Indigenous health performance measurement systems in Canada, Australia, and New Zealand

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The worldwide use of health performance measurement has emerged over the past two decades. Health service managers try to improve effi ciency and outcomes by linking cycles of evaluation to clear and measurable objectives. The World Health Organization (WHO) has defi ned three principal goals for health-care systems as: contributing to good health, responsiveness to the expectations of the population, and fairness of fi nancial contribution. In Canada, Australia, and New Zealand, the extent of Indigenous health disadvantage is well documented. Accordingly, expectations that the development of health performance measurement systems in these nations would give some priority to Indigenous health are reasonable. We discuss here the issues in health performance measurement systems in Indigenous societies within a human rights framework. Our research group examined information systems for Indigenous health in Canada, Australia, and New Zealand, through an extensive, country-specifi c review of both published and unpublished resources, as well as key informant interviews with national, regional, and community health measurement stakeholders. We asked national, regional, and community-level health information specialists and policymakers what health performance measurement systems are used, and how these systems relate to community-based health services and Indigenous peoples’ defi nitions of health. In our thematic analysis, we examined the underlying goals, processes, and contexts of existing Indigenous health measurement systems. We also looked for examples of best practice. Our inquiry identifi ed some advances in the development of Indigenous health performance measurements systems. However, we also identifi ed some important gaps, especially in the development of local and regional information systems and feedback to these systems, as well as in the processes for Indigenous input, including the application of Indigenous-specifi c frame works and indicators. The underlying intent of macro performance measurement systems varies, but includes the fi nancial accountability of programmes and services, political management of programmes, monitoring of the performance of services, and the development of capacity at a programme level. Macro refers to aggregated national or large regional systems. Some key informants felt that despite the often repetitive and lengthy service reporting, feedback processes remained inadequate, especially at community level. For example, our key Canadian informants reported that, in general, data are not compiled and fed back to either the health-care services or to the Indigenous communities from which they came. In New Zealand, key informants indicated that although the national Ministry of Health gathers Māori health data against a long list of indicators, much of those data are not used or fed back to the local level to inform Māori health-care planning and decision-making. Australia now produces a report every 2 years that collates performance data and indicators across a range of Aboriginal and Torres Strait Islander health-care and community service programmes. More importantly, the Australian Federal Health Department, has, since 2001, collaborated with the National Aboriginal Community Controlled Health Organisation on the analysis and publication of performance data from the health-care sector controlled by the Aboriginal community. All three countries have evidence of consultation with Indigenous people in the development of performance measurement systems. In Canada, the Aboriginal Health Reporting Framework process claims to centralise Indigenous consultation. However, the process is clearly driven by federal, provincial, and territorial accountability; is chaired by federal and provincial government representatives; and seeks to identify pan-Indigenous macro-level indicators. In New Zealand, the Ministry of Health held a Viewpoint of community meetings in 2004 to discuss what monitoring framework should be used nationally for Māori health. He Korowai Oranga, the national strategic framework for Māori health, was chosen. This framework can recognise both universal indicators of health such as mortality and disability, and Māori-specifi c indicators such as social determinants, secure cultural identity, and control over one’s destiny. The development of He Korowai Oranga included consultation meetings and written submission as methods of gaining Māori input. In Australia, a collaborative planning strategy has been developed for Aboriginal and Torres Strait Islander health that enables input from Indigenous service stakeholders into all levels and aspects of health system develop ment. Yet, opportunities for input from Indigenous Australian stakeholders outside of health or other community services are few. In all countries, some level of Indigenous involvement in the development of macro health systems has been achieved. Although eff ective consulta tive mechanisms are important, they should not divert attention from the necessity of enabling the development of local measurement systems that are Indigenous-driven. In Canada, several Indigenous groups responded to the gap in local Indigenous health information system Lancet 2006; 367: 2029–31