Shona Bates

In many parts of the world, health systems can be described to be in a situation of crisis and are organised around sickness rather than health. Populations are aging and many people are living wit...

Objectives: To examine two decades of Australian expenditure trends across components of primary health and to assess whether recent expenditure changes have been equitably distributed. Study Type: Descriptive modelling using standardised framework for classifying primary care expenditure. Setting: Australian public and private health expenditure data (2002–03 to 2022–23) were disaggregated into: broad primary health care services (Tier A); direct primary care, predominantly funding general practice (Tier B); and funding for enhanced primary care for people with greater needs (Tier C). Distributional analysis was conducted across geographies. Participants: No individual participants; analysis used aggregated health expenditure data across 327 Statistical Area Level 3 geographies. Main Outcome Measures: Proportions of total and public expenditure allocated to each tier; equity in public Tier B and Tier C spending across areas, assessed using standardised slope indices. Results: The share of total health spending allocated to primary care declined over the period. Tier A spending declined from 36.3% to 33.0% of total health spending; Tier B fell more sharply from 8.0% to 5.5%; and Tier C remained flat at 0.7%. Public spending trends were similar, but declines were more muted, with Tier C unchanged at 1.0%. Public spending on Tier B was 13% higher in the most disadvantaged areas than in the most advantaged areas in 2013–14; by 2023–24, this declined to 7%. Public Tier C spending remained progressive at 35% higher in the most disadvantaged areas, but decreased from 51% over the decade. Exploratory multivariate analyses suggested that Tier C spending was more redistributive than Tier B after accounting for need. Conclusions: Data indicate that primary care has declined as a funding priority in relative terms in Australia, and investment in high‐value care has remained stagnant and appears increasingly less redistributive. These patterns may have implications for health equity.

Governments are seeking innovative ways to address complex policy issues in increasingly fragmented and fiscally constrained service contexts. Co‐governance is a relatively new mechanism for facilitating collective decision‐making between government and other stakeholders. Effective co‐governance can be difficult to establish and resource‐ and time‐intensive to implement. This article presents findings from a study that aimed to develop a model for implementing effective co‐governance—relevant to both government and non‐government stakeholders. First, we developed a conceptual model of the co‐governance process based on a review of the literature. We then tested it in three very different co‐governance arrangements in Australia. Cross‐case analysis identified the drivers and process of co‐governance, components within each stage of the process, and factors that enabled its implementation. The model of co‐governance developed has practical application by guiding the implementation and evaluation of co‐governance and serving as a platform for future research. Points for practitioners: Co‐governance—government and community sharing decision‐making—is being used to respond to complex issues but is not well understood. We develop an evidence‐based model of co‐governance using three Australian case studies. The model describes when to consider co‐governance, such as addressing complex, long‐term issues, where there are fragmented responsibilities, and where there is low trust. The model sets out the process to establish, implement, and monitor co‐governance and the factors that support this process. The model can be used by government and community organisations to consider whether co‐governance is appropriate and, if so, how to implement it. The model can also be a platform for future research.

This is one of three case studies that form a larger project to identify methods to operationalise and implement co-governance arrangements. This project is being undertaken by the Social Policy Research Centre (SPRC), UNSW Sydney, funded by the Australia and New Zealand School of Government (ANZSOG) and the NSW Government. This case study documents the process of designing and proposing to establish a co-governance arrangement for the enduring National Disability Data Asset (NDDA) by the NDDA Pilot Disability Advisory Council (Pilot DAC). The National Disability Data Asset Pilot project that led to the implementation of the NDDA ran from 2019–2021 (see Box 1 for a description of the NDDA). The pilot involved six participating jurisdictions and was delivered by a National Project Team (hosted by the NSW Department of Premier & Cabinet) and a Technical Project Team (hosted by the Australian Institute of Health and Welfare). The Pilot DAC was established in 2020 to advise on the acceptability of the proposed NDDA; however, its scope and the mechanism to deliver this scope, over time grew into a process that had some of the practices that we may expect to see in co-governance arrangements – the key difference being the membership of the group did not include government representatives and it had been established by Ministers as an advisory council, hence this is not co-governance as defined by this project. The Pilot DAC was tasked to deliver recommendations to government on how the asset should be used and any governance or safeguard arrangements that should be in place to build and maintain public trust in the asset. Much of the work of the Pilot DAC occurred during the second half of 2021; Pilot DAC made its final recommendations to government at the completion of the pilot at the end of 2021.