Māori health inequalities reveal uncomfortable truths

I often think about a conversation I had with a friend while she was studying public health a few years ago. She had her eyes opened by epidemiology and health policy papers and shared with her parents about the unfair and unjust outcomes for Māori. It went down like a lead balloon. Her well-educated Pākehā parents believed New Zealand was an egalitarian society with a publicly funded health system and conditions where anyone could thrive. Therefore, the only explanation for poor outcomes was personal failure, right?

I don’t know how she navigated the conversation and whether she ever went back to the topic with her parents. But I often think of it because so much of the rhetoric on achieving better outcomes for all New Zealanders – Shane Reti talking about the new health targets, Winston Peters saying “colour doesn’t matter – delivery does”,¹ and David Seymour claiming programmes such as the Māori and Pacific Admissions Scheme at Auckland Medical School need to “stop discriminating”² – all have a core assumption that what works for one works for all, and that we all have the same chance to thrive.

I recently came across an article by Hayley Brown and Linda Bryder, which helps to give some historical context to this assumption. The article, Universal healthcare for all? Māori health inequalities in Aotearoa New Zealand, 1975– 2000,³ discusses the period from the passing of the Treaty of Waitangi Act 1975 to the establishment of the district health board system (through the New Zealand Public Health and Disability Act 2000) to understand why the “so-called universal, taxpayer-funded health system from 1938…has never delivered equitable outcomes for its Indigenous population”.

Māori have always tried to find ways to make the health system work. But despite their efforts, it has adapted to protect the status quo

Thanks to the Treaty of Waitangi Act, which established the Waitangi Tribunal, 1975 is a landmark year. But as Brown and Bryder point out, the reason this happened lies in years of Māori asserting their rights and protesting racism, including the 1975 land march (from Te Hāpua in the Far North to Parliament grounds) led by Dame Whina Cooper. However, this was not responded to through health sector policy responses by the National Government of the time. Nor had there been with the previous Labour Government, which in 1974, consulted on widespread changes to the health system and, in a 300-page document, only managed to use the word Māori 14 times, such was the lack of appetite for doing things differently.

It wasn’t until the 1980s that more substantive change at a national policy/health system level came – with the establishment of a standing committee on Māori health, the acknowledgement of the Treaty of Waitangi by the Department of Health and the setting up of “Māori-led” programmes within mainstream mental health services. As the authors point out, however, this did not lead to immediate improvements in outcomes (unsurprisingly, given the small scale of the change). What it did, though, is reflect “a gradual change of perspective” in agencies and “a new generation of politician entering Parliament…who were at least nominally more committed to addressing issues of equity and cultural competency”.

Again, the impetus for this came from Māori rather than the Government. And more than that, although the article does not really acknowledge it, it came from Māori women (the Māori Women’s Welfare League’s Rapuora report and consultation process directly leading to the articulation of Te Whare Tapa Whā as a Māori model of health and the establishment of the National Council of Māori Nurses in 1983). These developments and the work of Māori health leaders all laid the foundations for Māori health to be declared a departmental priority for the Department of Health following its sponsorship of Hui Whakaoranga.⁴

With the 1990s came another change in government for New Zealand and an even greater emphasis on the potential for the “market” to fix our health system.

Following on from a set of proposals by the newly elected National Party (Your Health & the Public Health, 1991) the focus was now on the role of the private sector in making individuals more (financially) responsible for their healthcare. There were “no arrangements for guaranteed Māori representation on the various new boards that were to be created”, but there was the increased possibility that Māori could be part of health service delivery.

Unfortunately, or perhaps by design, the health system did nothing to make it easy for these Māori services. Firstly, it was constantly reorganised over this period (from area health boards to regional health authorities and the roles of Crown health enterprises), making it hard to know how to build strong relationships (or who to have these relationships with).

Then, there were some of the hallmarks of health sector contracting with Māori – lack of consistent policy, short-term contracts, a competitive environment that, as Professor Tā Mason Durie said, “produced tensions and divisions that, far from creating efficiency, led to a multiplicity of poorly funded, underresourced authorities with high overheads and an incapacity to grapple with the wide-ranging demands of iwi development”.

By the year 2000, Māori health had worsened in many areas. The causes for this doubtlessly sit outside the health system itself – with the wider economy and economic policy having a disproportionate impact on Māori whānau. However, the health sector did not look at how it could change itself to better deliver for Māori. Instead, it looked to individuals and groups to solve their “own” problems and continued its long tradition of favouring those already doing okay.

In their conclusion, the authors argue that while the Treaty of Waitangi was embedded into the official policy (a sign of a commitment to Māori), there were impediments along the way – through a neoliberal government with market-driven policies – to the benefits of this being realised by Māori. Ultimately, more Māori health providers, who were not well supported, were no counter to the increased pressure on whānau regarding income, largescale unemployment, and other negative impacts on the social determinants of health.

I think this is why I find this historical context helpful. Firstly, it reminds us that Māori have always tried to find ways to make the health system work. But despite their efforts, it has adapted to protect the status quo (in terms of who benefits the most). This certainly felt like what happened with the Māori Health Authority, the result of decades of Māori thinking and activism, which built significant goodwill from Māori. But, in the end, the rhetoric of it going against the grain of our egalitarian, “good for all New Zealanders” identity (and an unreasonable expectation that it changed outcomes overnight) led to it being disestablished.

Secondly, the historical context reminds us that if we simply focus on the changes to the health system, we will miss the broader economic and societal changes that are likely to most impact Māori health outcomes, as they did in the 1990s.

The point of this is that those of us who recognise that egalitarianism is a myth need to keep our eye on, and advocate for, the wider social determinants of health because this will have more impact on outcomes than merely arguing for Te Aka Whai Ora to be reestablished.

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