**1. Introduction**

Australia is a federation of six states and two self-governing territories (the Australian Capital Territory and the Northern Territory), referred to in this paper for simplicity as 'the States'. These eight governmental entities share responsibility for health and health services with the Australian (Commonwealth) Government. Many health services are provided by governments, with the private sector also delivering services, notably in primary care, dentistry, private hospitals, and pharmacy. Health constitutes some 10% of the Australian economy [1] (p. 173).

Australia introduced a system of universal health insurance (now known as Medicare) in the 1970s and 1980s. This covered privately provided medical services and shared the funding of public hospitals between the Australian and State governments [2]. As a result, there was a need to know much more about the services that the Australian health system delivered across its many arms. The decades that followed have seen grea<sup>t</sup> progress in building a national health information infrastructure to inform health policy, resource allocation, and delivery of health care across the nation. That work continues.

This paper is a commentary that aims to briefly describe the main components of Australia's health statistics system, highlight its breadth, successes, and novel features, point out some limitations, and indicate directions for future development. It provides a succinct overview of the current state of health statistics in Australia, set within a historical

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**Citation:** Madden, R.; Fortune, N.; Gordon, J. Health Statistics in Australia: What We Know and Do Not Know. *Int. J. Environ. Res. Public Health* **2022**, *19*, 4959. https:// doi.org/10.3390/ijerph19094959

Academic Editors: Gabriel Gulis and Paul B. Tchounwou

Received: 14 December 2021 Accepted: 2 February 2022 Published: 19 April 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

context, to inform future work to improve and build on Australia's health information infrastructure, and to demonstrate the crucial role of health statistics in running an effective and responsive health system.

In preparing this commentary, we have drawn upon a broad range of reports, technical documents, and other resources available on the websites of Australia's two main national statistics agencies (the Australian Bureau of Statistics and the Australian Institute of Health and Welfare) and the Australian Department of Health. The paper accompanies, and is informed by, a range of papers from expert authors across the health statistics spectrum in Australia. It is hoped that the collection of papers will inform interested readers and stand as a comprehensive review of the strengths and weaknesses of Australian health statistics in the early 2020s.

#### **2. Australia's Statistical Agencies**

Health statistics in Australia come, in large part, from two official statistics agencies— the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. Both agencies are apolitical and explicitly serve all sectors of the community. Their values accord with the UN Fundamental Principles of Official Statistics [3], which state, as Principle 1, 'Official statistics provide an indispensable element in the information system of a democratic society, serving the Government, the economy and the public with data about the economic, demographic, social and environmental situation'. Principle 1 goes on to emphasise the need for impartiality and that statistics should be of 'practical utility'.

The (now) Australian Bureau of Statistics (ABS) dates from 1905, as the national statistics agency. It conducts a population census every five years, processes and publishes vital statistics, and conducts a range of social surveys, including in health. In 1987, the (now) Australian Institute of Health and Welfare (AIHW) was established to focus on health and community services statistics, especially using administrative data provided by the States. The AIHW works in conjunction with the ABS. Both agencies operate under national legislation which strictly protects the confidentiality and privacy of individual data [4,5]. The AIHW is required to report to Parliament on the state of Australia's health and health services every two years, in a publication called *Australia's Health*, beginning in 1988, with the most recent in 2020 [1].

#### **3. Development of Health Statistics**

This paper gives a brief description of various categories of health statistics in Australia, beginning with an outline of developments from the beginning of the 20th century. Sources of health statistics include patient and administrative data, surveys, and clinical registries.

Mortality statistics, including causes of death, have been collected since the late 19th century, with national data produced by the ABS from 1907.

Each State established a hospital in-patient data collection by the 1970s. Data on each patient episode was provided by the hospital to the State central collection. On its establishment, the first task for the AIHW was to produce national hospital in-patient statistics. This was a vital need as, under Medicare, funding of hospitals was now shared by the Commonwealth and States.

To pursue its charter, to bring together State health data into national collections, the AIHW led the development of the National Health Information Agreement in 1992. Under this agreement, all States agreed to establish national minimum datasets for key services, including hospital in-patients, and provide annual data to the AIHW for collation and publication. National minimum dataset specifications were developed, data standards were published in the National Health Data Dictionary (available in electronic form from July 1997) and, in the early 2000s, AIHW established a national online metadata registry for health, housing, and community services statistics and information (METeOR) [6].

National Health Information Plans were developed in 1995 and 2002 [7,8], to identify agreed priorities for national developments in health statistics. Development of a new National Health Information Strategy began in 2019 [9] but was not completed before national

health governance arrangements changed in the light of the COVID-19 pandemic. This paper refers to the priorities of the 2002 plan, many of which remain just as relevant today.

Australia follows international standards for data collection and analysis where these exist, notably for causes of death (World Health Organization (WHO)) [10] and health expenditure (Organisation for Economic Co-operation and Development (OECD)) [11]. The AIHW is the Australian Collaborating Centre for the WHO's Family of International Classifications, the focus for Australian work on the development and maintenance of health classifications.

Australia's health statistics are financed through a variety of arrangements, including national direct funding of AIHW and ABS, contract funding by Australian Government departments, and State health department funding for administrative data and some special-purpose collections.

### **4. Health Surveys**

The ABS conducted its first National Health Survey in 1977–1978, and these surveys have been repeated at regular intervals. In 2011, a National Nutrition and Physical Activity Survey and a National Health Measures Survey were added, providing biomedical information, in addition to self-reported information on health conditions such as cardiovascular disease, diabetes, kidney function, and risk factors.

The first of now regular National Aboriginal and Torres Strait Islander Health Surveys was conducted in 2004 [12]. Some health data are also collected in National Aboriginal and Torres Strait Islander Social Surveys [13].

In addition to these national health surveys, the AIHW has conducted a regular National Drug Strategy Household Survey, beginning in 1985, gathering information on the use of alcohol, tobacco, and illicit drugs [14].

The ABS conducted a National Survey of Mental Health and Wellbeing in 2007, giving a one-off view of the characteristics of people with mental health conditions (employment, housing, etc.) [15].

In 2019–2020, the ABS conducted a Patient Experiences Survey, covering health service use and experiences with health providers, as part of its annual Multipurpose Household Survey [16].

#### **5. Health Statistics for Aboriginal and Torres Strait Islander Peopless**

Australia has generally high health status, but notably, Aboriginal and Torres Strait Islander (Indigenous) people experience disadvantages, compared with other Australians, across a range of health outcomes [17].

Up to 1988, statistics on the health of Australia's Aboriginal and Torres Strait Islander people were almost non-existent. Australia became a nation in 1901. Its Constitution specified that 'Aboriginal natives' were not to be included in population estimates. This now-shocking provision ensured that there was little effort on statistics for the Indigenous population. Population estimates were conducted administratively, almost certainly underestimating the actual Indigenous population [18]. The exclusion provision was removed from the Constitution in 1967, and data about Indigenous status have been available since the 1971 Census, with Indigenous identification steadily improving over time [18].

In 1988, the first edition of AIHW's biennial report, *Australia's Health,* brought together an array of data to demonstrate the poor health status of Indigenous Australians.

The release of the first National Aboriginal and Torres Strait Islander Survey by the ABS in 1994 [19] marked a considerable step forward by producing a wide range of information on Indigenous people. The survey captured data on positive aspects of Indigenous life and culture, such as connection to land, as well as highlighting the systemic and intergenerational problems Indigenous people live with, including historical separation of children from families.

From 1996 on, the AIHW and ABS have worked in collaboration with Indigenous people to improve information on Indigenous health. A highlight was the release in 1997 of the first edition of *The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples*, published jointly by the two agencies and launched by the Australian Governor-General [20].

The development of Indigenous health statistics was the number one priority of the 2002 National Health Information Plan [8].

The development of Indigenous health statistics in Australia and many challenging issues are described by Ring and Griffiths [21] in this issue. The continuing, nationally acknowledged but persistent 'gap' between the health of Indigenous people and that of other Australians is highlighted each year in national 'Closing the Gap' reports [22]. Indigenous health statistics will remain a priority for development and a focus for lively debate into the future. Indigenous people are increasingly leading the development of new Indigenous controlled data and pushing the national statistical agencies to redouble their efforts.
