An opportunity to transform Australia’s neo-colonial health system

An opportunity to transform Australia’s neo-colonial health system

A global healthcare crisis looms. The cost of health care is rising at unsustainable rates alongside exponential population growth, an aging population, severe health workforce shortages and growing inequity. There is increasing interest and urgency to significantly reorientate health systems from the current neoliberal, clinician-centric system to one that privileges consumer and communities at all levels, to enable holistic, place-based approaches through value-based healthcare (VBHC).¹ Neo-colonial health institutions struggle with the profound meaning and implementation of this shift while Indigenous communities across the world continue their ancient work of community-led health care centred on connection to Mother Earth, Country, community, and holistic interconnected social and emotional wellbeing.

The ‘modern’ VBHC movement provides an opportunity to not only reform health care towards a more equitable, community-centred system, but to also acknowledge, honour and learn from global Indigenous knowledge, systems and ways of valuing knowing, being and doing. For Australia as a settler-colonial state, efforts to implement VBHC here are doomed to fail until the continued legacy of settler-colonial violence and systemic racism pervading Australia’s healthcare system is acknowledged, addressed and ameliorated.²

Indigenous health systems and VBHC

Through the privileging of community voices, knowledge and experiences, Indigenous governance and health systems ensure self-determined, place-based priorities and solutions, thus greater collective wellbeing.³ A critical example of this is the sustained success of Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHO). Formed by communities freed from state ‘protection’ Acts in 1967, thriving ACCHOs spread in the 1970s and 1980s with a governance model in direct contrast to the neoliberal direction of the Australian health system.⁴ Long before social determinants of health were acknowledged, the National Aboriginal and Islander Health Organisation (NAIHO), now known as the National Aboriginal Community Controlled Health Organisation, defined health as not just the physical wellbeing of an individual, but rather as the ‘social emotional and cultural wellbeing of the whole community’. At the Aboriginal Health Conference in 1982, Bruce McGuinness, who was instrumental in the emergence of NAIHO, expanded on this definition and called for health services to strive to achieve a system ‘where every individual is able to achieve full potential as human beings, and must bring about the total wellbeing of their community’.⁵ While mainstream services cultivated a system that privileged health professionals over patients and health consumerism over healthy communities, ACCHOs prioritised Indigenous ways of valuing, knowing, being and doing through the provision of comprehensive primary health care centred on Indigenous governance and community control.^6,7 It is an interesting thought experiment to imagine an alternate reality in which the power of the ACCHO model was recognised in the 1980s, neoliberalism was resisted, and place-based community-owned and -led comprehensive primary health care was valued and expanded for all communities – what a different world we would live in.

Community control and Indigenous governance systems extends beyond health service provision. Like VBHC, Indigenous health systems demand a substantial shift in the ownership, collection, value and dissemination of data, through the principles of Indigenous data sovereignty and Indigenous data governance.⁸ The presence of community voices at data interfaces has numerous benefits. The Aboriginal and Torres Strait Islander Community Health Service (ATSICHS) Brisbane has demonstrated the benefit of this in health systems with their integrated Data Ecosystem and roadmap. ATSICHS has a significant and long-standing history of integrated, community-driven cross-sector service provision with medical and dental clinics, a range of community health services, aged care facilities, and early childhood education programs. Through community leadership they have built and embedded a sophisticated integrated data ecosystem that ensures the needs and safety of their clients and enables client sovereignty to govern their own data. This includes the use of innovative flexible e-consent processes, as well as the provision of multiple avenues for community input into the service.⁹

Self-determination through community leadership, input and drive influences Indigenous health systems on many levels.¹⁰ Indigenous-owned services prioritise shared decision-making, giving precedence to the lived experience and expertise of clients. This approach decentres clinicians, positioning them as technical assistants supporting client empowerment and wellbeing rather than as the primary expert. While important in interpersonal healthcare interactions, these core Indigenous values have broader systemic impacts. Southcentral Foundation’s Nuka System of Care based in Anchorage, Alaska, is an entire health system created, managed and owned by Alaskan Native People. The community has led and built an innovative healthcare system. They did this by demedicalising health care and incorporating traditional Indigenous Knowledge and cultural practices alongside transparent strategic planning and data management, decentralised integrated care with integrated behavioural health professionals, and customer-owner health service models. This health system delivers high community satisfaction and financial benefits, as well as demonstrating significant improvements in health outcome and decreased tertiary health centre encounters.^11–13

Seeing the success and fiscal benefits of the Nuka System of Care, the Scotland National Health Service (NHS) unsuccessfully attempted to replicate the model in 2012. The short-lived trial failed to account for the deep cultural ways of governing and operating that are deeply integrated and embedded in all levels of the system. Post-trial analysis found that a significant contributing factor to the failure of the Scotland NHS trial was clinician resistance, particularly by doctors, who perceived erosion of their power, position and privilege as expert.¹³ Attempts at VBHC initiatives in Australia may face similar clinician resistance, an interface unfortunately familiar for Aboriginal and Torres Strait Islander health leaders. Counteracting this resistance will require a multi-level strategic approach from the education sector to human resource processes.^13,14

Truth, voice, treaty and VBHC

Australia’s neo-colonial health system systemically harms Aboriginal and Torres Strait Islander Peoples. To succeed in efforts to implement equitable, sustained VBHC, the foundations and ongoing impacts of settler-colonialism and neoliberalism on which the Australian health care system is built must be acknowledged. The health system cannot effectively serve all Australian people and communities until this shared colonial history is recognised through truth-telling. This truth will also share the power and strength of Aboriginal and Torres Strait Islander Peoples’ sovereignty, connection to Country and deep knowledge systems.

Aboriginal and Torres Strait Islander Peoples and communities are not asking permission to speak, we are inviting settler-colonial Australia to listen. Over the past 50 years, Aboriginal and Torres Strait Islander Peoples have gained Western accreditation to further validate our voice and knowledge. We have governed successful health systems, we have grown an exceptional health workforce, and we have built an extensive evidence base, but our people, our communities and our knowledge remain marginalised. Now more than ever, with an increasingly struggling health system, settler-colonial Australia needs to be silent, still, and listen to the knowledge that Aboriginal and Torres Strait Islander Peoples and communities so graciously continue to offer.¹⁵

While Western constructs focus on treaty as a political and legal agreement, I invite settler-colonial Australian health system institutions and its leaders to deep reflection on what authentic relationality through treaty with Aboriginal and Torres Strait Islander Peoples and Nations can mean for the Australian health system. Without partnerships, without relationality, without solidarity, without recognition of Aboriginal and Torres Strait Islander Peoples’ sovereignty, the Australian health system cannot change for the better. As VBHC gains momentum in Australia, I urge you to interrogate the incommensurable state of Australia’s neo-colonial health system,¹⁶ to move beyond the rhetoric of health equity¹⁷ and recognise the deep value in honouring the sovereignty and Knowledges of Aboriginal and Torres Strait Islander Peoples, communities and Nations.