Victorian Aboriginal Community Controlled Health Organisation (VACCHO) staff Abe Ropitini (left) and Jessica Mitchell (right). Image credit: Leigh Henningham.
On a recent bright but chilly winter morning, we met Abe Ropitini and Jessica Mitchell outside the Collingwood headquarters of the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) for a yarn and some photos.
We were there to talk about the launch of our implementation tool to help organisations in Melbourne’s north and west support Victoria’s Aboriginal Health and Wellbeing Workforce Strategy. However, the discussion was a broad and interesting one. So, we’ve published much of it below.
Abe Ropitini is a proud Māori man of Ngāti Kahungunu and Ngāti Maniapoto iwi with ancestral links to Palawa Mob from Northeastern Tasmania. He is VACCHO’s Executive Director of Population Health.
Jessica Mitchell is a proud Gunditjmara and Wemba Wemba woman. She is VACCHO’s Executive Manager of Workforce Development.
Here is what they had to say:
On who comprises Victoria’s Aboriginal health and wellbeing workforce
So, there are two answers to that question.
There is the health and wellbeing workforce across the entire health system, which is basically everybody who works in any health profession. There’s a basic expectation that if you’re practicing in a health profession in Victoria, that you are capable of practicing in a way that contributes to equitable outcomes for Aboriginal people.
The second answer is that there is an Aboriginal community-controlled health sector within the Victorian health system, which works specifically with Aboriginal Communities through service providers that are controlled by Aboriginal Communities. Those are our ACCHOs.
It’s critical that everybody involved in the health system at both of these levels know their roles and responsibilities, and the capabilities needed to work effectively with Aboriginal people.
On barriers to employment for Aboriginal people in the broader health sector
I think we have hesitancy around whether spaces are culturally safe for us, and whether we’ll potentially be the only Aboriginal person in the team. It can be isolating and hard to put up with other people expecting us to be the point of contact for anything, culturally, surrounding Aboriginal and Torres Strait Islander people. That’s a huge amount of emotional labour, which we call cultural load. It’s like, I appreciate that you’re curious about our ancient ceremonial protocols, but can we just remember that I am the receptionist.
To resolve this, it’s about hiring more Aboriginal people, but it’s also about taking away the expectation that any individual person can answer every question about, or on behalf of, Aboriginal people. That needs a collective approach, a team effort, to really ease the cultural load for individual workers.
When we hear that mainstream health services have not been able to recruit or retain Aboriginal people, we look at the position description, and we can often see why. Often, the service has not understood the real value added by an Aboriginal person who is part of the local Community, who can provide insight into the Community and build bridges into the service.
Unless there’s a recognition of that articulated in the way that roles are designed, Aboriginal people can find themselves in identified roles with a position description that doesn’t accurately reflect the relational nature of their responsibilities, and with managers who don’t fully understand their value.
On Victoria’s Aboriginal Health and Wellbeing Workforce Strategy
Our workforce strategy was developed partly in response to the shock of COVID-19 on the overall health system, and its specific impact on the Aboriginal community-controlled sector.
Through the many months of lockdowns, we had enormous turnover across the health system and a lot of people came out of it burnt out and tired. There’s now a looming workforce crisis in a number of areas – in particular GPs, mental health, and in the nursing workforce. We have big challenges in terms of being able to attract, recruit, develop and retain healthcare staff.
So we raced to develop a strategy for the recovery, rebuilding and long-term sustainability of the ACCHO workforce, so that we could urgently start advocating to government.
Part of what we identified in the development of the strategy was the need to equip and enable our allies in mainstream services too. That part of the health and wellbeing workforce – in hospitals, mainstream mental health services, aged care services – they have been just as shocked, in fact, in many ways more shocked, than us in the ACCHO sector. And so having a strategy that gives our allies an equity toolkit that they can implement within their services is something we see as very necessary.
On the role of primary health networks on implementing the workforce strategy
One of the most critical settings for cultural safety and equity is in primary health. In Australia we have primary health networks that are very good at looking at primary health challenges through a local lens.
‘One of the most critical settings for cultural safety and equity is in primary health.’
For example, in North Western Melbourne, the PHN is very good at scanning the local environment and putting together plans to respond to what communities need, and removing barriers for those communities by supporting services within their footprint.
The north and west of Melbourne is an area where the growth in the Aboriginal population has been enormous over the last 5 years. So, the amount of pressure that puts on our ACCHOs in the area is enormous as well.
We need mainstream providers to be working on cultural safety, and how to create more equitable experiences and outcomes for Aboriginal people walking through their doors, because at the current rate our ACCHOs are struggling to keep up with the demand for services in response to the growth of the population. It’s not just workforce challenges that constrain us, it’s also infrastructure.
‘We need mainstream providers to be working on cultural safety.’
So, we are very keen for the primary health network to have a role in driving and influencing primary health services to build trust with Aboriginal Communities, to provide culturally safe services and viable choices for people.
On how health sector leaders can help build a stronger Aboriginal health and wellbeing workforce
For health services to become more culturally safe, health professionals need their leaders to create authorising environments for them to slow down when they recognise the need to spend more time with patients.
If somebody’s coming in and a health professional recognises hesitancy, a trust deficit, or a communication barrier, then that professional should know that their leaders expect them to be flexible and they should know the practical limits to that flexibility.
For an Aboriginal person who’s walking through the door, whose past experience may mean that they have good reasons not to trust mainstream health services, it’s essential to spend time developing trust. The relationship and atmosphere should be explicitly anti-racist, and characterised by respect and patience so that people feel safe to share what’s going on in their lives.
If leaders can explicitly communicate that this is what they encourage, and if they can be transparent about the parameters in which health professionals can exercise flexibility, then we’ll get a more culturally responsive workforce capable of fostering experiences of cultural safety.
I agree. By doing all these things, it enables Mob to feel empowered in a health care setting and more likely to re-engage with that service in the future. That security helps them to take control of their current and future health journeys.
I also think leaders in health need to understand the socio-cultural context of colonisation and the intergenerational trauma that stems from it. Mainstream services and medical professions have historical baggage that needs to be acknowledged and reflected on.
It’s very powerful when Aboriginal health professionals within mainstream organisations and professions can witness that acknowledgement and reflection. It’s even more powerful when they can help shape the institutional conscience needed to embed anti-racism. So, leaders should be aware of that and should act intentionally when creating and designing identified roles and pathways for Aboriginal people.
On how western ways of working can better recognise Aboriginal Ways of Knowing, Being and Doing
I think it starts by looking at the model we practice in our ACCHOs: we look at patients holistically, not just as anatomical bits and pieces, or as a puzzle of medical problems to be solved. Actually seeing their whole self, their story, their connectedness to family and Community, and the social determinants of their situation. It’s a blended approach that combines high quality medicine with yarning, genuine relationships, sharing moments of warmth, connecting on a deeper level.
We also know that there’s a strong connection between a person’s culture and their sense of identity and belonging, and their health outcomes. I think we really try to embed that in the programs and clinical spaces in our ACCHOs.
‘There’s a strong connection between a person’s culture and their sense of identity.’
Yeah, I agree, and I think that our entire health system needs to learn from that and be more responsive to the cultural determinants of health. In the ACCHO sector it’s what we live and breathe.
Do people know where they’re from? Understand all the reasons they have to be proud of who they are? Have a strong sense of their identity and a strong sense of belonging? Know the places that were significant to their ancestors and which they can trace themselves back to? All of that forms the underlying basis of the whole health and wellbeing of a person.
Most people in Australia are born with that foundation intact. If you’re born into, say, an Italian, Greek, or white Australian family, those ingredients will be reasonably strong, or it will be possible for you to connect to them.
For many Aboriginal Communities, it was the thing that was removed. That’s the key difference: we need to recognise that it’s much harder to connect to the cultural enablers of health when your culture is the thing that was taken from you.
So, in the ACCHO sector, that’s what we’re working very hard on – reconnecting those often-broken connections to culture, country, Community, kinship. It’s important that all other parts of the health system have a baseline understanding of this challenge and recognise the importance of the relationship between people and place, community, culture, in assessing whether somebody is holistically healthy and well. Greater consciousness of that would be very helpful.
On Indigenous data sovereignty
Data has been collected about Aboriginal people for a long time in health. It’s been mostly used by non-Aboriginal people to frame questions about inequities and disparities.
Their focus is almost always on relatively higher rates of disease, comorbidity, mortality. Population health planners are using those questions to investigate ways to close the gap, right? But it’s not closing.
Compare that to when Aboriginal people have control of interpreting the same data: the framing of the question changes radically. Suddenly it’s no longer just about Aboriginal people experiencing more disease or not living as long.
New questions are added, like: why is our health system so incapable of producing equitable outcomes? And why do people not feel that they can trust health and social services to the extent that we need them to be able to? Why is there still such limited choice when it comes to accessing culturally safe services?
See – the standpoint in the questioning has been totally flipped. We’re no longer looking at a population and asking, “what’s wrong with you?” It’s now the health system that we’re questioning, which is exactly where our scrutiny should be focused.
So, data sovereignty is critically important for ensuring that the right people – from the right standpoint – are in control of framing the right questions, so that we are putting our scrutiny in the right place and solving the right problems.
In the absence of data sovereignty, data is interpreted and questions are framed in ways that drive the narrative of a population with higher disease and lower health literacy, which sits on the fundamental premise that there’s something wrong with Aboriginal people. We need to end that and put the focus back on critically needed system reform.
So, wrestling control of the ability to frame the questions we ask is extraordinarily important. And that’s why data sovereignty is such a big priority of ours.
North Western Melbourne Primary Health Network is encouraging all primary health services to use this tool to help strengthen the capacity of the workforce to deliver holistic health and wellbeing support to Aboriginal and Torres Strait Islander people.