This paper describes MIH care at two different points in time and reports the results of a collaborative health service redesign and a program of research aimed at health system reform. Researchers have worked alongside the NT Department of Health as they have developed policies and led reforms. The partnership between the research team and the Department of Health enabled evidence-informed improvements to health service delivery to be made. Our response to industry partners is exemplified by the latest sub-study conducted at the request of a leading NT clinician into the reasons for neonatal admissions to the nursery to benchmark and compare these nationally and clarify that these high rates of admission were all necessary (paper under review). Further publication and analysis of services conducted in the final year, with a focus on evaluation of improvements, is in train. Some reform has been successful, such as changes to models of maternity care showing positive outcomes , however improvements to infant care are urgently required.
Our program of work has identified continuing problems with infant service delivery that should be addressed at the institutional level. Practices such as adhering to evidence-based guidelines, attaining accurate enumeration of births for remote areas and organising staffing and skills around known workload and morbidity levels need to be implemented. The sub-study of service utilisation observed that one-third of neonates from the communities were admitted to the special care nursery  at rate more than twice the national average . Aboriginal infants are already compromised at birth with a birth weight nearly 186 g less than other Australian babies , more so if the mother smokes (nearly 250 g lighter) . The qualifications required of staff working in this area must be addressed institutionally as almost all nurses working with infants and children were insufficiently prepared to work in this specialised area . Improvement is also needed to the organisation and delivery of infant and child health care with a more supportive and continuous relationship with parents a priority.
It seems that teenage pregnancy is common in the NT, however problems usually associated with Aboriginal teenage births (such as LBW) are not due to maternal age, but rather related to the underlying poor health, socioeconomic disadvantage and a system that is challenged to support these young women, both culturally and medically. There is a need to use specific indicators, drawn from routinely collected data and our research, to inform and more accurately reflect the performance of health services and Aboriginal health status in this setting [25–27].
Our remote fieldwork identified a service that is dominated by acute presentations, rather than a community-engaged primary health system that promotes community, family health and well-being. Health system deficiencies in knowledge, recognition and support of local culture and child-raising need remedying to allow staff to be effective in promoting health and building resilience with parents of vulnerable infants . Reforms to service design such as extending the continuity of care model now employed by designated midwives and the MGP into child health would enable staff to work alongside women and families. Similarly, respectful informed relationships with community leaders, focused on parenting and working together, could address the seriously inequitable outcomes of Aboriginal infants.
Coordination of care between remote and regional services, particularly information sharing and communication, remained poor but is improving with the use of electronic information systems relatively recently introduced. Further improvement could occur by making MGP midwives responsible for discharge summaries with phone handovers (prior to discharge) to the care provider in the community. Computer based information systems for MIH could monitor adherence to clinical guidelines centrally, highlight abnormal health findings and encourage appropriate responses from remotely located care providers. This is particularly important in infant care and child health where staff lack formal knowledge and skills considered essential for employment in other areas of Australia.
Funding of current services is an additional challenge. There are very few universal health care payments or Medicare reimbursement items that the NT government can claim against to gain refunds from the federal government for providing these services. In addition there are very few private practitioners working in remote Australia who can generate additional Medicare revenue . Eligible midwives, who can claim against the national insurance system, are also currently underutilised in remote areas and, as with general practice, the relative numbers of uninsured and poor clients make a private practice model problematic except in very large remote communities.
Broadly based programs of work that aim to measure and describe the complex ‘real world’ of health services behavior and system improvement pose significant challenges in terms of designing, synthesising and reporting the results. A mixed-methods approach has enabled us to grapple with this complexity. Scrutiny of design occurred through highly regarded peer-reviewed funding mechanisms. The methodological rigour of our designs, and therefore the validity of the results of this synthesis are further demonstrated by the peer-reviewed publications from each sub- study.