AVID in Public Governance
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Intensifying Aboriginal Voice Integration and Diffusion in Public Health Governance
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AVID in Public Governance
- 1. Intensifying Aboriginal Voice Integration and Diffusion in Public Health Governance Dr Mark J Lock Australian Research Council Discovery Indigenous Research Fellow
- 2. Encoding Social Values “moral values and resource allocation cannot be isolated from the social interactions through which these are realised” Anderson, I. (1997). The Ethics of the Allocation of Health Resources in Race Matters: Indigenous Australians and ‘Our’ Society (pp. 191-208). Canberra: Aboriginal Studies Press.
- 3. Is there a governance wedge? • Argument: an intensification programme needs to consider the role of governance in Closing the Gaps • Theme: multiple points and pathways for encoding of social values into routine governance processes • Concepts: participation, governance, integration
- 4. Governance 1. Centre for Aboriginal Economic Policy Research (2004-2008). “Indigenous Community Governance Project”. Online. 2. NSW Auditor-General (2011). “Governance Lighthouse – Strategic Early Warning System”. Online . 3. NSW Auditor-General (2011). “Corporate Governance – Strategic Early Warning System”. NSW Auditor-General’s Report Volume Two 2011. Online 4. NSW Auditor-General (2015). “Governance Lighthouse – Strategic Early Warning System (Checklist)”. Online. “the evolving processes, relationships, institutions and structures by which a group of people, community or society organise themselves collectively to achieve the things that matter to them”1 2-4
- 5. Aboriginal Voice Integration & Diffusion in Public Health Collaboratives (AVID Study) @MarkJLock, @StudyAVID, www.avidstudy.com 1) Lutschini, M. (2005). Engaging with holism in Australian Aboriginal health policy – a review. Australian and New Zealand Health Policy, 2:15. Online. 2) Lock, M. (2007). Aboriginal holistic health: A critical review. Cooperative Research Centre for Aboriginal Health. Online. 3) Lock, M. et al. (2011). Indigenous participation in an informal national Indigenous health policy network. Australian Health Review, 35(3): 309-15. 4) Lock, M. (2012). The bright sides of assimilation. Med J Aust, 197(7):417-418. Online. 5) Lock, M. (2015). I want to end meaningless rhetoric in Indigenous politics. Online. 6) Lock, M. (2015). Shame and disgrace in the governance of food and nutrition policy for Aboriginal and Torres Strait Islander Peoples. Online. 7) Lock, M. (2015). Meet the Mob: Mark Lock. Online ‘there should be collaboration between and within Governments at all levels, their agencies and funded service providers to effectively coordinate services and programs’
- 6. Committees • A committee is a group that keeps minutes and loses hours (Milton Bearle) • Committees are key integration structures Single committee solution: I + C(p) > R
- 7. Committees as Knowledge Diffusion Networks
- 8. Governance Complexity • AVID Website Governance Visualisation • Corporate Governance and Accountability Compendium • Corporate Government Matrix • Policy Context and Strategic Alignment • The most effective committee consists of three members two of whom are usually absent (after Robert Copeland)
- 9. Governance Chain - BUFI • Committee (bubble):organisation (umbrella):social system (framework):acts/legislation (institution) • CRG/CCF/CF > CESC > MNCLHDGB > MNCLHD- ELT > NSW-SEF > MoH-ELT > MoH > Cabinet > Parliament > Governor-in-Council
- 10. HNELHD Governance Chain A committee is a cul-de-sac down which ideas are lured and then quietly strangled (Sir Barnett Cocks)
- 11. A Governance Formula A/Li+1 [SDFn+1] > (COt+1) > (CRn+1) > [BoDd+1 : (CAC; CPC)]: Eco : ORn+1 : OPn+1[RA/L+1] : OSn+1 [OSt+1] Organisation perspective:
- 12. CtG Intensification • multiple points and pathways for encoding of social values into routine governance processes. • Practical steps – much excellent work already being done by MNCLHD.
Editor's Notes
- Note: This presentation was developed as the keynote presentation to the Intensifying Closing the Gap Seminar organised by New South Wales Health’s Mid North Coast Local Health District (MNCLHD). The presentation was developed with the view to provide the audience with an appreciation of the role of public health governance in Closing the Gaps in Aboriginal health outcomes. The main question guiding the presentation was is there a governance wedge preventing closing the gaps? I acknowledge the traditional custodians of the land on which stand, the Dunghutti Nation, and pay my respects to Elders, past and present. Many thanks to Robyn Martin and Andrew Bailey for this invitation to present, participate and be a champion in the intensifying closing the gap seminar. I am a full-time research academic at the University of Newcastle, funded by the Australian Research Council who in 2013 awarded Peter O’Mara and I about ¾ million dollars to investigate Aboriginal Voice Integration and Diffusion in Public Health Collaboratives – or what we call the AVID study, which is essentially about answering the question where is my voice? It’s a study about the encoding of social values through committees, more detail of which follows.
- The quote that most affects my thinking about the efforts needed to intensify this closing the gap summit was written in ‘The Ethics of the Allocation of Health Resources’, where palawa trowerna academic Ian Anderson wrote that “moral values and resource allocation cannot be isolated from the social interactions through which these are realised” (Anderson, 1997, p. 192). He refers to the ‘moral’ behaviour enacted through the British form of colonisation on the First Peoples of Australia which, Anderson states ‘clearly demonstrates how moral values can be relativised through relations of power’ (Anderson, 1997, p. 193). There are many published works available that provide ample sources of the systemic racial discrimination against Australia’s First Peoples (Attwood, 2003; Attwood & Markus, 1999; Broome, 2002; Chesterman & Galligan, 1997; Eckermann, Dowd, Chong, Nixon, & Gray, 2010; Elder, 2003; Gardiner-Garden, 1999; Kidd, 1997; Reynolds, 2000, 2006). A key theme from these works is that the structuring of social relations occurs through the encoding of social values into State institutions. References: Anderson, I. (1997). The Ethics of the Allocation of Health Resources Race Matters: Indigenous Australians and ‘Our’ Society (pp. 191-208). Canberra: Aboriginal Studies Press. Attwood, B. (2003). Rights for Aborigines: Allen and Unwin. Attwood, B., & Markus, A. (1999). The struggle for Aboriginal rights: Allen and Unwin. Broome, R. L. (2002). Aboriginal Australians, black responses to white dominance 1788-2001. Chesterman, J., & Galligan, B. (1997). Citizens without rights: Aborigines and Australian citizenship: Cambridge University Press. Eckermann, A.-K., Dowd, T., Chong, E., Nixon, L., & Gray, R. (2010). Binan Goonj: bridging cultures in Aboriginal health: Elsevier Australia. Elder, B. (2003). Blood on the wattle: Massacres and maltreatment of Aboriginal Australians since 1788: New Holland Frenchs Forest, Australia. Gardiner-Garden, J. (1999). From Dispossession to Reconciliation. Retrieved from http://www.aph.gov.au/binaries/library/pubs/rp/1998-99/99rp27.pdf Kidd, R. (1997). The way we civilise: Aboriginal affairs, the untold story: Univ. of Queensland Press. Reynolds, H. (2000). Why weren't we told?: A personal search for the truth about our history: Penguin Books. Reynolds, H. (2006). The other side of the frontier: Aboriginal resistance to the European invasion of Australia: UNSW Press.
- It follows then that in seeking to Close the Gaps in Aboriginal peoples’ disadvantage, we would want to structure social relations in such a way in regard to principles such as equity, empowerment, and self-determination to name a few. A key way to do this is for the ‘full and ongoing participation by Aboriginal and Torres Strait Islander people and organisations in all levels of decision-making affecting their health needs’ (Australian Government, 2013, p. 10). The principle of participation is reflected in the NSW Aboriginal Health Plan (NSW Ministry of Health, 2012, p. 4), in the NSW Aboriginal Health Impact Statement and Guidelines, and the Mid North Coast Local Health District’s Community Engagement and Consumer Participation Framework 2015-2017. Indeed, it extends from the Alma Ata Declaration of Primary Health Care – particularly principles about full participation decision making (VI), the right and duty to participation in planning and implementation processes (IV). A key theme is that the principle of Aboriginal peoples’ participation is integrated throughout a number of policy documents, and is diffused in the health system’s operation and management. References: Australian Government. (2013). National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Retrieved from http://www.health.gov.au/natsihp NSW Ministry of Health. (2012b). NSW Aboriginal Health Plan 2013-2023. Retrieved from North Sydney: http://www0.health.nsw.gov.au/policies/pd/2012/PD2012_066.html NSW Ministry of Health. (2007). Policy Directive - Aboriginal Health Impact Statement and Guidelines. Retrieved from Sydney: http://www0.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_082.pdf Mid North Coast Local Health District. (2015). Mid North Coast Local Health District Community Engagement and Consumer Participation Framework 2015-2017. Retrieved from Coffs Harbour: http://mnclhd.health.nsw.gov.au/wp-content/uploads/MNCLHD-Community-and-Consumer-Engagement-Framework1.pdf World Health Organization, and World Health Organization. "Alma Ata Declaration." Geneva: World Health Organization (1978).
- Citizen participation is a key principle in the concept of governance. As you can see this particular definition of governance from the Centre for Aboriginal Economic Policy Research’s Indigenous Community Governance Project, is “the evolving processes, relationships, institutions and structures by which a group of people, community or society organise themselves collectively to achieve the things that matter to them” Garling, & Sanders, 2008, p. 9). As noted in the Corporate Governance and Accountability Compendium for NSW Health “The NSW Health System is committed to the principles and practice of good governance, across all public health organisations, in a way that involves stakeholder and community participation” (NSW Ministry of Health, 2012a, p. 2.01). For example, the NSW Auditor-General’s Corporate Governance Lighthouse is derived from some very good analysis (available online), is presented in an understandable graphic, and provides a checklist against the 17 criteria. As you can see on the graphic it states that ‘key stakeholder management is deliberately on top of the lighthouse’ and provides some key principles: who they are, what they are doing and how well they operate. The key theme is that governance is a strategic place for enabling greater citizen participation – especially for Aboriginal and Torres Strait Islander People. References: Hunt, J., Smith, D., Garling, S., & Sanders, W. (2008). Contested governance: Culture, power and institutions in Indigenous Australia: ANU E Press. At http://press.anu.edu.au/titles/centre-for-aboriginal-economic-policy-research-caepr/c29_citation/ NSW Ministry of Health. (2012a). Corporate Governance and Accountability Compendium for NSW Health. Retrieved from North Sydney: http://www.health.nsw.gov.au/policies/manuals/Pages/corporate-governance-compendium.aspx Centre for Aboriginal Economic Policy Research (2004-2008). “Indigenous Community Governance Project”. Online. NSW Auditor-General (2011). “Governance Lighthouse – Strategic Early Warning System”. Online . NSW Auditor-General’s Report Volume Two (2011). Online NSW Auditor-General (2015). “Governance Lighthouse – Strategic Early Warning System (Checklist)”. Online.
- The key phrase in the definition of governance in the previous slide is ‘organise themselves collectively’ which lead me to investigating the concept of integration. The concept of integration, like many other policy concepts (participation, collaboration, consultation, etc.) is positioned as a panacea for improving complex social phenomena. The Australian Government’s integration principle states that ‘there should be collaboration between and within Governments at all levels, their agencies and funded service providers to effectively coordinate services and programs’ (National Indigenous Reform Agreement 2008, p.A-21). In the document within which this statement is embedded there are no empirical foundations or operational manuals to guide health service executives in the right direction. At this point I exit to the AVID study website to explain some particular aspects of the AVID database (see the ‘network’ tab of the website). A key theme is the lack of an empirical foundation for the meaning, operationalisation, measurement, and monitoring of the integration principle. This is my goal in the AVID Study This slide provides some background notes on the presenter, Dr Mark J Lock. The point is that Mark has developed a line of research on policy concepts – holism, participation, and integration. You can check-out his profile (https://www.newcastle.edu.au/profile/mark-lock) and see that he has a fair bit of movement between different organisations throughout his work history, and each one had its particular committee culture. References: Council of Australian Governments. (2008). National Indigenous Reform Agreement (Closing the Gap). Retrieved from Canberra: http://www.federalfinancialrelations.gov.au/content/npa/health_indigenous/indigenous-reform/national-agreement_sept_12.pdf
- However, integration is rather a diffuse concept – it’s not possible to go into a supermarket and buy the ingredient “integration” to add to the collaboration soup! I think about integration, and indeed participation and governance, through the lens of committees. Committees – defined as formally constituted groups of people – are a key mechanism for citizen participation with the Australian State. Now participation should not to be reduced to only those formal interactions which occur through committees. Nevertheless, I propose that committees are significant sites of integration because a) they are formally sanctioned mechanisms of the State, b) they are ubiquitous instantiations of Western democracy, c) they are taken as routine structures of governance, and d) they are sites where social values are encoded into decision making processes. However, one of Australia’s cultural norms is to rely on the single committee solution proposed in regards to any issue (I) there is the ‘high level’ committee (C) of ‘prominent’ people (p) who will lead reform (R). But this represents simple thinking because of our complex, multifaceted environment. In fact committees are connected into a chain of knowledge diffusion. They key theme is that committees are connected into a chain of knowledge diffusion. Exit to the AVID study website https://avidstudy.newcastle.edu.au/vis/committees
- This figure is from my PhD thesis – The Participation of Indigenous People in National Indigenous Health Policy Processes, 2003-2004 data. Without going into the detail of the figure, the key point is that there are hundreds of committees and thousands of people giving advice about what to do in the health system. Another key point to note is that this is a map of Aboriginal peoples’ participation – it is possible to visualise a system perspective of participation and develop performance indicators accordingly. The key theme is that any single committee is structurally located within a much more complex governance environment. Reference: Lock, M. J. 2008. The Participation of Indigenous People in National Indigenous Health Policy Processes. Doctor of Philosophy, The University of Melbourne. https://minerva-access.unimelb.edu.au/handle/11343/35282
- So it is evident that governance is complex but can viewed from different angles such as a single committee, an organisation, as a system and indeed as an institution But it’s incredibly difficult to visualise the concept of governance and my attempt is the AVID website governance visualisation (click hotlink above) The social policy domain of health is complex as evident upon reading through the information of the NSW Corporate Governance Matrix, and the NSW Health Corporate Governance and Accountability Compendium, and MNCLHD’s Policy Context and Strategic Alignment section in the Community and Consumer Engagement Framework. Each of these documents provides details of the governance arrangements relevant to health, but it is difficult to cut through all the detail and see where strategic improvements could be made. The key point being that measuring, monitoring and evaluation the principle of integration should occur through different angles. References – refer to the references on slide number 4.
- My particular angle to cut-through the miasma of governance is to investigate the committee-organisation-system-institution linkages. This is what I call the BUFI governance chain: committee (bubble) : organisation (umbrella) : social policy system (frameworks) : acts/legislation (institutions). The colon ‘:’ denotes the myriad social relations inherent in each transition point. For example the governance chain for the Mid North Coast Local Health District is: Community reference groups/community connection forums/consultative forums > Community Engagement Sub-committee > Mid North Coast Health District Governing Board: MNCHDGB (Website with terms of reference, meeting minutes) > MNCLHDGB > Stewart Dowrick > MNCLHD Executive Leadership Team: MNCLHD-ELT (Service Agreement and corporate governance statement, and Model By-Laws) > Stewart Dowrick > NSW Health Senior Executive Forum: NSWH-SEF > Mary Foley > Ministry of Health Executive Leadership Team: MoH-ELT > Mary Foley > Ministry of Health: MoH (Acts and Regulations, Policy Directives, Policy and Procedures) > MoH (Jillian Skinner, Pru Goward) > NSW Cabinet > NSW Parliament > Governor-General > Governor-in-Council. They key point being that the complexity of governance can be empirically interrogated. References: The Board is responsible for ensuring effective corporate governance frameworks are established for the Mid North Coast Local Health District (attestation), see http://mnclhd.health.nsw.gov.au/wp-content/uploads/MNCLHD-2013_14-Corporate-Governance-Attestation-Statement-CE-and-Chair-signed-FINAL.pdf The Mid North Coast Local Health District’s (MNCLHD) Governing Board has worked to establish the Governance structure for the District in line with legislative and NSW Ministry of Health requirements. In doing so we have placed a strong emphasis on clinician and community engagement, and on ensuring our patients (and their carers and families) are at the centre of every decision we make. (strategic plan), see http://mnclhd.health.nsw.gov.au/wp-content/uploads/MNCLHD-GB-Review-January-2014-Strategic-Plan.pdf
- An example of empirical investigation is the HNELHD Governance Chain (2014), the links between committees are formal ‘reporting’ links and this graphic was constructed from publicly available information. This graphic reminds me that a committee is a cul-de-sac down which ideas are lured and then quietly strangled (Sir Barnett Cocks)
- In terms of measurement methodology I propose that there should be a way of coding the governance relationships of the BUFI linkages, such as through the example of the organisation: When a Board of Directors (BoD, a governing committee) resolves upon a set of decisions (BoDd+1), it is done so in the knowledge of a set of codified rules (CRn+1) explicitly written into the terms of the Constitution of an Organization (COt+1) which are themselves framed in terms of a particular social domain framework (SDFn+1) as defined in law through Acts and Legislation (A/Li+1). The executive committee (Eco) directs the organisational responses (ORn+1) to occur in accordance within the regulations of the Acts and Legislation (RA/L+1) through the organization’s numerous services (OSn+1) and practices (OPn+1) provided by many staff (OSt+1) such as health, welfare, education and so on. Furthermore, the BoD obtains advice (knowledge) through formally constituted community advisory committees (CAC) and clinical practice committees (CPC). This governance chain can be formed into a kind of social transformation formula (which is a work in progress). The key point is the possibility that concepts such as governance can be systematically investigated – much like the epidemiology of health with equations, calculations and analytical systems. The fact that this isn’t the case begs the question is governance the wedge preventing us from closing the gaps in Aboriginal disadvantage?
- Implications for an Intensified approach to Closing the Gaps: I’ve mentioned a number of key points in each of the slides: encoding of social relations, concepts (participation, governance, integration), strategic positioning of governance, poor foundations to operationalise principles, complexity of governance can be systemically investigated, and that committees are inter-connected into a knowledge diffusion network. Each of these points add to the main theme that there are multiple points and pathways for encoding of social values into routine governance processes. The MNCLHD has already embarked on many positive activities such as the mapping the services provided to Aboriginal people, mapping the committees of which the executives are members, and also the numerous range of specific programs and services. I would urge the MNCLHD to document the committees and committee members with the view to proving a link between the modification of governance arrangements and the MNCLHD’s future achievements in closing the gaps. Thank you!