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| Journal of the New Zealand Medical Association,
08-July-2011, Vol 124 No 1338
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Inequities in health and the Marmot Symposia: time
for a stocktake
Tony Blakely, Don Simmers, Norman Sharpe
Given the prospect of the general election in November, it
is timely for a stocktake on what has been done, and what we should do next, to
address inequities in health in Aotearoa New Zealand. To heighten the relevance
of this stocktake, Sir Michael Marmot is being hosted by the New Zealand Medical
Association (NZMA) next week (12 to 14 July 2011) for a series of activities and
symposia (convened by the Heart Foundation, and University of Otago, Wellington)
to discuss health inequities and ‘what next’.
Marmot has a long pedigree as one of the world’s
leading researchers on, and advocates to reduce, health inequities. He chaired
the World Health Organisation’s Commission on Social Determinants of
Health,1 led the recent ‘Marmot
Review’ of health inequalities in England and
Wales,2 and has just finished his tenure as the
President of the British Medical Association (BMA).
Following the BMA’s direct focus on health inequities,
the NZMA is now currently making this a major focus of its activity, and has
recently put out its position statement on health
inequities.3 The hosting of a visit by Marmot
is the next major step in the NZMA’s activity, with the purpose of
increasing public and professional awareness of inequities in health and
considering what concerted actions should occur next, especially those led by
Government.
This paper builds on position papers or ‘fact and
action sheets’ that the authors (and other colleagues) have prepared for
two symposia during Marmot’s visit, with the purpose of generating
discussion and debate. In particular, we focus on what we (i.e. New Zealand as a
whole, through the actions of Government, civil society and professional groups)
have done to address health inequities in recent decades, and what we should do
next. To that end, and to stimulate debate, we have identified a top 10 list
under each heading (Text Boxes 1 and 2).
We welcome debate on, and improvements to, our
listings—especially ‘what to do next’ (Text Box 2). (Comments
can be registered at www.uow.otago.ac.nz/HIRP-info.html.) In addition, as part
of the symposia activities, participants will be invited to submit their own
ideas on the next 10 most important steps this nation needs to take to reduce
the unacceptable and unjust burden of health inequities
What has been done to address health inequities in recent decades?There have been many activities, policies and programmes
that address health inequities in recent decades (Text Box 1). Many of these are
around processes, such as policies 4-7 that
flow through to affect health services provision and day to day practice.
Importantly, deprivation and ethnicity are now routinely used in funding
formulae for DHBs and primary health care. The Māori development kaupapa
since the 1970s, flowing through into Māori health providers and
influencing mainstream health service practice, has been critical.
Pacific health provider development has also progressed in
leaps and bounds. Many—if not just about all—major health promotion
programmes and screening programmes include tailored components for Māori
and Pacific audiences, for example Māori language components of Quit
campaigns. The One Heart Many Lives Programme has been a particular success in
heart health promotion focused primarily on Māori men. Specific tailoring
of programmes for lower socioeconomic groups, in addition to Māori and
Pacific (and Asian), is not as readily identifiable. Nonetheless, by using tools
such as the New Zealand Deprivation Index to target more deprived places,
activities such as service placement have been altered.
Whilst the recent Government has downplayed an explicit
focus on inequities (e.g. initiatives such as “better sooner more
convenient” and the push for integrated family health centres), it has
been possible to retain likely pro-equity initiatives such as “services to
increase access”, PHO funded and coordinated mental health services (such
as Wellington’s Compass Health “Primary Solutions”), and the
recent push on rheumatic fever prevention.
A big push has been made on research, monitoring and
evaluation – although perhaps not as much on programme evaluation as is
desirable. A big ticket item on intersectoral activity has been the retrofitting
and insulation of New Zealand’s housing stock—especially among lower
socioeconomic groups, and a programme that has enjoyed bipartisan support as a
win-win addressing both health (including health services
demand8) and energy efficiency. However, it is
challenging to identify other prominent intersectoral activities. Perhaps the
concept of Whanau Ora will help in breaking down much of the current siloed
thinking around the provision of healthy development and wellbeing.
Times change—and Governments change—as in
demonstrated by visiting the Ministry of Health’s website on health
targets (www.moh.govt.nz/healthtargets;
visited 8 June 2011). Three out of the six targets (immunisation, quitting
smoking, and better diabetes and cardiovascular disease services) are clearly
relevant to reducing inequities in health. However, the targets are reported by
DHB only—not by sociodemographics. You have to search the website archives
back to 2008-09 to find targets reported by ethnicity.
Much of the health workforce is acutely aware of the need to
address inequities, and likewise the backroom funders and planners, but ceasing
routine reporting on trends by sociodemographics leads to invisibility of the
issue, and eventual disappearance off policy and practice radars.
So what should we do next?Progress has been made. The gap between Māori and
non-Māori life expectancy has fallen back to 7–8 years—the same
level as in the early 1980s, and less than its peak of a nearly 10-year gap in
the late 1990s.9 But ongoing and concerted
policy effort will be required if we are to see both good improvements in
non-Māori life expectancy and even faster improvements in Māori (and
Pacific) life expectancy so as to close gaps. (For those interested in closing
gaps between New Zealand and other OECD countries, the answer is still likely to
be the same—maximising reductions in inequities may be the best way to
lift the average faster.)
Premature cardiovascular disease mortality has fallen
approximately 80% since 1970—but more rapidly in relative terms among
non-Māori so that the relative differences between Māori and
non-Māori have actually increased during this
period.9,10 Cancer inequalities are slowly
growing, in part a function of tobacco influences on incidence but also
generally worse survival among Māori across multiple
cancers.11–13
Diabetes, and its incubator obesity, and in turn its
progenitor of obesogenic environments, is the growing curse of our
times—and if unchecked will be a driver of widening inequalities. Mental
health and youth converge as a major issue for New Zealand, as evidenced by our
high youth suicide rates—again more so for Māori and lower
socioeconomic groups. A recent comprehensive report by the Chief Scientific
Advisor to the Prime Minister includes the following observation:
“New Zealand is a
temperate, peaceful, ethical and developed nation in which children should
flourish, yet it is actually one in which they experience some of the highest
rates of adolescent morbidity and mortality in the OECD.”
(p.54,14)
New Zealand is notorious for high child poverty rates and
poor social outcomes (including health) among our children and
youth—especially among a long tail of disadvantaged children and youth.
What to do? The above
report15 also comprehensively canvasses the
range of interventions in early childhood and adolescence to improve outcomes,
and notes that many interventions that we currently fund are (based on evidence)
likely to ineffective.15 For example, single
issue education campaigns in schools around drugs. Thus, improved programme
evaluation, more skilful scaling up of interventions that appear successful at
pilot stage, and redeployment of resources from ineffective to effective
programmes, are all ways to increase our “bang for our
buck”—and consistent with the ethos of the current political and
financial climate.
Moreover, quality early child programmes are often even more
effective among lower socioeconomic groups (e.g. family visiting programmes with
structured skills development for parents to manage and enhance child
behaviour). So, this is a potential win-win; redeployment of existing resources
to more effective programmes that also reduce inequities.
Second, and building on the word ‘quality’ that
is a priority of the current Government’s agenda (witness the Health
Quality and Safety Commission), lifting the quality of health service delivery
could be pro-equity. For example, there is some evidence of higher adverse
events in healthcare for Māori 16, that
may be addressed by quality systems.
Likewise, worse survival from cancer among lower
socioeconomic groups and Māori 11-13,17,18
hint at the likely role of improved access to health care as one way to reduce
inequities in health status. As treatments continue to improve in effectiveness,
the role of health services will probably increase in importance in the future.
And inequalities arising from, or failing to be prevented by, health services
are considered by most as being more of an inequity than an inequality (i.e.
more unfair), and therefore of higher policy importance to tackle. That all
said, the biggest gains in reducing health inequities are still likely to occur
outside of the treatment arms of health services.
Tobacco is one— if not ‘the’ example.
Making New Zealand tobacco-free is probably the single most important activity
to reduce inequalities in health. And such a goal is no longer considered just
the pipe dream of academics and radicals. Rather, the New Zealand Parliament (in
response to Māori Affairs Select Committee Report) has committed to a goal
of making NZ tobacco-free by 2025.19 20 We have
estimated that achieving this goal, compared to 2006 smoking rates continuing
unabated into the future, might result in 5 years gain in life expectancy for
Māori, 3 years for non-Māori, and a 2-year reduction in the life
expectancy gap – a triple
win-win-win.21
The future is also going to require joining up the
sustainability, climate change and health equity agendas. This will be
challenging. Nevertheless, substantial gains on multiple social bottom lines
could be achieved simultaneously. For example, improving the walkability of
neighbourhoods, reducing our reliance on the automobile, and shifting our
agricultural production to a lower saturated fat and lower carbon/methane
footing could generate many co-benefits.
The posturing and sabre rattling leading up to the next
general election is now well underway. We are being fed a diet of austerity,
echoing TINA (“There is no alternative”) of the 1980s. Some
reprioritisation is possible, need not lead to widening inequalities, and may
even be pro-equity.
For example, and deliberately off the two main Party’s
manifestos, by far and away the largest expenditure on welfare benefits in New
Zealand is that on superannuation—60% or $8 billion of the $13 billion
total welfare expenditure budget in 2009.22 Yet
the age of entitlement to government superannuation, 65 years, is the same as
that in 1899 when life expectancy was 25 years less! And we live in a society
with one of the highest child poverty rates in the
OECD.23
As a society we want to celebrate and protect the success of
our superannuation scheme, but not to the point of gross inequity compared to
younger (and more brown-faced, to be frank) people. Fair go— it is time
that the age of entitlement for superannuation is lifted (as it has in other
OECD countries), and allow some redistribution to other sections of our society,
particularly younger people.
Thus it is indeed timely for a stocktake to address health
inequities in Aotearoa New Zealand. We hope this Editorial will achieve the
objective of stimulating debate. We encourage the public and health
professionals to join in the discussion and debate at this opportune and crucial
time about ‘what to do next’ to improve the health of all New
Zealander’s, and reduce inequities.
Competing interests: None.
Author information: Tony
Blakely1; Don
Simmers2; Norman
Sharpe3
Acknowledgements: We
acknowledge the suggestions and comments on the ‘fact and action
sheets’ underlying this editorial (and Text Boxes 1 and 2 abstracted for
this Editorial) received from numerous colleagues.
Organisations supporting the visit of Marmot and related
activities include: the NZMA; Heart Foundation; University of Otago, Wellington;
School of Population Health, University of Auckland; Health Inequalities
Research Programme, UOW; Public Health Association; New Zealand College of
Public Health Medicine; and the Prior Centre.
Correspondence:
Tony Blakely, Health Inequalities Research Programme, University of
Otago – Wellington, PO Box 7343, Wellington, New Zealand. Fax: +64 (0)4
3895319; email: tony.blakely@otago.ac.nz
References:
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