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Care for chronic conditions for indigenous Australians: Key informants’ perspectives on policy
Health Policy 92 (2009) 211–217
Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
Care for chronic conditions for indigenous Australians: Key informants’ perspectives on policy Juan Baeza a,∗ , Ross Bailie b , Jenny M. Lewis c a
King’s College London, Department of Management, School of Social Science and Public Policy, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, United Kingdom b Menzies School of Health Research, Charles Darwin University, Darwin, Australia c School of Political Science, Criminology and Sociology, University of Melbourne, Melbourne, Australia
a r t i c l e
i n f o
Keywords: Chronic conditions Indigenous health Policy environment Australia
a b s t r a c t Background: The WHO’s 2002 global report, Innovative Care for Chronic Conditions proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions. This paper uses the policy environment component of the WHO framework as a lens through which to examine key informants’ perspectives on the management and prevention of chronic conditions in rural and remote Aboriginal communities in Australia. Methods: Twenty one semi-structured telephone interviews were conducted with a purposive sample of stakeholders, including senior commonwealth, state/territory and regional public servants and health service staff. All of the interviews were audio recorded, from which written summaries were produced. These summaries were then content analysed to build a composite picture of this area. Findings: The results indicate substantial success in developing national and sub-national strategies and refining funding and reporting arrangements. But much work remains to be done in strengthening partnerships, developing and retaining the workforce, and further shifting the focus from acute to chronic conditions. Conclusions: This paper provides a snapshot of the main policy issues, as identified by key informants, facing chronic disease management in rural and remote Indigenous communities in Australia. It has the potential to contribute to new national policy directions in Indigenous health. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The World health Organization (WHO) defines chronic conditions as health problems that require ongoing management over a period of years or decades [1]. Such health problems include cardio vascular disease, cancer, diabetes and certain mental health problems such as depression. The dramatic increase and overall prevalence of chronic conditions make these an important health policy issue [2]. The evidence on the nature of chronic conditions indicates that
∗ Corresponding author. Tel.: +44 020 7848 4634. E-mail address: [email protected] (J. Baeza). 0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2009.03.012
current health system arrangements around the world are not well suited to the effective delivery of chronic illness care [3,1]. The acute care paradigm has tended to dominate the thinking of policy makers, clinicians and managers at all levels of the policy process and the delivery of health care services [3,1]. 2. Background The WHO’s 2002 global report, Innovative Care for Chronic Conditions (ICCC) proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions [4]. The WHO’s ICCC framework splits the health system into three interlinked levels:
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Fig. 1. The ICCC framework. Source: WHO, 2002.
• Macro level: the policy environment. • Meso level: health care organization and community. • Micro level: patient interaction.
ment in Australia for tackling chronic conditions in rural and remote Aboriginal communities. 3. Methods
The focus of this paper is the policy environment which is depicted as an overarching context in Fig. 1. The WHO framework argues that it is essential to develop a positive policy environment at the macro level that provides appropriate support for effective chronic illness care in the form of legislation; leadership; integration of policies; building partnerships; financing; and human resource management. This paper examines the perspectives of key informants on the policy environment for chronic disease management in rural and remote Indigenous communities in Australia. The WHO framework is used to structure this analysis. Indigenous Australians experience a disproportionately high prevalence of, and morbidity and mortality from, chronic illness such as diabetes, renal disease and cardiovascular disease [5,6,7]. All Australians have access to primary care through general practice visits funded by Medicare [8], as well as services provided by state/territory and local governments. Indigenous people have an additional service, provided through Aboriginal community controlled health organisations (ACCHOs). Indigenous people’s access to general practice is limited, particularly in Australia’s Northern Territory (NT) where 70% of its Indigenous people live in rural and remote communities where there are few GPs [9]. With an increasing emphasis on enhancing the effectiveness of chronic illness care in some jurisdictions in Australia [10], it is timely to examine the policy environ-
This study of the policy environment was conducted within the context of an action research project on improving the quality of care in Indigenous primary health care services in Australia, the Audit and Best practice in Chronic Disease project (for more on the ABCD project see www.abcdproject.org.au). Interviews were conducted with a purposive sample of informants that included senior state and Commonwealth public servants [7], state/territory public servants [9], ACCHOs staff [6], and one health consultant (see Table 1). Two interviewees held dual roles – e.g. working in both a state department and an ACCHO, and Table 1 Interview sample. Number of interviews Commonwealth Central and state Offices of Aboriginal & Torres Strait Islander Health Central and state offices of the Department of Health and Ageing State/territory Northern Territory (NT) Department of Health and Community Services Western New South Wales Health (NSW) Department of Health, Western Australia (WA) Aboriginal community controlled health organizations Health consultant
5 2
4 2 3 6 1
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were interviewed in both capacities, so were counted twice in these figures. A total of 21 individuals were interviewed. Due to the wide geographical dispersion of this sample the interviews were conducted by telephone. The informants were selected from the three states/territories where the ABCD project was already in progress by January 2006 – New South Wales (NSW), the Northern Territory (NT), and Western Australia (WA). The aim was to examine how the current policy environment for chronic disease care in the Aboriginal sector was perceived by senior policy staff at the state/territory and Commonwealth levels and by key advocates within the ACCHO sector, providing perspectives of people who had input into policy development as well as responsibility for policy implementation. An initial sample was identified from discussions amongst the team of investigators who have extensive experience in this area, and this sample was expanded further as those who were interviewed suggested other informants. No further interviews were carried out once data saturation was deemed to have been reached [11]. The telephone interviews were carried out between March and June 2006 and were about 1 h in length. The interview schedule was semi-structured, and was used flexibly to allow informants to discuss issues that they felt were important. The interview schedule broadly reflected the policy dimensions that are identified in the ICCC framework and covered the following issues: • The information base for chronic conditions. • Current health policy for chronic conditions. • Inter and intra-agency partnerships, relationships and collaborations. • Legislative/governance frameworks for chronic conditions. • The prioritization of chronic conditions in plans. • Financial arrangements. • Workforce development. All of the interviews were audio recorded and written summaries were produced. These summaries were then content analysed in order to identify themes and thus build a composite picture from the various informants’ perspectives [12]. The study was granted ethics approval by the health research ethics committees in the jurisdictions where the ABCD study was operating and by the human research ethics committee of the University of Melbourne. 4. Results The major issues raised by these informants covered four of the six policy elements included at the macro level of the ICCC framework (strengthening partnerships; integrating policies; human resources and consistent financing) and one additional theme of policy and governance which arose inductively from the data. What is presented below is based on the analysis of the interview data. These results must be examined in the context of the sample from which they are derived. The policy environment is made up of a number of different stakeholders (e.g. politicians, public servants, service providers, the
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media, etc.) and this study examined it predominately from the perception of senior public servants and key advocates within the ACCHO sector who have extensive experience of working within this environment. These are an important group who occupy the space between politicians and the frontline health workforce. They therefore have a highly informed but particular view of the policy environment for Aboriginal chronic care. 4.1. Strengthening partnerships To promote a positive policy environment for tackling chronic conditions it is important to forge strong partnerships between the various government sectors. The ICCC framework argues that partnerships amongst the agriculture, labour, education and transportation sectors are particularly important (4:62). The interview data suggest that joint work between different departments at the various government levels (state/territory and Commonwealth) rarely occurs. There was also little evidence of joined-up work within the individual state/territory departments of health. Some informants stated that this was a difficult task to achieve that takes time and resources, both of which are in short supply in the Indigenous health sector. However, there was some evidence of joint work between education and health at the local level in both the NT and western NSW. There was also some indication of joint working between departments in the area of physical activity in the NT. Cost shifting between levels of government is a characteristic of the Australian health system. However, recent joint funding and reporting arrangements requiring one joint line of reporting for state and Commonwealth funds was seen by respondents to have eliminated this problem in NSW and provided a clear mechanism for strengthening partnerships between the state and Commonwealth level governments. Various informants from the NT and NSW stated that health based non-governmental organizations (NGOs) such as the Heart Foundation and the Cancer Council were now ready to work in an integrated way to promote the treatment of chronic conditions at the state/territory level and that this is also beginning, but more slowly, at the national level. Various informants mentioned that the Council of Australian Governments (COAG), which is the peak intergovernmental forum in Australia, agreements in various regions were initiating joint approaches in some health areas. COAG’s role is to initiate, develop and monitor the implementation of policy reforms that require cooperative action by Australian governments [13]. These data suggest that joint working was more prevalent at the local community level and less so to work at the state/territory or national levels. COAG could be seen to therefore have a potentially important role in strengthening partnerships at higher levels. Indeed, since the change of the Federal Government in Australia in 2007 (and after the completion of the interviews for this study) CAOG has proved to be a major vehicle for change, with the announcement of major partnership approaches, funding agreements and reform processes of relevance to Indigenous health and specifically chronic illness [14]. These recent COAG initiatives are rel-
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evant to a number of the other components of the ICCC Framework discussed below, including ‘human resources’ and ‘consistent financing’ 4.2. Integrating policies The Australian’s government’s National Chronic Disease Strategy [15] is a clear attempt to integrate policies to tackle chronic conditions at the national level. Developing a chronic disease strategy seems an important stage in providing more services and resources that focus on chronic diseases in an integrated way. That is, developing a strategy was not seen by informants to be just a paper exercise, but rather as being important in the allocation of funding for new positions with specific responsibilities in chronic illness care and the incorporation of such responsibilities into existing position descriptions. The approach of these strategies is practical and straight forward, which provides the services with a good basis to tackle chronic conditions [16]. Chronic disease care is mainly carried out within the primary care setting. The strategies, to varying extents, have enabled the jurisdictions to tackle chronic conditions in an integrated way encompassing prevention, promotion and control strategies as promoted by the ICCC [4]. 4.3. Human resources There are various factors that constrain services’ ability in providing good quality care to patients with chronic conditions. These limitations include the recruitment and retention of appropriately trained staff as well as certain weaknesses in staff skills in the area of chronic conditions. All the informants reported serious workforce issues, particularly in remote areas in terms of recruitment, retention and the capacity of the workforce. The informants reported difficulties in recruiting health workers into Aboriginal health services in general, and in remote areas in particular where there are many vacant positions. One informant stated that there was evidence (from the experiences in central Australia) that high quality induction and orientation programmes for health workers can improve retention of health care professionals. Recruitment and retention is not an issue that the ICCC framework addresses but is a factor that is particularly significant in the Aboriginal health context [17]. Various informants reported that most of the training of health staff occurs in the acute setting and not in primary care where most of the patients with chronic conditions reside. The result is that health professionals find it difficult to apply their skills in the chronic conditions arena, making them frustrated and depressed by its demands. The data suggest that a major issue is training in communication skills rather than any technical deficiencies, an issue identified in the ICCC framework [4]. However, other studies have reported that improvements in the quality of self management support that staff can offer could also be addressed by training programmes [18]. Education authorities at both the state/territory and Commonwealth levels have an important role to play in developing appropriate courses for primary care practitioners so that they can successfully cater for patients with
chronic conditions. However, informants from provider institutions reported having very limited influence on the educational institutions that produce health service staff. The other important human resource issue identified was the management capacity in the Aboriginal health sector. Some informants suggested that the role of the local health centre manager is crucial in setting up the systems and programs to improve care for patients with chronic conditions. Informants in all the jurisdictions stated that the development of middle management capability and capacity needs to be given a higher priority. Similar findings have been reported in the evaluation of the coordinated care trials–a series of trials aimed at improving the coordination of care for various conditions [17]. These data suggest that it has been more difficult to shift the attitudes of the regional managers than those of health centre workers. This may be due to the availability of suitable tools to deal with chronic conditions in health centres, while this is absent at the regional level. Informants in all the jurisdictions felt that there were significant problems associated with the recognition of, and award structures for, Aboriginal Health Workers (AHWs). Some suggested that the national registration of AHWs may help lift their profile. Others pointed to the problems that AHWs experienced in career progression from AHWs to registered nurse status. The ICCC framework [4] stresses the importance of non-physicians in providing good care to patients with chronic conditions; in the Aboriginal health context AHWs have a critical role to play but current conditions limit their role, and its desirability as a career. 4.4. Consistent financing In order to create a positive policy environment it is essential to have consistent and adequate financing arrangements to tackle chronic conditions. Interestingly, the general level of funding was not highlighted as a significant barrier in tackling chronic conditions. This is not to say that the Aboriginal health sector is well funded as various reports have highlighted the low levels of Aboriginal health funding when compared to mainstream health services [17,19]. The informants’ discussion of funding centred on a lack of capacity in the Aboriginal health sector that prevented it from effectively absorbing the large increase in Aboriginal health funding that is needed: They focussed on the barriers associated with the low numbers of appropriately skilled staff. The coordinated care trials evaluation also reported that ACCHO board members could be helped in better executing their roles by appropriate education initiatives. This illustrates the fact that targeted education programmes are needed for health service managers as well as health care professionals in order to allow them to deliver better chronic care to their populations[17] ×.. Funding arrangements, particularly through Medicare (the Australian universal health insurance system), were highlighted as a significant problem by most informants in the various jurisdictions. Many of them considered Medicare as a virtually inaccessible resource for Aboriginal communities who get far less than non-Aboriginal communities in this kind of funding [17,20]. This funding
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source is fee for service based for GPs and so is essentially uncapped. It could potentially provide ACCHOs with a greater degree of financial flexibility, so the fact that this does not occur effectively within Aboriginal communities represents a major barrier to the provision of positive care for chronic conditions in these communities. Another problem that informants highlighted was that Medicare is ill-suited to funding the treatment of chronic disease because it focuses so heavily on general practitioner (GP) payments. The ICCC framework makes it clear that care in the area of chronic conditions is often best carried out by non-physicians; a financial reimbursement system that favours GP provision is a serious barrier to others. Recent efforts to enhance the potential of Medicare to support chronic illness care for Indigenous Australians, such as the introduction of the Adult Health Check [21], fail to adequately address these key limitations. The problems associated with the funding structure of Aboriginal health services which involve various funding streams from the state and commonwealth governments was mentioned as a constraining issue for various health services. However, there was evidence of progress in this area as OATSIH has instituted some changes that attempt to move away from the ‘body part funding’ that provides money for discreet health areas, to a more holistic method of funding which encourages integrated health policy initiatives. Other initiatives which provide pharmaceutical funding to remote Indigenous services as compensation for relatively poor access to Medicare and funds for medicines are recent positive developments. Notwithstanding these initiatives, the Australian health system’s complex financing arrangements were seen to continue to pose challenges for Indigenous health services. 4.5. Policy and governance An important issue that was raised by most informants related to the capacity of Aboriginal health services to respond to the increasing demands of chronic diseases. Informants felt there was a need to increase the capacity of Aboriginal services to allow them to influence mainstream organizations and develop the leadership of the Aboriginal sector to facilitate their meaningful engagement in policy development, implementation and governance arrangements. These findings resonate with the evaluation of the co-ordinated care trials which also highlighted the fact that investment in training and education on governance processes in the chronic care area had a positive impact on community capacity building in remote Aboriginal communities [17]. 5. Discussion It is evident that while there have been some significant successes, there is potential for further developments to strengthen the policy environment for chronic illness care for Indigenous Australians. While there have been significant developments since the change of government in 2007, the impact of these policy initiatives on the ground will take some time to bear fruit and will require some significant
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challenges to be addressed if their potential is to be fully realised. The difficulties of strengthening partnerships between government departments and the lack of collaborative work to tackle chronic disease both within and between government departments were highlighted by a number of informants. For collaboration to occur between and within departments there need to be clear incentives for all those involved [22,23,24]. The difficulties involved in the joint working process should not be underestimated [25,26]. Collaboration is not a free good; it needs to be properly resourced [27]. Pooled budgets between state departments (e.g. health and education) and between state and commonwealth departments may be one way of supporting collaborations at the various levels [28], although internationally the evidence of success is mixed [29], there have been some signs of success in the Australian Indigenous primary care context [17,30]. Pooled budgets more broadly may also be an effective mechanism for shifting resources from the acute health sector into tackling chronic diseases. As well as strengthening the links between primary and secondary care, the connections between the Aboriginal health sector and the mainstream health sector also need to be properly supported [31]. The creation of departments such as OATSIH has benefited Aboriginal health [32] but such arrangements can either help or hinder the building of strong connections between Aboriginal health and mainstream health. The ICCC framework suggests that a multisectoral governing body should be implemented in order to advocate for the better provision of chronic conditions care ([4],72). This suggestion resonates with the findings of this study. In this study, it seems that workforce problems were associated with difficulties in recruitment and retention, a problem that others have also reported [33]. The other major workforce issue that was raised by the informants was the negative attitude towards chronic disease from some clinicians. Tackling chronic diseases requires a different set of skills to those required for acute health care; a paradigm shift is needed amongst health care professionals [34]. For some years the WHO has recognized that current educational programmes are inadequate for health care workers who are increasingly caring for patients with long-term chronic conditions [4]. Appropriate staff training for both clinicians and managers could tackle this issue in the short and medium terms. However, a positive policy environment can only occur in the long term by building partnerships between the health and education sectors to enable discussions to take place to address these important issues. The WHO’s ICCC framework advocates the creation of joint committees between education and health sectors so that a common understanding of what the medical/health education needs are can be reached ([4]: 73). This again fits with the findings of this study. The relative lack of Indigenous health funding through Medicare and the Pharmaceutical Benefits Scheme presents a major barrier to promoting consistent financing because service utilisation is not automatically linked to funding [19]. A complicating factor that the data highlight is the service capacity problems within the Aboriginal health sector, which acts as a constraint and prevents
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the sector from effectively using any possible increases in funding. This indicates that the first step is to make investments in the capacity of the Aboriginal health sector that will then enable the sector to provide a more effective health service for their population [35]. Leadership and advocacy featured in the informants’ accounts in relation to the limited number of staff with appropriate skills in the Aboriginal health sector, which constrains its influencing capacity within the wider health arena. Leadership and advocacy have played a very significant role in the evolution of Indigenous health services in Australia in the past, and so it is interesting that this aspect of the ICCC Framework received attention from the informants. The ACCHO staff included in the study sample were themselves leading advocates for this sector. An aspect of policy which emerged from this study and which could be more clearly identified as a policy issue within the ICCC Framework is that of promoting effective governance. Building effective local governance capacity for ACCHOs has received significant attention, but remains an important area for development. Within government health authorities, capacity of middle management has also been identified as a limiting factor in improving chronic illness care and should be a stronger focus for development. Also not clearly articulated in the ICCC Framework (or by the informants) is the potential for integration of aspects of policy, for example of policy on information systems to support policy on governance and vice versa, policy on financing to support appropriate workforce development, and financing to support partnerships. This study provides a summary of critical areas for policy development in chronic disease management in rural and remote Indigenous communities, as identified by key informants. It indicates how the ICCC framework can help structure an analysis of the policy environment, and how it might be improved by a stronger focus on workforce recruitment and retention, and governance at different levels within the system. This paper has the potential to contribute to newly emerging directions in Indigenous health policy in Australia, being led by the recently established National Indigenous Health Equality Council [36]. Acknowledgements The ABCD project is supported by funding from the Cooperative Research Centre for Aboriginal Health and the Commission for Safety and Quality in Health Care. RB’s work is supported by NHMRC Fellowship #283303. The authors would like to thank all those interviewed for generously giving up their time to participate in this study. References [1] World Health Organization. Human resources and national health systems. Shaping the agenda for action, Geneva: World Health Organization 2002. [2] Horton R. The neglected epidemic of chronic disease. The Lancet 2005. [3] Smith R. Improving the management of chronic disease. BMJ 2003;327:12. [4] World Health Organisation. Innovative care for chronic conditions: Building blocks for action: a global report. WHO Press: Geneva 2002.
[5] de Courten M, Hodge A, Dowse G, King I, Vickery J, Zimmet P.Review of the epidemiology aetiology pathogenesis and preventability of diabetes in Aboriginal and Torres Strait Islander populations. 1998. [6] Australian Bureau of Statistics and Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples. Canberra: ABS and AIHW 2001. [7] National Centre for Monitoring Cardiovascular Disease, Heart, stroke and vascular diseases: Australian facts 2004. Canberra: Australian Institute of Health and Welfare 2004. [8] Gillies A. What makes a good healthcare system? Comparisions, values drivers. Oxon: Radcliffe Medical Press; 2003. [9] Australian Bureau of Statistics. Regional statistics, Northern Territory 2004. Canberra: ABS 2004. [10] Bailie RS, Si D, Robinson GW, Togni SJ, d’Abbs PHN. A multifaceted health-service intervention in remote Aboriginal communities: 3-year follow-up of the impact on diabetes care. MJA 2004;181(4):195–200. [11] Guest G, Bunce A, Johnson L. How many interviews are enough? Field Methods 2006;18:59–82. [12] Harvey L. Critical social research. London: Unwin Hyman; 1990. [13] http://www.coag.gov.au/about coag/index.cfm (accessed February 7th 2009). [14] http://www.coag.gov.au/coag meeting outcomes/2008-1129/index.cfm#indigenous (accessed January 10th 2009). [15] National Health Priority Action Council, National Chronic Disease Strategy. Canberra: Australian Government Department of Health and Aging 2006. [16] Lloyd J, Wise M, Weeramanthri T. Changing shape: workforce and the implementation of aboriginal health policy. Australian Health Review 2008;32:174–85. [17] Australian Government Department of Health and Ageing. The national Evaluation of the second Round of Coordinated Care Trials. Canberra: Commonwealth of Australia 2007. [18] Dennis SM, Zwar N, Griffiths R, et al. Chronic disease management in primary care: from evidence to policy. Medical Journal of Australia 2008;188(8 Suppl.):S53–6. [19] Australian Institute of Health and Welfare. Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004–05. Canberra: AIHW; 2008. [20] Keys, Young. Aboriginal and Torres Strait Islander peoples’ access to Medicare and the PBS across Australia 1997. [21] http://www.health.gov.au/internet/main/publishing.nsf/Content/ pacd-medicare-healthchecks-questions.htm (accessed January 10th 2009). [22] Agranoff R. Managing within networks: adding value to public organizations. Washington: Georgetown University Press; 2007. [23] Mandell MP, ed. 2001. Getting results through collaboration. Networks and network structures for public policy and management. Westport CT: Quorom Books. [24] Sullivan H, Skelcher C, Working across boundaries: collaboddddration in public services. Basingstoke: Palgrave Macmillan 2002. [25] Clarke M, Hunter DJ, Wistow G. For Debate Local government and the National Health Service: the new agenda. Journal of Public Health 1997;19:3a. [26] Ansari W, Phillips C. ‘Partnerships, community participation and intersectoral collaboration in South Africa.’ Journal of Interprofessional Care 2001; 15 (2): 119–132. [27] Lewis JM. Partnerships, primary health care and health inequalities: problems and possibilities. Australian Journal of Primary Health 2004;10:38–45. [28] Battersby M. the SA HealthPlus Team (2005) ‘Health reform through coordinated care: SA HealthPlus.’ British Medical Journal, 330; 662–665. [29] Hultberg E, Glendinning C, Allebeck P, Lönnroth K. Using pooled budgets to integrate health and welfare services: a comparison of experiments in England and Sweden. Health and Social Care in the Community 2005;13:531–41. [30] Local Evaluation Team. Jirntangku Miyrta Katherine West Coordinated Care Trial Local Evaluation. Final Report. Darwin: Menzies School of Health Research 2000. [31] Baeza JI, Lewis J, Indigenous health organisations in Australia: connections and capacity. International Journal of Health Services, in press. [32] Anderson I, National strategy in Aboriginal and Torres Strait Islander Health: a framework for health gain? VicHealth Koori Health Research and Community Development Unit: Melbourne 2002. [33] Nolte E, McKee M. Caring for people with chronic conditions: a health system perspective. Maidenhead: Open University Press; 2008.
J. Baeza et al. / Health Policy 92 (2009) 211–217 [34] Pruit S, Epping-Jordan J. Preparing the 21st century global healthcare workforce. British Medical Journal 2005;330:637–9. [35] Mooney G, Houston S. An Alternative approach to resource allocation: weighted capacity to benefit plus MESH infrastruc-
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ture. Applied Health Economics & Health Policy 2004;3:29– 33. [36] http://www.health.gov.au/internet/ministers/publishing.nsf/ Content/mr-yr08-nr-nr104.htm (accessed 5th February 2009).
Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
Care for chronic conditions for indigenous Australians: Key informants’ perspectives on policy Juan Baeza a,∗ , Ross Bailie b , Jenny M. Lewis c a
King’s College London, Department of Management, School of Social Science and Public Policy, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, United Kingdom b Menzies School of Health Research, Charles Darwin University, Darwin, Australia c School of Political Science, Criminology and Sociology, University of Melbourne, Melbourne, Australia
a r t i c l e
i n f o
Keywords: Chronic conditions Indigenous health Policy environment Australia
a b s t r a c t Background: The WHO’s 2002 global report, Innovative Care for Chronic Conditions proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions. This paper uses the policy environment component of the WHO framework as a lens through which to examine key informants’ perspectives on the management and prevention of chronic conditions in rural and remote Aboriginal communities in Australia. Methods: Twenty one semi-structured telephone interviews were conducted with a purposive sample of stakeholders, including senior commonwealth, state/territory and regional public servants and health service staff. All of the interviews were audio recorded, from which written summaries were produced. These summaries were then content analysed to build a composite picture of this area. Findings: The results indicate substantial success in developing national and sub-national strategies and refining funding and reporting arrangements. But much work remains to be done in strengthening partnerships, developing and retaining the workforce, and further shifting the focus from acute to chronic conditions. Conclusions: This paper provides a snapshot of the main policy issues, as identified by key informants, facing chronic disease management in rural and remote Indigenous communities in Australia. It has the potential to contribute to new national policy directions in Indigenous health. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The World health Organization (WHO) defines chronic conditions as health problems that require ongoing management over a period of years or decades [1]. Such health problems include cardio vascular disease, cancer, diabetes and certain mental health problems such as depression. The dramatic increase and overall prevalence of chronic conditions make these an important health policy issue [2]. The evidence on the nature of chronic conditions indicates that
∗ Corresponding author. Tel.: +44 020 7848 4634. E-mail address: [email protected] (J. Baeza). 0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2009.03.012
current health system arrangements around the world are not well suited to the effective delivery of chronic illness care [3,1]. The acute care paradigm has tended to dominate the thinking of policy makers, clinicians and managers at all levels of the policy process and the delivery of health care services [3,1]. 2. Background The WHO’s 2002 global report, Innovative Care for Chronic Conditions (ICCC) proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions [4]. The WHO’s ICCC framework splits the health system into three interlinked levels:
212
J. Baeza et al. / Health Policy 92 (2009) 211–217
Fig. 1. The ICCC framework. Source: WHO, 2002.
• Macro level: the policy environment. • Meso level: health care organization and community. • Micro level: patient interaction.
ment in Australia for tackling chronic conditions in rural and remote Aboriginal communities. 3. Methods
The focus of this paper is the policy environment which is depicted as an overarching context in Fig. 1. The WHO framework argues that it is essential to develop a positive policy environment at the macro level that provides appropriate support for effective chronic illness care in the form of legislation; leadership; integration of policies; building partnerships; financing; and human resource management. This paper examines the perspectives of key informants on the policy environment for chronic disease management in rural and remote Indigenous communities in Australia. The WHO framework is used to structure this analysis. Indigenous Australians experience a disproportionately high prevalence of, and morbidity and mortality from, chronic illness such as diabetes, renal disease and cardiovascular disease [5,6,7]. All Australians have access to primary care through general practice visits funded by Medicare [8], as well as services provided by state/territory and local governments. Indigenous people have an additional service, provided through Aboriginal community controlled health organisations (ACCHOs). Indigenous people’s access to general practice is limited, particularly in Australia’s Northern Territory (NT) where 70% of its Indigenous people live in rural and remote communities where there are few GPs [9]. With an increasing emphasis on enhancing the effectiveness of chronic illness care in some jurisdictions in Australia [10], it is timely to examine the policy environ-
This study of the policy environment was conducted within the context of an action research project on improving the quality of care in Indigenous primary health care services in Australia, the Audit and Best practice in Chronic Disease project (for more on the ABCD project see www.abcdproject.org.au). Interviews were conducted with a purposive sample of informants that included senior state and Commonwealth public servants [7], state/territory public servants [9], ACCHOs staff [6], and one health consultant (see Table 1). Two interviewees held dual roles – e.g. working in both a state department and an ACCHO, and Table 1 Interview sample. Number of interviews Commonwealth Central and state Offices of Aboriginal & Torres Strait Islander Health Central and state offices of the Department of Health and Ageing State/territory Northern Territory (NT) Department of Health and Community Services Western New South Wales Health (NSW) Department of Health, Western Australia (WA) Aboriginal community controlled health organizations Health consultant
5 2
4 2 3 6 1
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were interviewed in both capacities, so were counted twice in these figures. A total of 21 individuals were interviewed. Due to the wide geographical dispersion of this sample the interviews were conducted by telephone. The informants were selected from the three states/territories where the ABCD project was already in progress by January 2006 – New South Wales (NSW), the Northern Territory (NT), and Western Australia (WA). The aim was to examine how the current policy environment for chronic disease care in the Aboriginal sector was perceived by senior policy staff at the state/territory and Commonwealth levels and by key advocates within the ACCHO sector, providing perspectives of people who had input into policy development as well as responsibility for policy implementation. An initial sample was identified from discussions amongst the team of investigators who have extensive experience in this area, and this sample was expanded further as those who were interviewed suggested other informants. No further interviews were carried out once data saturation was deemed to have been reached [11]. The telephone interviews were carried out between March and June 2006 and were about 1 h in length. The interview schedule was semi-structured, and was used flexibly to allow informants to discuss issues that they felt were important. The interview schedule broadly reflected the policy dimensions that are identified in the ICCC framework and covered the following issues: • The information base for chronic conditions. • Current health policy for chronic conditions. • Inter and intra-agency partnerships, relationships and collaborations. • Legislative/governance frameworks for chronic conditions. • The prioritization of chronic conditions in plans. • Financial arrangements. • Workforce development. All of the interviews were audio recorded and written summaries were produced. These summaries were then content analysed in order to identify themes and thus build a composite picture from the various informants’ perspectives [12]. The study was granted ethics approval by the health research ethics committees in the jurisdictions where the ABCD study was operating and by the human research ethics committee of the University of Melbourne. 4. Results The major issues raised by these informants covered four of the six policy elements included at the macro level of the ICCC framework (strengthening partnerships; integrating policies; human resources and consistent financing) and one additional theme of policy and governance which arose inductively from the data. What is presented below is based on the analysis of the interview data. These results must be examined in the context of the sample from which they are derived. The policy environment is made up of a number of different stakeholders (e.g. politicians, public servants, service providers, the
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media, etc.) and this study examined it predominately from the perception of senior public servants and key advocates within the ACCHO sector who have extensive experience of working within this environment. These are an important group who occupy the space between politicians and the frontline health workforce. They therefore have a highly informed but particular view of the policy environment for Aboriginal chronic care. 4.1. Strengthening partnerships To promote a positive policy environment for tackling chronic conditions it is important to forge strong partnerships between the various government sectors. The ICCC framework argues that partnerships amongst the agriculture, labour, education and transportation sectors are particularly important (4:62). The interview data suggest that joint work between different departments at the various government levels (state/territory and Commonwealth) rarely occurs. There was also little evidence of joined-up work within the individual state/territory departments of health. Some informants stated that this was a difficult task to achieve that takes time and resources, both of which are in short supply in the Indigenous health sector. However, there was some evidence of joint work between education and health at the local level in both the NT and western NSW. There was also some indication of joint working between departments in the area of physical activity in the NT. Cost shifting between levels of government is a characteristic of the Australian health system. However, recent joint funding and reporting arrangements requiring one joint line of reporting for state and Commonwealth funds was seen by respondents to have eliminated this problem in NSW and provided a clear mechanism for strengthening partnerships between the state and Commonwealth level governments. Various informants from the NT and NSW stated that health based non-governmental organizations (NGOs) such as the Heart Foundation and the Cancer Council were now ready to work in an integrated way to promote the treatment of chronic conditions at the state/territory level and that this is also beginning, but more slowly, at the national level. Various informants mentioned that the Council of Australian Governments (COAG), which is the peak intergovernmental forum in Australia, agreements in various regions were initiating joint approaches in some health areas. COAG’s role is to initiate, develop and monitor the implementation of policy reforms that require cooperative action by Australian governments [13]. These data suggest that joint working was more prevalent at the local community level and less so to work at the state/territory or national levels. COAG could be seen to therefore have a potentially important role in strengthening partnerships at higher levels. Indeed, since the change of the Federal Government in Australia in 2007 (and after the completion of the interviews for this study) CAOG has proved to be a major vehicle for change, with the announcement of major partnership approaches, funding agreements and reform processes of relevance to Indigenous health and specifically chronic illness [14]. These recent COAG initiatives are rel-
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evant to a number of the other components of the ICCC Framework discussed below, including ‘human resources’ and ‘consistent financing’ 4.2. Integrating policies The Australian’s government’s National Chronic Disease Strategy [15] is a clear attempt to integrate policies to tackle chronic conditions at the national level. Developing a chronic disease strategy seems an important stage in providing more services and resources that focus on chronic diseases in an integrated way. That is, developing a strategy was not seen by informants to be just a paper exercise, but rather as being important in the allocation of funding for new positions with specific responsibilities in chronic illness care and the incorporation of such responsibilities into existing position descriptions. The approach of these strategies is practical and straight forward, which provides the services with a good basis to tackle chronic conditions [16]. Chronic disease care is mainly carried out within the primary care setting. The strategies, to varying extents, have enabled the jurisdictions to tackle chronic conditions in an integrated way encompassing prevention, promotion and control strategies as promoted by the ICCC [4]. 4.3. Human resources There are various factors that constrain services’ ability in providing good quality care to patients with chronic conditions. These limitations include the recruitment and retention of appropriately trained staff as well as certain weaknesses in staff skills in the area of chronic conditions. All the informants reported serious workforce issues, particularly in remote areas in terms of recruitment, retention and the capacity of the workforce. The informants reported difficulties in recruiting health workers into Aboriginal health services in general, and in remote areas in particular where there are many vacant positions. One informant stated that there was evidence (from the experiences in central Australia) that high quality induction and orientation programmes for health workers can improve retention of health care professionals. Recruitment and retention is not an issue that the ICCC framework addresses but is a factor that is particularly significant in the Aboriginal health context [17]. Various informants reported that most of the training of health staff occurs in the acute setting and not in primary care where most of the patients with chronic conditions reside. The result is that health professionals find it difficult to apply their skills in the chronic conditions arena, making them frustrated and depressed by its demands. The data suggest that a major issue is training in communication skills rather than any technical deficiencies, an issue identified in the ICCC framework [4]. However, other studies have reported that improvements in the quality of self management support that staff can offer could also be addressed by training programmes [18]. Education authorities at both the state/territory and Commonwealth levels have an important role to play in developing appropriate courses for primary care practitioners so that they can successfully cater for patients with
chronic conditions. However, informants from provider institutions reported having very limited influence on the educational institutions that produce health service staff. The other important human resource issue identified was the management capacity in the Aboriginal health sector. Some informants suggested that the role of the local health centre manager is crucial in setting up the systems and programs to improve care for patients with chronic conditions. Informants in all the jurisdictions stated that the development of middle management capability and capacity needs to be given a higher priority. Similar findings have been reported in the evaluation of the coordinated care trials–a series of trials aimed at improving the coordination of care for various conditions [17]. These data suggest that it has been more difficult to shift the attitudes of the regional managers than those of health centre workers. This may be due to the availability of suitable tools to deal with chronic conditions in health centres, while this is absent at the regional level. Informants in all the jurisdictions felt that there were significant problems associated with the recognition of, and award structures for, Aboriginal Health Workers (AHWs). Some suggested that the national registration of AHWs may help lift their profile. Others pointed to the problems that AHWs experienced in career progression from AHWs to registered nurse status. The ICCC framework [4] stresses the importance of non-physicians in providing good care to patients with chronic conditions; in the Aboriginal health context AHWs have a critical role to play but current conditions limit their role, and its desirability as a career. 4.4. Consistent financing In order to create a positive policy environment it is essential to have consistent and adequate financing arrangements to tackle chronic conditions. Interestingly, the general level of funding was not highlighted as a significant barrier in tackling chronic conditions. This is not to say that the Aboriginal health sector is well funded as various reports have highlighted the low levels of Aboriginal health funding when compared to mainstream health services [17,19]. The informants’ discussion of funding centred on a lack of capacity in the Aboriginal health sector that prevented it from effectively absorbing the large increase in Aboriginal health funding that is needed: They focussed on the barriers associated with the low numbers of appropriately skilled staff. The coordinated care trials evaluation also reported that ACCHO board members could be helped in better executing their roles by appropriate education initiatives. This illustrates the fact that targeted education programmes are needed for health service managers as well as health care professionals in order to allow them to deliver better chronic care to their populations[17] ×.. Funding arrangements, particularly through Medicare (the Australian universal health insurance system), were highlighted as a significant problem by most informants in the various jurisdictions. Many of them considered Medicare as a virtually inaccessible resource for Aboriginal communities who get far less than non-Aboriginal communities in this kind of funding [17,20]. This funding
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source is fee for service based for GPs and so is essentially uncapped. It could potentially provide ACCHOs with a greater degree of financial flexibility, so the fact that this does not occur effectively within Aboriginal communities represents a major barrier to the provision of positive care for chronic conditions in these communities. Another problem that informants highlighted was that Medicare is ill-suited to funding the treatment of chronic disease because it focuses so heavily on general practitioner (GP) payments. The ICCC framework makes it clear that care in the area of chronic conditions is often best carried out by non-physicians; a financial reimbursement system that favours GP provision is a serious barrier to others. Recent efforts to enhance the potential of Medicare to support chronic illness care for Indigenous Australians, such as the introduction of the Adult Health Check [21], fail to adequately address these key limitations. The problems associated with the funding structure of Aboriginal health services which involve various funding streams from the state and commonwealth governments was mentioned as a constraining issue for various health services. However, there was evidence of progress in this area as OATSIH has instituted some changes that attempt to move away from the ‘body part funding’ that provides money for discreet health areas, to a more holistic method of funding which encourages integrated health policy initiatives. Other initiatives which provide pharmaceutical funding to remote Indigenous services as compensation for relatively poor access to Medicare and funds for medicines are recent positive developments. Notwithstanding these initiatives, the Australian health system’s complex financing arrangements were seen to continue to pose challenges for Indigenous health services. 4.5. Policy and governance An important issue that was raised by most informants related to the capacity of Aboriginal health services to respond to the increasing demands of chronic diseases. Informants felt there was a need to increase the capacity of Aboriginal services to allow them to influence mainstream organizations and develop the leadership of the Aboriginal sector to facilitate their meaningful engagement in policy development, implementation and governance arrangements. These findings resonate with the evaluation of the co-ordinated care trials which also highlighted the fact that investment in training and education on governance processes in the chronic care area had a positive impact on community capacity building in remote Aboriginal communities [17]. 5. Discussion It is evident that while there have been some significant successes, there is potential for further developments to strengthen the policy environment for chronic illness care for Indigenous Australians. While there have been significant developments since the change of government in 2007, the impact of these policy initiatives on the ground will take some time to bear fruit and will require some significant
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challenges to be addressed if their potential is to be fully realised. The difficulties of strengthening partnerships between government departments and the lack of collaborative work to tackle chronic disease both within and between government departments were highlighted by a number of informants. For collaboration to occur between and within departments there need to be clear incentives for all those involved [22,23,24]. The difficulties involved in the joint working process should not be underestimated [25,26]. Collaboration is not a free good; it needs to be properly resourced [27]. Pooled budgets between state departments (e.g. health and education) and between state and commonwealth departments may be one way of supporting collaborations at the various levels [28], although internationally the evidence of success is mixed [29], there have been some signs of success in the Australian Indigenous primary care context [17,30]. Pooled budgets more broadly may also be an effective mechanism for shifting resources from the acute health sector into tackling chronic diseases. As well as strengthening the links between primary and secondary care, the connections between the Aboriginal health sector and the mainstream health sector also need to be properly supported [31]. The creation of departments such as OATSIH has benefited Aboriginal health [32] but such arrangements can either help or hinder the building of strong connections between Aboriginal health and mainstream health. The ICCC framework suggests that a multisectoral governing body should be implemented in order to advocate for the better provision of chronic conditions care ([4],72). This suggestion resonates with the findings of this study. In this study, it seems that workforce problems were associated with difficulties in recruitment and retention, a problem that others have also reported [33]. The other major workforce issue that was raised by the informants was the negative attitude towards chronic disease from some clinicians. Tackling chronic diseases requires a different set of skills to those required for acute health care; a paradigm shift is needed amongst health care professionals [34]. For some years the WHO has recognized that current educational programmes are inadequate for health care workers who are increasingly caring for patients with long-term chronic conditions [4]. Appropriate staff training for both clinicians and managers could tackle this issue in the short and medium terms. However, a positive policy environment can only occur in the long term by building partnerships between the health and education sectors to enable discussions to take place to address these important issues. The WHO’s ICCC framework advocates the creation of joint committees between education and health sectors so that a common understanding of what the medical/health education needs are can be reached ([4]: 73). This again fits with the findings of this study. The relative lack of Indigenous health funding through Medicare and the Pharmaceutical Benefits Scheme presents a major barrier to promoting consistent financing because service utilisation is not automatically linked to funding [19]. A complicating factor that the data highlight is the service capacity problems within the Aboriginal health sector, which acts as a constraint and prevents
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the sector from effectively using any possible increases in funding. This indicates that the first step is to make investments in the capacity of the Aboriginal health sector that will then enable the sector to provide a more effective health service for their population [35]. Leadership and advocacy featured in the informants’ accounts in relation to the limited number of staff with appropriate skills in the Aboriginal health sector, which constrains its influencing capacity within the wider health arena. Leadership and advocacy have played a very significant role in the evolution of Indigenous health services in Australia in the past, and so it is interesting that this aspect of the ICCC Framework received attention from the informants. The ACCHO staff included in the study sample were themselves leading advocates for this sector. An aspect of policy which emerged from this study and which could be more clearly identified as a policy issue within the ICCC Framework is that of promoting effective governance. Building effective local governance capacity for ACCHOs has received significant attention, but remains an important area for development. Within government health authorities, capacity of middle management has also been identified as a limiting factor in improving chronic illness care and should be a stronger focus for development. Also not clearly articulated in the ICCC Framework (or by the informants) is the potential for integration of aspects of policy, for example of policy on information systems to support policy on governance and vice versa, policy on financing to support appropriate workforce development, and financing to support partnerships. This study provides a summary of critical areas for policy development in chronic disease management in rural and remote Indigenous communities, as identified by key informants. It indicates how the ICCC framework can help structure an analysis of the policy environment, and how it might be improved by a stronger focus on workforce recruitment and retention, and governance at different levels within the system. This paper has the potential to contribute to newly emerging directions in Indigenous health policy in Australia, being led by the recently established National Indigenous Health Equality Council [36]. Acknowledgements The ABCD project is supported by funding from the Cooperative Research Centre for Aboriginal Health and the Commission for Safety and Quality in Health Care. RB’s work is supported by NHMRC Fellowship #283303. The authors would like to thank all those interviewed for generously giving up their time to participate in this study. References [1] World Health Organization. Human resources and national health systems. Shaping the agenda for action, Geneva: World Health Organization 2002. [2] Horton R. The neglected epidemic of chronic disease. The Lancet 2005. [3] Smith R. Improving the management of chronic disease. BMJ 2003;327:12. [4] World Health Organisation. Innovative care for chronic conditions: Building blocks for action: a global report. WHO Press: Geneva 2002.
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