Monitoring and evaluation

A number of related elements have been undertaken that work together to monitor implementation and assess the Indigenous Chronic Disease Package’s effectiveness in achieving the Closing the Gap targets.

The elements are:

  • a monitoring and evaluation framework to guide the package’s monitoring and evaluation activities;
  • a formative evaluation of 24 sentinel sites;
  • a web-based system for Indigenous health services to use in reporting data;
  • use of national survey information;
  • ongoing analysis and reporting by the Department of Health including, for example, analysis of MBS and PBS data; and
  • national monitoring and evaluation of the package undertaken over 2011 to 2013. Back to Top

How this will help Indigenous Australians

Monitoring and early evaluation of the program through sentinel sites, as well as national evaluation and other information, has helped to determine how well the package is achieving its objectives of:
  • reducing chronic disease risk factors such as smoking, poor nutrition and lack of physical activity;
  • identifying chronic disease as early as possible;
  • providing effective treatment and ongoing management of chronic disease; and
  • building the workforce and the primary health care system’s capacity to more effectively address chronic disease in the Indigenous population.
The evaluations draw on data from a range of information sources and assess progress towards long term objectives of the package. Back to Top

Who implemented the new approach

  • The Department of Health (the department) developed the Indigenous Chronic Disease Package Monitoring and Evaluation Framework in 2009-10.
  • The department funded the Sentinel Sites Evaluation from 2010 to mid 2013.
  • The department has developed the OCHREStreams web-based reporting tool for use by Commonwealth funded Indigenous specific health care services. OCHREStreams provides a fast, reliable, secure and efficient web portal used for extracting data from clinical systems for health services to prepare and submit reports for the National Key Performance Indicators (nKPIs) and the Online Services Report (OSR). The collection of the nKPIs by Indigenous specific primary health care services contributes to assessing the ICDP’s effectiveness in Closing the Gap targets.
  • The department is assisting in the development of an enhanced Australian Health Survey to collect data on key risk factors such as nutrition, physical activity, obesity and sugar levels.

Indigenous Chronic Disease Package Monitoring and Evaluation Projects


Two evaluation projects were established to monitor and evaluate the Indigenous Chronic Disease Package (ICDP):
  • the Sentinel Sites Project and
  • the National Monitoring and Evaluation Project.

Indigenous Chronic Disease Package Sentinel Sites Project


Menzies School of Health Research undertook the ICDP Sentinel Sites Project from early 2010 to mid 2013.

The Sentinel Sites Evaluation (SSE) provided place-based feedback on the effectiveness of ICDP implementation from 24 sites across Australia. The SSE identified enablers, barriers and early outcomes of the ICDP.

The SSE has been a valuable tool for informing implementation and programme refinement under the ICDP as well as policy development.

The evaluation identified the following achievements of the ICDP:
  • improved access to primary health care services and to affordable medication
  • improved responsiveness of the general practice sector to the needs of Aboriginal and Torres Strait Islander people
  • significant steps towards the establishment of a new workforce
  • increased access to specialist, allied health and team-based approaches to chronic disease care.
An important finding of the evaluation is the wide variation in the effective implementation of the ICDP at the local level. A systems approach at the local, regional and national level was found to be important for developing and optimising service delivery to support the prevention and management of chronic disease. The organisational capability of health services was a key predictor of the success of the ICDP measures.

The Summary Report provides more information about the findings, messages and policy considerations of the Sentinel Sites Evaluation.
The other SSE reports are available on the publications page.Back to Top


Indigenous Chronic Disease Package National Monitoring and Evaluation Project


An overall national evaluation of the ICDP in 2012-13 is a key element of the ICDP evaluation strategy. The ICDP Monitoring and Evaluation Framework identified the need for national annual monitoring to assess the implementation progress phase and early impact of the ICDP.

The department has engaged KPMG together with Winangali, Ipsos Social Research Institute and Baker IDI Heart and Diabetes Institute, to undertake the national monitoring and evaluation of the ICDP. The project includes a range of consultations with stakeholders and communities through interviews, regional forums and community site visits.

The ICDP National Monitoring and Evaluation Project is currently being finalised. The Baseline Report and the First Monitoring Report which cover the first two years of ICDP implementation have been finalised and are available on the publications page.

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