Community health in Victoria: a history of challenges, adaptations and potential

Introduction

The Australian National Community Health Program (CHP) was introduced in 1973, ‘to encourage the provision of high quality, readily accessible, reasonably comprehensive, coordinated and efficient health and related welfare services at local, regional, state and national levels’ (Interim Committee of the National Hospitals and Health Services Commission 1973). Although offered nationally, Victoria, New South Wales (NSW) and South Australia (SA) in particular embraced the program and established networks of community health services in their states using different models.

In NSW the funding was used principally to establish or enhance services staffed by state government employees and operated through the state government regionally based health system, later local health districts. Community involvement was minimal and there was no community management or advocacy. Few services included primary medical care. In Victoria and SA, more of the funding was used to establish non-government operated multi-disciplinary primary healthcare services that emphasised community engagement, management and advocacy around the social determinants of health, with some using salaried doctors despite opposition from the Australian Medical Association. A range of other activities were funded across all states, including domiciliary care services, multi-disciplinary training for health professionals and evaluation capacity building.

After the cessation of the 1973 national CHP by the Fraser Liberal government in 1981, the goverments of Victoria, NSW and SA continued to fund their community health services; however, in 2004, SA community health centre boards were replaced by regional boards, and in 2012 when the Review of Non-Hospital Services (McCann 2012) was accepted, the SA government withdrew support for the program as it then operated, dropping the community development, health promotion and prevention focus and pursuing a more clinical model. NSW continued government-controlled community health services, however, the operation and focus of these varied greatly depending on different Local Health District priorities. In 1983, following the election of the Hawke Labor government, funding for community health services was restored to the states to the pre-Fraser figure but nationally rolled into federal–state general healthcare funding grants. A review of the CHP in 1986 by the Australian Community Health Association (ACHA) commented that, ‘Only Victoria could clearly indicate what happened to its original Program after absorption in general revenue sharing’ (Australian Community Health Association 1989). This statement remains true in 2025; Victoria is the only state in Australia that retains a non-government community health sector that started with the Whitlam CHP (Lewis et al. 2022).

In Victoria, two models of community health service have evolved over time and continue to operate in 2025. Fifty-five services are referred to as integrated community health services and operate as part of hospital networks. They offer a range of services, with a focus on programs to reduce hospital presentations by strengthening links to community-based care. Twenty-four services are described as ‘stand-alone’ or registered community health services, operating independently of the government as companies limited by guarantee. In 2025, the Victorian Government continues to fund community health services through a CHP for delivery of allied health, counselling and community nursing services for priority populations and for health promotion to local communities. All community health services are provided with and compete for funding for a range of other programs, with some of the large registered community health services having up to 60 different funding sources and offering a very wide range of services and programs.

This paper focuses on the history of generic community health services in Victoria, particularly the 24 in the category of ‘stand-alone’ or registered community health services. This research is part of a larger Australian Research Council (ARC) funded research project on the history of community health in Australia from 1970 to 2022. The ARC project sought to understand the political and institutional dynamics that affected the introduction and evolution of the CHP in Australia, particularly Victoria, NSW and SA, including the facilitators and barriers to the wider development of community health and the full implementation of the primary healthcare model. The current project explored the factors that have shaped Victoria’s community health sector, the challenges faced by the sector and the strategies or adaptations that have contributed to survival of the sector in Victoria.

Methods

Semi-structured oral history interviews were conducted with 84 people from June 2021 to March 2023. Interviewees had been involved in community health in Australia in a variety of roles since the 1970s, with a focus on services in SA, Victoria and NSW. Interviews using a semi-structured interview guide were conducted by all authors and collaborators on the larger research project, all of whom were experienced qualitative researchers. Full transcripts were produced and checked by interviewees. Additionally, 122 community health related policy documents and over 100 pieces of archival material from the 1970s onwards were collected and analysed. Analysis also included nine transcripts from oral history interviews conducted in 2017–2018, bringing the total number of interview transcripts to 93.

Interview data for this study came from 29 Victorian key stakeholders. Transcripts were analysed using a qualitative descriptive approach (Neergaard et al. 2009; Sandelowski 2010) with a focus on describing (1) challenges faced by the sector and (2) factors or actions that were perceived to support the continued existence of the sector. While the interview guide included some questions addressing these topics directly, challenges and facilitators were identified by interviewees in response to many questions, and relevant information was sought across the interviews. Transcripts were read by all authors. Summaries of the range of challenges and supporting factors described by interviewees and quotes representing them prepared by JM were reviewed by all authors to confirm the descriptions were comprehensive. A range of policy documents and archival material was reviewed by the authors to provide contextual information. The synthesis of data into the narrative was developed through discussions between all authors, all of whom had their own experiences of community health.

Interviewee quotes are included in the Results section, including the name of the interviewee where consent was given to be identified.

Results

When the Whitlam Labor government established the CHP in 1973, Victoria had a Liberal government, headed up by Dick Hamer with Alan Scanlan as health minister. Interviewees noted that Scanlan and George Rogan, the Secretary of the Health Department, were fiercely opposed to Whitlam and determined not to accept any Whitlam money; however, under the Victorian Hospitals and Charities Act 1922 (Hospitals and Charities Act 1922), non-government incorporated health services were able to receive direct government funding so their views did not impede the roll-out of the CHP. Some non-government health services were already established, such as the Collingwood Dispensary, the Trade Union Clinic and Research Centre in Western Region, and the Queenscliff and District Community Health Centre.

Through organisations like these, Victoria had a long tradition of separately incorporated healthcare organisations with volunteer committees of management, notionally elected by ‘contributors’. The struggle to set up the first community health centres (CHCs) under the Whitlam CHP was therefore able to build on a tradition of volunteer management and less government control and use a pre-existing legislative framework (not present in NSW) which could be adapted to community managed incorporated health centres. The community response to the Liberal State Government’s opposition, stoked in part by Australian Labor Party (ALP) branches, saw the creation of local community health groups organising with a view to applying for direct funding from the Australian Government to establish CHCs. Despite the opposition of the Secretary of the Health Department, the semi-autonomous Hospital and Charities Commission was willing to assist in the incorporation of the new CHCs in accordance with the requirements of the Hospital and Charities Act which it administered.

Victoria has always, in health and community services, seen a role for non-government organisations. And it has been part of the culture and part of the values across political and the public sector. (Paul Butler, senior public health executive)

Victoria has a different culture from NSW. Community development and consumer-led movements are more Victoria … Victoria tended to use the social development model of health rather than simply service delivery. (Helen Szoke, health consumer advocate)

There was something different in Victoria. Not sure if it was no convicts, central ALP control (in NSW) or the communist party organisers in Victoria – great capacity to organise. (Rennis Witham, ex CH CEO, Board member and CH advocate)

Community health services in Victoria were often established through the actions of left wing or other community activists. Services were localised and established largely in response to community advocacy. Services also had partnerships with a range of influential organisations such as the Victorian Council of Social Services (VCOSS), the Victorian Healthcare Association (VHA) and the unions. The NSW Government was happy to receive CHP funding but, unlike the predominant model of funding for separately incorporated organisations observed in Victoria and SA, maintained central control on the distribution of services and funds through their relatively new regionalised healthcare administrative structure, and staff were public servants.

The biggest difference to NSW … is the bureaucratic organisation. So we (in Victoria) had the Health Commission which allowed for independent boards, whereas in NSW it was all centralised. So in NSW it wasn’t going to happen even if they wanted it to because it was all run centrally, whereas in Victoria the history was of independent boards of health services – hospitals, until community health came along. So they had their own boards and were all accountable to the community. (Rennis Witham)

NSW called it community health, but community health centres were outposts of hospitals and the health department and only did health. (Tom Roper, Minister for Health in Cain Labor government)

Interviewees reported that the Hamer 1972–1981/Thompson 1981–1982 governments were more comfortable with progressive social policy that was consistent with the operation of community health services. With the Australian Government providing the funding, the Victorian Government allowed services to flourish. In 1976, Victoria proposed 149 ‘projects’ under the CHP. Twenty-one of these were ‘main CHCs (including primary medical care)’ – non-government services, largely community managed. Of the 727 CHP national projects described in 1976, Victoria was more focused on health centres and less on things such as health workforce education and training or aged care (Australian Community Health Association 1989). Of 58 ‘main CHCs (including primary medical care)’ established through the CHP nationally, 21 were in Victoria.

In Victoria, many health centres were established with the active involvement of local members of parliament, usually, but not always from Labor; for example, David Kennedy at Eaglehawk and David Mackenzie at Plenty Valley. This had clear advantages when Labor finally achieved office. Tom Roper was heavily involved in the development of the Brunswick CHC in his electorate and subsequently became the Minister for Health with the incoming Cain Labor government. Vivien McCutchen was a community activist involved in the establishment of Richmond Community Health Centre and was married to a Labor member of parliament and later state cabinet minister. John Cain was a volunteer at the free legal service at his local CHC at West Heidelberg.

Whitlam was defeated by Fraser in 1975 which led to a succession of budget cuts to the CHP, and federal funding of the program ended in 1981, but by then there were 187 CHP-funded ‘projects’ in Victoria. These created an identifiable ‘sector’ within the Victorian health system operating in a cultural climate that supported the model. The Victorian Community Health Association (VCHA) strongly advocated for the community health sector and later the Victorian Healthcare Association represented the sector, comprised of the non-government CHCs and community health programs integrated into other public health services as well as the public hospital sector. Interviewees reported that the Victorian Government and politicians accepted that advocacy was a legitimate role for services, particularly those established as community-managed non-government organisations.

Both Liberal and Labor Victorian Governments continued to fund the state CHP despite the declining support from the Australian Government under Fraser. Labor was returned to power federally under Hawke in 1983 and had promised a restoration of community health funding to 1975 levels as part of new federal–state health funding agreements. In 1983 the Hawke Labor government restored funding, but this was rolled into the general health grant. As a consequence, there was no longer a specific line item for community health or overall policy or guidelines for states to direct their community health program development. The Cain/Kirner Labor governments in Victoria (1982–1992) had a socially progressive agenda and the 1985 (Victorian) Ministerial Review of Community Health strongly supported community health services and ‘agencies’ (Henry 1985). In 1987, A New Focus for Community Health Services (Health Department Victoria 1987) expressed a commitment to community control through management committees as part of a proposal to develop more CHCs and extend the reach of the sector, aiming for statewide coverage. It stated that ‘the government is committed to the regional plans and priorities with new CHCs established’. Funding from the Hawke Labor Australian Government was used by the Cain Labor government in Victoria to set up a new round of CHCs in an attempt to remedy the maldistribution of services across the state which was the legacy of the 1973 first round process.

One interviewee commented on strong support at this time from left-leaning health ministers, while another suggested that, in part, the policy of increasing CHCs may have been adopted as a cheaper alternative to building new hospitals. However, other than receiving CHP funding, CHCs were initially largely autonomous of government. Although they were in receipt of government funding, Victorian CHC staff were not public servants, but employed by the funded organisation. To varying degrees, CHCs with their wide range of services and opportunities for social interaction were seen as community facilities, rather than part of government. This gave the staff and the organisation more autonomy including for advocacy, and state legislation supported this.

Local people would think of the community health centre as a place to talk to, early on. If the Council or any other group was wanting advocacy, or wanting to pick up on an issue, community health was where you would go. (Meredith Kefford, ex CH CEO, senior public servant)

One interviewee commented that overall the department was supportive:

We had quite a reasonable reputation with the government. You know, we delivered a lot of services – didn’t make too much of a nuisance of ourselves. (Vera Boston, ex CH CEO)

However, others commented that bureaucrats and the government were suspicious of the sector and sometimes, their lack of control over it.

Many in the department and in hospitals thought that we were a somewhat illegitimate contribution and that we were actually taking funds away from where health care should be, which is in hospitals, emergency departments and places like that. Or possibly general practice. (Philip Bain, ex CH CEO, Board member, government advisor)

While there was support for the growth of the sector, the government’s laissez-faire approach to how the community health sector used its funding changed significantly at this time. There were significant financial problems in the later years of the Cain/Kirner government and increasing demands for efficiencies and accountability.

The Cain Labor government under Minister David White was committed to gaining tighter policy control over public hospitals, including through what were called ‘health service agreements’ (or contracts) and through diagnostic-related group (DRG) based funding. CHCs were also impacted by this new managerialism, increasingly so after the Liberals, under Kennett, came to power in 1992 (Barraclough and Smith 1994).

The instigation of service agreements for community health services gave services less flexibility around activities, and reporting requirements also increased significantly.

The Cain government in the mid-late ‘80s introduced things like funding and service agreements where you had targets you have to meet … The clinical throughput becomes a priority … There’s no incentives often to engage at that community, early intervention, prevention type of level and that’s the difficulty. (Tim Walsh, ex CH CEO and Board member, government advisor)

In 1988 the Victorian Health Services Act 1988 (Health Services Act 1988) replaced the Hospitals and Charities Act. The Health Services Act recognised two types of organisations eligible to receive CHP funding in Victoria – independent registered ‘stand alone’ services (of which there were 41, most of which included general practitioners employed under various arrangements) and 59 ‘integrated’ community health services that were ‘units or divisions of larger health services such as metropolitan health services and rural health services or hospitals into publicly funded hospitals’. This legislative framework that remains, was described by the Victorian Auditor General’s Office (2018) as providing both integrated and registered community health services with the flexibility to make decisions about services they deliver with state government funding, based on local needs.

Although reported to change the culture and administration of community health, changes implemented under the Labor government were not existential challenges. Interviewees reported that the Kennett government was seen as the most serious threat to community health in Victoria.

The incoming Kennett Liberal government in 1992 heralded a profound shift in social and cultural expectations. The state’s financial situation was considered to be dire following the collapse of the State Bank and the Pyramid Building Society in 1990 and there was significantly reduced funding to public health organisations like VicHealth, Maternal Child Health Nursing and inner-city CHCs. Overall, there was a 42% drop in funding to community and public health spending during Liberal’s 7-year period of office (Alford 2000). The Victorian Health System Review in 1992 recommended continuing some of the previous Labor government’s changes including case-mix funding, public expenditure reduction and increased managerialism (Brand et al. 1992). Interviewees commonly expressed uncertainty as to how the community health sector survived in Victoria, particularly during the Kennett Liberal government era:

Every time a Liberal government came in in a state or federally there was terror that community health would be closed down. (Terri Jackson, ex CH CEO, CH advocate and academic)

The marketisation direction put in place a set of changes which I think weakened community health in this state. (Stephen Duckett, health economist, senior public health executive, academic, Board member)

The Kennett government aggressively pursued economic rationalist (neoliberal) policies, including small government and privatisation of public entities, marketisation of human services and the introduction of competitive tendering. Over their time in government there were forced amalgamations of local councils, closures of public schools and major changes to hospitals. Some interviewees commented that the government was pursuing major reforms across Victoria often in the face of significant opposition, and that this may have protected the community health sector to some extent. Although the government had a ‘push through’ approach, it could have been distracted by other agendas and may not have wanted to further antagonise community sentiment and members within its own party who supported community health, possibly including some health ministers.

It was also thought that community health may have been seen as small and insignificant and not a priority, given the scope of the government’s agenda. Some thought that although hospitals would have liked the community health money, it was not a significant amount and it may not have warranted the difficulty and potential risk of taking on some of the programs and functions provided by community health services, such as needle exchange and dealing with potentially problematic patients.

If they [hospitals] didn’t know where else to send something they’d flick it to us, particularly in the bush. Like alcohol and other drug services grew only because the hospital sector didn’t want to compete with us because they didn’t want ‘these druggies’ in there. (Jill Miller, ex CH CEO)

Although they were not a major focus for reform, the Kennett government did mandate government appointments to CHC boards of management. Some interviewees reported that government appointments to boards eroded the principle of community control in the sector, but another commented that it had little effect on the operation of services. Interviewees commented that some government-appointed board members were community members and others, who may not have been personally committed to the sector initially, became defenders of those services subsequently when they were under threat.

The funding cuts, however, were devastating, seriously threatening sustainability, particularly of smaller services. Infrastructure funding was frozen and there were significant staff redundancies. Some CHCs were absorbed into the new hospital networks but the health centres that remained independent had to adapt to the new marketised environment. Many health centres took an opportunistic approach. In order to be sustainable and to offset the funding cuts and the possibility of smaller services being targeted for closure, many services amalgamated, becoming large ‘corporate’-looking entities delivering services at multiple sites over large geographic areas – even interstate. This made them more noticeable and possibly more vulnerable to political interference, however, they were also arguably more likely to be successful in the competitive environment Kennett, and the Howard government federally, had created. This was characterised by a model of commissioning services at both state and federal levels. Larger services were better positioned to bundle funding from a range of sources and potentially cross-subsidise services otherwise not funded. They could cover the larger geographic catchments for which services were being commissioned without forming consortia. Community health with its range of services, understanding of chronic disease and geographic spread, was arguably well placed to respond to tenders.

Although understanding the reasons behind it, many interviewees were critical of the development of very large multi-site community health services on the basis that with the potential loss of community control and focus, they were no longer local entities. In addition, increasing managerialism, purported to have more emphasis on revenue and efficiency than primary healthcare principles, was seen by some to have taken the ‘progressive edge’ off community health.

Basically you created an ideology, a quite different ideology, that there isn’t local accountability, and there’s no local identity and so on – bigger is better. (Stephen Ducket)

Perhaps the most significant challenge to the sector – with ramifications that continue to this day – was the introduction of activity-based funding by the Kennett government in 1993. Designed for hospitals, this funding model was then applied to the state CHP funding that went to community health services, with significant negative consequences.

Service agreements, which were once a three page document became a 130 page document. (Vera Boston)

It (activity based funding) was seen as the ideal way of funding health services. And what happened was that a number of parts of the Victorian Government copied [advice provided for reforming hospital funding] … but didn’t understand … with disastrous consequences in all sorts of places. I think the people in the department only thought about illness and disability management. They didn’t think about the other products. (Stephen Duckett)

An output funding model, with the focus on direct service delivery, was not favourable to the community health sector. In addition, some CHCs had allied health and other services but chose not to have medical services, rather they focused on health promotion and prevention and the social determinants of health that were seen as the core of community health but difficult to quantify. Trust between the sector and the department was undermined.

How do you define the output of an ethnic health worker? And I think that move to output funding purchaser provider, just made a huge difference to community health... We had regular managers meetings, and we’d thought of the department and us as basically all on about the same thing. We’re all trying to improve health – that was our joint task and it just completely turned around (with the introduction of output funding) and that the department was there to try to get decent work out of us. The assumption that there was no trust anymore. The assumption was that you’d be taking the money and doing nothing if you could get away with it. (Meredith Kefford)

The consequence of government funding cuts and the need to seek funding elsewhere, increasingly through tendering and commissioning, was that services were less reliant on CHP government funding. For the majority of centres, the Victorian Government’s CHP became only one of many funding streams and a small one at that. The threat of withdrawal of funding was no longer significant to many, and to be deregistered under the Health Services Act was possible but had never been done.

Even if we lost our status as a community health service, we probably now have at least 50% or maybe even more – more like 60% of our services would continue … so it’s created an arms-length relationship between the Minister for Health and the Victorian State Government and the community health sector. (Peter Ruzyla, ex CH CEO)

The health services which have survived, have done so by being opportunistic, by recognising that they are well placed to deliver some programs and services and have enthusiastically gone after those funds and those responsibilities. (Paul Butler)

During the 1990s the sector had some support at the federal level. Ministers Brian Howe and Jenny Macklin (Macklin 1990) were both Victorians interested in social policy and reform consistent with community health, although they were more preoccupied with reform of general practice rather than advocating for community health.

I think it was only after he (Brian Howe) became health minister that I think he saw having a primary care service that could deliver social programs and health programs was of value. But of course, by that stage, he only had Victoria to work with. (Philip Bain, ex CH CEO and Board member, government advisor)

Any advantage of federal connections such as these largely disappeared with the incoming John Howard Coalition government in 1996. The sector was then confronted with economic rationalist/neoliberal governments at both the federal and state levels until the fall of the Kennett government in 1999.

The incoming Bracks and Brumby Labor Victorian Governments (1999–2010) operated in a context of strong reactions against Kennett’s harsh economic model and its impact on organisations that had previously worked well together but had become direct competitors during the previous 10 years. Initiatives such as the Primary Care Partnerships were established and well-resourced to encourage primary healthcare organisations to cooperate and improve coordination, with participation by the community health sector mandatory. Further policy development continued around community health services from 1999 to 2010 including a community health policy, guidelines and a strategy around supporting GPs in community health services. The community health sector in Victoria also responded to a perception from the private sector and hospitals and some in the Department, that they offered lesser quality services by further developing CHASP (Community Health Accreditation Standards Program) previously developed by the ACHA (Fry and King 1985, 1986; O’Tarpey 1998).

That led to the formation of QICSA (Quality Improvement Community Services Accreditation). So the sector voluntarily went into a system of quality assurance, so we could actually demonstrate that we had services that were equal, if not better than, many others in the sector. (Philip Bain)

In 2002 ‘Towards a community health policy framework’ was released (Community Health Unit 2002a). At the time there were 100 community health servicess providing primary health and health promotion services from more than 250 sites, with 41 stand-alone or independent and 59 integrated services.

Interviewees reported that in the early 2000s under an Abbott Liberal Australian Government, the Victorian Department of Health wanted CHP funding to incorporate health services recognised in the state government’s contribution to bilateral (state/federal) tax-sharing agreements for public health care. Some interviewees perceived this as a drive for greater control of the independent community health services by the state government. Informal legal opinion at the time suggested the change would affect the independent community health services’ not-for-profit (NFP) status and remove their eligibility to claim exemption from Fringe Benefit Tax. Advice (reported to be from within the government of the time) was that becoming companies limited by guarantee would remove this risk and enable the stand-alone CHCs to go on offering some additional benefits to staff as a way of attracting and retaining an appropriate workforce. Following this change in legal status, the department was reported to become more hostile and further distanced these community health services from the state government.

(For hospitals) the minister has direct control over the board and can appoint and dismiss the board members. But he or she can’t do that with a company limited by guarantee, like independent community health services. (Peter Ruzyla)

Suddenly we were going off on our own way and becoming completely independent, with our own boards and our company structure and our own ability to raise money. (Phillip Bain)

Interviewees noted that the growing size and complexity of these organisations led over time to the increasing use of appointed (expert) boards rather than community elected boards.

The state Baillieu/Napthine Liberal governments (2010–2014) didn’t engage with community health policy. The sector was an accepted part of the health system and many community health organisations continued to gain funding from diverse sources through ongoing competitive tendering processes.

Under the Labor government (2014–present), the community health sector has continued to be supported in policy but with ongoing requirements to tender for services and no growth to funding through the CHP component. A Community Health Taskforce established by the Victorian Government to respond to an audit of the CHP undertaken by the Victorian Auditor General’s Office (2018) proposed changes to the funding formula for the program (Community Health Unit 2002b), but by then, for many community health organisations, this funding was a small proportion of their overall budgets. In 2020, the sector was able to negotiate with the state government when the government proposed restrictions on activities supported by health promotion funding, ensuring that CHCs still had some flexibility to undertake innovative community development projects based on local need.

The early activism of the sector and subsequent independent boards were seen by many interviewees as a key reason for the ongoing existence of the sector in Victoria. When services were under threat, interviewees postulated that these activists were able to use their high levels of organisational skills and networks to defend those services.

They’ve [CHCs] been able to put together boards that are able to speak for them. I think that has been a very effective part of their survival in Victoria... I think it’s the strong committees of management, which include consumers and academics and activists. Some of them have got members of the Labor party on their boards of management. Some of them have been there for bloody decades. (Helen Keleher, public health advocate, academic)

Discussion

The community health sector in Victoria has survived through changing governments and changing ideological contexts. Multiple factors have contributed to this, but it could be argued that the basis for its survival ultimately rests with how it was initially established and the cultural environment in which it developed and continues to operate. Cultural and historic differences, particularly in comparison to the way the CHP was implemented in NSW, seem to have assisted the Victorian sector. The role of NGOs in health and community services is strong in Victoria, and the establishment and development of services through community activism and engagement may have provided a supportive cushion against threats from less supportive government policies.

In addition to the (albeit irregular) geographically wide distribution of CHCs, their high level of public recognition and sense of community ownership were seen as critical factors which aided their survival and worked against their closure or absorption into hospital networks. Although a number of Labor state politicians were involved in the establishment of individual community health services in their electorates, neither Liberal nor Labor governments were seen to be consistently supportive. CHCs, however, continued to be well connected, to their communities, through their political associations with individual parliamentarians and through their boards which later had government appointees and or influential professional members. As community health services expanded across the state, particularly in marginal seats and rural areas, members of parliament were unlikely to support the loss of local health services, particularly with a perception of a shortage of doctors, even if party ideology or budgetary constraints dictated it. In addition, over time, some staff from the community health sector were employed by the Health Department bringing with them an understanding and appreciation of the sector.

Although some services are still relatively small ‘stand-alone’ facilities, in response to the pressure from government and market forces, many have amalgamated into much larger organisations better able to compete with private services and to pool the residuum of funding after individual contracts have been concluded and direct this to otherwise unfunded activities. The large multisite community health organisations operating over broad geographic areas have sometimes been controversial within the sector, with some questioning the strength and authenticity of adherence to the principle of community control and the ability to be responsive to local needs. However, through this and other strategies, the sector has strengthened its sustainability and arguably the capacity to respond effectively to ongoing and emerging health issues in their communities. Adaptation has enabled them to be less reliant on government funding and support while also providing funds to continue more traditional community health services such as prevention and health promotion that are harder to get government to fund.

Many interviewees recognised that a strong response to the COVID-19 pandemic has strengthened the profile of community health within the Victorian health system but thought this was yet to be reflected in government funding or current policy at either a state or federal level. However, there was recognition of growing interest in the Victorian generic community health sector and Aboriginal Community Controlled Health Organisations (ACCHOs) models in government policy (e.g. Strengthening Medicare Taskforce Report, Australian Government 2023). Major challenges remain including workforce, particularly the sustainability of GP services within community health, the relationship with aged care services and the National Disability Insurance Scheme and in moving the government and community focus from acute services to multidisciplinary primary health care.

The community health sector continues to evolve in response to these challenges, while delivering a service model that reflects the principles of comprehensive primary health care. Within the current policy climate, the realisation of the principles remains a work in progress.

Future directions

Based on the research conducted and personal experience of the authors, we propose five new directions for policy, management and practice that could support this model to have a greater contribution to the health system in Australia:

The Victorian community health sector continues to evolve, with larger organisations, a diversity of funding streams and a more professional approach to management while delivering a service model that reflects the principles of comprehensive primary health care. Within the current policy climate, the realisation of the principles remains a work in progress.