Our brief review of the data on Indigenous life expectancy and mortality both within Australia and in New Zealand, Canada and the United States, reveal a complex and dynamic pattern but with a common characteristic – that there have been periods in all four countries where Indigenous health, measured by these indicators and looked at in absolute rather than relative terms, has improved.
The question we turn to now is whether there is any international evidence that health care in general and primary health care in particular contributed to these improvements.
Note that in this section we will continue to concentrate on answering this question at a jurisdictional / national level using life expectancy and mortality patters, rather than looking at specific case studies or programs, which will be the focus of the next chapter.
Our review of the literature did not find a large number of studies looking at Indigenous mortality patterns and attempting to link them to the provision of health care. Nevertheless, a number of studies seem to demonstrate that, just as health systems and primary health care have improved the health of populations in general, they have also done so for Indigenous populations elsewhere.
Notwithstanding a recent widening of the gap in that country, the comparative success of the United States in reducing the life expectancy gap between Indigenous and non-Indigenous peoples has been noted by many commentators.77 This success has been crucially attributed to the federal government’s unequivocal adoption of responsibility for providing health care to Native Americans through the Indian Health Service (IHS).
This political / administrative structure allowed the IHS to quarantine funds specifically for Indian health, and separated it from state-level political conflict about access to land and natural resources. However, of most relevance to our argument, the IHS’s integrated system of health care, based on the delivery of comprehensive primary health care (including mental health, environmental health and health education services) plus its own referral centres and even local hospitals, has been argued as having been critical in delivering better health for Indigenous peoples in the United States.78
This analysis is backed up quantitatively in a study of avoidable mortality amongst Native Americans in the United States.79 This study proposed the use of avoidable mortality as a way of measuring the impact of health systems on Indigenous communities, and found a 57% decrease in avoidable mortality among Native Americans between 1972 and 1987, at a rate of 7.5% per year, double the fall in the non-avoidable mortality rate of 3.7% per year. As we have seen in Chapter 2, this would strongly indicate that health care is at least partly contributing to the reductions in mortality. Top of page
In this particular study, the authors drew the conclusion that not-withstanding social, environmental and genetic factors, access to integrated, universal health care through the IHS, with a strong primary and preventive focus incorporating health promotion and disease prevention, improved the health and life expectancy of this disadvantaged population, despite their socioeconomic disadvantage.
A number of studies in New Zealand have also considered avoidable mortality amongst Maori people and have shown that avoidable causes of death make a considerable contribution (between 27% and 44%) to overall differences in mortality between Maori and non-Maori people80 and that deaths from avoidable causes were about two-and-a-half times more common amongst Maori compared to other New Zealanders.81
While it has been argued that the stalling of improvements in the life-expectancy of Maori people from the 1980s to the 1990s and consequent widening of the life expectancy gap is largely the result of socioeconomic factors, and in particular the economic reforms during this period which impacted disproportionately on Maori in terms of poverty and unemployment,82 differential access to health care was also considered to be an important contributing factor.
Specifically, It appears that the restructuring of the health system, including the introduction of co-payments, may have discouraged access to primary health care by Maori people, and that that this lack of access to preventive and primary health care services is a major contributor to the higher mortality suffered by that country’s Indigenous people.83
It has also been posited that, while the expansion of health services run by Maori communities under the restructured health system was unable to counter-balance these other factors, the renewed upswing in Maori life expectancy since the end of the 1990s can be attributed to these ‘by Maori, for Maori’ primary health care services.84 Top of page
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.
74 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.
76 Condon, J. R., T. Barnes, et al. (2004). "Improvements in Indigenous mortality in the Northern Territory over four decades." Ibid. 28(5): 445-451.
77 See below, and Bramley, D., Hebert, P., Tuzzio L., Chassin, M., (2005) Disparities in Indigenous Health: A cross-country comparison between New Zealand and the United States, American Journal of Public Health, May 2005, 95:5 844 – 850.
78 Kunitz, S. J. (1994). Disease and social diversity: the European impact on the health of non-Europeans. New York, Oxford University Press, 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. See also Kunitz, S. J. (1994). Disease and social diversity: the European impact on the health of non-Europeans. New York, Oxford University Press.
79 Hisnanick, J. and D. Coddington (1995 ). "Measuring human betterment through avoidable mortality: a case for universal health care in the USA." Health Policy 34(1): 9-19.
80 Tobias, M. and L. C. Yeh (2007). "How much does health care contribute to health inequality in New Zealand?" Australian and New Zealand Journal of Public Health 31(3): 207-10.
81 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
82 Blakely, T., M. Tobias, et al. (2005). "Widening ethnic mortality disparities in New Zealand 1981-99." Social Science & Medicine 61(10): 2233-51.
83 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.
84 Blakely, T., M. Tobias, et al. (2005). "Widening ethnic mortality disparities in New Zealand 1981-99." Social Science & Medicine 61(10): 2233-51.