Australian health system copes amid diverse landscape

Despite a huge and varied environment, the Australian national health care system provides adequate care to a diverse population. However, more resources are needed to help people in rural areas.

Global Notebook Australia, the sixth largest country in the world, is faced with many challenges in administering its sprawling land mass and diverse population. From the modern cities in the south to the remote reaches of the outback in the north there is tremendous variation in climate, terrain, population density and lifestyle. The government must provide for its people amid this great variety.

One area of challenge is providing public health care. While the national health system provides adequate care for many, improvements could be made.

“Like all public health care systems, the Australian system suffers from high demand, under-funding, weak capital programs and a constant blurring of health care responsibilities between the federal and state governments,” said Noel Alpins, MD, FACS, a refractive surgery specialist in practice in Melbourne.

“In Australia, the federal government provides the global funding for hospitals; however, the state governments have the responsibility for managing and distributing that funding on a localized basis,” Dr. Alpins told Ocular Surgery News International Edition.

The Australian federal government funds universal medical services and pharmaceuticals and gives financial aid to public hospitals, residential-care facilities, hostels and home and community care. It additionally funds health research and provides support for the training of health professionals and financial assistance to tertiary students.

But while funding comes from the federal government, state and territory governments are responsible for providing the services, including most acute and psychiatric hospital services. These sections of government also provide community and public health services, including school health, dental care, maternal and child health, occupational health, disease control activities and some health inspection functions. Local government is also engaged in a range of home care and personal preventive services, such as immunization.

According to the Australian Medical Association (AMA), national health spending has been almost constant as a share of gross domestic product (GDP) since 1991 and has grown little since the late 1970s. Health currently accounts for about 8% of Australia’s GDP. Per capita GDP in Australia is about $23,600. Roughly A$24 billion is spent by the government on public health care.

Public, private patients

Australia’s health care system offers universal coverage through Medicare, which was introduced in 1984. This government-run system offers health care services to every Australian citizen and is funded in part through a taxation surcharge of 1.5% of income.

Under Medicare, Australians are entitled to free public hospital care when they choose to be public patients. Hospital appointed doctors provide their medical care. State and territory governments provide public hospital services and work closely with the federal government and professional bodies to ensure that quality of care and appropriate standards are maintained.

For private care outside the hospitals, “The government will pay 85% of a standard government scheduled fee,” said Christopher M. Rogers, MBBS. “In that way, they try to sort of put a lid on costs.” The 15% out-of-pocket expense discourages patients from overusing the system.

Any physician can charge more than the government standard fee, and many do, but the patient is still reimbursed only 85% of the scheduled amount. According to Dr. Rogers, the government schedule fee is less than what the Australian Medical Association and Australian medical colleges think it should be. In turn, patients are paying significantly out of pocket for many medical services.

Public hospitals offer free care to those who cannot afford medical attention. The public system includes access to hospital treatment, general practitioner and specialist treatment and also access to pharmaceuticals.

Two-thirds of national health spending is funded through taxation and the rest by a mix of patient out-of-pocket costs, health insurance premiums and compensation insurance.

In 1997-98, there were 734 public acute care hospitals, representing 62% of hospital facilities and comprising 70% of total hospital beds, according to the Australian Bureau of Statistics (ABS).

Private health insurance

Some Australians choose to be treated as private patients in public hospitals or to use private hospitals. In the private sector, patients can choose to pay directly for medical costs or use private health insurance, which is utilized by about 32% of the country’s population.

The private sector enables timely access to treatment and allows patients to select their doctor of choice. Private insurers are prohibited from insuring all or part of non-hospital services that attract Medicare benefits.

According to the ABS, there were 317 private acute and psychiatric hospitals in 1997-98, with about 23,091 beds.

In the past, private hospitals tended to provide less complex, non-emergency care, such as simple elective surgery. However, they are increasingly providing complex, high technology services. Separate centers for ambulatory (non-admitted) and day-only admitted surgical procedures are mostly in the private sector.

The federal government is seeking a better balance between the public and private health sector by encouraging people to take out private health insurance, while preserving Medicare as the universal safety net. According to Australian physicians, inadequate funding from the government and too many controls over what supplementary private health insurance is permitted need to be addressed.

The advent of new technologies has opened up treatment access to more Australians with less debilitating surgical procedures, shorter hospital says and quicker recovery periods. According to Dr. Alpins, this has put cost pressures on the health care system. At the same time, Australia has witnessed a decline in the membership of private health insurance schemes from almost 50% in 1988 to barely 30% today.

In the past year, government initiatives to increase health insurance fund membership have taken off, but with limited access to increased public funding. Australian families on incomes of A$50,000 or more are being encouraged to use the private sector for specialist treatment and hospitalization, thus taking the pressure off the public system. This trend needs to continue to restore the public/private imbalance, physicians say.

Remote, rural Australia

“Rural areas have major problems attracting and retaining doctors,” said Ivan Goldberg, MBBS, FRACO, a glaucoma specialist in Sydney. “Many solutions have been proposed such as training more medical students from those areas, incentives of various sorts, locum backup arrangements, etc. City doctors rotate through country areas and training programs now all include rural rotations.” Patient movement is otherwise essential, he told Ocular Surgery News International Edition.

Government incentive schemes are in place to attract and maintain general practitioners and pharmacists to the remote areas of the country for a minimum of 5 years. The level of health care in these areas is restricted to the competencies of general practice, with specialist treatment and acute medical hospitalization still requiring travel to regional centers or metropolitan areas.

“There are insufficient numbers of medical practitioners who wish to locate in remote areas, and the health care specifically of remote indigenous communities leaves much to be desired,” Dr. Alpins said. “Indigenous mortality rates have an approximate 25-year differential with their [non-indigenous] counterparts.”

A recent ABS report on indigenous health found that of those who died, 53% of indigenous males and 41% of indigenous females were less than 50 years old. This is in contrast to 13% of overall male deaths and 7% of overall female deaths occurring in those aged 50 or less. Death rates were higher for indigenous people than for the total Australian population in every age group, but the largest differences were among people aged 35 to 54 years, with rates six to seven times higher for indigenous people. The AMA is encouraging the federal government to move to a needs-based funding formula for indigenous health.

Strict control of government-funded training positions in Australian hospitals ensures that the supply of health professionals and demand from health care consumers are in reasonable balance.

However, Dr. Alpins noted, “there is a surfeit of general practitioners in metropolitan Australia and a dearth in rural Australia despite ongoing governmental initiatives to encourage practitioners to move into rural and remote areas.”

But the uptake of technology is rapid in Australia, Dr. Alpins said, the skill level and innovation of specialists are high, and the only barriers to achieving the meeting of health demands of the population are the ongoing burgeoning costs.

In April the AMA and the National Aboriginal Community Control Health Organization collaborated to advance the cause of aboriginal health. Together they seek needs-based funding for aboriginal health, to counter the view that little can be done to improve the health of this population and that targeted funds would be beneficial for health outcomes.

Humanitarian role

“Outreach programs are well developed and excellent,” Dr. Goldberg said. “Australians have always felt a real humanitarian commitment to providing a service for underprivileged communities and are active in these efforts.”

The Fred Hollows Foundation, founded by Prof. Fred Hollows in 1992, is a community-based non-governmental organization committed to raising funds to continue the work of Prof. Hollows and his mission to reduce the backlog of cataract blindness and provide equity of access to health care.

This organization originally started working with health care providers in Nepal, Eritrea and Vietnam to provide the skill, technology and equipment to produce IOLs for cataract surgery locally in those countries. Training and equipment were also given to local surgeons to help them perform high-volume posterior chamber IOL cataract surgery. The foundation is now training doctors and providing them with the equipment necessary for modern cataract surgery in 19 countries across 3 continents.

In 1995, the foundation initiated an indigenous eye program in far north Queensland, Australia, and in the Torres Strait. In addition to providing eye surgery, equipment and training was provided and systems and procedures have been set up to guarantee that this area of Australia has access to necessary eye health care services.

For the more remote areas of Australia there is also the Royal Flying Doctor Service, which was founded in 1928 by the Rev. John Flynn. This service provides aeromedical emergency and health care service 24 hours a day, 365 days a year to people in the remote outback. Almost 200,000 patients have received medical attention through the Royal Flying Doctor Service. It has 17 bases, 38 aircraft and covers almost 12 million kilometers. The service costs about A$43 million a year to operate, and relies on grants from the federal, state and territory governments, but also relies on funds from other donors.

Ophthalmology and other resources

In Australia there are roughly 700 ophthalmologists for a population of 19 million. Approximately 25 new trainees start each year. Cataract surgery is performed by a majority of ophthalmic surgeons in Australia, and about 110,000 cataract procedures are expected to be performed this year. Refractive surgery is growing at a rate of about 30% a year. There is no health fund subsidy for refractive surgery, and fees are around A$2,000. Private cataract surgery fees have been relatively static at a level of A$850 to A$1,750 in recent years, Dr. Rogers said, due to restrictions on Medicare and private health insurance, which offers about A$700 in reimbursement.

According to the ABS, in 1998-99, about 281,200 people were employed in health occupations in Australia. February 1999 data from the Office for Aboriginal and Torres Strait Islander Health indicate that there were about 27 indigenous registered medical practitioners, 145 indigenous nurses and almost 1,300 aboriginal health workers working in the government and community sectors.

For Your Information:

Noel Alpins, MD, FACS, can be reached at 7 Chesterfield Rd., Cheltenham, Melbourne, 3192, Australia; +(61) 3-9584-6122; fax: +(61) 3-9585-0995; e-mail: alpins@newvisionclinics.com.au;

Ivan Goldberg, MBBS, FRACO, can be reached at 187 Macquarie St., Floor 4, Sydney, NSW 2000, Australia; +(61) 2-9247-9972; fax: +(61) 2-9232-3086; email: ivangoldberg@iname.com;

Christopher M. Rogers, MBBS, can be reached at 3/270 Victoria Ave., Chatswood, Sydney, 2067, Australia; +(61) 2-9424-9999; fax: +(61) 2-9410-3000; email: srsc@acay.com.au

The Australian Council of the Royal Flying Doctor Service can be reached at Level 5, 15-17 Young St., Sydney, 2000, Australia; +(61) 2-9241-2411; fax: +(61) 2-9247-3351; www.rfds.org.au

The Fred Hollows Foundation can be reached at Locked Bag 100, Rosebery, NSW 2018, Australia; +(61) 2-8338-2112; fax: +(61) 2-8338-2100; support@hollows.com.au