Empowering indigenous health workers through management training.

This regular column of Physician Executive appears under the auspices of the Royal Australian College of Medical Administrators, whose 300 members regularly receive the journal. While the column is written from the Australian perspective primarily for our Australian readers, it is also intended to be of interest to ACPE members. In this issue, the authors describe efforts in Australia to fully involve indigent populations in the provision and management of their health care services.

The extent of the health disadvantage in Australia's 260,000 indigenous people, the Aborigines and Torres Strait Islanders, is of national concern. Expectation of life at birth is between 15 and 20 years less than that of the nonindigenous population, comparing unfavorably with populations in Canada, the United States, and New Zealand, where life expectancy in indigenous peoples is between three and nine years less than that of the overall population.(1)

Although Aboriginal infant mortality rates have declined significantly, as late as 1987 they still ranged from 2.0 to 3.9 times the overall Australian rates. Leading causes of adult mortality were diseases of the circulatory and respiratory system, injury, and poisoning, with nutrition and lifestyle clearly contributing factors.(2) While much of the improvement in infant mortality may be attributed to health care interventions focused on infants and children, the lack of improvement in adult mortality over the same period reflects the absence of a more expansive vision of primary health care and associated community development.(1)

Aboriginal and Torres Strait Islander Health Workers

The 1970s saw an increased awareness of the disparity between the health of Australia's indigenous peoples and that of the rest of the population and a political commitment to change. In the mainland states, Aboriginal and Torres Strait Islander health workers were trained to play a role as "cultural brokers" in health, representing the needs of their people at a personal and community level and mediating the delivery of health services to them.(3) The extent to which these health workers acted as primary health care workers, providing both preventive and curative care, varied among the states and territories. In Queensland, the Aboriginal Health Program employed Aboriginal health workers and health assistants, working under public health nurses in health prevention strategies targeted at infants and children and based on growth monitoring and health education.(4)

The late 1980s saw a formalization of the training of Aboriginal and Torres Strait Islander health workers, with accredited certificate courses developed in tertiary and further education institutions around Australia. In Queensland, community-based representatives, working against considerable resistance in the former health department administration, effectively turned around the role of the Aboriginal and Torres Strait Islander health workers. With graduates of their certificate course now undertaking an expanded role in health services provision, and with a more sympathetic administration now addressing issues such as career structure and registration, they approached the Tropical Health Program, University of Queensland, to develop further training opportunities for health workers.

Participation in Management

A specific goal of the National Aboriginal Health Strategy was a high level of participation in health decision-making processes, both locally and in national forums. Empowerment and self-determination are as critical to the achievement of health outcomes as are improved health information, health infrastructure, service provision, and access.(4)

Rifkin suggests that this participation in health care may occur in a variety of ways and argues that the result of community involvement in health is related to the nature and extent of participation available. While it is relatively easy to achieve passive participation in the benefits of a program, or to generate support for its activities through fundraising or voluntary assistance, these activities do not allow the community to affect program goals, implementation, or outcomes. With participation in implementation of services, programs are made accountable to the communities they serve and articulate their values and priorities.(5) Planning, implementation, monitoring, and evaluation are essential tools of management, and while consultative processes may incorporate community inputs, real participation demands the development of appropriate management skills in indigenous health workers.

The National Aboriginal Health Strategy, aware of this relationship, has emphasized training in health as part of its commitment to self-determination.(4) Educational disadvantage within the Aboriginal and Torres Strait Islander communities, however,(6) combined with a sense of alienation from mainstream educational institutions, has resulted in a limited pool of indigenous health professionals. While the indigenous peoples of Canada and the United States have in some cases graduated generations of medical practitioners, surveys of Australian medical schools in 1989 identified fewer than five Aboriginal graduates.(7) Schemes designed to facilitate entry of indigenous candidates(8) and support units, such as the University of Queensland's Aboriginal and Torres Strait Islander Studies Unit, have had some modest success in recruiting and supporting indigenous medical students. However, given the limited pool of potential indigenous medical administration candidates, and the duration and complexity of training, the impact of current enrollments may not be experienced until well into the third millennium. Clearly, more immediate and accessible training in health management for Aboriginal and Torres Strait Islander health workers is needed.

The Bachelor of Applied Health Science (Indigenous Primary Health Care)

In July 1991, Queensland Health provided a medical administrator to the Tropical Health Program to commence curriculum development for an undergraduate degree that would give experienced health workers skills in health management in an environment that recognized their own culture not only in teaching/ learning strategies but also in terms of its perspectives on health and management. Working with an Aboriginal administrator, two reference groups were established, one in urban Brisbane, the second in Cairns, a northern provincial city with close links to former reserves and settlements. The groups were composed of 30 Aboriginal and Torres Strait Islander health professionals with a range of health experience: senior health workers, nurses, health administrators, university academics, educators, and community elders. The curriculum writer and three other nonindigenous consultants participated. Government and community-controlled health services were represented, together with the University's Aboriginal and Torres Strait Islander Studies Unit.

The structure and content of the curriculum reflects the composition of the reference groups. They adopted the definition of "health" provided by the National Aboriginal Health Strategy:

"Health to Aboriginal peoples is a matter of determining all aspects of their life, including control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity....

"In Aboriginal society there was no word, term or expression for 'health' as it is understood in Western society. It would be difficult from the Aboriginal perception to conceptualize 'health' as one aspect of life. The word as it is used in Western society almost defies translation but the nearest translation in an Aboriginal context would probably be a term such as 'life is health in life.'"(4)

The reference groups saw health in holistic terms, linking it at every point to body, land, and spirit. They identified the community as the key to understanding health, with health within the family seen as an appropriate access point for exploring health at both community and personal levels. The tree was suggested as an analogy for the structure of the course: its roots are grounded in an understanding of the family, its solid trunk represents good health .within the community, and the branches are reaching out to explore specific knowledge, technologies, and tools relating to personal and community health.

The curriculum uses a problembased teaching/learning methodology that builds progressively on students' knowledge. The theme of the first semester is "The Context of Aboriginal and Torres Strait Islander Health." The course commences with students' considering health within themselves and within their families, taking into account factors that contribute to health and illness. These factors are applied to the community as a whole , and the qualitative and quantitative skills required to begin analysis are provided. The anatomy and physiology relevant to major health problems are explored in integrated, problem-based exercises. The broader organizational context of health service provision is examined, and students are given the essential writing and accounting skills that enable them to access the system.

The second semester of the first year focuses on "Growth and Development." It deals with normal childhood development in the Aboriginal and Torres Strait Islander context and the major disease threats to child health. Quantitative skills at this stage enable measurement of growth and development and mapping of community parameters related to them.

There is a progression from this initial exploration of health issues to the development of communication and counseling skills, health promotion, and program management in the second year. Entitled "Changing Behavior in Individuals and Groups," this year focuses on behavioral change at a personal and community level to bring about health outcomes, using community development principles. Students address the management processes that bring about organizational change and provide a basis for health change in communities.

The third year, "Health in the Community," includes the development of skills in community diagnosis, health planning, and evaluation and provides for practical implementation of these skills in a community development project. This completes the iterative cycle, from identification of health-related issues, through analysis and evaluation of those issues, to the intervention, its implementation, evaluation, and feedback of outcomes.(9)

The course is expected to commence in 1994, with some subjects being piloted in late 1993. Providing access to potential students in remote Aboriginal and Torres Strait Islander communities is seen as one of the major challenges to be addressed. The recently appointed coordinator of the program, an Aboriginal academic with a background in management education, is using her MBA studies to explore Aboriginal cultural patterns of leadership, group structures, and decision making and their implications for management processes. Clearly, the teaching of health management principles is a two-way process, recognizing the strengths and resources of the Aboriginal and Torres Strait Islander communities and working with health workers toward self-determination in the management of health issues that confront them.

References

1. Kunitz, S., and others. "The Health of Populations on North Queensland Aboriginal Communities: Changes and Continuity." National Centre for Epidemiology and Population Health, Australian National University, Canberra, Working Paper Number 30: 1, pp. 36-8, June 1992.

2. Thompson, N. "Recent Trends in Aboriginal Mortality." Medical Journal of Australia 154(4):235-9, Feb. 18, 1991.

3. Soong, F. "The Role of Aboriginal Health Workers as Cultural Brokers." Australian Journal of Social Issues 18(4):268-74, Nov. 1983.

4. National Aboriginal Health Strategy Working Party. A National Aboriginal Health Strategy. Canberra: Australian Government Publishing Service, pp. LX,503,85-101, 1989.

5. Rifkin, S. "Lessons from Community Participation in Health Programmes." Health Policy and Planning 1(3):247-9, Sept. 1986.

6. National Health Strategy. "Enough to Make You Sick: How Income and Environment Affect Health," Research Paper Number 1, pp, 87,97-100, Sept. 1992.

7. Schwenke, J. "Training Aboriginal Doctors." Medical Journal of Australia 153(6):309-10, Sept. 17, 1990.

8. Biggs, J. "Special Admissions to a Medical School." Medical Journal of Australia 142(7):384-5, April 1, 1985.

9. Indigenous Primary Health Care Unit. "A Proposal for the Bachelor of Applied Health Science (Indigenous Primary Health care)," Tropical Health Program, University of Queensland, pp. 28-30, Sept. 1992.