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2.0 Introduction

Australia's health system is complex. It can perhaps be best described as a 'web': a web of services, providers, recipients and organisational structures.

This chapter looks at the many components of the Australian health system, how they are organised and funded, and how they are delivered to, and used by, Australians.

While for many Australians most of their contact with the health system involves a visit to a GP or pharmacist, these services are part of a much broader and complex network.

Complexity is unavoidable in providing a multi-faceted and inclusive approach to meeting the health system needs of Australia's many and varied residents, when those needs are shaped by many and varied factors, including gender, age, health history and behaviours, location, and socioeconomic and cultural background.

Behind the scenes of the health system is a network of governance and support mechanisms that enable the policy, legislation, coordination, regulation and funding aspects of delivering quality services. Governance, coordination and regulation of Australia's health services is a big job, and is the joint responsibility of all levels of government, with the planning and delivery of services being shared between government and non-government sectors.

As one might expect, a system of this scale and complexity costs. In 2011-12, health spending in Australia was estimated to be $140.2 billion, or 9.5% of GDP. The amount was around 1.7 times as high as in 2001-02, with health expenditure growing faster than population growth.

This growth can be attributed in part to societal changes such as population ageing, and to increased prevalence of chronic conditions, diseases and risk factors. Personal incomes, broader economic trends and new technologies also affect spending on health. In summary, our health does not exist separate to the rest of our society. Rather, the two are intertwined, and our nation's spending on health services reflects this.

Our health as a nation depends on our health as individuals-and vice versa. A 'healthy' health system, therefore, is fundamental to our national - and personal - wellbeing and prosperity.

2.1 Australia's health system

For most people their first contact with the Australian health system when they become ill is a visit to a general practitioner (GP). The GP may refer them to a specialist or a public hospital, order diagnostic testing, write them a prescription or pursue other treatment options. But patient and clinical care are just 2 components of a much broader and complex network that involves multiple providers working in numerous settings, supported by a variety of legislative, regulatory and funding arrangements.

So what is a health system? According to the World Health Organization, a health system is 'all the activities whose primary purpose is to promote, restore and/or maintain health' (WHO 2013b). Further, a good health system 'delivers quality services to all people, when and where they need them'.

While the configuration of services varies from country to country, common elements include robust funding mechanisms, a trained workforce, reliable information on which to base decisions and policies, and well-maintained facilities and logistics to deliver quality medicines and technologies (WHO 2013a).

Australia's health-care system is a multi-faceted web of public and private providers, settings, participants and supporting mechanisms. Health providers include medical practitioners, nurses, allied and other health professionals, hospitals, clinics and government and non-government agencies. These providers deliver a plethora of services across many levels, from public health and preventive services in the community, to primary health care, emergency health services, hospital-based treatment, and rehabilitation and palliative care.

Public sector health services are provided by all levels of government: local, state, territory and the Australian Government. Private sector health service providers include private hospitals, medical practices and pharmacies.

Although public hospitals are funded by the state, territory and Australian governments, they are managed by state and territory governments. Private hospitals are owned and operated by the private sector. The Australian Government and state and territory governments fund and deliver a range of other health services, including population health programs, community health services, health and medical research, Aboriginal and Torres Strait Islander health services, mental health services, and health infrastructure (see Chapter 8).

Navigating your way through the 'maze' of health service providers and responsibilities can be difficult (Consumers Health Forum of Australia 2013). Figure 2.1 provides an 'at a glance' picture of the main services, funding responsibilities and providers. Health funding and the composition of the workforce are covered in detail in a separate article and snapshot in this chapter, but an overview is provided here to outline the main elements of Australia's health system.

Figure 2.1: Health services-funding and responsibility

Pie chart showing responsibility for services, funding and share of expenditure for hospitals, primary health care and 'other recurrent'. Hospitals had the most share of expenditure with 40.4%, followed by primary health care with 38.2% and other recurrent with 21.3%.

Note: The inner segments indicate the relative size of expenditure in each of the 3 main sectors of the health system ('hospitals', 'primary health care', and 'other recurrent'). The middle ring indicates the relative expenditure on each service in the sector (shown by the size of each segment) and who is responsible for delivering the service (shown by the colour code). The outer ring indicates the relative size of the funding (shown by the size of each segment) and the funding source for the difference services (shown by the colour code). For more detail, refer to the main text.

The inner segments show the relative size of the expenditure in each of the main sectors of the health system, being hospitals, primary health care and other recurrent areas of expenditure. In the case of the hospital sector, this includes all services provided by public and private hospitals. Primary health care includes a range of front-line health services delivered in the community, such as by a GP, physiotherapy and optometry services, dental services and all community and public health initiatives. It also includes the cost of medications not provided through hospital funding. The category 'other recurrent' includes areas of recurrent spending that were not paid for by hospitals but that were not delivered through the primary health care sector, such as medical services other than those provided by general practitioners, medical research, health aids and appliances, patient transport services and health administration. It is important to note that these examples are not exhaustive, and each group of services consists of many types of activities.

The middle ring indicates the relative expenditure on the specific service types within each sector, and who delivers the service.

The outer ring shows the funding source for the different services and the relative size of the funding.

For more detailed information about expenditure, see 'How much does Australia spend on health care?' in this chapter.

The colour coding in the figure shows whether the service is provided by the private sector, public sector, or both. Private sector providers include private hospitals, medical practices and pharmacies. Public sector provision is the responsibility of state and territory governments for public hospitals, and a mixture of Australian Government and state, territory and local governments for community and public health services.

Who uses the health system?

The health system is used to varying degrees by Australian citizens, overseas visitors, temporary and permanent visa holders and asylum-seekers (Department of Health pers. comm. 20 January 2014). Their needs and expectations are shaped by many factors, including the nature and extent of their health status, as well as factors such as age, gender, where they live and their cultural background.

Our contact with the health system almost always begins at birth and, for most of us, continues frequently throughout our lives. These interactions can range from conducting simple over-the- counter transactions at a pharmacy to seeking treatment for complex and sometimes chronic illnesses. And while some of us have more interactions with health practitioners than others, even people who rarely visit a doctor or who have never been admitted to hospital are exposed to elements of the health system almost daily, including through health promotion messages or community health campaigns in the media. (See Chapter 8 'Prevention for a healthier future'.)

Types of health care

Primary health care

In Australia, primary health care is typically a person's first point of contact with the health system and is most often provided outside the hospital system (Government of Western Australia Department of Health 2013). A person does not routinely need a referral for this level of care, which includes services provided by general medical and dental practitioners, nurses, Indigenous health workers, pharmacists and other allied health professionals such as physiotherapists, dietitians and chiropractors.

Primary health care is delivered in a variety of settings, including general practices, Aboriginal and Community Controlled Health Services, community health centres and allied health services, as well as within the community, and may incorporate activities such as public health promotion and prevention. Primary health care accounts for almost as much health spending as hospital services, accounting for 36.1% ($50.6 billion) of total health expenditure in 2011-12 compared with 38.2% ($53.5 billion) on hospital services (see Chapter 2 'How much does Australia spend on health care?'). Primary health care is covered in detail in Chapter 8 'Primary health care in Australia'.

Secondary care

The primary health-care system does not operate in isolation. It is part of a larger system involving other services and sectors, and so can be considered as the gateway to the wider health system. Through assessment and referral, individuals are directed from one primary care service to another, and from primary services into secondary and other health services, and back again (AIHW 2008).

Secondary care is medical care provided by a specialist or facility upon referral by a primary care physician (Nicholson 2012). It includes services provided by hospitals and specialist medical practices (see Chapter 8 'Primary health care in Australia').

Hospitals

In Australia, hospital services are provided by both public and private hospitals. In 2011-12, there were 1,345 hospitals in Australia (AIHW 2013a) and total hospitalisations rose by 4.6% to almost 9.3 million from 2010-11 to 2011-12 (see Chapter 8 'Overview of public and private hospitals').

Hospital emergency departments are a critical component of hospitals and the health system. They provide care for patients who have an urgent need for medical or surgical care, and in some cases also provide care for patients returning for further care, or patients waiting to be admitted. In 2012-13, more than 6.7 million emergency department presentations were reported by public hospital emergency departments-or just over 18,000 each day (see Chapter 8 'Emergency departments: at the front line').

Primary Health Networks and Local Hospital Networks

Primary Health Networks

In 2011, the Australian Government established Medicare Locals to plan and fund extra health services in communities across Australia. Medicare Locals were created as local organisations, to coordinate and deliver services to meet particular local needs (Australian Government 2013). On 13 May 2014 the Australian Government announced that the 61 Medicare Locals would be replaced with a smaller number of Primary Health Networks, to be operational from 1 July 2015. Primary Health Networks are expected to align more closely with state and territory health network arrangements, and reduce duplication of effort.

Local Hospital Networks-how hospitals are organised

Local Hospital Networks (LHNs) are being established across the country to improve delivery, coordination and access to health services. LHNs are small groups of local hospitals, or an individual hospital, linking services within a region or through specialist networks across a state or territory. Responsibility for hospital management is devolved to LHNs, to 'increase local autonomy and flexibility so that services are more responsive to local needs' (Australian Government 2010).

There are 136 LHNs in Australia, of which 123 are geographically based and 13 are state or territory-wide networks that provide specialised hospital services across jurisdictions (DoHA 2011).

Emerging models of care

The development of new models of care, such as nurse-led walk-in clinics and day surgical procedures being performed in consultants' rooms, is shifting the boundaries between what traditionally would have been hospital-based care and care delivered by other health professionals.

Innovations such as personally controlled electronic health (e-health) records and telehealth also offer the prospect of improved communication and access to services. An e-health record allows patients and their doctors, hospitals and other health-care providers to view and share the patient's health information, if the person has given prior consent. This information can include a summary of medications, hospital discharge records, allergies and immunisations (Department of Health 2013f).

Telehealth services use communication technologies, such as video-conferencing, to deliver health services and transmit health information. Telehealth technology can improve access to services for people living in regional, rural and remote areas. Patients who previously had to travel to the nearest major city to see a specialist can instead use video-conferencing, which might be offered at their local GP or another local health-care venue (DoHA 2012).

The use of e-health technologies to self-monitor health is emerging as a key dimension in contemporary health care. A United States study (Fox & Duggan 2013) found that 69% of United States adults monitored a health indicator such as weight, diet or exercise, and that 20% used technology such as mobile phone applications or websites to do so. Digital platforms such as these can incorporate functions such as sensing and geospatial tracking to provide tailored feedback and enhance the ability for accurate assessment (Norman et al. 2007).

Patients can also now use devices such as blood pressure and blood glucose monitors in their own homes to track and manage their health status and potential health risks.

How the health system is funded

Health is an expensive business: in 2011-12, health expenditure in Australia was estimated at $140.2 billion, or 9.5% of gross domestic product (GDP), compared with $82.9 billion in 2001-02 and $132.6 billion in 2010-11 (AIHW 2013b). Almost 70% of total health expenditure during 2011-12 was funded by governments, with the Australian Government contributing 42.4% and state and territory governments 27.3%. The remaining 30.3% ($42.4 billion) was paid for by patients (17%), private health insurers (8%) and accident compensation schemes (5%).

Medicare

The Australian Government's funding contributions include a universal public health insurance scheme, Medicare. Medicare was introduced in 1984 to provide free or subsidised treatment by health professionals such as doctors, specialists and optometrists (Department of Human Services 2013b).

The Medicare system has 3 parts: hospital, medical and pharmaceutical (PHIO 2013). The major elements of Medicare include free treatment for public patients in public hospitals, the payment of benefits or rebates for professional health services listed on the Medicare Benefits Schedule, and subsidisation of the costs of a wide range of prescription medicines under the Pharmaceutical Benefits Scheme (Department of Human Services 2013b).

A person can have Medicare cover only, or a combination of Medicare and private health insurance coverage (PHIO 2013).

The government-funded schemes and arrangements aim to give all Australians access to adequate, affordable health care, irrespective of their personal circumstances. The schemes are supplemented by social welfare arrangements, such as smaller out-of-pocket costs and more generous safety nets for those who receive certain income-support payments (AIHW 2012).

Medicare and hospital treatment

Medicare offers free treatment and accommodation as a public patient in a public hospital, by a doctor appointed by the hospital (Department of Human Services 2014; PHIO 2013).

It usually covers:

  • free or subsidised treatment by health professionals such as doctors, specialists, optometrists and in specific circumstances dentists and other allied health practitioners and accommodation as a public patient in a public hospital
  • 75 per cent of the Medicare Schedule fee for services and procedures if you are a private patient in a public or private hospital (does not include hospital accommodation and items such as theatre fees and medicines)
  • some health-care services in certain countries (Department of Human Services 2014).

A public patient cannot choose their own doctor and may not have a choice about when they are admitted to hospital for elective procedures (PHIO 2013).

Medicare benefits are based on a schedule of fees (the Medicare Benefits Schedule, or MBS), which are set by the Australian Government after discussion with the medical profession. Practitioners are not required to adhere to the schedule (except for optometry) and can charge more than the scheduled fee. In these instances the patient is required to pay the extra amount, often called a 'gap' payment (ABS 2013; Queensland Government 2013).

Medicare does not cover:

  • medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons
  • ambulance services (PHIO 2013).

While Medicare benefits are generally not available for medical treatment a person receives overseas, the Australian Government has signed Reciprocal Health Care Agreements to help cover the cost of essential medical treatment (Department of Human Services 2013c) for Australians visiting certain countries.

Medicare and medical services

When a person visits a doctor outside a hospital, Medicare will reimburse 100% of the MBS fee for a general practitioner and 85% of the MBS fee for a specialist. If the doctor bills Medicare directly (bulk-billing), the patient will not have to pay anything (PHIO 2013). If the doctor charges more than the MBS fee, the patient has to pay the difference.

Medical costs that Medicare does not cover include:

  • ambulance services
  • most dental examinations and treatment
  • most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry and psychology services
  • acupuncture (unless part of a doctor's consultation)
  • glasses and contact lenses
  • hearing aids and other appliances
  • home nursing (PHIO 2013).

Medicare and prescription pharmaceuticals

Medicare also subsidises a wide range of prescription pharmaceuticals under the Pharmaceutical Benefits Scheme (PBS). Under the PBS, Australians pay only part of the cost of most prescription medicines bought at pharmacies. The rest of the cost is covered by the PBS. The amount paid by the patient varies, up to a maximum of $36.10 for general patients and $5.90 for those with a concession card (Department of Health 2013d).

If a medicine is not listed under the PBS schedule, the consumer has to pay the full price as a private prescription. Non-PBS medicines are not subsidised by the Australian Government (Department of Health 2013b). However, pharmaceuticals provided in public hospitals are generally provided to public patients for free, with the cost covered by state and territory governments.

A separate scheme, the Repatriation Pharmaceutical Benefits Scheme (RPBS), is administered by the Department of Veterans' Affairs (DVA) and provides access to a range of pharmaceuticals and dressings at a concessional rate for the treatment of eligible war veterans, war widows/widowers, and their dependants (Department of Human Services 2012; DVA 2012).

Other programs

Additional government programs are targeted at improving health services and outcomes for specific groups, such as people living in rural and remote Australia, Indigenous Australians, those with chronic illnesses and older Australians.

The Australian Government's $805 million Indigenous Chronic Disease Package, for example, aims to improve the way the health-care system prevents, treats and manages the chronic diseases that affect many Indigenous Australians. The goal is to reduce key risk factors for chronic disease in the Indigenous community (such as smoking), improve chronic disease management and follow-up, and increase the capacity of the primary care workforce to deliver effective care to Indigenous Australians with chronic diseases (Department of Health 2013a).

Other government initiatives include arrangements for Australians with chronic illnesses to receive Medicare benefits for allied health services that help manage their condition (Department of Human Services 2013a) and programs to improve health services in rural and remote communities, such at the Visiting Optometrists Scheme (Rural and Regional Health Australia 2013).

There are also special health-care arrangements for members of the Australian Defence Force and their families, and for war veterans and their dependants (AIHW 2012).

Private health insurance

Private health insurance is available for those who wish to fully or partly cover the costs of being admitted to hospital as a private patient and/or the costs of other ancillary health services (Private Healthcare Australia 2013). Part of the cost of being admitted as a private patient is also covered by the Australian Government through the MBS and PBS.

Private health insurance is not compulsory, and people who opt to buy private health insurance can mix and match the levels and type of cover to suit their individual circumstances. Private insurance also offers cover for some or all of the costs of a range of other items or services not covered by Medicare, such as ambulance services, dental services, prescription glasses, and physiotherapy (Department of Health 2013e).

Private patients have more control in choosing their treating doctor in hospital and may be able to reduce their waiting time for elective surgery by having treatment in a private hospital (Private Healthcare Australia 2013).

A person can choose to be treated as a public patient in a public hospital, even if they have private health insurance.

According to the Private Health Insurance Administration Council, at June 2013, 10.8 million Australians (47% of the population) had some form of private hospital cover and 12.7 million (55%) had some form of general treatment cover (Private Health Insurance Administration Council 2013).

Who governs health services?

Overall coordination of the public health system is the responsibility of all Australian health ministers, that is, the Commonwealth and state and territory ministers. Managing the individual Commonwealth, and state and territory health systems is the responsibility of the relevant health minister and health department in each jurisdiction.

The health ministers are collectively referred to as the Standing Council on Health, which has a supplementary coordination role. Membership of the council also includes the Commonwealth Minister for Veterans' Affairs and the New Zealand Health Minister (AHMAC 2013).

The Standing Council comes under the auspices of the Council of Australian Governments (COAG), which is the peak intergovernmental forum in Australia (AHMAC 2013).

The Standing Council oversees the implementation of COAG's national health reforms that aim to:

  • help patients receive more seamless care across sectors of the health system
  • improve the quality of care patients receive through higher performance standards, unprecedented levels of transparency and improved engagement of local clinicians
  • provide a secure funding base for health and hospitals into the future (AHMAC 2013).

The Standing Council's major focus is on achieving 'a better health service and a more sustainable health system for Australia', and on closing the gap between Indigenous and non-Indigenous Australians (AHMAC 2013). Its areas of responsibility cover:

  • hospitals and related health services
  • community health and primary health care
  • population health, health promotion and prevention
  • Indigenous health
  • mental health
  • e-health and information management
  • health workforce
  • aged care
  • clinical, technical and medico-ethical matters 
  • chronic diseases, non-transmissible diseases and transmissible diseases
  • rural health and access to health services
  • National Drug Strategy
  • health-related elements of emergency management and national security (AHMAC 2013).

The Standing Council is supported by the Australian Health Ministers' Advisory Council, which is a committee of the heads of health authorities from the Australian Government and the states and territories (AHMAC 2013).

Who regulates health services?

State and territory governments license or register private hospitals, and each state and territory has legislation relevant to the operation of public hospitals. State and territory governments are also largely responsible for health-relevant industry regulations such as for the sale and supply of alcohol and tobacco products (AIHW 2010).

The Australian Government's regulatory roles include overseeing the safety and quality of pharmaceutical and therapeutic goods and appliances, managing international quarantine arrangements, ensuring an adequate and safe supply of blood products, and regulating the private health insurance industry (AIHW 2010).

Registration of health professionals

A National Registration and Accreditation Scheme (NRAS) for health practitioners started on 1 July 2010. The NRAS has been established by state and territory governments to:

  • protect the public by ensuring that only suitably trained and qualified practitioners are registered
  • facilitate workforce mobility across Australia
  • enable the continuous development of a flexible, responsive and sustainable Australian health workforce (Department of Health 2013c).

Professions currently regulated under the scheme are:

  • Aboriginal and Torres Strait Islander health practice
  • Chinese medicine
  • chiropractic
  • dental practice
  • medicine
  • medical radiation practice
  • nursing and midwifery
  • occupational therapy
  • optometry
  • osteopathy
  • pharmacy
  • physiotherapy
  • podiatry
  • psychology (Department of Health 2013c).

Other parts of the system

Health services are supported by many other agencies. For example: research and statistical bodies provide information for disease prevention, detection, diagnosis, treatment, care and associated policy; consumer and advocacy groups contribute to public discussions and policy development; and universities and hospitals train health professionals. Voluntary and community organisations and agencies also make important contributions, including raising money for research, running educational and health promotion programs, and coordinating voluntary care.

What is missing from the picture?

Due to limitations in primary health care information in Australia, there is currently insufficient information to fully describe who needs primary health care services, what care they receive (including where they receive it, for what reason and from whom), and the outcome.

The implications of these limitations, and opportunities to improve information, are covered in detail in the Chapter 8 article 'Primary health care in Australia'.

This lack of data is in contrast to the comprehensive information available on Australian hospitals, including that published in the AIHW's annual Australian hospital statistics group of products.

Currently it is not easy to profile 'patient journeys' as they progress through and receive services from different parts of the health system. Such information could be very useful in providing insights into the overall effectiveness and efficiency of our health system. At present, relevant data are derived from different sources-notably primary care data from the Australian Government and data on hospitalisations from the states and territories-and is not identified at the patient level in a uniform way.

Data linkage techniques, carried out under stringent conditions to protect privacy, allow data to be analysed at the person level rather than the service level. To date, there have been some useful data linkage projects that examine specific issues (for example, the movement between hospitals and residential aged care facilities described in Chapter 6). However, there is untapped capacity to use data linkage to look at complex population-level health issues by examining what happens to people as they move through the health system, as suggested above.

Where do I go for more information?

Individual aspects of the health system are discussed in more detail throughout this report.

Detailed information on health spending and the health workforce is available.

Detailed information on Australian hospitals is available.

More information on health reform, health practitioner registration and Australian Government health policies is available from the Department of Health website.

More information on intergovernmental arrangements and agreements is available at the COAG agreements webpage.

References

ABS (Australian Bureau of Statistics) 2013. Year Book Australia, 2012. Health care delivery and financing. Canberra: ABS. ABS cat. no. 1301.0. Viewed 24 January 2014.

AHMAC (Australian Health Ministers' Advisory Council) 2013. Australian Health Ministers' Advisory Council. Canberra: AHMAC. Viewed 13 August 2013.

AIHW (Australian Institute of Health and Welfare) 2008. Review and evaluation of Australian information about primary health care: a focus on general practice. Cat. no. HWI 103. Canberra: AIHW.

AIHW 2010. Australia's health 2010. Cat. no. AUS 122. Canberra: AIHW.

AIHW 2012. Australia's health 2012. Cat. no. AUS 156. Canberra: AIHW.

AIHW 2013a Australia's hospitals 2011-12: at a glance. Health services series no. 49. Cat. no. HSE 133. Canberra: AIHW.

AIHW 2013b. Health expenditure Australia 2011-12. Health and welfare expenditure series no. 50. Cat. no. HWE 59. Canberra: AIHW.

Australian Government 2010. A national health and hospitals network for Australia's future-delivering better health and better hospitals. Canberra: Commonwealth of Australia.

Australian Government 2013. What is a Medicare Local? Canberra: Australian Government. Viewed 10 October 2013.

Consumers Health Forum of Australia 2014. Practice nurses and superclinics-why not both? Viewed 11 November 2013.

Department of Health 2013a. Closing the gap: tackling Indigenous chronic disease. Canberra: Department of Health. Viewed 23 January 2014.

Department of Health 2013b How much am I charged for non-PS items? Canberra: Department of Health, Viewed 28 November 2013.

Department of Health 2013c. National Registration and Accreditation Scheme (NRAS). Canberra: Department of Health. Viewed 10 October 2013.

Department of Health 2013d. Patient charges. Canberra: Department of Health. Viewed 19 November 2013.

Department of Health 2013e. Private health insurance. Canberra: Department of Health. Viewed 28 November 2013.

Department of Health 2013f. What is a personally controlled electronic (eHealth) record? Viewed 28 November 2013. 

Department of Human Services 2012. RPBS prescribing provision. Canberra: Department of Human Services. Viewed 5 December 2013.

Department of Human Services 2013a. Chronic disease management plan. Canberra: Department of Human Services. Viewed 23 December 2013.

Department of Human Services 2013b. Medicare for providers. Canberra: Department of Human Services. Viewed 24 January 2013.

Department of Human Services 2013c. Reciprocal Health Care Agreements. Canberra: Department of Human Services. Viewed 5 December 2013.

Department of Human Services 2014. About Medicare. Canberra: Department of Human Services. Viewed 21 January 2014.

DoHA (Department of Health and Ageing) 2011. Local Hospital Networks. Canberra: Department of Health and Ageing. Viewed 3 October 2013.

DoHA 2012. Telehealth. Canberra: Department of Health and Ageing. Viewed 28 November 2013.

DVA (Department of Veterans' Affairs) 2012. Repatriation Pharmaceutical Benefits Scheme. Canberra: DVA. Viewed 2 September 2013.

Fox, S and Duggan. M. 2013. Tracking for health. Washington, DC: Pew Internet & American Life Project: Viewed 4 December 2013.

Government of Western Australia Department of Health 2013. What is primary health care? Perth: Government of Western Australia. Viewed 28 November 2013.

Nicholson C 2012. Development of a framework for integrated primary/secondary health care governance in Australia. Presentation at Australian Government Department of Health and Ageing, 17 July 2012.

Norman GH, Zabinski MF, Adams MA, Rosenberg DE, Yaroch AL & Atienza AA 2007. A review of health interventions for physical activity and dietary behaviour change. American Journal of Preventive Medicine 22(4):336-45.

PHIO (Private Health Insurance Ombudsman) 2013. What is covered. Canberra: PHIO. Viewed 19 August 2013.

Private Healthcare Australia 2013 About Private Health. Canberra: Private Healthcare Australia. Viewed 28 November 2013.

Private Health Insurance Administration Council 2013. Membership & coverage June 2013. Canberra: PHIAC. Viewed 10 October 2013.

Queensland Government 2012. What does Medicare cover? Brisbane: the state of Queensland. Viewed 21 January 2014.

Rural and Regional Health Australia 2013. Visiting Optometrists Scheme. Canberra: Department of Health. Viewed 5 December 2013.

WHO (World Health Organization) 2013a. Health systems. Geneva: WHO. Viewed 28 November 2013.

WHO 2013b. Health systems strengthening glossary. Geneva: WHO. Viewed 28 November 2013.


2.2 How much does Australia spend on health care?

Health expenditure occurs where money is spent on health goods and services. Health expenditure data includes health expenditure by governments as well as individuals and other non-government sources such as private health insurers. The providers of health goods and services include hospitals, primary health care providers such as general practitioners (GPs), and other health professionals.

In 2011-12, Australia spent around $140.2 billion on health, around 1.7 times higher in real terms (after adjusting for inflation) than in 2001-02. Health expenditure has grown faster than population growth. Expenditure increased from $4,276 per person in 2001-02 to $6,230 in 2011-12.

Health expenditure has also grown faster than the broader economy. The ratio of health expenditure to gross domestic product (GDP) has increased from 6.8% in 1986-87 to 9.5% in 2011-12 (Figure 2.2). Total health expenditure has grown in real terms at an average rate of 5.4% per year over the last decade, while GDP has grown at a slower rate of 3.1% per year.

Figure 2.2: Total health expenditure to GDP ratio, 1986-87 to 2011-12

Line chart showing the trending increase in the health expenditure to GDP ratio from 1986-87 to 2011-12 from under 7% to over 9%.

Source: AIHW health expenditure database.

Health has become a larger part of the economy, which is not unique to Australia. Using the Organisation for Economic Co-operation and Development's (OECD) methods, in 2011-12, Australia's health expenditure to GDP ratio was slightly above average compared with other OECD countries (Figure 2.3). Australia's position within the OECD has not changed significantly over recent years as the ratio for other countries has also increased.

Figure 2.3: Health expenditure as a proportion of GDP, selected OECD countries, 2011

Column chart showing health expenditure as a proportion of GDP for selected OECD countries in 2011. The United States had the highest with over 16%, followed by France, Canada, New Zealand, the United Kingdom, Australia, Spain, Norway, Sweden and Ireland.

Source: AIHW 2013a.

Where does the money go?

There are 4 broad areas of health spending: hospitals, primary health care, other recurrent expenditure, and capital expenditure. In 2011-12, the largest component of health spending was for hospital services ($53.5 billion, or 38.2% of total health expenditure), delivered by both public and private providers (Figure 2.4). Hospital expenditure includes all spending incurred by hospitals and excludes expenditure on hospital-based services where the hospital did not directly incur the costs. For example, pharmaceuticals paid for by hospitals are included but pharmaceuticals purchased by patients directly from hospital-based pharmacies are excluded. Similarly, some medical services are provided by specialists in hospitals but these services are not paid for by the hospital as they may be covered by the Medicare Benefits Scheme or some other arrangement. This expenditure is also not treated as hospital expenditure.

Figure 2.4: Total expenditure on health, by area of expenditure, 2011-12 ($ billion)

Bar chart showing total expenditure on health, by area, during 2011-12. Hospitals had the most with $53.5 billion, of which $42 billion was spent on public hospitals.
  1. Includes general practitioner and vocational registrar services, practice nurses, enhanced primary care services and other unreferred attendances.
  2. Includes recurrent expenditure not paid for directly by hospitals but that was not delivered in the primary health care sector, such as all medical services except general practitioner and vocational registrar services, practice nurses, enhanced primary care services and other unreferred attendances.

Source: AIHW health expenditure database.

The second largest component of health spending was for primary health care services ($50.6 billion, or 36.1% of total health expenditure). Primary health care includes a range of front-line health services delivered in the community, such as GP services, dental services, other health practitioner services (for example, physiotherapists, optometrists), and all community and public health initiatives. It also includes the cost of medications not provided through hospital funding.

The remaining health spending was for other recurrent ($28.3 billion, or 20.2% of total health expenditure) and capital expenditure ($7.9 billion, or 5.6% of total health expenditure). The category 'other recurrent' includes areas of recurrent spending that were not paid for by hospitals but that were not delivered through the primary health care sector, such as medical services other than those provided by general practitioners, medical research, health aids and appliances, patient transport services and health administration.

The distribution of funding by the Australian Government, state and territory governments and the non-government sector varies depending on the area of health expenditure (Figure 2.5).

Hospital services (both public and private) received a total of $53.5 billion in 2011-12. The main funding sources were state and territory governments ($22.9 billion, or 42.8% of total hospital funding) and the Australian Government ($19.5 billion, or 36.5%). Non-government sources provided an additional $11.1 billion (20.7%).

Primary health care services received $50.6 billion in funding, slightly less than hospital services. The Australian Government was the main funder, providing $23.1 billion (45.7% of total primary health care funding), followed by the non-government sector ($20.4 billion, or 40.3%), and the state and territory governments ($7.1 billion, or 14.0%).

An additional $28.3 billion of funding was provided for other recurrent components of the health system while funding for health infrastructure (capital expenditure) was $7.9 billion. The main source of funding for other recurrent health care goods and services was the Australian Government, providing $16.5 billion or 58.5% of other recurrent health funding, while the non-government sources provided $8.5 billion (30.2%) and states and territories provided the remaining $3.2 billion (11.3%).

The state and territory governments provided close to two-thirds (65.1%) of the funding for capital expenditure.

Figure 2.5: Total health expenditure, by area of expenditure and source of funds, 2011-12

Column chart showing the components of each area of health expenditure. State and territory governments made up the highest proportion for hospitals, while the Australian Government made up the highest proportion for primary health care (approximately 50% in each case).

Source: AIHW health expenditure database.

Which diseases attract the most expenditure?

For expenditure that can be allocated to individual disease groups, the group with the highest spending nationally in 2008-09 was 'Cardiovascular disease' ($7.7 billion, or 10.4% of total disease expenditure), followed by 'Oral health' ($7.2 billion, or 9.7%) and 'Mental disorders' ($6.4 billion, or 8.6%) (Figure 2.6).

Figure 2.6: Allocated health expenditure in Australia, by disease group and area of expenditure, 2008-09

Bar chart showing health expenditure in Australia by disease group and area of expenditure in 2008-09. Cardiovascular, oral health and mental disorders were the three areas with the greatest allocated expenditure.

Source: AIHW disease expenditure database.

Aboriginal and Torres Strait Islander health

In 2010-11, the total amount spent on health goods and services for Aboriginal and Torres Strait Islander people was estimated at $4.6 billion, or 3.7% of Australia's total recurrent health expenditure. (Expenditure for Aboriginal and Torres Strait Islander people includes expenditure for Indigenous- specific health programs as well as a portion of the expenditure from mainstream health programs.)

This equated to $7,995 per Indigenous person, which was around 1.5 times the $5,437 spent per non-Indigenous Australian in the same year.

In 2010-11, publicly provided services such as public hospital and community health services were the highest expenditure areas for the Indigenous population. For example, the average per person expenditure on public hospital services for Indigenous Australians ($3,631) was more than double that for non-Indigenous Australians ($1,683).

For health services that have a greater proportion of the costs funded through out-of-pocket payments, such as pharmaceuticals and dental services, Indigenous expenditure is generally lower relative to the non-Indigenous population. For example, the average per person expenditure on dental services was $149 for Indigenous Australians, compared with $355 for non-Indigenous Australians.

A significant proportion of Aboriginal and Torres Strait Islander people live in Remote and Very remote areas and this has an effect on the cost of delivering goods and services. In 2010-11, it was estimated that $6,625 was spent per Indigenous person in Remote/Very remote regions, compared with $3,904 per Indigenous person in Major cities.

Who pays for health and how has this changed over time?

Funding for health goods and services comes from a range of sources, including the Australian Government; state, territory and local governments; and non-government sources, such as private health insurers, out-of-pocket payments by individuals and injury compensation insurers. Decisions about where and when money is spent on health often involve interactions between multiple bodies, including funders, providers and consumers.

Expenditure from all sources of funds has increased over the past decade (Figure 2.7). Governments have remained the dominant source of funding for health in Australia, with the Australian Government continuing to provide the majority of health funding. The share of funding provided by the Australian Government has declined, however, and so has the share provided by non-government sources, which includes individual out-of-pocket expenditure. The share provided by state and territory governments has increased.

In 2011-12, governments funded $97.8 billion, or 69.7% of total health expenditure ($140.2 billion) in Australia. The Australian Government contributed $59.5 billion, while the state and territory governments contributed $38.3 billion (Figure 2.7 and 2.8).

The Australian Government's contribution to total health expenditure dropped from 44.0% in 2001-02 to 42.4% in 2011-12. The state and territory contribution grew steadily from 23.2% to 27.3% over the same period (Figure 2.8).

In 2011-12, non-government sources (individuals, private health insurance and other non-government sources) funded $42.4 billion, or 30.3%, of total health expenditure in Australia. This was down from 32.8% in 2001-02.

Figure 2.7: Total health expenditure, by source of funds, constant prices, 2001-02 to 2011-12 ($ million)

Line chart showing the trending increase in total health expenditure between 2001-02 and 2011-12 of the Australian government, states and territories, individuals and private health insurance. Other non-government expenditure saw no significant net change.

Source: AIHW health expenditure database.

Figure 2.8: Total health expenditure, by source of funds as a proportion of total health expenditure, constant prices, 2001-02 to 2011-12 (per cent)

Line chart showing the trending decline in total health expenditure as a proportion of total health expenditure for the Australian Government between 2001-02 and 2011-12, and the fluctuation in other sources of funds (states and territories, individuals, private health insurance and other non-government).

Source: AIHW health expenditure database.

The largest share of non-government funding, $24.3 billion, was directly from individuals. Private health insurers funded $11.2 billion of health expenditure in 2011-12. Most of this funding was also sourced from individuals through private health insurance premiums.

Despite total expenditure growing faster than the broader economy, the main funders of health have not necessarily been spending a higher proportion of their incomes or revenues on health. Prior to the global financial crisis (GFC), which had its beginnings in 2007-08, the ratio of all government health expenditure to taxation revenue was relatively stable at around 20% (Figure 2.9). That suggests that, in broad terms, government revenues were increasing at the same rate as health expenditure. While the ratio of expenditure to GDP was increasing, the ratio to government revenues was relatively stable.

The GFC slowed government revenues without having an immediate impact on health expenditure. This increased the health to revenue ratio. The ratio has decreased slightly since 2009-10 as growth in government tax revenues has increased again. In 2011-12, the ratio of government health expenditure to taxation revenue was 25.6%.

Figure 2.9: The ratio of health expenditure to tax revenue across all governments, current prices, 2001-02 to 2011-12 (per cent)

Line chart showing the trending increase in the ratio of health expenditure to tax revenue across all governments between 2001-02 and 2011-12.

Source: AIHW health expenditure database.

Main drivers of health expenditure

Many studies have been conducted into the drivers of health expenditure over the past decade. Population ageing has attracted particular attention in this context (OECD 2013; Productivity Commission 2005, 2013; Treasury 2010). This is largely due to the fact that health care expenditure is generally higher in the older age groups. In 2008-09, expenditure in Australia on adults aged 85 and over was almost 20 times as high per person as expenditure on children aged 5 to 14 (Figure 2.10). This was true for both men and women.

On the surface this suggests that as a population ages, the number of people in the age groups where the most expenditure occurs will increase and, therefore, demand for health expenditure will increase (see Chapter 6 'Ageing and the health system').

The relationship between ageing and demand for health services is complex, however, and the extent to which current and projected growth in health expenditure can be attributed to population ageing is the subject of much debate. And in any case, over the past 25 years health expenditure in Australia has risen at a faster rate than either population growth or ageing.

Figure 2.10: Allocated health expenditure per person, by age and sex, 2008-09

Line chart showing the trending increase in health expenditure by age group. Data are shown for 2008-09 for both sexes. Trends for both sexes are similar with a spike for females around age 25-34. After ages 55-64 men begin to outpace women in terms of expenditure.

Source: AIHW health expenditure database.

Much of the growth in health expenditure can be attributed to non-demographic factors such as the development of new technologies, pharmaceuticals and diagnostic and treatment techniques-these enable a wider range of health conditions to be managed more effectively. Correspondingly, community expectations of the health system and access to such technologies and services have also increased, driving health expenditure up faster than demographic factors would predict (Coory 2004; OECD 2013; Productivity Commission 2005, 2013; Richardson & Robertson 1999; Treasury 2010).

The effect of population ageing on demand (and costs) for health services may also be mitigated by the fact that although lifetime health costs are concentrated in the last few years of life, as healthy life expectancy increases, end of life health costs are postponed (Calver et al. 2006; Karamanidis et al. 2007; OECD 2013). Some have cautioned, however, that over time an ageing population (perhaps with higher levels of chronic disease) with high expectations of access to new health technologies and quality services, will increase and compound the independent effect of population ageing on health system costs (Goss 2008; Productivity Commission 2005, 2013).

The state of the broader economy plays an important role in determining health expenditure. As shown earlier in this article, analysis of AIHW health expenditure data and international experience since the GFC suggests that while health expenditure has grown faster than the broader economy, it has tended to keep pace with growth in the revenue of governments, the key funders of health in Australia (Figure 2.9). This in turn suggests that health expenditure tends to correlate with increased revenue more strongly than increased demand for health services. Many OECD countries are experiencing a similar phenomenon (OECD 2013).

Another important and related factor in determining health expenditure is the efficiency of the health system, which is heavily influenced by government policies. In 2010, the OECD argued that life expectancy across OECD countries could be increased by 2 years if all countries had health systems as efficient as the most efficient systems across the OECD countries. They argued that this could be done without any additional expenditure. While Australia was identified as having one of the more efficient health systems, the OECD still suggested that life expectancies in Australia could be improved through improved health system efficiency (OECD 2010).

What is missing from the picture?

The AIHW's definition of health expenditure closely follows the definitions and concepts provided by the OECD's System of Health Accounts framework (OECD 2000). It excludes:

  • expenditure that may have a 'health' outcome but that is incurred outside the health sector (such as expenditure on building safer transport systems, removing lead from petrol, and educating health practitioners)
  • expenditure on personal activities not directly related to maintaining or improving personal health
  • expenditure that does not have health as the main area of expected benefit.

There are some data limitations in the AIHW health expenditure database, including:

  • Total health expenditure excludes some sources of expenditure, including Australian Defence Force expenditure, some local government expenditure and some non-government organisation expenditure.
  • There are some areas of expenditure for which data sources could be improved. For example, over-the-counter pharmaceuticals spending in Australia currently has no systemised data collection.
  • Much expenditure data cannot be apportioned to specific geographic areas.
  • There is a lack of comprehensive welfare expenditure information in Australia, which limits the degree to which comparisons and links can be made to this and other sectors.
  • There is a lack of health outcome measures that can be linked with health expenditure to assess the effectiveness of Australia's health care system.

A particularly important gap in the available data is estimates of how much money is spent on particular diseases, with the most recent estimates being from 2008-09. Not all health expenditure can be readily allocated to disease or injury groups-in 2008-09, the figure was around 30% of recurrent health expenditure. This included capital expenditure, expenditure on non-admitted patients, over-the-counter pharmaceuticals, patient transport services, aids and appliances, administration, most community and public health services, and other health practitioner services.

Disease expenditure information, while useful in its own right, does not necessarily give an indication of the loss of health due to that disease, the priority for intervention, or the need for additional expenditure.

Where do I go for more information?

Further information on health expenditure in Australia is available on the AIHW website.

Health expenditure Australia 2011-12 (AIHW 2013a) contains detailed information and analyses of health expenditure and funding in Australia.

Expenditure on health for Aboriginal and Torres Strait Islander people 2010-11 (AIHW 2013b) provides estimates on health expenditure for Aboriginal and Torres Strait Islander people.

Expenditure on health for Aboriginal and Torres Strait Islander people: an analysis by remoteness and disease (AIHW 2013c) complements the preceding report and provides disaggregated expenditure estimates at the regional level as well as for specific disease and injury groups. These reports are available for free download. Further information on health expenditure can also be found in the online data tables and cubes.

This publication provides the most recent estimates of disease expenditure in Australia (2008-09). Further information on disease expenditure in Australia is available on the AIHW website.

References

AIHW (Australian Institute of Health and Welfare) 2013a. Health expenditure Australia 2011-12. Health and welfare expenditure series no. 50. Cat. no. HWE 59. Canberra: AIHW.

AIHW 2013b. Expenditure on health for Aboriginal and Torres Strait Islander people 2010-11. Health and welfare expenditure series no. 48. Cat. no. HWE 57. Canberra: AIHW.

AIHW 2013c. Expenditure on health for Aboriginal and Torres Strait Islander people 2010-11: an analysis by remoteness and disease. Health and welfare expenditure series no. 49. Cat. no. HWE 58. Canberra: AIHW.

Calver J, Bulsara M & Boldy D 2006. In-patient hospital use in the last years of life: a Western Australian population-based study. Australian and New Zealand Journal of Public Health 30:143-6.

Coory M 2004. Ageing and healthcare costs in Australia: a case of policy-based evidence? Medical Journal of Australia 180:581-3.

Garnaut R 2008. The great crash of 2008. Melbourne University Press.

Goss J 2008. Projection of Australian health care expenditure by disease, 2003 to 2033. Health and welfare expenditure series no. 36. Cat. no. HWE 43. Canberra: AIHW.

Karamanidis K, Lim K, Da Cunha C, Talyor L & Jorm L 2007. Hospital costs of older people in New South Wales in the last year of life. Medical Journal of Australia 187:383-6.

OECD (Organisation for Economic Co-operation and Development) 2000. A system of health accounts, version 1.0. Paris: OECD.

OECD 2010. 'Health care systems: getting more value for money'. OECD Economics Department policy notes, No. 2. Paris: OECD.

OECD 2013. 'What future for health spending?' OECD Economics Department policy notes, No. 19 June 2013. Paris: OECD.

Productivity Commission 2005. Economic implications of an ageing Australia. Research report. Canberra: Productivity Commission.

Productivity Commission 2013. An ageing Australia: preparing for the future. Productivity commission research paper. Canberra: Productivity Commission.

Treasury 2010. Australia to 2050: future challenges. Intergenerational report series no. 3. Canberra: Treasury.


2.3 Who is in the health workforce?

Health practitioners include medical practitioners, nurses and midwives, and allied health professionals such as medical practitioners, psychologists and optometrists.

Nurses and midwives are the largest group in the health workforce, with 290,144 nurses and midwives employed in 2012 (Table 2.1). The number of full-time equivalent nurses and midwives employed for every 100,000 people is almost 3 times that of the next largest profession, medical practitioners. In 2012, there were 1,124 full-time equivalent nurses and midwives employed for every 100,000 people. There were 374 medical practitioners and, in other examples, 85 psychologists and 15 podiatrists.

Table 2.1: Employed health practitioners 2012
Practitioner type FTE rate(a)   Number
Nurses and midwives 1,124 290,144
Medical practitioners 374 79,653
Pharmacists  89 21,331
Psychologists  85 22,404
Physiotherapists 80 20,081
Dental practitioners (includes allied) 74 17,583
Medical radiation practitioners 47 7,806
Occupational therapists 45 7,231
Optometrists  17 4,066
Chiropractors 16 4,029
Podiatrists  15 3,491
Chinese medicine practitioners 13 3,580
Osteopaths 6 1,543
Aboriginal and Torres Strait Islander health practitioners 1 233
  1. FTE rate is the full-time equivalent number of employed per 100,000 population.
  2. Full-time equivalent number is based on a 38-hour week except for medical practitioners where it is based on a 40-hour week.

Source: National Health Workforce Data Set 2012.

The number of nurses and midwives and dental practitioners has increased significantly in the last few years. For example, the number of full-time equivalent medical practitioners employed rose by 16% from 2008 to 2012 and the number of nurses and midwives rose by 7% (see Chapter 9 'Indicators of Australia's health'). In part this reflects an increase in the availability of training places for people studying in the relevant fields. For example, the number of domestic commencements in medicine increased between 2007 and 2012 by 18.6% (DoHA 2012, 2013). For every 1,000 people employed in Australia (ABS 2014), there were 35 medical practitioners and nurses and midwives employed in 2008. This increased to 36 in 2012.

More broadly, between the 2006 and 2011 Australian Bureau of Statistics Censuses, the number of people employed in the health care and social assistance industry increased from 956,150 to 1,167,633 (22.1%). This rise was similar to that between 2001 and 2006 (Table 2.2).

Table 2.2: Number of people employed in the health care and social assistance industry(a)
Year Males Females Persons
2001 169,673 623,718 793,391
2006 204,501 751,649 956,150
2011   245,315   922,318   1,167,633  
  1. Based on the Australian and New Zealand Standard Industrial Classification (ANZSIC) 2006, Revision 1 released in 2008. Data for 2001 and 2006 have been concorded.

Source: ABS 2012.

International comparisons

Australia has a similar number of practising medical practitioners per capita as the OECD average and a higher per capita number of practising nurses (Figure 2.11). International comparisons are affected by different regional distributions, scopes of practice and by different hours worked in the various countries.

Geographic distribution

  • The concentration of health professionals in Major cities is greater than that for the broader population (Figure 2.12).
  • The exception is Aboriginal and Torres Strait Islander health practitioners, where the full-time equivalent rate of employed practitioners is greatest in Remote and Very remote areas.

Figure 2.11: Practising medical practitioners and nurses, selected countries, 2011

Column chart showing the number of nurses and medical practitioners per 100,000 population in selected countries in 2011. Of the countries shown, Switzerland had the highest number of nurses with over 1,600. Greece had the highest number of medical practitioners with over 600.

Note: Data include not only those providing direct care to patients, but also those working in the health sector as managers, educators, researchers.

Source: OECD 2013.

What is missing from the picture?

The data presented here do not account for the demand for health care or consider changes in the productivity of the workforce. In the future, longitudinal data from the National Registration and Accreditation Scheme, introduced in 2010, may enable a better understanding of the movement of different types of health professionals between work areas and geographical areas.

Where do I go for more information?

More information on the health workforce is available in the following AIHW reports, which are available for free download:

Allied health workforce 2012,

Dental workforce 2012,

Medical workforce 2012, and

Nursing and midwifery workforce 2012.

Figure 2.12: Proportion of selected health practitioners employed in Major cities, 2012

Bar chart showing that with the exception of A&TSI health practitioners, the proportion of health practitioners employed in major cities is greater than the proportion of the population who live in major cities. Chinese medicine practitioners were the category with the highest proportion (over 85%) followed by medical radiation practitioners (with over 80%).

Source: National Health Workforce Data Set 2012.

References

ABS (Australian Bureau of Statistics) 2012 Census of Population and Housing. Time series profile. ABS cat. no. 2003.0. Canberra: ABS.

ABS 2014. Labour Force, Australia, January 2014. ABS cat. no. 6202.0. Canberra: ABS.

DoHA (Department of Health and Ageing) 2012. Medical Training Review Panel sixteenth report. Canberra: DoHA. Viewed 16 August 2013.

DoHA 2013. Medical Training Review Panel sixteenth report. Canberra: DoHA. Viewed 16 August 2013.

OECD (Organisation for Economic Co-operation and Development) 2013. Health at a glance 2013: OECD indicators. Paris: OECD Publishing. Viewed 24 February 2014.