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

5.5 Regionalisation and Aboriginal community control

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

Page last updated: 17 April 2012

5.5.1 Introduction
5.5.2 Rationale for Aboriginal control of health services
5.5.3 Regionalisation activities begun under the EHSDI
5.5.4 EHSDI training, capacity building and community representation mechanisms
5.5.5 How effective and appropriate are the mechanisms for supporting regionalisation and Aboriginal community involvement?
5.5.6 Barriers to the involvement of Aboriginal communities in planning and governance of health services
5.5.7 Recent progress and future considerations
5.5.8 Conclusions

This section reports on the evaluation findings relating to Aboriginal communities’ involvement in health service planning and governance and the effectiveness of the planning and consultation processes on regional reform. The process of regional reform is occurring in different contexts in each region and this limits the ability to make generalisations across the four evaluation case study regions, or indeed any other region. The process of regional reform is also dynamic. We have provided an update on recent progress, but the views of many community-level evaluation participants are from the time of our case study visits (February–April 2010).

5.5.1 Introduction

The regionalisation of Aboriginal PHC services has been a vision of the 
NT AHF for some time. The concept of regionalisation as a service delivery model was explored by the NT AHF and others before the EHSDI (Bartlett et al 1997; Bartlett et al 2000). Several national programs previously conducted in the NT have used regionalisation approaches, such as the CCTs and the 
PHCAP (DoHA 2010). Shannon (2007) notes several potential benefits of regionalisation including:
  • improved health service delivery—enhanced coordination of health services based on population need, and greater competitive advantage through a larger funds pool and increased workforce retention and recruitment opportunities
  • effective and efficient organisations and businesses—the creation of economies of scale to facilitate shared resources, procurement and knowledge, enhanced purchasing power and opportunities to pool resources, and a support framework for smaller organisations (for example for enhanced business practices such as governance, mentoring, communication, and open IT systems)
  • a united Aboriginal PHC sector—a collective voice with stronger lobbying power including 
enhanced capacity to advocate for reform within the health system.
The NT discussion about regionalisation includes a commitment to greater 
community control. The Pathways to Community Control document developed by the NT AHF describes a framework that supports Aboriginal communities controlling the planning, development and management of PHC services (NT AHF 2008). The Pathways framework shows how community control might be realistically achieved given a community’s capabilities, supportive of its aspirations, and consistent with the objective of achieving efficient, effective and equitable health system functioning.

The NT AHF believes that greater levels of community involvement can result in more responsive health and family services systems, improved quality and cultural appropriateness of services, and improved levels of family and community functioning. Such outcomes can lead to improved levels of health and wellbeing for 
NT Aboriginal people (NT AHF 2008).

5.5.2 Rationale for Aboriginal control of health services

The movement towards increased Aboriginal control of PHC services in the NT is motivated by two main factors—concepts of Indigenous rights and international evidence supporting community participation in health care delivery.

The United Nations Declaration on the Rights of Indigenous Peoples, adopted by the United Nations General Assembly in 2007 and ratified by the Australian Government in 2009, states in article 2328:
      Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, Indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions.
Indigenous control of health service provision is seen as a direct expression of this right.

The concept of community involvement in PHC, that views people not only as recipients but as active participants in the planning and implementation of care, was first articulated in the Alma-Ata declaration of 197829:
      The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
The approach has recently been re-examined and further endorsed by the WHO (2008a). The effectiveness of strong primary health infrastructure on health outcomes has substantial evidential support (Starfield 2002) as does the specific element of community control (Crawford et al 2002).

Evidence suggests that health and social outcomes can be improved by empowerment strategies that support community participation in decision making and oversight in of healthcare (Wallerstein 2006). The condition for success is that the strategies are embedded in local contexts and are based on a strong and direct relationship between people and their health workers.

Indigenous controlled services have been shown in some settings to out-perform other delivery mechanisms for marginalised communities. In Manitoba, Canada, communities with better local access to PHC consistently show lower rates of hospitalisation for ambulatory care-sensitive conditions (conditions for which access to good PHC can prevent the need for hospital care). The longer community health services have been under community control, the lower its rate of admissions (Lavoie et al 2010). A recent study in New Zealand also demonstrated a lowering of ambulatory care-sensitive admissions through PHC and that improvements in access to care for Māori were most marked for the population served by Māori controlled providers (Carr and Lee 2009). Top of page

5.5.3 Regionalisation activities begun under the EHSDI

The EHSDI funding provided the opportunity for the NT AHF partners to start planning for and taking action to achieve increased community control and regionalisation. The NT AHF initially estimated that 14 to 17 HSDAs would be required based on population catchment areas (ideally between 3,000–6,000 persons), cultural identity and language groups, communities’ current and past affiliations, and existing DHF regions and DoHA planning region boundaries. The number of HSDAs and their boundaries were to be decided after wide community consultation.

In most proposed HSDAs there is a mix of ACCHO and NT Government service providers. Only two of the proposed new HSDAs include health services that are all managed by one agency (DHF). DoHA anticipated that regionalisation would initially involve integrated planning and improved coordination between service providers, leading later to full integration under one service provider (either an existing agency or a new entity) with responsibility for regional health service delivery. Implicit in the planning for regionalisation was the principle that there would be no forced amalgamations of health services. The NT Regionalisation of Aboriginal Primary Health Care Guidelines (DoHA 2010) provides descriptions of five possible regionalisation models and acknowledges that there may be other appropriate models.

AMSANT is the lead partner agency for the regionalisation component of the EHSDI. Funding from the 
EHSDI was provided to AMSANT to establish the Reform and Development Unit (RaDU). AMSANT was provided with EHSDI funding totalling $826,633 in 2008–09 and $1.437 million in 2009–10 for establishing and operating RaDU.

RaDU’s main regionalisation activities under the EHSDI focus on building the 
corporate, clinical and community competencies and capabilities required for regional steering committee (RSC) members and health service providers and communicating information concerning regionalisation within and across communities in the proposed HSDAs. This role includes:
  • negotiating HSDA boundaries
  • leadership and governance capacity building and training
  • negotiating HSDA governance and leadership arrangements
  • identifying the strengths, preferences, values and objectives of HSDA residents in consultation with community members
  • supporting the development of health plans to define:
  • longer-term strategic planning
    • a shorter-term service plan
    • a transition plan
  • undertaking risk management analysis (AMSANT 2009b).
RaDU staffing comprises a manager, three full-time and two part-time Regionalisation Coordinators, one Regionalisation Support Officer, one Communications Officer, a public health/policy consultant and one officer (plus a trainee) to provide logistical support.

The Barkly Regionalisation Unit (BRU) was established with EHSDI funding ($262,500 in 2008–09 and $766,310 in 2009–10) under the auspices of Anyinginyi Health Service to play a similar role as RaDU but specifically for the Barkly region. BRU has offices in Tennant Creek and staffing includes a Regional Coordinator, a Project Officer, Administrative Officer and a Cultural Broker.

Regionalisation activities began on the basis that action was not required in the four HSDAs with existing incorporated health boards—Katherine West, Katherine East, Katherine Urban and Alice Springs Urban. Rapid implementation was planned in the proposed HSDAs where a single ACCHO was already operating—Darwin Urban/Darwin Rural, West Arnhem, Barkly and Maningrida. RSCs needed to be established in East Arnhem, West Arnhem, Tiwi, Top End West and Central Australia HSDAs. Barkly HSDA already had a RSC in place. Following a review of regionalisation activities in July 2009, PHRG identified that East Arnhem, West Arnhem, Barkly and Central Australia HSDAs showed the greatest potential for achieving regionalisation and, as such, RaDU should focus their activities in these HSDAs.Top of page

The steps towards achieving increased community control and regionalisation were initially outlined in AMSANT’s Regionalisation Toolbox (AMSANT 2009b). This template has since been augmented with the development of DoHA’s draft NT Regionalisation of Aboriginal Primary Health Care Guidelines (see Box 5) and Support Kit for the Development Stage (DoHA 2010a). In 2010 DHF developed a draft Competency and Capability Support Framework which identifies the elements that RSCs need to address before advancing to the next regionalisation step.

Box 5: Stages towards regionalisation
The stages towards regionalisation, and steps needed to complete each stage, are closely aligned with the four staged process described in Pathways to Community Control (NT AHF 2008).

The flowchart in Box 5 shows the stages of regionalisation. It is shown as a four-stage process. [D]

At the end of 2010 all proposed HSDAs were in the development stage but were progressing at different rates. The development stage is primarily focused on community engagement, developing community capacity, identifying aspirations at a regional level and introducing health services reform elements. Key aspects of this stage against the two major goals of regionalisation are:

Community control and participation
  • sharing information about regionalisation
  • engaging with communities and key stakeholders across the HSDA
  • establishing a regional community representative group (i.e. a RSC)
  • considering models and evaluation options for regional reform and governance arrangements
  • setting directions for community engagement and governance development
  • developing a proposal detailing the preferred governance model
Regional health service reform
  • current providers aim to implement measures to improve services through systems reform
  • service providers engage through the establishment of a clinical leadership group to develop strategies to improve coordination and integration of existing services with the HSDA
  • developing a proposal for better coordination and integration of existing services.

Source: DoHA (2010a)

There is general agreement among NT AHF partners for 14 new HSDAs (Table 53), although at December 2010 the final number of HSDAs had not been decided. At least one proposed HSDA has a population of 10,000. Many interviewed as part of this evaluation considered this population size too large and unmanageable given the geographical spread of communities. The proposed Central Australia HSDA has split into two with consultation about boundaries continuing.

Table 53: Proposed HSDAs and status of reform process (April 2010)
Proposed HSDAStatus of regional reform
Top End region
Darwin (Urban and Rural)Darwin Rural and Darwin Urban health planning project being commissioned.
Top End WestAt initial community engagement stage, no steering group formed.
West ArnhemRed Lily Interim Health Board established.
Initial regionalisation proposal completed.
Regionalisation support unit funded.
TiwiAt initial community engagement stage, no steering group formed.
ManingridaAt initial community engagement stage, no steering group formed.
East ArnhemEast Arnhem RSC formed.
Working group established to progress initial proposal (step three of development stage of the NT AHF regionalisation guidelines).
BorroloolaAt initial community engagement stage, no steering group formed.
Katherine region
Katherine EastSunrise Health Service (established 2005).
Katherine WestKatherine West Health Board (established 1998).
Katherine UrbanWurli Wurlinjang Aboriginal Health Service (established 1991).
Barkly region
BarklyBarkly Health RSC formed.
Barkly Regionalisation Unit established.
Draft regionalisation proposal completed.
Central Australia region
Eastside (Triple A HSDA)Eastside Steering Committee formed.
At initial community engagement stage.
HSDA boundaries yet to be ratified.
Westside (Sunset HSDA)Westside Steering Committee formed.
At initial community engagement stage.
HSDA boundaries yet to be ratified.
Alice Springs UrbanCentral Australian Aboriginal Congress Inc (established 1973).
A number of community and regional level ACCHOs with high community input were operational in the NT before the EHSDI. There were 11 community-level ACCHOs (10 in regional or remote settings and one in Darwin); two area or regional ACCHOs; and four regions working towards community control under the auspices of an ACCHO or DHF (three in Central Australia and one in the Top End).

In the case study communities where ACCHOs manage the health service, the level of community engagement varied from very high in communities that had active Health Advisory Committees (HACs) or similar, to a lower level where one or two community representatives sit on a regional health board but community feedback and input into health service delivery did not occur very often, if at all.

DHF has long promoted the concept of local HACs in the communities in which they are the service provider; however, effectively engaging with community members, establishing HACs and supporting them to maintain ongoing information sharing and community input into planning service delivery has not been sustainable.

5.5.4 EHSDI training, capacity building and community representation mechanisms

The Regionalisation Toolbox document and subsequent Regionalisation Guidelines describe consultation and engagement at the community level and determining readiness for regionalisation as the first step in the regionalisation process. From August 2008 to September 2010, 90 public meetings were held across most of the proposed HSDAs, which were attended by representatives of the NT AHF partners. Engaging community members has been challenging and turnout of community members at meetings has generally been low. Few community members or leaders interviewed at the case study sites could recall attending such meetings, or if they did remember the event, they could not remember what was discussed. A consistent message from community members and a number of service providers was that the administrative processes of RSC meetings were inadequate, with minutes of meetings not being sent to attendees and a general lack of communication to participants and the community on the outcomes of such meetings.

Past experience with the successful development of Katherine West Health 
Board and Sunrise Health Service suggests that lengthy time frames are often required to negotiate regionalisation processes. At the time of writing, three proposed HSDAs (Barkly, West Arnhem, and East Arnhem) are making significant progress towards developing regional health boards. West Arnhem is the most advanced, having established the Red Lily Interim Health Board in April 2010. In East Arnhem and Barkly, RSCs have been formed and have met regularly to guide the regionalisation process in these areas.

In the case study communities, as at April 2010, one community which was 
already managed by a regional ACCHO had established processes in place to gain community members’ input into health service planning and other activities. The other four communities, which were at the early stages of the regionalisation process, had not yet made significant progress in engaging community members in health service planning. While there is acknowledgment that regionalisation can take a long time, the process has been underway for at least two years and there has been some frustration expressed by the NT AHF partners at the lack of progress. This is partly a leadership issue, as community leaders in regions where the partners are focusing their efforts have not stepped up, or been encouraged to step up.

Perhaps not surprisingly, several informants mentioned that community members seemed pre-occupied with issues that impact more directly on their everyday lives, such as housing, and have little interest or ambition to have input into their health service. Several community members said that their main concern was to be able to access their community health service when they or a family member are unwell, regardless of who was running the service.

Several people interviewed as part of the evaluation case studies, both at a community and regional level, mentioned that engaging with the wider community has become more difficult since major NT local government reforms were implemented and community councils were decommissioned. The local government reforms may also have affected the capacity of health services to engage with the community. As a result of the reforms, a number of community ACCHOs changed from being auspiced by a community council to being auspiced by a larger ACCHO. Having to change over to a larger regional structure while engaging with the community on planning the transition to community control, is likely to have put a strain on resources. On top of this, many services were already stretched as a result of the CHCI.Top of page

Several Aboriginal health staff, who are also RSC members, were interviewed as part of the evaluation case studies. They considered regionalisation to be a good idea for ‘coming together as one’ with other remote communities. They also believed this reform needed to progress slowly to take account of everyone’s concerns and different points of view.

In the three case study communities where DHF is the health service provider, staff believed their current service delivery model was still at the first step in the Pathways to Community Control distribution of responsibilities matrix (Table 54). In the remaining case study community, which is managed by an ACCHO, the HAC was no longer active. In most cases it would appear that relying on health service staff to initiate engagement with community members, or to develop and provide ongoing support of a community HAC, is not feasible or sustainable without support from an independent facilitator. There is also a risk that a HAC formed and supported by the local health service will largely reflect the views of the onsite non-Aboriginal health staff in whom community members place their trust. Community members are more likely to speak frankly about the service available in their community when a third and neutral party is present and when meetings are conducted at a neutral venue (not at the health service).

Table 54: Baseline health service model in the Pathways to Community Control distribution of responsibilities matrix
Service modelHealth service responsibilitiesCommunity responsibilities
NT Government PHC centresCompetent core and other priority primary health services on demand or delivered through program structure.
Provides services and model behaviours that are culturally secure.
Is broadly aware of community interests and concerns.
Community and families promote the timely and appropriate use of health and family services including compliance with treatment.
Community and family within the limits of their capability take responsibility for their own health.

Source: NT AHF (2008).

In Katherine East the health service employs a regionally-based Aboriginal Community Development Officer who focuses on appropriately communicating health matters to all community members, increasing community members’ health literacy, and supporting the functioning of the HAC in each community. In this model, a representative of the health service (usually the manager) attends the HAC meeting on an equal footing as a community member and any power imbalance is negated by having an outside facilitator. The representative from the health service provides an update on the community’s health issues in a manner that promotes community members increasing their health literacy. Elected health board members also attend the HAC meetings which provide an opportunity for them to be kept up-to-date with their community’s health concerns. This model offers the benefits of gaining the perspectives of consumers and local health staff on issues that can help frame discussions at regional health board meetings.

RaDU has so far focused on community engagement activities including bringing together people from different communities to discuss regionalisation and form interim RSCs, negotiating HSDA boundaries and, more recently, supporting some RSCs to develop interim regional health plans.

RaDU has promoted the Katherine West and Sunrise Health Service models as examples of what regions can strive towards. RaDU evaluation informants also recognised the possibility of different models developing in different regions, including not necessarily having a single health service provider in a region but different providers working together on a single health service plan. This message does not appear to have been communicated clearly to communities. DHF and ACCHO health service providers interviewed felt that the Katherine West Health Board model of regionalisation was the only model being promoted by RaDU and there was some negative reaction to this. One ACCHO representative who was reluctant to participate in regionalisation activities planned by RaDU, perceived that the Kimberly Aboriginal Medical Services Council’s model of regionalisation would offer the community he worked for more control of its health service than that suggested by RaDU.

RaDU has not yet been required to provide formal governance and other training 
and capacity building activities to RSCs. The RSCs in two HSDAs (West Arnhem and Barkly) will soon require this training and capacity building to meet the standards set out in the draft Regionalisation Competency and Capability Support Framework (DHF 2010). It is currently unclear what processes and resources RaDU will draw on in delivering this training, but experience from existing models (such as Sunrise Health Service) could usefully inform approaches to supporting communities in their governance role. Top of page

5.5.5 How effective and appropriate are the mechanisms for supporting regionalisation and Aboriginal community involvement?

Regionalisation is a complex process. It will involve moving towards a centralised regional governance structure for many community-level ACCHOs, while DHF services will move from a centralised management structure to a regional model. The process will also see DHF services move from NT Government control to Aboriginal community control and will involve merging existing community-controlled organisations and establishing new ones. This will require an internal change management process to facilitate the transition, with a particular need to focus on the cultural change required in some organisations and institutions. Funding has been provided for the new positions of Area Service Manager within DHF to act as change management agents. There has, however, been concern expressed by some DoHA officials that this has not yet been realised.

The evaluation found a lack of clarity among the partners on the role of RaDU 
and whether it had the capacity to fulfil its roles. In early 2009 DoHA and DHF representatives began to raise concerns about the manner in which RaDU was implementing the regionalisation agenda. Senior DoHA and DHF officers were concerned that RaDU and some interim RSCs were apparently unaware of the clinical and fiscal governance standards that would be required before responsibility for management of any community health services could be transferred to a new regional ACCHO.

AMSANT began developing the Regionalisation Toolbox (AMSANT 2009b) which describes the process of regionalisation in levels or stages. However work on the document has stopped. There appears to be disagreement about the lack of progress on the template. DoHA and DHF feel that the document lacked sufficient detail to direct a rigorous, well-organised process to increasing community control and regionalisation. They reported a belief that AMSANT/RaDU would develop fuller documentation to accompany the template, and were disappointed when this did not occur.

AMSANT stated that work stopped when it was realised that it would be necessary to identify approval processes for Aboriginal health boards seeking to assume control of PHC delivery within an HSDA. This would offer formal assurance of the competence and capability of the board to gain the endorsement of Australian Government and NT Government ministers. AMSANT did not feel in the best position to identify the specific government requirements that an aspiring regional health provider would need to comply with to be accepted as competent and capable.

DoHA responded to the need for system-wide consultation, negotiation and approval processes by seconding two senior staff to a project to prepare appropriate documentation. The resulting guidelines, developed with the assistance of partner-based workshops, laid down the steps for achieving regionalisation, based on the process outlined in Pathways to Community Control (see Figure 10).

These guidelines did not include a competency and capability framework for RSCs. The NT AHF partners had agreed in late 2008 that DHF would lead the development of this. At the time of writing, a draft Competence and Capability Framework has been completed but is yet to be endorsed by the NT AHF.

The delay in developing full documentation on the regionalisation process appears to have contributed to a lack of clarity among the partners about regionalisation aims and how to achieve these. Some informants expressed concern that the principles contained in Pathways to Community Control were becoming lost in the push to establish regional ACCHOs. This concern was reflected in the lack of activity happening to engage with community members.

AMSANT/RaDU also raised concerns about the challenge that resourcing the regionalisation process presents for their organisation. They had seen RaDU’s role as being focused on the governance aspects of regionalisation but felt this had broadened to regional health planning for which they have limited capacity. AMSANT/RaDU has also had concerns that the three partners have not always operated with one voice and feel that, at times, individual partners have undermined the process. RaDU had advocated for a development process that would be supported by a local evaluator in each region to ‘hold a mirror up to the process’ and enable wider learning across regions and the system (as was undertaken in Katherine West as part of the CCTs). This proposal was rejected by the NT AHF. Top of page

Figure 10: Pathways to increasing community control and regionalisation—development stage

Figure 10: Pathways to increasing community control and regionalisation—development stage

Source: DoHA (2010a).


Increasing tensions between the NT AHF partners led to the NT AHF holding a regionalisation workshop in Alice Springs in November 2009. Many PHRG and NT AHF members attended. The evaluation team reported at this workshop on the issues and ideas discussed at the first evaluation workshop—partnership, capacity and communication—as it was felt that these would provide a useful summary of some of the current issues underpinning many of the challenges in progressing regional reform. The regionalisation workshop outcomes (see Box 6) reflect the issues discussed and how these were to be addressed.

Box 6: Transforming the NT PHC System - key outcomes from the NT AHF regionalisation workshop
  1. That the partners agree to a shared vision for transforming the NT PHC system and the establishment of regional Aboriginal community controlled health services.
  2. That the term ‘regional Aboriginal community control’ be used consistently in all communications concerning the PHC regionalisation reform process.
  3. Finalise the review of the core services framework to inform the regionalisation process through engaging an appropriately qualified external consultant to work with the partners and prepare the required documentation for the NT AHF.
  4. That PHRG develop a proposal for NT AHF on the need for a ‘master plan’ which articulates the goals, objectives, and outcomes sought from the NT PHC system reform agenda.
  5. Consider the establishment of a panel of experts (consultants) available to both communities and the NT AHF partners to support regional reform activity and enhance capacity.
  6. AMSANT, with DHF and DoHA in-principle support, to develop a community engagement–consultation proposal to lead the process on behalf of the NT AHF. The proposal is to consider and/or include:
    • consistent language
    • a process for engagement (who does it and how is it done) based on the pathways to regionalised community control—development stage
    • the role of RaDU
    • a process for resolving conflict and community differences with HSDAs
    • recommend an approach to resource the consultation process
    • the development of a signed communiqué from all partners outlining the commitment to regionalisation and the communication principles for communities
  7. the development of a communication tool (key messages and documentation) to guide the consultation process.
  8. That DHF continue to develop the Competency and Capability Support Framework for consideration by the NT AHF partners.
  9. That PHRG continue to develop the Pathways to Community Control Development Stage flowchart and associated tools and supporting documentation detailing steps and respective partner roles and responsibilities.
  10. NT AHF to consider conducting a review of the NT Aboriginal Health Framework and business plan to consider the long-term reform strategy, how the PHRG links with the EHSDI, the relationship between NT AHF and PHRG and the capacity required with the partnership to achieve reform. This review is to consider implementing regional reform of Aboriginal PHC across the NT.

Source: DoHA (2009b).

The key outcomes described in the box encompass many of the issues identified in our Workshop 1 Report (Allen and Clarke 2009b). We are aware that some of the outcomes listed have already been met and others are being addressed. It is not clear if the outcomes described in points 5, 6 and 9 have been addressed or are currently being addressed. The solutions of many of these issues need to be generated by the NT AHF and cannot be prescribed. The process of identifying the solutions offers the benefits of:
  • all parties acknowledging that the issues are real and need to be addressed
  • facilitating a common understanding of the issue and its causes being addressed
  • there is common ownership of the solution avoiding future blame.
DHF and ACCHO managers and service providers interviewed at community and regional levels raised some general issues about the performance of RaDU. Many questioned whether the role RaDU plays in regionalisation is that of advocate for the ACCHOs or of independent facilitator. RaDU’s current role in regionalisation has placed them in a position of direct conflict with their own AMSANT members at times. Several participants suggested that there would be less tension among partner agencies if regionalisation negotiations between service providers were facilitated by a person independent of government and ACCHOs. AMSANT acknowledges that its leadership role on regionalisation has weakened its relationship with a number of services as its role extended beyond being purely an advocate for ACCHOs.

The impact of the approach and mechanisms used by RaDU (working without the benefit of the recently developed Regionalisation Guidelines) appear to be different depending on the context. In the HSDAs where there is one ACCHO service provider (West Arnhem and Barkly) and DHF is the other service provider, RaDU appears to have taken on the roles of advocate for the ACCHO and facilitator for developing a regionalisation HSDA service delivery model. Regionalisation is proceeding at a faster rate in these HSDAs. While no major disruptive issues have arisen in these HSDAs, several DHF officers expressed their dissatisfaction with RaDU’s processes and performance.

In the HSDA where there are multiple ACCHOs and DHF-managed services, tensions have developed between the ACCHOs themselves and between ACCHOs and DHF, causing major disruption in the regionalisation process. The situation was made more complex by the force of individual personalities coming into play and the regionalisation agenda being played out in a context where there is a long memory of what has gone before and the level of trust between agencies is fragile. In this HSDA, the regionalisation process was described by one manager as ‘destructive’. At one point the communications between the main players broke down. Those interviewed from each of the agencies involved were severe in their criticism of each other and of RaDU. In this proposed HSDA, neither ACCHOs nor DHF interviewees appeared to accept that RaDU could take on the role of independent facilitator. Top of page

While the written policy directions are now relatively clear, it became obvious to the evaluation team that among the NT AHF partners there was still ambivalence about transforming the NT PHC system and establishing regional ACCHOs. Communication within and across the NT AHF partners concerning increasing community control and regionalisation has not been consistent, and there appear to be varying degrees of acceptance the concept. There seems to be a lack of agreement among the partners on regionalisation aims and this was indirectly reflected in what we observed on the ground. RaDU’s role in leading the process will remain problematic while mixed messages from the leading organisations persist.

Trying to initiate and maintain effective engagement with communities while facilitating regional health service development presents two complex and resource-intensive activities for RaDU. It appears that the focus of community engagement activities has been more on ensuring that regionalisation messages are effectively and appropriately translated and communicated to communities—one-way communication model. It needs to be ascertained if RaDU has the capacity to be able to effectively engage with communities through a two-way communication model to enable communities to express their concerns, discuss issues and make suggestions or requests.

Several participants at regional and central levels questioned whether the EHSDI funding provided to support regionalisation activities was being well spent and represented value for money. We were not able to ascertain this as part of this evaluation. What we have identified is that this is a complex change process that is currently under-scoped and under-resourced requiring more coherent leadership from all parties if it is to be successful.

5.5.6 Barriers to the involvement of Aboriginal communities in planning and governance of health services

Successful involvement of Aboriginal communities in the planning and governance of their health service depends on the extent to which community members believe that increased community control and the move to regionalised ACCHOs will truly deliver improved health services and improved health outcomes. Past government policies and more recent experiences with the NTER and the CHCI mean community members are suspicious and less willing to engage with outsiders wanting to discuss health service reform or other issues. One evaluation participant, in response to a question about what has changed in remote communities over the past year, responded ‘more government interference, across the board’ (interview, government official). Some community leaders reported being over burdened with the number of requests coming from government agencies and others for them to participate in consultations and evaluations from which they can see no direct benefit for themselves or their community. Community members reported that there is always a lot of ‘talk’ but as yet they have seen little change and few benefits. The community members we spoke with continually reported that they felt let down that their poor housing and overcrowded living conditions were still not being effectively addressed. While there is general agreement that Aboriginal communities would benefit from greater input in running their health services, community members did not always favour the concept of a regional ACCHO as a means to achieve this.

Community responses to regionalisation reforms are strongly influenced by the attitudes and responses of health workers in the community. Health service staff in the case study communities felt they did not have the time or expertise to undertake significant community-engagement activities. In smaller communities there was often a more direct and personal relationship between the health service and the community but there was less capacity in these services to undertake community-engagement activities. The chronic staffing issues in some communities, especially high staff turnover, few Aboriginal staff, and a reliance on casual staff, mean many health workers have only lived and worked in a community for a short time and relationships of trust between health workers and communities are not developed. This adds to the challenge of successfully introducing the reforms.

The challenge is essentially that of trying to empower the people in remote 
communities when the larger system continues to disempower them. A number 
of health professionals that we interviewed felt that addressing this would require 
a community-development approach, at a pace of action dictated by the community. This may involve initial engagement with a small number of interested people in each community to increase health literacy. These people can then form the core of a community HAC. More community members can then be invited on to the HAC and broader capacity building activities can be undertaken. These activities would aim to empower HAC committee members to influence health service delivery in their community.

One example of this is the health service model in Katherine East where elected board or steering committee members and the manager of the local health service, police, school principal and others attend HAC meetings. The meetings are open to all community members if desired. Board or steering committee members are responsible for taking HAC meeting outcomes back to regional board or steering committee meetings. They are also responsible for bringing back information from these meeting to share with HAC members. If board members are not conscientious in their roles, minutes of HAC meetings can be sent to the administrators of the regional ACCHO for their information and any further action if necessary. This approach is resource intensive but any approach that tries to ensure true community input into regional ACCHO decisions will be similar. Ongoing support would always be required for the HAC to be sustainable.Top of page

5.5.7 Recent progress and future considerations

The draft NT Regionalisation of Aboriginal Primary Health Care Guidelines have been developed and are being introduced. These guidelines are very specific and have the support of the NT AHF but there appears to be some reluctance in implementing them. For example, some RSCs already established are not entirely happy about having to review their position and in some cases revise what was considered completed. Not having clear guidelines available at the beginning of the process means some RSCs have been led to believe they had made greater progress in moving towards a regional ACCHO than was considered by the NT AHF partners. Some RSCs have to redress community engagement and consultative processes, rectify issues such as the membership of steering committees and revise documentation already prepared. These difficulties should not arise in the future when RSCs will have prior knowledge about what steps are involved and what is required.

By early 2011 three proposed HSDAs appear to be progressing towards 
increasing community control and achieving a regionalised model of PHC service delivery. In the HSDA where acrimonious relationships between service providers had stalled activity, there are now signs that issues are getting closer to being resolved with proposals to establish a regionalisation unit that will be auspiced by an existing ACCHO. In another HSDA, a regionalisation unit has operated for around 18 months and an interim health board is expected to progress to full incorporation by 1 July 2011. In the third HSDA, the NT AHF has formally agreed that an existing ACCHO will be the regional service provider and it plans to become the fund holder for this HSDA from 1 July 2011, and the sole service provider in the region by 1 July 2013.

There is little activity occurring in the remaining four proposed HSDAs. RaDU, however, maintains open lines of communication with key people in these HSDAs. Regionalisation development processes will commence if sufficient interest is shown by communities. The reform process has shown little change in service configuration and delivery at this stage. This is to be expected given the size of the reform and its inherent challenges.

As discussed previously, the regionalisation model was considered appropriate for the NT by the NT AHF partners based on previous studies and the sustained positive outcomes of the CCTs regional ACCHOs (Katherine West Health Board and Sunrise Health Service). The move to regionalise PHC service delivery across the NT is in line with national and international trends in organising health service delivery. The model brings with it associated risks as well as benefits. There is an inherent tension between the goals of regionalisation and community control. Shannon (2007) highlights the risk of creating regional power bases with a limited ability to develop customised services, resulting in a sense of loss of community ownership and involvement. Several evaluation participants from the DHF, community-controlled sector and at a community level indicated that regionalisation processes had not yet brought the expected benefits and were viewed by some as a move away from, rather than towards, community control.

If the perception builds that regionalisation will not bring direct benefits in improved health services and improved health outcomes for Aboriginal people, then one obstacle after another is likely to present and make achieving regionalisation more difficult. The need for appropriate and effective communication strategies between the NT AHF partners, and from the NT AHF to community health service staff and community members, cannot be over emphasised. We note that the PHRG and the NT AHF are aware of this issue and moves have been made to improve communications.

It appears that many of the issues that have arisen during regionalisation 
processes are due to the fact that the regionalisation component of the EHSDI has been under-scoped and under-resourced. The partners’ roles have not always been clear and they are not currently ‘speaking as one voice’. There is a need for further discussion between the partners to confirm agreement on the aims, purposes and goals of regionalisation. Once agreement has been reached, the partners need to clearly identify:
  • the tasks involved in regionalisation (taking into account the stipulations 
in the guidelines and competency and capability framework)
  • what is involved in meeting these
  • the resources required
  • who is most appropriate to undertake these.
We recommend that planning should be informed by the principles in Pathways to Community Control and by the Regionalisation of Aboriginal Primary Health Care Guidelines. Consideration should also be given to the competencies and capabilities required of RSCs and potential ACCHOs. Deficiencies should be identified and preferably addressed before a regional ACCHO is commissioned. Top of page

The NT AHF partners have generally done well in managing the regionalisation reform and have successfully resolved several tensions between the partners. To maintain the progress of the reforms, regionalisation needs to be broken down into its component parts and strategies developed to address each of them. Currently AMSANT, through RaDU, appears to be tasked with managing the entire process; however, their strength lies in one of its components. The component parts of regionalisation are as follows:
  • The merger of ACCHOs and building community capacity. This process appears to best fit the expertise of AMSANT, as a representative of the organisations involved and with the experience of Katherine West and Sunrise Health boards to draw on. As AMSANT is an organisation of existing ACCHOs, some of whom may not benefit from regionalisation, this potential conflict of interest will need to be explicitly managed.

  • Decentralisation and a move to community control of DHF clinics. This process needs to be actively managed internally by DHF, with a clear focus on risks and benefits and a clear process for managing the risks. It appears that there is some concern at a senior level regarding decreased efficiency with the change from single provider to multiple provider structure. Efficiency and effectiveness, on the other hand, are part of the rationale of the regionalisation process. All parties need to discuss what impact the changes will have on efficiency and effectiveness.

  • Growing and supporting the new regional structures. For this process to be successful, there needs to be local (regional) leadership that can be heard across the different organisations and communities in the region, create a vision for the future and form the path forward. The Regionalisation Coordinators employed by RaDU have an important role to play in identifying and cultivating this community leadership.

    Greater use needs to be made of the examples of successful regionalisation. They do not need to be imitated as an exact blueprint, but rather used as a general lesson of what has been learnt in regionalisation processes. Experience with Katherine West Health Board and Sunrise Health Service shows that gaining community buy-in as part of a ‘bottom-up’ process of change is likely to lead to long-term success. Community members’ most direct relationship with the health system is with front-line staff in community clinics, who have an important role in communicating regionalisation messages. It is therefore critical that the front-line health workers of all organisations be brought together in the specific regions and help plan the way forward. This will facilitate both health service and community buy-in—key components of success.

  • Repositioning the system’s policy capacity to focus on the issue of implementation. The majority of current policy capacity appears to sit centrally within the Australian Government, while the bulk of the policy work needs to be applied to implementing reforms in the specific NT context. How to improve health has been known for decades. How to improve health in the specific (and differing) social and cultural contexts of the NT Indigenous communities is the challenge that needs to be met.
Effective communication, relationship management and resourcing strategies need to be applied to these processes. Most importantly, the control organisations (AMSANT, DHF, DoHA) need to act as advocates and demonstrate a unified approach. It is likely that there will be ongoing tensions among the partners and it will be difficult to reach consensus on some issues. This tension does provide for checks and balances when making decisions and progressing and overseeing regionalisation and the reform agenda. We observed instances when all three organisations used the partnership effectively. For example, AMSANT maintaining the focus on community control, DoHA calling for more rigour on regionalisation and DHF ensuring competency and capability frameworks are in place.

Consideration also needs to be given to how other sector-wide functions will operate under a regionalised approach. One of the expected benefits of regionalisation is a more unified Aboriginal PHC sector with an ability to work across the NT health system. Regionalisation reforms will create approximately 14 organisations, each governed by a board. There is a need for discussion regarding what will sit above these and how functions such as monitoring of the sector and sector-wide planning and policy will be undertaken.

To assist with developing the capacity of regional health organisations and promoting and maintaining the cohesiveness of the NT PHC system, we believe that there are a number of PHRG members who might take on a more direct mentoring role with developing regional ACCHOs. PHRG members are in the best position to explain NT AHF policies to developing RSCs, for example, concerning core PHC services and expanding these. PHRG members mentoring and engaging with regional ACCHOs more closely will promote better understanding and conformity to NT-wide policies and promote the integrity of the regional Aboriginal community-controlled PHC system. Taking such a direction would require that the current structure, functioning and resourcing of PHRG be reviewed.

The NT AHF needs to anticipate how best to intervene and support a regional ACCHO that is not providing sufficient, high-quality services to communities or finds itself in financial or other difficulties. With 14 or more regional ACCHOs in place it is likely that at various times one or more organisation may find itself in difficulty. We believe the responsibility for intervening early and dealing with this circumstance should rest with the NT AHF. This approach would mean that the NT AHF will need to agree in advance under what circumstances it would intervene and how it would provide the necessary support given the NT AHF does not currently have the resources to provide such support. It would also need to agree to a process of intervention including managing the relationship with specific funders of the services. This would require significantly more information about the operations of regional health organisations (information beyond the EHSDI program), including on financial matters. Having this information would also have the benefit of the NT AHF overseeing that there is equitable resourcing and services provided between HSDAs and between communities within HSDAs.

The points above are presented as discussion points only. We suggest that achieving a high quality NT-wide Aboriginal PHC system, maintaining its cohesion and ensuring its good governance, needs to be addressed prospectively rather than reactively. These suggestions would have resourcing implications for the NT AHF that would need to be considered.Top of page

5.5.8 Conclusions

The EHSDI is sometimes referred to as Phase 3 of the CHCI. Planning and implementing Phase 3 overlapped with the need for NT AHF partners to plan and implement Phase 2, the follow-up stage of the CHCI. Funding cycles meant NT AHF partners had little or no time to carefully scope, plan and then commence implementing the EHSDI program of increasing community control and establishing regionalised health service delivery models of Aboriginal PHC services across the NT.

Regionalisation is a complex task, involving elements of merging services, scaling up services and a change in management and governance control. Consequently, many of the problems arising over the past two years are due to a lack of clear policy direction in the early stages of the process and partners not sharing the same vision. This led to inconsistency in communications that caused confusion among the NT AHF partners. Other issues also arose because of RaDU’s apparent lack of resources and capacity in some areas to fulfil its roles. A review of RaDU’s roles and responsibilities was recommended as an outcome of the NT AHF regionalisation workshop and evaluation findings support the need for a review.

We feel that the regionalisation component of the EHSDI has been under-scoped and under-resourced and that the partners’ roles in the process have not always been clear. The partners need to reconfirm commitment to the regionalisation agenda and be clear on the aims and goals. There needs to be a new scoping of regionalisation under the direction of the NT AHF to more clearly identify the tasks involved, the action and resources required to meet these and the most appropriate people to undertake these. This scoping and planning should be informed by the principles contained in the foundation documents: Pathways to Community Control, the Regionalisation of Aboriginal Primary Health Care Guidelines and the draft Competency and Capability Support Framework. Much has been achieved and we would conclude that the reform is on the right track, but the process needs to be reinvigorated. supported by united leadership and appropriately resourced.
This would be further assisted if there were agreed medium term indicators of key dimensions of the reform. These indicators, developed collaboratively with communities, would set out the specific expectations of what is to be achieved through regionalisation. Key elements may include: the extent to which community members are involved in the planning and governance of health services; the degree of service improvement, which could be measured initially through increased service use; and efficiency, measured through monitoring the costs of service provision.

Community involvement in the delivery, management and control of PHC services before commencing the reform agenda was inconsistent. This position has not changed as a consequence of regionalisation activities to date. Activities concerning increasing Aboriginal community involvement and empowerment have, in the main, not commenced. A major challenge is to empower people in remote communities for whom the broader system has been largely disempowering. One of the main barriers to overcome is engaging with community members so that they believe and accept that increased community control and the move to regionalised ACCHOs will truly deliver improved health services and improved health outcomes. Adapting the community-participation model used by the health service in Katherine East is one option for the NT AHF to consider. This will require a community-development approach that takes time and resources.

Implementing an NT-wide regional Aboriginal community controlled PHC service model is not without risk. The NT AHF, with the support of PHRG, appears to have successfully navigated the challenges faced so far. To make further progress on the regionalisation agenda, we recommend that the partners develop strategies to address each component part of the process:
  • the merger of ACCHOs and building of community capacity
  • the decentralisation and move to community control of DHF clinics
  • growing and supporting the new regional structures
  • repositioning the policy capacity of the system to focus on the issue of implementation.
We also recommend developing medium-term indicators so all parties can see that their objectives are being met. This will ensure that the principles of regional Aboriginal community control of health services and equity of access are sustained.

28 - United Nations Declaration on the Rights of Indigenous Peoples, 13 September 2007. http://www.un.org/esa/socdev/unpfii/en/ drip.html
29 - Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978.

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