Health Matters: Framing the full story of health by AssociationofSalariedMedicalSpecialists

Health Matters

Framing the full story of health

Cartoons: Sharon Murdoch

Introduction A senior doctor once said to me that health is created in the places people live and in the ways they live. This presents a very different lens on what constitutes good health. It forces us to recognise that good health starts in our homes, in our schools, and in our workplaces. It also starts with the air we breathe, the water we drink and the opportunities we are offered. Our members – senior doctors and dentists working in the public health system – spend most of their working lives caring for people. We know they are regularly treating preventable illness and disease which have their roots in social factors such as poverty, racism, poor housing, unhealthy food and environments. Reducing demand for health care in New Zealand also means targeting inequity. To do this, we need greater investment in areas which, at first glance, may not appear to be linked to health at all. In this document, we piece together well-recognised social determinants of health. We look at a range of existing data, and show how New Zealand could do much, much more to improve people’s health and wellbeing. If we really started walking the talk about investing in health we would have: • plentiful social housing • a living wage as the minimum income for all • joined up access to education, social support, and health care • free primary health care. Some of the solutions we propose require: • removing barriers to health care in the community and hospitals, such as user charges • a much stronger commitment from government to addressing the well-known determinants of ill health, such as poverty and poor housing • establishing a separate Minister and Ministry for Public Wellbeing. We know there are workforce shortages across the system. We know that we need more medical and dental specialists. These shortages mean many New Zealanders miss out on timely care. Some are missing out altogether. A comprehensive workforce strategy and recruitment and retention action plan is urgently needed. We see Health Matters as a pocket guide for the incoming government – and the next one – and the next. Because investing in health is a long-term project and cannot be crammed into three-year election cycles. Long term investment in the social determinants of health will reap rewards for us all. He waka eke noa… let’s invest in each other.

Sarah Dalton ASMS Executive Director

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At a glance The health system as it stands perpetuates unequal outcomes and is not accessible to a growing number of New Zealanders. Addressing unmet need is critical for achieving health equity. This Health Matters publication proposes ways to address these through: • removing barriers to health care in the community and hospitals, such as user charges. • a much stronger commitment from government to address the well-known determinants of ill health, many of which lie outside the health system.

Removing barriers to health care • Any aspirations towards health equity will fail while we continue to impose user charges for primary care, which have the effect of excluding those with the highest health needs. Reform is also needed to address the uneven distribution of general practitioners (GPs) in the country. • Workforce shortages across the system, including medical specialists, mean many New Zealanders miss out on timely care or miss out altogether. A comprehensive workforce strategy and recruitment and retention action plan is needed urgently.

Addressing the determinants of health • Environment: ‘One Health’ approaches are needed to address the failure to predict and halt the emergence of Covid-19, and the growing global health threat of antimicrobial resistance, along with the threats posed by pollution and climate change. • Cultural alienation and institutional racism: Despite many years of government intentions to address health inequities for Māori and Pasifika, compared with Europeans, stark inequities remain. The Health and Disability System Review’s proposals to address inequities for Māori are seen by some as lacking teeth. The Review made no recommendations specific to Pasifika needs. It is clear that the health system continues to operate in breach of Treaty of Waitangi obligations. • Poverty: Up to a third of child hospital admissions are potentially avoidable. That is close to 70,000 child hospitalisations per year, mostly from poorer families. • Education: This year’s UNICEF ‘report card’ on child wellbeing ranked New Zealand’s education indicators a middling 20th out of 41 OECD countries. Poor education is associated with poor health due to income, resources, unhealthy behaviours, deprived neighbourhood, and other socioeconomic factors. Cold, damp school buildings also contribute to child ill-health. • Employment: The main factor determining adequate income is participation in paid employment. Minimum wage rates are inadequate to cover basic necessities. There is growing support for a ‘Living Wage’. • Unhealthy living: Tobacco, alcohol, and unhealthy foods such as soft drinks and processed foods contribute to about one third of premature death and disability, with wide inequities by ethnicity and levels of disadvantage. The Health and Disability System Review recommendations will not achieve health equity (a key part of its brief) because action is required across the whole of government and non-government sectors, which was beyond the scope of the Review.

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A social and economic case for investment There is strong evidence that historical prescriptions for austerity have tended to exacerbate economic crises. Improved government investments in health and social services, on the other hand, can create economic growth in the short-term (and therefore play an important part in economic recovery) in addition to long-term benefits.

Key recommendations • Remove barriers to health care services • Adopt a ‘Health in All Policy’ approach • Establish a Minister and standalone Ministry for Public Wellbeing • Adopt ‘proportionate universalism’ to achieve health equity • Fund policies to match wellbeing goals

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Health starts with equity Māori Despite improvements in some health outcomes for Māori, stark disparities between Māori and non-Māori populations remain. This raises questions about the effectiveness of health-related policies to date. Currently, official statistics show that compared with the Pākehā population, Māori in general will be poorer, more likely to be living in deprived neighbourhoods, less likely to own their own home, and more likely to be living in over-crowded conditions. Further, Māori will experience higher levels of discrimination, are more likely to leave school with less than NCEA Level 1 qualification, are more likely to be unemployed, more likely to be convicted of a criminal offence, are more likely to go to prison than Pākehā for the same types of crime, are more likely to smoke, experience alcohol-related harm, and face greater barriers to health care.1, 2, 3, 4 These factors all have a significant impact on health outcomes for Māori. Further, they contribute to: • Māori life expectancy being more than seven years lower than that for non-Māori • Mortality rates being higher for Māori than for non-Māori at nearly all ages • Māori health status remaining unequal with non-Māori across almost all chronic and infectious diseases as well as injuries, including suicide.5, 6 This health inequity is characteristic for indigenous peoples in colonised countries, even when socioeconomic factors are considered. Underlying causes include the loss of land, language, and identity. While colonisation is often considered to be a historical event, the wider ramifications of colonisation are passed to current generations. For Māori, as with other indigenous peoples, the effects of colonisation are expressed as systematic social, political, historical, economic, and environmental determinants of health, accumulated during a lifetime.7 Within the health system itself, studies have consistently demonstrated that doctors treat Māori differently from non-Māori, to the detriment of Māori. This bias results in the failure of Māori to receive cardiac revascularisation procedures even when clinical need is much greater, as well as evidence of poorer outcomes following stroke, obstetric intervention, higher rates of heart failure and asthma.8

“Whilst moral injury of doctors is a legitimate workplace concern, we must not forget the infinitely worse moral injury, indignity and hopelessness that parents experience every time they see their children suffer from illnesses caused by relentless poverty and entrenched systemic disadvantage.” – Paediatrician

In primary care, GP consultation times have been found to be shorter for Māori, and Māori patients are referred less often for further investigations than non-Māori.9 A six-year study on 89,000 New Zealand public hospital patients found Māori were more likely to be readmitted or to die within a month of leaving hospital than Pākehā. After adjusting for age and sex, the odds of readmission or death were 19% higher for Māori.10 Initiatives that have been designed to improve the health of Māori include the establishment of Māori health care providers, cultural competence training, community-led programmes, and a health literacy focus.

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However, according to some observers these health initiatives are often constrained by systemic inertia and an apparent ambivalence towards addressing the underlying causes of Māori health inequities.11 These underlying causes include income and poverty, employment and occupation, educational attainment, housing and discrimination. Health-damaging behaviour is likely to occur among those who are not financially or psychologically secure or live in deprived neighbourhoods.12 The Health and Disability System Review has proposed a Māori Health Authority to be responsible for monitoring and reporting on Māori health outcomes, managing Māori workforce initiatives, controlling Māorispecific innovation funds and advising on how to redress inequities in the system. The details of how it would work are yet to come. The proposal has been criticised, including from members of the Review panel, for lacking teeth.13 300

Māori

Pacific

Non Māori, Non-Pacific

Rates per 100,000 population

250

200

150

100

0 2009

2010

2011

2012

2013

2014

2015

2016

Years

FIGURE 1: AMENABLE MORTALITY RATES PER 100,000 POPULATION, AGES 0-74, 2009-2016 Rates per 100,000 age standardised to WHO world standard population Source: Ministry of Health 2019

Ministry of Social Development. The Social Report 2016 - Te pūrongo oranga tangata, MSD, June 2016. Treasury. Statistical Analysis of Ethnic Wage Gaps in New Zealand, Analytical Paper 18/03, September 2018. Ministry of Justice. Data Tables 2010-2019. Controller & Auditor-General. Summary of our Education for Māori Reports, October 2016. Ministry of Health. 2019. Wai 2575 Māori Health Trends Report. Wellington: Ministry of Health. Statistic NZ. Ngā Tūtohu Aotearoa – Indicators Aotearoa New Zealand, 2020. Hobbs M, Ahuriri-Driscoll A, et al. Reducing health inequity for Māori people in New Zealand (corresp.) The Lancet Vol 394 November 2, 2019. ASMS. Path to Patient Centred Care, Health Dialogue Issue 15 March 2018, pp26-31. Ibid. Rumball-Smith J, Sarfati D, Hider P, Blakely T. ‘Ethnic disparities in the quality of hospital care in New Zealand, as measured by 30-day rate of unplanned readmission/ death’. Int J Qual Health Care. 2013 Jul; 25(3): 248–54. 11. Hobbs et al (2019). 12. ASMS (2018). 13. Health and Disability System Review. 2020. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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Health starts with equity Pasifika Compared to all other ethnic groups in New Zealand, Pasifika have significant and persistent disparities in health outcomes. Pasifika are more likely to live in neighbourhoods of high deprivation, have the lowest household incomes, higher unemployment rates, the lowest rates of home ownership, and the highest rates of household crowding.1, 2, 3 These disparities in health and poor health service outcomes for Pasifika have persisted for more than two decades. The rate of potentially avoidable deaths is twice as high in Pasifika (47.3%) compared to non-Māori, non-Pasifika (23.2%). Rates of hospitalisation for Pasifika children are higher than all other ethnic groups for acute and chronic respiratory and infectious diseases and serious skin infections. The rate of hospitalisation for rheumatic fever is 50 times higher in Pasifika children than Pākehā children.4 There have been no significant improvements in rates of avoidable hospital admissions for Pasifika children over the last 10 years. Rates for Pasifika adults have improved slightly but remain well above non-Māori, nonPasifika rates (Fig 2). Pasifika also report high rates of unmet need for primary health care - 36% of Pasifika adults compared with 30% of Pākehā adults. Most of this unmet need is related to costs to see a GP.5 The Health and Disability System Review’s final report acknowledges many of these health inequities yet offers no recommendations specific to Pasifika to address them. This failure has been considered its “most important omission”.6

Standardised ASH rate per 100,000 population

10,000

Other

Māori

Pacific

9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 2015-16

2016-17

2017-18

2018-19

2019-20

Years

FIGURE 2: STANDARDISED AMBULATORY SENSITIVE HOSPITALISATION (ASH) RATES, 45-64 AGE GROUPS, 2015-JUNE 2020 Source: National Service Framework Library 2020

1. 2. 3. 4. 5. 6.

Pacific Perspectives. Health System Review – Pacific Report, Pacific Perspectives Ltd, July 2019. Health and Disability System Review. 2020. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR. Duncanson M, Richardson G, Child Poverty Monitor, NZ Child & Youth Epidemiology Service, University of Otago 2019. Pacific Perspective (2019) Ministry of Health. New Zealand Health Survey 2018/19. Tukuitonga C. Health review leaves Pasifika out in the cold, Newsroom 22 June 2020

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Health starts with addressing poverty Up to a third of child hospital admissions in New Zealand are potentially avoidable.1 That is close to 70,000 child hospitalisations per year, mostly from poorer families. If all those hospitalisations were reduced to equal those of the least deprived quintile, in 2018/19 avoidable hospitalisations would have been reduced by nearly 40%. While there have been some improvements since 2014/15, the most recent three years have seen virtually no progress (Fig 3).2 The New Zealand Health Survey 2018/19 shows that of the children in the poorest deprivation quintile:3 • Nearly one in four do not eat breakfast every day • One in eight eat a fast-food meal three or more times a week • Nearly one in five consume fizzy drinks three or more times a week • Nearly one in five have had teeth removed due to decay • 45% are reported as being overweight or obese Hospitalisation rates for respiratory conditions for children living in areas with the highest deprivation levels are three times as high as the hospitalisation rates for children living in areas with the lowest deprivation levels. In 2015/16, 22% of children ages 0-15 lived in households reporting that food ran out often or sometimes.4 In 2018 there were an estimated quarter of a million children (23%) living in households with disposable equivalised income less than 50% of the median after housing costs.

”I have seen diseases in New Zealand children which I have never seen before in my home country like rheumatic fever and bronchiectasis which are directly linked to poverty.” – Paediatrician

There were approximately 148,000 children (13%) living in households that were unable to afford six or more essentials for a decent standard of living.5 An estimated 65,000 children (6%) were living in households experiencing severe material hardship with a lack of nine or more essentials for a decent standard of living.6 The Government has established child poverty reduction targets for each primary measure of child poverty. Significant acceleration in child poverty reduction is necessary for the Government to meet these targets.7 The Government also launched a Child and Youth Wellbeing Strategy in 2019 taking a ‘proportionate universalism’ approach to achieving equity, which recognises that all children and young people need support regardless of their circumstances, but that some need more support than others. (Fig 4).8 Proportionate universalism is recommended by ASMS as an approach to achieving health equity for the whole population.

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120

2014/15

2015/16

2016/17

2017/18

2018/19

Rates per 1,000 children

100

0 Q1

FIGURE 3: STANDARDISED POTENTIALLY AVOIDABLE HOSPITALISATION RATES PER 1,000 CHILDREN AGED 0-15 BY DEPRIVATION QUINTILES (2014/15 - 2018/19) Source: Child Poverty Related Indicators Report, July 2020

Hospitalisations per 1,000 children

80 70

HOW ‘PROPORTIONATE UNIVERSALISM’ AIMS TO ACHIEVE HEALTH EQUITY (INDICATIVE)

60 50 40 30 20 10 0 Q1

FIGURE 4: STANDARDISED POTENTIALLY AVOIDABLE HOSPITALISATION RATES PER 1,000 CHILDREN DEPRIVATION QUINTILES 2018/19 Source: Child Poverty Related Indicators Report, July 2020

1. 2. 3. 4. 5. 6. 7. 8.

Hobbs M, Tomintz M, et al. Investigating the rates and spatial distribution of childhood ambulatory sensitive hospitalisations in New Zealand. GeoHealth Laboratory: A report commissioned by the Ministry of Health, October 2018 Ardern J. Child Poverty Related Indicators Report, Department of the Prime Minister and Cabinet, July 2020 Ministry of Health. New Zealand Health Survey 2018/19. Ardern J. Child Poverty Related Indicators Report, Department of the Prime Minister and Cabinet, July 2020. Duncanson M, Richardson G, et al. Child Poverty Monitor, New Zealand Child and Youth Epidemiology Service, University of Otago, 2019. Ministry of Health. Health and Independence Report 2018: Ministry of Health, June 2020. Duncanson M, Richardson G, et al. Child Poverty Monitor, New Zealand Child and Youth Epidemiology Service, University of Otago, 2019. Child and Youth Wellbeing Strategy 2019, Department of the Prime Minister and Cabinet, Aug 2019.

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Health starts in our environment The World Health Organisation (WHO) defines environment, as it relates to health, as “all the physical, chemical, and biological factors external to a person, and all the related behaviours”.1 Environmental health consists of preventing or controlling disease, injury, and disability related to the interactions between people and their environment. Maintaining a healthy environment is central to increasing quality of life and years of healthy life. Environmental factors are diverse and far reaching. They include: • exposure to hazardous substances in the air, water, soil, and food • natural and technological disasters • climate change • occupational hazards • the built environment Poor environmental quality has its greatest impact on people whose health status is already at risk. Therefore, environmental health must address the societal and environmental factors that increase the likelihood of exposure and disease.2 The adverse health effects of many environmental issues, particularly those associated with the growing threat posed by climate change, emphasise the critical need for whole-of-government policy approaches. Alongside the health impacts of climate change, recent experiences with Covid-19 and growing concern with antimicrobial resistance highlight the need to be better prepared for future global health crises and reinforce the critical importance of improving collaboration and effective resourcing.

“Health and wellbeing are not created in doctors’ offices or in hospitals. I am an intensive care doctor, but I know that for most people who end up with me they do so because of an embedded series of failures beforehand.” – ICU Specialist

One specific approach which promotes interdisciplinary collaboration on environmental health issues is ‘One Health’. Adopted by many major health agencies including the WHO, the focus of One Health is a whole of ecosystem approach to health. In recent times, this joined up approach continues to garner support in light of failures to predict and halt the emergence of Covid-19.3 Three areas of work have been highlighted as requiring a One Health approach: • food safety • the control of zoonoses (diseases that can spread between animals and humans) • combatting antibiotic resistance In the New Zealand context, the threat of growing antibiotic resistance continues to be a significant area of concern. In heavily redacted government documents released to the New Zealand Herald in 2019, officials advised Ministers that: “[antibiotic resistance] is a ‘One Health’ issue which requires a coordinated response across the human health, animal health, food and agricultural sectors. If we do not successfully address this threat now, there are likely

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to be wide-ranging impacts for New Zealand. The ability to treat infections in humans, animals and in the wider agriculture sectors will affect all New Zealanders, but the most vulnerable will be Māori and Pacific peoples, children, the health-impaired and the elderly.”4, 5 Attempts to develop and promote One Health approaches in New Zealand operate from a network of medical and veterinary researchers known as One Health Aotearoa. They face challenges that “demand new ways of collaboration across boundaries and knowledges”.6 One Health Aotearoa’s priorities are antimicrobial resistance, freshwater quality, and emerging infectious diseases. They say that climate change and ecosystem disruption is a cross cutting theme to which the three projects need to respond. An ‘action plan’ to improve infection control and public education concerning antimicrobial resistance in New Zealand was launched in 2017 but by 2018 was already being scaled back due to lack of funding. The action plan is funded from within existing budgets of the Ministry of Health and Ministry for Primary Industries. No increases in funding to address the shortfall are indicated in either the 2019 or 2020 Budgets.

1. 2. 3. 4. 5. 6.

World Health Organisation. Preventing disease through healthy environments. Geneva, Switzerland: WHO; 2006, p22 The Office of Disease Prevention and Health Prevention. https://health.gov/about-odphp Garine-Wichatitsky Binot M, et al. Will the COVID-19 crisis trigger a One Health coming-of-age? The Lancet Vol 4, e377-8, September 2020. Jones N. Exclusive: Kiwi war on superbugs downsized NZ Herald, 5 July 2019. Ministry of Health and Ministry for Primary Industries. Aide-memoir to the Ministers of Health and Primary Industries: New Zealand’s Antimicrobial Resistance Action Plan: Progress and priority for delivering over the next four years, 19 October 2018 Harrison S, Baker M, et al. One Health Aotearoa: a transdisciplinary initiative to improve human, animal and environmental health in New Zealand, One Health Outlook (2020) 2:4.

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Health starts with education Education is a fundamental social determinant of health. Reducing health disparities and improving population health can only be accomplished through a comprehensive understanding of the health benefits conferred by education.1 Poor education is associated with poor health due to income, resources, unhealthy behaviours, deprived neighbourhoods, and other socioeconomic factors. In turn, poor health is associated with educational setbacks and interference with schooling through learning disabilities, absenteeism, or cognitive disorders.2, 3 Breaking this circle of disadvantage requires cross-sector national policies that recognise the dual role of education — as a driver of opportunity as well as a reproducer of inequality.4 The health benefits of education are at the grass roots level - enabling people to develop a broad range of skills and traits that predispose them towards improved health outcomes. People with more education are likely to have better health literacy, live longer, experience better health outcomes, practice health promoting behaviours, and obtain timely health check-ups.5, 6 Countries that adopt policies for the improvement of education also reap the benefits of healthy behaviours such as reduced rates of smoking and obesity.

Unhealthy school buildings Cabinet papers released in 2018 show a third of school buildings in New Zealand did not meet optimum standards for health and hygiene. A similar number fell short of Ministry of Education standards for lighting, temperature and acoustics.7 Later that year the Education Minister Chris Hipkins was reported as saying that due to years of under-investment at least $200 million worth of school buildings were not fit for purpose and would have to be knocked down.8 He said the government wanted to bring all school buildings up to scratch by 2030 and that would cost about $1 billion a year for the following 10 years. As recently as September 2020, a New Zealand Herald report highlighted the health hazards of damp and mouldy schools raising questions as to how such conditions had been allowed to develop.9 This year’s UNICEF ‘report card’ on child wellbeing ranked New Zealand’s education indicators a middling 20th out of 41 OECD countries.10

Raghupathi, V., Raghupathi, W. The influence of education on health: an empirical assessment of OECD countries for the period 1995–2015. Arch Public Health 78, 20 (2020). 2. Ibid. 3. Hahn RA, Truman BI. Education Improves Public Health and Promotes Health Equity. Int J Health Serv. 2015;45(4):657–78. 4. Zajacova A, Lawrence E. The Relationship Between Education and Health: Reducing Disparities Through a Contextual Approach, Annu. Rev. Public Health 2018.39: 273-289 5. Luy M, Zannella M, et al. The impact of increasing education levels on rising life expectancy: a decomposition analysis for Italy, Denmark, and the USA, Genus, (2019) 75:11 6. AMA. Health in the Context of Education – 2014. Australian Medical Association, 6 May 2014. https://ama.com.au/position-statement/health-context-education-2014 7. Gerritsen J. Third of school buildings fall short on health and hygiene, Radio NZ, 9 July 2018. 8. NZ Herald. $200m in school buildings unusable, will have to be demolished, NZ Herald, 10 April 2018. 9. Fallon V. ‘Would the PM send Neve here?’: The sodden horror of a decile 1 school, Stuff, 5 September 2020. 10. UNICEF Innocenti, ‘Worlds of Influence: Understanding what shapes child well-being in rich countries’, Innocenti Report Card 16, UNICEF Office of Research – Innocenti, Florence, 2020 1.

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Health starts in our homes The quality and affordability of housing are key contributors to health and wellbeing. New Zealand has the least affordable metropolitan housing among six comparable countries.1 An average house costs six to eight times more than the average household income. Three times an average household income is considered affordable.2 Housing costs continue to rise faster than incomes and keep families trapped in cycles of poverty with insufficient income to meet other basic needs.3, 4 Housing unaffordability means more people rent. Rental dwellings are more likely to be cold, damp, mouldy, and in greater need of repair.5 An estimated 600,000 New Zealand homes are poorly insulated, and many are inadequately heated.6 Table 1 shows the number of housing-related hospitalisations experienced each year in New Zealand. Statistics also show poor housing conditions including overcrowding and associated disease transmission contribute to a further 116,000 injuries, some of which will require hospital admission.7

“No matter how good I am as a paediatrician, no matter how good our nurses are, no matter how good the inpatient care in hospital can be, I am discharging three in every four kids back to cold and damp homes. Which is the main reason they ended up in hospital in the first place.” – Paediatrician

Around 6,000 children are admitted each year for housing-sensitive hospitalisations. These children are nearly four times more likely to be re-hospitalised and 10 times more likely to die in the following 10 years than other children.8 Various initiatives have been introduced to address the lack of housing and poor housing standards. The general consensus from housing commentators is that more and better housing is needed, along with greater, more sustainable funding to improve current poor standards. TABLE 1: ESTIMATED ANNUAL HOUSING-RELATED HOSPITALISATIONS

Cause

Number

Bed nights

Attributed to household crowding (est. 10% of population)

1,005

3,612

Attributed to damp/mouldy homes

6,276

36,649

625

1,834

7,906

42,095

Attributed to cold homes Total Source: Motu Economic and Public Policy Research and the University of Otago, 2019

1. 2. 3. 4. 5. 6. 7. 8.

UK, USA, Australia, Canada, Ireland, New Zealand (Hong Kong and Singapore were also surveyed) Demographia. 16th Annual Demographia International Housing Affordability Survey: 2020. Riggs L, Howden-Chapman P, et al. New Zealand’s Burden of Disease from Housing, Motu Economic and Public Policy Research; University of Otago, Wellington School of Medicine, Department of Public Health, March 2019. Ministry of Social Development (MSD). The Social Report 2016, Te pūrongo oranga tangata, MSD, June 2016. Riggs et al (2019) Telfar-Barnard L, Bennett J, et al. Evidence base for a housing warrant of fitness, SAGE Open Medicine Volume 7: 1–7, 2019. Riggs et al (2019) Walls J. Housing Minister Phil Twyford unveils new standards for all NZ rental homes, NZ Herald, 24 February 2019.

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Health starts with our lifestyle Unhealthy commodities – tobacco, alcohol, and unhealthy foods such as soft drinks and processed foods that are high in salt, fat, and sugar – are leading risk factors for chronic non-communicable diseases. These commodities contribute about one third of the overall preventable health loss (through premature death and disability) in New Zealand, with wide inequities by ethnicity and levels of disadvantage. The following references the work of Health Coalition Aotearoa.1

Smoking The number of New Zealanders who smoke has dropped significantly over the past 20 years. However, tobacco use continues to take a catastrophic toll on New Zealanders, resulting in considerable suffering, debilitating diseases, and premature death. While overall smoking rates are reducing in New Zealand, large disparities remain. New Zealand is not on track to achieve the Government’s target of 2025 Smokefree Aotearoa, set at less than 5% smoking prevalence.

Alcohol At least 5% of premature death and disability in New Zealand is attributable to alcohol. Alcohol also reduces wellbeing through its social effects. New Zealand is not on track to achieve a WHO target of a 10% relative reduction in the harmful use of alcohol.

Unhealthy food Unhealthy diet and high BMI (overweight or obese) are the largest preventable risk factors in New Zealand. Jointly they account for 17.5% of premature death and disability. New Zealand is not on track to meet the WHO targets of no increase in adult obesity and diabetes from 2010 levels. Further, the consumption of sugary drinks is associated with dental caries, as well as weight gain and obesity. Dental caries is a continuing and significant health problem in New Zealand.

High BMI (obesity) 9% Unhealthy diet 9% Alcohol 5%

Tobacco 9%

Other 68%

FIGURE 5: PREVENTABLE PREMATURE DEATH AND DISABILITY IN NEW ZEALAND

1. 2.

Health Coalition Aotearoa. https://www.healthcoalition.org.nz/ New Zealand Dental Association. https://www.nzda.org.nz/public/our-initiatives/sugary-drinks

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Health starts with employment Participation in paid employment is an important determinant of health. In addition to providing income, employment enhances social status and improves self-esteem, provides social contact and a way of participating in community life, and increases opportunities for regular activity, which all help to enhance individual health and wellbeing.1 However, being able to enjoy these benefits depends on an income which is sustainable. New Zealand’s wages are low among comparable countries (Fig 6). Many workers are on minimum wage rates which is currently $18.90 an hour before tax. Some social researchers have assessed this as inadequate to cover basic necessities, sparking the ‘Living Wage Movement’. The current minimum ‘Living Wage’ is $22.10 an hour, which some employers have committed to paying.2, 3, 4 While well-paid employment is important for good health, some workplaces expose workers to health risks such as injury – an issue that is not improving (Fig 7).

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70,000 60,000

PPP US$

50,000 40,000 30,000 20,000 10,000

Switzerland

United States

Netherlands

Australia

Norway

Germany

Canada

United Kingdom

Sweden

France

New Zealand

FIGURE 6: AVERAGE ANNUAL WAGE IN 11 COUNTRIES, 2019 (PURCHASING POWER PARITY5 USD) Source: OECD Statistics 2020

14.0 12.0

Injuries/1000 FTEs

10.0 8.0 6.0 4.0 2.0 0 2010

2011

2012

2013

2014

2015

2016

2017

2018

FIGURE 7: CLAIMS FOR WORK-RELATED INJURIES RESULTING IN MORE THAN A WEEK AWAY FROM WORK Source: ACC 2020

1. 2. 3. 4. 5.

National Health Committee. The Social, Cultural and Economic Determinants of Health in New Zealand: Action to Improve Health. A Report from the National Advisory Committee on Health and Disability (National Health Committee), June 1998. King P, Waldegrave C. Report of an investigation into defining a living wage for New Zealand, Family Centre Social Policy Research Unit, commissioned for The Living Wage Campaign, December, Living Wage Aotearoa New Zealand, 2012. Waldegrave C, King P, Urbanovรก, M. Report of the Measurement Review for a New Zealand Living Wage, Living Wage Movement Aotearoa, 2018. Waldegrave, C. Living Wage Rate Update 2020/21. Purchasing Power Parity equalises the purchasing power of different currencies, taking into account the relative cost of living and inflation rates in different countries.

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Health starts with access to primary care Barriers to primary care result in barriers to hospital care. While free access to GPs for under-14s has improved primary care access for children, many adults continue to miss out, especially those with greatest need (Figs 8 & 9).1 Those with the greatest need - the poorest, Māori and Pasifika - have higher primary care-preventable hospitalisation rates than other groups.2 Despite countries such as the UK providing free GP services, the recent Health and Disability System Review has not recommended removing fees, saying that occurs only “in an ideal world”.3 The Review states “service fees are just one of many barriers to access and removing co-payments would not guarantee equitable access to services...” and “extending the reduction of co-payments would disproportionately benefit higher-income households.” This is contrary to the indications in Figures 8 & 9.4 There are compelling health reasons why GP fees must be removed. Other cost barriers (such as prescription charges and dental fees) also require attention, and a solution necessarily involves the social welfare and other sectors.5 Reform is also needed to address the uneven distribution of GPs. Under the current small-business model for primary care, Nelson-Marlborough for example, has almost twice the number of GPs per capita as Manawatū and the West Coast.6

FIGURE 8: ADULTS REPORTING UNMET NEED FOR GP SERVICE DUE TO COST

European/ Other

Quintile 5

0 Quintile 4

0 Quintile 3

Quintile 2

Māori

Pacific

Asian

Percentage

Quintile 1

Percentage

“Health care access problems we see include availability of affordable after-hours primary care, access to prescription medications and limited hospital outpatient clinic capacity.” – Emergency medicine specialist

FIGURE 9: ADULTS REPORTING UNMET NEED FOR GP SERVICES DUE TO COST, BY ETHNICITY

Source: NZ Health Survey 2018/19

1. 2. 3. 4. 5. 6.

Ministry of Health. New Zealand Health Survey 2018/19. Craig E, Anderson P, et al. Measuring potentially avoidable and ambulatory care sensitive hospitalisations in New Zealand children using a newly developed tool. NZMJ 30 October 2015, Vol 128 No 1424 Gould R, Atmore C, et al. The ‘elephants in the room’ for New Zealand’s health system in its 80th anniversary year: general practice charges and ownership models, NZMJ 1 February 2019, Vol 132 No 1489 Health and Disability System Review. 2020. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR. p122 Loh L, Trevallyan S, et al. The case for a systematic policy approach to free primary health care for vulnerable groups in New Zealand, NZMJ 30 October 2015, Vol 128 No 1424. MCNZ. The New Zealand Medical Workforce in 2016. (Data for 2017 and 2018 is more limited due to reduced response rates to the MCNZ Medical Workforce Surveys.)

HEALTH MATTERS OCTOBER 2020

Health starts with access to hospital care Hospitals have a crucial role to play in reducing health inequities. The burden associated with avoidable mortality means the health system in its own right can be considered a determinant of health.1 Access to hospital care in New Zealand compares poorly against international health systems.2 Of 11 comparable countries, New Zealand ranks: • 7th for emergency department waiting times • 9th for waiting times for elective surgery • 10th= for access to specialist tests (e.g. CT, MRI scans) • 9th for waiting times for a specialist appointment • 11th for waiting times treatment after diagnosis (Fig 10) Pre-Covid, it was estimated that 448,000 New Zealanders had unmet need for hospital care.3 An estimated additional 180,000 hospital procedures were reported to have been delayed due to the Covid lock-down.4 The causes of unmet need include, among many other things: Under-investment in the public health system spanning many years. Insufficient hospital beds: The numbers of acute beds and psychiatric beds per capita are among the lowest in OECD countries, leading to bed occupancy rates that are often well above accepted safety levels.5 The number of intensive care beds per population is also well behind comparable countries.6 An estimated 24% shortfall of DHB-employed senior doctors, based on assessments by clinical heads of departments.7

NZ UK Sweden Australia Canada Norway Germany France Netherlands US Switzerland 0

Percentage of survey respondents

FIGURE 10: PERCENTAGE OF DOCTORS SURVEYED REPORTING LONG HOSPITAL TREATMENT WAIT TIMES BY COUNTRY Source: Commonwealth Fund 2017 1. 2. 3. 4. 5. 6. 7.

Walsh M, Grey C. The contribution of avoidable mortality to the life expectancy gap in Māori and Pacific populations in New Zealand—a decomposition analysis NZMJ 29 March 2019, Vol 132 No 1492 Schneider E, Sarnak D, et al. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better US Health Care, Commonwealth Fund, July 2017. ASMS. Hospitals on the Edge, pp12-13, November 2019 Witton B. Backlog of people still waiting for diagnosis because of Covid-19 delays, Stuff, 5 September 2020. OECD Health Data 2020. Neilson M. Coronavirus: New Zealand’s intensive-care capacity well behind other nations, NZ Herald, 18 March 2020. ASMS. Surveys of clinical leaders on Senior Medical Officer (SMO) staffing needs. https://www.asms.org.nz/publications/researchbrief/

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Health starts with social and economic investment For many years it was widely believed that people’s health was largely driven by their country’s wealth. What is now suggested is the opposite, health and social equity are drivers of wealth. The OECD says New Zealand’s stark rich-poor divide, for example, had taken over a third off the country’s economic growth rate between 1990 and 2010, due in part to under-investment in human capital, including education and skills development.1, 2, 3, 4 Health, education, and social sectors contribute to wealth by creating a healthier, better educated, and therefore more productive labour force. They also create jobs, many of which are largely recession-proof, the needs for health care and education, for example, do not fall off simply because an economy is ailing.5, 6 Furthermore, analysis of spending by government sector indicates considerable economic gains from government spending in areas such as health, education, and the environment. A study based on 25 European countries estimated that every government dollar spent on health services generated more than four dollars in the domestic economy, largely through the creation of jobs and income. Spending on education and the environment saw eight-fold returns on investment, while spending on social protection generated nearly three dollars for every government dollar.7

“I well remember a child who needed frequent, 3 week-long admissions for bronchiectasis, but whose parents and whanau never came to see him during these times. After they were given a fridge, and got regular food parcels, they started visiting lots whenever he was in hospital. And it dawned on me just how crippling their hunger must have been to have stopped them coming previously.” – Paediatrician

These results corroborate existing evidence that suggest austerity measures have tended to exacerbate economic crises. Improved government investments can create economic growth in the short-term and therefore play an important part in economic recovery in addition to creating long-term benefits.8 Eliminating health inequities is a core public health principle providing not only benefits to wellbeing but also the broader economic benefits to society. But it means the long-term under-investment in health and the social determinants of health must be reversed. A good point of comparison for the Government’s vision for New Zealanders’ equality and wellbeing outlined in its “Wellbeing Budgets”, are Denmark, Norway, and Sweden. In 2018 all three countries were ranked in the top seven in the United Nations Development Programme’s inequality-adjusted human development index. New Zealand was ranked 18th. Their health and social care workforces, as a proportion of their total workforces, are 40% to 90% greater than New Zealand’s (Fig 11). Their government health spending as a proportion of GDP averaged 8.9% in 2018 compared with New Zealand’s 7.4%. New Zealand Government health spending in 2018 would have needed to be $4.4 billion higher to have matched the Scandinavian average. Their levels of government social spending are also markedly higher (Fig 12).

HEALTH MATTERS OCTOBER 2020

Denmark

Norway

Sweden

New Zealand

% of total employment

0 2013

2014

2015

2016

2017

2018

FIGURE 11: HEALTH AND SOCIAL EMPLOYMENT AS A PERCENTAGE OF TOTAL EMPLOYMENT FOR SCANDINAVIAN COUNTRIES AND NEW ZEALAND, 1980 TO 2018. Source: OECD 2020

Denmark

Norway

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% of GDP

25 20 15 10 5 0 1980

1985

1990

1995

2000

2005

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2015

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FIGURE 12: PUBLIC SOCIAL EXPENDITURE TRENDS FOR SCANDINAVIAN COUNTRIES AND NEW ZEALAND, 1980 TO 2018 Source: OECD 2020

1. 2. 3. 4. 5. 6. 7. 8.

Cingano F. Trends in Income Inequality and its Impact on Economic Growth, OECD Social, Employment and Migration Working Papers No. 163: 2014. 4 Conference Board of Canada. Health Care in Canada: An Economic Growth Engine, Canadian Alliance for Sustainable Health Care, January 2013. Bloom D, Canning D. Epidemics and Economics, Programme on Global Demography of Aging, Working Paper No. 9: 2006, Harvard School of Public Health. Monterubbianesi P, Grandes M, et al. New evidence of the health status and economic growth relationship, January 2016 Panoeconomicus 64(00):20-20 Ibid WHO. Healthy, prosperous lives for all: the European Health Equity Status Report. Copenhagen: WHO Regional Office for Europe; 2019. Reeves A, Basu S,et al. Does investment in the health sector promote or inhibit economic growth? Globalization and Health 2013, 9:43. ASMS. Reality check: The myth of unsustainable health funding and what Treasury figures actually show, Health Dialogue, Issue 9, August 2014.

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Recommendations • Remove barriers to health care services

This requires building the capacity of the system to meet increasing health needs. In primary care, it also requires the elimination of user charges and new funding arrangements for primary care practitioners to compensate for the loss of income.

• Adopt a ‘Health in All Policy’ approach

In addition to health promotion and other health focused activities in government, we encourage the adoption of a more encompassing approach to health such as the WHO’s Health in All Policy (HiAP). This approach aims to have good health as an outcome of all policies. This requires multisectoral action with a focus on achieving health equity. It encourages consideration of the policy’s impact on people’s health regardless of the primary aim of the policy in question.

This shift in emphasis requires strong working relationships between government health policymakers, politicians, and other policy makers, including those working in other government and non-government organisations. It further recognises, while other sectors can serve the goals of health, health can also determine the goals of other sectors.

According to the WHO: “HiAP is unlikely to thrive if there is no institutional or organisational presence in favour of it within the government”1. There must be a critical mass of people with time, funding, and skills to engage with the health sector, but also to strive beyond health, to build knowledge and evidence base for policy development and effective multisectoral action.

• Establish a Minister and standalone Ministry for Public Wellbeing

The public health community has long been arguing for a single independent body to oversee population health measures in New Zealand. There is a need for comprehensive partnerships and whole-ofgovernment action to be driven through Cabinet. A Minister for Public Wellbeing supported by a Ministry is vital. It would provide technical, economic, legal and policy resources to develop and implement public health policy, while facilitating a much stronger integrated approach to policymaking and implementation, including ‘Health in All Policy’ approaches.

The critical need for strong cross-government action to address the social determinants of health is acknowledged by the Health and Disability System Review. Unlike our proposal for a single Ministry of Public Health, it proposes that responsibilities for the social determinants of health are spread across all parts of the system, led by the Ministry of Health. This current fragmented approach does not appear to be working and similar approaches have not worked in other jurisdictions.

There are precedents for a whole-of-government public health strategy. Sweden, for example, regarded as one of the world’s leaders on public health (pre-Covid) had a clear focus on wider determinants of health 15 years ago. A key feature was a Minister for Public Health whose role was to coordinate policies and actions with other Ministers and oversee an inter-sectoral National Steering Group for implementing the policies, including the directors-general of all the relevant government agencies.2, 3, 4

HEALTH MATTERS OCTOBER 2020

• Adopt ‘proportionate universalism’ to achieve health equity

Proportionate universalism is a term which encompasses universal health care with a scale and intensity that is proportionate to the level of need across a population. This is a different approach to solely targeting the least disadvantaged groups. It aims to improve the health of the whole population while simultaneously improving the health of the most disadvantaged, faster.5

Targeting sections of the population, whether by age, ethnicity, or deprivation level, can be problematic as it can miss those with high health needs outside of the target groups. The same risk applies when health care is rationed according to clinical ‘thresholds’ which more often reflect funding pressures. Further, targeting may address the consequences of inequities rather than their causes.

Proportionate universalism, strongly supported by the Prime Minister in the 2019 Child and Youth Wellbeing Strategy, implies a need for action across the whole of society, focusing on those social factors that determine health outcomes.6

By contrast, ‘universal’ health systems, based on the philosophy of equal access, do not provide universal benefits. Universal policies in practice tend to favour those who are already in advantaged positions while failing to improve the circumstances of those living in disadvantaged conditions.

• Fund policies to match wellbeing goals

As outlined in this publication, the evidence and lessons from the past reveal fiscal policies, based on developing population wellbeing, offer the best chance to build a better social and economic future. Policies based on austerity measures, by contrast, exacerbate economic crises and result in worsening health and social inequities.

We recommend that future policies which have bearing on long term social and health outcomes are prioritised and adequately funded with cross party support. Health needs to be viewed as a long game and the social determinants of health recognised and prioritised accordingly. We encourage a whole of health approach with priority-setting and investment which goes further than political cycles or the makeup of the elected government of the day.

1. 2.

World Health Organisation. Helsinki Statement on Health in All Policies: Framework for country action, WHO 2014. Persson-Göransson E. Public health policy of Sweden – building a strategy based on wider determinants of health; presentation to the 6th Global Conference of Health Promotion, Ministry of Health and Social Affairs, Sweden, August 2005. Raphael D. The state’s role in promoting population health: Public health concerns in Canada, USA, UK, and Sweden, Health Policy 78 (2006) 39–55. Corbett S. Ministry for the Public’s Health: an imperative for disease prevention in the 21st century? MJA, Vol 183 No 5, 5 September 2005. Marmot M. Fair Society, Healthy Lives: The Marmot Review: Strategic review of health inequalities in England post-2010. London: The Marmot Review. Office of the Minister for Child Poverty Reduction and Office of the Minister for Children. Child Wellbeing Strategy – Scope and Public Engagement Process: Proposal for the Cabinet Social Wellbeing Committee, 6 August 2018.

3. 4. 5. 6.

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