L - R: Rhys Jones, Papaarangi Reid, Donna Cormack, Matire Harwood and Teresa Wall. Illustration: Gabrielle Baker

Summer health series: Why ‘reducing inequality’ isn’t enough

What lies beyond the new Labour government’s ‘first 100 days’ for health policy and outcomes for Māori? In part two of our series on the future of Māori health, former Ministry of Health advisor and policy analyst Gabrielle Baker asks if  ‘reducing inequality’ is aiming too low.

Click here to read part one.

The new Labour-led government is committed to reducing inequalities. They’ve said so in the confidence and supply agreement with the Greens and in the coalition agreement with New Zealand First. Recently the minister of health, David Clark, repeated the sentiment in an interview on Radio New Zealand — even being critical of the absence of the term in the 2016 New Zealand Health Strategy. But what does ‘reducing inequalities’ actually mean? Is it the right aim? And what would we see if the government makes good on its promise?

Talk of reducing inequalities was common through most of the early 2000s in the health sector — and you’ll see it peppered through documents, plans and reports of that era. At its most basic, reducing inequalities is about looking at how well different population groups are doing compared with each other, identifying where the differences are unjust and working to close the gap. The other term the previous Labour government used was ‘reducing disparities’, which is what the New Zealand Public Health and Disability Act 2000 sets as a purpose of the health sector. But when there was a change in government in 2008 ‘reducing inequalities’ gradually fell out of favour. As a term it was losing currency with experts anyway, because it set the standard too low.

Donna Cormack is a senior researcher and lecturer, splitting her time between Te Kupenga Hauora Māori at the University of Auckland and Te Ropū Rangahau Hauora a Eru Pōmare at the Wellington School of Medicine. Chatting over coffee, Donna expanded on this:

“This [the health system’s work] should not just be about reducing inequalities. If you’re happy just to reduce you’re saying Māori are less important. You’re still saying to Māori: ‘you’re not worth as much’.”

When I spoke with Teresa Wall, former deputy director of Māori health at the Ministry of Health and present chair of the Māori partnership board for Capital and Coast District Health Board, she was quick to say that equity is what we really want. In New Zealand we often think of ourselves as fair and it is easy to look internationally and feel a bit smug. But we should judge our level of fairness by looking at the results – not at whether we made the same services available to everyone. And when we look at results we aren’t doing so well. The cardiovascular disease mortality rate is twice as high for Māori as it is for non-Māori. And the cancer mortality rates are 1.5 times as high for Māori as for non-Māori. And we’ve known about these kinds of differences since at least 1980, when Dr Eru Pōmare released Hauora: Māori Standards of Health, which looked at Māori health from 1955-1975.

In early December I met with Matire Harwood about her work and what she thought the opportunities might be for a new government. In 2017, Matire won a fellowship in the L’Oreal-UNESCO for Women in Science programme for her research into health inequities between indigenous and non-indigenous people. Matire emphasised the need to avoid thinking a goal of equity would be too hard. “It’s something we can achieve in ten years.”

Donna said something similar: “Sometimes we see inequity as intractable but it isn’t. That’s not to say that this will be easy, but there are things you can do.”

The New Zealand health system is small and, where there is will, it is possible to make changes relatively quickly. Donna asked me to imagine what a health system would look like if it was pro-equity and anti-racist. It would look different to how it does now.

Here’s what you would see:

  • A genuine commitment to transform the health system and services where we aren’t seeing equitable results (admittedly that is almost everywhere right now). Donna referred to this as “a shift to focusing on the systems, structures and institutions that create and sustain inequities rather than on the individuals that are most impacted,” noting that the default at the moment is to say that poor health choices, like smoking and what we eat, are the reason for inequity without challenging the workings of the health system.
  • Patients, whānau and their communities setting goals for the health system.
  • Services centred on meeting health need, and for you and me that might mean changes to what hours clinics are open and where we can see our doctor, nurses, pharmacists, and other health professionals.
  • Quality ethnicity data.

Rhys Jones, public health physician and senior lecturer in Māori health at the University of Auckland echoed this, saying the whole system needs to be focused on equity. And it needs to be more than lip service. Māori health was a ‘priority’ in the ’90s, but improvement was incremental and the system recalibrated itself and maintained the status quo — to the benefit of those already doing pretty well. He says that for all the health agencies to really deliver on equity they need to be held to account.

“If we explicitly talk about equity, defined what it means and hold people accountable then we might get somewhere.” Rhys’s view was that there needs to be targets for equity, an expectation that all performance targets are achieved equitably, and an intolerance of failure to make progress.

There’s an ethical element to this ­– if we tolerate failure to achieve equity targets we are adding to Donna’s concerns that the health system is saying Māori are less important than Pākehā. When I talked briefly with Professor Papaarangi Reid at the recent Te Ohu Rata o Aotearoa (Māori doctor’s association) hui she challenged the health system to switch up its approach: what if we required ethical approval for anything that wasn’t already shown to improve outcomes for Māori and achieve equity, the way we require an ethical approach to research? This would set standards of proof, consent and transparency.

At this point you might want to point out that equity isn’t only about Māori. What about [insert any group that is disadvantaged by the current system]?” Well the health system should work for them too, and it is unacceptable that it doesn’t. There are lots of reasons you should be interested in how well the government does in Māori health and one of them is that an equitable health system that works for Māori would challenge what we do now in a way that would be good for everyone. We can’t ignore that the health system has been designed by and for a dominant group, and that it has been slow to recognise its growing irrelevance for parts of the population it is funded to serve.

Making good on the promise of ‘reducing inequalities’

While a focus on reducing inequalities is really positive – in part because there hasn’t been much explicit talk about this in the past few years – the smarter focus is on achieving equity. Equity is a better goal, more in line with a just society. It also requires there to be some urgency and for us to want more than incremental change on the fringes.

The new government must avoid pushing for one off projects that claim to be about “reducing inequalities” but that at best will only achieve improvement on the edges of the health system. The focus should be the way the health system is run, its structures and institutions. With this focus, the health sector would have leaders knowledgeable about equity, responsive to Māori and able to demonstrate success because it was just what they do every day. There would be consequences for health agencies that don’t achieve equity. And a commitment to making bold decisions that might mean disinvesting from things that don’t work equitably or investing more in areas that benefit Māori or other groups more than they benefit those already doing well. So when Donna asks again in a few years I’ll be able to say our health services are pro equity and anti racist and they’re doing really well for everyone.

Next week I’ll tell you this is good but not nearly enough because we also need to support Māori leadership and participation in the health sector. But for now let’s enjoy thoughts of our pro-equity, anti-racist future.

Next week: Māori participation in decision making. 

 

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