Elsevier

Health Policy

Volume 122, Issue 8, August 2018, Pages 837-853
Health Policy

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

https://doi.org/10.1016/j.healthpol.2018.05.001Get rights and content

Highlights

  • Explicitly design quality of care and payment policies to achieve equity.

  • Hold the healthcare system accountable through public monitoring and evaluation.

  • Address determinants of health for individuals and communities across sectors.

  • Share power with racial minorities and promote indigenous peoples’ self-determination.

  • Have free, frank, fearless discussions about structural racism, colonialism, and white privilege.

Abstract

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries’ approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country’s culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples’ self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.

Introduction

The achievement of health equity remains an important but elusive goal. The World Health Organization (WHO) states that “Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities therefore involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes. They also entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms [1].” Braveman and colleagues argue that equity requires the removal of obstacles to health such as poverty, discrimination, powerlessness, and lack of access to good jobs with fair pay, quality education and housing, safe environments, and healthcare [2], [3], [4]. WHO’s Commission on Social Determinants of Health notes the importance of all parts of government and the economy, and the need to coordinate policies to advance health equity [5]. Two of the 17 United Nations Sustainable Development Goals are good health and well-being, and reducing inequalities [6]. Specific health targets include universal health coverage, and access to quality healthcare services, medications, and vaccines. Key equity targets are to “ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices and promoting appropriate legislation, policies and action in this regard [6].”

Beyond human rights and social justice, compelling economic arguments support the pursuit of health equity. For example, the societal economic costs of health inequities between Māori and non-Māori children are estimated between $NZ62 million to $NZ200 million [7], and in the United States (U.S.) eliminating racial inequities would have saved over $1 trillion dollars 2003–2006 in direct medical costs, indirect costs such as lost productivity, and costs of premature deaths [8]. In addition, absenteeism and presenteeism incur major costs to businesses. Increasingly U.S. companies employ sociodemographically diverse workers and seek health plans that demonstrate they provide high quality care to all patients to enable a healthy workforce [9], [10].

We compare Aotearoa/New Zealand (Aotearoa/NZ) and U.S. approaches to advance health equity to inform policy efforts. We contrast important drivers of inequities, and mechanisms and tools for solutions. Aotearoa/NZ and the U.S. have many fundamental similarities that increase applicability of lessons. Both countries are western democracies with health systems comprised of publicly and privately funded components, although of differing proportions. The largest racial/ethnic group is of settler European descent, and both countries struggle from colonialism and racism and associated adverse health consequences [11], [12], [13]. Both countries have broadly implemented neo-liberal policies and structures from the 1980s onwards, leading to increased privatization and a greater emphasis on personal responsibility with a concomitant reduction in state policy, regulation, and funding [14]. Neoliberalism may negatively impact social justice, and some have argued that the state must assure equity of opportunity [15]. The subsequent rising income inequality has been associated with decreased social capital and cohesion, increased stress, and poorer overall population health [16].

Yet, Aotearoa/NZ and the U.S. also have significant population and geographic differences, and fundamental differences in culture, history, and values. As of 2017, Aotearoa/NZ has 4.6 million residents compared to the U.S. population of 326.4 million [17], and Aotearoa/NZ is geographically 34 times smaller than the U.S. [18] The largest ethnic minority groups in Aotearoa/NZ are the indigenous Māori (14.9%), Asian (11.8%), and Pacific peoples (7.4%) [19], while in the U.S. the largest ethnic minority groups are Hispanic (17.8%), African-American (14.0%), and Asian (6.5%) [20]. Indigenous American Indians and Alaskan Natives (AIAN) comprise 1.7% and Native Hawaiians and Pacific Islanders 0.4% of the U.S. population [20].

This paper will focus on the healthcare system as well as on the integration of the healthcare system with social services [21], [22]. While numerous important inequities exist across factors such as disability and refugee status, we will focus on race/ethnicity and socioeconomic status/socioeconomic deprivation. Intersectionality, the combination of intersecting systems of oppression that perpetuate discrimination and disadvantage based on factors such as race/ethnicity, class, sex, and gender identity [23], is frequently associated with worse outcomes than any one dimension of disadvantage [24]. Systems of discrimination and oppression cannot be completely understood in isolation [25]. Therefore, our paper will especially highlight issues for indigenous peoples and racial/ethnic minority population groups as they are more likely to experience disproportionate socioeconomic deprivation.

While multiple ethnic groups in Aotearoa/NZ suffer from important health inequities (Pacific peoples and Asians, among others), we will focus on pervasive Māori:non-Māori inequities because te Tiriti o Waitangi (the Māori version of the Treaty of Waitangi) between Māori and the British Crown in 1840 is the contractual relationship on which Aotearoa/NZ is founded [26]. Thus, indigenous rights conferred by the Treaty to monitor government action and inaction around inequities are fundamental to the legal and moral existence and operation of Aotearoa/NZ. We analyze the Aotearoa/NZ system in more detail than the U.S. system because a more extensive literature exists about the latter.

Section snippets

Conceptual model

We developed a conceptual model that places policy levers to achieve health equity within cultural and historical contexts, building upon more detailed equity models and literature (Fig. 1) [3], [5], [27]. Our model identifies that health equity among more and less advantaged groups is affected by the healthcare system and fundamental social factors, including housing, education, employment, poverty, food insecurity, and the criminal justice system. Government and private policies that impact

Health inequities in Aotearoa/New Zealand and the United States

A large empirical literature in both countries documents significant health inequities across race/ethnicity and socioeconomic status for mortality, morbidity, quality of care, and patient experience [13], [31], [32], [33], [34], [35]. In Aotearoa/NZ, life expectancy at birth is 75.1 years for Māori, and 82.1 years for non-Māori, a gap of 7.0 years [33]. When comparing least socioeconomically deprived to most deprived areas, life expectancy at birth was greater by 7.5 years in males and 6.1

Discussion

Analysis of Aotearoa/NZ and U.S. approaches to advance health equity yield important lessons. Nations must authentically commit to achieving health equity. For Aotearoa/NZ and the U.S., a chasm exists between national aspirational goals for health equity and persistent health inequities in quality of care and outcomes. Inequities across race/ethnicity and socioeconomic status after decades of Māori health, ethnic minority health, and care of socioeconomically deprived groups being declared

Conclusions

Intrinsic and extrinsic motivation need to be optimized to achieve health equity [151]. Nations need to truly value and prioritize equitable health outcomes to create the policies, incentives, and governing structures that will allow best practices to occur, and to close the gap between high-level policy intent and equitable health outcomes in the population. Success will require free, frank, and fearless discussions about the causes of inequities and a society’s underlying values, measurement

Conflict of interest statement

Declarations of Interest: Dr. Chin co-chairs the National Quality Forum Disparities Standing Committee. He is also a consultant to the Patient-Centered Outcomes Research Institute (PCORI) disparities portfolio and co-directs the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office.

Prior Presentations: This paper was presented in part at the National Institutes of Health (NIH) conference “Type 2 Diabetes and Obesity Disparities: Enhancing Lifestyle and

Acknowledgments

Funding: Dr. Chin was a William Evans Visiting Fellow in the Department of Preventive and Social Medicine at the University of Otago, Dunedin. For this paper, he was partially supported by the Chicago Center for Diabetes Translation Research [grant number NIDDK P30 DK092949] and the Robert Wood Johnson Foundation Finding Answers: Solving Disparities Through Payment and Delivery System Reform Program Office. The sponsors had no role in study design, the collection, analysis and interpretation of

References (182)

  • United Nations Development Programme

    Sustainable development goals

    (2018)
  • C. Mills et al.

    The cost of child health inequalities in Aotearoa New Zealand: a preliminary scoping study

    BMC Public Health

    (2012)
  • T.A. LaVeist et al.

    Estimating the economic burden of racial health inequalities in the United States

    International Journal of Health Services

    (2011)
  • M.H. Chin

    Creating the business case for achieving health equity

    Journal of General Internal Medicine

    (2016)
  • D.R. Nerenz et al.

    A simulation model approach to analysis of the business case for eliminating health care disparities

    BMC Medical Research Methodology

    (2011)
  • D.M. Cormack et al.

    Investigating the relationship between socially-assigned ethnicity, racial discrimination and health advantage in New Zealand

    PLoS One

    (2013)
  • A. Dean

    Ruth, Roger and Me: Debts and Legacies

    (2015)
  • N. Daniels

    Justice, health, and healthcare

    The American Journal of Bioethics

    (2001)
  • M. Rashbrooke

    The inequality debate: an introduction

    (2014)
  • Worldometers Countries in the world by population (2017)

    (2017)
  • Nationmaster Country vs. country: New Zealand and United States compared: geography stats

    (2017)
  • N.Z. Stats

    Ethnic group (total responses) by age group and sex, for the census usually resident population count, 2001, 2006, and Censuses

    (2013)
  • United States Census Bureau

    ACS Demographic and housing estimates: American Community Survey 1-Year Estimates

    (2016)
  • M.K. Abrams et al.

    Integrating medical and social services: a pressing priority for health systems and payers

    Health affairs blog

    (2016)
  • J. Feinglass et al.

    Integrating social services and home-based primary care for high-risk patients

    Population Health Management

    (2018)
  • K. Crenshaw
    (1989)
  • J.Y. Tan et al.

    High stakes for the health of sexual and gender minority patients of color

    Journal of General Internal Medicine

    (2017)
  • K. Crenshaw

    Mapping the margins: intersectionality, identity politics, and violence against women of color

    Stanford Law Review

    (1991)
  • H.A. Came et al.

    Realising the rhetoric: refreshing public health providers’ efforts to honour Te Tiriti o Waitangi in New Zealand

    Ethnicity & Disease

    (2017)
  • M.H. Chin et al.

    A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care

    Journal of General Internal Medicine

    (2012)
  • M.J. Grant et al.

    A typology of reviews: an analysis of 14 review types and associated methodologies

    Health Information & Libraries Journal

    (2009)
  • M. Conway

    Environmental scanning: what it is and how to do it…. thinking futures

    (2016)
  • A. Wilburn et al.

    Environmental scanning as a public health tool: Kentucky’ human papillomavirus vaccination project

    Preventing Chronic Disease

    (2016)
  • Ministry of Health

    Tatau Kahukura: Māori Health Chart Book 2015

    (2015)
  • T. Blakely et al.

    Tracking disparity trends in ethnic and socioeconomic inequalities in mortality, 1981–2004

    (2007)
  • J.M. Rumball-Smith

    Not in my hospital? Ethnic disparities in quality of hospital care in New Zealand: a narrative review of the evidence

    New Zealand Medical Journal

    (2009)
  • P. Jansen et al.

    He Ritenga Whakaaro: Maori experiences of health services

    (2008)
  • Ministry of Social Development

    The social report 2016–Te purongo orange tangata

    (2016)
  • S.J. Olshansky et al.

    Differences in life expectancy due to race and educational differences are widening, and many may not catch up

    Health Affairs

    (2012)
  • E. Schneider et al.

    Mirror, mirror 2017: international comparison reflects flaws and opportunities for better US Health Care

    (2017)
  • E.L. Tung et al.

    Spatial context and health inequity: reconfiguring race, place, and poverty

    Journal of Urban Health

    (2017)
  • L. McGovern et al.

    The relative contribution of multiple determinants to health outcomes

    Health policy brief

    (2014)
  • A. Mikaere

    Colonising Myths-Maori Realities: He Rukuruku Whakaaro

    (2011)
  • H. Trask

    From a Native Daughter: Colonialism and Sovereignty in Hawai'i

    (1999)
  • C.P. Jones

    Levels of racism: a theoretic framework and a gardener’s tale

    American Journal of Public Health

    (2000)
  • R. Dunbar-Ortiz

    An indigenous peoples’ history of the United States

    (2014)
  • I. Wilkerson

    The Warmth of Other Suns: The Epic Story of America’s Great Migration

    (2011)
  • R. Takaki

    Strangers from a different shore: a history of Asian Americans

    (1989)
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