COAG Reform Council speech NACCHO Summit: Health outcomes for Indigenous people


John Brumby

Indigenous Australians should enjoy the same health, education and employment outcomes as other Australians. But, instead there remains a persistent and terrible gap between the two in major areas.

Closing the gap between Indigenous and non-Indigenous Australians is a priority for all Australian governments. But closing the gap is a long-term challenge—one which requires enduring vigilance and resources”

John Brumby Chair NACCHO reform Council Speaking at the NACCHO SUMMIT

I would like to begin by acknowledging the traditional owners and custodians of the land on which we meet today, the Wurundjeri people of the Kulin nation. I pay my respects to their Elders both past and present.

It is my pleasure to be with you today to report on national progress in indigenous health.

As you know, the COAG Reform Council was established by COAG in 2006 to report on Australia’s national reform progress.

Our job is to hold all nine Australian governments accountable for implementing national reforms that began rolling out in 2008.

Importantly, we publicly report our findings to the Australian people.

In 2008, COAG agreed to goals on healthcare, education, skills and workforce development, disability, housing and closing the gap on Indigenous disadvantage.

That was six years ago.

Today I will be launching a supplement that focuses on the health outcomes for Indigenous people. The supplement draws on the findings we have made in two reports that we provide to the Council of Australian Governments (COAG) each year – the National Healthcare Agreement and the National Indigenous Reform Agreement.


Indigenous Australians should enjoy the same health, education and employment outcomes as other Australians. But, instead there remains a persistent and terrible gap between the two in major areas.

Closing the gap between Indigenous and non-Indigenous Australians is a priority for all Australian governments. But closing the gap is a long-term challenge—one which requires enduring vigilance and resources.

The Genesis of Closing the Gap

The genesis of the closing the gap campaign was a report in 2005 by Dr Tom Calma, the then Aboriginal and Torres Strait Islander Social Justice Commissioner.

The report called on the governments of Australia to commit to achieving health equality for Indigenous people within a generation.

This report sparked the National Indigenous Health Equality Campaign in 2006 that culminated in a formal launch of the close the gap campaign in Sydney in April 2007, where NACCHO was a leading voice calling for action.

NACCHO’s very name—National Aboriginal Community Controlled Health Organisation—reflects the campaign for self-determination … the wish of Indigenous Australians to have their own representative bodies.

On 20 December 2007, the Council of Australian Governments answered the call of NACCHO, ANTAR, Oxfam Australia and many other organisations and pledged to close the life expectancy gap between Indigenous and other Australians within a generation.

In March 2008, the Indigenous Health Equality Summit released a statement of intent which committed the Australian government, among other things, to achieve equality of health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by 2030.

NACCHO was a signatory to that statement. The parties also agreed to use benchmarks and targets to measure, monitor and report.

COAG & Closing the Gap

In November 2008, our nation’s leaders committed to closing the gap within a generation (25 years) in the National Indigenous Reform Agreement (NIRA).

Importantly, COAG agreed to be accountable for closing these gaps and appointed the COAG Reform Council to monitor progress.

As you well know, COAG has six targets as part of its objective of closing the gap.

  1. To close the life expectancy gap within a generation, by 2031.
  2. To halve the gap in mortality rates for Indigenous children under five within a decade, by 2018.
  3. To provide access to early childhood education for all Indigenous four-year olds in remote communities within five years, by 2013.
  4. To halve the gap in reading, writing and numeracy within a decade, by 2018.
  5. To halve the gap in the rate of Year 12 or equivalent attainment, by 2020.
  6. And, finally, to halve the gap in employment outcomes within a decade by 2018.

For the past five years, the COAG Reform Council has dissected the data, measured progress and independently reported on whether Australian governments are achieving these targets in both our NIRA report and our report under the National Healthcare Agreement.

Indigenous Supplement to Healthcare in Australia 2012–13

What we have found under the NIRA report, the National Healthcare agreement and the supplement I am releasing today is that the health of Indigenous Australians continues to be poorer than non-Indigenous Australians.

We found that Indigenous life expectancy at birth was 69.1 years for men and 73.7 years for women. This equates to a gap between Indigenous and non-Indigenous life expectancy of 10.6 years for men and 9.5 years for women.

Although the national gap in life expectancy did slightly narrow over the last five years, it is extremely unlikely that governments will be able meet the target to close the life expectancy gap within a generation (that is, by 2031).

The life expectancy gap and potentially avoidable death

Closing the gap on life expectancy is complex and requires action on a range of fronts.

We report on a range of indicators and targets about many things that may help to achieve improvements in Indigenous health. These include indicators relating to preventative health, primary care, hospitals and the medical workforce.

I would like to focus today on the results we have found in regards to death from potentially avoidable causes – either through prevention, or through early intervention via primary or community care.

In regards to deaths from potentially avoidable causes – we measure according to whether they could have been potentially prevented or potentially treated.

Deaths from potentially preventable causes are avoidable through primary healthcare (such as the care provided by a GP or community care), health promotion (such as by improving healthy habits and behaviours) and preventative health (such as vaccination against some diseases or help to quit smoking).

Deaths from potentially treatable causes are avoidable through appropriate therapeutic interventions, such as surgery or medication, before a condition worsens. This is often the case where diseases are prevented early, such as through screening programs.

What we found was that Indigenous people were three times as likely to die of an avoidable cause. This means that three-quarters of deaths of Indigenous people aged under 75 were avoidable either through early prevention or treatment.

By way of comparison, two-thirds of all Australians died from avoidable causes.

It is a tragedy to think of all of those taken before their time purely because they did not receive care early enough, or did not make the lifestyle changes to prevent disease.

Early intervention is vital

This finding underlines two things that NACCHO well knows if we are to close this terrible gap in life expectancy:

  1. Good access to primary or community care is vital.
  2. Prevention is better than cure.

There have been large increases in the rates of indigenous people having health checks claimable from Medicare over time, and this was true of all age groups.

The rate of child health checks has more than doubled, from 87.9 per 1000 in 2009-10 to 193.0 per 1000 in 2012-13. This is an average annual increase of 35.7 checks per 1000 children aged 0 to 14 years.

In the 15-54 years age group, the rate of health checks more than doubled from 74.5 per 1000 in 2009-10 to 196.0 per 1000 in 2012-13. This equated to an average annual increase of 40.3 checks per 1000 people.

In the 55 years or over age group, the rate of health checks more than doubled from 137.5 checks per 1000 people in 2009-10 to 304.6 per 1000 indigenous people in 2012-13. This equates to an annual average increase of 54.8 checks per 100 people from 2009-10 to 2012-13.

In child health we have also seen some pleasing improvement.

The rate of Indigenous child deaths decreased by 35% to 164.7 deaths per 100,000 Indigenous children compared to 77.2 per 100,000 for non-Indigenous children, and death rates are falling more quickly.

This means that the gap in the child death rate between Indigenous and non-Indigenous children decreased by 38% from 1998 to 2012, and we are on track to reach the current 2018 target.

This is a resounding achievement and is partly due to increases in immunisation rates and health checks:

  • In 2012, immunisation rates for Indigenous children aged 2 years and 5 years were the same as for all children. However, rates at 1 year still lag behind.
  • And, the rate of child (0–14 years) health checks doubled between 2009–10 and 2012–13

These results in access to immunisation and health checks are very positive and reflect the hard work and what can be achieved when governments and community stakeholders, such as NACCHO and others work together.

We should ensure that these gains are not undone.

As you know, the cost of healthcare is very topical at the moment. Australians are being asked to consider what they would pay for access to a primary care physician.

What we found in our results for this report was that one in eight (12%) indigenous people already delayed or did not go to a GP as a result of cost. More than two out of five (43.9%) Indigenous people delayed or did not see a dental professional due to cost. And one-third (34.6%) delayed or did not fill a prescription also due to cost.

When people start to avoid going to their primary or community care provider because of cost or other reasons, they often end up in hospital.

And, what we found was that rates of potentially preventable hospitalisations for Indigenous people were already three to four times higher than rates for other Australians.

These results provide context for governments when they are considering policies around access to primary care. Governments should be careful that they do not put up barriers to healthcare access for Indigenous people as it may undo the good work that has been done in this space over five years and end up creating a different burden on the hospital system.

Prevention is better than cure

The other component that we will need focus on to close the gap in life expectancy is prevention – particularly prevention of circulatory diseases, endocrine disorders (like diabetes) and some cancers.

The results we found this year show significantly more work needs to be done.

The heart attack rate for Indigenous people in 2011 was two and a half times higher than that of other people.

And Indigenous Australians are more than five times more likely to die of endocrine diseases (like diabetes), and one and a half times as likely to die from a circulatory disease or cancer.

One of the primary drivers in rates of heart attacks and endocrine disorders are rates of excess body weight.

Around 70% of adult Indigenous Australians have excess body weight, meaning that they are either overweight or obese. The rate of obesity by itself was 42%.

This compares poorly to the broader Australian population, where 63% of all adults had excess body weight and 27% were obese.

This high rate is extremely concerning. Particularly when you consider the increased risks it poses for chronic diseases and early death.

Finally, I would like to turn to lung cancer. In 2010, the rates of lung cancer for Indigenous Australians was nearly double the rate for non-Indigenous Australians.

What is most tragic about lung cancer is how preventable it is. Lung cancer is very strongly linked with whether or not a person smokes. We found that the Indigenous adult smoking rate is more than double the non-Indigenous rate (41.1% vs 16.0%).

So, that is a brief summary of the health report.

Without a doubt, the results are still not good enough to close the gap in many of the health outcomes for indigenous people.

We continue to have too many Indigenous people dying before their time, of preventable diseases and conditions.

However, there are green shoots; we have seen increases in access to primary care, and most pleasingly we are on track to close the gap in child deaths.

The social determinants of health

I think it is important to recognise that these health outcomes will also be critically determined by non-health factors, what’s referred to as the ‘social determinants of health.’ The recognition of these social determinants has, in the words of the National Rural Health Alliance, become a ‘rejuvenated agenda.’

Our working conditions — whether that be our incomes, job stability, or workplace safety — and factors like education and housing among many others, each make meaningful contributions to our health.

To draw on the words of Dr Margaret Chan, the Director General of the World Health Organisation:

‘…the social conditions in which people are born, live, and work are the single most important determinant of good health or ill health, of a long and productive life, or a short and miserable one.’

So, I would also like to discuss some results from our latest National Indigenous Reform Agreement report with you – particularly the results from education and employment.

We launched our latest NIRA report on government’s achievement against these targets in May.

We found that in literacy, numeracy and year 12 education, outcomes for Indigenous Australians are catching up with those of non-Indigenous Australians.

Between 2008 and 2013, the gap in the proportion of Indigenous and non-Indigenous students who met the national minimum standard narrowed in reading in all years and in Years 3 and 5 in numeracy.

In reading, the gap reduced most, by over 10 percentage points in Years 3 and 5. There were smaller reductions in Years 7 and 9 (1 to 3 percentage points).

In numeracy, the gap narrowed by 2 to 3 percentage points in Years 3 and 5 but widened in Year 9 by 4 percentage points. The gap widened in Year 7 by less than 1%.

The gap in the proportion of Indigenous and non-Indigenous 20–24 year olds who attained Year 12 or equivalent decreased significantly—by 12.2 percentage points .

And, over the past four years, the proportion of Indigenous Australians with or working towards a post school qualification increased from 33.1% to 42.3 %.

More work needed on childhood education, school attendance and employment

While most of this is heartening, our report also found that better results are needed in early childhood education, school attendance and in employment to meet COAG targets.

Early childhood education is a critical time for development as a successful learner. In 2012, 88% of Indigenous children in remote communities were enrolled in a preschool program in the year before school compared to 70% in major cities.

Similarly, 77% of children in remote areas attended a preschool program compared to 67% in major cities.

Another area of real concern we highlight is the falling rate of school attendance by Indigenous students in most year levels.

It’s very disappointing that—over four years—falls in Indigenous students’ attendance have outstripped any improvements made.

The worst drops in attendance were in South Australia the ACT and the Northern Territory, where attendance fell as much as 14 percentage points.

Only New South Wales and Victoria saw attendance rates improve and the gap narrow overall but even so, improvements were small —1 percentage point for most year levels.

Regular school attendance is vital for developing core skills in literacy and numeracy, and for successfully completing secondary education.

A slump in school attendance rates in all jurisdictions in the later years of compulsory schooling is particularly concerning given its potential to impact long-term economic participation.

Which leads me to employment – Australia is not on track to halve the gap in employment outcomes by 2018.

Since 2008, the gap between Indigenous and non-Indigenous employment outcomes has widened over the past five years by almost seven percentage points.

To give you some examples, we found just over 60% of Indigenous Australians were participating in the labour force, compared to almost 80% of non-Indigenous Australians.

And the overall unemployment rate for Indigenous Australians was four times that of non-Indigenous Australians—almost 22% compared to 5%.

Lower Indigenous employment and workforce participation has an impact right across the reform agenda, and must be prioritised for attention by COAG.

We, at the council, are pleased to see some positive outcomes under the Indigenous Reform Agreement, but are wary that there is still hard work and monitoring to be done in key areas.

Performance reporting matters

As you may be aware, the COAG Reform Council is being wound up on June 30, so we will no longer be reporting on these outcomes in the future.

In response to the news of the COAG Reform Council being abolished, Mick Gooda said:

“If we don’t have decisions made on the basis of the best evidence that we have available to us, we might as well be just making up things on the back of beer coasters again.”

The reports we release on Indigenous outcomes have not only enabled governments to monitor their performance. They have also equipped the public, and organisations such as NACCHO and the other peak bodies that are here today, with the information they need to hold governments to account for promises they have made in regards to Indigenous Australians.

Our reporting has provided the impetus for more focused effort to improve Indigenous health, education and economic participation and has highlighted important progress – reassuring governments and the community that change is indeed possible.

And after five years of reporting on governments’ performance, our reports have shown that we are still only at the beginning of the change required over a generation to close the gap.

I’ve been fortunate in my public life to have served in both federal and state parliaments, in opposition and in government.

And after all these years, I can honestly say that accountability—keeping governments honest—and evidence-based reform are not simply important ingredients  – they are absolutely essential to getting results and keeping governments on track.

Although we do not know for sure who will be reporting on the targets to close the gap in the future, it has been suggested that the Prime Minister’s department will report on achievement of targets.

I have a great deal of respect for the Department of Prime Minister & Cabinet and I’m sure there are people with the skills to do that in PM&C.

However, what the COAG Reform Council did that was particularly special was hold governments to account on the promises they have made, but did so independently of any one government.

We report independently on the progress of all nine of Australia’s governments—the Commonwealth, the States and the Territories—in closing the gap.

That independence ensured that our reporting was impartial and objective.

Who will do this in the future?

We need to consider how to increase the effectiveness of our independent public reporting on government progress, such as improving the quality of indicators, and accessing better data.

It is important in the future that someone, or some organisation, will be there to properly measure what governments are achieving with the billions of dollars in taxpayers’ money they are spending.

Crucially, it is important that any future design of performance reporting frameworks and targets must involve indigenous stakeholders as equal partners.

Consultation with governments is required under the IGA. It should extend to key Indigenous stakeholders such as the Closing the Gap coalition.

With a tri-lateral coalition of the Commonwealth, State governments, and Indigenous representatives – we truly have a real chance of closing the gap.

So, in my last week as chairman of the COAG Reform Council, allow me to pay tribute to the work of NACCHO and extend my best wishes for the future of Indigenous health reform.

Your voice matters and I know it will shape a better future for Indigenous Australians. Thank you.

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Closing the gap: who knows?

 John BrumbyThe National Aboriginal Community Controlled Health Organisation (NACCHO) has expressed grave concerns that the COAG Reform Council responsible for monitoring progress towards close the gap targets will close next week on 30 June.

At the 2014 NACCHO Health Summit in Melbourne today, Chairman of the COAG Reform Council, John Brumby, presented the findings of the Council’s final work on Aboriginal and Torres Strait Islander health monitoring, Healthcare in Australia 2012-13: Comparing outcomes by Indigenous status.

NACCHO chairperson Justin Mohamed thanked John Brumby and his Council staff for their efforts to ensure government policy to close the gap was translated into on-ground improvements for Australia’s First Peoples and their communities.

“It was six years ago that Australian governments took on the significant challenge of closing the gap on Aboriginal and Torres Strait Islander disadvantage in health, education, employment and other social areas,” Mr Mohamed said.”

“In that time Mr Brumby and his team have monitored progress on closing the gap, and reported publicly and free of political influence.”

“Today’s report confirms that for all the significant achievement made, including a decrease in the Aboriginal infant mortality rate by 35%, there remains work to be done to improve outcomes in other areas.”

“We are really worried that the millions of dollars being cut from across Aboriginal affairs at the Federal level, plus the introduction of new arrangements in accessing primary health care and changes to unemployment benefits, could potentially push the closing the gap targets even further from reach.”

“It’s now been more than a year since the National Partnership Agreement has lapsed and we still don‚t have any clear advice on how states, territories and the commonwealth plan to coordinate addressing the closing the gap targets.”

“Now there will be no independent umpire able to evaluate progress  ‘or lack of it’ and hold state and territory governments and the Federal Government accountable.”

“The Federal Government must urgently outline how it plans on keeping this priority area of health and social reform on track during the long-term commitment needed to close the gap”, Mr Mohamed said.

Read full report here