health & science

Tribunal finds universal health failings

Hundreds of pages of a Waitangi Tribunal report paint a bleak picture of the Crown's efforts to improve Māori health outcomes. Farah Hancock examines some of the key points.

Last week, over a decade after claims about Māori health inequities were lodged with the Waitangi Tribunal, a damning report was published.

In strong language - leaving no room for misinterpretation - the Tribunal found the Crown has fallen short of ensuring Māori health outcomes are equitable.

Variations of the word “fail” occur 37 times through the report and "institutional racism" nine times. The report suggested an “urgent and thorough intervention”.

An independent Māori Health Authority is recommended as well as addressing underfunding of Māori primary health organisations.

As a population group, Māori have on average the poorest health status of any ethnic group in New Zealand. Statistics show this hasn’t changed in the last 20 years despite $220 billion spent on the health system.

During the hearing, Te Kōhao Health managing director Lady Tureiti Moxon, one of the claimants who had waited 13 years to be heard, said currently Māori lives are seven years shorter than the lives of non-Māori.

“Māori are twice as likely to face discrimination in health, Māori are less likely to be referred for diagnostic tests, Māori children are over two and a half times as likely to have unfilled prescriptions due to cost and Māori are more than twice as likely to die from preventable diseases.”

The report lists further statistics, all equally grim.

Mortality rates for stroke are twice as high in Māori than non-Māori, three times as high for heart failure, eight and a half times higher for rheumatic heart disease.

The 231-page report found fault with Treaty compliance at almost every level of primary health care, from over-arching legislation to funding and accountability.

The Treaty of Waitangi includes four principles which are relevant to the claims. The principles of partnership, protection, equity and options.

The Public Health and Disability Act aims low

The Public Health and Disability Act is the legislation New Zealand’s health system operates within. One of its stated purposes is to reduce health disparities for Māori. Claimants said it should aim for equity instead.

The Tribunal agreed: “Aiming to simply ‘reduce health disparities’ does not capture the true urgency or active effort required by the Treaty principles of active protection and equity … The depth and persistence of the health inequities experienced by Māori indicate that the health system is barely reducing Māori health disparities, let alone achieving Māori health equity.”

The Treaty clause in the Act also came under fire. It mentions participation and collaboration, not partnership. It was labelled by the Tribunal as a “reductionist effort at a Treaty clause”.

The trickle-down effect of watered-down principles

“The watering down of the Treaty principles, particularly partnership, in the Act’s Treaty clause is reflected in the key strategies of the primary health care frame- work,” says the report.

For the last 20 years the Crown distilled Treaty principles relevant to the health sector as the “three Ps” – partnership, participation and protection. This thinking was set in 1988 and according to the Crown was an attempt to “create a common language for use by a large workforce”.

Even when included, the term partnership doesn’t mean true partnership, rather it's defined as involving Māori.

The Tribunal believes involvement does not equate to partnership.

“In our view, influencing decisions or participating in making them is not the same as making decisions.”

Representation rules ignored and Māori voices drowned out

District Health Boards have a statutory requirement to have Māori membership on boards proportional to the number of Māori in the DHB’s population. At the very least all boards must have two Māori members.

This has only happened once, in 2001.

“The data shows that on only one occasion, in 2001, have all district health boards had two Māori members. At no time have all district health boards complied with the proportionality clause.”

Even when present, Māori voices at the table are often ignored.

The Tribunal found this does “not afford Māori sufficient control of decision-making to be a fulfilment of the Treaty principle of partnership.”

Funded to fail

Primary Health Organisations (PHOs) were introduced in the 2000s. They were aimed at offering community-led healthcare where prevention as well as treatment could be achieved. Funding was given based on PHO members, not appointments.

During the hearing Moxon pointed out one Waikato Māori PHO was given $50,000 to establish. The money “could not realistically cover a full-time salary for one employee, let alone set up the infrastructure necessary to get the organisation off the ground”.

Another received $38,500 from Lakes District Health Board after “furious negotiations” to raise the amount from the $18,500 initially offered.

During the hearing the Crown agreed the way it decided how much money was required was “inadequate”.

The idea that half the cost of an appointment would come from members was also problematic for Māori PHOs who say those members who could afford to pay for appointments, could only afford to pay a small amount. Often, they were in poorer health and more expensive to care for than those of an average practice.

Only four of 14 Māori PHOs remain. Others have amalgamated or been forced to close.

The Tribunal found it was clear primary care had been underfunded at establishment and during operation.

The failure to address this for over a decade, despite advice and health inequity was found to be a breach of Treaty principles.

A lack of accountability and consequences

The report notes there’s a huge gap in accountability for performance.

The Crown told the Tribunal there are ways to hold DHBs to account. Funding can be withheld for poor performance, however, despite continuing poor health outcomes for Māori this has never been done.

For PHOs there’s even less accountability. Performance is self-audited.

Te Puni Kōkiri, the Ministry of Māori Development was also found to have failed Māori health. It has a statutory responsibility to monitor health. Aside from one review of a single DHB in 2004 it has done no monitoring. 

The Tribunal report is scathing of what it describes as a permissive approach to accountability:

“In our view, the accountability arrangements set out in the primary health care framework barely work to achieve the statutory aim to reduce Māori health disparities, let alone pursue or achieve Māori health equity.”

The recommendations – equity and independence

The first change recommended is getting rid of “reducing disparity” and replacing it with equity. The report dryly notes something as simple as this should not be controversial:

“Achieving health equity should be among the ultimate purposes of any just health system.”

The biggest change recommended is structural reform.

“… the Crown has led and controlled the design, structure and resourcing of the primary health system. This system has not addressed Māori health inequities … “

The creation of an independent Māori Health Authority is suggested.

“We make an interim recommendation that the Crown commit to exploring the concept of a stand-alone Māori primary health authority.”

Under the recommendation draft terms of reference would be completed and presented to the Tribunal by January 2020.

Additional recommendations were made in regard to assessing the level of underfunding which has occurred to date and new accountability measures.

Lady Tureiti Moxon said the 13-year wait to have the claim heard has been worthwhile.

“What more can be said, it’s been said – now it’s time to put the recommendation into action.”

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