1. What works? The social and economic determinants of Indigenous health Engaging with Indigenous communities

2. What works? The social and economic determinants of Indigenous health Professor Fran Baum Southgate Institute for Health, Society and Equity, Flinders University, Adelaide

3. Why social determinants are so important to health Scope and limitations of the review What worksWhat we don’t know 1 2 3 4 Overview

4. Commission on the Social Determinants of Health "(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible. Social injustice is killing people on a grand scale." In Australia that includes Indigenous peoples

5. Basic logic: what good does it do to treat people's illnesses/addictions/send them to gaol/......... then give them no choice to go back to or no control over the conditions that made them sick/addicted/commit crime in the first place?

6. Social Determinants get under our skin and cause diseases and health inequities …. Chronic stress is one of crucial pathways for Indigenous Peoples….

7. Wilkinson & Pickett 2009, 86 The Biology of Stress

8. Biological Pathways 1 …

9. Biological Pathways 2 … Source: Marmot & Wilkinson, 1999

10. How social determinants get into our brains and cause mental health problems Lack of control over work and home life Discrimination (racism, sexism) Long term chronic stress Poverty – managing on low income Living in area with high disorder & lack of safety Coping by using substances harmful to health – alcohol, tobacco, illegal drugs Chronic Disease Depression, Anxiety Barriers to seeking mental health care: cultural, financial, class, gender Unemployment Non-permanent work Gendered violence Early childhood not stimulating maximum brain development Social isolation & lack of meaningful contacts

11. Indigenous Health Outcomes 11 year life expectancy gap – 10 for women, 12 for men Higher rates of infectious and chronic disease Higher rates of risky behaviour driven by high risk social, economic and cultural environments

12. Scope, Frame and limitations of the study 1.Small budget for review 2.Rapid appraisal 3.Focus on Australian literature 4.Included “grey” literature 1.Social determinants as distal and proximal determinants 2.Attribution of health & equity impact 1.Not systematic review 2.Often no publicly available evaluation data and generally not RCTs or systematic approaches 3.Mainstream programs little evaluation (e.g Medicare, education, housing)

13. Osborne, Baum & Brown, 2013

14. WHAT SOCIAL DETERMINANTS INTERVENTIONS WORK TO IMPROVE INDIGENOUS HEALTH??

15. Education pathways to health: employment, healthy living skills, healthy parenting, valuing culture Education success factors:  High expectations of students and promoting positive Indigenous identity  Community development focus  ‘Whole of institution’ approach  Well-trained, high quality teachers  Indigenous culture and knowledge valued

16. Connection to family, community, culture and country pathway to health: promotes well-being, protective of health, social support Culture success factors:  Clear planning  Locally driven and owned by Indigenous communities  Elders  Land and country as means of healing  Strengths focus  Women taking leadership & governance roles  Good staff  Strategic inter-sectoral partnerships

17. Employment and income pathway to health: more resources for health and wellbeing Employment & income success factors:  Employment service agencies that have culturally competent trained staff, commitment to Indigenous peoples, links to business, collaborative partnerships with Indigenous communities, holistic support  Income management – controversial and evidence lacking for success in improving financial management skills  Increasing employment opportunities complex and embedded in history, racism

18. Housing pathway to health: complex, multi- directional and has large impact on health especially in remote communities Housing success factors:  Standardised method for improving health hardware  Local skills  Collaboration with Indigenous housing associations  Preventing homelessness  Strengths based, holistic case management

19. Racism pathway to health: increases stress with impacts on mental and physical health Anti-racism success factors:  Anti-discrimination legislation  Universal interventions across settings  Organisational development (e.g AFL)  Social marketing & Diversity training: challenge false beliefs; accurate info on Indigenous culture and impact of racism on health, emphasise shared values, involve Aboriginal people in development and design

20. Interaction with government systems pathway to health: treatment in these criminal justice, health etc. systems impacts directly on health Changing system success factors:  Culturally competent staff and service delivery  Indigenous people working in systems  Holistic, strengths based  Collaborative partnerships  Community development approach e.g. whole of community approach to crime prevention  PHC in health system

21. Health behaviours pathway to health: lifestyles affect health but they in turn reflect SDH Health behaviours success factors:  Acknowledge impact of broader determinants of health  Influence environments e.g. outlets selling tobacco  Supply restriction  Use strong community relationships to promote healthy lifestyles  Engage young people in alternative activities

22. What we don’t know Lack of good evaluation data Casual links complex Relative contribution Evaluation culture weak Resistance to adverse results rather than interest in learning Mainstream service evaluation Multi-directional relationships Casual links not linear or straight forward Hard to say how much each determinant contributes to health Interactive effect

23. Lessons from what works >Mainstream social determinants need to be flexible in order to respond to needs of Indigenous people >Cross government co-ordination and collaboration between government and community sector vital >Leadership with full commitment to CTG >Colonisation context: cultural, legacy of trauma and grief need to inform all action >Active engagement of Indigenous peoples including employment of Indigenous staff >Long term not short term pilot funding >Strengths based approaches >Good research and evaluation with adequate funding including of universal services

24. Action on SD of Indigenous health requires that we decide to commit resources Poverty and inequity is “not a preordained result of the forces of nature or the product of a curse of the deities. But the consequences of decisions which men and women take or refuse to take.” (quoted in Heywood and Altman,2000, p.173)

25. Q & A session Professor Fran Baum

26. Morning Tea

27. Engaging with Indigenous Australia – Exploring effective engagement with Aboriginal and Torres Strait Islander communities Dr Janet Hunt Fellow, Centre for Aboriginal Economic Policy Research Research School of Social Sciences Australian National University

28. What evidence did I look for? Literature in Australia – especially around regional engagement (16 studies from 12 diverse regions) And in sectors: health, natural resource management, early childhood With NGOs and companies, not only governments Indigenous engagement in other settler countries (Canada, USA, New Zealand) Engagement with marginalised people and placed–based approaches

29. What is ‘engagement’? ‘Engagement’ is a sustained relationship between groups of people working towards shared goals There is a spectrum of engagement – from low to high

30. The spectrum of engagement Aboriginal community: Has control – defines problem, goals & means Has delegated decisions Plans jointly Advises Is consulted Receives information

31. Factors in engagement History, culture and language Indigenous ‘communities’ Scale of engagement – multilayered? Governance & capacity Engaging with organisations Purpose Timeframes & media

32. Policy Context National policy National mechanisms Guidelines Recent Commonwealth approaches States & Territories Remote Australia Native Title and land rights

33. UN Declaration on Rights of Indigenous Peoples Article 18: Indigenous peoples have the right to participate in decision making in matters which would affect their rights, through representatives chosen by themselves in accordance with their own procedures, as well as to maintain and develop their own Indigenous decision making institutions. Article 19: States shall consult and cooperate in good faith with the Indigenous peoples concerned through their own representative institutions in order to obtain their free, prior and informed consent before adopting and implementing legislative or administrative measures that may affect them (UN General Assembly 2007:8).

34. Australia: Regional studies COAG trials (one in each jurisdiction - 7) Murdi Paaki Regional Assembly (5 studies) Ngaanyatjarra Regional Partnership (Sullivan) Noongar – 3 approaches (Barcham) Fitzroy Futures Forum (ATSI SJC) Lockhart River Qld (Hagan) Groote Eylandt & Bickerton Island RPA (Tempo)

35. What worked Leadership Resources Participatory processes Governance & capacity building

36. Leadership High-level government engagement; clear, adaptable policy framework for WOG, place-based approach. Regionally based senior people with decision making authority & high-level negotiation skills; staff building trust and respectful relationships. Leadership across all levels, governments and communities. People on the ground willing to try new approaches and make things work; ‘one size doesn’t fit all’ communities.

37. Resources Partnership processes themselves resourced: staff to manage the engagement & follow up decisions made Resources available to build partner capacities & to undertake the programs jointly agreed. Having flexible funds for all these purposes contributes to success.

38. Participatory Processes Communities were setting the agenda Planning started from community level upwards to regions. There was identification of Aboriginal strengths, assets and positives; leadership being developed ‘Less monitoring and more mentoring’ (Hagan 2009:27) Clarity about processes and effective communication. Clarity and agreement about desired outcomes and indicators, and well ‑ developed plans to achieve them long time frames: people ‘work at their pace and in their spaces’ (Hagan 2009:25); ‘change is chaotic and emergent’ (Hagan 2009:31) not a linear process.

39. Governance & capacity building Built on existing Indigenous governance structures, mechanisms and processes wherever possible Support and capacity building for communities and community representatives for engagement with governments Ongoing governance development; processes and structures designed by Aboriginal people - viewed by them as legitimate. Cultural legitimacy and government funding for regional governance body for engagement.

40. Groote Eylandt RPA Ministerial support Community driven partnership ALC – strategic approach Community $ and leverage, plus other funds Collaboration & trust Vision & high level leadership Effective implementation

41. Groote Eylandt RPA Needs more integrated plans and pooled funding Better alignment across govts More streamlined & collaborative processes at local level

42. Replicable? Key success factors Equality between partners & authority to proceed Community needs, aspirations the driving force Objectives, priorities shared by all parties Detailed planning & negotiation from outset Principles of operation - touchstone for partnership operations Adequate resourcing & long time frame Responsive & efficient management

43. What didn’t work Government arrangements Communities’ capacities Relationships

44. Government arrangements Different jurisdictions and departments with differences never resolved High-level government goals not adequately translated into specific plans and actions Organisational cultures discouraged flexibility and risk taking Insufficient focus on relationship building No streamlined, flexible funding

45. Communities’capacities Communities with weaker capacity to engage with government, or cynical about the ability of governments to change; little government support for community learning/capacity building. Community-level governance problems impeded their leaders’ ability to engage effectively with governments.

46. Relationships Insufficient participation, sense of shared ownership by Indigenous people in decision-making No genuinely shared objectives, performance indicators or benchmarks, or data for M & E Government agencies weren’t clear about roles and responsibilities in the partnership arrangements Government limitations not made clear to Indigenous partners from the outset

47. What works: sectoral findings Long term relationships based on trust Working within a framework of Aboriginal-driven decision making Power inequalities are addressed–strong mutual accountabilities Culturally competent staff Shared responsibility and accountability for shared objectives

48. What didn’t work? Example from Coastal zone decision-making (Rockloff & Lockie 2006) -Aboriginal people’s lack of financial & technical resources -Inequity re participation in meetings unpaid -Aboriginal people expected to attend bureaucratic meetings, with set agendas, & discuss issues through a ‘western’ lens -Little confidence that listened to & knowledge respected -Govt agencies & others failed to acknowledge considerable diversity among Aboriginal people (3 distinct cultural groups with own languages, customs, aspirations etc.)

49. Solutions? Indigenous people agenda-setting Capacity building – support (financial & other) for Aboriginal involvement; modification of processes & structures Cultural awareness training for government Ensuring Aboriginal specific views are respected, recorded; investing in relationships and communication based on equality, openness, & respect for each other’s values Supporting the development of Aboriginal governance structures (starts to challenge the power inequalities)

50. What works: Relationships Responding to Indigenous history, cultures and social dynamics Valuing skills and knowledge of community organisations and Indigenous people Clarity about purpose and relevant scale for engagement Engagement needs to relate to Indigenous concepts of wellbeing (not just COAG targets)

51. What works: Relationships Long-term relationships of trust, respect and honesty Accessible, ongoing communication and information Effective governance and capacity - Indigenous & among governments Appropriate timeframes

52. What works: Participatory processes Indigenous agency & decision-making from the outset an Indigenous-driven process with government as facilitator/enabler builds on existing community governance structures and Indigenous strengths and assets an empowering process - small achievements towards mutually agreed longer term goals

53. What works: Participatory Processes Recognition of power inequalities - sincere attempts to share power, through agreements Transparency of decision making processes and agreed conflict resolution mechanisms Strong mutual accountability relationships in agreements A high degree of clarity about desired outcomes, indicators Clearly defined roles and responsibilities in agreements and partnerships, some continuity of personnel Parties engage in joint planning of monitoring and evaluation to meet rights and needs of each

54. What works: Governance & leadership Effective and legitimate Indigenous governance arrangements Strong and strategic Indigenous leadership Indigenous leadership resourced & supported for engagement Very high level leadership, flexibility, and secure, adequate resources within governments Honesty about resource (or other) limitations; set achievable goals Culturally competent staff able to build trusting relationships

55. What works: Governance & leadership Investment in strengthening the governance of both Indigenous and government partners for effective partnership working Building on existing community organisations and governance structures Governments have capacity to respond to Indigenous priorities with pooled and flexible funding arrangements

56. Q & A session Dr Janet Hunt