Why is it important?:'Governance' involves having the processes and institutional capacity to be able to exercise control through sound decision-making. 'Competent governance' requires the means to establish good governance arrangements with the ultimate aim of achieving the social, cultural, and economic developments sought by citizens (Dodson et al. 2003).
Governance enables the representation of the welfare, rights and interests of constituents, the creation and enforcement of policies and laws, the administration and delivery of programs and services, the management of natural, social and cultural resources, and negotiation with governments and other groups (de Alcántara 1998; Hawkes 2001; Westbury 2002; Dodson et al. 2003). The manner in which such governance functions are performed has a direct impact on the wellbeing of individuals and communities.
The governance model of Aboriginal Community Controlled Health Services (ACCHSs) was first established in the 1970s, and by the 1990s ACCHSs were an important provider of comprehensive and culturally appropriate primary health care services to Aboriginal and Torres Strait Islander peoples (DoHA 2001; Larkins et al. 2006).
Competent governance in the context of Indigenous health must also address the cultural responsiveness of mainstream service delivery for Indigenous clients and effective participation of Indigenous people on decision making boards, management committees and other bodies, as relevant. The stewardship role of governments in their efforts to improve Aboriginal and Torres Strait Islander health is also critical. Attention should be given to assessing not only the levels of access to appropriate care but also the experiences of Aboriginal and Torres Strait Islander peoples in receiving care. Unfortunately, very little data are available nationally on these issues.
Findings:The Office of the Registrar of Indigenous Corporations (ORIC) helps to administer the Corporations (Aboriginal and Torres Strait Islander) Act 2006, which superseded the Aboriginal Councils and Associations (ACA) Act 1976. In 20010–11, 82 out of the 86 Indigenous health corporations incorporated under the ACA Act and registered with ORIC had been fully compliant with the required provision of documents.
In 2010–11, 202 Aboriginal and Torres Strait Islander primary health care services funded by the Australian Government provided data. Of these, 95% had a governing committee or board that met regularly; 99.5% had presented income and expenditure reports to the governing committee or board on at least two occasions through the year; 74% had a governing committee or board who were all Aboriginal and/or Torres Strait Islander people; and 79% had governing committee/board members who had received training related to governance issues.
In 2010–11, 47 Aboriginal and Torres Strait Islander substance use specific services funded by the Australian Government provided data. Of these, 98% had a governing committee or board that met regularly; all services had income and expenditure statistics presented to the committee or board on at least two occasions; 53% had a governing committee or board comprised entirely of Aboriginal and/or Torres Strait Islander people; and 75% had governing committee/board members who had received training related to governance issues.
In 2010–11, 39% of Aboriginal and Torres Strait Islander primary health care services had representatives on external boards (e.g., hospitals); 59% participated in Regional Planning Forums and 80% were involved in committees on health (e.g., steering groups). As at June 2010, 85% of services funded under the Healthy for Life program reported having formal mechanisms in place to involve their service population in planning, while 89% had a formal complaint mechanism.
In 2004–05, 15% of Indigenous Australians reported that they needed to but didn't visit a doctor in the previous 12 months, 8% did not visit another health professional when needed and 7% did not visit a hospital when they needed to (see measure 3.14). Some of the reasons people didn't access services reflect failures in health services to adequately address the needs of these patients. For example, 10–16% did not attend services because they disliked the service/professional, felt embarrassed or afraid, 5–6% felt the service would be inadequate and 1–2% were concerned about discrimination and cultural appropriateness. In addition, a range of other reasons people did not access health care when they needed to reflect potential failures in the governance of the health system as a whole, e.g., cost, transport/distance, or the service was not available in the area.
In 2008, 8% of people aged 15 years and over surveyed in the NATSISS disagreed or strongly disagreed with the statement 'Your doctor can be trusted'. In addition, 17% disagreed or strongly disagreed with the statement 'Hospitals can be trusted to do the right thing by you'.Top of Page
Implications:These data show a continuing number of Aboriginal and Torres Strait Islander primary health care services are demonstrating sound governance arrangements. Case studies of the performance and governance of three Aboriginal councils in Qld between 2000 and 2006 (Limerick 2009) identified contextual factors (such as education and skills, exposure to the 'outside world' and having a 'whole of community' focus in decision-making as opposed to family or kin orientation) as being significant in shaping successful governance attributes. It was also concluded from the case studies that 'ostensibly orthodox governance principles and practices are not only relevant in the unique cultural context of Indigenous governance, but perhaps have even greater importance in this context'.
A key strength of ACCHSs is their ability to respond flexibly to local community needs. Anderson and Brady (1995) suggest that self-determination has led to the development of health services with complex functions that are often a focal point for the community. Many ACCHSs are part of larger community organisations which perform other social functions as well as health, such as housing (Sullivan et al. 2007). It is important to note that the negotiation between a 'community controlled' organisational philosophy and the norms of central bureaucracies may at times give rise to 'conflicting ideas of accountability' (Anderson et al. 1995).
The Department of Health and Ageing aims to support continuous improvement in Indigenous-specific service delivery and sector capacity through:
- continuous improvement in the business planning and management systems of existing services;
- a robust Risk Management Framework;
- targeted support to organisations in difficulty;
- providing systems for improved reporting of service activity and client health status and supporting the use of electronic Patient Information Recall Systems;
- the development of enhanced governance practices through the NACCHO Governance and Member Support Initiative; and
- supporting accreditation through the Establishing Quality Health Standards initiative, and ensuring that cultural security is recognised in Australian healthcare standards.
Independent primary health care organisations—Medicare Locals—have been established with strong links to local communities and health professionals. Medicare Locals aim to improve coordination and integration of primary health care in local communities, address service gaps, and make it easier for patients to navigate their local health care system.
LHNs and Medicare Locals are collaborating to improve patient care and the quality of health and hospital services. They are working to better integrate general practice, primary health care and hospital care, so patients smoothly transition in and out of hospital and continue to receive the care they need. They are working together to identify and address local needs, including the needs of Aboriginal and Torres Strait Islander peoples and ACCHSs. The National Health Performance Authority will report on the performance of individual LHNs, hospitals and Medicare Locals in accordance with the Performance and Accountability Framework (NHPA 2012).
Table 44—Number and proportion of health corporations incorporated under the CATSI Act 2006 by compliance, 2010–11Top of Page
Source: AIHW analysis of The Office of the Registrar of Indigenous Corporations (unpublished data)
Table 45—Number and proportion of Aboriginal and Torres Strait Islander primary health-care services participating(a) in mainstream processes, 2010–11
|Representation on external boards (e.g. hospitals)|
|Participation in regional planning forums (e.g. under the framework agreements)|
|Involvement in committees on health (e.g. steering groups)|
|Total number of services(b)|
(a)A service is recorded as having conducted an activity if that activity was conducted by either the service itself or by one of its auspiced entities.
(b)Total number of services that provided information.Top of Page
Source: AIHW analysis of OATSIH Services Report, 2010–11
Table 46—Number and proportion of governing committee/board use, Aboriginal and Torres Strait Islander primary health-care services and substance-use services, 2009–10
|Services||Primary health care services Number||Primary health care services|
|Substance use services Number||Substance use services|
|Governing Committee or Board met regularly|
|Income and expenditure statements were presented to Committee or Board on at least two occasions|
|All of the Governing Committee or Board Members were Aboriginal and/or Torres Strait Islander|
|Governing Committee or Board received training|
|Total number of services|
Source: AIHW analysis of OATSIH Services Reporting, 2010–11Top of Page