On 15 June BusinessDesk published my article on the Māori Health Authority (MHA – Te Mana Hauora Māori): Māori Health Authority a good call but not a magic bullet.
I argued that establishing the Authority, on 1 July, as a separate government entity with significant decision-making powers and influence was a good political call providing that its existence alone was not seen as a magic bullet.
New structures don’t affect sustainable health system improvement. It is the way in which they work (and are allowed to work) that is critical. In other words, it is about internal and external culture.
I also identified that arguably the most effective work MHA could to would be to strongly advocate for legislation and policies to address social determinants of health which, while external to it, are the biggest driver of demand for (and cost of) healthcare. These determinants included poor housing, low incomes and limited educational opportunities.
The response through various social media outlets and other means was positive. But, while supportive of my argument, one response correctly noted that I should have emphasised more the importance of addressing cultural discriminations within the health system itself. Fair comment.
Worthy of further discussion
But there was another response which I also found thoughtful and worthy of further discussion. It came from a former senior manager in a smaller district health board (DHB) who was well respected by the health professionals he worked with and was responsible for.
In 2020 he was brought back to the DHB for about a year to do some work that included health and population statistics. Māori comprised nearly 54% of the DHB’s population. Compare this with the just over 17% for the whole of Aotearoa New Zealand.
In his words: “Māori disparities were appalling. However I ran all the same parameters against socioeconomic status and found exactly the same correlation.” He concluded that health problems or inequities are socio-economic while acknowledging that, in his DHB at least, around 80% of Māori live in low socio-economic areas.
This conclusion led him to doubt that the Māori Health Authority “…will help everybody” with low socio-economic status.
This is not a knee-jerk or redneck response. It is thoughtful, based on a study of relevant data, and raises some challenging questions. Afterall, poverty is poverty and should be dealt to regardless. These questions unfortunately are in the background of the most turgid and distracting current debates; class versus identity politics.
To call a spade a spade, at the core of inequities is exploitation. I consider class structure in the context of the kind of society that it existed in to be the ultimate driver of exploitation. To be pure in the tradition of historian EP Thompson in his The Making of the English Working Class, class is a relationship, not a thing. But that is a discussion for another occasion.
It is class exploitation which then leads to inequities such as poverty and discrimination. But racism, benign or otherwise, can’t be shunted away to the side-lines. Racism serves to both create divisions among those who are exploited (thereby preventing a shared collective consciousness) and further compound the level of exploitation of the victims of racism.
The most effective way of addressing the inequities of racism is to address the underlying exploitation.
Class exploitation: the cause of inequities
Hypothetically, if I had to choose between being exploited by a ‘white’ or ‘brown’ capitalist, I would chose neither. But it would be much more likely that my exploitation would be from the former rather than the latter.
To put things on a more tangible footing, with the benefit of hindsight, although well-intended I believe the form of vaccine rollout prioritisation for Māori was wrong. Had those vulnerable to the social determinants of health (that is, lower socio-economic status or class exploited) then the effectiveness of the rollout would have been enhanced.
There are deprivation indices which would have assisted. Even focussing on the communities surrounding low decile schools would have been a more effective approach.
But, in the context of this blog and the doubt raised by my responder about Te Mana Hauora Māori, it is likely that more Māori would have been vaccinated by this approach given their disproportionately high presence in this group.
A challenge for Riana Manuel, MHA chief executive
A challenge for Riana Manuel, MHA chief executive
Looking ahead this comes back to the effectiveness of the Māori Health Authority. If it is able to make a difference to how fairly Māori are treated within and have greater access to the health system, then this will be a major success worth crowing about.
But, if it goes further and advocates forcefully for government legislation and policies to first reduce and then eradicate the social determinants of health, then this would be an extraordinary success for all New Zealanders.
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion