This is the fifth report against the Aboriginal and Torres Strait Islander Health Performance Framework (HPF)—see Figure 1. The HPF monitors progress in Aboriginal and Torres Strait Islander health outcomes, health system performance and the broader determinants of health. The health of Aboriginal and Torres Strait Islander peoples is improving for a number of measures, although there remain many areas where further concerted effort will be needed to achieve improvements in health outcomes.
Between the 2006 and 2011 censuses there was a 30% increase in the estimated Indigenous Australian population, which has led to a major reworking of all of the trends involving population rates. The other key feature of this report is that it includes updates for the new national health survey results for 2012–13 (the previous HPF report was only able to use data from the 2004–05 survey). Data for all jurisdictions have now been included for hospital data (the last HPF report only included data from NSW, Victoria, Qld, WA, SA and the NT). Data quality limitations and the small size of many estimates affect our ability to effectively monitor Indigenous health and the performance of the health system (see Technical Appendix).
Council of Australian Governments (COAG) Targets
In 2008, COAG set six targets on closing the gap between Aboriginal and Torres Strait Islander peoples and non‑Indigenous Australians in the areas of health, education and employment. In 2014, COAG introduced a new target to close the gap in school attendance in 5 years. Current assessment of progress against these targets shows:
- Indigenous life expectancy and mortality rates have improved slightly, but progress will need to accelerate if the target is to be met by 2031.
- The 2013 child mortality rate was higher than the rate in 2012. Indigenous child death rates declined by 31% and the gap narrowed (by 35%) over the longer term from 1998.
- The 2013 target for Indigenous four year olds in remote communities to have access to early childhood education was not met (85% enrolled in 2013 compared with the required benchmark of 95%).
- The baseline data for the new school attendance target will be released in 2015.
- There has been no overall progress on the target to halve the gap in reading and numeracy achievements for Indigenous students by 2018.
- On a positive note, the target to halve the gap in Year 12 attainment by 2020 is on track.
- There has been no progress on the employment target since 2008.
Figure 2 shows that while long-term Indigenous mortality rates are declining, the rate of change will need to accelerate to reach the target.
Figure 2 shows total mortality rates for Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between 1998 and 2012, and an indicative trajectory of mortality rates required to close the gap in life expectancy by 2031. Analysis of mortality rates between 1998 and 2012 show a significant decline in the Aboriginal and Torres Strait Islander mortality rate (16%) and a significant narrowing of the gap with non-Indigenous Australians (18%) for people living in jurisdictions with adequate data quality (NSW, Qld, SA, WA and the NT combined). Progress will need to accelerate if the target is to be met by 2031
Source: ABS and AIHW analysis of National Mortality Database
Figure 3 shows the rate of progress against the child mortality target.
Figure 3 shows child mortality rates for Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between 1998 and 2012, and an indicative trajectory of mortality rates required to halve the gap in mortality rates for Indigenous children under five by 2018. There was a significant decline in the mortality rate for Indigenous children aged 0–4 years (33%) and a significant narrowing of the gap (41%). The target is currently on track to be met by 2018.
Source: ABS and AIHW analysis of National Mortality Database
Tier 1: Health Status and Outcomes
- Analysis of mortality rates between 1998 and 2013 shows a significant decline in the Aboriginal and Torres Strait Islander mortality rate (16%) and a significant narrowing of the gap with non‑Indigenous Australians (15%) for people living in jurisdictions with adequate data quality (NSW, Qld, SA, WA and the NT combined). These trends have been amended following the release of revised Indigenous population estimates based on the 2011 Census. They are subject to data quality issues (see Technical Appendix).
- There was a significant decline in Indigenous deaths due to avoidable causes, down 27% between 1998 and 2012, and a narrowing of the gap. An NT study of avoidable mortality between 1985 and 2004 found major declines in conditions amenable to medical care, but only marginal change for potentially preventable conditions such as lung cancer, chronic liver disease and car accidents (Li et al. 2009).
- Circulatory disease death rates—the most common cause of death for Indigenous Australians—declined by 40% between 1998 and 2012. This rate of decline was faster than for non‑Indigenous Australians and the gap narrowed. A study of acute myocardial infarction in the NT between 1992 and 2004 found an improvement in survival for Aboriginal people both prehospital and post-hospital admission, despite an increase in incidence of this disease over this period (You et al. 2009).
- Kidney disease death rates decreased significantly from 2006 to 2012 (by 40%) for Indigenous Australians and the gap has also narrowed with non‑Indigenous Australians. There has also been a slowing in incidence of Indigenous Australians with end stage renal disease, with no increase detected between 1996 and 2012 for females and persons (although there was an increase for Indigenous males).
- Respiratory disease death rates decreased significantly from 1998 to 2012 (by 27%) for Indigenous Australians and the gap has also narrowed.
Infant and child mortality
- There was also a significant decline in the mortality rate for Indigenous children aged 0–4 years (31%) and a significant narrowing of the gap (35%) between 1998 and 2013. There was a 64% decline in the mortality rate for Indigenous infants and a significant narrowing of the gap (83%) between 1998 and 2012.
- The low birthweight rate declined by 9% between 2000 and 2011 for babies born to Aboriginal and Torres Strait Islander mothers, and the gap narrowed (for singleton births excluding multiple births).
Chronic disease accounts for two-thirds of the health gap between Aboriginal and Torres Strait Islander peoples and non‑Indigenous Australians.
- The majority (70%) of Indigenous deaths in 2008–12 were due to chronic diseases (e.g. circulatory disease, cancer, diabetes, respiratory disease, kidney disease).
- During 2008–12 the leading causes of Indigenous deaths were circulatory disease (25%); neoplasms (including cancer) (20%); external causes (including suicide and transport accidents) (15%); endocrine, metabolic and nutritional disorders (including diabetes) (9%); and respiratory diseases (8%).
- In 2012–13, 20% of Indigenous adults had measured high blood pressure and most (79%) did not know that they had the condition.
- The gap between the two populations for deaths due to cancer is widening. There has been an 11% increase in cancer death rates for Indigenous Australians and a 5% decline for non‑Indigenous Australians between 2006 and 2012. It will take 10–20 years for the reductions in Indigenous smoking rates to flow through to improvements in cancer deaths. Research has found disparities in stage of diagnosis and treatment (including lower rates of surgery, chemotherapy and radiotherapy) and lower survival rates for Indigenous Australians.
- There has been no improvement in the mortality rate due to diabetes between 1998 and 2012.
- In 2012–13, 11% of Indigenous adults had diabetes (3 times the non‑Indigenous rate). Of those with diagnosed diabetes, 61% had high blood sugar levels indicating that the condition was not well managed, while 14% did not know they had the condition.
- The incidence of Indigenous Australians with end stage renal disease was 7 times the rate for non‑Indigenous Australians in 2010–12. In the 2012–13 Health Survey, 18% of Indigenous adults had blood/urine test results showing signs of kidney problems (infection, acute or chronic condition) and 89% of these people did not have a diagnosed chronic condition.
- External causes such as suicide and transport accidents accounted for 15% of Indigenous deaths in 2008–12. Indigenous Australians died from suicide and transport accidents at 1.9 and 2.5 times the rate of non‑Indigenous Australians respectively. There has been no improvement between 1998 and 2012 in Indigenous death rates due to external causes and no significant changes in suicide rates.
- Hospitalisation rates for injury and poisoning were the second most common reason for hospital admissions for Indigenous Australians, 1.8 times the rate for non‑Indigenous Australians.
- In 2012–13, nearly half (47%) of Indigenous Australians aged 18 years and over had a disability or restrictive long-term health condition. For all age groups combined, 36% of Indigenous Australians had a disability or restrictive long-term health condition, 1.5 times the non‑Indigenous rate. Approximately 10% of Indigenous Australians (all age groups) had a profound/severe/moderate core activity limitation, 1.6 times the non‑Indigenous rate.
- In 2011, 12.6% of babies born to Indigenous mothers had low birthweight, twice the non‑Indigenous rate. Analysis of these data has found a strong relationship between smoking during pregnancy and low birthweight. For Indigenous mothers, the percentage of low birthweight births was highest for those in the 35 years and over age group (19%) and between 12% and 13% for the other age groups (including teenagers).
Tier 2: Determinants of Health
- There has been a significant decline in smoking rates for Indigenous Australians aged 15 years and over between 2002 and 2012–13 (7 percentage points), which includes a significant improvement since 2008. The 15–17 year age group had the largest decline (from 33% to 19%).
- For those who continue to smoke, there has been a decline in the average number of cigarettes smoked daily (from 15 in 2008 to 13 in 2012–13), although there is no safe level of smoking.
- There has also been a decline between 2005 and 2011 in the rate of smoking for Indigenous women during pregnancy (from 54% to 50%).
- Between 2008 and 2012–13, the gap in the Year 12 or equivalent attainment rate for Indigenous Australians aged 20–24 years has narrowed by 11.6 percentage points and the COAG target to halve the gap by 2020 is currently on track (Australian Government 2015).
- In 2012–13, 43% of Aboriginal and Torres Strait Islander peoples aged 20–64 years reported they either had a Certificate III or above or were studying; a 17 percentage point increase from 2002. In 2011–12, 67% of non‑Indigenous Australians aged 20–64 years reported they had either a Certificate III or above or were studying.
- The rate of homelessness among Indigenous Australians fell by 14% between 2006 and 2011 (AIHW 2014q). Nationally, between 2004–05 and 2012–13, the proportion of Indigenous Australians living in overcrowded households declined by 4.5 percentage points (from 27.2% to 22.7%) and the gap narrowed. Between 2002 and 2012–13 there was also a 3 percentage point increase in home ownership among Indigenous Australians.
- There has been little change in Indigenous employment rates since 2008 and the target to halve the gap within a decade is not on track.
- Between 2008 and 2014, the proportion of Indigenous students at or above the National Minimum Standards in reading and numeracy has shown no statistically significant improvement nationally in any of the eight measures (Years 3, 5, 7 and 9 in reading and numeracy).
- Between 1996 and 2012 there was an 8 percentage point increase in higher education completions by Indigenous students; however this increase was at a slower rate than for other Australians and the gap has widened.
- In 2012–13, 23% of Indigenous Australians lived in overcrowded households, 5 times the non‑Indigenous rate.
- In 2011, Indigenous Australians were 14 times as likely as non‑Indigenous Australians to be experiencing homelessness (AIHW 2014q).
- The proportion of Indigenous households with structural problems and poor access to working facilities increased from 17% in 2008 to 22% in 2012–13.
- In 2012–13, 44% of Aboriginal and Torres Strait Islander peoples aged 15 years and over reported being a current smoker, 2.5 times the non‑Indigenous rate. There has been no improvement in very remote areas between 2002 and 2012–13.
- In 2011, 50% of Indigenous women smoked during pregnancy, 4 times the non‑Indigenous rate.
- In 2012–13, an estimated 57% of Aboriginal and Torres Strait Islander children aged 0–14 years lived in households with a current daily smoker, compared with 26% of non‑Indigenous children.
- In 2012–13, 38% of Aboriginal and Torres Strait Islander adults in non‑remote areas had undertaken a sufficient level of physical activity in the previous week (at least 150 minutes over 5 or more sessions a week).
- In 2012–13, 42% of Indigenous Australians aged 15 years and over reported eating the recommended intake of fruit and 5% for vegetables. These rates were lower than for non‑Indigenous Australians (ratio of 0.9 for fruit and 0.8 for vegetables).
- In 2012–13, 78% of Indigenous children aged 2–14 years met the recommended fruit intake and 16% the recommended vegetable intake.
- Indigenous Australians were 7 times as likely as non‑Indigenous Australians to go without food due to financial constraints in the previous 12 months.
Overweight and obesity
- In 2012–13, 66% of Indigenous Australians aged 15 years and over were overweight or obese. For obesity, Indigenous rates were 1.6 times those for non‑Indigenous Australians.
Risky/high risk alcohol consumption
- In 2012–13, 26% of Indigenous Australians aged 15 years and over had abstained from drinking alcohol in the 12 months prior to the survey, 54% exceeded the single occasion guidelines in the last 12 months and 18% the lifetime risk guidelines. There have been no significant changes in risky drinking since 2001.
- In 2012–13, 53% of Indigenous Australians aged 15 years and over reported never having used drugs and other substances, 23% reported using substances in the last 12 months and a further 23% reported having used substances but not in the last 12 months.
Low income and the distribution of income
- In 2012–13, 43% of Indigenous adults were in the bottom quintile of equivalised household incomes compared with 17% of non‑Indigenous adults. In comparison, only 6% were in the top quintile compared with 22% of non‑Indigenous adults.
- Aboriginal and Torres Strait Islander peoples are more likely to experience exposure to violence, child abuse and neglect, and contact with the criminal justice system than other Australians. The gap continues to widen for contact with the criminal justice system. In 2013, the Indigenous imprisonment rate was 13 times the rate for non‑Indigenous Australians and has increased by 68% since 2000.
- The 2011 Census found that Indigenous households were less likely than other households to have access to a motor vehicle (81% compared with 91%). In 2011, 46% of Indigenous households in very remote areas did not have access to motor vehicles compared with 8% of other households in very remote areas. In major cities the rate was 16% for Indigenous households and 10% for other households.
- In 2012–13, transport/distance was a reason why 16% of Indigenous Australians reported they did not access health services when they needed to. Transport/distance was a more commonly reported reason for not accessing care in remote areas (22%) than in non‑remote areas (15%).
Figure 4 shows the trends in Indigenous and non-Indigenous smoking rates for people aged 15 years and over together with a summary of key tobacco control initiatives implemented in Australia since 1990. There has been a significant improvement in smoking rates for Indigenous Australians aged 15 years and over between 2002 and 2012–13 (7 percentage point decline) which includes a significant improvement since 2008.
Tier 3: Health System Performance
Chronic disease detection and management
There has been a significant increase in a range of Medicare services claimed by Aboriginal and Torres Strait Islander peoples since the introduction of the Indigenous chronic disease initiatives in 2009–10:
- Trend analysis shows a statistically significant increase in health assessments for Indigenous Australians between July 2009 and June 2014—the rate has nearly tripled. The rate of change has accelerated since 2009–10 (see Figure 5).
- This is also true for GP management plans and team care arrangements. In the five years from 2009–10 to 2013–14, Medicare services claimed by Indigenous Australians for these items have doubled. Rates per 1,000 in the population are now higher for these services for Indigenous Australians than for non‑Indigenous Australians.
- There has been a significant increase in GP Medicare items claimed by Indigenous Australians between 2003–04 and 2013–14. The Indigenous rate is now higher than the non‑Indigenous rate (see Figure 6).
The national Key Performance Indicators monitor the performance of over 200 Australian Government-funded Indigenous primary health care organisations against the key process of care and health outcome performance indicators. In 2013–14, around 28,000 regular clients of these organisations had Type 2 diabetes. In the six months to December 2013, 49% of these clients had their blood glucose levels tested, with 33% reporting a blood sugar result in the recommended range (the same as in December 2012); and 64% had their blood pressure assessed, with 44% reporting a result in the recommended range (up from 42% in December 2012).
Figure 5 shows the rate per 1,000 persons of Aboriginal and Torres Strait Islander peoples receiving Medicare Benefits Schedule Health Assessments, by age group. Data is presented for age groups 0-14 years, 15-54 years, and 55 years an over. Data is presented for the period 2006-7 to 2013-14. Trend analysis shows a statistically significant increase in health assessments for Indigenous Australians between July 2009 and June 2014 (a doubling in the rate of health assessments). There has been acceleration in the rate of change since 2009-10 with an annual increase of 35% since 2009-10.
Source: AIHW analysis of Medicare Australia data
Figure 6 shows the ate per 1,000 persons of Aboriginal and Torres Strait Islander peoples receiving Medicare Benefits Schedule GP services from 2003-04 to 2013-14. There has been a significant increase in access to GPs by Indigenous Australians between 2003-04 and 2013-14. The Indigenous rate of GP services provided through Medicare is now higher than the non-Indigenous rate.
Source: Medical Benefits Division, Department of Health
Access to prescription medicines
- Up to 30 June 2014, 280,885 eligible Aboriginal and Torres Strait Islander patients benefited from the Closing the Gap Pharmaceutical Benefits Scheme (PBS) Co-payment Measure and over 99% of pharmacies have participated in the measure. A prescription volume of 8.8 million has been dispensed since the measure commenced in July 2010.
Increased availability of Indigenous-specific services
- Australian Government Indigenous-specific health programme expenditure increased from $115 million in 1995–96 to $693 million in 2012–13, a growth in real terms of 292%.The episodes of care delivered through Aboriginal and Torres Strait Islander primary health care services have more than doubled (from 1.2 million in 1999–2000 to 3.1 million in 2012–13).
Usual source of care
- Having a usual primary care provider is associated with good communication between the patient and provider, greater trust in the health care provider, improved preventive care and better health outcomes. Statistics from 2012–13 indicate that 86% of Indigenous Australians had a usual place to go for health problems/advice.
- In 2012–13, most Aboriginal and Torres Strait Islander people aged 15 years and over in non‑remote areas who saw a GP or specialist in the previous 12 months, reported the doctor always or usually: listened carefully to them (89%); showed respect to them (89%); and spent enough time with them (85%). The 2012–13 Patient Experience Survey provides comparable data for the total Australian population: GP listened (89%); showed respect (93%); and spent enough time (88%) (SCRGSP 2013).
- The proportion of Indigenous women accessing antenatal care at least once during pregnancy increased in NSW, Qld and SA combined between 1998 and 2011. In 2011, 99% of Indigenous women accessed antenatal care at least once during their pregnancy.
Immunisation coverage for children
- Immunisation rates are high for Indigenous children. By 2 years of age, coverage rates were close to those for other Australian children (91.4% of Indigenous children compared with 92.2% for other children) in December 2013. By 5 years of age the Indigenous rate (92.8%) was slightly higher than for other children (91.7%).
Barriers to accessing health care
- In 2012–13, 30% of Aboriginal and Torres Strait Islander peoples reported that they needed to, but didn't, go to a health care provider in the previous 12 months. This varied by type of service with 21% not going to a dentist, 14% to a doctor, 9% to a counsellor, 9% to other health professionals and 6% to hospital when needed. Indigenous Australians living in non-remote areas (32%) were more likely to report not seeking care when needed than those living in remote areas (22%).
- Cost was a major barrier to accessing care for over one-third (36%) of Indigenous Australians, particularly dentists (43%) and other health professionals (35%). For doctors, logistical reasons such as waiting times (22%) and transport/distance (14%) were commonly reported barriers as well as disliking service/being embarrassed or afraid (14%) or being too busy (30%). In remote areas, logistical reasons such as waiting times, availability of services and transport were a more commonly reported reason for not accessing care (54%) than in non‑remote areas (37%). In 2012–13, 12% of Indigenous Australians reported deferring treatment due to cost (ranging from 8% in SA to 21% in the ACT) (SCRGSP 2015).
- Selected potentially preventable hospitalisation rates for Aboriginal and Torres Strait Islander peoples were 3 times the non‑Indigenous rate during the period July 2011 to June 2013.
- Aboriginal and Torres Strait Islander peoples had lower rates of hospitalisations with a procedure recorded compared with non‑Indigenous Australians, and they also had lower rates of elective surgery.
- Discharge from hospital against medical advice was 8 times the rate for Indigenous Australians compared with non‑Indigenous Australians.
Aboriginal and Torres Strait Islander health workforce
- In 2011, 1.6% of the Indigenous Australian population was employed in health-related occupations compared with 3.4% of the non‑Indigenous population. In 2011, the occupations with the largest gap between Indigenous and non‑Indigenous Australians were nurses, medical practitioners and allied health professionals. Between 1996 and 2011 the rate of Indigenous Australians employed in the health workforce increased from 96 per 10,000 to 155 per 10,000.
- Aboriginal and Torres Strait Islander peoples are also under-represented in training for various health professions. Improving participation in training for health professions is a key priority across a broad range of disciplines including medicine, nursing, allied health and Aboriginal health workers.
- The supply of GPs was not uniform across the country, being greater in major cities (426 FTE per 100,000 population) than in remote/very remote areas (257 FTE per 100,000).
- Antenatal care for Indigenous women occurs later and less frequently than for non‑Indigenous women. In 2011, half of Indigenous mothers had their first antenatal session in the first trimester of pregnancy, compared with 66% of non‑Indigenous mothers.
Private health insurance cover
- In non‑remote areas, 20% of Indigenous Australians were covered by private health insurance. The most common reason that Indigenous Australians did not have private health insurance was that they could not afford it (72%). Lower rates of private health insurance contribute to reduced access to services, in particular dental, allied health, specialist services and private hospitals.In the two years to June 2013, 7% of hospitalisations with a procedure recorded for Indigenous Australians occurred in private hospitals compared with 53% for non‑Indigenous Australians.
Access to prescription medicines
- Between 2001–02 and 2010–11, average expenditure on pharmaceuticals per Aboriginal and/or Torres Strait Islander person rose from 33% to 44% of the amount spent per non‑Indigenous person ($369 compared with $832 in 2010–11). Note: this includes government expenditure plus out-of-pocket expenses. Estimates from 2010–11 do not yet fully capture the impact of the Closing the Gap PBS Co-payment Measure that commenced in July 2010.
Access to health care
- In 2012–13, 44% of Aboriginal and Torres Strait Islander peoples reported accessing health care in the previous two weeks (or 12 months for hospital admissions). This rate is lower than expected given the greater burden of illness experienced by Aboriginal and Torres Strait Islander peoples.
- A study of Indigenous Australians with diabetes living in remote NT communities found that those who visited primary care 2–11 times per year had lower rates of death and hospitalisation than those who visited less than twice a year. Preventing one hospitalisation for diabetes was cheaper ($248 for those with medium use, $739 for complicated cases) than the cost of one hospitalisation ($2,915)(Thomas, SL et al. 2014).