Aboriginal health care and public administration: Could a framework of reciprocal accountability reset the relationship?

Author: Judith Dwyer

Dwyer, Judith, 2016 Aboriginal health care and public administration: Could a framework of reciprocal accountability reset the relationship?, Flinders University, School of Health Sciences

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Primary Health Care (PHC) for Aboriginal and Torres Strait Islander people, compared to PHC for other Australians, is more often funded through complex, short-term contracts for tightly specified services; and is more likely to lack a legislative base that provides continuity and certainty. Relationships between the Aboriginal Community Controlled Health Organisation (ACCHO) sector (that provides PHC to approximately one half of all Aboriginal people) and government funders are characterised by the lack of trust that is built in to the contracting methods, and by systemic racism (discriminatory practices that are built in to the health care system with or without the intention of the individuals working within it). The work in this thesis explores these problems at the intersection of public administration and Aboriginal health care, and aims to articulate the basis for a resetting of the relationship, as a necessary precondition for the achievement of universal access to good PHC for all Aboriginal people and as an enabler for better care in the mainstream health system.

Public administration in health care and the ACCHO sector are shaped by two very different conceptual frameworks that are in tension and sometimes conflict. The ACCHO sector was founded on voluntary activism by Aboriginal communities as an expression of self-determination. Australian governments have adopted the thinking and methods characterised collectively as ‘New Public Management’ (Pollitt, 1995), a program of reform of the public sector that applies agency theory to contracting for services with the non-government sector and a mechanistic approach to the accountability relationship. The tension between these frameworks is played out in a post-colonising society that fails to recognise adequately the status of its First Peoples or the impacts of dispossession and colonisation.

This thesis brings together studies that explore the funding and regulatory environment of the ACCHO sector and government funders; the lack of legal foundations for government stewardship for Aboriginal health care; and the problem of systemic racism in the mainstream health system. It suggests that government approaches to Aboriginal health are characterised by ambivalent stasis, in which policy support for the ACCHO sector is undermined by distrust and concern about the financial and reputational risks of funding Aboriginal organisations in an environment of systemic racism.

The potential for an alternative approach to accountability, based on the concept of reciprocal accountability by both governments and the sector to Aboriginal communities, is suggested as basis for resetting the relationship and resolving a policy/program standoff.

Keywords: Aboriginal health, public administration, systemic racism, reciprocal accountability

Subject: Medicine thesis, Primary Health Care thesis, Public Health thesis

Thesis type: Doctor of Philosophy
Completed: 2016
School: School of Health Sciences
Supervisor: Professor Eileen Willis