The evidence at a national / jurisdictional level that improvements in Aboriginal and Torres Strait Islander health status (as measured by life expectancy and mortality rates) are the result of improved access to primary health care is indicative rather than direct. Furthermore, the scale of the changes – although reason for cautious optimism – is modest, corresponding to the modest improvements in funding and access, compared to the need for health care.
Falls in avoidable mortality relative to overall mortality for Aboriginal women since the early 1990s provides strong evidence that the health system as a whole is having a small but definite effect on improving health. However, without more detailed data about the categories of avoidable mortality, the evidence does not definitively associate these improvements with primary health care. However, improvements in infant mortality and changing disease mortality patterns are also suggestive of better primary health care access, though this is not conclusive at the levels of evidence that we see elsewhere in the world.
It is clear from overseas experience that despite the strong effects of socioeconomic disadvantage, improved access to primary health care leads to better health outcomes, especially in child and maternal health. This positive effect of primary health care is confirmed for Indigenous populations elsewhere. What then should we make of the relative weakness of the evidence in Australia?
The visibility of changeA contributing factor to the lack of the kind of strong evidence we see overseas for the efficacy of primary health care may be that such evidence is not yet visible, or only incompletely so, to national / jurisdictional statistical analysis in Australia.
At the national and jurisdictional level, there remain many gaps in the Aboriginal and Torres Strait Islander data. For example, the inclusion of Indigenous status on death notification forms is relatively recent in some jurisdictions (as late as the mid 1990s in Queensland)106 and only one jurisdiction (the Northern Territory) has good mortality / life expectancy data going back several decades.
Such gaps have made it difficult to demonstrate the existence of improvements in Aboriginal and Torres Strait Islander health, let alone be unequivocal about the contribution of the health system and/or primary health care to them.
It is also the case that in-depth studies to measure the efficacy of primary health care in Australia – comparable to those carried out by the John Hopkins group on county-level access to primary health care in the United States – have not been attempted in Australia, though it is unclear whether the data to support such studies is available.
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We must also consider the lag effect of improved primary health care. On some conditions (for example, infectious diseases) primary health care may have an immediate effect on mortality rates; for others (for example, chronic diseases such as ischaemic heart disease), improved access to primary health care may not have significant effects on mortality and life expectancy rates for many years.
In particular, there is now strong evidence that poor early childhood health is associated with the development of chronic disease in adult life107, as well as an increased risk of hospitalisation and premature death.108 This being the case, the full effect of the moderate increases in spending on, and access to, Indigenous primary health care during 1990s may not appear until well into this century in the shape of reduced risk of chronic disease.
In this view, primary health care is not just an immediate response to ill-health but also a long term investment in the health of populations. Consistent, sustained, long-term effort is therefore required if the full benefits of primary health care are to be realised.
A lack of high-quality long-term data may contribute to the relatively modest evidence for the positive effects of primary health care at a jurisdictional level in Indigenous Australia.
The time-lag between improvements in primary health care access and the realisation of its full benefits, particular in regard to the life-time health effects arising from good early childhood development, may also contribute to the relative weakness of the evidence in Indigenous Australia.
While data deficiencies and time lag may contribute to the weakness of the evidence at a jurisdictional level for the effect of primary health care on Aboriginal and Torres Strait Islander health status, there is no doubt that fundamentally the weakness of the evidence is a product of the only relatively small health gains made by the Aboriginal and Torres Strait Islander population.
Top of pageAs we have seen overseas, improvements in access to primary health care have a definite effect on life expectancy and mortality, but are not a magic bullet: other social determinants, particularly poverty, exert a strong negative effect on health. And in Australia, improvements in the social determinants of health for Aboriginal people have been mixed at best.
For example in the critical determinant of education, while literacy and numeracy levels in primary school have improved along with school retention rates, by both these measures Indigenous children in Australia continue to end up with a significantly poorer education than their non-Indigenous counterparts.109 It is also important to note that there may also be a significant lag in effect from improvements in education.
Similarly, with employment and income: while it appears that unemployment rates fell from 30% in 1994 to 20% in 2002 for Aboriginal and Torres Strait Islander people aged 18 to 64 years, these results must take into account the possible masking effect of CDEP, the relatively low degree of labour force participation, and the high number of long-term unemployed. Significantly, 42% of Indigenous adults in 2002 were in the lowest quintile of incomes (as measured by equivalised gross weekly household income). These figures would lead us to conclude that poverty continues to be a major driver of poor health outcomes in the Australian Indigenous community.110
There are also signs that exposure to violence, child abuse and neglect and contact with the criminal justice system (including imprisonment) are trending worse, and that physical activity is declining and overweight and obesity are increasing.111
This would lead to the conclusion that the high levels of disadvantage many Indigenous communities face in terms of income, education and infrastructure, continue to exert a dominant negative effect on health, one which the increased level of primary health care access has been able to modify but not conclusively reverse. The conclusion in the Northern Territory at least is that these social determinants continue to drive high levels of ill health, and that under these circumstance improved primary health care services can at best provide a brake on what would otherwise be accelerating mortality rates.112
The relatively modest evidence for a primary health care contribution to changes in life expectancy and mortality at a national or jurisdictional level is fundamentally a product of the (at best) modest health gains made by the Aboriginal and Torres Strait Islander population.
Consistent with the international evidence, it seems that Aboriginal and Torres Strait Islander people have yet to reap the full benefits of primary health care that their Indigenous counterparts overseas have achieved. The evidence points to further and sustained investment in primary health care, along with action on the social determinants, as a crucial strategy for ‘closing the gap’ in life expectancy between Indigenous and non-Indigenous Australians.
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Timeliness and effectiveness of primary health careNotwithstanding the continuing negative impact on health of many of the social determinants of health, we know that health systems in general, and primary health care in particular, can offset these effects to some extent through operating to prevent avoidable deaths.
To conclude this chapter, let us recall the definition of the key concept of avoidable mortality – that it constitutes those deaths which we would not expect to occur in the face of ‘timely and effective’ health care. The aim, then, if we want to reduce the number of avoidable deaths (and hence lower the overall mortality rate and higher life expectancy) is to ensure that health service in general and primary health care in particular are timely (that is, accessible) and effective.
Resourcing access to primary health careAn important point regarding the lack of strong evidence for the direct effects of primary health care on Aboriginal and Torres Strait Islander health at a national and jurisdictional level is that the scale of additional investment in primary health care has been small, and that therefore the improvements in health status are not surprisingly, small.
Welcome as the increases over the past decade or more are, no one seriously argues that they are adequate given the high burden of morbidity and mortality in the Indigenous community. Most public calls for equitable primary health care funding for Aboriginal and Torres Strait Islander communities place the extra funding required for primary health care in the $400 to $460 million per year range and have been current for around ten years.113
Against these estimates, the increases of recent years are modest at best: the real increase in annual funding for Aboriginal community controlled health services from 1998-99 to 2004-05 was a total of around $80 to $90 million; and while Medicare and PBS expenditures also increased over this period, part of this increase is the result of improved identification of Indigenous clients rather than increases in service. 114 Once population increases are taken into account, as well increasing health care costs, national expenditure on primary health services for Aboriginal and Torres Strait Islander people has not dramatically improved.115
We note also that calculations (such as those by the AMA and others, quoted above) based on meeting the deficit in health funding between Aboriginal and Torres Strait Islander and other Australians (based for example on excess morbidity and mortality rates) are imperfect. In particular, funding to meet the deficit in resources may not be sufficient to significantly closing the health gap. For example, if Indigenous communities have mortality or morbidity rates three times the mainstream rates, there is no reason to assume that therefore three times the level of funding per capita will successfully address that ill health: the ratio may be much greater than that given the high level of disadvantage in so many other areas of Aboriginal and Torres Strait Islander life.
It is also the case that funding for primary health care service delivery alone has certain limiters, especially in the form of the need for investment in capital infrastructure (especially in remote areas) and workforce development. The lack of comprehensive and funded plans to address such issues has further limited the effectiveness of moderately increased investments in primary health care delivery.
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These concerns raise the issue of a lack of an overall national approach to address Aboriginal and Torres Strait Islander health disadvantage.
The increases over the last decade in Commonwealth funding for Aboriginal community controlled health services have been important in contributing to the health gains over that period. However, these increases have not (except in the few instances where it has led to new health services) increased access to primary health care in areas which are not serviced by a community-controlled health service.
In Northern and remote Australia, many areas remain largely dependent on State / Territory government funded and/or run primary health care services. In urban areas where there is no Aboriginal community-controlled health service in the immediate vicinity, access generally depends on privately provided medical and allied health services funded by Medicare – Indigenous expenditure for which, while increasing, remains significantly lower than for non-Indigenous Australia.
Unfortunately, perhaps, the jurisdictional Framework Agreements on Aboriginal and Torres Strait Islander Health which followed the transfer of responsibility for primary health care funding did not require States and Territories to match Commonwealth funding increases. Nor was there a Commonwealth funding program to assist the States and Territories to make up the shortfall in primary health care (normally a Federal responsibility) in those States and Territories with populations largely un-serviced by the Commonwealth’s community controlled health service funding program.
Thus, in funding terms, Australia has had a ‘Commonwealth’ Aboriginal and Torres Strait Islander primary health care approach, rather than a national one. And to the extent that State and Territory Governments have not increased the resourcing of primary health care (including through funding Aboriginal community controlled services located within their jurisdictions) to anywhere near the level that the Commonwealth has, many Aboriginal and Torres Strait Islander communities have remained isolated from improvements in access to primary health care.116
The two key lessons for policy makers from this are first that a genuinely national approach is needed that involves all governments, consistent with the new Federal Government’s commitment to ending ‘the blame game’; and second that minor or incremental investments in Indigenous primary health care resourcing will (at best) produce minor or incremental changes in Aboriginal and Torres Strait Islander health status. Given the pattern of recent improvements, we can conclude that it is unlikely that such incremental changes will lead to any significant closing of the life expectancy gap between Indigenous and non-Indigenous Australians.
A national approach to addressing Indigenous health disadvantage is needed that involves action by all Australian Governments, including increasing spending on primary health care.
Incremental increases in Indigenous primary health care resourcing will (at best) lead to incremental changes in health status which are highly unlikely to lead to any significant closing of the health gap between Indigenous and non-Indigenous Australians.
Effectiveness of primary health careMany factors go towards making a health service effective, and we shall attempt to elucidate some of them in more detail in the following chapter.
Certainly, maximum participation of the community, up to and including full community control of services, is critical. The Aboriginal community-controlled health sector argues forcefully that the goal is for all Aboriginal communities to be serviced by a comprehensive primary health care under the full control of that community. However, without in any way contradicting that aspiration, there is also a powerful argument for the immediate provision of primary health care services to all Aboriginal people, as part of their rights to health. With the establishment of such services comes the responsibility for engagement with the community they serve, to maximise that community’s participation in their own health service, up to and including formal community control. Other Aboriginal Medical Services in the region and their representative organisations at a jurisdictional level have a vitally important role to play in this process.
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In addition, it is clear that the use of good evidence in designing primary health care services is important. Certain key interventions – such as child and maternal health, or chronic disease management – are essential investments in the health of Aboriginal and Torres Strait Islander communities, and all primary health care services, should deliver and be resourced to deliver at least these core services.117
Again, with the benefit of hindsight, it may be regretted that the Framework Agreements following the transfer of health funding responsibility from ATSIC to the Commonwealth Health Department, did not address the notion of the core services of primary health care, and come to an agreement about what were the minimum set of services that all primary health care services for Aboriginal and Torres Strait Islander people, regardless of governance structures, should deliver.
The barriers to such an agreement at the time were considerable: no doubt Government was concerned about the resourcing implications for such a set of core services, and some in the community-controlled sector may have been concerned that attempts to define a set of core services may have been used to impose a medical model on community-controlled services and subvert their independence. The evidence base for primary health care interventions was also relatively underdeveloped in Australia at that time.
Since then, at least some of the circumstances have changed.
First there is a clear commitment by the new Federal Government to close the life expectancy gap – an aim that is unlikely to be realised without significant additional investment in well-evidenced primary health care.
Second, the evidence itself has improved greatly since the mid-1990s about the particular interventions that are most effective.118
Third, some community-controlled health services have themselves become advocates of the need to ensure that evidence-based care is what they need to offer their communities, and indeed have become important sites where the conversation about imaginatively adapting the ‘evidence’ to local community priorities can take place. The productive nature of that conversation is reflected (as we shall see in the next chapter) in the dynamism and ability to solve problems of those services.
A national approach to closing the health gap between Indigenous and non-Indigenous Australians should ensure that all Aboriginal and Torres Strait Islander communities have access to a comprehensive suite of core primary health care services (including for chronic disease and for maternal and child health) regardless of funding streams or administrative responsibility for the health service.
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106 Freemantle, J., K. Officer, et al. (2007). Australian Indigenous Health—Within an International Context. Darwin, Cooperative Research Centre for Aboriginal Health.
107 Barker, D. J., Ed. (1993). Fetal and infant origins of adult disease. London, BMJ Publishing Group.
108 Power, C. and L. Li (2000). "Cohort study of birthweight, mortality, and disability." BMJ 320: 840-841.
109 Australian Health Ministers' Advisory Council (AHMAC) (2006). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. AHMAC. Canberra.
112 Thomas, D. P., J. R. Condon, et al. (2006). "Long-term trends in Indigenous deaths from chronic disease in the Northern Territory; a foot on the brake, a foot on the accelerator." MJA 185: 145-149.
113 Anderson, P. (2002). A packet of tomato seeds: Aboriginal health, community and capacity. Telstra National Press Club Address. Canberra, National Aboriginal Community Controlled Health Organisation. Australian Medical Association (AMA) (2007). Institutionalised Inequity. Not Just a matter of money. Report card on Aboriginal and Torres Strait Islander Health. Deeble, J. (2000). How much is needed? A needs-based funding formula for Aboriginal and Torres Strait Islander health, Australian Medical Association.
114 Australian Institute of Health and Welfare (2008). Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004–05. AIHW. Canberra.
116 We note that at the State / Territory level, increases in resourcing of health care to Aboriginal and Torres Strait Islander people have been largely through increases in Aboriginal people’s use of public hospitals.
117 Considerable work has been carried out in the Northern Territory by the community-controlled and government sectors on defining and agreeing on ‘core comprehensive primary health care services’, which include clinical services, support services (such as management and training), special programs (such as action on substance misuse, nutrition, environmental health) and advocacy and policy functions. See AMSANT web site at http://amsant.com.au/site/index.php?option=com_frontpage&Itemid=1
118 For example, see Couzos, S. and R. Murray (2008). Aboriginal primary health care: an evidence-based approach. 3rd Edition, Melbourne, Oxford University Press.; Central Australian Rural Practitioners Association (CARPA) (nd). CARPA Reference Manual, CARPA.