This dissertation presents an historical socio-political analysis of the introduction, development and demise of the Queensland Aboriginal Health Program (AHP). It traces over two decades the reality and rhetoric of a Commonwealth/State government initiative to improve the health status of indigenous Queenslanders. Historical and socio-political trends are analysed in terms of underlying themes such as scientific racism, institutional racism, systemic bias and structural violence. Structural violence (Galtung 1970) proves a particularly important concept as it correlates with the levels of physical and psychological violence which have characterised indigenous health since colonisation. Further, structural violence encompasses systemic frustration (Khan, 1978) which typifies many indigenous peoples' place in Australian society today.
The research uses Constructivist Fourth Generation Evaluation Methodology (Guba and Lincoln 1989) which Patton (1986) suggests, is a responsive process designed to develop understanding of a program's strengths and limitations as delineated by the whole nexus of groups and individuals affected by it. Within this framework an extensive review of over 1500 archival documents, 400 interviews with stakeholders inside and outside of AHP, a critique of relevant literature and participant observations and reflection on field notes were completed. In this thesis these data are related to AHP's mandate, structure and operations, to indigenous health statistics and government policies. Internal and external factors impacting on innovations, diffusion of information and change processes within the program are explored. AHP's philosophy, structure and achievements are then examined in relation to innovation theory and in terms of first, second and third order change. AHP's assets and achievements as well as the obstacles and limitations identified by stakeholders are highlighted.
The Constructivist Fourth Generation methodology adopted to evaluate AHP, is complex and the academic, pragmatic, political and ethical issues associated with the method are critiqued. It is concluded that no other methodology would have captured the range of perceptions and insights that stakeholders, especially staff and consumers, can bring to an evaluation process.
The data indicate that health teams within AHP achieved significant first order changes. Utilising a medical campaign approach they provided essential health crisis intervention in the program's early years. They also developed and implemented innovative health education strategies to increase consumer awareness and understanding of health and health services. However, evidence of second and third order change was rare. The Commonwealth/State political context in which AHP was funded, and the centralised bureaucracy through which it was administered, prohibited the likelihood of second and third order change which may have effected improvement in adult health. Indeed, health statistics over the program's 20 year operations indicate that although there has been dramatic improvement in infant mortality rates, general child health has not improved and adult health status has deteriorated. Thus, it is argued that AHP contributed unintentionally to structural violence in Aboriginal and Torres Strait Islander Health.
Technical expertise, objectivity, professionalism and paternalism dominated State and bureaucratic decision making about indigenous health. In the process, indigenous Health Workers, who were integral to AHP achieving its mandate, were, in terms of career path, remuneration, promotion and decision making, the least valued in the system.
At times AHP itself, was hamstrung by political pressures not to move ahead of what was happening in the general health system. It persistently alerted the bureaucracy over twenty years, for example, to the urgent need to implement a multi-sectoral approach to Aboriginal health, yet was unable to implement such an approach in its own operations. The dissertation argues that this pattern persists in general health care systems today.
In depth analysis of incongruencies between the philosophies and practices underlying Selective Primary Health Care and Comprehensive Primary Health Care, as well as related structural implications are explored in the dissertation. These provide opportunities for all health care systems, and especially those affecting indigenous communities, to confront the ramifications of mismatches between primary health care principles and practices on client well being. The incongruence between the rhetoric of consumer participation in health care and the reality of inflexible, bureaucratic, professional and funding structures blocking such an outcome has for too long been ignored by government. If culturally safe, accessible, affordable and appropriate services advocated by the Australian health system's commitment to primary health care, especially in relation to indigenous health, are to ever be realised, government structures, political and economic priorities and strategies must be seriously questioned and urgently changed.