The role of the Aboriginal Health Worker -
AHWs need community based training and traineeships
Kathy Abbott AHW (President) & Debra Fry AHW(Project
Officer)
The Central Australian and Barkly Aboriginal Health Worker
Association
Paper for the Aboriginal Health Conference 20th - 21st
August 1998 Millennium Hotel Sydney
Our Association has been invited to speak today as we are the first independent,
fully functioning Aboriginal Health Worker association in Australia. We
believe we represent concerns of AHWs across most of remote central and
northern Australia, from areas where communities and health teams have
developed AHW roles in response to isolation and the strength of cultural
traditions. However, some of our issues also relate to workers Australia
wide who identify themselves as Aboriginal Health Workers.
The main issue for all of us here is the holocaust in Aboriginal health.
We have been asked to speak on the role of Aboriginal Health Workers in
the health care delivery team. However, this title itself is a problem.
While the term AHW is often used, there is no functioning national definition
of an Aboriginal Health Worker. In the south-eastern states AHWs are not
allowed to perform clinical tasks and work more as liaison officers, health
promotion officers, or even as simply drivers.
The NT alone has a clinical definition of an AHW, and we have a registration
board for AHWs achieving a set of basic clinical skills. Many of our registered
workers have a high level of cultural skills but extremely low literacy
levels, yet we routinely perform complex health care tasks including suturing,
injections, immunisations diagnosis and the dispensing of medication.
In other remote areas, (like the Kimberlies, Cape York, remote South Australia),
AHWs often perform similar tasks, but are unprotected by the law. NT AHWs
say learning about health through providing clinical care gives us a strong
starting place in our community. Some of us may not remain in the clinic
forever, but we believe it is the right place to start our learning, to
gain respect to use our voice for health as we mature. Many AHWs in other
states wish to widen their clinical role, but are blocked by legal issues
and demarcation issues with other professionals.
Australia wide, the 1970s and 1980's saw the development of many creative
initiatives in Aboriginal health service delivery, including developing
roles and training for AHWs, especially from the community controlled
sector. However, the weaknesses of purely local responses and the health
crisis in our communities meant both health work-force planners and many
skilled AHWs wanted to develop certificated training, better career options
and better role definition. Some other health professionals were concerned
that some AHWs were too poorly trained to perform complex clinical tasks.
The 1990's therefore saw the development of many national and regional
bureaucratic policies on AHW training and career structures. AHW training
is now on the national training agenda. Many curriculum based AHW courses
have been developed with funding based on "bums on seats". In
1997 came the National AHW Competency Standards and the next few years
will see the national health training package finalised.
These developments may grow into a good training delivery system, but
there are many flys in this ointment. The current national agenda may
undermine the very existence remote AHWs - people with often low literacy,
selected by their community to act as cultural brokers between the mainstream
and the community. The writers of these standards do not often know the
work-force they are describing and almost no-one working in the various
sectors reads the fine print carefully. We are concerned national core
competencies for health, set at the high AQF 3 level, will be drafted
onto remote AHWs and onto our brothers and sisters working in HACC, alcohol,
mental health etc.
We will receive no competency recognition for our cultural skills, and
ability to work in great isolation, yet competencies for urban, literate
workers are well recognised. Who is properly representing the needs of
the quietest and least able to defend themselves group, the very remote
low literacy, ESL health workers working at the coal face? At the other
end of the spectrum, few remote Aboriginal community leaders and managers
have high academic qualifications, yet have been given positions based
on their community political skills. These people are already being excluded
from the high level jobs by absence of diplomas and will fail access appropriate
managerial training and recognition for their skills. If these people
are not encouraged to develop their skills and receive recognition, the
development of any form of community control will remain unrealised.
It is obvious the Australian National Training Authority Board has no
Indigenous community representation. But even placing a single NACCHO
representative on the Board will not address the problem, though it would
help and inviting the occasional black face to a community consultation
is a white-wash. We question whether the indigenous advisory body to ANTA
(ATSIPAC) has the teeth to have its views taken on board by the ITABs,
we are certain that very few indigenous people know about this board and
how to use it and we are uncertain as to how its members are selected.
Our Association has been involved in the competency standards yet we have
neither sent or received communication from this group. Appropriate bodies
must be developed, promoted and empowered to intervene in the development
of indigenous issues. VET training is the preferred training method for
the indigenous community, yet it is poorly represented in VET decision
making.
The history of AHW training in the NT
We illustrate our idea of how to integrate the best of parts AHW training
with the best of the health training package by looking at the history
of Northern Territory AHW training.
In the mid-1970s the NT Department of Health and Community Services developed
an AHW training system also used by the community controlled sector. In
1979 House of Representatives Standing Committee on Aboriginal Affairs
reported:
"The Aboriginal Health Worker training program developed in the
Northern Territory should be a model upon which the state training programs
are based."
We agree with this assessment and believe current AHW training should
be based on the same principles - AHW training was based on the recognition
health education and provision of Primary Health Care services must be
inseparable:
AHWs
- Were selected by their community.
- Learnt on the job, as trainees, in their community.
- Trainees were provided basic health literacy and numeracy training
- Were required to achieve basic clinical competencies
- Employer, trainee, clinical team and community were tightly bound
- Flexible training allowed trainees time for cultural and sorry business
and for people to learn at their own pace.
Despite this assessment, the Secretary to the Northern Territory Department
of Health & Community Services, Keith Fleming, circulated a letter
in July 1987 saying:
We need to make a choice about the future of Health Worker training.
There are two extremes of a training continuum that have vastly different
outcomes:
- Recruitment by the Department of literate Aboriginals who are trained
at, say, Batchelor College, in a formal course and who graduate with
a specific qualification. The product of this training is a non-community,
professional Health Worker.
- The original concept that the department pursued for Health Worker
training ie a community based health worker who is selected from the
community by the community to work for the community. Community selection
is essential and training is "on site". The primary responsibility
of the Health Worker is to be an agent for change within the community.
Literacy and clinical skills are an adjunct and not a primary focus
for Health Workers. The product of this training is a primary health
care worker.
The options for that time are described well - a non-community, professional
Health Worker versus a primary health care worker. In the end, neither
of the outcomes were achieved and the meaning of Primary Health Care has
been completely abused. In 1990 THS separated AHW training from its service
provision and tied its training to a curriculum based course at Batchelor
College. But educational institutions receive money for "bums on
seats", not success in the work-force. Years of neglect in remote
primary and secondary education cannot be made right by off-the-job adult
literacy based training.
At entry level training, remote, low literacy health worker recruits
do not want to leave their community to sit in class rooms separated from
learning skills on the job. Few have had experience of mainstream work
or education and their traditional learning styles are skills based. Most
students in off-the-job training, curriculum based courses drop out -
they are often mature aged people, with family responsibilities, shamed
by literacy problems, troubled by domestic problems when away from home,
unable to live on Abstudy, confused by lecturers talking and poorly supported
in their community clinic.
All on the ground health service providers agree, after 10 years, curriculum
based off-the-job training has completely failed to produce good clinical
and cultural graduates and that the old on the job training method was
better for undergraduate AHW training. Instead, THS is now trying actively
pursue option 1, to provide better quality assurance though enforcing
the external provider qualifications model of training onto their AHW
career structure. We say, there will be a complete failure to recruit
remote AHWs in a few years and the funding for their positions will be
allocated to non-indigenous professionals or urban indigenous middle management.
At the other end of the spectrum, AHWs wanting higher qualifications
are hamstrung by the absence of reputable qualifications arising from
sharing entry level training with low literacy cultural workers. Inappropriate
AHW training at entry level gives AHW training a "mickey mouse"
reputation. Currently skilled AHWs have few training options to specialise
and develop their career path.
However, despite our problems with the THS qualifications based career
structure, we are sympathetic to their refusal to accept all health care
training as their sole responsibility. Where community controlled organisations
have undertaken community based training alone, they have endless worry
for recurrent funding and have to "chisel" inappropriate options
to fund traineeships, like the current trend to use CDEP funding.
Our conclusions - community based trainers is the appropriate training
method.
We believe there is a way out of these worries. If community selection
of trainees or health managers is replaced by self-selecting higher literacy
workers, indigenous health professionals will not be empowered to make
decisions. Remote community decisions must be validated through families
and communities as well as by formal assessment of their competencies.
Training for entry level competencies must be provided on-the-job by
community based trainers, and directed to the people selected by the community,
training to appropriate competencies, not to curriculum. Training on the
commmunity avoids disruption of family life and provides training in real
situations, requiring identification of real problems and real solutions.
Training is not literacy dependant, and health literacy is learnt by doing
the work. This is the right way forward to promote community development.
We would like to recommend to Mr Fleming, some 11 years down the track,
our third option for AHW training.
3. Remote community based trainers must be employed to train and assess
to an appropriate AHW training package, delivered to on-the-job trainees
who are receiving a living trainees wage. Community based trainers are
to be supported and administered by the most appropriate regional structure
representing the interests of the industrial parties, through a memorandum
of understanding with each community. The outcome of this training would
be a professional primary health care worker.
We are confident that the good-will to implement these recommendations
is present in the Commonwealth. We do not believe our proposal require
higher funding levels, but they do require a reorganisation of funds and
considerable inter-departmental collaboration and very high level policy
decisions. Separate interest group considerations must not stop the delivery
of a rational and appropriate delivery of community based remote indigenous
health care training.
Overall we recommend:
- The Commonwealth must accept the intimate relationship between education
and health in remote Aboriginal communities and must take responsibility
for streamlining and funding remote PHC training.
- Training for the remote indigenous health work-force must be community
and work based.
- Each remote region must determine its own mechanism for supporting
community based training - the most obvious network is through Remote
Health Training Units to develop the brief in partnership with communities.
- Funding for indigenous health traineeships must be developed eg through
cashing out CDEP payments for trainees, group training schemes, major
employment stratgies and other intitiatives. DEETYA must develop and
facilitate these avenues. Employers in the health and community services
cannot wear the cost of educational neglect.
- The Australian National Training Board must include representatives
from the indigenous community controlled sector and must promote and
significantly empower the indigenous advisory group, ATSIPAC and ensure
its composition is determined appropriately
- Promote AHW professional development by increased resources for higher
education.
- The Commonwealth must investigate legal impediments affecting AHWs
in each of the 8 Australian legislatures including a review of registration
options for AHWs.
The Department of Health & Family Services must recognise health
service delivery in remote communities is based on multi-disciplinary
remote teams and allocate incentive program funding accordingly.
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