The dominance of big powerful NGOs

Despite their rhetoric about the importance of the not-for profit, non-government sector, the reality is that Federal and State Government policy and funding is predominately biased towards large corporate and business oriented NGO's. 

When it comes to shaping public policy, attracting public funding or winning large contracts there is an inherent bias towards larger more influential NGO's and to certain powerful service provider interests.

As Gavin Mooney points out, in the health sector it is always the  interests and the voice of the medical profession and the powerful bodies that represent them, who dominate public policy making and shape funding distribution. Mooney points out that in current debates about the direction of primary health care policy in Australia, smaller community based health NGO's, such as the Aboriginal community controlled health sector, which has strong links into Aboriginal communities and represents and advocates for Aboriginal people, are being marginalized

This piece appeared in Crikey and we acknowledge Crikey as the source.

Are Medicare Locals Entrenching Institutional Racism

by Gavin Mooney*

A few years ago, together with two Aboriginal colleagues, I wrote about institutional racism in the Australian health care system.

In the last few months, reading some of the documentation around on the new Medicare Locals (or Primary Health Care Organisations -- PHCOs) from the Department of Health and Aging, the Minister and the Australian General Practice Network (AGPN), it is evident that today such institutional racism is alive and well.

Indeed it is being built into the future of these PHCOs. In the current discussions on primary health care for the future in this country, the Aboriginal community controlled sector and its voice are being ignored.

The concern of that sector at not being invited to be engaged adequately in deliberations about the PHCOs is reflected in a recent media release here in the west from the Aboriginal Health Council of WA. That states, for example: "We are alarmed that there has been so little effort made by the minister and the Divisions of General Practice to involve our sector."

I do not think this is sour grapes on their part. I share that view. The views of the Aboriginal community controlled sector are not being sought and not being heard by the Minister, by the department or by the AGPN.

The reason? The new PHCOs are being seen as just bigger if fewer GP Divisions, with a few bells and whistles (which have been forced to be?) added on. This is reflected in the fact that all 15 of the new PHCOs are to be GP Divisions-based and according to the recent discussion paper from the department on Medicare Locals the rest will be "largely" Divisions-based.

In her speech to the APGN Forum in Perth 10 days ago this Divisions-focus was confirmed by the Minister.

As one example (but there are many) in that speech, she stated that her department was engaging consultants "to develop a funding formula that will enable funding for Medicare Locals to be fairly distributed, taking into account the needs of different parts of Australia".

According to the Minister the only body that the government will consult "before finalising the funding formula" is … the AGPN! No others seemingly and certainly no mention of consulting the Aboriginal community controlled sector on this funding formula.

But then, as the funding formula, according to the Minister, is to take into account only differences geographically ("the needs of different parts of Australia") and there is no mention of the differing cultural needs of Australians, such as the special cultural needs of Aboriginal Australians, then maybe she feels no need to run the funding formula past the community controlled sector.

The discussion document is similarly neglectful of the community controlled sector.

Yes, it lists that sector as one of several with appropriate "skill-sets" that "complement those offered by the Divisions of General Practice Network". But where is the recognition beyond "skill-sets" of the need to embrace the cultural base of the community controlled sector? Where is the acknowledgment that AMSs already often have the breadth of primary care that Divisions currently lack and which PHCOs are being asked to embrace?

It is noteworthy that the AGPN has set out some good principles, including on equity and on Aboriginal health, in its ‘blueprint document’ on PHCOs.

It is most unfortunate, however, that when AGPN comes to the operational end of things, as in its paper on a framework for PHCOs, both equity and Aboriginal issues are sadly neglected. When push comes to shove, the principles in the AGPN blueprint document thus turn out to be empty rhetoric.

There is still time for Minister Roxon and for AGPN to think again.

There remains a wonderful opportunity to build an exciting, fair and inclusive primary care sector in Australia. This needs to start with the idea of caring for patients and their health, sharing the vision with all relevant parties, including the Aboriginal community controlled sector, and embracing more firmly both equity and the social determinants of health.

Indeed I’d like to switch the letters round and have PHCOs become COPHs -- Caring Organisations for People’s Health, even if not in name at least in principle and practice.

I suspect that is what Australian citizens want. It is just a pity they are not being asked.

*Gavin Mooney is a health economist with an honorary appointment at the University of Sydney

Book Review: Disability and Euthansia in a Market Society

Gavin Mooney has reviewed this book by Western Australian disability advocate and activist Erik Leopldt. Erik's book is based on his PhD thesis.

A Book Review by Gavin Mooney

Book Reviewed:

Erik Leipoldt (2010) Euthanasia and Disability Perspective: An Investigation in The Netherlands and Australia VDM Verlag Dr. Müller Aktiengesellschaft, Saarbrücken

Each of the two central issues in this book - euthanasia and disability - is big in itself. Bringing the two together is a monumental task and especially when this is set in a values framework. The author succeeds in his efforts to do this and in a way which is both accessible and challenging.

The purposes of the study reported in this book were (p39) `to discuss Dutch and Australian disability perspectives towards euthanasia and physician assisted suicide; and to find how the life experiences of the informants [people with quadriplegia] ... may illuminate these perspectives'.

Yet to me the central theme of the book is not euthanasia as such nor indeed disability. What the book questions in debating these themes is what autonomy is and whether it merits being seen as so much of an individualistic phenomenon as it so often is, at least in this neo liberal world in which so many of us live. As Leipoldt argues `individual autonomy is the dominant discourse of our age'.

Without disagreeing I wonder if things are not changing. I have in the past been much struck by the work of the likes of Catriona McKenzie, Diana Meyers and Natale Stoljar [1] on relational autonomy and the idea of `community autonomy'. Despite the efforts of so many economists today (this reviewer is an economist) - particularly market economists - and many liberal philosophers to see us all as free floating atoms, that depiction of human beings just somehow does not ring true. We are social animals, we rely on others to some extent and maybe even take our identities in part from our interactions with others. And the interdependency of peoples across the globe has been heightened yet further by both the Global Financial Crisis and the threat of climate change. OK the impact of these on government policies and in turn on human relationships have not really percolated through yet. But this is one `trickling down' that I am confident will trickle down.

Certainly Rawls' placing of individuals behind his veil of ignorance was simply a philosophical construct to aid understanding. Yet it is so false that one has to question how valuable that device is in reaching any sort of understanding of what it means to be a person. Behind a veil of ignorance or a free floating atom? In an odd sense, much of a muchness and much of an unreality.

So for Leipoldt to look at euthanasia through the eyes of 28 people with quadriplegia in Australia and the Netherlands provides not only a novel view but one that in turn challenges the notion of individual autonomy in a most useful fashion. Whatever else, no one reading this will ever again see autonomy in quite the same way - unless maybe a person with disabilities.

The views of people with quadriplegia on this issue have not been examined before which is a quite startling revelation in itself. Leipoldt suggests (p38): `The perspective of people with disabilities may be able to contribute new ... aspects to the euthanasia debate. Major physical, social and psychological changes and challenges arise for a person who acquires a significant disability like quadriplegia.'

On the question of autonomy and individualism the shift to more of the latter is highlighted by one respondent (p 170): `people are becoming more assertive and demand more. I think that if you look ten years ahead people's autonomy will go further ... I think society will become more and more individualistic.'

The book is insightful on the issue of dependency with one response (p 205) suggesting that `dependency gives a very deep relationship with people and you'. And again (p 209): `How do we look at things like interdependence, that are the bigger issues? Because it doesn't matter how dependent or independent you are if you have people around you and you are part of what's happening and contributing to that then whether you can do it on your own isn't the issue.' Wonderfully for me, issues of reciprocity, mutuality, participation, sharing and caring shriek out from these pages.

There is a sense in which what this book tells us primarily in capturing the views of a group who are in many ways dependent and vulnerable as people with disabilities are two things. First interdependence and dependence are not negative traits; and second in some sense or other to be complete human beings we need to be interdependent and dependent and we need to recognise that need. These are particularly interesting issues in the very specific context of the main thrust for the author of this book i.e. euthanasia and disability. But for me the book shows that worshipping at the altar of individual autonomy or even individualistic autonomy is to bow down before false Gods. Such autonomy is almost certainly not attainable and, even if were, it aint worth attaining.

This is a powerful book at many levels.

Reference
1. C Mackenzie and N Stoljar (eds) 2000. Relational Autonomy. Oxford: OUP.