No accident government health plan ignores needs of Māori

Our political atmosphere is in an unpleasantly divisive state

Last month’s announcements covered a health sector delivery plan, governance, “partnerships”, telemedicine, primary care funding, workforce (overseas-trained doctors, more training placements for doctors and nurse practitioners, incentives for primary care practices to recruit nurses), and lowering the age for free bowel cancer screening. Each of these is worthy of a deep dive, and there is excellent analysis on most of these announcements, much of it in New Zealand Doctor Rata Aotearoa. But I couldn’t ignore the general pattern. None of these announcements are focused on Māori health outcomes. So, what does this package mean for Māori?

The short answer: very little.

It is, of course, by design. Our political atmosphere is in an unpleasantly divisive state. The pursuits of equity and the improvement of outcomes for those who the health (and other) systems have failed have gone from being widely accepted aims to being positioned as counter to the very ideas of respect, dignity and equality before the law (when it comes to Māori anyway).¹ Aiming to have a workforce that reflects the population has also been deemed woke and identity politics.²

The Government’s chosen course of action is to stay quiet and not bring too much attention to Māori health or equity. This is certainly the impression you get, for example, when you look at the Health Delivery Plan, released on the Health New Zealand Te Whatu Ora website on 7 March,³ which notes that there are Māori and Pacific health providers but is otherwise silent on there being any differences in population health needs. But maybe the equitable benefits are hidden just below the surface.

Let’s investigate the delivery plan itself. One of its key features is that Te Whatu Ora will fund and set up arrangements with private hospitals to treat patients, especially for elective surgery.⁴ For this to benefit Māori, it would either need to increase access or quality of care. In writing about public-private partnerships for hospitals a year ago in a New Zealand Medical Journal editorial, Philip Bagshaw and others noted that while a public and private health system can happily co-exist (as currently in Aotearoa), this becomes blurred where private companies try and “capture trade” from the public system (for example, having long-term agreements to provide publicly funded elective surgery) or where governments are reducing their responsibilities for healthcare and share the costs, risks and benefits with the private sector.

The editorial highlights systemic review evidence that privatisation does not lead to quality improvement. It also concludes that international experiences show that public-private partnerships “almost invariably” turn short-term gains (like increased volumes) into long-term pain and “a slow decline into a prohibitively expensive healthcare system and an unacceptable disparity of standards of care between the haves and the have-nots”.⁵

In other words, those who need public services the most are also most likely to be failed.

Of course, it is not a given that non-government providers will do worse for Māori. After all, a move towards increased contracting in the health sector and the provision of services from private providers in the early 1990s created an environment where Māori providers could enter the business of health.

Thirty-five years later, Māori health providers are often seen as the gold standard in primary care for Māori patients. However, the focus on public-private partnerships for elective surgery (which requires private hospitals) rules out Māori providers from participating. So, all up, this focus of the health sector plan is unlikely to benefit Māori in either the short or long term.

Telemedicine, one of the big announcements in early March, is another area where the benefit to Māori is unlikely. Health minister Simeon Brown announced plans to create a 24/7 user-pays digital health service. Not much detail has been released on this, but Mr Brown has said it will be “game-changing”.⁶

Telehealth can increase access to care and can (eventually, once all the systems are in place) create savings, thus enabling resources to be redirected to other priorities, but it also comes with risks. Jason Gurney and others looked at some of the pros and cons of telehealth in 2021.⁷ In the wake of the COVID-19 response, they highlighted pros like the potential to reduce exposure to infectious disease and the possibility of building off Māori-run call centres.

However, they also emphasised the potential for telehealth to increase inequities as, even without user charges, it relies on a person having access to technology, a good quality phone or internet connection and a private space for a virtual appointment.

Telehealth also doesn’t cater well to those with more complex health needs, nor does it suit those who value and benefit from in-person healthcare. All up, it is hard to see telehealth having net benefits for Māori in the short to medium term. While there is a possibility of eventually benefiting because of efficiency gains, these will be some time away.

The last of the announcements I’ll look at in depth is the bowel cancer screening programme age-range extension. Its impact on Māori health is more straightforward. Funding for Māori and Pacific-focused bowel cancer screening has been redirected so that “everyone” aged 58 and over can benefit. It is the classic case of choosing between addressing the highest need or treating everyone exactly the same. One-size-fits-all won in the face of evidence.

If you need more background, free bowel cancer screening has been extended by two years.⁸ For years, Māori health experts have advocated for an extended age range for bowel cancer screening. This has been deemed too hard by successive governments, which talked of the pressure this would place on the overall health system.

It is predominantly Māori and Pacific populations who have bowel cancer at younger ages than non-Māori so, in line with the evidence, tentative steps (with some funding) were put into a gradual rollout of screening so Māori and Pacific people could access bowel cancer screening from 50 years of age (in Australia the eligibility is 45 years,⁹ so even 50 wasn’t as low as it could have gone).

As Nina Scott, Hei Āhuru Mōwai chair, said, the Government’s new plan “will increase inequities in access to screening and in bowel cancer death rates”.

Let’s revisit the question of what this package means for Māori. The longer answer is that it means very little in terms of improving outcomes and has the potential to make things worse before anything gets “better”.

As always, the solution to improving Māori health lies in rangatiratanga and Māori being able to deliver Māori solutions. And this, in turn, requires explicit moves that some might call woke while others would call sensible, empowering or – even – social investment.

Gabrielle Baker (Ngāpuhi, Ngāti Kuri) is an independent health policy consultant