by Conan Tait

Submissions close on 9 December on the Pae Ora draft new Health Act

The Government is rushing through [as is usual for them] the biggest Health System Reforms in 40 years. All the DHB’s are going and there is a whole new system just for Maori — who will have two systems to use: the Maori System and the one “for other population groups” (as defined by Section 7).

The objection below has been filed. It points out serious problems. After reading it — here — you may want to object, too.

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This Bill creates two health systems. My children will benefit from having the use of two systems, a great double dip for them. As a parent I should rejoice that they are better off than the 84% of their fellow New Zealanders and their racially excluded classmates of other ethnicities whether Chinese, Indian or ‘other’. 

The provision of a health system, like the provision of an education system must, in a democracy, be based on criteria other than the purely political.

It was stated in Politics and Public Health: “Public health is grounded principally in science, and on objective/rational consideration of the evidence.” The author goes on to consider political interventions that displace that cornerstone. Like an Old Testament prophet, the author foresees exactly what is happening here: “Public health advocates also fear that the voice of public health scientists will be suppressed or discounted in the political process, particularly when evidence conflicts with positions that are grounded in non scientific considerations.” (My emphasis added) 

On the objectives of the Bill:

For convenience to the purposes of this submission, I set out particular objectives enumerated in the Bill: 

 (1) “achieve equity by reducing health disparities among New Zealand’s population groups, in particular for Māori” Section 3;

 (2) “to give effect to the principles of te Tiriti o Waitangi (the Treaty of Waitangi)” Section 5, 

(3) “requires health entities to be guided by the health system principles, which, among other things, are aimed at improving the health system for Māori and raising hauora Māori outcomes” (S6(a));

 (4) “by engaging with Māori to develop, deliver, and monitor services and programmes designed to raise hauora Māori outcomes” (s7(b))’

(5) undertaking promotional and preventative measures to protect and improve Māori health and wellbeing (s13). Section 18 relating to the Maori Health authority and exclusively the right of Maori is “to achieve the best possible health outcomes for whānau, hapū, and Māori in general”;

They are so general and ill-defined as to have no determinable meaning. In other words the politicians, the courts, the providers can interpret what is meant according to their own perceptions — a scenario for chaos.   Even the political objectives should be based on evidence and not be merely a policy imposition made at the behest of a highly effective small pressure group. Objective (2) is a purely political one.

General Grounds of Concern

The Bill runs counter to the underlying ethos of New Zealand culture — equality for all. I am fully aware that in our Post Modernist age, Enlightenment thinking and the age of reason are trashed as being part of the oppressive colonialist mindset and must be ignored. However, the average non-elitist kiwi still thinks that reason, usually thought of as common sense and the kiwi sense of decency and fair-play are evocations of the principles of the Enlightenment, some aspects of which are captured in the NZ Bill of Rights Act.

The controversial assumption that inequality of outcomes result from a ‘racist’ Health System

The intellectual contribution to the underpinnings of the Bill are summarised in excerpts from certain papers used as backgrounders for this bill. Jones R, Crowshoe L, Reid P, et al in Educating for Indigenous Health Equity: An International Consensus Statement. Acad Med. 2019; 94 (4) – 512-9 say this about NZ:  “Medical education has historically been complicit in furthering the goals of colonisation and perpetuating inequitable structures, processes and outcomes. As a first step, institutions need to acknowledge their historical and contemporary role in the colonial project, including acceptance of evidence that health professionals and health systems contribute to the maintenance of health inequities.”

All these claims are mere assertions and not based on evidence, emperical or otherwise. 

The dubious assumption that a Dual Health System will succeed in getting equality of outcomes

The Bill states that by providing a Maori Health Authority better outcomes are guaranteed. Again no data from studies are there to support it. However, there is plenty of evidence pointing to the likelihood of very little gain. In a comprehensive study (being a review of numerous reviews) Interventions to improve cultural competency in healthcare: a systematic review of reviews by M Truon. Y Paradies & Naomi Priest, the learned authors stated:

“Care must also be taken to avoid over-focusing on ‘culture’. Although cultural differences may worsen the problem of differential access and discrimination, broader factors such as poor education and poverty may play a greater role in the poorer health outcomes of some individuals and groups in the community [60]. However income and race/ethnicity as risk factors for health disparities can overlap and discrimination is often a driver of socio-economic disparities.” [61].

The benefit/cost effectiveness is not considered

In Interventions to improve cultural competency in healthcare (cited above) the experts state that a body, such as Parliament/Ministry must do the research. They emphasise how crucial it is.

“There is also need for research to examine the time and resources required to implement interventions in addition to identifying the most feasible and effective approaches [6]. This is particularly important for organizational or systemic approaches where cost-benefit/effectiveness is an important consideration”.

There is nothing in the White Paper or elsewhere that shows that any in depth cost-benefit-effectiveness research has been undertaken. In light of ill defined goals such a task would be impossible. 

The claim the “This [new dual system] will reduce system complexity” 

This claim is made in the preamble to the Bill with not a shred of evidence.  There is no cost-benefit analysis, again. However, the introduction of a highly complex new second health system is passed off with this rather astounding claim. 

Looking at specific clauses in the Bill

Lack of definitions

I will not detail all the definition problems, but these are some:

1. S5 “to give effect to the principles of te Tiriti o Waitangi (the Treaty of Waitangi)”.  Conspicuously absent is any attempt to define what the specific principles of the Treaty are that pertain specifically to healthcare provision for all New Zealanders. It is a carte blanche for the politicians to proclaim what they decide those principles are. 

The attempted definition in the Bill’s introduction says nothing to assist interpretation and ascertain meaning: “The Bill is intended to give effect to the principles of te Tiriti o Waitangi (the Treaty of Waitangi). A descriptive clause sets out the provisions that give effect to the Crown’s obligations. The Bill also sets out principles that will guide decision-makers, incorporating the concepts of the principles for the health system discussed by the Waitangi Tribunal in the WAI 2575 Inquiry”. 

2. ‘Equity’ used in Section 3 not defined. It is a meaningless phrase unless adequately contexturalised. Equity is defined in World Health terms — Equity recognizes that each person has different circumstances and allocates the exact resources and opportunities needed to reach an equal outcome. Is that is what is meant?  

3. ‘Equitable’ is used numerous times without definition. The Cambridge English Dictionary defines it thus: ” treating everyone equally; fair”. Does it mean ‘equally’ or ‘fairly’? There is a significant difference. Is it equality of mortality rates? Or making sure Maori visit their doctors as often as a pakeha hypocondriac? 

4. ‘Maori‘ is not defined. Will it be the definition of Māori ethnic population by Statistics NZ, “ethnicity is the ethnic group or groups a person identifies with or has a sense of belonging to.” Māori ethnic population is the population who identify themselves with Māori ethnicity. It is a measure of cultural affiliation (in contrast to race, ancestry, nationality, or citizenship).

Section 7 provides “the health system should provide opportunities for Māori to exercise decision-making authority on matters of importance to Māori and for that purpose, have regard to both—

(i) the strength or nature of Māori interests in a matter

(ii) the interests of other health consumers and the Crown in the matter. Giving priority to one race is abhorrent. This is amplified by saying the Crown and Health Consumers are twins for the purposes of the legislation.

Section 18 provides “to achieve the best possible health outcomes for whānau, hapū, and Māori in general”. There is no equivalent provision for non-Maori. And who determines ‘best possible’? The hospital that gives you second best, pharmac who gives you an unsatisfactory generic? The idea is fine if applicable to all — but what will the costs be?

Oh, Government of kindness and Wellbeing why are you going to pass an Act that purports to remove the current system — proudly identified by most Kiwi’s — because you have decided it is “racist” and worse, that it is founded on “white privileged colonialist health principles.” And so we will have a dual system based on race/culture.

Such a monumental change should go to the people. Your election manifesto breathed not a word of this. You have given mere days to make objections. You have not advertised it like you advertised Three Waters. That was propaganda as ruled by the Public Services Commissioner and had to be withdrawn. Is there transparent democracy in NZ? Make it so.

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Can the ‘Leftards’ not see the irony in promoting an answer to what they claim is a ‘racist’ system, one that actually is racist?  Obviously not. —Eds