Consultation submissions

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Submitter name

Heather Came

Submitter organisation

Health Equity Now

5 November 2015

Re: Submission on the Update of the New Zealand Health Strategy
To Whom it May Concern,
Thank you for the opportunity to participate in the redevelopment of the revised New Zealand Health Strategy (NZHS). We acknowledge the commitment to Māori health, reducing inequities and Te Tiriti o Waitangi demonstrated in the strategy. We also recognise the complex challenge of refreshing such a strategy for the health sector.
This submission is on behalf of Health Equity Now. Formed in 2013 our rōpū is a professional network of public health professionals committed to promoting health equity within the administration of the public health sector. The current membership is Dr. Nicole Coupe, Claire Doole, Ngaire Rae, Trevor Simpson, Associate Professor Tim McCreanor, Dr. Jonathan Fay, Emma Rawson, Grant Berghan, Lisa McNab, Robert Muller, Sue Turner and Dr. Heather Came. Collectively we have nearly 250 years of experience working within the public health sector!

Core Recommendations

  1. Prioritise investment in public health within the NZHS.

Investment in public health is cost effective. Such investment saves considerable clinical treatment costs, and maintains the health of the workforce - which is a prerequisite for economic prosperity. Tailored public health measures are critical to population level efforts to advance health equity, and have more reach and impact at a population level than interventions in the secondary and tertiary health sectors.

  1. Specifically how you will meet your Te Tiriti o Waitangi obligations.

Te Tiriti o Waitangi is the foundational document of New Zealand and is embedded within health legislation. Over and above what is articulated in He Korowai Oranga (Ministry of Health, 2014); we would like to see the NZHS specifically address the following questions:

  • i) Kāwanatanga - How will hapū/iwi/Māori be involved in decision making at all levels of the health sector?

  • ii) Tino rangatiratanga – How are hapū/iwi/Māori aspirations reflected within the NZHS?

  • iii) Ōritetanga – What specific actions will be undertaken to ensure equitable outcomes between Māori and other New Zealanders?

Being specific is important as it enables accountability around Māori health and allows Māori as Treaty partners the opportunity to monitor and track progress.

  1. Commit to transforming institutional racism within the administration of the heath sector.

Institutional racism is a pattern of differential access to material resources and power by race, which advantages and privileges one sector of the population while disadvantaging enacting racism against another (Came, 2012). Addressing institutional racism is central to efforts to address health inequities. We would like transforming institutional racism to become a target and/or priority of the health sector. To credibly champion health equity, we believe health funders and policy makers as leaders in the sector need to get their own houses in order. Our research shows systemic racism within the administration of the New Zealand public health sector and this needs to be urgently addressed (Came, 2014; Came, Doole, Lubis, Garrett, McCreanor, & Coupe, 2015).

  1. Address the negative determinants of health for Māori and Pacific populations.

The evidence around the impact of the wider determinants of health on health status is considerable (Pickett & Wilkinson, 2011) particularly in relation to indigenous peoples (Mowbray, 2007). We support the ongoing investment into healthier housing. However, we want the NZHS to clearly articulate what the contribution of the health sector will be to addressing other modifiable determinants of health. Without committing to specific actions, the NZHS discourse on determinants of health risks becoming rhetoric.

  1. Continuing to improve access to primary care services for the sections of the population with unmet need.

There is a pattern of access in primary care; those who need the most get the least (Jatrana & Crampton, 2009). New Zealand has a mixed business and government funded model of primary health care. Visits to the general practitioner and medications from pharmacy are still beyond the reach of the most financially disenfranchised New Zealanders. Improving access for very low access New Zealanders makes sense fiscally and as a measure to improve quality of life.

Other Feedback

Health Equity

It is heartening to see the commitment to health equity throughout this strategy. The challenge this opens is how to ensure these words become everyday praxis within all levels of the health sector rather than rhetoric. We welcome the work of Fiona Cram (2014) that articulates specific evidence-based recommendations about how to embed equity within the health system. She focusses on the domains of leadership, knowledge and commitment, and nominates action points for the whole health system, health organisations and practitioners. This body of work needs resources invested into it, to ensure it is well operationalised, monitored and evaluated.
We agree with your statement:

It can struggle to ensure equitable access to limited resources, and health disparities persist. … finding new ways of working to deliver the services we need. (p1)

We appreciate that there are limited resources to invest in the health sector and that this decision-making is complex. As above, we argue there is over whelming evidence of the cost effectiveness of investing in public health (Mearns, 2013; Mernagh et al., 2011; Owen et al., 2012; Shearer & Shanahan, 2006; Wright, Bates, Cutress, & Lee, 2001). Money invested in keeping people well leads to considerable savings in clinical treatment costs later. The invisibility of public health within this strategy is a potentially expensive omission ten years out.

To support both health investment and disinvestment decisions we would like to see mandatory use of the Heath Equity Assessment Tool (Ministry of Health, 2004) and/or the Whānau Ora Impact Assessment (Ministry of Health, 2007). This discipline would help ensure equity remains a core focus of the health sector.
We disagree with your statement “New Zealand’s health system performs well” (p. 2).
Marriot and Sim’s (2014) recent report and Tatau Kahukura: Māori health chart book (Ministry of Health, 2015) and before that the Hauora Māori health report series (Pōmare, 1980; Pōmare & De Boer, 1988; Pōmare et al., 1995; Robson & Harris, 2007) show entrenched heath inequities between Māori and other New Zealanders. This suggests that the health system is not working for all New Zealanders. For instance life expectancy rates sound high (p2) but when you look closer (p. 6) it reveals the inequities. We welcome the life expectancy gap between Māori and other New Zealanders becoming a core measure of performance of the health sector.

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