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

5.4 The EHSDI reforms—leadership and governance

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

Page last updated: 17 April 2012

5.4.1 Governance arrangements
5.4.2 Future health system reform
5.4.3 Summary and conclusions

5.4.1 Governance arrangements

Governance of the EHSDI was initially managed through the Chief Executive Officers’ Group (CEOs’ group), which comprised top-tier managers of the three NT AHF partners—DoHA, DHF and AMSANT. This group provided high-level strategic direction for the increased health services funding in the NT as part of the NTER. The initial planning work for the EHSDI was undertaken by a working group led by DoHA with representation from each partner from the NT AHF.

In September 2008 responsibility for the strategic governance of the EHSDI was delegated from the CEOs’ group to the NT AHF. This involved governance arrangements and investment decisions for the second year of the initiative. It was in marked contrast to the decision making in the CHCI which remained in Canberra. This indicates a degree of recognition of the capacity and trust in the NT remote health sector which was not apparent in the lead up to the CHCI itself.

The PHRG is made up of a group of senior policy and clinical officials from the NT AHF partners. It was formed to oversee the implementation of the EHSDI. This included the expectation that the PHRG would address any strategic issues associated with the EHSDI, including guiding PHC reform activities, overseeing the regional reform process and developing policy frameworks to guide the EHSDI implementation (EHSDI Governance Arrangements, paper for NT AHF meeting no. 41, September 2008).
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Discussion on governance

The partnership between the Australian Government, NT Government, and the 
Aboriginal controlled health sector under the NT AHF is a significant achievement in inter-agency collaboration. The commitment of the three organisations to working in partnership, as well as locating decision making in the NT, is commendable. These existing governance arrangements have strengthened the sector’s ability to respond to the developments which occurred under the EHSDI. The extensive development of both structures and relationships before the EHSDI meant that the sudden increase in resourcing was largely able to be managed within existing frameworks. Existing NT AHF structures were used to oversee the implementation of the major EHSDI components, enabling the $88.572 million of EHSDI funding to be managed into the system relatively effectively.

The wider NTER was perceived as having both negative and positive elements by the majority of NT informants we spoke to. Collectively they approached what they viewed as the negative aspects with a ‘harm minimisation’ approach and looked to the positive aspects to strengthen their existing efforts in PHC system reform. It has been apparent during this evaluation, including in the evaluation workshops, that a number of issues have arisen especially ‘overload’ and potential ‘burnout’ of key individuals behind the reform process. The decision to decentralise responsibility to the NT for implementation of the EHSDI was also accompanied by instructions from senior officials in the Australian Government to invest in front-line health staff and services rather than build the administrative function in the NT. This has meant that the bulk of the implementation policy work that inevitably accompanies a sector under significant change has had to be managed largely within existing capacity and notably by the PHRG.

The NT AHF governance group has chosen not to establish a joint policy capacity. The existing policy capacity in the organisation is either insufficient to address implementation policy requirements related to the reform process, or not enough capacity is being directed at supporting the reforms.

We attempted to ascertain the current level of policy capacity within the system and where this is located. Within the NT, we estimated that there is one FTE staff member located in DHF with a focus on strategic policy on remote PHC. Other policy capacity within DHF is predominantly program-based and there is no specific strategic Aboriginal policy capacity. AMSANT has approximately 1.5 FTE staff working on NT remote health issues. This includes a public health medical officer (PHMO) allocated to Primary Health Advisory Group issues and excludes PHMO allocated capacity on national the PHMO network and for organisational submissions and policies. We were unable to obtain an estimate of the NT remote health policy capacity of DoHA, or an indication of how any capacity is split between DoHA’s offices in Canberra and the NT.

Although we have been unable to determine the exact level of capacity, it is 
clear that there is currently insufficient policy work being undertaken to sustain the pace needed to implement the reform agenda effectively. This has led to inefficiencies during the reform process. For example, there has been a lack of progress on the building of a workforce strategy and delays in developing a strategic position on hubs services. This issue will need to be addressed if the current reform process is to be sustained.

Continuing partnership between governments and the Aboriginal community controlled health sector, and between federal and territory agencies, is critical. The representative make-up of the NT AHF of funders (DoHA, DHF), policy makers (DoHA, DHF), service providers (AMSANT, DHF), and consumers (AMSANT) provides the capacity required to direct and monitor the reform process and is well-positioned to make progress on the agenda. Several issues need to be considered to ensure that governance continues to be effective and efficient in the future.

There appear to be some problems with the way the NT AHF carries out its role. The NT AHF needs to focus on governance and oversight, rather than the practical, operational implementation of the reforms. Many management issues, such as decision making on core services and contract management, are currently being addressed by the NT AHF because there is insufficient support capacity to undertake this work. This suggests a need to re-establish and clarify the NT AHF’s function and then look at its form. Its function should include bringing coherence to the partners on policy and funding.

All three partners need to revise and refine their relationships, roles and responsibilities to respond to the current environment. Establishing a joint policy capacity would require each of the partners to relinquish some power. There does not appear to be a strong appetite for this despite clear evidence that each agency devolving power and changing concepts of accountability would increase efficiency and effectiveness. The fact that there have been some challenges during the organisational change process is to be expected.

A comprehensive communications strategy has been developed by the NT AHF, which should support a more coherent approach between partners and communicate consistent messages to stakeholders about the reforms. The partners need to focus further on implementing this strategy and on communications across and between the partners, and communication within each partner agency.

The NT AHF should consider options for a higher-level of independent 
consumer representation (that is, consumer voices not aligned to any of the partners) within sector wide governance arrangements. AMSANT is a peak 
body and while ACCHOs represent the community, they are too close to service delivery and funding to be the only consumer voice. Existing mechanisms for consumers’ voices, such as the Health Complaints Commission, could be strengthened to act as a vehicle for communication of consumers’ experience 
of health services. The reports of these organisations could be formally considered by the NT AHF as a means of consumer input into its decisions, outside the interests of provider organisations.

The second challenge is the CHCI evaluation finding that a significant bottleneck in the NT remote health system is not the accessibility of PHC (though the continuing challenges of this should not be underestimated), but at the interface with secondary care and other referred services (see Section 4.3 for further details). Although the NT AHF is well positioned to provide leadership over this interface, its focus to date has been on the institutional arrangements such as the community control and the quality improvement aspects. Possible responses to this challenge are discussed in the following section on the government reforms and the scope of PHC.
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5.4.2 Future health system reform

In 2009 the Australian Government received the following advice from the 
National Health and Hospitals Reform Commission. We expect this advice will be a strong influence on the future of the EHSDI as it recommends:
  • aggregation of all funding under a national Aboriginal and Torres Strait Islander health authority
  • improving nutrition in targeted remote Indigenous communities
  • strengthening the vital role of community controlled health services
  • training and recognition of an Indigenous health workforce and a workforce for Indigenous health
  • remote and rural areas be given ‘top-up’ funding to an equivalent amount of funding on a 
per capita basis as communities with better access to medical, pharmaceutical and other primary health care services
  • increasing funding for patient travel and accommodation, strategies to improve health workforce supply and clinical training opportunities in remote and rural areas.
The Australian Government announcement in response to this advice was to expand the boundary of PHC to encompass a broader range of services (DoHA 2010b). Some hospital outpatient services are to be characterised as part of the PHC system. This has considerable implications for the continued development of the NT PHC system, particularly the current ‘scope’ of PHC and the interface between PHC and secondary care services. It does not appear that the idea of a single funder for Aboriginal health care has been favoured.

The current discussion by the PHRG and the NT AHF uses a modified version of the WHO essential health system building blocks as a framework for the strategic direction of services (NT AHF 2009b; WHO 2007a). This comprehensive discussion document demonstrates the depth of planning and system understanding that the PHRG is able to produce to support further system development.

This raises a critical point for the future of PHC services in the NT—further consideration must be given to the scope of PHC. PHC is described in the core services framework as a layer or the first formal level of care in the health system. This is further reinforced in the PHRG discussion document which specifically excludes other layers of the system (NT AHF 2009c):
      Although the effectiveness and efficiency of the NT Aboriginal PHC system is fundamentally influenced by many factors in the secondary and tertiary level elements of the NT Health system and broader social and economic systems, these are not considered within scope for this paper.
The effectiveness of the health system as a whole depends on effectively linked primary and secondary care as part of a holistic people-centred approach. Recent international discussion has described PHC as ‘a hub from which patients are guided through the health system’ (WHO 2008b). This approach moves away from the focus on layers (primary health care, secondary health care) and their respective institutions (health centres, hospitals) toward PHC as a comprehensive and continuous set of services from which people are guided through the health care system. This discussion has grown from the need to address the consequences of the isolation of PHC from the wider health system and the lack of responsiveness of the secondary care system to population needs related to chronic diseases, particularly for the poor (see Table 52).
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Table 52: Aspects of care that distinguish conventional health care from people-centred primary care
Conventional ambulatory medical care in medical clinics or outpatient departmentsDisease control programsPeople-centred primary care
Focus on illness and cureFocus on priority diseasesFocus on health needs
Relationship limited to moment 
of consultationRelationship limited to program implementationEnduring personal relationship
Episodic curative careProgram-defined disease control interventionsComprehensive, continuous and person-centred care
Responsibility limited to effective and safe advice to the patient at the moment of consultationResponsibility for disease control targets among the target populationResponsibility for health of all in the community along the life cycle; responsibility for tackling determinants of ill-health
Users are consumers of the care 
they purchasePopulation groups are targets of disease control interventionsPeople are partners in managing their own health and that of their community

Source: WHO (2008b).


The governance capacity that the NT has demonstrated to date shows that it is well-positioned to approach this next level of PHC reform. The PHRG is currently actively considering the breadth of PHC at the local level (DHF 2009b) (see Figure 9).
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Figure 9: Conceptual model of integrated primary health care and community services

Figure 9: Conceptual model of integrated primary health care and community services

Source: DHF (September 2008), health submission to the NTER Review Board.

[D]

This model would see the inclusion of a wider range of services as part of 
PHC such as mental health, alcohol and other drug services, family and children’s services, and aged and disability services. There would clearly be advantages to a more explicit link between the wider range of services and the community governance and management arrangement of regionalised services. This would prevent duplication and increase the critical mass of services resulting in efficiency gains.

There are compelling arguments to revisit the vertical reach of the NT PHC system. The concept of hubs could be expanded to include secondary and referred services in a fully integrated model. Coupled with the Australian Government’s intention to move outpatient services from secondary to primary care, vertical integration presents an opportunity for the existing partnership to develop a focus on secondary and referred service arrangements that more explicitly meet the needs of the populations they serve.

The exact nature of engagement with the secondary care and referred service functions still needs to evolve, based on evidence of current patterns of service use. A starting point could be the mapping of available secondary care and referred services against the PHC sector’s knowledge of the services required for their population, using data such as waiting lists for outpatient services and procedures. The evaluation team observed that many of the referred and secondary services lacked a ‘population perspective’ in the way they were organised. Services were provided in an ad hoc manner rather than according to population need. This leads to an undersupply of necessary services in many areas. This could be mitigated by moving towards integrated funding models based on the Australian Government’s new PHC scope which considers some outpatient services as part of the PHC system.

The last issue of scope of the NT PHC system relates to the extent to which the PHC system influences the wider determinants of health. Feedback from the case studies indicated that in many areas the communities were reasonably satisfied with health service provision, but were very concerned with the lack of development on issues such as housing. On the other hand, some PHC sector stakeholders have expressed concern that a focus on the wider determinants may lead to a diversion of PHC funding, just as the PHC sector is finally moving towards a more sustainable funding base (interview, health professional). Experience of strong health, housing and social service arrangements have demonstrated that such engagement does not lead to a diminution of the health focus but a strengthening of the impact of the interventions across all the sectors involved (Pholeros, Rainow and Torzillo 1993; Bullen et al 2008).

Health services are a major determinant of health and when operating effectively can have a substantial impact on health improvement and health equity. A recent report from New Zealand (Tobias and Yeh 2009) looked at the impact of health services on amenable mortality over a 25-year period. It demonstrated that health service provision accounted for a third of the fall in mortality and a quarter of the reduction of the mortality gap between the Indigenous Māori population and the rest of the population. Tobias and Yeh’s findings confirm that health services are one of the best investments for reducing health inequities.

It should also be noted that two thirds of the health improvement and three quarters of the inequality reduction occurred through factors outside the health sector. It was apparent in our evaluation that in many remote communities the health system is better organised and its governance structures more developed than those of other sectors. For example, there is a justifiable expectation in the community that much more needs to be done to improve the current housing situation and thereby the health of the people living in sub-standard housing. The issue for the NT PHC sector is how it can work with and support positive change in the wider determinants of health without lessening its focus on improving PHC service provision or becoming the fix-it team for matters outside its operational scope.

Health service responses to addressing social determinants can be divided into three areas—addressing 
equity issues within health services, preventing or ameliorating the health damage caused by living and growing in disadvantaged circumstances and tackling poverty and other wider determinates more directly (Whitehead et al 2009).

The NT PHC sector focus is currently on addressing equity issues within health services at the primary level 
by directly addressing geographic and ethnic inequalities. We have suggested that a people-centred approach, where the PHC sector is more actively involved in referred and secondary services, would further extend the positive impact of the sector and bring a stronger health equity focus to the bulk of health expenditure that occurs in the hospital sector.

The current services are also closely focused on preventing or ameliorating health damage caused by living and growing up in disadvantaged circumstances. At least one ACCHO currently employs an Environmental Health Officer and many other organisations work closely with community stores to encourage improved nutrition. Broadening the scope of work of health services to include a wider range of community services would further strengthen the impact of PHC in this area. Positive and innovative government policies—such as fresh food subsidies in remote communities and funding for initiatives such as market gardens—would help by providing the mandate for a wider scope of PHC influence.

The direct impact of health services on poverty is also evident and could be given a sharper focus. Health services are employers and stimulate local economies and income levels have an impact on social determinants. Provided there is increasing participation of Aboriginal people at all levels of the organisation, PHC services can help improve health status through service delivery and employment opportunities. Addressing the obstacles that are hindering increased Aboriginal participation, such as the lack of education and training opportunities in remote areas, should be a high priority.

The pathway to effective partnerships is not always clear-cut. For example, in many remote communities the poor quality of housing and lack of services to repair and rebuild houses means that working more closely with housing services may have little impact. The most pragmatic contribution health services may therefore make could be to highlight the effects of poor housing on health and advocate for increased investment in housing.

While stronger engagement with social services is important, Bailie et al (2008) suggest that practitioners are often not inquiring about social issues during screening due to a lack of appropriate and effective referred services. Increased links between the health, housing and social sectors must therefore be supported by a commitment to build strong referred services, built on reliable information about the precise services the community requires. Information sharing between agencies, such as health services providing information to social service agencies, can assist with this process.

In order for the NT AHF to support positive change in the wider determinants of health, there may be benefit in it establishing formal links with FaHCSIA and other government agencies such as Territory Housing. This should stop short of formally including another government agency in the NT AHF as this would shift the current balance of power between the government and non-government sectors and between the federal and territory levels.
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5.4.3 Summary and conclusions

Before the NTER, work was underway to develop governance structures for the NT health sector, mainly through the NT AHF partnership of DoHA, DHF and AMSANT. These existing frameworks served the developments in the sector well, providing the initial framework through which to manage the sudden increase in resourcing that came with the EHSDI.

The majority of policy work on the EHSDI has been undertaken by the PHRG, a group of senior policy and clinical officials from the NT AHF partners. The existing level of implementation policy resources to support the reforms, however, is insufficient to effectively sustain the pace of the reform agenda. Policy capacity needs to increase to sustain the pace and positive impacts of the reform process. This is particularly important in light of the emergent Australian Government health policy direction that includes the decision to broaden the scope of PHC approaches to include some hospital outpatient services. Moves to strengthen the health sector’s interaction with the wider social determinants of health will also need to be supported by increased policy capacity.

Overall, there is a need to consider the governance functions required to guide the EHSDI reform process and then determine the best way to fulfil these functions. This includes a need to re-establish and clarify the NT AHF’s function, which should include a mandate to reach consensus among the partners on policy and funding. Then the form of that policy and funding can be considered. A commitment to an ongoing partnership between the Australian Government, NT Government, and the Aboriginal controlled health sector is critical for making progress on the reform agenda. The NT AHF partners need to further consider enhancing communications across and between the partners and communication within each partner agency.

The governance functions of the NT AHF would be further enhanced with non-aligned consumer representation. This could include providing a forum for community voices to ensure they are heard independently from service providers.

A commitment to organisational change is required from all three partners to respond to the current environment. The NT AHF needs to maintain a focus on governance and oversight functions, rather than the practical implementation aspects of the reforms, if it is to continue to contribute positively to the ongoing program of reform.
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