Concluding comments

Concluding comments

It is clear from this overview of current health status that Indigenous people remain the least healthy sub-population in Australia. Being a ‘snapshot’ of the most recent indicators of health status – with little attention to trends – the overview, however, doesn’t reflect the evidence that the health status of Australia’s Indigenous people continues to improve slowly.

For a start, there have been significant reductions in recorded mortality in recent years in a number of jurisdictions. ²¹ Age-standardised death rates for Indigenous people living in WA, SA and the NT declined by around 25% over the period 1991-2008 [1][2]. The decline for Indigenous females (27%) was somewhat higher than the decline for Indigenous males (23%). The declines in death rates for Indigenous people have resulted in statistically significant closing of the gaps in rates between Indigenous and non-Indigenous people, but the rate ratio was 2.9 in 2008.

An earlier analysis of Indigenous mortality in the NT, the jurisdiction with by far the best quality data about Indigenous deaths, provides evidence of declines in death rates for some causes of death and a slowing in the increase in rates for others [3]. In the twelve-year period 1990-2001, the death rate for chronic obstructive pulmonary disease declined significantly. The death rates for stroke and renal failure for people aged less than 50 years also declined, but not significantly. On the other hand, the rates for ischaemic heart disease and diabetes mellitus increased significantly in the period 1990-2001, but at lesser annual rates of change than documented for the period 1977-1989. Importantly, there have been significant declines in recent years in death rates from avoidable causes.

The most recent estimates of life expectancy at birth for Indigenous people – 67.2 years for males and 72.9 years for females in 2005-2007 – are higher than previous estimates, but, as the ABS warns, the apparent improvements are likely to be due largely to revised statistical methods [4]. ²²

Indigenous infant mortality rates for WA, SA and the NT declined significantly over the 18-year period 1991-2008 [1]. The Indigenous rate declined by 55% over that period, slightly more than the 43% decline of the rate for non-Indigenous people. The Indigenous:non-Indigenous rate ratio declined by 59% from 4.3 to 3.2.

The declines in infant mortality rates have occurred despite the lack of real changes in the birthweights of babies born to Indigenous mothers – the mean weights of babies are still around 200 grams less than the weights of babies born to non-Indigenous mothers [5]. Importantly, the proportions of low birthweight (less than 2,500 grams) babies born to Indigenous mothers increased by 13% over the 18-year period 1991-2008 and are still around twice those of babies born to other mothers [1]. The proportions of low birthweight babies born to other mothers increased by 7%, resulting in a 19% increase in the difference in proportions between the Indigenous and non-Indigenous populations. The ratio of proportions increased by 6% (this increase is not statistically significant).

In terms of specific health conditions, substantial improvements have occurred in the overall impact of many infectious diseases (partly due to immunisation programs) including:

• reductions in the impact of respiratory infections in childhood [6]
• substantial declines in death rates from invasive pneumococcal pneumonia (mostly due to the introduction of vaccination programs) [7]
• reductions in the incidence and severity of trachoma (though inflammatory trachoma remains endemic in some remote communities of central and northern Australia) [8]
• a substantial reduction in the prevalence of HBV infection (since the introduction of vaccination programs) [9]
• a rapid decline in the incidence of invasive Hib disease in Indigenous children (following the introduction of vaccination) [9]
• a reduction in the number of new cases of TB, from 79 in 1984 [10] to an average of around 30 in the mid 2000s [11].

There have also been improvements in a number of areas contributing to health status:

• as well as the contributions that immunisation has made to the declines in the infectious diseases noted above, routine immunisation coverage of Indigenous and other children up to five years of age are similar [1]
• the participation of Indigenous people in sporting and recreational events increased between 2002 and 2008 [12]
• the level of smoking among Indigenous people has decreased slightly in recent years [13][14]
• there have been some improvements in the performance of Indigenous primary and secondary schoolchildren in recent years, and the proportion of Indigenous young people receiving a year 12 certificate increased between 2001 and 2008 [15][12].

There is no doubt other evidence of improvement in some measures health status, and of deterioration in others. But, clearly, the gap between the health status of Indigenous people and that of other Australians is still very, very wide.

There have also been substantial improvements in the availability of information about the health of Aboriginal and Torres Strait Islander people. Such information is crucial for both policy and strategy development and for monitoring progress towards the various targets set recently as a part of the Council of Australian Governments (COAG) commitments to ‘closing the gap’ in health between Indigenous and other Australians (see below) [16].

The preparation of this overview has benefited greatly from some of these improvements, particularly the introduction of regular reporting about various aspects of Indigenous health. The first of these substantial reports was the 1997 The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples [17], produced jointly by the ABS and the AIHW. The second was the Indigenous compendium to the annual Reports on government services produced by the Steering Committee for the Review of Government Service Provision (SCRGSP), first published by the Productivity Commission in 2003 [18]. This report was complemented by a biennial report on key indicators of Indigenous disadvantage, also produced by the SCRGSP and published by the Productivity Commission (the first report was published in November 2003) [19]. These reports were followed in 2006 with the first report in the Aboriginal and Torres Strait Islander health performance framework series [20]. This report, prepared by the AIHW for the Australian Department of Ageing, is accompanied by substantial detailed analyses. Subsequent reports in this series were published in 2008 and 2011 [21][22].

Along with these substantial reports on Indigenous health and related areas, continuing attention has been directed at improving the various data collections that feed into these and other reports. This work, overseen by the National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data (NAGATSIHID), has achieved considerable progress, but the current NAGATSIHID strategic plan acknowledges the need for ‘new data collections or enhancing existing collections’ … ‘so that a comprehensive information base is available to inform policy, practice and service delivery’ ([16], p.13).

Despite the considerable progress that has been made, it will be very obvious to readers of this overview that many existing collections are in need of enhancement. For a start, the identification of Indigenous people in most of the various health and related data collections is still far from complete. Few of the collections have good national coverage of Indigenous people, and, for many, good information is only available for a minority of jurisdictions and/or is quite dated. The limited information available about cancer among Indigenous people is a good example. Cancer is the second most common cause of death among Indigenous people, but the most recent reasonably comprehensive information available about cancer incidence relates to 2000-2004. There is even less information about deaths from cancer. Readers of this overview will recognise many other areas where there is a need for substantial enhancements.

In view of the commitments made in December 2007 by all Australian governments, through the COAG, ²³ to ‘closing the gap’ in disadvantage between Indigenous and other Australians [23], the need for reliable, up-to-date, comprehensive information about the health of Indigenous people is more important than ever. The ‘closing the gap’ commitments were stimulated by the Social Justice Report 2005, which highlighted the vast gap between the health of Indigenous and other Australians and called on Australian governments to commit to achieving Indigenous health equality within 25 years [24]. ²⁴

Following the release of the report, 40 of Australia’s leading Indigenous and non-Indigenous health peak bodies and human rights organisations joined forces to launch a campaign to ‘close the gap’ on health inequality [25]. In December 2006, the coalition published an open letter to the Prime Minister, the State Premiers and Territory Chief Ministers, parliamentarians and the Australian public calling for an end to Indigenous health inequality. The ‘close the gap’ campaign was launched in April 2007.

The Indigenous Health Summit, held in March 2008, concluded with the Prime Minister issuing, on behalf of the Australian Government and the Indigenous peoples of Australia, a statement of intent ‘to work together to achieve equality in health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by the year 2030’ ([26], p.1).

In March 2008, the Prime Minister also announced establishment of the National Indigenous Health Equality Council, ²⁵ which ‘advises the [Australian Government’s] Minister for Health and Ageing, the Hon Nicola Roxon MP, on the achievement of equitable and sustainable health outcomes for Aboriginal and Torres Strait Islander peoples’ ([27], p.546).

Reflecting the increased attention directed to Indigenous reform, it is now a standing item on all COAG meetings. As a part of its deliberations about ‘closing the gap’, COAG has agreed on a number of specific targets for reducing Indigenous disadvantage in the areas of education, early childhood development, health and employment. The targets are to:

• close the life expectancy gap within a generation
• halve the gap in mortality rates for Indigenous children under five within a decade
• ensure access to early childhood education for all Indigenous four year olds in remote communities within five years
• halve the gap in reading, writing and numeracy achievements for children within a decade
• halve the gap for Indigenous students in year 12 attainment rates by 2020
• halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade [28].

In addressing these targets, COAG has committed $4.6 billion over four years across early childhood development, health, housing, economic participation, and remote service delivery, and has also achieved a number of supportive commitments by the corporate and community sectors [28]. Agreement has been reached also on the establishment of a new national Indigenous representative body.

This is the first time that such a high level of commitments has been made by the Australian, state and territory governments and others, raising the possibility of substantial reductions in the health and other disadvantages experienced by Indigenous people.

As encouraging as these commitments are, achievement of substantial improvements in the health and wellbeing of Indigenous people will depend largely on the effective implementation of comprehensive strategies and policies that address the complexity of the factors underlying the disadvantages experienced by Indigenous people.

Importantly, effective, integrated comprehensive strategies and policies will need to be sustained for a long period of time, as improvements to the extent set in the various targets will not occur in the short-term. The timeframes for the ‘closing the gap’ targets suggest there is some awareness by governments of the enormity of the challenge, but the real test will be to sustain the commitments through changing political and economic cycles.

References

1. Australian Institute of Health and Welfare (2011) Aboriginal and Torres Strait Islander health performance framework 2010: detailed analyses. Canberra: Australian Institute of Health and Welfare
2. Australian Institute of Health and Welfare (2008) Aboriginal and Torres Strait Islander health performance framework, 2008 report: detailed analyses. Canberra: Australian Institute of Health and Welfare
3. Thomas DP, Condon JR, Anderson IP, Li SQ, Halpin S, Cunningham J, Guthridge SL (2006) Long-term trends in Indigenous deaths from chronic diseases in the Northern Territory: a foot on the brake, a foot on the accelerator. Medical Journal of Australia; 185(3): 145-149
4. Australian Bureau of Statistics (2009) Experimental life tables for Aboriginal and Torres Strait Islander Australians: 2005-2007. Canberra: Australian Bureau of Statistics
5. Laws PJ, Li Z, Sullivan EA (2010) Australia's mothers and babies 2008. Canberra: Australian Institute of Health and Welfare
6. Australian Indigenous HealthInfoNet (2005) Review of respiratory disease among Indigenous peoples. Retrieved from http://www.healthinfonet.ecu.edu.au/chronic-conditions/respiratory/reviews/our-review
7. Roche PW, Krause V, Cook H, Barralet J, Coleman D, Sweeny A, Fielding J, Giele C, Gilmour R, Holland R, Kampen R, Brown M, Gilbert L, Hogg G, Murphy D (2008) Invasive pneumococcal disease in Australia, 2006. Communicable Diseases Intelligence; 32(1): 18-30
8. Taylor HR, National Indigenous Eye Health Survey Team (2009) National Indigenous eye health survey: minum barreng (tracking eyes): full report. Melbourne: Indigenous Eye Health Unit, The University of Melbourne
9. Menzies R, Turnour C, Chiu C, McIntyre P (2008) Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia, 2003 to 2006. Canberra: Department of Health and Ageing
10. Penny M, Thomson N (1987) A preliminary analysis of Aboriginal tuberculosis, 1984. Aboriginal Health Information Bulletin; 8: 15-18
11. Barry C, Konstantinos A, National Tuberculosis Advisory Committee (2009) Tuberculosis notifications in Australia, 2007. Communicable Diseases Intelligence; 33(3): 1-12
12. Steering Committee for the Review of Government Service Provision (2011) Overcoming Indigenous disadvantage: key indicators 2011. Canberra: Productivity Commission, Australia
13. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05. Canberra: Australian Bureau of Statistics
14. Australian Bureau of Statistics (2010) National Aboriginal and Torres Strait Islander social survey, 2008: Table 10. Indigenous persons aged 15 years and over, by age groups by sex [data cube]. Retrieved from http://abs.gov.au/AUSSTATS/SUBSCRIBER.NSF/log?openagent&4714.0_aust_010_2008.xls&4714.0&Data%20Cubes&6959208EE47E867DCA25770B0016F56D&0&2008&21.04.2010&Previous
15. Australian Curriculum Assessment and Reporting Authority (2010) National Assessment Program - Literacy and Numeracy: achievement in reading, writing, language conventions and numeracy: national report for 2010. Sydney: Australian Curriculum Assessment and Reporting Authority
16. National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data (2011) National Advisory Group on Aboriginal and Torres Strait Islander Health Information strategic plan 2011-2015. Canberra: Australian Institute of Health and Welfare
17. Australian Bureau of Statistics, Australian Institute of Health and Welfare (1997) The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. Canberra: A joint program of the Australian Bureau of Statistics and the Australian Institute of Health and Welfare
18. Spence J (2003) Liquor restrictions in Queensland Indigenous communities. Indigenous Law Bulletin; 5(25): 5-6
19. Steering Committee for the Review of Commonwealth Service Provision (2003) Overcoming Indigenous disadvantage: key indicators 2003 report. Canberra: Productivity Commission
20. Australian Health Ministers’ Advisory Council (2006) Aboriginal and Torres Strait Islander health performance framework 2006 report. Canberra: Department of Health and Ageing
21. Australian Health Ministers’ Advisory Council (2011) Aboriginal and Torres Strait Islander health performance framework: 2010 report. Canberra: Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing
22. Australian Health Ministers’ Advisory Council (2008) Aboriginal and Torres Strait Islander health performance framework report 2008. Canberra: Department of Health and Ageing
23. Council of Australian Governments (2009) National Indigenous reform agreement (closing the gap). Canberra: Council of Australian Governments
24. Aboriginal and Torres Strait Islander Social Justice Commissioner (2005) Social justice report 2005. Sydney: Human Rights & Equal Opportunity Commission
25. Calma T (2009) Close the gap campaign for Aboriginal and Torres Strait Islander health equality by 2030: a community guide. Canberra: Australian Human Rights Commission
26. Australian Government (2008) Statement of intent. Paper presented at the Indigenous Health Equality Summit: Close the Gap. 20 March 2008, Canberra
27. Anderson I (2009) Close the Gap: National Indigenous Health Equality Council. Medical Journal of Australia; 190(10): 546
28. Department of Families Housing Community Services and Indigenous Affairs (2009) Closing the gap on Indigenous disadvantage: the challenge for Australia. Canberra: Commonwealth of Australia

Endnotes

21. Being based on recorded deaths, for which the level of under-identification of Indigenous status is uncertain and, to some extent, variable, the source report notes that ‘caution should be exercised in assessing trends in Indigenous mortality over time’.

22. A variety of techniques has been developed by demographers to estimate life expectancy in instances where registration of deaths is incomplete. This is effectively the case with Indigenous deaths: even though very few Indigenous deaths will not be registered, many Indigenous deaths are not correctly identified as such.

23. COAG is ‘the peak intergovernmental forum in Australia, comprising the Prime Minister, State Premiers, Territory Chief Ministers and the President of the Australian Local Government Association (ALGA)’.

24. The Social justice report is an annual report of the Australian Human Rights Commission’s Aboriginal and Torres Strait Islander Social Justice Commissioner.

25. The Council was re-named National Aboriginal and Torres Strait Islander Health Equality Council in August 2011.

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