The Essentials

Australia is devoting more resources to the health of its Indigenous peoples. Between 2010-2011 and 2016-2017, federal spending per capita increased by 5.6% annually in real terms, according to AIHW data cited by the Queensland Chief Health Officer. Between 2010 and 2019, cardiovascular mortality declined by 18% among Aboriginal people. The overall gap persists because housing, employment, and education largely escape health spending. Certain studies associated with AIHW link community-led services to better outcomes, while noting that the level of evidence varies across indicators.

A country can spend more and progress more slowly than it believes it should. Australia is experiencing this at a large scale today, and the lesson is uncomfortable for both camps that have disputed the Indigenous question for decades.

On one side, those demanding larger budgets can point to increased appropriations. On the other, those skeptical of public policy effectiveness can point to the persistence of the gap. Both are right about their half of the problem. AIHW data reveal a third variable, more difficult to negotiate politically: governance itself.

Cardiovascular Mortality Declines, Yet the Overall Mortality Gap Remains Unchanged

Let us start with what has worked. Between 2010 and 2019, cardiovascular mortality fell by 18% among Aboriginal and Torres Strait Islander people. Over the same period, preventable hospitalisations for diabetes declined in several regions where targeted primary care programs were deployed. These are lives saved, concrete results, and it would be intellectually dishonest to minimise them.

Yet these gains have not translated into a reduction of the gap. Indigenous Australians still die on average approximately 8.8 years earlier than non-Indigenous men, and 8.1 years earlier for women (ABS data 2020-2022). The life expectancy of Indigenous men was 71.6 years over the period 2015-2017, then 71.9 years in 2020-2022, compared with 80.2 years for non-Indigenous men over the same period 2015-2017, and 80.6 years in 2020-2022. For women, the gap was 7.8 years over the period 2015-2017; it reaches 8.1 years according to 2020-2022 data. Slow but measurable progress is documented on these indicators, even if the trajectory remains largely insufficient to achieve the goal of closing the gap by 2031.

The mechanism is less mysterious than it might appear. Health spending acts on treatable pathologies—heart disease, type 2 diabetes, respiratory infections. It does not directly act on the factors that generate these pathologies at a higher rate in Indigenous communities: overcrowded housing that facilitates the spread of tuberculosis and respiratory diseases, structural unemployment that deepens poverty and despair, limited access to quality education. Treating effects without addressing causes produces partial improvements that do not accumulate into catch-up.

Social Determinants Deepen a Gap That Healthcare Alone Cannot Close

AIHW documents these determinants with precision. In 2021, approximately 19% of Indigenous people live in overcrowded housing, that is approximately 10% of Indigenous households, compared with 5% for the general population. The employment rate for Indigenous adults aged 15 to 64 is 52% in 2021 (56% for ages 25-64), compared with 75% for non-Indigenous people. These gaps alone explain a substantial portion of the mortality gap, independently of healthcare access.

International epidemiological literature confirms this diagnosis. Social determinants of health—housing, income, education, social capital—are responsible for approximately 30 to 55% of health inequalities between population groups in high-income countries, according to work published in academic literature and WHO reports. Healthcare access, however important, represents only a fraction of this variance.

For Australia, this means that Aboriginal health is partly the result of housing, employment, and education policies carried out, or not carried out, over decades. Health ministries do not govern these variables. They can, at best, mitigate their effects. The inter-ministerial coordination required to act on the full picture remains, according to successive AIHW reports, largely insufficient.

Community-Led Programs Perform Better, and the Data Shows It

Aboriginal Community Controlled Health Organisations (ACCHO), health centres managed by and for Indigenous communities, display better results on several indicators of primary care and preventable hospitalisations. Available comparisons, however, do not always cover strictly equivalent areas. The National Aboriginal Community Controlled Health Organisation (NACCHO), which brings together these structures, documents their role in diabetes prevention and management without providing, in available sources, a direct numerical comparison on childhood vaccination.

The reasons are not mysterious either. These services employ Indigenous staff, speak local languages, and are embedded in networks of trust built over years. They treat health as a dimension of a broader community project, not as an outsourced service. The rate of follow-up consultations, a proxy for continuity of care, is measurably higher in these organisations.

This finding has a direct political implication: transferring governance, not just budget, to these structures would likely yield better results at comparable cost, or even lower cost. The Albanese government has, since 2022, engaged discussions on expanding ACCHO funding, with commitments within the framework of the National Agreement on Closing the Gap. Yet the effective transfer of decision-making on resource allocation remains partial and contested by several States.

The 2031 Target Is Already Compromised, the 2050 Trajectory Takes Shape

Australia has set itself a formal objective: close the life expectancy gap by 2031, within the national “Closing the Gap” program. The current trajectory makes this objective difficult to achieve. At the pace of reduction observed over the past ten years, the gap will not be closed before several decades.

AIHW regularly publishes assessments of this trajectory. Its reports indicate that if current trends continue, the life expectancy gap will persist well beyond 2031. The exact formulation of projections and their assumptions vary across editions; it would be inaccurate to set a precise date for “2050” without reviewing the full models. What is documented, however, is that the 2031 target would require a substantial acceleration in the pace of reduction, not observed to date.

This situation has measurable generational effects. An Indigenous child born today in a rural community in the Northern Territory enters a system where the probabilities of premature mortality, preventable hospitalisation, and educational disengagement are structurally higher. These inequalities are transmitted: adults in poor health have greater difficulty maintaining employment, which affects the living conditions of subsequent children. Health budgets can mitigate some of these effects; they do not break the chain so long as living conditions remain unchanged.

A Political Tension That Neither Abstract Universalism Nor Identity Politics Resolves

Australian political debate stumbles here on a genuine conceptual difficulty. Yascha Mounk, in his work on tensions between liberal universalism and identity politics, poses a central question for this type of situation: are policies targeted at specific ethnic or cultural groups compatible with a liberal democratic project, or do they reinforce categorisations that weaken social cohesion in the long term?

The question is legitimate. It arose acutely during the October 2023 referendum on the Voice to Parliament, the proposal to inscribe in the Australian Constitution a consultative Indigenous body. The referendum was rejected 60% to 40%, in a configuration where “No” advocates had precisely mobilised the universalist argument: why inscribe a specific voice for one group, rather than strengthen institutions that represent all Australians?

Health data limit the scope of this argument. The life expectancy gap reaches 8.8 years for men and 8.1 years for women according to ABS data 2020-2022. Institutional universalism has therefore produced very different results depending on the group. Dani Rodrik formulates an analogous principle for economics: durably asymmetrical distributions call for targeted instruments. Appropriate regulation can then make the principle of equality more effective.

For Indigenous health in Australia, effectiveness depends on targeting and proximity. ACCHO organisations know the populations they serve and adapt care to local realities. Results documented across several indicators support a pragmatic reading of their role.

Shared Decision-Making Changes Health Governance

The National Agreement on Closing the Gap, signed in 2020 between the federal government, States, and national Indigenous organisations, contains four “Priority Reforms”. These concern formal partnerships and shared decision-making, strengthening of the community-controlled sector, transformation of government organisations, and shared access to data and information at regional level. These axes respond to the limitations of programs designed with insufficient community participation.

Shared decision-making gives Indigenous communities a formal place in defining health priorities, allocating resources, and evaluating outcomes. It transforms a model historically centred on Canberra and State capitals, where local participation occurred chiefly at the implementation stage.

The Productivity Commission’s final report, published in February 2024, concludes that governments have largely failed to honour their commitments under the agreement and calls for fundamental changes in power-sharing. Funding has grown faster than transformation in allocation decisions. Performance observed in several ACCHO programmes strengthens the interest in evaluating this rebalancing.

The difference between a system where one spends more on Aboriginal health and a system where Aboriginal people decide how to spend is both symbolic and operational: local priorities diverge from national priorities, and trust mechanisms that make programs effective are not decreed from the capital.

Lessons Australia Offers to Other Wealthy Countries

Australia is not an isolated case. Canada, New Zealand, and the United States face comparable configurations: Indigenous peoples who live on average shorter lives than the rest of the population, targeted health spending on the increase, and mortality gaps that decline slowly or not at all. New Zealand, with its Māori health programs founded on the concept of “whānau ora” (overall family wellbeing), offers a partial counter-example: slightly better results on certain indicators of child health, achieved by integrating health into a broader community approach.

These comparisons suggest that the Australian problem is structural, thus common to other contexts. Everywhere that profound health inequalities coexist with inequalities in housing, employment, and education, healthcare spending alone is insufficient. Everywhere that policies have been designed for communities without those communities, results have been disappointing.

In Australia, in 2025, the issue concerns more the architecture of budgets than their amount: who decides, who allocates, who evaluates? Progress measured on cardiovascular mortality shows that the health system can achieve results when properly oriented. The persistence of the overall gap shows that this orientation must be defined within the communities concerned.

The 2031 target for “Closing the Gap” will probably be missed. It then matters whether this failure leads to a review of governance mechanisms, or merely to increased budgets for the following decade.

Sources

  1. Australian Institute of Health and Welfare, Indigenous Health Performance Framework: https://www.indigenoushpf.gov.au/report-overview/overview/summary-report
  2. Productivity Commission, final review of the National Agreement on Closing the Gap, February 2024
  3. National Aboriginal Community Controlled Health Organisation (NACCHO), annual performance reports of ACCHO
  4. The Lancet, meta-analyses on social determinants of health and mortality inequalities in high-income countries
  5. Yascha Mounk, The Identity Trap (Penguin Press, 2023)
  6. Dani Rodrik, Straight Talk on Trade (Princeton University Press, 2017)
  7. AIHW HPF – Indigenous health spending (measure 3.21): https://www.indigenoushpf.gov.au/measures/3-21-health-expenditure
  8. ABS – Indigenous life expectancy 2020-2022: https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/aboriginal-and-torres-strait-islander-life-expectancy/latest-release
  9. AIHW HPF – Cardiovascular mortality (measure 1.05): https://www.indigenoushpf.gov.au/measures/1-05-cardiovascular-disease
  10. AIHW – First Nations housing: https://www.aihw.gov.au/reports/australias-welfare/indigenous-housing
  11. AIHW HPF – Employment (measure 2.07): https://www.indigenoushpf.gov.au/measures/2-07-employment
  12. Closing the Gap – Official targets: https://www.closingthegap.gov.au/national-agreement/targets
  13. ANU POLIS – Results of Voice 2023 referendum: https://polis.cass.anu.edu.au/research/publications/detailed-analysis-2023-voice-parliament-referendum-and-related-social-and
  14. Productivity Commission – Review of the National Agreement on Closing the Gap: https://www.pc.gov.au/inquiries-and-research/closing-the-gap-review/report/
  15. National Agreement on Closing the Gap – signed in 2020: https://www.closingthegap.gov.au/national-agreement