Most of the social determinants of health lie beyond the mandate of the health sector. Actions are required in many non-health sectors, including local government, social development, transport, finance, education and justice. The health sector has a role in advocating for and actively encouraging inter-sectoral approaches to addressing the social determinants of health and the whole of society needs to be involved along with the whole of government.110
NZMA’s position statement emphasises the importance of inter-agency collaboration in addressing not only health disparities, but also the value of working across sectors to address the socio-economic factors that contribute to structural discrimination.
Many in the health sector have identified the importance of cultural competence and cultural safety in the delivery of health and disability services to Māori, Pacific and Asian communities. Cultural competency programmes provide one avenue to address structural discrimination and ethnic inequalities in health.
While there are multiple and evolving definitions of cultural competence, one comparatively simple definition that the Ministry of Health uses in discussing cultural competence in the health sector is: “the capacity of a health system to improve health and wellbeing by integrating cultural practices and concepts into health service delivery.”111 Cultural competency also requires acknowledgement of one’s own culture in order to understand the culture of patients and clients, thereby providing more effective and culturally-appropriate health services. The significance of cultural competence has grown since the introduction of the Health Practitioners Competence Assurance Act (HPCAA) of 2003, which outlines cultural competence requirements for doctors and health practitioners.
The Medical Council of New Zealand has adopted the following definition of cultural competence:
Cultural competence requires an awareness of cultural diversity and the ability to function effectively, and respectfully, when working with and treating people of different cultural backgrounds. Cultural competence means a doctor has the attitudes, skills and knowledge needed to achieve this. A culturally competent doctor will acknowledge:
that New Zealand has a culturally diverse population
that a doctor’s culture and belief systems influence his or her interactions with patients and accepts this may impact on the doctor-patient relationship
that a positive patient outcome is achieved when a doctor and patient have mutual respect and understanding.112
The concept of cultural safety is closely related to cultural competence
, although one that was developed from within New Zealand as a uniquely New Zealand concept. Cultural safety was first developed in the nursing field in the 1990s and has since been adopted by other health professions. Cultural safety, according to University of Otago researcher Marion Gray
, is about positive attitudinal change toward those who are culturally different from us and becoming aware of power relationships between health professionals and clients. A key concept in cultural safety is that “a nurse or midwife who can understand his or her own culture and the theory of power relations can be culturally safe in any context.”113
Cultural safety is intended to contribute to ameliorating the disparities with existing health care delivery for Māori by beginning to address and change health practitioner attitudes, including racism. Although developed as an indigenous approach to health inequalities for Māori, culturally safe frameworks have also developed for Pacific and Asian communities.114 Cultural Safety also places emphasis on the bicultural relationship between Māori and Pākehā in New Zealand and the obligations that come under the Treaty of Waitangi.
As described earlier in the previous section, recent studies on health outcomes provide consistent evidence that some doctors treat patients differently based on ethnicity. Many health professionals may be unaware of biased attitudes and unaware that these attitudes can be translated into practice. These studies illustrate the manifestation of structural discrimination through the often unconscious and unspoken bias of health practitioners. Research has indicated that health disparities for Māori, Pacific and Asian peoples are strongly linked to the behaviour of their health care providers.115 Cultural competency initiatives and cultural safety frameworks can be used to address these embedded health disparities. Health outcomes for Māori, Pacific and Asian people can be improved when health professionals are supported to develop greater cultural competence and awareness of their own attitudes towards people who are culturally different from themselves.
The Medical Council of New Zealand acknowledges that “a culturally competent approach should also recognise that addressing inequalities in health care means addressing barriers between different communities and health-care systems.”116 Thus cultural competence initiatives can also be used to address systemic barriers to health equality. The Medical Council further outlines a commitment to addressing structural discrimination and systemic barriers in their 2006 Statement on Cultural Competence by outlining that health practitioners must have “a willingness to appropriately challenge the cultural bias of individual colleagues or systemic bias within health care services where this will have a negative impact on patients.”
The Ministry of Health recognizes that “cultural competence of the workforce is vital to ensure equity in access to appropriate and high quality care” and has implemented a variety of initiatives to embed cultural competence practices, including a recent report that develops support for Pacific Cultural Competencies in health, local District Health Board community health programmes and a soon-to-be released online cultural competency tool for health providers. The New Zealand Health Practitioners Competence Assurance Act 2003 supports ongoing visibility and government regulation of cultural competence measures.
Despite these government measures, it is important for health care organisations to provide leadership in evaluating, properly resourcing and providing incentives for continued adherence to cultural competency initiatives. A 2011 study of health equity in New Zealand outlined the importance of organisational leadership in challenging “habitual and inequitable” practices, both of health practitioners and health systems. The study stated: “it is an organisational responsibility to set frameworks that can guide development, implementation and monitoring of cultural competency in the workforce.”
Many in the health sector stress the importance of all government departments to work together collaboratively at the structural level to make an impact on health inequalities: “Increasing cultural competency is a shared responsibility, requiring partnerships across a wide range of sectors − including health
, social services, education
, justice and research − using systematic and sustainable approaches.”117