We need transformative change in Aboriginal health

Overcoming the soft bigotry of low expectations

Change is complex and invariably poorly managed and understood in Aboriginal affairs, including Aboriginal health. At worst, it is a competition between recycled ideas that have gained or lost currency with changes in the dominance of political ideologies. At best, it is developmental change, a slow and marginal improvement on what we are currently doing.

Comparison of the 1989 National Aboriginal Health Strategy (NAHS) Working Party report and the 1994 evaluation of the implementation of the NAHS with the current National Aboriginal and Torres Strait Islander Health Plan (2013–2023) (http://www.health.gov.au/natsihp) shows that we continue to seek change in the same key areas. Holistic approaches rich in evidence-based thinking, emphasis on community control of health services, inter-sectoral collaboration and improved monitoring and accountability are themes that have repeatedly been highlighted in almost the same way despite the passage of almost a quarter of a century. So what is wrong with this?

Let’s start with the sustainability of public interest in, and commitment to, Aboriginal health and the consequential lack of willingness of our political leaders to live up to their promises. Politicians regularly overpromised and underdelivered in Aboriginal affairs. Former Disability Discrimination Commissioner Graeme Innes describes the “soft bigotry of low expectations”1 as a barrier that people living with disability confront in health care. Sarra has similarly highlighted the impact of low expectations on Aboriginal education outcomes.2 I think the same “soft bigotry” applies to public expectations of Aboriginal health.

It is true that incrementally, slowly, too slowly, things are changing in some areas. Infant mortality in the Aboriginal and Torres Strait Islander population is declining,3 and we have seen significant decreases in avoidable deaths in some jurisdictions4 and improvement in access to medications.5 Aboriginal health is better today than it was in 1971 when the first Aboriginal Medical Service was established, but we need to ask ourselves whether the incremental gains, given elapsed time and effort invested, are sufficient? Where is the tectonic shift that will propel change in Aboriginal health forward at a much more rapid rate? Where is the new strategy that will deliver the Closing the Gap targets on time?

Prime Minister Malcolm Turnbull has said of the Closing the Gap campaign that “we cannot sugar-coat the enormity of the job that remains”6 and has called for innovative and new approaches. Leader of the Opposition Bill Shorten has encouraged us to listen to the “whispering at the bottom of our hearts”7 because it speaks honestly to the unease arising from the knowledge that we can and must do better.

Incremental change is insufficient if our aspirations for Aboriginal and Torres Strait Islander health and the results we deliver are to better align. We need to eschew the soft bigotry of low expectations, of slow incremental change, and embrace a more transformative change agenda.

We need change that not only develops new knowledge but, importantly, puts what we already know into practice efficiently and equitably. The research, for example, supporting the importance of access to high quality, consistent, comprehensive primary health care is extensive,8 but we have largely taken a patchwork approach to coverage in Aboriginal health.

It is still too much the case that Aboriginal and Torres Strait Islander peoples are confronted by a system in which the core services necessary to underscore a successful healthy journey across life are inconsistently available and of varying quality.9 Not all can access prenatal, infant, early childhood, adolescent, adult life and later life services as individuals or as cohorts when, and at a level, they require.10 In this issue, Ah Chee and colleagues provide an example of how transformative change can be implemented through an innovative model based on intervention before Aboriginal children reach school age.11

We need to shift from a program of low expectations to an approach that reinvents organisations and transforms structures, systems, technologies and processes to provide change that transforms the culture of organisations, professions and the workforce and the relationships across societal silos; change that reshapes public policy, financing and accountabilities. We need transformation not incremental change and it will be complex and risky. Tolerating incremental change costs lives, money and economic and social capital.

If we continue to rely on the slow and incremental, we will continue to bear these unacceptable costs. Without transformative change, we are doomed to be haunted by the whispers at the bottom of our hearts.