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Mutual obligation and Indigenous health: thinking through incentives and obligations

Emma Kowal
Med J Aust 2006; 184 (6): 292-293. || doi: 10.5694/j.1326-5377.2006.tb00241.x
Published online: 20 March 2006

As shared responsibility agreements between Indigenous communities and the Australian Government become more prevalent, where their goal is health improvement we need to consider whether the rewards and obligatory behaviours are acceptable, whether communities have real freedom of choice, whether the arrangements can be implemented and evaluated, and whether they will improve health.

The Howard Government’s New arrangements in Indigenous Affairs have seen 76 shared responsibility agreements (SRAs) signed between leaders of 64 Indigenous communities and the Australian Government.1 The first SRA publicised, in December 2004, entailed community leaders in Mulan in the East Kimberly ensuring that children were given showers daily in return for funding for a new petrol bowser and health programs. The main rationale for the agreement presented in the media was improving child health, particularly reducing the incidence of trachoma.2

The near-silence of health commentators on this issue was, thankfully, broken last year by Collard and colleagues in this Journal.3 These authors questioned the morality of the government in placing conditions on the provision of basic rights to Indigenous communities. However, behind both the government’s enthusiasm and Collard et al’s criticism lie enduring public health dilemmas. Below, I present five questions that may help readers consider these issues as they relate to the Mulan SRA in particular, and to incentives and obligations in general.

But first, we need a working definition. In the context of health, let us say that “mutual obligation” means obligating people to adopt healthy behaviours in return for a reward. While the Mulan agreement incorporated a number of obligations and rewards (see Box), here I focus on the obligation of parents and children to maintain hygienic behaviours and the reward of a petrol bowser.

The key questions presented here refer only to obligations placed on communities, rather than on governments. Furthermore, for the purposes of this discussion, it is assumed that community members are in a position to fulfil the obligations (for example, they have access to a functioning water supply).

Do communities freely choose to participate?

This is the key issue for Collard and colleagues,3 and others for whom community autonomy and self-determination are central concerns. They suggest that the Mulan community was not “well placed to judge whether the benefit they will get from a petrol bowser will be worth the ‘price’ they have agreed to pay”,3 implying an element of exploitation or coercion in the government’s approach. The proponents of the agreements, however, argue they enhance community autonomy by allowing the community to deal directly with government, rather than through intermediaries in multiple bureaucracies.9

Some would consider that the substantial power difference between a small, isolated Aboriginal community and the Australian Government means that a community can never freely participate, even if community representatives truly believe they are making an autonomous choice. Others think that to dismiss the choices communities make as “false” is paternalistic.10

Will it improve health?

The public health literature indicates that incentives and obligations that promote healthy behaviours have a role in improving health.7 The lack of attention to the implementation and evaluation of these agreements on the government’s part suggests that they, at least, are not taking the potential health benefits seriously. A more serious approach to the potential health benefits of SRAs would employ public health expertise and an evidence-based approach. For instance, face-washing programs need to be integrated with screening and treatment programs and environmental health programs to have maximum impact on trachoma rates.11

It is also difficult to judge how genuinely Indigenous communities themselves are engaging with the health-related obligations of SRAs. A pessimistic view might be that, to access much-needed resources, communities are agreeing to obligations they have no intention or ability to meet. This may have the inadvertent effect of focusing the public health gaze on individual behaviours and distracting us from necessary structural change. An optimistic view would welcome the opportunity for community leaders to voice their concerns about health and adopt novel health promotion approaches, in a similar vein to alcohol restrictions and “no school, no pool” policies. There may also be potential to use the agreements to hold the government accountable for the provision of basic infrastructure and services necessary for good health.

The political reality of SRAs is complex and fraught. However, the current focus on incentives and obligations provides an opportunity to reflect on the variety of methods available for practising public health, and the factors that may affect the application of SRAs in Indigenous contexts.

  • Emma Kowal

  • Centre for Health and Society, University of Melbourne, Melbourne, VIC, and Menzies School of Health Research, Institute for Advanced Studies, Charles Darwin University, Darwin, NT.


Correspondence: 

Competing interests:

None identified.

  • 1. Australian Government. Shared responsibility agreements. Available at: http://www.indigenous.gov.au/sra/kit/what_are.pdf (accessed Sep 2005).
  • 2. Metherell M, Gauntlett K. Aborigines strike fuel for hygiene deal. The Sydney Morning Herald 2004; 9 Dec. Available at: http://www.smh.com.au/news/National/Aborigines-strike-fuel-for-hygiene-deal/2004/12/08/1102182364537.html (accessed Feb 2006).
  • 3. Collard K, D’Antoine H, Eggington D, et al. “Mutual” obligation in Indigenous health: can shared responsibility agreements be truly mutual? Med J Aust 2005; 182: 502-504. <MJA full text>
  • 4. Lehmann D, Tennant MT, Silva DT, et al. Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study. BMJ 2003; 327: 415-419.
  • 5. Morgan DL, Allen RJ. Indigenous health: a special moral imperative. Aust N Z J Public Health 1998; 22: 731-732.
  • 6. Gray D, Saggers S. The evidence base for responding to substance misuse in Indigenous minority populations. In: Stockwell T, Gruenewald P, Toumbourou J, et al, editors. Preventing harmful substance use: the evidence base for policy and practice. London: John Wiley & Sons, 2005: 381-393.
  • 7. Smedley L, Syme S, editors. Promoting health: interventional strategies from social and behavioural research. Washington, DC: National Academy Press, 2000.
  • 8. Beauchamp D. Lifestyle, public health and paternalism. In: Doxiadis S, editor. Ethical dilemmas in health promotion. London: John Wiley & Sons, 1987: 69-80.
  • 9. Australian Government. Office of Indigenous Policy Coordination. New arrangements in Indigenous affairs. Available at: http://www.oipc.gov.au/About_OIPC/new_arrangements.asp (accessed Sep 2005).
  • 10. Karvelas P, Lewis S. Howard right, says Mundine. The Australian 2004; 14 Dec: 1.
  • 11. Cook J. Trachoma and the SAFE strategy. Commun Eye Health J 1999; 32: 49-51.

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