August Evaluation of Primary Health Care Funding to Aboriginal and Torres Strait Islander Health Services

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1 August 2009 Evaluation of Primary Health Care Funding to Aboriginal and Torres Strait Islander Health Services

2

3 August 2009 Evaluation of Primary Health Care Funding to Aboriginal and Torres Strait Islander Health Services

4 Cover Image Tingari Dreaming at Walukurtitje 2001 Linda Syddick Napaltjarri (c ) Acrylic on Canvas Copyright Linda Syddick Napaltjarri Licensed by VISCOPY, Sydney Community: Napaltjarri Orientation: Vertical Society: Viscopy Category: Painting Commonwealth of Australia 2009 ISBN Department of Finance and Deregulation This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney General s Department, National Circuit, Barton ACT 2600 or posted at

5 Contents ABBREVIATIONS 1 SUMMARY AND RECOMMENDATIONS 3 Executive Summary 4 Context 4 This evaluation 6 Methodology 7 Key findings 8 Conclusion 9 Department s response 9 Acknowledgements 9 Recommendations 10 BACKGROUND Overview of Evaluation 14 Introduction 14 Evaluation objectives and questions 16 Evaluation scope and focus 17 Methodology 17 Context 19 EVALUATION RESULTS AND FINDINGS Efficiency and Effectiveness of the Department s management of PHCF Program 22 Determination of primary health care service priorities 22 Program design and delivery 25 Funding Allocation processes 26 Analysis and recommendations 29 3 Efficiency and effectiveness of program service delivery Improving access to effective primary health care services for Indigenous Australians 30 Service Activity Reporting/ Drug and Alcohol Service Reporting 30 Assessment of whether the Department / OATSIH is achieving its objective 36 Analysis and recommendations 40 i

6 ii 4 Efficiency and effectiveness of the processes Assessing how PHCF influences health outcomes for Indigenous Australians 43 Service Development Reporting Framework (SDRF) 44 The Aboriginal and Torres Strait Islander Health Performance Framework 48 Other reporting frameworks 51 Healthy for Life 51 Northern Territory initiatives 53 Analysis and recommendations 55 5 Efficiency and effectiveness of the Department s Management of the PHCF Program Engagement with Services 60 Communication and support 61 Governance 62 Workforce 64 Infrastructure 66 Financial management and reporting 67 Administration capability 69 Sharing and dissemination of good practice 69 Risk Assessment Profile Process 70 Analysis and Recommendations 72 APPENDICES 75 Appendix 1 Methodology 76 Appendix 2 Supporting Data 89 Appendix 3 Participating Organisations 116 Appendix 4 Terms of Reference 118

7 Abbreviations ACCHO ACT AHW AMS ATSIHS BTH CO DASR DoHA Finance MBS NACCHO NSW NT NTAHF OATSIH OEA PBS PHC PHCAP PHCF QAIHC QLD RAP SA SAR SDRF STO Aboriginal Community Controlled Health Organisations Australian Capital Territory Aboriginal Health Worker Aboriginal Medical Service Aboriginal and Torres Strait Islander Health Service Bringing Them Home Central Office Drug and Alcohol Services Activity Reporting Department of Health and Ageing Department of Finance and Deregulation Medicare Benefits Schedule National Aboriginal Community Controlled Health Organisation New South Wales Northern Territory Northern Territory Aboriginal Health Forum Office for Aboriginal and Torres Strait Islander Health Office of Evaluation and Audit (Indigenous Programs) Pharmaceuticals Benefits Scheme Primary Health Care Primary Health Care Access Program Primary Health Care Funding Queensland Aboriginal and Islander Health Council Queensland Risk Assessment Profile South Australia Service Activity Reporting Service Development Reporting Framework State/Territory Office(s) 1

8 Abbreviations TAS VACCHO VIC Tasmania Victorian Aboriginal Community Controlled Health Organisation Victoria 2

9 Summary and Recommendations

10 Summary and Recommendations Executive Summary 4 Context 1. The purpose of this report is to provide findings and recommendations in relation to the efficiency and effectiveness of the Primary Health Care Funding (PHCF) program as administered by the Office for Aboriginal and Torres Strait Islander Health, within the Department of Health and Ageing (DoHA). 2. The significant health gains experienced by many Australians have not been shared by the Indigenous community, who continue to suffer a greater burden of ill health than the rest of the population. Indigenous Australians have lower levels of access to health services, increased health risk factors, poorer health and a shorter life expectancy than non-indigenous people. 1 The gap in adult life expectancy between Indigenous people and non-indigenous Australians is estimated by the Australian Bureau of Statistics as 9.7 years for females and 11.5 years for males. 2 Indigenous Australians however, also suffer a burden of disease that is two-and-ahalf times greater than that of the total Australian population. Chronic conditions were responsible for 70 per cent of this difference. Research confirms that many of the poor health outcomes described are related to the continued socio-economic disadvantages experienced by Indigenous people. 3 These include poor access to education and medical care, low incomes, overcrowded housing, and poor nutrition The establishment of the Office for Aboriginal and Torres Strait Islander Health (OATSIH) in , 6 was a key response from the Government to specifically focus on Indigenous health. A core long-term strategy of OATSIH is to improve access of Aboriginal and Torres Strait Islander people to comprehensive and 1 Australian Institute of Health and Welfare. Indigenous Australians Health, Overcoming Indigenous Disadvantage Report 2009 page 47 table Blakely T, Hales S, Woodward A. Poverty: Assessing the distribution of health risks by socioeconomic position at national and local levels. WHO Environmental Burden of Disease Series no. 10. Geneva: WHO, Oxfam Australia. Close the Gap Solutions to the Indigenous Health Crisis facing Australia. Victoria: Oxfam Australia, OATSIH was officially established in 1994; however, it was on 1 July 1995 that responsibility for Aboriginal and Torres Strait Islander health was transferred from the Aboriginal and Torres Strait Islander Commission (ATSIC) to the Health portfolio. Office for Aboriginal and Torres Strait Islander Health, nsf/content/health-oatsih-about 6 At its inception, OATSIH was known as the Office for Aboriginal and Torres Strait Islander Health Services (OATSIHS). OATSIHS subsequently became OATSIH in 1999 to reflect more accurately its long term strategy and work. Australian Indigenous HealthInfoNet (2008). Major developments in national Indigenous health policy since Retrieved 17/02/09 from < timelines.htm>.

11 Summary and Recommendations effective primary health care and substance use services. 7, 8 OATSIH receives funding through DoHA to improve access to primary health care for all Indigenous Australians by providing culturally sensitive Indigenous health services. The funds are allocated to provide a range of health services including substance use, social and emotional wellbeing services in the local community. This PHCF is provided to a variety of organisation types for example Aboriginal Community Controlled Health Organisations (ACCHO), State-managed organisations, Divisions of General Practice and others. 4. Since 2008, the Australian Government has committed to the Closing the Gap initiative 9 that aims to turn around Indigenous disadvantage relating to life expectancy, child mortality, and access to education and employment. In order to close the gap, the Council of the Australian Governments (COAG) has committed $425.3 million in new funds across eight portfolios and has set six key targets. In addition to supporting these targets, COAG have put forward a number of strategic platforms to address the drivers of disadvantage and work towards closing the gap. Closing the gap for life expectancy by 2030 is a national priority, with a number of other intermediate targets, such as decreasing child mortality rates. 5. It is well recognised, that in order for significant gains to be made towards closing the gap, Indigenous health needs to be part of a holistic agenda. 10 An integrated whole of government approach is now the preferred way forward to address the social and economic determinants of health, alongside improving health services. Furthermore the focus on Indigenous health will be a central part of the larger agenda, but hand in hand with other strategic platforms, comprising: healthy homes, safe communities, early childhood, schooling, economic participation, and governance and leadership. 5 7 Primary health care encompasses clinical care for acute and chronic conditions, allied health, population health programs (e.g. immunisation, screening and health promotion), facilitation of access to secondary and tertiary health services, client / community assistance and advocacy, services provided by GPs, nurses, and allied health, sexual health services, maternal and child health services, hearing services, nutrition services, chronic disease services, including diabetes, asthma, and cardiovascular disease (CVD), and eye health services. 8 Department of Health and Ageing. Office for Aboriginal and Torres Strait Islander Health (OATSIH). health.gov.au/internet/main/publishing.nsf/content/health-oatsih-about, last updated 5/12/07, accessed 25/06/08. 9 Closing the gap between Indigenous and non-indigenous Australians. Statement by the Honourable Jenny Macklin MP. 13 May National Health and Hospitals Reform Commission- A Healthier Future for All Australians, Interim Report December 2008, Page 205.

12 Summary and Recommendations 6. Therefore, primary health care (PHC) is central to achieving health outcomes and is likely to be a central element to the efforts of closing the gap. Given the increasing focus by all levels of Government on Indigenous health services it is timely to evaluate the performance of OATSIH and its delivery of the PHCF as well as its systems for assessing the influence that the funding is having on improving health outcomes. This evaluation 6 7. The Office of Evaluation and Audit (Indigenous Programs) (OEA) within the Department of Finance and Deregulation (Finance) identified an evaluation of the PHCF Program in its Work Program. The PHCF is currently administered by DoHA through OATSIH. 8. This evaluation covered the period between to and focussed on the recurrent funding provided to Services meaning that the data reported are limited to the abovementioned time period and funding area. It is important to mention during this period, there have been a number of changes in policies and procedures, along with implementation of new budget initiatives which have impacted on the period of the evaluation. While these have not been specifically addressed, it is important that they are noted to provide context for the ongoing changes in OATSIH. These changes are listed in Section 1 of the report that follows. 9. PHCF, as administered by OATSIH involves the provision of funding to a variety of organisations such as ACCHOs and State-managed organisations, based on historical allocations and new budget measures, as well as the management of these allocations. This management component not only involves the planning processes around funding allocation, but also encompasses the measurement and assessment of whether the PHCF program is meeting its stated objective of improving access. 10. The overarching objective of the evaluation was to assess the efficiency and effectiveness of: i. The Department s management of PHCF program as funded to Aboriginal and Torres Strait Islander Health Services (ATSIHSs) 11 ii. Program service delivery by ATSIHSs in improving access to effective primary health care services for Indigenous Australians iii. The Department s processes for assessing how PHCF influences health outcomes for Indigenous Australians 11 Please note that ATSIHSs are also referred to as OATSIH Services

13 Summary and Recommendations 11. This was addressed through an assessment of: i. How the Department plans and manages the provision of funding for primary health care services through the PHCF Program ii. How the Department assures itself that PHCF has improved Indigenous Australians access to primary health care services iii. The Department s processes for assessing the influence of primary health care services on health outcomes for Indigenous Australians iv. The engagement of the Department with ATSIHSs in the planning, delivery and management of PHCF Methodology 13. The evaluation was conducted over a period of eight months, with a total of 203 individual stakeholders 12 involved. Stakeholders included representatives from: OATSIH Central Office and State and Territory Offices (STOs), Peak Bodies, State/ Territory Health Departments and OATSIH Services. The evaluation was conducted over five stages, which included a design phase (Stage 1), an implementation stage (Stage 2), and three reporting stages (Stages 3, 4 and 5). 14. In Stage 1 Design, an evaluation plan, interview guide and an electronic survey (e-survey) were developed based on the Terms of Reference. 15. Stage 2 Implementation, involved quantitative and qualitative data collection and analysis. In order to capture qualitative data, the evaluation conducted semistructured interviews 13 and an e-survey. Semi-structured interviews were carried out face to face or by telephone with the stakeholders mentioned above, whilst the e-survey was administered via to OATSIH Services. The e-survey process enabled the collection of perceptions from a larger sample across the key areas of investigation, whilst the interview approach informed the evaluation by providing opportunities for in-depth exploration of these key areas and clarification of information. 16. The evaluation also included 12 site visits across Australia. The purpose of these visits was to understand the way in which PHCF operated at the ground level and to gauge the level of contact and presence that OATSIH has had with Services. Services are important stakeholders within PHCF, being the front line of PHC service delivery. Additionally, OATSIH Services have the direct link to the Indigenous community to which they serve As distinct to the number of Services that participated. Please note that each e-survey response was counted as one stakeholder. 13 All semi-structured interviews, with the exception of two Peak Body interviews, were carried out face-to-face. These two Peak Body interviews were undertaken via teleconference.

14 Summary and Recommendations 8 Key findings 17. The overarching key findings of the evaluation will now be presented. Overall, the findings suggest that since OATSIH s inception, OATSIH has been continually evolving to become a more efficient and effective organisation. This evolution is palpable at the operational/process level, but is yet to achieve its potential at the more strategic and policy direction level. In particular: Results of the evaluation indicate that the methods by which OATSIH determines health priorities and funding decisions are heavily weighted towards process oriented objectives. Overall the data from both the Service Activity Reporting (SAR) and the proxy measures developed suggest that, nationally, OATSIH is enabling improved access to primary health care services by Indigenous Australians. However, currently, data issues impose limitations on the evaluation s ability to provide a definitive assessment of improvements in access. To that extent, there is limited understanding of the impact of the PHCF on access. Existing reporting mechanisms directly related to the PHCF, i.e. the Service Activity Reporting (SAR)/ Drug and Alcohol Service Activity Reporting (DASR) and the Service Development Reporting Framework (SDRF), are limited in their measurement of health outcomes. In addition: - Data collected through the Service Development Reporting Framework (SDRF) are only used by STOs and not reported or used presently at the national level to inform on whether health outcomes are improving. - There is no apparent linkage between the SDRF and SAR/DASR with other reporting frameworks, apart from duplication in measures. - The Health Performance Framework is reported at a population level and therefore health outcomes cannot be attributed to the PHCF program or to the Services. - Other program specific reporting, such as the Healthy for Life program and the Northern Territory Emergency Response Project are moving in the right direction with greater emphasis on monitoring health outcomes. While Services are generally positive about relations with OATSIH, there are opportunities to improve communication and relationships between OATSIH and Services. Project Officers are the key to engagement and strong relationships with Services and the role of Project Officers in mentoring and supporting Services needs consistent and ongoing support from STOs and OATSIH Central Office.

15 Summary and Recommendations Conclusion 18. The evaluation has identified areas for incremental improvement and noted these through the report. Looking to the future, the underlying demand for primary health care services remains high, the funding for Indigenous health has been increasing sharply, and the focus on Indigenous health is likely to increase significantly. The imperative will be to focus on health outcomes and to align and understand the impact of activities on the Closing the Gap goals. The challenge for OATSIH will be to assure itself that its systems for policy development, prioritisation, delivery and measurement allow it to meet those opportunities. Department s response The Department is continually evolving and modifying many aspects of the primary health care program. This ongoing work responds to new Government initiatives, feedback from the sector and emerging health issues. Many of the recommendations in the report were overtaken by this work with new initiatives either in the implementation phase or completed prior to the release of the report. In particular the need to reform sector reporting to achieve a focus on outcomes was identified following the announcement of the COAG Closing the Gap initiative in early 2008 and a major round of consultations on reporting commenced in late 2008 and concluded in May Significant reforms to sector reporting are currently underway with progressive implementation. The Department continues to consult with the sector at a national, jurisdictional and local level to identify opportunities for further program reforms and on how to best target primary health care resources. 9 Acknowledgements 20. OEA would like to thank the individuals, communities, and organisations that participated in this evaluation. Their time, commitment and enthusiasm are greatly appreciated. In particular, we would like to thank all the interview participants from OATSIH Central Office and State/Territory offices, Services, the National Aboriginal Community Controlled Health Organisations (NACCHO) Affiliates and State/Territory Health Departments. Appendix 3 contains a list of all the organisations that participated in the interview process.

16 Summary and Recommendations Recommendations Recommendation 1 Determination of primary health care service priorities, program, program design and funding allocation processes Paragraph 2.28 and 2.29 Overall, it is recognised that OATSIH has in place a consultation strategy that engages with the sector across national, jurisdictional and regional levels through a variety of groups and forums. Despite this however, there are consistent perceptions from the stakeholders interviewed as part of this evaluation that greater consultation by OATSIH is required, particularly in relation to the priority setting and program design process. 10 OEA recommends that OATSIH continue to build on their existing consultation strategy and seek additional opportunities to engage directly with Services at the local level to seek their views on national priorities and program design. Recommendation 2 Service Activity Reporting/ Drug and Alcohol Service Reporting Paragraph 3.21 OEA recommends that, OATSIH review the current SAR/DASR with the aim of developing and implementing more direct measures of access i.e. the rates of persons (an unduplicated count) who use specific services in the population. Recommendation 3 Data collection on health outcome measures Paragraph OEA recommends that OATSIH: a) develop and implement measures of the health outcomes that can be related to the access created by PHCF b) improve current outcome reporting by developing linkages between SDRF, SAR/ DASR and other reporting frameworks c) aggregate reports nationally with appropriate segmentation to enable enhanced benchmarking.

17 Summary and Recommendations Recommendation 4 Duplication of reporting requirements Paragraph Overall, it is recognised that OATSIH is conducting a review of reporting requirements, which aims to reduce duplication and streamline reporting for all of their Services. In light of this and the data collected, OEA recommends that OATSIH use its Review of Reporting Requirements to: a) assess the data currently being collected through the various reporting mechanisms with the view towards increasing the number of outcome related measures (relates also to Recommendation 3) b) develop a streamlined approach to reporting that integrates activity, operational performance, and health outcomes c) facilitate opportunities for Services to provide input into the revision of reporting requirements through timely consultation. 11 Recommendation 5 Service Development Reporting Framework Paragraph While stakeholders reported the SDRF process has been useful and effective, OEA recommends OATSIH make the following improvements: a) develop a standard set of performance measures for inclusion into the SDRF Action plans which include a mix of both activity and outcome measures b) review the timeframes for the SDRF cycle to ascertain if adjustments are needed to minimise delays in receipt of funding. Recommendation 6 Planning, delivery and management of the PHCF program Paragraph OEA recommends that OATSIH ensure regular engagement with and support of Services through: a) developing a minimum standard for Project Officer contact and site visits to the Services which allows for flexibility to accommodate greater levels of support for Services when they are experiencing difficulties b) expanding the availability of Business Management Training and Board Governance Training c) developing a systematic approach to disseminating information on good practices to Services both at a national level and at a State/Territory level.

18 Summary and Recommendations Recommendation 7 Risk Assessment Profile process Paragraph OEA recommends that OATSIH make the following additional improvements to the RAP process: 12 a) develop and disseminate a standard set of communication and guidelines to be disseminated to all Services regarding the new RAP process which clearly outlines every step of the process, including: preparation, timeframes, review processes and dispute resolution processes b) allow for flexibility to adapt some of the assessment items in the RAP to reflect the nature of the services being provided by each individual organisation c) continue to conduct reviews of the RAP to seek feedback on other areas for improvement and refinement.

19 Background

20 Background 1. Overview of Evaluation Introduction The significant health gains experienced by many Australians have not been shared by Indigenous Australians, who continue to suffer a greater burden of ill health than the rest of the population. Indigenous Australians have lower levels of access to health services, increased health risk factors, poorer health and a shorter life expectancy than non-indigenous people. 14 The gap in adult life expectancy between Indigenous people and non-indigenous Australians is estimated by the Australian Bureau of Statistics as 9.7 years for females and 11.5 years for males. 15 Indigenous Australians however, also suffer a burden of disease that is two-and-ahalf times greater than that of the total Australian population. Chronic conditions were responsible for 70 per cent of this difference. Research confirms that many of the poor health outcomes described are related to the continued socio-economic disadvantages experienced by Indigenous people. 16 These include poor access to education and medical care, low incomes, overcrowded housing, and poor nutrition One of the approaches to addressing the inequalities in Indigenous health and recognising the need for a greater focus on improving the health of Aboriginal and Torres Strait Islander peoples, was through the establishment of the Office for Aboriginal and Torres Strait Islander Health (OATSIH) in A key longterm strategy of OATSIH is to improve access of Aboriginal and Torres Strait Islander people to comprehensive and effective primary health care and substance use services. 18, 19 OATSIH receives funding through the Department of Health and Ageing (DoHA) to improve access to primary health care for all Indigenous Australians by providing culturally sensitive Indigenous health services. The funds are allocated to provide a range of health services, substance use services, social and emotional wellbeing services in the local community. This Primary Health 14 Australian Institute of Health and Welfare. Indigenous Australians Health, Overcoming Indigenous Disadvantage Report 2009 page 47 table Blakely T, Hales S, Woodward A. Poverty: Assessing the distribution of health risks by socioeconomic position at national and local levels. WHO Environmental Burden of Disease Series no. 10. Geneva: WHO, Oxfam Australia. Close the Gap Solutions to the Indigenous Health Crisis facing Australia. Victoria: Oxfam Australia, Primary health care encompasses clinical care for acute and chronic conditions, allied health, population health programs (e.g. immunisation, screening and health promotion), facilitation of access to secondary and tertiary health services, client / community assistance and advocacy, Services provided by GPs, nurses, and allied health, sexual health services, maternal and child health services, hearing services, nutrition services, chronic disease services, including diabetes, asthma, and cardiovascular disease (CVD), and eye health services. 19 Department of Health and Ageing. Office for Aboriginal and Torres Strait Islander Health (OATSIH). health.gov.au/internet/main/publishing.nsf/content/health-oatsih-about, last updated 5/12/07, accessed 25/06/08.

21 Background Care Funding (PHCF) is provided to both Aboriginal Community Controlled Health Organisations (ACCHO) and State-managed organisations. ACCHOs account for 76 per cent of the 255 Services Indigenous health funding through OATSIH has been steadily increasing since ($114.8 million) with a particularly large increase in funding being observed in ($265.6m). OATSIH s budget of $526.2 million 21 is primarily allocated to: funding health service providers for the delivery of primary health care services to their local communities (approx $374 million) 22 funding new programs and services through new budget measures (some of which are directed at facilitating access to primary health care (PHC) services 23 and increasing the uptake of the Medicare Benefits Schedule (MBS) / Pharmaceutical Benefits Scheme (PBS)) The Australian Government has committed to the Closing the Gap initiative 25 that aims to turn around Indigenous disadvantage relating to life expectancy, child mortality, and access to education and employment. In order to close the gap, the Council of the Australian Governments (COAG) has committed $425.3 million in new funds across eight portfolios and has set six key targets. In addition to supporting these targets, the COAG have put forward a number of strategic platforms to address the drivers of disadvantage and work towards closing the gap. Closing the gap by 2030 is a national priority. Some of the health related strategies and investment for include 26 : $19 million over three years to strengthen the Indigenous health workforce $21.5 million boost over five years to improve remote area health services in the Northern Territory Department of Health and Ageing. OATSIH-funded organisations. Information provided by OATSIH dated 4 July Portfolio Budget Statements 2007/08, Outcome Some of the new budget measures that have been introduced to date are: Establishing quality health standards, Family centred primary health care (i.e. previously known as PHCAP), plus, Northern Territory Emergency Response improving child and family health and expanding health service delivery, New Directions child and maternal health, Better Outcomes for Hospitals and Community Health, Link Up and Bringing Them Home. 23 Previously known as the Health Care Access Program (PHCAP), which was introduced to improve access to Primary Health Care (PHC) Services. 24 Refers specifically to the Urban Brokerage initiative which provides resources for up to 5 brokerage Services to be established across Australia in highly populous areas to facilitate access to culturally appropriate GP and specialist Services. 25 Closing the gap between Indigenous and non-indigenous Australians. Statement by the Honourable Jenny Macklin MP. 13 May

22 Background $49.3 million over four years as part of COAG commitment to support substance and alcohol rehabilitation and treatment services across Australia, particularly in remote areas $14.5 million in tackling high rates of smoking in Indigenous communities $101.5 million over five years to for New Directions: An equal start in life for Indigenous children child and maternal health services. 16 Evaluation Objectives and Questions 1.5 The overarching objectives of this evaluation as outlined in the Terms of Reference were to assess the efficiency and effectiveness of: i. The Department s management of PHCF program as funded to ATSIHSs ii. Program service delivery by ATSIHSs in improving access to effective primary health care services for Indigenous Australians iii. The Department s processes for assessing how PHCF influences health outcomes for Indigenous Australians. 1.6 This was addressed through an assessment of the following: i. How the Department plans and manages the provision of funding for primary health care services through the PHCF Program ii. How the Department assures itself that PHCF has improved Indigenous Australians access to primary health care services iii. The Department s processes for assessing the influence of primary health care services on health outcomes for Indigenous Australians iv. The engagement of the Department with ATSIHSs in the planning, delivery and management of PHCF. 1.7 The evaluation was also required to evaluate and comment on: the program performance framework, reporting arrangements and use of program performance data by the Department the extent to which the program is meeting its stated objectives the processes used to assess funding applications and decision making program design and delivery issues and how priorities for primary health care services are determined the geographic distribution of service delivery organisations and in relation to the Department s view of needs impact of issues such as health workforce, availability of suitable infrastructure, remoteness and environmental factors on the delivery of the program where feasible processes in place for ensuring that ATSIHSs operate efficiently and effectively in line with program expectations

23 Background perspectives from a sample of ATSIHSs on current funding arrangements and the effectiveness of support arrangements the identification of better practice examples in the context of identification of issues affecting the management and operations of ATSIHSs. Evaluation Scope and Focus 1.8 The time period covered in this evaluation was from to The evaluation was primarily focussed on evaluating the base/recurrent funding component of the PHCF, which in constituted approximately 70 per cent of OATSIH s overall budget of $526.2 million. The following areas of PHCF were specifically excluded from this evaluation: Examination of the Resource Allocation Model (including the principles, formulae and processes underpinning the model) Specific funding provided for any new programs, including the following: - Bringing Them Home (BTH) and Link Up - capital works (major and minor) - organisational development and related activities - Whole of Government activities. 1.9 Funding for the recent Healthy for Life budget measure was not examined in detail, however given that five out of the 12 Services that were selected for site visits were Healthy for Life sites, there were opportunities to examine the differences that exist between the Healthy for Life Services compared to the non- Healthy for Life Services and thus make a number of observations on this where appropriate The funding for the Closing the Gap initiative was predominantly introduced in the financial year and therefore the impact of this has also not been considered. Access to primary health care is critical for preventing ill health, better management of chronic disease, and improving health outcomes to close the gap in life expectancy between Indigenous and non-indigenous Australians. 17 Methodology 1.11 The evaluation was conducted over a period of eight months and involved five key stages of work. The five stages are depicted in Figure 1.1 below.

24 Background Figure 1.1: PHCF Evaluation Methodology Stages Activities Stage 1 Design (Jun Aug 08) Document Review Key Informant Interviews Sample Frame Design Evaluation Framework Design PHCF Evaluation Plan 18 Stage 2 Implementation (Sep Dec 08) Semi-structured interviews (n=36) E=Survey (n=72) Data Analysis Quantitative data request Stage 3 Discussion Paper Consolidation Discussion Paper Stage 4 and 5 Draft Report and Final Report Consultation Draft Report Final Report 1.12 Further details on all the key activities undertaken at each stage can be found at Appendix 1. In summary, the main data collection activities undertaken included: Key informant interviews in Stage 1 were conducted with OATSIH (Central Office and STOs) to gain an understanding of how PHCF is managed and administered, the roles and responsibilities of the different offices and branches, and the key activities undertaken in liaising with Services. Semi-structured interviews were the main source of data for the evaluation. A total of 36 interviews 27 were conducted with the three stakeholder groups. Interviews were conducted face-to-face, except for two interviews that were undertaken via telephone. Interviews were semi-structured in order to provide 27 Interviews were carried as one-on-one or group based sessions depending on the preferences of the interviewee/s. The majority of interviews were carried out as group interviews with between three and nine interviewees present. Please note: although 36 interviews were undertaken, the number of stakeholders is greater due to the majority of interviews being carried out with more than three interviewees.

25 Background the interviewees with the flexibility to raise relevant issues, which may not have been raised as part of the interview questions. e-survey The e-survey (see Appendix 2 for the summary of e-survey results) was ed to 159 Services. 28 Seventy two responses were received, representing a response rate of 45 per cent. The e-survey consisted of 35 multiple choice and Likert scale items, as well as opportunities for respondents to provide comments to each question or general comments at the end of the survey Three major stakeholder groups were identified for inclusion in the evaluation and were as follows: OATSIH (Central Office, STOs) Services (with emphasis on ACCHOs) External stakeholders (i.e. State/Territory Government and Peak Bodies) Overall, a total of 203 individual stakeholders 29 were involved in the evaluation, with six per cent from OATSIH Central Office, 14 per cent from OATSIH STOs, 15 per cent from external stakeholders consisting of peak bodies and State/ Territory Health Departments, and 65 per cent from Services, of which 30 per cent participated in face-to face interviews and 35 per cent responded to the e-survey Context 1.15 As mentioned previously, this evaluation covered the period between to and focussed on the recurrent funding provided to Services. There have been a number of changes in policies and procedures along with new initiatives which have impacted on the period of the evaluation. Some of these have been included as part of the evaluation while others have not The changes in policies and procedures and/or new initiatives that are addressed in this evaluation include: the Service Development Reporting Framework (SDRF) that was introduced in All Services are now required to complete the SDRF as part of their funding agreement 28 Please note that the although the PHCF evaluation was focused on Aboriginal Community Controlled Health Organisations (ACCHOs), a handful of non-acchos were also sent the e-survey (due to difficulties in categorising some of the Services) and as such are included in the e-survey data. Eleven per cent of respondents were non- ACCHOs. 29 As distinct to the number of Services that participated. Pleas note that each e-survey response was counted as one stakeholder. 30 Each e-survey response was counted as an individual stakeholder.

26 Background 20 the new Risk Assessment Process (RAP), which was modified in 2007, making it significantly more comprehensive compared to previous years and modifying the processes of assessment the commencement of triennial funding agreements in 2007, where previously funding agreements were on an annual basis to all Services The changes in policies and procedures and/or new initiatives that were not addressed in this evaluation but nevertheless are reported below to provide context for the ongoing changes in OATSIH include: the implementation of the Northern Territory Emergency Response Initiative, which will change the way health services are to be delivered in the Northern Territory as a means of improving levels of access to primary health care services. The initial focus of this initiative is on improving the health of children in the Northern Territory through facilitating greater numbers of child health checks being conducted. 31 The level of financial investment for this initiative is significant, with over $53.4 million dollars committed in the financial year. the publication of the first Health Performance Framework (HPF) published in 2006, which is an initiative driven through the auspice of the Australian Health Ministers Advisory Council. The HPF was to provide a basis for measuring the impact of the National Strategic Framework for Aboriginal and Torres Strait Islander Health and to inform policy analysis, planning and program information to support closing the gap in Indigenous disadvantage. the commissioning of a benchmarking and review project to develop a better understanding of their Services along with the costs of service delivery. the commencement of a Reporting Rationalisation Project, which is a review of all Services reporting requirements with the aim of reducing duplication and streamlining reporting for Services. the commencement of funding for Services to improve their information technology systems (ICT funding) along with improving governance and management skills through funding Business Management Training programs for Services management staff. 31 A Progress Report on the Child Health Check Initiative is available on OATSIH s website. This progress report covers the period July 2007 to October 2008.

27 Evaluation Results and Findings

28 Evaluation Results and Findings 2. Efficiency and Effectiveness of the Department s management of PHCF Program This section will present the finding related to the efficiency and effectiveness of the Department s management of PHCF program as funded to Services through an assessment of how the Department plans and manages the provision of funding for primary health care services through the PHCF Program. 22 This chapter examines and comments on the perceptions of various stakeholders on a range of topics including: how priorities for primary health care services are determined program design and delivery issues OATSIH s management of funding allocation and decision making processes. Determination of primary health care service priorities 2.1 One area of investigation for this evaluation included the examination of OATSIH s process for determining the primary health care services priorities, which subsequently influences how funding is allocated and distributed. 2.2 Health priorities are determined at the national level by the Executive team at OATSIH s Central Office and at the State/Territory level by STOs, in conjunction with other State agencies. 2.3 At the national level, health priorities are developed by the OATSIH Central Office inline with whole of government priorities and national agendas which are influenced by Parliament decisions. In addition, OATSIH Central Office reported they have an extensive consultation strategy that enables them to engage the sector at the national, jurisdictional and regional level to allow input into the national priority setting process. The strategy includes consultations with: the National Indigenous Health Equality Council (NIHEC) a forum which is tasked by the Minister the Indigenous Health Partnership Forums at the jurisdictional level (further detail on this can be found at paragraph 2.5) the Business Improvement Group (BIG) which consists of NACCHO and its State/Territory Affiliates the Indigenous Chronic Disease package under the National Partnership Agreement (NPA) on Closing the Gap in Indigenous Health Outcomes, which engage with peak bodies and key stakeholders directly the jurisdictional level through a series of workshops and meetings where staff from funded health Services are invited to attend.

29 Evaluation Results and Findings 2.4 Despite this however, interview data revealed the majority of Services and external stakeholders still perceive they were not able to provide as much input into the determination of national priorities as they would have liked, with the process being described as a top down approach to priority setting and therefore not necessarily consistent with local priorities. OATSIH Central Office noted that the process of consultation is challenging, as even when they believe comprehensive consultation is conducted and feedback from the sector is incorporated in to the decision making process, often not all parties will feel that they have been heard or were adequately consulted. 2.5 State/Territory priorities, on the other hand, are developed through a structured regional planning process in collaboration with partnerships at each State and Territory (see Figure 2.1). These partnerships provide the foundation for collaboration across State based agencies to determine State and Territory specific health priorities. The partnerships generally consist of representatives from the STOs, State Health Departments and State/Territory NACCHO Affiliates and are formalised through framework agreements between each group. 2.6 As part of the State/Territory planning process, regional priority profile and plans are developed. These Regional priority profiles include relevant and available data on the region, for example population levels and medical service use, to provide a picture of the health status of the local Indigenous populations. The plans are also used to consult with partners and to identify the priorities. Once the priorities are identified and agreed, they are then fed into the State level priority plan that assists in determining the overall strategic direction and funding for the State/ Territory. This process has been perceived by stakeholders to be useful as it enables planning to occur at the regional level and therefore to take into consideration the variations in needs and issues being dealt with by individual regions. 2.7 At the State/Territory level, partnerships between the different State based agencies were reported to facilitate discussion and agreements on health priorities along with identification of gaps and needs in funding which are then taken into consideration by each funding agency when determining allocations. These partnerships have led to the development of cross agency strategies for the planning for the future delivery of Indigenous health services and priorities. Many of the external stakeholders interviewed indicated that these planning forums were vital, however there is always room for improvement and greater collaboration. A number of external stakeholders also indicated that there were additional opportunities for OATSIH and State Health Departments to collaborate, not just in relation to determining health priorities but also in relation to achieving consistency in service operation and management. 2.8 Mixed responses were obtained from Services on the opportunity to provide feedback to OATSIH. Most indicated that they were able to provide feedback through the STOs, while others indicated they provided feedback through their NACCHO Affiliate. 23

30 Evaluation Results and Findings Figure 2.1: OATSIH Regional Planning Process Regional Planning Process CO STANDARD DATA SET All data will be provided in a standard format to provide consistency across STOs. (For full details of the measures used in the process please refer to the Health measures at Attachment A1.) Tier 1 Determinants of Health Tier 2 Health Status and Outcomes Tier 3 Health System Performance (includes current funding) STO ADDED DATA Any qualitative information as well as any additional statistical data specific to that state. 24 OUTCOME 8 STO added Tier 1 Determinants of Health Analyse data for each health measure by OPR and briefly summarise conclusions. (Attachment 1)* STO added Tier 2 Health Status and Outcomes Analyse data for each health measure by OPR and briefly summarise conclusions. (Attachment 2)* Tier 3 Health System Performance (includes current funding) Analyse data for each health measure by OPR and briefly summarise conclusions. (Attachment 3)* Analyse data for each OPR taking into consideration existing investment, the demography of the region, and the health need, in order to determine health service need under Outcome 8. (Attachment 4) Decision making process to determine whether an approach needs to be developed to meet the health service need identified. For each OPR individually, determine 3 year approaches, based on Best Buys, to meet the identified health service need that are in line with the government s priorities. (Attachment 5a)* CURRENT YEAR GOVERNMENT POLICY Risk involved Modify approaches and/or determine additional approaches to meet health service need. (Attachment 5b) Determine any risk and capacity issues involved with implementing chosen approaches.* Regional Plan Public Version Summary of health service needs and approaches. Summary of demographic data. Summary of OPR analysis (without data). (Public document)* No major risk Evidence-based Regional Plan Regional Plan Internal Attachments Detailed analysis of the three assessment components. In depth analysis of each OPR. Summary of proposed approaches and potential funding sources. (Attachment 1, 2, 3, 4, 5) * Points where external consultation may occur in an ongoing process. Source: OATSIH Regional Planning Process Flowchart, version 28 July 2008.

31 Evaluation Results and Findings Program design and delivery 2.9 Program design and delivery were included as part of the evaluation as it was one of the nine areas the evaluators were asked to comment on as part of the Terms of Reference (refer to Section 1, 1.7) The design and delivery guidelines of new programs to be implemented across OATSIH Services are generally developed at the OATSIH Central Office level in consultation with stakeholders. OATSIH Central Office reported their primary method for consultation and communication for program design and delivery is through the Business Improvement Group (BIG) and other consultation forums as described previously in paragraph The consultation process was reported to vary depending on the nature and type of program being designed. For example, consultation may be required with other agencies or clinical experts in relevant program areas and new programs that are cabinet in confidence have different consultation processes. OATSIH Central Office also reported challenges with timing of funding decisions for monies allocated near the end of a fiscal year, i.e. allocation may need to occur quickly cutting short the ability for robust consultation When explored with interview participants, external stakeholders and Services perceived a need for greater consultation by OATSIH in relation to program design. It was also reported that the timeframes for consultation should reflect the level of complexity of the program being designed and the subsequent advice to be provided. Other concerns expressed include: program success may be limited due to the inappropriateness of the program being implemented to the Indigenous communities, particularly given the diversity of health issues being experience by individual communities program guidelines limit variations or adaptations to suit individual community needs, again to account for the differences across the communities Services and external stakeholders agreed that greater consultation in the development of priorities and program design will facilitate the: appropriateness/effectiveness of the programs being developed, particularly considering the cultural context in which they will be implemented and the importance of the holistic nature of health care service provision to the Indigenous community implementation of the right programs in the communities will subsequently facilitate better access to the program reduction in duplication of funding across agencies and greater opportunities to reduce gaps through collaboration. 25

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