Health systems and health status

Does better health care lead to better health?

  • The work of Thomas McKeown in the 1970s and more recently, substantial evidence of the importance of the social determinants of health, have critically challenged the ‘common-sense’ idea that improved population health is simply the result of better health care.

Measuring the effect of the health system

  • Studies of avoidable mortality conclude that, notwithstanding the powerful effects of the broader social determinants of health and socioeconomic factors in particular, health systems do have a significant effect on the health of populations.
  • Recent studies of avoidable mortality within Australia conclude that, consistent with the patterns seen overseas, the health system within this country has contributed significantly to improving population health over the last forty years.

Does better primary health care lead to better health?

  • On an international level, stronger primary health care systems at a national level are associated with better health outcomes (especially relating to infant health indicators such as low birth weight and infant mortality from 1 to 12 months of age).
  • Internationally, stronger primary health care systems at a national level are associated with lower overall national health care costs.
  • Evidence from overseas – principally the United States – shows a strong correlation between increased between primary health care resources and lower mortality rates, and in particular with better maternal and infant health.
  • Increased primary health care resources are also shown to be able to offset some of the harmful health effects of socioeconomic disadvantage and inequality.
  • Evidence of reductions in avoidable mortality for conditions susceptible to primary, secondary and tertiary intervention in Australia since 1980 suggest that primary health care has made a significant contribution to improved population health in this country.

Changes in Indigenous health status

The health of Indigenous peoples

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  • 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 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.
  • 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.

Primary health care and Indigenous health: Overseas

  • Evidence from the United States and New Zealand suggest that primary health care has contributed to narrowing the life expectancy gap between Indigenous and non-Indigenous peoples in those countries, with the Indian Health Service in particular credited with a major contribution in the US. There is also evidence that poorer access to primary health care is associated with a widening life expectancy gap.

Primary health care and Indigenous health: Australia

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  • 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.
  • 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.
  • 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.
  • 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.

Policy lessons from the evidence

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  • 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.
  • However, 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.
  • 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.
  • 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 basic suite of comprehensive 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.

Local evidence and lessons

  • The following principles are associated with primary health care interventions which show success at a local level:
  1. genuine local Indigenous community engagement to maximise participation, up to and including full community control
  2. a collaborative approach to working with other service providers
  3. delivery of core primary health care programs such as maternal and child health and/or chronic disease prevention, detection and management
  4. evidence-based approaches adapted to local conditions
  5. a multidisciplinary team approach employing local community members
  6. service delivery that harmonises with local Aboriginal and Torres Strait Islander ways of life
  7. adequate and secure resourcing. Top of page