"It's Feeding the Beast": Lessons for Governance of Public Health Surveillance and Response From an Australian Case Study Analysis.

Background: Public health is a core governmental responsibility, with ministries or departments of health responsible for setting and ensuring adherence to standards, managing performance and instituting reforms as required. Although North Queensland (NQ), Australia has a well-developed health infrastructure, the COVID-19 pandemic exposed significant vulnerabilities in its public health surveillance and response system. Globally, research has highlighted how human and cultural elements ("system software") influence the effectiveness of infrastructure, governance, and data systems ("system hardware"). This study examines the interaction between these elements to examine specific governance challenges and opportunities for strengthening communicable disease surveillance and response in NQ.

Methods: Using an embedded case study design, we analysed four disease units-COVID-19, tuberculosis (TB), arboviruses, and sexually transmitted infections (STIs)-through interviews (n=47), document review, and observations across NQ health services (October 2020-December 2021). Data were mapped against Sheikh and colleagues' hardware-software framework to examine the nature of governance bottlenecks in this region of northern Australia.

Results: Two key governance challenges emerged: (1) Accountability deficits-Hospital and Health Services (HHSs) lacked clear reporting or performance monitoring systems within Queensland's devolved health service governance model, contributing to inconsistent prioritisation of resourcing for communicable disease functions by health service leadership. Within HHSs, public health units (PHUs) faced systemic underfunding, with prevention services accounting for as little as 0.1% of some health service budgets. (2) Data governance failures-Fragmented, siloed data systems, restrictive data-sharing norms, and risk-averse culture hindered coordinated surveillance and response efforts. Weak interoperability and mistrust in data-sharing partnerships further compromised system effectiveness.

Conclusion: This study highlights how political, normative, and structural factors shape public health performance alongside the more commonly assessed functional and technical dimensions. Findings suggest the need to improve performance monitoring systems, leadership, and data governance to build an effective, accountable, and data-driven surveillance and response system in NQ.