Aboriginal and Torres Strait Islander people and primary health care: patterns of service use, preferences, and access to services 2024

The following section discusses the 5 main themes emerging from the results of the project.

Theme 1 – Service availability is good at a national level, but it is critical to look at lower level geographies and the availability of specific service types

One of the key questions for this project was the extent to which Aboriginal and Torres Strait Islander people have access to primary health care services, what types of services are available, and what groups/areas have service gaps.

The findings from both the NATSIHS analysis and the spatial analysis show that, at the national level, nearly all Aboriginal and Torres Strait Islander people have a service available within their perceived local area (NATSIHS) or within a 60-minute (1–hour) drive time (spatial analysis).

For example, the survey data indicate that, in 2018–19, 99% of an estimated 814,000 Aboriginal and Torres Strait Islander people had access to some form of health service in their local area.^[1] The drive time analysis showed a similar pattern, with just over 972,000 of 983,000 people having a primary health care service within a 1–hour drive.

However, these national numbers mask important variation across Australia, both geographically and for particular subgroups of people.

What types of primary health care services are available in people’s local areas and how does it vary?

The NATSIHS data showed that more people lived in areas with mainstream GPs than in areas with an Aboriginal Medical Service (AMS)/Community Clinic (CC) – 689,500 (85%) compared with 547,800 (67%).

The locations of these services were not randomly distributed – those living in more remote areas^[2], who had lower incomes, and who lived in more disadvantaged areas were more likely to report having an AMS/CC in their local area, while mainstream GPs were more concentrated in more urban and more advantaged areas. This pattern is expected as AMS/CC services are targeted towards areas and populations of greater need.

Of course, people may live in areas with more than one type of service. Further analysis of the self-reported availability of primary care services showed that, in 2018–19, an estimated:

• 440,000 (54%) of the estimated 814,000 Aboriginal and Torres Strait Islander people lived in areas with both an AMS/CC and a mainstream GP
• 249,500 people (31%) lived in areas with only a mainstream GP
• 107,900 people (13%) lived in areas with only an AMS/CC
• 17,000 people (2.1%) lived in areas with neither an AMS/CC nor a mainstream GP.

Those living in Very remote areas and in Major cities were the least likely to report having both an AMS/CC and a mainstream GP in their local area (33% and 51%, respectively). Sixty per cent of those in Very remote areas had access only to an AMS/CC, and 45% of those in Major cities reported only mainstream GPs in their local areas. Those living in the Northern Territory were the most likely to report an AMS/CC as the only primary health care service in their area, followed by Queensland and Western Australia (53%, 17% and 14%, respectively).^[3]

Where are the service gap areas and how does it vary?

While the NATSIHS focuses on perceived availability of services, the spatial analysis is used to look at where services are available within particular drive times. The drive time results showed that, overall, there were 131 IAREs (of 412) where more than 200 people lived outside a 1-hour drive to one or more service types (which include ACCHOs, any IAHP‑funded service, mainstream GPs). These are categorised as service gap areas.

From a policy perspective, the highest priority areas are likely to be those where Aboriginal and Torres Strait Islander people have little to no access to any primary health care service. Of the 131 service gap areas, there are 14 where more than 200 people live outside a 1–hour drive to any of the included primary health care services (Table 1), all but one of which are Very remote.^[4]

There are also an additional 46 IAREs with no IAHP-funded service. A higher proportion of these are regional IAREs (30), with 15 Remote/Very remote IAREs, and one IARE classified as a Major city, but where the majority of the population who live more than 1 hour from an IAHP-funded service are in regional Statistical Area Level 1 areas (SA1s).

Sources: Service locations for the IAHP-funded services are from the 2022–23 OSR data collection and include only those with declared primary health functions (excluding sites only providing maternal and child health services). Mainstream GP locations are from the NHSD, excluding sites also in the OSR. For more details see Appendix 1 in the PDF.

Theme 2 – Most Aboriginal and Torres Strait Islander people have a usual source of care, but are not always able to use the type of primary health care service they prefer (availability plays a key role)

Another key question for this project was not just whether Aboriginal and Torres Strait Islander people have primary health care services in their area, but whether they have a usual source of care and how that matches with their preferred source of care.

The NATSIHS results suggest that, in 2018–19, nearly all (92%) Aboriginal and Torres Strait Islander people had a usual source of care (751,400 of 814,000 people). It is not known whether those without a usual source of care used multiple sources or whether they had not needed health care.

What types of primary health care services would Aboriginal and Torres Strait Islander people prefer to use, and what factors are associated with those preferences?

People’s preferences for primary health care service providers are related to a number of factors, including availability/accessibility, familiarity, costs, previous experiences, waiting times, and relationships with individual health practitioners. The NATSIHS asked respondents about the type of health service they would like to use if they had the choice (but did not ask why they selected that particular type of service). However, previous research has shown that Aboriginal and Torres Strait Islander clients of ACCHOs particularly value the welcoming/culturally safe environment in which care is delivered, its accessibility, and the flexibility and breadth of services offered (comprehensive primary health care) (Gomersall et al. 2021).

Nationally, the results indicate that 48% of Aboriginal and Torres Strait Islander people (390,600 of 814,000) would prefer an AMS/CC and 43% (350,000) a mainstream GP. Fewer than 7% preferred a hospital as their main source of care.

Preference for an AMS/CC was higher among those living in regional and Remote/Very remote areas, those living in areas with higher levels of disadvantage, females compared with males, adults who had experienced unfair treatment in the past 12 months and those reporting stronger cultural ties (highlighting the importance of culturally safe care).

It is important to note that preferences are strongly related to the types of services available in people’s local areas. The results from a multivariate regression model on the factors predicting preference for an AMS/CC (compared with any other type of service) showed that, after controlling for other factors, the strongest predictor of preference for an AMS/CC was having one in a person’s local area. Those who had only an AMS/CC in their area were 5.2 times as likely to prefer an AMS/CC as those without one, and those who had both an AMS/CC and a mainstream GP in their area were 2.3 times as likely to prefer an AMS/CC.

Where did people usually get their care?

Usual source of care is strongly related to the services available in a person’s local area as well as preferences. However, it is also important to note that:

• some people will travel outside their local area for a service they prefer
• there may be different services in the area in which people work compared with the area in which they live (so they may access care near where they work)
• availability does not mean that a service will have the capacity to serve everyone in their area.

The results showed that of 814,000 Aboriginal and Torres Strait Islander people, 439,500 (54%) had a mainstream GP as their usual provider and 277,100 (34%) had an AMS/CC.

At a broad level, consistent with how primary health care services are distributed throughout Australia, there is a strong relationship between remoteness and usual source. Around 15% of those living in Major cities had an AMS/CC as their usual source of care, compared with 75% of those living in Very remote areas, while 75% of those in Major cities had a mainstream GP compared with 27% of those in Remote areas.^[5]

How well does usual source match up with preferred source? Who has an unmet need for an AMS/CC?

Putting these numbers together with where people preferred to go shows that nearly all Aboriginal and Torres Strait Islander people who expressed a preference for a mainstream GP had one as their usual source of care (88%) – fewer than 3% used an AMS/CC.

However, of the 390,600 people who expressed a preference to attend an AMS/CC, 248,000 (64%) reported one as their usual source of care, meaning that 142,200 Aboriginal and Torres Strait Islander people did not use an AMS/CC even though that was their preferred source. Nearly 30% used mainstream GPs and another 5.7% reported that they had no usual source of care.

The findings indicate that among those who preferred an AMS/CC but did not have one as their usual source there were around:

• 87,000 people with a long-term and ongoing health condition
• 56,000 people with disability
• 30,000 adults with high/very high levels of psychological distress
• 24,000 adults who had experienced unfair treatment over the previous 12 months.

There were also considerable geographic variations in unmet need (which are a combination of both the distribution of where Aboriginal and Torres Strait Islander people live and where services are located). The highest numbers of Aboriginal and Torres Strait Islander people with an unmet need for an AMS/CC were:

• 68,000 people in Major cities and 42,000 people in Inner regional areas
• 57,000 people in New South Wales and 39,000 people in Queensland
• 65,000 people in areas in the lowest Socio-Economic Indexes for Areas (SEIFA) quintiles and 57,000 in the next 2 quintiles (noting that the proportions of people in these areas who used an AMS/CC is higher than for those in more advantaged areas).

The impact of having an AMS/CC in the local area is clear, with 91% of those with only an AMS/CC in their area using one. Notably, among those who said they had both an AMS/CC and a mainstream GP in their local area, 72% reported using an AMS/CC as their usual source.

Results from the multivariate regression for Aboriginal and Torres Strait Islander people aged 18 and over who preferred to use an AMS/CC found that the strongest predictor of being able to use an AMS/CC was having one in their local area. Controlling for all other variables:

• those who had only an AMS/CC available in their local area were 77 times as likely to be able to use an AMS/CC as those with no AMS/CC available
• those who had both an AMS/CC and a mainstream GP in their area were 24 times as likely to be able to use an AMS/CC as those without an AMS available.

Theme 3 – Satisfaction with primary health care is high, but Aboriginal and Torres Strait Islander people still have unmet needs for primary health care services (especially dental care)

Overall, people rated their own personal GP and experience with the health care they received in the past year quite highly – fewer than 10% rated the health care they received as either poor or fair (noting that these questions were asked only in non-remote areas).

Unmet need for primary health care can be measured in several ways. The NATSIHS asked respondents directly if there had been an occasion within the past 12 months when they needed a service but did not access it (and to choose as many reasons from a list as applicable).^[6] Respondents were also asked the timing of their most recent visit to a selected set of primary care providers – these data can be used to compare timing against population‑wide best practice guidelines (for example, seeing a GP at least once a year for a health check and seeing a dentist at least once a year for cleaning/a check-up).

What does the timing of most recent visits tell us?

The NATSIHS results show that a much higher proportion of Aboriginal and Torres Strait Islander people visited a GP in the past 12 months than saw a dentist. In 2018–19, out of 792,600 Aboriginal and Torres Strait Islander people, 688,200 had seen a GP in the past 12 months (87%), 95,500 (12%) had visited one more than 12 months ago, and 8,900 had never visited a GP (1.1%).

The pattern for dental visits is quite different. Out of 775,000 Aboriginal and Torres Strait Islander people aged 2 and over, 338,500 (44%) had seen a dentist in the past 12 months. Another 129,400 (17%) had seen a dentist between 12 months and 2 years before the survey, leaving one-quarter (194,600) who had not had a dental visit in the last 2 years and 94,600 (12%) who had never had a dental visit.

How many people had an unmet need for GP/dental services and what were their reasons?

The results from the direct questions on unmet needs show the same patterns. In 2018–19, out of 814,000 Aboriginal and Torres Strait Islander people, 101,400 (13%) had at least one instance in the past 12 months when they needed to see a GP but did not, while out of 774,600 Aboriginal and Torres Strait Islander people aged 2 and over, 146,800 (19%) had at least one instance in the past 12 months when they needed dental care but did not get it.

There are particular groups for whom unmet need for both GPs and dentists was higher, including those:

• in Major cities and regional areas
• in areas of greater disadvantage
• whose usual source of care was not an AMS/CC
• who had experienced unfair treatment/discrimination in the past 12 months
• with poorer self-assessed health status
• with a long-term health condition
• with disability.

Interestingly, the reasons cited for unmet need differed for GPs and for dentists:

• for GPs, the top 5 reasons were too busy; decided not to seek care; long waiting times; transport/distance; dislikes (service/professional, afraid, embarrassed)  
• for dentists, the top 5 reasons were cost; too busy; dislikes (service/professional, afraid, embarrassed); long waiting times; decided not to seek care.

While cost was the top reason for unmet need for dentists, it was not in the top 5 reasons for unmet need for GPs, where more personal reasons (such as being too busy and deciding not to seek care) were the top 2. This is likely to reflect the impact of Medical Benefits Schedule (MBS) rebates for GP services but not for dental care, noting that the proportion reporting cost as a reason for unmet dental care was twice as high among those whose usual source of care was a mainstream GP compared with those whose usual source was an AMS/CC.

Theme 4 – Importance of ACCHOs/IAHP-funded services

Both the spatial analysis and the NATSIHS results highlight the importance of ACCHOs and other IAHP-funded services in providing primary health care for Aboriginal and Torres Strait Islander people. Particularly in more remote areas, IAHP-funded services (both ACCHOs and non-ACCHOs) are often the only source of primary health care.

The drive time results showed that 15% of those in Remote areas and 64% of those in Very remote areas live more than a 1-hour drive to a mainstream GP. When IAHP-funded services are included, it means that 99% of those in Remote areas and 89% of those in Very remote areas live within a 1-hour drive of at least one primary health care service.^[7]

The cultural and financial effects of AMS/CC services are shown throughout the NATSIHS results. As discussed previously in this summary, they are an important source of care for those who have experienced unfair treatment and those with stronger cultural ties.

Those whose usual source of care was an AMS/CC were more likely than those whose usual source of care was a mainstream GP to say their GP always spent enough time with them, listened to them, showed respect for them, and explained things clearly.^[8]

AMS/CCs also help to defray the costs of health care for their clients, particular for non-GP primary health care services. There are striking differences in who was required to provide a co-payment (among those who had seen a provider in the past 2 weeks), particularly for specialists and for other health providers (which includes allied health services):

• While co-payments for consultations with GPs were relatively infrequent overall, they were higher for those whose usual source of health care was a mainstream GP compared with those whose usual source of care was an AMS/CC (5.9% to <1%).
• There was a considerable difference in co-payments for specialists and other health providers between those whose usual source of care was a mainstream GP (28% and 29%, respectively) and those whose usual source of care was an AMS/CC (7.3% and 6.0%, respectively).

Theme 5 – What is considered ‘local area’ varies by remoteness

Another important question for the project was whether there was alignment between what people perceived as service availability in their local areas and what the spatial analysis showed (for example, whether or not there were services).

The NATSIHS results were compared with the drive time results using 2 different time boundaries (15 minutes and 30 minutes) across remoteness areas (acknowledging that the perception of what someone’s local area is may differ substantially between those in more urban and more remote areas).

All IAHP-funded services were included as the closest representation of AMS/CC because they capture the ‘community clinic’ side.

For those in Major cities and Inner regional areas, the 15-minute drive time matches closely with people’s perceived availability of services in local areas (it is also important to note that service locations themselves may have changed between 2018–19 and 2022–2024). However, when the longer drive time of 30 minutes or less is considered, there is little to no alignment between the survey results and drive time results.

The results for those in Outer regional areas are not as clear cut. The survey respondents were more likely to indicate that the only source of primary care in their local area was an AMS/CC (17%), while the results from the spatial analysis indicate that it was less than 2%.

For those in Remote and Very remote areas, the 30-minute drive time limit seems to match more closely with the NATSIHS results. It is also interesting that in Very remote areas, 4.4% of Aboriginal and Torres Strait Islander people indicated that there was no primary care service in their local area, while the drive time results showed that for 16% of people there was no service within a 30-minute drive time. This may be due either to data gaps or that people in more remote areas consider a much larger area/larger drive time boundary to be their local area.

Notes:

1. The service types were AMS/CC, hospital, other doctor not from an AMS, traditional healer, other, none; respondents were asked to tick all that were available. Respondents defined local areas as they saw fit – they were not given instructions to use specific boundaries. Around 6,500 people would say there was no health service in their area, but the standard error is high and the estimate should be used with caution.
2. Information about remoteness is summarised in this report by the Australian Statistical Geographical Standard (ASGS) for Remoteness Areas (RA). The ASGS's remoteness structure categorises geographical areas in Australia into 5 remoteness areas, which are characterised by a measure of relative geographic access to services: Major cities, Inner regional, Outer regional, Remote, Very remote. For more information, see the ABS’s Australian Statistical Geography Standard (ASGS).
3. Detailed tables of state/remoteness could not be constructed for this variable because of small numbers/suppression rules.
4. See Chapter 6 for the full results and discussion of the other 117 IAREs.
5. The small number of Aboriginal and Torres Strait Islander people in Very remote areas with a mainstream GP meant that the estimate has a high standard error and should be used with caution.
6. There is no information about why the respondents felt they needed to see a GP (or dentist) in the first place, so caution must be used around these results.
7. Again, it is important to note that there may be primary care services that are available on the ground but not included in either the NHSD or OSR.
8. Questions were asked only of those in non-remote areas.