There are many examples that point to manifestations of structural discrimination within the health system, some of which are highlighted below.
Literature on health outcomes provides consistent evidence that some doctors treat patients differently based on ethnicity. One study found that only two per cent of Māori diagnosed with clinical depression were offered pharmaceutical intervention, compared with 45 per cent of non-Māori patients with the same diagnosis.93 Additionally, doctors spend 17 per cent less time (2 minutes out of a 12 minute consultation) interviewing Māori than non-Māori patients.94 Pacific peoples are referred to specialists at lower rates (20 per cent versus the national average of 30 per cent) particularly involving access to surgical care.95 Once age is taken into account, Māori attend GP appointments at the same rate as non-Māori, but obtain fewer diagnostic tests, less effective treatment plans and are referred for secondary or tertiary procedures at lower rates than non-Māori patients.96 Research following the National Primary Medical Care Survey has shown that general practitioners are less likely to have a high level of rapport with their Pacific patients, ordered fewer tests and investigations (17.8 per cent compared to 24.9 per cent) and referred Pacific patients to specialists at lower rates (20 per cent versus the national average of 30 per cent) than their Pākehā patients.97
These studies illustrate the manifestation of structural discrimination through the often unconscious and unspoken bias of health practitioners. Many health professionals may be unaware of biased attitudes and unaware that these attitudes can be translated into practice. Cultural misunderstandings, unconscious bias and uninformed beliefs about Māori, Pacific and ethnic minority patients by health practitioners have contributed to health disparities. Health outcomes for Māori, Pacific and ethnic minority communities 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.98 The benefits of culturally-appropriate healthcare programmes are discussed in the first case-study following this systemic analysis.
Although it is important to attend to the unconscious bias of health care practitioners, addressing individual attitudes (of doctors, nurses and so on) alone will not shift structurally discriminatory practices. A 2007 article about institutional racism and healthcare disparities, stressed the importance of focusing on policies, and practices within systems, not just on individual attitudinal changes:
The history of racism in medicine and healthcare ... illustrates that the problem of healthcare disparities is not simply one of individual behaviour. It is a problem that is rooted in organizational and institutional structures and practices. Given how embedded racism is in institutions such as healthcare, a significant shift in the system’s policies, practices and procedures is required to address institutional racism and create organizational and institutional change to reduce healthcare disparities.99
Health workforce diversity
Another manifestation of structural discrimination is the under-representation of Pacific and Māori peoples in the health workforce. A study of New Zealand’s District Health Boards (DHBs) shows that only three per cent of the nearly 60,000 people employed by DHBs are Pacific peoples. In the Auckland region, Pacific peoples are under-represented in this sector, seven per cent of the workforce, despite making up around 12 per cent of the regional population.100 Additionally, most Māori and Pacific DHB employees are concentrated in administrative and nursing roles.101
Ministry of Health monitoring also offers data on the Māori health workforce. According to their research:
in 2009, active Māori medical practitioners represented 3 percent of the medical practitioner workforce (330 out of 11,164). 102 Between 2006 and 2009, the number of active Māori medical practitioners increased from 240 to 330, an increase of 90 or 38% (all active medical practitioners increased from 9547 to 11,164, an increase of 1617 or 17%)
between 2006 and 2010, the proportion of active Māori midwives was between 6 and 8 percent of the total active midwife workforce. During this time, the number of active Māori midwives increased by 45 or 29% (2006, 153; 2010, 198), while the number of all active midwives increased from 2303 to 2639, an increase of 336 or 15%
in 2008, there were 156 active Māori dentists representing 5 percent of all active dentists (3419). Of the active Māori dentists, 113 (or 72%) were female
in 2010, there were 60 active Māori psychologists representing 4 percent of all active psychologists (1346). Forty two (or 70% of) active Māori psychologists were female. The main employers of active Māori psychologists were DHBs (15) and self employed practices (15).103
In 2010, the Ministry of Health published research on Shifting Māori Health Needs to enable the health workforce to more appropriately meet the health needs of the growing Māori population. The report found that, given the projected increase in the Māori population over the next 10-20 years, it would be necessary to recruit over 150 Māori students into medical education each year for the next 10 years. In addition, Māori secondary school students needed to be encouraged to study science and then be supported to successfully do so (at personal and curriculum levels). Māori students in tertiary medical education also needed personal, pedagogical and curriculum support. Curriculum changes in medical education are also being endorsed by health workforce and system planners here and internationally. Workplaces need to support Māori doctors to be Māori and to practice within Māori models of health care delivery. Achieving these targets requires a cross-government approach.104
A 2011 study on Future Directions for a Māori Dental Health Workforce, for example, highlighted the need to expand the dental health workforce to optimise the oral health needs of Māori 0-17 year-olds. The study recommended structural changes to the workforce including: raising the proportions of Māori dental health practitioners via incentives in the education system (e.g. changes to the secondary curriculum and recruitment into university); introducing cultural competency training for non-Māori oral health professionals; the purchasing of more Māori oral health services; and the provision of oral health services at times and in places that are most accessible for Māori whānau. 105
Better representation of Māori and Pacific people in the health workforce would have significant benefits. Māori patients have higher rates of visits and increased engagement with Māori healthcare providers and likewise for Pacific patients and Pacific providers.106 A report commissioned by the Ministry of Health shows that where patients and healthcare professionals are of the same ethnicity, there are better health outcomes for patients.107
It is important to note that increasing numbers of both Pacific and Māori healthcare providers alone will not necessarily shift structurally discriminatory practices. As one interviewee said, “adding more brown faces in an organisation doesn’t necessarily change policies or structures.” However, this striking under-representation reflects one of many institutional barriers facing Pacific and Māori communities within the health system and is a policy area in which to focus further attention.
In addition to lack of workforce diversity, pay disparity is another manifestation of structural discrimination and a barrier to health equality. Of particular note is the issue of pay disparity between Māori and Iwi health workers in primary health care services and health care workers in DHBs. According to evidence provided by the New Zealand Nurses Organisation (NZNO), Māori and Iwi health workers earn up to 25 per cent less than their colleagues in hospital settings. This funding inequity stands as an additional barrier to recruitment and retention of Māori health workers at the community level. Anecdotal evidence from Māori and Iwi employers highlights these barriers:
“It is difficult to recruit and retain staff due to limitations of contract prices.”
“As a Maori provider, we have had great difficulty in attracting nurses as we have not been able to match mainstream rates.”108
NZNO and representatives of the Māori and Iwi employers jointly presented to the Health Select Committee on 29 April 2009. The uniqueness of the joint presentation was commented on by members of the Committee.
On 23 July 2009 the Health Select Committee issued their report and unanimously made the following recommendations to the Government:
We agree with the petitioners that there is an equity issue regarding pay rates for Māori and iwi health service workers. We recommend that the Government establish a working group to address the issues raised in the petition and report publicly on its findings within six months. In addition, we recommend that the Government instruct the working group to provide us with a report on its progress within three months of its implementation.109
In August 2009 the Government indicated in the “Government Response to The Report of the Health Committee on Petition 2005/177 Ngaitia Nagel and 11,370 others” that they did not support the Health Committee’s unanimous recommendation to establish a working group. No further progress on this issue was therefore made, although the need to address pay inequity remains.
Additional government funding is needed to recruit and retain a skilled and culturally competent workforce. Māori nurses and primary health workers play a vital role in the Māori community health sector and in improving health outcomes for Māori. They have the essential skills, qualifications and experience but are being paid significantly less than their colleagues in other sectors. This is an issue of equity and needs to be addressed.
Kerri Nuku, Kaiwhakahaere of Te Runanga o Aotearoa NZNO further described the importance of addressing this inequity in a 2010 presentation to the Māori Affairs Select Committee:
Māori health improvements require Māori health workers, so whether we are talking about smoking cessation programmes or a whanau-based approach to Māori well-being, Māori health professionals are the key to success. Unless we achieve pay equity, our highly prized and overworked 'Māori for Māori' workforce will continue to be a limited resource, and any new initiatives will continue to struggle and fail. We urge you to look beyond the symptoms of ill health in our communities to the cause. Inequalities in the health sector are a barrier to reducing inequalities in our people.
In addition to pay, NZNO also identify other inequities in working conditions, including terms for annual leave, sick and domestic leave and merit payments.