Australia has an illness system, not a health system

Australians can expect to live to 83 years of age. That gives us the tenth longest lifespan in the world. 

But a new international study of 204 countries published in The Lancet Public Health estimates that the average Australian now spends 13.9 of those years living with illness or disability. That’s about one-sixth of our lives and second worst in the world, behind only the United States. 

This is our ‘morbidity gap’ – or ‘sickspan’ – the difference between how long we live and how long we live in good health.  

It isn’t an isolated result. A 2024 study in the JAMA Network Open used a different international dataset and method, but reached much the same conclusion. It estimated that, in 2019, Australia’s sickspan was 12.1 years, again second only to the United States. 

The Lancet study also tracked changes from 1990 to 2023, during which time Australia’s morbidity gap increased by 2.9 years – the second-largest rise recorded globally, narrowly behind Kuwait. 

Our illness system 

A successful health system should postpone disease and aim to compress illness into a shorter period later in life. Instead, Australia is seeing an expansion of morbidity. 

This reinforces an argument I have made previously. That Australia doesn’t have a health system. We have an illness system. 

We’re very good at rescue. But our institutions and funding arrangements are overwhelmingly organised around responding after illness has developed. Providers are paid for episodes of treatment. Performance is measured by consultations, scans, admissions and procedures. Far less attention is paid to whether people remain healthy, illness is prevented, or whether treatment leaves patients feeling and functioning better. 

Australia spends more on health care than most comparable countries. In 2023, we devoted 10.3% of our GDP to medical care compared to 6.5% in 1990. Our spending on acute services – mainly hospitals and specialist care – has grown faster than spending on primary care.  

But we spend less on prevention than the average OECD country. We’re among the world’s most overweight nations. Preventable chronic illness fills our hospital beds – avoidable hospitalisations are above the OECD average, costing about $7.7 billion each year. 

The relationship between healthcare expenditure and sickspan – shown in the chart below – isn’t straightforward. But it illustrates that high medical expenditure is no guarantee of healthy longevity. Despite our higher-than-average health spend, Australia has a substantially larger sickspan than countries such as Japan, Austria and Chile, which spend a similar or greater share of their GDP on healthcare. 

Medical care remains essential and can extend life. It can sometimes turn what would have been an early death into years lived with a chronic condition. But population health is shaped by much more than medical treatment. Things like income, housing, education, working conditions, and access to healthy food all affect when illness begins and how disabling it becomes. 

Medical interventions do little to promote health compared to healthier living, which is driven by social, economic and cultural factors. These are far less costly than medical care. 

In high-income countries, musculoskeletal, cardiovascular and mental health conditions account for much of the morbidity gap. The Lancet study identifies high blood glucose, high body mass and tobacco use among the leading preventable risks. 

These problems can’t be solved by building more hospitals. They require sustained investment in primary care, social care and early support for people to manage chronic conditions. They require action on the environments that promote unhealthy food, physical inactivity, smoking and harmful alcohol consumption. And they require governments to start treating prevention as a fundamental part of our health system. 

Measuring what matters 

As the Lancet study shows, we would do well to start measuring what matters.  

Life expectancy is an important measure. But in modern times it’s no longer a sufficient way of measuring a healthy Australia.

Governments could report healthy life expectancy, the morbidity gap, and illness avoided as headline indicators of national performance. Given our high obesity rates, consumption of processed, sugar-laden food and beverages could also be an indicator. 

All of this is eminently achievable in the data-rich society we now inhabit. 

In addition, healthcare funding could move away from simply paying for the volume of services delivered towards also rewarding prevention, care coordination, and things that matter to people: improvements in symptoms, function and quality of life. 

None of this diminishes the importance of treating people who are already ill. Good hospitals, specialists and medicines remain essential. But a system that concentrates its resources downstream will always be less effective and less efficient than it could be.