Aboriginal health outcomes in Australia remain unacceptably poor. In 2009, a government and community partnership in the Hume Region of northern Victoria identified the cultural competence of mainstream health services as one of five key priorities for its four-year ‘Close the Health Gap’ Plan. Overseen by a broad-based working party, an Aboriginal Health Cultural Competence Framework and Audit Tool were developed and are now being piloted. This letter outlines key aspects of the partnership process used to develop the framework and audit tool and discusses lessons for implementation. In particular, we identify three issues prominent in this developmental process: the internal dynamics of the working party; a human rights approach being embedded in the framework and audit tool; and implementation issues – in particular whether implementation should be voluntary or compulsory.
The national ‘Close the Gap’ (CTG) Campaign, which commenced in March 2006, brought new energy to the ongoing advocacy from Aboriginal community-controlled health services and others to address poor Aboriginal health outcomes. Under the COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, Victoria delegated all departmental regions to develop their own four-year ‘Close the health gap’ plans in 2009. As one of five key priorities for the Hume Region, the Closing the Health Gap (CTHG) Steering Committee established a separate working party to oversee the development of the framework and audit tool. The membership on the working party included Aboriginal health and Traditional Owner organisations, Department of Health and health services. The working party tendered the project. The consultant team drew on the extensive national and international literature on cultural competence frameworks and audit tools, including local material.1–3 The framework and audit tool were workshopped over a series of four workshops in the second half of 2011. The five focus areas of Organisational Effectiveness, Engagement and Partnerships, Culturally Competent Services, Workforce Development and Public Image and Communications show the breadth of the framework. Eight Standards were agreed across these focus areas with 21 Indicators, as well as a set of complementary standards for the health ‘system’ level. The audit tool then provides guidelines for systematically reviewing an organisation's Aboriginal cultural competence practice, linked to the standards and indicators, with the intended result of developing an associated action plan.
The relative strength from the combined views of all stakeholders, Aboriginal communities and organisations, health services, health professions, bureaucracy and academic participants enabled an approach that maximised and respected all these perspectives in the development of the framework and audit tool. This was underpinned by the honesty of some health service representatives in identifying a lack of knowledge in regards to Aboriginal health and a willingness to learn from the substantial number of experienced Aboriginal workers and community members on the working party. This, coupled with the significant time commitment provided by working party members, was critical to developing a framework and audit tool that would be practical and acceptable to a diverse range of health services.
Through applying a human rights approach, we sought to address broader criticisms of the CTG approach; that is, it tends to be focused on a deficit based model of Aboriginal society and primarily concerned about minimum standards.4,5 This has included, for example, some quite specific indicators addressing individual leadership and staff performance such as “Board members and senior managers demonstrate Aboriginal Cultural Competence in their actions and practice and this is part of their performance appraisal”.
There was also some discomfort expressed by working party members as to the place of ‘advocacy- related’ audit statements, due to them being quite general, rather than specific to health service delivery – for example, “Issues related to power, autonomy and decision-making are explicitly considered by our organisation and regularly discussed with staff at Aboriginal organisations” and “Staff act as advocates for Aboriginal service users recognising the impact of discrimination and colonisation on their health”. However, after discussion, the working party accepted that such statements would be challenging staff and organisations to a higher level of cultural competence.
One of the most contentious issues for the working party was whether health services should be mandated to implement the framework at the direction of the Department. While Departmental officials explained that it was beyond the brief of a regional office to be mandating compliance, health service representatives also identified a risk of a mandatory framework, particularly in the absence of additional funding, in that it may generate a ‘compliance response’ rather than a deeper level of self-reflection and organisational review that is necessary to implement this type of framework. This discussion also acknowledged the work undertaken by the consulting team to formally link the audit tool to existing accreditation processes which are mandatory, as well as the system level decision to have the organisation audits externally facilitated by experienced Aboriginal professionals.
In closing, we argue that the ‘journey’ of the working party illustrates key principles, processes and practices that services implementing the framework, and the health system as a whole, will need to embrace to ensure its effective implementation. This will need to be underpinned by sustained commitment to system level standards, particularly the ongoing analysis of the quality of organisations’ Aboriginal Cultural Competence Action Plans within a wider Aboriginal health evaluation framework. Clearly, this is going to require sustained support beyond the current four-year CTHG commitment.