We have developed theoretical program models for child wellness checks and the PHC system reform to inform major issues and questions for future monitoring and evaluation and the ongoing implementation of the reforms. While the models have limitations (such as the risk of over-simplifying and de-contextualising the programs), they are a useful way of illustrating relationships between different parts of the health system and focusing on the key issues underpinning these relationships.
4.4.1 Child wellness checksIn constructing a theoretical model and identifying issues and questions for future monitoring and evaluation of child wellness checks, we have assumed a programmatic response. There are other ways of delivering child wellness services and the majority of PHC is likely to be provided outside formal screening programs, such as when a child presents at a clinic with an illness. Children’s journeys through the system should be the same and access to services and outcomes need to be monitored for children who receive services through a wellness check program and children who receive services outside the program. The child wellness check model, therefore, sits within this broader context of child wellness services and the health system.
The theoretical model for future child wellness checks is shown in Figure 1. The child wellness check, as the principal activity, is at the centre of the model and involves a cyclic process of checking, treatment, referral and follow-up treatment. In this model the wellness check includes the whole treatment pathway and not just the screening element. Importantly, there is an element of prevention and early detection in child wellness checks (that is, identifying conditions before they are symptomatic and preventing illnesses from happening) and not all children will require treatment and referral. The model then sets out the main elements of the development process (inputs) and the hierarchy of anticipated outputs and outcomes, from both a health service perspective (left side of model) and population health perspective (right side).
There is a focus in the model on the development process for wellness checks, reflecting a number of the central themes from the CHCI evaluation. This is depicted by the two central (and closely related) ideas (and their component parts) shown within the central and corresponding outer circles on either side of the model. The collection and analysis of information should address the following:top of page
- the nature of the health problem
- the population group that needs to be targeted for the health problem
- the determinants of health associated with the health problem and the target population and which need to be addressed
- the nature of any inequalities that exist in the target population and the types of intervention that will reduce these inequalities
- the types of intervention regarded as effective in addressing the health issue and which of these are acceptable to the target population
- how considerations of cost, cost-effectiveness, workforce, infrastructure and the operating environment will affect any interventions that might be selected
- the sustainability of any interventions that might be selected.
Table 7: Monitoring and evaluation questions for child wellness checks
Key monitoring and evaluation questions
|The wellness check focuses on condition(s) which are important for the target population (i.e. the population health need is defined)||
|The target population is defined||
|There is a suitable test specific to the condition(s)||
|There is an acceptable treatment/intervention for the condition(s)||
|Early treatment is better than later||
|Facilities for diagnosis and treatment are available||
|The resources are economically balanced in relation to possible expenditure on medical care as a whole||
|Data is collected and used to improve service delivery||
|The wellness check is part of a continuous process and not a one-off project||
4.4.2 NT PHC system reformThe theoretical model for the NT PHC system reform is shown in Figure 2. The model reads from bottom to top, beginning with identifying assumptions and context, and then the system level ‘enablers’, which are the inputs and resources required for each of the health systems building blocks. The next level requires appropriateness, effectiveness and efficiency in planning, managing and delivering services.
Shifting to the service level, the model details the types of outcomes that might be expected in the short term (1–3 years). The next level considers the changes that might be expected in community development and capability over the medium term (3–5 years). Beyond this the model moves to longer term (5–10 years) outcomes for community members or individuals, with the Council of Australian Governments (COAG) outcomes for Aboriginal and Torres Strait Islander health as the ultimate outcome.
Down the right-hand side of the model are four deeper, cross-cutting themes that apply across all levels of the system:
- partnership, capacity and communication
- improved partnerships/relationships with Aboriginal communities
- improved coordination of services
- sustainability of inputs, activities and outcomes.
- service availability and use against the core PHC service framework
- equity in access to core PHC services
- coordination of health care across the health system (for example between primary and specialist services) and of health care with other social services such as child protection, corrections, housing and special education.
Leadership and governance
- the effect of regionalisation models on: health service utilisation and acceptability/ satisfaction; the engagement of Aboriginal communities in health service governance, planning and delivery; and efficiency
- the capacity for systems-wide approaches to health strategy, policy and data collection, analysis and use
- the effectiveness of partnerships and engagement with other sectors and departments.
- progress against any agreed workforce strategies
- the impact of additional positions created under the EHSDI on the scope of PHC services and service utilisation
- the effectiveness of systems and processes for recruiting, training and supporting AHWs and for supporting Aboriginal employment and career pathways within the PHC system more generally.
- progress against any agreed funding targets, funding equity between regions and the ability of the system to spend resources effectively.
- the effectiveness of CQI activities and of the collection and use of information and data to support health service planning and delivery at a local level.
Long-term health and wellbeing outcomes
- To what extent has the gap in life expectancy between NT Aboriginal and non-Aboriginal people been reduced?
- To what extent has the gap in mortality rates for NT Aboriginal and non-Aboriginal children under five years of age been reduced?
- To what extent have health and wellbeing improved, for whom, how and why, and what else happened?
- To what extent have social determinants improved, for whom, how and why, and what else happened? top of page
4.4.3 Further evaluation considerationsEvaluation, like other aspects of service delivery, can become something that is ‘done to’ communities rather than a tool in which they are actively engaged and empowered. Future evaluation approaches need to see the regionalised community controlled organisations as a main reference point and as active participants in the evaluation process. A formative approach, and one in which the participants are active players in all aspects of the process, is recommended.
The need for the Australian Government to determine whether it is getting value for money from its investment in NT remote PHC services has been a major driver of this evaluation. Future evaluation must not only meet these needs, but give a more predominant role to the questions coming from remote communities.
Our conclusion from this evaluation of the CHCI and the EHSDI is that formative evaluation approaches, which are longer-term and more interactive with the participants, are likely to be most valuable.
Figure 2: Model of program theory for NT PHC system reform
top of page
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 child health check 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 long-term 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.
8 This includes funding from OATSIH, DoHA Regional Health Service funding, and NT Government funding.