There are challenges in almost every form of human interaction.
You’ll find them in personal and family relationships, employment, financial arrangements and collective bargaining between unions and employers. These challenges can often be positive.
However, if the expectations of these challenges are unrealistically high, then conflict and toxicity are not far away.
Politics is no exception. In fact, it’s fertile territory for unrealistic expectations.
Reducing health disparities
A case in point is the Pae Ora Act, which came into force on July 1.
The act is best known for transferring the funding, planning and providing of healthcare services of the Ministry of Health to a new organisation called Health New Zealand (Te Whatu Ora).
It replaces district health boards (DHBs) with a new Health NZ organisation and sets up the new Māori Health Authority (Te Aka Whai Ora).
Section 3 of the act says its purpose is the public funding and provision of services.
There are three features of equal statutory weight:
- One to protect, promote and improve the health of all New Zealanders.
- Another is to build towards pae ora (healthy futures) for all New Zealanders – that is, a population health focus. These purposes are to be commended.
- The third feature of the act’s purpose is both commendable and problematic because it’s unrealistic. It’s to achieve equity by reducing health disparities among NZ’s population groups, in particular for Māori.
In other words, it’s the health system’s responsibility to reach equity by reducing health disparities.
Let’s compare this with the legislation this act replaced.
The ‘purpose’ section of the NZ Health and Disability Act 2001 was more than 330 words long. There are nearly 70 words in the Pae Ora Act.
The repealed act had a strong focus on universal access to healthcare for all – and on population health.
DHBs were set up to give this teeth by being responsible for their geographically defined populations, including their role in integrating care between community and hospital services.
Equity did not feature as much in the legislation that followed. There was a reference to reducing health disparities by improving the health outcomes of Māori and other population groups.
The wording was modest, but realistic given what drives health disparities.
How long will you live?
The best indicator of health disparities is life expectancy.
- In 2022, the life expectancy of New Zealanders was 82.65 years.
- Back in 2000, life expectancy was 77.57 years.
In other words, during the little over 20 years we had district health boards, life expectancy went up by 5.08 years.
It’s difficult to say what might have contributed to this increase. Certainly, in the 2000s the Helen Clark government significantly increased funding for primary care, with a sizeable increase in general practitioner (GP) consultations.
If you improve access to primary care, inevitably better healthcare will follow.
But there’s more revealing data.
Māori life expectancy not going up
In 2000, Māori life expectancy was seven years less than the overall NZ rate. And 22 years later, the gap is still seven years. So, what does this tell us?
First, Māori life expectancy more or less increased at the same rate as other New Zealanders during these years.
Overall, primarily through DHBs, the health system did a pretty good job in improving life expectancy for Māori.
This is particularly so because there were the severe cutbacks forced on DHBs in the 2010s by the then National-led government through ‘light austerity’ measures.
I say ‘light’, compared with countries like Greece, Spain and the United Kingdom – but austerity, nevertheless.
Second, and this is where there’s a lack of realism on the part of those responsible for drafting the purpose clause of the Pae Ora Act.
Health disparities, including for Māori, are driven from outside, rather than inside the health system by factors the health system has no control over.
These outside drivers are known as ‘social determinants of health’. They include:
- Low incomes (the main one).
- Poor housing.
- A lack of educational opportunities.
Those people disadvantaged by these social determinants of health struggle to get access to healthcare in time – or at all.
Things the health system can't fix
The health system can’t fix this, but it can do some useful work towards it.
A good example was developing integrated care through clinically developed and led health pathways between the community and the hospital.
This work was pioneered by the Canterbury DHB. Integration was a feature of the 2001 act, but it’s completely thrown out under the 2022 act. I believe this is a serious error of judgment.
Improving access to primary care for Māori can improve the impact of social determinants, but these core issues can only be addressed by new government laws and policies.
We could boost incomes through fair pay agreements, by replacing the minimum wage with the living wage (about $2 extra per hour) and upping benefit levels to take beneficiaries out of poverty.
But a health system can’t do this. Only governments can.
Labour health minister Annette King got it back in 2000 when she was drafting her NZ Health and Disability Act. Health disparities were also part of her legislation, but with much less hyped expectation.
It didn’t need the health system to “achieve equity”, because it hasn’t got the powers to do that.
In contrast, our current Labour health minister Andrew Little is a more rigid and much less insightful thinker.
The lens through which he views the health system is a blinkered one.
He ensured that reducing health disparities, particularly for Māori, is one of three main purposes of his act, but he has also required the health system to achieve this equity.
It simply can’t be done.
He's created an expectation that can only be delivered by his government through legislation and policies.
I support the setting up of the Māori Health Authority. It can play an important role in improving outcomes for Māori. But expecting it to address the drivers of social determinants of health is simply unrealistic and will lead to frustration.
Annette King was part of a government that under-promised and over-delivered.
Andrew Little is part of a government that over-promises and under-delivers. Approaching health inequity is evidence of that.