Chapter 5
Health and border control measures
5.1
Having outlined the strategies and programs aimed at resolving health
concerns and related matters on the PNG side of the border, the committee turns
its attention to border control as a means to counter some of the problems
associated with health and the free movement provisions of the Treaty. In this
chapter, the committee considers the cross border measures that Australia has
in place to dissuade or prevent PNG citizens from entering Australia to access
medical services in the Torres Strait. The committee also looks at the funding
arrangements for the provision of health care in Australia for PNG visitors.
Key border control measures
5.2
Although the Treaty does not provide for traditional inhabitants from
PNG to travel across the border to access health facilities in the Torres
Strait, many do so. Australia implements a number of measures to manage the
movement of people across the border.
Treaty awareness visits
5.3
Education and a sound understanding of the provisions of the Treaty are vital
to achieving a high level of compliance with the free movement provisions. To raise
awareness and disseminate information about the provisions of the Treaty, a
number of government agencies together with their Queensland, Torres Strait and
PNG counterparts undertake regular Treaty awareness visits to traditional
communities.[1]
The visits are conducted by the DFAT Treaty Liaison Officer in the Torres
Strait, who is accompanied by officers from several other Australian government
agencies such as DIAC and DoHA.[2]
5.4
One of the important messages conveyed during these visits is that attending
health clinics is not a traditional activity. Mr Brett Young, Australia's
Torres Strait Treaty Liaison Officer, explained 'we make it very clear at every
community we visit that you are not to visit Australia for health purposes'.[3]
In addition to these visits, the written guidelines for traditional visitors, which
make clear that visits to medical clinics are not traditional activities, are distributed
to the communities.[4]
Refuse entry
5.5
Despite efforts to inform PNG nationals about arrangements under the
Treaty, many continue to cross the border to access health clinics. To prevent such
breaches of the Treaty provisions, Australia resorts to border enforcement
measures. Mr Young informed the committee that during the Treaty awareness visits,
local residents are informed that if they do visit the Torres Strait for health
reasons, they:
...will be turned around by an immigration officer, that
immigration officers are on the ground in the Australian communities, and we
draw a line under that. It is quite clear.[5]
5.6
To enforce the free movement provisions, Australia has Immigration
Movement Monitoring Officers (MMOs) based on most Torres Strait Islands. Upon
arrival, PNG traditional inhabitants are met by an MMO and asked to identify the
reason for their visit. Entry is 'generally refused' if the main purpose is to visit
for health reasons.[6]
DIAC noted that travel for the purposes of accessing health care 'is the most
common reason for people being refused immigration clearance on Saibai and
Boigu Islands'.[7]
5.7
Mr Stephen Allen, DIAC, informed the committee that before MMOs turn
people back to PNG, they are required to consider the travellers' health and
wellbeing 'to ensure that there is no risk involved' in returning them to PNG.[8]
Traditional inhabitants will undergo a 'fitness to travel' assessment conducted
by Queensland Health at the local health clinic.[9]
PNG nationals seeking treatment at island health clinics are 'automatically
tested for STIs [sexually transmitted infections] and HIV'.[10]
5.8
If the assessment reveals only minor ailments, the traditional
inhabitant will not be allowed to stay. However, as noted in chapter 3, if
the health problem upon arrival requires further treatment or appears while the
person is on the island, PNG nationals 'are in the same position as anyone else
in the community who may become ill and may require health treatment'. In
deciding whether a person is allowed to stay, immigration officers follow usual
procedures.[11]
In general, PNG nationals seeking medical treatment who become unlawful
non-citizens in these circumstances are not detained.[12]
Rather, their presence 'is monitored and their departure is facilitated at the
earliest point at which it is reasonable to do so taking account of their
health, well being and safety'.[13]
A more rigorous approach
5.9
Recently, Australian border enforcement agencies in the region have applied
a more exacting and thorough procedure to screening visitors. Mr Allen
explained that a comparison of last year's statistics on traditional movements with
this year's statistics demonstrates the success of the 'much more rigorous
approach' taken to assess these movements. He informed the committee that this
new system has produced 'a substantial increase in the number of refused
immigration clearances' and a decline in the number of traditional movements.[14]
The statistics show that from 1 July 2009 to 31 May 2010, 1,157 were refused
entry on health grounds, with an undisclosed number also refused entry because
they were accompanying a person seeking health treatment.[15]
5.10
This figure coincides with an 11.7 per cent drop in the number of
traditional visits. Mr Andrew Heath, DIAC, explained that this year [2010],
particularly on Saibai, MMOs were refusing clearance to people who perhaps
should have been denied entry in previous years.[16]
He stated further:
Since 1 July last year [2009] we have implemented the new
recording structure and protocol, so each of our MMOs on all of the islands are
refusing clearances consistently. A case in point is Boigu, for example. Its
refusal rate is double, but the difference between Boigu’s refusal rate and
Saibai’s refusal rate over the last 12 months is a lot less.
We established some business rules, and all MMOs are assessing
the purpose of their visit.[17]
5.11
Mr Allen explained that the new approach is intended to continue into
the future and to be a permanent change in DIAC's operations'.[18]
The committee considers the effectiveness of this more rigorous system and the overall
trend in refusing immigration clearances to PNG visitors to the Torres Strait
in the chapter on law and order.
Closing the border
5.12
Under the provisions of the Treaty, Australian or PNG authorities may
close the border to minimise the risk of transmission of diseases across the
border in the Torres Strait. Paragraph 2 of Article 16 determines that both
countries shall bear in mind the 'importance of discouraging the occurrence,
under the guise of free movement or performance of traditional activities' of
practices that could damage effective health protection and control.[19]
Therefore, in accordance with sub-paragraph (3)(c) of Article 16 of the Treaty,
each party to the agreement may limit or prevent free movement by applying 'such
immigration, customs, health and quarantine measures, temporary or otherwise,
as it considers necessary to meet problems which may arise'.[20]
5.13
Free movement may be restricted, for example, when there is a shortage
of food or water or concerns exist about the transmission of disease. This
provision was used at the time of the H1N1 (swine flu) epidemic in 2009 when
authorities closed the border due to concerns about the virus spreading to PNG.[21]
In DIAC's view, the use of these provisions was very effective in limiting the
potential spread of the H1N1 influenza virus.[22]
More recently, all cross border travel under the free movement provisions was
restricted due to a cholera outbreak in Daru.[23]
As another example, Queensland Health informed the committee that cases of MDR
TB would present a valid reason to close the border between Australia and PNG because
of 'the inability to treat it and the potential for its spread'.[24]
5.14
This provision has also been used to relieve the strain on essential
services. For example, in June 2010, Mr Young informed the committee that:
Only two weeks ago, the councillor on Badu requested that movement
be restricted under the free movement provisions of the treaty while they had a
large influx of people and pressure on their water.[25]
5.15
On a more regular basis, the border has been temporarily closed 'to
restrict the days on which visitors may arrive on Saibai Island to Tuesdays and
Wednesdays to address the shortage of water in the latter part of the dry
season'.[26]
According to Mr Young, his office had supported all requests by community
leaders for a temporary restriction on cross-border movement, explaining:
There have been a dozen occurrences in the past 12 months of
islands requesting that and it has been granted on every occasion—and article
16 of the treaty clearly gives us the power to do that.[27]
5.16
As discussed later in chapter 7, some local leaders would like to see a strict
enforcement of this border measure when communities request a closure.
Providing health care and mixed messages
5.17
The committee has noted that on many occasions, traditional inhabitants
are allowed to remain in Australia to receive medical assistance on
humanitarian or public health grounds. The committee provided details on the
care they receive at Australian health clinics, including being evacuated to
the mainland for medical treatment.
5.18
During the course of the inquiry, witnesses did not raise issues about
the quality of health care delivered to PNG nationals while in Australia. However,
some witnesses raised concerns about the provision of these services generating
demand in PNG for Australian services. They argued that by providing health
services to visiting PNG nationals, Australia was encouraging more people to seek
access to those services, For example, Mayor Gela drew attention to the new
health facility on Saibai which has received a 'substantial amount' of Australian
Government funding. He stated:
Here we are, utilising taxpayers' money to build a
brand-spanking new facility, but I was told it is not only to accommodate the
needs of my people; it is to accommodate the people from Western Province who
come through.
5.19
Mayor Gela asked, 'what signal are we sending?'[28]
Ms Nardi appreciated that improving the delivery of health services in the
Torres Strait that cater for the needs of PNG visitors sends a mixed message:
It is a strategy to try and see how we can maintain the
balance where we treat that which we need to treat but, at the same time, do
not make it so attractive that we find that we have an onslaught of Papua New Guineans
coming to receive our health services.[29]
5.20
Evidence to the inquiry and the committee's conversations with local health
professionals indicated that the inconsistency between the Treaty provisions
and the reality of PNG nationals presenting at island health clinics has produced
confusion among health workers regarding the treatment of these visitors. The
Queensland Nurses' Union (QNU) argued that there had been 'continuing lack of
clarity about the level of support' that should be provided to PNG nationals visiting
Australian health clinics and called for the Australian Government to provide a
clear strategy and funding to meet the demand for these services.[30]
5.21
Responding to calls of this kind, Queensland Health established a policy
and issued guidelines for its staff for the treatment of PNG nationals at
Torres Strait health clinics.[31]
The guidelines state that treatment should be confined to:
-
emergencies;
-
where 'timely and appropriate care' in PNG is unlikely; or
-
where there is a risk of communicable diseases spreading within
the local community.[32]
5.22
The guidelines have been submitted for consultation through the HIC and
the policy is to be reviewed on a six-monthly basis.[33]
Committee view
5.23
The committee acknowledges the significant contribution that health care
professionals in the Torres Strait are making to improve the health and
wellbeing of PNG nationals seeking medical attention at their clinics. Often
they face quite difficult circumstances in delivering these health services. The
committee takes this opportunity to acknowledge their work and commend their
dedication.
5.24
The committee also understands the need to discourage or deter PNG
nationals from crossing the border for medical assistance. In this regard, the
committee believes that the tightening-up of protocols for entry and their
enforcement is helpful. Ultimately, however, the committee believes that a satisfactory
and lasting solution to the problem will only be achieved through marked
improvements in the provision of health services in PNG.
5.25
Such improvements will take time and for the foreseeable future,
Queensland Health will be called on to continue to provide health services to
PNG nationals presenting at its clinics. On humanitarian and public health
grounds, the committee fully supports Queensland Health in this endeavour. This
situation, however, raises the question of responsibility and funding. The committee now turns to examine the cost of treating
PNG nationals at Torres Strait health clinics and elsewhere in Queensland and
funding arrangements between the state and federal governments in this regard.
5.26
During the course of the inquiry, the committee became aware of the significant
and increasing expenditure associated with providing health care to PNG
nationals at Australian health facilities. These high costs are borne by
Australia.[34]
Over the five years from 2004–05 to 2008–09, bed-day costs have risen from
$1,405 to $1,875.[35]
The Queensland Government indicated that pharmaceutical costs for a single
admission for the treatment of tuberculosis at Thursday Island hospital in 2008
alone were $24,588.[36]
The table below indicates some of the costs of treating PNG nationals in Torres
Strait health clinics.[37]
Table 5.1: Estimated cost to Queensland Health for treatment of PNG
nationals, 2004‑2009
|
Year |
2004–05 |
2005–06 |
2006–07 |
2007–08 |
2008–09 |
|
Number of patients |
242 |
322 |
296 |
260 |
198 |
|
Patient days |
2,314 |
2,486 |
2,112 |
3,392 |
1,940 |
|
Patient costs |
$3,247,624 |
$4,016,397 |
$3,357,552 |
$5,809,098 |
$3,638,559 |
|
At island clinics (underestimations due to
inconsistent data capture) |
|
Patient days |
1,636 |
1,733 |
1,831 |
1,759 |
1,380 |
|
Patient costs |
$369,736 |
$391,658 |
$413,806 |
$397,534 |
$311,880 |
|
Medical transfers |
$688,800 |
$705,600 |
$769,000 |
$763, 000 |
$637,600 |
|
Pharmacy |
n/a |
n/a |
n/a |
n/a |
$261,807 |
|
Total cost |
$4,306,160 |
$5,113,655 |
$4,540,358 |
$6,969,632 |
$4,600,561 |
5.27
The Queensland Government observed that the figures reflect 'a very
conservative estimate of the costs of service delivery to PNG nationals', with
actual expenditure likely to be higher.[38]
It also explained that PNG nationals are more expensive to treat as a result of
co-morbidities, interpreter services, etc.[39]
According to the Queensland Government, a review is being conducted to
establish the actual costs of patient transport.[40]
Australian Government funding to
Queensland Health
5.28
The division of responsibilities and funding between the state and
federal governments regarding the treatment of PNG nationals at Australian
health clinics and hospitals has been an issue for a long time.[41]
While the Australian Government is committed to providing health care to PNG
nationals on humanitarian and public health grounds, it is the Queensland
Government, through Queensland Health, that provides that care.
5.29
QNU called on the Australian Government to provide a clear strategy and
funding 'to meet the demand for health services'.[42]
Both the Community and Public Sector Union and QNU called for adequate funding
towards the treatment of PNG nationals in the Torres Strait.[43]
5.30
According to DoHA, the Australian Government acknowledges the additional
burden imposed on Queensland Health and is keen to reduce it. The Government
also recognises the role of Queensland Health in minimising the risk of the
transmission of communicable diseases to Australian communities from PNG. In its
2009–10 Budget, the Australian Government provided $16.2 million over four
years towards Queensland Health's costs for providing services to PNG nationals.[44]
In 2009–10, the grant was $3.8 million, rising to $4.4 million in the forward
estimates for 2012–2014.[45]
The funding comes from DoHA's portfolio budget.[46]
5.31
Queensland Health pointed out that the $3.8 million allocation in 2010 would
meet only part of the actual costs of providing health services to PNG
nationals and that the gap was widening.[47]
Even with the grant rising by $0.6 million in the forward estimates, the
funding still falls short by over two million dollars. Queensland Health made
clear that the Australian Government is aware of this shortfall and that there
is an 'expectation that there will be a negotiated outcome'.[48]
5.32
DoHA informed the committee that apart from direct funding, 'Additional
funds are provided to the Queensland Government through broader agreements',
including the National Healthcare and other National Partnership Agreements.[49]
DoHA also provides annual funding for the delivery of health services in the
Northern Peninsula Area and the Torres Strait, including funding to Queensland
Government, amounting to $12.2 million dollars in 2009–10. In addition, the Australian
Government provides funding for the Torres Strait Health Protection Strategy as
follows:[50]
Table 5.2: Funding for Torres Strait Health Protection
Strategy
|
Year |
2009/10 |
2010/11 |
2011/12 |
2012/13 |
| |
$4.7m |
$4.8m |
$2.1m |
$2.2m |
5.33
The committee notes that the Australian Government provides funding to
the Queensland Government for the provision of health care to PNG nationals.
However, it is concerned that the gap between that funding and the actual costs
incurred by Queensland is significant. Furthermore, it is aware that statistics
suggest that the demand for health services is increasing. Even though data
regarding the treatment of PNG nationals at Torres Strait health facilities is
incomplete, the committee believes that Australian Government funding to
Queensland Health should adequately reimburse the state for providing these
services.
Recommendation 6
5.34
The committee recommends that the Australian Government review its
funding to Queensland Health to ensure that such funding is commensurate with
the actual costs incurred by Queensland Health in providing health care to PNG
nationals.
5.35
Comprehensive and reliable data is needed to be able to assess accurately
the costs associated with providing health services to visiting PNG nationals. In
this section, the committee looks at the current data regarding PNG nationals
using Torres Strait health clinics.
Collecting data
5.36
Discussions between the Queensland and Australian governments about the costs
of delivering health care to PNG nationals have been complicated by the lack of
reliable data on the nature and number of services provided and associated
costs. DoHA explained that data regarding the treatment of Australian nationals
in the Torres Strait is reported directly to its national surveillance systems.[51]
However, under the healthcare agreements, DoHA is not required to keep
statistics on PNG visitors.[52]
Queensland Health has collected some data on PNG nationals visiting the island
health clinics but the coverage has been incomplete. DIAC collects statistics
regarding traditional movements and activities but does not collect information
about the number of PNG nationals who subsequently visit the health clinics.[53]
Immigration statistics 'go so far as to tell us how many of the visitors' were
refused immigration clearance.[54]
5.37
Ms Nardi informed the committee that past data capture issues 'have been
recently resolved through a process that commenced on 10 March 2010'.[55]
She explained:
The data has been essentially a manual collection. There were
also some community issues in relation to the gathering of data around Papua
New Guinea nationals. The information system that we used was actually a recall
system, so the clinicians who were looking after the Papua New Guinean patients
did not want to enter them into the system because they did not want to be in a
position where they had to recall them because they were across the border. So
there was a lot of myth from that particular community in relation to what
capturing the Papua New Guinean data would do. It has taken some time to get
the process in place, but we have been able to address those concerns and those
needs and have been able to get a robust process in place. There is also the
issue that data was captured in a whole range of different areas for different
purposes. So the primary healthcare data was captured separately from the acute
care data. We now have a process, we believe, that will bring all that data
together in a meaningful way.[56]
5.38
The type of data now to be collected by Queensland Health staff consists
of a range of standard data fields, which include people's names, their home
address and presenting conditions. Data would record a person who has been
redirected home but returned for a subsequent visit as 'two presentations'.[57]
Queensland Health expressed confidence in its new data-gathering process which,
in its view, would render them 'in a far stronger position to provide reliable
and robust data'.[58]
For example, the Queensland Health guidelines state that all patients should be
recorded on an electronic information system and identified as PNG nationals,
if applicable.[59]
DoHA acknowledged the Queensland Government's efforts to develop reporting
arrangements to support the improved data collection system.[60]
5.39
The committee recognises the importance of having complete and accurate
data on PNG nationals accessing health services in the Torres Strait that provides
a comprehensive coverage on the nature, number and costs of PNG nationals
accessing these services. The data should take account of the costs of
transporting patients and the number of patients returning to PNG needing
follow-up treatment.
5.40
The committee is encouraged by Queensland Health's assurances about
improved data capture and its potential effect on negotiating adequate funding
arrangements between state and federal governments. This data should be
compatible with that collected by DIAC to provide a comprehensive picture of
PNG nationals who enter Australia through the Torres Strait, including the
number, nature and length of visits.
Recommendation 7
5.41
The committee recommends the Australian Government offer assistance to
help the Queensland Government fund the implementation of the new data
collection systems for PNG nationals accessing health services in the Torres
Strait; and provide funding, if required, for a review of the effectiveness of
this system.
Recommendation 8
5.42
The committee also recommends that the Department of Immigration and
Citizenship ensure that its statistics on PNG nationals visiting Australia,
including those in Australia receiving medical treatment, are complete and
complement those collected by Queensland Health.
5.43
The committee heard evidence during its visit to the Torres Strait
regarding PNG women choosing to give birth in Australia due to a belief that
they would be eligible for the baby bonus and an improved chance of obtaining
Australian citizenship. It also heard of concerns regarding PNG nationals
taking up housing commission accommodation on Badu.[61]
The committee urges the Australian Government to investigate the origins,
extent and veracity of these claims so that it is better placed to dispel any
misconceptions and to devise education programs that will convey correct
information to all in the region about entitlements.
Recommendation 9
5.44
The committee recommends that relevant Australian government agencies
combine their efforts to ascertain whether, or the extent to which, PNG
nationals are coming to Australia to access social services, whether they are
misinformed about their entitlements and, if so, the source of this
misinformation and how best to correct it.
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