The Link Between Primary Health Care and Health Outcomes for Aboriginal and Torres Strait Islander Australians
Primary health care and Indigenous health: Australia
The Australian Health Ministers’ Advisory Council, after reviewing in depth the evidence about changes in Aboriginal and Torres Strait Islander health status, recently concluded that
The progress of recent years demonstrates that … government investment, particularly in primary health care, is beginning to pay dividends in some areas.85
A number of researchers looking in detail at the changes in life expectancy and mortality for Aboriginal and Torres Strait Islander communities have drawn similar conclusions.86
However, is there evidence at the jurisdictional level for primary health care delivering improved mortality or life expectancy outcomes for Aboriginal and Torres Strait Islander populations?
When we came to examine a similar question for populations as a whole in the previous chapter, we found a number of studies thrown up by our literature search which specifically addressed the question and delivered a clear ‘yes’. Unfortunately, despite some excellent evidence beginning to accumulate, Australia is yet to see specific studies in the Indigenous field that determine the relationship between primary health care access and health status as measured by life expectancy / mortality.
There are, of course, other possible measures of the effectiveness of primary health care systems, such as ambulatory care sensitive hospitalisations, that is hospitalisations which are potentially avoidable through preventive care and early disease detection and management, usually delivered in a primary health care setting.
Such measures are important in their own right. However, they fall outside the scope of this report which is focused on the less ambiguous outcome measures of life-expectancy and mortality. While clearly mortality is an unambiguously bad result, increasing hospitalisations may represent either a good or a bad health care outcome, even for causes that are theoretically preventable. Often the first impact of a developing primary health care system is to increase such admissions, of patients who might otherwise have died. Over time these admissions might be expected to fall if primary health care is of high quality and accessible.
Indigenous primary health care spending in AustraliaJust as measuring the health status of Indigenous Australians is beset by data and methodological difficulties, so is measuring expenditure on their health. While recent figures show data going back to 1995-96, earlier years are not comparable with later, and comparisons can only be made from 1998-99 onwards.87 Nevertheless, a few broad points can be made. Top of page
There is no doubt that the successful campaign by sections of the Aboriginal community-controlled health sector and others to have funding responsibility for Aboriginal primary health care transferred from ATSIC to the Commonwealth Health Department in 1995 ultimately led to increased funds for Aboriginal and Torres Strait Islander primary health care, including through such new programs as the Primary Health Care Access Program. Funding for Aboriginal community controlled health services increased from $233 per Indigenous person in 1998-99 to $426 per person in 2004-05 (in constant 2004-05 dollars), an increase of 83% to a total of $193 million.88
Further, reforms to the Medical and Pharmaceutical Benefits Schemes (MBS and PBS) to ensure that funding reached Aboriginal communities which were often not served by private General Practitioners and / or pharmacies also led to increased Aboriginal and Torres Strait Islander use of these schemes, from $237 per Indigenous person in 1998-99 to $364 in 2004-05, up 53%. (It is worth noting, however, that Aboriginal and Torres Strait Islander per capita expenditure for these schemes remains under half of that for other Australians).89
There were only minor changes ($27 per person or 4%) in State / Territory expenditures on community and public health for Aboriginal and Torres Strait Islander people over this period.
These figures demonstrate a small but real increase in investment in primary health care for Aboriginal and Torres Strait Islander communities since the 1990s. They have led to an increase in the staffing and episodes of services delivered by the Aboriginal community-controlled sector, and greater access to prescription medicines through the PBS section 100 arrangements.90
Nevertheless, these increases are not dramatic measured against the continuing high burden of morbidity and mortality in the Indigenous community, and also taking into account the fact that overall health care expenditure in Australian also increased over this period, that the Indigenous population continues to increase (and at a higher rate than the mainstream population), and that health care costs have risen over this period. Note that The implications of the evidence for resourcing of Indigenous primary health care is further discussed below. Top of page
Expenditure on Indigenous primary health care (as measured by funding of Aboriginal community-controlled health services and Aboriginal and Torres Strait Islander access to MBS and PBS) increased in real terms by 83% and 53% respectively between 1998-99 and 2004-05. However, the significance of such increases must be set against increased health care costs, an increasing Indigenous population, and continuing excess rates of morbidity and mortality in the Indigenous community.
Avoidable mortality and Aboriginal and Torres Strait Islander populationsAs we have seen, avoidable mortality is an important measure of the effect of health systems on the health of populations. The recent atlas of avoidable mortality in Australia and New Zealand91 provides extensive information, but unfortunately does not include trends over time in Indigenous avoidable mortality. Fortunately, the Aboriginal and Torres Strait Islander Health Performance Framework Report92 does and their figures for Aboriginal and Torres Strait Islander people in Western Australia, South Australia and the Northern Territory give us direct evidence about the health system’s effect.
Top of page This data shows that the period 1991 to 1996 saw significant declines in avoidable mortality among Indigenous Australians (with an average yearly decline in the rate of around 18 deaths per 100,000). Note however, that only the avoidable mortality rates for Indigenous women improved significantly relative to the non-Indigenous population.
However, the following period, 1997–2003 saw an accelerating decline in avoidable mortality rates among Indigenous Australians (an average yearly decline in the rate of around 29 deaths per 100,000) and this time the decline was significant for both Indigenous women and men relative to their non-Indigenous counterparts.
Obviously, a fall in avoidable mortality rates is positive. However, to be sure about the effect of the health system itself, it is necessary to compare changes in avoidable mortality with changes in overall mortality.
As we can see in the following graph, over the period 1991-2003, overall mortality rates for Indigenous Australians in NT, WA and WA fell by 22%, while avoidable mortality rates fell only slightly more (25%). This would indicate, at best a weak effect of the health system on the health status of Aboriginal people.
However, the differences between men and women are significant: while both total and avoidable mortality rates fell by only 7% for Indigenous men (indicating little or no effect by the health system), for women total mortality rates fell by 36%, while avoidable mortality fell by 42%, which suggests a small but definite effect by the health system between the early 1990s and the first years of the 21st century.
Top of page Critical to note at this juncture is the lag effect of health services on mortality – improvements in access to health services now, particularly primary health care services concerned with early childhood health as well as early detection and management of long-term chronic disease, may not be reflected in improved mortality / life expectancy figures for some years to come.
Declines in avoidable mortality rates compared with overall mortality rates for Indigenous women during the period 1991-2003 provide direct evidence of small but definite effect on Indigenous women’s health status by the actions of the health system.
It is not easy to determine the extent to which these falls in avoidable mortality are the result of the actions of the primary health care sector in particular.
One could hypothesise that the stark difference in the falls in avoidable mortality rates for men and women (reflected also, of course, in overall life expectancy and mortality figures which show improvements for Aboriginal and Torres Strait Islander women but few or none for men) are the result of differential access to primary health care services. This hypothesis is supported by the many primary health care service providers who note how relatively difficult it is to engage with adult men compared to women and children.
As we saw in Chapter 2, avoidable mortality has been broken down into sub-categories depending on whether mortality is avoidable through primary interventions (where the initial onset of the condition is preventable through individual behaviour change or public health policy), secondary interventions (where already established conditions are amenable to early intervention and ongoing management, particularly in a primary health care setting), or tertiary interventions (medical or surgical treatments). However, there is no publicly available breakdown of Indigenous avoidable mortality rates by these sub-categories.
Instead, there are two other sources of data which suggest that primary health care may be having an effect: infant mortality and disease mortality patterns. Top of page
Infant mortalityJust as there is a ‘life expectancy gap’, an ‘infant mortality gap’ between Indigenous and non-Indigenous peoples exists in First World countries.
In the United States, the infant mortality rate of babies born to Indigenous mothers is 9.8 per 1,000 live births, compared to 6.8 for all births (gap 3.0 per 1,000 live births); the mortality rate of Canadian First Nation infants was 6.4 per 1,000 live births compared to the overall Canadian rate of 5.3 (gap 1.1); and in New Zealand the mortality rate of Maori infants was 8.9 per 1,000 live births compared to 5.7 for the total New Zealand population (gap 3.2).93
However, just as the life expectancy gap is greater in Australia between Indigenous people and non-Indigenous people, so is the infant mortality gap: Aboriginal and Torres Strait Islander infants in 2003 had a mortality rate of 11.6 per 1,000 live births, compared to 3.4 for the other Australian infants (a gap of 8.1 per 1,000 live births).94
Although this clearly indicates an area of concern, there is positive news in that the infant mortality rate is improving and the infant mortality gap narrowing: from 1991 to 2003, in those jurisdictions with good data (WA, SA and NT), the Indigenous infant mortality rate halved from 21.9 per 1,000 live births to 11.6 per 1,000 live births, the gap likewise halving from over 16 to around 8 per 1,000 live births.95
Looking further back, at least in the Northern Territory increases in life expectancy between 1967 and 2000 were significantly due to large declines in infant / early childhood mortality, especially in the period from the 1960s to the 1980s. This has been linked to improved access to primary care services in remote areas, both through government and community-controlled services, from the 1970s onwards.96 Top of page
Experienced researchers and activists in the field point to these improvements as being the result of primary health care. And while linking these declines specifically and unambiguously to better primary health care is yet to be done, it is important to remember that the John Hopkins group (see Chapter 2) found that stronger primary health care systems are associated with better health outcomes especially relating to infant health,97 and that greater primary care resources are associated with better infant mortality rates.98
The improvements in infant mortality in Australia therefore reflect the pattern one would expect from improved primary health care services. Taken in combination with the evidence from avoidable mortality that health care systems are measurably improving Aboriginal and Torres Strait Islander women’s health in particular, this provides an indication that the primary health care system may be partly responsible for improving infant mortality rates.
Improvements in Aboriginal and Torres Strait Islander infant mortality rates are consistent with better access to primary health care services. Nevertheless, Indigenous infant mortality rates remain almost three times greater than for other Australians, and significantly worse than those for Indigenous peoples overseas.
Disease mortality patterns99We can also gain an indication of the effect of primary health care through looking at the changing patterns of mortality for specific diseases. If there are documented improvements in mortality rates for those conditions which are most susceptible to primary health care, this may indicate that it is those services which are leading to the observed health changes.
The best evidence comes from the Northern Territory, where the identification of Indigenous status and recording of causes of death allow an analysis of trends in disease mortality going back to the 1960s.
The study of Indigenous life expectancy since the 1960s in the Territory raised the possibility, that better access to primary health care and the establishment of Aboriginal primary health care services may have contributed to the improvements in this area.100 Top of page
The last forty years has seen infectious disease and respiratory infections contributing less to the gap in life expectancy between Aboriginal and non-Aboriginal people, and chronic disease contributing more. In the early 1980s, for example, communicable disease and maternal, perinatal and, nutritional conditions contributed to a little over one-third of the life expectancy gap; by the late 1990s they were contributing only one-sixth. During the same period, while non-communicable diseases rose from contributing about 60% to almost 80% of the gap in life expectancy.101 These figures are similar to those found nationally, where it is estimated that currently non-communicable diseases explain 70% of the health gap.102
This may be the result to some extent of improved housing and environmental health conditions; however, it may well also reflect the fact that infectious diseases are the ones most immediately and easily sensitive to primary health care interventions, whereas chronic diseases are both less easy to address and have a relatively long time lag before the effects of primary health care interventions are reflected in mortality and therefore life expectancy figures.
Further, a recent study of Indigenous health for the period 1977 to 2000 in the Northern Territory shows that death rates for a number of chronic diseases is slowing and even, for some conditions, beginning to fall, and that this may be attributable to better access to primary and specialist medical care gradually ‘putting the brakes on’ chronic disease mortality.103
A study of cancer mortality over the period 1977 to 2000104 has shown a rise in cancer rates associated with smoking amongst the Indigenous population of the Territory. However, there were also significant falls in mortality rates for cervical cancer – mortality which is highly avoidable through early detection by Pap smear screening105, which is in turn dependent on a functioning primary health care sector. It may also be significant that the major falls in mortality from this condition occurred in the late 1990s, concurrent with major increases in investment in primary health care.
Changes in disease mortality patterns – including the shift from mortality due to infectious disease to mortality due to chronic conditions – have been well documented, especially in the Northern Territory, and are plausibly related to the development and actions of primary health care services. Top of page
85 Australian Health Ministers' Advisory Council (AHMAC) (2006). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. AHMAC. Canberra.
86 For example 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, Wilson, T., J. R. Condon, et al. (2007). "Northern Territory indigenous life expectancy improvements, 1967-2004." Australian and New Zealand Journal of Public Health 31(2): 184-8.
87 Australian Institute of Health and Welfare (2008). Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004–05. AIHW. Canberra.
90 Australian Health Ministers' Advisory Council (AHMAC) (2006). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. AHMAC. Canberra.
91 Page, A., Tobias, M., Glover, J., Wright, C., Hetzel, D., and Fisher, E. (2006) Australian and New Zealand Atlas of Avoidable Mortality. Adelaide, PHIDU, University of Adelaide.
92 Australian Institute of Health and Welfare (AIHW) (2007). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006: detailed analyses. Canberra, AIHW.
93 Freemantle, J., Officer, K., McAullay, D. & Anderson, I. (2007), Australian Indigenous Health—Within an International Context, Cooperative Research Centre for Aboriginal Health, Darwin
94 Australian Health Ministers' Advisory Council (AHMAC) (2006). Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. AHMAC. Canberra.
95 Ibid. Note however a study specific to Western Australia which found the infant mortality rate gap widening despite improvements in the absolute rate between 1980 and 2001 - Freemantle, C., R. Read, et al. (2006). "Patterns, trends, and increasing disparities in mortality for Aboriginal and non-Aboriginal infants born in Western Australia, 1980–2001: population database study." Lancet 367(9524): 1758-1766.
96 Wilson, T., J. R. Condon, et al. (2007). "Northern Territory indigenous life expectancy improvements, 1967-2004." Australian and New Zealand Journal of Public Health 31(2): 184-8.
97 Starfield, B. and L. Shi (2002). "Policy relevant determinants of health: an international perspective." Health Policy 60(3): 201-218.
98 Shi, L., J. Macinko, et al. (2004). "Primary care, infant mortality, and low birth weight in the states of the USA." J Epidemiol Community Health 58(5): 374-80.
99 We note the recent extensive national study of disease patterns and mortality (Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Aboriginal and Torres Strait Islander peoples. Brisbane: School of Population Health, The University of Queensland) which provides an unparalleled snapshot of the current burden of disease in Aboriginal and Torres Strait Islander communities. Its findings accord with much of the following evidence, without, unfortunately, providing any analyses of trends from which the possible effects of primary health care might be adduced.
100 Wilson, T., J. R. Condon, et al. (2007). "Northern Territory indigenous life expectancy improvements, 1967-2004." Australian and New Zealand Journal of Public Health 31(2): 184-8.
101 Zhao, Y. and K. Dempsey (2006). "Causes of inequality in life expectancy between Indigenous and non-Indigenous people in the Northern Territory 1981-2000: a decomposition analysis." MJA 184: 490-494.
102 Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Aboriginal and Torres Strait Islander peoples. Brisbane: School of Population Health, The University of Queensland.
103 Thomas, D. P., J. R. Condon, et al. Ibid."Long-term trends in Indigenous deaths from chronic disease in the Northern Territory; a foot on the brake, a foot on the accelerator." 185: 145-149.
104 Condon, J. R., T. Barnes, et al. (2004). "Long term trends in cancer mortality for Indigenous Australians in the Northern Territory." Ibid. 180: 504-507.
105 Tobias, M. and G. Jackson (2001). "Avoidable mortality in New Zealand, 1981-97." Australian and New Zealand Journal of Public Health 25(1): 12-20.
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