National Strategic Framework for Chronic Conditions

Objectives

The National Strategic Framework for Chronic Conditions provides overarching policy direction for preventing and managing chronic conditions in Australia from 2017 to 2025, with a vision that all Australians live healthier lives through effective prevention and management.[1]It adopts a systemic, person-centred approach that addresses shared determinants, risk factors and multimorbidity rather than treating conditions solely as separate diseases.[2]Its central purpose is to reduce the physical, psychological, social and financial impacts of chronic conditions, improve health outcomes and quality of life, and support a sustainable health system.[3]

• Focus on prevention for a healthier Australia, including reducing preventable chronic conditions and associated behavioural, biomedical and social risk factors.[4][5]
• Provide efficient, effective and appropriate coordinated care that enables people with chronic conditions to optimise quality of life, with fewer complications, multimorbidities, disabilities and premature deaths.[6][7]
• Target priority populations experiencing inequitable outcomes, including Aboriginal and Torres Strait Islander people, culturally and linguistically diverse communities, older people, carers, people experiencing disadvantage, rural and remote populations, people with disability or mental illness, and people who are or have been incarcerated.[8][9]
• Address health promotion and risk reduction, partnerships, critical life stages, timely detection and intervention, active engagement, continuity of care, accessible services, information sharing, supportive systems, Aboriginal and Torres Strait Islander health, and community action and empowerment.[10]
• Apply prevention across the life course and disease continuum, including settings such as childcare centres, schools, workplaces, urban environments and health services.[5]
• Reduce disparities in chronic-condition outcomes between Aboriginal and Torres Strait Islander people and non-Indigenous Australians, contributing to the goal of closing the life-expectancy gap by 2031.[9][11]

Implementation

Implementation relies on coordinated national action while allowing partners to tailor policies, strategies, services and actions to local circumstances, health responsibilities and governing authorities.[4]The Framework is directed at decision-makers, health services, providers, industry, communities, carers and families, and is intended to operate through shared responsibility across government, health and non-health sectors.[1][10]National coordination is provided through collaboration between the Commonwealth and state and territory governments under the Australian Health Ministers' Advisory Council.[2]

• Coordinate prevention and chronic-condition management across primary, community, acute, specialist, mental health, aged-care and disability services, using integrated and person-centred care models.[12][13]
• Engage people with chronic conditions, carers and families in shared decision-making, personalised care planning, treatment preferences, self-management and individual quality-of-life goals.[14][12]
• Strengthen a capable workforce through training in health literacy, communication, technology and flexible multidisciplinary team-based care.[12][15]
• Improve service access through flexible delivery, telehealth, digital health, out-of-hospital care where clinically appropriate, and action on barriers related to cost, transport, remoteness, workforce availability and affordability.[15][16]
• Promote timely detection through health checks, integrated risk assessments, evidence-based screening, diagnostic pathways, referral processes and appropriate follow-up, while avoiding over-diagnosis, unnecessary procedures and excessive financial outlay.[17][18]
• Build responsible partnerships among governments, non-government organisations, the private sector, industry, researchers, communities, individuals, carers and families, with clear governance, shared expertise and coordinated investment.[19]
• Collaborate with environment, housing, education, employment, transport and social-service sectors to address social, economic and environmental determinants of health.[1]
• Deliver culturally safe, accessible, high-quality, affordable and locally responsive services for priority populations, including through Aboriginal and Torres Strait Islander community participation, leadership, workforce representation and partnerships with Aboriginal Community Controlled Health Organisations.[9][11][20]
• Use consistent, reliable, secure and de-identified data, supported by informed consent, My Health Record, data linkage, research translation and continuous quality improvement, to improve care and population planning.[21][22]
• Develop nationally agreed performance measures and a companion reporting mechanism collaboratively with jurisdictions and experts, using existing data where possible and aligning with World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 reporting requirements.[23]
• Monitor progress at Objective, Strategic Priority Area and Outcome levels through example indicators, with responsibility shared by partners and indicative reporting roles for the Australian Institute of Health and Welfare, Australian Bureau of Statistics and Commonwealth Department of Health.[4][24][25]
• Review the Framework every three years through a collaborative process involving partners, experts and all jurisdictions, informed by achievement against the Objectives.[23]

Monitoring & Evaluation

The Framework uses an outcomes-based monitoring model, with success assessed at the levels of its three Objectives, Strategic Priority Areas and associated short-, long-term and aspirational outcomes.[4]It seeks nationally consistent performance measurement, regular public reporting and three-yearly review across jurisdictions.[23]

• Develop a nationally agreed performance-measure set to monitor activity and achievement, aligning measures where possible with Australia’s reporting commitments under the World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020.[26][23]
• Measure prevention outcomes through morbidity, mortality, disease burden, risk-factor prevalence and the unconditional probability of death between ages 30 and 70 from cardiovascular disease, cancers, diabetes or chronic respiratory diseases.[27]
• Track prevention indicators including smoking, harmful alcohol use, physical activity, blood pressure, blood glucose, cholesterol, dietary intake, overweight and obesity, selected chronic conditions, psychological distress and alcohol-related harm.[27]
• Monitor early-life and prevention measures including smoking during pregnancy, low birth weight, breastfeeding, childhood tobacco-smoke exposure, developmental health checks, immunisation, screening, preventive drug therapy and counselling.[24][6]
• Assess care quality and access through health literacy, patient experience, chronic-condition care plans, chronic disease management Medicare items, access to care, cancer waiting times, potentially preventable hospitalisations, bulk-billing, out-of-pocket expenditure, unmet need due to cost, workforce availability and uptake of My Health Record.[28]
• Assess complications and outcomes through unplanned hospital readmissions, multimorbidity, chronic conditions among people with disability, potentially avoidable deaths and Potential Years of Life Lost.[25]
• Monitor priority-population outcomes through socioeconomic circumstances, health behaviours, clinical risk factors, hospital readmissions, disability, service access, cultural safety, the Indigenous health workforce and accreditation of Indigenous primary health-care services.[29][26]
• Use Closing the Gap targets, including the 2031 life-expectancy target, alongside improved collection of Aboriginal and Torres Strait Islander health data to track progress towards equitable outcomes.[9][11]
• Use consistent, reliable, secure and de-identified health information, data linkage, research, performance review and continuous quality improvement to support monitoring, service evaluation and safer care.[21]
• Assign indicator reporting mainly to the Australian Institute of Health and Welfare, the Australian Bureau of Statistics and the Commonwealth Department of Health, while recognising that some data are not routinely available or have completeness limitations.[24][6][25][29][26]
• Develop the reporting mechanism collaboratively with states, territories and experts; encourage organisational reporting; publish a companion reporting document at regular intervals; and review the Framework every three years based on progress against its Objectives.[23]

Costing & Financing

The Framework presents prevention and effective chronic-condition management as important to reducing long-term pressure on the health system and supporting its sustainability, but it does not provide a programme budget, costing methodology, financing plan, resource-mobilisation target or quantified funding gap.[3][30][23]

• Recognise that chronic conditions create growing pressure on Australia’s health budget, services and workforce as prevalence, treatment and medicine costs, and demand for services increase.[31][30]
• Record approximately 27 billion Australian dollars in direct allocated health-care expenditure for cardiovascular diseases, oral health, mental illness and musculoskeletal conditions in 2008-2009, equal to 36 per cent of allocated health expenditure.[30]
• Recognise that wider economic costs include residential care, lost productivity and other non-health-sector expenditure, alongside social costs such as reduced independence, stigma and disability; the supplied evidence does not quantify these costs.[30]
• Use prevention to reduce the volume and severity of chronic conditions, delay disease onset, minimise progression and complications, and generate long-term health and economic benefits.[3][5]
• Allocate and use resources efficiently, including funding, according to identified health needs over the long term.[10]
• Use responsible partnerships to pursue efficient resourcing, shared investment and reduced duplication, without specifying monetary allocations or partner contributions.[19]
• Consider fiscal and regulatory levers, where appropriate, to incentivise healthy behaviours; no fiscal instruments, values or implementation arrangements are specified.[32]
• Recognise financial barriers to access, including costs of chronic-condition management, multiple medicines, health services, travel, accommodation and support services.[16]
• Consider funding and incentive arrangements that account for access barriers, alongside innovative funding and care models; the source provides no budget amounts, allocations, financing sources or economic assumptions.[15][16][33]
• Use timely and appropriate detection to avoid unnecessary procedures, over-medicalisation and excessive financial outlay for individuals and families.[17]