In part four of our series on the future of Māori health, former Ministry of Health advisor and policy analyst Gabrielle Baker looks at where social investment and health intersect and asks if we’re spending money on the right services.
In previous weeks I’ve talked about equity, inequality and Māori involvement in decision making. These are important foundations for the health system. But for most of us it isn’t what we judge the government’s performance in health by. We want reliable health services that we trust, when we need them. We want health services that work for us.
Minister of health David Clark will be under pressure to trust in health services and professionals to do what they do best. Yet these same services haven’t figured out how to consistently deliver for Māori. So something needs to change.
How are health services doing now?
One indicator health officials use to keep an eye on system performance is ambulatory sensitive hospitalisations. The language is unnecessarily complicated, but it covers a situation where someone wouldn’t have been hospitalised if other health services (like the kind you get from your GP) had worked. The reasons behind going to hospital are varied — there might not have been services available when they were needed, the services may have been inaccessible or unaffordable. Or the quality of the care may have been inadequate.
Whatever the exact causes, we know that for lots of people the system works okay. But time and time again the same population groups are disproportionately hospitalised where it might have been avoided. Mostly it is Māori and Pacific people. Often it is kids with conditions like asthma that should have been better managed in primary care.
Isn’t this about people needing to take better care of themselves? (Spoiler – no it isn’t)
To make sure people are able to get the services they need (so bigger consequences, like being hospitalised, are avoided) we need to look beyond this being the result of individual choice. There are myths like “people choose not to use services that would keep them well”. But we need to challenge this because evidence doesn’t support it. I spoke with Matire Harwood, a South Auckland based GP, researcher and senior lecturer at Auckland University about this in the context of immunisation – the kind of health intervention that can prevent kids from getting sick.
“There is a discourse around Māori refusing to have immunisations which is just not true. When you look at the data you see that Māori kids have their first immunisations. So we are okay with immunisation itself. It’s after three months when the rates drop off, which is when parents go back to work. So you need to think about whether there are problems with the accessibility of services for working parents, for example.”
Maybe it is about having more money for health services?
Labour Party policy is to invest $8 billion in health over the next four years. Primary care, cancer treatment, mental health (particularly community services) and rebuilding Dunedin hospital are all poised to benefit from this cash injection. But just picking areas for investment without understanding how it relates to the overall objectives of the government – that stuff about reducing inequalities – seems unlikely to deliver on what’s been promised.
So it is not surprising the people I spoke to weren’t strong advocates for more funding so much as they were advocating for pro-equity, anti-racist use of health sector resources.
Leanne Te Karu, a prescribing pharmacist who works primarily in Turangi and Papakura, wasn’t wholly convinced that more funding is needed. “What I see is perpetuation of a model that is not premised on equity and hence is an unwise spend.”
Many services aren’t working for Māori but are funded because that’s what we’ve always done. In contrast, programmes that focus specifically on improving the health of Māori might – at best – be able to secure one-off funding.
“I led a project, funded by the Ministry of Health. The funding was to develop and test an approach centred on Māori to build the health literacy of whānau to improve clinical management, especially around medications. The project was very successful. Feedback was that people had never felt so empowered as when they were able to direct their doctor about their condition and medication. The whole community benefits when people are this empowered. Sadly, finding ongoing funding for this type of model has not been possible.”
Matire Harwood also talked about wastage created by services that aren’t working for Māori and the need for accountability. “There needs to be better use of the kinds of levers the health system has.”
I spoke with Sir Matiu Rei a few weeks ago in Porirua. Sir Matiu is the executive director of Ngāti Toa Rangatira, which also runs Ora Toa (one of the country’s four Māori owned Primary Health Organisations). He said something similar:
“Parts of the health sector know they are underperforming – they have the data to show it – but they seem happy for it to stay unknown. [They] don’t want to let it be known how badly the system’s been treating Māori.”
So what would pro-equity, anti-racist investment in services look like? When I asked people what services they would spend money on there were no quick fixes.
We can start by shifting the power to the community
Something you could do immediately is involve Māori in service design. Leanne talked about this too: “How about we ask the community what they want and how it should be delivered? How about we truly engage?”
Some things are already in place and are showing promise. Matire used Whānau Ora as an example of giving people a say in how money is spent to support their needs. “Good examples are coming through from Te Pou Matakana and the Whānau Direct fund where people get to say what their aspirations are. They commit to these aspirations and get creative about how to achieve them. Funding might then be available to help. It could mean buying an exercycle to help a person get fitter and healthier. And it can work.”
Other things are in place too, but the jury is out on how effective they are. A term that has attracted a lot of government interest in the past couple of years is co-design and there is a proliferation of design laboratories and use of experts across the health system.
Co-design seems to cover a range of activity, from stakeholders providing information or stories as part of a design process to help make a service fit for purpose to supportive and sustained partnerships with whānau and communities to effectively address the issues. Or it could mean something in between.
There is room for cynicism. Paula King, a public health physician and clinical research fellow at Otago University, has been looking at co-design in health services and equity for Māori children and young people and their whānau.
“The ‘co’ part of the word co-design is key, Paula says. She points out that it is problematic if a Crown agency gets to set the boundaries unilaterally or control how the information is used, while still calling it co-design.
Paula also notes the irony of the way co-design is evolving. “The very word laboratory sits awkwardly with community. There are significant ethical issues if Crown agencies with a history of structural violence against Māori children and young people (for example abuse of children and people with disabilities in state care) establish laboratories with a focus on children and young people”.
So the uneasy conclusion is there isn’t evidence yet that the haven’t yet got a way for co-design to deliver on equity aims.
The answers aren’t all in the health sector
Leanne Te Karu sees that the answers don’t all lie in health services. “There is no way that I’m fixing people by sitting in a clinic without collaboratively working with other professionals – you can’t just patch people up knowing they are going back to garages as their housing”.
Rhys Jones, a public health physician, senior lecturer and advocate for action that aligns health, environmental and equity goals, sees potential for government to push agencies and sectors to work together to have a bigger impact. “We should be incorporating health and health equity in all policies. I think we’d see a fundamental shift, with agencies working towards the same overarching aim instead of having policy objectives that compete with each other. A good example is the transport sector. If we include considerations about the health and health equity impacts of transport decisions, we’d see funding allocations and transport outcomes looking radically different. We would rapidly move away from our existing system that promotes chronic disease, injuries, climate pollution and inequity, replacing it with healthy, sustainable transport that facilitates equitable access to society’s resources.”
Social investment has been touted as a way to break down the silos between agencies on the basis of data that tells us where to spend. According to Treasury, social investment means using information to better understand the people who need public services and what works for them. But the new minister for social development Carmel Sepuloni has shared concerns about social investment: “We don’t agree with New Zealanders being deemed potential liabilities for the state. With that negative stigma put on New Zealand citizens, with them being deemed potential risks and predictive risk modelling used to assess risk.”
This concern was echoed by Donna Cormack, who splits her time between Auckland and Otago Universities, “We are over-surveilling particular groups of people, to the point we make it look like being Māori predicts risk. Interrogating the data government agencies hold isn’t going to tell us anything we don’t already know at a high level. It doesn’t change our beliefs of who we think deserves our support.”
And this takes us back to the idea that the health system needs to be clear on its values before it can get the services and investment decisions right.
So what does our minister of health need to do?
The health portfolio is huge and David Clark has a task ahead of him in getting services to work more equitably. But luckily, advice is at hand.
David, if you’re reading, here’s what I think you most need to know:
- The health system is expensive to run, and needs investment, but there is also wastage and money is spent on services that don’t deliver for Māori.
- Set expectations of equity. Services should be getting the same results for Māori as they are for all other groups.
- Monitor services, and report on performance by ethnicity. Services that don’t perform for Māori need consequences, including public scrutiny. You also need to be bold and disinvest in mainstream services that aren’t working for Māori – this is what a commitment to equity looks like.
- Use the mental health inquiry and your focus on improving access to primary care services to showcase meaningful involvement of Māori in service design. Imagine the inroads that would make to a pro-equity, anti-racist system!
- Look beyond clinical health services and seek out cross-sectoral ‘wins’ – work with your colleagues on health equity in all policies because you will find ways to deliver on the Government’s big statements around “reducing inequalities” if you do.
The way Māori are treated in the health sector hasn’t happened by accident. Nor are inequitable outcomes the result of individuals choosing to make it hard for the health system. To be honest, I think this point is just that you need to stay woke.
Maybe the answer is also in investing more in services that are run by Māori owned organisations? Next week I’ll explore this – and its links with the Crown – Māori relationship, so it will be one for David Clark and Kelvin Davis to both keep an eye out for.