E.1 OverviewCultural diversity is an important aspect of Australia's community with over 40% of the population either born overseas or has a parent born overseas.1 Burdekin (1993) identified that given the majority of people from non-English speaking backgrounds have come to Australia as migrants, the process of migration is a significant focus in considering prevalence, diagnosis and treatment of mental health problems, disorders, and illnesses in different ethnic groups.
Mental health issues can affect people of all ages and from different cultural and social groups.2 In 2007, one in five Australians aged 16–85 years had a mental disorder,3 and many studies have highlighted that people from diverse backgrounds will face numerous barriers when accessing timely and appropriate mental health care. These barriers include:
- Language - reluctance to use services due to language and cultural differences, lack of interpreter use or misuse of interpreters; limited information available in community languages;
- Cultural differences between client and clinician - culturally insensitive attitudes of organisations and service providers, lack of appropriately trained staff to work with CALD consumers;
- Knowledge - limited of awareness/knowledge about available services and GP referral patterns;
- Experience - pre-migration experience and/or trauma experiences; and
- Stigma - differences in cultural explanations and perceptions surrounding mental health. 4 5 6
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The work by the MMHA must support those objectives of the National Mental Health Strategy and the National Suicide Prevention Strategy, with consideration given to the Council of Australian Governments' (COAG) National Action Plan on Mental Health (2006-2011) and other relevant national plans/initiatives. To achieve this, the MMHA project has five priority work areas in the current Funding Agreement:
- Policy / Secretariat;
- Community Capacity Building and Development;
- Communication, Education and Information Dissemination;
- Consumer and Carer Support and Representation; and
E.2 MMHA reviewMMHA has been reviewed on two previous occasions: in 2001 when MMHA was formally known as the Australian Transcultural Mental Health Network; and in 2006 as MMHA. The findings and recommendations have been considered in the conduct of the current review.
This review has been commissioned nearly one year into the new Funding Agreement (2009-11). Stakeholders were informed by DoHA in November 2008 that this review (to be finalised in 2008-09) would identify priorities and future scope of work. The review outcomes and recommendations are intended to be considered in the implementation of the project during the remainder of the current funding period.
E.3 Review objectives and scopeThe overall aim of the review is to determine the appropriateness, effectiveness and efficiency of the Project. In doing so, the review aims to determine whether MMHA is:
- Achieving the outcomes that were originally identified;
- Internally structured in a manner whereby the responsibilities and decision making process is clear, ethical and transparent;
- Operating appropriately, effectively and is sustainable under the current model; and
- Identifying appropriate priorities and scope of work for future consideration.
- Effectiveness, suitability and sustainability of the current program model including:
- Implementation and impact of previous evaluation recommendations.
- Instances where there have been delays in implementation of the project and reasons for those delays.
- Effectiveness, representation and suitability of the governance and accountability model of MMHA, including decision making processes and identification of any areas requiring improvement including:
- Impact of previous evaluation recommendations;
- Identifying whether clear ethical and transparent decision making processes exist.
- Effectiveness of the financial and service management structures and identification of any areas requiring improvement including:
- The extent to which the project's inputs have been minimised, or outputs maximised, in achieving the project's intended products and services;
- Trends over time in the ratio of administrative to program costs;
- Under or overspends in years to date.
- Review of program planning and needs analysis design and processes:
- Extent to which the project is currently consistent with Australian Government priorities;
- The nature and extent of continuing community need;
- Alternative strategies available to address the need, and any implications for future delivery of the project.
- Identification of priorities and scope of work for future consideration; and
- Current reporting requirements including identification of clear and meaningful performance measures for future consideration and implementation. Top of page
E.4 Evaluation methodologyThe review involved confirmation of a project plan with the Department which provided an overview of the methodology to be employed throughout the conduct of the study and the purposes and expected outcomes for each stage.
The review process was underpinned by the following key approaches:
- comprehensive review of all available relevant documentation and data, including financial information
- consultations with key internal and external stakeholders
- synthesis and analysis of information obtained from the documentation review, financial assessment and stakeholder consultations in order to inform conclusions regarding the efficacy and effectiveness of the project and formulation of recommendations regarding the future viability of the project.
E.5 Key findingsThe review is to determine the effectiveness and efficiency of the MMHA project and identify future direction. As with other reports, this report was commissioned to inform the thinking of the Department in the development of possible strategies for the support and development of addressing the needs of the transcultural community of Australia with respect to mental health issues and suicide prevention. Accordingly the project is intended to support national strategies and actions plans developed by the Department addressing mental health and suicide prevention respectively. The project provides the conduit to inform policy direction in these respective portfolios specific to the transcultural community as well as providing a means of trialling projects and ensuring that the transcultural community and service sector supporting this community have an effective voice in the development and implementation of said national strategies. Accordingly it is critical that the MMHA is able to readily identify and reflect the transcultural mental health and suicide prevention environment today.
The review findings are presented in five parts:
- Project governance and accountability
- Project model
- Project planning
- Project financial and service management
- Project reporting and performance measures.
E.5.1 Project governance and accountability
- The governance arrangements for the MMHA appear to be ineffective and undermine the projects ability to achieve its objectives in an efficient manner.
- Documentation pertaining to governance of the project does not clearly identify the accountability lines and lines of communication between all parties making up the MMHA project.
- An inconsistent use of terminology (MMHA referred to as project, program, peak body) only serves to foster confusion among stakeholders as to MMHA's role and function (discussed further in chapter 4 and chapter 5).
- Confusion exists amongst stakeholders as to who is responsible for driving the MMHA project and there is a lack of transparency associated with the decision making processes occurring throughout the life cycle of the project.
- Communication appears to be poor within the project. Examples include minutes of meetings not being made available in a timely fashion, stakeholders being unaware of the disbanding of the Consortium in November 2008.
- Disillusionment exists amongst some stakeholders as to the effectiveness of the MMHA project due to a lack of clear direction, competing stakeholder agenda, poor governance and management processes.
E.5.2 Program model
- The MMHA model is based on a highly collaborative and partnership engendering philosophy which is appropriate for the issues of the transcultural mental health and suicide prevention. However the model has not been effectively implemented.
- MMHA has established various forums with which to engage with these stakeholders however these forums have not worked effectively for a range of reasons. The key issues relate to the size of some of the forums, the lack of transparency and clear role delineations as well as overall management of the project.
- The current form of the MMHA model is not sustainable. Clearer reporting lines need to be established, greater clarity in the respective roles and responsibilities of the respective stakeholders of the MMHA project need to be defined and stronger governance arrangements need to be implemented.
E.5.3 Project planning
- The MMHA planning processes are ineffective. Evidence of strategic planning specifying the direction of the MMHA project had not been undertaken.
- While different planning mechanisms and processes have been established over the course of the project's life, overall their effectiveness has been undermined. This applies in particular to the Consortium. While an appropriate forum at the onset for planning, it has become less effective for a number of reasons, including:
- the multicultural mental health landscape changed
- was not inclusive of newer players
- was seen as having somewhat tokenistic representation of carers and consumers
- was increasingly costly to run
- had poor governance
- too complex in composition (diversity in membership, competing agendas, size, etc.) to enable effective decision making to occur.
- In the absence of the Consortium, there is a question as to whether the JOG in conjunction with the MMHA secretariat have sufficient knowledge or understanding of the "on the ground" issues important to the transcultural sector in the areas of mental health and suicide prevention. Accordingly there is a question as to whether these two bodies will adequately replace or compensate for the role and function initially intended to be covered by the Consortium. Stakeholders have also asked under this new structure how relevant representatives of the transcultural community and service/support sector are to have effective input into the direction and achievements of the MMHA project.
- The majority of stakeholders felt that the MMHA lacked strategic focus and input into policy development. The greater focus of planning activities was seen to be on the development of products and services.
- There is a bias in the focus of activities undertaken to MMHA toward addressing mental health issues and less on suicide prevention.
- There is a current lack of baseline data from which to undertake effective strategic and project planning and this will need to be addressed in the immediate future.
E.5.4 Project financial management
- The project's ratio of administrative to program costs are within the expected benchmarks established in the evidence.
- The review team questions whether the level of funding currently provided to the project is warranted given a three year history of carry over of significant funds.
- It is difficult to reconcile a view expressed by stakeholders that the level of funding of the MMHA is insufficient to enable the MMHA to undertake a range of projects given the significant carry over of funds for the last three consecutive years.
- The project in its current form is not sustainable.
E.5.5 Project reporting and performance measures
- MMHA project has met its reporting requirements from a process perspective but current performance measures do not adequately inform the Government about the quality or value of the project.
- The current suite of performance indicators are relevant in respect to the objectives of the project however they are highly quantitative and process output focussed.
E.6 ConclusionsThis review has been conducted in a dynamic environment: one which is characterised by an increasingly more diverse and complex multicultural mental health landscape, both in terms of the primary target audience (i.e. individuals from CALD communities) and the service providers that support them.
Based on the review teams' review and analysis of project documentation, financial assessment and stakeholder consultations, we conclude that the MMHA project has to undergo significant changes in order to be efficacious and effective. The findings of this review indicate that the Project has become 'out of step' with the reality of recent changes in the multicultural mental health landscape. It is vital that this mechanism is able to remain aligned with this landscape. This is even more important in view of the markedly different profiles of newer immigrants to Australia. It is acknowledged that the ability to do so is somewhat hampered by a general paucity of baseline data on the mental health needs of CALD communities.
Further the review has highlighted that the project portfolio pertaining to suicide prevention has maintained a lesser profile and it is unclear whether this reflects a lack of priority on behalf of the stakeholders, a lack of resources or skill set within MMHA or a lack of need within this cohort. This is partly driven by the lack of baseline data in this area.
The findings of this review reveal that the effectiveness and efficiency of the Project has been undermined by a lack of alignment with the changing multicultural mental health landscape. Moreover, deficiencies in the Project's planning processes, governance and accountability arrangements and financial/service management structure have also served to undermine the potential impact of the Project.
Whether funded in the future as a project, program or some other entity, the findings of this review point to some key changes that must be considered with respect to its operation and management.
It must be:
- underpinned by appropriate and sound planning processes, including the development of a strategic plan in consultation with all relevant key stakeholders
- capable of effectively engaging all relevant key stakeholders to assist in the identification and setting of work priorities and strategic directions in a manner that is appropriate to their respective knowledge, expertise, and capacity to contribute
- capable of ongoing effective monitoring of target group need and able to identify and respond to changes in need in an appropriate and timely manner
- supported by appropriate and sound governance structures to ensure clear accountability, transparent decision making, and effective stakeholder communication.
1 Beyondblue. (2008). Diversity, Multiculturalism and Mental Health. Available on the beyond blue website (www.beyondblue.org.au)
2 Australian Bureau of Statistics. (2008). Media Release: One in five Australians have a mental illness: ABS. Available on the Australian Bureau of Statistics website (www.abs.gov.au)
3 Australian Bureau of Statistics. (2007). National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Available on the Australian Bureau of Statistics website (www.abs.gov.au)
4 Beyondblue. (2008) op.cit.
5 Multicultural Mental Health Australia, National Ethnic Disability Alliance, Australian Mental Health Consumer Network and the Australian Government Department of Health and Ageing.(2004). Reality Check: culturally diverse mental health consumers speak out.
6 Long, H., Pirkis, J., Mihalopoulos, C., Naccarella, L, Summers, M., & Dent, D. (1999). Evaluating Mental Health Services for Non-English Speaking Communities. Australian Transcultural Mental Health Network.
7 Standard Funding Agreement between Department of Health and Ageing and Sydney West Area Health Service. July 2008 to 30 June 2011.