, they are also grieving the deaths of those close to them and searching for a sense of belonging and identity. These multiple sources of stress can prove too burdensome, and many Aboriginal young people in this region are turning to drugs or alcohol to cope, according to this urban- based Aboriginal CEO and other ACCHS representatives.

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Identity problems were not only discussed by interviewees in urban areas, but across the state. Amanda, a practice manager from an outer-regional location, echoed Rosemary’s concern with identity loss:

Me: So what do you think are the sort of underlying causes of the problems that people present here with? What’s the root cause?

Amanda: There’s actually – there’s a heap of them. So identity is one. A lot of people are taken away and then you know find their way back, trying to find their roots.

Amanda’s explanation, and the many other similar responses from the interview cohort, demonstrate the dominance of historical factors such as transgenerational trauma, child removals and cultural loss and, to a slightly lesser extent, other forms of official and social discrimination, such as inferior provisioning of public services, and racist treatment by the general public, as was explored in-depth in Chapters 2 and 9. The dominant causal factors in interviewees’ renderings of the historical trauma narrative are the government and institutional policies that led to the widespread separation of Aboriginal children from their families.

The impact of historical trauma on Social and Emotional Wellbeing Many interviewees emphasised the non-physical aspects of health when explaining how historical trauma leads to First Nations’ health inequality. Many Interviewees referred to the concept of Social and Emotional Wellbeing (SEWB) when explaining how ACCHS try to improve their clients’ mental health, strengthen their social, cultural and family lives, in response to historical trauma. Their definitions of SEWB, like the definitions found in the relevant literature stress the underlying causes of ill health, some of which are Aboriginal- specific, such as connection to country.

The literature on Aboriginal and Torres Strait Islander health engages with the concept of SEWB in some detail (see for example Tsey et al. 2009; Grieves 2006; Zubrick et al. 2014; Priest et al. 2013; Kelly et al. 2009; Rigby et al. 2011). Gee and colleagues define SEWB as “a multi-dimensional concept of health that includes mental health, but which also encompasses domains of health and wellbeing such as connection to land or ‘country’, culture, spirituality, ancestry, family, and community” (2014, 55). The Australian Institute of

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Health and Welfare has developed eight SEWB indicators: “psychological distress, impact of psychological distress, positive wellbeing, anger, life stressors, discrimination, cultural identification and removal from natural family” (AIHW 2009, x).

However, not all these domains are Aboriginal-specific. For example, “life stressors” could be socio-economic in nature and therefore would also affect non-Aboriginal people’s SEWB. Kilcullen, Swinbourne and Cadet-James (2016) identified four Aboriginal-specific dimensions to SEWB: “connectedness to country”, “family and kinship”, “cultural knowledge” and “social support”. They concluded that Aboriginal people’s SEWB was influenced by social and individual resources such as “coping skills”, “knowledge”, “connectedness” and “social support” (Kilcullen et al. 2016, 453). These resources were not specific to Aboriginal people but were, nevertheless, found to be crucial determinants of Aboriginal SEWB. Some interviewees also emphasised that Aboriginal peoples’ health is affected by their ability to cope with challenges, and the skills and social support networks they have at their disposal. These factors are discussed in relation to “the family environment”, later in the chapter. In this section of the chapter I concentrate on the Aboriginal-specific determinants of SEWB, to analyse how ACCHS respond to historical trauma and its effects on Aboriginal SEWB.

The above definitions and indicators of SEWB are consistent with many ACCHS representatives’ understandings of Aboriginal health and wellbeing. Just over one third of interviewees referred to SEWB in their explanations of Aboriginal health, its determinants, and ACCHS’ efforts to improve it. Adam, the Community Health Programs Manager from an inner-regional ACCHS, described SEWB as “the mental space” and drew a causal link between Aboriginal SEWB and transgenerational trauma, born out of the Stolen Generations. Additionally, Adam identified related socioeconomic challenges that ACCHS try to combat:

Those big, you know, the broader issues, the systemic issues. Financial [stress] is massive, and the trauma: trauma informing social and emotional wellbeing of the mob. We’re just not moving anywhere, you know. (Adam)

Similarly, Linda, the CEO of a neighbouring inner-regional ACCHS, described the enduring nature of trauma and detailed her organisation’s response to it:

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It takes many, many years to – if ever – to recover from something traumatic. And so we may never cure [it], we can just help people live with [it] and manage [it]. (Linda)

The following excerpt comes from an interview with Carole, the Family Services Unit Manager at an inner-regional ACCHS. Carole is responsible for overseeing SEWB programs that focus on family dynamics and parenting. In her work she witnesses the effects of historical trauma and sees how they impact multiple generations. Her story is quoted here at length as it reveals, in vivid detail, the pathways from historical trauma to contemporary family dysfunction:

We’ve also got our social and emotional wellbeing workers who are working with the fellas from transgenerational trauma where they could have been Stolen Gen. They’re up to three generations now of Stolen Generation kids. So, the first generation of parents that were stolen, when they ended up having babies – but a lot of those ended up drug or alcohol affected because they were trying to mask the upbringing that they had by being taken away, not knowing who they are, where they’re from, loss of Country, loss of language. So they end up doing drugs, whatever, or having mental health issues because they’re masking all these issues. They have children – or they may have been raped and had babies – then kids were taken off them. So they were never taught how to love. This loving, nurturing environment: they weren’t taught. So that then goes on to the next generation because ‘mum can’t give me a hug and say I love you because she doesn’t know how!’ And that’s why we’ve got now it could be third generation of all this domestic violence, everything’s going on, because [love] was never taught to them. Mum might have a clean house because that’s all she knows, is to clean the house! Because they were domestics, but she doesn’t know how to hug the kids, she doesn’t know how to show her love, she can’t teach this. And that’s where we’re having all this trans-generational stuff is happening. And all they know is maybe violence… (Carole)

In another example, Tim, the CEO of an inner-regional ACCHS, describes how unresolved trauma impacts SEWB:

… Aboriginal people come with a unique past and history, … often a lot of hurts that can stem right back to the stolen generation, … things that they haven’t been able to … to deal with. … that has flowed onto complex comorbidities in their clinical needs, it flows onto their conversations and emotions that come out of poorly-dealt-with conflict from the past. The

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stress that they live with on a day-to-day basis, having not dealt with those fundamental historical issues, that flows onto their social and emotional wellbeing and their physical wellbeing, it’s really significant. (Tim)

A great many Aboriginal people who were removed from their families by governments and religious institutions were not placed into loving environments, as the ‘Bringing them Home’ report illustrated in horrific detail (HREOC 1997). Carole contends that this lack of love produced parenting problems as well as substance abuse and mental health problems; since the people who were removed were never shown an example of how to bring up a child lovingly they could not raise their own children in this way. Substance abuse makes family violence more likely, (Boles & Miotto 2003) and family violence is the evidence that trauma travels through the generations and destabilises Aboriginal family environments, as Carole’s account demonstrates. Tim’s response outlines how unresolved trauma can cause multiple health problems, which can be physical, social and emotional in nature. He uses the concept of stress to explain how trauma transforms into health problems, which is also a common explanation offered by social determinants scholars (e.g. Brunner & Marmot 2006; Siegrist & Marmot 2004; Braveman, Egerter & Mockenhaupt 2011).

Adam, an Aboriginal manager at an inner-regional ACCHS, describes the intergenerational effects of historical trauma in slightly different terms. He explains that historical trauma can situate multiple generations of the same family in a low-socioeconomic position:

Transgenerational trauma…is significant and over the years it’s sort of evolved, or I see it as [having] evolved into transgenerational disadvantage because the trauma part of it, as the generations go on they’re less impacted by that trauma, the acts, but they’re still significantly impacted by that disadvantage. Because when the acts were happening there was limited education, limited means to gain funding so their place within community is lower, they’re in that lower socioeconomic [position], and these guys here [now] are still feeling those effects and they’re on that same trajectory. …The emphasis needs to go on that next generation, the youngest generation. Because the mums that are having these babies are still impacted. And it’s engrained, … they’re predisposed for feeling the emotions and the hurt and everything, it just travels through the body (Adam)

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Adam hints at the psychological effects of trauma being passed on from mother to child, which is a theory that has received some attention in the literature as well (see for example Boulton 2016; Atkinson 2002; Atkinson, Nelson & Atkinson 2010; Healing Foundation 2017; Atkinson et al. 2014; Krieg 2010; Paradies 2010).

In summary, a number of ACCHS representatives explained that Aboriginal health is an all- encompassing state of being, composed of physical, social and emotional, and cultural elements. Interviewees’ conceptualisations of Aboriginal health as a holistic state of being that encompasses SEWB as well as physical health lay the groundwork upon which the historical trauma narrative is built. Some interviewees also explained how SEWB can be impacted by socioeconomic disadvantage, which is the focus of the next narrative tier in the theory.

Tier 2: From socioeconomic disadvantage to illness, “hopelessness and despair” The second tier of ACCHS representatives’ theory of First Nations health inequity is what I call the poverty narrative. The poverty narrative was enunciated by around one third of the interview cohort. These interviewees concentrated on the health impacts of living in disadvantaged socioeconomic conditions, emphasising poverty and financial stress, limited education, unemployment, lack of access to services, transport issues, and poor housing. Interviewees identified unemployment and poor-quality or inadequate housing as the primary causal factors impacting First Nations health. For example, Dominique, a very experienced Aboriginal CEO at an outer-regional ACCHS, described, in a similar way to many other interviewees, the socioeconomic issues facing Aboriginal people in her region.

Lack of housing, lack of infrastructure, the roads and where the housing commission are placing people – it’s like they’re making little ghettos, kind of things. I’d say housing would be the biggest one. And sometimes poverty and there’s really some places where there’s nowhere for people to go to. Like, I know we have a problem with our youth on the streets, but there’s no youth hostel and things like that… (Dominique)

Dominique’s account, and many others like it from the interview cohort, details the clustering of socioeconomic disadvantage in Aboriginal communities, where the combination of poor infrastructure and inadequate housing is creating “ghettos”. In a related way, many interviewees pointed to unemployment as a root cause of Indigenous

153 peoples’ social and health issues. For example, Amy, the CEO of an outer-regional ACCHS, explained how unemployment can lead to mental illness and despair:

There’s no open racism but you walk down the street and you don’t see a black face in the shop[s]. Aboriginal unemployment is very very high. And so people don’t get opportunities to actually do anything. So they have a sense of hopelessness and despair that life isn’t going to be any better. And that leads to depression. That leads to mental health issues. That leads to drug and alcohol issues. (Amy)

For Amy, and other interviewees who share her views, underlying racism is a cause of economic marginalisation in Aboriginal communities. She describes unemployment as concern weighing on the minds of Aboriginal people, and succinctly clarifies how socioeconomic marginalisation can lead to distress and existential despair. It is Amy’s belief with few escape routes out of poverty, many people in this Aboriginal community are becoming unwell.

A minority of interviewees underlined the role played by financial stress, when relating the poverty narrative. These interviewees also identify either housing or unemployment as additional contributing factors. Peter, a non-Indigenous manager at an urban-based ACCHS, emphasised, as did some other interviewees, that financial stress can be so overwhelming “that it can make health a secondary issue”. Moreover, another interviewee, Adam, outlines how his organisation gives food to Aboriginal people who are experiencing financial stress:

We’ve got a limited bucket of money and we get a lot of people coming in and requesting assistance … We’ve made the decision that we only assist with food and meat and groceries, you know that sort of stuff, just to get them through to pay day. ’Cause a lot of them are living from payday to payday. (Adam)

Adam’s response highlights the inadequacy of funding allocated to poverty reduction. The negative impact of financial stress on Aboriginal health, particularly on child health, has been noted in the social-determinants literature (e.g. Walter & Mooney 2007, 163-4).

Another interviewee, Kate, the team leader of a remote ACCHS, describes the financial stress faced by the local Aboriginal community. She outlines the practical steps that her

154 organisation takes to address them, also making a connection between living conditions and health outcomes:

So we were having lots of issues with heating, cooling in the summer, heating in the winter, water… just consistent water, electricity issues, and they were huge factors that made our clients – well my clients – unwell. So and then you’d have them dealing with financial situations, … A lot of people I assisted with going to charity services going to oh ah is it Anglicare? They do little payments like loans… little loans. If you needed a washing machine … like, up to the amount of [$]1200. So it was sitting down with them and saying what do you need the most, is it a fridge is it a washing machine? Is it a lawn mower? So we look at those things and [ensure] that they’re physically able to pay those things off. (Kate)

The fact that this ACCHS manager directs her clients to a non-Indigenous charity organisation for assistance with emergency finance indicates that there are very few alternatives available to Aboriginal people in remote locations. Kate’s utilisation of the mainstream service also highlights the lack of funding available to ACCHS that seek to mitigate financial stress and poverty for their Aboriginal clients.

Tristan, the Aboriginal CEO of a remote ACCHS, also recounts the poverty narrative. In response to a question about how he understands the “gaps” between Aboriginal and non- Aboriginal health outcomes, Tristan paints a clear picture of the socio-economic circumstances facing Aboriginal people in his region:

The high unemployment, … not great turnouts in education with kids going to school, food, you know there’s no money coming into the families, there’s domestic violence, it’s a bit of everything. So the kids get a start to life that’s not great and they’re out doing break and enters and things, stealing food and what they can. (Tristan)

Tristan describes material circumstances so dire that Aboriginal children are forced to steal food. If these children were apprehended by law enforcement agencies and then sent to juvenile detention centres, their health would inevitably also suffer as a result of the negative health effects of incarceration (Krieg 2006). Annette also described food insecurity amongst Aboriginal children in an outer-regional town, leading to desperate behaviour:

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Annette: The other day there were kids running in and out of Woolworths. Woolworths now have the free fruit for people that are shopping there but these little Aboriginal kids were running in and out.

Me: Just to get something to eat?

Annette: Just to get fruit to eat. And it’s because they hadn’t had a feed for a couple of days.

In these examples, interviewees explain Aboriginal children’s behaviour as a rational response to unmet material needs, as opposed to the deviant acts of young criminals, as the state’s law-and-order responses imply (Brown 2012; Cunneen 2011). The above responses identify material poverty as a root cause of Indigenous young people’s health problems and illustrate how resultant behaviours could lead to problems with the criminal justice system.

Other interviewees described how housing problems negatively impact Aboriginal health, as has been outlined in the literature (e.g. Bailie 2007). Interviewees described overcrowding, unhygienic dwellings, and other hazards such as asbestos pollution. Sam stressed the issue of over-crowding:

You have a large number of people living in individual dwellings. You might have a dwelling that was built for four or five people. Ultimately you might have 10 to 12 people living in that dwelling so the burden then is on the living standard. You know what I mean? (Sam)

Similarly, Gwen, the CEO of an outer-regional ACCHS, described the condition of a house rented to an Aboriginal family:

Even the standards of housing around here that are being rented out to people, it’s disgusting. We had one client who moved in and the mould was that bad on the carpet, the carpet had been cleaned, but because of the water underneath the house and laying around the house and underneath the house, mushrooms were growing out of the carpet! (Gwen)

Gwen also described additional environmental health hazards, echoing Dominique’s comment about the ghettoisation of Aboriginal communities. Gwen, though, emphasises Aboriginal people’s perceptions of socioeconomic inequality and hints at their psychosocial effects on Aboriginal families’ wellbeing:

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The problem is some of the houses are the old asbestos houses from many years ago. And then they [Aboriginal tenants] see families that are living in four-bedroom beautiful brick homes, but they’re still back in the old houses. So I think more needs to be done in ensuring that the houses aren’t killing people. (Gwen)

Gwen’s comments also suggest that Aboriginal tenants’ perception of an unequal housing situation produces negative consequences (perhaps for their health or perhaps for their sense of social justice). Perceptions of inequality can also have physical health impacts, as was argued in chapter two. Gwen’s comments illuminate that poverty, because of the psychosocial health impacts of inequality, is both material and spiritual.

Poverty, according to some interviewees, makes crime more likely, and housing problems, in the eyes of many interviewees, are a direct cause of Aboriginal ill-health. Research on both urban and remote areas has also identified a link between poor and overcrowded housing and poor health outcomes for Aboriginal people, including poor SEWB (Anderson et al. 2016), and interpersonal conflict and abuse (Fien et al. 2011; Wild and Anderson 2007). These family-environment issues, closely related to housing, are the focus of the next narrative. It is widely acknowledged that the high levels of poverty prevalent in many Aboriginal communities are closely associated with these communities’ experiences of official discrimination and exclusion, colonial dispossession, child-removal policies and racism (e.g. HREOC 1997; Biddle 2012, 68; Behrendt 2009; Mitchell 2007; Walter and Saggers 2007; Boulton 2016). Based on the findings of this literature, and the interviewee accounts presented above, poverty can be understood as an intermediary cause of Indigenous health inequity, which stems fundamentally from historical processes of colonisation and oppression. I contend, in accordance with the views of many interviewees, that poverty can create health-damaging family environments. I present interviewees’ accounts of this final tier of ‘the causal cascade’ below.

Tier 3: How the family environment perpetuates “the cycle of hurts” I call the third tier of the participants’ theory of First Nations health inequality the family environment narrative. Interviewees who held to this narrative focused on the confluence of multiple pressures and stressors within individual Aboriginal households or “family units”.

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Around one third of the interview cohort agreed with Les’s view that people’s health is at least partially determined by “what they see in their family life or how they’re brought up”.

The main stressors in the family environment narrative are predominantly those same historical and economic factors mentioned in the historical trauma and poverty narratives: financial stress, unresolved trauma, grief and loss, inadequate housing, unemployment. However, the family-environment narrative explains Indigenous health disadvantage as the result of more proximal manifestations of suffering, such as abusing drugs (particularly ice) and alcohol, domestic violence, unhealthy eating, gambling, smoking, and child neglect. These behaviours in the family environment were then talked about as feeding into physical and mental health problems such: as diabetes; renal failure; cancers; respiratory disease; vision and hearing problems; cardiovascular disease; anxiety, depression; drug-induced psychosis; schizophrenia; and intergenerational trauma and disadvantage that start “the vicious cycle” all over again.

Amanda, an Aboriginal woman who is the practice manager of an ACCHS in a discreet Aboriginal community in an outer-regional area, listed the following family-related causes of health and social problems:

What [governments] see as the issues out here are not the issues. It’s the underlying stuff, the down to earth stuff. In-fighting, there’s Elder abuse and all the rest of it that no one understands, happens in the home – people taking money off people. Happens everywhere but it’s the family stuff. (Amanda)

Amanda’s insights, and similar comments offered by other ACCHS representatives, emphasise the particular social impacts of family conflicts that arise in Aboriginal households. The interviewees who subscribe to this narrative explained that many First Nations people do not have the “resources”, the “means”, or, in Tim’s words:

… the coping skills to deal with challenges that come up in that household, that include the past, that may include current conflict, and … your reaction to that … it may involve domestic violence.

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Some other interviewees pointed to the role played by a shortfall of other resources, such as education and heath literacy, describing them as root causes of Indigenous ill-health. These interviewees made linkages between health literacy and decisions around diet, prenatal care and/or personal hygiene. A minority of other interviewees stated that limited education can also exacerbate financial stress because of the lack basic living skills such as budgeting, cooking and shopping. Some interviewees explained that Aboriginal people’s lack of sufficient resources for coping with the challenges that present themselves in the immediate home environment can lead people to drug and alcohol abuse.

Carole explained substance abuse as something that people use to “mask” the psychological effects of being taken away from their families. Others stated that drug and alcohol abuse, and eating unhealthy food are somewhat normalised in some sections of Aboriginal communities, of which the same could be said about the broader Australian culture (Allan et al. 2012; Room 2010). For example, Lizzie states:

The normality of some children growing up, seeing mum and dad drunk or under the influence of drugs every day, that normalises the behaviour for them and (they think) there’s no other alternative. (Lizzie)

Lizzie’s account highlights a contemporary instance of intergenerational substance abuse, a phenomenon which has also been noted by Atkinson (2002, 169-79).

Similarly, the medical director of an inner-regional ACCHS, Jess, emphasised the family and health consequences of drug use, and agreed with the emerging research findings (Mattson, Crocker, & Nguyen 2011; Guerri, Bazinet & Riley 2009; Riley & McGee 2005) that link exposure to alcohol in-utero with subsequent behavioural problems:

There’s a lot of drug problems, a lot of ice in the community. That’s got its own health problems but it’s got its flow-on effect in families. Alcohol is a problem. It’s actually not perceived as a problem by the community, it’s normalised. But studies are coming out, not done here, but studies are coming out, and we can see it anecdotally, about babies that have had poisons in-utero and then the effect that has on their behaviour and basically [they’re] then ending up in the justice system. So early intervention there would be [ideal]… (Jess)

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Jess’ account positions foetal alcohol syndrome as an obvious effect of alcohol abuse, highlighting its lasting social and health consequences. Her final comment though, implies that very little is being done to address this issue in a preventative way, reflecting the curative biases in funding models, which I outline in Chapter 8.

The family environment narrative is fundamentally about exposure to traumatic events and stress in the home and the psychological and behavioural repercussions that follow. A combination of historical, economic and psychological social determinants, according to the interviewees who ascribed to the family environment narrative, become concentrated in Aboriginal families and communities. ACCHS representatives explain how the assemblage of stressors can lead to a range of self-destructive behaviours. In the words of Sam:

The social determinants cover like a blanket over the whole community and if you get no relief from that it’s only a matter of time before the community totally destroys itself. Now is that another form of genocide? I don’t want to go that deep but you think about it. (Sam)

The “social determinants” that Sam focused on in this interview were unemployment, racism and environmental problems such as poor-quality housing. His comments above convey a sense of urgency about the destructive behaviours that poverty and inequality can produce. Another ACCHS CEO, Natalie, gave an example of such behaviours and described the lengths to which her service went to alleviate the associated problems:

We had a domestic violence family, kids were at risk of being taken away, so we put mum in a parenting program, we put dad in rehab, we separated them for 12 weeks. Dad did the program, he come back, off the grog, with mechanisms to, you know, try and defuse when the arguments happen. Mum still liked to drink a bit so [he had] to remove himself from that. … We had to go through a private rehab because there’s nothing close and it cost us two grand out of our pocket to put that person through it. That was our own Medicare money that we had to [spend]. We thought it was important so paid for it. (Natalie)

Natalie’s account, and similar instances related by other ACCHS representatives, demonstrate the family-based model of care, where an ACCHS assists each member of the family. This example illustrates how some ACCHS use ‘flexible’ Medicare revenue, discussed in Chapter 4, to pay for un-funded services and facilitate their holistic approach to

160 healthcare. It also illuminates the lack of services and funding for drug and alcohol rehabilitation in NSW. Many interviewees were adamant that this was a priority area for government investment, an issue which Chapter 8 explores in detail.

Layering and linking three tiers of theory: the causal cascade Between these three accounts – the historical trauma narrative, the poverty narrative, and the family environment narrative – there is not a clear separation. There is significant overlap between interviewees’ explanations of the causes of Indigenous peoples’ health and social problems. Most interviewees’ reports merged into two or three narratives and around one third of the interview cohort touched on or fully explicated all three narratives. Only a minority of interviewees advanced only one narrative in isolation. Because of the overlap between ACCHS representatives’ explanations of Indigenous health inequality I believe it is useful to articulate how these three complementary narrative accounts combine to describe a cascade of causation. At the top of the cascade are those accounts that direct our attention to the backdrop of trauma, loss and dispossession; the weight of Australia’s racist history. Further down the cascade, in the second tier, there are stories that acknowledge the power of historical pressures, while also bringing in more contemporary socio-economic contexts. These can be understood as the material hangovers of Frontier Wars, dispossession, and segregation; they are the overflow of history. Then, down at the bottom of the cascade there are accounts that emphasise the specific behaviours in Aboriginal families or households. These third-tier accounts, which focus on ‘downstream’ effects (Siegrist & Marmot 2004; Anderson 2007), detail the social turbulence experienced and enacted by Indigenous families, outlining its health and social consequences. However, based on the interview data, no single-tier narrative seems fully to account for Indigenous health and social disadvantage. The most convincing causal stories link all three tiers together, explaining how the confluence of historical trauma, socioeconomic disadvantage and self-destructive behaviours in families combine to create a powerful cascade of health causation that rushes down onto Aboriginal families and communities.

The following narrative account clearly links all three tiers of the causal cascade, paying particular attention to the influence of trauma. The speaker is a non-Aboriginal CEO from an inner-regional ACCHS.

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I think the biggest health issues amongst our clients are social determinants of health, housing and employment in particular and education. I mean those three are all wrapped up in each other… and of course they’re ones over which we have minor influence, at best. The other one[s] – drug and alcohol and domestic violence are significant issues … [and] family breakdown and dysfunction. And a lot of these things – the drug and alcohol use, the violence, lateral violence – have their roots in a trauma history. So trauma-informed care is really particularly important. And that trauma history is at two lev– well it’s probably at more than two levels, but it’s individually – people’s individual lives – so [Jess’s] example of people’s mental health issues acting out, but also collectively – could be collectively within families, collectively within community… they have a really adverse impact. (Stephen)

The layering and cascading metaphors are useful because they help us understand how inherited histories and material realities can destabilise family and community life. The multi-layered cascade of causation makes the causes of First Nations health inequity difficult to isolate, and illustrates how the three tiers combine to make their health and social consequences progressively acute. The insights offered by ACCHS representatives, when viewed together, depict an image of Aboriginal families and indeed entire communities struggling to swim out of a whirlpool of pressure and suffering, where the dark waters of history and material deprivation suck them down.

Many of the causal factors that interviewees mentioned correspond with theoretical categories commonly used in models and theories of the social determinants of health (see, for example, Marmot 2006; Marmot 2005; CSDH 2008, 44; Braveman et al. 2011, S10; Graham 2004). However, many interviewees mentioned Indigenous-specific health determinants, such as intergenerational trauma associated with the child removal policies, which are less elaborated in the social determinants literature.

Other health-relevant concepts elaborated by the interview cohort are more closely related to individual Indigenous families’ lives, locating the analytic space further ‘downstream’ compared with typical ‘social determinants’ explanations (e.g. Brunner & Marmot 2006; Anderson 2007). Interviewees offered localised and nuanced accounts of the specific determinants of First Nations health and wellbeing in NSW, building on the broader structural explanations offered by the social determinants literature.

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ACCHS representatives’ complex understandings of Indigenous health inequality, I argue, are what makes the work of the ACCHS so important. This unique service model provides Aboriginal communities with a life-raft to escape from the health hazards at the base of the causal cascade. As the next section of the chapter details, ACCHS have designed complex and innovative solutions that seek to address the complex causes of Indigenous health and social inequality. Driving these solutions, interviewees maintain, is a holistic understanding of and approach to healthcare.

The holistic model of care: temporal, social, family and community understandings This section details how interviewees articulated the ACCHS approach to healthcare. The ACCHS model of care is commonly referred to as ‘holistic’ but the exact reference point of this holism is not always clearly articulated in the literature (e.g. Le Grande et al. 2017; DoH 2017a). The National and NSW peak bodies for ACCHS, the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Aboriginal Health and Medical Research Council (AH&MRC), define health and wellbeing as more than a physical state of being:

‘Aboriginal health’ means not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total wellbeing of their Community. It is a whole of life view and includes the cyclical concept of life- death-life. (NACCHO 2011, 12; AH&MRC 2008, 32; NAHS 1989, x).

As was outlined in Chapter 2, this holistic understanding of Aboriginal health was articulated in the first National Aboriginal Health Strategy (NAHSWP 1989, x) and it is now used by NACCHO and AH&MRC. There are similarities between the above definition of Aboriginal health, and interviewees’ descriptions of their ACCHS’ holistic approach to healthcare. However, interviewees referred to different kinds of holistic care, expanding upon the peak bodies’ definition of holistic health. Interviewees referred to four kinds of holistic healthcare: the whole life, the whole person; the whole family; the whole community. Some interviewees also outlined how such holistic care involved working with the community at multiple levels. As Tim stated: “we are constantly working towards an inclusive approach to the whole community, but right down to what’s happening in a family and household level that is affecting an individual’s health” (Tim).

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Caring for people “from cradle to grave” Firstly, interviewees who spoke about holistic health care as involving the whole life, simply put, referred to offering health services to clients of all ages. A minority of ACCHS CEOs and managers explained how their organisations’ approach to holistic healthcare involved accommodating a person’s health needs at any age. For these interviewees, holistic care has temporal or age-conscious element. While this is not the dominant understanding of holistic care across the data set, a minority of interviewees explained, using very similar terms, that treating the whole person meant offering health services at every stage of life. This was variously described as servicing people “from birth to death” (Roger), “from conception all the way through” (Dane), “from basically in-utero to grave” (Linda), and “from cradle to grave” (Tristan). Because of this whole-of-life approach, interviewees explained that ACCHS’ healthcare covers “maternal services… right through to aged-care services, so at some point in their lives they would have had contact with us” (Adam). These interviewees maintained that an aspect of the ACCHS holistic model of care relates to meeting the entirety of an Aboriginal person’s healthcare needs over a lifetime.

“Not just the clinical stuff”: responding to physical, social, emotional and cultural needs The second kind of holistic care the interviewees stressed involves caring for the whole person. The kind of holistic health care that these interviewees described has parallels with the ACCHS sector’s holistic definition of Aboriginal health and wellbeing, quoted above (NAHS 1989, x; NACCHO 2011, 12; AH&MRC 2008, 32). Just over half of the interview cohort spoke about health as something more than just a physical/biomedical state. They explained how physical, social, emotional, cultural and/or spiritual factors combine to create Aboriginal health and wellbeing. As one inner-regional CEO explained: “You’re not [just] dealing with someone’s physical stuff you’re dealing with everything that’s going on in their life” (Lizzie). Another ACCHS CEO, Rosemary, explained her organisation’s holistic approach to health as a response to community priorities:

And so apart from what’s happening in the clinic then we’ve got our community relations team who are running men’s groups, women’s groups, culture camps, to try and link those people in to not just the clinical stuff but the social and emotional stuff, the wellbeing stuff, the culture stuff because that’s what people are saying they need. (Rosemary)

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Interviewees emphasised that the ACCHS holistic approach treats people, not just body parts or symptoms. As this outer-regional CEO explained:

We don’t just look at ‘oh you’ve got a cut on your arm, let’s treat that’. We look at ‘how are you feeling inside? Alright so how about we deal with that? You might have a housing issue, let’s deal with that’. So it’s a whole range of things, we don’t just stop at the physical presenting medical problem. It’s the holistic approach. (Gwen)

Other interviewees from an inner-regional and outer-regional ACCHS located on ex- Aboriginal mission sites, also detailed how their organisations assist with funerals. In the outer-regional ACCHS, conducting funerals is considered crucial for the local Aboriginal community’s “spiritual wellbeing”, as Amanda notes, which governments do not fully understand or appreciate:

Koori people are very spiritual… and we need to be able to take sorry time to support them. Like we close down now for funerals and stuff. We actually use this room as the viewing room so they can view the body. We have to smoke it out, take the smoke detectors out, all that kind of stuff. [Governments] don’t understand all that. And that’s a day that we’re not having the service. But we’re providing a different kind of service to our people, and that’s the spiritual stuff. … (Amanda)

During times of acute grief and loss, Amanda explains, this ACCHS prioritises the social, emotional, and spiritual wellbeing of their communities. The inner-regional ACCHS, on the other hand, assists with funerals not only to help the community grieve, but also to help families cope with the associated financial expenses. Dane explains that his ACCHS assists people “financially towards things like the wake, you know, or funeral expenses”. On top of this, because of some Aboriginal people’s preference for being buried on their own Country, as some interviewees explained, this particular inner-regional AMS assists with and counsels people about transporting human remains:

The majority of the times they get … cremated and posted down. And the thoughts that that leaves with some of the families, even when you’re having that discussion with them – because it has to be had – because it is the cheapest option. It’s just, you imagine sitting there talking to a family, saying: ‘look this is the cheapest option, you’ve got to do this, they’ve got to come by mail’ … It’s just … it’s not right. That’s life, unfortunately, for

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Aboriginal people. It’s the degree of how much stress … you’re impacted by, how regularly and how serious that stress is, ’cause it’s just one ongoing flow of stress. (Adam)

By arranging funerals and trying to minimise the health impacts of poverty, Adam explains that his ACCHS is attempting to minimise the social and emotional impacts felt by families grappling with a key social determinant of Aboriginal health. In this and other ways, ACCHS are also poverty-reduction services, which is the focus of a later section of this chapter.

Responding to psychological distress with individualised care and group therapy Many ACCHS representatives explained that their holistic understanding of the health needs of the whole person necessitates a multi-faceted offering of health and other services for individuals. ACCHS representatives outlined the individualised SEWB services on offer specifically for mental health, including: counselling and mental health interventions using psychologists, psychiatrists and other mental health professionals. Around one third of the interviewees emphasised the widespread and serious nature of the mental health problems experienced by their communities. Rosemary, an urban-based CEO, stated, in a similar way to a number of other participants, that her Aboriginal clients with mental health problems were towards the serious end of the spectrum: “[They are] the high-end people who, you know, are fully medicated, [and we’re] probably never ever gonna get them right”. Rosemary’s comments underline the necessity of providing clinical mental health services in ACCHS.

Other interviewees outlined how ACCHS also offer SEWB programs that target specific social and emotional issues such as gambling, drug and alcohol abuse, grief and loss, and the trauma experienced by members of the Stolen Generations and their families. The interview data revealed that these SEWB programs can be individualised or group-based in nature. The services created to assist people affected by the Stolen Generations are commonly referred to as ‘Bringing them Home’ programs and emerged from recommendations made in the ‘National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families (HREOC 1997, 657). In some locations ACCHS have formed groups for members of the Stolen Generations, as a number of interviewees explained. These Bringing Them Home programs and groups often help people to find their family and trace their history. After reconnecting with family and Country “you finally find out where you belong.

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You have that sense of belonging. It all comes back” (Gwen). The CEO of a freshwater inner- regional ACCHS explains the impact of his service’s Bringing Them Home program:

Over time that group has become a very strong voice. Originally they were not, but the confidence that’s been built into and worked on with that group is huge, and now they get up and they stand up and they have their voice heard. And that’s a very powerful thing. (Harry)

ACCHS representatives, though, did not explain their sector’s approach to SEWB purely in a curative or health-management sense. Many interviewees explained how ACCHS have designed and implemented a variety of activities, classes, and programs that aim to enhance clients’ mental health, self-esteem, cultural pride and connectedness, among other aspects of SEWB. Interviewees described how some ACCHS across NSW are taking a positive approach to Aboriginal SEWB, building on community strengths, interests and abilities. Commonly cited examples of these positive SEWB programs included: exercise classes, cooking lessons, dance, art and music workshops, culture camps, sponsorship of local Aboriginal sporting teams, holiday excursions and activities for school children, beauty and personal grooming courses, and providing free access to an ACCHS-operated gymnasium.

The CEO of an outer regional ACCHS, Charlotte, described a “Koori Knockout Health Challenge” that her service offers, where community members are supported by dieticians and exercise physiologists to achieve their fitness goals in the lead up to the rugby league season. These social programs and activities, ACCHS CEOs and managers contended, are often driven by the members, even at a young age. For example, the team leader of an ACCHS in a remote location explained how her service had started up beauty courses after asking young people what they wanted and needed:

Some of the girls wanted to have some beauty courses so we got them a six-week program. The girls would go down on a Saturday through a partnership with a local hairdresser and she would provide them with hair and makeup tips. And she did their hair, she coloured their hair, [she’d] give them haircuts and she also provided them with lunch. And for the first time these girls were sitting in a hair-dressing shop. (Kate)

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In a similarly positive vein, other ACCHS representatives described how their organisations have created health, social or cultural groups for specific sections of the Aboriginal community. Many interviewees detailed the range of men’s, women’s, boys’, girls’, Elders’, and “mums and bubs” groups that their ACCHS have created. Interviewees framed these groups as safe spaces where people in similar life situations cans talk about health issues and make social connections. The CEO of a saltwater inner-regional ACCHS described her organisation’s Men’s Group as:

… an opportunity for Aboriginal men to talk about any issue that they want in a setting they feel comfortable with. But also if there’s anything around, you know, counselling then we have an opportunity then to support them and get them in to see those services. (Lizzie)

This statement indicates that there is also an opportunistic-healthcare aspect to the groups, where ACCHS engage in informal health screening and then refer group members to relevant support services. Many interviewees explained that the most important social grouping, in terms of health, is the family unit or household. Interviewees explained how some ACCHS in NSW have designed and implemented a number of family-focused SEWB services, which I explore below.

Treating the family as the unit of care The second level at which ACCHS work to improve Aboriginal SEWB is the family level. This is the third type of holism mentioned by interviewees: the whole family. The majority of interviewees gave some explanation of the influence that the family or home environment can have on Aboriginal health. Interviewees who described the whole-family approach or “the family-based approach” emphasised the ways that family members and their behaviours have an impact on the health of other individuals in the household. This links to the family environment narrative. Several ACCHS representatives described the strategies that their organisations employ to remedy these family-based health hazards, which are detailed below.

Some ACCHS in NSW provide targeted services for families at risk of having their children taken into Out-of-Home Care (OOHC). For example, one ACCHS from the interview cohort provides Functional Family Therapy (FFT) and Intensive Family-Based Services (IFBS). The

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NSW Government (2019) describes IFBS as an “intensive family preservation model” designed “to reduce the overrepresentation of Aboriginal children and young people in OOHC and to assist with stability issues for Aboriginal children and young people who may remain in the OOHC system”. FFT is a newer program, developed in the United States, that FaCS similarly describes as “a home-based treatment model for families where there has been physical abuse and/or neglect of a child or young person” (NSW Government 2018). Carole, a manager at the ACCHS that delivers these services, explained FFT a process where ACCHS staff “can work intensely with a family for up to 18 weeks. So if they don’t break that cycle [of family dysfunction] then their second chance is Functional Family Therapy”. Carole then explained that:

[FFT] is long long-term therapeutic service for the client so it could be anything 6–9 months where the therapist is working with a family. They work to change, I suppose to educate them and for them to change what’s happening in their lives, whether its drug-and-alcohol, whether it’s transgenerational trauma, whether its domestic violence, it’s all these long- term issues that have been going on. So they’re hoping to break these cycles within these families with this one-on-one [therapy]. (Carole)

This same ACCHS also runs a foster-care placement service for Aboriginal children in need of out-of-home care. Carole stated that this service has the capacity to arrange foster care for up to 50 children.

Out-of-Home Care is the final option, Carole explained, if FFT and IFBS do not change how families are living and behaving: “If you don’t change your lifestyle, change something within what’s happening for these children, the children will be removed” (Carole). Carole’s comments indicate that these services are designed to stabilise the family environment so that children will be safe from harm. These structured and intensive services are a response to the social and family turbulence at the bottom of the causal cascade, where families are struggling with transgenerational trauma, poverty, and the self- destructive behaviours that flow from them. This is a logical conclusion to ‘the family environment narrative’ and the three-tiered theory of Aboriginal health inequality as a whole.

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A minority of other ACCHS CEOs specified that their organisations ran a “mums and bubs group”, taking a whole-family approach to child and maternal health. These interviewees described a preventive approach, rather than the curative approach of FFT and IFBS that Carole described. Mums and bubs groups were described as social occasions where young mothers get together to share their stories and experiences of motherhood. Some interviewees also stated that GPs, Aboriginal Health Workers and nurses are present at group meetings to provide information and allay the mothers’ fears or concerns. In one remote ACCHS, Tristan stated that fathers are also involved in these groups. The fathers can also access relevant support services, such as drug and alcohol counselling, that will improve the overall health of the family, according to Tristan. One ACCHS has also developed a “roll and stroll” walking group for young mothers.

Roll and stroll was an idea brought up by the maternal team as a way of engaging mums who were having difficulty or finding it a bit hard to look after bub. So this was a way for them to socialise with other mums and bubs but also have a team, like a health worker and a nurse there so if there were issues while they were out walking they could bring it up in that setting and it’s not such a formal thing. And a lot of the girls were really receptive to that. (Lizzie)

This simple family health program has the benefits of promoting exercise, creating social opportunities and providing health information in an unintimidating setting, all vital attributes of healthy communities. The CEO, Lizzie, explained that her ACCHS also offers activities to the children, giving the mothers a break while they walk and talk. These whole- of-family programs and groups can be understood as additional examples of ACCHS attempting to strengthen Aboriginal “family environments”, through enhancing SEWB and offering health education.

Community events as healthcare interventions A final kind of holism, outlined by a minority of interviewees, refers to the ACCHS sector’s attempts to care for the whole community. According to these ACCHS representatives, holistic care involves hosting events and designing places that will improve the wellbeing of the whole community. Interviewees described a range of cultural events and celebrations (such as NAIDOC balls), commemorations of significant Aboriginal anniversaries (such as

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Sorry Day) and culturally appropriate community spaces (such as walking tracks, a “Sorry Garden” and other forms of community gardens). In one example of a health intervention aimed at the whole-of-community level, Dominique described how her ACCHS was organising a community healing event to help people cope with the accumulation of grief and loss “because this year in this community and around there’s been that many deaths. Old ones, younger ones…” (Dominque).

Offering comprehensive and coordinated clinical services from a “one-stop-shop” Based on the testimony of interviewees, it is clear that in putting their holistic philosophy of health into practice, ACCHS across New South Wales (NSW) provide a comprehensive range of clinical and non-clinical health services. Several interviewees described this comprehensive model of care as a “one-stop-shop” for health. Sam described ACCHS as “super clinics in their own right” and “total multi-purpose centres”.

Although ACCHS do much more than treat their clients’ biomedical health issues (Baba, Brolan and Hill 2014), clinical health procedures do make up a substantial and important part of their work, according to interviewees. ACCHS representatives described the wide range of clinical health services that they make available to their communities. All of the participating ACCHS in this study provide GP services at no cost to clients. Interviewees from half of the participating ACCHS said their organisations also directly provide or facilitate access to bulk-billing dental services. All ACCHS in the study employ nurses and Aboriginal Health Workers. Depending on the size of the organisation, its level of funding and the specific needs of the local Aboriginal people, interviewees described how their ACCHS also give clients access to a comprehensive range of specialist services. The specialist services listed were: cardiology, endocrinology, gynaecology, ophthalmology, cardiology, psychiatry, ear, nose and throat specialists, paediatrics, pharmacy, pain rehabilitation, and geriatrics. Many ACCHS included in this study also work with and employ a range of allied health professionals including: psychologists, occupational therapists, dieticians, physiotherapists, exercise physiologists, speech pathologists, optometrists, podiatrists, diabetes educators, mental health workers/nurses, and counsellors. Interviewees explained that specialists and allied health service providers visit on a rotating basis and see patients at ACCHS’ clinics, making the services more accessible for the local community. Interviewees also explained that much of the ACCHS’ clinical and allied health care is related to the treatment and

171 management of chronic diseases such as diabetes, renal disorders and cardiovascular conditions. This chronic disease care is one of the ACCHS sector’s crucial contributions to Aboriginal health improvement, as the chronic-care gap has been identified as a key factor underlying the life expectancy gap (Vos et al. 2009, 475).

Just over half of the interviewees touched on the coordinated nature of the health services their ACCHS provides. Many interviewees argued that for comprehensive health care to work optimally, different teams within the one organisation need to be communicating and working together. As Charlie, the CEO of an inner-regional ACCHS, stated: “Aboriginal health should never be siloed”. Other interviewees contended that for Aboriginal wellbeing to improve, ACCHS must address physical, social and emotional, and cultural factors in unison. As Roger, an urban-based Aboriginal CEO, urges:

Understand how important it is to us: culture and the wellbeing. It’s all come together. It’s all in the one suitcase, it’s not separated. Nothing’s separated, it’s all together. One go down, we all go down. Instead of separating components, you know. (Roger)

A minority of interviewees stated that care-coordination is easier inside the ACCHS sector because a lot of the referrals to additional services are, as Rosemary put it, handled “in- house” by the one organisation. Some interviewees highlighted how GP management plans are used as centralised repositories of health information and care coordination, containing the client’s history of care, test results and instructions about the services they required. Different teams across the ACCHS then use those documents to guide their actions and facilitate care-coordination. The interviewees who explained the utility of GP management plans are spread across major cities, inner- and outer-regional and remote locations, indicating their widespread usage. The following excerpt describes how GP management plans are used for care coordination inside an ACCHS:

So we take those GP management plans and ensure that the client gets access to the services that they need. You know, we are set up so that we can do a lot of that internally. If a GP management plan comes in for a chronic disease patient, ‘Jane’ our chronic disease care coordinator will be on the doorstep making sure that the doctor has filled out the right paperwork and that they’ve got the referral processes in place. And then she will follow up with those patients to ensure that they’re meeting their requirements (Harry)

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Harry’s ACCHS employs a staff member specifically to coordinate and integrate patient care. The care coordinator tries to get doctors, referred service providers, and even the clients themselves working together to make sure each is doing all they can to integrate care and improve the client’s health. GP management plans are one tool that ACCHS use to hold to account each person involved in their clients’ healthcare. GP management plans are also an important source of Medicare-generated income for ACCHS. The incentives and outcomes of this funding model are discussed in Chapter 7.

Mitigating the health impacts of poverty through subsidised care and “emergency relief” Interviewees explained that ACCHS are accessible for Aboriginal people living in poverty because most services are provided at no cost to the clients. Just over one third of interviewees stated that this was an important element of the ACCHS model, which differentiated it from mainstream services. Employing Aboriginal people is another way that ACCHS reduce Aboriginal poverty. This is demonstrated by the fact that, significantly, the ACCHS sector is “the largest employer industry of Aboriginal and Torres Strait Islander people within Australia” (Alford 2014, 11), as was mentioned in Chapter 2. Not only does the creation of Aboriginal employment boost the skills and economic base of those employees, it also lifts the socioeconomic circumstances of their families (Alford 2014, 43). This notion was explicated by Linda, an inner-regional ACCHS CEO:

[S]omeone working in a household, having employment changes so many things. It can mean better housing, it can mean better food options, it can mean children participating in social sports such as football, little athletics. They’re all very expensive; if you’ve got five kids that need to go to footy, that’s a lot of dollars you need to find. (Linda)

Just over half of all interviewees argued that Aboriginal employment was an important benefit of the ACCHS model. Many interviewees also argued that Aboriginal employment also contributes to the culturally appropriate nature of Aboriginal Community Controlled service provision, a point which I explore in the next section of the chapter.

A number of ACCHS representatives described how their services offered much-needed assistance to clients struggling with everyday material challenges. The practical services described by interviewees include: transport to and from the ACCHS and external

173 specialists’ appointments, emergency finance, delivery of medications, school bus services, before-school breakfast clubs, free access to gymnasiums, providing food to families in crisis, housing assistance, supervising Work Development Orders where people can work off their fines, shopping trips, budgeting advice, and bringing mobile health clinics to isolated communities. Scholars of the social determinants of health and health inequality have been arguing for many decades that poverty is a fundamental social determinant of health and wellbeing (see Chapter 2). The social determinants literature and evidence given by interviewees both suggest that ACCHS’ poverty-mitigation work reduces some of the health- damaging effects of poverty in Aboriginal communities. I argue that this is a key strength of the ACCHS model and an area where the sector adds value to the health system as a whole.

Providing culturally appropriate healthcare The available literature on the ACCHS sector underscores the comprehensive range of services as well as the culturally sensitive way in which these services are provided (Campbell et al. 2017; Baba, Brolan & Hill 2014; Alford 2014; Hurley et al. 2010; Panaretto et al. 2014). This method of relating to and caring for Aboriginal clients is commonly referred to as ‘culturally appropriate care’ or ‘cultural safety’ (see Chapter 2). The interview responses confirmed this concept’s relevance to Aboriginal health service delivery. Culturally appropriate care was discussed in every interview and by almost every interviewee. In a broad sense, interviewees spoke about culturally appropriate care in terms of making clients feel “safe”, “welcome”, and/or “comfortable”. Adorning the waiting room with Aboriginal artwork, hanging the Aboriginal flag, putting up “pictures of the old people”, and providing a quiet place for people to come and sit and drink a cup of tea, were some of the strategies that interviewees mentioned as having a positive effect on community perceptions of the service. One inner-regional CEO described the feeling that ACCHS are trying to avoid producing in their patients:

That’s like a woman walking into a room full of men. The intimidation that she would feel walking into that room, it’s the same as [an Aboriginal person] walking into a sterile White waiting room. (Lizzie)

Lizzie and many other interviewees understand that it is valuable for Aboriginal clients to see people like them working inside their local ACCHS.

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Some interviewees also said that having a high-proportion of Aboriginal staff members, especially in client-facing roles, was an important strategy for making clients feel comfortable coming to the ACCHS. A few interviewees maintained that this effect was amplified if the Aboriginal staff were local people known in the community. One Aboriginal manager, Carole, described how culturally appropriate measures make Aboriginal clients feel when they come to the ACCHS:

You’ll come in you’ll see an Aboriginal face, you’ll feel comfortable, you’ll see community info in the waiting room, you’ll bump into family and friends in the waiting room. (Carole)

Aboriginal manager Dane described the ‘cultural embeddedness’ of his ACCHS:

We are community. We are part of community. We hold the name of the Country that people sit on and have walked on for thousands of years. (Dane)

For local Aboriginal staff this can affect how they see themselves at work, according to Adam: “if you ask our mob that work here, they are – they know – they are community members first and employees second”. All of this suggests that the high proportion of Aboriginal staff in the ACCHS sector marks it as an Aboriginal space and makes it more likely that Aboriginal community members will feel comfortable going there.

Based on interviewees’ explanations of the culturally appropriate ways that ACCHS relate to their clients, it seems that the concept of trust, and the interactions it makes possible are fundamental to culturally appropriate care. Most interviewees implied, or directly stated, that nurturing community trust was important for the success of the service. As one urban- based CEO, Rosemary put it: “If they don’t trust they won’t come”. This apprehension can be partially explained by Australia’s history of racial discrimination in health settings such as hospitals, as was explored in Chapter 2. As Dane explains:

When you look at the history and what’s happened with Aboriginal and Torres Strait Islander people through history, there is that engrained fear in our culture that, you know, we’re not necessarily a people that go to buildings for help … so to speak. We go to our family, we go to our community, and our country. (Dane)

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Aboriginal peoples’ memories of institutional racism run deep, as Sam contends: “That’s why AMSs were set up in the first place because there was so much racism out there and prejudice that our people were not being treated”. Even today, ACCHS must work hard to overcome Aboriginal people’s fear of clinical health settings and memories of government- sponsored discrimination:

They have to take into account like, the trauma from the Stolen Generations. Walking into a building even like this we make it as friendly as we can, but a lot of people associate it with government, even though it’s not. (Natalie)

To make a trusting relationship between ACCHS and Aboriginal communities more likely, interviewees explained that ACCHS across NSW employ several different strategies. One of the strategies described was to offer cultural guidance and mentoring to non-Indigenous staff, particularly doctors. Several interviewees spoke about the structured cultural education programs that their ACCHS designed for staff members. For example, the CEO of an ACCHS in an outer-regional area detailed how her ACCHS would take GPs and clinic staff to culturally and historically significant places to expand their understanding of Aboriginal people’s historical and material circumstances:

Like, we take them out to where we were fringe-dwellers living on the river. I’ll say ‘That’s where I grew up’. [They’ll exclaim:] ‘What?’. That’s where we grew up, in a little tin shack me mum built, and older brother built, with old pieces of iron from the tip. (Charlotte)

Another community trust-building strategy, mentioned by almost one third of the interview cohort, was to establish strong relationships with Elders and leaders. Respected and knowledgeable community leaders, Elders are a source of political, moral and cultural authority (Busija et al. 2018; Warburton and McLauglin 2007, 52-53; Lohoar, Butera and Kennedy 2014, 11-14; Warburton and Chambers 2007). ACCHS representatives gave examples of how they try to demonstrate to their communities that their ACCHS enjoy the support of local Elders. They explained that this was done in order to increase their organisations’ community legitimacy and build trust. As one urban-based CEO explained:

I started with the Elders: the Elders who people respect. So you bring them in as your team, you know. And then people see that. They say: ‘Oh, geez he’s got hold of this fella well … he

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must be a good bloke’. I go over and get Auntie [M]… , she’s a lovely old lady, everybody loves her. So you have them around. And they make you look good. But you help them, you do things for them. And you do it with them. (Roger)

This final point speaks to the issue of empowerment, which is explored in Chapter 7.

“We take our time”: building trust through long consultations In describing what culturally appropriate care involves in practice, around half of the interviewees commented on ACCHS’ different approach to time, compared to mainstream services. Interviewees maintained that, compared to mainstream GPs, ACCHS GPs spend more time with patients. As Linda contended: “what we do differently is we take our time. So mainstream medicine is usually about six minutes per consult; our minimum is 15, and [up] to half an hour”. Similarly, Lizzie, an inner-regional Aboriginal CEO, argued:

We’re not a production line. … Our minimum appointment is around 25-30 minutes. …I don’t want to sound disrespectful here to mainstream services, but .. our job’s … to provide that service for the patient. It’s not about us making money from that patient. So however long it takes that patient to talk to us about their needs, so be it. We make time for that. (Lizzie)

I interpret these comments as a critique of the biomedical approach to healthcare, which focuses on offering a targeted diagnosis of illness and prescribing medication. Many interviewees characterised mainstream GP services as embodying the biomedical approach, portraying typical mainstream GP interactions as:

A five-minute appointment … the doctor will say ‘What are you here for? Tell me what’s wrong with you. Here’s a script. Bye. See you next time’. (Harry)

Many interviewees also perceived mainstream GPs as operating on very strict time schedules. For example:

I know that some of the registrars that come here from private practice say that they really felt under pressure because they had to get people in and out and in and out because they had to be making that money for the practice. (Amy)

Many other interviewees held very similar views on mainstream GPs’ approach to time. These comments about time can also be understood as also a critique of the activity-based

177 funding model that incentivises short interactions between doctors and patients, problematising any further changes to the ACCHS funding model that would see it become more activity-based. The proposed changes to the IAHP funding model, for example, would move ACCHS onto a capitation-based model, where providers are paid based on patient numbers (Duckett an Willcox 2015, 99; Chapter 4; see also Chapter 8).

Interviewees stated that ACCHS offer longer appointment to their clients because of an underlying motivation to meet all of the clients’ health needs, where caring for the client comes before making money for the organisation. Many interviewees argued that these priorities were reversed in mainstream settings. Other interviewees maintained that ACCHS doctors spend longer with Aboriginal patients because they present with complex health problems and co-morbidities. As this ACCHS CEO explains:

In an AMS doctors generally tell me that they’ve got to have long consultations with individuals because they don’t just come there with one illness they come there with multiple illnesses and they say if they give a short consultation and they’re only treating one illness that doesn’t do the patient justice. (Sam)

Another interviewee contended simply that “five-minute medicine does not work” (Charlie). Moreover, interviewees not only described long consultations as clinically necessary, making it possible for ACCHS doctors to treat all the client’s health issues, they also alluded to ‘taking your time’ being central to culturally appropriate health care:

We need to be very fair, inclusive, respectful. … it’s a totally different role to, you know, if that person presented to a GP practice and they were looking at one set of health issues, and then they try and discuss something else, and the GP says, ‘Well you actually need to make another 15 minute appointment to get to that next issue’. We can never view a client like that… they won’t come back for the second appointment because they were so pissed off about the way they were spoken to in the first appointment. (Tim)

As other interviewees also maintained, gaining Aboriginal patients’ trust is one of the things ACCHS do better than mainstream health services, and taking more time appears to be a crucial part of that process.

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Several interviewees maintained that longer appointments allowed ACCHS GPs to build rapport with Aboriginal clients, with one interviewee also stating that this rapport led some clients to be more interested in their own and their family’s health:

Down here we’ve got them in, there’s no pressure on the client. The client sits there, we go overtime with the appointments, which we’ve got whacked on the fingers about, but it’s giving more to the client. And you’re getting good results because that client’s either… picking up on their own health … ‘Oh I might need to do this’ or ‘That doctor’s real good to me, I can understand what the doctor’s talking about’ … It’s a big step in their life…. And you find that those people are asking for more services, looking after their kids’ health more … [even] some of the men, you used to have to drag some of them in, but now a lot of them are coming in [to the ACCHS] freely now … (George)

From this response, it can be concluded that the practice of offering longer consultations is a reliable strategy to allow ACCHS doctors to make clients feel more comfortable talking about and seeking assistance with their complex health issues. Conversely, some interviewees maintained that when doctors become more focused on generating Medicare revenue through quick consultations, that detracted from their ability to connect with patients:

And that’s what we say to our doctors, you know. ‘You’ve gotta talk to the clients, talk to them about their kids, talk to them about sport. They’ll answer you. Create that relationship’, you know? ‘Touch them ’cause they’ll go out there and tell other people: “Aw that doctor didn’t even touch me!” That’s important to them, you know. They want you to touch them so they can create a relationship with you, feel comfortable when they come and see you next time… So we educate and we do that cultural training with a lot of our doctors, you know, for the doctors we go and do that to try and break down those barriers. (Roger)

Educating doctors about the importance of spending time with patients, as this CEO and others contend, is an essential element of ACCHS’ cultural training practice, which differentiates them from mainstream service providers.

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Conclusion This chapter has provided details of what ACCHS do, how they do it and why. It has sketched a three-tiered explanation of ACCHS representatives’ understandings of Aboriginal health and social problems. It has described the historical, socio-economic and family causes of Aboriginal peoples’ health and social problems, based on interviewees’ explanations of the root causes and how they manifest as health problems in individuals, families and communities. The causal cascade metaphor was used to illustrate the connection between all three tiers of the causal story, and to emphasise the downwards pressure exerted when all three levels combine to produce an oppressive effect on Aboriginal people. The chapter has also documented interviewees’ holistic understandings of Aboriginal health and wellbeing and outlined the comprehensive range of health and social services that these understandings inspire. Four main holisms were described: the whole life, the whole person, the whole family, and the whole community.

The chapter linked specific ACCHS services and programs to these distinct yet interrelated aspects of holistic Aboriginal wellbeing. These services were not only clinical or biomedical health services, but also included allied health services and, crucially, services, policies and programs that mediate the effects of poverty. They do this through creating employment, subsidising services and making them more accessible through transport and outreach services to isolated community members. This chapter explained how ACCHS are more than health services and described the specific ways that they address some of the root causes of Aboriginal health inequity.

The key concept of SEWB was also defined and the ways that different ACCHS operationalise it and try to enhance it were explained and specified. SEWB services target Aboriginal families, completing the ACCHS comprehensive response to all three dimensions of Aboriginal health causation. In conceptualising the role of the ACCHS sector in the health system, the chapter engaged with interviewees’ explanations of the uniquely Aboriginal elements of the ACCHS sector’s health philosophy. My analysis identified how a number of ACCHS in the interview cohort considered the social and spiritual implications of health and illness in the community. ACCHS are able to understand and respond to these non-clinical considerations because they are part of the Aboriginal community and understand how they work in a sociological sense.

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The chapter has argued that ACCHS make a unique and invaluable contribution to the health system. That is: they possess a grounded understanding of the particular constellation of historical, socioeconomic and family-based determinants of Aboriginal health and wellbeing in each of their communities; and they formulate a multi-pronged response to these problems, attempting to prevent the ‘cycle of hurts’ from repeating itself in the next generation. The fact that ACCHS do this in partnership with local communities, embodied in the community-elected board of Aboriginal directors, is a fundamental advantage of the ACCHS model. Mainstream health services cannot replicate this, by definition. ACCHS’ ability to empower Aboriginal people to take control of their health is perhaps the most important contribution of the sector, based on interviewees’ responses and theorising. Empowerment as a way of improving Aboriginal health outcomes is explored further in Chapter 7.

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Chapter 7.

Navigating corporate governance challenges while maintaining Community Control

[T]hat’s a very tough juggle for anyone on a not-for-profit board, especially someone that wants to be, number one, representing the rights and responsibilities of the community and the members who have elected them, and trying to weigh that up with the changes that are non-negotiable in our contracts and our overseeing bodies… – Tim

[W]e are the middleman because we’re trying to deal with this government policy that wants to standardise, but also a cultural ethic that says we need to provide what it is that our communities want us to provide, and in a way that they want it provided. – Harry

The biggest issue impacting Aboriginal Medical services moving forward is governance. Because you’ve got communities saying ‘This will do us’. You’ve got governments saying ‘We want this’. They’re two poles apart. There’s a gap, isn’t there. Close this gap. Compromise. – Charlie

This chapter is about how interviewees made sense of their Aboriginal Community Controlled Health Services’ (ACCHS) strategic decision-making processes, and their understandings of how Community Controlled boards of directors attempt to meet the expectations of community members and Government regulators and funding bodies. Throughout the interviews, most participants offered insights into how their ACCHS were governed, with some interviewees also evaluating the ACCHS sector’s overall governance model. Interview responses were clustered around a set of themes related to community representation and bottom-up decision making, strategic planning, business stewardship and legal compliance. In these themes there is a tension between what is commonly referred to as “corporate governance” (Tricker 2018) and what one Aboriginal CEO, Charlie, described as “cultural governance”. Corporate governance is generally concerned with the obligations of company directors, the oversight of finances and audit, managing conflicts of interest and risk management (ASIC 2014). Charlie, the Aboriginal CEO of an inner-regional ACCHS, offers an explanation of the distinction between corporate and cultural governance:

Cultural governance means that we have people in our community who can provide advice to us on what they believe is the culture of this community. The corporate governance talks

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about the culture of the organisation as a healthcare provider. And that talks about accreditation, systems, processes, recruitment, compliance, all those things. (Charlie)

This tension between distinctive modes of governance and competing lines of accountability has been previously identified by scholars of Indigenous Affairs policy and Aboriginal organisations (e.g. Moran et al. 2016; Brigg and Curth Bibb 2017). David Martin has characterised the space in which Aboriginal organisations (such as ACCHS) operate as “an ambiguous and fraught intercultural domain” (2005, 195). It can also be conceived as “the cultural interface”, to use Martin Nakata’s terms (2010, 56), where Indigenous and Western knowledge systems are both “constantly at play”, with neither existing in isolation from the other.

In this study, interviewees raised a number of practical and political issues that arise when ACCHS boards try to perform cultural and corporate governance simultaneously. Interviewees also outlined the solutions that their organisations are currently pursuing to manage these tensions of ‘intercultural governance’ (Brigg and Curth-Bibb 2017). These challenges and solutions are the focus of the opening section of this chapter.

Defining governance in the ACCHS sector The picture of governance that these interviewees painted is more complex than the commonly cited definition of the ACCHS model, set out by ACCHS’ state level peak body, the Aboriginal Health and Medical Research Council (AH&MRC). AH&MRC positions “Community Control” as the essential governance criteria qualifying an organisation as an ACCHS. For a health service to be an Aboriginal Community Controlled Health Service it must be: “governed by an Aboriginal board of management elected by a local Aboriginal community membership” (AH&MRC 2008, 6). This criterion focuses on the structures of community representation that link ACCHS to their local Aboriginal communities. Put simply, “An ‘Aboriginal Community Controlled Organisation’ is an organisation whose governance is characterised by Aboriginal Community Control” (AH&MRC 2008, 36, emphasis added). The AH&MRC definition says nothing, though, of the financial and legal compliance, and risk management tasks that interviewees observe their boards undertaking, tasks which many interviewees described as onerous and outside the skillset of some community board members.

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This raises questions about the complex and diverse set of activities that Community Controlled boards are required to undertake. Interviewees’ responses also prompt reflection on whether Aboriginal community directors are equipped, or should be required, to oversee the financial and legal side of the business as well as representing the local community’s needs and preferences. Nevertheless, evidence from interviews indicates that ACCHS boards are still grounded in their communities and are not yet pursuing government outcomes over community priorities.

Setting the strategic direction of the ACCHS, in line with ‘what the community wants’ Several interviewees explained that ACCHS’ boards of directors were responsible for making strategic decisions, approving spending, and ensuring their organisations’ survival and growth. Harry, an inner-regional ACCHS CEO, described the board’s core function as: “developing the service in a strategic manner”. Just under half of the interview cohort saw “strategic planning” as one of the board’s main purposes. Dane emphasised, in a similar way to other interviewees, that the board had to align the ACCHS’ strategic direction with “what the community wants us to do”. Moreover, several other interviewees interpreted ACCHS boards as existing to represent the wants and needs of local Aboriginal communities. These interviewees characterise ACCHS boards as a representative form of local-level Aboriginal self-determination, a point that has been made in the literature on the governance of Aboriginal organisations (Davis 2013; Mazel 2016).The following response from Lizzie, the Aboriginal CEO of an inner-regional ACCHS, describes the interactions between ACCHS management and the community-elected board of Aboriginal directors: “As the CEO of this organisation I take that direction from the board, in terms of what they see, because the board’s supposed to be representative of community”. Collectively, these interview responses convey a sense of grassroots community governance, where community boards respond to the directly articulated or perceived needs of local Aboriginal people.

Another ACCHS CEO, Dominque, explained, in a similar way to other interviewees, that community accountability is achieved through regular elections of local Aboriginal people, who then direct the organisation:

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[O]ur service is run by a board. The board is elected every two years. So you’ll have one board for two [years] and then you rotate. So they’re community members and they also work on our organisation’s strategic plans, they set all those. (Dominique)

For other participants, Community Control was seen as a requirement for ACCHS to prosper, an idea that the following statement exemplifies. For example:

[T]he community can make or break organisations like this and if you don’t have a board that is representative of your community or doesn’t have the community’s best interests [in mind] then that’s an issue. I just think you can get the required skill sets to meet what government want you to do in terms of having your finances and your compliance in check. I think you can do that through different structures and different avenues. I think [if] you’re a community organisation, that’s got to be your core business. (Rosemary)

Rosemary’s statement above highlights the tensions between community and corporate governance. Conversely, Lizzie acknowledged the value of community input into the decision-making process, but problematised the way her board members used their influence:

It’s very important working with them. And the benefits being that you’re getting direct knowledge and feedback from community, because these are people living in the community. The downfall to that is sometimes they can’t delineate between the personal and what their role and responsibility is on a board. So I’ve got one particular board member that’s come on since December and every meeting I’ve documented that she’s attacked me on something personal. ‘Why can’t my husband get into the dentist?’ ‘Well he’s [non- Aboriginal]. I’m sorry, love.’ (Lizzie)

Some other interviewees also raised the issue of board members being unable to clearly distinguish between personal or family matter and board responsibilities. These responses illuminate the complex and overlapping incentives that ACCHS boards must respond to when governing their organisations.

Mitigating against familial biases Two interviewees mentioned that it was important for ACCHS not to be nepotistic in their decision-making. One of these interviewees, Harry, also mentioned that his ACCHS had

185 instituted anti-nepotism policies related to board membership. After searching the publicly available constitutions and rule books of ACCHS in New South Wales, I identified three ACCHS with anti-nepotism policies in place. These organisations are not necessarily the same organisations interviewed for this project. Biripi Aboriginal Corporation Medical Centre’s rule book stipulates that no more than two directors can be of the same immediate family (Biripi ACMC 2019, 10). The Albury Wodonga Aboriginal Health Service constitution specifies that no more than one member of the same family can be on the board at the same time, nor can partners of current staff be elected to the board (AWAHS n.d., 11). Katungul Aboriginal Corporation Regional Health and Community Services’ rule book states that directors cannot be members of the CEO’s immediate family (KACRHCS 2018, 8). These policies vary in their scope but their underlying message is that governance problems and democratic deficit can arise if close-knit family groups are allowed to dominate organisations designed to be representative of the entire local Aboriginal community. This phenomenon has been termed ‘controlled communities’ by Brigg and Curth-Bibb (2017) who also note its problematic nature and outline some structural solutions adopted by ACCHS in Queensland.

Can a community board act as a responsible steward of ACCHS business? Many interviewees offered an articulation of the principles and activities traditionally conceptualised as ‘corporate governance’, also describing how their boards and managerial teams engaged with them. Many interviewees emphasised the financial and legal aspects of board governance. Around one third of the interviewees underlined the board’s responsibility for ensuring organisational compliance with legal obligations and funding conditions. These corporate governance responsibilities are very similar to those of non- profit boards in general (e.g. Cornforth 2001). Additionally, a minority of interviewees contended that one “role of the board is to keep the organisation solvent” (Lizzie). In the eyes of these participants, this work did not require fine-grained accounting and scrutiny of financial minutiae but required an understanding of the overall financial situation and trajectory of the organisation. Rosemary explained that this was to safeguard “the long- term viability of the organisation”. Shirley, a non-Aboriginal manager from an inner-regional ACCHS expanded on this point:

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They [the board] have to have ethical governance so they have to know what’s going on. They don’t have to know the ins and outs of each detail but they need to know that we’re trading viably … they need to be aware of what’s going on and make decisions on which tenders we’ll apply for, how much money we’ll spend in, like, facilities, things like that. But as far as when someone wants to go and buy a pack of chewing gum, no. (Shirley)

Similarly, Les, the Aboriginal CEO of a large outer-regional ACCHS, in outlining his organisation’s internal structures and management systems, emphasised the importance of financial risk management for ensuring organisational success: “I think the other big factor is, when you talk about risk, the financial management area… it’s a big one. It’s a cog to the whole organisation”. While Les did not explicitly state that this was the responsibility of the board, he later expressed a preference for having a financial advisor on the board:

[W]e’ve investigated changing our constitution to have two skills-based members other than our board members: one being a legal advisor, one being a financial advisor. And they would have full voting rights on the board, but they may be non-Aboriginal, because if we can’t get Aboriginal people … (Les)

This Aboriginal ACCHS CEO not only implied that ACCHS boards should act as stewards of ACCHS finances, a view that was shared by many other participants, he also implied that his current board of Aboriginal directors was ill-equipped to perform this task. Les raises questions about the corporate governance capacity of Aboriginal community directors, a concern shared by around half of those interviewees who commented on ACCHS governance. However, this board’s lack of financial and legal skills would be true of many community organisations - not just Aboriginal ones - especially where the board is made up of unremunerated volunteers.

In a related way, Amy, a non-Indigenous CEO of an outer-regional ACCHS explained her organisation’s corporate governance challenges:

We have 100% Aboriginal board members. I would say that their experience and competence in governance is limited. So I have to try to guide them to make sure that we comply with all of our regulations. (Amy)

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Amy also explained the meaning of governance for her, highlighting the blurred line between board governance and internal ACCHS operations:

Me: So for you is governance something that is focused on government requirements and sort of legal requirements as per funding and that kind of thing?

Amy: Ah, it’s a part of it. I would just call that regulatory stuff. Governance is more about running a business and making sure that you comply with regulations. And I suppose some of those regulations are funding requirements but it’s not the bulk of it…Because we are a business. And for a lot of NGOs that’s a difficult concept for people to understand, that you are actually operating a business. It’s a hard concept for the board to understand because they want to get involved in operational issues, when they should be looking at how to be a business.

This blurred line between governance and “operational issues” was articulated in very similar terms by Lizzie:

But the problem is that sometimes they bring their personal stuff. They tend to cross the line between governance and operational. I’m employed to run the organisation. The governance side is there to ensure that the organisation stays solvent and that we are meeting all our legal obligations under the agreements with the Commonwealth and state. That’s what the board’s job is. But unfortunately, sometimes it gets a bit clouded with some of the things that, … as a board member, they feel that they’re entitled to. (Lizzie)

These interview responses give the impression that corporate governance is just as important as community governance for ACCHS. They also indicate that some ACCHS boards have trouble maintaining a separation between two of their core functions: operational management and strategic planning. Carver argues that for boards to function effectively, directors need to be able to distinguish between the two roles: the “board as manager” and the “board as planner” (Carver 1997, 12-12; see also Hubbard 2003, chapter 3). These comments should not be taken as evidence of widespread misgivings amongst the interview cohort about the functioning of ACCHS boards. The negative appraisals of ACCHS governance were in the minority. Even among the interviewees who commented critically on ACCHS governance, around half held their board members in high esteem overall, contending that they performed their roles effectively.

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Re-structuring ACCHS around business principles Some participants mentioned that in recent years they had been trying to run their ACCHS more like a business. For a minority of interviewees, this decision was taken in order to make their organisation more financially independent:

[W]e’re really just looking at the commercial and business opportunities that the organisation needs to make to be viable because we don’t want to be dependent on government funding. (Rosemary)

Similarly:

The funding – you’re always fearful … that the government comes in and changes and cuts your funds… So that’s how we’ve turned our thing around and [we] look to run like a business so that if it ever happens … you’ve got that backup and you’re viable without relying on their funding. (Dominique)

In a related way, other interviewees framed their decision to make their ACCHS more business-like as a response to Government pressure or incentives. Approximately one third of the interview cohort said that their services were under pressure to become more business-savvy. Funding reforms via the Indigenous Advancement Strategy (IAS) and the PHNs, and the upcoming changes to the IAHP, were the most commonly cited sources of this pressure by interviewees. Harry articulated this pressure as a government ‘expectation’:

[A]ll funding bodies in my view are moving towards a business model of service not a community-based model of service and so the expectations are that you will run as a business. So you have to have things in place that will allow you to function in that environment and the structure of the board needs to understand that you know it’s a business in its purest sense. And yes we’re providing community service but we have to run like a business. (Harry)

Additionally:

Government’s been saying this for the last six years: that we are a business. (Charlie)

And again:

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[W]e are being pushed to be more business-savvy … It’s coming from the Department of Health, and from State Health actually. They’re all looking at what we’re making through Medicare, making sure that we’re maximising Medicare. And that’s impacting on, well from a clinician’s point of view they feel it’s impacting on patient care. (Rosemary)

This same interviewee, Rosemary, interpreted governments’ preference for business-like ACCHS as an economic decision. However, she also argued that governments were overlooking valuable Aboriginal community obligations:

I think the government’s main concern is about how their money’s being spent, and what’s the outcome from their investment. And I get all that but there is also the accountability and responsibility back to community for the services you deliver. If the government were that interested in what was happening [they’d] go and talk to the community. They don’t do that. They’re not interested in that. (Rosemary)

A number of ACCHS representatives explained that their services had developed a commercial side to their operations, in order to generate more revenue that could then be used to expand services to community. As Tristan, the CEO of a remote-located ACCHS, outlines:

So we’re a pretty big organisation and we’re a lot different to most AMSs… we have other businesses that we own and run and we use … that income to support the AMS in delivering its services…. so we’ve got four clinics: two AMS clinics and we’ve got two private practices. We own a gym, we own a funeral home. Yeah so we’ve got a bit of everything. We auspice the management of … [another] Aboriginal Medical Service, we run it as well. All up I think we’ve got about 75 staff on the books. So we’re the largest private, non-government organisation employer in [the] shire so yeah we employ about 15 doctors right across the organisation, so yeah we’re pretty big. (Tristan)

Similarly, Gwen and interviewees from other ACCHS explained that their ACCHS offer GP services to non-Aboriginal patients, which generates Medicare revenue that is then used to subsidise other Aboriginal specific services and programs that do not generate revenue or attract adequate funding. In order to generate sufficient revenue to maintain the full range of services and programs this ACCHS has to provide many instances of care to the non- Aboriginal population. In effect:

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We have about 11,000 people on our books. Just over 3000 are Aboriginal people. So we have Aboriginal-specific programs, so obviously our GP clinics and our nurses, so the medical clinic is open to everyone. We’re probably the only bulk-billing service in town, that fully bulk bills. And then we have other services that are Aboriginal-specific so they’re only open to Aboriginal people and their non-Aboriginal spouses. Like the drug and alcohol program and a whole range of other programs that we’ve got here. (Gwen)

Gwen’s ACCHS makes its services available to the Aboriginal and non-Aboriginal residents of the town. However, given that Gwen stated that her organisation’s main goal was to “to work towards Aboriginal people enjoying the same standard of health as non-Aboriginal Australians”, the fact that her ACCHS services so many non-Aboriginal people appears to be a means of generating revenue rather than as a fundamental goal of the organisation. This indicates that the current funding model does not adequately compensate this ACCHS for its Aboriginal-specific programs and services, leading them to search for revenue through other, more ‘mainstream’ and commercial, areas of service provision. This pattern of service commercialisation has been observed across the Indigenous sector in recent decades (Hunt 2008, 43), indicating systemic problems within both Commonwealth and state-level Aboriginal-specific funding models. Dane described a similar pattern of servicing increasing numbers of non-Aboriginal clients:

… we see non-Indigenous people as well. … we’re seeing that increase and we’re seeing clients come from other areas in the region because of changes to Medicare, changes to the way that local doctors work. … We’re structured around being a bulk-billing practice so we’re seeing more and more of these clients come in. So at the moment, whilst our funding hasn’t increased, we’re taking on a whole ‘nother (sic) portion of community … and it becomes a balancing act in that you are trying to provide health care for everybody [but] with a focus on Aboriginal and Torres Strait Islander people. (Dane)

This interviewee problematised the way that health funding structures can distract ACCHS from their core business of providing healthcare to Aboriginal and Torres Strait Islander people.

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One board, two roles: balancing corporate and community governance Most interviewees broadly conceptualised the term ‘governance’ as involving the oversight and steering of ACCHS strategic direction. However, a minority of interview responses also highlighted how ACCHS governance involved negotiation and compromise, as boards tried to “juggle” competing demands: those of Governments and those of community:

[T]hey’re doing this constant juggle with … the feedback they’re getting from community. So, they’re hearing issues that will be often partially factual, they’re coming to the table wanting the full picture, because they want to be able to respond to their family, to their community. And that puts them in an exceedingly vulnerable position as directors. I would say an unreasonable position, because what the community are expecting of them is not considered good corporate governance. They are expecting them to be across all the details of what’s going on and are putting pressure on them … to be asking those questions, which prevents the board from staying on top of the significant compliance and subsequent policy changes that the organisation needs to make. (Tim)

Similarly:

“[I]t’s around trying to balance your Community Control, your regulator responsibilities, your legal frameworks, your funding frameworks, your Work Health and Safety, with your Community-Control expectations, with your operational stuff. So, you know, you’ve got to get a balance of all those things in regards to priorities and what is needed to move forward. (Les)

The idea of striking a “balance” between community and corporate governance responsibilities was also raised by this interviewee:

[Y]ou’re not ever going to be a Community Controlled organisation unless you’ve got Aboriginal people on your Board. … [But] when it goes badly it goes really badly, and it does impact on that corporate culture of that organisation, and we need to get more skills-based Board members to balance that out. … I’ve got a couple of Board members [who have] MBA, Diploma of Commerce, law degree, they all help. And so we also have community representation as well, so people who just belong to the community. They bring community skills and knowledge to the Board as well. But when it’s an uneven balance it becomes too community as opposed to the governance part of it. (Linda)

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These interviewees, and others, seem to interpret their organisations’ governance balance as tipping towards to community side of the scale. However, there is also the risk that Aboriginal community organisations can become so focused on corporate governance and ‘what government wants’ that they become “quasi government-controlled health services”, as Brigg and Curth-Bibb (2017) have argued. Moreover, as Aboriginal-specific service delivery becomes increasingly contractualised ACCHS “find their primary accountability – toward their constituents or members – being skewed toward bureaucratic or administrative accountability” (Moran, Porter & Curth-Bibb 2016, 361). The idea of a governance balance seems particularly apt in this context, given the evidence of the problems that can arise for organisations that favour the community or corporate side.

The constitution of an ACCHS in remote NSW explicitly acknowledges the intercultural nature of board governance, including a ‘cultural preamble’. It states:

Mindful of the heritage and structure of Aboriginal society and the role of elders and the Law in Aboriginal culture, the Constitution is drafted as an attempt to synchronise corporate structures with cultural models of governance and, compliance with prescribed requirements for the composition of the organisation’s governing committee is undertaken fully conscious that this obligation reflects a system of government intrinsically different from Aboriginal culture. (BAHSL 2014, 34).

Moreover, this document also makes clear the cultural responsibilities of office holders such as the chairperson and the CEO. Specifically, the chairperson is responsible for ensuring that the organisation exercise “absolute discretion, culturally appropriate protocol and confidentiality” when dealing with any matters related to “Aboriginal religion, associated spiritual matters, cultural traditions, customs, heritage, lore, law, sacred sites, land rights and Community knowledge” (BAHSL 2014, 39). Similarly, the CEO is responsible for, alongside their numerous corporate governance and management responsibilities, managing the organisation’s administration of “support and educational services for Aboriginal culture and heritage to enhance spiritual healing within the Community” (BAHSL 2014, 55). This is a clear example of an ACCHS codifying a mix of corporate and cultural governance into its overarching legal document.

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“It’s empowered our communities”: ACCHS governance as localised self- determination Almost all interviewees affirmed the importance of Aboriginal community empowerment in health. There is some encouraging literature that links political empowerment to health gains. The work of Wallerstein stands out in this field (2006; 2002; 1992). She describes empowerment as both “an outcome by itself” and “a viable public health strategy” (Wallerstein 2006, 4). Murphy (2014, 320) has theorised that political empowerment or self- determination can be conceived of as a “collective capability”, employing Sen’s (1999) terminology.

However, other scholars have problematised the very concept of the Aboriginal ‘community’ itself. Peters-Little (2000, 13) contends that Indigenous groups only came to be referred to as ‘communities’ in the 1970s, when the Whitlam Government sought to distribute new funding for the delivery of Indigenous-specific services. She further asserts that “the structure of ‘community boards’ is based on western notions of representativeness” and argues that its top down imposition onto Indigenous contexts primes Aboriginal organisations “for administrative failure” (Peters-Little 2000, 13). Morphy (2008) highlights the complex nature of determining who belongs to an Indigenous organisation’s service ‘community’. Her research illustrates the overlapping bonds and obligations, both administrative and cultural, that link diverse groups of Aboriginal people to an Aboriginal Community Controlled service based in Yirrkala (Morphy 2008, 131-133). These critiques unsettle the seemingly straightforward explanation of ‘Aboriginal Community Control’ offered in an earlier section of this chapter. Nevertheless, many interviewees spoke of Aboriginal Community Control as an invaluable component of ACCHS’ structure, which empowers Aboriginal people to take control of their own health.

Each ACCHS is “Governed by an Aboriginal body which is elected by the local Aboriginal community” (NACCHO 2011, 5). This gives members of the local Aboriginal community a level of ownership and control of the organisation. Just under one third of the interviewees spoke of the ACCHS model as bestowing community members a sense of ownership over the organisations. Interviewees explained that this ownership structure creates certain lines of accountability and a level of community responsibility for the success of the organisation.

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Gwen, the Aboriginal CEO of an outer-regional ACCHS explained the empowering effects of community accountability:

[G]iving that ownership back to us [means that] if we don’t succeed then it falls on us. So we’re going to give it the best shot we possibly can because we’re not going to let our communities down. (Gwen)

Similarly, Annette stated that Community Control makes it more likely that Aboriginal patients will access health care: “The community feel that it’s theirs and it belongs to them and that’s why they come here”. Another CEO, Linda, conceived of Community Control as almost an end in itself:

AMSs are here for a purpose and it’s about empowering our community to take control of their own health. (Linda)

These responses show how the ACCHS ownership structure empowers while also allocating responsibility. Charlotte, the CEO of an outer-regional ACCHS in a small country town contended that Community Control has “empowered our communities to take more responsibility for their own health, and their family’s health” Other interviewees also explicitly linked Aboriginal Community Control to the concept of empowerment. Since the community owns the organisation, interviewees explained, it is responsible for the quality of its services. Additionally, doing what is best for the community is a central motivator for ACCHS staff, as many interviewees articulated, making it more likely that services will be acceptable in the eyes of clients.

Several ACCHS representatives described giving the community responsibility for the organisation as a key function of Community Control. Similarly, Sam described Community Control as “having the right to advance yourself in your community”. Interviewees confirmed that the Aboriginal community’s power is vested in the board, which is then responsible for the strategic direction of the ACCHS. Community Control in health is, according to almost all interviewees, about giving Aboriginal people the power to improve their own health and wellbeing.

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Roger, the Aboriginal CEO of an urban-based ACCHS, explains how Community Control can make Aboriginal clients invested in the ACCHS’ work. He gave the example of his community enforcing and respecting the ACCHS’ smoke-free zone:

You have a big function, I see people tellin’ ’em: ‘You can’t smoke here, brother’. Then they’ll go out. No arguments about it, they say: ‘Sorry, I didn’t realise’. But the community are tellin’ ’em. So that’s where you see that the people own it. (Roger)

This sense of investment is enhanced by the fact that ACCHS staff are predominantly Aboriginal community members as well. The organisation’s performance will be especially important for ACCHS Aboriginal staff not just because of their professional commitment to their work, but also because of their partial ownership of the organisation as community members, and sometimes direct usage of the services on offer. As Roger clarifies: “They would never do anything wrong to interfere with this operation ’cause it’s theirs”. Aboriginal Community Control as a governance model, as the above evidence demonstrates, produces tangible benefits for the health behaviours of Aboriginal people.

Navigating corporate governance challenges: strategies and recommendations Participants disagreed over what should be done to overcome governance challenges. Amongst the interviewees who proposed possible solutions, there was a division between those who favoured reforming the board itself and those who favoured supporting the board with training and through the employment of additional staff with corporate governance expertise. Additionally, a minority of interviewees expressed a preference for dedicated youth positions on the board. I outline these recommendations one by one.

Finding skills-based board members As previously stated, some ACCHS representatives contended that there should be skills- based positions on ACCHS boards, and that these positions could be filled by non-Aboriginal people. Interviewees, such as the non-Aboriginal CEO quoted below, who had already managed to create these skills-based positions expressed a sense of satisfaction over the impact that this structural change had engendered in their ACCHS:

The Board is to ensure the governance and compliance of this organisation, to provide experience and knowledge… I’ve got a couple of skills-based directors on the board to

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provide me with support as well as provide the organisational culture to this organisation. So our board of directors are very supportive and positive [about] our organisation and that filters through. (Linda)

Another CEO, Charlie, explained, in similar terms to a number of other ACCHS representatives, how his organisation looked for corporate governance skills when filling positions on the board. Charlie also highlighted how a structural shift towards corporate governance capacity was in keeping with government priorities:

We’ve been a skill-based board for 7 years – 8 years. Where we have our old constitution was people couldn’t be nominated, people had to nominate in writing that they would like to be considered to be on the board of this organisation. We got a letter of commendation from the government because we took that line. Wasn’t influenced by anybody, we just knew that we have to be serious about change. (Charlie)

This comment suggests that governments favour ACCHS that scaffold corporate governance capacity into their most authoritative decision-making forums. It also suggests that some managers in the ACCHS sector perceive corporate governance as a vital skill for their boards to possess.

None of the interviewees denied that good corporate governance was a prerequisite for a thriving ACCHS sector, although several interviewees doubted that Aboriginal community directors possessed the necessary skill set to thrive in this area. The potential for ACCHS boards to be dominated by people with limited corporate governance experience was expressed forcefully by Les, the Aboriginal CEO of an outer-regional ACCHS:

[I]t’s a numbers game. So someone can come in there and be non-illiterate (sic), not go to school, know nothing about health, nothing about business and yet be elected onto the board, where they are technically and legally accountable and responsible for our organisation. So if the shit hits the fans they’re blamed. So I could have a situation where – we have seven board members – where all those board members elected … some may not know how to read or write, some may know nothing about health, business and yet they’re responsible for the organisation. (Les)

Les also waded into the debate over skills-based board members:

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[O]ur sector had an argument and – at least ten years ago – they were sitting up there saying, you know: ‘We don’t need a skills-based board, we’ve got skills: we’re Aboriginal’. And the argument that come (sic) out of one of our high-level state meetings was: ‘We should be paid’. It wasn’t about look at, well, why ain’t you being paid or why are [there] issues … the services that I’ve seen that have gone, been defunded is because of bad governance and bad management. So … I think [a] skills-based board is part of the solution. (Les)

Another CEO, Harry, a non-Indigenous man from a freshwater inner-regional community explained how his organisation shortlists potential board members through a formal and structured application process:

[W]hen you apply for the board you don’t just do an application and say I want to be a part of the board. There’s also key criteria that you have to address and then that is reviewed by the current board in terms of ‘Well is this person going to value add to what the organisation currently is doing?’ And then those members are put up to the community to say well these are the ones that fit what the organisation needs. (Harry)

Another non-Aboriginal CEO, Tim, also stated that his organisation had ‘debated’ changing the constitution to make room for “skill-based directors for one or two positions” who would have to make a “submission in writing prior to the AGM expressing interest and skills of a director”. These changes had not been adopted by his board at the time of writing, indicating that some ACCHS boards are reticent to cede any governance power to non- community-based directors.

Based on a scan of publicly available information on ACCHS websites, it was discovered that one remote-located ACCHS gives its community-elected board members the option of appointing additional ‘Independent Directors’ to the board. These appointments are for Aboriginal people who do not reside in the local area, but who bring “relevant qualifications, skills or industry experience which will be of benefit to the Corporation” (Maari Ma HAC 2019, 17). This is a slight variation on the skills-based board proposal outlined above, in that it is at the discretion of the community-elected board to determine whether and which additional skills are required. Aboriginality, though, remains a key criterion. The website of another ACCHS outlined how its board includes two positions for skills-based directors who

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“bring a different and additional professional perspective to the organisation” (OAMS n.d., para 3). Overall, the skills-based board approach appears to be mainly a strategy for adding corporate skills to ACCHS boards, while trying to maintain Aboriginal Community Control.

Adding additional governance staff, not board members Other interviewees were not convinced that having a skills-based board was the best way to strengthen ACCHS’ corporate governance capacity. Some ACCHS representatives explained how their organisations achieved good corporate governance through staffing changes rather than through board reforms. For example, several ACCHS in the interview cohort employ auditors or finance officers/managers to oversee their financial and legal compliance and manage financial risk. Rosemary argued forcefully, as did a minority of other ACCHS representatives, that the creation of these staff positions strengthened corporate governance without weakening Aboriginal Community Control:

[T]here’s been a lot of talk around – at the national level NACCHO’s moving to a smaller board, talking about the introduction of independent directors with skill-sets. And I see the benefit of that but I’m also cautious about that because I don’t think you can underestimate the pull that these boards have in their communities. The directors are elected on for a reason. And if an organisation is set up to serve a community then you need to have community people leading it. … They bring the voice, they bring the needs, the community concerns to the table, because sometimes I might read that differently to how they do. And so that balance is good. … I think the sector’s got to be cautious around yes, everyone’s got to operate like a business … and you’ve got to have the required skill-set on your board, but I think there’s other structures that you can set up where that can happen. (Rosemary)

More specifically:

[Y]ou can have sub committees, you can have advisory councils you can do all that, you can have good structures internally around finance and compliance. I mean we’ve put a business manager in to make sure that’s all on track so it’s not a – the board’s overseeing that and making sure that’s all done but we’ve got somebody actually doing that. (Rosemary)

In summary:

[Y]ou can have good governance and have a community board [as well]. (Rosemary)

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Similarly, Tim explained that his ACCHS had created governance sub-committees on the board to help focus the directors’ attention and help them develop a level of governance expertise in a specific service area, such as out-of-home care or clinical health. These are some of the interviewees’ proposed alternative models of governance that would not technically dilute the power of Aboriginal Community Controlled boards.

Appointing youth to the board A minority of interviewees implied that corporate governance capacity was stronger amongst younger generations of Aboriginal people, and argued that, therefore, youth positions on the board were a good idea. For example:

My board’s made up of a lot of local Elders. My wish would be that we could have some younger members and maybe some with a bit more skill base. Because I have to feed off what the board tells me and so my board needs to be skilled and have an understanding of a lot of the impacts on us, so that we can still do our work. (Lizzie)

One organisation had instituted youth positions on the board, which their CEO contended was a source of governance renewal:

And then their kids are coming up, you know, the young ones coming through. We’ve changed the constitution to have youth on the constitution [the board] and then reflected on it, so what we’ll do now we’ll change it again to put a male and a female. Now we’ve got a new chairperson, a new deputy that were voted in there before Christmas, came through the Youth Program, [now they’re] on the board. … ’cause they’re the future… I’m not going to be here much longer. (Roger)

This would seem to suggest that some ACCHS representatives believe younger generations, who have had greater access to formal education that their older relatives, would increase the corporate governance capacity of the organisations, and also give ACCHS governance stability into the future.

Prioritising governance training The most commonly mentioned technique for fortifying ACCHS’ corporate governance capacity was formal governance training. Tim explained what this involved in practice:

They’ve done extensive governance training; the company secretary has been away with me

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and completed the highest level of Australian Institute of Company Directors qualification. We’ve had ORIC involved in a lot of dialogue in the board and members meetings to try and have that on-the-job training for what they do. (Tim)

Similarly, Lizzie explained why this training was important for board members:

I think unfortunately a lot of them don’t understand the full role and responsibilities of what they do. Especially the legal ramifications, and that’s why I’ve got that governance training coming up and I’m prepared to pay this lady $5000 just for the weekend to reiterate that to my board because we’re at a crossroads now where we’re being investigated, we have changes in our funding, we have changes in our reporting, we’re going to be penalised for our non-compliance in meeting our KPIs, and so these are all the impacts that my board need to understand… (Lizzie)

In a slightly different way, Jess, the non-Aboriginal medical director of an inner-regional ACCHS, highlighted the importance of formal training but also emphasised the importance of implementation:

[W]hat we have to realise is that it’s [the ACCHS sector] grown from a cottage industry and we really do need to move with the times and we have to be accountable. We have to be flexible and we have to be realistic in what we can expect. … It’s a matter of governance training and applying the governance training. There’s a big difference. You can tick the box and have governance training but whether you actually put the principles into practice … (Jess)

Les, though, outlined the limitations of governance training, especially when things get personal:

[W]e have annual governance training so those three board members have got their Certificate 4 in Indigenous Governance and [are] currently working towards diplomas. But I’ve still found that there’s been a couple of situations that’ve involved people that are closely linked to those [board members] and all that training just goes out the window. (Les)

Like other interviewees, Amy surmised that governance training is about giving community board members the requisite skills to perform complex roles:

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I think it’s just about education, really trying to give the board the best possible information and skills to be good board members. Because a lot of those people too, it’s hard being a board member, and you don’t just automatically have all those skills, all those wonderful governance skills. (Amy)

From these responses I interpret that there is a sense amongst ACCHS CEOs and managers in NSW that governance training is part of the solution to the sector’s corporate governance challenges, but that it will require some time for the corporate principles learned in training to be incorporated into the “habitus” (Bourdieu 2002) of ACCHS board governance. Therefore, a combination of two or more of the above recommendations may be a more robust approach to institutionalising corporate governance principals and practice in ACCHS.

Conclusion This section has explored interviewees’ understandings of governance and the work undertaken by ACCHS’ boards of community directors. Two very different modes of governance were uncovered through analysis of the interview data. These were corporate governance and community governance (or cultural governance, as one interview expressed it). I have highlighted interviewees’ enunciations of the tensions between corporate governance responsibilities (involving financial risk management and legal compliance) and community governance and accountability (involving the steering of ACCHS towards community priorities). I found that interview responses reiterated some previously articulated research findings about the difficulties of performing corporate and community governance simultaneously. I identified evidence in interview responses of some more specific governance challenges facing the ACCHS sector. These were: board members blurring the line between governance oversight and interfering with internal ACCHS operations; and board members not possessing adequate corporate governance skills to perform their roles. This section also proposed a number of potential solutions to these ACCHS governance challenges, based on proposals and strategies already implemented by interviewees and their organisations. These possible solutions were: creating skill-based positions on ACCHS boards; investing in governance training for board members; employing additional staff to assist with corporate governance responsibilities; and creating allocated youth positions on boards. The interview data examined in this section contains further evidence that governments are prioritising corporate governance models over Aboriginal

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Community Controlled governance. This highlights the ongoing tendency towards New Public Management and neoliberalisation in the administration of Indigenous Affairs policy.

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Chapter 8.

Follow the money: Aboriginal health funding, competitive contracting, and neoliberal austerity

So many people want to put their ladle in the bucket. – Caitlin

This chapter unpacks Aboriginal Community Controlled Health Service (ACCHS) representatives’ experiences and appraisals of government funding and reporting systems. It covers three main themes: ACCHS’ funding scarcity; increasing competition for Aboriginal health funding through open tendering; conflicting funding preferences for holistic and clinical healthcare. Based on the testimony of ACCHS representatives, it is clear that there is room for government funding bodies to re-assess their funding structures and reorganise them around ACCHS’ community-grounded and holistic approach to health.

Running an Aboriginal Medical Service “on a shoestring” This chapter relates interviewees’ accounts of the challenges that arise when running an ACCHS while relying on government funding. The majority of interviewees in this study believe strongly that their ACCHS are not allocated enough funding. When asked to identify “the biggest challenges” facing their organisations, the majority of interviewees gave a response that was directly related to the quantity and (in)stability of government funding, or the way in which it was allocated. Sam, a CEO based in an inner-regional area, encapsulates, in a similar way to many other interviewees, the impact of funding constraints on ACCHS:

The biggest challenge is maintaining our funding from federal and state governments and hoping to the Dear Lord that the Medicare system doesn’t change. Because the way it is [under current arrangements] probably 100% of the AMSs are being pushed into generating more Medicare income to subsidise their operating costs. And if Medicare was to end tomorrow, at least 50% of the AMSs would probably go down… or at least 50% of their programs would disappear. … They’d just be running on a shoestring. … Funding is the key element to ongoing services. (Sam)

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Similarly, for Tristan, the Aboriginal CEO of an ACCHS in a remote location, insufficient funding is a primary concern:

Obviously money’s our biggest problem – we don’t get enough of it. We really have to generate a lot of income to provide the services we’ve got. So it’s a big issue right across the board with employing people. And we can’t employ people long-term…everyone’s on a 12- month contract waiting for the funding agreement. Currently funding agreements [are] anything from two years to three years. If they were put out to five or eight years or something like that it would give a bit more security and we could probably do a lot more planning but definitely funding’s really low for what we do. (Tristan)

This CEO views the short-term nature of ACCHS funding agreements as an added impediment to effective service planning and workforce retention. Another CEO, Linda, argued, as did other interviewees, that the funding available from governments is insufficient to cover the wages of additional workers, minimising the utility of this funding:

The hardest part of the role is, whilst managing the expectations, trying to divvy up the small amount of funding that’s available. I call it bird food. And deciding whether it’s actually worth our while. … [S]ome of the funding out there is just small bits of money. It’s not [enough to fund] a position. It’s like [enough for] one day a week. How are you supposed to get someone in for one day a week? And so therefore you’ve got to decide well that’s actually not worth the tender writing that goes into that … so it’s making those decisions. (Linda)

Funding insecurity was a commonly articulated challenge amongst the interview cohort, with much of this insecurity being explained as the result of frequent policy changes, increasing competition for funding, and the entry of more non-Aboriginal service providers into the Aboriginal primary healthcare domain. ACCHS representatives’ accounts of the increasingly competitive and insecure nature of Aboriginal service funding are in keeping with previous research findings from scholars of Indigenous Affairs policymaking (Strakosch 2019, 117; Sullivan 2015; Howard-Wagner, Bargh & Altamirano-Jiménez 2018). In response to the question of what their organisations needed to be at their most effective, the most common response was, in essence, “more funding”. Some interviewees said what their organisations most needed is more staff, more access to specialist care and/or more

205 physical space in their clinics; all of which would require more financial resources or funding. Others stated that their ACCHS’ top priority was consistent or guaranteed funding. Together, these interviewees, all of whom said their organisations needs more - or at least, more stable - funding, made up the majority of the interview cohort. Concerns about funding levels, and about funding insecurity are thus clearly dominant among this cohort of interviewees.

Open tenders and contestable contracts: “everyone and their dog competing for the dollars” Virtually everyone in the interview cohort said the competitive nature of government funding processes is a pressing challenge for ACCHS. Many interviewees linked this competitive tendering or contestable contracting to the Federal Coalition government’s Indigenous Advancement Strategy (IAS) and/or the Primary Health Networks (PHNs), as this excerpt exemplifies:

Well the government doesn’t even know what they’re doing themselves, so. You know, [they’re] up in arms, their funding guidelines change. … they make it harder for ACCHS because they set up other little groups that’s very competitive, … like Primary Health Networks, PHNs … And like, even Prime Minister and Cabinet with their funds they opened it up, that’s that IAS funding … people had to tender for it. … it made it harder, and you have to get a professional person that knows how to do good tender writing to win the money. So they made it very competitive. (Dominique)

Similarly:

You get everyone and their dog competing for the [Aboriginal] dollars to get the resources and the funding. … Yeah I’d say in the last seven years or so … that’s the way the government is rolling, started those kind of programs like … the [Indigenous] Advancement Strategy policy. (Charlotte)

These two excerpts, both taken from interviews with the Aboriginal CEOs of outer-regional ACCHS, and the many others like them from rest of the interview cohort draw attention to instability of Indigenous Affairs funding arrangements. They also highlight how the creation of PHNs and the introduction of the IAS have produced a number of practical challenges for ACCHS, who now have to complete complex funding applications to win funding and

206 compete with new non-Indigenous players in the Indigenous health service delivery space, as discussed in Chapter 4.

Struggling with the increase in competitive tendering Many interviewees strongly believed that competitive funding processes are more common now than in the past. The below excerpt is from an interview with the CEO, Medical Director, and Quality Manager at a large inner-regional ACCHS. It conveys a deep sense of unease at the increasing use of competitive tendering to distribute Aboriginal health funding, which echoes the sentiments of a number of other ACCHS representatives in the interview cohort:

Me: I was going to ask is about this, what I perceive to be increasing use of competitive tender processes for funding. Is that something that seems to be becoming more common?

Jess [Medical Director]: It’s certainly more common and it’s a threat.

Shirley [Quality Manager]: It’s a huge risk.

Stephen [CEO]: It’s probably the biggest threat in the next five years.

Jess: Yep.

Me: Why do you perceive it to be such a threat?

Stephen: Because every new program in Indigenous health and Indigenous primary health care is being done through competitive tender, and generally through the PHNs. They’re the vehicle for it. And I mean we’re a large, well-staffed, well-skilled service [and] even we find it a struggle to pull together the staff to be able to do the tender…

Similarly:

Being able to compete with new funding streams is our biggest concern. And if new funding streams are going to eventually erode primary healthcare dollars then we won’t have a hope in hell of competing. We don’t have the skills within Aboriginal services to be advocating for and completing complex new proposals. We write applications all the time, very few of them are competitive, just because of, number one, time; number two, we don’t have the specific grant-writing people in an organisation this size. (Tim)

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The new funding streams to which this interviewee referred are those that emerged from the creation of the IAS and PHNs. The above excerpts, and the numerous others like them in the interview data, underscore how the Commonwealth’s competitive tendering models threaten ACCHS’ financial stability, primarily because of ACCHS’ limited time and staffing.

“Sucking the blood off Aboriginal programs”: new mainstream competitors in the Aboriginal service-delivery market Chapter 4 detailed the Coalition government’s introduction of open competitive tendering for Indigenous health funding under the IAS and the PHNs. The implementation of these New Public Management (NPM) policies has exposed the ACCHS sector to competition from non-Aboriginal organisations, with many interviewees characterising these policy developments very negatively. One Aboriginal CEO, in keeping with the views of many others, stated that the IAS had created a situation where “the big church groups and … other big [non-Aboriginal] organisations … are jumping in on Black money” (Gwen), referring to Aboriginal-designated funding. Another similarly-critical Aboriginal CEO described the impact the IAS has had on the Indigenous health space: “It opened it up for a lot of Whitefella organisations, basically, and the bigger ones that have all the resources to do all the fancy writing to grab hold of the dollars.” (Charlotte). Roger, the Aboriginal CEO of an urban-based ACCHS, emphasised the inexperience of the mainstream providers who are now receiving funding to deliver Aboriginal-specific services:

They don’t even know what they’re doing. They have enough work to do in the charity area so [why]’re they sucking the blood off Aboriginal programs, where [we’re] doing a lot of good…? (Roger)

Many other interviewees maintained, as does NACCHO (2019) and other Aboriginal Community Controlled organisations (ATSIPO 2016) that ACCHS should be the government’s preferred providers of health and wellbeing services to Aboriginal and Torres Strait Islander communities. These ACCHS representatives believe their organisations should not be required to compete with mainstream organisations for the funding to deliver Aboriginal health services, and that the superiority of their experience and skills should be recognised by the Commonwealth.

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Grant funding, such as that available under the IAS, is not the only financial area where Aboriginal organisations are coming up against stiff competition from mainstream organisations. Several interviewees gave detailed instances of loopholes in the Medicare funding system where mainstream health providers claim Aboriginal-specific items from the Medicare Benefits Schedule (MBS). As the proportion of overall revenue that ACCHS receive in grant-form diminishes, they are increasingly reliant on Medicare revenue, and in particular on Aboriginal-specific Medicare items. Interviewees claim that some tributaries of this Medicare revenue stream are being diverted by “mainstream providers … trying to cash in”, to use Rosemary’s expression. The most commonly cited and controversial loophole relates to Item 715 on the MBS, the Aboriginal and Torres Strait Islander Peoples Health Assessment, which generates a $212.25 fee per service. Medicare will only pay one health service to perform this health check, and only once every nine months. Hence, some ACCHS justifiable annoyance when Aboriginal clients:

… don’t even know that they’ve had one done. We ask them if they’ve had a health assessment elsewhere, they go ‘No, no, no’, so then we do it and then it gets rejected by Medicare because it has been claimed elsewhere. (Amy)

The MBS defines the 715 health check as an “assessment of a patient's health and physical, psychological and social function and consideration of whether preventive health care and education should be offered to the patient, to improve that patient's health and physical, psychological and social function” (DoH n.d. b, para 15).

ACCHS representatives’ main cause for concern stems from their experience and knowledge of mainstream practitioners “doing that 715 health check, getting that money for that, but they’re not doing the follow up”, as Gwen states. Some interviewees also claimed that not only were mainstream services not providing the required follow up care, but they were referring clients to the local ACCHS for that care. For example:

‘Oh [the AMS’s] got a dietician, you should go and see them, and [the AMS’s] got a podiatrist, they’ve got a mental health team’. And they refer [the client] to us. But they’ve done the health check. … They’ve got the Medicare money and we’re meant to deliver the follow up care for nothing. (Rosemary)

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Interviewees explained that this follow-up care could involve secondary care, preventative healthcare guidance and health education, which they described as crucial to the effectiveness of the 715 health assessment. As Peter put it: “it’s actually the effectiveness of the assessment and how they wrap the care around in the subsequent nine months or 12 months that’s more critical”. As Chapter 5 outlined, many ACCHS can provide internal referral pathways for their clients, simplifying follow-up care. The MBS briefly explains the follow-up measures that 715 health assessments must include as: “making or arranging any necessary interventions and referrals and documenting a simple strategy for the good health of the patient”. The fact that these interventions and referrals are so vaguely defined on the MBS could be one reason why mainstream GPs are able to claim the full rebate for performing health checks, even if they deliver minimal subsequent care to the patient. An additional complicating factor could be that the MBS suggests doctors prescribe “a simple strategy” for good health. Reflecting on the complex and multi-layered causes of Aboriginal illness that interviewees explained, as presented in Chapter 6, I would argue that this call for a simple strategy for good health is dangerously insufficient. This MBS item ought to be revised to reflect the complexity of the work required to make these Aboriginal health assessments an effective strategy for improving Aboriginal health, rather than a revenue generating exercise for service providers.

One policy reform suggested by Peter, an urban-based ACCHS manager, was to have a two- tiered payment system for the 715 check. He explained that this two-tiered Medicare rebate would involve the government assessing services on their ability to deliver adequate follow up care and “if [the] AMS can demonstrate that they [sic] provide access to Aboriginal health workers and teams and other community events and activities” then it would receive an additional payment for the provision of this additional care, on top of the payment for providing the original health assessment. This is one strategy that the Commonwealth could explore to incentivise the provision follow-up care after a health assessment.

A minority of other interviewees described mainstream providers routinely gaming the Medicare system, writing GP management plans (item 721) for Aboriginal clients with chronic disease but patently failing to resolve the underlying issues. They also described mainstream providers approaching Aboriginal patients to get them to register with their

210 service for chronic disease management. These registrations attract a $250 payment to the service for each Aboriginal client registered. This falls under the Practice Incentives Program, which is another funding area that ACCHS representatives highlighted as being a target for mainstream providers. An ACCHS CEO in an inner-regional area explained that: “some practices, and one in particular here, are aggressive at trying to get people to sign up for the Aboriginal PIP [Practice Incentive Program] … so they can get that payment” (Stephen). For mainstream health services, according to some interviewees, “it’s all about money! So they will give somebody a ring … and say ‘Oh you need to come in for your health assessment’. They don’t even do them properly but they claim the funding” (Amy). One ACCHS manager suggested that to prevent mainstream services from exploiting these Aboriginal-specific Medicare items for financial gain, “there needs to be more audits around mainstream practices [using them] as a revenue source” (Peter). This alludes to an accountability deficit in the mainstream health sector, quite the opposite of the accountability overburden experienced by the ACCHS sector, which is explored in Chapter 9.

One ACCHS manager, expressing a similar sentiment to many other interviewees, perceived a fundamental difference between the motivations of staff working in ACCHS compared to mainstream general practice:

I’ve had the opportunity to work with General Practice and at the AMS, and it is all about that care and those networks with the AMS. I remember one time I went out to a General Practice because it was my role to go out there and promote the program and try and get them on board. I had a meeting with a practice manager and their comment to me was “every person that walks in that door is money” and that’s how they see people. Every person that walks in our door is supported. It’s not about the money, it’s about the health and the care of that person. (Claire)

Many interviewees argued that ACCHS operate according to a different health philosophy to other actors in the health system. This philosophical difference is even more pronounced when ACCHS are compared to mainstream general practices, which are privately operated for-profit businesses. These differences between ACCHS and other mainstream GPs in terms of motivations and priorities could explain why ACCHS managers perceive mainstream

211 service providers to be gaming the Medicare system, at the expense of Aboriginal patients and services, in order to secure financial gain.

Accountability deficits, mainstream health providers and Aboriginal health outcomes At some locations, interviewees reported that their ACCHS and local mainstream providers were delivering comparable Aboriginal-health services, aiming to achieve similar outcomes and reach similar segments of the population. One such example was the Aboriginal Maternal and Infant Health Service (AMIHS) funded by NSW Health and usually delivered out of Community Health Services under the remit of LHDs. Interviewees from one inner- regional ACCHS claimed their child and maternal health team delivered a service similar to the AMIHS offered by the mainstream provider. However, these interviewees claimed that the ACCHS’ service reached greater numbers of Aboriginal people than the AMIHS. The non- Aboriginal CEO Tim explains:

We are delivering a parallel program here that’s [funded] by the Commonwealth Government that delivers exactly the same measurable targets to twice as many mums and bubs because it’s an inclusive program with a social and emotional wellbeing program that incorporates all of the other needs of those mums and bubs. So, we can have wrap-around services around those mums and children that make that a very unique and personal experience for them, as opposed to going through a Community Health Centre that has minimal wrap around services, minimal Aboriginal health workers in that environment. (Tim)

Tim notes that it is his ACCHS’ personalised and holistic care that differentiates it from the mainstream service, attracting higher numbers of Aboriginal mothers to the program. Dane, the practice manager at the same ACCHS as Tim, also commented, in a separate interview, on the duplication between mainstream and ACCHS-delivered maternal and infant health services. However, he emphasised the funding inequity that accompanies the different levels of client engagement between the ACCHS and the mainstream service:

Under the IAHP funding is the funding for our maternal health strategy. Now we service between 40 and 50 women a year, pregnant women. You have the Aboriginal Infant Maternal Strategy, which is the AMIHS program, who gets the same amount of funding as us … So that’s where it’s disproportionate in that, you know, we’re servicing 50-odd clients,

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between 40 and 50. They [mainstream service providers] might service 20-25 on the same amount of funding. … It’s just the way that it is. … And …for them the push is to get more clients because that’s their base funding; their funding can only go up from there. Whereas ours, regardless of the client intake we have, our funding is stagnant, it stays the same. (Dane)

Dane, in highlighting his organisation’s inability to earn more money through doing more work, concludes that the different funding models in operation in the state government- funded health services compared to the ACCHS are inequitable. Because this ACCHS’ maternal and infant health service is funded through grants under the Commonwealth’s IAHP, not under activity-based funding through NSW Health, it will not automatically earn any more money when it services more clients. The ACCHS could apply for increased grant funding in the subsequent funding round or financial year, but there would be no guarantee that the Commonwealth government would grant an increase.

Tim made a case for closer engagement between ACCHS and NSW health, highlighting the role of monitoring and accountability for achieving closer engagement:

I think we all need to stand on good outcomes and what’s best for a client, and that needs to be how these kinds of programs are evaluated, as opposed to whatever historically has gone before. If [mainstream] staff need to get on and partner and work with the Aboriginal sector, they need to be performance managed to do so. (Tim)

Another CEO from an ACCHS located in the same Local Health District (LHD) as the ACCHS referenced above, and which also receives Commonwealth funding for maternal and infant health services, commented on the lack of engagement between her service and the mainstream organisation delivering AMIHS:

Lizzie: We don’t have an AMIHS here [at the ACCHS] but we have a New Directions [Mothers and Babies Service]. The AMIHS is under [the LHD].

Me: Yeah other CEOs were telling me about this [AMIHS] program too. So do you think it’s a complementary program or do you think it’s overlap?

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Lizzie: Doesn’t do anything for us. And it’s around the partnership, there’s no partnership there.

This point, while not directly related to accountability or funding, highlights how some ACCHS and mainstream health providers are concurrently delivering very similar, potentially overlapping programs, but working in isolation from each other because of strained relations between the Aboriginal and mainstream services. ACCHS CEOs and managers working in this region of NSW heavily criticised the LHD referred to above for its lack of engagement with Aboriginal organisations, and its disrespectful treatment of Aboriginal people.

ACCHS representatives not only raised concerns about the performance and accountability of Aboriginal programs run by LHDs but also about Aboriginal programs run by mainstream non-government organisations (NGOs). Several interviewees gave examples of mainstream organisations receiving funding to deliver Aboriginal-specific services but then attracting very low client numbers. In relation to funding under the IAS, an ACCHS CEO raised concerns about a non-Aboriginal organisation which may not be delivering the Aboriginal-specific services for which it receives funding:

Amy: For the youth mentor [program] we got $110,000 … only for 18 months. …I got a phone call the other day from the PM&C saying that the youth mentor [program] is not going to be [refunded]… that’s it. Canned.

Me: Any reasoning?

Amy: Well I had heard on the grapevine that the reasoning behind it was because inadvertently, they’d funded three youth services in our area. And the other two are two big organisations. We service over 95% of the Aboriginal population in [our town]. And my response back to him was ‘Well you tell me why we are losing our funding when we service all the Aboriginal people. And we know that they’re not accessing those services and you’re going to give it to non-Aboriginal organisations.’

Me: And what did they say to that?

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Amy: ‘I’ll get back to you’. But I haven’t received anything in writing yet. I said ‘I’m not happy’.

Later in the interview, when trying to make sense of this seemingly irrational decision, Amy identified the funding distortions created by competitive tendering and activity reporting:

I’m just thinking about this youth services money, that’s on my goat at the moment, because I know one of the ones [funded services], you know, the doors are hardly ever open and they’re not servicing Aboriginal people anyway. But they’re still going to get the funding because they know how to report and write a fancy story. (Amy)

Amy concludes that large mainstream organisations’ ability to write acceptable reports is what guarantees these organisations ongoing funding, giving them a competitive edge over the smaller, under-resourced ACCHS. In her eyes, the quality or even the quantity of services is not being measured adequately by the PHN and the Commonwealth government.

Other ACCHS representatives stated that Aboriginal-specific services offered by mainstream organisations had very low visibility in the local Aboriginal community. For example, Gwen, the Aboriginal CEO of an outer-regional ACCHS argued that both the Commonwealth and NSW governments should reassess their decisions to fund mainstream service providers to deliver Aboriginal-specific services because of performance concerns:

If they’re going to be pouring out money, is the intereach-ers and the Uniting Church and all those groups actually achieving the results? … I went to a meeting not long ago with the Rural Doctors Network and we got a list of all these programs that have been rolled out through the Primary Health Network across the region – half of those programs we’ve never heard of! And yet they’ve been funded for a couple of years. They’re Aboriginal specific programs. … [RDN said] ‘Oh yeah they’re run out of the mainstream medical practice’. How many [Aboriginal] people know about them? And they’re wondering why they’re getting very low numbers attending. I said ‘We didn’t even know about it’ [the services]. (Gwen)

It is abundantly clear that if this Aboriginal CEO, who has been in this role for over 16 years, did not recognise the names of many of the Aboriginal-specific programs and services that mainstream services were offering in her region, then very few local Aboriginal and Torres Strait Islander people would recognise these services either, much less make use of them.

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The inaccessibility and inappropriateness of mainstream health services for Aboriginal clients is a well-recognised health policy challenge (DoH 2017a, 23-4; Osborne et al. 2013, 44; Scrimgeour and Scrimgeour 2008). There is also substantial evidence demonstrating that Aboriginal and Torres Strait Islander people, in general, prefer to seek healthcare at ACCHS (Campbell et al. 2017; Mackey et al. 2014; Panaretto et al. 2014). It is unclear how the Commonwealth Government’s recent policy decisions that direct Aboriginal health funding to mainstream organisations will overcome these inaccessibility issues. One ACCHS manager posed a question that summarises these accountability and accessibility:

If they think mainstream is best placed to do it, then they need to fund them and monitor them [to make sure] that they are actually servicing these clients… (Peter)

One form of monitoring suggested by an ACCHS CEO was for government agencies to cross- check the information submitted in funding applications with other information held by separate government agencies, who may also fund these organisations:

maybe doing a reference check with your other funding sources and seeing how [they] actually really do perform … just checking at a local level if they’re actually providing services. (Amy)

This CEO also suggested that funders should seek information from other service providers in the local area, particularly those that had been listed as references on funding applications:

Maybe it’s also about, you know, when you write a tender you’re meant to provide a referee. Nobody’s ever rung me to check. And I’ve been a referee on a lot of tenders for other organisations. No-one’s ever rung me and checked. So maybe it’s about following due process too. (Amy)

Other interviewees provided examples of competitive tendering processes resulting in Aboriginal-specific health funding being awarded to mainstream organisations who were ill- equipped to deliver the services they had promised. This is perhaps the most glaring example of a mainstream organisation winning a tender without having the necessary resources in place to service the local Aboriginal community:

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I applied for the mental health one. We didn’t get that but who got it? [A local NGO] got it. Well then we got a letter from [that NGO] the other day saying that they didn’t have enough counsellors to provide support for the program. Why give the money to someone that doesn’t have the infrastructure to support it? (Annette)

The funding process to which this ACCHS manager is referring was administered by the regional PHN. Unsurprisingly, this ACCHS representative believes the PHN should have properly investigated this mainstream NGO’s capacity, particularly in relation to staffing, to provide mental health services to the local Aboriginal community before the funding was approved.

Together, these interview responses sketch a picture of inefficient and even irresponsible government funding systems. ACCHS representatives provide accounts of government agencies distributing Aboriginal-health-and-wellbeing funding to mainstream organisations that deliver fewer services than ACCHS on the same level of funding. Some ACCHS representatives claim that mainstream organisations are under-performing and that government continues to fund them because they are able to evade scrutiny under government’s insufficient monitoring and accountability processes (as noted by the ANAO 2019). Other interviewees allege that governments place too much store in activity reports and funding acquittals, rather than seeking information from somewhat more independent sources of evaluation, such as other service providers or funders. These testimonies are strongly indicative of – at least – poor communication and animosity between many ACCHS and their mainstream counterparts. One ACCHS manager, Kate, even stated that “when it comes to patients that we take … to the hospital, they’re [hospital staff] often probably threatened at our presence”. One suggested strategy for creating more effective partnerships and effective communication between ACCHS and mainstream health services, as outlined by Tim, a non-Aboriginal ACCHS CEO, is “dual accountability”:

[We need] dual accountability through contracts – not MOUs – that hold each other to account for specific KPIs around engagement, respectful communication, and how to work with Aboriginal people. … [A]n MOU around a partnership is useless unless there is dual accountability holding each partner to account for what is agreed to. That, I believe, needs to be contractual. (Tim)

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This policy recommendation rests on the assumption that mainstream and ACCHS are fundamentally guided by their funding agreements or contracts. Funding is the main bargaining chip that governments wield to influence public and non-profit organisations; without these resources many of these organisations would not survive. Another ACCHS CEO advanced a similar idea when puzzling over what would happen if she approached the director of Aboriginal Health with an ad-hoc partnership proposal:

I could ring her up and say ‘We’re doing some great work around this’, but would she be interested?’ [The answer would be] probably not, because that’s not what she has to report on or what she’s accountable for or responsible for. And if I was sitting in her seat, I’d probably just be accountable to what I’ve got to report on and what I’m being measured against. (Rosemary)

This CEO’s statement implies that mainstream health services, in this case LHDs, offer the kinds of Aboriginal-specific services that their reporting obligations and performance measurement frameworks most value, rather than the services of most benefit to their Aboriginal clients. In essence, she believes that mainstream services are not accountable to Aboriginal communities for their performance in Aboriginal health; rather, they are accountable to governments. But the ACCHS sector is beholden to Aboriginal-specific forms of accountability, as discussed in previous chapters, because of its formal and informal ties to local Aboriginal people. As the Aboriginal CEO quoted in the above paragraph states, referring again to the motivations of the LHD’s director of Aboriginal Health: “My interest is: we’ve got a problem, we want to fix it. Community want something done. I have to do it. What would her interest be?” (Rosemary). ‘To satisfy government, first and foremost,’ is the clear implication contained in her rhetorical question.

The information presented in this section of the chapter indicates that there is great scope for Aboriginal-specific forms of accountability to be introduced to mainstream health services’ contracts and performance monitoring frameworks.

Grappling with “over the top” tender applications The following excerpts encapsulate some of the practical and financial difficulties that competitive tendering presents for grassroots Aboriginal organisations. Many interviewees stated that writing complex funding applications is a central challenge presented by

218 competitive tendering. One interviewee commented on the complexity of the tenders administered by the PHN in the Hunter, New England and Central Coast region:

They put out these tenders, as I said I’m a very experienced tender writer, [but] I have never in my whole life seen a tender as complicated, as difficult, so much so that we decided not to do half of them because they were just so over the top. (Amy)

The Operations Manager from a separate ACCHS under the jurisdiction of the same PHN expressed a similar concern:

… The actual application process through Tenderlink was extensive, exhaustive, repetitive, unnecessary. I’ve done funding submissions for NGOs before and it [the PHN process] was just … it was not a positive experience, writing and repeating [yourself]. (Peter)

Another CEO, from a small ACCHS in a small outer-regional country town, expressed a similar level of exasperation but in relation to the IAS funding application process:

… [W]e didn’t apply for anything from them because have you seen their application? You’ve got to have a PhD to [be able to] put it in. When you’re a small organisation, small community, we’re time limited, you’re limited [in your] resourcing and stuff like that, to actually fill in and justify your existence to that program is just ridiculous. (Charlotte)

These excerpts indicate that the difficulties associated with completing tender applications are not due to the inexperience or incompetence of ACCHS staff, many of whom have had long careers in service delivery and extensive experience writing tenders. These ACCHS representatives imply that the cause of the problem lies with the unreasonable expectations and requirements set out by the Commonwealth government and PHNs. The fact that these ACCHS representatives also find these key funding processes in the Aboriginal health sector more challenging than the funding processes that operate in mainstream service-delivery contexts alludes to an institutional racism that leads funding bodies to more heavily scrutinise Aboriginal organisations.

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Inequitable processes “making the strong stronger and sometimes the weak stay weak” Many interviewees believed the complexity of competitive tendering produces inequitable funding outcomes for smaller organisations. A number of interviewees lamented that their organisations are not well-equipped to prepare competitive funding applications because they do not have the same level of tender-writing experience on staff as other large non- Aboriginal NGOs. Even the CEO from one of the larger ACCHS in the interview cohort explained how his service had contracted a professional grant writer to complete its IAS funding application:

Harry: That was an issue. The amount of money it took, like we got a consultant in to do our funding applications.

Me: Oh, to do your tender applications?

Harry: Yeah because the sort of information that they were asking for was critical. The services were critical and we didn’t want to lose the opportunity, so we put investment into ensuring that we had the best opportunity to get that funding through. But other organisations wouldn’t have been able to do that.

Me: How much did those consultant fees cost?

Harry: I can’t remember now, I think it was around 25-30 [thousand dollars] something like that. … So when you think about it we had to pay more money to get the same services that we had in the first place. … So how cost effective is that? You know we wasted 20-30 thousand, whatever it cost us, I can’t remember, we wasted that amount of money to get exactly the same [funding] as what we had.

Relatedly, the following quote captures the sense of exasperation expressed by a number of interviewees relating to the indiscriminate nature and inequitable outcomes of PHN and IAS funding processes:

… the [PHN funding application] process just seems to be allowing anyone to go into it without really much thought as to why they want to run a process like that. … And large NGOs have capacity, they’ve got HR departments and finance departments, and they’ve got

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tender writers. So they’re making the strong stronger and sometimes the weak stay weak. … The process is not empowering, it can go the other way. (Peter)

Another interviewee highlighted how his organisation needed to take staff away from their usual roles in order to complete competitive tender applications:

And look we’ve done really well with them, we’ve got some really good tender writers on staff but you’ve got to take people out of their job for three weeks to do it. And these are people who are writing one or two tenders a year, not writing one or two tenders a week. (Stephen)

A number of ACCHS CEOs argued that the competitive tendering process did not focus on the results that service provider organisations had already achieved. As this urban-based CEO alleges:

We got funding [from the IAS] but that was a – it’s like the PHN stuff – it was a strategy that put us back 20 years I reckon, where the best submission writers got money. … we didn’t get what we asked for but we got some funding for our preschool and some for Social and Emotional Wellbeing, so we were happy we got some funding. But the whole process was poor, very poor. And, again, it was just submission-based. So they didn’t look at any of our previous activity and say ‘You guys have got capacity to do this, you’ve got this catchment’ – there was none of that. It’s the same as the PHN stuff, … they didn’t come and talk to us and say ‘How many patients you got? What’s your occasions of service like? What’s your health outcomes data like?’ None of that, so they don’t know what we could do, what we could deliver. (Rosemary)

These excerpts show how ACCHS in NSW have had to devote significant time and resources to the IAS and PHN funding application processes. This extra effort, though, does not appear to have produced any additional funding for many ACCHS.

Organisational “stress” in an uncertain and fast-paced funding environment Some ACCHS representatives commented on the difficulties created by the short timeframes offered to organisations applying for funding through both the PHNs and the IAS. This is an issue that has been previously noted in the Senate inquiry into the IAS and the

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ANAO audit of the same policy (Senate FPARC 2016; ANAO 2017) As the operations manager from an urban-based service stated:

We were concerned at the pace of the funding application, that we only had three weeks from when the EOIs [expressions of interest] came out to when they were due in. So I think that in itself shows a real haste in the way they’re doing things, and we need more time to talk to our partners around delivering on what’s required and what’s targeted. We need time to review data... (Peter)

One Aboriginal CEO in an urban-based ACCHS believed his organisation lost funding for its smoking cessation program because of challenges that arose when writing funding applications under time pressure:

Like, we had a good smoking program. We lost that. We were doing some good stuff, people giving up smoking. But we lost it, mainly because they said that the application wasn’t done properly. But it was a rush, you know, but they don’t understand. We had it for three years, we did some good stuff, … we were probably doing the best, one of the best ones right across the country. We were told that. And you [would have] thought they would’ve said: ‘Look, something must be wrong here’. Well then you’re talking about bureaucrats now, assessing those things. Well if they were smart and had any compassion about Aboriginal health they would’ve thought: ‘Well there must be something wrong’, you know, ‘They’re supposed to be going good, … they have done a lot of good, so we should talk to them a little bit more and find out’. Because [the application] was something that we had to have done, we didn’t deal with – it was just done wrong at the wrong time. A lot of things was (sic) happening at that time. (Roger)

These interview responses show how funding applications can be overlooked or de- prioritised when organisations are busy dealing with more pressing concerns – with serious consequences for some organisations’ future funding and the continuation of successful health programs.

Other interviewees emphasised the “stress” surrounding the uncertainty of IAS funding:

… it was a bit of a stressful time because we had to potentially [lay off] staff, staff that had been with us for six of seven years! ‘You may not have a job when this all comes out’. We

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were lucky. We got it. But we have to run again because two of our programs run out June 2018. And we don’t know if we’re going to have drug and alcohol program, TIS [Tackling Indigenous Smoking] program. It’s that uncertainty. (Gwen)

Similarly, in an interview conducted on 13 February 2018, Harry lamented:

… have I had word from the Prime Minister and Cabinet about the [IAS] funding that expires in June? No. I haven’t. So it creates more stress. (Harry)

And another example:

Adam: [the IAS] wasn’t introduced well, communicated well. There was a lot of hystericals, you know, around… worry.

Me: But it wasn’t, in your mind, it wasn’t such a massive change, it was just a new process?

Adam: No, it was at the time. Bloody oath! We had the whole Social and Emotional Wellbeing [team’s] wages were on the line there. So … if we were one of the ones that didn’t get funded, there’s my team [gone].

The instability produced by the Commonwealth’s introduction of competitive funding processes under the IAS, as these interview responses exemplify, created substantial worry and trepidation amongst ACCHS workers in NSW. These examples also show that interviewees had good reason to be stressed, given the loss of funding for successful programs and the subsequent termination of ACCHS staff. Thus, the funding instability produced by the Commonwealth’s Indigenous Affairs funding overhaul has created insecurity, with health implications for the ACCHS clients who lose access to services, and the ACCHS workers who lose their jobs.

“Political football”: adjusting to new rules, responding to new requirements Some ACCHS CEOs said frequent changes to funding and reporting structures were a major challenge for their organisations. These interview responses illuminate how some ACCHS sector managers experience a sense of precariousness about their organisations’ future. The key areas of change highlighted were in ACCHS-sector Key Performance Indicators and funding-allocation methodologies:

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So some of the funding has been changed … in the state [government] level they’ve changed where they may have decreased funding but increased KPIs in terms of what we report on. An example of that is they’ve taken sexual health funding from the AMSs, Okay? So they give us other money from other programs so we [now] have to report on different things… (Lizzie)

She continues:

Lizzie: … another concern that we have is the penalties via our funding that we will receive or we won’t receive if we don’t meet KPIs. That’s not been done before and we’re not sure what the philosophy is.

Me: So this is something that will come into effect soon?

Lizzie: Yes, from Commonwealth level…

Another Aboriginal CEO, from an outer regional ACCHS, expressed a similar idea but more strongly emphasised the feeling of uncertainty that policy changes created:

… it’s always a worry when you work in Aboriginal affairs, don’t matter if it’s health or wherever. They use us like a football and they can just, you know, stroke of a pen. We could be gone tomorrow. So we’re always working in that environment, first up. (Charlotte)

The following statement encapsulates the sense of frustration that a number of interviewees expressed over what they perceived to be unnecessary policy changes:

I find it really frustrating that there’s people there who want to reinvent the wheel. How about we pay for the wheel? How about we put some services in? … I get outside oncologists funded one-day-a-week under Rural Doctors [Network]. I could fill every day for her, every day! And yet they want innovation. How about we just put services in and try and get something happening. (Linda)

Overall, the evidence presented above paints a picture of ACCHS existing in an extremely unstable financial and policy environment. Interviewees’ responses also convey a deep sense of exasperation, produced by the disproportionate power of the Commonwealth government and its intermediaries the PHNs. The above excerpts demonstrate that ACCHS

224 in NSW are forced to respond rapidly to top-down political pronouncements and policy changes, because of their dependence of government funding. The stress created by this funding instability, and the time required to learn new processes and respond to new requirements, impacts upon ACCHS and diverts some of their attention away from delivering health services to First Nations peoples.

Medicare machines: maximising revenue to compensate for funding shortfalls An earlier section of this chapter presented data that illuminated how ACCHS are orienting their services towards a more business-like approach. Many ACCHS representatives explained that their services were trying to maximise Medicare revenue, with some also explaining that this strategy was a way of lessening their organisations’ dependence on government grant funding. In order to secure more Medicare revenue, some interviewees explained, certain ACCHS are trying to align their services with the financial incentives of the MBS. These interviewees also explained how their ACCHS reinvested additional Medicare revenue into the under-funded aspects of their service. For example:

… when we lose a program we have to figure out how we keep that program going, and generally that’s through our Medicare revenue. That’s what we use that [revenue] for, to pay for programs that we don’t get funded for. [But we provide it anyway] because it’s a community need. (Lizzie)

Similarly:

… we just signed off on two Youth Development Officers – from our Medicare funds – for a pilot of 12 months, because you can’t go past what you’re going to generate in Medicare in the next year. So we’ll fund those positions from our Medicare [revenue] because that’s what the community wants … I think we get 70 grand from Family and Community Services for a youth position. It’s not even enough to put anyone one who’s got any skills to do anything, you know. … It’s crap. When you take your on-costs out of it there’s nothing left. So we’ll fund that and … they’ll have a great impact on access to our services for youth … (Rosemary)

Sam’s statement summarises the overall situation:

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Well there are AMSs that feel that they’ve been pushed by government into becoming a Medicare machine to generate income and some of those AMSs have allowed other people in the general community to come into their Medical Services so they can generate Medicare. They’ve been squeezed and pushed into that environment because ultimately in an AMS, doctors generally tell me that they’ve got to have long consultations with individuals because they don’t just come there with one illness they come there with multiple illnesses. They say if they give a short consultation and they’re only treating one illness, that doesn’t do the patient justice. (Sam)

One ACCHS has even employed a Medicare officer to ensure that GPs are claiming the total amount of Medicare revenue they are entitled to. According to Charlie, the CEO of this ACCHS, the Medicare officer “pays for herself” through the revenue she generates through auditing Medicare claims and receipts. The above interview responses, and others like them from the rest of the cohort, show how Medicare revenue is becoming an increasingly valuable income stream for ACCHS who are seeing their grant funding diminish or be destabilised.

Diversifying income streams to mitigate financial risk Regarding the issue of financial risk in the ACCHS sector, a minority of ACCHS CEOs stated that their services had adopted a strategy of income stream diversification in response to the possibility that they might lose some of their government funding. For example:

… when I first started here the budget was 750,000 dollars and that was it. And that was to run the service. That was Commonwealth money. And … over time we’ve increased it to diversify the income streams that are coming in, which means … if one of those funding streams fell apart and we weren’t re-funded, there are other opportunities… It’s a risk environment but because we’ve diversified, we’ve not put all our eggs in one basket. We’re looking at how to ensure the service continues even though we might lose a funding source from time to time. (Harry)

He continues,

Because there’s such a period of change that’s occurring around structure and funding and guidelines and Medicare, I think what we need to do is work out … how we can future proof the organisation. Because if things get tougher and you don’t do that then I think there’s a

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difficulty. I don’t think you can rely on government bodies to make some of those decisions, you’ve got to do that for yourself. (Harry)

This interviewee, and other ACCHS representatives who made similar comments, highlights the agency that some ACCHS exercise, even in the face of an uncertain future of government funding for Aboriginal health.

“The burden of reporting” Previous scholarship has identified and critiqued the burdensome activity-reporting and accountability requirements that apply to the ACCHS sector (Dwyer et al. 2009; Sullivan 2011; Moran et al. 2016). Some of the interview responses in this study indicate that reporting requirements remain a major challenge for ACCHS. Just over one third of the interview cohort characterised their organisations’ reporting regime as burdensome or unreasonable. For example:

The burden of reporting, I think, is huge and there’s not much that we can do about that apart from advocate that it is a problem for us. Because you’ve got to report to so many funding bodies and they’ve all got their own way of doing it. They – like you said, do we have a definition of health? Well every occasion of service has a different definition depending on how you see the world. (Harry)

Similarly:

I do a lot of reporting, … massive amount. I probably write … between 14 and 16 reports a year … so at least once a month I’m doing a report. … I’m in the middle of three reports at the moment. It’s end of financial year, and then I think we’ve got another three in the holding pattern waiting to be pulled together. (Linda)

Or in another’s words:

And reporting: you’ve got to do your OSR [online services report], you’ve got to do your nKPI [national Key Performance Indicators] report. There’s a whole range of reports that we have to do … and our budgets have to go in with that and then we have to have our audits done to prove that we’ve spent the money where we said we’ve spent it. We’re the most reported (haha) you know? We get more tied up with reporting. That’s what I should have

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wrote [sic] down [about] how I spend my day, is just making sure everything’s up to scratch so that our reports are right [and] on track. (Amy)

The quantity and complexity of reporting requirements was identified as a key issue by many interviewees. As one outer-regional ACCHS CEO stated: “You almost need a full-time position funded just to do the reporting” (Natalie). Indeed, this has become a reality for at least one ACCHS, which now employs a full-time business manager to oversee the organisation’s reporting and compliance obligations.

“[N]umbers … not narratives”: the quantitative nature and clinical focus of reporting structures Around one quarter of the interviewees posited that government- and/or PHN-mandated reporting did not capture the most important elements of ACCHS’ work. One inner-regional ACCHS CEO was critical of what he perceived to be a reporting bias that favoured quantitative over qualitative measures of ACCHS output:

… reporting structures and all of that sort of stuff are very driven to …[for example] the number of people you’ve done Aboriginal health checks on, not the outcome, not how you’ve done them, not how long it’s taken to do them or how difficult it’s been to get them in, just how many. (Harry)

This same CEO characterised the content of mandatory reports to government funding bodies as: “They’re numbers, they’re not narratives”.

Some other interviewees said that reporting structures produced only a partial picture of what ACCHS were doing. In reference to the information available in reports to government funding bodies, one urban-based CEO stated, in keeping with the comments of a number of other interviewees, that:

It’s [based on] what they extract from your systems and that’s how you’re judged. As a service that’s how you’re judged, on your clinical [services]… Mums and Bubs is a classic example. All they’d know about is birthweight recorded and immunisations. … They wouldn’t know about at-risk mums or the mum who we’re working with to get her kids back. That’s important stuff! They wouldn’t know about that. (Rosemary)

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A minority of ACCHS representatives contended that the reporting mechanisms lacked ‘community indicators’ or failed to ask questions that would elucidate the complex nature of ACCHS’ work. This was argued to be problematic because it would give government agencies a skewed understanding of Aboriginal health problems and the services ACCHS provide to address them. As this interviewee states:

I think a lot of our State and Commonwealth and PHN indicators don’t have any of those community indicators. If you actually have a look at the list of indicators that we have they’re all clinical indicators and they’re all process indicators. So a big issue is the lack of community indicators. … there’s not one indicator in there that takes into account the wellbeing framework. (Peter)

The CEO and Practice Manager of an outer-regional ACCHS expressed a similar idea, but in different terms. After listing some of the non-clinical services that the ACCHS delivers (such as shopping bus runs, help with driver’s licenses, and assistance with Centrelink) they concluded:

Natalie [CEO]: But see none of this is like – you don’t report on it with your nKPIs. You report on birthweights, smoking status, weight, height, diabetes, immunisations, drug and alcohol. You don’t [report] the rest of it. Like, if they knew what we actually did …

Amanda [Practice Manager]: They could understand why we’re so busy and why we have trouble trying to put the reporting in the right box.

The above comments illuminate some of the potential knowledge gaps in the government departments responsible for overseeing Aboriginal and Torres Strait Islander health services. These comments can also be interpreted as evidence of a clinical bias in government funding systems. If the focus of reporting structures is on instances of clinical care rather than health and wellbeing interactions in community-based settings, this seems to indicate that government funding bodies place a higher value on clinically oriented health services.

The cost of competition: losing health programs that “looked at the root cause” Interviewees’ commonly stated that there was not enough government funding directed towards health promotion, disease prevention and early intervention. Around one quarter

229 of the interview cohort said that more funding should be earmarked for services and programs designed to keep people healthy and prevent illness from happening in the first place. As this outer-regional ACCHS CEO explains:

… We need more money for health promotion and early detection, prevention, that sort of stuff, for us to start working with people before they come to us with a health issue and then it’s too late. (Natalie)

In another outer-regional ACCHS, the clinic manager expressed a similar desire to run health promotion programs:

… We try and do programs but at the moment the money’s been just – phew – cut… cut, cut, cut, cut. We would have had, a couple of years ago, we had cooking classes, we had exercise programs, we had stop-smoking programs, what else, we had mother daughter nights, we had all sorts of stuff happening, but because of the money cuts we can’t run those programs anymore … And because we’re so short staffed, the staff here – the Health Workers are helping the doctors and doing health checks and things like that so we don’t have time to run programs anymore. Which is a pity because I think the programs looked at the root cause or helped the root cause – like cooking classes, that helped. And they were taught budgeting as well so they could do a meal for ten dollars, and feed four [people] on ten dollars. (Annette)

Annette’s testimony tallies the casualties of the Abbott Government’s attack on Indigenous- services funding. In just one ACCHS, Commonwealth funding cuts led to the cessation of health promotion activities, women’s health events, anti-smoking programs, and even curtailed education initiatives for giving Aboriginal families everyday living skills. The loss of ACCHS’ anti-smoking programs, which Roger also pointed to in an earlier section of the chapter, is particularly concerning because of the high rates of smoking in First Nations communities (NSW Health 2018) and the potential for comprehensive tobacco reduction strategies delivered by ACCHS to reduce Indigenous smoking rates (Lovett, Thurber and Maddox 2017). Overall, these interview responses identify critical gaps in the Commonwealth’s Indigenous health funding systems, pointing to a need to redirect funding to preventive services.

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Overlooked areas of funding: capital works, wages and Social and Emotional Wellbeing Around one quarter of the interview cohort also saw capital works or infrastructure as a priority area that requires more government investment. They argued that because of the growing demand for services (see also AIHW 2016) and the range of health services and providers that ACCHS accommodated (see Chapter 5) more investment in infrastructure is required.

Some other interviewees commented on the low salaries paid to workers in the ACCHS sector, a challenge they linked back to government funding shortfalls. One urban-based CEO was scathing in her appraisal of the rates of pay in the ACCHS sector, as were other interviewees:

Rosemary: And that’s the other thing, you can’t offer great wages, well we don’t offer great wages, we’re under shitty award [rates]. That’s the other thing I’d like to see done is our Aboriginal Health Worker award, Aboriginal Community Controlled award re-looked at. It is one of the biggest barriers to attracting staff to our sector, because the wage is so shit.

Me: So it’s much lower than it is in mainstream?

Rosemary: Oh… [yes]. Unbelievable. We don’t pay anyone according to that award. We pay above award for everything because it’s so shit. And to me that’s … very significant because it’s saying something about the sector, what people think the skill set of the sector is.

In the above excerpt this urban-based Indigenous CEO posits that the ACCHS sector’s low wages act as both a deterrent for potential employees and an implicit denigration of staff already working there. In a related way, Peter, an urban-based non-Indigenous Operations Manager, described how lower wages could dissuade staff in the state health system from moving to the ACCHS sector. He also implied that this would have serious consequences:

You cannot fund five projects on an FTE [full-time equivalent] of four people if you expect five people to be there. [Our] wages are too low. We can’t expect people from the state [health] system to be here because [our] wages are too low. So someone’s got to look at that seriously. We can talk about community engagement, we can talk about a whole lot of stuff here, but if you don’t have the Aboriginal workforce working around the Aboriginal

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community, what hope have we got? And there’s an urgency that cannot be understated here. (Peter)

Other interviewees highlighted the discrepancies between their own salaries and those of their mainstream counterparts:

Amanda: And really funding for us, our jobs, what we do, we don’t get paid for. If they were to look at what we do every day in regards to our wage compared to someone else in a big medical centre, they get lots more money than us, and a lot less jobs that they do. (Practice Manager)

Me: So you need to be able to offer more competitive wages? Yeah?

Natalie: Mmm-hmm. Like I bet you [that] a practice manager of a mainstream organisation would get more than I do as a CEO.

Amanda: I know a practice manager in a mainstream organisation. And she gets in the hundreds [of thousands of dollars], and she gets a car, gets her rent, and electricity paid and a house.

Social and emotional wellbeing (SEWB), broadly conceptualised, was another area of service provision that interviewees highlighted as in need of additional funding. One interviewee, Caitlin, regretted that a community garden had lost government funding , another manager, Peter, argued that there was a need for more counselling in his region , and another ACCHS representative, George, stated that his organisation struggled to attract funding for cultural programs and activities . Additionally, multiple other interviewees stated that there needed to be more funding allocated to domestic violence services, as well as to drug and alcohol services. The lack of drug and alcohol services is particularly glaring, given the extent that the drug ice is impacting NSW Aboriginal communities, which most interviewees identified as a pressing social issue in need of more attention.

Collectively, the above statements demonstrate that there are many services that ACCHS deliver that do not attract government funding. Interviewees’ responses indicate that government funding systems do not always correlate with the ACCHS sector’s holistic, family-based model of healthcare. Some interviewees explicitly stated that governments

232 need to take a more comprehensive approach to Aboriginal health funding, as this statement exemplifies:

The holistic approach needs to be funded. NSW does see it a little bit because you get that mental health component of your funding but that’s not enough to cover the whole needs of a whole community and address those issues that are leading to the health issues. (Natalie)

In a similar way, another CEO argued that the only the clinical aspects of the holistic model attracted government funding and attention:

… government bodies in particular talk about holistic care and social determinants but I don’t think they understand it. They can understand it from a theory; it all makes sense how housing, employment, how that impacts on people’s health. But when you’re dealing with that on a daily basis it has a whole different meaning; it’s not that big broad view of yeah, housing does impact, employment does impact – that makes sense. When you deal with it on a daily basis how do you put a structure in place that 1) accounts for their activity and 2) that is valued? … Nobody funds that work. I don’t think the policy makers or the funders – because everything’s moving more – the Key Performance Indicators that we have to report on, they’re moving more and more clinically based. (Rosemary)

Another ACCHS manager posed a question to government funding bodies, highlighting what he perceived to be the differences between the ACCHS sector’s services and the services offered in the mainstream:

So in some ways they’ve got to work out what they want. Do they want Aboriginal controlled organisations to be just another mainstream fee-for-service provider or do they genuinely want them to be an NGO that provides a range of services around child and family, around youth, around adult healthcare, around prevention, early intervention, and around end-of- life care, in such a holistic way that they actually step back and look at the data and say ‘Well what would it take to turn this around?’ (Peter)

Peter’s juxtaposition of the mainstream and ACCHS approach to care implies that the latter has a much greater chance of achieving significant improvements in Aboriginal health, and therefore governments should invest in it.

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Many interviewees argued forcefully that government funding models, predominantly those administered by the Commonwealth and the PHNs, do not align with the ACCHS sector’s holistic model of health care. This disconnect, as the numerous examples presented in this chapter have shown, means that ACCHS must generate revenue in other ways in order to continue providing holistic care to First Nations. One obvious implication for practice is that Governments should fully fund the holistic range of services offered by ACCHS.

ACCHS’ complex relations with government Having read the critical comments above one might expect ACCHS representatives to report that they had strained relationships with government agencies. However, many interviewees reported that they enjoyed generally positive and productive relationships with government departments and funding bodies. Around one third of the interviewees said their organisations had a good relationship with relevant government agencies. Not all interviewees directly commented on their organisations’ relationship with governments, but those who did generally expressed satisfaction with their interpersonal interactions with government, or at least did not express dissatisfaction. The same cannot be said, however, of interviewees’ evaluations of their relations with PHNs, which are explored in the next chapter. One possible reason why ACCHS representatives related more positive experiences of their dealings with government agencies compared to those with PHNs could be to do with the longer associations between the ACCHS sector and government departments. The PHNs are very recent arrivals in the Aboriginal health space and many of the individuals who run PHNs come from a mainstream health background, which may have limited their exposure to Aboriginal organisations and their distinctive concerns and ways of working. At least one interviewee, Gwen, did comment on the difficulty of establishing new relationships with the Department of Prime Minister and Cabinet (PM&C) after Indigenous Affairs funding was transferred there under the IAS. Institutional memory appears to have some importance in this space.

Conclusion This chapter has explored interviewees’ experiences of government funding and reporting processes and their understandings of the major challenges facing the ACCHS sector. Overall, interviewees argued that the sector was inadequately funded for the work it carried out. Interviewees highlighted funding shortfalls in a number of non-clinical areas of care

234 including health promotion, SEWB, capital works and domestic violence services. This section has also delved into ACCHS representatives’ evaluations of the competitive funding processes that are becoming increasingly common in Indigenous Affairs policy. Interview responses, in general, portrayed these processes as overly complex, time-consuming, unnecessary and unjust. Interviewees also argued that competitive funding processes brought with them the risk that Indigenous health service delivery would be opened up to culturally inappropriate organisations. This chapter also detailed some of the revenue generation strategies that ACCHS are employing in the face of what interviewees perceive to be an insecure funding future for the sector and an unstable political environment more broadly. These strategies, such as Medicare revenue maximisation and income stream diversification illuminate the innovative capacity of ACCHS and suggest that there is still some space available for Aboriginal communities to exercise agency through their representative health service-delivery organisations, even under what appears to be a renewed government push towards mainstreaming.

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Chapter 9.

Swimming against ‘the mainstream’: strained relations and barriers to cooperation

That institutional racism is still there, and it’s thriving. And government policy, to us, is supporting that. – Lizzie

Well, we basically have a genuine commitment to each other. It’s not just window-dressing it’s actually putting money or resources where their mouth is. – Sam

This chapter examines Aboriginal Community Controlled Health Service (ACCHS) managers’ and CEOs’ relations with mainstream health services and funding bodies. It also explores these representatives’ knowledge and understandings of how the mainstream health system treats Aboriginal people. Three key themes related to ACCHS-mainstream relations emerged during analysis of the interview data. I conceive of the main themes as ‘strained relations between ACCHS and mainstream health and other services’, ‘cultural, historical, social and political barriers to closer cooperation’ and ‘the benefits of stronger partnerships between ACCHS and mainstream service providers’. In general, interviewees argued there was a need for closer partnerships between the Aboriginal Community Controlled Health Sector and the rest of the health system. One of the main reasons given for the persistence of strained relations was mainstream’s indifference to or negative perceptions of ACCHS. This could be because mainstream health actors lack knowledge of the ACCHS model or because they hold a bias against the more holistic approaches to healthcare taken by ACCHS. Underlying these strained relations are a suite of policies, which I argue inform the behaviour of people working in mainstream health settings, as the chapter’s opening quote alludes to. I also argue that these policies give insufficient direction to mainstream staff regarding their delivery of culturally appropriate healthcare, and their engagement with Aboriginal understandings of health and wellbeing.

Interviewees emphasised that Aboriginal people often need to - or decide to - use mainstream health services as well as ACCHS. Interviewees therefore, contended that for Aboriginal clients’ health journeys to be as smooth and effective as possible, all parts of the

236 health system need to work together harmoniously. Some of the most commonly mentioned barriers to better relations between mainstream services and ACCHS included: mainstream services not prioritising Aboriginal health or cultural safety, competition for funding between mainstream organisations and ACCHS, ongoing and historical racism and discrimination against Aboriginal people in mainstream health settings, and mainstream organisations having more power than ACCHS in decision-making regarding Aboriginal health.

Interviewees stated that their ACCHS wanted to work in partnership with non-Indigenous health services such as hospitals, general practices, medical specialists and Local Health Districts (LHDs)to improve Indigenous health outcomes. Several interviewees made use of the concept of ‘two-way learning’ to explain how closer cooperation between ACCHS and mainstream health services would lead to better outcomes for Aboriginal patients. In this scenario, interviewees explained that ACCHS would share their knowledge of how to work respectfully and effectively with Aboriginal clients, and mainstream service providers would share their clinical or biomedical health expertise. Some interviewees also emphasised the importance of working towards common goals, where both parties are held accountable for performance. This idea of ‘dual accountability’, enforced perhaps via contractual obligations, could act as an organising and stabilising factor in future ACCHS-mainstream partnerships, some ACCHS representatives argued. Interviewees raised many issues in relation to the Primary Health Networks (PHNs), many of which were related to the above themes, but some were unique. The PHN-related issues are presented separately in this chapter because of the deep concern expressed by interviewees over the damaging potential of these new players in the healthcare system.

If closer partnerships can be forged, and ‘two-way learning’ is able to take place, a number of interviewees contended that this would make mainstream health settings more comfortable places for Aboriginal and Torres Strait Islander peoples and relieve some of the strain experienced by ACCHS trying to offer comprehensive services with minimal resources. If combined with an increase in Aboriginal staff numbers in mainstream health settings and a more balanced power dynamic between Aboriginal and non-Aboriginal health organisations these partnerships could increase clinical effectiveness and communication

237 between mainstream health staff and Aboriginal patients and improve Aboriginal health outcomes.

Defining the ‘mainstream’ In this chapter the term ‘mainstream’ is treated as a synonym for non-Indigenous or White. In the Australian context, mainstream also implies ‘dominant’ because of the unequal relationship and unbalanced power dynamics that characterise relations between First Nations and other Australians, and between their respective organisations and institutions. The term ‘mainstream’ is used here in reference to service-delivery organisations and elements of the Australian healthcare system that are not Aboriginal Community Controlled. The term ‘mainstream’ and the practice of ‘mainstreaming’ the health and other services offered to First Peoples are both politically controversial and contested (Howard-Wagner, Bargh & Altamirano-Jiménez 2018; Hunt 2008; Behrendt 2005; Strakosch 2015, 5; Maddison 2009). This is partially because of their close association with the Howard government’s top- down and assimilatory policy prescriptions, particularly in the period following its abolition of the Aboriginal and Torres Strait Islander Commission (ATSIC) in 2005. The term mainstream can connote normality but it can also be read as a symbol of White Australia’s continued dominance over First Nations, even when it comes to Indigenous people’s own health and wellbeing. But the underlying process of ‘mainstreaming’ can be seen as a governmental imposition onto Indigenous peoples of the logics and practices of the dominant healthcare institutions, limiting Indigenous self-determination in health. Mainstreaming, then, can be understood as a policy manifestation of the overarching Settler colonial logic of elimination, which structures the state’s interactions with Indigenous peoples and their service-delivery organisations (see Chapter 3). The evidence presented in this chapter shows that the dominant position of mainstream or Settler colonial institutions in the health system has the effect of marginalising Indigenous organisations and ways of caring.

Nevertheless, ‘mainstream’ is a term now in common parlance amongst those working in Indigenous sector organisations, including many interviewees in this study. ‘Mainstream’, in this context, denotes the people, organisations, systems, norms, services and physical spaces that constitute non-Indigenous responses to First Nations peoples’ health issues. Interviewees often use the term in a more politically neutral way, simply in reference to the

238 ideas, practices and outcomes of non-Indigenous healthcare systems. However, at other times they are highly critical of ‘mainstream’ ways of caring for or dealing with Aboriginal people and organisations. Therefore ‘mainstream’ is a term used by many interviewees to signal those things that are not in keeping with the ACCHS model of care and governance. In this way, interviewees sometimes use the term ‘mainstream’ in a critical sense, implying a damaging, limited or inappropriate approach to First Nations health and wellbeing. A range of service delivery and administrative health organisations constitute the mainstream health system.

Mainstream health services include general practitioners’ (GPs) surgeries, public and private hospitals, medical specialists’ clinics, community health centres and allied health services offered by mainstream for-profit or non-profit organisations. PHNs are also categorised as part of the mainstream health system because they work closely with mainstream service providers and PHN managers seem to have more in common with health managers and administrators than public servants. This understanding was acquired through a search of publicly available information on PHN websites where the identity and experience of PHN board members and executive staff are detailed. Local Health Districts (LHDs) are another part of the mainstream health system since they are the managerial arm of state- government-operated public health services. Interviewees often spoke of PHNs as part of the mainstream health system, although at other times interviewees interpreted them as part of government. On the other hand, LHDs were conceptualised by almost all interviewees as a core part of the mainstream health system. The confusion over the role and function of PHNs could be due to their relative novelty and their multiple responsibilities to procure and fund services, to gather information and in some cases to provide services themselves. While there is some discussion of the PHNs in previous chapters, the bulk of the analysis of how PHNs interact with ACCHS is included in this chapter, as much for analytic focus as anything else.

Research participants’ knowledge of ‘mainstream’ health and other services The content of this chapter is drawn predominantly from research participants’ insights into the actions and rationales of the mainstream health sector. Around two thirds of the ACCHS representatives interviewed for this study have work experience in mainstream health or other forms of mainstream service-delivery and/or administration, including policing,

239 juvenile justice, and Medicare assessing. Just over half the interview cohort has experience working in the mainstream health system, such as working in nursing in public hospitals, working in a LHD, or working for a PHN. Because of the breadth of interviewees’ work experiences, some of the insights detailed in this chapter will be applicable to mainstream service-provision in general, not just mainstream health service provision. Moreover, it is worth remembering that most interviewees are First Nations people. Therefore, many of them also have direct personal experience of seeking healthcare in mainstream settings as an Aboriginal person, which adds nuance to their understandings of how the mainstream health system treats Aboriginal people. Additionally, as the chapter outlines, ACCHS representative possess a lived understanding of how mainstream health and other services deal with ACCHS, because these organisations frequently work together so that Aboriginal clients can receive a comprehensive range of services. As one interviewee stated, in line with the views of a number of others, “there needs to be collaboration, … ACCHS can’t do it by ’emselves” (Les). In this chapter, interviewees’ overlapping and complementary forms of knowledge provide an informative representation of how mainstream and First Nations services currently interact in the domain of Indigenous health service delivery. Overall, ACCHS representatives tell a story of domination, exclusion and disregard, peppered with hopeful examples of collaboration, partnership and working towards common goals. Such First Nations stories are not often heard in health policy analysis, making this an important example of minority voices speaking up to dominant institutions and actors.

ACCHS’ relations with mainstream service providers: mixed results This section explores interviewees’ experiences of interacting and working with mainstream service providers and managers. Around half the interview cohort stated that their ACCHS has a good relationship with the LHD, and/or with another mainstream service-providers in their area. Interviewees described productive working relationships between their ACCHS and some general practices, TAFEs, local councils, non-profit healthcare providers and PHNs. For example:

We have a very good relationship and partnership with Area Health [the LHD], because we know that they’re our big brothers. They’ve got everything, you know? … And we want them to respect us in what we do. And they do. We have a good relationship with the CEO, we

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have a good relationship with the Aboriginal director and they get involved in a lot of our programs. (Roger).

This urban-based ACCHS CEO emphasised, in a similar way to other interviewees, that ACCHS depend on their “big brothers”, the LHDs, because they are some of the most powerful actors in the health system, controlling valuable health resources, such as hospital operating theatres and medical equipment, and possessing specific health expertise, such as in allied health and specialised medicine.

The following statement from an outer-regional ACCHS CEO expresses a similar sentiment:

Me: What’s your relationship like with the mainstream sector?

Kate: It’s pretty good. It could be better. We’re working on that but currently we’ve got a good working relationship. With the mainstream, with the Local Health District there we’ve got a partnership so … we’ve got specialist services … that come here [to the hospital] and do theatre work. So [the LHD’s] giving that to our specialist services. So your ophthalmologists, for cataract removal and all that, pterygiums, and ENTs where they might do grommets, tonsillectomy … so they come here [employed by the ACCHS] but they go [to the hospital] to do the theatre [surgeries]. … [W]e have a meeting every two months… and if we have any issues we ring them up and we have a meeting with the health service manager.

Other interviewees described more formal arrangements between their ACCHS and the other mainstream health providers/funders in the region. This urban-based ACCHS manager, like others in the interview cohort, described a formal process of joint planning and decision-making between his organisation and its local mainstream counterparts:

We have a tri-partite agreement with [the LHD] and the PHN. Every three years we have a high-level agreement with the chairs and CEOs of each of those organisations. … So we have an equal partnership model. … [W]e meet and review the Aboriginal Health Plan, … that goes through a series of planning [stages] looking at data and looking at community input into what their needs [are] … [W]e certainly have strategic links with [mainstream] health. (Peter)

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This same interviewee though, also had this to say about his ACCHS’ relationship with its regional PHN:

The PHN’s our new funding body and I think they’ve got a lot to learn. We’ve had discussions with them and I think they equally want to see it work but I think [because of] the experience we’ve had … we’re cautiously watching it. (Peter)

Some other interviewees described a situation of both formal partnerships at a strategic level, and effective cooperation at the level of service delivery. The Aboriginal CEO of an inner-regional ACCHS described the tangible benefits of working in partnership with the LHD:

The Federal Government gave us a grant to buy a property and build a new medical centre … but [they] wouldn’t fund dental so with our partnership with the Local Health District … we said ‘Look we’re building this beautiful new medical centre but we need your support to build a beautiful dental clinic. So NSW Government and the Local Health District, they afforded us about 900,000 dollars [and] … we were actually able to purchase two dental chairs and have the infrastructure there for a third dental chair for the future … it was a state-of-the-art dental clinic for the entire [region]. … Our staff and [the LHD] staff combined and the LHD became the employer of all the staff. Our dental grant from NSW oral health unit was doubled … and we went from a two-day adult dental clinic to a four-day adult dental clinic, and five-day-a-week dental therapy program. And with a dental therapy program we’re able to generate Medicare income. And … the LHD they’ve committed that whatever Medicare we generate [we can] put it towards an adult denture program. So we’ve now become self-sufficient in funding a denture program for our Elders, our adults. … So … [t]he benefit of having a partnership was [being] able to achieve that. (Sam)

This was perhaps the most positive example of ACCHS-mainstream cooperation given by any interviewee in the cohort. Although there were many other positive examples of ACCHS- mainstream interactions, interviewees more often described positive partnerships between ACCHS and individual mainstream health professionals, rather than between ACCHS and the management or executive teams of mainstream health services.

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Productive relations with external health providers Interviewees gave many examples of positive relations between non-Indigenous health professionals and ACCHS staff and clients. Non-Indigenous health professionals are often employed directly by ACCHS as GPs, nurses, or managers. At other times they act in a visiting capacity providing specialist or allied health services out of ACCHS clinics. In one discrete Aboriginal community in an outer-regional area, the ACCHS relies heavily on its relationships with visiting health providers because of its limited capacity to attract and employ permanent staff. This ACCHS offers room space to mainstream and other Aboriginal Community Controlled Services who are willing to travel to the community to deliver services:

Natalie [CEO]: We’ve got [external] services coming to us saying we want to do this, we say ‘Yeah come on in let’s work together’.

Amanda [Practice Manager]: We have one room that we allocate to services that are visiting and it works well.

They continue:

Natalie: We’ve [now] got the MOU with the hospital. … We had no optometrist out here so we went and got a new one to come out because the old one wouldn’t come. So we[‘ve now] got a really good rapport with [a nearby optometrist]. …

Amanda: RDN do the podiatrists and other allied health services. … [And staff from a larger neighbouring ACCHS] come over with their dental service …

Amanda: Look at the MOU, the hospital and the director of nursing is happy to put her doctors towards the end of their registrar [training] on a rotation out here.

This CEO and practice manager, both Aboriginal women, express a willingness to work with any other providers who are interested in servicing ACCHS clients in this isolated community.

In another town in a remote part of NSW the ACCHS employs all the GPs, so its relationship with mainstream health service professionals is a close one:

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Because we [own] the private practices in town here … we employ all the doctors in the town. Obviously because we own the private practices we’ve got a good relationship with them. We [also] provide the VMO [Visiting Medical Officer] services to the hospital. So on- call emergency call outs and those kind of things. … We meet with the hospital managers pretty regularly and talk with them … I wouldn’t say we do a lot of work closely together, but where we can we try and pair up and do some work. (Tristan)

In this case the hospital relies on some of the doctors employed by the ACCHS. This point about reliance is reiterated by another remote-located ACCHS CEO, though in slightly more colourful and disparaging terms, in reference to her organisation’s interactions with a local general practice:

Some days [our relationship’s] really good and engaging and we get on really well and other days it’s pretty poor. And they often probably rely on us a lot more than they need to, which then says [about] them ‘what a slack bunch of cretins’. You know like, do what you need to. Like, if you do need our assistance, be polite and ask for that assistance instead of saying ‘go down to the AMS and they’ll help you’. Some days we’re able to assist and some days we can’t. (Kate)

Based on these ACCHS representatives’ experiences, it appears that for ACCHS located in remote or isolated parts of NSW, partnerships with mainstream service providers are especially important for the delivery of a holistic range of services to their communities. Some ACCHS CEOs and managers are unhappy that mainstream providers sometimes rely on them too heavily, referring patients on to the ACCHS too frequently. Other interviewees in non-remote locations also expressed frustration about the way mainstream practices refer clients to ACCHS, specifically when they do not want to provide the follow up care after the initial health assessment. This is often because of financial incentives built into the Medicare system, as discussed in Chapter 8 and elaborated later in this chapter.

Some ACCHS are partnering with university-based research centres to deliver services that receive minimal government funding, as the following quote explains:

We’ve actually got a mobile clinic, it’s a van, it’s a Mercedes Benz, the only Merc I’ll ever drive … It’s on permanent loan from the University … We can go anywhere. We’ve been to football and done flu clinics, we’ve been to schools and have done health assessments, we

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do the hearing clinics out of it, we can do oral health screening out of it, … We’ve actually run out of room in [town] and we’re thinking of parking it outside the door and using it as another consult room. (Amy)

The above statement highlights how effective partnerships with mainstream research institutions such as universities can expand ACCHS’ ability to reach clients. This interview response also highlights how these partnerships can lessen the effects of infrastructure funding shortages, mentioned in Chapter 9, and the lengths to which ACCHS are willing to go to provide more services to their communities.

Even though many interviewees stated that their services did not enjoy positive relations with mainstream providers, some interviewees emphasised the ease of working with mainstream providers. One ACCHS CEO even stated that her organisation found it easier to work with mainstream services than with Aboriginal organisations in the local area:

We probably have better relationships with mainstream services than we do with local Aboriginal organisations. … We don’t have a good relationship with the [Aboriginal] aged- care service, and we don’t have a good relationship with the [Local Aboriginal] Land Council. It’s that tall poppy syndrome, I reckon. It’s the ‘You get more money than us, you should be doing this with it’. (Gwen)

It is not always a question of shared identity, as some other interviewees maintained, when it comes to working effectively with Aboriginal people and organisations. This ACCHS CEO suggests that local political and material factors, such as competition over scarce funding can turn Aboriginal community organisations against each other.

Expanding services through referral networks Many interviewees also reported that their ACCHS enjoy strong and positive relationships with mainstream health service providers. Some interviewees, although in the minority, described a carefully curated referral network that their ACCHS employs to complement the services on offer inside their organisation. These reports of complementary networks are in keeping with the ACCHS’ holistic approach to healthcare outlined in Chapter 5. For example:

Yeah, there are referral networks and we do things like we have a connection to Juvenile Justice both in NSW and Victoria. We’ve got … Work Development Orders so people can

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work off their fines here. So ... that’s not health related but it is if you think about ‘OK the person’s stress levels are huge because they’ve got all these fines, they’re going to make bad choices about licenses and driving if they don’t get these paid off, that has a detrimental effect on their stress, which is a huge causal relationship to physical health’. (Harry)

Similarly:

So holistic healthcare is also mental health, housing, … financial hardships, those sorts of things. So we provide a broad spectrum of services. Not all of them are specific to us, so we may actually access services externally and then create a pathway for people to travel to that. … It’s about introduction, it’s about ‘Go and see David, he’s a nice guy, I’ve already phoned him and told him’. … And … we can vet people and make sure that our clients are going to be well taken care of. And then we touch base with [clients] to make sure that service was good. (Linda)

Making sure patients feel comfortable going to referred services, in the eyes of this CEO and some others in the interview cohort, is an essential part of an ACCHS’ work.

Another CEO, from an outer-regional town, contended that ACCHS need to refer patients externally in order to reduce the workload of ACCHS staff who sometimes feel obligated to do whatever clients need:

And we can only do what we can only do. … Some of our staff feel that if DOCs [NSW Department of Community Services] don’t do this, or Housing don’t do this, or Education [don’t] do that [then] it’s our responsibility. Sorry, it’s not our responsibility. We need to refer because it only drains our staff and it only puts more pressure on our staff, which is not good for our organisation or our staff. So I’ve got to play a hard task master sometimes. (Les)

A number of other interviewees also highlighted the necessity for ACCHS to refer clients to, and work with, mainstream service providers. In the following example the Aboriginal CEO of an outer-regional ACCHS reflects on how her service tries to offer holistic services, in partnership with mainstream services, to address the social determinants of health, such as education:

You try to take on all of that you’d go mad trying to work out how to do it. So all you can do is work with existing agencies that provide those other services, provide support. Like, with

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education we provide the gym free of charge to all the kids that are coming. They get the breakfast on their account. So it’s working with those other agencies to help them meet their targets. (Gwen)

This CEO is referring to a before-school program that her organisation runs for Aboriginal students, where ACCHS staff “pick the kids up in the morning, they bring them to the gym, they give them breakfast and then they take them to school” (Gwen). She emphasises the potential gains of working with other services that fall outside of what would traditionally be classified as health, which in this case are education services. The program is also designed to improve education outcomes through raising attendance. The CEO’s statement implies that this program is only made possible by the cooperation of mainstream services and administrators, such as local schools and the Department of Education, and embodies the ACCHS sector’s holistic approach to Aboriginal health and wellbeing.

Another ACCHS CEO, also from an outer-regional location which also services remote Aboriginal communities, emphasised in a similar way to a number of other interviewees, how working with mainstream services can create opportunities for ACCHS to broaden the range of services it offers to clients:

Dominique: Mainstream might have other things that we can tap into for our clients …

Me: And do they work via referrals if you go to the mainstream health centre then?

Dominque: Yeah most of the time it’s referrals … We work closely with the services up there, [with] Community Health especially because they’ve got the allied health workers, … the speech [therapy], the physio and all that sort of stuff. So we refer them and … the GPs and everyone works closely to try to get those services for our clients.

This point harks back to an earlier point, made by another CEO, Roger, about the LHDs being ACCHS’ “bigger brothers” and possessing much-needed health professionals and resources, which some ACCHS try to access for their clients.

In response to some ACCHS’ limited capacity to provide the full range of health services, at least two ACCHS are trying to give Aboriginal clients the skills and confidence to seek healthcare in mainstream settings, limiting clients’ dependence on ACCHS in the process:

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It’s a big job and we’ve got to acknowledge, the staff here are starting to, we can’t fix everything. You have to refer, you have to follow up, you have to take that approach where people are doing for themselves. You can’t do everything for everybody. Because that’s what’s happened. That’s the other thing I’ve noticed about this sector too is people become very dependent. And they’re dependent for a reason but what are we putting in place for self-empowerment so that people can turn up at mainstream service and if they’re being discriminated against and they’re not getting the care that they need, that they actually say something. Because what happens is they don’t [say anything] and they just come back to us and say ‘I didn’t like it there. I’m not going back I didn’t like it.’ (Rosemary)

Some other interviewees explained that when clients are not confident or able to navigate the mainstream health system on their own, the ACCHS will arrange for a staff member to accompany them, or speak to mainstream service providers on clients’ behalf, acting as an advocate. This advocacy can improve relations between ACCHS and mainstream service providers, according to a few interviewees, because it makes it more likely that patients will show up to subsequent appointments and that they will be prepared both financially and medically when they arrive. As this CEO, and other interviewees, explained:

We transport our patients … to [external] specialist appointments that are made here. So if our doctor says you need to see a paediatrician, as an example, our admin will organise that appointment before the person leaves, and then our transport will be booked in … So it means that from an external point of view we are trying to create better relationships with other services outside because people will turn up [for their appointments]. And they [will] understand what the requirements are when they turn up. So if there’s a cost related to specific services they’ll know that in advance; if we can talk to [service providers/specialists] about bulk billing then we’ll try to do that. (Harry)

ACCHS representatives maintain that because the comprehensiveness of ACCHS’ services depends in many cases on the strength of ACCHS’ relationships with mainstream health service providers, ACCHS staff do whatever they can to nurture and sustain these inter- organisational links. It can be strongly argued that promoting, formalising and strengthening these relationships to bring ACCHS and mainstream service providers closer together should be a high order priority for policy makers.

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Strained relations between ACCHS and mainstream organisations Not all ACCHS representatives reported positive relationships between their services and mainstream service providers and funders. Approximately half of the interview cohort portrayed their ACCHS’ relationship with LHDs and/or mainstream non-government organisations (NGOs) as mainly negative or mixed, with roughly an even split between the two. These interviewees described many instances of unsatisfactory interaction between their ACCHS and local mainstream health services. They expressed their misgivings about ACCHS-mainstream relations primarily with reference to mainstream providers’: minimal understanding of the ACCHS model; tokenistic engagement with ACCHS; negative assumptions about ACCHS. The impression that arises from these interview responses, when they are viewed together, is that these ACCHS managers and CEOs feel as though the mainstream health system does not value the work ACCHS do, nor understand it. Each of the above points will now be considered in more detail.

Minimal understanding of the ACCHS model (and Aboriginal health) Many interviewees made comments that either directly stated or implied that mainstream health services do not understand or value the ACCHS model of holistic healthcare. One Aboriginal CEO from an inner-regional ACCHS was strident in her criticism of how mainstream health services engage with ACCHS:

We’re the leader for primary healthcare services for Aboriginal people [but] our sector is not valued or respected enough for that to be [made] policy or … embedded in the way mainstream services do their business. We’re still looked at as an alternative, not as [the] best practice model … mainstream don’t see why services need to be different. [They just ask:] ‘Why can’t [Aboriginal people] access the service through the front door like everyone else?’ (Lizzie)

As was argued in Chapters 2 and 6, one of the key differences between mainstream health services and Aboriginal Community Controlled Services is ACCHS’ employment of high numbers of First Nations staff. Building on this idea, the CEO from an ACCHS that neighbours the one referenced above commented on her perception of mainstream health services’ understanding of the importance of having Aboriginal staff in health settings:

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I’m not sure [mainstream organisations] actually understand why they need Aboriginal people in their organisation to begin with. You know because Australian mainstream doesn’t have a lot of education around Aboriginal communities. (Linda)

In a similar way, a remote-area ACCHS CEO explains that mainstream health professionals generally do not see the difference between what is on offer in the mainstream health system compared to what ACCHS offers:

I think mainstream – unless, obviously they’ve had the opportunity to work in an AMS, they don’t see the difference. Since we’ve taken over two private practices and brought them in to show them how we work they’ve – you know their eyes have opened up and they’ve said ‘Geez we didn’t know you done [sic] so much with each client’, kind of thing. So that was a big surprise for them. (Tristan)

The following exchange illustrates how some ACCHS managers perceive a broad disregard for ACCHS knowledge and expertise within the mainstream health sector:

Me: Do the mainstream providers ask [the ACCHS] about the health needs of the patients that you guys deal with?

Dane: No.

Me: … or the community? They don’t ask?

Dane: No and neither do Justice Health. And that’s the biggest problem so that’s what I was saying, it’s not seen as central. So it’s … when a client goes into hospital or when a client is in prison … it just is a request: ‘Please send us their medical records’. So, not a ‘Can you provide us an opinion on treatment …’. It’s: ‘please send us a copy of their medical records’. So then you find a situation where people are put in prison, you know, or in hospitals and then they’ll come back [home] and [their] treatment programs and regimes will have completely changed. So then, you know, we’re playing catch up to do that.

Patient care can be compromised when health providers do not collaborate and share relevant information about patient needs and previous treatments. This interviewee presents mainstream providers’ lack of interest in engaging with ACCHS or the low priority that they give to Aboriginal clients’ health as the cause of this care-coordination failure.

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Another ACCHS CEO, from a small outer-regional town, felt mainstream service providers do not possess the necessary knowledge to effectively deliver Aboriginal health services:

We get inundated with a lot of people [from mainstream organisations] especially when they have the regional setups. … they come in, they don’t know nothing about our community. So what do we do? We’ve got to sit, day after day, explaining about our community. And they’re picking our brains, [asking] how are they gonna work? So we’ve basically got to sit down and tell them how to work in our community. (Charlotte)

Moreover, this very experienced ACCHS CEO contends that not only do most mainstream health service providers lack the skills to work well with Aboriginal communities, they expect Aboriginal organisations to give them these skills, even when ACCHS and mainstream providers are in direct competition for funds.

That’s meant to be the work of the PHN. They’re meant to be working with the mainstream providers on skilling them up to do the [Aboriginal] health checks appropriately … That’s not our job but I have seen it in one of the PHN tenders, that AMSs would do that. But I don’t see that as our role. They’re [mainstream providers] our competitors. Why would we work with them? If you look at it from a business point of view, and we are being pushed to be more business-savvy, then yeah you wouldn’t do it. (Rosemary)

In a related way, another ACCHS CEO implies that there is an Aboriginal-health knowledge deficit amongst the broader Australian population. He believes, though, that it is partially the responsibility of ACCHS to remedy this lack of understanding:

How we represent Community Control is to actually provide feedback on why there’s Community Controlled services, why you have identified positions, why you have specific funding only for Aboriginal people. Because if that information’s not known … [then] non- Aboriginal people [might] say: ‘Well, why do these Blackfellas get all this and we don’t …?’. So you’ve got to try and educate around Closing the Gap, around, the life expectancy rates, around chronic illness rates between non-Indigenous and Aboriginal people. So it’s educating around why we have services such as we have. (Les)

Les believes that ACCHS should try to engage with non-Aboriginal people in general “along the lines of reconciliation”. He also states that ACCHS “shouldn’t escalate anything around

251 racism” because that approach has “damaged the relationship between Aboriginal and non- Aboriginal people”. While this CEO was in general more critical of other ACCHS than of mainstream service providers, his comments reinforce the sense that many senior leaders in the ACCHS sector see a need for closer engagement between Aboriginal and non-Aboriginal health services, and for non-Aboriginal services and society to understand more about Aboriginal health.

But an Aboriginal manager from an inner-regional ACCHS, along with others in the interview cohort, outlined how culturally inappropriate practices in mainstream health settings could impact on Aboriginal health. The example he gives highlights the difference between the mainstream approach and the ACCHS holistic, wrap-around approach:

Every Aboriginal woman is a high-risk pregnancy. So at 32 weeks they’re required to book in to the hospital. Now if they don’t book in, … the hospital makes two telephone calls to the client. If the client doesn’t respond then that’s it, they just leave them. … Now the issue with that is … you then have a situation where … the client hasn’t booked in, so when you hit 40 weeks and the client fronts up to the hospital screaming because she wants this baby out, the hospital’s … got no paperwork, they don’t even know what the hell’s going on, they’re trying to sort the paperwork out to get her into the delivery suite. You’ve then got the husband who wants someone to fix his wife, and because they’re not he’s threatening to bash the shit out of everyone who comes into the room, so then the police are called and this already traumatic experience of giving birth to a child is just ten-fold exacerbated. (Dane)

Later in this same interview, another ACCHS manager explained that many Aboriginal clients are already “on a heightened level, emotionally” whenever they attend mainstream health services, which underscores the sense that additional support and planning are needed whenever an Aboriginal patient goes into hospital. In summary:

Rather than looking at it and going, ‘OK well the issue is, that person might have five different mobile phones, they might live in three different residences’ … Yet [their] policy is ‘we make two phone calls and if they don’t respond in two phone calls then that’s it’. (Dane)

Other ACCHS representatives also highlighted the differences between ACCHS’ and mainstream health providers’ understandings of what adequate healthcare looks like. The

252 following example comes from a manager in a remote location, who is lamenting the lack of forewarning that her service receives before the local hospital discharges Aboriginal clients from its care:

It usually is like ‘Oh well the AMS will help them sort it out’. So they’ll just send them down and yeah it’s like once they’re out of their care that’s it, ‘We don’t need to follow up’ … We’ve tried to work with them and say ‘Look if somebody’s coming out of hospital and you need us to maintain ongoing care it’d just be nice to have us know that’. Instead of seeing them turning up somewhere, or seeing them walking around town or a family member ringing up and saying ‘Hey this person’s not well, she looks crap, … she’s just come home from the hospital’… So it’s then up to us [the AMS] to make contact with that person and say ‘What’s happening? … what do you need from us?’ And that’s the most common scenario. (Kate)

Overall, these participants’ comments emphasise the instances where mainstream organisations lack knowledge of Aboriginal health and Aboriginal services, or do not agree with how ACCHS work. They also highlight some of differences between mainstream and ACCHS understandings of adequate healthcare. One final comment draws our attention to the role of research in creating educational resources for mainstream service providers. This comment, made by the Aboriginal CEO of an urban-based ACCHS, calls for further research into the ACCHS model, particularly in relation to the economic efficiencies it generates:

What I’d like to see is the work that we… the [ACCHS] models of care well documented and understood, because I don’t think they’re … written anywhere… and not in a way that I’ve seen that makes sense to people who don’t work in the sector … There’s been attempts … but we need something that talks to mainstream about what we do, not talks to us because we know it. And to do a bit of modelling around the cost of [our model] because I think [what] they’d find is that what we do we do very efficiently… (Rosemary)

Tokenistic engagement to ‘tick a box’ A minority of interviewees stated that mainstream organisations sometimes engaged with their ACCHS primarily because it was required of them, because of government policies or funding conditions. Some interviewees referred to this process as a box-ticking exercise. For example, Stephen, a non-Indigenous CEO from an inner-regional ACCHS, explains:

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[From] all those mainstream services always we get … regular approaches for a ‘tick the black box’ letter, [which shows] support from the AMS, to support their tender (Stephen).

Similarly:

Some of the agencies are OK to engage with but you just need to be wary because sometimes they only engage so they can tick a box to say that they’ve engaged with an Aboriginal service. (Lizzie)

And again:

I’m not interested in assisting someone to tick a box. I’ll get involved in projects that will benefit the Aboriginal community, not because [mainstream] need to say that they’ve engaged. (Linda)

Other interviewees explained that this frustration arises because the benefits of these interactions, such as funding and praise, flow only to mainstream organisations:

You work with the government people and NGOs, you work with people that got no idea basically how to work with Aboriginal people, Aboriginal communities. They want you to sit down and tell them how to do things, and [then they] go and justify their little existence in their positions without any credit back to community. (Charlotte)

Negative assumptions about ACCHS and their staff Around one third of the interview cohort either directly or indirectly stated that ACCHS were viewed as inferior to non-Aboriginal services by non-Indigenous medical providers. Interviewees variously contended that these racist views, or negative social constructions, are held by mainstream service providers, government funding bodies, and non-Aboriginal society in general. A non-Aboriginal CEO from an ACCHS in an inner-regional area stated that negative assumptions about ACCHS are particularly prevalent in the regional PHN:

I think that the mainstream, and this includes mainstream funders – not so much … the government but the Primary Health Network, I think they see us as doing an inferior standard of care because our model is different. (Stephen)

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This CEO contends that those in charge of Aboriginal health funding view ACCHS’ points of difference as deficiencies. The logical extension of this line of argument is that if mainstream funders view ACCHS as inferior because they are different, ACCHS will be forced to change their practices to be more in keeping with the mainstream if they want to be considered for mainstream funding. Another CEO remarks on the way she perceives funding to be affected by mainstream funders’ negative appraisals of ACCHS’ distinctive ways of working:

Me: … and what kind of conditions are attached to those funding agreements?

Lizzie: They’re a lot more stringent. And a lot more accountability is held, I feel, on Aboriginal Community Controlled organisations. We have a lot of hoops that we have to jump through and again it’s that they just don’t understand why services need to be different.

This Aboriginal CEO feels that mainstream funding bodies do not understand the ACCHS model and that they therefore impose additional accountability requirements because they interpret ACCHS’ difference as a financial risk. This CEO’s comments imply that to a certain degree ACCHS must work harder than mainstream organisations to win funding because mainstream funders believe Aboriginal people are incapable financial managers.

Similarly:

Instead of us going to [the PHN] and begging for money, the money should be coming straight to us. And us reporting to [the PHN]? We [should] report straight to whoever gives the money to them [i.e. the Commonwealth]. It’s not fair, it belittles us as organisations, that we can’t manage that [money] ourselves. (Gwen)

She continues:

And yes if they don’t trust Aboriginal organisations to do the right thing then put some sort of risk-management stuff in place … they’d be surprised at how many [Aboriginal] organisations would probably come up performing a lot better than what Primary Health Networks do, given the opportunity. (Gwen)

This CEO maintains that the Commonwealth government holds a bias against Aboriginal organisations, borne out in its decision to channel Aboriginal health funds through and vest

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Aboriginal health decision-making authority in PHNs. Such a bias, if it exists, would obviously impact ACCHS’ chances of attracting government funding.

Echoing the point about ACCHS being scrutinised more than other organisations, this ACCHS manager implies that the ACCHS sector’s accountability burden is unnecessary and unfair:

The accountability is very low in some sectors, and yet we totally feel like we are over- burdened by accountability in our sector, we’re watched upon all the time. Yet we’ve got very strong financial governance processes … and acquittal processes in place. (Peter)

A non-Aboriginal CEO, from an organisation with branches in inner-and outer-regional towns, maintains that mainstream service providers presume that Aboriginal organisations will be careless and lax:

I always say to staff ‘you’ve got to be twice as good as any other service to be judged as half as good’… because we’re an Aboriginal service. So people think that we won’t do things properly, … that we’ll do it half-baked … that we won’t pay the bills. … And that’s why I’ve got it so that if a bill comes in we pay it straight away … And everyone … is always amazed when they come to our service because they didn’t believe it’d be as good as it is. So there is a higher expectation … mind you [our ACCHS] has a really good reputation because we do a lot of inter-agency stuff… but it’s something that we’ve had to work at and we’ve had to maintain. (Amy)

As her comments makes clear, this CEO believes that it is her ACCHS’ association with Aboriginality that gives it a lower social standing in the rest of the community. In a subsequent comment this CEO also implied that mainstream prejudices are the reasons why she and other ACCHS representatives “don’t get invited sometimes to important community meetings and stuff. We just [get told that] ‘it’s a bit of an oversight’”. This sense that ACCHS are viewed negatively by their non-Aboriginal peers is not confined to rural areas. Interviewees from urban areas expressed similar sentiments:

There’s this misconception that AMSs don’t run well. … [W]e’ve been through, with AH&MRC, … a forensic audit. Straight away they assumed there was a misappropriation of funds … [T]he Department of Health, … because there was an underspend of money, they assumed that something was going on. And there was nothing. That to me was like ‘wow if

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they can do that to a state [peak] organisation, guess who they’re gonna come [for]? They’re gonna come after all of us [ACCHS]. (Rosemary)

She continues:

They think that people are incompetent who are on [ACCHS] boards. … they think there’s not good governance practices, conflicts of interest, you know. (Rosemary)

This CEO, after experiencing the audit into Aboriginal Health and Medical Research Council’s (AH&MRC) finances and operations that was commissioned by the Commonwealth DoH in 2015, believes there is an underlying assumption in government that Aboriginal organisations are corrupt and incompetent.

Amongst the interview cohort there are also some interviewees who feel as though mainstream society views Aboriginal people as unreasonably avaricious:

And you get people saying ‘Oh youse are always looking for money’, but we’re looking for money to do the right stuff. We’re not pocketing the money. We’re not doing anything silly with it. Everything’s accounted for or we wouldn’t get accredited or we wouldn’t get our next year’s funding. (Amanda)

This same speaker and her colleague expand on this point, reflecting on mainstream Australia’s opinion of Aboriginal organisations and peoples:

Natalie: [They think] that we get all the money. That Aboriginal people get everything for nothing.

Amanda: That we get all the fringe benefits, we get everything for nothing, all these free services, but it’s not the case. We struggle to get it and we struggle to keep it.

Whether it be via the imposition of additional accountability requirements, the initiation of forensic audits, the channelling of Aboriginal health funding through non-Aboriginal administration bodies, or the assumption that ACCHS will not pay their bills, mainstream services, funding bodies and governments convey to a number of people in the ACCHS sector the impression that they are being discriminated against. Many interviewees felt strongly that mainstream funding bodies and service providers, and non-Aboriginal society

257 generally, believe Aboriginal organisations and peoples to be negligent and incompetent financial managers, purely because of their Aboriginality.

Additionally, as the final two quotes below in this section and others like them emphasise, ACCHS representatives have directly observed and now sense that mainstream Australia judges First Nations to be undeserving of Indigenous-specific funding. This supports a constructivist interpretation of Indigenous health policy, which would identify society’s dominant norms as causal factors underlying the distribution of benefits and burdens through policy. As was theorised in Chapter 3 using the work of Schneider and Ingram (1997; 2005), socially marginalised groups, such as First Nations, are more likely to miss out on government funding, because of the lack of political capital that is likely to flow back to government if it favours disadvantaged over advantaged social groups. Disadvantaged groups, such as ACCHS, are also more likely to be treated with contempt or suspicion by governments and other policy actors because of a social and political impetus for government to reward the compliant and punish the deviant (Ingram and Schneider 1997). A number of ACCHS CEOs believe strongly that the presence of undeniably racist attitudes in mainstream health organisations, mainstream health-funding bodies, and in governments explain the disadvantaged position of ACCHS in the health system. Indeed, one ACCHS CEO Lizzie, stated as much: “That institutional racism is still there, and it’s thriving. And government policy, to us, is supporting that”.

Explaining the inconsistent relationships: the role of luck and mainstream health managers’ personalities Some interviewees explained the inconsistent engagement between ACCHS and LHDs as a matter of luck, whereby the relationship is dependent on mainstream health managers’ attitudes and willingness to work with ACCHS. For example, as this CEO expresses, good relations between ACCHS management and the LHD CEO will not necessarily translate into good relations between mainstream health staff and Aboriginal patients:

I think that my relationship with [x] – he’s the CEO [of the LHD] – is good and I believe he’s genuine around Aboriginal people. [But] his businesses are really big and it’s going to take a lot of time for that to filter through his army… that’s due to the size. It’s a base hospital here

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in this town, it’s a big hospital… for a regional hospital. And I think that because the army is so big there it does take time. (Linda)

In a related way, an urban-based ACCHS CEO argued that the relationship between her organisation and mainstream health organisations, such as LHDs and PHNs depended on personal relationships being developed between senior managers over the long term:

Rosemary: The relationship’s really good at the service delivery level, like at the clinician level. We have a lot of visiting specialists from the LHD, great dental partnership, our mental health [partnership]… But from a strategic, forward planning [perspective], … not so good. And I think … operationally it’s because it’s happened over ten years plus. … there’s a partnership. The same visiting specialist we had ten years ago, we’ve still got. So it’s relationship-based… [but] because they’ve [the LHD] had big change in leadership, in management. Year after year. And so has the old Medicare Local. And the PHN’s only new. So they’re the key ones and … And for [the ACCHS], I’ve been here three years. But before that we had six CEOs in six years.

Me: A lot of churn.

Rosemary: There’s a lot of change in all three of the big providers of health in [town]. There’s been a lot of change in that CEO level. So … you get started and then someone leaves.

These two perspectives, viewed together, indicate that for mainstream health services to work effectively with Aboriginal clients and ACCHS, both frontline health staff and senior managers in the mainstream health system will need to be committed to improving Indigenous health and working respectfully with First Nations people. Whether these two factors are in alignment will be influenced by luck and the intentions of mainstream health staff managers, in the absence of clear and binding policy direction.

An inner-regional ACCHS CEO illuminates the inconsistent engagement between mainstream health providers and ACCHS. He believes the strength of these relationships depends on the personal inclinations of mainstream health managers, but also hints at the way policy or government pressure can shift these dynamics:

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Me: Do mainstream health providers or, or relevant government branches engage with Indigenous perspectives on health and wellbeing, or do they consult your organisation about the health needs of the community here?

Tim: Here? No. But, I have seen it happen in many other places. I believe the history with consulting with [the local Aboriginal] people [here] has been particularly challenging. The Primary Health Network is trying to change the way they interact with us now, but that’s come with considerable pressure from the Commonwealth to change that dialogue. The Local Health District has had a particularly disrespectful past to [the local Aboriginal] people, and the subsequent dialogue that happens now is challenging. It’s something we’re constantly working at. It’s better with some, you know, as time goes by, individuals come and go from organisations, it does improve. I think there’s at least a recognition of the need for significant respectful dialogue between mainstream services [and ACCHS].

This CEO’s testimony contains evidence that some mainstream organisations, in this case the PHN, are at least now attempting to engage respectfully with ACCHS, partially as a result of Commonwealth government intervention and pressure.

Some ACCHS representatives expressed a sense of frustration that they had to constantly to educate non-Indigenous service-providers about how to work with Aboriginal people. Others also implied that as long as partnerships between mainstream services and Aboriginal organisations and communities rely on individual relationships and learning, ACCHS’ task of educating the mainstream will be never-ending.

I worked with the police sorting out the problems between the police and our Aboriginal people … And that was a very hard job … it was something that you couldn’t do all the time, it was too hard. Because … new police come in and just go back to the beginning again and you start again. You have a fight, you go back to the beginning. It was a no-win situation. But you see – and there was a lot of good police in there who helped us out but it’s like – I would look at it like you go into a shopping centre and you see ‘Food Court’, eh? And I always look at the cleaners wiping the tables down; it’s a never-ending job. (Roger)

Roger’s comment could be interpreted as implying that Aboriginal organisations are constantly required to clean up the mess left behind by non-Aboriginal service providers

260 who have a limited understanding of how to work effectively and respectfully with Aboriginal people.

Another ACCHS CEO outlined some of the challenges to continuity of care that arise when ACCHS’ relationships with mainstream health services are ad-hoc and personality based:

Like you know discharging [Aboriginal] patients at 4 o’clock on a Friday. My clinic’s closed at 3 on a Friday. Can youse be a bit more considerate when youse are [discharging patients] you know? So staff will bring those to me, issues about you know the ED [Emergency Department] people and so then I just go in and I meet with [her]. So the relationship’s ad- hoc and it could be a lot more productive if it was regular. Instead of me going in there and putting out fires. (Lizzie)

Obviously if an Aboriginal patient was discharged from hospital at a time when the local ACCHS was closed, and that patient usually relied on the ACCHS for transport and follow-up care, this situation could create financial, logistical and treatment adherence problems. This is just one of the potential benefits that could arise from more formalised partnerships between ACCHS and mainstream health providers.

ACCHS’ relations with Primary Health Networks This section presents ACCHS CEOs’ and managers’ perspectives on the PHNs. During the interview process I asked ACCHS CEOs and managers to reflect on their dealings with the PHN, and to explain the impact that these newly created commissioning organisations were having on ACCHS and their services. This section presents data that outlines how some ACCHS are working with their regional PHNs. It relates ACCHS representatives’ experiences with the PHNs and outlines some of their main concerns about how PHNs are working with the ACCHS sector. Six recurring themes were detected in the interview data. These are: inconsistent treatment of ACCHS; prioritising reporting over service delivery; unequal and fractious relationships; knowledge gaps in Aboriginal health and service delivery; struggling to gain funding and long-term investment; and yearning for closer engagement. The chapter moves through these themes from top to bottom, in a fashion that mirrors the PHN policy hierarchy where government sits at the top, delegating authority and resources to the PHNs in the middle, who then distribute funding to and set conditions for ACCHS working at the grassroots level.

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Inconsistent treatment of ACCHS The testimonies of several ACCHS representatives provide evidence of considerable variation between how PHNs operate across different regions of NSW. I argue that this behavioural inconsistency stems from the deliberately vague policy direction from the Commonwealth Department of Health (DoH), which encourages PHNs to embrace flexibility, innovation and respond to local needs (DoH 2016a). More specifically, several interviewees highlighted the inconsistent engagement with ACCHS by PHNs across NSW. Several interviewees linked this uneven engagement to the non-binding nature of “the PHN and ACCHO Guiding Principles” (DoH 2016b). These principles were developed by NACCHO and other Aboriginal peak bodies, in conjunction with PHNs and the DoH’s Indigenous Health Division (NACCHO 2017). However, the lack of Commonwealth oversight and enforcement of these principles limits the bargaining power of ACCHS. This has been shown by the difficulties many ACCHS have encountered in trying to convince PHNs that they are relevant service providers, let alone special ones that should be preferred. The PHNs’ apathy towards the ACCHS sector has also been noted by ACCHS in the Northern Territory (AMSANT quoted in NACCHO 2016, 41).

An inner-regional ACCHS CEO and other interviewees linked PHNs’ inconsistent engagement with ACCHS to the discretion they are afforded in this area by the Commonwealth government:

We have to be able to trust the direction, the policy direction that’s coming from the Commonwealth to the PHNs. PHNs are regularly telling us: ‘Well, no they’re just guidelines from the Commonwealth’, and they’re right. They are guidelines from the Commonwealth. They’re not policy direction that ensures that PHNs are making consistent decisions right across the 31 [PHN] regions in this country. You know, there’s some examples where PHNs are working incredibly respectfully and efficiently with Aboriginal organisations and there’s many that are not. (Tim)

This CEO implies that the policy framework that guides PHNs in their interactions with ACCHS is not strong enough. His point about ‘trust’ and Commonwealth policy direction relates to the ACCHS sector desiring a more stable policy and funding environment, where managers can feel confident that they know what to expect from funders such as the PHNs. His comments also imply that the Commonwealth government needs to set more rigid

262 standards for PHNs to meet. The following statement from an inner-regional CEO illustrates this point:

And I have to sort of say, from a PHN point of view, one of the difficulties with the PHNs – in my view – is that … they all vary. There is no standard. … The way which they develop their contracting arrangements or monitor programs is hugely different across the regions. … To me, that’s a concern because we’re reporting on the same program. Like, the ITC [Integrated Team Care] program is the same across the country, but the reporting standards are different per PHN. So that’s a problem I think. … I fail to see how that creates equity across service provision where one service is being asked to jump [through] hoops around getting funding for certain things and others are not being asked for the same requirements. (Harry)

This CEO was critical of the variable contracting arrangements, reporting requirements and funding processes between PHNs. His concerns about PHNs engaging with ACCHS consistently and fairly across different regions speak to a belief that ACCHS should be able to know what to expect from PHNs, in terms of engagement, funding and reporting.

Prioritising reporting over service delivery Other interviewees also spoke of the specific problems that have arisen where PHNs, acting as intermediaries between the Commonwealth and the service providers it funds, have been offered substantial flexibility in how they will operate. A common issue raised relates to the unusually high levels of reporting that some PHNs require:

So the actual guidelines are Commonwealth guidelines but because they’ve given all the funding to the PHN they’ve also given the PHN the flexibility to put whatever they want to into the contract and that varies right across Australia as to how much extra [reporting the PHN will require]. So for us we know what the basic requirements are from the Commonwealth and this PHN has superimposed a considerable layer of reporting, which of course then means that time has to be given – like Yes Minister – has to be given to doing that reporting. There’s no extra staff to do it so that takes away from providing services. (Jess)

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Another interviewee, from the same organisation as the one quoted above, also questioned the PHN’s priorities, stating that it was more concerned with paperwork than helping people:

Our funding body for that, which is the Primary Health Network, are currently withholding a- quarter-of-a-million dollars’ worth of funding from us because they don’t like our reporting. But their CEO has acknowledged ‘You’re doing the work, you’re delivering a good service’, but they don’t like the reporting. So the focus is on the reporting rather than the service delivery. There’s a mainstream organisation working in the same space [and] their reporting is apparently fantastic, but we’ve had staff working in there saying ‘Yeah but their service delivery’s crap, they’re not doing much of a service, their focus is on the reporting’… Yeah so, what matters is the paperwork not the people. (Stephen)

Other interviewees also contended that the PHNs were prioritising public finance accountability and efficiency over patient care:

Well the last lot of tendering they did was around value for money, you know costing a service. How much does it cost you to treat that person? And we said ‘We really don’t work on that basis. We don’t cost a service. We don’t cut people off at 12 visits or 15 visits. We don’t do that. We’re not about to do that’. So we opted not to tender a submission for that funding and missed out. (Rosemary)

This CEO’s comment provides an insight in the economic rationalist priorities that are guiding PHN funding processes, and illustrates their inappropriateness for Aboriginal service-delivery contexts.

Recent research has highlighted the dominance of upwards modes of accountability to government, over downwards accountability to service users in the funding arrangements that apply to ACCHS (Moran, Porter and Curth-Bibb 2016). It could be that the PHNs’ own internal structures and objectives lead them to concentrate more on performance measurement and monitoring rather than the challenges of front-line service delivery. Their role as commissioning agencies, providing services only as a last resort (DoH 2016a, 11), incentivises them to collect data about health system performance. The PHNs’ focus on

264 reporting can, therefore, be understood as a direct consequence of the Commonwealth’s investment in commissioning.

Some ACCHS CEOs and managers have concluded that PHNs have too much flexibility when determining how they will work with ACCHS and what they will require of them. While the PHN Grant Programme Guidelines do state that PHNs must use Community Advisory Committees, the guidelines only minimally define the function of these committees as to: ‘provide community perspective to PHN boards’ (DoH 2016a, 8).The lack of clear policy direction is one reason behind the varying levels of engagement with ACCHS across NSW. ACCHS representatives raised concerns over equitable treatment of service providers, perverse incentives where reporting detracts from service provision and the heightened organisational uncertainty that is produced by the indefinite nature of Commonwealth policy guidance to PHNs. There is no evidence that the empowerment of ACCHS and Aboriginal communities is a priority area for PHNs.

Unequal and fractious relationships Some ACCHS CEOs and managers are frustrated because PHNs have excluded them from key decision-making forums on Indigenous health. PHN CEOs have the power to control who participates in key discussions around Aboriginal health services. This runs contrary to the Government’s own PHN Grant Programme Guidelines, which state: ‘PHNs must have broad engagement across their region including with … Aboriginal Medical Services’ (DoH 2016a, 7, emphasis added). It also contradicts the principle of ‘Aboriginal and Torres Strait Islander Community Control and Engagement’ that informs the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (Australian Government 2013b, 10), and the associated Implementation Plan (DoH 2015b, 5). Nevertheless, some PHNs have disregarded these nationally established guidelines and strategies, as this informant’s statement indicates:

The Commonwealth actually put out a guideline on how PHNs and AMSs should interact… We had a meeting with the CEO of the PHN and all the AMSs in the region. And I’m quoting the guidelines to him. And he said: ‘We didn’t have anything to do with putting them together, we don’t have to abide by them’. We’ve asked for Aboriginal representation on the board [of the PHN]. Nup. We asked for an Aboriginal Advisory Committee. Nup. (Amy)

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The situation appears to be similar for ACCHS in other PHN regions. One urban-based CEO, Rosemary, contended that her regional PHN’s practices were the cause of the relationship breakdown:

We don’t have a relationship with the PHN. Their practices are culturally inappropriate in my experience, in my opinion and yeah we’ve actually opted out. (Rosemary)

In a similar way, another interviewee, Peter, highlighted his organisation’s sub-optimal relationship with the PHN, concluding that the problem was rooted in the PHN’s lack of understanding of his ACCHS’ most pressing challenges. He states:

We have dialogue with them, I don’t think that’s the issue. It’s a case of them [not] living and breathing the problems that we have. (Peter)

Putting it another way, Peter concluded: “they don’t invest their own time coexisting with AMSs”. This ACCHS manager’s comments, and related data offered by others in the interview cohort, show that some PHNs are not prioritising ACCHS as sites for investment. Consequently, the PHNs are not interested in understanding the specific challenges faced by the ACCHS sector. These ACCHS CEOs and managers describe their relationships with PHNs as unequal, inappropriate, and lacking in understanding.

The fractious relationship between some ACCHS and their regional PHNs in NSW has meant that PHNs are not always utilising ACCHS’ knowledge of Aboriginal communities:

Well a good example is the current ITC program – so the Integrated Team Care arrangements. [The PHN] gave two thirds of the money to non-Aboriginal organisations and one third to AMSs…It’s an Aboriginal-specific program. And we said: ‘Look, we should be getting more because we see more Aboriginal clients’. [The PHN replied]: ‘No you don’t’. I said: ‘Well, where are you getting your stats from? Your stats aren’t accurate.’ Our stats’d be accurate because we know how many Aboriginal people live in our communities. No sense in using ABS because it’s not accurate. You know, our ABS, I think’s 823, or something like that, for [our town] … only. We know there’s more than 1000 Aboriginal people that live just in [our town]. (Gwen)

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This ACCHS CEO is frustrated because her PHN has decided the level and nature of Aboriginal healthcare need without consulting her organisation. As an Aboriginal organisation it has access to valuable sources of knowledge and information about the community, such as population size. This grassroots knowledge could complement the official data sets compiled by the Australian Bureau of Statistics, for example. One way to fix this knowledge utilisation problem would be to institutionalise the principle of Aboriginal community control in all PHN actions and policies related to Indigenous health. Mandating agreements between ACCHS and PHNs would give ACCHS more say in how Indigenous health issues are approached by PHNs in their local areas and make PHN-funded programs more responsive to the specific conditions and needs of Aboriginal communities.

A minority of ACCHS representatives in the cohort reported positive relations with PHNs. Some CEOs and managers reported that their ACCHS had representation on PHN boards and advisory committees. Some interviewees spoke positively about instances where PHNs had run closed tenders for ACCHS, directly approaching them with funding opportunities. Others, also in the minority, emphasised that the creation of PHNs had added additional support and services for Aboriginal clients with chronic illnesses, referring specifically to the Integrated Team Care program. Others noted that the PHN had been trying to improve the relationship with local ACCHS, after getting off to a shaky start. One manager offered this perspective: “One thing I will say, with the PHN in my opinion, in the last 12 months [they] seem to be making a significant effort into finding out what local communities want…” (Dane). This interview was conducted in July 2017, during the PHNs’ second year of operations. He also stated that the PHN had recently become more receptive to the idea of the ACCHS being made the preferred provider of Aboriginal health services:

We strongly advocate that if there’s an Aboriginal service in the area and there’s Aboriginal money then that money should sit with the [Aboriginal] service, as opposed to sitting with the mainstream. In the last 12 months it’s starting to become, I guess, banging the drum long enough, [the PHN has] started to come on board and listen to that. We’ve been successful in a lot of funding in the last 12 months. (Dane)

This comment indicates that there is potential for PHNs to become more supportive of ACCHS, after prolonged periods of ACCHS advocacy. However, this was the exception to the

267 rule across the interview cohort, with many more ACCHS representatives contending that their service has an unproductive working relationship with the PHNs. These positive examples of PHN interactions and partnerships were in the minority by a substantial margin.

In summary, the evidence above suggests that where policy does not require PHNs and other mainstream organisations to work with and consult Aboriginal organisations, there will be many instances where they fail to do so.

Knowledge gaps in Aboriginal health and service delivery One of the strongest PHN-related themes to emerge from the interview data relates to the PHNs’ lack of knowledge of First Nations approaches to health and health service delivery. This is important because both ACCHS-sector advocates and Indigenous health policy experts have argued that the PHNs’ ability to improve Indigenous health outcomes is dependent on how well it engages ACCHS’ skills and knowledge (e.g. Couzos, Delaney Thiele and Page 2016). It is not clear that the PHN has a coherent strategy for engaging with ACCHS and concerns have been raised over Indigenous cultural safety. This is because the PHN’s competitive tendering processes clear the way for non-Indigenous service providers to enter Indigenous healthcare settings (Russell 2015, 77). The following statement emphasises this concern:

Who is PHN to say that an organisation is culturally safe or culturally appropriate? … And who says they’re culturally appropriate? And what happened to Aboriginal people’s freedom of choice? You know, they’re just being ignored, they’re not consulted about this… Putting a dot art painting on the wall doesn’t mean you’re culturally appropriate, it’s just tokenistic… I just feel that Aboriginal people don’t get given… they don’t have a say and yet it’s their health that we’re talking about, you know. At least with us we give them a choice. (Linda)

Some ACCHS representatives feel that the PHNs are not attuned to the culturally specific health needs and expectations of Aboriginal and Torres Strait Islander peoples. Moreover, the ACCHS CEO quoted above feels that Aboriginal peoples’ right to self-determination was not respected in the top-down decision-making process that led to the creation of the PHN.

In a related way, there is a feeling amongst some within the ACCHS sector that PHNs are not familiar with and have not sufficiently engaged with the ACCHS model of care or the

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Aboriginal definition of health (see NACCHO 2017; Wright and Lewis 2017, 33). In response to a question about the differences and similarities between ACCHS and non-Indigenous health services, a very experienced CEO from an urban ACCHS had this to say:

No, they don’t even… they don’t even touch the surface of what we do. I’m on the PHN board. [The] PHN is mainly all doctors and they’re fascinated. I did a presentation to them and did a video. They couldn’t believe it, what we do. (Roger)

This response suggests that PHN board members have limited knowledge of ACCHS’ ways of working, and, that because the majority of PHN board members come from a conventional clinical health background, they do not understand ACCHS’ holistic conceptualisation of Aboriginal community wellbeing (see AH&MRC 2008, 32). That said, these PHN board members being ‘fascinated’ by the CEO’s presentation indicates that there is potential for these organisations to learn from and work more closely with this ACCHS in the future.

Other interviewees were concerned about the effects of PHN funding processes on the ACCHS holistic model of care. A minority of interviewees offered examples of PHN funding processes that could potentially fragment patient care:

Oh and they had absolutely no understanding of Aboriginal health service delivery. So with everything, every tender they put out they divided it up. It was like – I’m just trying to think of the drug and alcohol [tender] – so they had withdrawal management was one tender you could put in for, psychosocial counselling was another tender you could put in for, … all these segments, rather than seeing [that] if you did one you sort of had to do it all, that it was all integrated. (Amy)

This ACCHS manager expresses a similar concern:

Yes, sometimes we have to hit our heads against walls because they just still don’t understand. Like when I worked for [the] Primary Health [Network] they were really not understanding. They just basically said ‘No, you get this money allocated to you for this and that’s all you spend it on’. And it’s like well you know there’s a missing link, there’s always a missing link and you’re not allowing that link to be linked. You’re just saying, just deal with that, nothing else matters. (Kate)

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Another ACCHS CEO lamented the PHN’s lack of knowledge about the health needs of First Nations peoples, which stemmed from its failure to engage with relevant Aboriginal organisations:

The PHN, it was flawed from the start, because they were asked to do an Aboriginal Health Needs Assessment and they did that with no consultation or data from our sector. And so this Needs Assessment was meant to inform how they would commission services and they didn’t do it and so we were off on the wrong foot from the start. (Rosemary)

This experienced Aboriginal CEO maintains, like others in the interview cohort, that the PHN did not consult the ACCHS sector or make use of ACCHS data in preparation for the commissioning of additional services for Aboriginal and Torres Strait Islander people. She went on to claim that the PHNs also have limited knowledge of the ACCHS sector itself:

And they know nothing about Aboriginal Health… Well I’ll take that back. They know nothing about the [ACCHS] sector. And so they’ll say ‘Oh you only service 25% of the population’. Well I don’t know where you got that data from but even if we did, you’re looking at GP visits, you’re not looking at the wrap around services. So your data’s flawed from the start. (Rosemary)

A persuasive interpretation of the above interview responses, taken together, is that PHNs know very little about the ACCHS model of holistic health care. This is evidenced by their focus on GP interactions when measuring ACCHS’ patient engagement, their fragmented funding arrangements and their limited consultation with Aboriginal Community Controlled organisations. This may produce serious challenges for Aboriginal health equity, given the advantages of holistic health care for reducing health inequity, as outlined in Chapter 2.

Struggling to gain funding and long-term investment Some ACCHS managers and CEOs commented on the PHNs’ lack of investment in their sector. The government’s under-funding of the ACCHS sector has attracted persistent criticism from Indigenous health and policy scholars for many years (Alford 2014; Grant et al. 2008, 19). The following comment came in response to a question about the Indigenous Advancement Strategy (IAS), another recent policy initiative that has been similarly criticised

270 for not engaging with Indigenous community organisations, underscoring how ACCHS feel ignored by funding and policy bodies:

It’s the same as the PHN stuff, there was no – they didn’t come and talk to us and say ‘How many patients you got? What are your occasions of service like? What’s your health- outcomes data like?’ None of that, so they don’t know what we could do, what we could deliver. (Rosemary)

Similarly:

The [PHN funding] process did not interview Aboriginal organisations and say: ‘This is what is funded to do, how do you think you can deliver? How do you think we can help you shape up something? What do you have capacity on? What don’t you have capacity on?’ It basically was ‘[You’re] just another provider’. (Peter)

These ACCHS representatives see value in a process where governments, or intermediaries such as PHNs, would directly approach Aboriginal services with long-standing relationships with their communities in order to assess the possibility of building upon what is already in place. This did not occur with the PHN in these regions. This could be because the PHNs do not understand the special role of ACCHS in the health system, viewing them as no different to mainstream providers.

Other interviewees gave examples of PHNs offering inadequate funding, making it difficult for ACCHS to employ additional staff. This mirrors the behaviour of government departments, which offer inadequate funding to ACCHS, as examined in Chapter 8. An offer of inadequate funding can increase the workload of ACCHS staff if the organisation decides to offer a new program or service without employing additional workers. As Adam explains: “They’re providing us the funding to run programs but it’s not enough to put a staff member on so we’ve got to use … current staff that we’ve got to run additional programs”. PHN funding scarcity can also impact on the quality of the staff who will have to be willing to work for low wages: “It’s like this PHN drug and alcohol funding: how do you advertise positions when you’ve only got a contract for 12 months? And how do you get good staff?” (Amy).

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Yearning for closer engagement The following statement from a manager at an urban-based ACCHS cuts to the heart of what I believe to be the problem with PHNs, based on the evidence presented above. This interviewee eloquently articulates the strongly held view that funding and policy bodies should work with and build on the work of Indigenous community organisations:

We’ve already told them: ‘Have more dialogue with us’… it’s about relationships, it’s about understanding the [Indigenous health] space. It’s not just contract management … It’s really about making sure that the funding isn’t piecemeal. … We don’t want to be set up for failure… So this is the issue: I think the reporting is important and I think the dialogue with our funders is really, really important. It’s about having healthy relationships and discussions with our funders around what the challenges are both at an organisational level and at a community level… It’s stepping back and actually sharing the problem rather than administering a contract. (Peter)

This manager believes that PHNs need to invest more in the ACCHS sector and that they should share responsibility for Indigenous health outcomes. He also sees a need for PHNs and governments to better understand the challenges faced by ACCHS and their communities. However, this would require not just the PHNs but the Australian Government to give up its commitment to contestable funding, an approach based on the idea that there should be a competitive service market.

In summary, the evidence above suggests that the inconsistent behaviour, relations and requirements of PHNs stem from vague policy direction at the Commonwealth level. It also suggests that many PHNs possess minimal knowledge of ACCHS and the health needs of First Nations. Interviewees also attested to the PHNs’ lack of strategic investment in the ACCHS sector. Interview data portrays PHNs as the more powerful partner in their relationship with ACCHS in NSW. However, there were some positive examples of PHNs responding to ACCHS advocacy, giving the sector hope that the relationship could be more equal in the future with some ACCHS gaining recognition for their special role in the health system. In order to remedy these problems, one possible solution would be for the DoH to make PHN engagements with ACCHS non-negotiable, tying ACCHS involvement in PHN planning and decision-making about Aboriginal health to PHN funding. From the perspective of ACCHS representatives, for the PHNs to better support ACCHS as front-line

272 providers of primary health care to Aboriginal people, its funding model needs to become more holistic, and ACCHS treated as preferred providers.

Unequal power: Mainstream organisations and norms dominate Many interviewees referred to the unequal power dynamics that characterised ACCHS’ relations with the mainstream, mentioning PHNs, LHDs and governments. Stephen, the CEO of an outer-regional ACCHS, characterised his organisation’s relationship with its regional PHN as a “master-servant kind of relationship”, while another manager, Carole, from this same ACCHS, likened the PHN funding process to “mission manager days, when they’re doling out their rations”. The CEO of a separate ACCHS in the same region, Gwen, described her organisation’s interactions with the PHN in very similar terms, stating: “our Primary Health Network and us [sic] have never enjoyed an equal relationship… It’s been they’re at this level and we’re asking for something”. Clearly, this CEO sees the PHN as far more powerful than her ACCHS because it controls large amounts of Indigenous health funding and decides to which organisations this funding will be allocated. In other words, PHNs control both resources and decision-making for Indigenous health.

In relation to ACCHS’ relations with LHDs, other interviewees described a comparable power asymmetry. A clinical services manager from an inner regional ACCHS outlined the power dynamic and priorities underlying the LHD’s interactions with his organisation:

It’s still very much a mainstream focus. … The focus is not about how they can work with us, it’s how we can work with them. It’s ‘We want you to come to the table and tell us what you can do for us’, as opposed to … us saying to them: ‘What can you do for the Aboriginal people in this area? How can we make a difference …?’ (Dane)

Based on Dane’s evidence, the LHD sets the terms of engagement, and ensures that any such engagement is geared towards mainstream priorities. Extending his argument about LHDs engaging with ACCHS to further their own objectives, this same interviewee highlighted one obvious indicator of Aboriginal exclusion from LHD decision-making: “You’ve only got to look at how boards are made up in mainstream … I don’t even think there’s one Aboriginal representative on the board of the Local Health District” (Dane).

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Other interviewees offered examples of mainstream health services exercising their power to minimise ACCHS’ influence in mainstream decision-making forms. Outlining a stark example of unilateral decision-making by a mainstream CEO, this ACCHS CEO describes how the structure of a partnership between the LHD and local ACCHS was dramatically overhauled, minimising the participation of Aboriginal organisations:

When [a new CEO] took over … [the previous health partnership] became a sub-committee of the LHD. That wasn’t how it was set up. Previously it was co-chaired by the [LHD’s] director of Aboriginal health and an AMS CEO. And there were eight AMSs including mine that had membership to that partnership. We show up for a meeting and the CEO says ‘We’ve changed the terms of reference. This is now a sub-committee of the LHD board and as such will be chaired by an LHD board member’. No consultation at all with the AMS CEOs. (Lizzie)

According to this Aboriginal CEO, the health partnership is now dominated by LHD staff and board members, with only one AMS represented. Lizzie concluded, sarcastically: “They’re doing it all. They’re solving the woes of all the Blacks in [the region] because they don’t need AMSs.”. The fact that this rearrangement could occur and that ACCHS could do nothing about it, indicates a significant power imbalance between LHDs and ACCHS.

Some other interviewees, alluding to the power that comes with access to resources, highlighted the fact that the LHDs also control most of the state’s health funding and staff, a point that was touched on at the beginning of the chapter. One ACCHS manager, Peter, succinctly expressed a view held by many interviewees: “All the health workforce sits in the state healthcare system”. Similarly, in reference to a mainstream Community Health Service, run by an LHD, Adam, an ACCHS manager, explained that “we need them because they’ve got the specialists to provide the psychological assistance …, or the drug and alcohol counselling or the clinical … and getting them into the rehabs”. Overall interviewees’ comments suggest that the power dynamic between ACCHS and PHNs, and between ACCHS and LHDs are remarkably similar; both the PHNs and LHDs command greater resources than ACCHS and governments affords PHNs and LHDs the authority to make decisions about Aboriginal health without requiring input from ACCHS.

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Interviewees’ responses suggest mainstream health organisations regularly dictate terms to ACCHS. Based on the evidence from interviews and the Aboriginal health and politics literature (see Chapter 2) it can be reasonably concluded that this unequal power dynamic is likely to perpetuate the instances where mainstream services are failing to deliver adequate and culturally appropriate healthcare to Aboriginal people. On the basis of sentiments strongly expressed by interviewees, it seems clear that there need to be more Aboriginal people working in positions of power in mainstream health settings and more Aboriginal community representatives in mainstream health forums.

Many ACCHS CEOs and managers related examples of mainstream services treating them with disregard and excluding them from key Aboriginal health decision-making forums. Overall, ACCHS representatives characterised the mainstream approach to healthcare as fragmented, individualised, biomedical, reactive and rushed. They argued for closer partnerships between ACCHS and mainstream services to alter the priorities and practices of mainstream organisations, bringing them closer to ACCHS holistic, family-based approach to care. These proposals for closer partnerships are outlined below.

ACCHS’ desire for closer partnerships, self-determination and two-way learning Most interviewees expressed views that were supportive of closer partnerships between ACCHS and mainstream service providers. Some outlined the benefits of closer partnerships between mainstream providers in terms of cost efficiency and reduced organisational stress. Others stated that closer partnerships should be prioritised because ACCHS and mainstream providers are “in the same business”, as Sam put it, and should be working together towards their shared objectives. A few interviewees linked ACCHS’ health services to reductions in the numbers of Aboriginal people being admitted to public hospitals, with Linda describing this as a “win-win for everyone”. Others stressed the interdependence between mainstream providers and ACCHS, a theme that was raised in an earlier section of the chapter. This interdependence, interviewees explained, stems from the distinctive yet complementary abilities and resources that Aboriginal and mainstream health services possess. Many interviewees contended that through coming together and sharing knowledge mainstream health services and ACCHS could engage in “two-way learning”. This ‘two-way learning’ is the subject of this final section of the chapter.

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Two-way learning Around one third of the interviewees raised something of relevance to sharing complementary skills and knowledge between the mainstream and ACCHS. The CEO of an inner-regional ACCHS, who also has experience working in Central Desert communities, gave the most detailed explanation of this in terms of the Aboriginal concept of the Malparara Way or “the strength of working together” (see also NPY Women’s Council 1999) during a discussion about the need for closer partnerships between ACCHS and mainstream organisations:

I think [this ACCHS] would be naïve to think that we can survive without those effective partnerships. And they need to be two-way learning. That word is the Malparara way. It means you bring something to the table, I bring something to the table. Together we’re better, and we will deliver better services, more functionally, more appropriately, more respectfully. … the Malparara way is a way of communicating effectively that’s respectful to both skills that come to the table. … The mob get it because the Elders functioned on respectful communication, and if that falls over, the partnerships would fall over. (Tim)

Respectful communication and sharing resources are the essence of two-way learning and the key to successful partnerships, according to this non-Indigenous CEO. The clinical services manager from this same ACCHS described two-way learning using similar terms, but emphasised Aboriginal organisations’ leading role:

The role of [ACCHS] is to lead, should be, to lead mainstream as to what is culturally appropriate for the people and what is not culturally appropriate for the people. And … it’s a two-way learning: we can learn from them and they can learn from us. (Dane)

Other interviewees, while not specifically referring to two-way learning as a concept, emphasised the way that people trained in the mainstream health system providers and ACCHS could share knowledge for the betterment of Aboriginal health. For example, this CEO reflects on the learning of a doctor who has been working at the ACCHS:

What we want is for him to go out into the bigger, brighter world and treat people, Aboriginal clients and other Aboriginal community members with the respect that we have taught him, you know. And his medicine for Aboriginal people should be really great. (Linda)

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Another CEO described a similar dynamic in her ACCHS:

And it’s like, we contract a private psychologist, but we had him working out of our building for a couple of years beforehand, so he became culturally appropriate. So we’re also educating service providers. (Amy)

While these examples relate to one side of the two-way learning process, the fact that ACCHS contract and employ health professionals trained in mainstream institutions is evidence that they value the clinical knowledge they bring with them. A minority of other interviewees spoke of more formalised instances of two-way learning, via staff exchange programs between ACCHS and hospitals. Facilitated by a partnership between an LHD and an ACCHS, Aboriginal and non-Aboriginal staff alike are able to gain a better understanding of Aboriginal Community Controlled and mainstream health contexts. The Aboriginal CEO of the ACCHS involved explains how he and his LHD partners have arranged for:

non-Aboriginal staff to come and work in the AMS, and Aboriginal staff to work in the hospitals. So we become familiar with those environments, to break down their barriers and yeah, which creates more effective communication. (Sam)

ACCHS representatives from a discrete Aboriginal community in an outer-regional area spoke hopefully about a similar staff exchange in their area, referring to a recent memorandum of understanding (MOU) between the local hospital and the ACCHS:

Natalie: And another thing too, [the MOU] will make the hospital more culturally appropriate. They’ll come out here and do some work experience … doctors, nurses, admin. We’re going to sort of swap them… Our workers can get the mainstream experience, theirs will get the Indigenous health … experience.

Me: So they’ll learn a lot from you, for sure.

Amanda: And vice versa.

These interviewees point to the mutual benefits and knowledge gains that will accrue to both parties to the agreement.

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Other interviewees alluded to productive interactions between mainstream and Aboriginal community knowledges when discussing the ways that doctors and Aboriginal health workers could cooperate in caring for Aboriginal clients’ health. While some interviewees contended that the skill set of Aboriginal Health Workers was not sufficiently valued in mainstream settings, a few interviewees argued that their skill sets were complementary and that the relationship needed to be based on “equal partnership”. One interviewee contended that:

It goes back to respect, which goes both ways. Health workers and doctors should show mutual respect. Both have to make sure they are working together to heal the client. Doctors have formal training, but Aboriginal Health Workers have training in life experience. (Caitlin)

This senior Aboriginal manager also contended that Aboriginal Health Workers could facilitate effective communication between non-Aboriginal doctors and older Aboriginal clients, and help them to navigate cultural protocols surrounding “men’s and women’s business”. While this interviewee emphasised all that mainstream health professionals can learn from ACCHS, other interviewees underlined the areas where ACCHS could both learn from and make use of mainstream health professionals and their skills, particularly in relation to corporate governance, which was discussed in detail in Chapter 7.

Conclusion This chapter has described the unstable and often tense relationships between mainstream service providers and funding organisations. It also shared some examples of how some ACCHS are working productively with LHDs, hospitals, non-Indigenous health professionals, and PHNs. The chapter also outlined how ACCHS in New South Wales develop referral networks with mainstream service providers to expand the range of health and other services available to Aboriginal and Torres Strait Islander peoples. Through insights shared by ACCHS representatives this chapter explained these referral networks as a pragmatic response to the unequal resourcing of the ACCHS sector compared to the mainstream health system. ACCHS representatives presented numerous accounts of strained, acrimonious, and tokenistic relations between ACCHS and mainstream health organisations. The continuous emergence of these unproductive relations was explained as the

278 consequence of enormous power discrepancies between the mainstream health sector and the ACCHS sector and the lack of binding policy direction mandating Aboriginal Community Control in health.

The Aboriginal community voices that speak throughout this chapter make clear that there are still many instances of institutional racism in the health system, indicating a structural flaw in how mainstream health services are administered and directed through policy. ACCHS representatives though, are working to overcome the cultural, economic and political barriers, attempting to establish stronger partnerships. The front-line accounts offered in this chapter explore the ways that ACCHS CEOs and managers are attempting to gain both the respect of the mainstream health system and a seat at the decision-making table for Aboriginal health. Some interviewees are hopeful that through closer engagement with the mainstream a process of two-way learning will be possible, improving the overall offering of health services available to First Nations peoples.

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Chapter 10.

Conclusion and policy recommendations: calling for greater Aboriginal Community Control

We’re mostly Aboriginal people so we understand things a bit better for our staff and for our communities than a non-Aboriginal person would coming in. I just think it’s a perfect fit. Who better to take care of our problems than us? – Gwen

This final chapter reviews the arguments and evidence presented in the thesis, draws out their implications for practice and makes a series of policy recommendations. The specific recommendations are based on Aboriginal Community Controlled Health Service (ACCHS) representatives’ suggestions, in keeping with the thesis’ decolonising methodology. The recommendations are directed at specific policy actors: governments; Primary Health Networks (PHNs); ACCHS; Local Health Districts; and mainstream non-government organisations (NGOs) and health professionals. I also comment on current developments around the Closing the Gap Refresh, which offer First Nations organisations the prospect of greater involvement in national policy efforts to remedy Indigenous health inequities. The recommendations are grouped into six thematic categories related to: culture, resources, power, process, accountability and governance.

Answers to research sub-questions This thesis has provided a detailed and nuanced response to the first of the three research sub-questions: What are the features and guiding philosophies of ACCHS in New South Wales? The evidence presented in Chapters 6 and 7 detailed the holistic and culturally appropriate model of care that is implemented by ACCHS in New South Wales (NSW). ACCHS representatives explained that their services are targeted at the fundamental causes of Aboriginal health inequity. Drawing on interviewees’ explanations of the importance of Aboriginal Community Control, this thesis has outlined how ACCHS empower First Nations peoples to take control of their health and wellbeing, which interviewees perceive as the special role of ACCHS in the health system.

Interviewees’ accounts of what ACCHS do, how and why, have been used to develop a theory of the ACCHS holistic model of care, linking their practices to their understandings of

280 the root causes of Indigenous health and social problems. Chapter 6 gave a new account of ACCHS representatives’ philosophies of Aboriginal health, considering physical, social, emotional and spiritual factors. By analysing interviewees’ accounts of what makes ACCHS special, empirical links have been made between ACCHS’ healthcare philosophies and their implementation through services, programs, events and other interactions with communities and clients. This thesis’ modelling of the ACCHS holistic approach to healthcare makes a substantive contribution to the Aboriginal health and policy literatures and expands knowledge of ACCHS’ health philosophy.

The second research sub-question, How are current policies, funding arrangements, and ‘mainstream’ norms and practices affecting ACCHS and Indigenous self-determination in health?, was answered in Chapters 7, 8 and 9. These chapters explored the many challenges facing ACCHS in NSW. Interviewees argued that the current policies and funding models represent an existential threat to the ACCHS sector. The extensive use of first-hand accounts of how federal government policies affect Aboriginal organisations and communities gives the policy analysis in this thesis a grounded quality, rarely evidenced in policy evaluations. A close examination of policy documents and scholarly literature, and in-depth interviews with ACCHS CEOs and managers have revealed that open competitive tendering for Aboriginal health funding is undermining Aboriginal Community Control in health. This thesis has also presented evidence of neoliberal priorities driving policy in Indigenous Affairs at the federal level.

The thesis has illuminated some of the many ways that neoliberalism and New Public Management (NPM) have affected the ACCHS sector. These conclusions echo previous research findings from other scholars. Marsh, for example, found that the multiple accountabilities produced by NPM approaches to funding ACCHS create high transaction costs that detract from service delivery (2015, 273; see also Dwyer et al. 2009). Chapter 8 of this thesis confirmed that this is still a problem for ACCHS today, as they struggle with complex and lengthy activity reports and grant applications, while also striving to deliver high-quality services and programs for clients. Overall, this thesis reiterates Sullivan’s conclusion that under NPM Indigenous-sector organisations are “under-acknowledged and over-regulated” (Sullivan 2011, 62). Over-regulation is particularly acute when it comes in

281 the form of contract management, which is a technique that the neoliberal state deploys to silence and control NGOs across society (see Maddison & Hamilton 2007; Maddison & Carson 2017). This thesis, particularly in Chapters 3, 7 and 8, has found that ACCHS are still being subjected to the problematic NPM reforms that are prescribed by neoliberalism.

Findings from research on other areas of Indigenous policy in Australia are also reproduced in this thesis. Habibis (2018, 180-2) has argued that the Commonwealth’s remote Indigenous housing policies are exemplary of ongoing neo-paternalist attempts to “normalise” remote-dwelling Indigenous peoples and assimilate them to White ways of living. Morphy (2008, 141) has similarly identified a “neo-assimilationist challenge” facing Aboriginal organisations attempting to create employment and deliver community services. She highlighted how new standards of governance were imposed on Aboriginal community organisations, designed to guarantee their “commercial effectiveness” (DEWR quoted in Morphy 2008, 141). In a similar way, this thesis has argued that the neoliberal logics that structure the Indigenous Advancement Strategy (IAS), the Indigenous Australians’ Health Programme (IAHP) and the PHNs encourage ACCHS to assimilate to mainstream or White ways of doing business and delivering services (see Chapters 3 and 4).

The conclusions of this thesis also reflect the findings from the broader literature that details how neoliberal marketisation has transformed the non-government social service delivery sector. Eikenberry & Kluver (2004), for example, explain how non-profit service delivery organisations have adopted some of the practices and values of the private sector, in response to neoliberal policy reforms in the United States. Gingrich (2011) also shows how marketisation has transformed service-delivery in the non-profit sector, however her study demonstrates that the practice has varied widely across different countries. This thesis has arrived at similar conclusions, finding that current Commonwealth policies do indeed encourage the non-profit sector, including ACCHS, to adopt private sector values and behaviours (see Chapters 4, 6, 8 and 9). However, in line with Gingrich, the thesis has shown that this occurs through a specific form of marketisation, namely contestability, which was explored and explained in Chapters 3 and 4.

The thesis has also outlined some of the ways that policy is (re)producing negative stereotypes about Aboriginal organisations and peoples. Chapter 9 offered new evidence of

282 ongoing racism in health settings and in Australian society more broadly, demonstrating that racism remains a fundamental determinant of Indigenous health inequity. These are some of the ways policies, funding arrangements and mainstream norms and practices are impacting ACCHS and impeding Indigenous self-determination in health.

In response to the final research sub-question, In what ways could governments change policies to allow space for greater Indigenous self-determination in health?, policy recommendations have been generated through both engagement with the relevant literature and a deep analysis of the interview data. Below, building on the evidence and arguments forwarded in this thesis, I outline key policy changes that would increase ACCHS’ positive health impacts, and improve the effectiveness of the health system for First Nations peoples.

Recommendation 1: Cultural change: confront institutional racism As Chapters 2 and 8 demonstrated, institutional racism is a barrier to effective health service delivery to Aboriginal and Torres Strait Islander peoples. Governments, PHNs and mainstream service providers have a responsibility to address these cultural barriers and prejudices, and to make healthcare settings more culturally safe and appropriate to the health needs of Aboriginal peoples. The following recommendations call for a cultural change in healthcare, tackling institutional racism and the expanding mainstream service- providers’ and governments’ understandings of the holistic approach. These recommendations call on Governments and mainstream healthcare organisations to increase their knowledge of Aboriginal approaches to and understandings of health and wellbeing, and to develop their own capacities to deliver culturally safe healthcare to First Nations peoples.

1.1. Governments, Primary Health Networks, Local Health Districts, and mainstream NGOs need to develop educational programs on cultural safety and anti-racism for the recurrent and mandatory training of frontline staff and health managers. This training should be designed and led by representatives from local Aboriginal communities and organisations (including ACCHS). Aboriginal collaborators and cultural safety educators must be adequately compensated for their time and input and given the time, authority, and support to stimulate discussion and self-reflection amongst mainstream health staff.

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1.2. Governments, Local Health Districts, Primary Health Networks, and mainstream NGOs must meet their obligations to address racism as a barrier to Indigenous employment. Funding systems could incentivise the employment of Indigenous staff members in mainstream health organisations and mainstream health managers should develop cultural safety policies to prevent the isolation of Indigenous employees in mainstream health organisations. Funding for mainstream health and other service delivery organisations should be conditional on the achievement of Indigenous employment quotas. Training and career development opportunities for Indigenous employees should be mandatory for all organisations receiving government funding to provide services to First Nations communities. Primary Health Networks, the federal Department of Health, the newly created National Indigenous Australians Agency and the NSW Ministry of Health should assess the Indigenous employment and training strategies of mainstream services in all funding applications, making these strategies mandatory requirements for all organisations receiving funding to deliver services to First Nations communities.

1.3. Local Health Districts, Primary Health Networks, mainstream NGOs, governments and higher-education institutions such as universities, should invest in training on the principles and practices of the ACCHS holistic model of health care.

1.4. The Commonwealth Department of Health, the Primary Health Networks and NSW Health must acknowledge the need for them to fund services that address the impacts of historical and contemporary trauma on First Nations peoples. Mainstream health service providers must provide culturally safe and trauma-informed care to First Nations clients, considering local history and socio-economic conditions. Local Health Districts, Primary Health Networks and mainstream NGOs should develop locally relevant trauma-informed health strategies in collaboration with local Aboriginal organisations and community members.

1.5. Governments, Local Health Districts, Primary Health Networks should create more opportunities for “two-way learning”. Formal partnership agreements between Local Health Districts and ACCHS should be established, facilitating staff exchange programs and closer collaboration between these complementary sectors of the health system. Closer partnerships should also be established between ACCHS and Primary Health Networks.

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Governments could incentivise these partnerships by tying them to Primary Health Networks’ and Local Health Districts’ funding for Indigenous health service provision.

Recommendation 2: Increase and stabilise funding: resource the ACCHS model of holistic care One of the most persistent challenges facing ACCHS in NSW is that they do not have enough funding, nor do they have funding stability, as Chapters 5 and 8 discussed. The evidence presented in this thesis shows that for the positive impacts of ACCHS’ services to be increased governments must invest in them over the long term. The following recommendations detail how governments could more effectively resource ACCHS.

2.1. The Commonwealth Department of Health should allocate additional base funding to ACCHS, restoring the funding cuts from the 2014 budget. This would allow ACCHS to deliver additional and a greater range of services and to attract additional highly-skilled staff. In the current neoliberal context this may be an unpalatable option for governments looking to reduce their fiscal outlay, however it will be necessary unless ACCHS can find other ways of generating revenue.

2.2. Governments and Primary Health Networks must stabilise the policy and funding environment in which ACCHS operate. Adopting five-year funding agreements as standard practice in First Nations health-service-provision would allow ACCHS to plan over the longer term, recruit skilled staff, and establish greater Aboriginal-community commitment to and trust in new health programs and services.

2.3. Governments and Primary Health Networks should fund all elements of the ACCHS family-based holistic model of health care. More funding should be invested in illness- prevention, health promotion programs, and early intervention. More funding should also be allocated to poverty mitigation services or ‘emergency relief’.

2.4. Social and Emotional Wellbeing services should be a funding priority for Primary Health Networks and governments. Additional funding should be allocated for mental health services (including Bringing them Home Programs and Men’s Groups, Mums and Bubs Groups), domestic violence services and drug and alcohol treatment and rehabilitation services and their value recognised. The creation of more Aboriginal Community Controlled

285 residential drug-and-alcohol rehabilitation centres should be a priority area for government investment.

2.5. The Commonwealth should alter the payment structures of the Medicare Benefits Schedule to reflect the longer and more complex nature of consultations with Aboriginal and Torres Strait Islander patients in ACCHS.

2.6. Government Departments and Primary Health Networks should consider reforming Indigenous primary healthcare funding models to account for client numbers, the range of services provided, and the quality of care. Rather than judging organisations on their grant- writing ability and value for money considerations (as in open competitive tendering) governments should prioritise the ACCHS values of holistic primary health care as the best- practice approach for improving First Nations health.

Recommendation 3: Cede power: recognise ACCHS as leaders in Aboriginal health care The ACCHS sector’s relative powerlessness compared to government actors and mainstream health organisations such as LOCAL HEALTH DISTRICTs is a major challenge, as was argued in chapters 7 and 8. The following recommendations set out some strategies for overcoming this power asymmetry through reforming Indigenous health decision-making and funding processes.

3.1. Governments should mandate Aboriginal representation on PHN boards and the establishment of Aboriginal Consultative Committees. Aboriginal representation and consultation should be mandatory for all Primary Health Networks that receive Commonwealth funding for Indigenous primary health care.

3.2. Governments, Primary Health Networks and Local Health Districts must address the power imbalance, giving ACCHS a leading role in Aboriginal health. A proportion of all Indigenous primary health funding should be quarantined for ACCHS and they should have the discretion to spend it on the services of most need, as determined by First Nations communities. In line with the recommendations of the Redfern Statement, outlined in Chapter 1, governments and Primary Health Networks should make ACCHS preferred

286 providers of Aboriginal primary health care, and implement a more relational approach to contracting.

3.3. The Commonwealth should commission an audit of Indigenous primary health care funding currently administered by Primary Health Networks. Primary Health Networks’ Indigenous specific health funding should be transferred to ACCHS and Aboriginal Community Control of this funding should be formalised.

3.4. Governments, Primary Health Networks, Local Health Districts, mainstream NGOs and ACCHS should work towards closer partnerships in First-Nations health services and planning. ACCHS should be offered a leading role in all partnerships, in recognition of their experience, expertise and connections to local First Nations communities. The Commonwealth and NSW governments should make it mandatory for Local Health Districts, Primary Health Networks and mainstream NGOs to engage with ACCHS and other relevant Aboriginal organisations when making decision about Aboriginal health and other services.

3.5. Governments, Primary Health Networks, and Local Health Districts should ask ACCHS and other First Nations’ representatives to co-design new selection criteria and priority areas for Indigenous health funding. Aboriginal organisations, including ACCHS, should take a leading role in this redesign to ensure that funding priorities and processes align with the health priorities of Aboriginal communities. Any redesign of grant selection criteria could consider measures that would give weighting to Aboriginal Community Control over service provision, given the health benefits that flow from this model, as Chapter 2 explained. This would structure Indigenous self-determination into the funding model the use of open competitive tendering.

3.7. Primary Health Networks and government funders should consider running closed tender processes with ACCHS. This would involve directly approaching ACCHS to discuss the possibility of using new funding to expand existing services and build on ACCHS knowledge and experience. While contestability and the competitive tendering processes that it inspires are central elements of current approaches to NPM in Australia, their application to Indigenous health policy contexts should be considered carefully in light of the evidence presented in this thesis.

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3.6. Governments, Primary Health Networks, and Local Health Districts need to establish open channels of communication with Aboriginal Community Controlled organisations and First Nations peoples. This is needed to promote Aboriginal Community Control over the decisions that directly affect Aboriginal health services.

Recommendation 4: Simplify processes: streamline reporting and tender writing The bureaucratic overburden emerged in this research as a constant source of stress and frustration for ACCHS managers and CEOs. Overly complex and duplicated reporting requirements, particularly from Primary Health Networks, are preventing ACCHS staff from delivering services, as chapters 7 and 8 demonstrated. This was found to have a disproportionate effect on the ACCHS sector. This section of recommendations offers some strategies for streamlining reporting and reorienting it towards Aboriginal-community measures of success or failure.

4.1. Governments and Primary Health Networks should reduce and streamline ACCHS activity reporting and grant application requirements. Commonwealth departments and Primary Health Networks should coordinate their reporting requirements to reduce the duplication and complexity of ACCHS’ reporting and funding applications.

4.2. Government departments and Primary Health Networks should collaborate with ACCHS and other First Nations representatives to develop locally relevant performance indicators and measures of success. This would more closely align government accountability mechanisms with First Nations priorities, making performance measurement and evaluation meaningful and useful processes for local Aboriginal communities. This work could inform and build on the Productivity Commission’s recent efforts to develop a whole- of-government Indigenous Evaluation Strategy (Productivity Commission 2019).

4.3. The Commonwealth government should make all Aboriginal health funding the responsibility of the Department of Health. Social and Emotional Wellbeing funding, and funding for drug and alcohol services, recently transferred to the new National Indigenous Australians Agency, should be administered by the Department of Health thereby recognising the holistic nature of health and wellbeing and the need for coordinated and integrated service responses. Locating these portfolio responsibilities in Health would also

288 simplify activity reporting and make the ‘ghettoisation’ of Aboriginal health services less likely.

Recommendation 5: Monitor ‘the mainstream’: hold Local Health Districts and non-Aboriginal NGOs accountable for Aboriginal health Chapter 7 outlined how some mainstream service providers are taking advantage of Aboriginal-specific Medicare items, using them as a revenue source without providing adequate follow-up care and information to Aboriginal patients. Evidence from ACCHS representatives also highlighted inefficiencies in mainstream service providers’ performance in Aboriginal health. Thus, holding mainstream organisations accountable for Aboriginal health outcomes presents a major challenge to the performance of the health system in this area. Below, are some strategies for improving accountability through funding reforms.

5.1. The Commonwealth government should commission an audit of the use of Aboriginal-specific Medicare items. The audits should look at Chronic Disease Management Plans (MBS item 721), Team Care Arrangements (MBS item 723) and Aboriginal and Torres Strait Islander Peoples Health Assessments (MBS item 715). The audit should assess the level at which ACCHS and mainstream service providers are claiming these Medicare items, and the level of services being provided by each type of service provider. Some measures of patient outcome should also be developed, and the effectiveness of these Medicare funded procedures should be evaluated. The evaluation should consider client satisfaction, referral to additional services, follow up care, as well as chronic-disease-management outcomes.

5.2. Pending the outcome of the above-mentioned audit, the Commonwealth should consider reforming the Aboriginal and Torres Strait Islander Peoples Health Assessment (MBS item 715) into a two-tiered system, with a higher rate of payment going to service providers that provide follow-up care and disease management services to First Nations clients.

5.3. Government departments and Primary Health Networks should conduct reference checks for organisations applying for Indigenous health funding, as suggested by Amy in Chapter 8. Aboriginal Community Controlled organisations or purpose-built committees representing Aboriginal service-users are two possible sources of such references.

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Government funding bodies and Primary Health Networks should also cross-check information presented in funding applications with information held by other Departments or Primary Health Networks who have previously entered into funding agreements with prospective funding recipients.

5.4. Governments and Primary Health Networks should prioritise funding for organisations that can demonstrate connections and accountability to local First Nations communities. Having Aboriginal representation on the board or having an Aboriginal Consultative Committee with veto power are two possible strategies for generating greater First Nations oversight of service providers working in their communities. Aboriginal Community Control should be the overarching principle guiding funding in Indigenous health, with First Nations participation in the governance of Indigenous health service delivery being the ultimate goal.

Recommendation 6: Strengthen ACCHS governance against external and internal instability Chapter 6 explored the tensions ACCHS boards of directs encounter when trying to perform both corporate and community governance simultaneously. Interviewees offered four main recommendations for improving the corporate governance capacity of Aboriginal Community Controlled boards. The recommendations listed below are mindful of the fundamental importance of Aboriginal Community Control in First Nations health service delivery, and therefore prioritise community governance over corporate governance, while suggesting ways of strengthening the latter.

6.1. Considering the increasing corporate governance requirements imposed by governments and other funding bodies, ACCHS should consider creating skills-based positions on their boards of community directors. These positions should be filled by members of the local First Nations community to ensure a balance between corporate and community governance. If an ACCHS decides to appoint non-Aboriginal skills-based directors, these positions should never outnumber the Aboriginal community positions, to maintain Aboriginal Community Control. Another option is to create positions on ACCHS boards for non-voting skills-based directors, to allow for corporate governance specialists who may not be Indigenous people.

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6.2. ACCHS should consider employing corporate governance specialists, such as finance officers and business managers to reduce the workload of the CEO and assist the Aboriginal community board with its corporate governance responsibilities. The Commonwealth and NSW Governments and the Primary Health should explore options for funding these new ACCHS staff positions to reduce the associated costs for ACCHS. These corporate governance specialists should report to the Aboriginal community through the CEO and the Aboriginal community board of directors.

6.3. ACCHS should explore options for recruiting youth onto their boards of community directors. The inclusion of younger members of First Nations communities in governance structures could help ACCHS better understand and respond to the health-and- wellbeing needs of Aboriginal young people and future proof the organisations.

6.4. ACCHS should maintain their commitment to corporate governance training. The Commonwealth government should provide more funding opportunities for ACCHS board members and staff who wish to complete such training. The NSW government should provide more funding to the Aboriginal Health and Medical Research Council (AH&MRC) for the purposes of running corporate governance training for affiliated ACCHS. The delivery of corporate governance training by Aboriginal peak bodies such as AH&MRC should be prioritised because of their ability to understand ACCHS’ community governance responsibilities.

6.5. The Commonwealth government and/or the NSW government should consider sponsoring a series of NSW or national ACCHS-sector governance forums, where ACCHS CEOs and board members would meet to discuss strategies for balancing corporate and community governance responsibilities. This would not just involve training in corporate governance but conceptualising what Aboriginal Community Control means now and finding governance models that would ensure its continuation into the future.

Providing new answers to enduring policy problems This thesis concludes that that ACCHS sector’s role is to provide holistic, trauma-informed care to Aboriginal families, individuals and communities, in ways that respect local cultural requirements and accommodate local socioeconomic circumstances. The ACCHS sector

291 emerged as a response to institutional racism and poverty, as Chapter 2 detailed, and its holistic model of primary health care reflected international aspirations for greater community participation in health services. The ACCHS sector’s complex appreciation of the root causes of Indigenous health inequality, as documented in Chapter 6, and its multi- faceted responses to them make these Aboriginal Community Controlled organisations critically important to current efforts to Close the Gaps.

Additionally, the Aboriginal Community Controlled governance model is unique in the health system. The linkages between ACCHS and the First Nations communities that they serve make these organisations locally accountable. This governance structure also empowers Aboriginal communities to take control of their own health. Localised empowerment through Aboriginal Community Control is ACCHS’ defining characteristic and is essential to their special role in the health system.

The evidence presented in this thesis details the multifarious challenges faced by ACCHS in NSW. Overall, they relate to the ACCHS sector’s lack of power and resources relative to government policymakers, funding bodies and mainstream health providers. Mainstream Australia’s culture of healthcare, organised around the biomedical understanding of health and embodying an institutional racism that denigrates Aboriginal models of care, forecloses holistic family-based healthcare options for Aboriginal peoples and organisations. The biases and incentive structures of government funding and reporting systems reinforce this biomedical dominance and institutional racism. The ongoing influence of neoliberal ideology and the popularity of NPM policy techniques also undermine ACCHS’ holistic model of care, threating their funding, and pushing them towards a more business-minded approach. These cultural, ideological, material, bureaucratic, and political challenges are destabilising the ACCHS sector in NSW and undermining progress towards Aboriginal health equity.

The research and analysis conducted in this project have produced a thoroughgoing response to the overarching research question that was set out in Chapter 1:

In what ways might government policy be reformed to allow space for genuine Aboriginal self-determination in health and enable ACCHS to improve First Nations’ health and wellbeing?

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Based on conversations with key stakeholders in the ACCHS sector in NSW, this research concludes that closer partnerships and structural reform are essential if the health system is to better serve First Nations peoples. Interviewees, in their explanations of individual, family and community-level health, urged governments to recognise ACCHS as the leaders in primary health care for First Nations peoples. Therefore, this thesis concludes that governments must give ACCHS greater autonomy and more stable resourcing if these critically important organisations are to overcome the multiple health challenges facing their peoples. In simple terms, ACCHS need more power to make a bigger impact on First Nations health.

The evidence gathered from the field in this research project highlighted a critical need for the Commonwealth and NSW governments and mainstream health service providers to confront the institutional racism that informs service provision and funding decisions. Aboriginal cultural safety in healthcare settings must be prioritised and Aboriginal understandings of health and wellbeing must be respected, and appropriately and adequately funded if Aboriginal health outcomes are to improve.

This thesis has found that the current funding models, application and reporting processes and accountability structures in operation in Indigenous health are not supportive of Aboriginal Community Control. These processes require an overhaul, bringing them into line with First Nations priorities, values and organisational structures.

This thesis concludes that ACCHS too must confront their own internal organisational challenges and find ways of balancing the older cultural governance with the newly imposed corporate governance.

Evidence presented in this thesis shows that the mainstream elements of the NSW health system need to develop their inter-cultural capacity in the interests of the quality of First Nations health care.

Central contributions of this research This thesis has expanded understanding of the outcomes of three major Commonwealth policies by gathering data from the frontlines of Aboriginal service delivery and mapping the grass-roots effects in Aboriginal organisations and communities. It has uncovered

293 substantial evidence of institutional racism in Indigenous health policy and service delivery, theorising the influence of settler-colonial ideological structures in funding systems and processes of care. A major contribution of this thesis is its development of a complex and nuanced theory of Aboriginal health inequity, based on ACCHS representatives’ understandings of the root causes of First Nations peoples’ health and social problems.

An important contribution of this thesis has been its exploration of how the Commonwealth’s creation of PHNs has significantly destabilised the Indigenous health service delivery space, because of the disproportionate power that these new quasi- government actors enjoy. Voicing the ACCHS sector’s concerns about this development is an important outcome of this research project. Overall, this thesis has generated knowledge about what the ACCHS sector does that is unique and why it should be nurtured, documenting the sector’s unparalleled understanding of Aboriginal health and wellbeing and its deep roots in NSW Aboriginal communities.

The thesis provides a significant repository of knowledge about the many challenges facing these organisations daily. The geographical scope of the study, the number of participating individuals and organisations and its theoretical and analytical ambition make this study a valuable source of information for policymakers, researchers and practitioners engaged or interested in Aboriginal health services, organisations and policy.

Future research directions One of the crucial contributions of this research has been its examination of the Aboriginal Community Controlled governance model, exploring implications for the appropriateness and responsiveness of services. The embryonic literature investigating the linkages between community empowerment and wellbeing offers some promising avenues for understanding how the political structures of community organisations influence their effectiveness. Future research should focus on the mechanisms that translate local-level organisational accountability and community participation service delivery into improved health outcomes for the individuals, families and communities that use those services. As Chapter 6 explored, there is a growing evidence base that demonstrates a correlation between greater community involvement in service delivery and greater community health benefits.

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This research project has found evidence of recent Indigenous Affairs policy changes having a detrimental impact on a significant part of the Indigenous sector. Future studies are warranted mapping the broader effects of the IAS on Aboriginal Community Controlled organisations in areas other than health. Similar investigations should be conducted into the IAS’s impact on Aboriginal Legal Services, Local Aboriginal Land Councils, and Aboriginal childcare organisations. This would shed light on the broader outcomes of this significant shift in the Commonwealth government’s approach to Indigenous Affairs policymaking. Future research should also look at how ACCHS in other Australian states and territories have fared under the IAS, IAHP and PHNs. Given the seismic change that these policies created for ACCHS in NSW, it seems appropriate to compare their experiences with ACCHS in other states, to look for adaptation and resilience-building strategies and to evaluate the policy influence and approaches of other state and territory governments in First Nations health.

Emerging sites of First Nations empowerment The Commonwealth government is currently considering alternate approaches to Indigenous Affairs policy making, particularly in health. The available information about the Closing the Gap Refresh indicates that governments are exploring ways to act on the social and cultural determinants of Indigenous health, building on the findings of a recent report (DoH 2017a). Additionally, the Council of Australian Governments has signed a partnership agreement with a coalition of peak Aboriginal Community Controlled organisations, including AH&MRC and the National Aboriginal Community Controlled Health Organisation (NACCHO), whose CEO Patricia Turner, alongside former Indigenous Affairs Minister Nigel Scullion, was co-chair of the first meeting of the parties (Morrison & Turner 2019). The agreement (COAG & CoP 2019) commits governments to shared decision-making, policy design and monitoring of new Closing the Gap targets. This decision has been welcomed by NACCHO, with the CEO stating: “This is the first time Aboriginal and Torres Strait Islander community controlled organisations have had an equal voice at the table on Closing the Gap so I expect that the conversation will shift to what we believe is needed to achieve it” (NACCHO 2019b, para. 2). The Commonwealth also recently announced another promising development related to Indigenous empowerment, with the new Minister for Indigenous Australians Ken Wyatt committing his government to a referendum on an Indigenous

295 recognition in the Constitution (though not a voice to parliament) within the next three years (Wyatt 2019). Whether or not these promises materialise in policy authority and increased resources for First Nations organisations and communities remains to be seen, although they are hopeful signs for the future of Indigenous self-determination in health.

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References.

Aboriginal and Torres Strait Islander Peak Organisations [ATSIPO] (2016). The Redfern Statement National Congress of Australia’s First Peoples, retrieved from http://nationalcongress.com.au/about- us/redfern-statement/ viewed 19/10/2017.

Aboriginal and Torres Strait Islander Social Justice Commissioner [ATSISJC] (2015). “Submission no. 15 to the Senate Inquiry into Commonwealth Indigenous Advancement Strategy tendering processes” Australian Human Rights Commission, retrieved from http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administ ration/Commonwealth_Indigenous/Submissions, viewed 23/09/2016.

Aboriginal and Torres Strait Islander Social Justice Commissioner [ATSISJC] (2016) ‘Social Justice and Native Title Report 2016’, Australian Human Rights Commission, available at https://www.humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social- justice/publications/social-justice-and-2, accessed 14/01/2020.

Aboriginal and Torres Strait Islander Social Justice Commissioner (1996). ‘Indigenous Deaths in Custody 1989 – 1996’ Australian Human Rights Commission, retrieved from https://www.humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social- justice/publications/indigenous-deaths-custody, accesses 23/10/2018

Aboriginal Health and Medical Research Council of New South Wales [AH&MRC] (2008), ‘Constitution’, retrieved from http://www.ahmrc.org.au/media/resources/ah-mrc-constitution- strategic-plan/283-ah-mrc-of-nsw-constitution/file.html

Aboriginal Health and Medical Research Council of New South Wales Ethics Committee (2016). ‘Guidelines for Research into Aboriginal Health: Key Principles’ Aboriginal Health and Medical Research Council of New South Wales, retrieved from https://n8p4t5m5.stackpathcdn.com/wp- content/uploads/2019/07/AHMRCGuidelinesforResearchKeyPrinciples.pdf

Aboriginal Health and Medical Research Council of NSW (2015). “Aboriginal communities improving Aboriginal health: An evidence review on the contribution of Aboriginal Community Controlled Health Services to improving Aboriginal health”, accessed 17/02/2017, retrieved from http://www.ahmrc.org.au/media/resources/research/298-aboriginal-communities-improving- aboriginal-health/file.html

Ah Chee, D (2019) ‘Given this history of strength and success, why do Aboriginal health dollars keep going to NINGOs?’ Croakey, 14 August, retrieved from https://croakey.org/given-this-history-of- strength-and-success-why-do-aboriginal-health-dollars-keep-going-to- ningos/?mc_cid=5728659737&mc_eid=7269a969fc, accessed 10/09/2019.

Albury Wodonga Aboriginal Health Service [AWAHS] (n.d.) ‘Constitution of Albury Wodonga Aboriginal Health Service Ltd’, available at https://www.awahs.com.au/wp- content/uploads/2019/08/AWAHS-Constitution-05-09-20181.pdf, accessed 06/01/2020.

Alexander H (2016) “Calls for a permanent Aboriginal medical service in western Sydney as another one goes under” The Sydney Morning Herald, March 6, retrieved from

298 http://www.smh.com.au/national/health/calls-for-a-permanent-aboriginal-medical-service-in- western-sydney-as-another-one-goes-under-20160303-gn9jhc.html, viewed 29/04/16

Alford K (2015) “Indigenous health expenditure deficits obscured in Closing the Gap reports” MJA 203 (10), pp. 403-4

Alford, K (2014), ‘Economic Value of Aboriginal Community Controlled Health Services’ National Aboriginal Community Controlled Health Organisation, retrieved from https://apo.org.au/node/39333

Allam L (2019) ‘Government fails to guarantee funding for key Indigenous body’, The Guardian, 18 June, retrieved from https://www.theguardian.com/australia-news/2019/jun/18/national- indigenous-body-will-have-to-meet-strict-conditions-for-funding-administrator

Allan J, Clifford A, Ball P, Alston M, Meister P, (2012) ‘You're Less Complete if You Haven't Got a Can in Your Hand: Alcohol Consumption and Related Harmful Effects in Rural Australia: The Role and Influence of Cultural Capital’, Alcohol and Alcoholism, Volume 47, Issue 5, Pp. 624- 629, https://doi.org/10.1093/alcalc/ags074

Altman J (2014) “Indigenous policy: Canberra consensus on a neoliberal project of improvement” in C Miller and L Orchard, Australian Public Policy: Progressive Ideas in the Neoliberal Ascendency, Policy Press, Bristol.

Altman, J & Hinkson, M (2007) Coercive Reconciliation: Stabilise, Normalise, Exit Aboriginal Australia, Arena, North Carlton.

Altman, J (2007) ‘Neo-Paternalism and the Destruction of CDEP’, Arena Magazine 90, August– September.

Altman, J (2009). “Beyond Closing the Gap: Valuing Diversity in Indigenous Australia” Centre for Aboriginal Economic Policy Research, Working Paper No. 54.

Anderson I (2007) ‘Understanding the processes’, in B Carson, T Dunbar, RD Chenhall & R Bailie 2007, Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 21-40

Anderson IP & Whyte JD (2008) “Research, Evaluation and Aboriginal Health Care” in S Couzos & R Murray for the Kimberley Aboriginal Medical Services Council, Aboriginal Primary Health Care, Oxford University Press, South Melbourne.

Anderson I, Robson B, Connolly M, Al-Yaman F, Bjertness E, King A, et al. (2016) “Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study”, vol. 338, no. 10040, https://doi.org/10.1016/S0140-6736(16)00345-7

ASIC (2014) ‘Corporate Governance’ retrieved from https://asic.gov.au/regulatory- resources/corporate-governance/

Aspin, C, Brown, N, Jowsey, T, Yen, L, Leeder, S (2012) ‘Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study’. BMC Health Services Research; vol. 12, no. 143.

299

Atkinson, J (2002) Trauma Trails, Recreating Song Lines: The Transgenerational Effects of Trauma in Indigenous Australia, Spinifex, North Melbourne.

Atkinson, S. (2011). ‘Moves to measure wellbeing must support a social model of health’. BMJ: British Medical Journal (Online), 343 doi: http://dx.doi.org/10.1136/bmj.d7323

Atkinson J, Nelson J, & Atkinson C (2010) “Trauma, Transgenerational Transfer and Effects on Community Wellbeing” in N Purdie, P Dudgeon, & R Walker (eds), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice, Australian Institute of Health and Welfare, Canberra, ACT, pp. 135-144. Available at https://www.aipro.info/wp/wp- content/uploads/2017/08/Trauma_transgenerational_transfer.pdf, accessed 14/01/2020.

Atkinson J, Nelson J, Brooks R, Atkinson C & Ryan K, (2014) “Addressing Individual and Community Transgenerational Trauma”, in P Dudgeon, H Milroy and R Walker (eds.) Working Together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice, Commonwealth of Australia, available at https://www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/working- together-second-edition/working-together-aboriginal-and-wellbeing-2014.pdf, accessed 14/01/2020, pp. 289-306.

Attwood B (2003), Rights for Aborigines, Allen & Unwin: Crows Nest.

Attwood, B (1992) ‘Introduction’, Journal of Australian Studies, vol. 16, no. 35, pp. 1-16, DOI: 10.1080/14443059209387113.

Australian Bureau of Statistics (2016b) ‘2016 Census Community Profiles’, Commonwealth of Australia, retrieved from https://www.abs.gov.au/websitedbs/D3310114.nsf/Home/2016%20Census%20Community%20Profi les

Australian Bureau of Statistics [ABS] (2016a) ‘ASGS Volume 5 - Remoteness Structure’ retrieved from http://www.abs.gov.au/ausstats/[email protected]/mf/1270.0.55.005

Australian Bureau of Statistics (2017) ‘2016 Census shows growing Aboriginal and Torres Strait Islander population’, Media Release 27 June, available at https://www.abs.gov.au/ausstats/[email protected]/MediaRealesesByCatalogue/02D50FAA9987D6B7CA258 14800087E03, accessed, 07/01/2020

Australian Government (2013a) ‘National Commission of Audit: Terms of Reference’, Commonwealth of Australia, retrieved from https://www.ncoa.gov.au/sites/g/files/net4136/f/nca_terms_of_reference.pdf, accessed 30/10/1987

Australian Government. (2013b). National Aboriginal and Torres Strait Islander Health Plan 2013– 2023. Commonwealth of Australia, Accessed 22 May 2018. Retrieved from http://www.health.gov.au/natsihp

Australian Government (2014a) “Budget Paper No. 2, Budget 2014-15, Expenses Measures: Indigenous Affairs Programmes - rationalisation” Commonwealth of Australia, retrieved from http://budget.gov.au/2014-15/content/bp2/html/bp2_expense-20.htm accessed 23/05/2016

300

Australian Government (2014b) “Health Portfolio Budget Statements 2014-15, Outcome 5: Primary Health Care”, Commonwealth of Australia, retrieved from http://www.health.gov.au/internet/budget/publishing.nsf/Content/2014- 2015_Health_PBS_sup1/$File/2014-15_Health_PBS_2.05_Outcome_5.pdf accessed 24/04/2018

Australian Government (2016) “Australian Government response to the Senate Finance and Public Administration References Committee Report: Commonwealth Indigenous Advancement Strategy tendering processes” retrieved from https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Adminis tration/Commonwealth_Indigenous/Government_Response, accessed 24/04/2018

Australian Institute of Aboriginal and Torres Strait Islander Studies [AIATSIS] (2012), ‘Guidelines for Ethical Research in Australian Indigenous Studies’, AIATSIS, Canberra, retrieved from https://aiatsis.gov.au/sites/default/files/docs/research-and-guides/ethics/gerais.pdf

Australian Institute of Health and Welfare (2018) ‘Aboriginal and Torres Strait Islander health organisations Online Services Report – key results 2016-17’, Aboriginal and Torres Strait Islander health services report no. 9. Cat. no. IHW 196. Canberra: AIHW, retrieved from https://www.aihw.gov.au/reports/indigenous-health-welfare-services/health-organisations-osr-key- results-2016-17/contents/table-of-contents

Australian Institute of Health and Welfare (2009) ‘Measuring the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples’, Cat. no. IHW 24. Canberra: AIHW,retrieved from https://www.aihw.gov.au/getmedia/5b75be10-49ee-4d9c-baf0- 5092936c585e/msewatsip.pdf.aspx?inline=true

Australian Institute of Health and Welfare (2016) ‘Healthy Futures Aboriginal Community Controlled Health Services Report Card 2016’, Australian Institute of Health and Welfare, Canberra, Cat. no. IHW 171, retrieved from https://www.aihw.gov.au/reports/indigenous-health-welfare- services/healthy-futures-aboriginal-community-controlled-health-services-report-card- 2016/contents/table-of-contents

Australian Institute of Health and Welfare (2017b) “National Key Performance Indicators for Aboriginal and Torres Strait Islander primary health care: Results from June 2016” Australian Government, retrieved from https://www.aihw.gov.au/reports/indigenous-health-welfare- services/nkpis-indigenous-australians-health-care-2016/contents/table-of-contents accessed 3/04/2018

Australian Institute of Health and Welfare [AIHW] (2017a), ‘Aboriginal and Torres Strait Islander Health Performance Framework: New South Wales’ Cat. no. IHW 182. Canberra: AIHW, retrieved from https://www.aihw.gov.au/reports/indigenous-health-welfare/health-performance-framework- 2017-nsw/contents/table-of-contents

Australian National Audit Office [ANAO] (2017) “ANAO Report No.35 2016–17: Indigenous Advancement Strategy” Commonwealth of Australia, retrieved from https://www.anao.gov.au/work/performance-audit/indigenous-advancement-strategy, accessed 24/04/2018

Australian National Audit Office (2019) ‘Evaluating Aboriginal and Torres Strait Islander Programs’ Commonwealth of Australia retrieved from https://www.anao.gov.au/sites/default/files/Auditor- General_Report_2018-2019_47.PDF

301

Australian National Audit Office (2007) ‘Whole of Government Indigenous Service Delivery Arrangements’, Commonwealth of Australia, available at https://www.anao.gov.au/sites/default/files/ANAO_Report_2007-2008_10.pdf, accessed 11/01/2020.

Awabakal (2018) ‘Annual Report 2017 – 2018’, Awabakal Ltd, Wickham, NSW, available at http://www.awabakal.org/Awabakal-Annual-Report2018-Web.pdf, accessed 06/01/2020

Awofeso, N (2011), ‘Racism: a major impediment to optimal Indigenous health and health care in Australia’. Australian Indigenous Health Bulletin, vol. 11, no. 3, pp. 1-13.

Baba, JT, Brolan, CE and Hill, PS (2014), ‘Aboriginal medical services cure more than illness: a qualitative study of how Indigenous services address the impacts of discrimination in Brisbane’, International Journal for Equity in Health. Vol. 13, no. 56. doi: https://doi.org/10.1186/1475-9276- 13-56 .

Bacchi, C (2009), Analysing policy: what’s the problem represented to be?, Pearson Education, Frenchs Forest.

Bacchi, C (2012), ‘Introducing the ‘What’s the Problem Represented to be?’ approach’, in A Bletsas & C Beasley (eds.), Engaging with Carol Bacchi: Strategic Interventions and Exchanges, University of Adelaide Press, Adelaide.

Bailie R (2007) ‘Housing’ in B Carson, T Dunbar, RD Chenhall & R Bailie 2007, Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 203-230.

Bartlett, B, and Boffa, J (2005) ‘The impact of Aboriginal community controlled health service advocacy on Aboriginal health policy’ Australian Journal of Primary Health vol. 11, no. 2, pp. 53-61. https://doi.org/10.1071/PY05022

Battin T., (1998) ‘Unmaking the Australian Way’, in P Smyth and B Cass (eds.), Contesting the Australian Way: States, Markets and Civil Society, Cambridge University Press, pp. 94-110.

Baum FE, Legge DG, Freeman T, Lawless A, Labonté R, Jolley GM, (2013) “The potential for multidisciplinary primary healthcare services to take action on the social determinants of health: actions and constraints”, BMC Public Health, vol. 13, no. 460, retrieved from http://www.biomedcentral.com/1471-2458/13/460

Baum, F (2010) ‘Overcoming Barriers to Improved Research on the Social Determinants of Health’ MEDICC Review, Vol 12, No 3, pp. 36-38.

Baum, F 2015, The New Public Health, Fourth Edition, Oxford University Press, South Melbourne.

Baxter PE, Hewko SJ, Pfaff KA, Cleghorn L, Cunningham BJ, Elston D, Cummings GG (2015) “Leaders' experiences and perceptions implementing activity-based funding and pay-for-performance hospital funding models: A systematic review” Health Policy, vol. 119, no. 8, pp. 1096-1110.

Behrendt L (2005) ‘False Dichotomies and Other Barriers to Policy-Making for Aboriginal Communities’ in D Austin-Broos & G Macdonald (eds), Culture, Economy and Governance in Aboriginal Australia: Proceedings of a Workshop of the Academy of Social Sciences in Australia, Sydney University Press. Sydney, pp. 231-9.

302

Behrendt L (2009) ‘Home: The importance of Place to the Dispossessed’, South Atlantic Quarterly, vol. 108, no. 1, pp. 72-85.

Bell, K, Couzos, S, Daniels, J, Hunter, P, Mayers, N and Murray, R (2000), ‘Aboriginal Community Controlled Health Services’ in Commonwealth Department of Health and Aged Care, (ed.) General Practice in Australia: 2000. Commonwealth Department of Health and Aged Care, Canberra, pp. 74- 104, retrieved from http://www.kooriweb.org/foley/resources/pdfs/120.pdf

Bennett S, (1999), White Politics and Black Australians, Allen & Unwin, Crows Nest.

Berger PL & Luckmann T (1966) The Social Construction of Reality: A Treatise in the Sociology of Knowledge. Penguin Books, London.

Best, O (2014), ‘The cultural safety journey: An Australian nursing context’ in O Best and B Fredericks (eds) Yatdjuligin: Aboriginal and Torres Strait Islander Nursing and Midwifery Care, Cambridge University Press, Port Melbourne, pp. 51-73.

Best, O and Fredericks, B (eds) (2014), Yatdjuligin: Aboriginal and Torres Strait Islander Nursing and Midwifery Care, Cambridge University Press, Port Melbourne.

Bevan G & Hood C (2006) “What’s measured is what matters: targets and gaming in the English public health care system”, Public Administration, vol. 84, no. 3, pp. 517–538.

Biddle, N (2012), ‘Improving Indigenous health: Are mainstream determinants sufficient?’, in B Hunter and N Biddle (eds), Survey Analysis for Indigenous Policy in Australia Social Science Perspectives, ANU E Press, pp. 65-78, retrieved from https://press.anu.edu.au/publications/series/caepr/survey-analysis-indigenous-policy-australia

Bielefeld S (2016) “Neoliberalism and the return of the guardian state: Micromanaging Indigenous peoples in a new chapter of colonial governance” in Will Sanders (ed.), Engaging Indigenous Economy: Debating Diverse Approaches, Australian National University Press, Canberra, pp. 155-169.

Bielefeld, S (2018), ‘Indigenous peoples, neoliberalism and the state: A retreat from rights to ‘responsibilisation’ via the cashless welfare card’ in D Howard-Wagner, M Bargh and I Altamirano- Jiménez (eds), The Neoliberal State, Recognition and Indigenous Rights: New Paternalism to New Imaginings. Canberra: Australian National University Press, pp. 147-166.

Biggs, A., (2003) ‘Medicare – Background Brief’, Parliamentary Library of Australia, Canberra, retrieved from https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/Pu blications_Archive/archive/medicare

Biripi Aboriginal Corporation Medical Centre (2019) ‘The Rule Book of Biripi Aboriginal Corporation Medical Centre’, available at https://biripi.org.au/wp-content/uploads/2019/09/Consolidated-Rule- Book.pdf, accessed 06/01/2020.

Birn AE (2009) “Making it Politic(al): Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health” Social Medicine, vol. 4, no. 3, September, pp. 166-182.

Boles, SM & Miotto K, (2003) “Substance abuse and violence: A review of the literature, Aggression and Violent Behavior, vol. 8, Issue 2, pp. 155-174, https://doi.org/10.1016/S1359-1789(01)00057-X

303

Bond C (2015) “Indigenous-controlled sector the clear loser of Indigenous Reform Agenda” Crikey, 23 March, retrieved from https://www.crikey.com.au/2015/03/23/indigenous-controlled-sector-the- clear-loser-of-indigenous-reform-agenda/, viewed 22/09/2016.

Booth, M., & Boxall, A. (2016). Commissioning services and primary health networks. Australian Journal of Primary Health, 22, 3–4.

Boulton, J (2016), Aboriginal Children, History and Health: Beyond Social Determinants, Routledge, New York.

Bourdieu P (2002) “Habitus” In: Hillier J and Rooksby E (eds) Habitus: A Sense of Place, pp. 27–34. Burlington, VT: Ashgate.

Bourke Aboriginal Health Service Limited [BAHSL] (2014) “Constitution”, available at https://www.bahs.com.au/assets/uploads/115/files/BAHSConstitution.pdf, accessed 17/01/2020.

Bourke, CJ, Marrie, HM and Marrie, A (2018) ‘Transforming institutional racism at an Australian hospital’, Australian Health Review, https://doi.org/10.1071/AH18062

Boxall A (2011) “What are we doing to ensure the sustainability of the health system? Research Paper no. 4 2011–12”, Parliamentary Library, retrieved from https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pu bs/rp/rp1112/12rp04 accessed 24/04/2018.

Bradfield S (2006) “Separatism or Status-Quo?: Indigenous Affairs from the Birth of Land Rights to the Death of ATSIC”, Australian Journal of Politics and History, vol. 52, iss. 1, pp. 80-97.

Braveman, PA, Egerter, SA, Mockenhaupt RE (2011), ‘Broadening the Focus The Need to Address the Social Determinants of Health’ American Journal of Preventive Medicine, vol. 40, no. 1S1 pp. S4 –S18, doi: 10.1016/j.amepre.2010.10.002

Breen L (2007) ‘The researcher “in the middle”: Negotiating the insider/outsider dichotomy’, The Australian Community Psychologist, Volume 19 No 1, pp. 165-174

Brigg M & Murphy L (2011) ‘Beyond Captives and Captors: Settler-Indigenous Governance for the 21st Century’, in S Maddison and M Brigg (eds) Unsettling the Settler State: Creativity and Resistance in Indigenous Settler-State Governance, The Federation Press, Annandale.

Brigg M (2007) ‘Biopolitics meets Terrapolitics: Political Ontologies and Governance in Settler- Colonial Australia, Australian Journal of Political Science, 42:3, 403-417, DOI: 10.1080/10361140701513554

Brigg, M & Curth-Bibb, J (2017) “Recalibrating intercultural governance in Australian Indigenous organisations: the case of Aboriginal community controlled health”, Australian Journal of Political Science, vol. 52, no. 2, pp. 199-217.

Brooks, R., te Riele, K., & Maguire, M. (2014) “Identity, power and positionality”. In Research Methods in Education: Ethics and education research (pp. 100-116). London: SAGE Publications Ltd, doi: 10.4135/9781473909762.

304

Broome R, (2010), Aboriginal Australians: A history since 1788, 4th edition, Allen & Unwin: Crows Nest.

Brown L (2012) ‘The criminalisation of conduct: Indigenous youth in the criminal justice system’, Indigenous Law Bulletin, Volume 7 Issue 28, pp. 8-11.

Brunner, E and Marmot, M (2006), ‘Social organisation, stress and health’ in M Marmot and RG Wilkinson (eds) The Social Determinants of Health, second edition, Oxford University Press, Oxford, pp. 6-30.

Bullinah Aboriginal Health Service Aboriginal Corporation [AHSAC] (2015), ‘Annual Report 2014’, Ballina NSW, available at http://bullinahahs.org.au/wp-content/uploads/2019/02/Annual-Report- 2014-2015.pdf, accessed 06/01/2020.

Bullinah Aboriginal Health Service Aboriginal Corporation [AHSAC] (2014), ‘Annual Report 2015’, Ballina NSW, available at http://bullinahahs.org.au/wp-content/uploads/2019/02/Annual-Report- 2013-2014.pdf, accessed 06/01/2020.

Bulloch H & Fogarty W (2016) “Freeing the ‘Aboriginal Individual’: Deconstructing ‘Development as Freedom’ in Remote Indigenous Australia”, Social Analysis, vol. 60, iss. 3, Autumn, pp. 76–94.

Burgmann, V (2003), “The Aboriginal Movement” in Power, profit and protest: Australian social movements and globalisation, Allen & Unwin, Crows Nest.

Burns, JK (2015), ‘Poverty, inequality and a political economy of mental health’, Epidemiology and Psychiatric Sciences, vol. 24, iss. 2, pp. 107-113 doi:10.1017/S2045796015000086.

Busija L, Cinelli R, Toombs MR, Easton C, Hampton R, Holdsworth K, Macleod B, Nicholson GC, Nasir BF, Sanders KM, McCabe MP (2018) ‘The role of elders in the wellbeing of a contemporary Australian Indigenous community’, The Gerontologist, gny140, https://doi.org/10.1093/geront/gny140

Calma T (2007a) “Social determinants and the health of Indigenous peoples in Australia – a human rights based approach”, Workshop paper presented by Mr Darren Dick on behalf of Mr Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner, International Symposium on the Social Determinants of Indigenous Health, Adelaide, 29-30 April, retrieved from https://www.humanrights.gov.au/news/speeches/social-determinants-and-health-indigenous- peoples-australia-human-rights-based

Calma T (2007b) “What makes good Indigenous Policy – Good, Better, Best – Policymaking for Indigenous Australians”, speech at the Collaborative Indigenous policy development: IQPC 6th Annual Conference, May 1, retrieved from https://www.humanrights.gov.au/news/speeches/collaborative- indigenous-policy-development, accessed 18/10/2017.

Calma, T (2007c) ‘Creating futures: influencing the social determinants of mental health and wellbeing in rural, Indigenous and Island peoples’ Australasian Psychiatry, vol. 15 supplement, pp. S5-S9.

Campbell MA, Hunt J, Scrimgeour DJ, Davey M, Jones V (2017) “Contribution of Aboriginal Community-Controlled Health Services to improving Aboriginal health: an evidence review”, Australian Health Review, vol. 42, no. 2, pp. 218–226. https://doi.org/10.1071/AH16149

305

Campbell, S and Brown, S (2004), ‘Maternity care with the women's business service at the Mildura Aboriginal Health Service’, Australian and New Zealand Journal of Public Health vol. 28, no. 4, pp. 376-82.

Carey, G., Buick, F., Pescud, M. and Malbon, E. (2016). ‘Preventing Dysfunction and Improving Policy Advice: The Role of Intra-Departmental Boundary Spanners.’ Australian Journal of Public Administration 76(2): 176-186.

Carmichael, S and Hamilton, C (1967), Black Power: The Politics of Liberation in America, Random House, New York.

Carver J (1997) Boards That Make a Difference: A New Design for Leadership in Nonprofit and Public Organiszations, Second Edition, Jossey-Bass Publishers, San Francisco.

Cass, B (1998) ‘The Social Policy Context’, in P Smyth and B Cass (eds.), Contesting the Australian Way: States, Markets and Civil Society, Cambridge University Press, pp. 38-58.

Chadwick E. (1842/1965) Report on the sanitary condition of the labouring population and on the means of its improvement. Reedited with introduction by MW Flinn. University Press, Edinburgh.

Chandler MJ, Lalonde CE (1998) “Cultural continuity as a hedge against suicide in Canada’s First Nations”, Transcultural Psychiatry, vol. 35, iss. 2, pp. 191–219, https://doi.org/10.1177%2F136346159803500202

Chandler MJ, Lalonde CE. (1998), ‘Cultural continuity as a hedge against suicide in Canada’s First Nations’. Transcultural Psychiatry, 35 191–219.

Charmaz K (2006) Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis, Sage Publications, London.

Chesterman J & Galligan, B., (1997) Citizens Without Rights: Aborigines and Australian Citizenship, Cambridge University Press, Cambridge.

Chesterman J (2005) Civil Rights: How Indigenous Australians Won Formal Equality, University of Queensland Press, St Lucia.

Coffin, J and Green, C (2017) ‘Decolonising Australian community development tools’, in C Kickett- Tucker, D Bessarab, J Coffin and M Wright (eds), Mia Mia Aboriginal Community Development: Fostering cultural security, Cambridge University Press, Port Melbourne. Pp. 73-90.

Colebatch HK (2006) ‘Mapping the work of policy’ in H.K. Colebatch, Beyond the Policy Cycle: The policy process in Australia, Allen and Unwin, Crows Nest.

Colgrove J (2002) "The McKeown Thesis: A Historical Controversy and Its Enduring influence" American Journal of Public Health, vol. 92, no. 5, pp. 725-729.

Collyer, F, Harley, K &Short S (2015) “Money and markets in Australia’s healthcare system” in G. Meagher & S. Goodwin (eds.) Markets, Rights and Power in Australian Social Policy, Sydney University Press, Sydney.

306

Commission on the Social Determinants of Health [CSDH] (2008), ‘Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health’ World Health Organization, Geneva. retrieved from https://www.who.int/social_determinants/thecommission/finalreport/en/

Commonwealth of Australia (2019), “Closing Gap Prime Minister’s Report 2019” Department of Prime Minister and Cabinet, retrieved from https://ctgreport.pmc.gov.au/sites/default/files/ctgreport-2019.pdf?a=1

Conifer, D, Leslie T, Tilley C, Liddy M (2017) “Closing the gap: Australia is failing on Indigenous disadvantage goals” ABC News, 14 February, retrieved from http://www.abc.net.au/news/2017-02- 14/closing-the-gap-report-card-failing/8268450

Considine M & Lewis J (2003) “Bureaucracy, Network, or Enterprise? Comparing Models of Governance in Australia, Britain, the Netherlands, and New Zealand”, Public Administration Review, vol. 63, no.2, pp. 131-140.

Considine M, O’Sullivan S & Nguyen P (2014) “Governance, Boards of Directors and the Impact of Contracting on Not-for-profit Organizations – An Australian Study”, Social Policy and Administration, Vol. 48, no. 2, pp. 169-187.

Coombs D (2018) ‘Primary Health Networks’ impact on Aboriginal Community Controlled Health Services’, Australian Journal of Public Administration, 77, S37-46, DOI: 10.1111/1467-8500.12357.

Cordella A & Willcocks L (2010) “Outsourcing, bureaucracy and public value: Reappraising the notion of the “contract state”, Government Information Quarterly, vol. 27, iss. 1, pp. 82-88.

Cornforth C (2001) What Makes Boards Effective? An examination of the relationships between board inputs, structures, processes and effectiveness in non-profit organisations”, Corporate Governance, 9(3):217-227.

Costa G, Spadea T, Dirindin N, (2002) ‘Italy’ in J Mackenbach and M Bakker (eds), Reducing inequalities in health: a European perspective. Routledge, London, pp. 229–239.

Council of Australian Governments (2008) “National Indigenous Reform Agreement” Commonwealth of Australia, retrieved from http://www.federalfinancialrelations.gov.au/content/npa/health_indigenous/indigenous- reform/national-agreement_sept_12.pdf, accessed 7/12/2015.

Council of Australian Governments [COAG] & The Coalition of Aboriginal and Torres Strait Islander Peak Organisations [CoP] (2019) ‘Partnership Agreement on Closing the Gap’, retrieved from https://www.coag.gov.au/sites/default/files/agreements/partnership-agreement-closing-the- gap_0.pdf

Couzos S & Delanay Thiele D (2009) “Closing the Gaps Depends on ACCHSs”, The Medical Journal of Australia, letters to the editor, vol. 190, no. 10, p. 541.

Couzos S & Delaney Thiele D (2007) “The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples?” Medical Journal of Australia, vol. 186, no.10 pp. 522-24.

307

Couzos S, Delaney Thiele D & Page P (2016) ‘Primary Health Networks and Aboriginal and Torres Strait Islander health’ Medical Journal of Australia, 204(6): 234-237.

Croakey (2015) “Hostile policies & processes: Indigenous health orgs under pressure (again) to secure funding” retrieved from https://croakey.org/hostile-policies-processes-indigenous-health- orgs-under-pressure-again-to-secure-funding/ accessed 24/04/2018.

Crouse T & Lowe PA (2018) ‘Snowball Sampling’, in B. Frey (ed.) The SAGE encyclopedia of educational research, measurement, and evaluation (Vols. 1-4). Sage Publications, Thousand Oaks, doi: 10.4135/9781506326139.

Cunneen, C, (2011) “Indigenous Incarceration: The Violence of Colonial Law and Justice” The Violence of Incarceration, UNSW Law Research Paper No. 2011-3. pp. 209-224, Available at SSRN: https://ssrn.com/abstract=1739351

Cunningham J & Baeza J I (2005) “An ‘experiment’ in Indigenous social policy: the rise and fall of Australia’s Aboriginal and Torres Strait Islander Commission (ATSIC)” Policy & Politics, vol. 33, no. 3, July, pp. 461-473.

Cunningham, J. (2002), 'Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous', Medical Journal of Australia, vol. 176, no. 2, pp. 58-62, doi: 10.5694/j.1326- 5377.2002.tb04284.x .

Dahlgren G and Whitehead M (1991), ‘Policies and strategies to promote social equity in health’. Institute for Future Studies, Stockholm.

Davidson H (2015) ‘Indigenous services plead with federal government to rethink cuts’, The Guardian, 10 March, retrieved from https://www.theguardian.com/australia- news/2015/mar/10/indigenous-services-plead-with-federal-government-to-rethink-cuts

Davis M (2013) “Community control and the work of the National Aboriginal Community Controlled Health Organisation: putting meat on the bones of the UNDRIP” Indigenous Law Bulletin, July / August, vol. 8, iss. 7, pp. 11-14.

Davy, C, Harfield, S,Mcarthur, A, Munn, Z, & Brown, A (2016) ‘Access to primary health care services for Indigenous peoples: A framework synthesis’, International Journal for Equity in Health, vol. 15, no. 1 pp. 1-9. Doi: 10.1186/s12939-016-0450-5. de Jong, G (2017) “Activity-based funding in mental health: a disastrous path”, Australasian Psychiatry, vol. 26, no. 1, pp. 27-29.

Denniss, R (2019), ‘The Morrison election: What we know now’, The Monthly, June, retrieved from https://www.themonthly.com.au/issue/2019/june/1559397600/richard-denniss/morrison-election- what-we-know-now

Department of Health (2015a) “Indigenous Australians’ Health Programme: Programme Guidelines” Commonwealth of Australia, available at http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-programme-lp accessed 14/11/16.

308

Department of Health (2016a) “Primary Health Networks: Grant Programme Guidelines” Australian Government, retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN- Program_Guidelines, accessed 23/10/2018.

Department of Health (2016b) “Designing and Contracting Services Guidance”, Australian Government, retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/PHNCommissioningResources accessed 10/04/2018.

Department of Health (2016c) “Primary Health Networks (PHNs) and Aboriginal Community Controlled Health Organisations (ACCHOs) – Guiding Principles’ Australian Government, retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Accho accessed 23/04/2018

Department of Health (2016d) ‘Health Workforce Locator’, Commonwealth of Australia, retrieved from https://www.health.gov.au/resources/apps-and-tools/health-workforce-locator/health- workforce-locator#hwc-map

Department of Health (2017b) “Development of a Funding Model for the Indigenous Australians’ Health Programme” (PowerPoint presentation), presented at AH&MRC Meeting Ground 14-16 June 2017, retrieved from http://www.ahmrc.org.au/media/resources/ahmrc-meetings/meeting-ground- 2017.html

Department of Health (n.d. a) ‘Indigenous Australians’ Health Programme: Programme Guidelines’, Australian Government, retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-programme-lp, accessed 23/10/2018.

Department of Health (n.d. b) ‘Medicare Benefits Schedule - Item 715’, available at http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=715&qt=ItemID, accessed 17/01/2020.

Department of Health (2017a), ‘My Life My Lead - Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations’, Commonwealth of Australia, retrieved from https://www.health.gov.au/internet/main/publishing.nsf/Content/D2F6B905F3F667DACA2580D400 014BF1/$File/My%20Life%20My%20Lead%20Consultation%20Report.pdf

Department of Health (2015b). Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023. Commonwealth of Australia. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/AC51639D3C8CD4ECCA257E8B00 007AC5/$File/DOH_ImplementationPlan_v3.pdf

Department of Finance and Deregulation [DoFaD] (2010) ‘Strategic Review of Indigenous Expenditure: Report to the Australian Government’, Commonwealth of Australia, available at https://webarchive.nla.gov.au/awa/20120317043308/http://www.finance.gov.au/foi/disclosure- log/2011/docs/foi_10-27_strategic_review_indigenous_expenditure.pdf, accessed 11/01/2020.

Department of Prime Minister and Cabinet (2014a) “Indigenous Advancement Strategy Guidelines” Commonwealth of Australia, retrieved from https://www.dpmc.gov.au/sites/default/files/publications/ias_guidelines.pdf, accessed 11/11/16.

309

Department of Prime Minister and Cabinet (2014b) “Indigenous Affairs” in Annual Report 2013-14, Part 2: Performance report, Commonwealth of Australia, retrieved from https://www.dpmc.gov.au/sites/default/files/publications/annual_reports/2013- 14/html/indigenous-affairs.html accessed 11/11/2016.

Department of Prime Minister and Cabinet [PM&C] (2015a) “Attachment E: IAS Funding”, in submission no. 48 to the Senate Inquiry into Commonwealth Indigenous Advancement Strategy tendering processes, retrieved from http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administ ration/Commonwealth_Indigenous/Submissions viewed 23/05/2016.

Department of Prime Minister and Cabinet (2015b) “Submission to the Senate Finance and Public Administration References Committee”, submission no. 48 to Senate Inquiry into Commonwealth Indigenous Advancement Strategy tendering processes, available at: http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administ ration/Commonwealth_Indigenous/Submissions viewed 23/05/2016.

Department of Prime Minister and Cabinet (2016) ‘Indigenous Advancement Strategy Grant Guidelines’, Australian Government, https://www.pmc.gov.au/sites/default/files/publications/ias- grant-guidelines.pdf, accessed 23/10/2018.

Department of Prime Minister and Cabinet (n.d. a) “IAS 2014 GRANT ROUND REPORTING” Australian Government, available at https://www.pmc.gov.au/indigenous-affairs/grants-and-funding/ias-2014- grant-round-reporting, accessed 23/04/2018.

Department of Prime Minister and Cabinet (n.d. b) “IAS GRANT REPORTING (EXCLUDING IAS 2014 GRANT ROUND)” Australian Government, available at https://www.pmc.gov.au/indigenous- affairs/grants-and-funding/ias-grant-reporting, accessed 23/04/2018.

DiAlto, S. J., (2005) ‘From “Problem Minority” to “Model Minority”: The Changing Social Construction of Japanese Americans’, in A. L. Schneider and H. M. Ingram (eds.) Deserving and Entitled: Social Constructions and Public Policy, State University of New York Press: Albany, pp. 81-103.

Dickinson H. (2015). Commissioning public services: The definition and aims matter. The Mandarin, 22 January. Retrieved from https://www.themandarin.com.au/18604-commissioning-public- services-definition-aims-matter/

Dickinson, H. (2014). Public service commissioning: What can be learned from the UK experience?. Australian Journal of Public Administration, 73(1), 14–18.

Diefenbach T (2009) “New Public Management in public sector organisations: the dark side of managerialistic ‘enlightenment’, Public Administration, vol. 87, no. 4, pp. 892–909.

Dolowitz, D. and Marsh, D., (2000) ‘Learning from Abroad: The Role of Policy Transfer in Contemporary Policy-Making’ Governance: An International Journal of Policy and Administration, 13(1):5-24.

Donato R & Segal L (2013) ‘Does Australia have the appropriate health reform agenda to close the gap in Indigenous health?’ Australian Health Review vol. 37, no. 2, pp. 232-238, https://doi.org/10.1071/AH12186

310

Downing, R, Kowal, E and Paradies, Y (2011), ‘Indigenous cultural training for health workers in Australia’, International Journal for Quality in Health Care, vol. 23, Iss. 3, pp. 247- 257, https://doi.org/10.1093/intqhc/mzr008

Duckett, S and Wilcox, S (2015), The Australian Health Care System, Fifth Edition, Oxford University Press, South Melbourne.

Dunleavy P & Hood C (1994) “From Old Public Administration to New Public Management” Public Money & Management, 14:3, pp. 9-16

Durey A (2010) “Reducing racism in Aboriginal health care in Australia: where does cultural education fit?” Australian and New Zealand Journal of Public Health, vol 34, no. s1, pp. S87-S92

Dutton, P. (2013). “Medicare locals review”, Commonwealth of Australia. Media release 16 December. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/A2B4614AB99CB4D3CA257C4 3000CF88A/$File/PD025.pdf

Dutton, P., (2014) ‘Indigenous Health Services’, 20 May press release, Australian Government, available from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/20F0C26B83DCB979CA257CD E00204E64/$File/PD037.pdf, accessed 23/10/2018.

Dwyer J, Boulton A, Lavoie JG, Tenbensel T & Jacqueline Cumming J (2014) “Indigenous Peoples’ Health Care: New approaches to contracting and accountability at the public administration frontier”, Public Management Review, vol. 16, no. 8, pp. 1091-1112.

Dwyer J, O’Donnell K, Lavoie J, Marlina U, Sullivan P (2009) “The Overburden Report: Contracting for Indigenous Health Services”, Flinders University and Cooperative Research Centre for Aboriginal Health, available at http://www.lowitja.org.au/sites/default/files/docs/Overburden%20summary%20brochure.pdf

Dwyer JM, Lavoie J, O’Donnell K, Marlina U, Sullivan P (2011), “Contracting for Indigenous Health Care: Towards Mutual Accountability” The Australian Journal of Public Administration, vol. 70, no. 1, pp. 34–46.

Edwards L (2013) “The Passion of Politics - The role of ideology and political theory in Australia : Chapter 14 : Aboriginal rights movement”, Allen & Unwin, Crows Nest.

Edwards L (2002) How to argue with an economist: reopening political debate in Australia, Cambridge University Press: New York.

Eikenberry AM & Kluver JD (2004), “The Marketization of the Nonprofit Sector: Civil Society at Risk?” Public Administration Review, vol. 64, no. 2, pp. 132-140.

Elrod JK & Fortenberry Jr, JL (2017) “The hub-and-spoke organization design: an avenue for serving patients well” BMC Health Services Research, 17(Suppl 1):457; doi 10.1186/s12913-017-2341-x.

Emy, H., (1998) ‘States, Markets and The Global Dimension: An Overview of Certain Issues in Political Economy, in P Smyth and B Cass (eds.), Contesting the Australian Way: States, Markets and Civil Society, Cambridge University Press, pp. 17-37.

311

Engels, F (1845/1968) The Condition of the Working Class in England, trans. and ed. W. O. Henderson and W. H. Chaloner, Stanford University Press, Palo Alto.

England, KVL (1994) ‘Getting Personal: Reflexivity, Positionality, and Feminist Research’, Women in the Field, vol. 46, no. 1 pp. 80-89.

Ernst, J (1998) “A Competitive Future: The Industry Commission and the Welfare Sector” in P Smyth and B Cass (eds.), Contesting the Australian Way: States, Markets and Civil Society, Cambridge University Press, pp. 215-227.

Ezzy D (2003) Qualitative Analysis, Routledge, London.

Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) ‘Structural violence and clinical medicine’. PLoS Medicine 3(10): e449. DOI: 10.1371/journal.pmed.0030449.

Fassin D (2005) ‘Compassion and Repression: The Moral Economy of Immigration Policies in France’, Cultural Anthropology, Volume 20, Issue 3, pp. 362-387, https://doi.org/10.1525/can.2005.20.3.362

Fawcett, B., Goodwin, S., Meagher, G., & Phillips, R., (2010) Social Policy for Social Change, Palgrave Macmillan, Houndmills.

Fenna A (2004) Australian Public Policy, Second Edition, Pearson Education Australia, Frenchs Forest.

Fien J, Charlesworth E, Lee G, Baker D, Grice T, Morris D (2011) “Life on the edge: Housing experiences in three remote Australian indigenous settlements”, Habitat International, Vol: 35, Issue: 2, Page: 343-349, http://dx.doi.org/10.1016/j.habitatint.2010.11.007

Fischer, F (2003), Reframing Public Policy: Discursive Politics and Deliberative Practices, Oxford University Press, Oxford.

Fogarty W, Bulloch H, McConnell S & Davis M (2018) “Deficit Discourse and Indigenous Health: How narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy” The Lowitja Institute & National Centre for Indigenous Studies, Canberra.

Foley, G (2011) “Black power, land rights and academic history”, Griffith Law Review, vol. 20, no. 3, pp. 608-618.

Foley, G (1991), ‘Redfern Aboriginal Medical Service: 20 Years On’, Aboriginal and Islander Health Worker Journal’, vol. 15, no. 4 pp. 4-8.

Foley, G (2009) ‘Black Power in Redfern 1968 – 1972’ in K de Souza and Z Begg (eds) There Goes the Neighbourhood: Redfern and the Politics of Urban Space, Break Down Press, Carlton, pp. 12-21.

Ford, L., (2012) ‘Locating indigenous self-determination in the margins of settler sovereignty: An introduction’, in L. Ford and T Rowse (eds) Between Indigenous and Settler Governance, Taylor and Francis Group, EBook Central.

Foucault, M (1973), ‘The Birth of the Clinic: an Archaeology of Medical Perception’, Pantheon, New York.

312

Fowkes L and Sanders W (2015), ‘A Survey of Remote Jobs and Communities Program(me) Providers: One Year In, CAEPR Working Paper no. 97, http://caepr.cass.anu.edu.au/sites/default/files/docs/Working_Paper_97_FowkesAndSanders_0.pdf

Fowkes, L., (2016) ‘Impact on Social Security Penalties of Increased Remote Work For the Dole Requirements’ CAEPR Working Paper no. 112, http://caepr.cass.anu.edu.au/sites/default/files/docs/16-081-WP- WORKDOLE%2BD%2822Jun16%29_0.pdf

Francis M (1996) ‘Social Darwinism and the construction of institutionalised racism in Australia’, Journal of Australian Studies, Vol. 20(50-51), pp. 90-105.

Furlong, P. and Marsh D., (2010) ‘A Skin Not a Sweater: Ontology and Epistemology in Political Science’ in D. Marsh and G. Stoker Theory and Methods in Political Science, Palgrave Macmillan: Bassingstoke, pp. 184-21.

Galtung J (1969) ‘Violence, peace and peace research’, Journal of Peace Research, 6:167–191.

Gardiner-Garden J (2014) “Indigenous Affairs: Budget Review 2014–15 Index”, Parliamentary Library of Australia, available at https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pu bs/rp/BudgetReview201415/Indigenous accessed 09/04/2018

Gee, G., Dudgeon, P., Schultz, C., Hart, A., Kelly, K.. (2014). “Aboriginal and Torres Strait Islander social and emotional wellbeing”, in P Dudgeon, H Milroy, and R Walker (eds.) Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (2nd ed., pp. 55-68). Canberra: Department of The Prime Minister and Cabinet. Available at https://www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/working- together-second-edition/working-together-aboriginal-and-wellbeing-2014.pdf, accessed 14/01/2020.

Germov J (2014) “Imagining health problems as social issues” in J Germov (ed.) Second Opinion: An Introduction to Health Sociology (fifth edition), Oxford University Press, South Melbourne.

Gibson, K (2000) "Accounting as a tool for Aboriginal dispossession: then and now", Accounting, Auditing & Accountability Journal, 13(3): 289-306.

Gilbert N & Gilbert B (1989) The Enabling State: Modern Welfare Capitalism in America, Oxford University Press, New York and Oxford.

Gingrich JR (2007) Whose Market is it Anyways: Making Multiple Markets in the Welfare State. PhD dissertation, University of California, Berkeley.

Gingrich, J. (2011). Making Markets in the Welfare State: The Politics of Varying Market Reform, Cambridge: Cambridge University Press. doi:10.1017/CBO9780511791529.

Goffman E (1974) Frame Analysis: An Essay on the Organisation of Experience, Harvard University Press, Cambridge.

Gomm R (2004) Social Research Methodology: a critical introduction, Palgrave Macmillan, Houndmills.

313

Gooda, M (2015) Comments to Senate Finance and Public Administration References Committee Public Hearings, Canberra, Senate Committee Hansard, p. 9, https://parlinfo.aph.gov.au/parlInfo/download/committees/commsen/41748f1f-74a4-4e5d-a08d- 08dcbb4662e6/toc_pdf/Finance%20and%20Public%20Administration%20References%20Committee _2015_06_29_3594_Official.pdf;fileType=application%2Fpdf#search=%222010s%202015%20finance %20and%20public%20administration%20references%20committee%22

Goodwin S & Phillips R (2015) “The marketisation of human services and the expansion of the not- for-profit sector” in G Meagher & S Goodwin, Markets, Rights and Power in Australian Social Policy, Sydney University Press.

Gordon M & Hunter F (2016) “Australia failing to close the gap between Indigenous and non- Indigenous people” Sydney Morning Herald, February 10, available at http://www.smh.com.au/federal-politics/political-news/australia-failing-to-close-the-gap-between- indigenous-and-nonindigenous-people-20160209-gmq15x.html, viewed 18/10/2017.

Govil, D, Lin, I, Dodd, T, Cox, R, Moss, P, Thompson, S, and Maiorana A (2013) ‘Identifying culturally appropriate strategies for coronary heart disease secondary prevention in a regional Aboriginal Medical Service’, Australian Journal of Primary Health, vol. 20, no. 3, pp. 266–272, http://dx.doi.org/10.1071/PY12117

Graham H (2004) “Social Determinants and their unequal Distribution: Clarifying Policy Understandings”, The Milbank Quarterly, vol. 82, no. 1, pp. 101-124.

Graham, M (2008) ‘Some Thoughts on the Philosophical Underpinnings of Aboriginal Worldviews’. Australian Humanities Review, iss. 45. http://australianhumanitiesreview.org/2008/11/01/some-thoughts-about-the-philosophical- underpinnings-of-aboriginal-worldviews/

Grande S (2004) Red Pedagogy: Native American Social and Political Thought, Rowman and Littlefield, Lanham.

Grant M, Wronski I, Murray RB, Couzos S (2008) “Aboriginal Health and History”, in S Couzos and R Murray (eds.) Aboriginal Primary Health Care: An Evidence-Based Approach, Third Edition, Oxford University Press, Melbourne.

Grattan M (2017) “The gap of Indigenous disadvantage is being closed too slowly: report” The Conversation, February 14, available at https://theconversation.com/the-gap-of-indigenous- disadvantage-is-being-closed-too-slowly-report-72963, viewed 18/10/17

Grey S and Sedgwick C (2015) ‘Constraining the community voice: The impact of the neoliberal contract state on democracy’ New Zealand Sociology, Vol. 30, No. 1, pp. 88-110.

Grieves V, (2006) ‘Indigenous Wellbeing: A framework for Governments’ Aboriginal Cultural Heritage Activities’, Department of Environment and Conservation NSW, available at https://www.environment.nsw.gov.au/-/media/OEH/Corporate-Site/Documents/Aboriginal-cultural- heritage/indigenous-wellbeing-framework-governments-aboriginal-cultural-heritage-activities- 070001.pdf, accessed 14/01/2020.

314

Guerri, C, Bazinet, A & Riley, E (2009) “Foetal Alcohol Spectrum Disorders and Alterations in Brain and Behaviour”, Alcohol and alcoholism vol. 44. pp. 108-14. https://dx.doi.org/10.1093%2Falcalc%2Fagn105

Guinness L and Gruen R (2011), “The changing world of healthcare finance”, in L Guinness and V Wiseman (eds.), Introduction to Health Economics: Second Edition, Open University Press, Maidenhead, pp. 133-147.

Guinness L. and Wiseman V., (2011) ‘Health care markets and efficiency’, in L Guinness and V Wiseman (eds.), Introduction to Health Economics: Second Edition, Open University Press, Maidenhead, pp. 117-132.

Habibis D (2018) ‘Ideology vs context in the neoliberal state’s management of remote Indigenous housing reform’, in D Howard-Wagner, M Bargh and I Altamirano-Jiménez (eds), The Neoliberal State, Recognition and Indigenous Rights: New Paternalism to New Imaginings. Canberra: Australian National University Press, pp. 167-184.

Hall, P (1993), ‘Policy Paradigms, Social Learning, and the State: The Case of Economic Policymaking in Britain’, Comparative Politics, vol. 25, no. 3, pp. 275-296.

Hall, SE, Bulsara, CE, Bulsara, MK, Leahy,TG, Culbong, MR, Henrie, D & Holman, CD (2007), ‘Treatment Patterns for Cancer in Western Australia: Does being Indigenous make a difference?’, Medical Journal of Australia, vol. 181, no. 4, pp. 191–4.

Halligan J (2007) “Reintegrating Government in Third Generation Reforms of Australia and New Zealand” Public Policy and Administration, vol. 22, no. 2, pp. 217-238.

Hancock., L (2006) ‘Bringing in the Community Sector: Partnerships and advocacy’ in H. K. Colebatch (ed.), Beyond the Policy Cycle: The policy process in Australia, Allen & Unwin: Crows Nest. pp. 42-65.

Hanson P (1996) ‘Maiden speech to parliament’, House of Representatives Hansard, Parliament of Australia, 10 September, p. 3859, https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22chamber%2Fhans ardr%2F1996-09-10%2F0038%22

Hart MA (2010) “Indigenous Worldviews, Knowledge, and Research: The Development of and Indigenous Research Paradigm” Journal of Indigenous Voices in Social Work, vol. 1 iss. 1, February, pp. 1-16.

Harvey, D (2005) A Brief History of Neoliberalism, Oxford University Press OUP, Oxford.

Hayek, F., (1944) The Road to Serfdom, Routledge: London.

Head B (2008) “Three Lenses of Evidence-Based Policy” The Australian Journal of Public Administration, vol. 67, no. 1, pp. 1–11.

Head, B., (2005) ‘Governance’, in P. Saunders and J Walter (eds) Ideas and Influence: Social Science and Public Policy in Australia, UNSW Press: Sydney, pp. 44-63.

Healing Foundation (2017) ‘Our Healing Our Way: Leading and Shaping our Future’, National Youth Healing Forum Report, available at

315 https://healingfoundation.org.au/app/uploads/2017/12/HF_National_Youth_Healing_Forum_Repor t_Nov2017_V7_WEB.pdf, accessed 14/01/2020.

Henderson J, Javanparast S, MacKean T, Freeman T, Baum F, Ziersch A (2017) “Commissioning and equity in primary care in Australia: Views from Primary Health Networks”, Health and Social Care in the Community, January, vol. 26, no. 1, pp. 80-89.

Henderson, G, Robson, C, Cox, L, Dukes, C, Tsey, K, and Haswell, M (2007) ‘Social and emotional wellbeing of Aboriginal and Torres Strait Islander people within the broader context of the social determinants of health’ in I Anderson, F Baum and M Bentley (eds.) Beyond Bandaids: exploring the underlying social determinants of Aboriginal health. Cooperative Research Centre for Aboriginal Health, Casuarina, NT, Australia, pp. 136-164.

Henderson, J., Javanparast, S., MacKean, T., Freeman, T., Baum, F. and Ziersch, A. (2018) ‘Commissioning and equity in primary care in Australia: Views from Primary Health Networks’. Health and Social Care in the Community 26(1):80-89.

Henry, BR, Houston, S and Mooney GH (2004) ‘Institutional racism in Australian healthcare: a plea for decency’, Medical Journal of Australia, vol. 180, no. 10, pp. 517-520. doi: 10.5694/j.1326- 5377.2004.tb06056.x.

Heyman, NE, White, NE and Spurling, GK (2009), ‘Improving Indigenous patients’ access to mainstream health services: the Inala experience’ Medical Journal of Australia, vol. 190, no. 10 pp. 604-606. doi: 10.5694/j.1326-5377.2009.tb02581.x.

Hinkson, M (2002) ‘Exploring ‘Aboriginal’ Sites in Sydney: A shifting politics of place?’ Aboriginal History Vol. 26, pp. 62-77.

Hockey J (2014) “Budget Speech 2014-15”, Australian Government, viewed 13/03/2018, available at http://www.budget.gov.au/2014-15/content/speech/html/speech.htm

Hockey J (2015) “Budget Speech 2015”, Australian Government, viewed 13/03/2018, available at http://www.budget.gov.au/2015-16/content/speech/html/speech.htm

Holland C (2016) “Progress and priorities report 2016” Close the Gap Steering Committee, accessed 17/02/2017, available at https://www.humanrights.gov.au/sites/default/files/document/publication/Progress_priorities_rep ort_CTG_2016_0.pdf

Holland, C., (2018). ‘A ten-year review: the Closing the Gap Strategy and Recommendations for Reset’, Close the Gap Campaign Steering Committee for Indigenous Health Equality, available at https://www.humanrights.gov.au/sites/default/files/document/publication/CTG%202018_FINAL- WEB.pdf, accessed 23/10/2018.

Hood C & Dixon R (2015) “What We Have to Show for 30 Years of New Public Management: Higher Costs, More Complaints”, Governance: An International Journal of Policy, Administration, and Institutions, Vol. 28, No. 3, July, (pp. 265–267).

Hood C & Peters G (2004) “The Middle Aging of New Public Management: Into the Age of Paradox?” Journal of Public Administration Research and Theory, Vol. 14, no. 3, pp. 267-282.

316

Hood C, (1991) “A public management for all seasons?” Public Administration, vol.69, no. 1, pp.3-19.

Horvath J (2014) “Review of Medicare Locals: Report to the Minister for Health and Minister for Sport”, available at http://health.gov.au/internet/main/publishing.nsf/Content/review-medicare- locals-final-report , viewed 10/04/2018.

Howard-Wagner D (2018a) Governance of indigenous policy in the neo-liberal age: indigenous disadvantage and the intersecting of paternalism and neo-liberalism as a racial project, Ethnic and Racial Studies, vol. 41, no. 7, pp. 1332–1351, https://doi.org/10.1080/01419870.2017.1287415

Howard-Wagner D (2018b), “Aboriginal organisations, self-determination and the neoliberal age: A case study of how the ‘game has changed’ for Aboriginal organisations in Newcastle” in D Howard- Wagner, M Bargh and I Altamirano-Jiménez (eds), The Neoliberal State, Recognition and Indigenous Rights: New Paternalism to New Imaginings. Canberra: Australian National University Press. Pp. 147- 166.

Howard-Wagner, D, M Bargh and Altamirano-Jiménez I (2018) ‘From new paternalism to new imaginings of possibilities in Australia, Canada and Aotearoa/New Zealand: Indigenous rights and recognition and the state in the neoliberal age’, in The Neoliberal State, Recognition and Indigenous Rights: New Paternalism to New Imaginings. Canberra: Australian National University Press. Pp. 1- 42.

Hubbard, G (2003) The Not-For-Profit Director, Australian Institute of Company Directors, Sydney.

Hudson S (2016) “Mapping the Indigenous Program and Funding Maze”, Centre for Independent Studies, Research Report 18, August, available at http://www.cis.org.au/app/uploads/2016/08/rr18- Full-Report.pdf accessed 23/04/2018.

Human Rights and Equal Opportunity Commissioner [HREOC] (1997) “Bringing them Home: Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families”, Commonwealth of Australia, available at https://www.humanrights.gov.au/publications/bringing-them-home-report-1997, accessed 23/04/2018.

Hunt, J (2008), ‘Between a rock and a hard place: self-determination, mainstreaming and Indigenous community governance’, in J. Hunt, D. Smith, S. Garling and W. Sanders (eds), Contested Governance: Culture, power and institutions in Indigenous Australia, Research Monograph No. 29, Centre for Aboriginal Economic Policy Research: The Australian National University, Canberra, available at https://press.anu.edu.au/publications/series/centre-aboriginal-economic-policy- research-caepr/contested-governance

Hunter, B (2008) ‘Conspicuous Compassion and Wicked Problems: The Howard Government’s National Emergency’, Agenda, Vol. 14, No. 3, 35-51.

Hunter, D (2008) “Choice and competition in health systems” in The Health Debate, Policy Press, Bristol, pp. 89-118.

Hurley C, Baum F, Johns J, Labonte R (2010) “Comprehensive Primary Health Care in Australia: findings from a narrative review of the literature”, Australasian Medical Journal, vol. 1, no. 2, pp. 147-152.

317

Inala Wangarra (n.d.) “Submission no. 11 to the Senate Inquiry into Commonwealth Indigenous Advancement Strategy tendering processes” available at http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administ ration/Commonwealth_Indigenous/Submissions, viewed 21/04/2017.

Industry Commission (1996) “Competitive Tendering and Contracting by Public Sector Agencies” Australian Government Publishing Service, Melbourne, available at https://www.pc.gov.au/inquiries/completed/public-service-tenders-contracts accessed 23/04/2018

Institute for Urban Indigenous Health [IUIH] (2018) ‘Annual Report 2017-18’, Windsor QLD, available at http://www.iuih.org.au/Portals/0/PDF/IUIH_2017-18_AnnualReport_V8.pdf?ver=2019-01-17- 143421-707, accessed 05/01/2020.

Jan S, Conaty S, Hecker R, Bartlett M, Delaney S, Capon T (2004) ‘An holistic economic evaluation of an Aboriginal community-controlled midwifery programme in Western Sydney’, Journal of Health Services Research and Policy, vol. 9, no. 1, pp. 14-21.

Jensen, L. S., (2005) Constructing and Entitling America’s Original Veterans’, in A. L. Schneider and H. M. Ingram (eds.) Deserving and Entitled: Social Constructions and Public Policy, State University of New York Press: Albany, pp. 35-62.

Jordan, K, Bulloch, H, & Buchanan, G (2010) “Statistical Equality and Cultural Difference in Indigenous Wellbeing Frameworks: A New Expression of an Enduring Debate”, Australian Journal of Social Issues, vol. 45, no. 3, pp. 333-362.

Jowsey T, Yen L, Ward, N, McNab, J, Aspin, C, Usherwood, T and SCIPPS Team (2012) ‘It hinges on the door: time, spaces and identity in Australian Aboriginal Health Services’. Health Sociology Review; vol. 21, no. 2, pp. 196-207. https://doi.org/10.5172/hesr.2012.21.2.196

Julia, C and Valleron, A-J 2011 ‘Louis-Rene ́ Villerme ́ (1782/1863), a pioneer in social epidemiology: re-analysis of his data on comparative mortality in Paris in the early 19th century’, Journal of Epidemiology and Community Health, vol. 65: pp. 666-670. doi:10.1136/jech.2009.087957.

Karp, P (2019) ‘Greens blast decision to extend cashless welfare card to all in NT’, The Guardian, 25 March, https://www.theguardian.com/australia-news/2019/mar/25/greens-blast-decision-to- extend-cashless-welfare-card-to-all-in-nt

Karvelas P (2014) “From 26 indigenous programs to five” The Australian, 22 January, accessed via Factiva on 28/03/2018.

Katungul Aboriginal Corporation Regional Health and Community Services [KACRHCS] (2018) ‘Rule book of Katungul Aboriginal Corporation Regional Health and Community Services’, available at https://irp-cdn.multiscreensite.com/f02022af/files/uploaded/Rule%20book%201816.pdf, accessed 06/01/2020.

Keating M (2004) Who Rules? How government retains control of a privatised economy, The Federation Press: Leichhardt.

Keating P (1992) “Redfern Address”, Sydney, 10 December, available at http://education.abc.net.au/home#!/media/522255/prime-minister-keating-s-redfern-address-1992

318

Keen S (2006) “Non-government organisations in policy” in H.K. Colebatch, Beyond the Policy Cycle: The policy process in Australia, Allen and Unwin, Crows Nest.

Keen, S., (2006) ‘Non-government organisations in policy’, in H. K. Colebatch (ed.), Beyond the Policy Cycle: The policy process in Australia, Allen & Unwin: Crows Nest. pp. 27-41.

Kelaher, M, Sabanovic, H, La Brooy, C, Lock, M, Lusher, D, and Brown, L (2014) ‘Does more equitable governance lead to more equitable health care? A case study based on the implementation of health reform in Aboriginal health Australia’ Social Science and Medicine, vol. 123, pp. 278-286, https://doi.org/10.1016/j.socscimed.2014.07.032

Kelaher, MA, Ferdinand, AS and Paradies Y (2014) ‘Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities’ Medical Journal of Australia, vol. 201, no. 1, pp. 44-47. doi: 10.5694/mja13.10503.

Keleher, H (2016), ‘Primary health care systems and reforms’ in E Willis, L Reynolds and M Keleher (eds) Understanding the Australian Health Care System, third edition, Elsevier, Chatswood. Pp. 75- 90.

Kelly, K, Dudgeon, P, Gee, G, & Glaskin, B (2009) “Living on the Edge: Social and Emotional Wellbeing and Risk and Protective Factors for Serious Psychological Distress among Aboriginal and Torres Strait Islander People”. In Discussion Paper no. 10, Co-operative Research Centre for Aboriginal Health, Casuarina, Northern Territory, available at http://www.indigenouspsychology.com.au/Assets/Files/AIPA-Living-on-the-Edge-web.pdf, accessed 14/01/2020.

Kickbusch, I (2008), ‘Healthy Societies: addressing 21st century health challenges’ South Australian Department of Premier and Cabinet, Adelaide.

Kickbusch, I (2012), ‘Editorial: Addressing the interface of the political and commercial determinants of health’, Health Promotion International, Vol. 27 No. 4, pp. 427-8, doi:10.1093/heapro/das057.

Kilcullen M, Swinbourne A, Cadet-James Y (2016) ‘Aboriginal and Torres Strait Islander Health and Well-Being: Implications for a Cognitive Behavioural Therapy Framework’ Australian Psychologist, vol. 51, iss. 6, pp. 453-462, https://doi.org/10.1111/ap.12159

Kingdon, J (2003) ‘Problems’ in Agendas, Alternatives and Public Policies, second edition, Longman, New York.

Kowal, E (2008) ‘The Politics of the Gap: Indigenous Australians, Liberal Multiculturalism, and the End of the Self-Determination Era’, American Anthropologist, Vol. 110, Issue 3, pp. 338–348.

Kratochwil F (2008) ‘Constructivism: what it is (not) and how it matters’, in D. Della Porta and M Keating Approaches and Methodologies in the Social Sciences: A Pluralist Perspective, Cambridge University Press, Cambridge.

Krieg AS (2010) ‘Aboriginal incarceration: health and social impacts’, Medical Journal of Australia, Volume 184, Number 10, pp. 534-536.

Krieger, N (2012), ‘Methods for the Scientific Study of Discrimination and Health: An Ecosocial Approach’, American Journal of Public Health, vol. 102, no. 5, pp. 936-945.

319

Kvale S (2007) “Analysing interviews” in Doing Interviews, Sage Publications, London, pp. 102-120. http://dx.doi.org/10.4135/9781849208963.n9

Labonte, R (1994) ‘Health Promotion and Empowerment: Reflections on Professional Practice’ Health Education Quarterly, vol. 21, no. 2, pp. 253-68.

Lapsley I (2009) ‘New Public Management: The Cruellest Invention of the Human Spirit?’ Abacus, Vol. 45, No. 1, pp. 1-21, doi: 10.1111/j.1467-6281.2009.00275.x.

Larkins, SL, Geia, LK & Panaretto KS (2006), Consultations in General Practice and at an Aboriginal community controlled health service: do they differ? Rural and Remote Health, vol. 6, no. 560, pp. 1- 12. www.rrh.org.au/journal/article/560

Larson, A, Gillies, M, Howard, PJ & Coffin, J (2007), ‘It's enough to make you sick: the impact of racism on the health of Aboriginal Australians’, Australian and New Zealand Journal of Public Health, vol. 31, no. 4, pp. 322-329. doi:10.1111/j.1753-6405.2007.00079.x

Lavoie J, Boulton A & Dwyer J (2010) “Analysing contractual environments: lessons from Indigenous health in Canada, Australia and New Zealand”, Public Administration, vol. 88, no. 3, pp. 665–679.

Lavoie JG, Forget EL, Prakash T, Dahl M, Martens P, O’Neil JD (2010) “Have investments in on-reserve health services and initiatives promoting community control improved First Nations’ health in Manitoba?” Social Science and Medicine, vol. 71, iss. 4, pp. 717–24 https://doi.org/10.1016/j.socscimed.2010.04.037

Lavoie JG, Forget EL, Prakash T, Dahl M, Martens P, O’Neil JD. (2010) ‘Have investments in on- reserve health services and initiatives promoting community control improved First Nations’ health in Manitoba?’ Social Science and Medicine, 71: 717–24. doi:10.1016/j.socscimed.2010.04.037.

Le Grand J (1991) “Quasi-Markets and Social Policy”, The Economic Journal, September, pp. 1256- 1267.

Le Grand, J (2009), “Choice and competition in publicly funded health care”, Health Economics, Policy and Law, vol. 4, no. 4, pp. 479-488.

Le Grande M, Ski CF, Thompson DR, Scuffham P, Kularatna S, Jackson AC, Brown A (2017) “Social and emotional wellbeing assessment instruments for use with Indigenous Australians: A critical review”, Social Science & Medicine, vol. 187, pp. 164-173, https://doi.org/10.1016/j.socscimed.2017.06.046

Lea, T., Thompson, H., McRae‐Williams, E. and Wegner A., (2011). ‘Policy fuzz and fuzzy logic: researching contemporary Indigenous education and parent–school engagement in north Australia’, Journal of Education Policy, Vol. 26, No. 3, pp. 321–339.

Ley S & Nash F (2015), “$1.4 billion boost in primary care for Indigenous communities”, joint media release, 5 March, available at http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015- ley014.htm, accessed 24/04/2018.

Liamputtong R (2013) Qualitative Research Methods: Fourth Edition, Oxford University Press, South Melbourne.

320

Liberal Party of Australia (2013) “Our Plan: Real Solutions for all Australians”, Bambra Press, Port Melbourne, available online at http://australianpolitics.com/downloads/liberal/13-01-26_our- plan_liberal-party.pdf

Lister R (2010) Understanding Theories and Concepts in Social Policy, The Policy Press, Bristol.

Lloyd D and Wolfe P (2016) “Settler colonial logics and the neoliberal regimes”, Settler Colonial Studies, vol. 6, no. 2, pp. 109-118.

Lohoar S, Butera N and Kennedy E (2014) ‘Strengths of Australian Aboriginal cultural practices in family life and child rearing’, Australian Institute of Family Studies, CFCA Paper No. 25, available at https://aifs.gov.au/cfca/publications/strengths-australian-aboriginal-cultural-practices-fam, accessed 17/01/2020.

Louis MR & Bartunek JM (1992), ‘Insider/Outsider Research Teams: Collaboration Across Diverse Perspectives’. Journal of Management Inquiry, 1(2), 101– 110. https://doi.org/10.1177/105649269212002

Lovett, R (2014) ‘A History of health services for Aboriginal and Torres Strait Islander people’, in O Best and B Fredericks (eds) Yatdjuligin: Aboriginal and Torres Strait Islander Nursing and Midwifery Care, Cambridge University Press, Port Melbourne, pp. 31-50.

Maari Ma Health Aboriginal Corporation [HAC] (2014) ‘Annual Report 2013/2014’ Broken Hill, NSW, available at http://www.maarima.com.au/pdf/annual_reports/maari-ma-annual-report-2014-final- LQ.PDF, accessed 06/01/2020.

Maari Ma Health Aboriginal Corporation (2016) ‘Annual Report 2015/2016’ Broken Hill, NSW, available at http://www.maarima.com.au/uploads/documents/annual- reports/MaariMaa_AnnualReport_2016_WEB.PDF, accessed 06/01/2020.

Maari Ma Health Aboriginal Corporation (2019), ‘Rule Book of Maari Ma Health Aboriginal Corporation’, available at http://maarima.com.au/uploads/documents/2570%20Rule%20Book.pdf, accessed 06/01/2020.

Macdonald, JJ (2010), ‘Health Equity and the Social Determinants of Health in Australia’, Social Alternatives, vol. 29, no. 2, pp. 34-40.

Mackey, P, Boxall, A-M & Partel, K (2014), ‘The relative effectiveness of Aboriginal Community Controlled Health Services Compared with Mainstream Health Service’, Deeble Institute for Health Policy Research, Australian Healthcare and Hospitals Association, evidence brief no. 12, September 16. http://ahha.asn.au/publication/evidence-briefs/relative-effectiveness-aboriginal-community- controlled-health-services.

Maddison S & Denniss R (2009) An Introduction to Australian Public Policy: Theory and Practice, Cambridge University Press, Port Melbourne.

Maddison S & Hamilton C (2007) “Non-government organisations” in C. Hamilton & S. Maddison (eds.) Silencing Dissent: How the Australian government is controlling public opinion and stifling debate, Allen & Unwin, Crows Nest.

321

Maddison S (2009) “A History of Policy Failure” in S. Maddison, Black Politics: Inside the Complexity of Aboriginal Political Culture, Allen & Unwin, Crows Nest.

Maddison S (2010) ‘White Parliament, Black Politics: The Dilemmas of Indigenous Parliamentary Representation’ Australian Journal of Political Science, Vol. 45, No. 4, December, pp. 663–680.

Maddison S (2013) ‘Indigenous identity, “authenticity” and the structural violence of settler colonialism’, Identities, 20:3, 288-303, DOI: 10.1080/1070289X.2013.806267.

Maddison S and Carson A (2017) “Civil Voices: Researching not-for-profit Advocacy”, Pro Bono Australia & Human Rights Law Centre, available online at https://civilvoices.com.au/ viewed 08/04/2018.

Mamdani M (1998) When Does a Settler Become a Native? Reflections on the Colonial Roots of Citizenship in Equatorial and South Africa, Cape Town, University of Cape Town, 1998.

Marmot M (2015) The Health Gap: The Challenge of an Unequal World, Bloomsbury.

Marmot M (2008) “Closing the gap in a generation: health equity through action on the social determinants of health”, The Lancet, vol. 372, pp. 1661-9.

Marmot MG, Davey Smith G, Stansfeld S, Patel C, North F, Head J, White I, Brunner E, Feeney A (1991), ‘Health inequalities among British civil servants: the Whitehall II study’, The Lancet, vol. 337, iss. 8754 pp. 1387-1393, https://doi.org/10.1016/0140-6736(91)93068-K

Marmot, MG (2005), ‘Social determinants of health inequalities’, The Lancet, vol. 365, iss. 9464, pp. 1099-1104, https://doi.org/10.1016/S0140-6736(05)71146-6

Marmot, MG (2006), ‘Social causes of social inequalities in health’ in S Anand, F Peter and A Sen (eds) Public Health, Ethics and Equity, Oxford University Press, Oxford.

Marmot, MG (2011), ‘Social Determinants and the Health of Indigenous Australians’, Aboriginal & Islander Health Worker Journal, vol. 35, no. 3, pp. 21-22. doi: 10.5694/j.1326-5377.2011.tb03086.x.

Marmot, MG, Allen, J, Bell R, Bloomer, E, Goldblatt, P (2012), ‘WHO European review of social determinants of health and the health divide’ The Lancet, vol. 380, iss. 9846, pp. 1011-1029, https://doi.org/10.1016/S0140-6736(12)61228-8

Marmot, MG, Shipley, MJ & Rose, G [Geoffrey] (1984), ‘Inequalities in death – specific explanations of a general pattern?, The Lancet, vol. 323, iss. 8384, pp. 1003-1006 https://doi.org/10.1016/S0140- 6736(84)92337-7

Marmot, MG, Siegrist J, & Theorell T (2006), ‘Health and the psychosocial environment at work’, in M Marmot and RG Wilkinson (eds) The Social Determinants of Health, second edition, Oxford University Press, Oxford, pp. 97-130.

Marsh, I (2015) ‘The Malfunctions of New Public Management: A case study of governance in Indigenous affairs’ in John Wanna, Evert A. Lindquist and Penelope Marshall (eds.) New Accountabilities, New Challenges, ANU Press, The Australian National University, Canberra, Australia.

322

Martin, DF (2005), ‘Governance, Cultural Appropriateness and Accountability’, in D Austin-Broos & G Macdonald (eds), Culture, Economy and Governance in Aboriginal Australia: Proceedings of a Workshop of the Academy of Social Sciences in Australia, Sydney University Press. Sydney, pp. 189- 202.

Martini, A., Marlina, U., Dwyer, J., Lavoie, J., O’Donnell, K., Sullivan, P., (2011) ‘Aboriginal Community Controlled Health Service Funding: Report to the Sector’, The Lowitja Institute and Flinders University, Carlton South and Bedford Park, available at https://www.lowitja.org.au/lowitja- publishing/L008, accessed 23/10/2018.

Marx, K. & Engels, F. (1970) The German Ideology, International Press, New York.

Mattson, S.N., Crocker, N. & Nguyen, T.T. “Fetal Alcohol Spectrum Disorders: Neuropsychological and Behavioral Features” Neuropsychology Review, vol. 21, iss. 2, pp. 81-101, https://doi.org/10.1007/s11065-011-9167-9

Mazel, O (2016) “Self-Determination and the Right to Health: Australian Aboriginal Community Controlled Health Services” Human Rights Law Review, vol. 16, pp. 323-355.

McDonald A., and Besser, L., (2016) ‘Indigenous organisations investigated amid allegations of fraud and corruption by senior figures’ ABC News online, 6 June, available at https://www.abc.net.au/news/2016-06-06/indigenous-organisations-investigated-allegations- fraud/7476570

McGregor R (2009) ‘One People: Aboriginal Assimilation and the White Australian Ideal’, History Australia, vol. 6, no. 1, pp. Pages 03.1-03.17, DOI: 10.2104/ha090003

McGregor R (2011), Indifferent Inclusion: Aboriginal People and the Australian Nation, Aboriginal Studies Press, Canberra.

McGuigan J (2005) “Neo-liberalism, culture and policy” International Journal of Cultural Policy, vol. 11, no. 3, pp. 229-241.

McKeown, T (1979), The Role of Medicine: Dream, Mirage or Nemesis?, Princeton University Press, Princeton.

McKinlay, JB (1975) ‘A Case for Refocussing Upstream—The Political Economy of Illness’, in AJ Enelow & JB Henderson (eds), Applying Behavioral Science to Cardiovascular Risk, American Heart Association, Washington D.C.

McNeill, JA & Reiger, KM (2015) ‘Rethinking Prenatal Care Within a Social Model of Health: An Exploratory Study in Northern Ireland’, Health Care for Women International, 36:1, 5- 25, DOI: 10.1080/07399332.2014.900061

Meagher G and Goodwin S (2015) “Introduction: Capturing marketisation in Australian social policy”, in G. Meagher & S. Goodwin (eds.) Markets, Rights and Power in Australian Social Policy, Sydney University Press, Sydney.

Meagher G and Wilson S (2015) “The politics of market encroachment: Policymaker rationales and voter responses”, in G. Meagher & S. Goodwin (eds.) Markets, Rights and Power in Australian Social Policy, Sydney University Press, Sydney.

323

Milligan L (2014) ‘Insider-outsider-inbetweener? Researcher positioning, participative methods and cross-cultural educational research, Compare: A Journal of Comparative and International Education, 46:2, 235-250, DOI: 10.1080/03057925.2014.928510

Mitchell, J (2007), ‘History’ in B Carson, T Dunbar, RD Chenhall & R Bailie 2007, Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 41-64.

Mitrou M, Cooke M, Lawrence D, Povah D, Mobilia E, Guimond E, & Zubrick SR (2014) ‘Gaps in Indigenous disadvantage not closing: a census cohort study of social determinants of health in Australia, Canada, and New Zealand from 1981–2006’, BMC Public Health, 14:201, http://www.biomedcentral.com/1471-2458/14/201

Mokak R (2015) ‘The Lowitja Institute Submission to the Senate Finance and Public Administration Committee’, Lowitja Institute, Commonwealth Indigenous Advancement Strategy tendering processes, Submission 69, https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Adminis tration/Commonwealth_Indigenous/Submissions?main_0_content_1_RadGrid1ChangePage=4_20

Mooney G, (2012) The Health of Nations: Towards a New Political Economy, Zed Books, London and New York.

Mooney, J, Riley, L & Blacklock, F (2017), ‘Dimensions of Aboriginal community development’, in C Kickett-Tucker, D Bessarab, J Coffin and M Wright (eds), Mia Mia Aboriginal Community Development: Fostering cultural security, Cambridge University Press, Port Melbourne.

Moore, SP, Green, AC, Bray, F, Garvey, G, Coory, M, Martin, J & Valery, PC (2014), ‘Survival disparities in Australia: an analysis of patterns of care and comorbidities among indigenous and nonindigenous cancer patients’, BMC Cancer, vol. 14, no. 517, https://doi.org/10.1186/1471-2407-14- 517

Moran M, Porter D, and Curth-Bibb J (2014) ‘Funding Indigenous organisations: improving governance performance through innovations in public finance management in remote Australia’ Closing the Gap Clearinghouse, Australian Institute of Health and Welfare, available at https://www.aihw.gov.au/getmedia/cc5909f4-869f-4a75-aed9-e170d1e0a5b8/ctgc- ip11.pdf.aspx?inline=true, accessed 11/01/2020.

Moran M, Porter D, Curth-Bibb J (2016) “The Impact of Funding Modalities on the Performance of Indigenous Organisations”, Australian Journal of Public Administration, vol. 75, no. 3, pp. 359-372.

Moran, M (2016) Serious Whitefella Stuff: When Solutions Became the Problem in Indigenous Affairs, Melbourne University Press, Melbourne.

Moreton-Robinson A (2007) ‘Introduction’, Sovereign Subjects: Indigenous Sovereignty Matters, Allen & Unwin, Crows Nest.

Moreton-Robinson A (2013) ‘Towards an Australian Indigenous Women's Standpoint Theory’, Australian Feminist Studies, vol. 28, no. 78, pp. 331-347, https://doi.org/10.1080/08164649.2013.876664

324

Moreton-Robinson, A., (2004) ‘Whiteness, epistemology and representation’, in A. Moreton- Robinson (ed.) Whitening race: essays in social and cultural criticism, Aboriginal Studies Press: EBOOK ISBN 9780855755782.

Morgan Disney & Associates (2006) ‘A Red Tape Evaluation in Selected Indigenous Communities: Final Report for the Office of Indigenous Policy Coordination’ available at https://www.dss.gov.au/sites/default/files/documents/05_2012/indigenous_redtapereport. pdf, accessed 11/01/2020.

Morgan M (2015) “Less than half IAS funding awarded to Indigenous organisations” NITV News, 29 June, available at http://www.sbs.com.au/nitv/article/2015/05/04/less-half-ias-funding-awarded- indigenous-organisations, viewed 29/04/16.

Morphy F (2008) “Whose governance, for whose good? The Laynhapuy Homelands Association and the neo-assimilationist turn in Indigenous policy” in J. Hunt, D. Smith, S. Garling and W. Sanders (eds), Contested Governance: Culture, power and institutions in Indigenous Australia, Research Monograph No. 29, Centre for Aboriginal Economic Policy Research: The Australian National University, Canberra, available at https://press.anu.edu.au/publications/series/centre-aboriginal- economic-policy-research-caepr/contested-governance

Morrison S & Turner P (2019) ‘Partnering with Indigenous Australians to Close the Gap’ https://www.pm.gov.au/media/partnering-indigenous-australians-close-gap

Morrison S (2016) “Budget Speech” Commonwealth of Australia, viewed 13/03/2018, available at http://budget.gov.au/2016-17/content/speech/html/speech.htm

Morrison S (2017) “Budget Speech” Commonwealth of Australia, viewed 13/03/2018, available at http://www.budget.gov.au/2017-18/content/speech/html/speech.htm

Morse JM (2004) ‘Purposive sampling’ in M. S., Lewis-Beck, A. Bryman, A., & T. Futing Liao, The SAGE encyclopedia of social science research methodsThousand Oaks, CA: Sage Publications, Inc. doi: 10.4135/9781412950589.

Moses D (2004) “Genocide and Settler Society in Australian History” in D. Moses (ed.) Genocide and Settler Society: Frontier Violence and Stolen Indigenous Children in Australian History, Berghahn Books, New York and Oxford.

Mudge S L (2008) “What is neo-liberalism?” Socio-Economic Review, issue 6, pp. 703–731.

Muller, L (2014), ‘A Theory For Indigenous Australian Health and Human Service Work: Connecting Indigenous Knowledge and Practice’, Allen & Unwin, Crows Nest.

Murphy, M (2014), ‘Self-determination as a Collective Capability: The Case of Indigenous Peoples’, Journal of Human Development and Capabilities, vol. 15, no. 4, pp. 320-334, https://doi.org/10.1080/19452829.2013.878320

Murray M, Nelson G, Poland B, Maticka-Tyndale E, Ferris L (2004), ‘Assumptions and Values of Community Health Psychology’, Journal of Health Psychology, vol. 9, no. 2, pp. 323–333, https://doi.org/10.1177/1359105304040897

325

Nakata M (2007) ‘The Cultural Interface’ The Australian Journal of Indigenous Education, 36 (5), pp. 7-14.

Nakata M (2010) The Cultural Interface of Islander and Scientific Knowledge’, The Australian Journal of Indigenous Education, iss. 39, pp. 53-7.

National Aboriginal Community Controlled Health Organisation [NACCHO] (2011), ‘Constitution’, http://www.naccho.org.au/wp-content/uploads/NACCHO-CONSTITUTION-Ratified-Ver-151111-for- ASIC-.pdf

National Aboriginal Community Controlled Health Organisation (2016), ‘Annual Report 2015-16’, http://www.naccho.org.au/wp-content/uploads/J2880-NACCHO-Annual-Report_ACCESSIBLE.pdf

National Aboriginal Community Controlled Health Organisation (2017), “Aboriginal input in Primary Health Networks critical to closing the gap” March 2 media release, available at http://www.naccho.org.au/wp-content/uploads/NACCHO-1703-MR-PHNs.pdf-Final.pdf, accessed 23/04/2018.

National Aboriginal Community Controlled Health Organisation (2018), ‘Annual Report 2017-2018’, http://www.naccho.org.au/wp-content/uploads/NACCHO-Annual-Report-2017-18.pdf

National Aboriginal Community Controlled Health Organisation (2019a) ‘NACCHO Aboriginal Health and #PHNs : David Coombs from @NuraGili : Primary Health Networks’ impact on Aboriginal Community Controlled Health Services’, 7 January, accessed 17/12/2019, retrieved from https://nacchocommunique.com/2019/01/07/naccho-aboriginal-health-and-phns-david-coombs- from-nuragili-primary-health-networks-impact-on-aboriginal-community-controlled-health-services/

National Aboriginal Community Controlled Health Organisation (2019b) ‘New Closing the Gap targets and approach to be discussed by Coalition of Aboriginal Peak Organisations’, retrieved at https://www.naccho.org.au/new-closing-the-gap-targets-and-approach-to-be-discussed-by- coalition-of-aboriginal-peak-organisations/

National Aboriginal Community Controlled Health Organisation [NACCHO] (2015), “Submission – Senate Standing Committees on Finance and Public Administration Commonwealth Indigenous Advancement Strategy tendering processes”, Submission 70, Commonwealth Indigenous Advancement Strategy tendering processes, available at http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administ ration/Commonwealth_Indigenous/Submissions, accessed 23/04/2018.

National Aboriginal Health Strategy Working Party, (1989) ‘A National Aboriginal Health Strategy’, Canberra.

National Commission of Audit (2014) “Towards Responsible Government: Phase One report”, Commonwealth of Australia, available at http://www.ncoa.gov.au/report/ accessed 23/04/2018.

Navarro V (2012) “Preface” in G Mooney, The Health of Nations: Towards a New Political Economy, Zed Books, London and New York.

Navarro, V (2007), ‘What is a National Health Policy?’ International Journal of Health Services, vol. 37, no. 1, pp. 1-14, https://doi.org/10.2190/H454-7326-6034-1T25

326

Navarro, V, Muntaner, C, Borrell, C, Benach, J, Quiroga, A, Rodríguez-Sanz, M, Vergés, N, Pasarín, MI (2006), ‘Politics and health outcomes’, The Lancet, vol. 368, iss. 9540, pp. 1033-1037, https://doi.org/10.1016/S0140-6736(06)69341-0

Nazroo, JY (2003), ‘The Structuring of Ethnic Inequalities in Health: Economic Position, Racial Discrimination, and Racism’, 2003, American Journal of Public Health, vol. 93, no. 2, pp. 277-284, doi: 10.2105/ajph.93.2.277

Neal, M., (2018) ‘Indigenous leader and family members face court on fraud charges worth more than $650,000’ ABC News online, 2 October, available at https://www.abc.net.au/news/2018-10- 01/indigenous-leader-geoff-clark-and-family-members-fraud-charges/10325190

Nettleton, S (2006), The Sociology of Health and Illness (second edition), Polity Press, Cambridge.

Newman, L, Baum, F & and Harris E (2006), ‘Federal, State and Territory government responses to health inequities and the social determinants of health in Australia’, Health Promotion Journal of Australia, vol. 17, no. 3, pp. 217-225. https://doi.org/10.1071/HE06217

Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council Aboriginal Corporation [NPY Women’s Council] (1999) Malparara way: the strength of working together, NPY Women's Council, Alice Springs.Nicholson A, Behrendt L, Vivian A, Watson N &Harris M (2009) “Will they be heard? - a response to the NTER Consultations June to August 2009” Jumbunna Indigenous House of Learning, available at http://intranet.law.unimelb.edu.au/staff/events/files/Willtheybeheard%20Report.pdf

Nowatzki, NR (2012), ‘Wealth, Inequality and Health: A Political Economy Perspective’, International Journal of Health Services, vol. 42, no. 3, pp. 403–424 http://dx.doi.org/10.2190/HS.42.3.c

NSW Government (2019) ‘Intensive Family Based Services’, available at https://www.facs.nsw.gov.au/providers/funded/programs/atsi/intensive-family-based-services- aboriginal, accessed 11/01/2020.

NSW Government (2018) ‘Protecting Our Kids’, available at https://www.facs.nsw.gov.au/families/support-programs/protecting-our-kids/protecting-our-kids, accessed 11/01/2020.

NSW Government & Aboriginal Health and Medical Research Council of New South Wales (2015) “NSW Aboriginal Health Partnership Agreement 2015-2025”, NSW Ministry of Health, available at http://www.health.nsw.gov.au/aboriginal/Documents/Aboriginal-Health-Partnership- Agreement.pdf, accessed 18/10/2017.

O’Flynn J (2007) “From New Public Management to Public Value: Paradigmatic Change and Managerial Implications” The Australian Journal of Public Administration, vol. 66, no. 3, pp. 353–366

Office of the Registrar of Indigenous Corporations (2017) ‘The Registrar’s powers to intervene’, Policy Statement 5, Australian Government, available at http://www.oric.gov.au/resources/policy- statements, accessed 23/10/2018.

Ong, KS, Carter, R, Kelaher, M & Anderson, I (2012), ‘Differences in primary health care delivery to Australia’s Indigenous population: a template for use in economic evaluations’ BMC Health Services Research, vol. 12, no. 307, pp. 1-11, https://doi.org/10.1186/1472-6963-12-307

327

Orange Aboriginal Medical Service [OAMS] (n.d.) ‘Governance’, available at https://www.oams.net.au/governance/, accessed 06/01/2020.

O'Reilly J, Busse R, Häkkinen U, Or Z, Street A, Wiley M (2012) “Paying for hospital care: the experience with implementing activity-based funding in five European countries” Health Economics, Policy and Law, vol. 7, no. 1, pp. 73-101.

Osborne, K, Baum, F & Brown, L (2013), ‘What works? A review of actions addressing the social and economic determinants of Indigenous health’, Issues Paper no. 7 produced for the Closing the Gap Clearinghouse, Australian Institute of Health and Welfare, https://www.aihw.gov.au/reports/indigenous-australians/what-works-a-review-of-actions- addressing-the-social-and-economic-determinants-of-indigenous-health/contents/table-of-contents

Osbourne D & Gaebler T (1993) Reinventing Government, Penguin Press, New York.

Panaretto KS, Dellit A, Hollins A, Wason G, Sidhom C, Chilcott K, Malthouse D, Andrews S, Mein J, Ahkee B, McDermott R (2017), ‘Understanding patient access patterns for primary health-care services for Aboriginal and Islander people in Queensland: a geospatial mapping approach’, Australian Journal of Primary Health, vol. 23, no. 1, pp. 37-45. doi: 10.1071/PY15115.

Panaretto KS, Wenitong M, Button S, Ring IT, (2014) “Aboriginal community controlled health services: leading the way in primary care”, Medical Journal of Australia, vol. 200, no. 11, pp. 649- 652.

Panaretto, KS, Lee, HM, Mitchell, MR, Larkins, SL, Manessis, V, Buettner, PG & Watson, D (2005), ‘Impact of a collaborative shared antenatal care program for urban Indigenous women: a prospective cohort study’. Medical Journal of Australia, vol. 182, no. 10, pp. 514-9. doi: 10.5694/j.1326-5377.2005.tb00017.x

Paradies Y, Harris R & Anderson I (2008) “The Impact of Racism on Indigenous Health in Australia and Aotearoa: Towards a Research Agenda” Discussion Paper Series No. 4, Cooperative Research Centre for Aboriginal Health and Flinders University, available at https://www.lowitja.org.au/sites/default/files/docs/Racism-Report.pdf

Paradies, Y (2007) ‘Racism’, in in B Carson, T Dunbar, RD Chenhall & R Bailie (eds), Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 65-86.

Paradies, Y (2017), ‘Overcoming racism as a barrier to community development’, in C Kickett-Tucker, D Bessarab, J Coffin and M Wright (eds), Mia Mia Aboriginal Community Development: Fostering cultural security, Cambridge University Press, Port Melbourne. Pp. 169-185.

Paradies, YC & Cunningham, J (2012b), ‘The DRUID study: exploring mediating pathways between racism and depressive symptoms among Indigenous Australians’, Social Psychiatry and Psychiatric Epidemiology, vol. 47, no. 165. https://doi.org/10.1007/s00127-010-0332-x

Paradies, YC & Cunninham, J (2012a), ‘The DRUID study: racism and self-assessed health status in an indigenous population’, BMC Public Health, vol. 12, no. 131, https://doi.org/10.1186/1471-2458-12- 131

328

Pearson N (2007) ‘White guilt, victimhood and the quest for a radical centre’, The Griffith Review, no. 16, https://griffithreview.com/articles/white-guilt-victimhood-and-the-quest-for-a-radical- centre/

Pearson N (2009) ‘Our Right to Take Responsibility’ in Up From the Mission: Selected Writings, Black Inc., Melbourne.

Pellegrino E D (1999) “The Commodification of Medical and Health Care: The Moral Consequences of a Paradigm Shift from a Professional to a Market Ethic”, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, vol. 24, iss. 3, January, pp. 243–266.

Perche D (2016) “Can Turnbull change course in Indigenous Affairs?” The Conversation, September 2, available at https://theconversation.com/can-turnbull-change-course-in-indigenous-affairs-64589 accessed 11/11/2016.

Perche, D (2018) ‘Recalibrating the machinery of government for Indigenous Affairs: Towards a new policy design for self-determination’, vol. 77, iss. S1, pp. S28-S36.

Perche, D., (2017) ‘Economic rationalism and Indigenous Affairs: the project of “normalisation”’ in A. Yeatman (ed.) Economic Rationalism in Canberra: Twenty-Five Years On, Working Papers in the Human Rights and Public Life Program, no. 5: May, Whitlam Institute, Western Sydney University. https://www.whitlam.org/publications/2017/7/12/economic-rationalism-in-canberra-twenty-five- years-on

Perheentupa, J. (2018) “Whitlam and Aboriginal self-determination in Redfern.” Australian Journal of Public Administration, 77: S13–S18. doi: 10.1111/1467-8500.12354.

Peters-Little F (2000) ‘The Community Game: Aboriginal Self Determination at the Local Level’, Research Discussion Paper no. 10, Australian Institute of Aboriginal and Torres Strait Islander Studies, Canberra ACT, available at https://aiatsis.gov.au/sites/default/files/products/discussion_paper/littlefp-dp10-community-game- aboriginal-self-definition-local-level.pdf, accessed 16/01/2020.

Peterson N (2005) ‘What can Pre-Colonial and Frontier Economies tell us about Engagement with the Real Econonomy? Indigenous Life Projects and the Conditions of Development. in D Austin-Broos & G Macdonald (eds), Culture, Economy and Governance in Aboriginal Australia: Proceedings of a Workshop of the Academy of Social Sciences in Australia, Sydney University Press. Sydney, pp. 7-18.

Phillips, G (2019), ‘Australia must embrace 'cultural safety' if we are to close the gap’, The Guardian, 16 May, https://www.theguardian.com/commentisfree/2019/may/16/australia-must-embrace- cultural-safety-if-we-are-to-close-the-gap

Pollitt C (1995) “Justification by Works or by Faith? Evaluating the New Public Management” Evaluation, vol. 1, no. 2, pp. 133-154.

Pollitt C (2007) ‘The New Public Management: An Overview of Its Current Status’, ADMINISTRAŢIE ŞI MANAGEMENT PUBLIC, no. 8, p. 110-115.

Pope C, Ziebland S & Mays N (2007) ‘Analysing Qualitative Data’, in Qualitative Research in Health Care. doi:10.1002/9780470750841.ch7

329

Povinelli E (2010) “Indigenous politics in late liberalism”, in J Altman and M Hinkson, Culture Crisis: Anthropology and Politics in Aboriginal Australia, UNSW Press, pp. 17-31.

Powles, J (2001), ‘Healthier Progress: historical perspectives on the social and economic determinants of health’, in R Eckersley, J Dixon & B Douglas (eds.), The Social Origins of Health and Well-being, Cambridge University Press, Port Melbourne.

Priest, N, Paradies, Y, Trenerry, B, Truong, M, Karlsen, S, Kelly, Y (2013), ‘A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people’, Social Science & Medicine, vol. 95, pp. 115-127, https://doi.org/10.1016/j.socscimed.2012.11.031

Productivity Commission (2016) “Overcoming Indigenous Disadvantage: Key Indicators 2016” Commonwealth of Australia, accessed 17/02/2017, available at http://www.pc.gov.au/research/ongoing/overcoming-indigenous-disadvantage/2016

Productivity Commission (2017a) “Introducing Competition and Informed User Choice into Human Services: Identifying Sectors for Reform”, Commonwealth of Australia, available at https://www.pc.gov.au/inquiries/completed/human-services/identifying-reform/report accessed 24/04/2018

Productivity Commission (2017b) ‘Indigenous Expenditure Report 2017’, Australian Government, available at https://www.pc.gov.au/research/ongoing/indigenous-expenditure-report, accessed 17/01/2020.

Productivity Commission (2019) ‘Indigenous Evaluation Strategy: Issues Paper, retrieved from https://www.pc.gov.au/inquiries/current/indigenous-evaluation/issues/indigenous-evaluation- issues.pdf

Pusey M (1991) ‘Economic Rationalism in Canberra: A nation-building state changes its mind’, Cambridge University Press, Cambridge.

Ramsden, I (2002) Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu, University of Wellington, Wellington.

Rappaport J (1981), ‘In Praise of Paradox: A Social Policy of Empowerment over Prevention’, American Journal of Community Psychology, vol. 9, no. 1, pp. 1-25, https://doi.org/10.1007/BF00896357

Read, P (1981) ‘The Stolen Generations: The Removal of Aboriginal Children in NSW, 1883 to 1969: Discussion Paper for the Aboriginal Children’s Research Project’, NSW, Family and Children’s Services Agency, Sydney.

Reconciliation Australia (2016) “The State of Reconciliation in Australia (summary): Our History, Our Story, Our Future” available at https://www.reconciliation.org.au/the-state-of-reconciliation-in- australia-report/, viewed 18/10/2017.

Reconciliation Australia (2018), ‘2018 Australian Reconciliation Barometer’, https://www.reconciliation.org.au/wp-content/uploads/2019/02/ra_2019-barometer- brochure_web.single.page_.pdf

330

Referendum Council (2017) “Uluru statement from the heart” available at https://www.referendumcouncil.org.au/sites/default/files/2017- 05/Uluru_Statement_From_The_Heart_0.PDF , accessed 18/10/2017

Reid JB, Taylor K and Hayes, C (2016) ‘Indigenous health systems and services’ in E Willis, L Reynolds and M Keleher (eds), Understanding the Australian Health Care System, third edition, Elsevier, Chatswood. Pp. 153-166.

Rein M & Schön D (1996) ‘Frame-Critical Policy Analysis and Frame-Reflective Policy Practice’ Knowledge and Policy: The International Journal of Knowledge Transfer and Utilization, Spring, Vol. 9, Number 1, pp. 85-104.

Reynolds H (2006) The Other Side of the Frontier, UNSW Press, Sydney.

Reynolds, H (1996), Aboriginal Sovereignty: Reflections of race, state and nation, Allen & Unwin, Crows Nest.

Rhodes RAW (1996), “The New Governance: Governing without Government”, Political Studies, vol. XLIV, pp. 652-667.

Rifkin SB (2003) ‘A Framework Linking Community Empowerment and Health Equity: It Is a Matter of CHOICE’, Journal of Health, Population and Nutrition, Vol. 21, No. 3, pp. 168-180.

Rigby, CW, Rosen, A, Berry, HL, Hart, CR, (2011) “If the land’s sick, we’re sick: The impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales”, Australian Journal of Rural Health, vol. 19, iss. 5, pp. 249–254. https://doi.org/10.1111/j.1440-1584.2011.01223.x

Rigney L-I (1999) “Internationalization of an Indigenous Anticolonial Cultural Critique of Research Methodologies: A Guide to Indigenist Research Methodology and Its Principles”, Wicazo Sa Review, Vol. 14, No. 2, pp. 109-121.

Riley, E. P., & McGee, C. L. (2005) “Fetal Alcohol Spectrum Disorders: An Overview with Emphasis on Changes in Brain and Behavior”, Experimental Biology and Medicine, vol. 230, iss. 6, pp. 357-365, https://doi.org/10.1177/15353702-0323006-03

Rivkin-Fish, M. (2011) ‘Learning the Moral Economy of Commodified Health Care: “Community Education,” Failed Consumers, and the Shaping of Ethical Clinician-Citizens’ Cult Med Psychiatry 35: 183. https://doi.org/10.1007/s11013-011-9208-0

Robinson, DE (2007), ‘US Health and Health Care: Does Political Inequality Make Us Sick?’ New Political Science, vol 29, no. 4, pp. 529-534, https://doi.org/10.1080/07393140701740957

Robinson, S., Dickinson, H., & Durrington, L. (2016). Something old, something new, something borrowed, something blue? Reviewing the evidence on commissioning and health services. Australian Journal of Primary Health, 22(1), 9–14.

Rochefort, D., & Cobb, R. (1994). ‘Problem definition: An emerging perspective’. In D. Rochefort, & R. Cobb (Eds.), The politics of problem definition: Shaping the policy agenda. Lawrence: University Press of Kansas.

331

Rogers, N (2008) ‘From "Treatment" to "Care": Developing Youth Drug Treatment Services using a Social Model of Health’. Australian Journal of Primary Health 14, 52-58. https://doi.org/10.1071/PY08007

Room R (2010) ‘The long reaction against the wowser: The prehistory of alcohol deregulation in Australia’, Health Sociology Review, vol. 19, iss. 2, pp. 151-163, DOI: 10.5172/hesr.2010.19.2.151

Rose, G [Geoffrey] (1985) “Sick Individuals and Sick Populations”, International Journal of Epidemiology, vol. 14, pp. 32–8.

Rose, G [Gillian] (1997) “Situating knowledges: positionality, reflexivities and other tactics”, Progress in Human Geography vol. 21, no. 3 pp. 305-320.

Rowe W E (2014) ‘Positionality’ in D. Coghlan & M. Brydon-Miller (eds) The SAGE Encyclopedia of Action Research, SAGE Publications Ltd, https://dx.doi.org/10.4135/9781446294406.n277

Rowse T (2005a) ‘The Indigenous Sector’ in D Austin-Broos & G Macdonald (eds), Culture, Economy and Governance in Aboriginal Australia: Proceedings of a Workshop of the Academy of Social Sciences in Australia, Sydney University Press. Sydney, pp. 213-230.

Rowse T (2005b) Contesting assimilation, API Network, Perth.

Rowse T (2013) “The Politics of ‘Aboriginal Society’” History Australia, vol. 10, no. 2, pp. 136-158.

Rowse T (2017) Indigenous and Other Australians Since 1901, UNSW Press, Sydney.

Rowse, T (2002) Indigenous Futures: Choice and Development for Aboriginal and Islander Australia, UNSW Press, Sydney

Rowse, T (2012), Rethinking Social Justice: From ‘Peoples’ to ‘Populations’, Aboriginal Studies Press, Canberra.

Russell L (2014) “Impact of the 2014-25 Budget on Indigenous Programs and Services” Menzies Centre for Health Policy, University of Sydney, available at https://ses.library.usyd.edu.au/bitstream/2123/11442/1/2014-15IndigenousProvisions.pdf, accessed 24/04/2018.

Russell L (2015), “Indigenous Provisions in the 2015-16 Budget” https://ses.library.usyd.edu.au/bitstream/2123/13476/1/2015-16%20Indigenous%20Budget.pdf

Russell L. M., (2013) “Reports indicate that changes are needed to close the gap for Indigenous health”, Medical Journal of Australia, vol. 199, no. 11, pp. 1-2.

Ryan, L, Debenham, J, Brown, M, Pascoe, W, (2017) ‘Colonial frontier massacres in Eastern Australia 1788-1872’, Centre For 21st Century Humanities, University of Newcastle, https://c21ch.newcastle.edu.au/colonialmassacres/map.php

Saggers, S & Gray, D (1991), ‘Aboriginal Health & Society: The Traditional and Contemporary Aboriginal Struggle for Better Health, Allen & Unwin, Crows Nest.

332

Saggers, S & Gray, D (2007), ‘Defining what we mean’, in B Carson, T Dunbar, RD Chenhall & R Bailie 2007, Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 1-20.

Sanders W (2018) ‘Missing ATSIC: Australia’s need for a strong Indigenous representative body’ in D Howard-Wagner, M Bargh and I Altamirano-Jiménez (eds), The Neoliberal State, Recognition and Indigenous Rights: New Paternalism to New Imaginings. Canberra: Australian National University Press. Pp. 113-130.

Sanders W (2004) Indigenous Centres in the Policy Margins: The CDEP Scheme Over 30 Years’, Australian Council of Social Service Congress 2005, Unknown, Strawberry Hills, NSW, pp. 75-82.

Sanders W (2010) ‘Ideology, Evidence and Competing Principles in Australian Indigenous Affairs: From Brough to Rudd via Pearson and the NTER’ Australian Journal of Social Issues Vol.45 No.3 SPRING, pp. 307-331.

Sanders W (2013) “Changing Agendas in Australian Indigenous Policy: Federalism, Competing Principles and Generational Dynamics”, Australian Journal of Public Administration, vol. 72, no. 2, pp. 156–170.

Sanders, W (2008) ‘In the name of failure: A generational revolution in Indigenous Affairs’ in Aulich, C. & Wettenhall, R. (eds) Howard’s Fourth Government: Australian Commonwealth Administration 2004-2007, UNSW Press, Kensington.

Schmid H (2003) “Rethinking the policy of contracting out social services to non-government organizations” Public Management Review, vol. 5, no. 3 pp. 307-323.

Schneider AL & Ingram H (1997) Policy Design for Democracy, University Press of Kansas, Lawrence.

Schneider AL & Ingram HM (2005) Deserving and Entitled: Social Constructions and Public Policy, State University of New York Press, Albany.

Schneider AL, Ingram H & deLeon P (2014) “Democratic Policy Design: Social Construction of Target Populations” in PA Sabatier & CM Weible, Theories of the Policy Process (Third Edition), Westview Press, Boulder.

Schrecker, T & Bambra C (2015), How Politics Makes Us Sick: Neoliberal Epidemics, Palgrave Macmillan, London.

Schulte-Tenckhoff I (1999) Reassessing the Paradigm of Domestication: the Problematic of Indigenous Treaties, Review of Constitution Studies, vol. 4, no.2 pp. 239-89.

Scrimgeour M and Scrimgeour D (2008) “Health Care Access for Aboriginal and Torres Strait Islander People Living in Urban Areas, and Related Research Issues: A Review of the Literature”, Discussion Paper Series: No. 5, Cooperative Research Centre for Aboriginal Health, Casuarina.

Scullion N (2014) “Delivering our commitments for Indigenous Australians”, media release 13 May, Department of Prime Minister and Cabinet, available at https://ministers.dpmc.gov.au/scullion/2014/delivering-our-commitments-indigenous-australians, accessed 11/11/2016.

333

Scullion N (2015) “Greens not telling whole story on IAS funding”, Media Release, 5 May, available at http://www.nigelscullion.com/media-hub/indigenous-affairs/greens-not-telling-whole-story-ias- funding, viewed 23/09/2016.

Sen A (1999) Development as Freedom, Oxford University Press, Oxford.

Senate Finance and Public Administration References Committee [Senate FPARC] (2016), “Report: Commonwealth Indigenous Advancement Strategy tendering processes” Commonwealth of Australia, available at http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Finance_and_Public_Administ ration/Commonwealth_Indigenous/Report, viewed 29/04/2016.

Shaw, M Dorling D and Davey Smith G (2006), ‘Poverty, social exclusion and minorities’, in M Marmot and RG Wilkinson (eds) The Social Determinants of Health, second edition, Oxford University Press, Oxford, pp. 196-223.

Sheridan J (2016) “Activity Based Funding: The implications for Australian health policy” Master of Arts Research Thesis, University of Sydney, available at https://ses.library.usyd.edu.au/bitstream/handle/2123/15763/2016_Jeanette_Sheridan_thesis.pdf;j sessionid=03A907E5A5CC0794F4558936E71349E2?sequence=2, accessed 23/04/2018.

Sherwood, J., Lighton, S., Dundas, K., French, T., Link-Gordon, D., Smith, K., & Anthony, T. (2015). Who are the experts here? Recognition of aboriginal women and community workers in research and beyond. AlterNative, 11(2), 177–190.

Siegrist, J & Marmot, M (2004), ‘Health inequalities and the psychosocial environment - two scientific challenges’, Social Science and Medicine, vol. 58, pp. 1463-1473.

Silburn, K., Thorpe, A., Carey, L., Frank-Gray, Y., Fletcher, G., McPhail, K. and Rumbalara Aboriginal Co-operative (2016), Is Funder Reporting Undermining Service Delivery? Compliance reporting requirements of Aboriginal Community Controlled Health Organisations in Victoria, The Lowitja Institute, Melbourne.

Siltala J (2013) “New Public Management: The Evidence-Based Worst Practice?” Administration and Society” vol. 45, no. 4, pp. 468-493.

Simonds VW & Christopher S (2013) “Adapting Western Research Methods to Indigenous Ways of Knowing”, American Journal of Public Health, vol. 103, no. 12, pp. 2185-2192

Simpson A (2014) Mohawk Interruptus: Political Life Across the Borders of Settler States, Duke University Press, Durham.

Smith, D & Hunt, J (2008), ‘Understanding Indigenous Australian governance—research, theory and representations’, , in J. Hunt, D. Smith, S. Garling and W. Sanders (eds), Contested Governance: Culture, power and institutions in Indigenous Australia, Research Monograph No. 29, Centre for Aboriginal Economic Policy Research: The Australian National University, Canberra, available at https://press.anu.edu.au/publications/series/centre-aboriginal-economic-policy-research- caepr/contested-governance

Smith, D., (2008) ‘Cultures of governance and the governance of culture: transforming and containing Indigenous institutions in West Arnhem Land’, in J. Hunt, D. Smith, S. Garling and W.

334

Sanders (eds), Contested Governance: Culture, power and institutions in Indigenous Australia, Research Monograph No. 29, Centre for Aboriginal Economic Policy Research: The Australian National University, Canberra, available at https://press.anu.edu.au/publications/series/centre- aboriginal-economic-policy-research-caepr/contested-governance accessed 23/10/2018.

Stanner WEH (1968) “The Great Australian Silence” (Extract from The Boyer Lectures: After the Dreaming) in Robert Manne (ed) (2010) WEH Stanner: The Dreaming and other essays, Black Inc, Melbourne.

Stone, D (2002) ‘Decisions’ in Policy Paradox: The Art of Political Decision-Making, WWNorton, New York.

Stone, D (1989), ‘Causal Stories and the Formation of Policy Agendas’, Political Science Quarterly, vol. 104, no. 2, pp. 281-300.

Strakosch E (2015) Neoliberal Indigenous Policy: Settler Colonialism and the ‘Post-Welfare’ State, Palgrave Macmillan, Houndmills.

Strakosch E (2019) ‘The Technical is Political: Settler Colonialism and the Australian Indigenous Policy System’, Australian Journal of Political Science, vol. 54, no. 1, pp. 114-130.

Strauss, A & Corbin JM (1990) Basics of qualitative research: Grounded theory procedures and techniques. Sage Publications, Thousand Oaks.

Sturgess, G. L. (2018). Public service commissioning: Origins, influences, and characteristics. Policy Design and Practice, 1(3), 155–168.

Sturgess, G. L., Argyrous, G., & Rahman, S. (2016). Commissioning human services: Lessons from Australian convict contracting. Australian Journal of Public Administration, 76(4), 457–469.

Sullivan, P. (2011), Belonging Together: Dealing with the politics of disenchantment in Australian Indigenous Policy, Aboriginal Studies Press, Canberra.

Sullivan, P. (2009) “Reciprocal Accountability: Assessing the Accountability Environment in Australian Aboriginal Affairs Policy”, International Journal of Public Sector Management, 22:1 pp57–72.

Sullivan, P. (2018) ‘The tyranny of neoliberal public management and the challenge for Aboriginal community organisations’ in D Howard-Wagner, M Bargh and I Altamirano-Jiménez (eds), The Neoliberal State, Recognition and Indigenous Rights: New Paternalism to New Imaginings. Canberra: Australian National University Press. Pp. 201-215.

Sullivan, P. (2010) “The Aboriginal Community Sector and the Effective Delivery of Services: Acknowledging the Role of Indigenous Sector Organisations.” Desert Knowledge Cooperative Research Centre, working paper 73, http://www.nintione.com.au/resource/DKCRC-Working-paper- 73_Indigenous-sector-oganisations.pdf.

Sweet M (2015) “Devastating news for Aboriginal health in western Sydney”, Crikey, June 26, available at http://blogs.crikey.com.au/croakey/2015/06/26/devastating-news-for-aboriginal- health-in-western-sydney/, viewed 29/04/16.

335

Taylor P 2019 ‘Wyatt rules out indigenous voice in people poll’ The Australian, August 17, https://www.theaustralian.com.au/nation/wyatt-rules-out-indigenous-voice-in-people-poll/news- story/60672a9a4b05f1b80805abc671ca6e96

Taylor, K & Guerin, P (2010), Health Care and Indigenous Australians: Cultural safety in practice, Palgrave Macmillan, South Yarra.

The Mandarin (2018) “Turnbull: we are committed to doing things with, not to, Aboriginal people”, viewed 12/03/2018, available at https://www.themandarin.com.au/88266-turnbull-committed- doing-thing-with-aboriginal-people/

Thomas MD, Blacksmith J & Reno J (2000) Utilizing Insider-Outsider Research Teams in Qualitative Research. Qualitative Health Research, 10(6), 819– 828. https://doi.org/10.1177/104973200129118840

Thomas, DP, Heller, RF & Hunt, JM (1998), ‘Clinical Consultations in an Aboriginal Community- Controlled Health Service: A Comparison with General Practice’, Australian and New Zealand Journal of Public Health vol. 22, no. 1, pp. 86-91. https://doi.org/10.1111/j.1467-842X.1998.tb01150.x

Thompson, J. (2015). “The costly abolition of Medicare locals”. Analysis and Policy Observatory. Retrieved from http://apo.org.au/node/58917

Thornton P.H., Ocasio W. & Lounsbury M. (2012) The Institutional Logics Perspective: A New Approach to Culture, Structure and Process, Oxford University Press, Oxford.

Tricker B (2018) Corporate Governance: Principles, Policies and Practices, Oxford University Press, Oxford.

Tsey K, Harvey D, Gibson T & Pearson T (2009) “The role of empowerment in setting a foundation for social and emotional wellbeing” Advances in Mental Health vol. 8, no. 1, pp. 6–15. https://doi.org/10.5172/jamh.8.1.6

Tuhiwai-Smith L (1999) Decolonizing Methodologies: Research and Indigenous Peoples, Zed Books, London and New York, University of Otago Press, Dunedin. van Hulst M & Yanow D (2016), ‘From Policy “Frames” to “Framing”: Theorizing a More Dynamic, Political Approach’, American Review of Public Administration, Vol. 46(1) 92–112, DOI: 10.1177/0275074014533142. van Ryan, M and Fu, SS (2011), ‘Paved with Good Intentions: Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health?’, American Journal of Public Health, Vol 93, No. 2, pp. 248-255.

Van Slyke DM (2003) “The Mythology of Privatization in Contracting for Social Services” Public Administration Review, vol. 63, no. 3 pp. 296-315.

Veracini L (2011) Settler Colonialism: A Theoretical Overview, Palgrave Macmillan, Houndmills.

Veracini L (2015) The Settler Colonial Present, Palgrave Macmillan, Houndmills.

Victorian Aboriginal Health Service [VAHS] (n.d), ‘About VAHS’, https://www.vahs.org.au/about/

336

Villerme ́ L-R. (1840) ‘Tableau de l’e tat́ physique et moral dans ouvriers employe ś dans les manufactures de coton, de laine et de soie’. Renouard, Paris.

Vos T, Barker B, Begg S, Stanley L, Lopez AD, (2009) ‘Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap’, International Journal of Epidemiology, Volume 38, Issue 2, Pp. 470–477, https://doi.org/10.1093/ije/dyn240

Wacquant L (2009) Punishing the Poor: The Neoliberal Government of Social Insecurity, Duke University Press, Durham and London.

Wacquant L (2010), ‘Crafting the Neoliberal State: Workfare, Prisonfare, and Social Insecurity’ Sociological Forum, Vol. 25, No. 2, DOI: 10.1111/j.1573-7861.2010.01173.x

Wacquant L (2012) “Three steps to a historical anthropology of actually existing neoliberalism”, Social Anthropology, vol. 20, no. 1, pp. 66-79.

Wade, E., Smith, J., Peck, E., & Freeman, T. (2006). Commissioning in the reformed NHS: Policy into practice. Health Services Management Centre/NHS Alliance, University of Birmingham. Retrieved from https://www.birmingham.ac.uk/Documents/college-social-sciences/social- policy/HSMC/publications/2006/Commissioning-inthe-reformed-NHS.pdf

Wadsworth, M and Butterworth, S (2006), ‘Early Life’, in M Marmot and RG Wilkinson (eds) The Social Determinants of Health, second edition, Oxford University Press, Oxford, pp. 31-53.

Wallerstein N (1992) “Powerlessness, Empowerment, and Health: Implications for Health Promotion Programs” American Journal of Health Promotion, vol. 6, no. 3, January/February, pp. 197-205.

Wallerstein, N (1992) ‘Powerlessness, Empowerment, and Health: Implications for Health Promotion Programs’, American Journal of Health Promotion, vol. 6, no. 3, pp. 197-205.

Wallerstein, N (2002) ‘Empowerment to reduce public health disparities’ Scandinavian Journal of Public Health, vol. 30, suppl. 59, pp. 72-77.

Wallerstein, N (2006) ‘What is the evidence on effectiveness of empowerment to improve health?’ WHO Regional Office for Europe (Health Evidence Network report), Copenhagen http://www.euro.who.int/__data/assets/pdf_file/0010/74656/E88086.pdf

Walter M & Mooney G (2007) ‘Employment and welfare’ in B Carson, T Dunbar, RD Chenhall & R Bailie 2007, Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 153-176

Walter M & Saggers S (2007) ‘Poverty and social class’, in B Carson, T Dunbar, RD Chenhall & R Bailie 2007, Social Determinants of Indigenous Health, Allen and Unwin, Crows Nest, pp. 87-108.

Wand A (2014) “Activity-based funding: implications for mental health services and consultation- liaison psychiatry”, Australasian Psychiatry, vol. 22, no. 3, pp. 272-276.

Wanna, J., Butcher, J., and Freyens B (2010) Policy in action: the challenge of service delivery, UNSW Press: Sydney.

337

Warburton J and Chambers B (2007) ‘Older Indigenous Australians: their integral role in culture and community’, Australasian Journal on Ageing, vol. 26, iss. 1, pp. 3-7, https://doi.org/10.1111/j.1741- 6612.2007.00213.x

Warburton J, McLaughlin D. (2007) “Passing on our culture: how older Australians from diverse cultural backgrounds contribute to civil society” Journal of Cross-Cultural Gerontology, Volume 22, Issue 1, pp 47–60, https://doi.org/10.1007/s10823-006-9012-4

Ward J, Bryant J, Worth H, Hull P, Solar S, Bailey S (2013), ‘Use of health services for sexually transmitted and blood-borne viral infections by young Aboriginal people in New South Wales’, Australian Journal of Primary Health, vo. 19, no. 1, pp. 81-6.

Ware, V (2013), ‘Improving the Accessibility of Health Services in Urban and Regional Settings for Indigenous People’, Australian Institute of Health and Welfare, Canberra.

Wharam JF, Frank MB, Rosland AM, Paasche-Orlow MK, Farber NJ, Sinsky C, Rucker L, Rask KJ, Barry MJ, Figaro MK (2011) “"Pay-for-performance" as a quality improvement tool: perceptions and policy recommendations of physicians and program leaders” Quality Management in Health Care, vol. 20, no. 3, pp. 234-45.

Wild R & Anderson P (2007) “Ampe Akelyerne-mane Meke Mekarle: Little Children are Sacred”, Report of the NT Board of Inquiry into the protection of Aboriginal children from sexual abuse, Darwin: Northern Territory Government.

Wilkinson RG and Marmot M (eds) (2006), The Social Determinants of Health, second edition, Oxford University Press, Oxford.

Wilkinson, R & Marmot, M (eds) (2003), ‘Social Determinants of Health: The Solid Facts, second edition’ World Health Organisation, Copenhagen, http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf

Wilkinson, R and Pickett, K (2010) “The Spirit Level: Why Equality is Better for Everyone”, Penguin Books, London.

Wilkinson, RG (2006) ‘Ourselves and others – for better or worse: social vulnerability and inequality’ in in M Marmot and RG Wilkinson (eds) The Social Determinants of Health, second edition, Oxford University Press, Oxford, pp. 341-357.

Williams, DR (2006), ‘Race, Socioeconomic Status, and Health: The Added Effects of Racism and Discrimination’, Annals of the New York Academy of Sciences, vol. 896, iss. 1, pp. 173-188, https://doi.org/10.1111/j.1749-6632.1999.tb08114.x

Williams, DR, Neighbors, HW, Jackson, JS (2003), ‘Racial/ethnic discrimination and health: findings from community studies’, American Journal of Public Health, vol. 93, no. 2, pp. 200-8, https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.93.2.200

Wilson, S., (2008). Research Is Ceremony: Indigenous Research Methods. Fernwood Publishing, Halifax, Canada.

Wolfe P (1994) ‘Nation and MiscegeNation: Discursive Continuity in the Post-Mabo Era’, Social Analysis: The International Journal of Anthropology, No. 36, pp. 93-152.

338

Wolfe P (1999) Settler Colonialism and the Transformation of Anthropology: The Politics and Poetics of an Ethnographic Event, Bloomsbury, London.

Wolfe, P (2016), Traces of History: Elementary Structures of Race, Verso, New York and London.

World Health Organisation [WHO] (1978), ‘Declaration of Alma Ata’, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September, available at http://www.who.int/publications/almaata_declaration_en.pdf

Wright J (2014) ‘Commission of Audit - who, what, why and where’, Sydney Morning Herald, May 1, https://www.smh.com.au/politics/federal/commission-of-audit--who-what-why-and-where- 20140501-zr2af.html

Wright P & Lewis P (2017) “Progress and Priorities Report 2017”, Close the Gap Campaign Steering Committee, available at http://www.humanrights.gov.au/sites/default/files/document/publication/Close%20the%20Gap%2 0report%202017.pdf, accessed 22/03/2017.

Wyatt K (2017) “Call for Indigenous skills to assist Primary Health Networks” 1 March media release, Department of Health, available at http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2017- wyatt020.htm accessed, 24/04/2018.

Wyatt K (2019) ‘National Press Club Address - 'Walking in Partnership to Effect Change' https://ministers.pmc.gov.au/wyatt/2019/national-press-club-address-walking-partnership-effect- change

Yeatman, A. (2017) ‘Competition Policy and the Destruction of the Welfare State’ in A. Yeatman (ed.) Working Papers in the Human Rights and Public Life Program, No 4: April, Whitlam Institute within Western Sydney University, available at https://www.whitlam.org/publications/2017/10/24/neoliberal-government-and-its-implications-for- public-office-and-the-welfare-state

Yerin Aboriginal Health Services Incorporated [AHSI] (2017) ‘Annual Report 2016 – 2017', Wyong, NSW, available at https://yerin.org.au/wp-content/uploads/2018/03/Yerin-Annual-Report-2017- WEB.pdf, accessed 05/01/2020.

Zubrick SR, Shepherd CCJ, Dudgeon P, Gee G, Paradies Y, Scrine C, & Walker R (2014) ‘Social Determinants of Social and Emotional Wellbeing’ in P Dudgeon, H Milroy and R Walker (eds.) Working Together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice, Commonwealth of Australia, available at https://www.telethonkids.org.au/globalassets/media/documents/aboriginal-health/working- together-second-edition/working-together-aboriginal-and-wellbeing-2014.pdf, accessed 14/01/2020, pp. 93-112.

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Appendices

Appendix 1: Interviewees and remoteness map “Adam”

- Indigenous, Community Health Programs Manager, inner-regional, male, four years’ experience,

“Amanda”

- Indigenous, Practice Manager, outer-regional, female, 20 years’ experience,

“Amy”

- Non-Indigenous, CEO, outer-regional, female, seven years’ experience

“Annette”

- Non-Indigenous, Clinic Manger, outer-regional, female, 15 years’ experience

“Caitlin”

- Indigenous, Community and Cultural Inclusion Officer, outer-regional, female, 15 years’ experience

“Carole”

- Indigenous, Family Services Unit Manager, female, inner-regional, 16 years’ experience

“Charlie”

- Indigenous, CEO, inner-regional, male, 12 years’ experience

“Charlotte”

- Indigenous, CEO, outer-regional, female, 20 years’ experience

“Clair”

- Indigenous, Project Officer, inner-regional, female, 19 years’ experience

“Dane”

- Indigenous, Clinical Services Manager, inner-regional, male, 18 months’ experience

“Dominique”

- Indigenous, CEO, female, outer-regional, 30 years’ experience

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“George”

- Indigenous, Program Officer/Team Leader Social and Emotional Wellbeing, outer-regional, male, 24 years’ experience

“Gwen”

- Indigenous, CEO, outer-regional, female, 16 years and 4 months’ experience

“Harry”

- Non-Indigenous, CEO, male, inner-regional, 10 years’ experience

“Jess”

- Non-Indigenous, Medical Director, inner-regional, female, 20 years’ experience

“Joanne”

- Indigenous, Community Programs Manager, outer-regional, female, three months’ experience

“Kate”

- Indigenous, Team Leader, remote, female, three years’ experience

“Les”

- Indigenous, CEO, male, outer-regional, 15 years’ experience

“Linda”

- Non-Indigenous, CEO, inner-regional, female, 11 years’ experience

“Lizzie”

- Indigenous, CEO, female, inner-regional, 10 years’ experience

“Natalie”

- Indigenous, CEO, female, outer-regional, one year’s experience

“Peter”

- Non-Indigenous, Operations Manager, urban-based, male, two and a half years’ experience

“Roger”

- Indigenous, CEO, male, urban-based, 17 years’ experience

“Rosemary”

- Indigenous, CEO, urban-based, female, 20 years’ experience

“Sam”

- Indigenous, CEO, male, inner-regional, 40 years’ experience

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“Shirley”

- Non-Indigenous, Quality Manager, inner-regional, female, two years’ experience

“Stephen”

- Non-Indigenous, CEO, male, inner-regional, 18 years’ experience

“Tim”

- Non-Indigenous, CEO, inner-regional, male, 25 years’ experience

“Tristan”

- Indigenous CEO, male, remote, 10 years’ experience

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Australian Statistical Geographic Standard Remoteness Areas (2016) of New South Wales. Source: Department of Health 2016d, available at https://www.health.gov.au/resources/apps-and-tools/health-workforce-locator/health- workforce-locator#hwc-map

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Appendix 2: Interview questions

INTERVIEW PLAN

Project title: The struggle for health equity: challenges facing Aboriginal Community Controlled Health Services

Research question: What is the role of the Aboriginal Community Controlled Health Services in the health system and what challenges do they face in their efforts to improve Indigenous health? How can governments and mainstream health care providers work more effectively with ACCHS?

Before we start, do you have any questions that you want to ask me?

Preliminary questions:

What is your official job title?

How long have you been in this role?

How long have you been working in Aboriginal and Torres Strait Islander health, or in Aboriginal community organisations?

Do you identify as an Aboriginal or Torres Strait Islander person? Is this your Country that we are on here?

Interview questions:

1. Could you describe what a typical day at work is like for you?

2. Who accesses your services?

3. What are the biggest health issues in the local Aboriginal community?

a. What about social issues?

b. And how does that compare to the non-Indigenous population?

4. What do you think are the root causes of these problems? What do you think is driving this?

a. Are the health and social issues linked?

b. How do they affect each other?

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5. What’s been working well, in terms of addressing these problems? Successes

a. What programs and services do you offer?

6. What do you see as your organisation’s main goals?

7. How do you operate compared to other health providers? Similarities, differences?

a. How so?

b. Examples?

8. Does your organisation define health in a particular way?

a. How does that compare to mainstream services approach to health?

b. How does that influence what you do here?

9. What makes your service attractive to Aboriginal people?

a. What is it that makes your patients keep coming back?

10. How does your organisation make decisions?

a. How does it decide its goals?

b. Can you tell me about the role of the board of community directors?

c. Does government have any influence?

11. What can you tell me about the significance of Aboriginal Community Control?

a. Does it affect Aboriginal health?

12. What are the biggest challenges facing your organisation?

a. What about for you in your role?

13. How is your organisation funded?

a. Does this affect what you are able to do? How?

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b. Have your funding arrangements changed in recent years?

c. Do you compete with other organisations for funding?

d. What effect is that having?

14. Has the Indigenous Advancement Strategy impacted your organisation?

a. How?

15. What about the Primary Health Networks? Do they affect your work?

16. I noticed that there were some IAHP funding changes announced. What do you think about this?

17. What’s your relationship like with governments? State, Federal, Local?

a. Could this be improved? How?

18. What’s your relationship like with mainstream health providers?

a. Could this be improved? How?

19. How could we increase the positive impacts of ACCHS’ work?

a. What does your organisation need to be its most effective?

b. What do you need so that you can deliver the best possible services?

20. What do you think is needed to improve Aboriginal and Torres Strait Islander health?

a. Or how can we close the gaps in health?

• What do you think of the current approach to Closing the Gaps in health?

• Do you have any other comments about Aboriginal health and health services?

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Appendix 3: Participant Information Statement

PARTICIPANT INFORMATION STATEMENT

This information sheet is for you to keep.

Research Project Title: The struggle for health equity: challenges facing Aboriginal Community Controlled Health Services (ACCHS)

1) What is the study about?

This study aims to: 1) give voice to the ACCHS sector; 2) highlight ACCHS’ strengths; 3) understand the effects of competitive tenders and conditional grant funding; 4) find out how ACCHS interact with governments and mainstream health services; 5) make recommendations for reform.

The study looks at the effects of recent government funding policies related to Aboriginal health organisations. Specifically, it studies the impact of reforms introduced by the Abbott Government, such as the Indigenous Advancement Strategy (IAS) and the Indigenous Australians’ Health Programme (IAHP). It assesses how these policies affect Aboriginal Community Controlled Health Services (ACCHS) and other Aboriginal health organisations.

2) Who is carrying out the study?

David Coombs from the School of Social Sciences at the University of New South Wales (UNSW) runs the study. David is a PhD student and this research is for his thesis. Professor Alex Broom and Dr Diana Perche supervise this study. An Aboriginal Governance Committee gives advice on this study.

3) What does the study involve?

The study involves interviews with senior staff at ACCHS in New South Wales. Where consent is given, audio recordings of the interviews will be made. These recordings will be transcribed for accuracy. Only the researchers will have access to participants’ details and interview data. Digital recordings and transcriptions will be stored on password-protected computers. Physical records and data will be stored in locked filing cabinets in secure offices at UNSW. This data will be stored for five years, and will then be destroyed.

4) How much time will the study take?

Approximately one to two hours of your time will be required.

5) Can I withdraw from the study?

You can decide to be part of the study or not. You can withdraw from the study at any time. If you withdraw from the study there will not be any negative consequences for you or your organisation.

6) Will anyone else be told about the study’s results?

The results of the study will be included in a written thesis, to be submitted for examination to UNSW. Individual research participants and participating ACCHS will not be identified in the thesis unless they consent to this. The study’s results may be reported in policy briefings, and academic conferences and journals. However, research participants and participating ACCHS will not be identified in any such publications without their consent. Anonymous quotes from the interview transcriptions may be included in the final thesis or associated reports.

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You and your organisation can choose to be named in the final thesis and related publications. If you want this to happen, both you and your organisation must give written consent. Your interview responses can also be attributed directly to you and your organisation. If you want this to happen, both you and your organisation must give written consent.

7) Will the study benefit me?

The study is an opportunity for you to share your views on the way governments fund and interact with ACCHS. It is a chance for you to explain how policy changes have impacted your organisation. It allows you to share your knowledge and experience with others working to improve Aboriginal and Torres Strait Islander health.

You will receive a $100 gift card for your time. The gift card will be for a major retailer such as Myer, David Jones, Coles or Woolworths. Please tell the researcher which retailer you prefer.

You will be given a summary of the research results. This summary may help you and your organisation better understand how recent funding changes have affected ACCHS across NSW. This summary may also give you a clearer picture of why the government decided to make policy changes. It may also give you some idea of what you can expect from government in the future.

8) Can I tell other people about this study?

Yes, you can tell anyone you like about the study.

9) Who can I contact if I have any questions?

Once you have read this information statement David Coombs will get in touch with you to explain the research project in more detail. If after that time, or at any stage of the research process, you have any questions or require more information please contact:

Mr David Coombs, researcher and PhD student UNSW / School of Social Sciences / Nura Gili Indigenous Programs Phone: 0422 271 301 / (02) 9385 8353 Email: [email protected] or Dr Diana Perche, principal supervisor UNSW / Nura Gili Indigenous Programs Phone: (02) 9385 2251 Email: [email protected] or Professor Alex Broom, associate supervisor UNSW / School of Social Sciences Phone: (02) 9385 2829 Email: [email protected]

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10) What if I have any concerns or complaints?

The ethics aspects of this study have been approved by the Aboriginal Health & Medical Research Council (AH&MRC) Ethics Committee.

The AH&MRC and the Ethics Committee have established procedures for addressing complaints about ethical matters in current research in Aboriginal health.

The contact details for the AH&MRC Ethics Committee are: Phone: (02) 9212 4777 Email: [email protected]

All correspondence containing complaints or concerns about this research should be sent to:

The Chairperson AH&MRC Ethics Committee Aboriginal Health & Medical Research Council of NSW PO Box 1565 Strawberry Hills, NSW 2012

The UNSW Human Research Ethics Committee has noted the AH&MRC’s ethics approval and its ethics review process.

Thank you.

David Coombs

I would like to show my respects and acknowledge the Bedegal people, the Traditional Custodians of the land on which UNSW’s Kensington campus stands, and to pay my respects to Elders past and present.

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Appendix 4: Aboriginal Community Organisation Consent Form

ABORIGINAL COMMUNITY ORGANISATION CONSENT FORM

Name of Aboriginal Community Organisation: (This must be an Aboriginal Community Controlled Health Service (ACCHS) unless otherwise approved by the Ethics Committee):

………………………………………………………………………………………………….

PROJECT TITLE: The struggle for health equity: challenges facing Aboriginal Community Controlled Health Services

PRINCIPAL RESEARCHER: Dr Diana Perche (primary supervisor) RESEARCH ORGANISATION: University of New South Wales

(The following section must be completed by the Chairperson or CEO of the Aboriginal community organisation.)

I, …….……………………………………………………………… confirm that the (Please write your full name)

……………………………………………………………………………………….. (Please write name of Aboriginal organisation) gives its consent to the above research project, subject to the following conditions:

1. We have the right to withdraw our consent and cease any further involvement in the research project at any time without any penalty and without giving any reasons.

2. The purpose of the research, as outlined in the attached brief, has been explained we have had the opportunity to ask questions about the project. We have received satisfactory answers to our questions and have been given adequate time to consider the appropriateness of the project.

3. We have been provided with the following information in writing: • The names of all people and organisations responsible for the security of data and who will have access to the data. • Details of the proposed storage and destruction of data.

4. The researcher will need to obtain additional consent from us if there are any changes to the project from the information provided under paragraphs [2] and [3] above.

5. Any information that any member of our staff provides or any personal details of our clients obtained in the course of this research, are confidential and any information that could identify individual participants will neither be used nor published.

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6. Unless otherwise explicitly agreed, any information provided in the course of this research that identifies our organisation or the Aboriginal community which it serves will not be used nor published without our written permission.

7. The researcher will ensure there is continuing consultation with the community and our organisation during the course of the research. The research will not proceed until all required negotiation has occurred to our satisfaction.

8. The ethical provisions relating to the health of Aboriginal people, as set out in AH&MRC and NHMRC publications, will be complied with and the project will not proceed until the AH&MRC Ethics Committee has endorsed the project.

9. The researchers will obtain the written individual consent of all participants in the research.

10. We understand that if we have any complaints or questions concerning this research project we can contact the principal researcher mentioned above; the Chairperson or CEO, or the Chairperson of the AH&MRC Ethics Committee as follows:

The Chairperson AH&MRC Ethics Committee PO Box 1565 Strawberry Hills NSW 2012 Telephone: 9212 4777

Signed on behalf of …………………………………………………………………...... (insert name of Aboriginal organisation)

Signature ………………………………………………………………………………………..

Position in the organisation ………….…………………… (Board Chair or CEO)

Date ………….……………………

Witnessed by ……………………………..……………… Date ……………………………..

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As the Chief Researcher in the project, I acknowledge the conditions set out above.

Name: ………………………………………………………………………………………….

Signature………………………………..……………………… Date ………………………

Witnessed by ……………………………..……………… Date ………………………..

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Appendix 5: Participant Consent Form

PARTICIPANT CONSENT FORM

I, ...... consent to participate in the research project: (please write your full name)

TITLE: The struggle for health equity: challenges facing Aboriginal Community Controlled Health Services

In giving my consent I acknowledge that:

1. The research procedures and time requirements have been explained to me and I have understood them.

2. I have read and understood the Participant Information Statement and have been given the opportunity to discuss any concerns or questions with the researcher(s).

3. I understand that participation in the research project is voluntary, and that I am able to withdraw from the project at any time without it affecting my relationship with the researchers or the research institution, either now or in the future.

4. I understand that, unless I agree otherwise, my involvement is strictly confidential and no information about me will be used in any way that reveals my identity.

5. If I do agree to be identified in the study, my consent will be indicated by my initials in the first box at the end of this consent form.

6. I have been given the choice not to have the interview proceedings recorded via a voice recorder. If I do not wish to be recorded then this will be indicated by my initials in the second box at the bottom of this consent form.

Signed: ......

Name: ......

Date: ......

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Please initial any boxes that apply to you:

I agree to be identified in this study and have my comments attributed to me.

I do not wish to have my voice recorded during the interviews.

I do not wish to be identified in the publication of results.

If you have any complaints or concerns about this research project, you can contact the Aboriginal Health & Medical Research Council (AH&MRC) Ethics Committee secretariat (phone (02) 9212 4777; email [email protected]). AH&MRC and the Ethics Committee have established procedures for addressing complaints about ethical matters in current research in Aboriginal health. All correspondence containing complaints or concerns about this research should be sent to:

The Chairperson

AH&MRC Ethics Committee Aboriginal Health & Medical Research Council of NSW PO Box 1565 Strawberry Hills, NSW 2012

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Appendix 6: AH&MRC Ethics Approval Letter

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Appendix 7: Macquarie University Ethics Approval Letter

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