Co-designing Australia’s National Aboriginal and Torres Strait Islander Health Plan 2021–2031: a realist evaluation

Landmark policies such as the National Agreement on Closing the Gap urge governments to adopt genuine partnership and shared decision-making with First Nations peoples. Our study examines how policymakers and First Nations peoples co-designed the National Aboriginal and Torres Strait Islander Health Plan (NATSIHP) 2021–2031. We use realist evaluation to understand Context-Mechanism-Outcome (CMO) configurations. We collected data through yarning, interviews, and document analysis, focusing on how co-design mechanisms operated within specific contexts to produce observed outcomes. The context encompassed key policy actors, a tenuous First Nations health policy landscape, and non-negotiables like First Nations-led decision-making and content addressing cultural safety and systemic racism. Mechanisms included a culturally safe environment and shared decision-making. The outcomes showed a positive experience among participants in co-designing a national First Nations health policy, though there was disappointment in its implementation and accountability, underscoring the need for stronger follow-through. We highlight the imperative for governments to foster culturally safe environments for collaborative and inclusive policy design. Policymakers must empower First Nations peoples to create policy content that addresses systemic issues like racism. While co-designing policy with First Nations yields benefits, adherence to implementation and accountability measures is critical to avoid wasted efforts.