3.13 Competent governance

Key facts

Why is it important?

‘Governance’ refers to the evolving processes, relationships, institutions and structures by which a group of people, community or society organise themselves collectively to achieve things that matter to them. Governance enables the representation of the welfare, rights and interests of constituents, the administration and delivery of programs and services, the management of resources, and negotiation with governments and other groups (Hawkes 2001; Hewitt de Alcántara 1998; Westbury 2002). Governance occurs at the community, local, regional and national level. The manner in which governance functions are performed has a direct effect on the wellbeing of individuals and communities.

This measure explores the role of competent governance of Indigenous primary health care services in the delivery of care to Aboriginal and Torres Strait Islander people.

Governance at the community level plays a vital role in the delivery of primary health care for Indigenous Australians. Community control of health services allows Indigenous Australian communities to determine their own priorities, protocols and procedures. The care these services provide will also reflect the values and principles of the community they serve.

The Aboriginal Community Controlled Health Services (ACCHSs) model is the main governance model adopted by Indigenous primary health care providers. An ACCHS is an incorporated organisation initiated and based in local Indigenous communities. They deliver a holistic, comprehensive, and culturally appropriate health service to the community. While the capabilities and capacity of ACCHSs vary, this model of care provides important options for Indigenous Australians (Moran et al. 2014).

Findings

What does the data tell us?

The Office of the Registrar of Indigenous Corporations (ORIC) administers the Corporations (Aboriginal and Torres Strait Islander) Act 2006 (CATSI Act). The legislation sets out governance standards, with special measures to suit the needs of Indigenous Australians. In 2017–18, 661 corporations that identified as having principal activities of health and community services were incorporated under the CATSI Act and were registered with ORIC. Of these, 624 were required to submit annual reports to ORIC under the CATSI Act, and 523 (84%) complied with their obligations (Table D3.13.2).

Governing committees/boards

In the 2017–18 Online Services Report (OSR), 156 of the 198 (79%) Commonwealth-funded Indigenous primary health care organisations reported having a governing committee/board (Table D3.13.3).

Of these 156 organisations, 155 (99%) reported that their committee/board had met as frequently as required of the constitution; 155 (99%) had presented income/expenditure reports to the committee/board on at least two occasions during the year; 108 (69%) had a committee/board who were all Aboriginal and/or Torres Strait Islander people, and 132 (85%) had committee/board members who had received training related to governance issues. Less than half of these 156 boards (68 or 44%) included at least one independent (skill-based) member (Table D3.13.3, Figure 3.13.1).

In 2017–18, 77 of the 79 (97%) Commonwealth-funded organisations providing substance-use services for Indigenous Australians reported having a governing committee/board. Of these 77 organisations, 76 (99%) reported that their committee/board had met as frequently as required of the constitution; 77 (100%) had presented income/expenditure reports to the committee/board on at least two occasions during the year; 47 (61%) had a committee/board who were all Aboriginal and/or Torres Strait Islander people; and 64 (83%) had committee/board members who had received training related to governance issues (Table D3.13.4, Figure 1.13.1).

Figure 3.13.1: Proportion of governing committee/board information by organisations providing Indigenous primary health care services and substance-use services to Indigenous Australians, 2017–18

Source: Table D3.13.3, Table D3.13.4. AIHW analyses of Online Services Report data collection, 2017–18.

Participation in planning processes

Competent governance also includes participation in planning processes and engagement with community members (see measure 3.08 Cultural competency). Of the 198 Commonwealth-funded Indigenous primary health care organisations in the 2017–18 OSR, 195 (99%) reported having accessible and appropriate client/community feedback mechanisms in place (Table D3.08.14); 125 (63%) had representatives on external boards (such as hospitals); 193 (98%) had participated in organisational planning processes; 164 (83%) had participated in regional health planning processes; and 121 (61%) had participated in state/territory or national policy development (Table D3.13.5, Figure 3.13.2).

Figure 3.13.2: Proportion of Aboriginal and Torres Strait Islander primary health care services participating in planning and policy activities, 2017–18

Source: Table D3.13.5. AIHW analyses of Online Services Report data collection, 2017–18.

What do research and evaluations tell us?

Research has identified that Indigenous primary health care services (e.g., ACCHSs) outperform mainstream services, as Indigenous primary health care services are often controlled by their local communities and therefore are underpinned by the values and principles of communities they serve. For example:

• 95% of Indigenous primary health care providers had a formal commitment to providing culturally safe health care (AIHW 2019).
• ACCHSs are more likely than mainstream services to improve the health outcomes of Indigenous Australians (Harfield et al. 2018).
• Many Indigenous clients have a preference for services delivered by ACCHSs rather than mainstream services (AH&MRC 2015).

A study comparing the health outcomes for Indigenous Australians using ACCHSs with the outcomes achieved through mainstream services showed that ACCHSs (Panaretto et al. 2014):

• reflect the patient-centred medical home model (Stange et al. 2010)—the suggested best practice for general practice (Claire 2012; DoHA 2009).
• have a greater than 60% coverage of the Indigenous population outside major metropolitan centres.
• consistently improved performance in key best-practice care indicators.
• performs better than mainstream general practice in several areas, including prevention, chronic disease management, risk factor monitoring, and health assessment.

ACCHSs are found to play a significant role in training the medical workforce and employing Indigenous Australians. ACCHSs have also been found to rise to the challenge of delivering best-practice care, and there is a case for expanding ACCHSs into new areas (Panaretto et al. 2014).

A recent paper found that culture is the fundamental component of the success of Indigenous primary health care service delivery. Culture is critical to ensuring community participation, enabling Indigenous ownership and governance by engaging communities. Culture is also essential in ensuring the approach to care is culturally appropriate, relevant and holistic, such as traditional healing (Harfield et al. 2018).

The Indigenous Community Governance Project by the Centre for Aboriginal Economic Policy Research and Reconciliation Australia has provided academic rigour to the examination of governance practices. The project provides a framework for negotiation between Australian governments, their agents and Indigenous groups over the appropriateness of different governance processes, values and practices, and over the application of related policy, institutional and funding frameworks within Indigenous affairs (Hunt et al. 2008; SCRGSP 2016).

Evaluations and studies of Indigenous reform initiatives have identified aspects of good practice by governments needed to support the governance of Indigenous organisations. These include:

• long-term contracting to build trust, enhance capacity and afford Indigenous organisations sufficient time to operate in a complex environment
• good contract management to simplify compliance requirements and reduce transaction costs
• risk sharing and management through clearer communications and reporting lines
• working with Indigenous Australians to better understand the complex nature of First Nation’s affairs, and ensure their voices are heard in decision-making, research and evaluation

• simplified data collection, monitoring and information sharing, based on sound performance and health outcome indicators, using a single reporting framework (Dwyer et al. 2009; OIPC 2006; Yu et al. 2008).

An evaluation of a community engagement strategy, applied across five districts in Perth, found that actively engaging Indigenous communities in decisions about their health care resulted in stronger relationships between community members and health services, improved health services that were more culturally appropriate, and increased access to, and trust in services (Durey et al. 2016).

The Institute for Urban Indigenous Health (IUIH) developed a new regional and systematised model—IUIH System of Care—for how primary care is delivered and intersects with the broader health system. The IUIH System of Care facilitates an integrated approach that engages across local, system and community levels. A review of the IUIH System of Care found improvements in outcomes among Indigenous Australian clients, and that there is the capacity to deliver similar improvements in health access and outcomes in other regions (Turner et al. 2019).

Implications

The data show that the majority of Indigenous primary health care providers are demonstrating sound governance arrangements, including planning processes and having a governing committee/board in place.

However, there is a lack of data to measure other factors of governance, such as the participation of Indigenous Australians in decision-making (SCRGSP 2016).

A key strength of ACCHSs is their ability to respond flexibly to local community needs. It has been suggested that self-determination has led to the development of health services with complex functions that are often a focal point for the community. However, key challenges include the demands placed on Indigenous health services by their constituents and their funders (Moran et al. 2014).

Good and effective governance among services can be facilitated by improved coordination among government agencies in their interaction with services, removing duplication of programs and functions, adapting to change, establishing a stable policy environment and effective processes, and learning from evidence drawn from past evaluations (Henry 2007; SCRGSP 2011).

The policy context is at Policies and strategies.

References

• AH&MRC (Aboriginal Health & Medical Research Council) 2015. Aboriginal communities improving Aboriginal health: an evidence review on the contribution of Aboriginal Community Controlled Health Services to improving Aboriginal health. Sydney.
• AIHW (Australian Institute of Health and Welfare) 2019. Cultural safety in health care for Indigenous Australians: monitoring framework. Canberra: AIHW. 
• Claire LJ 2012. Australian general practice: primed for the "patient-centred medical home". Medical Journal Australia 197:365-6.
• DoHA (Australian Government Department of Health and Ageing) 2009. Primary Health Care Reform in Australia: Report to Support Australia's First National Primary Health Care Strategy.
• Durey A, McAullay D, Gibson B & Slack-Smith L 2016. Aboriginal Health Worker perceptions of oral health: a qualitative study in Perth, Western Australia. International Journal for Equity in Health 15:4.
• Dwyer J, O'Donnell K, Laviole J, Marlina U & Sullivan P 2009. Overburden Report: Contracting for Indigenous Health Services, The. Overburden Report: Contracting for Indigenous Health Services, The:viii.
• Harfield. SG, Davy. C, McArthur. A, Munn. Z, Brown. A & Brown. N 2018. Characteristics of Indigenous primary health care service delivery models: a systemic scoping review. Globalization and Health 14.
• Hawkes DC 2001. Indigenous peoples: self-government and intergovernmental relations. International Social Science Journal 53:153-61.
• Henry K 2007. Creating the right incentives for Indigenous development. The Treasury.
• Hewitt de Alcántara C 1998. Uses and abuses of the concept of governance. International Social Science Journal 50:105-13.
• Hunt J, Smith D, Garling S & Sanders W 2008. Contested governance : culture, power and institutions in indigenous Australia. Canberra: CAEPR.
• Moran M, Porter D & Curth-Bibb J 2014. Funding Indigenous organisations: improving governance performance through innovations in public finance management in remote Australia.  (ed., Australian Institute of Health and Welfare). Canberra: Closing the Gap Clearinghouse.
• OIPC (Office of Indigenous Policy Coordination) 2006. A Red Tape Evaluation in Selected Indigenous Communities: A report by Morgan Disney Associates. Canberra , ACT.
• Panaretto KS, Wenitong M, Button S & Ring IT 2014. Aboriginal community controlled health services: leading the way in primary care. The Medical Journal of Australia 200:649-52.
• SCRGSP (Steering Committee for the Review of Government Services Provision) 2011. Overcoming Indigenous disadvantage: Key indicators 2011. Canberra, Productivity Commission (Steering Committee for the Review of Government Service Provision).
• SCRGSP 2016. Overcoming Indigenous Disadvantage: Key Indicators 2016. Canberra: Productivity Commission.
• Stange KC, Nutting PA, Miller WL, Jaén CR, Crabtree BF, Flocke SA et al. 2010. Defining and measuring the patient-centered medical home. J Gen Intern Med 25.
• Turner LR, Albers T, Carson A, Nelson C, Brown RB & Serghi M 2019. Building a regional health ecosystem: a case study of the Institute for Urban Indigenous Health and its System of Care. Australian journal of primary health.
• Westbury ND 2002. The importance of Indigenous governance and its relationship to social and economic development. Unpublished Background Issues Paper produced for Reconciliation Australia. Canberra.
• Yu P, Duncan ME & Gray B 2008. Northern Territory Emergency Response: Report of the NTER Review Board.  (ed., Government A).