Background

This is the third report against the Aboriginal and Torres Strait Islander Health Performance Framework (HPF). The first report, published in 2006, was developed under the auspice of the Australian Health Ministers’ Advisory Council to provide the basis for measuring the impact of the National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH).

The HPF is designed to inform policy analysis, planning and program information to support the goal of the NSFATSIH which is to ensure ‘that Aboriginal and Torres Strait Islander peoples enjoy a healthy life equal to that of the general population that is enriched by a strong living culture, dignity and justice.’ Results from this report can be used to review current commitments and guide further comprehensive and coordinated effort to close the gap in Indigenous disadvantage.

The HPF monitors progress in closing the gap in Indigenous health outcomes, health system performance and broader determinants of health. Health systems comprise all the organisations, resources and activities whose primary purpose is to improve health. Governments, through their stewardship role in policy, planning and program delivery, have a key role to play in defining vision and direction as well as exerting influence and measuring performance. The HPF comprises three tiers:

Tier 1—Health status and outcomes

Measures of prevalence of disease or injury, human function, life expectancy and wellbeing. How healthy are people? Is it the same for everyone? What are the opportunities for improvement?

Tier 2—Determinants of health

Measures of the determinants of health including socioeconomic status, environmental factors and health behaviours. Are the factors that determine good health changing? Is it the same for everyone? Where and for whom are these factors changing?

Tier 3—Health system performance

Measures of the health system including effectiveness, responsiveness, accessibility and sustainability, and how they are changing over time.

Data quality issues limit the ability to monitor the health outcomes and the performance of the health system in relation to Aboriginal and Torres Strait Islander peoples (see Technical Appendix for details). Initiatives to improve data quality have been introduced in recent years, and are now yielding results. However, while there are clear improvements in several key data collections, the capacity to identify trends is still impaired by poor data from earlier periods.

COAG Targets

In December 2007, the Council of Australian Governments (COAG) re-affirmed its commitment to closing the gap in Indigenous disadvantage and endorsed a number of high-level targets including to close the life expectancy gap within a generation and to halve the gap in mortality rates for children under 5 years within a decade.

Close the gap in life expectancy within a generation

  • According to the latest data available (for the period 2005–07), the gap in life expectancy at birth between Aboriginal and Torres Strait Islander peoples and other Australians is estimated at 11.5 years for males and 9.7 years for females.
  • Assuming current improvements in total Australian life expectancy continue, an annual increase in life expectancy of 0.8 years for Indigenous males and 0.6 years for females is needed to close the gap in life expectancy by 2031. As improving life expectancy is dependent on initiatives across the determinants of health, it is still too early for the data to demonstrate progress for this target.
  • The next five years will provide a clearer picture of how the mortality gap is changing and the progress towards meeting the life expectancy target by 2031. In the absence of trend data for Indigenous life expectancy, mortality rates provide an indication of progress. While there has been a decline in Indigenous mortality over the last two decades, there has also been a decline in non-Indigenous death rates and although the mortality gap has narrowed it has not closed.

Halve the gap in mortality rates for Indigenous children under 5 within a decade

  • In 2008, the national Indigenous child mortality rate was 221 per 100,000 compared to 100 per 100,000 for non-Indigenous children. This makes the baseline gap 121 per 100,000.
  • To achieve the target, the gap in national child mortality rates needs to reduce to 60 per 100,000. This would require 18 fewer Indigenous deaths of children aged under five years over the decade.
  • Based on historical data, if current trends continue, it is likely that Indigenous child mortality rates will fall within the range of the target by 2018.
Effective primary care underpins almost all the strategies that can be delivered through the health system (e.g. antenatal care, immunisation, early detection and screening and chronic disease management), and many of the strategies targeted at healthy behaviours. Strengthening the system of comprehensive primary care can be expected to have substantial benefits to health outcomes.

Tier 1: The health status of Aboriginal and Torres Strait Islander peoples

Improvements

Mortality

  • All-cause mortality rates for Aboriginal and Torres Strait Islander peoples living in Western Australia, South Australia and the Northern Territory declined by 25% between 1991 and 2008 and the gap has narrowed. There have been greater declines for Indigenous women compared with Indigenous men. Recent trends based on data from the above jurisdictions and New South Wales and Queensland combined show no significant changes in Indigenous mortality rates between 2001 and 2008.

Avoidable mortality

  • There has been a significant decline in Indigenous deaths due to avoidable causes and the gap has narrowed.

Circulatory disease

  • Deaths caused by circulatory disease—the most common cause of death for Aboriginal and Torres Strait Islander peoples—declined by 29% between 1997 and 2008.

Infant mortality

  • Indigenous infant mortality declined by 55% between 1991 and 2008 and the gap has narrowed significantly.

Pneumonia

  • Hospitalisation for pneumonia for children aged 0–4 years declined substantially and the gap has narrowed.

Continuing concern

Chronic disease contributes to two-thirds of the health gap between Indigenous and non-Indigenous Australians.

  • Fifty-eight per cent of excess deaths are due to chronic diseases (i.e. circulatory disease as well as cancer, diabetes, respiratory disease and kidney disease).
  • While deaths from circulatory disease for Aboriginal and Torres Strait Islander peoples decreased significantly between 1997 and 2008, in recent years there has been no further closing of the gap.
  • Deaths from respiratory disease also decreased significantly during the period 1997–2008, however the gap has remained.
  • The gap between the two populations for deaths due to cancer is widening. The rate of improvement in cancer deaths has been greater for other Australians than for Aboriginal and Torres Strait Islander peoples over recent years.
  • For kidney disease the mortality gap has widened in recent years because the rate of increase in deaths is faster for Indigenous Australians.
  • There has been no improvement in deaths due to diabetes.
  • Incidence of end stage renal disease has more than tripled over the last decade.

Injury and poisoning

  • Injury and poisoning accounted for 15% of Indigenous deaths in 2004–08. Indigenous Australians died from intentional self-harm (suicide) and transport accidents at 2 and 3 times the rate of non-Indigenous Australians respectively.
  • Hospitalisation rates for injury and poisoning are twice as common as rates for non-Indigenous Australians.

Disability

  • Half of Aboriginal and Torres Strait Islander Australians aged 15 years and over have a disability or long-term health condition.

Sexually transmissible infections

  • Notifications for chlamydia and gonorrhoea infections have continued to increase.

Hospitalisation

  • Hospitalisation rates for Aboriginal and Torres Strait Islander peoples are 40% higher than for other Australians excluding dialysis and 230% higher including dialysis. The main factors causing the increase are admissions for renal dialysis, circulatory diseases and diabetes complications. The implications of the increase in hospitalisations are not clear. It may reflect increases in the incidence and prevalence of disease, improved access to primary health care, hospital care and/or better identification of Aboriginal and Torres Strait Islander people in hospital data.

Low birthweight

  • This is twice as common for babies born to Aboriginal and Torres Strait Islander mothers than other Australian babies. The rate also appears to be increasing. There is a strong relationship between smoking during pregnancy and low birthweight.

Chronic ear disease

  • Indigenous children are 3 times more likely to be diagnosed with severe otitis media than non-Indigenous children.

Oral health

  • Aboriginal and Torres Strait Islander children have 50% more decayed, missing and filled teeth than non-Indigenous children indicating a large unmet need for dental care.

Tier 2: Health Determinants

Improvements

Access to functional housing

  • In 2008, 99% of Indigenous households reported that they had working facilities for washing people, 94% reported working facilities for washing clothes/bedding, 94% reported working facilities for storing/preparing food and 98% reported working sewerage systems.
  • This varied considerably by remoteness, with 21% of Aboriginal and Torres Strait Islander people in very remote communities reporting a lack of working facilities for the storage and preparation of food.

Education

  • For reading, there was a slight reduction in the gap between Indigenous and non-Indigenous students for Years 3, 5 and 7 between 2008 and 2009. There was also a decline in the gap for numeracy for Years 5 and 9. Although small, these improvements are in the right direction.

Employment

  • The employment rate for Indigenous Australians increased from 44% to 54% between 2001 and 2008.

Continuing concern

Smoking

  • In 2008, 47% of Aboriginal and Torres Strait Islander Australians aged 15 years and over smoked. This was a small but potentially important improvement from 2002, when the rate was estimated to be 51%.
  • Around half of Indigenous Australian women smoke during pregnancy, 3 times the rate of other pregnant women.
  • An estimated 65% of Aboriginal and Torres Strait Islander children aged 0–14 years live in households with a current daily smoker compared with 32% of non-Indigenous children.

Physical activity

  • In 2004–05, 47% of Aboriginal and Torres Strait Islander people aged 15 years and over in non-remote areas reported being sedentary. This increased from 37% in 2001. This was one and a half times the rate for other Australians.

Nutrition

  • In remote areas, 20% of Indigenous people aged 12 years and over reported no usual daily fruit intake and 15% reported no usual daily intake of vegetables. The corresponding proportions for Indigenous people aged 12 years and over in non-remote areas were 12% and 2% respectively.
  • Aboriginal and Torres Strait Islander people aged 12 years and over were twice as likely to report no usual daily fruit intake and 7 times as likely to report no daily vegetable intake as non-Indigenous Australians (ABS 2006a).

Overweight and obesity

  • Rates of overweight and obesity increased steadily between 1995 and 2004–05. Among Indigenous people aged 15 years and over in non-remote areas, rates increased from 51% to 60%. Indigenous Australians were nearly twice as likely to be obese as non-Indigenous Australians.

Risky/high risk alcohol consumption

  • In 2008, an estimated 17% of Indigenous people aged 15 years and over reported drinking at chronic risk/high risk levels in the past 12 months, representing no significant change since 2002 (15%).

Overcrowding in housing

  • Approximately 25% of Indigenous Australians live in overcrowded households. The problem is worse in remote areas.

Education

  • Despite some improvements in literacy and numeracy, the proportion of Indigenous students achieving the reading, writing and numeracy benchmarks in Years 3, 5, 7 and 9 remain below the corresponding proportions for all students.

Unemployment

  • Despite increasing employment rates nationally, the unemployment rate for Aboriginal and Torres Strait Islander peoples increased between 2001 and 2008 from 7% to 11%. Unemployment rates continue to remain higher than corresponding rates for non-Indigenous Australians.

Low income and the distribution of income

  • In 2008, 49% of Aboriginal and Torres Strait Islander people were in the bottom 20% of mean equivalised household incomes. The corresponding rate in 2006 was 40%.

Community safety

  • Exposure to violence, child abuse and neglect, and contact with the criminal justice system (including imprisonment) are more likely to be experienced by Aboriginal and Torres Strait Islander peoples than other Australians.

Transport

  • Fewer Indigenous households in non-remote areas (50%) had ready access to motor vehicles (i.e. garaged or parked at or near their dwelling) compared with non-Indigenous households (85%).

Tier 3: Health System Performance

Access to health care

  • Access to and utilisation of medical services is less than expected given higher levels of illness.
  • In 2004–05, the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) found that 42% of Aboriginal and Torres Strait Islander Australians reported accessing health care in the last two weeks (12 months for hospital admissions). This is similar to the non-Indigenous rates, but lower than expected given the greater burden of illness experienced by Indigenous Australians.
  • Indigenous Australians are twice as likely to visit casualty/outpatients and half as likely to see a dentist. Barriers to accessing care included cost, cultural appropriateness and transport availability.
  • In 2008, 30% of Aboriginal and Torres Strait Islander peoples aged 15 years and over reported problems with accessing health and other services (e.g. legal, employment and Centrelink). Access issues were higher in remote areas than non-remote areas. Of the people reporting having problems accessing services, close to two-thirds reported having problems accessing dentists, followed by doctors (32%), hospitals (22%) and Aboriginal and Torres Strait Islander health workers (19%).
  • In 2008, 80% of Aboriginal and Torres Strait Islander Australians aged 15 years and over agreed that their doctor could be trusted.
  • There has been a significant increase in the number of hospitalisations for Indigenous Australians for conditions that could have been treated in primary health care, particularly chronic conditions.
  • Less hospital episodes for Indigenous Australians have a procedure recorded compared with other Australians.
  • Between July 2006 and June 2008, Indigenous Australians were discharged from hospital against medical advice at almost 6 times the rate of other Australians.

Increased availability of Indigenous specific services

  • Funding of Aboriginal and Torres Strait Islander primary health care services has increased in recent years and there has been a 52% increase in episodes of care delivered through these services.

Usual source of care

  • Having a usual primary care provider is associated with good communication between the patient and provider, greater trust in the health care provider, improved preventive care and better health outcomes. Statistics from 2004–05 indicate that 91% of Indigenous Australians usually went to the same GP or Aboriginal medical service.

Antenatal care

  • Access to antenatal care is high for Aboriginal and Torres Strait Islander women but occurs later and less frequently than for other women.

Immunisation coverage for children

  • This has improved for Aboriginal and Torres Strait Islander children. By age 5, coverage rates are close to those for other Australian children.

Aboriginal and Torres Strait Islander health workforce

  • The Indigenous Australian workforce is integral to ensuring that the health system has the capacity to address the needs of Aboriginal and Torres Strait Islander peoples. In 2006, 1.2% of the Indigenous population was employed in health-related occupations. This is below the proportion of the non-Indigenous population (approximately 3%).
  • Aboriginal and Torres Strait Islander people are also under-represented in training for various health professions. Improving participation in training for health professions is a key priority across a broad range of disciplines including medicine, nursing, allied health and Aboriginal health workers.
  • Another major challenge is the recruitment and retention of staff in Indigenous-specific health services and in mainstream services located in areas with significant Aboriginal and Torres Strait Islander populations.

Access to prescription medicines

  • Has improved for Indigenous Australians but remains significantly lower than for non-Indigenous Australians.

Resources

  • On a per capita basis, average health expenditure for Aboriginal and Torres Strait Islander peoples is 31% higher than the expenditure for other Australians. This contrasts with measures of health status showing mortality rates, infant mortality and the occurrence of a broad range of diseases at much higher levels (200% to 300% higher) for Aboriginal and Torres Strait Islander peoples.
  • Expenditure estimates show higher rates for Indigenous Australians for public hospital use and community health services and lower rates for medical services through the MBS (including GP services), dental services and medications compared with non-Indigenous Australians.

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