How the Social Determinants of Indigenous Health became policy reality for Australia’s National Aboriginal and Torres Strait Islander Health Plan
Significant health inequities persist between Aboriginal and Torres Strait Islander people and non-Indigenous Australians, resulting from the past and continuing impacts of colonisation and contemporary social, economic and cultural inequalities.
Since 2008 Australian governments have committed to ‘Closing the Gap’ targets and implemented policies to reduce or eliminate inequalities in health, education and employment outcomes affecting Aboriginal and Torres Strait Islander people. However, progress has been slow and indeed for some targets the ‘gaps’ have remained or even widened.
Critics argue that one reason for the lack of policy progress is the repeated failure of Australian governments to genuinely engage with Aboriginal and Torres Strait Islander representatives as partners in policy development, or properly consult with affected communities.
Aboriginal and Torres Strait Islander advocates have also consistently called for greater attention in policy to rights of self-determination and recognised social determinants of Indigenous health (SDIH) such as strong culture, culturally appropriate services, and the adverse impacts of racism – although with limited success.
Thus it is crucial to recognise (rare) instances of policy making that run counter to these trends – that do demonstrate effective partnerships and consultation, acknowledge rights and give attention to SDIH – and seek to understand the factors that enabled this to occur.
The current National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (NATSIHP) recognises the centrality of Indigenous cultures to health and wellbeing, commits to support for Aboriginal community-controlled health organisations and recognises a need to address racism in the Australian healthcare system. In this paper we report on research to investigate how this paradigm shift occurred in development of the NATSIHP such that, for the first time in Australia, a SDIH approach was adopted in national policy on Aboriginal and Torres Strait Islander Health.
We adopt a complementary approach to theory and apply theories on advocacy coalitions, a multiple streams approach (MSA) to agenda setting, and policy framing to identify the key factors that enabled this paradigm shift in policy to occur. Our methodology, centred on interviews with senior policy actors, provided rich data for analysis. The perspectives unearthed aided our comprehension of factors impeding recognition of SDIH in policy, and those which enabled previously contentious issues to be accepted; notably including a first-time policy acknowledgement of racism as central to Indigenous Australians’ health.
Bacchi’s investigative insistence on ‘What’s the problem represented to be?’ underpinned our analysis of the role of problem framing. Not only was the combined Australian governments ‘Closing the gap’ strategy a result of a potent, Indigenous-led ‘Close the Gap’ movement, but the holistic lens through which the latter-mentioned movement viewed health provided the perspective necessary to reframe the ‘problem’:
From day one it was conceived of or agreed by all parties that you can’t just look at health in isolation.
As in Kingdon’s (2011) MSA framework, Indigenous leadership groups acted as pro-active policy entrepreneurs, using government’s commitments to develop a new Indigenous health plan as an opportunity to set the agenda. All interviewees described how a tightly-knit policy community evolved, one that appeared to fit the definition of an advocacy coalition by operating over an extended period and sustaining ‘core’ policy beliefs, as in Sabatier and Jenkins-Smith (1999) approach. From this coalition, the National Health Leadership Forum (NHLF) emerged, which proved vital in opening windows and using them effectively:
- Indigenous groups … already working collegiately through the Close the Gap Campaign … form[ed] a separate group whose sole purpose [was] to be a partnership interface … the National Health Leadership Forum
- One of the things which I think really worked … was that the Aboriginal health leadership was really co-ordinated and well positioned …
This group took a strong partnership approach from the outset, being noted as: a pro-active, rather than a reactive partner; one involved from the original premise/design work; and one with a formalised role in governance. Our interviewees noted the role of the NHLF in moving government actors’ comprehension beyond broad awareness of the importance of education, housing and employment to a grasp of how less-easily accepted social and cultural determinants of Indigenous health actually play out. ‘Narrative’ evidence heard from Indigenous Australians during policy consultations also contributed to a deeper understanding of SDIH, including impacts of racism:
…[That] narrative evidence … was quite influential in supporting our case … it deepened our understanding of what the issues and the impacts were, particularly around tradition and culture; racism was a big word … the narrative was what facilitated the honest and frank conversation about racism.
Speaking to the broader range of community members they (government actors) actually could see … the living, breathing side of social determinants
Particular lessons we draw from this study include that well-articulated issues – with visibility, credibility and momentum – maximise the likelihood of windows of opportunity actually opening. Further, a publically-recognised, authoritative leadership – in this case the NHLF – is better-positioned, in the words of Kingdon (2011) to establish a ‘claim a hearing’. However, while the role of this advocacy coalition was key to effecting a paradigm shift in Australian health policy to recognise SDIH, and holds lessons learned for future policy development, shifts in the political environment – as recognised in the MSA – may reinforce or undermine the change. At the time of writing, the Australian government has put Indigenous leadership at the helm of ‘refreshing’ the National ‘Closing the Gap’ targets – though it is unclear whose formulation of the ‘problem’ will prevail. (1) In contrast, the Uluru Statement from the Heart, calling on government to enshrine an Indigenous advisory body to national parliament in the Constitution, has been rejected, despite the work of the demonstrably-authoritative Indigenous advocacy coalition involved. (2)
(1) Dept. of Prime Minister and Cabinet, Australian Government. Special Gathering Statement – Closing the gap refresh: Building pathways for future prosperity, accessed at https://closingthegaprefresh.pmc.gov.au/sites/default/files/special-gathering-statement-coag.pdf
(2) Hobbs, H. Why the government was wrong to reject an Indigenous ‘Voice to Parliament’. The Conversation. Accessed at, https://theconversation.com/why-the-government-was-wrong-to-reject-an-indigenous-voice-to-parliament-86408