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3.13 Competent governance

Why is it important?

'Governance' involves having the processes and institutional capacity to be able to exercise control by making and applying rules, mobilising and managing resources and through sound decision making. 'Competent governance' requires the means to establish good governance arrangements with the ultimate aim of achieving the social, cultural, and economic developments sought by constituents (Hawkes 2001; de Alcántara 1998; Westbury 2002; Dodson et al. 2003). 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 Organisations (ACCHOs) was first established in the 1970s, and by the 1990s, ACCHOs were an important provider of comprehensive primary health care services for Aboriginal and Torres Strait Islander peoples (Larkins et al. 2006; DoHA 2001). While the capabilities and capacity of ACCHOs 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 Athe 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(ORIC) helps to administer the Corporations (Aboriginal and Torres Strait Islander) (CATSI) Act 2006, which superseded the Aboriginal Councils and Associations (ACA) Act 1976. In 2012–13, 91 out of the 93 Indigenous health corporations incorporated under the CATSI Act and registered with ORIC were compliant with the required provision of documents.

In 2012–13, 170 Australian Government-funded Indigenous primary health care organisations provided data on governance through the Online Services Report. Of these organisations, 98% reported that their committee/board had met as frequently as required of the constitution; 97% had presented income and expenditure reports to the committee or board on at least two occasions during the year; 74% had a committee or board who were all Aboriginal and/or Torres Strait Islander peoples; and 85% had committee/board members who had received training related to governance issues. In 2012–13, 95% of organisations had formal mechanisms in place for client and community feedback.

In 2012–13, 62 Australian Government-funded organisations providing Indigenous substance-use-specific services provided data through the Online Services Report. All of these organisations reported that the governing committee or board met as frequently as required in the constitution; 98% of services had income and expenditure statistics presented to the committee or board on at least two occasions; 53% had a governing committee or 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.

In 2012–13, of the 205 Australian Government-funded Indigenous primary health care services in the Online Services Report, 57% had representatives on external boards (e.g. hospitals) and 87% participated in regional health planning processes.

As at June 2011, 86% of services funded under the former Healthy for Life programme reported having meetings of reference groups or other advisory committees to involve their service population in planning and 86% had a formal complaint mechanism.

The 2012–13 Health Survey included questions on patient experience and reasons for not accessing health care 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/, 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).

In the 2012–13 Health Survey, 16% of Indigenous Australians reported they had been treated badly in the last 12 months because they are Aboriginal or Torres Strait Islander. Of those, 20% felt they had been treated unfairly by doctors, nurses or other staff in hospitals or doctors' surgeries. Around 7% of Indigenous Australians reported that they avoided seeking health care because they had been treated unfairly. Most Aboriginal and Torres Strait Islander peoples aged 15 years and over living in non-remote areas that saw a GP or specialist in the previous 12 months, reported the doctor always or usually: listened carefully to them (89%), showed respect to them (89%) and spent enough time with them (85%).

In the 2008 Social Survey, 8% of Indigenous Australians aged 15 years and over disagreed or strongly disagreed with the statement 'Your doctor can be trusted'. In addition, 17% disagreed or strongly disagreed with the statement 'Hospitals can be trusted to do the right thing by you'.

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).

The Indigenous Advancement Strategy started on 1 July 2014, replacing more than 150 programmes and services with five broad, flexible programmes: Jobs, Land and Economy; Children and Schooling; Safety and Wellbeing; Culture and Capability and Remote Australia Strategies. These programmes seek to foster a new engagement with Aboriginal and Torres Strait Islander peoples and make funding more flexible and better designed to meet the aspirations and priorities of individual communities. The Culture and Capability Programme will support 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 will fund a range of activity that will achieve outcomes such as, but not limited to:

  • improved leadership and governance capacity of Indigenous people, families, organisations and communities
  • strengthening the capacity of Indigenous organisations so that they are able to effectively deliver Government services to Indigenous people and communities
  • engaging 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
  • a robust risk management framework
  • 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
  • supporting quality service delivery through organisational and GP accreditation
  • 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.

As part of the 2014–15 Federal Budget, the Australian Government announced that Primary Health Networks (PHNs) would be established and would replace Medicare Locals from 1 July 2015. Service continuity will remain a priority.

Table 3.13-1 Number and proportion of health corporations incorporated under the CATSI Act 2006 by compliance, 2012–13
Compliance status Number Per cent
Compliant 91 98
Not compliant 2 2
Total 93 100

Source: AIHW analysis of The Office of the Registrar of Indigenous Corporations (unpublished data)

Table 3.13-2 Number and proportion of Indigenous primary health care organisations participating in mainstream processes, 2012–13
Process No. Per cent
Representation on external boards (e.g. hospitals) 117 57
Participation in regional health planning processes 179 87
Total number of services 205 100

Note: a service is recorded as having conducted an activity if that activity was conducted by either the service itself or by one of its auspiced entities.

Note: total number of services that provided information

Source: AIHW analysis of OSR data collection, 2012–13

Table 3.13-3 Governing committee/board use by organisations providing primary health care services and substance-use services to Aboriginal and Torres Strait Islander peoples, 2012–13
Governing Committee /Board attribute Primary health care services
No.
Primary health care services
%
Substance use services
No.
Substance use services
%
Frequency of governing committee or board meeting met the requirement of the constitution 167 98 62 100
Income and expenditure statements were presented to committee or board on at least 2 occasions 165 97 61 98
All of the governing committee or board members were Aboriginal and/or Torres Strait Islander 125 74 35 53
Governing committee or board received training 144 85 51 82
Total number of services 170 100 62 100

Source: AIHW analysis of OSR data collection, 2012–13