Beyond the pipeline: a critique of the discourse surrounding the development of an Indigenous primary healthcare workforce in Australia

Abstract

A central strategy in addressing health disparities experienced by Indigenous people has been based on a concern with workforce improvement. In this paper, the Indigenous Australian healthcare workforce literature since 1977 is reviewed and its scope of concern, as being often limited to questions of ‘supply’, is critiqued. The pipeline metaphor, whether used explicitly or implied, regularly focuses attention on closing the gap on Indigenous representation within the health workforce. The exception though is the discourse concerning Indigenous Health Workers (IHWs), where questions concerning the legitimacy of the role continue to abound within a workforce hierarchy where community knowledge, though shown to be crucial to culturally safe health service provision, is trumped by the other health professions whose knowledges and legitimacy are not in question. This contrast exemplifies the need to examine the working of power not just ‘supply’. The pipeline metaphor is disrupted with concerns about a range of other ‘gaps’ – gaps in the recognition of Indigenous knowledges, in organisational structures, in governance and in self-awareness by the health professions of their whiteness. As the health system continues to measure workforce development in terms of pipeline capacity, our study questions what happens beyond the pipeline.

… but what about the Aboriginal and/or Torres Strait Islander Health Worker academic? Transcending the role of ‘unknowing assistant’ in health care and research through higher education: a personal journey

“…The AIHWJ told a different story, one about the limitations of the health system in its ability to care for Aboriginal and Torres Strait Islander peoples. Rather than focussing on ‘fixing’ the A&TSIHW workforce via ‘upskilling, developing, empowering and enhancing’ A&TSIHW capabilities, the journal emphasised listening and learning from A&TSIHWs, recognising their leadership and scholarship (Bond et al ., 2019). The AIHWJ celebrated achievements of A&TSIHWs, shared positive stories and successes, honoured Elders and honoured those who made significant contributions to Indigenous health (Albany, 2010).…”

“…Discourses ‘about’ A&TSIHWs typically focus on the need to upskill, develop, empower and enhance A&TSIHW capabilities and even rendered the A&TSIHW as part of the problem in terms of barriers to improving the health of Indigenous peoples through high smoking rates, high job turnover, lacking awareness of specialists roles and having low literacy and numeracy (Bond et al ., 2019). The question has been raised as to why the validation of this ethnic-based health workforce continues to feature so predominantly in the workforce literature when the same is not required for other health professions within Australia such as doctors and nurses (Bond et al ., 2019), and why the A&TSIHW is problematised as a barrier to better health. Here, we are constantly reminded about the lack of education of A&TSIHWs, not recognising that the skills and capabilities required are not necessarily taught in western academic institutions.…”

“…The Aboriginal and Islander Health Worker Journal (AIHWJ) published 177 issues from 1977 to 2016 and represented the voices of A&TSIHWs across Australia giving a very different perspective of the work of the A&TSIHW and matters of concern to A&TSIHWs. The AIHWJ was designed ‘to strengthen the hand, and the professional role, of those responsible for health in Aboriginal communities’ and its articles exist as an invaluable archive for Indigenous health discourse today (Cawte, 1977; Bond et al ., 2019). A number of A&TSIHWs who made intellectual contributions to the AIHWJ were not only A&TSIHWs, they were also advocates for their people and in some cases leading Aboriginal and Torres Strait Islander civil rights activists who are today honoured as trailblazers, and are acknowledged and thanked for paving the way for subsequent generations of Aboriginal and Torres Strait Islander people.…”

Looking forward looking black: making the case for a radical rethink of strategies for success in Indigenous higher education

“…We observed elsewhere the emergence of an Indigenous health workforce literature and the role of higher education in the early 2000s (Bond et al ., 2019 a ). This literature has been less concerned with Indigenous cohorts and enclaves, and more focused on keeping count of Indigenous participation in health professions with population parity typically set as the marker of success.…”

“…Funded by a call for research into Indigenous health workforce by The Lowitja Institute in 2017, we sought to understand how the IHP had contributed to the successes of the IHP cohort. Some of the research team members were former staff and students from the IHP who over the years had often ruminated over the success of IHP (Bond et al ., 2019 a ). This study enabled us to retrospectively look at and map the careers of Indigenous health professionals who graduated from the IHP between 1994 and 2005, focussing on the background of each prior to enrolment in the IHP; professional milestones and significant professional relationships over a 20 year period across various facets of the health system.…”