Leading the way: the contribution of Aboriginal community controlled health organisations to community health in Australia

Policy timeline

Policies and details of seminal events were collected via web, library and archive searches. To be considered a relevant strategic policy, documents needed to include goals, objectives and strategies relevant to community health. We included policy documents related to general community health, including primary health care, and to Aboriginal health and women’s health, as these are all underpinned by a comprehensive vision of primary health care. Policy documents included formal government policies, and discussion papers and reports that influenced government decisions and action. The research team included investigators with long-term experience and knowledge of ACCHOs and community health in Australia, who reviewed draft policy timelines for comprehensiveness.

Interviews

To recruit interviewees, contact details were retrieved from web searches and professional networks. In many cases, a member of the research team had a pre-existing professional relationship with the interviewee. We used a purposeful sample (Patton 2007) to include information-rich representation from generalist, Aboriginal, women’s and workers’ community health services, participants with policy or academic expertise, and to ensure data on South Australian, Victorian and New South Wales community health services, and Aboriginal community controlled health services nationwide. Snowball sampling (Parker et al. 2019) was also used where participants recommended other potential interviewees. Members of the research team emailed invitations to participate to potential participants. Interviewees provided informed consent prior to the interview, with most waiving their right to anonymity. The semi-structured interview guide was developed by the research team to reflect the project research questions, and covered the interviewee’s role over time in the community health sector, and their perspective on community health, equity, community development, multidisciplinary teams, governance, funding and political support, and changes in these over time. Interviews were conducted face to face or by videoconference and lasted approximately 1 h. In addition to 68 interviews, four focus groups were conducted (three in South Australia and one in Victoria) with a total of 11 participants. Focus groups were semi-structured, and included experts in community health in that state who could provide a group account of the history of the sector in their particular state. Each focus group was made up of members with a shared historical experience. This was particularly useful for prompting each other’s memories, as well as clarifying with colleagues about historical, institutional and political facts. For example, one of the focus groups was with women who worked in women’s health centres in SA over the 1980s to early 2000s. It also captured the collaborative nature of the community health movement during this period, and complimented the more traditional one on one oral history interviews. An additional eight interviews conducted previously by Victorian research team members on the history of community health in that state prior to the research project were included in the analysis to yield further information on community health in Victoria. Interviewees quoted in the paper gave their permission for their names to appear.

As indicated in Table 1, five interviewees were Aboriginal, and 11 interviewees primarily had experience in Aboriginal community health, although more had spent part of their careers in Aboriginal community health. Most participants’ experiences of ACCHOs and community health spanned decades, including beginning from the 1970s and 1980s, and into the 2000s.

Analysis

A team approach was taken to thematic analysis. Policy documents and interview transcripts were imported into QSR NVivo. We developed a coding framework for the interviews that included a mix of a priori themes based on community health principles and our project research questions, and content identified as analysis progressed, developed and refined through team discussions. Preliminary analyses were presented at a series of team analysis workshops, a public webinar with 82 registrants, with a breakout session that discussed the ACCHO findings, and at a NACCHO annual general meeting session, to review and reflect on the ideas and findings. This paper focuses on analysing themes from the interviews relevant to the role and contribution of ACCHOs in community health in Australia, and the relationships between ACCHOs and generalist community health. First author TM, a Waljen public health physician and researcher, contributed to planning, debate and interpretation of findings, and the webinar and NACCHO sessions, and identification of themes for this paper. Analysis for this paper was guided by the framework developed by Baum et al. (2017) to describe comprehensive primary health care that emphasises principles including a holistic, social view of health, multidisciplinary teamwork, community participation, action on social determinants of health, and equity. Given the topic of Aboriginal health, the analysis was also guided by the key principles prevalent in Indigenous theories of wellbeing, as summarised in Mackean et al. (2022), such as collective wellbeing, culture, and Indigenous self-determination, sovereignty and rights, as central to Indigenous wellbeing, and wellbeing as collective and based on interrelationships rather than as an individual attribute.

Ethics approval

Ethics approval was received from the Flinders University Human Research Committee (Project No: 4168), Aboriginal Health Research Ethics Committee (AHREC Protocol: 04-22-974) and the Central Australian Human Research Ethics Committee (HREC Reference Number: CA-22-4379).

The ACCHO model of community health

Admiration for the ACCHO model was universal among interviewees, even when they acknowledged implementation challenges. ACCHOs were commended for their comprehensive model of primary health care: ‘they were more comprehensive. They weren’t just a medical service.’ (Ben Bartlett, non-Indigenous, GP in Aboriginal health). ACCHOs were seen to excel at accessibility, pursuing multiple strategies to ensure they reached, and were welcoming for, Aboriginal and Torres Strait Islander peoples:

they could contact people out of hours, they got transport, that they felt the people were on their side, that it wasn’t racist. But it’s all these little things that make it up to be an acceptable service. (Fran Baum, non-Indigenous, SA community health)

They did a lot more things that we didn’t do in community health, and they still do. Like transport, you know, come pick up someone and bring them to the appointment. So, very different model, a bit more hands on, model. (Kristine Olaris, non-Indigenous, Vic community health)

ACCHOs’ commitment to a social view of health and health promotion that sought to empower individuals and the community was also acknowledged as a nation-leading strength:

I think for me the main difference was that socioenvironmental model, grass roots partnership, empowerment, you know, that much more of the embodiment of Ottawa Charter in community health compared to any other health service that I knew about. (Kaye Mehta, non-Indigenous, SA community health)

This included placing an ‘emphasis on culture’, which ‘was really powerful’ (Elizabeth Becker, non-Indigenous, SA community health). Attending to cultural and spiritual determinants of health was seen as a strength of the ACCHO model:

With Aboriginal Health, you know, the spiritual is present. That’s not present in other models, and I think that’s very, very important as a cultural determinant of health. … there is the central element that goes to land, community and connection, and country and people… which I know is entirely embedded in that model, and I would wager is key to its efficacy too. (Lyn Morgain, non-Indigenous, Vic community health)

The attention paid by ACCHOs to living conditions and environments demonstrated innovative ways of improving health to the generalist community health sector. The Nganampa Health Council, established in 1984 by the Pitjantjatjara people in the far north of South Australia, conducted a detailed survey of living conditions and environments in its geographic area, which included housing, food and essential services, such as water, power and waste removal. The survey produced a list of nine prioritised healthy living practices and described the infrastructure needed for these practices to be conducted (Torzillo et al. 1992). A detailed ‘survey and fix’ methodology evolved and has been applied across Aboriginal communities in regional and remote Australia. These efforts have illustrated the complexities of advocating for and implementing ‘housing for health’ programs in Indigenous public policy (Lea and Pholeros 2010; Pholeros et al. 2013). This work initiated by Nganampa Health Council demonstrated the need for a multi-sectoral approach in health, and the value of a social and environmental perspective to the generalist community health sector. One interviewee described the power of ACCHOs consulting with community elders:

the sense of the importance of elders in the community, importance of consulting with elders in the work that community health centres do, and that incredible respect that people have. (Kristine Olaris, non-Indigenous, Vic community health)

Several interviewees pointed out that ACCHOs employing Aboriginal health professionals was an important strength:

Another important reason to fund health services is the employment and training provided to people in the Aboriginal community, and the role modelling of career options. As a result of having Aboriginal Health Services, there are now more Aboriginal doctors, nurses and health practitioners. … without an Aboriginal Health Service, those Aboriginal workers and community members wouldn’t have got to see in the same way that medicine and nursing, and most health disciplines, are possibilities for them. (de-identified, non-Indigenous, GP)

These characteristics of the ACCHO model reflect the commitment to self-determination and community control that underpins the sector:

In Aboriginal community control, the community appoint the board. That is a form of self-determination. (de-identified, Aboriginal, ACCHO manager)

A strong theme was that the ACCHO model was a good model for all Australians:

Aboriginal models of community controlled organizations have come to be accepted as almost benchmarks of how things perhaps could be in wider society… the Federal and State governments need to realise that these are very good models with a lot of potential benefits for the wider community and, yeah, they’ve got quite a bit to learn from this model, I think. (de-identified, non-Indigenous, Aboriginal health)

They all want to adopt our model and you know everyone wants to adopt our model. Even Greg Hunt (former Coalition Health Minister 2017–20) said… rural health should be based same as NACCH… It’s a great, the best model, he said. I said well, you know it’s not just rural communities, Minister, you should have it right throughout Australia for every Australian. (Pat Turner, Aboriginal, national Aboriginal health)

Interactions between ACCHOs and the generalist community health sector

Some interviewees reported the two sectors had extensive interaction, including interviewees, and other workers and key actors moving between Aboriginal, women’s community health and generalist community health, or working across all. There were ‘lots of networking connections’ (Judith Dwyer, non-Indigenous, SA, women’s health and Aboriginal health) between ACCHOs and the rest of the community health sector. For example:

There was a lot of exchange between doctors who worked in community health and went to work in Aboriginal Health Services. That happened quite frequently. I did notice that an enormous number of our registrars who came to work at the health centre also did rural rotations to remote Aboriginal community health services. (Lyn McKenzie, non-Indigenous, Vic women’s health and Aboriginal community health)

The two sectors were described as ‘real fellow travellers’ (de-identified, non-Indigenous, SA community health), and that ‘they co-evolved’ (Ian Anderson, Aboriginal, national Aboriginal health). The Public Health Association was cited as a venue for collaboration, as a ‘hook into the mainstream’ (Judith Dwyer, non-Indigenous, SA, women’s health and Aboriginal health) for the ACCHOs.

Alukura is a long-term project by an ACCHO in Alice Springs, Central Australian Aboriginal Congress to offer women-only care related to birthing matters, pregnancy, childbirth, and the care of women and their infants in ways that preserve and recognise Aboriginal identity, culture, law and languages, and is guided by the Grandmothers’ Law (Ah Chee et al. 2001). Concerns in the mid-1980s from the Commonwealth Department of Health that services delivered by Alukura would result in lower standards of care compared with existing services were dissipated following a review of Alukura services based on Community Health Accreditation and Standards Program (Carter et al. 2004). The Community Health Accreditation and Standards Program program, an activity of the Australian Community Health Association, the national advocacy body for the community health sector, developed a set of standards based on community health principles and values, and a review process to assess the extent to which a centre or service achieved the standards (Fry 1990). This example illustrates productive collaboration between the ACCHO and the generalist community health sectors.

Some interviewees described close collaboration; for example, one community health service in Victoria collaborated with the local ACCHO on:

various committees, on joint projects, joint publications, all sorts of stuff. Our staff worked a lot with [ACCHO] staff around homelessness issues, injecting drug use issues etc. When we appointed Aboriginal Liaison workers, we invited [ACCHO] to sit on interview panels, we got them to deliver training of various kinds, so we worked reasonably closely together. (Vera Boston, non-Indigenous, Vic community health)

Not all interviewees shared this viewpoint, with one interviewee reflecting ‘They always felt a bit separate to me’ (de-identified, non-Indigenous, GP). Another reported that for their community health service, connections with the local ACCHO were ‘pretty limited’ (de-identified, non-Indigenous, SA community health). Although there were examples of collaboration, community health was sometimes more of a competitor than an ally, as this example shows:

whereas you would think, wouldn’t you, that community health services – with the philosophical base and the objectives that we’ve talked about here… would be able to get on perfectly well with the AMS [Aboriginal Medical Service]. And we didn’t… So when I got there in 1985, I discovered that there was this team of about four or five people who were based in Redfern … who were doing community health-type work, early childhood work … this seemed to me to be completely bizarre, they’re about one block away from the AMS, and we had our own little Aboriginal health unit. It was – seemed extraordinarily strange to me, because why not rely on the community-based organization to do it? And the answer to that, is an answer around bureaucracies and hierarchies. (Greg Stewart, non-Indigenous, NSW community health)

This was exacerbated by competition over resources:

There was a lot of competition, because the states believed that they were entitled to a bunch of money to provide services for Aboriginal people, and do things to and for Aboriginal people… there was quite a lot of resistance and competition between independent services and state based services. Because there was money involved and people had their careers in the state sector (de-identified, non-Indigenous, Aboriginal health)

One interviewee noted how women’s health and Aboriginal health were driven by different ideas:

It’s similarities and differences in community health between Women’s health and Aboriginal community… The vision, the alternative models are pretty much the same, but the emphasis is perhaps a little different. Gender and patriarchy more essential to the analysis in Women’s health, race and post-colonialism with Aboriginal Health. (Brian Stagoll, non-Indigenous, Vic community health)

The contributions of the ACCHO movement to community health

Interviewees discussed the contributions the ACCHO movement had made to community health, and how they had inspired generalist community health models:

The whole [ACCHO] sector has transformed the health system in really quite profound ways. It changed from that very local, voluntary-led notion of control and care to almost a part of a system and part of the sector. (Ian Anderson, Aboriginal, national Aboriginal health)

The following account is from a key actor in the South Australian health and community health system from the 1970s to 2010s:

I went to Whyalla and had quite a lot to do with [Aboriginal] services on the peninsula and upper north, so I got hugely influenced by what you saw and what you experienced, and some great people that I worked with who were trying to make a difference in Aboriginal health. (Jim Birch, senior health service executive and Former CE SA Health, non-Indigenous)

Another interviewee reflected:

It was just an inspiration for me to arrive [at the ACCHO] and find myself working in quite a different situation than I had experienced before. In that it was a vibrant community organisation providing primary health care in a different way to what I’d previously experienced. So that was my first exposure to community health. I learned a lot about what community was and what it meant, very quickly, just by being in that environment. (de-identified, non-Indigenous, Aboriginal health)

One particular contribution of the ACCHO sector was as a model of community control of health services. Aboriginal models of community control inspired community inclusion and governance in generalist community health services, as these examples show:

Well, community control, we were reaching towards at [community health centre name], but I don’t think any of us had a good idea of what community meant. Whereas, I think in Aboriginal health … there’s a much better idea about what community means. (de-identified, non-Indigenous, Vic community health)

We knew that we had to respond to the community, and we had to be in touch with the community, … probably an idea that’s particularly come from Aboriginal services. So, the best example is Aboriginal health services. Nobody, but Indigenous people, can run Aboriginal health services … So, I think it’s, we had an inkling, as I mentioned before, with the Women’s Health Centre and the women’s health services, that that was important. (Rick Mohr, non-Indigenous, NSW community health)

During the COVID-19 pandemic, ACCHOs played a critical role in supporting the health of their community, serving as a trusted source of health promotion information, enabling on the ground contract tracing, and to act as a collective voice for communities (Finlay and Wenitong 2020; Schultz 2020). The ACCHOs’ ability to respond to the pandemic and promote the health and needs of their local communities was cited as a demonstration of the strength of the model:

I think that the COVID pandemic experiences have made it very, very clear that had we had a platform of community health centres across Australia that had been there for years, and had developed trusted relationships with their local communities and subgroups within those communities, how easy, relatively easy it would have been to mobilise action … The Aboriginal community health-controlled health centres have shown that. (de-identified, non-Indigenous, national community health)

ACCHOs’ retention of a strong model of community health

There were powerful shared forces that challenged the ACCHO and generalist community health services, including managerialism (the introduction of private sector management techniques into the public service, typically focusing on financial management and quantitative performance targets; Baum 1996):

I think managerialism that’s crept into the whole health sector has really borne down on Aboriginal organisations in the form of reporting requirements and endless assessments of activities (de-identified, non-Indigenous, Aboriginal health)

The issue of multiple funding streams with consequent high level of reporting requirements has long been reported as a challenge for ACCHOs, with ‘multiple sources of funding right across all governments. What comes with it is multiple reporting requirements, let alone the accreditation burden, the standards’ (de-identified, Aboriginal, Aboriginal health). Funding models were reported to be a challenge, particularly fee for service models fostering a more individualised primary medical care model:

There’s been increasing pressure on Aboriginal health services over the last few years to focus more and more on clinical services work. There’s been more and more pressure to generate funding through Medicare/Medical Benefits Schedule rather than being able to rely on the block funding. And that tends to be working with individuals rather than families or groups. (de-identified, non-Indigenous, GP)

Crucially, interviewees within and outside the ACCHO sector agreed that the ACCHO sector resisted these forces better, and having kept the integrity of their model to a greater degree than generalist community health. Some interviewees attributed this to ACCHOs being part of the movement for self-determination:

I think it’s the, I suppose the self-determination, the tenacity of Aboriginal people that said, ‘We deserve this. We need this. This is for our future generations. (de-identified, Aboriginal, Aboriginal health)

One interviewee noted that ACCHOs appeared to be well organisation, including through highly regarded jurisdictional peak bodies, whereas the generalist community health movement was by comparison ‘very disparate’ (de-identified, non-Indigenous, SA community health). Outside of ACCHOs, one interviewee described ‘what has been retained of community health services’ as ‘hanging on by their fingernails, really’ (de-identified, non-Indigenous, Aboriginal health).

Key Aboriginal senior actors and bureaucrats, Ian Anderson and Pat Turner, both noted a shift over the decades from sidelining to valuing the ACCHO sector, and respecting the model they had developed:

In the Northern Territory, there was a high degree of reluctance to have the AMSANT [Aboriginal Medical Services Alliance Northern Territory] as a signatory … In 2017, this is a passage of about 20 years, and the first thing the Northern Territory government said to me is, ‘Don’t bugger up our relationship with the community controlled sector’. Which is telling in terms of how much that relationship had evolved and come in that period of time. (Ian Anderson, Aboriginal, national Aboriginal health)

This respect was seen as one of the reasons for ACCHOs’ longevity:

I think Aboriginal community health services are now very much an accepted part of the health system. I think it is probably going to be hard to actually get rid of them. I think that they will continue… that particular kind of approach to community health, comprehensive primary health care, multidisciplinary teams, providing health care where the priorities are determined by the local community. That kind of approach to health care has traditionally been very much the strength of the Aboriginal community controlled health service movement. (de-identified, non-Indigenous, Aboriginal health)

One interviewee also felt there were strong spokespeople for the ACCHO model:

I’m just thrilled to see the voice of Indigenous Australia or First Nations people just being stronger and stronger. … we never had that strong spokespeople, I don’t think. I think in some ways we might have been complacent. We just never saw the urgency of it or something until it was too late. (Kaye Mehta, non-Indigenous, SA community health)

Another reason put forward for ACCHOs’ longevity was the strengthening effect of cooperation between sectors for Aboriginal affairs, particularly in Victoria:

the power of the Aboriginal Medical Service in remote communities was actually assisted greatly by the prior arrival of Aboriginal Legal Services. So, these things actually work cooperatively, hugely cooperatively. And enabled health. (Brian Stagoll, non-Indigenous, Vic community health)