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

5.1 The context from which the EHSDI arose

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

Page last updated: 17 April 2012

5.1.1 Coordinated care trials
5.1.2 Primary Health Care Access Program
5.1.3 The NT Aboriginal Health Forum
5.1.4 Announcement of the EHSDI

PHC in remote areas of the NT is largely provided by community health centres staffed by Aboriginal Health Workers (AHWs) and Remote Area Nurses (RANs). A wider range of services is offered by visiting GPs and other health professionals, who provide allied health and specialised services such as dental, ENT, and audiology services. Health centres in larger communities often have their own resident GPs or allied health staff.

There are two main governance structures in the NT remote health system—DHF managed services and Aboriginal community controlled services. DHF remote health services are mainly funded through the NT Government and administrative activities such as recruitment and payroll are centralised. Funding to ACCHOs is largely provided by the Australian Government through contracted funding agreements between health services and DoHA. ACCHOs are locally managed and administered under a board of elected community representatives. Two regional ACCHOs also act as fund managers and provide governance at a regional level for community-based health centres.

Table 37 outlines the differing governance, funding and employment arrangements of NT remote health providers. The system is a little more complex than this table suggests with a number of services being provided jointly by DHF and ACCHOs and a number of ACCHOs working under the auspice of a ‘parent’ service. This system has not changed substantially since the NTER was introduced.
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Table 37: Remote Aboriginal PHC services in the NT(a)
DHF remote health centresACCHOsRegional ACCHOs
Governance and staffingManaged and staffed by DHF employeesManaged by a board which employs the staffManaged by an incorporated board which employs the staff and provides services across a region
FundingMainly by NT GovernmentMainly by Australian GovernmentBy Australian Government and NT Government
Number of services59(b)24(b)(c)Two independent regional level services (consisting of 17 community health centres)

(a) These services are also able to be accessed by non-Aboriginal people.
(b) This includes mixed-model clinics which are operated through a DHF/ACCHO partnership.
(c) This includes services which operate multiple health centres and provide health care for large populations.

Although the breakdown of the number of services suggests that DHF provides the majority of health services in the NT, it is important to note that some ACCHOs, such as the Central Australian Aboriginal Congress, Danila Dilba and Miwatj service large populations as well as providing services to visitors in regional centres. Some of these services also provide hub support to remote areas. We attempted to compare data on the populations covered by the different sectors, but were unable to obtain this information.

These arrangements differ markedly from the broader Australian PHC system. Most Australians access PHC through GPs in private practices that are largely funded through the Medicare-based fee-for-service framework. Medicare is a universal health care system which contributes to the cost of specific services provided by medical professionals, based on a government-set fee schedule. The system is largely premised on providing rebates for episodic health care provided by GPs.

The demographic and geographic characteristics of the NT have led to challenges in providing adequate PHC services such as:
  • There are long-term, chronic workforce shortages across the health spectrum.
  • A high proportion of the population is Aboriginal with high levels of morbidity and mortality.
  • The costs of delivering services are much higher than in urban or rural areas.
  • There is a lack of doctors, who act as gatekeepers to Medicare access. Per capita Medicare claims in the NT are the lowest of any state or territory, claiming 52 per cent of the national average Medicare benefit in 2003–04 (Byron et al 2005).
  • Most health centres are small. Economies of scale mean there are increased costs associated with administering claims for Medicare funding.
  • Most PHC services in remote areas are provided by professionals whose services are, on the whole, not refundable under Medicare.25
Reform of the NT remote health system had commenced before the announcement of the NTER. Preceding the intervention, there had been a 15-year period of intermittent development, in which innovation was occurring both with the development of individual ACCHOs, as well as in the NT-wide organisational arrangements.
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5.1.1 Coordinated care trials

Aboriginal and Torres Strait Islander Coordinated Care Trials (CCTs) were initiated in 1997 as part of an Australian Government and state and territory government reform effort to improve the coordination of health care services to Indigenous communities. The first round of trials was conducted between 1997 and 1999 as part of a broader trial of multidisciplinary care planning and included four Indigenous-specific locations around Australia. Two of these were in remote regions of the NT—Katherine West and Tiwi.

The aim of these trials was to improve health status in the chosen communities by pursuing three main reforms (Robinson et al 2003):
  • the establishment of regional Aboriginal health boards comprised of elected community members, to act as fund managers and providers of health services to the trial populations
  • the pooling of Australian Government and state and territory government health funds, which were placed under the control of the health boards
  • the implementation of a system of coordinated care to enable more timely delivery of services, enhanced participation of consumers in decision making regarding their own care and more effective prevention and management of existing conditions.
Evaluation of the trials found enhanced access to services, progress in infrastructure development and improved individual and community empowerment (Esterman and Ben-Tovin 2002). In the NT, the trials resulted in a significant increase in health service funding, the development of integrated regional systems of service delivery where only disparate services had existed before, and the introduction of computer technology supporting electronic care plans and medical records (Robinson et al 2003).

The second round of CCTs began in 2002 and ran for three years. These trials included the Katherine East area of the NT, which became Sunrise Health Service. The trials had similar objectives to the original CCTs—to improve the health of communities and increase community understanding and control of health and related services (Esterman and Ben-Tovin 2002). Specific aims of the Sunrise Health Service trial site included increasing PHC resources through funds pooling and improved care planning for high-risk clients (DoHA 2007). The evaluation of the Sunrise CCT (DoHA 2007) found increased access to more culturally appropriate services, improved community awareness of health services and a move from sporadic clinic attendances towards planned care.

One of the CCT sites in the NT, Tiwi Health Board, went into administration in 2003. Robinson et al (2002) report that financial constraints imposed on the board in 2001 saw AHW positions cut or not immediately replaced, permanent doctors replaced with temporary locums and nurse and educator positions terminated. Financial issues led to the board being placed in administration in September 2003, with debts of close to $2.5 million (‘Ex-Tiwi boss calls for enquiry’, Pharmacy News, 8 October 2003).

The other two trial sites, Katherine West Health Board and Sunrise Health Service, continue to operate as regional health boards. Both have been highlighted as examples of good governance. Sunrise Health Service was highly commended in the 2005 Indigenous Governance Awards, which praised excellent financial management, a clear vision and high strategic planning ability. A review of effective models of rural and remote PHC in Australia (Wakerman et al 2006) described Katherine West Health Board as one of the ‘exemplary models of PHC service delivery which have been evaluated and shown to be successful in meeting their stated goals’.
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5.1.2 Primary Health Care Access Program

The Primary Health Care Access Program (PHCAP) was announced in the 1999 Federal Budget as an Australian Government partnership with state and territory governments, ACCHOs and the now-defunct ATSIC. The program built on the CCTs and aimed to increase funding to local health systems serving Indigenous communities in areas identified as having the highest relative need. Key objectives were increasing the availability of appropriate PHC services, creating local health systems to better meet the needs of their communities and facilitating greater community responsibility in health and wellbeing.

In the NT, the policy involved the provision of per-capita funding to 21 Health Service Zones of approximately 2,000 people per zone. Funding was to be pooled with current DHF expenditure on health. These funds were to be used in accordance with decisions made by local health boards; however, while the PHCAP provided a significant increase of funding into the health care system, several commentators have asserted that the program did not receive adequate funding to achieve its aims. Anderson (2004) states that the amount of funding provided through the program did not meet its programmatic benchmarks and targets, while the AMA (2003) asserted that the funds were not enough to provide health services on an equitable basis. A Human Rights and Equal Opportunities Commission report (HREOC 2005) noted that not all planned PHCAP zones had been rolled out and claimed that the program had never been fully or appropriately funded.

Although the program was subjected to criticism, it represented a major Aboriginal health policy reform. The funding and policy approaches which commenced under PHCAP have clearly influenced the subsequent development of the EHSDI.

5.1.3 The NT Aboriginal Health Forum

The NT AHF is comprised of representatives of three significant organisations with an interest in health in the NT—AMSANT, DHF and DoHA. In 1998 a partnership agreement (the NT Aboriginal and Torres Strait Islander Framework) was signed and the NT AHF was established shortly after in line with this agreement. The NT AHF represents a cooperative approach to improving Aboriginal health outcomes, providing strategic guidance and planning to facilitate development of the NT health sector.

Before the arrival of the EHSDI, the three organisations had made several steps towards PHC reform in the NT. This included agreement on a set of core PHC services. The original core PHC services list was developed in 2005 by the DHF Aboriginal Health Strategy Unit and updated in 2007 by an NT AHF technical working group which released the policy document, Indigenous Access to Core PHC Services in the NT (NT AHF 2007b). The paper outlined the evidence base for increased investment in PHC based on a regionalised model and proposed a strategy to increase Indigenous access to a range of core PHC services. The document also proposed expanding the range of services offered at regional or hub level to include support services outside the usual boundaries of PHC.

The NT AHF also collaborated on developing a policy framework (NT AHF 2008) and obtained high-level agreement to move towards community control of remote health services. The policy document, Pathways to Community Control, provided a framework to support greater Aboriginal community participation in planning, development and management of PHC services.

The NT AHF was well advanced in developing system-wide performance indicators for Aboriginal health 
(NT AHKPIs) and had supported the implementation of an electronic records system (patient information and recall system or PIRS).

These activities did not, however, represent a consolidated reform effort such as that currently being implemented through the EHSDI.
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5.1.4 Announcement of the EHSDI

The EHSDI was announced as part of the 2008 Federal Budget, which included a commitment of $99.7 million to expand and improve health service delivery in remote NT Indigenous communities over two years from July 2008. Discussion on the need to enhance PHC in the NT had begun much earlier. A memorandum of understanding signed between the Australian Government and the NT Government on 17 September 2007 notes that both governments recognised the need to ‘improve access to quality health care, delivered more efficiently and effectively, to remote Indigenous communities in the Northern Territory’. The document outlines the Australian Government’s commitment to providing $100 million over a two-year period to improve the quality, accessibility and efficiency of PHC. Two specific uses for the funding are outlined—the employment of additional doctors, nurses and other health professionals to deliver a wider range of PHC services and the establishment of the RAHC.

The need for additional investment in the remote PHC system was confirmed during the CHCI. It quickly became apparent that the NT health system could not cope with the influx of resources and personnel during the provision of child health checks. The EHSDI attempts to address concerns that were raised during the CHCI about the state of remote health infrastructure. An NTER monitoring report released in 2009 (FaHCSIA 2009c) notes that a lack of workforce availability and local infrastructure, particularly staff accommodation, 
had been identified as major impediments to the roll out of child health checks and follow-up services.

Several submissions to the NTER Review Board also highlighted that the CHCI had confirmed the need for longer-term funding of the NT remote health system. Concerns were voiced regarding the limited time-bound nature of the CHCI and criticised the fact that the initiative represented a ‘one off’ intervention (Dr Rob Roseby et al; AMSANT; AIDA—submissions to the NTER Review Board 2008). Other submitters stated that the CHCI had highlighted the need for ongoing investment in health infrastructure, specialist medical services and outreach programs (Australian Association of Social Workers; Tangentyere Council; Central Australian Specialists—submissions to the NTER Review Board 2008).

The EHSDI aims to move the CHCI from being a time-bound intervention to a sustained delivery of increased health services for remote Indigenous communities in the NT. Specific goals include increasing the availability and efficiency of PHC in remote locations, delivering more regionally-based PHC services in remote NT communities and recruiting and deploying health professionals to the NT (FaHCSIA 2009c).

The EHSDI builds on and consolidates the ongoing vision of the NT AHF of significant reform for the remote NT PHC system. The key pillars of the reform process were identified by the partners at the first EHSDI formative evaluation workshop as—core PHC services, CQI, leadership, governance and regionalisation, NT AHKPIs and workforce and infrastructure. These components are intended to work together as part of a long-term reform agenda.

The EHSDI funding was directed towards specific interventions:
  • expanded PHC services
  • development of regions (regionalisation) and the move towards Aboriginal community control
  • the RAHC
  • capital and infrastructure investment
  • the development of hub services
  • evaluation.
From our initial discussions with the NT AHF and PHRG it became clear that the primary purpose of the EHSDI was to strengthen the development of NT remote PHC, and the discrete items in the EHSDI package were a sub-set of that. Our evaluation has focused on this wider purpose.

25 - DHF (2008) Information for the NTER Review.

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