NSW Health promotes and provides accountable and culturally safe services, programs and working environments that are free of racism for Aboriginal people and inclusive of the needs of priority population groups.
The National Agreement arose from acknowledgement, by all governments, of what Aboriginal and Torres Strait Islander communities and organisations had been saying for a long time–fundamental changes were needed to governments’ ways of developing and implementing policies and programs that affect Aboriginal and Torres Strait Islander people’ lives41. To embed these changes over the long term, it was recognised that government institutions themselves need to undergo wholesale transformation, particularly in terms of addressing systemic racism, promoting cultural safety, and addressing the consequences of discrimination42.
Culturally unsafe health systems –those which diminish, demean or disempower the cultural identities and cultural needs of Aboriginal communities43 –result in reduced access to healthcare, lower quality of care when it is delivered, and compounding risks to health and wellbeing. Transformation of government institutions and systems so they are culturally safe and equity-focused will help ensure improved outcomes across the social, emotional, spiritual, cultural, and physical health and wellbeing of Aboriginal people.
By committing to the National Agreement, the NSW Government is also committing to being accountable for its funding decisions and allocations, and for achieving improved outcomes for Aboriginal people. This expectation applies equally to all government departments and agencies involved in implementing the NSW Implementation Plan for Closing the Gap.
NSW Health has systems and mechanisms that can be leveraged to increase accountability for Aboriginal health. They include the NSW Health Performance Framework, Aboriginal health focussed KPIs and improvement measures in service and funding agreements between NSW Health and various government and non-government organisations (NGOs), and other health reports monitoring system responses to Aboriginal health priorities. Strong accountability mechanisms are needed to drive and implement change, so it’s critical to strengthen and extend on these existing systems to ensure NSW Health sets high standards for transparency and responsiveness in meeting its commitments.
The strategies outlined under this priority will be essential for supporting the monitoring and evaluation of the plan and strengthening NSW Health’s Aboriginal governance and accountability mechanisms. This priority is also complementary to the work outlined under Reform priority 4.2 -Data accountability, transparency and useability.
“If there’s a KPI around it, you tend to get more attention on it. KPIs keep the system accountable to achieve Aboriginal health outcomes. Previously, Aboriginal health was seen as an Aboriginal Health Team responsibility, but now Aboriginal health has been made a whole-of-system responsibility”. Aboriginal NSW Health staff (metropolitan) consultation participant
“If there’s a KPI around it, you tend to get more attention on it. KPIs keep the system accountable to achieve Aboriginal health outcomes. Previously, Aboriginal health was seen as an Aboriginal Health Team responsibility, but now Aboriginal health has been made a whole-of-system responsibility”.
NSW Health is held accountable for how it works to improve the health and wellbeing of Aboriginal people, and the outcomes that are achieved.
Cultural safety is an outcome, rather than a process. The Aboriginal person accessing healthcare judges how well the care setting, providers and processes respect and meet their cultural needs44. Similarly, the Aboriginal staff member judges how well their workplace respects and meets their cultural needs. This cannot be achieved solely by setting requirements for NSW Health policymakers and service providers to undertake discrete cultural ‘awareness’ or ‘competence’ training activities in which they learn about Aboriginal cultures. Rather, healthcare providers, policymakers and organisations must be prepared to challenge their own cultural values, biases, privileges and power structures on an ongoing basis45, 46.
As cultural safety means healthcare experiences and workplaces are free of racism, anti-racism practices are essential. It is well-known that racism increases the burden of disease –and decreases the quality of life of Aboriginal people47, 48, 49. In fact, institutional and interpersonal racism, and the intergenerational trauma that many Aboriginal people continue to experience as a consequence of racist colonial systems, account for almost half of the gap in health outcomes between Aboriginal and non-Aboriginal people50. In particular, evidence from the Mayi Kuwayu: the National Study of Aboriginal and Torres Strait Islander Wellbeing, indicates the psychological harm of interpersonal discrimination experienced by Aboriginal people51. There is an urgent need to address the devastating consequences of racism and discrimination, including unacceptably high rates of suicide, self-harm, and psychological distress experienced by Indigenous Australians52.
Non-Aboriginal people must be guided by Aboriginal people’s expertise and lived experience in learning about cultural safety, while not creating emotional or time burdens or expectations for Aboriginal staff and community members, in addition to meeting their existing workloads.
Currently, a wide range of national, state-based and local Aboriginal organisations in NSW offer training in culturally safe healthcare delivery and creating culturally safe workplaces. Such training requires participants reflect on racism, unconscious bias, white privilege, the dominance of non-Aboriginal cultures as ‘the norm’ in Australia, and how to counteract these ingrained power structures through practicing anti-racism. Clinical safety is “inextricably linked” with cultural safety53. Addressing both requires dedicated and planned action that includes and extends beyond cultural safety training to enable institutional change.
Cultural safety is institutionally embedded so Aboriginal staff, clients, external colleagues and community members experience cultural safety in all levels, areas and services of NSW Health.
“If you don’t have culturally safe environments for your staff and consumers, your workforce is going to leave or you’re not going to be able to attract anyone in the first place. And if you haven’t got a culturally safe space for your consumers, you’re not going to be able to build partnerships with anyone”. Health staff (metropolitan) consultation participant
“If you don’t have culturally safe environments for your staff and consumers, your workforce is going to leave or you’re not going to be able to attract anyone in the first place. And if you haven’t got a culturally safe space for your consumers, you’re not going to be able to build partnerships with anyone”.
Equitable access to quality healthcare that genuinely addresses the needs of Aboriginal people was the foundation of the original community-led Close the Gap campaign54 and ultimately led to development of the National CTG Agreement55, 56, 57. The call for health equity remains paramount today, not just as a core human right as articulated in the United Nations Declaration on the Rights of Indigenous Peoples58.
The World Health Organisation defines health equity as “the absence of unfair, avoidable or remediable [health] differences among groups of people, whether those groups are defined socially, economically, demographically, geographically or by other dimensions of inequality (e.g., sex, gender, ethnicity, disability, or sexual orientation)” and states that health equity is achieved when everyone can attain their full potential for health and wellbeing59.
A closely linked concept–health justice–can be understood as the process of advancing health equity60 by breaking down structural and systemic barriers that create unfair and unequal health outcomes. Government systems must embed health justice and equity in both principle and practice to meet the health and wellbeing needs of Aboriginal people. This is particularly the case for priority populations, who often face multiple, compounding sources of injustice and inequity in health and linked social service systems (such as child protection, aged care and disability support).
Priority population groups within Aboriginal communities include children and young people, families, Elders and Stolen Generations survivors/descendants, people with disability, incarcerated people, and LGBTIQ+ people.
“We need to keep building the capability of non-Aboriginal staff. Sometimes non-Aboriginal people are not confident to consider Aboriginal health, and they’re worried they’ll do the wrong thing...asking an Aboriginal person is a short-cut to self-education, but it shifts responsibility back onto Aboriginal staff.” Aboriginal NSW Health staff (regional) consultation participant
“We need to keep building the capability of non-Aboriginal staff. Sometimes non-Aboriginal people are not confident to consider Aboriginal health, and they’re worried they’ll do the wrong thing...asking an Aboriginal person is a short-cut to self-education, but it shifts responsibility back onto Aboriginal staff.”
Health justice and equity are institutionally embedded so Aboriginal clients, community members, staff and external colleagues from priority population groups experience their needs being recognised and included.