This section includes a summary of our findings in relation to the:
- development of the CHCI
- coverage of the child health checks
- delivery of follow-up services
- impact of the CHCI on health service delivery and the health system
- impact of the CHCI on health status.
4.1.1 Development of the CHCIThe CHCI arose from intense political pressures and through an unusually rapid process. The initial announcement of the NTER measures included compulsory checks for all Aboriginal children aged 0–15 years to identify and treat health problems and any effects of sexual abuse (Brough 2007). Widespread criticism from the medical profession on the compulsory aspect of checks prompted intense discussion between ministers, officials and professional organisations. A change in policy, stating that child health checks would not be compulsory, was announced by the Health Minister 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.
The final form of the child health check was a response to the health sector’s concerns, moving from an activity that it perceived as unethical, towards a response that still fulfilled the broader intent of the Australian Government’s original policy position of examining children, but now not for sexual abuse.
An existing program, MBS Item No. 708, provided a de facto policy platform and an alternative approach to assessing the health of Indigenous children. This provides health checks for Aboriginal and Torres Strait Islander children aged less than 15 years and is intended to facilitate early detection, diagnosis and intervention for common and treatable conditions. Although MBS Item No. 708 became the policy basis for the child health check program 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 GP will be the main provider of care, involving other health practitioners in a PHC team as appropriate, and that the check is carried out as part of an ongoing relationship with a health clinic or health practitioner. This was not the case in the delivery of the CHCI.
There is no record of government officials engaging in a policy discussion on whether the individual items in the child health checks conformed to established criteria for the design and operation of screening programs, such as those issued by the World Health Organization (Wilson and Jungner 1968). This is not unusual—many ‘health check’ programs are implemented without adhering to the WHO principles, despite the desirability of doing so. Similarly, we could find no evidence of consideration of appropriate approaches to Indigenous communities, specifically of the acknowledged and previously common practice of consulting with communities before a health initiative is undertaken by someone outside the community. While child health checks had long been a feature of the NT health system there was no analysis of the strengths and weaknesses of these checks before the design and launch of the CHCI. This information should have been part of any policy consideration before the CHCI was implemented. top of page
4.1.2 Coverage of the CHCIThis section addresses CHCI evaluation objective 1—assess the extent to which the child health checks reached the target population.
The estimated overall coverage rate of the child health checks is between 57–65 per cent of the total eligible population (Table 1) depending on the data definitions used.
Table 1: Number and proportion of children who had a child health check (July 2007 to 30 June 2009)
Number of children who had a CHC(a)
Proportion of eligible population who had a CHC
|Analysis of CMI linked data(b)||8,415||14,647||57.5%|
|AIHW analysis of CHCI data(c)||10,605||16,259||65.2%|
(a) Figures exclude 4,000 checks provided under the MBS (item 708). These checks were not specifically funded through the NTER.
(b) The Client Master Index (CMI) is an NT-wide database of all clients accessing public health services within the NT. Estimated eligible population based on the Australian Bureau of Statistics definition of excluding urban areas, and on the population aged 0–15 years at the child health check finishing time in each region.
(c) Estimated eligible population based on Australian Bureau of Statistics Indigenous resident population figures for 2006 for children aged 0–15 years who live in communities and town camps covered by the CHCI.
Source: DHF analysis of CMI data; AIHW and DoHA (2009).
Table 2: Number and proportion of children who had a child health check and coverage by region (July 2007 to 30 June 2009
Children who had a CHC
Coverage of CHCs
Proportion of eligible population who had a CHC
|Alice Springs Rural||1,926||22.9||3,202||60.1|
|Alice Springs Urban||96||1.1||256||37.5|
|East Arnhem District||2,045||24.3||3,227||63.4|
Source: DHF analysis of CMI data.Child health check coverage rates for the five case study communities are shown in Table 3. Two estimates are provided—one based on the child health check dataset and associated estimates from the Australian Bureau of Statistics/DoHA and the other on community level data, including community level population estimates. This further highlights the challenge in estimating coverage rates. top of page
Table 3: The proportion of children in the five case study communities who received child health checks according to different eligible child population estimates (July 2007 to 30 June 2009)
Population aged 0–15 years
Number of children who had a child health check
Australian Bureau of Statistics/DoHA estimates(a)
Community level estimates(b)(c)
Community level data(b)(c)
Alternative estimate based on community data
a) AIHW analysis of CHCI data.
(b) DHF data as at 3 September 2009.
(c) Health service estimate dated 31 August 2008. Population estimate as at the commencement of the CHCI. The number is likely to include records for children who also use the services of a nearby Homelands health service (an Australian Government taskforce team is said to have travelled to one Homeland community only, otherwise children living in Homelands communities were checked at the health service in Community B); children who periodically come and live in the community and use the service; visiting children; and children who have since moved to live in other communities.
(d) HIC MBS Item No. 708 Child Health Check.
(e) Health service staff in this community believe that a coverage rate of approximately 89 per cent accurately reflects the proportion of children who received checks.
Child health check coverage was higher among 2–9 year olds and lower for children aged 14–15 years and children who were less than one year old. These results support the experience of health service staff working in one of the case study communities—eligible children in the older age ranges, for a number of different reasons, did not wish to have a child health check. It may indicate that older children are more likely to access health care when they see a reason to (for example when they are ill or injured). The low coverage among the under one-year-old age group may be due to the carers of these children choosing not to attend an additional check-up on top of other checks already attended for newborn children.
Other reasons given for why children did not get a check include:
- children were living in another community at the time the child health check team visited
- some guardians felt frightened by the early media coverage and controversy surrounding the intent of the checks (that is, the initial focus on checking for signs of child sexual abuse)
- some guardians felt their children did not need a check as they had recently been checked.
- Children who received a child health check were significantly more likely to have previously been hospitalised than children who did not have a check. For the period 1 July 1991–30 June 2007, age-adjusted hospitalisation rates (per 1,000 population) were 253 for the group of children who had a check and 207 for the group of children who did not. Actual (non-age-adjusted) rates for the two groups over this period show an average of 3.4 hospitalisations per child for the group of children who had a check, compared to 2.8 hospitalisations per child for the group who did not have a health check.
- Children who received a child health check were significantly more likely to have participated in the GAA program than children who did not get a check, with an average number of attendances of 3.5 compared to 1.9 for children who did not have a health check.5
- There was no significant difference in the proportion of children with low birth weights between the population who received a child health check and the population who did not.6
- There was little difference between the two groups in the reasons for hospitalisation.
The difference in GAA participation rates suggests that children who received a child health check are more likely to attend checks and that the CHCI was, therefore, not an effective mechanism for reaching children who did not already attend check-ups. The data on low birth weights does not strongly suggest that either population (the checked or the non-checked) is healthier than the other. top of page
4.1.3 Delivery of follow-up servicesThis section addresses CHCI evaluation objective 3—assess the extent to which requested primary care, allied heath and specialist follow-up services have been received, the gaps in existing health service delivery and barriers to completing follow-up treatment.
The proportion of children receiving at least one referral from the child health checks was 69.5 per cent (AIHW and DoHA 2009). The most common referrals were for: PHC (38.6 per cent); dental (35.1 per cent); tympanometry and audiology (14.0 per cent); and paediatrics (12.1 per cent).
At the time of writing, many children had not received the services to which they had been referred through the CHCI (see Table 4). As at 2 November 2009, 19.6 per cent of children referred for PHC follow-up, 42.0 per cent referred to paediatric services, and 57.4 per cent referred to other specialist services had not been seen by these services. By 19 July 2010, 39.8 per cent of children referred to dental services, 34.2 per cent to an ENT specialist and 45.4 per cent to tympanometry and audiometry services had not been seen by these services.
These outcomes are not unexpected given the large number of referrals, the existing (pre-CHCI) service patterns for the main referral areas, the already high workloads of some specialists, the time constraints and the rush to establish systems, the need to procure infrastructure and recruit staff, and general logistical problems. Not all these referrals, however, will be outstanding. Some children will no longer require the service they were referred to, and some children will not be able to be traced for follow-up (for example they will have moved out of the prescribed areas).
Overall, the number of follow-up services actually provided is likely to be greater than indicated in Table 4, because in some cases children received services but no chart review was completed and some received additional referrals as a result of their initial specialist consultation.
In any screening program, there is a moral and ethical duty to follow up on the conditions identified. The level of follow-up from the CHCI, as at July 2010, ranged from 42.6–80.4 per cent, depending on the type of referral (Table 4). The total number of referrals was 10,404, of which 6,677 (64.2 per cent) had been followed up and 3,727 (35.8 per cent) had not been followed up.7
It seems that there was no system in place that could capture whether follow-up services were received outside the more traditionally recognised PHC or secondary health care services. This was a significant deficiency, particularly given the critical role of services such as family, community, housing and social support in addressing the broader needs of Aboriginal children.
Table 4: Number of children with a child health check referral and number of referrals provided (July 2007 July 2010)
Children with a referral from check(b)
Children with a referral from check and chart review completed (c)
Children seen at least once by referred service (number of referrals provided)(d)
Children seen at least once (%)(d)
Children who have not been seen (%)(d)
|Primary health care (at 30 June 2009; chart review data at 2 November 2009)|
|All NTER areas|
|Paediatrician (at 30 June 2009; chart review data at 2 November 2009)|
|All NTER areas|
|Dental (at 19 July 2010)|
|All NTER areas|
|ENT specialist(c) (at 19 July 2010)|
|All NTER areas|
|Tympanometry and audiometry (at 19 July 2010)|
|All NTER areas|
|Other specialists (at 30 June 2009; chart review data at 2 November 2009)|
|All NTER areas|
(a) The CHCI in community E used non-standard forms and the referral information was not available for analysis, so is not included in this table.
(b) The number of children with referral does not equal the number of referrals because one child can have multiple referrals. Dental, and tympanometry/audiometry referral is based on the number of referrals made at the first child health check. ENT referrals also include referrals received at chart review.
(c) For PHC, paediatric and other specialist referrals, only children who received a chart review can be identified if they have or have not been seen by these follow-up services.
(d) For PHC, paediatric and other specialist referrals, number and percentage is based only on those who had a chart review completed. For dental, ENT and tympanometry/audiometry, the data comes from separate dental and audiology data collections. The dental data does not include follow-up services provided by ACCHOs independent of NTER funding.
Source: AIHW and DoHA (2009); Data supplied by AIHW (August 2010).
Initially there were inadequate processes for administering and organising referrals for specialist follow-up services that had been transferred from local service providers to the DHF. Specialist follow-up services were delivered through visiting or outreach services and workforce shortages meant that these services were often supply driven (that is, driven by the availability of specialists rather than the demand for services). For example in case study community B, paediatric follow-up services were referred to the DHF paediatrician who provided routine visits to the community, which at the time were scheduled for approximately one day every three months. The number of referrals (approximately 84), on top of an existing waiting list, proved to be an overwhelming workload for the single paediatrician. No additional paediatric services were forthcoming and the CHCI follow-up referrals were largely not acted upon.
The NT remote health system also lacked the necessary infrastructure to provide specialist services. For example, the funding agreement between DoHA and DHF for dental services stipulated ‘a visit to each prescribed community with treatment provided as required, assessing and treating as required 100 per cent of eligible children’ (DHF, correspondence, September 2008). However, case study community B did not receive dental facilities and equipment until late 2009, preventing a large number of children from receiving follow-up services under the funding agreement.
New service delivery models for hearing/ENT and dental services may contribute to overcoming barriers to the delivery of services to remote communities. CHCI funding enabled DHF to develop a comprehensive case management service delivery model for a range of services for children identified with ear disease and hearing impairment. The case management model tracks children through all parts of the system.
DHF established a new unit with DoHA funding called the Helping Hands Child Oral Health Program to deal with the large number of dental referrals. To overcome the workforce shortage a new service delivery model was developed based on recruiting staff from interstate for three-week placements to provide mobile dental services, outreach services and secondary hospital (surgical) services.
While these service delivery models are positive developments, it would be beneficial to monitor and evaluate the models once they are fully operational to assess what impact they are having on health outcomes. The effectiveness and sustainability of these new service delivery models would be enhanced by integrating care with PHC, including health promotion.
It is not possible to report on the quality of the child health check assessments and how many unnecessary follow-up referrals may have been made. The differences in referral patterns between some visiting child health check teams working in the same community indicate inconsistencies in referring between different doctors. Variation in aspects of clinical practice is common in all health systems, leading to different referral patterns. Interviews with a number of NT health professionals suggested that some over-referral occurred and this is likely to reflect inexperience and a lack of confidence of some doctors working outside their normal scope of practice. top of page
4.1.4 Impact of the CHCI on health service delivery and the health systemThis section addresses CHCI evaluation objective 4.1—whether the CHCI has led to improvements in health service delivery.
Impact on staff and servicesThe impact of the CHCI on existing health services and staff varied significantly. Where the child health checks were done as part of a Medicare item 708 check, the clinics continued to deliver these Medicare checks and the CHCI had no noticeable effect on how they were delivered. Where a clinic recruited its own dedicated staff to do the child health checks, other services had to be suspended for a week so the staff could focus on doing the checks. This put staff under pressure to get the checks completed so normal services could resume as soon as possible.
In other cases, the child health checks were done by visiting Australian Government task force teams with other services running as normal. In three of the four communities we studied that involved visiting task force teams, the resident teams worked closely with the visiting teams to provide support, advice and direction, as well as continuing to provide normal services. This led to heavy workloads for resident teams. However, it also helped to integrate the checks into normal clinic business and for members of the community this often meant that the checks were almost indistinguishable from normal clinic services.
Several negative impacts on staff and services were apparent, including the need to reassure the community about the child health checks and to overcome feelings that ranged from general scepticism about the checks to real fear that people’s children would be taken away. We found evidence of tensions between visiting teams and resident staff, who in some cases were angry that outside staff were being brought in to do the checks. There were also tensions between members of the visiting teams who were not used to working together or used to the conditions in remote communities. The additional workload and stress at the time of the CHCI was an issue for resident health workers.
The lack of engagement between the CHCI and the people and structures in various parts of the health system at the policy and planning stage, before the child health checks started, appears to have been quite destructive. For example, this led to children being viewed by health services as ‘your kids’ or ‘our kids’ depending on whether they were accessing a service through a child health check referral or a referral from normal service delivery. Staff morale and motivation at various levels suffered within the system and within both the government and ACCHO sectors. In its health impact assessment, the Australian Indigenous Doctors’ Association (AIDA) identified disempowerment of local services as one of eight negative impacts of the CHCI, quoting a senior Aboriginal official:
- It disheartened a lot of people who’d been doing a lot of hard work in the Northern Territory for a long time. I think that was negative. People feeling, you know who’ve worked for 10, 15 years, working very hard, suddenly felt that you know their contribution wasn’t valued. (AIDA and Centre for Health and Equity Training, Research and Evaluation 2010)
- closing clinics and/or suspending normal PHC services in order to deliver the checks
- duplicating assessments when the child health checks were not coordinated with existing services including routine health checks of children (AIDA and Centre for Health Equity Training, Research and Evaluation 2010)
- the administrative burden associated with processing child health check forms and managing referrals (which generally fell on the existing service)
- existing specialist follow-up appointments being ‘bumped’ by referrals generated by child health checks
- over-referrals taking up the time of specialists
- the loss of capacity of staff, particularly Aboriginal, who either left the workforce or whose morale was damaged as a result of feeling disempowered or stigmatised by the NTER process.
- the extra resources were welcome, particularly capital infrastructure in clinics, audiology equipment and additional staff time for follow-up services
- noticeable improvements in the delivery of some health services such as more dentists on the ground and improved audiology services
- sharing of health knowledge between the staff and visiting teams.
- substantial investment in addressing child health problems
- improved access to medical, dental and specialist health care services. top of page
Impact on the NT PHC systemAny improvements in the NT PHC system seem to be only noticeable for follow-up services. The CHCI program model explains a number of limitations. While the CHCI provided a one-off surge in capacity, there was not always the organisation or infrastructure within the system to respond to this sort of surge. As a result, there was a ‘bubble’ of Aboriginal children aged 0–15 years who had a child health check but were in a system that was not sufficiently organised to provide a clinical pathway through to secondary and tertiary care. The ‘fly-in/fly-out’, one-off service model did not always achieve sufficient engagement with the existing staff and services to have any real, ongoing influence on either the staff and services or the PHC system more generally.
While the CHCI’s more immediate impacts on staff and services were largely negative, the program has evolved to achieve some successes which have the potential to bring positive impacts at the systems level. The follow-up phase of CHCI has left a legacy of system infrastructure, including additional audiology booths and dental equipment. The CHCI follow-up phase also led to the development of new service delivery models, such as the hearing/ENT and dental delivery models outlined previously, which are having a positive effect at the NT PHC system level.
The CHCI has added a lot of information and data to the PHC system. During the case studies, we heard that larger organisations with more resources have been able to use the data to improve programs and to review the treatment of some conditions. This includes the DHF which, as the main provider of oral health services in remote communities, has used data from the CHCI dental collection to plan regular oral health services. Smaller organisations and providers with fewer resources, however, do not have the capacity to make use of the CHCI data. There is a widespread view among NT health professionals that the CHCI data has ‘told us nothing we didn’t already know’, leaving no legacy to the system for increasing knowledge of disease and treatment in Aboriginal children.
There is evidence that the CHCI data has been used to support greater understanding, particularly within the Australian Government, about the needs of Aboriginal children in the NT and the extent to which the services and systems are able to respond to this need. Since the CHCI was implemented, DoHA has regularly been asked at Senate Estimates hearings about the progress of the checks and follow-up referrals, as well as the prevalence of the specific conditions found. The CHCI data provided the basis for responses to the committee. In responding to a series of questions on the progress of the CHCI at the Senate Standing Committee on Community Affairs, a DOHA senior manager made the link between the data, better understanding and the PHC reforms in the NT:
- It [the regular analysis and publication of CHCI data] is part of the reason why the significant change in primary health care is taking place in the Northern Territory and remote services—partially in response to a better understanding of the types of conditions that children have and the types of services that primary health care needs to be able to deliver (Commonwealth of Australia 2009).
While the CHCI itself may not have been the most effective or appropriate initiative, the sustained media and political attention generated by the initiative ensured that NT remote health remained visible on the political agenda and eventually led to the announcement of the EHSDI, which has the potential to have a longer-term impact on health outcomes. A significant challenge for the future will be to ensure that the health needs of Aboriginal children remain visible and high priority for both the Australian Government and the NT Government. top of page
4.1.5 Impact of the CHCI on health statusThis section addresses CHCI evaluation objectives 4.2 and 4.3—consideration of the health status of children in relation to the social determinants of health and consideration of treatment outcomes.
Health services, both local and visiting, provided a significant amount of treatment during the child health checks. Just over half (53.2 per cent) of all children were treated with at least one medication, while 6.7 per cent of children were given a vaccination (AIHW and DoHA 2009). Of the 4,346 children who received a dental check as part of the CHCI, 59.6 per cent received oral health education, 52.2 per cent received treatment for previously untreated caries and 25.5 per cent received treatment for inadequate dental hygiene including plaque and calcification (data supplied by AIHW, August 2010).
While many of the diseases found and treated during the CHCI could potentially impact on population health status within the time frame of the evaluation, there is limited data on these impacts.
There were 1,091 children who had two or more audiology checks as at 19 July 2010 as part of the CHCI. The average period of time between the first and last check was 164 days (around five and a half months). Table 5 shows that for the 514 children who had at least some hearing impairment at the time of their first audiology check, the degree of hearing impairment improved for around half (54.5 per cent) and deteriorated for around a third (34.1 per cent) of all children.
Table 5: Changes in the degree of hearing impairment between the first and latest check for Aboriginal children who had at least two audiology checks (19 July 2010)
Degree of hearing impairment
Source: Data supplied by AIHW (August 2010).Any changes in the degree of hearing impairment may be attributed to the treatment provided through the CHCI, factors that affected diagnosis (such as the doctors’ knowledge of diseases and the equipment used for testing), or changes associated with social determinants. It is important to note that the biggest variable is the natural history of audiology conditions which tend to be chronic and recurrent rather than deteriorating, so some fluctuation in the degree of hearing impairment between checks is to be expected.
The general view among case study participants was that children’s health had not changed since the NTER. There was a feeling that oral health had improved due to the services that were provided and given that the baseline in access to dental services was so low before the CHCI. There was also a feeling that the dental services were focusing on treating symptoms rather than causes and that improvements may not be sustainable. There was also a view that the large number of audiology checks and improved access to specialist care may have temporarily reduced the prevalence of ear disease, but that the small amount of surgery done was, as expressed by one health professional interviewed, ‘nothing that would change the
long-term health of the population’.
While the CHCI may impact on the health of individual children in the short term, intervention while poor social conditions continue will have little impact at a population level as children simply get re-infected or continue to live in conditions that promote or exacerbate chronic illness. Case study participants identified poor quality housing as a critical issue. We used a social determinants of health assessment tool, developed by the Menzies School of Health Research (MSHR 2006), to get a baseline measure of where each case study community sat on a range of indicators. The results matched the stories we heard about the poor condition of housing, with the ‘healthy housing’ indicators scoring, on average, as ‘poor’ and significantly lower than the other factors.
It is vital to take a holistic approach to health care, with a focus on acute and preventative care and engagement with wider social determinants. While we acknowledge that the NTER involved a wide range of measures including housing, income support, and education, in practice there did not appear to be a strong relationship between the CHCI and these other initiatives. Future policy needs to focus on the broader aim of relieving poverty and improving the economic and social conditions in remote Aboriginal communities. Provision of access to quality medical care, linked with better housing, education and employment opportunities is critical to improving Aboriginal health at a population level.
2 This percentage is based on the total number of resident children measured as part of the GAA program, as a proportion of the total number of resident children.
3 Eligibility based on residence in DHF’s Client Master Index and ABS definition of identifying population in prescribed areas.
4 Estimate based on CHC dataset and pro-rata of the ABS population estimate of Indigenous children aged 0-5 years living in prescribed areas.
5 This data is based on participation in the GAA program delivered by DHF service providers between 1992–93 and 2008. Data from
all NT service providers for the period 2003–06 shows a similar result.
6 We looked at low birth weight because it is an important indicator of both the immediate health of the newborn and of the longterm
risk of adult chronic disease.
7 These figures refer to the number of referrals and not the number of children. A child may have multiple referrals.