The previous post examined how the Aboriginal and Torres Strait Islander community health sector continues to be overburdened by government managerialism and reporting requirements.
In the article below, Selwyn Button, CEO of the Queensland Aboriginal and Islander Health Council (QAIHC), argues that the focus of government reporting requirements should shift to looking at outcomes rather than inputs (Croakey comment: and isn’t this a familiar concern right across the health sector!).
He also argues that real health service improvement will be driven by communities themselves, rather than by government contracts.
The priority should be to build and develop “the capacity of our communities to ask the hard questions of their local organisations,” he says.
Our communities will drive health service reform better than input-focused government contracts
Selwyn Button writes:
Over the past 12 months, community controlled services across the country have entered into new contractual relationships with major funding bodies, predominantly the Federal Health Department, to support the improvement of health outcomes for Aboriginal and Torres Strait Islander people across the country.
Through this process we have seen significant new investment in community controlled service delivery, which is a welcome move, whilst also ensuring that organisations remain accountable to government for the resources they received through a range of new reporting measures, streamlined into a single agreement.
This was a major recommendation from the Overburden Report, compiled by Professor Judith Dwyer and her colleagues in 2009, that sought to make sense of complexities in funding arrangements for community controlled organisations, to support greater focus on service delivery as opposed to administration and compliance.
Finally, governments had started to listen to what their funded research was telling them.
What this new contract relationship should have created was an environment where community controlled health services could focus on doing what they do best – providing quality health care to our people. It would have been an ideal opportunity to also right the service-provider relationship – where Governments purchased quality health care outcomes not administrative outcomes.
Only months before the commencement of the 2011/2012 financial year, representatives from the Office of Aboriginal and Torres Strait Islander Health (OATSIH), which happens to be the major funder of primary health services across the country for our people, undertook a road show across the country to highlight and discuss impending changes to the contractual relationship between governments and community controlled services.
Workshops were held in every State and Territory capital city, with a view to ensuring that all stakeholders were aware of impending changes and outline how new contracts and explanatory handbooks would support improved understanding of demands on services and expectations from government. When establishing solid relationships between purchasers of services and providers of health care, it is important for both parties to understand each other’s needs and how to address concerns throughout the contract period.
Many of these workshops left participants more confused than before commencing, although left some glimmer of hope that there would be some joint work around the ongoing development and updating of the Funding Agreement Handbook, which would be used as a guide for both OATSIH and community controlled service staff.
Unfortunately, at this point and still today, there is no clear indication from OATSIH what they are seeking to purchase from community controlled services.
The contracts outline priority areas for program delivery, with a focus on inputs such as primary health care, social and emotional well-being, child and maternal health etc, without providing clear indication of what OATSIH want to achieve across all areas, other than to say it all contributes to the six Close the Gap National targets.
They don’t however provide solid links between health service outcomes and their known impact on clients’ health outcomes.
Consequently, we can only draw one conclusion from this confused contractual state: that governments do not yet truly understand what it is they want to purchase in terms of Indigenous health outcomes.
A focus on inputs rather than outputs
Community controlled services have and will continue to preach that comprehensive primary health care is needed for the health of our people.
Community controlled health service delivery commenced on the premise that to achieve the best health outcomes for our people, we need to provide comprehensive services, not just your average primary care services, and consequently there has been much attention across the sector to build and strengthen this approach over time, with great outcomes.
Furthermore, we can assume that the fundamental notion of a formidable purchaser/provider relationship is not a priority, as governments want to continue the notion of providing grant monies to community controlled organisations tied to a range of preventative measures that are not necessarily related to performance in health service provision.
Perhaps Governments are simply not ready to move to purchaser provider relationships where outcomes and not inputs are the contractual foundations.
How do we draw these conclusions?
Firstly, I am yet to hear complaints from any community controlled service across the country that is ever questioned by OATSIH in relation to a lack of health assessments completed over a quarterly reporting period.
Rather, much of these contractual discussions centre around questions concerning governance models, constitutional changes, budget expenditure against unreported items, employee fractions on projects and other related things. Is it that Government believes such matters are a better indication of performance by each service?
Again Government remain focussed on inputs and monitoring administrative functions of service providers rather than focussing on health outcomes delivered.
Don’t get me wrong, all of the aforementioned items are important in the broader scheme of running successful businesses, although these fundamental questions should be resolved at the time of developing and endorsing relevant annual Action Plans and related project budgets.
Building capacity of community controlled organisations to do this consistently will enable and inform successful new business models to support health outcomes, and we are already starting to see this happen in many areas.
This process is being developed and led by the sector itself, which is a clear demonstration of organisational maturity and growth to support outcomes for our people. The sector must and should continue to be responsible for internal reform and improvements, whilst also setting higher expectations for itself, rather than be dictated to by governments.
What I am advocating, though, is that quarterly discussions are better spent on performance outputs and outcomes that can lead to improved health benefits for clients.
This process is not what a purchaser/provider relationship should look like when governments are attempting to purchase quality health services to support outcomes for Aboriginal and Torres Strait Islander people.
Government push for control
The current contractual relationship enables and supports ongoing government manipulation of community controlled organisations in a manner they believe will benefit communities the most. Admittedly, there are circumstances across the country where this is required, although experiences tell us that community controlled services are already delivering the best health outcomes for their own people and this is not being supported to continue and strengthen.
More concerning with the current contractual arrangement is Government seeking to ensure they can run community controlled organisations from within their departments, again evidenced in the contractual focus on day-to-day operations and inputs.
What we need at this point is not for governments to assume and attempt to maintain total control over community organisations, nor do we wish for community controlled organisations to think that they can do as they please with no accountabilities to anyone, as this is not community controlled either.
Given the growth in organisational maturity and experience in health service delivery, community controlled services are seeking to assume responsibility as the major provider of health care to our own people.
Although with this responsibility comes greater accountability, but not just to government but our accountability must be to the communities we serve, through robust reporting and monitoring mechanisms that are designed to provide clients and community with relevant information and data to meet their needs.
Governments will continue to seek improved accountability through contractual relationships, although this needs to improve and give recognition to existing processes, like those already compulsory for organisations through clinical and organisational accreditation processes.
The development of relevant Action Plans and budgets for government and community are and still should be essential, although ongoing monitoring of performance can be better achieved through focussing upon health outputs and outcomes that will lead to fundamental change.
Reporting to communities
Additionally ensuring that all organisations are regularly reporting to their local communities will further drive transparency in organisations, consequently leading to improved outcomes that can be measured competently by both community and government.
This is the relationship we need to start building and developing: the capacity of our communities to ask the hard questions of their local organisations, which demands far greater weight and attention than that of governments.
In Queensland, these reforms have commenced and we are starting to see a dramatic shift in community interactions with their local community controlled service because of it.
We now need to see this spread across the country so that the people who need high quality health services the most, Aboriginal and Torres Strait Islander people, are demanding it from their local service and seeking to ensure it continues to improve and grow.
The challenge for governments in all of this is to determine what role they are seeking to play in supporting this reform process.
Are they still wanting to remain in an old grant provision mentality of providing resources to our services that are restricted by a range of reporting and compliance requirements?
Or do they seek to see fundamental change in health outcomes through new relationships that pay tribute to services that are providing high quality health care for our people and achieving relevant outcomes?
This shift requires significant attitudinal change by governments, reflected in the language they use, and demonstrated in contractual relationships that support and enable services to do their jobs, rather than restrict them into long-winded reporting regimes.
Then we will see real improvements and communities openly demanding further improvements from their local service.
• You can follow Selwyn Button on Twitter