pathways to community control - lilyredlily.org.au/.../2009_final_pathways-to-community...pathways...

www.nt.gov.au/health

Pathways to Community ControlAn agenda to further promote Aboriginal community control

in the provision of Primary Health Care Services

© CoverillustrationsuppliedbyNorthernEditions

The Fire and Water Suite Artist:JornaNapurruruaNelsonYuendumu (Walpiri-AncientSymbolsofBushfires,Waterholes,Lightening,RainandDesertSoaks)

PathwaystoCommunityControl

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Table of Contents

Executive Summary 5

Introduction 7

Purpose 8

Describing the Continuum of Community Participation and Control of Primary Health Care Services 10

Figure1TheContinuumofACommunityParticipation

andControlPartnershipMatrix 11

Partnership Matrix

Table1DescribingDistributionofResponsibilities 12

Being Competent and Capable 16

Diagram1HealthSystem 17

Table2DemonstratingaFunctioningHealthService 19

Building Community and System Functioning 2�

Community Side 2�

Public Sector Side 24

Taking Action - Transitioning 24

1 DevelopmentStage 25

2 ConsolidationStage 26

� ImplementationStage 27

4 EvaluationStage 28

Conclusion 29


5

Executive Summary

TheprimarypurposeofthisdocumentistocreateaframeworkthatsupportsAboriginalcommunities’controlintheplanning,developmentandmanagementofprimaryhealthcareandcommunitycareservicesinamannerthatisbothcommensuratewiththeircapabilitiesandaspirationsandconsistentwiththeobjectiveofefficient,effectiveandequitablehealthsystemsfunctioning.

NorthernTerritoryAboriginalHealthForum(theForum)partnersbelievethatgreaterlevelsofcommunityinvolvementbringsbenefitsbothtotheprocessofhealthandfamilyservicedeliveryandtothehealthofthosethatareengaged.BenefitspotentiallyonoffertoAboriginalTerritoriansincludeamoreresponsivehealthandfamilyservicessystem,improvedqualityandculturalsecurityofservicesandimprovedlevelsoffamilyandcommunityfunctioning;allcontributingtoimprovedlevelsofhealthandwellbeing.

WithinthisframeworkcommunitycontrolreferstotheprinciplethatAboriginalcommunitieshavetherighttoparticipateindecisionmakingthataffectstheirhealthandwellbeing.ItalsoreferstotheorganisationalmodelofAboriginalcommunitycontrolledhealthservicesthathasexistedformorethan�0years.PartieshaveagreedthatcommunitycontrolledgovernanceofhealthservicesistheoptimalexpressionoftherightofAboriginalpeopletoparticipateindecisionmaking.

Theframeworkseekstoexamplehowtheprogressiveextensionoftherighttoparticipatecanbereflectedinorganisationalarrangementswithinthehealthsector.Theframeworkreflectsthatnotallcommunitieswillhavethesameaspirationorcapabilitytomanagetheplanning,developmentanddeliveryofprimaryhealthandfamilyservicesatthesamepointintime.

Howeverthisframeworkdoescontemplateaprogressivemovementtogreaterlevelsofcommunityparticipationincludingmovementtothecommunitycontrolledhealthservicemodel.Theframeworkexploresthekeypartnershipresponsibilitiesunderthedifferentexamplesandsubsequentlyoutlinessomeofthekeycapabilitiesandleveloffunctioningrequiredofeachpartyunderthatmodel.Thispartnershipbetweencommunitiesandthehealthsystemiscriticaltoachievinganefficient,effectiveandequitablelevelofhealthsystemfunctioning.

Theframeworkcreatesapolicyspaceinwhichcommunityandorganisationaldevelopmentcanoccurandconnect;andinwhichpartnershipbetweencommunityandpublicsectorcangrow.Theactivitywithinthisspaceisnotstaticastheobjectivesofeithercommunityorgovernmentcanchange.Hencethisframeworkthinksaboutthispolicyspaceasdynamicandcapableofrespondingtothechangingcircumstances.

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Thisframeworkmakesexplicitacommitmenttostrengthenlevelsofcommunityandsystemsfunctioninginsupportofgreatercommunityparticipationandcontrol.IndoingsotheForumpartnersremainmindfuloftheneedfor:

• consistencyandcontinuityofservicecapacityandarrangements; • qualityandcoverageofservices; • managementofrisk;and • fairness.

TheForumpartnersagreethatthemanagementofprimaryhealthcareservicesisafunctionthatrequiresspecialisedskillsandknowledgeandthatorganisationalarrangementsstructuredunderthisframeworkshouldreflectaspecificcompetenceandexperienceinanorganisationprimarilydedicatedtothepurposeofprimaryhealthcareservicedelivery.

Thisframeworkcontemplatesafour-stageprocessthroughwhichcommunityparticipationandcontrolcouldbeencouraged.Thesestagesareaslisted:

1. Development 2. Consolidation �. Implementation 4. Evaluation


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Intr duction

TheForumistheprincipalpartnershipmechanismcreatedbytheNTFrameworkAgreementonAboriginalandTorresStraitIslanderHealth.TheForumhasagreedthattheobjectivesoftheFrameworkAgreementwouldbewellservedbyfurtherstrengtheningatalocalleveltheengagementofAboriginalcommunitiesinthefunctionalplanning,development,deliveryandmonitoringofhealthservices.Thekeyprinciplesdrawingthepartiestogetheronthisissueare:

• Aboriginalcommunityparticipationisakeyelementofsustainable,viable, effectiveandefficientdeliveryofprimaryhealth;

• asharedcommitmenttothedevelopmentofastrategytosecuregreaterlevels ofAboriginalcommunitycontrolinthedeliveryofprimaryhealthcareintheNT;

• asharedcommitmenttofosteraneffectivepartnershipbetweengovernments, communitiesandprovidersthatensuresbestpracticegovernanceofservices andoptimalhealthgain;and

• asharedcommitmenttopersonalandcommunitydevelopmentasanintegral contributortoimprovedlevelsofcommunityparticipationandcontrol.

ThisframeworkseekstosupportAboriginalcommunitiesandpublicsectoragenciesintheireffortstoincrementallyrealisethesesharedprinciples.

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Purp se

InthispapertheconceptofcommunityreferstoAboriginalpeoplelivinginaparticularplaceand/orbelongingtoaparticularculturalgroup.Whilstthisnotionofcommunityfocusesonpopulationsorgroupsthispaperincludesconceptsandresponsibilitiesthatmayfalltofamiliesand/orindividualswithincommunities.

TheprimarypurposeofthisframeworkfromapolicyperspectiveistoincreasethelevelofcommunityparticipationandcontrolinthehealthandfamilyservicessectorintheNT.TheForumpartnersrecognisethatthelevelandnatureofcommunityparticipationwillvarydependingonarangeoffactors.Howeverpartnersbelievethatcommunitycontrolbringsbothbenefitstotheprocessandtothehealthofthosethatareengaged.

TheForumpartnersagreethatonemodeldoesnotfitallneeds.Inthedevelopmentofthisframework,communityparticipationismeanttoreflectthelevelofengagementeachcommunityseekstoexertovertheplanning,developmentandmanagementofprimaryhealthcareservices.Broadlyspeakingacommunity’sdecisionsaboutparticipationseekstoinfluencesingularlyorincombinationfourmajorgoals:

• identifyingand/ordefiningissues/problems; • identifyingand/ordevelopingsolutions; • managingand/ordeliveringsolutions;and • monitoringandevaluatingservices.

Thisframeworkidentifiescommunityparticipationasourpolicygoal.Thisimpliesthatascommunityaspirationsandcapabilitiesexpandgovernmentsshouldbereadytoengagewithcommunitiestorealisetheseaspirationsinamannerconsistentwiththeneedtoensureafunctioninghealthsystem.Theframeworkrecognisesthatsuccessfulimplementationrequiresthatboththecommunityandgovernmentneedtohavethenecessaryskillsandinsightsforthepartnershipjourney.

‘Put another way, community engagement has the potential to improve the quality of the service supplied, but it can also improve the opportunities and capacities of those who rely on services, so lessening their need for them’1.

1 RogersBandRobinsonE(2004)ActiveCitizenshipCentreReport–Thebenefitsofcommunityengagementareview oftheevidence,IPPR


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Communitycontrolrequirescommunitiesandtheirorganisationstopossessboththeunderstandingofandtheabilitytoapplytheknowledgeandcompetenceonwhichsoundengagementisbuilt.Italsodependsonthecapabilityofgovernmentorganisationsandstructurestounderstandandfindnewwaysofworkingthatrespondtocommunity’scallsforgreaterlevelsofengagement.

ExperienceintheNTtellsusthatthisunderstandingalreadyexistsinmanyplaces.SuccessmayrequiretheForumpartnerstobothcommittofindingwaysofbuildingorreleasingexistingcapacityforcommunityengagementincurrentserviceprovidersaswellasneweffortstobuildcapabilitywhereitdoesnotexist.

InsummarythisAgendarecognises:

• communityparticipationcantakedifferentformsandwillnotalwaysbestatic;

• thecommunitycontrolledhealthservicemodelasprovidingthegreatestlevelof communityparticipationinhealthservicedelivery;

• knowledge,skill,competence,motivationandopportunityarerequiredforcommunities, organisationsandindividualstoengageeffectivelyindiscussions,decision-making, governanceandservicedelivery;

• bothcommunitiesandpublicsectororganisationsmayhavegreaterpotentialandcapacity toengageeffectivelythaniscurrentlyrecognised;

• arangeofbarriersoperatingwithincommunitiesandorganisations(andintheinteraction betweenthem)mayconstraincapability,suggestingthatreleasingcapacity,maybeas importantasbuildingit;and

• theForumpartnersarecommittedtoreleasinguntappedpotentialandbuildingnew capabilitiesinsupportofcommunityparticipationandcontrol.

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Describing the C ntinuum of Community Participation and Control of Primary Health Care Services

TheForumpartnersrecognisethatacrosstheTerritorytheextentofcommunityparticipationandcontrolvariessignificantly.InsomecommunitieshealthservicesaremanagedandprovidedbytheDepartmentofHealthandFamilies(DHF).Inthesecommunitiesthelevelofcommunityparticipationiscomparatively,morenarrow.Inotherlocations,communitiescontracttheprovisionofservicesfromexternalprovidersandhereincreasedcommunityparticipationisexercisedthroughdecisionsaboutwhatservicesaretobeprovided;whoshouldprovidethem;andwhethertheservicesareprovidedinasatisfactorymanner.

Yetinothercommunities,communitycontrolledAboriginalhealthservicesprovidehealthcare,andherecommunityparticipationiscomparativelymoreencompassingandiswhathashistoricallybeendefinedbyAboriginalpeopleascommunitycontrol.TheForumpartnersrecognisethatcommunityparticipationandcontrolisareflectionofwherecommunityandgovernmentpreferencesandcapabilitieslieatanyparticulartime.

Thisframeworkprovidesapolicyplatformthatcreatesspaceforcommunityandgovernmentstopursueorganisationalandcommunitydevelopmentthatmaycontributetochangestothenatureoflocalcommunityparticipationandcontrolofhealthandfamilyservices.

Thisframeworkrecognisesthatthecircumstancesofcommunitiesandtheirhealthservicescanchangeandthatthischangemayinvolveeithergreaterorlessercommunityparticipationorcontrol.InordertoensureAboriginalpeoplecontinuetoreceivecorehealthandfamilyservicestheForumpartnersremaincommittedtoastrongpartnershipthataccommodatesunexpectedorproblematicchange.

Thisframeworkdescribessomeofthecriticalresponsibilitiesandcapabilityrequiredinbothcommunityandgovernmentsinanumberofservicemodels.Theuseoftheseexamplesisnotmeanttolimittherangeofservicemodelsthatmightbeconsideredbutrathertodemonstratehowthemixofcapabilityrequirementsandresponsibilitieschangeasacommunityprogressestowardscommunitycontrol.

Thefactthatthisframeworkdescribesbothsidesofthispathwayisimportant.TheForumexperiencesuggeststhatsuccessisbuiltthrougheffectivepartnerships.ThispartnershipenvironmentisdescribedinFigure1(nextpage).


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Figure 1. TheContinuumofCommunityParticipationandControl

ThecontinuumofcommunityparticipationandcontroliseasilydescribedtowardstheextremeseitherbytheprimaryhealthcarecentresthatarefundedandmanagedbytheDepartmentsolelyoralternativelybytheexistenceofindependentcommunitycontrolledAboriginalHealthServices.Thelevelofresponsibilityheldontheonehandbythepublicsectorandontheotherbythecommunitysectorchangesascommunitiesmovealongthiscontinuum.

Thiscontinuumrecognisesexistingstructuresbutcontemplatesbothdifferentmodelsbetween,andnewmodelsoutsidethecurrentservicemodelsdescribedabove.ThesenewmodelsmightforexampleincluderegionalhealthservicemodelsbasedonaggregatedPHCAPzones.

TheForumpartnersareconsciousthatthecontinuumisatwo-wayenvironment,communitiesmayinresponsetochangingcircumstancesmovealongthecontinuuminbothdirections.TheForumpartnersagreethatthereareanumberofpossibleservicedeliverymodels.Someofthefactorsdefiningtheviabilityandsuitabilityofservicemodelsinclude:

• communitypreferences; • communitycapability; • need; • demographicsandgeography; • organisationalstrength; • leadership; • funding; • workforce;and • publicpolicysettings.

Governmentsandcommunitieswillneedtotakethesemattersamongothersintoaccountindecisionmakingabouthowandwhendevelopmentorchangesinservicemodelsareproposed.

PublicSector

CommunitySector

NTGHealthClinicmodel

Greater public sector responsibity

Greater community sector responsibity

AMSModel

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Partnership Matrix

Thissectiondescribesthecriticalchangestothedistributionofresponsibilitiesbetweenthepublicsectorandcommunitysectorunderanumberofservicemodelexamples.Importantlyatnotimeisresponsibilityvestedinonesectoralone.Theprovisionofhealthandfamilyservicesisaresponsibilitysharedbetweengovernments,NGOs,communities,familiesandindividuals.Ascircumstancesandservicemodelschangetheresponsibilitiesofsectorsalsochanges.Table1(below)demonstratesthischangingpartnershipmatrixasthechoiceofmodelchanges.

Table 1. DescribingDistributionofResponsibilities

Service Model Public Responsibilities Community Responsibilities

NTG Primary Health Care Centres

Competentcoreandotherpriorityprimaryhealthservicesondemandordeliveredthroughprogramstructure.

Providesservicesandmodelbehavioursthatareculturallysecure.

Isbroadlyawareofcommunityinterestsandconcerns.

Communityandfamiliespromotethetimelyandappropriateuseofhealthandfamilyservicesincludingcompliancewithtreatment.

Communityandfamilywithinthelimitsoftheircapability,takeresponsibilityfortheirownhealth.

Proactive NTG Primary Health Care Centres

Providescompetentcoreandotherpriorityprimaryhealthandfamilyservicesondemandorthroughstructuredprogrammes.

Providesservicesandmodelsbehavioursthatareculturallysecure.

Engagesindatadevelopment,managementandreporting.

Proactivelyinterpretswithcommunitylocalhealthdata,needsandcommunitypreferencestoidentifyprioritiesandplanactivities.

Inadditiontotheabove:

Supportscommunityandfamilyengagementwithhealthandfamilyservicesinformationabouttheircommunityandtheirfamiliesneeds;activelyengagesinconsultationprocessesaroundhealthandfamilyserviceissues.

Proactive NTG Primary Health Care Centres with advisory structure

InadditiontotheresponsibilitiesofProactiveNTGPHCCentre:

Workswithaformaladvisorycommitteecomprisedofcommunitymemberstowhominformationisregularlyprovidedandwhoseviewsareactivitysoughtandconsidered;and

Activelyengagesingooddatadevelopmentandmanagementandreporting.

InadditiontotheproactivePHCCentre:

CommunityestablishesanAboriginalhealthadvisorygroupthatactsasaneffectivelinkwiththePHCCentretocollect,interpretandconveycommunityvalues,viewsandpriorities;and

Respondstoinformationandpromoteshealthandfamilywellbeinginthecommunityandfamilies.


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Proactive NTG Primary Health Care Centres with shared care or management arrangements

In addition to the responsibilities of Proactive NTG PHC Centre with advisory structures:

Shares the health and community care and/or management responsibilities with structured and viable community controlled organisations.

Provides relevant information to the community and service partner in a timely manner.

An appropriate community based legal entity is in place with a local operating governance structure or committeeandcompliantgovernanceandregulatoryframework.

ThroughalegalentityprovidescompetentpartialorwholeprogrammecentredservicesthatformpartofthesuiteofcoreservicesorregionalprioritiesofferedthroughtheNTGPHCCentree.g.providespartoftheantenatalcareservicestopregnantwomen,orprovidesallhealthservicetoolderpeople.

Thegoverningcommitteeproducesandmaintainsanappropriatestrategicandannualbusinessplanfortheprogrammesitisincontrolof.

Competentstaffareengagedtomanageandprovideservices.

Appropriateorganisationalstructures,processesandcontrolsareinplaceandworkingeffectivelytomanageresources,accountabilitiesandservices.

Providesrelevantinformationtothecommunityandservicepartnerinatimelymanner.

Aboriginal Community Controlled fund holder purchasing PHC Centres from a competent provider

IntheeventthattheNTGistheprovider.Underthetermsoftheserviceagreementwiththefundholder:

Providescompetentculturallysecurecoreandotherpriorityprimaryhealthandfamilyservicesaccordingtotheserviceagreement

Proactivelyinterpretsinconsultationwithcommunitiesandfundholderlocalhealthdata,needsandcommunitypreferences;

Reportstothefundholderonactivityandcomplieswiththecontract;and

Inconjunctionwiththefundholderprovidesrelevantinformationtothecommunity.

Anappropriatecommunitybasedlegalentityisinplacewithalocaloperatinggovernancestructureorcommitteeandcompliantgovernanceandregulatoryframework.

Appropriateorganisationalstructures,processesandcontrolsareinplaceandworkingeffectivelytomanageresources,andaccountabilitiesandpurchaseservices.

Fundsareappliedviaserviceagreementwithasingleserviceprovider.

Thelegalentitymonitorsproviderperformanceagainsttheserviceagreement.

Supportscommunityandfamilyengagementwithhealthandfamilyservicesinformationabouttheircommunityandtheirfamiliesneeds;activelyengagesinconsultationprocessesaroundhealthandfamilyserviceissues.

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Auspice model with advisory structure

InadditiontotheresponsibilitiesofAboriginalcommunitycontrolledprimaryhealthcareserviceprovideroperatingunderfundholdermodel:

Workswithaformaladvisorycommitteecomprisedofcommunitymemberstowhominformationisregularlyprovidedandwhoseviewsareactivitysoughtandconsidered.

Activelyengagesingooddatadevelopmentandmanagementandreporting.

InadditiontotheAboriginalcommunitycontrolledprimaryhealthcareserviceprovideroperatingunderauspicemodel:

CommunityestablishesanAboriginalHealthAdvisoryGroupthatactsasaneffectivelinkwiththeauspiceorganisationtocollect,interpretandconveycommunityvalues,viewsandpriorities.

Respondstoinformationandpromoteshealthandcommunitywellbeinginthecommunityandfamilies.

Community controlled primary health care service

Respondsappropriatelyandwithincapacitytorequestsforinformationandsupportfromtheserviceprovider.

Meetscontractualobligationsifany.

Maintainsanengagementwiththeservicetopromote,protectandmaintainthehealthandwellbeingofTerritorians.

Providescompetentcoreandotherpriorityprimaryhealthservicesondemandorthroughaprogrammestructure.

Producesastrategicandannualbusinessplan.


Isbroadlyawareofcommunityinterestsandconcerns.

Meetscontractualobligationstofunderandobligationstothecorporateregulator

Proactive community controlled health service

Respondsappropriatelyandwithincapacitytorequestsforinformationandsupportfromtheserviceprovider.


MaintainsanengagementwiththeservicetopromoteprojectandmaintainthehealthandwellbeingofTerritorians.

Providescompetentcoreandotherpriorityprimaryhealthservicesondemandorthroughaprogrammestructure.


Proactivelyinterpretsinconsultationwiththecommunitylocalhealthdata,needsandcommunitypreferencestoidentifyprioritiesandplanandevaluateactivities.

Meetscontractualobligationstofunderandobligationstocorporateregulator.

Regional community controlled health service

Respondsappropriatelyandwithcapacitytorequestsforinformationandsupportfromtheserviceprovider.


MaintainsanengagementwiththeservicetopromoteprojectsandmaintainthehealthandwellbeingofTerritorians.

Provides competent culturally secure core and other priority primary health services on demand or through a programme structure.

Proactively manages services on a regional basis in consultation with individual communities.

Proactively interprets in consultation with communities within the region health data, needs and community preferences to identify priorities, plan and evaluates activities.

Meets contractual obligations to funder and obligations to the corporate regulator.


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TheForumpartnersagreethatsustainablehealthgainispredicatedoncompetentandcapableservicemodels.Togethertheservicemodelsofferedaboveprovideasenseoftheevolvingnatureofcommunityparticipationandcontrolandoftheneedforstructureddevelopmentofskills,knowledgeandthecapabilitytosuccessfullyoperate,whichevermodelisapplied.

Thiscontinuumisnotsequential.Communitiesarenotrequiredtostepthrougheachinordertoprogress.Itisalsopossiblethatnewhybridmodelsmayemerge.Insomecasesthelevelofcommunityparticipationandcontrolmaychangedramaticallyineitherdirectionasleveloffunctioningchanges.

ThePathwaystoCommunityControlaredescribedasacontinuumbecausecircumstanceorpreferencemaychangeovertime.Issuesthatmighttriggerchangeinthemodelofservicedeliveryinacommunityorregionmightinclude:

• sustainedanddemonstratedenhancementofcommunitycapabilitiesandcompetence; • sustainableimprovementsintheorganisationalcompetenceofaserviceprovider; • healthandfamilyservicedemand; • publicpolicychanges; • erosionofacommunityororganisation’scompetenceorcapability; • changecreatedbyeconomiesofscaleordiseconomiesofsmallscale;and • treatmentofidentifiedserviceormanagementofriskinorganisations.

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Being C mpetent and Capable

Viableandsustainablecommunitycontrolofhealthservicesdependsontwokeyprocesses.Firstly,thehealthserviceprovidermustbecompetentinorganising,managinganddeliveringhealthandfamilyservices.Secondlytheymustalsobeabletoinformandworkwiththecommunityincludingrespondingtothecommunity’sprioritiesandvalues.

Theefficientandeffectiveprovisionofservicesisreliantuponthecapabilityofhealthserviceproviderstoapplytheavailableresourcestotheachievementofagreedhealthandwellbeinggoals.Capabilityrefersfirstlytotheextenttowhichserviceprovidersareabletodemonstratethattheyhaveengagedcommunitiesindeterminingthevaluesincludingforexamplefairness,culturalresponsivenessandthemarkersagainstwhichserviceprovisionistobejudged.Secondlywhetherproviderscantranslatecommunityprioritiesandvaluesintomanagementandoperationaldecisionmaking.

Communitiesandgovernmentswillbeinterestedinwhetherserviceproviderscancompetentlymanagethefunctionalelementsofahealthservice.Competencyreferstofundamentalknowledge,ability,orexpertiseinaspecificsubjectareaorskillset,inthiscaseskillsnecessarytomanageaprimarycarehealthservice.

Being CapableIn summary service providers are contributing to the capability of communities where they can demonsrate they have:

• structureed a functioning ongoing relationship with the community that enables a clear articulatoin of and engagement with the community’s strengths, preferences, values and objectives; and

• applied their technical and professional skills in a manner that serves thesestrengths,preferences,valuesandobjectivesefficiently and effectively.


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Being CompetentIn summary competence exists where service providers can demonstrate their ability to:

• prioritise resource use to meet the health needs of communities;

• use and organise resources in a manner that systematically contributes to health and wellbeing goals and objectives; and

• maintain sound professional standards and organisational processes.

Bringingcapabilityandcompetencetogetherinasystem(seeDiagram1below)providesbothcommunitiesandgovernmentswithconfidencethatresourceswillbewellmanaged;thatthecommunity’sculture,prioritiesandpreferenceswillbetakenintoaccount;andthatprogresstowardshealthgoalscanbemonitoredagainstagreedvaluesandstandards.

Diagram 1. HealthSystem

Capability

Competence

Developinghealthresources

Organisinghealthresources

Deliveringhealthservices

Health

Fair

Responsiveness

Inthisframeworktheobjectiveistocombinebothcapabilityandcompetencesothatwecancreateandsustainfunctioningserviceprovisionandgreaterhealthgain.

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Importantlyunderthisframeworkpublicsectorproviderssharearesponsibilitytooptimisecompetenceandcapability.Thismeansthatwherethepublicsectorcontinuestomanageservicestheymusthavedeliberatestrategiesandprocessesinplacetocontributetocompetentandcapableservicedelivery.Thisisaresponsibilitythatfallsalsotothecommunitysector.

Communitiesmayexpressanaspirationaboutthesortofhealthservicemodeltheybelieveisrequiredintheircommunityorregion.Insomecasescommunitiesmayseektonegotiateagreaterroleintheplanning,deliveryandmanagementofhealthandwellbeingservicesthancurrentlyisthecase.Similarly,othercommunitiesmayexpresstheviewthatnochangeisrequired.

Wheretheseaspirationsseekanewmodelofserviceprovisionthisframeworkcontemplatesthatserviceprovidersmustpossessanddemonstratethenecessarycompetenciesandcapabilitiespriortofulltransitiontothenewmodel.Changestothehealthservicearrangementsshouldbeunderpinnedbyastructuredtransitionplanthatincludesspecificattentionandsupportforthedevelopmentofthenecessarycompetenciesandcapabilities.Table2(nextpage)describesthesentinelcapabilitiesandcompetenciesthatfalltoeitherthepublicorcommunitysectorunderthesamesetofmodelsusedearlier.WhereprovidersmeettheserequirementstheForumpartnersbelievethatserviceproviderswillhaveachievedaleveloffunctioningthatjustifiesthetransitionto,orcontinuedsupportforthatservicemodel.Againthesemodelsarenotmeanttobetheonlymodelsthatmightbeusedbuttheystandratherasaguidetothechangingnatureofkeycompetenciesandhenceexamplethesortofdevelopmentnecessarytosupporttransition.


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Service Model Public Sector Functioning Community and Community Sector Functioning

NTG Primary Health Care Centres

Staffhavegeneralisedknowledgeofthecommunity’scircumstancesandculture.

Serviceprovidersengagecompetentlywithindividualclientsandprovideserviceseffectivelyaroundtheindividualpatient’sneeds.

Healthgoalsandobjectivesareoutputbased.Resourcesareorganisedaroundindividualneed.

Competentstaffareengagedtomanageandprovideservices.Appropriateorganisationalstructuresandprocessesareinplaceandworkingeffectively.

Generallyexternalpartiesgovernstaffingandotherprogrammedecisions.

Evaluationofperformanceisundertakenexternallyandclientandcommunitysatisfactionisstructuredbroadlyaroundgenericcomplaintsmanagementprocesses.

Datacollationandanalysisisadhocfocusedaroundspecificexternalrequirements.

Individual and community health capability generally low.

Community and individual demand for health care is generally episodic

Individuals generally present with high levels of undiagnosed disease.

Proactive NTG Primary Health Care Centres

Serviceprovidersengagecompetentlywithindividualclients,providecoreservicesconsistently.

Staffprovidesculturallysecureservicesandhavegeneralisedknowledgeofthecommunity’scircumstancesandpriorities.Engagesinprogrammespecificconsultationwithcommunity.

Localdataandexperienceisproactivelyusedtodesignandsupportasuiteofpopulationhealthservices,forexampleHSAKandGAA.

Consumptionofresourcesisdrivengenerallybypersonalhealthservicepatternsbutexplicitlyincludesprioritypopulationhealthconsiderations.

Healthgoalsandobjectivesaresubstantiallyoutputbasedbutincludearangeofoutcomemeasuresrelatedtopopulationhealthgoalsandobjectives.

Localresourcemanagementrelatesprimarilytoutilisationofstaffingresourcestoachievepersonalandpopulationhealthservicecoverage.

Localdataandevaluationinfluencesresourcemanagementandplanningdecisions.

Some individuals, families or sub groups within the community provide advice on specific programme issues.

Demand for episodic health care continues, but there is an appropriate level of community enrolment in population health programmes.

Individual and community health and wellbeing capabilities are present but are generally unorganised.

Table 2. DemonstratingaFunctioningHealthService

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Proactive NTG Primary Health Care Centres with shared care or management arrangements


•competentandformalservicepartnershipstructuresexistforspecificprogrammes,forexampleantenatalcare,women’sandmen’shealthcare.

•theresponsibilityforelementsofspecificprogrammesissharedwithexternalproviderseitherfromthecommunityoranotheracceptablepartneraccordingtoagreedprotocols.


•whereestablished,thecommunitypartnersprovideelementsofsharedprogrammesaccordingtoagreedprotocols.

Proactive NTG Primary Health Care Centres with advisory structures


HasaformaladvisorystructurethatenjoysacompetentandhonestpartnershipwiththePHCCentreandwhich:

•enjoystheconfidenceofthecommunity.•Isprovidedrelevantinformationinatimelymannerfromwhichtheycanformadvice.•carriesinfluenceinthestrategicdecisionsofthePHCCentre;and•reflectsthecommunity’spreferences.

Inadditiontotheresponsibilitiesabove:

•formaladvisorystructurecompetentlyusesinformationandculturalsocialprojectstoformulateadvice;and

•advisorystructuremonitorstheserviceprovider’scompliancewithadviceandisabletoeffectivelyadvocateonbehalfofcommunityinterests.


InadditiontothequalitiesoffunctioningdescribedforaproactiveNTGPHCCentre:

•deliversservicesinaccordancewithvolume,qualityandpricestandardssetunderthetermsofthecontractappropriately.

•respondsappropriatelytotheadviceofthecommunity;and

•inconjunctionwiththefundholderrespondstocommunityconsultation.

Anappropriatecommunitybasedlegalentityisinplacewithaneffectivelocalgovernancestructurethatiscompliantwithgovernanceandregulatoryframeworks.

Withinthescopeofthecommunity’spreferencesandobjectivesfulfilsanyobligationsassociatedwiththecontractforservices.

Contributescompetentlytoaneffectivemonitoringregimeoftheperformanceandculturalsecurityoftheprovidersserviceandisabletoadvocateonbehalfofcommunityinterestseffectively.


MonitorsthehealthandwellbeingofAboriginalTerritoriansandeither:

•advisescommunityandproviderofeventsthatwarranttheirattentionand/orintervenesasappropriatetoprotectpublichealthandwellbeing;and

•fulfilanyresponsibilitiesidentifiedunderthecontract.


Withinthescopeofthecommunitiespreferencesandobjectivesfulfilsanyobligationscreatedunderthecontractforservices.

Contributestoaneffectivemonitoringregimeoftheperformanceandculturalsecurityoftheprovidersserviceandisabletoadvocateonbehalfofcommunityinterestseffectively.


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InadditiontothequalitiesoffunctioningdescribedforaproactiveNTGPHCCentre:

•deliversservicesinaccordancewithvolume,qualityandpricestandardssetunderthetermsofthecontractappropriately.

•respondsappropriatelytotheadviceofthecommunity;and

•inconjunctionwiththefundholderrespondstocommunityconsultation.


Withinthescopeofthecommunity’spreferencesandobjectivesfulfilsanyobligationsassociatedwiththecontractforservices.

Contributescompetentlytoaneffectivemonitoringregimeoftheperformanceandculturalsecurityoftheprovidersserviceandisabletoadvocateonbehalfofcommunityinterestseffectively.


MonitorsthehealthandwellbeingofAboriginalTerritoriansandeither:

•advisescommunityandproviderofeventsthatwarranttheirattentionand/orintervenesasappropriatetoprotectpublichealthandwellbeing;and

•fulfilanyresponsibilitiesidentifiedunderthecontract.


Withinthescopeofthecommunitiespreferencesandobjectivesfulfilsanyobligationscreatedunderthecontractforservices.

Contributestoaneffectivemonitoringregimeoftheperformanceandculturalsecurityoftheprovidersserviceandisabletoadvocateonbehalfofcommunityinterestseffectively.

Community controlled primary health care service

Efficientandeffectivefundingandaccountabilitymechanismsandprocessesareinplaceandoperatingwell.

FundingAgreementsofferclearguidanceofserviceperformanceoutcomesandtimelines.

Appropriatemechanismsforthereferral,treatmentanddischargeofclientstoandfromsecondaryandtertiaryacuteandotherservicesexist.

Anappropriatecommunitybasedlegalentityisinplacewithaneffectivelocalgovernancestructureorcommitteethatiscompliantwithgovernanceandregulatoryframeworks.

Thegoverningcommitteeproducesandmaintainsappropriatestrategicandannualbusinessplans.Competentstaffareengagedtomanageandprovideservices.Appropriateorganisationalstructures,processesandcontrolsareinplaceandworkingeffectively.

Serviceprovidersengageeffectivelywithindividualclientsandprovidesservicesinresponsetoindividualpatient’sneeds.

Healthgoalsandobjectivesareoutputbased.Resourcesareorganisedaroundindividualserviceneeds.

Staffhavegeneralisedknowledgeofthecommunity’scircumstancesandculture.

Performanceevaluationisundertakenexternallyandclientandcommunitysatisfactionisstructuredbroadlyaroundgenericcomplaintsmanagementprocesses.

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Regional community controlled health service

Efficientandeffectivefundingandaccountabilitymechanismsandprocessesareinplaceandoperatingwell.

FundingAgreementsofferclearguidanceofserviceperformanceoutcomesandtimelines.

Appropriatemechanismsforthereferral,treatmentanddischargeofclientstoandfromsecondaryandtertiaryacuteandotherservicesexist.

An appropriate regionally based legal entity is in place with an effective governance structure or committee is compliant with governance and regulatory frameworks

The governing committee is representative of the region it serves and produces, maintains and monitors its strategic and business plans and operational guidelines.

Competent staff are engaged to manage and provide services. Appropriate organisational structures, process and controls are in place and working effectively to manage resources, accountabilities and services.

Service providers engage effectively with individual clients, provide core services and priority populations health services consistently.

Staff provide culturally secure services and have specialist knowledge of the community’s circumstances and priorities

including at a regional and sub regional level. Engages in programme specific consultation with community.

Local data and experience is proactively used to design and support service provision and resource allocation including population health services for example HSAK, GAA and disease control

Health goals and objectives are substantially output based but include a range of outcome measures related to population health goals and objectives.

Consumption of resources is driven generally by both personal health service patterns and priority population health considerations.

Local management of staffing and other resources to achieve personal and population health service coverage according to agreed regional standards.

Data and evaluation is proactively used to influence resource allocation, management and planning decisions at a regional level.


2�

2 UNCommissiononSustainableDevelopment(1996,p.2).

Building C mmunity and System Functioning

“Capacity-development,likesustainabledevelopment,encompassesawiderangeofaspects,includingthehuman,technological,organisational,financial,scientific,culturalandinstitutional…capacity-buildingistheprocessandmeansthroughwhichGovernmentsandlocalcommunitiesdevelopthenecessaryskillsandexpertisetomanage…”2

InadditiontooutliningthelevelsofcompetenceandcapabilitynecessaryforsustainableservicedeliveryandgovernancethisframeworkcommitstheForumpartnerstoaproactiveandprogressiveefforttopromotehigherlevelsofcommunityfunctioning.SucheffortswillassistAboriginalcommunitiestoassumegreaterlevelsofresponsibilityintheNTpartnershiptoimproveAboriginalhealth.Contributionstoimprovedlevelsofcommunityfunctioningwillalsocontributetoothercommunitydevelopmentneeds.

TheForumanditsmembershavealreadyundertakenanumberofprojectsthatseekstobuildthecapacityofcommunitiesandthehealthservicesystemtoevolvetogreaterlevelsofcommunityparticipationandcontrol.Theseinclude:

• regionalplanning • serviceandfinancebenchmarking • auspicingarrangementsforservices;and • HealthServiceDevelopmentOfficers

Whilsttheseeffortsareworthwhileamoresystematicapproachthatbuildsonpastexperienceisrequiredifwearetosecuregreatercommunityparticipationandcontrol.

Community Side

Onthecommunityside,capabilitybuildingwillnotalwaysbeaboutskillingthecommunitytorunand/orprovidehealthservice;serviceorganisationswillemployexperiencedandqualifiedstafftofulfilthatrole.HoweverthecapabilitiesofcommunitiesandBoardsofManagementarethresholdissueswithinthisframework.

Thesestructuresmustbeabletoservethecommunity’sinterests,stayconnectedwiththecommunity’spreferencesandvaluesanddischargestrategiccorporateresponsibilitieseffectively.

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Capabilitybuildingwithinthevariousformsofcommunityparticipationcontemplatedbytheframeworkmayrequiredevelopmentinanumberofkeyareasincluding:

• knowledge building:thecapacitytogrowskills,utiliseresearchanddevelopment andfosterlearning; • supporting information:thecapacitytocollect,accessandutilisequalityinformation; • leadership:thecapacitytodevelopshareddirectionsandinfluencewhathappens intheprovisionofservices; • authority:givingthecommunitytheauthoritytomovealongthispathway; • responsibility:thecapacitytoacceptresponsibilityforimprovinghealthstatus; • network building:thecapacitytoformpartnershipsandalliances;and • governance:thecapabilitytoachieveeffectivestrategicmanagementandcorporate performanceincludingriskmanagement.

Public Sector Side

Muchoftheorganisationalinfrastructurenecessarytodischargeserviceresponsibilitiesexistinthepublicsector.However,thereareanumberofareascriticaltotheobjectivesofthisframeworkwherethepublicsectorhasincreasinglyrecognisedtheneedforimprovement.Thesehavebeenin:

• communityengagement:howtoscope,define,implementandevaluatecommunity engagementstrategiesandcommunityvaluesandpreferences;and • culturalsecurityofservices:ensuringthatclientsdonotsufferlessfavourableoutcomes becauseofculturaldifferencesbetweenAboriginalpeopleandserviceproviders.

Similarlyincreasinglevelsofcommunityparticipationwillplacedemandsoncurrentserviceprovidersparticularlyinrespectof:

• skillingstafftoappropriatelyrespondtothescopeofengagementsoughtbycommunities; and • buildingsystemsthatensuretheculturalsecurityofservicesoffered.

Taking Action – Transitioning

Inadoptingaframeworktobuildcommunityandsystemsfunctioninginsupportofgreatercommunityparticipationandcontrolbothcommunitiesandgovernmentswillbeconcernedwith:

• consistencyandcontinuityofservicecapacityandarrangements; • qualityandcoverageofservices; • managementofrisk; • fairness,and • responsiveness


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Thisframeworkcontemplatesafour-stageprocessinwhichcommunityaspirationstoadoptaparticularservicesmodelcouldbeframed:

1. Development 2. Consolidation �. Implementation 4. Evaluation

1. Development Stage

Inthedevelopmentstageserviceprovisionwillbelargelyunaffected.However,paralleleffortsthatinvolvethecommunityasawholeareundertakenthat:

Improve information:healthandfamilyservicesinformationispresentedtothecommunitythatencouragesanactivediscussionofhealthissues,andbuildscapacityforcommunitiestomakeinformeddecisionsabuttheirprioritiesforhealth.

Elicit community preferences:theobjectiveistoestablishthequalitiesandcharacteristicsthecommunitybelievesareimportanttothechoiceofservicemodel.Thecommunitycouldconsiderthequestion‘Whatarethevaluesandpreferencesthatwebelieveareimportanttothedecisionaboutaservicemodel?’

Evaluate the options:inthiselementthecommunity,basedontheirpreferencesandprioritiesreviewallofthepotentialservicemodelsandmakessomedecisionsabouthowwellornotthemodelsreflecttheirvaluesandpreferences.

Choosing a model:havingweigheduptheoptionsthecommunityshoulddiscusstheresultsandmaythenbeinapositiontodecidewhichmodelsuitsthem.Atthisstagethecommunitymayelecttocreatealeadershipgroupthatpursuesthereformsoughtbycommunity.Insomecasessuchleadershipgroupshavevisitedothercommunitiestolookatdifferentservicemodelsthatareinoperationinordertohelpthemdecidewhichmodelmightbestsuitthem.

Beyondthecommunitythereareconsiderationstakenbyhealthplanners(suchastheForum)andbygovernmentsthatwillimpactonthenatureandpaceofreform.Suchconsiderationsinclude:

• equity; • relativeneedofacommunitycomparedtoothers; • cost; • consistencyandcontinuityofservicecapacityandorganisationalarrangements;

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• qualityandcoverageofservices;and• managementofrisk.

Anindicativetimeframeforthedevelopmentstageis12to18months.

2. Consolidation Stage

Intheconsolidationstageworkbeginstobuildthecapabilityofcommunities,theleadershipgroupandtheservicesproviderstoaccommodatetheproposedreform.Duringtheconsolidationstagetheprovisionofhealthservicesmaynotbeaffectedexceptforagrowingexchangeofviewsandinformation.Thisexchangehowevermaycontributeinitselftoanimprovementtocurrentprovisionofservices.BytheendofthisstagealegalentitywouldhavebeenformedsothattheleadershipgroupisconsolidatedintoanelectedhealthboardthathasgreateraccountabilitytothecommunityorregionthroughopenAnnualGeneralMeetings.

Leadership: theleadershipgroupmeetsregularly,andprovidesdirectionforthestafforcommunitymembersworkingtobuildreform.Thisleadershipgroupcanhelpthecommunitydemonstrateitscapabilitytogrowskills,utiliseresearchanddevelopmentandfosterlearning,andprovidedirectiontoandclearlyarticulatecommunityneedsandaspirations.Itmayalsohelpbuildthecapacitytodevelopshareddirectionsandinfluencewhathappensintheprovisionofservices.ThegroupmightalsoconsidertheemploymentofaHealthServiceDevelopmentOfficer(HSDO)toassistinthevariouselementsoutlinedinthisstage.

Create a Health Plan: withthesupportofthecommunitytheleadershipgroupcouldconstructahealthplanforthecommunityorregion.Healthplanscouldataminimumsetoutdemographics;anoverviewofthedeterminantsofhealth;informationaboutthecurrenthealthstatus;detailsofcurrentserviceprovisionincludingananalysisofanygaps;theproposedmodelandtheleadershipgroupsstrategiestodelivercoreservices;communitycontrolandculturalsecurityandotherservicedevelopmentandmanagementissues.

Associatedwiththisistheneedfortheleadershipgrouptohaveafirmviewofhowtheyaregoingtoimplementthetransition.

Community Engagement: essentialtosuccessfulreformistheabilityoftheleadershipgrouptodemonstrateeffectivecommunityengagementwiththereformandappropriatelevelsofcommunityconfidenceintheprocess.Aspartofthis,thedevelopmentofafullyconstitutedlegalentitywithbroadconsultationwiththecommunityorregionisessentialtoensurethattheleadershipgroupisaccountableandformalisedtoafullyfunctioninghealthboard.


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Builds Networks:theleadershipgroupandothersshouldtakethetimetobuildnetworksandformfunctioningpartnershipsandallianceswithrelevantstakeholders.TheForumpartnersbelievethisisanimportantfeatureofsuccessfulcommunitygrowthanddevelopment.Thesenetworkscanhelpclarifypotentialfundingavailabletosupportthereformprocessandexamplesuccessfulinitiativesinotherlocations.

Governance:theincorporatedlegalentitydemonstratesthecapabilitytoachieveeffectivestrategicmanagementandcorporateperformanceincludingriskmanagement;putsinplacethecorporateframeworknecessarytosupporttheidentifiedservicemodels;demonstratesfinancialexpertiseintermsofaclearcapacitytomeetallfundingcompliancerequirements;preparesanannualbusinessplanfromthehealthplanwithclearlyidentifiedperformanceindicators.Evaluation Strategy:partnersinthereformshouldagreeanevaluationstrategythatservestoshowprogressagainsttheobjectivesofthereform.Suchanagreementcouldprovidethebasisfortheevaluationstage.

Anindicativetimeframeforcompletionoftheconsolidationstageis12to24months.TheForumwillregularlymonitortheprogress.

3. Implementation Stage

TheimplementationstageiscommencedwhenthenecessarytransitionalarrangementsareinplaceandwhentheHealthBoardorHealthServicesCommitteehasassumedfullmanagementresponsibilityforthedeliveryofprimaryhealthcareservicesonaninitialbasis.Fundspoolingtoasingleprovidershouldoccurwithinthisstage.TheprovisionofhealthandfamilyserviceswillbemostaffectedduringtheimplementationstageandaccordinglytheForumandgovernmentswillbeinterestedinmonitoringchangeandminimisingrisk.

Monitoring Change:thestakeholderswillbeinterestedtoensurethattheimplementationofreformismeetingallappropriatemilestones.GovernmentsandtheForumwillbeconcernedtoensurethatanyrisktoservicesforthecommunityisminimisedandthatsustainablecorporate,serviceandotherengagementarrangementsareoperatingwell.

Business Planning:havingtakenontheappropriateresponsibilitiesundertheservicemodel,servicemanagerswillneedtoensurethatsoundbusinessplanningisinplaceandtiedtooperationaldecisionmaking.

Effort Maintained and Commitments Met:partnersmaintaineffortinsupportofhealthoutcomesforthecommunity.Serviceoutputsforthecommunityrequiredbythehealthplanarebeingsatisfactorilymetunderthenewarrangement.

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ConfidenceofCommunity:thecommunitycontinuestohaveconfidenceinthemodelandrelateddecisionsandisabletoofferthenecessaryadvicethroughwell-establishedmechanismstoaddressconcernsorcelebratesuccesses.

ConfidenceofFunders:thenewarrangementscontinuetomaintainandbuildtheconfidenceoffunders.

ConfidenceofCorporateRegulators:wherethemodelinvolvesanindependentcorporateentitythecontinuingconfidenceofthecorporateregulatorisessential.

Data Collection:appropriateandsounddatacollection,collationandanalysisareoccurringbothtosupportoperationalandstrategicneeds.

Anindicativetimeframeforcompletionoftheimplementationstageis12to24months.

4. Evaluation Stage

Evaluationoftheperformanceofservicemodelsisimportanttotheongoingsuccessofanyserviceprogramme.Evaluationmeansmakingajudgmentabouttheserviceseffectiveness(i.e.havetheoriginalobjectivesbeenmet)andefficiency(i.e.howwellresourcesarebeingused).Itentailslookingatoutcomesaswellasatactivities;atrelevanceaswellasnumbers;atwhatcouldhavebeendoneaswellaswhatwasdone.Theevaluationstrategyoutlinedduringtheconsolidationstagecouldformthebasisforactionhere.

Stakeholder Engagement: theengagementofkeystakeholders(funders,communitynetworksandleadership)isimportanttosoundevaluation.Stakeholderscanhelpframesomeofthequestionstobeaddressedbytheevaluation.Thesediscussionsmightalsoassistinmarshallingtheresources(perhapscashandin-kindcontributions)toconducttheevaluation.

Setting clear Objectives and Logic:evaluationstrategiesshouldsetoutthemainservicecomponentsandtherelatedimplementationorbusinessobjectivestobeevaluatedsothatalogicalformatandexpectationisestablished.

UseofEvaluationReport:evaluationsshouldprovideabasistoenhancethestrategic,businessorotheroperationalandcorporatedecisions.

Theevaluationstageshouldcommencenosoonerthantwoyearsafterthecommencementoftheimplementationstageornomorethan12to18monthsaftertheimplementationstageisfinalised.


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C nclusion

AboriginalandTorresStraitIslandercommunitieshavelongassociatedtheimportanceofcommunitycontroltotheachievementofhealthandwellbeinggoals.

Researchsuggeststhatthedevelopmentofgreaterlevelsofcommunityandfamilyfunctioningthatiscognisantofculturalvaluesandprocess�maycontributetobetterhealthandwellbeing.ThisframeworkseekstobuildthenecessaryandongoingpartnershipbetweenhealthandwellbeingstakeholdersintheNT,serviceandculture,thatdeliversaconsciousanddeliberateefforttosupportcommunityengagementin,andcontroloverhealthandwellbeing.Encouragingthisengagementstakeholdersanticipategreaterlevelsofcommunityfunctioningandgreaterlevelsofhealthandwellbeing.

3ChandlerandLalonde,CulturalContinuityasaHedgeAgainstSuicideinCanada’sFirstNations,

pathways to community control - lilyredlily.org.au/.../2009_final_pathways-to-community...pathways...

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