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

7.1 The Child Health Check Initiative

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

Page last updated: 17 April 2012

7.1.1 Development of the CHCI
7.1.2 Coverage of the child health checks
7.1.3 Delivery of follow-up services
7.1.4 Impact on health service delivery and the health system
7.1.5 Impact on health status

The CHCI evolved to achieve some credible successes in areas such as dental and hearing/ENT health; however, its overall impact was dulled by a lack of precision in the way it interacted with communities and the existing health care system. The needs of Aboriginal children living in remote communities in the NT remain critically high and there remains a significant need for improvement in the health system to meet these needs. The level of improvement needed warrants continued support for existing partnerships and the sharing of aspirations, resources and expertise between the Australian Government, the NT Government and the Aboriginal community controlled sector. On the ground the health system needs to continue to build comprehensive PHC services that connect seamlessly with more specialised services.

7.1.1 Development of the CHCI

The CHCI arose from an intense national political process that precluded the development of policy documentation before the launch of the initiative. The evaluation found that:
  • in the absence of specific policy documents, the existing MBS Item No. 708 became the de facto policy for the CHCI; however, it was designed for the context of an ongoing relationship between a child and a medical practitioner and was not developed for the specific conditions in remote NT communities
  • the child health checks did not follow international best practice for screening programs, such as those issued by the WHO (Wilson and Jungner 1968)
  • there is no evidence of consideration of appropriate approaches to Indigenous communities-specifically consultation with communities before a health initiative is implemented
  • while child health checks had long been a feature of the NT health system, there was no analysis of the strengths and weaknesses of these checks before the design and launch of the CHCI.
Recommendation 1-Before developing and implementing child health screening programs or other initiatives to improve child health, the responsible agency must develop a program logic and implementation plan to establish links between the health problem, the target population, the health system and social determinants of health.

The analysis should include identification of the strengths and weaknesses (including bottlenecks) within the current system and its interfaces (such as between primary and secondary care), to ensure effective and timely follow-up of referrals and to avoid duplicating services or exacerbating existing gaps. Planning should include a thorough analysis of the costs and benefits of new programs, initiatives and processes, measured against the costs and benefits of continuing or enhancing existing systems (including systems for providing routine care outside formal programs). An analysis of the acceptability of the program to local populations should also be undertaken. Actions to positively influence the social determinants that give rise to health conditions should be an integral part of any program.
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7.1.2 Coverage of the child health checks

The child health checks reached between 57 and 65 per cent of the target population. In considering how effective this coverage was, this evaluation found that:
  • coverage was higher in small communities and among children aged 2 to 9 years
  • coverage was lower in large communities and among older children, especially those aged 14 to 15 years, and children under one year
  • the coverage rate for younger children (0 to 4 years) was similar to the coverage rate for the NT GAA program
  • the very high coverage rate in some communities (close to 100 per cent) suggests that the program had the potential to achieve a higher level of coverage across the NT
  • there is no evidence that the child health checks were better (or worse) at reaching hard-to-reach children: the 57 to 65 per cent of the eligible population who received a health check appeared to be no better or worse off than the 35 to 43 per cent who did not receive a check
  • children who received a child health check were more likely to have had a previous hospitalisation than children who did not have a health check, suggesting that they had poorer health status, and/or better access to hospital services and/or other, more general, ‘health seeking’ characteristics
  • there is some evidence that the population who received a health check was more likely to be accessing the health system through existing health screening programs.

Recommendation 2-Child health screening programs should monitor and report on service use and outcomes of both the population that accesses the program and the eligible population that does not access it.

This information will allow ongoing assessment of the needs of all children in the eligible population and enable assessment of the effectiveness of program implementation and the capacity of the system to respond to these needs.
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7.1.3 Delivery of follow-up services

Almost 70 per cent of children who had a health check received at least one referral, most commonly for PHC and dental services. Out of a total of 10,404 referrals, 6,677 (64.2 per cent) had been followed up and 3,727 (35.8 per cent) had not. The evaluation found that:
  • formal planning for follow-up referrals began late and was done under significant pressure from tight timelines and a preoccupation with implementing the first health checks under the CHCI
  • the large number of follow-up referrals generated by the child health checks, coupled with an acute lack of infrastructure and resources needed to provide dental, hearing and other services in remote communities, exposed a bottleneck in the system. Some places (such as smaller communities) and some service processes (such as referred paediatric service processes in Central Australia) were able to cope with this bottleneck better than others
  • once the follow-up services were established, many children who received or were eligible to receive a health check had increased access to dental, tympanometry, audiology and ENT services
  • despite better access to services, the demand for follow-up services still exceeds the capacity of the system to provide them. We are concerned that 3,727 referrals had not been followed up one to three years after they had been requested. There is a need to develop and implement transition plans for how outstanding referrals that still require follow-up are to be dealt with once the NTER and Closing the Gap funding ceases, as has already been done for ENT/hearing follow-up (DHF 2010a). Such plans need to be developed in the context of a comprehensive PHC approach rather than as stand-alone ‘vertical’ programs
  • there were differences in referral patterns between different child health check teams working in the same community, indicating inconsistencies in referring between different doctors and probable over-referral. This probably reflects the inexperience and lack of confidence of some visiting child health check doctors who were working outside their normal scope of practice
  • new service delivery models for dental and hearing/ENT services have overcome a number of barriers to the delivery of services to remote communities, potentially enabling better and more efficient service delivery if these services continue to be funded and are developed in the context of a comprehensive PHC approach
  • continued resourcing is required to complete the CHCI referrals and sustain follow-up service delivery to ensure that children are moved from PHC to specialist follow-up care efficiently and within an appropriate period of time. The alternative approach-periodic blitzes-is not as effective in addressing the chronic health needs of Aboriginal children.

Recommendation 3-Ensure that the elements of improved referred service provision gained through the CHCI can be sustained with adequate funding and a sufficient workforce.

Rather than relying on short-term special program funding, the Australian Government and the NT Government need to agree on core, long-term funding for providing these services (especially for paediatrics, hearing and dental health). This funding needs to be coordinated to enable provision over the full care pathway from primary care to secondary and other referred services and specialist care. In the short term, there is a need to develop and implement transition plans for each type of CHCI follow-up service for which there are any outstanding referrals that still require follow-up at the end of the current funding arrangements. This may require reviewing all the outstanding referrals with PHC providers to ensure that transition plans apply only to children who still have a clinical need for follow-up services.
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7.1.4 Impact on health service delivery and the health system

Much of the evaluation of the CHCI focused on service and systems-level impacts. Many of our findings in this area have a direct link to the lack of policy and planning processes for the CHCI. More recent achievements in some areas of follow-up service delivery have the potential to bring significant improvements at the systems level.

The main evaluation findings are:
  • there was a lack of policy development before the CHCI was announced, a disregard of the existing NT PHC services and system, and inadequate consultation with the health sector and with remote Aboriginal communities. This resulted in the implementation of a one-off health check and follow-up services that were initially uncoordinated with existing services, the disempowerment of local services and staff, and some guardians of children who reported feeling frightened and traumatised by the experience
  • many health providers and professionals working in the NT focused on ‘making the best of a bad thing’, demonstrating a high level of commitment and achieving some success
  • but success tended to come at the cost of mental stress and fatigue and significant opportunity costs (such as disruption to existing service delivery)
  • the extra resources brought into the system by the CHCI-around $18 million for child health checks and $37 million for follow-up services-were welcome and much needed. But the funding has ‘patched’ the system rather than providing a long-term fix. Without continued funding, and a long-term strategy for funding follow-up services, recent gains in developing more effective and efficient models of service delivery (especially in dental and hearing services) risk being lost
  • the CHCI data has been used to ‘tell the story’ in Canberra-to keep the health needs of Aboriginal children and the ability of health services to meet these needs as a key policy area for the Australian Government.

Recommendation 4-Develop a national policy and accompanying guidelines on child health screening specific to remote Aboriginal communities, in consultation with these communities and drawing on the experience of the NT health sector in delivering relevant programs (such as the CHCI, GAA/Healthy Under 5 Kids and HSAK) before implementing any new child health screening programs.

7.1.5 Impact on health status

A significant amount of treatment was provided during the roll-out of the child health checks (just over half of all children were treated with at least one medication) and the follow-up services, particularly dental services (4,346 children had dental treatments). While many of the conditions found and treated during the CHCI could affect population health status within the time frame of the evaluation, there is limited data on these effects. The evaluation found:
  • there was some evidence of improvement in hearing: the number of children with any hearing loss between their first and last audiology check decreased
  • conversely, over a third of children who had some hearing impairment at the time of their first check had worse hearing by the time of a subsequent test. Audiology conditions tend to be chronic and recurrent, and some fluctuation in the degree of hearing impairment between checks is to be expected
  • improved service delivery models for dental and hearing services are likely to bring changes in health status if they are sustained and implemented in the context of a comprehensive PHC approach and if social determinants improve
  • even with adequate follow-up, medical intervention in the context of ongoing poor social conditions, particularly unhealthy housing and overcrowding, will have a limited long-term impact at population level. While the NTER involved a wide range of measures-including on housing, income support and education-in practice there did not appear to be a strong relationship between the CHCI and other measures, and little change was observed at the community level, particularly in housing.
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