Access and Equity: Improving health outcomes for Aboriginal and Torres Strait Islander people Dr Fadwa Al YamanSocial and Indigenous group

PresentationIndigenous population in AustraliaGap in key health outcomes Drivers of the gap in health outcomes Health risk factorsSocioeconomic disadvantage Health system performance and barriers to access Gap by location and impact on closing the gapPolicy context closing the gap targets and building the evidence base

Aboriginal and Torres Strait Islander population

2.5% (517,000) of the total Australian populationNSW has the largest Indigenous population followed by Qld

Indigenous population distribution by location

78.767.282.672.9A life expectancy gap of 9.7 years for females and 11.5 years for males

Chart1

78.767.2

82.672.9

Non-Indigenous

Indigenous

Years

Life Expectancy Estimates, 2005 -2007

Sheet1

MalesFemales

Non-Indigenous78.782.6

Indigenous67.272.9

Sheet2

Sheet3

Age distribution of deaths among Indigenous and non-Indigenous Australians, NSW, Qld, WA, SA and NT, 20022006Source: AIHW analysis of National Mortality Database (HPF, 2008)

The five main causes of mortality are preventable Circulatory diseases 27%Cancer 18%Injury 15% Endocrine and metabolic including diabetes 8%Respiratory 8%

End Stage renal disease Source: AIHW analysis of Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)rratratee

Drivers that contribute to the gapGapHealth risk factorsHealth system performanceSocio-economic & environmental factorsHealth risk factors Health system performanceSocio-economic & environmental factorsGap

What contributes to the gap?Health risk factors Gap

What is the gap in risk behavioursSmoking 47% twice the non-Indigenous rate Alcohol 17% long term risky (same) Overweight and obesity 60% twice as many obese Physical inactivity 47% 1.5 times No daily intake of fruit twice the rateNo daily intake of vegetables 7 times

What contributes to the gap?Socio-economic & environmental factorsGap

Index of disadvantageSource: AIHW analysis of ABS 2006 Census data

Socio-economic disadvantage Lower proportion in year 11 go on to complete year 12 (63% vs. 83%) Lower proportions achieving literacy, numeracy benchmark at year 3, 5 and 7Lower proportion are employed 48% vs. 72%Higher proportion in overcrowded housing

Education and risk behaviours

Unemployment and smoking

What contributes to the gap?Health system performanceGap

Health system performance Lower access to key procedures (59% vs 81%)Higher use of hospitals and emergency departments and lower use of Medicare (.59 of non-Indigenous Australians)Higher discharge against medical advice (6 times the rate)Late access to antenatal care (97% vs 98% but only 54% attended in 1st trimester vs 72%)Lower screening rates for cervical (52% vs 61%) and breast cancer (36% vs 56%)Under-represented among health professionals 1% while representing 1.9% of the relevant working populationWhile expenditure on health is higher ($1.31 per Indigenous person for every $1 on non-Indigenous person) but not proportionate to need

Chronic disease ambulatory care sensitive hospital admissions

Per cent of people who accessed health care, by type of health care Source: ABS and AIHW analysis of 2004-05 National Aboriginal and Torres Strait Islander Health Survey and 2004-05 National Health Survey

Chart1

2015

63

2523

46

Indigenous

non-Indigenous

per cent

Chart4

2015

63

2523

46

Indigenous

non-Indigenous

per cent

Sheet1

NSWVicQldWASATasACTNTAust.

(per cent)

Current smoker535251485651445652

NSW59

Vic48

Qld57

WA59

SA63

Tas52

ACT50

NT58

Aust57

admitted to hospital2015

visitng casualty/outpatients63

doctor consultation (GP or other specialist)2523

dental consultation46

consultation with other health professional2013

Sheet1

0

0

0

0

0

0

0

0

0

Per cent

Sheet2

00

00

00

00

Indigenous

non-Indigenous

per cent

Sheet3

A higher proportion of Indigenous Australians in non-remote areas reported they needed to go to a doctor, dentist or other health professional Source: ABS and AIHW analysis of 200405 NATSIHS.

Chart6

95

2316

1710

77

Non-remote

Remote

per cent

Sheet1

Accessing health care(a)NSWVicQldWASATasACTNTAustralia

per cent

Admitted to hospital15.214.114.618.617.614.113.522.416.4

Visited casualty/ outpatients43.45.674.62.82.3(b)44.8

Doctor consultation (GP and/or specialist)19.72819.21918.422.313.120.620.1

Dental consultation(c)2.93.4533.73.6(d)4.64.13.8

Consultation with other health professional13.714.7161617.411.21633.517.3

Total accessing health caree(e)38.645.140.743.44038.334.751.641.9

NSW38.6

Vic45.1

Qld40.7

WA43.4

SA40

Tas38.3

ACT34.7

NT51.6

Aust41.9

admitted to hospital2015

visitng casualty/outpatients63

doctor consultation (GP or other specialist)2523

dental consultation46

consultation with other health professional2013

Sheet1

0

0

0

0

0

0

0

0

0

Per cent

Sheet2

00

00

00

00

Indigenous

non-Indigenous

per cent

Sheet3

RemotenessSexAge groupTotal

Non-remoteRemoteMaleFemale014154445+

per cent

Whether needed to go to dentist in last 12 months but didnt

Yes231619237292621

No7784817793717479other health professional95

Total persons(b)331,272121,086222,020230,338158,717220,89672,745452,358dentist2316

Reasons didnt go to a dentistdoctor1710

Cost3215273022303029hospital77

Too busy (including work, personal or family responsibilities)151115136(c)161314

Dislikes (service/professional/2120192213(c)231921

afraid /embarrassed)

Waiting time too long or not available at time required2123182428202222

Decided not to seek care148161010(c)131513

Transport/distance728111118101111

Not available in area3289810(c)898

Felt it would be inadequate2(c)2(d)3(c)2(c)3(d)1(c)4(c)2(c)

Discrimination/ not culturally appropriate/ language problems(d)1(d)1(d) (d) d)1(c) (c)

Other97(c)9723758

Total who needed to visit dentist but didnt(b)74,06218,87140,50152,43210,49563,72918,70992,933

Whether needed to visit doctor in last 12 months but didnt

Yes171013174222215

No8390878396787885

Total persons(b)348,315125,995232,362241,948180,669220,89672,745474,310

Reasons why didnt visit the doctor when needed to

Cost144(c)111312(c)1310(c)12

Too busy (including work, personal or family responsibilities)2617212611(c)262424

Dislikes (service/professional/10111568(c)10910

afraid/embarrassed)

Waiting time too long or not available at time required1415141418(c)1314(c)14

Decided not to seek care2722302424272626

Transport/distance1128(c)121520121714

Not available in area2(d)13(c)3(c)4(c)8(d)35(d)4(c)

Felt it would be inadequate57(c)553(d)57(c)5

Discrimination/ not culturally appropriate/ language problems11(d)(d)1(c)n.p.1(c)11(c)

Other125101115(c)101111

Total who needed to visit doctor but didnt(b)57,65312,01229,42840,2377,01047,05415,60169,665

(continued)

Table 3.10.10 (continued): Whether needed to go to a dentist, doctor, other health professional or hospital and reasons didnt go, by remoteness area, sex and age, Indigenous Australians, 200405(a)

RemotenessSexAge groupTotal

Non-remoteRemoteMaleFemale014154445+

per cent

Whether needed to go to other health professional in last 12 months but didn't

Yes9578211108

No9195939297899092

Total persons(b)348,315125,995232,362241,948180,669220,89672,745474,310

Why didnt go to other health professional (OHP)

Cost335(d)263022(c)312428

Too busy (including work, personal or family responsibilities)2720242614(c)2921(c)26

Dislikes (service/professional/1211(c)141111(c)147(c)12

afraid/embarrassed)

Waiting time too long or not available at time required7(c)199(c)924(c)699

Decided not to seek care1816191613(c)162317

Transport/distance7(c)15(c)7(c)97(c)8(c)8(c)8

Not available in area2(c)30779(c)610(c)7

Felt it would be inadequate5(c)5(d)5(c)5(c)10(d)4(c)7(c)5

Discrimination/ not culturally appropriate/ language problems2(d)2(d)2(d)1(d)0(d)2(c)n.p.*2

Other1110(c)111014(c)1011(c)11

Total who needed to visit OHP but didnt(b)29,6995,97115,96819,7024,20024,0857,38535,670

Whether needed to go to hospital in the last 12 months but didnt

Yes777729127

No9393939398918893

Total persons(b)348,315125,995232,362241,948180,669220,89672,745474,310

Why didnt visit hospital

Cost5(c)3(c)4(c)5(c)4(d)4(c)5(c)4

Too busy (including work, personal or family responsibilities)171612(c)208(d)201216

Dislikes (service/professional/189(c)20116(d)171716

afraid/embarrassed)

Waiting time too long or not available at time required1810(c)171516(c)1615(c)16

Decided not to seek care2526282322(c)223425

Transport/distance1334142327172019

Not available in area2(c)8(c)3(c)4(c)4(d)3(c)6(c)4(c)

Felt it would be inadequate67(c)6(c)7(c)14(c)4(c)8(c)6

Discrimination/ not culturally appropriate/ language problems2(c)2(d)1(d)2(c)1(d)2(c)1(d)2(c)

Other15915(c)1217(c)158(c)14

Total who needed to visit hospital and didnt(b)22,9828,84015,43016,3923,87319,3828,56731,822

Sheet3

00

00

00

00

Non-remote

Remote

per cent

Barriers for not going to a doctor Transport 28% in remote vs 11% in non-remote Not available in the area (13% vs 2%)Cost (4 vs 14%) Waiting time (14% vs 15%)

Inequity by locations Some health conditions Self assessed health is better in remote areas Asthma prevalence is lower Arthritis prevalence is lower Social and emotional distress is lower Heart and circuitry disease is higher Diabetes prevalence is higher

Differential risk factors by remoteness Did not eat fruit (20% vs 12) and vegetables (15% vs 2%) daily Smoking is higher in remote (53% vs45%)Alcohol (abstain higher in remote (38% vs 19%, short term risky higher 23% vs 18%, long term risky lower (15% vs 17%) Illicit drugs lower (16% vs 22%)Obesity 58% in remote vs 56% in non-remote

Social and economic disadvantage increase with remoteness Schooling: completion of higher level of schooling is worse in remote areasLess likely to own their home in remote areas

To impact on closing the gap The extent of the gapThe extent of under identification Which group is most affected (men , women , young, old etc) Where do they live 75% Indigenous Australians live in non- remote areas

The policy contextClosing the Gap and building the evidence base

Closing the Gap TargetsClose the life expectancy gap within a generation (2031)Halve the gap in the mortality rate for Indigenous children under five within 10 years (2018)Ensure all Indigenous four year olds have access to quality early childhood programs within five years (2013)Halve the gap in reading, writing and numeracy achievements for Indigenous children within a decade (2018)Halve the gap for Indigenous students in Year 12 attainment rates or equivalent by 2018Halve the gap in employment outcomes within a decade (2018)

National Indigenous Reform AgreementBuilding Blocks for Indigenous ReformCOAG recognises that overcoming Indigenous disadvantage will require a long-term, generational commitment that sees major effort directed across a range of strategic platforms or Building Blocks which support the reforms aimed at Closing the Gap against the six specific targets.

NIRA indicators and data issues 27 indicators covering the 6 targets for annual reporting Some come from survey and some form admin data Survey cycles dont support annual reporting Main reporting issue for administrative data is under identification of Indigenous Australians in these data sets (hospital, mortality, perinatal etc) especially in urban areas Comparing indicators by jurisdictions and by remoteness is misleading b/c of variable levels of completeness of identificationNeed to produce and use adjustment factors to allow comparisons

Problems/Implications, cont

The closing the gap policy has made Indigenous issues highly prominent and it is likely to affect Indigenous peoples willingness to identifyMore capture of events (mortality)Better access to health services

The impact of change in the non-Indigenous population against the targets can be an issue in closing the gapNon-indigenous population will continue to improve and this will impact on the gap

Improving Data QualityIn July 2009, $46 million provided to close the data gapsImprove the quality of data collections at source Census counts & population estimates Compliance with AIHW Best Practice GuidelinesEnhance the comprehensiveness of existing data Enhanced Perinatal Data Set to collect alcohol use and Indigenous status of the baby Create a national data set where none currently exist National primary health care data collectionDevelop a business case for identification on pathology formsAssess the level of under identification in key data sets so adjustments can be made Trajectories work to assess whether we are on track to reach targets

Summary and implications

Recognition of the complex and interrelated impact of determinants of health on health outcomes and setting targets to address these

COAG committed $4.6 Billion to address Indigenous disadvantage in early childhood, housing, health, education, employment and service delivery There is a recognition for the need of good data and evidence monitor progress and check if we can meet the targets To close the gap, we need to focus not only on where the gap is largest but also where the biggest impact is likely to be in terms of population numbers

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