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ACCESS TO HEALTH SERVICES
The 2004-05 NATSIHS also collected information on the reasons that Indigenous people did not use health care services when needed, and on barriers to access. Factors such as transport and distance, long waiting times and cost were reported by a high proportion of those who had not seen a doctor when needed (AHMAC 2006).
While a higher proportion of Indigenous people in non-remote areas reported cost as a reason for not seeking health care when needed, transport/distance and the service not being available in the area were more commonly given as reasons by people in remote areas. For example, cost was reported as a reason for not seeing a dentist when needed by 32% of respondents in non-remote areas, compared with 15% of those in remote areas (graph 10.3). On the other hand, respondents in remote areas were much more likely than those in non-remote areas to report transport/distance (28% compared with 7%), or a service not being available in the area (28% compared with 3%) as reasons for not seeing a dentist when needed (AHMAC 2006).
10.3 REASONS FOR NOT VISITING A DENTIST WHEN NEEDED, Indigenous persons aged 2 years and over - 2004-05
Cultural and language barriers
A lack of understanding of Aboriginal and Torres Strait Islander culture, concepts of health and history, and Western-dominated models of care can result in Indigenous Australians feeling disempowered and less likely to use health services (Bailey 2005). According to Anderson et al (2004), Aboriginal and Torres Strait Islander peoples may need a different approach when consulting a GP, because of differences in how Indigenous people respond to illness and how they interact with health care providers.
Communicating with service providers
The 2002 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) collected information on whether Indigenous Australians spoke a language other than English at home and whether they had difficulty communicating with service providers. About 14% of Indigenous people aged 15 years and over reported that they spoke a language other than English at home. Indigenous people living in remote areas were much more likely to report speaking an Aboriginal or Torres Strait Islander language at home (39%) than were those living in non-remote areas (2%) (ABS 2004d).
Difficulties in communicating with service providers may also affect treatment choices and treatment outcomes. Around 11% of Indigenous adults reported that they had difficulty understanding and/or being understood by service providers. Indigenous people living in remote areas were more likely than those in non-remote areas to report experiencing difficulty (19% compared with 8%) (ABS & AIHW 2005).
Condon et al (2006) examined the effect of speaking a language other than English on health outcomes in a study about cancer diagnosis and treatment in the Northern Territory. Among Indigenous people diagnosed with cancer, those with an Indigenous first language had a much higher risk of cancer death than English language speakers. Indigenous people were more likely to have a more advanced stage of cancer at diagnosis than non-Indigenous people, and for those whose first language was Indigenous, poorer treatment after diagnosis was also a contributing factor. The authors note that while Indigenous first language may point to possible communication difficulties, it is also 'a marker of social, cultural, economic, educational and geographic factors'.
Treatment when seeking health care
The 2004-05 NATSIHS asked Indigenous Australians how they felt they were treated when they sought health care in the previous 12 months. The majority (77%) of Indigenous people reported that they felt they were treated the same as non-Indigenous people, 5% reported that they were treated better than non-Indigenous people and 4% reported that they were treated worse than non-Indigenous people (AIHW 2007a). A higher proportion of Indigenous people in remote areas reported that they were treated better than non-Indigenous people (11% compared with 3%). Approximately 16% of Aboriginal and Torres Strait Islander people felt that they were treated badly when they sought health care because they were Indigenous.
Availability of health professionals, services and facilities
Indigenous Australians are more likely to live outside urban areas than non-Indigenous Australians, and are therefore more likely to live further from mainstream health services and health professionals. Aboriginal health services, operating in many parts of the country, including remote areas, go some way towards addressing the differences in health service provision for a more geographically dispersed population. Indigenous people living in more remote areas, however, still do not have access to many of the services provided in urban areas.
Location of health professionals
The number of medical practitioners per head of population decreases with increasing geographic remoteness. This limits access to medical practitioners for people in rural and remote areas. As a higher proportion of Indigenous Australians live in rural and remote areas, they are more likely to have to move or travel substantial distances in order to get access to medical care. The supply rate of medical practitioners is measured by the full-time equivalent (FTE) rate per 100,000 population.
In 2005 there were more than twice as many medical practitioners per person in major cities (335 FTE per 100,000) as in remote/very remote areas (148 FTE per 100,000) (table 10.4). The number of medical specialists per person in major cities was eight times that in remote areas. The concentration of primary care practitioners, specialists and specialists in training in major cities and inner regional areas can be partially explained by the location of facilities for services provided by these types of professions.
Between 2002 and 2005, there was a slight increase in the supply of medical practitioners in Australia (from 271 FTE to 288 FTE per 100,000). The increase was spread across all remoteness areas.
The pattern across remoteness areas was different for nurses compared with medical practitioners. In 2005, the supply rate of nurses was highest in very remote areas (1,177 FTE per 100,000) and second highest in outer regional areas (1,139 FTE), while major cities had the lowest rate of nursing supply (1,074 FTE) (table 10.5). Between 2001 and 2005, the supply of nurses in Australia increased from 1,031 to 1,133 FTE per 100,000 population.
People living in discrete Indigenous communities
Detailed information about the distance to, and the availability of, health facilities and health professionals for people living in discrete Indigenous communities is collected in the ABS Community Housing and Infrastructure Needs Survey (CHINS). The 2006 CHINS collected data from a total of 1,187 discrete Indigenous communities with a combined population of approximately 92,960 (ABS 2007d). Approximately 87% of the Indigenous people in these communities were living in remote and very remote parts of Australia. Nearly three-quarters (73%) of all communities included in the CHINS reported a usual population of less than 50.
The 2006 CHINS collected data on access by all communities to three types of health facilities - hospitals, Aboriginal Primary Health Care Centres and other (state funded) community health centres. These questions were asked separately for each community.
There were 10 discrete communities (with a usual population of 14,090) that had a hospital located within the community, and another 89 communities (with a usual population of 7,743) that had a hospital located within 10 kilometres of the community (table 10.6). Over half (56%) of the people living in discrete Indigenous communities (51,992 people in 755 communities) were located 100 kilometres or more from the nearest hospital.
There were 107 discrete communities (with a usual population of 41,450) that had an Aboriginal primary health care centre within the community, and 104 communities (with a usual population of 7,743) that were located within 10 kilometres of such a centre. Over one-quarter of those living in discrete Indigenous communities (27% or 25,486 people) were located 100 kilometres or more from the nearest Aboriginal primary health care centre (table 10.6).
There were 104 discrete communities (with a usual population of 35,737) that had some other (generally state funded) community health centre located in the community and 113 communities (with a usual population of 8,101) that were located within 10 kilometres of such a centre. One-quarter of people living in discrete Indigenous communities were located 100 kilometres or more from the nearest other (state funded) community health centre (table 10.6).
Of the 755 discrete Indigenous communities that were located 100 km or more from the nearest hospital, 268 (35%) reported having access to a medical emergency air service. The remaining 487 communities (with a usual population of 9,337), did not have access to a medical emergency air service.
Availability of health professionals
While location of health services provides one measure of access, people in communities may also have access to visiting health professionals or health workers. The CHINS collected information for all communities on the availability of services from four types of health professionals - doctors, registered nurses and female and male Indigenous health workers.
In 2006, there were 14 communities (with a usual population of 11,344) who had daily access to a doctor and another 162 (with a usual population of 37,447) with weekly to monthly access (table 10.7). Around four in ten people usually resident in these communities (39,759 people or 43%), did not have regular access to a doctor.
People living in discrete Indigenous communities had greater access to registered nurses than to doctors. There were 120 communities (with a usual population of 44,923) that had daily access to a nurse and another 81 communities (with a usual population of 9,717) with weekly or monthly access to a nurse. There were 37,237 people (40%) living in communities that did not have regular access to a registered nurse.
Some 15% of communities had access to a female health worker at least monthly and 11% had access to a male health worker at least monthly.
Community access to other selected health professionals (such as dentists, obstetricians, optometrists) was collected from communities with a population of 50 or more and all communities with a population of 50 or less that were self-administered (375 communities in total). Access could be anything from daily to less than three-monthly visits, or visits as required. Around one-third (32%) of the communities surveyed reported having access to a drug and alcohol worker, 113 communities (30%) had access to a dietician and 103 communities (27%) had access to a dentist (graph 10.8). A much smaller proportion of communities reported having access to an obstetrician or gynaecologist (13%), and ear, nose and throat or respiratory specialist (10%).
Distance to various health services provides one measure of access, but lack of transport may mean that comparatively short distances are an impediment to service use. Lack of transport can impact on people living in both remote and non-remote areas. Data are available from the 2006 Census (for all Indigenous households) on the number of motor vehicles owned or used by household members and garaged or parked at or near the dwelling on Census night.
The 2006 Census shows that Indigenous households were more likely than other households to be without access to a motor vehicle (graph 10.9). The proportion of Indigenous households that did not have a motor vehicle was 21%, compared with 9% for other households. These proportions were similar to those reported in the 2001 Census (23% and 9% respectively). Indigenous households in remote and very remote areas were less likely than those in non-remote areas to have ready access to a motor vehicle.
In the 2004-05 NATSIHS, difficulty with transport/distance was reported as the main reason that Indigenous Australians didn't visit the following services when needed in the previous 12 months - a hospital (19%), doctor (14%) and other health professional (8%). Around one in ten Indigenous people (11%) reported transport/distance as the main reason for not visiting a dentist when needed in the previous 12 months. A higher proportion of Indigenous people living in remote areas than in non-remote areas reported transport/distance as a reason for not accessing health services.
Many health services provided outside of public hospitals involve direct out-of-pocket payments by patients. This has a greater impact on access to health services for people with limited economic means and, given the generally poorer economic position of Aboriginal and Torres Strait Islander people (see Chapter 2), the effect is likely to be greater on Indigenous Australians than on other Australians.
Services which require out-of-pocket payments include those provided by dentists, physiotherapists, psychologists and other health professionals not covered by Medicare or not provided as part of a comprehensive primary health care service. It also includes pharmaceuticals not covered by the Pharmaceutical Benefits Scheme (PBS). In addition medical services subsidised under Medicare can attract co-payments if they are not bulk-billed. In the December quarter 2006, 72% of medical services were bulk-billed (DoHA 2007b). In 2005-06, GP bulk-billing rates were higher in capital cities than in rural or remote areas (SCRCSSP 2007b). Regardless of location, all Australian Government funded Aboriginal Community Controlled Health Services that have doctors or allied health workers can apply to be covered by Medicare and patients using these services are bulk-billed.
The 2004-05 NATSIHS collected information on whether people in non-remote areas were required to make a co-payment for their last visit to a medical practitioner or other health professional. Around 15% of Indigenous people in non-remote areas were required to make a co-payment to the doctor, 37% were required to make a co-payment to a specialist and 17% were required make a co-payment to other health professionals (AIHW 2007a).
People who are prescribed drugs under the PBS are also required to make out-of-pocket co-payments. The amount that a patient pays is adjusted to some extent in accordance with the patient's ability to pay. Different co-payments apply to concession card holders, pensioners and general patients. The PBS also has safety net provisions that protect individuals and families from large overall expenses for PBS medicines.
Private health insurance
Lack of health insurance is a barrier to accessing private hospitals and the services of those health professionals who work solely or primarily within the private health system. In the 2004-05 NATSIHS and 2004-05 NHS, a much higher proportion of Indigenous than non-Indigenous Australians in non-remote areas reported that they were not currently covered by private health insurance (83% compared with 49%) (AIHW 2007a).
The large gap in private health insurance coverage between Indigenous and other Australians is due, at least in part, to the relative economic disadvantage of Indigenous Australians. The most common reasons reported by Indigenous Australians for not getting private health insurance were that they could not afford it (65%), and that they felt that Medicare cover was sufficient (19%) (AIHW 2007a).
A working telephone in the home is often considered a necessity in cases of emergency so that health services such as hospitals, ambulances and doctors can be contacted quickly. People without a working telephone in the home are less equipped to seek medical help when required. Of those surveyed in the 2002 NATSISS, 71% of Indigenous Australians aged 15 years and over reported having a working telephone in their home. Indigenous people living in non-remote areas were almost twice as likely to have a working telephone (82%) as those living in remote areas (43%) (ABS 2004d).