The Link Between Primary Health Care and Health Outcomes for Aboriginal and Torres Strait Islander Australians

The health of Indigenous peoples

This review explores the evidence both domestically and internationally as to whether access to high quality primary health care is essential to enhancing Indigenous health status.

Page last updated: June 2008

Indigenous peoples, who have come to be known as the ‘Fourth World’ or ‘nations without states’ are found in many countries. However, the position and health status of the ‘Fourth World’ is strongly affected by that of the country within which they are located. Australia, as a First World, wealthy nation with a small – but in health terms, highly disadvantaged – Indigenous population, is most often compared to other nations in a similar position, namely the United States, Canada and New Zealand.

In this section we shall follow this convention and look briefly at the changing health status of Native American, Canadian First Nations, and New Zealand Maori populations, before turning to look at the latest data on health status of Australian Indigenous people.

The changing health status of Indigenous peoples of New Zealand, Canada, and United States

There are numerous methodological difficulties with estimating mortality rates / life expectancy figures for Indigenous populations, not least the problems centring around either the identification of ethnicity on death records or the estimation of the total Indigenous population.60 All attempts to estimate life expectancies, and especially to compare them over time or across countries should therefore be treated with caution; in particular international comparisons are subject to the different methodologies used in different countries to estimate life expectancy and other measures of health status.61

Nevertheless, it is universally accepted that measured by life expectancy and mortality rates, the health of Indigenous peoples in First World countries is significantly worse than that of the mainstream populations of those countries. What is also clear is that the health status of these populations – no less than that of nations as a whole – is not static.

In New Zealand, for example, the picture over the last half-century has been mixed. In the early 1950s, life expectancies for Maori were 54 years for men and 56 years for women, with a gap of around 14 and 17 years to non-Maori men and women respectively.

Maori life expectancy then increased rapidly from the 1950s until the early 1980s to around 64 years for men and 69 years for women and at this time the life expectancy gap with non-Maori had narrowed substantially to only 6 to 8 years. However, during the 1980s and 1990s, Maori life expectancy remained relatively static, only improving by around 2 years while non-Maori life expectancy continued a steeper upward path.
By 1999, the life expectancy gap therefore widened quite dramatically to around 10 years – or back to what it had been in the early to mid-1960s.62 (Fortunately, the early years of the twenty-first century have seen Maori life expectancy begin to increase once more).
A similar pattern is evident in the United States, where between 1940 and 1980 there were substantial improvements in the health of Native Americans as measured by life expectancy: female Native American life expectancy improved dramatically by 23 years over this period to around 75 years; male Native American life expectancy improved by 16 years to around 67 years.63 At this point the life expectancy gap with the ‘white’ population was down to only 3 to 4 years.64

However, it appears there has been little major improvement in Native American life expectancy since around 1980, while the life expectancy of the non-Native population continued to improve. By the mid 1980s, the gap had widened to almost 5 years (both sexes) and by the period 1996-98 it was almost 6 years.65

Canada shows a slightly different pattern: the data since the mid-1970s show a fairly steep improvement in First Nations life expectancy between 1975 and 1990 (from around 59 years for men and 66 years for women, to around 67 years for men and 74 years for women). This period saw the life expectancy gap between First Nations peoples and Canadians as a whole narrow from 10 to 11 years in 1980 to 7 to 8 years in 1990.

Since then the rate of increase in First Nation life expectancy has been improving at a slower rate, In 2000, life expectancy at birth for ‘Registered Indians’ was estimated at around 69 years for men and a little under 77 years for women. This slowing of improvements meant that the 1990s saw no appreciable improvement in the gap in life expectancy between First Nation and Canadian men in general (7.4 years in 2000), while for women it narrowed slightly (down to 5.2 years in 2000).66

The health of Indigenous peoples in First World countries, measured by life expectancy, is significantly worse than that of the mainstream populations of those countries.

Broadly speaking, New Zealand, the United States and Canada saw major health improvements for Indigenous populations up to around the 1980s, leading to an appreciable narrowing of the gap in life expectancy between Indigenous and mainstream populations. However, between the 1980s and the end of the century, a slowing or stalling of Indigenous health improvements measured by life expectancy meant that the gap failed to close significantly (Canada) or even widened (New Zealand and the United States).

Aboriginal and Torres Strait Islander health status

The health status of Australia’s Indigenous peoples has often been compared unfavourably with that of other Indigenous peoples in First World Countries. This is unfortunately borne out by the facts.

Aboriginal and Torres Strait Islander life expectancy

The life expectancy gap in Australia between Indigenous people and the mainstream population is greater than that in the countries examined above: the most recent Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) figures for the period 1996-2001 give life expectancies for Indigenous males and females of around 59 years and 65 years respectively, compared to 77 years and 82 years for the populations as a whole. This gives a gap in life expectancy of around 17 years for both sexes – considerably greater than that seen in the other First World countries.67
It is important to note the qualified nature of these figures; the ABS themselves note that data problems meant that experimental methods are used to calculate life expectancies and that the estimates they come up with should only be used as indicative.68

Indeed, a recent study69, using what the authors describe in depth as a stronger methodology, derives life expectancy figures for Indigenous Australian 4 to 5 years higher than the ABS estimates for the same period as above (69 years for female and 64 for male) with a corresponding narrower life expectancy gap of 13 and 12 years. Nevertheless, the authors come to the same conclusion as the AIHW/ABS and indeed every other commentator: that, measuring health by life expectancy, the Indigenous population of Australia is significantly more disadvantaged than those of Canada, New Zealand or the United States.

Aboriginal and Torres Strait Islander life expectancy in 1996-2001 has been officially estimated at around 60 years for men and 65 for women, with a gap to non-Indigenous life expectancies of around 17 years for both sexes. Other estimates have put the life expectancy of Australia’s Indigenous people higher (at around 64 years for men and 69 years for women) and the life expectancy gap consequently lower.

Irrespective of which figures are used, it is clear that, measured by life expectancy, Aboriginal and Torres Strait Islander people have worse health than their Indigenous counterparts overseas, with a much greater life expectancy gap to the mainstream population.

Closing the Gap

Whatever the estimates of life expectancy, there has been much criticism of the apparent inability of Australia to narrow the gap between the life expectancy of Indigenous and non-Indigenous Australians.70

These criticisms – based not just on the statistics but also backed up by the life experience of Aboriginal and Torres Strait Islander people – have considerable weight and have been the subject of innumerable reports, campaigns and lobbying by Aboriginal communities, their representative health services, and their supporters.

Recently the issue has been taken up forcefully in a national campaign to ‘Close the Gap’ in life expectancy, supported by more than 40 Indigenous and non-Indigenous organisations, including Oxfam Australia, and calling on governments to commit to closing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation.71

This aim has now been adopted by the incoming Federal Government, with the Prime Minister, in his Apology to Australia’s Indigenous Peoples on 13 February 2008, committing the Government to closing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation. This target along with halving the gap in mortality rates for Indigenous children under five within a decade was also endorsed by all Australian jurisdictions at the Council of Australian Governments meeting on 20 December 2007.

The changing nature of Indigenous health

The campaigns for narrowing the gap between the health of Aboriginal and Torres Strait Islander people and other citizens are clearly justified, and any government commitment to closing the health gap will no doubt be widely welcomed.

However, a concentration on the relativity of Aboriginal and Torres Strait Islander health compared to mainstream health can sometimes mask improvements in the absolute health status of Indigenous Australians. One of the unintended consequences of this has been an assumption that the statistics are relentlessly bad, that 'nothing ever changes’ in Aboriginal health and that (in some minds at least) we should therefore be sceptical about the possibilities of genuine improvements in Aboriginal health.

Against this view must be placed some of the positive changes in Indigenous health status measured over time, in particular using the key measures of life expectancy and mortality.

On a national level (based on data from WA, NT and SA), the most recent Aboriginal and Torres Strait Islander Health Performance Framework Report 2006 reports positive results in overall mortality rates (which decreased by 24% for women and 6% for men between 1991 and 2003), as well as infant mortality which declined by 44%, and perinatal mortality which fell by around 55% over the same period.72

Consistent with falling mortality, life expectancy at birth may also be rising. ABS figures appear to document an improvement from 1991-1996 to 1996-2001, but the Bureau cautions against comparing the figures due to different methodologies in calculation for the two periods. Nevertheless, the alternative, and methodologically consistent, method of calculating life expectancies referred to above saw a modest increase between the two periods of around 1 year for both men and women.73

It has been suggested that one reason for the cynical view about the possibility of positive change in Aboriginal and Torres Strait Islander health is the lack of long-term, reliable datasets that are able to track life expectancy and mortality changes over many decades.74

In the Northern Territory, however, a number of studies based on a reliable dataset of death registrations stretching back into the 1960s have been able to and extend the picture.

It appears that in that jurisdiction, between 1967 and 2004 life expectancy at birth increased by 8 years for Indigenous men and around 14 years for Indigenous women (to 60 and 68 years respectively) and the gap between Indigenous and non-Indigenous life expectancies declined for women from over 20 years in the 1960s to around 15 years (while still unfortunately increasing for men from 15.5 to 17.7 years).75

During this period, mortality rates declined in all age groups but especially in infant / early childhood mortality, and in older age groups for infectious, maternal and nutritional conditions with a moderate decline in injury mortality.76

Despite the fact that the gap in life expectancy has not narrowed appreciably, there have been some positive changes in Aboriginal and Torres Strait Islander health status that give grounds for optimism such as significant decreases in Indigenous overall mortality, infant mortality and perinatal mortality rates during the 1990s.

Research from the Northern Territory indicates improvements in life expectancy (by 8 years for Indigenous men and 14 years for Indigenous women) from the 1960s until 2004. Most of this was the result of substantially improved infant mortality rates.

60 For a discussion of some of these, see Hill, K., B. Barker, et al. (2007). "Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?" International Journal of Epidemiology 36(3): 580-589. We note that the estimation – and especially the comparison – of Indigenous health status is complex and fraught with such difficulties; accordingly, we can only provide a brief sketch of the main facts here.
61 For more information on this important and technically complex area, see Hill, K., B. Barker, et al. (2007). "Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?" International Journal of Epidemiology 36(3): 580-589.
62 Ajwani, S., T. Blakely, et al. (2003). Decades of Disparity: Ethnic mortality trends in New Zealand 1920-1999. Wellington, Ministry of Health and University of Otago.
63 Condon, J. R., T. Barnes, et al. (2004). "Improvements in Indigenous mortality in the Northern Territory over four decades." Australian and New Zealand Journal of Public Health 28(5): 445-451.; National Centre for Health Statistics (2007). Health, United States, 2007 with Chartbook on Trends in Health of Americans. U. D. o. H. a. H. Services. Washington DC, US Government Printing Office.
64 Condon, J. R., T. Barnes, et al. (2004). "Improvements in Indigenous mortality in the Northern Territory over four decades." Australian and New Zealand Journal of Public Health 28(5): 445-451.
65 Hill, K., B. Barker, et al. (2007). "Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?" International Journal of Epidemiology 36(3): 580-589.
66 Health Canada "Statistical Profile on the Health of First Nations in Canada.", Health Canada. (2002). "Healthy Canadians: A Federal Report on Comparable Health Indicators 2002." from http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2002-fed-comp-indicat/2002-health-sante5_e.html.
67 AHMAC Australian Health Ministers' Advisory Council (AHMAC) (2006). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. AHMAC. Canberra.
68 Ibid. p 148
69 Hill, K., B. Barker, et al. (2007). "Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?" International Journal of Epidemiology 36(3): 580-589.
70 Ring, I. and D. Firman (1998). "Reducing indigenous mortality in Australia: lessons from other countries." Medical Journal of Australia 169: 528-533.; Kunitz, S. J. and M. Brady (1995). "Health care policy for Aboriginal Australians: the relevance of the American Indian experience." Aust. NZ J Public Health 19: 549-58.
71 See Oxfam Australia at http://www.oxfam.org.au/campaigns/indigenous-health/
72 Australian Health Ministers' Advisory Council (AHMAC) (2006). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. AHMAC. Canberra.
73 Hill, K., B. Barker, et al. (2007). "Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?" International Journal of Epidemiology 36(3): 580-589.