Part two: Progress in the national effort to close the gap

(a) Progress against the achievement of life expectancy equality

In 2009, the ABS began to estimate Aboriginal and Torres Strait Islander life expectancy over periods of three years (to have a greater deaths certificates ‘pool’ than that provided by one-year periods) and to use the five-yearly Censuses to verify the accuracy of the identification of Aboriginal and Torres Strait Islander people on death certificates.^[57]

As noted in the Campaign Steering Committee’s 2012 Shadow Report, the reliance on the Census data for the verification of deaths data allows for only three points at which life expectancy can be assessed prior to 2030: 2016, 2021, and 2026. The Census in 2031 will provide data to assess whether the 2030 target was met.^[58]

In the years in between, the COAG Reform Council has relied on mortality rates data as proxy indicators for life expectancy, with both 1998 and 2006 baselines for data established. Using a 1998 baseline, the COAG Reform Council’s 2011-12 Report shows decreasing deaths rates in Queensland and the Northern Territory. These decreases drive an overall positive change in what it refers to as a ‘five state total’. The ‘five state total’ is the five states whose deaths data is deemed reliable and which therefore acts as a proxy national indicator. This good news should be tempered by the findings that there were no significant changes to death rates in three of the states (South Australia, New South Wales and Victoria). Further, the Northern Territory remained the only ‘on target’ jurisdiction likely to meet the 2031 equality target.^[59]

Figure 1.1 Average annual change in Indigenous death rates per 100 000 from 1998 to 2011 and change required to meet 2031 target.

	Average annual change 1998-2011		Average annual change required from 2011 to meet 2031 target
	Indigenous	Non-Indigenous	Indigenous
NSW	ns	-6.5	-34.4
Qld	-18.0	-10.1	-40.7
WA	ns	-9.2	No published target
SA	ns	-6.8	-29.2
NT	-47.0	-10.8	-47.1
Total	-12.2	-7.8	-40.3

Note: ns No significant change.
Source: ABS - see Appendix D.

Source: COAG Reform Council, Indigneous Reform 2011-12: Comparing Performance Across Australia, p 14.

In 2013, noting the slow progress against the life expectancy target seen so far, the COAG Reform Council noted that ‘efforts to improve Indigenous life expectancy may take many years to show results’.^[60]

Improvements to life expectancy

In November 2013, the ABS published a revised life expectancy estimate for Aboriginal and Torres Strait Islander people in 2010-2012,^[61] being 69.1 years for Aboriginal and Torres Strait Islander men and 73.7 years for women.^[62] Although within the margin for error,^[63] this was taken at face value by the ABS as evidence of a slight reduction in the life expectancy gap of 0.8 years for men and 0.1 years for women since 2005-07.^[64]

	2005-07	2010-12	Change from 2005-07 to 2010-12
Men	11.4	10.6	-0.8
Women	9.6	9.5	-0.1

The Campaign Steering Committee did not expect that turning round years of health inequality would occur rapidly at the startup phase of the national effort to close the gap - that commenced in July 2009. In that regard it is reasonable to assume that many of the Aboriginal and Torres Strait Islander deaths that occurred over 2005-06 – 2010-12 were the result of chronic conditions that built up in the decades prior to 2009. This is borne out by the analysis of the COAG Reform Council mortality data referred to above. It found for the five state total, over 2011-12 the greatest single cause of Aboriginal and Torres Strait Islander deaths was circulatory diseases (26.3%) that it defined to include heart attacks and strokes.^[65]

 

Reductions in smoking rates and improvements in maternal and child health

Further evidence for the slow pace of change that might be expected in reducing rates of chronic disease without the national effort to close the gap was provided by the November 2013 release of the 2012-13 ABS Australian Aboriginal and Torres Strait Islander Health Survey (AATSIHS) results.^[66]

The data clearly demonstrated the stark reality of health inequality in this nation. However, the survey showed a significant drop in the rate of tobacco smoking among Aboriginal and Torres Strait Islander people. ABS data shows, in 2012–13, two in five (41%) Aboriginal and Torres Strait Islander people aged 15 years and over smoked on a daily basis, a decrease from 51% in 2002. This represented a progressive decrease in daily smoking rates for Aboriginal and Torres Strait Islander people, declining from 51% in 2002 to 45% in 2008, and then to 41% in 2012–13.^[67]

However, despite the decrease in the proportion of Aboriginal and Torres Strait Islander daily smokers reported in 2012-13, the ABS estimates that health outcomes will continue to reflect the smoking patterns in 2002 as the damage from these high levels of smoking will take some time to dissipate.^[68]

AATSIHS also provided sobering evidence of the need for a continuing focus on changing behaviours, apart from smoking, that contribute to chronic disease. It also demonstrates the folly of cutting preventative health programs for Aboriginal and Torres Strait Islander people while the national effort is underway. Of particular concern, the survey found no significant change over time in ‘lifetime risk’ for consumption of alcohol over 2005-07 and 2012-13.^[69] It also highlighted the need for greater focus on reducing the rates of obesity^[70] and increasing the number of Aboriginal and Torres Strait Islander people engaging in daily exercise – areas where significant gaps with the non-Indigenous population are evident.^[71]

(b) Evidence that the foundations for the achievement of health and life expectancy equality by 2030 are in place

Smoking is estimated to be the single biggest cause of death for Aboriginal and Torres Strait Islander people^[72] and is estimated to contribute to 12% of the disease and mortality gap.^[73] The decline in smoking rates highlighted above is good news.

There are similar ‘green shoots’ evident in maternal and child health data that indicate slow but sure generational health improvements are occurring among Aboriginal and Torres Strait Islander people. Many of these trends were evident prior to the commencement of the national partnership agreement on 2 July 2009.^[74] However the national effort to close the gap can be expected to demonstrate an acceleration of these trends over time as the programs are given time to have impact.

From 1998 to 2011, the mortality rate of Aboriginal and Torres Strait Islander children under the age of five years decreased at a significantly faster rate than the non-Indigenous rate (by an average of 5.7 deaths per 100,000 per year compared to 1.7 deaths per 100,000 for non-Indigenous children).^[75] As a result, the five-State total is on track to meet the COAG Closing the Gap Target to halve the gap in child mortality rates by 2018. If the trend from 1998 to 2011 continues, the 2018 target will be achieved.^[76]

However, much of this reduction has been driven by reduction in Sudden Infant Death Syndrome and the scope for further reductions from this cause is diminishing.^[77] While it is likely that treatment gains have played a significant role, as discussed in last year’s Shadow Report,^[78] birth weight trends indicate the need for a stronger focus on services for mothers and babies. Nonetheless the improvements being seen suggest that significant and real improvements can be expected over time as these children grow up to become healthier adults than in previous generations.

This highlights the need to maintain funding and programs associated with the successful child and maternal health programs operated by the ACCHSs, and that were expanded by the 2008 COAG National Partnership Agreement on Indigenous Early Childhood Development with funding of $547 million over five years. Services through this agreement are delivered primarily, but not exclusively, through ACCHSs.

As an example, the New Directions Mothers and Babies Services, an element of the above national partnership agreement, were established in 82 sites by 2013.^[79] Initial funding of $90.3 million for 2007-11 was followed by an additional $133.8 million for four years in 2011-12.^[80] A second element of the national partnership agreement is a broad program for increasing access to antenatal care, pre-pregnancy and teenage sexual and reproductive health services particularly for young women. Total funding for this initiative is $107 million over six years.^[81]

The positive outcomes provide support for continuing funding for the National Partnership Agreement on Indigenous Early Childhood Development beyond July 2014.

But perhaps most importantly, these positive outcomes provide evidence of the possibility of generational change when Australian governments and Aboriginal and Torres Strait Islander peoples, work in partnership with empowered communities to address long-standing health issues.

The $1.57 billion COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes has helped contribute to the expansion of the ACCHSs (although the Campaign Steering Committee would like to see significantly more expansion through a renewed agreement). It has also underpinned programs that provide further evidence for the establishment of a foundation for significant health improvements over the next 16 years.

The Campaign Steering Committee welcomes the news that, under the leadership of the National Coordinator for Tackling Indigenous Smoking, Dr Tom Calma AO, Tackling Indigenous Smoking Teams are operational in 57 identified regions nationwide as of 30 June 2013.^[82]

In all, an additional 344 full time equivalent population health workers have been funded under the program which has been rolled out since 2010.^[83] Each Regional Tackling Smoking and Health Lifestyle Team generally comprises one Regional Tobacco Coordinator, three Tobacco Action Workers and two Healthy Lifestyle Workers.^[84] These teams work on the ground in communities to develop local programs that empower and support community members to quit including by referring them to clinicians, Quitlines and being available for one-on-one support if necessary. Among young people the focus is on preventing them from taking up smoking in the first instance.^[85]

The Campaign Steering Committee believes the accelerating impact of the Tackling Indigenous Smoking Program provides significant support for the national effort to close the gap. It also provides evidence of the value of genuine partnerships between Australian governments and Aboriginal and Torres Strait Islander communities in the national effort.

With this important foundation for reducing smoking rates in place, the Campaign Steering Committee expect further significant reductions over the next decade. The Campaign Steering Committee notes that the National Healthcare Agreement target to halve the Aboriginal and Torres Strait Islander smoking rate by 2018 provides a measure for progress.^[86] However, it is critical that funding and other support for the program continues if this to occur and the wider promise in the program realised.

Further, as discussed in part one of this report, in many Aboriginal and Torres Strait Islander communities, ACCHSs already provide a solid foundation for the necessary health gains to be made over the next 16 years and their capacity to do so was expanded by the additional funding and capacity-building provided under the national effort to close the gap. From 2008-09, supported by additional funding from national partnership agreements, there has been an increase of 30 services overall and an additional 400,000 episodes of care delivered.^[87]

It is critical, that in looking forward, Australian governments continue to build on this foundation. The Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report attributes a number of significant improvements to the national partnership agreements. These include:

• A significant increase in a range of Medicare Benefits Schedule (MBS) services claimed by Aboriginal and Torres Strait Islander people for identifying and managing chronic disease since the introduction of the Indigenous Chronic Disease Package.^[88]

• Significant increases in the number of health checks since the commencement of the national partnership agreement.^[89]

• Significant increases in the number of GP management plans and team care arrangements claimed by Aboriginal and Torres Strait Islander people through Medicare;^[90]

• Significantly improved access to medicines through the Closing the Gap Pharmaceutical Benefits Scheme (PBS) co-payment measure, with 96% of pharmacies reported to be participating in the measure.^[91]

• Drug and alcohol services have seen a 9% rise in clients over 2009-10 and 2010-11.^[92]

These findings are elaborated in the Australian Institute of Health and Welfare (AIHW) and NACCHO’s 2013 Healthy for Life Aboriginal Community Controlled Health Services Report Card.^[93] They provide a measure of the concrete results and positive health outcomes that flow from the presence of ACCHSs in communities and that can be attributed to the national effort to close the gap.

In demonstrating this service capability, ACCHSs have demonstrated their capacity to empower communities to make the necessary health gains to close the gap over the next two decades. In particular, with this essential foundation in place, significant outcomes in relation to chronic disease and maternal health can be expected over time.

(c) Necessary increases in health expenditure since 2009

The Productivity Commission’s 2012 Indigenous Expenditure Report found that government health spending was $2.02 per Aboriginal and/or Torres Strait Islander person for every dollar spent per non-Indigenous person in 2010-11.^[94]

Government spending increased by $847 per Aboriginal and/or Torres Strait Islander person over 2008-09 to 2010-11. This equated to an average annual growth rate of 6.1%, and contributed to an overall 12% increase in total Aboriginal and Torres Strait Islander health expenditure in that period.^[95] This is to be welcomed and reflects much needed increased funds as a result of the national partnership agreements.

Government expenditure is only part of the overall health expenditure picture. Significant private expenditure also occurs (i.e. private health insurance) and must be factored in. In fact to focus only on government significantly distorts the expenditure picture. Over 2010-11 Australian governments provided 91.4% of total Aboriginal and Torres Strait Islander health expenditure compared to 68.1% of total non-Indigenous health expenditure.^[96]

Health expenditure for Aboriginal and Torres Strait Islander people varies considerably across the states and territories. For example, over 2010–11, the Northern Territory spent on average $8,498 per person on Aboriginal and Torres Strait Islander people, more than twice the amount spent in New South Wales ($3,977).^[97] AIHW note that this is likely to reflect, at least in part, the higher cost of delivering services in remote areas and the economies of scale in the more populous states. It is also likely that the demand for dialysis varies in different parts of Australia. A similar but less pronounced pattern was observed for non-Indigenous Australians, with the Northern Territory spending approximately 29% more per non-Indigenous person than New South Wales.^[98] Nonetheless the differences between various jurisdictions are notable and are worthy of further analysis and consideration.

 

In terms of total health expenditure over 2010–11, $1.47 was spent per Aboriginal and/or Torres Strait Islander person for every dollar spent per non-Indigenous person.^[100] This ratio (1.47) was a slight increase from the ratio of 1.39 reported in 2008–09, prior to the implementation of the national partnership agreements.^[101]

AIHW note that the differences in per capita total health expenditure between Indigenous and non-Indigenous Australians are likely to reflect:

• Differences in the average costs of delivering goods and services to the two populations. In 2010–11, 23.3% of Aboriginal and Torres Strait Islander people lived in remote and very remote areas of Australia where the cost of providing health goods and services is significantly higher than for the vast majority of non-Indigenous Australians who do not.^[102]

• Differences in the way Aboriginal and Torres Strait Islander people use the health system. In 2010-11, 40% of total Aboriginal and Torres Strait Islander health expenditure was for the use of hospitals, compared to approximately 25% of total non-Indigenous expenditure.^[103] Every dollar that can be redirected into primary health care service, from the hospital system, is money better spent and ‘proactively’ contributes to better health outcomes rather than being ‘reactive’ spending that does not drive health improvements.

Looking forward, the Campaign Steering Committee is concerned that the next tranches of Aboriginal and Torres Strait Islander people’s health expenditure data, for 2012-13 and 2014-15, may show significant cuts to Aboriginal and Torres Strait Islander health expenditure.

 

 

 

(d) Conclusion

Since the commencement of the national effort to close the gap in July 2009, reductions in smoking rates and maternal and child health outcomes in particular have been demonstrated. These positive outcomes provide some evidence that the national effort to close the gap is working, and that generational change is possible and they provide encouragement that the gap will close by 2030.

The demonstrated impact of ‘closing the gap’-related investment in the ACCHSs is another sign of change occurring. In this, a substantial foundation has been built that will help underpin the long-term address to chronic disease necessary over the next two decades.

Time must be allowed for ‘big picture’ change to be seen. Life expectancy rates, in particular, can only be expected to change at a slow pace. It did not surprise the Campaign Steering Committee that the new Aboriginal and Torres Strait Islander life expectancy estimate indicated only small absolute and relative gains over 2005-07 and 2010-12. This is because the estimate largely relates to the period prior to the national effort to close the gap and the associated funds ‘hitting the ground’ and having an impact. It tells us why the national effort and the national partnership agreements were, and remain, necessary. It is still too early to assess the impact of the national effort and the agreements themselves with such information.

In the context of achieving Aboriginal and Torres Strait Islander health equality, the ‘false economy’ of short-term savings as evidenced in the past 18 months must be examined critically. A dollar saved today may result in the need to spend many more in years to come. In particular, the national effort to close the gap requires a shift from expenditure on hospitals to that on primary health care with its preventative emphasis, as well as preventative health programs per se, and health promotion activities.

The longer-term prospect (i.e. by around 2030) is that spending on Aboriginal and Torres Strait Islander health will begin to reach parity with the non-Indigenous population as health equality is achieved. However, at this point in time and for the foreseeable future increased spending should be expected.

In particular, investment in the national effort to close the gap must continue and shortsighted cuts to preventative and related programs must stop. The $1.57 billion National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes expired in June 2013, and the $564 million National Partnership Agreement on Indigenous Early Childhood Development will expire in June 2014. The upkeep of such agreements and the continuation of guaranteed funding over significant spans of time is a critical factor. Funding levels must be maintained at least over the next agreement cycle, if not beyond.

---

^[57] Life tables for the Aboriginal and Torres Strait Islander Australian population for the period 2005 to 2007 were first published in May 2009 in Australian Bureau of Statistics, Experimental Life Tables for Aboriginal and Torres Strait Islander Australians, 2005–2007 (cat. no. 3302.0.55.003), 2009.
^[58] See above note 37.
^[59] COAG Reform Council, Indigenous Reform 2011-12: Comparing performance across Australia, 2013, p 14. URL: http://www.coagreformcouncil.gov.au/reports/indigenous-reform/indigenous-reform-2011-12-comparing-performance-across-australia (Accessed 14 January 2014).
^[60] As above, p 7.
^[61] Australian Bureau of Statistics, Life Tables for Aboriginal and Torres Strait Islander Australians, 2010-2012, (cat. no. 3302.0.55.003), 2013. URL: http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/BD51C922BFB7C6C1CA257C230011C97F/$File/3302055003_2010-2012.pdf (Accessed 14 January 2014).
^[62] As above, p 6.
^[63] As above, pp 45-46.
^[64] As above, p 6.
^[65] See above note 59, p 14.
^[66] Results for this survey are being released over 2013-14. Australian Bureau of Statistics, Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia, 2012-13 (cat. no. 4727.0.55.001), 2013. URL: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4727.0.55.001Main%20Features99992012-13?opendocument&tabname=Summary&prodno=4727.0.55.001&issue=2012-13&num=&view= (Accessed 14 January 2014).
^[67] As above, Tobacco Smoking. URL: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/39E15DC7E770A144CA257C2F00145A66?opendocument (Accessed 14 January 2014).
^[68] As above.
^[69] As above, Alcohol consumption – Lifetime and single occasion risk, http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/3D7CEBB5503A110ECA257C2F00145AB4?opendocument (Accessed 14 January 2014).
^[70] As above, Overweight and Obesity, http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/A07BD8674C37D838CA257C2F001459FA?opendocument (Accessed 14 January 2014).
^[71] As above, Exercise levels, http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/D2ACE34A8487C1C7CA257C2F00145B46?opendocument (Accessed 14 January 2014).
^[72] See above note 7.
^[73] Vos, T., Barker, B., Stanley, L., Lopez, A., The Burden of Disease and Injury in Aboriginal and Torres Strait Islander peoples 2003, The University of Queensland, 2007.
^[74] The agreement was due to commence on 1 January 2009, but was revised and was signed on the 2 July 2009 COAG meeting. See above note 8, p 4.
^[75] See above note 59, p 21.
^[76] As above, p 21.
^[77] Australian Health Ministers’ Advisory Council, Aboriginal and Torres Strait Islander Health Performance Framework 2012, 2012, p 171. URL: http://www.health.gov.au/internet/publications/publishing.nsf/Content/oatsih-hpf-2012-toc (Accessed 14 January 2014). Sudden Infant Death Syndrome is no longer counted as a separate indicator apart from infant mortality.
^[78] Close the Gap Campaign Steering Committee, Shadow Report 2013 - On Australian governments’ progress towards closing the gap in life expectancy between Indigenous and non-Indigenous Australians, 2013, p 16.URL: http://www.humanrights.gov.au/close-gap-indigenous-health-campaign#shadow (Accessed 14 January 2014).
^[79] NIRA Review Working Group, Review of the National Indigenous Reform Agreement Performance Framework, Final Report, Commonwealth of Australia, 2011, p 14. URL: http://www.coag.gov.au/node/447 (Accessed 14 January 2014).
^[80] As above.
^[81] As above.
^[82] Correspondence, Dr Tom Calma AO and the author, December 2013 (on file).
^[83] As above.
^[84] As above.
^[85] As above.
^[86] National Healthcare Agreement 2012, Council of Australian Governments, 2012, p A-5. URL: http://www.federalfinancialrelations.gov.au/content/npa/healthcare/national-agreement.pdf (Accessed 14 January 2014).
^[87] Comparing with data presented in: See above note 31.
^[88] See above note 77, p 4, 149.
^[89] As above, p 4.
^[90] As above, p 129.
^[91] As above, p 153.
^[92] As above, p 143.
^[93] Australian Institute of Health and Welfare, National Aboriginal Community Controlled Health Organisation, Healthy for Life, Aboriginal Community Controlled Health Services Report Card, 2013. URL: http://www.naccho.org.au/download/naccho_health_futures/NACCHO%20AIHW%20healthy%20for%20Life%20Report%20Card.pdf (Accessed 14 January 2014).
^[94] Steering Committee for the Review of Government Service Provision (Productivity Commission), Indigenous Expenditure Report, Commonwealth of Australia, 2012, p 127. URL: http://www.pc.gov.au/__data/assets/pdf_file/0007/119356/indigenous-expenditure-report-2012.pdf (Accessed 14 January 2014).
^[95] Australian Institute of Health and Welfare, Expenditure on health for Aboriginal and Torres Strait Islander people 2010–11, 2013, p vii. URL: http://www.aihw.gov.au/publication-detail/?id=60129542787 (Accessed 14 January 2014).
^[96] As above.
^[97] As above, p 15.
^[98] As above.
^[99] As above, p 21.
^[100] As above, pp vii, 6.
^[101] As above, p vii.
^[102] As above, p 8.
^[103] As above, p 8.
^[104] See above note 78.
^[105] Hurst, D., Healthy Lifestyles program funding cut, Brisbane Times, 24 September 2012. URL: http://www.brisbanetimes.com.au/queensland/healthy-lifestyle-programs-funding-cut-20120924-26fsf.html, in particular, see link to Queensland Health document setting out discontinued grants to various programs: http://images.brisbanetimes.com.au/file/2012/09/24/3660778/health.pdf (Both accessed 14 January 2014).
^[106] NSW Health Told to Find $3 billion In Savings, ABC News, 4 September 2012. URL: http://www.abc.net.au/news/2012-09-14/243-billion-squeezed-from-nsw-health-budget/4260814 (Accessed 14 January 2014).
^[107] Wills, D., 200 nursing positions to be cut from South Australian hospitals in health department savings blitz, The Advertiser, 30 September 2013. URL: http://www.adelaidenow.com.au/news/south-australia/nursing-positions-to-be-cut-from-south-australian-hospitals-in-health-department-savings-blitz/story-fni6uo1m-1226730350856 (Accessed 14 January 2014); South Australian Government to cut health services, ABC News, 9 August 2013. URL: http://www.abc.net.au/news/2013-08-09/health-sector-cuts-jack-snelling-jobs-mental-health-report-/4875228 (Accessed 14 January 2014).
^[108] Hockey, J., Robb, .A, Final Update on Coalition Election Policy Commitments, (Media Release), 5 September 2013. URL: http://www.liberal.org.au/latest-news/2013/09/05/final-update-federal-coalition-election-policy-commitments (Accessed 29 November 2013)
^[109] Crowe, D., Health costs under microscope, The Australian, 27 November 2013. URL: http://www.theaustralian.com.au/national-affairs/policy/health-costs-under-microscope/story-fn59nokw-1226769098588#sthash.RXp1mCcQ.dpufhttp://www.theaustralian.com.au/national-affairs/policy/health-costs-under-microscope/story-fn59nokw-1226769098588# (Accessed 14 January 2014).
^[110] Commonwealth Agencies to be Cut by Abbott Government, News.com.au, 22 September 2013. URL: http://www.news.com.au/national/commonwealth-agencies-to-be-cut-by-abbott-government/story-fncynjr2-1226724733088 (Accessed 14 January 2014).