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