Australian Indigenous

Overview of Indigenous health 2004

This overview is also available as a downloadable PDF using Adobe Acrobat.

Health expenditure

• Health expenditure
• Concluding comments
• Glossary
• Endnotes
• References
• Abbreviations

Estimated total expenditure by Australian governments and the private sector on health services to Indigenous people in the 1998-99 financial year was $1,245 million [151]. This is equivalent to $3,065 per person compared with $2,518 per person for non-Indigenous people - a ratio of 1.22:1 (this compares with a ratio of 1.08 in 1995-96 [152]). When relative income position is taken into account, public expenditure on the health of Indigenous people appeared to be similar to that for non-Indigenous people in low-income groups, despite the much lower health status of Indigenous people [151].

The majority of Indigenous health expenditure was allocated through mainstream health programs which generally do not, or only incompletely, document use specifically by Indigenous people [151].

Indigenous people were, on average, much higher users than non-Indigenous people of publicly funded health services and State-funded health services, particularly admitted patient services in hospitals and community health services [151]. Compared with non-Indigenous people, Indigenous people used fewer private services such as doctors in private practice, private hospitals, dentists, and privately funded allied health professionals.

The Commonwealth and State governments contributed very similar amounts to health services for Indigenous people [151]. Over 50% of the Commonwealth's contribution was indirect through its contribution to public hospital funding. Expenditures were much lower for Indigenous people than for other Australians in the major Commonwealth-funded health programs, Medicare and the Pharmaceutical Benefits Scheme: per person expenditure for Indigenous people was 37% of that for non-Indigenous people.

The ratio of Indigenous to non-Indigenous service use would be lower than the expenditure ratio of 1.22:1 if the higher costs of providing services in remote areas could be factored in [151]. Access to Medicare-funded services and pharmaceutical benefits decreased as remoteness increased, but admitted patient expenditure increased with increasing remoteness.

After controlling for population and inflation, there were areas in which there had been increases in funding and service provision between 1995-96 and 1998-99 [151, 152]. However, the inadequacy of these levels of expenditure on Indigenous health was identified by a comprehensive review undertaken by the Commonwealth Grants Commission (CGC). The review concluded that 'the poorer health status of Indigenous people, and their greater reliance on the public health [care] system, would justify at least a doubling of the average per capita expenditure on non-Indigenous people' [153]. The CGC conclusion about the inadequacy of spending on Indigenous health services was matched by similar conclusions about expenditure on a number of health-related areas, such as education, training, employment, housing, and infrastructure [153]. In view of the importance to health of these 'up-stream' factors, the achievement of major gains in Indigenous health will require a much greater commitment by governments in many areas - not simply an increase in spending on health services.

Professor John Deeble has estimated that, on equity grounds (defined as access to equal health care resources based on equal health needs), the expenditure ratio for 1998-99 should have been 1.42 (that is, per capita expenditure for Indigenous people should have been 42% more than for non-Indigenous people) [154]. After taking account of changes in overall health expenditures up to 2001-02, additional funding for Indigenous health (improved access to Medicare and PBS benefits, and expansion of the Primary Health Care Access Program), Professor Deeble concluded that 'about $250 million . would therefore remain a minimum estimate in the current shortfall in Indigenous health spending overall' [154]. If this extra money was provided, the network of Indigenous-specific primary care services could be further expanded. However, as Professor Deeble points out, there would be logistical difficulties in staffing the new and expanded services, so considerable funds would initially have to go into capacity development and training.

More recent research undertaken for the Australian Medical Association (AMA) by Access Economics, one of Australia 's leading independent economic analysts, concluded that the increases in recent years in Indigenous health funding were 'too slow to make any early inroads into the severe health problems among Indigenous Australians' [155, p.18] . It was estimated that to redress the Indigenous health deficit funding for primary health care services alone required an additional $400 million per annum. The AMA estimated that a further $52.5 million was required annually for training-related costs to meet the need for more Indigenous and non-Indigenous health workers [156, 157].

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Concluding comments

Indigenous people remain the least healthy sub-population in Australia , and there is evidence that the disparity between Indigenous and non-Indigenous health, at least measured by mortality, has widened in recent years [158]. The lack of real improvement in Indigenous mortality in Australia contrasts markedly with the situation among Indigenous people in New Zealand , Canada and the United States . The success achieved in those countries 'generates considerable confidence that effective action in Australia will produce substantial changes in Indigenous health' [158]. Achievement of these changes will require progress in five areas: infrastructure (including physical environmental and socioeconomic aspects); Indigenous self-determination of health services; access to a network of community-controlled primary healthcare services; an adequate level of resources; and a skilled workforce.

Substantial progress has been made in the past decade in some aspects of Indigenous health, and there have been improvements in some indicators of Indigenous health status [159]. As well, all Australian governments have made a commitment through the Council of Australian Governments to address the enormous disadvantages experienced by Indigenous people [160].

Within the health sector, the substantial increase in resources provided by the Commonwealth since 1995-96 has enabled consolidation and expansion of the Australia-wide network of Aboriginal community-controlled health services and of Indigenous-controlled substance-misuse services, and development of the role of NACCHO (National Aboriginal Community Controlled Health Organisation) in national advocacy and in support of Indigenous-controlled services [159]. The growth and development of NACCHO, its affiliates, and community-controlled health and substance-misuse services are significant advances, but, as pointed out by the CGC, the poorer health status of Indigenous people justifies further substantial increases [153].

The actual amount of extra funds required to enable Indigenous people get access to high quality, integrated primary health care services and to ensure progress towards an adequate, appropriate workforce are probably at least $450 million per year, the amount by which the AMA believes Indigenous health was under-funded in 2004 [157, p.2]. Funding increases of this order, complemented by the COAG developments and infrastructure progress, are essential to ensure that Australia doesn't just keep 'treading water on . Aboriginal and Torres Strait Islander health' [157, p.2].

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View Abbreviations

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Endnotes

1. In 2002, the most recent year for which estimates are available, the number of deaths identified as Indigenous was only 55% of the number expected (ABS, 2003). The only jurisdiction with a reasonable proportion identified correctly as the Northern Territory (85%). The proportions for the other jurisdictions were: Victoria (41%, Queensland (56%), WA (62%), SA (59%) and Tasmania (22%). An estimate wasn't available for the ACT.

2. A supplementary sample of 3,198 Indigenous people plus 483 included in the core NHS sample resulted in a total Indigenous sample of 3,681 (ABS, 2002).

3. The CDEP scheme offers unemployed Indigenous Australians the opportunity of working in community-managed projects and enterprises if they forego unemployment-related social security benefits.

4. The information summarised here has been extracted and/or derived from two main sources: the five-yearly Australian Census of Housing and Population (ABS, 2002); the 2001 Community Housing and Infrastructure Needs Surveys (CHINS), which collected information about housing in discrete Indigenous communities throughout Australia (ABS, 2002)

5. Information about discrete Indigenous communities - defined as geographic locations, bounded by physical or legal boundaries, and inhabited or intended to be inhabited predominantly (i.e. > 50% of usual residents) by Indigenous people, with housing or infrastructure that is managed on a community basis - was collected by the 2001 CHINS.

6. It should be noted that this maternal mortality ratio (MMR) is based on the direct and indirect deaths only, and excludes deaths to women where the cause was classified as 'incidental'. As such, the MMR is not directly comparable with those calculated for previous three-year periods, which were presented for all maternal deaths (including incidental deaths) and for direct deaths.

7. In the ICD, cardiovascular diseases are referred to as 'Diseases of the circulatory system'.

8. Information about rates of pancreas cancer were not available for Queensland

9. Specific information about the deaths from cancer is not available for Queensland and SA.

10. The age-standardised rate for Indigenous women in the NT in 1997-2000 was around 14 deaths per 100,000, but, being calculated using the 2001 Australian ERP, is not comparable with the other age-standardised rates that were calculated using the World Standard Population.

11. Hepatitis B is the main risk factor for primary liver cancer.

12. The module of mental health questions used in the general NHS, the Kessler Psychological Distress Scale 10 (K-10), was omitted from the Indigenous supplement as it was not considered culturally appropriate.

13. The ICD chapter 'Mental and behavioural disorders', used for the classification of both hospitalisation and mortality, is very broad. As well as mental illness and mental health problems, it includes mental retardation and a broad sub-category for disorders relating to the use of psychoactive substances (including alcohol, tobacco, other drugs and volatile substances). The chapter doesn't include, however, the results of intentional self-harm, which are classified within the ICD chapter 'External causes of morbidity and mortality'.

14. Renal (and urologic) disease includes conditions affecting the function of the body's urinary system, which involves the kidneys, ureters, bladder and urethra.

15. Details of new cases of ESRD are collected and collated by the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The figures presented in Table 17 have been derived from data provided by ANZDATA.

16. It is possible that some of this increase may reflect under-reporting by respondents to the 1994 NATSIS.

17. See Burns et al., 2003 for details.

18. These jurisdictions are the only ones with reasonable levels of identification of Indigenous people in notifications. Indigenous rates have been compared with those for all other people, including those for whom Indigenous status was not known.

19. Note figures have not been adjusted for reporting delay. The figures quoted here are aggregated nationally, and may conceal differences across Australia, particularly between rural/remote and urban areas, for which the patterns may be quite different (see 94 Skov S, Bowden F, McCaul P, Thompson J, Scrimgeour D (1996) HIV and isolated Aboriginal communities. Medical Journal of Australia;165:41-42 ).

20. Defined as less than the third percentile of World Health Organization reference values.

21. As with all areas of Indigenous health, there is considerable diversity in the impact of ear disease among Indigenous people across Australia . In particular, ear disease has not been identified as a major problem among Torres Strait Islander people. The patterns described in this section do not apply to all Indigenous people, but they are characteristic for many Indigenous communities, particularly those in remote parts of the country.

22. Some literature suggests that chronic discharge may lead also to sensorineural hearing loss (Couzos et al., 2003). Sensorineural hearing loss is permanent and is commonly caused by nerve damage that impedes the transmission of sound from the inner ear to the brain. When conductive and sensorineural hearing loss coexist, the hearing loss is referred to as 'mixed'.

23. As noted in the section entitled 'Hospitalisation', it is likely that the Australia-wide numbers and rates under-estimate Indigenous hospitalisation by as much as 25%.

24. The study did not include Indigenous people living in institutions.

25. Bearing in mind the generally higher levels of some risk factors documented for Indigenous people living in more remote parts of Australia, the levels of disability among Indigenous people in the Taree area may well be lower than in at least some other parts of the country.

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120 Australian Institute of Health and Welfare (2002) Chronic diseases and associated risk factors in Australia, 2001. (ISBN 1 74024 153 3) Canberra: Australian Institute of Health and Welfare

121 Genco RJ (1996) Current view of risk factors for periodontal diseases. Journal of Periodontology ;67(10):1041-1049

122 Jeffcoat MK, Chestnut C (1993) Systemic osteoporosis and oral bone loss: evidence shows increased risk factors. Journal of the American Dental Association ;124(11):49-56

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124 Armfield JM, Roberts-Thomson KF, Slade GD, Spencer AJ (2003) Child dental health survey, Northern Territory 2000. (AIHW Catalogue no. DEN 125) Adelaide: University of Adelaide

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129 World Health Organization (2001) International classification of functioning, disability and health. Geneva: World Health Organization

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142 National Health and Medical Research Council (2003) The Australian immunisation handbook. 8th ed. Canberra: Commonwealth of Australia

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145 O'Leary C (2002) Fetal alcohol syndrome, a literature review. Canberra: Commonwealth of Australia

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147 Shoobridge J, Vincent N, Allsop S, Biven A (1998) Using rapid assessment methodology to examine injecting drug use in an Aboriginal community: a collaborative project conducted by the Aboriginal Drug and Alcohol Council, the Lower Murray Nungas Club, and the National Centre for Education and Training on Addiction. National Centre for Education and Training on Addiction and the Aboriginal Drug and Alcohol Council

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150 Aboriginal Drug & Alcohol Council (SA) Inc, Shaw G, Mosey A, Gray D, Stearne AE (2003) 'They sniffed and they sniffed and it just wasn't there': an evaluation of the COMGAS Scheme. Adelaide: Aboriginal Drug and Alcohol Council (SA) Inc.

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153 Commonwealth Grants Commission (2001) Report on Indigenous funding. Canberra: Commonwealth Grants Commission

154 Deeble J (2003) Expenditures on Aboriginal and Torres Strait Islander health. Kingston, ACT: Australian Medical Association

155 Access Economics (2004) Indigenous health workforce needs: a report by Access Economics Pty Limited for the Australian Medical Association. Canberra, ACT: Access Economics

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157 Australian Medical Association (2004) AMA Discussion Paper, 2004: Healing hands - Aboriginal and Torres Strait Islander workforce requirements. Canberra: Australian Medical Association

158 Ring IT, Firman D (1998) Reducing Indigenous mortality in Australia: lessons from overseas. Medical Journal of Australia ;169:528-533

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Last updated: 12 January, 2005