AMA 15th National Conference 2003 - AMA President, Dr Kerryn Phelps -Presentation of Public Report Card 2003 - Aboriginal and Torres Strait Islander Health - Time for Action

It is 12 months since I presented the first AMA Public Report card on Aboriginal and Torres Strait Islander Health. It was titled No More Excuses. And there were none. There still aren't.

This report brought together a wide range of statistics on health and health services, and the related areas of education and social justice.

It provided an assessment of progress made and what needed to be done. It gave examples of positive achievements regionally and internationally.

Overall it showed the appalling state of Aboriginal and Torres Strait Islander health.

It also highlighted the greater progress that had been made by other developed countries - countries which have made a greater investment in primary health care, environmental improvements and social justice.

Not a lot has changed in Indigenous Health in the last 12 months. At least not in terms of outcomes for Aboriginal and Torres Strait Islander people.

You will see from the health information presented that this simply confirms the picture of continuing ill health.

However, to its credit, we can report that the Government has moved in appropriate policy directions, which we hope will lead to better health outcomes in the future.

Firstly to further the introduction of the Primary Health Care Access Program announced in 1999/2000.

This program aims to provide new primary health care services and enhance existing services that are responsive to local priorities. These will be community controlled or have a high degree of community participation.

The Commonwealth has announced that PHCAP services will be funded to take account of a range of factors including the level of illness in the community and relative lack of use of the MBS and PBS by Aboriginal communities.

My concern is how quickly this program will make a tangible difference. We must monitor this.

Secondly, the Government has developed further its Workforce Strategic Framework.

As a part of this, the Australian Health Ministers Advisory Council has taken responsibility for working with the States and Territories to develop a more adequate and available health workforce that will support enhanced primary health care and linked specialist services.

Thirdly, the NH&MRC has agreed to the importance of ensuring 5% of research funding is allocated to Indigenous Health. This was the target set by the Health Is Life Report. The NH&MRC should be commended for meeting this target in the 2002 funding round. I urge it to continue to do this, and to focus on research to give insights into appropriate responses to these complex problems.

So, overall we have evidence of more appropriate Government policy and planning, better coordination by government bodies and more appropriate allocation of research funds.

But what has been accomplished that makes a difference to Aboriginal and Torres Strait Islander people?

So far, not enough has been translated into expanded and adequately staffed health services capable of meeting health needs and preventing disease.

That is why the Report Card this year is called Time for Action.

The 2003 Public Report Card provides new information on four areas:

• The extent of hospital usage by Aboriginal and Torres Strait Islander people,

• Reported health conditions and risk factors in the National Health Survey;

• Updated estimates of the levels of health service funding required to deliver health services to Aboriginal and Torres Strait Islander people on an equitable basis; and

• information from the most recent Census on the extent of disadvantage experienced by Aboriginal and Torres Strait Islander people.

We have tried to present a balanced picture in the Report Card, acknowledging areas of progress and examples of programs that have been successful as well as areas where progress has not been made.

The 2003 Report Card does not update all statistics provided last year.

It is important, for example, to wait for reliable trend data on comparative mortality before revising this information.

For this reason the first section of the 2002 Report Card dealing with mortality data has been reprinted. This has been included in the 2003 Report Card to provide the broad picture about the ill health of Aboriginal and Torres Strait Islander people.

Use of Hospitals

Recent data on hospital separations confirm the fact that Aboriginal and Torres Strait Islander people visit hospitals twice as often as other Australians. This is the case both for hospital admissions and for visits to casualty and accident and emergency units.

Such major use of hospitals reflects the poorer health of Aboriginal and Torres Strait Islander people. It is also consistent with a significant lack of access to primary health care services.

Lets look at the major diagnostic conditions accounting for these admissions.

The top three are:

• Conditions involving dialysis ie renal failure;
• Endocrine diseases such as diabetes; and
• Injury/ poisoning
.

The graphs illustrate the differential between Indigenous and non-Indigenous people for their use of hospitals for these conditions.

You can see that for conditions involving dialysis the rates were 6.4 times higher for Aboriginal and Torres Strait Islander men and 14 times for women.

For endocrine diseases, rates were over 4 times higher for Aboriginal and Torres Strait Islander people. And for Injury or poisoning - the rates were approximately double those for the rest of Australians.

The differentials are very clear and if anything they underestimate the true differences.

Such differences were also found in the National Health Survey of conditions reported in the community.
For example, 11% of Indigenous people reported having diabetes compared to 3% of non-Indigenous people.

And 17% of Indigenous females, aged 15-24 years reported a condition as the result of an injury or accident compared to 9% for other Australian females.

While these statistics are disturbing, they do not begin to portray the experience of illness of Aboriginal and Torres Strait Islander communities.

If you were an indigenous citizen of this country how acceptable would this be. It is important for all to be clear that change is possible.

Both Report Cards give examples of successful interventions showing what can be achieved.

One study in 2001, for example, showed a 32% reduction in hospital admission for diabetes related conditions through systematic recall and diabetes outreach.

This is important news.

Another study of a Queensland community showed a significant reduction in level of injury.

It is worth paying particular attention to statistics on End Stage Renal Disease particularly in areas such as the Northern Territory and the Torres Strait Islands.

According to one researcher, the incidence of End Stage Renal Disease in the NT for Aboriginal people reached 838 per million, doubling every four years. These figures are among the highest in the world.

It is in this context that the work of Professor Wendy Hoy is important.

Through a systematic treatment program in the Tiwi Islands she was able to achieve:

• an estimated 57% lower dialysis rate; and
• an estimated 50% decrease in natural death in the treatment group as opposed to control,

This suggests enormous potential for improvement.

Overall Funding

So how adequately are health services for Aboriginal and Torres Strait Islander communities funded?

Professor John Deeble was originally commissioned by the AMA to estimate the level of funding required to establish services on an equitable basis.

In particular he noted the lack of uptake of services rebated through the Medicare Benefits Schedule and the underuse of the Pharmaceutical Benefits Scheme.

In 1998-99, the ratio of Indigenous to non-Indigenous expenditures per person was 0.38 for the MBS and 0.31 for pharmaceutical benefits.

Professor Deeble's estimate, in 2000, was that overall, $245 million per annum was required to fund health services for Aboriginal and Torres Strait Islander people on an equitable basis, taking account particularly of comparative mortality,

This figure has set the benchmark by which the level of funding has been judged.

This work also debunked the idea that Indigenous Health is a grossly overfunded area - and perhaps, by implication, one where funding was not able to achieve results.

The AMA recently asked Professor Deeble to update his estimates to see whether greater equity has now been achieved.

The full paper has been printed and is available with the 2003 Report Card.

In his latest paper, Professor Deeble notes that the average expenditure for each Indigenous person in 1998-99 was 22% higher than for non-Indigenous people - an increase from 8% in 1995-96.

This is despite levels of illness three times those of the rest of the population.

He points out that funding of Indigenous specific health services by the Commonwealth government rose by $70 million between 1998-99 and 2001-02.

And spending by States and Territories also increased during this time.

He also takes account of the fact that all Australian health expenditures rose by at least 22% per person over this period - most of it in areas used least by Aboriginal people such as private hospitals and specialist care.

He argues that Indigenous people are entitled to their share of this increase.

Professor Deeble's conclusion is that achieving equity in funding still requires an additional $250 million per year. In reaching this conclusion he has taken account of factors such as comparative levels of mortality, costs of service delivery and per capita increases in health spending.

He emphasises that the majority of these additional funds should be allocated to primary health care where early identification of illness and appropriate intervention will yield the greatest dividends.

He further argues that additional funding over and above this amount is required to prevent the current levels of chronic disease.

He recommends that such additional funds be allocated to public health and preventive programs such as health promotion, health education and screening.

For this he suggests an indicative additional amount of $50 million per annum or an estimated $12 per Aboriginal and Torres Strait Islander person. He considers this to be utterly achievable.

I agree.

Evidence of need for preventive programs is also provided by the National Health Survey - which shows, for example, that Aboriginal and Torres Strait Islander adults are twice as likely to be smokers and more likely to be overweight or obese - (61% compared to 48%). These are risk factors for diseases such as diabetes that we have been discussing.

Progress Achieved So Far

I previously referred to the progress achieved by the Government in relation to policy development and planning in key relevant areas - primary health care and workforce development.

I noted that funding for Indigenous specific health services had increased.

How adequate are these developments in meeting profound needs?

Primary Health Care

I noted last year that funding of Aboriginal Community Controlled Health Services had increased in the late 1990s but had appeared to level off subsequently.

At the same time, episodes of care provided by Community Controlled Health Services increased by almost 40% to 1,200,000. In 2000-2001, this total has again increased by almost 10%.

At the same time funding to these services has increased from $135.2 million in 2000-2001 to $164.138 million in 2001-02.

Aboriginal Community Controlled Health Services provide a model of service delivery that enables Aboriginal people to shape the services that they use. While the increase in funding is welcome, it is still short of the level required.

I also note that in the current Federal Budget the increase in funding for Indigenous Specific Health Services over the forward estimate period was only 5.5%.

Primary Health Care Access Program

The Primary Health Care Access Program was announced in 1999/2000.

The Program aims to provide access to clinical care; population health programs; client and community assistance and advocacy. Funding is based on a benchmark of between two and four times the average use of the MBS to reflect health needs and the isolation faced by some communities.

A total of $78.8 million has been allocated since 1999/2000. This total will rise to $133.5 million in 2003/04. From 2003/04 the base recurrent funding will be $54.7 million per annum

This is encouraging. However, as Deeble notes it is not sufficient to establish equitable funding. I am concerned that no new PHCAP funding was announced in the current budget.

New primary health care services are being established on the basis of regional priorities and in consultation with Aboriginal communities.

Services piloted in the Coordinated Care trials in the Tiwi Islands, Katherine West, Wilcannia, Derbari Yerrigan have been transferred to this funding stream.

A new service has just become operational in North Metro Adelaide.

And a range of comprehensive primary health care services in the Northern Territory are targeted to become operational during 2003/04.

These are being established under five new local Health Boards run by the Aboriginal communities.

It is hoped that they will enable better coordination between health and other administrative areas. Funding is also being provided for infrastructure such as housing for health workers.

Many Aboriginal communities, however, have expressed concern at the time taken by the planning process and at what sometimes seem inordinate delays in getting services established on the ground.

Time is running out. The services are required on a national basis. AMA leadership and support can accelerate progress.

Workforce

In order to support the expansion of accessible primary health care services it is essential to have adequate numbers of doctors, nurses and other health workers available.

It is also necessary for specialist services to link effectively with community based health care. Such health workers should also be representative of the communities for whom they are providing services - we need many more health workers from an Aboriginal and Torres Strait Islander background.

The Commonwealth government has put in place a Workforce Strategic Framework and State and Territory implementation plans are currently being developed with draft plans established by the NT and WA.

What is lacking is a clearer set of targets for the training of the additional health workers - particularly those from an Aboriginal and Torres Strait Islander background - with defined time lines.

The AMA has advocated for the urgent establishment of a National Training Plan to meet this need.

In New Zealand such planning has resulted in 5% of the health workforce being from a Maori background.

A minimum of 150 tertiary training places per year need to be identified for Aboriginal and Torres Strait Islander students on an annual basis commencing in this financial year.

In terms of distribution this would enable 30 places for Medicine; 40 for Nursing; 20 for Allied/Public Health and 50 for Graduate Aboriginal Health Workers on an annual basis.

The Government has recently announced additional education places for doctors and nurses.

The AMA calls on the Federal Government to announce the above numbers of identified places for Aboriginal and Torres Strait Islander students as part of this initiative.

The current differentials in Indigenous/non-Indigenous ratios need to be halved in the next ten years.

Last year I highlighted the comparative progress made by other developed countries such as the US, Canada and NZ in achieving improvements in the health of their Indigenous peoples.

These countries have moved earlier to establish primary health care services.

There is no excuse for Australia's delay.

Ultimately, however, health is governed by the opportunities available to a people in society as a whole.

The ability to have access to the same environmental standards we take for granted; the ability of children to take advantage of the same educational opportunities; the ability to join the workforce. The feeling that overall justice will prevail.

These are the factors that ultimately affect health.

The last Report Card drew attention to the problems in environmental living conditions. The recent Budget did not provide additional funding for this.

In terms of educational opportunities, the Report Card notes the improvements that are slowly being made in the extent to which Indigenous Australian children are remaining at school and meeting the benchmarks attained more generally.

Again more needs to be done. I repeat time is running out. The levels of disadvantage are compounding

The recent Census documents the extent of disadvantage experienced by Aboriginal and Torres Strait Islander people. This underlines the extent to which opportunities must be opened up. Meaningful reconciliation is a part of this.. It requires greater commitment across all sectors.

Conclusion

In conclusion let me return to the Health Sector.

There is clear evidence that best practice medical care and preventive programs can improve Indigenous Health. In particular, the work of Professor Wendy Hoy has shown the way.

Progress in establishing access to the right services and programs must be accelerated. Policy must be translated more quickly into functioning services.

The funding required, ie the additional $250 million per annum for health services, must be phased in over a clearly specified period of time. Professor Deeble's estimate of an additional $50 million per year must be implemented in effective prevention and population health programs.

There must be a National Training Plan that will produce the required numbers of health workers, particularly those from an Aboriginal and Torres Strait Islander background.It is time for action.

End