Australia's COVID-19 response: Digital infrastructure of help but implementation remains a challenge

Australia's ongoing plans to upgrade its health information system helped by the Digital Health Strategy seem even more practical due to the pandemic. But as evident during the pandemic, administrative lapses and the complex matrix of power between state and federal government could tarnish those plans.

Australia has been lauded for its efficient response to COVID-19 which has helped the country keep its total cases tally much below even the daily increase levels in some of its developed counterparts. After hitting the daily peak of 460 cases on March 28, Australia had managed to bring down daily cases to below 30 just a month later. Since April 20, daily cases have been below that number albeit a surge in late June which has raised concerns over a second wave reportedly linked to lapses in the state of Victoria.

The country recorded its first COVID-19 case on January 25, less than a month after China had detected early cases of the then-unnamed virus. Australia was quick to ban foreign travelers first from the epicenter Hubei and then from the whole mainland China as cases rose. Australian citizens returning from China were also required to self-isolate for 14 days.

COVID-19 cases in Australia rose exponentially in March with the first cases of local transmission reported on March 2. A few debacles followed which include the docking of Ruby Princess cruise ship at Sydney Harbour when some 2,700 passengers, dozens of them laden with the virus, were allowed to depart and they went on to catch trains, buses, and even overseas flights. The ship became the largest single source of coronavirus infections in the country.

The government tightened social distancing measures in late March by banning public gatherings of more than two people and shutting down non-essential economic activity to control the spread. Overseas arrivals were also banned in the following weeks with only a few exceptions for Australian citizens until recently when the country finalized ‘travel bubble’ arrangements with a few countries as it prepares to reopen the economy.

The outbreak, or at least the ‘first wave’, subsided in Australia in mid-April and the country also launched a contact-tracing app on April 26 called ‘COVIDSafe’. The app allows health officials to trace the physical contact history of infected individuals by utilizing Bluetooth if the app is installed on the smartphones of both the contact as well as the infected person. However, downloading the app is voluntary and concerns have been raised about its usability as well as implications on the privacy of citizens. Ever since its launch, developers have complained that the app fails to detect contacts, especially in cases of devices running iOS and when screens are locked. Some media reports have even claimed that the app hasn't been able to identify any suspected cases that had not already been found through manual contact tracing but it was previously being linked to a low number of active cases in the country.

More than 6.5 million people have downloaded the app but questions over its effectiveness still remain especially as no close contacts have been identified by the app even during the 'second wave' in Victoria.

Australia's response to COVID-19 relied on the globally-acknowledged approach of testing, tracing, and isolating along with physical distancing and movement restrictions but it also leveraged its advancements in health information system through the Australia Institute of Health and Welfare (AIHW) as well as deployed other technologies for digital health.

In response to COVID-19, AIHW is assisting Australia’s Department of Health with the monitoring of COVID-19 and assessing the country’s hospital capacity along with continued efforts to compile data on other diseases and use of other healthcare services.

Apart from leveraging its effective health information system, Australia has also invested heavily in expanding access to telehealth to reduce the burden on healthcare infrastructure. As part of the $2.4 billion health package announced in response to COVID-19, the government has provided $669 million to expand Medicare-subsidised telehealth services to cover more diseases. Since the pandemic began, more than 12 million telehealth consultations have been billed under Medicare.

To further support the efforts to expand access to telehealth, the Australian government also made regulatory changes allowing electronic prescriptions. While paper prescriptions will still be available, the regulatory changes make them optional and give an alternative to prescribers and patients. In the coming months, the Australian government will also launch an Active Script List model to issue electronic prescriptions, which will essentially be a centralized list of prescriptions that is expected to assist management and adherence, a feature that will be especially useful for patients who are using multiple medicines.

Acknowledging the increased risk of mental health issues and domestic violence due to the fallout of isolation, Australia is also providing support for those issues through its digital health initiatives as well as the COVID-19 health package.

The “second wave” in Victoria has made Australia’s daily coronavirus cases rebound and hit a peak of 468 cases on July 22 after weeks of recording a low number of cases. Victoria's outbreak and the reimposed lockdown could derail the country's plan to reopen its economy and has also raised calls for greater accountability along with questions on the usability of some strategies, particularly the COVIDSafe app.

But authorities have expressed confidence that such outbreaks could be managed and had been kept in consideration while preparing the initial response plan.

Strong digital infrastructure

Australia has one of the most effective health information systems in place to ensure regular availability of credible health data that can inform decisions about public and private healthcare funding for policymaking, interventions, and technologies.

• Australian Institute of Health and Welfare

AIHW is at the center of Australia’s health information system and is tasked to develop, maintain, and enhance healthcare data by publishing reports that support monitoring of the health and welfare of Australians. The data is largely drawn from administrative data sources which include hospital records but AIHW also conducts surveys and relies on other sources like clinical registries for specific data sets.

AIHW collects and reports statistical information on a wide range of health and welfare topics, including expenditure, hospitals, diseases, injuries, mental health, aging, homelessness, housing, disability, child protection, and the needs of indigenous Aboriginal and Torres Strait Islander people. The institute is an independent statuary agency and deems its independence necessary to ensure the credibility of data given the complex structure of Australia’s healthcare system divided between federal, state, and local governments.

Apart from providing the healthcare data to policymakers and publishing reports, bulletins, and other data products on its website, AIHW also provides healthcare data to researchers and service providers subject to data privacy and confidentiality laws.

• National Digital Health Strategy

Acknowledging that digital information is the bedrock of high-quality healthcare, the Australian government had also launched a National Digital Health Strategy in 2018. The strategy aims to optimize the country’s health system in a way that gives people more choice, control, and transparency while also reducing inequality in access to health services.

Australia already has an electronic health record called ‘My Health Record’ although almost 10% of citizens had opted out before the deadline at the start of last year. The record allows healthcare service providers to instantly access information about the past medical history of patients and it is implemented throughout the public hospital system along with secure messaging, discharge summary capabilities, eReferral, and booking capabilities which are all being implemented within states and territories.

Building on those initiatives, National Digital Health Strategy aims to benefit Australians by helping to prevent adverse drug events, reduce medical errors, improve vaccination rates, better coordinate care and better inform treatment decisions; and sustain a more efficient health system, through less time searching for patient data, reduction of avoidable hospitalizations, and reduced duplicated pathology tests and x-rays which inconveniences patients and increases the cost of healthcare. Implementation of the strategy can also improve the patient experience by putting patients at the center of their healthcare, and keeping people out of the hospital; provide greater access to healthcare for people living in rural and remote areas of Australia; protect the national digital health infrastructure and secure the personal health information of Australians.

Australia is also in the process of reforming its healthcare supply chains to create an interoperable system that improves efficiency for providers and consumers. The Digital Health Agency of Australia is creating a central repository of data called National Product Catalogue (NPC) about medical products ranging from large devices to medicines along with an eProcurement solution that is aimed at streamlining purchasing process with the latest technology.

Problems with Australian healthcare

Despite these advancements in digital health space, Australia’s health system continues to face some challenges that are persistent to traditional healthcare delivery along with new challenges posed by emerging technologies.

• Inequality in healthcare

Australia faces persistent challenges in ensuring equal access to healthcare as people of socioeconomic disadvantage, especially those of indigenous Aboriginal and Torres Strait Islander descent, are often associated with poorer health outcomes.

AIHW reports that although Australians have a life expectancy of 82 years, one of the highest among OECD countries, and the second-lowest overall mortality of OECD countries, inequalities persist in age-standardized mortality rates among different population groups. The high number of premature deaths associated with the lowest socioeconomic areas also stagnates overall life expectancy. One study by the University of Melbourne has concluded that there are differences in death rates among lower and higher area socioeconomic deciles even within major cities.

• Challenges to universal coverage

Australia has a universal access-focussed public health system i.e Medicare which extends to even foreign nationals of specific countries that have reciprocal agreements. Public-funded Medicare co-exists with private insurers and is largely based on principles of choice and access.

Although Medicare is an integral part of Australia’s health system and contributes greatly to policies aimed at closing the inequality gap, it was never intended to stand alone. It was designed in the context of being complemented by a private health-care system, primarily funded through a private health insurance system. Australia maintains that a mixed model of balanced private and public health services is integral to the provision of universal access to high-quality and affordable healthcare services for all Australians. There is also a common perception that private healthcare means better services especially due to the differentiating stance of successive governments over the role of the private sector in healthcare. The rising cost of the health system, being able to respond to new health issues, and hospital waiting times are some other challenges impacting the delivery of universal coverage.

• Challenges to rural healthcare

The majority of Australia’s population is concentrated in large cities specifically in the south-east of the country. Around 70% of the non-indigenous population lives in major cities, 18% in inner-regional areas, 9% in outer regional areas, 1.4% in remote areas, and less than 1% in very remote areas, according to AIHW.

Therefore, the unequal distribution of health professionals between urban and remote areas poses a big challenge to Australia’s health system. Inadequate rural healthcare is also often cited as the reason for poorer health outcomes in indigenous communities because their proportion is higher than non-indigenous Australians living in remote areas. Aboriginal and Torres Strait Islander people continue to experience a greater health disadvantage and have a life expectancy of around 10 years less than non-indigenous Australians.

Regional communities are also often dependent on farming for livelihood but experts have said that increasing globalization is adversely affecting those communities, which in turn forces young people to move to bigger cities, creating an older age demographic in remote areas which is more prone to diseases and with more difficulty accessing healthcare.

• NCDs

Non-Communicable Diseases (NCDs) are a problem that Australia shares with many other countries and is often blamed on lifestyle factors and an aging population. In 2014–2015, more than 11 million Australians (50%) had at least one of eight chronic conditions (arthritis, asthma, back problems, cancer, chronic obstructive pulmonary disease, diabetes mellitus, diseases of the circulatory system, and mental and behavioral problems).

• Administrative lapses

As evident during COVID-19 response, administrative lapses are also a major challenge in front of Australia’s health system. Right from the initial weeks of the outbreak in the country, the improper handling of Ruby Princess cruise ship staggered Australia’s response. Even the ‘second wave’ in Victoria is being linked to mistakes and lapses which could have a nationwide impact in the coming weeks.

Australia's second-most populous city recently began a six-week lockdown following a spike in new coronavirus cases and states around the country tightened internal borders to prevent a second wave from sweeping the country. On July 24, Victoria reported 280 new infections, down from the recent peak in the state but well above the rate of other states. Other states and territories have recorded few or zero cases in recent weeks and are continuing to reopen their economies.

Even before COVID-19, administrative lapses in Australia’s health system have often been reported and are linked to the complex matrix of insurers, providers, and services accountable to different levels of government at federal, state, and territorial levels.

Conclusion and agenda for discussion

Despite the administrative lapses, Australia has so far managed to control the COVID-19 outbreak without blatantly ignoring other diseases and mental pressure that has been inflicted upon its citizens due to the pandemic and the subsequent lockdown. Advancements in digital infrastructure in recent years have helped the governments educate people about the infection and successfully enforce social distancing along with other precautionary measures.

Australia's ongoing plans to upgrade its health information system helped by the Digital Health Strategy seem even more practical due to the pandemic. But as evident during the pandemic, administrative lapses and the complex matrix of power between state and federal government could tarnish those plans given the increasing concerns about the efficiency of few initiatives, including the COVIDSafe app, taken to fight the pandemic.

Meanwhile, the massive investment in telehealth during the pandemic could be fruitful in a country like Australia where the majority of the population is concentrated in major cities. Telehealth could help close the gap between healthcare delivery in remote and urban areas, a challenge that has been regularly cited as a reason for poorer health outcomes of indigenous Aboriginal and Torres Strait Islander people.

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.