The first ever Oral Health Equity Symposium was held on Thursday and Friday last week. Gabrielle Baker went along to see how the best in New Zealand’s dental sector are hoping to tackle inequities in New Zealand’s oral healthcare.

It’s no secret that our health system works better for some than it does for others. Nor is it a secret that a combined legacy of “murder house” stories from adults remembering their school dental clinic visits and the prohibitive cost of seeing a dentist once we turn 18 means that good oral health and regular dental visits are luxuries for many, requiring bravery and serious coin. 

Oral health data also shows a picture of health sector failure, even when the service is “free”. For example, Māori and Pacific children under five are more likely than other children to have cavities (whether or not they live in areas with fluoridated water supply). 

Over the past two days I joined the 155 other people attending the first ever Oral Health Equity Symposium, in Wellington, hosted by the Māori Oral Health Quality Improvement Group. 

The big question of the symposium was essentially – how do we achieve equity and truly ensure good oral health for everyone? 

As I’ve mentioned before, when we talk about health equity (and its counterpart, inequity) we are talking about unjust and unfair differences in health outcomes between populations. If we are doing it right, we are also talking about a wider picture of differential access to the “determinants of health” – the things that keep us well or contribute to us being unwell. And we are also acknowledging that it is a human rights imperative to address these differences. 

Oral health as a te Tiriti issue

Because the concept of equity is so rooted in us being aware of context, it was natural enough that Symposium presentations quickly became about the fundamental issue of the role of te Tiriti o Waitangi in oral health. 

Otago University professor Peter Crampton delivered a presentation he had worked on with colleague Kura Lacey. Among other things the presentation provided highlights of the Health and Disability System Review panel interim report, published last month. This included the comment that “Māori as Tiriti/Treaty partners have not been well served by the health and disability system.” 

The aymposium was also addressed by Hon Peeni Henare, associate minister of health, who acknowledged the recent recommendations from the Waitangi Tribunal in its report Hauora, calling them “fantastic”. But this praise did not equate to the government accepting the Waitangi Tribunal recommendations from its first look into health services and outcomes. Instead, it was more of a comment that there is an opportunity to design a gradual process that leads to more equitable outcomes for Māori.

Oral health is a policy Cinderella

Moving beyond the more constitutional content of the symposium’s presentations, there was also significant discussion on the government’s oral health priorities (or lack of them). During the symposium oral health was described as a Cinderella policy area, in reference to it receiving less attention than it should from policy makers. 

• The last national oral health policy, Good Oral Health For All, For Life, was released in 2006 and only one of the seven priority actions has been achieved. Meanwhile the inequities in access to oral health services and in good oral health outcomes remain and there doesn’t appear to be any consequences (for the Ministry, DHBs or providers) for the lack of equitable progress. 
• Good oral health is central to our overall wellbeing (affecting our ability to do everything from smiling freely to chewing food easily) yet it is treated as a separate and siloed issue in terms of health funding. 
• 77 percent of general practice services are publicly funded compared to 24 percent of dental services. This creates a very real barrier to access for people, partially explaining the steep costs we all experience as adults seeking dental care. 
• Only a very small amount of this public oral health funding is available for services for adults on low income (about 8 percent of DHB oral health funding).

Māori oral health providers as the equity solution

During his address, Minister Henare referred to the work of his father, the late Erima Henare, in setting up Ngāti Hine Health Trust and trying to achieve a lot with very little money. I first met Erima Henare within weeks of starting work in Māori health policy at the Ministry of Health more than 13 years ago. At the time, Ngāti Hine Health Trust and four other Māori health providers were being funded to expand their oral health services, so to me the story of oral health is inextricably linked to Māori leaders and health providers advocating for Māori self-determination and expecting to be being properly funded for the delivery of services.

Self-determination too was a thread of the symposium. Whānau stories shared throughout the sessions emphasised the need for Māori led services, and for a culturally safe, culturally competent oral health workforce. Members of the oral health quality improvement group, such as Ora Toa (based in Porirua and Wellington) shared how they run their services to improve Māori outcomes. And presenters shared their views that achieving equity would be easy enough if there was substantial investment in Māori providers working in Māori communities. Yet, only around ten of the 280 Māori health providers throughout the country have contracts to deliver oral health services.  

Despite this there was still an optimism surrounding the symposium. “There’s a lot of momentum out there in the sector, particularly from Māori providers and community leaders, to turn the tide and urgently tackle inequities in the health system,” says Charrissa Keenan, an experienced health researcher, policy advisor and oral health expert who worked with the Māori oral health Quality Improvement Group on the symposium. 

Where to now? 

Keenan and her colleagues presented an equity matrix to the symposium that proposes a set of actions and priorities for oral health, which was added to over the two days. This includes advice to government to demonstrate a commitment to water fluoridation, the reduction in the availability of sugary drinks and increased DHB accountability for equity. To paraphrase Moana Jackson, who spoke on the second day of the symposium, the act of imagining the matrix and its content are important steps in achieving Māori wellbeing and improving oral health. 

The other crucial step though, as was made so clear in the symposium, is to sort the fundamental te Tiriti relationship. The Waitangi Tribunal has given its indication of how to do this in primary health care at least, through Māori self-determination, support for Māori health providers and legislative change to require equity in health. It has also said that an independent Māori health authority should be explored by the Crown and claimants as part of a Treaty compliant health system.

These are not small changes, and while they may have to be gradually achieved, they have to be done with Māori as partners. Because doing it the other way, without Māori, is what got us this expensive, scary oral health system that Māori providers and others are having to work so hard to change.