GUEST BLOG: Ian Powell – Reducing health inequity

My final article published by BusinessDesk in 2022 (20 December) discussed the challenge of Aotearoa New Zealand’s health system reducing health disparities in order to reduce inequity as now expressly required by legislation:  New health system can’t fix what’s broken in society.

My focus was on the unrealistic expectations of the Pae Ora Act which took effect last July and created both Health New Zealand (Te Whatu Ora) and the Māori Health Authority (Te Aka Whai Ora). It also abolished the 20 district health boards which had been established in January 2001.

The purpose of the Pae Ora Act is the public funding and provision of health services. In this context it has three features of equal statutory weight:

1. Protect, promote and improve the health of all New Zealanders.
2. Build towards pae ora (healthy futures) for all New Zealanders. In other words, a population as well as personal health focus.
3. Achieve equity by reducing health disparities among New Zealand’s population groups, in particular for Māori.

These are laudable objectives but the third is unrealistic partly because the health system can’t achieve equity and partly with the statutory weight given to it achieving this objective.

The previous, now repealed, legislation was modest by contrast but realistic in terms of what drives health disparities. It required the then district health boards to improve the health outcomes of Māori and other population groups which they did.

DHBs performance on health disparities

In BusinessDesk I highlighted the best overall indicator of health disparities – life expectancy. I said:

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.

The most likely reason was significantly increased primary care funding in the 2000s by Helen Clark’s Labour-led government (1999-2008). It made access to primary care more affordable leading to a big increase in general practitioner consultations. Much of this is due to then Health Minister Annette King (1999-2005).

Annette King: health minister who established DHBs and enhanced general practice access

In respect of Māori health disparities in particular, the data is extremely revealing. In 2000, Māori life expectancy was seven years less than the overall New Zealand rate. Twenty-two years later, the gap is still seven years. So, what does this tell us? Two things as I discussed in BusinessDesk.

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.

Second:

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. 

Governments rather than the health system can more fully address health disparities. Fair pay agreements should low boost incomes if not obstructed (or repealed by a future National-led government).

The government could also boost incomes by replacing the minimum wage with the living wage (about $2 extra per hour) and upping benefit levels to take beneficiaries out of poverty.

Rob Campbell got it

In response to my BusinessDesk article then Te Whatu Ora Chair Rob Campbell commented on LinkedIn that same day (20 December):

1. Te Whatu Ora will “address inequities driven by social determinants of health”. That is our role. We will not overcome or reverse them on our own;

2. We have a lot of work to do in both our direct and our funded services to eliminate access and service inequities which reinforce wider social inequities;

3. So plenty to do. More than enough to focus on ahead of ultimate victory over inequality. No one I have met in the health services is under any misapprehension that we can do so alone.

4. I do wonder about the terminology. Many of the inequities and poor outcomes are driven by what we might more accurately describe as “commercial determinants”.

Rob Campbell: on the right path

Although I would have expressed it differently Campbell was on the right path. He did not criticise the unrealism of the legislative health disparities requirement.

However, he recognised that although Te Whatu Ora could not achieve equity through removing health disparities on its own (arguably he does imply that it could do it more than it can), it could mitigate them.

Mitigation doable

One way of mitigating health disparities is developing integrated care through clinically developed and led health pathways between community and hospital healthcare as pioneered by the former Canterbury DHB. It has been internationally recognised as an outstanding success. This includes as a means of managing the risk of rising acute care demand.

Unfortunately, in 2020, the government chose to force out Canterbury’s senior management team. This team had supported the engagement rather than managerial culture that enabled this distributed clinical leadership to achieve this success

Unfortunately this engagement culture was crushed by the hierarchy of the Ministry of Health and Treasury supported by EY business consultants and endorsed by the Government, including former Health Minister Chris Hipkins.

This crushing (coup by another name) is discussed further in my two articles published by the Democracy Project in 2021 (15 April and 19 May): A Very Bureaucratic Coup: Part 1 and A Very Bureaucratic Coup: Part 2.

There is also the role and potential of Te Aka Whai Ora to consider. It has the potential to improve Māori access to culturally appropriate quality health services to, in the first instance, primary care in communities.

This opportunity is well articulated by Rob Campbell in a Stuff opinion piece (13 February) prior to his sacking as Chair of Health New Zealand: Māori Health Authority must succeed.

Other mitigation opportunities

There are also measures that could be pursued within the health system to mitigate health disparities although they would first require government action. For example, it could remove an important financial barrier to accessing to medical services and oral healthcare by ensuring free access to general practitioners and dentists.

This is well argued in a Newsroom article (6 February) by Dr Esther Willing, Senior Lecturer in Hauora Māori and Director of Kōhatu Centre for Hauora Māori, University of Otago: Time for free access to GPs and dentists.

Stuff journalist Hannah Martin meanwhile on 8 February identified scrapping prescription fees as a means of improving health outcomes: Scrap prescription fees .

What a genuine government would do

If the Labour government genuinely wants to reduce inequity by reducing health disparities then it first has to take the necessary legislative and policy decisions focussed on reducing the impact of external social determinants.

Then it needs to focus on ensuring, notwithstanding its highly centralised and vertical structure, that Te Whatu Ora actively encourages a health professional led engagement culture. This culture should be distributed throughout all levels of the health system with the objective of enabling the health system to do its bit to mitigate health disparities.

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