Australian Institute Health Welfare Aus 221

Australia’s health 2018 is the 16th biennial health report
Australia’s health 2018

of the Australian Institute of Health and Welfare. This edition
profiles current health issues in a collection of feature articles
and statistical snapshots that cover a range of areas, including:
• A ustralia’s health system
• C auses of ill health
• D eterminants of health
Australia’s
• H ealth of population groups
• I ndigenous health
• P revention, treatment and health services
health
2018
AIHW
+61 2 6244 1000 [email protected] @aihw
www.aihw.gov.au GPO Box 570 1 Thynne Street

Canberra ACT 2601 Bruce ACT 2617
Australia Australia
Stronger evidence,
better decisions,
improved health and welfare
Australia’s
health
2018
The Australian Institute of Health and Welfare is a major national agency whose purpose is to
create authoritative and accessible information and statistics that inform decisions
and improve the health and wellbeing of all Australians.
© Australian Institute of Health and Welfare 2018

This product, excluding the AIHW logo, Commonwealth Coat of Arms and any material owned by a third
party or protected by a trademark, has been released under a Creative Commons BY 3.0
(CC BY 3.0) licence. Excluded material owned by third parties may include, for example, design and layout,
images obtained under licence from third parties and signatures. We have made all reasonable efforts to
identify and label material owned by third parties.
You may distribute, remix and build upon this work. However, you must attribute the AIHW as the
copyright holder of the work in compliance with our attribution policy available at
<www.aihw.gov.au/copyright/>. The full terms and conditions of this licence are available at
<http://creativecommons.org/licenses/by/3.0/au/>.
This publication is part of the Australian Institute of Health and Welfare’s Australia’s health series.
A complete list of the Institute’s publications is available from the Institute’s website <www.aihw.gov.au>.
ISSN 1032-6138
ISBN 978-1-76054-319-8 (PDF)
ISBN 978-1-76054-320-4 (Print)
Suggested citation
Australian Institute of Health and Welfare 2018. Australia’s health 2018. Australia’s health series no. 16.
AUS 221. Canberra: AIHW.
Australian Institute of Health and Welfare

Board Chair Director
Mrs Louise Markus Mr Barry Sandison
Any enquiries relating to copyright or comments on this publication should be directed to:
Website and Publishing Unit
Australian Institute of Health and Welfare
GPO Box 570
Canberra ACT 2601
Tel: (02) 6244 1000
Email: [email protected]
Published by the Australian Institute of Health and Welfare.
Report designed using art by Penny Deacon.
Please note that there is the potential for minor revisions of data in this report.
Please check the online version at <www.aihw.gov.au>.
The Hon Greg Hunt MP
Minister for Health
Parliament House
Canberra ACT 2600
Dear Minister,
On behalf of the Board of the Australian Institute of Health and Welfare, I am pleased to
present to you Australia’s health 2018, as required under Subsection 31(1) of the Australian
Institute of Health and Welfare Act 1987.
This edition continues the AIHW tradition of delivering high quality evidence and value-added
analysis on health-related issues. It provides comprehensive coverage of topics, including
new narrative on topical issues, and provides insights into how national health information
assets and future data could better meet the needs of policy makers, researchers and
the public.
I commend this report to you as a significant contribution to national information on
health-related issues, and to the development and evaluation of health policies and
programs in Australia.
Yours sincerely
Mrs Louise Markus

Chair
AIHW Board
16 May 2018
Contents
Preface�� viii
Acknowledgments�� x
1
Chapter 1 An overview of Australia’s health 1
1.0 Overview��2
1.1 What is health?��4
1.2 Profile of Australians��7
1.3 How healthy are Australians?��10
1.4 Indicators of Australia’s health��13
1.5 International comparisons��29
1.6 What is missing from the picture?��32
2
Chapter 2
2.0
Australia’s health system
Overview��38
37
2.1 How does Australia’s health system work?��40

2.2 How much does Australia spend on health care?��54
2.3 Who is in the health workforce?��65
2.4 Digital health��69
2.5 Secondary use of health information��72
3 Chapter 3
3.0
Causes of ill health
Overview��82
81
3.1 Burden of disease across the life stages��84

3.2 Leading causes of death��88
3.3 Chronic conditions��94
3.4 Cancer�� 103
3.5 Mesothelioma�� 106
3.6 Coronary heart disease�� 111
3.7 Stroke�� 115
3.8 Diabetes�� 118
3.9 Chronic kidney disease�� 121
3.10 Arthritis and other musculoskeletal conditions�� 124
iv
3.11 Chronic respiratory conditions�� 128
3.12 Mental health�� 132
3.13 Eating disorders�� 135
3.14 Dementia�� 138
3.15 Injury�� 142

3.16 Family, domestic and sexual violence�� 146
3.17 Opioid harm�� 150
3.18 Oral and dental health�� 153
3.19 Communicable diseases�� 156
4
Chapter 4
4.0
Determinants of health 163
Overview�� 164
4.1 Impacts of the natural environment on health�� 166
4.2 Social determinants of health�� 179
4.3 Health literacy�� 183
4.4 Contribution of selected risk factors to burden of disease�� 186
4.5 Tobacco smoking�� 200
4.6 Alcohol risk and harm�� 204
4.7 Illicit drug use�� 208
4.8 Insufficient physical activity�� 225
4.9 Diet�� 228
4.10 Overweight and obesity�� 231
4.11 Biomedical risk factors�� 245
4.12 Antenatal risk factors�� 248
5
Chapter 5
5.0
Health of population groups 253
Overview�� 254
5.1 Socioeconomic groups�� 256
5.2 Rural and remote populations�� 259
5.3 Culturally and linguistically diverse populations�� 271
5.4 People with disability�� 277
5.5 Lesbian, gay, bisexual, transgender and intersex people�� 284
5.6 Veterans�� 288
5.7 Prisoners�� 300
v
6
Chapter 6
6.0
Indigenous health 305
Overview�� 306
6.1 Profile of Indigenous Australians�� 308
6.2 Indigenous health and wellbeing�� 312
6.3 Indigenous child mortality and life expectancy�� 316
6.4 Ear health and hearing loss among Indigenous children��320
6.5 Health behaviours of Indigenous Australians�� 331
6.6 Social determinants and Indigenous health�� 335

6.7 Size and sources of the Indigenous health gap �� 339
6.8 Indigenous Australians’ access to and use of health services��353
6.9 Supply of the health workforce for the Indigenous population��357
7
Chapter 7
7.0
Prevention, treatment and health services 371
Overview�� 372
7.1 Health promotion�� 374
7.2 Immunisation and vaccination�� 377
7.3 Suicide prevention activities�� 380
7.4 Cancer screening�� 384
7.5 Primary health care�� 387
7.6 Medicines in the health system�� 400
7.7 Overview of hospitals�� 412
7.8 Funding sources for the care of admitted patients��415
7.9 Safety and quality of hospital care�� 418
7.10 Emergency department care�� 430
7.11 Elective surgery�� 433
7.12 Radiotherapy�� 436
7.13 Organ and tissue donation�� 439
7.14 Labour, birth and outcomes�� 442
7.15 Caesarean sections�� 445
7.16 Variation in health care provision�� 450
7.17 Patient-reported experience and outcome measures��454
7.18 Coordination of health care�� 464
7.19 Specialised alcohol and other drug treatment services��468
7.20 Mental health services�� 472
7.21 Palliative care services�� 477
vi
Methods and conventions�� 480
Symbols�� 485
Acronyms and abbreviations �� 486
Glossary�� 490
Index�� 522
vii
Preface
Australia’s health 2018 marks the 16th biennial flagship report on health that the
Australian Institute of Health and Welfare (AIHW) has released since it was
established in 1987.
This latest national report card continues the trend of providing independent,
trusted and timely information to the wide range of Australians who use it—the
community, policymakers, service providers and researchers.
Australia’s health 2018 examines health using a person-centred approach—this takes

the view that a person’s health is part of a broader social context and encompasses
the ideas that health:
• is an important part of how people feel and function
• c ontributes to, and is influenced by, social and economic wellbeing
• c an exist in degrees of good, as well as poor, health and varies over time.
The report profiles our health status and use of health services, and takes an in-depth
look at topical health issues, including the contribution of risk factors to disease
burden; how the health of the population is linked to the natural environment; and
the factors contributing to the increasing prevalence of overweight and obesity in our
community. Other featured topics include mesothelioma—Australia has one of the
highest diagnosis rates in the world for this cancer—and the increasing harm caused
by the use of both pharmaceutical and illegal opioids.
The series of feature articles accompanies a collection of short statistical snapshots
that outline the leading types of illness, risk factors, health behaviours, and the services
available to help prevent and treat ill health.
The report also contains a breadth of information on the health—and health
inequalities—experienced by some population groups, including Indigenous
Australians; Australians from culturally and linguistically diverse backgrounds;
Australian veterans; lesbian, gay, bisexual, transgender and intersex Australians;
and Australians living in rural and remote areas.
The AIHW manages a number of national health information assets, and works with
state and territory governments, the Australian Bureau of Statistics, other independent
bodies and the non-government sector, to ensure that the data included in Australia’s
health 2018 are comprehensive, accurate and timely.
viii
Despite this, and ongoing efforts to develop and improve national health data,
many gaps remain and information that are collected are not always used to their
full potential. These and other data limitations are listed in ‘What is missing from
the picture?’ sections throughout the report. Australia’s health information and data
environment is changing rapidly, with increasing demands made on the collection,
reporting and use of health data. There is a strong need for a strategic approach to
how we manage national health data assets in Australia—a strategy that provides
a desirable vision for the future of Australia’s national information resources.
A structured, strategic approach to data and evidence is critical to support

continuous improvement, innovation and progress in health.
For users who seek more detailed information, we are pleased to be able to provide
a range of online visual presentations that supplement selected material throughout
the report. This includes, for the first time, dedicated online reporting of Australia’s
performance against national indicators of health. All online content is available at
<www.aihw.gov.au/reports/australias-health/australias-health-2018>.
For those who seek an ‘at a glance’ summary of the key facts and concepts from the
main report, we have again released an Australia’s health: in brief companion report.
I extend my thanks to everyone involved in producing this report and acknowledge
the valuable contributions of the external experts and agencies involved in
reviewing material.
This collaborative process, and the suite of Australia’s health 2018 products that it has
helped to produce, highlight the AIHW’s commitment to its 5 strategic goals—to be
leaders in health and welfare data; drivers of data improvements; expert sources of
value-added analysis; champions for open and accessible data and information; and
trusted strategic partners.
The AIHW is committed to providing its data in the most accessible, user-friendly
formats possible. As such, we are considering new approaches and structures
for our biennial health and welfare reports and also welcome your feedback via
[email protected]. This will allow us to continue to deliver on our mission of
providing stronger evidence, leading to better decisions and improved health and
welfare for all Australians.
Barry Sandison
Director
ix
Acknowledgments
Producing Australia’s health 2018 was an Institute-wide effort. In addition to the individuals
acknowledged below, many other staff from the AIHW and its collaborating units
contributed time and expertise. We gratefully acknowledge the work of the publishing,
website, media and governance teams, as well as the support and advice from data
custodians, data visualisation specialists and the statistical advisor.
Steering committee
Fadwa Al-Yaman, Michael Frost, Jenny Hargreaves, Matthew James, Lynelle Moon,
Barry Sandison, Louise York
Project management team

Jacinta Blazevska, Simone Brown, Pooja Chowdhary, Dinesh Indraharan
Author liaison group

Vicki Bennett Gary Hanson Sally Mills
Kerrin Bleicher Belinda Hellyer Anna O’Mahony
Mark Cooper-Stanbury Moira Hewitt Rebecca Richter
Kim Dobbie Sushma Mathur Claire Sparke
Authors
Michelle Barnett Kristina Da Silva Barbara Gray
Eleanor Bateman Jess Dawson Melanie Grimmond
Tylie Bayliss Michael de Looper Dale Gruber
Garth Bearman Stephen Dent Dominic Guinane
Jacinta Blazevska Alison Dias Jenna Haddin
Emily Bourke Kim Dobbie Kate Hafekost
Ruby Brooks Fiona Douglass Justin Harvey
Simone Brown Anthea Duri Wendy Ho
Karen Byng Deanna Eldridge Karen Hobson
Sam Chambers Mardi Ellis Shann Hulme
Pooja Chowdhary Stephanie Fletcher Ann Hunt
Cathy Claydon Alison Gee Dinesh Indraharan
Elizabeth Clout Steve Glaznieks Clara Jellie
Denae Cotter Annabelle Golles Linda Jensen
Peta Craig Michelle Gourley Jenni Joenpera
x
Jennifer Kerrigan Graeme Morris Claire Sparke
Alise Kha Rachel Muntz Josh Sweeney
Helena Kopunic Felicity Murdoch Prem Thapa
Claire Lee-Koo Deanna Pagnini Gareth Thomas
Ammie Li James Pearce Jason Thomson
Sophie Lindquist Eric Pelletier Veronique Thouroude
Miriam Lum On Melinda Petrie Ian Titulaer
Rin Rin Ly Bronwen Phillips Nick Von Sanden

Karen Malam Naila Rahman Thao Vu
David Meere Anna Reynolds Anne-Marie Waters
Anika Merkley Kate Riley Sandler Tom Watson
Lucas Mills April Roberts-Witteveen Jenny Webb
Sally Mills Nikki Schroder Sophie Widdup
Jennaya Montgomery Candace Sheppard Dian Xu
Maddeline Mooney Shubhada Shukla
Rosalind Morland Annabeth Simpson
External reviewers
Thanks to the following experts for reviewing Australia’s health 2018 articles:
Professor Amanda Baker—University of Newcastle

Dr Ching Choi—University of New South Wales
Professor Robert Cumming—University of Sydney
Professor Annette Dobson—University of Queensland
Dr Stephen Duckett—Grattan Institute
Dr Marian Esler—Australian Government Department of Social Services
Mr Rohan Greenland—National Heart Foundation of Australia
Professor Phillipa Hay—University of Western Sydney
Adjunct Associate Professor Martin Hensher—Tasmanian Government Department
of Health and Human Services, and University of Tasmania
Professor Michael Humphrey—Perinatal Adviser to the Australian Institute of Health
and Welfare
Associate Professor Fay Johnston—Menzies Institute for Medical Research, University
of Tasmania
Professor Louisa Jorm—University of New South Wales
Ms Elise Kennedy—Australian Bureau of Statistics
Dr Kairi Kõlves—Australian Institute for Suicide Research and Prevention, Griffith University
Associate Professor Stephen Lambert—University of Queensland
xi
Ms Xiaoyan Lu—Australian Sports Commission
Professor Stephen O’Leary—University of Melbourne, and National Health and Medical
Research Council (Australia) Practitioner Fellow
Associate Professor Chris Pearce—University of Melbourne, and Outcome Health
Professor Anna Peeters—Deakin University
Mr Alan Philp—Australian Government Department of Health
Mr Andrew Phillips—National Rural Health Alliance
Dr Jennifer Power—La Trobe University
Professor Malcolm Sim—Monash University

Dr Len Smith—Australian National University
Professor Stephen Touyz—University of Sydney
Dr Miranda Van Hooff—University of Adelaide
Mr Shannon White—Australian Government Department of Health
Thanks also to the following organisations and Australian Government departments

and agencies:
Australian Bureau of Statistics

Australian Commission on Safety and Quality in Health Care
Australian Digital Health Agency
Australian Organ and Tissue Donation and Transplantation Authority
Department of Health
Department of the Prime Minister and Cabinet
Department of Veterans’ Affairs
National Disability Insurance Agency
NPS MedicineWise
Safe Work Australia
xii
Additional material online
Australia’s health 2018 is available online in PDF format. Individual articles and
snapshots are also available in PDF format for easy downloading and printing.
Australia’s health 2018: in brief is a companion report to Australia’s health 2018.
It presents some of the key findings and concepts from the main report and is
available online in HTML and PDF formats.
Australia’s health 2018 and Australia’s health 2018: in brief can be viewed and
downloaded for free at <www.aihw.gov.au/reports-statistics/health-welfare-

overview/australias-health/>.
This edition of Australia’s health has a comprehensive online presence,
including online data visualisation tools that present dynamic or interactive
content, supplementary tables that present the data underlying the charts in
each chapter and supplementary documents that present additional technical
information.
Online data visualisation tools are available for the following topics:
• B
urden of disease scenario modelling
• B
MI: where do you fit?
• S
upply of the health workforce for the Indigenous population maps
• Indicators of Australia’s health.
Online data visualisation tools can be viewed at <www.aihw.gov.au/reports/

australias-health/australias-health-2018/contents/table-of-contents>.
Supplementary tables can be viewed and downloaded at <www.aihw.gov.au/

reports/australias-health/australias-health-2018/data>.
Supplementary documents can be viewed and downloaded at <www.aihw.gov.au/

reports/australias-health/australias-health-2018/related-material>.
Australia’s health 2018 Australia’s health 2018: in brief
xiii
xiv
Chapter 1
An overview of Australia’s health
1
1.0 Overview
Good health is important—it influences not only how we feel, but also how we go about our
everyday lives. Health can mean different things to different people, but is widely accepted
to be much more than the presence or absence of disease. It incorporates dimensions of
physical, mental and social wellbeing and is influenced by factors such as our:
• individual and psychological make-up
• lifestyle
• environment and cultural influences
• socioeconomic conditions
• access to quality health care programs and services.
Australians generally have good health and an effective health system. How do we
know this? We use a range of measures, such as life expectancy, mortality and morbidity,
to monitor Australia’s health over time and to compare it with that of other countries.
For instance, we use the Australian Health Performance Framework to assess the health
of our population and the performance of our health system. Since 1988, Australia’s
health has reported biennially on national indicators across the domains of health status,
determinants of health, and the health system. Trend assessment for indicators across
these three domains show mixed results:
• W
e have seen some favourable trends in the health status domain, including a decline
in the incidence rate of heart attacks, bowel cancer and the prevalence of severe or
profound core activity limitation. However, there have been unfavourable trends too:
hospitalisations for injury and poisoning have been increasing.
• T
he proportion of adults who are daily smokers, who are at risk from long-term harm
from alcohol and who have an educational attainment of a non-school qualification or
above have all been trending favourably over the last 10 years. However, not all news in
the determinants of health domain is positive: the proportion of people who are obese
and overweight has been increasing over the past 20 years.
• A
ssessment of the health system domain shows favourable progress for a number of
indicators, including immunisation rates for 1- and 5-year-olds and potentially avoidable
deaths. There has been no change over the last 10 years in some measures, such as
wait times for emergency departments, however, the wait time for elective surgery has
increased (an unfavourable trend).
Australia is a diverse nation. Its more than 25 million people have different backgrounds
and lived experiences. In 2016, more than one-quarter (26%) of its people were born
overseas, an estimated 3.3% (787,000) identified as Aboriginal and Torres Strait Islander
and about 71% (17.2 million) lived in Major cities.
2
Nationally, our life expectancy at birth has increased over time. Between 1890 and 2016,
it rose for males from 47.2 to 80.4 years, and for females from 50.8 to 84.6 years.
Australia now has the fifth highest life expectancy for males and the eighth highest for
females compared with other member countries of the Organisation for Economic
Co-operation and Development (OECD).
We are living longer lives, and those extra years are being lived in good health. A person
can, however, have different states of health at different stages of their life. A measure
called the health-adjusted life expectancy estimates, on average, how many years are
lived in full health. It forecasts that males born in 2011 can expect to have 1.7 more years
in full health than males born in 2003, while females can expect 1.2 more years.
While Australia performs well internationally on some measures of health, there is
Chapter 1
room for improvement on others. At 12%, Australia has one of the lowest rates of
smoking among adults in the OECD, and a better than average rate of colon cancer
survival, ranking third best. However, it has higher rates than the OECD average of
alcohol consumption and obesity among people aged 15 and over.
The AIHW manages many important national health and welfare data collections.
Evidence based on these data—together with health information collected by other
government and non-government agencies—are used to inform research findings and
policy decisions. Despite the breadth of health information available, there are gaps in
our knowledge and opportunities to make better use of existing data, including through
data linkage. Australia’s health information and data environment is also changing rapidly.
A coordinated, strategic approach to identify gaps, overlaps and priorities in health
information would benefit policy, service delivery and research needs.
3
1.1 What is health?
SNAPSHOT
Health is a state of wellbeing. It reflects the complex interactions of a person’s

genetics, lifestyle and environment. Generally, a person’s health depends on two
things: determinants (factors that influence health) and interventions (actions taken
to improve health, and the resources required for these interventions).
Some definitions view the health of an individual as the presence or absence of disease
or medically measured risk factors. The World Health Organization’s definition of health
is broader and more multidimensional—namely, ‘a state of complete physical, mental

and social well being and not merely the absence of disease or infirmity’ (WHO 1946).
Australians are generally seen to enjoy good health and to have an effective health
system. How do we know this? We use the Australian Health Performance Framework to
assess the health of our population and health system. It outlines health indicators that
describe specific elements of our health or aspects of our health system’s performance;
it also compares data for different population groups, different geographic regions, and
internationally. The Framework includes the domains of health status, determinants of
health, and the health system (see Chapter 1.4 ‘Indicators of Australia’s health’).
Measures of health status

Figure 1.1.1 outlines some of the more common measures of the health status of an
individual and a population.
Figure 1.1.1: Common measures of health
The number of years of life, on average, remaining to an

Life expectancy individual at a particular age if death rates do not change.
The most commonly used measure is life expectancy at birth.
Mortality The number of deaths in a population in a given period.
Ill health in an individual and levels of ill health within a

Morbidity population (often expressed through incidence, prevalence
and comorbidity measures—see Glossary).
One year of healthy life lost due to illness and/or death.

Disability-adjusted DALYs are calculated as the sum of the years of life lost due to
life year (DALY) premature death and the years lived with disability for people
living with the health condition or its consequences.
Health-adjusted The average length of time an individual at a specific age can

expect to live in full health; that is, time lived without the health
life expectancy consequences of disease or injury.
Self-assessed An individual’s own opinion about how they feel about their
health status health, their state of mind and their life in general.
4
These measures are useful to compare health outcomes across different populations
as well as to look specifically at certain health conditions (see Chapter 3 for more
information on health conditions; chapters 5 and 6 for more information on the health
of population groups).
We glean many useful insights into the health of individuals and populations from
health data. Information so gained can then be used to improve health and health
services and to reduce health inequity across population groups.
Impact of determinants
Health determinants are multifaceted, interrelated factors that influence health.
Chapter 1
Figure 1.1.2 divides them into four groups. The main direction of influence (as shown
by the horizontal arrows) is from left to right; that is, from contextual factors (such as
culture and affluence) through to more immediate influences (such as blood pressure).
The importance of the broader social determinants of health—not only social, but also
economic, political, cultural and environmental determinants—is becoming better
understood. Essentially, these are the conditions into which people are born, grow, live,
work and age (WHO 2015). At all stages along the path, the various factors shown in the four
groups in Figure 1.1.2 interact with an individual’s physical and psychological make-up.
As well, the factors within each of these groups often interact with each other and are
closely interrelated (see Chapter 4 for more information on determinants of health).
Role of the health system

A major aim of any health system is to prevent disease and other ill health and injury
and to maintain health—not just to treat illness—so that people remain as healthy
as possible for as long as possible. This approach includes a focus on the quality and
timeliness of health care received, including preventive health care such as screening
and immunisation. However, as health is not merely the absence of disease, our health
system also plays a vital role in positively influencing our health status by building social
and physical environments that support health and promote healthy behaviours
(see Chapter 7 for more information on prevention, treatment and health services).
Where do I go for more information?

More information on health definitions, social determinants of health, global health
actions and data can be obtained from the World Health Organization website
<www.who.int>.
References
WHO (World Health Organization) 1946. Preamble to the Constitution of the World Health Organization
as adopted by the International Health Conference, New York, 19–22 June 1946. New York: WHO.
WHO 2015. Social determinants of health. Geneva: WHO. Viewed 8 January 2018,
<http://www.who.int/social_determinants/en/>.
5
6
Figure 1.1.2: Framework for determinants of health
Broad features Socioeconomic Health behaviours Biomedical factors

of society characteristics Tobacco use Birthweight
Culture Education Alcohol consumption Body weight
Affluence Employment Health and
Physical activity Blood pressure wellbeing over time
Social cohesion Income and wealth Dietary behaviour Blood cholesterol
Family, neighbourhood Life expectancy,
Social inclusion Use of illicit drugs Glucose tolerance mortality
Political structures Housing Sexual practices Immune status Subjective health
Media Access to services Vaccination Functioning, disability
Language Migration/
refugee status Psychological factors Illness, disease
Environmental factors Food security Stress Injury
Natural Trauma, torture
Knowledge,
Built attitudes and beliefs Safety factors
Geographical location Health literacy Risk taking, violence
Remoteness Occupational health
Latitude and safety
Individual physical and psychological make-up

Genetics, antenatal environment, gender, ageing, life course and intergenerational influences
Note: Blue shading highlights selected social determinants of health.

1.2 Profile of Australians
SNAPSHOT
In 2018, our estimated population is 25.2 million:
aged 0–4 1.6 million
Chapter 1
aged 85
0.5 million
and over
Source: ABS 2013.
In 2016, an estimated 3.3% of Australians identified

as Aboriginal and/or Torres Strait Islander—
787,000 people (ABS 2017a).
In 2016, 26% of people were born overseas—

6.1 million people (ABS 2017e).
In 2015, an estimated 18% of people had disability—

4.3 million people (ABS 2016).
7
In 2016:
Growth
from 2006
7
1% lived in Major cities—
21%
17.2 million people
1
8% lived in Inner regional areas—
15%
4.4 million people
8
.6% lived in Outer regional areas— 8.4%
2.1 million people
1
.3% lived in Remote areas—
1.4%
308,000 people
0
.8% lived in Very remote areas—
5.7%
194,000 people (ABS 2017f)
In December 2017, the employment to population ratio for

people aged 15 and over was 62% and the unemployment
rate was 5.4% (ABS 2017d).
In 2017, of people aged 20–64, 66% held a non-school

qualification and 31% had attained a Bachelor degree
qualification or higher (ABS 2017b).
In 2015–16, in real terms, the average disposable household income (after adjusting
for the number of people in the household) was $1,009. The weekly income for
low-income households was $421; for middle-income households it was $856 and
for high-income households, $2,009 (ABS 2017c).
$2,009
$1,009 $856
$421
Average Low income Middle income High income
8
References
ABS (Australian Bureau of Statistics) 2013. Population projections, Australia, 2012 (base) to 2101.
ABS cat. no. 3222.0. Canberra: ABS.
ABS 2016. Disability, ageing and carers, Australia: summary of findings, 2015. ABS cat. no. 4430.0.
Canberra: ABS.
ABS 2017a. Australian demographic statistics, Mar. 2017. ABS cat. no. 3101.0. Canberra: ABS.
ABS 2017b. Education and work, Australia, May 2017. ABS cat. no. 6227.0. Canberra: ABS.
ABS 2017c. Household income and wealth, Australia, 2015–16. ABS cat. no. 6523.0. Canberra: ABS.
ABS 2017d. Labour force, Australia, Dec. 2017. ABS cat. no. 6202.0. Canberra: ABS.
ABS 2017e. Migration, Australia, 2015–16. ABS cat. no. 3412.0. Canberra: ABS.
ABS 2017f. Regional population growth, Australia, 2016. ABS cat. no. 3218.0. Canberra: ABS.
Chapter 1
9
1.3 How healthy are
SNAPSHOT
Australians?
Australians generally have good health. We know this based on the range of measures
we use (see Chapter 1.1 ‘What is health?’) to compare our health over time or with that
of other countries (see Chapter 1.5 ‘International comparisons’).
Australians are living longer…

Life expectancy at birth in Australia has risen steadily over time. In 2016, life expectancy
at birth was 80.4 years for males and 84.6 years for females (Figure 1.3.1).
Figure 1.3.1: Life expectancy at birth, by sex, 1886–2016
Life expectancy at birth (years)

90 Females
80
70 Males
60
50
40
30
20
10
0
1886 1896 1906 1916 1926 1936 1946 1956 1966 1976 1986 1996 2006 2016
Year
Sources: ABS 2014, 2017; Table S1.3.1.
Life expectancy measures how long, on average, a person is expected to live, based on
current age and sex-specific death rates. Life expectancy changes over a person’s lifetime;
as they survive through birth, childhood and adolescence, their chance of reaching older
age increases. Men aged 65 in 2016 could expect to live another 19.6 years and women
aged 65 could expect to live another 22.3 years (ABS 2017).
…and with more years in good health

Are longer lives also healthier lives? During their lifetime, a person can have different states
of health. The health-adjusted life expectancy (HALE) estimates, on average, how many
years a person will live in full health. As life expectancy has increased, so, too, has the
HALE—meaning people are living longer, and with more years of full health. Males born in
2011 could expect 1.7 more years in full health than males born 8 years earlier; females
could expect 1.2 more years. These gains in healthy years are comparable to the gains in
life expectancy. We are still, however (in 2011), living the same number of years in ill health
as we were in 2003: 9.0 years for males and 9.9 for females (Figure 1.3.2).
10
Figure 1.3.2: Life expectancy at birth in full health (HALE) and ill health, by sex,
2003 and 2011
Life expectancy (years) Full health Ill health

90
80 9.9
9.0 9.8
70 8.9
60
50
40
70.9 73.2 74.4
69.2
30
Chapter 1
20
10
0
2003 2011 2003 2011
Males Females
Source: AIHW 2017; Table S1.3.2.
Australia is making population health gains

We can assess the current health status of the population by looking at the impact of living
with illness and dying early. We call this the ‘burden of disease’ and express it as disability
adjusted life years (DALYs). (DALYs measure the number of years of healthy life lost due
either to premature death—dying before the ideal life span—or to living with ill health due
to illness or injury.)
There were good gains in the health of the Australian population between 2003 and 2011.
Based on findings from the 2011 Australian Burden of Disease Study, the age-standardised
DALY rate fell by 10%, mostly due to reductions in premature death (Figure 1.3.3).
Figure 1.3.3: Composition of total burden of disease (DALY rate), 2003 and 2011
Year Years lost due to illness or injury Years lost due to premature death
210.5 DALYs
2003
2011 189.9 DALYs
0 50 100 150 200 250

DALYs per 1,000 population
11
Australians rate their health well
In 2014–15, more than half (57%) of Australians aged 15 and over self-rated their health as
‘excellent’ or ‘very good’—similar to the proportion recorded a decade earlier, in 2004–05
(ABS 2015).
How we rate our health
Poor Fair Good Very good Excellent

4 10 29 37 20
Per cent
These self-assessed health measures provide insight into the health of Australians at a
population level. Health indicators are an important way to assess not only the health
of our population but also the success of our health services and the health system.
The health indicators currently agreed for national reporting are presented in Chapter 1.4
‘Indicators of Australia’s health’. This report also presents disease-specific measures of
mortality and morbidity in Chapter 3. Some population groups have higher rates of illness,
health risk factors and death than others. Chapters 5 and 6 present information on health
inequalities and measure the health of selected population groups.

Self-assessed health measures are collected in the Australian Bureau of Statistics National
Health Survey. The most recent results for the 2014–15 National Health Survey and
measures of life expectancy are available at <www.abs.gov.au>.
The reports Australian Burden of Disease Study: impact and causes of illness and death in
Australia 2011 and Health-adjusted life expectancy in Australia: expected years lived in full
health 2011 are available for free download from <www.aihw.gov.au>.
References
ABS (Australian Bureau of Statistics) 2014. Australian historical population statistics, 2014. ABS cat. no.
3105.0.65.001. Canberra: ABS.
ABS 2015. National Health Survey: first results, 2014–15. ABS cat. no. 4364.0.55.001. Canberra: ABS.
ABS 2017. Life tables: states, territories and Australia, 2014–2016. ABS cat. no. 3302.0.55.001.
Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2016. Australian Burden of Disease Study: impact and
causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4.
Canberra: AIHW.
AIHW 2017. Health-adjusted life expectancy in Australia: expected years lived in full health 2011.
Australian Burden of Disease Study series no.16. BOD 17. Canberra: AIHW.
12
1.4 Indicators of
FEATURE ARTICLE
Australia’s health
Health indicators are an important way to assess the health of our population and the
success of our health services and health system. These summary measures describe
particular aspects of our health and health system performance and have a range of
purposes. They can:
• o
ffer insights into the health of Australians and the quality of the health system at a
Chapter 1
point in time (and allow different population groups, different regions and different
countries to be compared)
• p
rovide information on the effectiveness of changes to policies or new practices and
programs (when measured consistently over time)
• improve accountability and transparency of service provision, and support consumer
choices relating to health care
• e
ncourage ongoing improvement in service delivery by highlighting areas of innovation
and where better performance is needed.
The indicators selected generally reflect what is important to governments, service

providers, funders of services (including taxpayers), and to patients and the broader
Australian community.
Nationally agreed health indicators are usually compiled and reported as ‘sets’ of
measures, organised into frameworks. Health indicator frameworks provide the
conceptual basis for the indicator sets; they describe the broad aspects of health, its
determinants and the health care system to be measured (for example, equity, quality
and efficiency). They also depict the relationships between the indicators within the
framework, and provide transparency in describing which aspects of the system are
being assessed (or not able to be assessed).
In Australia, a number of health indicator frameworks are used to assess aspects of our
health and health system. Some are related, and hence specific indicators may appear
in more than one framework—but they have different purposes. This article provides
information on the major national indicator frameworks in Australia, including the new
Australian Health Performance Framework (AHPF). It also outlines the latest data available
against the indicators agreed for reporting under the National Health Performance
Framework (NHPF), now subsumed by the AHPF.
13
New Australian Health Performance
Framework
The AHPF was recently agreed by Australian and state/territory health ministers. It
provides a single, enduring framework that can be used in different ways to assess the
Australian health care system and its inputs, processes and outcomes (NHIPPC 2017).
It replaces the NHPF and the Performance and Accountability Framework, which had
separate but interrelated purposes:
• T
he NHPF was agreed by the Australian Health Ministers’ Advisory Council in 2001
(NHPC 2002) to provide a conceptual framework to understand and evaluate the
health of Australians and the health system, and to serve as a general support for
performance assessment, planning and benchmarking in the health sector. In recent
years, the AIHW reported biennially on the national indicators agreed under this
framework in the Australia’s health report series (see, for example, AIHW 2016a).
• T
he Performance and Accountability Framework was agreed under the National
Health Reform Agreement (COAG 2011) to provide Australians with comparable,
locally relevant information about the performance of hospitals and health services
to support informed decision making by consumers and health care providers and
managers. The Performance and Accountability Framework indicators were identified
for reporting in two streams: for Primary Health Networks, and for hospitals/Local
Hospital Networks; data are published by the AIHW on the MyHealthyCommunities
and MyHospitals websites, respectively.
While these indicator frameworks and indicators were designed for different uses,
the purposes were related; hence, there was some overlap in the indicators reported.
Health ministers decided that it would be preferable to merge the frameworks into a
single framework that could be used in a flexible way. This would enable reporting
for use by different audiences, for different populations and at different levels of the
health system (for example, reporting at the international, national, state/territory,
and local area level).
The AHPF comprises a Health System Conceptual Framework, and a Health System
Performance Logic Model.
Health System Conceptual Framework

The conceptual framework depicts the indicator domains relevant to assessing the
health system as a whole, namely: health status, determinants of health, and the
health system (Figure 1.4.1). Key components are identified within these domains
(for example, within the health status domain, it is relevant to consider including
indicators that relate to health conditions, human functioning, wellbeing and deaths).
14
The conceptual framework also identifies a range of information needs that can be
considered as ‘health system context’; that is, factors that are often beyond the direct
control of health system decision makers (such as the demographic composition of the
population). This is not a performance domain as such, but recognises information that
is relevant in the planning, delivery and evaluation of health services.
‘Equity’ is recognised as a principle that applies across all domains, and one that should
be reflected in appropriate reporting. The interrelationships between all domains is
recognised explicitly in this framework presentation.
Health System Performance Logic Model
Chapter 1
The performance logic model presents similar domains to the conceptual model, but
is organised in a program logic model. This indicates how the framework could be used
to evaluate the outcome of specific health programs, initiatives and interventions—that is,
in a performance measurement context (Figure 1.4.2).
For example, a number of the domains that were considered ‘health system context’
in the conceptual framework are considered to be ‘health system inputs’ in this model.
Similarly, the ‘health status’ domain in this model is re-framed in terms of ‘health system
outcomes’ where the focus is on measuring change in health status associated with
a specific intervention or policy. The Health System Performance Logic Model is
based on the service process model used for the Report on Government Services (RoGS)
(SCRGSP 2018), which is further described elsewhere in this article.
Implementing the new framework

Indicator sets and reporting arrangements for the AHPF will be developed, aiming to
ensure that indicator content and reporting formats continue to reflect national strategic
priorities for health and health care delivery, and are delivered in ways that are most
relevant for key audiences.
In the first instance, indicators previously agreed for reporting under the NHPF and the
Performance and Accountability Framework have been transferred to the AHPF. Data for
those indicators previously agreed to be relevant for national reporting (that is, the NHPF
indicators) are summarised later in this article, but presented against the AHPF conceptual
framework. At a later date, it is expected that these existing indicators will be reviewed in
working towards a full set of indicators under the framework.
This work is also expected to identify relevant tiers for reporting that would allow for data
presentation to be disaggregated in different ways—for example, at the state/territory
and national levels and at different geographic levels, as well as for individual service
providers, targeted population groups, people experiencing different health conditions,
and for public and private health care providers and funders.
15
16
Figure 1.4.1: AHPF Health System Conceptual Framework
Objective: to improve health outcomes for all Australians and ensure the sustainability of the Australian health system
Equity
Determinants Health status

Health system
of health • H ow healthy are
• Is the health system (by itself, and with others)
• A re the factors that Australians?
working to prevent illness, injury and disease?
influence good health • Is it the same for
• Is it delivering safe, effective, and accessible
changing for the better? everyone?
coordinated care appropriate for each individual?
• Where and for who are • W hat are the best
• Is the health system efficient and sustainable? opportunities for
these factors changing?
• Is it the same for Effectiveness improvement?
everyone? Safety
Health conditions
Health behaviours Appropriateness
Human function
Personal biomedical factors Continuity of care
Wellbeing
Environmental factors Accessibility
Deaths
Socioeconomic factors Efficiency and sustainability
Community Governance Information,

Health system Demographics and Financing Workforce Infrastructure research
and
context social capital structure and evidence
Note: See supplementary document S1.4 ‘Australian Health Performance Framework: detailed Health System Conceptual Framework’ for a more detailed version of this
figure <www.aihw.gov.au/reports/australias-health/australias-health-2018/related-material>.
Source: Adapted from National Health Information and Performance Principal Committee 2017.
Figure 1.4.2: AHPF Health System Performance Logic Model
Equity
Health system inputs Health system

Health system activities and outputs
outcomes
Governance and Health Health outcomes
structure Health care Health system
protection and • H
ealth conditions
delivery improvement
promotion • H
uman function
Financing (incl. PROMs)
• W
ellbeing (incl. PROMs)
Quality dimensions • D
eaths
Workforce
Workforce outcomes
Effectiveness Appropriateness Efficiency
• K
nowledge and skills
Infrastructure • W
orkforce morale
Continuity of • W
orkforce wellbeing
Safety Accessibility
care
• W
orkforce safety
Information, research
and evidence Health system
sustainability
• H uman, technological
and physical capital
continuously maintained
Determinants of health and upgraded
• ommunity & social capital
C • W
aste is minimised,
Health system value is maximised
Demographics • Socioeconomic factors Health behaviours
context • Environmental factors • Adverse environmental
• Biomedical factors impacts are minimised
PROM = Patient-reported outcome measure.

Source: Adapted from National Health Information and Performance Principal Committee 2017.
17
Chapter 1
Other national health performance
frameworks
As well as the AHPF, there are other national performance indicator frameworks and
monitoring activities used in Australia and applied in the health context. Key frameworks
are summarised in this section.
National Healthcare Agreement

The National Healthcare Agreement is an agreement between the Australian Government

and state and territory governments that outlines the role and aims of Australia’s health
system, the roles and responsibilities of the parties, the policy and reform directions
proposed to achieve desired outcomes, and accountability requirements (COAG 2012a).
These requirements include reporting against specific performance indicators and
performance benchmarks outlined within the specified outcome areas (better health,
better health services, social inclusion and Indigenous health, and sustainability of the
health system). Where possible, indicator data are disaggregated for specific population
groups to ensure that the aims of focusing on social inclusion and tackling Indigenous
disadvantage are being met.
The National Healthcare Agreement indicator data are reported annually in the RoGS
series (for example, SCRGSP 2018), along with other indicator data.
As well as the National Healthcare Agreement, a range of other national agreements
(for example, the National Indigenous Reform Agreement—COAG 2012b) include
performance indicators for health and health service delivery. Some of these indicators
are also included in the National Healthcare Agreement.
Report on Government Services

Publication of an annual RoGS was initiated by the heads of government (now the
Council of Australian Governments) to provide information on the equity, efficiency and
effectiveness of a range of government human and social services in Australia, and to
promote ongoing performance improvement. The first RoGS was published in 1995.
In recent years, the RoGS has been based on performance indicators set against
a framework (consistent across all service areas) that reflects the review’s focus
on outcomes, consistent with the demand of governments for outcomes-oriented
performance information.
Performance indicators included in the RoGS are supplemented by information on
outputs, grouped under equity, effectiveness and efficiency headings. The RoGS for 2018
included chapters on public hospitals, ambulance services, primary and community
health, and mental health management (SCRGSP 2018).
18
Sector and population specific frameworks
As well as national performance frameworks, there are several other (related)
performance frameworks. These support more in-depth monitoring of the health
status of, and services delivered to, specific populations—for example, the Aboriginal
and Torres Strait Islander Health Performance Framework (AHMAC 2017)—or focus
on specific types of health services, such as the National Core Maternity Indicators
(AIHW 2016b).
Performance monitoring and reporting at other ‘levels’ of the health system are
also undertaken; for example, by states and territories, by some service provider
organisations, and by participating in international reporting activities (see Chapter 1.5
Chapter 1
‘International comparisons’ for some indicator data available at the international level).
Over time, some of these Australian indicator frameworks may be ‘re-framed’ by the
owners of the indictor sets and presented against the AHPF. This would help to ensure that
similar indicators in different indicator sets are reported consistently wherever possible.
Other related monitoring and reporting activities

Supplementing the national indicator framework and performance reporting
arrangements are the activities of health service providers in measuring and
monitoring performance within their organisations, and in improving clinical outcomes
and the appropriateness of services. These activities are related to (but not considered
the same as) ‘performance reporting’, and organisations may or may not choose to make
this information publicly available. For example, the national Key Performance Indicators
for Aboriginal and Torres Strait Islander primary health care support continuous quality
improvement within services (AIHW 2017).
In recent years, the Australian Commission on Safety and Quality in Health Care has
supported these activities. As part of its work to lead coordinated improvement in
safety and quality in health care across Australia, the Commission undertakes and helps
to enable the development of safety- and quality-related indicators for use in such local
monitoring (see Chapter 7.9 ‘Safety and quality of hospital care’ for more information
about safety and quality monitoring in Australian hospitals).
19
AHPF indicators for national reporting
The rest of this article presents the latest data for indicators currently agreed for
national reporting in the AHPF. These indicators were previously agreed as NHPF
indicators; the other indicators that have been transitioned to the AHPF were previously
agreed for reporting either at local area levels (that is, at the Primary Health Network
level), or the hospital (or Local Hospital Network) level. Data for those indicators will
continue to be made available on the MyHealthyCommunities and MyHospitals websites.
Key findings are presented in the following section—reported in three sections that align
with the AHPF conceptual framework domains: health status, determinants of health, and
health system. Note that as there are currently no agreed information requirements for
the ‘health system context’ domain (as there was no equivalent domain included in the
previous NHPF), information on this domain is not presented in this chapter, although
relevant context information is available elsewhere in this report. Where possible,
indicators are disaggregated for relevant population groups to ensure that they also
satisfy the ‘equity’ reporting requirements under the framework.
Also included for each section is a table stating whether new data have become available
since Australia’s health 2016 (AIHW 2016a) and whether the available data show a
favourable or unfavourable trend (where this could be assessed).
For more information on each indicator and to view detailed data see the online
data visualisation tool at <www.aihw.gov.au/reports/australias-health/australias-
health-2018/contents/indicators-of-australias-health>.
Assessment of trends
Trends have generally been assessed using the most recent 10 years of data where
comparable data were available for at least 3 time periods. In a small number of cases
(where data sources have become available irregularly or on a triennial basis), a slightly
longer time period was considered (up to 12 years). These time periods were used for
the trend assessment even where time series information is presented in this article
for longer periods; the exceptions are cancer survival rates and rates of overweight and
obesity, for which the trend assessment is based on the longer time series information
discussed in the indicator text.
A favourable trend is noted when the indicator has moved in the desired direction—for
example, the proportion of people eating the recommended number of serves of fruit and
vegetables should increase and instances of unsafe sharing of needles should decrease.
A trend is considered unfavourable if it is opposite to the desired direction. For indicators
where the measure does not appear to have changed meaningfully over the time period,
the trend is described as ‘no change’. For indicators where there are insufficient data to
support trend analysis, the trend is described as ‘no data/insufficient data’.
20
Limitations of the AHPF performance indicators
The performance indicators for national reporting were last reviewed and endorsed
(as indicators under the NHPF—now replaced by the AHPF) by health ministers in 2009.
Over time, some limitations have become evident for a number of them. Data quality
may have diminished, for example, where changes in service delivery has meant that
data would need to be captured from more disparate sources, or changes in policies and
priority areas for monitoring have meant that the usefulness of some indicators is now
questionable.
In this report, a small number of indicators previously reported at the national level are
not reported here:
Chapter 1
• S
urvival following an acute coronary heart disease event (last reported in 2012). The AIHW
has judged that, due to changes in the method used to identify acute coronary events,
reporting on this indicator is not appropriate.
• P
roportion of people with diabetes who complete a GP annual cycle of care (last reported
in 2012). The AIHW has assessed that the available data are likely to result in an
underestimate, due to changes in treatment patterns, and a recognition that people
with diabetes may use other avenues for care.
• S
elected potentially avoidable GP-type presentations to emergency departments (last
reported in 2014). Previous work has shown limitations in the method used (AIHW 2015)
and so the data are not presented here; indicator data are presented in the RoGS
(SCRGSP 2018).
• C
ost per casemix-adjusted separation for acute and non-acute episodes (last reported in
2014). A range of stakeholders regard the previous calculation method as being no
longer appropriate, and a revised method has not yet been agreed.
For indicators where no new data are available or where new data could not be readily
obtained, previously reported data are used, though new disaggregations are presented
where appropriate.
21
Key results
Health status
The health status domain is assessed by considering measures related to the incidence or
prevalence of health conditions, and measures related to human functioning, wellbeing
and mortality rates and life expectancy.
The indicators reported for health status are outlined in Table 1.4.1.
• In 2015, the heart attack rate for men was more than twice that for women, though
rates have declined for both men and women since 2007. Overall, there has been a
decline of 37% in the rate of heart attack since 2007.
• In the latest 10 years for which data are available, there has been an increase in the
incidence of breast cancer in females and a decrease in the incidence of bowel cancer.
Rates of melanoma of the skin and lung and cervical cancer have remained stable over
this period.
• O
ver the last 10 years for which data are available, notification rates for hepatitis B
and C have fallen, but rates of syphilis, chlamydia and gonorrhoea have risen.
The notification rate of human immunodeficiency virus (HIV) has remained steady
and was 4.2 notifications per 100,000 people in 2016.
• In 2013, there were 5,100 new cases of end-stage kidney disease—an age-standardised
rate of 19 per 100,000 people. The incidence rate increases substantially with age.
• In 2015–16, there were an estimated 509,900 hospitalised cases due to injury and
poisoning. Rates of hospitalised cases for injury and poisoning increase substantially
with age for people aged 75 and over.
• In 2015, 5.0% of liveborn singleton babies were of low birthweight. The proportion of
low birthweight singleton babies born to Aboriginal and Torres Strait Islander mothers
was 2.2 times the proportion of babies born to non-Indigenous mothers.
• In 2015, 1.4 million people had a severe or profound core activity limitation—that is, a
limitation in communication, mobility and/or self-care activities. Overall, the proportion
of people with a severe/profound core activity limitation had decreased since 2003.
• T
he death rate for infants aged under 1 and children aged 1–4 has decreased since
2001—a trend that has been maintained in the most recent 10 years for which data are
available. Since 2001, the death rate for Indigenous infants also fell, however, the rate is
still almost twice that for all infants.
• L
ife expectancy for a boy born in Australia between 2014 and 2016 was 80.4 years, and
for a girl, 84.6 years. However, the estimated life expectancy for an Indigenous boy born
between 2010 and 2012 was 10.6 years lower than for a non-Indigenous boy, and for
girls the difference was 9.5 years.
22
Table 1.4.1: Indicators of AHPF domain—health status
Trend legend ..
Favourable Unfavourable No change No data/insufficient data
New data 10-year trend

AHPF dimension/Indicator
available assessment
Health conditions
Incidence of heart attacks Yes
Incidence of selected cancers
Breast cancer (females) (a) Yes —
Chapter 1
Bowel cancer Yes
Melanoma of the skin Yes
Lung cancer Yes
Cervical cancer Yes
Incidence of sexually transmissible infections and blood-borne viruses
Syphilis Yes
Human immunodeficiency virus (HIV) Yes
Hepatitis B Yes
Hepatitis C Yes
Chlamydia Yes
Gonorrhoea Yes
Incidence of end-stage kidney disease Yes
Hospitalisation for injury and poisoning Yes
Proportion of babies born with low birthweight Yes
Human function
Severe or profound core activity limitation Yes
Wellbeing
Psychological distress No
Self-assessed health status No
Deaths
Infant/young children mortality rate
All infants (<1 year) Yes
Indigenous infants (<1 year) Yes
All children aged 1–4 years Yes
Life expectancy
All males Yes
All females Yes
Indigenous males No ..
Indigenous females No ..
(a) Breast cancer incidence has increased but is not assessed as unfavourable because increases in observed
incidence may be due to improved detection.
23
Determinants of health
The determinants of health domain is assessed by considering measures related to
health behaviours, and personal biomedical, environmental and socioeconomic factors.
The indicators reported for health status are outlined in Table 1.4.2.
• In 2014–15, 14.5% of people aged 18 years and over smoked daily (16.9% of men and
12.1% of women). Age-adjusted daily smoking rates have fallen since 1989–90.
• In 2014–15, 17% of adults consumed more than 2 standard drinks per day on average,
exceeding the lifetime risk guideline. Men were almost 3 times as likely as women to
consume alcohol at risky levels.
• In 2014–15, 50% of adults and 68% of children ate sufficient serves of fruit, and 7% of
adults and 5% of children ate sufficient serves of vegetables.
• O
ver half (52%) of all adults aged 18–64 were not sufficiently active to gain a health
benefit in 2014–15; among adults aged 65 and older, 75% were not sufficiently active.
• In 2016, 19% of injecting drug users reported using needles and syringes after
someone else.
• T
he proportion of households with children aged 0–14 in which a person smokes inside
the home fell between 1995 and 2016 (from 31% to 2.8%).
• T
he proportion of Australian adults who are overweight or obese was 63% in 2014–15;
among children aged 5–17, it was 27%.
• In 2015–16, 2.2 million people lived on less than half the median equivalised household
income (that is, less than $427 per week), including 1.2 million people living on less than
40% of the median ($341).
• M
ore than two-thirds (69%) of people aged 25–64 had a non-school qualification
in 2017. People living in Major cities and Inner regional areas were more likely to have
a non-school qualification than people living in Outer regional or in Remote and
Very remote areas.
24
Table 1.4.2: Indicators of AHPF domain—determinants of health
Trend legend ..

Health behaviours
Health literacy No ..
Proportion of adults who are daily smokers No
Chapter 1
Proportion of adults at risk of long-term harm from alcohol No
Fruit and vegetable intake No ..

Physical inactivity No ..
Unsafe sharing of needles Yes
Children exposed to tobacco smoke in the home Yes
Personal biomedical factors
Proportion of persons obese and overweight No (a)
Environmental factors
Water quality No
Socioeconomic factors
Proportion of people with low income Yes
Educational attainment Yes
(a) The trend assessment for this indicator is based on 20 years of data (rather than 10).
25
Health system
The health system domain is assessed through measures related to the quality of the health
system (that is, aspects of effectiveness, safety, appropriateness, and the continuity and
accessibility of care), and also by looking at the efficiency and sustainability of health care.
The indicators reported for the health system domain are outlined in Table 1.4.3.
• O
verall, immunisation rates for children aged 1 and 5 have risen in recent years, though
the 10-year trend for immunisation rates among 2-year-olds has shown no clear trend.
• N
early two-thirds (65%) of females who gave birth in 2015 attended at least one
antenatal visit in the first trimester of pregnancy.
• A
bout half of all women in the relevant target age groups participated in BreastScreen
Australia and the National Cervical Screening Program (55% and 56% respectively) in
2015 and 2016 combined. For the National Bowel Cancer Screening Program, 41% of
invitees in targeted age groups participated in 2015 and 2016.
• In 2015–16, there were an estimated 26.4 potentially preventable hospitalisations per
1,000 people (accounting for 6.4% of all hospital separations). These are hospitalisations
that are thought to have been avoidable if timely and adequate non-hospital care had
been provided.
• T
he 5-year relative survival for all cancers combined for 2009–2013 was 68%, an
increase of 20 percentage points from 48% in 1984–1988. This represents the
percentage of people diagnosed with cancer who survived for at least 5 years after
diagnosis, relative to people of the same age and sex in the general population.
• In 2016, there were around 27,000 potentially avoidable deaths in Australia—105
deaths per 100,000 people. This is a decrease of 45% from the rate in 1997. These
are deaths from selected conditions that are considered to have been potentially
preventable in the context of the present health system.
• In 2015–16, there were 5.4 adverse events per 100 hospital separations. These are
incidents in which harm resulted to a person receiving health care, such as infections
and problems with medication and medical devices.
• M
ore than 148.7 million non-referred general practitioner (GP) attendances were claimed
through Medicare in 2016–17 and 127.5 million (86%) of these services were bulk-billed.
• In 2016–17, the median waiting time for all admissions from the public hospital elective
surgery waiting list was 38 days. Overall, Indigenous Australians had longer median
waiting times than Other Australians for elective surgery (45 and 38 days respectively).
• In 2016–17, 73% of all emergency department presentations were seen within the
recommended time for their triage category. Presentations triaged as Urgent had
the lowest proportion of presentations seen on time (66%), while almost 100% of
Resuscitation presentations were seen within the recommended time.
• T
he number of employed full-time equivalent medical practitioners and nurses/midwives
rose (by 14% and 12% respectively) between 2011 and 2016. In 2016, the rate of
full-time equivalent medical practitioners was 400 per 100,000 population; for nurse/
midwives it was 1,145 per 100,000 population).
26
Table 1.4.3: Indicators of AHPF domain—health system performance
Trend legend ..

Effectiveness
Immunisation rates for vaccines in the national schedule
1 year Yes
2 years Yes
Chapter 1
5 years Yes
Adults No ..
Proportion of pregnancies with an antenatal visit in the first trimester Yes
Cancer screening rates
Breast Yes ..
Cervical Yes
Bowel Yes ..
Selected potentially preventable hospitalisations Yes
Survival of people diagnosed with cancer Yes (a)
Potentially avoidable deaths Yes

Survival following acute coronary heart disease event (b)
— ..
Safety
Adverse events treated in hospital Yes
Falls resulting in patient harm in hospitals Yes
Appropriateness
No indicators for this dimension
Continuity of care
Proportion of people with asthma with a written asthma action plan No
Proportion of people with mental illness with a GP care plan No
Proportion of people with diabetes with a GP annual cycle of care (b) — ..
Accessibility
Bulk-billing for non-referred (GP) attendances Yes
Differential access to hospital procedures Yes ..
Waiting time for elective surgery Yes
Waiting time for emergency department care Yes
Selected potentially avoidable GP-type presentations to emergency departments (b)
— ..
Efficiency and sustainability
Cost per casemix-adjusted separation for acute and non-acute care episodes(b) — ..
Net growth in health workforce
Medical practitioners Yes
Nurses and midwives Yes
(a) T
he trend assessment for this indicator is based on 30 years of data (rather than 10).
ot reported here due to lack of data or agreed methodology—see section ‘Limitations of the AHPF
(b) N
performance indicators’.
27
What is missing from the picture?
As already noted, the indicators previously agreed for reporting under the NHPF
(as national-level indicators) have been reported here against the AHPF domains where
suitable data are available. In the future, it is expected that the framework will be
‘re-populated’ with a refreshed set of indicators for national reporting (also identifying
indicators suitable for other levels of reporting). It will be necessary to identify information
needs associated with those areas of the framework for which national-level indicators
had not previously been agreed—including the ‘appropriateness’ component area in the
health system domain, and all components of the ‘health system context’ domain, as
these information needs were not covered by the NHPF.

For more health indicators, see the MyHealthyCommunities and MyHospitals websites.
More information about the performance of health and other government services is
available at <www.pc.gov.au>.
More information about safety and quality monitoring of health services is available at
<www.safetyandquality.gov.au>.
References
AHMAC (Australian Health Ministers’ Advisory Council) 2017. Aboriginal and Torres Strait Islander Health
Performance Framework 2017 report. Canberra: AHMAC.
AIHW (Australian Institute of Health and Welfare) 2015. Emergency department care 2014–15: Australian
hospital statistics. Health services series no. 65. Cat. no. HSE 168. Canberra: AIHW.
AIHW 2016a. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.
AIHW 2016b. National Core Maternity Indicators data visualisations. Canberra: AIHW. Viewed 13 December
2017, <https://www.aihw.gov.au/reports/mothers-babies/ncmi-dynamic-data-displays/contents/dynamic-
data-displays>.
AIHW 2017. National Key Performance Indicators for Aboriginal and Torres Strait Islander primary health
care: results from June 2016. National key performance indicators for Aboriginal and Torres Strait Islander
primary health care series no. 4. Cat. no. IHW 177. Canberra: AIHW.
COAG (Council of Australian Governments) 2011. National Health Reform Agreement. Canberra: Council on
Federal Financial Relations. Viewed 27 March 2018,
<http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/national-agreement.pdf>.
COAG 2012a. National Healthcare Agreement. Canberra: Council on Federal Financial Relations. Viewed
13 December 2017, <http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/healthcare_
national-agreement.pdf>.
COAG 2012b. National Indigenous Reform Agreement. Canberra: Council on Federal Financial Relations.
Viewed 13 December 2017, <http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/
indigenous-reform/national-agreement_sept_12.pdf>.
NHIPPC (National Health Information and Performance Principal Committee) 2017. Adelaide: COAG Health
Council. The Australian Health Performance Framework. Viewed 16 February 2018,
<http://www.coaghealthcouncil.gov.au/Portals/0/OOS318_Attachment%201.pdf>.
NHPC (National Health Performance Committee) 2002. National report on health sector performance
indicators 2001. Brisbane: Queensland Health.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2018. Report on
government services 2018. Canberra: Productivity Commission.
28
1.5 International
SNAPSHOT
comparisons
Australia matches or betters other comparable countries on many measures of health.
However, there is room for improvement on some measures.
This snapshot compares Australia with other member countries of the Organisation
for Economic Co-operation and Development (OECD) in 2015 (or the nearest available
year of data), unless otherwise noted. These 34 other countries provide a useful
Chapter 1
comparison for Australia as most are considered to be developed countries with
high-income economies.
Health status
The health status of a population can be considered in many ways, such as by rates of
illness and injury, and by measures of life expectancy and death. Compared with other
OECD member countries, Australia has:
• the fifth highest life expectancy at birth for males and the eighth highest for females
• a rate of deaths due to coronary heart disease close to the OECD average
• a prevalence of dementia similar to the OECD average (Figure 1.5.1).
While life expectancies at birth for males and females in Australia have increased from
2005 to 2015, Australia’s rankings among OECD member countries have dropped slightly
over this time, from fourth to fifth highest for males and from fifth to eighth highest for
females (OECD 2007).
The health status of a population can also be considered in terms of disability-adjusted life
years (DALYs). A DALY is equivalent to a single year of ‘healthy’ life lost due to illness and/
or death (see Chapter 3.1 ‘Burden of disease across the life stages’). Compared with other
OECD member countries, Australia had the fourth lowest rate of DALYs in 2016 (IHME 2017).
Determinants of health are factors that influence health status, and include health
behaviours and biomedical factors. Compared with other OECD member countries,
Australia has:
• one of the lowest rates of smoking among people aged 15 and over
• a level of alcohol consumption similar to the OECD average
• a
rate of obesity among people aged 15 and over that is well above the OECD average
(Figure 1.5.1).
29
Health system
The performance of a health system can be assessed by looking at measures such as
access to care, quality of care, and health expenditure. However, greater resources do not
necessarily mean a health system performs better. Compared with other OECD member
countries, Australia has:
• a level of health care expenditure per person close to the OECD average
• c lose to the OECD average number of practising doctors, practising nurses, and hospital
beds per 1,000 population (Figure 1.5.2)
• a better than average rate of colon cancer survival, ranking third best (Figure 1.5.1)
Figure 1.5.1: Australia’s performance among OECD member countries,

selected indicators, 2015 (or nearest available year of data)
Bottom OECD Top

Australia
performer average performer
77.9 80.4
Life expectancy, males
69.7 81.2
(years at birth)
83.1 84.5
Life expectancy, females
77.7 87.1
(years at birth)
112 85
Coronary heart disease mortality
328 34
(per 100,000 population)
14.8 14.2
Dementia prevalence
23.3 7.2
(cases per 1,000 population)
18.4 12.4
Daily smoking (% of people
27.3 7.6
aged 15 and over)
9.7 9.0
Alcohol consumption (litres per
12.6 1.4
person, aged 15 and over)
27.9 19.4
Obesity (% of people aged 15
38.2 3.7
and over)
62.8 70.6
Colon cancer survival (%) 51.5 71.7
Note: Data for Australia reflect those in the OECD.Stat database and may differ from data presented
elsewhere in this report due to the potential for slight variation in data definitions and calculation
methodologies.
Source: OECD 2017; Table S1.5.1.
30
Figure 1.5.2: Comparison of Australia’s health care resources as one of the 35 OECD
member countries, selected indicators, 2015 (or nearest available year of data)
OECD
Lowest Australia Highest
average
4,003 4,708
Health care expenditure (total
1,080 9,892
spending per person, USD PPP)
3.4 3.5
Practising doctors
Chapter 1
1.8 6.3
9.0 11.5
Practising nurses
2.0 18.0
3.8 4.7
Hospital beds
1.5 13.2
USD PPP = United States dollars purchasing power parities.

Note: Data for Australia reflect those in the OECD.Stat database and may differ from data presented
elsewhere in this report due to the potential for slight variation in data definitions and calculation
methodologies.

Making valid comparisons of health across countries can be challenging, as data
collection and reporting methods can vary. Comparisons of health system performance
can be particularly difficult because of the different ways health systems operate.
These differences should be considered when making comparisons.
Participation in international efforts to standardise data collection and reporting, such
as the development of the International Classification of Diseases 11th Revision, is an
important step in improving the comparability of data between countries.

More information on international health data, including other health indicators,
is available at <www.aihw.gov.au/reports-statistics/health-welfare-overview/international-
comparisons/overview> and <data.oecd.org/health.htm>.
References
IHME (Institute for Health Metrics and Evaluation) 2017. Global Burden of Disease Study 2016 (GBD 2016)
disability-adjusted life years and healthy life expectancy 1990–2016. Seattle: IHME. Viewed 22 February 2018,
<http://ghdx.healthdata.org/record/global-burden-disease-study-2016-gbd-2016-disability-adjusted-life-
years-and-healthy-life>.
OECD (Organisation for Economic Co-operation and Development) 2007. Health at a glance 2007: OECD
indicators. Paris: OECD.
OECD 2017. Health at a glance 2017: OECD indicators. Paris: OECD.
31
1.6 What is missing from
SNAPSHOT
the picture?
The AIHW manages many important national health and welfare data collections and
ensures that the information it reports is comprehensive, accurate and timely. Other
government and non-government agencies also collect and report health information
based on surveys, registries and administrative data collections. This information is used
to inform research findings and policy decisions that improve the health and wellbeing
of Australians. Despite efforts by policy, service delivery and statistical agencies, both
individually and collaboratively, to develop and improve national health data, there
remain opportunities to make better use of existing data and fill gaps in our knowledge.
A key issue for all data users is ensuring that information collected is used in the most
effective manner; that is, turning ‘big data’ into ‘smart data’. Information may be collected
in ‘silos’ and may not be readily accessible or integrated or even comparable from one
jurisdiction to another. Improving access to and use of existing data (see Chapter 2.5
‘Secondary use of health information’) would benefit Australians both through health
research and through enhanced policy and service delivery. Additionally, it will allow
real data gaps to be identified. This will be important for future National Healthcare
Agreements, and is timely in the context of Australia’s Digital Health Strategy (see
Chapter 2.4 ‘Digital health’) and, more broadly, the Australian Government’s public
data agenda (PM&C 2018).
However, there is currently no overarching strategic approach implemented to manage
and address these gaps nationally. A strategy, with associated action plan, could improve
health information assets and would be guided by policy, service delivery and research
needs. This requires an understanding of the health information environment and health
priority areas. The ‘enhanced health data’ priority associated with the current national
health reform agenda (COAG 2018) provides an ideal opportunity to initiate development
of a strategy and a work plan.
Individual chapters in this report describe data gaps under the ‘What is missing from the
picture?’ headings. Some articles and snapshots list gaps that are unique to the topic or
data collection. Data gaps exist where no national data are currently available or where
data collected are not comprehensive. The ‘What is missing from the picture?’ sections
may also describe analysis or research gaps that may be addressed by making better use
of existing data.
This snapshot lists some of the major gaps, both data and analysis gaps, in health data
and considers how they can be filled.
32
Major data gaps
A number of health data gaps are identified throughout this report. These gaps include:
• primary health care data (see Box 1.6.1)
• incidence and prevalence data for certain health conditions (for example, dementia and
mental health)
• t he ability to measure patient pathways through the health system, including across
different service types and different jurisdictions
• longitudinal data to measure outcomes related to health determinants, health
conditions or health interventions
Chapter 1
• t he ability to identify some populations of interest in health data (for example, people
with disability)
• g
eospatial information to look at locational variation in health and the effects of
population growth and demographic change.
Box 1.6.1: Gaps in primary health care data

Primary health care and hospital services each account for more than one-third
of health expenditure in Australia but compared with the volume of hospital
information that exists, there is a surprising lack of primary health care data.
Medicare services data provide some insight into variation in use of primary health
care (mostly general practice) across Australia, but do not include information
about why patients visit health professionals, their diagnosis, the treatment or care
they received, test results or referrals for further care. There is currently no national
data that allows assessment of the appropriateness, cost-effectiveness, safety,
quality and accessibility of primary health care. The cessation of the Bettering the
Evaluation and Care of Health survey (which collected data on general practice
visits including patient demographics, types of problems being managed and the
type of care provided from 1998 to 2015–16) has enlarged the primary health care
data gap. Additionally, there are no comprehensive, national data for ambulance,
aeromedical, allied health or state-funded community health services.
There have been developments to improve the completeness and utility of primary
health care data, including a commitment to develop a national primary care data
set. Making electronic health information available for secondary use will support
improved primary health care data but is not a total solution.
Filling data gaps

The goal of filling these major health data gaps is to achieve stronger evidence for better
decisions and improved health for Australians. The AIHW is working with government and
non-government agencies to fill some of these gaps and make better use of existing data,
including through data linkage.
33
Data linkage, also called data integration, is a process that combines information from
multiple databases, while preserving privacy, to tell a much more powerful story than
would be possible from a single source. The Productivity Commission’s (2017) Data
Availability and Use, Inquiry Report highlighted the substantial value of data linkage because
it enabled ‘more insights to be derived from information already collected’. Data linkage is
cost-effective because it re-uses existing data, and is non-intrusive because it avoids the
need to re-contact people whose information has already been collected. Data linkage is
most commonly used to measure health outcomes; for example, showing that the human
papillomavirus vaccination is effective in reducing cervical cancer (Gertig et al. 2013).
However, it is also valuable for patient pathways—for example, hospital re-admission

following a heart attack (Lopez et al. 2017)—and for identifying populations within an
existing data collection.
Data linkage is increasingly being used to link across health and welfare; for example, the
National Integrated Health Services Information Analysis Asset brings together aged cared
with health services data (AIHW 2018). The volume and complexity of linkage projects
undertaken by the AIHW continues to increase.
Much of this work centres on achieving valid and valuable person-centred data while
ensuring that individual privacy is protected. Person-centred data are beneficial for insight
on an individual’s health situation, their treatment pathways, interactions and experiences
with heath care and their health outcomes, potentially leading to improved coordination
and quality of care. However, individuals need to trust how their data will be handled, feel
they have control over how and who will use it and see the value and benefits in its use.
A national direction for filling data gaps

Australia’s health information and data environment is changing rapidly, with increasing
demands made on the collection, reporting and use of health data. There is a strong need
for a strategic approach to how we manage national health data assets in Australia—a
strategy that provides a desirable vision for the future of Australia’s national information
resources. The overall aim would be that future developments in national health data
assets are more coordinated, cost-effective and tailored to current health priority areas.
This rapid change and current technological developments mean that now is the time
to build on current health information work and existing infrastructure to improve how
we use and share data. The AIHW is well placed to work with Australian and state and
territory agencies to provide strategic direction and improve coordination. This would
ensure investments are well targeted, and that new and improved data collections match
national priorities.
Improved coordination and planning of health information work could assist in creating
a more comprehensive list of current and future national information gaps and overlaps,
as well as identifying priorities—as determined by policy and policymakers, strengthening
the links between policy and outcomes. A structured, strategic approach to data and
evidence is critical to support continuous improvement, innovation and progress in
health—strengthening it as a ‘learning system’.
34
References
AIHW (Australian Institute of Health and Welfare) 2018. Approved AIHW linkage projects.
Canberra: AIHW. Viewed 19 April 2018, <https://www.aihw.gov.au/our-services/data-linkage/
approved-aihw-linkage-projects>.
COAG (Council of Australian Governments) 2018. Heads of Agreement between the Commonwealth
and the States and Territories on public hospital funding and health reform. Canberra: Commonwealth
of Australia. Viewed 2 May 2018, <https://www.coag.gov.au/about-coag/agreements/
heads-agreement-between-commonwealth-and-states-and-territories-public-0>.
Gertig DM, Brotherton JML, Budd AC, Drennan K, Chappel G & Saville AM 2013. Impact of a
population-based HPV vaccination program on cervical abnormalities: a data linkage study. BMC
Medicine 11:227.
Lopez D, Nedkoff L, Knuiman M, Hobbs MST, Briffa TG, Preen DB et al. 2017. Exploring the effects
of transfers and readmissions on trends in population counts of hospital admissions for coronary
Chapter 1
heart disease: a Western Australian data linkage study. BMJ Open 7(11). e019226. doi: 10.1136/
bmjopen-2017-019226.
PM&C (Department of the Prime Minister and Cabinet) 2018. Public data. Canberra: PM&C. Viewed
19 April 2018, <https://www.pmc.gov.au/public-data>.
Productivity Commission 2017. Data availability and use, final report. Canberra: Productivity Commission.
35
36
Chapter 2
Australia’s health system
37
2.0 Overview
This chapter looks at key aspects of the health system in Australia—how it works, who
funds it, and the composition of the workforce that delivers frontline services. It also
examines the importance of digital health and secondary use of health data in achieving
better health outcomes for all Australians.
Every day, millions of Australians come in contact with the health system. It may be
as simple as a visit to the pharmacist to pick up a prescription—or a more complex
interaction, such as being admitted to hospital for surgery. The job of the health system
is to respond to these individual needs by offering timely and appropriate treatment
and services.
Australia’s health system has different components—health promotion, primary health
care, specialist services and hospitals—each supported, in turn, by a network of other
organisations, including research bodies, surveillance authorities, medical boards and
consumer health groups. Health care services are delivered, operated and funded by
the Australian Government and state and territory governments, as well as by the
private sector and not-for-profit organisations. Government departments also play
a central role in health policy and service planning.
Australia’s health system currently faces many challenges. These include demographic
changes and the demand for health services; coordinated management of chronic
conditions; greater availability and access to health data; and advances in medical
research, science and technology (such as genetic testing).
Spending on health has grown in real terms (after adjusting for inflation)—by 50%
between 2006–07 and 2015–16, from $113 billion to $170 billion. This compares with
a population growth of about 17% over the same period; it means that, in 2015–16,
spending on health amounted to nearly $7,100 per person. Using Organisation for
Economic Co-operation and Development (OECD) methods, Australia spends more on
health as a proportion of gross domestic product (9.6%) than New Zealand (9.2%) and
the OECD average (9.0%) but less than the United Kingdom (9.7%), Canada (10.6%) and
the United States (17.2%).
Together, hospitals (39%) and primary health care (35%) account for three-quarters of
health spending. Governments fund the majority of spending (67% or $115 billion), and
non-government sources fund the remaining $56 billion (33%). Individuals contributed
more than half ($29 billion) of the non-government funding.
Australia has a large, diverse health workforce that includes a variety of professions, many
of which are regulated by the Australian Health Practitioner Regulation Agency (AHPRA).
In 2016, there were more nurses and midwives employed (315,000) than any other health
care professional—more than 3 times as many as medical practitioners (91,000). Nine in
10 nurses were women, compared with 4 in 10 medical practitioners and dentists.
Over the past decade, the number of women entering medical practice has grown;
in 2016, more than half (53%) of employed medical practitioners under the age of 35
were women, compared with 43% in 1997.
38
Some occupations that play an important role in delivering health care services are not
regulated by the AHPRA. For example, there are 69,000 receptionists, 25,000 nursing
support and personal care workers, and 21,000 medical technicians working in the
health industry.
Today, many Australians actively participate in monitoring their own health; for example,
they might wear a fitness device to record how much exercise they do each day or use
a smartphone to record what they eat. For health care providers, digital technology can
provide opportunities to improve continuity of care—for example, by making it easier to
share a person’s clinical notes between all the health practitioners involved in their care.
This can lead to improved quality of care.
Technology—in particular, digital technology—has had a huge impact on data generation,
access and availability. So, what does happen to all the information collected on
our health?
Health data can be collected for a variety of reasons: for a patient admitted to hospital,
the primary reason may be to monitor their progress so that they can get the care they
need. But health data can also be used for ‘secondary’ reasons: to provide a holistic
Chapter 2
overview of the health system and the pathways that individuals take when using health
services. For example, access to health data may enable researchers to examine trends
in health spending, look at potential risk factors and determinants of health and disease,
or track hospital wait times.
The unprecedented volume and diversity of data currently available offer new
opportunities for the secondary use of data. In health, this has the potential to lead to
improved processes, increased efficiency, better targeting of resources and, ultimately,
a healthier population.
39
2.1 How does Australia’s
FEATURE ARTICLE
health system work?

A person is likely to use the health system in various ways throughout their life. This
pattern reflects their health needs at different life stages, the social and environmental
impacts on their health, and personal circumstances. Some people may visit a pharmacy
or general practitioner (GP) infrequently; some may have regular appointments with a
GP, specialists or other health practitioners; others may need to go to hospital for tests,
treatments or emergencies.
The World Health Organization describes a good health system as one that ‘delivers
quality services to all people, when and where they need them’ (WHO 2018).
Australia’s health system is a complex mix of health professionals and service providers
from a range of organisations—from all levels of government and the non-government
sector. Collectively, they work to meet the health care needs of all Australians. Health
services are delivered in numerous ways and settings, including through health promotion
and education programs, diagnosis, treatment and preventive services in the community,
treatment and care in hospitals, rehabilitation in hospitals and the community, and
palliative care.
A variety of organisations support these services. Health departments and other
government agencies are responsible for policy and service planning. Research and
statistical organisations collect and publish information on health conditions and issues
(including monitoring, assessing, evaluating and reporting). Universities and health
services train health professionals. Consumer and advocacy groups have a role in public
debates on health policy and regulation. Voluntary and community organisations support
health service functions through activities such as fundraising for research and raising
awareness of health issues through education programs.
This article provides an overview of the structure of the health system in Australia and
some of the many changes and challenges it currently faces.
Delivery of health care services

The health care system has multiple components—health promotion, primary health care,
specialist services and hospitals. To meet individual health care needs, a person
may need—or have to engage with—the services of more than one part of the system.
Health promotion
Health promotion focuses on preventing the root causes of ill health through activities
such as governance, promoting health literacy, and population health programs. Through
prevention and education programs and public awareness campaigns, health promotion
is geared to educating the public on health issues, preventing avoidable health conditions
40
and improving the overall health of the population. Examples of health promotion include
skin cancer awareness campaigns, cancer screening programs (for breast, cervical and
bowel cancers), immunisation programs, alcohol and drug abuse prevention programs,
anti-tobacco smoking awareness campaigns, and domestic violence education. Health
promotion is an important part of primary health care. See Chapter 7.1 ‘Health promotion’
for more information.
Primary health care

Primary health care is often a person’s first contact with the health system. It comprises a
range of services that are not referred: general practice, allied health services, pharmacy
and community health. Various health professionals deliver these, including GPs, nurses,
allied health professionals, community pharmacists, dentists and Aboriginal and Torres
Strait Islander health workers (Department of Health 2015). Primary health care can also
include activities related to health promotion, prevention and early intervention, and the
treatment of (and care for) acute and chronic conditions. See Chapter 7.5 ‘Primary health
care’ for more information.
Chapter 2
Primary Health Networks are coordinating bodies that work directly with GPs, other
primary health care providers, hospitals, and the broader community to increase the
efficiency and effectiveness of health services and improve the coordination of care for
patients moving between different services or providers (Department of Health 2016b).
There are 31 Primary Health Networks across Australia, operating since 2015.
Specialist services
Specialist services support people with specific or complex health conditions and issues,
such as antenatal services for pregnancy, radiotherapy treatment for cancer and mental
health services. Specialist services are generally referred by primary health care providers
and often described as ‘secondary’ health care services. In many cases, a formal referral
is required for an individual to access the recommended specialist service. There are a
range of medical specialists to whom people can be referred—for example, surgeons,
physicians, psychiatrists, obstetricians and gynaecologists, as well as for diagnostic
services such as pathology and imaging.
Hospitals
Hospitals are a crucial part of Australia’s health system, delivering a range of services to
admitted and non-admitted patients (outpatient clinics and emergency department care).
See Chapter 7.7 ‘Overview of hospitals’ for more information on hospitals.
State and territory governments largely own and manage public hospitals—which usually
provide ‘acute care’ for short periods (although some provide longer term care, such
as for some types of rehabilitation). While people needing care for a mental health
problem can access specialised units of general hospitals, a small number of public
psychiatric hospitals specialise in this care and sometimes provide care for long periods
(AIHW 2017a).
41
Private hospitals are mainly owned and operated by either for-profit companies or
not-for-profit organisations; they can include day hospitals as well as hospitals providing
overnight care (AIHW 2017a).
Local Hospital Networks are state and territory authorities set up to manage public
hospital services and funding. All public hospitals in Australia are part of a Local Hospital
Network. Currently, there are 136 of these networks in Australia—122 are geographically
based networks and 14 are state-wide or territory-wide networks that may deliver
specialised hospital services across some jurisdictions (AIHW 2017d). ‘Local Hospital
Networks’ is the term used nationally; terms used in states and territories for these
networks vary.
Responsibility for the health system

Australia’s health system may be more accurately described as various connected health
systems, rather than one unified system. The Australian Government, state and territory
governments and local governments share responsibility for it, including for its operation,
management and funding. While the overarching framework for the health system is
laid out by government, the private sector also operates and funds some health services.
These include operating private hospitals, pharmacies and many medical practices, as well
as funding through private health insurance.
The structure of the health system has its roots in Australia’s federal system of
government, which initially left the states with primary responsibility for providing health
services, including public hospital services. Changes to the Constitution in 1946 allowed
the Australian Government to become involved in the funding of public hospital services
(Biggs 2003). This resulted in the funding, operational and regulatory arrangements that
exist today between the Australian Government and state and territory governments.
Intergovernmental agreements, such as the National Health Reform Agreement 2011,
have continued to reshape the health system in recent years (Duckett 2017; Glance 2017).
All Australian health ministers are members of the Council of Australian Governments
(COAG) Health Council—the forum for cooperation on health issues and the health system
(COAG Health Council 2014).
Roles of each level of government

The main roles of each level of government in Australia’s health system are as
described here:
• T
he Australian Government is responsible for leading the development of national
health policy, administering Medicare (including funding GP and private medical
services), providing funds to states and territories for public hospital services, providing
oversight of Primary Health Networks, funding medicines through the Pharmaceutical
Benefits Scheme, regulating private health insurance, funding community-controlled
Indigenous primary health care, organising health services for veterans and funding
health and medical research.
42
• S
tate and territory governments are responsible for funding and managing public
hospitals, regulating and licensing private hospitals, providing oversight of local health
networks, delivering public community-based and primary health services, delivering
preventive services such as cancer screening and immunisation programs, ambulance
services and health complaints services.
• L
ocal governments, in some jurisdictions, are responsible for environmental
health-related services such as waste disposal and water fluoridation, community and
home-based health and support services and delivery of health promotion activities.
The three levels of government also share some responsibilities, including education and
training of health professionals, regulation of health workforces, improvements in safety
and quality of health care, and funding of health programs and services (Biggs 2013a;
Duckett & Willcox 2015; PM&C 2014).
Funding arrangements
The complex structure of Australia’s health system is reflected in its funding
Chapter 2
arrangements. The health system is funded by all levels of government. Funding also
comes from non-government organisations, private health insurers, and individuals when
they pay for some products and services without full, or with only partial, reimbursement.
In 2015–16, an estimated $170 billion was spent on health in Australia—10% of gross
domestic product (AIHW 2017c). Total government spending accounted for two-thirds
(67%) of health expenditure, and non-government sources funded the remaining
third (33%). Individuals funded 17% of total health expenditure in 2015–16 through
out-of-pocket expenses, mostly on primary health care, dental services and non-
subsidised medicines; private health insurers funded 8.8% (AIHW 2017c).
The Australian Government and state and territory governments funded 41% and 26%
of total health expenditure, respectively (AIHW 2017c). The Australian Government usually
provides the majority of funding for medical services and subsidised medicines. State and
territory governments fund most of the total expenditure for community health services.
Funding of public hospital services is shared between the Australian Government and
state and territory governments. Government spending accounted for most of the
$5.2 billion spent on health research in Australia in 2015–16 (AIHW 2017c).
Figure 2.1.1 shows the funding sources and responsibilities for the various components
of Australia’s health system. The figure makes it clear that funding of any part of
the system does not necessarily correlate with responsibility for its management or
operation. For example, the Australian Government partially funds public hospitals, but
is not responsible for managing or regulating them; this is the responsibility of state and
territory governments.
43
Figure 2.1.1: Health services—responsibility, funding sources and proportion
of expenditure, 2015–16
Responsibility for services

and health services
State and territory governments

Public hospital services
Private providers
Medications
Medical services (referred)
Private hospitals
Medical services (non-referred)

Source
Combined public and Australian Government
private sector State and territory and local governments
Community and public health Non-government
Dental services
Administration and research
Other health goods and services
Other health practitioners
0 5 10 15 20 25 30
Per cent
Note: The figure does not show responsibility, funding sources or proportion of health expenditure for
capital expenditure and medical expenses tax rebate.
Source: AIHW 2017c (Table A6); Table S2.1.1.
See Chapter 2.2 ‘How much does Australia spend on health care’ for more information on
funding of the health system.
Medicare
Australia’s health system is underpinned by Medicare—a universal public health
insurance scheme. Medicare is funded by the Australian Government through general
taxation revenue and a 2% Medicare levy (ATO 2017a; Biggs 2016a). Intergovernmental
agreements for public hospital funding between the Australian Government and state
and territory governments guarantee Medicare cardholders access to fee-free treatment
as public patients in public hospitals (Boxall 2014). Medicare also covers a portion of
the Medicare Benefits Schedule fee for medical services and procedures, and Medicare
cardholders have access to a range of prescription pharmaceuticals subsidised under the
Pharmaceutical Benefits Scheme (Biggs 2016a; Department of Health 2018; DHS 2017a).
See Chapter 7 for more information.
Some medical and allied health services are not subsidised through Medicare. For example,
Medicare does not usually cover costs for ambulance services, most dental examinations
and treatments, physiotherapy and optical aids (such as glasses and contact lenses).
44
Not everyone in Australia can access Medicare. Currently, it is available only to Australian
and New Zealand citizens, permanent residents in Australia, and people from countries with
reciprocal agreements (DHS 2017b, 2017c). Most people outside these categories have to
pay full fees for health services or take out private health insurance (PrivateHealth 2017c).
Private health insurance

Private health insurance is an option for managing health care expenses. People can
choose the type of cover to buy. The two types of cover available are:
• h
ospital cover for some (or all) of the costs of hospital treatment as a private patient
• g
eneral treatment (‘ancillary’ or ‘extras’) cover for some non-medical health services not
covered by Medicare—such as dental, physiotherapy and optical services (Department
of Health 2017d; PrivateHealth 2017d).
As at June 2017, 11.3 million Australians (46% of the population) had some form of private
patient hospital cover, and 13.5 million (55%) had some form of general treatment cover
(APRA 2017).
Chapter 2
Private health insurance works in tandem with the publicly funded system. Part of the cost
of hospital admission as a private patient is covered by Medicare (the medical fee) and
part can be covered by insurance (Boxall 2014). A person with private health insurance
can also choose to be treated as a public patient in a public hospital (PrivateHealth 2017e).
The Australian Government offers a means-tested rebate to people who hold private
health insurance; the intent is to reduce pressure on the publicly funded system by
encouraging people to take up private health insurance (PrivateHealth 2017a). Further,
the Medicare levy surcharge is imposed on people who earn above a specified income
threshold and do not have private health insurance (ATO 2017b; PrivateHealth 2017b).
Regulation and consumer protections

The Australian Government and state and territory governments are responsible for
health system regulation. Various regulatory agencies within the system work to ensure
that acceptable standards and quality of care and services are met, and that people
are protected when using health goods and services and when dealing with health
professionals. These objectives align with the Australian Charter of Healthcare Rights
(see Box 2.1.1).
The Australian Government regulates the safety and quality of pharmaceutical and
therapeutic goods and appliances. The Therapeutic Goods Administration is responsible
for regulating therapeutic goods, including prescription medicines, vaccines, sunscreens,
vitamins and minerals, medical devices, blood and blood products (TGA 2017).
State and territory governments manage and administer public hospitals; regulate and
license private hospitals; license pharmacies; and regulate, inspect, license and monitor
health premises (Biggs 2013a). They are also responsible for regulating industries that
affect individual and population/community health, such as the sale and supply of
alcohol and tobacco (AIHW 2016).
45
The different levels of government share responsibility for regulating food standards, the
safety and quality of health care, and the health workforce. The Australian Commission on
Safety and Quality in Health Care—established by the Australian Government and state
and territory governments—sets safety and quality standards to improve the quality of
health care in Australia. This includes clinical care standards and national standards in
mental health services (ACSQHC 2017b). See Chapter 7.9 ‘Safety and quality of hospital
care’ for more information.
Box 2.1.1: The right to health and the Australian Charter of Healthcare Rights
The right to health was first included in the preamble to the World Health
Organization Constitution in 1946. It is enshrined in the international human rights
framework, recognising the ‘right of everyone to the enjoyment of the highest
attainable standard of physical and mental health’ (ICESCR 1966). However, the right
to health is not the same as the right to be healthy—it refers to the right to ‘the
enjoyment of a variety of goods, facilities, services and conditions necessary for its
realisation’ (WHO 2008).
The Australian Charter of Healthcare Rights was endorsed by Australian and state
and territory health ministers in 2008 (ACSQHC 2017a). The Charter describes the
key rights of patients and health consumers who seek or receive health services.
It was developed by the Australian Commission on Safety and Quality in Health Care
to support the provision of safe and high-quality health care by educating patients,
families and those working in the health system about their rights to health care.
The seven rights in the Charter apply to anywhere health care is delivered, and
relate to:
• Access—the right to health care
• Safety—the right to safe and high-quality care
• Respect—the right to be shown respect, dignity and consideration
• C
ommunication—the right to be informed about services, treatment, options and
costs in a clear and open way
• Participation—the right to be included in decisions and choices about care
• Privacy—the right to privacy and confidentiality of personal information
• Comment—the right to comment on care and to have concerns dealt with.
The application of the Charter to the health system is informed by three guiding
principles:
(i) the right of everyone to access health care
(ii) the commitment of the Australian Government to international agreements
recognising the right to health
(iii) the acknowledgement of and respect for the different cultures and ways of life
in Australian society.
While the Charter is not enforceable, it reflects accepted standards and expectations.
For more information, see <www.safetyandquality.gov.au/national-priorities/
charter-of-healthcare-rights>.
46
The regulation of the health system includes the registration of health professionals.
The National Registration and Accreditation Scheme was established to ensure that
only suitably trained and qualified health practitioners are registered. The scheme is
implemented by national boards and supported by the Australian Health Practitioner
Regulation Agency (AHPRA). Currently, 14 health professions are covered, including medical
practitioners, nurses, dental practitioners, optometrists, psychologists, pharmacists and
physiotherapists (AHPRA 2015). The scheme aims to protect the public and provide access
to safer health care by regulating health practitioners (AHPRA 2017a). As well, a National
Code of Conduct for non-registered health care workers was approved by the Australian
and state and territory health ministers in 2015 (Department of Health 2016a).
Complaints handling mechanisms play a key role in regulating the health system. State and
territory health complaints organisations handle complaints about health service providers
(individuals and organisations) and work with AHPRA for complaints about registered
health practitioners (AHPRA 2017b). The Office of the Australian Information Commissioner
takes complaints about privacy breaches of health information and data (OAIC 2017). The
Private Health Insurance Ombudsman handles complaints about private health insurers
(Commonwealth Ombudsman 2017). As well, complaints handling mechanisms are
Chapter 2
available to people who have been discriminated against in the provision of and/or access
to health services through the various anti-discrimination bodies at both the federal and
state and territory levels.
Health and welfare links

A person’s health is not isolated from other facets of their life; it is tied to their social,
economic and individual circumstances. In a similar way, the health system is connected
to other sectors, particularly to welfare. Some examples of this nexus between health
and welfare at the service, policy and program levels are the National Disability Insurance
Scheme (NDIS) and child care services.
The NDIS uses an insurance-based model to provide individualised support to people
with disability. It has markedly changed how services are delivered, requiring people to
navigate multiple systems—such as health, disability and housing—and to interact with
various government and non-government personnel. See Chapter 5.4 ‘People with disability’
Government policies that seek to influence people’s behaviour or respond to a concern can
also affect health and welfare outcomes. In 2015, concern about low childhood vaccination
rates in some pockets of the country saw the Australian Government implement a ‘No Jab,
No Pay’ policy—to encourage parents to vaccinate their children in order to be eligible for
child care rebates (Klapdor & Grove 2015). In 2017, laws were passed in New South Wales,
Victoria and Queensland, and introduced in South Australia, to give effect to the ‘No Jab,
No Play’ policy, preventing children who have not been vaccinated from attending child
care (NCIRS 2017; SA Parliament 2017). See Chapter 7.2 ‘Immunisation and vaccination’
for more information on vaccination.
Further, there is a recognised association between poorer health outcomes and lower
socioeconomic position, and other forms of disadvantage (ACOSS 2017; Marmot 2016).
For example, people with mental health conditions and those who have experienced family,
domestic or sexual violence are most likely to be clients of specialist housing services
(AIHW 2017b). See Chapter 4.2 ‘Social determinants of health’ for more information.
47
Changes and challenges to the
health system
Health systems are not static but adjust and change to accommodate demographic,
social, economic, environmental and technological changes. Challenges currently faced
by the Australian health system include:
• d
emographic changes and the demand for health services
• c oordinated management of chronic conditions
• g
reater availability of and access to health data
• a
dvances in medical research, science and technology.
This section briefly discusses some of these complex challenges facing the health system.
The 2015 Intergenerational Report: Australia in 2055 presents a complex picture of
Australia’s health care needs over the next 4 decades: changes to the structure of
Australia’s population over this time will have implications for demand for health services
(Department of the Treasury 2015). A greater proportion of the population is projected
to be aged 65 and over by 2054–55, alongside a smaller proportion of traditional working
age (ages 15–64).
With increasing life expectancy and improvements in health, people are more likely
to remain active for longer, and ‘active ageing’ may see older Australians participate
in the workforce and in the community for longer (AIHW 2017e; Department of the
Treasury 2015). However, many health conditions and associated disability become more
common with age, and older Australians are higher users of health services than younger
Australians (AIHW 2016). For example, while people are living longer and healthier lives,
the prevalence of health conditions associated with ageing, such as dementia, is projected
to increase (see Chapter 3.14 ‘Dementia’).
The health system will need to accommodate changes in the demand for health services.
This may mean a demand for different types of health services for a healthier older
population to maintain good health, while continuing to provide support and services for
those affected by health conditions associated with old age (AIHW 2017b, 2017e). These
multiple demands on the health system will require a health workforce that can meet such
diverse needs.
Managing chronic conditions is another challenge to the health system (Duckett 2017;
Productivity Commission 2017) as these conditions represent a substantial burden in
Australia (see Chapter 3.3 ‘Chronic conditions’). The rising prevalence of many chronic
conditions and the growing number of patients with complex comorbidities increase the
demand for flexible, person-centred treatment models. Mental health is an example of a
need for a care model that provides care options of varying intensity to suit people with
differing needs (Biggs 2016b; NMHC 2014).
To tackle this issue, the Australian Government and state and territory governments
are taking a national approach to coordinated care under the National Health Reform
Agreement (COAG Health Council 2016; Productivity Commission 2017). As well, the
Health Care Homes initiative aims to provide better coordination and continuity of care
48
for patients with chronic and complex conditions through a team of health professionals
who develop a shared care plan for the patient (Department of Health 2017a).
Nonetheless, coordination of care remains a challenge, particularly where patient health
and medical information are not shared between providers (Glance 2017). See Chapter 7.18
‘Coordination of health care’ for more information.
Access to more data and their effective use is important in providing the evidence for
action on, and changes to, health policy, programs and services. Linking different health
information across the health system for use in health care provision presents both
opportunities and challenges. My Health Record is an attempt to improve services to
patients by tackling the problems of information sharing across different sectors. It will
also create the potential for access to far richer health data that can greatly help to deliver
a higher standard of clinical care and coordination. See chapters 2.4 ‘Digital health’; 2.5
‘Secondary use of health information’ for more information.
Advances in medical science, and genomics in particular, have seen a growth in genetic
testing services, including in Australia (Aubusson 2017; Vinkhuyzen & Wray 2017).
Genomic testing has the potential for early diagnosis of a range of health conditions
Chapter 2
and diseases, as well as prevention and treatment options for people able access these
services (Amor 2017). Genomic testing services pose many ethical and potentially legal
considerations, including the high cost to consumers, whether the tests actually inform
treatment options, the impact on a healthy person of discovering a predisposition to
a certain disease, privacy issues, and how such information may be used by insurance
companies (Amor 2017; Vinkhuyzen & Wray 2017).
Technological innovations are also having an impact on health and medical services—from
digital health technologies, to the potential use of automated dispensing machines for
medicines (Dickinson 2017), through to medical artificial intelligence for diagnostic testing
(Oakden-Rayner 2017). These technologies may provide efficiencies and improvements for
the health system, but they have implications for patients and the health workforce.
To meet some of these challenges facing the Australian health system, the Australian
Government has invested in medical research and technological innovation through the
Medical Research Future Fund. The fund complements current research and innovation
funding to improve health outcomes (Department of Health 2017c). As well, the Australian
Government is investing in information technology and infrastructure to support the
health system by replacing the IT system used to deliver Medicare payments in order to
improve efficiency and outcomes (Department of Health 2017b).
Other systemic challenges include the rising cost of the health system for governments
and individuals (AIHW 2017c; Biggs 2013b, 2016b), the ability to respond to emerging
health issues (for example, thunderstorm asthma) (Davies et al. 2017), disparities in
access to health services (Biggs 2016a; Russell 2017) and elective surgery and emergency
department waiting times (Duckett 2017). These challenges are not unique to Australia,
though, and several countries face very similar issues with their health systems.
49
The health system provides necessary health services and supports efforts to improve and
maintain the health of individuals and the population. Two key elements for improving
services and better meeting individual health needs, are understanding their experiences
as patients and consumers of health services, and tracking individual pathways through
the health system. There are still considerable challenges in being able to track patient
experiences and individual pathways through the health system. Data linkage can improve
the understanding of pathways through the health system.

Individual aspects of the health system are discussed in more detail throughout this report.
More information on primary health is available on the AIHW website at
<www.aihw.gov.au> and <www.myhealthycommunities.gov.au>.
Detailed information on Australian hospitals is available at <www.aihw.gov.au/reports-
statistics/health-welfare-services/hospitals/overview> and <www.myhospitals.gov.au>.
Detailed information on health spending and the health workforce are available at
<www.aihw.gov.au/reports-statistics/health-welfare-overview/health-welfare-expenditure/
overview> and <www.aihw.gov.au/reports-statistics/health-welfare-services/workforce/
overview>, respectively.
More information on health reform, health practitioner registration and Australian
Government health policies is available from the Department of Health website at
<www.health.gov.au>.
More information on health services and health system regulation in states and territories
is available from the various state and territory health department websites.
More information on intergovernmental agreements is available at the COAG Health
Council website at <www.coaghealthcouncil.gov.au>.
References
ACOSS (Australian Council of Social Service) 2017. Health. Sydney: ACOSS. Viewed 27 November 2017,
<http://www.acoss.org.au/health/>.
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2017a. Australian Charter
of Healthcare Rights. Sydney: ACSQHC. Viewed 1 December 2017,
<https://www.safetyandquality.gov.au/national-priorities/charter-of-healthcare-rights/>.
ACSQHC 2017b. Our work. Sydney: ACSQHC. Viewed 8 December 2017,
<https://www.safetyandquality.gov.au/our-work/>.
AHPRA (Australian Health Practitioner Regulation Agency) 2015. AHPRA FAQ. 27 August 2015. Melbourne:
AHPRA. Viewed 1 December 2017, <http://www.ahpra.gov.au/About-AHPRA/What-We-Do/FAQ.aspx>.
AHPRA 2017a. National Registration and Accreditation Scheme Strategy 2015–20. 16 October 2017.
Melbourne: AHPRA. Viewed 23 November 2017,
<http://www.ahpra.gov.au/About-AHPRA/What-We-Do/NRAS-Strategy-2015-2020.aspx>.
AHPRA 2017b. Other health complaints organisations. 18 October 2017. Melbourne: AHPRA.
Viewed 21 November 2017, <http://www.ahpra.gov.au/Notifications/Further-information/
Health-complaints-organisations.aspx>.
AIHW (Australian Institute of Health and Welfare) 2016: Australia’s health 2016. Australia’s health series
no.15. Cat. no. AUS199. Canberra: AIHW.
50
AIHW 2017a. Australia’s hospitals at a glance 2015–16. Health services series no. 77. Cat. no. HSE 189.
Canberra: AIHW.
AIHW 2017b. Australia’s welfare 2017. Australia’s welfare series no. 13. AUS 214. Canberra: AIHW.
AIHW 2017c. Health expenditure Australia 2015–16. Health and welfare expenditure series no. 58.
Cat. no. HWE 68. Canberra: AIHW.
AIHW 2017d. METeOR (Metadata Online Registry). Establishment—local hospital network identifier, code
NNN. Canberra: AIHW. Viewed 4 December 2017, <http://meteor.aihw.gov.au/content/index.phtml/
itemId/680985>.
AIHW 2017e. Older Australians at a glance: web report. 21 April 2017. Canberra: AIHW. Viewed
4 March 2018, <https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/
demographics-of-older-australians>.
Amor D 2017. Gene testing for the public: a way to ward off disease, or a useless worry? 22 June 2017.
Melbourne: The Conversation. Viewed 28 February 2018, <https://theconversation.com/gene-testing-for-
the-public-a-way-to-ward-off-disease-or-a-useless-worry-79757>.
APRA (Australian Prudential Regulation Authority) 2017. Private health insurance membership and
coverage (September 2017). Sydney: APRA.
ATO (Australian Taxation Office) 2017a. Medicare levy. 18 October 2017. Canberra: ATO. Viewed
24 November 2017, <https://www.ato.gov.au/Individuals/Medicare-levy/>.
Chapter 2
ATO 2017b. Medicare levy surcharge. 29 June 2017. Canberra: ATO. Viewed 8 December 2017,
<https://www.ato.gov.au/Individuals/Medicare-levy/Medicare-levy-surcharge/>.
Aubusson K 2017. Australian-first whole genome sequencing and health testing open to public. 19 June 2017.
Sydney: The Sydney Morning Herald. Viewed 1 March 2018, <https://www.smh.com.au/healthcare/
australianfirst-whole-genome-sequencing-and-health-testing-open-to-public-20170619-gwtsgm.html>.
Biggs A 2003. Hospitals in Australia. Canberra: Department of Parliamentary Services. Viewed
11 December 2017, <https://www.aph.go v.au/About_Parliament/Parliamentary_Departments/
Parliamentary_Library/Publications_Archive/archive/Hospitals>.
Biggs A 2013a. Health in Australia: a quick guide. Canberra: Department of Parliamentary Services.
Viewed 6 March 2018, <https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/
Parliamentary_Library/pubs/rp/rp1314/QG/HealthAust>.
Biggs A 2013b. Sustainable funding of health care: challenges ahead. Canberra: Department of
Parliamentary Services. Viewed 4 February 2018, <https://www.aph.gov.au/About_Parliament/
Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook44p/FundingHealthCare>.
Biggs A 2016a. Medicare: a quick guide. 12 July 2016. Canberra: Department of Parliamentary Services.
Viewed 27 October 2017, <http://parlinfo.aph.gov.au/parlInfo/download/library/prspub/4687808/upload_
binary/4687808.pdf;fileType=application%2Fpdf#search=%22library/prspub/4687808%22>.
Biggs A 2016b. Medicare and health system challenges. August 2016. Canberra: Department of
Parliamentary Services. Viewed 8 December 2017, <https://www.aph.gov.au/About_Parliament/
Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook45p/MedicareChallenges>.
Boxall A 2014. Explainer: what is Medicare and how does it work? 31 July 2014. Melbourne: The
Conversation. Viewed 8 December 2017, <https://theconversation.com/explainer-what-is-medicare-and-
how-does-it-work-22523>.
COAG (Council of Australian Governments) Health Council 2014. COAG Health Council 2014 Terms of
Reference. Canberra: COAG.
COAG Health Council 2016. COAG Health Council meeting communique – 7 October 2016. Canberra: COAG.
Commonwealth Ombudsman 2017. Private Health Insurance Ombudsman. Canberra: Commonwealth
Ombudsman. Viewed 22 November 2017, <http://www.ombudsman.gov.au/about/private-health-insurance>.
Davies J, Thien F & Hew M 2017. Thunderstorm asthma: who’s at risk and how to manage it.
6 November 2017. Melbourne: The Conversation. Viewed 20 November 2017,
<https://theconversation.com/thunderstorm-asthma-whos-at-risk-and-how-to-manage-it-86397>.
Department of Health 2015. Primary care. 14 July 2015. Canberra: Department of Health. Viewed
24 November 2017, <http://www.health.gov.au/internet/main/publishing.nsf/Content/primarycare>.
51
Department of Health 2016a. National Registration and Accreditation Scheme (NRAS). 2 February 2016.
Canberra: Department of Health. Viewed 23 November 2017,
<http://www.health.gov.au/internet/main/publishing.nsf/content/work-nras>.
Department of Health 2016b. Primary Health Networks (PHNs). 23 September 2016. Canberra: Department
of Health. Viewed 23 November 2017, <http://www.health.gov.au/internet/main/publishing.nsf/Content/
PHN-Home>.
Department of Health 2017a. Health Care Homes. 10 October 2017. Canberra: Department of Health. Viewed
23 November 2017, <http://www.health.gov.au/internet/main/publishing.nsf/Content/health-care-homes>.
Department of Health 2017b. Modernising Health and Aged Care Payments Services Program. Canberra:
Department of Health. Viewed 4 February 2018, <http://www.health.gov.au/internet/main/publishing.nsf/
Content/medicare-aged-care-payments-transformation-program>.
Department of Health 2017c. Overview of the Medical Research Future Fund. 22 December 2017. Canberra:
Department of Health. Viewed 31 January 2018, <http://www.health.gov.au/internet/main/publishing.nsf/
Content/medical-research-future-fund-mrff-overview-budget-2017>.
Department of Health 2017d. What is private health insurance? 31 January 2017. Canberra: Department of
Health. Viewed 31 January 2018, <http://www.health.gov.au/internet/main/publishing.nsf/Content/health-
privatehealth-whatisPHI>.
Department of Health 2018. About the PBS. 1 January 2018. Canberra: Department of Health. Viewed
11 January 2018, <http://www.pbs.gov.au/info/about-the-pbs>.
Department of the Treasury 2015. 2015 intergenerational report: Australia in 2055. Canberra: Department
of the Treasury.
DHS (Department of Human Services) 2017a. Medicare services. 27 August 2017. Canberra: DHS. Viewed
23 November 2017, <https://www.humanservices.gov.au/individuals/subjects/medicare-services>.
DHS 2017b. RHCA—medical care for visitors to Australia. 9 November 2017. Canberra: DHS. Viewed
24 November 2017, <https://www.humanservices.gov.au/individuals/enablers/rhca-medical-care-visitors-australia>.
DHS 2017c. Who can get a Medicare card? 9 November 2017. Canberra: Department of Human Services.
Viewed 23 November 2017, <https://www.humanservices.gov.au/individuals/enablers/who-can-get-
medicare-card>.
Dickinson H 2017. Replacing pharmacists with robots isn’t the answer to better productivity. 25 October 2017.
Melbourne: The Conversation. Viewed 2 March 2018, <https://theconversation.com/replacing-pharmacists-
with-robots-isnt-the-answer-to-better-productivity-86231>.
Duckett S 2017. Australia’s health system is enviable, but there’s room for improvement. 22 September 2017.
Melbourne: The Conversation. Viewed 27 October 2017, <https://theconversation.com/australias-health-
system-is-enviable-but-theres-room-for-improvement-81332>.
Duckett S & Willcox S 2015. The Australian health care system. 5th edn. South Melbourne: Oxford University
Press.
Glance D 2017. It’s complicated. The OECD details problems with Australia’s health care system.
17 November 2017. Melbourne: The Conversation. Viewed 27 November 2017, <https://theconversation.
com/its-complicated-the-oecd-details-problems-with-australias-health-care-system-50773>.
ICESCR (International Covenant on Economic, Social and Cultural Rights) 1966. Article 12(1). Geneva: Office of
the United Nations High Commissioner for Human Rights.
Klapdor M & Grove A 2015. ‘No jab, no pay’ and other immunisation measures. Canberra: Department
of Parliamentary Services. Viewed 29 November 2017, <https://www.aph.gov.au/About_Parliament/
Parliamentary_Departments/Parliamentary_Library/pubs/rp/BudgetReview201516/Vaccination>.
Marmot M 2016. 2016 Boyer Lectures: fair Australia: social justice and the health gap. Sydney: Australian
Broadcasting Corporation.
NCIRS (National Centre for Immunisation Research and Surveillance) 2017. No jab no play, No jab no pay
policies. August 2017. Sydney: NCIRS. Viewed 6 March 2018,
<http://www.ncirs.edu.au/consumer-resources/no-jab-no-play-no-jab-no-pay-policies/>.
NMHC (National Mental Health Commission) 2014. The national review of mental health programmes and
services. Sydney: NMHC.
52
OAIC (Office of the Australian Information Commissioner) 2017. Health information and medical research.
Sydney: OAIC. Viewed 24 November 2017,
<https://www.oaic.gov.au/privacy-law/privacy-act/health-and-medical-research>.
Oakden-Rayner L 2017. Artificial intelligence won’t replace a doctor any time soon, but it can help with
diagnosis. 19 September 2017. Melbourne: The Conversation. Viewed 5 March 2018,
<https://theconversation.com/artificial-intelligence-wont-replace-a-doctor-any-time-soon-but-it-can-help-
with-diagnosis-83353>.
PM&C (Department of the Prime Minister and Cabinet) 2014. Reform of the Federation white paper.
Issues paper 3: Roles and responsibilities in health. 11 December 2014. Canberra: PM&C.
PrivateHealth (PrivateHealth.gov.au) 2017a. Australian Government private health insurance rebate.
Canberra: Office of the Private Health Insurance Ombudsman. Viewed 8 December 2017,
<https://www.privatehealth.gov.au/healthinsurance/incentivessurcharges/insurancerebate.htm>.
PrivateHealth 2017b. Medicare levy surcharge. Canberra: Office of the Private Health Insurance
Ombudsman. Viewed 8 December 2017, <https://www.privatehealth.gov.au/healthinsurance/
incentivessurcharges/mls.htm>.
PrivateHealth 2017c. Overseas visitors & overseas students. Canberra: Office of the Private Health
Insurance Ombudsman. Viewed 24 November 2017, <https://www.privatehealth.gov.au/healthinsurance/
overseas/>.
PrivateHealth 2017d. What is covered? Canberra: Office of the Private Health Insurance Ombudsman.
Chapter 2
Viewed 24 November 2017, <https://www.privatehealth.gov.au/healthinsurance/whatiscovered/default.htm>.
PrivateHealth 2017e. What is covered by Medicare? Canberra: Office of the Private Health Insurance
Ombudsman. Viewed 24 November 2017, <https://www.privatehealth.gov.au/healthinsurance/
whatiscovered/medicare.htm>.
Productivity Commission 2017. Shifting the dial: 5 year productivity review. Melbourne: Productivity
Commission.
Russell L 2017. When second best isn’t good enough. 18 July 2017. Croakey. Viewed 27 October 2017,
<https://croakey.org/when-second-best-isnt-good-enough-australias-health-system-ranks-highly-on-all-but-
equity/>.
SA Parliament (Parliament of South Australia) 2017. SA legislative tracking. Adelaide: Parliament of South
Australia. Viewed 6 March 2018, <http://www.parliament.sa.gov.au/LEGISLATION/BILLSMOTIONS/SALT/
Pages/default.aspx?SaltPageTypeId=2&SaltRecordTypeId=0&SaltRecordId=4203&SaltBillSection=2>.
TGA (Therapeutic Goods Administration) 2017. Who we are & what we do. Canberra: Department of Health.
Viewed 11 December 2017, <http://www.tga.gov.au/who-we-are-what-we-do>.
Vinkhuyzen A & Wray N 2017. Why we should test everyone’s genes to predict disease. 24 October 2017.
Melbourne: The Conversation. Viewed 5 March 2018,
<https://theconversation.com/why-we-should-test-everyones-genes-to-predict-disease-83146>.
WHO (World Health Organization) 2008. Constitution of WHO: principles. Geneva: WHO. Viewed
1 December 2017, <http://www.who.int/about/mission/en/>.
WHO 2018. Health systems. Geneva: WHO. Viewed 28 January 2018,
<http://www.who.int/topics/health_systems/en/>.
53
2.2 How much does
FEATURE ARTICLE
Australia spend on
health care?
Health expenditure is money spent on health goods and services. It includes money
spent by governments as well as by individuals and other non-government funders,

such as private health insurers. The money is spent so that health goods and services can
be provided by hospitals, primary health care providers (such as general practitioners),
other health professionals and others.
Trends in health expenditure

Changes in health expenditure occur over time due to a range of factors including
increased population, government policy changes, new technologies, changes in patterns
of care, as well as increases in the costs of health service delivery.
Health expenditure was $170 billion in 2015–16

Total expenditure on health increased each year in real terms (after adjusting for
inflation), from $113 billion in 2006–07 to $170 billion in 2015–16—an annual average rate
of 4.8% (Figure 2.2.1). This growth slowed from 6.2% per annum between 2006–07 and
2011–12, to 3.4% between 2011–12 to 2015–16.
Figure 2.2.1: Total health expenditure, adjusted for inflation, 2006–07 to 2015–16
$ billion
180
160
140
120
100
80
60
40
20
0
2006– 07 2007– 08 2008– 09 2009 –10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
Year
Note: Inflation-adjusted prices expressed in terms of 2015–16 prices.

Source: AIHW health expenditure database; Table S2.2.1.
54
Health expenditure grew faster than population
growth
Between 2006–07 and 2015–16, growth in total health expenditure was greater than the
growth in the population. The population grew by 17% from 20.6 million in 2006–07 to
24.0 million in 2015–16, while total health expenditure (adjusted for inflation) grew by 50%
over the same period. Per capita (per person) health expenditure increased 22% (adjusted
for inflation) over this period, from $5,493 to $7,096—an increase of $1,603 per person
(Figure 2.2.2).
Figure 2.2.2: Health expenditure per person, adjusted for inflation, 2006–07 to
2015–16
$ per person
8,000
7,000
Chapter 2
6,000
5,000
4,000
3,000
2,000
1,000
0
2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
Year
Note: Inflation-adjusted prices expressed in terms of 2015–16 prices.

The proportion of GDP spent on health has increased

The growth in health expenditure was also greater than the growth in the economy as a
whole. Gross domestic product (GDP) had an average annual growth rate of 2.8% between
2006–07 and 2015–16. When expressed as a proportion of GDP, health expenditure grew
from 8.7% of GDP in 2006–07 to 10.3% of GDP in 2015–16 (Figure 2.2.3).
55
Figure 2.2.3: Ratio of health expenditure to GDP, 2006–07 to 2015–16
Per cent
12
10
4
0
2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
Year
Sources: AIHW health expenditure database; ABS 2017a; Table S2.2.3.
The proportion of tax revenue spent on health rose

then fell
Total government health expenditure was equivalent to about 21% of total tax revenue in
2006–07 and 2007–08. Following the global financial crisis, this share increased to 26% in
2009–10, mainly due to a relative drop in tax revenues. The proportion has since remained
around 25–26% (Figure 2.2.4).
Figure 2.2.4: Government health expenditure, as a percentage of taxation

revenue, 2006–07 to 2015–16
Per cent
30
25
20
15
10
0
2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
Year
Sources: AIHW health expenditure database; ABS 2017b; Table S2.2.4.
International comparisons
In addition to the National Health Accounts framework the AIHW uses to report
expenditure domestically, data is also prepared using the Organisation for Economic
Co-operation and Development (OECD) System of Health Accounts. This system is used
by OECD member countries to report health expenditure to support international
comparisons between member countries.
56
Australia’s proportion of health expenditure to GDP
is higher than the OECD average
Using the OECD System of Health Accounts method (OECD, Eurostat & WHO 2011), the
proportion of Australia’s health expenditure to GDP was 9.6% in 2016. The average for all
OECD countries was 9.0% (Figure 2.2.5). The Australian figure is higher than that for New
Zealand (9.2%) and lower than that for the United Kingdom (9.7%) and Canada (10.6%). The
United States was by far the highest spender, with the health sector making up 17.2% of its
GDP in 2016. The System of Health Accounts data are not comparable with the data presented
elsewhere in this article as they do not include the same scope of expenditure.
Figure 2.2.5: Health expenditure as a proportion of GDP, using the OECD

System of Health Accounts, OECD countries and OECD average, 2016
Country
United States
Switzerland
Chapter 2
Germany
Sweden
France
Japan
Canada
Netherlands
Norway
Belgium
Denmark
Austria
United Kingdom
Australia
Finland
New Zealand
OECD average
Spain
Portugal
Italy
Iceland
Slovenia
Chile
Greece
Ireland
Korea
Hungary
Israel
Czech Republic
Slovak Republic
Estonia
Poland
Luxembourg
Mexico
Latvia
Turkey
0 2 4 6 8 10 12 14 16 18
Per cent
57
Where is the money spent?
Health expenditure occurs when money is spent on health goods and services, and
investment in equipment and facilities. This excludes expenditure that might have a
‘health’ outcome, such as education of health practitioners. Recurrent expenditure is the
expenditure on goods and services, such as medicines, medical services, hospital services,
or public health activities. Capital expenditure is the expenditure on fixed assets such as
new buildings.
Hospitals and primary health care account for

three-quarters of total health expenditure
In 2015–16, recurrent health expenditure was $160 billion, and capital expenditure
$10 billion. The two major areas of expenditure in 2015–16 were hospitals ($66 billion)
and primary health care ($59 billion)—together they accounted for 74% of total
expenditure (Figure 2.2.6).
Figure 2.2.6: Proportion of total health expenditure, by broad area of

expenditure, 2015–16
7%
3%
6% Hospitals
Primary health care

10% 39%
Referred medical services
Capital expenditure
Research
Other services
35%
Sources: AIHW health expenditure database; Table S2.2.6.
Each broad area of expenditure consists of specific components; for example, ‘hospitals’
consists of public and private hospital services. For these specific components, the largest
proportion of expenditure for 2015–16 was for public hospital services ($51 billion),
followed by referred medical services ($18 billion), and private hospitals ($15 billion).
Expenditure on unreferred medical services was $12 billion; both community and public
health (combined), and benefit-paid pharmaceuticals had expenditures of $11 billion; the
expenditure (for each component) on all other medications, dental services, and capital
expenditure was $10 billion; it was $6 billion on other health practitioners; and $4 billion (for
each component) on aids and appliances, and on patient transport services (Figure 2.2.7).
58
Figure 2.2.7: Total health expenditure, by area of expenditure, 2015–16
Area of expenditure
Private hospitals
Unreferred medical services
Benefit-paid pharmaceuticals(a)
Capital expenditure
All other medications
Dental services
Community health and other
Research
Chapter 2
Aids and appliances
Administration
Patient transport services
Public health
0 10 20 30 40 50 60
$ billion
(a) B
enefit-paid pharmaceuticals are pharmaceuticals accessed through the Pharmaceutical Benefits
Scheme and Repatriation Pharmaceutical Benefits Scheme.
Who pays for what?

Healthcare in Australia is funded by the Australian Government, state and territory
governments, and non-government entities such as individuals, private health insurers,
third-party insurers and workers compensation. These sources of funds pay for health
care across the health system through various funding arrangements.
Governments funded two-thirds of health expenditure

In 2015–16, governments funded $115 billion of the total health expenditure (67%) with
non-government sources funding the remaining $56 billion (33%).
Of the $115 billion government contribution in 2015–16, the Australian Government
contributed $70 billion (61%), with state and territory governments contributing
$44 billion (39%).
In 2015–16, funding by individuals was $29 billion. This was 53% of the $56 billion in
non-government funding, or 17% of total health expenditure.
59
Figure 2.2.8 shows the proportion of total expenditure from each source of funds from
2006–07 to 2015–16. The proportion contributed by the Australian Government was
between 42% and 44% from 2006–07 to 2008–09, and remained steady at 41% from
2012–13, following the introduction of means testing of the private health insurance
rebate in April 2012. The proportion of expenditure from private health insurance funds
was steady at around 7% between 2006–07 and 2011–12, increasing to 9% in 2015–16.
State and territory expenditure was between 25% and 26% from 2006–07 to 2010–11,
and 26% to 27% from 2011–12 to 2015–16. Expenditure by individuals was steady over
the decade, at around 17%. Other non-government expenditure fluctuated between 6%
and 7% over the decade.
Figure 2.2.8: Proportion of health expenditure, by source of funds, 2006–07 to

2015–16
Per cent
50
45
40
35
30
25
20
15
10
0
2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
Year
Australian Government State/territory governments Health insurance funds

Individuals Other non-government (a)
(a) ‘Other non-government’ includes workers’ compensation and third-party insurance.

60
Source of funds varies for areas of
expenditure
The funding of different areas of expenditure within the health system is not evenly
distributed between the various sources of funding (Figure 2.2.9). The majority of
expenditure on benefit-paid pharmaceuticals is from the Australian Government. State
and territory government expenditure is the largest component of community and public
health expenditure, while individuals paid for the majority of all other medications.
Figure 2.2.9: Proportion of health expenditure, by source of funds and area of

expenditure, 2015–16
Area of expenditure
Benefit-paid pharmaceuticals (a)
Chapter 2
Unreferred medical services
Research
Administration
Public health
Private hospitals
Aids and appliances
Dental services
Community health and other
All other medications
0 20 40 60 80 100
Per cent
Australian Government State/territory governments

Health insurance funds Individuals
Other non-government (b)
(a) B
enefit-paid pharmaceuticals are pharmaceuticals accessed through the Pharmaceutical Benefits
Scheme and Repatriation Pharmaceutical Benefits Scheme.
(b) ‘Other non-government’ include workers’ compensation and third-party insurance.
61
Indigenous health expenditure
Indigenous health expenditure per person is more
than for non-Indigenous Australians
The total health expenditure for Aboriginal and Torres Strait Islander Australians
differs from that for non-Indigenous Australians. The estimated health expenditure in
2013–14 for Indigenous Australians was $8,515 per person compared with $6,180 for
non-Indigenous Australians—38% as high. This is not inconsistent with the higher health
needs of Indigenous Australians and the higher cost of delivering services in rural and
remote areas, where a greater proportion of Indigenous Australians live compared with
non-Indigenous Australians (AIHW 2017a, 2017b; SCRGSP 2017). Of the total health
expenditure per person for Indigenous and non-Indigenous Australians, in 2013–14:
• t he Australian Government provided 38% ($3,261) of the health expenditure for
Indigenous and 44% ($2,698) for non-Indigenous Australians
• s tate and territory governments provided 39% ($3,329) of the health expenditure for
Indigenous and 24% ($1,508) for non-Indigenous Australians
• n
on-government sources provided 23% ($1,926) of the health expenditure for
Indigenous and 32% ($1,974) for non-Indigenous Australians (Figure 2.2.10).
Figure 2.2.10: Health expenditure per person, by Indigenous status and source
of funds, 2013–14
$ per person
9,000 Indigenous Non-Indigenous
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Australian Government State/territory Non-government Total
governments
Source of funds
Source: AIHW 2017a; Table S2.2.10.
62
The distribution of health expenditure across the areas of expenditure for Indigenous
Australians differed from that for non-Indigenous Australians. Figure 2.2.11 shows that
more is spent per person on hospital and community health services for Indigenous
Australians than for non-Indigenous Australians, and less is spent on medications and
medical services for Indigenous Australians than for non-Indigenous Australians.
Figure 2.2.11: Health expenditure per person, by Indigenous status and area
of expenditure, 2013–14
Area of expenditure
Community health
Medical services
Private hospitals
Chapter 2
Medications
Dental services
Indigenous
Non-Indigenous
Research
Aids and appliances
Public health
Administration
0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000

$ per person
What is the AIHW doing?

The AIHW is undertaking work in the following areas:
• Improving the compatibility of domestic and international expenditure reporting.
The System of Health Accounts framework has been updated to include items not
currently disaggregated in the current AIHW methodology. Work is continuing to update
reporting to these new methods.
• C
onsidering new and alternative sources of health expenditure information. The
AIHW reviews the data sources available and methods employed to estimate health
expenditure when necessary. This ensures that the estimates it produces are of a high
quality. New sources of health expenditure data are being investigated for items such
as out-of-pocket expenditure, private prescriptions, and hospital services.
63
• E
xpanding and improving estimations for disease expenditure by developing a formal
method for future use. This will enable detailed analysis of the reasons for expenditure
in certain areas of the health system.

The health expenditure data collection does not include information from some funding
sources. Health-related costs from the Australian Defence Force or from correctional
and detention facilities are not collected for inclusion in the AIHW health expenditure
database. Data for programs that are self-funded by local governments (such as public
health initiatives funded and run by local authorities or councils) are not included
in the health expenditure database collection. Funding for health care received by
local government authorities from a state or territory government is included in that
jurisdiction’s expenditure. Not all expenditure by non-government organisations is
included, such as initiatives run from private donations to the organisations. Some
payments from the Australian Government are counted as expenditure in the financial
year the payment occurred even if it related to services provided and expenditure
incurred by service providers in earlier years.

More information on Australian health expenditure and methods is available at
<www.aihw.gov.au/reports-statistics/health-welfare-overview/health-welfare-expenditure/
overview>. The report Health expenditure Australia 2015–16 and other recent publications
are available for free download. Information on international comparisons for each
country is available at <data.oecd.org/healthres/health-spending.htm>.
References
ABS (Australian Bureau of Statistics) 2017a. Australian national accounts: national income, expenditure
and product, March 2017. ABS cat. no. 5206.0. Canberra: ABS.
ABS 2017b. Taxation revenue, Australia, 2015–16. ABS cat. no. 5506.0. Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2017a. Aboriginal and Torres Strait Islander Health
Performance Framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW.
AIHW 2017b. Australian health expenditure—demographics and diseases: hospital admitted patient
expenditure 2004–05 to 2012–13. Health and welfare expenditure series no. 59. Cat. no. HWE 69.
Canberra: AIHW.
OECD (Organisation for Economic Co-operation and Development) 2017. Health Statistics 2017.
WHO Global Health Expenditure Database. Paris: OECD.
OECD, Eurostat & WHO (World Health Organization) 2011. A system of health accounts. OECD Publishing.
Paris: OECD.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2017. 2017 Indigenous
expenditure report. Canberra: Productivity Commission.
64
2.3 Who is in the health
SNAPSHOT
workforce?
The health workforce in Australia is large and diverse, covering many occupations.
These include health practitioners registered by the Australian Health Practitioner
Regulation Agency (AHPRA) (Box 2.3.1) as well as other health professionals and health
support workers.
Registered health practitioners

Box 2.3.1: Australian Health Practitioner Regulation Agency and the National
Registration and Accreditation Scheme
The AHPRA regulates Australia’s health practitioners in partnership with the National
Chapter 2
Registration Boards. The current list of registered health professions are Aboriginal
and Torres Strait Islander Health Practice, Chinese Medicine, Chiropractic, Dental,
Medical, Medical Radiation Practice, Nursing and Midwifery, Occupational Therapy,
Optometry, Osteopathy, Pharmacy, Physiotherapy, Podiatry and Psychology. The
AHPRA intends to start registering Paramedics by the end of 2018 (AHPRA 2017).
See Chapter 2.1 ‘How does Australia’s health system work?’ for more information
on health workforce registration.
Source: AHPRA 2017.
The National Health Workforce Dataset shows that nurses and midwives are the largest
group in the registered health workforce—with almost 370,000 registered and more than
315,000 employed in 2016 (Table 2.3.1).
Table 2.3.1: Key workforce statistics and full-time equivalent (FTE) rates for
selected health professions
Nurses Medical
and midwives practitioners Psychologists Physiotherapists Dentists
369,790 in 2016 101,070 in 2016 29,163 in 2016 29,591 in 2016 16,549 in 2016
Registered  7.4% from  10.5% from  9.1% from  15.8% from  6.9% from
344,190 in 2013 91,472 in 2013 26,725 in 2013 25,545 in 2013 15,479 in 2013
315,137 in 2016 91,341 in 2016 25,213 in 2016 24,255 in 2016 14,634 in 2016
Employed  6.8% from  10.8% from  9.2% from  15.2% from  8.4% from
295,177 in 2013 82,408 in 2013 23,089 in 2013 21,052 in 2013 14,634 in 2013
FTE per 1,145 in 2016 400 in 2016 89 in 2016 92 in 2016 58 in 2016
100,000  0.9% from  4.7% from  3.5% from  10.8% from  3.6% from
people 1,155 in 2013 382 in 2013 86 in 2013 83 in 2013 56 in 2013
Percentage 89% in 2016 41% in 2016 79% in 2016 66% in 2016 41% in 2016
that are about the same  from 39% in  from 77% in  from 68% in  from 38% in
women as in 2013—90% 2013 2013 2013 2013
Source: Department of Health National Health Workforce Dataset 2013 and 2016.
65
In FTE terms, there were 1,145 FTE nurses and midwives, and 400 FTE medical
practitioners for every 100,000 people in 2016. The number of FTEs for other professions
was much lower, with 89 psychologists, 92 physiotherapists and 58 dentists for every
100,000 people.
In 2015, Australia had more doctors (3.5) and registered nurses (11.5) per 1,000 people
than Canada (2.7 and 9.9, respectively), the United Kingdom (2.8 and 7.9) and
New Zealand (3.0 and 10.3) (OECD 2017a, 2017b).
The age profile of nurses and midwives is changing

The age group profile of nurses and midwives is changing: the size of the middle age
group is decreasing while younger and older age groups are growing. From 2013 to 2016,
the number of employed nurses and midwives aged 20–34 increased by 15,500, or 19%.
The size of the group aged 35–54 fell by 3,500 or 2.1%, and the group aged 55 and over
grew by 11,000, or 15%.
More women are becoming medical practitioners

A larger proportion of medical practitioners entering the workforce are women. In 1997,
43% of employed medical practitioners under the age of 35 were women. This has grown
to around 53% since 2014 (Figure 2.3.1). In 2016, 31% of employed medical specialists
were women, up from 16% in 1997.
Figure 2.3.1: Proportion of employed medical practitioners who are women,

by age, 1997–2016
Per cent
60
50 Under 35
40
35-54
30 All ages
20
55 and over
10
0
1995 2000 2005 2010 2015
Year
Sources: AIHW Medical Labour Force Survey: 1997 to 2009; AIHW National Health Workforce Dataset: 2011
and 2012; Department of Health National Health Workforce Dataset: 2013 to 2016.
66
Even though the trend is towards more women in the health workforce, medical
practitioners (and dentists) still have a relatively low proportion of women compared
with other health practitioners. In 2016, women represented 41% of medical practitioners
(and dentists) (Table 2.3.1).
Australia has many overseas-trained registered health professionals

Migrant/overseas-trained health workers form a substantial part of the health workforce
in Australia. For example, in 2016, 33% of medical practitioners employed in Australia
received their initial qualification overseas. They make up 31% of employed medical
practitioners in Major cities and 41% of employed medical practitioners in rural and remote
areas of Australia.
Health workers and professions not registered

Many people employed in the health sector work in occupations that are not registered
by the AHPRA, but they play an important role in delivering health services. These
Chapter 2
occupations include clerical workers, health information managers, welfare professionals,
service workers, cleaners and gardeners.
In the Australian Bureau of Statistics (ABS) 2016 Census of Population and Housing
(the Census), more than 800,000 people reported working in the health services industry.
Between 2011 and 2016, the number of people employed in health services grew from
674,000 to 801,000 (ABS 2017).
Among the health industry occupations (other than AHPRA registered professions)
identified in the 2016 Census, the largest groups were 69,000 receptionists, 25,000 nursing
support and personal care workers, 21,000 medical technicians, 21,000 dental assistants,
17,000 general clerks and 13,000 ambulance officers and paramedics. There were also
9,000 kitchen hands and 10,000 commercial cleaners, most of whom worked in hospitals.

The AHPRA does not register all health professionals. There is thus little information on
those professions not required to register. This includes, for example, dietitians, speech
therapists, sonographers, audiologists and social workers.

More information on registered health professions is available at the AHPRA at
<www.ahpra.gov.au> and workforce data are available via the Department of Health
website at <hwd.health.gov.au>.
Workforce data are sourced from the National Health Workforce Dataset—Australian
Government Department of Health. The workforce data used in this publication were
provided by the AHPRA.
67
References
ABS (Australian Bureau of Statistics) 2017. ABS Census table builder. Canberra: ABS. Viewed 19 January 2018,
<https://auth.censusdata.abs.gov.au/webapi/jsf/dataCatalogueExplorer.xhtml>.
AHPRA (Australian Health Practitioner Regulation Agency) 2017. Australian Health Practitioner Regulation
Agency annual report 2016/17. Melbourne: AHPRA.
OECD (Organisation for Economic Co-operation and Development) 2017a. Health at a glance 2017:
OECD indicators. Paris: OECD Publishing.
OECD 2017b. OECD.Stat 2017. Paris: OECD. Viewed 17 January, 2018,
<http://stats.oecd.org/viewhtml.aspx?datasetcode=HEALTH_REAC&lang=en#>.
Acknowledgements
Workforce data are sourced from the National Health Workforce Dataset—Australian Government
Department of Health.
The workforce data used in this publication were provided by the Australian Health Practitioner
Regulation Agency.
68
2.4 Digital health
SNAPSHOT
Digital health is about using technology to collect and share a person’s health information.
It can be as simple as a person wearing a device to record how much exercise they do
each day, to health care providers sharing clinical notes about an individual.
For individuals, this technology can help people to track and control their own health
information and inform decisions about their health. For health care providers, it can
support continuity of care; improve interactions between providers and patients; and
improve the effectiveness, efficiency and delivery of services.
This snapshot explains how digital health is being used in Australia, with a focus on
the Australian Government’s digital health strategy and online health information
initiative—My Health Record.
How digitally connected are we?
Chapter 2
Health information can be recorded and shared on a variety of digital devices and
platforms, including general practitioner, hospital and pathology systems; smartphones,
tablets, desktop computers, smartwatches, and social networks. The clear majority of
Australians have access to digital technology. It is estimated that:
• 8
6% of households had internet access at home in 2016–17 (ABS 2018)
• 8
8% of people aged 18–75 owned or had access to a smartphone in 2017
(Drumm et al. 2017)
• 7
8% of adults used the internet to find health-related information in 2015
(Research Australia 2017)
• 9
6% of general practitioners used computers for clinical purposes in 2014−15
(Britt et al. 2015)
• 2
3% of Australians had a My Health Record in March 2018. By the end of 2018, all
Australians will have a My Health Record unless they opt out (ADHA 2017b, 2018).
Digital health in practice

The scope and use of digital health technologies are growing and changing rapidly. This is
enabling real-time information to be available to both patients and their health care providers.
The following initiatives are examples of the growth and benefits of digital health:
• T
here is growing use of digital systems by Australian health care providers, including
general practices, community pharmacies and public and private hospitals.
• E
lectronic health records are associated with improved quality and safety of care in
enhancing clinical decision support and improving handover of care between health
care providers (National E-Health Transition Authority 2015).
• C
ardiac rehabilitation programs (CRPs) are crucial for improving the health of patients
recovering from a heart attack. An Australian CRP delivered through a smartphone
resulted in higher attendance (80% compared with 62%) and higher levels of completion
(80% compared with 47%) than a face-to-face, centre-based CRP (Varnfield et al. 2014).
69
• M
edication-prescribing errors are a serious patient safety issue and costly to public
health budgets. An international review found that a change from paper-based ordering
to electronic ordering in intensive care units resulted in an 85% reduction in error rates
for prescription of medications (Prgomet et al. 2016).
Australia’s Digital Health Strategy

In August 2017, all Commonwealth, state and territory health ministers agreed to the
following seven strategic priorities for digital health in Australia:
• h
ealth information is available whenever and wherever it is needed through the
My Health Record
• e
very health care provider can communicate with their patients and other health care
providers through secure digital technologies
• h
igh-quality data with a commonly understood meaning can be used with confidence
• a
ll prescribers and pharmacists have access to electronic prescribing and dispensing
by 2022
• m
aximum use is made of digital technology to improve accessibility, quality, safety,
and efficiency of care
• a
ll health care professionals can confidently and efficiently use digital health
technologies
• t he digital health industry thrives and delivers world-class innovation (ADHA 2017a).
My Health Record is an online platform for storing a person’s health information, including
their Medicare claims history, hospital discharge information, diagnostic imaging reports,
and details of allergies and medications (ADHA 2017b). The person and their authorised
health care provider(s), can access these details securely at any time (Box 2.4.1).
Box 2.4.1: Case study

Paige was diagnosed with epilepsy as a teenager and lost her hearing after her first
child was born. This is her story:
At one point during my pregnancy I had to keep track of more than 12 obstetric
outpatient hospital visits, 3 neurology appointments, various pathology tests as
well as GP visits. To add to this, my husband and I have five children...It became
increasingly difficult to keep track of everything. My Health Record helps me keep a
single record of my own health information, and the whole family has an individual
My Health Record…Personally, it means my medical history is easily accessible to
manage my health…As a parent, it empowers me to take control and gain visibility
of my family’s health care and make the most informed decisions (ADHA 2017a).
In early 2018, around 23% of Australians had a My Health Record. By the end of 2018,
all Australians will be registered unless they choose to opt out (ADHA 2017b, 2018).
Given this, the Australian Government has built substantial privacy and security
safeguards into the legislation establishing the My Health Record (ADHA 2016). A 2017
consumer-perspective review of My Health Record found that although there are some
70
concerns about privacy and security, there is sufficient trust in the government to put
systems in place to ensure this (Van Kasteren et al. 2017). See Chapter 2.5 ‘Secondary
use of health information’ for more information on the legal instruments that regulate
sensitive data.

There are no national data available to allow detailed understanding of the use and
outcomes from the vast range of digital health applications.

Detailed information on Australia’s National Digital Health Strategy is available at
<www.digitalhealth.gov.au/about-the-agency/publications/australias-national-digital-
health-strategy>.
Information about My Health Record for individuals and health care providers is available
at <www.myhealthrecord.gov.au>.
Chapter 2
References
ABS (Australian Bureau of Statistics) 2018. Household use of information technology, Australia, 2016–17.
ABS cat. no. 8146.0. Canberra. ABS.
ADHA (Australian Digital Health Agency) 2016. Legislation and governance. Sydney: ADHA. Viewed
11 December 2017, <https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/legislation>.
ADHA 2017a. Annual report 2016–17. Sydney: ADHA. Viewed 3 November 2017, <https://www.digitalhealth.
gov.au/about-the-agency/publications/reports/annual-report/Annual_Report_Australian_Digital_Health_
Agency_2016-2017_Online.pdf>.
ADHA 2017b. Australia’s National Digital Health Strategy: safe, seamless and secure. Sydney: ADHA. Viewed
3 November 2017, <https://www.digitalhealth.gov.au/about-the-agency/publications/australias-national-
digital-health-strategy/ADHA-strategy-doc-(2ndAug).pdf>.
ADHA 2018. My Health Record statistics. Sydney: ADHA. Viewed 23 March 2018 <https://myhealthrecord.
gov.au/internet/mhr/publishing.nsf/Content/news-002>.
Britt H, Miller GC, Henderson J, Bayram C, Harrison C & Valenti L et al. 2015. General practice activity in
Australia 2014−15. General practice series no. 38. Sydney: Sydney University Press.
Drumm J, White N, Morne S & Davey M 2017. Smart everything, everywhere: mobile consumer survey
2017—the Australian cut. Sydney: Deloitte. Viewed 4 December 2017, <http://landing.deloitte.com.
au/rs/761-IBL-328/images/tmt-mobile-consumer-survey-2017_pdf.pdf?utm_source=marketo&utm_
medium=lp&utm_campaign=tmt-mobile-consumer-survey-2017&utm_content=body>.
National E-Health Transition Authority 2015. My eHealth record to national eHealth record transition
impact evaluation: phase 1 evaluation report. Sydney: National E-Health Transition Authority Ltd.
Prgomet M, Li L, Niazkhani Z, Georgiou A & Westbrook J 2016. Impact of commercial computerized provider
order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and
mortality in intensive care units: a systematic review and meta-analysis. Journal of the American Medical
Informatics Association 24(2):413–22. doi:org/10.1093/jamia/ocw145.
Research Australia 2017. Australia speaks! Research Australia opinion polling 2017. Sydney: Research
Australia. Viewed 4 December 2017, <https://researchaustralia.org/wp-content/uploads/2017/08/2017-
Opinion-Poll-Digital.pdf>.
Van Kasteren Y, Maeder A, Williams P & Damarell R 2017. Consumer perspectives on MyHealth Record:
a review. In: Ryan A, Schaper L & Whetton S (eds). Integrating and connecting care: selected papers from
the 25th Australian National Health Informatics Conference. Amsterdam: IOS Press 239:146–152. doi:
10.3233/978-1-61499-783-2-146.
Varnfield M, Karunanithi M, Lee C-K, Honeyman E, Arnold D, Ding H et al. 2014. Smartphone-based home
care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a
randomised controlled trial. Heart 100(22):1770–9. doi:10.1136/heartjnl-2014-305783.
71
2.5 Secondary use of health
FEATURE ARTICLE
information
Every day, the clear majority of Australians log on to some form of digital technology, such
as a smartphone or a tablet. In 2014–15, 86% of Australian households—including 97% of
those with children under 15—had internet access (ABS 2016). This ‘doorway’ to the digital
world has brought with it unprecedented access to vast volumes of data—including data
on our health and welfare.
Health data relate to information gathered on people’s health (and factors that affect
it) and the health system. These data can be collected from a diverse range of sources,
including the health care system itself, health practitioners, medical research, or
individuals tracking their own health. For example, wearable trackers have been used to
track and increase physical activity (Kaiser et al. 2016) and social media data have been
used to provide early insight into disease outbreaks (Brown 2015).
The amount of health data generated is increasing rapidly. One report estimated that
the global amount of health data being generated grew by 48% every year, and that the
amount of health data is expected to exceed 2,000 exabytes (2 billion terabytes) by the
year 2020 (EMC 2014).
The growth in digital technology and ‘digital health’—the term used when this
technology is used to collect and share a person’s health information (see Chapter 2.4
‘Digital health’)—has increased the volume of data available for health research. This, in
turn, has increased opportunities for ‘secondary use’ of health data to improve the health
system and the wellbeing of Australians.
What is meant by secondary use?

‘Secondary use’ of data refers to any application of data beyond the reason for which
they were first collected (known as the primary use or purpose). For example, the primary
use of data collected to treat a patient in a hospital is to provide the patient with the care
they need in that hospital episode; a secondary use could be to aggregate patients’ data
to compare hospital performance across Australia.
Secondary use of data presents an enormous opportunity to improve the health
treatment that Australians receive. Health data can be used in this way to monitor and
improve hospital performance—this can include improving flagging facilities (where
this can be done) and identifying top-performing hospitals. Processes and practices of
top-performing health facilities can then be adopted by others, thereby improving quality
of care overall.
However, use of an individual’s health data to enable these improvements must be
balanced against the risk to their privacy. Australia has many legal requirements and
systems in place to ensure that privacy is protected.
72
This article focuses on two aspects of secondary use of health data: the insights that can
be gained from secondary use of administrative data, and how data integration can be
used to gain a deeper and broader view of the health system and the many factors that
affect a person’s health outcomes. Aspects of privacy protection with the processes that
support these uses are also discussed.
Insights from administrative data

Health care in Australia is delivered by a variety of professionals in many different
settings—from state-of-the-art operating rooms to care provided in a patient’s home.
Administrative data can be considered as data collected from running these services and
programs. In the case of health, these cover data from hospitals, health professionals,
pharmacies and allied health care.
Using these data for secondary purposes can help to glean a holistic overview of the
health system and the pathways that individuals take when using health services. For
example, access to the data allows a variety of analyses to be undertaken, including
Chapter 2
examining trends in health expenditure, examining patient outcomes from particular
treatments, looking at potential risk factors and determinants of health and disease, and
tracking hospital wait times. Another application of secondary use is identifying, and then
inviting, patients for clinical trials and studies.
Using this vast amount of data has the potential for improvements in the quality and
safety of health care—and in clinical and administrative processes—as well as for better
targeting of resources. Ultimately, the potential is there for a healthier population.
Many of the chapters in this report show the wide application and benefits of secondary
use of data for research purposes.
Data linkage
The value of administrative data increases when individual data sets are linked to provide
a more robust picture of the people using the services and the system. Data linkage and
data integration combine information from two or more data sets to create a new, more
detailed data set that can tell a much more meaningful story than would be possible from
a single data source. This may involve bringing together data from the same source over
different time periods to see the effect of events that have occurred across a person’s
life, or bringing together two different data sets to get a broader understanding of factors
that can affect a person’s health. For example, researchers at the University of New South
Wales are examining the factors that lead to poor outcomes following prescription opioid
use by linking Medicare, pharmaceutical, mortality and cancer data sets (AIHW 2017a).
Bringing these data together will provide researchers with a much more comprehensive
view than if they were to examine each data source individually.
Today’s unprecedented volume, diversity and speed of data generation present many
new opportunities for data linkage. As more health data become available, academics,
researchers and organisations such as the AIHW are looking at how data linkage can
provide insights into the health of Australians and the performance of the health system.
73
Box 2.5.1 provides two examples of data linkage projects which have enabled better
responses to health problems.
The AIHW is one of a small number of accredited integrating authorities in Australia—the
others include the Australian Bureau of Statistics and the Australian Institute of Family
Studies (NSS 2014). These organisations can undertake high-risk data integration projects
using Commonwealth data as they have strict privacy and confidentiality controls in place.
There are also state-based data linkage units that link state and territory data for research
purposes. These units, along with the AIHW, are members of the Population Health
Research Network, a collaboration to build data linkage infrastructure at the national level
(Productivity Commission 2017).
Box 2.5.1: Data linkage—two case studies

In 2017, the AIHW first published a report providing new insight into suicide
among contemporary Australian Defence Force (ADF) personnel (with at least 1
day of service since 1 January 2001). The study constructed a data set by linking
ADF personnel administrative data and the National Death Index. This linked data
set was then supplemented by information on confirmed suicide deaths from
the Defence Suicide Database and cause of death information from the National
Mortality Database. This linkage allowed the AIHW to identify characteristics of the
contemporary ex-serving population associated with suicide risk (see Chapter 5.6
‘Veterans’). Following from this, the AIHW and the Department of Veterans’ Affairs
have now begun a 3-year partnership to monitor veteran suicide rates and develop
a comprehensive profile of the health and welfare of Australian veterans and their
families to understand their current situation and future needs (AIHW 2017b).
Researchers from the University of South Australia, the University of Adelaide and
the Flinders Centre for Innovation used data linkage to uncover important insights
into colorectal cancer treatment patterns. The researchers linked data from the
South Australia Cancer Registry to hospital and radiotherapy data. The Population
Health Research Network carried out the linkage, ensuring that the researchers
themselves did not access any information that could identify individuals. The study
found that recommended treatments were less likely to be performed on people
who were older, who lived in rural areas or who had severe or multiple diseases.
This information promises to improve outcomes by highlighting a segment of the
population that can be targeted to ensure that they receive the recommended
treatment for colorectal cancer (Beckmann et al. 2014).
Programs such as the Data Integration Partnership for Australia are developing ways
to efficiently derive the most societal benefit from new linkage opportunities, while
maintaining the consideration and protection given to privacy. The program brings
together agencies from across the Australian Government to work together on data
integration projects that will better indicate how factors that influence health and welfare
affect outcomes for Australians.
74
Taking a person-centred approach to data
The increasing availability of digital data comes with a community expectation that
public data will be used to improve outcomes for Australian people. There is now
growing interest in person-centred data—a model that focuses on the individual and
recognises that the various aspects of a person’s life interact, and are influenced by,
their own specific circumstances. For example, a person’s health outcomes are affected
by multiple influences, including their genetic make-up; where they live; their housing
and employment; how much they earn; and a multitude of other biological, lifestyle,
socioeconomic, societal and environmental factors.
Privacy, security and current protections

Governments, organisations and individuals now have unprecedented access to a
growing volume of digital data. The ever-increasing delivery of faster, high-quality,
useable information comes with the obligation that public data are held securely, and that
individual privacy is protected. The Productivity Commission’s Inquiry on data availability
Chapter 2
and use suggests that, on the whole, people are willing to make their information available,
but this willingness is conditional. The public needs to trust how data are handled; they
also need to feel that they have some control over how they will be used and who will
use them, and to see (and ideally directly benefit from) the potential value of this use
(Productivity Commission 2017).
A 2017 survey showed that 93% of Australians support using medical records for research.
As well, more than 95% of survey respondents had moderate, high or very high trust that
researchers would use health data responsibly (Research Australia 2017).
Australia has many legislative arrangements to protect individual privacy. These protections
ensure that the privacy of individuals is respected, while ensuring that data are available to
use for public benefit, particularly in health research. The Privacy Act 1988 (Cwlth) recognises
that it is often impractical or impossible for researchers to obtain people’s consent for the
use of their data in specific research projects. As such, a set of guidelines produced by the
Privacy Commissioner must be followed by any researcher approved to use health data
without patient consent. These guidelines also assist human research ethics committees in
deciding whether research projects should be approved (OAIC n.d.).
Commonwealth Integrating Authorities adhere to strict protections and data standards
when creating linked data sets. At the AIHW, an Ethics Committee reviews each linkage
project to ensure that it complies with applicable legislation and individual privacy
guidelines. As well, many research data sets are adjusted before release to researchers
to reduce the risk of disclosure of personal information. These adjustment processes can
include de-identification, where information that would identify individuals is removed to
protect an individual’s privacy.
75
Further privacy protection is ensured by adhering to the ‘separation principle’. This
principle, which is embedded in the processes of all integrating authorities, requires that
directly identifiable information (for example, names, addresses) and content data (for
example, instances of services used) are kept separately. This means that the people able
to identify subjects of the data are not able to learn any information about them, further
minimising any risk to people’s privacy.
Other codes and guidelines ensure research integrity and the protection of privacy.
The Australian Code for the Responsible Conduct of Research provides a framework for
institutions engaged in research to develop appropriate procedures and codes of conduct
(NHMRC 2016). The National Statement on Ethical Conduct in Human Research contains
guidelines used by researchers and ethics committees. These guidelines cover areas such
as ethical review, risk management, patient consent and lines of responsibility (NHMRC 2013).
Where to from here?

Technology—in particular, digital technology—has had a huge impact on data generation,
access and availability. The increasing opportunities for secondary use of data promise
that Australians’ health can be improved through the appropriate use of high-quality,
useable information from new and existing sources. Two of the biggest influences on the
future of secondary use of health data will be the growth in data availability and the trend
towards ‘open data’. These trends come with increased risks to privacy and steps need to
be taken to ensure privacy protections keep pace with technological advances.
More health data available

The increased use of technology in providing health care is one of the biggest drivers
behind the growth in health data. Electronic patient medical records, such as the
Australian Government’s My Health Record, are ‘one of the most visible aspects of the
increasing proliferation of data in health care’ (Stanford Medicine 2017:14). The My Health
Record is a secure online summary that combines health data from multiple sources (see
Chapter 2.4 ‘Digital health’). By the end of 2018, every Australian who has not opted out of
the program will receive their own My Health Record (ADHA 2018).
While the primary use of My Health Record is to store and make available individuals’
medical information, it also provides a rich opportunity for secondary use of data. At
the time of writing, there have been no secondary uses of these data. However, the
Framework to guide the secondary use of My Health Record system data was released
and the AIHW was appointed to manage and release My Health Record data for secondary
purposes (Department of Health 2018).
Further to this, the all-encompassing presence of technology in our daily lives—wearing
pedometers and heart rate monitors on our wrists, and tracking our exercise from
smartphones—means that the potential for data provision and use is expanding rapidly.
The share of global health data taken up by connected devices is expected to more than
double between 2016 and 2020 (EMC 2014). Patient monitors and video cameras are
examples of these connected devices—they are components of the so-called ‘Internet of
Things’. The data generated by these devices offer a rich opportunity for secondary uses.
76
Open data
As more data become available, greater access—particularly to person-centred data—will
continue to unlock added value from these data assets. Open data are used to describe
data sources that have little to no restrictions on their access and use. However, due to
the sensitivity and personal nature of many types of health data, most individual-level
health data will not be open and must be treated with appropriate respect for an
individual’s privacy. In practice, there are still many open data sources relevant to health
research; for example, data bases on the weather are relevant to researching seasonal
illnesses such as influenza.
There has been a push for increasing access to government data and the availability
of open data resources. Technological developments can enable personal health
information, such as that collected by mobile devices, to be combined with open data
sources to provide more relevant real-time data to users, practitioners and researchers.
Where health data sources are not classified as open data, de-identified views and
extracts may be prepared to be compatible with a wider variety of future uses.
Chapter 2
Challenges ahead
The opportunities presented by the increasing availability and scope of health data
are enormous, but there are also challenges. As this article has stated, one of the main
challenges is how to ensure that potential gains of data sharing and secondary use do not
impinge on the privacy of individuals.
The variety of different types of information poses a challenge when it comes to the use
of the data. Secondary use of administrative and other data sets can be very insightful,
given their reach and scope, but these data also have limitations. Examples of limitations
can include poor documentation, small numbers of data items, and uncertainty about the
quality of information (Jorm 2015). Assuring that health data collections are inter-operable
ensures that the technical challenges inherent in using research data are minimised, and
that the promise of secondary data use can be realised.

While the potential benefit from secondary use of health information is great, it is
dependent on an understanding of the health information landscape. This requires
knowledge of what health data are currently collected, where gaps and overlaps exist
and the priority areas for researchers and policy makers. There is currently no holistic
approach to implementing a national health information strategy. A coordinated,
strategic approach to identify gaps, overlaps and priorities would further enhance the
use of national health data assets.

More information on AIHW, what we do, our privacy policy and our data governance
is available at <www.aihw.gov.au/about-us>.
The Framework to guide the secondary use My Health Record system data is available at
<www.health.gov.au/internet/main/publishing.nsf/Content/eHealth-framework>.
77
References
ABS (Australian Bureau of Statistics) 2016. Household use of information technology, Australia, 2014–15.
ABS cat. no. 8146.0. Canberra: ABS. Viewed 29 January 2018, <http://www.abs.gov.au/AUSSTATS/[email protected]/
Lookup/8146.0Main+Features12014-15?OpenDocument>.
ADHA (Australian Digital Health Agency) 2018. Welcome to My Health Record. Canberra: ADHA.
Viewed 29 January 2018, <https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/content/home>.
AIHW (Australian Institute of Health and Welfare) 2017a. Approved AIHW linkage projects. Canberra: AIHW.
Viewed 29 January 2018, <https://www.aihw.gov.au/our-services/data-linkage/approved-aihw-linkage-
projects>.
AIHW 2017b. Incidence of suicide among serving and ex-serving Australian Defence Force personnel
2001–2015: in brief summary report. Cat. no. PHE 213. Canberra: AIHW.
Beckmann KR, Bennett A, Young GP & Roder DM 2014. Treatment patterns among colorectal cancer
patients in South Australia: a demonstration of the utility of population-based data linkage. Journal of
Evaluation in Clinical Practice 20:467–77.
Brown J 2015. Using social media data to identify outbreaks and control disease. Folsom, CA: Government
Technology. Viewed 29 January 2018, <http://www.govtech.com/data/Using-Social-Media-Data-to-Identify-
Outbreaks-and-Control-Disease.html>.
Department of Health 2018. Framework to guide the secondary use of My Health Record system data,
May 2018. Canberra: Department of Health.
EMC Corporation 2014. The digital universe: driving data growth in healthcare. EMC Corporation. Viewed
29 January 2018, <https://www.emc.com/analyst-report/digital-universe-healthcare-vertical-report-ar.pdf>.
Jorm L 2015. Routinely collected data as a strategic resource for research: priorities for methods and
workforce. Public Health Research and Practice 25(4).
Kaiser DW, Harrington RA & Turakhia MP 2016. Wearable fitness trackers and heart disease. JAMA
Cardiology 1(2):239.
NHMRC (National Health and Medical Research Council) 2013. Summary of national statement content.
Canberra: NHMRC. Viewed 28 January 2018, <https://www.nhmrc.gov.au/research/responsible-conduct-
research/summary-national-statement-content>.
NHMRC 2016. Australian code for the responsible conduct of research. Canberra: NHMRC. Viewed
28 January 2018, <https://www.nhmrc.gov.au/guidelines-publications/r39>.
NSS (National Statistical Service) 2014. Accredited integrating authorities. Canberra: NSS. Viewed
28 January 2018, <http://www.nss.gov.au/nss/home.nsf/pages
/Data%20Integration:%20Accredited%20Integrating%20Authorities>.
OAIC (Office of the Australian Information Commissioner) n.d. Health information and medical research.
Canberra: OAIC. Viewed 28 January 2018, <https://www.oaic.gov.au/privacy-law/privacy-act/health-and-
medical-research>.
Productivity Commission 2017. Data availability and use. Report no. 82, Canberra: Productivity Commission.
Research Australia 2017. Australia speaks! Research Australia 2017 public opinion polling. Darlinghurst:
Research Australia. Viewed 29 January 2018,
<https://researchaustralia.org/wp-content/uploads/2017/08/2017-Opinion-Poll-Digital.pdf>.
Stanford Medicine 2017. Harnessing the power of data in health. Viewed 28 January 2018,
<https://med.stanford.edu/content/dam/sm/sm-news/documents
/StanfordMedicineHealthTrendsWhitePaper2017.pdf>.
78
This page left intentionally blank
Chapter 2
79
80
Chapter 3
Causes of ill health
81
3.0 Overview
Most Australians are affected by ill health at some point in their life. For some, the effects
of the illness or injury will be short term; for others, they can be long lasting and have a
severe impact on their quality of life. This chapter provides information on the leading
causes of ill health in Australia, including cancer, cardiovascular disease mental health
conditions and musculoskeletal conditions. It also features specific diseases and injuries
that are important for subsets of the population: mesothelioma; eating disorders; family,
domestic and sexual violence; opioid harm; and communicable diseases. This overview
highlights some, but not all, causes of ill health presented in this chapter.
Burden of disease analysis is one way to measure the impact of different diseases or
injuries on a population. It combines the burden of living with ill health and the burden
of dying prematurely. For all ages combined, the leading cause of total disease burden
in Australia in 2011 was coronary heart disease, followed by lung cancer for males and
other musculoskeletal conditions for females. The leading causes differ across age groups,
reflecting that people experience different health problems at different stages of their
life. For example, for children aged 5–14, the top 3 causes of total disease burden were
asthma, anxiety disorders and depressive disorders; for Australians aged 85–94, they were
coronary heart disease, dementia and stroke.
Cause of death information is another way to identify leading causes of ill health in a
population. In 2016, coronary heart disease was the leading cause of death in Australia
for males, and dementia and Alzheimer disease for females. The leading causes of death
also differ across age groups. In general, external causes such as land transport accidents,
suicide and accidental poisoning are more prominent among people aged 15–44, while
chronic conditions are more prominent among people aged 45 and over.
Most illness and deaths in Australia are caused by chronic conditions. Chronic conditions
can place a high burden on individuals, their families and carers, and the health system.
It is estimated that 1 in 2 (50%) Australians have at least one of 8 selected common
chronic conditions: arthritis, asthma, back pain and problems, cancer, cardiovascular
disease, chronic obstructive pulmonary disease, diabetes, and mental health conditions.
Collectively, these conditions accounted for 61% of the total disease burden in 2011 and
contributed to 87% of deaths in 2015.
Cancer is a diverse group of several hundred diseases; collectively, cancer is the greatest
cause of disease burden in Australia, accounting for around one-fifth (19%) of the total
disease burden. It is estimated that about 380 people will be diagnosed with cancer and
133 people will die from cancer every day this year—that is about 138,300 new cases and
48,600 deaths in 2018. The most commonly diagnosed cancers in 2018 will be prostate
cancer for males and breast cancer for females. Mesothelioma has the lowest 5-year
relative survival of all cancer types at 6.4%. The main cause of mesothelioma is exposure
to asbestos, and Australia has one of the highest rates of mesothelioma incidence in
the world.
82
Coronary heart disease is the leading specific cause of total burden of disease in
Australia, accounting for 7.7% of the total disease burden. It affects about 1 in 30 adults
(3.3%, 645,000 people), and 1 in 6 people aged 75 and over. Every day in Australia, about
170 people aged 25 and over experience an acute coronary event (a heart attack or
unstable angina).
Diabetes is an area of health concern for Australia. Prevalence of the disease has tripled
over the last 25 years, and 6.1% of the adult population (1.2 million people) self-report
having diabetes. Death rates for people with diabetes are almost double those for the
general Australian population.
Two common chronic conditions are musculoskeletal conditions and chronic respiratory
conditions—each of which affects around 1 in 3 Australians. Nearly 6.9 million Australians
have musculoskeletal conditions such as arthritis, back pain and osteoporosis and about
7 million Australians are affected by chronic respiratory conditions such as hay fever
and asthma.
Almost half (45%) of Australians 16–85 will experience a mental disorder such as
depression, anxiety or substance use disorder at some stage in their life; an estimated
20% of adult population and 14% of children and young people experienced a mental
health disorder in the past 12 months. Eating disorders are a group of mental illness
which affect anywhere from 4–16% of the population. Eating disorders were the 10th
leading cause of non-fatal disease burden for females aged 15–44 years in 2011, and
are of particular concern for younger females.
Chapter 3
Dementia is a growing challenge for Australia as the population ages and life expectancy
increases. In 2018, 376,000 Australians will have dementia and 61% of people with
dementia will be female. In 2016, dementia replaced heart disease as the leading
underlying cause of death for females and remained the third leading cause of death
for males.
Family, domestic and sexual violence causes more illness, disability and premature death
for women aged 25–44 than any other risk factor. Exposure to intimate partner violence is
linked to depressive and anxiety disorders, early pregnancy loss, homicide and violence,
suicide and self-inflicted injuries, alcohol use disorders, and children born prematurely or
with low birthweight. One in 6 (17%, or 1.6 million) Australian women have experienced
physical or sexual violence by a current or former cohabiting partner, since the age of 15.
Serious cases can end in hospitalisation or death.
The use and misuse of opioid drugs can result in overdose and physical harm. Australian
statistics show recent increases in opioid-related poisonings, overdoses and deaths—
between 2007 and 2016, there was an 89% increase in drug-induced deaths involving
opioids, and between 2011–12 and 2015–16, opioid-related hospitalisations increased
by 12%.
83
3.1 Burden of disease across
SNAPSHOT
the life stages

People experience different health problems at different times of their lives—from infancy
and childhood through to old age. Hence, they have different health needs at different
life stages. This snapshot presents the leading causes of total burden at each life stage.
Life stages are broadly divided into infants, children and young people (aged 0–24),
working-age adults (aged 25–74) and older people (aged 75 and over).
Burden of disease analysis is useful to measure the impact of different diseases or injuries
on a population. It combines the burden of living with ill health (non-fatal burden) with
the burden of dying prematurely (fatal burden). See Box 4.4.1 in Chapter 4.4
‘Contribution of selected risk factors to burden of disease’ for an explanation of burden
of disease analysis.
Disability-adjusted life years (DALYs) is a summary measure of disease burden. One DALY
is 1 year of ‘healthy life’ lost due to illness and/or death—the more DALYs associated with
a disease or injury, the greater the burden of that disease.
In 2011, 4.5 million DALYs were lost due to illness or premature death.
For all ages combined, the leading cause of total burden was coronary heart disease,
at 7.7% of total burden, followed by lung cancer for males and other musculoskeletal
conditions for females (Figure 3.1.1).
Figure 3.1.1: Leading causes of total burden, by sex, 2011
1st 2nd 3rd 4th 5th

Other Suicide and
Coronary heart Lung cancer Back pain and
Males musculoskeletal self-inflicted
disease (9.4%) (3.9%) problems (3.4%)
(3.6%) injuries (3.5%)
Other
Coronary heart Anxiety disorders Back pain and
Females musculoskeletal Dementia (4.6%)
disease (5.8%) (4.1%) problems (3.9%)
(4.6%)
Other
Coronary heart Back pain and Lung cancer
Persons musculoskeletal COPD (3.6%)
disease (7.7%) problems (3.6%) (3.4%)
(4.1%)
 Cancer  Cardiovascular  Respiratory  Injuries  Neurological  Mental  Musculoskeletal
COPD = chronic obstructive pulmonary disease.

Source: Australian Burden of Disease Study 2011; Table S3.1.1.
84
Infants, children and young people
(aged 0–24)
Infant and congenital conditions accounted for most of the burden in children aged
under 5; the 5 leading causes of burden in this age group were all from this disease group
(Figure 3.1.2). Nearly three-quarters (72%) of the total burden in this age group were
experienced by infants. Among children aged 1–4, other mental disorders (for example,
sleep disorders and separation anxiety), asthma and other gastrointestinal infections were
the causes contributing the most burden.
Among children aged 5–14, asthma was the leading cause of burden, closely followed by
anxiety disorders (Figure 3.1.2). The 5 leading causes of burden in this age group were
either mental and substance abuse disorders or respiratory diseases. While asthma and
anxiety disorders were the leading 2 causes of burden among boys aged 5–14, this order
was reversed among girls in this age group (Supplementary Table S3.1.1). Dental caries
also featured in the 10 leading causes of burden among children aged 5–14, reflecting the
importance of oral and dental health.
Suicide and self-inflicted injuries and anxiety disorders were the leading causes of
burden in young people aged 15–24 (Figure 3.1.2). Among young males, suicide and
self-inflicted injuries was the leading cause of burden, followed by alcohol use disorders
(Supplementary Table S3.1.1). Among young females, anxiety and depressive disorders
Chapter 3
were the leading 2 causes of burden.
Figure 3.1.2: Leading causes of total burden among people aged 0–24, by age, 2011
Age group 1st 2nd 3rd 4th 5th

Preterm birth
and low Birth trauma Sudden infant Other congenital
Other disorders
Under 5 birthweight and asphyxia death syndrome conditions
complications of infancy (7.2%)
(12%) (6.3%) (5.5%)
(16%)
Upper
Anxiety Depressive Conduct respiratory
5–14 Asthma (11%)
disorders (10%) disorders (7.0%) disorder (5.8%) conditions
(5.5%)
Suicide and
Anxiety Depressive Alcohol use
15–24 self-inflicted Asthma (5.4%)
disorders (7.5%) disorders (6.8%) disorders (5.6%)
injuries (8.4%)
 Infant/congenital  Respiratory  Mental  Injuries
85
Working-age adults (aged 25–74)
Young working-age adults (25–44) experience anxiety disorders as the leading cause of
burden, with back pain and problems a close second (Figure 3.1.3). While suicide and
self-inflicted injuries is ranked third among leading causes of burden in this age group,
it continues to be the leading cause among men aged 25–44 (Supplementary Table S3.1.1).
Coronary heart disease is the leading cause of burden in adults aged 45–64 and
persists as the leading cause for all but the oldest age group (figures 3.1.3, 3.1.4). Other
musculoskeletal conditions and back pain and problems round out the top 3 causes of
burden in this age group. Coronary heart disease is a far greater health problem for men
in this age group than for women: men experienced nearly 4 times the burden due to
this disease (76,900 DALYs for men compared with 19,500 DALYs for women). The leading
cause of disease burden for women aged 45–64 was other musculoskeletal conditions,
followed by breast cancer (Supplementary Table S3.1.1).
The older working-age population (aged 65–74) experienced an increasing burden from
coronary heart disease (Figure 3.1.3). Chronic conditions such as lung cancer, chronic
obstructive pulmonary disease (COPD) and other musculoskeletal conditions made up
the top 5.
Figure 3.1.3: Leading causes of total burden among people aged 25–74,
by age, 2011
Anxiety Suicide and Other

Back pain and Depressive
25–44 disorders self-inflicted musculoskeletal
problems (6.5%) disorders (6.3%)
(6.7%) injuries (6.4%) (4.7%)
Coronary Other Back pain

Lung cancer Anxiety
45–64 heart disease musculoskeletal and problems
(4.8%) disorders (3.4%)
(7.5%) (5.7%) (5.0%)
Coronary Other
Lung cancer
65–74 heart disease COPD (6.4%) musculoskeletal Diabetes (3.6%)
(6.9%)
(10%) (4.5%)
 Cancer  Cardiovascular  Respiratory  Mental  Endocrine  Musculoskeletal  Injuries

86
Older people (aged 75 and over)
The burden from coronary heart disease was highest among older people aged 75–84
(88,050 DALYs; Figure 3.1.4). Dementia was the second leading cause of burden, followed
by COPD, stroke and lung cancer. These diseases are also the 5 leading causes of death in
Australia (see Chapter 3.2 ‘Leading causes of death’).
Dementia is more prominent among older people aged 85–94 (Figure 3.1.4). While
coronary heart disease is the leading cause of burden in this age group, dementia is a close
second, and is the leading cause among women aged 85–94 (Supplementary Table S3.1.1).
Stroke is the third leading cause of burden in this age group, among both men and women.
The leading causes of burden among very old people (aged 95 and over) includes chronic
conditions (dementia, coronary heart disease and stroke; Figure 3.1.4). The top 5 also include
infections and injuries, which can be more hazardous to a person’s health in older age.
Figure 3.1.4: Leading causes of total burden among people aged 75 and over,
by age, 2011

Coronary
Dementia Lung cancer
75–84 heart disease COPD (6.8%) Stroke (6.1%)
(7.7%) (4.5%)
(13%)
Chapter 3
Coronary
85–94 heart disease Dementia (15%) Stroke (8.6%) COPD (4.9%) Diabetes (2.7%)
(17%)
Lower
Dementia Coronary heart respiratory
95+ Stroke (9.2%)
infections
Falls (2.8%)
(21%) disease (19%)
(3.1%)
 Infections  Cancer  Cardiovascular  Respiratory  Neurological  Endocrine  Injuries


The Australian Burden of Disease Study 2011 is based on the best available data, and
applies methods suited to the Australian context. Yet, there are some limitations to
burden of disease analysis, including methods and available data. See Australian Burden
of Disease Study: impact and causes of illness and death in Australia 2011 for a more detailed
discussion of these limitations.

More information on the Australian Burden of Disease Study is available at <www.aihw.
gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-disease/overview>.
The report Australian Burden of Disease Study: impact and causes of illness and death in
Australia 2011 and other recent releases are available for free download.
87
3.2 Leading causes of death
SNAPSHOT
Leading causes of death is a useful measure of population health. It is of most value when
making comparisons over time or between population groups. Changes in the pattern of
causes of death can result from changes in behaviours, exposures to disease or injury, and
social and environmental circumstances, as well as from data coding practices (Box 3.2.1).
Box 3.2.1: Deaths data

Causes of death are documented on death certificates by medical practitioners or
coroners, and coded by the Australian Bureau of Statistics using the World Health
Organization International Statistical Classification of Diseases and Related Health
Problems (ICD).
The ICD allows diseases that cause death to be grouped in a way that is meaningful
for monitoring population health. The AIHW uses the disease groups recommended
by the World Health Organization (Becker et al. 2006), with minor modifications to
suit the Australian context.
Leading causes of death presented in this snapshot are based on the ‘underlying
cause of death’, which is the disease or injury that began the train of events leading
to death.
Most deaths, however, result from more than one contributing disease or condition.
Analyses using ‘associated causes of death’ may offer insight into the disease
processes occurring at the end of life or, for injury causes of death, the nature of
the injury.
What are the leading causes of death

in Australia?
There were 158,500 deaths in Australia in 2016 (81,900 males; 76,600 females).
The age-standardised death rate for males was 1.4 times as high as for females
(637 per 100,000 males and 448 per 100,000 females).
Death rates generally increase with increasing age. However, the death rates among
males aged 15–29 are more than twice as high as for females of the same age; specifically,
for men aged 20–24, the death rate is 2.6 times as high as for women of the same age.
The leading cause of death for males was coronary heart disease, accounting for 10,870
(13%) deaths. Dementia and Alzheimer disease was the leading cause of death for
females, accounting for 8,447 (11%) deaths, closely followed by coronary heart disease
(8,207; 11% of deaths). Cerebrovascular disease (which includes stroke), lung cancer
and chronic obstructive pulmonary disease (COPD) make up the top 5 leading underlying
causes of death in Australia in 2016 for males and females of all ages combined
(Figure 3.2.1).
88
Males account for more deaths due to coronary heart disease, lung cancer and COPD.
Females account for the majority of deaths due to cerebrovascular disease and dementia
and Alzheimer disease.
Figure 3.2.1 Leading causes of death, by sex, 2016
1 Coronary heart disease 10,870 8,207
2 Dementia and Alzheimer disease 4,679 8,447
3 Cerebrovascular disease 4,239 6,212
4 Lung cancer 5,023 3,387
5 Chronic obstructive pulmonary disease 3,903 3,309
Note: Leading causes of death are based on underlying causes of death and classified using an AIHW-modified
Chapter 3
version of Becker et al. 2006.
Source: National Mortality Database; Table S3.2.1.
Leading causes of death by age

As well as differences by sex, the leading causes of death also vary by age. Chronic
conditions feature more prominently among people aged 45 and over, while the leading
causes of death among people aged 1–44 are external causes, such as accidents and
suicides (Figure 3.2.2).
Among infants, perinatal and congenital conditions caused most deaths (77% of deaths).
Land transport accidents were the most common cause of death among children aged
1–14 (12%). Suicide was the leading cause of death among people aged 15–24 (34%),
followed by land transport accidents (21%). For people aged 25–44, it was also suicide
(21%), followed by accidental poisoning (12%).
Coronary heart disease was the leading cause of death for people aged 45–64, followed
by lung cancer. For people aged 65–74, it was also lung cancer followed by coronary heart
disease. Dementia and Alzheimer disease was the second leading cause of death among
people aged 75 and over, behind coronary heart disease.
89
Figure 3.2.2: Leading causes of death, by age group, 2014–2016

Perinatal and Accidental
Other ill-defined Spinal muscular
Under 1 congenital SIDS threats to
causes atrophy
conditions breathing
Perinatal and Accidental
Land transport Other ill-defined
1–14 congenital drowning and Brain cancer
accidents causes
conditions submersion
Land transport Accidental Other ill-defined

15–24 Suicide Assault
accidents poisoning causes
Accidental Land transport Coronary heart Other ill-defined

25–44 Suicide
poisoning accidents disease causes
Coronary heart Colorectal

45–64 Lung cancer Suicide Breast cancer
disease cancer
Coronary heart Cerebrovascular Colorectal

65–74 Lung cancer COPD
disease disease cancer
75 and Dementia and

Coronary heart Cerebrovascular
Alzheimer COPD Lung cancer
over disease disease
disease
SIDS = sudden infant death syndrome.

Note: ‘Other ill-defined causes’ include the following codes: Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified (ICD-10 codes R00–R99, excluding R95: SIDS; Cardiac arrest,
unspecified (I46.9); Respiratory failure of newborn (P28.5); Other unspecified convulsions (R56.8). AIHW
General Record of Incidence of Mortality (GRIM) books are available for selected leading causes of death.
Have leading causes of death changed

over time?
In Australia, mortality rates have continued to decline since at least the early 1900s.
The age-standardised death rate fell by 69% between 1910 and 2015 for males, and by
73% for females. The leading causes of death in the early 1900s were diseases of the
circulatory system.
The 10 leading causes of death in 2016 were generally the same as in 2006, albeit with
different rankings (Figure 3.2.3).
• F
or males, coronary heart disease was the leading cause of death in both these years,
accounting for 18% of deaths in 2006 and 13% in 2016. Though it was the leading cause
of death in both years, the death rate from coronary heart disease fell substantially
over the decade. The largest change in leading causes of death for males from 2006
to 2016 was the rise of dementia and Alzheimer disease, from seventh to third place.
Diabetes and suicide also rose in rank over this period.
• F
or females, coronary heart disease, cerebrovascular disease, breast cancer and
heart failure fell in rank from 2006 to 2016. On the other hand, there were notable
90
increases—for dementia and Alzheimer disease (from third to first place) and for COPD
(from sixth to fifth place). Cancer of unknown or ill-defined primary site moved out of
the 10 leading causes of death for females in 2006 and was replaced by influenza and
pneumonia in 2016.
Figure 3.2.3: Leading causes of death, by sex, 2006 and 2016
2006 2016
Rank Male deaths (%) Leading causes of death, males, 2006 Leading causes of death, males, 2016 Male deaths (%)
RankRank Male
Maledeaths
deaths (%)
(%) Leading causes
Leading causesof death, males,
of death, 2006
males Leading causes
Leading causesof of
death, males,
death, 2016
males Male
Male deaths
deaths (%)(%)
1 17.9 Coronary heart disease Coronary heart disease 13.3
1 1 17.9
17.9 Coronary heart disease Coronary heart disease 13.3
13.3
2 6.8 Lung cancer Lung cancer 6.1
2 2 6.8
6.8 Lung cancer Lung cancer 6.16.1
3 6.5 Cerebrovascular disease Dementia and Alzheimer disease 5.7
3 3 6.5
6.5 Cerebrovascular disease Dementia and Alzheimer disease 5.75.7
4 4.3 Prostate cancer Cerebrovascular disease 5.2
4 4 4.3
4.3 Prostate cancer Cerebrovascular disease 5.25.2
5 4.0 COPD COPD 4.8
5 5 4.0
4.0 COPD COPD 4.84.8
6 3.1 Colorectal cancer Prostate cancer 4.0
6 6 3.1
3.1 Colorectal cancer Prostate cancer 4.04.0
7 3.0 Dementia and Alzheimer disease Diabetes 3.1
7 7 3.0
3.0 Dementia and Alzheimer disease Diabetes 3.13.1
8 2.9 Cancer of unknown or ill-defined primary site Colorectal cancer 3.0
8 8 2.9
2.9 Cancer of unknown or ill-defined primary site Colorectal cancer 3.03.0
9 2.7 Diabetes Suicide 2.6
9 9 2.7
2.7 Diabetes Suicide 2.62.6
10 2.4 Suicide Cancer of unknown or ill-defined primary site 2.5
10 10 2.4
2.4 Suicide Cancer of unknown or ill-defined primary site 2.52.5
RankRankFemale
Femaledeaths
deaths (%) Leading
Leadingcauses of death,
causes females,
of death, 2006
females Leading causes
Leading causesof of
death, females,
death, 2016
females Female
Female deaths
deaths (%)(%)
Rank Female deaths (%) Leading causes of death, females, 2006 Leading causes of death, females, 2016 Female deaths (%)
1 1 16.6
16.6 Coronary heart disease Dementia and Alzheimer disease 11.0
11.0
1 16.6 Coronary heart disease Dementia and Alzheimer disease 11.0
2 2 10.7
10.7 Cerebrovascular disease Coronary heart disease 10.7
10.7
2 10.7 Cerebrovascular disease Coronary heart disease 10.7
3 3 6.9
6.9 Dementia and Alzheimer disease Cerebrovascular disease 8.18.1
3 6.9 Dementia and Alzheimer disease Cerebrovascular disease 8.1
4 4 4.1
4.1 Lung cancer Lung cancer 4.44.4
4 4.1 Lung cancer Lung cancer 4.4
5 5 4.0
4.0 Breast cancer COPD 4.34.3
5 4.0 Breast cancer COPD 4.3
6 6 3.2
3.2 COPD Breast cancer 3.93.9
6 3.2 COPD Breast cancer 3.9
Chapter 3
7 7 2.9
2.9 Cancer of unknown or ill-defined primary site Diabetes 2.92.9
7 2.9 Cancer of unknown or ill-defined primary site Diabetes 2.9
8 8 2.8
2.8 Diabetes Colorectal cancer 2.62.6
8 2.8 Diabetes Colorectal cancer 2.6
9 9 2.7
2.7 Heart failure Influenza and pneumonia 2.52.5
9 2.7 Heart failure Influenza and pneumonia 2.5
10 10 2.6
2.6 Colorectal cancer Heart failure 2.52.5
10 2.6 Colorectal cancer Heart failure 2.5
Notes
1. R
ankings are based on the number of deaths; a decline in rank does not necessarily mean a decline in
the number of deaths.
2. D
ata for 2016 are based on the preliminary version of cause of death data and are subject to further
revision by the Australian Bureau of Statistics.
3. C
oloured lines link the leading causes of death in 2006 with those in 2016: a blue line means that the
ranking of the cause of death remained the same in 2016 as in 2006; a green line, that the ranking of the
cause of death rose compared with that in 2006; and a red line, that the ranking of the cause of death in
2016 decreased compared with that in 2006.
Do the leading causes of death vary

among population groups?
Leading causes of death differ among population groups. This may be driven by variations
in the population characteristics, causes of death at different ages, the prevalence of
illness and risk factors, and access to health services. For example, mortality rates in
Remote and Very remote areas are higher than in Major cities. These disparities can be
amplified by higher rates of illness among Aboriginal and Torres Strait Islander people,
who make up a greater proportion of the population in more remote areas.
91
Indigenous Australians
• In 2012–2016, the 5 leading causes of death for Indigenous Australians were coronary
heart disease, diabetes, COPD, lung cancer and suicide.
• F
or Indigenous Australians, the age-standardised mortality rate for diabetes was
almost 6 times as high as for non-Indigenous Australians (64 compared with
11 deaths per 100,000 population). For COPD, it was 3 times as high (52 compared with
17 deaths per 100,000).
Remoteness areas
• C
oronary heart disease was the leading cause of death across all areas (cities, regional
and remote areas) in 2011–2015; in Very remote areas, the age-standardised mortality
rate was 1.7 times as high as in Major cities.
• D
iabetes was the second leading cause of death in Very remote areas and the seventh
in Major cities—the age-standardised mortality rate was almost 4 times as high in
Very remote areas as in Major cities.
Socioeconomic areas
• T
he five leading causes of death (see Figure 3.2.1) were common in all five
socioeconomic areas in 2011–2015.
• F
or people living in the lowest socioeconomic area, age-standardised mortality rates
for diabetes, COPD, lung cancer and suicide were about twice as high as for people
living in the highest socioeconomic area.
Mortality data for 2016 by remoteness area and socioeconomic area were not available
at the time of writing.

• S
ocioeconomic factors such as highest level of education achieved and main occupation
are known to be associated with mortality and particular causes of death. These
individual measures are not collected in Australian deaths data. However, analysis of
such factors is possible with linked health data.
• D
eaths information is not the only measure of impact of disease in a population.
Burden of disease analyses, for example, measure both the impact of living with
disease and injury and dying prematurely (see Chapter 3.1 ‘Burden of disease across
the life stages’).
92
More information on deaths and leading causes of death in Australia—including the
General Incidence of Mortality (GRIM) books and Mortality Over Regions and Time
(MORT) books—is available on the AIHW website at <www.aihw.gov.au/reports-statistics/
health-conditions-disability-deaths/life-expectancy-deaths/overview>.
The annual Australian Bureau of Statistics publications Deaths, Australia, 2016 (ABS 2017b)
and Causes of death, Australia, 2016 (ABS 2017a) also provide the latest information on
mortality in Australia.
Data visualisation on the burden of disease provides data on the years of life lost and
number of deaths by diseases and is available at <www.aihw.gov.au/reports-statistics/
health-conditions-disability-deaths/burden-of-disease/overview>.
References
ABS (Australian Bureau of Statistics) 2017a. Causes of death, Australia, 2016. ABS cat no. 3303.0.
Canberra: ABS.
ABS 2017b. Deaths, Australia, 2016. ABS cat no. 3302.0. Canberra: ABS.
Becker R, Silvi J, Ma Fat D, L’Hours A & Laurenti R 2006. A method for deriving leading causes of death.
Bulletin of the World Health Organization 84:297–304.
Chapter 3
93
3.3 Chronic conditions
FEATURE ARTICLE
Chronic conditions are a substantial global, national and individual health issue,
contributing to both premature mortality and morbidity. Globally, they are leading causes
of disease burden, responsible for around 70% of deaths worldwide (WHO 2017a).
Nationally, rates of chronic conditions and their associated risk factors are increasing; this
has a heavy impact on the Australian health care system. At an individual level, Australians
diagnosed with one or more chronic conditions often have complex health needs, die
prematurely and have poorer overall quality of life.

Chronic conditions are generally long-lasting and, given Australia’s ageing population, their
treatment and management are needed for longer periods of an individual’s life.
The term ‘chronic condition’ refers to a wide range of conditions, illnesses and diseases,
which are detailed in Box 3.3.1.
Box 3.3.1: Definitions for chronic conditions

Defining chronic conditions is complex as the term covers a number of broad health
and disease and management concepts.
Chronic conditions are generally characterised by their long-lasting and
persistent effects. Once present, they often persist throughout a person’s life, so
there is generally a need for long-term management by individuals and health
professionals. They are also called non-communicable diseases or long-term
conditions and are referred to as such in data sources cited in this article.
The most common chronic conditions include cardiovascular disease (such as
coronary heart disease and stroke), cancer (such as breast and colorectal cancer),
chronic respiratory conditions (such as chronic obstructive pulmonary disease
and asthma), chronic musculoskeletal conditions (such as arthritis and back pain),
diabetes, and mental health conditions (such as depression). Based on self-reported
survey data, almost 1 in 5 (18%) Australians had cardiovascular disease, 18%
had mental health conditions and 16% had back pain and problems in 2014–15.
Prevalence of chronic conditions also varied by age—mental health conditions and
asthma were more common in people aged under 45, while cardiovascular disease
and arthritis were more common in older age groups (ABS 2015).
In the broadest sense, chronic conditions include infectious diseases that persist
in the long term (sometimes for life), such as chronic hepatitis B and human
immunodeficiency virus (HIV), congenital disorders such as spina bifida, genetic
disorders such as cystic fibrosis and other conditions, and disorders or disability
stemming from injury such as limb amputation.
Chronic condition comorbidity (or multimorbidity) is the presence of two or more
chronic conditions at the same time. Around 1 in 4 (23%) Australians had two or
more chronic conditions in 2014–15 (ABS 2015). Comorbidity was the focus of a
feature article in Australia’s health 2016, based largely on data from the Australian
Bureau of Statistics 2014–15 National Health Survey; it is a good baseline reference
for this subject (see section ‘Where do I go for more information?’).
94
This article summarises the increasing global, Australian and individual burden of chronic
conditions, describes interventions aiming to combat this trend and provides the context
for condition-specific information presented elsewhere in this chapter.
Global picture and trends

Non-communicable (chronic) disease is a global health problem. The burden of chronic
disease exceeds that of communicable (infectious) disease and deaths from chronic
disease disproportionately affect lower income countries and populations, threatening
sustainable development (WHO 2017a, 2017b).
Disease burden or impact can be measured by the disability-adjusted life year (DALY),
equivalent to a single year of ‘healthy’ life lost due to illness and/or death (see
Chapter 4.4 ‘Contribution of selected risk factors to burden of disease’). Data from the
Global Burden of Disease Study 2016 show that the share of the total global DALYs due
to non-communicable disease has:
• increased steadily globally (from 44% in 1990 to 61% in 2016), while the proportion
attributable to communicable (infectious) disease fell (from 34% to 21%)
• r emained steady in Australia at around 84–88% (compared with 2.2–2.4% for
communicable disease and 8.8–11% for injury) (Figure 3.3.1).
In lower income countries, the increase in the relative burden from non-communicable
disease and the decrease in communicable disease burden is occurring more rapidly
Chapter 3
than in high-income countries (including Australia). While this shift in the distribution of
the disease burden toward non-communicable disease is seen globally, there are some
regions where communicable disease is still a major health issue.
Figure 3.3.1: Burden of communicable disease, injury, maternal and neonatal

conditions and non-communicable disease, (a) globally and (b) in Australia,
1990, 2000, 2010 and 2016
(a) Maternal and neonatal conditions (b) Maternal and neonatal conditions
Communicable disease Communicable disease
Injury Injury
Non-communicable disease Non-communicable disease
Proportion of DALY (Global) Proportion of DALY (Australia)
100 100
80 80
60 60
40 40
20 20
0 0
1990 2000 2010 2016 1990 2000 2010 2016
Year Year
Source: GBD Collaborative Network 2017; Table S3.3.1.
95
Although the share of total burden due to non-communicable disease is high in Australia,
the rate of that burden has fallen over time—a positive sign. Between 1990 and 2016, the
rate of DALY for non-communicable disease in Australia:
• d
ecreased from more than 21,600 to more than 19,700 DALYs per 100,000 population
• w
as second lowest among selected high-income countries in 1990 (after Canada), and
lowest in 2016 (Figure 3.3.2).
Figure 3.3.2: Rate of non-communicable disease burden, Australia and

selected high-income countries, 1990, 2000, 2010 and 2016
DALY per 100,000 population

Australia Canada
30,000
New Zealand United Kingdom
28,000 United States
26,000
24,000
22,000
20,000
18,000
0
1990 2000 2010 2016
Year
Source: GBD Collaborative Network 2017; Table S3.3.2.
A big problem for Australia

Chronic conditions have a substantial impact in Australia—for the population, the health
system and individuals. Self-reported survey data from 2014–15 reveals that 1 in 2 (50%)
Australians had at least 1 of 8 selected common chronic conditions: arthritis, asthma,
back pain and problems, cancer, cardiovascular disease, chronic obstructive pulmonary
disease (COPD), diabetes, and mental health conditions (ABS 2015). These conditions:
• w
ere involved in 37% of hospitalisations
Hospitalisations Deaths Burden of
(based on principal or additional 2015-16 2016 disease 2011
diagnosis) in 2015–16
• c ontributed to 87% of deaths (based 37% 87% 61%
chronic chronic chronic
on underlying or associated causes conditions conditions conditions
of death) in 2015
• a
ccounted for 61% of the total burden of
disease in Australia in 2011, based on the Australian Burden of Disease Study 2011
(Figure 3.3.3). (Note that estimates from this study are not directly comparable with
those from the Global Burden of Disease Study due to differences in methods and data
sources used for Australia.)
96
Figure 3.3.3: Selected common chronic conditions: hospitalisations (2015–16),
deaths (2016) and burden of disease (DALY; 2011)
Condition
Arthritis 3.3
Asthma 0.5
Back pain and problems 2.4
Cancer 10.2
Cardiovascular disease 10.7

Chronic obstructive
pulmonary disease 1.4
Diabetes 9.9
Mental health conditions 7.9
Other conditions 93.9
Arthritis 2.0
Asthma 1.1
Cancer 33.3

Chronic obstructive
10.2
Chapter 3
pulmonary disease
Diabetes 10.4
Arthritis 3.8
Asthma 2.4
Cancer 18.5

Chronic obstructive 3.6
pulmonary disease
Diabetes 2.3
Notes
1. E
ach hospitalisation and death can involve more than one chronic condition; therefore, the sum of
individual conditions is greater than the chronic condition total.
2. T
he category ‘Other conditions’ encompasses all conditions not listed as selected common chronic conditions
and represents the proportion of hospitalisations or deaths that involve at least one of these ‘Other
conditions’. It is possible for a single hospitalisation or death to involve both chronic and ‘Other
conditions’; hence, the sum of ‘Other conditions’ and the chronic condition total exceeds 100.
3. Includes hospitalisations with the selected conditions recorded as either the principal or an additional diagnosis,
and deaths with the selected conditions recorded as either the underlying or an associated cause of death.
Sources: National Hospital Morbidity Database 2015–16; National Mortality Database 2016; Australian Burden
of Disease Study 2011; Table S3.3.3.
97
The burden of these conditions rests disproportionately with males and older Australians.
Males were slightly more likely than females to be hospitalised with 1 of the selected
8 chronic conditions; at least 1 of those conditions was recorded in 39% of all male
hospitalisations compared with 35% of all female hospitalisations. There was no substantial
sex difference in the proportion of deaths involving chronic conditions in 2016, accounting
for 87% of male and 86% of female deaths in that year.
When the influence of age is considered, the rate of hospitalisation and death from these
conditions was consistently higher among males over time; however, the difference in
rates between the sexes fell slightly (Figure 3.3.4). The rate of hospitalisations for chronic
conditions gradually fell from being 16% higher among males than females in 2006–07 to
10% higher in 2015–16. There was a smaller general decrease in the difference in mortality
rates between the sexes over time: males were 45% more likely than females to die from
chronic conditions in 2007 and 43% more likely in 2016.
Figure 3.3.4: Trends in selected chronic conditions: (a) hospitalisations

(2006–07 to 2015–16) and (b) mortality (2007 to 2016), by sex
(a) (b)
Hospitalisations per 100,000 population Deaths per 100,000 population
18,000 700
16,000
600
14,000
500
12,000
10,000 400
8,000 300
6,000
Males Females Persons 200 Males Females Persons
4,000
100
2,000
0 0
2006–07 2009–10 2012–13 2015 –16 2007 2010 2013 2016
Year Year
Notes
1. Includes hospitalisations with the selected conditions recorded as either the principal or an additional
diagnosis, and deaths with the selected conditions recorded as either the underlying or an associated
cause of death.
2. ‘Selected’ chronic conditions include the 8 common conditions defined in Box 3.3.1.
Source: National Hospital Morbidity Database 2015–16; National Mortality Database 2016; Table S3.3.4.
The proportion of hospitalisations and deaths that involved at least 1 of the selected
8 chronic conditions generally rose as age increased: from less than 10% of hospitalisations
and deaths among children aged 0–4, to 56% of hospitalisations and 87% of deaths
among people aged 85 and over.
While older Australians experience the greatest burden of these chronic conditions,
younger Australians are also affected. Around 3 in 4 (70%) hospitalisations for chronic
conditions and 1 in 3 deaths (33%) occurred among people aged under 75. The proportion
of deaths from chronic conditions of people aged under 75 (known as ‘premature’ deaths)
was higher for males (39%) than for females (26%). There was no change in the proportion
of premature deaths, or the difference between sexes, over time.
98
What could this mean for an individual?
Chronic conditions are so common that most people are affected in some way, either
by having a condition themselves or knowing someone who does.
Many chronic conditions share common risk factors that are largely preventable or
treatable; for example, tobacco smoking, physical inactivity, overweight and obesity,
unhealthy diets and high blood pressure. Preventing or modifying these risk factors
can reduce the risk of developing a chronic condition and result in large population and
individual health gains by reducing illness and rates of death (see Chapter 4).
Many of these risk factors are common to several chronic conditions, and this can mean
an increase in the proportion of people who have more than one of these conditions.
These people are generally more frequent users of the health care system and require
more complex interventions and treatment to manage their conditions.
Beyond the population impact in terms of economic and disease burden, chronic conditions
have a major impact on the individual and their social and support networks in terms of
quality of life, disability, productivity and participation. Based on unadjusted self-reported
data from the 2014–15 National Health Survey—and compared with the total Australian
population—people with at least 1 of the 8 selected long-term conditions had generally
lower labour force participation (24–49%, compared with 52%) and generally higher rates of:
• d
isability, restriction or limitation (32–63% compared with 19%)
Chapter 3
• h
igh or very high psychological distress (17–40% compared with 12%)
• b
odily pain experienced in the previous 4 weeks (78–89% compared with 68%)
• f air or poor health (24–46% compared with 15%) (ABS 2015).
Due to these impacts on the individual, it is important that people with chronic conditions
receive high-quality and coordinated care (taking into account risk factors and
comorbidities) and are actively engaged with their treatment and management plan,
leading to better health outcomes (AHMAC 2017).
What is Australia doing to combat

chronic conditions?
Global initiatives
Australia contributes to several global initiatives for the prevention and management of
chronic conditions. The Global Action Plan for the Prevention and Control of NCDs, 2013–2020
provides countries with a selection of policy options and related goals to work towards
in achieving nine voluntary global targets relating to non-communicable diseases; these
targets include a 25% reduction in premature mortality from cardiovascular disease, cancer,
diabetes or chronic respiratory conditions by the year 2025 (WHO 2013). At a broader level,
the United Nations’ Sustainable Development Goals include those to ensure good health
and wellbeing by reducing premature mortality from non-communicable disease by
one-third by 2030 (UN 2015).
99
National initiatives
The growing prevalence of chronic conditions among Australia’s population, coupled with
a reduction in the death rate from these diseases, is increasing the pressure on the health
care system. As people are living longer, often with more than 1 chronic condition, they
require treatment and management for longer periods of time. This increases the need
for emergency department visits, admitted patient hospital admissions, out-of-hospital
services, medicines and palliative care.
Nationally, there are various programs to promote healthy lifestyles. These include
a range of tobacco control measures, strategies to reduce harmful levels of alcohol

consumption, and actions for the early detection of cancer and other chronic conditions
(see Chapter 7.1 ‘Health promotion’).
Community management of care for chronic conditions is primarily provided by general
practitioners. Around 1 in 3 (35%) health problems managed by general practitioners was
chronic in 2015–16 (Britt et al. 2016). With the aim of improving coordination of care for
people with chronic conditions, the Australian Government has implemented a range of
approaches including:
• a
ccess to care plans and assessments through the Medicare Benefits Schedule for the
planning and management of chronic conditions
• s ubsidies through the Pharmaceutical Benefits Scheme for a range of medicines used in
the treatment of chronic conditions
• introduction of Health Care Homes where patients are enrolled with a specific general
practice or Aboriginal Community Controlled Health Service to coordinate their
care and to facilitate services by a care team, which can include a range of health
professionals (for example, general practitioner, specialists, allied health professionals,
practice nurses) (Department of Health 2017).
See chapters 7.5 ‘Primary health care’, 7.18 ‘Coordination of heath care’ for information
about how patients use general practitioner services in Australia.
Recognising how chronic conditions and the increasing impact of multimorbidity are
interrelated, in 2017, all Australian health ministers endorsed the National Strategic
Framework for Chronic Conditions (the Framework). The Framework provides guidance
for the development and implementation of policies, strategies, actions and services to
tackle chronic conditions. The Framework addresses primary, secondary and tertiary
prevention of chronic conditions, recognising that there are often similar underlying
principles for the prevention and management of many chronic conditions. It moves away
from a disease- specific approach and better caters for shared health determinants, risk
factors and multimorbidities across a broad range of chronic conditions.
The Framework outlines three objectives that focus on preventing chronic conditions,
providing efficient, effective and appropriate care to manage them and targeting priority
populations (AHMAC 2017).
100
The AIHW has a long history of monitoring and reporting on chronic conditions, risk
factors and health outcomes among the Australian population. In 2016, the National
Centre for Monitoring Chronic Conditions (NCMCC) was formed in response to the need
for a more streamlined, integrated and prioritised approach for reporting on chronic
conditions. The NCMCC integrates holistic reporting on chronic conditions comorbidity
and risk factors with disease-specific monitoring to provide a ‘bigger picture’ of chronic
conditions in Australia. In so doing, it brings together work programs on:
• c ardiovascular diseases, diabetes and chronic kidney disease
• c hronic respiratory conditions
• c hronic musculoskeletal conditions.
This work is complemented by ongoing work to update and extend the Australian
Burden of Disease Study (see Chapter 3.1 ‘Burden of disease across the life stages’;
Chapter 4.4 ‘Contribution of selected risk factors to burden of disease’) and reporting on:
• t he use of health services among people with chronic conditions (for example,
potentially preventable hospital admissions and mental health services)
• d
isparities in specific population groups (for example, prisoners and Aboriginal
and Torres Strait Islander Australians)
• d
isease expenditure.
Chapter 3
Better information on the number of people newly diagnosed and currently living with
chronic conditions, such as dementia, osteoporosis and degenerative eye diseases, could
benefit future health services planning.
Additional data on the treatment, management and impact of chronic conditions—
including in respect to primary care, proper use of medicines, quality of life, and
participation in work and education—will contribute to a more complete picture of the
individual impact of chronic conditions in Australia and the effectiveness of current
strategies to prevent and manage these conditions.
A number of national data sets contain information on chronic conditions. Data linkage
can improve the understanding of patient outcomes, disease interactions and pathways
through the health system.

More information on chronic conditions is available on the AIHW website at <www.aihw.
gov.au/reports-statistics/health-conditions-disability-deaths/chronic-disease/overview>.
More information on burden of disease in Australia is available on the AIHW website
at <www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-
disease/overview>.
Summary information on chronic condition comorbidity can be found in Chapter 3.3
of Australia’s health 2016, available on the AIHW website at <www.aihw.gov.au/reports/
australias-health/australias-health-2016/contents/chapter-3-leading-causes-of-ill-health>.
101
References
ABS (Australian Bureau of Statistics) 2015. National Health Survey: first results 2014–15.
ABS cat. no. 4364.0.55.001. Canberra: ABS.
AHMAC (Australian Health Ministers’ Advisory Council) 2017. National Strategic Framework
for Chronic Conditions. Canberra: Department of Health. Viewed 22 February 2017,
<http://www.health.gov.au/internet/main/publishing.nsf/content/nsfcc>.
Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L et al. 2016. General practice activity
in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press.
Department of Health 2017. Health care homes. Canberra: Department of Health. Viewed
20 December 2017, <http://www.health.gov.au/internet/main/publishing.nsf/Content/health-care-homes>.
GBD (Global Burden of Disease) Collaborative Network 2017. Global Burden of Disease Study 2016
(GBD 2016) results. Seattle: Institute for Health Metrics and Evaluation (IHME). Viewed 27 November 2017,
<http://ghdx.healthdata.org/gbd-results-tool>.
UN (United Nations) 2015. Transforming our world: the 2030 Agenda for Sustainable Development.
New York: UN. Viewed on 22 November 2017, <https://sustainabledevelopment.un.org/content/
documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf>.
WHO (World Health Organization) 2013. Global action plan for the prevention and control of
noncommunicable diseases 2013–2020. Geneva: WHO. Viewed 22 November 2017,
<http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1>.
WHO 2017a. Noncommunicable diseases. Geneva: WHO. Viewed 22 November 2017,
<http://www.who.int/mediacentre/factsheets/fs355/en/>.
WHO 2017b. World health statistics 2017: monitoring health for the SDGs. Geneva: WHO.
102
3.4 Cancer
SNAPSHOT
Cancer is a diverse group of several hundred diseases where some of the body’s cells
become abnormal and begin to multiply out of control. In 2011, cancer (as a disease
group) was the greatest cause of disease burden in Australia, accounting for around
one-fifth (19%) of the total disease burden.
Cancer is a notifiable disease in all Australian states and territories. The Australian Cancer
Database holds data on all new cases of cancer diagnosed in Australia since 1 January
1982. Common non-melanoma skin cancers, including basal cell carcinoma and squamous
cell carcinoma are not reportable to cancer registries. So, incidence and survival data
presented for all cancers combined do not include these cancers.
This snapshot presents cancer incidence and mortality estimates for 2018. The estimates
are a mathematical extrapolation of past trends.
How common is cancer?

Incidence
In 2018, it is estimated that:
Chapter 3
• a
bout 138,300 new cases of cancer will be diagnosed in Australia, an average of about
380 people every day—more than half (54%) of these cases will be diagnosed in males
• t he risk of being diagnosed with any cancer before the age of 85 will be 1 in 2 for males
and females
• t he most commonly diagnosed cancers in males will be prostate cancer (17,700 cases),
colorectal cancer (9,300), melanoma of the skin (8,700) and lung cancer (7,200)
• t he most commonly diagnosed cancers in females will be breast cancer (18,100 cases),
colorectal cancer (7,700), melanoma of the skin (5,700) and lung cancer (5,500).
The age-standardised incidence rate of all cancers combined rose from 383 per 100,000
population in 1982 to a peak of 504 per 100,000 in 2008, before decreasing to 484 per
100,000 in 2014. It is projected to continue to fall to 472 per 100,000 in 2018 (Figure
3.4.1). The increasing trend to 2008 was largely due to a rise in the number of diagnosed
prostate cancers in males and breast cancers in females. This trend may have been the
result of increased formal and informal population screening, and improvements in
technologies and techniques used to identify and diagnose cancer.
103
Figure 3.4.1: Trends in incidence of all cancers combined, 1982–2018
Number Rate (per 100,000 population)

Actual number Estimated number
160,000 600
Actual rate (per 100,000) Estimated rate (per 100,000)
140,000
500
120,000
400
100,000
80,000 300
60,000
200
40,000
100
20,000
0 0
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
Year
Notes
1. C
ancers coded in the International Statistical Classification of Diseases and Related Health Problems,
tenth revision (ICD-10) as C00-C97, D45, D46, D47.1 and D47.3, except those C44 codes that indicate
basal or squamous cell carcinoma of the skin.
2. T
he 2015–2018 estimates presented in blue bars and the blue dotted line are based on 2002–2013
incidence data.
3. T
he rates were age standardised to the Australian population as at 30 June 2001 and are expressed per
100,000 population.
Source: Australian Cancer Database 2014; Table S3.4.1.
Cancer incidence by stage at diagnosis

In 2015, the AIHW, Cancer Australia and state and territory cancer registries committed to
work together to produce national population-level data on incidence by cancer stage at
diagnosis for the first time for breast, prostate, colorectal and lung cancers and melanoma
of the skin. These cancers were selected as they account for the most number of cancers
diagnosed. Cancers can be assigned a ‘stage’ that reflects the seriousness of the disease.
Stages range from 1 (best prognosis) to 4 (worst prognosis).
Collection and analysis of cancer staging data will enhance understanding of the variability
in the cancer stage at the time of diagnosis and how this relates to treatments received
and to survival rates.
In 2011:
• m
ost cancers were diagnosed at stage 1, with melanoma of the skin having the highest
percentage diagnosed at stage 1 (78%)
• 1
2% of people diagnosed with 1 of the 5 most commonly diagnosed cancers presented
with a stage 4 cancer—stage 4 cancer accounted for 42% of lung cancers diagnosed,
which was the highest percentage of the 5 most common cancers
• t he percentage of Aboriginal and Torres Strait Islander people who were diagnosed
with stage 4 cancer was generally higher than for non-Indigenous Australians (except
for prostate cancer).
104
Impact
Survival
Information on survival from cancer indicates a cancer prognosis and the effectiveness of
treatment available. Relative survival of less than 100% means that people with cancer had
a lower chance of surviving for at least 5 years after diagnosis than the general population.
In 2010–2014 in Australia:
• individuals diagnosed with cancer had, on average, a lower (69%) chance of surviving
for at least 5 years after diagnosis compared with their counterparts in the general
population (referred to as ‘5-year relative survival’, see Glossary)
• a
mong people who had already survived 5 years past their cancer diagnosis, the chance
of surviving for at least another 5 years was 91%
• f or males, 5-year relative survival was highest for testicular cancer (98%) and prostate
cancer (95%) and lowest for mesothelioma (5.8%) and pancreatic cancer (9.1%)
• f or females, 5-year relative survival was highest for thyroid cancer (98%) and lip cancer
(97%) and lowest for mesothelioma (9.7%) and pancreatic cancer (9.2%)
• B
etween 1985–1989 and 2010–2014, 5-year relative survival for all cancers combined
rose from 49% to 69%.
Chapter 3
Deaths
It is estimated that, in 2018, around 48,600 people will die from cancer, an average of
around 133 deaths every day. Males will account for more than half (57%) of these deaths.
It is estimated that between 1982 and 2018, the age-standardised mortality rate for all
cancers combined will drop by around 24% from 209 deaths per 100,000 population to
159 deaths per 100,000.

There are no national registry data on the stage (severity) of cancer at diagnosis except
for breast, prostate, colorectal and lung cancers and melanoma of the skin, and these
data are currently available for 2011 only. Information is also not readily available on the
treatments applied to individual cases of cancer, the frequency of recurrence of cancer
after treatment, or the incidence of common non-melanoma skin cancers (basal cell
carcinomas and squamous cell carcinomas).

The reports Cancer in Australia: an overview, 2017, Australian Cancer Incidence and Mortality
(ACIM) books 2017, Cancer incidence projections: Australia 2011 to 2020, Cancer survival and
prevalence in Australia: period estimates from 1982 to 2010, and Cancer mortality trends and
projections: 2013 to 2025 are available for free download.
105
3.5 Mesothelioma
SNAPSHOT
Mesothelioma is an aggressive form of cancer in the mesothelium—the protective lining of

the body cavities and internal organs, such as the lungs, heart and bowel. There is no known
cure for it and the average time between diagnosis and death is 9 months (AMR 2017).
In 2010–2014, mesothelioma had the lowest 5-year relative survival of all cancer types,
at 6.4%. This means that people diagnosed with mesothelioma had a 6.4% chance of
surviving for at least 5 years compared with their counterparts in the general population
(Australian Cancer Database 2014).

The main cause of mesothelioma is exposure to asbestos, with symptoms usually taking
20–30 years after first exposure to appear (AMR 2017). The term ‘asbestos’ refers
to a group of naturally occurring fibrous minerals that do not readily break down.
Mesothelioma is of particular relevance in Australia, where asbestos use was widespread
from the 1950s to the 1980s (MacFarlane et al. 2012). Due to its durability and fire and
chemical resistance, asbestos was used extensively in construction, including residential
homes, as well as for other purposes such as industrial plants and equipment. In
December 2003, the import and use of all forms of asbestos was prohibited, yet there is
still a large amount of it in buildings and in other products used today (AMR 2017).
The latest information and detailed data on mesothelioma in Australia are available
in Mesothelioma in Australia 2016: 6th annual report (AMR 2017). Key findings from this
report are included in this snapshot. Data are sourced from the Australian Mesothelioma
Registry (AMR 2017) (Box 3.5.1).
Box 3.5.1: Australian Mesothelioma Registry (AMR)

The AMR is a national registry of information specific to mesothelioma and
asbestos exposure. It aims to better understand the relationship between asbestos
exposure and this disease. Since 2011, it has collected information on new cases
of mesothelioma diagnosed in Australia from 1 July 2010, fast-tracked by the state
and territory cancer registries. The AMR also collects information on asbestos
exposure from consenting mesothelioma patients through a postal questionnaire
and telephone interview.
How common is mesothelioma?

Australia has one of the highest rates of mesothelioma incidence in the world. The rate
of new cases of mesothelioma recorded by the AMR has showed little change since the
AMR data collection began in 2011, with the highest rate of 2.9 per 100,000 population
recorded in 2012.
106
In 2016, the AMR was notified of 700 people newly diagnosed with mesothelioma in
Australia; the incidence of the disease that year varied by state and territory (Figure 3.5.1).
Mesothelioma is more common in men than women, accounting for around 4 in 5 (81%)
cases. This is likely due to men more often working in industries at risk of asbestos
exposure (such as construction trades) and completing non-paid home renovations.
Rates were highest in Western Australia, where the rate for men was more than
double the national rate. Exposure to asbestos has been responsible for many cases
of mesothelioma in the Western Australian town of Wittenoom, well known for past
mining of asbestos (Franklin et al. 2016).
Figure 3.5.1: Incidence rate of mesothelioma, by sex and state and territory, 2016
Rate (number per 100,000 population)
10
Males Females
9
8
7
6
5
4
Chapter 3
3
2
1
0
NSW Vic Qld WA SA Tas ACT Total
State / territory
Notes
1. Directly age standardised using the 2001 Australian standard population.
2. Data for the Northern Territory were not published.
Source: Australian Mesothelioma Registry 2017; Table S3.5.1.
In 2016, age at diagnosis ranged from 21 to 95. Age-specific rates of mesothelioma

generally increased with age, with the highest rate for people aged 85 and over. For
men, the rate was highest for people aged 85 and over, at 53 per 100,000 population.
For women, the rate was highest for people aged 80–84, at 7.4 per 100,000 population
(Figure 3.5.2).
107
Figure 3.5.2: Age-specific incidence rate of mesothelioma, by age group and
sex, 2016

Males Females
60
50
40
30
20
10
0
<55 55-59 60-64 65-69 70-74 75-79 80-84 85+
Age group
Note: Age-specific rate using the Australian estimated resident population as at 30 June 2016.
Impact
575 mesothelioma patients were recorded by the AMR as having died in 2016, at a rate
of 2.0 per 100,000 population—84% of these deaths were of men. The mortality rate was
highest in Western Australia, at 3.9 per 100,000 population.
Cause of death information was available for 260 (45%) deaths recorded by the AMR in
2016. Where cause of death was recorded, mesothelioma was the underlying primary
cause of death for 235 cases (90%).
Asbestos exposure
As at 3 April 2017, 701 participants had completed both the voluntary questionnaire
and telephone interview components of the assessment since the start of the AMR. Of
these people, 651 (93%) provided information indicating possible or probable asbestos
exposure. For the remaining 50 participants (7.1%), the exposure assessment did not
produce information indicating asbestos exposure in either occupational or
non-occupational contexts (Figure 3.5.3). This should not be taken, however, to mean that
these participants were never exposed to asbestos.
108
Figure 3.5.3: Summary of occupational and non-occupational asbestos
exposure assessment, 2011–2016
Neither
Occupational occupational or
Non-occupational Both occupational and exposure non-occupational
exposure only non-occupational exposure only exposure
232 338 81 50
Non-occupational
exposure Neither
Occupational
exposure
A total of 570 participants were identified as having possible or probable non-occupational

exposure. Based on information provided, 363 participants reported having done major
home renovations that involved asbestos products. Other common potential exposures
included living in a house while renovations were occurring, and servicing car brakes
and/or clutches.
Chapter 3
Based on jobs held during their working career, 491 participants were identified as
having possible or probable occupational exposure. Most of these people had a history
of working in trades, such as in the construction or metal industries or as an electrician,
plumber or mechanic. Almost 9 in 10 (87%) participants with a trade history were
classified as having possible or probable exposure.

Data on mesothelioma notifications are fast-tracked to the AMR by state and territory
cancer registries. The incidence and mortality data presented in this snapshot are likely
to be an underestimate, as it is probable that not all notifications for 2016 were recorded
in the AMR data set when the annual report was published. The AMR data set is regularly
updated back to 1 July 2010.
The participation rate in the voluntary components of the AMR is low, with only around
20% of patients diagnosed with mesothelioma taking part. This is partially due to patients
dying or being too unwell to participate. Given this low participation rate, it is currently
unknown how representative exposure information is. As well, the results of the asbestos
exposure assessments consider only the probability of asbestos exposure. Information
about the duration, intensity or frequency of exposure has not been reported.
109
More information on the AMR is available at <www.mesothelioma-australia.com/home>.
The report Mesothelioma in Australia 2016: 6th annual report and previous annual reports
are available for free download at <www.mesothelioma-australia.com/publications-and-
data/publications>.
People diagnosed with mesothelioma can choose to self-notify their diagnosis by
contacting the AMR via email at [email protected] or on the toll-free AMR information
line 1800 378 861.
References
AMR (Australian Mesothelioma Registry) 2017. Mesothelioma in Australia 2016: 6th annual report. NSW
Health: Cancer Institute NSW. Viewed 25 October 2017, <https://www.mesothelioma-australia.com/
publications-and-data/publications>.
Franklin P, Reid A, Olsen N, Peters S, de Klerk N, Brims F et al. 2016. Incidence of malignant mesothelioma
in Aboriginal people in Western Australia. Australian and New Zealand Journal of Public Health 40:383–7.
MacFarlane E, Benke G, Sim MR & Fritschi L 2012. OccIDEAS: an innovative tool to assess past asbestos
exposure in the Australian Mesothelioma Registry. Safety and Health at Work (SH@W) 3:71–6.
110
3.6 Coronary heart disease
SNAPSHOT
Coronary heart disease (CHD) is the leading single cause of disease burden and death in
Australia. It occurs when there is a blockage in the blood vessels that supply blood to the
heart muscle. There are two major clinical forms—heart attack and angina (see Glossary).
CHD is largely preventable, as many of its risk factors are modifiable. These include
tobacco smoking, high blood pressure, high blood cholesterol, physical inactivity,
poor nutrition, and overweight and obesity (see Chapter 4 for more information on
determinants of health).
How common is coronary heart disease?

In 2014–15, an estimated 645,000 Australians aged 18 and over (3.3% of the adult
population) had CHD, based on self-reported estimates from the Australian Bureau of
Statistics 2014–15 National Health Survey. The prevalence of CHD increases rapidly with
age, affecting around 1 in 6 adults aged 75 and over.
In 2015, based on hospital and mortality data, an estimated 61,600 people aged 25 and
over had an acute coronary event in the form of a heart attack or unstable angina—
around 170 events every day.
Impact
Chapter 3
Burden of disease
In 2011, CHD accounted for 7.7% of the total burden of disease in Australia. It accounted
for 12% of the overall fatal burden of disease and 3.2% of the non-fatal burden.
The burden was more than twice as high in males than females and increased rapidly
from age 45 onwards—to 17% among people aged 85 and over (Figure 3.6.1).
Figure 3.6.1: Rate of total burden due to CHD, by age and sex, 2011
DALYs per 1,000

250
Males
200
Females
150
100
50
0
0–14 15 –44 45 –64 65 –74 75 –84 85+
Age group
111
CHD burden can be attributed to several risk factors. In 2011, high blood pressure was
responsible for the most CHD burden, estimated at 33%, followed by high cholesterol
(28%), overweight and obesity (25%), tobacco use (14%) and physical inactivity (11%).
Between 2003 and 2011, the overall burden from CHD reduced by 32%. This was driven
largely by a 35% drop in the fatal burden of CHD. The non-fatal burden also fell by 21%.
Deaths
In 2016, CHD was the leading single cause of death in Australia, accounting for 19,100
deaths as the underlying cause of death. This represents 12% of all deaths, and 43% of
cardiovascular deaths. More than 40% (8,000) of CHD deaths resulted from a heart attack.
Overall, the CHD death rate has fallen by 79% since 1980, or 4.3% per year. While CHD
death rates fell substantially in each age group, the rate of decline was more rapid for
those aged 75 and over than for younger age groups (Figure 3.6.2).
Figure 3.6.2: CHD death rates, people aged 55 and over, by age and sex, 1980–2016
Rate (deaths per 100,000 population)

4,000 Men 75+
Women 75+
3,500
Men 55–74
3,000
Women 55–74
2,500
2,000
1,500
1,000
500
0
1980 1985 1990 1995 2000 2005 2010 2015
Year
Source: National Mortality Database. Table S3.6.2.
Treatment and management

Cardiovascular medicines
In 2015, more than 100 million Pharmaceutical Benefits Scheme prescriptions for
cardiovascular medicines were dispensed to the Australian community—34% of the total
prescription medicines dispensed.
The prescription medicines most commonly dispensed were those to lower blood
pressure and to lower blood cholesterol. Dispensing of prescription lipid-modifying agents
rose by 66% between 2005 and 2015, while dispensing of calcium channel blockers and
renin-angiotensin system agents—both agents to lower blood pressure—increased by
41% and 38%, respectively.
112
Hospitalisations
In 2015–16, there were 157,000 hospitalisations where CHD was the principal diagnosis
(1.5% of all hospitalisations). Of these, 36% were for heart attack (56,000) and 28% for
angina (44,500). Most admissions for heart attack (78%) and angina (63%) were emergency
admissions.
Between 2003–04 and 2015–16, the age-standardised rate of hospitalisations declined
by 29%, from 804 to 569 hospitalisations per 100,000 population.
CHD was the leading cause of hospitalisation for cardiovascular disease in 2015–16
(28% of all hospitalisations with a principal diagnosis of cardiovascular disease). However,
for people aged 85 and over, hospitalisation rates for heart failure and cardiomyopathy
were 50% higher than for CHD (5,000 and 3,200 hospitalisations per 100,000 population,
respectively), reflecting the increasing need for hospital care for heart failure and
cardiomyopathy among the elderly.
Of all CHD hospitalisations, 45% had a coronary angiography (a diagnostic procedure) and
24% underwent revascularisation (surgical procedures to restore blood supply to the heart).
Variations among population groups

The impact of CHD varies among population groups, with rates being 2.0–3.1 times as high
among Aboriginal and Torres Strait Islander people as among non-Indigenous Australians.
Chapter 3
Generally, the impact of CHD increases with increasing remoteness and socioeconomic
disadvantage. Rates were 1.4–2.4 times as high in Remote/Very remote areas as in Major cities,
and 1.3–2.2 times as high in the lowest socioeconomic areas compared with the highest.
Remote and Lowest / highest

Indigenous / Very remote / socioeconomic
Comparing rates for: non-Indigenous Major cities areas
Having CHD 2.0× n.a. 2.2×
Hospitalised for CHD 2.4× 1.5× 1.3×
Dying from CHD 2.1× 1.4× 1.6×
Having an acute
2.7× n.a. n.a.
coronary event
Burden of disease 1.7x (Remote) / 2.4×

3.1x 1.8×
(DALYs) (Very remote)
n.a. not available
113
There are no reliable national and jurisdictional data on the number of new cases of CHD
or heart failure each year. Proxy measures that combine hospital and mortality data are
used to estimate new cases of CHD; however, these methods do not count the less severe
cases of CHD that do not result in hospitalisation.
Further information is needed on primary health care and on the long-term outcomes of
people treated for CHD. Data linkage can improve the understanding of patient outcomes
and pathways through the health system.

More information on coronary heart disease is available at <www.aihw.gov.au/reports-
statistics/health-conditions-disability-deaths/heart-stroke-vascular-diseases/overview>.
The following reports are available for free download on the AIHW website: Cardiovascular
health compendium, Trends in cardiovascular deaths, and Medicines for cardiovascular
disease.
114
3.7 Stroke
SNAPSHOT
Stroke occurs when a blood vessel supplying blood to the brain either suddenly becomes
blocked (known as an ischaemic stroke) or ruptures and begins to bleed (known as a
haemorrhagic stroke). Either may result in part of the brain dying, leading to sudden
impairment that can affect a number of functions. Stroke often causes paralysis of parts
of the body normally controlled by the area of the brain affected by the stroke, or speech
problems and other symptoms, such as difficulties with swallowing, vision and thinking.
Stroke is often preventable because many of its risk factors are modifiable. These include
high blood pressure, physical inactivity, overweight and obesity, and tobacco smoking (see
Chapter 4 for more information on determinants of health).
How common is stroke?

In 2015, an estimated 394,000 people—199,000 males and 195,000 females—had had
a stroke at some time in their lives, based on self-reported data from the Australian
Bureau of Statistics 2015 Survey of Disability, Ageing and Carers (ABS 2016). The estimated
prevalence of stroke (1.7% of Australians) has remained similar between 2003 and 2015.
The proportion of people who had disability resulting from stroke also remained similar
Chapter 3
over the period (2003–2015), at around 40%.
In 2015, there were around 36,700 stroke events—around 100 every day. The rate of these
events, based on hospital and mortality data, fell by 26% between 2000 and 2015, from an
age-standardised rate of 176 to 130 per 100,000 population (Supplementary Table S3.7.1).
Impact
Burden of disease
In 2011, stroke accounted for 3.0% of the total burden of disease in Australia and was the
eighth leading specific cause of disease burden.
Stroke was the third highest disease burden in people aged 85 and over, accounting for
7.5% of the burden in men and 9.4% of the burden in women.
Deaths
In 2016, there were 8,200 deaths with stroke recorded as the underlying cause, accounting
for 5.2% of all deaths in Australia.
Between 1980 and 2016, overall death rates for stroke have fallen by three-quarters (74%),
or 3.7% per year (Supplementary Table S3.7.2).
The rate of decline has remained steady in people aged 75 and over but slowed among
younger age groups (Figure 3.7.1).
115
Figure 3.7.1: Stroke death rates, people aged 55 and over, by age and sex,
1980–2016
Deaths per 100,000 population

1,600 Women 75+
Men 75+
1,400
Men 55 –74
1,200
Women 55–74
1,000
800
600
400
200
0
1980 1984 1988 1992 1996 2000 2004 2008 2012 2016
Year
Treatment and management of stroke

Hospitalisations
In 2015–16, there were 37,300 acute care hospitalisations with a principal diagnosis
of stroke (Supplementary Table S3.7.4), at a rate of 134 per 100,000 population.
Hospitalisation rates were higher among males than females (1.4 times as high), and most
hospitalisations (72%) were for people aged 65 and over (Supplementary Table S3.7.4).
The average length of stay for stroke patients in acute hospital care was 8 days in 2015–16.
Stroke patients in rehabilitation care had an average length of stay of 26 days.
Variation by population group

The impact of stroke varies among population groups, with rates being 1.5 to 2.3 times
as high among Aboriginal and Torres Strait Islander people as among non-Indigenous
Australians. Death rates and burden of disease were similar in Remote and Very remote
areas compared with Major cities. Hospitalisation rates for stroke were 1.3 times higher in
Remote and Very remote areas compared with Major cities. The impact of stroke was 1.2 to
1.4 times as high in the lowest socioeconomic areas compared with the highest.
116
Being hospitalised
1.7x 1.3x 1.3x
for stroke
Dying from stroke 1.5x Similar 1.2x
Burden of disease Similar (Remote) /

2.3x 1.4x
(DALYs) Similar (Very remote)

Currently, there is no comprehensive national monitoring of new cases of stroke.
Only stroke events that result in hospitalisation or death can be monitored, although
this includes most strokes.
National data on stroke treatment and care responses such as time to treatment and
medicine usage can further enhance stroke monitoring. Data linkage can also improve
Chapter 3
the understanding of patient outcomes and their pathways through the health system.

More information on stroke is available at <www.aihw.gov.au/reports-statistics/health-
conditions-disability-deaths/heart-stroke-vascular-diseases/overview>.
The following reports are available for free download on the AIHW website:
Cardiovascular health compendium and Trends in cardiovascular deaths.
References
ABS (Australian Bureau of Statistics) 2016. Microdata: Disability, Ageing and Carers, Australia, 2015.
ABS cat. no. 4430.0.30.002. Canberra: ABS. AIHW analysis of Expanded Confidentialised Unit Record File,
DataLab.
117
3.8 Diabetes
SNAPSHOT
Diabetes is a chronic condition marked by high levels of sugar (glucose) in the blood. It is
caused by the body’s being unable to produce insulin (a hormone made by the pancreas
to control blood glucose levels) or to use insulin effectively, or both.
The main types of diabetes are:
• t ype 1 diabetes—an autoimmune disease that usually has an onset in childhood or
early adulthood
• t ype 2 diabetes—the most common form of diabetes, generally having a later onset.
It is largely preventable and is often associated with lifestyle factors such as insufficient
physical activity, unhealthy diet, obesity and tobacco smoking. Risk is also associated
with genetic and family-related factors
• g
estational diabetes—when higher than normal blood glucose is diagnosed for the first
time during pregnancy.
The treatment of diabetes aims to maintain healthy blood glucose levels to prevent both
short- and long-term complications, such as heart disease, kidney disease, blindness and
lower limb amputation. All people with type 1 diabetes need insulin replacement therapy,
as do a proportion of people with other forms of diabetes as their condition worsens
over time.
How common is diabetes?

Based on self-reported estimates from the Australian Bureau of Statistics 2014–15
National Health Survey, more than 1 in 20 (6.1%, or 1.2 million) Australian adults had
diabetes. However, self-reported data are likely to underestimate diabetes prevalence.
Analysis of measured diabetes data from 2011–12 showed that for every 4 adults with
diagnosed diabetes there is 1 with undiagnosed diabetes.
An estimated 1 in 5 (19%) Australians aged 75 and over had diabetes in 2014–15,
compared with 1.3% of people aged 18–44. Diabetes was also more common in males
(6.8%) than females (5.4%).
The age-standardised rate of self-reported diabetes has more than tripled over 25 years—
from 1.5% in 1989–90 to 4.7% in 2014–15.
Impact
Burden of disease
Diabetes was the 12th leading cause of disease burden in 2011, responsible for 2.3%
of the total direct burden of disease and injury in Australia. If the health loss from both
diabetes and other diseases for which diabetes is a risk factor is considered, the burden
due to diabetes almost doubles.
118
Deaths
Diabetes was the underlying cause of around 4,770 deaths in 2016. However,
it contributed to 16,450 deaths (10% of all deaths) (Supplementary Table S3.8.1).
An examination of deaths among people with diagnosed diabetes provides a more complete
picture of diabetes-related deaths. Age-adjusted death rates for people with diabetes were
almost double those for the general Australian population. The disparity in death rates was
highest in people aged under 45 with type 1 diabetes (4.5 times as high), and type 2 diabetes
(5.8 times as high) (figures 3.8.1 and 3.8.2).
Between 2009 and 2014, death rates fell by 20% for people with type 1 diabetes but rose
by 10% for people with type 2 diabetes. As death rates have been declining in the general
population, the mortality gap has widened for people with type 2 diabetes but reduced
for people with type 1 diabetes, compared with the general population.
Figure 3.8.1: All-cause mortality rates for Figure 3.8.2: All-cause mortality rates for
people with type 1 diabetes compared with people with type 2 diabetes compared
general population, by age, 2012–2014 with general population, by age, 2014
Rate (deaths per 100,000 population) Mortality rate ratio Rate (deaths per 100,000 population) Mortality rate ratio
9,000 People with type 1 diabetes 5 16,000 7
People with type 2 diabetes
8,000 General population 14,000
General population 6
Ratio 4
7,000 Ratio
12,000
5
6,000
10,000
3
4
Chapter 3
5,000
8,000
4,000 3
2 6,000
3,000
2
4,000
2,000 1
2,000 1
1,000
0 0 0 0
<45 45–54 55–64 65–74 75+ <45 45– 54 55– 64 65– 74 75– 84 85+
Age group Age group
Source: Table S3.8.2. Source: Table S3.8.3.

Diabetes medicines
• In 2015, more than 11 million Pharmaceutical Benefits Scheme and Repatriation
Pharmaceutical Benefits Scheme prescriptions for diabetes medicines were dispensed
to the Australian community (Department of Health 2016).
• T
he most commonly dispensed prescription medicines for managing diabetes were
metformin, sulfonylureas, DPP4 (dipeptidyl peptidase 4) inhibitors, and insulin.
Metformin prescriptions made up almost half of all dispensed diabetes medicines;
it was the ninth most dispensed medicine to the Australian community in 2015.
• In 2016, there were 27,700 people who began using insulin to treat their diabetes—9.5%
with type 1 diabetes, 59% with type 2 diabetes, 29% with gestational diabetes and 1.9%
with other forms of diabetes.
Hospitalisations
Diabetes was recorded as the principal and/or additional diagnosis in around 1 million
hospitalisations in 2015–16, accounting for 10% of all hospitalisations in Australia.
119
The impact of diabetes varies among population groups, with rates being 3–6 times
as high among Aboriginal and Torres Strait Islander people as among non-Indigenous
Australians. Generally, the impact of diabetes increases with increasing remoteness and
socioeconomic disadvantage. Rates were almost twice as high in Remote/Very remote areas
compared with Major cities, and 2–3 times as high in the lowest socioeconomic areas
compared with the highest.

Having diabetes 3.5× Similar 2.6×
Hospitalised for type 2 diabetes 4.0× 2.0× 2.0×
Dying from diabetes 4.0× 1.8× 2.3×
Burden of disease (DALYs) 5.6x 2.3× 2.3×

There are several data gaps for diabetes. Currently, there are no national data on
the number of new cases of diagnosed type 2 diabetes and no regular collection of
biomedical data to better understand diabetes prevalence.
There is limited national data to monitor complications associated with gestational
diabetes and pre-existing diabetes in pregnancy. There is a need for national primary
health care data on screening, self-care management, and appropriateness of care
and health across the life course.

More information on diabetes is available at <www.aihw.gov.au/reports-statistics/health-
conditions-disability-deaths/diabetes/overview>.
The following reports are available for free download: Incidence of insulin-treated
diabetes in Australia, Deaths among people with diabetes in Australia, 2009–2014 and the
Cardiovascular disease, diabetes and chronic kidney disease—Australian facts series
(Mortality; Prevalence and incidence; Morbidity—hospital care; Risk factors; Aboriginal
and Torres Strait Islander people).
Reference
Department of Health 2016. Australian statistics on medicines 2015. Canberra: Department of Health.
Viewed 5 December 2017, <www.pbs.gov.au/info/browse/statistics#ASM>.
120
3.9 Chronic kidney disease
SNAPSHOT
The kidneys filter and remove waste from the blood. Kidney disease occurs when the
nephrons (the functional units in the kidneys that filter blood) are damaged. Chronic
kidney disease (CKD) is where evidence of kidney damage and/or reduced kidney function
lasts at least 3 months. The most severe form of CKD is end-stage kidney disease (ESKD),
for which people usually need kidney replacement therapy (KRT)—a kidney transplant or
dialysis—to survive.
Many cases of CKD are preventable, as several of its risk factors—such as high blood
pressure, insufficient physical activity, overweight and obesity, and tobacco smoking—are
modifiable. Simple tests of a person’s blood and urine can identify most cases of CKD when
the disease is in its early stages, enabling treatment to prevent or slow its progression.
How common is chronic kidney disease?

In 2011–12, an estimated 1 in 10 people (1.7 million Australians) aged 18 and over had
biomedical signs of CKD. The risk of CKD increases rapidly with age, affecting around
2 in 5 (42%) people aged 75 and over.
There were around 5,100 new cases of ESKD in Australia in 2013, which equates to
around 14 new cases per day. Of these, around 50% were receiving KRT.
Chapter 3
The rate of new cases of KRT-treated and non-KRT-treated ESKD increased with age for
all age groups up to age 74. From age 75, rates of non-KRT-treated ESKD rose rapidly—an
11-fold increase from ages 65–74 (from 13 to 145 per 100,000 population) (Figure 3.9.1).
Figure 3.9.1: Incidence rate of ESKD, by age and treatment status, 2013
Rate (number per 100,000)

160 KRT-treated Non-KRT-treated
140
120
100
80
60
40
20
0
0–54 55–64 65–74 75+
Age group
Sources: AIHW analysis of linked Australia and New Zealand Dialysis and Transplant Registry, National Mortality
Database and National Death Index; Table S3.9.1.
Between 1997 and 2013, the number of new cases of KRT-treated and non-KRT-treated ESKD
increased by 71% and 35%, respectively. However, the rate for both treatment groups has
remained relatively stable since 2001—an average of 10 per 100,000 population per year.
121
Impact
Burden of disease
In 2011, CKD was responsible for 0.9% of the total burden of disease and injury in
Australia (see Chapter 4.4 ‘Contribution of selected risk factors to burden of disease’ for
definitions of burden of disease). The burden of CKD increased rapidly with age from
ages 35–39, with CKD being the eighth leading cause of burden among people aged 85
and over.
CKD is also a risk factor for other diseases. In 2011, it was responsible for 19% of
peripheral vascular disease burden, 8.4% of dementia burden and 7.2% of stroke burden.
If the health loss from both CKD and other diseases for which CKD is a risk factor is
considered, the burden due to CKD doubles.
Deaths
CKD contributed to around 17,000 (11%, or 1 in 9) deaths in 2016, with 75% of these
recording CKD as an associated cause of death. CKD is more often listed as an associated
cause as the disease itself may not lead directly to death. When CKD was an associated
cause of death, coronary heart disease (21%), heart failure and cardiomyopathy (7.4%),
and dementia and Alzheimer disease (7.0%) were the most common underlying causes
of death (Supplementary Table S3.9.3).

Hospitalisations
In 2015–16, CKD was recorded as the principal and/or additional diagnosis in around
1.7 million hospitalisations—16% of all hospitalisations in Australia.
Of these, 81% (1.4 million) were for regular dialysis treatment, making dialysis the most
common reason for hospitalisation in Australia. On average, dialysis patients attend
3 sessions per week. Age-standardised rates for dialysis have increased by 24% over the
last decade, from 4,200 per 100,000 population in 2005–06 to 5,200 per 100,000 in 2015–16.
There were more than 300,000 hospitalisations for CKD excluding dialysis in 2015–16.
Most (87%) had CKD as an additional diagnosis. Age-standardised rates have increased
by 22%, from 138 per 100,000 population in 2005–06 to 169 per 100,000 in 2015–16.
Kidney replacement therapy

In 2015, around 23,000 people received KRT. Of these, 54% had dialysis while 46% had a
kidney transplant. The number of people receiving KRT has more than doubled in the
last 2 decades, from around 9,300 to 23,000 (ANZDATA 2016).
122
The impact of CKD varies among population groups, with rates being 2.1–7.3 times as high
among Aboriginal and Torres Strait Islander people as among non-Indigenous Australians
and 1.8–2.3 times as high in Remote/Very remote areas compared with Major cities.
Generally, the impact of CKD increases with increasing socioeconomic disadvantage. Rates
were 1.6–2.0 times as high in the lowest socioeconomic areas compared with the highest.

Having CKD 2.1× n.a. 1.6×
Hospitalised for CKD

5.0× 2.3× 1.9×
(excluding dialysis)
Dying from CKD 3.7× 1.8× 1.7×
Burden of disease
7.3× n.a. 2.0×
(DALYs)
Chapter 3
n.a. not available

Currently, there are only two surveys that provide reliable national data on biomedical
signs of CKD. Regular data collection would allow for more timely prevalence estimates
and the reporting of trends. Further, while there are national data on new cases of ESKD,
there are no national data on new cases of CKD.

More information on CKD is available at <www.aihw.gov.au/reports/chronic-kidney-
disease/chronic-kidney-disease-compendium/contents/how-many-australians-have-
chronic-kidney-disease>.
Find interactive maps on Geographical variation in chronic kidney disease.
These reports on CKD can be downloaded for free: Incidence of end-stage kidney disease in
Australia 1997–2013 and the Cardiovascular disease, diabetes and chronic kidney disease—
Australian facts series (Mortality; Prevalence and incidence; Morbidity—hospital care; Risk
factors; Indigenous Australians).
Reference
ANZDATA (Australian and New Zealand Dialysis and Transplant Registry) 2016. ANZDATA 39th annual report
2016. Adelaide: ANZDATA.
123
3.10 Arthritis and other
SNAPSHOT
musculoskeletal conditions
Arthritis and other musculoskeletal conditions are a group of conditions affecting the bones,
muscles and joints. These conditions include osteoarthritis, rheumatoid arthritis, juvenile
arthritis, back pain and problems, gout, and osteoporosis or osteopenia (low bone density)
(see Glossary).
How common are arthritis and other

musculoskeletal conditions?
Arthritis and other musculoskeletal conditions are very common, affecting around 1 in
3 (30%) Australians. Self-reported data from the Australian Bureau of Statistics 2014–15
National Health Survey indicates that, of the nearly 6.9 million people (30% of the total
population) with arthritis and other musculoskeletal conditions, 3.7 million (16%) had back
pain and problems (the most common musculoskeletal condition), 3.5 million (15%) had
arthritis and 801,000 (3.5%) had osteoporosis (ABS 2015). Females and older people were
more likely to have arthritis and other musculoskeletal conditions:
• M
ore than half (55%) of all people with musculoskeletal conditions were female.
• C
ompared with males, in each age group, females had a similar prevalence of back pain
and problems and were 20–50% more likely to have arthritis.
• O
verall, females were around 4 times as likely as males to have osteoporosis, but there
was substantial variation by age.
• More than half (53%) of all people with musculoskeletal conditions were aged 55 and over.
• O
ne in 4 (26%) Australians aged 55 and over had back pain and problems, 44% had
arthritis and 11% had osteoporosis.
People with arthritis and other musculoskeletal conditions often have other chronic and
long-term conditions. This is referred to as ‘comorbidity’, where two or more health
problems occur at the same time.
In 2014–15, for people with:

Arthritis + Arthritis
other chronic condition(s) only
arthritis, 79% had at least one other
chronic condition 79% 21%
Back pain and problems + Back pain and

other chronic condition(s) problems only
back pain and problems, 65% had
at least one other chronic condition. 65% 35%
The proportion of people with comorbidities increased with age: from 74% (aged 45–64)
to 86% (aged 65 and over) for people with arthritis and from 49% (aged 0–44) to 89%
(aged 65 and over) for people with back pain and problems.
124
Impact
Arthritis and other musculoskeletal conditions are large contributors to illness, pain and
disability. Individuals with these conditions have higher rates of poor health, psychological
distress and reduced participation in work and education. In 2015, of the people with
disability in Australia, 14% had back problems and 13% had arthritis as the main long-term
health condition causing the disability (ABS 2016).
According to the Australian Burden of Disease Study 2011, musculoskeletal conditions
contributed to:
• 1
2% of the total disease burden (fatal and non-fatal) in Australia. This disease group
was the fourth leading contributor to total burden after cancer, cardiovascular disease,
and mental and substance use disorders
• a
lmost one-quarter (23%) of non-fatal burden (that is, the impact of living with illness
and injury)
• a
higher burden among females than males—females experienced more than half
(55%) of the burden due to all musculoskeletal conditions combined, and two-thirds
(66%) of the burden due to osteoarthritis. Males experienced most of the burden
due to gout (83%).
Some of the total burden due to musculoskeletal conditions can be attributed to
Chapter 3
preventable risk factors. In 2011:
Overweight and obesity Occupational exposures

and hazards
contributed to: contributed to:
10% of total burden of all 5.4% of total burden of all

musculoskeletal conditions musculoskeletal conditions
45% of the burden of osteoarthritis 17% of the burden of back

pain and problems
39% of the burden of gout
See Chapter 4.4 ‘Contribution of selected risk factors to burden of disease’ for more
information on definitions and the burden of disease associated with these conditions.
125
In primary health care settings
Musculoskeletal conditions are primarily managed in primary health care settings by
a range of health professionals. Treatment combines physical therapy, medicines
(for pain and inflammation), self-management (such as diet and exercise), education
on self-management and living with the condition, and referral to specialist care where
necessary. Based on survey data, musculoskeletal conditions were managed at an
estimated 18% of general practice visits in 2015–16 (Britt et al. 2016).
In hospitals
Musculoskeletal conditions can also be managed in hospitals for more severe disease
or when specialised treatment or surgery is needed. In 2015–16, there were more than
763,000 hospitalisations involving treatment and management of musculoskeletal
conditions; this represented 7.2% of all hospitalisations in that year. Osteoarthritis was
the most common musculoskeletal reason for hospitalisation (accounting for 33% of all
musculoskeletal hospitalisations), followed by back pain and problems (22%). Other less
common musculoskeletal reasons for hospitalisation were rheumatoid arthritis (1.7%),
osteoporosis (1.1%), gout (1.0%) and juvenile arthritis (0.3%).
Pharmacotherapy
As mentioned earlier, pharmacotherapy (medicines) is used extensively to manage
musculoskeletal conditions. Many are non-prescription and bought over-the-counter,
some are prescribed in primary care, and others—such as the specialised biologic
disease-modifying anti-rheumatic drugs (bDMARDs)—can only be prescribed by a
rheumatologist and administered in hospital. In 2015–16, 47% of hospitalisations for
juvenile arthritis and 70% for rheumatoid arthritis involved at least one procedure
for the administration of pharmacotherapy.
Surgery
Joint replacement surgery is a common treatment for people with osteoarthritis who do
not respond to medicines. Between 2005–06 and 2015–16, the rate of joint replacement
surgery where osteoarthritis was the principal diagnosis increased by 36% for total knee
replacements and 38% for total hip replacements (AOA 2017).
126
The prevention, management and treatment of musculoskeletal conditions beyond hospital
settings cannot currently be examined in detail due to limitations in available data on:
• p
rimary and allied health care at the national level
• u
se of over-the-counter medicines to manage pain and inflammation
• d
iagnosis information for prescription pharmaceuticals (which would allow a direct link
between musculoskeletal conditions and use of subsidised medicines)
• p
atient outcomes, pathways through the health system and quality of care.

More information on arthritis and other musculoskeletal conditions is available at
<www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/arthritis-
musculoskeletal-conditions/overview>.
References
ABS (Australian Bureau of Statistics) 2015. National Health Survey: first results, 2014–15.
ABS 2016. Disability, ageing and carers, Australia: summary of findings, 2015. ABS cat. no. 4430.0.
Canberra: ABS.
AOA (Australian Orthopaedic Association) 2017. Australian Orthopaedic Association National Joint
Chapter 3
Replacement Registry. Annual report. Adelaide: AOA.
Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L et al. 2016. General practice activity
in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press.
127
3.11 Chronic respiratory
SNAPSHOT
conditions
Chronic respiratory conditions affect the airways, including the lungs, as well as
passages that transfer air from the mouth and nose into the lungs. These conditions
are characterised by symptoms such as wheezing, shortness of breath, chest tightness
and cough. Conditions include asthma, chronic obstructive pulmonary disease (COPD)—
which covers emphysema and chronic bronchitis—allergic rhinitis (‘hay fever’) and other
conditions such as chronic sinusitis, bronchiectasis, occupational lung diseases, sleep
apnoea, pulmonary fibrosis and cystic fibrosis.
This snapshot focuses on asthma and hay fever (given the large numbers of people
affected by these conditions) and COPD (given the poor health and wellbeing outcomes
associated with this condition).
Risk factors associated with chronic respiratory conditions can be behavioural,
environmental or genetic. These include tobacco smoking (particularly for COPD),
exposure to viral infections and air pollutants, and inheritance of genes linked with
respiratory illnesses such as cystic fibrosis.
How common are chronic respiratory

conditions?
Based on self-reported data from the Australian Bureau of Statistics 2014–15 National
Health Survey (ABS 2015):
• c hronic respiratory conditions are estimated to affect almost one-third (31% or 7 million
people) of Australians
• t he 2 most common respiratory conditions are hay fever and asthma, with hay fever
affecting an estimated 4.5 million Australians (19% of the population) and asthma an
estimated 2.5 million (11%)
• h
ay fever is most common in the middle years of life, and is most prevalent in people
aged between 15 and 59
• a
sthma rates vary by sex and age, and are more common in males at younger ages
(0–14) and more common in females at older ages (15 and over)
• 6
9% of persons with COPD said that they currently smoked cigarettes or had smoked
cigarettes in the past (see Supplementary Table 3.11.2).
COPD, which mainly affects middle aged and older people, was less prevalent than hay
fever or asthma, affecting an estimated 460,400 Australians aged 45 and over (5.1%).
However, a large international study (Burden of Obstructive Lung Disease—BOLD), which
tested the lung function of nearly 10,000 people, estimated that the prevalence of COPD
in Australia was 7.5% for people aged 40 and over and 30% for people aged 75 and over
(Toelle et al. 2013).
128
Impact
Chronic respiratory diseases contribute substantially to the disease burden in the Australian
population. The Australian Burden of Disease Study found that, in 2011, respiratory
conditions contributed 8.3% of the total burden of disease and injury in Australia:
• R
espiratory diseases were ranked as the sixth leading contributor to total burden,
after cancer, cardiovascular diseases, mental and substance use disorders,
musculoskeletal conditions, and injuries.
• C
OPD contributed the highest percentage of total burden of all respiratory conditions
(43%), followed by asthma (29%) and upper respiratory conditions (including hay fever,
20%).
• B
urden associated with respiratory diseases rose with increasing remoteness and was
higher among people in lower socioeconomic areas.
COPD was the fifth leading underlying cause of death in Australia in 2016, with 7,212
deaths (4.6% of all deaths); 70% (5,056) of these deaths were of people aged 75 and over.
Further:
• b
etween 2005 and 2015, among people aged 45 and over, the age-standardised death
rate for COPD slowly increased, from 64 to 70 deaths per 100,000 population, but
dropped slightly in 2016 to 68 deaths per 100,000
• b
etween 2011 and 2015, among people of all ages, the age-standardised death rates
Chapter 3
for asthma remained steady at 1.5 deaths per 100,000 population but increased to
1.6 deaths per 100,000 in 2016 (Figure 3.11.1)
• in 2016, there were 455 deaths due to asthma and 381 deaths due to bronchiectasis.
An example of the tragic impact of respiratory conditions occurred in November 2016
in Melbourne, Victoria. Nine people died and several thousands were hospitalised due
to asthma associated with a thunderstorm that triggered high pollen levels in the local
environment (see Chapter 4.1 ‘Impacts of the natural environment on health’).

In most cases, chronic respiratory conditions are managed in primary health care.
In 2014–15, an estimated 61% of people with asthma reported visiting a general
practitioner specifically for their asthma at least once in the previous year (ABS 2017).
In the previous survey in 2011−12, an estimated 57% of people with asthma reported
visiting a general practitioner specifically for their asthma at least once in the previous
year (ABS 2013). In 2014–15, an estimated 75% of children aged 0–14 with asthma were
reported to have visited a general practitioner at least once for their asthma in the last
year (ABS 2017).
Asthma guidelines recommend that all people with asthma should have a written asthma
action plan. However, in 2014–15, based on self-reported survey data, only an estimated
28% of people with asthma as a long-term condition had a written asthma action plan
(with 24% reported to have one in 2011−12; ABS 2013). In 2014–15, an estimated 57% of
children aged 0–14 with asthma were reported to have an asthma action plan (ABS 2017).
129
Between 2005–06 and 2015–16, the age-standardised hospitalisation rates for asthma
fell 12% (from 192 to 169 hospitalisations per 100,000 population). Over the same period,
rates for COPD fluctuated (from a low of 670 to a high of 731 hospitalisations per 100,000
population aged 45 and over) (Figure 3.11.2).
Figure 3.11.1: Age-standardised death rates for asthma (all ages) and COPD
(aged 45 and over), 2005–2016
Rate (deaths per 100,000 population)

80
COPD
70
60
50
40
30
20
10 Asthma
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Note: Rates have been age standardised to the 2001 Australian population.
Figure 3.11.2: Age-standardised hospitalisation rates for asthma (all ages) and
COPD (aged 45 and over), 2005–06 to 2015–16
Rate (hospitalisations per 100,000 population)
800
COPD
700
600
500
400
300
Asthma
200
100
0
Year
Note: Rates have been age standardised to the 2001 Australian population.
Source: National Hospitals Morbidity Database; Table S3.11.1.
130
The prevention, management and treatment of chronic respiratory conditions beyond
hospital settings (including the appropriateness of care relating to clinical guidelines)
cannot be examined in detail because of a lack of data on primary health care. Data
linkage can improve the understanding of pathways through the health system.
Many adults have features of both asthma and COPD, known as asthma–COPD overlap;
further work is needed to better measure this overlap. It is important to identify and
measure people with asthma–COPD overlap as they are at higher risk than patients
with asthma or COPD alone; they have more symptoms, more flare-ups, greater need
to use health care, and a higher mortality (National Asthma Council Australia and Lung
Foundation Australia 2017).

More information on chronic respiratory conditions in Australia is available at
<www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/asthma-other-
chronic-respiratory-conditions/overview>. The report The burden of chronic respiratory
conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011 and
other recent publications can be downloaded from the AIHW website.
References
Chapter 3
ABS (Australian Bureau of Statistics) 2013. Australian Health Survey: health service usage and health related
actions, 2011–12. Table 7.3. ABS cat. no. 4364.0.55.002. Canberra: ABS.
ABS 2015. National Health Survey: first results 2014–15. ABS cat. no. 4364.0.55.001. Canberra: ABS.
ABS 2017. Health service usage and health related actions, Australia, 2014–15. Table 7.3. ABS cat. no.
4364.0.55.002. Canberra: ABS.
National Asthma Council Australia and Lung Foundation Australia 2017. Asthma–COPD overlap. Melbourne:
National Asthma Council Australia.
Toelle BG, Xuan W, Bird TE, Abramson MJ, Atkinson DN, Burton DL et al. 2013. Respiratory symptoms
and illness in older Australians: the Burden of Obstructive Lung Disease (BOLD) study. Medical Journal
of Australia 198:144–8.
131
3.12 Mental health
SNAPSHOT
Good mental health is a state of wellbeing in which an individual realises their own
potential, can cope with the normal stresses of life, can work productively and fruitfully,
and is able to contribute to their community (WHO 2014). A considerable proportion
of the Australian population will experience a mental illness at some time in their life
(see Chapter 3.13 ‘Eating disorders’; Chapter 4.7 ‘Illicit drug use’; Chapter 5.4 ‘People with
disability’).
The terms ‘mental illness’ and ‘mental disorder’ are often used interchangeably and
describe a wide range of mental health and behavioural disorders which vary in duration
and/or severity. The effect of mental illness on the individuals, families and/or carers
concerned can be severe and its influence on society as a whole is far reaching. Social
problems often associated with mental illness include poverty, unemployment or reduced
productivity, and homelessness. People with mental illness may also experience isolation,
discrimination and stigma.
How common is mental illness?

Australia’s National Survey of Mental Health and Wellbeing is a program of three targeted
mental health epidemiological surveys. Together, these surveys provide a detailed view of
the prevalence of mental disorders in Australia:
• T
he adult component of the National Survey of Mental Health and Wellbeing
(conducted most recently in 2007) estimates that around 8.5 million (45%, based
on the estimated 2015 population) Australians aged 16–85 will experience a high
prevalence mental disorder, such as depression, anxiety or a substance use disorder in
their lifetime. Around 20% of the population experienced a common mental disorder
in a 12-month period. Of these, Anxiety disorders (such as social phobia) were the
most prevalent, affecting 1 in 7 (14%) people, followed by Affective disorders (such as
depression) (6.2%) and Substance use disorders (such as alcohol dependence) (5.1%)
(ABS 2008). The age distribution of high prevalence mental disorders in 2007 was
similar to that found 10 years earlier from the same survey (conducted in 1997/1998,
depending on the age group) (Figure 3.12.1).
• T
he National Survey of People with Psychotic Illness (conducted most recently in 2010)
showed that almost 64,000 people with a psychotic illness are in contact with public
specialised mental health services each year (Morgan et al. 2011). The survey did not
cover private service providers, such as private psychiatrists, psychologists and private
hospitals.
• T
he Australian Child and Adolescent Survey of Mental Health and Wellbeing (conducted
most recently in 2013–14) estimates that 560,000 children and adolescents aged
4–17 (almost 14%) experienced a mental disorder in the 12 months before the survey
(Lawrence et al. 2015).
132
Figure 3.12.1: Per cent of Australians with high prevalence mental
disorders, by age group, 1997 and 2007
Age group
65+
2007
55 – 64 1997
45 – 54
35 – 44
25 – 34
16/18 – 24
6 –17
0 5 10 15 20 25 30
Per cent
Notes
1. F
or the 6–17 age group, the data are for 1998 and 2013–14.
2. F
or the 16–18 to 24 age group, the 1997 data relate to people aged 18–24 and the 2007 data to people
Chapter 3
aged 16–24.
3. P
revalence data from the National Survey of People with Psychotic Illness are not included in this figure.
4. S
ome caution should be exercised in comparing findings from the two adult surveys because they
sampled from slightly different age ranges and used somewhat different approaches to gauge the
presence of mental illness in the past 12 months. It may be that these differences in method account
for the small increase in overall prevalence over time.
Sources: Department of Health and Ageing 2013; Lawrence et al. 2015; Table S3.12.1.
Impact
While the National Survey of Mental Health and Wellbeing provides valuable insights, the
severity and duration of a mental illness are critical factors in understanding its impact on
individuals, families and society as a whole. Severe and persistent mental illnesses, such
as psychotic disorders, have a relatively low prevalence but have a substantial impact on
individuals, their families and society due to the ongoing and sometimes extensive care
needs required to support the individual. Mental and substance use disorders contributed
12% of Australia’s total burden of disease in 2011, making it the third highest burden
disease group.
A person experiencing poor mental health may not meet the diagnostic criteria for a
mental disorder (Slade et al. 2009), but their condition may still have a negative impact on
their life. Poor mental health may also be associated with suicidality—the collective term
for suicidal ideation, suicide plans and suicide attempts. While suicidality is more common
in people with mental disorders, it is not confined solely to this group (Slade et al. 2009).
133
People who experience suicidal ideation and make suicide plans are at increased
risk of attempting suicide. At some point in their lives, 13% of Australians aged 16–85
have experienced suicidal ideation, 4.0% have made suicide plans and 3.3% have
attempted suicide (Slade et al. 2009). Between 2007 and 2016, an average of around
2,600 Australians died by suicide each year (ABS 2017). Suicide and self-inflicted injuries
contribute to 2.5% of Australia’s total burden of disease (see Chapter 7.3 ‘Suicide
prevention services’).

Given the passage of time since the last adult survey of mental health was conducted,
it would be appropriate to consider cost-effective methods to update prevalence
information on Australian adults.
There is also a lack of information on the activities of non-government community mental
health organisations being used to support Australians with mental health issues. These
services (both not-for-profit and for-profit) focus on wellbeing, support and assistance for
people who live with mental illness rather than the assessment, diagnosis and treatment
undertaken by clinical services.

More information on mental health in Australia is available in Mental Health Services in
Australia or Australian Burden of Disease Study: impact and causes of illness and death in
Australia 2011.
If you or someone you know needs help please call:

Lifeline 13 11 14 beyondblue 1300 22 4636 Kids Helpline 1800 55 1800
References
ABS (Australian Bureau of Statistics) 2008. National Survey of Mental Health and Wellbeing 2007: summary
of results. ABS cat. no. 4326.0. Canberra: ABS.
ABS 2017. Causes of death, Australia, 2016. ABS cat. no. 3303.0. Canberra: ABS.
Department of Health and Ageing 2013. National Mental Health Report 2013: tracking progress of mental
health reform in Australia 1993–2011. Canberra: Department of Health and Ageing.
Lawrence D, Johnson S, Hafekost J, Boterhoven de Haan K, Sawyer M, Ainley J et al. 2015. The mental health
of children and adolescents: report on the second Australian Child and Adolescent Survey of Mental Health
and Wellbeing. Canberra: Department of Health.
Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V et al. 2011. People living with
psychotic illness 2010: report of the second Australian National Survey. Canberra: Department of Health.
Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J et al. 2009. The mental health of Australians
2: report on the 2007 National Survey of Mental Health and Wellbeing. Canberra: Department of Health
and Ageing.
WHO (World Health Organization) 2014. Mental health: a state of well-being. Geneva: WHO. Viewed
December 2017, <http://www.who.int/features/factfiles/mental_health/en/>.
134
3.13 Eating disorders
SNAPSHOT
Eating disorders are a group of mental illnesses typically characterised by problems
associated with disordered eating or body weight control, and a severe concern with
body weight or shape (Treasure et al. 2010). Disordered eating behaviours may include
overeating or insufficient food intake. There are four types of commonly recognised eating
disorders:
• a
norexia nervosa—characterised by the persistent restriction of food and water intake,
intense fear of gaining weight and disturbance in self-perceived weight or body shape
• b
ulimia nervosa—characterised by repeated binge-eating episodes followed by
compensatory behaviours like self-induced vomiting or laxative misuse
• b
inge eating disorder—characterised by repeated episodes of binge-eating, often with
a sense of loss of control while eating
• o
ther specified feeding or eating disorder—people with this disorder present with
many of the symptoms of anorexia nervosa, bulimia nervosa or binge eating disorder,
but may not meet the full criteria for diagnosis of one or more of these disorders
(Fairweather-Schmidt & Wade 2014).
How common are eating disorders?
Chapter 3
It is difficult to get consensus on prevalence estimates for eating disorders in Australia
(NEDC 2010). Estimates vary substantially between data sources due to different
diagnostic thresholds and the small number of large-scale population research projects
(Hay et al. 2015). The estimated prevalence of any eating disorder varies, depending
on whether narrower clinical diagnostic or broader behavioural criteria are used. For
Australians aged 15 and over, estimated prevalence is 4–16% (Hay et al. 2008; Hay et al.
2015; Wade et al. 2006). Estimated prevalence varies according to the type of disorder—
research suggests binge eating disorder and other specified feeding or eating disorder
are the most prevalent disorders in Australia (Hay et al. 2017; Wade et al. 2006).
Impact
Eating disorders cause considerable psychological distress. They were ranked as the
10th leading cause of non-fatal disease burden for females aged 15–44 in 2011.
The report Paying the price: the economic and social impact of eating disorders in Australia,
commissioned by The Butterfly Foundation, notes that there are few data on the
economic costs of eating disorders (Deloitte Access Economics 2012). The report suggests,
though, that the social and economic costs due to eating disorders are substantial. Based
on 2008–09 AIHW health expenditure data, adjusted for inflation, the report estimates
that, in 2012, costs to the health system related to eating disorders may have been close
to $100 million, with the resulting impact on productivity being as high as $15 billion.
135
Australians with eating disorders may access treatment through a range of health care
settings. These include specialised and non-specialised mental health services, such as
community mental health care and admitted patient care. National data on hospital
admitted patient care show that, in 2015–16, there were about 8,000 overnight and same-
day hospitalisations of people with a principal diagnosis of any eating disorder. Of these
hospitalisations, 61% included those for specialised admitted patient psychiatric care
(Supplementary Table S3.13.2). As well, about 104,000 community mental health service
contacts had a principal diagnosis of eating disorders in 2015–16.

Australians with eating disorders may also present to primary health care services, such as
general practitioners. However, data are generally lacking on people with eating disorders
accessing health services.
A wide variety of specialised eating disorder services and organisations can be accessed
by people needing support, including child and adolescent mental health services and
specialised inpatient eating disorder services (Victorian Department of Health 2014).
Variation by population groups

Eating disorders may occur at any stage of life, but research suggests that they occur
most often among young women (Hay et al. 2008; Hay et al. 2017; Wade et al. 2006).
The Australian Child and Adolescent Survey of Mental Health and Wellbeing estimated
that, in 2012–13, 2.4% of young people aged 11–17 reported problem eating behaviours
(Lawrence et al. 2015). A greater proportion of females (3.5%) than males (1.4%) reported
these behaviours (Lawrence et al. 2015).
In 2015–16, 95% of Australian hospitalisations with a principal diagnosis of an eating
disorder were for females. Females aged 15–24 made up the largest proportion of these
hospitalisations (57%) (Figure 3.13.1).
Figure 3.13.1: Hospitalisations with a principal diagnosis of eating disorders,

by age and sex, 2015–16
Per cent of hospitalisations
60
50 Males Females
40
30
20
10
0
<15 15 – 24 25 – 34 35 – 44 45+
Age group
Source: National Hospital Morbidity Database; Table S3.13.1.
136
In 2015–16, 58% of community mental health care contacts with a principal diagnosis
of eating disorders were provided to girls and women aged 15–24. The next largest
proportion of those contacts (14%) were provided to girls aged under 15 (Supplementary
Table S3.13.3).

There is a lack of nationally consistent data on eating disorders, especially prevalence,
estimated costs to society, and service access (NEDC 2010).

More information about eating disorders is available from The Butterfly Foundation
<www.thebutterflyfoundation.org.au> and The National Eating Disorders Collaboration
<www.nedc.com.au>.
References
Deloitte Access Economics 2012. Paying the price: the economic and social impact of eating disorders
in Australia. Report commissioned by The Butterfly Foundation. Melbourne: The Butterfly Foundation.
Fairweather-Schmidt K & Wade TD 2014. DSM-5 eating disorders and other specified eating and feeding
disorders: is there a meaningful differentiation? International Journal of Eating Disorders 47:524–33.
Hay P, Mitchison D, Collado AEL, Gonzalez-Chica DA, Stocks N & Touyz S 2017. Burden and health-related
quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the
Australian population. Journal of Eating Disorders 5:21.
Chapter 3
Hay PJ, Girosi F & Mond J 2015. Prevalence and sociodemographic correlates of DSM-5 eating disorders
in the Australian population. Journal of Eating Disorders 3:19.
Hay PJ, Mond J, Buttner P & Darby A 2008. Eating disorder behaviors are increasing: findings from two
sequential community surveys in South Australia. PLoS ONE 3:e1541.
Lawrence D, Johnson S, Hafekost J, Boterhoven De Haan K, Sawyer M, Ainley J et al. 2015. The mental health
of children and adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health
and Wellbeing. Canberra: Department of Health.
NEDC (National Eating Disorders Collaboration) 2010. Eating disorders prevention, treatment &
management: an evidence review. Report compilation led by The Butterfly Foundation. Viewed
2 February 2018, <http://www.nedc.com.au>.
Treasure J, Claudino AM & Zucker N 2010. Eating disorders. The Lancet 375:583–9.
Victorian Department of Health 2014. Victorian eating disorders strategy. Melbourne: Victorian
Wade TD, Bergin JL, Tiggemann M, Bullik CM & Fairburn CG 2006. Prevalence and long-term course
of lifetime eating disorders in an adult Australian twin cohort. Australian and New Zealand Journal of
Psychiatry 40:121–9.
137
3.14 Dementia
SNAPSHOT
Dementia is a term used to describe a group of similar conditions that gradually impair
brain function. It is commonly associated with memory loss, but can affect speaking,
thinking and moving. A person’s personality may also change, and health and functional
ability generally decline as the condition progresses. Dementia not only affects individuals
with the condition but also has a substantial impact on their families and carers, and
society more broadly.
How common is dementia?

Australian data on dementia prevalence are lacking, so the following estimates are based
on international information, adjusted for the Australian context.
In 2018, an estimated 376,000 people in Australia had dementia; this figure is projected to
grow to 550,000 by 2030 (Figure 3.14.1).
Figure 3.14.1: Estimated number of people with dementia, by age, 2010–2030
Number ('000)
600
85 and over
65–84
500
Under 65
400
300
200
100
0
2010 2018 2030
Year
In 2018, around three-fifths (61%) of people with dementia were women, and two-fifths
(43%) were aged 85 and over. A similar number of men and women had dementia in the
younger age groups, but, among people aged 85 and over, there were more than twice as
many women as men (partly the result of the higher proportion of women in this age group).
An estimated 8.7% of people aged 65 and over in Australia had dementia in 2018.
However, the rate of dementia varies between population subgroups: for example,
dementia prevalence is estimated to be 2–5 times higher among Aboriginal and Torres
Strait Islander people than among non-Indigenous people, and Indigenous Australians
experience many risk factors for dementia (such as heart disease, diabetes and tobacco
use) at higher rates than non-Indigenous people (Flicker & Holdsworth 2014; Li et al. 2014;
Radford et al. 2015; Smith et al. 2008).
138
Impact
Dementia is more common among older people. Hence, the number of deaths due to
dementia has been increasing steadily alongside the growing number of older people in
the population—Australia’s ageing population and increases in life expectancy increase
the effect dementia has on society.
Among people aged 65 and over, dementia was the second leading cause of total burden
of disease in 2011 (accounting for 7.8% of years of life lost due to illness or death) and the
leading cause of non-fatal burden (accounting for 10% of years of life lost due to living
with the disease).
In 2016, dementia replaced heart disease as the leading underlying cause of death for
women, remaining the third leading cause for men (ABS 2017). This may reflect not
only an increase in the number of older people with dementia, but also changes in how
dementia deaths are recorded. There were more than 25,000 deaths in 2016 where
dementia was considered either to have directly led to the death (as the underlying cause),
or to have contributed to it (as an associated cause)—almost 69 deaths each day. When
trends over time were considered, the balance between dementia being recorded as an
associated, rather than an underlying, cause of death changed. In 2007, for every death
where dementia was recorded as the underlying cause, there were 1.4 deaths where it
was recorded as the associated cause. By 2016, the ratio was 0.9, meaning that there
were slightly more deaths recorded as being due to, rather than involving, dementia.
Chapter 3
See chapters 3.1 ‘Burden of disease across the life stages’, 3.2 ‘Leading causes of death’
for more information on burden of disease and deaths.
Risk factors
Several factors to which people are exposed over their lifetime, or at particular points in
their life, are known to contribute to the risk of developing dementia. These include some
unmodifiable risk factors, such as age, genetics and family history. A number of other
factors, however, can be altered or treated—that is, they are considered modifiable risk
factors. Reducing these could reduce the prevalence of dementia.
Many modifiable risk factors assessed to have a causal association with dementia are
also associated with vascular diseases (such as coronary heart disease and stroke).
‘Vascular’ risk factors for dementia include behavioural risk factors (tobacco smoking and
physical inactivity) and metabolic risk factors (high blood pressure and obesity), as well
as some vascular diseases themselves (stroke, diabetes, atrial fibrillation and chronic
kidney disease).
Jointly, these vascular risk factors represented 30% of the total burden from dementia
in Australia in 2011. This means that almost one-third of healthy years of life lost due to
premature death or ill health from dementia were accounted for by the combined effects
of these eight factors.
Individually, vascular risk factors were each responsible for 5.2–8.4% of the dementia
burden. The individual vascular risk factors (assessed to have a convincing causal
association with dementia) that contributed most to the dementia burden were physical
139
inactivity (8.0%), stroke (6.7%) and high blood pressure (6.0%). Chronic kidney disease
was assessed to have a probable causal association with dementia and was responsible
for 8.4% of dementia burden (Figure 3.14.2). However, the largest health gains could be
achieved by reducing the prevalence of vascular risk factors that are trending upwards,
namely diabetes and obesity.
Figure 3.14.2: Contribution of vascular risk factors to dementia burden in

Australia, by risk factor, 2011
Chronic kidney disease 8.4
Stroke 6.7
Diabetes 5.3
Atrial fibrillation 5.2
High blood pressure 6.0
Obesity 5.6
Physical inactivity 8.0
Tobacco use 4.8
0 3 6 9
Per cent

There is no known cure for dementia. Dementia care generally focuses on alleviating the
behavioural and psychological symptoms of the condition through various medications or
non-drug therapies and support. Four dementia-specific drugs are available for Alzheimer
disease: donepezil for mild, moderate and severe disease; galantamine and rivastigmine
for mild to moderately severe; and memantine for moderately severe to severe. They are
subsidised through the Pharmaceutical Benefits Scheme. In 2015, 514,000 Pharmaceutical
Benefits Scheme prescriptions were dispensed for these medications (Department of
Health 2016).
People with dementia may also use a mix of health and aged care services. For example,
22,200 people aged 65 and over were admitted to hospital in New South Wales in 2015–16
with dementia as the principal diagnosis or comorbidity (CEE 2016). Nationwide, as at
30 June 2017, 89,500 people with dementia were living in permanent residential aged care
(representing around half of all people in care).
140
Currently, there are no national data on how many people in Australia are affected by
dementia—instead, numbers are estimated based on international data and modelling.
While combining multiple sources to identify dementia cases has been shown to produce
plausible prevalence estimates (Waller et al. 2017), the lack of comprehensive data
affects the ability to monitor the incidence and prevalence of dementia and how it is
treated and managed. Data linkage may improve understanding of patient outcomes
and disease interactions.

More information on deaths and leading causes of death in Australia, including the
General Incidence of Mortality (GRIM) books and Mortality Over Regions and Time (MORT)
books, is available on the AIHW website at <www.aihw.gov.au/reports-statistics/health-
conditions-disability-deaths/life-expectancy-deaths/overview>. More information on
vascular risk factors for dementia is available in the AIHW report Contribution of vascular
diseases and risk factors to the burden of dementia in Australia. Further information on
dementia is available at <www.aihw.gov.au/reports-statistics/health-conditions-disability-
deaths/dementia/> and in the report Dementia in Australia.
References
Chapter 3
ABS (Australian Bureau of Statistics) 2017. Causes of death, Australia, 2016. ABS cat. no. 3303.0.
Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2012. Dementia in Australia. Cat. no. AGE 70.
Canberra: AIHW.
AIHW 2016. Contribution of vascular diseases and risk factors to the burden of dementia in Australia:
Australian Burden of Disease Study 2011. Australian Burden of Disease Study series no. 9. Cat. no. BOD 10.
Canberra: AIHW.
CEE (Centre for Epidemiology and Evidence) 2016. HealthStats NSW: dementia hospitalisations. Sydney:
NSW Health. Viewed 21 November 2017,
<http://www.healthstats.nsw.gov.au/Indicator/bod_dementhos/bod_dementhos>.
Department of Health 2016. Australian statistics on medicines 2015. Canberra: Department of Health.
Accessed 21 Feb 2018, <http://www.pbs.gov.au/info/statistics/asm/asm-2015>.
Flicker L & Holdsworth K 2014. Aboriginal and Torres Strait Islander people and dementia: a review of
the research. Alzheimer’s Australia 41. Canberra: Alzheimer’s Australia.
Li SQ, Guthridge SL, Eswara Aratchige P, Lowe MP, Wang Z, Zhao Y et al. 2014. Dementia prevalence and
incidence among the Indigenous and non-Indigenous populations of the Northern Territory.
Medical Journal of Australia 200:465–9.
Radford K, Mack HA, Draper B, Chalkley S, Daylight G, Cumming R et al. 2015. Prevalence of dementia in
urban and regional Aboriginal Australians. Alzheimer’s & Dementia 11(3):271–9.
Smith K, Flicker L, Lautenschlager NT, Almeida O, Atkinson P, Dwyer D et al. 2008. High
prevalence of dementia and cognitive impairment in Indigenous Australians. Neurology 71:1470–3.
Waller M, Mishra GD & Dobson AJ 2017. Estimating the prevalence of dementia using multiple linked
administrative health records and capture—recapture methodology. Emerging Themes in Epidemiology
14(3). Viewed 21 November 2017, <https://dx.doi.org/10.1186%2Fs12982-017-0057-3>.
141
3.15 Injury
SNAPSHOT
Injury is a major contributor to mortality, morbidity and permanent disability in Australia.

In 2011, it accounted for 8.8% of the total burden of disease in Australia, and was the
fifth leading cause of burden. Based on self-reported data, 7.0% of the main long-term
health conditions experienced by the estimated 4.3 million Australians living with
disability occurred due to injury or poisoning (ABS 2016).
This snapshot describes the overall patterns of injury in Australia. Other chapters of
this report describe injury in the context of family, domestic and sexual violence
(see Chapter 3.16 ‘Family, domestic and sexual violence’) and opioid use and misuse
(see Chapter 3.17 ‘Opioid harm’).
How common is injury?

Injury deaths
• Injury was recorded as a cause of more than 12,600 deaths in 2014–15 in
Australia—8.1% of all deaths.
• T
he age-standardised rate of injury deaths in 2014–15 was 48 per 100,000 population.
This rate has remained relatively steady since 2004–05, following a decrease from 55
per 100,000 population in 1999–00.
• Injury death rates were highest for men and women aged over 65; 42% of male injury
deaths and 68% of female injury deaths occurred in this age group.
• Injury death rates for males were higher than for females in every age group, especially
at ages 25–44.
• T
he most common causes of injury deaths were falls (37% of all deaths), suicide (23%)
and transport crashes (11%), though there were differences in the leading causes of
injury death for males and females (Figure 3.15.1). For males, suicide was the leading
cause (29% of all male injury deaths); for females, falls were the leading cause (53% of
female injury deaths).
• A
ge-standardised rates of injury deaths for Aboriginal and Torres Strait Islander
people were twice the rate for non-Indigenous people (97 and 48 deaths per 100,000
population, respectively).
• R
ates of injury death increased with increasing remoteness—from 43 deaths per
100,000 population in Major cities to 88 deaths in Very remote areas.
142
Figure 3.15.1: Proportion of injury deaths, leading causes, by sex, 2014–15
1. Falls 27% 53%
2. Suicide 29% 14%
3. Transport 13% 8%
4. Poisoning (pharmaceuticals) 11% 8%
Source: AIHW: Henley & Harrison, forthcoming 2018a; Table S3.15.1.
Hospitalised injury cases
Chapter 3
• In 2014–15, there were more than 480,000 cases of hospitalised injury in Australia.
• H
ospitalised injuries can range from single fractures to catastrophic injuries, such
as spinal cord injury or severe traumatic brain injury. About 1 in 6 (15%) hospitalised
injury cases were classified as ‘high threat to life’. Serious injuries often cause persisting
problems and ongoing need for health care services.
• T
he main causes of hospitalised injury were falls (41%), followed by injury due to
inanimate mechanical forces (for example, being struck by an object, including sports
equipment, or contact with powered tools; 14%), and transport crashes (12%).
• M
ales accounted for more than half (55%) of all injury cases. The rate of injury for males
overall was 2,300 cases per 100,000 males, compared with 1,600 per 100,000 females.
• F
or both males and females, age-specific rates of injury were much higher in age groups
above age 75. Males had a higher rate of injury than females across all age groups up to
about ages 65–69; in older age groups, females had much higher rates.
• T
he number of hospitalised injury cases per 100,000 population was higher for
Indigenous people (3,600) than for Other Australians (1,900).
143
Presentations to public hospital emergency
departments
Information on injury occurrence is also available from data on why people present to
hospital emergency departments.
Data on the main diagnosis are available in a consistent format for 68% of all emergency
department presentations. These data show that there were 1.3 million presentations
for injury in 2013–14 (27% of the emergency presentations for which suitable data were
available). This would be equivalent to an estimated 1.9 million presentations for injury
across all Australian public hospital emergency departments.

More than one-quarter (28%) of presentations to emergency departments for injury were
for children aged 0–14, with a further 19% for people aged 15–24 (Figure 3.15.2).
Figure 3.15.2: Injury-related emergency department presentations, by age

and sex, 2013–14
Number
200,000
Males Females
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
0 –14 15 – 24 25 –34 35 – 44 45 – 54 55 – 64 65 – 74 75+
Age group
Source: AIHW: Henley & Harrison, forthcoming 2018b; Table S3.15.2.
Overall, 22% of emergency department presentations were for soft-tissue injury, 21% for
fractures and 18% for open wounds.
Most people treated for an injury in an emergency department were not admitted for
further care in hospital (82%). The likelihood of being admitted varied by the nature of the
injury: people with internal organ injuries, intracranial injuries, or exposure to poisons or
toxins were most likely to be admitted (86%, 44% and 45%, respectively), though these
cases accounted for only 5.9% of all injury presentations to emergency departments.
144
Limited data are available on cases treated in other health care settings, including by
general practitioners, at sports medicine clinics, by physiotherapists and elsewhere.
As noted, the data available on emergency presentations are incomplete. Also, the
nationally available data include very limited information on the events and circumstances
that result in the injury (for example, transport crashes).
Many injury cases, especially (but not only) those needing hospital admission, leave the
person with long-lasting disability. Data linkage can improve the understanding of patient
outcomes and pathways through the health system.

More information about hospitalisations and deaths due to injury in Australia is available
at <www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/injury/
overview>.
References
ABS (Australian Bureau of Statistics) 2016. Disability, ageing and carers, Australia: summary of findings,
2015, data cubes. ABS cat. no. 4430.0. Canberra: ABS. Viewed 21 February 2018,
<http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4430.02015?OpenDocument>.
AIHW (Australian Institute of Health and Welfare): Henley G & JE Harrison, forthcoming 2018a. Trends in
injury deaths, Australia, 1999–00 to 2014–15. Injury research and statistics series no. 112. Cat. no. INJCAT
Chapter 3
192. Canberra: AIHW.
AIHW: Henley G & Harrison JE, forthcoming 2018b. Use of emergency department data to enhance routine
injury surveillance: technical report. Canberra: AIHW.
145
3.16 Family, domestic and
SNAPSHOT
sexual violence
Family, domestic and sexual violence (FDSV) is a major health and welfare issue in
Australia (see Glossary for definitions). While men, women and children from all walks
of life can experience FDSV, some groups are at particular risk, including Aboriginal and
Torres Strait Islander women, young women, pregnant women and women with disability.
Intimate partner violence has serious impacts on women’s health. See Chapter 4.4
‘Contribution of selected risk factors to burden of disease’ for more information on the
burden of disease impacts on women due to intimate partner violence.
This snapshot provides an overview of hospitalised assaults and deaths in the context
of family and domestic relationships.
How common is FDSV?

One in 6 (17%, or 1.6 million) Australian women have experienced physical or sexual
violence by a current or former cohabiting partner, since the age of 15. Further, 1 in 16
(6.1%, or 0.5 million) men have experienced this kind of violence since the age of 15.
For women who had children in their care while experiencing violence from a current
partner, half (50%) said the children had seen or heard the violence; this proportion
increased when the violence was perpetrated by a former partner (68%) (ABS 2017).
Impact of FDSV
FDSV generates a range of responses and consequences, involving both health and
welfare services. FDSV can have serious impacts on a victim’s health. In 2011, it
contributed to more burden of disease (the impact of illness, disability and premature
death) than any other risk factor for women aged 25–44 (Ayre et al. 2016). Seven
disorders or events were causally linked to exposure to intimate partner violence:
depressive and anxiety disorders, early pregnancy loss, homicide and violence, suicide
and self-inflicted injuries, alcohol use disorders, and children born prematurely or with
low birthweight. Serious cases of FDSV can end in hospitalisation or death.
Hospitalised injury
In 2014–15, there were more than 19,000 hospitalisations due to an assault injury. Of
these hospitalisations, nearly 1 in 5 (18% or 3,400) people reported that the perpetrator
was a Spouse or domestic partner, with Other family member reported for a further 8.8%
(1,700 hospitalisations).
Where the perpetrator was identified, a Spouse or domestic partner was recorded for
almost half (45%) of all hospitalisations of female assault victims—or more than 2,800
cases. For men, a Spouse or domestic partner was recorded as the perpetrator for almost
146
1 in 20 (4.4%) hospitalisations—or about 560 cases (Figure 3.16.1). Sex differences were
also apparent in assault injury hospitalisations when the perpetrator was identified as
Other family member, including Parents (15% of female hospitalisations compared with
8.6% of males).
The type of perpetrator for assault injury hospitalisations also differed by age group.
For children, most perpetrators were Parents or Other family members (80% for children
aged 0–4 and 40% for children aged 5–14). Spouse or domestic partner was the most
commonly identified perpetrator among people aged 15–24 (13%) and 25–44 (22%).
The most commonly identified perpetrator for people aged 65 and over was Other family
member (23%).
Figure 3.16.1: Assault injury hospitalisations, by reported perpetrator, by sex,

2014–15
Males Females
Spouse or domestic partner
Other family member
Other known person
Chapter 3
Person(s) unknown
to the victim
Other specified person
Unspecified person
60 50 40 30 20 10 0 10 20 30 40 50 60
Per cent
Note: Around half of all assault hospitalisations did not have a reported perpetrator, and results should be
interpreted with some caution.
Deaths
From 1 July 2012 to 30 June 2014, there were 487 homicide incidents, involving 512 victims.
A domestic relationship was the most common relationship between a victim and the
homicide offender; more than 200 domestic homicide incidents were recorded involving
213 victims and 200 perpetrators. Of these incidents:
• 6
3% (126) were intimate partner incidents
• 1
5% (30) were incidents involving a parent (or step-parent) killing a child (filicide)
• 1
0% (21) were incidents where a child killed a parent or step-parent (parricide)
• 8
% (16) were other family incidents, such as those involving cousins, aunts/uncles,
grandparents and so on
• 4
% (7) were incidents where one sibling killed another (siblicide).
147
Females were predominantly the victims of domestic homicide (65%) and males largely
the offenders (79%). Almost 4 in 5 (79% or 99) victims of intimate partner homicide
between 2012 and 2014 were women (Figure 3.16.2)—this represents nearly 1 woman
per week being killed by an intimate partner. Men were 80% of the offenders in cases
of intimate partner homicide (Figure 3.16.2).
While females were over-represented as victims of all types of domestic homicide
combined, males were over-represented as victims of some forms of domestic homicide,
particularly homicides involving siblings (78%) (Figure 3.16.2). Males were 100% of the
offenders for homicides involving siblings (Bryant & Bricknell 2017).
Figure 3.16.2: Type of homicide, by gender of victims and offenders, 2012–13

to 2013–14
Per cent Males Females

100
80
60
40
20
0
Victim
Victim
Victim
Victim
Victim
Victim
Offender
Offender
Offender
Offender
Offender
Offender
Intimate Other
partner Filicide Parricide Siblicide family Total
Source: Bryant & Bricknell 2017; Table S3.16.2.
148
While there are data for reporting on certain aspects of FDSV, there are notable gaps in
respect to the health impacts of FDSV. For example, there is no national information—
or incomplete or inconsistent capture of information—on emergency department
presentations and general practitioner visits. This makes it difficult to answer questions
to support research and policies, such as:
• W
hat health services and responses do victims and perpetrators of FDSV need and use,
and how coordinated are they?
• W
hat are children’s experiences of FDSV?
• W
hat are the pathways, impacts and outcomes for victims and perpetrators of FDSV?
• W
hich groups are at greater risk of FDSV?
• H
ow do the health impacts of FDSV vary by location (noting that data are available
for some, but not all, states and territories)?
• W
hat programs and interventions are the most effective to prevent and respond
to FDSV?
These data gaps limit the extent to which we can understand the health impacts and
outcomes for victims and perpetrators. There is also very limited information about
specific at-risk groups, such as Indigenous people, children, culturally and linguistically
diverse communities, and adults and children with disability.
Chapter 3
More information on FDSV is available at <www.aihw.gov.au/reports-statistics/behaviours-
risk-factors/domestic-violence/overview>. The report Family, domestic and sexual violence in
If you are experiencing domestic or family violence or know someone who is,
please call 1800RESPECT (1800 737 732) or visit the 1800RESPECT website.
References
ABS (Australian Bureau of Statistics) 2017. Personal Safety Survey 2016. ABS cat. no. 4906.0. Canberra: ABS.
Ayre J, Lum On M, Webster K, Gourley M & Moon L 2016. Examination of the burden of disease of intimate
partner violence against women in 2011: final report (ANROWS Horizons, 06/2016). Sydney: ANROWS.
Viewed 15 November 2016, <http://media.aomx.com/anrows.org.au/s3fs-public/BoD%20Horizons.pdf>.
Bryant W & Bricknell S 2017. Homicide in Australia 2012–13 to 2013–14: National Homicide Monitoring
Program Report. Canberra: Australian Institute of Criminology.
149
3.17 Opioid harm
SNAPSHOT
Statistics for Australia show recent increases in the use of opioids, and opioid-related
poisonings, overdoses and deaths. This reflects international trends.
Opioids are chemical substances that have a morphine-type action in the body. They are
most commonly used for pain relief, but are addictive and can lead to dependence. Opioid
drugs can be either illicit (predominantly heroin) or prescription (including codeine, which
has been a prescription-only medication in Australia since February 2018). They include:
• opiates—drugs naturally derived from the opium poppy, such as codeine and heroin
• semi-synthetic opiates, such as hydromorphone and oxycodone
• synthetic opioids, such as fentanyl and methadone.
Because opioids are addictive, there is the potential for dependence and misuse for both
therapeutic and illicit opioids. Harm from the use of opioids can be social (for example,
crime), mental/behavioural and physical. This snapshot focuses on the physical and
mental/behavioural harms, in particular poisonings and dependence.
How common is opioid use and misuse?

Prescription opioids
Opioids are medically prescribed for two main reasons: pain management and the
treatment of heroin and other opioid dependence—commonly referred to as Opioid
Substitution Therapy or pharmacotherapy.
The AIHW’s analysis of Pharmaceutical Benefits Scheme data shows that 11.1 million
opioid prescriptions were dispensed in 2014–15.
Opioid prescriptions rose by 24% between 2010–11 and 2014–15, from 369 to 456
prescriptions per 1,000 population.
Oxycodone (and oxycodone/naloxone) accounted for 1 in 3 (34%) opioids prescribed in
2014–15, prescriptions for which increased by 68% over the period (from
2.3 million to 3.8 million). Codeine prescriptions were the second most common opioid
prescription in 2014–15, accounting for almost 1 in 4 (23%).
Misuse and illicit use of opioids

Using self-reported data from the National Drug Strategy Household Survey of people
aged 14 and over in 2016:
• 3.6% had recently used pharmaceutical opioids for non-medical purposes
• o
f those reporting use, over-the-counter codeine products were the most common (2.5%),
followed by prescription codeine products (for example, Panadeine Forte) (1.4%). Less
common was oxycodone (0.6%), tramadol (0.3%), morphine (0.1%) and fentanyl (<0.1%)
• o
nly a small proportion (1.3%) reported ever using heroin in their life, and 0.2%
reported using recently (in the last 12 months). However, 49% of recent users reported
using heroin once a week or more.
150
Impact
Opioid use and misuse can result in dependence, overdose, physical harm or, in the worst
case, death. In 2011, opioid use was responsible for 0.9% of the total burden of disease
and injuries. Most of the burden due to opioid use was due to accidental poisoning (63%)
and opioid dependence (29%). A further 7.8% of the burden due to opioid use was from
suicide and self-inflicted injuries.
The National Hospital Morbidity Database can be used to calculate the rate of
hospitalisations with a principal diagnosis of poisoning or mental and behavioural
disorders due to opioids. This rate indicates the impact over time on Australia’s hospital
system of opioid use and misuse. The National Mortality Database can be used to report
on deaths from opioid poisoning.
In recent years, opioid-related hospitalisations and deaths have risen:
• In 2015–16, the rate of hospitalisations with an opioid-related principal diagnosis was
37 per 100,000 population, a 12% increase since 2011–12 (33 per 100,000 population).
• A
nalysis of the National Mortality Database found that, in 2016, more than 1,100
drug-induced deaths mentioned opioid poisoning (one or more times), up 89% from
591 deaths in 2007.
Of opioid deaths in 2016:
Chapter 3
• 550 mentioned other opioids (includes prescription painkillers such as
oxycodone, morphine and codeine)
• 3
61 mentioned heroin
• 2
08 mentioned methadone
• 2
34 mentioned other synthetic narcotics (for example, fentanyl and
tramadol).

Some treatment for acute poisoning and overdose is provided in hospitals to admitted
patients or by emergency departments and general practitioners to non-admitted
patients. There are also specialised Alcohol and Other Drug Treatment Services (AODTS)
that provide a range of treatments for clients who use, misuse or are dependent on
opioids. These treatments include counselling, information and education, rehabilitation,
support and case management, withdrawal management and/or pharmacotherapy.
Information about the treatment provided is captured in the AODTS National Minimum
Data Set (see Chapter 7.19 ‘Specialised alcohol and other drug treatment services’).
In 2016–17:
• h
eroin was the fourth most common principal drug of concern (5.2% of closed
treatment episodes) and was listed as a drug of concern (principal or additional) in
7.5% of closed treatment episodes
• a
n opioid pharmaceutical (for example, codeine, oxycodone, fentanyl or methadone)
was the principal drug of concern in 3.3% of closed treatment episodes and a drug
of concern (principal or additional) in 6.8% of closed treatment episodes.
151
Opioid pharmacotherapy treatment is one of the main types of treatment used for opioid
drug dependence. It involves replacing the opioid drug of dependence with a legally
obtained, longer lasting opioid (methadone, buprenorphine or buprenorphine–naloxone)
that is taken orally. Clients receive pharmacotherapy treatment for a range of opioid drugs
(both prescribed and illegal) to reduce withdrawal symptoms, the desire to take opioids,
and the euphoric effect of taking opioids. This treatment type is captured for a particular
day (snapshot) in the National Opioid Pharmacotherapy Statistics Annual Data (NOPSAD)
collection.
Based on the NOPSAD, on a snapshot day in June 2017, nearly 50,000 people in Australia
(20 per 10,000 population) received opioid pharmacotherapy treatment. Of these clients:
• 3
8% reported heroin as their opioid drug of dependence, followed by oxycodone (5.2%),
morphine (4.3%), codeine (4.2%) and methadone (4.1%)
• t he median age (across all pharmacotherapy types) was 42
• a
round two-thirds (65%) were male.

In Australia, medicines containing codeine were available over-the-counter until
1 February 2018. Reporting of pharmaceutical prescriptions does not reflect the total
amount of codeine obtained before this date.
National data on drug-related ambulance attendances are currently not available.
Emergency departments are a key source of treatment for opioid-related poisonings.
No data on emergency department presentations are included in this snapshot due to
data limitations (which limit the ability to accurately determine the substances involved
in poisoning presentations).
This snapshot does not capture harms relating to violence and injury arising from
opioid use because data are incomplete; it can also be difficult to attribute these harms
to opioids directly.

More information on opioid drug use is available at <www.aihw.gov.au/reports-statistics/
behaviours-risk-factors/illicit-use-of-drugs/overview>.
More information on opioid treatment services is available at <www.aihw.gov.au/reports-
statistics/health-welfare-services/alcohol-other-drug-treatment-services/overview>.
More information on causes of death in Australia is available at <www.abs.gov.au/
AUSSTATS/[email protected]/Lookup/3303.0Main+Features12016?OpenDocument>.
The following report and other recent releases relating to this topic are available for free
download on the AIHW website: Non-medical use of pharmaceuticals: trends, harms and
treatment 2006–07 to 2015–16.
152
3.18 Oral and dental health
SNAPSHOT
Good oral health (including dental health) is important for overall wellbeing. Without it,
general quality of life and the ability to eat, speak and socialise is compromised, resulting
in pain, discomfort and embarrassment. Poor oral health is also associated with other
health problems such as stroke, cardiovascular disease and adverse pregnancy outcomes
(COAG Health Council 2015).
In 2011, poor oral health (mainly tooth decay, gum disease and tooth loss) contributed
4.4% of the non-fatal burden of disease in Australia.
How common is poor oral and dental health?

Ha et al. (2016) reported that the National Child Oral Health Study 2012–14, which
included a clinical examination component, found that:
• a
bout 2 in 5 (42%) children aged 5–10 had experienced decay in their primary (baby)
teeth and more than 1 in 4 (27%) had untreated decay in these teeth
• a
lmost 1 in 4 (24%) children aged 6–14 had experienced decay in their permanent teeth,
and more than 1 in 10 (11%) had untreated decay in these teeth.
The National Survey of Adult Oral Health 2004–06, which included a clinical examination
Chapter 3
component, showed that for people aged 15 and over:
• more than 1 in 4 (26%) had untreated tooth decay
• a
lmost 1 in 4 (23%) had moderate or severe gum disease, which increased to
more than 1 in 2 (53%) among people aged 65 and over.
Proportion of people with untreated tooth decay
Age Per cent
5–10 (a) 27%
6–14 (a) 11%
15+ (b) 26%
(a) Data are for 2012–14.

(b) Data are for 2004–06.
Sources: AIHW: Chrisopoulos et al. 2016; Ha et. al. 2016.
153
The National Dental Telephone Interview Survey 2013 (based on self-reported
information) found that, for people aged 15 and over, 1 in 20 (4.4%) had no natural teeth,
including 1 in 5 (19%) people aged 65 and over. Dentate people (people who had at least
one natural tooth) had 5 missing teeth on average, rising to 11 missing teeth for dentate
people aged 65 and over. For dentate people:
• 1
in 7 (16%) had experienced toothache within the previous year
• 1
in 5 (20%) avoided eating certain foods because of oral health problems within the
previous year
• 1
in 4 (27%) felt uncomfortable with their dental appearance.
Use of dental health services

Brennan et al. (2016) reported that the National Child Oral Health Study 2012–14 found
that for children aged 5–14:
• 1
in 10 (11%) had never visited a dentist
• 8
1% had visited a dentist in the 12 months before the survey
• 5
7% last attended a private dental service.
The 2016–17 Patient Experience Survey found that, in the last 12 months, for people
aged 15 and over:
• 4
8% saw a dental professional. The proportion who visited a dentist in the last
12 months was lowest for people aged 25–34 (34%) and highest for people
aged 55–64 (53%)
• 1
7% who reported that they needed to visit a dentist, had not done so (ABS 2017).
The National Dental Telephone Interview Survey 2013 found for people aged 15 and over:
• a
lmost half (44%) had favourable (proactive) dental visiting patterns (visiting at least
once a year for a check-up rather than a problem)
• 4
in 5 (84%) dental visits were made to a private dental practice
• 1
in 3 (35%) dentate people delayed or avoided going to the dentist due to cost;
this was an increase from 25% in 1994.
Almost $10 billion was spent on dental services in Australia in 2015–16. The majority (58%)
of this cost was paid by patients directly, with individuals spending an average of $239
on dental services over the 12-month period (see Chapter 2.2 ‘How much does Australia
spend on health care?’ for more information).
As well as visits to dental professionals, there were more than 67,000 potentially
preventable hospitalisations for dental conditions in 2015–16, accounting for 80,000 bed
days. Adjusting for age, the rate of potentially preventable hospitalisations for dental
conditions increased between 2013–14 and 2015–16, from 279 to 284 separations per
100,000 people.
154
There are limited routinely collected data on oral health status, as the surveys noted in
this snapshot are conducted relatively infrequently. There is also limited information
about dental services provided in Australia, especially in relation to those provided in
the private sector.
Some national data are routinely collected from public dental services, but they are not
currently nationally comparable and focus only on waiting times for some adult patients.
Further, they do not cover reasons for, and the nature and outcomes of, public sector
dental care provision.

More information is available on the AIHW website at Dental and oral health. The
following report is available for free download: Oral health and dental care in Australia:
key facts and figures 2015.
References
ABS (Australian Bureau of Statistics) 2017. Patient experiences in Australia: summary of findings, 2016–17.
AIHW (Australian Institute of Health and Welfare): Chrisopoulos S, Harford JE & Ellershaw A 2016. Oral
health and dental care in Australia: key facts and figures 2015. Cat. no. DEN 229. Canberra: AIHW.
Brennan DS, Ju X, Amarasena N, Dooland M, Peres KG, Mejia GC et al. 2016. Patterns of dental services use
Chapter 3
by Australian children. In: Do LG & Spencer AJ (eds). Oral health of Australian children: the National Child
Oral Health Study 2012–14. Adelaide: University of Adelaide Press.
COAG Health Council 2015. Healthy mouths, healthy lives: Australia’s National Oral Health Plan 2015–2024.
Adelaide: SA Dental Service.
Ha DH, Roberts-Thomson KF, Arrow P, Peres KG & Do LG 2016. Children’s oral health status in Australia,
2012–14. In: Do LG & Spencer AJ (eds). Oral health of Australian children: the National Child Oral Health
Study 2012–14. Adelaide: University of Adelaide Press.
155
3.19 Communicable diseases
SNAPSHOT
Communicable diseases are caused by infectious agents and can be passed from one
person or animal to another. Transmission can occur directly (through contact with
bodily discharge), indirectly (for example, by sharing a drinking glass) or by vectors
(such as mosquitoes). These diseases are caused by bacteria, viruses, parasites or fungi
or their toxic products. Examples include malaria, influenza and chicken pox.
Throughout the 1900s, improved sanitation and new prevention and treatment
options drastically reduced the burden of communicable diseases. Vaccination is a

key preventative measure and has been highly successful in reducing infections from
serious diseases such as polio and measles (see chapters 7.1 ‘Health promotion’;
7.2 ‘Immunisation and vaccination’).
Although the total burden of communicable diseases in Australia is relatively small (1.6%),
they are an important cause of ill health. Many have the potential to cause serious illness
and outbreaks. Some have developed resistance to antimicrobial agents, increasing the
risk of more lengthy and complex treatment and poor outcomes (ACSQHC 2017).
How common are communicable diseases?

Most people will experience an infection with a communicable disease during their
lifetime—for example, a common cold or a stomach bug. Mostly, the illness is mild
and short lived and medical care is not needed or sought. The prevalence of many
communicable diseases is therefore difficult to determine. However, certain diseases
have to be reported to health authorities (Box 3.19.1); this requirement ensures that a
consistent and comparable data set is collected over time, providing information about
who is affected.
Box 3.19.1: Notifiable diseases

Notifiable diseases are a subset of communicable diseases. Legislation requires
that each detected case is reported to state and territory health departments.
Notification means that trends in the number and characteristics of cases can
be monitored over time and outbreaks can be detected promptly. This enables
interventions to be implemented to prevent or reduce transmission. Monitoring,
analysis and reporting on notifiable diseases occurs nationally via the National
Notifiable Disease Surveillance System (NNDSS).
More than 500,000 cases of notifiable diseases were reported to the NNDSS in 2017.
The most commonly notified diseases were:
• laboratory-confirmed influenza (a respiratory infection) (around 250,000 notifications)
• c hlamydial infection (a sexually transmitted infection) (around 96,700 notifications)
• g
onococcal infection (a sexually transmitted infection, also called gonorrhoea) (around
28,400 notifications)
• campylobacteriosis (a gastrointestinal infection) (around 26,700 notifications) (Figure 3.19.1).
156
In 2017, influenza activity in Australia was high, although it varied between states and
territories. Overall, the reported numbers of notifications, people seeking care at primary
care providers and hospitals, and hospital admissions were the most since the 2009
pandemic year. However, the 2017 season was not characterised by greater severity;
both the number of people admitted to intensive care, and the mortality associated with
influenza were within the normal range, considering the large number of notified cases
and the main type of influenza causing illness (influenza A (H3N2)). It is difficult to identify
specific causes for the high level of influenza activity; however, in eastern states and
territories, the season began 1 month earlier and the high point of activity lasted longer
compared with patterns for previous years (Department of Health 2017a).
The extent of under-notification and trends in notifications of communicable diseases
can change if patients become more likely to seek medical care for infection or screening,
if the number of laboratory tests requested by health practitioners increases, or if
laboratory tests become more sensitive. For example, it is possible that increased rapid
testing contributed, in part, to a dramatic increase in influenza notifications in 2017
compared with 2016 (Department of Health 2017b). The rise in the chlamydia and
gonorrhoea notification rate over time was associated with the gradual introduction of
more sensitive laboratory tests and an increased number of tests being performed (Kirby
Institute 2017; Figure 3.19.1).
Figure 3.19.1: Notification rates for selected notifiable diseases, 2013–2017
Chapter 3
Notification rate (per 100,000 population)
1,000 Influenza
Chlamydial infection
Campylobacteriosis
800
Gonococcal infection
600
400
200
0
2013 2014 2015 2016 2017
Year
Source: Department of Health 2018; Table S3.19.1.
157
Hospitalisations and deaths
Some people who become infected with communicable diseases end up with a
severe infection, resulting in hospitalisation. In 2015–16, 93% of the nearly 400,000
hospitalisations for communicable diseases were for non-notifiable diseases
(Supplementary Table S3.19.1). The hospitalisation rate for non-notifiable communicable
diseases increased by 43% since 2000–01, to 240 per 1,000 population in 2015–16
(more than 372,000 hospitalisations). The most common diagnosis was lower respiratory
tract infections (such as pneumonia and bronchitis), accounting for almost 143,000
hospitalisations (36%) in 2015–16. Of the nearly 28,000 hospitalisations for notifiable

diseases, influenza was the most common diagnosis associated with hospitalisation
(10,800, 38%). The hospitalisation rate per 1,000 population for notifiable communicable
diseases ranged between 13 in 2007–08 and 20 in 2015–16 (Figure 3.19.2a).
In 2015, slightly more than 6,300 deaths were attributed to communicable diseases.
The majority of deaths occurred in people aged over 65 and were caused by non-notifiable
lower respiratory infections. The death rate per 100,000 population due to non-notifiable
communicable diseases ranged between 14 in 2008 and 24 in 2003 (Figure 3.19.2b). Of the
800 deaths attributed to notifiable diseases between 2000 and 2015, the most common
diagnoses were influenza (282) and chronic hepatitis C infection (225).
Figure 3.19.2a: Age-standardised Figure 3.19.2b: Age-standardised

hospitalisations rates for notifiable mortality rates for notifiable and
and non-notifiable communicable non-notifiable communicable
diseases, 2000–01 to 2015–16 diseases, 2000–2016
Rate (hospitalisations per 1,000 population) Rate (deaths per 100,000 population)
300 30
250 Non-notifiable diseases 25
Non-notifiable diseases
200 20
150 15
100 10
50 Notifiable diseases
Notifiable diseases 5
0
0
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
2013-14
2014-15
2015-16
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Year
Year
Source: National Hospital Morbidity Database; Source: National Mortality Database;

Table S3.19.1. Table S3.19.1.
158
Selected outbreaks of communicable diseases in 2017
The notification system in Australia enables public health authorities to detect outbreaks
and increases in communicable diseases. Many outbreaks occur each year—such
as widespread seasonal outbreaks of influenza or localised outbreaks of diseases
transmitted through, for example, consumption of contaminated food. Of interest
because of their severity, ongoing nature, geographic spread and impact on Aboriginal
and Torres Strait Islander people are outbreaks of invasive meningococcal disease (IMD)
and infectious syphilis, shown for the period 2008–2017 in Figure 3.19.3.
Figure 3.19.3: Notification rates for new syphilis infections and invasive
meningococcal disease, serogroup W, 2008–2017
Syphilis notification rate IMD, serogroup W notification

per 100,000 population rate per 100,000 population
20 0.7
18
0.6
16
14 0.5
12
0.4
10
Chapter 3
New syphilis
0.3
8
6 0.2
4 IMD, serogroup W
0.1
2
0 0.0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Year
Invasive meningococcal disease, type W

There are five main types of IMD—caused by types (‘serogroup’) A, B, C, W and Y.
A national immunisation program against serogroup C (MenC) was introduced in
2003 in response to an increase in notified cases, particularly among adolescents and
young adults. Between 2003 and 2014, the rates of IMD infection declined, with most
cases infected with serogroup B. However, in 2014, the number of IMD cases caused
by serogroup W (MenW) began to increase, with 17 cases reported. MenW was the
predominant cause of IMD in 2016, with 108 cases reported.
159
Cases are scattered around Australia, but the impact on Indigenous Australians has been
comparatively greater (compared with Other Australians), particularly in central Northern
Territory. As at 31 December 2017, there were 140 MenW cases reported in 2017; it was
the predominant serogroup causing IMD infections. The notification rate in 2017 among
Indigenous Australians was 7.0 cases per 100,000, compared with 0.4 cases per 100,000
among other Australians (Department of Health 2017c). Relevant state and territory
governments responded to increased cases of MenW by funding targeted vaccination
programs in areas affected or linked by cultural and geographical ties, using combination
ACWY vaccines.
Syphilis
Syphilis is a sexually transmitted infection. Left untreated, it can irreversibly damage the
brain, nerves, eyes, heart, spinal cord and joints, causing serious illness and possibly
death. Pregnant women can pass the infection to their baby, increasing the chance of
stillbirth. Syphilis can be prevented through safe sexual practices or treated with antibiotics.
Since January 2011, an ongoing outbreak of new syphilis infections has affected
Indigenous Australians living in rural and remote areas of northern and central Australia.
Around 1,950 cases have been associated with this outbreak (as at 31 January 2018)
(Department of Health 2017d), of which around two-thirds were people aged 15–29.
Responses to the outbreak have included increased screening, public health alerts, an
Indigenous-specific public awareness campaign and active follow-up of cases. In parallel,
there have been increases in cases of new syphilis reported in men who have sex with
men, predominantly aged 20–39, living in urban areas of Victoria and New South Wales.

Notifications of notifiable communicable diseases to the NNDSS represent only a portion
of all the cases occurring in the community. This is because not all individuals with notifiable
diseases present for medical care and, of people who do, not all are tested and/or notified.
The proportion of under-reporting may vary between diseases, over time, and across
jurisdictions. The number of notifications may be influenced over time by changes in testing
practices; for example, by an increased propensity to test and/or to use more sensitive
diagnostic tests. These changes may be influenced by both clinician practice and patient
expectations. For non-notifiable communicable diseases, the number of cases requiring
hospitalisation is a small fraction of the total number of cases occurring in the community.
It is difficult to estimate with any certainty what the total number of cases might be.
160
More information about the selected outbreaks of communicable diseases in Australia
in 2017 can be found here:
• M
enW outbreak <www.health.gov.au/internet/main/publishing.nsf/Content/
ohp-meningococcal-W.htm>
• s yphilis outbreak: <www.health.gov.au/internet/main/publishing.nsf/Content/ohp-
infectious-syphilis-outbreak.htm>
• influenza season: <www.health.gov.au/internet/main/publishing.nsf/Content/
cda-surveil-ozflu-flucurr.htm>
• links for further information on other notifiable diseases: <www.health.gov.au/cda>.
References
ACSQHC (Australian Commission on Safety and Quality in health Care) 2017. AURA 2017: second Australian
report on antimicrobial use and resistance in human health. Sydney: ACSQHC.
Department of Health 2017a. 2017 influenza season in Australia: a summary from the National Influenza
Surveillance Committee. Canberra: Department of Health. Viewed December 2017,
<http://www.health.gov.au/internet/main/publishing.nsf/Content/097F15A91C05FBE7CA2581E20017F09E
/$File/2017-season-summary-22112017.pdf>.
Department of Health 2017b. Australian influenza surveillance report. No. 12, 2017, 14–27 October.
Canberra: Department of Health. Viewed December 2017, <http://www.health.gov.au/internet/main/
publishing.nsf/Content/8FC4EA9E4C6E3F5CCA2581D4001BBC9A/$File/ozflu-surveil-no12-2017.pdf>.
Department of Health 2017c. Invasive meningococcal disease: national surveillance report—with a focus
Chapter 3
on MenW3. December 2017. Canberra: Department of Health. Viewed February 2018,
<http://www.health.gov.au/internet/main/publishing.nsf/Content/5FEABC4B495BDEC1CA25807D001327FA
/$File/31-Dec17-IMD-Surveillance-report.pdf>.
Department of Health 2017d. Multijurisdictional syphilis outbreak working group (MJSO), meeting
communique. 22 February 2018. Canberra: Department of Health. Viewed February 2018,
<http://www.health.gov.au/internet/main/publishing.nsf/Content/71E8A32E7518E532CA25801A0009A217
/$File/Feb-2018-communique.pdf>.
Department of Health 2018. National notifiable diseases surveillance system, 2018. Canberra: Department
of Health. Viewed January 2018, <www.health.gov.au/nndssdata>.
Kirby Institute 2017. HIV, viral hepatitis and sexually transmissible infections in Australia: annual
surveillance report 2017. Sydney: Kirby Institute, University of New South Wales.
161
162
Chapter 4
163
4.0 Overview
A person’s health and wellbeing is influenced by individual, societal and socioeconomic
factors. This chapter focuses on these ‘determinants of health’ or ‘risk factors’, which
combine to affect the health of individuals and communities. They include broad features
of society and environment; socioeconomic characteristics; a person’s knowledge,
attitudes and beliefs; health behaviours; psychological factors; safety factors; and
biomedical factors.
Determinants can affect health positively or negatively—they are attributes, characteristics

or exposures that increase or decrease the likelihood that a person develops a disease
or health disorder. Many risk factors can be changed or controlled to improve health
outcomes or to reduce the chance of ill health. In turn, a person’s health status influences
social and socioeconomic factors; for example, their ability to work, earn an income or
participate in their community.
The natural environment is one factor that can affect our physical and mental health.
This includes the quality of air and water, the positive and negative health effects of
exposure to ultraviolet radiation (adequate exposure can guard against Vitamin D
deficiency, while excessive exposure has been linked to various types of skin cancer),
and the potential impact of extreme weather events. For example, there have been
several ‘thunderstorm asthma’ events in Australia in recent years, with the event in
Victoria in 2016 resulting in 9 deaths.
Many key drivers of health are integral to our everyday living and working conditions—the
circumstances in which we grow, live, work and age. One of these social determinants
is socioeconomic position, which can be described in terms of educational attainment,
income level, and occupational status. In general, every step up the socioeconomic ladder
has a corresponding benefit for health. It is estimated that closing the health gap between
the most and least disadvantaged Australians would spare around half a million people
from chronic illness.
What we know about health and health behaviours can influence how much and how
effectively we engage in looking after our own health; however, based on the 2006
Australian Bureau of Statistics Health Literacy Survey, only 4 in 10 (41%) adults have a
level of health literacy that allows them to meet the complex demands of everyday life.
Many chronic conditions share common risk factors that are largely preventable, such
as tobacco smoking, excessive alcohol consumption, overweight and obesity, physical
inactivity and high blood pressure. Almost one-third of the overall disease burden in
Australia could be prevented by reducing exposure to modifiable risk factors. Small
personal lifestyle changes can have big health gains for the whole population—if we all
did an extra 15 minutes of brisk walking, 5 days a week, Australia’s disease burden due to
physical inactivity would be cut by about 14%.
164
Fewer Australians are smoking than ever before—and 62% of the population have never
smoked—but the decline in smoking rates has slowed, with no decline seen between 2013
and 2016. Tobacco use continues to be the single risk factor causing the most disease
burden in Australia, with the largest impact from tobacco use on cancer, respiratory
diseases and cardiovascular diseases.
As well, fewer Australians are drinking at levels that contribute to alcohol-related harm
over a lifetime. However, about 26% of people drink more than is recommended on a
single occasion, and they do this at least once each month. Younger people show more
promising trends when it comes to alcohol—fewer people aged 12–17 are drinking and
a greater proportion are abstaining from drinking altogether.
In 2016, Australia recorded the highest number of drug deaths seen in 20 years (1,800
deaths). Hospitalisations associated with illicit drug use have been increasing over the
last 5 years, reaching 57,900 in 2015–16 (from 38,200 in 2011–12).
Eating a healthy diet reduces the risk of diet-related conditions and can protect against
associated chronic conditions such as type 2 diabetes. However, the eating habits of many
Australians do not meet recommended dietary guidelines. For example, about 99% of
children, 97% of men and 95% of women do not consume the recommended serves of
vegetables, and more than two-thirds (69%) of children and almost half (47%) of adults
exceed the recommended intake of free sugars (they should account for less than 10%
of energy).
Together with eating a healthy diet, getting enough exercise can reduce the risk of many
chronic conditions and other disease risk factors, such as overweight and obesity, and
high blood pressure. Despite this, 92% of young people aged 13–17, 52% of adults aged
18–64 and 75% of adults aged 65 and over are not doing the recommended amount of
exercise for their age each week.
Chapter 4
Almost two-thirds (63%) of Australian adults are overweight or obese. The prevalence has
increased over time. Of particular concern, is the growing rate of severe obesity, which
almost doubled between 1995 and 2014–15 among adults.
Elevated blood pressure and blood lipids are linked to disease risk. Slightly more than
1 in 3 (6 million) Australian adults have high blood pressure, and almost 2 in 3 (8.4 million)
have abnormal blood lipid levels.
165
4.1 Impacts of the natural
FEATURE ARTICLE
environment on health
The health of the Australian population is linked to the state (or health) of our natural
environment—the air we breathe, the water we drink and bathe in, and the soils our
food grow in (EPA Victoria 2017). The Department of Health uses the World Health
Organization’s (WHO’s) definition of environmental health:

Environmental health addresses all the physical, chemical, and biological factors
external to a person, and all the related factors impacting behaviours. It encompasses
the assessment and control of those environmental factors that can potentially affect
health. It is targeted towards preventing disease and creating health-supportive
environments (WHO 2017b).
This article presents a selection of evidence on the impact of the ‘natural environment’
on the physical and mental health of Australia’s population (Box 4.1.1). It also describes
government policies and community programs currently in place in Australia to prevent
and manage ill health that is related to the natural environment.
Box 4.1.1: What is meant by the ‘natural environment’?

The meaning of the word ‘environment’ is very broad. Essentially, our environment
is made up of all the external elements that surround, influence and affect life. One
way to view it is to see it as two interlinked domains: the ‘natural environment’ and
the ‘built environment’.
The ‘natural environment’ can be classified as all the landscapes, habitats (on
land, and in the air and water) and species on earth, and the ‘built environment’ as
everything made by people (AIHW 2012). The natural environment can be positively
and negatively affected by human intervention and impact. It, in turn, can positively
and negatively affect people and their physical and mental health.
What is the current state of the natural

environment and its effect on human
health?
Most Australians have access to clean drinking water, safe food products, and effective
waste collection and sanitation. However, factors such as population growth and
distribution, extreme weather events and climate change (see Box 4.1.2) place increasing
pressure on Australia’s natural environment. This may, in turn, adversely affect the health
of its population.
166
Australia’s population is steadily increasing. The population of 22.7 million as at June 2012
is projected to increase to between 36.8 and 38.3 million by 2061—in September 2017,
the population sat at around 24.7 million (ABS 2013; ABS 2017). This growth and the
changing geographical distribution of the population are placing increasing pressure on
the natural environment. The growing concentration of people in urban areas, particularly
in south-eastern cities and coastal regions, has led to increased land clearing and
construction of further infrastructure such as water and sewerage facilities (ABS 2014b).
Air quality
Air becomes polluted when it contains gases, particles, dust or fumes in amounts
considered harmful to humans and animals, or damaging to plants and natural materials.
Pollutants emitted directly into the atmosphere, from either natural sources or human
sources such as factories and cars, are called primary pollutants (organic compounds
and nitrogen oxide are two such pollutants); they can undergo chemical changes in the
atmosphere to form secondary pollutants such as ozone (Keywood et al. 2016).
Long-term exposure to air pollution increases the risk of morbidity and mortality from
cardiovascular disease and respiratory diseases (particularly asthma) (WHO 2013). Barnett
et al. (2005) demonstrated that exposure to air pollutants was associated with short-term
increases in respiratory hospitalisations for children aged 0–14, while a study by Bowatte
et al. (2017) found a strong correlation between traffic-related air pollution and an
increased risk of asthma, wheezing and worsening lung function.
Australia has national air quality standards, known as the National Environment
Protection Measure for Ambient Air Quality. These standards set the acceptable levels
of key pollutants, which are monitored across 75 sites across all states and territories.
Compared with many other developed countries, Australia has very clean air (OECD
Chapter 4
2017). All its capital cities have very good air quality, based on assessment of PM2.5 (fine
particulate matter less than 2.5 microns in diameter) (see also Chapter 9.2 of Australia’s
Welfare 2017). Further, the landmark report Australia: State of the Environment 2016
notes that Australia’s air quality is improving, with declining levels of lead and nitrogen
dioxide since 2011 (Keywood et al. 2016). This positive trend aside, there is no safe lower
threshold for health impacts, and continued improvement in air quality will result in
continued population health benefits (Broome et al. 2015; Pope & Dockery 2006).
The Australian Burden of Disease Study (ABDS) 2011 reported that 1.3% of all fatal
burden, 5.9% of the fatal burden due to coronary heart disease and 4.8% of the fatal
burden due to stroke was attributable to air pollution (AIHW 2016a; Figure 4.1.1). (See
Box 4.4.1 in Chapter 4.4 ‘Contribution of selected risk factors to burden of disease’ for
more information on burden of disease and definitions on fatal and non-fatal burden.)
167
Figure 4.1.1: Fatal burden of disease attributable to air pollution, by linked
disease, 2011
Per cent
7
5
0
Chronic obstructive Lung cancer Stroke Coronary heart disease
pulmonary disease
Linked disease
Climate change and extreme weather events (see section ‘Extreme weather events’ later
in this article) are increasing our population’s exposure to air pollution. Ozone formation
increases in warmer weather. Increasing fire weather drives more bushfires and fuel
reduction burns, which increase the population’s exposure to episodes of severe air
pollution. One such example was the hazard reduction burning that took place near
Sydney in May 2016; it is estimated to have caused 14 deaths and 87 admissions to
hospital for heart and lung conditions (Broome et al. 2016).
Water quality
Water quality relates to the physical, chemical and biological properties of water, including
colour, clarity, salinity, acidity, chemical contaminants (such as pesticide residues and
heavy metals) and microbial contaminants (such as bacteria, viruses and protozoa). Most
water sources in Australia need some treatment, or ongoing management, to ensure
that they are safe for human consumption or recreational activity. The effects on human
health of contaminated water may include skin and eye irritation, and conditions such as
gastroenteritis (including infections like giardiasis and cryptosporidiosis).
States and territories are largely responsible for managing water supplies and achieving
optimal water quality as defined in the Australian Drinking Water Guidelines 2011.
The Bureau of Meteorology reported that, in 2015–16, the average proportion of the
population where microbiological compliance was achieved was almost 100% (Bureau
of Meteorology 2017).
168
While some water treatment practices remove disease-causing organisms, others fortify
water sources to prevent disease, such as fluoridation to prevent tooth decay. Fluoride
occurs naturally in water, but at levels below those set out in the current guidelines to
prevent and manage tooth decay, particularly among children and people with limited
access to dental services (NHMRC 2017b). Optimum levels of water fluoridation are
achieved by adding fluoride to the drinking water supply—a practice that has been
occurring in parts of Australia for over 60 years—and is the responsibility of local councils
in cooperation with state and territory governments. In 2016, the National Health and
Medical Research Council (NHMRC) reported that water fluoridation in Australia reduces
tooth decay by between 26–44% in children and adolescents and 27% in adults
(NHMRC 2017a).
Food safety
Food is a vital feature of the natural environment. It is declared unsafe when its
contamination is likely to physically harm a person who consumes it. Some food is
contaminated through exposure to microbes, chemicals, biotoxins and other pollutants in
the air, water or soil. Contamination can also occur when foods are not correctly handled
before consumption, such as during production, packaging and preparation.
When unsafe food is consumed, people commonly develop symptoms of gastroenteritis.
Campylobacteriosis (caused by the Campylobacter bacterium) is the most commonly
notified gastrointestinal disease in Australia, followed by salmonellosis (caused by the
Salmonella bacterium). In Australia, foodborne illness is common—in 2017, around
16,400 cases of salmonellosis and 26,700 cases of campylobacterosis were reported in
the National Notifiable Diseases Surveillance System, although it is not known how many
of these cases resulted from the consumption of unsafe food (Department of Health
2018). In 2016–17, there were 61 food recalls conducted by Food Standards Australia
Chapter 4
New Zealand in response to the consumption of potentially unsafe food. Of these,
microbiological, chemical or biotoxin contamination was the cause in 14% of the recalls
(FSANZ 2017). A study by Kirk et al. (2014) showed that unsafe food was responsible
for an estimated 4.1 million cases of foodborne gastroenteritis, more than 30,800
hospitalisations and nearly 100 deaths in Australia in 2010.
The ABDS 2011 reported that gastrointestinal infections (including camplyobacteriosis,
salmonellosis, rotavirus and other gastrointestinal infections) accounted for 41% of the
non-fatal infectious burden and 3.8% of the fatal infectious disease burden (AIHW 2016a).
Ultraviolet radiation: sun exposure, Vitamin D and

skin cancer
Compared with other countries, Australia has a high level of solar ultraviolet (UV) radiation
(Olsen et al. 2015). UV radiation can both positively and negatively affect a person’s
health—adequate exposure to UV radiation can guard against Vitamin D deficiency and
reduce the risk of chronic musculoskeletal conditions (Lucas et al. 2006), while excessive
exposure has been linked to various types of skin cancer.
169
In Australia, adequate blood levels of Vitamin D are considered to be greater than or equal
to 50 nmol/L; however, in 2011–12, 23% of Australian adults (or 4 million people) had a
Vitamin D deficiency (ABS 2014a). Low levels of Vitamin D are associated with an increased
risk of osteoporosis through increased risk of falls in older Australians, and bone and joint
pain; low levels in women can also affect the levels of Vitamin D in unborn children
(Joshi et al. 2010; Osteoporosis Australia 2017).
Excessive exposure to UV radiation—either from the sun, or by other means such as
tanning and solariums (which emit cancer-causing UVA and UVB radiation)—is the main
risk factor for skin cancer (AIHW 2016a; Cancer Council Australia 2018). Melanoma is the
most common skin cancer reported as cause of death (of all skin cancers) (AIHW 2017).
The ABDS reported that high sun exposure, as an environmental risk factor, accounted for
0.8% of total burden of disease and injury in 2011, due to melanoma and non-melanoma
skin cancers (AIHW 2016a). In 2016, there were an estimated 13,300 new cases of
melanoma, which accounted for 10% of all cancers diagnosed that year (excluding basal
cell carcinoma and squamous cell carcinoma) (AIHW 2016b).
While the rate of new diagnoses of melanoma increased between 1982 and 2006 (from 28
to 61 cases per 100,000 population for males and 26 to 39 cases per 100,000 for females),
rates have remained relatively steady since 2006 (Figure 4.1.2). This stabilisation may
be due in part to increased awareness of the risks of excessive sun exposure through
long-running education campaigns (see section ‘How are we managing the impact of the
natural environment on human health?’).
Figure 4.1.2: Trend in age-standardised incidence rates for melanoma, by sex,

1982–2018
Number of new cases per 100,000 population

70
Males
60
50
Females
40
30
20 Actual rate
Estimated rate
10
0
1982 1987 1992 1997 2002 2007 2012 2018
Year
Notes
1. Cancer coded in the International Classification of Diseases and Related Health Problems, 10th revision
(ICD-10) as C43.
2. The rates were age standardised to the Australian population as at 30 June 2001, and are expressed per
100,000 population.
3. The 2014–2018 estimates for incidence are based on 2004–2013 incidence data.
170
Extreme weather events
‘Extreme weather events’ are classified as unusual weather events or phenomena that are
at the extremes of a ‘typical’ historical distribution, such as violent storms, exceptionally
high levels of rainfall, and heat waves or droughts that are longer or hotter than is typical.
Extreme weather events often have substantial social and economic impacts and may be
hazardous to human life. Resulting health effects may be immediate and physical (such
as death and injury due to bushfires), short term (for example, loss of shelter or access
to clean water due to cyclone or floods) or long term (such as mental health problems or
chronic injury) (Morrissey & Reser 2007).
Thunderstorm asthma
‘Thunderstorm asthma’ is defined as asthma triggered by an uncommon combination of
high pollen and a particular type of thunderstorm, during which pollen grains are swept
into the clouds as the storm forms (Asthma Australia 2017). Several thunderstorm asthma
events have been reported in Australia in recent years—Wagga Wagga in 1997, Canberra
in 2010, and Victoria in 2016 (Victorian Department of Health and Human Services 2017b).
The Victorian event was the most noteworthy of these events on record. It resulted in
a 58% increase in presentations to public hospital emergency departments on 21–22
November 2016 (9,900 compared with a previous 3-year average of 6,300) and 9 deaths
(Victorian Department of Health and Human Services 2017b).
Heatwaves
A heatwave is defined as 3 or more days of high maximum and minimum temperatures
that are unusual for a location and are monitored by the Bureau of Meteorology. It is
expected that extreme heat events, such as heatwaves, will occur more often and with
Chapter 4
greater intensity in the future (Bureau of Meteorology 2018). Understanding the health
impacts of heatwaves is important in Australia (Tong et al. 2010). Potential conditions
resulting from heatwaves range from minor rashes and body cramps, through to those
that require hospitalisation and sometimes result in death, such as heat stroke (severe
hyperthermia). A report by the WHO stated that heat related deaths in Australasia
attributable to climate change are predicted to increase from 217 in 2030 to 605 in 2050,
based on the current climate (WHO 2014).
The Victorian Department of Health and Human Services (2009) reported a 62% increase
in deaths during a heatwave period from 26 January to 1 February 2009, compared with
the average number of deaths for the same week between 2004–08.
Bushfires
The frequency and intensity of bushfires is increasing in Australia (Dutta et al. 2016); it
is important, therefore, to understand the effects of these events on human health and
ways to mitigate these effects (Johnston 2017). Numerous studies have described the
impact of bushfires on human health:
• B
etween 1967 and 2013, bushfires accounted for 433 deaths (173 alone during ‘Black
Friday’ in 2009) and more than 8,000 injuries (Geoscience Australia n.d.; Parliament of
Victoria 2010).
171
• Johnston et al. (2014) examined 46 validated fire smoke event days between 1996 and
2007 in Sydney, and found marked increases in same-day emergency department
attendance—23% for asthma, 12% for chronic obstructive pulmonary disease and 7.0%
for respiratory conditions, while Haikerwal et al. (2015) found a 7.0% increase in risk for
out-of-hospital cardiac arrests during the 2006–07 Victorian bushfires.
• B
ushfires increase the risk of burns, physical trauma such as injury from car accidents,
psychological trauma such as post-traumatic stress, depression, substance abuse and
domestic violence (Johnston 2009; McDermott & Palmer 1999; Yzermans et al. 2005).
• S
evere bushfires also put population water reservoirs at risk (Johnston 2009) through
silting up (loss of storage capacity), and through contamination from run-off and toxic
algal blooms.
Drought
Although some areas of Australia are naturally dry, periods of below-average rainfall,
known as drought, have adverse outcomes for the natural environment, and flow-on
effects for human health. Not only does drought reduce the supply and quality of water
and food, it increases the probability of bushfires and affects air quality (for example, via
dust storms) (Centres for Disease Control and Prevention 2017; Kalis et al. 2009).
Drought, rain following drought, and human adaptation to drought (in the form of water
storage tanks) has also been shown to increase the risk of vector-borne (mosquito)
disease, such as dengue fever and Ross River virus (Trewin et al. 2013).
Results from the Rural and Regional Families Survey showed that, in 2007, 18% of farmers
currently experiencing drought reported mental health problems, compared with 11%
who had experienced drought in the past year or past 3 years and 7.0% who had not
experienced drought in the past 3 years (Edwards et al. 2008; Figure 4.1.3). Hanigan et al.
(2012) found that increasing drought was associated with a 15% increased relative risk of
suicide among men aged 30–49.
Figure 4.1.3: Proportion of farmers reporting mental health problems,

by drought experience, 2007
Drought experience
Current drought
Drought in last year
Drought in last 3 years
No drought in last 3 years
0 5 10 15 20
Per cent
Source: Edwards et al. 2008; Table S4.1.3.
172
Box 4.1.2: Climate change and human health
Human activities, such as burning fossil fuels, agriculture and deforestation,
have led to an increase in greenhouse gas (GHG) emissions, contributing to a
phenomenon known as climate change (Department of the Environment and
Energy n.d.d).
Between 1995 and 2005, Australia’s GHG emissions increased from 24.2 to 25.8
tonnes of GHG per capita (OECD 2016). In 2007, Australia became a signatory to the
Kyoto Protocol, an international agreement among nations to collaboratively reduce
GHG emissions. Since then, Australia has reduced emissions by 13%, from 25.6 to
22.3 tonnes of GHG per capita (OECD 2016).
The WHO has reported that climate change is negatively affecting both social
and environmental determinants of human health—access to clean air and safe
drinking water and adequate food resources (WHO 2017a). Likely effects of climate
change on the natural environment include increased temperatures (due to excess
GHG in the atmosphere), changes to rainfall and wind patterns, and acidification of
the oceans (Department of the Environment and Energy n.d.c).
Climate change is predicted to increase the risk of extreme weather events
(Department of the Environment and Energy n.d.b). Further, research on climate
change highlights a strong correlation between the frequency and intensity of
extreme weather events and changes to the natural environment. These factors are
likely to amplify the adverse impact of the natural environment on human health.
Changes to weather patterns (such as increased rainfall and tidal changes) are
expected to increase disease vector populations such as mosquitoes, which, in turn,
will lead to larger areas of disease transmission over longer durations (Garnaut 2008).
While major vector-borne diseases such as dengue fever are currently not common
Chapter 4
in Australia, the predicted increase in temperatures and rainfall as a result of
climate change has the potential to increase and change the geographic distribution
of vector populations, and affect human infection rates (McMichael et al. 2006;
Russell 1998).
How are we managing the impact of the

natural environment on human health?
Although Australia ranks highly in terms of environmental performance in a global
context, the Australia: State of the Environment 2016 report noted that, if current local
trends continue, Australia’s natural environment in 2050 will be markedly different from
what it is today. The detrimental effects of climate change (such as rising temperatures
and reduced precipitation), the reduction in the quality of Australia’s groundwater
resources, increased demands for land in coastal areas (placing increasing demands on
resources) and potential threats to human health from extreme weather events and disease
will have profound effects on the health of Australia’s population (Jackson et al. 2017).
173
There are many areas where Australia’s natural environment is predicted to improve
because of current policies and programs; it is expected that these improvements will
have a positive effect on human health. Examples of those initiatives currently in place
at the national, state and local level—and their observed or predicted impact on human
health—include:
• t he National Clean Air Agreement, developed in 2015, which aims to reduce pollution
and improve air quality through actions undertaken by the community and government
at all levels. Actions include increasing the standards against which air particles are
reported (Department of the Environment and Energy n.d.a). It is expected that ongoing
improvements to air quality will reduce the level of respiratory disease and acute
respiratory events
• t he Australian Drinking Water Guidelines, which is a framework by which good
management of water supplies assures safety at point of use, and which is reported
against by the Bureau of Meteorology (Bureau of Meteorology 2017; NHMRC & NRMMC
2011). Improved reporting, improved sampling, and early detection and mitigation of
problems have been shown to have a positive impact on water quality in New South
Wales (Byleveld et al. 2016)
• a
number of SunSmart campaigns, which have been enacted in Australia since the
early 1980s to increase awareness of the dangers and health risks associated with UV
radiation exposure. These campaigns have been shown to have a positive impact on
the detection and diagnosis of melanoma and other skin cancers. Since the launch in
2007 of one of the most publicly recognised campaigns—Clare Oliver: No Tan is Worth
Dying For—incidence rates of melanoma have stabilised (Figure 4.1.2).
See Chapter 7.1 ‘Health promotion’ for more information on other health programs
and policies.
In 2016, the Environmental Health Standing Committee (formed by the Australian
Government and state and territory governments) developed a 2016–2020 Strategic Plan.
The Plan highlighted the importance of anticipatory, integrated responses to changes
in the natural environment that may affect health and of an early understanding of the
risk factors that result from environmental variation—for example, the health impacts
of changes to air and water quality and extreme weather events resulting from climate
change (enHealth 2016).
Tracking and forecasting extreme weather events is one way to lessen the impact
on human health by warning of forecasted weather events. This gives governments,
communities and individuals a better chance to respond. For example:
• t he Victorian State Government has been working with the Bureau of Meteorology to
forecast the risk of thunderstorm asthma events (Victorian Department of Health and
Human Services 2017a)
• t he Sentinel National Bushfire Monitoring System provides 144 national observations
per day (every 10 minutes), via satellite, to notify emergency services and the public
about potential bushfires (Geoscience Australia 2015)
174
• t he NSW Government issued a heatwave plan in 2011 (updated in 2018) to help in
preparing for, responding to and recovering from heatwaves, with human health being
the primary focus (NSW Government 2018).
At a national and global level, Australia is committed to dealing with climate change and
its impacts, including the downstream adverse effects on human health (United Nations
n.d.). In 2016, Australia reaffirmed its commitment to the Kyoto Protocol and endorsed
the Paris Agreement, including a pledge to reduce emissions by 26–28% below 2005 levels
by 2030; to further increase Australia’s renewable energy capacity; and to manage climate
risks by building resilience in the community, economy and environment (Department of
Environment and Energy n.d.c.).

Understanding the impact of the natural environment on human health is complex. In
recent years, research has focused on a better grasp of the causal links between human
health and the environment. However, many data gaps still exist that need to be filled to
ensure this continues, such as:
• c onsideration of real-time or more frequent data collections that gather and link data
on human health and the natural environment, including determining causality, and
monitoring trends and projections
• p
rovision of data by small geographic areas to measure human exposure to factors of
the natural environment at a local level.
Another area of interest is research that focuses on the effect of climate change on the
health of populations at risk, including older Australians, people in low socioeconomic
areas, socially or geographically isolated individuals and communities, and Aboriginal and
Torres Strait Islander people (AAOS 2015).
Chapter 4
The 2011 AIHW report Health and the environment: a compilation of evidence collates
evidence on the relationship between health and a selected list of environmental
factors (AIHW 2011). It also discusses the difficulties involved in assessing the broader
relationship between health and the environment.
Every 5 years, the Department of the Environment and Energy produces a report on the
Australian state of the environment (Australian State of the Environment Committee 2016).
The 2016 edition is available from <soe.environment.gov.au/download/reports>.
References
AAOS (Australian Academy of Science) 2015. Climate change challenges to health: risks and opportunities.
Recommendations from the 2014 Theo Murphy High Flyers Think Tank. Canberra: AAOS.
ABS (Australian Bureau of Statistics) 2013. Population Projections, Australia 2012 (base) to 2101. ABS
cat. no. 3222.0. Canberra: ABS.
ABS 2014a. Australian Health Survey: biomedical results for nutrients, 2011–12: feature article: Vitamin D.
ABS 2014b. Measures of Australia’s progress, 2013. ABS cat. no. 1370. Canberra: ABS.
ABS 2017. Australian demographic statistics—September quarter 2017. ABS cat. no. 3101. Canberra: ABS.
175
AIHW (Australian Institute of Health and Welfare) 2011. Health and the environment: a compilation of
evidence. Cat. no. PHE 136. Canberra: AIHW.
AIHW 2012. Australia’s health. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW.
AIHW 2016a. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011.
Australian Burden of Disease Study series no. 3. BOD 4. Canberra: AIHW.
AIHW 2016b. Skin cancer in Australia. Cat. no. CAN 96. Canberra: AIHW.
AIHW 2017. Cancer in Australia 2017. Cancer series no.101. Cat. no. CAN 100. Canberra: AIHW.
Asthma Australia 2017. Thunderstorm asthma. Chatswood: Asthma Australia. Viewed 1 November 2017,
<https://www.asthmaaustralia.org.au/sa/about-asthma/resources/onair/2017/feb/thunderstorm-asthma>.
Barnett AG, Williams GM, Schwartz J, Neller AH, Best TL, Petroeschevsky AL & Simpson RW 2005. Air
pollution and child respiratory health—a case-crossover study in Australia and New Zealand. American
Journal of Respiratory and Critical Care Medicine 171:1272–8.
Bureau of Meteorology 2017. National performance report 2015–16: urban water utilities, part A.
Melbourne: Bureau of Meteorology.
Bureau of Meteorology 2018. About the heatwave service. Melbourne: Bureau of Meteorology.
Viewed 21 February 2018, <http://www.bom.gov.au/australia/heatwave/about.shtml>.
Bowatte G, Lodge CJ, Knibbs LD, Lowe AJ, Erbas B, Dennekamp M et al. 2017. Traffic-related air pollution
exposure is associated with allergic sensitization, asthma, and poor lung function in middle age. Journal of
Allergy and Clinical Immunology 139(1):122–9.
Broome RA, Fann N, Cristina TJN, Fulcher C, Duc H & Morgan GG 2015. The health benefits of reducing air
pollution in Sydney, Australia. Environmental Research 143:19–25.
Broome RA, Johnston FH, Horsley J & Morgan GG 2016. A rapid assessment of the impact of hazard
reduction burning around Sydney, May 2016. Medical Journal of Australia 205(9):407–8.
Byleveld PM, Leask SD, Jarvis LA, Wall KJ, Henderson WN & Tickell JE 2016. Safe drinking water quality in
Australia. Public Health and Research Practice 26(2).
Cancer Council Australia 2018. Skin cancer. Sydney: Cancer Council Australia. Viewed 24 October 2017,
<http://www.cancer.org.au/about-cancer/types-of-cancer/skin-cancer.html>.
Centres for Disease Control and Prevention 2017. Drought and your health. Atlanta: National Center for
Environmental Health. Viewed 21 February 2018, <https://www.cdc.gov/features/drought/index.html>.
Department of the Environment and Energy n.d.a. Air quality. Canberra: Department of the Environment
and Energy. Viewed 24 October 2017, <http://www.environment.gov.au/protection/air-quality>.
Department of the Environment and Energy n.d.b. Climate change impacts in Australia. Canberra:
Department of the Environment and Energy. Viewed 21 February 2018,
<http://www.environment.gov.au/climate-change/climate-science-data/climate-science/impacts>.
Department of the Environment and Energy n.d.c. Government and international initiatives. Canberra:
Department of the Environment and Energy. Viewed 24 October 2017,
<http://www.environment.gov.au/climate-change/government>.
Department of the Environment and Energy n.d.d. Understanding climate change. Canberra: Department
of the Environment and Energy. Viewed 6 November 2017, <http://www.environment.gov.au/climate-
change/climate-science-data/climate-science/understanding-climate-change>.
Department of Health 2018. National Notifiable Diseases Surveillance System. Notifications of All diseases
by State and Territory and Year. Canberra: Department of Health. Viewed 28 November 2017,
<http://www9.health.gov.au/cda/source/rpt_1.cfm>.
Dutta R, Das A & Aryal J 2016. Big data integration shows Australian bush-fire frequency is increasing
significantly. Royal Society Open Science 3(2):150241.
Edwards B, Gray M & Hunter B 2008. Social and economic impacts of drought on farm families and rural
communities. Submission to the Productivity Commission’s Inquiry into Government Drought Support.
Melbourne: Australian Institute of Family Studies.
enHealth (Environmental Health Standing Committee) 2016. Preventing disease and injury through
healthy environments: Environmental Health Standing Committee (enHealth) Strategic Plan 2016 to 2020.
Canberra: Department of Health.
176
EPA Victoria (Environmental Protection Authority Victoria) 2017. Human health. Melbourne: EPA Victoria.
Viewed 1 November 2017, <http://www.epa.vic.gov.au/your-environment/human-health>.
FSANZ (Food Standards Australia New Zealand) 2017. Annual report 2016–17. Canberra: FSANZ. Viewed
26 February 2018, <http://www.foodstandards.gov.au/publications/annualreport201617/Documents/
FSANZ%20Annual%20Report%202016-17%20Preliminary%20information.pdf>.
Garnaut R 2008. The Garnaut climate change review. Port Melbourne: Cambridge University Press.
Geoscience Australia n.d. Bushfire. Canberra: Geoscience Australia. Viewed 28 November 2017,
<http://www.ga.gov.au/scientific-topics/hazards/bushfire>.
Geoscience Australia 2015. Upgraded bushfire monitoring capability to keep communities safer. Canberra:
Geoscience Australia. Viewed 8 November 2017, <http://www.ga.gov.au/news-events/news/latest-news/
upgraded-bushfire-monitoring-capability-to-keep-communities-safer>.
Haikerwal A, Akram M, Del Monaco A, Smith K, Sim MR, Meyer M et al. 2015. Impact of fine particulate
matter (PM2.5) exposure during wildfires on cardiovascular health outcomes. Journal of the American
Heart Association 4(7).
Hanigan IC, Butler CD, Kokic PN & Hutchinson MF 2012. Suicide and drought in New South Wales,
Australia, 1970–2007. Proceedings of the National Academy of Sciences of the United States of America
109(35):13950–5.
Jackson WJ, Argent RM, Bax NJ, Clark GF, Coleman S, Cresswell ID et al. 2017. Australia—state of the
environment 2016: overview. Canberra: Department of the Environment and Energy.
Johnston F 2009. Bushfires and human health in a changing environment. Australian Family Physician
38:720–4.
Johnston F, Purdie S, Jalaludin B, Martin K, Henderson S & Morgan G 2014. Air pollution events from forest
fires and emergency department attendances in Sydney, Australia 1996–2007: a case-crossover analysis.
Environmental Health 13(105).
Johnston F 2017. Understanding and managing the health impacts of poor air quality from landscape fires.
Medical Journal of Australia 207(6):229–30.
Joshi D, Center JR & Eisman JA 2010. Vitamin D deficiency in adults. Australian Prescriber 33(4).
Kalis MA, Miller MD & Wilson RJ 2009. Public health and drought. Journal of Environmental Health 72:10–1.
Keywood MD, Emmerson KM, Hibberd MF 2016. Ambient air quality: health impacts of air pollution. In:
Australia—state of the environment 2016. Canberra: Department of the Environment and Energy.
Chapter 4
Kirk M, Ford L, Glass K & Hall G 2014. Foodborne illness, Australia, circa 2000 and circa 2010. Emerging
Infectious Diseases 20(11):1857–64.
Lucas R, McMichael T, Smith W & Armstrong B 2006. Solar ultraviolet radiation. Global burden of disease
from solar ultraviolet radiation. World Health Organisation Environmental Burden of Disease series, No. 13.
Geneva: World Health Organisation.
McDermott BM & Palmer LJ 1999. Post-disaster service provision following proactive identification of
children with emotional distress and depression. Australian and New Zealand Journal of Psychiatry
33:855–63.
McMichael AJ, Woodruff RE & Hales S 2006. Climate change and human health: present and future risks.
The Lancet 367(9513):859–69.
Morrissey S & Reser J 2007. Natural disasters, climate change and mental health considerations for rural
Australia. Australian Journal of Rural Health 15:120–5.
NHMRC (National Health and Medical Research Council) 2017a. Information paper—Water fluoridation:
dental and other human health outcomes. Report prepared by the Clinical Trials Centre at University of
Sydney. Canberra: NHMRC.
NHMRC 2017b. NHMRC Public Statement—water fluoridation and human health in Australia. Canberra:
NHMRC. Viewed 6 December 2017, <https://www.nhmrc.gov.au/_files_nhmrc/file/publications/17667_
nhmrc_-_public_statement-web.pdf>.
NHMRC & NRMMC (National Resource Management Ministerial Council) 2011. Australian Drinking Water
Guidelines: paper 6. National Water Quality Management Strategy. Canberra: NHMRC & NRMMC.
177
NSW Government 2011. State Heatwave Sub Plan: a sub plan of the NSW State Disaster Plan. Sydney: NSW
Government. Viewed 26 March 2018, <https://www.emergency.nsw.gov.au/Documents/plans/sub-plans/
SubPlan_HeatWave.pdf >.
OECD (Organisation for Economic Co-operation and Development) Data 2016. Air and GHG emissions.
Paris: OECD. Viewed 6 November 2017, <https://data.oecd.org/air/air-and-ghg-emissions.htm>.
OECD 2017. Exposure to PM2.5 in countries and regions in OECD.Stat. Paris: OECD. Viewed 23 February
2018, <http://stats.oecd.org/>.
Olsen CM, Wilson LF, Green AC, Bain CJ, Fritschi L, Neale RE et al. 2015. Cancers in Australia attributable
to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Australian and New
Zealand Journal of Public Health 39(5):471–6.
Osteoporosis Australia 2017. Vitamin D. Sydney: Osteoporosis Australia. Viewed 1 November 2017,
<https://www.osteoporosis.org.au/vitamin-d>.
Parliament of Victoria 2010. 2009 Victorian Bushfires Royal Commission: final report summary. Melbourne:
Parliament of Victoria. Viewed 28 November 2017,
<http://royalcommission.vic.gov.au/finaldocuments/summary/PF/VBRC_Summary_PF.pdf>.
Pope CA & Dockery DW 2006. Health effects of fine particulate air pollution: lines that connect. Journal of
the Air and Waste Management Association 56:709–42.
Russell RC 1998. Mosquito-borne arboviruses in Australia: the current scene and implications of climate
change for human health. International Journal for Parasitology 28(6):955–69.
Tong S, Ren C & Becker N 2010. Excess deaths during the 2004 heatwave in Brisbane, Australia.
International Journal of Biometeorology 54:393–400.
Trewin BJ, Brian H, Kay BH, Darbro JM & Hurst TP 2013. Increased container-breeding mosquito risk owing
to drought-induced changes in water harvesting and storage in Brisbane, Australia. International Health
5(4):251–8.
United Nations n.d. Sustainable development goals—goal 13: take urgent action to combat climate change
and its impacts. New York: United Nations. Viewed 15 January 2018,
<http://www.un.org/sustainabledevelopment/climate-change-2/>.
Victorian Department of Health and Human Services 2009. January 2009 heatwave in Victoria: an
assessment of health impacts. Melbourne: Victorian Department of Health.
Victorian Department of Health and Human Services 2017a. Epidemic thunderstorm asthma forecasting.
Melbourne: Victorian Government Department of Health. Viewed 28 November 2017, <https://www2.
health.vic.gov.au/public-health/environmental-health/climate-weather-and-public-health/thunderstorm-
asthma/forecasting>.
Victorian Department of Health and Human Services 2017b. The November 2016 Victorian epidemic
thunderstorm asthma event: an assessment of the health impacts—The Chief Health Officer’s Report,
27 April 2017. Melbourne: Victorian Department of Health.
WHO (World Health Organization) 2013. Review of evidence on health aspects of air pollution—REVIHAAP
project: technical report. Bonn: WHO European Centre for Environment and Health.
WHO 2014. Quantitative risk assessment of the effects of climate change on selected causes of death,
2030s and 2050s. Geneva: WHO. Viewed 28 March 2018,
<http://www.who.int/globalchange/publications/quantitative-risk-assessment/en/>.
WHO 2017a. Climate change and health. Geneva: WHO. Viewed 20 November 2011,
<http://www.who.int/mediacentre/factsheets/fs266/en/>.
WHO 2017b. Environmental health. Geneva: WHO. Viewed 7 November 2017,
<http://www.searo.who.int/topics/environmental_health/en/>.
Yzermans CJ, Donker GA, Kerssens JJ, Dirkzwager AJE, Soeteman RJH & ten Veen PMH 2005. Health
problems of victims before and after disaster: a longitudinal study in general practice. International Journal
of Epidemiology 34:820–6.
178
4.2 Social determinants
SNAPSHOT
of health
Evidence supports the close relationship between people’s health and the living and working
conditions which form their social environment. Factors such as socioeconomic position,
conditions of employment, power and social support—known collectively as the social
determinants of health—act together to strengthen or undermine the health of individuals
and communities. The World Health Organization (WHO) describes social determinants as:
…the circumstances in which people grow, live, work, and age, and the systems put in
place to deal with illness. The conditions in which people live and die are, in turn, shaped
by political, social, and economic forces (CSDH 2008).
According to the WHO, social inequalities and disadvantage are the main reason for unfair
and avoidable differences in health outcomes and life expectancy across groups in society.
In 2015, the all-cause mortality rate for people in the lowest socioeconomic group was
1.5 times as high as for people in the highest socioeconomic group (see Chapter 5.1
‘Socioeconomic groups’). This is reflected in life expectancy gaps. In 2011, Australian males
and females in the lowest socioeconomic group lived, on average, 5.7 and 3.3 years less
than males and females in the highest socioeconomic group.
This snapshot provides a brief overview of some of the key social determinants of health
in Australia.
Socioeconomic position
Socioeconomic position can be described by indicators such as educational attainment,
Chapter 4
income or occupation. In general, every step up the socioeconomic ladder is accompanied
by a benefit for health. The relationship is two-way—poor health can be both a product of,
and contribute to, lower socioeconomic position (see Chapter 5.1 ‘Socioeconomic groups’).
• In 2017, 66% of people aged 20–64 held a non-school qualification, an increase of
8.5 percentage points since 2007 (ABS 2017a).
• A
round 13% of the Australian population were estimated to be in relative income
poverty in 2013–14, a figure that has changed little over the last 10 years (ACOSS 2016).
• A
mong major occupation groups, Managers had the highest average weekly total cash
earnings in 2016 ($2,298), and Sales workers, the lowest ($652) (ABS 2017b).
Early life
The foundations of adult health are laid in-utero and during the perinatal and early
childhood periods. The different domains of early childhood development—physical,
social/emotional and language/cognition—strongly influence school success, economic
participation, social citizenship and health.
• O
ne in 10 (10%) mothers who gave birth in 2015 smoked at some time during their
pregnancy, a drop from 15% in 2009. In 2015, smoking rates varied from 3.4% in the
highest socioeconomic group to 18% in the lowest socioeconomic group.
179
• M
ore than 1 in 5 (22%) children entering primary school in 2015 were assessed as being
developmentally vulnerable on one or more domains, including physical health and
wellbeing, social competence, emotional maturity, language and cognition skills, or
communication skills and general knowledge.
• O
ne in 10 (10%) children aged 4–12 were classified as having abnormal social and
emotional wellbeing in 2013–14, affecting their individual and relational characteristics
in their home, school and community environments.
Social exclusion
Social exclusion is a term that describes social disadvantage and lack of resources,
opportunity, participation and skills (McLachlan et al. 2013) (see Glossary). Social exclusion
through discrimination or stigmatisation can cause psychological damage and harm
health through long-term stress and anxiety. Poor health can also lead to social exclusion.
• M
ore than one-fifth (22%, or 4.3 million people) of Australians aged 15 and over
experienced some degree of social exclusion in 2015, with 5.3% (1.0 million)
experiencing deep social exclusion and 1.1% (210,000) very deep social exclusion
(Brotherhood of St Laurence & Melbourne Institute 2017).
• P
eople in certain groups are more likely to experience social exclusion, including
women, people aged over 65, immigrants from non-English speaking countries,
Aboriginal and Torres Strait Islander people, people with disability or a long-term health
condition, early school leavers, single-person and lone-parent households, and public
housing tenants (Brotherhood of St Laurence & Melbourne Institute 2017).
Employment and work

The psychosocial stress caused by unemployment has a strong impact on physical and
mental health and wellbeing. Once employed, participating in quality work helps to
protect health, instilling self-esteem and a positive sense of identity, while providing the
opportunity for social interaction and personal development.
• T
he proportion of the Australian population aged 15 and over who are employed
(employment-to-population ratio) has fluctuated over the last 20 years, from 58% in
December 1997 to 62% in December 2017. Over the same period, the unemployment
rate fell from 7.9% to 5.4% (ABS 2017c).
• In June 2017, there were 1.4 million jobless families in Australia (21% of all families)—a
similar figure to that in June 2012 (20%)—and around 339,000 jobless families (11%) had
dependants (ABS 2017d).
Housing and homelessness

Access to appropriate, affordable and secure housing can limit the risk of Australians
being socially excluded by factors such as homelessness, overcrowding and poor physical
and mental health.
Poor-quality housing influences physical and mental health. Young people, Indigenous
Australians, people with long-term health conditions or disability, people living in
180
low-income housing, or people who are unemployed or underemployed are at greatest
risk of living in poor-quality housing (Baker et al. 2016).
• O
n Census night in 2016, more than 116,000 men, women and children in Australia
were estimated to be homeless, or 50 per 10,000 population—an increase of 4.6%
from 48 per 10,000 population in 2011 (ABS 2018).
• A
s at 30 June 2016, around 195,000 households were on social housing waiting lists,
with 47% having waited for more than 2 years.
• In 2016, overcrowding in households, based on those households needing one or more
extra bedroom, was 3.8%, up from 3.4% in 2011. Overcrowding was much higher for
Indigenous households at 10% (but down from 12% in 2011).
Built environment
The built environment is the setting for human activity. It affects health equity through
its influence on local resources, behaviour and safety. The built environment also affects
other social determinants, including housing conditions, access to work and educational
opportunities.
Urban environments that promote health encourage and support physical activity; they
also strengthen social interaction and enable access to healthy food.
• A
lmost all (98%) Canberra residents lived within 400 metres of public green space in
2011, compared with 79% of Melbourne residents (Coleman 2017).
• N
early one-quarter (22% or 2.0 million people) of commuters had lengthy travel times
of 45 minutes or more one way in 2012, with resultant financial costs through journey
delay, as well as stress, fatigue and other health impacts (Coleman 2017).
Better health through action on social
Chapter 4
determinants
Action on the social determinants of health is an appropriate way to tackle unfair and
avoidable health inequalities.
One study estimates that if action were taken on social determinants—and the health
gaps between the most and least disadvantaged closed—0.5 million Australians could
be spared chronic illness, $2.3 billion in annual hospital costs could be saved, and
Pharmaceutical Benefit Scheme prescription numbers cut by 5.3 million (Brown et al. 2012).
In Australia, a focus has been on social and cultural determinants aiming to close the gap
in Indigenous health (see Chapter 6.6 ‘Social determinants and Indigenous health’).
The WHO Commission on Social Determinants of Health has suggested that countries
adopt a ‘whole-of-government’ approach to deal with the social determinants of health,
with policies and interventions from all sectors and levels of society (WHO 2011). The
evidence shows that actions within four main areas (early child development, fair
employment and decent work, social protection, and the living environment) are likely
to have the greatest impact on the social determinants of health (Saunders et al. 2017).
181
Data and analysis gaps limit the monitoring of social determinants. Many health data
collections do not include socioeconomic information. There is scope to link health
and welfare data—as in the South Australian Early Childhood Data Project (Nuske et al.
2016)—to provide a broader understanding of the experience of population cohorts, the
relationships between health and welfare, and greater evidence for causal pathways to
good health.

A detailed discussion of social determinants of health appeared in Australia’s health 2016.

For more information on disadvantage and social inequalities, see the AIHW report
Australia’s welfare 2017.
The WHO plays a leading role in supporting countries to take action on the social
determinants of health: <www.who.int/social_determinants/sdh_definition/en>.
References
ABS (Australian Bureau of Statistics) 2017a. Education and work, Australia, May 2017. ABS cat. no. 6227.0.
Canberra: ABS.
ABS 2017b. Employee earnings and hours, Australia, May 2016. ABS cat. no. 6306.0. Canberra: ABS.
ABS 2017c. Labour force survey, April 2017. ABS cat. no. 6202.0. Canberra: ABS.
ABS 2017d. Labour force, Australia: labour force status and other characteristics of families, June 2017.
ABS 2018. Census of population and housing: estimating homelessness, 2016. ABS cat. no. 2049.0.
Canberra: ABS.
ACOSS (Australian Council of Social Service) 2016. Poverty in Australia 2016. Sydney: ACOSS.
Baker E, Lester LH, Bentley R & Beer A 2016. Poor housing quality: prevalence and health effects. Journal
of Prevention & Intervention in the Community 44:219–32.
Brotherhood of St Laurence & Melbourne Institute 2017. Social exclusion monitor. Melbourne:
Brotherhood of St Laurence. Viewed 19 January 2017,
<https://www.bsl.org.au/research/social-exclusion-monitor/>.
Brown L, Thurecht L & Nepal B 2012. The cost of inaction on the social determinants of health. Report
no. 2/2012: CHA-NATSEM second report on health inequalities. Canberra: National Centre for Social and
Economic Modelling.
Coleman S 2017. Australia: state of the environment 2016: built environment. Canberra: Department of the
Environment and Energy.
CSDH (Commission on Social Determinants of Health) 2008. Closing the gap in a generation: health
equity through action on the social determinants of health. Final report of the Commission on Social
Determinants of Health. Geneva: World Health Organization.
McLachlan R, Gilfillan G & Gordon J 2013. Deep and persistent disadvantage in Australia. Canberra:
Productivity Commission.
Nuske T, Pilkington R, Gialamas A, Chittleborough C, Smithers L & Lynch J 2016. The early childhood data
project. Research series 2016. Adelaide: School of Public Health, The University of Adelaide.
Saunders M, Barr B, McHale P & Hamelmann C 2017. Key policies for addressing the social determinants
of health and health inequities. Copenhagen: World Health Organization Regional Office for Europe.
WHO (World Health Organization) 2011. Closing the gap: policy into practice on social determinants of
health: discussion paper. Geneva: WHO.
182
4.3 Health literacy
SNAPSHOT
Australians are encouraged to actively participate in maintaining their heath. Health
literacy can influence how much and how effectively people do this. It has two major
components (ACSQHC 2014a):
• I ndividual health literacy is about a person’s ability to access, understand and apply
health information; for example, to complete health care forms or navigate the health
care system.
he health literacy environment describes the infrastructure, people, policies and
• T
relationships of the health care system. Aspects of the health literacy environment
include patient referral pathways, coordination of care, and hospital design.
Why is health literacy important?

Health literacy plays a part in the safety and quality of health care. It can influence
decisions people make, such as how often to take medication, when to access health care
services, and which services to access. Low individual health literacy can be associated
with higher rates of hospitalisation and emergency care use, sometimes indicating poor
management of health conditions outside the hospital system (Bush et al. 2010).
Low levels of health literacy are also associated with undesirable outcomes, such as
premature death among older people, lower participation in preventative programs
(including influenza vaccination and cervical and breast cancer screening) (Berkman et al.
2011), and poor medication adherence (Diug et al. 2011). As health systems are becoming
increasingly complex, health literacy is becoming more important.
Chapter 4
How health literate are Australians?
In 2006, the Australian Bureau of Statistics (ABS) conducted a Health Literacy Survey.
Respondents were asked to complete a range of tasks designed to test their understanding
of health promotion, health protection, disease prevention and management, and
navigation of the health system. Responses indicated that only 41% of adult Australians
had a level of health literacy that would allow them to meet the complex demands of
everyday life (ABS 2009).
A person’s health literacy can be influenced by their cultural beliefs, language, disability,
education, income and health status (Sørensen et al. 2012). For example, the ABS survey
showed that health literacy was lower in people who speak English as a second language
(26%) and higher in people who have completed a Bachelor degree or higher (70%).
Health literacy was also higher among people with high incomes (63%) than among
people on low incomes (21%) (ABS 2009).
See Chapter 1.4 ‘Indicators of Australia’s health’ for more information on health literacy
as an indicator.
183
Limited information is available on the health literacy environment. The ABS Survey
of Health Care 2016 (ABS 2017) did not directly measure health literacy but contained
some relevant questions. Analysis revealed that 95% of respondents reported that their
specialist doctor explained treatment choices in a way that they could understand, and
88% reported that their general practitioner usually or always involved them in decisions
about their own health care. Shared decision making by the provider and patient is
needed for effective communication.
See Chapter 7.18 ‘Coordination of health care’ for more information on the ABS Survey of
Health Care.
How can health literacy be improved?

In 2014, all Australian health ministers endorsed the ‘National statement on health
literacy’ (ACSQHC 2014b) developed by the Australian Commission on Safety and Quality
in Health Care (the Commission). The statement proposed a coordinated approach to
improve the health literacy of Australians across three areas:
1. Incorporate health literacy into health care systems; for example, through legislation,
policies, plans, standards, funding mechanisms and educational curriculums.
2. Improve communication of health information between providers and users, including
interpersonal communication, written information and health promotion campaigns.
3. Include health literacy in the education of adults, children and health care providers.
Several national initiatives relating to one or more of these areas are underway
(Box 4.3.1).
Box 4.3.1 Initiatives to improve health literacy

The Commission and Healthdirect Australia have developed ‘Question builder’, an
online tool for patients to prepare for a medical appointment. It allows patients to
select questions they want to ask at the appointment and prepare for questions
the doctor may ask them. This allows the patient to be more involved in their own
health care and improves their ability to make informed decisions (ACSQHC 2017a).
The Commission also released ‘Top tips for safe health care’, a booklet that provides
information about what people should consider when interacting with the health
system, such as finding good information, asking about care after leaving hospital
and giving feedback (ACSQHC 2017b).
‘Choosing Wisely Australia’ is an initiative of NPS MedicineWise; it is based on
‘Choosing Wisely’, developed by the ABIM Foundation in the United States.
‘Choosing Wisely Australia’ includes strategies to encourage and empower people
to communicate effectively with their doctor. It provides evidential information
on different options to help patients avoid unnecessary tests, treatments and
procedures, and better understand their options (NPS MedicineWise 2016).
184
Health literacy is a broad and complex concept that is difficult to measure. As outlined
in this snapshot, there are limited Australian data available on health literacy (related to
the individual or environment). The last national survey measuring health literacy was
conducted more than a decade ago, in 2006 (ABS 2009). The ABS will conduct another
similar survey in 2018, following up respondents from the 2017–18 National Health Survey.
While there is evidence to inform the improvement of some aspects of health literacy,
work has yet to be finished in creating a common measurement scale to evaluate the
effectiveness of new strategies. Further work to develop suitable performance measures
and identify the most appropriate data to collect would be useful.

More information on health literacy and safety and quality in health care is available on
the Commission’s website <www.safetyandquality.gov.au>.
Information on the Choosing Wisely initiative is available on the Choosing Wisely website.
Information on the Question Builder initiative is available on the Health Direct website.
References
ABS (Australian Bureau of Statistics) 2009. Health literacy. ABS cat. no. 4233.0. Canberra: ABS.
ABS 2017. Survey of health care. ABS cat. no. 4343.0. Canberra: ABS.
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2014a. Health literacy: taking action
to improve safety and quality. Sydney: ACSQHC.
ACSQHC 2014b. National statement on health literacy. Sydney: ACSQHC.
ACSQHC 2017a. Question builder. Sydney: ACSQHC. Viewed 10 November 2017,
<https://www.safetyandquality.gov.au/questionbuilder>.
Chapter 4
ACSQHC 2017b. Top tips for safe health care. Sydney: ACSQHC. Viewed 18 December 2017,
<https://www.safetyandquality.gov.au/publications/top-tips-for-safer-health-care/>.
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN,
Harden E, Tant E, Wallace I & Viswanathan M 2011. Health literacy interventions and outcomes: an updated
systematic review. Evidence Report/Technology assessments 199:1–941.
Bush R, Boyle F, Ostini R, Ozolins I, Brabant M, Soto EJ et al. 2010. Advancing health literacy through primary
health care systems. Canberra: Australian National University.
Diug B, Evans S, Lowthian J, Maxwell E, Dooley M, Street A et al. 2011. The unrecognized psychosocial
factors contributing to bleeding risk in warfarin therapy. Stroke 42:2866–71.
NPS MedicineWise 2016. What is Choosing Wisely Australia? Sydney: NPS MedicineWise. Viewed
10 November 2017,
<http://www.choosingwisely.org.au/about-choosing-wisely-australia/what-is-choosing-wisely-australia>.
Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z et al. 2012. Health literacy and public
health: a systematic review and integration of definitions and models. BMC Public Health 12.
185
4.4 Contribution of selected
FEATURE ARTICLE
risk factors to burden of

disease
Risk factors such as tobacco use, risky alcohol consumption, illicit drug use, not getting
enough exercise, and poor eating patterns can have a detrimental effect on health. Almost
one-third of the overall disease burden could be prevented by reducing exposure to these
and other modifiable risk factors (AIHW 2016a). Even small changes to our daily exercise
routines or body weight could substantially reduce disease burden. For example, an extra
15 minutes of brisk walking, 5 days each week, could reduce the disease burden in the
population due to physical inactivity by about 14% (AIHW 2017c). The loss of 3 kilograms
by a person of average height could reduce disease burden in the population due to
overweight and obesity by 14% (AIHW 2017b).
Burden of disease analysis (Box 4.4.1) measures the combined impact of morbidity
(non-fatal burden) and mortality (fatal burden) in a consistent manner so as to assess
and compare the health loss from different diseases and injuries in a population. The
analysis also estimates the contribution of various risk factors to disease burden.
Burden of disease estimates are designed to inform health policy for the prevention,
early intervention and treatment of diseases and risk factors, as well as to inform health
promotion and management strategies and resource allocation.
Box 4.4.1: What is burden of disease?

Burden of disease analysis quantifies the gap between a population’s actual health
and an ideal level of health in a given year—that is, every individual living in full
health to the theoretical maximum life span—for all diseases at the same time.
It does this by measuring the health consequences of living with ill health and injury
(non-fatal burden) and of dying prematurely from illness and injury (fatal burden).
It also quantifies the contribution of various risk factors to this burden.
Burden of disease is measured using the summary measure disability-adjusted life
years (DALYs). One DALY is 1 year of ‘healthy life’ lost due to illness and/or
death—the more DALYs associated with a disease or injury, the greater the burden.
The total disease burden is the sum of all DALYs (burden) estimated for all
diseases and injuries in the year of study for the whole population.
The attributable burden reflects the direct relationship between a risk factor
(for example, overweight and obesity) and a disease outcome. It is the amount of
burden that could be avoided if the risk factor were removed or reduced to the
lowest possible exposure. When the risk factor is a disease, such as diabetes, the
additional burden from diseases linked to the disease risk factor represents the
indirect burden. More information about indirect burden can be found in section
‘Diabetes and chronic kidney disease as risk factors for other diseases’.
(continued)
186
Box 4.4.1 (continued): What is burden of disease?
Linked diseases are those that have a causal association with the risk factor
of interest. A disease was included in the analysis if it was considered to have
a ‘convincing’ or ‘probable’ level of evidence supporting a causal association,
according to criteria set by the World Cancer Research Fund—a highly regarded
set of criteria for evaluating evidence. Burden of disease studies use data on how
prevalent the risk factor is in the population, and relative risks, to measure the
size of the association between risk factors and linked diseases. Relative risks are
a measure of how much more likely an outcome is in people exposed to the risk
factor than in people who are not (AIHW 2016b).
Details on the methods used to calculate burden of disease in the Australian
Burden of Disease Study are in the AIHW report Australian Burden of Disease Study
2011: methods and supplementary material.
The Australian Burden of Disease Study (ABDS) 2011, undertaken by the AIHW, provides
information on the burden of disease and injury for the Australian population for
around 200 diseases and injuries (grouped into 17 disease groups) and 29 risk factors
(see Chapter 3.1 ‘Burden of disease across the life stages’).
This article presents information on estimates of disease burden attributable to selected
risk factors for 2011. This work draws on the latest evidence on the causal association
between different diseases and injuries (referred to as ‘linked diseases’ in this article) and
the risk factor. The following risk factors are included: overweight and obesity, physical
inactivity, alcohol and illicit drug use, intimate partner violence, and diseases considered
as risk factors for other diseases—chronic kidney disease (CKD) and diabetes. Table 4.4.1
summarises the proportion of disease burden attributed to these risk factors, by selected
Chapter 4
disease groups, and in total.
See Chapter 3.14 ‘Dementia’ for information on the contribution of vascular risk factors
and diseases to the burden of dementia in Australia.
This article does not cover other leading risk factors included in the ABDS 2011, such as
tobacco use (representing 9.0% of the burden in 2011) and high blood pressure (4.9%).
See chapters 4.5 ‘Tobacco smoking’, 4.11 ‘Biomedical risk factors’ for more information
on these risk factors.
187
Table 4.4.1: Proportion of disease burden attributed to selected risk factors, 2011
Risk factor
Insufficient Intimate
Overweight physical Illicit drug partner
and obesity Alcohol use activity use violence(a)
All diseases
7.0 4.6 2.6 2.3 1.4
and injuries
Disease group
Cancer 7.2 4.4 2.9 0.7 ..
Cardiovascular 18.0 1.8 8.0 .. ..
Mental(b) .. 12.2 .. 6.1 7.2
Injuries .. 17.9 .. 12.7 7.1
Endocrine 50.6 .. 18.0 .. ..
(a) Estimates are for women who were subject to violence from cohabiting partners only.
(b) Includes mental and substance use disorders.
Note: Blank cells (. .) indicate that the risk factor has no associated diseases or injuries in the disease group.
Sources: AIHW 2017b, 2017c, 2018b; Ayre et al. 2016.
Overweight and obesity

Overweight and obesity is a major public health issue, with nearly 2 in 3 (63%) adults and
more than 1 in 4 (28%) children in Australia considered overweight or obese (ABS 2015).
Overweight and obese adults have an increased risk of cardiovascular disease, CKD,
some types of cancer, diabetes and musculoskeletal problems (AIHW 2017c).
Seven per cent (7.0%) of the total health burden in Australia in 2011 was due to
overweight and obesity. The attributable burden due to overweight and obesity was
higher in males (7.3% of all burden) than in females (6.6%). Around 63% of the burden
was due to fatal outcomes.
Overweight and obesity was linked to 22 diseases; 11 types of cancer, 3 cardiovascular
conditions, CKD, diabetes, dementia, gallbladder disease, gout, back pain and problems,
osteoarthritis, and asthma. Figure 4.4.1 presents the top 10 linked diseases. Overweight
and obesity was responsible for 53% of diabetes burden, 45% of osteoarthritis burden and
38% of CKD burden in 2011. An estimated 22% of breast cancer burden in females was
due to overweight and obesity.
188
Figure 4.4.1: Proportion of linked disease burden (DALYs) due to overweight
and obesity, by sex and top 10 linked diseases, 2011
Linked disease
Diabetes
Osteoarthritis
Oesophageal cancer
CKD
Breast cancer
Coronary heart disease
Stroke Males
Back pain and problems Females
Bowel cancer
Dementia
0 10 20 30 40 50 60
Linked disease burden (per cent)
Source: AIHW 2017b; Table S4.4.1.
The lowest socioeconomic area experienced the greatest burden attributable to

overweight and obesity, at a rate 2.3 times that of the highest socioeconomic area.
There was a clear pattern of decreasing burden with increasing socioeconomic area
for both males and females (Figure 4.4.2).
Chapter 4
Figure 4.4.2: Age-standardised DALY rate due to overweight and obesity,
by sex and socioeconomic area, 2011
DALY rate (per 1,000 population)

Males Females
25
20
15
10
0
1 2 3 4 5
Lowest Highest
Socioeconomic area
Note: Rates were age standardised to the 2001 Australian Standard Population.
189
Around 14% of disease burden due to overweight and obesity in 2020 could be avoided
if everyone in the population at risk in 2011 reduced their body mass index (BMI) by 1
(equivalent to around 3 kilograms in a person of average height), and maintained that loss
to 2020 (AIHW 2017b). BMI is a commonly used method to determine if a person is normal
weight, underweight, overweight or obese and is calculated by dividing the person’s
weight (in kilograms) by their height (in metres) squared. See Chapter 4.10 ‘Overweight
and obesity’ for more information on overweight and obesity.
Even if the current rises in overweight and obesity in the population were halted (by
people just maintaining their current weight), an estimated 6.3% of future disease burden
due to overweight and obesity could be avoided.
For more scenario modelling results see the online data visualisation tool at
<www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/
burden-of-disease-scenario-modelling>.
Insufficient physical activity

Insufficient physical activity is a major risk factor for ill health in Australia, with more
than half of adults not meeting the current Australian recommended physical activity
guidelines (ABS 2015). Physical activity is an important factor in preventing or reducing
overweight and obesity, which is a leading contributor to disease in Australia. Insufficient
physical activity increases the risk of a range of diseases, such as cardiovascular disease,
type 2 diabetes and some cancers (Kyu et al. 2016).
In 2011, 2.6% of the total disease burden was due to insufficient physical activity in people
aged 20 and over. This finding was similar for both men and women. Around 74% of this
burden was due to fatal outcomes.
Insufficient physical activity was linked to 7 diseases—coronary heart disease, diabetes,
bowel cancer, dementia, stroke, breast cancer, and uterine cancer. It was responsible for
between 10% and 20% of disease burden for each of these diseases (Figure 4.4.3).
Figure 4.4.3: Proportion of linked disease burden (DALYs) due to insufficient

physical activity for people aged 20 and over, by sex, 2011
Linked disease
Diabetes
Bowel cancer
Uterine cancer
Men
Dementia
Women
Breast cancer
Stroke
0 5 10 15 20 25
Source: AIHW 2017c; Table S4.4.3.
190
People in the lowest socioeconomic area experienced rates of disease burden due to
insufficient physical activity at 1.7 times those of the highest socioeconomic area. There
was a clear pattern of decreasing burden with increasing socioeconomic area for both
men and women (Figure 4.4.4).
Figure 4.4.4: Age-standardised DALY rate due to insufficient physical activity

for people aged 20 and over, by sex and socioeconomic area, 2011

8
Men Women
7
0
1 2 3 4 5
Lowest Highest
Socioeconomic area
Source: AIHW 2017c; Table S4.4.4.
Chapter 4
An extra 15 minutes of moderate activity (such as brisk walking), 5 days each week by
everyone in the population at risk in 2011—maintained over time to 2020—could reduce
disease burden due to insufficient physical activity in the population by an estimated 14%.
If this activity time were increased to 30 minutes, the burden could be reduced by 26%
(AIHW 2017c). All ages would benefit, particularly people aged 65 and over.
For more scenario modelling results see the online data visualisation tool at
burden-of-disease-scenario-modelling>.
After taking into account the complex interactions between insufficient physical activity
and overweight and obesity, an estimated 9.0% of the total disease burden in 2011 was
due to these risk factors combined.
See Chapter 4.8 ‘Insufficient physical activity’ for more information on physical activity.
191
Alcohol and illicit drug use
Alcohol and illicit drug use contribute substantially to the health burden in Australia,
both on their own as dependency disorders, and as risk factors for other diseases and
injuries. They present many risks of immediate and chronic harm to the individual and
their families, bystanders and the broader community. Immediate consequences include
antisocial behaviour and exposure to violence (including domestic and family violence),
traffic accidents, injury, poisoning, crime and trauma (Department of Health 2017;
Laslett et al. 2011; NHMRC 2009; Stafford & Burns 2015). Chronic harms include chronic
health conditions that may result from alcohol or illicit drug use, such as cardiovascular
disease, cancer, mental health problems and dependency disorders (AIHW 2016c). The
broader societal and economic impacts—such as antisocial behaviour, crime, productivity
losses, costs associated with health care and law enforcement, and harm to families and
communities—are not measured in the Australian Burden of Disease Study.
Alcohol and illicit drug use were the two leading risk factors for disease burden in males
aged 15–44 in 2011 (AIHW 2016a).
Together, alcohol and illicit drug use were responsible for 6.7% of the total disease burden
in Australia in 2011, of which three-quarters was experienced by males. Alcohol and illicit
drug use were responsible for 4.5% (6,660) of deaths and a higher proportion of years
of life lost (8.1%) due to the relatively young age at which these deaths occurred. These
estimates are based on analysis of the combined impact of both risk factors, adjusted for
the interaction between them.
Alcohol use
Alcohol use was linked to 26 diseases or injuries (which included alcohol use disorders):
11 types of injury (including suicide and self-inflicted injuries, road traffic injuries—motor
vehicle occupants, homicide and violence, and accidental poisoning), 6 types of cancer
(including liver, breast, and mouth and pharyngeal cancer), 4 cardiovascular diseases
(including stroke, coronary heart disease and hypertensive heart disease), alcohol
dependence, chronic liver disease, epilepsy, lower respiratory infections, and pancreatitis.
Alcohol use was responsible for 4.6% of the total disease burden in Australia in 2011,
of which three-quarters (73%) was experienced by males. Around 59% of the burden
attributable to alcohol use was due to fatal outcomes; however, this varied by age, sex
and linked disease.
Alcohol use was responsible for 100% of the burden due to alcohol dependence, 37%
of the mouth and pharyngeal cancer burden, between 30% and 35% of the burden due
to different types of road traffic injuries, and 23% of the homicide and violence burden
(Figure 4.4.5).
192
Figure 4.4.5: Proportion of linked disease burden (DALYs) due to alcohol use for
people aged 15 and over, by sex and selected linked diseases or injuries, 2011
Linked disease/injury
Alcohol use disorders
Liver cancer
Chronic liver disease
Road traffic injuries—motorcyclists
Mouth and pharyngeal cancer
Road traffic injuries—motor vehicle occupants Males
Epilepsy Females
Breast cancer
Homicide and violence
Suicide and self-inflicted injuries
Falls
0 20 40 60 80 100
The lower the socioeconomic area, the higher the rate of burden attributable to alcohol
use. The lowest socioeconomic area experienced rates of burden attributable to alcohol
use that were 1.9 times those of the highest socioeconomic area.
There was also a clear pattern of increasing attributable burden with increasing
remoteness, with Very remote areas experiencing 2.4 times the rate of burden
Chapter 4
attributable to alcohol use as Major cities (AIHW 2018b).
Illicit drug use

Illicit drug use—which includes opioids (such as heroin and prescription opioids),
amphetamines, cannabis, cocaine and other illicit drugs, as well as unsafe injecting
practices—was linked to 13 diseases and injuries: drug use disorders, chronic liver
disease, hepatitis B, hepatitis C, liver cancer, suicide and self-inflicted injury, human
immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), accidental
poisoning, road traffic injuries—motorcyclists, road traffic injuries—motor vehicle
occupants, depressive disorders, schizophrenia, and anxiety disorders.
Overall, illicit drug use was responsible for 2.3% of the total burden of disease and injury
in Australia in 2011, of which three-quarters (75%) was experienced by males. More than
two-thirds (69%) of the burden attributable to illicit drug use was due to fatal burden;
however, this varied by age, sex and linked disease.
Illicit drug use was responsible for 65% of the accidental poisoning burden. For other
linked diseases, illicit drug use was responsible for 42% of hepatitis B burden, 26% of
chronic liver disease burden, and 21% of liver cancer burden (Figure 4.4.6).
193
Figure 4.4.6: Proportion of linked disease burden (DALYs) due to illicit drug use
for people aged 15 and over, by sex and selected linked diseases or injuries, 2011
Linked disease/injury
Illicit drug dependence
Hepatitis C (acute)
Accidental poisoning
Hepatitis B (acute)
Chronic liver disease
Liver cancer Males

HIV/AIDS Females
Road traffic injuries—motorcyclists
Road traffic injuries—motor vehicle occupants
Suicide and self-inflicted injuries
0 20 40 60 80 100
The majority of the burden due to illicit drug use was from opioid use (41%), followed
by amphetamine use (18%). As well, 18% was from diseases contracted through unsafe
injecting practices. Cocaine use and cannabis use accounted for a further 8.0% and 6.6%,
respectively.
Opioid use was responsible for around half (52%) of the total disease burden due to
accidental poisoning. Amphetamine use was responsible for around 7.5% of the total
burden of road traffic injuries. One-quarter (26%) of the burden of chronic liver disease
and one-fifth (21%) of liver cancer disease burden was a result of unsafe injecting
practices.
There was a clear pattern of increasing attributable burden due to illicit drug use
with decreasing socioeconomic area. The lowest socioeconomic area experienced
rates of burden attributable to illicit drug use that were 2.6 times those of the highest
socioeconomic area.
There was a general pattern of increasing attributable burden with increasing remoteness,
for amphetamine use, unsafe injecting practices and cocaine use. For cannabis use, there
was no clear pattern by remoteness in rates of attributable burden (Figure 4.4.7). For
opioid use, the rate in Major cities was 1.6 to 2 times as high as those for other remoteness
areas.
194
Figure 4.4.7: Age-standardised DALY rate due to drug use for people aged 15
and over, by drug type or practice and remoteness area, 2011

3.0
Major cities Inner regional Outer regional Remote Very remote
2.5
2.0
1.5
1.0
0.5
0.0
Opioid use Amphetamine use Unsafe injecting Cocaine use Cannabis use
Drug type or practice
See Chapter 3.17 ‘Opioid harm’; chapters 4.6 ‘Alcohol risk and harm’, 4.7 ‘Illicit drug use’ for
more information on alcohol and drug use in Australia.
Intimate partner violence
Chapter 4
Intimate partner violence is an important public health issue that can have substantial
social, economic and health impacts (AIHW 2018a). Around 1 in 4 (23%) women
experienced violence by an intimate partner in 2016, compared with 1 in 13 (7.8%) men
(ABS 2017). The seriousness of this issue prompted the development of The National
Plan to Reduce Violence against Women and their Children 2010–2022. The Plan aims to
ensure that fewer women experience violence and that more women and children can
live safely (COAG 2011).
Intimate partner violence was associated with 7 diseases or injuries: depressive disorders,
anxiety, early pregnancy loss, suicide and self-inflicted injuries, homicide and violence,
alcohol use disorders, and preterm birth and low birthweight complications (AIHW 2016a).
An estimated 1.4% of the total disease burden in 2011 was attributable to physical/sexual
intimate partner violence by the current or previous cohabiting partner of women aged
18 and over. This increased to 2.0% when intimate partner violence by non-cohabiting
partners was included (Ayre et al. 2016).
Anxiety disorders made up the greatest proportion of this attributable burden (37%),
followed by depressive disorders (33%) and suicide and self-inflicted injuries (20%).
See Chapter 3.16 ‘Family, domestic and sexual violence’ for more information on
intimate partner violence in Australia.
195
Diabetes and chronic kidney disease as
risk factors for other diseases
Diseases such as diabetes and CKD are increasingly common in Australia, in part due to
changing lifestyle and behaviour, and an ageing population. These and other diseases can
also act as risk factors for other diseases (referred to as linked diseases, see Box 4.4.1).
For example, diabetes can increase the risk of coronary heart disease, stroke, peripheral
vascular disease and dementia (Cheng et al. 2014; Emerging Risk Factors Collaboration
2010; Prince et al. 2014; Vigneri et al. 2009).

The burden of each disease, as calculated in the ABDS 2011, captured the ‘direct’ disease
burden. For example, the direct burden of diabetes is the burden most closely related
to diabetes, such as diagnosed diabetes, diabetic neuropathy and retinopathy. To fully
account for the health loss attributable to diabetes, the ‘indirect’ or additional burden
from diseases linked to diabetes must also be calculated. This includes the proportion of
burden of linked diseases caused by other diabetes complications (for example, coronary
heart disease and stroke). To estimate the collective burden, the direct and indirect
burden are added.
This section focuses on diabetes and CKD as risk factors for other diseases, as they
are increasingly common in Australia and have major impacts on health and other
support services.
The ABDS 2011 reported that diabetes and CKD were responsible for 2.3% and 0.9%,
respectively, of the total burden of disease and injury in Australia in 2011 (the direct
burden). When the indirect burden due to linked diseases was taken into account, the
burden due to either diabetes or CKD doubled (the collective burden) (4.2% for diabetes
and 2.0% for CKD).
Diabetes was responsible for 21% of the CKD burden, 14% of the stroke burden and
11% of the coronary heart disease burden (Figure 4.4.8). Males had a larger proportion
of disease burden attributable to diabetes for all linked diseases, except coronary heart
disease and stroke.
196
Figure 4.4.8: Proportion of burden (DALYs) attributable to diabetes, by sex and
linked disease, 2011
Linked disease
CKD
Stroke
Liver cancer
Uterine cancer
Peripheral vascular disease
Pancreatic cancer
Males
Dementia
Females
Kidney cancer
Bowel cancer
Bladder cancer
Breast cancer
0 5 10 15 20 25
Direct DALY (per cent)
Source: AIHW 2016d; Table S4.4.8.
CKD was responsible for 19% of peripheral vascular disease burden, 8.4% of dementia
burden and 7.2% of stroke burden (Figure 4.4.9). A larger proportion of disease burden
was attributable to CKD in females in every linked disease.
Chapter 4
Figure 4.4.9: Proportion of burden (DALYs) attributable to CKD, by sex and
linked disease, 2011
Linked disease
Peripheral vascular disease
Dementia
Males
Females
Stroke
0 5 10 15 20 25
Direct DALY (per cent)
Source: AIHW 2016d; Table S4.4.9.
197
Scenario modelling analysis showed that, in 2020, around one-fifth (21%) of future
diabetes burden, and 4.8% of future CKD burden could be avoided if the current rise in
these diseases were halted (AIHW 2016d).
See chapters 3.8 ‘Diabetes’, 3.9 ‘Chronic kidney disease’ for more information on diabetes
and CKD in Australia.

The AIHW is currently updating Australia’s burden of disease estimates to the 2015
reference year; results are expected to be released in early 2019. This will include updated
information on the burden due to different diseases and risk factors in Australia, such
as those described in this article. As part of this work, the AIHW will be including disease
expenditure estimates to align with burden of disease categories, to enable health system
expenditure and corresponding disease burden to be compared.

While the studies described here add important information about the contribution of
certain risk factors to the burden of disease in the Australian population, there are still
gaps which, if filled, could improve current insights. For instance, the burden of risk factors
such as insufficient physical activity and alcohol and illicit drugs could not be estimated in
children due to a lack of evidence on their association with diseases in younger ages. The
full impact that overweight and obesity in children has on disease burden in adulthood is
also currently unknown.

References
ABS (Australian Bureau of Statistics) 2015. National Health Survey: first results, 2014–15. ABS cat. no.
4364.0.55.001. Canberra: ABS.
ABS 2017. Personal safety, Australia, 2016. ABS cat. no. 4906.0. Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2016a. Australian Burden of Disease Study: impact
and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3.
Cat. no. BOD 4. Canberra: AIHW.
AIHW 2016b. Australian Burden of Disease Study 2011: methods and supplementary material. Australian
Burden of Disease Study series no. 5. Cat. no. BOD 6. Canberra: AIHW.
AIHW 2016c. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.
AIHW 2016d. Diabetes and chronic kidney disease as risks for other diseases: Australian Burden of Disease
Study 2011. Australian Burden of Disease Study series no. 8. Cat. no. BOD 9. Canberra: AIHW.
AIHW 2017a. A picture of overweight and obesity in Australia 2017. Cat. no. PHE 216. Canberra: AIHW.
AIHW 2017b. Impact of overweight and obesity as a risk factor for chronic conditions: Australian Burden
of Disease Study. Australian Burden of Disease Study series no. 11. Cat. no. BOD 12. Canberra: AIHW.
198
AIHW 2017c. Impact of physical inactivity as a risk factor for chronic conditions: Australian Burden of
Disease Study. Australian Burden of Disease Study series no. 15. Cat. no. BOD 16. Canberra: AIHW.
AIHW 2018a. Family, domestic and sexual violence in Australia 2018. Cat. no. FDV 2. Canberra: AIHW.
AIHW 2018b. Impact of alcohol and illicit drug use on the burden of disease and injury in Australia:
Australian Burden of Disease Study 2011. Australian Burden of Disease Study series no. 17. Cat no. BOD 19.
Canberra: AIHW.
Ayre J, Lum On M, Webster K, Gourley M & Moon L 2016. Examination of the burden of disease of intimate
partner violence against women in 2011: final report (ANROWS Horizons, 06/2016). Sydney: ANROWS.
Cheng D, Fei Y, Liu Y, Li J, Xue Q, Wang X et al. 2014. HbA1C variability and the risk of renal status
progression in diabetes mellitus: a meta-analysis. Plos One 9:e115509.
COAG (Council of Australian Governments) 2011. The National Plan to Reduce Violence against Women
and their Children: including the first three-year action plan. Canberra: Department of Families, Housing,
Community Services and Indigenous Affairs.
Department of Health 2017. The National Drug Strategy 2017–2026. Canberra: Department of Health.
Emerging Risk Factors Collaboration 2010. Diabetes mellitus, fasting blood glucose concentration and risk
of vascular disease: a collaborative meta-analysis of 102 prospective studies. The Lancet 375:2215–22.
Kyu HH, Bachman VF, Alexander LT, Mumford JE, Afshin A, Estep K et al. 2016. Physical activity and risk
of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic
review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ 354:i3857.
Laslett A, Room R & Ferris J 2011. Surveying the range and magnitude of alcohol’s harm to others in
Australia. Addiction 106(9):1603–11.
NHMRC (National Health and Medical Research Council) 2009. Australian guidelines to reduce health risks
from drinking alcohol. Canberra: NHMRC.
Prince M, Albanese E, Guerchet M & Prina M 2014. World Alzheimer report 2014—dementia and risk
reduction: an analysis of protective and modifiable factors. London: Alzheimer’s Disease International.
Stafford J & Burns L 2015. Australian drug trends 2014. Findings from the Illicit Drugs Reporting System
(IDRS). Australian Drug Trends 2014 no. 127. Sydney: National Drug and Alcohol Research Centre,
University of New South Wales.
Vigneri P, Frasca F, Sciacca L, Pandini G & Vigneri R 2009. Diabetes and cancer. Endocrine-Related Cancer
16:1103–23.
Chapter 4
199
4.5 Tobacco smoking
SNAPSHOT
The decline in daily smoking has slowed

Successful public health strategies over several decades have seen daily smoking rates
in Australia decline. The National Drug Strategy Household Survey showed that the daily
smoking rates halved between 1991 and 2016 (from 24% to 12%). However, there was no
decline between 2013 and 2016 (AIHW 2017).
The majority of daily smokers are aged 40

and over
People aged 40–49 continued to be the age group most likely to smoke daily (16.9%) and
no improvement in the smoking rate was seen for this group in 2016 (16.2% in 2013 and
16.9% in 2016).
The population of smokers is ageing and the majority (57%) of daily smokers in 2016 were
aged 40 and over—different from the trend 15 years ago when the majority were aged
14–39. Long-term reductions in smoking have been largely driven by fewer people ever
taking up smoking. Between 2001 and 2016, the proportion of people who reported never
smoking rose from 51% to 62% (AIHW 2017).
Some groups are making positive changes

Considerable progress towards reducing smoking continued to be made among
teenagers—the proportion of teenagers who were current smokers (people who reported
smoking daily, weekly or less than weekly) declined from 5.0% in 2013 to 2.1% in 2016.
Young people also continued to delay the uptake of smoking, with the average age at
which people aged 14–24 smoked their first full cigarette increasing from 14.3 years in
2001 to 16.3 years in 2016 (a significant increase from 15.9 years in 2013).
There were also fewer people being exposed to tobacco smoke: the proportion of
dependent children exposed to tobacco smoke inside the home continued to decline,
from 3.7% in 2013 to 2.8% in 2016 (a dramatic fall from 31% in 1995), and the proportion
of pregnant women smoking during their pregnancy declined from 15% in 2009 to 10%
in 2015.
People living in the lowest socioeconomic area were one of the few groups to report a
decline in daily smoking between 2013 and 2016—from 20% to 18%—but they still have
a much higher smoking rate than people living in the highest socioeconomic area (6.5%)
(AIHW 2017).
200
Some groups are more likely to smoke
daily than others
Good health is not shared equally among people in Australia and smoking is one example
of a key risk factor for disease that contributes to these inequalities. Although some
improvements are being made among these groups, daily smoking continues to be more
commonly reported among Aboriginal and Torres Strait Islander people (see Chapter 6.5
‘Health behaviours of Indigenous Australians’), people living in the lowest socioeconomic
area, people identifying as homosexual/bisexual, and people who were unable to work
or were unemployed (Figure 4.5.1).
Figure 4.5.1: Proportion of people who are daily smokers, by selected

demographic characteristics, 2016
Socioeconomic
Lowest 18%
area
Highest 7%
Remoteness
Major cities 11%

area
Remote/Very remote 21%

orientation
Heterosexual 12%
Sexual
Chapter 4
Homosexual/bisexual 19%
Mental health
Have not been diagnosed/

10%
treated for mental illness
Diagnosed/treated
24%
for mental illness
Employment status
Employed 13%
Unemployed 23%
Unable to work 30%
201
Most smokers want to quit
According to the National Drug Strategy Housing Survey 2016, 7 in 10 (69%) current
smokers planned to quit smoking and 3 in 10 (29%) tried to quit in the previous 12 months
but did not succeed. The main reason smokers tried to quit or change their smoking
behaviour was because it was costing too much money (52%).
Smoking is the leading risk factor for disease

Tobacco smoking is the leading preventable cause of death and disease in Australia and
a leading risk factor for many chronic conditions.
The Australian Burden of Disease Study estimated that tobacco use contributed to
almost 18,800 deaths in 2011—more than 1 in every 8 (13%) deaths. Taking into account
illness as well as deaths, tobacco use caused more disease and injury burden in Australia
than any other single risk factor and was responsible for 9.0% of the total burden of
disease. The largest impact from tobacco use is on cancer, respiratory diseases and
cardiovascular disease.
The total burden attributable to tobacco use was only slightly lower (0.2%) in 2011 than
in 2003 (equivalent to an 18% decline in the age-standardised rate), despite reductions in
tobacco use and exposure over this period. This may be because health improvements
from reductions in tobacco use take longer to become evident in cancer and chronic
respiratory diseases (for which burden rates are still increasing) than in cardiovascular
disease (for which there has been a large decrease in burden) (AIHW 2016).
Smokers have poorer health than

non-smokers
In 2016, smokers were less likely to rate their health as ‘excellent’ than people who had
never smoked (8.3% compared with 22%) and were more likely than people who had
never smoked to self-report being diagnosed with, or treated for, a mental illness in the
previous 12 months (28% compared with 12% for people who had never smoked). The
proportion of smokers self-reporting a mental illness also increased—both in recent years
(from 21% in 2013), and over the last decade (17% in 2007).
The mechanisms linking tobacco smoking with mental health problems are complex;
however, it is understood that people may perceive that smoking helps to relieve or
manage psychiatric symptoms of their disorder (Minichino et al. 2013). It has also been
shown that people with mental health conditions may find it difficult to stop smoking;
however, on quitting, they are likely to experience improvements in their mood, general
wellbeing, mental health and quality of life (Greenhalgh et al. 2016).
A high proportion of smokers also drink alcohol in risky quantities (49% exceeded the
lifetime or single-occasion risk guidelines in 2016) and use illicit drugs (36% had used at
least one illicit drug in the previous 12 months). Risky alcohol consumption and illicit drug
use are both risk factors that increase the likelihood of a person’s developing a disease or
health disorder.
202
There are limited national data available on how and why people quit smoking, and
how they successfully maintained quitting. Most survey questions related to changes in
behaviour or stopping smoking are targeted at smokers not ex-smokers.
There are currently no regular data collections on smoking prevalence among homeless
people or on the relationship status of household smokers (for example, parent or sibling).

More information on tobacco smoking is available at <www.aihw.gov.au/reports-statistics/
behaviours-risk-factors/smoking/overview>. The reports National Drug Strategy Household
Survey 2016: detailed findings and Tobacco indicators: measuring midpoint progress—
reporting under the National Tobacco Strategy 2012–2018 and other recent releases are
available for free download.
References
AIHW (Australian Institute of Health and Welfare) 2016. Australian Burden of Disease Study: impact
and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3.
AIHW 2017. National Drug Strategy Household Survey 2016: detailed findings. Drug statistics series no. 31.
Cat. no. PHE 214. Canberra: AIHW.
Greenhalgh EM, Stillman S & Ford C 2016. Smoking and mental health. In: Scollo MM & Winstanley MH
(eds). Tobacco in Australia: facts and issues. Melbourne: Cancer Council Victoria. Viewed 12 January 2018,
Chapter 4
<http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-12-smoking-and-mental-health>.
Minichino A, Bersani FS, Calo WK, Spagnoli F, Francesconi M, Vicinanza R et al. 2013. Smoking behaviour
and mental health disorders—mutual influences and implications for therapy. International Journal of
Environmental Research and Public Health 10(10):4790–811.
203
4.6 Alcohol risk and harm
SNAPSHOT
The consumption of alcohol is widespread in Australia and associated with many social
and cultural activities. While most Australians drink alcohol at levels that cause few
harmful effects, a large proportion drink at levels that increase their risk of harm—
affecting not only themselves but also families, bystanders and the broader community
(NHMRC 2009). The latest estimate of the social costs of alcohol abuse in Australia was
slightly more than $14 billion—through productivity losses, traffic accidents, crime and
health care costs (Manning et al. 2013).
Trends in alcohol consumption in Australia

The overall volume of alcohol consumed by people in Australia increased from the
equivalent of 9.5 litres of pure alcohol per person in 2014–15 to 9.7 litres in 2015–16.
However, this is lower than the 9.8 litres recorded in 2013–14 (ABS 2017).
The National Drug Strategy Household Survey (NDSHS) 2016 found that slightly more than
3 in 4 (77%) Australians consumed alcohol in the previous 12 months. The NDSHS data
reveal several changes in drinking patterns compared with those for 2013, including that:
• p
eople are drinking less often—daily and weekly drinking rates have declined
• f ewer young people aged 12–17 are drinking alcohol and the proportion
abstaining from alcohol has increased
• p
eople aged 14–24 are delaying starting to drink—the average age at which they first
tried alcohol has increased
• f ewer people are exceeding the lifetime risk guideline (Table 4.6.1).
Table 4.6.1: Significant changes in drinking behaviours, 2013 and 2016
Drinking behaviours 2013 2016

Drank alcohol daily (14 years and over) 6.5% 5.9%
Drank alcohol weekly (14 years and over) 37.3% 35.8%
Drank alcohol less often than weekly (14 years and over) 34.5% 35.8%
Abstained from alcohol (12–17 years) 72.3% 81.5%
Age when had first full serve of alcohol (14–24 years) 15.7 years 16.1 years
Exceeded lifetime risk guidelines (14 years and over) 18.2% 17.1%
Source: AIHW 2017.
These changes are positive; however, the proportion exceeding the single occasion risk
guideline (see Box 4.6.1) at least once a month remained unchanged (at about 26%) as
did the proportion consuming 11 or more standard drinks in one single drinking occasion
in the past year (at about 15%).
204
Box 4.6.1: Summary of the Australian Guidelines to Reduce Health Risks from
Drinking Alcohol
The National Health and Medical Research Council publishes guidelines for reducing
health risks of drinking alcohol. The data for alcohol risks in this report are reported
against the following two guidelines:
• G
uideline 1 (lifetime risk): To reduce the risk of alcohol-related harm over a
lifetime (such as chronic disease or injury), a healthy adult should drink no more
than two standard drinks a day
• G
uideline 2 (single occasion risk): To reduce the risks of injury on a single
occasion of drinking, a healthy adult should drink no more than four standard
drinks on any one occasion (NHMRC 2009).
The data presented relates to the proportion of people exceeding the single
occasion risk guidelines once a month or more often.
Young people drinking less but no change

among older people
Young adults (aged 18–24) historically consume alcohol at higher rates for both lifetime
and single occasion risk than any other age group (see Box 4.6.1 for definitions of risk).
Overall trends since 2001 show, however, that while patterns for older age groups
remained stable (or rates increased in some cases), rates among young people drinking in
excess of guidelines for lifetime risk and single occasion risk declined (Figure 4.6.1).
In 2016, young adults remained the group most likely to drink in excess of single occasion
risk guidelines but the rates of lifetime risky drinking were similar across all age groups
Chapter 4
(about 1 in 5) except for those aged 65 and over, where the rate was lower (13%).
Figure 4.6.1: Exceeded lifetime and single occasion risk, people aged 18 and
over, by age group, 2001, 2013 and 2016
Lifetime risk Single occasion risk

Age group Age group
18–24 18–24
25–34 25–34
35–44 35–44
45–54 45–54 2001

2013
55–64 55–64
2016
65+ 65+
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Per cent Per cent
Note: See Box 4.6.1 for definitions of lifetime and single occasion risk.
205
Impact of alcohol consumption
Alcohol use was estimated to be responsible for 4.6% of the total burden of disease and
injury and 3.4% of deaths (more than 5,000 deaths) in Australia in 2011, based on revised
estimates from the Australian Burden of Disease Study 2011 (AIHW 2018).
information on the burden due to alcohol use.
Hospitalisation and treatment

Over the 5 years from 2011–12 to 2015–16, the number and rate of hospitalisations in
Australia with a drug-related principal diagnosis of alcohol use increased. In 2015–16,
there were 68,000 hospital separations (representing 0.5% of all hospital separations)
where alcohol was the drug-related principal diagnosis—an increase from 62,000
separations in 2011–12 (or from 275 to 284 hospitalisations per 100,000 population)
(supplementary tables S4.6.2, S4.6.3).
The number of closed episodes provided in publicly funded alcohol and other drug
treatment agencies across Australia for a person’s own drug use (where alcohol was the
principal drug of concern) fell between 2012–13 and 2016–17 (from 64,000 to 62,000
episodes). As a proportion, this equates to a decline from 41% to 32% of total episodes
of treatment. See Chapter 7.19 ‘Specialised alcohol and other drug treatment services’
Alcohol-related incidents and harm

Excessive consumption of alcohol increases the risk of people putting themselves and
others at risk of harm (AIHW 2017). The NDSHS showed that, in 2016 almost 1 in 6 (17%)
recent drinkers aged 14 and over put themselves or others at risk of harm while under
the influence of alcohol in the previous 12 months—significantly down from 21% in 2013.
In 2016, the most likely risky activity undertaken while under the influence of alcohol
was driving a motor vehicle (9.9% of recent drinkers). Overall, more than 1 in 5 (22%)
Australians had been a victim of an alcohol-related incident in 2016—down from 26% in
2013. Between 2013 and 2016, verbal abuse (22% and 19%, respectively), being put in fear
(13% and 11%) and physical abuse (8.7% and 7.3%) all declined.

Data on self-reported alcohol consumption are likely to produce an underestimate of
the total amount of alcohol consumed in Australia (Livingston & Callinan 2015). While
wholesale data are an alternative measure of consumption, these data cannot identify
individual drinking levels and the number of drinkers exceeding the recommended
alcohol guidelines. Alcohol consumption data based on wholesale data are also likely to be
an overestimate as no adjustments are made for alcohol used in the preparation of food
or discarded as waste. The estimates are also generally only available at the national level
as estimates at the state or regional level are not available for all jurisdictions.
206
More information on alcohol consumption and harm in Australia is available at
<www.aihw.gov.au/reports-statistics/behaviours-risk-factors/alcohol/overview>. The
report National Drug Strategy Household Survey 2016: detailed findings and other recent
releases are available for free download.
The report Impact of alcohol and illicit drug use on the burden of disease and injury in
Australia: Australian Burden of Disease Study 2011 and other recent releases are available
for free download.
References
ABS (Australian Bureau of Statistics) 2017. Apparent consumption of alcohol, Australia, 2015–16. ABS cat.
no. 4307.0.55.001. Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2017. National Drug Strategy Household Survey 2016:
detailed findings. Drug statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW.
AIHW 2018. Impact of alcohol and illicit drug use on the burden of disease and injury in Australia:
Australian Burden of Disease Study 2011. Australian Burden of Disease Study series no.17.
Livingston M & Callinan S 2015. Underreporting in alcohol surveys: whose drinking is underestimated?
Journal of Studies on Alcohol and Drugs 76(1):158–164.
Manning M, Smith S & Mazerolle P 2013. The societal costs of alcohol misuse in Australia. Trends & Issues
in Crime and Criminal Justice 454. Canberra: Australian Institute of Criminology.
NHMRC (National Health and Medical Research Council) 2009. Australian Guidelines to Reduce Health Risks
from Drinking Alcohol. Canberra: NHMRC.
Chapter 4
207
4.7 Illicit drug use
FEATURE ARTICLE
Harms from illicit drugs affect all Australian communities, families and individuals,
either directly or indirectly. These harms are numerous and include health impacts
such as injury, poisoning and mental illness; social impacts such as violence, crime and
trauma; and economic impacts such as related costs of health care and law enforcement
(Department of Health 2017).
Since 1985, there has been a coordinated approach to dealing with licit and illicit drug use
in Australia. Illicit drug policy is the responsibility of all levels of government and various
government agencies. The National Drug Strategy 2017–2026 is the latest cooperative
strategy to recognise that illicit drug use is a health and social issue, while acknowledging
the role of law enforcement to detect and deter drug crime (Department of Health 2017).
The first part of this article profiles illicit drug use (see Box 4.7.1 for a definition) and
examines the four most commonly used illicit drugs: cannabis, cocaine, ecstasy and meth/
amphetamines. The second part considers the relationship between illicit drug use and
mental health across various age groups and by sociodemographic characteristics (see
Chapter 3.12 ‘Mental health’ for more information on mental health).
Box 4.7.1: Definition of illicit drug use

‘Illicit use of drugs’ covers the use of a broad range of substances, including:
• illegal drugs—drugs prohibited from manufacture, sale or possession in
Australia, including cannabis (non-medical use, see Box 4.7.2), cocaine, heroin
and amphetamine-type stimulants
• p
harmaceuticals—drugs available from a pharmacy, over-the-counter or
by prescription, which may be subject to misuse (when used for purposes,
or in quantities, other than for the medical purposes for which they were
prescribed)—for example, opioid-based pain relief medications, opioid
substitution therapies, benzodiazepines, steroids, and over-the-counter codeine
(not available since 1 February 2018 but it was when data were collected for the
National Drug Strategy Household Survey—NDSHS)
• o
ther psychoactive substances—legal or illegal, potentially used in a harmful
way—for example, kava; synthetic cannabis and other synthetic drugs; or
inhalants such as petrol, paint or glue (MCDS 2011).
Each data collection cited in this article uses a slightly different definition of illicit
drug use; see the relevant report for information.
208
Impact of illicit drug use
According to the AIHW report Impact of alcohol and illicit drug use on the burden of disease
and injury in Australia (AIHW 2018b), illicit drug use contributed to 2.3% of the total
burden of disease and injury in 2011. This included the impact of opioids, amphetamines,
cannabis, cocaine and other illicit drugs, as well as injecting drug use. One-third (33%) of
the burden was from accidental poisoning. A further 31% was from drug dependence
(see Chapter 4.4 ‘Contribution of selected risk factors to burden of disease’).
Drug use disorders accounted for a large proportion of burden for ages 25–44: for men,
it was the eighth leading cause of burden, contributing to 3.2% of burden in this age group
(AIHW 2018b). Around 89% of the burden due to drug use disorders was non-fatal and a
higher amount of burden was experienced by men (72%) than women (28%).
Mental and substance use disorders (bipolar affective disorder, anxiety, substance use,
behavioural and developmental disorders, schizophrenia and intellectual disability)
includes disorders associated with alcohol and other drug use, as well as mental health
issues that occur independently of substance use. In Australia in 2011, mental and
substance use disorders:
• w
ere responsible for an estimated 12% of the total disease burden, making it the
third most burdensome group of diseases—together with musculoskeletal conditions
(also 12%)—behind cancer (19%), and cardiovascular disease (15%)
• w
ere the leading cause of non-fatal burden, accounting for almost one-quarter (24%)
of all years spent living with disease
• w
ere the main causes of burden for late childhood, adolescence and adulthood to
age 44
• a
ccount for more years of life lost due to disability than any other disorders
Chapter 4
(AIHW 2016).
Harms from illicit drug use

The number of drug-induced deaths and hospitalisations with a drug-related principal
diagnosis has increased over recent years in Australia.
Drug-induced deaths
Drug-induced deaths are defined as those that can be directly attributable to drug use
from toxicology and pathology reports. This includes overdoses (accident or suicide) or
where drugs were found to be a direct contributor to the death, such as where a person
was involved in a traffic accident and under the influence of drugs at the time of death
(ABS 2017).
In 2016, there were 1,808 drug-induced deaths, equating to 1.1% of all deaths
(ABS 2017)—the highest number of drug-induced deaths recorded over the past 20 years.
It is similar to the peak in 1999 of 1,740 deaths, which, at that time, was largely due to an
increase in heroin-related deaths. However, the death rate per capita of 7.5 per 100,000
population in 2016 is lower than it was in 1999, when it was 9.2 deaths per 100,000.
209
The most common drug class identified in data for drug-induced deaths over the past
decade was opioids (this drug class includes the illegal use of heroin and licit and illicit use
of opiate-based analgesics—such as codeine, oxycodone and morphine—and synthetic
opioid prescriptions—such as tramadol, fentanyl and methadone).
Between 1999 and 2016, there was a 4-fold increase in the number and rate of
meth/amphetamine deaths, from 0.4 to 1.6 deaths per 100,000 population (ABS 2017).
Drug-related hospitalisations
The National Hospital Morbidity Database contains information on drug-related
hospitalisations. (This database includes all separations of admitted patients from public
and private hospitals in Australia.) Drug-related separations refer to hospital care with
selected principal diagnoses of a substance misuse disorder or harm.
In 2015–16, 0.5% of the 10.6 million separations in Australia’s public and private hospitals
had a drug-related (excluding alcohol) principal diagnosis.
The total number and rate of drug-related (excluding alcohol) hospitalisations has
gradually risen over the last 5 years from around 38,300 in 2011–12 to 57,900 in 2015–16
(or from 170 to 237 per 100,000 population) (Supplementary Table 4.7.2). The rise in
drug-related (excluding alcohol) hospitalisations has been largely driven by increases
associated with amphetamines and cannabinoids. This is particularly the case for
amphetamine-related separations, which increased from 24 separations per 100,000
population in 2011–12 to 63 separations per 100,000 in 2015–16 (Figure 4.7.1).
Figure 4.7.1: Hospital separations with a drug-related principal diagnosis

(selected drugs), 2011–12 to 2015–16
Hospital separations
(number per 100,000 population)
70
Amphetamines
60
Antidepressants
and antipsychotics
50
Opioids
40 Non-opioid analgesics
30 Cannabinoids
20 Multiple drug use
Cocaine
10
Hallucinogens
0
2011–12 2012–13 2013–14 2014–15 2015–16
Year
Note: All rates are based on the latest version of the Australian estimated resident population as at
31 December of the reference year.
210
Treatment
The Alcohol and Other Drug Treatment Services National Minimum Data Set reported a
total of 128,000 treatment episodes in 2016–17 (66%) where the principal drug of concern
was an illicit drug excluding alcohol (this includes prescription drugs and volatile solvents)
(see Chapter 7.19 ‘Specialised alcohol and other drug treatment services’).
Similar to drug-related hospitalisations (which had an increase in cannabinoids and
amphetamine-related separations), treatment episodes for amphetamines and
cannabis also increased over this period. Between 2011–12 and 2016–17, treatment
for amphetamines almost tripled, from 16,900 to 49,700 episodes, and treatment for
cannabis rose from 32,300 to 41,900 treatment episodes (AIHW 2018a).
Current use and trends in illicit drugs

According to the NDSHS 2016, 8.5 million (or 43%) people aged 14 and over in Australia
had illicitly used a drug at some point in their lifetime (Figure 4.7.2). This includes
cannabis, ecstasy, meth/amphetamine, cocaine, hallucinogens, inhalants, heroin,
ketamine, gammahydroxybutyrate (commonly known as GHB), synthetic cannabinoids,
new and emerging psychoactive substances, and the misuse of pharmaceuticals (namely,
painkillers/analgesics and opioids, tranquillisers/sleeping pills, steroids and methadone
or buprenorphine).
Around 3.1 million (or 16%) people had illicitly used a drug in the last 12 months. This
includes the non-medical use of pharmaceuticals. While the proportion of Australians
using illicit drugs is higher than in 2007, there has been no clear trend since 2001.
The number of people illicitly using drugs increased from about 2.6 million in 2001 to
3.1 million in 2016 (Supplementary Table S4.7.3).
Chapter 4
Figure 4.7.2: Recent and lifetime use of any illicit drug, people aged 14 and over,
2001 to 2016
Per cent
Lifetime (a) use
45
40
35
30
25
20 Recent (b) use
15
10
5
0
2001 2004 2007 2010 2013 2016
Year
(a) Used at least 1 of 16 illicit drugs in 2016 in their lifetime—the number and type of drug used varied
between 2001 and 2016.
(b) Used at least 1 of 16 illicit drugs in 2016 in the previous 12 months—the number and type of drug used
varied between 2001 and 2016.
Source: National Drug Strategy Household Survey; Table S4.7.3.
211
Among the 16% of people aged 14 and over in Australia who used illicit drugs recently in
2016, 4 in 5 reported using illegal drugs such as cannabis and cocaine, or other substances
such as inhalants. The remaining 1 in 5 reported misuse of a pharmaceutical drug (without
use of any illicit drug).
Overall, an estimated 1 million people (or 4.8%) aged 14 and over had used a pharmaceutical
drug for non-medical purposes in the past 12 months. The pharmaceuticals most
commonly used in Australia for non-medical purposes were pain-killers/opioids (3.6%)
and tranquillisers/sleeping pills (1.6%) (Supplementary Table S4.7.4). The majority of
people who used a pain-killer/opioid for non-medical purposes reported misusing an
over-the-counter codeine product (75%), followed by prescription codeine products (40%)

(AIHW 2017).
Over one-quarter (28%) of people who misuse pharmaceuticals did so daily or weekly,
making pharmaceutical misuse one of the most commonly used drugs; it was second only
to cannabis (36% of users did so daily or weekly), and use was more frequent than for
meth/amphetamines (20%).
The 4 most commonly used illegal drugs in the previous 12 months among people
aged 14 and over were cannabis (10%), cocaine (2.5%), ecstasy (2.2%) and
meth/amphetamine (1.4%).
Cannabis
Cannabis is the most commonly used illicit drug in Australia—35% of people have used
it in their lifetime and 1 in 10 (10%) reported using it in the last 12 months. Lifetime and
recent use of cannabis have remained relatively unchanged since 2004 (Supplementary
Table S4.7.4). Cannabis is used frequently among recent users, with more than 1 in 3
(36%) using it as often as daily or weekly (Table 4.7.1). Cannabis users were older in
2016—both the age of first use and the average age of recent users have increased since
2013 (Supplementary Table S4.7.5).
Box 4.7.2: Medicinal cannabis in Australia

In 2016, the Federal Parliament of Australia passed the Narcotic Drugs Amendment
Act 2016 to allow the controlled cultivation of cannabis in Australia for medicinal
and related scientific purposes, via a national licensing scheme (Hughes 2016). Both
Australian and state and territory governments have implemented legislative and
policy change to allow the cultivation, manufacture, prescribing and dispensing
of medicinal cannabis products for patients in Australia (Department of Health
Therapeutic Goods Administration 2017).
At the time of collecting the 2016 NDSHS data, however, no state or territory had
legalised cannabis for medicinal use. Recreational use of cannabis remains illegal
across all federal, state and territory laws in Australia.
212
Table 4.7.1: Snapshot of drug use for the top 4 most commonly used illegal drugs,
2016
Meth/
Cannabis Cocaine Ecstasy amphetamines
Among people aged 14 and over:
34.8% 9.0% 11.2% 6.3%
Lifetime use
(6.9 million) (1.8 million) (2.2 million) (1.3 million)
Recent use (last 12 10.4% 2.5% 2.2% 1.4%
months) (2.4 million) (500,000) (400,000) (280,000)
Change in recent use
Stable (10.2%) Stable (2.1%) Stable (2.5%)  2.1%
since 2013
Long-term trend in  (12.9%  (1.3%  (2.9%  (3.4%
recent use since 2001 in 2001) in 2001) in 2001) in 2001)
Average age of first use
19 24 22 22
(14 years and over)
Average age of first use
17 21 19 19
(14–29 years)
Among recent users:
Age group most likely
20–29 (22.1%) 20–29 (6.9%) 20–29 (7.0%) 20–29 (2.8%)
to use
Used weekly or
36.4% 3.2% 1.9% 20.4%
more often
Flowers/Head Powder Pills Crystal/ ice
Main form used
(68.2%) (97.8%) (51.2%) (57.3%)
Chapter 4
Average age of user 34 31 28 34
Diagnosed or treated
28.2% 24.6% 26.5% 42.3%
for a mental illness
High or very high
psychological distress 23.8% 21.9% 26.6% 37.2%
levels
 Statistically significant increase.
 Statistically significant decrease.
Source: National Drug Strategy Household Survey.
Cocaine
In 2016, cocaine was the second most commonly used illicit drug in the previous 12 months,
with 2.5% of the population aged 14 and over reporting its use. The proportion of people
using cocaine rose from 1.0% in 2004, and cocaine use in Australia is currently at the
highest levels seen since 2001 (Supplementary Table S4.7.4). The proportion of people
using cocaine in their lifetime has also increased, from 8.1% in 2013 to 9.0% in 2016, and
has doubled since 2001 (from 4.4%).
213
Most people who use cocaine do so relatively infrequently, with about 2 in 3 (64%) using
it only once or twice a year (Supplementary Table S4.7.6). Among people aged 14–29 in
2016, the average age of first use was 21; this has been consistent over the last decade.
This is older than the average age of first use for other illicit drugs, such as cannabis (17)
and ecstasy (19). Across all age groups, the average age of recent users increased by
about 2 years between 2004 and 2016 (from age 29 to 31) (Supplementary Table S4.7.5).
Ecstasy
The recent use of ecstasy among people aged 14 and over peaked in 2007, at 3.5%, and
has since declined—to 2.2% in 2016. The average age of first use for people aged 14–29
has remained stable, at about age 19 since 2007 (though slightly older in 2001 and 2004).
The average age of recent ecstasy users was 28, which is younger than users of cannabis,
cocaine and meth/amphetamines (Table 4.7.1). The majority of recent ecstasy users used
it once or twice a year (51%) (Supplementary Table S4.7.6).
Meth/amphetamines
Meth/amphetamine use has been declining since 2001, when 3.4% of people aged 14 and
over had used it recently. Recent use declined significantly between 2013 and 2016
(from 2.1% to 1.4%). This decline was mainly driven by a substantial decrease among
people in their 20s; among whom recent use of meth/amphetamines halved between
2013 and 2016 (from 5.7% to 2.8%) and has declined by 75% since 2001 (from 11% to
2.8%) (Supplementary Table S4.7.7). The average age of recent users rose between 2013
and 2016 from 30 to 34 (Supplementary Table S4.7.5).
Average age of meth/amphetamine users 34
30 30
29
26 years 27
3.4% 3.2%
2.3% 2.1% 2.1%
1.4%
Recent use of meth/amphetamines
2001 2004 2007 2010 2013 2016
In 2013, the main form of meth/amphetamines used changed: ice replaced powder
as the preferred form. This trend continued in 2016, with 57% of meth/amphetamine
users reporting that crystal/ice was the main form of meth/amphetamines used in the
previous 12 months (a significant increase from 22% in 2010). Over the same period, the
use of powder decreased, from 51% in 2010 to 20% in 2016. While overall recent meth/
amphetamine use declined between 2013 and 2016, the proportion using crystal/ice
remained relatively stable between 2013 and 2016 (1.0% and 0.8%, respectively) and has
increased since 2010 (0.4%). Use of forms other than crystal/ice has fallen since 2007 and
significantly declined between 2013 and 2016 (from 1.0% to 0.6%) (AIHW 2017).
214
Frequency of drug use
Some drugs are used much more often than others. Very few cocaine and ecstasy users
used the drug as often as weekly (only about 2–3%) but 1 in 5 meth/amphetamine
users used the drug weekly or more often (AIHW 2017). Therefore, when examining
the share of people in Australia using an illegal drug weekly or more often in 2016,
meth/amphetamines was the second most commonly used illegal drug after cannabis
(Supplementary Table S4.7.6). This is clear when comparing survey data with data from
the Australian Criminal Intelligence Commission’s National Wastewater Drug Monitoring
Program (NWDMP) (Box 4.7.3). The NWDMP found that meth/amphetamine was the most
highly consumed illicit drug tested across all regions of Australia (ACIC 2017), noting that
the program does not test for cannabis or heroin.
Box 4.7.3: National Wastewater Drug Monitoring Program

The NWDMP analyses wastewater samples from 54 treatment plants across
Australia (excluding the Northern Territory and Tasmania). The third report in the
series was based on data from sewage analysis of 14.2 million people, or 61% of the
population.
The wastewater was tested for 13 illicit and licit (legal) substances, including cocaine,
ecstasy (3, 4-methylenedioxymethamphetamine, abbreviated to MDMA), alcohol,
tobacco and several prescription medications. Estimates are produced on the amount
of each drug consumed by the community over a specified period (ACIC 2017).
Age and sex comparisons for the top 4 most

commonly used illegal drugs
Chapter 4
People aged 14–29
Yong people aged 14–19 were far less likely to use illicit drugs in 2016 than in 2001. Use of
cannabis halved over this period while use of ecstasy and cocaine declined by one-third,
and use of meth/amphetamines dropped considerably, from 6.2% to 0.8% (Figure 4.7.3).
The Australian Secondary Students’ Alcohol and Drug Survey identified similar trends.
Among secondary students aged 12–17, the use of an illicit drug declined from 20% in
2005 to 15% in 2014 (White & Williams 2016).
A smaller proportion of people in their 20s were using illicit drugs in 2016 than in 2001.
Recent use of cannabis, meth/amphetamines and ecstasy were lower in 2016 than in
2001. However, people in their 20s continue to be more likely to use cannabis, ecstasy or
cocaine in the previous 12 months than any other age group (Figure 4.7.3).
215
Figure 4.7.3: Proportion of people aged 14–29 who used illicit drugs in the
previous 12 months, by age group, 2001, 2013 and 2016
14-19 20-29
Any illicit drug Any illicit drug
Cannabis Cannabis
Ecstasy Ecstasy
2001
Cocaine Cocaine 2013
Meth/ Meth/
2016
amphetamines amphetamines
0 10 20 30 40 0 10 20 30 40
Per cent Per cent
People aged 40 and over

In 2001, about 12% of people in their 40s had used an illicit drug in the previous 12 months.
This had increased to 14% by 2013, and to 16% in 2016. People in their 40s were the
only age group to show a significant increase in use between 2013 and 2016. People in
their 50s generally have some of the lowest rates of illicit drug use, but have also shown
increases in recent use since 2001, from 6.7% to 12% in 2016. The rise in the use of any
illicit drug was largely driven by an increase in both the recent use of cannabis and the
non-medical use of pharmaceuticals (for both age groups) (Figure 4.7.4).
Figure 4.7.4: Proportion of people aged 40–59 who used illicit drugs in the
previous 12 months, by age group, 2001, 2013 and 2016
40-49 50-59
Any illicit drug Any illicit drug
Cannabis Cannabis
Ecstasy Ecstasy 2001
Cocaine Cocaine
2013
2016
Meth/ Meth/
amphetamines amphetamines
0 10 20 30 0 5 10 15 20 25 30
Per cent Per cent
Note: The 2001 ecstasy and cocaine estimates for people aged 50–59 are less than 0.1 and have a very high
relative standard error.
216
People who were using illicit drugs in their late 20s in 2001 would be in their early 40s in
2016. In 2001, people in their 20s had a high prevalence of illicit drug use compared with
people in their 20s in 2016. The increase in illicit drug use seen among people in their 40s
may be due to their continued use of illicit drugs as they age.
Illicit drug use among specific population groups

Illicit drug use varies across different population groups in Australia. Table 4.7.2 focuses
on those groups that have some of the largest disparities in illicit drug use compared
with the general population—people living in more remote areas, people who were
unemployed, people identifying as homosexual or bisexual, and people with a mental
illness or high levels of psychological distress.
Table 4.7.2: Proportion of people aged 14 and over who used illicit drugs in the
previous 12 months (per cent), by selected population groups, 2016
Any Meth/
illicit drug Cannabis Ecstasy Cocaine amphetamines
Remote/
24.8 17.0 1.9 *0.7 *3.5
Very remote
Unemployed people 23.6 18.7 2.9 *2.4 4.6
Homosexual/
41.7 31.4 11.0 8.9 6.9
bisexual people(a)
People with a
26.6 19.4 3.9 4.1 4.1
mental illness
People with high/
very high levels
30.2 21.8 5.2 5.1 4.7
of psychological
Chapter 4
distress(b)
Total (aged 14
15.6 10.4 2.2 2.5 1.4
and over)
* Estimate has a relative standard error between 25% and 50% and should be interpreted with caution.
(a) F
indings for people who identify as gay, lesbian or bisexual (reported as homosexual/bisexual in the National
Drug Strategy Household Survey) were grouped together for data quality purposes but it is important to note
that there are differences in substance use between these groups.
(b) A
ged 18 and over.
Illicit drug use and mental health

There is a strong association between illicit drug use and mental illness. However, it is
often difficult to determine to what extent drug use causes mental health problems, and
to what degree mental health problems give rise to drug use (Loxley et al. 2004). A mental
illness may make a person more likely to use drugs—for example, for short-term relief
from their symptoms—while other people may have drug problems that trigger the first
symptoms of mental illness. Some drugs cause drug-induced psychosis, which usually
passes after a few days. However, if someone has a predisposition to a psychotic illness
such as schizophrenia, the use of illicit drugs may trigger the first episode in what can be
217
a lifelong mental illness (Sane Australia 2017). The use of drugs can interact with mental
illness in ways that create serious adverse effects on many areas of functioning, including
work, relationships, health and safety.
Comorbidity or the co-occurrence of a drug use disorder with one or more mental
health issues complicates treatment and services for both conditions. Using drugs can
worsen the symptoms of mental illness and may mean that treatment is less effective
(Department of Health 2017). Data from multiple sources indicate the prevalence of
comorbidity in Australia:
• 2
6% of recent illicit drug users had been diagnosed or treated for a mental illness in the
previous 12 months (AIHW 2017)

• 2
2% of recent illicit drug users reported high or very high levels of psychological distress
in the previous 4 weeks (AIHW 2017)
• 2
6% of prison entrants reported illicit drug use in the previous 12 months and had ‘ever
been told’ they had a mental health condition, including drug and alcohol abuse (AIHW 2015)
• 1
5% of prison entrants reported illicit drug use in the previous 12 months and were
currently on medication(s) for a mental health condition (AIHW 2015)
• 2
9% of young people (aged 13–17) with a major depressive disorder had used cannabis
in their lifetime (Lawrence et al. 2015)
• 6
6% of people with a psychotic illness had used cannabis in their lifetime and 33% had
used it in the past year (Department of Health and Ageing 2011)
• 8
.7% of people with a mental disorder in the previous 12 months had a comorbid
diagnosis of substance use and at least one other mental disorder (either anxiety
disorder, affective disorder or both) (ABS 2007).
Mental illness among people who use illicit drugs

According to the 2016 NDSHS estimates, 16% of the general population aged 14 and over
had been diagnosed or treated for a mental illness in the previous 12 months, a significant
increase from 14% in 2013. The proportion of adults experiencing high or very high levels
of psychological distress also increased, from 10% in 2013 to 12% in 2016 (AIHW 2017).
Increasing literacy and awareness about mental illness in Australia may partially explain
these reported increases among the general population (National Mental Health
Commission of NSW 2015); however, there are likely to be other factors involved, including
changing trends and patterns in the use of alcohol and other drugs. In fact, the 2016
NDSHS showed that self-reported rates of mental illness were higher among people who
reported the use of illicit drugs in the previous 12 months than among people who had
not used over this period. Specifically, mental illness was reported by:
• 2
6% of people who had used any illicit drug in the previous 12 months, compared with
14% of people who had not used an illicit drug in the previous 12 months
• 2
8% of recent cannabis users
• 2
6% of recent ecstasy users
• 4
2% of recent meth/amphetamine users
• 2
5% of recent cocaine users (Supplementary Table S4.7.8).
218
Between 2013 and 2016, the proportion of people who self-identified as being diagnosed
with, or treated for, a mental illness significantly increased among recent users of
cannabis, ecstasy, meth/amphetamines and cocaine (Supplementary Table S4.7.8). The
most noticeable increase was among recent users of ecstasy (from 18% to 26%), followed
by recent users of meth/amphetamines (from 29% to 42%).
Figure 4.7.5 shows that these increases were consistent for people in their 20s, 30s and
40s but only statistically significant for some age groups. More specifically:
• e
cstasy and meth/amphetamine users in their 20s reported the largest increases in
diagnosis or treatment for mental illness between 2013 and 2016 (from 18% to 29%
for ecstasy users and from 26% to 44% for meth/amphetamine users)
• c annabis users in their 20s, 30s and 40s all reported significant increases in mental
illness over the 3-year period
• illicit drug users in their 40s were most likely to report a mental illness (31%) and, in this
age group, the proportion of cocaine users with a mental illness more than doubled
between 2013 and 2016 (from 12% to 30%)
• a
mong people in their 30s who used illicit drugs, the increase in mental illness was only
significant for cannabis users (from 20% to 30%).
The Ecstasy and Related Drugs Reporting System, which surveys regular psychostimulant
users, also reported a significant increase in self-reported mental health problems
between 2013 and 2017 (from 30% to 46%) (Sutherland et al. 2017).
Figure 4.7.5: Proportion of illicit drug users with a mental illness, by age group,
2013 and 2016
Drug
Chapter 4
Any illicit #
20-29 years
Cannabis #
Ecstasy #
Meth/amphetamine #
Cocaine
Any illicit
30-39 years
Cannabis #
Ecstasy
Meth/amphetamine
Cocaine
Any illicit # 2013

40-49 years
Cannabis # 2016
Ecstasy
Meth/amphetamine
Cocaine #
0 10 20 30 40 50
Per cent
# = statistically significant increase between 2013 and 2016.
219
Psychological distress among people who use illicit
drugs
Psychological distress is higher among people who use illicit drugs than among people
who do not. Specifically, high or very high levels of psychological stress were reported by:
• 2
2% of people who reported using illicit drugs in the previous 12 months, compared
with 9.7% of people who did not report illicit drug use
• 2
4% of recent cannabis users
• 2
7% of recent ecstasy users
• 3
7% of recent meth/amphetamine users
• 2
2% of recent cocaine users (Supplementary Table S4.7.10).
The proportion of recent users of illicit drugs with high or very high levels of psychological
distress increased between 2013 and 2016. The increase in high or very high levels of
psychological distress was most noticeable among people who had used ecstasy in
the last 12 months—it increased from 18% in 2013 to 27% in 2016 (Supplementary
Table S4.7.10). High or very high distress levels also significantly increased among people
who had used meth/amphetamines in the previous 12 months. This increase was mainly
driven by the increase in psychological distress levels in users in their 20s and 40s
(Figure 4.7.6).
People in their 20s who used illicit drugs reported the largest increase in psychological
distress between 2013 and 2016. The increases in high or very high psychological distress
levels between 2013 and 2016 were consistent across recent users of cannabis (from 20%
to 28%), ecstasy (from 21% to 32%) and meth/amphetamines (from 29% to 49%). People
in their 30s who used illicit drugs were less likely to experience psychological distress than
users in their 20s and 40s and the increase between 2013 and 2016 was not significant.
220
Figure 4.7.6: Illicit drug users with high or very high levels of psychological
distress, by age group, 2013 and 2016
Drug
Any illicit #
Cannabis
20-29 years
#
Ecstasy #
Meth/amphetamine #
Cocaine
Any illicit
Cannabis
30-39 years
#
Ecstasy
Meth/amphetamine
Cocaine
Any illicit # 2013

Cannabis
40-49 years
2016
Ecstasy
Meth/amphetamine
Cocaine
0 10 20 30 40 50 60
Per cent
Chapter 4
Sociodemographic characteristics such as sexual orientation, socioeconomic area,
remoteness area, employment status, education and household type may be associated
with illicit drug use and mental health (Table 4.7.3).
Use of an illicit drug in the previous 12 months, and being diagnosed or treated for a
mental health condition, was particularly high among:
• s ingle people with dependent children (43%)
• p
eople who were unemployed (40%)
• p
eople identifying as homosexual or bisexual (37%)
• p
eople living in the lowest socioeconomic area (35%)
• p
eople living in Inner regional areas (32%)
• p
eople who had completed a certificate or diploma (31%).
221
Table 4.7.3: Proportion of Illicit drug users aged 18 and over diagnosed or
treated for a mental illness in the previous 12 months, by sociodemographic
characteristics, 2013 and 2016
Sociodemographic characteristic 2013 2016

Remoteness area
Major cities 19.6 24.6 #
Inner regional 25.1 32.2 #
Outer regional 22.0 30.9 #
Remote/Very remote 21.1 26.3

Socioeconomic area
1 (Lowest) 25.9 35.0 #
2 22.9 27.9
3 21.8 26.8
4 19.2 24.0
5 (Highest) 15.0 18.0
Education
Post-school education 19.0 26.5 #
Certificate or diploma 20.5 30.7 #
Bachelor degree or higher 15.6 23.2 #
No post-school education 23.6 26.8
Employment status
Employed 15.3 20.9 #
Student 16.4 25.7
Unemployed 36.9 40.1
Home duties 23.6 36.8
Unable to work 57.4 62.0
Sexual orientation
Homosexual/bisexual 32.8 36.8
Heterosexual 19.3 25.2 #
Household
Single with dependant children 34.7 42.9
Couple with dependant children 13.5 21.9 #
Parents with non-dependant
children 24.8 21.1
Single no children 27.6 31.3
Couple no children 16.1 21.3 #
Total population 20.7 26.5 #
222
The Alcohol and Other Drug Treatment Services National Minimum Data Set does not
capture the mental health status of a person seeking treatment.
Identifying mental health issues in people who access treatment will have greater
relevance to policy makers, program designers and service planners.
Data linkage between people accessing AOD treatment services and mental health-related
services would provide a better understanding of the overlap and interaction between
these services.

More information on illicit drug use is available at <www.aihw.gov.au/reports-statistics/
behaviours-risk-factors/illicit-use-of-drugs/overview> and <www.aihw.gov.au/reports-
statistics/health-conditions-disability-deaths/burden-of-disease/overview>. The report
National Drug Strategy Household Survey 2016: detailed findings and Impact of alcohol and
illicit drug use on the burden of disease and injury in Australia: Australian Burden of Disease
Study 2011 and other recent releases are available for free download.
For more information on mental health services see <www.aihw.gov.au/reports/mental-
health-services/mental-health-services-in-australia/report-contents/summary>.
Additional research and statistics on illicit drug use are available from the websites of
the National Drug and Alcohol Research Centre, National Drug Research Institute, and
the National Centre for Education and Training on Addiction.
References
ABS (Australian Bureau of Statistics) 2007. National survey on mental health and wellbeing: summary
of results, 2007. ABS cat. no. 4326.0. Canberra: ABS.
Chapter 4
ABS 2017. Causes of death, Australia, 2016. ABS cat. no. 3303.0. Canberra: ABS.
ACIC (Australian Criminal Intelligence Commission) 2017. National wastewater drug monitoring program,
report 3. Canberra: ACIC.
AIHW (Australian Institute of Health and Welfare) 2015. The health of Australia’s prisoners 2015. Cat. no.
PHE 207. Canberra: AIHW.
AIHW 2016. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011.
Australian Burden of Disease Study series no. 3. BOD 4. Canberra: AIHW.
AIHW 2017. National Drug Strategy Household Survey 2016: detailed findings. Drug statistics series no. 31.
AIHW 2018a. Alcohol and other drug treatment services in Australia 2016–17: key findings. Canberra: AIHW.
Viewed 20 April 2018, <https://www.aihw.gov.au/reports/alcohol-other-drug-treatment-services/aodts-
2016-17-key-findings/contents/summary>.
AIHW 2018b. Impact of alcohol and illicit drug use on the burden of disease and injury in Australia:
Australian Burden of Disease Study 2011. Australian Burden of Disease Study series no. 17.
Department of Health and Ageing 2011. People living with psychotic illness 2010: Report on the second
Australian national survey. Canberra: Department of Health and Ageing.
Department of Health 2017. The National Drug Strategy 2017–2026. Canberra: Department of Health.
Viewed 22 February, <https://campaigns.health.gov.au/drughelp/resources
/publications/report/national-drug-strategy-2017-2026>.
223
Department of Health: Therapeutic Goods Administration 2017. Guidance for the use of medicinal
cannabis in Australia: overview. Canberra: Department of Health. Viewed 26 February 2018,
<https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-australia-overview>.
Hughes C 2016. The Australian (illicit) drug policy timeline: 1985–2016, Drug Policy Modelling Program.
Sydney: University of New South Wales. Viewed 26 February 2018,
<http://dpmp.unsw.edu.au/resource/drug-policy-timeline>.
Lawrence D, Johnson S, Hafekost J, Boterhoven de Haan K, Sawyer M, Ainley J et al. 2015. The mental health
of children and adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health
and Wellbeing. Canberra: Department of Health. Viewed 21 January,
<http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-m-child2>.
Loxley W, Toumbourou J, Stockwell TR, Haines B, Scott K, Godfrey C et al. 2004. The prevention of substance
use, risk and harm in Australia: a review of the evidence. Canberra: The National Drug Research Institute
and the Centre for Adolescent Health. NHMRC
MCDS (Ministerial Council on Drug Strategy) 2011. The National Drug Strategy 2010–2015. Canberra:
Commonwealth of Australia.
National Mental Health Commission of NSW 2015. National surveys of mental health literacy and stigma
and national survey of discrimination and positive treatment: a report for the Mental Health Commission
of NSW. Sydney: Mental Health Commission of NSW.
NHMRC (National Health and Medical Research Council) 2017. NHMRC centre of research excellence in
mental health and substance use. Viewed 20 November 2017, <https://comorbidity.edu.au/content/about-us>.
Sane Australia 2017. Drugs & mental illness. Melbourne: Sane Australia. Viewed 13 November,
<https://www.sane.org/mental-health-and-illness/facts-and-guides/drugs-and-mental-illness>.
Sutherland R, Roxburgh A, Uporova J & Ritter A 2017. Australian drug trends 2017: preliminary findings
from the Ecstasy and related Drugs Reporting System. Sydney: National Drug and Alcohol Research Centre,
University of New South Wales.
White V & Williams T 2016. Australian secondary school students’ use of tobacco, alcohol, and
over-the-counter and illicit substances in 2014. Melbourne: Centre for Behavioural Research in Cancer,
Cancer Council Victoria.
224
4.8 Insufficient physical
SNAPSHOT
activity
Regular physical activity is important for optimal health and wellbeing. It reduces the risk
of many chronic conditions (such as cardiovascular disease and type 2 diabetes) and other
disease risk factors such as overweight and obesity and high blood pressure. Strength
and resistance training is also important to achieve and keep good health as it improves
muscle strength and bone density, protecting against injury and osteoporosis.
Insufficient physical activity is a key risk factor contributing to disease burden in Australia.
Given the role it plays in chronic conditions, it is important for Australians to achieve
the optimal levels of physical activity recommended in Australia’s Physical Activity
and Sedentary Behaviour Guidelines (Department of Health 2017). See Chapter 4.4
‘Contribution of selected risk factors to the burden of disease’ for more information on
the health impact of insufficient physical activity.
Physical activity by age group Physical activity

Based on self-reported data from the Australian Bureau of Statistics guidelines:
National Health Survey, in 2014–15, 56% of adults aged 18 and over
were not sufficiently active (ABS 2015).
After adjusting for age, the proportion of adults aged 18 and over
180
mins
who reported completing less than the recommended amount
each day
of physical activity decreased over time, from 49% in 2007–08 to
2–5 years
44% in 2014–15 (ABS 2017).
Chapter 4
Children and young people (aged 2–17)
In 2011–12, an estimated 39% of children aged 2–5 did less than 60
the recommended 180 minutes of physical activity each day; 74% mins
of children aged 5–12 and 92% of young people aged 13–17 did not each day
complete 60 minutes of moderate to vigorous intensity physical
5–12 and 13–17 years
activity every day (ABS 2013).
Adults (aged 18–64)
In 2014–15, an estimated 52% of adults aged 18–64 did less than the 150-300 75-150
mins or mins
recommended 150 minutes of moderate intensity physical activity, moderate vigorous
or 75 minutes of vigorous intensity physical activity, across 5 or more over 5 sessions

sessions each week. An estimated 70% of adults did no strength-based per week
activities. Only 19% of adults aged 18–64 did the recommended 18–64 years
amount of physical activity and strength-based training (ABS 2016).
Older people (aged 65 and over)
In 2014–15, for older Australians (aged 65 and over), an estimated 30
mins
75% did not do 30 minutes of moderate or vigorous intensity physical
activity on at least 5 days each week. Among people aged 65–74, 72% on at least 5 days
of women were insufficiently active; this increased to 92% for people per week
aged 85 and over. For men aged 65–74, 73% were insufficiently active, 65 years and older
and this was similar for people aged 85 and over (74%) (ABS 2015).
225
Types of physical activity
Physical activity can be sport and leisure activities, household chores, working or active
travel. Some common forms of physical activity include swimming, tennis, golf, gym
activities and bushwalking. The three most popular organised sport and physical activities
by age group according to the Australian Sports Commission’s AusPlay survey for 2016–17
(ASC 2017) are presented here.
Three most popular organised sport and leisure physical activities:

Children aged 5–11(a) Young people aged 12–17(a)(b)

1. Swimming
(39%) 1. Football/soccer (22%)
2. Football/soccer (19%) 2. Basketball (15%)
3. Australian football (12%) 3. Netball (15%)
Adults aged 18–64 Older Australians aged 65+

1. Recreational walking (41%) 1. Recreational walking (62%)
2. Fitness/gym activities (36%) 2. Fitness/gym activities (26%)
3. Athletics (including jogging) (18%) 3. Swimming (12%)
(a) D
ata on participation for children aged 0 to 14 are reported by parents and relate to organised out-of-school
sports and activities.
(b) D
ata on participation for children aged 15 to 17 are self-reported and relate to both organised and
non-organised sports.
According to self-reported data from the National Health Survey, in 2014–15, walking was
the only form of physical activity for 40% of adults aged 18–64:
• 1
6% walked for transport as their only type of physical activity
• 1
1% walked for exercise only
• 1
3% walked for both exercise and transport as their only type of physical activity.
Physical activity across population groups

Physical activity rates varied across population groups. Based on self-reported data from
the National Health Survey, in 2014–15, 60% of adults aged 18–64 living in Outer regional
and Remote areas of Australia were insufficiently active compared with 50% in Major cities.
Physical activity rates for adults aged 18–64 also varied with socioeconomic area; 63% of
adults in the lowest socioeconomic area were insufficiently active, compared with 40% in
the highest socioeconomic area (ABS 2016).
In 2012–13, more Aboriginal and Torres Strait Islander people aged 18 and over living in
non-remote areas were insufficiently active compared with non-Indigenous Australians of
the same age living in the same areas (64% compared with 56%) (ABS 2014).
226
There is a lack of data to monitor long-term trends in physical activity levels among
different groups, especially young children. Surveys that collect comprehensive physical
activity data, such as the total amount of time and frequency of physical activity
completed, are administered infrequently. The 2011–12 National Nutrition and Physical
Activity Survey (a component of the 2011–13 Australian Health Survey) is the most recent
survey with data of this comprehensive nature and is only a single time point.
Current data collected in physical activity surveys do not capture occupational physical
activity (that is, physical activity done as part one’s job) or activity due to household
chores, which could contribute to a large part of adult physical activity. Furthermore, the
data are self-reported and are therefore prone to misreporting. When measured data are
captured (for example, pedometer steps), there are no standardised methods.
Using discrete categories for reporting on physical activity, such as against the Australian
Physical Activity and Sedentary Behaviour Guidelines, is also a limitation because it does
not take into account the relationship between extra health benefits gained and increases,
however small, in activity levels.

More information on physical activity is available on these AIHW websites:
• <
www.aihw.gov.au/reports/biomedical-risk-factors/risk-factors-to-health/contents/
insufficient-physical-activity>
• <www.myhealthycommunities.gov.au/national/abs0055>.
The report Impact of physical inactivity as a risk factor for chronic conditions: Australian
Burden of Disease is available for free download.
Chapter 4
References
ABS (Australian Bureau of Statistics) 2013. Microdata: Australian Health Survey, 2011–12. ABS cat. no.
4324.0.55.001. Canberra: ABS. AIHW analysis of Expanded Confidentialised Unit Record File.
ABS 2014. Australian Aboriginal and Torres Strait Islander Health Survey: Physical Activity, 2012–13,
Australia. ABS cat. no. 4727.0.55.004. Canberra: ABS.
ABS 2015. National Health Survey: First Results, 2014–15, Australia. ABS cat. no. 4364.0.55.001.
Canberra: ABS.
ABS 2016. Microdata: National Health Survey, 2014–15. ABS cat. no. 4324.0.55.001. Canberra: ABS. AIHW
analysis of Basic Confidentialised Unit Record File.
ABS 2017. National Health Survey, 2014–15. Customised report. Canberra: ABS.
ASC (Australian Sports Commission) 2017. AusPlay survey results July 2016–June 2017. Canberra: ASC.
Department of Health 2017. Australia’s Physical Activity and Sedentary Behaviour Guidelines. Canberra:
Department of Health. Viewed 29 January 2018, <http://www.health.gov.au/internet/main/publishing.nsf/
content/health-pubhlth-strateg-phys-act-guidelines>.
227
4.9 Diet
SNAPSHOT
The food and beverages we consume (our diet) play an important role in our overall
health and wellbeing. Food provides energy, nutrients and other components that, if
consumed in insufficient or excess amounts, can result in ill health. A healthy diet helps
to prevent and manage health risk factors such as overweight and obesity, high blood
pressure and high cholesterol, as well as associated chronic conditions, including
type 2 diabetes, cardiovascular disease and some forms of cancer. Diet-related chronic
conditions are among the leading causes of death and disability in Australia.
The five food groups

The Australian Dietary Guidelines provide advice on healthy eating habits to promote
overall health and wellbeing, reduce the risk of diet-related disease and protect against
chronic conditions. They recommend that Australians eat a wide variety of nutritious
foods from the five food groups every day (NHMRC 2013). Food intake data from 2011–12
(the most comprehensive robust national dietary data available) show that most
Australians did not consume the recommended number of serves from the five food
groups (Table 4.9.1). Intake was particularly low for vegetables and legumes/beans (for
children and adults); lean meats and alternatives (for children); and milk, yoghurt, cheese
and alternatives (for women).
Table 4.9.1: Proportion of the population with usual food intakes below the
recommended serves (per cent), by age group, sex and food group, 2011–12(a)
Food group Boys Girls Men Women
Vegetables and legumes/beans 99.6 99.7 96.5 94.8
Fruit(b) 53.5 54.0 70.7 77.0
Grain (cereal) foods 60.5 73.7 66.6 75.6
Lean meat and poultry, fish,

eggs, nuts and seeds and 92.4 98.7 79.1 87.0
legumes/beans
Milk, yoghurt, cheese and

80.4 79.8 89.9 96.5
alternatives
(a) B
oys and girls aged 2–18; men and women aged 19 and over.
(b) Includes dried fruit, fresh or canned fruit and fruit juice.
Source: ABS 2016b.
228
Key ‘risk’ nutrients
The Australian Dietary Guidelines recommend limiting intake of foods containing
saturated fat, added salt, added sugars and alcohol (NHMRC 2013). Food intake data
from 2011–12 show that, as with the five food groups, many Australians are not following
these recommendations.
• S
aturated and trans fats should make up no more than 10% of total energy intake
(NHMRC 2006). In 2011–12, both children and adults exceeded this recommendation
(14% of total energy intake for children and 12% for adults) (ABS 2014).
• A
dults should consume no more than 2,000 mg of sodium each day (NHMRC 2006).
In 2011–12, average sodium intake for both men and women exceeded this
recommendation (2,779 mg for men and 2,090 mg for women) (ABS 2014).
• F
ree sugars (sugars added to foods by manufacturers, cooks or consumers, as well
as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates)
should make up less than 10% of total energy intake (WHO 2015). In 2011–12,
over two-thirds (69%) of children and almost half (47%) of adults exceeded this
recommendation. On average, free sugars contributed to 13% of total energy
intake for boys and girls, 11% for men and 10% for women (ABS 2016a).
• T
o reduce the risk of alcohol-related disease and injury, healthy men and women
should consume no more than two standard drinks on any one day (NHMRC 2009).
In 2011–12, 10% of women and almost 3 times as many men (29%) exceeded this
recommendation (ABS 2012). See Chapter 4.6 ‘Alcohol risk and harm’ for more
information.
Chapter 4
Information on food and nutrient intake is important for policy makers, educators and
health professionals in their work to promote optimal health and wellbeing. Most data
on national food and nutrient intake in Australia are collected from surveys that are
administered infrequently and based on self-reported information, which makes them
prone to underreporting.
229
More information on nutrition is available on these AIHW websites:
• <
www.aihw.gov.au/reports/biomedical-risk-factors/risk-factors-to-health/contents/risk-
factors-and-disease-burden>
• <
www.aihw.gov.au/reports-statistics/behaviours-risk-factors/food-nutrition/overview>.
Further information about the Australian Dietary Guidelines is available at

<www.eatforhealth.gov.au>.
Data from the Australian Bureau of Statistics 2011–13 Australian Health Survey are
available at <www.abs.gov.au/australianhealthsurvey>.
References
ABS (Australian Bureau of Statistics) 2012. Australian Health Survey: first results, 2011–12. ABS cat. no.
4364.0.55.001. Canberra: ABS.
ABS 2014. Australian Health Survey: nutrition first results—foods and nutrients, 2011–12. ABS cat. no.
4364.0.55.007. Canberra: ABS.
ABS 2016a. Australian Health Survey: consumption of added sugars, 2011–12. ABS cat. no. 4364.0.55.011.
Canberra: ABS.
ABS 2016b. Australian Health Survey: consumption of food groups from the Australian Dietary Guidelines,
2011–12. ABS cat. no. 4364.0.55.012. Canberra: ABS.
NHMRC (National Health and Medical Research Council) 2006. Nutrient reference values for Australia and
New Zealand including recommended dietary intakes. Canberra: NHMRC.
NHMRC 2009. Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC.
NHMRC 2013. Australian Dietary Guidelines. Canberra: NHMRC.
WHO (World Health Organization) 2015. Guideline: sugars intake for adults and children. Geneva: WHO.
230
4.10 Overweight and obesity
FEATURE ARTICLE
Overweight and obesity—defined as abnormal or excessive fat accumulation—is a major
public health issue in Australia. Australia’s measured obesity rate now ranks fifth among
Organisation for Economic Co-Operation and Development (OECD) countries (OECD 2017).
Over the past two decades, the proportion of Australians with a healthy body weight has
decreased, and the proportion who are obese has increased. Of concern is the growing
rate of severe obesity (body mass index, or BMI, of 35 kg/m2 or above), which almost
doubled between 1995 and 2014–15. This growing obesity trend has costly impacts for the
individual and for the Australian economy and health care system.
Overweight and obesity result from a sustained energy imbalance in the body—when
energy intake from eating and drinking is greater than energy used through physical
activity (AIHW 2016a). It is influenced by a complex interplay of individual, environmental
and societal factors.
A diet consistent with the Australian Dietary Guidelines is recommended to maintain
a healthy weight (NHMRC 2013a). This is one that is relatively high in cereals (mostly
wholegrains), vegetables and legumes/beans, fruit, some lean meats and poultry, fish,
eggs, tofu, nuts and seeds, and milk, yoghurt and cheese—mostly reduced-fat—and a
limited intake of energy-dense, nutrient-poor foods (that is, those containing saturated
fat, added salt, added sugars and alcohol) (NHMRC 2013b). See Chapter 4.9 ‘Diet’ for more
information on the dietary behaviours of Australians.
Energy is spent through bodily functions and physical activity, including sport, organised
recreation, and incidental activity (NHMRC 2013a). In 2014–15, over half (52%) of
Australian adults aged 18–64 were insufficiently active, including 15% who were inactive
(ABS 2015). See Chapter 4.8 ‘Insufficient physical activity’ for more information on
Chapter 4
Australians’ physical activity.
The way that we live has changed. Australian adults now spend more time sitting or lying
down (not just when sleeping). In 2014–15, Australians spent an average of 34 hours per
week sitting at leisure, up from 31 hours per week in 2011–12 (ABS 2013a, 2016b).
As the waistlines of Australians continue to expand, it is important to examine both the
extent of the problem, and the influence of factors such as the environment and society
in which a person lives on their dietary and physical activity behaviours.
The most common and practical ways to measure overweight and obesity in population
surveys are to calculate a person’s BMI or measure their waist circumference (Box 4.10.1).
Box 4.10.1: How is overweight and obesity measured at the

population level?
weight in kg
BMI is calculated by dividing a person’s weight BMI =
(height in m)2
(in kilograms) by their height (in metres) squared.
The information in this article uses the BMI classifications for adults defined by
the World Health Organization (WHO). Obesity is split into three classes, according
to severity, with more severe obesity associated with a higher risk of comorbidities
(WHO 2000).
231
<18.50 18.50– 25.00– 30.00– 35.00– >40.00
24.99 29.99 34.99 39.99
Waist circumference is another common measure of overweight and obesity.

A waist circumference above 80 cm for women and 88 cm for men is associated
with a higher risk of metabolic complications (WHO 2011). The following categories
were developed by the WHO and are used in this article:
Waist circumference
Increased risk of Substantially increased risk

metabolic complications of metabolic complications
Men: 94 cm or more Men: 102 cm or more

Women: 80 cm or more Women: 88 cm or more
Differences in body composition may affect the appropriateness of BMI and waist
circumference as population-level measures of overweight and obesity. Different
BMI and waist circumference cut-off points might need to be considered for certain
population groups such as older people; people with high muscle mass; and ethnic
groups, including Aboriginal and Torres Strait Islander, Pacific Islander, South Asian,
Chinese and Japanese populations (NHMRC 2013a).
For the information in this article, the same BMI and waist circumference measures
were used for all adult population groups, based on measured—not
self-reported—weight, height and waist circumference.
Measuring overweight and obesity among children and adolescents is
complicated due to their growing bodies. At the population level, a series
of age- and sex-specific BMI ranges developed by Cole et al. (2000) are
recommended to monitor overweight and obesity in children. These ranges
were used for information presented in this article and can be accessed on
the Department of Health website (Department of Health 2009).
To calculate your BMI and see how you compare with the rest of Australia see
the online data visualisation tool at <www.aihw.gov.au/reports/australias-health/
australias-health-2018/contents/bmi-where-do-you-fit>.
232
Who is overweight or obese?
Adults
Based on measured BMI, in 2014–15:
• a
lmost two-thirds (63%) of Australians aged 18 and over were overweight or obese
(36% overweight but not obese, and 28% obese) (ABS 2015)
• o
verall, men (71%) had higher rates of overweight and obesity than women (56%).
A greater proportion of men (42%) than women (29%) were overweight but not obese,
while a similar proportion of men (28%) and women (27%) were obese
• m
en were most likely to be overweight but not obese at age 35–44 (48%), and to be
obese at age 65–74 (38%). Women were most likely to be overweight but not obese
at age 75–84 (41%), and obese at age 55–64 (35%) (Figure 4.10.1).
Figure 4.10.1: Proportion of overweight and obese adults (based on measured

BMI), by age and sex, 2014–15
Per cent Overweight but not obese Obese

90
80
70
60
50
40
30
Chapter 4
20
10
0
18–24 25–34 35–44 45–54 55–64 65–74 75–84 85+ 18–24 25–34 35–44 45–54 55–64 65–74 75–84 85+
Men Women
Age
Source: ABS 2015; Table S4.10.1.
Based on measured waist circumference (Box 4.10.1), in 2014–15:

• a
bout one-quarter (24%) of men and one-fifth (21%) of women aged 18 and over had a
waist circumference that indicated an increased risk of metabolic complications
• a
greater proportion of women (45%) than men (35%) had a waist circumference that
indicated a substantially increased risk of metabolic complications (ABS 2015).
Children
In 2014–15:
• o
ne in 5 (20%) children aged 2–4 were overweight or obese—11% were overweight but
not obese, and 8.7% were obese (ABS 2015)
233
• m
ore than 1 in 4 (28%) children and young people aged 5–17 were overweight or
obese—20% were overweight but not obese, and 7.4% were obese
• f or both children and young people aged 2–4 and 5–17, similar proportions of boys and
girls were obese
• b
oys were most likely to be overweight but not obese at age 16–17 (29%), while this
was most likely for girls at age 8–11 (21%). The highest prevalence of obesity was at
age 16–17 for boys (8.2%) and age 5–7 for girls (12%) (Figure 4.10.2).
Figure 4.10.2: Proportion of overweight and obese children and young people
aged 2–17, by age and sex, 2014–15
Per cent Overweight but not obese Obese

40
35
30
25
20
15
10
0
2–4 5–7 8–11 12–15 16–17 2–4 5–7 8–11 12–15 16–17
Boys Girls
Age
In 2012–13, after adjusting for differences in age structure, Indigenous people aged 18
and over were 1.2 times as likely to be overweight or obese as non-Indigenous people,
and 1.6 times as likely to be obese (ABS 2014a). See Chapter 6.5 ‘Health behaviours
of Indigenous Australians’ for more information on overweight and obesity among
Indigenous Australians.
Socioeconomic areas
It is well established that social determinants affect a person’s health status. In Australia,
there is evidence of a gradient in overweight and obesity prevalence across socioeconomic
areas (see Glossary).
In 2014–15:
• a
dults in the lowest socioeconomic area (the lowest fifth) were more likely to be obese
(34% for 3 obesity classes combined) than adults in the highest socioeconomic area
(22% for 3 obesity classes combined). Adults in the highest socioeconomic area were
most likely to have a normal body weight (41%) compared with all other socioeconomic
area; adults in the lowest socioeconomic area were least likely (32%) (Figure 4.10.3)
234
• o
ne-third (33%) of boys aged 2–17 in the lowest socioeconomic area were overweight
or obese compared with 22% of boys in the highest socioeconomic area. Similarly,
more than one-third (38%) of girls aged 2–17 in the lowest socioeconomic area were
overweight or obese compared with 24% of girls in the highest socioeconomic area
(ABS 2016b).
Figure 4.10.3: Proportion of adults in each BMI category, by socioeconomic

area, 2014–15
Per cent
50 1 (Lowest) 2 3 4 5 (Highest)
40
30
20
10
0
Underweight Normal weight Overweight but Obese class I Obese class II Obese class III
not obese
BMI category
Note: Socioeconomic areas 1–5 refer to area-based fifths derived using the ABS Index of Relative
Socio-Economic Disadvantage (ABS 2013b).
Chapter 4
Source: ABS 2016b; Table S4.10.3.
Geographical variation
One of the major factors associated with overweight and obesity is the area in which an
individual lives. This includes their remoteness area and Primary Health Network (PHN) area.
In 2014–15:
• a
dults living in Major cities were most likely to have a body weight in the normal weight
range (37%), while adults living in Inner regional and Outer regional/Remote areas were
most likely to have a body weight in the obese range (34% and 37%, respectively).
There were a greater proportion of obese adults in Inner regional and Outer regional/
Remote areas than in Major cities, with the proportion of adults with more severe obesity
(Obese class II and III) increasing with increasing remoteness (Figure 4.10.4)
• a
mong children, boys aged 2–17 living in Outer regional/Remote areas were 1.3
times as likely to be overweight or obese as boys living in Major cities (35% and 27%,
respectively). For girls aged 2–17 living in Outer regional/Remote areas, the rate of
overweight or obesity (36%) was 1.5 times as high as for girls living in Major cities
(24%). Boys and girls in Inner regional areas were the least likely to be overweight or
obese (21% and 23%, respectively) (ABS 2015)
235
• p
revalence of overweight and obesity varied among PHNs, from 53% in Northern
Sydney to 73% in Country South Australia. Prevalence was higher among regional PHNs
(69%) than among metro PHNs (61%). For more information on variation among
PHNs see Healthy communities: overweight and obesity rates across Australia, 2014–15
(AIHW 2016b).
Figure 4.10.4: Proportion of adults in each BMI category, by remoteness area,

2014–15
Per cent
Major cities Inner Regional Outer Regional/Remote
40
30
20
10
0
Underweight Normal weight Overweight but Obese class I Obese class II Obese class III
not obese
BMI category
The growing obesity trend

Over the past 20 years, the distribution of BMI has shifted among Australian adults.
Fewer adults are now in the healthy weight range, and more in the obese range. Figure
4.10.5 shows the change in BMI among Australian adults between 1995 and 2014–15.
236
Figure 4.10.5: Distribution of BMI, people aged 18 and over, 1995 and 2014–15
Per cent
Overweight Obese Obese
Underweight Normal weight but not obese class I class II Obese class III
10
6
1995
5
2014–15
4
0
16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48
BMI (kg/m2)
Sources: ABS 2013c, 2016b; Table S4.10.4.
Adults in 2014–15 were significantly more likely to be obese than adults of the same age
20 years earlier for all but one age group. The largest relative difference was at age 18–21:
in 2014–15, 15% of adults were obese at age 18–21, almost double the proportion who
were obese at the same age in 1995 (7.2%) (AIHW 2017b).
Since 1995, the proportion of Australian adults with a BMI in the more severe obesity
ranges (class II and class III obesity) has increased. This proportion almost doubled
Chapter 4
between 1995 and 2014–15, from 4.9% to 9.4% among Australian adults (Table 4.10.1).
Table 4.10.1: Age-standardised prevalence of more severe obesity

(class II and class III obese), per cent (95% CI), people aged 18 and
over, by sex, 1995 to 2014–15
Year Men Women Persons

1995 3.4 (2.9–4.0) 6.3 (5.5–7.1) 4.9 (4.4–5.4)
2007–08 7.1 (6.1–8.1) 8.7 (7.7–9.7) 7.9 (7.2–8.6)
2011–12 7.9 (7.2–8.6) 11.0 (10.3–11.8) 9.5 (8.9–10.0)
2014–15 8.0 (7.1–8.9) 10.7 (9.8–11.6) 9.4 (8.7–10.0)
Notes
1. Class II and class III obesity refers to a measured BMI of 35.00 kg/m2 or more.
2. T
he span presented in parentheses is the 95% confidence interval. We can be
95% confident that the true value lies within this interval.
Sources: ABS 2010, 2013c, 2014b, 2016b.
237
Why are our waistlines expanding?
Overweight and obesity is influenced by a range of determinants at the individual level,
including biological and behavioural factors. As well, the contribution of social and
environmental factors is becoming increasingly apparent. The interrelated nature of these
factors contributes to the complexity of obesity. For example, individual behaviours such
as eating habits can be influenced by social eating norms and by environmental factors
such as accessibility to fresh and healthy food (CDC 2015).
Individual and behavioural factors

At the individual level, having a healthy diet and sufficient physical activity is central to
maintaining the body’s energy balance (NHMRC 2013a). A person’s appetite, satiety,
metabolism and body fat distribution can contribute to overweight and obesity; this might
be influenced by genetics and epigenetic changes (NHMRC 2013a). Epigenetic changes
are alterations in gene expression that can be brought about by a range of factors
(for example, intrauterine growth restriction) and passed between generations. These
changes can predispose individuals to obesity by influencing how energy balance is
regulated (NHMRC 2013a).
As already noted, how Australians live has changed over the past 20 years. Positive
changes in health behaviours include a relative drop in consumption of free sugars
between 1995 and 2011–12 (ABS 2017). (Free sugars are those added to foods and drinks,
and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.)
Negative changes in health behaviours include an increased consumption of energy-
dense, nutrient-poor foods; low consumption of fruit and vegetables; and a move towards
less active transport and more sedentary leisure time activities. These behaviours have
contributed to an increased obesity prevalence (Allender et al. 2012).
Obesogenic environment
The term ‘obesogenic environment’ has been used to describe an environment that
promotes obesity among individuals and populations (Swinburn et al. 1999).
Change in food portion sizes

A study comparing portion sizes from the 1995 National Nutrition Survey and the 2011–12
National Nutrition and Physical Activity Survey found a significant increase (up to 66%) in
energy per typical portion in common discretionary foods, including pizza, cake, sausages,
cereal bars, processed meats, ice cream and wine (Zheng et al. 2017).
Built environment
Factors of the built environment (see Glossary) such as low walkability, a high density of
convenience food outlets and the relatively cheap price and heavy promotion of energy-dense
foods have been shown to contribute to greater energy intake, and less energy expenditure
at a population level (Allender et al. 2012). Several studies have noted that access to green
space is associated with reduced obesity—this might be due to more recreational walking,
more physical activity and less sedentary time (Lachowycz & Jones 2011; WHO 2016).
238
As the boundaries of Australian cities continue to expand, individuals may have to travel
further—with increased travel times—to reach destinations such as workplaces, retail
zones, services, food outlets and open public spaces such as parks (Zapata-Diomedi
& Veerman 2016). This may mean that active travel (such as walking to a destination)
is replaced with less active forms of travel such as car trips (VicHealth 2016). A recent
Australian study found that people living 20 km or further away from city centres had an
increased waist circumference compared with people who lived less than 9 km from a
city centre (Sugiyama et al. 2016).
Changing work lives

Australians are now spending more hours at work. The OECD ranks Australia 10th of 38
included member and partner countries for the proportion of its workers (13%) working
‘very long hours’ (50 hours or more per week as defined by the OECD) (OECD 2015). The
workplace environment and its surrounds can have an adverse impact on the health of
adults (AIHW 2012). Influencing factors include the proximity of food outlets, long working
hours, access to food vending machines, event catering, and public transport access.
Occupation also plays a role, with predominantly office-type settings being associated
with sedentary work (Parry & Straker 2013). This, in turn, has been linked to weight gain
and to chronic conditions such as heart disease, diabetes and cancer (independent of the
amount of time spent on physical activity) (Thorp et al. 2011; Wilmot et al. 2012).
For many families with all adults in paid employment, longer working hours leaves less
time for food preparation, family recreation and physical activity (Australian National
Preventative Health Agency 2014). Meal times are often fragmented: people may eat at
different times and in different places (often outside the home) and rely heavily on snack
and convenience foods. More than 58% of Australians’ total food spending in 2014 was
on discretionary food items, including potato chips, processed meats, soft drinks and
Chapter 4
chocolates (ABS 2016a).
School environment
Foods in school facilities such as canteens, cafeterias and vending machines can influence
the choices and intake of students, with children and adolescents consuming up to two
meals and snacks per day at school, 5 days a week (Espinel & King 2009). School policies
may regulate the food available for purchase, however, and supportive play equipment
and activity programs can encourage students to participate in physical activity (Escalante
et al. 2013).
The majority of schools across Australia use a ‘traffic light’ scheme to classify foods sold
in canteens—red foods are restricted, amber foods should not dominate and healthy
green food should fill the menu (Hills et al. 2015). Strategies such as these support the
healthy eating of Australian schoolchildren through increased availability and promotion
of healthy food and drinks in schools (NSW Department of Education 2017). Such policies
have proved influential: a previous canteen strategy in New South Wales that used the
traffic light approach saw a rise in the proportion of schools offering no energy-dense,
nutrient-poor (red) food items on their menu, from 7.0% in 2007 to 22% in 2010
(Hills et al. 2015).
239
Technology
In the home environment, Australian children and young people now spend about 20%
of their waking lives in front of screens on weekdays, and 30% on weekends—including
watching television, being on computers, and playing electronic games (Australian
Institute of Family Studies 2015). Screen-based activities in young people and adults are
strongly linked to obesity, with higher obesity rates associated with higher screen time
(independent of physical activity) (Banks et al. 2011; Boone et al. 2007). Fewer hours of
screen time in adolescence has also been shown to reduce the likelihood of obesity in
adulthood (Boone et al. 2007).
Use of electronic devices such as smart phones and tablets during normal sleep time has
been found to be associated with overweight and obesity among young people. Among
a sample of 3,700 adolescents (in school grades 6, 8 and 10) in New South Wales, young
people who usually used electronic devices during normal sleep time were 1.3 times as
likely to be overweight or obese as adolescents who sometimes or never did (Mihrshahi
et al. 2017).
Food advertising
The WHO found that the advertising of unhealthy food influences children’s food
preferences, purchase requests and consumption patterns (WHO 2010). The average
Australian child will be exposed to 35 hours of food advertising on television over the
course of a year, of which over half will be for unhealthy foods (King et al. 2013). The
Australian food industry responded in 2009 with initiatives to limit the exposure of
unhealthy food advertising to children, but a recent study showed there had been no
subsequent change in this exposure in Australia from 2011 to 2015 (Watson et al. 2017).
Health burden of overweight and obesity

The health consequences of overweight and obesity are considerable. Burden of disease
analyses have shown that, in 2011, 7.0% of the total burden of disease in Australia was
due to overweight and obesity, with 63% of this due to fatal burden. Men (7.3%) had a
greater burden of disease from overweight and obesity than women (6.6%) (AIHW 2017a).
information on burden of disease.
Being overweight or obese is also associated with higher mortality. A recent study of
adults with a BMI above the ‘normal weight’ range (that is, a BMI of at least 25 kg/m2)
showed the risk of death from all causes rose by 31% with each 5 kg/m2 increase in BMI
in Australian and New Zealand populations (di Angelantonio et al. 2016). An investigation
into the effect of obesity on life expectancy found that, compared with people with a
normal BMI, life expectancy was reduced by 2–4 years for people with class I obesity,
and by 8–10 years for people with class III obesity (NHMRC 2013a; PSC 2009).
240
Chronic conditions among overweight and
obese adults
Among adults, overweight and obesity increases the likelihood of developing many
chronic conditions, including some cancers, some cardiovascular diseases, asthma,
back pain and problems, chronic kidney disease, dementia, diabetes, gallbladder disease,
gout, and osteoarthritis (AIHW 2017a).
In 2014–15, Australian adults who were overweight or obese reported higher rates
of many chronic conditions than adults of normal weight (Figure 4.10.6). For several
conditions, obese adults were more likely to report that they had a chronic condition than
adults who were overweight but not obese, who in turn reported higher rates than adults
of normal weight (ABS 2015).
Figure 4.10.6: Prevalence of selected chronic conditions in adults, by BMI

category, 2014–15
Chronic condition
Arthritis
Asthma
Back problems
Cancer
Chronic obstructive pulmonary disease Normal weight

Overweight but not obese
Diabetes mellitus
Obese
Chapter 4
Heart, stroke and vascular disease
Hypertension
Kidney disease
Mental and behavioural problems
Osteoporosis
0 10 20 30
Per cent
Economic impact of overweight and obesity

Illnesses associated with overweight and obesity have a considerable impact on the
Australian economy; PwC Australia estimated that obesity cost it $8.6 billion in 2011–12 (in
2014–15 dollars). This included an estimated $3.8 billion in direct costs and $4.8 billion in
indirect costs (for example, absenteeism and government subsidies), but did not account
for further costs from reduced wellbeing and forgone earnings (PwC Australia 2015). The
report estimated that, if no further action is taken to slow the rise in obesity, there will be
$87.7 billion in added costs due to obesity over a 10-year period (2015–16 to 2024–25).
241
In 2014–15, more than 124,600 procedures relating to weight-loss surgery were billed to
Medicare—in public and private hospitals, and in non-hospital settings. In public hospitals,
the estimated total cost of the 10 most common weight loss surgery procedures was
$30.4 million. The total cost for these Medicare-billed procedures in public and private
hospitals, and non-hospital settings combined, was about $62.8 million, with about
$25.7 million in benefits paid by Medicare, and about $37.1 million paid in out-of-pocket
costs by patients and/or health insurers (AIHW 2017c).

More regular and extensive monitoring of body weight and waist circumference and of the
risk factors contributing to overweight and obesity (both behavioural and environmental)
would contribute to a greater understanding of which obesity prevention strategies are
working, and for whom and where.
Robust data on the contribution of genetic and epigenetic factors to overweight
and obesity in Australia are currently limited. Data of this kind would help to better
understand the genetic and molecular basis of obesity and shed light on the complex
interplay of individual and environmental factors leading to this health risk factor.

More information on overweight and obesity is available at <www.aihw.gov.au/reports-
statistics/behaviours-risk-factors/overweight-obesity/overview>.
The following reports are available for free download:
• A picture of overweight and obesity in Australia 2017
• Overweight and obesity in Australia: a birth cohort analysis
• Healthy communities: overweight and obesity rates across Australia, 2014–15
• Impact of overweight and obesity as a risk factor for chronic conditions: Australian Burden of
Disease Study series no.11
• Weight loss surgery in Australia 2014–15: Australian hospital statistics.
References
ABS (Australian Bureau of Statistics) 2010. Microdata: National Health Survey: summary of results,
2007–2008 (reissue). ABS cat. no. 4364.0. Canberra: ABS. AIHW analysis of Expanded Confidentialised Unit
Record File.
ABS 2013a. Australian Health Survey: updated results, 2011–2012. ABS cat. no. 4364.0.55.003. Canberra: ABS.
ABS 2013b. Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia, 2011.
ABS 2013c. Microdata: National Nutrition Survey, 1995. ABS cat. no. 4807.0.30.001. Canberra: ABS.
ABS 2014a. Australian Aboriginal and Torres Strait Islander Health Survey: updated results, 2012–13. ABS
cat. no. 4727.0.55.006. Canberra: ABS. AIHW analysis of Basic Confidentialised Unit Record File.
ABS 2014b. Microdata: Australian Health Survey, core content—risk factors and selected health conditions,
2011–12. ABS cat. no. 4324.0.55.003. Canberra: ABS. AIHW analysis of Expanded Confidentialised Unit
Record File.
ABS 2016a. Consumer Price Index, Australia, Dec. 2015. ABS cat. no. 6401.0. Canberra: ABS.
242
ABS 2016b. Microdata: National Health Survey, 2014–15. ABS cat. no. 4324.0.55.001. Canberra: ABS. AIHW
analysis of Expanded Confidentialised Unit Record File.
ABS 2017. Australian Health Survey: consumption of added sugars, 2011–12. ABS cat. no. 4364.0.55.011.
Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2012. Australia’s food and nutrition. Cat. no. PHE 163.
Canberra: AIHW.
AIHW 2016a. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.
AIHW 2016b. Healthy communities: overweight and obesity rates across Australia, 2014–15. Cat. no. HPF 2.
Canberra: AIHW.
AIHW 2017a. Impact of overweight and obesity as a risk factor for chronic conditions: Australian Burden of
Disease Study. Australian Burden of Disease Study series no. 11. Cat. no. BOD 12. Canberra: AIHW.
AIHW 2017b. Overweight and obesity in Australia: a birth cohort analysis. Cat. no. PHE 215. Canberra: AIHW.
AIHW 2017c. Weight loss surgery in Australia 2014–15: Australian hospital statistics. Cat. no. HSE 186.
Canberra: AIHW.
Allender S, Gleeson E, Crammond B, Sacks G, Lawrence M, Peeters A et al. 2012. Policy change to create
supportive environments for physical activity and healthy eating: which options are the most realistic for
local government? Health Promotion International 27(2):261–74.
Australian Institute of Family Studies 2015. Australian children’s screen time and participation in
extracurricular activities. Melbourne: Australian Institute of Family Studies.
Australian National Preventative Health Agency 2014. Obesity: prevalence trends in Australia. Canberra:
Australian National Preventative Health Agency.
Banks E, Jorm L, Rogers K, Clements M & Bauman A 2011. Screen-time, obesity, ageing and disability:
findings from 91,266 participants in the 45 and Up Study. Public Health Nutrition 14:34–43.
Boone JE, Gordon-Larsen P, Adair LS & Popkin BM 2007. Screen time and physical activity during
adolescence: longitudinal effects on obesity in young adulthood. International Journal of Behavioral
Nutrition and Physical Activity 4:26.
CDC (Centers for Disease Control and Prevention) 2015. Health Equity Resource Toolkit for State
Practitioners Addressing Obesity Disparities. Atlanta: CDC.
Cole TJ, Bellizzi MC, Flegal KM & Dietz WH 2000. Establishing a standard definition for child overweight
and obesity worldwide: international survey. BMJ 320:1240–3.
Chapter 4
Department of Health 2009. About overweight and obesity. Canberra: Department of Health. Viewed
23 June 2017, <http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-
hlthwt-obesity.htm>.
di Angelantonio E, Bhupathiraju SN, Wormser D, Gao P, Kaptoge S, de Gonzalez AB et al. 2016. Body-mass
index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four
continents. The Lancet 388:776–86.
Escalante Y, García-Hermoso A, Backx K & Saavedra JM 2013. Playground designs to increase physical
activity levels during school recess. Health Education & Behavior 41:138–44.
Espinel P & King L 2009. A framework for monitoring overweight and obesity in NSW. Sydney: NSW
Department of Health, Physical Activity Nutrition Obesity Research Group.
Hills A, Nathan N, Robinson K, Fox D & Wolfenden L 2015. Improvement in primary school adherence to the
NSW Healthy School Canteen Strategy in 2007 and 2010. Health Promotion Journal of Australia 26:89–92.
King L, Hebden L, Grunseit L, Kelly B & Chapman K 2013. Building the case for independent monitoring of
food advertising on Australian television. Public Health Nutrition 16:2249–54.
Lachowycz K & Jones AP 2011. Greenspace and obesity: a systematic review of the evidence. Obesity
Reviews 12:e183–e9.
Mihrshahi S, Drayton B, Bauman A & Hardy L 2017. Associations between childhood overweight, obesity,
abdominal obesity and obesogenic behaviours and practices in Australian homes. BMC Public Health 18:44.
NHMRC (National Health and Medical Research Council) 2013a. Clinical practice guidelines for the
management of overweight and obesity in adults, adolescents and children in Australia. Canberra: NHMRC.
NHMRC 2013b. Australian Dietary Guidelines. Canberra: NHMRC.
243
New South Wales Department of Education 2017. Why we need a strategy for providing healthy food and
drink in NSW schools. Sydney: NSW Department of Education. Viewed 25 January 2018,
<https://healthyschoolcanteens.nsw.gov.au/about-the-strategy/why-we-need-this-strategy>.
OECD (Organisation for Economic Co-operation and Development) 2015. Work–life balance. Paris: OECD
Publishing. Viewed 15 December 2017, <http://www.oecdbetterlifeindex.org/topics/work-life-balance/>.
OECD 2017. Overweight and obesity among adults. In: Health at a glance 2017: OECD indicators. Paris:
OECD Publishing.
Parry S & Straker L 2013. The contribution of office work to sedentary behaviour associated risk. BMC
Public Health 13:296.
PSC 2009. Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57
prospective studies. Lancet 373:1083–96.

PwC Australia 2015. Weighing the cost of obesity: a case for action. Australia: PwC Australia.
Sugiyama T, Niyonsenga T, Howard N, Coffee N, Paquet C, Taylor A et al. 2016. Residential proximity
to urban centres, local-area walkability and change in waist circumference among Australian adults.
Preventive Medicine 93:39–45.
Swinburn B, Egger G & Raza F 1999. Dissecting obesogenic environments: the development and application
of a framework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine
29:563–70.
Thorp A, Owen N, Neuhaus M & Dunstan D 2011. Sedentary behaviours and subsequent health outcomes
in adults: a systematic review of longitudinal studies 1996–2011. American Journal of Preventative Medicine
41:207–15.
VicHealth 2016. Physical activity and sedentary behaviour: evidence summary. Melbourne: Victorian Health
Promotion Foundation.
Watson W, Lau V, Wellard L, Hughes C & Chapman K 2017. Advertising to children initiatives have not
reduced unhealthy food advertising on Australian television. Journal of Public Health (Oxford) 39(4):787–92.
WHO (World Health Organization) 2000. Obesity: preventing and managing the global epidemic. Report of
a WHO consultation. WHO Technical Report series 894:i–xii, 1–253.
WHO 2010. Set of recommendations on the marketing of foods and non-alcoholic beverages to children.
Geneva: WHO.
WHO 2011. Waist circumference and waist–hip ratio: report of a WHO expert consultation. Geneva, 8–11
December 2008.
WHO 2016. Urban green spaces and health. Copenhagen: WHO.
Wilmot EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ et al. 2012. Sedentary time in adults
and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis.
Diabetologia 55:2895–905.
Zapata-Diomedi B & Veerman JL 2016. The association between built environment features and physical
activity in the Australian context: a synthesis of the literature. BMC Public Health 16:484.
Zheng M, Rangan A, Meertens B & Wu J 2017. Changes in typical portion sizes of commonly consumed
discretionary foods among Australian adults from 1995 to 2011–2012. Nutrients 9:E577.
244
4.11 Biomedical risk factors
SNAPSHOT
Biomedical risk factors are bodily states that have an impact on a person’s risk of disease.
This snapshot focuses on three biomedical risk factors: blood pressure, blood lipids
and blood glucose—elevated levels of which have been directly linked to specific health
outcomes such as cardiovascular disease, chronic kidney disease and diabetes. Obesity,
which is also a biomedical risk factor, is discussed in Chapter 4.10 ‘Overweight and obesity’.
The information in this snapshot is based on the Australian Bureau of Statistics 2011–12
Australian Health Survey (ABS 2013) and 2014–15 National Health Survey (ABS 2017).
High blood pressure

High blood pressure—also known as hypertension—is a risk factor for chronic conditions,
including heart failure, chronic kidney disease and stroke. See Chapter 3 for more
information on these chronic conditions.
In 2014–15, an estimated 1 in 3 (34%, or 6 million) Australian adults had high blood
pressure. This comprised 23% who had uncontrolled high blood pressure and 11% whose
blood pressure was controlled by blood pressure medication.
The proportion of men with high blood pressure was slightly higher than for women (35%
and 32%, respectively) and increased with age, being highest in people aged 75 and over
(82%) (ABS 2014; Supplementary Table S4.11.1).
Abnormal blood lipids
Chapter 4
Abnormal levels of blood lipids, such as cholesterol and triglycerides—also known
as dyslipidaemia—can lead to the build-up of fatty deposits in the blood vessels and
contribute to the risk of cardiovascular disease.
In 2011–12, an estimated 2 in 3 (65%, or 8.4 million) Australian adults had abnormal
blood lipid levels. This included 59% with uncontrolled blood lipids and 6.7% with normal
blood lipid levels who were taking lipid-modifying medication (ABS 2014; Supplementary
Table S4.11.2).
Impaired glucose regulation

Impaired glucose regulation is a condition where blood glucose levels are higher than
normal, but not high enough to be regarded as type 2 diabetes. People with impaired
glucose regulation are at increased risk of diabetes and cardiovascular disease.
Measurement of blood glucose levels after fasting provides a measure of glucose regulation.
In 2011–12, an estimated 3.1% (416,000) Australian adults had impaired glucose
regulation, affecting a greater proportion of men (4.1%) than women (2.1%).
Impaired glucose regulation was highest in people aged 75 and over (7.5%).
245
Multiple biomedical risk factors
Biomedical risk factors can have an interactive or cumulative effect on disease risk.
Multiple risk factors can increase the risk of disease, lead to earlier disease onset,
increase severity and complicate treatment.
The development of one risk factor can lead to the occurrence of another, or they may
have shared causes. For example, high blood pressure and dyslipidaemia are often
related to poor diet and being overweight.
• In 2011–12, an estimated 1 in 4 (25%) Australian adults had both high blood pressure
and abnormal blood lipids. This increased with age, from 4.3% in people aged 18–34 to
65% in people aged 75 and over.
• A
lmost 3 in 4 (71%) adults had either high blood pressure, abnormal blood lipids
or both risk factors. This was highest in people aged 75 and over (96%) (ABS 2014;
Supplementary Table S4.11.3).
29% 46% 25%

Neither risk factor High blood pressure or Both risk factor
abnormal lipids
Managing risk factors

Treating or managing biomedical risk factors includes changes in lifestyle (such as
dietary modifications or increased physical activity), use of medications, and surgery.
Improvements in biomedical risk factors can prevent disease, delay disease progression
and improve treatment outcomes, and have the potential to improve the health of the
population.
• In 2014–15, an estimated 15% of adults had measured high blood pressure but were
not taking any blood pressure medication.
• A
round 8.1% of adults with measured high blood pressure reported that they took
medicines to lower blood pressure. Measured high blood pressure, despite the use of
medication, was highest in people aged 75 and over (33%) (ABS 2014; Supplementary
Table S4.11.1).
• In 2011–12, the majority of people with measured dyslipidaemia (87%) were not
using lipid modifying medications. This reflects current guidelines, which state that
prescription of lipid modifying medications is not based on abnormal blood lipids alone,
but on the absolute risk of cardiovascular disease (RACGP 2016). The absolute risk of
cardiovascular disease considers risk factors, such as blood pressure and cholesterol
levels, in combination.
• A
total of 7.7% of people were identified as having abnormal blood lipids, despite
reporting using lipid lowering medications. Poorly controlled blood lipids, despite the
use of medication, was highest in people aged 65–74 (20%) (ABS 2014; Supplementary
Table S4.11.4).
246
National surveys collecting information on biomedical risk factors are infrequent.
The most recent national data on blood lipid and blood glucose levels were collected
in 2011–12. More surveys will be needed to continue to monitor the levels of these
risk factors in the Australian population.

More information on biomedical risk factors is available at <www.aihw.gov.au/reports-
statistics/behaviours-risk-factors/biomedical-risk-factors/overview>.
The report Cardiovascular disease, diabetes and chronic kidney disease—risk factors is
References
ABS (Australian Bureau of Statistics) 2013. Australian Health Survey: users’ guide, 2011–13. ABS cat. no.
4363.0.55.001. Canberra: ABS.
ABS 2014. Microdata: Australian Health Survey, core content—risk factors and selected health conditions,
2011–12. ABS cat. no. 4324.0.55.003. Canberra: ABS. AIHW analysis of Expanded Confidentialised Unit
Record File.
ABS 2016. Microdata: National Health Survey, 2014–15. ABS cat. no. 4324.0.55.001. Canberra: ABS. AIHW
analysis of Expanded Confidentialised Unit Record File.
ABS 2017. National Health Survey: users’ guide, 2014–15. ABS cat. no. 4363.0. Canberra: ABS.
RACG (The Royal Australian College of General Practitioners) 2016. Guidelines for preventive activities in
general practice. 9th edn. East Melbourne, Victoria: RACGP.
Chapter 4
247
4.12 Antenatal risk factors
SNAPSHOT
A mother’s antenatal characteristics, such as age, weight and whether she smoked or
drank alcohol during pregnancy, influences the health outcomes of a mother and her
child. Data on maternal and baby outcomes are collected by health professionals
for the National Perinatal Data Collection at the AIHW. This snapshot uses these
data to explore aspects of the mother, and her child’s health.
Women are giving birth later in life

The age when a woman gives birth can be a risk factor for obstetric and perinatal
outcomes. Adverse outcomes are more likely in women aged under 20 and over 40.
Consistent with recent trends in Australia, women are continuing to give birth later in life,
with the average age rising from 29.7 in 2005 to 30.3 in 2015. The average age of first-time
mothers is also rising, from 28.1 in 2005 to 28.9 in 2015.
29.7 30.0 30.3

years years years
2005 2010 2015
99.9% of women had at least one

antenatal visit
Antenatal care is associated with positive child and maternal health outcomes, with
regular antenatal care visits in the first trimester (before 14 weeks’ gestational age),
leading to fewer interventions in late pregnancy and positive outcomes for child health.
The Australian Antenatal Guidelines recommend that the first antenatal visit occur within
the first 10 weeks of pregnancy and that first-time mothers with an uncomplicated
pregnancy attend 10 visits (7 visits for later uncomplicated pregnancies) (AHMAC 2012).
Almost all mothers (99.9%) who gave birth in 2015 had at least 1 antenatal visit, 95% had
5 or more visits, and 58% had 10 or more. In 2015, 47% of mothers attended at least 1
antenatal visit in the first 10 weeks of pregnancy; 10% did not start antenatal care until
after 20 weeks’ gestation.
1 in 10 women smoked during pregnancy

Smoking during pregnancy is a preventable risk factor associated with poorer perinatal
outcomes like low birthweight, preterm birth and an increase in perinatal death. Of all
mothers who gave birth in 2015, 1 in 10 (10%) reported smoking at some point during their
pregnancy (a reduction from 15% in 2009).
248
Rates of smoking were slightly higher in the first 20 weeks of pregnancy (10%) compared
with after 20 weeks of pregnancy (7.6%). In 2015, almost 1 in 4 (23%) of the more than
30,400 mothers who gave birth reported smoking during the first 20 weeks of pregnancy
(but not throughout the rest of their pregnancy). The rate for reported smoking during
the first 20 weeks of pregnancy was highest for women aged under 20 (32%).
1 in 5 women were obese during

pregnancy
Being overweight or obese during pregnancy contributes to an increased risk of
complications throughout pregnancy and delivery. Pregnant women who are obese have
an increased risk of thromboembolism, pre-eclampsia, gestational diabetes, post-partum
haemorrhage and wound infections. Babies of mothers who are obese have higher rates
of neonatal death, congenital anomaly and stillbirth compared with babies of mothers
who are not obese (CMACE & RCOG 2010).
Of mothers who gave birth in 2015

• 3
.9% were underweight (BMI <18.50)
• 5
0% were in the normal weight range (BMI 18.50–24.99)
• 2
6% were overweight but not obese (BMI 25.00–29.99)
• 2
0% were classified as obese (BMI ≥30.00)
Alcohol consumption and domestic
Chapter 4
violence during pregnancy
Fetal Alcohol Spectrum Disorder describes the range of effects that can occur in a baby
who has been exposed to alcohol in its mother’s womb (Burns et al. 2013; NHMRC 2009).
According to the National Drug Strategy Household Survey, 56% of women abstained from
drinking during pregnancy in 2016, an increase from 40% in 2007.
About 1 in 2 (49%) women consumed alcohol before they knew they were pregnant.
A large proportion of these women stopped drinking alcohol once they found out they
were pregnant, but 1 in 4 (25%) continued to drink after they found out they were
pregnant (AIHW 2017).
Domestic violence is a leading preventable contributor to death, disability and illness for
women aged 15–44. Data from the Australian Bureau of Statistics 2016 Personal Safety
Survey indicate that an ‘estimated 187,800 women who experienced violence by a current
partner were pregnant at some point during the relationship. Of the women surveyed,
nearly 1 in 5 (18%) experienced violence during their pregnancy’ (ABS 2017).
249
Routine administrative data, as opposed to survey data, are needed on several key
antenatal risk factors, including alcohol consumption and domestic violence during
pregnancy.

The information in this article was largely drawn from Australia’s mothers and babies
2015—in brief. Other AIHW publications used for this article were National Drug Strategy
Household Survey, 2016 and Screening for domestic violence during pregnancy: options for
future reporting in the National Perinatal Data Collection.
References
ABS (Australian Bureau of Statistics) 2017. Personal Safety, Australia 2016. ABS cat. no. 4906.0. Canberra:
ABS.
AHMAC (Australian Health Ministers’ Advisory Council) 2012. Clinical Practice Guidelines: Antenatal
Care—Module 1. Canberra: Department of Health.
AIHW (Australian Institute of Health and Welfare) 2017. National Drug Strategy Household Survey—detailed
findings: 2016. Drug statistics series no. 31. Cat. no. PHE 214. Canberra: AIHW.
Burns L, Breen C, Bower C, O’Leary C & Elliot EJ 2013. Counting fetal alcohol spectrum disorder in Australia:
the evidence and the challenges. Drug Alcohol Review 32(5):461–7.
CMACE & RCOG (Centre for Maternal and Child Enquiries & Royal College of Obstetricians and
Gynaecologists) 2010. Management of women with obesity in pregnancy. CMACE/ RCOG Joint
Guideline. Viewed 17 August 2017, <https://www.rcog.org.uk/globalassets/documents/guidelines/
cmacercogjointguidelinemanagementwomenobesitypregnancya.pdf>.
NHMRC (National Health and Medical Research Council) 2009. Australian Guidelines to Reduce Health Risks
from Drinking Alcohol. Canberra: NHMRC.
250
This page left intentionally blank
Chapter 4
251
252
Chapter 5
Health of population groups
253
5.0 Overview
Where you live, how much you earn, whether you have disability—and a raft of other
factors—can affect your health status and health outcomes. This chapter explores the
different health experiences of certain population groups in Australia: socioeconomic
groups; rural and remote populations; culturally and linguistically diverse populations;
people with disability; lesbian, gay, bisexual, transgender and intersex people; veterans;
and prisoners. Some of these groups experience higher rates of illness, disability and
death, and are more likely to engage in risky health behaviours (such as tobacco smoking)
than the general population. Aboriginal and Torres Strait Islander people also face major
health disparities; these are examined in detail in Chapter 6.
In 2014–15, people living in the lowest socioeconomic group were 2.6 times as likely as
people in the highest group to have diabetes, and 1.7 times as likely to have heart, stroke
or vascular disease. Death rates were nearly 1.5 times as high for people in the lowest
socioeconomic group than for people in the highest group—with even higher death rate
differences for specific causes, such as chronic obstructive pulmonary disease (2.2 times)
and lung cancer (1.8 times). People in the lowest socioeconomic group were more
likely than people in the highest group to smoke daily (2.7 times).
Around 3 in 10 (29%, 7 million people) Australians live in rural and remote areas. Rural
and remote populations can face multiple challenges due to their geographic isolation,
and often experience poorer health outcomes than people living in cities. The proportion
of adults engaging in many behaviours associated with poorer health is higher in rural and
remote areas than in metropolitan areas (for example, 22% of people in Outer regional/
Remote areas smoke daily compared with 13% of people in Major cities). In 2015, people
living in Very remote areas had a mortality rate almost 1.4 times as high as people living in
Major cities.
More than 1 in 4 (26%) Australians were born overseas. As a population group, immigrants
often have lower mortality rates and self-reported chronic conditions than Australian-born
residents. This ‘healthy migrant effect’ could be partly due to health screenings people
must pass before migration. However, culturally and linguistically diverse populations are
a heterogeneous group with different health experiences. For example, in 2016, people
born in Malaysia had lower rates of mortality than Australian-born residents but the rates
for people born in Scotland were higher.
As a group, the 4.3 million (18%) Australians with disability experience poorer health than
people without disability. People with disability are around 7 times as likely as people
without disability to assess their health as poor or fair (41% compared with 6.5%) and this
rises to 10 times as likely for people with severe or profound core activity limitation (61%).
People with disability are also more likely than people without disability to have mental
health conditions—almost half (47%) of people with severe or profound core activity
limitation, and more than one-third (37%) of other people with disability, self-reported
that they had anxiety-related problems, compared with 11% of people without disability.
254
It is estimated that Australians of diverse sexual orientation, sex or gender identity may
account for up to 11% of the population—LGBTI (lesbian, gay, bisexual, transgender,
or intersex) is the abbreviation often used to refer to this population group. Part of the
challenge in identifying and reporting on the health of this population stems from a lack of
specific data; however, there is evidence that LGBTI people face disparities in terms of their
mental health, sexual health and rates of substance use. For example, almost 1 in 3 (32%)
homosexual/bisexual people aged 16 and over in Australia met the criteria for an anxiety
disorder in the previous 12 months, compared with 1 in 7 (14%) heterosexual people.
The service experience of members of the Australian Defence Force (ADF) may affect
their health needs as veterans. Several studies have recognised a ‘healthy soldier effect’,
due mainly to the ongoing need to keep fit and having ready access to health care
during service. Ex-serving men have a lower all-cause mortality rate than all Australian
men of the same age. Men aged 55 and over who served in the ADF generally report
similar rates of selected chronic conditions—arthritis, back pain and problems, chronic
obstructive pulmonary disease, diabetes, diseases of the circulatory system, and mental
and behavioural problems—compared with men of the same age who have not served.
There is ongoing concern about the incidence of suicide among serving and ex-serving
ADF personnel. Although suicide rates among men serving full time or in the reserves are
lower than rates for all Australian men, the rates for ex-serving personnel are higher.
For ex-serving men aged 18–29, the rate is 1.7 times as high as that for all Australian men
of the same age. There are substantial gaps in our understanding of women’s experiences
in the ADF. This is due to the historically small number of women represented in the ADF,
which has limited this research.
On average, prisoners have poorer health than the general Australian population and
greater levels of risk factors for poor health—1 in 2 (50%) prison entrants had a history
of mental health conditions, 1 in 3 (31%) had a current chronic condition and 3 in 4 (74%)
were current smokers in 2015. Australia’s prison population is ageing—the number
of prisoners aged 50 and over increased by 84% between 2005 and 2015—and older
prisoners (like older people in the general population) are more likely to suffer from
chronic conditions and disability.
Chapter 5
255
5.1 Socioeconomic groups
SNAPSHOT
Socioeconomic factors are important determinants of health. Generally, people in lower

socioeconomic groups are at greater risk of poor health, have higher rates of illness,
disability and death, and live shorter lives than people from higher socioeconomic groups
(Mackenbach 2015). The higher a person’s socioeconomic position, the healthier they tend
to be—a phenomenon often termed the ‘social gradient of health’ (see Chapter 4.2 ‘Social
determinants of health’).
This snapshot compares socioeconomic groups on a range of health measures across

4 key health areas, focusing on people in the lowest and highest socioeconomic groups,
where differences are usually large. It highlights that for almost all health measures,
people from lower socioeconomic groups in Australia fare worse.
Socioeconomic position was determined using the Index of Relative Socio-Economic
Disadvantage (IRSD) (ABS 2013). The IRSD is a measure based on where people live, and
reflects the overall or average level of socioeconomic disadvantage of the population of
an area (see Glossary).
Health risk factors Figure 5.1.1: Proportion of adults who

On most health risk factors, people in the were inactive or insufficiently active,
lowest socioeconomic group fared worse by socioeconomic group, 2014–15
than people in the highest socioeconomic
Per cent
group. In particular, it is estimated they were:
80
• 2.7 times as likely to smoke daily in 2016
• 1.6 times as likely to be obese in 2014–15
• 1
.4 times as likely to be inactive or 70
insufficiently active in 2014–15
(Figure 5.1.1)
• 1
.2 times as likely to have high blood 60
pressure in 2014–15
• a
t similar lifetime risk of harm from
drinking alcohol in 2016. 50
0
1 2 3 4 5
Lowest Highest
Socioeconomic group
256
Chronic conditions Figure 5.1.2: Prevalence of heart,
Rates of chronic conditions were also higher stroke and vascular disease, by
for people in the lowest socioeconomic socioeconomic group, 2014–15
group, compared with people in the Per cent
highest socioeconomic group. In particular, 8
it is estimated they were:
• 2
.7 times as likely to have chronic 6
obstructive pulmonary disease in 2014–15
• 2
.6 times as likely to have diabetes in 4
2014–15 (ABS 2015)
• 1
.7 times as likely to have heart, stroke 2
or other vascular disease in 2014–15
(Figure 5.1.2)
0
• 1
.7 times as likely to be newly diagnosed 1 2 3 4 5
Lowest Highest
with lung cancer in 2008–2012 Socioeconomic group
• 1
.6 times as likely to have biomedical signs
of chronic kidney disease in 2011–12.
Mortality
In 2015, the all-cause mortality rate of people in the lowest socioeconomic group was
652 per 100,000 population, compared with 604 in the second group, 542 in the third,
497 in the fourth, and 449 in the highest socioeconomic group—people in the lowest
socioeconomic group were 1.5 times as likely to die from all causes (Figure 5.1.3).
Mortality data for 2016 by socioeconomic area were not available at the time of writing.
Disease-specific death rates were
generally higher for people in the lowest Figure 5.1.3: All-cause mortality rate,
socioeconomic group, compared with people by socioeconomic group, 2015
in the highest group. In particular, they were:
Deaths per 100,000 population
• 2
.2 times as likely to die from chronic
700
Chapter 5
obstructive pulmonary disease in 2011–15
• 2
.1 times as likely to die from potentially
avoidable causes in 2015—this being a 600
premature death that could have been

avoided with timely and effective health care
500
• 1
.8 times as likely to die from lung cancer
in 2011–15
400
• 1
.2 times as likely to die from cerebrovascular
disease (mostly stroke) in 2011–15 0
1 2 3 4 5
• likely to die at a similar rate (1.0 times) Lowest Highest
from dementia and Alzheimer disease Socioeconomic group
in 2011–15. Source: National Mortality Database; Table S5.1.3.
257
Burden of disease Figure 5.1.4: Total burden of disease,
Burden of disease analysis combines by socioeconomic group, 2011
estimates of the fatal and non-fatal impact
DALY per 1,000 population
of disease (see Chapter 4.4 ‘Contribution of
250
selected risk factors to burden of disease’).
Compared with people in the highest
socioeconomic group, people in the lowest 200
socioeconomic group experienced burden

of disease that was estimated to be:

150
• 1
.5 times as high for all causes in 2011
(Figure 5.1.4)
• 2.3 times as high for diabetes in 2011 100
• 2.0 times as high for lung cancer in 2011 0

1 2 3 4 5
• 1
.8 times as high for anxiety disorders Lowest Highest
Socioeconomic group
in 2011
• 1.4 times as high for stroke in 2011 DALY = Disability-adjusted life year.
Source: Table S5.1.4.
• similar (1.0 times) for dementia in 2011.
In terms of population impact, if all Australians had experienced the same burden as
people in the highest socioeconomic group in 2011, the total disease burden could
have been reduced by one-fifth (21%).

Monitoring the health gaps between socioeconomic groups is ongoing. Most data
collections in Australia do not include information to measure individual socioeconomic
position, leading to a reliance on area-based measures. Statistical linkage of health and
welfare data sets could provide added information on wealth, education, employment
and other social determinants. This would enable more accurate assessments of
socioeconomic position and help to better understand the relationships patient outcomes
and pathways through the health system for individuals in different socioeconomic groups.

Many reports from the AIHW include analysis of health indicators based on socioeconomic
position (for example, Australian Burden of Disease Study: impact and causes of illness and
death in Australia 2011).
For more information about disadvantage and social inequalities, see the AIHW report
Australia’s welfare 2017.
References
ABS (Australian Bureau of Statistics) 2013. Census of population and housing: Socio-Economic Indexes
for Areas (SEIFA), Australia, 2011. ABS cat. no. 2033.0.55.001. Canberra: ABS.
Mackenbach JP 2015. Socioeconomic inequalities in health in high-income countries: the facts and the
options. In: Detels R, Gulliford M, Karim QA & Tan CC (eds). Oxford textbook of global public health. Vol. 1.
6th edn. Oxford: Oxford University Press.
258
5.2 Rural and remote
FEATURE ARTICLE
populations
Around 7 million people—about 29% of the population—live in rural and remote areas
(ABS 2017e). These Australians face unique challenges due to their geographic isolation,
and they often have poorer health and welfare outcomes than people living in major cities.
The proportion of adults engaging in behaviours associated with poorer health—such
as tobacco smoking and excessive alcohol consumption—is higher in rural and remote
areas than in metropolitan areas, as is (generally) the prevalence of chronic conditions.
These poorer health outcomes may be due to factors such as disadvantage in education,
employment opportunities, income and access to services.
Despite poorer health outcomes for some, the Household, Income and Labour Dynamics
in Australia Survey found that Australians living in small towns (of fewer than 1,000
people) and in non-urban areas generally experienced higher levels of life satisfaction
than those living in major cities (Wilkins 2015).
This article presents information to help assess the health of rural and remote
populations. The term ‘rural and remote’ covers all areas outside Australia’s major cities,
classified by the Australian Statistical Geography Standard as Inner regional, Outer regional,
Remote or Very remote (ABS 2014). Due to small population sizes, data for Outer regional,
Remote and Very remote areas are sometimes combined for reporting purposes.
Profile of rural and remote Australians

In 2016, the age and sex distribution of Australians varied with remoteness. More than
half (51%) of the population in Major cities were female compared with 46% in Very remote
areas. People living in Remote and Very remote areas were relatively younger than people
living in more populated areas. The proportion of males aged 14 and under was 19% in
Major cities and 22% in Very remote areas. The proportion of females aged 14 and under
was 18% in Major cities and 24% in Very remote areas (Figure 5.2.1). Chapter 5
Comparatively, 13% of males in Major cities were aged 65 and over, compared with 18%
in Inner regional areas and 17% in Outer regional areas. The proportion of females aged
65 and over was 15% in Major cities, compared with 20% in Inner regional areas and 18%
in Outer regional areas.
259
Figure 5.2.1: Australian population, by age group, sex and remoteness area, 2016
Very remote Remote

Age group Age group
85+ 85+
75 – 84 75 – 84
65 – 74 65 – 74
55 – 64 55 – 64
45 – 54 45 – 54
35 – 44 35 – 44
25 – 34 25 – 34
15 – 24 15 – 24
5 –14 5 –14
0–4 0–4
20 15 10 5 0 5 10 15 20 20 15 10 5 0 5 10 15 20
Per cent Per cent
Outer regional Inner regional

Age group Age group
85+ 85+
75 – 84 75 – 84
65 – 74 65 – 74
55 – 64 55 – 64
45 – 54 45 – 54
35 – 44 35 – 44
25 – 34 25 – 34
15 – 24 15 – 24
5 – 14 5 –14
0–4 0–4
20 15 10 5 0 5 10 15 20 20 15 10 5 0 5 10 15 20
Per cent Per cent
Major cities
Age group
85+
75 – 84
65 – 74
55 – 64
45 – 54
35 – 44
25 – 34
15 – 24
5 –14
0–4
20 15 10 5 0 5 10 15 20
Per cent
Males Females
Source: ABS 2017d; Table S5.2.1.
260
The geographical distribution of Aboriginal and Torres Strait Islander people and
non-Indigenous Australians also varied by remoteness area. In 2011, a greater
proportion of the Indigenous population lived in rural and remote areas compared
with non-Indigenous Australians:
Inner Outer Very

Major cities regional regional Remote remote
Indigenous 35% 22% 22% 7.7% 14%
Non-Indigenous 71% 18% 8.7% 1.2% 0.5%
Source: ABS 2013.
See Chapter 6 for information on Indigenous health by remoteness area.
In 2017, the proportion of people with a Bachelor degree or above also varied
by remoteness area:
• 36% in Major cities
• 19% in Inner regional areas
• 18% in Outer regional areas
• 18% in Remote and Very remote areas (ABS 2017a).
As at December 2017, the employment-to-population ratio across Australia was 63%.

Except for Greater Perth, greater metropolitan areas had a higher proportion of employed
people than did the rest of their respective state or territory (Figure 5.2.2). This may be
due to lower levels of access to work outside Major cities and to the higher number of
retired older people living in these areas (ABS 2008; NRHA 2013).
See Chapter 4 for more information on the social determinants of health.
Chapter 5
261
Figure 5.2.2: Employment-to-population ratio, by greater metropolitan areas
and the rest of states and territories, 2017
Northern Territory
73%
Rest of Queensland
60%
Rest of
Western Australia
Greater Brisbane
69%
65%
Rest of
New South Wales
58%
Greater Perth
64% Greater Sydney
65%
Rest of South Australia ACT
59% Greater Adelaide 71%
60%
Rest of Victoria
59%
Rest of Tasmania
Greater Melbourne 56%
64% Greater Hobart
61%
Sources: ABS 2017b; Table S5.2.2.
Health status
Behaviours associated with poorer health, the rate of chronic conditions as well as disease
burden can be assessed across remoteness areas.
Risk factors
Taking into account the different age structure of people living in the different remoteness
areas, people living in rural and remote areas are more likely to have higher rates of
health risk factors. Compared with people in Major cities, people in Outer regional/Remote
areas had higher rates of daily smoking, risky alcohol consumption, physical inactivity and
overweight and obesity in 2014–15:
262
Outer regional/
Major cities Inner regional Remote
Current daily smoker 13% 18% 22%
Overweight or obese 61% 67% 68%
No/low exercise level 64% 69% 72%
Exceeded lifetime alcohol

16% 18% 24%
risk guideline
High blood pressure 22% 24% 22%
Notes
1. T
he symbol ‘%’ represents the prevalence of the risk factor in each region (excluding Very remote areas
of Australia).
2. Proportions were age standardised to the 2001 Australian Standard Population.
Chronic conditions
Taking into account the different age structure of people living in the different remoteness
areas, self-reported rates of selected chronic conditions were similar for people living in
Major cities, Inner regional and Outer regional/Remote areas in 2014–15, with the exception
of heart, stroke and vascular disease rates being higher in Inner regional areas compared
to Major cities:
Outer regional/
Major cities Inner regional Remote
Asthma 10% 12% 12%

Chapter 5
Osteoarthritis 7.7% 9.1% 9.3%
Back pain and problems 16% 16% 16%
Diabetes 5.8% 6.6% 7.3%
Heart, stroke and vascular

21% 25% 22%
disease
Notes
1. The symbol ‘%’ represents the prevalence of chronic conditions in each region (excluding Very remote areas of
Australia).
2. P roportions were age standardised to the 2001 Australian Standard Population.
263
Disease burden
Burden of disease analyses reveal health inequalities between rural and remote
communities and Major cities. Burden of disease—expressed as disability-adjusted life
years (DALYs)—is a measure of the health impact of disease on a population in a given
year: both from dying, and living with, disease and injury (AIHW 2016a).
People living in Very remote areas experienced the highest total burden per population
(301 DALY per 1,000 population), and people in Major cities the lowest (181). The rate for
Very remote areas was 1.7 times the rate for Major cities (Table 5.2.1).
Table 5.2.1: DALY rate and rate ratio, by remoteness area, 2011
Major Inner Outer Very

cities regional regional Remote remote
Age-standardised rate
181.4 205.3 206.8 242.0 300.8
(number per 1,000 population)
Rate ratio 1.0 1.1 1.1 1.3 1.7
Notes
1. Rates were age standardised to the 2001 Australian Standard Population.
2. Rate ratios compare the rate of burden for remoteness areas with that for Major cities.
Source: AIHW 2016a.
For most disease groups, age-standardised rates of disease burden increased with
remoteness and were highest in Very remote areas. The greatest absolute difference in
DALY rates of burden between Major cities and Very remote areas was for injuries (15 and
44 DALY per 1,000 population, respectively). The greatest relative difference in DALY rates
of burden was for kidney and urinary diseases, with Very remote areas having more than
6.0 times the rate of Major cities; this was followed by endocrine disorders (3.2 times) and
injuries (3.0 times). For a full breakdown of DALY rates of disease groups, see AIHW 2016a
and Supplementary Table S5.2.5.
See Chapter 3.1 ‘Burden of disease across the life stages’ for more information on burden
of disease.
Deaths
In 2015, age-standardised overall mortality rates increased as remoteness increased,
with people living in Very remote areas having a mortality rate almost 1.4 times as high as
people living in Major cities (759 per 100,000 population compared with 524 per 100,000
population) (Table 5.2.2). Mortality data for 2016 by remoteness area were not available
at the time of writing.
264
Table 5.2.2: Median age at death, mortality rate and rate ratio, by remoteness
area, 2015

cities regional regional Remote remote
Median age at death (years) 82.0 81.0 79.0 76.0 67.0
Age-standardised rate
(number per 100,000 524.3 593.0 611.4 657.4 759.3
population)
Rate ratio 1.0 1.1 1.2 1.3 1.4
Notes
1. Rates were age standardised to the 2001 Australian Standard Population.
2. Rate ratios compare the remoteness area rate with the Major cities rate.
Source: AIHW 2017b.
Potentially avoidable deaths

Potentially avoidable deaths are deaths among people aged under 75 that are considered
potentially preventable either by having individualised care or by being treated through
existing primary or hospital care. In 2015, age-standardised potentially avoidable death
rates increased as remoteness increased, with people living in Very remote areas having
a death rate over 2.5 times as high as people living in Major cities (256 per 100,000
population compared with 96 per 100,000 population) (Figure 5.2.3).
Figure 5.2.3: Age-standardised potentially avoidable death rate,

by remoteness area, 2015
Remoteness area
Major cities
Inner regional
Chapter 5
Outer regional
Remote
Very remote
0 50 100 150 200 250 300

265
Access to health care
The challenges of geographic spread, low population density, limited infrastructure,
as well as the higher costs of delivering rural and remote health care, can affect access
to health care.
Health workforce
Except for general practitioners (GPs), there is a marked decline in the full-time equivalent
rate (based on total weekly hours worked) of most types of health care professionals
per 100,000 population as remoteness increases (Figure 5.2.4). The higher rate of GPs in
Remote/Very remote areas may be due to them having a broader scope of practice, given
lower levels of supply for almost all other health professionals.
Figure 5.2.4: Employed health professionals, full-time equivalent rate,

by remoteness area, 2016
Health professionals
Major cities
Psychologists
Inner regional
Podiatrists
Outer regional
Physiotherapists Remote/ Very remote
Pharmacists
Optometrists
Occupational therapists
Medical practitioners—specialists
Medical practitioners—GPs
Dentists
Chiropractors
0 20 40 60 80 100 120 140 160 180 200

Full-time equivalent rate (per 100,000 population)
Source: National Health Workforce Data Set; Table S5.2.7.
See Chapter 2.3 ‘Who is in the health workforce?’ for more information on health
workforce supply.
266
Primary health care
Primary health care covers a large range of providers and services across health care
sectors. Primary health care is the entry level to the health system and, as such, is usually
a person’s first encounter with the system (AIHW 2016b).
Based on self-reported data, there was little variation in the proportion of people visiting
a GP across remoteness areas (Table 5.2.3). However, people living outside Major cities
were less likely to have visited a dental professional or an after-hours GP.
The relative lack outside Major cities of specialists and primary care professionals who
were not GPs may help to explain why people living in these areas were more likely to
have visited a hospital emergency department in the last 12 months (18% in Outer regional/
Remote/Very remote areas, 16% in Inner regional areas, and 13% in Major cities).
Table 5.2.3: Experience of health services in the last 12 months (per cent),
by remoteness area, people aged 15 and over, 2016–17
Outer regional/
Major Inner Remote/
Health care service cities regional Very remote
Saw a GP 82.4 83.8 81.5
Saw a GP for urgent medical attention 8.9 9.8 10.8
Saw an after-hours GP 9.3 6.6 5.8
Received a prescription for medication from a GP 67.4 71.3 69.5
Saw a dental professional 50.0 44.6 41.3
Saw a medical specialist 36.3 36.4 33.6
Visited a hospital emergency department 12.7 15.8 17.9
Source: ABS 2017c; Table S5.2.8.
See Chapter 7 for more information on health service statistics.
Experiences with GP care vary by remoteness. In 2016–17:
21% of people in Outer regional/Remote/Very Remote areas waited longer

than they felt was acceptable to get an appointment with a GP (compared Chapter 5
with 19% in Inner regional areas and 18% in Major cities)
33% of people in Outer regional/Remote/Very Remote areas reported they

could not see their preferred GP on one or more occasions (compared
with 28% in Inner regional areas and 25% in Major cities)
11% of people in Outer regional/Remote/Very Remote areas reported their

GP sometimes, rarely or never spent enough time with them (compared
with 8.9% in Inner regional areas and 9.3% in Major cities)
4.8% of people in Inner regional areas reported that they at least once
delayed seeing, or did not see, a GP when they needed to because of cost
(compared with 4.6% in Outer regional/Remote/Very Remote areas and
3.9% in Major cities) (ABS 2017c).
267
In a study of rural and remote health conducted by the Royal Flying Doctor Service of
Australia (RFDS), survey respondents in rural and remote areas reported spending an
average of 1 hour travelling to see a doctor for a non-emergency reason: some travelled
as long as 5 or more hours. For urgent medical care, the majority of survey respondents
were able to access a doctor within 4 hours, although some waited up to 6 days or longer
(Bishop et al. 2017). See Chapter 7.5 ‘Primary health care’ for more information on
primary health care.
Potentially preventable hospitalisations

A potentially preventable hospitalisation (PPH) is an admission to hospital that could

potentially have been prevented had there been appropriate individualised preventative
health care or early disease management—usually delivered in primary care and
community-based care settings (AIHW 2017a).
In 2015–16, the overall rate of PPHs was highest for residents of Remote and Very remote
areas (40 and 61 per 1,000 population, respectively), and lowest for residents of Major
cities (25 per 1,000 population). Residents of Remote and Very remote areas had the highest
rates of PPHs across all PPH categories (vaccine preventable conditions, acute conditions,
and total chronic conditions) (Table 5.2.4). However, there is variation from community to
community, both inside and outside Major cities (NHPA 2015).
Table 5.2.4: PPH rate (hospitalisations per 1,000 population), by selected PPH and
remoteness area(a)(b)(c), 2015–16

Type of PPH cities regional regional Remote remote
Vaccine preventable conditions 2.1 1.4 1.5 3.1 9.0
Acute conditions 11.7 13.3 15.1 20.4 30.1
Total chronic conditions (d)
11.4 12.5 13.4 16.6 23.7
Diabetes complications 1.7 2.0 2.2 2.8 4.6
Chronic conditions
9.7 10.5 11.3 13.9 19.1
(excluding diabetes)
Total 25.0 27.0 29.9 39.5 60.9
(a) D
ata are presented by the remoteness area in which the patient usually lives, rather than the hospital.
(b) Includes public and private hospitals.
(c) P
PH rates are directly age standardised using populations by remoteness areas, which do not include persons
with unknown or migratory area of usual residence.
(d) A
s more than one chronic condition may be reported for a separation, the sum of Diabetes complications and
Chronic conditions (excluding diabetes) does not necessarily equal the total number of separations for
Chronic conditions.
Source: AIHW 2017a.
268
Hospitalisations
Low levels of access to primary health care can mean that people from rural and remote
areas present to a hospital with conditions that could have been treated by a primary
health care practitioner and, instead, seek help later in the course of a disease
(Duckett et al. 2013).
In 2015–16, the total number of hospitalisations per 1,000 population varied by
remoteness area. Rates were highest for people living in Very remote areas
(746 per 1,000 population) (Table 5.2.5). This was 1.8 times the rate of Major cities.
Table 5.2.5: Hospitalisation rate, by remoteness area(a)(b), 2015–16

Hospitalisations cities regional regional Remote remote
Hospitalisations per 1,000 population(c) 409.6 415.5 415.4 479.4 745.8
Hospitalisation rate ratio(d) 1.0 1.0 1.0 1.2 1.8
(a) Data are presented by the remoteness area in which the patient usually lives, rather than the hospital.
(b) Includes public and private hospitals.
(c) H
ospitalisation rates are directly age standardised using populations by remoteness areas, which do not
include persons with unknown or migratory area of usual residence.
(d) T
he hospitalisation rate ratio is equal to the hospitalisation rate for regional/remote areas divided by the
hospitalisation rate for Major cities.
Source: AIHW 2017a.
See Chapter 7 for more information on hospital care.
Targeted health care

Specialist outreach in rural and remote areas can improve early intervention and the
coordination of care, as well as reducing the rate of hospitalisations.
The RFDS provides 24-hour emergency care to people in rural and remote Australia.
Health care professionals, including doctors, nurses, mental health workers and
dentists, deliver care. In 2016–17, the RFDS made around 336,000 total patient contacts,
transported around 107,000 patients, conducted around 88,500 telehealth consultations Chapter 5
and provided around 10,800 episodes of dental care (RFDS 2017).

It can be difficult to assess the implications of remoteness to health due to gaps in the
availability and coverage of health data in rural and remote areas—and in information
available at the local area level. For example, the Australian Bureau of Statistics National
Health Survey does not include Very remote areas of Australia.

More information on rural and remote health is available on the AIHW website
<www.aihw.gov.au/reports/rural-health/rural-remote-health/contents/rural-health>.
This web report and other recent releases are available for free download.
269
References
ABS (Australian Bureau of Statistics) 2008. Australian social trends, 2008. ABS cat. no. 4102.0.
Canberra: ABS.
ABS 2013. Estimates of Aboriginal and Torres Strait Islander Australians, June 2011.
ABS 2014. Remoteness structure. Canberra: ABS. Viewed 22 January 2018,
<http://www.abs.gov.au/websitedbs/D3310114.nsf/home/remoteness+structure>.
ABS 2016. Microdata: National Health Survey, 2014–15. ABS cat. no. 4324.0.55.001. Canberra: ABS.
AIHW analysis of Expanded Confidentialised Unit Record File.
ABS 2017a. Education and work, Australia, May 2017. ABS cat. no. 6227.0. Canberra: ABS.
ABS 2017b. Labour force, Australia, detailed—electronic delivery, Dec. 2017. ABS cat. no. 6291.0.55.001.
Canberra: ABS.
ABS 2017c. Patient experiences in Australia: summary of findings, 2016–17. ABS cat. no. 4839.0
Canberra: ABS.
ABS 2017d. Population by age and sex, regions of Australia, 2016. ABS cat. no. 3235.0. Canberra: ABS.
Derived by AIHW from SA1 estimated resident populations.
ABS 2017e. Regional population growth, Australia, 2016. ABS cat. no. 3218.0 Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2016a. Australian Burden of Disease Study: impact and
causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4.
Canberra: AIHW.
AIHW 2016b. Primary health care in Australia. Canberra: AIHW. Viewed 11 December 2017,
<https://www.aihw.gov.au/reports/primary-health-care/primary-health-care-in-australia/contents/
about-primary-health-care>.
AIHW 2017a. Admitted patient care 2015–16: Australian hospital statistics. Health services series no. 75.
Cat. no. HSE 185. Canberra: AIHW.
AIHW 2017b. MORT (Mortality Over Regions and Time) books: remoteness area, 2011–2015. Canberra:
AIHW.
Bishop L, Ransom A & Laverty M 2017. Health care access, mental health, and preventive health: health
priority survey findings for people in the bush. Canberra: Royal Flying Doctor Service of Australia.
Duckett S, Breadon P & Ginnivan L 2013. Access all areas: new solutions for GP shortages in rural Australia.
Melbourne: Grattan Institute.
NHPA (National Health Performance Authority) 2015. Healthy communities: potentially preventable
hospitalisations in 2013–14. Sydney: Australia.
NRHA (National Rural Health Alliance) 2013. A snapshot of poverty in rural and regional Australia.
Canberra: NRHA.
RFDS (Royal Flying Doctor Service) 2017. Annual national report 2016/17. Canberra: RFDS.
Wilkins R 2015. The Household, Income and Labour Dynamics in Australia Survey: selected findings
from waves 1 to 12. Melbourne: Melbourne Institute of Applied Economic and Social Research.
270
5.3 Culturally and
SNAPSHOT
linguistically diverse
populations
Australia’s population includes many people who were born overseas, have a parent
born overseas or speak a variety of languages. Together, these groups of people are
known as culturally and linguistically diverse (CALD) populations. The Australian Bureau of
Statistics (ABS) defines the CALD population mainly by country of birth, language spoken
at home, English proficiency, or other characteristics (including year of arrival in Australia),
parents’ country of birth and religious affiliation (ABS 1999). Country of birth is the most
common data element among AIHW health data collections (in 12 data collections, see
Supplementary Table S5.3.4) and is used in this snapshot.
According to the 2016 Census of Population and Housing, almost half of Australians
(45% or 10.6 million) were either born overseas (26% or 6.2 million) or had one or both
parents who were born overseas (19% or 4.5 million) (ABS 2017a).
In 2016, the most common overseas

countries of birth were:
Over 300 languages are spoken

in Australia:
• 1
in 5 (21%) people speak a
England New Zealand non-English language at home
3.9% (908,000) 2.2% (518,000)
• E
nglish is not the first language
for 15% or 3.5 million people
• E
nglish is not spoken at home
for 0.5% or 117,000 people.
China India Sources: ABS 2017a, 2017b.

2.2% (510,000) 1.9% (455,000) Chapter 5
Source: ABS 2017a.
Migration patterns have varied over time, both in the number of migrants and the country
or region where people previously lived. After World War II, there was an increase in
European (non-United Kingdom) migrants coming to Australia (Hugo 2004); from the
mid-70s, the number of migrants from Asia began to increase. This growth in migrants
from Asia has continued over the last four decades. Over the same period, the majority
of European migrants arriving in Australia previously resided in the UK and Ireland
(Figure 5.3.1).
271
Figure 5.3.1: Migrant arrival to Australia, by region of last residence,
1975–76 to 2015–16
Number
Sub-Saharan Africa
500,000
Americas
450,000 Asia
400,000 North Africa and the Middle East

Rest of Europe
350,000
United Kingdom and Ireland
300,000 New Zealand and Pacific
250,000
200,000
150,000
100,000
50,000
6
6
0
0
6
2
8
6
–1
–1
–1
–8
–0
–1
–8
–9
–8
–8
–8
–9
–9
–0
–0
–0
–0
–7
–7
–9
–9
09
11
13
15
75
77
79
81
83
85
87
89
91
93
95
97
99
01
03
05
07
20
20
20
20
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
Year
Sources: ABS 2017c, 2018; Table S5.3.1.
Health differentials
Nearly one-quarter of Australians are first-generation immigrants and they make up
a large section of Australia’s CALD population. Research in several countries with high
immigrant populations, including Australia, has found that migrant populations are
often healthier than native-born populations (Kennedy et al. 2014). Compared with the
Australian-born population, some immigrants have been found to have lower mortality
rates and self-reported chronic conditions (Jatrana et al. 2014; Kennedy et al. 2007).
For example, immigrants from Africa, the Middle East and India reported to have fewer
chronic conditions compared with Australian-born individuals. This pattern is known
as the ‘healthy migrant effect’. It is often explained by the health screenings that host
countries require before people migrate, and immigrants having a higher health and
wealth status to be able to physically and financially migrate to another country
(Kennedy et al. 2014).
This healthy migrant effect can disappear after immigrants have lived in Australia for a
long time (Jatrana et al. 2017). A longitudinal study found that when immigrant groups
from non-English speaking countries had been in Australia for more than 10 years,
their mental health and self-assessed health were worse than that for Australian-born
individuals (Jatrana et al. 2017).
Conversely, immigrants from English-speaking countries were found to have advantages
related to physical health, mental health and self-assessed health. English proficiency had
an effect on the difference in health between populations, as a language barrier could
hinder an individual’s access to health services. It can also have an impact on employment,
which has broader socioeconomic implications.
272
Mortality
Figure 5.3.2 shows age-standardised mortality rates (for any cause of death) among the
most common countries of birth reported in the 2016 Census. Consistent with the healthy
migrant effect, people born in some Asian countries had the lowest rates of mortality
due to any cause (including South Korea, Malaysia and China). Scottish-born people had
the highest all-cause mortality rates (701 per 100,000 population), which was higher than
Australian-born people (608 per 100,000).
While the all-cause mortality rates in Figure 5.3.2 show the healthy migrant effect, after
looking at cause-specific mortality (Supplementary Table S5.3.2), this effect does not
seem to apply across the board for all CALD populations, as the populations are not
homogeneous. For example, people born in the Philippines had the highest mortality
rate due to cerebrovascular disease (42 per 100,000 population) but had the third lowest
mortality rate due to chronic obstructive pulmonary disorder (COPD) (4.8 per 100,000).
Figure 5.3.2: Age-standardised all-cause mortality rate, by country of birth, 2016
Country of birth
Scotland 701
Australia 608
Germany 562
Italy 533
England 532
New Zealand 530
Greece 457
India 415
Sri Lanka 393
South Africa 393 Chapter 5

Philippines 353
Vietnam 328
China 313
Malaysia 305
South Korea 305
0 100 200 300 400 500 600 700 800
Mortality rate (deaths per 100,000 population)
273
Potentially preventable hospitalisations
Potentially preventable hospitalisations (PPHs) allow for an examination of hospitalisations
that could be considered to be largely preventable if timely and adequate care were
provided through population health services, primary care and outpatient services.
High rates of PPHs can indicate decreased access to primary care or continuing care
support (AHMAC 2017).
Figures 5.3.3 and 5.3.4 both show similar patterns among all PPHs and PPHs due to
chronic conditions, for the most common countries of birth reported in the 2016 Census.
Compared with Australian-born people, people born in Asian countries had lower
age-standardised rates of PPHs (4.4 per 1,000 population among South Korean-born, and
5.2 per 1,000 among Chinese-born). Individuals born in Australia and New Zealand had
the highest PPH rates (14.4 and 13.9 per 1,000 population, respectively). People born in
Italy, Scotland and Germany also had higher rates.
Among Italian- and Greek-born people, among PPHs due to chronic conditions, the most
common conditions were congestive cardiac failure (CCF) and COPD. Among Chinese- and
Vietnamese-born people, PPHs were most common for anaemia and CCF (Figure 5.3.4).
Figure 5.3.3: Age-standardised PPH Figure 5.3.4: Age-standardised PPH

rate, by country of birth, 2015–16 rate for chronic conditions,
by country of birth, 2015–16
Country of birth Country of birth
Australia 14.4
14.4 Australia 12.5
12.5
New Zealand 13.9 New Zealand 12.2
Italy 12.4 Italy 10.9
Scotland 11.9 Germany 10.4
Germany 11.8 Scotland 10.4
England 11.7 South Africa 10.2
South Africa 11.7 England 10.1
Philippines 9.2 Philippines 8.0
Greece 9.0 Greece 7.7
Sri Lanka 8.2 Sri Lanka 7.4
India 7.4 India 6.6
Malaysia 7.0 Malaysia 6.1
Vietnam 6.8 Vietnam 6.1
China 5.2 China 4.5
South Korea 4.4 South Korea 3.8
0 5 10 15 0 5 10 15
Rate (Number per 1,000 Rate (Number per 1,000
population) population)
Sources: National Hospital Morbidity Database; Sources: National Hospital Morbidity Database;
Table S5.3.3. Table S5.3.3.
274
Refugee health
For immigrants from some countries—especially refugees—migration can be a source
of trauma, and refugees have been found to have high rates of mental health problems
(FECCA 2015; Schweitzer et al. 2011; Shawyer et al. 2017; Sheikh-Mohammed et al. 2006;
Steel et al. 2009). Refugees in Melbourne were found to be 3.1 times more likely to have a
mental disorder and twice as likely to have post-traumatic stress disorder (PTSD) compared
with Australian-born individuals (Shawyer et al. 2017). Rates of PTSD, depression, and
anxiety were 3–4 times higher among Tamil asylum seekers than other immigrants (Minas
et al. 2013). As well, Iraqi and sub-Saharan African refugees in Australia were found to have
lower levels of mental health literacy compared with the general Australian population,
indicating that targeted mental health promotion would benefit these refugee populations
(Sheikh-Mohammed et al. 2006; Slewa-Younan et al. 2014).
The refugee subsection of the CALD population is particularly vulnerable. Being able to
identify and understand the specific needs of refugees is essential to improving their
health status in Australia. States and territories have refugee health networks, and most
have programs that include a focus on mental health service. Programs include screening,
assisting survivors of torture and trauma, delivering community health outreach for newly
settled refugees, and providing an initial point of contact to the health system.

The ABS has a set of Standards for Statistics on Cultural and Language Diversity that includes
a Minimum Core Set of Cultural and Language Indicators: country of birth, main language
other than English spoken at home, and proficiency in English. While these standards exist,
their use in national health data collections could be improved to better understand diverse
CALD populations and identify their specific needs. As well, it would be useful to have more
information related to how long individuals have been in Australia, language use patterns,
their need for an interpreter, parents’ country of birth, and refugee status.
Language barriers can lead to an under-representation of CALD people where English is
used in surveys or is required for self-reported information.
Where do I go for more information? Chapter 5

The online report Older Australia at a glance touches on older CALD people, and an
evaluation of CALD measures in a variety of data sets and assessment instruments can
be found in the report Cultural and linguistic diversity measures in aged care.
275
References
ABS (Australian Bureau of Statistics) 1999. Standards for Statistics on Cultural and Language Diversity.
ABS 2017a. Census of Population and Housing: cultural diversity data cube. ABS cat. no. 2071.0.
Canberra: ABS.
ABS 2017b. Census reveals a fast changing, culturally diverse nation. Canberra: ABS. Viewed
3 November 2017, <http://www.abs.gov.au/ausstats/[email protected]/lookup/Media%20Release3>.
ABS 2017c. Migration, Australia, 2015–16. ABS cat. no. 3412.0. Canberra: ABS. Customised report.
ABS 2018. Overseas Arrivals and Departures, Australia, Feb 2018. ABS cat. no. 3401.0. Canberra: ABS.
Customised report.
FECCA (Federation of Ethnic Communities’ Councils of Australia) 2015. Review of Australian research on
older people from culturally and linguistically diverse backgrounds. Canberra: FECCA.
Hugo, G 2004. A new paradigm of international migration: implications for migration policy and planning in
Australia. Canberra: Department of Parliamentary Services. Viewed 30 April 2018, <https://www.aph.gov.
au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp0304/04rp10>.
Jatrana S, Pasupuleti SSR & Richardson K 2014. Nativity, duration of residence and chronic health
conditions in Australia: do trends converge towards the native-born population? Social Science and
Medicine 119:53–63.
Jatrana S, Richardson K & Samba SRA 2017. Investigating the dynamics of migration and health in Australia:
a longitudinal study. European Journal of Population. doi:org/10.1007/s10680-017-9439-z.
Kennedy S, Kidd MP, McDonald JT & Biddle N 2007. The healthy immigrant effect and immigrant selection:
evidence from four countries. Program for Research on Social and Economic Dimensions of an Aging
Population (SEDAP). Research paper no. 164. Hamilton: SEDAP, McMaster University.
Kennedy S, Kidd MP, McDonald JT & Biddle N 2014. The healthy immigrant effect: patterns and evidence
from four countries. Journal of International Migration and Integration 16(2):317–32.
Minas H, Kakuma R, Too LS, Vayani H, Orapeleng S, Prasad-Ildes R, Turner G, Procter N & Oehm D 2013.
Mental health research and evaluation in multicultural Australia: developing a culture of inclusion.
International Journal of Mental Health Systems 20137:23.
Schweitzer RD, Brough M, Vromans L & Asic-Kobe M 2011. Mental health of newly arrived Burmese
refugees in Australia: contributions of pre-migration and post-migration experience. The Australian and
New Zealand Journal of Psychiatry 45(4):299–307.
Shawyer F, Enticott JC, Block AA, Cheng I-H & Meadows GN. The mental health status of refugees and
asylum seekers attending a refugee health clinic including comparisons with a matched sample of
Australian-born residents. BMC Psychiatry 17:76.
Sheikh-Mohammed M, Macintyre CR, Wood NJ, Leask J & Isaacs D. Barriers to access to health care for
newly resettled sub-Saharan refugees in Australia. Medical Journal of Australia 185(11-12):594-7.
Slewa-Younan A, Mond J, Bussion E, Mohammed Y, Guajardo MGU, Smith M, Milosevic D, Lujic S & Jorm FA
2014. Mental health literacy of resettled Iraqi refugees in Australia: knowledge about posttraumatic stress
disorder and beliefs about helpfulness of interventions. BMC Psychiatry 14:320.
Steel Z, Chey T, Silove D, Marnane C, Bryant RA & van Ommeren M 2009. Association of torture and other
potentially traumatic events with mental health outcomes among populations exposed to mass conflict
and displacement: a systematic review and meta-analysis. Journal of the American Medical Association
302(5):537–49.
276
5.4 People with disability
SNAPSHOT
An estimated 1 in 5 people in Australia (18% or 4.3 million people) had disability in 2015,
including about 1.4 million people (5.8% of the population) with severe or profound
disability (ABS 2016a) (see Box 5.4.1 for definitions). Disability and health have a complex
relationship—long-term health conditions might cause disability, and disability can
contribute to health problems. The nature and extent of a person’s disability can also
influence their health experiences.
This snapshot looks at the health of people with disability, the risks to their health,
and their experiences of health care.
Box 5.4.1: Defining and measuring disability

There are many different concepts and measures of disability, making comparisons
across different data sources challenging. The AIHW promotes measures based on
the International Classification of Functioning, Disability and Health (WHO 2001),
which underpins the disability categories used here.
The data used in this snapshot are primarily from the Australian Bureau of Statistics
(ABS) Survey of Disability, Ageing and Carers (SDAC) 2015 and the National Health
Survey (NHS) 2014–15, with supplementary information from the ABS Patient
Experience Survey 2015–16 and 2016–17, and the National Disability Insurance
Scheme (NDIS) (Box 5.4.2).
To identify disability, the SDAC asks participants if they have at least one of a list
of limitations, restrictions or impairments, which has lasted, or is likely to last,
for at least 6 months and that restricts everyday activities (ABS 2016a). The NHS
asks similar questions but with less detail (ABS 2016d). The Patient Experience
Survey does not identify disability, and data from it refer to Australians generally
(ABS 2016e, 2017).
This snapshot groups people with disability as people:
• w
ith severe or profound core activity limitation—unable to do, or always or
Chapter 5
sometimes needs help with, a core activity (self-care, mobility and communication);
this is referred to in this snapshot as ‘with severe or profound disability’
• w
ithout severe or profound core activity limitation—has a mild or moderate core
activity limitation, or has restriction in schooling or employment; this is referred
to in this snapshot as ‘with other forms of disability’.
Unlike the SDAC, the NHS does not report on people living in institutional settings,
such as aged care facilities (ABS 2016d). To avoid under-representing disability
among certain groups, this snapshot therefore focuses on people aged under 65
who live in households.
277
Health status
People with disability generally rate their health as poorer than other Australians.
They were around 6.2 times as likely as people without disability to assess their health
as ‘poor’ or ‘fair’ in 2014–15 (41% compared with 6.5%) (Figure 5.4.1). This is especially the
case for people with severe or profound disability (61%), who were about 10 times as
likely as people without disability, and almost twice as likely as people with other forms
of disability (36%), to assess their health as ‘poor’ or ‘fair’ (Figure 5.4.1).
Participants in the NDIS (Box 5.4.2) also rated their health as poorer than other
Australians, with 50% aged 25 and over assessing their health as ‘poor’ or ‘fair’ between
1 July 2016 and 30 September 2017 (Figure 5.4.1).
Figure 5.4.1: Self-assessed health, by broad disability status (2014–15), and for
NDIS participants (1 July 2016–30 September 2017)
NDIS participants(a)
People with severe or profound disability(b)
People with other forms of disability(b)
People with disability—total(b)
People without disability(b)
0 20 40 60 80 100
Per cent
(a) NDIS participants aged 25 and over, 1 July 2016–30 September 2017. See also Box 5.4.2.
(b) ABS 2014–15 NHS respondents aged 15–64; includes people who may be NDIS participants.
Sources: ABS 2016c; NDIA unpublished data 1 July 2016–30 September 2017; Tables S5.4.4, S5.4.1.
278
Box 5.4.2: National Disability Insurance Scheme
The NDIS is a substantial change to how services are delivered to people with
disability in Australia. It uses an insurance-based model to provide Australians
with ‘permanent and significant’ disability the ‘reasonable and necessary support’
needed to participate in everyday life. The NDIS was introduced through trial sites
from 1 July 2013, with the transition to the full scheme occurring progressively from
1 July 2016.
NDIS Outcomes Framework

The NDIS Outcomes Framework collects information about how participants and
their families and carers are faring in different areas (domains) of life over time.
Two versions of the framework exist: a short form questionnaire, asked of all
participants; and a long form asked of a sample of new participants each year.
Different questionnaires (both for participants and for their families and carers)
have been developed for defined participant age groups, recognising that different
milestones are important at varying stages of life.
The framework covers areas (or domains) that are not the direct responsibility of
the NDIS—such as the ‘health and wellbeing’ domain, which includes questions
on the health outcomes of NDIS participants aged 15 and over. The short form
includes 4 health-related questions: self-rated health; whether the participant
has a regular doctor; difficulties accessing health services; and visits to hospital.
The long form includes a much broader range of questions, asking (in addition)
about the participant’s outlook on life, health screening, diet and exercise, alcohol
consumption, smoking, mental health (the Kessler 6), and resilience (the Brief
Resilience Scale). A selection of health and wellbeing questions is also included in
the questionnaires for families and carers.
Some initial results from the NDIS health and wellbeing domain short form are
included in this snapshot. This information was collected from around 35,000
transition participants aged 25 and over with a first plan approved between
1 July 2016 and 30 September 2017.
Chapter 5
Mental health
Experiences of disability often involve mental health issues. Mental health conditions
can be both a cause and an effect of disability, and often involve activity limitations
and participation restrictions beyond the ‘core’ areas of communication, mobility and
self-care—for example, in personal relationships.
Notwithstanding this broader scope, almost half (47%) of people with severe or
profound core activity limitation, and more than one-third (37%) of people with other
forms of disability, self reported anxiety-related problems in 2014–15 (ABS 2016c).
This compares with 11% of people without disability (ABS 2016c).
279
An estimated 43% of people with severe or profound disability self reported that they had
mood (affective) disorders such as depression, compared with 35% of people with other
forms of disability, and 7.3% of people without disability (ABS 2016c).
People with severe or profound disability had higher levels of psychological distress
compared with people with other forms of disability in 2015 (Figure 5.4.2). Higher levels
of psychological distress indicate that a person may have, or is at risk of developing,
mental health issues.
See Chapter 3.12 ‘Mental health’ for more information on the mental health of the general
Australian population.
Figure 5.4.2: Level of psychological distress, by broad disability status, 2015
Per cent
100
80 Very high psychological distress
High psychological distress

60
Moderate psychological distress
40
Low psychological distress
20
0
With severe or With other forms
profound disability of disability
Note: People with disability aged 18–64. Level of psychological distress measured using the Kessler
Psychological Distress Scale (K10).
Risk factors
Limitations in activities and restrictions in participation can affect people’s lifestyles and
pose risks for health.
In 2014–15, compared with people without disability, people with disability were:
• more likely to report an insufficient level of physical activity in the last week
• more likely to report that they smoked daily
• less likely to report risky alcohol consumption in the last week (Figure 5.4.3).
See chapters 4.5 ‘Tobacco smoking’, 4.6 ‘Alcohol risk and harm’, 4.8 ‘Insufficient physical
activity’ for more information on risk factors for the general Australian population.
280
Figure 5.4.3: Prevalence of selected risk factors, by broad disability status,
2014–15
Per cent
80 With severe or With other forms Without disability
profound disability of disability
60
40
20
0
Insufficient physical activity Daily smoker(b) Risky alcohol consumption
in the last week(a) in the last week(a)
(a) Aged 18–64.

(b) Aged 15–64.
Health care
People with disability generally use health services—such as general practitioners (GPs),
medical specialists and hospital emergency departments—more than people without
disability. For example, in 2014–15, 93% of people with disability had visited a GP, 58%
had visited a medical specialist, and 20% had visited a hospital emergency department in
the last 12 months, compared with 82%, 26%, and 10%, respectively, of people without
disability (ABS 2016c).
Compared with people with other forms of disability, people with severe or profound Chapter 5
disability were more likely to visit, in the last 12 months:
a GP for urgent care a medical specialist a hospital emergency

24% compared with 18% 70% compared with 59% department
29% compared with 24%
281
In 2015, about 1 in 8 (13%) people with disability who went to an emergency department
in the last 12 months felt that their GP could have provided that care instead (ABS 2016b).
Some people with disability experience difficulties in accessing health services, such as
unacceptable or lengthy waiting times, cost, inaccessibility of buildings, and discrimination
by health professionals. They may also experience issues caused by lack of communication
between different health professionals who treat them. This can vary by the extent or
severity of disability (Table 5.4.1).
Table 5.4.1: Difficulties in accessing health services in last 12 months, by broad

disability status, 2015
With severe or With other forms

profound disability (%) of disability (%)
Had difficulty accessing medical facilities 38.2 34.5
Experienced unfair treatment or discrimination

from health staff 20.2 16.0
Delayed or did not see a GP because of the cost 20.5 19.1
Waited longer than they felt was acceptable to

get an appointment with a GP 26.2 21.0
Delayed or did not see a medical specialist

because of the cost 23.5 27.9
Waited longer than they felt was acceptable to

get an appointment with a medical specialist 32.6 28.5
Delayed or did not see a dentist because of the cost 57.9 65.7
Still waiting to receive public dental care 33.7 35.7
Delayed or did not go to hospital because of the cost 22.3 24.7
Experienced issues caused by lack of

communication among different health
professionals 20.4 16.1
As the patient experience information in the SDAC is collected only from people with
disability and their carers, it is not possible to make direct comparisons with people
without disability. Although from a different source, information from the ABS Patient
Experience Survey 2015–16 (ABS 2016e) suggests that people with disability are more likely
to face barriers such as cost when accessing some types of health services. For example:
Compared with all Australians, because of the cost, people with disability aged 15–64
were more likely to delay seeing, or not see, in the last 12 months:
a GP a dentist
20% compared with 16% 65% compared with 61%
Sources: ABS 2016b, 2016e.
282
The NDIS Outcomes Framework (Box 5.4.2) collects information on areas outside the
responsibility of the NDIS, such as use of, and access to, health services. Initial results
suggest that NDIS participants had some difficulty accessing or using health services,
with about 1 in 3 (32%) people aged 25 and over having trouble (NDIA 2017). Reasons
included access issues (9%), no support (6%), no transport (5%), the attitudes and/or
experience of health professionals (6%), and cost (5%) (NDIA 2017).
NDIS participants are more likely than Australians generally to go to hospital—41% had
been to hospital at least once in the last 12 months, compared with 11% of Australians
aged 25–64 in 2016–17 (ABS 2017; NDIA 2017). They also attend hospital more often—
56% of NDIS participants who had attended hospital in the past 12 months had been
more than once, compared with 23% of Australians aged 25–64 who had been to
hospital (NDIA 2017; ABS 2017).

The NDIS data presented in this snapshot signal the potential for much richer data on the
subset of all people with disability who are NDIS participants. As the NDIS matures, it is
expected that comprehensive data on assessed needs, supports provided and goals met
(outcomes) will be collected and progressively made available for further research and
policy development.
One key data gap relates to the availability of administrative data on the use of mainstream
health services by people with disability. At present, many health-related data collections—
such as those on hospitals, the Medicare Benefits Schedule, and the Pharmaceutical
Benefits Scheme—do not include a way to identify if a person has disability. This limits the
ability to report comprehensively on the use of specific health services and to examine the
interactions between health and other service sectors.

More information about access to health services by people with disability is available
in the web report <www.aihw.gov.au/reports/disability/access-health-services-disability/
contents/content>.
See the ABS website for more information on the SDAC, the NHS, and the Patient
Experience Survey. See the National Disability Insurance Agency website for more
information on the NDIS. Chapter 5
References
ABS (Australian Bureau of Statistics) 2016a. Disability, ageing and carers, Australia: summary of findings,
2015. ABS cat. no. 4430.0. Canberra: ABS.
ABS 2016b. Microdata: disability, ageing and carers, Australia, 2015. ABS cat. no. 4430.0.30.002. Canberra:
ABS. AIHW analysis of the confidentialised unit record file.
ABS 2016c. Microdata: National Health Survey, 2014–15. ABS cat. no. 4324.0.55.001. Canberra: ABS.
AIHW analysis of ABS TableBuilder.
ABS 2016d. National Health Survey: users’ guide 2014–15. ABS cat. no. 4363.0. Canberra: ABS.
ABS 2016e. Patient experiences in Australia: summary of findings, 2015–16. ABS cat. no. 4839.0. Canberra: ABS.
ABS 2017. Patient experiences in Australia: summary of findings, 2016–17. ABS cat. no. 4839.0. Canberra: ABS.
NDIA (National Disability Insurance Agency) 2017. National Disability Insurance Scheme, unpublished data.
Canberra: NDIA.
WHO (World Health Organization) 2001. International Classification of Functioning, Disability and Health.
Geneva: WHO.
283
5.5 Lesbian, gay, bisexual,
SNAPSHOT
transgender and
intersex people
The abbreviation LGBTI, often used to refer to people of diverse sex, gender and sexual
orientation, stands for lesbian, gay, bisexual, transgender, or intersex. However, the
limitations of this term when trying to describe the full extent of people’s genders,
relationships, sexualities and lived experiences should be acknowledged.
Part of the challenge in identifying and reporting on the health of the LGBTI population
stems from the lack of data sources that include information on diverse sex, gender and
sexual orientation—both administrative data collections and population-based surveys.
This snapshot presents information from those few known data sources that do include
such information. It refers primarily to people who identify as homosexual, bisexual,
heterosexual, or other sexual orientation.
Who are LGBTI people?

Collectively, LGBTI people are recognised as a specific minority population group.
Individually, they come from all walks of life and are part of all other population groups.
How LGBTI people identify themselves is influenced by many factors, including their age,
ethnicity, socioeconomic position and their lived experiences and relationships with others.
The 2016 National Drug Strategy Household Survey estimates that 3.2% of adults
identify as homosexual or bisexual and 2.4% as not sure/other orientation. Based on the
Australian Bureau of Statistics 2014 General Social Survey, 3.0% of adults identified as gay,
lesbian or as having an ‘other’ sexual orientation (ABS 2015).
In a survey of 1,168 students aged 12–17 from rural areas of Australia, 89% were attracted
only to people of the opposite sex. Of the remaining 11%, 6% were unsure, 2% were attracted
to both sexes and 3% were attracted only to people of the same sex (Hillier et al. 1996).
Analysis of the 2016 Census of Population and Housing shows that the number of
same-sex couples in Australia represents around 1 in 100 (0.9%) of all couple families
(either with or without children) (ABS 2017). Just under half of same-sex couples are
female (49%), and one-quarter (25%) of female same-sex couples have children. Despite
there being slightly more male same-sex couples, a considerably smaller proportion
of male same-sex couples have children (4.5%). People in same-sex couples tend to be
younger than people in opposite-sex couples (median ages of 40 and 48, respectively)
(ABS 2017).
People in same-sex couples are more likely to live in capital cities, tend to be more
highly educated, have higher labour force participation rates and earn higher incomes
than people in opposite-sex couples (ABS 2017).
284
How healthy are LGBTI people?
Evidence from small-scale LGBTI targeted studies, and some larger population-based
surveys, indicate that LGBTI people face disparities in terms of their mental health
(ABS 2008), sexual health (KI 2017) and rates of substance use.
The 2016 National Drug Strategy Household Survey found that adults who identified as
homosexual or bisexual or not sure/other sexual orientation reported higher levels of
psychological distress than heterosexual adults. Figure 5.5.1 shows that experiencing
high or very high psychological distress was more likely to be reported for homosexual
or bisexual people (28%) and people who were not sure/other (23%) compared with
heterosexuals (11%).
Figure 5.5.1: Level of psychological distress(a), people aged 18 and over,

by sexual orientation, 2016
Per cent
80
70 Heterosexual Homosexual / Bisexual Not sure / Other
60
50
40
30
20
10
0
Low Moderate High or very high
(a) R
eported low, moderate, high or very high psychological distress on the Kessler Psychological Distress
Scale (K10).
Chapter 5
The most recent National Survey of Mental Health and Wellbeing estimated that almost
1 in 3 (32%) homosexual/bisexual people aged 16 and over in Australia met the criteria for
an anxiety disorder in the previous 12 months, compared with 1 in 7 (14%) heterosexual
people (ABS 2008). Similarly, almost 1 in 5 (19%) homosexual/bisexual people met the
criteria for an affective disorder in the previous 12 months compared with 1 in 17 (6.0%)
heterosexual people.
While national suicide data by diverse sex, gender and sexual orientation are not
available, there is evidence that LGBTI people are at a higher risk of suicidal behaviours
(Skerrett et al. 2015) and have the highest rates of suicidality compared with any
population in Australia (see Glossary) (Rosenstreich 2013).
285
The 2016 National Drug Strategy Household Survey found that illicit drug use in the last
12 months was more common among people who identified as homosexual or bisexual
(42%) than among heterosexual people (14%). This pattern was seen across all age groups.
Considering only those people with high or very high psychological distress, homosexual
or bisexual people were more likely to smoke cigarettes (35%), consume an average of
more than 2 standard alcohol drinks per day (28%) and engage in illicit drug use (51%)
than heterosexual people (29%, 22%, and 27%, respectively). It has been suggested that
many LGBTI people use these substances to cope with the discrimination and difficulties
that LGBTI people regularly experience, that there may be a normalisation of substance
use in some LGBTI social settings, and that people who identify as being homosexual or
bisexual are generally more accepting of regular adult use of drugs than people who are
heterosexual (Leonard et al. 2015).
Research undertaken by the Kirby Institute shows that the proportion of gay and bisexual
men reporting condomless intercourse with casual male partners in the past 6 months
increased from 38% in 2012 to 44% in 2016 (Kirby Institute 2017). The Gay Community
Periodic Surveys estimate that among gay and bisexual men who had intercourse with
casual male partners in the previous 6 months, 40% reported consistent condom use
in 2016 and 44% in 2013 (Mao et al. 2017). By comparison, the most recent Australian
Study of Health and Relationships 2012–2013 estimates that, of people who had casual
sex in the previous 6 months, 49% of people who had vaginal intercourse and 48% of
heterosexual men always used a condom (Kirby Institute 2017; Richters et al. 2014).
Male-to-male sex continues to be the major HIV risk exposure in Australia, with 70% of
new HIV diagnoses in 2016 attributed to male-to-male sex (Kirby Institute 2017). From
2014, pre-exposure prophylaxis for HIV prevention (PrEP) became available in Australia
and, from 2016, large state-funded PrEP programs were implemented in some states.
This has resulted in an increase in the uptake of PrEP among non-HIV-positive gay and
bisexual men—from 1.9% who reported PrEP use in the previous 6 months in 2015 to
4.9% in 2016—according to the Gay Community Periodic Surveys (Kirby Institute 2017).

As outlined in this snapshot, there are known data limitations in reporting on sex- and
gender-diverse populations in Australia. Also, the available information reported here is
limited to gay, lesbian and bisexual people. It is currently not possible to accurately describe
the health of LGBTI people in Australia due to the lack of national population-based data
collections that include relevant data items. This situation could be dealt with by developing
a nationally agreed set of LGBTI data items for inclusion in population based-surveys and
administrative data sets, where relevant.
The Australian Bureau of Statistics has released the Standard for Sex and Gender
Variables (ABS 2016), which defines standard classification categories for capturing
information about sex and gender in data collections. It is expected that, over time, the
new standard will result in improved data about sex and gender diversity in Australian
health data collections.
286
For more information on the health of LGBTI people in Australia see the National LGBTI
Health Alliance website <www.lgbtihealth.org.au>. It provides information on LGBTI
health-related programs, services and research, focused on LGBTI and other sexuality- and
gender-diverse people and communities.
References
ABS (Australian Bureau of Statistics) 2008. National Survey of Mental Health and Wellbeing 2007: summary
of results. ABS cat. no. 4326.0. Canberra: ABS.
ABS 2015. General Social Survey: Summary Results, Australia, 2014. ABS cat. no. 4159.0. Canberra: ABS.
ABS 2016. Standard for sex and gender variables. ABS cat. no.1200.0.55.012. Canberra: ABS.
ABS 2017. Census of population and housing: reflecting Australia—stories from the census, 2016, same-sex
couples in Australia, 2016. ABS cat. no. 2071.0. Canberra: ABS.
Hillier L, Warr D & Haste B 1996. The Rural Mural: Sexuality and Diversity in Rural Youth. Melbourne:
National Centre in HIV Social Research, Program in Youth/General Population, La Trobe University.
Kirby Institute 2017. HIV, viral hepatitis and sexually transmissible infection in Australia: annual surveillance
report 2017. Sydney: KI, University of NSW.
Leonard W, Lyons A & Bariola E 2015. A closer look at private lives 2: addressing the mental health and
well-being of lesbian, gay, bisexual and transgender (LGBT) Australians. Monograph series no. 103.
Melbourne: The Australian Research Centre in Sex, Health and Society, La Trobe University.
Mao L, Holt M, Newman C & Treloar C (eds) 2017. Annual report of trends in behaviour 2017: HIV and STIs
in Australia. Sydney: Centre for Social Research in Health, UNSW Sydney.
Richters J, de Visser R, Rissel C & Grulich A 2014. Australian study of health and relationships: sex in
Australia 2 summary. Sydney: University of NSW. Viewed 2 February 2018, <http://www.ashr.edu.au/>.
Rosenstreich G 2013. LGBTI people: mental health and suicide. 2nd edn, rev. Sydney: National LGBTI
Health Alliance.
Skerrett DM, Kõlves K & De Leo D 2015. Are LGBT populations at a higher risk for suicidal behaviours in
Australia? Research findings and implications. Journal of Homosexuality 62:883–901.
Chapter 5
287
5.6 Veterans
FEATURE ARTICLE
The term ‘veteran’ has traditionally been used to describe former Australian Defence Force
(ADF) personnel who were deployed to serve in war or war-like conflict environments.
This article takes a broader approach, defining a veteran as a person with any experience
in the ADF. The veteran community broadly refers to veterans and their families and
carers, and to the ex-service organisations that support them (Hodson & McFarlane 2016;
Tehan 2017c). For many veterans, their unique service experience means they may have
unique health-related requirements above those of the broader community.

This article focuses on specific aspects of health for known veterans but is somewhat
limited by the availability of data on the whole veteran population. Due to
the historically small number of women in the ADF, most results are only presented
for men.
Diverse veteran community

Veterans include current serving, reserve and ex-serving personnel both with and
without operational experience—such as service in World War II, in Korea and Vietnam,
in peacekeeping operations and operations in the Middle East. The veteran community
also includes partners and dependants, carers, war widows and widowers. Veterans are
a diverse group, with different roles and experiences in the ADF. The diversity of the
group is reflected in the range of definitions currently used for a veteran. Most broadly,
a veteran can be defined as any ‘person who is serving or has served in the ADF’ (Tehan
2017a). In 2016–17, there were around:
• 5
8,200 Australians serving in the ADF Permanent Force—0.3% of the Australian
population aged 16 and over
• 5,300 ADF Permanent Force separations
• 3
20,000 veterans who had been deployed—1.6% of the Australian population
aged 16 and over. (Note: This estimate does not represent a complete picture of
veterans as not all will have been deployed)
• 2
91,000 Department of Veterans’ Affairs (DVA) clients—more than 55% of these were
veterans themselves and the rest were their families—this group represented 1.2% of
the whole Australian population (ABS 2017; Defence 2017a; Tehan 2017c).
The DVA estimates that around only 1 in 5 (20%) veterans are clients for whom it holds
information on their health and welfare status and access to services; this means that
the health and welfare status of the remaining veteran population is largely unknown
(DVA 2017c).
288
As the environment in which the ADF operates continues to change, so, too, do the
composition and needs of current and future veteran cohorts and their families.
An increase in military operations over the last decade or so has resulted in a new cohort
of contemporary veterans. While this cohort shares the military experience of previous
generations, their needs differ from those of their predecessors, due to factors such as
the impact of multiple deployments or deploying as smaller contingents or individuals,
rather than larger unit formations; the nature of recent warfare; and an extended working
life for many members after their discharge (DVA 2013).
Who is responsible for veterans’ health

and welfare?
The Department of Defence is responsible for the health care of current serving ADF
members up until the date of their transition to civilian life; this includes primary health
care, dental and mental health services, hospital care, ancillary health care specialist
services, diagnostic and radiology services, rehabilitation and suicide prevention
(Defence 2016; DVA 2017a).
After transition, these people can access health care services under Medicare, state and
territory government health arrangements, the private sector and (if relevant) those
administered by the DVA for eligible veterans, war widows and widowers and dependants.
DVA funds a wide range of payments and services—including pensions, compensation and
income support, as well as health services such as medical, dental, allied health, specialist
services, hospitals, pharmaceuticals, surgery, whole-of-person rehabilitation, counselling,
transport and home care (DVA 2017a).
DVA and the Department of Defence are jointly responsible for support for personnel
transitioning from the ADF into civilian life (JSCFADT 2015). The Defence transition
program provides ADF personnel and their families with support and services that include
tailored career coaching, Your Money and You (financial information), medical (including
registering for Medicare, sourcing private health insurance, and finding a general
practitioner), funding for financial counselling, employment and interview skills, training
and education, housing and relocation, and rehabilitation and compensation as needed Chapter 5
(Defence 2017b).
Risk and protective factors of ADF service

The service experience of ADF members may have an impact on their health needs as
veterans, presenting both protective factors and risk factors for their health. Their type
of service, rank, length of service, reason for discharge and transition experience are
some factors that may have an effect (AIHW 2018; Kang et al. 2015; Katz et al. 2012;
Hoffmire et al. 2015).
289
The healthy worker effect is demonstrated by the generally better health and lower
mortality rates of employed populations compared with the general population—usually
due to lower participation in employment among people with serious illness, injury
or disability. Several studies have recognised the ‘healthy soldier effect’ as protection
afforded above that of the general employed population, due mainly to their ongoing
need to stay fit and to having ready access to health care during service (Harrex et al. 2003;
Kang et al. 2015). While ex-serving personnel may no longer have the protective benefits
of ready access to health care, some of the benefits of good physical health may remain
and be reflected in the lower all-cause mortality rate in ex-serving ADF personnel
compared with an age-matched population of Australian men (AIHW 2018).

Transition from military to civilian life is an important event in a veteran’s life. While many
have transitioned without seeking help, others find the process difficult and uncertain.
They move from the structured, purpose-driven and supported military environment—
where housing, medical services, training and education are provided or subsidised as a
condition of service—to the largely unstructured and unsupported nature of civilian life
(Defence 2017b). The transition process is thus recognised as a time of stress, anxiety,
vulnerability and uncertainty for some individuals (DVA 2013; JSCFADT 2015; Kapur et al.
2009). People leaving the military with service-related problems such as chronic ill health,
injury, chronic pain or psychological concerns may experience greater difficulties
(DVA 2017b).
What do we know about the health of

Australia’s veterans?
Due to limitations in the data currently available on veterans, a comprehensive picture of
the health of the veteran population cannot be provided. Work is currently underway in
a number of areas to deal with this gap, including the Transition and Wellbeing Research
Program, via research commissioned under DVA’s Applied Research Programme and the
strategic partnership between DVA and AIHW (see sections ‘What is the AIHW doing?’ and
‘What is missing from the picture?’ for further details).
According to the 2014–15 National Health Survey, men aged 55 and over who served in
the ADF generally report similar rates of selected chronic conditions—arthritis, back pain
and problems, chronic obstructive pulmonary disease (COPD), diabetes mellitus, diseases
of the circulatory system and mental and behavioural problems—as men in the same
age group who have not served. However, men aged 55–64 who served in the ADF report
higher rates of mental and behavioural problems and arthritis than men of the same age
who have not served—1.8 times and 1.6 times higher, respectively (Figure 5.6.1).
290
Figure 5.6.1: Prevalence of selected chronic conditions for men aged 55 and
over, by age group and ADF service status, 2014–15
Diseases of the
Per cent Arthritis Per cent circulatory system
80 80
70 70
60 60
50 # 50
40 40
30 30
20 20
10 10
0 0
55–64 65–74 75+ 55–64 65–74 75+
Age group Age group
Back pain and problems Mental and behavioural

Per cent (dorsopathies) Per cent problems
35 35 #
30 30
25 25
20 20
15 15
10 10
5 5
0 0
55–64 65–74 75+ 55–64 65–74 75+
Age group Age group
Per cent COPD Per cent Diabetes mellitus

25 25
20 20
15 15 Chapter 5
10 10
5 5
0 0
55–64 65–74 75+ 55–64 65–74 75+
Age group Age group
Men who have served in the ADF Men who have not served in the ADF
# = A statistically significant difference between the ADF population group and Australian men of the same age.
291
According to self-reported data in the 2014–15 National Health Survey (NHS), after
adjusting for differences in age structure, men aged 18 and over who had ever served
in the ADF were as likely to rate their health as ‘very good’ or ‘excellent’ as men who had
not served (56% and 55%, respectively).
The 2010 ADF Mental Health Prevalence and Wellbeing Study found that 1 in 5 (22%)
people in the ADF population experienced a mental disorder in the previous 12 months.
More than half (54%) of the ADF population had experienced an anxiety, affective or
alcohol use disorder at some stage in their lifetime, which was higher than that among
the Australian community (49%). Men in the ADF had a greater prevalence of affective
disorders (9.4%) than men who had not served (5.7%) and a lower prevalence of alcohol
disorders (5.6%) than men who had not served (8.8%) (Van Hooff et al. 2014).
Incidence of suicide among serving and ex-serving

ADF personnel
There has been ongoing concern within the ADF, veteran and wider Australian
communities about the incidence of suicide in serving and ex-serving ADF personnel.
However, until recently, there was a lack of rigorous statistical evidence to inform
targeted strategies and plans to support people at risk. A recent study has provided
accurate numbers and rates of suicide death among contemporary ADF personnel who
have at least 1 day of service from 1 January 2001 (AIHW 2016b, 2018). Suicide rates
were examined for three ADF populations—those serving full time, in the reserves
and ex-serving personnel (hereafter referred to as the 3 ADF populations; Box 5.6.2).
Comparisons were made with the Australian population (AIHW 2016b, 2018), and
service-related characteristics associated with suicide death in ex-serving personnel
were presented (AIHW 2018).
Box 5.6.2: Defining the 3 ADF populations

The term ‘ADF personnel’ refers to serving, reserve and ex-serving ADF members.
It does not include civilian personnel employed by the Department of Defence.
Serving full time: ADF members serving in a regular capacity in the Royal
Australian Navy (Navy), Australian Army (Army) or the Royal Australian Air Force
(Air Force) on or after 1 January 2001, on continuous full-time service, or
participating in the gap year program.
Reserve: ADF members in the active or inactive reserve forces for the Navy, Army
or Air Force on or after 1 January 2001. Most members leaving full-time service
transition to the inactive reserve forces, unless there are medical or other grounds
preventing this.
Ex-serving: ADF members in the serving or reserve population on or after
1 January 2001 and who were discharged after 1 January 2001. The ex-serving
population increased by around 5,000 per year in the period of study (2001–2015).
292
Between 2001 and 2015, there were 325 suicide deaths among people with at least 1 day
of ADF service since 2001. Of these, 51% (166) were ex-serving at the time of their death,
28% (90) were serving full time and 21% (69) were in the reserves.
Men made up 84% of the ADF populations examined in the study. The clear majority of
suicide deaths identified occurred among men—93% (303 deaths), with 6.8% (22 deaths)
among women.
The rate of suicide death among women in the 3 ADF populations was highest for women
aged 18–29 (AIHW 2018). This was similar to the rate in Australian women of the same
age. Due to the smaller number of women in the study, further detailed analysis on
women was not possible.
Suicide rates among men serving full time or in the reserves were lower than rates for all
Australian men (AIHW 2018; Figure 5.6.2). In contrast, the suicide rate for ex-serving men was:
• 1
.2 times as high as the rate for men in the Australian population—however, after
adjusting for age, the rates are similar; this result is still of interest, though, when
considered in the context of the lower all-cause mortality in ex-serving men compared
with all Australian men
• 1
.7 times as high for men aged 18–29 compared with all Australian men of the same
age (Figure 5.6.3)
• m
ore than twice as high as for men serving full time or in the reserves (Figure 5.6.2);
for ex-serving men aged 18–29, the suicide rate was around 3 times as high as for
men of the same age serving full time or in the reserves (Figure 5.6.3)
• more than twice as high as for ex-serving women.
Figure 5.6.2: Crude rate of suicide death, ADF populations compared with
Australian men, 2002–2015

35 #
30 154
25
24,720
20 #
Chapter 5
#
71 60
15
10
0
Serving (17–70) Reserve (16–78) Ex-serving (17–84) Australia (17–84)
Population group (age group)
Note: The number of deaths in each group is displayed above the bars. The thin vertical lines superimposed
over the top end of each bar are 95% confidence intervals (CIs). The rate shown for Australian men is based
on the age range of the ex-serving population (ages 17–84, crude rate = 21.7). The crude rate in Australian
men aged 17–70 is 21.8 and for men aged 16–78, is 21.4.
Sources: National Mortality Database 2002–2015; Linked PMKeyS–National Death Index data 2002–2015;
Table S5.6.2.
293
Figure 5.6.3: Suicide death, rate for ADF populations and all Australian men,
by age, 2002–2015
Rate (number 100,000 population)

50
# Serving Reserve Ex-serving Australia
45 55
40
88
35
30
10,899
25
# 5,184 #
# # # 6,308
20 15 35
40 10 11
#
15
10
0
18 – 29 30 – 49 50 – 69
Age group
Note: The number of deaths in each group is displayed above the bars. Where a number is not shown, it has
been suppressed to ensure confidentiality. The thin vertical lines superimposed over the top end of each
bar are 95% CIs.
Sources: National Mortality Database 2002–2015; Linked PMKeyS–National Death Index data 2002–2015;
Table S5.6.3.
The following service-related characteristics were associated with higher risk of suicide
death among ex-serving men:
• m
edical discharge—suicide in men discharged involuntarily for medical reasons is
1.9 times more likely than in men discharged voluntarily
• a
ll ranks other than commissioned officers—ex-serving personnel separated in all
ranks other than commissioned officer are 2.2 times more likely to die by suicide than
commissioned officers.
Length of service was not a significant predictor of suicide death once all available
information—age, service (Navy, Army, Air Force), rank, reason for discharge and the time
between discharge from the ADF and death—was controlled for (AIHW 2018). However,
results suggest an increased likelihood of suicide in ex-serving men with less than 1 year
of service when compared with men who had served 10 years or more.
The key findings for this study are calculated from certified deaths information only.
Differences between the results for this study and other publicly reported estimates may
be due to the study scope and/or the source of cause of death information. Other factors
to consider when interpreting these results are described in the full report (AIHW 2018).
294
While these results cannot indicate if a particular characteristic is the cause of the suicide
death, they do help to identify groups of people who may be at higher risk of suicide
death—including personnel discharged for medical reasons and personnel discharged in all
ranks other than commissioned officers. This information has helped to inform policy and
to increase supports to reduce suicide rates among serving and ex-serving ADF personnel.
Since 1 July 2017, in response to the findings of this study, the Australian Government has
made free mental health treatment available to all current and former members of the
permanent ADF, and implemented case management services for personnel discharged
from a mental health hospital (Australian Government 2017; Tehan 2017b).
The Australian Government has also committed to the annual monitoring of key findings
from the study (Australian Government 2017). The AIHW will continue to independently track
these data to further our understanding of this complex issue and to inform future policy
and interventions to reduce suicide rates among serving and ex-serving ADF personnel.
Mortality and cancer incidence in aircraft

maintenance personnel
Between 1974 and 2000, the Air Force undertook a series of formal Deseal/Reseal (DSRS)
programs, alongside informal repair activities, to correct fuel leaks inside the fuel tanks
of F-111 aircraft. Several concerns were raised about health outcomes among Air Force
personnel who worked on these programs and associated activities at the Air Force
Base at Amberley in Queensland. The repair work was suspended in 2000, and a series
of inquiries and health studies followed—one of these was the Mortality and Cancer
Incidence Study (MCIS) (AIHW 2016a).
The purpose of the MCIS was to determine whether the personnel exposed to (involved
in) the DSRS programs at Amberley (the DSRS Study Population) experience higher than
expected rates of mortality or cancer incidence compared with two groups of non-exposed
Air Force personnel based at Amberley and Richmond (Comparison populations; see
Box 5.6.4). The number of exposed women in the study population was too small for
meaningful comparisons, so the DSRS Study and Comparison populations include men only.
Chapter 5
Box 5.6.4: Comparison populations
The two Comparison populations were matched to the DSRS Study Population by
age, sex, rank, and posting/exposure category—but differed by occupation and
environment/location. These populations were:
• t he Air Force Base Amberley Comparison Population—sourced from individuals
with similar environmental exposures (located at the same base, in Queensland),
but different occupational exposures (non-technical role)
• t he Air Force Base Richmond Comparison Population—sourced from individuals
with similar occupational exposures (technical, aircraft maintenance), but different
environmental exposures (located at a different base, in New South Wales).
295
Four iterations of the MCIS have been undertaken to date. Findings from the fourth study
in relation to cancer incidence in 1982–2010 show that, of the 149 cancers diagnosed,
the most common were prostate cancer (21% of all cancers), melanoma of the skin
(17%) and colorectal cancer (13%). The MCIS confirms that the personnel exposed to the
DSRS programs at Amberley experience higher than expected rates of cancer incidence
compared with the two groups of non-exposed Air Force personnel based at Amberley and
Richmond. Results also show that involvement in the DSRS programs was associated with:
• a
23%–30% increase in the rate of cancer diagnosis (compared with both the Amberley
and Richmond Comparison populations) (Figure 5.6.4)
• a 39% increase in the rate of cancer diagnosis (compared with the Australian population)
• h
igher incidence of non-Hodgkin lymphoma (more than 2 times as high compared with
the Amberley Comparison Population)
• h
igher incidence of lung cancer (nearly 2 times as high compared with the Richmond
Comparison Population) (AIHW 2016a).
Figure 5.6.4: Relative risk ratios for cancer incidence (1982–2010), cancer
mortality and all cause mortality (1999–2012): DSRS Study Population
compared with Comparison populations
Relative risk (ratio)

2.5
Amberley Comparison Population Richmond Comparison Population
2.0
#
#
1.5
#
1.0
0.5
0.0
Cancer incidence Cancer mortality All-cause mortality
# = Indicates statistically significant finding at the 95% CI.

Note: The dashed horizontal line marks where relative risk is 1.0. If the relative risk is greater than 1.0, the
number of cancers or deaths in the Study population is higher than that for the Comparison populations.
It the relative risk is less than 1.0, the number of cancers or deaths in the Study population is lower than
that for the Comparison population. The thin vertical lines represent the 95% CI around the (weighted)
incidence/mortality relative risk. That is, there is 95% certainty that the true difference in incidence/mortality
rates between the Study population and the Comparison populations sits within that interval.
Sources: AIHW linkage analysis of the Australian Cancer Database 2010 and the National Death Index;
Table S5.6.4.
296
There were 52 deaths from all causes in the fourth MCIS Study Population in 1999–2012,
making the all-cause mortality rate in the DSRS Study Population lower when compared
with the Amberley Comparison Population (27%) (AIHW 2016a). Of these deaths, 29 (56%)
were from cancer, making it the leading cause of death for that population.
When interpreting these findings, it is important to keep in mind the nature of the ongoing
scrutiny of the Study Population and their health status, which can introduce biases into
the study. Further information on the methods and factors to consider when interpreting
these results can be found in the full report (AIHW 2016a).

DVA and the AIHW have established a 3-year strategic partnership from 2017–2020, to
build a comprehensive profile of the health and welfare of Australia’s veterans, including
current and ex-serving persons, their families and carers. A broad population-level
approach will be taken—beyond current serving and DVA clients—to analyse health and
welfare outcomes for veterans. Existing disparate data sources will be explored to identify
opportunities to consolidate information from:
• survey data where people self-identify as having ADF service
• a
dministrative data that include questions, variables or flags relating to ADF service or
receipt of DVA entitlements
• future data integration.

DVA estimates that only around 1 in 5 (20%) veterans are known to them as clients, for
whom they hold a range of information about health and welfare status and access to
services (DVA 2017c). This means that the health and welfare status of the remaining 80%
of the veteran population is largely unknown.
Veterans are not readily identifiable in many general population health and welfare data
sources. While some data sources include questions, variables or flags relating to ADF
service or the receipt of DVA health and welfare entitlements, the different definitions
used of ‘a veteran’ limits comparisons across these sources. Developing a standardised
veteran indicator—and extending the use of this in existing surveys or administrative
collections—would enable data on veterans to be consistently identified and analysed
Chapter 5
across a broader range of existing data sources.
Research focusing on a subset of the veteran population and/or particular conflicts—for
example, Vietnam veterans—is limited in its capacity to support population-level analyses.
As well, while survey and administrative by-product data sources cover aspects of multiple
domains (including health, social support and housing), they are limited in both their
capacity to provide holistic coverage of all domains and to support longitudinal analysis.
There are also substantial gaps for the education, employment, justice and safety, and
income and finance domains.
As well, there are substantial gaps in our understanding of women’s experiences in the
ADF. This is due to the historically small number of women represented in the ADF, which
has limited this research.
297
More information on veterans is available at <www.aihw.gov.au/reports-statistics/
population-groups/veterans/overview>.
The report Incidence of suicide among serving and ex-serving Australian Defence Force
personnel and other releases are available for free download.
The report Fourth Study of mortality and cancer incidence in aircraft maintenance personnel:
a continuing study of F-111 Deseal/Reseal personnel 2016 and previous releases are available
for free download.
More information on the Department of Veterans’ Affairs is available at <www.dva.gov.au>.

More information on the Department of Defence is available at <www.defence.gov.au>.
More information on the Australian Senate inquiry into suicide by veterans is available at
<www.aph.gov.au>.
References
ABS (Australian Bureau of Statistics) 2016. Microdata: National Health Survey, 2014–15, TableBuilder. ABS
cat. no. 4324.0.55.001. Canberra: ABS. Findings based on AIHW analysis of ABS TableBuilder data.
ABS 2017. Australian demographic statistics, Dec. 2016. ABS cat. no. 3101.0. Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2016a. Fourth study of mortality and cancer incidence in
aircraft maintenance personnel: a continuing study of F-111 Deseal/Reseal personnel 2016. Cancer series
no. 99. Cat. no. CAN 98. Canberra: AIHW.
AIHW 2016b. Incidence of suicide among serving and ex-serving Australian Defence Force personnel
2001–2014. Cat. no. PHE 212. Canberra: AIHW. Viewed 27 September 2017, <http://www.aihw.gov.au/
publication-detail/?id=60129557674>.
AIHW 2018. Incidence of suicide among serving and ex-serving Australian Defence Force personnel
2001–2015: detailed analysis. Cat. no. PHE 218. Canberra: AIHW.
Australian Government 2017. Australian Government response to the Foreign Affairs, Defence and Trade
Committee Report: The constant battle—suicide by veterans. Tabled by the Minister for Veterans’ Affairs
24 October 2017. Viewed 28 November 2017, <https://www.dva.gov.au/consultation-and-grants/reviews/
government-reports>.
Defence (Department of Defence) 2016. Joint Health Command annual review 2015–16. Canberra:
Department of Defence. Viewed 27 November 2017, <http://www.defence.gov.au/health/home/docs/
JHC_Annual_Review_2015-16.pdf>.
Defence 2017a. Annual report 2016–17. Canberra: Department of Defence. Viewed 27 November 2017,
<http://www.defence.gov.au/AnnualReports/16-17/>.
Defence 2017b. Defence Community Organisation: leaving the ADF. Canberra: Department of Defence.
Viewed 21 November 2017, <http://www.defence.gov.au/dco/transition/>.
DVA (Department of Veterans’ Affairs) 2013. Veteran Mental Health Strategy: a ten year framework
2013–2023. Canberra: DVA.
DVA 2017a. Factsheet HSV01—health services available to the veteran community 2017. Canberra: DVA.
Viewed 21 November 2017, <https://www.dva.gov.au/factsheet-hsv01-health-services-available-veteran-
community>.
DVA 2017b. Factsheet VCS05—transition to civilian life 2017. Canberra: DVA. Viewed 21 November 2017,
<https://www.dva.gov.au/factsheet-vcs05-transition-civilian-life>.
DVA 2017c. VetAffairs vol. 33, no. 3, Spring 2017. Viewed 21 November 2017, <https://www.dva.gov.au/
about-dva/publications/vetaffairs/vol-33-no3-spring-2017>.
Harrex WK, Horsley KW, Jelfs P, Van Der Hoek R & Wilson EJ 2003. Mortality of Korean War veterans: the
veteran cohort study. A report of the 2002 retrospective cohort study of Australian veterans of the Korean
War. Canberra: DVA.
298
Hodson S & McFarlane A 2016. Australian veterans—identification of mental health issues. Australian
Family Physician 45(3):89–98.
JSCFADT (Joint Standing Committee on Foreign Affairs Defence and Trade) 2015. Review of the Defence
Annual Report 2013–14. Canberra: Joint Standing Committee on Foreign Affairs, Defence and Trade.
Viewed 27 November 2017, <http://www.aph.gov.au/Parliamentary_Business/Committees/Joint/Foreign_
Affairs_Defence_and_Trade/2013-14_Defence_AR/Report>.
Kang HK, Bullman TA, Smolenski DJ, Skopp NA, Gahm GA & Reger MA 2015. Suicide risk among 1.3 million
veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology 25:96–100.
Kapur N, While D, Blatchley N, Bray I & Harrison K 2009. Suicide after leaving the UK armed forces—a
cohort study. PLOS Medicine 6:e26.
Katz IR, McCarthy JF, Ignacio RV & Kemp J 2012. Suicide among veterans in 16 states, 2005 to 2008:
comparisons between utilizers and nonutilizers of Veterans Health Administration (VHA) services based on
data from the National Death Index, the National Violent Death Reporting System, and VHA administrative
records. American Journal of Public Health 102:S105–S10.
Hoffmire C, Kemp JE & Bossarte RM 2015. Changes in suicide mortality for veterans and nonveterans by
gender and history of VHA service use, 2000–2010. Psychiatric Services 66:959–65.
Tehan, the Hon. D 2017a. Joint communique: veterans’ ministers meeting. 8 November. Canberra. Viewed
12 December 2017, <http://minister.dva.gov.au/media_releases/2017/nov/joint_vmm.htm>.
Tehan, the Hon. D 2017b. Launching $6 million research centre to support veterans with PTSD. Media
release by Minister for Veterans’ Affairs, Minister for Defence Personnel. 15 September. Canberra. Viewed
21 November 2017, <http://minister.dva.gov.au/media_releases/2017/sep/va125.htm>.
Tehan, the Hon. D 2017c. Ministerial statement on veterans and their families. Media release by Minister
for Veterans’ Affairs, Minister for Defence Personnel. 14 August. Canberra. Viewed 21 November 2017,
<http://minister.dva.gov.au/media_releases/2017/aug/va110.htm>.
Van Hooff M, McFarlane AC, Davies CE, Searle AK, Fairweather-Schmidt AK, Verhagen A et al. 2014. The
Australian Defence Force Mental Health Prevalence and Wellbeing Study: design and methods. European
Journal of Psychotraumatology 5:1–12.
Chapter 5
299
5.7 Prisoners
SNAPSHOT
The prison population in Australia is increasing, both in overall number and as a

proportion of the population. The health profiles of prisoners are different from those
of the general community; they have higher levels of mental health disorders, illicit drug
use, chronic conditions, communicable disease and disability.
The prison population is fluid, with many prisoners entering and leaving prison each year.
In 2015, more than 50,000 people entered prison and more than 50,000 were discharged.
This constant movement through the prison system means the health issues of Australia’s
prisoners become health issues for the whole community.
This snapshot uses the 2015 National Prisoner Health Data Collection (NPHDC) to report
on the health and demographic profile of people entering prison. Where data are
available, broad comparisons are made between the health of prisoners and that of the
general community.
Who is in prison in Australia?

The prisoner population is predominantly male, with Aboriginal and Torres Strait Islander
people over-represented in the prison system (Table 5.7.1).
Table 5.7.1: Prison and general population demographics, 2016
Prison population General adult population
Male 9 in 10 (92%) 1 in 2 (49%)
Indigenous 1 in 4 (27%) 1 in 50 (3.0%)
Sources: ABS 2016c, 2017b.
People entering prison are often from disadvantaged backgrounds (Table 5.7.2).
Table 5.7.2: Prison entrants and general population socioeconomic factors, 2015–2016
Prison entrants, 2015 General adult population
Homeless 1 in 4 (24%) were homeless 1 in 200 (0.5%) were homeless on

in the month before entering Census night, 2016
prison
Unemployed 1 in 4 (27%) were 1 in 25 (4.4%) aged 15 and over
unemployed and looking for were unemployed and looking for work
work in the month before in February 2015
entering prison
Education level 2 in 3 (68%) had an education 1 in 5 (21%) aged 15–74 had an education
level of Year 10 or below level of Year 10 or below in May 2015
Note: Comparisons should be interpreted with caution due to differences in age structure, age intervals
and time periods between the prison population and the general population data.
Sources: ABS 2015b, 2016b, 2018; AIHW 2015.
300
What do we know about the health of
Australia’s prisoners?
People entering prison are likely to have mental and physical health problems,
and behave in ways that are risky to their health (Table 5.7.3).
Table 5.7.3: Prison entrants and general population health conditions, 2014–2016
Prison entrants, 2015 General adult population
Mental health 1 in 2 (50%) reported a history of a 1 in 5 (19%) aged 18–54 reported

condition mental health condition a long-term mental or behavioural
health condition in 2014–15
Chronic health 1 in 3 (31%) reported a current 1 in 5 (22%) aged 18–54 reported

condition chronic health condition a current chronic health condition
in 2014–15
Hepatitis C 1 in 3 (31%) tested positive to 1 in 50 (1.9%) aged 18–54

hepatitis C were estimated to be living with
chronic hepatitis C in 2015
Current smoker 3 in 4 (74%) were current smokers 1 in 6 (16%) aged 18 and over
were current smokers in 2016
Used illicit 2 in 3 (67%) had used illicit drugs 1 in 5 (19%) aged 18 and over
drugs during the 12 months before reported using illicit drugs during
entering prison the 12 months before being
surveyed in 2016
Notes
1. C
hronic health conditions reported by prison entrants included arthritis, asthma, diabetes, cancer and
cardiovascular disease only, whilst chronic health conditions in the general population also included chronic
respiratory conditions, chronic musculoskeletal conditions and mental health conditions.
2. W
here possible, an age range of 18–54 in the general population was used for health comparisons as the vast
majority of prison entrants were aged under 55 with only 2.4% aged 55 and over.
3. C
omparisons should be interpreted with caution due to differences in age structure, age intervals and time
periods between the prison population and the general population data. Chapter 5
Sources: ABS 2015c, 2015a, 2016b; AIHW 2015, 2017; Kirby Institute 2016.
Compared with people living in Australian households from the same age group,
people entering prison are more likely to have disability—meaning that they have core
activity limitation in one or more of the areas of self-care, mobility and communication.
Core activity limitation for people entering prison is:
• 1.1 times as likely as for people living in Australian households for people aged 20–34
• 1.5 times as likely for people aged 35–49
• 1.3 times as likely for people aged 50–64 (ABS 2016a).
As most people entering prison in the 50–64 age group are aged under 55, the
comparison for this age group likely underestimates the limitation that older prisoners
have compared with people of the same age in the general population.
301
The prison population is ageing
The Australian prison population is growing faster than the Australian population, with
older prisoners the fastest growing age group (ABS 2017a). The number of prisoners
aged 50 and over increased by 84%—from 2,400 prisoners in 2005 to 4,400 in 2015—and
by 170% for prisoners aged 65 and over—312 prisoners in 2005 to 842 in 2015 (ABS 2005b,
2015d). This substantial increase compares with a 27% increase in the Australian
population aged 50 and over between 2005 and 2015 and a 34% increase in the number
of Australians aged 65 and over (ABS 2005a, 2015a).
The steep rise over time in the number of older prisoners is due to a few reasons:
long prison sentences, mandatory sentencing, sentencing of historical sex offenders,
reduced options for early release and the decline in preventable deaths over time
(AIC 2015; Baidawi et al. 2011; Trotter & Baidawi 2015).
How healthy are older prisoners?

Older people, including older prisoners, are more likely to suffer from chronic conditions
and disability, and need medication, treatment and support with daily living, compared
with younger people.
Prisoners experience ‘accelerated ageing’, where signs of ageing occur 10 to 15 years
earlier than for the rest of the population (Baidawi et al. 2011; Williams et al. 2012).
For this reason, 50 years is commonly used as the threshold for considering a prisoner
in Australia to be ‘old’ (Trotter & Baidawi 2015).
As well as being more likely to have core activity limitation, people entering prison
aged 50 and over often have other health conditions, reportedly brought to their attention
by a doctor or nurse. For instance:
• 1 in 3 (33%) reported being told they had arthritis
• 2 in 11 (18%) reported being told they had diabetes
• 1 in 6 (16%) reported being told they had cardiovascular disease
• 1 in 18 (5.5%) reported being told they had cancer.

The NPHDC aims to collect data from all public and private prisons in Australia on people
who enter prison, prisoners who visit a prison clinic, prisoners who are taking prescription
medication while in custody, prison clinic services and staffing levels, and prisoners
discharged from prison. Currently, data are collected every 3 years through surveys
conducted in prisons over a 2-week period. In 2015, the response rate for people entering
prison was 49% and included prisoners from 84% of prisons in Australia. The AIHW is
working with all jurisdictions to improve the completeness of this data collection. Data
linkage can improve the understanding of prisoner outcomes and pathways through the
health system and is being explored by AIHW in collaboration with the Australian Bureau
of Statistics.
Longitudinal data on individual prisoners’ health—that is, from prison entry to release—are
not currently available. Likewise, data on the continuity of care after prisoners leave the
prison health system are not available.
302
More information on the health of Australia’s prisoners, including information on the use
of prison health services by people in prison and information on people being discharged
from prison, is available at: <www.aihw.gov.au/reports-statistics/population-groups/
prisoners/overview>.
The report The health of Australia’s prisoners, 2015 and other recent releases are available
for free download.
Information on prisoners in Australia is also available at
<www.abs.gov.au/ausstats/[email protected]/mf/4517.0>.
References
ABS (Australian Bureau of Statistics) 2005a. Australian demographic statistics, Jun. 2005. ABS cat. no. 3101.0.
Canberra: ABS.
ABS 2005b. Prisoners in Australia, 2005. ABS cat. no. 4517.0. Canberra: ABS.
ABS 2015a. Australian demographic statistics, Jun. 2015. ABS cat. no. 3101.0. Canberra: ABS.
ABS 2015b. Education and work, Australia, May 2015. ABS cat. no. 6227.0. Canberra: ABS.
ABS 2015c. National Health Survey: first results, 2014–15. ABS cat. no. 4364.0.55.001. Canberra: ABS.
ABS 2015d. Prisoners in Australia, 2015. ABS cat. no. 4517.0. Canberra: ABS.
ABS 2016a. Microdata: disability, ageing and carers, Australia, 2015. ABS cat. no. 4430.0.30.002
Canberra: ABS. AIHW analysis of Basic Confidentialised Unit Record File.
ABS 2016b. Participation, job search and mobility, Australia, February 2015. ABS cat. no. 6226.0.
Canberra: ABS.
ABS 2016c. Prisoners in Australia, 2016. ABS cat. no. 4517.0. Canberra: ABS.
ABS 2017a. Australian demographic statistics, Dec. 2016. ABS cat. no. 3101.0. Canberra: ABS.
ABS 2017b. Census of population and housing: reflecting Australia - stories from the Census, 2016.
ABS 2018. Census of population and housing: estimating homelessness, 2016. ABS cat. no. 2049.0.
Canberra: ABS.
AIC (Australian Institute of Criminology) 2015. Deaths in custody in Australia: National Deaths in Custody
Program 2011–12 and 2012–13. Canberra: AIC.
AIHW (Australian Institute of Health and Welfare) 2015. The health of Australia’s prisoners 2015.
AIHW 2017. National Drug Strategy Household Survey 2016: detailed findings. Drug Statistics series no. 31. Chapter 5
Baidawi S, Turner S, Trotter C, Browning C, Collier P, O’Connor D et al. 2011. Older prisoners—a challenge
for Australian corrections. Trends and Issues in Crime and Justice 426.
Kirby Institute 2016. National blood-borne viruses and sexually transmissible infections surveillance and
monitoring report, 2016. Sydney: Kirby Institute, University of New South Wales.
Trotter C & Baidawi S 2015. Older prisoners: challenges for inmates and prison management. Australian
and New Zealand Journal of Criminology 48:200–18.
Williams BA, Goodwin JS, Baillargeon J, Ahalt C & Walter LC 2012. Addressing the aging crisis in US criminal
justice health care. Journal of the American Geriatrics Society 60:1150–6.
303
304
Chapter 6
Indigenous health
305
6.0 Overview
Aboriginal and Torres Strait Islander people are the Indigenous peoples of Australia.
Indigenous Australians can be of Aboriginal origin, Torres Strait Islander origin, or
both. There were an estimated 787,000 Indigenous Australians in 2016—3.3% of the
total Australian population, with an estimated growth in their population size of 19%
since 2011. This chapter presents information on the health status of the Indigenous
population, as well as the determinants of health and access to health services that are
specific to the Indigenous population.

For Indigenous Australians, good health is more than the absence of disease or illness;
it is a holistic concept that includes physical, social, emotional, cultural, spiritual and
ecological wellbeing, for both the individual and the community. This concept of good
health emphasises the connectedness of these factors and recognises how social and
cultural determinants can affect health.
As a group, Indigenous Australians experience widespread disadvantage and health
inequality. In 2014–15, Indigenous Australians were at almost half as likely as
non-Indigenous Australians to rate their health as ‘fair’ or ‘poor’, and much less likely to
rate their health as ‘excellent’ or ‘very good’. Compared with non-Indigenous Australians,
Indigenous Australians are 1.7 times as likely to have disability or a restrictive
long-term health condition and 2.7 times as likely to experience high or very high levels
of psychological distress.
The gap in life expectancy between Indigenous and non-Indigenous Australians in
2010–2012 was around 10.6 years for males and 9.5 years for females. Health inequality
can start early for Indigenous people—reflected in infant and child mortality rates being
generally higher in their communities. Further, although rates have declined in recent
years, Indigenous children are 2.1 times as likely as non-Indigenous children to die before
the age of 5.
Indigenous children and adolescents are also far more likely than non-Indigenous children
to be affected by ear infections and hearing loss. Although the proportion of Indigenous
children with poor ear health and hearing loss has decreased in the last 15 years, the
rate of long-term ear/hearing problems in children aged 0–14 is still almost 3 times that
for non-Indigenous children (8.4% compared with 2.9%). Poor ear and hearing health
can profoundly affect a child’s life, impeding cognitive development, auditory processing
skills and speech and language development. Hearing loss can lead to social isolation
and problems with school attendance, which, in turn, can have life-long negative social
consequences. For many Indigenous children, hearing loss and the associated aftermaths
further compound many of the disadvantages already facing Indigenous Australians.
306
Much of the understanding of the ‘health gap’ between Indigenous and non-Indigenous
Australians is based on factors generally recognised as contributing to good health,
including:
• d
ifferences in the social determinants of health—Indigenous Australians, on average,
have lower levels of education, employment, income, and poorer quality housing than
non-Indigenous Australians
• d
ifferences in health risk factors—Indigenous Australians, on average, have higher
rates of risk factors that can lead to adverse health outcomes, such as tobacco smoking,
risky alcohol consumption and insufficient physical activity for good health
• d
ifferences in access to appropriate health services—Indigenous Australians are
more likely than non-Indigenous Australians to report greater difficulty in accessing
affordable health services that are close by.
Socioeconomic factors account for more than one-third (34%) of this health gap—household
income is the largest individual contributor to the overall gap (14%), followed by employment
status (12%). Health risk factors contribute 19% of the gap—with differences in smoking
rates between Indigenous and non-Indigenous Australians being the largest contributor,
at 10%. While the Indigenous smoking rate has fallen substantially in recent years—from
51% in 2002 to 42% in 2014–15—it is still 2.7 times as high as that for non-Indigenous
Australians.
Access to appropriate, high-quality and timely health care can help to improve health
outcomes. Indigenous Australians can use mainstream or Indigenous-specific primary
health care services. In 2015–16, Indigenous primary health care services were delivered
across nearly 370 sites, more than two-thirds of which were in Very remote (33%),
Remote (13%) and Outer regional (23%) areas.
The geographic distribution of the Indigenous population can pose substantial challenges
for workforce recruitment and delivery of health services. For example, access to midwives
is critical for the health of Indigenous women, who are less likely to attend antenatal care
in the first trimester of pregnancy, and have higher levels of social disadvantage. These
factors contribute to the higher likelihood that babies born to Indigenous mothers will
be premature, of low birthweight and/or will die before their first birthday. Looking at
the supply of midwives across Australia, 15% of Indigenous women of child-bearing age
live in areas likely to pose the highest challenges for supply of a midwife workforce.
This percentage is 8 times as high as that for non-Indigenous women of child-bearing
age (1.8%).
Chapter 6
307
6.1 Profile of Indigenous
SNAPSHOT
Australians
Aboriginal and Torres Strait Islander people are the Indigenous peoples of Australia.
They comprise hundreds of groups, each with their own distinct set of languages, histories
and cultural traditions. Indigenous communities pass on knowledge, tradition, ceremony
and culture from one generation to the next through language, performance, protection
of significant sites, storytelling and the teachings of Elders. Indigenous Australians live in
all parts of the nation, from major cities to remote tropical and desert areas.
The Australian Government defines Indigenous Australians as people who are of Aboriginal
or Torres Strait Islander descent, who identify as being of Aboriginal or Torres Strait
Islander descent and who are accepted as such in the communities in which they live, or
have lived. In most data collections, a person’s Indigenous status is based on the first two
parts of this definition. While there is evidence that Aboriginal and Torres Strait Islander
people are more likely to identify as Indigenous now than in the past, there is still
under-counting of Indigenous Australians in official statistics. The Australian Bureau of
Statistics takes the Census counts (the number of people who identified as Indigenous)
and adjusts the data to produce the estimated resident population data (ERP) and this
snapshot uses ERP data where possible.
How many people identify as Indigenous?

In 2016, an estimated 787,000 Australians identified as Indigenous (3.3% of the
population). Between 2011 and 2016, the estimated Indigenous population increased by
19%, compared with an 8.0% increase for the non-Indigenous population (ABS 2017a).
These are preliminary estimates, with the final ERP estimates to be released later in 2018.
In 2016, 91% of people identifying as Indigenous were of Aboriginal origin, 5.0% were of
Torres Strait Islander origin and 4.1% identified as being of both Aboriginal and Torres
Strait Islander origin (ABS 2017a).
Where do Indigenous Australians live?
In 2011,
35% lived in Major cities— 22% lived in Inner regional

233,100 people areas—147,700 people
22% lived in Outer regional 7.7% lived in Remote

areas—146,100 people areas—51,300 people
14% lived in Very remote

areas—91,600 people
Source: ABS 2013.
308
9.3%
27.7 % In 2016, one-third (33%) of
12.6 % Indigenous Australians lived
5.3% in New South Wales, and
33.3% another 28% in Queensland.
0.9%
7.2%
3.6%
Source: ABS 2017b.
Age profile
The Indigenous population has a much younger age distribution than the non-Indigenous
population. The median age of the Indigenous population in the 2016 Census was 23,
compared with 38 for the non-Indigenous population (ABS 2017c).
In 2016, 34% of Indigenous Australians were aged under 15, compared with 18% of
non-Indigenous Australians, and only 4.3% of Indigenous Australians were aged 65 and
over (Figure 6.1.1).
Figure 6.1.1: Population distribution, by age and Indigenous status, 2016
Age
85+
80 –84
75 –79 Indigenous population
70 –74 Non-Indigenous population
65 –69
60 –64
55 –59
50 –54
45 –49
40 –44
35 –39
Chapter 6
30 –34
25 –29
20 –24
15 –19
10 –14
5–9
0–4
0 2 4 6 8 10 12
Per cent
Source: ABS 2017a; Table S6.1.1.
309
Household composition
In 2016, Indigenous households were more likely to be made up of families, and less
likely to be lone-person households than non-Indigenous households (Table 6.1.1).
Table 6.1.1: Percentage distribution of household composition,

by Indigenous status, 2016
Household composition Indigenous Non-Indigenous

One family 74.7 69.2
Multiple families 5.1 1.8

Lone person 14.7 24.7
Group 5.5 4.2
Source: ABS 2017c.
Language
The 2016 Census reported that:
• o
ne in 10 (10%) Indigenous people spoke an Indigenous language at home
• 1
50 different Australian Indigenous languages were spoken at home
• 8
5% of the 63,800 Indigenous people who spoke an Indigenous language at home
reported speaking English well or very well (ABS 2017d).
Social and economic capital

In 2016:
• t he employment-to-population ratio among people aged 15 and over (employment
rate) for Indigenous Australians was 45%
• 1
2% of Indigenous households owned their homes outright, another 26% owned with
a mortgage, and the majority (57%) rented their dwellings
• m
edian equivalised household income for Indigenous Australians was $1,203
• t he proportion of Indigenous people aged 20–24 who had completed Year 12 or its
equivalent increased by more than a third between 2011 and 2016, from 37% to 47%
(ABS 2017d).
Family and cultural life

Data from the 2014–15 National Aboriginal and Torres Strait Islander Social Survey show
that Indigenous Australians have strong connections to family, community and culture
(Figure 6.1.2).
310
Figure 6.1.2: Percentage distribution of participation in aspects of family and
cultural life, Indigenous Australians, 2014–15
Aspect of family, community or culture
Identified with a clan or language group
Involved in a cultural event in last 12 months
Recognised an area as homeland/traditional country
Could get support in time of crisis from

family outside household
Felt able to have a say with family and friends
Involved in a sport, social or community activities
0 20 40 60 80 100
Per cent

Changes in Indigenous identification rates between Censuses can affect population counts
and the statistics derived from them. Due to the small Indigenous population in some
jurisdictions and remoteness areas, it is not always possible to produce specific, reliable
statistics for smaller areas. Detailed information on cultural factors and participation is
only available every 3 years from Indigenous-specific surveys.

Find more information on the composition of the Indigenous population on the
Australian Bureau of Statistics website at
<www.abs.gov.au/Aboriginal-and-Torres-Strait-Islander-Peoples>.
An overview of reports and statistics about Indigenous Australians is available from
the AIHW website at Indigenous Australians.
References
ABS (Australian Bureau of Statistics) 2013. Estimates of Aboriginal and Torres Strait Islander Australians,
June 2011. ABS cat. no. 3238.0.55.001. Canberra: ABS.
Chapter 6
ABS 2016. National Aboriginal and Torres Strait Islander Social Survey, 2014–15. ABS cat. no. 4714.0.
Canberra: ABS.
ABS 2017a. Australian demographic statistics, Mar. 2017. ABS cat. no. 3101.0. Canberra: ABS.
ABS 2017b. Census of Population and Housing—counts of Aboriginal and Torres Strait Islander Australians,
Australia, 2016. ABS cat. 2075.0. Canberra: ABS.
ABS 2017c. Census of Population and Housing: reflecting Australia—stories from the Census, 2016.
ABS 2017d. 2016 Census of Population and Housing—Aboriginal and Torres Strait Islander peoples profile.
311
6.2 Indigenous health
SNAPSHOT
and wellbeing
For Aboriginal and Torres Strait Islander Australians, good health is more than just
the absence of disease or illness; it is a holistic concept that includes physical, social,
emotional, cultural, spiritual and ecological wellbeing, for both the individual and the
community. This concept of health emphasises the connectedness between these factors
and recognises the impact that social and cultural determinants have on health.
This snapshot presents information on three aspects of health and wellbeing for the
Indigenous population, drawn from the 2014–15 National Aboriginal and Torres Strait
Islander Social Survey: perceived health status, disability and long-term health conditions,
and social and emotional wellbeing—each of which fits within the Indigenous definition of
health. See chapters 6.3 ‘Indigenous child mortality and life expectancy’, 6.4 ‘Ear health
and hearing loss among Indigenous children’ for more information on other health outcomes.
Perceived health status

One way to measure health is to ask people how good or how poorly they rate their
current health. Self-assessed health status is a subjective measure that depends on an
individual’s expectations for their own health and their comparisons with others around
them (Delpierre et al. 2009).
In 2014–15, an estimated 40% of Indigenous Australians aged 15 and over rated their
health as ‘excellent’ or ‘very good’, 35% as ‘good’ and 26% as ‘fair’ or ‘poor’ (ABS 2016).
Indigenous males were more likely to rate their health as ‘excellent’ or ‘very good’ than
Indigenous females (43% compared with 37%). Indigenous parents rated the health of
their children aged 0–14 positively in 2014–15: 83% rated it as ‘excellent’ or ‘very good’,
13% as ‘good’, and 4.0% as ‘fair’ or ‘poor’.
Self-assessed health status varies across remoteness areas; Indigenous Australians living
in Very remote and Remote areas were less likely to rate their health as ‘fair’ or ‘poor’ than
Indigenous Australians in regional areas or Major cities (Figure 6.2.1).
312
Figure 6.2.1 Self-assessed health status for Indigenous Australians,
by remoteness area, 2014–15
Remoteness
Very remote
Remote
Outer regional
Inner regional
Major cities
0 20 40 60 80 100
Per cent
The patterns for both sex and remoteness differ from those for more objective measures
of health—such as hospitalisations or health risk factors, where men and people living in
more remote areas have higher rates. These differences may arise because perceptions of
one’s own health status may incorporate broader aspects of health, including social and
emotional wellbeing and functioning. Thus, subjective and objective measures should be
viewed as complementary indicators of health.
In 2014–15, Indigenous Australians were at least twice as likely as non-Indigenous
Australians to rate their health as ‘fair’ or ‘poor’, and almost half as likely to rate their health
as ‘excellent’ or ‘very good’. These differences have changed little since 2008 (ABS 2016).
Disability status and long-term health conditions

On average, people living with disability or long-term health conditions have substantially
poorer health than people living without disability.
In 2014–15, an estimated 45% of Indigenous Australians (almost 200,000 people) had
disability or a long-term health condition that restricted their everyday activities, at 1.7
times the rate of non-Indigenous Australians (ABS 2016). Physical disability was the type
Chapter 6
most often reported in 2014–15, followed by sight/hearing/speech disability (Figure 6.2.2).

The long-term health conditions with the highest self-reported prevalence among
Indigenous Australians in 2014–15 were eye diseases and vision problems (29%),
respiratory diseases (24%), musculoskeletal diseases (22%) and cardiovascular disease
(16%) (ABS 2016).
313
Figure 6.2.2: Type of disability, Indigenous Australians, 2014–15
Type of disability
Physical
Sight/hearing/speech
Other
Psychological
Intellectual
Head injury, stroke or

brain damage
0 20,000 40,000 60,000 80,000 100,000 120,000 140,000
Number of Indigenous Australians
Note: As people can have multiple forms of disability, the numbers add up to more than the total 199,764
reporting a disability or long-term health condition.
Social and emotional wellbeing

Two related indicators of social and emotional wellbeing are the extent to which people
experience stressors in their lives, and their levels of psychological distress.
In 2014–15, more than two-thirds (68%) of Indigenous Australians had experienced one or
more stressors in the last 12 months; the stressors reported most often were the death of
a family member or close friend (28%), inability to get a job (18%), serious illness (12%) and
mental illness (10%) (ABS 2016).
While the majority of Indigenous Australians report low or very low levels of psychological
distress (67%), one-third (30%) experience high or very high levels of psychological distress
(2014–15). These levels are 2.7 times as high as those for non-Indigenous Australians
(11%, 2012–13 data). Indigenous Australians who had experienced at least one stressor
were 1.9 times as likely to report high/very high levels of psychological distress as
Indigenous Australians who had not experienced a stressor (36% compared with 19%)
(ABS 2016).

Information on the many dimensions of health for Indigenous Australians comes mainly
from survey data, which is collected only every 3 to 6 years (depending on the measure).
Because of small numbers, it is difficult to produce estimates for small geographic areas.
There is also a lack of longitudinal data, which would enhance our ability to examine the
determinants of positive and negative health outcomes for cohorts of people.
314
The AIHW reports Australian Burden of Disease Study: impact and causes of illness and death
in Aboriginal and Torres Strait Islander people 2011, and The health and welfare of Australia’s
Aboriginal and Torres Strait Islander peoples 2015, are available for free download from
the AIHW website. For more detailed data see the supplementary online tables from the
Aboriginal and Torres Strait Islander Health Performance Framework.
References
ABS (Australian Bureau of Statistics) 2016. National Aboriginal and Torres Strait Islander Social Survey,
2014–15. ABS cat. no. 4714.0. Canberra: ABS.
Delpierre C, Lauwers-Cances V, Datta G, Lang T & Berkman L 2009. Using self-rated health for analysing
social inequalities in health: a risk for underestimating the gap between socioeconomic groups? Journal of
Epidemiology and Community Health 63:426–32.
Chapter 6
315
6.3 Indigenous child
SNAPSHOT
mortality and
life expectancy
Child mortality and life expectancy are widely used as overall indicators of population
health. Although Australia’s national child mortality rates are low and life expectancy is
high compared with that of other countries, there are significant disparities in both these
measures between Aboriginal and Torres Strait Islander people and non-Indigenous
Australians. In 2008, the Council of Australian Governments (COAG) committed to
halving the gap in child (ages 0–4) mortality rates within 10 years (2018) and closing
the gap in life expectancy between Indigenous and non-Indigenous Australians within
a generation (by 2031).
Child mortality
The latest available data from the jurisdictions with acceptable levels of Indigenous
identification in their mortality data (New South Wales, Queensland, Western Australia,
South Australia and the Northern Territory) show that, in 2016, 113 Indigenous children
aged 0–4 and 726 non-Indigenous children aged 0–4 died, yielding:
• a
child death rate of 146 per 100,000 for Indigenous children and 70 per 100,000
for non-Indigenous children
• a
gap of 76 deaths per 100,000 children
• a
rate ratio of 2.1 (that is, Indigenous children were 2.1 times as likely to die during
early childhood as non-Indigenous children) (AIHW 2018).
To meet the Closing the Gap target and halve the gap in child mortality rates by 2018,
a reduction of at least 26 deaths (across the jurisdictions with available data combined)
is required between 2016 and 2018. Achieving this goal begins with understanding the
age distribution and causes of death underpinning these patterns.
Age distribution of Indigenous child deaths

The risk of dying during early childhood varies by age, with deaths during the first year
of life making up 82% of all Indigenous child deaths and 84% of all non-Indigenous child
deaths. There is a great deal of variation across the first year, with 40% of Indigenous
infant deaths and 42% of non-Indigenous infant deaths occurring on the first day of life
(Table 6.3.1).
316
Table 6.3.1: Percentage distribution of infant deaths, by age at death and
Indigenous status, NSW, Qld, WA, SA and the NT combined, 2011–2015
Age at death Indigenous Non-Indigenous

<1 day 40.0 42.0
1 day – 1 week 8.8 15.9
1 week – 1 month 13.2 13.0
1–3 months 19.8 14.3
3–6 months 11.6 8.1
6 months – 1 year 6.6 6.6
Number of infant deaths 500 3,393
Note: Deaths registered in 2012 and earlier are based on the final version of cause of death data;
deaths registered in 2013 are based on revised data; deaths registered in 2014 and 2015 are based
on preliminary cause of death data. Revised and preliminary data are subject to further revision by
the Australian Bureau of Statistics.
Source: National Mortality Database.
Infant mortality rates (which measure the risk of dying) for these age groups show
that Indigenous infants are 3 times as likely as non-Indigenous infants to die between
1 and 6 months of age, and twice as likely to die for all other age categories (except for
1 day–1 week, where the risks are equal) (Figure 6.3.1).
Figure 6.3.1: Infant deaths per 1,000 live births, by age at death and
Indigenous status, 2011–15 (NSW, Qld, SA, WA and the NT combined)
Infant mortality rate

3 Indigenous Non-Indigenous
1
Chapter 6
0
<1 day 1 day-<1 week 1 week- <1 month 1-<3 months 3-<6 months 6 months -<1 year
Age at death
Note: Deaths registered in 2012 and earlier are based on the final version of cause of death data; deaths
registered in 2013 are based on revised data; deaths registered in 2014 and 2015 are based on preliminary cause
of death data. Revised and preliminary data are subject to further revision by the Australian Bureau of Statistics.
Source: National Mortality Database.
The age distribution of child deaths is related to the cause-of-death distribution.
317
Causes of death responsible for the child mortality gap
Three causes of death accounted for 85% of the gap in child mortality rates between
Indigenous and non-Indigenous children aged 0–4 in 2011–15: pregnancy/birth-related
conditions (40% of the gap); sudden infant death syndrome (SIDS) and other unknown
causes (26%); and accidents, injuries and other external causes (18%) (Supplementary
Table S6.3.2).
These causes are not randomly distributed throughout infancy and early childhood but
are related to the age of the child (Supplementary Table S6.3.3). Data from 2011–15 show
that during the first month of life, pregnancy/birth-related conditions were responsible
for 78% of Indigenous infant deaths (241 babies). Between 1 and 3 months, SIDS and
other unknown causes were the leading cause of death, responsible for 89 Indigenous
infant deaths (47% of Indigenous deaths in this age group). Accidents, injuries and other
external causes were responsible for the highest proportion of Indigenous child deaths
between ages 1–4 (59 deaths; 54% of all Indigenous child deaths in this age group).
Opportunities for improvement

The factors underlying the higher infant and child mortality rates for Indigenous children
are complex; they include higher rates of preterm birth and low birthweight, higher rates
of maternal smoking during pregnancy, poorer pre-pregnancy maternal health, higher
levels of social disadvantage, poorer access to antenatal and birthing services, and
higher likelihood of living in overcrowded housing (AHMAC 2017; AIHW 2014).
Analyses of the child mortality data show that there are three targeted areas with
potential to improve outcomes for Indigenous infants and young children:
• r educing preterm births
• r educing tobacco smoking
• r educing SIDS and sleep-related deaths (see AIHW 2018 for more detail).
Life expectancy
In 2010–2012, life expectancy at birth for Indigenous Australians was estimated to be
69.1 years for males and 73.7 years for females. By comparison, the life expectancy at
birth for non-Indigenous Australians was 79.7 years for males and 83.1 years for females.
Between 2005–2007 and 2010–2012, the gap in life expectancy between Indigenous and
non-Indigenous Australians decreased from 11.4 to 10.6 years for males, and from 9.6
to 9.5 years for females. Although the life expectancy of Indigenous Australians is slowly
improving, the current rate of progress indicates that the COAG target will not be met by
2031. Meeting the target is made more challenging as non-Indigenous life expectancy is
expected to increase over the coming years (PM&C 2016). Including the projected gains
in non-Indigenous life expectancy, in order to close the gap there would need to be a
15–19 year increase in Indigenous life expectancy in the 25-year period from 2006 to
2031 (Figure 6.3.2).
318
Figure 6.3.2: Trajectories of life expectancy at birth, by sex and Indigenous
status, 2006–2031
Males Females
Life expectancy (years) Life expectancy (years)
90 90
85 85
80 80
75 75
70 70
65 65
0 0
2006 2011 2016 2021 2026 2031 2006 2011 2016 2021 2026 2031
Non-Indigenous males trajectory (NIRA) Non-Indigenous females trajectory (NIRA)

Indigenous trajectory needed to meet target Indigenous trajectory needed to meet target
Indigenous males current trajectory Indigenous females current trajectory
Indigenous males data points Indigenous females data points
NIRA = National Indigenous Reform Agreement.
Sources: NIRA trajectories and AIHW analyses; Table S6.3.4.

Indigenous deaths data are reported for only five jurisdictions (New South Wales,
Queensland, Western Australia, South Australia and the Northern Territory) and may not
reflect the national picture. The other jurisdictions have lower levels of identification and
a small number of Indigenous deaths.
There is also a need for improved capture of factors in the pre-conception, pregnancy,
birth and early childhood periods that may influence childhood mortality outcomes—for
example, diet and nutrition, exposure to stress, psychological distress, domestic violence,
alcohol use during pregnancy, breastfeeding, immunisation, and sleep-related behaviours.

See the AIHW reports Closing the Gap targets: analysis of progress and key drivers of change and
Chapter 6
Timing impact assessment for COAG Closing the Gap targets: child mortality for more information.
References
AIHW (Australian Institute of Health and Welfare) 2014. Timing impact assessment of COAG Closing the Gap
targets: Child mortality. Cat. no. IHW 124. Canberra: AIHW.
AIHW 2018. Closing the Gap targets: 2017 analysis of progress and key drivers of change. Cat. no. IHW 193.
Canberra: AIHW.
PM&C (Department of the Prime Minister and Cabinet) 2016. Closing the Gap Prime Minister’s report.
Canberra: PM&C.
319
6.4 Ear health and hearing
FEATURE ARTICLE
loss among Indigenous

children
Ear disease and associated hearing loss are highly prevalent among Aboriginal and
Torres Strait Islander children. Hearing loss may result from genetic causes, complications
at birth, certain infectious diseases, chronic ear infections, use of certain medicines,
injuries and accidents, exposure to loud noise, and ageing. Worldwide, 60% of childhood
hearing loss is due to preventable causes (WHO 2017).
Otitis media is the key condition contributing to hearing loss among Indigenous children,
and it is treatable and preventable (Burns & Thomson 2013). Otitis media is the
inflammation of the middle ear, typically caused by bacterial and viral pathogens that
also cause common childhood illnesses (Burns & Thomson 2013). Infections can present
themselves in various ways, including as acute infections (which can be recurrent), the
presence of middle ear fluid without the usual signs of infection, or as chronic infections
with persistent discharge (Kong & Coates 2009). Short-lasting mild to moderate hearing
loss is common during uncomplicated otitis media (Williams & Jacob 2009). Hearing loss
is greater and lengthier in chronic and complicated infections (O’Connor et al. 2009) and
can become long term or permanent unless corrected by surgery. Generally, otitis media
incidence is highest in children aged 6–24 months and then again in children aged 4–5
years (Burns & Thomson 2013).
The clinical presentation of otitis media infections differs for Indigenous and
non-Indigenous children. Otitis media is characterised in Indigenous children by a
younger age at first episode, higher frequency of infection, greater severity and greater
persistence than in non-Indigenous children (Jervis-Bardy et al. 2017). Repeated ear
infections, which are often undiagnosed and untreated, are substantially and significantly
associated with hearing problems at a later stage (Yiengprugsawan et al. 2013). Between
the ages of 2 and 20, an Indigenous child or young person is likely to experience hearing
loss from middle ear infections for at least 32 months, compared with 3 months for
non-Indigenous children/young people (Kong & Coates 2009).
Studies have consistently shown that ear disease is more common in Indigenous children
(AIHW 2014) than in non-Indigenous children. In 2011, the rate of burden (measured
using disability-adjusted life years—DALYs) from hearing loss in Indigenous children
aged 0–14 was 12 times as high as for non-Indigenous children (69.4 and 5.6 DALYs
per 1,000, respectively). Similarly, the rate of burden from otitis media in Indigenous
children was 8.6 times as high as for non-Indigenous children (41.9 and 4.9 DALYs per
1,000, respectively). Several studies have found that Indigenous children living in remote
areas experience higher rates of severe and persistent ear infections than their urban
counterparts (AHMAC 2017).
320
Impact of poor hearing health
Poor ear and hearing health is a serious problem, which can profoundly affect a child’s
life. Figure 6.4.1 shows that the key developmental period for language, vision, hearing
and higher cognitive functioning occurs during the first few years of life and extends into
adolescence. Higher rates of hearing loss associated with otitis media for Indigenous
children aged 6–24 months and 4–5 years overlaps with this important developmental
period (Burns & Thomson 2013).
Poor hearing can impede cognitive development, auditory processing skills, and speech
and language development, resulting in poor attention and listening (Burns & Thomson
2013; Burrow et al. 2009; Williams & Jacob 2009). Hearing loss can also have an impact
on social and emotional wellbeing. It can lead to behavioural problems, such as irritability
and disobedience, which in turn, can lead to social isolation, problems with school
attendance and early school-leaving (Burrow et al. 2009).
These compounding problems can lead to life-long negative social consequences for
the child, as well as for their family and community—for example, limited employment
options and income, increased antisocial behaviours, and increased contact with the
criminal justice system (Burns & Thomson 2013; Burrow et al. 2009). Therefore, for many
Indigenous children, hearing loss and its associated consequences further compound
many of the disadvantages already facing Indigenous Australians.
Figure 6.4.1: Human brain development throughout the lifespan
Time courses for synaptogenesis
Higher cognitive functions (prefrontal cortex)

Receptive language area/speech production
(angular gyrus Broca’s area)
Seeing/hearing (visual cortex/auditory cortex)
Experience-dependent synapse formation

Neurogenesis in the hippocampus
Adult levels of synapses
-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 1011 12 1 2 3 4 5 6 7 8 9 1011 12 13 14 15 16 17 18 19 2030 40 5060 70

Chapter 6
Months Months Years Decades

Age
Source: Shonkoff & Phillips 2000.
321
How common is poor ear health and
hearing loss?
This section refers to a number of national surveys (self-reported data) described
previously (AIHW 2014). Self-reported surveys are likely to underestimate hearing loss
as respondents can be unaware of the extent of their own or their child’s hearing loss,
particularly in mild cases (AIHW 2016).
Based on self-reported data from the Australian Bureau of Statistics 2014–15 National
Aboriginal and Torres Strait Islander Social Survey, the rate of long-term ear/hearing
problems in Indigenous children aged 0–14 was estimated to be almost 3 times the rate
for non-Indigenous children (8.4% compared with 2.9%) (ABS 2016; see also Figure 6.4.2).
Among Indigenous children with ear/hearing problems, one-third had otitis media (ABS
2016). Self-reported ear/hearing problems were less common among Indigenous children
aged 0–3 (3.2%) than among children aged 4–14 (10.5%), and 9.5% of Indigenous boys and
7.4% of girls reported ear/hearing problems (ABS 2016).
Prevalence of self-reported ear/hearing problems in Indigenous children
Indigenous children
3.2% aged 0–3
10.5% Indigenous children

aged 4–14
8.4 %
in Indigenous Indigenous girls
7.4% aged 0–14
children aged 0–14
9.5% Indigenous boys

aged 0–14
Source: ABS 2016.
Self-reported Australian Bureau of Statistics survey data collected in 2014–15 show that
fewer Indigenous and non-Indigenous children experienced long-term ear/hearing
problems than in 2001.
The gap in self-reported prevalence of long-term ear/hearing problems between
Indigenous and non-Indigenous children has narrowed (Figure 6.4.2). Self-reported
ear/hearing problems for Indigenous children living Remote/Very remote areas was 18%
in 2001, and 11% in 2014–15. Among Indigenous children in non-remote areas, the
percentage was 11% in 2001 and 8.4% in 2014–15 (ABS 2016).
322
Figure 6.4.2: Children aged 0–14 with a self-reported long-term hearing
problem, by Indigenous status, 2001 to 2014–15
Per cent
Indigenous Non-Indigenous
12 Linear (Indigenous) Linear (non-Indigenous)
10
0
2001 2004-05 2008 2011-13 2014-15
Year
The extent of poor ear health among Indigenous children and young people in the
Northern Territory corroborated problems identified during the Child Health Check
Initiative (CHCI) introduced under the Northern Territory Emergency Response (NTER).
Data for the CHCI showed that between July 2007 and June 2009, of the 9,400 Indigenous
children who received health checks in NTER Prescribed Areas, 30% had ear disease. In
response, the Australian Government funded outreach ear and hearing services through
various funding arrangements, via the National Partnership on Northern Territory Remote
Aboriginal Investment (Box 6.4.1).
Box 6.4.1: Northern Territory Remote Aboriginal Investment (NTRAI) Hearing

Health Program (HHP) for remote children
In 2016, of the 2,300 children and young people (aged 0–19) reached by the
NTRAI HHP, nearly half (47%, 1,068) had some form of otitis media; of these
children and young people, nearly three-quarters (71%, 759) had observed hearing
loss. Two-thirds (65%) of all children aged 0–2 in the program had otitis media, with
Chapter 6
53% of them having hearing loss. Fifty-nine per cent (59%) of children aged 3–5 had
otitis media, with 78% of the group experiencing hearing loss (AIHW 2017b).
Data collections for the NTRAI HHP have some limitations: children and young
people who receive services are not a random sample of Indigenous children in
the Northern Territory, because these services target children with high need
(AIHW 2017b).
323
Factors associated with poor hearing health
Social and economic factors
Several social and economic factors are associated with the presence of middle ear
disease among Indigenous children. A study using the Australian Early Development
Census (AEDC)—which examined the relationship between socioeconomic position and
hearing loss in both Indigenous and non-Indigenous children—found that socioeconomic
position was strongly associated with hearing loss in Indigenous children, but not in
non-Indigenous children. A potential contributing factor is the higher likelihood

of Indigenous children living in remote locations, which is associated with a lower
socioeconomic position, and as such, decreased access to health services
(Simpson et al. 2017).
Other studies have found that ear disease and hearing loss are typically found in
children experiencing socioeconomic disadvantage (AHMAC 2017; Burns & Thomson
2013). Factors associated with socioeconomic disadvantage that increase the risk of
otitis media for Indigenous children include premature birth, not being breastfed and
nutritional deficiencies (Burns & Thomson 2013; Burrow et al. 2009; Kong & Coates 2009).
Environmental factors
Environmental factors are another key determinant of ear/hearing problems. Children
are more likely to have ear/hearing problems if they have been exposed to household
overcrowding, poor hygiene, and inadequate access to running water or functioning
sewerage and waste removal systems (AHMAC 2017; Burns & Thomson 2013). These
factors are strongly associated with remoteness (Simpson et al. 2017).
Second-hand tobacco smoke and exposure to wood smoke also contribute to increased
risk of otitis media (Burns & Thomson 2013; Burrow et al. 2009). In 2014–15, 57% of
Indigenous children aged 0–14 lived in households where there was at least one daily
smoker. This figure decreased from 68% in 2004–05, but is still 2.7 times the rate for
non-Indigenous children (21%) (ABS 2016). In 2014–15, 13% of Indigenous children lived
in households in which someone smoked inside. Survey data from 2014–15 reported
that 17% of Indigenous children in remote areas lived in households in which someone
smoked inside, compared with 13% in non-remote areas (ABS 2016).
The 2014–15 Aboriginal and Torres Strait Islander Social Survey data were used to examine
self-reported hearing loss by different social, economic and environment factors. The data
show that the percentage of hearing problems among Indigenous children who lived in:
• t he most socioeconomically disadvantaged households was 9.1%, compared with 6.3%
among Indigenous children living in the least socioeconomically disadvantaged households
• o
vercrowded households was 10%, compared with 7.7% among Indigenous children
living in non-crowded households
• h
ouseholds with a regular indoor smoker was 9.8%, compared with 8.2% among
Indigenous children living in households that did not have a regular indoor smoker
(ABS 2016).
324
Barriers to health care
Limited access to health care can result in delayed diagnosis, treatment and management
of middle ear disease among Indigenous children, and therefore prolong periods
of hearing loss and impairment (AIHW 2017b). Indigenous children wait longer than
the recommended time to see an audiologist and/or ear, nose and throat (ENT)
surgeon. Research has shown that 1 in 5 (18%) Indigenous children in rural and remote
areas waited longer than the recommended period of 3 months for audiology testing
(Gunasekera et al. 2009; Simpson et al. 2017).
In 2014–15, of those children with an ear/hearing problem, 83% had received treatment
such as medication, surgery, or consultation with a specialist (ABS 2016). More than
1 in 4 (26%) Indigenous children who had an ear or hearing problem but did not receive
treatment lived in Remote areas compared with 14% of children in non-remote areas
(ABS 2016).
Limited access to primary health care has been associated with factors that include poor
health awareness in carers (who do not know when children should receive health care),
inadequate health care infrastructure in remote areas, or a lack of culturally appropriate
services. Specialist care is limited in remote areas (Burns & Thompson 2013).
Department of Health guidelines recommend training of health care practitioners,
together with efforts to increase awareness of clinical guidelines to ensure Indigenous
children who attend primary health care are appropriately screened or treated for otitis
media and hearing loss. Indigenous child health checks provide opportunity for detection,
antibiotic treatment, follow-up assessment and referral to speech and audiology services.
It is also important that primary health care providers are able to diagnose and treat
chronic otitis media, as well as to work with audiologists and specialist ENT surgeons to
manage hearing loss and to support the child and their family or carer through intensive
follow-up and management (Darwin Otitis Guidelines Group et al. 2010).
Health services
Primary health care
The Bettering the Evaluation and Care of Health data collection (commonly called the
BEACH data collection) is a national study of general practice activity that reports on
problems managed, investigations ordered and treatments provided by those general
practitioners surveyed. Between 2010 and 2015, 8.4% of all problems managed by general
Chapter 6
practitioners for children aged 0–14 were ear problems. Among this cohort, Indigenous
children were 30% more likely to present for ear problems than non-Indigenous children
(11% and 8.9%, respectively). For children aged 5–14, Indigenous children were less likely
to present for ear problems than non-Indigenous children (5.5% compared with 7.4%)
(AIHW 2017a).
325
Hospitalisations
Between July 2014 and June 2016, there were nearly 3,700 hospitalisations for
Indigenous children (aged 0–14) for diseases of the middle ear and mastoid process. The
hospitalisation rate for Indigenous children was slightly higher than for non-Indigenous
children (7.4 compared with 6.4 per 1,000, respectively). The hospitalisation rate for
middle ear and mastoid process problems in non-Indigenous children has remained
relatively stable since 2004–05. For Indigenous children, the rate increased after 2007–08,
which coincides with the NTER, and may reflect improved diagnosis and use of ear health
services (Figure 6.4.3).

Hospitalisations for diseases of the middle ear and mastoid process reflect use of health
services, rather than the prevalence of these conditions in the community.
Figure 6.4.3: Rate of hospitalisations of children aged 0–14 for diseases of the
middle ear and mastoid process, by Indigenous status, 2004–05 to 2015–16

9
0
2004–05 2005–06 2006–07 2007–08 2008–09 2009 –10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
Year
Myringotomy (incision in the eardrum to relieve pressure caused by excessive fluid build-
up) and/or tympanoplasty (a reconstructive surgical treatment for a perforated eardrum)
are common procedures associated with diseases of the middle ear and mastoid process.
Of the 3,700 hospitalisations for Indigenous children with diseases of the middle ear and
mastoid process, three-quarters (76%) had myringotomy and/or tympanoplasty. Between
July 2014 and June 2016, the overall rate of myringotomy and tympanoplasty procedures for
children aged 0–14 was similar for Indigenous children (5.6 per 1,000) and non-Indigenous
children (5.7 per 1,000) (Figure 6.4.4). However, non-Indigenous children had their
procedures at relatively younger ages than Indigenous children.
326
Figure 6.4.4: Rate of middle ear related procedures for diseases of the middle
ear or mastoid process in children aged 0–14, by age group and Indigenous
status, 2014–16

10
0
0-4 5-9 10-14 Total 0-14
Age group
Non-Indigenous children in Major cities and regional areas were more likely to have
procedures in hospital for the middle ear compared with Indigenous children living in the
same remoteness areas. However, in Remote and Very remote areas, Indigenous children
were almost twice as likely as non-Indigenous children to have hospital procedures for
the middle ear (8.8 compared with 4.7 per 1,000 population), and 2.1 times as likely to be
hospitalised for problems with the middle ear or mastoid process (13.3 compared with
6.2 per 1,000) (Figure 6.4.5). Between July 2014 and June 2016, Indigenous children were
hospitalised for tympanoplasty procedures at 4 times the rate of non-Indigenous children.
Figure 6.4.5: Rate of middle ear related procedures and of hospitalisations

for diseases of the middle ear or mastoid process for children aged 0–14, by
Indigenous status and remoteness category, 2014–16
14 Major city Inner and outer regional Remote and very remote
12
10
8
Chapter 6
0
Indigenous Non-Indigenous Indigenous Non-Indigenous
Procedures Hospitalisations
327
One in 10 (9.9%) children fitted with a hearing aid or cochlear implant in 2010 were
Indigenous. This proportion is more than 2.5 times as high as that for non-Indigenous
children requiring the same treatment (AIHW 2017a).
Interventions and preventive actions

The proportion of Indigenous children with poor ear health and hearing loss has fallen
in the last 15 years. Over that time, a range of government prevention programs aimed
at decreasing the prevalence of ear disease and hearing loss have been implemented.
Effective interventions and programs include:
• a
ntibiotic treatments
• immunisation programs against Haemophilus influenza type b (Hib) and Streptococcus
pneumoniae, which help to reduce the number of otitis media episodes
• n
eonatal screening for early identification of congenital malformations and early
intervention, enabling timely treatment and management
• r outine child health checks that incorporate ear and hearing assessments, allowing for
early identification, management and treatment and, if necessary, the fitting of hearing aids
• c ase management models of service delivery where a coordinator administers clinical
care, and links children with specialist and community health services
• g
reater access to surgical ENT care, which involves greater coordination nationally
of available resources
• Indigenous-specific clinical guidelines, which provide the basis for better management
of ear disease and resultant hearing loss
• t argeted screening and treatment services for ear health and hearing loss through
programs such as the national Healthy Ears, Better Hearing, Better Listening Program
and the hearing health element of the National Partnership on NTRAI (see Box 6.4.2)
(AIHW 2014).
As well as medical interventions, attention should be given to dealing with social and
economic challenges, including education strategies to combat hearing loss related to otitis
media (Burrow et al. 2009). These efforts must involve the child’s family, maternal and child
health care providers, and be embedded in coordinated primary care systems (AIHW 2014).
Box 6.4.2: NTRAI HHP: impact of intervention

The NTRAI HHP (see also Box 6.4.1) provides outreach ear and hearing services to
high-risk Indigenous children and young people in remote parts of the Northern
Territory. These services have four components—health promotion and prevention,
audiology services, Clinical Nurse Specialists, and ENT teleotology services (where a
clinical examination, including digital imaging of the ear, is performed and reviewed
later or remotely by a specialist).
As a result of this program, hearing health and prevalence ear conditions in this
population group have improved. In December 2016, compared with July 2012,
the proportion of children with at least one ear disease decreased by 15%, and the
proportion of children with hearing loss decreased by 10%. Of the children who
moved through the HHP over time, 51% had improved hearing loss and 62% had
improved hearing impairment.
328
There is no national statistical profile of ear disease and associated hearing loss among
Indigenous children using diagnostic assessment. National data are lacking on the extent
of management and treatment of otitis media and other ear problems in primary health
care. Without good-quality surveillance, it is difficult to understand the size and key
determinants associated with the hearing problem.
The 2018–19 National Aboriginal and Torres Strait Islander Survey (NATSIHS) will include a
hearing test, which will supplement data already collected in the NATSIHS on self-reported
hearing loss. This aims to provide a national picture on hearing loss in Indigenous
Australians but will not provide information about its causes. This survey does not sample
non-Indigenous Australians.
Further work could be done to investigate the link between hearing health data (collected
since 2007 as part of the CHCI in the Northern Territory) and vulnerability (using the
AEDC) and educational outcomes using the National Assessment Program—Literacy and
Numeracy data.

More information about hearing health in Indigenous children can be found in:
• A
ustralian Health Ministers’ Advisory Council’s Aboriginal and Torres Strait Islander
Health Performance Framework 2017 report <www.pmc.gov.au/sites/default/files/
publications/indigenous/hpf-2017>.
• A
IHW’s Northern Territory Remote Aboriginal Investment: Ear and Hearing Health Program—
July 2012 to June 2016 <www.aihw.gov.au/reports/indigenous-health-welfare-services/
nt-ear-hearing-program-to-2016/related-material>.
• A
IHW’s Aboriginal and Torres Strait Islander Health Performance Framework 2017:
supplementary online tables <www.aihw.gov.au/reports/indigenous-health-welfare/
health-performance-framework-report/data>.
• A
ustralian Medical Association’s 2017 Report card on Indigenous health—a national
strategic approach to ending chronic otitis media and its lifelong impacts in Indigenous
communities <www.ama.com.au/system/tdf/documents/2017%20Report%20Card%20
on%20Indigenous%20Health.pdf?file=1&type=node&id=47575>.
References
Chapter 6
AIHW (Australian Institute of Health and Welfare) 2014. Ear disease in Aboriginal and Torres Strait Islander
children. Resource sheet no. 35 produced by the Closing the Gap Clearinghouse. Canberra: AIHW.
AIHW 2016. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal
and Torres Strait Islander people 2011. Australian Burden of Disease Study series no. 6. Cat. no. BOD 7.
Canberra: AIHW.
AIHW 2017a. Aboriginal and Torres Strait Islander Health Performance Framework 2017: supplementary
online tables. Cat. no. WEB 170. Canberra: AIHW.
329
AIHW 2017b. Northern Territory Remote Aboriginal Investment: Ear and Hearing Health Program—July
2012 to June 2016. Cat. no. IHW 176. Canberra: AIHW.
Burns J & Thomson N 2013. Review of ear health and hearing among Indigenous Australians.
Perth: Edith Cowan University. Australian Indigenous HealthInfoNet. Viewed on 5 December 2017,
<http://www.healthinfonet.ecu.edu.au/other-health-conditions/ear/reviews/our-review>.
Burrow S, Galloway A & Weissofner N 2009. Review of educational and other approaches to hearing loss
among Indigenous people. Perth: Edith Cowan University. Australian Indigenous HealthInfoNet. Viewed on
5 December 2017, <http://www.healthinfonet.ecu.edu.au/other-health-conditions/ear/reviews/our-review-
education>.
Darwin Otitis Guidelines Group & Office for Aboriginal and Torres Strait Islander Health Otitis Media
Technical Advisory Group 2010. Recommendations for clinical care guidelines on the management
of otitis media in Aboriginal and Torres Strait Islander populations. Canberra: Department of
Health. Viewed on 30 January 2018, <www.health.gov.au/internet/main/publishing.nsf/Content/
B8A6602C7714B46FCA257EC300837185/$File/Recommendation-for-clinical-guidelines-Otitis-Media.pdf>.
Gunasekera H, Morris PS, McIntyre P & Craig JC 2009. Management of children with otitis media: a
summary of evidence from recent systematic reviews. Journal of Paediatrics and Child Health 45(10):554–63.
Jervis-Bardy J, Carney AS, Duguid R & Leach AJ 2017. Microbiology of otitis media in Indigenous Australian
children. The Journal of Laryngology & Otology 131(S2):S2–11.
Kong K & Coates HLC 2009. Natural history, definitions, risk factors and burden of otitis media. The Medical
Journal of Australia 191(9 Suppl):S39.
O’Connor TE, Perry CF & Lannigan FJ 2009. Complications of otitis media in Indigenous and non-Indigenous
children. The Medical Journal of Australia 191(9 Suppl):S60.
Shonkoff JP & Phillips D 2000. From neurons to neighborhoods: the science of early childhood
development. Committee on Integrating the Science of Early Childhood Development. Washington DC:
National Academy Press.
Simpson A, Enticott JC & Douglas J 2017. Socioeconomic status as a factor in Indigenous and
non-Indigenous children with hearing loss: analysis of national survey data. Australian Journal of Primary
Health 23(2):202–7.
WHO (World Health Organization) 2017. Deafness and hearing loss fact sheet. Geneva: WHO. Viewed on
5 December 2017, <http://www.who.int/mediacentre/factsheets/fs300/en/>.
Williams CJ & Jacobs AM 2009. The impact of otitis media on cognitive and educational outcomes.
The Medical Journal of Australia 191(9 Suppl):S39.
Yiengprugsawan V, Hogan A & Strazdins L 2013. Longitudinal analysis of ear infection and hearing
impairment: findings from 6-year prospective cohorts of Australian children. BioMed Central (BMC)
Pediatrics 13(1):28.
330
6.5 Health behaviours of
SNAPSHOT
This snapshot provides a high-level overview of the prevalence of health risks among
Aboriginal and Torres Strait Islander Australians. These risks include smoking and
alcohol consumption, dietary behaviours, physical inactivity and overweight and obesity.
See Chapter 4 for more information on how these risks affect health outcomes and
Chapter 6.6 ‘Social determinants and Indigenous health’ for more information on the
determinants of these risks.
Prevalence
Figure 6.5.1 presents rates of health-related behavioural risks for Indigenous and
non-Indigenous Australians. Although Indigenous Australians have higher rates of
risky health behaviours, these differences are small, except for tobacco smoking.
In 2014–15, the rate for Indigenous Australians for tobacco smoking was 2.8 times
that for non-Indigenous Australians.
Figure 6.5.1: Age-standardised prevalence of selected health behaviours and

risk factors, by Indigenous status
Health behaviour
Inadequate daily vegetable intake
Overweight or obese
Not sufficiently active for health (non-remote areas)
Inadequate daily fruit intake Indigenous
Non-Indigenous
Risky alcohol consumption (single-occasion risk)
Current daily smoker
0 20 40 60 80 100
Per cent
Chapter 6
Note: Vegetable intake, fruit intake and smoking are for 2014–15; weight, physical activity, alcohol
consumption are for 2012–13.
Sources: ABS 2014a, 2014b, 2016. Table S6.5.1.
Tobacco smoking
Tobacco smoking is the single most important preventable cause of ill health and death in
Australia, for both Indigenous and non-Indigenous Australians. In 2014–15, around 42%
of Indigenous people aged 15 and over were current smokers (186,000 current smokers).
331
The smoking rate for Indigenous people aged 15 and over was 2.7 times as high as for
non-Indigenous adults (42% compared with 15%, age-standardised rate) (ABS 2017).
Although the gap in smoking rates remains, Indigenous people have made several
improvements over time:
• S
moking rates among Indigenous Australians declined from 51% in 2002 to 42% in
2014–15. This decline was concentrated in non-remote areas, however, with little
change to smoking rates in remote areas.
• T
he likelihood of quitting smoking has increased: in 2002, 24% of Indigenous adults who
had ever smoked had successfully quit smoking. By 2014–15, this had increased to 36%.
• F
ewer Indigenous young people aged 15–17 are smoking now than in the past—a
drop from 30% in 1994 to 17% in 2014–15. As current smokers generally start smoking
around this age, preventing uptake in this group will likely result in lower future rates
of current smokers (ABS 2017).
Alcohol consumption
A comparison of data collected in 2008 and 2014–15 indicates that there have been
significant positive changes in alcohol-related behaviours among Indigenous Australians:
• In 2014–15, 40% of Indigenous people aged 15 and over reported that they either drank
no alcohol during the previous 12 months or only on one occasion. This is an increase
from 36% in 2008.
• In 2014–15, 31% of Indigenous people aged 15 and over reported that they drank
alcohol at what is considered a risky level on at least a single occasion (known as
short-term risk), compared with 38% in 2008.
• In 2014–15, 15% of Indigenous people aged 15 and over reported that they drank
alcohol at lifetime risky levels, a decrease from 19% in 2008 (ABS 2016).
Diet
According to self-reported data, in 2014–15, only 4.7% of Indigenous children aged 4–14
and 4.0% of Indigenous people aged 15 and over had an adequate daily intake of both
fruit and vegetables. Among Indigenous children, 65% had an adequate daily intake of
fruit and 5.5% had an adequate daily intake of vegetables. Among Indigenous adults, 46%
had an adequate daily intake of fruit and 5.8% had an adequate daily intake of vegetables
(ABS 2016).
Insufficient physical activity

For an adult in a non-remote area, being sufficiently active for health is defined as having
150 minutes of physical activity over five or more sessions per week. The most recent
age-standardised data on physical activity levels among Indigenous adults show that,
in 2012–13, about 2 in 3 (64%) Indigenous adults aged 18 and over in non-remote areas
were not sufficiently active for health; this figure is higher than the comparable rate for
non-Indigenous Australians (56%) (ABS 2014a).
In 2014–15, around three-quarters (76%) of Indigenous children aged 4–14 were physically
active for at least 60 minutes every day during the previous week (ABS 2016).
332
Overweight and obesity
There are differences in weight status between Indigenous and non-Indigenous
Australians, and these begin in childhood. Based on measured body mass index (BMI),
in 2012–13, Indigenous girls aged 2–14 were 2.0 times as likely to be underweight (7.9%
versus 3.9%) and 1.6 times as likely to be obese (9.8% versus 6.1%) as non-Indigenous
girls of the same age. The patterns were similar for boys, but the difference between
Indigenous and non-Indigenous boys was smaller than for girls.
The prevalence of overweight and obesity is higher for adults than for children for both
Indigenous and non-Indigenous Australians. Indigenous females are 1.7 times as likely
to be obese as non-Indigenous females, while Indigenous males are 1.4 times as likely
to be obese as non-Indigenous males (figures 6.5.2, 6.5.3). See Chapter 4.10 ‘Overweight
and obesity’ for more information on the growing obesity trend in Australia and an
explanation of BMI measures.
Figure 6.5.2: Proportion of females aged 15 and over in each weight (BMI)
category, by Indigenous status, 2012–13
Per cent
50
40
30
20
10
0
Underweight Normal weight Overweight Obese
BMI category
Source: ABS 2014b, Table S6.5.2.
Figure 6.5.3: Proportion of males aged 15 and over in each weight (BMI)
category, by Indigenous status, 2012–13
Per cent
40
Chapter 6
30
20
10
0
Underweight Normal weight Overweight Obese
BMI category
Source: ABS 2014b, Table S6.5.3.
333
National data on behavioural risk factors relies mainly on survey data. Changes in the
type of data collected, and its frequency, make it difficult to examine trends over time
or between smaller geographic areas.

For more details on health behaviours and biomedical risks for Indigenous Australians,
see the Australian Aboriginal and Torres Strait Islander Health Survey 2012–13 and the
supplementary online tables from the Aboriginal and Torres Strait Islander Health
Performance Framework.
References
ABS (Australian Bureau of Statistics) 2014a. Australian Aboriginal and Torres Strait Islander Health Survey:
physical activity, 2012–13—Australia. ABS cat. no. 4727.0.55.004. Canberra: ABS.
ABS 2014b. Australian Aboriginal and Torres Strait Islander Health Survey: updated results, 2012–13.
ABS cat. no. 4727.055.006. Canberra: ABS.
ABS 2016. National Aboriginal and Torres Strait Islander Social Survey, 2014–15. ABS cat. no. 4714.0.
Canberra: ABS.
ABS 2017. Aboriginal and Torres Strait Islander peoples: smoking trends, Australia, 1994 to 2014–15.
334
6.6 Social determinants and
SNAPSHOT
Indigenous health
Good health is related to a complex set of underlying factors that include health
behaviours, access to and use of health services, environmental factors and health
endowment. These are not randomly distributed throughout society but are related
to what are called the social determinants of health (see Chapter 1.1 ‘What is health?’;
Chapter 4.2 ‘Social determinants of health’).
Broadly, social determinants are the circumstances in which people grow, live, work
and age. They can be measured by indicators that reflect an individual’s own personal
situation—such as their income, education, employment, and levels of social support and
social inclusion. For Aboriginal and Torres Strait Islander Australians, social determinants
also include factors such as cultural identity, family, participation in cultural activities
and access to traditional lands (see Chapter 6.1 ‘Profile of Indigenous Australians’).
Social determinants can also reflect the broader social and political context in which
people live. This can be captured to some degree by area-level indicators of socioeconomic
position, accessibility of health services, and characteristics of the built environment that
promote health (including green space, playgrounds and good housing stock).
This snapshot presents examples of the relationship between selected social
determinants and three aspects of Indigenous health: child health, self-assessed
health status, and health behaviours. The focus is predominantly on how these social
determinants help to explain variation in behaviours and outcomes among the
Indigenous population.
Social determinants and child health

The association between social determinants and child health is well established,
and is evident before and during pregnancy. For example, women with higher levels
of socioeconomic resources and social capital have been shown to have better
pre-pregnancy health, greater access to and use of health services, better access to
nutritious foods during pregnancy, more social support and better housing, and to face
less income-related stress. These factors affect infant health and development, which,
in turn, have lifelong effects (AIHW 2014; Behrman & Butler 2007; Burris et al 2011).
For example, babies who weigh less than 2,500 g at birth (low birthweight) are at higher
Chapter 6
risk of dying during infancy, and of having poorer long-term health and development
(Arnold et al. 2016; Zhang et al. 2014). The most recent data (2015) show that 12% of
babies born to Indigenous mothers were of low birthweight, a rate that is 1.9 times
that of babies born to non-Indigenous mothers.
335
Data from the National Perinatal Minimum Data set show that nearly half (49%) of
Indigenous mothers who gave birth in 2014 lived in the lowest socioeconomic areas,
while only 4.0% lived in the highest socioeconomic areas. A multivariate analysis of
perinatal data for 2012–2014 indicates that (excluding preterm and multiple births)
51% of low birthweight births to Indigenous mothers were attributable to smoking,
compared with 16% for non-Indigenous mothers. Another 21% were attributable to the
socioeconomic context of the areas in which Indigenous mothers live (as measured
by the Socio-Economic Indexes for Areas). After adjusting for age differences and other
factors, it was estimated that if Indigenous mothers had the same distribution across
socioeconomic areas as non-Indigenous mothers, the rate of low birthweight would be

reduced by 10%.
Social determinants and self-assessed health

Indigenous Australians most likely to report very good or excellent health in 2014–15 lived
in the highest socioeconomic areas, were employed, had higher educational attainment
(Year 12 or higher), and felt safe or very safe alone in their homes after dark (Figure 6.6.1).
Figure 6.6.1: Proportion of Indigenous Australians aged 15 and over reporting

very good or excellent health, by selected social determinants, 2014–15
Per cent
60
40
20
0
Highest Lowest Employed Unemployed Year 12 Year 10 Feels safe/very Feels unsafe/very
socioeconomic socioeconomic attainment attainment safe at home unsafe at home
areas areas or higher or below
Social determinants
Social determinants and health behaviours

The social gradient in health is clear in a number of health behaviours: Indigenous
Australians with more social, economic and cultural advantages are more likely to
engage in behaviours that promote good health. For example, Indigenous Australians
who were employed in 2014–15 were less likely to smoke, less likely to use illicit
substances, and more likely to have an adequate daily fruit intake than Indigenous
people who were unemployed (Figure 6.6.2).
336
Figure 6.6.2: Selected health behaviours by employment status, Indigenous
Australians, 2014–15
Per cent
Employed Unemployed
80
60
40
20
0
Does not smoke No substance misuse Adequate daily fruit intake
Health behaviour
Smoking is the single most important preventable cause of ill health and death in Australia
(see Chapter 6.5 ‘Health behaviours of Indigenous Australians’). Several indicators within
the broad category of social determinants are associated with smoking rates among
Indigenous Australians:
• Indigenous Australians in the highest two income quintiles were less likely to smoke
than Indigenous people in the lowest income quintile (30% versus 56% in 2014–15).
• Indigenous adults with higher levels of educational attainment were less likely to smoke
in 2014–15—28% of Indigenous people who completed year 12 smoked, compared with
51% of Indigenous people who reached Year 11 or below.
• Indigenous Australians living in the highest socioeconomic areas were less likely to
smoke than Indigenous people in the lowest socioeconomic areas (18% versus 50% in
2014–15).
• Indigenous Australians who participated in organised sports were less likely to
smoke than Indigenous people who did not: 32% versus 47% in 2014–15 (ABS 2016).

While there is a great deal of evidence on the socioeconomic aspects of social
determinants, there is less work on the other aspects of social determinants (such as
Chapter 6
social capital). As well, our ability to examine the effects of social determinants on infant
health outcomes is hampered by the lack of data on key maternal factors. These factors
include educational attainment, which has been shown to be a key determinant of
pregnancy-related health, behaviours and infant health outcomes in other countries.

More information on the social determinants of Indigenous health in Australia can be
found in the Closing the Gap targets: analysis of progress and key drivers of change report,
available at <www.aihw.gov.au>.
337
References
AIHW (Australian Institute of Health and Welfare) 2014. Timing impact assessment for COAG Closing the
Gap targets: child mortality. Cat. no. IHW 124. Canberra: AIHW.
Arnold L, Hoy W & Wang Z 2016. Low birthweight increases risk for cardiovascular disease hospitalisations
in a remote Indigenous Australian community—a prospective cohort study. Australian & New Zealand
Journal of Public Health 40(S1):S102–6.
Behrman RE & Butler AS (eds) 2007. Pre-term birth: causes, consequences, and prevention. Institute of
Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes. Washington
DC: National Academies Press.

Burris HH, Collins Jr JW & Wright RO 2011. Racial/ethnic disparities in pre-term birth: clues from
environmental exposures. Current Opinion in Pediatrics 23(2):227–32.
Zhang Z, Kris-Etherton PM & Hartman TJ 2014. Birth weight and risk factors for cardiovascular disease and
type 2 diabetes in US children and adolescents: 10 year results from NHANES. Maternal & Child Health
Journal 18(6):1423–32.
338
6.7 Size and sources of the
FEATURE ARTICLE
Indigenous health gap
Employment and hours worked, household income, educational attainment and whether
a person smokes explain most of the differences in health outcomes between Aboriginal
and Torres Strait Islander peoples and non-Indigenous Australians.
Indigenous Australians, on average, have worse health than non-Indigenous Australians.
Some measures have improved—for instance, there has been a significant decrease in
mortality rates since the late 1990s, and a reduction in smoking since the early 2000s
(AHMAC 2017; PM&C 2018). But on many measures, large disparities remain in health
outcomes between Indigenous and non-Indigenous Australians. This is referred to as
the ‘health gap’.
The extent of the health gap has been increasingly well documented. Understanding
continues to grow about the many and complex factors that can influence and contribute
to it (AHMAC 2017; AIHW 2014b:329–39; see also chapters 6.5 ‘Health behaviours of
Indigenous Australians’, 6.6 ‘Social determinants and Indigenous health’).
A person’s health is influenced by their home, school, workplace, community and
experiences of social institutions and systems (CSDH 2008). Much of the understanding
of the health gap is based on observed differences between Indigenous Australians and
non-Indigenous Australians of factors widely recognised as key determinants of good
health (Biddle 2012; Mackenbach 2015; Marmot 2011; Shepherd et al. 2012). These
differences include those in:
• s ocial determinants of health: Indigenous Australians, on average, have lower levels
of education, employment, income, and poorer quality housing than non-Indigenous
Australians (AHMAC 2017; AIHW 2017)
• h
ealth risk factors: Indigenous Australians, on average, have higher rates of smoking
and risky alcohol consumption, do less exercise, and have a greater risk of high blood
pressure than non-Indigenous Australians (AHMAC 2017; AIHW 2017)
• a
ccess to appropriate health services: Indigenous Australians are more likely than
non-Indigenous Australians to report difficulty in accessing affordable health services
that are close by (AIHW 2015).
This article quantifies the main factors that contribute to the Indigenous health gap and
offers a renewed opportunity to focus on policies and programs to reduce it. Solutions
Chapter 6
need to be directed to dealing with the underlying causes of poor health among
Indigenous Australians throughout their lives.
The Council of Australian Governments has a number of Closing the Gap targets that aim
to reduce differences in key areas between Indigenous and non-Indigenous Australians.
Two of these focus on important measures of health status—life expectancy and child
mortality. Currently, Indigenous Australians can be expected to live about 10 years less
than non-Indigenous Australians, and Indigenous babies and children are twice as likely to
die as their non-Indigenous counterparts (see Chapter 6.3 ‘Indigenous child mortality and
life expectancy’).
339
The health gap: fewer Indigenous Australians are
in ‘good health’
This article examines the difference in the percentage of Indigenous and
non-Indigenous adults assessed to be in ‘good health’, based on a composite measure
of ‘good health’ described below and in Box 6.7.1. This gap is different from other health
gaps that may be mentioned—for example, when discussing differences in life expectancy
or mortality (see Chapter 6.3 ‘Indigenous child mortality and life expectancy’) or burden
of disease studies (AIHW 2016a).
In 2011–13, just under 3 in 10 (28%) Indigenous adults aged 15–64 were assessed to be
in good health, compared with more than 5 in 10 (54%) non-Indigenous adults in this age
group—a gap of 26 percentage points (Figure 6.7.1). After accounting for the small effects
of differences in age, gender and location, this produces an adjusted health gap of nearly
27 percentage points.
This article explores how this gap arises and estimates the extent to which different social
determinants and health risk factors contribute to this 27-percentage point gap (as adjusted).
Figure 6.7.1: Proportion of people aged 15–64 assessed to be in good health,

by Indigenous status, 2011–13
Per cent
60
50
40
30
20
10
0
Sources: AIHW analyses of ABS 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey,
ABS 2011–12 Australian Health Survey; Table S6.7.1.
340
How is ‘good health’ measured?
The measure of ‘good health’ used in this analysis has three components:
1. s elf-assessed health status
2. s elf-reported selected long-term health conditions (morbidity score)
3. e
motional wellbeing, reflecting a person’s self-reported level of distress (emotional
distress score).
This combination is consistent with the World Health Organization’s view of good health
as ‘a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity’ (WHO 1948). The level of good health on each of these three
components is shown in Figure 6.7.2.
A person is in ‘good health’ if they have a score of 3.0 or more on the composite measure
(the calculation of the composite good health score is further explained in Box 6.7.1).
Box 6.7.1: The composite ‘good health’ measure

The level of self-assessed health status in both the 2012–13 Australian Aboriginal and
Torres Strait Islander Health Survey (AATSIHS) and 2011–12 Australian Health Survey (AHS)
is reported in five categories. For this analysis, these categories were assigned a score
from 5 to 1, corresponding to ‘excellent’, ‘very good’, ‘good’, ‘fair’ and ‘poor’, respectively.
The morbidity score is based on the widely used Charlson Index (Charlson et al.
1987). It sums the number of conditions reported by a respondent but ignores the
weighting factor usually associated with the severity of the condition (which was not
reported in these surveys). The conditions used to generate this morbidity score
include cancer; and conditions of the circulatory, respiratory, nervous, endocrine,
urinary and musculoskeletal systems. The morbidity score ranged from 0 to 21.
The emotional distress score was calculated as the sum of 5 individual Kessler-5
scores, measuring how often respondents reported feeling nervous, without hope,
restless or jumpy, ‘everything was an effort’, and ‘so sad that nothing could cheer
them up’, in the 4 weeks before the survey. The score for each response was scaled
from 0 (none of the time) to 4 (all the time), and summed over the 5 responses,
resulting in emotional distress scores that ranged from 0 to 20.
The composite health score for an individual was then calculated as follows:
composite score = self-assessed health score – morbidity score – ( emotional distress

2
score – 2
)
For this analysis, a person was considered to be in good health if their score was 3.0
Chapter 6
or higher. If they scored less than 3.0, they were considered not to be in good health.
Applying a cut-off score simplifies the analysis because it creates an outcome with
two possibilities: ‘good health’ or ‘not in good health’. The chosen cut-off value of 3.0
is consistent with that of a previous AIHW (2014b:329–39) analysis.
The largest gap in the three components of the composite good health score occurs for
the emotional distress score. The average emotional distress score for Indigenous adults
is 5.0 while it is only 2.2 for non-Indigenous adults. The mean value of the composite
health score is 0.1 for Indigenous adults and 2.2 for non-Indigenous adults (Figure 6.7.2).
341
Figure 6.7.2: Average score for aggregate composite health and
sub-components, by Indigenous status, 2011–13
Score 5.0
4 3.6
3.1
3
2.2 2.2
2 1.6
1.3
0.1
0
Aggregate composite Self-assessed health Emotional distress Morbidity score
health score score score
Average good health score and sub-components
Note: These average scores are based on the actual sample of individuals used in the regression models
estimated; hence, they may not be representative of the overall population of people aged 15–64 in these
two surveys. Given the large number of explanatory variables used, individuals for whom any of the
regression variables were missing are excluded from the estimation sample from which these average
values are computed.
The proportion of people in good health on the composite measure was calculated using
data from the Australian Bureau of Statistics (ABS) 2012–13 AATSIHS for Indigenous
Australians. Comparable non-Indigenous data were sourced from the ABS 2011–12 AHS.
Both surveys contain detailed information on people’s health outcomes and on their
social determinants and health risk factors (ABS 2013, 2014).
The final sample of individuals for this analysis consisted of around 3,180 Indigenous
and 8,150 non-Indigenous working-age adults (aged 15–64). This age group was chosen
because some key determinants of health used in the analysis, such as hours worked, are
best defined for people who have not reached the standard retirement age.
More recent AHS data are now available, but the next round of the Indigenous-specific
health survey is only being conducted this year. Hence, this article uses the 2012–13
AATSIHS and 2011–12 AHS.
342
More than half the gap is explained by
11 factors
Statistical analysis was used to see which factors were highly associated with good health.
The results show that more than half of the health gap (53%) is explained by
11 selected factors (Figure 6.7.3). These factors were broadly classified into two groups:
social determinants (5) and health risk factors (6).
Social determinants Health risk factors

• E
mployment and hours worked • Binge drinking
• H
ighest non-school qualification • High blood pressure
• L
evel of school completed • O
verweight and obesity status
• H
ousing adequacy (sufficient number (body mass index)
of rooms) • Inadequate fruit and vegetable
• H
ousehold income consumption
• Insufficient physical exercise
• Smoking
The combined social determinants explain slightly more than one-third (34%) of the health
gap and the selected health risk factors account for another 19%.
Figure 6.7.3: Proportion of the adjusted health gap explained by differences

in social determinants and health risk factors between Indigenous and
non-Indigenous Australians, 2011–13
Gap due to other Social

factors determinants
46.8% 34.4%
(unexplained
component)
Chapter 6
Health
risk factors
18.8% Overlap between
social
determinants &
health risk factors
(10.8%)
343
An estimated 11% of the total health gap can be attributed to the overlap, or interactions,
between the social determinants and health risk factors. This is because the two sets of
factors influence each other—their combined total contribution to the gap is less than the
sum of their separate contributions. See chapter 6.6 ‘Social determinants and Indigenous
health’, which explores an example of these interactions—between smoking status and
household income and education.
For more information see supplementary document S6.7 ‘Method for estimating the
sources of the health gap’ available online at <www.aihw.gov.au/reports/australias-health/
australias-health-2018/related-material>.
Tackling the different factors would reduce the gap

The analysis indicates that the adjusted health gap would be reduced from 27 percentage
points to 13, if Indigenous working-age adults had the same average values for the
11 selected factors as non-Indigenous working-age adults. Most of the 14-percentage
point reduction would come from social determinants (9 percentage points), with a
5-percentage point reduction due to health risk factors.
Another way to look at this result is this: 42% of Indigenous working-age adults would
have been assessed as being in good health if they had had the same average values as
non-Indigenous adults for the 11 selected factors (and the demographic and locational
factors). This figure is well above the 28% of Indigenous adults in good health from the
current survey results (shown in Figure 6.7.1).
Nearly half the gap is not explained by the

selected factors
While differences between Indigenous and non-Indigenous Australians across the
11 factors explain 53% of the gap, around 47% is left unexplained.
This unexplained component of the health gap partly reflects the possible effects of
factors that contribute to good health but which were not able to be included in the
statistical analyses, such as access to health care services. Improving access to health care
services relative to need is of crucial importance for better Indigenous health outcomes
(AHMAC 2017; AIHW 2014a, 2015); but this aspect could not be measured by the current
survey data.
This analysis is based only on relationships between health status at one point in time
(2011–13) and the social determinants and health risk factors. It does not account for the
cumulative effects of any early life events on current health, or the effects of different
social determinants and health risk factors that applied at other points in time. These
effects will also be part of the unexplained component of the health gap, along with the
effects of other factors that are intrinsically difficult to measure in a survey that records
information at one point in time.
One part of the unexplained component of the health gap, however, will also reflect the
effects of other disadvantages on health outcomes that occur due to the marginal position
of Indigenous Australians in relation to mainstream society (Marmot 2011).
344
Social determinants have the greatest effect on the
health gap
Household income differences contributed almost 14% of the overall health gap,
followed by differences in employment and hours worked (12%), and level of school
completed (8.7%) (Figure 6.7.4).
Among the health risk factors, differences in smoking status made the greatest
contribution to the health gap, at 10%, followed by overweight and obesity status (7.2%).
Together, household income, employment/hours worked and smoking status account for
36% of the total health gap, which is more than two-thirds (68%) of the total contribution
made by the 11 selected factors.
If Indigenous adults were to have the same average levels as non-Indigenous adults of
just these three factors (that is, same household income, same employment rate and
hours worked, and same smoking rate), the health gap would be reduced by more than
a third—from 27 percentage points to around 17 percentage points.
Figure 6.7.4: Contribution of individual social determinants and health risk

factors to the adjusted health gap between Indigenous and non-Indigenous
Australians, 2011–13
Household income 13.7

Social determinants
Employment and hours worked 12.3
Level of school completed 8.7
Highest non-school qualification - 0.5
Housing adequacy (sufficient number of rooms) 0.2
Smoking status 10.0
Overweight and obesity status (BMI) 7.2

Health risk factors
Binge drinking 1.3
Inadequate fruit and vegetable consumption 0.7
Insufficient physical exercise - 0.4
High blood pressure 0.0
Unexplained component 46.8

Chapter 6
-10 0 10 20 30 40 50
Per cent
Note: The contribution of a variable to the gap can be either positive or negative. A positive contribution
means that the predicted gap would be lower than the actual gap if the two subgroups had the same levels
of that explanatory variable. A negative contribution means that the predicted gap would be higher than the
actual gap if the two subgroups had the same levels of that explanatory variable. A negative contribution
also helps to ‘explain’ the gap in the sense that, were it not for the differences observed on that variable, the
actual health gap would have been higher. The two negative contributions shown in this graph, however,
are small and not significantly different from zero.
345
How do the key factors affect good health?
This section focuses on the five factors that contribute to most (98%) of the explained
health gap between Indigenous and non-Indigenous adults in this analysis:
1. h
ousehold income (equivalised by household size)
2. e
mployment and hours worked
3. s moking status
4. level of school completed
5. o
verweight and obesity status.
It presents the results of statistical analysis on how much the presence (or absence) of
these factors affects a person’s chance of being in good health. These results are the first
steps from which the contributions to the gaps were estimated. The analysis was carried
out separately for the sample of Indigenous and non-Indigenous adults, and this section
also highlights differences in results between the two groups.
The analysis estimated an odds ratio (OR) of a person being in good health for each
factor—that is, the odds that a person would be in good health if they were exposed to
a specific factor (for example, if they were a current smoker) compared with the odds
of being in good health if they were not exposed to that factor (not smoking).
How the value of the estimated OR should be interpreted for each factor is outlined below.
An OR value of… means…

1 (or close to 1) the factor has little or no effect on the odds of being in good health,
compared with a person in the reference group.
Greater than 1 the factor increases the odds of being in good health, compared with
a person in the reference group. This implies a positive association
between that factor and the good health measure.
Less than 1 the factor decreases the odds of being in good health, compared with
a person in the reference group (a negative association between the
factor and the good health measure).
Note that the odds of being in good health is not exactly the same as the likelihood
(or probability) of being in good health. However, these concepts are directly related,
and a factor that leads to increased odds also increases the likelihood.
For more information see supplementary document S6.7 ‘Method for estimating the
sources of the health gap’ available online at <www.aihw.gov.au/reports/australias-health/
australias-health-2018/related-material>.
346
Focusing on aspects of each factor that increases the odds that someone will be in
good health may offer a more targeted approach to reducing the health gap.
For some factors described in the sections that follow, the same factor significantly
increases the odds of being in good health for non-Indigenous adults, but not for
Indigenous adults. This may be an effect of the statistical model (considering the smaller
Indigenous sample size, and inherently more non-Indigenous adults than Indigenous
adults in ‘good health’ in the reference categories used to calculate the ORs). However,
some of these differences in the estimated results form part of the unexplained
component of the health gap.
The results on the estimated ORs for these selected five variables are shown in
Figure 6.7.5, and summarised in the following sections.
Employment and household income

Being employed and working for at least 25 hours a week with a higher income have
positive effects on a person’s health status.
Both Indigenous and non-Indigenous adults have significantly increased odds of being
in good health—by a factor of at least 1.5—if they:
• work in paid employment for at least 25 hours each week
• h
ave a household income in the top 30% of all households (when all household incomes
are ranked from highest to lowest).
Employed non-Indigenous adults have significantly increased odds of being in good
health—even if they work in paid employment for fewer than 25 hours each week—
compared with non-Indigenous people who are not employed. For Indigenous adults,
the health benefits of being employed are observed only for people who work more than
25 hours a week, compared with not working at all.
There is a similar pattern for people who earn a mid-range income—that is, in the middle
40% of all households when income is ranked from highest to lowest—compared with
people whose incomes are in the lowest 30%. Earning a mid-range income (middle 40%)
significantly increases the odds of being in good health for non-Indigenous adults only.
For Indigenous adults, a significant effect of income in improving health is seen only for
people in the top 30% of all households.
Smoking status
Being a current smoker (compared with not smoking) reduces the odds of being in
Chapter 6
good health (1.5 times less likely) for both Indigenous and non-Indigenous adults.
347
Level of school completed
Both Indigenous and non-Indigenous adults who have completed a higher level of
secondary schooling have greater odds of being in good health.
For Indigenous adults, a higher level of schooling significantly increases the odds of a
person being in good health only if they have completed Year 12 (compared with the
reference category of having completed Year 9 or below). That is, for Indigenous adults
who have completed Year 10 or 11, there is little or no increase in their odds of being
in good health, compared with people who have completed Year 9 or below.
Non-Indigenous adults have significantly increased odds that they will be in good health
if they have completed any year of schooling above Year 9.
Overweight and obesity status

Being obese (a body mass index, or BMI, ≥30.00) significantly reduces the odds of being
in good health, compared with adults in the normal weight range (BMI 18.50–24.99).
In the class III obese category (BMI ≥40.00), the odds of being in good health are more
than 3 times lower among non-Indigenous adults, and more than 2 times lower for
Indigenous adults, compared with adults in the normal weight range.
Being in the overweight but not obese range (BMI 25.00–29.99) significantly reduces
the odds of being in good health (compared with people in the normal weight range;
BMI 18.50–24.99), but only for non-Indigenous adults. For Indigenous adults, there are
no significant differences in the odds of being in good health, whether they are in the
normal or overweight but not obese BMI ranges (18.50–24.99; 25.00–29.99).
348
Figure 6.7.5: Estimated odds ratios for being in good health, by Indigenous
status, 2011–13
Reference category for the Indigenous adults Non-Indigenous adults

odds ratio estimates
0.5 1.0 1.5
Household income (equivalised)

Income in lowest 30% (lowest 3 deciles)—reference Group
Income in middle 40% (middle 4 deciles) 1.12 1.39*
Income in highest 30% (top 3 deciles) 1.51* 1.62*
Hours worked
Not employed (working 0 hours/week)—reference Group
Worked <25 hours/week 1.12 1.37*

Worked 25-39 hours/week 1.58* 1.61*
Worked 40+ hours/week
1.52* 1.70*
Smoking status
Current non-smoker—reference Group
Current smoker 0.66* 0.67*
Level of school completed

Completed Year 9 or below—reference Group
Completed Year 10 1.16 1.32*
Completed Year 11 1.06 1.30*
Completed Year 12 1.34* 1.57*
Overweight and obesity status

Normal weight (BMI 18.50—24.99)—reference Group
Underweight (BMI <18.50) 0.80 0.93
Overweight but not obese (BMI 25.00—29.99) 0.80* 1.00
Class I and II obese (BMI 30.00—39.99) 0.48* 0.66*
Class III obese (BMI ≥ 40.00) 0.32* 0.47*
0.5 1.0 1.5
Odds ratio
* E
stimated odds ratio (OR) are statistically different from 1 at the conventional 5% test level. The actual
estimated value then indicates whether this estimate is significantly higher than 1 or significantly lower
than 1. No asterisk means the estimated OR is not significantly different from 1 (meaning the odds of
Chapter 6
being in good health does not vary significantly between the designated category and the baseline
or reference category for that factor).
Sources: AIHW analyses of ABS Australian Aboriginal and Torres Strait Islander Health Survey 2012–13,
ABS 2011–12 Australian Health Survey.
349
What does this mean?
These results illustrate the usefulness of looking behind the aggregate health gap to
identify the key differences or sources that lead to the gap. The findings identify the
most effective areas to target to reduce the health disparities between Indigenous and
non-Indigenous Australians.
This sort of analysis shows how targeted policies can play a role in reducing health
disparities. Considering the five factors that contribute most to the explained health
gap—and the significantly increased odds of being in good health achieved through
particular outcomes—health disparities could be reduced through policies that facilitate,

for example, Indigenous Australians completing Year 12, being employed with close to
full-time hours of work, not smoking, and maintaining a healthy weight.
The analysis also shows that improvements in one area, such as higher educational
attainment, can also indirectly improve health outcomes by affecting other key factors,
such as not smoking and working longer hours (which are associated with higher
educational attainment).

The AIHW has a long history of monitoring and reporting on Indigenous health and
socioeconomic outcomes, and the gaps observed between the Indigenous and
non-Indigenous populations.
The AIHW prepares the detailed online tables for the biannual Aboriginal and Torres Strait
Islander Health Performance Framework report, which provides the latest information on
how Indigenous Australians are faring according to a wide range of health performance
measures. The AIHW also has a regular publication series titled The health and welfare of
Australia’s Aboriginal and Torres Strait Islander peoples.
The AIHW has undertaken technical analyses of the sources of the Indigenous health gap
on other indicators, including life expectancy (AIHW 2016b:234–41); on the incidence
of low birthweight babies using data from the National Perinatal Minimum Data set
(AIHW 2017); and on the burden of disease (AIHW 2016a).

It is likely that differences in access to affordable and nearby health services explain some
proportion of the health gap between the Indigenous and non-Indigenous populations.
That aspect, however, was not covered in this analysis. The topic is explored in chapter 6.8
‘Indigenous Australians’ access to and use of health services’. It could not be used in this
analysis of the sources of the gap because data on similar types of access measures were
not available from the surveys used for both Indigenous and non-Indigenous populations.
350
The analysis in this chapter is based on detailed health-related data from nationally
representative and well-regarded surveys conducted by the ABS. However, the variables
used to create the ‘good health’ measure at the centre of this analysis are derived from
self-assessed/self-reported data. There are some known limitations of self-reported data
in providing an accurate picture of objective health—analysis of self-reported measures
alone may not be enough to inform health policy. The analysis could be extended with
additional measures of the Indigenous health gap, reflecting objective health status.
Also, the data used for this analysis are from cross-sectional surveys that record
point-in-time information. They ignore the potentially strong cumulative effects on current
health, and social determinants and health risk factors, arising from early life events.
As well, this analysis looked only at the gap in health status of working-age adults
(aged 15–64). Results may differ for other age groups.
Neither did this analysis consider any cultural determinants of health for Indigenous
Australians. There is growing recognition that cultural determinants are important for
Indigenous health, as a strong connection to culture is correlated with good health
through strengthened identity, resilience and wellbeing (Department of Health 2017).

More information about the main contributors to the Indigenous life expectancy gap can
be found in Chapter 5.8 in Australia’s health 2016.
More information on the previous analysis of the sources of the health gap can be found
in Chapter 7.8 of Australia’s health 2014.
More information on geographical variation in Indigenous people’s access to primary
health care services relative to need is available in the report Access to primary health care
relative to need for Indigenous Australians.
More information on the Aboriginal and Torres Strait Islander Health Performance
Framework is available at: <www.aihw.gov.au/reports/indigenous-health-welfare/health-
performance-framework/contents/summary>.
See also supplementary document S6.7 ‘Method for estimating the sources of the
health gap’ available online at <www.aihw.gov.au/reports/australias-health/australias-
health-2018/related-material>.
References
ABS (Australian Bureau of Statistics) 2013. Australian Health Survey: updated results,
2011–2012. ABS cat. no. 4364.0.55.003. Canberra: ABS.
Chapter 6
ABS 2014. Australian Aboriginal and Torres Strait Islander Health Survey: updated results, 2012–13.
AIHW (Australian Institute of Health and Welfare) 2014a. Access to primary health care relative to need for
Indigenous Australians. Cat. no. IHW 128. Canberra: AIHW.
AIHW 2014b. Australia’s health 2014. Australia’s health series no. 14. Cat. no. AUS 178. Canberra: AIHW.
AIHW 2015. Spatial variation in Aboriginal and Torres Strait Islander people’s access to primary health care.
Cat. no. IHW 155. Canberra: AIHW.
351
AIHW 2016a. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal
and Torres Strait Islander people 2011. Australian Burden of Disease Study series no. 6. Cat. no. BOD 7.
Canberra: AIHW.
AIHW 2016b. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW.
AIHW 2017. Aboriginal and Torres Strait Islander Health Performance Framework 2017: supplementary
online tables. Cat. no. WEB 170. Canberra: AIHW.
Biddle N, 2012. Improving Indigenous health: are mainstream determinants sufficient? In: Hunter B &
Biddle N (eds). Survey analysis for Indigenous policy in Australia: Social Science Perspectives. CAEPR
Research Monograph no. 32:65–78.
Charlson ME, Pompei P, Ales KL & MacKenzie CR 1987. A new method of classifying prognostic comorbidity
in longitudinal studies: development and validation. Journal of Chronic Disease 40:373–83.

CSDH (Commission on Social Determinants of Health) 2008. Closing the gap in a generation: health
equity through action on the social determinants of health. Final report of the Commission on Social
Determinants of Health. Geneva: World Health Organization.
Department of Health 2017. My life my lead—opportunities for strengthening approaches to the social
determinants and cultural determinants of Indigenous health: report on the national consultations.
Mackenbach JP 2015. Socioeconomic inequalities in health in high-income countries: the facts and the
options. In: Oxford textbook of global public health. Vol. 1. 6th edn. Oxford: Oxford University Press.
Marmot M 2011. Social determinants and the health of Indigenous Australians. Medical Journal of Australia
194(10):512–13.
PM&C (Department of the Prime Minister and Cabinet) 2018. Closing the Gap Prime Minister’s report 2018.
Canberra: PM&C.
Shepherd CCJ, Li J & Zubrick SR 2012. Social gradients in the health of Indigenous Australians. American
Journal of Public Health 102(1):107–17.
World Health Organization (WHO) 1948. Preamble to the constitution of the World Health Organization.
New York: WHO.
352
6.8 Indigenous Australians’
SNAPSHOT
access to and use of
health services
To evaluate whether the health system is adequately meeting the needs of Aboriginal
and Torres Strait Islanders, it is important to understand their access to, and use of,
health services. Indigenous Australians may access mainstream or Indigenous-specific
primary health care services (ISPHCS), which offer prevention, diagnosis and treatment
of ill health in a range of settings (see Chapter 7.5 ‘Primary health care’). The Australian
Government and/or state and territory governments fund Indigenous-specific services.
They are available through community clinics, services provided by Aboriginal Community
Controlled Health Organisations (ACCHOs) and other health care facilities. There are also
Indigenous-specific services offered within some public hospitals in Australia.
Conceptually, access can mean many things. It can refer to whether health services are
geographically accessible (that is, within a reasonable travel time/distance), financially
accessible, culturally accessible, or whether they have the workforce or capacity to see
patients when they need assistance. From a systemic perspective, where health services
are located and how often people access or use those that are available are important
measures. Data on all these aspects are rarely available, however. In their absence,
service use is often used as a proxy measure.
This snapshot focuses on three indicators of service access and use: the availability
of services provided by ISPHCS, the use of selected health services claimed through
Medicare, and the use of hospital services.
Indigenous-specific primary health care services

In 2015–16, ISPHCS were delivered by 204 organisations from 368 sites. Two-thirds
(136 organisations) were ACCHOs; the other 68 comprised state and territory
government-run organisations and other non-government-run organisations.
ISPHCS are an important service provider for Indigenous Australians throughout
Australia. In 2015–16, one-third (33%) of services were located in Very remote areas,
23% in Outer regional areas and 21% in Inner regional areas. Smaller proportions were
in Remote areas (13%) and Major cities (10%).
Chapter 6
ISPHCS provided 3.9 million episodes of care to around 461,500 clients in 2015–16.
However, because people may use several different ISPHCS, the number of clients is
greater than the number of unique individuals who have used an ISPHCS (that is, if a
person uses 2 different services, they will be counted as 2 clients—one at each service).
Most (89%) sites operated 5 days or more per week, and 26% offered 24-hour emergency
care, which was similar to the scenario in 2014–15 (88% and 26%, respectively). Most sites
provided clinical services, such as the diagnosis and treatment of chronic illnesses (85%),
antenatal care (75%), maternal and child health care (80%), and mental health and counselling
services (84%). Many also offered tobacco programs (61%) and substance-use programs (60%).
353
Use of selected health services claimed
through Medicare
Data from 2015–16 show that Medicare Benefits Schedule (MBS) claim rates for general
practitioner (GP) visits were 10% higher for Indigenous than non-Indigenous Australians,
but claim rates for specialist services were 43% lower. This may reflect difficulties in
accessing specialist services (Figure 6.8.1).
Both the number and rates of MBS health checks among Indigenous Australians rose
significantly from 2006–07 to 2015–16 for all age groups (Figure 6.8.2; Table 6.8.1).
In 2006–2007, there were around 22,500 health checks performed. By 2015–16, that
number had risen to nearly 197,000.
Figure 6.8.1: Age-standardised rate of claimed Medicare services, by selected

types of service and Indigenous status, 2015–16
Type of Medicare service
Non-referred GP
Pathology
Imaging
Indigenous
Specialist
Non-Indigenous
Allied health
Miscellaneous diagnostic
0 2,000 4,000 6,000 8,000

Rate (services claimed per 1,000 population)
Source: DHS 2017; Table S6.8.1.
Figure 6.8.2: Rate of MBS health checks for Indigenous Australians, by age,
2006–07 to 2015–16
Rate (number of checks per 1,000 population)

400
55+
300 15-44
0-14
200
100
0
2006-07 2015-16
Year
Source: DHS 2017; Tables S.6.8.2.
354
Table 6.8.1: Number of MBS health checks/assessments for Indigenous Australians(a)
(MBS item 715(b)), by age, 2006–07 to 2015–16(c)
Age 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16
0–14 6,315 12,397 14,160 17,363 22,415 31,078 39,420 47,414 55,245 63,790
15–44 12,775 15,684 18,369 23,197 38,331 51,757 65,525 80,645 91,172 103,565
55+ 3,473 4,262 5,254 6,602 10,623 13,744 17,216 22,295 25,369 29,404
Total(d) 22,563 32,343 37,783 47,162 71,369 96,580 122,160 150,354 171,786 196,758
(a) Indigenous identification not adjusted using Voluntary Indigenous Indicator (VII) data.
(b) A
s Item 715 started in May 2010, MBS codes 704, 706, 708 and 710 were reclassified as 715 for prior years.
(c) F
inancial year reporting.
(d) T
otal may not sum exactly due to rounding.
Source: DHS 2017.
Hospital services
Indigenous Australians are relatively high users of hospital services, most of which are
accessed through public hospitals. Between July 2013 and June 2015, there were around
458,000 hospitalisations (excluding dialysis) for Indigenous Australians; this equates to a
rate that is 1.3 times the rate for non-Indigenous Australians. There were an additional
393,000 dialysis-related hospitalisations.
Admissions for potentially preventable conditions (PPHs) reflect hospitalisations that
might have been prevented through the timely and appropriate provision and use of
primary care or other non-hospital services (Li et al. 2009). In 2013–15, the rate for PPHs
was 3 times as high for Indigenous Australians (69 per 1,000 compared with 23 per 1,000
for non-Indigenous Australians).
The leading cause of hospitalisation in 2013–15 for Indigenous Australians was injury,
poisoning and other external causes, followed by respiratory system diseases (Figure 6.8.3).
The only specific cause of hospitalisation where the rate for non-Indigenous Australians
was higher than that for Indigenous Australians was for digestive conditions.
Figure 6.8.3: Age-standardised rates of the leading causes of Indigenous

hospitalisation, by Indigenous status, 2013–15
Cause of hospitalisation
Injury and poisoning and other
consequences of external causes
Respiratory
Chapter 6
Digestive
Circulatory
Mental and behavioural disorders Indigenous

Non-Indigenous
Genitourinary
0 10 20 30 40 50
Rate (hospitalisations per 1,000 population)
Note: Excluding dialysis and pregnancy/childbirth.
355
Comprehensive data on Indigenous Australians’ use of mainstream health services
are lacking. This makes it difficult to determine patterns in the use of health services.
Incomplete identification of Indigenous people in mainstream health services data can
also lead to an underestimation of service use. Data are also missing on the number
of unique individuals using ISPHCS as clients who use more than one service are
counted within each service.

For more information on spatial access to services see the AIHW reports Spatial variation
in Aboriginal and Torres Strait Islander women’s access to 4 types of maternal health services,
Spatial variation in Aboriginal and Torres Strait Islander people’s access to primary health
services and Access to primary health care relative to need for Indigenous Australians.
Data and information on ISPHCS are available from the AIHW website:
<www.aihw.gov.au/reports-statistics/health-welfare-services/indigenous-health-welfare-
services/overview>, and the interactive health check tool is available at
<www.aihw.gov.au/reports/indigenous-health-welfare-services/indigenous-health-check-
mbs-715-data-tool/contents/dynamic-data-displays>.
References
DHS (Department of Human Services) 2017. Medicare Item Reports. Data online at
<http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp>.
Li SQ, Gray NJ, Guthridge SL & Pircher SBLM 2009. Avoidable hospitalisation in Aboriginal and
non-Aboriginal people in the Northern Territory. Medical Journal of Australia 190(10):532–6.
356
6.9 Supply of the health
FEATURE ARTICLE
workforce for the
Indigenous population
Appropriate, culturally safe and accessible services are an essential component of health
care for Aboriginal and Torres Strait Islander Australians (Department of Health 2013).
Previous work by the AIHW has shown, however, that not all Indigenous Australians have
equal access to health service locations, and that, on average, areas characterised by
poorer access also have poorer health outcomes (AIHW 2015, 2017).
The differential supply and accessibility of health services is compounded by the fact
that Indigenous Australians are more likely than non-Indigenous Australians to live in
Remote and Very remote areas. This population distribution is important because distance
and remoteness often pose substantial challenges for workforce recruitment and health
service delivery, particularly in areas where populations are widely dispersed or isolated.
Identifying areas of relative workforce supply challenges is an important first step for
policy discussions on how to:
• improve supply in these areas, or
• e
nsure that residents’ needs for primary health care services are met in other ways
(such as through outreach services, telehealth and e-health, medical chests with
essential supplies for emergency and non-emergency treatment, the S100 Remote
Aboriginal Health Services Program for accessing medicines, and online/telephone-based
counselling by psychologists).
This article focuses on how the supply of three groups of relevant health professionals—
general practitioners (GPs), dentists and midwives—is distributed across Australia. It uses
a new index developed by the AIHW, the Geographically-adjusted Index of Relative Supply
(GIRS), to identify areas with supply challenges, and looks at the numbers and percentages
of Indigenous Australians who live in these areas. Summary-level information is also
presented on the relative workforce supply for nurses, pharmacists, psychologists and
optometrists. It is important to note that the GIRS is a relative supply measure—it is not a
measure of the extent to which people are able to access services.
What is the GIRS?

Chapter 6
The GIRS is an index used to compare health workforce supply across small geographic
areas. It ranges from 0 to 8 and was calculated for each of the 2,092 Statistical Area Level
2s (SA2s) in Australia, using workforce data from 2014. Areas with lower GIRS scores face
relatively more challenges with workforce supply than those with higher GIRS scores. This
does not imply, however, that areas with higher GIRS scores do not face such challenges.
The GIRS takes the known workforce supply based in an area and adjusts it for three other
factors—land size, population dispersion, and the proximity of the population to the relevant
service locations. Box 6.9.1 provides an overview of why these factors are important.
357
Box 6.9.1: Why create the Geographically-adjusted Index of Relative Supply?
Without taking account of land size, population dispersion and the proximity of
the population to relevant service locations, comparisons of workforce supply
across areas can be misleading. For example, the most common way to measure
workforce supply is to calculate a provider-to-population ratio, which looks at
the number of full-time providers per 1,000 people in an area. Now consider the
following three areas:
Area B
Land size—geographically small
Population dispersion—dense
A Workforce supply—4 providers working the
equivalent of 3 full-time providers
Proximity to services—close to another densely
populated area (C)
B C
1,000 km 30 km
Area A Area C
Land size—geographically large Land size—geographically small
Population dispersion—sparse Population dispersion—dense
Workforce supply—2 full-time providers Workforce supply—1 full-time provider
Proximity to services—no neighbouring areas Proximity to services—close to another
with service providers densely populated area (B) with more providers
Health-care provider Population (indicative of where people live)
For these three example areas, the provider-to-population ratios are:

A: 1 provider per 1,000 people (2 full-time providers divided by 2,000 people)
B: 1 provider per 1,000 people (equivalent of 3 full-time providers divided by 3,000
people— made up of 4 part-time providers)
C: 0.25 provider per 1,000 people (1 full-time provider divided by 4,000 people).
Based on provider-to-population ratios, the workforce supply in areas A and B is
the same, and there is a lower workforce supply in area C. Comparing areas A and
B, however, shows that area A is much bigger, its population is widely dispersed
across its large area, and its 2 providers are both located in one corner of the area.
Many of the people living in area A are likely to have poorer access to the services
because of the distance they have to travel within the area and the fact that there
are no services in neighbouring areas. Furthermore, it is likely that the providers in
area A also serve populations in other nearby areas, so the provider-to-population
ratio potentially overstates the workforce supply available to people in that area.
It also appears from the provider-to-population ratio that area C faces the most
workforce supply challenges of the three areas; however, people in area C are
within a reasonable driving distance of the providers in area B and can access
services in that area as well. Thus, the provider-to-population ratio understates
the workforce supply available to people in area C.
358
Box 6.9.1 (continued): Why create the Geographically-adjusted Index of
Relative Supply?
The GIRS takes into account how hard it might be for people to access services
based on the dispersion of the population, the size of the area and whether people
can access services in neighbouring areas. Therefore, it is a better indicator of the
relative workforce supply in an area than provider-to-population ratios on their own.
For more information see supplementary document S6.9 ‘Estimating the supply
of the health workforce’ available online at <www.aihw.gov.au/reports/australias-
health/australias-health-2018/related-material>.
Relationship between the GIRS and health outcomes

The GIRS aims to capture relative workforce supply across areas. A low GIRS score would
be expected to indicate an area where the risk of poor health outcomes is relatively
high because of these supply challenges. One indicator that has been shown to relate
to poor access to primary health services is potentially preventable hospitalisations
(PPHs)—namely, hospitalisations that might have been prevented through the timely and
appropriate provision and use of primary care or other non-hospital services
(AIHW 2014a; Li et al. 2009).
A correlation analysis of GIRS scores with PPH rates at the SA2 level found that areas with
lower relative workforce supply were significantly more likely to have a higher percentage
of hospitalisations that were potentially preventable than areas with higher relative
workforce supply. The relationship between PPH and relative workforce supply was
tested separately for GPs, pharmacists and dentists, and the association was statistically
significant for all three professions (AIHW 2016a).
Bringing together relative workforce supply and the

distribution of the Indigenous population
Information on the number of Indigenous and non-Indigenous Australians living in each
SA2 was linked with the GIRS scores to calculate the number of Indigenous people who
live in areas with relative workforce supply challenges.
The next section of this article presents the findings for GPs, dentists and midwives.
Guide to GIRS scores

Chapter 6
There is an inverse relationship between GIRS scores and the likelihood of relative
workforce supply challenges; that is, areas with a GIRS score of 0 or 1 are likely to
face higher workforce supply challenges than areas with a GIRS score of 6–8.
359
General practitioners
GPs are medical practitioners who are registered with the Medical Board of Australia.
After completing their university studies, they receive provisional registration and
must complete an internship and specialist training before receiving general
medical registration.
GPs play a key role in Australia’s primary health care system. Their duties include
providing preventive care and screening, managing acute and chronic illnesses and
providing a link to specialist and multidisciplinary care. They also perform important
legal functions, such as certifying documents and assessing eligibility for programs
such as the Disability Support Pension. GPs work in a variety of settings, including in
private, solo or group practices; in Indigenous Specific Primary Health Care Services
(ISPHCS) and/or community health services; and in hospital-based clinics. They may also
provide additional services outside their practice locations, including at outreach clinics
and through home visits and visits to locations such as aged care facilities (AIHW 2014a).
Given the higher health needs of the Indigenous population relative to the non-Indigenous
population, the supply of the GP workforce is a critical issue for Indigenous people.
Identifying areas in which Indigenous people live that have relatively low supplies of
GPs provides a starting point for further examination and potential policy follow-up.
Relative workforce supply of GPs and relationship to

the distribution of the Indigenous population
The geographic distribution of the relative workforce supply of GPs throughout Australia
is shown in Figure 6.9.1. There were 39 areas with a high probability of GP workforce
supply challenges (GIRS scores of 0–1): 23 were in Very remote areas, 7 in Remote areas,
6 in Outer regional areas and 3 in Inner regional areas (for more information on the
distribution of the GIRS by remoteness see Supplementary Table S6.9.1.
For an interactive version of the map in Figure 6.9.1, see the online data
visualisation tool at <www.aihw.gov.au/reports/australias-health/australias-
health-2018/contents/supply-of-the-health-workforce-for-the-indigenous-
population-maps>.
360
Figure 6.9.1: GP GIRS scores by SA2, 2014
GIRS for GPs
More than 46,000 Indigenous Australians (6.9% of the Indigenous population) live in the
39 areas with the highest likelihoods of GP workforce supply challenges. This percentage
is 14 times as high as that for non-Indigenous Australians (0.5%) (Table 6.9.1).
Table 6.9.1: Distribution of SA2s and population by area-level relative GP workforce

supply (GIRS score), 2014
Population distribution (number) Population distribution (%)
GP GIRS Number Non- Non- Rate

score of SA2s Indigenous Indigenous Total Indigenous Indigenous ratio
0–1 39 46,199 108,321 154,520 6.9 0.5 13.8
Chapter 6
2–3 397 169,980 2,438,260 2,620,529 25.4 11.3 2.2

4–5 834 279,754 9,372,408 9,691,475 41.9 43.4 1.0
6–8 822 172,308 9,680,037 9,853,282 25.8 44.8 0.6
Total 2,092 668,241 21,599,026 22,319,806 100.0 100.0
Note: Lower GIRS scores indicate areas with higher probabilities of workforce supply challenges compared
with areas with higher GIRS scores. The Indigenous and non-Indigenous populations do not add up to the total
population as the Australian Bureau of Statistics did not provide a breakdown by Indigenous status for 23 SA2s.
Only SA2s with at least a population of 100 were included.
361
Dentists
Dentists are independent practitioners who provide assessment, diagnosis, treatment,
management and preventive services related to oral health. The education requirement
for a graduate dentist to be registered is a minimum 4-year full-time education program
approved by the National Board (Dental Board of Australia 2015).
Physical, financial and cultural access to dentists is a critical issue for Indigenous
health. Indigenous Australians have overall poorer oral health than non-Indigenous
Australians, which includes having more caries (cavities), more tooth loss and higher
rates of periodontal disease. Poor dental health has important social as well as physical
consequences, and can affect all aspects of daily life.
Dentist services may be delivered by resident or visiting dentists at private practice
locations, in clinic/hospital settings, through ISPHCS or through mobile dental services.
Relative workforce supply of dentists and relationship

to the distribution of the Indigenous population
The relative workforce supply of dentists across Australia is shown in Figure 6.9.2.
There were 43 areas with the highest probability of dentist workforce supply challenges
(GIRS scores of 0–1): 25 in Very remote areas, 7 in Remote areas, 10 in Outer regional areas
and 1 in an Inner regional area (for more information on the distribution of the GIRS by
remoteness see Supplementary Table S6.9.2.
population-maps>.
362
Figure 6.9.2: Dentist GIRS scores by SA2, 2014
GIRS for dentists
Nearly 77,000 Indigenous Australians (12% of the Indigenous population) live in the
43 areas with the highest likelihoods of dentist workforce supply challenges. This
percentage is 19 times as high as that for non-Indigenous Australians (Table 6.9.2).
Table 6.9.2: Distribution of SA2s and population by area-level relative dentist

workforce supply (GIRS score), 2014

Dentist
GIRS Number Non- Non- Rate
Chapter 6
0–1 43 76,803 132,602 209,405 11.5 0.6 18.8

2–3 396 137,746 2,388,973 2,539,008 20.6 11.1 1.9
4–5 749 272,780 8,272,467 8,584,560 40.8 38.3 1.1
6–8 905 180,912 10,804,984 10,986,833 27.1 50.0 0.5
Total 2,092 668,241 21,599,026 22,319,806 100.0 100.0
Note: Lower GIRS scores indicate areas with higher probabilities of workforce supply challenges compared with
areas with higher GIRS scores. The Indigenous and non-Indigenous populations do not add up to the total population
because the Australian Bureau of Statistics did not provide a breakdown by Indigenous status for 23 SA2s.
363
Midwives
Midwives provide care and advice to women during pregnancy, labour and birth; they
also provide postnatal care for women and babies in diverse settings, including the home,
community, hospitals, clinics, ISPHCS, and health units (AIHW 2013b). Midwives can be
registered as nurses, as midwives, or as both. Only data on midwifery-specific full-time
equivalents were included in the midwifery GIRS.
To register and practise as a midwife, a person must have appropriate qualifications in
midwifery. There are two paths to obtaining these qualifications. Midwives can first qualify
as a registered nurse and then undertake additional education and training in midwifery.
However, some universities now offer direct-entry midwifery undergraduate programs.
Direct-entry midwives, as with other midwives, must be registered with the Nursing and
Midwifery Board of Australia to practise, but are restricted to practising midwifery only,
whereas other midwives can also practise general nursing.
Access to midwives is particularly critical for the health of Indigenous mothers and
babies. Indigenous mothers are less likely to attend antenatal care in the first trimester
of pregnancy, have higher levels of social disadvantage, and are more likely to smoke
during pregnancy. These factors contribute to the higher likelihood that babies born to
Indigenous mothers are born prematurely and are of low birthweight. Both these factors
increase the likelihood of babies dying before their first birthday.
There are a large number of government and non-government initiatives to improve
access to high-quality, culturally appropriate care for Indigenous mothers and babies in
order to reduce these disparities (AIHW 2014b).
Relative workforce supply of midwives and

relationship to the distribution of Indigenous women
of child-bearing age
The relative workforce supply of midwives across Australia is shown in Figure 6.9.3.
There were 120 areas with the highest probability of midwife workforce supply challenges
(GIRS scores of 0–1): 34 in Very remote areas, 22 in Remote areas, 51 in Outer regional areas
and 13 in Inner regional areas (for more information on the distribution of the GIRS by
remoteness see Supplementary Table S6.9.3.
population-maps>.
364
Figure 6.9.3: Midwife GIRS scores by SA2, 2014
GIRS for midwives
Because the midwife workforce supply is most relevant for women of child-bearing age,
the focus on the population distribution across areas is on women aged 15–44. Slightly
more than 19,000 Indigenous women of child-bearing age (15%) live in areas with the
highest likelihood of midwife workforce supply challenges. This percentage is 8 times
as high as that for non-Indigenous women of child-bearing age (Table 6.9.3).
Table 6.9.3: Distribution of SA2s and the population of women of child-bearing age
by area-level relative midwife workforce supply (GIRS score), 2014

Midwife
GIRS Number Non- Non- Rate
Chapter 6
0–1 120 19,017 74,966 98,083 15.3 1.8 8.4

2–3 364 23,267 376,302 415,632 18.8 9.1 2.1
4–5 723 43,390 1,521,669 1,626,721 35.0 36.9 0.9
6–8 884 38,309 2,149,469 2,302,754 30.9 52.1 0.6
Total 2,091 123,983 4,122,406 4,443,190 100.0 100.0
Note: Lower GIRS scores indicate areas with higher probabilities of workforce supply challenges compared with areas
with higher GIRS scores. The Indigenous and non-Indigenous populations do not add up to the total population
because the Australian Bureau of Statistics did not provide a breakdown by Indigenous status for 23 SA2s.
365
Additional professions
The focus of this article has been on relative workforce supply challenges for GPs, dentists
and midwives, as measured by the GIRS. These findings are drawn from a larger project
that also examined the workforce supply of nurses, pharmacists, psychologists and
optometrists (AIHW 2016a).
A summary of GIRS scores for all seven professions is presented in Table 6.9.4.
It shows that, relative to other professions, a greater proportion of areas faced likely
supply challenges (GIRS score of 0 or 1) for midwives (5.7%) and optometrists (2.7%).
By comparison, less than 1% of areas faced supply challenges for nurses.
Table 6.9.4: Distribution of SA2s by relative workforce supply and profession
Number of SA2s by GIRS scores and profession

GIRS score GPs Nurses Midwives Pharmacists Dentists Psychologists Optometrists
0–1 39 17 120 45 43 49 56
2–3 397 436 364 391 396 400 365
4–5 834 808 723 750 748 687 776
6–8 822 831 884 906 905 956 895
Total 2,092 2,092 2,091 2,092 2,092 2,092 2,092
% of SA2s by GIRS scores and profession
GIRS score GPs Nurses Midwives Pharmacists Dentists Psychologists Optometrists
0–1 1.9 0.8 5.7 2.2 2.1 2.3 2.7
2–3 19.0 20.8 17.4 18.7 18.9 19.1 17.4
4–5 39.9 38.6 34.6 35.9 35.8 32.8 37.1
6–8 39.3 39.7 42.3 43.3 43.3 45.7 42.8
Total 100 100 100 100 100 100 100
Note: Includes only SA2s with resident populations of at least 100 people and valid data on all four GIRS components.
Scores of 0 and 1 indicate a higher probability that an area faces supply challenges compared with areas with
higher GIRS scores. There are only 2,091 SA2s with valid midwife GIRS scores.
Consistency in relative workforce supply within areas

Individual GIRS scores are important to identify areas of workforce supply challenge for
each profession. Another issue is the consistency in workforce supply across professions.
In other words, if an area had likely workforce supply challenges for one profession, did
it also have these challenges for other professions? It might be expected, for example,
that regions with a lower relative supply of GPs or nurses might also have a lower relative
supply of dentists or psychologists.
To measure the consistency of relative workforce supply across the seven professions,
the number of times that each SA2 had a GIRS score of 0 or 1 (that is, it was measured
as having a low level of relative supply for that profession) was counted across the seven
professions. Values for this summary score can range between 0 (no GIRS scores of 0 or 1)
to 7 (GIRS scores of 0 or 1 for every profession). Unlike the GIRS scores, where a lower
score means a higher potential for workforce supply challenges, higher values on the
summary score reflect a higher number of workforce supply challenges.
366
The spatial distribution of this summary score is presented in Figure 6.9.4. There were
39 SA2s (1.9%) that had relative workforce supply challenges for at least four of the seven
included professions. More than 72,600 Indigenous Australians (11%) live in these areas,
compared with 0.4% of the non-Indigenous population. This includes more than 30,000
Indigenous Australians living in areas with likely workforce supply challenges for at least
six of the seven included professions (Table 6.9.5).
Figure 6.9.4: Summary score of relative workforce supply challenges across

professions by SA2, 2014
Number of GIRS scores of 0 or 1

0–3 (2051 SA2s)
4 (14 SA2s)
5 (12 SA2s)
6 (11 SA2s)
7 (2 SA2s)
Missing data on one or more components (53 SA2s)
Population less than 100 (52 SA2s)
Chapter 6
For an interactive version of this map see the online data visualisation tool at
supply-of-the-health-workforce-for-the-indigenous-population-maps>.
367
Table 6.9.5: Summary score of relative workforce supply across all seven professions
Population distribution
Areas Number %
No. of Non- Non-
Summary score SA2s % Indigenous Indigenous Indigenous Indigenous
0 (no GIRS scores
of 0 or 1 for any 1,936 92.5 534,066 20,786,865 80.5 97.0
profession)
1 79 3.8 29,100 402,938 4.4 1.9

2 17 0.8 14,888 69,048 2.2 0.3
3 20 1.0 12,539 83,105 1.9 0.4
4 14 0.7 19,030 45,677 2.9 0.2
5 12 0.6 22,589 26,496 3.4 0.1
6 11 0.5 26,357 16,514 4.0 0.1
7 (GIRS scores of
0 or 1 for every 2 0.1 4,695 1,225 0.7 0.0
profession)
Total 2,091 100.0 663,264 21,431,868 100.00 100.00
Note: Higher numbers of GIRS scores of 0 or 1 indicate a greater level of relative workforce supply challenges.
SA2s included are only those with resident populations greater than 100 and valid data for all seven GIRS scores.

The AIHW is incorporating relative workforce supply measures in analyses of how
area-level characteristics can help to explain geographic variation in health outcomes
for Indigenous Australians.

The GIRS was unable to include important factors such as the adequacy of services,
the extent to which services are financially or culturally accessible and the extent to
which the services in an area meet the needs of the population as data on these factors
are unavailable.

For more information on relative workforce supply, see Spatial distribution of the supply of
the clinical health workforce 2014: relationship to the distribution of the Indigenous population.
For related reports, see Spatial variation in Aboriginal and Torres Strait Islander women’s
access to 4 types of maternal health services, Spatial variation in Aboriginal and Torres Strait
Islander people’s access to primary health services and Access to primary health care relative
to need for Indigenous Australians.
See also supplementary document S6.9 ‘Estimating the supply of the health workforce’
available online at <www.aihw.gov.au/reports/australias-health/australias-health-2018/
related-material>.
368
References
Dental Board of Australia 2015. Registration standards. Viewed 11 September 2015,
<http://www.dentalboard.gov.au/Registration-Standards.aspx>.
Department of Health 2013. National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
Li SQ, Gray NJ, Guthridge SL & Pircher SLM 2009. Avoidable hospitalisation in Aboriginal and
non-Aboriginal people in the Northern Territory. Medical Journal of Australia 190(10):532–6.
Chapter 6
369
370
Chapter 7
Prevention, treatment and
health services
371
7.0 Overview
A fundamental aim of any health system is to prevent disease and reduce ill health.
Australia has a large and complex network of health providers and services, not all
of which can be featured in this report. This chapter presents information on health
promotion and specific prevention services, primary health care, hospitals and selected
specialised treatment services. It also looks at the coordination of health care
and the use of patient reported measures to improve the quality of health services,
patient experiences and patient outcomes. This overview highlights some, but not all,
of the topics presented in this chapter.
Health promotion plays an important role in preventing disease and injury. It can help
to build social and physical environments that support healthy behaviours. Two of the
biggest health promotion success stories in Australia have been the reductions in road
deaths since the 1970s, and in smoking rates since the 1990s.
Other key preventive measures are immunisation, disease screening, and programs
aimed at preventing suicide. Immunisation in Australia begins at birth, with routine
vaccines provided against 16 diseases, including measles, mumps and whooping
cough. More than 90% of all children had received all the scheduled vaccinations at the
ages of 1, 2 and 5. Immunisation is a safe and effective way to protect against harmful
communicable diseases at the population level.
Population-based cancer screening is another major area of health prevention, through
national programs for breast, cervical and bowel cancers. Rates of participation in the
three programs were 55% of the target population for breast cancer screening, 55% for
cervical cancer screening and 41% for bowel cancer screening.
Suicide is a serious public health problem in Australia. A wide range of programs and
services are available: some have suicide prevention as a core goal; others work either
to reduce known risk factors for suicide or suicidality or to provide emergency medical
care (for example, ambulance services). Suicide prevention-specific initiatives range from
universal activities delivered to the whole population—regardless of their level of suicide
risk—to acute care provided to people at imminent risk of suicide, and to follow-up after
suicide attempts.
Medicines, too, play an important preventive role in the everyday lives of Australians.
They are also designed to treat and cure disease and health conditions. Some medicines
are available by prescription only from a health professional; others can be bought
over-the-counter in places like pharmacies and supermarkets. In 2016–17, more than
280 million prescriptions were subsidised by the Australian Government under the
Pharmaceutical Benefits Scheme (PBS). Medicines to treat cardiovascular conditions were
the most common, accounting for 88.4 million dispensed prescriptions. The Australian
Government spent about $12 billion on PBS medicines in 2016–17.
Primary health care is typically the first point of contact people have with the health
system in Australia, often delivered by a general practitioner (GP). But primary health care
also includes allied health professionals, community health workers, nurse practitioners,
pharmacists, dentists, Aboriginal and Torres Strait Islander health practitioners and midwives.
372
A sizeable proportion of health care services are delivered in primary health settings. In
2014–15, 85% of Australians had seen a GP in the last 12 months, 47% had seen a dentist,
and 28% had seen another primary health professional such as a pharmacist (8.1%),
physiotherapist (8.0%) or an optician or optometrist (6.5%). On average, people are using
more primary health services than they were 10 years ago.
Hospitals are also an integral part of our health system. Australia has more than 1,300
public and private hospitals collectively providing about 30 million days of patient care a
year. Emergency departments in public hospitals respond to about 21,000 presentations
a day—or 7.8 million a year. People aged 65 and over, children aged under 5 and
Indigenous Australians are over-represented in emergency department presentations,
compared with their representation in the Australian population. Nearly one-third (31%)
of emergency patients are admitted to hospital for further care.
Some people admitted to hospital need surgery. About two-thirds of elective surgery
(that is, planned surgery) in Australia is performed in private hospitals. Patients
undergoing elective surgery in public hospitals are clinically assessed, then placed on a
waiting list. In 2016–17, the median waiting time was 38 days.
In 2015–16, 4.5 million (42%) of the 10.6 million services for admitted patients in both
public and private hospitals were at least partially funded through private health
insurance. In public hospitals, 14% of admissions were at least partially funded by private
health insurance; in private hospitals, 83% of admissions were partially funded.
In Australia, the clear majority (97%) of the more than 300,000 births in 2015 occurred in
a hospital (around three-quarters in public hospitals and one-quarter in private hospitals).
One-third (33%) of babies born were delivered by caesarean section—the eighth highest
rate among 33 of the 35 member countries of the Organisation for Economic Co-operation
and Development reporting data.
The Australian health system also provides specialised treatment services to help people
with a broad range of health concerns, including mental illness and alcohol and drug use.
In 2015–16, about $9 billion was spent on services related to mental health, more than
half ($5.4 billion) of which was for state and territory specialised services. In 2015–16, GPs
provided almost one-third (31%) of the 11.1 million services related to mental health that
were subsidised by Medicare—and state and territory community mental health services
a further 9.4 million contacts.
Alcohol is the most common principal drug of concern for people seeking help at alcohol and
drug treatment services—32% of treatment episodes are for alcohol. However, over the past
five years, the percentage of clients seeking alcohol treatment services has fallen slightly.
Health systems can be difficult to navigate, especially for people with multiple conditions
or complex, long-term health care needs. Coordinating care so relevant information
is transferred between providers (for example, a GP and a specialist) and settings (for
example, an emergency department and primary health care) is crucial if a patient is to
receive consistent, cohesive care. Based on self-reported survey results, an estimated
98% of people had a usual GP or usual place of care, and 65% of people with a usual GP
Chapter 7
had been going to their GP for 5 or more years. Overall, people were positive about their
experiences—96% reported receiving excellent, very good or good quality of care.
373
7.1 Health promotion
SNAPSHOT
Our health behaviours—whether we smoke, drink alcohol, are immunised, have a healthy
diet or undertake regular physical activity—play a leading role in how healthy we are.
A major aim of the health care system is to positively influence our health behaviours to
prevent disease and reduce ill health.
Health promotion is a broad term. It encompasses activities that help communities and
individuals to increase control over their health behaviours. It focuses on preventing the
root causes of ill health—rather than on treatment and cure—and incorporates elements
of governance (actions by government, for example legislation and taxes), health literacy
and population health programs (for example, through public awareness campaigns)
(see Chapter 4.3 ‘Health literacy’), and urban planning (WHO 2016).
To change a health behaviour, a mix of interventions are often used for greater
effectiveness. An example is the comprehensive range of tobacco control measures
implemented in Australia, which include: health warnings on tobacco packaging; the
requirement for tobacco products to have plain packaging; prohibitions on tobacco
advertising, promotion and sponsorship; smoking restrictions in public places;
anti-smoking social marketing campaigns; and tobacco excise (tax) increases.
Health promotion in Australia

Australia has a long history of health promotion (Box 7.1.1), with health promotion
initiatives implemented by all levels of government and non-government organisations.
Activities include direct interventions aimed at immediate change, and those that aim
to educate and indirectly influence behaviour over the long term.
Box 7.1.1: Selected history of health promotion in Australia

Governance
1932–present: School-based diphtheria vaccination programs undertaken.
Diphtheria vaccination continues to be on the childhood immunisation schedule.
1951–1973: After the State Grants (Milk for School Children) Act was passed in 1950,
states and territories provided free milk to children in schools in a bid to improve
their diet.
1953–present: Fluoridated water was first introduced to Australia (Beaconsfield,
Tasmania) in 1953. All states and territories currently fluoridate their drinking water
(coverage varies).
1973–present: All states and territories require fitted seatbelts to be worn in motor
vehicles, and helmets for motorcycle riders and passengers.
1997–present: The Immunise Australia Program was introduced in 1997, which
funds the purchase of vaccinations for Australians. Routine immunisation began in
the 1950s, with the first nationally funded infant program in 1975.
continued
374
Box 7.1.1 (continued): Selected history of health promotion in Australia
2006–present: The requirement for graphic health warnings on tobacco product
packaging was implemented in 2006; this was expanded in 2012 to include an
increase in the size of the warning.
2009–present: Food Standards require folic acid to be added to bread-making flour
and iodine to bread via iodised salt.
2012–present: Plain packaging legislation stipulates that all retail packaged tobacco
products must be supplied in plain packaging.
2016–present: The Drug and Alcohol Program funds a range of drug and alcohol
treatment, prevention and national leadership activities.
2016–present: The Healthy Food Partnership aims to make healthier food choices
easier, with initiatives based on portion size, reformulation, and communication
and education.
Health literacy and population health programs

1975–1981: ‘Life. Be in it’ was an Australian Government program and advertising
campaign encouraging Australians to be more active.
1981–present: The ‘Slip, Slop, Slap’ campaign aimed to modify sun protection attitudes
and behaviour. The message was changed to ‘Slip, Slop, Slap, Seek, Slide’ in 2007.
1987: The ‘Grim Reaper’ television advertisements aimed to shock Australians into
discussions about HIV transmission.
1989–2015: The Heart Foundation ‘Tick Program’ aimed to help consumers make
healthier food choices. Following the introduction of the ‘Health Star Rating System’
(see below), the Heart Foundation retired the Tick Program and it is currently being
phased out on products.
1997–2004: The ‘Every cigarette is doing you damage’ campaign featured graphic
advertisements of the damage done by cigarette smoking.
2000–present: The ‘Good Sports Program’, run by the Alcohol and Drug Foundation,
aims to change the alcohol drinking culture among sporting clubs.
2010–present: ‘Hello Sunday Morning’ is an initiative that uses technology to
support individuals in changing their relationship with alcohol.
2014–present: The ‘Health Star Rating’ is a front-of-pack labelling system that
displays a standard way to compare the nutritional value of similar products.
2016–2017: ‘Girls Make Your Move’ is a recent Australian Government campaign
that aimed to encourage girls and young women aged 12–19 to be more active.
Urban planning
2005–2010: VicHealth’s ‘Food for All’ program aimed to enhance access to nutritious
food through integrated planning of factors that influence access to food: transport,
housing, economic development and land use.
Current: Housing developments are being designed with health at the centre of
Chapter 7
planning, such as the Selandra Rise development on the outskirts of Melbourne.

The Heart Foundation’s ‘Healthy Active by Design’ website has been designed to
help incorporate health into the design of our built environment.
375
Success stories
Two of the biggest health promotion success stories in Australia have been reductions
in road deaths, from 30 per 100,000 population in 1970 to 5.4 per 100,000 population in
2016 (BITRE 2010, 2017) and daily tobacco smoking rates, from 24.3% in 1991 to 12.2% in
2016 for people aged 14 and over. There have, however, been other notable successes.
Mandatory folic acid fortification was introduced in Australia in 2009 to help prevent
neural tube defects (serious birth defects). Following this initiative, the rate of neural tube
defects fell (to 2011) by 14.4%. The decrease was largest for teenagers (54.8% reduction)
and Aboriginal and Torres Strait Islander women (74.2% reduction). The reduction in
neural tube defects in the Indigenous population is of particular note given that previous
strategies to increase folic acid intake and reduce neural tube defects in this population
were unsuccessful.
Australia’s immunisation program has successfully reduced the incidence of harmful
infectious diseases. Since routine immunisations were started in Australia in the 1950s,
death and disability from many once-common infectious diseases (such as polio and
diphtheria) are now rare (Department of Health 2013). Examples of successes following
more recent additions to the vaccination schedule include a reduction in hospitalisations
and deaths due to rotavirus (a cause of gastroenteritis) (Reyes et al. 2017), and a
reduction in morbidity due to varicella (chickenpox) (Sheridan et al. 2017) (see Chapter 7.2
‘Immunisation and vaccination’).

Monitoring and evaluation are important to assess the performance of health promotion
initiatives. Monitoring relies on available data to determine who is most affected by
a health problem, and whether the situation changes after intervention. While data
are available to help with monitoring some specific interventions, more work could be
undertaken for systematic monitoring of health promotion initiatives in Australia.

For more information on health promotion in Australia, see the Australian Health
Promotion Association website: <www.healthpromotion.org.au>.
For information on the global campaign for health promotion as a major health
strategy, or for the principles of health promotion, see the World Health Organization
website: <www.who.int/healthpromotion>.
References
BITRE (Bureau of Infrastructure, Transport and Regional Economics) 2010. Road deaths in Australia
1925–2008. Canberra: BITRE.
BITRE 2017. Road trauma in Australia, 2016: statistical summary. Canberra: BITRE.
Department of Health 2013. National Immunisation Strategy for Australia, 2013–2018. Canberra:
Reyes J, Wood J, Beutels P, Macartney K, McIntyre P, Menzies R et al. 2017. Beyond expectations: post-
implementation data shows rotavirus vaccination is likely cost-saving in Australia. Vaccine 35:345–52.
Sheridan S, Quinn H, Hull B, Ware R, Grimwood K & Lambert S 2017. Impact and effectiveness of childhood
varicella vaccine program in Queensland, Australia. Vaccine 35:3490–7.
WHO (World Health Organization) 2016. What is health promotion? World Health Organization. Viewed
6 November 2017, <http://www.who.int/features/qa/health-promotion/en/>.
376
7.2 Immunisation and
SNAPSHOT
vaccination
Immunisation is a safe and effective way to protect against harmful communicable diseases
and, at the population level, prevent the spread of these diseases among the community.
In Australia, routine immunisation begins at birth, and includes vaccines against 17 diseases,
including measles, mumps and whooping cough (Department of Health 2018b).
The Australian Government funds a range of vaccinations for eligible people under the
Immunise Australia Program. The influenza vaccine, for example, is available, for free, to
pregnant women, Aboriginal and Torres Strait Islander people, people aged 65 and over,
and people who are medically at risk and thus more likely to experience complications
from influenza. Additional vaccines may also be funded through state and territory
programs, through the workplace and bought privately by prescription.
For immunisation to have the greatest benefit, a large proportion of the community
must be fully immunised. In the past, target coverage rates have been around 90%,
with these rates for children being largely achieved. However, due to a higher level of
vaccine coverage needed to achieve community immunity for measles, an aspirational
national immunisation target has been set at 95% of all children to be fully immunised
(Department of Health 2018a).
Childhood immunisation rates

All Australian children are expected to have received specific immunisations by a certain
age according to the National Immunisation Program Schedule. Fully immunised status
is measured at ages 1, 2 and 5 and means that a child has received all the scheduled
vaccinations appropriate for their age.
In 2016, the immunisation rate for all children aged 1 was 93.4%; it was 91.4% for 2-year
olds and 93.2% for 5-year-olds.
For Indigenous children in 2016, the national immunisation rates for children aged 1 and 2
were lower than the rates for all children. In contrast, the immunisation rate for 5-year-old
Indigenous children was higher than the rate for all children (95.2% compared with 93.2%)
(Table 7.2.1).
Table 7.2.1: Proportion of children assessed as fully immunised (per cent), by age, 2016
Age
1 2 5
All children 93.4 91.4 93.2

Indigenous children 91.2 89.1 95.2
Chapter 7
Source: Department of Health 2017.
377
Figure 7.2.1 presents the immunisation rates for children aged 1 and 2 from 1999 to 2016
and for children aged 5 from 2005 to 2016. It shows that the immunisation rate for:
• 1
-year-olds remained relatively stable between 2001 and 2012. The slight fall in the rate
for 2013 and 2014 may have been due to a change in the definition of ‘fully immunised’
• 2
-year-olds increased markedly from 1999 to 2004 and remained relatively stable above
90% until 2013. Changes in the definition of ‘fully immunised’, made in 2014, may have
contributed to the drop in 2015
• 5
-year-olds increased from 74.4% in 2005 to 93.2% in 2016. Children who have had
catch-up immunisations are included as ‘fully immunised’ even if they were not fully
immunised when they were aged 1 or 2.
Figure 7.2.1: Immunisation rates for children aged 1, 2 and 5, 1999 to 2016
Per cent
95
90
85
80
75 1-year-olds
2-year-olds
70
5-year-olds
65
60
0
1999 2001 2003 2005 2007 2009 2011 2013 2015
Year
Human Papillomavirus immunisation rates

A national Human Papillomavirus (HPV) vaccination program (using the quadrivalent
HPV vaccine, which protects against four types of HPV) was introduced for school-aged
girls in 2007 and extended to boys in 2013. From 2018, a new vaccine will be introduced,
protecting against nine types of HPV. Of young people turning 15 in 2016, around 79% of
girls and nearly 73% of boys were fully immunised against HPV (NHVPR 2017).
378
Until now there has been no regular and nationally consistent source of data with which
to estimate vaccination coverage in adolescents and adults. Population surveys have
previously been used to estimate vaccination coverage in the adult population or in
selected population groups.
The Australian Immunisation Register is a national register that details all funded
vaccinations and most privately purchased vaccines given to individuals of all ages who
live in Australia. It was set up in 1996 as the Australian Childhood Immunisation Register
and renamed following its expansion in 2016. Adult vaccination data captured in the
register will be reported when reliable estimates can be obtained (Department of Human
Services 2017).

Australia generally has high immunisation rates, which have increased steadily over time;
however, variation still exists across local areas. More information on immunisation at the
local level is available at <www.myhealthycommunities.gov.au>.
More information on the Immunise Australia Program is available at
<www.immunise.health.gov.au>.
References
Department of Health 2017. AIR—annual coverage historical data. Canberra: Department of Health.
Viewed 29 November 2017, <http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/
Content/acir-ann-cov-hist-data.htm>.
Department of Health 2018a. Immunisation coverage rates are improving. Canberra: Department of
Health. Viewed 4 April 2018, <https://beta.health.gov.au/news-and-events/news/immunisation-coverage-
rates-areimproving>.
Department of Health 2018b. What is immunisation? Canberra: Department of Health. Viewed 4 April 2018,
<https://beta.health.gov.au/topics/immunisation/getting-started/what-is-immunisation>.
Department of Human Services 2017. About the Australian Immunisation Register. Canberra: Department
of Human Services. Viewed 18 April 2018, <https://www.humanservices.gov.au/individuals/enablers/about-air>
NHVPR (National HPV Vaccine Program Register) 2017. Coverage data. Melbourne: NHVPR. Viewed
9 January 2018, <http://www.hpvregister.org.au/research/coverage-data>.
Chapter 7
379
7.3 Suicide prevention
SNAPSHOT
activities
Suicide prevention activities in Australia are complex. Government agencies, service
providers and the non-government sector all have interconnected responsibilities.
Although these activities are a priority area under the 5th National Mental Health and
Suicide Prevention Plan, there is currently limited published information on government
investment in suicide prevention and the resulting service activity at the national and
jurisdictional level (often delivered by non-government organisations). This snapshot
provides an overview of available data for this investment and activity and outlines
potential areas for improved data collection and reporting.
How common is suicide and suicidality?

Suicide is a major public health problem, both in Australia and internationally. According
to the AIHW’s Australian Burden of Disease Study, suicide and self-inflicted injuries are
the fourth leading cause of fatal burden of disease in Australia, accounting for 4.9% of the
fatal burden of disease in 2011. In 2012, it was estimated that the economic cost of suicide
death in Australia was $1.7 billion (KPMG 2013).
Despite ongoing efforts to improve suicide prevention initiatives, the age-standardised
suicide rate of both males and females shows an overall increase from 2007 to 2016, from
16 to 18 per 100,000 population for males and 5 to 6 per 100,000 population for females.
Aboriginal and Torres Strait Islander people remain disproportionately affected by suicide.
In 2016, the age-standardised suicide rate for Indigenous people was 24 per 100,000
population—twice the rate for the non-Indigenous population, at 12 (ABS 2017).
Suicidal ideation, suicide plans and suicide attempts—collectively called ‘suicidality’—are
more common than suicide deaths and can have a profound impact on individuals,
families, communities and society. The 2007 National Survey of Mental Health and
Wellbeing estimated that, at some point in their lives, 13% of Australians aged 16–85 have
experienced suicidal ideation, 4.0% have made suicide plans and 3.3% have attempted
suicide (Slade et al. 2009).
How much do governments spend on

suicide prevention activities?
The Australian Government’s total expenditure under the National Suicide Prevention
Strategy (NSPS) increased from $1.9 million in 1995–96 to $49.1 million in 2015–16. The
Australian Government also contributes to suicide prevention through investments in
broader programs and services for homelessness, Indigenous health, employment,
education, community welfare, drugs and alcohol, and mental health.
State and territory governments also fund initiatives under their own suicide prevention
strategies. This expenditure is currently not publicly reported in a consolidated form by all
jurisdictions.
380
Types of suicide prevention activities
The causes of suicide and suicidality are complex and multifaceted. There are therefore
a wide range of suicide prevention programs and services, some of which have suicide
prevention as a core goal (for example, gatekeeper training), and others to reduce known
risk factors for suicide or suicidality, or to provide emergency medical care (for example,
ambulance services, see Box 7.3.1). These types of programs and services can be referred
to as ‘suicide prevention-specific’ and ‘suicide prevention-related’, respectively.
Suicide prevention-specific initiatives range from universal activities (those delivered to
a whole population, regardless of their level of suicide risk), to acute care provided to
people at imminent risk of suicide, and to follow-up after suicide attempts and postvention
(intervention after a person’s suicide to support that person’s family, friends and peers).
Box 7.3.1: Ambulance attendances in Victoria

Ambulance services may provide a pathway to hospital care for people at risk of
suicide. In 2013, data were collected on suicide-related ambulance attendances in
five states and territories for a pilot surveillance system for cases related to suicide,
self-harm, overdose and mental health. Data from Victoria cover the full 12 months.
Over this period, Victoria reported ambulance attendance at 150 suicide deaths,
6,500 suicide attempts, and 7,300 cases of suicidal ideation without suicide attempt.
The patient was transported to hospital in 99% of suicide attempt attendances and
97% of suicidal ideation attendances (Lloyd et al. 2015).
People may also present to emergency departments either by ambulance or by other

means; however, the current national emergency department data collection lacks the
specificity to report accurately on this activity.
Comprehensive data are not available on how many suicide prevention-specific and
suicide prevention-related initiatives and services operate in Australia. However, from
1999 to 2005, the NSPS funded 156 local suicide prevention projects (Headey et al. 2006);
around 50 projects were funded under the NSPS and Taking Action to Tackle Suicide
package from 2006–07 to 2012–13 (AHA 2014).
Admitted hospital care

Suicidal ideation or suicide attempts may result in admission to hospital for specialised
mental health care. National admitted hospital data cannot be used to distinguish
between suicidal ideation, non-suicidal self-injury and suicide attempts, so activity relating
to these types of presentations is collectively reported as intentional self-harm.
In 2015–16, more than 32,900 separations (32,780 public hospital separations and 128
private hospital separations) had a principal diagnosis of injury or poisoning related to
intentional self-harm. Indigenous patients were over-represented among these, making
Chapter 7
up 8.2% of hospitalisations for intentional self-harm. There has been minimal variation in
the number of separations for intentional self-harm over the 5 years to 2015–16.
381
Psychological services
The Access to Allied Psychological Services program enables a range of health, social
welfare and other professionals to refer consumers who have been diagnosed with a
mild to moderate mental disorder to a mental health professional for short-term focused
psychological services. In 2015–16, more than 7,200 people accessed suicide prevention
initiatives (7,000 suicide prevention services and 200 services specifically for Indigenous
people). Collectively, these consumers were provided almost 42,700 sessions (an average
of 6 sessions per consumer), and 480 consumers (6.6% of consumers accessing the
initiative) received 13–18 sessions.
Postvention services
Postvention services, as mentioned earlier, support and assist people who have been
exposed to or bereaved through suicide, to help reduce their distress and the risk of ‘suicide
contagion’ (AHA 2014). An example of a postvention service provider is headspace’s School
Support, which, in 2015–16, worked with more than 1,600 Australian school communities to
prepare for, respond to and recover from a suicide (headspace 2016).
Teleweb services
Teleweb services provide telephone or web-based crisis support, or self-help programs.
Several teleweb services provide suicide prevention services in Australia. The biggest of
these is Lifeline which, in 2016–17, received about 933,400 calls through its telephone
crisis support line—an average of about 2,600 calls per day. For around 130 calls per day,
the person seeking help was considering suicide now or in the future; for about 105 of
these calls, safety plans were created to help the caller to manage their suicidality and
take steps to recovery. Lifeline also had about 46,200 conversations through its Online
Crisis Support Chat service, around 42% of which identified suicide as a safety issue
(Lifeline Australia 2017).

Currently, data on suicide prevention expenditure, program and service activity are not
systematically collected and publicly reported at the national and jurisdictional levels.
Australian Government expenditure under the NSPS is reported annually, but there is
limited reporting on the number and type of services resulting from this investment. State
and territory governments complement Australian Government initiatives with their own
suicide prevention plans, designed to meet local needs, but data on the expenditure and
service activity for these plans are not publicly reported in any state or territory.
In February 2017, the Australian Government announced that 12 Primary Health Networks
(PHNs) would be given responsibility for conducting suicide prevention trials to strengthen
mental health care and suicide prevention in their region. Data collected on the suicide
prevention activities of these PHNs are expected to be publicly reported in 2019–20.
382
Hospital emergency departments are important points of contact for many people
experiencing suicidal crisis. However, existing national emergency department data
collections cannot currently be used to reliably report on suicide or presentations related
to intentional self-harm. Some states and territories have undertaken data linkage to
better understand emergency department response to suicide-related activity.
Currently, there is no data source to routinely report on the activities of first responders
across Australia—including ambulance attendances—for self-harm or suicide behaviours
(Box 7.3.1 describes a pilot surveillance project for this data).
A number of states and territories have also created suicide registers to glean more
detailed information on individuals who died from suicide; however, there is no nationally
consistent approach to reporting this information at this time.
The inclusion of suicide in the 5th National Mental Health and Suicide Prevention
Plan, and the commitment to better the quality of care for individuals who present to
hospital after a suicide attempt, provide key opportunities to improve the collection and
reporting of data on suicide prevention activities and to enhance understanding of suicide
prevention needs and subsequent outcomes for Australians.

The 5th National Mental Health and Suicide Prevention Plan is available on the Council of
Australian Governments Health Council website.
More information about suicide deaths is available in the Australian Bureau of Statistics
report Causes of death, Australia, 2016.
More information about mental health expenditure and service data is available in the
AIHW report Mental Health Services in Australia.

References
ABS (Australian Bureau of Statistics) 2017. Cause of death, Australia, 2016. ABS cat. no. 3303.0. Canberra: ABS.
AHA (Australian Healthcare Associates) 2014. Evaluation of suicide prevention activities: final report.
Melbourne: AHA.
Headey A, Pirkis J, Merner B, VandenHeuvel A, Mitchell P, Robinson J et al. 2006. A review of 156 local
projects funded under Australia’s National Suicide Prevention Strategy: overview and lessons learned.
Australian e-Journal for the Advancement of Mental Health 5:1–15.
headspace (National Youth Mental Health Foundation) 2016. Annual report 2015–16. Melbourne: headspace.
KPMG Health Economics 2013. The economic cost of suicide in Australia. Canberra: Menslink.
Lifeline Australia 2017. Annual report 2016–17. Canberra: Lifeline Australia.
Lloyd B, Gao CX, Heilbronn C & Lubman DI 2015. Self harm and mental health-related ambulance
Chapter 7
attendances in Australia: 2013 data. Fitzroy, Victoria: Turning Point.

Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J et al. 2009. The mental health of Australians
2: report on the 2007 National Survey of Mental Health and Wellbeing. Canberra: Department of Health
and Ageing.
383
7.4 Cancer screening
SNAPSHOT
Population-based cancer screening is an organised, systematic and integrated process

of testing for signs of cancer or pre-cancerous conditions in populations without obvious
symptoms. In Australia, there are national population-based screening programs for
breast, cervical and bowel cancers. They are run through partnerships between the
Australian Government and state and territory governments. The programs target
particular populations and age groups where evidence shows screening is most effective
at reducing cancer related morbidity and mortality.
BreastScreen Australia
BreastScreen Australia, established in 1991, provides free 2-yearly screening
mammograms (see Glossary) to women aged 40 and over, and actively targets women
aged 50–74.
• In 2015–2016, nearly 1.8 million women aged 50–74 participated in BreastScreen
Australia—around 55% of the target population.
• P
articipation is lower among Aboriginal and Torres Strait Islander women, at around
37% of the Indigenous population, as well as among women living in Very remote areas
(47%) and women from a culturally or linguistically diverse background (48%).
• M
ore than half (59%) of all breast cancers detected through BreastScreen Australia are
small (≤15 mm); small breast cancers are associated with more treatment options and
improved survival.
National Cervical Screening Program

Before 1 December 2017, the National Cervical Screening Program (NCSP), established
in 1991, targeted women aged 20–69 for a 2-yearly Papanicolaou smear, or ‘Pap test’
(see Glossary).
• In 2015–2016, more than 3.8 million women aged 20–69 participated in the NCSP—
around 55% of the target population. This equates to an age-standardised rate of 56%.
This rate was a slight fall on what had been a relatively steady rate since 2004–2005—
around 58–60% (Figure 7.4.1).
• P
articipation varies across remoteness areas. It is highest in Inner regional areas (57%)
and lowest in Very remote locations (46%); it increases with increasing socioeconomic
position (from 50% in the lowest socioeconomic area to 62% in the highest area).
• F
or every 1,000 women screened, around 7 have a high-grade abnormality detected,
providing an opportunity for treatment before possible progression to cervical cancer.
384
Figure 7.4.1: Number of participants and age-standardised participation rate
(per cent) of women aged 20–69 in the NCSP, 1996–1997 to 2015–2016
Number of participants Participation (per 100,000)

5,000,000 Number of participants Participation 100
90
4,000,000 80
70
3,000,000 60
50
2,000,000 40
30
1,000,000 20
10
0 0
0
01 01
03 03
09 09
12 12
13 13
14 14
11 11
04 04
99 99
97
98 98
8
07 07
15 15
6
02 2
10 0
5
06 06
20 200
20 200
01
20 200
20 201
20 200
20 –20
20 20
20 –20
20 20
20 –20
20 20
20 –20
20 –20
19 –19
9
20 20
20 20
20 20
–1
–1
–2
–
–
–
–
–
–
00
08
96
97
05
19
19
19
Year
Note: Rates from 1996–1997 to 2003–2004 are not directly comparable with rates from 2004–2005 onwards,
because a different source of hysterectomy fractions was used to adjust the population.
Source: AIHW analysis of state and territory cervical screening register data; Table S7.4.1.
National Bowel Cancer Screening Program

The National Bowel Cancer Screening Program (NBCSP) was established in 2006. In 2014,
the Australian Government announced that it would be expanded and, once fully
implemented in 2020, would offer free 2-yearly screening for all Australians aged 50–74.
The program currently targets men and women turning 50, 54, 58, 60, 62, 64, 66, 68, 70, 72
and 74, and invites them to screen for bowel cancer using a free immunochemical faecal
occult blood test (iFOBT) (see Glossary). In 2015–2016, nearly 3.2 million people were invited
to participate in the program. Of these:
• a
bout 1.3 million returned a completed iFOBT kit for analysis—a participation rate of
41%. Participation was higher among women (43% of all women invited) than men (39%)
(Figure 7.4.2)
• o
f participants who underwent a colonoscopy in 2016 after a positive screen, 1 in 29
(3.8%) were diagnosed with a confirmed or suspected bowel cancer, and 1 in 17 (6.0%)
were diagnosed with an advanced adenoma (pre-cancerous tumour)
• t he participation rate has remained relatively stable for men and women combined over
time; it started at 44% in 2007–2008, decreased to 36% in 2012–2013 then increased to
Chapter 7
41% in 2015–2016 (Figure 7.4.2).
385
Figure 7.4.2: Participation rate (per cent), National Bowel Screening Program,
2007–2008 to 2015–2016
Participation rate (per cent)

60
40
20
Males Females Persons
0
1
0
5
8
12
6
13
4
01
01
01
00
00
01
01
20
20
–2
–2
–2
–2
–2
–2
–2
–
–
07
08
11
12
13
09
10
14
15
20
20
20
20
20
20
20
20
20
Year
Notes
1. Data presented are for rolling 2-year participation periods.
2. Trend data use the performance indicator specifications retrospectively on previous years’ data.
Source: NBCSP Register, as at 30 June 2017; Table S7.4.2.

National cancer data do not reveal if a new case of cancer was identified through
screening. This information can currently only be collated using probabilistic data linkage.
Participation in cervical screening cannot be measured nationally for Indigenous women
because Indigenous status is not included on all pathology forms in all states and
territories (the only source of information for cervical screening registers). However,
available evidence on participation in cervical screening by Indigenous women suggests
that Indigenous women are under-screened.

The BreastScreen Australia monitoring report 2014–2015, Cervical screening in Australia, 2018,
and National Bowel Cancer Screening Program: monitoring report 2018 are available for
free download.
386
7.5 Primary health care
FEATURE ARTICLE
Primary health care is the frontline of Australia’s health care system. It is typically the
first point of contact people have with the health system and includes a broad range
of services delivered outside the hospital that generally do not need a referral. Many
Australians receive most of their primary health care through their general practitioners
(GPs), although primary health care providers also include allied health professionals,
community health workers, nurses, pharmacists, dentists, midwives and Aboriginal and
Torres Strait Islander health workers and practitioners (Department of Health 2013).
Primary health care providers deliver a wide range of services to the community,
including health promotion and prevention, early intervention, treatment of acute
conditions and management of chronic conditions. While the bulk of these services
are subsidised under Medicare—a universal public insurance scheme—all levels of
government, as well as many private and non-government organisations, are involved in
funding and delivering primary health care. See Chapter 2.1 ‘How does Australia’s health
system work?’ for more information.
Primary health care aims to improve the overall health of the population by providing
a consistent point of care across people’s life span that is tailored to patients’ needs
and coordinated with the rest of the health system. Effective primary health care can
improve outcomes at a lower cost than for hospital and secondary care, and help to
avoid unnecessary hospitalisations (OECD 2017).
Australia’s primary health care system faces several ongoing challenges. These include
inequalities in access to effective and coordinated care, as well as increasing demand
(due to an ageing population and rising levels of chronic conditions and risk factors).
Yet, despite its importance, the availability of reliable high-quality data on our primary
health care system is limited. This makes it difficult to assess its performance with
the same rigour as applied for hospital care, and to identify and monitor areas where
improvements are needed.
This article provides an overview of Australia’s primary health care sector, with a focus on
the scale, type and accessibility of GPs, allied health and dental care. It also includes some
information on the role that primary health care providers play in referring patients
and supporting their access to other non-hospital (‘secondary’) health care, such as
specialist doctors.
What is the scale and nature of primary

health care in Australia?
A substantial proportion of health care services in Australia are delivered in primary
health care settings. In 2015−16, primary health care accounted for 35% (or $59 billion)
Chapter 7
of Australia’s total health expenditure, while hospital services accounted for 39%, and
referred medical services for 10% (AIHW 2017b). See Chapter 2.2 ‘How much does
Australia spend on health care?’ for more information.
387
In 2014−15, 85% of Australians saw at least one GP in the previous 12 months, 47% saw
a dentist, and 28% saw another primary health professional such as a pharmacist (8.1%),
physiotherapist (8.0%) or an optician or optometrist (6.5%) (ABS 2017b).
Table 7.5.1 presents an overview of the scale and type of primary health care in Australia.
Over the past decade, the number of services claimed per person each year has steadily
increased for most types of primary health services. This means that, on average, people
are receiving more primary health care services than they were 10 years ago. More
detailed information about allied health and dental services can be found in Table 7.5.2.
Table 7.5.1: Use of primary health care (and related non-hospital services),
2007–08 and 2016−17
Type of service Number of Services per 100 Change in rate

services, 2016–17 people, 2016–17 since 2007−08
(million) (rate) (%)
Primary health care services
GPs 148.3 602.7 17.5 

Allied health type services 71.2 289.3 43.1 
Dental 45.8 186.1 ..
Non-referred practice nurse 2.1 8.5 65.4 
Indigenous-specific primary health 3.9 .. 84.5 
care services
Prescriptions dispensed 293.1 1,191.5 ..
(PBS and RPBS)
Non-hospital referred services
Pathology 120.0 487.9 20.0 

Diagnostic imaging 23.7 96.4 33.5 
Specialists 23.0 93.4 14.8 
.. no data / insufficient data
PBS = Pharmaceutical Benefits Scheme; RPBS = Repatriation Pharmaceutical Benefits Scheme
Note: Excludes services delivered to admitted hospital patients. Upward-facing arrows () and downward-facing
arrows () denote a change of at least 5.0% between 2007–08 and 2016–17. Results for Indigenous-specific
primary health care services are for 2015–16 and 2008–09 as data for 2016–17 and 2007–08 were unavailable
at the time of publication. The percentage increase is for the increase in number of Indigenous-specific primary
health care services over the time period, not the change in rate. Detailed notes are available in Supplementary
Table S7.5.1.
Sources: ABS 2017a; AIHW 2017a; AIHW analysis of Department of Health Medicare Benefits Schedule (MBS)
data 2018; AIHW analysis of Department of Health PBS and RPBS data 2018; Australian Prudential Regulation
Authority 2017; Department of Health 2017a; Table S7.5.1.
Table 7.5.1 does not include services that were completely paid for by patients or were
subsidised by the Department of Veterans’ Affairs (DVA), compensation arrangements
or through other publicly funded programs. In 2015–16, 6.1 million GP and specialist
attendances, 3.6 million allied health services and 721,000 dental services were processed
by the DVA (Department of Human Services 2016). In the same year, it was estimated that
2.6% of GP encounters were not Medicare or DVA-subsidised (Britt, Miller & Henderson
et al. 2016). See Chapter 5.6 ‘Veterans’ for more information on veterans’ health.
388
General practitioners
GPs are the first point of contact that many Australians have with the health system for a
health concern. There are currently limited national data on the health conditions for which
people seek GP care, and the type of treatment given and recommended to patients.
GPs treat a broad range of health issues. Data from the final year of the Bettering the
Evaluation and Care of Health (BEACH) Survey of GPs estimated that, in 2015−16, 40%
of GP encounters included managing at least one chronic health problem (Britt, Miller &
Henderson et al. 2016).
Problems of a general and unspecified nature—such as general check-ups, prescriptions
and general immunisations—were managed at 19% of GP visits (Figure 7.5.1).
Since 2006−07, the proportion of GP encounters at which at least one psychological
problem was managed has steadily increased,
from 10% to 12% in 2015−16, while the
proportion of GP encounters where at least In 2015–16, the main problems
one circulatory problem (such as hypertension) managed by GPs were:
was managed decreased from 16% to 14% • respiratory (at 19% of GP visits)
(Britt, Miller & Bayram et al. 2016). • musculoskeletal (17%)
GPs also provide urgent medical care. In 2016−17, • skin (16%)
it is estimated that 9.3% of people aged 15 and over • circulatory (14%).
saw a GP for urgent medical care (ABS 2017c).
Figure 7.5.1: Proportion of GP encounters at which at least one problem was

managed, by type of problem, 2015−16
Per cent
25
20
15
10
0
Neurological
Digestive
Circulatory
Musculoskeletal
Psychological
Endocrine and
metabolic
Respiratory
system
Female genital
General and
unspecified
Skin
Problem managed
Note: Data are from the BEACH survey of GPs. The type of problem is categorised by the International
Classification for Primary Care Version 2 (ICPC-2) chapter. Each chapter contains multiple types of related
problems (for example ‘Respiratory’ includes upper respiratory tract infection and asthma). If two problems
Chapter 7
from the same chapter were managed at the same encounter, the occasion was counted only once.
Categories are not mutually exclusive. Multiple types of problems from different ICPC-2 chapters may have
been discussed at each GP encounter. The thin vertical line superimposed over the top end of each bar are
95% confidence intervals.
Source: Britt, Miller & Henderson et al. 2016; Table S7.5.2.
389
What kind of care do GPs give?
GPs use a wide range of treatments to manage patients’ health problems. These include
referring patients to other health professionals for assessment, treatment and tests.
The BEACH survey estimated that in 2015–16:
• 52% of GP visits had at least one medication prescribed
• 42% of visits involved a clinical or procedural treatment

(most commonly advice or education)
• 26% of visits involved a referral for a pathology, imaging or other type of test
• 15% of visits involved a referral to specialists, allied health services, hospitals or

emergency departments
• 9.3% of visits involved a recommendation for over-the-counter medications

(most commonly paracetamol)
• 7.4% of visits had a vaccine or medication provided directly to the patient

(most commonly the influenza virus vaccine) (Britt, Miller & Henderson et al. 2016).
More than one type of these actions occurred in under half of GP visits (45%)
(Britt, Miller & Henderson et al. 2016). See Chapter 7.6 ‘Medicines in the health system’
for more information about medicines.
GPs also play an important role in providing lifestyle advice and education to people,
with an emphasis on the ‘SNAP’ risk factors: smoking, nutrition, alcohol and physical
activity (RACGP 2015).
In 2014–15, of people aged 15 and over:

• 14% discussed reaching a healthy weight with a GP
• 11% discussed eating healthy food or improving their diet
• 10% discussed increasing physical activity (ABS 2017b).
In the same year (2014–15), 33% of adult smokers discussed reducing or quitting smoking
with a GP, 31% of adults who were obese discussed reaching a healthy weight, and 10%
of adults who (on average) drank more than 2 standard drinks per day discussed drinking
alcohol in moderation (ABS 2017b).
Enhanced GP care
Medicare supports enhanced GP care of complex patients through Medicare-subsidised
Enhanced Primary Care (EPC) services. In 2016−17, 12.6 million EPC GP attendances were
provided to 5.2 million people (21% of all Australians) (Department of Health 2017a). These
sessions involve GPs conducting thorough health checks for at-risk people, including people
aged 75 and over, aged 40–49 with high risk of developing type 2 diabetes, and refugees.
390
EPC services also include developing and reviewing health plans for people with chronic,
complex or mental health conditions. Where patients need multidisciplinary, team-based
care from a GP and other health professionals—for example, specialists or allied health
providers—the other health professionals are also involved in developing the patient
plan. These plans provide a structured way for GPs (and, where relevant, a team of health
care providers) to organise their patients’ care, keep up-to-date and comprehensive
information on their health and care, and help them achieve their treatment goals.
The plans also allow eligible patients to access Medicare-subsidised allied health services
(Department of Health 2018). See Chapter 7.18 ‘Coordination of health care’ for more
information.
Allied health
Allied health professionals include a broad range of health practitioners who are not
doctors, nurses or dentists. Allied health professionals include, but are not limited to,
Indigenous health practitioners, chiropractors, occupational therapists, optometrists,
osteopaths, pharmacists, physiotherapists, podiatrists, psychologists, sonographers and
speech pathologists (Allied Health Professions Australia 2017).
There are limited comprehensive data on allied health services in Australia, even though
it is estimated that around one-quarter of the population uses them (ABS 2017b).
Australians can access subsidised allied health services through their private health
insurance if they have general treatment (‘ancillary’ or ‘extras’) cover, or through Medicare
where eligible (most commonly through EPC services). There has been a marked increase
in the use of these allied health services over the past decade (Table 7.5.2). At present,
we do not have national data on allied health services accessed outside of private health
insurance or Medicare.
Dental services
As for allied health services, there are limited national data on dental services that are not
claimed through private health insurance, or (in limited circumstances) through Medicare.
Use of dental services claimed through general private health insurance have increased
by 35% in the last 10 years (Table 7.5.2). In June 2017, 55% of the population had general
private health insurance (Australian Prudential Regulation Authority 2017) and were thus
eligible to claim these dental and allied health services.
Chapter 7
391
Table 7.5.2: Use of allied health and dental services, 2007−08 and 2016−17
Number of Services per 100 Change in

Type of service services, 2016–17 people, 2016–17 rate since
(million) (rate) 2007−08 (%)
Medicare-subsidised allied health services

Optometry 8.9 36.1 34.9 
Mental health 5.3 21.5 132.1 
Podiatry 3.0 12.3 430.8 
Physiotherapy 2.2 9.0 311.6 

Other 1.7 6.9 58.3 
Total allied health (Medicare) 21.1 85.9 91.1 
General private health subsidised allied health services

Optical 11.6 47.3 54.9 
Physiotherapy 11.5 46.9 34.6 
Chiropractic 9.4 38.1 3.0 ~
Natural therapies 6.2 25.1 133.2 
Other 11.4 46.2 4.3 ~
Total allied health 50.1 203.5 29.3 
(general private health)
Dental
General private health insurance 40.6 164.9 35.0 
Child Dental Benefits Schedule and MBS 5.2 21.2 ..
Total dental 45.8 186.1 ..
.. no data / insufficient data
MBS = Medicare Benefits Schedule
Note: Upward-facing arrows () denote a change of at least 5.0% between 2007–08 and 2016–17. A tilde (~ )
denotes a change of less than 5.0% between years. Detailed notes are available in Supplementary Table S7.5.3.
Sources: ABS 2017a; AIHW analysis of MBS data set 2018; Australian Prudential Regulation Authority 2017;
Department of Health 2017a; DHS 2018; Table S7.5.3.
Access to primary health care

The Australian primary health care system aims to improve health and prevent illness
by providing care that is accessible, appropriate, responsive to needs, patient-centred,
high quality, safe, coordinated across the health sector, and sustainable (Department of
Health 2013). See chapters 7.17 ‘Patient-reported experience and outcome measures’,
7.18 ‘Coordination of health care’ for more information.
392
Accessible primary health care is important for the early detection and treatment of
risk factors and conditions, and improved health outcomes. A person’s ability to access
appropriate and quality primary health care is influenced by their specific health needs
as well as by factors such as where they live, their socioeconomic circumstances, and
their cultural background. People living in rural and remote or low socioeconomic
areas, Indigenous Australians and people with disability tend to have poorer access to
health care and worse health outcomes (Department of Health 2013). See Chapter 5 for
information about the inequality of health outcomes across Australia.
The accessibility of primary health care is explored by looking at whether people delayed
or did not use care, due to cost or other reasons, and differences in access to bulk billed
services, after-hours care and telehealth services. See Chapter 2.3 ‘Who is in the health
workforce?’; Chapter 5.2 ‘Rural and remote populations’ for more information.
How many people faced barriers to primary

health care?
In 2016−17, of people aged 15 and over:
26% delayed seeing, or did not see, a GP at least once when needed,
16% of whom reported this was because of cost (4.1% of all people who
needed to see a GP, or an estimated 663,000 people)
31% delayed seeing or did not see a dental professional at least once
when needed, 60% of whom reported this was because of cost (18% of
all people who needed to see a dentist, or 2 million people)
7.3% of people who needed a prescription medication delayed or

avoided filling it due to cost (974,000 people) (ABS 2017c).
Since 2013–14, the estimated number of people who delayed or did not see a GP at least
once when needed has fallen from 4.6 to 4.2 million people (ABS 2017c).
Who faced barriers to primary health care?

There is a ‘social gradient’ in experiencing cost barriers to dental professionals and
prescription medicines—meaning that people living in the lowest socioeconomic areas
are more than twice as likely to face cost barriers to both these types of health care
compared with people living in the highest socioeconomic areas (Figure 7.5.2). In contrast,
across socioeconomic areas, there was little variation in the percentage of people who
experienced a cost barrier to GP care (Figure 7.5.2).
Access to care was also worse for people who reported poorer health. They represented
Chapter 7
around 14% of people aged 15 and over—or 2.7 million people. People who reported their
health to be fair or poor were about twice as likely to experience a cost barrier to dental
professionals or prescription medicines compared with people who rated their health
positively (ABS 2017c).
393
Figure 7.5.2: Proportion of people aged 15 and over who delayed or did
not seek care at least once when needed due to cost, by type of care and
socioeconomic area, 2016−17
Per cent
30 Prescription medication
GP Dental professional
25
20
15
10
0
1 2 3 4 5
Lowest Highest
Socioeconomic area
Note: Socioeconomic areas are based on area of residence using the ABS Index of Relative
Socio-Economic Disadvantage.
Access to bulk-billed services

Under Medicare, health providers can choose to bulk-bill their services. This means that
the patient has no out-of-pocket costs for the service. In 2016−17, 86% of GP attendances
in Australia were bulk-billed. This proportion has increased steadily from a low of 68% in
2003−04 to an all-time high in 2016–17.
The proportion of GP attendances bulk-billed across Australia varies considerably across
jurisdictions, ranging from 89% in the Northern Territory to 62% in the Australian Capital
Territory (Department of Health 2017a).
Bulk-billing rates have also increased for other kinds of non-hospital Medicare services,
particularly non-hospital specialist attendances (32% in 2007−08 to 41% in 2016−17),
diagnostic imaging (68% to 84%), and pathology (95% to 99%) (Department of Health 2017a).
After-hours GP care
There has been considerable policy emphasis on improving access to after-hours primary
health care, including access to after-hours telehealth services.
In 2016−17, 24% of Australians (5.8 million people) claimed 11.9 million after-hours GP
services through Medicare. This translates into 49 after-hours GP visits per 100 people
over the year. This has steadily increased, from 27 after-hours GP visits per 100 people
in 2007−08 (AIHW analysis of MBS data set 2018; Supplementary Table S7.5.5). Access
to after-hours GP services varies substantially across the country depending on where
people live and the area’s socioeconomic disadvantage (AIHW 2017c).
394
In 2016−17, an estimated 2 million people aged 15 and over reported that they needed
to see an after-hours GP in the last 12 months (ABS 2017c). Of these people, 26% (around
528,000 people) reported that they could not do so at least once when needed. This
proportion has fallen from 34% in 2013−14.
However, the rate of improvement has not been the same for all people. In 2016−17, the
percentage of people who did not see an after-hours GP at least once when needed was
highest for people who self-assessed their health as fair or poor (40%), and for people
living in Inner Regional areas (37%). Since 2013−14, the percentage of people who did not
see an after-hours GP when needed has improved markedly for people who rated their
health as excellent, very good or good (it reduced from 32% to 22%); it has not improved
as well for people who rated their health as ‘fair or poor’ (44% to 40%, Figure 7.5.3).
Figure 7.5.3: Percentage of people aged 15 and over who did not see an
after-hours GP at least once when needed, by self-assessed health status,
2013–14 to 2016−17
Per cent
50
40
30
20
Fair or poor health
Excellent, very good or good health
10
Total
0
2013‒14 2014‒15 2015‒16 2016‒17
Year
Sources: ABS 2014, 2015, 2016, 2017c; Table S7.5.6.
Telehealth
Telehealth is the delivery of health services through information and communication
technologies such as videoconferencing. Improving access to telehealth services,
particularly for people with chronic and mental conditions, is a key priority for Australian
Government and state and territory governments (Australian Digital Health Agency 2017;
Department of Health 2017b; Nous Group 2015; NSW Ministry of Health 2016).
Telehealth has the potential to tackle many challenges that Australia’s health system
faces, including improving access to care for people living in rural and remote areas and
for people with mobility issues. Along with opportunities stemming from the revolution
Chapter 7
in digital health technologies, advances in telehealth can provide a cost-effective way to

support people with chronic conditions to more effectively self-manage their health
(Box 7.5.1). See Chapter 2.4 ‘Digital health’ for information on digital health solutions.
395
Box 7.5.1: Tele-monitoring systems
Tele-monitoring systems allow patients to take their own vital signs (for example,
blood pressure), and then videoconference or secure message the information to
their care coordinators. A 1-year trial of the use of home tele-monitoring systems
by patients with chronic conditions by the Commonwealth Scientific and Industrial
Research Organisation found that these systems reduced mortality by more than
40%; they also reduced the rate of hospital admissions by 53% (and reduced the
rate of length of stay when admitted by almost 76%), and reduced MBS and PBS
expenditure by 46% and 26%, respectively (Celler et al. 2016).
Australians can use online and telephone advice at any time via Healthdirect Australia.
In 2016−17, healthdirect responded to:
• 746,000 calls to healthdirect helplines
• 75,500 calls to the after hours GP helpline
• 9.7 million online visitors
• 6,800 video calls (Healthdirect Australia unpublished data, January 2018).
In October 2014, healthdirect Video Call was launched. From 2017, healthdirect began
supporting health organisations in New South Wales, Victoria and Western Australia
to integrate the use of video calls with their everyday delivery of services (Healthdirect
Australia 2017).
Telehealth video consultations with Patient-end telehealth support

specialists can also be subsidised through A local primary health care worker
Medicare for people in rural and remote (such as a GP, nurse or Indigenous
areas, people living in residential aged care health practitioner or worker) may be
facilities and Indigenous Australians. This present with the patient during their
program expanded in November 2017 to video consultation with a specialist to
include consultations with allied mental give clinical support.
health professionals.
The uptake of Medicare-subsidised video conferencing has increased steadily since

the introduction of Medicare rebates and incentives in 2011 (figures 7.5.4, 7.5.5).
Across Australia in 2016−17, 65,000 people claimed 115,000 Medicare-subsidised video
consultations with specialists and 50,500 ‘patient-end’ support services. This represents a
rate of 47 telehealth services and 21 patient-end support services per 10,000 population.
These rates were highest in the Northern Territory and Tasmania (AIHW analysis of MBS
data set 2018; DHS 2018; supplementary tables S7.5.7, S7.5.8).
396
Figure 7.5.4: Number of telehealth Figure 7.5.5: Number of patient-end
services per 10,000 population, telehealth support services per
2011−12 and 2016−17, by state 10,000 population, 2011−12 and
and territory 2016−17, by state and territory
Services per 10,000 population Services per 10,000 population
120 2016‒17 120 2016‒17

2011‒12 2011‒12
100 100
80 80
60 60
40 40
20 20
0 0
NSW Vic Qld WA SA Tas ACT NT Australia NSW Vic Qld WA SA Tas ACT NT Australia
Jurisdictions Jurisdictions
Sources: ABS 2017a; DHS 2018; Table S7.5.7. Sources: ABS 2017a; DHS 2018; Table S7.5.8.

The AIHW, in partnership with the Australian Bureau of Statistics, conducted the
Coordination of Health Care Study. This study fills a national data gap and will inform
policy decisions by providing nationally consistent and locally relevant results about
patients’ coordination and continuity of care. The study involves linking consenting
participants’ survey results to their MBS, PBS, hospital and emergency department
records both 1.5 years before and after the survey was conducted. This will help to identify
predictors of poor coordination experiences and the outcomes associated with poor
coordination of care—for example, to assess the association between higher versus lower
coordination of primary health care among people with chronic health conditions and their
use of emergency departments or hospitals. See Chapter 7.18 ‘Coordination of health care’
for more information on this study.

There are currently limited detailed data on primary health care consultations. From 1998
to 2016, the BEACH surveys of GP activity provided insight into patient demographics,
types of problems being managed, and the type of care provided by GPs. However, the
2015–16 BEACH data collection was the last survey to be done.
Chapter 7
Although Medicare services data provide some insight into variation in use of primary
health care across Australia, they do not include information about why patients visit
health professionals, their diagnosis, treatment, test results or referrals for further care.
397
There are also limited national data for ambulance, aeromedical, allied health, dental or
state-funded community health services.
Without these data, it is difficult to assess the appropriateness, cost-effectiveness, safety,
quality and accessibility of primary health care. For example, without data on the reason
for a consultation, prescription or test, it is difficult to define ‘appropriate’ use and hence
understand the scale and cost of duplicate and unnecessary prescribing, imaging and
treatments. It is also difficult to attribute improvements in health outcomes to the primary
health care system, as responsibility for health outcomes is across the health care sector
and there is often a lag time between intervention and improved health outcome.
Developments are now underway to improve the completeness and use of primary health
care data. These include:
• a
commitment to develop a national primary care data set. This will help to measure
and monitor primary health care performance at a local, regional and national level
to enable research, inform policy, and identify regionally specific issues and best-case
practices to better understand health and health care in the community
• o
ngoing reviews and consolidation of national reporting frameworks (see Chapter 1.4
‘Indicators of Australia’s health’)
• implementation of Australia’s National Digital Health Strategy
• d
evelopments in data linkage capacity. Data linkage can improve the understanding of
patient outcomes and pathways through the health system
• developments in ensuring the anonymity and secure transfer of data.

Local level primary health care data are available at <www.myhealthycommunities.gov.au>.
Information about Indigenous people’s access to primary health services can be found in
Aboriginal and Torres Strait Islander health organisations: online services report—key results
2015–16.
References
ABS (Australian Bureau of Statistics) 2014. Patient experiences in Australia: summary of findings, 2013–14.
ABS 2017a. Australian demographic statistics, June 2017: Table 4. Estimated resident population, states and
territories (number). ABS cat. no. 3101.0. Canberra: ABS.
ABS 2017b. National Health Survey: health service usage and health related actions, Australia, 2014–15.
ABS 2017c. Patient experiences in Australia: summary of findings, 2016–17. ABS cat. no. 4839.0. Canberra: ABS.
AIHW (Australian Institute of Health and Welfare) 2017a. Aboriginal and Torres Strait Islander health
organisations: online services report—key results 2015–16. Aboriginal and Torres Strait Islander health
services report no. 8. Cat. no. IHW 180. Canberra: AIHW. Viewed 21 January 2018, <https://www.aihw.gov.
au/getmedia/3d8f3435-4fe4-4580-ab32-e1608bbb6b9c/20797.pdf.aspx?inline=true>.
AIHW 2017b. Health expenditure Australia 2015–16. Health and welfare expenditure series no. 58.
398
AIHW 2017c. MyHealthyCommunities web update: Medicare Benefits Schedule—GP and specialist
attendances and expenditure in 2015–16. Canberra: AIHW.
AHPA (Allied Health Professions Australia) 2017. What is allied health? Melbourne: AHPA. Viewed
20 February 2018, <https://ahpa.com.au/what-is-allied-health/>.
Australian Digital Health Agency 2017. Australian Digital Health Agency annual report, 2016–17. Sydney:
Australian Digital Health Agency.
Australian Prudential Regulation Authority 2017. Benefit trends—June 2017: ancillary benefits [Microsoft
Excel spreadsheet]. Private health insurance statistical trends. Viewed 17 November 2017,
<http://www.apra.gov.au/PHI/Publications/Pages/Statistical-Trends.aspx>.
Britt H, Miller GC, Bayram C, Henderson J, Valenti L, Harrison C et al. 2016. A decade of Australian general
practice activity 2006–07 to 2015–16. General practice series no. 41. Sydney: Sydney University Press.
Viewed 21 January 2018, <https://ses.library.usyd.edu.au/handle/2123/15514>.
Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L et al. 2016. General practice activity in
Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press. Viewed 21 January 2018,
<https://ses.library.usyd.edu.au/handle/2123/15514>.
Celler B, Varnfield M, Sparks R, Li J, Nepal S, Jang-Jaccard J et al. 2016. Home monitoring of chronic disease
for aged care. Canberra: Australian e-Health Research Centre, CSIRO. Viewed 21 January 2018,
<https://www.csiro.au/en/Research/BF/Areas/Digital-health/Improving-access/Home-monitoring>.
Department of Health 2013. National Primary Health Care Strategic Framework. Viewed 21 January 2018,
<http://www.health.gov.au/internet/main/publishing.nsf/Content/6084A04118674329CA257BF0001A349E/
$File/NPHCframe.pdf>.
Department of Health 2017a. Annual Medicare statistics—financial year 1984–85 to 2016–17 [Excel
spreadsheet]. Annual Medicare statistics. Viewed 9 November 2017,
<http://www.health.gov.au/internet/main/publishing.nsf/content/annual-medicare-statistics>.
Department of Health 2017b. Budget to deliver telehealth boost for rural psychological services. Viewed
21 January 2018, <http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-
yr2017-hunt035.htm>.
Department of Health 2018. Medicare Benefits Schedule book, effective 01 January 2018. Canberra:
DHS (Department of Human Services) 2016. Overview of the Department of Veterans’ Affairs claiming
channels—financial year 2015–16 [Excel spreadsheet]. Overview of the Department of Veterans’ Affairs
claiming channels. Viewed 24 January 2018, <https://data.gov.au/dataset/58ebeb4e-6235-407d-9756-
4a7d89ec4500>.
DHS 2018. Medicare Australia statistics. Canberra: DHS. Viewed 30 January 2018,
<http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp>.
Healthdirect Australia 2017. Annual report: business highlights 2016–17. Sydney: Healthdirect Australia.
Nous Group 2015. Strategic review of telehealth in NSW: final report. Viewed 21 January 2018,
<http://www.health.nsw.gov.au/telehealth/Documents/strategic-review-of-telehealth-in-NSW.PDF>.
NSW Ministry of Health 2016. NSW Health Telehealth Framework and Implementation Strategy:
2016–2021. Viewed 21 January 2018, <http://www.health.nsw.gov.au/telehealth/Publications/
NSW-telehealth-framework.pdf>.
RACGP (The Royal Australian College of General Practitioners) 2015. Smoking, nutrition, alcohol, physical
activity (SNAP): a population health guide to behavioural risk factors in general practice. 2nd edn.
Melbourne: RACGP.
Chapter 7
399
7.6 Medicines in the
FEATURE ARTICLE
health system
Medicines contribute to Australians’ quality of life and improvements in life expectancy
by curing or delaying the onset of diseases, relieving symptoms and preventing health
complications. Some medicines are only available via prescription from a health
professional, while others can be bought over-the-counter at places such as pharmacies
and supermarkets.
Providing consumers with access to affordable medicines is a key part of the Australian
health care system. The Australian Government helps people to pay for many medicines
dispensed in nearly 300 million prescriptions each year under two subsidy schemes
(Box 7.6.1)—at a cost of more than $12 billion in 2016–17.
This article describes some of the recent trends in the volume and cost of medicines
dispensed under the Pharmaceutical Benefits Scheme (PBS) and the Repatriation
Pharmaceutical Benefits Scheme (RPBS), as well as those not covered by these schemes.
The focus of this article is on the PBS, rather than the RPBS, as the PBS accounts for the
majority of all prescriptions and payments.
Box 7.6.1: What are the PBS and the RPBS and how do they work?
The PBS and the RPBS subsidise the cost of many medicines in Australia. The PBS
is available for current Medicare card holders and the RPBS for Department of
Veterans’ Affairs (DVA) Health Card holders.
The Australian Government administers the PBS under the National Health Act 1953;
the RPBS is administered under the Veterans’ Entitlements Act 1986. The PBS began
in 1948 and has expanded over time. Today, around 5,300 brands of medicines,
used to treat a wide range of health conditions, are listed on the Schedule of
Pharmaceutical Benefits. The RPBS subsidises pharmaceuticals available under the
PBS and additional medicines and items (including wound dressings) for eligible
veterans, war widows and widowers, and their dependants.
Under the PBS and the RPBS, the Australian Government sets a maximum
‘co-payment’ amount that people pay towards the cost of their medicines. Table
7.6.1 shows this amount, and the eligibility requirements to access the schemes.
The Australian Government pays pharmacies the difference between a consumer’s
co-payment and the PBS price of a medicine, as listed on the Schedule of
Pharmaceutical Benefits. Some medicines are priced below the co-payment amount,
so the consumer pays the total cost and the government does not contribute.
Patients fall into two broad categories: general and concessional. By far the majority
of subsidised PBS prescriptions (around 90%) are dispensed for concessional
patients, whose co-payment is substantially less than that to general patients.
Concessional patients whose accumulated PBS co-payments reach the ‘safety net’
threshold amount during a calendar year ($384 for 2018) pay no further
co-payments for PBS/RPBS medicines for the rest of the year.
(continued)
400
Box 7.6.1 (continued): What are the PBS and the RPBS and how do they work?
Table 7.6.1 Eligibility and co-payment amounts for the PBS and RPBS
Patient category Eligibility to access Maximum co-payment(a)
Medicare card (for PBS) or $39.50 (non-safety net)

General
DVA Health Card (for RPBS) $6.40 (safety net)
Medicare card and one of

the following:
• Pensioner Concession Card
• Seniors Health Card $6.40 (non-safety net)
Concessional
• Health Care Card $0.00 (safety net)
• DVA Health Card
• Safety Net Card
(a) As at 1 January 2018.

Source: Department of Health 2018.
Generally available medicines and those available under special arrangements

All subsidised medicines are listed on the Schedule of Pharmaceutical Benefits
under Section 85 (s85) of the National Health Act 1953. Most of these medicines
(referred to as s85 medicines) are listed on the General Schedule and are
generally available to consumers. They are dispensed mainly through community
pharmacies, although some are available through eligible hospitals to day patients
and patients on discharge.
Other subsidised medicines (referred to as s100 medicines) are available under
‘special arrangements’, described in Section 100 (s100) of the Act. The special
arrangements for many of these medicines mean that they are prescribed under
specific conditions, supplied through hospitals, require specialised medical
supervision, and are high in cost.
An example is the Highly Specialised Drugs (HSD) Program, which accounted for
more than 60% of the cost to the Australian Government of all s100 medicines in
2016–17. This program allows for certain medicines to be prescribed and dispensed
in hospitals and now (via the ‘HSD community access’ arrangements) through
general practitioners (GPs) and community pharmacies. HSD includes treatments
for hepatitis and human immunodeficiency virus/acquired immune deficiency
syndrome (HIV/AIDS).
Other programs operating under the special arrangements of s100 of the Act
include the supply of medicines for opiate addiction treatment, chemotherapy
and in-vitro fertilisation (IVF) programs. They also include arrangements to supply
Chapter 7
medicines to people living in isolated areas—such as to Aboriginal and Torres Strait

Islander patients in remote areas of Australia via Aboriginal Health Services.
401
The PBS and RPBS do not cover:
• medicines dispensed via private prescriptions
• over-the-counter medicines
• medicines supplied to public hospital in-patients.
Another Australian Government program for medicines, separate from the PBS, is the Life
Saving Drugs Program. It currently provides subsidised access to 13 expensive life-saving
medicines for 9 rare and life-threatening conditions. These medicines are not considered
cost-effective enough to be listed on the PBS but are funded and made available to eligible
patients with recognised rare diseases.
The number of prescriptions fell in

2016–17 while spending grew
In 2016–17, more than 280 million prescriptions were dispensed under the PBS (Figure 7.6.1),
down nearly 2% from the previous year. A further 9.3 million prescriptions were dispensed
under the RPBS, also a drop (10%) from 2015–16 (Department of Health 2017).
Figure 7.6.1: Number of PBS and RPBS prescriptions dispensed, 2013–14 to

2016–17
Year PBS RPBS
2016–17
2015–16
2014–15
2013–14
0 50 100 150 200 250 300
Prescriptions dispensed (millions)
Note: Includes prescriptions priced above and below the co-payment; s85 and s100 medicines;
by date of supply.
Source: AIHW analysis of Department of Health PBS and RPBS data 2018; Table S7.6.1.
In 2016–17, the Australian Government spent $12.1 billion on all PBS medicines (including
s100 medicines)—an increase of 11% from $10.8 billion the previous year. This amounts
to about 0.7% of gross domestic product (GDP), contributing slightly more as a proportion
of GDP than the previous year.
402
Consumers paid $1.3 billion in patient contributions on generally available (s85)
prescriptions priced above the co-payment in 2016–17—about 13% of the total
expenditure on PBS medicines—with the Australian Government contributing the
remaining 87% (Department of Health 2017).
Individual consumers spend on medicines both within and outside the PBS. Medicines
that do not require a prescription can be bought over-the-counter in a pharmacy or in
other retail outlets (for example, supermarkets). Individuals spent a total of $10.8 billion
on medicines (including prescriptions priced above and below the co-payment,
over-the-counter medicines and private prescriptions) in 2015–16 (AIHW 2017a).
Aside from government and individual consumers, hospitals are a major source of
spending on medicines. Public hospitals reported spending around $2.9 billion on
medicine supplies not covered by the PBS/RPBS in 2015–16 (AIHW 2017b; Figure 7.6.2).
Figure 7.6.2: Spending on medicines by funding source, 2015–16
$ (billions)
12
10
0
Individuals(a) Public hospitals PBS
(a) Spending by individuals includes on prescriptions priced above and below the co-payment,
over-the-counter medicines and private prescriptions.
Sources: AIHW 2017a, 2017b; Department of Health 2016; Table S7.6.2a.
Cardiovascular medicines are the most

often dispensed
Medicines used to treat cardiovascular conditions were dispensed in larger volumes than
medicines for other conditions over the 3 years to 2016–17 (Figure 7.6.3). These include
Chapter 7
cholesterol-lowering medicines (such as statins)—as raised cholesterol is a major risk

factor for developing cardiovascular disease.
403
Figure 7.6.3: Number of PBS prescriptions dispensed by Anatomical
Therapeutic Chemical(a) (ATC) group, 2014–15 to 2016–17
ATC group
Cardiovascular
Nervous
Alimentary
Anti-infectives
Respiratory
Musculoskeletal
Blood 2016–17
Sensory 2015–16
Genitourinary
2014–15
Hormonal
Dermatological
Anti-neoplastic
Other
0 10 20 30 40 50 60 70 80 90 100
Prescriptions dispensed (millions)
(a) A
TC is a classification of medicines according to the body system/organ on which they act.
This figure shows the most basic ATC level (level 1).
Note: Includes prescriptions priced above and below the co-payment; s85 and s100 medicines;
by date of supply; excludes RPBS.
Sources: AIHW analysis of Department of Health PBS data 2018; Table S7.6.3.
Although the volume of medicines dispensed for cardiovascular disease remains

higher than for other groups of medicines, the number of statins dispensed has been
relatively stable over recent years. As an example, atorvastatin—the medicine most often
dispensed—was dispensed in a similar volume from 2014–15 to 2016–17—at around 10
million prescriptions each year (Figure 7.6.4).
Other commonly dispensed medicines

Medicines to treat nervous system conditions were the second largest group dispensed.
Although the number of prescriptions dispensed for these medicines has historically been
on the rise, it fell in 2016–17 (Figure 7.6.3).
Medicines for the digestive tract (alimentary system) were the third most dispensed group
and showed a slight growth in prescriptions from 2014–15 to 2016–17. For example,
medicines to treat conditions caused by too much acid in the stomach showed marginal
increases in the volume dispensed in 2016–17, with esomeprazole reaching 9 million
prescriptions and pantoprazole 6.5 million prescriptions (Figure 7.6.4).
Three types of antibiotics were among the 10 most commonly dispensed medicines
(Figure 7.6.4). The prescribing of antibiotics is explored further in Box 7.6.2.
404
Figure 7.6.4: Ten most common medicines, by number of PBS prescriptions
dispensed, 2016–17
Drug name (common use)
Atorvastatin (cholesterol)
Rosuvastatin (cholesterol)
Esomeprazole (gastric reflux)
Pantoprazole (gastric reflux)
Perindopril (blood pressure)
Amoxicillin (antibiotic)
Cephalexin (antibiotic)
Metformin (diabetes)
Amoxicillin + clavulanic acid (antibiotic)

Irbesartan (blood pressure)
0 2 4 6 8 10 12
Prescriptions (millions)
Note: s85 medicines only; includes prescriptions priced above and below the co-payment; by date of supply;
excludes RPBS.
Box 7.6.2: Prescribing of antibiotics

Antibiotics destroy or slow the growth of bacteria. They are used to treat a variety of
infection sites, such as skin, respiratory tract and urinary tract infections, as well as
infected wounds.
Australia has relatively high rates of antibiotic prescribing compared with other countries
and with the Organisation for Economic Co-operation and Development (OECD) average.
Medicine usage can be measured as Defined Daily Doses (DDDs). These are the doses for
a particular medicine that are assumed to be the average per day for an adult. The overall
volume of antibiotics dispensed in Australia was 23.4 DDDs per 1,000 people per day in
2015, higher than the OECD average of 20.6 DDDs (OECD 2017).
In 2016–17, more than 60% of patients who used the PBS were dispensed at
least one antibiotic. The most commonly dispensed antibiotics were amoxicillin,
cephalexin, and amoxicillin with clavulanic acid.
There is concern that, in some cases, antibiotics may have been prescribed
inappropriately to treat a condition—for example, a viral infection or a toothache.
However, prescribers of PBS medicines are currently not required to include on
a script the reason they prescribed a medicine, limiting the ability to assess if
antibiotics are being prescribed unnecessarily in Australia.
Unnecessary prescribing of antibiotics leads to a higher risk of adverse side effects
Chapter 7
and, importantly, increased anti-microbial resistance in the population. Anti-microbial

resistance poses a major health issue because the bacteria adapt so that antibiotics no
longer work on them, leading to the emergence of so-called ‘superbugs’ (WHO 2017).
405
GPs prescribe the most medicines
Up until 2008, only medical practitioners (GPs and specialists) and participating dental
practitioners could prescribe PBS medicines. Authorised optometrists have been able to
write certain PBS prescriptions since January 2008 and authorised nurse practitioners
and midwives since September 2010.
GPs still prescribe the most PBS medicines—around 90% of all medicines dispensed.
Hence, the most commonly dispensed medicines from prescriptions issued by GPs in
2016–17 broadly reflect overall prescribing patterns, as shown in Figure 7.6.4.
Medicines commonly prescribed by other

occupation groups
The most commonly dispensed medicines for 2016–17, by authorised occupation group,
are outlined in Table 7.6.2. Note that some medicines listed on the PBS may be used
to treat a variety of conditions (indications) and this article refers to just some of the
common conditions treatable by these medicines.
Table 7.6.2: Most common medicines, by number of prescriptions dispensed,

by selected occupational groups, 2016–17
Occupation group Most common medicine(s) Used to treat…
Medical specialists Latanoprost; High pressure inside the eye, due

(other than GPs) methylphenidate to glaucoma or other eye diseases;
Attention Deficit Hyperactivity
Disorder and narcolepsy
Dentists Amoxicillin Bacterial infections
Optometrists Fluorometholone; Eye conditions due to inflammation

latanoprost or injury; high pressure inside
the eye
Nurse practitioners Atorvastatin; High cholesterol; gastric reflux

esomeprazole
Midwives Cephalexin Bacterial infections
Note: Includes prescriptions priced above and below the co-payment; s85 and s100 medicines included;
by date of supply; excludes RPBS.
Source: AIHW analysis of Department of Health PBS data 2018; Table S7.6.2b.
People aged 65 and over take the

most medicines
The majority of PBS prescriptions are dispensed to people aged 65 and over (Figure 7.6.5).
In 2016–17, people aged 80–84 had the highest rate of script dispensing per 1,000 people,
followed by people aged 75–79. This is broadly consistent with people in these age groups
also using a relatively higher proportion of hospital and other health services (AIHW
2016:349–65).
406
For people aged 50 and over, the most commonly dispensed medicines were:
• a
torvastatin and rosuvastatin—mainly used to treat high cholesterol and lower the risk
of stroke, heart attack or other heart complications
• e
someprazole and pantoprazole—mainly used to reduce the amount of acid produced
in the stomach and prevent peptic ulcers.
As people aged 50 and over received 75% of all PBS medicines dispensed, these
commonly dispensed medicines are consistent with those most dispensed overall
(Figure 7.6.3).
Figure 7.6.5: Rate of PBS prescriptions dispensed, by age group, 2016–17
Rate (prescriptions per 1,000 population)

50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
0 –4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75 –79 80–84 85+
Age group
Notes
1. Includes prescriptions priced above and below the co-payment; s85 and s100 medicines; by date
of supply; excludes RPBS.
2. T
he population figures are taken from the Australian Bureau of Statistics Estimated Resident Population
(the official estimate of the Australian population) as at 31 December 2016.
Source: AIHW analysis of Department of Health PBS data 2018; Table S7.6.5.
A few specialised medicines account for

a disproportionate share of government
spending
In 2016–17, around 1% of all PBS prescriptions were for medicines made available under
the special arrangements of s100. Yet the total cost of s100 medicines accounted for 26%
of spending on all PBS medicines, up from 19% in 2011–12 (Figure 7.6.6).
Chapter 7
While government spending on all other medicines has remained relatively stable,
spending on s100 medicines has been increasing—it grew by around 15% in the year
from 2015–16 to 2016–17 (Department of Health 2017).
407
The main increases in spending for s100 medicines are due to the steady rise in HSD
and chemotherapy medicines. The often high cost of these medicines means that even a
moderate growth in the number of prescriptions dispensed can substantially affect spending.
For example, from 2015–16 to 2016–17, the number of prescriptions dispensed for:
• p
ertuzumab (for breast cancer) increased by 45%, which led to a rise in government
spending of about $10 million
• p
embrolizumab (for melanoma) increased by 65%, which led to a rise in government
spending of more than $50 million.
The rise in spending on s100 medicines may partly be explained by more comprehensive
recording of PBS data for s100 prescriptions. Other factors contributing to the increase
include the growing incidence of diseases such as cancer and Alzheimer disease, improved
disease diagnosis and treatment methods, and the expensive new medicines produced by
pharmaceutical companies’ research and development programs.
Figure 7.6.6: Government expenditure on PBS generally available (s85)

medicines and medicines available under special arrangements (s100),
2011–12 to 2016–17
$ (billions)
14 s100
s85
12
10
0
2011–12 2012–13 2013–14 2014–15 2015–16 2016–17
Year
Note: Includes s85 and s100 medicines; by date of supply; excludes RPBS.
New hepatitis C medicines accounted for the most

government spending
In 2016–17, some relatively new hepatitis C antiviral medicines, medicines for arthritis,
and medicines to treat macular degeneration (a leading cause of blindness) accounted
for the most spending on medicines by the Australian Government (Figure 7.6.7).
408
Figure 7.6.7: Ten medicines accounting for the most Australian government
spending on medicines, 2016–17
Drug name (common use)
Ledipasvir + sofosbuvir (hepatitis C)

Sofosbuvir (hepatitis C)
Daclatasvir (hepatitis C)
Adalimumab (arthritis)
Aflibercept (macular degeneration)
Ranibizumab (macular degeneration)
Trastuzumab (cancer)
Pregabalin (relieves damaged nerves)
Fingolimod (multiple sclerosis)
Denosumab (osteoporosis)
0 200 400 600 800 1,000

$ (millions)
Note: Includes s85 and s100 medicines; by date of supply; excludes RPBS.
Approximately 230,000 Australians are infected with the hepatitis C virus, which causes
liver inflammation; however, before 2016, less than 2% of people with hepatitis C were
treated and cured annually. In March 2016, the Australian Government listed several new
direct-acting antiviral medicines for hepatitis C on the PBS. Compared with the medicines
previously available for people with hepatitis C, these are easier to take, have fewer side
effects and are more effective, with the capacity to eventually cure people of the disease.
Newer medicines—especially those still under a patent—are usually more expensive than
older ones (see Box 7.6.3). The listings for hepatitis C (ledipasvir + sofosbuvir; sofosbuvir;
daclatasvir) on the general schedule in March 2016 are some of the costliest medicines on
the PBS. Expenditure on these medicines contributed substantially to an increase in PBS
expenditure from March 2016 onwards. The total increase in government expenditure in
2016–17 for PBS medicines (excluding s100) was 8.5% compared with the previous year
(Department of Health 2017).
Other medicines accounting for substantial

government spending
Other medicines that accounted for relatively greater amounts of government spending
in 2016–17 were those used to treat:
• r heumatoid arthritis—with $324 million spent on adalimumab and $148 million on
etanercept
Chapter 7
• m
acular degeneration—with $247 million spent on aflibercept and $200 million on
ranibizumab
• c ancer—with $161 million spent on trastuzumab and $131 million on pembrolizumab
(Supplementary Table S7.6.7).
409
Box 7.6.3: How does the Australian Government manage the cost of our medicines?
The Australian Government has several policies to control the cost of medicines
listed on the PBS. An important one is the Price Disclosure Policy, which requires
pharmaceutical companies to provide data to the government on the sale prices
for their medicine brands in the market. The government uses this information to
decide how much it pays for PBS-listed medicines.
Another policy initiative has been the government’s encouragement for listing
generic versions of medicines. At the end of a medicine’s patent period, other
companies can offer generic brands (‘bioequivalent’; with active ingredients

identical to the original) or biosimilar brands (with very similar but not identical
active ingredients) at a cheaper price. Statutory requirements reduce the price of
the original medicine by 16% when the first bioequivalent or biosimilar medicine
(with the same manner of administration as the original) is listed on the PBS.
Natural health products are the most

popular over-the-counter medicines
Among over-the-counter products sold in pharmacies that did not require a prescription,
natural health products were the largest selling items in 2015–16 ($1.4 billion). These
include naturally occurring substances that can be used to maintain or restore health,
such as vitamins and minerals, herbal medicines, homeopathic preparations and
probiotics. Analgesics were the second largest selling group ($537 million).
Compared with the previous year, growth in sales in 2015–16 was also greatest for natural
health products, at about 21%. Digestive care and smoking cessation products both
recorded a growth in sales of more than 9% from 2014–15 to 2015–16 (Figure 7.6.8).
Figure 7.6.8: Spending on over-the-counter products, by product group,

2014–15 to 2015–16
Product group
Natural health
Analgesics
Cough and cold
Digestive care
First aid and sports medicine
Allergy
Weight management and sports nutrition
2015–16
Eye and ear care
Foot care 2014–15
Oral care
Home self-care
Antifungal
Smoking cessation
Sexual health
0 200 400 600 800 1,000 1,200 1,400 1,600
$ (millions)
Source: IRI customised report, 2015–16; Table S7.6.8.
410
Except for the PBS Schedule of Pharmaceutical Benefits—which lists restrictions and
authority requirements (which outline the medical conditions) for some medicines—there
is little information recorded on PBS prescriptions about the disease or condition for which
a medicine is prescribed. This information would greatly help in assessing how many
prescriptions are prescribed, and how much money is spent on each disease group.
It may also shed some light on whether some medicines are being over-prescribed for
certain conditions.
In previous years, results of the Bettering the Evaluation and Care of Health (BEACH)
surveys provided some insights into the prescribing patterns of GPs. (The survey was
discontinued after 2015–16.) Better understanding prescribing patterns may be helped
by future improvements in primary care data (see Chapter 7.5 ‘Primary health care’).
Furthermore, there is at present an incomplete picture of medicines dispensed in
hospitals. This is because medicines for admitted patients in public hospitals are not
subsidised under the PBS and are therefore not included in the PBS data. PBS medicines
are available for non-admitted patients and patients on discharge from hospitals, but
only for states and territories that are part of the Public Hospital Pharmaceutical Reforms.
Nationally collated data on medicines dispensed to hospital admitted patients would
provide a clearer picture of the overall use of medicines in Australia.

For more information on medicine statistics in Australia, visit the Medicare Statistics
website or the PBS Statistics webpage.
References
AIHW (Australian Institute of Health and Welfare) 2016. Australia’s health 2016. Australia’s health series
no. 15. Cat. no. AUS 199. Canberra: AIHW.
AIHW 2017a. Health expenditure Australia 2015–16. Health and welfare expenditure series no. 58.
AIHW 2017b. Hospital resources 2015–2016: Australian hospital statistics. Health services no. 78.
Department of Health 2016. Expenditure and prescriptions twelve months to 30 June 2016. Canberra:
Department of Health. Viewed 26 April 2018, <http://www.pbs.gov.au/info/statistics/pbs-expenditure-
prescriptions-30-june-2016>.
Department of Health 2017. Expenditure and prescriptions twelve months to 30 June 2017.
Canberra: Department of Health. Viewed 22 January 2018, <https://www.pbs.gov.au/info/statistics/
expenditure-prescriptions-twelve-months-to-30-june-2017>.
Department of Health 2018. Pharmaceutical benefits: fees, patient contributions and safety net thresholds.
Canberra: Department of Health. Viewed 24 January 2018, <http://www.pbs.gov.au/info/healthpro/
explanatory-notes/front/fee>.
OECD (Organisation for Economic Co-operation and Development) 2017. Health at a glance 2017:
OECD indicators. Paris: OECD Publishing. Viewed 30 January 2018, <https://www.oecd.org/australia/
Health-at-a-Glance-2017-Key-Findings-AUSTRALIA.pdf>.
Chapter 7
WHO (World Health Organization) 2017. Antibiotic resistance: fact sheet. Geneva: WHO. Viewed
22 December 2017, <http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/>.
411
7.7 Overview of hospitals
SNAPSHOT
Hospitals are an important part of Australia’s health system, providing services to many
Australians each year.
In 2015–16, there were 701 public hospitals in Australia, with 61,000 beds (a rate of 2.56 beds
per 1,000 population—similar to the 2.62 per 1,000 in 2011–12). Public hospitals were
very diverse in location, size and the services provided. The 30 principal referral hospitals
(mostly located in metropolitan areas) had an average of 659 beds each, while 69% of
hospitals had fewer than 50 beds.

In the same year (2015–16), there were 630 private hospitals (including day hospital
facilities), with 33,100 hospital beds. This was 1.39 beds per 1,000 population—an increase
from the 1.30 per 1,000 in 2011–12.
Both hospital sectors provide services for admitted and non-admitted patients
(outpatient clinics and emergency department care).
Admitted patient services

Admitted patient services, or hospitalisations (see Glossary), are provided when a patient
is formally admitted to a hospital. Hospitalisations can either be on the same day or
involve a stay in hospital of 1 or more nights. The broad types of admitted patient care
are medical, surgical (see Chapter 7.11 ‘Elective surgery’) and other acute care, along with
childbirth, mental health care and subacute (for example, rehabilitation) and non-acute
care. About 3 in every 5 (59%) hospitalisations occurred in public hospitals.
About 6.3 million (59%) hospitalisations occurred in public hospitals and 4.3 million in
private hospitals (Table 7.7.1).
Non-admitted patient services

Non-admitted patient care includes care provided in emergency departments and
outpatient clinics. Non-admitted patient care can also include the dispensing of medicines
to patients not admitted to the hospital, and district nursing and some community health
services provided by hospitals—those activities are not included in the information
presented here. For some emergency department services, the patient is later admitted
to hospital; that admitted patient activity is not included here.
Public hospitals provide the majority of non-admitted patient services.
412
Table 7.7.1: Characteristics of admitted patient services, public and private
hospitals, 2015–16
Public hospitals Private hospitals
6.3 million (an average 4.3 million (an average

Hospitalisations increase of 3.3% per year increase of 3.7% per year
since 2011–12) since 2011–12)
Acute care—medical 4.3 million 1.3 million
Acute care—surgical 1.0 million 1.5 million
Acute care—other 420,000 895,000
Childbirth 234,000 76,000
Mental health care 133,000 171,000
Subacute care—rehabilitation 103,000 332,000
Subacute and
97,000 18,000
non-acute care—other
47% overnight stays; 29% overnight stays;
Overnight versus same-day
53% same-day 71% same-day
Number of days of 20 million (average increase of 10 million (average increase of
patient care 1.5% per year since 2011–12) 2.5% per year since 2011–12)
Average length of stay 5.7 days (average decrease of 5.2 days (average decrease of
(for overnight stays) 1.3% per year since 2011–12) 0.4% per year since 2011–12)
Note: Private hospitals that are contracted by state and territory governments to provide public hospital services are
included here under public hospitals. Non-admitted patient data exclude the Australian Capital Territory, as data were
not provided for 2015–16. In 2015–16, non-admitted patient care service events reported for 19 other services included
local hospital networks and some private hospitals in Western Australia.
Source: National Hospital Morbidity Database.
Outpatient clinics
In outpatient clinics, patients consult specialist medical practitioners, have diagnostic
services or other procedures, or are provided with allied health or specialist nursing
care—without being admitted to hospital. In 2015–16, about 33.4 million outpatient clinic
service events were reported for 604 public hospitals and 19 other services that provided
outpatient care for public patients:
• 4
6% of services were in allied health and/or clinical nurse specialist clinics—Midwifery
and maternity (2.1 million service events) and Primary health care (1.8 million) were the
most commonly reported
• 2
9% were in medical consultation clinics—Orthopaedics (1 million service events) and
Medical oncology (consultation) (632,000) were the most commonly reported
• 1
6% were in stand-alone diagnostic clinics—Pathology (microbiology, haematology,
biochemistry) (2.8 million service events) and General imaging (1.8 million) were the
Chapter 7
most commonly reported

• 7
.9% were in procedural clinics—Dental (920,000 service events) and Radiation oncology
(treatment) (756,000) were the most commonly reported.
In 2015–16, 92 private hospitals provided about 1.5 million outpatient clinic services (ABS 2017).
413
Emergency departments
In 2016–17, there were about 7.8 million presentations to Australia’s 287 formal public
hospital emergency departments. This was an average of more than 21,000 each day across
Australia and represented a 2.0% increase (after adjusting for the number of hospitals
included) from 2015–16 (7.5 million) (see Chapter 7.10 ‘Emergency department care’).
In 2015–16, about 538,000 accident and emergency services were provided by 36 private
hospitals. These hospitals included those that did not have a formal accident and
emergency unit but treated accident and emergency patients (ABS 2017).

Although well-developed hospitalisation data are available, there are variations in how
hospital services are defined and counted between jurisdictions. Data are based on each
hospitalisation or service, rather than on individuals, and current national data cannot
easily be used to analyse care patterns for patients hospitalised several times. Similarly,
it is difficult to analyse patterns of care across admitted and non-admitted patient settings
(including non-hospital settings such as primary health care). Data linkage can improve
the understanding of patient outcomes and pathways through the health system.
As well, there are limitations in examining issues related to patients’ accessing outpatient
clinics and emergency departments because these data do not contain the same level of
detail as hospitalisation data, particularly for diagnosis.
Private hospital data are collected, analysed and disseminated through different
reporting pathways. As a result, private hospital data may not be consistent across the
various collections, or with data for public hospitals.

More information on hospitals in Australia and the services they provide is in reports
from the Australian hospital statistics series: Admitted patient care 2015–16; Elective surgery
waiting times 2016–17; Emergency department care 2016–17; Non-admitted patient care
2015–16; Hospital resources 2015–16; and Staphylococcus aureus bacteraemia in Australian
public hospitals 2015–16; and from Australia’s hospitals 2015–16 at a glance and Private
hospitals, Australia, 2015–16.
Information about activity and performance for more than 1,000 Australian public and
private hospitals is on the My Hospitals website.
References
Australian Bureau of Statistics (ABS) 2017. Private hospitals, Australia, 2015–16. ABS cat. No. 4390.0.
Canberra: ABS.
414
7.8 Funding sources for
SNAPSHOT
the care of admitted
patients
Australian hospitals collect information about the funding source for admitted patient
hospitalisations. The information presented in this snapshot relates to hospitalisations for:
• public patients, who are admitted at no charge (publicly funded)
• patients whose stay was either completely or partially funded by private health insurance
• p
atients funded by other sources (see Glossary for definitions of public, private health
insurance and other patients).
The data are drawn from the AIHW’s National Hospital Morbidity Database and relate
to the funding source reported against each episode of admitted patient care, or
hospitalisation (see Glossary).
In 2015–16, of the 10.6 million hospitalisations for admitted patients in public and private
hospitals combined:
• 5
.3 million, or 51%, were public patients (an average increase of 3.1% per year since
2006–07)
• 4
.5 million, or 42%, were at least partially funded by private health insurance (an average
increase of 5.6% per year since 2006–07)
• 7
77,000, or around 7.3%, were funded by other sources, including self-funded patients,
Department of Veterans’ Affairs patients and compensation claim patients (an average
decrease of 0.2% per year since 2006–07).
Public hospitals
In 2015–16, around 5.2 million hospitalisations were for public patients (83% of all public
hospital admissions) and 872,000 (14%) were at least partially funded by private health
insurance (Figure 7.8.1). Since 2006–07, public patient hospitalisations increased by 2.8%,
on average, each year and hospitalisations funded by private health insurance increased
by 9.6%, on average, each year.
• T
he majority (85%) of same-day hospitalisations were public patients and 13% were
funded through private health insurance.
• E
ighty-one per cent (81%) of overnight stay hospitalisations were for public patients
while 15% were funded through private health insurance.
Chapter 7
415
Private hospitals
In 2015–16, around 3.6 million hospitalisations were funded by private health insurance
(83% of all private hospital admissions) and 162,500 (3.8%) were public patients (Figure
7.8.1). Since 2006–07, hospitalisations funded by private health insurance increased by
4.9% on average each year, and public patients by an average of 14% each year.
• E
ighty-two per cent (82%) of same-day hospitalisations were funded by private health
insurance and 4.7% were public patients.
• T
he majority (86%) of overnight stay hospitalisations were funded by private health
insurance, with less than 1.5% for public patients.
Figure 7.8.1: Proportion of hospitalisations by funding source, public and

private hospitals, 2015–16
Public hospitals Private hospitals
Public patient
Private health insurance
Other funding
How do public patients and patients funded

by private health insurance compare?
In 2015–16:
• p
atients whose admission to hospital was an emergency were more likely to be
publicly funded than funded through private health insurance—74% and 21% of
hospitalisations, respectively
• e
lective admissions were more likely to be funded by private health insurance than
publicly funded (56% and 35%, respectively)
• a
mong patients living in Major cities, 47% of hospitalisations were public patients and
46% were funded by private health insurance
• a
mong patients living in Outer regional areas, 63% of hospitalisations were public
patients and 31% were funded by private health insurance—the equivalent figures for
patients from Remote and Very remote areas (combined) were 83% and 14%, respectively
416
• t he majority (62%) of hospitalisations for people living in the highest socioeconomic
areas were funded through private health insurance and 31% were for public patients
• a
mong people living in the lowest socioeconomic areas, 66% were hospitalisations for
public patients and 27% were funded through private health insurance.

Information is not available on the number of hospitalisations for patients who have
private health (hospital) insurance but did not use it.
Hospital admissions can be completely or partially funded by private health insurance.
The data show only that private health insurance was used as a source for funding
hospital admissions; they do not give information about how much funding was provided
by private health insurance for each hospitalisation and what proportion of the total cost
it represented.

More information on the funding of public and private hospital services is available in
Private health insurance use in Australian hospitals 2006–07 to 2015–16.
Further information about private health insurance in Australia, including information on
hospitalisations funded by private health insurance, can be sourced from the Australian
Prudential Regulation Authority website.
Chapter 7
417
7.9 Safety and quality of
FEATURE ARTICLE
hospital care
The safety and quality of the care provided in Australia’s hospitals are of utmost
importance to all patients, their families and carers. It is a key focus for Australian
governments, service providers and health professionals.
This article summarises how the safety and quality of hospital care are measured and
reported in Australia and presents data on selected measures. The future of safety
and quality measurement in hospitals is also discussed, particularly in the context of
patient centred care—where the patient is empowered and encouraged to be an active
participant in their care.
What is meant by safety and quality?

Informally, the term ‘safety and quality’ is often summarised as: the right care, in the
right place, at the right time and cost. Formal definitions vary slightly, depending on the
source. The Australian Commission on Safety and Quality in Health Care (the Commission)
defines safety as ‘reducing the risk of unnecessary harm associated with health care to an
acceptable minimum’ (ACSQHC 2017a). The Australian Health Performance Framework
(AHPF) defines safety as ‘the avoidance or reduction to acceptable limits of actual or
potential harm from health care management or the environment in which health care is
delivered’ (NHIPPC 2017).
The Commission defines quality as ‘the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes, and are consistent
with current professional knowledge’ (ACSQHC 2015). In the AHPF there is no specific
‘quality’ domain, as quality relates to all health system information domains, including
‘Effectiveness’, ‘Continuity of care’, ‘Accessibility’ and ‘Appropriateness’ (see Chapter 1.4
‘Indicators of Australia’s health’).
A safe and high-quality health system provides the most appropriate and best-value
care, while keeping patients safe from preventable harm. The benefits to the patient
are paramount.
The AHPF, and a number of national agreements, support monitoring of the safety and
quality of patient care in hospitals.
Improving safety and quality

A range of organisations act to improve safety and quality of health care. They may focus
their efforts nationally, at the state or territory level (for example, health departments), at
the service level (for example, individual hospitals), at the clinical level or for specific areas
of health care (health professional associations). At a national level, the Commission is the
key agency, providing national leadership to improve the safety and quality of health care
in Australia (Box 7.9.1).
418
Box 7.9.1: Australian Commission on Safety and Quality in Health Care
The Commission’s role is to lead and coordinate national improvements in safety and
quality in health care. To achieve a safe, high-quality and sustainable health system,
it works in partnership with patients; carers; clinicians; the Australian, state and
territory health systems; the private sector; managers; and health care organisations.
The Commission aims to:

• e
nsure the health system enables patients, consumers and members of the
community to participate as partners with their health professionals in all aspects
of health care
• ensure patients and consumers are kept safe from preventable harm
• h
ave a health system that provides the right care, minimises waste and optimises
value and productivity
• h
ave a health system that supports safe clinical practice by implementing robust
and sustainable improvement systems (ACSQHC 2017a).
Areas of work for the Commission include:

• d
eveloping and implementing the National Safety and Quality Health Service
Standards that provide consistent standards about the level of care consumers
can expect from health services
• d
eveloping and maintaining indicators aimed at promoting local safety and
quality improvement
• s upporting the health system to reduce unwarranted clinical variation. This work
included publishing the first and second atlases of health care variation, which
showed substantial variation in treatment across Australia (see Chapter 7.16
‘Variation in health care provision’ for more information)
• u
pdating the Framework for Australian Clinical Quality Registries (ACSQHC
2014) which provides guidance on how to establish and develop clinical quality
registries to enable benchmarked feedback to be provided to individual clinicians
on their clinical performance
• w
orking in partnership with patients, consumers, health care providers, policy
makers and members of the community towards having person centred health
care organisations. This includes work to improve health literacy (see Chapter 4.3
‘Health literacy’ for more information)
• s upporting the consistent and routine use of patient-reported outcome measures
and patient-reported experience measures to drive quality improvement in a way
that brings patients’ voices and outcomes to the fore (see Chapter 7.17
‘Patient-reported experience and outcome measures’ for more information).
Chapter 7
Pricing mechanisms are part of national efforts in improving safety and quality of
hospitals. Box 7.9.2 outlines recent initiatives to integrate safety and quality into the
pricing and funding of public hospitals.
419
Box 7.9.2: Pricing for safety and quality
In 2017, the Australian Government and states and territories agreed to integrate
safety and quality into the pricing and funding of public hospitals (CFFR 2017).
The aim is to improve patient health outcomes and safety, and support greater
efficiency of the health system.
When all reforms are in place, it is intended that funding and pricing for public
hospitals will be linked to sentinel events (events that result in death or serious
harm to a patient), hospital-acquired complications, and avoidable readmissions to
hospital. Patient-centred care is one of the key principles underlying these reforms.
To varying extents, safety and quality are integrated into the pricing and funding of
privately funded hospital care; the nature of such arrangements will vary depending
on individual agreements between health insurers and hospitals.
Efforts to improve the safety and quality of health care include public reporting of
information on these issues, including reporting by the AIHW. Reporting on safety and
quality supports accountability and transparency in service provision. When relevant
information is reported back to health professionals, health providers and the public,
it can improve decision making and patient outcomes.
Alongside these efforts are the activities undertaken by states and territories and health
service providers to measure and monitor performance within their jurisdictions, or by
organisations to improve clinical outcomes and the appropriateness of their services.
Selected indicators of the safety and

quality of hospital care
This section presents information on the routinely reported national indicators of safety
and quality of care for admitted patients in Australian hospitals.
Information on the indicators discussed in this section—except for Staphylococcus aureus
bacteraemia (SAB) cases in hospitals, and sentinel events—is derived from the AIHW’s
National Hospital Morbidity Database (NHMD). It should be noted that the data in the
NHMD are collected primarily to record care provided to admitted patients; use of them
for purposes such as reporting adverse events is developing, and evidence of validity is
incomplete. The results should therefore be treated with caution.
Note, too, that the available information does not give a complete picture. For example,
there is no routinely available information on some aspects of quality, such as continuity
or responsiveness of hospital services.
420
Health care-associated infections: Staphylococcus
aureus bacteraemia cases in hospitals
SAB is an infection often associated with health care. It occurs when Staphylococcus aureus
bacteria (‘Golden staph’) infect the bloodstream (bacteraemia). When associated with
health care procedures, these infections are considered to be potentially preventable.
Hospitals aim to have as few SAB cases as possible.
In fact, the rate of SAB is a national performance indicator for public hospitals.
The performance benchmark is that the rate of SAB (including methicillin resistant
Staphylococcus aureus, or MRSA) is no more than 2.0 per 10,000 days of patient care for
acute care public hospitals in each state and territory.
In 2016–17, for public hospitals:
• the national rate of SAB was 0.8 cases per 10,000 days of patient care
• all jurisdictions had rates below the national benchmark
• a
lmost all hospitals, for which data were published, had rates below the national
benchmark (99%)
• m
ost cases of SAB (81%) were treatable with commonly used antibiotics. These cases
are termed methicillin-sensitive Staphylococcus aureus (MSSA) cases, while 19% of cases
were MRSA (antibiotic resistant) cases (AIHW 2017a).
Between 2012–13 and 2015–16, rates of SAB fell from 0.9 cases to 0.7 cases per 10,000
days of patient care, then increased in 2016–17 to 0.8. The number of SAB cases dropped
from 1,717 in 2012–13 to 1,450 in 2015–16, then increased to 1,502 cases in 2016–17. The
number of MRSA cases decreased from 391 in 2012–13 to 278 cases in 2015–16, then
increased to 290 cases in 2016–17 (Figure 7.9.1).
For 2016–17, SAB data for 89 (14% of all) private hospitals were reported. All private
hospitals that reported SAB data had rates below the national benchmark. The national
rate of SAB in private hospitals that had reported data was 0.4 cases per 10,000 days of
patient care (AIHW 2017a). The data for public hospitals may not be comparable with the
data for private hospitals because recording practices may differ.
Improvements in the hand hygiene of health care workers is the highest priority for
reducing the risk of infections associated with health care. Hand Hygiene Australia
reported that, in October 2017, hand hygiene compliance in all hospitals (public and private
combined) was about 85% (HHA 2017). Between July 2012 and June 2017, hand hygiene
compliance in public hospitals increased from about 76% to 84%. Between July 2013 and
June 2017, hand hygiene compliance in private hospitals increased from 76% to 86%.
SAB performance information for individual public hospitals and for some private
hospitals is available on the AIHW’s MyHospitals website (see section ‘Where do I go for
more information?’).
Chapter 7
421
Figure 7.9.1: Cases of SAB in public hospitals, by antibiotic sensitivity status
(MSSA or MRSA), 2012–13 to 2016–17
Number of cases
MSSA MRSA
2,000
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
2012–13 2013–14 2014–15 2015–16 2016–17
Year
Clostridium difficile infections associated with heath care

Clostridium difficile infection (CDI) is a gastrointestinal infection that commonly affects
hospitalised patients and people in the community. The transmission, prevention and
control of CDI is complex because it can be exacerbated by treatment with antibiotics;
it can also spread between patients because of poor infection control and contaminated
hospital surfaces and medical equipment (ACSQHC 2017c).
Each year between 2011–12 and 2015–16, around 1 in 800 (around 8,000) hospitalisations
in public hospitals involved patients with CDI. For around 30% of these hospitalisations,
the patients were admitted to hospital with a diagnosis of CDI; the rest acquired the
infection during their hospital stay (ACSQHC 2017c).
Adverse events treated in hospitals

‘Adverse events treated in hospitals’ is a measure of the safety and quality of the care
provided to admitted patients. It covers a range of events, rather than focusing on one
type, such as readmissions or falls. This indicator is limited to adverse events that can be
identified by specific codes for diseases and injuries in the NHMD and therefore may not
include all adverse events.
Adverse events are defined as incidents where harm resulted to a person receiving
health care. They include the adverse effects of drugs, injuries that occur during care,
and conditions that occur after procedures (such as infections and bleeding). Some of
these events may be preventable.
422
Adverse events can lead to increased length of stay and poorer patient outcomes, along
with increased costs of treatment. This indicator is based on an event (or events) identified
by the treating doctor in the clinical record as having had an adverse outcome that
resulted in, or affected, hospital admission. One hospitalisation may have more than one
adverse event.
In 2015–16:
• a
bout 576,000 hospitalisations (5.4 per 100) reported 1 or more adverse events
(Figure 7.9.2)
• t hese hospitalisations accounted for about 6.6 per 100 hospitalisations for public
hospitals and 3.8 per 100 for private hospitals. The data for public hospitals are not
comparable with those for private hospitals because their casemix differs and
recording practices may also be different
• t he most common adverse event group reported was Procedures causing abnormal
reactions/complications (around half of all hospitalisations with 1 or more adverse event);
this pattern was consistent for both public and private hospitals (AIHW 2017b).
See Chapter 1.4 ‘Indicators of Australia’s health’ for more information.
Figure 7.9.2: Adverse events per 100 hospitalisations, all hospitals, 2015–16
Adverse event
Other external causes

of adverse events
Misadventures to patients during
surgical and medical care
Infection following a procedure
Haemorrhage and haematoma

complicating a procedure
Selected post-procedural disorders
Other diagnoses of complications of

medical and surgical care
Complications of internal prosthetic devices
Adverse effects of drugs, medicaments

and biological substances
Procedures causing abnormal
reactions/complications
All adverse events
0 1 2 3 4 5 6
Number of adverse events (per 100 hospitalisations)
Note: The adverse events presented are not mutually exclusive, and a hospitalisation may include more than
one adverse event.
Chapter 7
423
Another way to assess the overall safety and quality of care provided to admitted patients is
to measure diagnoses reported as being acquired during the hospital episode (Box 7.9.3).
Box 7.9.3: Hospital-acquired diagnoses

Hospital-acquired diagnoses is another measure of the overall safety and quality
of care provided to admitted patients. This measure overlaps with the safety
and quality performance indicators presented in this article but is not, in itself,
a national performance indicator. This measure and the performance indicators
should not be added together due to this overlap.

The Classification of Hospital-Acquired Diagnoses is a system that allows hospitals
to identify, count and monitor events as markers of patient safety (ACSQHC 2013).
The hospital-acquired diagnoses included in the classification are broader than
those defined as hospital-acquired complications (described later), and include
post-procedural complications, adverse drug events, accidental injuries, specific
infections and metabolic disorders. A hospital-acquired diagnosis is identified using
a condition onset flag (which indicates whether the condition was apparent before
or after hospitalisation), along with diagnosis information.
In 2015–16:
• m
ore than 889,000 hospitalisations reported a hospital-acquired diagnosis.
These accounted for about 9.8% of hospitalisations in public hospitals and 6.6%
in private hospitals
• f or public hospitals, the most common hospital-acquired diagnoses were Labour,
delivery and postpartum complications and Cardiovascular complications (accounting
for 20% and 17% of hospitalisations that included a hospital-acquired diagnosis,
respectively)
• f or private hospitals, the most common hospital-acquired diagnoses were
Gastrointestinal complications, accounting for 20% of hospitalisations that included
a hospital-acquired diagnosis
• P
ost-procedural complications accounted for about 12% of hospital-acquired
diagnosis in public hospitals and 15% in private hospitals (AIHW 2017b)
• a
bout 30% of hospital-acquired diagnoses were also classified as ‘Adverse events
treated in hospital’.
Falls resulting in patient harm in hospitals

This indicator is intended to report where a fall occurred in hospital during an episode of
care, resulting in patient harm. Falls resulting in patient harm in hospitals is a subset of
‘Adverse events treated in hospital’.
In 2015–16, about 34,000 hospitalisations (3.2 per 1,000 hospitalisations) reported a fall.
The rate of falls reported was higher for public hospitals (4.6 per 1,000 hospitalisations)
than for private hospitals (1.3 per 1,000) (AIHW 2017b). The difference between the rates
in public and private hospitals may reflect differences in casemix and recording practices
(also see Chapter 1.4 ‘Indicators of Australia’s health’).
424
The data presented have some limitations. The indicator identifies falls that occur in
any health service area, as it is not currently possible to identify those that occur just in
hospitals. Therefore, rates may overestimate falls in hospitals. However, patients with an
injury as the primary reason for hospitalisation are excluded to minimise including falls
that occurred before admission. These rates may also be underestimated, as 18%
of hospitalisations recording a fall did not state where it occurred.
Unplanned readmissions
This indicator includes hospitalisations for which an unplanned readmission to the same
public hospital occurred within 28 days after surgery (for selected surgical procedures),
and the cause of the hospitalisation was an adverse event. The diagnosis codes used to
identify adverse events for unplanned readmissions are a subset of those used in ‘Adverse
events treated in hospitals’. ‘Unplanned readmissions’ account for 6.4% of hospitalisations
with ‘adverse events’.
Rates of unplanned or unexpected readmissions to the same public hospital were highest
for Tonsillectomy and adenoidectomy (35 per 1,000 hospitalisations) and Hysterectomy
(33 per 1,000 hospitalisations) (Figure 7.9.3). For Cataract extraction, only about 3
per 1,000 hospitalisations were readmitted within 28 days.
Routine linkage of hospital data will improve the reporting of this indicator by allowing an
unplanned readmission to any, rather than the same, hospital to be identified (see section
‘What is the AIHW doing?’).
Figure 7.9.3: Rate of readmission to the same public hospital within 28 days of
surgery, selected types of surgery, 2015–16
Surgery
Cataract extraction
Hip replacement
Appendicectomy
Knee replacement
Prostatectomy
Hysterectomy
Tonsillectomy and adenoidectomy
0 5 10 15 20 25 30 35 40
Readmissions (per 1,000 hospitalisations)
Chapter 7
425
Sentinel events
‘Sentinel events’ includes a subset of ‘adverse events’ that result in death or serious harm
to a patient. They include events such as procedures for the wrong patient or body part
that resulted in death or permanent loss of function, or an infant’s discharge to the wrong
family. Australian health ministers have agreed on a national core set of sentinel events
(ACSQHC 2017b). This list is currently under review, with completion expected in 2018.
In 2014–15, there were 99 sentinel events in Australian public hospitals. The most
commonly reported was Retained instruments or other material after surgery requiring
re-operation or further surgical procedure, of which there were 33. The number of events
ranged from 85 to 102 between 2010–11 and 2014–15 (SCRGSP 2017).
Hospital-acquired complications
A hospital-acquired complication (HAC) is a complication for which clinical action may
reduce (but not necessarily eliminate) the risk of its occurring—for example, selected
infections or pressure injuries (ACSQHC 2017a). The nationally agreed Hospital Acquired
Complications List can be found on the Commission’s website.
There is overlap between the number of HACs and the number of hospitalisations that
reported a hospital-acquired diagnosis (Box 7.9.3). There will also be some overlap with
adverse events treated in hospitals, falls resulting in patient harm in hospital, and CDIs
associated with health care.
In 2015–16, a HAC was reported for about 184,000 hospitalisations. The most common
complication was Healthcare associated infection (Figure 7.9.4).
Figure 7.9.4: Rate of HACs, selected complications, all hospitals, 2015–16
Complication
Pressure injury
Third and fourth degree perineal

laceration during delivery
Gastrointestinal bleeding
Respiratory complications
Surgical complications requiring

unplanned return to theatre
Medication complications
Delirium
Cardiac complications
Health care associated infection
0.0 0.2 0.4 0.6 0.8 1.0

Complications (per 100 hospitalisations)
426
Box 7.9.4 highlights some areas of work underway at the national level to support
improved measurement of safety and quality of hospital care in the future. These relate
broadly to improvements to data, and improvements in the integration of data.
International comparisons
Australia also monitors the safety and quality of its health services through participation
in the Organisation for Economic Co-operation and Development (OECD) Health Care
Quality Indicators project. The OECD publishes selected data in its ‘Health at a glance’
series (OECD 2017). Table 7.9.1 lists the indicators related to patient safety against which
Australian data were reported for the most recent OECD collection—and shows how
Australia compares with other OECD countries. For this subset of indicators, rates were
higher for Australia than the OECD average.
Table 7.9.1: OECD selected patient safety indicators, Australia (2014–15) and OECD
average (2015, or nearest year)
Indicator Australia OECD average
Rate per 100,000 surgical hospitalisations
Foreign body left in during procedure 8.8 5.4
Post-operative deep vein thrombosis in hip and knee surgeries 1,113 357
Post-operative pulmonary embolism in hip and knee surgeries 549 301
Post-operative sepsis in abdominal surgeries 2,658 2,117
Rate per 100 vaginal deliveries
Obstetric trauma—vaginal delivery with instrument 7.2 5.7
Obstetric trauma—vaginal delivery without instrument 2.5 1.5
Note: Caution should be taken in interpreting these findings due to differences in data capture and reporting that
may influence the reported rates.
Source: OECD 2017.
The OECD acknowledges the challenge in collating data of this type in a comparable
manner, and suggests that some caution should be taken in interpreting the results.
Differences in hospital admission practices, data coding practices, and sources of data
(for example, whether they are based on hospital administrative data or registry-based
data) can result in large variations in the rates reported.
Chapter 7
427
The work that the AIHW is doing to set up routine linkage of data is outlined in Box 7.9.4.
The AIHW’s suite of products, including Australian hospital statistics and the MyHospitals
website, are intended to inform the public on selected safety and quality measures at the
national, state and territory and hospital level, on an annual basis.
Box 7.9.4 Measuring safety and quality in the future

Improved data
Data on patient outcomes are central to assessing the safety and quality of hospital
care. This article includes data on some outcome measures; however, there are
currently limited national data on patient experience, and no nationally reported data
on outcomes described by patients themselves. Routine collection of standardised
patient-reported experience is important, as is further consideration of the most
effective and efficient way to integrate patient-reported outcome measures.
Clinical Quality Registries (CQR) are an important means to monitor outcomes and
drive quality improvements in care. Australian registries have evolved over time
in a fragmented way. In 2016, Australian governments committed to developing a
national CQR strategy to provide a systematic approach to funding and governing
CQR for diseases, conditions and procedures with high cost and disease burden
on the Australian health system. The aim is to optimise the use of CQR to inform
safety and quality improvement purposes and patient outcomes.
The World Health Organization recently released the 11th revision of the
International Classification of Diseases (ICD). The ICD-11 has several features that
will enhance reporting on hospital care safety and quality. In particular, it will allow
explicit linking between harm associated with hospital care and the mechanism
and cause of the harm—for example, if a person bleeds heavily after a surgical
procedure, the surgery (cause) will be able to be linked to the subsequent bleeding
(harm). Concepts align with the current knowledge in adverse events and safety.
Improved integration of data

Improving the integration of hospital and other health service data at a national
level will better support the measurement of safety and quality outcomes.
The AIHW is currently working with Australian, state and territory government
authorities to establish routine linkage of data for hospitals, the Medicare Benefits
Schedule, the Pharmaceutical Benefits Scheme, residential aged care, and deaths.
Routinely linked data sets such as these will provide a stronger foundation to
investigate patient outcomes after hospital care—not only as readmissions to
hospital, but also as deaths, or through investigation of the patient’s use of general
practitioners or pharmaceuticals.
Integration of hospital data with other data sources, for example clinical-quality
registries, and potentially the My Health Record in the future (see Chapter 2.4
‘Digital health’), may also inform questions about the outcomes for patients after
care in hospital.
428
National reporting on safety and quality in hospitals has focused mainly on admitted care,
rather than on care provided in outpatient and emergency departments. This is generally
because the data collected for admitted care are more detailed and can better support
investigation and reporting. The MyHospitals website (see ‘What is the AIHW doing?’)
publishes safety and quality indicators for most public hospitals and some private hospitals.
In 2017, the Productivity Commission suggested that more data were needed to better
support patient choice in Australia (PC 2017) and noted the need to increase the number
of indicators (particularly outcome indicators) reported for individual hospitals in the
future. Expanding the number of private hospitals for which these data are separately
reported is also important so as to provide patients and health providers with a more
complete picture of hospital care.
It should be noted that the measurement of safety and quality is more developed for
hospitals than other health sectors, or areas such as aged care and primary care.

For more information on safety and quality of hospital care see the Australian Commission
on Safety and Quality in Health Care website, AIHW hospitals page and MyHospitals website.
References
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2013. Classification of hospital
acquired diagnoses. Sydney: ACSQHC. Viewed 5 March 2018, <https://www.safetyandquality.gov.au/
our-work/indicators/classification-of-hospital-acquired-diagnoses/>.
ACSQHC 2014 Framework for Australian clinical quality registries. Sydney. ACSQHC.
ACSQHC 2015. Australian Commission on Safety and Quality in Health Care annual report 2014/15.
Sydney: ACSQHC.
ACSQHC 2017a. Australian Commission on Safety and Quality in Health Care annual report 2016–17.
Sydney: ACSQHC.
ACSQHC 2017b. Australian sentinel events list. Sydney: ACSQHC. Viewed 20 February 2018,
<https://www.safetyandquality.gov.au/our-work/indicators/australian-sentinel-events-list./>.
ACSQHC 2017c. Vital signs 2017: the state of safety and quality in Australian health care. Sydney: ACSQHC.
AIHW (Australian Institute of Health and Welfare) 2017a. Staphylococcus aureus bacteraemia in Australian
public hospitals 2016–17: Australian hospital statistics. Health services series no. 83. Cat. no. HSE 198.
Canberra: AIHW.
AIHW 2017b. Admitted patient care 2015–16: Australian hospital statistics. Health services series no. 75.
CFFR (Council on Federal Financial Relations) 2017 Addendum to the National Health Reform Agreement.
Canberra: CFFR. Viewed 1 December 2017, <http://www.federalfinancialrelations.gov.au/content/npa/
health/other/Addendum_to_the_National_Health_Reform.pdf>.
HHA (Hand Hygiene Australia) 2017. National data 2017. Melbourne: HHA. Viewed 30 January 2018,
<Hand Hygiene Australia - National Data>.
NHIPPC (National Health Information and Performance Principal Committee) 2017. The Australian Health
Performance Framework. Viewed 16 February 2018, <http://www.coaghealthcouncil.gov.au/Portals/0/
Chapter 7
OOS318_Attachment%201.pdf>.
PC (Productivity Commission) 2017. Introducing competition and informed user choice into human
services: reforms to human services. Draft report. Canberra: PC.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2017. Report on
government services 2017. Canberra: PC.
429
7.10 Emergency department
SNAPSHOT
care
Emergency departments are a critical part of Australia’s health care system, providing
care for patients who require urgent medical attention.
Most larger public hospitals have purpose-built emergency departments. Some smaller
public hospitals can also provide emergency services though informal arrangements.
Accident and emergency services can also be provided by private hospitals. In 2015–16,
there were 36 private hospitals in Australia providing these services.
The information presented in this snapshot relates to the 287 Australian public hospitals
with purpose-built formal emergency departments that are staffed 24 hours a day. These
hospitals report to the AIHW’s National Non-Admitted Patient Emergency Department
Care Database (NNAPEDCD). The latest available estimate (2014–15) indicated that
around 88% of all public hospital emergency services were provided in formal emergency
departments covered by the NNAPEDCD.
Emergency department presentations

In 2016–17, there were about 7.8 million presentations to public hospital emergency
departments. This was an average of more than 21,000 each day across Australia.
Between 2012–13 and 2016–17, after adjusting for hospital coverage changes, the number
of emergency department presentations increased by an average of 2.6% each year.
In 2016–17:
• e
mergency department presentations were evenly split for males (50%) and females
(50%)
• t he most common 10-year age groups presenting at emergency departments were
people aged 25–34 (14%) and 15–24 (13%).
Some population groups were over-represented in emergency department

presentations compared with their representation in the population as a whole:
21% were aged 65 and over (15% of the population)
11% were aged under 5 (7% of the population)
6.5% were Aboriginal and Torres Strait Islander people

(3.3% of the population)
430
Patients who present to the emergency department are ‘triaged’ on arrival according
to the urgency of their need for care. Fewer than 1% of emergency department
presentations were assigned a triage category (see Glossary) of Resuscitation (those
who need immediate treatment); 13% were assigned to Emergency (requiring attention
within 10 minutes); 37% were Urgent (attention within 30 minutes); 41% were Semi-urgent
(attention within 60 minutes); and 9.3% were Non-urgent (attention within 120 minutes).
The majority (75%) of people who presented to emergency departments either walked in,
or came by private transport, public transport, community transport, or taxi. About 25% of
presentations arrived by ambulance, air ambulance or helicopter rescue service, with 83%
of Resuscitation patients arriving by this mode.
One-quarter (25%) of emergency department presentations had a diagnosis related to
injury (including fractures and burns) or poisoning (see Chapter 3.15 ‘Injury’).
Overall, around 31% of emergency department patients were admitted to hospital for
further care and around 1.9% of patients were referred to another hospital for admission.
Another 61% departed without being admitted or referred, and around 3.6% did not wait
to be attended by a health care professional.
Waiting time in emergency departments

Emergency department waiting time is the time that elapses from presentation in the
emergency department to start of clinical care. In 2016–17, nationally, 50% of patients
were seen within 19 minutes; 90% were seen within 95 minutes.
A patient is said to be ‘seen on time’ if the time between presentation at the emergency
department and the start of their clinical care is within the time specified by the triage
category to which they are assigned.
About 73% of emergency department presentations were seen on time, including almost
100% of Resuscitation patients and 77% of Emergency patients. For Non-urgent patients, the
proportion seen on time was 92%—higher than that for patients assessed as Urgent and
Semi-urgent (Figure 7.10.1).
The proportion of emergency department presentations seen on time was fairly stable
between 2012–13 and 2016–17, ranging from 73% (in 2012–13 and 2016–17) to 75%
(in 2013–14).
In 2016–17, about 72% of emergency department presentations were completed in
4 hours or less. This was slightly less than the equivalent figure for 2015–16 of 73%,
but higher than the figure for 2012–13 of 67%.
For patients who were subsequently admitted, the proportion of presentations completed
within 4 hours increased from 36% in 2012–13 to 49% in 2016–17.
Chapter 7
431
Figure 7.10.1: Proportion of patients seen within the clinically recommended
time, by triage category, 2016–17
Triage category
Resuscitation
Emergency
Urgent
Semi-urgent
Non-urgent
All presentations
0 20 40 60 80 100
Per cent
Source: NNAPEDCD 2016–17; Table S7.10.1.

The scope of the NNAPEDCD is limited to formal emergency departments in public
hospitals. It may not be representative of emergency services provided in hospitals
that do not have formal emergency departments.
It is not possible to determine whether the patient had been referred to the emergency
department by another doctor or health service. It is also not possible to identify the
admitted patient episode for those patients who are later admitted. Data linkage can
improve the understanding of patient outcomes and pathways through the health system.
In 2016–17, principal diagnosis information was reported using a variety of classifications,
and was only reported for about 96% of presentations. There was no information on the
procedures or on other treatments provided in the emergency department.

More detailed information can be found in the report Emergency department care 2016–17:
Australian hospital statistics.
Information about emergency occasions of service provided by private hospitals is
reported to the Australian Bureau of Statistics Private Health Establishments Collection
and is presented in the Private hospitals, Australia reports.
432
7.11 Elective surgery
SNAPSHOT
Surgery that is planned and can be booked in advance is classified as elective surgery.
Prioritising and scheduling patients for elective surgery is an important consideration for
Australian hospitals.
Private hospitals report about two-thirds (67%) of the 2.2 million hospitalisations for
elective surgery in Australia (1.5 million hospitalisations compared with about 733,000 for
public hospitals in 2015–16). The most common procedure group reported for elective
admissions involving surgery in both public and private hospitals were Procedures on
musculoskeletal system (155,000 and 436,000, respectively). In public hospitals, these were
followed by Gynaecological procedures (124,000) and Dermatological and plastic procedures
(107,000). In private hospitals, the second and third most common procedure groups were
Procedures on eye and adnexa (320,000) and Dermatological and plastic procedures (269,000).
Between 2011–12 and 2015–16, hospitalisations involving elective surgery rose by an
average of 2.2% each year—2.5% in private hospitals and 1.7% in public hospitals.
For overnight hospitalisations involving elective surgery, the average length of stay was
3.6 days in public hospitals and 3.1 days in private hospitals.
Elective surgery in public hospitals, 2016–17

In 2016–17, Australia’s public hospitals admitted 748,000 patients from elective surgery
waiting lists. For patients undergoing elective surgery:
• 2
2% were admitted for General surgery (surgery on organs of the abdomen, including
breast surgery)
• 1
5% were admitted for Orthopaedic surgery (surgery on bones, joints, ligaments and
tendons, including hip and knee replacements).
The most common type of surgery performed in 2016–17 was Cataract extraction,
with 71,500 admissions. This was followed by Cystoscopy (56,000 admissions);
Skin lesion—excision of (49,000); Hysteroscopy, dilatation and curettage (32,000);
Tonsillectomy (removal of the tonsils and adenoids; 19,500); Cholecystectomy (19,000);
Total knee replacement (17,000); Inguinal herniorrhaphy (hernia repair; 17,000);
Hysterectomy (11,500); and Total hip replacement (11,000).
Waiting times for elective surgery in public

hospitals, 2016–17
Information on elective surgery waiting times is only available for patients admitted from
public hospital waiting lists. These patients are assessed clinically by a surgeon, who
Chapter 7
determines the urgency of their need for surgery, before they are placed on a waiting
list. Waiting time for elective surgery is calculated from the time a patient is placed on the
waiting list until they are admitted for surgery.
433
In 2016–17:
• t he median waiting time (the time within which 50% of all patients were admitted)
for elective surgery was 38 days
• 90% of all patients were admitted within 258 days
• just under 1.7% of people took longer than 365 days to be admitted for surgery
• m
edian waiting times were longest in New South Wales (54 days) and shortest in the
Northern Territory (28 days)
• t he median waiting time for Aboriginal and Torres Strait Islander people was higher
than for Other Australians—45 days and 38 days, respectively

• t he surgical speciality with the longest median waiting time was Ophthalmology surgery
(eye surgery), at 73 days; the shortest median waiting time was Cardiothoracic surgery,
at 16 days
• t he median waiting times for surgical procedures varied: it was 209 days for
Septoplasty (surgery to correct the septum) and 13 days for Coronary artery bypass graft
(Figure 7.11.1).
Changes in elective surgery and waiting

times in public hospitals
Between 2012–13 and 2016–17:
• a
dmissions from public hospital elective surgery waiting lists increased by about 2.0%
per year (after adjusting for the number of hospitals included)
• e
lective surgery admissions per 1,000 population increased by an average of 0.9%
per year (after adjusting for the number of hospitals included)
• t he largest annual increases in elective surgery admissions were for Cystoscopy
(increasing by 5.0% each year, on average) and Total hip replacement (increasing by
4.4% each year, on average)
• t he largest annual decrease in elective surgery admissions was for Varicose vein
treatment, which decreased by around 2.6% on average each year
• t he overall median waiting time for elective surgery tended to increase—it was 36 days
in both 2012–13 and 2013–14, 35 days in 2014–15, 37 days in 2015–16 and 38 days in
2016–17
• t he largest increase in median waiting times was for Myringoplasty/tympanoplasty
(surgery to repair a perforated eardrum), increasing from 123 to 170 days
• t he proportion of people who waited more than 365 days for elective surgery
decreased, from 2.7% to 1.7%.
434
Figure 7.11.1: Median waiting time (days) for admission to public hospital for
selected surgical procedures, 2016–17
Septoplasty
Total knee replacement
Total hip replacement
Tonsillectomy
Cataract extraction
Hysterectomy
Inguinal herniorrhaphy
Cholecystectomy
Skin lesion— excision of
Cystoscopy
Hysteroscopy, dilatation and curettage
Coronary artery bypass grafting
0 30 60 90 120 150 180 210

Median waiting time (days)
Source: National Elective Surgery Waiting Times Data Collection; Table S7.11.1.

There is no information available about waiting times for elective surgery in private hospitals.
Data on the urgency of the need for elective surgery have not been reported in this
snapshot. In 2012, the AIHW and the Royal Australasian College of Surgeons worked
together to develop national definitions for elective surgery urgency categories, at the
request of the Standing Council on Health. The development of the national definitions
resulted in a package of six integrated components proposed for adoption. These are
outlined in National definitions for elective surgery urgency categories: proposal for the
Standing Council on Health. The revised definitions were implemented in 2015; however,
some inconsistencies still exist in the assignment of urgency categories between the states
and territories. These inconsistencies are expected to decrease over the coming years.
The measurement of waiting time from placement on the elective surgery waiting list to
hospital admission for that surgery does not take account of the time patients wait from
their initial referral for consultation with a surgical specialist. Under the auspices of the
Australian Health Minister’s Advisory Council, the AIHW is progressing work to develop a
nationally agreed approach for measuring access time to elective surgery that includes
the time from referral.

More information can be found in the reports Elective surgery waiting times 2016–17:
Chapter 7
Australian hospital statistics; Admitted patient care 2015–16: Australian hospital statistics;
and the National definitions for elective surgery urgency categories: proposal for the
Standing Council on Health.
435
7.12 Radiotherapy
SNAPSHOT
Radiotherapy uses radiation directed at a localised area to kill or damage cancer cells.
It is a well-established, effective and safe way to treat cancer and a small number of
other conditions.
Radiotherapy is usually given as one of a series of outpatient treatments over a defined
period, though under some circumstances patients may be treated as admitted patients.
The optimal time frame for the treatment depends on whether it has a curative,
prophylactic or palliative intent (see Glossary for definition of these treatment types).
There are several types of radiotherapy. The data in this snapshot relate to the most
common form in Australia—megavoltage external beam radiotherapy, delivered by linear
accelerator machines.
Radiotherapy activity
About 60,600 courses of radiotherapy began in 2015–16 (delivered at 44 public sector
sites and 33 private sector sites). For these courses:
• 70% of patients starting a course of radiotherapy treatment were aged 60 and over
• breast, prostate and lung cancers were the most common reasons for radiotherapy
• m
ore than half (58%) of the radiotherapy courses were intended to cure disease
(curative), 38% were palliative and 1.1% were to prevent disease (prophylactic)
• t here was a clear relationship between the age of the patient and whether the
treatment was curative or palliative. The younger the patient, the more likely the
treatment was intended to be curative (Figure 7.12.1)
• 2
.0% of courses were clinically assessed as emergency treatment (that is, radiation
treatment to begin within 24 hours), with most of these (96%) being palliative
• p
ublic providers delivered two-thirds (67%) of radiotherapy courses, while private
providers delivered one-third (33%).
Radiotherapy waiting times

In 2015–16, 50% of patients received treatment within 9 days of being assessed as ready
for care, and 90% received treatment within 27 days.
Waiting times were shortest for patients receiving palliative radiotherapy, and longest
for patients receiving curative radiotherapy (Figure 7.12.2). Palliative patients are more
likely to need less complex treatment techniques, so their treatment can generally be
scheduled around that for other patients without causing major delay for those patients
(RANZCR 2013).
436
Figure 7.12.1: Radiotherapy courses, by intention of treatment and age group,
2015–16
Per cent
90
80
70
Curative
60
50
40
Palliative
30
20
10
Prophylactic
0
0–19 20–39 40– 49 50–59 60– 69 70–79 80– 89 90+
Age group
For patients who were clinically assessed as emergency patients, 91% began treatment
on the same or next day.
Waiting times for non-emergency courses were the same as for all courses, as most
courses are non-emergency.
Of male patients with a principal diagnosis of prostate cancer, 50% started treatment
within 10 days, and 90% within 29 days. Of female patients with a principal diagnosis of
breast cancer, 50% started treatment within 8 days, and 90% within 28 days.
Figure 7.12.2: Radiotherapy waiting times by intention of treatment, 2015–16
Days
90% started treatment within
35
50% started treatment within
30
25
20
15
10
5
0
Curative Palliative Prophylactic
Chapter 7
Intention of treatment
437
Other waiting periods—such as the times between contacts with a general practitioner,
medical oncologist and radiation oncologist, and the time between the first consultation
with a radiation oncologist and the patient becoming ready for care—are not collected.
Agreement on appropriate benchmark waiting periods for non-emergency patients
(for example, those based on relevant clinical characteristics) would allow better
reporting of the appropriateness of waiting times for radiotherapy.

More information on radiotherapy in Australia is available in the report Radiotherapy in

Australia, 2015–16, which can be downloaded for free.
References
AIHW (Australian Institute of Health and Welfare) 2017. Radiotherapy in Australia 2015–16. Cat. no. HSE 191.
Canberra: AIHW.
RANZCR (The Royal Australian and New Zealand College of Radiologists) 2013. Management of waiting
lists in radiation oncology: quality in the timeliness of patient care. Sydney: RANZCR.
438
7.13 Organ and tissue
SNAPSHOT
donation
Organ and tissue donation involves retrieving organs and tissue from suitable donors
to transplant into a recipient. There are two types of donation: deceased (after brain or
cardiac death) and living.
• O
rgans that can be donated from deceased donors include the heart, lungs, liver,
kidneys and pancreas.
• Living donors can donate a kidney or, in rare cases, partial liver.
• T
issues that can be donated include bone, tendons, ligaments, skin, and selected
parts of the eye.
Depending on individual circumstances, more than one organ and/or tissue may be
donated by one person; therefore the number of recipients will exceed the number of
donors in any given year.
Few people die in a way that makes organ donation possible—in fact, only around 1–2%
(around 1,100 in 2016) of people who die in hospital each year are suitable to become
organ donors (OTA 2017a). When a person dies and donation is a possibility,
the family’s permission is sought.
People aged 16 and over who wish to become donors can join the Australian Organ Donor
Register at <www.donatelife.gov.au>, which is checked when the potential for donation
arises. While the majority of Australians are willing to become donors (67%), only 34% are
registered (OTA 2017a; Social Research Centre 2017, cited in OTA 2017b). Registration is
important as 9 in 10 families agree to donation if their loved one was a registered donor
and the family has prior knowledge of the donation decision.
Most kidneys and parts of liver transplanted from living organ donors are from donors
genetically or emotionally related to the recipient. However, there are also donors through
the Australian Paired Kidney Exchange Program. This program identifies matches for
patients who are eligible for a kidney transplant, and have a living donor who is willing but
unable to donate because of an incompatible blood or tissue type.
Organ donation
In 2016, the number of deceased organ donors was the highest since national recording
of organ donation began in 2009. In 2016, there were 503 deceased organ donors—more
than double the number in 2009 (247). Between 2009 and 2016, the number of recipients
increased from 799 to 1,447 (Figure 7.13.1). In 2016, there were 267 living organ donors
who donated their kidney (265) or part of their liver (2) (OTA 2017a).
Chapter 7
439
Figure 7.13.1: National deceased organ donations and transplants,
2009 to 2016
Number
1,800
Organ donors Transplant recipients Organs transplanted
1,600
1,400
1,200
1,000
800
600
400
200
0
2009 2010 2011 2012 2013 2014 2015 2016
Year
Sources: OTA 2016, 2017a; Table S7.13.1.
Tissue donation
In 2016, there were 4,291 donors of tissue, including musculoskeletal, skin and
cardiovascular tissue, excluding eyes. Of these, 424 were deceased donors, who gave
650 tissue donations. This was almost double the 327 tissue donations in 2012, the year
national reporting on tissue donation began.
The 3,867 living tissue donors, who gave 3,923 tissue donations, excluding eyes, were
mainly patients undergoing joint replacement surgery.
There were 1,281 deceased eye donors in 2016—an increase of 39% since 2009 (922)
(OTA 2016a, 2017a).
Transplants
Consistent with the growth in organ donation, the overall number of organs transplanted
from deceased donors increased by 80%, from 938 organs in 2009 to 1,687 in 2016
(Figure 7.13.1). In 2016, kidneys were the organ most often transplanted from
deceased donors (841), followed by liver (283) (OTA 2017a).
Organs transplanted from deceased donors, 2016
Kidney 841 Lungs 386 Liver 283 Heart 124 Pancreas 52
One intestinal transplant is not included.
440
In 2016, there were 2,085 corneal transplants, with all requests for eye tissue transplantation
being met; transplant rates remained relatively consistent since 2012. There were 7,468 other
tissue transplant recipients, most (95% or 7,073) of whom received musculoskeletal tissue.
The number of tissue transplant recipients more than doubled from 3,691 in 2013 to 7,468
in 2016 (OTA 2017a).
Organ transplant waiting list

At the start of 2016, there were 1,480 patients listed on solid organ transplant waiting
lists. A further 1,609 new patients were listed during that year. Of the total number of
wait listed patients in 2016:
• 1,447 received a transplant from a deceased donor
• 38 received a transplant from a living donor
• 259 were removed from the list for various reasons
• 35 died while on the waiting list (ANZDATA 2017).

The AIHW’s National Hospital Morbidity Database has information available on procedures,
patient diagnoses and other information for most deceased donations, all live donations
and all transplants. Further work could be undertaken to understand how these data could
complement the Organ and Tissue Authority’s reported data.

More information on organ and tissue donation, including signing up to the Australian
Organ Donor Register is available at <www.donatelife.gov.au>.
Some information on selected outcomes for organ transplants is available at the Australia
and New Zealand dialysis and transplant registry.
References
ANZDATA (Australia and New Zealand Dialysis and Transplant Registry) 2017. Australia and New Zealand
Dialysis and Transplant Registry annual report. Section 12: organ waiting list. Adelaide: ANZDATA.
Viewed 19 February 2018, <http://www.anzdata.org.au/anzod/ANZODReport/2017/c12_waitinglist_
v1.0_20171116.pdf>.
OTA (Organ and Tissue Authority) 2016. Australian donation and transplantation activity report
2015. Canberra: OTA. Viewed 29 November, 2017, <http://www.donatelife.gov.au/sites/default/files/
Australian%20Donation%20and%20Transplantation%20Activity%20Report%202015.pdf>.
OTA 2017a. Australian donation and transplantation activity report 2016. Canberra: OTA. Viewed
22 November 2017, <http://www.donatelife.gov.au/sites/default/files/Australian%20Donation%20and%20
Transplantation%20Activity%20Report%202016.pdf>.
OTA 2017b. Donation facts and statistics. Canberra: OTA. Viewed 22 November 2017,
<http://www.donatelife.gov.au/sites/default/files/Facts%20and%20Stats%20Fact%20Sheet%20-Feb%20
2017.pdf>.
Chapter 7
441
7.14 Labour, birth and
SNAPSHOT
outcomes
The health of a baby at birth is a key determinant of their health and wellbeing throughout
life. Data on most births in Australia are collected by health professionals and included in
the National Perinatal Data Collection. This snapshot uses these data to explore aspects of
labour, birth and baby outcomes.

In 2015, about 304,300 women in Australia gave birth to around 309,000 babies, an
increase in both the number of mothers who gave birth and babies born since 2005
(around 13%).
Of births in 2015:
Mother’s remoteness area Baby boys slightly
of usual residence: outnumbered baby girls:
73% Major cities 51% Boys
16% Inner regional 49% Girls
8.4% Outer regional
2.5% Remote/Very remote
Place of birth: Aboriginal and Torres

97% were in a hospital Strait Islander status:
Public—73% 4.3% of mothers

Private—27% 5.4% of babies
How labour started: Pain relief:

50% spontaneous labour 77% mothers in labour
29% induced labour received pain relief
21% no labour onset
Method of birth
Vaginal birth was the most common method of delivery of all mothers who gave birth
in 2015 (2 in 3 women, or 67%). One in 3 (33%) women underwent a caesarean section,
including women who:
• had no labour onset
• required a caesarean section after labour onset, and/or
• had decided to have a caesarean section during pregnancy.
442
In 2015, Aboriginal and Torres Strait Islander mothers were slightly less likely to have a
caesarean section than non-Indigenous mothers (32% and 34%, respectively). They were
also 7 times as likely as non-Indigenous mothers to be aged under 20 (15% compared
with 2.1%).
Overall, vaginal birth rates have decreased while caesarean section rates have increased.
In 2015, rates of spontaneous labour onset were higher among younger mothers.
Once labour starts, it may be necessary to intervene to speed up or augment the labour.
Labour augmentation occurred for 16% of mothers in 2015; this rate was higher for
first-time mothers (43% of women with spontaneous labour onset). See Chapter 7.15
‘Caesarean sections’ for more information.
Gestational age of babies

The average gestational age for all babies was
38.6 weeks. This varied in relation to birth status Gestational age of live births:
(for example, liveborn or stillbirth) and multiple Preterm (20–36 weeks) 8.7%
pregnancies (for example, twins and triplets). Term (37–41 weeks) 91%
Babies of multiple pregnancies were more likely Post-term (42+ weeks) <1%
to be born preterm (64%) as were babies born to
Indigenous mothers (14%).
Birthweight
Birthweight is a key indicator of infant health and
a determinant of a baby’s chance of survival and Birthweight categories:
health later in life. Incidence of babies born both High: 4,500 grams and over
small for gestational age and of a low birthweight Normal: 2,500–4,499 grams
was more common among babies born to mothers Low: <2,500 grams
who smoked during pregnancy, Indigenous mothers Extremely low: <1,000 grams
and multiple births (twins, triplets). For all births in
2015, the average birth weight was 3,327 grams.
Babies born at a Admission to special care

low birthweight: nurseries (SCNs) and neonatal
1 in 16 (6.5%) intensive care units (NICUs):
liveborn 74% of preterm births
60% of twin births
94% of other multiple births
Apgar Scores
Apgar scores are clinical indicators that determine a baby’s condition shortly after birth.
Chapter 7
These scores are measured on a 10-point scale for several characteristics. An Apgar score
of 7 or more at 5 minutes after birth indicates the baby is adapting well to the environment.
In 2015, 98% of liveborn babies had an Apgar score of 7 or more at 5 minutes.
443
Resuscitation and admission to special care nurseries
and neonatal intensive care units
In 2015, 1 in 5 (19%) liveborn babies needed some form of active resuscitation immediately
after birth. Resuscitation methods are undertaken to establish a baby’s independent
respiration and heartbeat or to treat respiratory effect and correct metabolic disturbances.
These methods range from least severe (suction) to severe (external cardiac massage and
ventilation). Admission to an SCN or NICU was required for 16% of liveborn babies, with
preterm, multiple births and babies born to Indigenous mothers more likely to be admitted.
Perinatal Mortality
Perinatal mortality is the death of a baby during the period immediately before birth
(fetal death) and up to 28 days after birth (neonatal death). In 2015, there were 9 perinatal
deaths for every 1,000 births (2,849 total). The most common cause of perinatal death
was congenital abnormalities. Factors associated with higher rates of perinatal death
were maternal age, maternal Indigenous status and multiple pregnancy. Perinatal
mortality rates decreased dramatically as gestational age and birthweight increased.
In 2015, perinatal death rates in relation to gestational age were highest among babies
born at 20–27 weeks’ gestation (693 deaths per 1,000 births) and were lower among
babies born at term (37–41 weeks) (2 deaths per 1,000 births). In relation to birthweight,
perinatal death rates were highest among extremely low birthweight babies (691 per
1,000 births) and lowest among babies with a birthweight of 2,500 grams or higher
(2 deaths per 1,000 births). The perinatal death rate increased among babies with a
birthweight over 5,000 grams (10.3 per 1,000 births).

Australia’s maternal and perinatal mortality rates are among the lowest in the world.
However, efforts to develop national data standards and to improve data availability
and consistency will allow specific areas of concern to be better monitored and targeted
by health services. The AIHW is currently working and consulting with jurisdictions
to improve data availability and quality on maternal health conditions (hypertensive
disorders, diabetes, overweight and obesity, and primary postpartum haemorrhage),
baby resuscitation and induction of labour. Currently, data on these indicators are either
inconsistent or require national data standards to be developed for mandatory data
supply. More recent and consistent data on birth anomalies would also help to develop
a better picture about labour, birth and baby outcomes.

More information on Australia’s mothers and babies, are available at
<www.aihw.gov.au/reports-statistics/population-groups/mothers-babies/overview>.
The reports Australia’s mothers and babies 2015—in brief and Perinatal deaths in Australia
2013–2014 are available for free download.
444
7.15 Caesarean sections
SNAPSHOT
Since 1985, the World Health Organization (WHO) has recommended a population
caesarean section rate of 10–15% to ensure mortality rates are kept low for mothers and
babies (RHR 2015). Of the close to 309,000 babies born to 304,300 women in 2015 in
Australia, 33% (101,370) were born by caesarean section.
According to the latest Organisation for Economic Co-operation and Development (OECD)
data, in 2014, Australia had the eighth highest caesarean section rate of 33 countries, with
a caesarean rate of 34 per 100 live births—higher than the OECD average of 28 per 100
live births (OECD 2017). The caesarean section rate among OECD countries ranged from
16 per 100 live births for Finland to 53 per 100 for Turkey (OECD 2017).
Caesarean section rates are increasing

Between 2005 and 2015, the rate of birth by caesarean sections in Australia continued to
rise, from 30% of births in 2005 to 33% of births in 2015. Both emergency (unplanned) and
elective (planned) caesarean section births have increased in Australia over time, but there
seems to be a larger increase in rates of planned caesarean sections (ACSQHC 2017).
As caesarean section rates increase, it is important that mothers are aware of the risks
involved with this procedure, and that caesarean sections should occur only when there is
a clinical need (RHR 2015).
Variation in caesarean section rates

In 2015, of the 51,372 women who had previously had a caesarean section, most (85%)
had a repeat caesarean section. Of all mothers who gave birth, having had a previous
caesarean section was the most common reason given for having one in 2015. Nearly
one-quarter (23%) of mothers had a primary caesarean section (that is, they had not had
a caesarean section before).
Other factors related to mothers being more likely to have a caesarean section were:
• maternal age of 40 or more (52%)
• mothers who had a multiple birth (69% of twins and 88% of other multiples)
• mothers whose babies were breech, where the baby exits buttocks or feet first (87%).
Women who gave birth in a private hospital were also more likely to have a caesarean
section (45%) than women who gave birth in a public hospital (30%) (Table 7.15.1).
Chapter 7
445
Table 7.15.1: Factors related to mothers being likely to have a caesarean section, 2015
Caesarean births Vaginal births
Previous caesarean 85% 15%

Total = 51,372 Number = 43,584 Number = 7,787
40 years and over 52% 48%

Twins 69% 32%

Other multiple births 88% 12%

Total = 237 Number = 209 Number = 28
Breech presentation 87% 13%

Birthed in a private hospital 45% 55%

Note: Not stated values included in denominator ’Total‘.

Source: National Perinatal Data Collection; Table S7.15.1.
Rates using the Robson classification system

In 2015, the WHO guidelines were revised. The WHO now recommends that, rather than
a population-based estimate of caesarean section rate, the Robson classification (also
called the 10-group classification) be used to evaluate and compare caesarean section
rates between groups of women (ACSQHC 2017; RHR 2015). This classification system
groups women into 10 mutually exclusive groups based on obstetric characteristics, such
as parity (number of previous pregnancies), onset of labour, whether there has been a
previous caesarean section, and the baby’s gestational age (RHR 2015).
The AIHW, in collaboration with the National Maternity Data Development Project
Advisory Group, recently undertook preliminary work using the National Perinatal Data
Collection 2015 data for the first time to group women into the 10 Robson classification
categories. Women presenting with a breech pregnancy were most likely to have a
caesarean section (92% for first pregnancies, 86% for subsequent pregnancies) followed
by those with singleton pregnancies near term who had one or more previous caesarean
sections (85%). Focusing on key groups within the Robson classification provides a more
detailed understanding of caesarean section rates among different classification groups.
This will allow a more targeted intervention, and further understanding of the relatively
high caesarean section rate in Australia.
446
Women who gave birth in 2015, by the ten Robson classification categories
First time mother, singleton pregnancy, First time mother, singleton

baby in breech (feet first) presentation pregnancy, baby in cephalic (head first)
6,076 women gave birth in this group presentation, >37 weeks gestation,
5,574 had a caesarean section induced labour or caesarean section
before labour
92%
caesarean rate
54,043 women gave birth in this group
24,447 had a caesarean section
45%
caesarean rate
Mother has previously given birth with
current singleton baby in breech
(feet first) presentation All women with a singleton pregnancy,
baby in cephalic (head first)
4,714 women gave birth in this group presentation, ≤ 36 weeks gestation,
including women with previous
86%
caesarean rate caesarean scars
40%
caesarean rate
Mother has previously given birth
with a previous caesarean scar,
singleton pregnancy, baby in cephalic Mother has previously given birth
(head first) presentation, >37 weeks without a previous caesarean scar,
gestation, induced labour or singleton pregnancy, baby in cephalic
caesarean section before labour (head first) presentation, >37 weeks
44,403 women gave birth in this group gestation, induced labour or
37,586 had a caesarean section caesarean section before labour
85%
caesarean rate 39,920 women gave birth in this group
16%
caesarean rate
Multiple pregnancy, including women

with previous caesarean scars First time mother, singleton pregnancy,
4,540 women gave birth in this group baby in cephalic (head first)
3,086 had a caesarean section presentation, >37 weeks gestation,
spontaneous labour (not induced)
68%
caesarean rate
16%
caesarean rate
All women with a singleton pregnancy,
baby in traverse (side on) or oblique
lie, including women with previous Mother has previously given birth
caesarean scars without a previous caesarean scar,
singleton pregnancy, baby in cephalic
(head first) presentation, >37 weeks
gestation, spontaneous labour
48%
caesarean rate (not induced)
2.4%
caesarean rate
Vaginal births after caesarean section

rates have declined over time
Chapter 7
The rate of women opting for a vaginal birth after having had a previous caesarean
section (VBAC) declined slightly between 2005 and 2015. The rate of mothers having
a successful VBAC (with or without instrumentation) for their current birth was 16.5%
in 2005, decreasing to 15.2% in 2015 (Figure 7.15.1).
447
Figure 7.15.1: Mothers who had a vaginal birth who have had a previous
caesarean section, 2005 to 2015
Per cent
17.0
16.5
16.0
15.5
15.0
14.5
14.0
0.0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Monitoring caesarean sections in Australia

The National Core Maternity Indicators (NCMIs) present information on measures of
clinical activity and outcomes over time to monitor the safety and quality of maternity
care. The indicators related to caesarean section in the NCMIs include ‘Caesarean section
for selected women giving birth for the first time’ and ‘Women having their second birth
vaginally whose first birth was by caesarean section’. Monitoring the rates of caesarean
sections is an important way to ensure that there is continual improvement in the quality
of maternity services in Australia.

There are limited data on caesarean sections, especially in terms of planned versus
emergency caesarean sections. These data are essential if best evidence-based practices
are to be implemented across settings, and to better inform policy decisions.
As noted in this snapshot, caesarean section rates using the Robson classification are
a more effective way to view caesarean section rates than reporting a population rate.
Future routine reporting and analysis of caesarean sections using this system will allow
policy and practice to more effectively target specific groups of women.

More information on mothers and babies in Australia, including the perinatal dynamic data
displays and the National Core Maternity Indicators report and display, are available at
<www.aihw.gov.au/reports-statistics/population-groups/mothers-babies/overview>.
The report Australia’s mothers and babies 2015—in brief and other recent releases are
448
References
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2017. The Second Australian Atlas
of Healthcare Variation. Sydney: ACSQHC. Viewed 21 November 2017,
<https://www.safetyandquality.gov.au/atlas/atlas-2017/>.
OECD (Organisation for Economic Co-operation and Development) 2017. Health at a glance 2017:
OECD indicators. Paris: OECD Publishing. Viewed 27 November 2017, <http://dx.doi.org/10.1787/
health_glance-2017-en>.
RHR (Department of Reproductive Health and Research) 2015. WHO statement on caesarean section rates.
WHO/RHR/15.02. Geneva: WHO. Viewed 21 November 2017, <http://www.who.int/reproductivehealth/
publications/maternal_perinatal_health/cs-statement/en/>.
Chapter 7
449
7.16 Variation in health care
SNAPSHOT
provision
The use of health care can vary according to where people live. Understanding variation
across geographic areas is important to improve the quality, appropriateness and value
of health care provided to patients. In 2017, the Australian Commission on Safety and
Quality in Health Care (the Commission), in collaboration with the AIHW, published ‘The
second Australian atlas of healthcare variation’ (the Atlas) (ACSQHC & AIHW 2017). The
Atlas showed variation in health care use, depending on where people live.
Why measure variation in health care

provision?
Some variation in health care use is to be expected. It can be associated with differences
in patients’ health or personal preferences for treatment. However, in certain cases, some
people may receive inappropriate or unnecessary care, while others may miss out on care
that might be beneficial (unwarranted variation). Unwarranted variation may indicate:
• the need to deliver services more fairly based on patient need
• t he need for patients to have better information on their options and on the likely
benefits and harms of a particular treatment
• g
aps in accessible evidence for clinicians and the need for evidence-based guidelines or
clinical care standards
• the need for changes in clinical training
• t he need to review whether financial incentives could be changed to encourage more
appropriate care (ACSQHC & AIHW 2017).
Tackling unwarranted variation can help to improve the quality of health care. Measuring
it is the first step.
Information on unwarranted health care variation—such as presented in the Atlas
series—can stimulate further awareness and investigation of the variation, and can be
used to promote strategies to reduce unwarranted variation. For example, in response to
the Atlas series:
• s tates and territories and professional bodies have instigated quality improvement
initiatives (for example, changes to clinical care models, development of further training
for health professionals, and updating of clinical guidelines)
• t he Commission has developed clinical care standards to promote appropriate care (for
example, the ‘Heavy menstrual bleeding clinical care standard’) (ACSQHC 2017a)
• h
ealth services accredited under the National Safety and Quality Health Service
Standards (ACSQHC 2017b) will be required to monitor and review clinical variation from
2019 onwards.
450
Variation in the rates of selected health care
The Atlas included indicators for surgical interventions, women’s health and maternity,
chronic disease and infection, and cardiovascular conditions. Some summary findings
are provided in this snapshot, and rates for hysterectomy are presented in more detail.
For example, the Atlas found that:
• t he rate of hospitalisation for endometrial ablation (used to treat heavy menstrual
bleeding) was 21 times as high in the Statistical Area Level 3 (SA3) with the highest
rate compared with the SA3 with the lowest rate
• t he rate of hospitalisation for lumbar spinal decompression (used to treat
degeneration of the spinal joints) was 5.2 times as high in the SA3 with the highest
rate compared with the SA3 with the lowest rate
• t he rate for third or fourth degree perineal tears (tears of the skin and other tissues
mainly during childbirth) per 1,000 vaginal births was 12 times as high in the SA3 with
the highest rate compared to the SA3 with the lowest rate.
All rates are based on the population living in the area.
Hysterectomy
Hysterectomy, or the surgical removal of the womb (uterus), is a major surgical
procedure commonly used to treat heavy menstrual bleeding. The Atlas examined rates
of hysterectomy across Australia, excluding hysterectomies due to cancer. It found a
6.6-fold difference between the lowest and highest rate of hysterectomy between SA3s
(Figure 7.16.1). Overall, rates were higher in Inner regional and Outer regional areas
compared with Major cities or Remote and Very remote areas. The rate of hysterectomy for
Aboriginal and Torres Strait Islander females was about 10% lower than the rate for other
females.
Potential reasons for the variation, outlined in the Atlas, include differences in:
• patient education and awareness of treatment options
• patient preferences
• clinician awareness of the guidelines for the management of heavy menstrual bleeding
• access to primary care services
• private health insurance coverage.
Improving access to less invasive treatments, such as pharmaceutical treatments and
endometrial ablation, may help some adolescents and women avoid the need for
hysterectomy.
Chapter 7
451
Figure 7.16.1: Age-standardised hospitalisation rate for hysterectomy,
DARWIN
females aged 15 and over, by SA3, 2014–15
DARWIN
BRISBANE
BRISBANE
PERTH
PERTH
SYDNEY
SYDNEY
CANBERRA
CANBERRA
ADELAIDEADELAIDE
Hospitalisation rate
Hospitalisation rate(number
(numberperper
100,000 females)
100,000 females)
MELBOURNE
407–763
407–763 307–327
307–327
189–223
189–223 MELBOURNE
377–406 291–306 115–188
377–406
349–376 291–306
256–290
115–188
not published
349–376
328–348 256–290
224–255 not published
328–348 224–255
HOBART
HOBART
Note: For detailed maps of the capital cities see The second Australian atlas of healthcare variation.
Source: ACSQHC & AIHW 2017.

One of the key challenges in examining health care variation relates to the configuration
of Australia’s health data collections. Information about health care is recorded in a range
of different collections, which can make it difficult to accurately monitor the care provided
to patients. The AIHW, in collaboration with jurisdictions, is working to improve the
integration of health services data—for example, routine linkage (for statistical purposes)
of data for hospitals, Medicare Benefits Schedule, Pharmaceutical Benefits Scheme,
residential aged care, and deaths—which will provide a better understanding of health
care delivery and outcomes in the future.
452
The data in the Atlas series provide an overarching picture of health care variation.
Further investigation of factors that may explain some of the variation—such as disease
prevalence or differing supply of health professionals across Australia—can be informative
and has already been conducted by some jurisdictions and/or service providers in
response to the Atlas series. The Atlas series focuses on a relatively small number of
types of health care, sometimes depending on data availability. Analysis of variation,
such as this, is potentially possible for a wide range of health services.
Understanding the outcomes for patients who have received health care—for example,
patient-reported wellbeing or post-surgery outcomes—is also a key factor when
considering variation. Improved collection and integration of outcome data at a national
level will enhance the understanding of health care variation in the future.

More information on health care variation is available in The first Australian atlas of
healthcare variation and The second Australian atlas of healthcare variation.
The AIHW also publishes a range of data on health care variation across geographical
areas, such as Cancer screening in Australia.
References
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2017a. Heavy Menstrual Bleeding
Clinical Care Standard. Sydney: ACSQHC. Viewed 29 November 2018,
<https://www.safetyandquality.gov.au/publications/heavy-menstrual-bleeding-clinical-care-standard/>.
ACSQHC 2017b. National Safety and Quality Health Service Standards. 2nd edn. Sydney: ACSQHC.
ACSQHC & AIHW (Australian Institute of Health and Welfare) 2017. The second Australian atlas of
healthcare variation. Sydney: ACSQHC.
Chapter 7
453
7.17 Patient-reported
FEATURE ARTICLE
experience and
outcome measures
Patient-reported measures collect information about the experience of health services,
and the outcomes of health services, as described by patients. They differ from many
other measures of health service delivery which are based on information from
providers of health services. Patient-reported measures can be used to measure health
performance—for both national and local area monitoring—and to inform ongoing
improvements in the quality of health services. Currently, their use is largely restricted
to discrete health services and contexts (Thompson et al. 2016).
Interest is growing in strengthening and coordinating efforts to collect patient-reported
information to benefit patients and the health system as a whole. To this end, patient
reported measures have been included in the scope of the new Australian Health
Performance Framework (AHPF) as measures for potential development to inform
assessments of the appropriateness and safety of care in particular (NHIPPC 2017).
This article presents information on the current and potential use of patient-reported
experience and outcome measures in Australia.
Patient-reported experience measures

Patient-reported experience measures (PREMs) are used to obtain patients’ views and
observations on aspects of health care services they have received. This includes their
views on the accessibility and physical environment of services (for example, waiting
times and the cleanliness of consultation rooms and waiting spaces) and aspects of the
patient–clinician interaction (such as whether the clinician explained procedures clearly
or responded to questions in a way that they could understand).
Patient-reported experiences in Australia

The Australian Bureau of Statistics Patient Experience Survey (PES) is undertaken
annually to report on patient experiences of health care services (in general) in Australia.
This national population-based survey collects information on the use of, and experiences
with, selected health service providers by people aged 15 and over.
According to the PES, in 2016–17, 18% of people felt that they had waited longer than
they felt was acceptable to get an appointment with a general practitioner (GP) in the last
12 months, and 21% had waited longer than they felt was acceptable for an appointment
with a medical specialist.
For people who had seen a GP for urgent medical care at some stage in the last 12 months,
63% were able to see the GP within 4 hours of making an appointment at their most recent
visit, but a quarter (25%) waited for 24 hours or more.
454
PES respondents reported that a high proportion of health professionals ‘always’ or
‘often’ listened carefully, showed respect, and spent enough time with them in their
communications. Dental professionals were identified as most likely to always display
these characteristics, with doctors and specialists in emergency departments least
likely to do so (Figure 7.17.1). This may reflect the different nature of these health care
interactions, and the circumstances in which these different services might be accessed.
Figure 7.17.1: Key patient experience measures, selected health professionals,

2016–17
Health professional listened carefully

Health professional Always Often
GPs
Medical specialists
Dental professionals
Hospital services (doctors and specialists)
Hospital services (nurses)
Hospital emergency department (doctors and specialists)
Hospital emergency department (nurses)
0 10 20 30 40 50 60 70 80 90 100
Per cent
Health professional showed respect

Health professional Always Often
GPs
Medical specialists
0 10 20 30 40 50 60 70 80 90 100
Per cent
Health professional spent enough time with the patient

Always Often
Health professional
GPs
Medical specialists
Chapter 7
0 10 20 30 40 50 60 70 80 90 100
Per cent
455
The PES is useful to obtain a picture of how patients’ view their experiences in accessing
key health care services, and their satisfaction with aspects of the clinical interaction in
general. The data it provides are used in national health performance assessment—for
example, as reported in the Report on Government Services (SCRGSP 2018). However, they
cannot be specifically used to support service improvement because they:
• r elate to all relevant services provided in the last 12 months (and so do not necessarily
relate to experiences with a single service provider or organisation)
• d
o not identify the specific service provider(s) used (and so information cannot be fed
back to them)
• a
re not restricted to assessment of recent experiences; the information may be
collected up to 12 months after the service was provided, which may influence
responses provided.
Using patient experiences data for service improvement

There are several programs in Australia where patient experience data are collected for
specific services, and then fed back to service providers to drive continuing improvement
of those services. Data may also be aggregated to allow some overarching monitoring
of services. One such program is the Your Experience of Service survey, which has been
adopted in some parts of the public mental health sector; the program aims to help mental
health services and consumers work together to build better services (see Box 7.17.1).
There are a number of other standardised PREMs developed for general use across
health services. Examples include the United Kingdom’s National Health Service surveys,
the Canadian Patient Experiences Survey and the Victorian Healthcare Experience Survey
(CIHI 2018; Picker Institute Europe 2018; Victorian DHHS 2017a).
In relation to hospital care, the Australian Hospital Patient Experience Question Set
(AHPEQS) has recently been developed. It is a nationally consistent tool for assessing
patient experiences in the hospital sector in a way that can be fed back to providers.
The AHPEQS is a set of 12 questions about a person’s recent experience in a private
or public hospital or day procedure service, regardless of their condition or the type
of treatment they receive. The questions cover a range of aspects of their care and
experience—such as patient involvement, responsiveness to needs, clear communication,
patient safety, and harm and distress (ACSQHC 2017a). The questions were based on
focus group discussions with Australian health care consumers, which identified the
key dimensions seen to be important influences on the quality of their experience
(Figure 7.17.2).
In the future, it is intended that the AHPEQS will provide a nationally consistent method
to monitor and benchmark patient experience across Australia, for both public and
private health care services. These data can then be used within services to drive
improvement and, will, potentially, be a data source for the patient experience
indicators anticipated in the AHPF.
456
Box 7.17.1: Your Experience of Service Survey
Monitoring consumer and carer experiences of service is an action under the Fifth
National Mental Health and Suicide Prevention Plan (The Fifth Plan) (CHC 2017).
All levels of government have had a long-standing interest in developing a
standardised national measure of mental health consumer experiences of care
that would support quality improvement, service evaluation and benchmarking
between mental health services.
The Your Experience of Service (YES) survey was developed for use with public
mental health services. It asks questions about patients’ perceptions of their
treatment and the care they received (for example, did they feel welcomed,
respected and safe; were they provided with information about the service,
their rights and responsibilities; and was a suitable care plan developed).
The YES survey is currently used in three states (New South Wales, Victoria and
Queensland). In general, the survey form (which identifies the service provider) is
offered to patients at discharge or at other appropriate intervals, and they complete
it anonymously. Data are collated centrally, and an aggregated data report is
provided to services to encourage review and continuous improvement.
Individual states have publicly reported on YES data. Some of the key findings
presented in their reports are detailed here:
• In Victoria, nearly two-thirds (65%) of people who attended a clinical mental
health service in the previous 3 months rated their experience as excellent or very
good. The main factor associated with positive experiences was ‘staff showing
respect for your feelings’, which was further influenced by ‘feeling welcome’, ‘staff
making an effort to see you when you wanted’, ‘staff showing hopefulness for the
future’ and ‘respect for individual values and feeling safe’ (Victorian DHHS 2017b).
• In New South Wales, 39% of people rated their overall experience as excellent
and 28% as very good in 2016–17. Composite score data (based on responses to
all relevant questions) in that state are also presented for local health districts/
specialty health networks and hospitals—which identify those services that have
scores that are significantly more positive than the state average, and those that
are significantly lower (NSW Ministry of Health 2017).
• In Queensland, 44% of people rated their overall experience as excellent,
and 26% as very good in 2016. Across the state, the most positive scores were
related to ‘showing respect’, ‘ensuring safety and fairness’ and ‘supporting active
participation’. Lower scores were given for ‘providing information and support’
and ‘making a difference’ (Queensland Health 2017).
These data are used at the statewide level to monitor services in general. The data
for individual services are used by those services to compare their results with
those of others, and to prioritise improvement activities.
Chapter 7
The Fifth Plan commits governments to national pooling and reporting of YES
survey data in the future.
457
Figure 7.17.2: Dimensions of patient experience (hospital care)
Interpersonal Clinical quality Care delivery Administrative

interactions interactions interactions interactions
I am heard I can get the I have confidence in My hospital puts

Patient right care at the the professionals the needs of
within a I am cared
right time treating me patients first
health about
I experience I am discharged at My hospital is well
service I am informed
high quality and the right time with the managed overall
safe clinical care right plan
I am known
My appointments
My personal care needs
I am treated as and waits are well

are attended to
a human being managed
My care is tailored to
I understand my needs My feedback is
what welcome and
professionals My hospital is clean acted upon
say and welcoming
My health records
Different parts of my are well managed
care are co-ordinated
I am treated equally
no matter who I am
Source: Adapted from ACSQHC 2017b.
Patient-reported outcome measures

As well as interest in activities aimed at expanding the use of PREMs, there is also strong
interest in promoting and coordinating the use of patient-reported outcome measures
(PROMs, see Box 7.17.2)—both in Australia and other countries.
The International Consortium for Health Outcomes Measurement (ICHOM), established
in 2012, aims to promote the collection and reporting of common data for patients with
identified health conditions, and to support international efforts to share data and improve
health internationally. The ICHOM assembles global teams of stakeholders (including
patients) to review existing instruments and recommend those that are valid and appropriate
for use in a range of cultures. As well, they recommend additional data that should be
collected and used in conjunction with health outcomes data (for example, information
about the age of the patient and comorbidities that may affect expected outcomes).
Building on the work of the ICHOM, the Organisation for Economic Co-operation and
Development (OECD) has prioritised activities to promote the coordinated use of
standardised questionnaires within OECD member countries (including Australia) among
priority population groups. This international coordination may provide opportunities for
international comparison and data sharing in addition to national use. In the first instance,
this work is focusing on patients who have undergone hip or knee replacement surgery,
and patients who are receiving treatment for cancer or mental illness (OECD 2017).
Within Australia, the Australian Commission on Safety and Quality in Health Care is
currently leading the development of a national approach to the routine use of PROMs to
inform local evaluations and improvement. This will be based on three types of evidence:
• w
hat has been shown to be effective (and ineffective) in health systems internationally
where PROMs are already extensively used
• what is already happening in terms of PROMs use in the Australian health sector
• what Australian consumers and other stakeholders want and need.
458
Box 7.17.2: What are patient-reported outcome measures?
PROMs are used to obtain information from patients on their health status, usually
using standardised and validated questionnaires. When used before and after
a health care intervention (or at points throughout a longer term therapeutic
intervention), information on the self-reported changes in health status associated
with these interventions are considered to be measures of health outcomes.
The questionnaires can be designed either for use with all patients—regardless of
their health condition or the type of treatment they may be receiving—or for use
with specific patient groups (for example, cancer patients).
Typically, PROMs for general use measure aspects such as overall health and
wellbeing (or ‘health-related quality of life’), the severity of symptoms such as pain,
measures of daily functioning (activities required for self-care and to support social
interactions) and psychological symptoms. The most common questionnaires used
range in length from 5 to 36 questions, and typically ask respondents to assess
attributes of their health and functioning on a rating scale.
Examples of general purpose PROMs in common use include the Short Form-36
(SF-36), Patient-Reported Outcomes Measurement Information System (PROMIS)
and the World Health Organization Quality of Life Instrument (WHOQoL-BREF)
(HealthMeasures 2018; Ware & Sherbourne 1992; WHO 2018).
Disease- or condition-specific PROMs are designed to assess aspects of health that
might be more specifically associated with a particular health condition (Williams
et al. 2016). For example, a measure designed for use in people who experience
inflammatory bowel disease might include questions on bowel symptoms, as
well as more general questions about pain and discomfort, fatigue, and ability to
participate in activities.
The two types of PROMs have different uses. Generic PROMs can be used to
compare the health gains across different health conditions. Condition-specific
PROMs may be more useful in settings where the aim is to compare outcomes
associated with different treatments for a specific condition.
What are the potential benefits of using PROMs?

PROMs have long been used in research settings as part of the evaluation of health
interventions. Their systematic use in real-world health care delivery settings is proposed
to improve health systems on a number of levels (see, for example, Black 2013;
Williams et al. 2016).
At the patient level, the collection of PROMs data can influence the patient–clinician
interaction. It does this in two ways: by focusing attention on important aspects of
patients’ lives that might be affected by their health condition, and by providing a means
Chapter 7
to prompt discussion between the health care provider and the patient. This, in turn, can
enhance information sharing (including about patients’ priorities for their health care)
and support shared decision making about treatments. In particular, aggregated PROMs
459
data could enhance shared decision making with patients by providing evidence-based
information on expected outcomes at specific times after a health intervention (for
example, at 2 weeks, 4 weeks and 3 months after a knee replacement). This information
could help patients to make informed choices about their care.
At the service level, these data can be used for performance reporting and benchmarking
by individual clinicians and/or health care services. In this way, providers can ensure that
the outcomes achieved overall for their patients are comparable with those achieved by
others (when adjusted for relevant patient characteristics). This information can then be
used to review systems, processes and approaches to care (where poorer outcomes are
seen), or to support sharing of information about good practices with better outcomes.
Another key potential use for PROMs lies in the ability of data—if available at the
aggregate level and for a wide range of health services—to inform health care decisions
at the system level. Specifically, if data were available about the improvements to health,
quality of life and functioning status associated with specific health interventions or
procedures (or the extent to which they slowed a decline in health status), this could
substantially help the health system to re-focus on those interventions that deliver the
best value for patients and for the system as a whole.
Examples of the use of patient-reported outcome

measures in health care delivery
This section describes some specific areas where there has been some cooperative
effort in Australia to collect and share information about health outcomes (including
patient-reported outcomes) associated with care. These are the Palliative Care Outcomes
Collaboration (PCOC) and the Prostate Cancer Outcomes Registry.
Palliative Care Outcomes Collaboration

The PCOC is a national program open to all palliative care service providers (providing
either admitted patient or community-based services). It was set up in 2005. Participation
is voluntary; in a recent period (January–June 2017), 127 services contributed data.
The program was established to promote the routine use of standardised, validated
clinical assessment tools in clinical practice. One of the instruments used that is designed
to be reported by patients is the Symptom Assessment Scale (Aoun et al. 2011), which
measures distress associated with a range of symptoms. The instrument also allows
assessment by proxy (for example, a carer) if the patient is unable to give the relevant
rating directly.
Assessments are conducted daily for admitted patients, or at contact for hospital
consultative and community-based settings. Assessments can be done face to face or
by telephone, as appropriate to the setting.
460
In this program, the data are primarily used as a benchmarking tool, rather than to
formally evaluate different types of interventions. Outcomes data are collated, along with
information about the patient’s demographic profile, episode and setting of care, and phase
of care (which provides information on the patient’s needs and their clinical condition);
these added data form an important context for analysis of the patient health status data.
Summary reports are then returned to individual service providers to help in benchmarking.
State, territory and national reports are also published. These reports compare
aggregated data on a range of benchmarks that have been developed in consultation with
participating services. For example, in relation to pain, fatigue and breathing problems,
relevant benchmarks aim that:
• a
t least 90% of patients with absent or mild distress associated with the symptom
(as measured by the Symptom Assessment Scale) at the start of their phase of palliative
care have absent or mild distress at the end of the phase
• a
t least 60% of patients with moderate or severe distress associated with the symptom
at the start of their phase of palliative care have absent or mild distress at the end of
the phase (PCOC 2014).
For palliative care phases that ended between January and June 2017, relevant
benchmarks were achieved (nationally) for patients who had absent or mild pain-related
distress at the start of the care phase for hospital/hospice care only, and for patients who
had absent or mild distress associated with breathing problems (for both hospital/hospice
and community based care) (Figure 7.17.3). Nationally, relevant benchmarks were not
met in the other areas, though these benchmarks were met in some individual services
(Allingham et al. 2017).
Figure 7.17.3: Proportion of palliative care phases where patient care met
relevant PCOC benchmarks, by care setting, January–June 2017
Per cent of phases

100
90
80
70
60
50
40
30
20
10
0
Pain Fatigue Breathing Pain Fatigue Breathing
problems problems
Absent or mild distress, Moderate or severe distress,

remaining absent or mild becoming absent or mild
PCOC benchmark (level of symptom distress)
Chapter 7
Hospital/hospice Community Applicable benchmark
Source: Allingham et al. 2017; Table S7.17.2.
461
Prostate Cancer Outcomes Registry
Clinical quality and population (disease- or condition-specific) health registries also
provide a context in which patient-reported health outcomes data can be collected and
used to assess treatments and services provided by specific health service providers
(Williams et al. 2016).
One example is the Prostate Cancer Outcomes Registry–Australia and New Zealand.
Established in 2013, it tracks the treatment and outcomes of men with prostate cancer
(PCOR–ANZ 2016). Participating sites (distributed across most states and territories in
Australia, and throughout New Zealand) recruit men diagnosed with prostate cancer to
provide information about their treatment and other clinical data. Participants are then
asked to periodically complete standardised questionnaires that capture data on their
health-related quality of life. This includes reporting on symptoms that may be
specifically associated with prostate cancer and its treatment (such as urinary
continence and sexual functioning).
This information can be used to describe the patterns of treatment for patients
(including those receiving no treatment, but who are under active surveillance) and
enables monitoring of trends and benchmarking for all participating sites through public
reporting at an aggregate level. As well, the data support activities to improve quality:
reports sent back to participating sites and clinicians are framed in a way that allows them
to compare their clinical practices and outcomes achieved for similar patients. The data
can also be used to advise patients on the likelihood of symptoms associated with specific
treatments and help them to understand how these might change over time.
As well, the data are made available to researchers, under specific conditions, to explore
specific research questions.

As already noted in this article, work is going on across the health sector to collect and
report patient reported data on experiences of care and health outcomes; this is currently
mainly restricted to selected settings and sectors. The value of these activities could be
greatly enhanced by introducing more nationally coordinated technical and governance
arrangements and by introducing improved data infrastructure. These activities could
ensure that the data collected on outcomes and experiences are aligned (wherever
possible). They also could establish a potential for national sharing of data or linkage
arrangements to enable improvements in the delivery of health care at a range of levels.

More information about the current use of PROMs in Australia and the AHPEQS is
available at <www.safetyandquality.gov.au>.
More information on the YES survey for the mental health sector (including sample
survey forms and application forms for use) is available in Mental health services in
Australia, which is available for free download.
462
References
ABS (Australian Bureau of Statistics) 2017. Patient experiences in Australia: summary of findings, 2016–17
data cubes. ABS cat. no. 4839.0. Canberra: ABS. Viewed 24 January 2018,
<http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4839.02016-17?OpenDocument>.
ACSQHC (Australian Commission on Safety and Quality in Health Care) 2017a. Australian Non-proprietary
Hospital Patient Experience Question Set (AHPEQS): status update. Viewed 20 December 2017, <https://www.
safetyandquality.gov.au/wp-content/uploads/2017/09/AHPEQs-update-for-web-September-2017.pdf>.
ACSQHC 2017b. Summary of development and testing of the AHPEQS, December 2017. Sydney: ACSQHC.
Allingham S, Clapham S, Quinsey K, Mastroianni F & Foskett L 2017. Patient outcomes in palliative
care: national results for January–June 2017, detailed report. Wollongong: Palliative Care Outcomes
Collaboration, Australian Health Services Research Institute, University of Wollongong.
Aoun SM, Montessoro L, Kristjanson LJ & McConigley R 2011. Measuring symptom distress in palliative care:
psychometric properties of the Symptom Assessment Scale. Journal of Palliative Medicine 14(3):315–21.
Black N 2013. Patient reported outcome measures could help transform healthcare. British Medical Journal
346:f167.
CHC (COAG [Council of Australian Governments] Health Council) 2017. The Fifth National Mental Health
and Suicide Prevention Plan. Canberra: Department of Health.
CIHI (Canadian Institute for Health Information) 2018. Patient experience. Ottawa: CIHI. Viewed
24 January 2018, <https://www.cihi.ca/en/patient-experience>.
HealthMeasures 2018. PROMIS. Evanston: Northwestern University. Viewed 24 January,
<http://www.healthmeasures.net/explore-measurement-systems/promis>.
NHIPPC (National Health Information and Performance Principal Committee) 2017. The Australian Health
Performance Framework. Viewed 16 February 2018, <www.coaghealthcouncil.gov.au/Portals/0/OOS318_
Attachment%201.pdf>.
NSW Ministry of Health 2017. Your Experience of Service: what consumers say about NSW mental health
services, 2016–17. Viewed 11 December 2017, <http://www.health.nsw.gov.au/mentalhealth/Documents/
yes-survey-report-2016-2017.pdf>.
OECD (Organisation for Economic Co-operation and Development) 2017. OECD work on health. Paris:
OECD. Viewed 24 January 2018, <http://www.oecd.org/health/Health-Brochure.pdf>.
PCOC (Palliative Care Outcomes Collaboration) 2014. Palliative Care Outcomes Collaboration: clinical
manual. Wollongong: Australian Health Services Research Institute, University of Wollongong.
PCOR–ANZ (Prostate Cancer Outcomes Registry–Australia and New Zealand) 2016. Prostate cancer
outcomes Australia, 2016. Melbourne: Monash University. Viewed 24 January 2018,
<https://pcor.com.au/wp-content/uploads/2016/06/PCOR-ANZ-Annual-Report_2016_FINAL.pdf>.
Picker Institute Europe 2018. NHS surveys. Oxford: Picker Institute Europe. Viewed 24 January 2018,
<http://www.nhssurveys.org/>.
Queensland Health 2017. Your Experience of Service: statewide report, 2016. Queensland Health: Brisbane.
SCRGSP (Steering Committee for the Review of Government Service Provision) 2018. Report on government
services, 2018. Part E, Chapter 10: Primary and community health. Viewed 29 March 2018, <www.pc.gov.au/
research/ongoing/report-on-government-services/2018/health/primary-and-community-health>.
Thompson C, Sansoni J, Morris D, Capell J & Williams K 2016. Patient-reported outcome measures: an
environmental scan of the Australian healthcare sector. ACSQHC: Sydney.
Victorian DHHS (Victorian Department of Health and Human Services) 2017a. Victorian Healthcare
Experience Survey—VHES. Melbourne: Victorian DHHS. Viewed 24 January 2017, <https://www2.health.vic.
gov.au/hospitals-and-health-services/quality-safety-service/patient-experience-survey>.
Victorian DHHS 2017b. Victoria’s mental health services annual report, 2016–17. Victorian DHHS: Melbourne.
Ware JE & Sherbourne CD 1992. The MOS 36-item Short Form Health Status Survey (SF-36): 1, conceptual
framework and item selection. Medical Care 30:473–83.
Williams K, Sansoni J, Morris D Grootemaat P & Thompson C. 2016. Patient-reported outcome measures:
Chapter 7
literature review. ACSQHC: Sydney.

WHO (World Health Organization) 2018. WHO Quality of Life-BREF (WHOQOL-BREF). Geneva: WHO. Viewed
24 January 2018, <http://www.who.int/substance_abuse/research_tools/whoqolbref/en/>.
463
7.18 Coordination of
SNAPSHOT
health care
Coordination of health care involves the delivery of consistent, coherent and connected
health services to patients. These factors are what enables and sustains:
• an ongoing relationship between a patient and a provider
• the timely transfer of relevant patient information between different care providers
• t he cooperation between these providers to allow for the provision of connected health
care (RACGP 2017).
Coordination of health care is particularly important for the growing number of patients
with multiple diseases or complex care needs, such as people living with cancer, arthritis,
cardiovascular disease and mental illness (Primary Health Care Advisory Group 2016).
The Coordination of Health Care Study (the Study) aims to fill a national data gap by
providing nationally consistent and locally relevant results, allowing for valid comparisons
between local areas to inform policy efforts.
Box 7.18.1: Survey of Health Care

The Survey of Health Care 2016 (the Survey)—the first component of the Study—
looks at experiences with coordination of health care for people aged 45 and over
who had at least 1 general practitioner (GP) visit in the 12 months before being
selected for the survey (November 2014 to November 2015).
The Survey was conducted from April 2016 to June 2016. All responses relate to the
12 months before the time that each respondent completed the survey. The Survey
explored:
• whether people had a relationship with a usual GP or place of care
• r espondents’ experiences with person-centred care and with transfer of information
between a GP or practice and hospitals, emergency departments and specialists
• respondents’ access and barriers to care.
All results reported in this snapshot come from the Survey. For detailed results,
see Survey of Health Care Australia, 2016 (ABS & AIHW 2017).
Relationship with usual GPs/usual place

of care
GPs are the first point of contact for many Australians with health problems. GPs deliver
a variety of care—treating short-term and long-term illnesses and providing preventive
care and health education. A usual GP/usual place of care is one to which people
choose to visit consistently (if possible) when they need health care. This is often
because a person and their usual GP/usual place of care have built mutual knowledge,
understanding and trust—reasons associated with positive outcomes, such as better
quality of care, better GP–patient communication and greater uptake of preventive and
health promotion strategies.
464
In 2016, based on responses to the self-reported Survey (see Box 7.18.1):
• 98% of people were estimated to have a usual GP/usual place of care
• 6
5% of people with a usual GP reported that they had been going to their GP for 5 or
more years
• p
eople aged 65 and over were more likely to have a usual GP than people aged 45–64
(94% compared with 83%) (ABS 2017).
Overall, people were positive about their experiences with those aspects of the health
system surveyed, with 96% reporting that they received excellent, very good or good-quality
care from their usual GP/usual place of care.
In 2016, most people said that their usual GP/usual place of care:
• was always or usually aware of their health care history (85%)
• always or usually involved them in making decisions about their health care (88%)
• a
lways or usually explained test results, such as blood tests and x-rays, in a way that
could be understood (88%)
• always or usually asked about things in work or life that affected their health (56%)
• m
ade them feel completely or very comfortable talking about personal problems
related to their health (80%) (ABS 2017).
For a full breakdown of the response categories to the surveyed aspects of a patient’s
experience with their usual GP/usual place of care, see Supplementary Table S7.18.1.
Coordination between GPs and other

health providers
Effective communication and timely transfer of information between a patient’s usual
GP/usual place of care and other health care providers is essential to allow consistent
and continuous care to be provided in the right place and at the right time.
In 2016, results varied for the proportion of people who reported that their usual GP
or others in their usual place of care seemed informed about the care they had received
from other health providers.
More than half (55%) of people saw a specialist doctor for their own health. Of these
people:
• 7
6% said their usual GP/usual place of care seemed informed about the care they
had received from the specialist doctor
• 8
.7% said their usual GP/usual place of care did not seem informed about the care
they had received from the specialist doctor, or did not seem to know about it until the
patient told them (ABS 2017).
Almost 1 in 5 (18%) people reported visiting an emergency department. Of these people:
• 6
2% said their usual GP/usual place of care seemed informed about follow-up needs or
Chapter 7
medication changes after their visit to the emergency department

• 1
8% said their usual GP/usual place of care did not seem informed about the follow-up
needs or medication changes after their visit to the emergency department, or did not
seem to know about it until the patient told them (ABS 2017).
465
Slightly more than 1 in 5 (22%) people were admitted to hospital. Of these people:
• 6
6% said that their usual GP/usual place of care seemed informed about the follow-up
needs or medication changes after their hospital admission
• 1
1% said that their usual GP/usual place of care did not seem informed about the
follow-up needs or medication changes after their hospital admission, or did not seem
to know about it until the patient told them (ABS 2017).
About 4 in 5 (82%) people reported taking at least one type of medication on an ongoing
basis and 71% reported that they had had a test, x-ray or scan. Of these people who took
medications or had tests:

• 72% said that a health professional reviewed all medications being taken
• 4
.2% said they had been given a wrong medication or dose by a doctor, nurse or
pharmacist
• 8
9% said that results from blood tests, x-rays or scans were available at their
scheduled health care appointment (ABS 2017).
The proportions presented for the response categories do not add up to 100% as not
all categories are shown here. For a full breakdown of the response categories to the
surveyed aspects of a patient’s experience with the transfer of information between other
health care providers and their usual GP/usual place of care, see Supplementary Table
S7.18.2.

The second part of the Study involves linking data from the 2016 Survey of Health Care for
consenting participants with specific data items from the Medicare Benefits Schedule and
Pharmaceutical Benefits Scheme (including Repatriation Pharmaceutical Benefits Scheme
data). The data will also be linked with hospitalisation data, including visits to emergency
departments and admissions to hospital. This analysis is being undertaken in 2018, and will
allow for a broad range of research and policy issues related to health care to be explored.
The outcomes of these undertakings will be detailed in future AIHW and Australian Bureau
of Statistics (ABS) publications.

The Survey of Health Care captures data only on those aged 45 and over who had seen a GP
in the 12 months before being selected for the survey. As a result, the data cannot be used
to investigate unmet health needs for the whole population; for example, data on patient
experiences with the coordination of health care is required for younger age groups. Further
analysis of the existing survey data can also provide insight into the experiences of patients
with more complex needs, such as multiple long-term health conditions.

The joint ABS and AIHW publication Survey of Health Care Australia 2016 is available at
<www.abs.gov.au>.
466
References
ABS (Australian Bureau of Statistics) 2017. Survey of Health Care publication tables, 2016. ASB cat. no. 4343.0.
Canberra: ABS.
ABS & AIHW (Australian Institute of Health and Welfare) 2017. Survey of Health Care Australia 2016.
ABS cat. no. 4343.0. Canberra: ABS & AIHW.
Primary Health Care Advisory Group 2016. Better Outcomes for People with Chronic and Complex Health
Conditions. Canberra: Department of Health.
RACGP (The Royal Australian College of General Practitioners) 2017. Standard for General Practices:
5th edition. Melbourne: RACGP. Viewed 21 February 2018, <https://www.racgp.org.au/your-practice/
standards/standards-for-general-practices-(5th-edition)/>.
Chapter 7
467
7.19 Specialised alcohol and
SNAPSHOT
other drug treatment

services
Alcohol and other drug treatment services help people to deal with their drug use through
a range of treatments. Treatment objectives can include reducing or stopping drug use,
and improving social and personal functioning. Treatment services include detoxification
and rehabilitation, counselling and pharmacotherapy, delivered in residential and
non-residential settings. Opioid pharmacotherapy is one treatment for dependence on
opioid drugs, such as heroin and morphine.
Information on publicly funded alcohol and other drug treatment services in Australia
and on the people and drugs treated is collected through the Alcohol and Other Drug
Treatment Services National Minimum Data Set (AODTS NMDS). The National Opioid
Pharmacotherapy Statistics Annual Data (NOPSAD) collection contains information on
pharmacotherapy treatment—that is, opioid substitution therapy (OST)—provided to
people dependent on opioid drugs.
Agencies whose sole function is to prescribe or provide dosing services for opioid
pharmacotherapy are excluded from the AODTS NMDS as data from these agencies are
captured in the NOPSAD collection.
Who uses alcohol and other drug

treatment services?
In 2016–17, 836 publicly funded alcohol and other drug treatment agencies provided
more than 200,000 closed treatment episodes to around 127,000 clients aged 10 and
over, who sought specialist alcohol and other drug treatment services.
Clients of alcohol and other drug treatment services were more likely to be male than
female, and most likely to be aged 20–39. Aboriginal and Torres Strait Islander people
were over-represented among clients seeking alcohol and other drug treatment services
(15% of all clients compared with 2.7% of the Australian population aged 10 and over).
Who uses alcohol and other drug treatment services?
2 in 3 were male Around 1 in 7 were Indigenous More than half

were aged 20–39
468
Who receives opioid pharmacotherapy
treatment?
On a snapshot day in mid-2017, nearly 50,000 clients received opioid pharmacotherapy
treatment at more than 2,700 dosing points across Australia.
Clients receiving opioid pharmacotherapy treatment had broadly similar characteristics
to the clients receiving alcohol and other drug treatment services, but were more likely
to be slightly older. Pharmacotherapy clients were more likely to be male than female,
and most likely to be aged 30–49. Indigenous Australians were over-represented among
pharmacotherapy clients (9.2% of all clients compared with 3.3% of the total Australian
population).
Who receives opioid pharmacotherapy treatment?
2 in 3 were male Around 1 in 11 were Indigenous Two-thirds were

aged 30–49
For which drugs do people seek treatment?

In 2016–17, alcohol was the principal drug of concern that led to the largest percentage of
clients to seek alcohol and other drug treatment services. Over the last 5 years, however,
the percentage of clients seeking alcohol treatment services has fallen slightly. Over the
same period, the percentage of treatment episodes attributable to amphetamines as a
principal drug of concern has more than doubled.
The top drugs that led clients to seek The fastest growing treatment area
treatment were: is for amphetamine use, with
treatment episodes more than
doubling the last 5 years:
Alcohol 32%
Amphetamines 26% 2012–13 22,000
Cannabis 22%
2016–17 50,000
Heroin 5.2%
Chapter 7
469
In 2017, heroin continued to be the most
The top opioid drugs that led clients
common principal drug of concern for
to seek pharmacotherapy were:
clients receiving opioid pharmacotherapy
treatment, with methadone the most
Heroin 38 %
common form of OST provided.
Oxycodone 5.2 %
Morphine 4.3 %
Codeine 4.2 %
Methadone 4.1 %
Alcohol and other drug treatment patterns

across age groups
There were notable differences by age group in the most common principal drugs of
concern for which alcohol and other drug treatment services were provided in 2016–17
(Figure 7.19.1):
• w
here cannabis was the principal drug of concern, most clients of these services
tended to be younger; with 36% aged 20–29 and 32% aged 10–19
• w
here amphetamines were the principal drug of concern, most clients (73%) were
aged 20–39
• w
here alcohol was the principal drug of concern, most clients were older; with 51%
aged 40 and over and only 6.9% aged 10–19.
Figure 7.19.1: Principal drug of concern for clients by age group, 2016–17
Per cent
100
90
80
70 60+
60 50–59
40–49
50
30–39
40
20–29
30 10–19
20
10
0
Alcohol Amphetamines Heroin Cannabis
Principal drug of concern

470
It is difficult to quantify fully the scope of alcohol and other drug treatment services in
Australia. There are a variety of settings in which people receive treatment for alcohol
and other drug-related issues that are not in scope for the AODTS NMDS. These include
services provided by not-for-profit organisations and private treatment agencies that do
not receive public funding; some treatment services provided in hospitals by specialist
alcohol and other drug treatment services, prisons, correctional facilities and detention
centres; primary health care services; and accommodation services.
Because of the specifications for each data collection (AODTS NMDS and NOPSAD) and
the complexities of the sectors, it is not possible to identify people who receive a course
of pharmacotherapy treatment via a dosing point as well as treatment from a publicly
funded alcohol and other drug treatment service. Also, the AODTS NMDS does not cover
all agencies providing substance-use services to Indigenous Australians.
The AODTS NMDS does not currently include data describing the mode of delivery for a
client’s main treatment type, or data describing treatment outcomes or treatment waiting
times. The AIHW is investigating options to deal with these data gaps, intending that such
data may become available in future iterations of the collection.

More information on specialised alcohol and other drug treatment services in Australia
is available at <www.aihw.gov.au/reports-statistics/health-welfare-services/alcohol-other-
drug-treatment-services/overview>.
The reports Alcohol and other drug treatment services in Australia 2016–17 and National
opioid pharmacotherapy statistics 2017 can be downloaded from the AIHW website:
<www.aihw.gov.au>.
References
AIHW (Australian Institute of Health and Welfare), forthcoming 2018a. Alcohol and other drug treatment
services in Australia 2016–17. Canberra: AIHW.
AIHW 2018b. National opioid pharmacotherapy statistics 2017. Canberra: AIHW. Viewed 17 April 2018,
<www.aihw.gov.au/reports/alcohol-other-drug-treatment-services/nopsad-2017/contents/summary>.
Chapter 7
471
7.20 Mental health services
SNAPSHOT
Mental illness contributes substantially to the burden of disease in the community

(see Chapter 3.12 ‘Mental health’). In Australia, people with mental disorders can access
a variety of support services, delivered by the Australian Government and state and
territory governments and by the private and not-for-profit sectors. A range of health
care professionals provide these services in a number of care settings.
This snapshot provides a brief overview of the volume of mental health service activity,
the associated workforce, and ongoing efforts to improve the safety and quality of
mental health care in Australia.
Where might people go for Who might people see for

mental health care? mental health care?
Specialised hospital services— General practitioners

public and private Psychiatrists and other medical staff
Residential mental health services Psychologists
Community mental health Nurses—registered and enrolled

care services Social workers
Private clinical practices Other allied health professionals
Non-government Peer workers

organisation services Other personal care staff
Service use
A considerable number of support services are provided to people with a mental
illness each year. For example, state and territory community mental health care
services provided more than 9.4 million contacts in 2015–16 (Table 7.20.1).
472
Table 7.20.1: Selected mental health-related services provided, 2015–16/2016–17(a)
Service type Volume Selected findings
Medicare-subsidised mental 11.1 million General practitioners (GPs) (31%) were

health-related services(b) services the largest providers of these services.
People accessing 2.4 million Females accessed these services at a

Medicare-subsidised mental people rate of about 1.5 times that of males.
health-related services(b)
Mental health-related 36 million Antidepressant medication

prescriptions(c) prescriptions accounted for about 69% of all
mental health-related prescriptions(c).
Community mental health 9.4 million More than 1 in 5 contacts were provided
care service contacts contacts to patients with a principal diagnosis of
schizophrenia.
Emergency department 273,000 Aboriginal and Torres Strait Islander

services presentations people accounted for 10% of mental
health-related presentations.
Overnight admitted patient 244,900 Overnight admitted patient hospitalisations

hospitalisations hospitalisations with specialised mental health care made
up about 64% of all overnight mental
health-related hospitalisations.
(a) Medicare and prescription data shown are for 2016–17.

(b) Includes psychiatrists, GPs, clinical psychiatrists, other psychologists and other allied health services.
These services are billed as mental health-related items, which underestimates the total mental
health-related activity, especially for services provided by GPs.
(c) P
rescriptions subsidised and under co-payment under the Pharmaceutical Benefits Scheme and Repatriation
Pharmaceutical Benefits Scheme.
Spending
About $9 billion, or $373 per person, was spent on mental health-related services in
Australia during 2015–16—representing 7.7% of total government health expenditure.
This spend had increased by an annual average of 1.4% per person from 2011–12 to
2015–16. The total expenditure in 2015–16 includes:
• a
bout $5.4 billion, or $227 per person, spent on state and territory specialised
mental health services (including $2.4 billion on public hospital services for
admitted patients and $2.0 billion on community mental health care)
• a
bout $1.1 billion, or $47 per person, spent on Medicare-subsidised services.
This spending increased by an annual average of 3.9% per person over the 5 years
to 2015–16
• a
bout $564 million, or $24 per person, spent on mental health-related prescriptions
Chapter 7
subsidised under the Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical

Benefits Scheme, mostly to subsidise antipsychotic (50%) and antidepressant (37%) drugs.
473
Workforce
A variety of professionals deliver care and support to people with mental illness, including
psychologists, psychiatrists, mental health nurses, GPs, social workers, counsellors and
peer workers. Available workforce data for some of these professions, show that in 2015:
• t here were about 24,500 registered psychologists, 21,000 mental health nurses and
3,100 psychiatrists in Australia
• a
bout 31% of mental health nurses were men, while around 10% of the general nursing
workforce were men
• a
bout 62% of psychiatrists were men, while around 70% of all medical specialists were
men. About 22% of psychologists were men
• a
bout 32% of mental health nurses and 44% of psychiatrists were aged 55 and over.
The age profile of registered psychologists was younger, with 72% aged under 55.
In 2015–16, there were about 32,000 full-time equivalent (FTE) staff employed in state and
territory specialised mental health care services. Nationally, this equates to 133 FTE staff
per 100,000 population. In the same period, there were about 3,300 FTE staff employed in
private hospital specialised mental health services, equating to 14 FTE staff employed per
100,000 population.
Safety and quality of mental health services

In Australia, there has been a sustained effort to minimise the use of restrictive practices
in mental health care settings, such as seclusion and restraint. The National Mental Health
Commission’s Position Statement on seclusion and restraint in mental health calls for
leadership across a range of priorities, including ‘national monitoring and reporting on
seclusion and restraint across jurisdictions and services’ (NMHC 2015).
Seclusion events in mental health care settings

Seclusion is defined as the confinement of a patient at any time of the day or night alone
in a room or area from which free exit is prevented. Reducing and, where possible,
eliminating the use of seclusion is a policy priority in Australian mental health care and
has been supported by changes to legislation, policy and clinical practice.
Public reporting enables services to review their individual results against state and
territory and national rates and like services, thereby supporting service reform and
quality improvement agendas. The national data show a substantial reduction in the
use of seclusion within specialised acute public hospital mental health services since the
AIHW’s first reported restrictive practice data in 2008–09. There was an average annual
decrease of 8.9% from 2008–09 to 2016–17 (Figure 7.20.1).
474
Figure 7.20.1: Rate of seclusion events, public sector acute mental health
hospital services, 2008–09 to 2016–17
Rate (per 1,000 bed days)

18
16
14
12
10
0
2008 –09 2009 –10 2010–11 2011–12 2012 –13 2013 –14 2014 –15 2015 –16 2016–17
Year
Source: National Seclusion and Restraint Database; Table S7.20.1.

From 1 July 2016, the role of Primary Health Networks has included responsibility for
leading mental health planning and integration with states and territories;
non-government organisations; National Disability Insurance Scheme (NDIS) providers;
the private sector; and Indigenous, drug and alcohol and other related services and
organisations. Data on the activity of Primary Health Networks—collected under the
Department of Health’s Primary Mental Health Care Minimum Data Set—are anticipated
to be available for reporting in 2018–19.
People with psychiatric disability who have substantial and permanent functional
impairment are eligible to access funding through the NDIS. As well, for people with
disability other than psychiatric disability, funding may also be provided for mental
health-related services and support if required. Data on the supports accessed under
the NDIS by people with psychiatric disability are not currently available for reporting.
Chapter 7
475
The Bettering the Evaluation and Care of Health (BEACH) surveys provided data for the
AIHW to report on mental health-related services provided by GPs. The 2015–16 BEACH
data collection was the last to be conducted (see Chapter 7.5 ‘Primary health care’). This
leaves the Medicare Benefits Schedule (MBS) items as the only source of data on mental
health-related services provided by GPs. Not all mental health-related GP encounters are
billed using mental health-specific MBS items—so these items are an underestimate of
total mental health-related GP activity.
There are no nationally consistent data on the workforce or activities of mental health
non-government organisations (NGOs) to inform policy, practice and planning of their
activities. This is a notable data gap as NGOs play an important role in providing
non-clinical mental health-related services to people living with mental illness, their
families and carers.

More information on mental health services and on restrictive practices in mental heath
services is available in the Mental Health Services in Australia report.

Reference
NMHC (National Mental Health Commission) 2015. Position statement on seclusion and restraint in
mental health. Sydney: NMHC.
476
7.21 Palliative care services
SNAPSHOT
Palliative care aims to relieve suffering and improve the quality of life for people with a life
threatening condition and their families (WHO 2016).
Palliative care is delivered by various government agencies in all jurisdictions in Australia,
as well as by private and not-for-profit bodies. It is provided in almost all health care
settings, including neonatal units, paediatric services, general practices, acute hospitals,
residential and community aged care services, and generalist community services.
Specialist palliative care services operate from professional inpatient services, hospices
and community-based specialist services (Department of Health and Ageing 2010).
The demand for palliative care services is likely to increase in Australia in future years
due to a growing and ageing population as well as to the high burden of disease, related
to the higher prevalence of cancer and other chronic conditions, in older age groups.
Palliative care in hospitals

A person may receive palliative care as an admitted patient in hospital and may require
one or more hospitalisations while receiving this care. A subset of these patients will die
in hospital. Admitted patient data in public and private hospitals show that:
• f rom 2011–12 to 2015–16, palliative care-related hospitalisations increased by 28% to
almost 74,000 (Figure 7.21.1), compared with an increase of 15% of all hospitalisations
over the same period
• h
alf (51%) of all admitted patients who died in hospital had received palliative care in
2015–16
• a
lmost half (48%) of palliative care-related hospitalisations recorded a principal
diagnosis of cancer in 2015–16.
Figure 7.21.1: Palliative care hospitalisations, 2011–12 to 2015–16
Number
80,000
75,000
70,000
65,000
60,000
55,000
50,000
Chapter 7
0
2011–12 2012 –13 2013 –14 2014 –15 2015 –16
Year
477
Medications for palliative care treatment
The use of prescription medications is an important part of palliative care. One of
the attributes of this type of care is to ‘provide relief from pain and other distressing
symptoms’ (WHO 2014). In the majority of cases, this involves medications being
prescribed by the treating clinician.
• O
ver the 5 years from 2011–12 to 2015–16, the rate of subsidised palliative care-related
prescriptions increased at an average annual rate of 17% nationally.
• In 2015–16, there were more than 83,000 palliative care-related prescriptions provided
to almost 52,500 patients.

• T
he majority (90%) of palliative care-related medications were prescribed by a general
practitioner; other medical specialists prescribed 7.7%, and palliative medicine
specialists prescribed 2.4% in 2015–16.
• In 2015–16, $4.4 million dollars was spent in benefits for medications included on the
palliative care schedule (an average of $118 per patient). The average cost per patient
ranged from $80 in Victoria to $265 per patient in the Australian Capital Territory.
Workforce
The palliative care workforce is made up of a number of professional groups, including
specialist palliative medicine physicians, nurses, general practitioners, pharmacists, other
medical specialists (such as oncologists and geriatricians), as well as other health workers,
support staff and volunteers.
Nationally, in 2015, there were about 210 specialist palliative medicine physicians and
more than 3,300 palliative care nurses. About 3 in 5 (62%) doctors employed as a specialist
palliative medicine physician were women, which is more than double the female
proportion of all employed medical specialists (30%).

The fragmented and incomplete nature of palliative care data is well recognised and one
of the challenges is identifying these activities across different health and social care
settings. The AIHW is involved in current national data development activities aimed
at addressing some of the recognised data gaps in the palliative care space.

More information on palliative care in Australia can be found at <www.aihw.gov.au>. Recent
publications, including Palliative care services in Australia, are available for free download.
More information on the Pharmaceutical Benefits Scheme is available at <www.pbs.gov.au>.
References
Department of Health and Ageing 2010. Supporting Australians to live well at the end of life: National
Palliative Care Strategy 2010. Canberra: Department of Health and Ageing.
WHO (World Health Organization) 2014. Global atlas of palliative care at the end of life. Geneva: WHO.
WHO 2016. WHO definition of palliative care. Geneva: WHO. Viewed 16 November 2015,
<http://www.who.int/cancer/palliative/definition/en/>.
478
Methods and conventions
Symbols
Acronyms and abbreviations
Glossary
Index
479
Methods and conventions
Age standardisation
This is a method of removing the influence of age when comparing populations with
different age structures—either for different populations at the same time, or for the
same population at different times. It is based on the use of standard population, which
in this report is the Australian estimated resident population as at 30 June 2001 (Table A1).
This report uses direct age standardisation, which is generally used when there are large
populations under study and the age-specific rates are reliable. Direct age-standardised
rates are presented for most incidence, prevalence, hospitalisations and deaths data.
Calculating direct age-standardised rates

There are 3 steps to calculate direct age-standardised rates:
Step 1: Calculate the age-specific rate for each age group.
Step 2: Multiply the age-specific rate by the corresponding standard population for
each age group for the expected number of cases in each age group.
Step 3: Sum the expected number of cases in each age group and divide this sum by
the total of the standard population to give the age-standardised rate.
480
Table A1: Standard population for use in
age standardisation, Australia, 30 June 2001
Age group Population

0 253,031
1–4 1,029,326
5–9 1,351,664
10–14 1,353,177

15–19 1,352,745
20–24 1,302,412
25–29 1,407,081
30–34 1,466,615
35–39 1,492,204
40–44 1,479,257
45–49 1,358,594
50–54 1,300,777
55–59 1,008,799
60–64 822,024
65–69 682,513
70–74 638,380
75–79 519,356
80–84 330,050
85 and over 265,235
Total 19,413,240
Source: ABS 2003.
Average annual rates of change

Average annual rates of change or growth rates have been calculated as geometric rates:
Average rate of change =

(( Pn
Po
) N
1
) x 100
where Pn = value in later time period

Po = value in earlier time period
N = number of years between the two time periods.
481
Classifications used
The classification of deaths follows the 10th revision of the International Classification of
Diseases (WHO 2011). Diseases treated in hospitals are classified using the International
statistical classification of diseases and related health problems, 10th revision, Australian
Modification (ICD-10-AM), of which the 10th edition is the latest version (ACCD 2016).
The procedures performed during a hospital stay are classified using the Australian
Classification of Health Interventions.
Data subject to revision

This report draws data from a range of administrative and survey data sets, all of which
are subject to change. Such changes may arise from:
• t he nature and timing of the data collection—for example, notifiable diseases are based
on a ‘real-time’ collection of reported cases, and the counts and rates could change daily
• a
regular program of updates and maintenance—for example, for 2007 data onwards,
the Australian Bureau of Statistics (ABS) revises cause-of-death data using information
pertaining to coroners’ cases that was not available at the time of original processing
• n
ewly discovered errors or anomalies.
The latest version of a data set has been used wherever possible. In cases where the data
change frequently, the date of the release is noted. Revisions and changes in coverage
should be considered when interpreting changes over time.
Note: Cause of Death Unit Record File data are provided to the AIHW by the Registries of
Births, Deaths and Marriages and the National Coronial Information System (managed
by the Victorian Department of Justice) and include cause of death coded by the ABS.
The data are maintained by the AIHW in the National Mortality Database.
Quality assurance
The report content was largely prepared by AIHW staff, and was subject to rigorous
internal review and clearance processes. Additional external peer reviewers were used to
validate and strengthen the content of the report.
Data sources
The best available information has been used to inform the report, drawn from a range
of data sources that are referenced throughout the report. Most of the data sources are
national collections managed by the AIHW and the ABS. These are supplemented by other
data collections, as appropriate.
Each of the data sources used in the report has strengths and limitations that affect how
the data can be used and what can be inferred from the results. The AIHW takes great
care to ensure that data used are correct and that the conclusions drawn are robust.
482
Although this report is published in 2018, some of the statistics refer to 2014–15 or earlier.
This is because some data, such as population-based surveys, are collected every 3–5
years or even less often. Also, it can often take some time before data are fully processed
and provided to the AIHW. Finally, the AIHW often needs time to analyse the data and
ensure the statistics are accurate and of high quality.
Given the comprehensive nature of this report, and the time it takes to prepare a
compendium report of this scale, it is possible that some other reports may be released
by the AIHW or others with more recent data. Readers are referred to the latest releases
in the ‘Where do I go for more information?’ sections of articles and snapshots.

Effects of rounding
Entries in columns and rows of tables may not add to the totals shown, because of
rounding. Unless otherwise stated, derived values are calculated using unrounded numbers.
Dates and time spans

Periods based on full calendar years (1 January to 31 December) are written as, for
example, 2018 for 1 year. When there are 2 or more calendar years in the period, the first
and final years are written in full. For example, 2017–2018 is a 2 calendar-year span and
2016–2018 covers 3 calendar years.
Periods based on financial years (1 July to 30 June) are written with a second number which
is abbreviated: for example, 2017–18 for 1 financial year, 2016–18 for 2 and 2015–18 for 3.
A longer span of financial years is written as ‘In the 10 years from 2008–09 to 2017–18…’.
Some surveys may be based on other 12-month spans—for example, the general practice
Bettering the Evaluation of Care and Health (BEACH) survey is based on collection periods
from 1 April to 30 March. These are presented as for financial years; for example, 2017–18
would be a ‘year’ or 12-month period.
Use of icons
Icons and infographics are visual representations of data that are intended to present
complex information quickly and clearly. Generally, these graphics simplify information so
it can be easily understood and, as such, carry a risk of generalising or stereotyping. This
is not the intention of the AIHW, which endeavours to use icons only to improve the clarity
and accessibility of information.
483
Use of italics
Italics are used in this report:
• f or remoteness categories derived using the Australian Statistical Geography Standard.
The main categories are Major cities, Inner regional, Outer regional, Remote and
Very remote
• f or publication titles
• t o indicate terms that are part of a formal medical category/classification scheme.
For example, triage categories: Emergency, Urgent, Semi-urgent and Resuscitation.
References
ABS (Australian Bureau of Statistics) 2003. Australian demographic statistics, September quarter 2002. ABS
cat. no. 31010.0. Canberra: ABS.
ACCD (Australian Consortium for Classification Development) 2016. International statistical classification
of diseases and related health problems, tenth revision, Australian Modification. Tenth edition. Adelaide:
Independent Hospital Pricing Authority.
WHO (World Health Organization) 2011. International statistical classification of diseases and related health
problems, tenth revision. Fifth edition 2016. Geneva: WHO.
484
Symbols
$ Australian dollars, unless otherwise specified
% per cent
< less than
> more than

≤ less than or equal to
≥ more than or equal to
* estimate has a relative standard error of 25% to 50% and should be used
with caution
# statistically significant finding—see individual usage for details on how

significance was derived
.. no data/insufficient data
‘000 thousands
m metre
mg milligram
kg kilogram
nmol/L nanomoles per litre
n.a. not available
485
Acronyms and abbreviations
AATSIHS Australian Aboriginal and Torres Strait Islander Health Survey
ABDS Australian Burden of Disease Study
ABS Australian Bureau of Statistics
ACCHO Aboriginal Community Controlled Health Organisation
ACT Australian Capital Territory
ADF Australian Defence Force

AHPEQS Australian Hospital Patient Experience Question Set
AHPF Australian Health Performance Framework
AHPRA Australian Health Practitioner Regulation Authority
AHS Australian Health Survey
AIDS acquired immune deficiency syndrome
AIHW Australian Institute of Health and Welfare
AMR Australian Mesothelioma Registry
AODTS NMDS Alcohol and Other Drug Treatment Services National Minimum Data Set
ASGC Australian Standard Geographical Classification
ASGS Australian Statistical Geography Standard
ATC Anatomical Therapeutic Chemical
bDMARDs biological disease-modifying anti-rheumatic drugs
BEACH Bettering the Evaluation and Care of Health
BMI body mass index
CALD culturally and linguistically diverse
CDI Clostridium difficile infections
CHD coronary heart disease
CI confidence interval
CKD chronic kidney disease
COAG Council of Australian Governments
COPD chronic obstructive pulmonary disease
CRP Cardiac Rehabilitation Program
DALY disability-adjusted life year
DDD Defined Daily Doses
DSRS deseal/reseal
DPP4 dipeptidyl peptidase 4
DVA Department of Veterans’ Affairs
486
ENT ear, nose and throat
EPC Enhanced Primary Care
ERP estimated resident population
ESKD end-stage kidney disease
FDSV family, domestic and sexual violence
FTE full-time equivalent
GDP gross domestic product

GHG greenhouse gas
GIRS Geographically-adjusted Index of Relative Supply
GP general practitioner
GRIM books General Incidence of Mortality books
HAC hospital acquired complication
HALE health-adjusted life expectancy
HIV human immunodeficiency virus
HPV Human Papillomavirus
HSD Highly Specialised Drugs
ICD International Classification of Diseases
ICD-10 International Statistical Classification of Diseases and Related Health
Problems, Tenth revision
ICD-10-AM International Statistical Classification of Diseases and Related Health
Problems, Tenth revision, Australian Modification
ICD-11 International Statistical Classification of Diseases and Related Health
Problems, Eleventh revision
ICHOM International Consortium for Health Outcomes Measurement
ICPC-2 International Classification for Primary Care, Version 2
iFOBT immunochemical faecal occult blood test
IMD invasive meningococcal disease
IRSD Index of Relative Socio-Economic Disadvantage
ISPHCS Indigenous-specific primary health care services
IVF in-vitro fertilisation
K10 Kessler Psychological Distress Scale
KRT kidney replacement therapy
LGBTI lesbian, gay, bisexual, transgender or intersex
LHN Local Hospital Network
MCIS Mortality and Cancer Incidence Study
MDMA 3,4-methylenedioxymethamphetamine
487
MORT books Mortality Over Regions and Time books
MRSA methicillin-resistant Staphylococcus aureus
MSSA methicillin-sensitive Staphylococcus aureus
NATSIHS National Aboriginal and Torres Strait Islander Health Survey
NBCSP National Bowel Cancer Screening Program
NCMCC National Centre for Monitoring Chronic Conditions
NCMI National Core Maternity Indicators
NCSP National Cervical Screening Program

NDIS National Disability Insurance Scheme
NDSHS National Drug Strategy Household Survey
NGO non-government organisation
NHMD National Hospital Morbidity Database
NHPF National Health Performance Framework
NHS National Health Survey
NHWDS National Health Workforce Data Set
NICU neonatal intensive care unit
NIRA National Indigenous Reform Agreement
NNAPEDCD National Non-Admitted Patient Emergency Department Care Database
NNDSS National Notifiable Diseases Surveillance System
NOPSAD National Opioid Pharmacotherapy Statistics Annual Data
NPHDC National Prisoner Health and Data Collection
NSPS National Suicide Prevention Strategy
NSW New South Wales
NT Northern Territory
NTER Northern Territory Emergency Response
NTRAI HHP Northern Territory Remote Aboriginal Investment Hearing Health Program
NWDMP National Wastewater Drug Monitoring Program
OECD Organisation for Economic Co-operation and Development
OME otitis media with effusion
OR odds ratio
OST opioid substitution therapy
PBS Pharmaceutical Benefits Scheme
PCOC Palliative Care Outcomes Collaboration
PES Patient Experience Survey
PHN Primary Health Network
488
PMKeyS Personnel Management Key Solution
PPH potentially preventable hospitalisation
PREM patient-reported experience measure
PrEP Pre-exposure prophylaxis for HIV prevention
PROM patient reported outcome measure
PTSD post-traumatic stress disorder
Qld Queensland

RFDS Royal Flying Doctor Service
RoGS Report on Government Services
RPBS Repatriation Pharmaceutical Benefits Scheme
s85 Section 85 of the National Health Act 1953 (Cwlth)
s100 Section 100 of the National Health Act 1953 (Cwlth)
SA South Australia
SA2 Statistical Area level 2
SA3 Statistical Area level 3
SAB Staphylococcus aureus bacteraemia
SCN special care nursery
SDAC Survey of Disability, Ageing and Carers
SEIFA Socio-Economic Indexes for Areas
SF-36 Short Form-36
SHA System of Health Accounts
SIDS sudden infant death syndrome
UNHCR United Nations High Commissioner for Refugees
UV ultraviolet
VBAC vaginal birth after caesarean section
Vic Victoria
WA Western Australia
WHO World Health Organization
WHOQoL-BREF World Health Organization Quality of Life Instrument
YES Your Experience of Service
YLD years lived with disability
YLL years of life lost
489
Glossary
Aboriginal and Torres Strait Islander health practitioner: A person who has completed
a Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care (Practice)
and is registered with the Aboriginal and Torres Strait Islander Health Practice Board of
Australia. The practitioner may undertake higher levels of clinical assessment and care
within their agreed scope of practice. This role became nationally registered from 1 July 2013
under the National Registration and Accreditation Scheme for health professions.
Aboriginal and Torres Strait Islander health worker: An Aboriginal and/or Torres Strait
Islander with a minimum qualification in the field of primary health care work or clinical
practice. This includes Aboriginal and Torres Strait Islander health practitioners who
are one speciality stream of health worker. Health workers liaise with patients, clients and
visitors to hospitals and health clinics, and work as a team member to arrange, coordinate
and deliver health care in community health clinics.
Aboriginal or Torres Strait Islander: A person of Aboriginal and/or Torres Strait Islander
descent who identifies as an Aboriginal and/or Torres Strait Islander. See also Indigenous.
abnormal blood lipid levels: Abnormal levels of fats in the blood, such as cholesterol or
triglycerides. Here it has been defined as total cholesterol ≥5.5 mmol/L, LDL cholesterol
≥3.5 mmol/L, HDL cholesterol <1.0 mmol/L in men or <1.3 mmol/L in women, triglycerides
≥2mmol/L, or use of lipid-modifying medication.
absolute cardiovascular disease risk: A measure of the overall risk of cardiovascular
disease rather than considering individual risk factors, such as cholesterol or blood
pressure, in isolation.
abstainer (alcohol): A person who has not consumed a full serve of alcohol in the
previous 12 months.
accelerated ageing: A process where a particular population, such as prisoners, show the
level of health and signs of ageing at a younger age than another population, such as the
general population.
Accessibility/Remoteness Index of Australia: Classifies the level of accessibility to
goods and services (such as to general practitioners, hospitals and specialist care) based
on proximity to these services (measured by road distance).
acquired immune deficiency syndrome (AIDS): A syndrome caused by the human
immunodeficiency virus (HIV). If HIV is untreated, the body’s immune system is
damaged and is unable to fight infections and cancer.
acute: A term used to describe something that comes on sharply and is often brief,
intense and severe.
acute care: Care provided to patients admitted to hospital that is intended to cure illness,
alleviate symptoms of illness or manage childbirth.
acute otitis media: The general term for acute otitis media both with and without
perforation. It is the presence of fluid behind the eardrum and at least one of the
following: bulging eardrum, red eardrum, recent discharge of pus, fever, ear pain or
irritability. A bulging eardrum, recent discharge of pus and ear pain are the most reliable
indicators of acute otitis media.
490
additional diagnosis: The diagnosis of a condition or recording of a complaint—either
coexisting with the principal diagnosis or arising during the episode of admitted patient
care (hospitalisation), episode of residential care or attendance at a health care
establishment—that requires the provision of care. Multiple diagnoses may be recorded.
ADF personnel: Serving and ex-serving members of the Australian Defence Force; civilian
personnel employed by the Department of Defence are excluded.
admission: An admission to hospital. In this report, the term hospitalisation is used to
describe an episode of hospital care that starts with the formal admission process and
ends with the formal separation process. The number of separations has been taken as

the number of admissions; hence, the admission rate is the same as the separation rate.
admitted patient: A patient who undergoes a hospital’s formal admission process.
adverse event: An incident involving harm to a person receiving health care. It includes
infections, falls and other injuries, as well as reactions or complications due to surgery and
other procedures, medical devices or medication—some of which may be preventable.
Adverse events in health care can occur inside or outside hospitals and can be the cause
of hospitalisation as well. The rate of adverse events treated in hospital is used as an
indicator of safety in Australia’s health system.
age-specific rate: A rate for a specific age group. The numerator and denominator relate
to the same age group.
age standardisation: A way to remove the influence of age when comparing populations
with different age structures. This is usually necessary because the rates of many
diseases vary strongly (usually increasing) with age. The age structures of the different
populations are converted to the same ‘standard’ structure, and then the disease rates
that would have occurred with that structure are calculated and compared.
age structure: The relative number of people in each age group in a population.
air pollutants: Pollutants that include ozone (O3), nitrogen dioxide (NO2), particulate
matter (PM10 or 2.5), carbon monoxide (CO), sulfur dioxide (SO2) and biological allergens.
all ranks other than commissioned officer: A Defence member who holds a Sailor,
Other Ranks or Airman/Airwoman rank.
allergic rhinitis: A bodily response triggered by an allergic reaction. The symptoms may
include a runny or blocked nose and/or sneezing and watery eyes. Also known as ‘hay fever’.
allied health professional: A health professional who is not a doctor, nurse or dentist.
Allied health professionals include (but are not limited to) Aboriginal and Torres Strait
Islander health practitioners, chiropractors, occupational therapists, optometrists,
osteopaths, pharmacists, physiotherapists, podiatrists, psychologists, sonographers and
speech pathologists.
Alzheimer disease: A condition marked by progressive loss of brain function, shown by
worsening short-term memory, confusion and disorientation. A common form of dementia.
angina: Temporary chest pain or discomfort when the heart’s own blood supply is
inadequate to meet extra needs, as in exercise.
anorexia nervosa: A type of eating disorder characterised by the persistent restriction
of food and water intake, intense fear of gaining weight and disturbance in self-perceived
weight or shape.
491
antenatal: The period covering conception up to the time of birth. Synonymous with prenatal.
antenatal care: A planned visit between a pregnant woman and a midwife or doctor to
assess and improve the wellbeing of the mother and baby throughout pregnancy. It does
not include visits where the sole purpose is to confirm the pregnancy. Also known as an
antenatal visit.
anxiety disorders: A group of mental disorders marked by excessive feelings of
apprehension, worry, nervousness and stress. Includes generalised anxiety disorder,
obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and
various phobias.
Apgar score: Numerical score used to indicate a baby’s condition at 1 minute and at 5
minutes after birth. Between 0 and 2 points are given for each of 5 characteristics: breathing,
colour, heart rate, muscle tone and reflex irritability. The total score is between 0 and 10.
arthritis: A group of disorders for which there is inflammation of the joints—which
can then become stiff, painful, swollen or deformed. The two main types of arthritis are
osteoarthritis and rheumatoid arthritis.
asbestos: A group of naturally occurring fibrous minerals that do not readily break down.
associated cause(s) of death: A cause(s) listed on the Medical Certificate of Cause of
Death, other than the underlying cause of death. They include the immediate cause, any
intervening causes, and conditions that contributed to the death but were not related to
the disease or condition causing death. See also cause of death.
asthma: A common, chronic inflammatory disease of the air passages that presents as
episodes of wheezing, breathlessness and chest tightness due to widespread narrowing
of the airways and obstruction of airflow.
asthma–COPD overlap: A condition where adults have features of both asthma and
chronic obstructive pulmonary disease (COPD).
atrial fibrillation: An uneven and fast heartbeat.
attributable burden: The amount of burden that could be avoided if the risk factor were
removed.
augmentation of labour: Intervention after the spontaneous onset of labour to help its
progress.
Australian Standard Geographical Classification (ASGC): Common framework defined
by the Australian Bureau of Statistics for collecting and disseminating geographically
classified statistics. The framework was implemented in 1984 and its final release was in
2011. It has been replaced by the Australian Statistical Geography Standard (ASGS).
Australian Statistical Geography Standard (ASGS): Common framework defined by the
Australian Bureau of Statistics for collecting and disseminating geographically classified
statistics. It replaced the Australian Standard Geographical Classification (ASGC) in
July 2011.
average length of stay: The average number of patient days for admitted patient
episodes. Patients who have an admission and a separation on the same date are
allocated a length of stay of 1 day.
492
avoidable deaths: See potentially avoidable deaths.
back pain and problems: A range of conditions related to the bones, joints, connective
tissue, muscles and nerves of the back. Back problems are a substantial cause of disability
and lost productivity.
benefit-paid pharmaceuticals: Pharmaceuticals listed in the schedule of the
Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits
Scheme (RPBS) for which pharmaceutical benefits have been paid or are payable. Does
not include listed pharmaceutical items where the full cost is met from the patient
co-payment under the PBS or RPBS.

binge drinking: The consumption of an excessive amount of alcohol in a short period of time.
binge eating disorder: An eating disorder characterised by repeated episodes of binge
eating. Binge eating means eating large amounts of food in a short period of time, often
accompanied by a feeling of loss of control or an inability to stop eating.
birthweight: The first weight of a baby (stillborn or live born) obtained after birth (usually
measured to the nearest 5 grams and obtained within 1 hour).
blood cholesterol: Fatty substance produced by the liver and carried by the blood
to supply the rest of the body. Its natural function is to supply material for cell walls
and for steroid hormones, but if levels in the blood become too high this can lead to
atherosclerosis (a disease in which plaque builds up inside the arteries) and heart disease.
blood pressure: The force exerted by the blood on the walls of the arteries as it is
pumped around the body by the heart. It is written, for example, as 134/70 mmHg, where
the upper number is the systolic pressure (the maximum force against the arteries as
the heart muscle contracts to pump the blood out) and the lower number is the diastolic
pressure (the minimum force against the arteries as the heart relaxes and fills again
with blood). Levels of blood pressure can vary greatly from person to person and from
moment to moment in the same person. See also high blood pressure/hypertension.
body mass index (BMI): The most commonly used method of assessing whether a person
is normal weight, underweight, overweight or obese (see obesity). It is calculated by
dividing the person’s weight (in kilograms) by their height (in metres) squared—that is,
kg ÷ m2. For both men and women, underweight is a BMI below 18.5, acceptable weight is
from 18.5 to less than 25, overweight but not obese is from 25 to less than 30, and obese
is 30 and over. Sometimes overweight and obese are combined—defined as a BMI of
25 and over.
breech presentation: A fetal presentation where a baby’s buttocks are at the opening of
the uterus. In a frank breech, the legs are straight up in front of the body. In a complete
breech the legs are folded, but the feet are above the buttocks. In an incomplete breech,
the feet are below the buttocks.
bronchiectasis: An abnormal widening of the lungs’ air passages (bronchi). This allows
infections to develop and leads to coughing with pus and sometimes blood. It has several
causes, including cystic fibrosis; reduced immune functioning; and infections such as
tuberculosis, whooping cough (pertussis) and measles.
bronchitis: Inflammation of the main air passages (bronchi). May be acute or chronic.
493
built environment: The human-made surroundings that provide the setting for people to
live, work and recreate. It incorporates the building and transportation design of a setting,
including elements such as open green spaces, bike ways/footpaths, shopping centres,
business complexes and residential accommodation, together with their supporting
infrastructure (such as transport, water and energy networks).
bulimia nervosa: A type of eating disorder characterised by repeated binge eating
episodes followed by compensatory behaviours. Binge eating episodes involve eating
large amounts of food in a short period of time accompanied by feeling a loss of control or
inability to stop eating. Compensatory behaviours include self-induced vomiting, laxative or
diuretic misuse, fasting, excessive exercise or the inappropriate use of any drugs for weight
control (that is, drugs that have not been prescribed to the individual for weight control).
bulk-billing: The process where a medical practitioner or optometrist sends the bill for
services directly to Medicare, so the patient pays nothing. Also known as direct billing.
burden of disease and injury: A term referring to the quantified impact of a disease
or injury on an individual or population, using the disability-adjusted life year (DALY)
measure.
caesarean birth (also caesarean section or C-section): A method of birth where a
surgical incision is made in the mother’s uterus via the abdomen to directly remove the baby.
Campylobacteriosis: A disease caused by Campylobacter bacteria. It is a one of the most
common causes of gastroenteritis in Australia and is a notifiable disease.
cancer (malignant neoplasm): A large range of diseases where some of the body’s cells
become defective, begin to multiply out of control, invade and damage the area around
them, and can then spread to other parts of the body to cause further damage.
cancer incidence: The number or rate of new cases of cancer diagnosed in a population
during a given time period.
capital expenditure: Spending on large-scale fixed assets (for example, new buildings
and equipment) with a useful life extending over several years.
cardiomyopathy: A condition where there is direct and widespread damage to the heart
muscle, weakening it. It can be due to various causes, such as viral infections and severe
alcohol abuse. It can lead to an enlarged, thickened and dilated heart as well as heart failure.
cardiovascular disease/condition: Any disease of the circulatory system, namely the
heart (cardio) or blood vessels (vascular). Includes angina, heart attack, stroke and
peripheral vascular disease. Also known as circulatory disease.
caries: Bacterial disease that causes the demineralisation and decay of teeth and can
involve inflammation of the central dental pulp.
case-fatality: The proportion of people with a disease or medical condition who die
within a specified time period.
casemix: The range and types of patients (the mix of cases) treated by a hospital or
other health service. Casemix classifications (such as Australian Refined Diagnosis
Related Groups) provide a way to describe and compare hospitals and other services for
management purposes.
494
cause(s) of death: All diseases, morbid conditions or injuries that either resulted in or
contributed to death—and the circumstances of the accident or violence that produced
any such injuries—that are entered on the Medical Certificate of Cause of Death. Causes
of death are commonly reported by the underlying cause of death. See also associated
cause(s) of death and multiple causes of death.
cerebrovascular disease: Any disorder of the blood vessels supplying the brain or its
covering membranes. A notable and major form of cerebrovascular disease is stroke.
child: A person aged 0–14 unless otherwise stated.

child mortality rate: The number of deaths in a given period among children aged 0–14
per 100,000 children of the same age. Can also be presented for specific age groups
within this age range, such as for children aged 0–4 which is also called the under-five
mortality rate.
chlamydia: The most common sexually transmissible infection in Australia, caused by
Chlamydia trachomatis bacteria. It is treatable and may not cause symptoms; however,
it can lead to serious illness if untreated. It is a notifiable disease.
cholesterol: See blood cholesterol.
chronic: A term describing something that is persistent and long lasting.
chronic diseases/conditions: A diverse group of diseases/conditions, such as heart
disease, cancer and arthritis, which tend to be long lasting and persistent in their
symptoms or development. Although these features also apply to some communicable
diseases (infectious diseases), the term is usually confined to non-communicable
diseases.
chronic kidney disease (CKD): A term that refers to all conditions of the kidney, lasting
at least 3 months, where a person has had evidence of kidney damage and/or reduced
kidney function, regardless of the specific cause.
chronic obstructive pulmonary disease (COPD): Serious, progressive and disabling
long-term lung disease where damage to the lungs (usually because of both emphysema
and chronic bronchitis) obstructs oxygen intake and causes increasing shortness of
breath. By far the greatest cause of COPD is cigarette smoking.
chronic sinusitis: The inflammation of the lining of one or more sinuses (large air cavities
inside the face bones). It occurs when normal draining of the sinuses is obstructed by
swelling, excessive mucus or an abnormality in the structure of the sinuses.
chronic suppurative otitis media with discharge: A persistent suppurative (see
suppurative) discharge for more than 6 weeks from the middle ear through a perforation
in the tympanic membrane (eardrum). Importantly, the diagnosis of this condition is
appropriate only if the perforation is seen and is large enough to allow the discharge to
flow out of the middle ear space.
chronic suppurative otitis media without discharge: A perforation (hole) in the
tympanic membrane (eardrum) without evidence of discharge or fluid behind the eardrum.
It is also known as ‘inactive chronic suppurative otitis media’ and ‘dry perforation’.
circulatory disease: Alternative name for cardiovascular disease.
495
clinical urgency category: A category in which a patient on the public hospital waiting
list for surgery is placed after a clinical assessment of urgency. The categories are as
follows: Category 1—procedures that are clinically indicated within 30 days; Category 2—
procedures that are clinically indicated within 90 days; Category 3—procedures that are
clinically indicated within 365 days.
closed treatment episode: A period of contact between a client and a treatment
provider, or team of providers. An episode is closed when treatment is completed, when
there has been no further contact between the client and the treatment provider for
3 months, or when treatment has stopped.
Clostridium difficile infection: A gastrointestinal infection that commonly affects

hospitalised patients and people in a community.
cohort: A group of people who share a similar characteristic (for example, age).
collective burden: The sum of the direct burden and the indirect burden.
colorectal (bowel) cancer: This disease comprises cancer of the colon, cancer of the
rectosigmoid junction and cancer of the rectum (ICD-10 codes C18–C20).
commissioned officer: An appointed Defence member who holds a rank of Midshipman
or Officer Cadet, or higher.
communicable disease: Disease or illness caused by infectious organisms or their toxic
products. The disease may be passed directly or indirectly to humans through contact
with other humans, animals or other environments where the organism is found.
community health services: Non-residential health services offered to patients/clients
in an integrated and coordinated manner in a community setting, or the coordination of
health services elsewhere in the community. Such services are provided by, or on behalf
of, state and territory governments.
comorbidity: A situation where a person has two or more health problems at the same
time. Also known as multimorbidity.
condition (health condition): A broad term that can be applied to any health problem,
including symptoms, diseases and various risk factors (such as high blood cholesterol, and
obesity). Often used synonymously with disorder.
conductive hearing loss: A deviation of hearing threshold from the normal range
associated with reduced conduction of sound through the outer ear, tympanic membrane
(eardrum) or middle ear, including the ossicles (middle ear bones).
confidence interval: A range determined by variability in data, within which there is a
specified (usually 95%) chance that the true value of a calculated parameter lies.
congenital: A condition that is recognised at birth, or is believed to have been present
since birth, including conditions inherited or caused by environmental factors.
congenital anomaly: A structural, functional or metabolic abnormality that is present at
birth, even if not diagnosed until months or years later.
constant prices: Dollar amounts for different years that are adjusted to reflect the prices
in a chosen reference year. This allows spending over time to be compared on an equal
dollar-for-dollar basis without the distorting effects of inflation. The comparison will reflect
only the changes in the amount of goods and services purchased—changes in the ‘buying
power’—not the changes in prices of these goods and services caused by inflation.
496
co-payment: The costs incurred by an individual for payment of a Pharmaceutical Benefits
Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) medicine.
core activity: Term used in discussions of disability that refers to the basic activities of
daily living: self-care, mobility and communication.
core activity limitation: A limitation where someone needs help with—or is having
difficulty in using aids and equipment for—self-care, mobility and/or communication. See
also disability, mild or moderate core activity limitation and severe or profound core
activity limitation.

coronary heart disease: A disease due to blockages in the heart’s own (coronary)
arteries, expressed as angina or a heart attack. Also known as ischaemic heart disease.
course of radiotherapy: A series of one or more external beam radiotherapy treatments
prescribed by a radiation oncologist. A patient can receive more than one course of
radiotherapy at the same time (courses that are simultaneous or overlap). One course of
radiotherapy may cover multiple phases and multiple treatment plans.
curative treatment: A treatment given with the intention of curing disease.
current prices: Expenditures reported for a particular year, unadjusted for inflation.
Changes in current price expenditures reflect changes in both price and volume.
cystic fibrosis: A serious hereditary disease where mucus from glands is too thick
and sticky, affecting the lungs and other organs. The person is prone to frequent chest
infections, with related problems such as severe bronchiectasis, and has a much
shortened life expectancy.
DALY: See disability-adjusted life year.
data linkage: The bringing together (linking) of information from two or more different
data sources that are believed to relate to the same entity (for example, the same
individual or the same institution). This linkage can yield more information about the
entity and, in certain cases, provide a time sequence—helping to ‘tell a story’, show
‘pathways’ and perhaps unravel cause and effect. The term is used synonymously with
‘record linkage’ and ‘data integration’.
dementia: A general term for disorders characterised by worsening mental processes
(such as Alzheimer disease or vascular dementia). Symptoms include impaired memory,
understanding, reasoning and physical functioning.
dental condition: Any issue with the teeth or gums that can affect a person’s oral health.
dental services: Services provided by registered dental practitioners. These include
cleft lip and palate services; dental assessment; oral and maxillofacial surgery items;
orthodontic, pedodontic and periodontic services; and other dental items listed in the
Medical Benefits Schedule. The term covers dental services funded by health funds, state
and territory governments and by individuals’ out-of-pocket payments.
dentate: The term used to describe someone with at least one natural tooth.
deployment: Warlike or non-warlike service overseas by members assigned for duty with
a United Nations mission or a similar force.
depression: A mood disorder with prolonged feelings of being sad, hopeless, low and
inadequate, with a loss of interest or pleasure in activities and often with suicidal thoughts
or self-blame.
497
depressive disorders: A group of mood disorders with prolonged feelings of being sad,
hopeless, low and inadequate, with a loss of interest or pleasure in activities and often
with suicidal thoughts or self-blame.
deseal/reseal (DSRS): A term used to describe the formal F-111 aircraft fuel tank repair
and maintenance programs that required degraded tank sealant (deseal) to be removed
and a new sealant (reseal) applied. As well as these formal programs, ad hoc maintenance
was undertaken as part of routine tank repairs and maintenance to keep the aircraft
operational.
determinant: Any factor that can increase the chances of ill health (risk factors) or good
health (protective factors) in a population or individual. By convention, services or other

programs that aim to improve health are usually not included in this definition.
diabetes (diabetes mellitus): A chronic condition where the body cannot properly use
its main energy source—the sugar glucose. This is due to a relative or absolute deficiency
in insulin, a hormone produced by the pancreas that helps glucose enter the body’s cells
from the bloodstream and be processed by them. Diabetes is marked by an abnormal
build-up of glucose in the blood; it can have serious short- and long-term effects. For the
three main types of diabetes, see type 1 diabetes, type 2 diabetes and gestational diabetes.
diagnostic imaging: The production of diagnostic images; for example, computed
tomography, magnetic resonance imaging, X-rays, ultrasound and nuclear medicine scans.
dialysis: An artificial method of removing waste substances from the blood and regulating
levels of circulating chemicals—functions usually performed by the kidneys.
digital health: The electronic management of health information. This includes using
technology to collect and share a person’s health information. It can be as simple as a
person wearing a device to record how much exercise they do each day, to health care
providers sharing clinical notes about an individual.
direct burden: The burden calculated in burden of disease analysis to capture the main
disabling consequences of the disease. For example, the direct diabetes burden includes
diabetic nephropathy, neuropathy and retinopathy.
disability: An umbrella term for any or all of the following: an impairment of body
structure or function, a limitation in activities, or a restriction in participation. Disability is
a multidimensional concept and is considered as an interaction between health conditions
and personal and environmental factors. See also core activity limitation, mild or
moderate core activity limitation and severe or profound core activity limitation.
disability-adjusted life year (DALY): A year (1 year) of healthy life lost, either through
premature death or equivalently through living with disability due to illness or injury. It is
the basic unit used in burden of disease and injury estimates.
discharge (Australian Defence Force): Separation from the Australian Defence Force.
discretionary foods: Foods and drinks not necessary to provide the nutrients the body
needs, but which may add variety. Many are high in saturated fats, sugars, salt and/or
alcohol, and are energy dense.
disease: A physical or mental disturbance involving symptoms (such as pain or feeling
unwell), dysfunction or tissue damage, especially if these symptoms and signs form a
recognisable clinical pattern.
498
disorder (health disorder): A term used synonymously with condition.
disposable household income: Gross household income less income tax, the Medicare
levy and the Medicare levy surcharge. It is the household income left after taxes are
deducted that is available to support consumption and/or saving.
domestic violence: A set of violent behaviours between current or former intimate
partners—typically, where one partner aims to exert power and control over another,
usually through fear. Domestic violence can include physical violence, sexual violence,
and emotional and psychological abuse.

DPP4 inhibitors: A class of oral diabetes drugs that work by inhibiting the enzyme
dipeptidyl peptidase 4 (DPP4). This inhibiting action enhances the levels of active incretin
hormones, which act to lower blood glucose levels by increasing insulin secretion and
decreasing glucagon secretion (a hormone that has the opposite effect of insulin by
increasing blood glucose levels).
drug-induced deaths: Deaths that include those due to acute instances of poisoning, or
where drug use (including dependence) was thought to be the underlying causal factor.
They are classified due to their intent—accidental, suicidal, undetermined intent or
assault. Further, they include deaths from illicit drugs (for example, heroin, amphetamines
and cocaine) and licit drugs (for example, benzodiazepines and anti-depressants).
Alcohol- and tobacco-related deaths are excluded from this definition.
drug-related hospitalisation: Hospital care with selected principal diagnoses of drug use
disorder or harm (accidental, intended or self-inflicted) due to selected drugs.
dyslipidaemia: Abnormal levels of fats, such as cholesterol or triglycerides, in the blood.
elective surgery: Elective care in which the procedures required by patients are listed
in the surgical operations section of the Medicare Benefits Schedule, excluding specific
procedures often done by non-surgical clinicians.
emergency status (radiotherapy): An indicator of whether the treatment required for
the patient is clinically assessed as an emergency. An emergency is where the treating
clinician has assessed that the waiting time for treatment cannot exceed 24 hours.
emphysema: A chronic lung disease where over-expansion or destruction of the lung
tissue blocks oxygen intake, leading to shortness of breath and other problems.
end-stage kidney disease (ESKD): The most severe form of chronic kidney disease
(CKD), also known as Stage 5 CKD or kidney failure.
epilepsy: A common, long-term brain condition where a person has repeated seizures.
estimated resident population (ERP): The official Australian Bureau of Statistics estimate
of the Australian population. The ERP is derived from the 5-yearly Census counts and is
updated quarterly between each Census. It is based on the usual residence of the person.
Rates are calculated per 1,000 or 100,000 mid-year (30 June) ERP.
ex-serving (Australian Defence Force): Includes serving, reserve, and ex-serving
members in the Australian Defence Force.
ex-smoker: A person who has smoked at least 100 cigarettes or equivalent tobacco in his
or her lifetime, but does not smoke now.
499
extreme weather event: An unusual weather event or phenomenon at the extreme of a
‘typical’ historical distribution, such as a violent storm, exceptionally high levels of rainfall,
or a heat wave or drought that is longer or hotter than normal.
family violence: Violence between family members as well as between current or former
intimate partners. For example, family violence can include acts of violence between a
parent and a child. ‘Family violence’ is the preferred term used to identify experiences of
violence for Indigenous people as it encompasses the broad range of extended family and
kinship relationships within which violence may occur.
fatal burden: Quantified impact on a population of premature death due to disease or
injury. Measured as years of life lost (YLL).

fertility rate: Number of live births per 1,000 females aged 15–49.
fetal death (stillbirth): Death, before the complete expulsion or extraction from its
mother, of a product of conception of 20 or more completed weeks of gestation, or of 400
g or more birthweight. Death is evidenced by the fact that, after such separation, the fetus
does not breathe or show any other signs of life, such as beating of the heart, pulsation of
the umbilical cord or definite movement of voluntary muscles.
filicide: A homicide where a parent (or step-parent) kills a child.
first trimester: The first 3-months of a pregnancy. Pregnancy is divided into three
trimesters: first trimester (conception to 13 weeks), second trimester (13 to 26 weeks) and
third trimester (26 to 40 weeks).
forceps: Hand-held, hinged obstetric instrument applied to the fetal head to assist birth.
full-time equivalent (FTE) workforce or workload: A standard measure of the size of a
workforce that takes into account both the number of workers and the hours that each
works. For example, if a workforce comprises 2 people working full time 38 hours a week
and 2 working half time, this is the same as 3 working full time—that is, an FTE of 3.
gastrointestinal: A term relating to the stomach and the intestine.
gastrointestinal infection: An infection that occurs when a micro-organism or its toxic
product affects the gastrointestinal tract (including the stomach and intestines) causing
illness such as pain, vomiting, diarrhoea and other symptoms.
general inflation: The rise in the general price level of goods and services in the economy.
general practitioner (GP): A medical practitioner who provides primary comprehensive
and continuing care to patients and their families in the community.
general private health insurance: Private health insurance to cover non-hospital
medical services that are not covered by Medicare, such as dental, optical, physiotherapy,
other therapies and ambulance. Also known as ‘ancillary’ or ‘extras’ insurance.
genomics: The study of genes and their functions, and related techniques. Genomics
addresses all genes and their interrelationships to identify their combined influence on
the growth and development of the organism.
gestational age: Duration of pregnancy in completed weeks, calculated either from the
date of the first day of a woman’s last menstrual period to her baby’s date of birth, or via
ultrasound, or from clinical assessment during pregnancy, or from examination of the
baby after birth.
500
gestational diabetes: A form of diabetes that is first diagnosed during pregnancy
(gestation). It may disappear after pregnancy but signals a high risk of diabetes occurring
later on in life. See diabetes (diabetes mellitus).
gonorrhoea: A common sexually transmissible infection caused by Neisseria gonorrhoeae
bacteria. It is treatable; however, if left untreated, it can lead to serious illness. It is a
notifiable disease.
gout: A disease brought on by excess uric acid in the blood, causing attacks of joint pain
(most often in the big toe) and other problems.

gross domestic product (GDP): A statistic commonly used to indicate national wealth.
It is the total market value of goods and services produced within a given period after
deducting the cost of goods and services used up in the process of production but before
deducting allowances for the consumption of fixed capital.
gum disease: A disease of the gums and other tissues that attach teeth to the jaws.
haemorrhage (bleeding): The escape of blood from a ruptured blood vessel, externally or
internally.
haemorrhagic stroke: A type of stroke caused by the rupture and subsequent bleeding
of an artery in the brain or its surroundings.
health: Term relating to whether the body (including the mind) is in a well or ill state. With
good health, the state of the body and mind are such that a person feels and functions
well and can continue to do so for as long as possible.
health-adjusted life expectancy: The average number of years that a person at a specific
age can expect to live in full health; that is, taking into account years lived in less than full
health due to the health consequences of disease and/or injury.
health administration: Activities related to formulating and administering government
and non-government health policy, and in setting and enforcing standards for health
personnel and health services. One activity, for example, is the regulation and licensing of
providers of health services.
The term includes only those administrative services that cannot be allocated to a
particular health good or service. Such services might include, for example, maintaining
an office for the Chief Medical Officer, a departmental liaison officer in the office of the
Minister, or other agency-wide items for which it is not possible to derive appropriate or
meaningful allocations to particular health programs.
health indicator: See indicator.
health inflation: The rise in the price level of goods and services in the health sector.
health literacy: The ability of people to access, understand and apply information about
health and the health care system so as to make decisions that relate to their health.
health outcome: A change in the health of an individual or population due wholly or
partly to a preventive or clinical intervention.
health promotion: A broad term to describe activities that help communities and
individuals increase control over their health behaviours. Health promotion focuses
on addressing and preventing the root causes of ill health, rather than on treatment
and cure.
501
health research: Research with a health socioeconomic objective, which is done in
tertiary institutions, private non-profit organisations, and government facilities. It excludes
commercially oriented research that private business funds, the costs of which are
assumed to be included in the prices charged for the goods and services (for example,
medications that have been developed and/or supported by research activities).
health status: The overall level of health of an individual or population, taking into
account aspects such as life expectancy, level of disability, levels of disease risk factors
and so on.
hearing: The sense for perceiving sounds; includes regions within the brain where the
signals are received and interpreted.

hearing impairment: Describes the degree of impairment associated with hearing
loss in the ‘better hearing ear’, using a scale of mild, moderate, severe and profound. It
is based on the degree of deviation from normal thresholds in the ‘better ear’, calculated
as a 3frequency average of the threshold of hearing (in decibels Hearing Level; dB HL)—
500 Hz (hertz), 1,000 Hz and 2,000 Hz.
hearing loss: Any hearing threshold response (using audiometry—the testing of a person’s
ability to hear various sound frequencies) outside the normal range, to any sound stimuli,
in either ear. Hearing loss in a population describes the number of people who have
abnormal hearing. Hearing loss may affect one ear (unilateral) or both ears (bilateral).
heart attack: Life-threatening emergency that occurs when a vessel supplying blood
to the heart muscle is suddenly blocked completely by a blood clot. The medical term
commonly used for a heart attack is myocardial infarction. See also cardiovascular disease.
heart failure: A condition that occurs when the heart functions less effectively in pumping
blood around the body. It can result from a wide variety of diseases and conditions that can
impair or overload the heart, such as heart attack, other conditions that damage the heart
muscle directly (see cardiomyopathy), high blood pressure, or a damaged heart valve.
hepatitis: Inflammation of the liver, which can be due to certain viral infections, alcohol
excess or a range of other causes.
high blood cholesterol: Total cholesterol levels above 5.5 mmol/L.
high blood pressure/hypertension: Definitions can vary but a well-accepted definition is
from the World Health Organization: a systolic blood pressure of 140 mmHg or more or a
diastolic blood pressure of 90 mmHg or more, or if [the person is] receiving medication for
high blood pressure. Also see blood pressure.
hospital private health insurance cover: Private insurance cover for the cost of
in-hospital treatment by medical practitioners, and hospital costs such as accommodation
and theatre fees.
hospital services: Services provided to a patient who is receiving admitted patient
services or non-admitted patient services in a hospital, but excluding community health
services, health research done within the hospital, non-admitted dental services, patient
transport services and public health activities. They can include services provided off site,
such as dialysis or hospital in the home.
502
hospitalisation: Synonymous with admission and separation; that is, an episode of
hospital care that starts with the formal admission process and ends with the formal
separation process. An episode of care can be completed by the patient’s being discharged,
being transferred to another hospital or care facility, or dying, or by a portion of a hospital
stay starting or ending in a change of type of care (for example, from acute to rehabilitation).
household: A group of two or more related or unrelated people who usually live in the
same dwelling, and who make common provision for food or other essentials for living; or
a single person living in a dwelling who makes provision for his or her own food and other
essentials for living, without combining with any other person.

housing adequacy: A measure to assess whether a dwelling is overcrowded. The number
of bedrooms a dwelling should have to provide freedom from crowding is determined
by the Canadian National Occupancy Standard. This standard assesses bedroom
requirements based on the following criteria:
• there should be no more than 2 people per bedroom
• children aged under 5 of different sexes may reasonably share a bedroom
• children aged 5 and over of opposite sex should have separate bedrooms
• children aged under 18 and of the same sex may reasonably share a bedroom
• s ingle household members aged 18 and over should have a separate bedroom, as
should parents or couples.
human immunodeficiency virus (HIV): A virus that damages the immune system and
makes it harder for a person to fight infection. There is no cure for HIV but there are
treatments available to stop its progression.
hypertension: See high blood pressure.
illicit drugs: Illegal drugs, drugs and volatile substances used illicitly, and pharmaceuticals
used for non-medical purposes.
illness: A state of feeling unwell, although the term is also often used synonymously
with disease.
imaging: See diagnostic imaging.
immunisation: A procedure designed to induce immunity against infection by using an
antigen to stimulate the body to produce its own antibodies. See vaccination.
immunochemical faecal occult blood test (iFOBT): A test used to detect tiny traces of
blood in a persons’ faeces that may be a sign of bowel cancer. The iFOBT is a central part
of Australia’s National Bowel Cancer Screening Program.
impaired fasting blood glucose: Blood glucose levels between 6.1 to 6.9 mmol/L, which
is above normal but less than diabetes levels.
impaired glucose regulation: Condition in which blood glucose levels are higher than
normal but less than required for a diagnosis of diabetes, but which signal an increased
risk of developing type 2 diabetes.
impairment: Any loss or abnormality of psychological, physiological or anatomical
structure or function.
503
incidence: The number of new cases (of an illness or event, and so on) occurring during a
given period. Compare with prevalence.
incidence relative risk (cancer): The ratio of the observed cancer incidence rate in the
study population to the estimated (weighted) rate in the comparison population(s).
Index of Relative Socio-Economic Disadvantage (IRSD): One of the set of
Socio-Economic Indexes for Areas for ranking the average socioeconomic conditions
of the population in an area. It summarises attributes of the population such as low
income, low educational attainment, high unemployment and jobs in relatively unskilled
occupations.
indicator: A key statistical measure selected to help describe (indicate) a situation

concisely so as to track change, progress and performance; and to act as a guide for
decision making. It may have an indirect meaning as well as a direct one; for example,
Australia’s overall death rate is a direct measure of mortality but is often used as a major
indicator of population health. Taking this point further, time spent watching television
may be used as one indicator of physical inactivity.
Indigenous: A person of Aboriginal and/or Torres Strait Islander descent who identifies as
an Aboriginal and/or Torres Strait Islander. See also Aboriginal or Torres Strait Islander.
indirect burden: In burden of disease analysis (where the disease of interest is considered
to be a risk factor (that is, disease-as-risk) for associated or ‘linked’ diseases), it is the burden
from these linked diseases due to the disease-as-risk. For example, diabetes is considered
to be a risk factor for coronary heart disease, stroke, dementia and other diseases, so the
indirect burden is the burden attributable to diabetes for these linked diseases.
induction of labour: Intervention to stimulate the onset of labour.
infant: A child aged under 1.
infant mortality rate: The number of deaths among children aged under 1 in a given
period, per 1,000 live births in the same period.
inflammation: Local response to injury or infection, marked by local redness, heat,
swelling and pain. Can also occur when there is no clear external cause and the body
reacts against itself, as in auto-immune diseases.
influenza (flu): An acute contagious viral respiratory infection marked by fever, fatigue,
muscle aches, headache, cough and sore throat.
instrumental delivery: Vaginal delivery using forceps or vacuum extraction.
insulin: Hormone produced by the pancreas which regulates the body’s energy sources,
most notably the sugar glucose. It is an injectable agent that helps lower blood glucose
levels by moving glucose into cells to be used as energy.
intention of treatment (radiotherapy): The reason treatment is provided to a patient;
the intention may be:
• prophylactic
• curative
• palliative.
International Classification for Primary Care, Version 2 (ICPC-2): An internationally
accepted classification system for primary care data.
504
International Statistical Classification of Diseases and Related Health Problems
(ICD): The World Health Organization’s internationally accepted classification of death and
disease. The Tenth Revision (ICD-10) is currently in use. The ICD-10-AM is the Australian
Modification of the ICD-10; it is used for diagnoses and procedures recorded for patients
admitted to hospitals.
intervention (for health): Any action taken by society or an individual that ‘steps in’
(intervenes) to improve health, such as medical treatment and preventive campaigns.
intimate partner violence: A set of violent behaviours between current or former
intimate partners. See also domestic violence.

invasive meningococcal disease: A serious though uncommon disease caused by
Neisseria meningitidis bacteria. Five types cause human illness in Australia: serogroups A,
B, C, W and Y. It is a notifiable disease.
ischaemia: A reduced or blocked blood supply. See also ischaemic heart disease.
ischaemic heart disease: See also heart attack and angina (chest pain). Also known as
coronary heart disease. See also ischaemia.
ischaemic stroke: A type of stroke due to a reduced or blocked supply of blood in the
brain. Also known as cerebral infarction.
juvenile arthritis: Inflammatory arthritis in children that begins before their 16th
birthday and lasts at least 6 weeks. Also known as juvenile idiopathic arthritis.
Kessler Psychological Distress Scale—10 items (Kessler-10; K10): A survey device that is
used to measure non-specific psychological distress in people. It uses 10 questions about
negative emotional states that participants in the survey may have had in the 4 weeks leading
up to their interview. The designers recommend using only for people aged 18 and over.
kidney replacement therapy: Having a functional kidney transplant or receiving
regular dialysis.
kidney transplant: A procedure whereby a healthy kidney is taken from one person and
surgically placed into someone with end-stage kidney disease. The kidney can come
from a live or deceased donor.
length of service (Australian Defence Force): The time between the date of hire and
date of discharge from the Australian Defence Force.
life course: A series of life stages that people are normally expected to pass through
as they progress from birth to death. For example, stages often included are: birth and
infancy, childhood, youth, working age, and older age.
life expectancy: An indication of how long a person can expect to live, depending on the
age they have already reached. Technically, it is the number of years of life left to a person
at a particular age if death rates do not change. The most commonly used measure is life
expectancy at birth.
lifetime risk (alcohol): The accumulated risk from drinking either on many drinking
occasions, or on a regular (for example, daily) basis over a lifetime. The lifetime risk of
harm from alcohol-related disease or injury increases with the amount consumed. For
healthy men and women, drinking no more than 2 standard drinks on any day reduces
the lifetime risk of harm from alcohol-related disease or injury.
505
linked disease: A disease or condition on the causal pathway of the risk factor, and
therefore more likely to develop if exposed to the risk.
lipids: Fatty substances, including cholesterol and triglycerides, that are in blood and
body tissues.
live birth (live born): The complete expulsion or extraction from its mother of a product
of conception, irrespective of the duration of pregnancy, which, after such separation,
breathes or shows any other evidence of life (such as the beating of the heart, pulsation
of the umbilical cord or definite movement of voluntary muscles), whether or not the
umbilical cord has been cut or the placenta is attached; each product of such birth is
considered live born (WHO definition).

long-term condition: A term used in the Australian Bureau of Statistics National Health
Surveys to describe a health condition that has lasted, or is expected to last, at least
6 months. See also chronic diseases/conditions.
low birthweight: Weight of a baby at birth that is less than 2,500 grams.
mammogram: An X-ray of the breast. It may be used to assess a breast lump or as a
screening test in women with no evidence of cancer.
mandate: An official order.
maternal age: Mother’s age in completed years at the birth of her baby.
measles: A highly contagious infection, usually of children, that causes flu-like symptoms,
fever, a typical rash and sometimes serious secondary problems such as brain damage.
It is preventable by vaccination.
median: The midpoint of a list of observations that have been ranked from the smallest to
the largest.
median age: The age point at which half the population is older than that age and half is
younger than that age.
medical services expenditure: Expenditure on registered medical practitioners services.
It excludes medical services provided to public patients admitted to public hospitals and
medical services provided to public patients at outpatient clinics in public hospitals. Most
medical services in Australia are provided on a fee-for-service basis and attract benefits
from the Australian Government under Medicare. These include both private in-hospital
medical services and out-of-hospital medical services.
This term also includes medical services not from the Medical Benefits Schedule, such as
vaccines for overseas travel, as well as some expenditure by the Australian Government
under alternative funding arrangements.
medical specialist: A doctor who has completed advanced education and clinical training
in a specific area of medicine.
Medicare: A national, government-funded scheme that subsidises the cost of personal
medical services for all Australians and aims to help them afford medical care. The
Medicare Benefits Schedule (MBS) is the listing of the Medicare services subsidised by
the Australian Government. The schedule is part of the wider Medicare Benefits Scheme
(Medicare).
506
Medicare levy: A 2% tax on taxable income charged to fund Medicare. The Medicare levy
is reduced if taxable income is below a certain threshold.
Medicare levy surcharge: A levy paid by Australian taxpayers who do not have private
hospital cover and who earn above a certain income.
medications: Benefit-paid pharmaceuticals and other medications.
melanoma: A cancer of the body’s cells that contain pigment (melanin), mainly affecting
the skin. Survival rates are very high for those whose melanoma is detected and removed
early, but low if not.

mental illness (or mental disorders): Disturbances of mood or thought that can affect
behaviour and distress the person or those around them, so that the person has trouble
functioning normally. They include anxiety disorders, depression and schizophrenia.
mesothelioma: An aggressive form of cancer occurring in the mesothelium—the protective
lining of the body cavities and internal organs, such as the lungs, heart and bowel.
metformin: A medication that lowers blood glucose levels by reducing the amount of
stored glucose released by the liver, slowing the absorption of glucose from the intestine,
and helping the body to become more sensitive to insulin so that it works better.
midwife: A person, typically a woman, who is trained to help women in childbirth.
mild or moderate core activity limitation: The limitation of a person who needs no
help but has difficulty with core activities (moderate) or has no difficulty (mild) with core
activities, but uses aids or equipment, or has one or more of the following restrictions:
• cannot easily walk 200 metres
• cannot walk up and down stairs without a handrail
• cannot easily bend down to pick up an object from the floor
• cannot use public transport
• can use public transport but needs help or supervision
• n
eeds no help or supervision but has difficulty using public transport.
See also disability, core activity limitation and severe or profound core activity limitation.
monitoring (of health): A process of keeping a regular and close watch over important
aspects of the public’s health and health services through various measurements, and
then regularly reporting on the situation, so that the health system and society more
generally can plan and respond accordingly. The term is often used interchangeably with
surveillance, although surveillance may imply more urgent watching and reporting, such
as the surveillance of infectious diseases and their epidemics. Monitoring can also be
applied to individuals, such as hospital care where a person’s condition is closely assessed
over time.
morbidity: The ill health of an individual and levels of ill health in a population or group.
mortality: Number or rate of deaths in a population during a given time period.
mortality relative risk: The ratio of the observed mortality rate in the study population
to the estimated (weighted) rate in the comparison population(s).
multimorbidity: A situation that occurs when a person has two or more health problems
at the same time. Also known as comorbidity.
507
multiple causes of death: All the causes listed on the Medical Certificate of Cause of
Death. These include the underlying cause of death and all associated cause(s) of
death. See also cause of death.
multiparous (multipara): A pregnant woman who has had at least one previous
pregnancy resulting in a live birth or stillbirth.
musculoskeletal: A term that relates to the muscles, joints and bones.
musculoskeletal condition: One of a group of conditions, along with arthritis and other
conditions, that affects the bones, muscles and joints. These other conditions include
back pain and problems, juvenile arthritis, osteoarthritis, osteopenia, osteoporosis

(low bone density) and rheumatoid arthritis.
My Health Record: An online platform for storing a person’s health information, including
their Medicare claims history, hospital discharge information, diagnostic imaging reports,
and details of allergies and medications.
natural environment: A setting that includes all vegetation and animal species (including
micro-organisms), habitats and landscapes on earth, but excludes aspects of the
environment that result from human activities. The natural environment includes air,
water and climate.
neonatal death: The death of a live born baby within 28 days of birth.
neural tube defects: A group of serious birth defects that occur in utero during the
development of the brain or spinal cord.
neurology: A branch of medicine concerned especially with the structure, function and
diseases of the nervous system.
never smoker: A person who does not smoke now and has smoked fewer than 100
cigarettes or the equivalent tobacco in his or her lifetime.
non-admitted patient: A patient who receives care from a recognised non-admitted
patient service/clinic of a hospital, including emergency departments and outpatient
clinics.
non-fatal burden: The quantified impact on a population of ill health due to disease or
injury. Measured as years lived with disability (YLD), which is also sometimes referred to
as years of healthy life lost due to disability (YLL).
non-hospital medical services: Medical services delivered to patients who are not
admitted patients.
non-Indigenous: People who have declared that they are not of Aboriginal or Torres Strait
Islander descent. Compare with Other Australians.
non-medical use: The use of drugs either alone or with other drugs to induce or enhance
a drug experience for performance enhancement or cosmetic purposes (this includes
pain-killers/analgesics, tranquillisers/sleeping pills, steroids and meth/amphetamines and
other opioids such as morphine or pethidine).
non-organised sport: Activities not organised by a club or recreation association—for
example, running or walking for leisure.
508
non-school qualification: An educational qualification other than that of pre-primary,
primary or secondary education. Non-school qualifications comprise a Bachelor degree;
a Master degree; a Doctorate; a Diploma; a Graduate Diploma; an Advanced Diploma; a
Certificate I, II, III and IV (trade certificates); and a Graduate Certificate.
notifiable disease: A group of communicable diseases that are reported to state and
territory health departments, as required by legislation. The information enables public
health responses and the monitoring of disease activity.
nutrition: The intake of food, considered in relation to the body’s dietary needs.

obesity: Marked degree of overweight, defined for population studies as a body mass
index of 30 or over. See also overweight.
obesogenic environment: An environment that promotes obesity among individuals and
populations. It includes physical, economic, political and sociocultural factors.
obstetrics: The branch of medicine and surgery concerned with childbirth and midwifery.
occupational exposures and hazards: Chemical, biological, psychosocial, physical and
other factors in the workplace that can potentially cause harm.
occupational lung diseases: Diseases that result from breathing in harmful dusts
or fumes, such as silica, asbestos and coal dust. This exposure typically occurs in the
workplace. Pneumoconiosis, or scarring of the lung tissue caused by inhaled dust, is one
of the most common forms of occupational lung disease.
odds ratio: A measure of the association between an exposure and an outcome. The
odds ratio represents the odds that an outcome will occur, given a particular exposure,
compared with the odds of the outcome’s occurring in the absence of that exposure.
The value of the odds ratio is interpreted as:
• a
n odds ratio close or equal to 1 means that the exposure has little or no effect on the
odds of the outcome’s occurring
• a
n odds ratio greater than 1 means that the exposure increases the odds of the
outcome’s occurring
• a
n odds ratio less than 1 means that the exposure decreases the odds of the outcome’s
occurring.
opioid: A chemical substance that has a morphine-type action in the body. Opioids
are most commonly used for pain relief, but they are addictive and can lead to drug
dependence.
opioid substitution therapy (OST): The provision to opioid drug users of a prescription
medicine that replaces their drug of choice (for example, heroin) and helps them to
manage their addiction. This medicine is usually supplied in a clinically supervised
setting. OST is also called opioid replacement therapy or maintenance therapy. The three
medicines most commonly used as OST in Australia are methadone, buprenorphine and
buprenorphine-nalaxone.
optometry: The practice of primary eye care, including testing for visual acuity and
prescribing treatments for eye disorders.
oral health: The health of the mouth, tongue and oral cavity; the absence of active
disease in the mouth.
509
Organisation for Economic Co-operation and Development (OECD): An organisation of
35 countries, including Australia, that are mostly developed and some emerging (such as
Mexico, Chile and Turkey); the organisation’s aim is to promote policies that will improve
the economic and social wellbeing of people around the world.
organised sport: Activities done through an organisation, such as through a club or
sporting body; this may also include school physical education classes.
osteoarthritis: A chronic and common form of arthritis, affecting mostly the spine, hips,
knees and hands. It first appears from the age of about 30 and is more common and
severe with increasing age.
osteopenia: A condition when bone mineral density is lower than normal but not low
enough to be classified as osteoporosis.
osteoporosis: A condition that causes bones to become thin, weak and fragile, such that
even a minor bump or accident can break a bone.
Other Australians: People who have declared that they are not of Aboriginal or Torres
Strait Islander descent, and people whose Indigenous status is unknown. Compare with
non-Indigenous.
other health practitioner services: Services that health practitioners (other than
doctors and dentists) provide. These other practitioners include, but are not limited to,
audiologists, chiropractors, dieticians, homeopaths, naturopaths, occupational therapists,
optometrists, physiotherapists, podiatrists, practice nurses, practitioners of Chinese
medicine and other forms of traditional medicine, and speech therapists.
other medications: Pharmaceuticals for which no Pharmaceutical Benefits Scheme
(PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) benefit was paid.
They include:
• p
harmaceuticals listed in the PBS or RPBS, the total costs of which are equal to, or less
than, the statutory patient contribution for the class of patient (under co-payment
pharmaceuticals)
• p
harmaceuticals dispensed through private prescriptions that do not fulfil the criteria
for payment of benefit under the PBS or RPBS
• o
ver-the-counter medicines, including pharmacy-only medicines, aspirin, cough and
cold medicines, vitamins and minerals, herbal and other complementary medicines, and
various medical non-durables, such as condoms, adhesive and non-adhesive bandages.
other patients: Primarily people whose hospitalisations were self-funded, or funded by
worker’s compensation, motor vehicle third party personal claims or the Department of
Veterans’ Affairs.
other specified feeding and eating disorder: An eating disorder that may present with
symptoms of anorexia nervosa, binge eating disorder or bulimia nervosa but may not
meet the full diagnosis criteria for any of these disorders individually. People with other
specified feeding and eating disorder may present with symptoms such as disordered
eating, weight control behaviour, distorted body image or an overvaluation of body weight
or shape.
510
otitis media: All forms of inflammation and infection of the middle ear. Active
inflammation or infection is nearly always associated with a middle ear effusion (fluid in
the middle ear space).
otitis media with effusion (OME): The presence of an intact eardrum and middle ear
fluid without symptoms or signs of acute infection. Other terms used to describe OME
include ‘glue ear’, ‘serious otitis media’ and ‘secretory otitis media’. OME may be episodic
or persistent.
outcome (health outcome): A health-related change due to a preventive or clinical
intervention or service. (The intervention may be single or multiple, and the outcome may

relate to a person, group or population, or be partly or wholly due to the intervention.)
out-of-pocket costs/expenditure: The total costs incurred by individuals for health care
services over and above any refunds from Medicare and private health insurance funds.
over-the-counter medicines: Medicine that one can buy without a prescription from a
pharmacy or retail outlet.
overweight: Defined for the purpose of population studies as a body mass index of
25 or over. See also obesity.
overweight but not obese: Defined for the purpose of population studies as a body
mass index between 25 and less than 30.
palliative treatment (or palliative care): Treatment given primarily to control pain
or other symptoms. Consequent benefits of the treatment are considered secondary
contributions to quality of life.
Pap test: See Papanicolaou smear.
Papanicolaou smear (Pap smear): a procedure to detect cancer and precancerous
conditions of the female genital tract, which is the screening test of the National Cervical
Screening Program. During a Pap test, cells are collected from the transformation zone of
the cervix—the area of the cervix where the squamous cells from the outer opening of the
cervix and glandular cells from the endocervical canal meet. This is the site where most
cervical abnormalities and cancers are detected. For conventional cytology, these cells are
transferred onto a slide, and sent to a pathology laboratory for assessment. Collected cells
are then examined under a microscope to look for abnormalities.
parricide: A homicide where a child kills a parent or step-parent.
pathology: A general term for the study of disease, but often used more specifically to
describe diagnostic services that examine specimens, such as samples of blood or tissue.
patient days: The number of full or partial days of stay for patients who were admitted to
hospital for an episode of care and who underwent separation during the reporting period.
A patient who is admitted and separated on the same day is allocated 1 patient day.
patient transport services: The services of organisations primarily engaged in
transporting patients by ground or air—along with health (or medical) care. These services
are often provided for a medical emergency, but are not restricted to emergencies. The
vehicles are equipped with lifesaving equipment operated by medically trained personnel.
Patient transport services include public ambulance services or flying doctor services, such
as the Royal Flying Doctor Service and Care Flight.
511
Also included are patient transport programs, such as patient transport vouchers or
support programs to help isolated patients with travel to obtain specialised health care.
From 2003–04 onwards, this category includes patient transport expenses included in the
operating costs of public hospitals.
peacetime service: Service provided by a Australian person who is serving, or has served,
with a Peacekeeping Force outside Australia. These are military operations in support of
diplomatic efforts to restore peace between belligerents, who may not be consenting to
intervention and may be engaged in combat activities.
peer worker: A person employed (or engaged via contract), either part time or full time,
on the basis of their lived experience, to support others experiencing a similar situation.
performance indicators (of the health system): Measures (indicators) that can relate
to the health system as a whole or to parts of it (such as hospitals, health centres and
so forth). The measures include accessibility, effectiveness, efficiency and sustainability,
responsiveness, continuity of care and safety.
perinatal: Describes something that pertains to, or that occurred in, the period shortly
before or after birth (usually up to 28 days after).
perinatal death: A fetal or neonatal death of at least 20 weeks gestation or at least
400 grams birthweight.
perinatal mortality rate: The number of perinatal deaths per 1,000 total births (fetal
deaths plus live births).
peripheral vascular disease: A disease characterised by pain in the extremities, often the
legs, due to an inadequate blood supply to them.
permanent force: Members of the permanent forces of the Australian Defence Force—
Permanent Navy, Regular Army and Permanent Air Force—who usually serve in a full-time
capacity and commit to an initial minimum period of service commensurate with the job
role, rank and level of training.
pertussis: A highly infectious bacterial disease of the air passages marked by explosive
fits of coughing and often a whooping sound on breathing in. It is preventable by
vaccination. Also known as whooping cough.
Pharmaceutical Benefits Scheme (PBS): A national, government-funded scheme that
subsidises the cost of a wide range of pharmaceutical drugs for all Australians to help
them afford standard medications. The Schedule of Pharmaceutical Benefits (schedule)
lists all the medicinal products available under the PBS and explains the uses for which
they can be subsidised.
pharmacotherapy: The treatment of disease and illnesses using pharmaceutical drugs.
physical therapy: The treatment or management of physical disability, malfunction, or
pain using therapeutic exercises, physical modalities such as massage and hydrotherapy,
assistive devices, and patient education and training. Often referred to as physiotherapy.
pneumonia: Inflammation of the lungs as a response to infection by bacteria or viruses.
The air sacs become flooded with fluid, and inflammatory cells and affected areas of the
lung become solid. Pneumonia is often quite rapid in onset and marked by a high fever,
headache, cough, chest pain and shortness of breath.
512
population estimates: Official population numbers compiled by the Australian Bureau of
Statistics at both state and territory and statistical local area levels by age and sex, as at 30
June each year. These estimates allow geographical areas of differing population sizes and
age structures to be compared.
population health: Typically, the organised response by society to protect and promote
health, and to prevent illness, injury and disability. Population health activities generally
focus on:
• prevention, promotion and protection rather than on treatment
• populations rather than on individuals

• the factors and behaviours that cause illness.
In this sense, the term is often used synonymously with public health. It can also refer to the
health of particular subpopulations, and comparisons of the health of different populations.
post-neonatal death: The death of a live born baby after 28 days and within 1 year of birth.
post-partum: A term that indicates an occurrence after childbirth, with reference to the
mother.
post-traumatic stress disorder (PTSD): The development of a set of reactions in people
who have experienced a traumatic event that might have threatened their life or safety,
or others around them. Examples of traumatic events can include war or torture, serious
accidents, physical or sexual assault, or disasters. A person who has PTSD can experience
feelings of helplessness, horror or intense fear.
potentially avoidable deaths: Deaths among people younger than age 75 that are
avoidable in the context of the present health care system. They include deaths from
conditions that are potentially preventable through individualised care and/or treatable
through existing primary or hospital care. They are a subset of premature deaths. The rate
of potentially avoidable deaths in Australia is used as an indicator of the health system’s
effectiveness. Potentially avoidable deaths are classified using nationally agreed definitions.
(A revised definition was adopted in the National Healthcare Agreement 2015 leading to
differences in the counts and rates of potentially avoidable deaths published previously.)
potentially preventable hospitalisations (PPHs): Hospital separations for a specified
range of conditions where hospitalisation is considered to be largely preventable if timely
and adequate care had been provided through population health services, primary
care and outpatient services. The PPH conditions are classified as vaccine preventable,
chronic and acute. Respective examples include influenza and pneumonia, diabetes
complications and COPD, and dental and kidney conditions. The rate of PPHs is currently
being used as an indicator of the effectiveness of a large part of the health system, other
than hospital inpatient treatment.
pre-eclampsia: A condition that complicates pregnancy and is characterised by high
blood pressure, fluid retention and protein in the urine. The placental function may be
compromised.
premature deaths (or premature mortality): Deaths that occur at a younger age
than a selected cut-off. The age below which deaths are considered premature can vary
depending on the purpose of the analysis and the population under investigation. In this
report, deaths among people aged under 75 are considered premature.
513
prescription pharmaceuticals: Pharmaceutical drugs available only on the prescription
of a registered medical or dental practitioner and available only from pharmacies.
pre-term birth: Birth before 37 completed weeks of gestation.
prevalence: The number or proportion (of cases, instances, and so forth) in a population
at a given time. For example, in relation to cancer, refers to the number of people alive
who had been diagnosed with cancer in a prescribed period (usually 1, 5, 10 or 26 years).
Compare with incidence.
prevention (of ill health or injury): Action to reduce or eliminate the onset, causes,
complications or recurrence of ill health or injury.

principal diagnosis: The diagnosis established after study to be chiefly responsible for
occasioning an episode of patient care (hospitalisation), an episode of residential care or
an attendance at the health care establishment.
primary health care: These are services delivered in many settings, such as general
practices, community health centres, Aboriginal health services and allied health practices
(for example, physiotherapy, dietetic and chiropractic practices) and come under
numerous funding arrangements. Expenditure on primary health care includes recurrent
expenditure on health goods and services, such as on medical services, dental services,
other health practitioner services, pharmaceuticals and community and public health services.
Primary Health Network: Primary Health Networks were established on 1 July 2015.
These networks are intended to play a critical role in connecting health services across
local communities so that patients, particularly those needing coordinated care, have the
best access to a range of health care providers, including practitioners, community health
services and hospitals. Primary Health Networks work directly with general practitioners,
other primary care providers, secondary care providers and hospitals.
prisoner: An adult aged 18 and over held in custody, whose confinement is the
responsibility of a corrective services agency. Prisoners includes sentenced prisoners, and
prisoners held in custody awaiting trial or sentencing (remandees). Juvenile offenders,
people in psychiatric custody, police cell detainees, people held in immigration detention
centres, or Australians held in overseas prisons, are not included.
private health insurance patients: Patients whose hospitalisations had any funding
from private health insurance.
private hospital: A privately owned and operated institution, catering for patients who
are treated by a doctor of their own choice. Patients are charged fees for accommodation
and other services provided by the hospital and by relevant medical and allied health
practitioners. The term includes acute care and psychiatric hospitals as well as private
free-standing day hospital facilities.
private patient: A person admitted to a private hospital, or a person admitted to a
public hospital who decides to choose the doctor(s) who will treat them or to have private
ward accommodation—this means they will be charged for medical services, food and
accommodation.
procedure: A clinical intervention that is surgical in nature, carries a procedural risk,
carries an anaesthetic risk, and requires specialist training and/or special facilities or
equipment available only in the acute-care setting.
514
prophylactic treatment: Treatment given to prevent the occurrence of disease at a site
that shows no sign of active disease but is considered to be at risk.
protective factors: Factors that enhance the likelihood of positive outcomes and lessen
the chance of negative consequences from exposure to risk.
psychological distress: Unpleasant feelings or emotions that affect a person’s level of
functioning and interfere with the activities of daily living. This distress can result in having
negative views of the environment, others and oneself, and manifest as symptoms of mental
illness, including anxiety and depression (see also Kessler Psychological Distress Scale).

public health: Activities aimed at benefiting a population, with an emphasis on
prevention, protection and health promotion as distinct from treatment tailored to
individuals with symptoms. Examples include the conduct of anti-smoking education
campaigns, and screening for diseases such as cancer of the breast and cervix. See also
population health.
public hospital: A hospital controlled by a state or territory health authority. In Australia,
public hospitals offer free diagnostic services, treatment, care and accommodation to all
eligible patients.
public hospital services expenditure: Services provided by public hospitals from the
balance of public hospital expenditure remaining after costs of community health services,
public health services, non-admitted dental services, patient transport services, and health
research activities conducted by public hospitals have been removed and reallocated to
their own expenditure categories.
public patients: Patients who are admitted to hospital at no charge and are mostly
funded through public sector health or hospital service budgets.
quintile: A group derived by ranking the population or area according to specified criteria
and dividing it into five equal parts. The term can also mean the cut-points that make
these divisions—that is, the 20th, 40th, 60th and 80th percentiles—but the first use is
the more common one. Commonly used to describe socioeconomic areas based on
socioeconomic position.
Rank (Australian Defence Force): A term that describes one’s position in the Australian
Defence Force operational hierarchy. Analysis by rank is presented for two broad groups:
commissioned officer, and all ranks other than commissioned officer.
rate: A rate is one number (the numerator) divided by another number (the denominator).
The numerator is commonly the number of events in a specified time. The denominator is
the population ‘at risk’ of the event. Rates (crude, age-specific and age-standardised) are
generally multiplied by a number such as 100,000 to create whole numbers.
real expenditure: Expenditure that has been adjusted to remove the effects of inflation
(for example, expenditure for all years has been compiled using 2015–16 prices).
Removing the effects of inflation allows comparisons to be made between expenditures in
different years on an equal dollar-for-dollar basis. Changes in real expenditure measure
the change in the volume of goods and services produced (see constant prices).
reason for discharge (Australian Defence Force): The main reason recorded for a
person’s separating (discharging) from the Australian Defence Force. Analysis by reason
for discharge is presented for two broad groups: voluntary discharge—includes voluntary
515
redundancies and resignations; and involuntary discharge—comprises personnel deemed
unsuitable for further duty for disciplinary, medical and operational reasons. Involuntary
discharge is further divided into discharge for medical reasons, and non-medical
involuntary discharge (which includes being physically unfit for service, training failure and
disciplinary reasons).
recent user (alcohol and other drugs): Someone who has used in the last 12 months.
record linkage: See data linkage.
recurrent expenditure: Spending (expenditure) on goods and services that are used
during the year (for example, salaries). Compare with capital expenditure.
referred medical services: Non-hospital medical services that are not classified as
primary health care (see unreferred medical services).
refugee: A person who is subject to persecution in their home country and in need of
resettlement. The majority of individuals considered to be a refugee are identified by the
United Nations High Commissioner for Refugees (UNHCR) and referred by the UNHCR
to Australia.
relative income poverty: A situation where a family’s income is low compared with
that of other families. It is assessed by the proportion of households with an equivalised
income that is less than 50% of the national median equivalised household income.
relative risk: This measure is derived by comparing two groups for their likelihood of
an event. It is also called the risk ratio because it is the ratio of the risk in the ‘exposed’
population divided by the risk in the ‘unexposed’ population. It is also known as the rate ratio.
relative survival (cancer): A measure of the average survival experience of a population
of people diagnosed with cancer, relative to the ‘average’ Australian of the same sex and
age, at a specified interval after diagnosis.
remoteness classification: Each state and territory is divided into several regions based
on their relative accessibility to goods and services (such as to general practitioners,
hospitals and specialist care) as measured by road distance. These regions are based on
the Accessibility/Remoteness Index of Australia and defined as Remoteness Areas by
either the Australian Standard Geographical Classification (ASGC) (before 2011) or
the Australian Statistical Geographical Standard (ASGS) (from 2011 onwards) in each
Census year. The five Remoteness Areas are Major cities, Inner regional, Outer regional,
Remote and Very remote. See also rural.
Repatriation Pharmaceutical Benefits Scheme (RPBS): An Australian government
scheme that provides a range of pharmaceuticals and wound dressings at a concessional
rate for the treatment of eligible veterans, war widows/widowers, and their dependants.
reserve/reservist: An Australian Defence Force member in the active or inactive reserve
forces of the Navy, Army or Air Force. Most members leaving full-time service make
the transition to the inactive reserve forces, unless there are medical or other grounds
preventing this.
respiratory condition: A chronic respiratory condition affecting the airways and
characterised by symptoms such as wheezing, shortness of breath, chest tightness
and cough. Conditions include asthma and chronic obstructive pulmonary disease
(COPD)—which includes emphysema and chronic bronchitis.
516
resuscitation of baby: Active measure taken shortly after birth to assist the baby’s
ventilation and heartbeat, or to treat depressed respiratory effort to correct metabolic
disturbances.
revascularisation: A procedure to restore adequate blood flow to the heart or other part
of the body, usually after the supply has been reduced or blocked, as in angina or a heart
attack. Revascularisation includes methods such as angioplasty and coronary artery
bypass graft surgery.
rheumatoid arthritis: A chronic, multisystem disease whose most prominent feature
is joint inflammation and resulting damage, most often affecting the hand joints in

symmetrical fashion. It can occur in all age groups but most commonly appears between
ages 20–40. Its causes are not certain but involve auto-immune processes.
risk: The probability of an event’s occurring during a specified period of time.
risk factor: Any factor that represents a greater risk of a health disorder or other
unwanted condition or event. Some risk factors are regarded as causes of disease; others
are not necessarily so. Along with their opposites (protective factors), risk factors are
known as determinants.
rural: Geographic areas outside urban areas such as towns and cities. In this report,
rural and remote encompasses all areas outside Australia’s Major cities according to the
remoteness classification of the Australian Statistical Geographic Standard. In many
instances, the term ‘rural and remote’ is used interchangeably with the classification terms
‘regional and remote’.
saturated fats: Fats, most often of animal origin, that are solid at room temperature and
whose fatty acid chains cannot incorporate additional hydrogen atoms. In excess, they
tend to raise blood cholesterol.
screening (for health): A systematic method of detecting risk factors or suspicious
abnormalities among people who are symptom free, so that health problems can be
either prevented or followed up, diagnosed and treated as early as possible.
Screening is usually done through special programs aimed at higher risk groups in
the population. A variant of screening, often known as case-finding, is where clinicians
opportunistically look for risk factors or abnormalities in people when seeing them for
other reasons; for example, when many doctors routinely measure blood pressure in all
patients consulting them.
screen time: Activities done in front of a screen, such as watching television, working on
a computer, or playing video games.
separation (from hospital): The formal process where a hospital records the completion
of an episode of treatment and/or care for an admitted patient—in this report, described
by the term hospitalisation.
separation (from military service): See discharge.
service (Australian Defence Force): The three broad arms of the Australian Defence
Force—the Navy, Army and Air Force.
serving full time (Australian Defence Force): A term that describes Australian Defence
Force members serving in a regular capacity in the Navy, Army or Air Force on continuous
full-time service, or participating in the gap year program.
517
severe or profound core activity limitation: The limitation of a person who needs help
or supervision always (profound) or sometimes (severe) to perform activities that most
people undertake at least daily—that is, the core activities of self-care, mobility and/or
communication. See also core activity limitation and disability.
sexual violence: The occurrence, attempt or threat of sexual assault experienced by a
person since the age of 15. Sexual violence can be perpetrated by partners in a domestic
relationship, former partners, other people known to the victims, or strangers.
sexually transmissible infection: An infectious disease that can be passed from one
person to another by sexual contact. Examples include chlamydia and gonorrhoea
infections.
siblicide: A homicide where one sibling kills another sibling.
single-occasion risk (alcohol): A single-occasion risk, in the context of alcohol, is defined
as the risk of alcohol-related injury arising from having a sequence of drinks without the
blood alcohol concentration reaching zero in between them. The risk of an alcohol-related
injury arising from a single occasion of drinking increases with the amount consumed. For
healthy men and women, drinking no more than 4 standard drinks on a single occasion
reduces the risk of alcohol-related injury from that occasion.
sleep apnoea: A situation that occurs when a person repeatedly stops breathing during
sleep. It has the same cause as snoring—reduced air flow at the back of the mouth—
but is more extreme. More common in males and the obese, it leads to poorer mental
functioning during the day and a greater risk of accidents.
smartphone: A mobile phone built on a mobile operating system, with more advanced
computing capability and connectivity.
smartwatch: A mobile device, consisting of a package that includes a computer and
display, attached to a bracelet.
smoker: Someone who reports smoking daily, weekly or less than weekly.
social determinants of health: The circumstances in which people are born, grow up,
live, work and age, and the systems put in place to deal with illness. These circumstances
are in turn shaped by a wider set of forces: economics, social policies and politics.
social exclusion: A situation where people do not have the resources, opportunities and
capabilities they need to learn, work, engage with or have a voice in their communities.
Composite measures of social exclusion weight indicators such as income level, access to
education, unemployment, poor English, health services and transport, and non-material
aspects such as stigma and denial of rights. These measures are typically divided into
three levels: marginal exclusion, deep exclusion and very deep exclusion.
Socio-Economic Indexes for Areas (SEIFA): A set of indexes, created from Census data,
that aim to represent the socioeconomic position of Australian communities and identify
areas of advantage and disadvantage. The index value reflects the overall or average level
of disadvantage of the population of an area; it does not show how individuals living in
the same area differ from each other in their socioeconomic group. This report uses the
Index of Relative Socio-Economic Disadvantage.
518
socioeconomic position: An indication of how ‘well off’ a person or group is. In this
report, socioeconomic areas are mostly reported using the Socio-Economic Indexes for
Areas, typically for five groups (quintiles)—from the most disadvantaged (worst off or
lowest socioeconomic area) to the least disadvantaged (best off or highest socioeconomic
area).
solar ultraviolet (UV) radiation: High-energy rays from the sun which are invisible to the
human eye. UV radiation is divided into three types according to wavelength (UVA, UVB
and UVC). UVA, and to a lesser extent UVB, are not wholly absorbed by atmospheric ozone
and therefore are of interest for human health.

specialist attendance: A specialist attendance is a referred patient-doctor encounter
(with Medicare funding benefits), such as a visit, consultation and attendance (including a
video conference) with a medical practitioner who has been recognised as a specialist or
consultant physician for the purposes of Medicare benefits.
specialist services: Services that support people with specific or complex health
conditions and issues, who are generally referred by primary health care providers. They
are often described as ‘secondary’ health care services. In many cases, a formal referral
is required for an individual to be able to access the recommended specialist service.
spontaneous labour: The onset of labour without intervention.
standard drink (alcohol): A serve that contains 10 grams of alcohol (equivalent to
12.5 millilitres of alcohol). It is also referred to as a full serve.
Staphylococcus aureus bacteraemia (SAB): An infection of the bloodstream. When
associated with health care procedures, these infections are considered to be potentially
preventable.
statins: A class of drugs commonly used to lower blood cholesterol.
statistical significance: A statistical measure indicating how likely the observed
difference or association is due to chance alone. Rate differences are deemed to be
statistically significant when their confidence intervals do not overlap, since their
difference is greater than what could be explained by chance.
stillbirth: See fetal death (stillbirth).
stroke: An event that occurs when an artery supplying blood to the brain suddenly
becomes blocked or bleeds. A stroke often causes paralysis of parts of the body normally
controlled by that area of the brain, or speech problems and other symptoms. It is a major
form of cerebrovascular disease.
substance misuse: Use of illicit drugs (illegal drugs, drugs and volatile substances used
illicitly, and pharmaceuticals used for non-medical purposes).
substance use disorder: A disorder of harmful use and/or dependence on illicit or licit
drugs, including alcohol, tobacco and prescription drugs.
suicidal ideation: Serious thoughts about ending one’s own life.
suicidality: The collective term for suicidal ideation, suicide plans and suicide attempts.
suicide: An action to deliberately end one’s own life.
sulfonylureas: A class of medicines that lower blood glucose levels by stimulating the
pancreas to release more insulin.
519
suppurative: A term that describes pus produced in response to inflammatory bacterial
infections.
syphilis (infectious): A sexually transmitted infection, which if untreated can cause
irreversible damage. It is caused by Treponema pallidum bacteria. It is a notifiable disease.
tablet (information and communication technologies): A hand-held, internet-enabled,
wireless personal computer, usually having a touchscreen or a digital pen-enabled
interface, and no hardware keyboard.
telehealth: Health services delivered using information and communication technologies,
such as videoconferencing.
thromboembolism: The obstruction of a blood vessel, usually a large vein, with
thrombotic material carried in the blood from its site of origin to block another vessel.
tooth decay: Decay of the teeth caused by caries, and progressing to cavities in the
enamel and the dentine.
trachoma: An infectious disease of the eye caused by Chlamydia trachomatis. If left
untreated, follicles form on the upper eyelids and grow larger until the granulations
invade the cornea, eventually causing blindness.
Transition (Australian Defence Force): In the context of military services, the process
of moving from full-time Australian Defence Force service into civilian life.
treatment episode: The period of contact between a client and a treatment provider or
a team of providers. In the context of alcohol and other drug treatment, each treatment
episode has 1 principal drug of concern and 1 main treatment type. If the principal drug
or main treatment changes, a new episode is recorded.
treatment type: In the context of alcohol and other drug treatment, the type of activity
that is used to treat the client’s alcohol or other drug problem. Examples include
assessment only, counselling, information and education only, pharmacotherapy,
rehabilitation, support and case management only, and withdrawal management
(detoxification).
triage category: A category used in the emergency departments of hospitals to indicate
the urgency of a patient’s need for medical and nursing care. Patients are triaged into
1 of 5 categories on the Australasian Triage Scale. The triage category is allocated by an
experienced registered nurse or medical practitioner.
triglyceride: A compound made up of a single molecule of glycerol and three molecules
of fatty acid. Triglycerides are the main constituents of natural fats and oils.
type 1 diabetes: A form of diabetes mostly arising among children or younger adults
and marked by a complete lack of insulin. Insulin replacement is needed for survival.
See diabetes (diabetes mellitus).
type 2 diabetes: The most common form of diabetes, occurring mostly in people
aged 40 and over, and marked by reduced or less effective insulin. See diabetes
(diabetes mellitus).
Under-five mortality rate: see child mortality rate.
520
underlying cause of death: The disease or injury that initiated the train of events leading
directly to death, or the circumstances of the accident or violence that produced the fatal
injury. See also cause of death and associated cause(s) of death.
underweight: A category defined for population studies as a body mass index less than
18.5.
unreferred medical service: A medical service provided to a person by, or under the
supervision of, a medical practitioner—being a service that has not been referred to
that practitioner by another medical practitioner or person with referring rights.
In this report, these are medical services that are classified as primary health care

(see referred medical services).
vaccination: The process of administering a vaccine to a person to produce immunity
against infection. See immunisation.
vacuum extraction: A procedure to assist birth using traction or rotation on a suction cap
applied to the baby’s head.
vascular risk factors: Metabolic and behavioural risk factors that increase the risk
of vascular disease. They also increase the risk of some vascular diseases themselves
(‘diseases-as-risks’, such as diabetes, stroke, atrial fibrillation and chronic kidney
disease) that involve or increase the risk of damaged blood vessels, and which jointly and
individually increase the risk of dementia.
vector-borne disease: A disease, parasite or infection transmitted from one host to
another by a vector. The largest group of vectors are insects and other arthropods, most
commonly mosquitoes, ticks, flies, lice and fleas. The abundance and distribution of vector
populations (and hence the spread of vector-borne diseases) is closely intertwined with
environmental conditions that encourage their survival.
weighting: Adjustment of the characteristics of one group so they are statistically similar
to the characteristics of another group so that comparisons of the effect under study can
be more certain.
wellbeing: A state of health, happiness and contentment. It can also be described as
judging life positively and feeling good. For public health purposes, physical wellbeing
(for example, feeling very healthy and full of energy) is also viewed as critical to overall
wellbeing. Because wellbeing is subjective, it is typically measured with self-reports, but
objective indicators (such as household income, unemployment levels and neighbourhood
crime) can also be used.
whooping cough: See pertussis.
workforce: People who are employed or unemployed (not employed but actively looking
for work). Also known as the labour force.
years lived with disability (YLD): A measure calculated as the prevalence of a condition,
multiplied by a disability weight for that condition. Sometimes referred to as years of
healthy life lost due to disability (YLD).
years of healthy life lost due to disability: See years lived with disability (YLD).
years of life lost (YLL): For each new case, years of life lost equals the number of years
between premature death and the standard life expectancy for the individual.
521
Index
age, 7, 465
alcohol and other drug treatment services clients,
468, 469, 470
alcohol consumption, 204, 205
arthritis and other musculoskeletal conditions, 86,
A 124, 290, 291
AATSIHS, 341, 342 back pain and problems, 86, 291
abdominal surgeries, post-operative sepsis in, 427 blood lipids, 246
ABDS, see burden of disease blood pressure, 245, 246

burden of disease, see age and burden of disease
ABIM Foundation, 184
cancer, see age and cancer
abnormal blood lipids, see cholesterol and

triglycerides cardiovascular disease, see age and cardiovascular
disease
Aboriginal and Torres Strait Islander Health
Performance Framework report, 350 children and young people, see age of children
and young people
Aboriginal Australians, see Indigenous Australians
at death, see age at death
Aboriginal Community Controlled Health
Organisations (ACCHOs), 353 dementia, 138
abstention from alcohol, 204, 249 diabetes, 86, 87, 118, 119, 290, 291
abstention from smoking, 200, 202 diet, 228, 229
Access to Allied Psychological Services program, 382 disability, 301
accidental drowning and submersion, 90 health workforce, 66; mental health services, 474
accidental falls, see falls hospital patients, see age of hospital patients
illicit drug users, 212–14, 215–17; with mental
accidental threats to breathing, 90
conditions, 219–23
accidents, see injuries; transport accidents
impaired glucose regulation, 245
ACSQHC, see Australian Commission on Safety and
Indigenous Australians, see age of Indigenous
Quality in Health Care
Australians
‘active ageing’, 48
injuries, 22, 89, 90, 142, 143, 144; burden of
activity, see disability and functioning; physical disease, 85–7
activity
kidney disease, 122
acute coronary events, see coronary heart disease
life expectancy, see life expectancy
acute hospital care, 413 medicines dispensed to, 406–7
mental health seclusion events, 474–5 mental health, see age and mental health
stroke, 116 mothers, 248, 249, 443; method of delivery, 446
adalimumab, 409 older people, see age of older people
additional diagnoses, see comorbidities opioid pharmacotherapy treatment clients, 152, 469
administration, expenditure on, 59, 61, 63 oral health, 153, 154
administrative data, secondary use of, 72–8 overweight and obesity, 233–4, 237
admitted patients, see hospitals and hospitalisations physical activity, 225–6
adolescents, see children and young people prisoners, 301–2
advanced adenoma, 385 remoteness areas, 259–60
adverse events in hospitals, 27, 422–6 respiratory conditions, 85–7, 128, 129, 290, 291
complications of medical and surgical care, 423, same-sex couples, 284
426–7 smokers, 200; pregnant women, 249
advertising of food, 240 veterans, 290–1
aero-medical health services, 269 see also children and young people; infants; older
affective disorders, 132, 218, 280, 292 people
see also depression age and burden of disease, 84–7
aflibercept, 409 coronary heart disease, 86, 87, 111
African migrants, 272, 275 kidney disease, 122
after-hours GP consultations, 267, 394–5 stroke, 115
Healthdirect Australia GP helpline calls, 396 age and cancer, 103
burden of disease, 86, 87
522
deaths, 89, 90 age-standardised death rates, 88
mesothelioma, 107–8 asthma, 129
radiotherapy treatment, 436, 437 cancer, 92, 105
age and cardiovascular disease, 94, 111 chronic obstructive pulmonary disease (COPD),
burden of disease, 86, 87, 111, 115 92, 129
deaths, 89, 90, 112, 115–16 communicable diseases, 158
hospitalisations, 113, 116 culturally and linguistically diverse populations, 273
veterans, 290, 291 diabetes, 92, 119
age and mental health, 94, 132, 133 Indigenous Australians, 92, 142, 380
burden of disease, 85–7, 209 injuries, 142

eating disorders, 136 potentially avoidable deaths, 265
illicit drug users, 219–21 remoteness areas, 92, 264–5
veterans, 291 respiratory conditions, 129
age at death, 88, 89–90, 98 socioeconomic groups, 92
cardiovascular disease, 89, 90, 112, 115–16 suicide, 92, 380
children, 22, 23, 316–17 age-standardised hospitalisation rates
communicable diseases, 158 cardiovascular disease, 113, 355
diabetes, 119 communicable diseases, 158
injuries, 142 hysterectomy, 452
perinatal mortality, 444 Indigenous Australians, 355
respiratory conditions, 129 injuries, 143, 355
suicide, 293, 294 kidney disease, 122
see also life expectancy; premature death potentially preventable hospitalisations, 274
age of children and young people, 7 respiratory conditions, 130, 355
alcohol first tried, 204 age-standardised rates
cigarette first smoked, 200 cancer, 103–4; melanoma, 170
at death, 22, 23, 316–17 cervical cancer screening, 384, 385
ear disease and hearing loss, 320, 321, 322, 323; diabetes, 118
hospital procedures, 327 end-stage kidney disease (ESKD), 22
gestational, see gestational age Indigenous Australians, 332
immunisation and vaccination, 26, 27, 377–8 overweight and obesity, 189, 237
oral health, 153 physical activity, 332
overweight and obesity, 233–4 smoking, 24
physical activity, 225, 226 stroke, 115
age of hospital patients, 98 age-standardised rates burden of disease (DALY
cardiovascular disease, 113, 116 rate), 11
ear diseases and hearing loss, 327 remoteness areas, 264
emergency department presentations, 430 due to risk factors, 191, 202
injuries, 22, 143, 144; family, domestic and sexual socioeconomic areas, 189
violence victims, 147 aged care, 34, 109
age of Indigenous Australians, 309 ageing of population, 48, 302
at death, 22, 23, 316–17 see also older people
ear disease and hearing loss, 320, 321, 322, 323; AHPF, 14–17, 20–8, 418, 454, 456
hospital procedures, 327 aids and appliances, 58, 59, 61, 63
health checks, 354–5 complications of internal devices, 423
immunisation rates for children, 377 hearing aids and cochlear implants, children with, 328
age of older people, 7 air quality, 167–8, 172, 174
burden of disease, 87, 122 aircraft (aero-medical) health services, 269
dementia, 138 aircraft maintenance personnel, 295–7
kidney disease, 121, 122 Alcohol and Drug Foundation, 375
PBS prescriptions, 406, 407 alcohol and other drug treatment services, 151, 206,
physical activity, 225 211, 468–71
523
Alcohol and Other Drug Treatment Services National antenatal risk factors, 248–50
Minimum Data Set (AODTS NMDS), 151, 211, 223, 468–71 antibiotics, 405
alcohol consumption, 24, 25, 204–7, 229 Clostridium difficile treatment, 422
alcohol and other drug treatment services drug of Staphylococcus aureus bacteraemia (SAB)
concern, 206, 469, 470 treatment, 421, 422
burden of disease due to, 85, 188, 192–3, 206 antidepressants and antipsychotics, 210, 473
general practitioner (GP) discussions about, 390 antifungal over-the-counter medicines, 410
health promotion, 375 anxiety disorders, 132, 218
homosexual and bisexual people, 286 burden of disease, 84–6; due to intimate partner
Indigenous Australians, 331, 332; contribution to violence, 195
health gap, 345 LGBTI people, 285
international comparisons, 29, 30 people with disability, 279

people with disability, 280–1 refugees, 275
pregnant women, 249 socioeconomic groups, 258
remoteness areas, 262–3 veterans, 292
socioeconomic groups, 256 see also stress
tobacco smokers, 202 AODTS NMDS, 151, 211, 223, 468–71
alcohol use disorders, 192, 193 Apgar scores, 443
veterans, 292 appendicectomy, 425
young people, 85 appliances, see aids and appliances
alimentary system disorders, see digestive disorders artery bypass graft, 434, 435
all ranks ADF personnel, 294 arthritis and other musculoskeletal conditions, 101,
allergic rhinitis (hay fever), 128, 129 124–7
allergies, 410 burden of disease, 84, 86, 97, 125, 189
allied health services, 266, 388, 391, 392 deaths, 97
Indigenous Australians Medicare claims, 354 general practitioner (GP) consultations, 389
optometrists, 266, 366, 406: see also vision Indigenous Australians, 313
problems and eye diseases medicines dispensed, 126, 404, 409
physiotherapists and physiotherapy, 65, 66, 266, overweight and obese adults, 125, 189, 241
388, 392
prisoners, 302
see also pharmacists; psychologists
remoteness areas, 263
Alzheimer disease, see dementia
arthritis and other musculoskeletal conditions
Amberley Air Force Base, 295–7 hospitalisations, 97, 126, 458
ambulance officers and paramedics, 67 elective surgery, 433, 434; waiting times, 435
ambulance services (patient transport), 58, 59, 61 lumbar spinal decompression, 451
emergency department arrivals by, 431 outpatient clinic service events, 413
expenditure and funding, 63 safety and quality, 425, 427
Royal Flying Doctor Service (RFDS), 269 tissue transplant recipients, 441
suicide-related attendances, 381 veterans, 290, 291
amoxycillin, 405, 406 see also joint replacement surgery
amphetamines (meth/amphetamines), 210, 213, 214–17 asbestos exposure, 106, 107, 108–9
alcohol and other drug treatment services drug of Asian migrants, 271–5
concern, 211, 469, 470
asphyxia and birth trauma, 85
burden of disease due to, 194–5
assault, 90, 146–7, 206
mental illness reported by users, 218–21
see also family, domestic and sexual violence
AMR, 106–10
assisted vaginal deliveries, 427
anaemia, 274
associated causes of death, 88
analgesics (painkillers), 210, 212, 410
chronic kidney disease (CKD), 122
angina, see coronary heart disease
dementia, 139
anorexia nervosa, 135
diabetes, 119
antenatal care, 26, 27, 248
asthma, 128–31, 167
Indigenous women, 353
burden of disease, 85, 97, 129
524
children and young people, 85, 128; treatment National Partnership on Northern Territory
and management, 129, 167 Remote Aboriginal Investment funding, 323
hospitalisations, 97, 130; emergency department private health insurance rebate, 45, 60
presentations during extreme weather events, suicide prevention expenditure, 380
171, 172
Australian Guidelines to Reduce Health Risks from
overweight and obese adults, 241 Drinking Alcohol, 205
remoteness areas, 263 Australian health ministers, see Council of Australian
thunderstorm triggered, 171, 174 Governments Health Council
asthma written action plans, 27, 129 Australian Health Ministers’ Advisory Council, 14, 435
asylum seekers, 275 Australian Health Performance Framework (AHPF),
athletics, 226 14–17, 20–8, 418, 454, 456

Atlas of healthcare variation, 450–3 Australian Health Practitioner Regulation Agency
(AHPRA), 47, 65
atorvastatin, 404, 405, 406, 407
Australian Health Survey (AHS), 227, 245, 341, 342
atrial fibrillation, 140
Australian Hospital Patient Experience Question Set, 456
attempted suicide, 380, 381
Australian Immunisation Register, 379
audiology testing waiting times, 325
Australian Mesothelioma Registry (AMR), 106–10
AusPlay survey, 226
Australian Organ Donor Register, 439
Australia: State of the Environment report, 167, 173
Australian Paired Kidney Exchange Program, 439
Australian Aboriginal and Torres Strait Islander
Health Survey (AATSIHS), 341, 342 Australian Secondary Students’ Alcohol and Drug
Survey, 215
Australian Antenatal Guidelines, 248
Australian Sports Commission, 226
Australian atlas of healthcare variation, 450–3
Australian Statistical Geographical Standard, 259
Australian Burden of Disease Study, see burden of
disease Australian Study of Health and Relationships, 286
Australian Cancer Database, 103 Australia’s National Digital Health Strategy, 70–1
Australian Capital Territory, 171, 181 Australia’s Physical Activity and Sedentary Behaviour
Guidelines, 225
see also states and territories
average age
Australian Charter of Healthcare Rights, 45, 46
alcohol first tried, 204
Australian Child and Adolescent Survey of Mental
Health and Wellbeing, 132, 136 illicit drug users, 212, 213, 214
Australian Childhood Immunisation Register, 379 mothers, 248
Australian Code for the Responsible Conduct of tobacco smokers start, 200
Research, 76 average disposable income, 8
Australian Commission on Safety and Quality in average length of hospital stay, see length of
Health Care (ACSQHC), 19, 46, 418–19 hospital stay
Australian atlas of healthcare variation, 450–3 average weekly total cash earnings, 179
health literacy initiatives, 184 avoidable deaths, see potentially avoidable deaths
patient-reported outcome measures (PROMs), 458
Australian Criminal Intelligence Commission, 215 B
Australian Defence Force (ADF) babies, see births and pregnancy; infants
aircraft maintenance personnel, 295–7 back pain and problems, 97, 124, 125
suicide among contemporary personnel, 74, 292–5 burden of disease, 84, 86, 97, 189
transition into civilian life, 289, 290 hospitalisations, 97, 126
see also veterans overweight and obese adults, 189, 241
Australian Defence Force Mental Health Prevalence remoteness areas, 263
and Wellbeing Study, 292
veterans, 290, 291
Australian Dietary Guidelines, 228–30
bacterial infections, see infections
Australian Drinking Water Guidelines, 168, 174
basketball, 226
Australian Early Development Census, 324
bedrooms, 181
Australian football, 226
beds in hospitals, 412
Australian Government, 42–7, 59–62
international comparisons, 30, 31
child care rebate, 47
behaviours, see health determinants
Immunise Australia Program, 374, 377
benefit-paid pharmaceuticals, see pharmaceuticals
525
Bettering the Evaluation and Care of Health (BEACH) breast cancer, 23, 103, 104
data collection, 33, 325, 389–90, 411, 476 burden of disease, 86; due to risk factors, 188,
binge drinking, see alcohol consumption 189, 190, 193, 197
binge eating disorder, 135 deaths, 90, 91
biological disease-modifying anti-rheumatic drugs medicines dispensed, 408
(bDMARDS), 126 radiotherapy, 436, 437
biomedical risk factors, 245–7 screening (BreastScreen Australia), 27, 384
see also blood pressure; cholesterol and triglycerides breathing threats and problems, 90, 461
birth, life expectancy at, see life expectancy breech births, 446, 447
birth trauma and asphyxia, 85 Britain, see United Kingdom
births and pregnancy, 248–50, 413, 442–9
bronchiectasis, 129
antenatal care, 26, 27, 248, 353 built environment, 181, 238–9, 375
burden of disease associated with maternal and bulimia nervosa, 135
neonatal conditions, 85, 95 bulk-billing, 26, 27, 394
hospital care safety and quality, 424, 426, 427 burden of disease (Australian Burden of Disease
neural tube defects, 376 Study [ABDS]), 11, 84–7, 95–7, 101
see also Indigenous births and pregnancy; infants; arthritis and other musculoskeletal conditions, 84,
mothers 86, 97, 125, 189
birthweight, 22, 23, 443 cancer, see cancer burden of disease
Indigenous babies, 22, 335, 350; attributable to cardiovascular disease, see cardiovascular disease
social determinants, 336 burden of disease
perinatal death rates, 444 communicable diseases, 95, 156
bisexual, people identifying as, see lesbian, gay, dementia, see dementia and Alzheimer disease
bisexual, transgender and intersex people burden of disease
bladder cancer, 197 diabetes, see diabetes burden of disease
bladder examination (cystoscopy), 433, 434 ear disease and hearing loss, 320
waiting times, 435 gastrointestinal infections, 85, 169
blood-borne viruses, see sexually transmissible injuries, 84–7, 95, 142, 151, 188
infections and blood-borne viruses international comparisons, 29
blood glucose regulation, 245 kidney disease, see kidney disease burden of disease
blood lipids, see cholesterol and triglycerides mental health, see mental health burden of disease
blood medicines, 404 oral health, 153
blood pressure (hypertension), 245, 246 remoteness areas, 113, 117, 264
burden of disease due to, 112, 140 respiratory conditions, 84–7, 97, 129, 168, 202
Indigenous Australians, 345 socioeconomic groups, 258
overweight and obese adults, 241 see also premature death
pharmaceuticals (medicines), 112, 245, 246, 405 burden of disease due to risk factors, 186–99
remoteness areas, 263 air quality, 167–8
socioeconomic groups, 256 alcohol use, 85, 188, 192–3, 206
blood sugar levels, see diabetes atrial fibrillation, 140
bodily pain, see pain blood pressure, 112, 140
body weight, see overweight and obesity; underweight cholesterol, 112
bones, see arthritis and other musculoskeletal diabetes, 140, 196–8
conditions family, domestic and sexual violence (intimate
bowel cancer (colon/colorectal cancer), 22, 23, 103, 104 partner violence), 146, 195
aircraft maintenance personnel, 296 food safety, 169
burden of disease due to risk factors, 189, 190, 197 illicit drug use, 188, 192, 193–5, 209
deaths, 90, 91 kidney disease, 140, 197
screening, 27, 385 occupational exposures and hazards, 125
survival after, 30 overweight and obesity, 112, 125, 140, 188–9, 240
treatment patterns, 74 physical inactivity, 112, 140, 188, 190–1
boys, see age; children and young people; sex (gender) stroke, 140
brain cancer, 90 sun exposure, 170
tobacco smoking, 112, 140, 202
526
Bureau of Meteorology, 168, 171, 174 capital cities, 181
bushfires, 171–2, 174 air quality, 167
hazard reduction burning, 168 green space, 181
The Butterfly Foundation, 135 same-sex couples, 284
bypass graft, 434, 435 see also remoteness areas
capital expenditure, 58, 59
C cardiac rehabilitation programs, 69
caesarean section deliveries, 442–3, 445–9 cardiomyopathy and heart failure, 90, 91, 113, 122
calcium channel blockers, 112 cardiovascular disease (circulatory system diseases,
CVD), 94, 101, 111–17
camplyobacertiosis, 156, 157

burden of disease, see cardiovascular disease
Canada, 456
burden of disease
see also international comparisons
cardiac arrest during bushfires, 172
Canberra, 171, 181
general practitioner (GP) consultations, 389
see also capital cities
Indigenous Australians, 113, 117, 313
cancer, 22, 23, 103–10
medicines, 112, 246, 403–4, 405, 406, 407
aircraft maintenance personnel, 295–6
overweight and obese adults, 241
burden of disease, see cancer burden of disease
prisoners, 302
data linkage, 73, 74
remoteness areas, 92, 113, 263
deaths, see cancer deaths socioeconomic groups, 257
hospitalisations, 97, 458, 477; outpatient clinic veterans, 290, 291
service events, 413
see also blood pressure; cholesterol and
medicines dispensed, 404, 408, 409 triglycerides; coronary heart disease; stroke
overweight and obese adults, 188–9, 241 cardiovascular disease burden of disease, 84, 86, 87,
prisoners, 302 97, 111–12, 115
radiotherapy, 74, 413, 436–8 population groups, 113, 117
see also bowel cancer; breast cancer; cervical as risk factor, 140
cancer; lung cancer; melanoma; prostate cancer; cardiovascular disease burden of disease due to risk
survival after cancer factors, 112, 188, 202
Cancer Australia, 104 air quality, 167–8
cancer burden of disease, 84, 86, 87, 97 chronic kidney disease (CKD), 122, 197
socioeconomic groups, 258 diabetes, 196–7
cancer burden of disease due to risk factors, 188 overweight and obesity, 112, 189
air pollution, 168 physical inactivity, 112, 188, 190
alcohol use, 188, 192–3 tobacco use, 112, 202
chronic kidney disease (CKD), 197 cardiovascular disease deaths, 88–92, 112, 115–16
diabetes, 197 international comparisons, 29, 30
overweight and obesity, 188–9 population groups, 92, 113, 117; culturally and
physical inactivity, 188, 190 linguistically diverse populations, 273
sun exposure, 170 premature mortality (fatal burden of disease), 99,
tobacco use, 202 111, 112
cardiovascular disease hospitalisations, 34, 97, 116
cancer deaths, 88–92, 97, 99, 105
after air pollution exposure, 168
fatal burden of disease due to risk factors, 168, 170
elective surgery, 434, 435
mesothelioma, 106, 108
heart transplants, 440
socioeconomic groups, 257
hospital-acquired complications, 426
cancer of unknown or ill-defined primary site, 91
hospital-acquired diagnoses, 424
cancer screening, 27, 384–6
Indigenous Australians, 117
cannabis (cannabinoids), 212–13, 215–17
population groups, 113, 117, 355; culturally and
alcohol and other drug treatment services drug of
linguistically diverse populations, 274
concern, 211, 469, 470
cars, see motor vehicles; transport accidents
casemix costs per separation, 21
hospitalisations, 210
casual sex, 286
mental disorders among users, 218–21
cataracts, 425, 433, 435
527
Census of Population and Housing 2016 physical activity, 225, 226, 227, 375
culturally and linguistically diverse populations, same-sex couples with, 284
271, 274 tobacco smoke exposure in home, 25, 200;
health workforce not registered, 67 Indigenous, 324
homeless people, 181, 300 tobacco smoking, 200, 332
Indigenous Australians, 308 see also age; infants
same-sex couples, 284 Chinese migrants, 271, 273, 274
cephalexin, 405, 406 chiropractors, 266, 392
cereal (grain) foods, 228 chlamydia, 23, 156, 157
cerebrovascular disease, see stroke Cholecystectomy, 433, 435
cervical cancer, 22, 23 cholesterol and triglycerides (abnormal blood lipids,

Human Papillomavirus (HPV) vaccination dyslipidaemia), 245, 246
program, 34, 378 coronary heart disease (CHD) burden of disease
screening program, 27, 384–5; Indigenous due to, 112
women, 386 medicines, 112, 245, 403–4, 405, 406, 407; people
Charlson Index, 341 with measured dyslipidaemia not using, 246
check-ups ‘Choosing Wisely Australia’, 184
dental visits, 154 chronic conditions, see diseases and illness
Indigenous Australians, 354–5; children, 323, 325 chronic kidney disease, see kidney disease
chemists, see pharmacists chronic obstructive pulmonary disease (COPD), 128–31
chemotherapy, 408 burden of disease, 84, 86, 87, 97, 129; due to air
pollution, 168
chickenpox, 376
deaths, 88–92, 97, 99, 129; population groups,
child care, 47 257, 273
Child Health Check Initiative, 323 emergency department presentations during
childhood immunisation, 26, 27, 374, 377–8, 379 extreme weather events, 172
‘No Jab, No Pay’ policy, 47 hospitalisations, 97, 130; potentially preventable, 274
children and young people, 7 overweight and obese adults, 241
alcohol consumption, 85, 204, 205 socioeconomic groups, 257
arthritis, 126 veterans, 290, 291
asthma and respiratory conditions, 85, 128; cigarettes, see tobacco smokers
treatment and management, 129, 167 circulatory system diseases, see cardiovascular disease
burden of disease, 85 cities, see capital cities; remoteness areas
deaths, 89, 90: see also infant deaths CKD, see kidney disease
developmentally vulnerable, 180 Clare Oliver: No Tan is Worth Dying For, 174
diet and nutrition, 228, 229, 374; school canteen classifications, 88, 277, 428
traffic light approach, 239
body mass index (BMI), 231–2
family, domestic and sexual violence, 147, 148;
witnessed by, 146 caesarean section rates, 446–7
health promotion campaigns aimed at, 374 disability, 277
hospitalisations, 98, 167 hospital-acquired diagnoses, 424
Human Papillomavirus (HPV) immunisation rates, 378 remoteness areas, 259
illicit drug use, 215–16, 217, 218 socioeconomic groups, 256
Indigenous Australians, see Indigenous children cleaners, 67
and young people clerks, 67
injury emergency department presentations, 144 climate change, 173, 175
meningococcal disease serogroup C (MenC) heat-related deaths attributable to, 171
immunisation program, 159 Clinical Quality Registers, 419, 428
mental health, 85, 132, 180, 218; eating disorders, clinical treatments, see procedures and treatments
136–7
clinicians, see medical practitioners
oral health, 153, 169; dental service attendance, 154
Closing the Gap targets, 316–19
overweight and obesity, see overweight and obese
children and young people Clostridium difficile, 422
COAG, see Council of Australian Governments
528
cocaine, 213–14, 215–17 coronary heart disease, 111–14
burden of disease due to, 194–5 hospitalisations, 113, 440; elective surgery waiting
hospitalisations, 210 times, 434, 435
mental illness reported by users, 218–19 medicines prescribed, 112, 407
cochlear implants and hearing aids, children with, 328 see also heart attacks
codeine, 150, 152, 212 coronary heart disease burden of disease, 84, 86, 87,
111–12, 113
cold and cough medicines, 410
coronary heart disease burden of disease due to risk
colon/colorectal cancer, see bowel cancer factors, 112
commercial cleaners, 67 air quality, 167–8
commissioned ADF officers, 294 chronic kidney disease (CKD), 197

Commonwealth Government, see Australian diabetes, 196–7
Government
overweight and obesity, 112, 189
Commonwealth Integrating Authorities, 74, 75
physical inactivity, 112, 190
Commonwealth Scientific and Industrial Research
coronary heart disease deaths, 88–92, 112, 113
Organisation, 396
associated causes, 122, 167–8
communicable diseases, 156–61, 169, 376
burden of disease, 95, 156
costs
see also immunisation and vaccination; sexually
transmissible infections; vaccine preventable diseases alcohol abuse, 204
communication with health professionals, 184, 282 eating disorders, 135
community health services food spending, 239
expenditure and funding, 59, 61; per person, 63 hospitals, 181, 282
mental health, 473; eating disorder contacts, 136, 137 overweight and obesity, 241–2
community pharmacies, see pharmacists and social determinants, effect of, 181
pharmacies suicide death, 380
comorbidities (additional diagnoses), 48, 94, 101 tobacco smoking, 202
arthritis and other musculoskeletal conditions, 124 see also out-of-pocket expenses
chronic kidney disease (CKD), 122, 197 costs, health service use delayed or not used
dementia, 140 because of, 154, 393–4
diabetes, 197 people with disability, 282, 283
mental health, 218 remoteness areas, 267
see also associated causes of death; health cough and cold medicines, 410
determinants Council of Australian Governments (COAG), 18
complaints handling mechanisms, 47 Closing the Gap targets, 316–19
complications of medical and surgical care, 423, 426–7 National Health Reform Agreement, 14, 48
conceptual framework, 14–16 National Healthcare Agreement, 18
condoms, 286 Council of Australian Governments Health Council
(health ministers), 14, 21, 42
conduct disorders, 85
digital health priorities, 70
congenital conditions, see infant and congenital
conditions health literacy statement, 184
congestive cardiac failure (CCF), 274 National Strategic Framework for Chronic
Conditions, 100
consumer protection, see regulation and consumer
protections regulation and consumer protections initiatives,
46, 47
contagious diseases, see communicable diseases
sentinel events core set, 426
contributing causes of death, see associated causes
of death crystal methamphetamine, see amphetamines
Coordination of Health Care Study, 397, 464–7 culturally and linguistically diverse populations, 271–6
COPD, see chronic obstructive pulmonary disease BreastScreen Australia participation, 384
core activity limitations, see disability and functioning health literacy, 183
corneal transplants, 441 curative radiotherapy treatments, 436–7
coronary angiography, 113 CVD, see cardiovascular disease
Coronary artery bypass graft, 434, 435 cystoscopy, 433, 434
waiting times, 435
529
D physical activity, 225, 226, 227
primary health care, 389–90, 391, 397–8
daclatasvir, 409
prisoners, 301, 302–3
daily drinking, see alcohol consumption
radiotherapy, 438
daily smoking, see tobacco smokers
remoteness areas, 259, 269
dairy products, 228, 374
respiratory conditions, 128, 131
DALYs, see burden of disease
social health determinants, 182
Data Integration Partnership for Australia, 74
data linkage (integration), 33–4, 73–5, 428, 466
stroke, 117
data sources, gaps and deficiencies, 32–5, 101
tobacco smoking, 203
alcohol and other drug treatment services, 471
variation in health care measures, 450–3

alcohol consumption, 206–7
veterans, 74, 288, 290–8
arthritis and other musculoskeletal conditions,
124, 127 see also classifications; definitions; standards
biomedical risk factors, 247 data sources, gaps and deficiencies for health
system, 50
births and pregnancy, 444, 446–7, 448
digital health, 71
burden of disease, 87, 95, 96; due to risk factors,
192, 198 health expenditure and funding, 56–7, 63–4;
suicide prevention, 380
cancer, 103, 105; mesothelioma, 106, 109–10
health workforce, 67; supply for Indigenous
communicable diseases, 156, 157, 160–1
population, 257–9, 369
coordination of health care, 397, 464, 466
secondary use of health information, 77
coronary heart disease, 114
data sources, gaps and deficiencies for hospitals, 414
culturally and linguistically diverse populations,
elective surgery, 435
271, 275
emergency departments, 430, 432
deaths and causes of death, 88, 92; suicide
prevention, 380, 381, 382–3 funding for admitted patient care, 415, 417
dementia, 138, 139, 141 organ and tissue donation, 441
diabetes, 118, 120 safety and quality, 420, 421, 423, 424–5, 427–9
diet, 229–30 data sources, gaps and deficiencies for Indigenous
Australians, 308, 310–11, 312, 314–15
disability, 277, 279, 282, 283
cervical cancer screening, 386
environmental health, 175
deaths, 319
family, domestic and sexual violence, 149
ear health and hearing loss, 322–4, 329
health literacy, 183–4, 185
health behaviours, 334
health promotion, 376
health gap, 341, 342, 350–1
hospitals, see data sources, gaps and deficiencies
for hospitals health service access and use, 356
illicit drug use, 208, 210–11, 215, 219, 223 health workforce supply, 357–9, 369
immunisation and vaccination, 378, 379 social determinants, 336, 337
Indigenous Australians, see data sources, gaps day hospitals, see same-day hospitalisations
and deficiencies for Indigenous Australians days of patient care, see patient days
injuries, 145 deaths and causes of death, 88–93, 96, 97
international comparisons, 31 aircraft maintenance personnel, 295, 297
kidney disease, 123 Australian Defence Force (ADF) personnel, 292–5
LGBTI people, 284–7 bush-fire related, 168, 171
mental health, 132, 133, 134, 475–6; eating cancer, see cancer deaths
disorders, 135, 136, 137 cardiovascular disease, see cardiovascular disease
opioid harm, 150–2 deaths
oral health, 153–5 children, 89, 90: see also infant deaths
overweight and obesity, 238, 242 communicable diseases, 157, 158, 376
palliative care, 478 culturally and linguistically diverse populations, 273
patient experience and outcome measures, 454–62 data linkage, 73, 74
performance indicators, 28 dementia and Alzheimer disease, 88–91, 122, 139, 257
pharmaceuticals (medicines), 411 diabetes, 90–2, 97, 99, 119; Indigenous
530
Australians, 92, 120 delivery and delivery methods (births), 427, 442–3, 445–9
drug-induced, 151, 209–10 perineal tears hospitalisation rate, 451
gastroenteritis, 169 dementia and Alzheimer disease, 138–41
heat-related, 171 deaths, 88–91, 122, 139; socioeconomic groups, 257
home tele-monitoring systems, reductions caused international comparisons, 29, 30
by, 396 dementia and Alzheimer disease burden of disease,
homicide, 147, 192, 193 84, 87, 139
in hospital, 477 due to risk factors, 122, 139–40, 189, 190, 197
Indigenous Australians, see Indigenous deaths socioeconomic groups, 258
injuries, see injury deaths denosumab, 409

kidney disease, 122 dental assistants, 67
organ and tissue donations after, 439–41 dental caries, 85, 153, 169
waiting for organ transplant, 441 dental services and oral health, 153–5, 391, 392
palliative care, 477–8; patient-reported outcome burden of disease, 85
measures, 460–1 expenditure and funding, 44, 59, 61, 154; per
perinatal, 444: see also infant deaths person, 63
potentially avoidable, 26, 27, 257, 265 medicines, 406; over-the-counter, 410
remoteness areas, see remoteness areas, deaths outpatient clinic service events, 413
and causes of death in people with disability, 282
respiratory conditions, see respiratory conditions remoteness areas, 269
deaths
water fluoridation, 169
socioeconomic groups, see socioeconomic groups
dentists, 65, 66
and areas, deaths and causes of death in
PBS prescriptions, 406
suicide, see suicide
remoteness areas, 266, 362
tobacco smoking, 202
women, 67
see also associated causes of death
workforce supply for Indigenous population,
decayed teeth (dental caries), 85, 153, 169
362–3, 366
deceased organ donors, 439–41
dentists, visits to, 154, 388, 455
decisions, patient involvement in, 184, 465
costs as reason for delaying or not seeking care,
deep vein thrombosis, post-operative, 427 282, 393–4
Defence Suicide Database, 74 remoteness areas, 267
definitions, 4–5 Department of Defence, 289
adverse events, 422 Department of Health, 166, 232, 325
Australian Defence Force (ADF) personnel, 292 Department of Veterans’ Affairs (DVA), 74, 288, 289,
chronic conditions, 94 290, 297
culturally and linguistically diverse (CALD) see also veterans
populations, 271 depression and depressive disorders
digital health, 72 antidepressant prescriptions, 473
disability, 277 burden of disease, 85, 86; due to intimate partner
elective surgery, 435 violence, 195
emergency department waiting time, 431 refugees, 275
environmental health, 166 young cannabis users, 218
fully immunised children, 378 see also suicide
heatwave, 171 Dermatological and plastic procedures, 433
illicit drug use, 208 Deseal/Reseal (DSRS) programs, 295–7
determinants, see health determinants
natural environment, 166
developmentally vulnerable children, 180
quality, 418
diabetes, 101, 118–20, 245
safety, 418
deaths, 90–2, 97, 99, 119
seclusion, 474
GP annual cycle of care completions, 21
secondary use, 72
hospitalisations, 97, 119, 120; potentially
thunderstorm asthma, 171 preventable, 268
veterans, 288
Indigenous Australians, 92, 120
see also classifications; standards
medicines prescribed, 119, 405
531
overweight and obese adults, 188, 189, 241 disposable income, see income
prisoners, 302 distress, see psychological distress; stress
remoteness areas, 92, 120, 263, 268 doctors, see medical practitioners
socioeconomic areas and groups, 92, 120, 258 domestic violence, see family, domestic and sexual
veterans, 290, 291 violence
diabetes burden of disease, 86, 87, 97, 118 donepezil, 140
due to risk factors, 188, 189, 190 DPP4 inhibitors, 119
population groups, 120 drink driving, 206
as risk factor, 140, 196–8 drinking, see alcohol consumption
diagnosis, cancer incidence by stage at, 104 drinking water, see water quality
diagnostic imaging, 354, 388, 394 drought, 172

dialysis, 122, 355 drowning, 90
diet and nutrition, 228–30, 375 Drug and Alcohol Program, 375
children and young people, 228, 229, 374; school drug dependence (drug use disorders), 194, 209
canteen traffic light approach, 239 comorbidity with mental health issues, 218
eating disorders, 135–7 drugs, 208–24
folic acid fortification, 376 alcohol and other drug treatment services, 151,
food advertising, 240 206, 211, 468–71
food portion sizes, 238 burden of disease due to, 188, 192, 193–5, 209
food safety, 169 health promotion, 375
general practitioner (GP) discussions about, 390 homosexual and bisexual users, 217, 222, 286
see also fruit and vegetable intake; overweight Indigenous users, 336–7
and obesity injecting practices, 24, 25; burden of disease due
digestive disorders to, 194–5
general practitioner (GP) consultations, 389 opioid harm, 150–2
Indigenous hospitalisations, 355 opioid treatment outcomes, 73
medicines dispensed, 404, 405, 406, 407 prisoners using, 218, 301
over-the-counter medicines, 410 tobacco smokers using, 202
digital health, see technology see also alcohol consumption; pharmaceuticals;
tobacco smokers
dipeptidyl peptidase 4 inhibitors, 119
dyslipidaemia, see cholesterol and triglycerides
diphtheria, 374
disability-adjusted life years, see burden of disease
disability and functioning, 22, 23, 277–83 E
Indigenous Australians, 313, 314 ear health and hearing loss, 320–30, 434
people with long-term conditions, 99 early life, see births and pregnancy; children and
young people; infants
prisoners, 301
eating, see diet and nutrition
psychiatric disability, 475
eating disorders, 135–7
after stroke, 115
ecstasy, 213, 214, 215–17
see also burden of disease
mental illness reported by users, 218–21
discrimination or unfair treatment, 282
Ecstasy and Related Drugs Reporting System, 219
diseases and illness, 82–161
edentate people, 154
culturally and linguistically diverse populations, 272–5
education and educational attainment, 8, 24, 25, 179
Indigenous Australians, 313–14, 341–2
developmentally vulnerable children, 180
overweight and obese adults, 241
health literacy, 183, 184
prisoners, 301, 302
health workers, 67, 325, 362, 364
social determinants, effect of, 181
illicit drug users with mental illness, 222
see also arthritis and other musculoskeletal
conditions; burden of disease; cancer; prisoners, 300
cardiovascular disease; communicable diseases; remoteness areas, 261
deaths and causes of death; dementia; dental same-sex couples, 284
services and oral health; diabetes; digestive
disorders; hospitals and hospitalisations; injuries; school-based health promotion campaigns, 374,
respiratory conditions 382; immunisation and vaccination, 374, 378
532
school food facilities, 239 eondometrial ablation, 451
students using illicit drugs, 215 epilepsy, 193
education and educational attainment of Indigenous equivalised disposable household income, 24
Australians, 310 Indigenous Australians, 310, 349
contribution to health gap, 345–7, 348, 349 ESKD, see kidney disease
self-assessed health status, 336 esomeprazole, 404, 405, 406, 407
tobacco smokers, 337 etanercept, 409
elective surgery, 27, 49, 433–5 European migrants, 271–2, 273, 274
electronic devices, adolescents using, 240 ‘Every cigarette is doing you damage’ campaign, 375
emergency department presentations, 414, 430–2 exercise, see physical activity

during extreme weather events, 171, 172 expenditure, see health expenditure
injuries, 144 external causes, see injuries
mental health, 473 extreme weather events, 171–3, 174–5
patient experience, 455, 465 eye problems, see vision problems and eye diseases
people with disability, 281–2
potentially avoidable GP-type, 21, 282
remoteness area presentations, 267
F
F-111 aircraft maintenance personnel, 295–7
waiting times, 26, 27, 49, 431–2
falls
Emergency emergency department presentations,
431, 432 burden of disease, 87; due to alcohol use, 193
emergency hospital admissions, 416 deaths from, 142, 143
coronary heart disease (CHD), 113 hospitalisations, 143
emergency radiotherapy treatment, 436, 437 resulting in patient harm in hospitals, 27, 424–5
emotional distress, 341–2 families, see households
see also psychological distress family, domestic and sexual violence (intimate
partner violence), 47, 146–9
emphysema, see chronic obstructive pulmonary disease
burden of disease due to, 188, 195
employment and unemployment, 48, 180, 239
pregnant women, 249
illicit drug users, 217; with mental illness, 222
farmers, 172
Indigenous Australians, 310, 336–7; contribution
to health gap, 345–7, 349; psychological distress, fatalities, see deaths
reason for, 314 fatigue, 461
occupations, 179 fats intake, 229
people with long-term conditions, 99 fear caused by alcohol-related incidents, 206
prisoners, 300 Federal Government, see Australian Government
remoteness areas, 261, 262 females, see sex (gender); women
same-sex couples, 284 fentanyl, 150
tobacco smokers, 201, 336–7 Fetal Alcohol Spectrum Disorder, 249
see also health workforce; occupational exposures filicide, 147, 148
end-stage kidney disease, see kidney disease finance, see costs; health expenditure and funding
endocrine disorders fingolimod, 409
burden of disease, 86, 87; due to risk factors, 188 first aid and sports medicine over-the-counter
general practitioner (GP) consultations, 389 products, 410
see also diabetes first-time mothers, 248, 443, 446, 447
English as a second language speakers, 271, 272 fitness/gym activities, 226
health literacy, 183 Flinders Centre for Innovation, 74
Indigenous Australians, 310 flu, 156, 157, 158
English migrants, 271, 273, 274 flu and pneumonia deaths, 91
Enhanced Primary Care services, 390–1 fluoridation of water, 169, 374
environmental health determinants, 25, 166–78 fluorometholone, 406
ear disease and hearing loss in children, 324 folic acid fortification, 376
obesogenic, 238–40 food, see diet and nutrition
Environmental Health Standing Committee, 174 ‘Food for All’ program, 375
533
Food Standards Australia New Zealand food recalls, 169 potentially avoidable emergency department
foot care over-the-counter medicines, 410 presentations, 21, 282
football, 226 preferred GP not seen, 267

prescriptions, 267, 390, 406; palliative-care
foreign body left in during procedure, 426, 427
related, 478
fractures, 144
remoteness areas, 267–8, 395
Framework for Australian Clinical Quality Registries, 419
time taken, 267, 455
free sugars intake, 229
waiting time, 267, 282, 454
fruit and vegetable intake, 25, 228 generic brand medicines, 410
Indigenous Australians, 331, 332, 336–7; genitourinary diseases, 355, 404
contribution to health gap, 345
genomic testing, 49
full-time equivalent (FTE) health workforce

employment, 26, 65–6 geographical areas, see remoteness areas
mental health services, 474 Geographically-adjusted Index of Relative Supply

(GIRS), 357–69
German migrants, 273, 274
functioning, see disability and functioning
gestational age, 443, 447
funding, see health expenditure and funding
antenatal visits, 248
perinatal death rates, 444
G gestational diabetes, 118, 119, 120
galantamine, 140 girls, see age; children and young people; sex (gender)
gastrointestinal diseases and disorders, 169 ‘Girls Make Your Move’, 375
burden of disease, 85, 169 Global Action Plan for the Prevention and Control of
camplyobacertiosis, 156, 157 NCDs, 2013–2020, 99
Clostridium difficile, 422 Global Burden of Disease Study, 95
hospital-acquired complications, 426 glucose regulation, 245
hospital-acquired diagnoses, 424 golden staph, 421–2
rotavirus, 376 gonorrhoea, 23, 156, 157
gay, people identifying as, see lesbian, gay, bisexual, ‘Good Sports Program’, 375
transgender and intersex people gout, 125, 126
Gay Community Periodic Surveys, 286 government roles and responsibilities, 42–7, 59–63
GDP, health spending as proportion of, 55–6, 57, 402 see also Australian Government; states and
gender, see lesbian, gay, bisexual, transgender and territories
intersex people; sex (gender) grain (cereal) foods, 228
general clerks, 67 Greek migrants, 273, 274
general practitioners (GPs) green space, access to, 181, 238
computer use for clinical purposes, 69 greenhouse gas emissions (GHG), 173, 175
remoteness areas, 266, 360 ‘Grim Reaper’ television advertisements, 375
workforce supply for Indigenous population, gross domestic product (GDP), health spending as
360–1, 366 proportion of, 55–6, 57, 402
general practitioners consultations, 388, 389–91, 455, gum disease, 153
464–6 gym/fitness activities, 226
after-hours, 267, 394–5; Healthdirect Australia GP
helpline calls, 396
arthritis and other musculoskeletal conditions, 126 H
asthma, 129 haemodialysis, 122, 355
bulk-billing, 26, 27, 394 Haemophilus influenza type b, 328
cost, as reason for delay/not seeing, 267, 282, haemorrhage and haematoma, 423
393, 394 hallucinogens, 210
diabetes annual cycle of care patients, 21 hand hygiene compliance in hospitals, 421
ear problems, 325 hay fever, 128, 129
Indigenous Australians, 325, 354 hazard reduction burning, 168
mental health, 473; patients with care plans, 27 headspace, 382
people with disability, 281–2 health-adjusted life expectancy (HALE), 10–11
534
health administration expenditure, 59, 61, 63 health system, 14–15, 20, 26–7, 38–78
health behaviours, see health determinants see also allied health services; health expenditure
health care decisions, patient involvement in, 184, 465 and funding; health workforce; hospitals and
hospitalisations; primary health care
health care history, GP/place of care awareness of, 465
Health System Conceptual Framework, 14–16
Health Care Homes Initiative, 48–9, 100
Health System Performance Logic Model, 15, 17
health check-ups, see check-ups
health workforce (health professionals), 65–8
health classifications, see classifications
expenditure and funding on, 44, 58, 59, 61; per
Health Council, see Council of Australian
person, 63
Governments Health Council
Indigenous population, supply for, 357–69
health data, see data sources, gaps and deficiencies
mental health services, 474, 476

health determinants (risk factors; health behaviours),
14–15, 24–5, 164–250 palliative care, 478
Indigenous health gap, 343–9 registration, 47, 65–7
international comparisons, 29 remoteness areas, 67, 266; supply for Indigenous
population, 360, 362, 364
see also alcohol consumption; biomedical risk
factors; diet and nutrition; drugs; overweight and see also pharmacists
obesity; physical activity; tobacco smokers Healthdirect Australia, 184, 396
health expenditure and funding, 42, 43–5, 54–64 Healthy Active by Design website, 375
dental services, 44, 59, 61, 154 Healthy Food Partnership, 375
home tele-monitoring systems, reductions caused healthy migrant effect, 272, 273
by, 396 healthy soldier effect, 290
international comparisons, 30, 31 hearing aids and cochlear implants, children with, 328
mental health services, 473 hearing and ear health, 320–30, 434
pharmaceuticals (medicines), see pharmaceuticals heart attacks, 22, 23
expenditure and funding
cardiac rehabilitation programs (CRPs), 69
primary health care, 58, 387
deaths, 112
research, see research expenditure
hospitalisations, 34, 113
suicide prevention activities, 380
medicines, 407
see also costs; private sector expenditure and funding
heart failure and cardiomyopathy, 90, 91, 113, 122
health gap, 316–19, 339–52
Heart Foundation, 375
health indicators, see performance indicators
heart transplants, 440
health insurance, see Medicare; private health insurance
heatwaves, 170, 175
health literacy, 25, 183–5, 375
‘Hello Sunday Morning’, 375
about mental illness, 218; refugees, 275
hepatitis B, 22, 23
Health Literacy Survey, 183
burden of disease due to illicit drug use, 193, 194
health ministers, see Council of Australian
Governments Health Council hepatitis C, 22, 23
Health Ministers’ Advisory Council, 14, 436 burden of disease due to illicit drug use, 194
health performance, see performance indicators deaths, 158
health professionals, see health workforce medicines, 408–9
health promotion, 374–6 prisoners, 301
SunSmart campaigns, 174, 375 herniorrhaphy, 433, 435
health regulation, see regulation and consumer heroin, 150, 209
protections alcohol and other drug treatment services drug
health research expenditure, see research expenditure of concern, 151, 469, 470
health risk factors, see health determinants opioid pharmacotherapy treatment, 470
health screening, see cancer screening Hib, 328
‘Health Star Rating System’, 375 high blood pressure, see blood pressure
health status, 4–5, 14–15, 22–3 high body weight/mass, see overweight and obesity
international comparisons, 29 high cholesterol, see cholesterol and triglycerides
see also deaths; disability and functioning; high income groups, see income
diseases and illness high sugar levels, see diabetes
Highly Specialised Drugs Program, 401
535
hip replacements, 126, 433, 434, 458 injuries, see injury hospitalisations
readmissions after surgery, 425 kidney disease, 122, 123; Indigenous Australians
waiting times, 435 dialysis-related, 355
HIV, 22, 23 mental health, see mental health hospitalisations
burden of disease due to illicit drug use, 194 organ and tissue transplants, 122, 439–41
‘Grim Reaper’ advertisements, 375 palliative care, 477
due to male-to-male sex, 286 patient experience, 455, 458–62, 466
medicines, 286 people with disability, 282, 283
home potentially preventable, see potentially
preventable hospitalisations
children and young people’s screen-based
remoteness areas, see remoteness areas,
activities, 240
hospitals and hospitalisations in
children exposed to tobacco smoke in, 25, 200;
Indigenous, 324 respiratory conditions, see respiratory conditions
hospitalisations
Indigenous Australians feeling safe/very safe at, 336
socioeconomic groups and areas, 113, 117, 120,
Indigenous languages spoken at, 310 123; patient type, 417
internet access, 72 Statistical Area Level 3 (SA3) rates, 451–2
tele-monitoring systems, 396 suicidal ideation and suicide attempts, 381
home ownership, Indigenous, 310 weight-loss surgery procedures, 242
home self-care over-the-counter medicines, 410 see also acute hospital care; emergency
homeless people, see housing and homelessness department presentations; private hospitals;
homicide, 147, 192, 193 public hospitals
homosexual, people identifying as, see lesbian, gay, hospitals and hospitalisations expenditure and
bisexual, transgender and intersex people funding, 42, 43, 44, 58, 59, 61, 387
hormonal medicines, 404 admitted patient care, 415–17
hospital-acquired complications, 426–7 per person, 63
hospital-acquired diagnoses, 424 hours worked, 239
hospital beds, 412 contribution to health gap, 345–7, 349
international comparisons, 30, 31 household income, see income; socioeconomic
groups and areas
hospitals and hospitalisations, 41–2, 96–8, 412–35
Household, Income and Labour Dynamics in
adverse events, see adverse events in hospitals
Australian Survey, 259
alcohol-related, 206
households
arthritis, see arthritis and other musculoskeletal
conditions hospitalisations
Indigenous, 310, 324
births, see births and pregnancy
internet access at home, 72
cancer, 97, 458, 477; outpatient clinic service
events, 413 jobless families, 180
cardiovascular disease, see cardiovascular disease overcrowding, 181
hospitalisations same-sex couples, 284
casemix costs per separation, 21 with tobacco smokers, 203; children’s exposure,
communicable diseases, 157, 158 25, 200, 324
data linkage, 74 housing and homelessness, 47, 180–1, 203, 375
dementia, 140 Indigenous Australians, 181, 310, 324;
diabetes, 97, 119, 120, 268
prisoners, before entering prison, 300
drug-related, 151, 210
see also home
elective surgery, 27, 49, 433–5
human immunodeficiency virus, see HIV
emergency department patients admitted, 144, 431
Human Papillomavirus (HPV) vaccination program,
gastroenteritis, 169
34, 378
home tele-monitoring systems, reductions caused
hypertensive diseases, see blood pressure
by, 396
hysterectomy, 425, 433, 435, 451–2
Indigenous Australians, see Indigenous
hospitalisations Hysteroscopy, dilation and curettage, 433, 435
536
I suicide prevention services, 382
syphilis outbreak, 160
ice, see amphetamines
tobacco smokers, see Indigenous tobacco smokers
illicit drugs, see drugs
Indigenous births and pregnancy, 335–6, 442
illness, see diseases
antenatal care, 353
imaging services, 354, 388, 394, 413
birthweight, 22, 335, 350; attributable to social
immigrants, see culturally and linguistically diverse
determinants, 336
populations
caesarean section, 443
immunisation and vaccination, 26, 27, 374, 376, 377–9
midwives workforce supply to population, 364–5,
GP visits, 390
366
Human Papillomavirus (HPV), 34, 378
neural tube defects, 376

Indigenous children, 328, 377
primary health care services, 353
invasive meningococcal disease, 159, 160
smoking during pregnancy, 318, 336
Immunise Australia Program, 374, 377
Indigenous children and young people, 309, 335–6
Impact of alcohol and illicit drug use on the burden of
birthweight, 22, 335, 350; attributable to social
disease and injury in Australia, 209
determinants, 336
deaths, 316–18
inactivity, see physical activity
ear health and hearing loss, 320–30
inanimate mechanical force, injury due to, 143
fruit and vegetable intake, 332
income, 8, 24, 25, 179
immunisation and vaccination, 328, 377
health literacy, 183
overweight and obesity, 333
Indigenous Australians, 310, 337; contribution to
physical activity, 332
health gap, 345–7, 349
tobacco smokers, 332
same-sex couples, 284
Indigenous deaths, 91–2, 316–19
see also socioeconomic groups and areas
Index of Relative Socio-economic Disadvantage
(IRSD), 256 coronary heart disease, 92, 113
Indian migrants, 272, 273, 274 diabetes, 92, 120
indicators of health, see performance indicators infants, 22, 23, 316–18
Indigenous Australians, 306–69 injuries, 142
alcohol and other drug treatment services clients, life expectancy, 23, 316, 318–19
468, 469 psychological distress, reason for, 314
births, see Indigenous births and pregnancy stroke, 117
burden of disease, 113, 117, 120, 123; ear disease suicide, 92, 380
and hearing loss, 320 Indigenous health gap, 316–19, 339–52
cancer incidence by stage at diagnosis, 104 Indigenous hospitalisations, 355
cancer screening, 384, 386 coronary heart disease, 113
cardiovascular disease, 92, 117, 313, 355 diabetes, 120
children, see Indigenous children and young people ear and mastoid process diseases, 326–9
chronic kidney disease (CKD), 123; dialysis-related elective surgery waiting times, 434
hospitalisations, 355
emergency department presentations, 430;
deaths, see Indigenous deaths mental health related, 473
dementia, 138 health expenditure per person, 63
diabetes, 92, 120 hysterectomies, 451
geographical location, see remoteness areas, injuries, 143; intentional self-harm, 381
Indigenous Australians in
kidney disease (CKD), 123
health expenditure per person, 62–3
stroke, 117
hospitalisations, see Indigenous hospitalisations
Indigenous languages, 310, 311
housing, 181, 310, 324; contribution to health
gap, 345 Indigenous-specific primary health care services
(ISPHCS), 353, 388
invasive meningococcal disease, 160
Indigenous tobacco smokers, 331–2, 336–7
mental health, 314, 353, 355, 473
children’s exposure, 324
overweight and obesity, 234
contribution to health gap, 345–7, 349
prisoners, 300
537
pregnant women, 318, 336 Indigenous Australians, 355, 381
primary health care programs, 353 suicidal ideation and suicide attempts, 381
individual out-of-pocket expenses, see out-of-pocket instrumental vaginal deliveries, 427
expenses insulin, 118, 119
induced labour, 442 insurance, see Medicare; private health insurance
infant (perinatal) and congenital conditions intensive care units, 70
burden of disease, 85 influenza admissions, 157
cause of death, 89, 90, 444; Indigenous infants, 318 neonatal and special care nurseries admissions,
neural tube defects, 376 443, 444
intentional injury, see suicide and self-inflicted injuries
infant deaths, 22, 23, 98
Intergenerational report, 48
cause, 89, 90, 318

internal organ injuries, 144
Indigenous, 22, 23, 316–18
internal prosthetic devices, complications of, 423
perinatal, 444
international comparisons, 29–31
infants
air quality, 167
birthweight, see birthweight
antibiotic prescribing, 405
burden of disease, 85 burden of disease, 95–6
emergency department presentations, 430 caesarean section deliveries, 445
immunisation, 26, 27, 374, 377–8, 379; ‘No Jab, No health expenditure, 56–7
Pay’ policy, 47
health workforce, 66
see also births and pregnancy
hospital patient safety, 427
infections hours worked, 239
antibiotics, see antibiotics mesothelioma, 82
burden of disease, 87 overweight and obesity, 30, 231
Clostridium difficile, 422 International Consortium For Health Outcomes
following procedure, 423, 427 Measurement, 458
hospital acquired complications, 426 International Statistical Classification of Diseases
lower respiratory, 87, 158 and Related Health Problems (ICD), 88, 277, 428
Staphylococcus aureus bacteraemia (SAB), 421–2 internet, 69, 72
see also otitis media intersex, people identifying as, see lesbian, gay,
bisexual, transgender and intersex people
infectious diseases, 156–61
intimate partner violence, see family, domestic and
see also communicable diseases; immunisation sexual violence
and vaccination; sexually transmissible infections
intracranial injuries, 144
influenza, 156, 157, 158
invasive meningococcal disease, 159–60
influenza and pneumonia deaths, 91
iodine, 375
information technology, see technology
Iraqi refugees, 275
Inguinal herniorrhaphy, 433, 435
irbesartan, 405
injecting drug practices, 24, 25
IRSD, 256
ISPHCS, 353
injuries and other external causes, 142–5
Italian migrants, 273, 274
burden of disease, 84–7, 95, 142; due to risk
factors, 151, 188
bush-fire related, 171 J
see also falls; poisoning; transport accidents jobless families, 180
injury deaths, 89, 90, 142–3 jobs, see employment
Indigenous infants, 318 jogging and athletics, 226
poisoning, 89, 90, 143, 151 joint replacement surgery, 126, 458
see also suicide elective, 433, 434; waiting times, 435
injury hospitalisations, 22, 23, 143–4 living tissue donors, 440
emergency department presentations, 144 safety and quality, 425, 427
falls, 143; resulting in patient harm in hospitals, juvenile arthritis, 126
27, 424–5 juveniles, see children and young people
family, domestic and sexual violence victims, 146–7
538
K linguistically diverse background, see culturally and
linguistically diverse populations
Kessler-5, 341
lip cancer, 105
key performance indicators, see performance indicators
lipid disorders, see cholesterol and triglycerides
kidney cancer, 197 listen carefully, health professionals who, 455
kidney disease (acute kidney injury [AKT], chronic/ live births, see births and pregnancy
end-stage kidney disease [CKD/ESKD]), 22, 23, 101,
121–3 liver cancer, 193, 194, 197
overweight and obese adults, 241 liver disease, 193, 194
remoteness areas, 123, 264 liver transplants, 439, 440
socioeconomic groups, 257 living organ donors, 439, 441

kidney disease burden of disease, 122, 196–8 living tissue donors, 440
dementia burden due to, 140, 197 local governments, 43, 64, 169
due to overweight and obesity, 188, 189 Local Hospital Networks, 42

location birth took place, 442
population groups, 123, 264
long-term conditions, see diseases and illness
kidney replacement therapy (KRT), 121, 122, 439–41
low income groups, see income
dialysis, 122; Indigenous Australians, 355
lower respiratory infections, 87, 158
kitchen hands, 67
lumbar spinal decompression, 451
knee replacements, 126, 458
lung cancer, 22, 23, 103
aircraft maintenance personnel, 296
readmissions after surgery, 425
burden of disease, 84, 86, 87, 168, 258
Korean migrants, 273, 274
deaths, 88–92, 257; fatal burden of disease
attributable to air pollution, 168
L incidence by stage at diagnosis, 104
labour, see births and pregnancy radiotherapy, 436
labour force, see employment; health workforce socioeconomic groups, 257, 258
land transport accidents, see transport accidents lung transplants, 440
languages, see English as a second language lymphomas, 296
latanoprost, 406
lead, 167 M
ledipasvir + sofosbuvir, 409 macular degeneration, 409
length of hospital stay, 413 major cities, see capital cities; remoteness areas
elective surgery, 433 Malaysian migrants, 273, 274
home tele-monitoring systems, reductions caused males, see men
by, 396
managers, 179
stroke, 116
marijuana, see cannabis
see also overnight hospitalisations; patient days;
maternity, see births and pregnancy
same-day hospitalisations
meal times, 239
lesbian, gay, bisexual, transgender and intersex
people (LGBTI, sexual orientation), 284–7 measles, 377
illicit drug users, 217, 286; with mental illness, 222 median age
male-to-male sex, 286; syphilis notifications, 160 at death, 265
tobacco smokers, 201, 286 Indigenous Australians, 309
‘Life. Be in it’ campaign, 375 opioid pharmacotherapy treatment clients, 152
life expectancy, 3, 10–11, 23 same-sex couples, 284

median elective surgery waiting times, 434–5
Indigenous Australians, 23, 316, 318–19
median equivalised disposable household income, 24
obese people, 240
medical discharge from ADF, 294
medical practitioners, 26, 27, 65, 66–7, 455
Life Saving Drugs Program, 402
Lifeline, 382
remoteness areas, 266–7
lifestyle behaviours, see health determinants
see also general practitioners; specialist medical
practitioners
539
medical research expenditure, see research expenditure prisoners, 218, 301
Medical Research Future Fund, 49 refugees, 275
medical services expenditure and funding, 44–5, 58–9, 61 tobacco smokers, 201, 202
per person, 63 veterans, 290, 291, 292–5
medical technicians, 67 see also depression; neurological (nervous
Medicare (Medicare Benefits Schedule [MBS]), 44–5, system) conditions; stress
49, 100 mental health burden of disease, 84–6, 97, 133, 209
allied health services claims, 354, 392 eating disorders, 135
bulk-billing, 26, 27, 394 due to risk factors, 188, 193, 194, 195
data linkage, 73 socioeconomic groups, 258
Enhanced Primary Care services, 390–1 suicide, 84–6, 134, 380

home tele-monitoring systems and video mental health hospitalisations, 41, 97, 458, 473, 474–5
conferencing rebates and incentives, 396 admitted patient expenditure, 413
Indigenous Australians’ claims, 354–5 eating disorders, 136
information not covered by service data, 33 Indigenous Australians, 355
mental health-related services subsidised, 473 mental health nurses, 474
weight-loss surgery procedures billed, 242 mesothelioma, 105, 106–10
see also general practitioners consultations metformin, 119, 405
Medicare levy, 44 methadone, 152, 470
surcharge, 45 methamphetamines, see amphetamines
medicinal cannabis, 212 methicillin resistant/sensitive Staphylococcus aureus
medicines, see pharmaceuticals (MRSA/MSSA) cases, 421, 422
melanoma, 22, 23, 103, 170 methylphenidate, 406
aircraft maintenance personnel, 296 middle ear infections, see ear health and hearing loss
incidence by stage at diagnosis, 104 Middle East, migrants from, 272, 275
pembrolizumab, 408 midwives, see nurses and midwives
SunSmart campaigns, 174 migrants, see culturally and linguistically diverse
Melbourne, 181, 275, 375 populations
memantine, 140 milk products, 228, 374
men, 288 Misadventures to patients during surgical and medical
care, 423
testicular cancer, 105
mood (affective) disorders, 132, 218, 280, 292
see also prostate cancer; sex (gender)
see also depression
meningococcal disease, 159–60
morbidity, see disability and functioning; diseases
menstrual bleeding, 451
morphine, 150, 152
mental health and mental health services, 47, 94,
132–7, 392, 472–6 mortality, see deaths
care models, 48 Mortality and Cancer Incidence Study, 295–7
children and young people, 85, 132, 180, 218; mortgages, Indigenous households with, 310
eating disorders, 136–7 mothers, 248–50, 442–3
deaths, 97: see also suicide and self-inflicted injuries alcohol consumption during pregnancy, 249
farmers experiencing drought, 172 antenatal care, 26, 27, 248, 353
general practitioner (GP) consultations, 389; care Indigenous women, 335–6, 353, 442, 443;
plans, 27 midwives workforce supply to, 364–5, 366
hospitalisations, see mental health method of birth, 442–3, 445–9, 451
hospitalisations perineal tears, 451
illicit drug users, 213, 217–22 see also reproductive and maternal conditions
Indigenous Australians, 314, 353, 355, 473 mothers smoking during pregnancy, 179, 248–9
LGBTI people, 285 birthweight, 336
migrants, 272 Indigenous women, 318, 336
overweight and obese adults, 241 motor vehicles and drivers, 374
patient experience measure, 457 driving under influence of alcohol, 206
patient outcome measures, 458 see also ambulance services; transport accidents
people with disability, 279–80 motorcyclists, 193, 194, 374
540
mouth and pharyngeal cancer burden of disease, National Health Survey (NHS), 94, 99, 185, 245
192, 193 arthritis and other musculoskeletal conditions, 124
multiple births, 443, 446, 447 coronary heart disease, 111
multiple causes of death, see associated causes of death diabetes, 118
multiple chronic conditions, see comorbidities disability, 277
multiple sclerosis, 409 physical activity, 225, 226, 227
musculoskeletal conditions, see arthritis and other respiratory conditions, 128
musculoskeletal conditions
veterans, 290–2
My Health Record, 49, 69–71, 76–7
National Health Workforce Dataset, 65–7
MyHealthyCommunities website, 14, 20
National Healthcare Agreement, 18
MyHospitals website, 14, 20

National Hospital Morbidity Database (NHMD), 415,
Myringoplasty/tympanoplasty, 326, 327, 434 420, 441
drug-related admissions, 151, 210
N National Immunisation Program Schedule, 377–8
narcotic drugs, see drugs National Integrated Health Services Information
Narcotic Drugs Amendment Act 2016, 212 Analysis Asset, 34
National Aboriginal and Torres Strait Islander Social National Maternity Data Development Project
Survey, 310 Advisory Group, 446
ear health and hearing loss, 322, 324 National Mental Health and Suicide Prevention Plan,
380, 383, 457
National Aboriginal and Torres Strait Islander Survey,
329 National Mental Health Commission, 474
National Bowel Cancer Screening Program, 27, 385–6 National Mortality Database, 74, 151
National Centre for Monitoring Chronic Conditions, 101 National Non-Admitted Patient Emergency
Department Care Database (NNAPEDCD), 430, 432
National Cervical Screening Program, 27, 384–5, 386
National Notifiable Diseases Surveillance System,
National Child Oral Health Study, 153, 154
156–60, 169
National Clean Air Agreement, 174
National Nutrition and Physical Activity Survey, 227, 238
National Code of Conduct for non-registered health
National Nutrition Survey, 238
care workers, 47
National Opioid Pharmacotherapy Statistical Annual
National Core Maternity Indicators, 448
Data (NOPSAD) collection, 152, 468
National Death Index, 74
National Partnership on Northern Territory Remote
National definitions for elective surgery urgency categories Aboriginal Investment, 322
proposal for the Standing Council on Health, 435
National Perinatal Data Collection, 336, 446
National Dental Telephone Interview Survey, 154
The National Plan to Reduce Violence against
National Digital Health Strategy, 70–1 Women and their Children, 195
National Disability Insurance Scheme (NDIS), 278, National Prisoner Health Data Collection (NPHDC),
279, 283, 475 300, 302
National Drug Strategy 2017–2026, 208 National Registration and Accreditation Scheme, 47, 65
National Drug Strategy Household Survey (NDSHS), National Safety and Quality Health Service
150, 208, 211–14, 218–19 Standards, 419, 450
alcohol consumption, 204, 206; during pregnancy, 249 National Statement on Ethical Conduct in Human
LGBTI, people identifying as, 284, 285, 286 Research, 76
mental illness, 218–21 ‘National statement on health literacy’, 184
smoking, 200, 202 National Strategic Framework for Chronic
Conditions, 100
National Environment Protection Measure for
Ambient Air Quality, 167 National Suicide Prevention Strategy (NSPS), 380, 381
National Health Act 1953, 400, 401 National Survey of Adult Oral Health, 153
s100 medicines, 401, 407–8 National Survey of Mental Health and Wellbeing,
132, 133, 285, 380
National Health and Medical Research Council, 169
National Survey of People with Psychotic Illness, 132
alcohol guidelines, 205, 229
National Wastewater Drug Monitoring Program, 215
dietary guidelines, 228–9
natural environment, see environmental health
National Health Performance Framework (NHPF), 14,
15, 20, 21, 28 natural health medicines, 410
National Health Reform Agreement, 14, 48 natural therapies, 392
541
NDIS, 278, 279, 283, 475 mental health services, 474
NDSHS, see National Drug Strategy Household Survey palliative care, 478
needles, unsafe sharing of, see injecting drug practices PBS prescriptions, 406
neonatal intensive care units and special care visits to, 388
nurseries. admission to, 443, 444 workforce supply for Indigenous population,
neonates, see births and pregnancy; infants 364–5, 366
neoplasms, see cancer nursing support and personal care workers, 67
netball, 226 nutrition, see diet and nutrition
neural tube defects, 376
neurological (nervous system) conditions, 84, 87, 389 O
medicines dispensed, 404, 409 obesity, see overweight and obesity

see also dementia obstetrics services, see births and pregnancy
New South Wales, 160, 171, 174 occupational exposures
child care, 47 arthritis and other musculoskeletal conditions, 125
dementia hospitalisations, 140 asbestos, 106, 108–9
hazard reduction burning near Sydney, 168 occupational therapists, 266
heatwave plan, 175 occupations, 179, 239
overweight and obese children and young people, see also health workforce
240; school canteen traffic light approach, 239
odds ratio for being in good health, 346–9
Richmond Air Force Base, 295–7
OECD, 56–7, 427, 458
Your Experience of Service Survey, 457
New Zealand, 462
oesophageal cancer, 189
migrants from, 271, 273, 274
Office of the Australian Information Commissioner, 47
older people, 7, 34
NHMRC, see National Health and Medical
Research Council burden of disease, 86–7, 122
NHPF, 14, 15, 20, 21, 28 chronic obstructive pulmonary disease (COPD),
128
NHS, see National Health Survey
deaths, 89, 90, 98
nitrogen dioxide, 167
dementia, see dementia
NNAPEDCD, 430, 432
diabetes, 86, 87, 118
‘No Jab, No Pay’ policy, 47
emergency department presentations, 430
non-admitted patients, 412, 413
kidney disease, 121, 122
see also emergency department presentations
life expectancy, 10
non-government sector, see private sector
medicines dispensed to, 406–7
non-Hodgkin lymphoma, 296
oral health, 154
non-referred medical services, 44, 59, 388
physical activity, 225, 226
prisoners, 301–2
non-school qualifications, see education
see also age
Non-urgent emergency department presentations,
431, 432 open data, 77
NOPSAD collection, 152, 468 open wounds, 144
Northern Territory, 160 operations, see procedures and treatments
Child Health Check Initiative, 323 Ophthalmology surgery waiting times, 434
Northern Territory Emergency Response (NTER), 323, 326 opioid pharmacotherapy treatment, 152, 469, 470
Northern Territory Remote Aboriginal Investment opioids, 73, 150–2
Hearing Health Program (NTRAI), 323, 328 burden of disease due to, 194–5
notifiable diseases, 156–61, 169 deaths, 151, 210
see also cancer hospitalisations, 151, 210
see also heroin
NPS MedicineWise, 184
optometry, see vision problems and eye diseases
nurses and midwives, 26, 27, 65–6
oral health, see dental services
hospital patients’ experience, 455
organ and tissue donation, 122, 439–41
542
Organisation for Economic Co-operation and weight management and sports nutrition
Development, 56–7, 427, 458 over-the-counter medicines, 410
see also international comparisons see also underweight
organised sport, 226, 337 oxycodone, 150, 152
orthopaedics, see arthritis and other musculoskeletal
conditions
osteoarthritis, 125, 126, 189, 263
P
pain, 99
osteoporosis, 124, 126, 241, 409
mothers in labour, 442
Other diagnoses of complications of medical and
surgical care, 423 palliative care patients, 461
Other external causes of adverse events, 423 painkillers (analgesics), 210, 212, 410

otitis media, 320–1, 322, 323 palliative care, 460–1, 477–8
environmental factors, 324 Palliative Care Outcomes Collaboration, 460–1
health care, 325 palliative radiotherapy treatments, 436–7
out-of-pocket expenses (individual funding), 43, 59–61 pancreas transplants, 440
dental expenses, 154 pancreatic cancer, 105, 197
private health insurance, 45 pantoprazole, 404, 405, 407
weight-loss surgery costs, 242 paracetamol, 390
out-of-pocket expenses for medicines, 400, 403 parents, 147, 148
over-the-counter, 410 partner violence, see family, domestic and sexual
violence
palliative care, 478
passive smoking by children in home, 25, 200
outer regional areas, see remoteness areas
Indigenous, 324
outpatient clinics, 413
pathology, 354, 386, 388, 394
over-the-counter medicines, 390
outpatient clinic service events, 413
codeine products, 150, 212
patient days, 413
spending on, 410
Staphylococcus aureus bacteraemia rates per, 421
overcrowding in households, 181, 324
see also length of hospital stay
patient experience and outcome measures, 184,
overnight hospitalisations, 413 454–63, 465
funding sources, 415, 416 people with disability, 282
mental health-related, 473 remoteness areas, 267
see also length of hospital stay; same-day Patient Experience Survey, 154, 277, 282, 454–6
hospitalisations
patient transport, see ambulance services
overseas-born population, see culturally and
linguistically diverse populations Paying the price: the economic and social impact of
eating disorders in Australia, 135
overseas comparisons, see international comparisons
PBS, see pharmaceuticals
overseas-trained registered health professionals, 67
pembrolizumab, 408, 409
overweight and obese children and young people,
24, 233–4, 237 per person drug-induced death rates, 209
Indigenous Australians, 333 per person health expenditure, 55
measuring, 232 Indigenous health, 62–3
obesogenic environment, 239–40 mental health services, 473
socioeconomic areas, 235 per person primary health care claims, 388
overweight and obesity, 25, 231–44 Performance and Accountability Framework, 14, 15
burden of disease due to, 112, 125, 140, 188–90, performance indicators, 13–35
240; combined with insufficient physical activity, 191 caesarean sections, 448
general practitioner (GP) discussions about, 390 hospital safety and quality, 27, 420–7
Indigenous Australians, 331, 333, 348, 349; patient experience, 456
contribution to health gap, 345–7, 348, 349 patient outcome measures, 458–62
international comparisons, 30, 231 perinatal and congenital conditions, see infant and
pregnant women, 249 congenital conditions
remoteness areas, 235–6, 262–3 perinatal mortality, 444
socioeconomic groups, 234–5, 256 see also infant deaths
543
perindopril, 405 people with disability, 280–1
perineal tears, 451 remoteness areas, 226, 262–3
peripheral vascular disease, 122, 197 socioeconomic groups, 226, 256
personal problems, talking with GP/place of care see also overweight and obesity
about, 465
Physical Activity and Sedentary Behaviour Guidelines, 225
Personal Safety Survey, 249
physicians, see medical practitioners
pertuzumab, 408
physiotherapists and physiotherapy, 65, 66, 266, 388, 392
pharmaceutical poisoning, see poisoning
place of birth, 442
pharmaceuticals (prescription and non-prescription
medicines/medications, Pharmaceutical Benefits PM2.5, 167
Scheme [PBS] and Repatriation Pharmaceutical pneumonia and influenza deaths, 91
Benefits Scheme [RPBS]), 100, 388, 390, 400–11, 466 podiatrists and podiatry, 266, 392
adverse effects, 423 poisoning, 150
arthritis and other musculoskeletal conditions, burden of disease due to drug use, 193, 194, 209
126, 404, 409
deaths, 89, 90, 143, 151
blood pressure management, 112, 245, 246, 405
emergency department presentations, 144
cholesterol management, 112, 245, 246, 407;
population, 7–8
statins, 403–4, 405, 406, 407
see also age; sex (gender)
costs as reason for delaying or not filling
prescriptions, 393–4 population ageing, 48, 302
data linkage, 73 see also older people
dementia, 140 population growth, 55, 167
diabetes, 119, 405 remoteness areas, 8
expenditure and funding, see pharmaceuticals population health programs, 375
expenditure and funding Population Health Research Network, 74
hospital acquired complications, 426 Post-procedural disorders, 423, 424
mental health, 473 post-school qualifications, see education
misuse, 150–2, 212, 216 post-traumatic stress disorder, 275
opioids, see opioids potential years of life lost, see burden of disease
palliative care, 478 potentially avoidable deaths, 26, 27
prescribing errors, 70 remoteness areas, 265
remoteness area prescriptions, 267 socioeconomic groups, 257
social determinants, effect of, 181 potentially avoidable GP-type emergency
department presentations, 21, 282
see also immunisation and vaccination
potentially preventable hospitalisations, 26, 27
pharmaceuticals expenditure and funding, 44, 58, 59,
402–3, 407–10 culturally and linguistically diverse populations, 274
home tele-monitoring systems, reduction caused dental conditions, 154
by, 396 Indigenous Australians, 355
palliative-care medications, 478 remoteness areas, 268
per person, 61 Staphylococcus aureus bacteraemia (golden staph,
source of funds, 61 SAB) cases, 421–2
pharmacists and pharmacies, 70, 388, 400 workforce supply correlation, 359
remoteness areas, 266 pre-exposure prophylaxis for HIV prevention (PrEP), 286
workforce supply to Indigenous population, 366 pregabalin, 409
pharyngeal and mouth cancer burden of disease,
pregnancy, see births and pregnancy
192, 193
premature death (fatal burden of disease), 11, 98
Philippines, migrants from, 273, 274
due to air pollution, 167–8
physical abuse (assault), 90, 146–7, 206
see also family, domestic and sexual violence due to alcohol use, 192, 193, 206
physical activity and inactivity, 25, 72, 225–7, 231 coronary heart disease, 111, 112, 167–8
built environment affects, 181, 238–9 dementia, 139
burden of disease due to, 112, 140, 188, 190–1 gastrointestinal infections, 169
general practitioner (GP) discussions about, 390 global initiatives to reduce, 99
health promotion, 375 due to illicit drug use, 194
Indigenous Australians, 331, 332, 337; due to overweight and obesity, 188, 190, 240
contribution to health gap, 345 due to partner violence, 195
544
suicide and self-inflicted injuries, 84–6, 193, 194, procedures and treatments
195, 380 arthritis and other musculoskeletal conditions,
see also age at death; life expectancy; potentially 126, 433, 434, 435
avoidable deaths; survival cancer, 74, 413, 436–8
prescription medicines, see pharmaceuticals coronary heart disease, 69, 113, 434, 435, 440
pressure injuries, 426 diabetes, 118, 119
preterm births, 443 ear and mastoid process diseases, 326–9
complications, 85 elective surgery, 433, 434–5
Price Disclosure Policy, 410 end-stage kidney disease (ESKD), see kidney
primary health care, 33, 387–99 replacement therapy
eating disorders, 136 genomic testing, 49

expenditure and funding, 58, 387 opioid pharmacotherapy, 152, 469, 470
Indigenous Australians, 353–5, 388; ear problems, 325 organ and tissue donations, 122, 439–41
musculoskeletal conditions, 126 outpatient clinics, 413
outpatient clinic service events, 413 rehabilitation, see rehabilitation hospital care
remoteness areas, 267–8 safety and quality, 423–4
see also general practitioners specialist doctor’s explanation of choices,
understandability of, 184
Primary Health Networks (PHNs), 41, 42, 382, 475
Statistical Area Level 3 (SA3) rates, 451–2
overweight and obesity prevalence among, 236
weight-loss surgery, 242
Primary Mental Health Care Minimum Data Set, 475
see also pharmaceuticals
principal diagnoses, see hospitals and
hospitalisations Productivity Commission, 34, 75, 429
prisoners, 218, 300–3 profound activity limitations, see disability and functioning
privacy, see regulation and consumer protections prophylactic radiotherapy treatments, 436, 437
Privacy Act 1988 (Cwlth), 75 prostate cancer, 103, 104, 462
private health insurance, 45, 47 aircraft maintenance personnel, 296
health system funding paid by, 60–1; admitted deaths, 91
patients at least partially funded by, 415–17 radiotherapy waiting times, 437
people with dental and allied health cover, 391, 392 survival after, 105
Private Health Insurance Ombudsman, 47 Prostate Cancer Outcomes Registry, 462
private health insurance rebate, 45, 60 prostatectomy, 425
private hospitals, 42, 412–14 prostheses, see aids and appliances
accident and emergency services, 414, 432 provider-to-population ratios, 358–9
adverse events, 423 psychiatric disability, 475
births in, 442, 446 psychiatrists, 474
elective surgery, 433 psychological distress, 23, 125
expenditure and funding, 44, 58, 59, 61, 416; per illicit drug users, 213, 217, 218, 220–1
person, 63 Indigenous Australians, 314
falls resulting in patient harm in, 424 LGBTI people, 285, 286
hand hygiene compliance, 421 people with disability, 280
hospital-acquired diagnoses, 424 people with long-term conditions, 99
mental health services staff, 474 psychologists, 64, 65, 474
Staphylococcus aureus bacteraemia (SAB) cases, 421 remoteness areas, 266
suicidal ideation and suicide attempts, 381 workforce supply for Indigenous population, 366
private patients, 45 psychotic illness, 132, 218, 473
private sector expenditure and funding, 44, 59, 64 PTSD, 275
see also out-of-pocket expenses; private health public dental services, 282
insurance public health expenditure, 59, 61
private sector services, 42 per person, 63
dental consultations, 154 Public Hospital Pharmaceutical Reforms, 411
expenditure and funding, 44 public hospitals, 41, 42, 412–14
radiotherapy sites, 436 adverse events, 423
see also general practitioners; pharmacists and births in, 442; caesarean sections, 445
pharmacies; private hospitals Clostridium difficile cases, 422
545
elective surgery, 27, 49, 433–5 remoteness areas (major cities, regional and
falls resulting in patient harm in, 424 remote), 8, 259–70
hand hygiene compliance, 421 births and pregnancies, 353; ISPHCS services, 353
hospital-acquired diagnoses, 424 cardiovascular heart disease, 92, 113, 117, 263
medicine supplies not covered by PBS/RPBS, 403, 411 cervical cancer screening, 384
mental health services, 473 diabetes, 92, 120, 263, 268
private patients, 45 general practitioner (GP) consultations, 267; not
seeing after-hours when needed, 395
public patients, see public patients
health workforce, 67, 266; supply for Indigenous
Staphylococcus aureus bacteraemia (SAB) cases, 421–2
population, 360, 362, 364
suicidal ideation and suicide attempts, 381
illicit drug users, 194–5, 217; with mental illness, 222
weight-loss surgery procedures, 242

Indigenous Australians, see remoteness areas,
public hospitals expenditure and funding, 42, 43, 44, Indigenous Australians in
58, 59, 61
kidney disease, 123, 264
admitted patient care, 415, 416–17
overweight and obesity, 235–6, 262–3
medicine supplies not covered by PBS/RPBS, 403
physical activity, 226, 262–3
per person, 63
tobacco smokers, 201, 262–3, 324, 332
sentinel events link, 420
see also states and territories; Statistical Area Levels
public patients, 44, 45, 415–17
remoteness areas, burden of disease in, 264
outpatient clinic patients, 413
due to alcohol use, 193
public radiotherapy sites, 436
pulmonary embolism, post-operative, 427
diabetes, 120
PwC Australia, 241
due to illicit drug use, 194–5
kidney disease, 264
Q respiratory conditions, 129
qualifications, see education stroke, 117
Queensland, 457 remoteness areas, deaths and causes of death in, 91,
Amberley Air Force Base, 295–7 92, 264–5
‘Question builder’, 184 chronic kidney disease (CKD), 123
quitting smoking, 202, 203 coronary heart disease, 92, 113
cessation products, spending on, 410 diabetes, 92, 120
Indigenous Australians, 332 injuries, 142
over-the-counter medicines, 410 stroke, 117
remoteness areas, hospitals and hospitalisations in,
R 268–9
radiotherapy, 74, 436–8 chronic kidney disease (CKD), 123
outpatient clinic service events, 413 coronary heart disease, 113
rainfall, 172 diabetes, 120
ranibizumab, 409 ear and mastoid process diseases, 327
readmissions after surgery, 425 hysterectomies, 451
receptionists, 67 patient type, 416
recurrent expenditure, see health expenditure and potentially preventable hospitalisations, 268
funding stroke, 117
referred medical services, 388, 390 remoteness areas, Indigenous Australians in, 62, 261
expenditure and funding, 44, 58, 59, 61 ear disease and hearing loss, 322–3, 324; health
refugees, 275 care, 325, 327, 328
regional areas, see remoteness areas physical activity, 332
registration of health professionals, 47, 65–7 primary health care services, 353
regulation and consumer protections, 45–7, 49 self-assessed health status, 312–13
My Health Record, 70–1 syphilis infections, 160
secondary use of health information, 75–6 tobacco smokers, 332; households with children, 324
rehabilitation hospital care, 413 workforce supply for population, 360, 362
stroke, 116 renin-angiotensin system agents, 112
546
renters, Indigenous, 310
Repatriation Pharmaceutical Benefits Scheme
S
(RPBS), 400–1, 402 safe at home, Indigenous Australians feeling, 336
see also pharmaceuticals safety and quality, 450

Report on Government Services (RoGS), 15, 18 hospital care, 27, 418–29
reproductive and maternal conditions, 451–2 mental health services, 474–5
elective surgery, 433, 435 sales workers, 179
gestational diabetes, 118, 119, 120 salmonellosis, 169
hysterectomies, 425, 433, 435, 451–2 salt, 229, 375
research expenditure, 43, 49, 58, 59 same-day hospitalisations (day hospitals), 413
per person, 63 funding sources, 415, 416

source of funds, 61 same-sex couples, 284
residential aged care, 109 saturated and trans fats intake, 229
respect, health professionals showing, 455 schizophrenia, 473
respiratory conditions, 101, 128–31 schooling, see education
burden of disease, 84–7, 97, 129; due to risk Scottish migrants, 273, 274
factors, 168, 202 screen-based activities, 240
children and young people, 85, 128, 129, 167 seatbelts, 374
general practitioner (GP) consultations, 389 seclusion events in mental health care settings, 474–5
Indigenous Australians, 313 secondary health services, see hospitals and
medicines dispensed, 404 hospitalisations; specialist medical practitioners
see also asthma; chronic obstructive pulmonary secondary students using illicit drugs, 215
disease; influenza secondary use of health information, 72–8
respiratory conditions deaths, 88–92, 97, 99, 129
sedentary behaviour, see physical activity
influenza, 157, 158
self-assessed health status, 12, 23
population groups, 257, 273
health service costs as reason for delaying or not
thunderstorm asthma, 171 seeking care, 393
respiratory conditions hospitalisations, 97, 130 immigrants, 272
after air pollution exposure, 167, 168 Indigenous Australians, 312–13, 336, 341–2, 350–1
emergency department presentations during not seeing after-hours GP when needed, 395
extreme weather events, 171, 172
people not seeking after-hours GP when needed, 393
people with disability, 278
people with long-term conditions, 99
influenza, 157, 158
tobacco smokers, 202
Resuscitation emergency department presentations,
431, 432 veterans, 292
Retained instruments or other material after surgery self-harm, see suicide and self-inflicted injuries
requiring re-operation or further surgical procedure, Semi-urgent emergency department presentations,
426 431, 432
revascularisation, 113 sensory medicines, 404
rheumatoid arthritis, 126, 409 sentinel events, 420, 426
Richmond Air Force Base, 295–7 Sentinel National Bushfire Monitoring System, 174
risk factors, see health determinants ‘separation principle’, 76
rivastigmine, 140 sepsis, post-operative, 427
road traffic accidents, see transport accidents Septoplasty, 434, 435
Robson classification, 446–7 severe activity limitations, see disability and
RoGS, 15, 18 functioning
rosuvastatin, 405, 407 sex (behaviour), 286
rotavirus, 376 see also sexually transmissible infections
Royal Australasian College of Surgeons, 435 sex (gender)
Royal Flying Doctor Service (RFDS), 268, 269 alcohol and other drug treatment services clients,
RPBS, 400–1, 402 468, 469
see also pharmaceuticals alcohol consumption, 24, 84, 192, 193, 229
Rural and Regional Families Survey, 172 arthritis and other musculoskeletal conditions,
84, 86, 124, 125, 189
547
asthma, 85, 128 mesothelioma, 105, 107–8
blood pressure, 245 survival after, 105
burden of disease, see sex (gender) and burden sex (gender) and cardiovascular disease, 115
of disease burden of disease, 84, 86, 111, 115; due to risk
cancer, see sex (gender) and cancer factors, 189, 190, 196–7
cardiovascular disease, see sex (gender) and deaths, 88–9, 90–1, 112, 116
cardiovascular disease heart attack rates, 22
children, see sex (gender) of children and young people sex (gender) and death, 88–9, 90–1, 98
death, see sex (gender) and death cancer, 88–9, 90–2, 105; mesothelioma, 108
dementia, see sex (gender) and dementia coronary heart disease, 88–9, 90–1, 112
diabetes, 90, 91, 118, 189, 190, 196–7 dementia, 88–91, 139
diet, 228, 229; eating disorders, 136 domestic homicides, 148
family, domestic and sexual violence victims, injuries, 142
146–7, 148, 195
stroke, 116
health workforce, 65, 66–7; mental health
services, 474; palliative care, 478 suicide, 293, 380
hospitalisations, see sex (gender) of hospital patients sex (gender) and dementia, 138
illicit drug use, 192, 193, 194, 209 burden of disease, 84, 87; due to risk factors, 189,
190, 197
deaths, 88–91, 139
injuries, see sex (gender) and injuries
sex (gender) and injuries
kidney disease (CKD, ESKD), 22, 189, 197
deaths, 142
life expectancy, see sex (gender) and life
expectancy due to drug use, 193, 194
mental health, 84–6, 473; eating disorders, 135, 136–7 emergency department presentations, 144
older people, see sex (gender) of older people hospitalisations, 143; family, domestic and sexual
violence victims, 146–7
opioid pharmacotherapy treatment clients, 469
sex (gender) and life expectancy, 3, 10–11, 23
overweight and obesity, see sex (gender) and
overweight and obesity Indigenous Australians, 23, 318–19
physical activity, 190–1, 225 international comparisons, 29, 30
prisoners, 300 socioeconomic groups, 179
remoteness areas, 259–60 sex (gender) and overweight and obesity, 233, 234,
235, 237
same-sex couples, 284
burden of disease due to, 188–9, 240
smokers, 24
young people, see sex (gender) of children and
young people waist circumference, 232, 233
sex (gender) and burden of disease, 84–7 sex (gender) of children and young people, 442
due to alcohol use, 84, 192, 193 burden of disease, 85
arthritis and other musculoskeletal conditions, 84, ear disease and hearing loss, 322
86, 125 eating disorders, 136–7
cardiovascular disease, 84, 86, 111, 115; due to Human Papillomavirus (HPV) immunisation rates, 378
risk factors, 189, 190, 196–7 overweight and obesity, 234, 235; Indigenous
chronic kidney disease (CKD), 197 Australians, 333
diabetes, 196–7 sex (gender) of hospital patients, 98
eating disorders, 135 eating disorders, 136
due to illicit drug use, 193, 194, 209 emergency department presentations, 144, 430
due to overweight and obesity, 188–9, 240 injuries, 143, 144; family, domestic and sexual
physical inactivity, 190–1 violence victims, 146–7
sex (gender) and cancer, 103 stroke, 116
bowel cancer screening, 385 sex (gender) of Indigenous Australians
burden of disease, 84; due to risk factors, 189, ear disease and hearing loss, 322
190, 193, 194, 197 life expectancy, 23, 318–19
deaths, 88–9, 90–2, 105, 108 overweight and obesity, 333
melanoma, 103, 170 self-assessed health status, 312, 313
548
sex (gender) of older people prisoners, 300
burden of disease, 87 stroke, 117
life expectancy, 10 tobacco smokers, 200, 201, 256, 337; during
physical activity, 225 pregnancy, 179, 336
sexual health over-the-counter medicines, 410 socioeconomic groups and areas, burden of disease in
sexual orientation, see lesbian, gay, bisexual, coronary heart disease, 113
transgender and intersex people diabetes, 120
sexually transmissible infections and blood-borne kidney disease, 123
viruses, 22, 23, 156, 157, 159, 160 stroke, 117
deaths, 158 socioeconomic groups and areas, burden of disease

illicit drug users: burden of disease due to, 193, 194 in due to risk factors
medicines, 286, 408–9 alcohol use, 193
prisoners, 301 illicit drug use, 194
see also HIV overweight and obesity, 189
siblings, homicide involving (siblicide), 147, 148 physical inactivity, 191
SIDS, 85, 90, 318 respiratory conditions, 129
sitting at leisure, hours per week at, 231 socioeconomic groups and areas, deaths and causes
of death in, 92, 257
skin cancers, 103, 170, 174
see also melanoma
skin disorders
diabetes, 92, 120
stroke, 117
general practitioner (GP) consultations, 389
sodium intake, 229
medicines dispensed, 404
sofosbuvir, 409
sleep time, young people using electronic devices soft-tissue injury, 144
during, 240
South African migrants, 273, 274
sleeping pills/tranquillisers, 212
South Australia, 47
‘Slip, Slop, Slap’ campaign, 375
South Australia Cancer Registry, 74
smartphones, 69
South Korean migrants, 273, 274
smokers of tobacco, see tobacco smokers
special care nurseries and neonatal intensive care
soccer, 226 units. admission to, 443, 444
social costs, see costs specialised alcohol and other drug treatment
social exclusion, 180 services, 151, 206, 211, 468–71
social health determinants, 179–82 specialised mental health services, 472–6
Indigenous health, 335–8, 343–9 eating disorders, 136, 137
see also education; employment; income psychotic illness, 132
social housing waiting lists, 181 see also mental health hospitalisations
specialist medical practitioners, 41, 266, 388, 406, 455
socioeconomic groups and areas, 256–8
bulk-billing rates, 394
births and pregnancy, 179, 336; birthweight, 336
coordination with other health providers, 465
cervical cancer screening, 384
Indigenous Australians’ Medicare claims, 354
palliative care, 478
people with disability visiting, 281, 282
diabetes, 92, 120, 258
ear disease and hearing loss in children, 324
treatment choices, understandability of
health service costs as reason for delaying or not explanation of, 184
seeking care, 393, 394
waiting time to get appointment, 282, 454
hospitalisations, 113, 117, 120, 123; patient type, 417
women, 66
spending, see health expenditure
Indigenous Australians, 336.337 spinal muscular atrophy, 90
overweight and obesity, 234–5, 256 spontaneous labour, 442, 443, 447
physical activity, 226, 256 sport, 226, 337, 375
549
sports medicine and first aid over-the-counter sugar levels in blood, see diabetes
products, 410 suicidality, 133–4, 285, 380, 381
sports nutrition and weight management over-the- suicide and self-inflicted injuries, 89–92, 142, 143, 380–3
counter medicines, 410
Australian Defence Force personnel, 74, 292–5
Sri Lankan migrants, 273, 274
burden of disease, 84–6, 380; due to risk factors,
standard drinks, see alcohol consumption 193, 194, 195
standards, 419, 450 LGBTI people, 285
cultural and language diversity, 275 veterans, 74
sex and gender variables, 286 young people, 85
see also classifications; definitions sulfonylureas, 119
Standards for Statistics on Cultural and Language
sun exposure, 169–70, 174, 375

Diversity, 275
surgery, see elective surgery; procedures
Staphylococcus aureus bacteraemia (SAB), 421–2
Survey of Disability, Ageing and Carers (SDAC), 115,
state and territory cancer registries, 74, 103, 104, 106 277, 282
State Grants (Milk for School Children) Act, 374 Survey of Health Care, 184, 464–6
states and territories, 42, 43, 45–7 survival after cancer, 26, 27, 105
bulk-billing, 394 of colon, 30
cannabis, 212 mesothelioma, 105, 106
elective surgery waiting times, 434 survival after coronary heart disease event, 21
health expenditure and funding, 43, 44, 59–62; Sustainable Development Goals, 99
palliative-care medications, 478
swimming, 226
Indigenous populations, 309
Sydney, 172
influenza activity, 157
Symptom Assessment Scale, 460–1
Local Hospital Network names, 42
syphilis, 23, 159, 160
mesothelioma, 107, 108
syringes, unsafe sharing of, see injecting drug practices
suicide, 380, 383
System of Health Accounts, 56–7, 63
telehealth, 396–7
water fluoridation, 169, 374
statins, 403–4, 405, 406, 407 T
Statistical Area Levels Taking Action to Tackle Suicide package, 381
hospitalisation rates (SA3s), 451–2 Tamil asylum seekers, 275
workforce supply for Indigenous population taxation, 44, 45
(SA2s), 357, 360–8 child care rebate, 47
Streptococcus pneumoniae, 328 private health insurance rebate, 45, 60
stress, 341–2 revenue spent on health, 56
palliative care patients, 460–1 technology (digital health), 49, 69–78
see also psychological distress children and young people using, 240
stroke (cerebrovascular disease), 115–17 health promotion programs using, 375
stroke burden of disease, 87, 115, 117 ‘Question builder’, 184
due to risk factors, 122, 167, 189, 190, 196–7 suicide prevention services, 382
as health risk factor, 140 telehealth, 269, 395–7
stroke deaths, 88–91, 117 teenagers, see children and young people
culturally and linguistically diverse populations, 273 teeth, see dental services and oral health
premature mortality (fatal burden of disease): due teetotalism, 204, 249
to air quality, 167–8 telehealth, 269, 395–7
socioeconomic groups and areas, 257 tele-monitoring systems, 396
substance use disorders, 132 television
burden of disease, 85 food advertising, 240
Indigenous programs, 353 health promotion advertisements, 375
see also alcohol consumption; drugs teleweb suicide prevention services, 382
sudden infant death syndrome (SIDS), 85, 90, 318 10-group classification, 446–7
sugar intake, 229 territories, see states and territories
550
testicular cancer, 105 tramadol, 150
tests, 466 tranquillisers/sleeping pills, 212
explanation of results, 465 trans and saturated fats intake, 229
therapeutic goods, 45 transgender, people identifying as, see lesbian, gay,
see also aids and appliances; pharmaceuticals bisexual, transgender and intersex people
thunderstorm asthma, 171, 174 transplants, 122, 439–41
thyroid cancer, 105 transport, 283
‘Tick Program’, 375 travel times, 181, 239; to see doctor, 268
time travel to emergency departments, 431
ADF personnel length of service, 294 see also ambulance services; motor vehicles

farmers reporting mental health problems transport accidents, 376
drought experience, 172 burden of disease due to risk factors, 192, 193, 194
food advertising exposure of children, 240 deaths, 89, 90, 142, 143
health professional consultations, 455; general hospitalisations, 143
practitioners (GPs), 267, 268, 455
trastuzumab, 409
hours worked, 239; contribution to health gap,
345–7, 349 treatments, see procedures and treatments
on physical activity, 191, 225 triage categories of emergency department

presentations, 26, 431–2, 435
screen-based activities by children and young
people, 240 triglycerides, see cholesterol and triglycerides
sitting at leisure, 231 trust in researchers using health data, 75
travelling, 181, 239; to see doctor, 268 twin births, 443, 446
see also length of hospital stay; waiting times tympanoplasty/myringoplasty, 326, 327, 434
tissue and organ donation, 122, 439–41 type 1 diabetes, 118, 119
tobacco smokers, 24, 25, 200–3 type 2 diabetes, 118, 119, 120
burden of disease due to, 112, 140, 202
cessation products, spending on, 410 U
chronic obstructive pulmonary disease (COPD), 128 ultraviolet radiation, 169–70, 174
with disability, 280–1 underlying causes of death, see deaths and causes
general practitioner (GP) discussions about, 390 of death
health promotion, 375, 376 underweight, 232, 235, 236, 237
homosexual and bisexual people, 201, 286 Indigenous Australians, 333
households with children (children exposed in mothers giving birth, 249
home), 25, 200, 324 odds ratio for being in good health, 349
Indigenous Australians, see Indigenous tobacco unemployment, see employment
smokers
unfair treatment or discrimination, 282
United Kingdom, 456
odds ratio for being in good health, 346–8, 349
migrants born in, 271–2, 273, 274: see also
over-the-counter cessation medicines, 410
international comparisons
people with disability, 280–1
United Nations, 99
pregnant women, see mothers smoking during
United States, 184
pregnancy
prisoners, 301
University of Adelaide, 74
remoteness areas, 201, 262–3, 324, 332
socioeconomic groups and areas, 179, 200, 201, University of New South Wales, 73
256, 337 University of South Australia, 74
young people, 200, 332 unplanned readmissions after surgery, 425
Tonsillectomy and adenoidectomy, 425, 433, 435 unreferred medical services, 44, 59, 61
tooth decay, 85, 153, 169 see also general practitioners
‘Top tips for safe health’, 184 upper respiratory conditions, 129
Torres Strait Islanders, see Indigenous Australians Urgent emergency department presentations, 26,
total joint replacements, see joint replacement surgery 431, 432
traffic-related air pollution, 167 uterine cancer, 190, 197
551
V waiting times
audiology testing, 325
vaccination, see immunisation and vaccination
elective surgery, 27, 49, 433–5
vaccine preventable diseases, 376
emergency departments, 26, 27, 49, 431–2
potentially preventable hospitalisations, 268
general practitioner (GP) appointments, 454;
see also immunisation and vaccination; infections
people with disability, 282; remoteness areas, 267
vaginal births, 427, 442, 443, 446
medical specialist appointments, 282, 454
after previous caesarean section, 447–8
public dental services, 282
perineal tears hospitalisation rate, 451
radiotherapy, 436–8
vaginal intercourse, 286
walking, 191, 226, 238–9
varicella, 376
wastewater drug monitoring, 215

Varicose vein treatment, 434
water fluoridation, 169, 374
vascular diseases, see cardiovascular disease
water quality, 25, 168–9, 174
vegetable consumption, see fruit and vegetable intake
weather, 171–3, 174–5
verbal abuse incidents, 206
weekly income, 8
veterans, 74, 288–99
weekly total cash earnings, 179
primary health care services processed by DVA, 388
weight, see overweight and obesity; underweight
Veterans’ Entitlements Act 1986, 400
welfare, links with, 47
see also pharmaceuticals
wellbeing, 4
VicHealth, 375
health indicators, 23
Victoria, 160, 456
see also psychological distress; self-assessed
ambulance suicide-related attendances, 381
health status
bushfires, 172
wholesale alcohol sales data, 206
thunderstorm asthma, 171, 174
Wittenoom, 107
urban planning, 375
women
Your Experience of Service Survey, 457
general practitioner (GP) consultations for genital
Victorian Department of Agriculture, 171 system problems, 389
video conferencing, 396 uterine cancer, 190, 197
Vietnamese migrants, 273, 274 see also breast cancer; sex (gender)
violence, victims of, 90, 146–7 wood smoke, children’s exposure to, 324
alcohol-related, 206 work, see employment; health workforce
see also family, domestic and sexual violence; World Cancer Research Fund, 187
suicide and self-inflicted injuries
World Health Organization (WHO), 46, 173, 240, 459
vision problems and eye diseases, 388, 392
body mass index (BMI) classifications, 231–2
corneal transplants, 441
Commission on Social Determinants of Health, 181
elective surgery, 433; waiting times, 434, 435
environmental health, definition of, 166
eye donors, 440
health, definition of, 4
Indigenous Australians, 313; optometrists
workforce supply for population, 366 health system, description of, 40
macular degeneration, 409 heat-related deaths report, 171
medicines dispensed, 406, 409 International Statistical Classification of Diseases
and Related Health Problems (ICD), 88, 428
optometrists, 266, 366, 406
population caesarean section rate, 445, 446
readmissions after surgery, 425
social health determinants, description of, 179
Vitamin D deficiency, 170
wounds, emergency department presentations for, 144
W Y
Wagga Wagga, 171
young people, see children and young people
waist circumference, 232, 233, 239
Your Experience of Service survey, 456, 457
waiting lists
elective surgery, 433, 434, 435
organ transplants, 441
social housing, 181
552
Australia’s health 2018 is the 16th biennial health report

of the Australian Institute of Health and Welfare. This edition
profiles current health issues in a collection of feature articles
and statistical snapshots that cover a range of areas, including:
• A ustralia’s health system
• C auses of ill health
• D eterminants of health
Australia’s
• H ealth of population groups
• I ndigenous health
• P revention, treatment and health services
health
2018
AIHW
+61 2 6244 1000 [email protected] @aihw
www.aihw.gov.au GPO Box 570 1 Thynne Street

Canberra ACT 2601 Bruce ACT 2617
Australia Australia
Stronger evidence,
better decisions,
improved health and welfare

Australian Institute Health Welfare Aus 221

Uploaded by

Copyright:

Available Formats

Australian Institute Health Welfare Aus 221

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Australian Institute Health Welfare Aus 221

Uploaded by

Copyright:

Available Formats

Australia’s health 2018 is the 16th biennial health report

Australia’s health 2018

Australia’s health 2018

www.aihw.gov.au GPO Box 570 1 Thynne Street

© Australian Institute of Health and Welfare 2018

Australian Institute of Health and Welfare

Published by the Australian Institute of Health and Welfare.

Report designed using art by Penny Deacon.

Mrs Louise Markus

2.1 How does Australia’s health system work?������������������������������������������40

3.1 Burden of disease across the life stages����������������������������������������������84

Australia’s health 2018

6.6 Social determinants and Indigenous health���������������������������������������� 335

Australia’s health 2018

Australia’s health 2018 examines health using a person-centred approach—this takes

Australia’s health 2018

Project management team

Author liaison group

Australia’s health 2018

Professor Amanda Baker—University of Newcastle

Professor Malcolm Sim—Monash University

Thanks also to the following organisations and Australian Government departments

Australian Bureau of Statistics

Australia’s health 2018

Online data visualisation tools can be viewed at <www.aihw.gov.au/reports/

Supplementary tables can be viewed and downloaded at <www.aihw.gov.au/

Supplementary documents can be viewed and downloaded at <www.aihw.gov.au/

Australia’s health 2018 Australia’s health 2018: in brief

Health is a state of wellbeing. It reflects the complex interactions of a person’s

is broader and more multidimensional—namely, ‘a state of complete physical, mental

Measures of health status

Figure 1.1.1: Common measures of health

The number of years of life, on average, remaining to an

Mortality The number of deaths in a population in a given period.

Ill health in an individual and levels of ill health within a

One year of healthy life lost due to illness and/or death.

Health-adjusted The average length of time an individual at a specific age can

Role of the health system

Where do I go for more information?

Broad features Socioeconomic Health behaviours Biomedical factors

Individual physical and psychological make-up

Note: Blue shading highlights selected social determinants of health.

aged 0–4 1.6 million

aged 5–14 3.1 million

aged 15–24 3.2 million

aged 35–44 3.4 million

aged 45–54 3.3 million

aged 55–64 2.9 million

aged 65–74 2.2 million

aged 75–84 1.2 million

Source: ABS 2013.

In 2016, an estimated 3.3% of Australians identified

In 2016, 26% of people were born overseas—

In 2015, an estimated 18% of people had disability—

In December 2017, the employment to population ratio for

In 2017, of people aged 20–64, 66% held a non-school

Average Low income Middle income High income

Australians are living longer…

Figure 1.3.1: Life expectancy at birth, by sex, 1886–2016

2.1 How does Australia’s health system work?��40

3.1 Burden of disease across the life stages��84

6.6 Social determinants and Indigenous health�� 335