3.13 Competent governance
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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 (Hunt et al, 2008). ‘Competent governance’ requires legitimacy, leadership, power, resources and accountability (Dodson & Smith, 2003). 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 (Hewitt de Alcántara, 1998; Hawkes, 2001; Westbury, 2002). The manner in which governance functions are performed has a direct impact on the wellbeing of individuals and communities.
The governance model of Aboriginal Community Controlled Health Services (ACCHSs) was first established in the 1970s, and by the 1990s, ACCHSs were an important provider of comprehensive primary health care services for Aboriginal and Torres Strait Islander peoples (Larkins et al, 2006; Department of Health and Ageing, 2001). While the capabilities and capacity of ACCHSs vary, this model of care provides important options for Indigenous Australians (Moran et al, 2014).
Competent governance includes mainstream service delivery for Indigenous clients and effective participation of Indigenous people on decision-making boards, management committees and other bodies, as relevant (see measure 3.08). The stewardship role of governments to improve the health of Aboriginal and Torres Strait Islander peoples is also critical. Attention should be given to assessing not only the levels of access to appropriate care but also the experiences of Aboriginal and Torres Strait Islander peoples in receiving care.
Findings
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 2014–15, 86 Indigenous health corporations were incorporated under the CATSI Act and registered with ORIC. All 85 corporations required to submit annual reports to ORIC complied with their obligations under the CATSI Act.
In the 2014–15 Online Services Report (OSR), 163 of the 203 Commonwealth-funded Indigenous primary health care organisations (80%) reported having a governing committee/board. Of these, 98% reported that their committee/board had met as frequently as required of the constitution; 98% had presented income/expenditure reports to the committee/board on at least two occasions during the year; 74% had a committee/board who were all Aboriginal and/or Torres Strait Islander peoples; and 79% had committee/board members who had received training related to governance issues.
In 2014–15, 65 of the 67 Commonwealth-funded organisations providing substance-use services for Aboriginal and Torres Strait Islander people reported having a governing committee/board. Of these, 99% reported that the governing committee/board met as frequently as required of the constitution; 100% had income/expenditure statements presented to the committee or board on at least two occasions; 55% had a governing committee/board comprised entirely of Aboriginal and/or Torres Strait Islander peoples; and 82% had governing committee/board members who had received training related to governance issues.
Of all the 203 Commonwealth-funded Indigenous primary health care organisations in the 2014–15 OSR, 93% reported having accessible and appropriate client/community feedback mechanisms in place, 63% had representatives on external boards (e.g. hospitals) and 86% had participated in regional health planning processes.
From the patient perspective, the 2012–13 Health Survey included questions on reasons for not accessing specific health care services when needed in the previous 12 months. According to these data, 21% of Indigenous Australians reported needing to, but not, going to a dentist, 14% to a doctor, 9% to a counsellor, 9% to other health professionals, and 6% to hospital (see measure 3.14).
Some of the reasons people did not access services reflect failures in health services to adequately address the needs of these patients. For example, 13–27% did not attend services because they disliked the service/professional or felt embarrassed/afraid, 1–18% felt the service would be inadequate and 2–4% were concerned about discrimination and cultural appropriateness. These reasons were highest for those needing to, but not accessing counsellors. In addition, a range of other reasons people did not access health care when they needed to reflect potential failures in the governance of the health system as a whole (e.g. cost, transport/distance, or the service was not available in the area).
The 2014–15 Social Survey included questions on discrimination and patient experience. In 2014–15, 35% of Indigenous Australians reported that they had been treated unfairly in the previous 12 months because they are Aboriginal and/or Torres Strait Islander. Around 14% of Indigenous Australians reported that they avoided situations due to past unfair treatment. Of those, 13% had avoided seeking care from doctors, nurses or other staff at hospitals or doctor’s surgeries because of previous unfair treatment.
When asked about their experiences with doctors in 2014–15, Indigenous Australians in non-remote areas reported that their GP only sometimes, rarely or never: showed respect for what was said (15%), listened to them (20%) or spent enough time with them (21%). Around 6%of Indigenous Australians aged 15 years and over disagreed or strongly disagreed with the statement ‘Your doctor can be trusted’. In addition, 13% disagreed or strongly disagreed with the statement ‘Hospitals can be trusted to do the right thing by you’.
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).
Figures
Table 3.13-1
Number and proportion of health corporations incorporated under the CATSI Act 2006 by compliance, 2014–15
| Compliance | Number | Per cent |
|---|---|---|
| Compliant | 85 | 100 |
| Not compliant | 0 | 0 |
| Total required to report | 85 | 100 |
| Total registered | 86 | .. |
Source: AIHW analysis of The Office of the Registrar of Indigenous Corporations (unpublished data)
Table 3.13-2
Indigenous primary health care organisations participating in engagement and planning activities, 2014–15
| Engagement and planning activities | No | Per cent |
|---|---|---|
| Representation on external boards (e.g. hospitals) | 128 | 63 |
| Participation in regional health planning processes | 175 | 86 |
| Participation in state/territory or national policy development processes | 96 | 47 |
| Total organisations | 203 | 100 |
Source: AIHW analysis of 2014–15 OSR data collection
Table 3.13-3
Governing committee/board use by organisations providing Indigenous primary health care services and substance-use services to Aboriginal and Torres Strait Islander peoples, 2014–15
| Governing committee/board attributes | Primary health care services | Substance use services | ||
|---|---|---|---|---|
| No. | Per cent | No. | Per cent | |
| Frequency of governing committee or board meeting met the requirement of the constitution | 159 | 98 | 64 | 99 |
| Income and expenditure statements were presented to committee or board on at least 2 occasions | 159 | 98 | 65 | 100 |
| Governing committee or board received training | 128 | 79 | 53 | 82 |
| All of the governing committee or board members were Aboriginal and/or Torres Strait Islander | 120 | 74 | 36 | 55 |
| Total organisations with a governing committee or board | 163 | 100 | 65 | 100 |
| Total organisations | 203 | .. | 67 | .. |
Source: AIHW analysis of 2014–15 OSR data collection
Implications
Organisations are more effective in delivering services and achieving development outcomes when there is strong governance in place. Key challenges include the demands placed on Indigenous health services by their constituents and their funders (Moran et al, 2014).
Under the Indigenous Advancement Strategy (IAS), Aboriginal and Torres Strait Islander organisations receiving significant Commonwealth funding are required to transfer their incorporation to the CATSI Act to strengthen governance.
Under the IAS, the Culture and Capability Programme supports Indigenous Australians to maintain their culture, participate equally in the economic and social life of the nation and aims to ensure that Indigenous organisations are capable of delivering quality services to their clients. The programme funds a range of activities designed to:
- improve the leadership and governance capacity of Indigenous people, families, organisations and communities
- strengthen the capacity of Indigenous organisations so that they are able to effectively deliver Government services to Indigenous people and communities
- engage Indigenous Australians on decisions over matters that affect them.
The Australian Government Department of Health aims to support effective clinical and organisational governance through continuous improvement in Indigenous specific service delivery and sector capacity by:
- continuous improvement in the business planning and management systems of existing services
- targeted support to organisations in difficulty
- providing an online system for improved reporting of service activity and client health status and supporting the use of electronic Patient Information Recall Systems
- ensuring that cultural security is recognised in Australian health care standards.
The National Health Reform Agreement included the establishment of new health governance structures: Local Hospital Networks (LHNs) and primary health care organisations. Responsibility for hospital management has been devolved to LHNs to increase local autonomy and flexibility so that services are more responsive to local needs, and provide more flexibility for local managers and clinicians to drive innovation, efficiency and improvements for patients. A total of 136 LHNs were established in all states and territories by 1 July 2012. LHNs will continue to engage with local primary health care providers and aged care services to enable their views to be considered when making decisions on service delivery at the local level, and to deliver better integration and smoother transitions for patients across the health system.
On 1 July 2015, 31 Primary Health Networks (PHNs) were established to increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and to improve coordination of care to ensure patients receive the right care in the right place at the right time. The PHN performance framework encompasses three tiers of performance: national headline indicators, local indicators and organisational indicators. The initial focus for PHN performance is on organisational indicators that reflect PHN maturity and growing capacity in engaging with stakeholders including LHNs, clinicians and service providers; building strong governance structures; and commissioning services. As PHNs complete their first round of commissioning in 2016–17, the focus will shift to indicators that demonstrate improved regional service delivery, quality of care and local health system integration. In the longer term national headline indicators will take precedence.