With growing health expenditures and greater scrutiny of health care spending, the results of economic evaluations are increasingly used to assist decisions about health care resource allocation . Economic evaluations assist decision-makers to determine which health interventions represent the best ‘value for money’ in terms of maximizing the health of the population with the available funds.
Such economic evidence is valuable, particularly for groups who experience health disadvantage such as Australia’s Aboriginal and Torres Strait Islander (or Indigenous) population, to indicate where resources are best placed to help bridge the health gap. Australia’s Indigenous population has a health status much worse than that of the general Australian population, with life expectancy 10 years below that of non-Indigenous Australians , and standardized morality and infant mortality rates more than twice as high . This poorer health is grounded in complex historical, geographic, economic and socio-cultural factors, in many ways similar to those faced by colonized indigenous peoples worldwide. The available evidence suggests that mainstream primary health care services have struggled to deal with these issues and improve the Indigenous health discrepancy, and that population specific services are warranted [4–7].
It is generally accepted within Australian policy discourse that greater resources are necessary to improve Indigenous health [4, 8, 9]. Qualitative evidence suggests that ‘best practice’ primary health care for the Indigenous population is based on self-determination and community control, epitomized by the Aboriginal Community Controlled Health Service (ACCHS) model of comprehensive primary health care [10–12]. An ACCHS is defined as being an incorporated Aboriginal organization, initiated and based in a local Aboriginal community, governed by a locally elected Aboriginal body, and delivering a holistic and culturally appropriate health service to the community that controls it . Community control is a central component of this model; in other words, the health service is run by Aboriginal people, for Aboriginal people. Based on the premise of providing ‘equity of access’, ACCHSs have been found to provide equitable and more effective primary health care for the Indigenous population . However, the funding of ACCHSs remains fragmented and is generally considered insufficient to meet the greater health need .
The results of economic evaluations could help determine the best use of resources to improve Indigenous health. However, such evidence specific to the Indigenous context remains deficient. In part, this can be explained because economic evaluation techniques depend on modeling from existing quantitative data, to determine both the total costs of a health intervention, and to extrapolate to improvements in health effect or benefit . Due to the relatively small size of Australia’s Indigenous population, there is a lack of cost and effectiveness data specifically pertaining to this group that takes into account their unique demographic features, socio-cultural context, and preferred health service models. Therefore, there is a corresponding lack of Indigenous specific health economics data. This means that resource allocation decisions for Indigenous health are often based on mainstream economic evidence which may not be representative, or not based on economic evidence at all. Under these circumstances cost-effectiveness results may be distorted, and health inequalities may in fact be perpetuated rather than improved.
This paper describes one method by which this deficiency in Indigenous health economics data could be overcome. The ‘Indigenous Health Service Delivery (IHSD) Template’ has been developed, which quantifies the differences in how health interventions are delivered to the Indigenous population via ACCHSs compared to mainstream general practitioner (GP) based services, the latter being the standard form of primary health care available in Australia. Differences in costs and benefits have been identified, measured and valued in the construction of the template. The IHSD Template can then be applied to adapt mainstream data, to allow its economic evaluation as if interventions were delivered to the Indigenous population via best practice methods of health service delivery. Therefore, economic evaluation results which are based on mainstream evidence can be made more relevant to the Indigenous context and facilitate more meaningful resource allocation recommendations.
An additional advantage of the IHSD Template is that it provides a measure of equitable health service provision, in terms of the additional costs incurred and the improved health benefits that result. Therefore, it is an important potential tool for decision-makers when achieving health equity is a pressing policy imperative, in an area where, to date, quantitative data has been limited.
The research outlined in this paper comprised part of the larger Assessing Cost Effectiveness in Prevention (ACE-Prevention) project, which evaluated the cost-effectiveness of interventions to prevent chronic disease in the Australian population . As part of this study, separate economic evaluations were performed for the general (or total) Australian population and for the Indigenous Australian population. Separate evaluations were necessary to account for differences in demographics, the target disease burden, the prevalence and distribution of harmful exposures, the way health interventions are delivered, and their effectiveness. The content of this paper draws on the Indigenous component of the ACE-Prevention project, and expands on information contained within the ACE-Prevention final report and dissemination pamphlets [16, 17].