Current Issues Brief 18 1999-2000

The National Health Priority Areas Initiative

Jacqueline Dewar
Social Policy Group
27 June 2000

Major Issues

The Australian health care system currently faces the dual challenge of containing costs and maximising the health of the population. In 1997-98, total recurrent health care expenditure⁽¹⁾ in Australia was estimated to be $47.3 billion, an increase of $3.0 billion on the 1996-97 estimate of $44.3 billion.⁽²⁾ As a percentage of GDP, health care expenditure in 1997-98 was 8.4 per cent, which was slightly higher than the 8.3 per cent recorded in the previous year and slightly higher than the 8.2 per cent of GDP for the years since 1991-92.⁽³⁾ While there has been a reduction in the rate of health expenditure growth, health care expenditure continues to rise. As finances become more limited globally, there is a need to seek cost efficient and cost-effective strategies for health systems and health care interventions.⁽⁴⁾ In Australia the National Health Priority Areas (NHPA) initiative is one such strategy.

The NHPA initiative is a collaborative effort between the Commonwealth, State and Territory governments and draws on relevant expertise in the non-government sector. It seeks to bring a policy emphasis to areas that are recognised as posing the greatest burden of disease in the community and for which there is the possibility of significant burden reduction. The national health priority areas together represent around 70 per cent of the burden of illness and injury currently experienced by the Australian community. The intended scope of the NHPA encompasses the 'continuum of care' which includes prevention, screening and early invention, treatment, rehabilitation, continuing care, palliation and health research. The NHPA initiative seeks to improve the health and well-being of the Australian population through:

• reducing the burden of illness
• reducing health inequalities
• access to quality care and health services across the health continuum, and
• partnership between all sectors.

Australian Health Ministers have endorsed six NHPAs to date: Cardiovascular Health, Cancer Control, Injury Prevention and Control, Mental Health, Diabetes Mellitus and Asthma.

As part of the strategic approach to the NHPAs, a national baseline report on each priority area has been prepared for Australian Health Ministers, with the exception of Asthma, which will be reported upon later this year.

A recent independent review of the NHPA initiative found that there was strong cross sector support for the initiative, and the inclusion of certain diseases within the NHPA initiative has delivered positive health outcomes. While the disease focus of the NHPAs was not supported by all, it was generally considered the most appropriate way forward. Structural problems have been identified with the NHPA initiative and there appears to have been a lack of impact on priority populations, notably the Indigenous population.

The report of the independent review of the NHPA initiative was circulated to stakeholders for comment and deliberation, however it has not been released more widely. At its meeting in February 2000, the Australian Health Ministers' Advisory Committee considered, but did not formally endorse, the report. It is understood, however, that the report has served to inform considerations of the future development of the NHPA initiative.

Although assessment indicates that the NHPA initiative has enjoyed mixed success to date, it is an evolving and ongoing process. However it appears that many challenges remain.

Introduction

The National Health Priority Areas (NHPA) initiative is a collaborative effort of Commonwealth and State and Territory governments, which draws upon relevant expertise in the non-government sector, to target diseases and conditions where significant gains could be achieved in terms of costs and in the health of Australia's population. In broad terms the initiative is said to:

• monitor health outcomes and progress in the NHPA
• identify the most appropriate and cost-effective points of intervention
• identify the most appropriate role for government and non-government organisations in fostering the adoption of best practice
• identify and discourage inappropriate practice, and
• address some of the underpinning determinants of health such as education, employment, and socioeconomic status.⁽⁵⁾

The National Health Priority Action Council (NHPAC), formerly the National Health Priority Committee is responsible for the operation of the NHPA initiative. The NHPAC is a subcommittee of the Australian Health Ministers' Advisory Council (AHMAC) and its membership is currently under review. The NHPAC advises AHMAC on the coordination of the NHPA initiative but does not have program funding to allocate to initiatives within the NHPA.⁽⁶⁾ The Council is expected to plan and oversight the future development of the NHPA initiative.

Australian Health Ministers have endorsed six NHPA: Cardiovascular Health, Cancer Control, Injury Prevention and Control, Mental Health, Diabetes Mellitus and Asthma.

As part of the strategic approach to the NHPA initiative, baseline reports on the NHPAs have been prepared for Australian Health Ministers, with the exception of Asthma which will reported upon later this year. The reporting process is significant in developing a national approach to each of the identified areas. The First Report on National Health Priority Areas 1996, was released in August 1997. This was followed in July 1998 by the National Health Priority Areas Report: Cancer Control 1997 and National Health Priority Areas Report: Injury Prevention and Control 1997. In July 1999 three further reports, the National Health Priority Areas Report: Diabetes Mellitus 1998, the National Health Priority Areas Report: Mental Health 1998 and the National Health Priority Areas Report: Cardiovascular Health 1998 were released. A report on Asthma is being prepared in 2000.

AHMAC has now agreed that the biennial reporting requirement should be undertaken by the Australian Institute of Health and Welfare through its Australia's Health biennial series.

In light of the significance of the initiative, its relatively low profile outside of the health sector and the release of the most recent NHPA reports, this paper provides an overview of the NHPA initiative. A brief summary of the status and cost of health and disease in Australia is provided in order to contextualise the NHPA initiative. The development of the NHPA initiative is discussed and brief descriptions provided of similar initiatives in the United Kingdom and the United States. Each of the six NHPAs is examined together with the progress to date made towards the agreed national health outcomes. This analysis will comment on the potential value of the NHPA initiative and national health outcomes and will canvass its likely future development.

The paper makes use of the most recent available data. Updated data on each NHPA is expected to be included in Australia's Health 2000, which is to be launched by the Australian Institute of Health and Welfare in late June 2000.

What is Health?

The national President of the Public Health Association of Australia, Fran Baum, suggests that health has a cultural significance in modern society and argues:

Despite this significance in developed secular cultures the word health is difficult to define as it carries substantial social, professional and cultural baggage. Its contested nature is evident in the variety of ways it is defined by different groups of health professionals, health economists and consumers. Commonly, definitions have tended to focus on ill health rather than health, that is: what health isn't rather than what it is. The limitations of health being defined as 'the absence of disease' led the World Health Organization (WHO) to define health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. This widely used definition locates health within a social context and places an emphasis on positive experience. However, this somewhat utopian definition has been criticised as measurements of health are not available from a single indicator⁽⁸⁾ and concepts such as 'well-being' are difficult to quantify.

In the last decade or so, health as 'outcome' has been a prominent model used by Australian health departments in designing health care policy. Health outcome is commonly defined as a 'change in a patient's current and future health status that can be attributed to antecedent health care'.⁽⁹⁾ While this definition cites an individual's health status, this approach generally refers to an improvement in an acute or chronic problem directed at populations rather than individuals.⁽¹⁰⁾ Consequently it is a useful tool used to monitor the health status of a population. At the October 1996 meeting of the Australian Health Ministers Advisory Council (AHMAC), health as outcome was defined as 'a change in the health of an individual, a group of people or a population, which is wholly or partially attributable to an intervention or series of interventions'.⁽¹¹⁾

What is the State of Australia's Health?

Over the past three decades the health of Australians has continued to improve. Michael de Looper and Kuldeep Bhatia⁽¹²⁾ of the Australian Institute of Health and Welfare, reviewed six broad categories; population, fertility and pregnancy, important causes of ill-health, mortality, health services and resources, and health determinants to conclude that Australia is one of the world's healthiest countries. Infant mortality is low, at 5 deaths per 1000 in the first year of life and average life expectancy is approximately seventy-eight years.

Table 1: Life Expectancy at Birth 1997

Table 2: Infant Mortality Rate 1997

Mortality is one of the best measures of community health or ill health. Approximately 125 000 deaths are recorded in Australia each year. Male mortality continues to exceed female rates. Of the 128 719 deaths recorded in Australia in 1996, 68 206 were males and 60 513 were females.⁽¹³⁾ Deaths of people aged 70 years and over account for 69 per cent of all deaths, 21 per cent occur at ages 50-69, 8 per cent at ages 20-49, and 2 per cent at ages less than 20 years.⁽¹⁴⁾ As Australia's population continues to age the number of deaths each year are expected to rise. The five major causes of death in Australia are ischaemic heart disease, cerebrovascular disease (stroke), lung cancer, chronic obstructive pulmonary disease, and colorectal cancer. There has been a decline in levels of mortality for all areas of between 3.6 per cent to 1 per cent.⁽¹⁵⁾

Life expectancy is another indicator of a population's health. Over the period 1920-22 to 1960-62 the average number of years of life remaining for men aged 65 increased from 12 to 12.5 years. For women the increase in life expectancy for the same period improved from 13.6 to 15.7. Over the past thirty-five years, from 1960-62 to 1996, the life expectancy of men aged 65 increased to 15.9 years and for women aged 65 years to 19.5.⁽¹⁶⁾

However, it should be noted that variations of health status are seen in different sub-populations. Aboriginal and Torres Strait Islander peoples experience poorer health than the general Australian population. This is evident in life expectancy at birth in 1992-94 being 14-18 years lower for Indigenous males and 16-20 years lower for Indigenous females than for other Australians. The crude rate of hospitalisation among Indigenous populations is almost 50 per cent higher than for the total Australian population.⁽¹⁷⁾

Costs of Disease

Health service expenditure in Australia was estimated to be $47.3 billion in 1997-98, an increase of $3.0 billion on the 1996-97 estimate of $44.3 billion. As a percentage of GDP, health care expenditure in 1997-98 was 8.4 per cent, which was slightly higher than the 8.3 per cent recorded in the previous year and slightly higher than the 8.2 per cent of GDP for the years since 1991-92.⁽¹⁸⁾ While there has been a reduction in the rate of health expenditure growth, health care expenditure continues to rise. As finances become more limited globally, there is a need to seek cost efficient and cost-effective strategies for health systems and health care interventions.⁽¹⁹⁾ In Australia the National Health Priority Areas (NHPA) initiative is one such strategy.

In 1993-94 (latest available costings), the cost of disease was estimated to be over 90 per cent of Australia's total recurrent health expenditure or just over $31 billion. This figure does not include the indirect cost of disease, such as, lost production, costs incurred by family members caring for patients, nor the costs of capital expenditure, community health services and public health programs.⁽²⁰⁾ Health system costs for diseases and injuries in 1993-94 are summarised in the table below.

Table 3: Health System Costs for Diseases and Injury 1993-94 ($billion)

Source: Mathers, C. et al., Health System Costs of Diseases and Injury in Australia 1993-94: an analysis of costs, service use and mortality for major disease and injury groups, Canberra, Australian Institute of Health and Welfare, 1998

The total health system costs in 1993-94 for females were $17.9 billion which were 32 per cent higher than for males at $13.5 billion. Total health system costs for males increase with age, peaking in the age group 65-74 years and for females peaking in the age group 25-34 years, representing child-bearing and related genitourinary system health cost.⁽²¹⁾

The Development of the National Health Priority Areas Initiative

Developments in the public health area in the early 1980s led to the World Health Organisation's (WHO) global strategy Health for All by the Year 2000⁽²²⁾, recently renewed as Health for All in the 21^st Century.⁽²³⁾ This strategy proposed that 'all people in all countries should have at least such a level of health that they are capable of working productively and of participating actively in the social life of the community in which they live'. Australia's response to the WHO charter was the Health for All Australians report. The report compiled 20 goals and 65 targets which sought a national approach to improve health and reduce inequalities in health among population groups.⁽²⁴⁾

In 1993 these goals and targets were revised in the report Goals and Targets for Australia's Health in the Year 2000 and Beyond. Reductions in mortality and morbidity, reductions in health risk factors, improvements in health literacy, and the creation of health-supportive environments were the central components of this report.

Better Health Outcomes for Australians was the 1994 report that further refined the goals and targets set out in the previous publications. Four main areas for action were identified: cardiovascular health, cancer control, injury prevention and control, and mental health.

The strategy underlying Better Health Outcomes for Australia continued to develop and be refined culminating in 1996 with the National Health Priority Areas (NHPA) initiative. The National Health Priority Committee (NHPC) first met in March 1997 and held its final meeting in November 1999. The National Health Priority Action Council (NHPAC) is now being established. This Council is expected to plan and oversight the future development of the NHPA initiative.

Developments in Other Countries

The movement towards preventive health is seen in initiatives occurring in other first world countries. Like Australia, countries such as the United States and the United Kingdom have developed national health programs that target major areas of disease cost and burden.

Saving Lives: Our Healthier Nation is a United Kingdom initiative, which aims to improve the health of the population as a whole by increasing the length of people's lives and the number of years people spend free from illness. Four national priority areas have been identified and targets have been set for the year 2010. The UK government has committed 21 billion to the program and estimated that in reaching the set targets 300 000 untimely deaths will be prevented. Saving Lives: Our Healthier Nation identifies cancer, heart disease and stroke, accidents and mental health as its four national priority areas.⁽²⁵⁾

In the United States, Healthy People 2010 is a federal government initiative which aims to increase the quality and years of healthy life, and reduce disparities in health among different population groups. The program has identified 28 specific focus areas and 467 objectives to improve health. Healthy People 2010 recognises that the adoption of goals and objectives will not of themselves improve population health but rather, are part of a larger, systematic approach to health improvement. This systematic approach comprises four key elements:

• Goals
• Objectives
• Determinants of health and
• Health status

The initiative has built upon earlier 'Healthy People' initiatives. Although the US Department of Human Services and Health has administrative responsibility for the initiative, input has been provided from a diverse range of groups.⁽²⁶⁾

The National Health Priority Areas initiative

In Australia, the National Health Priority Areas (NHPA) initiative seeks to bring a national health policy focus to diseases or conditions that have a major impact on the health of Australians and offer potential for significant health gain. The six NHPA represent the disease groups with the largest cost burden. While precise figures on total costs in each NHPA are difficult to establish, the following table provides a estimate of disease costs in each area in 1993-1994.

Table 4: Health System Costs for the NHPA 1993-1994

1. 1996.
2. (b) Minister for Health and Aged Care, Hon. Dr Wooldridge, House of Representatives, Debates, 14 October 1999: 8713

Source: Mathers⁽²⁷⁾ et al: 192-3, and NHPA Reports 19971998.

Cardiovascular Health

Cardiovascular disease (CVD) accounts for more deaths and more health expenditure than any other disease or injury group in Australia. Cardiovascular diseases are all those which involve the heart and the circulation system. Main forms of this disease in Australia are coronary heart disease, stroke and peripheral vascular disease. Behavioural factors such as smoking, high blood pressure, high blood cholesterol, physical inactivity, obesity and excessive alcohol use contribute significantly to the risk of developing cardiovascular diseases.

In 1996, cardiovascular diseases accounted for 53 989 or 41.9 per cent of all deaths among Australians. The majority of these deaths were due to coronary heart disease and stroke. Men are more likely than women to die from coronary heart disease across all age groups. Women are more likely to die from stroke at ages higher than 84 years. Men from lower socio-economic status groups are 54 per cent more likely to die from coronary heart disease than men in higher socio-economic groups and women from lower socio-economic groups are 124 per cent more likely to die from these diseases than their counterparts in higher socio-economic groups. Indigenous male death rates from CVD are 2.4 times higher than those for all Australian males, and for Indigenous females the rate is 2.6 times higher than for all Australian females.⁽²⁸⁾

Stroke is the cause of nearly 25 per cent of all chronic disability in Australia. About one-third of people who have a stroke are permanently disabled with a degree of paralysis, difficulty with communication and other problems which may impact on their quality of life and their ability to function in society.⁽²⁹⁾

The total direct cost of heart, stroke and vascular disease was estimated at $3.719 billion in 1993-94.⁽³⁰⁾ At 12 per cent of recurrent health expenditure it represents the single most expensive disease group in terms of health system cost. Cardiovascular disease health system costs rise with age, reaching around $1700 per capita per year for men and women aged 75 years and over. The average treatment cost for a heart attack is estimated to be $5060 for men and $4760 for women in the age range 25-69 years.

Indicators for Cardiovascular Health

There are 30 NHPA indicators of cardiovascular health, eight of which are risk factors that also relate to one or more of the other NHPAs. Under the NHPA initiative progress is measured by time trends in risk factor prevalence, and morbidity and mortality. Progress in the 22 indicators for cardiovascular health and eight common risk factor indicators has been reviewed and reported upon. Positive outcomes were noted in a number of areas. Death rates for CVD and stroke in the total population have decreased. The prevalence rates for tobacco smoking and high blood pressure have continued to fall. However, the prevalence of overweight and obesity continues to rise and there appears to be little change in recreational physical activity levels over the past twenty years. Additionally, national targets for Indigenous populations for mortality, morbidity or risk factors are unlikely to be met.⁽³¹⁾ A summary of the cardiovascular health indicators and their reported progress is provided below.

Table 5: Cardiovascular Health: Summary of Trends of Selected Indicators

Source: NHPA Cardiovascular Health. A Report on heart, stroke and vascular disease. 1998:34.

A broad range of programs that occur at the Commonwealth, State and Territory levels contribute to or have the potential to contribute to achieving the targets in cardiovascular health. A selection of the more prominent programs is listed in Appendix 1.

Cancer Control

Cancer is a diverse group of diseases characterised by the proliferation and spread of abnormal cells. On average, one in three men and one in four women are likely to develop cancer before the age of 75. Each year approximately 345 000 new cases of cancer are diagnosed in Australia. New cases of cancer are rising, however, this can be partially accounted for by population growth, an aging population and an increase in detection rates. Cancer accounts for 29 per cent of male deaths and 25 per cent of female deaths.⁽³²⁾ The direct costs of cancer were estimated at $1.361 billion in 1993-1994.⁽³³⁾

Eight cancers have been targeted in the cancer control priority area, including lung cancer, melanoma, non-melanocytic skin cancer, colorectal cancer, prostate cancer in males and cancer of the cervix and breast cancer in females. In 1998, non-Hodgkins Lymphoma was added to the list of priority cancers. Prostate cancer is the most common form of cancer among males (13 000 new cases diagnosed each year), excluding non-melanocytic skin cancer. Lung cancer is the most common cause of cancer deaths among males. Among females, breast cancer is the most common cause of cancer-related mortality among women. Nearly 9800 new cases of breast cancer are diagnosed each year.⁽³⁴⁾

Non-melanocytic skin cancer is the most common cancer in Australia with between 250 000 and 300 000 cases diagnosed each year. This type of skin cancer is generally less life-threatening than melanoma. Australia has the highest incidence rate in the world of non-melanocytic skin cancer.⁽³⁵⁾

Indicators for Cancer Control

Twenty-six priority indicators have been set for the Cancer Control NHPA, including for cancers of the lung, breast, colorectum, prostrate, and cervix as well as melanoma. Only in 16 of these indicators is sufficient data available to report on progress. In addition a number of indicators such as 'death rate for colorectal cancer' or 'incidence of breast cancer among women aged 50-74 years' had no targets set. However progress has been noted in a modest number of areas. These include declining death rates from cancer of the trachea, bronchus and lungs for males; decline in the incidence of cancer of the cervix among women aged 20-74 and decline in the death rates for breast cancer among women aged 50-74.⁽³⁶⁾ A summary of selected cancer control indicators and their reported progress is provided below.

Table 6: Cancer Control Summary of Trends of Selected Indicators

Source: Commonwealth Department of Health and Family Services & Australian Institute of Health and Welfare, National Health Priority Areas Report: Cancer Control 1997. Canberra: Australian Institute of Health and Welfare, 1998.

A wide variety of initiatives aimed at cancer prevention, education and management is occurring at the National and State and Territory level. Appendix 2 provides a summary of priorities for action recommended to the Commonwealth by the National Cancer Control Initiative. Readers should note that these recommendations were superseded by the establishment of the National Cancer Strategies Group under the auspices of the former National Health Priority Committee to develop priorities for action under a National Cancer Strategy, for consideration by Australian Health Ministers. This work is currently being finalised.⁽³⁷⁾

Injury Prevention and Control

In 1996 injuries accounted for over 7000 deaths and nearly 400 000 hospitalisations. Direct medical costs attributed to injury were estimated to be $2.607 billion in 1994.⁽³⁸⁾ Injury is the fourth leading cause of death in Australia and is the predominant threat to life for children and young adults. While injury accounted for 5.7 per cent of all deaths in Australia in 1994, it accounted for 62 per cent of deaths at ages 1-24 years (males 72 per cent; females 48 per cent). Two major causes of death were suicides (31 per cent) largely attributed to poisoning by barbiturates and motor vehicle traffic accidents (27 per cent).⁽³⁹⁾ Only a small minority of injuries are fatal, with approximately forty hospital admissions for every one death.

Indicators for Injury Prevention and Control

There are 34 NHPA indicators of injury prevention and control. Causal mechanisms and risk factors for injury and poisoning are well enough understood to allow effective preventive measures to be designed. Consequently, injury prevention and control indicators show positive progress. Generally, it appears that year 2000 targets will be met in this area. In particular, there has been a reduction in deaths from injury for the total population and for a number of specific causes of death including road transport, falls, and fire burns and scalds in older people, homicide deaths in females aged 20 to 39 years, and drowning in early childhood.⁽⁴⁰⁾ However, the rate of hospitalisation for falls injury among older people and among children aged 0-9 years will need to decline substantially as will death rates for homicide among children aged 0-9 years if year 2000 targets are to be reached. Additionally, death rates for Indigenous compared with non-Indigenous populations may not be reached.

Table 7: Injury Prevention and Control: Summary of Trends of Selected Indicators

Source: Commonwealth Department of Health and Family Services & Australian Institute of Health and Welfare, National Health Priority Areas Report: Injury Prevention and Control 1997. Canberra: DHFS & AIHW, 1998.

A summary of selected National and State and Territory initiatives in injury prevention and control is supplied in Appendix 3. A national Injury Prevention Action Plan is now being developed.⁽⁴¹⁾

Mental Health

Mental Health is the capacity of individuals and groups to interact with one another and the environment, in ways that promote subjective well-being, optimal development and the use of cognitive, affective and relational abilities. However, the measurement of mental health is complex and mental health problems and disorders refer to the spectrum of cognitive, emotional and behaviour disorders.⁽⁴²⁾ The prevalence of mental illness in Australia is not fully established, however, it is estimated that one in five or one in four individuals will be affected by a mental health problem some time in their life.

Suicide ranks highly among deaths attributed to mental ill health. Psychiatric disorders such as alcoholism, personality disorders, schizophrenia and drug abuse along with clinical depression contribute to a large proportion of deaths. Direct costs of mental health and related services are estimated at $2.58 billion in 1993-94.⁽⁴³⁾

Indicators for Mental Health

A recent NHPA report on mental health and depression identified ten priority indicators. The focus of that report complements rather than duplicates the National Mental Health Strategy.⁽⁴⁴⁾ The ten priority indicators cover death and hospitalisation rates for suicide and self-inflicted injury, prevalence of anxiety and depression and awareness and use of best practices guidelines in general practice management of depression. A summary of the mental health indicators and their reported progress is provided below.

Table 8: Mental Health: Summary of Trends of Selected Indicators

Source: Commonwealth Department of Health and Aged Care & Australian Institute of Health and Welfare, National Health Priority Areas Report: Mental Health 1998. A report focusing on depression. Canberra: Australian. Institute of Health and Welfare, 1999.

A summary of selected initiatives in mental health at the National and State and Territory level is included in Appendix 4. A National Depression Action Plan is currently under development.⁽⁴⁵⁾

Diabetes Mellitus

Diabetes is characterised by high blood levels of glucose, caused by deficient production of insulin and/or resistance to its action. Complications from this chronic disease can include heart disease, stroke, blindness, kidney problems and lower limb amputations. Diabetes is the seventh leading cause of death in Australia.⁽⁴⁶⁾ However, diabetes is a contributing factor in a larger number of deaths. For example, although diabetes was the underlying cause of death for 2991 persons in 1996, it was mentioned on the death certificate for a further 8839 deaths where the main cause of death was attributed to other conditions/diseases.⁽⁴⁷⁾

There are four main categories of diabetes:

• Type 1 diabetes, characterised by a complete deficiency of insulin, and estimated to be present in 10 to 15 per cent of people with diabetes in Australia
• Type 2 diabetes, the predominant form of diabetes in Australia and worldwide. It is a common chronic disease among people over 50 years and is characterised by a relative insufficiency of insulin and resistance to its action
• Gestational diabetes, which occurs during pregnancy in about 4 to 6 per cent of women not previously known to have diabetes, and greatly increases their risk of developing diabetes later in life
• Other types, including diabetes secondary to other biological and metabolic events, in addition to known genetic abnormalities.⁽⁴⁸⁾

The National Diabetes Strategy and Implementation Plan identified diabetes as a common, chronic and costly disease which incurs an enormous personal and public health burden. Diabetes was added to the National Health Priority Areas in 1996 as it affects significant numbers of Australians and is disproportionately prevalent in particular populations. Indigenous Australians have one of the highest prevalence rates of non-insulin dependent diabetes mellitus (type-2 diabetes) in the world. Approximately 800 000 Australians are living with diabetes, half of whom are unaware that they have the disease. This figure represents about 4 per cent of the total population. The incidence of diabetes is rising, with the number having doubled since the early 1980s. It is estimated that by the year 2010, 950 000 Australians will be affected by diabetes.⁽⁴⁹⁾

The total cost of diabetes is approximately $1.2 billion annually or about $3000 per year for each person with diabetes. Individuals with diabetes experience a reduced life span and higher rates of heart, kidney and eye disease and stroke than non-diabetics.⁽⁵⁰⁾ In recognition of this, the Federal Government allocated funding of $7.7 million (over three years) in its 1996-97 Budget for National Diabetes Strategy initiatives. An additional $2.17 million has been made available for 1999-2000. These initiatives aim to help reduce the incidence of diabetes and the impact of complications of diabetes in Australia, as well as reducing the social, economic and health costs of this disease to the community.

Several initiatives commenced in 1999, including:

• The Vision Impairment Program (commenced April 1999)
• The Defuse Diabetes campaign (commenced November 1999)
• The National Diabetes Strategy (endorsed by Health Ministers August 1999)
• The Australian Diabetes, Obesity and Lifestyle (AUSDIAB) Study (launched April 1999)
• Commencement of the National Diabetes Register at the Australian Institute of Health and Welfare.⁽⁵¹⁾

Indicators for Diabetes Mellitus

Strategies to prevent NIDDM have been developed. Currently, there are no accepted forms of insulin dependent diabetes mellitus (IDDM) prevention. A set of twenty priority indicators has been developed for diabetes. The table below summarises these indicators, noting whether progress on each has been reported in the 1998 NHPA report on diabetes.

Table 9: Summary of NHPA Indicators for Diabetes

Source: Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare, National Health Priority Areas Report, Diabetes Mellitus 1998, Summary Document, Canberra, DHAC and AIHW, 1999.

Several population groups requiring special attention have been identified. These groups are: Indigenous Australians; people from culturally and linguistically diverse backgrounds; people living in rural and remote areas; children and adolescents; and older Australians.⁽⁵²⁾

A summary of selected initiatives in management, prevention and education concerning diabetes mellitus is provided in Appendix 5.

Asthma

In August 1999 the Commonwealth, State and Territory Health Ministers added asthma to the National Health Priority Areas. Asthma is the sixth NHPA and the Commonwealth Government committed $8 million over three years in the 1999-2000 Budget to support the needs of people with asthma in the Australian community. It is estimated that asthma affects two million Australians and costs the community about $700 million each year. Some 700 people die each year from asthma.⁽⁵³⁾ A National Asthma Action plan is being developed.⁽⁵⁴⁾

A Review of the NHPA Initiative

At the Australian Health Ministers' Advisory Council (AHMAC) meeting in March 1998 it was decided that a review of the NHPA should be undertaken to consider the lessons learnt to date, the experiences of jurisdictions in working in NHPA and to examine common threads across the NHPA. Oceania Health Consulting undertook the review, which commenced in March 1999 and was completed in June. While the report of the independent review of the NHPA was circulated to stakeholders for comment and deliberation, it has not been released more widely. At its meeting in February 2000, the Australian Health Ministers' Advisory Committee considered, but did not formally endorse, the report. It is understood, however, that the report has served to inform considerations of the future development of the NHPA initiative.

Support for the NHPA Initiative

Oceania Health Consulting found that support for the NHPA initiative was strong in both the government and non-government sectors. The initiative provided a useful framework in which priorities were identified for the purpose of coordinating and focusing effort in health care research, services and prevention and to ensure the limited health resources are used in accordance with government's priorities.⁽⁵⁵⁾ It was argued that the current NHPA initiative had appropriately identified and focused attention on health priorities that comprise the largest burden of mortality and morbidity in Australia.

Additionally, the NHPA are well supported by non-government organisations who have argued that the initiative has added weight and credibility to the respective disease groups and has assisted organisations in their requests for funding.⁽⁵⁶⁾

The Disease Focus of the NHPA Initiative

The NHPA framework incorporates the entire continuum from prevention to treatment and care. This was noted in the Review as an asset by the non-government sector as the initiative has enabled professionals and stakeholders to participate in a collaborative process, where historically they had operated fairly autonomously, and to view their contribution as part of a greater whole.⁽⁵⁷⁾ There was general agreement that the NHPA initiative should retain its focus on the burden of disease which the priorities encompass.

The Impact of the NHPA Initiative on Priority Populations

Indigenous people, rural communities and the socially and economically disadvantaged are priority populations across all of the NHPAs. In the consultations with the non-government sector, the review found that achievements have been limited among priority populations and it appears that the disease focus of the NHPA initiative may artificially detach the health issues of a population from the environmental, social and cultural context that influences health and well-being. The Review found that 'there appears to have been a lack of impact on priority populations to date, especially Indigenous Australians'.⁽⁵⁸⁾

What Difference has the NHPA Initiative Made?

While there is enthusiastic support for the NHPA initiative, Oceania Health Consulting found there was a diversity of views regarding the extent to which the NHPA initiative has made any difference in practice. The NHPAs were reported as being influential by most stakeholders, however, activity was not always explicitly related to the NHPA initiative. The non-government sector felt that the National Health Priority Areas were largely rhetoric and not adequately supported by strategic direction, infrastructure or resources.

Despite being a collaborative initiative, the NHPA initiative was viewed by both non-government organisations and some States and Territories as a Commonwealth Government initiative. It was therefore not adequately translated into action at the State and Territory level. The NHPAs appeared to have had little direct impact on policy making, yet the initiative had provided a framework by which States and Territories could develop a systematic approach to planning and purchasing.⁽⁵⁹⁾

Future Directions of the NHPA Initiative⁽⁶⁰⁾

At the 25 February meeting of AHMAC the proposed future directions for the NHPA initiative were discussed. AHMAC agreed to the renaming of the National Health Priority Committee to the National Health Priority Action Council (NHPAC), and to the appointment of the Commonwealth Chief Medical Officer to chair the Council. AHMAC also agreed to a refocussing of the NHPA initiative into three key streams of activity:

National Action

The NHPAC is to identify key strategic actions within and/or across NHPAs that would benefit from national collaborative effort and facilitate, advise and report on national effort in these areas. These national actions would not necessarily be Commonwealth-led and may involve some or all jurisdictions.

Other Action

Jurisdictions are to identify strategic actions within and/or across NHPAs for implementation within their jurisdictions, with the NHPAC providing a forum for information sharing and dissemination about this work.

Performance Monitoring of the NHPAs

Ongoing surveillance, analysis and reporting against agreed priority indicators will be undertaken by the AIHW and reported in its biennial report Australia's Health (Australia's Health 2000 is expected to be released in late June 2000). The NHPAC is to provide advice to AHMAC and Health ministers on strategic action required in the NHPAs arising from the published data.

In its response to the AHMAC decision, the NHPAC's proposed membership arrangements and its terms of reference are being reviewed for a report to AHMAC in early June 2000. The NHPAC will be responsible for developing a NHPA Action plan for consideration by Health Ministers in 2000.

Conclusion

While structural problems have been identified with the NHPA initiative there is overwhelming support for its continuance. The NHPA have provided a national framework for the reporting and monitoring of six disease areas which incur the greatest burdens of cost and disease in Australia. It can be argued that the inclusion of certain diseases within the NHPA has made a difference. In cardiovascular health there has been a decline in smoking rates in adults, coronary heart disease death rates and stroke death rate. The incidence of lung and prostrate cancer have declined in males and females have shown a decline in the incidence of cancer of the cervix.

Death rates for injury and poisoning, road transport-related injury and falls among people aged 65 years and over have all shown favourable trends. Indicators for mental health also show improvement, particularly in the rates of depression and anxiety disorders. However, health gains have not been seen across the board and improvement appears to have been limited within the priority populations. In particular, within the area of Indigenous health there has been a clear lack of impact and in future this will need to be addressed.

The NHPA is an initiative that has evolved in Australia's attempt to develop a national approach to health reporting and monitoring. Its heritage within the earlier programs of Goals and Targets for Australia's Health in the Year 2000 and Better Health Outcomes for Australia has to some degree shaped the structural arrangements of the NHPA and the parameters for success. Although assessment indicates that the NHPA initiative has enjoyed mixed success to date, it is an evolving and ongoing process. However it appears that many challenges remain. As the independent review of the NHPA initiative concluded: 'there is much more that can be done to improve health in the National Health Priority Areas'.⁽⁶¹⁾

Endnotes

1. Total Recurrent Health Expenditure includes all expenditure by Commonwealth, State and Territory Governments, health insurance funds and individuals.
2. Australian Institute of Health and Welfare, Health Expenditure Bulletin. No 15 Australia's health services expenditure to 1997-98, Canberra, 1999.
3. ibid.
4. UNCTAD Secretariat, 'International Trade in Health Services: Difficulties and Opportunities for Developing Countries' in Simonetta Zarrilli & Colette Kinnon (eds.) International Trade in Health Services: A Development Perspective, United Nations/WHO, Geneva, 1998, p. 4.
5. Oceania Health Consulting, Review of the National Health Priority Areas Initiative, Commonwealth Department of Health and Aged Care, Canberra, 1999, p. 1.
6. Oceania Health Consulting, Review of the National Health Priority Areas Initiative, Commonwealth Department of Health and Aged Care, Canberra, 1999.
7. Baum, Fran, The New Public Health: An Australian Perspective, OUP, Melbourne, 1998, p. 3.
8. Australian Institute of Health and Welfare, Australia's Health 1998. The Sixth biennial report of the Australian Institute of Health and Welfare, Canberra, 1998.
9. Melissa Jee & Zeynep Or, Health Outcomes in OECD Countries: A Framework of Health Indicators for Outcome-Oriented Policymaking, OECD, Paris, 1999.
10. Baum, Fran, The New Public Health: An Australian Perspective, OUP, Melbourne, 1998.
11. Australian Institute of Health and Welfare & Commonwealth Department of Health and Family Services, First Report on National Health Priority Areas, Australian Institute of Health and Welfare, Canberra, 1997, p. 4
12. Michael de Looper and Kuldeep Bhatia, International Health - How Australia Compares, Australian Institute of Health and Welfare, Canberra, 1998.
13. Australian Institute of Health and Welfare, Australia's Health 1998. The Sixth biennial report of the Australian Institute of Health and Welfare, Canberra, 1998, p. 7.
14. ibid., p. 7.
15. ibid., p. 9.
16. ibid., p. 11.
17. ibid., pp. 29-33.
18. Australian Institute of Health and Welfare, Health Expenditure Bulletin. No 15 Australia's health services expenditure to 1997-98, Canberra, 1999.
19. UNCTAD Secretariat, 'International Trade in Health Services: Difficulties and Opportunities for Developing Countries' in Simonetta Zarrilli & Colette Kinnon (eds.) International Trade in Health Services: A Development Perspective, United Nations/WHO, Geneva, 1998, p. 4.
20. Australian Institute of Health and Welfare, Australia's Health 1998, p. 193.
21. ibid., p.194.
22. World Health Organization, Global Strategy for Health for All by the Year 2000, WHO, Geneva, 1981.
23. www.who.int.archives/hfa/policy
24. Oceania Health Consulting, Review of the National Health Priority Areas Initiative, Commonwealth Department of Health and Aged Care, Canberra, 1999, p. 49.
25. www.doh.gov.uk/ohn/execsum.htm
26. Further information on this initiative can be found at www.health.gov/healthypeople/document
27. Mathers, C. et al., Health System Costs of Diseases and Injury in Australia 1993-94: an analysis of costs, service use and mortality for major disease and injury groups, Australian Institute of Health and Welfare, Canberra, 1998.
28. Commonwealth Department of Human Services and Health, Better Health Outcomes for Australians. National Goals, Targets and Strategies for Better Health Outcomes Into the Next Century, Canberra, 1991, p. 46.
29. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare, NHPA Report: Cardiovascular Health 1998, DHAC & AIHW, Canberra, 1999, p. 9.
30. Commonwealth Department of Health and Family Services and Australian Institute of Health and Welfare, National Health Priority Areas: Cardiovascular Health: A Report on Heart, Stroke and Vascular Disease, Australian Institute of Health and Welfare & Commonwealth Department of Health and Family Services, Canberra, 1998.
31. ibid., p. xii.
32. Australian Institute of Health and Welfare, Australia's Health 1998, p. 85.
33. www.health.gov.au/pubs/cancer/cancer.pdf
34. Commonwealth Department of Health and Family Services and Australian Institute of Health and Welfare, National Health Priority Areas Report: Cancer Control 1997, Canberra, DHAC & AIHW, 1998, p. ix-xii.
35. Commonwealth Department of Health and Family Services and Australian Institute of Health and Welfare, National Health Priority Areas Report: Cancer Control 1997, p. x.
36. Australian Institute of Health and Welfare & Commonwealth Department of Health and Family Services, First Report on National Health Priority Areas, Summary Document, Australian Institute of Health and Welfare, Canberra, 1997.
37. Advice from the Commonwealth Department of Health and Aged Care.
38. Commonwealth Department of Health and Aged Care & Australian Institute of Health and Welfare, National Health Priority Areas: Injury Prevention and Control, Australian Institute of Health and Welfare, Canberra, 1998.
39. ibid., p. 87.
40. ibid., p. ix.
41. Advice from the Commonwealth Department of Health and Aged Care.
42. Commonwealth Department of Health and Aged Care & Australian Institute of Health and Welfare, National Health Priority Areas: Mental Health: A Report focusing on Depression, Australian Institute of Health and Welfare, Canberra, 1998, p. xi.
43. ibid., p. 31.
44. Oceania Health Consulting, Review of the National Priority Areas Initiative, Commonwealth Department of Health and Aged Care, Canberra, June 1999.
45. Advice from the Commonwealth Department of Health and Aged Care.
46. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare, National Health Priority Areas: Diabetes Mellitus, Australian Institute of Health and Welfare, Canberra, 1998, p. ix.
47. ibid., p.20.
48. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare, National Health Priority Areas: Diabetes Mellitus, p. ix.
49. ibid., p. 5.
50. ibid., p. 145.
51. Advice from the Commonwealth Department of Health and Aged Care.
52. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare, National Health Priority Areas: Diabetes Mellitus, p. 21.
53. Minister for Health and Aged Care, Hon. Dr Wooldridge, House of Representatives, Debates, 14 October 1999, p. 8713.
54. Advice from the Commonwealth Department of Health and Aged Care.
55. Oceania Health Consulting, Review of the National Health Priority Areas Initiative, p. 9.
56. ibid., p. 9.
57. ibid., p. 9.
58. ibid., p. v.
59. ibid., p. 13.
60. Material in this section has been drawn from advice provided by the Commonwealth Department of Health and Aged Care.
61. Oceania Health Consulting, op. cit., p. 46.

Appendix One

Sample of Current Initiatives Relating to Cardiovascular Health

Source: DHAC & AIHW National Health Priority Areas Report, Cardiovascular Health 1998: A Report on Heart, Stroke and Vascular Disease.

Note: For a more detailed overview of initiatives occurring please see the above source.

Appendix Two

Sample of Priorities for Action* Relating to Cancer Control

Introduction

After completing the consultative process, 21 proposals were considered by the National Cancer Control Initiative Management Committee. Taking account of the relevant variables it was decided to recommend 13 actions or sets of actions as having priority for implementation. The following table indicates the areas covered.

Actions Recommended for Priority Implementation

Source: Department of Health and Family Services and Australian Institute of health and Welfare, National Health Priority Areas Report, Cancer Control 1997.

*Note: See comments in the section on Cancer Control in the body of the report.

Appendix Three

Sample of Current Initiatives Relating to Injury Prevention Activities

Source: National Health Priority Areas, Injury Prevention and Control, 1997

Note: a National Injury Prevention Plan 2000-02 is being developed.

Appendix Four

Sample of Current Initiatives Relating to Mental Health and Depression

The following table is a sample of initiatives relating to depression and are broadly representative of the following categories:

1. promotion, prevention and community education;
2. early intervention;
3. management and treatment; and
4. evaluation and monitoring.

Note: Categories in the table below will be numbered to reflect the above descriptions.

Source: National Health Priority Areas, Mental Health: A Report Focusing on Depression, 1998

Note: For a more detailed overview of initiatives occurring please see the above source.

Appendix Five: Sample of Current Initiatives Relating to Diabetes Mellitus

Source: National Health Priority Areas Report, Diabetes Mellitus 1998, 1999

Note: For a more detailed overview of initiatives occurring please see the above source.

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