Transparency and accountability: theory and practice

The ANAO today released a report into Primary Healthcare Grants under the Indigenous Australians’ Health Program (link here).

The report identified a range of shortcomings, more misdemeanors than major issues. I don’t propose to provide a summary or detailed analysis as the report largely speaks for itself. I particularly commend it to readers interested in Indigenous health administration issues.

Notwithstanding its critical content, I confidently predict that the various issues identified, the ANAO report will garner very little media coverage or even Senate scrutiny.

In reading the report, however, one particular issue caught my attention, and it sparked an observation which is perhaps worth noting since it opens a window on to a much larger dynamic which can operate in the APS. This dynamic is where Ministers push the boundaries, public servants don’t see a way to hold the line, and ultimately it is Departments which are exposed as not meeting appropriate accountability norms.

Amongst its various findings, the ANAO uncovered the following issue. Included in comments on the lack of value for money assessments on a billion dollar round of funding, the ANAO also noted at para 16:

The department was also unable to provide evidence it had undertaken a value for money assessment regarding the $114 million grant to the Northern Territory Government. In virtually all cases, risk assessments formed part of the assessment process.

Later in the report, the ANAO provided more information:

2015 Northern Territory government grant

3.13 The Northern Territory government had been funded under pre-IAHP grant programs for the provision of primary healthcare to Indigenous Australians, mostly through clinics in remote areas. As part of seeking Ministerial approval about the funding process under the IAHP, the department advised the Minister that it would only make a formal offer of a grant following receipt of a specific grant proposal and undertaking a value for money assessment against the ‘deliverables’ in the proposal. The Minister approved this approach in mid May 2015.

3.14 No specific departmental assessment plan or selection criteria was developed for the Northern Territory grant. The department contacted the Northern Territory Department of Health on 26 June 2015 to request that it provide a proposal. Departmental records indicate that a formal offer of a $114 million funding agreement to the Northern Territory Government was made on 6 August 2015, before the proposal was received on 15 August 2015. A funding agreement was signed in October 2015. The department was unable to supply the ANAO with evidence that it had undertaken value for money or risk assessments of the proposal.  

The ANAO, whose remit is the operations of Departments and not Ministers, leaves the impression that this was largely an oversight on the part of the Department.

My own experience working within Government tells me that Departments rarely take decisions on these sorts of matters without clear authority from Ministers. There may or may not have been evidence on the file, but it would be a severely career limiting move for a public servant to act without ministerial authority on a grant to a subsidiary jurisdiction such as the NT. Instead, what we have is a ‘mistake’ by the Department, and when caught out by the ANAO, the Department expresses contrition, agrees with the ANAO recommendations, and resolves to do better in the future.

If my supposition is correct, (and I emphasise, it is merely supposition), this would tell us a number of things.

First that the NT Government of the day was apparently so incompetent that they could not develop a timely funding proposal making the case for Commonwealth funding.

Second that there may have been formal or informal signals from ministers to ‘just get on with it’.

Third, that in such circumstances the senior bureaucrats in the Health Department at that time may have felt unable to stand up to the Minister. The provision of frank and fearless advice seems increasingly rare in the highly politicised (with a small p) world of public policy administration in Australia, and this may well have been another instance.

Fourth, that there may have been electoral considerations in play as the timing of the decision to grant the funds to the NT was in the year before an NT election. The then CLP Government, headed by Chief Minister Adam Giles, was closely aligned with the Nationals. The Federal Health Minister at the time was Peter Dutton; the Assistant Health Minister was Nationals Senator Fiona Nash.

Fifth, that if the Senate Estimates Committees are doing their job, we could expect that there would be direct questions at the next hearings directed to determining whether there was ministerial involvement in the Department’s decision to prematurely offer the funds to the NT Government. And if not, what action was taken to counsel the officers involved in making the premature offer without a value for money assessment.

To sum up, what we appear to have with this audit is a good degree of transparency, courtesy of the efforts of the ANAO, but limited or non-existent accountability. There was merit in the traditional Westminster notion that Ministers are responsible for the actions of their Departments. Ever since that notion lost effective traction, accountability standards within Government have gone downhill. And the voting public and taxpayers are the losers. In theory we have accountability, in practice we don’t.

Budget prophylaxis: the RACP pre-budget submission and Indigenous sexual health

The Royal Australian College of Physicians has released its pre-budget policy submission for the 2018-19 budget (link here). The RACP pre-budget submission includes sections on a range of key health issues including Indigenous health.

The May budget may appear to be over the horizon, but work will have already started within government on developing the budget. Agencies will have developed and costed proposals, Ministers will be sieving and choosing which proposals to take to the Expenditure Review Committee of Cabinet (ERC). The Department of Finance will shortly provide agencies and Ministers with various budget parameters and rules for considering the proposals. Cabinet may have set down the broad parameters within which proposals for new spending will be considered, including the levels of off-setting savings required for each proposal. And soon ERC will begin its more intensive rounds of meetings.

The bottom line is that there are no free lunches. Every program is vulnerable to be included on a Finance Department hit list of potential savings. Every budget proposal undergoes a process of multiple review and sieving, is critiqued by the Finance Department, and then more formally by ERC. To be successful, it needs to be rigorously developed, have identified offsetting savings, outshine competing claims from within the relevant agency, be supported by the relevant Minister, and then be supported by ERC which requires that it be aligned with the Government’s overarching budget and policy strategy.

The publication of pre-budget submissions by advocacy groups and peak bodies thus operate to raise the public profile of key issues, and can assist a minister in arguing for his or her new spending proposals by pointing to external support for particular initiatives. Unfortunately, too often these submissions come too late, or fail to be backed up with more intensive media follow-up by the authors. As a result, they can often be entirely ignored by government.

I thought I would use the release of this submission to draw attention to sexual health within the Indigenous community as a policy issue which demands greater attention and understanding both in the general community and within the Indigenous community. It is a topic I know very little about, but recognise as one which is of increasing significance and concern given the youthful demographic profile of the Indigenous population nationally.

The RACP pre-budget submission has this to say (footnotes excluded):

Sexual Health

There continue to be ongoing outbreaks of infectious syphilis across Australia affecting Aboriginal and Torres Strait Islander people, which has occurred in the context of increasing rates of other Sexually Transmitted Infections (STIs) and some Blood Borne Viruses (BBVs) in some Aboriginal and Torres Strait Islander communities. STIs are endemic in some regions; an unprecedented syphilis epidemic in Queensland began in 2011 and extended to the Northern Territory, Western Australia and South Australia.

Since 2011 there have been six fatalities in Northern Australia from congenital syphilis, and a further three babies are living with serious birth defects in the Northern Territory. In addition, there has been one reported case of congenital syphilis so far in 2017 in South Australia. Despite the existence of a number of Federal and state-level sexual health strategies, the situation remains dire.

Appropriate funding needs to be allocated to the implementation of the Fifth National Aboriginal and Torres Strait Islander Blood-Borne Viruses and Sexually Transmissible Infections Strategy and sexual health services; particularly to ensure sufficient capacity for the delivery of core STI/BBV services within models of care that provide comprehensive primary health care services (particularly Aboriginal and Torres Strait Islander community controlled health services). People should have access to specialist care when needed, through integration with comprehensive primary health care services to ensure sustainable and culturally appropriate service provision.

We welcome the plans to activate a short-term response across the state and territories on the continuing syphilis outbreaks, coordinated by the Federal Department of Health. However, whilst this Action Plan and short-term funding is urgently needed; the short-term activities need to be coordinated with and contribute to longer-term strategies and investments.

The RACP recommends [inter alia] that the Australian government:

• Allocate sufficient funding for the implementation of the Fifth National Aboriginal and Torres Strait Islander Blood-Borne Viruses (BBV) and Sexually Transmissible Infections (STI) Strategy.

• Fund the syphilis outbreak short-term action plan and coordinate this response with long term strategies.

 • Allocate long-term funding for primary health care and community- led sexual health programs to embed STI/BBV services as core primary health care (PHC) activity, and to ensure timely and culturally supported access to specialist care when needed, to achieve low rates of STIs and good sexual health care for all Australians.

• Invest in and support a long-term multi-disciplinary sexual health workforce and integrate with PHC to build longstanding trust with communities.

• Allocate funding for STI and HIV point of care testing (POCT) devices, the development of guidelines for POCT devices and Medicare funding for the use of POCT devices.

These recommendations appear sensible and quite modest, but also contain quite sobering information, which is made more concerning by the reality that the sexually active cohort of the Indigenous population is information poor. Yet with appropriate behaviour modification and/or treatment, most of these issues are or would be avoidable.

If I have a criticism of the RACP submission, it is that it provides no information on what the RACP would consider to be adequate funding for the various actions and initiatives it is proposing. There is a sense in which the RACP has abdicated the issue of funding adequacy to the government, and decided to focus solely on identifying issues which require prioritisation. I understand this as a pragmatic strategy, but remain sceptical that funding adequacy can be a victim of political rhetoric and spin.

Nevertheless, the RACP has done the public a service in identifying the health priorities it has. Their submission includes a range of other Indigenous related issues, as well as a larger number of mainstream health issues (many of which are highly relevant to Indigenous citizens’ health too). I recommend readers have a quick look at the RACP submission.

My suggestion is that it would be useful if post-budget, the RACP released a short assessment of the Government’s budget decisions in the health area along with a checklist of the RACP proposals and the relevant amounts allocated by the Government. I will try to have a closer look at this policy issue in future posts.

Finally I wish to acknowledge the NACCHO website for pointing me to the RACP pre-budget submission (link here).

Social determinants of health….or structural determinants of poor policy

In March 2017, the Minister for Health, Ken Wyatt announced a new online public consultation portal, with the rather obtuse tag My Life My Lead, to facilitate consultations on the social determinations of health to support the next iteration of the implementation plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-23 (link here).  The Minister’s media release included the following paragraph:

We will use feedback from the consultation portal to consider factors that impact on the social determinants of health like education, employment, justice, income and housing, as well as the important role cultural determinants play in supporting better health outcomes.

On 21 December 2017, the Minister released the report of the consultations undertaken since March (link here).

Seven priority areas have been identified in My Life My Lead, which will be integral to the next iteration of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan. It will also help inform our Closing the Gap refresh agenda,” Minister Wyatt said.

The seven priorities are: 1. Culture at the centre of change 2. Success and wellbeing for health through employment 3. Foundations for a healthy life 4. Environmental health 5. Healthy living and strong communities 6. Health service access 7. Health and opportunity through education.

The full title of the report is:

My Life My Lead - Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations December 2017.

The report is a useful addition to the policy dialogue on Indigenous affairs, and as the Minister noted, should be a useful contribution to the Closing the Gap refresh exercise currently underway. The Ministers reference to a ‘refresh agenda’ in his media release rather than a more neutral term was perhaps unwise, but let’s give him the benefit of the doubt on terminology.

The report is well written and succinctly lays out key data points on social determinants of health within a simple yet effective framework. The authors have done a good job in this respect, and this makes the report worth reading. Here is the link to the full report.

However, the substantive concern emerging from the report in my view is the complete disjunction between the title: ‘opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health’, and the sections of the report on ‘next steps’ which are invariably drafted in vague or obtuse bureaucratese, designed to sound positive, but to make no commitments whatsoever (notwithstanding the heading ‘next steps’).

I refer interested readers to the first paragraph under the heading ‘What makes this approach different?’ on page 7, and point out that there is absolutely no indication of how the government intends to implement this new ‘approach’ to the social determinants of health.  Or to take up a particular hobby horse of mine, on Indigenous housing, the report spends just three paragraphs on this issue (in the section on Priority Four: Environmental Health). I reproduce the text in full below:

A lack of adequate and functional housing and overcrowding also remains a significant impediment to improving all aspects of Aboriginal and Torres Strait Islander health. In 2014-15, around one quarter of dwellings in which Aboriginal and Torres Strait Islander people resided had major structural problems.

Furthermore, in remote areas, one in six households did not have working facilities for preparing food and 15 per cent did not have facilities for washing clothes and bedding— double the rate of non-remote areas.

Despite only making up three per cent of the Australian population, one in four clients of specialist homelessness services (24 per cent) in 2015-16 were Aboriginal or Torres Strait Islander. In addition, homelessness, inadequate housing and overcrowded housing have the potential to contribute to higher rates of Aboriginal and Torres Strait Islander people in incarceration, further exacerbating the cycle of disadvantage. (page 17)

The points made are on point, but hardly comprehensive. The relevant section on Next Steps states:

Addressing the underlying environmental health conditions that contribute to poor health outcomes in many Aboriginal and Torres Strait Islander communities will lead to long term improved health, education and employment outcomes and can be achieved by:

·         Supporting safe and secure housing;

·         A national approach to environmental health; and

·         Increasing the Aboriginal and Torres Strait Islander environmental health workforce. (page 19)

There is no indication whatsoever as to how the Government intends to address the three potential actions above, and indeed, each of the identified actions are intermediate steps which if they were to be implemented may or may not be successful depending on policy design, resources, implementation capability, coordination and collaboration, and policy commitment.

In relation to housing, supporting safe and secure housing is a no brainer. Yet there is every indication (link here) that the Government is pursuing a retrograde policy of reducing support for safe and secure housing in remote regions where disadvantage is most severe.

My Life My Lead outlines succinctly in 34 pages and 62 footnotes what we already knew. Yet it provides no substantive indication about how the Government intends to address the reality that the determinants of health outcomes are in very large measure to be found in areas outside the health domain, and worse, ignores entirely the reality that government support for those external determinants of poor health are inadequate or being wound back or reduced.

The absence of any attempt to devise a programmatic link between the target problem (in this case health outcomes) and the resources available (budget appropriations) is the major flaw in this exercise in persuading us that the Government is doing something constructive.

A similar flaw already exists in the Closing the Gap construct (link here) and is likely to be regurgitated in the outcomes of the refresh exercise currently underway.

There are two broader observations emanating from this vignette of the Indigenous policy machine at work which are worth making:

First, the effectiveness of government programs and initiatives is more complex than is generally understood, and in particular, program interventions which are aimed at changing behaviour to deliver improved outcomes depend for a large part of their efficacy on the fact that the target population is positively disposed to the intentions and approaches of government. Yet the accumulated experience of disadvantaged citizens, including Indigenous citizens, is that in relation to addressing disadvantage governments are rarely serious, are focussed on rhetoric over substantive action, suffer from endemic attention deficit disorder syndrome, are incapable of sustaining positive engagement, regularly swing toward punitive policies, and are not prepared to enter into real partnerships. In these circumstances, the production of yet another report which is strong on rhetoric but weak on substance just strengthens the cynicism and low expectations disadvantaged citizens have in relation to governments.

Second, Minister Wyatt is an Aboriginal politician with deep experience in the Indigenous health sector and an undoubted commitment to improving the health outcomes of Indigenous citizens. The fact that he oversighted the production and publication of this report is an indicator of just how deep the structural impediments to good policy making are in our public policy system.  

In other words, while the focus on social determinants of poor health and the cultural determinants of improved health are steps in the right direction, it might be time to focus much more attention of the structural and political determinants of poor policy.