David Lillis: Our Prioritised Health System and Pacific People

In this article we make the case for our Pacific populations being our most deprived and vulnerable demographic in health and wellbeing. We suggest that resourcing the health and wellbeing of New Zealanders should be predicated, not on the basis of ethnicity, but instead on the basis of need.

Findings of the BULA SAUTU Report

In 2021 we saw the publication of a landmark study from the Health Quality & Safety Commission - BULA SAUTU A window on quality 2021: Pacific health in the year of COVID-19. He mata kounga 2021: Hauora Pasifika i te tau COVID-19.

Drawing on various prior studies and censuses, this report (Health Quality & Safety Commission, 2021) summarises a very significant study of the health and wellbeing of Pacific people in New Zealand. The study served to confirm what was already well known within the Pacific community and to health professionals across the country. The report demonstrates that various socioeconomic issues experienced by Pacific people provide impediments to good health. It suggests that New Zealand’s health system is fragmented and that current models of care are not working properly for Pacific people, often are hard to access for Pacific people, and that critical shortages exist within the Pacific health workforce.

Of all ethnic groups in New Zealand, Pacific peoples are amongst those most affected by inequities in the socioeconomic determinants of health, including living in areas of high socioeconomic deprivation, being unemployed, and having low weekly earnings. These factors can affect health directly (for example, through damp, cold, and overcrowded conditions, which increase the transmission of infectious diseases) and indirectly (for example, by limiting opportunities to engage in health-promoting behaviours).

Health and Disability System Review: Interim Report (2019).

Initiatives that Empower Disadvantaged Groups

Over the last few years, several key reports have given expression to a desire within and outside of Government to empower Māori. Among them is Te Pūtahitanga (2021), which calls for a policy approach that is enabled by, and responsive to, Te Tiriti o Waitangi and Mātauranga Māori (Māori traditional knowledge).

Another critical document is He Puapua (Charters et al, 2019). He Puapua states that, if Māori have the ability to exercise full authority over our lands, waters and natural resources and implement indigenous solutions, Aotearoa will be a thriving country for all.

We believe that initiatives that empower all disadvantaged groups, including Māori, are to be encouraged and given our full support, but to be delivered on the basis of demonstrated need, rather than on the basis of self-reported ethnicity. In New Zealand it is possibly the Pacific community that experiences the greatest shortfalls in certain health and economic outcomes, and therefore requires at least equal support to Māori if their health outcomes are to be improved

In 2020 the Ministry of Health published Ola Manuia: Pacific Health and Wellbeing Action Plan 2020 - 2025 (Ministry of Health, 2020). This plan recognises that health inequities are complex and interact with socioeconomic status. It highlights the factors that affect the health of Pacific people, including education, housing, income, employment and culture.

The Health of Pacific People in other Countries

It is important to note that health issues and socioeconomic issues faced by Pacific people in New Zealand are exactly those faced by Pacific people in Australia and the Pacific region. For example, The Australian Health Review found increasing health inequality between the Pacific and the rest of the world and forecasted that Pacific island health inequities will grow unless profound changes are made to health systems in the region (Australian Health Review, 2017).

Another study, this time of the health of Pacific people and Māori in Queensland, found poorer health outcomes for those groups than the total Queensland population. Many of the social and economic determinants of health were found to be interrelated and complex, and lay outside the jurisdiction of the health sector (Queensland Health, 2011). The key issues identified in that study included social exclusion, economic disadvantage, overcrowded and inadequate housing, parenting issues, low literacy and educational attainment, and overrepresentation in low paid employment.

The Pacific Population in New Zealand

According to the 2018 Census, approximately 381,640 people in New Zealand identified with at least one Pacific ethnic group (Statistics New Zealand, 2018). The total population at that time was approximately 4,699,755, so that Pacific people made up about 8.1% of New Zealand’s population. Approximately 91.6% were English speakers and 37.8% spoke two languages (Statistics New Zealand, 2018). Pacific people had a much younger age profile than the general population. Between 30% and 40% were younger than 15 years of age, compared with 20% for the New Zealand population (Health Quality & Safety Commission, 2021).

For comparison, in 2018, the New Zealand population included: European (3,297,860 people or 70.2% of the population), Māori (775,840 people or 16.5%), Asian (707,600 people or 15.1%), Middle Eastern, Latin American and African (70,330 people or 1.5%).

In 2018, almost two-thirds of the Pacific population lived in Auckland (243,970 Pacific people, or 15.5% of the population). Other territorial authorities with significant communities of Pacific people were: Porirua (14,870 people or 26.3%), Christchurch (14,180 people or 3.8%), Lower Hutt (12,000 or 11.5%), Wellington (10,390 people or 5.1%) and Hamilton (9,740 people or 6.1%); (Massey University, 2022).

The report defines ‘Pacific peoples’ as a collective term for diverse ethnic and cultural groups with heritage links to Pacific island countries. It tells us that the seven largest Pacific ethnic groups in New Zealand are as follows: Samoan, Cook Islands Māori, Tongan, Niuean, Fijian, Tokelauan and Tuvaluan. In fact, Statistics New Zealand lists more than 17 Pacific ethnicities.

The Health and Wellbeing of Pacific People

Below we discuss the most critical findings that are addressed in detail within the Health Quality & Safety Commission report of 2021:

Household Overcrowding and Home Ownership

The 2013 Population Census showed that Pacific groups constituted the highest subgroups for percentages of people living in crowded households. Pacific people were eight times more likely than Europeans to live in a crowded house (39.8%, compared with 20% of Māori). Pacific people were the least likely of all ethnicities to own their own home (33%, compared with 70% of Europeans).

Pacific people are more likely than other ethnic groups to live in neighbourhoods of high deprivation (Ministry of Health, 2019). Approximately 24% of Pacific people (compared with 8.5% of Europeans) reported not having enough money to meet their everyday needs (Pacific Perspectives, 2019).

Employment, Income and Deprivation

Pacific people were less likely to be employed than all other ethnic groups. Pacific median weekly incomes were lower than those of other groups; the disparity being greatest for males. Pacific women’s median weekly income was second lowest of all groups (marginally ahead of women of Middle Eastern/Latin American/African origin).

A higher percentage of Pacific children lived in poverty than Māori, European and Asian children.

In 2018 Pacific people ranked worst of all ethnicities within every category of deprivation in material standard of living. From Statistics New Zealand’s Wellbeing statistics, derived from the General Social Survey (Statistics New Zealand, 2019), we see that Pacific people reported keeping costs down in the previous 12 months by:

1.      Spending less on hobbies or special interests than they would like (80%)

2.      Delaying replacing, or repairing, broken or damaged appliances (71%)

3.      Cutting back on or going without trips to shops or local places (70%)

4.      Putting up with feeling cold (59%)

5.      Going without fruit or vegetables (56%)

6.      Postponing or putting off visits to the doctor (38%)

7.      Not paying bills on time due to shortage of money (38%).

At 37%, Pacific people rated highest of all ethnicities (by 11 percentage points) in being very limited by money when buying or thinking about buying clothing or shoes.

Life Expectancy

On average, Pacific people lived six fewer years than non-Māori, non-Pacific, and this gap has widened over the last 20 years.

Medical Conditions

Compared with children from other ethnic groups, Pacific children experienced higher incidence of medical conditions, including asthma, dental problems and ear and skin infections. The Health Quality & Safety Commission report reminds us that such conditions are associated with social determinants of health, including poverty and overcrowding. The report goes on to say that such inequities in child health outcomes are long-standing and indicate gaps and insufficiencies in current models of care. Failures within screening programmes that originally were designed to identify issues early, in addition to problems relating to access and quality of care, contribute to poor outcomes for Pacific people.

Pacific people experienced greater incidence of long-term conditions, including diabetes, gout, cardiovascular disease, kidney disease, cancer and asthma. The report states that long-term conditions are the most important contributors to the difference in life expectancy between Pacific people and non-Māori, non-Pacific.

Younger Pacific adults experienced twice the prevalence of diabetes than Māori, and five times the rate of European and other ethnicities.

Pacific and Māori patients were far less likely to receive a kidney transplant as their first treatment for kidney failure than New Zealand Europeans.

Pacific people and Māori had the highest rates of acute coronary syndrome (heart attacks and unstable angina) but the lowest rates for receiving angiography (an investigation that checks for blocked or narrowed blood vessels in the heart) and coronary revascularisation (a procedure for unblocking obstructed or disrupted blood vessels, restoring blood flow to the heart, reducing chances of long-term damage and improving chances of survival).

Pacific people and Māori exhibited the highest rates of death or recurrent myocardial infarction (i.e. a heart attack) within a year of their initial acute coronary syndrome.

Mental and Emotional Health

The Health Quality & Safety Commission report suggests significant prevalence of mental health and wellbeing issues connected with increasing complexity of ethnic and other identities. Probably, such issues are already leading to rising rates of depressive symptoms and attempted suicide among Pacific youth, in particular, among those living in high deprivation areas. Thankfully, rates of actual suicides are falling.

End of Life

Hospices provide palliative care, delivering psychosocial, spiritual and physical needs at the end of life. The Health Quality & Safety Commission report states that most deaths in European populations occur after age 65 years, but that 44% of deaths within Pacific populations occur among those under 65 years.

The Pacific Health and Wellbeing Action Plan 2020 – 2025

Ola Manuia: Pacific Health and Wellbeing Action Plan 2020 – 2025 (Ministry of Health, 2020), is a very welcome step forward in addressing the health needs of New Zealand’s Pacific people. This plan identifies several critical focus areas, including:

1.      Changing the way health services work, to improve access, equity and quality of health care for Pacific people and decrease the burden of priority Pacific health issues

2.      Building a health and disability system that is fair, sustainable and responsive to the health needs of Pacific people and provides timely access to effective and quality health care

3.      Decreasing health inequities and providing healthier living and working environments for Pacific communities

4.      Strengthening Pacific research, data collection and the use of Pacific data to drive evidence-based actions that improve Pacific health outcomes.

In her foreword to the Pacific Health and Wellbeing Action Plan, Jenny Salesa, Associate Minister of Health, reminds us that achieving the vision of the plan requires a shared commitment to supporting Pacific peoples’ aspirations to live and thrive in healthy and safe environments and that no individual or agency can achieve the vision if acting in isolation. She says that the challenge is for New Zealand to do things differently in order to realise the best outcomes for Pacific people.

The Health Issues of Pacific People

The Health Quality & Safety Commission report suggests that communication presents major challenges for Pacific families in which English is a second language. The report reminds us that Pacific populations are diverse, young, growing, primarily urban and increasingly born in New Zealand. They are more likely to experience material deprivation than other New Zealanders in employment, income, wealth and housing. Each of these forms of deprivation has long-term effects on health.

The report states that Pacific populations have particular strengths, challenges and needs, but that currently the health system is not designed to meet Pacific needs. Access to this system is often difficult for Pacific people. Of course, reduced access and reduced uptake of healthcare services can lead directly to poor health outcomes.

However, the report suggests hope for the future - often centred on the strengths of communities - and it states that a transformatory approach for the health of Pacific people can be built on community strength and resilience.  

We can agree with a crucial statement within the report - that outcomes in later life are influenced by social advantages and disadvantages that pertain over a person’s lifetime. We agree that interventions and responses are best directed towards the causes and determinants of poor health and inequity rather than at the consequences. We agree with the assertion that, if the causes are systemic, then the best solutions involve systemic and structural change.

The Health Quality & Safety Commission report suggests that if we embrace and draw on the expertise, knowledge and worldviews of Pacific people, it could then be possible to strengthen the diversity, inclusiveness and responsiveness of our health system, and improve health outcomes for the Pacific community of New Zealand.

Addressing the Health Issues of Pacific People

Clearly, we need both greater investment in communication and outreach to the Pacific community and greater recruitment of young Pacific people into the medical, health and nursing professions. Initiatives such as the Pacific Community Health Fund (Ministry of Health, 2021) can make significant contributions to the health and wellbeing of Pacific people, but are not enough. We need a health system that is responsive to the needs of Pacific people and we need funding that proportions resources to areas of greatest need. Possibly New Zealand’s health system is already sufficiently responsive and what we really need is to raise awareness of healthcare within Pacific communities and to facilitate greater access.  

The Health Quality & Safety Commission report states that we must ensure that our care is holistic, integrated and comprehensive. We agree. We also agree that resourcing should be made available to support Pacific providers in delivering models of care that address dynamic interactions between health, social circumstances and economic factors holistically. Finally, indeed New Zealand must build on and strengthen these models of care by facilitating rapid access to social, financial and housing support within the health system, recognising that good health cannot be achieved without addressing the context within which Pacific people live.

We must analyse and evaluate New Zealand’s health issues in order to identify priority groups on the basis of need rather than of ethnicity. The Health Quality & Safety Commission report provides aggregated statistics for Pacific people but does not provide statistics at the level of each discrete ethnic group (e.g. Samoan, Cook Islands Māori, Tongan, Niuean, Fijian, Tokelauan and Tuvaluan). However, even within particular Pacific groups we may identify even more specific needs. New Zealand needs a more effective targeted approach and it could be that persistent use within public reports of the generic catch-all categories - ‘Pacific’ and ‘Māori-Pacific’ - can give a false impression that the health needs of specific groups have been addressed equitably. Analysis and evaluation of ethnic-specific equity issues at finer levels of aggregation may reveal that New Zealand has a long way to go if we are to achieve equality of outcomes, given the different needs of particular groups. For example, we need to identify health issues for particular Pacific groups such as Tokelauans (the largest community in New Zealand, based in Wellington), those derived from Tuvalu or Kitibati in West Auckland; Pacific people living in South Auckland (e.g. Otara, Manurewa, Mangere, Porirua, and in rural localities where there are people of mixed Māori and Pacific heritage).

Health Authorities for Ethnic and Cultural Groups?

Finally, in his foreword to the Health Quality & Safety Commission report, Associate Professor Collin Tukuitonga suggests that shortcomings in Pacific health outcomes reflect systemic bias and racism in New Zealand’s health and disability system, as well as lack of diversity in the health workforce. A review could identify the presence or otherwise of systemic bias and racism in New Zealand’s health sector and, if present, its extent and how to address bias and racism. Perhaps a process such as asset mapping could be useful here, including the identification of the institutions, individuals and citizen associations that exist within communities that could serve as positive resources as we work towards better health and wellbeing for Pacific people.

However, explaining differential outcomes across demographic groups as resulting primarily, or to any significant extent, from bias or racism, may or may not reflect reality. If in reality bias and racism are no longer significant, then in focusing on bias and racism we may fail to address the true causes (principally socioeconomic, poor housing and overcrowding, lifestyle choices and genetics).

Nor should disparate outcomes provide a sole justification for significant change that clearly is intended to benefit one group disproportionately, when other demographic groups are also disadvantaged. Thus, not only Māori have poorer outcomes in health and education, but also Pacific people and, reviewing the official statistics on health and wellbeing in New Zealand, we see that Pacific people are even more disadvantaged than Māori on certain indices. 

Conferring special privilege to one particular group (for example, through the creation of health authorities for particular ethnic and cultural groups) will not repair inequality and, in fact, are unfair on those groups that miss out; nor will expending scarce resources to address structural racism and bias if these problems are no longer significant and if the core structural and systemic problems lie elsewhere. The true agents of disparity, principally socioeconomic in nature, may lie largely outside of the jurisdictions of education and health. Here we have an argument against the creation of health authorities for specific demographics, especially those defined on the basis of self-reported ethnicity.

In the democratic nation that is New Zealand, we can engender social and economic progress for Pacific people and, indeed, for all disadvantaged groups, through education; employment; healthy and affordable housing; awareness of, and ready access to, high quality healthcare, and through positive connections to the wider society.

Acknowledgements

I wish to thank John Fiso and Taulalo Fiso for valuable discussions during the preparation of this article.

References

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Dr David Lillis trained in physics and mathematics at Victoria University and Curtin University in Perth, working as a teacher, researcher, statistician and lecturer for most of his career. He has published many articles and scientific papers, as well as a book on graphing and statistics.