Our vision for Aotearoa in 2040: Health equity is the norm
All whānau enjoy the highest possible standard of health and wellbeing.
RACP recommendations to make health equity the norm
- Health resources must be prioritised according to equity and need, delivered by a culturally safe and pro-equity health system.
- People who experience long-term conditions and/or disabilities are supported to enjoy a good quality of life.
Nina is 4 and lives with 12 other whānau members in a 3-bedroom house.
Nina spends a lot of time in hospitals, particularly in the winter. She has had bronchiolitis twice and was hospitalised for 2 weeks with pneumonia during winter last year. During lockdown, Nina and the other children quickly got sick and complained of sore throats. Sniffles and coughs are a common occurrence for the whānau, and several of the children in the household have asthma.
The house is still uninsulated. The whānau run an unflued LPG gas heater in the living room when it gets really cold as it’s all they can afford. The LPG heater increases the moisture inside and the home feels damp, especially in winter. There is often mould growing on the walls. A heat pump was installed but it’s too expensive to use.
Health equity remains unrealised
Two of the fundamental goals of the Aotearoa NZ health system are to maximise the health of the population and to
minimise inequity in health outcomes. Practically, this has meant that our health system has reflected the Pākehā majority, both in design and service delivery — the inequity is inbuilt.
Health inequities are differences in outcomes between groups of people which are avoidable, unjust and result from uneven access to resources, wealth, power and privilege. Health equity recognises that the allocation of resources, access to and quality of healthcare some people receive are powerful factors in how people who are unwell get better, and how sick they get in the first place.
Yet through decades of reports, inquiries and analysis, the common factors are well-known:
- Colonisation, land dispossession and oppression imposed by a foreign system.
- The proliferation of poor housing, unsafe working conditions, unemployment, racism and low incomes.
- Barriers to accessing care and treatment such as cost, transport and geography, which are tolerated by a system that purports on the surface to deliver equal care to all New Zealanders.
The third article of Te Tiriti o Waitangi makes an exacting commitment to Māori health equity, affording Māori all the rights and privileges of British citizens. The Waitangi Tribunal has found that the ōritetanga or equity principle not only protects Māori from discrimination, the Crown is obligated to actively promote equity for Māori.
Life expectancy and avoidable mortality: the realities of inequity
The impacts of the systems, socioeconomic determinants and barriers are illustrated by the profound differences in life expectancy: Māori will, on average die sooner than non-Māori, non-Pacific people. The gap differs between men (7.4 years) and women (7 years) and varies regionally around Aotearoa.
First episode rheumatic fever hospitalisation rates, Māori and non-Māori, 1996-98 to 2014-16
Ministry of Health, Māori health trend reports, 2019.
Research has also shown that for causes of death where Māori are over represented, like cancer, heart disease and stroke, much of the mortality attributed to these causes is both preventable and open to change. Preventable chronic illness is life-limiting and reduces quality of life. Rheumatic heart disease is a cause of preventable and avoidable death with
pronounced inequity of outcome: the mortality rate for Māori is more than eight times the rate for non-Māori non-Pacific people.
Nina was tired and said her arms and legs hurt. Her mum Shannon and her sister Tamara decided to take Nina to the hospital Emergency Department, where Nina was admitted to the paediatrics ward. Imaging confirmed a diagnosis of Rheumatic Fever and she was started on antibiotics.
Nina will need monthly, painful penicillin injections for at least 10 years. She may experience long periods in hospital, need to use a wheelchair and may be unable to participate in sport. In later life, Nina could develop other complications with her liver or need surgery to insert stents in her heart due to damaged heart valves.
Three trajectories influencing the development of inequitable outcomes continually come to the fore.
The first is access to the upstream determinants of good health like safe and warm housing, education and employment opportunities.
The second and third, access to health care and the quality of care received, are heavily mediated by a system where racism is in-built.
Preventative programs, such as swabbing the throats of children to diagnose and treat Group A Streptococcus infection, can lead to a reduction in rates of hospitalisation for Rheumatic Fever but it won’t eliminate the inequity. Only through supporting the upstream determinants — preventing crowding and raising household incomes — will a
difference to health outcomes and end the incidence of preventable health conditions like rheumatic fever be made.