Comment

The budget: widening not closing the gap on indigenous health

 
For the first time in many decades, Aboriginal health actually faces the prospect of going backwards. The road to effectively dealing with one of the biggest health failures in the western world, by  eliminating the gross differences in health between Aboriginal and Torres Strait Island people and the rest of the population, has been too long, too slow and too uneven, but nonetheless generally improving, even if at a somewhat glacial pace.

Perhaps the most significant event was the formation of the first Aboriginal Community Controlled Health Service in Redfern in 1971, from the realisation that mainstream services were simply not reaching or going to meet the needs of Aboriginal health. From that early beginning, such services have now expanded to a national network of about 150 ACCHSs all around Australia. But more, rather than less, support for these services is needed, as  the limited evidence available indicates that they outperform mainstream services in the prevention and management of chronic disease and other health issues.

Commonwealth and state and territory governments largely focused on environmental issues in the 1980s.  There were large dollops of strategies, frameworks and unfunded policies  but little or no actual action towards the prevention and treatment of the major health problems. In a way, the formation of ATSIC with responsibility, but limited resources for some health services, let mainstream health departments off the hook until responsibility for health was transferred to the Commonwealth Health Department in the mid-1990s. That transfer led to a progressive increase in funding to ACCHSs and measures to make it easier for Aboriginal and Torres Strait Island people to access the national schemes for medical and pharmaceutical benefits.

But the most significant step was a major turnaround in Commonwealth, state and territory health services through much-needed injections of funds for health, education, employment and remote services through four-year National Partnership Agreements (NPA) between the Commonwealth and states for the Closing the Gap program. These agreements aimed, among other things, to halve the child mortality gap in a decade, and eliminate the life expectancy gap in 25 years - and allocated $1.6 billion for much-needed health services to help achieve those goals.

However the NPAs finished in mid-2013 and everyone has been waiting to hear what the new government will do to continue and build on those developments.

Well the news is grim and delivers a double whammy. Firstly the co-payments for medical, pharmaceutical and diagnostic services are likely to have their greatest impact on Aboriginal people. The most recent published information shows that Australia's indigenous people, despite having at least twice the need for such services because of worse health, actually used them at about 70-75 per cent of the rate of the rest of the population in 2010-11. No doubt, use has gone up a little since those figures, but, on a needs basis, the issue for indigenous people is certainly not excessive use of these services, as current use is probably around one-third of what is actually required and the co-payments will almost certainly make it significantly worse.

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But the budget contains more bad news. Incredibly, $130 million has been cut from smoking programs over the next five years. This is astonishingly short-sighted and beggars belief. There had been early indications of progress with reducing smoking among indigenous people but stop-start approaches in smoking just don't work.

Smoking is an intractable behaviour and requires multi-pronged, sustained, long-term effort. There is simply nothing else which has the potential to make quite as big a contribution towards short-term reductions in mortality for the major cause of death and the chief contributor to the life expectancy gap (heart disease), as reducing smoking. Smoking is also a major factor in the child mortality gap through its role in low birth weight and infant mortality.

But it doesn't stop there. Substantial funds have been cut from indigenous primary healthcare services and chronic disease self-management programs. All in all, it looks as though a total of $270 million has been cut from what was previously committed for the next three years. Overall the hit to Aboriginal health programs seems to be perhaps one of the biggest to any program (when you consider the small size of the Aboriginal population) and coupled with the impact of co-payments for medical, pharmaceutical, diagnostic and lab services, this budget is a very significant backward step - the biggest probably on record and with major deleterious implications for Aboriginal health. And on top of everything else, there is the uncertainty about what the states are doing after the end of the NPAs. This is not the way to Close the Gap.

These cuts are not going to balance the national accounts and the rationale for them is almost impossible to fathom. Part of it is no doubt the mindless rhetoric about 'frontline services' - although they have taken a hammering too. Smoking programs are not some kind of optional extra, some frippery and an indulgent manifestation of a nanny state. Reductions in smoking have played a very major role in the continuing health gains for the Australian population as a whole and helped to make Australia one of the healthiest countries in the world, But Aboriginal smoking rates are still more than twice that of the rest of the population and it is simply impossible to Close the Gap while they remain that high.

Hopefully it is not too late. There is talk of a new funding allocation methodology for indigenous health which ''will ensure investments are directed to areas of need, priorities and population growth, and deliver the most effective outcomes''. But, without a realisation of what these cuts actually mean to the health and lives of Aboriginal people, the overall funding cuts will remain unless the political process can deliver on its responsibilities to Australia's first peoples.

Ian Ring is a professorial fellow at the Australian Health Services Research Institute at the University of Wollongong.

 

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