Background

Australia operates a universal visa system to manage the movement of non-citizens across its borders. This visa system acts as a screening mechanism to prevent people who pose a security, criminal or health risk from entering Australia. People who wish to migrate permanently to Australia, or to stay temporarily, must apply to the Department of Immigration and Citizenship (DIAC) for an appropriate visa. Currently, there are about 150 visa types for managing applicants in different situations. In 2004–05, DIAC received 4.5 million visa applications and granted 4.3 million visas.

Within the visa system, health risks are managed according to the health requirement of the Migration Act 1958 (the Act) and the Migration Regulations 1994 (the Regulations). The health requirement (also called the health criteria) is a relatively small but important component of DIAC's broader remit for border control. The intent of the health requirement is to:

• protect the Australian community from public health risks;
• contain public expenditure on health care and community services; and
• safeguard Australians' access to health services in short supply.

Diseases such as tuberculosis (TB), Human Immunodeficiency Virus (HIV), malaria and hepatitis B and C are associated with high incidence, morbidity and mortality globally, and may incur high medical costs. Serious health conditions, for example cardiac, pulmonary or renal disease, may also draw heavily on hospital resources or put additional pressure on long waiting lists for organ transplants. Against this backdrop, the health requirement for visa applicants has an important role in contributing to Australia's high standard of health and containing health costs.

In line with the health requirement, each visa applicant is required to have their health assessed by DIAC and to satisfy the Public Interest Criteria 4005–4007 (PIC) outlined in the Regulations. The extent of health screening undertaken will vary depending on DIAC's policy requirements and each applicant's situation, particularly their country of origin, length of proposed stay in Australia, and current health status. Some applicants need only to make a health declaration, while others require more extensive health assessments.

Meeting the Health Requirement

The health requirement applies to all visa applicants and must be met before a visa can be granted. The foremost components of the health requirement stipulate that the visa applicant:

• is free from tuberculosis;
• is free from a disease or condition that would result in a threat to public health or danger to the Australian community; and
• does not have a disease or condition that is likely to: require health care or community services while in Australia; result in significant costs to the Australian community; or prejudice the access of an Australian citizen or permanent resident to health care or community services.

Visa applicants complete a health declaration as part of their visa application and, depending on the applicant's individual circumstances, may be required to undergo further health assessment to establish whether they meet the health criteria. In 2004–05, DIAC processed over 400 000 health assessments, each involving one or more of the following: a medical examination; a chest x-ray; blood tests; and other specialist examinations (see Figure 1).

DIAC maintains a panel of more than 3 600 overseas medical doctors and radiologists who perform medical examinations offshore on DIAC's behalf. Each applicant's medical reports are forwarded to DIAC for final assessment and clearance. Where an applicant's medical results indicate a significant disease or condition, a Medical Officer of the Commonwealth (MOC) assesses the medical reports and forms an ‘opinion' on whether the visa applicant: meets or does not meet the health requirement; is eligible for a health waiver; or should be placed on a health undertaking. DIAC's case officers cannot change a MOC opinion and must take the MOC opinion into consideration when making the final decision to grant or reject a visa application.

The following figure shows key elements of DIAC's health requirement approval process and the approximate number of visa applications associated with each stage of the process in a one year period.

Figure 1 Visa applications assessed against the health requirement 2004-05

 Source: Compiled by the ANAO, based on DIAC's

Audit objective

The audit objective was to assess the effectiveness of DIAC's administration of the health requirement of the Migration Act 1958 (the Act). To achieve this objective, the ANAO examined whether DIAC was setting and implementing the health requirement in accordance with the Act, the Migration Regulations 1994 (the Regulations), and DIAC's own guidelines.

Overall audit Conclusion

DIAC had established administrative structures, procedures and guidelines to implement the health requirement specified in the Migration Act 1958 (the Act) and the Public Interest Criteria (PIC). While DIAC complied with the intent of section 60 of the Act, the audit identified several limitations and gaps in DIAC's administrative processes underpinning its implementation of the PIC. These limitations and gaps weakened DIAC's ability to fully assess the appropriateness, consistency, and efficiency of its health screening of visa applicants. This also meant that DIAC could not determine the effectiveness of its implementation of the health requirement in protecting Australia from public health threats, containing health costs and safeguarding access of Australians to health services in short supply—important DIAC objectives under the health requirement.

DIAC's primary focus for health screening of visa applicants is to protect Australia from tuberculosis (TB). TB is the only disease specifically identified in the PIC, largely due to the significance and long history of TB as a global public health threat. Concurring with this focus, DIAC's guidelines and procedures for implementing the health requirement for TB were well-established. Notwithstanding these guidelines and procedures, DIAC should strengthen its arrangements to reduce the health risks associated with TB. In particular, DIAC's health risk matrix for assessing temporary visa applicants should be kept up to date, to ensue that visa applicants of highest TB risk were identified.

In some cases, individuals identified as having inactive TB (or who have a history of treatment for TB), are allowed entry into Australia providing they sign a ‘health undertaking'. DIAC requires a person on a health undertaking to report to a designated health authority in their State or Territory of residence for a follow-up health assessment. This is a precautionary measure to check that their TB has not become active since their last medical examination. DIAC has few mechanisms to monitor or ensure visa holders' compliance with health undertakings, and thus cannot determine whether health undertakings are effective in terms of meeting the intent of the health requirement. DIAC would improve the effectiveness of health undertakings by establishing arrangements with the States and Territories that enable better monitoring and reporting of compliance.

DIAC guidelines and procedures for areas of the PIC concerning health threats other then TB, and to determine significant costs and prejudice to access, were less well established. In particular, DIAC had not determined which diseases or conditions constituted a ‘disease or condition that would result in a threat to public health' for immigration purposes. While DIAC included some infectious diseases of global significance within this criterion, the reasons or a firm basis for doing so was often unresolved and undocumented. DIAC did not follow a systematic process for incorporating new or emerging health risks into its guidelines and risk management framework. This weakened DIAC's ability to develop responsive and soundly based migration guidelines and procedures, and to ensure that its guidelines aligned with other national public health policies.

To implement the PIC, DIAC requires technical advice from DoHA on public health issues. However, cross-agency collaboration between DIAC and DoHA had not been formalised. This affected the timely development of migration health screening guidelines and procedures. Stronger cross-agency arrangements would be beneficial in: defining roles and responsibilities; supporting the review and updating of DIAC's risk management framework for migration health screening; and in providing a timely and sound basis for the development of guidelines and procedures on immigration health matters, particularly in relation to public health threats and migration health screening.

Data management for the purposes of internal management of the health requirement and external reporting were also areas that required strengthening, both in terms of IT system capability and use of data. DIAC's capacity to store and manage information on the health requirement was limited by the differences between its many IT systems and the lack of a central repository for client health data. Gaps in DIAC's client health data was reflected throughout its visa application processes, with consequential weaknesses in monitoring of health undertakings and health waivers undermining DIAC's ability to determine compliance or consistency with its own guidelines.

There is a particular need to address these IT limitations, as they weaken DIAC's efficiency in processing and managing visa applications, and diminish its capacity to generate meaningful data to monitor, evaluate and report performance against the health requirement. Under its Systems for People initiative, DIAC has outlined preliminary costings and priorities for the redesign of its IT systems for health processing.

DIAC's performance framework provided little scope for performance monitoring and reporting of the health requirement. There were no outputs for the health requirement and one effectiveness measure, pertaining solely to TB. DIAC's performance framework needs to include a broader range of performance indicators and measures to provide better accountability and transparency of the health requirement. This will involve DIAC defining the cost and quality of the health requirement services it provides and assessing the overall effectiveness of the PIC.

Key Findings

Governance and coordination (Chapter 2)

Under the Migration Act 1958 (the Act) and the Migration Regulations 1994 (the Regulations), the Department of Immigration and Citizenship (DIAC) has responsibility and primary carriage for administering the health requirement and assessing the health of visa applicants. DIAC produced guidelines which set out its policies and procedures for managing health assessments (health screening) according to the Public Interest Criteria (PIC) 4005–4007 of the Regulations. DIAC also consulted with other agencies to assist in aligning its guidelines with other government policies. The ANAO considered whether effective cross-agency coordination and consultation arrangements were in place, including documented and agreed roles and responsibilities, to ensure timely advice on migration health matters.

Historically, DIAC has relied on the Department of Health and Ageing (DoHA) to provide technical advice on national public health issues, including the setting of health screening requirements for specific diseases (for example, tuberculosis (TB), hepatitis B, and Human Immunodeficiency Virus (HIV)) and other migration matters (for example, health services in short supply in Australia and health screening of refugees). However, there were longstanding difficulties associated with coordination and provision of technical advice for the health requirement. This had delayed updating of DIAC's guidelines for health screening.

Two previous reports (a 1992 Parliamentary Committee review of health processing in 1992¹ and an ANAO audit of the Family Migration Program in 2003²⁾recommended that agencies clarify their roles and responsibilities and formalise consultative arrangements for developing migrant and temporary entrant health screening policy. While agreeing to the recommendations, this audit found that DIAC and DoHA had not successfully defined, documented, or formally agreed their roles and responsibilities.
The ANAO notes that in December 2006, DoHA wrote to DIAC, describing DoHA's role ‘in relation to DIAC's administration of the health requirement' and inviting DIAC to discuss this further.

Developing guidelines and procedures (Chapter 3)

Information supporting the PIC is in DIAC's procedure manuals and guidelines, particularly Procedures Advice Manual 3 (PAM3), Instructions for Panel Doctors and Radiologists: medical and radiological examinations of Australian visa applicants (Panel Doctor Guidelines), and Medical Officer of the Commonwealth (MOC) Notes for Guidance. These documents set out procedures and policies for DIAC officers, doctors and MOCs to guide implementation of health assessments in line with PIC.

The ANAO examined DIAC's progress in developing guidelines to assist MOCs in forming their opinions, and DIAC's ability to develop sound and consistent procedures to support implementation of health screening in line with the intent of the PIC.

MOC Notes for Guidance

In 1992, the Parliamentary Committee review on health processing noted that there were ‘no official guidelines for assessing health conditions', and recommended that priority be given to producing guidelines to assist MOCs in forming their opinions. The Government agreed to the committee's recommendation. However, subsequent progress in developing the MOC guidelines (now referred to as Notes for Guidance) was slow; the process generally characterised by a series of contract difficulties, project delays, and partially completed work. Consequently, DIAC and ANAO audits (in 2002 and 2003 respectively) made similar findings regarding incomplete Notes for Guidance.

DIAC has identified 19 Notes for Guidance papers required to support MOC decisions. The ANAO found that the development, updating and review of the Notes for Guidance has continued to be problematic, characterised by a lack of priority setting and uncertain mechanisms for their endorsement. Recent work contracted by DoHA to produce five papers resulted in delays and unfinished work. The General Principles paper, written in January 2006, has not been endorsed.

During the audit, DIAC was progressing towards a new contract to develop 13 Notes for Guidance, with identified priorities. It is important that DIAC monitors progress of the development of the Notes for Guidance, and establishes appropriate mechanisms for the completion, endorsement, and regular revision of all 19 guidelines.

Guidelines defining the health criteria

Consistency of information across guidelines and procedures is important for promoting uniform interpretation and implementation of the PIC and DIAC's health screening policies. This should include clarity and consistency in defining specific terms and processes.

Generally, DIAC's guidelines were well targeted to their specific users and provided a useful overview of DIAC's health assessment process. Nonetheless, ANAO's analysis identified several gaps and inconsistency in DIAC's documentation. In particular, the health criterion indicating ‘threat to public health,' which must be met by applicants in order to be granted a visa, was not defined in DIAC's guidelines. Guidelines did not clearly explain which diseases constituted a public health threat under the health requirement. In addition, some costings for MOCs to determine ‘significant costs' were incomplete or out of date, and there was no systematic decision process for inclusion of items (or services) on DIAC's significant ‘prejudice to access' list. Consequently, DIAC was not providing a sound basis for MOCs to make consistent decisions on ‘prejudice of access'.

Health assessments (Chapter 4)

To a large degree, DIAC's system of health screening relies on the honesty of applicants to disclose health conditions that may put Australians at risk. It also relies on the integrity of panel doctors overseas and their ability to detect significant health issues and report these to DIAC.

All visa applicants for permanent entry undergo full health assessments. However, the extent of health assessment a temporary visa applicant undergoes depends on their individual level of risk, determined according to DIAC's multilayered risk management framework. Risk factors include length of stay, country of origin, intended activities in Australia, and factors of special significance.
The ANAO examined the effectiveness of DIAC's health assessment process in terms of DIAC's: risk management framework; management of panel doctors; and clearance of offshore medicals.

DIAC's health risk matrix for temporary visa applicants was largely based on the risk level of countries according to their incidence of TB. DIAC stated that it updated its list of countries and corresponding risk levels every two years (based on World Health Organisation data). However, DIAC's process for categorising a country's risk level was not transparent. In particular there was no record of when the countries' risk levels were last reviewed or the process for review. Therefore, DIAC could not verify that the health risk matrix was soundly based or up to date.

Risks or threats to Australia's public health may come from newly emerging (or re-emerging) disease or the changing incidence of disease in particular countries. If screening procedures and guidelines are not kept abreast of global trends, this could impact on the effectiveness of DIAC's screening procedures and expose Australia to disease threats, contrary to the intent of the health requirement. Diseases posing potential public health risk other than TB, for example HIV and hepatitis C, were incorporated into DIACs migration health screening risk framework in various ways. However, in general, there was little evidence of a systematic methodology for deciding migration health risks, including new or re-emerging communicable diseases, or for including these into DIAC's migration health risk framework.

Panel doctors

DIAC relies on overseas panel doctors to provide medical examinations to visa applicants. To this end, DIAC maintains a list of over 3 600 panel doctors and radiologists that it has approved to undertake medicals. DIAC's Global Medical Unit, (GMU) established in 2004, has implemented several improvements to the management of panel doctors. For example, GMU introduced a risk based model and audit program for panel doctors, mechanisms to monitor complaints, monthly performance reports for monitoring program performance, and newsletters for disseminating information to panel doctors and overseas posts. In addition, Global Medical Directors (GMD) from the GMU conduct overseas inspections of panel doctors and their facilities. This contributes to assessing service quality and to follow up of complaints or reported processing problems.

DIAC demonstrated thorough records for removal of doctors from the panel. However, documentation submitted to DIAC to support the approval of panel doctors did not meet DIAC's own standards. A small ANAO sample identified deficiencies in 50 per cent of approved panel doctor applications examined, including: illegible copies, non-certified documents, documents not translated, and photographs too unclear for identity purposes. Further improvements in this area would contribute to a higher level of integrity and reliability in the appointment of panel doctors.

Clearance of health assessments

Health assessments are either cleared by DIAC's overseas posts or the Local Clearance Unit (LCU), or referred to a MOC for further assessment and a medical opinion. Since 2004, DIAC has been centralising clearance of health assessments for some visa types within the LCU, to achieve greater efficiency and accuracy in processing. DIAC has established guidelines and procedures manuals for LCU operations and several levels of process controls. An internal quality assurance program had also commenced.

DIAC's clearance process for health assessments allows officers in ‘gazetted countries' to clear ‘A' cases (no significant health findings) and some ‘B' cases (significant health findings). DIAC's guidelines lack clarity in these clearance processes, which increases the risk of incorrect processing and/or missed referral of cases to MOCs. In particular, the ANAO found:

• there was no methodology or documentation to explain how DIAC arrived at its list of gazetted countries;
• the gazetted countries had not been revised since 2000;
• DAC had given local clearance capability to some non-gazetted countries, but not others. However, there was no methodology or records to explain the basis of these decisions; and
• DIAC's procedures did not clearly explain the circumstances in which ‘B' cases could be locally cleared by overseas posts.

Overall, a lack of transparency and rigour in DIAC's risk management framework for temporary applicants meant that DIAC could not be certain that it was assessing the health of applicants consistently, meeting its objective to ‘maintain high levels of integrity of health screening', or managing its specified risk ‘to identify applicants of concern'.

Health waiver (Chapter 5)

In most cases, failure to meet the health criteria results in refusal of the visa application. However, for some visa types, a health waiver is available. In these cases, a MOC provides an opinion to the DIAC decision maker, which includes a calculation of the potential cost for each health waiver. This cost takes into consideration the expected impact of the waiver in terms of health care and community services. All health waiver decisions must be reported to, and monitored by, DIAC's Health Policy Section. Cases with expected costs over $200 000 require consultation with the Health Policy Section prior to the final decision. Health Waivers cannot be granted if the applicant fails to satisfy the legislative provisions relating to tuberculosis, public health or health undertakings.

The ANAO examined DIAC's ability to ensure consistent waiver decisions in line with DIAC policy, and to accurately monitor and report on health waver decisions.

DIAC had documented procedures for administering health waivers, but it did not demonstrate consistent compliance with these. For example, ANAO sampling showed that a significant number of health waiver Minutes (waiver decision records) were incomplete: 22 per cent of reports examined did not include a MOC opinion and 65 per cent of 4006A waivers examined did not include written employer undertakings, contrary to DIAC's requirements.

DIAC's electronic records for health waiver decisions were also incomplete, with applicants' records fragmented between two databases. Discrepancies in figures between the two databases indicated that more than two-thirds of the health undertaking decisions were not reported to DIAC's Health Policy Section. This made it difficult for DIAC to obtain a history of waiver applicants or to consolidate data for compliance and reporting purposes.

Waiving the health requirement results in the Australian community absorbing the health and welfare costs of the visa applicant, and may increase demand for health and community services which are in short supply. In 2003, the ANAO audit report, Management of Selected Aspects of the Family Migration Program, identified deficiencies in health waiver data held by DIAC. The current audit found little improvement in DIAC's data.

Due to limitations in DIAC's health waiver process and tracking of decisions, DIAC was not able to show whether it had considered the health waiver for all eligible visa applicants, or accurately report the number of health waivers granted. Due to incomplete records, data on health conditions for waivers were also unreliable. Furthermore, DIAC could be underestimating the annual cost in exercising health waivers, because of its low compliance in reporting of health waiver decisions.

Health undertaking (Chapter 6)

Schedule 4 of the Regulations authorises MOCs to request a visa applicant to sign a health undertaking as a prerequisite to the applicant passing the health requirement. A health undertaking is used if the applicant has a medical condition that is not a public health risk, but requires follow-up treatment or examination once the applicant is in Australia.

Around 15 000 to 20 000 health undertakings are signed each year, and about 90 per cent of these are for TB follow-up. Other than TB and pregnancy, DIAC's guidelines did not provide comprehensive information on the diseases or conditions for which a health undertaking applied, or the circumstances in which they should or should not apply. This lack of guidelines to support MOC decisions puts DIAC at risk of making decisions or issuing health undertakings inconsistently.

Although an applicant signs a health undertaking with DIAC, once in Australia, the applicant's follow-up examination or treatment falls to the State or Territory of residence. DIAC has no formal agreements with States or Territories to administer health undertakings, or to monitor clients' compliance with health undertakings.

DIAC did not collect sufficient data to monitor compliance with health undertakings. Data available through DIAC's Health Assessment Tracking System (HATS) and a 2002 DIAC internal audit report were significantly different (604 and 5 535 cases of non-compliance respectively). The internal audit recommended modifications to HATS to allow compliance monitoring, but DIAC took no action in this respect.

As DIAC had not established mechanisms to monitor or control compliance with health undertakings, it could not show whether undertakings were effective in terms of protecting Australia's health, or their associated cost to Australia's health system.

Information technology systems (Chapter 7)

DIAC does not have a central system for managing the health requirement of visa applications or a central repository of client data. Current information technology (IT) support consists of several unintegrated IT systems that were developed to meet DIAC's business needs over the last 15 years. These systems are dissimilar in design and function. This has led to several difficulties and inefficiency in managing visa applicants' health records, and limits DIAC's ability to generate data for program monitoring and performance purposes.

Checking and clearing an applicant's health records usually involved the use of multiple screens across several different systems. This, and double or multiple entering of data into the various systems, increases the risk of errors occurring. Matching an applicant's records for case management or identity purposes can be lengthy or problematic if there are missing or duplicate records (for example, resulting from front end loading⁵or ineffective transfer of data from one IT system to another). Duplicate or incomplete records can lead to serious implications for identification and tracking of cases, as demonstrated by the Cornelia Rau case.⁶

DIAC did not monitor systems' down-time and the effects this had on business continuity or processing efficiency, or maintain systems logs to assist in monitoring and prioritising IT problems. Due to a lack of detail in data held within the various systems, DIAC was unable to provide a breakdown of health assessments, for example, to show the number of x-rays, HIV or Hepatitis B tests, or specialist examinations completed. There were also difficulties in producing reports on the total number of visas refused on health grounds. This information would be useful for monitoring trends in testing between different countries, informing policies on future screening needs, and revising DIAC's health screening risk management matrix.

Collectively, limitations and weaknesses in DIAC's IT systems prevented DIAC from fully meeting its objective ‘DIAC systems to support health assessment processing; allow seamless and effective decision making.' Under the new Systems for People initiatives, DIAC is planning major IT reforms which may see changes to the IT environment for health assessments. The changes aim to consolidate DIAC's IT into a more central system.

Monitoring and performance (Chapter 8)

As DIAC has primary carriage for the health requirement, its performance information is expected to provide a measure, or indication, of progress against set outcomes, outputs and performance indicators that align to key elements of the health requirement (as defined in PIC 4005–4007).

Under DIAC's outcome and output framework, the health requirement has one relevant outcome indicator ‘the extent to which public health and safety is protected through immigration screening'. It also has only one effectiveness measure ‘the incidence of TB relative to the percentage of overseas born in the Australian population compared to the same ratio for other major developed countries'. Other components of the PIC (other public health diseases of public health threat, significant cost, and prejudice to access) have no effectiveness indicators, and are not systematically monitored, measured, or reported.

The health requirement is an integral component of several DIAC programs that report against Output 1.1—non humanitarian entry, and is a legislated requirement for some 150 visa types. However, DIAC has set no outputs or measures specific to the health requirement. Because of the cross-program nature of the health requirement, DIAC also could not provide the full cost of administering the health requirement.

DIAC's performance monitoring for the health requirement has focused on internal management (operation level) guided by objectives and key indicators in Branch level business plans, and targets levels of activity, funding and reporting requirements defined in DIAC's Statements of Work. However, the Statements of Work were draft documents, which had ceased in late 2005. The replacement performance system was not yet in place. The ANAO found that local performance data was used to inform process improvements, but contributed little to broader annual reporting against outputs and outcomes.

Overall, DIAC was able to provide only minimal information on the performance of the health requirement, and had little capacity to gauge its own achievements. Essentially, the extent to which public health and safety was protected through immigration screening was not fully measured or reported. 

Agency responses to the audit

The ANAO made eight recommendations to assist DIAC in strengthening key aspects of its administration of the health requirement. DIAC agreed to each of the eight recommendations.

Recommendations 1 and 3 were also directed to DoHA. DoHA agreed to both of these recommendations.

DIAC's response

The department welcomes the report of the ANAO. Australia enjoys some of the best health standards in the world and this department views the protection of public health as a high priority. In order to help maintain these high standards DIAC administers one of the most comprehensive health screening processes in the world.

The ANAO has put forward some constructive findings in relation to the overall governance of the health requirement. DIAC agrees that the implementation of the health requirement would continue to be advanced through a collaborative approach to policy development with DoHA. The department notes and accepts the ANAO suggestions for reviewing current health policies and planning for emerging issues.

The department has made substantial progress in addressing some of the findings of the report. Contractual arrangements have been finalised for the completion of Notes for Guidance papers and the Health Services Project has commenced work on implementing an IT solution to address the processing and reporting issues identified by the ANAO.

DoHA's response

The Department of Health and Ageing (DoHA) acknowledges the need for cross-agency cooperation and supports the ANAO's recommendation to formalise consultative arrangements and roles and responsibilities between DIAC and Health.

DoHA understands that under the Administrative Arrangements Order (AAO), DIAC is responsible for administering the health requirement under the Migration Act 1958, with a range of agencies contribute technical advice in accordance with their expertise.

DoHA understands its role in relation to the health requirement is to provide broad public health advice and assistance to DIAC to access appropriate technical input to their development of policy on administering the health requirement under the Migration Act 1958. In addition, it is not appropriate for DoHA to endorse specific guidelines for use by DIAC as the professional colleges have the clinical expertise to provide this endorsement.

Footnotes

1 Joint Standing Committee on Migration Regulations, Conditional migrant entry: the health rules, Australian Government Publishing Service, Canberra, 1992.

2 ANAO Audit Report No.62, 2002–03, Management of Selected Aspects of the Family Migration Program. www.anao.gov.au

3 Migration Regulations 1994, Schedule 4 Public Interest Criteria (PIC) 4005–4007.

4 Gazetted countries are those listed by DIAC in the Australian Government Gazette, for the purpose of Regulation 2.25A.

5 Front end loading is where a person seeking entry to Australia submits medical results before their visa application. If the person fails to meet the health requirement, they would likely choose not to submit a visa application, and thereby avoid paying the (sometimes large) visa charge.

6 Mick Palmer AO APM, Inquiry into the Circumstances of the Immigration Detention of Cornelia Rau, Commonwealth of Australia, 6 July 2005; and Commonwealth Ombudsman, Inquiry into the Circumstances of the Vivian Alvarez Matter, Commonwealth of Australia, 26 September 2005.