Summer health series: You have the tools, now make a change

What lies beyond the new Labour government’s ‘first 100 days’ for health policy and outcomes for Māori? In the final installment of our series on the future of Māori health, former Ministry of Health advisor and policy analyst Gabrielle Baker sums up the core values needed to make big changes to our health system.

When I started this series I was driven by excitement over the election and a new – somewhat unexpected – coalition government. I wanted desperately to talk to people about what this all meant for Māori health. This isn’t a merely intellectual task though. The ability of the government to deliver on its aims to reduce inequalities, improve wellbeing and shift the Crown-Māori relationship is more than intriguing. It is vital. And failure is more than politically embarrassing, it is life and death.

The minister of health has been taking his job seriously in the first 100 days though. He appointed a Ministerial Advisory Group to “provide fresh perspective and independent advice about how we can improve our health system and deliver better services to New Zealanders.” With the prime minister he also launched the promised inquiry into mental health, seeking to recommend improvements to the mental health system (although the specific reference to equity of access in the Terms of Reference is a bit limiting – but it’s a start). This suggests an understanding of the need for change on a fairly large scale.

The prime minister recently spoke about a relationship shift with Māori — moving beyond the negotiation of Treaty settlements. She too seeks change. And she has been sending non-verbal signals, like hosting BBQs and spending five days at Waitangi.

As optimistic as this might make you, the positive signals will become rhetoric if it isn’t matched with tangible and obvious moves to a pro-equity and anti-racist health system.

A briefing to ministers, for the second 100 days and beyond

Because politicians are inundated with reports I don’t expect you David or Jacinda (or Julie Anne or Jenny or Winston or James) to have read every word that I’ve written. So consider this the executive summary of my interviews with Māori health experts over the past couple of months.

The health system should be pro-equity and anti-racist.

The inequalities we see across most health indicators tells us our health system hasn’t gone far enough in being pro-equity and anti-racist. This might be a daunting reality for many New Zealanders who like to believe we are egalitarian and fair. But if we are truly fair we need to ask why, time and time again, the same groups bear the burden of failure by government services. We can’t keep assuming it is an accident.

The good news for ministers and the government is you’re not alone. An evolved Crown-Māori relationship could be the way to explore what a pro-equity health system looks like.

When you do get a chance to look at health system redesign, challenge assumptions about what is possible. So many of these assumptions are part of our colonial legacy. Like assuming if a hospital exists, and people are technically able to come through the door, then job done. We might even have to respond with something quite out there, like shifting resources to develop some other kind of health system entirely.

Set expectations of equity

System change will take a while; it is probably a multi-electoral term project that will be hard to fit into a 100 day plan. But immediately you could set an expectation of equity for the health sector.

I’ve chosen the term equity carefully – because a focus on just reducing inequalities, as worthy as that sounds, says to Māori they are not worth as much. Accepting ‘reduction’ as success also implies that equity is too hard. The more likely situation though is equity makes moving away from the status quo more urgent and some of the people privileged by the current system (which includes health professionals as much as it includes the wider population) will find it hard to adjust. But equity is achievable. One example of where a pro-equity approach was tried is in improving immunisation rates for babies. If you click the link you can read about how there were greater gains in immunisation of Māori infants than for the total population. Yet even in this relatively good example, the rates for Māori were still lower than for any other population at December 2016. So setting an expectation of equity will only get you so far.

Monitor the heck out of health agencies

Once you set an expectation of equity you need to hold health agencies and providers accountable by giving consequences where standards aren’t met. These consequences might start as a light touch – like public scrutiny that would come from having to publicly report performance by ethnicity – and become much bolder, like divesting from services that are do not perform for Māori.

And if health agencies and services don’t know where to start, they can always ask people what they want.

Success isn’t just about outcomes. It’s also about the way outcomes are achieved.

Improving Māori health is not just an equity problem, it is about recognition of indigenous and Treaty rights. This is fundamental to any system redesign, and necessary in our current system if the Crown is to meet its Treaty obligations.

We have seen movement over the past few decades with the health system required to involve Māori in decision making – which means Māori board members on DHBs, Māori relationship boards as part of DHB governance and often Māori health units within agencies. DHBs must also involve Māori in service delivery. To some extent this has been successful and there are now around 225 Māori health providers, for example. And there are Kaupapa Māori programmes that privilege Māori views and are showing signs of working, like Te Kūwatawata.

But Māori providers can face scrutiny both from their funders and from the general public who expect 225 providers who collectively earn about $14 million in contracts to do more for Māori than what 20 DHBs, over 1000 general practices, over 2000 dental practices, 39 hospitals and nearly 1000 pharmacies do with around $16 billion each year. They can also find it hard to get sustainable funding even if they show signs of working, because so much of our health funding is tied up in things that are seen as sacrosanct, even if they fail Māori.

Demonstrate best practice when you push forward your investment priorities.

Labour policy is to invest $8 billion in a range of priority health areas. And in delivering on these you can demonstrate the kind of practices you want to see.

Be critical of data and analysis. Good quality analysis doesn’t frame Māori or other populations as the problem. Reinforcing myths like “Māori don’t engage with treatment” or “Māori are hard to reach” is both irresponsible (deliberately ignoring the possibility of service failure, perpetuating victim blaming) and unhelpful because it won’t tell you where to intervene unless you want to launch a public shame campaign (which as much as anything would be a complete waste of money).

Picking where to intervene is important though. Should you invest in hospital level services, or should more be delivered in the community through primary care providers? You can’t assume health services alone are the best place to spend your money and effort either. Something like a requirement of health equity in all policies would strengthen a cross-sectoral approach, with joint responsibility and goals across ministers and agencies. The mental health inquiry is a natural starting point, with the very clear links to social welfare, education and justice to name a few. This goes beyond just involving agencies in the inquiry and its findings though. Done right, ministers would look across their portfolios and ask whether and how all policies could contribute to more equitable mental health outcomes for people and populations at the intersection of all these systems.

It will be tempting to get quick wins and invest in new projects immediately. The previous Labour government had a reducing inequalities fund for example. And there are lessons from that approach, one of them being that once the funding is used up the project ends and there has been little to no change to the health system. Also it can send the wrong signal. It can imply to DHBs and other health funders that they can keep on doing an inadequate job in an area, and even though they are literally funded to do better they can pass responsibility for fixing the problem back to the government. There will of course be things worth one off or extra investment where it tactically can demonstrate system change. In those rare cases the same things about an expectation of equity (including in deciding where to invest – is it in response to Māori health need?), monitoring and involving Māori throughout.

L-R: Janice Kuka, Rhys Jones, David Tipene-Leach, Donna Cormack, Teresa Wall, Rawiri Jansen, Papaarangi Reid, Matire Harwood, Leanne Te Karu, Paula King.

Our ministers have already been given a briefing on the ins and outs of the health system and I don’t want to go over that same ground. So this is where your reading ends. Feel free to read repeatedly. And now you also have a bunch of people you can call on if you want to know any more about what they’ve discussed here. You’re welcome, ministers.

Read the rest of this series here.

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