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

5.3 Impact of the EHSDI on PHC services and infrastructure

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

Page last updated: 17 April 2012

5.3.1 Data sources
5.3.2 Funding for expanded PHC services
5.3.3 Extra staff as a result of the EHSDI service expansion funding
5.3.4 Capital and infrastructure
5.3.5 Timing of the EHSDI funding
5.3.6 Administrative burden of the EHSDI funding
5.3.7 Funding sustainability

This section looks at what the EHSDI has added to the NT PHC system, focusing on the PHC expansion 
aspect of the program.


5.3.1 Data sources

The sources of quantitative data on EHSDI expenditure were:
  • data supplied by the Canberra office of OATSIH detailing the total allocation and expenditure 
of the NTER health-related measures 2008–09 to 2011–12
  • data supplied by the NT office of OATSIH regarding the breakdown of EHSDI funding across proposed HSDAs.
The figures supplied by these two data sources differ slightly because the former details expenditure while the latter details allocation. The figures from the Canberra office have informed the overall discussion of the EHSDI funding, while data from the NT office provides a breakdown by region and have informed our more detailed analysis.

Qualitative data was obtained from key informant and case study interviews with:
  • health centre managers in both DHF and ACCHO clinics
  • health centre staff including nurses, AHWs and administrative staff
  • DoHA, DHF and AMSANT personnel.

5.3.2 Funding for expanded PHC services

As outlined in Section 3.2.2 there is broad acknowledgment that the funding of PHC services has been inadequate and inequitable in the NT. The under-resourcing of the NT health sector has been identified as a significant impediment to providing effective PHC services (Rosewarne and Boffa 2004).

The EHSDI funding package was widely welcomed by the health sector as a means of addressing the chronic funding shortage. The introduction of the EHSDI saw a significant increase in the flow of funding into PHC in the NT. From 1 July 2008 to 30 June 2010, a total of $47.717 million was paid directly to health service providers, with $17.807 million spent in 2008–09 and $29.910 million spent in 2009–10. This represents a significant addition to the existing annual NT PHC system funding of $104.4 million;27 an increase of 17.0 per cent in 2008–09 and 28.6 per cent in 2009–10.

Funding for service expansion was allocated to HSDAs on the basis of an EHSDI funding allocation model. This methodology was agreed on and endorsed by the NT AHF. This involved establishing a per capita EHSDI funding benchmark for each proposed HSDA which was determined by multiplying the national average MBS payment with an agreed remoteness factor, fluency in English language factor and NT cost of service delivery factor for each HSDA. The sum of these factors created the final benchmark. This formula was developed as a means to distribute the available EHSDI funding equitably among the HSDAs, rather than representing the total amount of funding required by each area.

The benchmark methodology was used by the NT AHF to determine which regions were prioritised for additional funding. The per capita figure was compared to existing levels of funding from all sources (including both Australian Government and NT Government recurrent funding) to determine final allocations. HSDAs that received existing funding equal to or higher than the EHSDI benchmark (Borroloola, Darwin Rural and Katherine West in 2008–09 and Darwin Rural in 2009–10) did not receive any additional funding. Central Australia and East Arnhem received the bulk of the EHSDI funding (24.1 and 28.6 per cent respectively in 2008–09; 26.8 and 27.8 per cent in 2009–10) due in a large part to the higher population of these areas. Table 39 shows the distribution of funding by HSDA.
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Table 39: Total EHSDI service expansion funding by HSDA (2008–10)
HSDA
Estimated 
resident population (2006 census)
Funding 2008-09
Funding 2009-10
Amount(a)
Per cent
Amount(a)
Per cent
Alice Springs Urban
5,637
$911,623
5.2
$744,290
2.7
Barkly
3,902
$1,029,219
5.9
$2,060,003
7.5
Borroloola
1,204
$0
0.0
$398,024
1.5
Central Australia
10,633
$4,216,791
24.1
$7,359,498
26.8
Darwin Rural
1,067
$0
0.0
$0
0.0
Darwin Urban
1,694(b)
$489,181
2.8
$868,400
3.2
East Arnhem
9,929
$4,999,083
28.6
$7,620,290
27.8
Katherine East
3,687
$671,617
3.8
$1,674,911
6.1
Katherine Urban
2,775
$1,044,899
6.0
$1,044,899
3.8
Katherine West
2,420
$0
0.0
$747,766
2.7
Maningrida
2,577
$1,465,907
8.4
$1,817,936
6.6
Tiwi
2,256
$833,398
4.8
$852,292
3.1
Top End West
3,275
$840,717
4.8
$956,016
3.5
West Arnhem
2,350
$997,076
5.7
$1,291,965
4.7
Total
53,406
$17,499,511
100.0
$27,436,290
100.0

(a) Regional allocation amounts differ from actual expenditure and from the NT total allocation amounts discussed earlier.
(b) This only includes the population within the NTER prescribed communities (i.e. residents of town camps and not the total Indigenous population).
Source: NT office of OATSIH, correspondence and documents on EHSDI funding methodology.


When considered as a percentage increase of pre-EHSDI PHC funding from all sources, as shown in Table 40, Darwin Urban received the greatest increase (47.6 per cent in 2008–09 and 84.5 per cent in 2009–10), followed by Maningrida (41.3 per cent in 2008–09 and 51.2 per cent in 2009–10). This is due to the fact that the amount of existing funding received by these areas was relatively low (Table 41), resulting in a large percentage increase. It is important to recognise that in applying the benchmark methodology, the NT AHF acknowledged that Darwin Urban was an exception to all other HSDAs due to a range of factors (such as the availability of mainstream health services and private GPs) and agreed that the EHSDI would focus specifically on the NTER prescribed communities within the Darwin Urban HSDA. Only the NTER prescribed communities in this HSDA were eligible for EHSDI funding.
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Table 40: Total EHSDI service expansion funding increase by percentage (2008–10)
HSDA
Current (pre-EHSDI) total PHC funding (OATSIH, RHS and DHCS)
Additional EHSDI funding 2008–09
Percentage increase
Additional EHSDI funding 2009–10
Per cent
Alice Springs Urban
$8,134,851
$911,623
11.2
$744,290
9.1
Barkly
$8,632,767
$1,029,219
11.9
$2,060,003
23.9
Borroloola
$3,855,001
$0
0.0
$398,024
10.3
Central Australia
$21,403,603
$4,216,791
19.7
$7,359,498
34.4
Darwin Rural
$2,910,863
$0
0.0
$0
0.0
Darwin Urban
$1,027,261
$489,181
47.6
$868,400
84.5
East Arnhem
$16,174,684
$4,999,083
30.9
$7,620,290
47.1
Katherine East
$9,051,495
$671,617
7.4
$1,674,911
18.5
Katherine Urban
$4,031,751
$1,044,899
25.9
$1,044,899
25.9
Katherine West
$8,090,202
$0
0.0
$747,766
9.2
Maningrida
$3,552,863
$1,465,907
41.3
$1,817,936
51.2
Tiwi
$4,677,977
$833,398
17.8
$852,292
18.5
Top End West
$8,245,293
$840,717
10.2
$956,016
11.6
West Arnhem
$4,586,017
$997,076
21.7
$1,291,965
28.2
Total
$104,374,628
$17,499,511
16.8
$27,436,290
26.3

Source: NT office of OATSIH, Correspondence and documents on EHSDI funding methodology.


As a result of the application of the EHSDI funding methodology, the funding difference between HSDAs is now much smaller. As shown in Table 41, regions that were furthest from their benchmark made the greatest gains towards it. Assuming the methodology is appropriate, regional level funding is now more equitable. We have not examined the appropriateness of the methodology in any detail.

In 2009–10 the funding allocation methodology was revised with updated population estimates, an improved remoteness factor through the use of a weighted remoteness scale and a refined low English fluency factor using data from the 2006 census. This was intended to more accurately reflect the costs associated with providing PHC in each region.

Table 42 shows the revised per capita benchmark and the amount of per capita funding received for each HSDA. Maintenance of funding ensured that all HSDAs received at least the same level of funding as in 
2008–09. As shown in Table 42 the per capita funding received by most regions in 2009–10 remains below 
the EHSDI benchmark.
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Table 41: Per capita EHSDI service expansion funding (2008–09)
HSDA
2008–09 per capita EHSDI benchmark
PHC funding excluding EHSDI
PHC funding including EHSDI
Percentage increase
$ per capita
% of bench- mark
$ per capita
% of bench- mark
Alice Springs Urban
$1,982
$1,402
70.7
$1,559
78.7
7.9
Barkly
$3,097
$2,150
69.4
$2,406
77.8
8.3
Borroloola
$3,033
$3,118
102.8
$3,117
102.8
0.0
Central Australia
$3,362
$1,946
57.9
$2,329
69.3
11.4
Darwin Rural
$2,482
$2,683
108.1
$2,682
108.1
0.0
Darwin Urban
$1,568
$568
36.3
$839
53.5
17.3
East Arnhem
$3,371
$1,574
46.7
$2,061
61.1
14.4
Katherine East
$3,033
$2,381
78.5
$2,557
84.3
5.8
Katherine Urban
$2,728
$1,394
51.1
$1,755
64.3
13.2
Katherine West
$3,033
$3,225
106.4
$3,225
106.4
0.0
Maningrida
$3,371
$1,336
39.6
$1,887
56.0
16.3
Tiwi
$3,334
$2,011
60.3
$2,369
71.1
10.7
Top End West
$3,334
$2,422
72.6
$2,669
80.1
7.4
West Arnhem
$3,371
$1,870
55.5
$2,276
67.5
12.1

Source: NT office of OATSIH, correspondence and documents on EHSDI funding methodology.


Table 42: Per capita EHSDI service expansion funding (2009–10)
HSDA
2009–10 per capita EHSDI benchmark
2009–10 current PHC funding
PHC funding including EHSDI
Percentage increase
$ per capita
% of bench- mark
$ per capita
% of bench- mark
Alice Springs Urban
$1,992
$1,443
72.5
$1,674
84.0
11.6
Barkly
$3,582
$2,212
61.8
$2,788
77.8
16.1
Borroloola
$4,015
$3,202
79.7
$3,117
77.6
-2.1
Central Australia
$3,538
$2,013
56.9
$2,653
75.0
18.1
Darwin Rural
$2,038
$2,728
133.9
$2,682
131.6
-2.2
Darwin Urban
$1,376
$606
44.1
$930
67.6
23.5
East Arnhem
$3,640
$1,629
44.8
$2,474
68.0
23.2
Katherine East
$3,515
$2,455
69.8
$2,900
82.5
12.7
Katherine Urban
$2,140
$1,453
67.9
$1,741
81.4
13.5
Katherine West
$3,949
$3,343
84.7
$3,225
81.7
-3.0
Maningrida
$3,176
$1,379
43.4
$2,134
67.2
23.8
Tiwi
$2,975
$2,074
69.7
$2,452
82.4
12.7
Top End West
$3,000
$2,518
83.9
$2,720
90.7
6.8
West Arnhem
$3,242
$1,951
60.2
$2,494
76.9
16.7

Source: NT office of OATSIH, correspondence and documents on EHSDI funding methodology.


5.3.3 Extra staff as a result of the EHSDI service expansion funding

The additional funding for expanding PHC services was intended to ‘employ 
more doctors, nurses, Aboriginal Health Workers and community health workers’ (FaHCSIA 2009c). The funding allocated to HSDAs enabled the creation of 251.46 FTE positions in the remote PHC workforce. This included 176.6 FTE positions in 2008–09 and a further 74.86 FTE positions in 2009–10. Table 43 shows the number of positions in each HSDA.
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Table 43: EHSDI funded positions by HSDA (2008–10)
HSDA
2008–09 positions
2009–10 positions
Number (FTE)
Per cent
Number (FTE)
Per cent
Alice Springs Urban
10.5
5.9
7.0
2.8
Barkly
7.5
4.2
18.5
7.4
Borroloola
0.0
0.0
0.0
0.0
Central Australia
48.5
27.4
52.9
21.0
Darwin Rural
0.0
0.0
0.0
0.0
Darwin Urban
0.0
0.0
3.0
1.2
East Arnhem
55.3
31.3
57.2
22.7
Katherine East
0.0
0.0
9.0
3.6
Katherine Urban
4.2
2.5
9.6
3.8
Katherine West
0.0
0.0
0.0
0.0
Maningrida
15.0
8.5
9.66
3.8
Tiwi
9.7
5.5
10.0
4.0
Top End West
9.0
5.1
8.45
3.4
West Arnhem
10.9
6.2
11.65
4.6
PHC reform support
6.0
3.4
6.5
2.6
Other EHSDI-funded roles
0.0
0.0
48.0(a)
19.1
Total
176.6
100.0
251.46
100.0

(a) This includes 14 alcohol and other drug positions; 12 hubs positions (full-time for a six-month period); and 22 hearing health positions (full-time for a five-month period).
Source: Data supplied by NT office of OATSIH.


The two HSDAs with the highest resident populations (East Arnhem and Central Australia) accounted for 59 per cent of funded positions in 2008–09 and 43.7 in 2009–10. As detailed in Table 44, taking into account the population of each HSDA, in 2008–09 Maningrida gained the most new positions—an additional 5.8 FTEs per 1,000 people—followed by East Arnhem (5.6 FTEs per 1,000), Central Australia (4.6 FTEs per 1,000) and West Arnhem (4.6 FTEs per 1,000). In 2009–10 East Arnhem gained the most positions (5.8 FTEs per 1,000) followed by Central Australia and West Arnhem (each with 5.0 FTEs per 1,000).
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Table 44: Increase in FTE positions per 1,000 population (2008–10)
HSDA
Estimated resident population 
(2006 census)
2008–09
2009–10
Number (FTE)
Increase per 1,000
Number (FTE)
Increase per 1,000
Alice Springs Urban
5,637
10.5
1.9
7.0
1.2
Barkly
3,902
7.5
1.9
18.5
4.7
Borroloola
1,204
0.0
0.0
0.0
0.0
Central Australia
10,633
48.5
4.6
52.9
5.0
Darwin Rural
1,067
0.0
0.0
0.0
0.0
Darwin Urban
1,694(a)
0.0
0.0
3.0
1.8
East Arnhem
9,929
55.3
5.6
57.2
5.8
Katherine East
3,687
0.0
0.0
9.0
2.4
Katherine Urban
2,775
4.2
1.5
9.6
3.5
Katherine West
2,420
0.0
0.0
0.0
0.0
Maningrida
2,577
15.0
5.8
9.66
3.7
Tiwi
2,256
9.7
4.3
10.0
4.4
Top End West
3,275
9.0
2.7
8.45
2.6
West Arnhem
2,350
10.9
4.6
11.65
5.0

(a) This only includes the population within the NTER prescribed communities (i.e. residents of town camps and not the total Indigenous population).
Source: Data supplied by NT office of OATSIH.


Interviews with health centre managers suggested that the impact at the community level was varied. The extra resources were generally welcomed by health staff, with noticeable improvements in some health services and a negligible difference in others. It is important to note that the extra funding was often not available until March or April 2009 at the earliest due to the lag time between signing funding agreements and funds being made available–see Section 5.3.5. The evaluation case studies took place from February to April 2010. Most new positions had been in place for less than 12 months at the time of the case study visits and some informants felt that they were only just starting to see the benefits of these positions in early 2010. In most case study communities we found that it was too early to measure tangible impacts as a result of new positions.

Larger health services did report a perceptible increase in staffing numbers, allowing the provision of additional services such as health screening or paediatric services. The EHSDI funding enabled additional core service staff to be employed and relieved previously understaffed services. Informants from smaller and more remote clinics reported only a slight increase in staffing numbers, such as a visiting medical professional coming for an extra half day per week. The type of health service may be another important variable here. Services in the smaller case study communities were mainly DHF-managed services and, as noted below, initially DHF made a considerable investment in non-clinical staff.

While many of the new positions have a focus on population health and preventative care, a number of health service staff spoke about the extra resources being diverted into acute care. The DHF clearly felt they were experiencing challenges in shifting the culture of remote health from an acute to a preventative focus (interview, government official). This shift is not helped by staff recruitment, where most remote staff are still recruited on the basis of acute skills, further exacerbated by the use of agency staff who often see their role as being based on acute care.

Recruitment and retention of staff remains an ongoing challenge in the case 
study communities, with a number of services stating that they were unable to fill the positions that they had received funding for. Several of the case study communities had staff vacancies at the time of visiting. The Remote Health Services division of DHF received around 145 of the new FTE positions, giving 
a total of around 480 FTEs. In May 2010 nearly all these positions were occupied by staff, although recruitment had been slow and challenging with more than one recruitment round needed to fill many positions. Some positions had been back filled using agency staff until permanent staff could be recruited (interview, government official).

Table 45 provides detail of the 176.6 FTE positions created in 2008–09. The largest number of positions were for Area Service Manager/Trainer/Coordinator/Business Manager roles (50.0 FTEs). Of these, 45 positions were employed by DHF clinics and five were employed by ACCHOs. This initial investment in non-clinical staff by DHF may have been a response to the transition to new service models under the EHSDI. Regionalisation processes will result in previously independently run, community-level ACCHOs moving towards a more consolidated model for each region. In contrast, DHF services, which have previously been managed from Darwin or Alice Springs, are decentralising with regionally based managers (Area Service Managers).
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Table 45: Number of EHSDI funded positions (2008-09)
HSDA
Number (FTE)
Per cent
Area Service Manager / Trainer / Coordinator / Business Manager
50.0
28.3
Nurse / Nurse Practitioner
27.5
15.6
Aboriginal Community Workers
24.5
13.9
AHW / Trainer
13.5
7.6
Aboriginal Career Development Officer
11.0
6.2
AOD worker
11.0
6.2
Driver
8.5
4.8
Rural Medical Practitioner / GP
6.0
3.4
Child and Adolescent Health
4.0
2.3
Public Health Coordinator
3.0
1.7
Health Promotion Officer
3.0
1.7
AHW 1 Apprentice
3.0
1.7
Business Support
3.0
1.7
Child and Maternal / Nurse Practitioner
2.5
1.4
GNP
2.0
1.1
Chronic Disease Coordinator
1.4
0.8
Senior Rural Medical Advisor
1.0
0.6
Community Paediatrician
1.0
0.6
Visiting Specialist
0.8
0.5
Total
176.6
100.0

Source: Data supplied by NT office of OATSIH.


Funding for follow-up services under the CHCI was on a short-term basis only, with an emphasis on providing clinical services outreach with only a small support team. The short-term funding meant it was difficult to establish management structures for the program as all staff had to be on short-term contracts to match the funding arrangements. Several informants stated that with the announcement of longer-term EHSDI funding there was a desire to build the capacity of health organisations and the initial priority with staffing was to strengthen management structures and systems. This may have led to a priority on recruiting management staff to lead the transition to a reformed PHC sector.

As shown in Table 46, workforce investment in 2009–10 saw a greater focus on ‘front-line’ staff.
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Table 46: Number of EHSDI funded positions (2009–10)
HSDA
Number (FTE)
Per cent
Doctor
9.9
3.9
Nurse / Nurse Practitioner
33.0
13.1
Aboriginal Health Worker / Apprentice
26.16
10.4
Aboriginal Community Worker / Trainee
59.5
23.7
Aboriginal Community Worker (Hearing Health)
9.5
3.8
Aboriginal Hearing Health Coordinator
2.0
0.8
Program Coordinator
19.0
7.6
Mental Health Worker
4.0
1.6
Pharmacist
0.5
0.2
Traditional Healer
1.0
0.4
Area Service Manager
9.0
3.6
Business Support
17.5
7.0
IT / Finance / Recruitment / Training and Development Officer
9.0
3.6
Maintenance Officer / Driver
3.4
1.4
AOD Worker
14.0
5.6
Hubs Positions (Darwin)(a)
7.0
2.8
Hubs Positions (Alice Springs)(a)
5.0
2.0
Hearing Health(b)
22.0
8.7
Total
251.46
100.0

(a) Full-time for a six-month period.
(b) Full-time for a five-month period.
Source: Data supplied by NT office of OATSIH.


In 2008–09 a total of 50 staff were employed in Aboriginal-specific positions including AHWs, Aboriginal Community Workers (ACWs) and Aboriginal Career Development Officers. In 2009–10 this had increased to just over 97 Aboriginal-specific positions. No data was available on the number of Aboriginal staff employed in general health positions. Interviews with health service managers indicated a desire to employ more Aboriginal staff but informants felt that it was difficult to recruit and retain appropriate staff. This was echoed by John Paterson, AMSANT Executive Officer, who stated that the majority of AMSANT’s members were having difficulty recruiting enough staff to continue to provide holistic and appropriate primary care (AMSANT media release 2009).

Informants reported that AHW roles were particularly difficult to fill. AHWs in the NT are regulated through the Health Practitioners Act 2004 and must be registered under the Aboriginal Health Workers Board of the Northern Territory. Requirements for registration include minimum qualifications, current competence, recent practice and good character (AHW Board of the NT 2008). AHWs play a key liaison role between medical professionals such as doctors and Indigenous patients; however, their role goes well beyond this. It encompasses a range of clinical and non-clinical duties including performing health checks, planning and running health promotion programs and delivering outreach services (Mitchell and Hussey 2006). As registered health practitioners, AHWs in the NT, unlike in other parts of Australia, are also able to diagnose and prescribe treatment. There are a number of other Aboriginal-specific health roles in the NT, including ACW, Aboriginal Mental Health Worker and Aboriginal Nutrition Worker. These roles do not require professional registration and do not have the same focus on clinical duties.

As shown in Figure 8 the number of registered AHWs in the NT has stagnated in the past decade. AHW numbers rose steadily from 105 in 1986 to a peak of 431 in 1999 and have since declined to 302 in 2008. This issue received media attention in March 2010 when ABC News reported that there were not enough AHWs in the NT to meet demand, highlighting 50 vacancies for health workers at government-controlled clinics alone (‘Urgent need for more Indigenous health workers’, ABC News, 5 March 2010).
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Figure 8: Number of registered Aboriginal Health Workers in the NT (1986–2008)

Figure 8: Number of registered Aboriginal Health Workers in the NT (1986–2008)

Source: AHW Registration Board of the NT.

[D]

A lack of promotion of the AHW role and unavailability of locally-based training and professional development opportunities was highlighted by informants as a potential reason for the declining numbers of workers. Interviews with health centre managers indicated that existing staff do not have time to develop and support AHWs and that managers rely on external training providers. Lack of community-based learning was identified as a barrier for Aboriginal staff to train for formal qualifications. Aboriginal staff expressed a preference for on the job, apprentice-style training; however, few local training opportunities are available. The current emphasis is on block training in regional centres.

AHW training in the NT is mainly provided by the Batchelor Institute, an Indigenous tertiary education institution with campuses in Batchelor (100 kilometres south of Darwin) and Alice Springs. The facility was placed into financial administration in August 2009 following a series of budget overruns, with the Australian Government and NT Government providing funding to prevent insolvency. Twenty-five AHW students were expected to graduate from the Institute at the end of 2010, but this represents only half the number of graduates required per annum (‘Urgent need for more Indigenous health workers’, ABC News, 5 March 2010). Further professional development and training for AHWs is available through Central Australian Remote Health Development Services (CARHDS) in Alice Springs, but CARHDS does not provide formally recognised full AHW training.

While training and recruitment of AHWs is a priority, it is important to note that there is a shortage of skilled and qualified Aboriginal staff in both clinical roles such as nurses and medical officers and non-clinical roles such as health administrators and managers. Culturally appropriate training and professional development opportunities should be examined for Aboriginal staff at all levels of the health system. Some efforts are currently underway to increase the number of Aboriginal staff in NT PHC. For example, DHF has recently instigated an ACW program intended to provide a career pathway for Aboriginal people to enter the remote health workforce (DHF Working Future newsletter, 10 September 2010).


5.3.4 Capital and infrastructure

Figures from the Canberra office of OATSIH show that in the 2008–09 and 2009–10 financial years, a total of $14.855 million of the EHSDI funding was spent on capital and infrastructure. Of this, $13.141 million was spent in 2008–09 and $1.714 million in 2009–10.

Table 47 shows capital and infrastructure spending by HSDA. In 2008–09, nearly 62 per cent of the funding was spent in three areas—Central Australia (28.3 per cent), East Arnhem (18.1 per cent) and Tiwi (15.3 per cent), with a further 14.7 per cent spent NT-wide. A total of 50 separate capital and infrastructure projects were funded in 2008–09.

The Central Australia and East Arnhem regions, having large populations and a large number of communities, had 20 projects at nine different service sites and 11 projects at six different sites respectively. Tiwi, which stands out from this list as receiving a significant proportion (15.3 per cent) of the 2008–09 capital and infrastructure funding, used the funding to build two sets of staff dwellings at one health service site.
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Table 47: Capital and infrastructure funding by HSDA (2008–10)
HSDA
2008–09
2009–10
Amount
Per cent
Amount
Per cent
Alice Springs Urban
$271,354
2.1
$0
0.0
Barkly
$1,587,672
12.1
$99,984
5.8
Borroloola
$100,000
0.8
$0
0.0
Central Australia
$3,700,990
28.3
$855,975
49.9
Darwin Rural
$45,831
0.3
$0
0.0
Darwin Urban
$380,178
2.9
$0
0.0
East Arnhem
$2,365,860
18.1
$176,805
10.3
Katherine East
$0
0.0
$0
0.0
Katherine Urban
$547,541
4.2
$364,629
21.3
Katherine West
$0
0.0
$148,526
8.7
Maningrida
$0
0.0
$68,410
4.0
Tiwi
$2,000,000
15.3
$0
0.0
Top End West
$170,000
1.3
$0
0.0
West Arnhem
$0
0.0
$0
0.0
NT Wide
$1,930,000
14.7
$0
0.0
Total
$13,099,426
100.0
$1,714,329
100.0

Source: Data supplied by NT office of OATSIH.


A large portion of the NT wide expenditure in 2008–09 ($1.88 million) was directed towards upgrading computer systems, namely the implementation of the Primary Care Information System (PCIS) in DHF clinics. This is an electronic records system which enables patient data to be manipulated and handled for reporting and analysis. The system has had positive reports from health services, although the roll out was not complete at the time of the evaluation case studies.

Interviews with health centre managers revealed that a lack of adequate and 
appropriate staff housing had been a barrier to filling staff positions in remote communities. In 2008–09, 78.5 per cent of EHSDI capital and infrastructure funding ($9.59 million) was spent on buildings, including staff accommodation and clinics. Increased investment in the construction or refurbishment of staff housing was commonly identified by informants as a tangible benefit of the EHSDI. The balance of the 2008–09 expenditure included $2.27 million (18.6 per cent) on information technology, $0.27 million (2.2 per cent) on vehicles, and $0.09 million (0.7 per cent) on clinic equipment.

In 2009–10 the EHSDI investment in capital and infrastructure dropped significantly to $1.714 million. Following an EHSDI Regional Infrastructure Assessment project, a total of $5.534 million in priority upgrades were funded, comprising $4.499 million provided under Better Outcomes for Hospitals and Community Health funding and $1.035 million EHSDI funding. The majority of the 2009–10 capital and infrastructure spend was in Central Australia, which received 49.9 per cent of the funding ($855,975) for projects including the purchase of a doctor’s house.

Table 48 shows capital and infrastructure spend by type of organisation. It shows that in 2008–09 DHF managed services received the bulk of the funding, while in 2009–10 the funding was split almost evenly, with ACCHOs receiving slightly over half. It is important to note that DHF is the asset owner, but not the service operator at some sites.


Table 48: Capital and infrastructure funding by organisation (2008–10)
Organisation
2008–09
2009–10
Amount
Per cent
Amount
Per cent
DHF
$9,205,000
70.3
$801,351
46.7
ACCHOs
$3,844,426
29.3
$912,978
53.3
AMSANT
$50,000
0.4
$0
0.0
Total
$13,099,426
100.0
$1,714,329
100.0

Source: Data supplied by NT office of OATSIH.


Health services in a number of the case study communities felt satisfied with the level of infrastructure funding that they had received, although as outlined in Section 5.3.5 many felt that the timing of funding was not optimal. In addition to staff accommodation, the increased provision of outreach services (in particular child health, immunisation and obstetrics) through infrastructure purchases, such as vehicles and mobile clinics, was a stated benefit of EHSDI funding.

Unlike EHSDI funding for expanded services, which was based on an agreed methodology, funding for infrastructure projects does not appear to have been guided by clear systems. Funding was allocated on the basis of proposals submitted by each HSDA to DoHA. Some case study participants described the funding process as ‘ad hoc’ and ‘confusing’ and stated that documented guidance on funding procedures would have been useful.

As may be expected with a new program, the planned EHSDI sub-program allocations proved to be impractical. Regionalisation activity was slow to commence and there was a lack of progress on developing hub services. EHSDI funds originally allocated for regional reform and hubs development were directed towards infrastructure as per the EHSDI Full Expenditure Strategy (NT AHF 2009b). This was approved by the NT AHF and allowed for the redistribution of any uncommitted EHSDI funds, provided they were within the spectrum the EHSDI. The amount of uncommitted funds was not determined until March 2009, leaving health services little time to plan as projects had to be approved by the end of the financial year (30 June 2009). While $6 million was originally allocated for capital and infrastructure in 2008–09, the proposals submitted totalled over $16 million and projects worth $13.141 million were eventually approved.
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5.3.5 Timing of the EHSDI funding

The initial announcement of the EHSDI specified a two-year time frame for the program, with no indication that the funding would continue beyond this period. The NT remote PHC sector had been under-resourced for a long time and there was a sense that the EHSDI funding may be a one time, limited opportunity to ‘get something done’ (interview, health professional). This created an imperative to spend the available resources quickly. The focus was on getting the money ‘on the ground’ with insufficient time to create a considered plan for disbursement of the EHSDI funds.

In 2008–09, 30 EHSDI expanded services funding agreements and 50 capital and infrastructure agreements were signed. As shown in Table 49, the majority of expanded service funding agreements (18 out of 30) were signed by DoHA in December 2008; however, no capital and infrastructure funding agreements had been signed by this date. Out of a total of 50 capital and infrastructure funding agreements, 16 were signed in February 2009 and 18 were not signed until June 2009. There was, on average, a lag time of around two months between signing funding agreements and funds being made available.


Table 49: Timing of signing of EHSDI funding agreements (2008–09)
Month in which agreement was signed
Number of funding agreements
Expanded PHC services
Capital and infrastructure
December 2008180
January 200937
February 2009616
March 200910
April 200900
May 200902
June 2009218
Date unknown07
Total3050

Source: Data supplied by NT office of OATSIH.


The lack of alignment between the release of capital and service funding led to instances of inefficient spending. Health services were granted funding for service expansion, but lacked the infrastructure to facilitate effective spending. For instance, several informants stated that they were allocated funding for additional staff members but did not have accommodation to house them. The funding for both service expansion and infrastructure could not usually be carried over between financial years, creating pressure to spend allocated grants quickly. This resulted in the construction of temporary buildings or staff hired because they were available rather than the most appropriate—a short-term ‘quick fix’ rather than a sustainable solution.

The 2009–10 Federal Budget included the announcement that funding for the EHSDI would be continued until 30 June 2012. The extended time period, combined with increased awareness of the problems with the initial roll out of funding, saw OATSIH commission a regional infrastructure assessment project in late 2009. This was to determine the state of remote health infrastructure in the NT and provide a basis from which to inform capital works funding decisions to facilitate more integrated and systematic distribution of funds. In 2009–10 EHSDI funding of $1.035 million was used to fund priority maintenance and upgrades identified through the assessment, including health facilities and staff accommodation properties. This has been supplemented by $4.499 million of Better Outcomes for Hospitals and Community Health funding.
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5.3.6 Administrative burden of the EHSDI funding

The EHSDI funding is one of many sources of finance for health service providers. While expressing appreciation for the additional funding, many informants indicated that the funding model was complex and added additional administrative pressure to already overburdened staff. In this context, the EHSDI was often viewed as ‘another grant on top of everything else’ with the process described as complicated and lacking documented guidance.

The issue of funding ‘overburden’ was highlighted by Dwyer et al (2009) in a report detailing the complexity of contracting arrangements for remote Aboriginal health services. The authors noted that funding of the NT remote Aboriginal PHC sector comes from multiple sources including the Australian Government, the NT Government, non-government organisations and some local governments and is usually provided on the basis of short to medium term contracts with cyclic application and reporting requirements. The report emphasises the fragmented nature of funding programs and the high workload and costs for health providers in applying for, negotiating, and reporting on multiple sources of funding.

Interviews with health centre managers suggested that they are currently experiencing many of these issues. Evaluation participants described accessing up to 43 different funding streams and grants, each with its own set of reporting requirements. Health centre managers stated that administration associated with funding grants sometimes detracted from their core business of delivering services to the community and undermined attempts to maintain a patient focus. Programmatic funding is often tied to a specific purpose and informants also believed that this made it difficult to direct funds to where they were most needed or to fill gaps in service delivery. Informants also expressed concern that the short-term, contract-based approach to funding resulted in a lack of ability to undertake long-term planning.

Establishing a health service purchasing body could be explored as a potential solution to these issues. This would involve pooling Australian Government and NT Government health funds under the control of a single organisation that acts as a purchaser of PHC services, incorporating greater flexibility for service providers to move and direct funding in response to changing circumstances and local contexts. Providers would apply and report to a single funding body, reducing the inefficiencies and administrative burden associated with multiple funding sources. This funding arrangement would enable the provision of a more comprehensive set of services as health providers would have the ability to map their services against the NT AHF-endorsed core service framework, assess gaps and direct funding to fill these gaps. Lavoie (cited in Dwyer et al 2009) asserts that Aboriginal organisations that are funded by a single Indigenous-specific authority are better able to provide comprehensive services and have an administrative and financial advantage.

The CCTs and PHCAP provide examples of how pooled funding has been operationalised in the past. In the CCTs, funds were provided to regional health boards on the basis of the average per capita expenditure on MBS and PBS nationally. This was to be pooled with funds allocated by the NT Government. The health boards acted as purchasers of services provided to trial populations, with the ability to develop their own priorities for service provision. Robinson et al (2003) note that for the first time this provided a mechanism for managing service delivery based on regional and community perspectives. PHCAP was intended to operate under a similar model, which involved the provision of per capita funding to 21 Health Service Zones. This was to be pooled with current DHF expenditure on health and used in accordance with decisions made by local health boards. While the establishment of regionalised health services under the EHSDI has not yet progressed to the point where regional health boards could act as funding purchasers, this could be investigated as a potential mechanism. In the medium term, we recommend that the NT AHF partner organisations engage in discussion about how to better coordinate the funding provided by different levels of government and different departments.


5.3.7 Funding sustainability

The lack of long-term funding for the EHSDI remains a concern as health services are not able to plan beyond 2012. The ability to develop a long-term strategic plan which would be provided for by recurrent funding would markedly increase the efficiency of spending.

The current EHSDI benchmark (see Section 5.3.2) is not necessarily an accurate reflection of the costs required to deliver comprehensive PHC services to remote communities. It has, however, provided a means to ensure more equitable funding between HSDAs and, in the absence of an accurate costing model, may be useful as an initial goal to guide PHC funding growth.

Table 50 shows the EHSDI benchmark for the last two financial years and the proportion of PHC funding (excluding EHSDI funding) against that benchmark. In 2008–09 the proportion of funding against the benchmark ranged from 36.3 per cent (Darwin Urban) to 108.1 per cent (Darwin Rural), a range of 71.8 percentage points. In 2009–10, with the revised benchmark, the proportion of funding against the benchmark ranged from 43.4 per cent (Maningrida) to 133.9 per cent (Darwin Rural), a range of 90.5 per cent. The two years are not directly comparable as the benchmark methodology and resulting benchmarks changed. However this does suggest that considerable inequity remains in funding across the regions despite the progress made under EHSDI.

Table 50 also shows that in 2008–09 three regions achieved the EHSDI benchmark while in 2009–10 only one region did (excluding EHSDI funding).
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Table 50: PHC funding, excluding EHSDI, as a proportion of EHSDI benchmark (2008–10)
Region / HSDA
Per capita EHSDI benchmark
Per cent of benchmark
(PHC funding excluding EHSDI)
2008–09
2009–10
2008–09
2009–10
Alice Springs Urban
$1,982
$1,992
70.7
72.5
Barkly
$3,097
$3,582
69.4
61.8
Borroloola
$3,033
$4,015
102.8
79.7
Central Australia
$3,362
$3,538
57.9
56.9
Darwin Rural
$2,482
$2,038
108.1
133.9
Darwin Urban
$1,568
$1,376
36.3
44.1
East Arnhem
$3,371
$3,640
46.7
44.8
Katherine East
$3,033
$3,515
78.5
69.8
Katherine Urban
$2,728
$2,140
51.1
67.9
Katherine West
$3,033
$3,949
106.4
84.7
Maningrida
$3,371
$3,176
39.6
43.4
Tiwi
$3,334
$2,975
60.3
69.7
Top End West
$3,334
$3,000
72.6
83.9
West Arnhem
$3,371
$3,242
55.5
60.2

Source: Data supplied by NT office of OATSIH.


Table 51 shows the level of funding required for all regions to reach the EHSDI funding benchmark in these years—a total of around $61.6 million in 2008–09 and $64.7 million in 2009–10. This equates to an increase of around 160 per cent on current PHC sector funding. The EHSDI funding of $17.8 million in 2008–09 and $30.6 million in 2009–10, certainly helped to reduce this gap; however, funding over the long term of around $60 million a year is required if the EHSDI benchmarks are to be achieved in more than a handful of regions.

As stated above, the current per capita benchmarks were developed as a means to distribute the available EHSDI funds. The use of a structured and transparent funding model avoids a ‘black box’ style of funding under which the reasons for funding decisions are obscured and ensures that decisions are based on a clear rationale. More work needs to be done on the EHSDI funding methodology to ensure that the model is robust and based on relative population health needs and the costs of delivering remote services to meet these needs so funding is delivered as fairly as possible.

The EHSDI funding has begun to address the gap in service funding, but there is still a considerable way to go before the health services for this population are adequately resourced. The Indigenous Access to Core PHC Services in the NT document (NT AHF 2007c) lists a range of core PHC services and argues that enabling access to these services at a community level will have a significant impact on Indigenous health outcomes. The paper estimated in 2007 that a figure of at least $3,600 per person per year would be required to provide access to the full range of core PHC services. The paper further suggests that the cost of providing a full range of PHC services (such as maternity, dental and allied health services), together with regional and jurisdiction wide supports and enablers would require annual funding of approximately $5,100 per capita. The current level of funding, even if all HSDAs received 100 per cent of their EHSDI benchmark, falls well short of this level.
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Table 51: Gap between current PHC funding, excluding EHSDI, and EHSDI benchmark (2008–10)
Region / HSDA
Estimated 
resident population 
(2006 census)
Gap to EHSDI benchmark (PHC funding excluding EHSDI funding)
2008–09
2009–10
Per capita
Total
Per capita
Total
Alice Springs Urban
5,637
$580
$3,269,460
$549
$3,094,713
Barkly
3,902
$947
$3,695,194
$1,370
$5,345,740
Borroloola
1,204
-$85
-$102,340
$813
$978,852
Central Australia
10,633
$1,416
$15,056,328
$1,525
$16,215,325
Darwin Rural
1,067
-$201
-$214,467
-$690
-$736,230
Darwin Urban
1,694(a)
$1,000
$1,694,000
$770
$1,304,380
East Arnhem
9,929
$1,797
$17,842,413
$2,011
$19,967,219
Katherine East
3,687
$652
$2,403,924
$1,060
$3,908,220
Katherine Urban
2,775
$1,334
$3,701,850
$687
$1,906,425
Katherine West
2,420
-$192
-$464,640
$606
$1,466,520
Maningrida
2,577
$2,035
$5,244,195
$1,797
$4,630,869
Tiwi
2,256
$1,323
$2,984,688
$901
$2,032,656
Top End West
3,275
$912
$2,986,800
$482
$1,578,550
West Arnhem
2,350
$1,501
$3,527,350
$1,291
$3,033,850
Total
53,406
$61,624,755
$64,727,089

(a) This only includes the population within the NTER prescribed communities (i.e. residents of town camps and not the total Indigenous population).
Source: Data supplied by NT office of OATSIH.


The health needs of the NT remote Indigenous population are complex and 
require a higher level of funding than non-Indigenous Australians to achieve gains. The core services document (NT AHF 2007c) quotes a 2004 paper commissioned by DoHA which states that per capita spending on health care should be 2.2 times that of the non-Indigenous population. Future funding of the remote PHC sector needs to consider the increasing burden of disease in the Aboriginal community and high rates of inflation in remote areas due to wage growth and higher operational costs in remote areas. The growth rate of funding may need to be set at a higher level than the average growth rate of Australian PHC expenditure.

In considering a sustainable funding model that extends beyond the current EHSDI time frame of 30 June 2012, we feel the following points should be considered:
  • Work should be undertaken by the NT AHF to quantify the cost of providing a comprehensive set of PHC services in each proposed HSDA to establish an accurate benchmark for each region.
  • A medium-term funding pathway needs to be established by the Australian Government so that the PHC sector is able to achieve the funding benchmarks.
  • Once these benchmarks are achieved, funding increases should, at a minimum, be tagged to Australian PHC funding benchmarks such as the MBS and pharmaceutical expenditure. This will ensure that increases in the Australian benchmark are reflected in NT benchmark increases. Growth in remote PHC spending may need to be more rapid than the mainstream due to the higher relative morbidity of the Aboriginal population.
  • The benchmark should be regularly reviewed and refined by the NT AHF to ensure that it is valid, appropriate and accurately reflects the costs of delivering comprehensive PHC services in NT remote areas.
  • Funding needs to be embedded in the national system so that it is sustained even when health issues in the NT are not high on the Australian Government political agenda.
  • Until a new benchmark based on accurate costings is established, the EHSDI benchmark may be useful as a short-term goal.

The funding model needs to be transparent and to have a long-term focus to enable providers, including regional ACCHOs, to plan ahead.

These funding considerations relate to the issue of providing PHC services to Indigenous people in remote NT communities. Issues of access, quality and cost of health services in urban areas were not part of the scope of this evaluation. Given the mobility of the Indigenous population in the NT and the high health needs of the urban Indigenous population, particularly displaced rural people living in urban areas, it could warrant evaluation in its own right. This would assess the adequacy of current approaches and funding as part of progressing health improvement for all Indigenous people in the NT.
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5.3.8 Summary and conclusions

The EHSDI represents a significant increase to the funding for providing PHC services in the NT, adding 17.0 per cent to the overall budget in 2008–09 and 28.6 per cent in 2009–10. The distribution of this funding across the proposed HSDAs, based on a clear and transparent funding methodology, has contributed to more equitable distribution of resources across the NT. Clearly the allocations are bringing regions up to the EHSDI benchmark. The benchmark is, however, an artificial one and is not based on an accurate costing model of delivering services in remote areas. We suggest the methodology for the benchmark be reviewed to ensure it fits new evidence of the cost of delivering PHC to remote areas.

The impact of the EHSDI funding on staffing levels has varied. Recruitment and retention of medical professionals is an ongoing challenge, with the lack of appropriate local training and support opportunities for AHWs highlighted as a significant barrier to increasing staff numbers. This could be addressed by developing on-the-job training programs for AHWs, with appropriate funding for support mechanisms.
The initial distribution of capital and infrastructure funding lacked a clear investment strategy, largely due to the pressure to spend funds quickly under the initial two-year time frame for the EHSDI. The subsequent Regional Infrastructure Assessment project, carried out in late 2009, facilitated more robust capital works investment in the 2009–10 financial year with funding allocations based on priorities identified by the assessment. Future investment in staff housing should be a priority to allow the employment of additional health professionals as an enabler to improved health services.

While the extra funding made available under the EHSDI was appreciated by health staff, it generally represented one of many diverse funding streams accessed by health services. Evaluation participants characterised the current PHC funding process as ‘complicated’ and highlighted the administrative burden that application, negotiation and reporting requirements of multiple funding sources placed on staff. Establishing a single health service purchasing body that funds all health services in the NT could be explored as a potential solution to these issues.

To provide for sustainable PHC service delivery, work needs to be undertaken by the NT AHF to develop a sound funding model to ensure equitable health service funding based on the true costs of service delivery. Funding should be embedded in the national system to ensure sustainability and this can only happen once a medium-term funding plan has enabled services to reach their benchmark. On the basis of the current EHSDI funding model, around $60 million is required per year (excluding current EHSDI funding) to reach these funding benchmarks.
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