Table 2 Articulation of principles by governments across National, State and Territory health policy planning documents

Shared responsibility

The concept of shared responsibility featured in National, VIC and WA health planning documents. In WA it was articulated that health is ‘everybody’s business’ and in VIC the ‘responsibility for all’ in the health sector. Nationally, the concept of shared responsibility was extended to include Aboriginal and Torres Strait Islander people as well as governments and health services, through the concept of having a ‘shared ownership’ of health initiatives. Overall, the principle of shared responsibility emphasises that governments and health organisations need to be accountable, responsive and inclusive to Aboriginal and Torres Strait Islander needs.

Cultural competence

This principle featured in all State and Territory health plans. Cultural competence, first defined by Cross et al. (1989) and adopted by the NHMRC is defined as “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals that enable them to work effectively in cross-cultural situations” [24]. In the years since, there has been a focus on related concepts such as cultural awareness, cultural security and cultural safety, with critique by Aboriginal scholars highlighting a preference cultural safety with its requirements for broader systemic change [25, 26].

Health planning emphasised that factors desirable to the health systems included constructs such as ‘culturally secure’ (WA, NT), ‘cultural respect’ (SA, VIC, NSW, QLD), ‘culturally safe’ (NT), ‘culturally sensitive’ (QLD), ‘cultural recognition’ (NSW, QLD), ‘culturally responsive’ (QLD, VIC), and ‘culturally accessible’ (WA)

Planning emphasised strengthening the capacity and capabilities of the health system to deliver culturally safe, secure and accessible health services, and of practitioners being respectful, sensitive, reflective and responsive to the views, traditions, values, expectations, worldviews and ways of working of the many diverse Aboriginal and Torres Strait Islander cultures that may be different from their own.

Engagement

Engagement was in six plans but not the QLD health plan. The articulation of engagement varied greatly across documents from ‘consultation’ and ‘input’ (VIC) to ‘participation’ and ‘involvement’ (National, NSW) to ‘participation to take back control’ and ‘responsibility’ (WA), through to full acknowledgement of ‘community control’ (SA). Despite inconsistent articulations of engagement, all six plans highlighted the importance of Aboriginal voices in health planning and delivery as well as the rights of Aboriginal people, communities and organisations to have control over decisions that impact on their health and wellbeing. In National and VIC planning, it was highlighted that it was governments who had a responsibility to expand opportunities for better engagement and collaboration.

Partnerships

The principle of partnership was embedded in all health planning documents, but there was not consistency regarding who needed to be a partner. Health plans referred to the importance of partnerships between Commonwealth and the State and Territory governments (National, WA), as well as between governments and Aboriginal people (National, QLD, NT), governments and communities (QLD, SA, NT, NSW) governments and Aboriginal organisations (National, VIC, NSW, WA) as well as with governments and other service providers and organisations (QLD, WA, SA, NT). Health planning detailed that partnerships involved governments and other stakeholders (Aboriginal and dominant organisations) actively establishing relationships and building effective long-term partnerships where there is collaborative ‘knowledge exchange’, ‘priority setting’, ‘information sharing’, ‘pooling of resources’ and ‘two-way skill transfer’. Partnerships were framed as important to ensuring Aboriginal voices, priorities and perspectives are reflected in policy and program design, planning, development, implementation and evaluation.

Capacity building

VIC, SA, QLD and NT health planning all had a capacity building principle, but there were not consistent articulations regarding whose or what capacity needed building. In VIC, the NT and SA capacity building operated from a deficit standpoint where emphasis was on building Aboriginal and Torres Strait Islander capacity, rather than recognising the existing community strengths and expertise. Here, capacity building entailed provision of skills, information or knowledge so that Aboriginal individual, families, communities, or organisations could be more responsive, manage change and/or maintain resilience. In QLD and the NT, the limitations of the health system were acknowledged, where capacity building drew upon strengthening the workforce and health system to provide more culturally responsive services.

Equity

Equity was a recognised human rights imperative and was understood as the offering of equal opportunities for health through the provision of available, accessible (physically and culturally), acceptable, quality, responsive and inclusive programs and services. The principle of equity was embedded within National, WA and NT documents and largely pertained to the reorientation of services so they were inclusive to the needs of Aboriginal and Torres Strait Islander people.

Accountability

Accountability was embedded in half of the health plans. However, there were not consistent articulations about who needed to be accountable and what for. Those required to be accountable to Aboriginal and Torres Strait Islander people included government (National, SA), the health sectors (VIC, WA), community organisations (SA) and mainstream health services (SA). Health plans stated that governments are accountable for monitoring and evaluating health activities, establishing measures of success, developing genuine and meaningful planning and service development partnerships, transparency in the allocation and use of public funds, and being responsive to performance. The health sector as a whole had accountability to lead and deliver health outcomes.

Evidence-based

Evidence-based was a guiding principle within the VIC and NT health plans. Evidence-based approaches were articulated as those that use evidence to inform health decision-making, policy and program design. Evidence-based approaches were presented as a way of ensuring that policy and programs are appropriate and effective, so they are positioned to deliver desired outcomes.

Holistic concept of health

Health plans for WA, SA, NSW, and VIC all had holistic concept of health as a stated principle. A holistic approach incorporates an understanding of the NACCHO definition of health as ‘not just the physical well-being of an individual but… the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community. It is a whole of life view and includes the cyclical concept of life-death-life’ [27] The SA, NSW and WA articulations of holism also drew on social determinants approaches where there is recognition that health systems, racism, history of dispossession, and loss of land and heritage, food, water, housing, unemployment, contribute to health outcomes and need attention. Articulations of social determinants also drew on strengths of Aboriginal culture, spirituality, family and community and the importance of country and how these impact on health.