Development of a Decolonising Framework for Aboriginal and Torres Strait Islander Health Policy Analysis in Australia The International Indigenous Policy Journal Volume 13 | Issue 3 December 2022 Development of a Decolonising Framework for Aboriginal and Torres Strait Islander Health Policy Analysis in Australia Helen Kehoe The Australian National University, Australia, helen.kehoe@anu.edu.au Heike Schütze UNSW Sydney, Australia, h.schutze@unsw.edu.au Geoffrey Spurling The University of Queensland, Australia, g.spurling@uq.edu.au Raymond Lovett The Australian National University, Australia, raymond.lovett@anu.edu.au Recommended Citation Kehoe et al., (2022). Development of a decolonising framework for Aboriginal and Torres Straight Islander health policy analysis in Australia. The International Indigenous Policy Journal, 13(3). https://10.18584/iipj.2022.13.3.11269 Development of a Decolonising Framework for Aboriginal and Torres Strait Islander Health Policy Analysis in Australia Abstract Analysis of policies relevant to Aboriginal and Torres Strait Islander Peoples could help improve health outcomes—a critical challenge in Australia. While there are many health policy analysis frameworks, we did not find one which supported decolonising approaches across stages of the policy cycle. Generic frameworks were not based on decolonising approaches, and so risk perpetuating structural inequalities underpinning health disparities. Aboriginal and Torres Strait Islander specific frameworks articulated ways of working rather than addressing policy stages. We devised a new policy analysis framework by drawing upon Aboriginal and Torres Strait Islander specific and other policy analysis frameworks. The new framework can help critically analyse existing Aboriginal and Torres Strait Islander health policy and guide future policy making. Acknowledgments HK is in receipt of Australian Government Research Training Program Fee-Offset Scholarship and Australian Government Research Training Program Domestic Scholarship Keywords Decolonising health policy, healthy policy frameworks, approaches to health policy analysis Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ 1 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Development of a Decolonising Framework for Aboriginal and Torres Strait Islander Health Policy Analysis Policies operationalise government agendas (Coveney, 2010), direct efforts, and allocate resources and therefore have far-reaching impacts in the health system (Lattimore et al., 2008). At a whole of population level, analysis of health policies can help build effectiveness, promote continuous improvement, ensure government accountability, and, ultimately, improve health outcomes (Cheung et al., 2010; Gilson et al., 2018; Phulkerd et al., 2016). There is limited guidance about conducting health policy analysis, and resources and theoretical foundations are scarce (Browne et al., 2018; Casey et al., 2019; Cheung et al., 2010; Walt et al., 2008). The range of analytical approaches reflects different theories about the nature of policy making itself (Browne et al., 2018; Gilson & Raphaely, 2008; Walt et al., 2008). As explained by Enserink et al., (2013) one theory suggests that policy arises from logical, rational, and “objective” processes undertaken by a single source of authority; another, the “garbage can” approach, sees policy developing through more chaotic processes which coincide through the input of multiple organisations and actors; while a third conceptualises policy as being generated through political and strategic gaming processes characterised by bargaining and power plays between networked stakeholders (Enserink et al., 2013). While no single theory is fully explanatory, different theories help understand different aspects of policy making. Similarly, different policy analysis approaches support different types of research questions (Browne et al., 2018), and no single approach is appropriate in all settings (Gilson et al., 2018). Analysing health policy in an Aboriginal and Torres Strait Islander setting is both situated within this complex policy analysis environment and uniquely informed by the context of settler colonialism. Applying Aboriginal and Torres Strait Islander Peoples’ world views and values to health policy analysis is needed to critique and reform the colonialism underpinning the majority of Australia’s policies affecting Aboriginal and Torres Strait Islander Peoples’ health. Examples of these policies include the forced removal of Aboriginal and Torres Strait Islander children from their families (Human Rights and Equal Opportunity Commission, 1997); compulsory income management and other interventions specific to Aboriginal and Torres Strait Islander Peoples’ introduced through the Northern Territory Emergency Response (Australian Indigenous Doctors’ Association and Centre for Health Equity Training Research and Evaluation UNSW, 2010); and Australia’s minimum age of criminal responsibility of 10 years (compared to the worldwide median age of 14) which leads to 70% of children aged 10-13 years in custody being Aboriginal and Torres Strait Islander (Aboriginal Legal Service (NSW/ACT) Limited, 2020). Such policies, and the colonialism on which they are based, underlie intersecting political, economic, and social inequalities faced by First Nations Peoples (Czyzewski, 2011; Mackean et al., 2020; Sherwood, 2013). These inequalities are demonstrated, for example, in the present-day disproportionate burden of disease among Aboriginal and Torres Strait Islander Peoples (estimated at 2.3 times greater than non-Indigenous Australians) (Australian Institute of Health and Welfare, 2020), and the persistent gap in life expectancies between Aboriginal and Torres Strait Islander Peoples’ and non-Indigenous Australians (8.6 years for males and 7.8 years for females) (Australian Institute of Health and Welfare, 2020). Ongoing colonisation is operationalised partly through “epistemological racism” (Larkin, 2006, p. 22), defined as the uncritical application of non-Indigenous world views (Rigney, 2001). Such factors underly the establishment and maintenance of the Australian state. They are epitomised by the lack of a treaty between Aboriginal and Torres Strait Islander Peoples and non-Indigenous settler 2 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 colonial society (Couzos & Murray, 2008), and expressed through the Constitution, under which “Indigenous Peoples in Australia are…largely at the mercy of Parliament and government in decisions made about their rights” (Morris, 2018 p. 2). This power imbalance is reflected in policy processes affecting Aboriginal and Torres Strait Islander Peoples. Aboriginal and Torres Strait Islander Peoples and organisations, as well as some non- Indigenous voices, have consistently called for Aboriginal and Torres Strait Islander Peoples to have control of the development of policies that affect them (Altman, 2009; Calma, 2007; Couzos & Murray, 2008; National Congress of Australia's First Peoples, 2016; Yunupiŋu, 1988). Despite this, the involvement of Aboriginal and Torres Strait Islander Peoples is typically sought at implementation—rather than design and development—phases of policy making, if at all (Couzos and Murray, 2008). Decolonisation approaches, or the “privileging of Indigenous voices and epistemologies” (Bainbridge et al., 2015, p. 4) have provided approaches to critique colonial hegemony in areas including research (Prior, 2007), journalism (Sweet et al., 2014), and education (Shahjahan, 2011); however decolonisation approaches to policy analysis are not well described in the literature. We aimed to develop a decolonising policy analysis framework informed by existing frameworks and associated literature, that could be used to both retrospectively assess existing policies and prospectively guide the development of new policies. Bridgman and Davis described the policy cycle model, and delineated policy stages as: consultation, coordination, decision, implementation, evaluation, identification of issues, policy analysis and policy instruments (Bridgman & Davis, 2004). Although the model has limitations, we drew upon this concept because it supports comprehensive analysis of all key features of public policy processes (Coveney, 2010). Our study focusses on analysis of the validity, alignment and quality of policies, as opposed, for example, to their effectiveness or impact (Cheung et al., 2010; Ellahi & Zaka, 2015). Materials and Method We conducted two separate literature searches to identify 1. generic policy analysis frameworks and, 2. decolonising policy analysis frameworks. We drew upon the frameworks identified through these searches, as well as other relevant literature that adds to or critiques them, to form a decolonised and comprehensive policy analysis framework and indicators for assessment. Search method, Inclusion Criteria and Screening Generic Policy Analysis Frameworks: Authors HK and HS searched five electronic databases (Informit Health, Informit Humanities, Medline, Scopus, and SOCIndex) for generic policy analysis frameworks. The search terms, developed using a modified version of the PICO framework (Population, Interest, Comparison and Outcome) (Schardt et al., 2007), were: policy analysis AND (tool OR framework OR guideline) AND health. The following limits were applied: subject - policy, policy making, policy analysis and health policy; published in English between 2000 and 2020; peer- reviewed; and available in full text online. First the titles and abstracts of papers were screened against the inclusion criteria and papers that did not meet the criteria were excluded. The remaining papers were retrieved in full and further screened against the inclusion criteria. The search was supplemented using Google Scholar, by scanning the reference lists of included articles, and through expert input. Articles were included if they used or proposed a health policy analysis framework which: incorporated a set of validated assessment 3 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 criteria; supported identification of optimal policy solutions; was designed for application by examining content through policy document analysis; supported the consideration of policy stages from problem identification to evaluation; articulated a theoretical basis and, as we saw these as more likely to be directly applicable, had been used in practice. There were no additional exclusion criteria. Australian decolonising policy analysis material: Authors HS and HK searched seven electronic databases (Humanities International Complete, Informit Health, Informit Humanities and Social Sciences Collection, Informit Indigenous Collection, Medline, Scopus, and SocIndex). A wide search for policy analysis in any context was undertaken and included grey literature. The PICO search terms were: (policy OR framework OR evaluation framework OR guideline OR reform) AND (self-determination OR human rights OR cultural safety OR decolonising) AND Australia AND (Aboriginal OR Torres Strait Islander OR Indigenous). Limits applied were: published in English between 2010 and 2020 and available in full text online. First the titles and abstracts of papers were screened against the inclusion criteria and papers that did not meet the criteria were excluded. The remaining papers were retrieved in full and further screened against the inclusion criteria. The search was supplemented by using the Lowitja Literature Search Engine and Google Scholar, by hand searching, and through expert input. Papers were included if they addressed culturally safe, decolonising approaches to health policy analysis in an Aboriginal and Torres Strait Islander context. There were no additional exclusion criteria. Analysis The frameworks identified in both searches, which became the “parent” frameworks for the development of a new framework, were studied to identify their analytical criteria and assessment indicators, if any. To reduce duplication, we developed a new framework by combining elements from existing frameworks (Bowen et al., 2010; Tuah et al., 2011) rather than either applying them in series as separate processes (Cairney, 2007) or by doing part of the analysis with one framework and a second part with another framework (Hodge & Davies, 2006). We systematically analysed each parent framework’s criteria to identify similarities and differences, then grouped criteria thematically into areas of commonality to develop principles for the new framework. We then developed corresponding indicators and ratings, drawing upon both the parent frameworks and the articles dealing with culturally safe, decolonising approaches to health policy analysis identified in the second literature search. The new framework was then piloted on a sub-set of existing policies specific to Aboriginal and Torres Strait Islander Peoples health, and further refined. Results Literature Search Results Generic policy analysis frameworks: The search yielded 668 results after duplicates were removed and limits were applied. The titles and abstracts of these papers were screened and resulted in 588 papers being removed leaving 80 papers. A further 78 papers were excluded after screening the full text against the inclusion criteria. The remaining two papers described or used a framework proposed by Cheung et al. (Cheung et al., 2010; Jackson et al., 2016) which met the inclusion criteria. No additional papers were identified through supplementary searching or expert input. 4 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 Australian decolonising policy analysis material: The search yielded 424 results after duplicates were removed. The titles and abstracts were screened and resulted in 368 being removed. The remaining 56 items were retrieved in full. Consistent with our broad search terms, we identified considerable literature which addressed decolonising approaches among these items (Anderson, 2008; Arnstein, 2019; Bruhn, 2014; Cairney and Oliver, 2017; Calma, 2007; Couzos and Murray, 2008; Czyzewski, 2011; Dudgeon et al., 2014; Gilroy et al., 2013; Hunt, 2013; Larkin, 2006; Lovett et al., 2019; Mitchell et al., 2019; National Constitutional Convention, 2017; Pahlman, 2014; Productivity Commission, 2013; Productivity Commission, 2019; Sherwood, 2013; Swan and Raphael, 1995; Thorpe et al., 2016; Vujcich et al., 2016; Yu, 2012). We also identified two explicit analytical frameworks: the Framework to assess cultural safety in Australian public policy authored by Mackean et al. (2020), and the Evaluation framework to improve Aboriginal and Torres Strait Islander Health authored by Kelaher et al. (2018). Subsequent hand searching did not find examples of where either had been applied in practice. Description and Analysis of Parent Frameworks Generic policy analysis framework: The Cheung et al. (2010) framework, which was designed to support the analysis of policy content through assessment of policy documentation, used a three-tier rating structure to grade policies against each criterion, and used and recommended a process of document mapping to identify linkages across policies. The framework was developed by adapting previously validated criteria based on von Wright’s “logic of events” theory (Rutten et al., 2003, p. 295). It suggests the analysis of seven criteria: accessibility of policy documentation; policy background or source; goals; resources; monitoring and evaluation; stakeholder involvement; and obligations of various implementers; and proposes indicators for each criterion, as well as a rating structure (Cheung et al., 2010). Australian decolonising policy analysis frameworks: The frameworks by Mackean et al. (2020) and Kelaher et al. (2018) critiqued and sought to improve policy processes affecting Aboriginal and Torres Strait Islander Peoples. The Mackean et al. framework is applicable to all policies (not just health policies) and comprises five main criteria: reflexivity, dialogue, power differences, decolonisation and regardful care. Each criterion is supported by three to five sub-criteria. The framework does not describe indicators for assessment (Mackean et al., 2020). While focussed on health policy evaluation, the Kelaher et al. framework is applicable to all stages of policy processes. It proposes 11 main criteria comprising: partnerships with Aboriginal and Torres Strait Islander organisations and communities; shared responsibility; engagement with Aboriginal and Torres Strait Islander people and communities; capacity building; equity; accountability; evidence based; holistic concept of health; cultural competence; data governance and intellectual property; and capitalising on Indigenous strengths. Each criterion has a description, outcomes, and indicators. The Kelaher et al. framework does not include a rating structure to grade policies (Kelaher et al., 2018). Results Overview and New Framework No single framework we identified was sufficient on its own to undertake comprehensive decolonising analysis of all policy stages described by Bridgeman & Davis, that is: consultation, coordination, decision, implementation, evaluation, identification of issues, policy analysis and policy instruments (2004). The generic framework was not based on decolonising approaches, and so risked perpetuating structural inequalities underpinning health disparities. Aboriginal and Torres 5 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Strait Islander specific frameworks articulated ways of working rather than addressing policy stages. Therefore, we drew upon all three parent frameworks, as well as other literature addressing policy analysis in a decolonising context, to develop the principles and indicators for our new analytical framework (Table 1). This process is detailed separately for each principle in the following section. While only two of the parent frameworks (Cheung et al., 2010; Kelaher et al., 2018) included indicators, we found that a clear articulation of the principle in practice made indicators obvious. For example, when we determined that accessibility of policy documentation was a necessary element of accountability, it was clear that the extent to which policy documentation was accessible was a correspondingly necessary indicator. Once the new framework was drafted, we piloted it by applying it to five health policies regarding Aboriginal and Torres Strait Islander Peoples access to the Australian Pharmaceutical Benefits Scheme. The testing consisted of assessing policy documentation on each of the five policies against the seven principles described in the draft framework. This process showed that the 29 indicators initially considered could be reduced to a final set of 21, as in practice we found that very similar indicators had been included under more than one principle. For example, the initial indicator set included an indicator regarding responses to emerging monitoring and evaluation findings under three principles, and this was streamlined to appear under just one principle. New Decolonising Framework Our decolonising analytical framework comprises seven inter-related principles. Two key principles (power sharing; and transparency and accountability) inform all phases of policy making and five additional principles relate to specific policy stages and processes: defensible policy basis; legitimate policy content and logic; ways of working that advance decolonisation; responsible policy implementation; and monitoring and evaluation. A model of our framework (see Figure 1) shows power sharing at the centre, as all other principles depend upon this. The principle of transparency and accountability encircles other principles as it detects and addresses any deficits in the policy process. The principles and their relationship to the three existing parent frameworks are described in Table 1. 6 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 Figure 1. Decolonising policy analysis framework model 7 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Table 1. Relationship between Proposed Principles and Existing Frameworks Principle Cheung et al. (Cheung et al., 2010) Mackean et al. framework (Mackean et al., 2020) Kelaher et al. framework (Kelaher et al., 2018) Power sharing Stakeholder involvement Dialogue Power differences Partnerships with Aboriginal and Torres Strait Islander organisations and communities Shared responsibility Engagement with Aboriginal and Torres Strait Islander people and communities Transparency and accountability Accessibility of policy documentation Accountability: (for) e.g., effects of policy inconsistency Accountability Ensure program documentation, evaluation briefs, request for tender documentation and evaluation reports are publicly available in perpetuity Defensible policy basis Policy background or source Recognition: (of) e.g., impacts of colonisation; respect for cultures Equity Evidence based Legitimate policy content and logic Goals Regardful care Holistic concept of health Ways of working that advance decolonisation Reflexivity Decolonisation Capacity building of Aboriginal and Torres Strait Islander communities Cultural competence Data governance and intellectual property Capitalising on Indigenous strengths Responsible policy implementation Resources Obligations of various implementers Implementation should be reviewed regularly against indicators and be revised in response to findings Monitoring and evaluation Monitoring and evaluation Monitoring and evaluation are the focus of the whole framework 8 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 Power Sharing While not using this terminology, all three existing frameworks included concepts relevant to power sharing in their main criteria. These comprised: stakeholder involvement (Cheung et al., 2010); dialogue and power differences (Mackean et al., 2020); and partnerships, shared responsibility, and engagement (Kelaher et al., 2018). The Mackean et al. (2020) and Kelaher et al. (2018) frameworks describe the role of Aboriginal and Torres Strait Islander Peoples affected by policies using nouns such as involvement, recognition, partnership, acknowledgement, engagement, and participation; and verbs such as understood, consulted, listened to, and have input to. Other key decolonising sources place greater emphasis on the impact of the underlying power imbalance between non-Indigenous Australians and institutions on the one hand, and Aboriginal and Torres Strait Islander Peoples on the other, and seek to address this through more formalised processes. This imbalance, characterised by Noel Pearson as the “elephant and the mouse problem” (Pearson, 2014, p. 8), has been described by Aboriginal and Torres Strait Islander Peoples as the “torment of powerlessness” (National Constitutional Convention, 2017, para. 7). Literature focussed on relations between government and Aboriginal and Torres Strait Islander Peoples underpinning policy processes (Calma, 2007; Hunt, 2013; Thorpe et al., 2016) is grounded on principles enshrined in the United Nations Declaration on the Rights of Indigenous People (United Nations General Assembly, 2007) and focussed on the Declaration’s requirement to obtain Aboriginal and Torres Strait Islander Peoples free, prior and informed consent about matters affecting them. In this literature, power sharing is described in terms of sovereignty, treaty, citizen control, delegated power and partnership; and is enacted through legal or contractual mechanisms which incorporate independent monitoring and reporting processes (Calma, 2007; Hunt, 2013; Thorpe et al., 2016). Our principle of power sharing is defined as policy environments where Aboriginal and Torres Strait Islander control and partnership is supported by legal or contractual requirements; Aboriginal and Torres Strait Islander Peoples and organisations are sufficiently resourced to participate in policy processes on an equal footing with government; and where their rights to free prior and informed consent are upheld. Transparency and Accountability The Kelaher et al. framework includes accountability as a main criterion, and the Mackean et al. framework includes this as a sub-criterion. Both highlight the need for processes to support continuous improvement: for example, the need to address policy failures (Mackean et al., 2020); and the importance of responding to evaluation findings (Kelaher et al., 2018). In addition, the Cheung et al. framework includes continued access to policy documents over time as a main criterion, and this is also articulated in the Kelaher et al. framework as a sub-criteria, as barriers to accessing materials and in mapping relationships between multiple components compromise analysis and accountability (Cheung et al., 2010; Kelaher et al., 2018). Other decolonising sources echo the need for greater transparency and accountability, and place this within the context of historic and ongoing policy failure. Failures include elements of incrementalism, failure to learn from previous experience resulting in cyclical processes and policy churn, and policy development processes which exclude Aboriginal and Torres Strait Islander 9 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Peoples (Calma, 2007; Couzos & Murray, 2008). Policy churn, where change is made without identifying problems with existing policy and how the changes address them, allows governments to avoid public scrutiny for policy failures (Monios, 2017). Our principle of transparency and accountability is defined as policy processes: where complete documentation detailing all policy stages is publicly available; and which incorporate strong accountability structures and processes embedded within all policy stages. Defensible Policy Basis The Cheung et al. and Kelaher et al. frameworks identify the basis on which policies are founded as a key criterion, while the Mackean et al. framework notes the importance of recognising the impacts of colonisation in policy bases as a sub-criterion. The Cheung et al. framework notes various sources of health policy (Cheung et al., 2010); while the Kelaher et al. framework describes the need to advance equity and make use of both established evidence and emerging evaluation outcomes in policy design (Kelaher et al., 2018). Both general policy and decolonising literature address the basis of policies. While evidence-based policy making is sometimes seen as best practice (Bowman et al., 2012; Productivity Commission, 2013), uncritical adoption of evidence-based medicine principles in the policy sphere is problematic. This is due to three main factors: policymaking is a judgement-based political process; the production of “evidence” itself is subjective (Cairney & Oliver, 2017; Pahlman, 2014; Vujcich et al., 2016); and policy making of substance may involve novel approaches where impacts are not fully predictable (Banks, 2009). These limitations have particular application in population health policy (Kemm, 2006). An over- reliance on evidence of effectiveness risks skewing the development of public health policy away from a social determinants focus and towards medical, individual-based solutions (Banta, 2003). In addition, evidence may be least available in relation to population sub-groups who are most in need of health interventions (Vujcich et al., 2016). An absolute requirement for evidence before action risks widening the gaps between advantaged and disadvantaged groups. From a decolonising perspective, these challenges have additional dimensions for health policy addressing the needs of Aboriginal and Torres Strait Islander Peoples. While Aboriginal and Torres Strait Islander representative bodies support evidence-based action (National Aboriginal Community Controlled Health Organisation, 2013), they do not do so uncritically (Couzos, 2008). For example, decolonising approaches highlight that understandings of what constitutes evidence are embedded in unequal power structures between non-Indigenous and Aboriginal and Torres Strait Islander Peoples (Larkin, 2006; Pahlman, 2014). Aboriginal health advocates have also underscored the risks of policy makers requiring “proof” that treatments shown to work elsewhere will be effective before extending them to Aboriginal and Torres Strait Islander Peoples (Couzos, 2008; Kelaher et al., 2018). In Aboriginal and Torres Strait Islander health, it may be “both necessary and justifiable” to develop policies despite a lack of strong evidence (Vujcich et al., 2016, p. 10), with the proviso that standard requirements for monitoring and review become of even greater importance (Banks, 2009). 10 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 Our principle of defensible policy basis is defined as policy processes where: the basis of the policy is clear, explicit and consistent; and the policy recognises knowledge gaps and establishes processes to address them. Legitimate Policy Content and Logic While the Cheung et al. framework does not address policy content, both the Mackean et al. and Kelaher et al. frameworks address the requirements of legitimate policy content in their main criteria and highlight the importance of the adoption of Indigenous knowledges. The only framework to address policy logic, the Cheung et al. framework, notes that policies should include clear goals, and be based on external consistency (the policy logic is supported by experience in other settings) and internal validity (the extent of alignment between policy logic and intended outcomes) (Cheung et al., 2010). From a decolonising perspective, legitimate policy content begins with recognising and responding to structural exclusion, access and racism; prioritising community-identified health priorities; and acknowledging the continuing impact of colonisation on Aboriginal and Torres Strait Islander health (Dudgeon et al., 2014; Gilroy et al., 2013; Swan & Raphael, 1995). Aboriginal and Torres Strait Islander knowledge, culture and history should be recognised and incorporated in policy content (Black & McBean, 2016). Policy content issues also include flexibility and eligibility criteria. Policies should be sufficiently flexible to meet local priorities (Gilroy et al., 2013; Hunt, 2013; Jackson et al., 2012), and eligibility criteria, whether for providers or recipients, should be carefully considered as these can limit coverage of the population intended to benefit (Lattimore et al., 2008). General policy analysis literature supports the concept of policy logic advanced in the Cheung et al. framework. Policies are intended to effect change through mechanisms based on inferences about causation, described as “if-then” links between each policy component (Langer et al., 2011, p. 1632). However, policies rarely make explicit their underlying theory of change, chains of policy logic or the assumptions which underpin them. The logical construction of these elements is of greatest importance when evidence is weak (Haby & Bowen, 2010). Examining the coherence, consistency and logic of policies is an important aspect of overall policy analysis (Howlett, 2017; Palmer & Short, 2000). Policy logic also involves locating new or revised policies within the existing policy landscape. Where policies are related, mapping connections between them is needed (Cheung et al., 2010) to ensure that policy “layering” (where new policies are added on top of existing similar policies) avoids creating conflict (Rudoler et al., 2019). From a decolonising perspective, Aboriginal and Torres Strait Islander policies have been weakened by policy fragmentation (Anderson, 2008; Browne et al., 2014), and by a failure to learn from existing evaluations (Bailie et al., 2019). Our principle of legitimate policy content and logic is defined as policy processes which: recognise and respond to the Indigenous social determinants of health and Aboriginal and Torres Strait Islander knowledge, culture and history; respond to Aboriginal and Torres Strait Islander-identified health priorities; allow for flexible adoption at local levels; are logically coherent; identify existing related policies and demonstrate integration with these; and maximise coverage of Aboriginal and Torres Strait Islander Peoples by minimising eligibility criteria for participants and health providers. 11 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Ways of Working to Advance Decolonisation Ways of working to advance decolonisation are not addressed in the Cheung et al. framework, but are included as main criteria in both the Mackean et al. and Kelaher et al. frameworks. Relevant criteria are reflexivity, power differences and decolonisation in the Mackean et al. framework and cultural competence, data governance and intellectual property in the Kelaher et al. framework. Themes identified in key decolonising literature relate to governance processes, data, and the realisation of capability. The importance of effective governance has been recognised for both government and Aboriginal and Torres Strait Islander organisations (Hunt, 2013). Government has responsibilities to provide sufficiently senior and culturally competent staff, to be transparent about limitations, and to improve coordination between different government agencies before seeking engagement with Aboriginal and Torres Strait Islander Peoples (Thorpe et al., 2016). Effective governance processes help support knowledge translation, and capture benefits for Aboriginal and Torres Strait Islander people (Mackean et al., 2020). Data regarding Aboriginal and Torres Strait Islander Peoples are intrinsically political (Bruhn, 2014; Walter & Suina, 2018; Yu, 2012). As part of self-determination, processes of collection and use of Aboriginal and Torres Strait Islander data currently controlled by governments must be transferred to Aboriginal and Torres Strait Islander Peoples to inform priorities and to monitor change, which will add to accountability (Davis, 2016; Lovett, 2016). Given entrenched power differentials between government and Aboriginal and Torres Strait Islander organisations, the realisation of capability is of critical importance (Hunt, 2013). Policy processes must support the leadership of Aboriginal and Torres Strait Islander people, communities and organisations to engage in all policy processes, and incorporate recognition of Aboriginal and Torres Strait Islander strengths (Swan & Raphael, 1995). Likewise, capacity building within government systems, to recognise limitations and engage in decolonising approaches, is also needed (Thorpe et al., 2016). Our principle of ways of working to advance decolonisation is defined as policy processes in which: government governance processes support decolonisation; resourcing of the realisation of capability throughout policy stages is adequate; and data governance agreements promote and maintain Aboriginal and Torres Strait Islander data sovereignty and intellectual property rights. Responsible Policy Implementation Policy implementation is not given high priority in the three source frameworks. The Cheung et al. framework includes limited recognition of this issue as a component of its main criterion of “obligations,” the Kelaher et al. framework refers to implementation as a sub-criterion, and the Mackean et al. framework does not address implementation. Other key sources note that implementation is an essential part of policy making and should be considered from policy inception (Bhuyan et al.,2010; Kennedy et al., 2019). From a decolonising perspective, ineffective implementation is characteristic of Aboriginal and Torres Strait Islander health policies (Australian Human Rights Commission, 2005; Calma, 2007). Implementation requires sufficient resourcing, including funding, timing and workforce (Baeza et al., 2009; Couzos & Murray, 2008; Dudgeon et al., 2014; Kalisch & Al-Yaman, 2013; Matthews et al., 2008) and time 12 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 limited policies are inherently limited in impact (Kalisch & Al-Yaman, 2013). Workforce constraints present particular challenges for Aboriginal and Torres Strait Islander health policies: addressing these is integral to policy implementation (Cox, 2014). Our principle of responsible policy implementation is defined as policy processes in which: resourcing is adequate to achieve policy goals; and implementation issues are identified and addressed as they arise. Monitoring and Evaluation While the Mackean et al. framework does not address monitoring and evaluation issues, these are embedded throughout the Kelaher et al. framework, and are identified as a main criterion in the Cheung et al. framework. Despite consensus in the general policy analysis literature that strong monitoring and evaluation processes are essential to both deliver the potential of current policies and improve the design of future policies (Productivity Commission, 2013, 2019), evaluations of public health policies are rare (Wharam & Daniels, 2007) and face particular challenges (Banta, 2003; Germov, 2009; Lattimore et al., 2008). Such challenges include the breadth of public health interventions across social determinants of health; the context-specific nature of health impacts which can limit generalisability; the time lag, or latency period, between intervention and outcome and, given the complexity of factors influencing health, the difficulties in attributing causation to particular interventions. From a decolonising viewpoint, evaluation is critical to monitor processes and outcomes “especially when evidence bases are weak” (Banks, 2009), and to ensure a human rights-based approach (Calma, 2007). Monitoring and evaluation should strengthen information systems to ensure availability of relevant data; guarantee government accountability to Aboriginal and Torres Strait Islander communities and the Australian public; and include pre-agreed targets. However, only a minority of Aboriginal and Torres Strait Islander policies are evaluated, and even when undertaken, evaluations are often not publicly released (Kelaher et al., 2018; Lokuge et al., 2017) or considered in either revising existing policies or developing new ones (Calma, 2007). Our principle of monitoring and evaluation is defined as policy processes in which: explicit monitoring and evaluation mechanisms are included from the outset; monitoring and evaluation findings are provided publicly and in formats accessible to Aboriginal and Torres Strait Islander Peoples; and evaluation and review findings are incorporated in policy improvements. Indicators and Rating Scale To assess if policy processes are decolonising, indicators for each of the framework’s principles were developed to help apply the framework in practice. These indicators guide assessment of the extent to which principles are embodied in existing or proposed policies, and, as used in the Cheung et al. framework, we applied a three-tier rating structure for this assessment (Table 2). 13 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Table 2. Principles, Indicators and Rating Scale Indicators Rating scale High Medium Low Principle 1. Power sharing 1a) What power sharing arrangements are in place? Aboriginal and Torres Strait Islander control and partnership is supported by legal or contractual requirements. Consultation, information, or advisory processes are in place. Power sharing processes are non-participatory OR no relevant material found. 1b) Are Aboriginal and Torres Strait Islander organisations sufficiently resourced to enable equality of participation at all policy stages*? Aboriginal and Torres Strait Islander representative organisations are sufficiently resourced to enable equality of participation at all policy stages. * Aboriginal and Torres Strait Islander representative organisations are insufficiently resourced to enable an equal level of participation and or not at all policy stages*. Aboriginal and Torres Strait Islander representative organisations are not resourced to enable participation OR no relevant material found. 1c) Are Aboriginal and Torres Strait Islander Peoples’ rights to free prior and informed consent to policy implementation upheld? Aboriginal and Torres Strait Islander Peoples’ rights to free prior and informed consent are fully upheld. Aboriginal and Torres Strait Islander Peoples’ rights to free prior and informed consent are partially upheld. Aboriginal and Torres Strait Islander Peoples’ rights to free prior and informed consent are contravened OR no relevant material found. Principle 2. Transparency and accountability 2a) Is policy documentation detailing all policy stages* available? Complete policy documentation detailing all policy stages* is available. Partial policy documentation detailing some policy stages* is available. Policy documentation is scant, or unavailable OR no relevant material found. 2b) What accountability structures and processes support the policy? Strong accountability structures and processes are embedded within all policy stages*. Some accountability structures and processes are associated with the policy and or at some policy stages*. Accountability structures and processes are absent OR no relevant material found. Principle 3. Defensible policy basis 3a) How is the basis of the policy presented? The basis of the policy (including the connection between policy basis and available evidence) is clear, explicit and consistent. The basis of the policy (including the connection between policy basis and available evidence) is partially clear, explicit and consistent. The basis of the policy (including the connection between policy basis and available evidence) is not clear, explicit and consistent. OR no relevant material found. 3b) How does the policy recognise knowledge gaps and respond to them? The policy explicitly recognises knowledge gaps and establishes processes to address them. The policy partially recognises knowledge gaps and/or processes to address these are unclear. Knowledge gaps and/or plans to address them are not acknowledged OR no relevant material found. 14 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 Indicators Rating scale High Medium Low Principle 4. Legitimate policy content and logic 4a) How does the policy recognise and respond to Indigenous social determinants of health (including structural exclusion, access, racism, and the continuing impact of colonisation), and Aboriginal and Torres Strait Islander knowledge, culture, and history? The policy explicitly recognises and responds to the Indigenous social determinants of health, and Aboriginal and Torres Strait Islander knowledge, culture, and history. The policy includes aspects indicating an implicit recognition of and/or response to the Indigenous social determinants of health, and Aboriginal and Torres Strait Islander knowledge, culture, and history. The policy does not refer to the Indigenous social determinants of health; and/or Aboriginal and Torres Strait Islander knowledge, culture and history OR no relevant material found. 4b) Does the policy respond to Aboriginal and Torres Strait Islander identified health priorities? The policy explicitly responds to Aboriginal and Torres Strait Islander identified health priorities. The policy implicitly and partially responds to Aboriginal and Torres Strait Islander identified health priorities. The policy does not respond to Aboriginal and Torres Strait Islander identified health priorities OR no relevant material found. 4c) Does the policy allow for flexible adoption at local levels? The policy has a high level of local flexibility. The policy has limited local flexibility. The policy does not have local flexibility OR no relevant material found. 4d) Is the policy logically coherent (that is, is the underlying theory of change clear; is policy logic supported by experience in other settings; and is policy structure logically consistent with policy goals?) Policy logic is coherent. , Policy logic is partially coherent. Policy logic is not coherent OR no relevant material found. 4e) How is the policy integrated with related policies? Policy identifies existing related policies and demonstrates full integration with these. Policy partially identifies existing related policies and/or is partially integrated with them. Policy does not identify existing related policies and/or is not integrated with them OR no relevant material found. 4f) Does the policy incorporate eligibility criteria or restrictions which impact on potential benefit? All Aboriginal and Torres Strait Islander Peoples and their health providers are eligible. There are minor eligibility criteria or restrictions which partially restrict access by Aboriginal and Torres Strait Islander Peoples and or their health providers. There are major eligibility criteria or restrictions which considerably restrict access by Aboriginal and Torres Strait Islander Peoples and or their health providers OR no relevant material found. Principle 5. Ways of working that advance decolonisation 5a) Do government governance processes (including provision of appropriately senior and culturally competent staff, transparency about limitations; and coordination between different government agencies) support decolonisation? Government governance processes advance decolonisation throughout all policy stages*. Government governance advance decolonisation to a lesser extent and/or at some points. Government governance processes do not advance decolonisation OR no relevant material found. 15 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Indicators Rating scale High Medium Low 5b) Does the policy include resourcing that promotes the realisation of capability (for both government and Aboriginal and Torres Strait Islander partners) throughout all policy stages*. The policy includes adequate resourcing that promotes the realisation of capability throughout all policy stages*. The policy includes some resourcing that promotes the realisation of capability at some policy stages*. The policy does not include resourcing that promotes the realisation of capability OR no relevant material found. 5c) Are data governance agreements in place that promote and maintain Aboriginal and Torres Strait Islander data sovereignty and intellectual property rights (including ensuring proper storage of, and access to, data for Aboriginal and Torres Strait Islander communities)? Clear written data governance agreements are in place that promote and maintain Aboriginal and Torres Strait Islander data sovereignty and intellectual property rights. Data governance agreements are weak, unclear, or incomplete. Data governance agreements are absent OR no relevant material found. Principle 6. Responsible policy implementation 6a) Is the policy adequately resourced (including funding, timing and workforce) to achieve its goals? Resourcing is fully adequate. Resourcing is partially adequate. Resourcing is inadequate OR no relevant material found. 6b) How does the policy respond to emerging implementation issues? Implementation issues are identified and addressed as they arise. Processes to identify and respond to implementation issues are unclear and/or inadequate. Implementation issues are not identified or responded to, OR no relevant material found. Principle 7. Monitoring and evaluation 7b) How are monitoring and evaluation findings communicated? Monitoring and evaluation findings are both publicly available and provided in formats accessible to Aboriginal and Torres Strait Islander Peoples including at the community level. Monitoring and evaluation findings are either not publicly available or provided only in general publicly available formats, with no Aboriginal and Torres Strait Islander specific communication. Monitoring and evaluation findings neither publicly available or provided in Aboriginal and Torres Strait Islander specific communication OR no relevant material found. 7c) How are policy improvements made in response to evaluation and review findings? Evaluation and review findings are incorporated in making policy improvements. Evaluation and review findings are partially considered in making policy improvements. Evaluation findings and review are not used to make policy improvements OR no relevant material found. *Policy stages are defined as: consultation, coordination, decision, implementation, evaluation, identification of issues, policy analysis, policy instruments (Bridgman & Davis, 2004). 16 The International Indigenous Policy Journal, 13. 3. DOI: 10.18584/iipj.2022.13.3.11269 Discussion Our study did not find a framework which supported a decolonising approach to the analysis of health policy content concerning Aboriginal and Torres Strait Islander Peoples across all policy stages. We integrated principles advanced by Aboriginal and Torres Strait Islander specific frameworks and associated literature on decolonising policy with a generic analytical framework to create a new framework to address this gap. The key strength of this study is the integration of Aboriginal and Torres Strait Islander analytical frameworks with an established, generic health policy analysis framework in the context of general policy analysis material and decolonising specific literature in particular. The major contribution of this study, the new decolonising framework, can be used to both retrospectively assess existing policies, and prospectively to guide the development of new policies. The framework’s seven principles and supporting rating matrix can assess the quality of policy design and development. Based on Aboriginal and Torres Strait Islander principles and practice, the framework provides an important tool in combatting implicit bias, or “mental associations that can lead to unintentional discrimination” (Payne & Vuletich, 2017, p. 49). Without such support for the conscious adoption of decolonising perspectives, policy analysis processes risk maintaining the implicit biases embedded in policy processes under review. Similar studies have developed analytical approaches to address the needs of other specific populations. For example, EquiFrame, which assesses the extent to which health policies advance the human rights of vulnerable groups (Amin et al., 2011), has been applied in a health literacy study (Trezona et al., 2018). Similarly, the He Pikinga Waiora Implementation Framework, which aimed to improve health programs for Māori communities, gauged policies against four culturally-based elements (Oetzel et al., 2017). In contrast to our decolonising framework, neither the EquiFrame or He Pikinga Waiora framework support consideration of all policy stages. However, both highlight the importance of criteria specifically focussed on the needs of minorities affected by policy processes. One limitation of this review is that the validity and utility of the framework are yet to established through practical application. The new framework, especially the proposed indicators, may require modification in light of these processes. An associated potential limitation is that the determination of ratings for policy attributes are necessarily at least partially subjective. A further limitation is that policy analysis is a highly contested field (Enserink et al., 2013). Particularly in regard to selection of an appropriate generic health policy analysis framework, we purposively drew upon theoretical foundations and analytical processes relevant to our research focus: that is, those that supported identification of optimal policy solutions; focussed on policy content; were designed for document analysis; and considered all policy stages. While we attempted to ensure our framework was informed by a breadth of related literature on policy and policy analysis, selecting one approach necessarily deselects others. Different research aims would require the use of different analytical approaches and may draw upon theories and frameworks not included in this review or incorporated in the framework. 17 Kehoe et al.: Development of a Decolonising Framework Published by Scholarsip@Western, 2022 Conclusion Analysis of Aboriginal and Torres Strait Islander health policy is needed to enable reflection, debate and learning (Couzos & Murray, 2008) but must be undertaken from a decolonising perspective to ensure such policy centres on Aboriginal and Torres Strait Islander principles. Our new policy analysis framework gives a structure in which a range of policy failures, such as the exclusion of Aboriginal and Torres Strait Islander Peoples from decision-making, poor implementation, and scant evaluation and monitoring, can be addressed. 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