She writes:

“The Inside Story article is great – it really brings out some of the complexities of this issue and the unresolved issues in the National Health and Hospitals Reform Commission recommendation. I hope it gets read by the DoHA team tasked with managing the G’ment’s response to the report and of course Roxon and her advisers.

What I find interesting is that in the NHHRC report and much of the commentary on it, there seems to be an assumption that our current system of one public insurer (Medicare) equals a lack of choice, innovation and diversity within health care and that a system of multiple, private insurers would be better at identifying and meeting consumer needs.

No-one seems to be asking why Medicare (or an alternative single public insurer) couldn’t deliver some of the benefits claimed for Medicare Select in the NHHRC Report.

There’s no intrinsic reason why a public insurance system can’t provide more choice and be more responsive to consumers – or is there?”

He writes:

“To call the Government’s private health insurance (PHI) proposals ‘reform’ is nonsense: it is just an extraordinarily clumsy way of grabbing money from higher income people earners, whether or not they have PHI. There are much easier ways to raise such revenues to fund public hospitals – just raise taxes (ie drop some of the totally unnecessary tax cuts).

If the Government wants serious reform of PHI policy, it could go in either of two directions:

• To the left, curtailing subsidies to PHI,  preferably by abolishing the PHI rebate entirely and abolishing the Medicare  levy surcharge (or making everyone pay it, to raise some revenue);  or

• To the right, opening up the possibility of PHI  taking a wider role (as advocated by the NHHRC), turning the PHI rebate into a  risk-rated premium in exchange for the funds taking full responsibility for  their members, including any public hospital costs; and dropping the Medicare  levy surcharge (or again, applying it to everyone).

Instead, we have this silly idea of means testing the rebate (with the risk of returning to the bad old days of spiralling premiums as PHI becomes increasingly focussed on the elderly and unattractive to the young and healthy), then attempting to avoid this risk by raising the levy surcharge (which must be the crudest form of subsidy for any industry, with no efficiency benefits whatsoever).

So, if you are on a high income and have PHI you lose the rebate, and if you are on a high income without PHI you face a higher levy surcharge.

For goodness sake, even if the Government is not interested in reform, it would be better and simpler just to raise taxes on higher incomes (ie drop the tax cuts which were never justified), rather than make the dog’s breakfast of PHI policy even more of a mess.

But if it is interested in reform, the Government needs to start being serious.

Personally, I would like to see a trial of the second option above, to see how well the funds could operate with wider responsibilities for their members and in a proper competitive market.

I do not think we know enough yet to accept the National Health and Hospital Reform Commission’s preferred long-term model, but it is certainly worth a trial.

Others, I know, would prefer the first option above, but I fear it would place too much reliance on the capacity of the national insurer and not give the public enough choice. But it would be serious reform, unlike the current proposals.”

So says health policy analyst Jennifer Doggett, who describes the rebate as “a textbook example of the worst health funding policy in Australia’s history“.

She writes:

“Imagine if car insurance provided rebates for fuel expenses and the Government subsidised the cost of that insurance.  What would result from this (thankfully) hypothetical situation?  People would use more petrol than they do currently (since they don’t incur its full cost), petrol would become more expensive (due to the increased cost of administering the scheme as well as the blunting effect of subsidies on price signals); and richer people, who have bigger cars (on average) and more money to purchase fuel, would benefit disproportionately from the subsidy than those on low incomes.

It’s an absurd proposition but it’s exactly what happens in relation to health care funded by private health insurance.  Nicola Roxon’s attempt last night to reduce the rebate subsidies for high income earners with private health insurance is one small step towards minimising the adverse impact of this costly policy on the public purse.  The fact that it was defeated in the Senate demonstrates how little understanding the Opposition has of health funding issues.

Private health insurance is one of the most inefficient and expensive mechanisms for paying for health care.  Private health insurance funds spend about 13% of revenue on administration, compared with the 3% spent by Medicare.  Partly this is due to the economies of scale of Medicare but also because private funds have to spend money on advertising to compete against each other.  Higher administration costs drive up premiums which ultimately come out of the pockets of consumers and tax payers.

Private health insurance is inefficient in other ways.  By shifting demand from public to private services, doctors and nurses are attracted away from the public sector.  We have a fixed number of doctors and nurses in Australia.  When demand increases in the private hospital sector, health professionals will move there away from public hospitals.  With widespread health workforce shortages, we should be ensuring that the first priority for health professionals is to care for the sickest people in the community. Generally these are found in the public system.

Private health insurance does not make it easier for the most disadvantaged people to afford the health care they need.  The group with the poorest health status in the community, Indigenous Australians, has the lowest level of private health fund membership.  People on low incomes often can’t afford the high gap payments that come with private care, even if they can afford the monthly premiums.  And people with chronic conditions often find that the annual limits and caps on rebates for treatments run out long before they have received the treatment they require.

In fact, in most cases private health insurance is not really insurance.  Fixed rebates combined with open ended co-payments, such as those required for ancillary services by most forms of private health insurance, do not limit the risk of consumers incurring high health care costs.  Rather they act as an inefficient and overly complex budgeting measure to assist consumers with managing health care expenses.

Given the high costs and other disadvantages of an insurance model for funding health care, it should be used minimally. In sharing the risk of very unusual and high cost health care needs, the advantages of an insurance model probably outweigh its risks.  However, given that (by definition) the majority of health consumers do not experience unusual and unpredictable high health care costs, private health insurance should not be supported or subsidised by government as a mechanism for funding predictable and regular forms of health care.

Instead of blocking the Government’s laudable (although not nearly comprehensive enough) attempt to reduce the inefficient subsidy for high income earners, the Opposition should be focussing on finding more efficient ways of funding health care. There are a number of options for this (some outlined in the National Health and Hospitals Reform Commission Report), almost any of which would be an improvement on the current private health insurance model.

The private health insurance rebate was a terrible Howard-era policy, designed to buy off pensioners scared about the introduction of the GST before the 1998 election. It’s served its purpose. It’s cost us (the tax payer) billions. It’s prevented the development of other innovative and efficient funding mechanisms which genuinely respond to consumer needs.

It’s time it was pensioned off and allowed to live out its days as a textbook example of the worst health funding policy in Australia’s history.”

That, at least, is the image that comes to Croakey’s mind when listening to Health Minister Roxon on the hustings recently, arguing that it is only fair and fiscally responsible that there be means testing of Government subsidies for private health insurance cover.  There she was, on the radio, in the newspapers and everywhere else, arguing that it is so unfair to expect lower income earners to be subsidising the cover of millionaires.

And then we hear that the $1.9 billion saved from the proposed means testing (the relevant legislation is expected to be up again for debate when the Senate resumes on September 7) could help fund long overdue e-health reforms.

It’s a finely balanced juggling performance given that this Government specifically excluded any consideration of the inequities of the current private health insurance rebate subsidies from the brief of the National Health and Hospitals Reform Commission.  The Sydney Morning Herald reported last month that: “When he announced the health reform commission last year, the Prime Minister, Kevin Rudd, specifically instructed the commission to keep clear of the rebate issue. This was in deference to the health insurance industry, to which Mr Rudd had given an undertaking before the election to retain the rebate.”

Meanwhile, a Croakey contributor, Jen Li, who has been watching the debate closely from the perspective of an experienced patient, has a question. She is wondering, who benefits from private health insurance?

Jen Li writes:

“Mark Metherell wrote in the Sydney Morning Herald recently that private health insurance numbers continue to rise because of anxiety about the public health system and waiting lists. I’m wondering whether the people who hold private health insurance because of lack of faith in the public system are doing it for the right reasons.

The public health system is undoubtedly under pressure and it seems that it is in need of a makeover at least in its management. But public hospitals are where new doctors, nurses and therapists get their training, where the most care is available for patients, and where you would go in the case of an emergency.

Often, doctors work in both private and public hospitals and clinics, and their performance does not change depending on whether you have some nice paintings in your room or whether you have the option of receiving wine with your dinner. Private hospitals are beautiful (or as beautiful as a hospital can be), with slightly softer beds, toilets that look like something in a fancy hotel, and carpeting in the hallways. I really don’t think that these are sufficient reasons for going into a private hospital.

There are many reasons why private health insurance can benefit an individual, such as if they need a hip or knee replacement, or if they are using it to cover dental or optical costs, or are using it for tax purposes.

To have it because you have no faith in the public system, however, seems misguided. Having private health insurance does not in any way guarantee your costs will be lower, nor does it guarantee you better care.

I am 24, and I recently spent 6 weeks in hospital. Nine days were in a private hospital, because the surgery I needed was “semi-urgent” and it was coming up to Christmas. Five days after the surgery, I had a stroke, still in the private hospital. I was transferred to the public system and spent a further five weeks there.

This whole experience of the surgery, private hospital stay, ICU in the private hospital, blood tests after the stroke, surgeon and anaesthetist costs came to around $24,600. Of that, about $5,800 was claimed back from Medicare. A further $2,000 was claimed back from my private health fund. I had a cover that the health fund recommended for someone who was young, single and without any pre-existing conditions. And yet this experience still left me with out-of-pocket costs of around $22,800 (I know the numbers don’t add up, but the receipts are very complicated. If someone can make sense of it and tell me how it all adds up, please get in touch!).

I am in no way regretting the experience, and I completely understand that there is no monetary value that can be put on the fact that I am still alive. I’m grateful for doctors and nurses in both hospitals I was in for keeping me alive, but at the same time, when it is claimed that people are taking out private health insurance because they do not trust the public system and would rather be in the private one, I wonder if these people are given all the facts and details. Health insurance companies love telling you what you get when you join, and they make it all seem such a great deal, but my own experience tells me otherwise.

Furthermore, I have also heard the argument that by taking out health insurance, we are alleviating the stress on the public system. This only seems to happen if you elect to go into a public hospital as a private patient, but it doesn’t seem as though many people choose this. And why would they? They receive the exact same care as if they were a public patient, and they are likely to incur costs.

I have a sneaking suspicion that those who benefit the most from private health insurance are not the patients or the public system, but instead the private health insurance companies, private doctors and private hospitals.”

• Jen Li is a geographer who was diagnosed with Cushing’s Disease last October, and had a stroke five days after surgery to remove a pituitary tumour. She has spent more time than she wanted to in the health system as a patient, and now has a goal to do a PhD on the relationship between the public and private health systems in Australia.

If you’ve read this far, you may also be interested in this Crikey article by economist Ian McAuley, arguing that the Government is actually increasing the incentives for high income earners to hold private insurance.

“The NHHRC report is not only a missed opportunity to create a system that will address equity and  efficiency in the current system – instead its proposals threaten both.

Of course no one would argue that primary health should not be strengthened, and that dental and mental health, Indigenous health, rural and remote health and aged care are not being failed by the current system. But identifying the changes needed is quite different from creating a system that will address them.

After years of debate, the commission has chosen to proceed largely in the same incremental direction we already find ourselves. Instead of finding in favour of structural reform that will ensure we have a sustainable and efficient system that will assist us to provide high quality care to the whole population, the commission has opted for an approach that will see the blame game continue and inequities entrenched.

Not content with the current status quo of a two tier system in hospital care, the commission has recommend we extend this to all health care and, in a highly risky first step towards managed care system, proposes a greatly increased role for the private sector and private health insurers.

This is the system from which the Obama administration are trying desperately to escape. The commissioners have chosen to mistake choice for equity, and thus have proposed greater choices for those who already have it, and less for those who don’t.

The proposal for Medicare Select threatens to take us in a direction where the sickest members of the community will have their health care limited to a basic package of care, while those who can afford it will be able to have as much as they like. A bit like now, only much, much worse.

This report should make the poor, the disadvantaged, the truly sick, and anyone with an sense of fairness very afraid for what lies ahead.

It is deeply disappointing and the health care sector and the community have every right to feel betrayed by this report as it does not reflect the feedback and ideas they so generously provided during the commission’s 16 month consultation.”

Prue Power is executive director of the Australian Healthcare & Hospitals Association, which represents public healthcare, and whose members include Queensland Health, South Australian Health, Tasmanian Health & Human Services, Northern Territory Health and ACT Health.

It’s time, she writes below, to expose the fallacy of this argument:

“A common argument coming from the private health sector is that the Government should support private care in order to take pressure off the public hospital system.  This argument has two significant flaws.

Firstly, it assumes that public and private hospital services are inter-changeable and thus that demand for public hospital services will be reduced by encouraging consumers to access private care.  In reality, public and private hospitals provide a very different set of services, with only limited duplication in some discrete areas.

For example, public hospitals provide almost 100 per cent of emergency services and deal with the vast majority of unplanned admissions.   Public hospitals also provide a number of highly specialised services not provided in the private sector, such as organ transplantation.  In addition to this, public hospitals are much more likely than private facilities to provide less profitable services, such as major burns and paediatric care.

In the event of a public health emergency, such as a flu pandemic, it is public hospitals that are expected to deal with the sudden increase in demand for care.  This means that the public hospital system is required to maintain a much greater reserve capacity than the private sector, which focuses mainly on planned admissions.

In rural and regional areas, the majority of hospital services are provided through the public system. There are very few private hospitals in the bush, primarily due to the higher cost of providing care in rural settings and the lower levels of demand.

In some areas, such as elective surgery, consumers have a choice about whether to access care in a public or private hospital.  However, all Australians, regardless of their private health insurance status, rely on public hospitals to provide them with high quality care in an emergency and for services not available in the private system.

Secondly, the argument that by supporting private health care pressure will be taken off public services assumes that both sectors operate independently of each other and that therefore increases in activity in the private sector can occur without taking resources away from the public sector.  This argument is also flawed.

One of the greatest constraints on the ability of public hospitals to provide additional services is workforce restrictions.  There is a fixed health workforce in Australia, with shortages in many key areas.

If the private sector provides additional services, it requires a larger health workforce.  These doctors, nurses and allied health workers are likely to come from public hospitals, thus further depleting the capacity of the public system.

Supporting the private sector to provide additional services means that public hospitals will have fewer staff to care for their larger and sicker patient population.

Both public and private hospitals play an important role in Australia’s health system and both should be supported by Government.  However, given their different service mix, and the constraints of a fixed health workforce, they should not be treated as two independent and interchangeable systems.

If the government is serious about supporting the public health system, it should do so directly and not rely on the private sector to reduce the pressure on overworked public hospitals. ”

More reading about these matters in this recent column from The Age.

He concluded that the industry might be flexing its might – warning the Government off making any real changes to current arrangements – as well as trying to attract customers through the time-honoured technique of a fear campaign.

In interesting timing, the SMH reported recently that the Rudd Government may be preparing for the sale of Medibank Private, with a draft platform to be put to Labor’s national conference next month calling on governments to “support and strengthen private health care”.

In NSW, the acting general secretary of the NSW Nurses’ Association, Judith Kiejda, is not impressed. She has written the following article for Croakey:

“This comes as no surprise given the prominence of private health insurance interests in the National Health and Hospitals Reform Commission and the failure thus far of that process to confront the truth about the impacts of the massive public subsidies currently enjoyed by the private health insurance industry.

Let’s be clear about the effects of privatising health care.  Essentially this is about increasing the burden of costs onto individuals and lessening the extent to which society takes collective responsibility for providing health care.  This cannot be the solution if our goal is to avoid the spiralling cost of care and lack of equity and access we see in the United States.

Australia’s expenditure on health as a proportion of GDP will not lessen because more of the burden is shifted to private interests.  More likely it will inflate costs because private sector providers and insurers demand profits.

Or, worse, it will lead to declining standards of care and we need look no further than the litany of issues emerging in the aged care sector to see what the profit imperative does to staffing levels and quality care.

If the private health insurance industry is so inefficient that it cannot survive without billions in public subsidies then surely good sense would demand that we direct our attention to how those billions could be invested in ways that ensure that every Australian has access to excellent care in the public system.

Universal insurance in this country has delivered very high standards of care at low costs compared to other systems.  Clearly there are a range of reforms necessary to ensure that this level of performance keeps pace with changing demographics and patterns of demand.

But to attempt to resolve the problems in the system with greater privatisation of the health care market is resigning ourselves to a system with higher overall costs and where there will necessarily be winners and losers.”

For everyone who believes that simply spending more money is the answer to the health system’s woes, this new report should be essential reading.

It’s a review of the evidence about efficiency and health systems, released today as a National Health and Hospitals Reform Commission background paper.

Here, after a speed read, are some of the more interesting snippets:

• The Productivity Commission (2006) estimated there is potential for a 10 to 20 per cent increase in the health sector’s efficiency. If, for example, a five per cent improvement in productivity were achieved through productivity reforms, it could result in net savings of around $3 billion (2005-06 dollars) – $2 billion for states and territories and nearly $1 billion or the Commonwealth. Other studies conclude, however, that the Australian health system is one of the most efficient in the world.

• It does not seem to matter, from an efficiency perspective, what the balance is between public and private expenditure.  Evidence suggests that there is no one right way to structure a health care system to ensure optimal efficiency.

• Queensland gets a number of positive mentions for its health reforms including its public reporting of hospital performance. The NSW Independent Pricing and Regulatory Tribunal says Queensland Health’s new hospital performance reporting system is best practice in Australia, and that NSW should consider following suit. Qld also gets a mention for introducing the first pay-for-performance system to be used in publicly funded health care services in Australia.

• One of the few Australian studies looking at inappropriate hospitalisation and length of stay found that 19 per cent of older patients surveyed in all public hospitals at one point in time needed a different form of care from the one they were receiving in hospital. Three-quarters were thought to need a more appropriate form of care.

• The private health insurance industry is not as efficient as either public insurers or other types of private insurers.  According to Australian Institute of Health and Welfare data, in 2006-07, private health insurers spent approximately 10 per cent of total expenses on administration while the Commonwealth spent 2.8 per cent and the states 1.5 per cent of their total recurrent expenditure on administration. Meanwhile, Australian general insurers spend, on average, approximately 7.4 per cent of revenue on administration. Private health insurers, which are broadly comparable to general insurers (Productivity Commission, 1997), spend approximately nine per cent of revenue on administration.

The report also details the human impact of Commonwealth/State cost shifting: “patient care is often driven by funding rather than clinical best practice”.

It gives quite a powerful explanation (for such a dry document) for why waste matters:

“The efficiency of the health care system is important, not only because it is key to delivering an affordable and sustainable health system, but also because it can be an ethical issue in terms of equity and fairness.  If waste occurs – whether through duplication, poor processes, unnecessary high cost inputs, errors, too much administration, spending on treatments that were not needed or unlikely to improve outcome or could have been provided with an equivalent or better outcome in a lower cost way – it will adversely impact other people’s access to health care in a system with finite financial, capital and human resources.”

Other key points:

• Reducing preventable adverse events could potentially free up an estimated $1 billion per year (in 2003-04 dollars) in hospitals for other services;

• Almost 10 per cent of hospital stays are potentially preventable if timely and adequate non-hospital health care was provided

• Only cost-effective interventions should be funded and there should be a single mechanism that assesses the cost-effectiveness of medical interventions, including preventive, pharmaceutical, medical and prostheses.

I wish I’d read it before giving a talk to health policy students at the ANU yesterday about lobby groups in health. Of course, you always end up preparing for these things at the last moment, generally late at night when the brain is frying rather than firing. I’ve already thought of some groups I should have mentioned but didn’t.

But here’s a quick summary of the talk anyway. Please add your additions and suggestions.

Lobby groups: professional

• The AMA is often called “the nation’s most powerful lobby group”, most recently in the SMH’s recent article previewing the presidential elections. Whether or not that is actually true is incidental, perception being reality. It’s who many journalists ring for comment on just about any development in health, whether or not the AMA spokesman actually has expertise in that area.

• The Pharmacy Guild. Their lobbying style is quite different to the AMA’s, as they operate largely behind closed doors and build their efforts around putting proposals and submissions into government. The national president Kos Sclavos once told me “we have more health economists than any other health group in Australia”. As well as 250 staff. But the real force is the reach of community pharmacy; it’s hard to think of a health professional with easier access to the community if governments get up their noses.

• Other professional and industrial organisations, ANF etc etc.

• There are also medical research institutes, but again their interests do not necessarily align with the broader public interest – often they are so reliant on industry funding, they are reluctant to speak up if it rocks the apple cart.

Lobby groups: business

• Pharma is the most obvious. Generally they do a very good job of influencing media coverage of their products, but often this is through third parties, so may not be obvious to a casual observer. As an industry, their image has taken a big hit in recent years.

• Other medical industries, eg surgical and devices companies

• Complementary products sector is big business despite the general public often viewing them as the ‘goodies’ (for some strange reason)

• Private health insurance lobby has to be judged one of the most successful, given the level of government support they receive despite widespread doubts about the value and merits of their product. Private hospitals also seem to do pretty well.

There is often a convergence between many professional and commercial lobby groups’ interests; for example, pharmacists flogging“non evidence based products”, and eminent medical experts and institutions lending their names and authority to marketing campaigns (see the Crikey Register of Influence for specifics)

• The un-health lobby groups – tobacco, alcohol, and food industries, to name just a few. They arguably have more influence over the community’s health than those described above.

So who represents the public interest?

This is a much tougher question to answer, though many may claim they do.

• Disease-based lobbies. The problem is that they are often narrowly focused and encourage the silo mentality that plagues health. Such groups are sometimes unduly influenced by commercial or professional interests.

• Patient groups. Again they are often focused around single issues and some, eg breast cancer, get more attention than others. Even those umbrella groups such as the Consumers Health Forum are representing their members’ interests, ie patients and that is not necessarily the same as the broader public interest.

• Groups such as the Public Health Association and CHOICE are attempting to represent the public health interest, but do not necessarily represent the broader community’s views.

Who represents those in greatest need, whether underserved groups such as Indigenous Australians or underserved issues such as the social and economic determinants of health?

Groups working in this area tend to be over-stretched and under-resourced. They are minnows compared to some of the sharks above.

The conclusion from all this is that much lobbying serves to reinforce the status quo in which society’s institutions, including government, tend to operate for the benefit of the well to do. More and better advocates are needed to agitate on behalf of the public interest in health, and especially on behalf of those in greatest need.

But as I said, this was all thought through late at night and in a great rush – it would be nice to hear others’ thoughts on these issues.

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The 18 May edition of the Medical Journal of Australia is devoted to Indigenous health,  and is well worth a read.

One article stands out in particular, both because of the vibrancy with which it is written and the poignancy of its subject – the lack of access to appropriate health services for Indigenous people in jails.

Beverley Spiers is an Aboriginal health worker at the Cessnock Correctional Centre and she writes with a zing and a candour that suggest she is passionate about her work and doesn’t mind ruffling feathers if that will help her patients.

She says Aboriginal prisoners don’t normally access the mainstream Justice Health centres in the jails because Aboriginal staff from many external Aboriginal Medical Services can’t regularly visit the the centres any more due to a lack of staff and funding.

“Despite the Royal Commission into Aboriginal Deaths in Custody 20 years ago, which recommended that culturally appropriate medical care be provided to offenders, with access to Aboriginal Health Workers wherever possible, and despite what you read in annual reports since then, Justince Health 10 years ago adopted an unofficial policy of mainstreamed take-it-or-leave-it medical service to Aboriginal offenders,” she writes.

“It is now slowly moving away from this stance by employing its own Aboriginal Health Workers as part of the health centre staffing profile, beginning with one of the newer facilities at Wellington in midwestern NSW.”

Spiers won the Dr Ross Ingram Memorial Essay Competition for an entertaining and moving description of her efforts to screen prisoners for kidney disease.

Other snippets from the journal include:

• Professor Wendy Hoy, from the University of Qld’s Centre for Chronic Disease, has weighed up the chances of Australia closing the gap in Indigenous life expectancy by 2030, and judged it “probably unattainable”. She argues that it will probably take several generations for Indigenous people’s health to approximate that of non-Indigenous Australians: “Rather than specify an unrealistic time line for aspirational goals, it would be better to focus on shorter-term process measures.”

• A new study showing that Aboriginal people in the NT are far more likely than other Australians to be hospitalised for problems that could have been prevented from reaching hospital with earlier, better treatment. Between 1998-99 and 2005-06, their avoidable hospitalisation rate was 11,090 per 100,000 population, nearly four times higher than the Australian rate of 2,848 per 100,000.

• Andrew Hewett, Executive Director of Oxfam Australia, raises concerns about the slowness of the Federal Government’s response to closing the gap efforts. In March last year, the federal government signed a statement of intent with leading Indigenous health groups, showing its intent to create a national action plan in partnership with peak Indigenous health groups.

“However, after more than a year, we are still waiting for the national plan and the partnership to eventuate,” says Hewett. “Peak Indigenous health groups have created a comprehensive list of targets they would like to achieve in a plan, and are inviting the government to engage with them, as was promised.” Hewett says Indigenous health groups know what to do to be effective. “For instance, the Victorian Aboriginal Health Service in Melbourne has immunisation rates that show an average of 91 per cent of their child patients are fully immunised, compared with rates of less than 50 per cent for Aboriginal children across Victoria.”

• The relative affordability of energy-dense foods (rich in sugars and fats) compared with nutrient-dense foods (such as meat, fruit and vegetables) in remote communities is a major cause of ill health, according to a new study based in one large remote community in northern Australia. The researchers suggest that efforts to improve nutrition should be placed in an economic framework rather than been seen as a matter of individual behavioural change. They conclude “our study highlights the investment that improving nutrition for Indigenous people in remote communities will require.” Meanwhile, other authors note, however, that nutrition issues were not included in the final National Indigenous Reform Agreement of COAG.

• Interventions to tackle smoking by pregnant Aboriginal and Torres Strait Islander women should focus on the social environment and the influences of social networks and partners rather than the traditional predictors of anenatal smoking, a study suggests.

• Lack of local birthing services means pregnant women from Cape York typically have to leave home at 36 weeks to travel to Cairns, meaning weeks away from family and friends “with detrimental social, cultural and financial consequences”. In 2006, 172 women from 14 Cape communities travelled to Cairns to give birth, three-quarters of whom identified as Aboriginal or Torrest Strait Islander.  The researchers say that reopening maternity units at Weipa and Cooktown hospitals would help.

• A new study gives some powerful insights into why so many Aboriginal people find hospitals and other health services daunting, unfriendly and unhelpful.

The news is not all gloomy, however. This article and another one suggest there’s a good news story just waiting to be told about the Inala Indigenous Health Service in Queensland.

The journal also includes pieces from the Australian Indigenous Psychologists Association and Indigenous Dentists’ Association of Australia, as well as organisations representing Indigenous doctors and nurses. That must be a first.

Oh, for some political attention to these issues, rather than worrying so much about health care for the well-heeled.