Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

3.2 Policy implementation

Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

Page last updated: 17 April 2012

3.2.1 The NTER
3.2.2 Development of the CHCI—process and good practice
3.2.3 Discussion

3.2.1 The NTER

The NTER package (Brough 2007) included various measures relevant to health but specifically called for the:
  • introduction of widespread alcohol restrictions on NT Aboriginal land
  • introduction of welfare reforms to stem the flow of cash going toward substance abuse and to ensure funds intended for children’s welfare are used for that purpose
  • enforcement of school attendance by linking income support and family assistance payments to school attendance for all people living on Aboriginal land and providing meals for children at school at parents’ cost
  • introduction of compulsory health checks for all Aboriginal children under 16 years to identify and treat health problems and any effects of abuse
  • acquisition of townships prescribed by the Australian Government through five-year leases including payment of just terms compensation
  • increasing of policing levels in prescribed communities, including requesting secondments from other jurisdictions to supplement NT resources, funded by the Australian Government and implemented as part of the immediate emergency response
  • intensification of ground clean up and repair of communities to make them safer and healthier by marshalling local workforces through work-for-the-dole
  • improvement of housing and reform of community living arrangements in prescribed communities including the introduction of market-based rents and normal tenancy arrangements
  • banning of pornography and introduction of audits of all publicly funded computers to identify illegal material
  • scrapping of the permit system for common areas, road corridors and airstrips for prescribed communities on Aboriginal land
  • improvement of the governance of government businesses in prescribed communities.
The announcement of the intervention noted that:
The national emergency response will be overseen by a taskforce of eminent Australians, including logistics and other specialists as well as child protection experts. Magistrate Sue Gordon, chair of the National Indigenous Council and author of the 2002 Gordon Report into Aboriginal child abuse in Western Australia has agreed to take a leadership role on the Taskforce (John Howard, speech at press conference 21 June 2007).

The NTER as a response to sexual abuse of Indigenous children

Much of the media commentary after the announcement of the NTER focused on the ability of the intervention to identify and address the sexual abuse of children. Editorial commentary in the August 2007 edition of the Medical Journal of Australia (Ring and Wenitong 2007) was supportive of the increased attention that intervention had brought to the issue of child abuse, but raised concerns about the lack of evidence base for the government’s strategies and highlighted the disjunction between the Little Children are Sacred recommendations and the NTER measures.

In interviews with the evaluation team, representatives of DoHA, DHF, AMSANT, the NT AMA, and the AIDA all stated that as soon as they became aware of the policy for compulsory sexual abuse examination of children they realised it was technically and ethically flawed.

Criticism from the medical profession of the compulsory aspect of the checks prompted a week of intense discussion between ministers, officials and professional organisations. A change in policy, stating that child health checks will not be compulsory, was announced by the Health Minister Tony Abbott on 28 June 2007. An official announcement on 5 July 2007 confirmed that health checks would be voluntary, carried out with the consent of parents or carers, and that forensic examinations for sexual abuse would not be part of the standard health check. This decision was praised by Dr John Boffa and colleagues in December 2007, noting that compulsory checks ‘ ... would have been a form of assault if carried out’ (Boffa et al 2007, p. 617) and expressing doubt that any doctor would have agreed to participate in such a process.

This sequence of events indicates the lack of policy discussion on the ethics, effectiveness and appropriateness of compulsory checks for sexual abuse before the announcement. The announcement on 21 June 2007 was the first health officials in the Australian and NT governments had heard of the intervention, including the intention to conduct compulsory medical examinations.

Refinement of the child health checks

The final form of the child health checks was a response by the Health Minister to the health sector’s concerns about carrying out an activity that it perceived as unethical, towards a response that fulfilled the broader intent of the Australian Government’s original policy position of examining children, but now not for sexual abuse. An existing program, the MBS Item No. 708, provided a de facto policy platform and an alternative approach to assessing the health of Aboriginal and Torres Strait Islander children.

MBS Item No. 708 provided health checks for Aboriginal and Torres Strait Islander children aged less than 15 years, intended to facilitate the early detection, diagnosis and intervention for common and treatable conditions. While MBS 708 became the basis for the CHCI, it was not designed for the specific conditions in remote NT communities. Its focus was the whole of the Australian Aboriginal and Torres Strait Islander population and it assumes that a general practitioner (GP) will be the main provider of care and that the check is carried out in the context of an ongoing relationship with a medical practice or medical practitioner.

The resulting check program was generalised and did not acknowledge the specific issues of the NT. This meant the CHCI itself was not seen as particularly useful by many in the NT health sector. One medical practitioner commented, ‘The general view was that the CHCI wouldn’t identify anything that wasn’t already known’.Top of page


3.2.2 Development of the CHCI—process and good practice

There are a number of important policy issues that should be considered, for reasons of good practice, before embarking on a child health check program. These include:
  • clearly identifying the overall objectives
  • an examination of the evidence base to identify and assess options to support the identification of a particular intervention as the preferable approach (in this case, screening)
  • a discussion on the best process to adopt in implementing an intervention.

Identifying objectives

The original objectives of NTER included establishing the prevalence of child sexual abuse; however, when the check became a more general child health check, officials hoped that the CHCI would improve their knowledge about the prevalence of conditions and actively improve the children’s health.

Health officials hoped the CHCI would provide care for children who previously had none, and establish, for the first time, the true level of specific health conditions among Indigenous children in the NT (interview, government official). The general view among Australian Government officials we interviewed was that the check, carried out by GPs, would identify and then treat the conditions found, leading to an improvement in health. This view dominated the early part of the CHCI and it was only after the program had been launched that Australian Government officials realised that the major bottleneck in the system was not only at the primary care level, but also at the interface with secondary care and other referred services (such as referrals to specialists and allied health services).

These issues could have been avoided had there been a process of policy development for the CHCI that was specific to the needs of children and the existing service arrangements in remote areas of the NT.

Child health checks as a screening program—an appropriate approach or a lost opportunity?

Child health checks, in the original MBS 708 and revised NTER form, were designed as a screening tool. Since 1968 the WHO has supported consideration of the following issues in designing and operating a screening program (Wilson and Jungner 1968):
  • the condition sought should be an important health problem for the individual and community
  • there should be an accepted treatment or useful intervention for patients with the disease
  • the natural history of the disease should be adequately understood
  • there should be a latent or early symptomatic stage
  • there should be a suitable and acceptable screening test or examination
  • facilities for diagnosis and treatment should be available
  • there should be an agreed policy on whom to treat as patients
  • treatment started at an early stage should be of more benefit than treatment started later
  • the cost should be economically balanced in relation to possible expenditure on medical care as a whole
  • case finding should be a continuing process and not a once and for all project.
There is no record of Government awareness of these criteria, or of a policy discussion of the extent to which the individual child health check items conformed to the criteria. As a result the design of the program did not include
an approach based on these long-established principles.

This is not unusual. Many ‘health check’ programs are implemented without adherence to the WHO principles, despite the desirability of doing so. National guidelines and reviews of the evidence related to child health checks indicate
that there was, and still is, considerable uncertainty about the value of child health screening and surveillance.

The current guidelines from the National Health and Medical Research Council (NHMRC) published in 2002 forthe Centre for Community and Child Health state that:
Although the early detection of health and other problems in children is a worthy goal, this review found there is little evidence for the effectiveness of screening programs in many domains. There are scant data about cost effectiveness. There are major issues of program quality, monitoring of compliance with referrals for assessment, and whether facilities exist in many communities for assessment and follow-up. In some cases, there is little evidence that therapy alters outcomes (Centre for Community and Child Health 2002).

A more recent review notes that the NHMRC child health screening guidelines were often inconsistent in their recommendations, and in many cases were not supported by evidence relevant to the primary care setting (Alexander and Mazza 2010).

The NHMRC guidelines may not always be relevant to the health conditions prevalent in the NT, with its specific patterns of both health conditions and health service provision. These types of regional variations demonstrate the need to base policy on a tailored and realistic understanding of how to maximise the health impact of child health checks, as well as broader consideration of the principles of screening. Without such consideration, there is a limited chance of any program improving the health of Indigenous children in the NT.

Implementation of the child health checks

Evidence and guidelines on appropriate approaches to Indigenous communities are well known in the Australian health system (Aboriginal Health and Medical Research Council and The Sax Institute 2007; AIATSIS (undated); Australian Health Ministers’ Advisory Council 2004; NHMRC 2002a; NHMRC 2003; NHMRC 2005) and in the NT in particular.10 We could find no policy discussion justifying a decision to establish the CHCI without following these accepted approaches, particularly the acknowledged and previously common practice of consultation with communities before a health intervention is initiated by someone outside the community.

There was no analysis of the strengths and weaknesses of existing child health check models in the NT before the design and launch of the CHCI. This information should have been part of any policy consideration before
the CHCI was implemented.

When it became apparent that much of the NT health sector was opposed to or ambivalent about the health check aspect of the NTER, Australian Government officials began to actively engage with the NT health sector. Subsequently the Australian Government developed a package focused on strengthening the health system. The trade-off to getting wider NT health sector support, including that of the Aboriginal community controlled health sector, was to link the CHCI with a significant package of support for strengthening the NT PHC sector.

While this approach resulted in publicly stated support and cooperation from the NT Government and nongovernment health sectors for both the CHCI and the EHSDI, many in the health sector felt uncomfortable with what they saw as a compromise or even a sell-out. This sense of an unethical trade-off underlies the considerable unease that we encountered among health workers in the NT in the course of this evaluation.

The health system response to the NTER

NT health officials’ response to the health aspects of the NTER was two dimensional—they saw the initially compulsory examination of children as potentially harmful; however, they were encouraged that attention was being drawn to the issues of the NT and saw this as an opportunity to attract increased resources to the sector. ‘At least something was being done’ was a typical response in interviews.

There was common understanding that the NT did not have adequate resourcing to support the remote PHC sector (McDermott et al 1997; Rosewarne and Boffa 2004; Mooney and Henry 2004). The NT was heavily reliant on special funding arrangements as it did not get an equitable share of the major national funding streams. Between 1993–94 and 2003–04, the NT’s share of the total MBS and Pharmaceutical Benefits Scheme (PBS) payments pool averaged 0.5 per cent and 0.3 per cent respectively, despite the NT being home to 1.0 per cent of the Australian population (Byron et al 2005). Researchers have estimated that the NT’s Medicare funding shortfall was $23.1 million in 2003–04—a gap which had increased from $15.8 million in 1994–95. The PBS funding shortfall in the NT was estimated to be $25.8 million in 2003–04 (Byron et al 2005). The NTER and the additional resources that accompanied it was seen by government officials as an opportunity to address the chronic under-resourcing of remote health services in the NT.

The pressure of public and political scrutiny resulting from the Little Children are Sacred report and the components of the NTER that involved increased resourcing were widely welcomed by the NT PHC sector. Despite the lack of evidence-based policy development, the sector saw the health aspects of the NTER as an opportunity to strengthen the existing PHC system.
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3.2.3 Discussion

Public policy processes are seldom tidy. The ideal, in which officials develop policy in a logical and evidence-informed process, fully considering the available evidence and consulting with affected parties, leading to considered decisions, seldom occurs (Torgerson 1985). Instead, policy specialists use terms such as ‘muddling through’ (Lindblom 1959) and ‘working in the policy swamp’ (Schon 1973) to describe what actually happens. However, when the ideal sequence (or at least parts of it) does occur, there is an increased chance of policy success.

In the case of the NTER, we found no evidence of detailed consideration of policy options. The options that had been developed in consultation with the communities involved (the recommendations in Little Children are Sacred) were ignored, or perhaps more accurately were left behind in the stampede. The Australian Government did not discuss policy implementation issues with DoHA, leading to the announcement of a policy which was technically and ethically flawed and which created fear among the groups it was intended toprotect (interviews, case studies, AIDA and Centre for Health Equity Training, Research and Evaluation 2010). The resulting alternative policy response, the CHCI, was also developed without adequate consideration of the broader policy issues such as evidence of effectiveness, and without consideration of the initial conditions of the system into which it was being imposed.

The framing of the problem as an emergency and the rapid development and implementation of the NTER may have been necessary to achieve the focused national attention needed to make substantial change. The boldness and shock impact of the NTER did ensure that health issues in the NT got on the political agenda and it was successful in leveraging significant attention and resources for the NT. Many welcomed any evidence of government action in preference to the perceived inaction of the past.

Consideration needs to be given to the conditions required for substantial change for a minority group in a democracy, particularly when the current policy setting is inadequate or even disabling for that minority. Governments have difficulty focusing on the needs of marginal groups and are more likely to act coherently and decisively in response to a crisis than they are when it is business as usual (Hay 1999). There are deep and unresolved differences on what is an appropriate response by government to address the needs of Aboriginal people—an approach where the main response required is duty of care for the vulnerable, or an approach where self-determination is the dominant theme.

Proponents of the former tend to see Aboriginal people (particularly men) as incompetent and/or perpetrators, Aboriginal culture as a negative influence on people’s development, and Aboriginal organisations as generally corrupt or inept. The solution is for the most vulnerable (abused Aboriginal children) to be protected by mainstream organisations such as health, police, and social services because the other potential intervention points—their families and communities—are unable to protect them. The resulting policy actions are mainstream, generalised and centralised, using existing organisations and social structures to address the issues.

The latter approach would determine an appropriate response to the crisis as the re-invigoration of the old and new instruments of Aboriginal society, the authority of families and elders, the support of Aboriginal controlled organisations and the defence of rights and title. The preferred approach is one of engagement, discussion and negotiation using existing social structures, particularly Aboriginal structures. The premise is that through strengthening these frameworks, the desired outcome will be achieved.

These opposing policy responses are never as clear-cut in practice. Aboriginal families and communities exercise a ‘duty of care’ as well as governments. The NTER had strong elements of the former in its approach to compulsory sexual abuse checks (quickly abandoned), and strong elements of the latter in its approach to the EHSDI.

In the time leading up to the NTER there was wide consensus in the Australian political and administrative systems on the magnitude of the problems faced by remote Aboriginal communities. There also appeared to be a broad consensus emerging on the inadequacy of the response to these issues by the different sectors in the NT, and a shared view that the approaches of the last 20 years, which had favoured self-determination, had not been very successful. Much of the effort had been counterproductive to the development of Aboriginal people. There were, and still are, divergent views on the reasons for this lack of progress.

These differences provide a complex environment for the evaluation of the CHCI and the EHSDI, as the policy development process did not seek to collect evidence on the reasons for the current situation before designing and implementing the next step. Simply put, there was not time. The unusual nature of these events leading to the starting position for the CHCI and the EHSDI programs had a major impact on the evaluation programs as they developed.

The Bush Book—the NT public health Bush Book is a resource for those who work in remote Aboriginal communities in the NT. It is written by those who have worked with remote community health care teams. Accessed at: http://www.health.nt.gov.au/Health_Promotion/Tools_for_Good_Practice/index.aspx

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