Pearls and Irritations

Aboriginal community controlled health services have many advantages, including their power to advocate and shame governments into action, according to Donna Ah Chee, CEO of the Central Australian Aboriginal Congress.

They also have an important role in behind-the-scenes advocacy, with Ah Chee sharing one such example involving the Northern Territory Primary Health Network in her recent keynote to a conference celebrating the 25th anniversary of the Aboriginal Medical Services Alliance Northern Territory (AMSANT).

Her speech, published below with permission, also outlines many other ways that ACCHOs outperform services run by governments and Non-Indigenous NGOs, or NINGOs.

“Despite our history of amazing achievements, funding for Aboriginal health keeps being given to NINGOs and other private providers,” she says.

Ah Chee also explains why a national processes of self-determination by implementing the demands contained in the Uluru Statement is critical for health and wellbeing.

Donna Ah Chee writes:

I begin by acknowledging and paying my respects to the Arrernte people, traditional custodians of the land on which we are meeting today, and to their Elders past, present and emerging. I also extend my appreciation to Kumalie (Rosalie) Riley for the very warm welcome to her country.

I am a Bundjalung woman from the far north coast of New South Wales, but I have lived on beautiful Arrernte country for over thirty years.

And let me say right at the start, that I am passionate about community-control.

Ever since I first worked for the Institute for Aboriginal Development here in Alice Springs back in the early nineties, I haven’t looked back. Later, I moved over the back fence of the IAD [Institute for Aboriginal Development] premises to begin work at Congress.

Since then I have spent many years in leadership positions at Congress, and within AMSANT.

Given this experience, it is a great pleasure to be here at AMSANT’s 25th anniversary conference. And I sincerely thank the Chair, Board and CEO of AMSANT for the invitation to speak to you today.

I want to use this opportunity to go back to basics: to discuss the strengths and achievements of this model we all share, the model of Aboriginal community-control.

I want to reiterate the role of Aboriginal community-control as an act of self-determination by our diverse peoples.

I want to describe what we Aboriginal people can achieve through Aboriginal community control – and in particular, what we can deliver that no other service model can.
Of course, we all know this.

We all have lived it in our lives and through the community controlled services we are part of.

But it’s worth stepping back sometimes and reminding ourselves about what our sector stands for and what we have achieved.

So what is community control?

To answer that question, let me take you back almost thirty years to 1991, to before AMSANT existed.

The Public Health Association of Australia, responding to advocacy from our sector here in Central Australia, was holding its annual conference in Alice Springs, not far from here, on the health of Indigenous peoples.

Congress and Anyinginyi gave a landmark address to the conference called Primary Health Care and Community Control. In this address, they described what community control meant to them. They said that [Aboriginal] Community control means at least:

• the right to set the agenda, to determine what the issues are
• the right to determine which programs or approaches are best suited to tackle the problems in the community
• the right to determine how a program is run, its size and resources
• the right to determine when a program operates, its pace and timing
• the right to say where a program will operate, its geographical coverage and its target groups
• the right to determine who will deliver the program, its staff and advisers.

In my view, this is still a great definition of what community control is about.

It is about us, as Aboriginal communities, determining the what, which, how, when, where and who of programs to address our health and wellbeing.

Given the process of colonisation in this country, and the effects on our health and wellbeing, these matters are for us to decide – not for some outside agency however well-intentioned; not for government; not for the non-Aboriginal experts.

While we work with all these groups in a spirt of good will and collaboration, in the end it is the Aboriginal community who decides how best to address our health and wellbeing.

Critical role of Boards

That is what community control means. It’s an act of self-determination.

And crucial for the exercise of this act of self-determination are our Boards. It is our Boards, the directly elected representatives of our peoples, who are at the heart of community control.

They are the ones who ultimately set the direction of our organisations, they employ the CEOs, they make the key strategic decisions for the organisation.

I know it is often a heavy burden of responsibility to carry, but without them the community-controlled model can’t exist.

So to all the members of our community-controlled Boards here today I would like to say a big ‘thank you’ from my heart: because without you, there is no community control.

So, that’s what our model is. But what does it do?

How is it better than government run services, or those run by Non-Indigenous NGOs (or NINGOs we call them)?

Well, again, I am sure the AMSANT members here will have strong views on how their service is better than those other, non-Aboriginal controlled models.

You will know this from your own experience, your own detailed knowledge of the communities you serve.

An ongoing fight

But I would like to reiterate those strengths of the model, as I see them, because we have to keep fighting for community control.

Despite our history of amazing achievements, funding for Aboriginal health keeps being given to NINGOs and other private providers.

Funding is not being allocated according to need, to the best practice community controlled model, and this is a serious threat to the health of our communities.

The first strengths of our model I want to talk about is what the academics call the ‘control factor’.

It has been shown that the less control people have over their lives and environment, the more likely they are to suffer ill health: powerlessness is a risk factor for ill-health and poor social and emotional wellbeing.

So, the very fact that the community-controlled model empowers our communities contributes to health and wellbeing in itself.

Our model empowers our mob by guaranteeing their input into decision-making, and embedding Aboriginal employment and leadership across our services.

Of course, within our services we have genuine partnerships with non-Aboriginal people, including our independent Board members, staff and advisers. We need their skills.

And we appreciate their commitment to working with us, under the leadership and direction of Aboriginal people. Because despite the rhetoric about Aboriginal input we often hear from government, no other way of governing services guarantees Aboriginal empowerment and control.

Points of difference

Our model is fundamentally different from those services which include Aboriginal community members but only in an advisory role, and where the organisation can ignore that advice if they please.

Organisations led by unelected boards with a majority of non-Aboriginal directors are not Aboriginal community-controlled organisations – it is that simple.

Each year AIHW reports annually on services receiving Commonwealth funding to address Aboriginal health. Their data shows that ACCHSs have Boards composed fully or of a majority of Aboriginal and Torres Strait Islander people.

By contrast, 75 percent of non-ACCHS organisations have no Aboriginal and Torres Strait Islander formal community input into decision making at all, either having no Board, or no Aboriginal and Torres Strait Islander representation on a Board.

These structures of community control have whole range of benefits in themselves, because the sense of control and empowerment itself is a big boost to health and wellbeing.

For example, in Canada it has been shown that First Nation communities that took steps to preserve their culture, and worked to control their futures through Indigenous-led organisations had much lower rates of youth suicide

The second big advantage of the Aboriginal controlled health service is our reach into the community. Simply put, our communities trust us and the services we provide.

In 2017-18, Aboriginal community controlled health services had 400,00 clients nationally – that’s 60 percent of the entire Aboriginal and Torres Strait Islander population across the country

Of course, it is important that Aboriginal people have choice about which services to access, just as it is for any person.

But it is clear that Aboriginal and Torres Strait Islander people have a clear preference for the use of Aboriginal community- controlled health services, leading to greater access to care and better treatment outcomes.

Our ability to deliver culturally safe care is fundamental to this preference, which in turn is founded upon those processes of community control I just described.

Questionable claims

On this point, we often hear this figure bandied about that “most Aboriginal people don’t access or want to access Aboriginal Medical Services”.
I think we have to call out this statistic whenever we hear it.

It’s based on one single survey, and the way the question is asked is clearly confusing – for example, the same question showed that a quarter of Aboriginal people in very remote areas supposedly ‘prefer’ to receive their health care in a hospital!

That’s clearly not right.

That figure also reflects that in many areas of Australia, our people don’t have access to Aboriginal community controlled health services, so our sector may not be ‘on the radar’ when it comes to where people prefer to get their care.

And it ignores the fact that our comprehensive model of care goes beyond the treatment of individual clients and is quite different to that offered by most mainstream services.

We treat those who are sick, but we also have prevention programs and we act to address the social determinants of health.

Overwhelmingly the evidence points to our sector as highly cost effective, with a major study concluding that:

up to fifty percent more health gain or benefit can be achieved if health programs are delivered to the Aboriginal population via ACCHSs, compared to if the same programs are delivered via mainstream primary care services.”

So whenever you hear that statistic about most Aboriginal people not wanting to use our services, I urge you to call it out for the nonsense that it is.

Our people need choice – but given a genuine choice they will overwhelmingly choose Aboriginal-community controlled health.

We see that here in Central Australia at the moment. Many remote communities with government clinics are coming to Congress and asking us to run their health services for them. They are tired of not having a say in the running of the under-resourced Government-run clinics in their communities.

This is not a criticism of the individual government-employed staff in these places, many of whom are dedicated and caring people.

But government is simply not able to duplicate the high levels of community input and cultural safety that our sector delivers.

Employment matters

This brings me to the third strength I would identify about our health services: we employ our own mob and train them up.

Our services are much more effective in employing Aboriginal people than government or mainstream NGOs.

In those organisations funded by the Commonwealth specifically to deliver health services to our people, Aboriginal community controlled health services have 57 percent Indigenous staff; compared to only 38 percent in non-ACCHS organisations.

Particularly significant is the much greater commitment of ACCHS organisations to employing Aboriginal and Torres Strait Islander people in training positions, and in leadership roles such as CEOs, managers or supervisors.

Nationally, our sector employs almost 3,500 Aboriginal and Torres Strait Islander workers, making it the largest employer of Aboriginal and Torres Strait Islander people in Australia.

This employment of our own people in our organisations – not just in front-line positions but as decision-makers and leaders – is crucial to our record of delivering culturally safe services.

So again, I would like to say thank you to all those Aboriginal staff of our services who are here today – truly our sector could not do it without you.

Powerful advocates

The last strength of our sector I want to highlight is our ability to hold Governments accountable.

We are able to speak up on behalf of our communities, to make sure that policies set by Governments don’t ignore our needs, and to make sure that our communities get an equitable share of funding and resources compared to those needs.

Back in the days before Aboriginal community controlled health services, government did whatever they wanted to do to address the health of our peoples, which was generally nothing or worse than nothing.

Just how badly the mainstream health system was failing our peoples is sometimes forgotten, so it’s worth revisiting some historical statistics.

For example, according to government figures based on the reports of concerned health professionals, the mortality rate for Aboriginal infants in Central Australia in the mid-1960s was estimated at 250 per 1,000 births.

In other words, fifty years ago, well within the lifetime of many of us in this room, a quarter of Aboriginal children died before their first birthday.

Even in the mid-1970s, the rate was 60 to 70 per 1,000: worse than all but the most disadvantaged developing countries today.

Today the rate has fallen to around 10 deaths per 1,000 live births as our health services have dramatically improved access to primary, secondary and tertiary health care.

It was to address the suffering behind these numbers that community-controlled health services were established by our communities across Australia, often initially with volunteers.

But our community-controlled services were also able to speak out about the needs of our mob. We were able to argue and shame the government into action.

This is where the establishment of AMSANT in 1994 was so crucial.

It brought together all the Aboriginal community controlled services in the Northern Territory so we could speak with a strong, collective voice to government.
And government was forced to listen.

I think Pat Anderson, who played an important role in AMSANT’s early years, will speak about that time and the important role that AMSANT played in the Northern Territory, at the national level, and even internationally.

And that role – a collective voice for our sector, our Boards, our communities – holding government to account is something that AMSANT has continued to do over the years.

Producing results

It is hard work. A lot of it is not very exciting. It means sitting in meetings, continuing to argue for the rights and needs of our sector and of our communities.

But it is important work, and it produces results.

I can give one example from a few years ago when the NTPHN was given the role by the Commonwealth government of distributing funds for tackling Alcohol and Other Drugs and Social and Emotional Wellbeing in Aboriginal communities.

I was on the NTPHN Board and argued strongly that our sector needed to get a fair share of those funds.

And even though I wasn’t there as a representative of AMSANT, I knew that AMSANT was backing me. And the rest of the NTPHN Board knew that too.

So in the end they made the right decision and worked through the Northern Territory Aboriginal Health Forum, where AMSANT sits, to develop a way to allocate these funds according to need.

This included the acceptance of the three streams of care, integrated AOD/mental health service model that AMSANT has championed for many years.

It also included a visionary decision to pool the separate AOD and mental health funds into a single funds pool to achieve this integrated model – no other PHN did this.

Once this work was done, the NTPHN was then able to use its commissioning framework to directly tender funds to where they were most needed, either our sector or, where there was not an Aboriginal health service, the NT Department of Health.

Rather than competition, collaboration was the key to this successful process.

As a result of this, a lot of our services were able to get funding for alcohol and other drugs and SEWB positions.

And that means vital services for our community members in the communities where they live.

And this was made possible because of the power and influence of AMSANT in holding the non-Aboriginal system to account, and as the collective voice of all our services, our Boards and our communities.

So I have talked about what community control is for me. And I have talked about our sector’s strengths and achievements: how it empowers our communities; how it improves access to culturally-secure services for our people; how it employs our mob and supports Aboriginal leadership; and how it is able to hold the non-Aboriginal health system to account.

For me, it is a privilege to be part of the sector and part of those achievements. But I can’t leave you today without looking forward.

As I said at the beginning, every Aboriginal community controlled health service is an act of self-determination.

AMSANT brings us together and amplifies our voice and our capacity to act.

Uluru Statement

But the job is not done.

As well as these things, we need national processes of self-determination for us as First Peoples of this continent.

As so beautifully captured by the Uluru Statement from the Heart in 2017, we need:

• a process of treaty-making to lay a firm basis for the future relationship of First Nations and those who came to this country later
• a process of truth telling about our shared past; and
• a constitutionally enshrined voice to Parliament to ensure ongoing structures for our input into policy making and the life of the nation.

Why are these things important for the health and wellbeing of our peoples?

First, as I discussed before, there is a strong relationship between disempowerment and poor health and wellbeing.

These genuine reforms – and the self-determinant policies and practices that /would flow from them – would increase our control over our own lives and can be expected to lead to better health and wellbeing outcomes.

Second, a treaty is important for many reasons, including that it would provide an enduring and just institutional foundation for the provision of health services.

For example, it was convincingly argued by the late Stephen Kunitz that the treaties with First Nations in Canada, Aoteraroa and the United States led to more effective and sustainable policy and service delivery arrangements, and consequently led to a much narrower health gap than we have here in Australia

This fact was shouted out loud by Aboriginal speakers at the recent Garma festival.

Last, the establishment of a permanent, constitutionally enshrined First Nations voice to the Federal Parliament would help end our marginalisation from national decision-making processes.

It will contribute to more effective policy making and program design.

And it might just help government fix its terrible record when it comes to the implementation of the recommendations of the many reviews, reports and commissions to which we have contributed over decades.

So I think we need to keep working at that local level with our communities – treating those who are sick, promoting good health, and addressing the social determinants.
We need to keep working through AMSANT at the Territory level to keep government and other agencies accountable.

And we need to keep moving forward on national processes of self-determination by implementing the demands contained in the Uluru Statement.

So, to finish, I would like to say thank you once again to all of you here at this celebration of AMSANT’s first twenty-five years.

I hope you find the next couple of days empowering and inspiring, an opportunity to reflect on the past and look to the future. But most of all, an opportunity to celebrate the great achievements of our Aboriginal community controlled sector.

• See complete list of references here.

This article was published by Croakey on the 14th of August 2019. 

Share and Enjoy !

SHARE TWEET SHARE COPY EMAIL PRINT