Who’s steering the ship? A case comparison of the governance of Aboriginal and Torres Strait Islander Health Workers across Northern Australia

Aims:
The overarching aim of this project is to extend and enhance work already conducted in Queensland (Cape York and Torres Strait) by evaluating the governance arrangements that drive individual and team performance of Aboriginal and Torres Strait Islander Health Workers (A&TSIHW) in the NT’s Top End Health Service and conducting a cross-jurisdictional comparison.

Using a case-based qualitative design, the project seeks to document the experiences and expectations of A&TSIHWs, their (non-Indigenous) clinical colleagues (e.g. nurses and doctors) and other key stakeholders from Top End Health Service, and compare these systematically with those in Queensland Torres and Cape Hospital and Health Service.

Queensland data collection is complete and preliminary findings from in-case analysis of these data have been accepted for presentation at domestic (Townsville Research Showcase) and international conferences (COPASAH Symposium, New Delhi India). Collection of TEHS data will support production of a similar in-depth case analysis for the Northern Territory and (adding considerable value) enable cross-case analysis of A&SIHW governance between the two jurisdictions.

About:
National and state-based health policy in Australia places A&TSIHW at the centre of efforts to ‘close the gap’ between Indigenous and non-Indigenous health outcomes. Yet little is known about the governance of this cadre of health workers, or the influence that competing expectations of, or obligations to, health service employers, colleagues, communities, and culture can have on recruitment, retention and performance.

Using a qualitative design, informed by Indigenous research methodologies, this project will expand on current Queensland-based work to address this gap in knowledge by exploring the governance arrangements that shape the work practices of A&TSIHW in the Northern Territory and potentially Western Australia.

Continuing the first systematic work relating to A&TSIHW governance carried out in Queensland as part of a 2019 with Hot North support, this project aims to
a) extend the project scope and characterize both the formal and informal rules and norms that influence A&TSIHW roles in the Top End Health Service of the NT, and
b) through cross-case analysis of QLD and NT data, develop new insights into the influence of different geographic, social and administrative structures on A&TSIHW performance.

The outcomes are expected to support efforts to strengthen Indigenous health workforce planning across Northern Australia.

Background:
Aboriginal and Torres Strait Islander Health Workers (A&TSIHW) are recognised nationally as playing an important role in delivering and facilitating culturally safe healthcare to Aboriginal and Torres Strait Islander peoples (Health Workforce Australia, 2014). Indeed, for over a decade, health policy in Australia has positioned A&TSIHW as central to ‘closing the gap’ in health outcomes of Aboriginal and Torres Strait Islander populations, particularly the rural and remote communities of northern Australia (Council of Australia Governments (COAG), 2009; Aboriginal and Torres Strait Islander Health Workforce Working Group, 2017). Various policies and strategies further note that A&TSIHW, operating within primary healthcare teams to deliver a range of preventive, promotive and disease management services, are those most likely to strengthen acceptability and access to care, in ways that help prevent and mitigate the impact of a growing burden of chronic disease in northern Aboriginal and Torres Strait Islander communities (McDermott et al, 2016; Couzos & Murray, 2008; Conway et al, 2017).

Notwithstanding such recognition within national policy and chronic disease frameworks, a recent literature review by the Applicant and colleagues highlighted ambiguity surrounding the nature of A&TSIHW roles, and a persistent gap between their idealised capabilities and presumed respect within primary healthcare teams, versus the experienced reality (Topp et al, 2018). Chronic work overload, persistent stress and emotional labour linked to dual, and often poorly defined cultural and clinical responsibilities were noted (Kirkham et al, 2017; Dawson et al, 2012; Conway et al, 2017). So too, the absence of either state or national scopes of practice for A&TSIHW, which placed pressure on individuals to fulfil ambitious locally-developed terms of reference, sometimes without sufficient support or supervision (Mitchell, 2006). These and other factors were linked, albeit loosely, to poor job satisfaction and potentially related difficulties in both recruitment and retention of A&TSIHW across Northern Australia (Health Workforce Australia, 2014). Against the backdrop of northern Australia’s high burden of chronic disease, the large numbers of A&TSIHW positions currently unfilled, and an aging and feminized workforce, there is an urgent need to confront and better understand how governance arrangements and the accountabilities that these imply, are impacting A&TSIHW, and their ability to help ‘close the gap’.