In a BusinessDesk article recently, the new Te Whatu Ora – Health NZ chair, Dr Karen Poutasi, said equity is at the heart of NZ’s new health legislation, the Pae Ora Act 2022.
She is absolutely correct. The act has three purposes as it provides public funding and delivers health services.
One is to “achieve equity in health outcomes among NZ’s population groups, including by striving to eliminate health disparities, in particular for Māori”.
The other two are to “protect, promote, and improve the health of all New Zealanders” and “build towards pae ora (healthy futures) for all New Zealanders”.
Equity was also part of the preceding Public Health and Disability Services Act 2000 and equity being at the heart of our health legislation is reinforced by many proactive statements about it by Health NZ.
The problem
It's logical that putting equity at the heart of the Pae Ora Act is putting it at the heart of the health system. The problem is that drivers of inequity are outside the health system and well beyond its ability to “eliminate”.
These drivers are what the World Health Organisation refers to as 'social determinants of health'. It describes them as the non-medical factors that influence health outcomes.
The organisation gives these examples of the social determinants of health, which influence health equity, positively and negatively:
- Income and social protection.
- Education.
- Unemployment and job insecurity.
- Working life conditions.
- Food insecurity.
- Housing, basic amenities and the environment.
- Early childhood development.
- Social inclusion and non-discrimination.
- Structural conflict.
- Access to affordable health services of decent quality.
The World Health Organisation says: "The lower the socioeconomic position, the worse the health."
These factors can be more important to health outcomes than health service or lifestyle choices. Sectors outside the health system contribute more to population health outcomes than the health system does.
Health system mitigation
The only way for the health system to address these social determinants is the last of these factors: healthcare access. This limits the role of health systems to easing the problem, rather than eliminating it.
NZ does have one positive example of its health system improving social determinants. It's the Canterbury district health board (DHB) which, from the mid-2000s, pioneered world-leading integrated health pathways between the community and the hospital.
Canterbury’s success was due to its culture and pathways being clinically developed and led.
You can use life expectancy as a useful indicator to measure inequity. When DHBs were set up in 2001, the life expectancy of Māori was around seven years less than non-Māori. By the time DHBs were abolished in 2022, there was no change.
Underwhelming, you might say. However, over the same period of time, the life expectancy of Māori and non-Māori went up at the same rate (nearly six years).
Now, look at Canterbury, much of it covered by the former DHB. The province has the fifth largest Māori population in the country. It now has a three-year difference in life expectancy. Reportedly, it's on a trajectory to lifespan equity in around 11 years. How come?
There will always be more than one contributing factor behind such a great outcome. Arguably, the most significant was Canterbury DHB’s focus on an integrated community response focused on individuals and whanau, reinforced by the health pathways with the hospital. This included better vaccination and screening rates.
Many Māori traditionally associated hospitals with being a place to die, because by the time they got there, their conditions were too complex for health professionals to save them. This was largely because early interventions and support that should have taken place hadn't happened.
Ironically, the senior leadership of Canterbury DHB found itself repeatedly undermined by the health ministry for much of the 2010s. Aided and abetted by the Labour-led government, it was eventually pushed out in a bureaucratic coup in 2020. It’s rough to be punished by success.
Poor intellectual legislative construct
Too fast and poorly planned
This takes us back to the designing of the Pae Ora Act, which came into effect on July 1, 2022. It happened too quickly.
The Heather Simpson review of the health and disability system was finished in 2020, but the government effectively turned it on its head.
This happened with its announcement in April 2021 to abolish the DHBs, which were the structures responsible for delivering the large majority of healthcare in NZ.
The April 2021 announcement radically changed the structure of the Simpson review’s proposed new Health New Zealand. HNZ has been predicated on DHBs remaining. Instead, it was to take over the funding and planning functions of the Ministry of Health. Suddenly, it was responsible for almost all of the health system.
But there was something worse than the lack of time to prepare and pass difficult new legislation in less than 15 months. It was the almost complete lack of trust and confidence by the Labour-led government in the people who led the health system.
It was generally known that when the Labour party was in opposition, leading up to the 2017 election, it had little confidence in the leadership of the health ministry. What was much less known (if at all), was its similar lack of trust and confidence in the leadership of the DHBs.
This proved fatal. The government turned to business consultants to design the restructure. This move marginalised the people who had the greatest experience of how public health systems worked.
This was a recipe for the poor health system laws we now have, issues that are showing up in so many tragic ways.
What should have happened
If all this expert experience had been involved, NZ's health system wouldn't be in the state we now see it.
Those experienced people would have warned us that if you put structural change before cultural change and then over-centralise an already centralised health system, there would be a terrible downside.
In the absence of a culture change, an already top-down central government leadership culture becomes even more top-down. It undermines the ability to reduce inequity.
To address inequity in the health system, including for Māori, you need two approaches.
First, focus on the social determinants of health. This can only be done by government actions outside the health system. This is the pathway to eliminating inequity.
Second, put fast and affordable access to comprehensive integrated healthcare at the heart of the health system. This is how to fix inequity.
