Funding, accountability and results for Aboriginal health services – Closing the policy implementation gap?

The need for more effective models of funding and accountability in Aboriginal primary health care is now widely acknowledged, and reforms of various kinds are being planned and negotiated. Changes in governance arrangements (towards community control) and in the stewardship approach of governments (more active engagement with the sector and its development) accompany these reforms. This project partnered with funders and providers in two Australian States/Territories (or jurisdictions) which are moving to implement reforms, in order to study them as they develop and generate evidence about what works and why.

The planned reforms generally aim to make primary health care (PHC) for Aboriginal communities more effective through improvements in the amount and/or methods of funding; through streamlining accountability measures; through changes in the governance of health care providers (in keeping with the principles of community control); and in the ways that governments fulfil their stewardship responsibilities for the strength and sustainability of the health care system. The reforms are based on the intention that governments and the PHC sector will work together in some ways that are fundamentally different from current practice (although more in line with official policy goals).

This project focused on the transfer/regionalisation processes in both the Northern Territory and Queensland, and examined the changes that enable or support this shift towards community controlled health care delivery. The project team sought to work with the jurisdictional forums and partners, providing formative feedback to the process and keeping with a modified action research approach.

This project examined the reforms as a set of nested case studies, and explained successes and failures, both in the processes of implementation and in the policy goals and settings. This knowledge has the potential to offer powerful guidance for governments and Aboriginal health care providers, with broader relevance for Aboriginal affairs, for the ‘third sector’ (non-government organisations) more generally, and for indigenous health policy and practice internationally.

Potential project outcomes

Government: Policy makers and program managers recognise the problems of implementation failure or underperformance, and several recent changes in contracting arrangements in most jurisdictions indicate a willingness to re-examine current contracting and accountability models; and possibly to move towards relational contracting and funds-pooling. Government end users benefit from the availability of a model validated with local experience that addresses barriers they recognise. The NT and Queensland reform plans represent impressively thorough and collaborative approaches to the development of effective PHC systems for Aboriginal communities. Credible evidence about the factors underlying degrees of success in their comprehensive goals has the potential to be of benefit to ongoing stewardship of the health system in these and other Australian jurisdictions, and internationally.

ACCHSs: ACCHSs, and their peak bodies, have long recognised the problems this project addressed, and have advocated for reform. System improvements that are better developed and more sustainable as a result of this project will benefit them through reduced administrative overheads, stronger relationships with funders, and enhanced capacity to deliver the integrated, responsive PHC which is their primary purpose.

Other providers of health care for Indigenous Australians: Mainstream health care providers and ACCHSs are part of one health system, and mainstream agencies are increasingly recognising their responsibilities to work constructively with ACCHSs in care delivery. Enhanced capacity in ACCHSs to deliver comprehensive PHC will reduce problems of coordination and ‘gap filling’ for their mainstream partners. Funding and accountability reform will also directly benefit those organisations that contract with government for Aboriginal PHC provision.

Mainstream NGOs: Contracting practices of government are increasingly recognised as problematic for mainstream NGOs. They also experience a high administrative burden, fragmentation of their activities and reporting, and the problems of lack of certainty. Alternative contracting and accountability models could be applied more broadly, and benefit all parties.

International health systems: Several other countries use similar contracting models for funding health care for indigenous people and holding them accountable, and experience similar problems. In particular, there are potential end users of the results of this project in New Zealand and Canada. Contracting is also used in many developing countries, where similar problems with specification, perverse incentives and high transaction costs are experienced.

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