Aboriginal and Torres Strait Islander Health Performance Framework - 2010
3.11 Competent governance
Why is it important?:‘Governance’ is about having the processes and institutional capacity to be able to exercise control through sound decision-making. ‘Competent governance’ is all about the means to establish good governance arrangements with the ultimate aim of achieving the social, cultural, and economic developments sought by citizens (Dodson & Smith 2003).
Governance enables the representation of the welfare, rights and interests of constituents, the creation and enforcement of policies and laws, the administration and delivery of programs and services, the management of natural, social and cultural resources, and negotiation with governments and other groups (de Alcantara 1998; Hawkes 2001; Westbury 2002; Dodson & Smith 2003). The manner in which such governance functions are performed has a direct impact on the wellbeing of individuals and communities.
Aboriginal Community Controlled Health Services (ACCHSs) were first established in the 1970s, and by the 1990s were an important provider of health services to Indigenous people in Australia. They can offer comprehensive primary health care appropriate to Aboriginal and Torres Strait Islander peoples (DoHA 2001; Larkins et al. 2006).
Competent governance in the context of Indigenous health must also address the cultural responsiveness of mainstream service delivery for Indigenous clients and effective participation of Indigenous people on decision-making boards, management committees and other bodies, as relevant. The stewardship role of governments in their efforts to improve Aboriginal and Torres Strait Islander health is also critical. Attention should be given to assessing not only the levels of access to appropriate care but the experiences of Aboriginal and Torres Strait Islander peoples in receiving care. Unfortunately, very little data are available nationally on these issues.
Findings:The Office of the Registrar of Indigenous Corporations (ORIC) helps to administer the Corporations (Aboriginal and Torres Strait Islander) Act 2006, which superseded the Aboriginal Councils and Associations (ACA) Act 1976. In 2008–09, 81 out of the 84 Indigenous health corporations incorporated under the ACA Act and registered with ORIC had been fully compliant with the required provision of documents.
In 2008–09, of the 202 Aboriginal and Torres Strait Islander primary health care services funded by the Australian Government who provided data: 86% had a governing committee or board that met regularly; for 95% income and expenditure reports had been presented to the governing committee or board on at least 2 occasions through the year; for 77% all members of the governing committee or board were Aboriginal and/or Torres Strait Islander people, and for 77%, the governing committee/board members had received training related to governance issues.
In 2008–09, of the 45 Aboriginal and Torres Strait Islander substance use specific services funded by the Australian Government who provided data: 98% had a governing committee or board that met regularly; for 57% all members of the governing committee or board were Aboriginal and/or Torres Strait Islander people, and for 71%, the governing committee/board members had received training related to governance issues.
In 2008–09, 40% of Aboriginal and Torres Strait Islander primary health care services had representatives on external Boards (e.g. hospitals); 57% participated in Regional Planning Forums and 77% were involved in committees on health (e.g. steering groups). Aboriginal and Torres Strait Islander representation on governing boards for mainstream public sector health varies considerably across the states and territories (SCATSIH & SIMC 2006).
As discussed in measure 3.12, 15% of Indigenous Australians reported that they needed to but didn’t visit a doctor in the previous 12 months, 8% did not visit another health professional when needed and 7% did not visit a hospital when they needed to. Some of the reasons people didn’t access services reflect failures in health services to adequately address the needs of these patients. For example, 10–16% did not attend services because they disliked the service/ professional, felt embarrassed or afraid, 5–6% felt the service would be inadequate and 1–2% were concerned about discrimination and cultural appropriateness. In addition, a range of other reasons people did not access health care when they needed to reflect potential failures in the governance of the health system as a whole e.g. cost, transport/distance, service not available in the area.
In 2008, 8% of people aged 15 years and over surveyed in the National Aboriginal and Torres Strait Islander Social Survey disagreed or strongly disagreed with the statement ‘Your doctor can be trusted’. In addition, 17% disagreed or strongly disagreed with the statement 'Hospitals can be trusted to do the right thing by you'.
Implications:This data shows a continuing number of Aboriginal and Torres Strait Islander primary health care services are demonstrating sound governance arrangements. Case studies of the performance and governance of three Aboriginal councils in Queensland between 2000 and 2006 (Limerick 2009) identified contextual factors (such as education and skills, exposure to the ‘outside world’ and ‘whole of community’ focus in decision-making as opposed to family or kin orientation) as being significant in shaping successful governance attributes. It was also concluded from the case studies that “ostensibly orthodox governance principles and practices are not only relevant in the unique cultural context of Indigenous governance, but perhaps have even greater importance in this context” (p. 424).
A key strength of ACCHSs is their ability to respond flexibly to local community needs. Anderson & Brady (1995) suggest that self-determination has formed health providers with complex functions that are often a loci for the community. Many ACCHSs are part of larger community organisations which perform other social functions as well as health such as housing (Sullivan & Oliver 2007). The negotiation between a ‘community controlled’ organisational philosophy with the norms of central bureaucracies may at times give rise to ‘conflicting ideas of accountability’ (Anderson & Brady 1995).
The Department of Health and Ageing aims to improve Indigenous-specific service delivery and sector capacity through:
- continuous improvement in the business planning and management systems of existing services;
- a robust Risk Management Framework;
- targeted support to organisations in difficulty;
- supporting the implementation and enhancement of clinical management and Patient Information Recall Systems; and
- supporting accreditation through the Establishing Quality Health Standards initiative, and ensuring that cultural security is recognised in Australian healthcare standards.
Independent primary health care organisations — to be called Medicare Locals — will be established with strong links to local communities and health professionals. Medicare Locals aim to improve coordination and integration of primary health care in local communities, address service gaps, and make it easier for patients to navigate their local health care system.
LHNs and Medicare Locals will collaborate to improve patient care and the quality of health and hospital services. They will better integrate general practice, primary health care and hospital care, so patients smoothly transition in and out of hospital and continue to receive the care they need. They will work together to identify and address local needs, including the needs of Aboriginal and Torres Strait Islanders and ACCHSs.
Table 64 – Number and proportion of health corporations incorporated under the CATSI Act 2006 by compliance, 2008–09
Table 65 – Number and proportion of Aboriginal and Torres Strait Islander primary health-care services participating(a) in mainstream processes, 2008–09
|Representation on external boards (e.g. hospitals)|
|Participation in regional planning forums (e.g. under the framework agreements)|
|Involvement in committees on health (e.g. steering groups)|
|Total number of services|
Source: AIHW analysis of Service Activity Reporting, 2008–09
Table 66 – Number and proportion of governing committee/board use, Aboriginal and Torres Strait Islander primary health-care services and substance-use services, 2008–09
Primary health care services
Substance use services
|Governing Committee or Board met regularly|
|Income and expenditure statements were presented to Committee or Board on at least 2 occasions|
|All of the Governing Committee or Board Members were Aboriginal and/or Torres Strait Islander|
|Governing Committee or Board received training|
|Total number of services|