HEALTH EQUALITY:A COMPARATIVE ANALYSIS OFAUSTRALIAN ABORIGINALS , TORRES STRAIT ISLANDERS ANDTHE FIRST NATIONS OF CANADAINTRODUCTIONEquality in health implies that ideally everyone should have a fair opportunity to attain his or her full health potential and, more reasonably, that no one should be disadvantaged from achieving this potential. Based on this definition, the aim of policy for equity and health is not to eliminate all health differences so that everyone has the same level and quality of health, but rather to reduce or eliminate those which result from factors which are considered to be avoidable and unfair. To appreciate the importance of striving for equity in relation to health, it is necessary to be aware of just how extensive are the differences in health found in the world today.
In every part of the region, and in every type of political and social system, differences in health have been noted between different social groups and between different geographical areas in the same country (Whitehead 2000). There is consistent evidence that inequalities in health result in disadvantaged groups having poorer survival chances, suffering a heavier burden of illness, and sharing a similar pattern of low quality of life The poor health of the Australian Aboriginals and Torres Strait Islanders is well known. Since the 1970s, mortality rates have been declining, but life expectancy has not changed and the gap between the Aboriginal population and the total Australian population has widened. This pattern contrasts with that of the Indigenous population of Canada where marked improvements in health have occurred. From that standpoint, this paper will discuss the important issues of health care inequalities that exist with the Aboriginals in Australia and compare them to those which subsist in the First Nations of Canada. POPULATION OF AUSTRALIAAustralians have among the highest life expectancy in the world and most have ready access to comprehensive health care of high quality. In the 1995 National Health Survey, 83% of Australians aged 15 or over reported their overall health as excellent, very good or good (ABS 1997).
The average life expectancy in 2000 was high for both men and women being 76 years and 82 years respectively. In terms of disability-adjusted life expectancy (DALE), Australia ranks in 2nd place after 191 countries (WHO 2000). In 1998, males at birth could expect to live for 63.3 years without experiencing major disability and women could live for 57.5 years free of disability (OECD 2000).Despite high measures of health among Australians, health disparities in service quality and access continue to exist between urban Australians and the Aboriginal Australians. Although, incomplete recordings in routine health data collection of Indigenous people remain barriers to a complete picture of their health, the available evidence suggests that they continue to suffer a greater burden of illness than the rest of the population.
In a total population of approximately 19 million in 2001, Australian Aboriginals make up 2.7% (500,000). Of this total, 34% live in metropolitan areas, 32% live in rural areas and 34% live in remote areas (ABS 2001). The general picture is identified as closer to a “third-world” health profile compared to the good health measures for the rest of the population. Life expectancy and age-specific mortality rates are much worse than for the general population with life-expectancy being 56 years for indigenous men at birth and 63 years for women. Thus, they live on average 15-20 years less than the rest of the Australian population (AIHW 2001). The report, Mortality of Indigenous Australians, suggests that while death rates have dropped slightly among Indigenous males, there has been no corresponding decline for Indigenous females (AIHW 1996).
Mortality rates are higher in all age groups, particularly in infancy with the IMR being 14.1, 2-4 times higher than the national average of 5.0 (WHO 2000). Figure 1: INDIGENOUS AND TOTAL POPULATIONS BY AGE, 2001(Source: ABS 2001)Aboriginals and Torres Strait Islanders are the most disadvantaged group of Australians. In many communities Aboriginals do not have adequate access to health care services, safe water, housing, power, or roads contributing to the burden of ill health. Social disadvantage and cultural disruption results in excess illness and premature deaths, injury and disability. The health statistics for Aboriginals are the worst of any group in Australia, and worse than those for comparable Indigenous populations in other countries (AIHW 2001).
At times groups of Aboriginals have been removed from their lands, moved onto reserves and lived in overcrowded conditions, with poor diet, contact with infectious diseases and lack of adequate health care: “In some cases Aboriginal and Torres Strait Islander family groups were broken up and communities were formed that bore little relationship to traditional kinship structures” (NATSIHC 2001). HEALTH CARE SYSTEM IN AUSTRALIAAustralia has a complex health care system with all levels of the government involved and both public and private sectors funding and providing health care. A key principle underlying Australia’s health system is universal access to most health care regardless of ability to pay.
Australia is committed to public financing and public involvement in health care with revenue stemming mainly from general taxation (Healy et al., 2001). The following figure shows the main organizations involved in the health sector: Figure 2: Organizational chart of health care system(Source: Healy, et al. 2001)The universal health insurance system, Medicare, is financed mainly through general taxation. There is a health tariff equivalent to 1.5% of taxable income above certain income threshold upon individual taxpayers.
Revenue raised by the Medicare levy has been equal to about 20% of total Commonwealth health expenditure and about 8.5% of total national health expenditure (ABS 2000). Medicare is available to people who live in Australia or hold Australian citizenship. Medical treatment is mostly free and its use largely unlimited. In-patient hospital care, and treatment by general practitioners and specialists is free, essential pharmaceuticals are subsidized, and there is no limit upon the amount of medical services that an individual may use (Mooney, et al. 1998).Figure 3: Total Health Expenditure as % of GDP, Australia and selected OECD countries, 1976-1999.
(Source: OECD Health Data 2000)Private health insurance covers a significant proportion of the Australian health care system with 30% of the population having additional private health insurance coverage in 1998 increasing to 45% in 2001, after the implementation of subsidies for purchasing, and tax penalties for not purchasing, private insurance (Healy, et al. 2001). Results from the 1995 NHS show 11% of Indigenous adults in non-remote areas had private insurance, compared with 43% of the non-Indigenous population, reducing the access of Aboriginal and Torres Strait Islander people to specialist care as a private patient in a hospital (ABS 1997).
The Commonwealth and state governments provide alternative services for Indigenous people in order to offer more accessible and responsive services and to empower local communities. Agencies serving the indigenous receive money for special programs with physicians generally billing Medicare for services provided. The Commonwealth funds community-based services through the Office for Aboriginal and Torres Strait Islander Health, and in 1998-1999 provided AUS $141 million for health services (AIHW 2001).
“According to an analysis of health expenditure in 1995-1996, about AUS $2320, per capita, was spent on health services to indigenous people, compared with AUS $2163 for services to non-indigenous people. However, this difference (8%) in expenditure is much smaller than the difference in many health status measures” (Deeble et al. 1998), as Aboriginal and Torres Strait Islander people have a greater requirement or need for health services because of their relatively poorer health status.There is evidence that the Australian healthcare system does not work well for Aboriginal and Torres Strait Islander peoples. Mainstream health services may not be culturally appropriate and are often located far from where many of them live.
Because of past mainstream health sector involvement in policies (i.e. the removal of children), some Aboriginal people are reluctant to use health services unless the issue is serious and urgent. As a result, multiple and complex health problems often develop that are more difficult to treat.
In addition, access to prevention and early intervention is inadequate, and a continuing relationship with the health system is difficult to achieve (NATSIHC 2000). When mainstream services that supported health and welfare were extended, there was inadequate attention to ensuring the responsiveness to the needs and wishes of Indigenous peoples. HEALTH CARE REFORMS IN AUSTRALIAOver the last decade, important advances have been made addressing Aboriginal and Torres Strait Islander Health. A framework, the Agreements on Aboriginal and Torres Strait Islander Health, has been developed for joint planning between governments and Indigenous organizations (AIHW 2001).
Aboriginal Health Services have developed a model of Aboriginal community control consistent with the model of best practice identified in the World Health Organization’s Jakarta Declaration (WHO 2000). Community control provides the community with the capacity to take responsibility for self-management. Where this has proven to be effective, community-controlled primary health care services are able to offer comprehensive primary care that is both scientific and culturally appropriate, and can work with the rest of the health care system.
Evidence suggests that improved access to comprehensive primary health care can make a real and sustainable difference to health status. The Office for Aboriginal and Torres Strait Islander Health (OATSIH) was developed to ensure the provision of effective, culturally appropriate clinical care, health promotion activities, and early intervention and effective disease management (ATSIC 2000). The Office has also been implementing long-term strategies based on 4 key goals: Developing infrastructure and resources necessary to achieve comprehensive and effective health care for Indigenous peoples;Improving the evidence-base which strengthen health interventions, such as mutual responsibility and social-cohesion;Addressing specific health issues and risk factors which impact the health status of Indigenous peoples; andImproving communication with primary health care services, Aboriginal and Torres Strait Islander peoples and the general population (ATSIC 2000).In order to overcome the health disparities that the Indigenous face key priorities that build community control of Aboriginal health services, increase Aboriginal and Torres Strait Islander participation in the workforce, reform health systems and increase funding must be sustained. CANADAIn comparison to Australia, Canada ranks 3rd in developed countries for measures of life expectancy, self-rated health and mortality rates. Life expectancy in Canada for men is 75.
7 years and 81.4 years for women, and is one of the highest in the industrialized world (Statistics Canada 1999). In 1996, Canada’s infant mortality rate of 5.6 per 1,000 live births dropped below the level of six infant deaths per 1,000 live births for the first time, dropping 4.6 in 2000 (WHO 2000). HEALTH CARE SYSTEMS IN CANADA Canada has a predominantly public financed, privately delivered health care system that is best described as an intermingling of 10 provincial health insurance schemes which are linked by national principles set at the federal level. The Canadian Health Act, developed by the federal government as a legislative framework for the national health system (Medicare), establishes the principles upon which the health system must be based on to receive full federal transfers: 1) universality which covers 100% of the insured population; 2) comprehensiveness requires that all health services are covered; 3) accessibility to health services; 4) portability; 5) and public administration (WHO 1996).
Health care is financed primarily through tax-based revenues and funding is transferred to the provinces as a combination of cash contributions and tax points. To receive federal funds, however, provincial insurance programs must adhere to the principles in the Canada Health Act (Health Canada 2001). Public sector funding represents about 72% of total health expenditure. The remaining 28% is financed privately through supplementary insurance, employer-sponsored benefits or out-of-pocket costs.
Canada’s total health expenditures, public and private, account for 9.2% of its GDP (Health Canada, 1996).Figure: Organizational Chart of Canada’s Health Care SystemIn 1998 the United Nations (UN) ranked Canada best in the world, among 174 countries, as measured by life expectancy, educational attainment and adjusted income. However, inequities in income distribution and literacy downgraded Canada’s rank from first to tenth on the United Nations Human Development Index.
This standing dropped when the Human Poverty Index for industrialized countries (which takes into account literacy, unemployment, percentage of people living below the poverty line and the percentage of people not expected to live past age 60) was applied (UNDP 1998). Like Australia, Canada has a significant Indigenous population. There are more than 600 First Nation and Inuit communities that speak more than 51 languages; and each band has its own culture, history and identity.
“They work to straddle values between two different worlds, their culture and the current social system of the dominant society. They traverse between the dominant society and their culture as citizens and productive members of both” (Health Canada 2000).Figure: Distribution of the First Nations and Canadian PopulationHEALTH CARE POLICY IN CANADADespite various inequities in relation to health indicators between the Indigenous and their Canadian counterparts, First Nations and Inuit group occupy a distinctive place in society.
More than 10 years ago, the Treasury Board approved resources to support the transfer of Indian Health Services from Health Canada to First Nations and Inuit wishing to assume responsibility and regain control of their own destinies (Health Canada 2000). The mandate of Health Canada was to ensure availability and access to health services for the First Nations, and to address health inequalities and disease threats so that they, too, can attain a level of health comparable to that of other Canadians (ACPH 1999). Health related services included programs in community and family health, injury prevention, disease control and prevention, environmental health, non-insured healthcare benefits, and treatment services (Bobet et al. 2002). In 1979, the Indian Health Policy was developed by the Federal Government on the basis of a shared commitment to “achieving an increasing level of health in Indian communities, generated and maintained by the Indian communities themselves,” with special preservation of culture and traditions.
The policy recognized the responsibilities of both federal and provincial governments in providing health services to First Nations and Inuit people (ACPH 1999). It also reasoned that improvements to the health status of the Indian population should be built on 3 pillars: 1) community development, both socio-economic and cultural/spiritual to remove the conditions of poverty and apathy which prevent members of the community from achieving a state of physical, mental and social well-being; 2) a relationship of trust between Indian people and the federal government; and 3) an interrelated Canadian health system consisting of its federal, provincial, municipal, Indian and private sectors (Health Canada 2001). COMPARATIVE DATAAUSTRALIACANADATOTAL POPULATION 19 million32 millionINDIGENOUS POP502,3391.1 millionLIFE EXPECTANCY (Males/Females)77 / 8277.
2 / 82.3LIFE EXPECTANCY FOR INDIGENOUS POP (Males/Females)56 / 6368.9 / 76.6DALE (years)73.272INFANT MORTALITY RATE54.6HEALTH EXPENDITURE8.50%9.
5% GDPWHO ON FAIRNESS (rank).971 (26).974 (17)WHO ON RESPONSIVENESS (rank)6.
86 (12)6.98 (7)WHO ON OVERALL HEALTH SYSTEM ATTAINMENT (rank).913 (12).971 (7)(Source: WHO 2000) In the above chart, Australia and Canada are about equal to one another in various life measures. However, life expectancy for Canada’s Indigenous population is significantly higher to that of the Australian Aboriginals; with fairness, responsiveness and overall attainment being higher as well. Canada’s health policies enacted for its Indigenous population have been effective in reducing health disparities as seen by, Life expectancy at birth in 2000 rose to 68.
9 years for males and 76.6 years for females, an increase from 1980 of 13.1% and 12.6% respectively (INAC 2002).In 1999, the birth rate was 23 births per 1,000 population, two times the comparable rate for Canada (Bobet et al. 2002).In 1979, the infant mortality rate among the First Nations was 27.
6 deaths per 1,000 live births. By 1999, that rate dropped to 8 deaths per 1,000 live births (INAC 2002).As a nation Canada is committed to improving the health promotion and protection of all its citizens, and to restoring the well-being of their underserved population. In order for Australia to learn from Canada’s lessons, a holistic approach which recognizes the diversity of Aboriginal and Torres Strait Islander cultures is essential to improving their health status.
For Aboriginals, health encompasses not only physical well-being, but social, spiritual and cultural well-being as well. Thus, links to improved environmental health, education, employment and enhanced community capacity are critical. Research has shown that addressing the social determinants of health and increasing the capacity and responsibility of Aboriginal communities for improving their own health is important to improved outcomes (NATSIHC 2001). A policy framework for health transfer such that Canada has will enable Australian’s Aboriginal communities to design health programs that meet their own needs, provides accountability, and allows community leaders financial flexibility for allocating funds according to health priorities.
Regional planning involving local Aboriginal organizations and all levels of government would help in joint planning and to identify gaps in services. Also of importance, is developing monitoring guidelines for vital statistics of the population and to ensure reporting on the progress of implementation strategies. Several aspects of Australian post-colonial indigenous experience may contribute to the country’s capacity to remove barriers to health equalities. Aboriginal affairs have traditionally been first a colonial then a State responsibility; and there has been constant tension between State interests, especially relating to land and management of the indigenous population. An official policy of assimilation maintained over many decades discouraged the creation of specialized health programs (Ring ; Firman 1998). Canada, in contrast, appears to be more advanced in the recognition of aboriginal rights and participation management through earlier recognition of legal rights to wildlife harvesting; and the negotiation of land claims (ACPH 1999).
Competition for federal health funding in Australia has meant that efforts to improve indigenous health have lacked coordination. Gathering together people from different tribal groups added to a lack of a single identity in many Aboriginal communities. Colonial paternalism and a lack of formal recognition have acted to create and reinforce a sense of powerlessness in Australian’s Indigenous population (Ring & Firman 1998).
The experience of the First Nations in Canada, along with similarities to Canada’s health care system, however, generates confidence that effective action in Australia will produce substantial changes in Indigenous health. Progress is needed in: infrastructure, self-determination of health services, access to a network of community-controlled primary healthcare services, an adequate level of resources and funding, and a skilled workforce. The Commonwealth must work in partnership with community leaders in order to provide a model to support infrastructure and achieve sustainable health gains.
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