Equity: What we got was not a lot - Send in a Budget to match the rhetoric? Well, maybe next year

My tradition each May is to be more or less overwhelmed by information on government websites about the annual Budget.

This year’s was a bit different for us fans of Vote Health. As Manatū Hauora – Ministry of Health notes on its website, this year is the second year of a multi-year funding approach.

The approach is intended to give health sector entities some certainty of funding, or at least more certainty than an annual budget provides. So the Budget itself was always unlikely to have many surprises from a health perspective, since the big decisions were made last year.

Nevertheless, the annual Budget exercise brings out the detective in me and I somehow still spent hours on the various government websites and reading through tables trying to figure out if there are any grounds for changing my tune and claiming this is better than last year’s “middling” budget.

Here are the main results of my web-browsing labours.

Speaking of not much money for a lot of work, Te Aka Whai Ora gets around 2 per cent of Vote Health

Prescription fees are low-hanging fruit, making removal of them perfect for a Budget announcement. By this I mean it is easy to understand, comparatively uncomplicated to implement, and the added cost to the health system is fairly manageable.

Eliminating the $5 patient payment for prescriptions will cost the health budget $707 million for the next four years, but there will be around $25 million in savings per year for Work and Income, which offers some support for prescription costs through the Disability Allowance and Special Needs Grants.

Research tells us that these copayments have a substantial effect on patient risk of hospitalisation. From a purely cost point of view, this means the move has the potential for even more savings for the health system overall.

Free prescriptions aren’t really pro-equity. Access to good quality healthcare is inequitable in Aotearoa, and Māori and Pacific populations are more likely to not pick up prescriptions because of cost than the non-Māori, non-Pacific population.

Making all prescriptions free removes this cost barrier but raises the question, is a universal, free-to-all approach best or should it be more targeted and provide more support where it is most needed (sometimes called proportionate universalism)?

The only guaranteed winners in a universal approach, like the one adopted for prescriptions, are the people who already benefit from the health system the most. People who can get to a pharmacy easily and those enrolled with a GP and able to afford the appointment or the amount charged for a prescription over the phone or through ManageMyHealth.

There will likely also be benefits for the people or groups who own pharmacies, with fewer systems to run and more prescriptions being filled which, while potentially an efficiency gain, is hardly a pro-equity move.

The Budget 2023 website refers to $20 million from the multi-year budget being reallocated to improve health equity for Māori and Pacific peoples. Although it isn’t immediately obvious in the documents, this is for outreach services to “lift immunisation and screening coverage for Māori and Pacific peoples, and implement approaches and improvements in care and treatment that increase life expectancy of Māori and Pacific peoples”. I couldn’t find much more detail about this so all I can say is it looks like not much money for a lot of work.

Speaking of not much money for a lot of work, Te Aka Whai Ora gets around 2 per cent of Vote Health to carry out its role and partner with Te Whatu Ora. Te Whatu Ora gets 48 per cent of Vote Health.

Almost anyone who advocated for a Māori health authority argued it was essential that Te Aka Whai Ora had a significant budget. In the Waitangi Tribunal discussions in 2018 and 2019, rough calculations were based on a Māori health authority having a budget proportionate to the Māori population (so, around 17 per cent of Vote Health).

There are practical reasons why such a change wouldn’t happen immediately (including because Te Aka Whai Ora is a new entity, and because it partners with Te Whatu Ora over some of its commissioning instead of holding the budget for that commissioning). But I will be keeping an eye on this figure as we should expect it to increase significantly over time.

And, lastly, the biggest investment announced in this Budget is $1 billion to increase health workforce pay rates and boost staff numbers. I’m entirely behind fair pay for the health workforce, especially when it doesn’t discriminate between different parts of the workforce (it can’t be a surprise that I don’t support a Western medical hierarchy) and when it doesn’t disadvantage Māori health providers and those wanting to work for Māori health providers.

By the time you read this, you would have already heard or read a dozen or so hot takes on the Budget, and will be well aware “middling” is still an accurate description.

In an election year, I was hoping for more than middling, but the promise that next year’s Budget will have a three-year horizon to align with a three-year Te Pai Tata New Zealand Health Plan makes logical sense. I hope, however, it is better aligned to the health system rhetoric around equity and the intention behind the establishment of a Māori Health Authority.

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