Cultural brokers

Amid concerns about pay, pathways and roles, the future for Indigenous health workers is now being questioned

On a day in the middle of spring in 1992, Indigenous health workers and educators from around Australia met in Brisbane to discuss the needs of the workforce. It was the first such national gathering and pointed to increasing recognition at the time of the importance of health workers as cultural brokers within Indigenous health.

Common challenges and plans for the future were discussed as part of an informal agenda and concerns about pay, educational standards and career structure were raised.

Recommendations coming out of the meeting included the need to establish a national representative body, national registration and portability of qualifications.

Those taking part agreed that it had been an important couple of days.

Cindy Shannon was there, and spoke to the audience of close to 100 about Australia’s first Bachelor of Applied Health Science (Indigenous Primary Health Care) which she had just helped to put in place at the University of Queensland (UQ).

Professor Shannon is now Pro Vice-Chancellor (Indigenous Education) at UQ. The UQ applied health sciences course is no longer offered — “it was probably a decade ahead of its time” — but she says many of the same issues continue to hamper the country’s health worker workforce.

“Issues around the careers structure and awards system are still unresolved. It’s still a very messy contested landscape”, Professor Shannon tells the MJA.

And, as the number of Indigenous health professionals gradually increases, a new question is beginning to be asked.

“I have watched the debate grow from the professionalisation of the Aboriginal health workforce to ‘do we even need health workers in the future?’” she says.

Workforce

In the more than 20 years since the Brisbane meeting, the National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA) has been established, and the Aboriginal and Torres Strait Islander Health Practice Board of Australia (ATSIHPBA) has established national registration as part of the Australian Health Practitioner Regulation Agency (AHPRA).

The broad range of roles filled by health workers means that getting a firm grasp on their numbers remains difficult.

NATSIHWA estimates that there are now around 2000 health workers nationally.

Of those, the Association has 500 full members — those who have completed the Certificate III in Aboriginal and Torres Strait Islander Primary Health Care.

And since the introduction of national registration on 1 July 2012, 324 Indigenous health practitioners have registered with the ATSIHPBA, for which they are required to have a Certificate IV in Aboriginal and Torres Strait Islander Primary Health Care or to have been previously registered with the Northern Territory Aboriginal Health Workers Board.

The vast majority of those who have registered are women (73%) and more than half are 45 years of age or older.

The workforce was established in the late 1960s and ‘70s, but had its beginnings in the early 1960s when Aboriginal women were employed in leprosy camps in the NT.

The move toward Indigenous health workers, Professor Shannon says, was prompted by the recognition that the mainstream was failing Aboriginal people due to poor cultural understanding.

Over time, the role has evolved to encompass everything from cultural brokering to health promotion and frontline clinical work, with vast differences across urban, rural and remote contexts and different geographical areas.

In 2011, the final report from the Health Workforce Australia (HWA) Aboriginal and Torres Strait Islander Health Worker Project defined the modern Aboriginal Health Worker as a person who identifies as an Aboriginal and/or Torres Strait Islander and is recognised by their community as such; who is the holder of the minimum or a higher qualification in Aboriginal and Torres Strait Islander primary health care; and who has a culturally safe and holistic approach to health care.

The same report pointed to a growing body of evidence linking Indigenous health worker involvement to improved health outcomes in Indigenous communities for diabetes care, maternal and infant care, palliative care and mental health care.

Recognition

Christine Ingram has been an Indigenous health worker for 24 years.

She became interested working in the area when she was still at school because members of her family were involved in health.

That interest initially led to training as a dental assistant and in that role she was given the opportunity to include more health-focused roles, such as screening.

As her basic skills began to accumulate, Ms Ingram decided to formalise her experience by completing a Certificate III in Aboriginal and Torres Strait Islander Primary Health Care (Practice).

“It developed from there but I’ve always maintained the oral health focus as well — ensuring that oral health doesn’t get lost in general health”, she says.

Today, she is acting deputy chief executive of the Victorian Aboriginal Health Service based in Fitzroy and NATSIHWA Treasurer.

Ms Ingram says it is important that health professionals recognise that Indigenous health workers play a big part in the care for Aboriginal people.

“It’s recognising what they can actually bring to the service that they’re working in. They’re colleagues, they’re co-workers.

“We talk about culturally competent people being able to deliver effective health care for Aboriginal people — you can’t do that without Aboriginal people alongside you providing that support.

“Communities don’t access mainstream organisations even though there could be a hospital up the road.

“Unless there’s actually an Aboriginal person there, they just won’t access services, which is sad. That is actual reality and that’s still happening today.”

Career pathway

While the figures are uncertain, there is some concern among representative groups such as NATSIHWA that the numbers of Aboriginal and Torres Strait Islander health workers may now be dropping at a time when the need continues to grow.

This has been attributed to the lack of any clear career pathway of health workers and to the fact that they remain one of the lowest paid groups of community workers in Australia.

Ms Ingram says that the lack of a clear career pathway and adequate income for health workers is making it difficult to keep trained staff working where they are most needed.

This, in turn, has prompted NATSIHWA to work with the Health Services Union and others to try to ensure that Indigenous health workers receive better pay.

It is hoped that this will prevent moves to the hospital or private sector where pay is better and responsibility is less.

“In their communities they are the key point”, Ms Ingram says.

“They’re vital to the health care system. But what’s happening is they are being skilled up within their communities and ACCHOs [Aboriginal community controlled health organisations], but because of funding or wage issues, they’re leaving to go to mainstream organisations and get paid a lot more for a lot less responsibility.”

Many others, like Ms Ingram, are moving into management roles, or get qualifications to take on more senior clinical roles.

The future

The recipient of the 2014 AMA Indigenous Peoples’ Medical Scholarship, Wayne Ah-Sam, was an Indigenous health worker for 20 years before deciding to switch and study medicine.

Now in his second year at the University of Newcastle, when he received the award, he said: “I had seen a lot of health issues and inequality which have greatly impacted on our people’s health.

“I felt that, as a health worker, I was only scratching the surface of a deep-rooted problem.”

Mr Ah-Sam is one of a small but significant group of health workers to have taken the step into medicine. Others choose to move into nursing or allied health.

It’s a move that everyone welcomes but it’s one that raises questions about the need for Indigenous health workers as cultural brokers in the future.

“I find it extraordinarily frustrating to be talking about the same things that we’ve been talking about for 20 years”, Professor Shannon says, referring to the 1992 conference.

“The absolutely entrenched failure to really grapple with who Aboriginal health workers are, what role they play and what their future is really stands out.”

In her role at UQ Professor Shannon is now focused on increasing the numbers of Aboriginal and Torres Strait Islanders across the health professions.

It is part of what she says will be a generational shift away from the idea of the emergence of new Indigenous health workers into the presence of Indigenous people in the health professions.

“I see things going in a direction that will ultimately see Aboriginal people in various other health service provider roles within health services. We all should be happy if we see a day when the doctor, the nurse and the physio are all Aboriginal and not the other way around.

“Will we need Aboriginal health workers in that environment?”