Download PDF
Professor Peter Crampton
MB ChB, PhD(Otago), DipObst(Auck), NZCPHM, MRNZCGP
Professor, Kōhatu, Centre for Hauora Māori
University of Otago
The Ministry of Health has defined health equity as follows (1):
In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes.
This is a fit-for-purpose definition because it focuses on the avoidable, the unjust, and on differences in levels of advantage. The theme of this issue of the New Zealand Medical Student Journal is ‘towards equity in health care’, and in this editorial I argue that now must be the turning point for equity in our health system. Equity means fairness. Equitable health outcomes are fair health outcomes. Fairness is a long-standing core value in Aotearoa, embedded in Te Tiriti and threaded into our national psyche. Yet, we have stubbornly stood back from our failure to achieve fair health outcomes.
Māori health outcomes are anything but equitable, as evidenced over many decades in the lived experience of countless whānau and documented in every report that has ever been written on the subject. While the social and economic determinants of health have a major part to play, the health system is also a key player in both driving and ameliorating inequitable health outcomes for Māori.
A powerful message has been sent to New Zealand by the Waitangi Tribunal in its first report from what will be a long-running inquiry into health (2). This report is clear and unequivocal. The Tribunal tells us to wake up and start implementing Te Tiriti, including the principle of equity, which requires the Crown to commit to achieving equitable health outcomes for Māori. To achieve this, we should honour the guarantee of tino rangatiratanga, which provides for self-determination and mana motuhake in the design, delivery and monitoring of health care.
The exercise of tino rangatiratanga in health is entirely achievable. There are excellent examples of primary health-care services that are designed to incorporate Māori values, respond to Māori health-care needs, and that are orientated around the principles of te ao Māori. And there is the huge added benefit that these services work well for patients of all ethnicities. Similar principles apply to the design and delivery of health services for Pacific communities and there are, as well, numerous long-established examples of primary health-care services that are specially tailored to meet the needs of low-income communities. In secondary and tertiary care, District Health Board (DHB) and hospital-based clinicians, managers, and leaders have shown us that transforming hospital-based health services to achieve equity is entirely within our reach.
In sum, we have plenty of experience from Māori, Pacific, community-based, and DHB-based examples that demonstrate we have the know-how and the ability to provide health services that serve the needs of populations most in need.
In addition to the Waitangi Tribunal’s inquiry, the Health and Disability System Review panel is, at the time of writing this editorial, about to release its interim report. The review of the health system was instigated by the Minister of Health last year with the brief of making recommendations about what changes are needed in order “to improve the performance, structure, and sustainability of the system with a goal of achieving equity of outcomes, and contributing to wellness for all, particularly Māori and Pacific peoples”. The panel, of which I am a member, recognises the huge opportunity occasioned by the review to refocus our health system on equitable health outcomes. Its final report will be completed in March next year and will include recommendations for the consideration of the Minister of Health and his Government colleagues, and for the consideration of governments in the future.
The health workforce has a central role in achieving equity. The health workforce has many strengths, but in order to meet current and future equity challenges, some positive changes are required. To ensure that tino rangatiratanga, the needs of Pacific communities, and the needs of low income communities will be continually at the centre of the frame of reference in the development and implementation of health policies, the health workforce must fully reflect these diverse communities in its makeup. Even though good progress is being made in some areas, true ethnic representation in the workforce would represent a marked shift in the recruitment, training, and support of health professionals, compared to the status quo in 2019.
Strong and skilled leadership is required. In order for leadership functions in health to be exercised, there is an urgent need for systematic investment in and development of health leadership capability that fully reflects the diversity of Māori, Pacific, Asian, and other communities. There is absolutely no excuse for any senior leader within the health system not to have strong working knowledge of te ao Māori. This should be a key criterion in appointment processes. Where lack of knowledge of te ao Māori is identified amongst existing or prospective leaders, then there are excellent professional development and support resources available to be drawn upon to help rectify the deficit.
New Zealand’s health system—communities, workers, leaders, and organisations—collectively has the knowledge, expertise, and skills to design and provide excellent primary and secondary health services to our diverse communities. The Waitangi Tribunal report and the Health and Disability System Review, along with the commitment and effort of individual health professionals and health organisations, do indeed provide us with the opportunity now to refocus and, where necessary, reshape our health system to achieve equity of health outcomes.
I encourage all medical students to commit to the values of fair, culturally appropriate, proportionate service delivery according to need and to equity in health outcomes. These values are at the heart of professionalism.
References
[1] Ministry of Health. Achieving equity [Internet]. Edition.: Ministry of Health, [cited 15 August 2019]. Available from: https://www.health.govt.nz/about-ministry/what-we-do/work-programme-2018/achieving-equity
[2] Waitangi Tribunal. HAUORA, rReport on sStage oOne of the hHealth sServices and oOutcomes kKaupapa iInquiry, pPre-publication version., Waitangi Tribunal: Wellington: WAI 2575; WAITANGI TRIBUNAL REPORT 2019. Wellington: Waitangi Tribunal, 2019.
About the author
Professor Peter Crampton is Professor of Public Health at Kohatu, the Centre for Hauora Maori at the University of Otago, Dunedin
Professor Peter Crampton
MB ChB, PhD(Otago), DipObst(Auck), NZCPHM, MRNZCGP
Professor, Kōhatu, Centre for Hauora Māori
University of Otago
The Ministry of Health has defined health equity as follows (1):
In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes.
This is a fit-for-purpose definition because it focuses on the avoidable, the unjust, and on differences in levels of advantage. The theme of this issue of the New Zealand Medical Student Journal is ‘towards equity in health care’, and in this editorial I argue that now must be the turning point for equity in our health system. Equity means fairness. Equitable health outcomes are fair health outcomes. Fairness is a long-standing core value in Aotearoa, embedded in Te Tiriti and threaded into our national psyche. Yet, we have stubbornly stood back from our failure to achieve fair health outcomes.
Māori health outcomes are anything but equitable, as evidenced over many decades in the lived experience of countless whānau and documented in every report that has ever been written on the subject. While the social and economic determinants of health have a major part to play, the health system is also a key player in both driving and ameliorating inequitable health outcomes for Māori.
A powerful message has been sent to New Zealand by the Waitangi Tribunal in its first report from what will be a long-running inquiry into health (2). This report is clear and unequivocal. The Tribunal tells us to wake up and start implementing Te Tiriti, including the principle of equity, which requires the Crown to commit to achieving equitable health outcomes for Māori. To achieve this, we should honour the guarantee of tino rangatiratanga, which provides for self-determination and mana motuhake in the design, delivery and monitoring of health care.
The exercise of tino rangatiratanga in health is entirely achievable. There are excellent examples of primary health-care services that are designed to incorporate Māori values, respond to Māori health-care needs, and that are orientated around the principles of te ao Māori. And there is the huge added benefit that these services work well for patients of all ethnicities. Similar principles apply to the design and delivery of health services for Pacific communities and there are, as well, numerous long-established examples of primary health-care services that are specially tailored to meet the needs of low-income communities. In secondary and tertiary care, District Health Board (DHB) and hospital-based clinicians, managers, and leaders have shown us that transforming hospital-based health services to achieve equity is entirely within our reach.
In sum, we have plenty of experience from Māori, Pacific, community-based, and DHB-based examples that demonstrate we have the know-how and the ability to provide health services that serve the needs of populations most in need.
In addition to the Waitangi Tribunal’s inquiry, the Health and Disability System Review panel is, at the time of writing this editorial, about to release its interim report. The review of the health system was instigated by the Minister of Health last year with the brief of making recommendations about what changes are needed in order “to improve the performance, structure, and sustainability of the system with a goal of achieving equity of outcomes, and contributing to wellness for all, particularly Māori and Pacific peoples”. The panel, of which I am a member, recognises the huge opportunity occasioned by the review to refocus our health system on equitable health outcomes. Its final report will be completed in March next year and will include recommendations for the consideration of the Minister of Health and his Government colleagues, and for the consideration of governments in the future.
The health workforce has a central role in achieving equity. The health workforce has many strengths, but in order to meet current and future equity challenges, some positive changes are required. To ensure that tino rangatiratanga, the needs of Pacific communities, and the needs of low income communities will be continually at the centre of the frame of reference in the development and implementation of health policies, the health workforce must fully reflect these diverse communities in its makeup. Even though good progress is being made in some areas, true ethnic representation in the workforce would represent a marked shift in the recruitment, training, and support of health professionals, compared to the status quo in 2019.
Strong and skilled leadership is required. In order for leadership functions in health to be exercised, there is an urgent need for systematic investment in and development of health leadership capability that fully reflects the diversity of Māori, Pacific, Asian, and other communities. There is absolutely no excuse for any senior leader within the health system not to have strong working knowledge of te ao Māori. This should be a key criterion in appointment processes. Where lack of knowledge of te ao Māori is identified amongst existing or prospective leaders, then there are excellent professional development and support resources available to be drawn upon to help rectify the deficit.
New Zealand’s health system—communities, workers, leaders, and organisations—collectively has the knowledge, expertise, and skills to design and provide excellent primary and secondary health services to our diverse communities. The Waitangi Tribunal report and the Health and Disability System Review, along with the commitment and effort of individual health professionals and health organisations, do indeed provide us with the opportunity now to refocus and, where necessary, reshape our health system to achieve equity of health outcomes.
I encourage all medical students to commit to the values of fair, culturally appropriate, proportionate service delivery according to need and to equity in health outcomes. These values are at the heart of professionalism.
References
[1] Ministry of Health. Achieving equity [Internet]. Edition.: Ministry of Health, [cited 15 August 2019]. Available from: https://www.health.govt.nz/about-ministry/what-we-do/work-programme-2018/achieving-equity
[2] Waitangi Tribunal. HAUORA, rReport on sStage oOne of the hHealth sServices and oOutcomes kKaupapa iInquiry, pPre-publication version., Waitangi Tribunal: Wellington: WAI 2575; WAITANGI TRIBUNAL REPORT 2019. Wellington: Waitangi Tribunal, 2019.
About the author
Professor Peter Crampton is Professor of Public Health at Kohatu, the Centre for Hauora Maori at the University of Otago, Dunedin