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Library Database and Resource Directory

Health Equity Clearinghouse

Contents

What is Health Equity?
New Zealand Resources
  Websites
  Toolkits and Guidelines
  Selected Reading
  Selected Journals

What is Health Equity?

Health equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically (WHO)

The concept acknowledges that not only are differences in health status unfair and unjust, but they are also the result of differential access to the resources necessary for people to lead healthy lives (NZ MoH)

A window on the quality of Aotearoa New Zealand's health care 2019 – a view on Māori health equity | Health Quality & Safety Commission (hqsc.govt.nz)

Every year the Commission publishes a document we call A window on the quality of Aotearoa New Zealand’s health care. The Window provides a snapshot of the quality of health care in the country. While equity has always been a component of the report’s analysis over its four-year history, this year’s report focuses solely on equity. 

Te ao Māori framework concepts

Wairuatanga

The holistic nature of Māori health, which links physical illness to emotional and spiritual wellbeing.  Hence wairuatanga is in the middle position of the framework, which makes culture a central focus in the design of services. The goal of wairuatanga is to embed tikanga Māori and cultural safety into the health system.

Pātuitanga

The growing and fostering of strong partnerships with Māori, which is fundamental to ensuring the right concepts are included in the design and delivery of services.

Whānau

Whānau need and improving health outcomes for whānau are the drivers to why services are created and designed. 

Rangatiratanga

The inclusion of Māori leadership in decision-making processes when services are designed.

Te ao Māori framework design

Each of the outer sections have two koru representing tapu and noa. The haehae lines bind each section together and connect and interact with each other.

The inside koru of each concept opens into wairuatanga, which allows wairuatanga to flow seamlessly throughout the entire framework. 

The outside koru opens into te ao Mārama. The pītau design on the edge of the outer sections represents new beginnings and is the interconnection between te ao Māori and te ao Mārama.

Editorial from the NZMJ (2021): 'Closing the gaps: health equity by 2040'

The main goals of the “once in a generation” Health and Disability System Review, which has led to a major system restructuring that’s now in its early stages, included better health outcomes for all and greater health equity, despite the review accepting that most of a person’s health status is determined by factors outside the system. In July this year, the Association of Salaried Medical Specialists (ASMS) and the Christchurch Charity Hospital Trust (CCHT) co-hosted a conference of health professionals to discuss the broader range of policies that are needed to address health inequities and improve health outcomes for all. This article outlines some of the key issues and recommendations to government emanating from that conference and contain in our report, Creating Solutions Te Ara Whai Tika: a roadmap to health equity by 2040.

Māori Health Priorities Report (2022)

This Māori Health Priorities report draws focus to the biggest contributors to health loss and health inequity for Māori, and also represent the greatest potential for intervention.  This report was commissioned by Te Aka Whai Ora to inform our positioning on the priorities for the interim New Zealand Health Plan (iNZHP) for Māori.

Equity is the new black—and black lives matter (2020)

Editorial from New Zealand Medical Journal

"There is overwhelming evidence of inequities in health outcomes for Māori—you need look no further than the previous issue of NZMJ or the Wai 2575 Māori Health Trends Report. COVID-19 also presents a concern for the likely disproportionate impact on Māori.

Council encourages all doctors, employers, training and professional organisations to consider the findings in the cultural safety Report, draw on the data, and use this as a basis for achieving long-term, positive change for the benefit of all patients and whānau.

While the Report offers an insight into current practice, it is only the first step on a long journey. It sets a baseline for ourselves and our stakeholders to use when developing programmes, strategies and policies that support us to drive change."

Racism

Whiria te Muka Tangata: Anti-Racism Systems Change.

Ministry of Health. 2023

This publication outlines a preliminary systems change model that provides an organisational and system-level blueprint for anti-racism action in health.

Evolution of Racism and Anti-Racism – Lessons for the Aotearoa New Zealand Health System (Stage One Literature Review)

Ministry of Health 2022

Evolution of Racism and Anti-Racism – Lessons for the Aotearoa New Zealand Health System.

This is the first literature review in the Ao Mai te Rā series. This review traces how understandings of racism and anti-racism have shifted over time and explores various concepts, language and definitions that have been used to date. The review considers how we might frame and think about racism and anti-racism within the Aotearoa New Zealand context and has been used to inform the Ministry’s position statement and working definitions for racism and anti-racism in health.

Best Practice Approaches to Addressing Racism – Lessons for the Aotearoa New Zealand Health System (Stage Two Literature Review)

Minstry of Health. 2023

This is the second literature review for phase one of Ao Mai te Rā: the Anti-Racism Kaupapa. This review explores best practice approaches to addressing racism in all its forms.

Anti-Racism Maturity Models – Lessons for the Aotearoa New Zealand Health System (Stage Three Literature Review)

Ministry of Health. 2023

This is the third and final literature review for phase one of Ao Mai te Rā: the Anti-Racism Kaupapa. This review examines the key features and characteristics of an anti-racism maturity model approach. 

 
Evolution of Racism and Anti-Racism Literature review and Summary Document (2022)

Position statement and working definitions for racism and anti-racism in the health system in Aotearoa New Zealand (2022)

Understanding 'white privilege?'

Racism and White Defensiveness in Aotearoa: A Pākehā Perspective (2018)

Māori health: 'We have to be talking about racism' (2018)

Videos

What is Health Equity? [Health Equity Institute]
This three-minute motion graphic video explains how social, economic, and environmental conditions can create health inequities and how these inequities can affect health disparities.

New Zealand Resources

Websites

Equity Explorer [HSQC]
The Equity Explorer provides information on how health and health care varies between groups of people, and between district health board (DHB) areas of Aotearoa New Zealand (NZ).

Two types of group are compared: ethnic groups and groups based on socioeconomic status (deprivation).

Māori Health Clearinghouse

Pacific Health Clearinghouse

Asian Health Clearinghouse

Health system quality dashboard
Health & Quality Safety Commission (NZ).
In partnership with Te Tumu Whakarae, HQSC has developed a new specific Māori Health Equity Report, using distinct data.

Toolkits and Guidelines

Hospital Ethnicity Data Audit Toolkit | Ministry of Health (2021)
A resource for assessing the quality of ethnicity data in New Zealand hospital settings, and supports quality improvement in this area.

The scope of the Toolkit (also known as HEDAT) includes four tools to assess the quality of ethnicity data and systems for data collection, recording and output within a hospital setting, and provides guidance on quality improvement activities. The Toolkit helps hospitals assess health care ethnicity data against the HISO 10001:2017 Ethnicity Data Protocols and, more broadly, against current best practice.

Creating Solutions Te Ara Whai Tika: A roadmap to health equity by 2040. (NZ: 2021)
Associated of Salaried Medical Specialists
The Creating Solutions Te Ara Whai Tika report by the Association of Salaried Medical Specialists Toi Mata Hauora, recommends a national goal of achieving health equity for all New Zealanders by 2040 and lays out a roadmap of policies to get there.

It follows presentations, discussions, and input from more than 200 health professionals who attended a virtual conference co-hosted by ASMS and the Canterbury Charity Hospital Trust, established by Dame Sue and Associate Professor Phil Bagshaw.

Achieving Equity in Health Outcomes: Highlights of selected papers [NZ; 2018]
Both in New Zealand and globally, our ability to address equity challenges in health has significantly improved over the past decades. In the Western world life expectancy has increased for all populations. However persistent disparities in health access, quality of services and outcomes remain. In Aotearoa New Zealand, Māori and Pacific and those in low socioeconomic groups remain the most disadvantaged.

The Government has mandated the Ministry of Health to take a bold approach that delivers tangible changes to system behaviour with measurable results in a three to five-year horizon. An approach that operates on a repeating cycle based around deepening the understanding of equity gaps, shifting thinking about where priorities for investment of time and resources lie, followed by increasing direct action to address inequalities is being developed.

This paper traces the beginnings of health equity and the philosophical and ethical foundations that sit behind it.  It looks at a selection of the international and local literature to help understand definitions of equity. It considers how framing and thinking about the concept of equity and approaches to addressing equity have evolved, and how progress to address equity can be measured.

The Health Equity Assessment Tool: a User's Guide  [NZ]
The Health Equity Assessment Tool: A User's Guide, has been developed by the University of Otago, Wellington, to help facilitate the use of the Health Equity Assessment Tool (HEAT).

The Health Equity Assessment Tool: A User's Guide gives a brief overview of inequalities in health, introduces the HEAT and its use, presents an in-depth look at each of the HEAT questions, and provides case examples of the tool's use.  This publication is an essential guide for those working in the health and disability to apply a strong equity focus to their work.

Equity of Health Care for Māori: A Framework [NZ]
This framework guides health practitioners, health organisations and the health system to achieve equitable health care for Māori through leadership, knowledge and commitment.

Quality improvement: no quality without equity? [NZ; 2017]
This ‘think piece’ from the Health Quality & Safety Commission signals our intention to tackle health inequities. 

HE PIKINGA WAIORA IMPLEMENTATION FRAMEWORK

University of Waikato, 2016

The Framework has indigenous self-determination at its core. All four elements have conceptual fit with Kaupapa Māori aspirations and all have demonstrated evidence of positive implementation outcomes.

A coding scheme derived from the Framework was applied to 13 studies of diabetes prevention in indigenous communities in Australia, Canada, New Zealand, and the United States. Cross-tabulations demonstrated that cultural centeredness (p=.008) and community engagement (p=.009) explained differences in diabetes outcomes and community engagement (p=.098) explained difference in blood pressure outcomes.

The Framework is intended as a planning tool to guide the successful development and implementation of interventions. Funders can use the Framework to assess the likely effectiveness of proposed interventions.

Community organizations can use the Framework to work with researchers or policy makers to strengthen each of the four elements.

Pitama, S., Huria, T., & Lacey, C. (2014). Improving Māori health through clinical assessment: Waikare o te Waka o Meihana. The New Zealand Medical Journal (Online), 127(1393). 

Health professionals play an important role in addressing indigenous health inequalities. This paper describes the further development and a new conceptualisation of the Meihana model (2007) and the Hui process (2011), which together have formed the indigenous health framework in the University of Otago, Christchurch undergraduate medical education programme for 4th–6th year medical students over the past 5 years. The components of the framework are defined followed by description of their application to clinical assessment. The indigenous health framework has been evaluated by medical students, health practitioners, Māori patients and whānau over this time and has been rated favourably as a clinically relevant framework that supports health practitioners to work effectively with Māori patients and whānau.

Creating an Indigenous Māori‐centred model of relational health: A literature review of Māori models of health - Wilson - 2021 - Journal of Clinical Nursing

Conclusions

This study highlights the importance and relevance of relational approaches to engaging Māori and their whānau accessing health services. It signals the necessary foundations for health practitioners to build trust-based relationships with Māori. Key elements for a Māori-centred model of relational care include whakawhanaungatanga (the process of building relationships) using tikanga (cultural protocols and processes) informed by cultural values of aroha (compassion and empathy), manaakitanga (kindness and hospitality), mauri (binding energy), wairua (importance of spiritual wellbeing).

Literature Review to Inform the Development of a Culturally Appropriate Assessment Model for Māori (2022)

Introduction

 The purpose of this literature review is to inform the development of a culturally appropriate assessment model that meets the need of Māori and whānau and will enable a holistic assessment of needs and inform the provision of care and support services. Capturing relevant findings from the literature will ensure that the processes undertaken to develop a culturally appropriate model are evidence based. The findings of the review are intended to assist the Francis Health project team and wider steering group in how best to approach this work.  The wider project is underpinned by a kaupapa Māori approach, one framework being utilised is the Te Pā Harakeke Framework. This literature review as an input contributes to Te Puawai in the framework. Te Puawai references the flower head of the harakeke plant and refers to the processes used within each function to give effect to the strategy of the kaupapa. Largely, it seeks to inform ways to weave Kaupapa Māori approaches with interRAI assessment to enable positive outcomes for Māori. The literature review is one of many information streams that is feeding into the project.

The scope of the literature review includes:

− Approaches undertaken to make established assessment tools culturally appropriate

− Approaches undertaken to develop assessment tools that are compliant with Te Ao Māori

− How to implement relational Māori models of health within an assessment tool

Reducing Inequalities in Health

Ministry of Health, 2002

Summary

In New Zealand, ethnic identity is an important dimension of health inequalities. Māori health status is demonstrably poorer than other New Zealanders; actions to improve Māori health also recognise Treaty of Waitangi obligations of the Crown. Pacific peoples also have poorer health than Pākehā. In addition, gender and geographical inequalities are important areas for action.

Addressing these socioeconomic, ethnic, gender and geographic inequalities requires a population health approach that takes account of all the influences on health and how they can be tackled to improve health. This approach requires both intersectoral action that addresses the social and economic determinants of health and action within health and disability services themselves.

Reducing Inequalities in Health proposes principles that should be applied to whatever activities we undertake in the health sector to ensure that those activities help to overcome health inequalities. The proposed framework for intervention entails developing and implementing comprehensive strategies at four levels.

1. Structural – tackling the root causes of health inequalities, that is, the social, economic, cultural and historical factors that fundamentally determine health.
2. Intermediary pathways – targeting material, psychosocial and behavioural factors that mediate the impact of structural factors on health.
3. Health and disability services – undertaking specific actions within health and disability services.
4. Impact – minimising the impact of disability and illness on socioeconomic position.

Intervention at these four levels should be undertaken nationally, regionally and locally by policy-makers, funders and providers.

The framework can be used to review current practice and ensure that actions contribute to improving the health of individuals and populations and to reducing inequalities in health. It also highlights the importance of factors outside the direct control of the health sector in shaping the health of our population. Those outside the health sector – particularly The Treasury, the social welfare, education, housing and labour market sectors, and local government – can contribute significantly to the task of reducing inequalities in health. Success in reducing inequalities in health brings positive results for the individual, the economy and society. It enables New Zealanders to live healthier, longer lives. In turn, a healthier population will increase the country’s prosperity.

Equity resources

The following frameworks, guidelines and statements have informed the principles that underpin our recommendations and specific actions:

He Pikinga Waiora Implementation Framework (Healthier Lives NSC, 2016)​

​He Ara Hauora Māori: A Pathway to Māori Health Equity (Medical Council of NZ, 2019)

Equity Tools ​

Gustafson, P., Lambert, M., Bartholomew, K. et al. Adapting an equity-focused implementation process framework with a focus on ethnic health inequities in the Aotearoa New Zealand context. Int J Equity Health 23, 15 (2024). https://doi.org/10.1186/s12939-023-02087-y

The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services.

Reducing Inequalities in Health Framework  (2002)​

Health Equity Assessment Tool - A Users Guide (2008)​

Whānau Ora Health Impact Assessment 2007​

Equity of Healthcare for Māori: Framework​

Analysis of Equity Tools 

In preparation for the restart of the health system and recovery from COVID-19. Te Rōpū Whakakaupapa Urutā has carried out a quick review and analysis of the existing equity tools currently available to the health sector. Our analysis provides information about each tool's development, origins, what the tool is, how long it has been in the system, examples of where the tools have been implemented and a view of their usefulness.

​As we plan for a restart of the health services and a desire to reset the system so that it achieves equity for Māori, being aware of these tools and using/adapting them might be helpful. 

​All tools to some degree use an intervention logic: problem definition, engagement with stakeholders, intervention planning, monitoring and evaluation.  

Additionally they are likely to be more useful in specific contexts. ​

For example:​

The Equity of Health Care for Māori, the Central Region DHBs Equity Framework and the Health Equity Assessment Tool and its’ users guide are health services focused.  

The Whānau Ora Health Impact Assessment can be used at both a policy and project level with its strength being on the health impacts resulting from other sector activities.   

The Reducing Health Inequalities Framework is a useful background document which identifies that actions needs to be in four areas: system, intermediary environments, health services and impact of ill health and disability it is best used with another tool that is more intervention focused.​

Our quick review and analysis is available here  (doc attached)

Selected Reading

The whitewashing of contracts: Unpacking the discourse within Māori health provider contracts in Aotearoa/New Zealand
Health and Social Care in the Community (2021)
Success of the proposed health reforms and the Māori Health Authority should require dismantling of non-Māori ways of commissioning and contracting, otherwise there is the continued risk of discriminatory contracting practices limiting the expression of self-determination for Māori health providers.

The Choosing Wisely campaign and shared decision-making with Māori
New Zealand Medical Journal (2021)
This work identified some structural issues in Choosing Wisely New Zealand that have limited the campaign’s ability to mitigate health inequities for Māori and helped to define a potentially transformative way forward. There was wide agreement among our participants that shared decision-making is not just a quality practice, but that it also has the potential to address health inequity among Māori by facilitating participation in healthcare that better meets self-identified need. “Practitioner dependent” factors like consumer trust, autonomy, good relationships and rapport with health providers and culturally appropriate resources are important and are as demanding of attention as systemic causes of health inequity, such as inadequate access to services, the social determinants of health and the structural determinants of health, including racism.

Barriers and facilitators for Māori in accessing hospital services in Aotearoa New Zealand
New Zealand Medical Journal (2021)
Māori health inequities result from systematic failures in the provision of healthcare by the public health system and historical structural failures that have led to the inequitable distribution of the social determinants of wellbeing for Māori compared to non-Māori.

He Tamariki Kokoti Tau: Tackling preterm incidence and outcomes of preterm births by ethnicity in Aotearoa New Zealand 2010‐2014.
International Journal of Gynecology & Obstetrics.(2021)
Conclusion
This study demonstrates that the Aotearoa New Zealand maternity system privileges whiteness, suggesting that clinical pathways for evidence-based medical care are not delivered systemically and equitably for all. Health pathways that focus on equity as a fundamental right will enhance health outcomes for Māori women and their infants.

The human and health costs of failure to implement pro-Tiriti and pro-equity health policies: let’s act as if we know this
New Zealand Medical Journal.  Vol 134 No 1542: 17 September 2021
After a twenty-year period of relative stability in the health system, we are entering a period of very considerable change. These changes are driven, in part, by a clearly stated desire on the part of government for fairer health outcomes for Māori. 

Inequities in people with gout: a focus on Māori (Indigenous People) of Aotearoa New Zealand / Te Karu, L., Dalbeth, N., & Stamp, L. K.
Therapeutic Advances in Musculoskeletal Disease (2021)
Health equity can be defined as the absence of systematic disparities in health between more and less advantaged social groups. Gout is one of the most common forms of arthritis and disproportionally affects Indigenous peoples, including Māori in Aotearoa New Zealand. Inequities in gout management are well documented and clearly evidenced in Indigenous populations. For example, while gout occurs at a younger age and is more severe in Māori, there is less regular dispensing of urate-lowering therapies. Indigenous peoples are also under-represented in clinical trials. Herein, we will review inequities in gout using Aoteoaroa New Zealand as an example. We will explore reasons for health inequities and challenges that need to be faced to achieve health equity.

Creating an Indigenous Māori-centred model of relational health: A literature review of Māori models of health (2021)
This study highlights the importance and relevance of relational approaches to engaging Māori and their whānau accessing health services. It signals the necessary foundations for health practitioners to build trust-based relationships with Māori. Key elements for a Māori-centred model of relational care include whakawhanaungatanga (the process of building relationships) using tikanga (cultural protocols and processes) informed by cultural values of aroha (compassion and empathy), manaakitanga (kindness and hospitality), mauri (binding energy), wairua (importance of spiritual wellbeing).

My role in tackling health inequalities: a frameworkl for allied health professionals
KingdFund (2021)

The King’s Fund has worked with AHPs from across the UK to develop a framework to support any AHP to think through and understand their contribution to tackling health inequalities, whatever their role. The framework details how AHPs can raise awareness, take action and optimise advocacy through six lenses: self; patients; clinical teams, pathway and service groups; communities and networks; systems; and nurturing the future. 

The framework is designed to support AHPs to do whatever they can – large or small – to tackle health inequalities.

Rapua Te Ara Matua: Equity report
Waikato DHB (2021)

WDHB endorsed the report, taking active ownership and explicitly acknowledging their DHB is:

"embedded in a healthcare system which has privileged the needs of the majority while failing to meet the needs of all"
"Waikato DHB is party to the systematic failure to adequately address and eliminate equity gaps and provide services that are culturally competent and holistic for Tangata Whenua" 

The report provides a clear view of the inequities experienced by Māori people and Pacific people and the systemic failure they continue to receive. While some of the data is undoubtedly confronting- the reality is this is what our priority populations endure on a daily basis.

Among other actions, the report identified (and we may have heard this before..) "Māori-led structural change was needed within the DHB to address the gaps in health equity."

Telehealth as a tool for equity: pros, cons and recommendations
NZMJ. Issue: Vol 134 No 1530: 19 February 2021
In this viewpoint, we consider whether telehealth is an equity-positive tool that might help to overcome some important barriers to health care access for Māori and Pacific people. We consider the equity ramifications of a shift toward models of care that maximise the use of telehealth solutions, and our recommendations regard how we might best achieve the equity-positive potential of telehealth for Māori and Pacific people.

Achieving Equity in Health Outcomes: Summary of a discovery process.
Ministry of Health. 2019.
In 2018, the Ministry of Health initiated a work programme on achieving equity in health outcomes. Specifically, this programme aims to ensure that equity is at the heart of the way New Zealand’s health and disability system operates and to promote the cultural shift needed to achieve that.  This report provides a brief summary of phase one of the Achieving Equity Work Programme: The Discovery Phase. The aim of the discovery phase was to identify where practical and coordinated effort could be undertaken to achieve a measurable shift in health equity in the next three to five years. Through an examination of the literature; a review of evidence; and consideration of what people said needs to be tackled in the health and disability system, common challenges and opportunities for achieving health equity in Aotearoa/New Zealand have been explored.

The Waitangi Tribunal’s WAI 2575 Report: Implications for Decolonizing Health Systems
Health and Human Rights Journal (2020)
Te Tiriti o Waitangi, a treaty negotiated between Māori (the Indigenous peoples of Aotearoa) and the British Crown, affirmed Māori sovereignty and guaranteed the protection of hauora (health). The Waitangi Tribunal, established in 1975 to investigate alleged breaches of the agreement, released a major report in 2019 (registered as WAI 2575) about breaches of te Tiriti within the health sector in relation to primary care, legislation, and health policy. This article explores the implications of this report for the New Zealand health sector and the decolonial transformation of health systems. The tribunal found that the Crown has systematically contravened obligations under te Tiriti across the health sector. We complement the tribunal’s findings, through critical analysis, to make five substantive recommendations: (1) the adoption of Tiriti-compliant legislation and policy; (2) recognition of extant Māori political authority (tino rangatiratanga); (3) strengthening of accountability mechanisms; (4) investment in Māori health; and (5) embedding equity and anti-racism within the health sector. These recommendations are critical for upholding te Tiriti obligations. We see these requirements as making significant contributions to decolonizing health systems and policy in Aotearoa and thereby contributing to aspirations for health equity as a transformative concept.

Baseline Data Capture: Cultural Safety, Partnership and Health Equity Initiatives FINAL REPORT (2020)
The Medical Council of New Zealand, in partnership with Te Ohu Rata O Aotearoa (Te ORA), is pleased to release an independent report outlining findings of the current state of cultural safety and health equity delivered by doctors practicing in Aotearoa New Zealand and experienced by patients and whānau. Māori patients’ experiences are the focus of the report, however many of the challenges and solutions will be applicable to other ethnic groups and populations who experience inequitable healthcare.

Creating an Indigenous Māori‐centred model of relational health: A literature review of Māori models of health. Journal of Clinical Nursing. (2021)
This study highlights the importance and relevance of relational ap-proaches to engaging Māori and their whānau accessing health services. It signals the necessary foundations for health practitioners to build trust- based relation-ships with Māori. Key elements for a Māori-centred model of relational care include whakawhanaungatanga (the process of building relationships) using tikanga (cultural protocols and processes) informed by cultural values of aroha (compassion and empa-thy), manaakitanga (kindness and hospitality), mauri (binding energy), wairua (impor-tance of spiritual wellbeing).

Racism and health in Aotearoa New Zealand: a systematic review of quantitative studies (2020)
Quantitative racism and health research in New Zealand consistently finds that self-reported racial discrimination is associated with a range of poorer health outcomes and reduced access to and quality of healthcare. This review confirms that experience of racial discrimination is an important determinant of health in New Zealand, as it is internationally. There is a pressing need for effectively designed interventions to address the impacts of racism on health.

Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research (2020)
Australia and New Zealand Journal of Public Health
This paper aims to synthesise the broader perspectives of Māori patients and their whānau (extended family, family group) of their treatment within the public health system. Our research question was ‘What are the experiences of Māori in the public health and/or hospital system in Aotearoa New Zealand?’

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition [NZ]
International Journal for Equity in Health
There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care...A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development.

Tofa Saili: A review of evidence about health equity for Pacific Peoples in New Zealand'
Pacific Perspectives (2019)
This report describes the health equity issues faced by Pacific families and communities. The report highlights approaches based on Pacific values and the strengths of Pacific communities. It is informed by the Pacific Aotearoa vision (Ministry of Pacific Peoples, 2019).

A window on the quality of Aotearoa New Zealand's health care 2019 – a view on Māori health equity
HQSC, 2019
Every year the Commission publishes a document we call A window on the quality of Aotearoa New Zealand’s health care. The Window provides a snapshot of the quality of health care in the country. While equity has always been a component of the report’s analysis over its four-year history, this year’s report focuses solely on equity. 

A window on the quality of Aotearoa New Zealand’s health care 2019 – a view on Māori health equity (Window 2019) highlights a number of areas where change is needed in the health system. The report is divided into three chapters. The first analyses inequity between how Māori and non-Māori access and receive health services, and the effects on equity of improvement activities in our system. The second chapter asks why these inequities exist, and the third chapter addresses opportunities for improvement.

Understanding inequalities: summary report. The impact of inequalities in the early
years on outcomes over the life course: Using international evidence to identify creative policy solutions.
Growing up in New Zealand, 2019.
The findings from the Growing Up in New Zealand study demonstrate that Māori and Pasifika children experience the highest burden of socioeconomic disadvantage in their early years as well as an unequal burden of significant co-morbidities in terms of health and development throughout their life course. By the time they start school (at age 5 years) many are already falling behind their peers in terms of preparedness for formal education and readiness to engage in learning.

The study has shown that inequalities in developmental opportunities and outcomes have their origins in early in life. Risk factors for early vulnerability cluster and there is no one single proxy marker of disadvantage. Additionally, morbidity and poor outcomes cluster. Persistent adversity is associated with a graded likelihood of poor outcomes (across the population). Further service use is not meeting measured need. Currently, access to early life universal services may be widening inequalities. A proportional-universalism approach to services is required if they are to meet real need and reduce inequalities.

'HAUORA: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry'
Waitangi Tribunal. 

Our stage one report addresses claims concerning the way the primary health care system in New Zealand has been legislated, administered, funded, and monitored by the Crown since the passing of the New Zealand Public Health and Disability Act 2000 (‘the Act’) Statistics.  In our report we explore whether the persistent inequitable health outcomes suffered by Māori are indicators of Treaty breach. In doing so, we ask whether a cause of the inequitable health statistics suffered by Māori is the legislative and policy framework of the primary health care system itself.  n approaching our task, we identified four main thematic issues to focus on for this stage of the inquiry : the Treaty-compliance of the Act and framework ; funding arrangements for primary health care ; accountability arrangements for primary health care ; and the nature of Treaty partnership arrangements in the primary health care sector.

The health equity measurement framework: a comprehensive model to measure social inequities in health
International Journal for Equity in Health201918:36

Clinical research trials achieving equitable health outcomes for Māori.  ACTA International Clinical Trials Conference 2019. Assoc Prof Matire Harwood.Dept General Practice, FMHS, University of Auckland
Includes discussion of the model for 'Explaining Ethnic Determinants of Health'.

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study [NZ]
BMC Medical EducationBMC series – 201818:18 (2018)

Lessons for Achieving Health Equity Comparing Aotearoa/New Zealand and the United States [NZ]
Health Policy 2019
To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples’ self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programmes explicitly address root causes.

Achieving health equity in Aotearoa: strengthening responsiveness to Māori in health research (2017). 
N Z Med J. 2017 Nov 10;130(1465):96-103.
Excellent health research is essential for good health outcomes, services and systems. Health research should also build towards equity and in doing so ensure that no one is left behind. As recipients of government funding, researchers are increasingly required to demonstrate an understanding of their delegated responsibilities to undertake research that has the potential to address Māori health needs and priorities. These requirements form the basis of responsiveness to Māori in health research, and several research institutions have implemented systems to support their organisational approach to this endeavour. However, many health researchers have a narrow view of responsiveness to Māori and how it might be relevant to their work. In this viewpoint paper we provide an overview of existing frameworks that can be used to develop thinking and positioning in relation to the Treaty of Waitangi and responsiveness to Māori. We also describe an equity-based approach to responsiveness to Māori and highlight four key areas that require careful consideration, namely: (1) relevance to Māori; (2) Māori as participants; (3) promoting the Māori voice, and; (4) human tissue. Finally, we argue for greater engagement with responsiveness to Māori activities as part of our commitment to achieving equitable health outcomes.

The Determinants of Health for Pacific Children and Young People in New Zealand (2014) (Determinants of Health for Children and Young People). New Zealand Child and Youth Epidemiology Service (2016)

Te Ohonga Ake The Determinants of Health for Māori Children and Young People in New Zealand Series Two (2016) New Zealand Child and Youth Epidemiology Service (2016)

The cost of child health inequalities in Aotearoa New Zealand: a preliminary scoping study[NZ]
BMC Public Health 12.1 (2012): 1.

Geography matters: the prevalence of diabetes in the Auckland Region by age, gender and ethnicity [NZ]
New Zealand Medical Journal 2016; 129 (1436): 25-37

Health equity in the New Zealand health care system: a national survey. [NZ]
International Journal for Equity in Health 10.1 (2011): 1.

Health equity: what does it mean for child health [NZ]
New Zealand Medical Journal 2011; 124 (1347)

Policy implementation for health equity in Aotearoa: examining healthy eating and physical activity programmes in Maaori and Pasifika communities [NZ]
Paper prepared by Arnell Hinkle (2010)

Solutions to child poverty in New Zealand [NZ]
Report prepared for the Office of the Children;s Commissioner (2012)

The politics of Māori health (2016)

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) (1998)
The principal findings of this report are:

social, cultural and economic factors are the main determinants of health

there are persisting health inequalities as a result of socioeconomic factors in New
Zealand and some evidence that these may be worsening

current trends in many socioeconomic factors in New Zealand are likely to widen
health inequalities further

there are good reasons for intervening to reduce socioeconomic inequalities in health

there are evidence-based interventions for reducing these inequalities

Selected Journals

Australia and New Zealand Journal of Public Health

Māori Health Review [NZ]

Pacific Health Review [NZ]

Asian Health Review [NZ]

 last updated  22 October 2025

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