Co-design and place-based approaches: Lessons from Indigenous-led initiatives in Australia’s primary health sector

In the wake of the unsuccessful 2023 referendum on constitutional recognition of First Nations Australians, governments and public agencies need to provide more effective policy support for Indigenous-led initiatives to meet Closing the Gap targets across sectors. The Indigenous-led primary health care sector can serve as a model, Dr Matt Fisher, Associate Professor Emma George and Professor Fran Baum from the University of Adelaide, Associate Professor Tamara McKean from Flinders University, and Professor Sharon Friel from the Australian National University write.

Generating and maintaining Indigenous health and wellbeing remains a contemporary challenge in Australia.
However, many of the ideas, governance models, and practices needed to deliver more effective and culturally safe policy already exist. What is needed is for these good practices to be strengthened, more widely implemented, and sustained.

Based on our recent research that covers stakeholder views on the operation and effects of Closing the Gap policy during 2008 to 2018, we found that public servants should draw on place-based and Indigenous-led approaches to make a meaningful difference.

Learning from indigenous-led primary health

Indigenous leadership and Indigenous-led organisations are crucial for successful public policy agenda setting, implementation and service delivery. Of course, a core purpose of the Uluru Statement’s call for a Voice to national parliament was to institute just such leadership, and that opportunity has been missed.

However, the Indigenous primary health care sector provides a model of good practice in policy leadership with networks and funded Indigenous-led NGOs working in partnership with government on policy development, workforce, and service delivery.

Other sectors such as education, child protection, employment, social housing and justice and corrections could adopt and adapt this model, and learn from the health sector’s experience, to improve their policies and practices, and meet new, broader Closing the Gap targets.

CREATING COHERENT POLICIES ACROSS SECTORS

The strengthening of current Closing the Gap policy, coming after the 2008-2018 period, is largely due to the leadership of the Coalition of Peaks representing Aboriginal and Torres Strait Islander peoples in Closing the Gap policy making, in partnership with federal and state/territory government leaders. The imperative to extend and improve an Indigenous-led, multisectoral approach (involving both federal and state/territory agencies) arises from an understanding of social determinants of Indigenous health (SDIH).

While Indigenous primary health care sector efforts to improve outcomes are effective, benefits are limited by the damaging effects of inadequate or punitive policies in other sectors, operating as determinants of health. This is a problem of policy incoherence, acting to undermine Closing the Gap policies.

Current Closing the Gap targets now take better account of this problem by including targets for state or territory-managed sectors such as child protection and corrections, but practical policy action to meet these targets is still falling short.

Embedding Cultural Safety Through Co-Design

However, a key lesson for public sector agencies and staff concerns the question of how to implement a multi-sectoral approach in a culturally safe and effective manner.

Our research showed that non-Indigenous stakeholders working in government agencies tended to see a multisectoral approach as a matter of high-level meetings between agency leaders and multiple ‘top-down’ strategies.

In contrast, Indigenous leaders we interviewed argued for a place-based approach, with multiple strategies led and implemented through localised governance, community-controlled services, community engagement, and culturally relevant strength-based strategies and programs.

To respond to this, public sector agencies should shift their thinking on policy governance, to move away from a ‘top-down’ performance-management approach and toward strategies of co-design and place-based approaches, working with local governance entities and services.

OVERCOMING ‘TOP-DOWN’ and ‘ONE-Size-Fits-All’ Approaches

Aboriginal community-controlled primary health care organisations provide models of this approach. The planned Voice to Parliament incorporated work with local-regional governance structures and organisations in this way.

Describing the limitations of an agency-driven, ‘top-down’ and one-size-fits-all approach to policy governance, one of our participants put it this way: “…some knucklehead 25-year-old with a masters degree sitting five kilometres from the centre of the CBD isn’t going to have the answer. The answer is going to sit here in [place name]… and the answer’s going to be different for every community.”

Developing multi-sectoral infrastructure for Indigenous leadership in policy development, governance, and service/program delivery will require a long-term commitment and support for Indigenous-led organisations to advance workforce training and development.

The Indigenous primary health care sector provides a good model of what this looks like in practice, through organisations such as Indigenous Allied Health Australia, the Australian Indigenous Doctor’s Association, the National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners, and the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives.

We acknowledge the contribution of the Rumbalara Aboriginal Co-operative to this research.

Read the full article ‘Stakeholder perceptions of policy implementation for Indigenous health and cultural safety: A study of Australia’s Closing the Gap policies’ in the Australian Journal of Public Administration.