By estimating health expenditure via the utilisation of health services as reported in the NHS, an important, and often overlooked, element of public health expenditure is excluded from the analysis—spending on the provision of environmental health infrastructure. Despite a well-established link in the international public health literature between living conditions and population health, few Australian studies have detailed the relationship between specific environmental problems and particular illnesses among Indigenous Australians. One pioneering study in this field is based on identifying nine healthy living practices for one community in the Anangu Pitjantjatjara lands (Pholeros et al. 1993). While this research indicated that improvements in environmental infrastructure can lead to specific improvements in health status, the key finding showed that this depends on ensuring that appropriate institutional arrangements are in place. In particular, it is essential that budgets make adequate provision for planning, design, supervision and maintenance of infrastructure, and that these actually occur. Among the reasons for a lack of such arrangements in the past, confusion over myriad responsibilities for service delivery and marginalisation of environmental health issues in the policy system has been highlighted.

The major government response to such inadequacies developed out of the National Aboriginal Health Strategy (NAHS) in 1990, which recognised an essential linkage between improved health outcomes and the provision of housing and infrastructure to acceptable minimum standards. Accordingly, funding allocations in the initial years of the NAHS primary health and environmental health programs included amounts directed at housing and infrastructure services within Aboriginal and Torres Strait Islander Commission’s (ATSIC) Community Housing and Infrastructure Program (CHIP). However, a review of CHIP in 1994 identified a range of problems including a failure to address housing and infrastructure needs in a holistic way. Allied to this was the short-term nature of the program-based approach to funding, which required communities to structure housing needs to the CHIP program rather than the other way around.

Such criticism led to the establishment, in the same year, of the Health Infrastructure Priority Projects (HIPP) program to pilot new program delivery arrangements for the construction of Indigenous community housing and infrastructure in 58 sites. This has subsequently expanded, and in 1998–99 a total of $103 million was allocated via NAHS/HIPP initiatives. Notwithstanding this environmental health expenditure, the 1999 Community Housing and Infrastructure Needs Survey (CHINS) found that fully one-third of the housing stock administered by Indigenous housing organisations in discrete communities remained in need of major repair or replacement (ABS 2000b:3). While part of the difficulty here is catch-up—given the legacy of previous neglect—the question of equity in regard to the adequacy of this public expenditure remains open.