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

4.2 The Expanding Health Service Delivery Initiative

The Child Health Check Initiative (CHCI) and the Expanding Health Service Delivery Initiative (EHSDI) were designed to address the health needs of people living in remote Aboriginal communities in the Northern Territory (NT).

Page last updated: 10 June 2011

This section includes a summary of our findings in relation to the:

  • context from which the EHSDI arose
  • impact of the EHSDI on PHC services and infrastructure
  • leadership and governance of the EHSDI
  • regionalisation and Aboriginal community control
  • impact of the RAHC on the NT remote health workforce
  • collection and use of information.

4.2.1 Context from which the EHSDI arose

Reform of the NT remote health system 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 in the development of individual ACCHOs as well as in NT-wide organisational arrangements. Developments included:
  • Coordinated Care Trials (CCTs)
      These aimed to improve the coordination of health care services to Aboriginal communities. Three NT-based services were included over the two trial periods. Two of these, Katherine West Health Board and Sunrise Health Service, continue to operate as regional health boards which have been externally recognised as examples of good governance.
  • Primary Health Care Access Program (PHCAP)
      This was intended to increase funding to local health services in Aboriginal communities in areas identified as having the highest relative need.
  • NT Aboriginal Health Forum
      This is comprised of representatives of AMSANT, DHF and DoHA. Before the EHSDI, the NT AHF agreed on a set of core PHC services and to move towards community control of remote health services. The AHF developed Pathways to Community Control (NT AHF 2008) as a framework in support of this, developed system-wide NT AHKPIs for Aboriginal health and oversaw the implementation of an electronic patient information and recall system (PIRS).
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4.2.2 Impact of the EHSDI on PHC services and infrastructure

This section addresses the EHSDI evaluation objective 1—impact and sustainability of the EHSDI on PHC service delivery and equitable distribution of resources.

The EHSDI saw a significant increase in the flow of funding into PHC in the NT. From 1 July 2008 to 30 June 2010 a total of $37.717 million was paid directly to health service providers, with $17.807 million spent in 2008–09 and $29.910 million spent in 2009–10. This represents a significant addition to the existing annual NT PHC system funding of $104.4 million8—an increase of 17.0 per cent in 2008–09 and 28.6 per cent in 2009–10.

Funding for service expansion was allocated to HSDAs on the basis of an EHSDI funding allocation model—this methodology was agreed on and endorsed by the NT AHF. This involved establishing a per capita EHSDI funding benchmark for each proposed HSDA which was determined by multiplying the national average MBS payment with an agreed remoteness factor, fluency in English language factor and NT cost of service delivery factor for each HSDA. The sum of these factors created the final benchmark. This formula was developed as a means of distributing the available EHSDI funding equitably amongst the HSDAs, rather than representing the total amount of funding required by each area.

The benchmark methodology was used by the NT AHF to prioritise regions for additional funding. The per capita figure was compared to existing levels of funding from all sources (including both Australian Government and NT Government recurrent funding) to determine final allocations. As a result of the application of the EHSDI funding methodology, the funding difference between HSDAs is now much smaller. Before the EHSDI, PHC funding for 2008–09 ranged from 36.3 per cent (Darwin Urban) to 108.1 per cent (Darwin Rural) of the regional EHSDI benchmark—a difference of 71.8 per cent. Including the EHSDI funding, PHC funding for 2008–09 ranged from 53.5 per cent (Darwin Urban) to 108.1 per cent (Darwin Rural) of the regional EHSDI benchmark—a difference of 54.6 per cent. In other words, regions that were furthest from their benchmark were making greatest gains towards it.

The use of a structured and transparent funding model ensures that decisions are based on a clear rationale. The current benchmark was developed as a means of distributing available funding and is not necessarily an accurate reflection of the costs required to deliver comprehensive PHC services to remote communities. The methodology will need further development before it can be used as a costing model for delivering services in remote areas.

Impact on PHC service delivery

The additional funding enabled the creation of 251 full-time equivalent (FTE) positions in the remote PHC workforce. This included 176.6 FTE positions in 2008–09 and a further 74.4 FTE positions in 2009–10. Of the positions funded in 2008–09 the largest number were for Area Service Manager/Trainer/Coordinator/Business Manager roles (50.0 FTEs). Of these, 45 FTEs were employed by DHF clinics and five were employed by ACCHOs. This initial investment in non-clinical staff by DHF may have been a response to the transition to new service models under the EHSDI. Regionalisation processes will result in previously independently
run, community level ACCHOs moving towards a more consolidated model for each region. In contrast DHF services, which have previously been managed from Darwin or Alice Springs, are decentralising with regionally based managers (Area Service Managers).

Workforce investment in 2009–10 saw a greater focus on ‘front-line’ staff. Of the 251 FTE positions, 97.2 were AHWs or Aboriginal Community Workers (ACWs), 46.9 were doctors, nurses or mental health workers and 34 were regional level hubs and hearing health positions. Of the 2009–10 positions, 35.5 were management or administration focused.

In most case study communities we found that it was too early to measure tangible impacts as a result of the new positions. Larger health services did report a perceptible increase in staffing numbers allowing the provision of additional services such as health screening, immunisation or paediatric services. The EHSDI funding enabled the employment of additional core service staff and relieved previously understaffed services. Informants from smaller and more remote clinics reported only a slight increase in staffing numbers, such as a visiting medical professional coming for an extra half day per week. While many of the new positions have a focus on population health and preventive care, a number of health service staff spoke about the extra resources being diverted into acute care because of the continued need for resources in front-line clinical care.

Recruiting and retaining staff remains an ongoing challenge in the case study communities with a number of services stating that they were unable to fill the positions they had received funding for. Informants reported that AHW roles were particularly difficult to fill. The number of registered AHWs in the NT has declined from a peak of 431 in 1999 to 302 in 2008 (AHW Registration Board of the NT). This appears to be due to a lack of promotion of the AHW role and a lack of locally-based training and professional development opportunities. The current emphasis on regionally-based block training is a barrier for Aboriginal staff who expressed a preference for on the job, apprentice-style training. top of page

Impact on remote health infrastructure

In the 2008–09 and 2009–10 financial years, a total of $14.855 million of the EHSDI funding was spent on capital and infrastructure. Of this, $13.141 million was spent in 2008–09 and $1.714 million in 2009–10. This funding was used on projects such as constructing or refurbishing staff accommodation, maintaining clinics, information technology and purchasing vehicles.

The initial roll out of capital and infrastructure funding lacked a clear investment strategy and there was a lack of alignment with the release of funding for service expansion. While the majority of expanded service funding agreements (18 out of 30) were signed in December 2008, most capital and infrastructure funding agreements were not signed until June 2009. This, combined with the pressure to spend funds quickly under the initial two-year EHSDI time frame, led to inefficient spending in many cases. For instance, several informants stated that they were allocated funding for additional staff members but did not have accommodation to house them. This resulted in the construction of temporary buildings—a short-term fix rather than a sustainable solution.

4.2.3 The EHSDI reforms—leadership and governance

Governance of the EHSDI was initially managed through the Chief Executive Officers’ Group (CEOs’ group), which comprised top-tier managers of the three NT AHF partners—DoHA, DHF and AMSANT. This group provided high-level strategic direction for the increased health services funding in the NT as part of the NTER. In September 2008 responsibility for the strategic governance of the EHSDI was delegated from the CEOs’ group to the NT AHF. This was in marked contrast to the decision making in the CHCI, which was retained in Canberra, and indicates a degree of recognition of the capacity and trust in the NT remote health sector which was not apparent in the lead up to the CHCI itself.

The partnership between the Australian Government, the NT Government and the Aboriginal community controlled health sector under the NT AHF is a significant achievement in inter-agency collaboration. These existing governance arrangements have strengthened the sector’s ability to respond to the developments which occurred under the EHSDI. The extensive development of both structures and relationships prior to the EHSDI meant that the sudden increase in resourcing could largely be managed within existing frameworks. Existing NT AHF structures were used to oversee the implementation of the major EHSDI components, enabling the $88.572 million of EHSDI funding to be managed into the system relatively effectively.

The PHRG, a group of senior policy and clinical officials from the NT AHF partners, was formed to oversee the implementation of the EHSDI. This included the expectation that the PHRG would address any strategic issues associated with the EHSDI, including guiding PHC reform activities, overseeing the regional reform process and developing policy frameworks to guide the EHSDI implementation (EHSDI Governance Arrangements, paper for NT AHF meeting no. 41, September 2008). The NT AHF governance group has chosen not to establish a joint policy capacity. The existing policy capacity in the PHRG member organisations is either insufficient to address implementation policy requirements related to the reform process, or not enough capacity is being directed at supporting the reforms. This issue will need to be addressed if the current reform process is to be sustained.

It is critical that there is a continuing partnership between governments and the Aboriginal community controlled health sector, and between federal and territory agencies. Several issues need to be considered to ensure that governance continues to be effective. The NT AHF needs to focus on governance and oversight, rather than the practical, operational implementation of the reforms. The NT AHF should consider options for a higher level of independent consumer representation (that is, consumer voices not aligned to any of the partners) within sector-wide governance arrangements.

AMSANT is a peak body and ACCHOs, while they represent the community, are too close to service delivery and funding to be the only consumer voice. Existing mechanisms for consumers’ voices, such as the Health Complaints Commission, could be strengthened to act as a vehicle for communicating consumers’ experience of health services. The NT AHF could formally consider reports from these organisations as a means of consumer input into its decisions. top of page

Future considerations for the EHSDI

The future of the EHSDI will be strongly influenced by the 2010 Australian Government decision to broaden the scope of PHC approaches.

Our evaluation findings, especially for the CHCI, suggest that there is a bottleneck between primary and secondary care and other referred services in the NT remote health system. There needs to be an effective link between primary and referred services for the health system as a whole to be effective. This requires a people-centred approach to healthcare which moves away from the focus on layers (PHC and secondary health care) and their respective institutions (health centres and hospitals) towards PHC as a comprehensive and continuous set of services that people are guided through. There would also need to be a wider range of services included as part of PHC such as mental health, alcohol and drug, aged care and disability services.

Broadening the scope of PHC will mean considering the extent to which the PHC system influences wider determinants of health such as poverty and other social determinants of health. Providing strong and interlinked health, housing and social services has been shown to strengthen the overall impact of each separate initiative.

The existing leadership and governance arrangements, if supported by an enhanced policy capacity, are well-positioned to engage with these wider systems issues as part of the ongoing program of reform.

4.2.4 Regionalisation and Aboriginal community control

This section addresses the EHSDI evaluation objective 2—the extent to which Aboriginal and Torres Strait Islander people were engaged and empowered to contribute to health service planning.

The regionalisation of PHC services has been a vision of the NT AHF for some time. Regionalisation processes are expected to support improved health service delivery, greater efficiency and a united Aboriginal PHC sector. The NT discussion about regionalisation also includes a commitment to greater community control. The Pathways to Community Control document describes a framework that supports Aboriginal communities’ control in planning, developing and managing primary health care. The framework shows how community control might be realistically achieved taking into account a community’s capabilities, supporting its aspirations and still meeting the objective of achieving an efficient, effective and equitable health system.

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 there would need to be 14–17 HSDAs based on population catchment areas (ideally between 3,000–6,000 people), 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, with no forced amalgamations of health services.

EHSDI funding totalling $826,633 in 2008–09 and $1.437 million in 2009–10 was provided to AMSANT to establish and run the Reform and Development Unit (RaDU). Major regionalisation activities under the EHSDI to be supported by RaDU include:
  • negotiating HSDA boundaries
  • building leadership and governance capacity and conducting 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 top of page
  • undertaking risk management analysis (AMSANT 2009a).
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. Past experience with the successful development of Katherine West Health Board and Sunrise Health Service suggests that negotiating these processes can take a long time.

In early 2011 three proposed HSDAs appeared to be progressing towards increased community control and achieving a regionalised model of PHC service delivery. In East Arnhem there are proposals to establish a regionalisation unit that will be auspiced by an existing ACCHO. In West Arnhem a regionalisation unit has operated for around 18 months and an interim health board is expected be fully incorporated by 1 July 2011. In Barkly 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.

The Regionalisation of Aboriginal Primary Health Care Guidelines (DoHA 2010) 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 in most of the proposed HSDAs, which were attended by representatives of the NT AHF partners. Getting community members to engage has been challenging and the turnout 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 regional steering committee (RSC) meetings were inadequate—minutes of meetings were not sent to attendees and there was a general lack of communication to participants and the community on the outcomes of these meetings.

In the case study communities, as at April 2010, one health service which was already managed by a regional ACCHO had established processes to facilitate input from community members on health service planning and other activities. The other four communities, which were at the early stages of the regionalisation process, had not been as successful in engaging community members in health service planning. Several informants mentioned that community members seemed pre-occupied with issues that more directly affect their everyday lives, such as housing, and have little interest or ambition to have input into health services. Several community members said that their main concern was being able to access a community health service when they or a family member are unwell, regardless of who was running the service.

RaDU has not yet been required to provide formal governance and other training and capacity building activities for RSCs. The RSCs in two HSDAs (West Arnhem and Barkly) will soon require this training and capacity building to be able 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 to deliver this training, but experience from existing models (such as Sunrise Health Service) could inform approaches to supporting communities in their governance role.

The evaluation found a lack of clarity among the partners about the role of RaDU and whether it had the capacity to fulfil its roles. In early 2009 AMSANT began developing the Regionalisation Toolbox (AMSANT 2009a) which describes the progression towards achieving regionalisation as levels or stages; however work on this document has now 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 efficiently direct the process of increasing community control and regionalisation. They believed that AMSANT/RaDU would develop more detailed documentation to accompany the template and were disappointed when this did not occur. AMSANT stated that work stopped when they realised it would be necessary to identify approval processes for Aboriginal health boards seeking control of PHC delivery in 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. These guidelines did not include a competency and capability framework for RSCs. The NT AHF partners 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 the aims of regionalisation and how to achieve these. Some informants expressed concern that the broader principles in Pathways to Community Control were becoming lost in the push for establishing regional ACCHOs. This concern was reflected in little or no engagement with community members.

AMSANT/RaDU has also raised concerns about the challenge that resourcing the process presents to their organisation. They saw RaDU’s role as being focused on the governance aspects of regionalisation, but feel this has since broadened to include regional health planning, for which they have limited capacity. 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.

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 between NT AHF partners about increasing community control and regionalisation has been inconsistent, and there appear to be varying degrees of acceptance of the concept. There seems to be a lack of agreement among the partners about 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.

It appears that many of the issues that have arisen during regionalisation processes are due to the regionalisation component of the EHSDI being under-scoped and under-resourced. The roles of the partners have often been unclear and they are not currently ‘speaking with one voice’. There needs to be further discussion between the partners to confirm agreement on the aims, purposes and goals of regionalisation. Once this happens, the partners need to clearly identify the tasks involved in regionalisation, how these will be met and resourced and who is most appropriate to undertake these. Regionalisation needs to be broken down into its component parts and strategies developed to address each of these. This includes: top of page
  • merging ACCHOs and building community capacity to contribute to the planning, management and governance of health services
  • decentralising and moving to community control of DHF clinics
  • expanding and supporting the new regional structures
  • repositioning the system’s policy capacity to focus on implementation issues.
Planning should be informed by the principles contained in Pathways to Community Control, the Regionalisation Guidelines, and the draft Regionalisation Competency and Capability Support Framework. Much has been achieved and we would conclude that the reform is on the right track, but that the process needs to be reinvigorated, supported by united leadership, and appropriately resourced.

4.2.5 Impact of the RAHC on the NT remote health workforce

This section addresses the EHSDI evaluation objective 3—the impact and sustainability of the RAHC on health workforce availability and sustainability in the NT.

The NT faces difficulties in recruiting health professionals. There is a high turnover of population and general workforce in the NT, particularly in smaller communities and more remote areas. The RAHC was established as part of the EHSDI to supply health professionals for short-term deployments to fill temporary vacancies in remote NT. In August 2008 Aspen Medical Pty Limited was contracted to establish and operate the program. Initially the RAHC recruited and deployed doctors, nurses, and allied health professionals. From July 2009 this was extended to include dentists, dental therapists and dental assistants.

There were 439 deployments by 227 individual health practitioners between 4 December 2008 and 31 May 2010. The average length of deployment was 3.8 weeks. These times include travel and training days—the actual length of time in the community is usually one or two days shorter. The longest deployment was a little over 17 weeks; the shortest one day. Of the 439 deployments, 261 (59 per cent) were nurses, 46 (10 per cent) doctors, 50 (11 per cent) allied health workers and 82 (19 per cent) dental practitioners. When dental practitioners were included in the second year (from 1 July 2009 to 31 May 2010) they made up 22 per cent of deployments. Up to 31 May 2010, 48 per cent of all deployments were undertaken by practitioners who had undertaken at least one previous RAHC deployment.

The RAHC was used by almost 75 per cent of services, though less so by DHF and smaller centres. ACCHO clinics have used considerably more RAHC practitioners than DHF clinics. On average, ACCHO clinics that used the RAHC had 9.8 placements to May 2010, compared to 4.2 for DHF clinics. The average length of deployment also differed—an average of 40.2 weeks of deployment for each of the ACCHO clinics compared to 14.4 for DHF clinics.

In interviews, ACCHO and DHF managers differed when commenting on the suitability of staff that the RAHC recommended. ACCHO managers generally thought that the RAHC was able to recommend suitable practitioners to fill vacancies and that, with only rare exceptions, the program had improved over time and the practitioners generally worked out well. All the DHF managers interviewed, on the other hand, thought that most RAHC recommended nurses and doctors did not have suitable experience and qualifications. For example, small and isolated clinics required nurses to have a high degree of clinical responsibility (for situations such as a major road injury or a complicated pregnancy), as well as being able to manage a range of PHC services such as immunisations and preventive care. Managers of such clinics (which are the rule in DHF services in the Central Australia region) were only prepared to accept nurses who had significant previous experience in remote Aboriginal communities. Several commented that the RAHC thought that a couple of weeks’ experience as part of a team during the CHCI counted as significant experience, whereas this was inadequate preparation for the broad role of a remote clinic nurse.

The Australian Government appears to be paying the RAHC the same as it would pay another agency for similar services—around $14 for each hour of deployment. With a growing number of repeat deployments and a growing corps of experienced practitioners, the cost per deployment for the RAHC may be expected to decrease.
Both DHF and ACCHO managers reported that the RAHC had made very little impact on overall workforce pressures in the NT. This is not surprising since the RAHC was only ever intended to supply short-term staff. Recruiting and retaining a permanent workforce is still the major concern for the NT particularly in its remote communities. The main workforce issues identified included the:
  • continued high level of reliance on agency nurses
  • need to resolve issues with AHW recruitment, training and support
  • need to overcome literacy barriers for AHWs and ACWs
  • lack of male AHWs and nurses
  • lack of accommodation being a barrier to recruiting permanent staff
  • competition to employ suitable local staff (for example from shire councils and schools).
There is a lack of coordination between the RAHC and other workforce planning and development initiatives. The future of the RAHC needs to be considered within the context of wider workforce issues in the NT. top of page

4.2.6 Collection and use of information

This section addresses part of the EHSDI evaluation objective 5—consideration of the NT AHKPIs project. It also addresses the EHSDI evaluation objective 6.3—impact of the regional reform process on information systems and planning capacity.

The EHSDI reform agenda includes a focus on improving information systems to support health service delivery. Data availability at the system level is critical for monitoring health system performance. Good quality information is needed on the state of NT Aboriginal population health and the functioning of PHC services.

Good quality data and information can be used to promote the efficient and effective operation of the NT remote health system. The collection, analysis and sharing of data across the sector can support goal setting and strategy development. The data can be used to inform policy, to direct resources, and to assist in planning new or targeted initiatives. The collection of system-wide information can also be used to examine the impact of initiatives on health outcomes.

Continuous quality improvement

CQI is considered a key component of PHC system reform and service improvement under the EHSDI. A total of $3.001 million of EHSDI funding has been spent on CQI to date. An EHSDI CQI strategy was endorsed by the NT AHF in March 2009, with the core aim of building on existing quality improvement activities to support long-term, coordinated and sustainable service improvement across the NT remote PHC sector. The strategy has five major components (AMSANT 2009b):
  • recruitment of two CQI Coordinators (Top End and Central) to be based at AMSANT to provide expert leadership in developing the sector-wide CQI model, and training and supporting CQI positions in the HSDAs
  • recruitment of a CQI Facilitator for each HSDA to assist health services with implementing CQI, and supporting and mentoring practitioners in the use of CQI
  • development of a CQI model which will provide consistency and sustainability in the NT with the flexibility to allow for local circumstances
  • establishment of a CQI program planning committee to provide advice, develop the NT CQI model and monitor implementation
  • evaluation of the CQI program to inform future development and CQI investment.
To date, there has been some progress towards implementing CQI activities as part of the EHSDI. The two lead CQI Coordinator positions have been filled, and a CQI planning committee has been set up and meeting regularly since mid-2009. A CQI model for NT Aboriginal PHC was developed by the committee and endorsed by the NT AHF. The recruitment of CQI Facilitators in each HSDA had been slow with most positions not yet filled at the time of the evaluation case studies. This was due to the slower than expected distribution of funding, and negotiations regarding the role of the Facilitators within HSDAs with multiple providers or where existing positions included some CQI responsibilities. These issues have largely been resolved and, as at February 2011, 10 of the positions had been successfully filled and three were vacant (CQI briefing paper to PHRG, February 2011).

The majority of informants we spoke to (over February–April 2010), including both health service staff and health centre managers, indicated that their knowledge of, and experience in, CQI was limited. The initial delay in recruiting CQI Facilitators meant that many health service staff received little information and assistance in implementing CQI activities. This has led to mixed feelings among informants, with some articulating cautious enthusiasm, while others felt anxious about their ability to put CQI systems into practice. There needs to be further investment in training at both a regional and local level, and for health service boards, managers and staff. This would be complemented by developing a resource (such as a manual or website) outlining the features of the various available CQI systems, costs, guidance on appropriate settings for using the tool and ways of celebrating and publicising CQI success stories and a peer-support system. top of page

NT Aboriginal Health Key Performance Indicators

The NT AHKPIs were developed in response to an identified need for a common set of indicators to establish a baseline for measuring Aboriginal health outcomes. While they were developed before the EHSDI, the NT AHKPIs are seen as a critical system-wide tool for supporting CQI activities under the EHSDI. The indicators are meant for use at all community-based health services in the NT including both DHF and ACCHO services. The goal of the system is to improve PHC services by providing data on aspects of health service functioning and on measures of population health. The information gained through the indicators aims to present a NT-wide view of processes and activities in Aboriginal PHC, and to highlight trends at both a regional and NT-wide level to inform Aboriginal health planning and policy development.

In 2003 the NT AHF agreed on 44 NT AHKPIs of which 19 have been developed. The 19 KPIs include 12 quantitative indicators of health services and seven qualitative indicators. These qualitative indicators cover management and support services (four indicators), linkages, policy and advocacy (one indicator) and community involvement (two indicators). Data has been systematically collected against the 12 quantitative KPIs, but the seven qualitative KPIs have yet to be finalised. Health service activities and outputs are tracked at regular intervals, with reports for each community and proposed HSDA produced twice each year.

At the time of writing, three NT AHKPI reporting cycles have been completed. All cycles achieved good coverage (over 95 per cent), but there are some problems with data integrity and technical issues. These include: incomplete data collection at health centres without electronic data collection systems; under-reporting of some data; irregularities in interpreting indicators; and incomplete data for some sites due to data entry backlog. In December 2009 a system review and assessment structure was formed to ensure that the biannual reports will continuously improve in quality, and develop in content and scope. Subsequent reporting cycles are therefore likely to be more useful and accurate.

Interviews with government officials suggested that they generally view the NT AHKPIs positively as a tool with the potential to inform Aboriginal health planning and decision making. For example, the NT AHKPIs could be used to establish a benchmark from which to measure progress towards health system goals and an evidence base on which to build policy decisions.

Evaluation participants raised several suggestions regarding how the NT AHKPI data could be more effectively disseminated. Informants stated that there had been a lot of negative media coverage of Aboriginal health and that getting news of achievements out remained a challenge. Gains revealed through the NT AHKPI data could be used to highlight successes at a local level to increase community pride, and at a national level to encourage further investment in Aboriginal health.

Informants also emphasised the need for greater communication with the Australian Government concerning health issues in remote NT communities. It was felt the Australian Government considered quantitative data most useful. Once issues with data quality are resolved NT AHKPI data has the potential to provide clear and concise evidence to highlight health needs in Aboriginal communities.

The NT AHKPIs monitor activities and quantifiable outputs, such as the number and proportion of underweight children, but do not provide data on the impacts or health outcomes of such activities. They offer a tangible means of reporting on health service outputs via numbers and trends, but cannot provide sufficient data to evaluate the performance of health services and the impact on Aboriginal health.
The NT AHKPIs are currently in the development and implementation phase, and the emphasis has been on ensuring systems and processes are in place and functioning effectively. The seven qualitative indicators are still in development and data has not been systematically collected against these. Such data (such as on unplanned staff turnover) would help to put the clinical data into context. As the system matures, consideration could be given to expanding the scope of the indicator set to include outcome and impact measures. These measures would need to be carefully chosen so that they are sensitive to change in PHC performance. Adding these to the existing process or ‘quality of care’ indicators would enable a more comprehensive picture of Aboriginal health in the NT and would enable the tracking of progress towards desired health outcomes.

8 This includes funding from OATSIH, DoHA Regional Health Service funding, and NT Government funding.

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