Achieving equity

Having a common understanding of equity is an essential foundation for coordinated and collaborative effort to achieve equity in health and wellness.

Definition of equity


Having a common understanding of equity is an essential foundation for coordinated and collaborative effort to achieve equity in health and wellness. The definition can be used in all work and engagements within the health and disability system including government agencies involved in the broader social and economic determinants of health. The definition can provide a common understanding of what is meant by equity.

The definition is designed to:

  • fit the New Zealand context
  • align with Te Tiriti o Waitangi obligations to go beyond just remedying disadvantage and reducing inequities, enabling Māori to flourish and lead their aspirations for health
  • be principle based
  • be inclusive enough to incorporate all possible dimensions of equity (indigenous, socio-economic, geographically, disability, etc.)
  • reflect the international literature on equity
  • reflect the definition put forward by the World Health Organization.

The definition

The Ministry’s definition of equity is:

In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes.

This definition of equity was signed-off by Director-General of Health, Dr Ashley Bloomfield, in March 2019.

Equity work programme

The Ministry’s Equity Work Programme aims to facilitate an equity focus across the health system’s operational landscape while promoting the cultural shift needed to affect the system change that achieves equity in health outcomes.

Collaboration is a key part of making equity real. We’re closely working with communities and organisations around Aotearoa New Zealand to make health outcomes more equitable.

In the video below, Keriana Brooking, former Deputy Director-General, Health System Improvement and Innovation and John Whaanga, Deputy Director-General, Māori Health, discuss their perspectives on achieving equity in health.

Equity perspectives

What does 'achieving equity' actually mean?

Keriana Brooking, Deputy Director-General, Health System Improvement and Innovation: People say if you're a Māori male with a disability or a mental health condition, your life expectancy is 25 years lower than if you're of the general population living on the North Shore.

And you would think in a country this size, to have such a stark difference in life expectancy would be something that we would all be incredibly concerned and want to proactively do something about.

This situation's been systemic: while life expectancy has increased for everybody, a gap still remains.

It might have narrowed, but we re now into a different conversation, which is not just about life expectancy, it's about healthy life expectancy.

So it's really hard to fathom for some people who have poor health that might not kill them, but low resources, how they will want to survive through living longer if actually their health is still not that great.

What are the greatest challenges for those working in the health system in improving equity?

John Whaanga, Deputy Director-General, Māori Health: The first thing is to understand that inequities exist.

We're lucky in a way in the health sector that we're able to get information quite quickly that shows us the state of things, and shows us where we have certain population groups led by Māori who are not doing well.

So I think that's the first thing we can do is understand and own that inequities exist. Secondly, I think it s to look at our own practice to say, can we do better?

Are we fairly treating all the people that come through our doors? Are we equally understanding of all the different cultural perspectives, aspirations that come through our door when we re providing services? Are there things we can we do better?

Challenging ourselves to understand that more of the same might not necessarily do anybody better, particularly those who are worse-off.

But I think it does start with understanding what equity is and how it exists, and then from my perspective it's about getting personal about it.

I take the view that I work in Māori health and Māori health improvement because I have a personal commitment to improve the socio economic circumstances of my people, and in doing that, contributing to New Zealand.

I don t see them as mutually exclusive. And so when I'm working I take my upbringing, my sense of community, the values that were instilled in me, and I take them into my workplace.

And for me that's what I need to do with equity.

I need to take it personally, and take on board a personal commitment, because achieving equity will be an accumulation of a whole lot of small things that people do.

And so each of us can contribute to achieving equity by doing the things we do better, by being open to look at new ways of doing things, and sometimes by challenging our own preconceptions about how things should work and being open to getting advice from people about different ways of looking at things.

How is the Ministry of Health definition of equity building understanding about equity?

Keriana: The thing that I think is really good about the equity definition is it is explicit about unjust and unfair.

I think for the health system and for New Zealand in general, the sooner I suppose that we accept and then act on the unjust and unfair part of our definition we've always known for a long time s it's been avoidable, we've always known for a long time that we need to do something about it but the real moral imperative I think of the area of both just and fair is something that New Zealand and the health system should really hold on to, because I think as new Zealanders, we consider ourselves to be both a just and fair society.

What's your role in relation to improving equity?

John: My role along with the Māori Health Directorate is to help set the agenda for action around the Ministry achieving its goals.

But I don t own those goals: achieving equity belongs to everybody in the Ministry, as it belongs to everybody in our sector.

It's not for me to own, it s for all of us to own and deliver on. So my role is to help shape some of the thinking, my role is to help provide some of the foundations for that thinking, and then to work with others in the Ministry to help them achieve it.

At the end of the day, they're the one's who know their business, they're the ones who know their responsibilities better than I do.

What we now have to do is put an equity lens across that to say are we doing the best we can do? Have we looked to see if what we re trying to put in place is in fact going to cause existing inequities to get worse?

What are we actually doing to address inequities?

Because one thing we do know is you do not address inequities indirectly, you must address them directly.

In the video below, former Director-General of Health Ashley Bloomfield shares his perspectives on achieving equity.

Equity perspectives: Dr Ashley Bloomfield, Director-General, Ministry of Health

What does 'achieving equity' actually mean?

Equity is quite a refined term. We might know what it means, we might have a definition.

However, what we should do is think about what it means for citizens: for New Zealanders.

One concept that people get, and it's something that's quite inherent in our national identity, is this concept of fairness. And equity, in a sense, is just a flash word for fairness.

So if you talked to people about, if someone accesses a health care service like a cancer treatment, and one person gets a different outcome from that treatment than another, that's not fair – people get that. If we try to couch it in terms like 'equity' and so on, then it may not resonate quite so much.

I think the example of immunisation in this country's a really good one.

Having trained in public health through the late-90s and the first part of the 2000s, we had not very good immunisation rates in this country, and particularly poor rates for Māori and Pacific children.

For Māori and Pacific, they were down in the 70s, and there was a very strong drive, a whole range of initiatives put in place to improve immunisation across the board for all children.

Most immunisations for most children, whether they're Māori or Pacific or non-Māori or non-Pacific, will be delivered in general practice by a nurse, so you might be able to get the first 80 percent of kids reasonably easily through that standard general practice visit.

But then to get the next 10 percent, there's a bit more effort required.

So that might require active recall, phoning the families, ensuring that they come in, and being opportunistic when they come in for other visits: for example an adult comes in for a consultation, asking about the children's vaccination status and actively immunising them then.

And then for that final five percent, it might require even more effort and therefore more resources. You might need to have dedicated teams who are going out and finding these children, going into their homes, and vaccinating them. So that's a really good example in my mind of applying an equity approach.

Or, in more technical language, you might call it 'proportionate universalism'. The two are not mutually exclusive - we have a universal health service: it's entitlement for all New Zealanders. But the degree of resource that we need to apply to ensure it's fair can, and should, differ, and that should be the experience of people. They should expect the system to deliver for them, regardless of what their level of need is.

If we improve our services – access to them and experience of services – for the people who perhaps are the most disadvantaged, everybody gets a benefit from that, not just because when they need to access services they are high quality and accessible, but actually we all benefit from having a healthier population.

There's us thinking more broadly about health, not just as an outcome, but health as an enabler of wellbeing, and wellbeing being about people being able to pursue their dreams and aspirations with their lives.

And health is just a key enabler of that.

So, I think everybody has the right to good health so that they can live their fulfilling life that they want to and achieve wellbeing.

How is the Ministry of Health definition of equity building understanding about equity?

I think this is a great bit of work that's been led out of the Ministry, working closely with others in the sector, with people with expertise, and also canvassing different views from different people to ensure that it does resonate, that people can understand it and get value from it.

I think it's a really good example of the Ministry's leadership in action, where we don't have all the expertise but we've got this role around convening.

It's been great to hear the feedback on that definition that's been very positive, not just about the definition but about the fact that the Ministry's led a process and come-up with a definition that's really useful. I think it will help guide the wider sector.

I just encourage staff to think all the time about 'how do we ensure what we're doing in our work is fair?

And, in particular, our starting point for the work should be – what does it mean for access to, for experience of, and for outcomes from care? – for the groups that are the most disadvantaged.

If that's the starting point, then you'll take an equity approach in all your work.

How will the new publication 'Achieving Equity in Health Outcomes' help achieve equity?

I'm really pleased to see us putting that publication out.

It canvasses the views that we've gone out and actively sought: it's analysed them and it just lays out the thoughts and ideas, and the aspirations I guess that people have in the sector for us to be able to achieve equity.

In the video below, Health Quality and Safety Commission Kaiwhakahaere Te Whai Oranga Kiri Rikihana talks about how collaboration is helping improve health equity.

[Title: Kiri Rikihana (HQSC) on health equity]

[Slide: How can we make health more equitable?]

[Kiri Rikihana to camera]

Improving equity and understanding equity starts with understanding of self, and how you go about your business day-to-day.

So what’s your privilege?

What are your biases in the work that you do?

How does your work affect others?

You need the data and you need the information to help understand how the work that you’re doing serves some populations well and may not serve other populations.

What’s the gap between the two, and what do you, what are the steps that you need to take to address that gap?

[Health Equity Assessment Tool cover image]

[Kiri Rikihana to camera]

There’s an amazing tool that’s been around since the 2000s called the Health Equity Assessment Tool: the HEAT Tool.

It’s the sort of tool that should be used on every piece of policy, every new programme because it helps to identify the gap between those that will benefit from a policy or a programme, and those that might not, and helps you, leads you through the steps to address that.

So I can’t recommend the HEAT Tool more highly.

[Achieving Equity in Health Outcomes cover image]

[Image of the Ministry's definition of equity]

I’ve been a part of the process as they’ve been consulting on the Ministry’s new Definition of Equity with the sector.

[Kiri Rikihana to camera]

And I love to see how it, the fact that we have a Definition for Equity that the sector can use, but also that it’s got some flexibility to have a different way of working with different populations depending on what they need.

[Slide: What is the Health Equity Hub?]

[Kiri Rikihana to camera]

Four years ago when I started working at the Health Quality and Safety Commission in my role as Kaiwhakahaere Te Whai Oranga, we realised very quickly that other organisations were grappling with what equity meant for them.

And for some of them it was about the difference for their patients or the consumers of health care, and for some it was about what it meant strategically for their organisation.

And so we decided that we needed to reach out to others to assist, to help us, but also for us to help them as well.

So it was really an opportunity to coalesce around this wicked problem.

Inequities are a wicked and thorny and difficult problem, and so we put the invitation out to all likeminded health organisations and we were really, really excited with the response.

So we’ve got PHARMAC and ACC, and we have a lot of the health colleges: the colleges of surgeons, and GPs, and so on.

And so, what we, it enables us to have a conversation about what equity means structurally, strategically and for the consumers and patients that we are looking after.

[Slide: What's the Health Equity Hub achieving?]

[Kiri Rikihana to camera]

What the Health Equity Hub is achieving is it’s giving a place and visibility for the conversation around equity to occur.

It’s not ignoring the fact that it’s hard for everyone to understand what it means, that there’ll be some people within your organisation who know what it is and actually can give you examples of work, what you can do differently, and there’ll be some people within the organisation who have no idea.

And so the Hub gives support to those individuals who are doing the hard work of transforming culture, and it also does what we’ve done with the Definition of Equity, provides a place where the organisations can come together and talk about it and say ‘does this, is this fit for us?’, you know, ‘does this suit us?’, ‘this is what our experience is’, so a conversation around how equity is going to look going into the future.

The Equity Work Programme was initiated in 2018 and has been supported by previous ELT members, including Alison Thom, former Acting Deputy Director-General Māori Health and Dr Jill Clendon, former Acting Chief Nursing Officer. Watch Alison and Jill discussing the importance of equity in the videos below.

Alison Thom, Former Māori Leadership, Senior Responsible Officer – Achieving equity

Kia ora. Nga mihi ki a kotou.

Addressing significant health disparities in Aotearoa New Zealand is both important and urgent. That Māori kids are much more likely than other kids to end up in ED, with issues that could’ve been dealt with easier and more early in primary care, is not ok. That people with serious mental health issues have a life expectancy 25 years less than others is shocking.

Delivering equitable outcomes to all New Zealanders is a priority for the Government, it’s a lead line in the New Zealand Health Strategy and it’s been something we’ve been working on for some time, with some gains. And yet still there are alarming inequalities when you look at the health and wellbeing of some groups of New Zealanders. Māori, Pasifika, people with disabilities and others.

It’s useful to talk about equity, to come to a common understanding and to figure out what we could be doing better. For instance, I often hear people talking about equity only in terms of access to services. Access to services is important, but it’s only one dimension of a very deeply ingrained, complex problem.

In short, inequity of health outcomes is a wicked problem and something that we all need to be working on. Some of the things that we should be thinking about include:

  • How resources are allocated.
  • Are services the right fit for people?
  • Are services accessible?
  • Is the system flexible and responsive to people, their needs and their circumstances?
  • And how does unconscious bias in the system play out for people’s health outcomes?

If the success of the New Zealand health system is measured by how it consistently delivers equitable outcomes to all New Zealanders, then we’ve got quite a bit of work to do.

So what are we doing here at the Ministry? I’m leading this key priority, Achieving equity, working right across the Ministry and also in partnership with the sector.

With this renewed focus on equity we know we’re not starting from scratch and we do know that everyone cares about this and everyone needs to be involved.

I look forward to keeping you updated on what we’re doing in this work programme and also to working with you to make a difference.

Noho ora mai.

Dr Jill Clendon, Former Chief Nursing Officer

Everything we do should have an equity lens on it. We need to be thinking about ‘if we do this activity over here, what does that mean for all of these groups in our population – what does this mean for Māori? What does it mean for Pacific? What does it mean for people on low incomes? How can the work that I do as a clinician, as a stakeholder in the health sector, the decisions that I make, the choices that I make around care provision – what does that look like in terms of an equity focus for those populations that need support to achieve the same outcomes as everybody else?’

So in New Zealand we’ve spent a lot of time looking at different definitions of equity from around the world. We wanted to take an approach that was going to give us something that was strengths-based, something that enables us to move forward in the conversations that we’re having around equity.

Those differences that people have in health are ‘not only avoidable but they’re also unfair and unjust’. So equity recognises that ‘different people have different levels of advantage, and that those different levels of advantage may require different approaches and resources to get the same outcomes.’ So that definition helps guide our work, helps guide our discussions, helps enable us as clinicians and as stakeholders in the sector to really focus our work, bring an equity lens to our work and understand the strengths-based approach that we can bring to working with those who have differences in outcomes, who are experiencing challenges around equity and how we can support them.

There are a number of barriers. I believe that one of the biggest barriers is ourselves, and it’s our understanding of what equity is and how we can really work on our own understanding of what equity is and how we can contribute in that space as clinicians.

Every single one of us has the ability to, and should be, working toward achieving equity in New Zealand. That is, every single clinician, every single manager, every single person needs to be thinking about the way they’re working, the way that they’re interacting, the cultural lens that they bring to their work, the strengths-based approach: considering ‘how does every single activity that I do, what actions do I take – how do they impact on the people that I’m working with, and how can I ensure that my activities result in improved equity, improved outcomes for the people that I’m working with?’

So we all absolutely have a role in this, it’s not just about the Ministry of Health having a high level definition of equity. It’s about every single one of us as clinicians, as workers, really working together to ensure that the work we do addresses equity issues.

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