A window on the quality of Aotearoa New Zealand’s health care 2019 – a view on Māori health equity, published by the Health Quality & Safety Commission, highlights a number of areas where change is needed in the health system.
The Window is an annual report
from the Commission and provides a snapshot of the quality of health care in this country. While equity has always been a component of the report’s analysis, this year’s report focuses solely on health equity for Māori.
Professor Alan Merry, chair of the Commission, says the report outlines why the health system must commit to equity and Māori health advancement. The sector needs to ensure services are where they are most needed and that they are appropriate to meet need, he says.
‘The report lays down a challenge for the health and disability sector to identify and remove institutional racism. Tools to do this include partnership models in decision making and a co-design approach to developing services with consumers and Māori communities.
‘We need to give our services, organisations and staff the knowledge, tools and official sanction to do this work.’
The report shows a pattern of inequities between Māori and non-Māori over their lifetimes.
‘From before birth through to old age we see inequity. Services are not as accessible for Māori, and even after services are accessed, Māori do not experience the same benefits as non-Māori,’ Professor Merry says.
Māori die on average seven years earlier than non-Māori, and are two-and-a-half times more likely to die from diseases that are potentially preventable with timely and effective health care. Māori get diseases commonly associated with older age earlier than non-Māori, and have higher rates of disability and multiple disability.
‘While broader social factors influence a person’s health, the patterns of inequities shown in this report suggest engagement with health services does not reduce inequity. In fact, the results suggest the health system creates further disadvantage for Māori.’
The report considers the harm for Māori from the intergenerational effects of colonisation, along with the failure to meet the requirements of Te Tiriti o Waitangi.
‘The presence of such inequities is highlighted in definitions of institutional racism. The challenge is moving from identifying these inequities, as this report does, to changing them.’
Professor Merry says while these issues are not new, the report’s data provides an evidence-informed discussion to support the health sector to understand where improvements need to be made.
‘Creating an awareness that institutional racism has severe effects – from psychological ill-health to physical harm to early death – is an important focus for improving the quality of health services.’
The report says a genuine commitment to Te Tiriti o Waitangi is required for the health system to achieve health equity for Māori.
‘The articles of Te Tiriti o Waitangi provide a framework to build and maintain appropriate long-term improvement.
‘Māori knowledge and worldviews, including Māori data and analysis approaches, can strengthen and broaden evidence bases for health care.
‘It is important Māori continue to use the health system while changes are made. This document reflects the start of a conversation involving Māori, the health sector, and other sectors,’ he says.
‘We expect a range of work to emerge from this discussion, both for the Commission and others.’
In the report’s foreword, Sir Mason Durie says ‘The report is clear. Action is needed on multiple fronts. A collective approach and a collective commitment are critical to remedying a situation that has lasted too long.’
Measures of access – services are less accessible for Māori
Barriers to health services prevent Māori from having the same access to health care as non-Māori. Multiple systemic factors result in measures that indicate:
Māori young people are tested for chlamydia more frequently than non-Māori, but not at a sufficiently high level in relation to underlying disease.
Hospital appointments are less accessible for Māori than non-Māori.
More adult Māori than non-Māori wait longer than three months for an appointment to see a specialist.
Cost is a much more frequent barrier to seeing a general practitioner (GP) for Māori compared with non-Māori, a trend that is not explained by the socioeconomic deprivation of the area people live in.
Measures of quality – services are not providing the same benefits for Māori
Even if services are accessed, the quality of those services is not equitable, as Māori do not benefit from them as much as non-Māori.
In childhood, suboptimal asthma control is seen in higher levels of prescriptions for reliever medications, with no preventer prescribed, potentially contributing to the 30 percent higher hospitalisation rate for asthma in Māori children.
In adulthood, Māori have twice the rate of hospital bed-days following an acute admission compared with non-Māori.
Māori adults consistently respond less positively than non-Māori to questions about their experience of communication with doctors and other hospital staff.
Compared with their non-Māori counterparts, older Māori have a higher number of hospital bed-days following a second acute readmission within a year.
Inappropriate prescribing of a combination of medications occurs at a much higher rate in older Māori than in older non-Māori, increasing the risk of acute kidney injury.
Following a hip fracture, the percentage of Māori having an operation on the day of admission to hospital or the next day has decreased steadily since 2013, while the rate for non-Māori has steadily improved.
Measures of improvement – efforts to improve health care do not always improve equity for Māori
National quality improvement programmes that address specific areas of harm to patients have achieved good results for non-Māori in many cases, but some have increased inequity in some areas for Māori.
The historical improvement in equity of childhood immunisation rates has reversed since 2014. Currently, rates are nearly 10 percentage points lower among Māori compared with non-Māori.
The reduced inequity for human papillomavirus vaccination appears to be driven by a worsening of completion of all vaccinations for non-Māori.
Glycaemic control monitoring of Māori with diabetes continues to be poorer compared with non-Māori.
Renal screening of people with diabetes is persistently lower in Māori compared with non-Māori.