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"Universal" health care in Australia and its dirty little secret



 
 
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Old April 8th, 2007, 01:21 AM posted to rec.travel.europe
PJ O'Donovan[_1_]
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Default "Universal" health care in Australia and its dirty little secret


http://www.mja.com.au/public/issues/...n10435_fm.html

MJA The Medical Journal of Australia

Crisis

Indigenous health: chronically inadequate responses to damning
statistics

Ian T Ring and Ngaire Brown
MJA 2002 177 (11): 629-631
Abstract
- Introduction
- Where do we stand on health?
- What about health spending?
- Why do we do so much worse than other countries?
- Why is the government not doing more?
- What do we need to do?
- Straws in the wind?
- References
- Author details

In the 10 years 1990-2000, despite improvements in some conditions,
there has been little or no overall progress in the health of the
Aboriginal and Torres Strait Islander populations of Australia. This
is
in stark contrast to the gains made in Indigenous health in other
countries. The issue is one of lack of commitment to and
implementation
of already existing policies. We need to (i) fully and adequately fund
the Primary Health Care Access Program to provide the out-of-hospital
services for prevention and early treatment required to break the
cycle
of ill-health; (ii) implement a National Training Plan to train the
necessary health workforce; and (iii) introduce a National
Infrastructure Plan to rectify the continuing deficiencies in water
supply, sanitation, education and other basic services.

The recent pioneering Public Report Card 2002 - Aboriginal and Torres
Strait Islander health, entitled No more excuses,1 outlines where we
are today and how the health of our Indigenous population compares
with
that of other similar countries - New Zealand, Canada and the United
States. Produced by the Australian Medical Association, it is a
"warts-and-all" assessment which is designed to show what is working
and where we need to do better.

Where do we stand on health?
There have certainly been some gains. The health of Indigenous infants
has improved dramatically, although from a low baseline, and most of
the gains occurred 20-30 years ago.2 The current infant mortality
rate for the Aboriginal and Torres Strait Islander population is
almost
three times that of the general Australian population, twice that of
the Maori, and 50% higher than the mortality rate of US Indigenous
infants.3 This is some improvement on previous rates, but we can and
should do better.

Death rates overall for Indigenous people in Australia are still three
times as high as for the rest of the population: diabetes death rates
are eight times as high, respiratory deaths four times as high and
circulatory conditions almost three times as high.4 These are
unacceptable statistics for treatable and preventable conditions.

On the other hand, there are number of recent good news stories.
Programs in the Northern Territory and elsewhere have shown that
birthweight, the critical factor in the survival of newborn infants,
can be improved.5,6 More dramatically, death rates from pneumonia have
dropped by around 40% since 1996 (derived from Australian Bureau of
Statistics data). This is important, because this reduction is likely
to be due, in part, to recent government initiatives for promoting
pneumococcal vaccination. This is a real indication of the kind of
rapid and substantial gains that can be achieved through application
of
knowledge we already have. (Well done, even if long overdue.)

Progress in providing access to health services for Aboriginal and
Torres Strait Islander communities is much too slow. There is a gross
shortage of doctors working in Indigenous health, with an estimated
60%
increase required (ie, at least 500 doctors). The number of nurses
also
needs to increase by 25%, and there are sizeable deficits in all the
other health professions.7

There has been some improvement in basic services and facilities to
some areas, but too many Aboriginal and Torres Strait Islander
communities still lack adequate water, electricity and sewerage
services.8,9 In other fields influencing health, there has been some
modest improvement in educational benchmarks, but still only a third
of
Aboriginal and Torres Strait Islander children reach Year 12 at
school.10

Most tellingly, however, are the data for the most reliable overall
measure of health - median age at death, currently 51 years for the
Aboriginal and Torres Strait Islander population. There has been no
improvement at all in this measure in the last 10 years.3 In this same
period, the median age at death for the total Australian population
increased by three years, so that the gap in median age between
Indigenous people and the rest of the population has now increased to
a
staggering 26 years. Median age at death is much higher for the
Indigenous populations of New Zealand (59 years), Canada (65 years)
and
the United States (63 years) and, in contrast to the situation in
Australia, has been progressively increasing for the last 25 years,11
and probably for much longer.

What about health spending?
Spending on Aboriginal and Torres Strait Islander health is
increasing,
but, incredibly, the Commonwealth Government, through programs under
its direct control, still spends less per capita on Indigenous people
than it does on the rest of the Australian population - 74c on
Indigenous Australians for every $1 spent on the rest of the
population! The real increase in spending on Indigenous health between
1995-96 and 1998-99 was 15%.12 This is worthwhile, but nowhere near
enough to cater for the higher levels of illness among Indigenous
people. There has been a major new initiative, the Primary Health Care
Access Program, with three key features: needs-based funding, funds
pooling and community control. However, the funding for the program is
totally inadequate, and at this stage only selected communities can
participate in a program which is needed for Indigenous people
throughout Australia.13 The consequences of the funding shortfall are
major deficiencies in the crucial prevention and early treatment
services required to break the cycle of ill-health.

Why do we do so much worse than other countries?
What is it about Australia that stops us from achieving the gains seen
in the health of the Indigenous populations in other Western
democracies, or, for that matter, in developing countries around the
world? There is, after all, nothing absolutely unique either about the
disease pattern or the history and circumstances of the Australian
Indigenous population. Heart disease, respiratory conditions, injuries
and diabetes are also the major conditions for the Indigenous
populations of other countries. Dispossession, forcible relocation,
removing children from their families, and heavy-handed paternalism
are
certainly not unique to Australia.

Nor is Australia incapable of doing well with health and health
services. Depending on which measurement you take, Australia is
arguably the second- or third-healthiest country in the world, with a
proud record in confronting difficult and complex issues such as AIDS
and cancers in women.14

Why is the government not doing more?
It is symptomatic of our lack of progress that this report card, and
its call for action, comes not from the government, but from health
professionals. Surely one would hope that some response, some soul
searching, some rethinking would be evoked by the fact that over the
last 10 years, despite some good news, the overall mortality of the
Australian Indigenous population, alone among Western nations, has not
improved, is much worse than for the Indigenous populations of New
Zealand and North America, and that the gap between the mortality rate
of the Indigenous population and that of the rest of the Australian
population is becoming wider. But no, there is simply a deafening
silence; a case of industrial deafness.

Shortfalls in medical services for rural areas have produced major
government programs and initiatives, and a massive injection of funds.
Where is the response to the huge shortage of doctors and nurses to
work in Indigenous health, and the major gaps in the workforce of all
the other health professions? For any other section of the population
there would be a massive outcry and appropriate remedial action.

In fact, for Aboriginal and Torres Strait Islander health, the
Commonwealth Government seems to be tied up with a curious logic that
requires "good news" from spending less on people with worse health
before it will fully rectify the health service deficiencies needed to
address the worse health!

Australia is locked into a cycle of endless consultation, policy and
strategy formulation and measurement. Report after report is produced
showing that Indigenous health is poor, improvement patchy at best,
and
that, overall, the gap between Indigenous and non-Indigenous health is
widening. These reports reach the highest levels of Australian public
and political life and are simply noted, or evoke defensive
bureaucratic responses. We must act on the reports, not just note
them.
Flat-lining for 10 years is not good enough!

Many worthwhile activities are under way, but would any informed
observer really claim that current or planned prevention and treatment
services, staff provision and training plans, and environmental
improvements, will do the job, or are anywhere near sufficient to
bring
about the Indigenous health gains seen in other countries most like
Australia?

What do we need to do?
We don't need new solutions, new strategies, some magic bullet. We
need
to implement strategies, like the National Aboriginal Health
Strategy,15 that have been around for more than a decade. The Report
Card reinforces previous calls for a national program to build up the
necessary community-controlled health services for prevention and
treatment; for the Primary Health Care Access Program to be given the
funds required to provide those services; for a National Training Plan
to train the staff, particularly Indigenous staff, required to deliver
those services; and for a National Infrastructure Plan to rectify the
continuing deficiencies in water supply, sanitation, education and
other basic services.

Australia spends over $50 billion per annum on health for its total
population.16 It isn't that the modest funds required for adequate
health services for Aboriginal and Torres Strait Islander people are
out of reach, or that the services required are beyond our technical
capacity. It is ultimately a commitment to implement the
recommendations of the endless reports, and this is what the AMA, in
support of Aboriginal and Torres Strait Islander organisations, is
urging on the nation.

Straws in the wind?
Despite the general lack of progress, there are straws in the wind.
The
appointment of a new Health Minister and a new head of the
Commonwealth
Department of Health provides a fresh opportunity for dealing with the
issues highlighted in the Report Card. Death rates of the NZ Maori and
the Indigenous peoples of Canada dropped by 30% in the 1970s.17 Over a
40-year period, the health of the Indigenous populations of the United
States improved twice as rapidly as that of the non-Indigenous
population.14 Australia can do the same, and that should be our aim.

Summary of the AMA Report Card on Aboriginal and Torres Strait
Islander
health

--------------------------------------------------------------------------------

Infant mortality rate

Indigenous rates are 2 times the total population rate
Rapid fall in the 1970s. Rates in Indigenous Australians almost twice
as high as those of the NZ Maori and US Indigenous populations

Low birthweight

Indigenous babies are twice as likely to have low birthweight.
Little overall improvement since 1991, but effective programs
developed and implemented in the Northern Territory and South
Australia

Expectation of life

The gap between Indigenous and non-Indigenous people is 20 years
In North America and New Zealand, the life expectancy gap (Indigenous
v non-Indigenous) is 5-7 years

Median age of death

For Indigenous people this is 25 years less than for non-Indigenous
people
There has been no improvement in the median age of death in the
Indigenous population in Australia in the past 10 years

Standardised mortality ratios

Indigenous rates are three times those of the total population
High rates for diabetes, respiratory, circulatory and other
conditions
in the Indigenous population

Mortality from pneumonia

A dramatic decline in Indigenous rates since 1996
Pneumoccocal and influenza vaccines may be contributing to the
decline
in mortality from pneumonia

Health workforce

Estimated at least 59% increase in doctors required, and a 25%
increase
in nurses
Required increase related to difficulties in accessing preventive and
early treatment services

Infrastructure

21 communities lack water, 80 lack electricity and 91 sewerage
Some improvement, but significant gaps

Education

Year 12 retention rates are 36% for Indigenous people v 73% for the
total population
Some improvement, but significant gaps

Health funding

15% real increase in government funding between 1995-96 and 1998-99
Level of health spending is 22% higher for Indigenous people but a
needs index of 200% is required

Aboriginal Community Controlled Health Services (ACCHS)

OATSIH funding of community-controlled services increased by 50%
between 1995-96 and 1999-2000
ACCHS with a network of culturally appropriate healthcare services
provides a model for Indigenous health services

--------------------------------------------------------------------------------

OATSIH = Office for Aboriginal and Torres Strait Islander Health.

References
Australian Medical Association. Public Report Card 2002. Aboriginal
and
Torres Strait Islander Health. No more excuses. Canberra: AMA, 2002.
Media releases 24 May 2002. Available at: www.ama.com.au/
Australian Bureau of Statistics. Deaths, 1999. Canberra: ABS, 2000.
(Catalogue No. 3302.0.)
Australian Bureau of Statistics. Deaths, 2000. Canberra: ABS, 2001.
(Catalogue No. 3302.0.)
Australian Bureau of Statistics, the Australian Institute of Health
and
Welfare. The Health and Welfare of Australia's Aboriginal and Torres
Strait Islander Peoples, 2001. Canberra: ABS, 2001. (Catalogue No.
4704.0.)
Mackerras D. Evaluation of the Strong Women, Strong Babies, Strong
Culture Program. In: Australian Bureau of Statistics. The health and
welfare of Australia's Aboriginal and Torres Strait Islander peoples,
1999. Canberra: ABS, 1999. (Catalogue No. 4704.0.)
Commonwealth Department of Health and Aged Care. Better health ca
studies in the successful delivery of primary health care services for
Aboriginal and Torres Strait Islander Australians. Canberra:
Commonwealth Department of Health and Aged Care, 2001.
Estimation of requirements for and supply of the health workforce for
Aboriginal and Torres Strait Islander peoples. In: National Strategic
Framework Aboriginal and Torres Strait Islander Health Workforce -
Consultation Draft, 2001. Canberra: Commonwealth Department of Health
and Aged Care; 2001.
Australian Bureau of Statistics. Housing and infrastructure in
Aboriginal and Torres Strait Islander communities 2002. Canberra: ABS,
2001. (Catalogue No. 4710.0.)
Aboriginal and Torres Strait Islander Commission. Aboriginal and
Torres
Strait Islander Commission Annual Report 1999-2000. Available at:
www.atsic.gov.au (accessed 19 April 2002).
Australian Bureau of Statistics. Australian social trends 2002.
Canberra: ABS, 2002. (Catalogue No. 4102.0.)
Ring I, Firman D. The health of Indigenous populations in Australia,
New Zealand and the United States of America. XVI International
Epidemiology Association World Congress of Epidemiology. Montreal,
August 18-22, 2002.
Australian Institute of Health and Welfare. Expenditures on health
services for Aboriginal and Torres Strait Islander people 1998-1999.
Canberra: Australian Institute of Health and Welfare, 2001.
Office for Aboriginal and Torres Strait Islander Health.
http://www.health.gov.au/oatsih/ (accessed October 2002, link updated
Nov 2005).
Ring I. Sidney Sax Oration. Public health in Australia - problems and
prospects. James Cook University and Public Health Association of
Australia, 2001. Unpublished (available from the author).
Australian Institute of Health and Welfare. Australia's health 2002.
Canberra: AIHW 2002. (AIHW Catalogue No. AUS-25.)
Ring I. Inequalities in health. The challenge for the nineties. The
1992 Elkington Oration. Brisbane: Queensland Health, 1993.
National Aboriginal Health Strategy Working Party. A National
Aboriginal Health Strategy. AGPS, 1989.
(Received 10 Jul, accepted 17 Oct 2002)

James Cook University, Brisbane, QLD.

Ian T Ring, MB BS, FAFPHM, Adjunct Professor of Public Health.
Australian Indigenous Doctors Association, Manuka, ACT.

Ngaire Brown, B Med, MPHTM, Chief Executive Officer.
Correspondence: Dr Ian T Ring, James Cook University, Townsville, QLD
4811. ian.ringATjcu.edu.au

Other articles have cited this article:
Paul Bauert, Elizabeth McMaugh, Carmel M Martin and Janet K Smylie.
Indigenous health: chronically inadequate responses to damning
statistics Med J Aust 2003; 178 (5): 246. [Letters]
http://www.mja.com.au/public/issues/178_05_030303/
letters_030303_fm-6...

Tim Usherwood. Chronic illness in the middle years Med J Aust 2003;
179 (5): 239. [Through Life]
http://www.mja.com.au/public/issues/179_05_010903/ush10273_fm.html

Stephen R Leeder. Achieving equity in the Australian healthcare
system* Med J Aust 2003; 179 (9): 475-478. [Healthcare]
http://www.mja.com.au/public/issues/179_09_031103/lee100203_fm.html

Nicholas J Talley. Helicobacter pylori infection in Indigenous
Australians: a serious health issue? Med J Aust 2005; 182 (5):205-206.
[Editorials]
http://www.mja.com.au/public/issues/182_05_070305/tal10003_fm.html

Joan Cunningham, Alan Cass and Peter C Arnold. Bridging the
treatment
gap for Indigenous Australians Med J Aust 2005; 182 (10): 505-506.
[Unequal Treatment - Editorial]
http://www.mja.com.au/public/issues/182_10_160505/cun10262_fm.html

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