The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples?

Aboriginal and Torres Strait Islander peoples’ share of the universal health coverage offered to all Australians is less per person than for other Australians: in the 2001–02 financial year, their Medicare expenditure was only 39% of that for other Australians; for dental services it was 24%; and for pharmaceuticals, 33%.13 Per-capita spending on medicines through the Pharmaceutical Benefits Scheme (PBS) in 2001–02 was $73.23 overall for Indigenous Australians, and only $59.82 in urban and regional areas, compared with $220.29 for other Australians.13 This conservatively amounts to a $67 million annual underspend, based on the national average, or a significantly higher shortfall if based on need. Aboriginal peoples have reduced access to medicines for a range of reasons similar to those for their overall poor access to primary health care.14

For a population with three times the rate of morbidity, and social, educational and economic disadvantage, overall spending on primary health care per person was only 23% higher for Indigenous Australians compared with other Australians in 2001–02.13 This included spending from all governments on state-run community health services, Aboriginal community controlled health services (ACCHSs), public health activities, non-admitted hospital services, Medicare, pharmaceuticals, patient transport, dental services, and aids and appliances. Federal and state/territory government commitment to ACCHSs, in their critical role as providers of culturally appropriate, comprehensive primary health care services to Aboriginal peoples,15 is not of sufficient scale to offset this inequitable expenditure.16,17

Analysts commissioned by the Australian Government in 2004 reported that funding for Indigenous-specific primary health care services should be around $1244 per capita.18 In reality, only $306 per capita was expended through such services by the Office for Aboriginal and Torres Strait Islander Health (OATSIH) in 2001–02.13 While the budget for these services has been growing,19 the gap has not closed (increases in annual expenditure to 2002 approximate those for health services used by non-Indigenous Australians),13 nor has growth been of a proportion commensurate with addressing inequity. Of Australia’s federal health expenditure of $38.4 billion in the 2005–06 financial year, the OATSIH budget comprised only 0.8%.20

Recently, the Aboriginal and Torres Strait Islander Health Performance Framework (HPF)19 and indicators of Indigenous disadvantage21 were developed to gauge Aboriginal peoples’ health improvements over time, based on select health determinants and health systems. While important, and an improvement on earlier indicators, they lack “right to health” indicators (designed to monitor the realisation of specific right to health norms, to hold duty-bearers to account),22 and targets and benchmarks to assess the health system’s responsiveness to Aboriginal peoples.5 For example, while the burden of Aboriginal children’s hearing loss is a measure in the HPF, proportionate federal government expenditure towards provision of hearing services in response to this problem is not. Differential access to the PBS is measured, but not efforts to enhance the quality use of medicines by Aboriginal peoples.23 Per-capita expenditure on primary health care disaggregated by Indigenous status is identified, but targets for the optimal level of expenditure are not.19

There is also an inability to report on the mainstream health sector’s relative expenditure on Aboriginal and other Australians under the bilateral Public Health Outcome Funding Agreements, which support schemes such as the National HIV/AIDS Strategy and the National Cervical Screening Program. Financial incentives for general practice and Divisions of General Practice initiatives also lack targets for proportionate funding to help address the excess disease burden in the Aboriginal population. Consequently, where data exist, they indicate that Aboriginal peoples are “locked out” of such programs, as shown below.

Overall spending per person on health services was only 18% higher for Aboriginal and Torres Strait Islander peoples than non-Indigenous Australians in 2001–02 (making up 2.8% of national health expenditure for 2.4% of the population), but nearly half of this expenditure was for use of hospital services, which was proportionately greater than hospital utilisation by other Australians.13 The two times higher rate of hospitalisation largely reflects Aboriginal peoples’ poor access to primary health care causing otherwise avoidable admissions, the use of emergency departments for primary care needs, and their need for renal dialysis.19

There is evidence of an inequitable distribution of health-related goods and services for Aboriginal and Torres Strait Islander peoples, including poorer access to: hospital procedures,24-26 population health programs developed for all Australians (eg, screening for breast and cervical cancer),27,28 rehabilitation services (eg, Commonwealth Hearing Services Program,29 cardiac rehabilitation programs30), immunisation,31 and general practice programs.32 As yet more frameworks designed to enhance health service delivery to Indigenous Australians33,34 are added to existing ones,15,35 an impression is created that action is being taken. Since duty-bearers are not held accountable in the provision of these services to Aboriginal peoples, and with few health policy reforms, there is little progress to report.