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 1 This page has been left blank intentionally. 2 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. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents a non-exclusive licence to archive and to make available (including to members of the public) my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known. I acknowledge that I retain all intellectual property rights which subsist in my thesis or dissertation, such as copyright and patent rights, subject to applicable law. I also retain the right to use all or part of my thesis or dissertation in future works (such as articles or books). …………………………………………………………… ……….……………………...…….… Signature Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years can be made when submitting the final copies of your thesis to the UNSW Library. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. 3 Originality Statement ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’ Signed …………………………………………….............. Date …………………………………………….............. 4 UNSW is supportive of candidates publishing their research results during their candidature as detailed in the UNSW Thesis Examination Procedure. Publications can be used in their thesis in lieu of a Chapter if: • The candidate contributed greater than 50% of the content in the publication and is the “primary author”, i.e. the candidate was responsible primarily for the planning, execution and preparation of the work for publication • The candidate has approval to include the publication in their thesis in lieu of a Chapter from their supervisor and Postgraduate Coordinator. • The publication is not subject to any obligations or contractual agreements with a third party that would constrain its inclusion in the thesis Please indicate whether this thesis contains published material or not: This thesis contains no publications, either published or submitted for publication ☐ Some of the work described in this thesis has been published and it has been documented in the relevant Chapters with acknowledgement ☒ This thesis has publications (either published or submitted for publication) incorporated ☐ into it in lieu of a chapter and the details are presented below CANDIDATE’S DECLARATION I declare that: • I have complied with the UNSW Thesis Examination Procedure • where I have used a publication in lieu of a Chapter, the listed publication(s) below meet(s) the requirements to be included in the thesis. Candidate’s Name Signature Date (dd/mm/yy) 5 Copyright statement ‘I hereby grant the University of New South Wales or its agents a non-exclusive licence to archive and to make available (including to members of the public) my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known. I acknowledge that I retain all intellectual property rights which subsist in my thesis or dissertation, such as copyright and patent rights, subject to applicable law. I also retain the right to use all or part of my thesis or dissertation in future works (such as articles or books).’ ‘For any substantial portions of copyright material used in this thesis, written permission for use has been obtained, or the copyright material is removed from the final public version of the thesis.’ Signed ……………………………………………........................... Date …………………………………………….............................. Authenticity statement ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis.’ Signed ……………………………………………........................... Date …………………………………………….............................. 6 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

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