People tend to get very fired up about the issue of mutual
obligation. But is it the right approach to improving conditions in
Indigenous communities? A public health approach to the debate needs
to consider the broader issue of incentives and obligations.

Public health has long advocated using incentives and disincentives to
direct behaviour such as health insurance refunds for healthy
activities and taxes on alcohol and tobacco. In evaluating the merits
of mutual obligation arrangements, there are a few key questions to
consider.

Is the “reward” – the discretionary funding that Shared Responsibility
Agreements (SRAs) provide – a privilege, or a right that government
should provide without strings attached? Most seem comfortable with the
idea that a swimming pool in a small community is a privilege, but
hesitate over petrol bowsers or airconditioners. The next question
concerns the obligated behaviour.

While some instances of community-directed obligations such as alcohol
restrictions are lauded by most, others argue that obligating parents
to send their kids to school or keep them clean is an intrusion into
the family unit reminiscent of assimilation. Still others question
whether communities have the means to fulfil their obligations.
Underlying all of these issues is the question of autonomy: do
communities freely choose to participate? Some consider that an
impoverished remote community has so little bargaining power that they
can never have a real choice, while others think it is paternalistic to
dismiss a community’s choices.

Last is the key issue of effectiveness. Can these arrangements be
implemented, and how will we know if they are? And although face
washing and swimming in chlorinated water are likely have some health
benefits, only a coordinated, evidence-based public health strategy
will maximise this effect. The whole discussion will remain academic if
the government has no intention of negotiating an evaluation strategy
for each SRA. If so, it is difficult to believe that the government is
interested in providing services in a way that most benefits Indigenous
people.

Dr Kowal’s article, “Mutual obligation and Indigenous health:
thinking through incentives and obligations” is published in the most
recent edition of The Medical Journal of Australia.

Peter Fray

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