Closing the gaps: health equity by 2040 - Lyndon Keene, Sarah Dalton


              Closing the gaps:
            health equity by 2040
                             Lyndon Keene, Sarah Dalton

       he main goals of the “once in a gen-      years for males and 5.5 years for females—
       eration” Health and Disability System     an improvement of 0.5 years and 0.3 years
       Review, which has led to a major          respectively over the 12-year period.
system restructuring that’s now in its early       At this rate of progress, Māori males
stages, included better health outcomes for      would achieve equity in life expectancy with
all and greater health equity, despite the re-   European/other males by around 2090—
view accepting that most of a person’s health    approximately 70 years. For Māori females
status is determined by factors outside the      and Pasifika males, equity with European/
system. In July this year, the Association of    other would not be achieved until well into
Salaried Medical Specialists (ASMS) and the      the 22nd century—approximately 127 years
Christchurch Charity Hospital Trust (CCHT)       and 134 years, respectively. Pasifika females
co-hosted a conference of health profession-     would need to wait approximately 220
als to discuss the broader range of policies     years.
that are needed to address health inequities
                                                   Comparisons of life expectancy between
and improve health outcomes for all. This
                                                 the poorest and wealthiest New Zealanders
article outlines some of the key issues and
                                                 over the same 12-year period show a
recommendations to government emanating
                                                 widening gap. In 2005–2007, males in the
from that conference and contain in our
                                                 wealthiest decile could expect to live 7.2
report, Creating Solutions Te Ara Whai Tika:
                                                 years longer than those in the poorest decile.
a roadmap to health equity by 2040.
                                                 By 2017–2019 the gap had widened to 10.6
                                                 years. Life expectancy gaps for females
Health inequities
                                                 were 5.4 years in 2005–2007 and 9 years in
   Health inequities have existed in New
Zealand since records began. They have
been described as immoral because for              The widening gaps are owing to a life
many years governments have known what           expectancy increase in the wealthiest
is needed to address them. Two decades           groups, especially over recent years, and a
ago, the New Zealand Health Strategy 2000        drop in the life expectancy of the poorest
included the goal of addressing health           groups (including a disproportionate
inequities as priority, recognising the “clear   number of Māori) in recent years.
international evidence” supporting policies        It is well recognised that health, well-
focusing on the broad economic and social        being and equity are strongly influenced
determinants of health, including access to      by the socioeconomic, political and cultural
healthcare.1                                     environments that people are exposed to.
  There have been some improvements,             This includes the quality of education, food,
such as a drop in the number of smokers,         housing, employment, transport and physical
but in general the public health issues          environment, along with factors such as
requiring attention today are the same ones      race, gender and social exclusion. Also, as
identified in 2000. In the period 2005–2007,     emphasised by the World Health Organi-
average life expectancy at birth for Māori       zation (WHO), health is influenced by the
males was 8.6 years less than for European/      distribution of power, money and resources,
other males; for females the gap was 8.1         which influence conditions of everyday life.3
years. By the period 2017–2019 the gaps had        Research has found the health status of
narrowed by just 1.3 years and 0.7 years.2       different groups classified by deprivation
  The life expectancy gap between Pasifika       produce social gradients where the more
and European/other in 2017–2019 was 5.6          deprived the neighbourhood the worse the

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                                                                            ISSN 1175-8716       © NZMA

health—and worse still when the effects of      reflect systematic social, political, historical,
institutional racism and cultural alienation    economic and environmental factors, accu-
are added to the mix.4,5                        mulated during a lifetime, and transferred
  In New Zealand, health inequities have        across multiple generations. For individuals,
been exacerbated by widening income gaps        they lead to cultural misunderstanding,
in large part owing to the ongoing cumu-        unconscious bias and racism.12–15
lative effects of the economic downturn in         To the extent that health professionals
the 1970s, the neoliberal policies introduced   engage with patients with positive intent,
in the 1980s and benefit cuts in the 1990s.     misperception and lack of connection
Between 1985 and 2013 New Zealand had           between patients from non-dominant
one of the biggest increases in income gaps     ethnic groups and medical professionals
among developed countries in the OECD.6         is not uncommon. Studies have consis-
  Although the government announced             tently demonstrated that doctors treat
in this year’s budget a hike in the weekly      Māori differently from non-Māori to their
main benefit rates, by between $32 and $55      detriment. Lack of cultural awareness,
per adult, as part of its stated commitment     latent biases and institutional racism lead to
to addressing poverty, an analysis of the       poorer health outcomes.16
budget by the Child Poverty Action Group          The health system itself is inaccessible to
found few families receiving benefits will      many. Around 1 in 8 European/other adults
be lifted over the poverty line. With the       and 1 in 5 Māori and Pasifika adults report
changes announced in the budget, Treasury       an unmet need for a GP service due to cost.
forecasts that child poverty will reduce from   As a conservative estimate, nearly 1 in 10
18.4% to only 17.0% by 2023.7,8                 people have an unmet need for hospital
  In other areas highlighted in our report,     care.17,18
the urgent need for more housing—and              The Health and Disability System Review
especially health housing—continues to          acknowledges “the system is facing severe
grow faster than the government can             workforce shortages for some professions.”
build. The government’s state house build       The Covid-19 pandemic has revealed the
programme well exceeded its plan to build       fragility of the thin white line that separates
or acquire 2,282 houses in the year to June     a safe system from an unsafe one.
2021. However, the growing demand for             The planned health system restructuring,
housing is far outstripping new supply. Well    depending on the yet-to-be-announced
over 24,000 households were on the public       detail, may go some way to addressing
housing waiting list in June this year. Mean-   health inequities and facilitate more
while, rents continue to rise steadily across   consistent access to services nationwide
the country.9,10                                and enable better integration of services.
   In education, according to UNICEF,           However, given most of the solutions to
New Zealand has one of the most unequal         good health lie outside the health system,
systems in the world and the gap between        the efforts to improve the effectiveness of
the highest and lowest performing students      health services are likely to struggle to make
is being made worse by poverty. In its 2018     significant headway until the broader deter-
Innocenti Report Card, UNICEF ranked            minants of ill-health are addressed.
New Zealand 33rd out of 38 countries for
educational inequality across preschool,        Is health equity achievable?
primary school and secondary school               In all societies there will be the poor,
levels. The report’s author commented that      relatively and absolutely. All societies have
under-resourced and stressed families and       social and economic inequalities. Which
communities, combined with racism and           raises the question: if the health-needs
bias in the educational system, contributed     gradient arises because of these inequalities,
to these inequities.11                          won’t there always be health inequities?
  Health inequalities for Māori are charac-       Sir Michael Marmot, one of the world’s
teristic of Indigenous peoples in colonised     leading authorities on health equity and
countries, even when socioeconomic factors      a keynote speaker at the ASMS-CCHT
are considered. The underlying causes           conference, responds to this question with

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                                                                              ISSN 1175-8716       © NZMA

evidence that the health of those most in         being Strategy, released in 2019, takes a
need can be improved markedly over 10             proportionate universalism approach. So
years. The hitch is that at the same time the     why not adopt this approach for the whole
health of those least deprived also tends to      population?22
improve at approximately the same rate, so          The approach “implies a need for action
the health equity gap remains. Says Marmot:       across the whole of society, focusing on
“The lesson I take from this is that if the       those social factors that determine health
health of the poor can be improved quickly,       outcomes.” It requires a whole-of-gov-
then there is nothing fixed about inequal-        ernment response with strong partnerships
ities in health. The fact that the slope of       across six key areas: early child devel-
the health gradient did not change despite        opment, education, employment and
overall improvements in health suggests           working conditions, having enough money
we need to look upstream to social determi-       to live on, healthy environments in which
nants of health inequity.”19                      to live and work, and a social determi-
  In addition, while all societies do have        nants approach to prevention. This in turn
social gradients in health, the slope varies. A   requires great investment in the health
European review of health inequalities that       system and in addressing the social determi-
looked at life expectancy at age 25 found         nants of ill health.
Central and European countries had low               To put this into context: to follow the
average life expectancy and big inequalities.     Nordic approach, as recommended by
Sweden, Norway and Mediterranean coun-            Marmot, New Zealand would need to lift
tries had long average life expectancy and        its public social spending (including health
smaller inequalities. Says Marmot: “We need       spending) from around 19% of GDP to
to move from an Estonian and Hungarian            around 25%, based in 2019 data.23
level of health inequity to a Nordic or Medi-
                                                    This would require political leaders,
terranean level... We [the Marmot Review]
                                                  policymakers and local management to
were convinced by the evidence that one of
                                                  relinquish old ways of thinking and stop
the secrets to good health in Nordic coun-
                                                  viewing health services in narrow financial
tries is a commitment to universalism.”20,21
                                                  terms, as an expenditure that needs to be
  Proportionate universalism, the approach        controlled. Rather, they need a broader
introduced in the Marmot Review, involves         social and economic perspective that
universal interventions that are imple-           recognises the overwhelming evidence
mented with a scale and an intensity that is      for investing in health for potentially
proportionate to the level of need across the     substantial social and economic gains.24–29
social gradient as opposed to solely targeting
                                                     As the United Nations’ High-Level
the least disadvantaged groups, a common
                                                  Commission on Health Employment and
response from governments focused on
                                                  Economic Growth points out that not only
cost-containment. This approach aims to
                                                  is investment in health good for popu-
improve the health of the whole population
                                                  lation health and wellbeing, but that the
while simultaneously improving the health
                                                  health sector is also a key economic sector,
of the most disadvantaged fastest.
                                                  a job generator and a driver of inclusive
                                                  economic growth.30
The solutions
   Proportionate universalism is gaining a lot      With the right level of investment to
of international attention, including in New      match the government’s vision for New
Zealand. A 2018 cabinet paper co-signed           Zealanders’ wellbeing, addressing chal-
by Prime Minister and Minister for Child          lenges such as those outlined above becomes
Poverty Reduction Jacinda Arden, proposing        much more achievable.
a child wellbeing strategy, explained: “A            The aim of improving the standards of
programme of joined-up (across sector and         living of those most in need would be greatly
life-stages) evidence-based interventions         advanced, for example, if benefits are set so
supported by the state... and delivered           people who depend on them are not living
according to proportionate universalism           in poverty, and if the minimum wage is set
principles, is empirically supported.”            at the same level as the voluntary “living
Consequently, the Child and Youth Well-           wage.”31

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   Pressures on young families would be           recruitment and retention, along with work-
lifted if the current policy of 20 hours of       force equity and diversity. Training places
free early childhood education (ECE) for          for health professionals must be increased,
3–5-year-olds is extended to 1–2-year-olds        based on a workforce census and current
as a first step towards addressing the cost       and forecast health and disability needs.
barriers to accessing ECE in New Zealand,            There is strong international consensus
which UNICEF reports is among the most            that, to meet the challenges facing today’s
unaffordable in a list of 41 countries.32         healthcare systems, traditional top-down
  In education, we recommend that policies        managerial leadership approaches are not
are introduced for schools to close the gaps      fit for purpose. A new type of leadership,
in educational performance between the            which is distributed to those with intimate
lowest and highest educational performers.        knowledge of the day-to-day workings of
Solutions include fairer distribution of          healthcare, is needed. These leaders—
high-quality learning across different            healthcare professionals—are best placed to
communities, increasing resources and             understand how to improve organisational
reducing stress in families and communities.      performance and influence care practices.
There is also an urgent need for significant        We recommend that health policies
improvement in health literacy and health         support a leadership model to nurture a
competencies, which should be addressed           collaborative culture and create conditions
early on in schools.                              in which responsibility, power and deci-
  In housing there is no silver bullet to solve   sion-making are distributed throughout
multiple issues. Many things need to happen       organisations and communities rather than
at once, but there is a common view that          a “top-down” hierarchy.
much greater public investment is needed             To help address ethnic health dispar-
along with stronger measures to ensure            ities, we call on the government to require
compliance with healthy homes standards,          public health and social organisations
including a mandatory rental housing              to demonstrate how they are supporting
“warrant of fitness.”                             health professionals to achieve culturally
   In the health sector, although free access     safe practice and address racism. Adequate
to GPs for under-14s has improved primary         resources must be provided for all
care access for children, many adults             government services to achieve cultural
continue to miss out, in part because of the      safety at every level, including sufficient
service fees. Those with the greatest need        staffing to allow time for learning and
(ie, the poorest groups, Māori and Pasifika)      self-reflection.
have higher preventable hospitalisation             To gain a better understanding of ethnic
rates than other groups. Accordingly, we          disparities and to monitor the effects of
recommend abolishing user charges for             government policies that impact on them,
primary care. Alternative funding arrange-        the collection, monitoring, analysis and
ments for GPs are needed that ensure              reporting of quality ethnicity data, from both
incomes are not negatively affected. Other        organisational performance and workforce
cost barriers (such as prescription charges,      perspectives, must be substantially improved.
travel costs and dental fees) also require
                                                     Other recommendations towards
attention, and solutions will necessarily
                                                  the overriding aim to achieve health
involve social welfare and other sectors.
                                                  equity by 2040 include ways to: improve
  Improving access to hospital care requires,     whole-of-government collaboration to
as a first step, regular independent and          effectively implement wellbeing policies;
comprehensive population surveys of unmet         strengthen actions concerning the impact
need for hospital services, with funding deci-    of climate change on health; improve
sions being based on meeting those needs.         government accountability for deliv-
Without such information, how can we              ering on policies; strengthen policies to
know how well the system is performing?           address the commercial determinants of
  A comprehensive health and disability           ill health; establish an independent health
workforce plan is critical for informing the      commission; and make health impact assess-
investment needed to address workforce            ments mandatory, supporting “Health in All
shortages, education, training, distribution,     Policy” approaches.

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                                                                             ISSN 1175-8716       © NZMA

   Finally, an important issue that is not         requires widespread public discussion.
included in the report (as it is targeted at the   Health professionals, who see the effects
government) concerns conference discus-            of the determinants of ill health every day,
sions around health advocacy. Feedback             are in a strong position to foster such public
from conference discussion groups reasoned         debate.
that governments will invest in and                  A key aim of Creating Solutions Te Ara
implement the transformational changes             Whai Tika, in addition to making recommen-
that are needed to improve health outcomes         dations to government, is to help stimulate
for all and achieve health equity if there         that debate. It is available on the ASMS and
is strong public support to do so, and this        CCHT websites.33

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                                                                               ISSN 1175-8716       © NZMA

                                          Competing interests:
  Creating Solution Te Ara Whai Tika was produced following the presentations and discus-
 sions from the virtual conference, Creating Solutions: Towards better health equity for all,
   held on 2-3 July 2021, the brainchild of Canterbury Charity Hospital trust founders Phil
Bagshaw and Dame Sue Bradshaw. We are especially grateful to them for their collaboration
 on these projects. We would also like to acknowledge the conference patron Sir Jerry Mate-
  parae GNZM, QSO, KStJ, the conference speakers and all the participants who took part in
 the discussions and provided valuable feedback. Finally, we wish to acknowledge Dr Lloyd
          McCann and Mercy Radiology who generously sponsored the conference.
                                           Author information:
                            Lyndon Keene: Health policy analyst, ASMS.
                              Sarah Dalton: Executive Director, ASMS.
                                          Corresponding author:
                       Lyndon Keene, C/- ASMS, PO Box 10763, The Terrace,
                           Wellington, 6143, Wellington, New Zealand

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                                                                                  ISSN 1175-8716       © NZMA
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