Healthcare System of Australia The Australian Government, through the Department of Health and Ageing, sets national health

policies and subsidises health services provided by state and territory governments and the private sector. Total expenditure on health by all levels of government and the private sector accounts for about 9.8 per cent of Australias gross domestic product. Like other countries, Australia faces growing pressures on health funding because of technological changes, increasing patient expectations and, to a lesser extent, an ageing population. The Australian Government funds universal medical services and pharmaceuticals and gives financial assistance to public hospitals, residential aged care facilities and home and community care for the aged. It is also the major source of funds for health research and provides support for training health professionals and financial assistance to tertiary students. State and territory governments provide a variety of direct health services, including most acute and psychiatric hospital services. State and territory governments also provide community and public health services, including school health, dental health, maternal and child health, occupational health, disease control activities and a variety of health inspection functions. The main health responsibilities of local government are in environmental control such as garbage disposal, clean water and health inspections. Local governments also provide home care and personal preventive services, such as immunisation. Healthcare Providers Public sector health financing The public health system is called Medicare. It ensures free universal access to hospital treatment and subsidised out-of-hospital medical treatment. It is funded by a 1.5% tax levy on all taxpayers, an extra 1% levy on high income earners, as well as general revenue In 1984 a comprehensive health care system, Medicare, was introduced. Medicare facilitates access by all eligible Australian residents to free or low-cost medical, optometric and public hospital care, while leaving them free to choose private health services. Individuals financial contributions to the public health care system are based on their income and are made through a taxation levy known as the Medicare levy. Australias public hospital system is jointly funded by the Australian Government and state and territory governments and is administered by state and territory health departments.

People admitted to public hospitals as public (Medicare) patients receive treatment by doctors and specialists nominated by the hospital. They are not charged for care and treatment or after-care by the treating doctor. Private patients in public or private hospitals can choose the doctor who treats them. Medicare pays 75 per cent of the Medicare schedule fee for services and procedures provided by the treating doctor. For patients who have private health insurance, some or all of the outstanding balance may be covered. Private patients are charged for hospital accommodation and items such as theatre fees and medicine. These costs may also be covered by private health insurance but are not covered by Medicare. Medicare Australia is the agency within the Department of Human Services responsible for processing and paying Medicare benefits for approved services. Medicare Australia also pays pharmaceutical benefits under the Pharmaceutical Benefits Scheme, which subsidises an agreed list of prescription drugs. For both medical and pharmaceutical services, safety net arrangements exist to make sure patients who need a high level of treatment or medication during a financial year do not incur significant out-of-pocket expenses. Out-of-pocket costs are the difference between the Medicare benefit and what the patient is actually charged. The Australian Government also provides medical, pharmaceutical and hospital services for veterans, war widows and their eligible dependants under legislation administered by the Department of Veterans Affairs. The Australian Government provides about two-thirds (67 per cent) of public sector expenditure on health, and state, territory and local governments provide the rest. Non-government health sector financing Private hospitals provide about one-third of all hospital beds in Australia. Private medical practitioners provide most out-of-hospital medical services and, along with salaried doctors, perform a large proportion of hospital services. Private practitioners provide most dental services and allied health services such as physiotherapy. About half of all Australians have private health insurance. Forty-three per cent of the population (or nine million people) are covered by hospital insurance for treatment as private patients in both public and private hospitals. Forty-three per cent of the population (or nine million people) have ancillary cover for non-medical services provided out of hospital, such as physiotherapy, dental treatment and the purchase of spectacles. The Australian Government is seeking to achieve a better balance between public and private sector involvement in health care by encouraging people to take out private health insurance, while it also preserves Medicare as the universal safety net. The Australian Government helps to make private health insurance more affordable by offering a 30 per cent rebate (and higher rebates for older Australians) for the cost of private health insurance premiums. Safety nets for medical services and

pharmaceuticals assist people facing high annual out-of-pocket health costs. An Extended Medicare Safety Net, introduced in 2004, provides further assistance by meeting 80 per cent of the out-of-pocket cost of medical services provided out of hospital once an annual threshold is reached. Private sector expenditure on health accounts for about one-third of total health expenditure. The majority (around 60 per cent) of this is individuals out-of-pocket expenses and the remainder is expenditure by private health and other insurers such as workers compensation and third-party motor vehicle insurers. Public Health Federal, State and Territory Governments have been the major providers of public health services for the people of Australia, and each jurisdiction is responsible for creating its own institutional arrangements for public health programs, individual priorities and divisions of labor. Constitutional responsibilities in this area rest largely with the States and Territories. Local government is an important contributor at the service level having a central role in public health surveillance and action. The resources available to governments in achieving public health objectives are considerable and include universities, non-government and community organisations, and the workforce, programs and institutions of the primary health care system. Successful public health activities are carried out through multidisciplinary teams, often with highly specialised expertise, using the range of regulatory powers available to the State with cooperation of the national level agencies. Australian Government has a broad policy leadership and financing role in health matters, while the States and Territories are largely responsible for the delivery of public sector health services and the regulation of health workers in the public and private sectors. All Australian governments are committed through the National Competition Policy to a consistent national approach to foster greater economic efficiency and improve the overall competitiveness of the Australian economy. The Policy requires that legislation should not restrict competition unless it can be demonstrated that the benefits to the community as a whole outweigh the costs, and the objectives of the legislation can only be achieved by restricting competition. Future issues and challenges

Socio-behavioural pathologies Ecological imbalance Linking health outcomes to health financing Health care reform National competition policy Multimedia and telecommunications

The Federal Government

National public health work is performed by the Public Health Division (and the Office of Aboriginal and Torres Strait Islander Health Services) of the Federal Department of Health and Family Services. Regulatory functions are provided by other organisations including the Australia New Zealand Food Authority (ANZFA), the Therapeutic Goods Administration (TGA), and other associated TGA agencies (e.g. the Environmental Health and Safety Unit, the Australian Radiation Laboratory, and the Nuclear Safety Bureau). The Australian Government thereby provides for a national regulatory framework which ensures environmental health and consumer protection for the Australian people. Legislation and other important functions are carried out by the National Health and Medical Research Council (NHMRC), the Australian Institute of Health and Welfare (AIHW) and the Health Insurance Commission (HIC) which have been discussed in Section 2 of this paper. In all cases, the Australian Government performs its activities in collaboration with State, Territory and local governments, and non-government, professional, and community organisations. Federal responsibilities include Medicare as well as special items such as nursing homes, home and other community care and disability services and child care. The newest legislation covers areas regarding food, nuclear codes, therapeutic goods and tobacco. The national development of public health policy has regard for Australia's involvement in international public health issues. The Australian Government of Australia actively participates in the work of the World Health Organisation (WHO) under international treaty obligations. There is continued strategic support for international health industry networks through overseas health projects where AusAID, the Australian Government agency for the administration of Australia's international aid, is the primary contributor. Australia is a party to international agreements on a variety of issues including research cooperation, international drug treaties, radiation, and health care. The Federal Governments public health effort affects the health of the community directly through the following core functions.

Facilitate the development of national public health policy. Facilitate ongoing planning, monitoring, reporting, research, training and evaluation of public health activities. Facilitate the development of national consistency in policy standards, legislation and regulation, workforce competencies, environmental protection, disease prevention and outbreak control methods. Foster and initially finance innovation in population health programs. Conduct national programs in public health. Advocate, build and strengthen a population health constituency with key players and with the public. Conduct, in consultation with other partners, Australias international responsibilities and obligations in public health.

The State and Territory governments

Most core functions of public health have traditionally been the responsibility of the States and Territories. Under the various Health Acts (which usually cover environmental health, communicable diseases, food safety and tobacco controls), States and Territories pursue the following public health objectives.

Identify public health issues state wide through epidemiological surveillance. Allow for timely intervention and monitoring of health outcomes. Develop policy related to communicable diseases, environmental health, immunisation, food, radiation safety, workplace risk, water quality, drugs and poisons, and emergency management. Organise preventive and early detection programs such as cancer screening, school health, etc. Support population health literacy and health promoting behaviour. Develop strategies for new and emerging health problems. Give government the power to act quickly in public health emergencies. Examine the effectiveness, and collaborate with all other government and non-government public health sectors and relevant authorities, to address public health issues and provide for an appropriately skilled public health workforce.

The individual jurisdictions organise their activities in a more similar than dissimilar way, to collaborate with all other public health sectors to develop and implement specific public health policy, programs and regulatory framework. Some states have adopted tobacco hypothecation as a way of funding tobacco control and other health promotion activities. Local government Within States and Territories, there are a large number of local government bodies that can perform public health service functions in a variety of ways with different emphasis from State to State, as determined in the respective Health Acts and Local Government Acts. Local councils vary with respect to the type (rural or metropolitan), the role they play, and the extent to which they respond to local needs. The local government interacts with public health activities involving environmental management, economic development, public safety, maintaining roads, cultural and recreational development, land use planning and provision of community services. Strategic planning of service delivery at the local level may be perceived as a more business oriented approach. Goods and services once provided by local government councils may be supplied by contractors. Councils are now both providers as well as purchasers of services. Universities and research institutions Australia has a strong public health academic sector both in research and in education. Australia has received four Nobel prizes in health related fields: Florey for the discovery of penicillin, Burnet for work in immunology, Eccles for the study of neurotransmission, and last year Doherty for his work in immunology. Continued

success promises future achievements in the health areas. It is expected that there will be an increased investment in commissioned strategic research. Eighteen universities and institutions in Australia offer public health workforce training programs. The establishment of the Public Health Education and Research Program (PHERP) enabled the expansion of post-graduate public health education. Additionally, PHERP supports public health training and research development through the provision of funds to academic centres of public health and by provision of funds to several institutions for specific initiatives (e.g. Aboriginal health, communicable diseases, training in health promotion practice). The role of preventive care is becoming increasingly significant and the current trend is to provide health promotion training to medical students through medical school curricula in Australia. There is a strong orientation towards evidence based health practice and some health outcome programs that have been established in part through the support of the NHMRC and Federal, State and Territory Governments. The Australasian Cochrane Centre facilitates the preparation, maintenance and dissemination of systematic reviews of controlled trials regarding health care interventions that help influence service provision and clinical practice. The Centre is linked to the international Cochrane Collaboration. In addition, AIHW has established the Australian Health Outcomes Clearing House which assists in the dissemination of information to the public health sector. There are other specific research institutions which play an important role in public health research efforts in Australia including national centres which focus on HIV/AIDS, immunisation and drugs and alcohol. Although the basis of their funding is governmental, they also receive significant funding from benefactors and grants. Health promotion foundations (e.g. Victorian Health Promotion Foundation) are an important source of health promotion research and training funds. There are some 40 WHO Collaborating Centres in Australia that contribute to public health activities. These research institutions are recognised by the international health community for their excellence in laboratory medical research, health promotion and education. Their respective focus is wide reaching and includes issues such as virus research, bio safety, vaccine production, food controls, and epidemiology on chronic disease, drug quality control, medical education, and health promotion. NGOs, professional and community organisations Non-government organisations have a significant role in building capacity for promoting health in communities, and in other sectors, and have often developed strong inter sectoral working relationships. This sector comprises a range of services which are funded from a variety of government and non-government sources, and the public health activities that are carried out by the different organisations are increasing as more government services are contracted out. Individual organisations generally focus on specific issues (e.g. heart disease, asthma, diabetes, and cancer), or on specific population groups (e.g. Aboriginals,

people with HIV/AIDS, and the aged). They therefore have specific knowledge, experience and access to individuals and communities. The larger organisations (e.g. the National Heart Foundation, the various State Anti-Cancer Councils, and the Asthma Foundation) all have designated funding specifically for public health research and health promotion, have well-established credentials and play clear roles in health care and promotion. A range of professional organisations (e.g. the Australian Public Health Association (PHA), the Australian Institute of Environmental Health (AIEH) and the Australasian Faculty of Public Health Medicine of the Royal Australasian College of Physicians) play significant roles in promoting the health of the Australian population. Their roles include workforce advancement through journals and specialised education, policy development and inter sectoral networking. The workforce represented by the wide variety of professional associations includes academics, administrators, community nurses, social workers, school teachers, youth workers, and others. Primary health care providers The backbone of the community based primary health care system is the general practitioner. Doctors are seen by the community as the most authoritative source for information and advice on reducing health risks and for many provide the main source of public health education. Important functions include encouraging greater use of one-to-one clinical consultation opportunities (patient management rather than solely treatment based methodologies), planned screening of patients, group education activities, broader community development strategies with or without a multi-disciplinary approach, and involvement in population based policy and planning activities. Divisions of General Practice were established in 1993 as groupings of general practitioners within specified geographic areas with the aim to improve local health service delivery and the health of their local communities by collaborating with the other sectors of the health system. This has been an important action in linking the medical sector with health promotion activities. Health professionals may also be encouraged to work in community health centres which are concerned with public health in general. During the 1970s and 1980s, there was expansion in community based primary health care. In addition to 4,600 community health centres across Australia, there are also women's health centres and community controlled Aboriginal health services. They provide a range of medical, allied health and health promotion programs for defined population groups and geographical catchments. A growing number of community health services are successfully working with Divisions of General Practice, local and other government sectors, community and nongovernment organisations. They contribute to community understanding and support for government public health policies and have a key role in promoting health through their access to key people within the community and the knowledge of the local community and its needs. Healthcare Financing

The Australian government has introduced a number of incentives to encourage adults to take out private hospital insurance. These include:

Lifetime Health Cover: If a person has not taken out private hospital cover by the 1st July after their 31st birthday, then when (and if) they do so after this time, their premiums must include a loading of 2% per annum. Thus, a person taking out private cover for the first time at age 40 will pay a 20 per cent loading. The loading continues for 10 years. The loading applies only to premiums for hospital cover, not to ancillary (extras) cover. Medicare Levy Surcharge: People whose taxable income is greater than a specified amount (currently $70,000 for singles and $140,000 for couples) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if the people in this income group are forced to pay more money one way or another, most would choose to purchase hospital insurance with it, with the possibility of a benefit in the event that they need private hospital treatment rather than pay it in the form of extra tax as well as having to meet their own private hospital costs. o The Australian government announced in May 2008 that it proposes to increase the thresholds, to $100,000 for singles and $150,000 for families. These changes require legislative approval. A bill to change the law has been introduced but was not passed by the Senate. A changed version was passed on 16 October 2008. There have been criticisms that the changes will cause many people to drop their private health insurance, causing a further burden on the public hospital system, and a rise in premiums for those who stay with the private system. Other commentators believe the effect will be minimal. Private Health Insurance Rebate: The government subsidises the premiums for all private health insurance cover, including hospital and ancillary (extras), by 30%, 35% or 40%. In May 2009, The Labor Government under Kevin Rudd announced that as of June 2010, the Rebate would become means-tested and offered on a sliding scale.

Healthcare Planning Federal Initiatives Medicare Australia is responsible for administering the universal health care-based Medicare which provides pays subsidies for health services. It is primarily concerned with the payment of Doctors and Nursing staff, and the financing of state-run hospitals. The Pharmaceutical Benefits Scheme provides subsidised medications to patients. The level of subsidy depends on the above noted tests. Low income earners may receive a card that entitles the holder to cheaper medicines under the PBS. A National Immunisation Program Schedule that provides many immunisations free of charge by the Federal Government, the Australian Organ Donor Register, a national register which registers those who elect to be organ donors. Registration is voluntary in Australia and is commonly recorded on a driver's licence or proof of age card are also managed by the Federal Government.

The Therapeutic Goods Administration is the regulatory body for medicines and medical devices in Australia. At the borders the Australian Quarantine and Inspection Service is responsible for maintaining a favourable health status by minimising risk from goods and people entering the country. The Australian Institute of Health and Welfare (AIHW) is Australia's national agency for health and welfare statistics and information. Its biennial publication Australia's Health is a key national information resource in the area of health care. The Institute publishes over 140 reports each year on various aspects of Australia's health and welfare. State Programmes Public Hospitals Each State is Responsible for the Operation of Public Hospitals. (Note: Private Hospitals are permitted in Australia) Healthcare Initiatives State based projects are regularly setup to target specific problems such as breast cancer screening programs, indigenous youth health programs or school dental health Non Government Organisations The Australian Red Cross collects blood donations and provides them to Australian Healthcare Providers. Other Health Services such as Medical Imaging (MRI and so on) are often provided by Private Corporations, but Patients can still claim from the government if they are covered by the Medicare Benefits Schedule. Medical Education Basic medical registration in Australia requires a practitioner to complete a comprehensive program of training and examination. A specialist medical practitioner must complete an additional program of advanced training and examination after completing their undergraduate medical degree and intern training. Basic medical qualifications Basic medical training consists of:

a primary medical degree obtained from a medical school accredited by the AMC after completion of either: - an undergraduate course in any discipline and then a 4-year, graduate entry medical course or - an undergraduate medical course of 5 or 6 years duration

and a 12-month internship in approved/accredited posts.

Specialist medical qualifications The education and training requirements for each medical specialty depend on the type of clinical medical practice, but can be summarised as:

pre-vocational training involving broad practical clinical experience in the intern and second postgraduate years, during which career aspirations are clarified vocational training in a chosen specialty.

Vocational training commonly includes basic and advanced training over from 3 to 7 years, depending on the specialty. The educational component of vocational training includes the completion of:

a broad education program in basic medical sciences and clinical skills, with objective assessment of proficiency supervised practical training in accredited training programs that emphasise graduated practical experience and further development of a knowledge base in the science and practice of the specialty the requirements for fellowship of the specialist medical college, including a range of structured objective assessments and satisfactory supervisors' reports.

The structured assessments conducted during specialist training and the progressive increase in experience and level of responsibility are closely related. To be safe to practise as a specialist, it is not possible to sit and pass these examinations in isolation from the training program. However, the specialist medical colleges allow medical practitioners who have undertaken comparable training and gained experience outside Australia and New Zealand to be assessed and recognised for specialist medical practice. To encourage the development of additional skills and to broaden career paths, the colleges support participation in research and completion of postgraduate degrees (PhD, MD) during training or during periods when training is temporarily interrupted. Healthcare Insurance Dint get any proper info Healthcare Reforms The Report and Draft Strategy have been prepared by the Australian Government Department of Health and Ageing, assisted by the External Reference Group (ERG), further informed by a large

number of submissions and discussions, including with representatives from state and territory health departments. The Draft Strategy is a high level action plan. This Report supports and expands on the issues which have determined the Key Priority Areas in the Draft Strategy. The Report and Draft Strategy have been prepared by the Australian Government Department of Health and Ageing, assisted by the External Reference Group (ERG), further informed by a large number of submissions and discussions, including with representatives from state and territory health departments. The Draft Strategy is a high level action plan. This Report supports and expands on the issues which have determined the Key Priority Areas in the Draft Strategy. Related reform processes The Draft Strategy was developed in the context of the historic Council of Australian Governments (COAG) National Healthcare Agreement Intergovernmental Agreement on Federal Financial Relations (NHA).1 The NHA between Commonwealth and state/territory governments, announced in November 2008, is framed with the objective of improving health outcomes for all Australians and the sustainability of the Australian health care system. The NHA defines the objectives, outcomes, outputs and performance measures, and clarifies the roles and responsibilities that will guide the Commonwealth, states and territories in the delivery of services across the health sector. Importantly, the NHA recognises that primary health care involves Commonwealth and state/territory responsibilities but depends on the significant role of private providers and community organisations. The NHA affirms the agreement of all governments that Australias health system should: be shaped around the health needs of individual patients, families and their communities; focus on prevention of disease and the maintenance of health, not simply the treatment of illness; support an integrated approach to the promotion of healthy lifestyles, prevention of injury and diagnosis and treatment of illness across the continuum of care; and provide all Australians with timely access to quality health services based on their needs, not ability to pay, regardless of where they live in the country.2

The Draft Strategy is a priority reform area identified under the NHA which also sets the policy direction to better connect hospitals, primary and community care to meet patient needs, improve continuity of care and reduce demand on hospitals. The development of the Draft Strategy has been undertaken alongside complementary health reform processes including the work of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Health Taskforce. Alongside these processes, initiatives in the 2009-10 Budget including those responding to the Maternity Services Review; the Rural Workforce Audit; the review of Commonwealthfunded rural health programs; and the review of rural classification systems, changes for nurse practitioners and the Closing the Gap National Partnership, contribute to primary health care reform in Australia.