Health Systems & Equity

Introduction to Health Systems

A health system encompasses all organisations, people, and actions whose primary intent is to promote, restore, or maintain health. The World Health Organisation identifies six building blocks of health systems: service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance. Understanding NZ's health system requires both the structural detail of recent reforms and the conceptual frameworks for understanding why health outcomes differ so profoundly between population groups.

The New Zealand Health System: Historical Context

Until 2022, NZ's health system was organised around District Health Boards (DHBs) — 20 geographically defined entities that both planned and provided health services. This structure dated from the New Zealand Public Health and Disability Act 2000. DHBs varied considerably in size, population, and capability, leading to fragmented service planning and inequitable access across regions.

Te Whatu Ora Reform (2022–present)

The Pae Ora (Healthy Futures) Act 2022 replaced the DHB structure with a radically simplified central model:

Te Whatu Ora — Health New Zealand (Health NZ): a single national commissioning and delivery agency that absorbed the functions of all 20 DHBs. Organisationally, it works through four regional divisions (Northern, Midland, Central, Southern) and numerous district and locality-level teams. The rationale was to eliminate DHB fragmentation, enable national workforce and capital planning, and enable system-wide equity strategies.

Te Aka Whai Ora — Māori Health Authority (MHA): a first-of-its-kind statutory body with independent commissioning power specifically for Māori health. The MHA could commission, fund, and monitor Māori health services independently of Health NZ, reflecting Article 2 of Te Tiriti (Tino Rangatiratanga — self-determination). The MHA was disestablished in June 2024 under the incoming government; its functions were absorbed into Health NZ, which created significant debate about the long-term commitment to Māori health equity.

Social Determinants of Health

The social determinants of health (SDOH) are the non-medical factors that shape health outcomes: the conditions in which people are born, grow, live, work, and age. These include income, education, employment, housing, food security, early childhood development, and social support networks.

The WHO Commission on Social Determinants (Marmot, 2008) established that health inequities are largely avoidable — they result from unjust social and economic arrangements rather than biological inevitability. The gradient of health tracks closely with socioeconomic position: the lower one's position in the social hierarchy, the worse one's health outcomes — this is the social gradient in health.

The Whitehead-Dahlgren Rainbow Model

The Dahlgren and Whitehead (1991) model (the "rainbow model") visualises the determinants of health as concentric arcs:

1. Individual lifestyle factors (innermost arc): diet, smoking, exercise — modifiable but influenced by social context
2. Social and community networks: social support, community cohesion, family
3. Living and working conditions: employment, housing, healthcare, food, education, agriculture/food production
4. General socioeconomic, cultural and environmental conditions (outermost arc): economic policies, cultural norms, environmental quality, global forces

The individual sits at the centre, with fixed characteristics (age, sex, constitutional factors). The model illustrates that individual behaviour does not occur in a vacuum — it is shaped by the surrounding social context, which is in turn shaped by broader structural forces.

In the NZ context, Māori and Pacific people are disproportionately represented in disadvantaged positions across multiple SDOH layers — lower median income, higher housing unaffordability, higher rates of unemployment, lower educational attainment — creating compounding disadvantage that manifests as systematic health inequity.

Institutional Racism in Health

Institutional racism describes policies, practices, and cultural norms within organisations that systematically disadvantage people of certain ethnicities, even without individual racist intent. In health:

• Implicit bias in clinical decision-making (under-treatment of Māori and Pacific patients)
• Underrepresentation of Māori and Pacific providers in the health workforce
• Service design that fails to account for cultural preferences and values
• Historical trauma and mistrust of health institutions among Māori (linked to colonisation and historical abuses)

Addressing institutional racism requires institutional self-examination (workforce data, cultural safety auditing), Māori and Pacific workforce development, and co-design of services with communities.

Health Literacy

Health literacy is defined as the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions. It encompasses:

• Functional literacy: ability to read health materials
• Communicative literacy: ability to interact with health providers and extract information
• Critical literacy: ability to critically evaluate health information and exercise autonomy

Low health literacy affects approximately one in three New Zealanders and is strongly associated with worse health outcomes, more preventable hospitalisations, less effective chronic disease management, and lower cancer screening uptake. Health literacy is not a fixed individual attribute — it is powerfully shaped by educational access and the complexity of health communication. Responsibility lies with the health system (plain language, universal precautions) as much as with individuals.

Equity vs. Equality

A foundational concept: equality means giving everyone the same (identical resources or interventions), while equity means giving people what they need to achieve a comparable outcome. Equity may require providing more resources to those with greater needs (proportionality principle). Visual metaphor: in the "three boxes" illustration, giving equal boxes to people of different heights allows the tallest to see but the shortest still cannot — equity requires giving the shortest person the most support.

In health policy: universal provision (same for all) does not achieve equity if some groups face additional barriers. Proportionate universalism (Sir Michael Marmot's concept) — delivering services universally but with scale and intensity proportionate to need — is the recommended approach. In NZ, this translates to equity-targeted funding formulae for Māori and Pacific health services.

The Treaty of Waitangi in Health

Te Tiriti o Waitangi (1840) is the founding document of Aotearoa NZ. Its three articles have direct health implications:

• Article 1 (Kāwanatanga): Crown governance, including health legislation and system design
• Article 2 (Tino Rangatiratanga): Māori sovereignty and self-determination — Māori must have control over their own health services and be partners in health system design
• Article 3 (Ōritetanga): equality of rights — Māori should have health outcomes equal to other New Zealanders

The Waitangi Tribunal (WAI 2575 Health Services and Outcomes inquiry) found significant Crown breaches of Treaty obligations in health, particularly in funding and organisational design. The establishment of Te Aka Whai Ora was a direct Treaty response, making its disestablishment contentious.