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Expanding the boundaries of health: a 'whole of government' case study [Paper presented at the 8th National Rural Health Conference, Alice Springs, 10-13 March 2005]



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Central to Health: sustaining well-being in remote and rural Australia 1

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Expanding the boundaries of health — a ‘whole of government’ case study Helen Bulis, Australian Government Department of Health and Ageing, Daniela Stehlik, Alcoa Research Centre for Stronger Communities, Division of Humanities, Curtin University of Technology

One of the most topical social policy planks of contemporary Australian governance is the concept of ‘whole of government’. This policy approach was adopted by the Council of Australian Governments (COAG) to improve the social and economic well-being of Indigenous people and their communities. The Commonwealth Department of Health and Ageing is the lead agency for one of the eight regions identified to trial this contemporary approach. This case study maps the structures, identifies the challenges and partnerships on the Anangu Pitjantjatjara Yankunytjatjara Lands in South Australia. Two projects that were endorsed by this COAG process will also be discussed in relation to expanding mainstream boundaries of program service delivery — the implementation of the Mai Wiru Stores policy and the establishment of Pitjantjatjara Yankunytjatjaraku (PYKu) Network.

INTRODUCTION

Internationally there has been a rethink of how the public sector operates with other government departments and its citizens in delivering services. A paradigm shift is emerging that is, from working for one departmental portfolio and with a limited number of stakeholders

to working together and engaging with a more diverse sector. In the UK, for example, Prime Minister Tony Blair promised change in a response to the White Paper Modernising Government that had as its mandate “to create a modern government for the new millennium”.1 His change agenda elicited the term “joined-up government” — a culture, not necessarily a structure that promoted collaboration, partnerships and different knowledges to provide “sustainable solutions to complex issues”.1

In Australia these notions were hinted by Nugget Coombes who chaired a Royal Commission on Australian Government Administration as early as 1976. He suggested that service delivery should be more at a “local level” so that the community could engage with a reachable government department which would encourage partnerships between local citizens and government decision makers.2 A recommendation of this Commission was implemented in 1987 that suggested less federal government departments to encourage more integrated functions such as policy and service delivery.2 Centrelink is a very visible model of the structural change by government to create a cross portfolio one stop shop.

Following on from this broad historical political agenda of structural change and integration the Australian Public Service Commission (APSC) engaged the Management Advisory committee (MAC) to review how the public service could work better across its portfolio and organisational boundaries.2 This report flags the government’s intention to work in a whole of government paradigm, which is explained as

Whole of government denotes public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues. Approaches can be formal and informal. They can focus on policy development, program management and service delivery.2

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The APSC report noted that the creation of the Council of Australian Governments (COAG) in 1992 was a commitment by the three levels of government (federal, state and local) to work more collaboratively and strategically consider national policies to address service delivery.2 The COAG role

… is to initiate, develop and monitor the implementation of policy reforms that are of national significance and which require cooperative action by Australian governments.3

BUILDING A COAG FRAMEWORK

COAG as a government forum meets on as needs basis and has met fourteen times since December 1992. Its co-operative ventures have included water reform, environmental regulations, National Competition Policy and counter-terrorism arrangements.

In November 2000 COAG issued a communiqué that committed governments to work in partnerships to improve the social and economic well-being of Indigenous people and communities. This was driven by the need to progress Aboriginal Reconciliation and recognition of the “mixed success” of governments to address Indigenous disadvantage.

A reconciliation framework was proposed and three priority actions were identified:

• investing in community leadership initiatives;

• reviewing and re-engineering programs and services to ensure they deliver practical measures that support families, children and young people. In particular, governments agreed to look at measures for tackling family violence, drug and alcohol dependency and other symptoms of community dysfunction; and

• forging greater links between the business sector and Indigenous communities to help promote economic independence.4

A further communiqué issued in April 2002 gave more detail on how practically to respond to these actions and demonstrate a commitment by governments to work in partnership. This included the nomination of trial sites around Australia in which Australian and State/Territory governments would work together with Indigenous communities to improve outcomes at a service delivery level and building community capacity. Underpinning this partnership was an undertaking by governments to work better together at all levels and across all departments and agencies. Furthermore the concept of ‘shared responsibility’ was mooted which meant

that the responsibility for the condition and well-being of Indigenous communities is one shared by the community, its families and individuals and with governments.5

THE COAG SITES AND THEIR GOVERNANCE

Eight sites were selected to trial this partnership across Australia. In WA it was the East Kimberley region, in the NT Wadeye (Port Keats), in Queensland Cape York region, in New South Wales Murdi Paaki region, Shepparton in Victoria, the northern region of Tasmania, the whole of the ACT and in South Australia the Anangu Pitjantjatjara Yankunytjatjara Lands. Each site has an Australian government secretary who has the role of ‘champion’ and their respective agency takes the lead with other government and community partners.2

For this case study the Department of Health and Ageing (DHAA) are the lead agency for the COAG trial site in SA — the Anangu Pitjantjatjara Yankunytjatjara (APY) lands. This area

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covers over 103 000 square kilometres in the far north west of SA and is protected under the Pitjantjatjara Land Rights Act (SA) 1981. While the Anangu population have cultural ties and communities that spread across into WA and NT the trial site is confined to the area defined in the SA Act. The population is estimated at 2600 with 34% under 15 years and only 9% over 55 years of age. The APY Lands represent 9.3% of SA’s Indigenous population and 0.5% of the total Australian Indigenous population.6

Governance structures that underpinned the trial site included a high level Ministers’ Group and the Secretaries group on Indigenous Issues that met in Canberra. An Indigenous Communities Co-ordination Taskforce was also established in Canberra to provide support to the Secretaries group and a broader co-ordination function across departments. On a more local level the Department of Health and Ageing set up a COAG team which included outposted officers based in Adelaide and support in Canberra. In September 2003 the former Aboriginal and Torres Strait Islander Services (ATSIS) appointed an officer to work solely on the COAG trial. The SA state government through the Department for Aboriginal Affairs and Reconciliation (DAARe) also set up structures that were originally known as the Anangu Pitjantjatjara (AP) Lands Intergovernment Interagency Collaboration Committee (APLIICC). In March 2004 this committee was replaced and the SA government created an AP Lands taskforce that reported to Premier and Cabinet. Both SA state structures had high level government heads whose departments had operational and funding interests in the AP Lands. The Australian government had most of its local state managers as members on the APLIICC but was limited to three representatives on the AP Lands Taskforce.

A COAG steering committee was established in 2003 by the lead agency, DHAA, which then had Anangu representation through the APY Executive, the State government (DAARe) and Commonwealth representation through the Aboriginal and Torres Strait Islander Commission (ATSIC) and ATSIS. The terms of reference included matters concerning collaboration and co-operation; guiding the development of a shared responsibility agreement (SRA) and community priorities. A federal Intergovernment group in Adelaide was also established to ensure the Australian government was collaborating and planning together. Besides these higher level structures were the COAG team’s networks at the more operational level that garnered local knowledge and shored up grass roots partnerships.

The central framework of these COAG trials was the Shared Responsibility Agreement (SRA). It was designed to be signed by all COAG trial partners to commit to working together and sharing responsibilities to meet the regional priorities and agreed outcomes to improve service

delivery. The original partners to this agreement were the lead agency, DHAA, the state government through DAARe, the Aboriginal and Torres Strait Islander Commission (ATSIC) and the designated Indigenous body Anangu Pitjantjatjara (AP) through its chairman. Five broad priority outcomes were agreed to after consultation with organisations and communities on the APY Lands. They were

• improving the health and well-being of Anangu by:

- implementing responses by all of the partners to the problem of substance misuse, and

- improving availability and affordability of healthy food supplies

• improving educational attainment, training opportunities, employment opportunities and career pathways, especially for younger Anangu

• improving access for Anangu to a wide range of social and community services by developing the infrastructure for regional delivery of basic services such as banking and

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financial facilities, postal and telecommunications services, and a range of Commonwealth government services eg Centrelink, Medicare easy claim, Job Network

• improving physical infrastructure, especially the quality, reliability and affordability of essential services, the maintenance and upgrade of roads, air and other public transport and appropriately designed, constructed and maintained community housing

• supporting and strengthening existing regional governance structures.7

The agreement has yet to be signed due mainly to many changes in Indigenous affairs in both the federal and state government and political changes on the APY Lands. However, the COAG trial progressed through two ‘endorsed’ projects despite these changes in governance arrangements. In September 2003, the steering committee of the APY Lands COAG trial met and agreed to proceed with two projects that could address outcomes identified in the SRA and that were reaffirmed in a COAG workshop held in Alice Springs for Anangu. As the lead agency DHAA initiated the development of these projects — the Mai Wiru regional stores policy and PY Ku network.

THE PROJECTS

The Mai Wiru Regional Stores policy

The Mai Wiru Regional Stores policy is the culmination of many years of consultation with Anangu, the community stores and other APY organisations. Mai Wiru translates as good food in Pitjantjatjara. As early as 1987 the Report of Uwankara Palyanyku Kanyintjaku — An Environmental and Public Health Review (UPK)8 identified the need for affordable, accessible and a quality food supply for Anangu on the AP Lands. Since then Anangu have persevered in seeking and arguing for a decent food supply for them. In 1998 the AP executive committee resolved to develop a policy and begin negotiations with government and other agencies.9

The Mai Wiru policy consisted of three stages — planning, development and implementation. All of these were sponsored by Nganampa Health who have a long history with Anangu (over 20 years) and are

… an Anangu community controlled health organisation providing comprehensive primary health care services to all the people living on the Anangu Pitjantjatjara Yankunytjatjara Lands …10

A steering committee was formed and included representatives from every community and APY organisations to begin the planning process. The Commonwealth Department of Family and Community Services (FaCS) through their Family and Community Network Initiative (FCNI) funded this participatory planning stage. FaCS also funded stage two the development of the policy through the then “Can Do Communities” Program. The policy document Mai Wiru was produced as a result of this funding.

The Mai Wiru report sets out why there needed to be a regional stores policy including the history of stores on the APY Lands, the health status of Anangu and in the context of international, Australian and South Australian policies on health and nutrition. A major part of the policy details its principles and regulations for the operations of the stores on the APY Lands. Individual councils own these stores so it was important to get each community council to endorse Mai Wiru. Appendix 2 of the policy document tables each community council’s resolution to support and adopt Mai Wiru for their community store.9

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Stage three was the implementation. This had the potential to meet outcomes identified in the SRA and ensure collaboration between governments, community and other Anangu organisations. All of these factors were consistent with the principles of COAG trials. The objectives of the implementation of Stage 3 are to ensure:

• access to healthy, affordable foods, sold in clean stores facilities;

• sale of food compliant with legislation governing the supply of foods and other goods, particularly in relation to storage, information and use-by dates;

• a focus within stores on nutrition as the highest priority and support of health promotion and nutrition programs;

• supply of free cold water and health takeaway foods;

• appropriate store facilities and adequate refrigeration of vegetables, fruit and meat;

• store compliance with ‘fair trading’ legislation including clear pricing displays, refunds for defective or broken goods; and

• employment and training of Anangu workers under appropriate wages and the development of a stores career path.11

Central to the implementation of the policy is the establishment of a Regional Stores Support Unit under the auspice of the Nganampa Health Council. The Unit is considered as an innovative and flexible approach to a regional health service. Activities of the Unit will include:

• establishment of a system for the bulk purchasing of supplies and freight;

• establishment of fixed pricing on healthy food items;

• standardising management systems and practices within stores;

• monitoring store compliance with the Mai Wiru Regional Stores Policy;

• providing ongoing training and development for store workers and managers; and

• work to ensure the Regional Stores Policy is enacted as an APY by-law.11

An application by Nganampa Health Council was made in 2003 to the lead agency the Department of Health and Ageing through the Regional Health Services program (RHSP) within the cross portfolio Health Services Improvement Division to implement the Mai Wiru policy.

At the time of the application there were four fundamental principles that underpinned RHSP

• local solutions for local health problems ensuring there is to be real health gain

• flexible, innovative and integrated solutions promoting better health

• governments supporting improved access to health services, particularly in small communities

• the Australian Government, and State and Territory and local governments collaborating to provide the best way to improve health in rural communities.12

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Furthermore the program acknowledges “that no two communities are alike and that there is no single solution for service-mix or activity” and that nutrition could be considered in a mix of services.

The funding criteria for Regional Health Services Program pre-2004 budget included

• population of towns receiving the service must be under 5000

• demonstration of broad community consultation

• majority of funding must be used to deliver new or additional primary health care services

• service delivery proposals must be comprehensive and address as many community identified needs as possible.12

Nganampa Health’s RHSP application to implement Mai Wiru seemed to be compatible with these principles, have a focus on nutrition and meet the basic for criteria of funding. However there was some doubt about whether the implementation of a policy that regulates stores was “primary health”. Subsequently there was some discussion between national program staff based in Canberra and the local COAG officer to enable an agreed understanding of what constituted primary health in this remote community context. In the Mai Wiru policy document it makes it very clear

The store has an important role in the holistic delivery of primary health care. It is the key source of nutrition for the community and makes a significant contribution to ensuring the physical well being of the community.9

The Department’s definition of primary health is based on the World Health Organisation Alma Ata Declaration

… essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation … It forms an integral part both of the country’s overall health system … and the overall social and economic development of the community … and constitutes the first elements of a continuing health care process.13

There are some obvious elements of this declaration that reinforce the Stores policy as primary health care such as full participation, social and economic development of communities and part of a continuum of health care. Nganampa Health Council has always ensured a participatory process in all their aspects of health care including the Stores Policy. The community stores out on the AP Lands are integral to the social and economic capacity and as previously mentioned the Mai Wiru policy clearly states stores as part of the continuum of health.

As a COAG project Mai Wiru has some integral partnerships that support the notion of collaboration — one of the basic principles of ‘whole of government’. One linkage is to the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council’s nutrition program which aims to improve parents’, children’s and the community’s awareness of healthy diets and healthy eating patterns. The Australian government department of Employment and Workplace relations (DEWR) funded traineeships through the TAFE sector for retail certificate II so Anangu can get jobs in the community stores and the Department of Education Science and Training (DEST) funded the local education body to employ two qualified retail trainers and 2

Anangu trainees for school to work transition. The former ATSIS over some years provided valuable infrastructure funds to upgrade or build new stores across the AP Lands. More recently Nganampa Health Council has engaged the business sector to support them in

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implementing a group purchase scheme of groceries and fresh produce, one of the key planks of the Mai Wiru policy.

PY Ku network

The Lead agencies of the COAG trials were given the imprimatur of change including “breaking down silos … (and) … extending flexibilities in program guidelines”.2 There were no actual guidelines or rules that stipulated neither what lead agencies could drive nor what projects the Secretaries could champion. This gave DHAA an opportunity to go beyond their mainstream health portfolio and fund a consultant to work with Anangu Pitjantjatjara executive and Anangu on the potential for a network of rural transaction centres (RTC) on the APY Lands. The outcome would be a fully costed and developed business plan as required by the funding body Department of Transport and Regional Services (DoTARS). The business case timeline was six months and included extensive consultations out on the APY lands. Intensive liaison with other Commonwealth and State government departments as well as non-government agencies was undertaken to explore and develop their participation in an RTC enterprise. The business plan would accord high priority to employment and training opportunities for Anangu together with potential commercial and enterprise opportunities that may arise with the development of an RTC network and government services on the AP Lands.

The proposed network model of rural transaction centres was given the name PY Ku which was suggested by Anangu and means Pitjantjatjara Yankunytjatjaraku “for the people”. The PY Ku Network is sponsored by PY Media, a local community controlled organisation who are the local technology service providers. They were successful in attracting infrastructure funds from DoTARS. What is proposed in this network model are

• public internet and video conferencing facilities that were funded by “Networking the Nation” and managed by PY Media will be migrated into the PY Ku Network. Technology and connectivity will be combined with new and improved services, providing staff and the public access to both technology and services

• Community Development Employment Program (CDEP) positions, providing employment opportunities to Anangu and links to potential employment throughout various organisations in the Pitjantjatjara Yankunytjatjara Lands

• integrated counter facilities, providing Anangu with a range of services, staff with a range of skills and experience and organisations with a range of service delivery options

• meeting rooms that will be equipped with video-conferencing technology, providing a range of meeting options for Anangu, Community and Homeland Councils and Government and non-Government organisations.

The PY Ku Network also aims to incorporate sufficient infrastructure for the provision of short-term offices and the management of overnight accommodation for professionals using the Centres. The infrastructure will be tailor designed to suit the individual requirements of each community and their associated homelands. The facilities will be utilised by Anangu organisations, Government agencies from the Commonwealth, South Australian and Northern Territory jurisdictions, non-Government organisations and Anangu themselves. A range of new services will be introduced, including on-line information, South Australian, Western Australian and Northern Territory Government services and possibly a regulated face-to-face Indigenous banking system. Existing services will be enhanced, including a significant expansion of Centrelink services and those services provided by Anangu organisations.

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The infrastructure grant is only one part of this network equation as the submission identified a number of partners both government and community based organisations who would participate in PY Ku. Their contribution both in one-off grants and in-kind support amounted to nearly $3 million compared to the infrastructure bid of $2.3 million to DoTARS. Partnerships and collaboration in this project have been intrinsic in the success of gaining the support of a major funding body.

The PY Ku network proposal was in response to a range of reports and structures which included the SA Government’s Coroner’s Report into Petrol Sniffing14, the COAG Draft Shared Responsibility Agreement7 and the Mai Wiru Stores Policy9. PY Ku therefore was not just about infrastructure around business and electronic service delivery but important links to health. By supporting the PY Ku network DHAA reinforced their role to support broader flexible and innovative ways to address a range of priority outcomes that were identified in the SRA including health, access to better services, employment and training.

CONCLUDING REMARKS

The COAG trial has given Health and Ageing an important opportunity to broaden its evidenced based policy for Indigenous health. The WHO’s declaration of Primary health is a check and balance that can be applied to the two projects that have been progressed on the APY Lands through the lead agency model and a Secretary that was prepared to support them. The declaration states that:

… socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation …13

Both projects were as a result of many years consultation with Anangu and their respective community controlled organisations and for two of these agencies the opportunity to become sponsors to progress them for their people. The WHO statement further adds that primary health is a part of “the overall social and economic development of the community”.13 Both the Mai Wiru stores policy and the PY Ku network have the potential to be cornerstones of Anangu economic life through the purchase of cheaper and more accessible food through the store and to realise their right to business/government and financial services in their own country. There is also the social (and economic) capacity to increase training and employment opportunities for Anangu through these services.

Although there were some challenges such as political change for all the COAG trial partners and the Department itself grappling with ‘whole of government’ there has been some positive outcomes for Aboriginal people on the Anangu Pitjantjatjara Yankunytjatjara Lands. There are always reports on the negatives for this region around petrol sniffing and governance and some misunderstanding about what COAG trials are about. The former is challenged by John Singer, Director of Nganampa Health in the Koori Mail15 who points out “it’s not ‘the pits’” as their law and culture is still alive, their language is strong and there are some success stories. The ‘misunderstanding’ about COAG trials may suggest that this trial is just fulfilling the Australian Government’s or lead agency’s agenda. However, these two projects under the COAG trial banner demonstrate the need for partnerships across departments, with Anangu and their community controlled organisations. The element of ‘shared responsibility’ between government, organisations, families and individuals will be now tested in the implementation and evaluation of these projects in the near and long term future.

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REFERENCES

1 Institute of Public Administration. Working Together — Integrated Governance. IPAA, Brisbane Australia, 2002.

2 Australian Public Service Commission. Ministerial Advisory Committee. Connecting Government: Whole of Government responses to Australia’s priority challenges, Canberra, 2004.

3 Council of Australian Governments. Ministerial Councils. , viewed 5th November 2004.

4 Council of Australian Governments’ Communiqué 3 November 2000 , viewed 5 November 2004.

5 Indigenous Communities Taskforce. Shared Responsibility Shared Future. COAG initiative. , viewed 30th June 2004.

6 Indigenous Communities Taskforce. Shared Responsibility Shared Future. Our Communities. , viewed 30th June 2004.

7 Department of Health and Ageing. Internal communication, 2003.

8 South Australian Health Commission. Report of Uwankara Palyanyku Kanyintjaku: an environmental and public health review within the Anangu Pitjantjatjara Lands, South Australian Health Commission Adelaide, 1987.

9 Nganampa Health Council and Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council. Mai Wiru — Regional Stores Policy. Nganampa Health Council Alice Springs, 2002.

10 Nganampa Health Council. Annual Report. Nganampa Health Council Alice Springs, 2003.

11 Department of Health and Ageing. Internal communication, 2004.

12 Department of Health and Ageing , viewed 7th October 2004.

13 Commonwealth Department of Health and Aged Care. Better Health Care — Studies in the successful delivery of primary health care services for Aboriginal and Torres Strait Islander Australians. Commonwealth of Australia, Canberra 2001.

14 Courts Administration Authority, South Australian Government. Coroner’s Report into Petrol Sniffing 2002 , viewed 22 November 2004.

15 Singer John. Koori Mail (page 21) 5 May 2004.

PRESENTER

Helen Bulis is an Australian Government public servant who has worked in Alice Springs, Perth, Darwin and most recently in Adelaide. She has had a long involvement with Indigenous service delivery and had the opportunity to work on the COAG trial on the Anangu Pitjantjatjara lands in 2003-04. Helen also has an interest in rural Australia and was a research assistant on the social impact of drought for Central Queensland University. She is currently undertaking a PhD on whole-of-government policy with the Alcoa Research Centre for Stronger Communities, Curtin University, WA.