Government

Radical change needed to address health inequity

It’s going to take time and strong leadership to overcome what the health minister calls the ‘postcode lottery’. Laura Walters reports on Aotearoa's health inequity problem.

Māori health is not just a Māori problem, IronMāori founder Heather Te Au Skipworth says.

Speaking at the opening of the Ministry of Health annual forum in Wellington on Tuesday, the mother-of-three (Ngāti Kahu, Ngāti Kahungunu, Te Arawa, Ngāi Tahu) shared her experience of learning to address health challenges in a different way - one with a kaupapa of whānau, wellbeing, and inclusivity.

Skipworth's first client as a lifestyle coach was a 180kg man.

Calling him obese and forcing him to be weighed and measured - as was required in her contract - was “invasive” and “convicting”, she said.

Instead, she learned to leverage her ability to build relationships and empathise with what she called her “fuller figure clients”.

Skipworth has again been voted onto Hawke’s Bay DHB, where she plans to focus on the devolution of services, and enhancing and growing kaupapa Māori services which are preventative and educational.

The siloed, one-size-fits-all approach was not going to address the the issue of poor health outcomes for Māori, she told the conference of health care sector representatives.

Amid the ongoing discussion of health equity, she said it was important to remember : “Because Māori are given more, it doesn’t mean that others get less; it doesn’t mean that anybody misses out.”

A bad year for health

This year, two key pieces of work have painted a damning picture of the country’s inequitable health system.

First, the Waitangi Tribunal report unequivocally said the Crown had failed in its duty and Treaty obligations.

In the report, released in July, variations of the word “fail” occurred 37 times and "institutional racism" nine times. It suggested an “urgent and thorough intervention”.

“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."

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.

Currently Māori lives are seven years shorter than those 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,” Te Kōhao Health managing director Lady Tureiti Moxon said.

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 issue of persistent inequity was reiterated through the first report of the Health and Disability System Review, delivered last month.

The review, led by Heather Simpson, described the system as a “confusing monolith”, and raised many of the same issues discussed for decades.

“But the reality is that these views have been being expressed, and supposedly agreed with, for decades. Yet the system changes have been only marginal at best."

Fragmentation and duplication were key issues, along with a lack of prevention and focus on wellness, and issues with a system that did not primarily serve consumers’ values and needs.

This resulted in inequitable outcomes and the so-called "postcode lottery" of healthcare.

The review also found a lack of leadership and accountability across the healthcare sector - something also raised in the Waitangi Tribunal report.

The degree of concurrence around what people wanted the system to achieve and how they wanted it to behave was described as “distressing” by Simpson.

This level of consensus on the challenges facing the system and the changes people wanted might seem like a good thing.

“But the reality is that these views have been being expressed, and supposedly agreed with, for decades. Yet the system changes have been only marginal at best,” she said.

Beginning to address the long-term problems

During his speech to the Ministry of Health forum on Tuesday, Health Minister David Clark spoke about the review being a “once in a generation opportunity”.

He spoke at length about a “legacy of underfunding”, which had hurt Kiwis.

“We’d inherited what I called a postcode lottery for health and wellbeing.

“Certainly, I was very clear from the start that one of our toughest challenges was achieving equity in Aotearoa.

“The reality is that we have avoidable, unfair and unjust differences in health and wellbeing outcomes for some people, particularly Māori and Pacific peoples, people living in poverty and people living rurally.

In order to fix health inequity, Aotearoa first needs to address the underlying drivers, including institutional racism, a Māori public health expert says. Photo: Lynn Grieveson

“We must address Māori health and we must improve equity across our entire population.”

Clark acknowledged these were long-term problems, and would not be solved quickly, but said he made no apologies for beginning work that specifically targeted Māori and Pacific health outcomes.

Change would take time, but the initiatives and actions the Government had put in place were an important start towards equity of health and wellbeing, he said, referring to cheaper and free GP visits, developing a Māori Health Action Plan and updating the Pacific Health Action Plan, as well as expanding the Māori health workforce, and creating a new Māori health directorate within the Ministry of Health.

Getting to the core of the issue

University of Otago Department of Public Health associate professor, and director of Eru Pōmare Māori Health Research centre, Bridget Robson said the minister was saying all the right things, but the proof would be in the implementation of wider systemic and societal changes.

Like many of the country’s systems – think justice, education, housing – the key drivers to health inequity stemmed from the forced implementation of a colonial system, she said.

The system, and sub-systems such as the way healthcare professionals were trained, remained rigid and resistant to change.

Despite some attempts the system had remained more-or-less the same since the 19th century.

In order for the country to truly address its health inequities, radical change and strong leadership were needed, Robson said.

Incremental change would be easier, and made sense regarding continuity of care, but that was unlikely to have the desired effect.

“People get sick of hearing about [institutional racism] but until it’s sorted, we need to talk about it.”

Robson said that, in order to achieve equity, Aotearoa would need to address the social determinants, including child poverty – and everything that drove it – and racism in the education, housing and work systems. That meant tearing down silos between core departments and service providers.

She said she understood it was a big ask to address institutional racism but it was the best way forward.

“People get sick of hearing about [institutional racism] but until it’s sorted, we need to talk about it.”

If the country was able to address institutional racism, create constitutional change in the form of a true Treaty partnership, and empower communities through culture, health access and outcomes would be more equitable.

Robson said she agreed the tribunal report and the system review presented a significant opportunity, and would likely take decades to implement, “but we have to start shifting now”.

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