The first stop on the Commonwealth Fund/AcademyHealth study tour this spring was Wellington, New Zealand. There’s always a danger during an experience like this to see in each of these countries what we wish for our own, but it is impossible to spend time with health care leaders and practitioners in New Zealand–or Aotearoa, as it is known locally–without seeing health equity as the foundation of recent reforms and integral to all facets of health and health care.
New Zealand has a population of five million people, 17 percent of whom are Māori; another 15 percent and nine percent identify as Asian or Pacific Islander respectively. Thirty percent of the country’s population live in its largest city, Auckland. The rest are spread out in smaller cities and rural areas across two main islands with a surface area equivalent to Colorado.
The 2022 Pae Ora (Healthy Futures) reforms reversed earlier legislation that had put health system decision making and health care delivery in the hands of 20 geographically based District Health Boards (DHBs). This was structurally challenging as each DHB had its own strategy to allocate funding to address local priorities. While theoretically more responsive to the needs of local communities, this structure did not mitigate health inequities and also led to data systems that were neither interoperable nor usable at the national level.
New Zealand’s Parliament created two new national organizations, Te Whatu Ora (Health New Zealand) and Te Aka Whai Ora (Māori Health Authority). Both organizations are separate from the Ministry of Health, which establishes overall policy and public health initiatives. Te Whatu Ora is responsible for commissioning providers to deliver care for all New Zealanders, while Te Aka Whai Ora works with the other two organizations to develop strategy for Maori health, monitor health system and health outcomes for Māori, develop the Māori health workforce, co-commission health and intersectoral services in collaboration with Te Whatu Ora, and host Iwi (tribe)-Māori Partnership Boards to assure services reflect local needs and traditions. Within the Health Ministry, a public health agency works nationally and regionally to achieve population health.
The foundation for public policy development in New Zealand is the country’s founding document, Te Tiriti o Waitangi, or the Treaty of Waitangi. Signed in 1840, the Treaty established the country with the expectation that the United Kingdom would protect the inhabitants: those of European ancestry as well as Māori people. Because the English and Māori versions of the treaty differed in consequential ways–the English version gives the British Crown absolute “sovereignty” over Māori lands while the Māori version indicates the Crown would have the less absolute “governorship”–there is an ongoing process of constitutional interpretation of the Treaty’s principles and resolution of claims brought by Māori against the Crown by a body known as the Waitangi Tribunal. Per the current reforms, the Treaty’s principles commit the government to equitable outcomes, assuring Māori engagement, co-design and decision-making, and support for the differing approaches and resources needed to address inequities.
At first, this structure might seem like a mechanism to separate health care for Māori from that available to the rest of the population. In fact, we repeatedly heard from Māori and non-Māori alike the message that, “What is good for Māori is good for all of Aotearoa.” Under the new system, there are health services in facilities intended to serve Māori, address inequities, and incorporate traditional approaches to healing, but they are available to any New Zealander. For those of us participating in the study tour, this integration of cultures was reinforced by the use of the Māori language in public meetings throughout our visit, beginning each site visit or meeting with a traditional Māori welcome and acknowledgement of ancestors.
There seems to be a surprising amount of consensus around the need for New Zealand to come to terms with its colonial past and embrace the cultural traditions of those who came to the country centuries before the first Europeans. For example, beyond the reforms themselves, there are significant efforts to adapt anti-racist and decolonizing efforts from elsewhere for use in New Zealand, such as anti-racism maturity models.
We gained only a surface-level understanding of these health care reforms, and by the admission of those with whom we talked, many of the technical and procedural aspects of implementing these changes are yet to be worked out. But New Zealand’s commitment to health equity as a core concept in all health care and its efforts to codesign and fund a system to realize it provide an important example for the United States.
For more about the 2023 study tour, check out this overview as well as AcademyHealth staff observations from Australia and Singapore.