1. Access and Equity: Improving health outcomes for Aboriginal and Torres Strait Islander people Dr Fadwa Al Yaman Social and Indigenous group

2. Presentation Indigenous population in Australia Gap in key health outcomes Drivers of the gap in health outcomes –Health risk factors –Socioeconomic disadvantage –Health system performance and barriers to access Gap by location and impact on closing the gap Policy context – “closing the gap targets” and building the evidence base

3. Aboriginal and Torres Strait Islander population 2.5% (517,000) of the total Australian population NSW has the largest Indigenous population followed by Qld

4. Indigenous population distribution by location

5. 78.7 67.2 82.6 72.9 A life expectancy gap of 9.7 years for females and 11.5 years for males

6. Age distribution of deaths among Indigenous and non-Indigenous Australians, NSW, Qld, WA, SA and NT, 2002–2006 Source: AIHW analysis of National Mortality Database (HPF, 2008)

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

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

13. Drivers that contribute to the gap Gap Health risk factors Health system performance Socio-economic & environmental factors Health risk factors Health system performance Socio-economic & environmental factors Gap

14. What contributes to the gap? Health risk factors Gap

15. What is the gap in risk behaviours Smoking 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 rate No daily intake of vegetables 7 times

16. What contributes to the gap? Socio-economic & environmental factors Gap

17. Index of disadvantage Source: AIHW analysis of ABS 2006 Census data

18. 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 7 Lower proportion are employed 48% vs. 72% Higher proportion in overcrowded housing

19. Education and risk behaviours

20. Unemployment and smoking

21. What contributes to the gap? Health system performance Gap

22. 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 1 st 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 population While expenditure on health is higher ($1.31 per Indigenous person for every $1 on non-Indigenous person) but not proportionate to need

23. Chronic disease ambulatory care sensitive hospital admissions Source: AIHW Analysis of National Hospital Morbidity Database

24. 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

25. 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 2004–05 NATSIHS.

26. 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%)

27. 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 areas –Less likely to own their home in remote areas

28. To impact on closing the gap The extent of the gap The 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

29. The policy context Closing the Gap and building the evidence base

30. Closing the Gap Targets Close 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 2018 Halve the gap in employment outcomes within a decade (2018)

31. National Indigenous Reform Agreement Early ChildhoodSchoolingHealth Economic Participation Healthy Homes Safe Communities Governance and Leadership Building Blocks for Indigenous Reform COAG 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.

32. 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 don’t 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 identification Need to produce and use adjustment factors to allow comparisons

33. Problems/Implications, cont… The “closing the gap” policy has made Indigenous issues highly prominent and it is likely to affect Indigenous people’s willingness to identify –More 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 gap –Non-indigenous population will continue to improve and this will impact on the gap

34. Improving Data Quality In July 2009, $46 million provided to “close the data gaps” –Improve the quality of data collections at source Census counts & population estimates Compliance with AIHW Best Practice Guidelines –Enhance 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 collection Develop a business case for identification on pathology form s –Assess 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

35. 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