Health and Life Expectancy
For progress on closing the health and life expectancy gap:
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At a national level, there have been some improvements to Indigenous child mortality. However, despite narrowing the gap in life expectancy, the rate of improvement is far too slow to close the gap. The situation is particularly bad for Indigenous people living in the Northern Territory, whose life expectancy is approximately 10 years shorter than non-Indigenous Australians (10.6 years for Indigenous males and 9.5 years for Indigenous females).
The National Aboriginal and Torres Strait Islander Health Plan is a framework designed to guide future investment in Indigenous health care until 2023. An Implementation Plan is currently being developed. As well as increased access to healthcare and specialist services, a heightened degree of consideration has been placed on social and social determinants of health.
On 1 July 2014, the government established the Indigenous Advancement Strategy, which combined over 150 programs into 5 streams, one of which is Safety and Wellbeing. Alongside this, the Indigenous Australians Health Program consolidated 4 previous funding streams to reduce costs and provide better flexibility of services. This program now encompasses primary health care, maternal and child health care, the Stronger Futures Health stream and a chronic disease fund. The government also dedicated $11.9 million to increasing access to essential primary health care for Indigenous people living in remote areas of the Northern Territory.
The Care for Kids' Ears program has achieved a 4% decrease in the number of Indigenous children with hearing conditions through raising awareness and promoting check-ups, but the rate remains double that of the non-Indigenous population.
Target #1: halve the gap in mortality rates for Indigenous children under 5 by 2018
Volatility in Indigenous child mortality rates since 2008 has contributed to uncertainty about achieving this target. Throughout the period between 1998 and2016, the Indigenous child mortality rate declined significantly, narrowing the gap by approximately 32%. Despite slowed progression in recent years, the government reported in 2018 that the target was on track.
This reduction of Indigenous child mortality by 32% means, in practical terms, that seventy-one more Indigenous children per thousand are now surviving past their fifth birthday compared to 1998. Despite these concrete gains, Indigenous children are still twice as likely to die under the age of five relative to non-Indigenous children.
Indigenous infant (<1yr) mortality accounts for the vast majority of Indigenous child deaths. Between 2012 and 2016, around 82% of Indigenous child deaths were infant deaths. Indigenous infants are twice as likely to die compared to their non-Indigenous counterparts. Despite this harrowing gap, there have been concrete gains in Indigenous infant mortality, with a 66.7% decline in Indigenous infant deaths between 1998 to 2016. The leading cause of Indigenous child mortality in infants (<1yr) is ‘perinatal’ conditions (such as, birth trauma, foetal growth disorders, complications of pregnancy and respiratory and cardiovascular disorders). This amounts to 53% of Indigenous infant deaths. The leading causes for child mortality in Indigenous children between 1-4 include Sudden Infant Death Syndrome, congenital malformation and injury and poisoning.
While all Australian jurisdictions have witnessed improvements in Indigenous child mortality rates, health outcomes vary substantially across jurisdictions. The Northern Territory continues to have both the highest child mortality rate and the largest gap between Indigenous and non-Indigenous child mortality at 332 deaths per 100,000 children.
It is true that health interventions take an extended period of time to produce measurable health outcomes. As such, the implementation timeframe for many Commonwealth programs, such as the Indigenous Child Development National Partnership Agreement, provides for a 10-year period before outcomes are expected. Given the proliferation of Indigenous child-health initiatives in the past 5 years, the full effect of health interventions is simply unknown. However, several intermediate measures demonstrate improvement in Indigenous child health outcomes, resulting in the potential for further reductions in child mortality rates. For example, there has been an increase in Indigenous women engaging with antenatal care programs, child immunisation (97.05% Indigenous Children are currently vaccinated as of 2019) and a statistically significant decrease is low birth-weight babies from 2005-2015. These improvements in child health risk factors are expected to result in further reductions in child mortality rates.
Child mortality rates are significantly influenced by factors such as the mother’s smoking habits, diet, exercise, socio-economic status and education level. Therefore, further reductions to child mortality rates will require an integrated approach. The Better Start to Life program has been expanded to improve access to child and maternal health programs. The program has greatly contributed to a decrease in the degree of women who smoked during their pregnancy (50% in 2009 to 45% in 2015).
Target #2: close the life expectancy gap within a generation (by 2031)
The national gap between Indigenous and non-Indigenous death rates has declined significantly by 14% since 1998. However little progress has been made since 2006. To meet the target of closing the life expectancy gap by 2031, Indigenous life expectancy must increase by 0.6-0.8 years annually. At the rate the gap is currently narrowing, it will take 495 years to ‘close the gap’. Therefore, more action needs to be taken. As the 2018 Closing the Gap report admitted this target is not on track to be met.
The most recent life expectancy statistics published in 2018 indicate that there is still a substantial gap in life expectancy between Indigenous and non-Indigenous men and women. At birth, Indigenous males have a life expectancy of 71.6 years (8.6 years lower than non-Indigenous males) whilst Indigenous females have an estimated life expectancy of 75.6 years (7.8 years less than non-Indigenous females). This demonstrates that there has only been a small reduction in the life expectancy gap since 2014 (2.5 years for indigenous males and 1.9 years for Indigenous females). It should however be noted that Indigenous expectancy rates lower with increased remoteness, while non-Indigenous life expectancy remains relatively consistent across urban, regional and rural areas.
The leading cause of Indigenous mortality in 2019 is chronic disease, including heart disease (which accounts for 12.1% of deaths), circulatory disease, diabetes and respiratory disease. There have been significant improvements in early detection and management of chronic disease and a reduction in the prevalence of smoking. For example, between 1998 and 2016, the decline in Indigenous mortality rates was the strongest for circulatory disease, with a reduction of about 45%. Similarly, the number of Indigenous people smoking has declined by 10% since 1994, meaning 45% of Indigenous people smoked in 2014-2015. Despite this, cancer mortality rates are on the rise, with an increase of 23% in cancer mortality for Indigenous individuals (compared to only 14% for their non-Indigenous counterparts) between 1998 and 2016. Intentional self-harm has also increased in Indigenous communities, rising from 17.7 per 100,000 persons in 2008, to 25.5 per 100,000 persons in 2017.
The 2015 Close the Gap Report noted that such a small improvement may actually be statistically insignificant as it is within the margin of error and could in fact mean that the small improvement in life expectancy is non-existent.
There is widespread recognition that Indigenous health outcomes in the Northern Territory are significantly worse than outcomes nationally. This translates to life expectancy also. In the Indigenous Reform 2012-13: Five Years of Performance report, the COAG Reform Council expressed particular concern for Indigenous people living in the Northern Territory, especially women. Male life expectancy was only 63 years, while female life expectancy has actually fallen 0.7 years since 2005 to 68.7 years.
More recently in the Northern Territory, Aboriginal male life expectancy rose slightly to 66 in 2019; see Closing The Gap report 2019 p. 126). The NT has the largest gap between Indigenous and non-Indigenous life expectancy. Therefore, Indigenous Australians living in the Northern Territory are expected to live 6 years shorter than Indigenous people in other parts of Australia. Additionally, the Northern Territory has the largest gap between Indigenous and non-Indigenous life expectancy, with Indigenous men and women both expected to live 14.4 fewer years (compared to approximately 10 years nationally).
The Northern Territory had the highest Indigenous mortality rate (1,478 per 100,000 population) as well as the largest gap with non-Indigenous Australians. Behavioural risk factors (i.e. smoking, diet and physical activity), as well as social determinants (i.e. income, education and employment) also contribute to disparities in health outcomes between Indigenous and non-Indigenous Australians and consequently, to the life expectancy gap. There is a complex relationship between Indigenous people and health service access, social disadvantage and health behaviours and these underlying factors must be comprehensively addressed in order to drive down the life expectancy gap.
Other 'gaps': chronic disease and mental health
Despite improvements in Indigenous health in recent years, Indigenous Australians have higher rates of chronic and preventable illnesses, and poorer self-reported health than non-Indigenous Australians. In several areas which are not specified as ‘Closing the Gap’ targets, Indigenous health is in fact deteriorating. For example, cancer mortality rates have risen by 23% for Indigenous Australians, contributing to a widening of the gap between Indigenous and non-Indigenous Australians cancer mortality rates. Similarly, Indigenous Australians are twice as likely as non-Indigenous Australians to have a severe or profound form of disability.
There are many dimensions to the poorer health status of Indigenous Australians compared with other Australians, one of which is greater difficulty in accessing affordable and culturally appropriate health services that are in close geographical proximity. A poor health outcome which attests to the difficulties faced by Indigenous Australians in accessing appropriate healthcare is the number of potentially avoidable deaths of Indigenous people. ‘Potentially avoidable deaths’ refer to deaths from conditions that could have been avoided given timely and effective health care. In the 5-year period of 2009 to 2013, approximately 61% of all death of Indigenous Australians aged 0–74 were classified as potentially avoidable deaths. After adjustment for age, the mortality rate of Indigenous people who died from potentially avoidable causes was more than 3 times the rate for their non-Indigenous counterparts.
Indigenous Australians are 3 times more likely to have diabetes and twice as likely to have chronic kidney disease as the non-Indigenous population. This likelihood increases 2.5 times for people living in remote areas. Additionally, Indigenous Australians tend to develop these chronic diseases at an earlier age. These chronic diseases account for 81% of the health gap that currently exists.
Co-morbidity is also an issue since these conditions often intersect. 70% of Australia’s Indigenous population are overweight or obese, which further increases the risk of chronic disease. Smoking also increases the risk of respiratory disease, although Indigenous smoking rates declined 10% in the decade from 2002-12.
The gap between Indigenous and non-Indigenous mental health is also declining. Poor mental health can also be a risk factor for chronic disease. In 2014-2015, just under a third of the Indigenous population reported experiencing high levels of psychological distress. The experience of psychological distress corresponds to Indigenous rates of suicide and hospitalisation. Indeed, the rate of deaths from suicide was twice the rate of non-Indigenous Australians, and Indigenous people are 1.8 times more likely to be hospitalised for psychological distress. The disproportionately high rates of suicide are worse in the Northern Territory, particularly in remote communities.
There have been some successes, such as a 40% decrease in circulatory disease since 1998. However, overall chronic disease rates have increased 2% from 2009-13. In 2015, the Healthy for Life program was granted $36.2 million to expand its work on the management of chronic disease in Indigenous communities.