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THE PROBLEM WITH NEEDS BASED HEALTH POLICY |
Denise Wilson, RN PhD FCNA(NZ) This article was originally going to review the status of our health policy with the formation of the ‘new' government post-election. To do this is rather premature as the government has just been announced, and reflects a move toward the centre-right. The Prime Minister, the Right Hon. Helen Clark, has indicated that the next term will be about ‘smart' policies, the exact nature of these policies and their influence on health is yet to be determined. It is, however, worth examining the ‘needs based' versus ‘race based' dialogue that emerged on the political landscape pre-election. As the ‘smart' policies for health are developed it is important to stand back and think about how what has gone on pre-election, may influence future health policies that as nurses and health professionals we will have to implement. The reactions to Don Brash's Orewa Speech (1) in January 2004 have created ripples (some would say tidal waves) on a pond, releasing an undercurrent of racism that has resulted in seemingly hasty reviews of government policy to ensure that what could be considered ‘race' based services are removed from view. The basis of this reaction lies in an underlying racism and the notion that socio-economic status alone is the cause for the disparities that exist in health. Therefore, it is concluded that ‘need' not ‘race' should be the defining factor for policy development and service delivery, and that socio-economic realities of individuals will determine their need. This notion appears to have been embraced with little critique of this shift in thinking and acting occurring, beginning by questioning whether it is ethnicity rather than race that is being referred to. The refocus on need has been accompanied by an underlying desire to ensure that we are all ‘one' people. But as Don Brash conceded in his Orewa Speech, Maori are far from a homogenous group, as are all those citizens who make up the diverse New Zealand population. The desire to achieve homogeneity within New Zealand, or more specifically what could be considered the social-engineering of Maori to be the same as other New Zealand citizens, resembles past assimilation policies that neglected the specific needs of Maori known to be necessary for Maori to thrive. Instead the ‘we are all one people' approach contributed to inequities and disparities in not only health status but also in education outcomes and socio-economic status. A notion of equality, where everyone receives the same, does little to recognise the diversity and difference that exists among a population or its sub-groups. Nor does it recognise that not everyone desires to be the same as others. The inequalities in health status that Maori experience have been a concern for not only Maori themselves but also for governments and health professionals over the last two decades. While gains in the health status of Maori have been made since the 1980s, they still experience a lower life expectancy when compared to other New Zealand citizens, access mainstream primary health services less, present to secondary health services acutely with often advanced conditions, and have less access to life-saving tertiary interventions. In short, their access and use of health services is of real concern. While the Decades of Disparity(2) report highlighted that those experiencing high deprivation are more likely to die earlier for all New Zealand citizens, Maori were still more likely to die compared to non-Maori who experienced the same level of deprivation. It is a fact that ethnic disparities in health exist and these extend beyond socio-economic status. The reality is that many Maori, as an ethnic group, experience some degree of compromised access, use, effectiveness, and quality of health services. Universal approaches to health care undertaken in the delivery of mainstream health services are not meeting their needs. This is evident from the continuing ‘gaps' in health status, and the ongoing pleas by Maori and other ethnic groups for culturally appropriate and acceptable health services. Determinants of health extend beyond the physical causes of ill-health or disease, and include other determinants. In addition to socio-economic status and physical influences, genetics, ethnicity, racism and the effects of colonisation (to name a few) are recognised determinants of health status. For example, genetics research is revealing differences in disease presentation between ethnic groups. Racism is becoming more prominent in the medical and health related literature and is seen to critically impact on health(3), with some believing it should be identified as a public health issue(4). Also the ongoing and intergenerational effects of colonisation on indigenous population on health status are of international concern, with colonised indigenous people, like Maori, experiencing poorer health status compared to other population groups within their country. Health is a socially and culturally constructed concept that is influenced by multiple factors beyond the sphere on an individual's control. There are many ways to achieve the same or an equal outcome. It is vital that health services are accessed in a timely manner so that health needs are identified and attended to in an appropriate way. He Korowai Oranga (the Maori Health Strategy) is an example of the previous Labour-led government negotiating this health strategy with Maori, maintaining its commitment to the Treaty of Waitangi and the Crown's ‘special relationship' with Maori. This strategy reflects the aspirations for Maori to achieve whanau ora as an overall goal, and affirms Maori approaches to health and wellbeing in order to achieve improved health outcomes. It is about meeting the unique health and wellbeing needs that extend beyond socio-economic needs. Maori specific policies are recognised as necessary to address and reduce the health disparities that exist(5). This is not simply Maori getting something ‘special' or ‘more', but being offered services that specifically address their needs with the aim that they enjoy the same health status as other ethnic groups within New Zealand. It is difficult to argue that race-based policy concerns exist in isolation from political motives. Indeed, the race-based/needs-based rhetoric is semantics aimed to appease the masses and risks disadvantaging Maori further, especially those who are in genuine need for Maori specific health policies and services. The political posturing that we have witnessed over recent times influences the way in which nurses and other health professionals are able to, or choose to, practise and ultimately work productively with Maori. As a nation and as a health profession, we need to be constantly working to ensure that at a minimum all citizens of New Zealand experience an equal health status. This requires nurses and others to think critically about ideas about health service delivery that are presented by those who are motivated by political gain. References:
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