Health Inequalities and Intersectionality

Health inequality refers to differences in health outcomes between population groups. Health inequity — a normative concept — refers to differences that are avoidable, unjust, and unfair. Not all inequalities are inequitable: genetic differences in cancer susceptibility may be unavoidable. But differences in cardiovascular mortality between Māori and non-Māori driven by socioeconomic deprivation, access to care, and racism are inequitable.

New Zealand has profound and persistent health disparities. Māori life expectancy at birth is approximately 7–8 years shorter than non-Māori New Zealanders. Māori experience higher rates of cardiovascular disease, diabetes, respiratory disease, rheumatic fever, and cancer; they have higher rates of ambulatory sensitive hospitalisations (conditions preventable with good primary care). Pacific peoples similarly experience higher rates of these conditions, compounded by language barriers and cultural distance from mainstream health services. Asian populations in NZ are heterogeneous; some groups (e.g., South Asian) have high rates of type 2 diabetes and cardiovascular risk.

Gender shapes health differently for men and women. Men have higher all-cause mortality at all ages, higher rates of occupational injury, suicide, and risk-taking behaviours. Women have higher rates of autoimmune disease, depression, and anxiety; they live longer on average but spend more years with disability. Non-binary and transgender people face particular barriers to healthcare access and have higher rates of mental health conditions.

Rurality creates health disparities through distance decay — the reduction in health service use as distance to services increases. Rural NZ has fewer specialists, GPs, and mental health services per capita. Rural populations have higher rates of injury, chronic obstructive pulmonary disease, and suicide. The rural health workforce challenge is compounded by recruitment and retention difficulties.

Intersectionality — developed by Kimberlé Crenshaw — describes how multiple social identities (race, gender, class, disability, sexual orientation) intersect to create compounded forms of discrimination and disadvantage. A Māori woman living rurally in poverty experiences health disadvantage that is not simply additive but qualitatively distinct from the sum of each disadvantage alone. This framework demands that health research and policy address multiple dimensions of disadvantage simultaneously.

The Population Attributable Fraction (PAF) estimates the proportion of disease burden in the total population that is attributable to a given risk factor. PAF = (prevalence of exposure × (RR − 1)) / (prevalence of exposure × (RR − 1) + 1). PAFs are used to prioritise public health interventions — a risk factor that is very common may have a higher PAF than a risk factor with a very high relative risk but low prevalence.

Proportionate universalism is a strategy for addressing health inequalities: services are universal but scaled in intensity proportional to level of need. This avoids the stigma of targeting while directing greater resources to more disadvantaged groups. It is central to the Te Pae Tata NZ Health Strategy 2023 approach to Māori and Pacific health equity.