Determining our Future

Foreword

Tēnā koutou

It is now 27 years since the National Health Committee (NHC) published its landmark report on 'The Social, Cultural and Economic Determinants of Health in New Zealand'. That report set out how most of health status is the result of factors outside health care. The 'building blocks' or determinants of good health sit across many of the silos we have established for Government policy and action. Nearly all are unevenly distributed, but the pattern of uneven distribution is consistent across them all, resulting in some population groups being consistently advantaged and others consistently disadvantaged, with resulting profound inequalities of health status.

I joined the NHC, and its sub-committee the Public Health Advisory Committee, shortly after the report was published. It was clear that the report had struck a chord. It was widely read and referenced, and our two committees were able to continue our investigation into the upstream factors driving patterns of health and illness.

Both of those committees are now long gone, but the Pae Ora Act 2022 created a new Public Health Advisory Committee, which I have had the honour and pleasure of chairing. It seemed timely to revisit these building blocks: are the factors identified by the NHC still driving health status? Are there new factors for us to take into account? How good a job have we collectively done of using the knowledge and tools developed a quarter of a century ago to improve health outcomes - and equity of outcomes? Above all: how can we do better?

This report should be a sobering one. It paints a mixed picture: there have been some improvements and glimpses of what is possible, though these have mostly been isolated and not translated into systemic improvement. The building blocks identified in 1998 remain the same, though some new factors are emerging that will likely have profound impacts on health status in the future. Despite what we know about what drives health status (and wellbeing outcomes in other sectors too), our responses have been too weak and fragmented to overcome institutional inertia and enable an effective response.

Yet against this gloomy picture positive options still exist. We can build on areas that have been making progress, and we can learn from those that have failed to make a difference. For me three critical lessons emerge. First, we need to understand that while our concern has been the building blocks of health status, these are the same factors that are the upstream drivers of every other aspect of wellbeing; addressing them will achieve positive outcomes across the whole range.

Secondly, creating effective government actions that are not hostage to sectoral silos will require clear and enduring commitment and direction from Ministers and chief executives, or else 'business as usual' will reassert itself. Thirdly, while it is the Government's job to create the environment for success through good policy settings and funding, successful programmes of action will be designed and implemented by iwi and hapū and by communities themselves. We need to trust and resource that process.

Ngā mihi

Kevin Hague
Chair

Public Health Advisory Committee Members

• Kevin Hague (Chair)
• Beverly Te Huia
• Professor Jason Gurney
• Associate Professor Ruth Cunningham
• Professor Peter Crampton
• Dr Caroline McElnay
• Faumuina Professor Fa’afetai Sopoaga

He mihi

Tēnā anō rā tātou katoa.

Tēnā anō hoki tātou i a rātou kua ngaro nei i te tirohanga kanohi, rātou i para i te ara e takahia nei e ngā uri whakaheke o te wā nei.

E mihi ana rā ki tā rātou i waiho mai ai, tā rātou tautoko mai i te kaupapa me te mana, te pūahoaho, te tauwhiro me te tohutohu me aha āhea. Nā ō rātou reo i āwhina te mahi raranga i te mahi kia kotahi.

Ko te pūrongo nei he whakaatatanga i te mahi tahi a rau ringa, a rau ngākau, a rau hinengaro kia tutuki ai te kaupapa. E mihi atu ana ki ngā kaipupuri i te mātauranga, ki ngā kaiarataki, ki ngā kairangahau, ki ngā kaitātari, ki ngā whānau i homai whakaaro kia taea ai te whakatutuki tā te pūrongo e kī nei.

Tēnā kia whakaingoatia ake i konei te hunga nei, ko Ian Lambie, ko Anna Stevenson, ko Huhana Hickey, ko Elana Curtis, ko Tristram Ingham, me Jacinta Fa’alili Fidow. 

Nā ō koutou whakaaro, tō koutou tūpato, tō koutou whakapau wā, i hōhonu ake ai, i kitea ai te ahunga o te mahi nei. E mihi ana ki tō koutou āta whakaaro me tō koutou ū ki te whakaaro kia kaha ake, kia tōkeke ake te wā kei mua i te aroaro.

Ehara te pūrongo nei i te takotoranga kōrero mō ngā mahi i tutuki engari he kokenga whakamua. E tono ana kia haere tonu ngā kōrero, kia pai ake ngā whakatau, kia mahi tahi.

Tēnā rā koutou i takahi nei i te ara o te panoni i ō mātou taha. 

Acknowledgements

We begin by acknowledging the unseen forces that guide and steady us – those who have come before and whose legacy continues to shape our journey.

We recognise those who have contributed to this kaupapa with insight, integrity, and care. Whether through leadership, research, lived experience, or advocacy – your voices have helped weave this work together.

This report stands as a reflection of many hands, hearts, and minds working together with purpose.  We acknowledge the knowledge holders, leaders, researchers, analysts, and whānau who contributed their insight and experience to shape what lies within these pages.

We especially thank our external reviewers: Ian Lambie, Anna Stevenson, Huhana Hickey, Elana Curtis, Tristram Ingham, and Jacinta Fa’alili Fidow. Your whakaaro, your care, and your time have added depth and direction to this work.  We are grateful for your openness, your clarity, and your commitment to building a stronger, more equitable future.

This report is not just a record – it is a stepping stone.  It invites further conversation, better decisions, and collective action. We thank you for walking with us in this journey toward change.

Executive summary

Determining our future health and wellbeing

Being healthy and well is much more than the absence of illness. Good health allows us to fulfil our potential and ‘live awesome lives’.¹ This report by the Public Health Advisory Committee (PHAC) looks forward to 2040 and examines how we can best improve health and wellbeing outcomes for everyone in Aotearoa New Zealand.

We are facing significant new challenges to our wellbeing, at a time when our health system is already over-stretched. Our population is more diverse, growing and ageing. The global political situation is changing and uncertain. There are increasing impacts of the climate crisis and environmental degradation, and potentially major effects on employment and society with increasing use of artificial intelligence (AI) and other digital technologies.

Twenty-five years on from the last major report on social, cultural, and economic determinants of health in Aotearoa New Zealand, this report brings together evidence on the health and wellbeing of our country, and what influences it. We use a wide range of sources, including findings from international and local research, evaluations of implementation experience, population data, and case studies. We draw on the experience and perspectives of community, iwi and public service leaders, and of young people, in understanding what is working and in proposing new approaches. These views have greatly enriched this report and the recommendations for action that PHAC offers.

What are the main influences on our health?

Many people think that individual behaviours and access to health care have the greatest effects on health, but this is not the case. Rather, health starts in our homes, schools and communities. Strong connections with our whānau and community, and where we live, work, learn and connect with the environment all have a greater influence on our health and wellbeing than health care. These influences are called the determinants of health.

The health system is also considered a determinant of health – and importantly, can reduce the impacts of poverty and other harmful exposures, and address the disabling consequences of health conditions. However, this report focuses primarily on factors outside health care, as these contribute significantly more than health care to our health and wellbeing.

Our health and wellbeing – tōtara in the forest of Tane

We use the image of tōtara trees in the forest as a metaphor to explore the influences that shape our health and wellbeing (Figure 1). The tōtara represents a person and their whānau. The tree’s health and growth depend on having fertile soil, stable bedrock and a healthy environment. The tree’s leaves and fruit are signs of growth which illustrate our health and wellbeing outcomes. These are the outward signs of what is happening under the soil and inside the tree.

The soil represents resources, such as having a secure home, access to healthy food and a stable income. These resources (or determinants) nourish us, so we can flourish and thrive. Trees get stability from their roots, which are part of a root network they share with other trees. People do best when they have strong relationships and connections, through whakapapa, shared interests or being part of a community. In this way the root networks illustrate our whānau and community connections.

Figure 1: Tōtara in the forest of Tane

The bedrock below the forest and soil is its foundation. In the same way, human rights, the right to health and Te Tiriti o Waitangi are fundamental to our society and wellbeing in Aotearoa New Zealand. They guarantee our freedoms, rights and obligations to each other. However, there are other elements in the bedrock and soil today which negatively influence the health and wellbeing of the forest. Discrimination, racism, the ongoing impacts of colonisation, and our current type of economic system are some of the structural issues in the bedrock of our society which create unequal access to the soil, the resources for health and wellbeing. 

This means that the determinants of health are not evenly spread across our society. For example, people living in less well-off communities are often exposed to multiple health damaging factors such as poorer working conditions, low incomes, greater traffic and air pollution, and lower quality housing, than people in more advantaged communities. Disabled people face discrimination in employment, earn lower incomes, and have poorer access to suitable housing. The determinants do not operate independently but act together, often with compounding effects.

How is Aotearoa New Zealand tracking?

Trends in determinants since 2000

Despite some progress overall, our review shows that since 2000, significant differences by socioeconomic status, ethnic group, disability and age have persisted across important determinants of health, including income, employment, and education. Indicators have gone backwards for all of us since 2000 in some critical areas, such as housing affordability, household crowding, food security, the quality of our natural environment, and levels of trust in government and within communities. (Section 3).

Young people told us that the cost of living and financial stressors are their greatest immediate concerns, limiting the opportunities they can take up and affecting their mental health. Many young people also feel overwhelmed, anxious, or angry about the climate crisis, pollution, the global situation, and inaction from decision-makers.

Trends in health outcomes since 2000

The report assesses progress in the health of our communities over the last 25 years, and what we have learned. Although overall we live longer lives, and important gains have been made over the last 25 years, these benefits have not been equally shared. This is reflected in persistent, but preventable, differences in health outcomes and life expectancy between communities in our country. These inequities largely parallel the trends we see in health determinants.

Health inequities today remain striking, as illustrated by how long we can expect to live. Children growing up in our most urban areas today can expect to live four years longer than those in the most rural areas. A Pākehā (European New Zealander) baby boy born in Waikato today can expect to live eight years longer than his Māori neighbour. Pākehā children can expect to live to 84 years in the northern region, seven years longer than Pacific peoples’ children – a gap that has increased since 2000.

In addition, complex long-term conditions such as diabetes are more prevalent, and our mental health is poorer, especially for children and young people. We are less physically active and more of us have unhealthy excess weight, contributing to diabetes, cancers, and disability. Our health system is under huge pressure – and we have a growing and ageing population which will increase these pressures. 

Why is it important to reduce inequities in health?

A healthy cohesive society and a resilient prosperous economy are key goals for government and are deeply intertwined. Inaction on health inequities has significant costs – predominantly for whānau and communities – but also for our health system and economy. Improving health and wellbeing through addressing the determinants that shape our health can reduce health system pressures. Improving health and reducing inequities in important health outcomes such as communicable diseases, youth mental health, and alcohol harm has collective benefits for all of us.

Te Tiriti o Waitangi reaffirms tino rangatiratanga for Māori and a place for non-Māori to live in Aotearoa New Zealand. In Te Tiriti, the Crown (our government) has committed to protect Māori health and deliver the best health outcomes for everyone. By 2040 it will be 200 years since our ancestors and tūpuna signed Te Tiriti o Waitangi, and we must achieve real and sustained progress in this partnership and in health outcomes for Māori.

Faced with unequal economic and social circumstances in Aotearoa New Zealand, and persistent disparities in health and wellbeing, many New Zealanders are worried about this lack of fairness. There are concerns especially for our children and young people, and the negative impacts that these inequities have on cohesion and sense of togetherness in our communities.

The good news is that these influences on our health are not fixed or inevitable. We can modify them through the social and economic policies and programmes we choose to implement. In this report we assess some of the areas of progress since 2000, such as the reduction in child poverty, and how positive change can be created. We also summarise evidence about policies and programmes that show effectiveness in improving wellbeing and reducing health inequities.

New challenges are shaping our wellbeing

We discuss some important current and emerging challenges to our health and wellbeing. Commercial entities such as the food, alcohol and tobacco and fossil fuel industries and their practices influence our health, directly and indirectly. We consider the potential impacts of the ‘megatrends’ – the climate crisis, and AI and digital technology, which will affect all aspects of our society in the coming decades.

So, what do we need to do?

In the face of the challenges shaping our future, PHAC’s recommendations to the Minister of Health and government for improving health equity and wellbeing are grouped around three main themes. Developing agreed multi-partisan, longer term wellbeing goals is a critical step for government to achieving health equity and wellbeing. The actions we propose reflect our assessment of the evidence and what we have heard from community, iwi and public service leaders, and young people. These actions are presented in more detail in the final section of the report. 

PHAC recommends that government:

• Invest in and empower communities, the root network of our forest. Wellbeing, social cohesion, economic prosperity, and health start within whānau and communities. Their mana, aspirations for self-determination, capacity and strengths are fundamentals to build on. Early support for children and their families is vital to improving health equity and wellbeing across the life course.
  • The whole public service needs to work collectively across government to achieve agreed wellbeing goals with communities. This requires making changes in the way public services work together, to enable and empower communities.
• Strengthen our bedrock, the fundamental structures of our society so that all New Zealanders have access to the resources they need to thrive.
  • We propose initiating a discussion on Te Tiriti o Waitangi as we move towards 2040, about how we want to govern our country.
  • Human rights need to be embedded further into our laws, public policies, and practice.
  • The government needs to articulate an explicit approach to economic growth, societal wellbeing and equity. We need an economic system that is more equitable and redistributive by design. Further use of income and wealth tax levers is needed to reduce income and wealth inequities, and to support adequate investment in social and health services.
• Invest in ‘win-win’ solutions that nourish the soil and which have compounding benefits for health and other social outcomes. 
  Solutions for existential challenges like the climate crisis sit outside the health system, but can be ‘win-win’, with benefits for health equity, and for other positive social, economic, and environmental outcomes.

While the focus of this report is on the determinants of health outside the health system, we recognise the important contribution health care makes to our health and wellbeing. We propose recommendations for the health system that align with the three themes above. The health system must retain health equity as a key goal. An equitable, accessible and non-discriminatory health system is core to realising a healthy future for us all.

Introduction

Good health allows us to fulfil our potential and ‘live awesome lives’.¹ This report by the Public Health Advisory Committee (PHAC) looks forward to 2040 and examines how we can best improve health and wellbeing outcomes in Aotearoa New Zealand for everyone.

Today, our health care system is facing huge pressures. Every day the headlines tell us there is a health ‘crisis’: ‘epidemics’ of diabetes and youth mental health, long waiting lists for hospital care, problems accessing primary care, inadequate staffing and unaffordable treatments.^2-4 We are also facing significant new demographic, environmental, and societal challenges which will strongly influence our future health and wellbeing.

Health starts in our homes, schools and communities. Strong connections with our whānau and community, and where we live, work, learn and connect with the environment all have a greater influence on our health and wellbeing than health care or individual behaviours. These influences are called the ‘determinants of health’.^5-7 Twenty-five years on from the last major report on determinants of health in Aotearoa New Zealand,⁸ the PHAC assesses progress in the health of our nation, what we have learned, and examines new and emerging challenges.

Evaluating the effects of big societal and policy changes on health and wellbeing is not like assessing the result of a single intervention in a randomised controlled study. Our society is complex and there can be unexpected or unintended effects. So, we bring together evidence from a wide range of sources on the health and wellbeing of our country, and what influences it. This includes research findings, evaluations of policy and programme implementation experience here and internationally, trends in population data since 2000, and case studies.

We also draw on the experience and perspectives of community, iwi and public service leaders, and of young people, to understand what is working and to propose new approaches. These views have greatly enriched this report and the actions we propose. Throughout the report we have included the voices of people we spoke with. Our methods are detailed further in Appendix 1.

In the final section we recommend actions to the Minister of Health, whole of government and the health sector. Many of these actions are ‘win-win’– they address the big challenges like the climate crisis, and at the same time they can significantly improve health equity and wellbeing outcomes in all our communities.

Challenges to our health and wellbeing

A changing society

By 2040 the population of Aotearoa New Zealand is predicted to reach 6 million.⁹ More of us will live in urban areas, with Auckland growing faster than other cities. Our society will be very diverse and have large populations of young Māori (>1 million), young Pacific peoples (>650,000) and young Asian peoples (>1 million).⁹ One-third of children will identify as Māori, and one in five as Pacific peoples. At the same time, in each ethnic group, the number and proportion of people over 65 years will increase.⁹

The demand on our health system is expected to significantly increase as our population grows and ages, and more people experience chronic conditions such as diabetes, cancer, and mental health conditions.^2,10 Given current trajectories, many more of us will experience impairments (disabilities) associated with these conditions and with ageing. Demand will also increase as we continue developing new, and often expensive, treatments.^11,12

Entrenched and unfair differences in health

Aotearoa New Zealand has entrenched but preventable differences in the health of different populations, with poorer outcomes disproportionately experienced by Māori and Pacific peoples. ^{i, 13,14} Children growing up in our most urban areas can expect to live four years longer than those in the most rural areas.

Girls growing up in the most socio-economically advantaged areas of our country will live five years longer than girls in the least advantaged areas. Despite some reduction in the life expectancy gap between Māori and Pākehā (European New Zealanders) since 2000, a Pākehā baby boy born in Hamilton today can expect to live eight and a half years longer than his Māori neighbour.

Pākehā children can expect to live to 84 years in the northern region, seven years longer than Pacific peoples’ children – a gap that has increased since 2000.¹⁵ The loss of potential wellbeing and experience of poor health impacts most on those directly affected and their families, but these losses diminish the overall wellbeing of us all.

[i] In Aotearoa New Zealand, ‘Pacific peoples’ is a collective term for diverse ethnic groups that trace their origins to indigenous peoples of the island nations of the Pacific, such as Tonga, Samoa, Niue, and the Cook Islands.

New challenges shaping our future wellbeing

In the coming decades there are important global and local influences – trade, economic and geopolitical changes, digital technologies, the climate crisis and environmental degradation – that will have increasing impacts on our health and wellbeing.^16,17 By 2040 our environment will face extensive effects of climate change and biodiversity loss.¹⁷ Our society is likely to be dramatically changed through artificial intelligence (AI) and other technologies.^18,19 Global geopolitics may be more confronting, and global and regional migration patterns may change.¹⁶ While the impact of these challenges is still uncertain, they have the potential to threaten our wellbeing and social cohesion, and destabilise our society and governance.

Why do we need to act?

In addition to responding to these demographic, environmental and social challenges, there are further fundamental reasons for action to achieve a healthy society. A healthy, cohesive society and resilient, prosperous economy are key goals for government.^20,21 A productive resilient economy needs healthy people, and greater disparities in health are associated with poorer economic performance of countries.²² Inaction on health inequities has significant costs – predominantly for whānau and for our society, but also for our health system and economy.²³ Improving health and wellbeing through addressing the determinants of health can reduce health system pressures. 

Social and economic prosperity are linked and depend on each other. Ensuring this concept is at the heart of our decision-making is important for achieving sustainable wellbeing, equity and greater self-reliance.²¹

In Te Tiriti o Waitangi, the Crown (our government) has committed to protecting Māori health and delivering the best health outcomes for everyone. Te Tiriti o Waitangi reaffirms tino rangatiratanga (sovereignty) for Māori and a place for non-Māori to live in Aotearoa.²⁴ By 2040 it will be 200 years since our ancestors and tūpuna signed Te Tiriti o Waitangi, and we must achieve real and sustained progress in honouring this relationship, putting Crown commitments into practice, and upholding the Crown’s obligations in relation to hauora Māori.

Improving health and reducing inequities in health outcomes such as communicable diseases, youth mental health and alcohol harm has benefits for all of us – as these have collective impacts, not just at an individual level.

Finally, these influences on our health are not fixed or inevitable. We can modify them through the social and economic policies and programmes we choose to implement.

We acknowledge health care is also an important determinant of health, which can reduce the impacts of poverty, toxic exposures and disability. However, this report focuses primarily on factors outside of health care, that contribute significantly more to our health and wellbeing. 

An alternative approach is needed

If we keep on with ‘business as usual’, our health system will become increasingly costly and over-burdened, and collectively we will have less optimal health outcomes. But as noted above, international and local research shows that health care does not make the biggest contribution to our wellbeing and health outcomes, or how these outcomes are distributed.^7,25 Where we live, our job, income, wealth and resources, our knowledge, skills, and sense of community and connectedness contribute significantly more. This is the rationale for our approach in focusing on and addressing these determinants of health.^6,7

In addition, many of the factors associated with poor health in Aotearoa New Zealand are strongly patterned by socioeconomic status and ethnicity. Toxic environmental exposures such as poverty, poor housing, water and air pollution, and food insecurity are unevenly distributed in our society. These factors are often interrelated and have complex and cumulative effects throughout our life, from birth to death, and across generations.²⁶ Modifying these determinants can more effectively influence our overall health and wellbeing than provision of health care. 

Outline of this report

Section 1 introduces PHAC’s vision of health and wellbeing, how determinants affect us as individuals and whānau, and the metaphor of tōtara and trees in a forest that illustrates this. It provides the background to the development of this report.

Section 2 synthesises evidence for relationships between the main determinants of health and their interconnections, and examines what drives these relationships. In this section, we also examine the biological mechanisms that explain how some determinants affect our mental and physical health. We consider why it is important that our society addresses entrenched and unfair health differences, particularly in the face of uncertainty and rapid societal changes.

Section 3 looks back to trends in key determinants of health equity and health outcomes over the last 25 years, while Section 4 looks to the future, identifying new or recently recognised influences on our health that will become increasingly important. These include AI and the digital environment, commercial interests and the climate crisis.

Section 5 reviews progress and outcomes since 2000 in some key policy areas that influence wellbeing, through the perspectives of community, iwi and public services leaders. We identify evidence for successful policies that can improve health equity.

Section 6 proposes actions for government. These were developed through review of implementation experience and research evidence in Aotearoa New Zealand and internationally; the learnings of community, iwi and public services leaders; and the perspectives of young people. We illustrate potential actions with two case studies (Appendix 2).

Good solutions can compound wellbeing benefits, including economic benefits. We propose ways to address today’s health inequities and improve everyone’s health, while addressing the significant challenges confronting our society.

1. Our vision – a healthy tōtara

Health and wellbeing are important to us all. Health encompasses our physical, mental, social, cultural and spiritual wellbeing. We experience good health and wellbeing in a personal and a collective sense. Our wellbeing is affected by our connections to our whānau, community and place, through whakapapa and whenua; our beliefs and sense of agency; our life experiences, and our genetic makeup.^7,27-29

From decades of research, we know that these personal and collective factors, combined with other key factors in our lives (where we live, our job, wealth, earnings, resources, knowledge and skills), contribute much more to our wellbeing and health than health care alone.^7,30,31 At an individual and collective level, these factors together produce combined, cumulative effects across our lives. Good health itself acts as a resource for future wellbeing, like a self-reinforcing spiral. For example, children whose health needs are met are more likely to fulfil their educational potential. This has a positive impact on our society and economy, and the health and wellbeing of the next generation.

Tōtara in the forest of Tane

We use the image of tōtara trees in the forest as a metaphor to explore the influences that shape our health (Figure 2). Trees in a forest appear simple, but they are part of complex and interrelated structures, systems and processes, like those of our whānau, communities and society. The diversity in our society reflects the biodiversity we see in a healthy forest.

The tōtara represents a person and their whānau. The tree’s health and growth depend on having strong root networks, fertile soil, a stable bedrock and healthy environment. The tree’s leaves and fruit are signs of growth, illustrating our health and wellbeing outcomes. These are the outward signs of what is happening under the soil and inside the tree.

The soil represents resources (determinants) like having a secure home, access to healthy food and a stable income. These conditions nourish us, so we can flourish and thrive. Trees get stability from their roots, which are part of a root network they share with other trees. This network helps the tōtara weather storms or other adverse events. People do best when they have strong relationships and connections, through whakapapa, shared interests or being part of a community. The root networks illustrate these whānau and community connections.

The bedrock below the forest is its foundation. Investing in the conditions that will nurture society as a whole enriches the bedrock and soil. In this way, human rights, our rights to health, and Te Tiriti o Waitangi, are fundamental to our society, relationships and wellbeing in Aotearoa New Zealand. They guarantee our freedoms and obligations to each other. Our economic and justice systems are other important elements in the bedrock. 

Figure 2. Tōtara in the forest of Tane

There are elements in the bedrock and soil today which negatively influence the health and wellbeing of the forest. Discrimination, racism and colonisation, and our current economic model are some of the structural issues in the bedrock of our society which continue to create unequal access to resources. In addition, the climate crisis, and the transformation of work and society that we expect AI to bring, are further critical challenges for the bedrock of our society. These ‘megatrends‘ are predicted to strongly influence our future health and wellbeing.^16,32

Our vision of health and wellbeing

In many consultations, hui and talanoa led by the health system in recent years, communities across Aotearoa New Zealand have expressed what good health and wellbeing mean to them, and the importance of the relationships and resources that contribute to that (Appendix 1). Communities want whānau to prosper and ‘live awesome lives’,¹ achieving their potential in positive engagement with their community and their environment. The thriving tōtara in the forest illustrates this idea.

[Being healthy means] living a full life surrounded by whānau doing things that matter.³³

PHAC’s vision of health is of intergenerational wellbeing (pae ora), where everyone’s potential is realised, and where we live collectively with a sense of belonging in a healthy, sustainable environment (te taiao). This vision of health and wellbeing is guided by two ‘touchstones’ or positive elements of our bedrock: the right to healthⁱⁱ and Te Tiriti o Waitangi. Te Tiriti o Waitangi affirms the right to health and underpins our vision for wellbeing in Aotearoa. It is a foundational commitment that shapes our relationships, how our society is organised and the rights and obligations we all hold.

[ii] The right to health is referred to in international treaties, including the International Covenant on Economic, Social and Cultural Rights and the United Nations Declaration on the Rights of Indigenous Peoples. It encompasses the determinants of health.

The right to health

Health is a fundamental human right.^34,35 Everyone has the right to enjoy the best physical, mental and spiritual health possible, and to access high quality health care that they need. Every family, regardless of who they are, where they live or how much they earn, should have the resources they need to ensure their children grow up healthy and have the opportunities to live their best lives.

‘Health equity’ is achieved when everyone can reach their full health and wellbeing potential.³² It implies that resources are distributed and processes are designed in ways most likely to equalise the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts.³⁶ Health equity is a right to ‘substantive equality’, which means people having equal opportunities and outcomes across multiple dimensions. In contrast, ‘formal equality’ means treating everyone equally, based on the norms of society’s dominant group.³⁷

Te Tiriti o Waitangi

In Te Tiriti o Waitangi, the Crown–Māori relationship acknowledges the responsibility of the Crown (our government) to govern (kawanatanga, Article 1); reaffirms the sovereignty of Māori chiefs (tino rangatiratanga, Article 2); and promises equity (ōritetanga or rite tahi, Article 3). PHAC recognises the government’s obligations to uphold Te Tiriti, which reaffirms Māori rights and lays a foundation for a just and equitable society for all in Aotearoa New Zealand.

We acknowledge the five principles that guide the health system, articulated by the Waitangi Tribunal in 2019.

• Tino rangatiratanga
• Equity
• Active protection
• Options
• Partnership.

The Pae Ora Act (2022) embedded the Crown’s intention to give effect to Te Tiriti o Waitangi in the health system in legislation.^39-42 PHAC supports reparative and restorative justice processes, recognising and acting on past and current injustices.

In the tōtara tree metaphor, the soil above the bedrock that nurtures the tree’s roots represents the expression of our rights and the more immediate influences this has on whānau wellbeing (such as adequate incomes, sustainable employment, equity in education, strong cultural identity, and safe and secure housing). When people’s rights are not observed or respected, access to resources for wellbeing, or the determinants of health, is more unequal. This results in inequities in the health and wellbeing of whānau and communities. 

Whakapapa of this report

Knowledge of the importance of the relationships between good health and wellbeing and the determinants is not new. Understanding this history provides important context for where we are now. Oranga (the Māori world view of wellbeing) acknowledges that wellbeing is interconnected with whakapapa and identity, our environment, and whānau or family group.²⁸

One could not be well if one’s whakapapa was disrupted, as it was from one’s whakapapa that knowledge about te ao Māori and self and group identity was sourced. One could not be well if one’s connection to the whenua was lost, as it was from the whenua that one’s self- and group identity, belonging, and nourishment was activated and practiced. One could not be well without whānau, the most intimate social unit within which one learned about and practiced the reciprocity of caregiving, nurturing, and the giving of security.²⁸

Contemporary public health practice and determinants of health

Contemporary public health practice developed in the 19th century in parallel with the Industrial Revolution in Europe and the USA, and as a key tool of the European colonial project.^43,44 The Industrial Revolution was accompanied by extreme poverty and atrocious working conditions, which had highly detrimental social and health impacts. Workplace injuries and death were common, and severely polluted water and air caused illness, epidemics and death. This situation led to the first Public Health Act in England in 1848. The Act triggered major policy changes to improve living and working conditions. This resulted in improved life expectancy for everyone, well before modern medical treatment was available.⁴⁵

In Aotearoa New Zealand, the history of public health is intimately linked with important determinants of health: colonisation, urban planning and the control of infectious diseases (through improved housing, safe water, access to health care, etc.).^46,47 Following the Great Depression of the 1930s, major reforms of many key determinants occurred, including employment and income support, the introduction of superannuation and public health care, and strategies to advance economic development, wellbeing and health outcomes.^48,49

Over the last three decades, public health researchers and practitioners in Aotearoa New Zealand have focused on understanding how determinants such as housing, urban transport, environmental factors, and racism and discrimination influence our wellbeing. The timeline in Appendix 3 shows some key public health research and reports that have been influential here and internationally in developing our knowledge, experience, and actions on determinants of health.

Previous Advisory Committee reports

In 1998, the National Health Committee (NHC)ⁱⁱⁱ published The Social, Cultural and Economic Determinants of Health in New Zealand: Action to Improve Health.⁸ This report summarised evidence on determinants of health in Aotearoa New Zealand. It recommended strategies that the health sector could implement to reduce socioeconomic inequalities in health and noted the importance of policies and interventions outside the health sector.

The Public Health Advisory Committee of the time then published The Effect of Environmental Factors on the Health of New Zealanders in 2002,⁵⁰ and A Way Forward: Public Policy and the Economic Determinants of Health in 2004.⁵¹

The first publication examined environmental issues linked to ill health and health inequalities (such as air and water quality) and issues emerging at that time (such as climate change and health in urban environments). The second publication explored the relationship between socioeconomic status and health.

These reports had considerable influence on public health, health system thinking, and actions on determinants of health and health equity in Aotearoa New Zealand.⁵² They inform how we approached this report in 2025, while contemporary evidence and perspectives have enlarged our understanding and provided new insights on present and future challenges.

[iii] The National Health Committee (NHC) existed in various forms from 1993-2016. The Public Health Advisory Committee was established as a sub-committee of the NHC in 2001 and formally dis-established in 2016, along with the NHC. The current PHAC was established under the Pae Ora Act in 2022 [Skegg, D. The Health of the People (2019). BWB Books].

Social and environmental changes since 1998

Our society and health system have changed significantly since the 1998 NHC report. We summarise key changes here, with further data and analysis provided in Section 3 and Appendix 4.

Changes to our population

Since the 1990s, our population has grown to over 5 million. Migration patterns have also changed – we are now a more diverse society, particularly in urban centres. Nearly two-thirds of Pacific peoples in Aotearoa New Zealand live in Auckland, which is now the world’s biggest urban centre for Pacific peoples. Two-thirds of Aotearoa New Zealand’s Asian peoples also live in Auckland.^53,54

Changes to how we see ourselves

Māori understandings about identity and belonging increasingly influence the collective national identity.^55,56 Māori media has had a major impact on the public’s understanding of issues that are important to Māori and Aotearoa New Zealand. More of us speak te reo Māori, and most of us believe Te Tiriti o Waitangi is an important partnership that must be honoured.⁵⁷ There has been settlement of some significant Treaty of Waitangi claims and government investment in line with Treaty commitments.⁵⁸

The Māori economy, including iwi-led enterprises, has grown significantly, and now outperforms Aotearoa New Zealand’s overall economic indicators.⁵⁹ The Māori tourism industry alone is worth more than $1.2 billion annually. On average, Māori tourism businesses generate more employment opportunities and pay higher salaries than non-Māori tourism businesses.⁶⁰ 

Changes to technology and education

Relying on technology is part of my everyday life. [Rangatahi, The HIVE]

Our society and systems are now driven by digital technologies that have revolutionised the way we live, work, learn, and play. The rate at which these technologies advance sometimes outpaces our ability to adequately mitigate risks and harms. Since 2000, there has been widespread – if still uneven – uptake of internet, digital technologies and social media. This has both major benefits and some negative social impacts, particularly for younger people.

[Social media] feeds misogyny amongst young men and Instagram encourages it… Dating apps suck for body image and the gender difference, meaning you get so used to rejection and makes meeting people feel less important. [Rangatahi, The HIVE]

Our education system has also changed significantly. New Zealanders, especially women, are more likely to study at tertiary level, to study at older ages, and are more qualified.⁶¹ The kōhanga reo movement, kura kaupapa Māori and whare wānanga have visibly contributed to Māori whānau development, educational achievement, leadership and wider success. 

Changes to our wealth

Since 2000 there have been small reductions in income inequality as a result of progressive tax and welfare transfers, but we still have large differences in wealth.⁶² Increasing globalisation and neoliberal economic policies have been associated with more casual and precarious employment, declines in home ownership and affordability, and increased rental stress.^63,64 Improvements up to 2022 in child poverty rates and household food security measure have stalled or reversed since 2023. 

Figure 3. The persistent relationships between ethnicity and socioeconomic deprivation (NZDep) in Aotearoa New Zealand, 1991-2023

non-Māori non-Pacific non-Asian

Asian

Māori

Pacific

Source: Crampton P. The persistent relationships between ethnicity and socioeconomic deprivation in Aotearoa (NZDep) 1991 and 2023. Personal communication; 2025⁶⁵

Figure 3 shows the proportion of each ethnic grouping by NZDep, in 1991 and in 2023. NZDep measures the level of socio-economic deprivation for people in small areas, based on nine Census variables. NZDep is displayed as deciles (10%), with each decile containing about 10% of small areas in New Zealand. Decile 1 represents areas with the least deprived scores and Decile 10 represents areas with the most deprived scores.⁶⁷

If socioeconomic deprivation were independent of ethnicity, each ethnic group would be equally distributed across the deprivation deciles (all the bars would be equal in height). However, the distribution is highly unequal: more than half the Māori population lives in the most deprived neighbourhoods (deciles 8–10). The Pacific population is even more skewed towards the most deprived deciles.

This negative relationship shown in Figure 3 between ethnicity and material deprivation in Aotearoa New Zealand, known as the ‘distribution gap’,⁶⁶ remains largely unchanged since 1991.⁶⁵ It reveals that the social and economic structures of opportunity and privilege in our country are profoundly patterned by colonisation and racism, and there remain significant obstacles to systemic and societal change. 

Changes to our natural environment

Our natural environment is under stress. We are experiencing more frequent severe weather events, and our environment (especially our rivers and lakes) is degrading. Over half of our rivers have moderate or severe organic pollution or nutrient enrichment, which often makes them unfit for swimming or drinking.¹⁷

Most of our indigenous marine and freshwater bird species are threatened with extinction, or are at risk of becoming threatened.¹⁷ Microplastics (pieces of plastic that are less than 5mm long which are formed when larger plastics break down) are now widespread throughout our marine environment and in freshwater organisms.¹⁷ Groundwater nitrates already exceed human health-based limits in parts of Canterbury, Waikato and Southland, mainly due to farm fertiliser run off.⁶⁸ Without any intervention, nitrate levels are projected to increase further.⁶⁹

Improvements to our health and wellbeing

Despite the ongoing challenges to achieving health equity, interventions in Aotearoa New Zealand’s health sector since 2000 have led to population health gains. Since 2000, the life expectancy gap between Māori and other ethnicities has been narrowing. It was 8.3 years in 2001-2003 and had reduced to 6.6 years by 2020-2022, a 20% decrease. Inequities in some other health outcomes have also decreased modestly, such as infant mortality.¹⁵

Public health programmes and interventions

Public health programmes and cross-sectoral interventions have contributed to improved health outcomes and life expectancy for all population groups. Programmes and policies such as immunisation, cancer screening, Smokefree Aotearoa 2025 and Healthy Homes standards have led to significant reductions in vaccine preventable diseases, cervical cancer, and health-damaging factors, such as smoking. ^15,70 

Although we are now living longer, more of us live with chronic conditions and their consequences, and some risks for ill health have worsened. We are less physically active now, and one in three adults has unhealthy levels of excess body weight (nearly double the proportion in 1998).⁷⁶ Other measures indicate our mental wellbeing has declined, especially for young people.⁷⁶ We have the highest rate of suicide in young people and children in the OECD.⁷⁷ An overall reduction in total population mortality has not necessarily reduced differences between the mortality rates of population groups.¹⁵ Even as the causes of illness and death change, these inequalities persist, showing that unequal social determinants have an ongoing impact on health outcomes.⁷⁸

In Section 3 and Appendix 4 we explore trends in determinants of health, health status and health inequities between 2000 and 2024 in further detail.

The COVID-19 pandemic

Notably, since 2020 we have lived through a global pandemic – which continues to have effects, particularly for people with chronic illness or disability. From 2020-2022, Aotearoa New Zealand’s evidence-based public health strategies, alongside income, business and social protection measures, contributed to lower morbidity and mortality, and less negative economic impact than that experienced in most other high-income countries.^79-81While global life expectancy declined by 1.6 years between 2019 and 2021 due to the pandemic, New Zealand was among the few countries that saw an increase.¹⁵

Diverse models of community and primary care

As a result of pro-equity policies, throughout the health system we now see more diverse models of community and primary care, and many more resilient, experienced Māori and Pacific health providers, Whānau Ora collectives^iv and Asian, disability and LGTBQIA+ services.^v

Multiple evaluations of these programmes demonstrate the strength of diversity in practice and the effectiveness of equitable approaches.^82-84 Understandings of cultural safety in the health system have developed over time.⁸⁵ Initial steps have been made to support the health system to better understand, react, and respond to racism in health.⁸⁶

[iv] Whānau Ora is a Māori-led and whānau-centred approach to whānau support that was developed jointly by Te Puni Kōkiri, the Ministry of Health and Ministry of Social Development from 2010.

[v] LGBTQIA+ is a term that includes people who identify as lesbian, gay, bisexual, transgender, queer, intersex or asexual, or who have more diverse sexualities, genders and sex characteristics.

Recognising the needs and aspirations of disabled people

‘Enabling Good Lives’⁸⁷ is a framework co-designed by the disabled community with government since 2011. It aims to give disabled people and their families decision-making power and autonomy, support inclusion and improve wellbeing outcomes. It is backed up by the Pae Ora (Healthy Futures) Act 2022, which committed the health system to achieving equity for disabled people. This approach and associated principles have been broadly accepted by the health and disability system, although not yet fully implemented. Achieving equity requires sustainable resourcing and a nationally consistent approach that is community-led, culturally responsive, and grounded in the principles of Te Tiriti o Waitangi.

Knowledge, evidence and analytical tools

We now have more evidence and experience from implementing policies and interventions, and better analytical tools, to understand and measure which policies and interventions in and outside the health system are effective at improving health outcomes and health equity. The most effective of these include redistributive tax policies and income support, high quality social housing, early childhood intervention and access to quality health and social services.^6,78,88-99

We also better understand the factors that support people to be resilient and enjoy good health and wellbeing. These factors – especially for children and young people – include whānau connection and trust, identity and community, and access to culture and language.^29,100,101 

2. Nourishing the tōtara in the forest

A large volume of research has been carried out worldwide over the last three decades on the relationships between the determinants of health, health outcomes and health inequities. At the same time, there has been substantial policy development, and implementation and evaluation of strategies and programmes aimed at addressing the causes and impacts of health inequities. This has significantly increased our understanding of why and how health outcomes of different social groups are not equally distributed, and how this can be addressed. ^7,78,90,109

In other words, we now know a lot more about how resources, ‘the soil’ in our metaphor, (such as secure housing, education outcomes, social cohesion and freedom from discrimination) nourish the tōtara, while an absence of resources starves the tree. We also understand better how the ‘bedrock’ beneath the soil, representing fundamental rights and societal power, positively or negatively influences the distribution of those resources.^104,110

In addition, through epigenetic, human developmental and biological research, we understand much more now about how the determinants can directly affect our bodies through biological mechanisms that lead to physical and mental health outcomes.^66,111

Why are determinants unevenly distributed?

Compared with 25 years ago, our society is more prosperous, we live longer, and many of our health outcomes have improved. These changes reflect improvements in critical determinants of health including education, income, and employment. However, these benefits have not been evenly distributed.^15,70 While our society has many strengths, we also recognise it has been heavily shaped by colonisation, racism, discrimination, Pākehā privilege and our free market economic system.^{28,43,112-118} These influences act in opposition to the positive rights and obligations in the bedrock that would nourish a healthy forest - they systematically limit who can access the best and most fertile soil.

Williams’ model, adapted by Te Kupenga Hauora Māori researchers at the University of Auckland,⁴³ depicts colonisation as the common underlying process behind these ‘basic causes’ of health inequity. It illustrates how resources and social status are distributed in Aotearoa New Zealand. This means our education, economic, justice and political systems work better for some groups than for others.^66,111 Consequently, some of us experience the relative prosperity of warm housing, rewarding jobs, and the ability to access health care services, if and when we need them. Others of us are much more exposed to drivers of ill health, such as material deprivation, unemployment, household crowding, and barriers to health care.^70,119,120

We explore some of the ‘bedrock’ influences below, including colonisation, racism and discrimination, and our type of economic system (neoliberalism); how they operate and influence our health and wellbeing.

Colonisation and colonialism

Colonisation (and its practices, colonialism) is based on ideologies of European superiority and empire-building.^115-117 Globally, colonisation has exploited Indigenous peoples and marginalised groups, enabling colonial settlers to accumulate economic benefits and wealth.^{27,29,43,118,121}

Effects of colonisation on Aotearoa New Zealand

Colonisation has profoundly shaped, and continues to shape, the social and economic conditions that underpin health and wellbeing outcomes in Aotearoa New Zealand.^115,118,122 To understand how colonisation drives ill health, we need to recognise the historical and systemic inequities that are still active today. As a negative influence, colonisation starves, rather than feeds, the soil and root structure of tōtara in the forest.

From the 14th to 19th centuries, Māori developed rich cultural practices and norms, structurally underpinned by whānau, hapū and kāinga. Land was shared within and between hapū, and kai and other materials were produced communally.²⁸ Māori also shared power, and hapū made decisions collectively. These societal settings meant that access to land, rivers and oceans was considered a collective resource. Likewise, beyond inter-hapū or inter-iwi conflict, few outside influences could influence decisions about the day-to-day lives of Māori.²⁸

Within decades of arriving in Aotearoa New Zealand, British settlers had, through colonial practices, usurped the tikanga (societal laws and norms) that Māori had established over more than 500 years. Māori lost access to land through illegal sales, confiscation, and alienation, with associated loss of access to food production and other resources.

Decisions about day-to-day living were now made by a colonial government with no Māori representation or control.²⁸ The sharp and rapid losses inflicted on Māori by colonisation reverberate today. Colonisation is not a distant historical event; it is a lived reality that continues to influence daily life and privilege Pākehā.^43,115 However, Māori have not been passive recipients of this process. They have survived – and often thrived – resisting colonial structures and systems, sometimes at great personal and collective cost.^27,115

Aotearoa New Zealand’s colonisation of Pacific nations

Pacific peoples’ experience in Aotearoa New Zealand is entwined with New Zealand colonial history in the Pacific, racial capitalism, Pacific migration following World War II and marginalisation.^124,125

Large-scale migrations of Pacific peoples to Aotearoa New Zealand began in the 1950s and continued throughout the rest of the 20th century.¹²⁶ Migration was often motivated by aspirations for a better education and prosperity, which would also support families and villages at home. Most Pacific migrants come from Cook Islands, Fiji, Niue, Samoa, Tokelau or Tonga, but some come from other Pacific nations.¹²⁴

In 1945 the population of Pacific peoples in Aotearoa New Zealand was just over 2,000; now it is nearly 443,000.¹²⁷ The population is diverse, young (half the population is under 25 years), growing and mostly urban (62% live in Auckland). Nearly half of Pacific peoples identify as Samoan, and nearly a third of those under 15 years also identify as Māori. Two-thirds of the population were born here.¹²⁷ Of those born overseas, more than 60% have lived in Aotearoa New Zealand for more than 10 years. One-third of Pacific households include extended families, and many span three or more generations.¹²⁷

Pacific peoples’ experience in Aotearoa New Zealand

Government and industries in Aotearoa New Zealand saw Pacific peoples as cheap labour for a growing economy, reflecting our colonial relationship with the Pacific.

But by the early 1970s, Aotearoa New Zealand’s economy was in decline, and political and public attitudes turned against Pacific migration. This led to increased hostility and overt racism towards Pacific peoples. Police and immigration authorities targeted Pacific peoples for immigration checks, despite 40% of ‘overstayers’ being British and American. This culminated in the infamous Dawn Raids, in which Pacific peoples’ homes were invaded as police looked for overstayers to deport.¹²⁴ 

Pacific peoples have made significant contributions to Aotearoa New Zealand, culturally and economically. A 2018 study for the Treasury estimated Pacific peoples contributed $3.1 billion to production GDP and $8 billion in income GDP to the economy.¹²⁸

Despite many having New Zealand citizenship, Pacific peoples migrating here faced and continue to face cultural and language barriers, personal and institutional racism, and difficulty accessing education, employment and higher incomes. This has led to material deprivation and inequities in health outcomes.^70,124

The life expectancy of Pacific peoples living in Aotearoa New Zealand is nearly six years lower than that of European New Zealanders.¹²⁹ This, and other health inequities, are directly associated with discrimination and differential access to education, income, housing and employment. These differences limit Pacific peoples’ opportunities to achieve the best health possible for their whānau, and to access timely, high-quality health care.¹²⁹

Pacific peoples in Aotearoa New Zealand are more likely to experience material deprivation than other New Zealanders. However, Pacific peoples have maintained stronger community connections, bonds of trust and religious identity than New Zealanders as a whole. They also rate their health and life satisfaction highly, although these measures have declined recently.⁷⁶ The strength, resilience and innovation of Pacific communities and Pacific health workers were evident during their highly effective response to the COVID-19 pandemic.¹⁴ 

Discrimination

Human, social, and economic rights, and freedom from discrimination, poverty and inequity, are fundamental to health and wellbeing. They form the bedrock of our tōtara forest.

These rights are enshrined in New Zealand legislation, including the Human Rights Act 1993 (HRA) and Bill of Rights Act 1990,¹³⁰ although full realisation of these rights is incomplete. The HRA makes it unlawful to discriminate on the grounds of sex (including pregnancy and childbirth), marital status, religious belief, ethical belief, colour, race, ethnic or national origin (nationality and citizenship), disability, age, political opinion, employment status, family status or sexual orientation. As with international human rights legislation, the HRA allows special measures that will advance disadvantaged groups and address historical disadvantage to achieve equality.¹³⁰

Many people understand discrimination as something that happens at a personal level, between individuals, but there are collective effects. The 2021 Whakatika report, based on a survey of Māori experiences of racism, notes that ‘Legal definitions of racism and discrimination, which look only at an individual without looking at the impact on whānau, hapū, iwi and Māori communities, fall short of capturing the true costs of racism as an attack on rangatiratanga.’¹³¹

Discrimination operates at structural and institutional levels. These types of discrimination shape what happens when we look for work or housing or seek health care.¹³² Māori and Pacific peoples’ experience of discrimination is reflected in their employment, housing, and health outcomes. Other groups, including disabled people and LGBTQIA+ people, also experience these types of discrimination, which are maintained and reinforced through social norms, public policy, economic systems, and organisational practices.

In this section of the report, we present evidence of how different forms of discrimination affect the health and wellbeing of individuals, whānau, and populations.

Racism

Racism can be understood as an organised and complex system, underpinned by false beliefs that people’s race or ethnicity makes them inherently superior or inferior. Racism operates to give a dominant racial or ethnic group privileges, while simultaneously disadvantaging others.¹³⁴ Racism underlies the ideology of colonialism but is broader than that.^{113,123,135,136} In Aotearoa New Zealand, racism underlies justifications for the dispossession of land and rights from Māori, and undermining of Māori knowledge (mātauranga Māori), spirituality and practices.²⁸

For Māori and Pacific peoples, racism, and other forms of discrimination, are a pathway to significant health inequities.^137-139 Māori, Pacific peoples and Asian peoples report a much higher prevalence of racial discrimination, and experience more forms of discrimination, than Pākehā, including when they access key determinants of health such as housing, employment and education. Young Māori, Pacific peoples and Asian peoples are two to five times more likely than young Pākehā to be exposed to racism. This exposure is strongly associated with poorer mental and physical wellbeing and scoring lower on having a sense of identity and of belonging.¹³⁸

Ableism and disablism

In 2023, the Household Disability Survey estimated that 17% of people in Aotearoa New Zealand, or around 851,000 of us, are disabled.¹⁴² Women, older people, Māori and LGBTQIA+ people are more likely to experience disability than other groups.^142,143

Despite on average being younger than the total population, Māori and LGBTQIA+ people have higher rates of disability than other groups. Pacific peoples are also more likely to experience disability than Pākehā, after adjusting for age differences between those populations.¹⁴⁴

Ableism and disablism refer to types of disability discrimination. Ableism favours people who are not disabled and discriminates against those with disabilities (whether those disabilities are visible or not).¹⁴⁶ For example, ableism includes designing a building without a ramp or lift for people who need them, or having inflexible working options or workplace accommodation.

Ableism was present in our historical approaches to disability such as the segregation of disabled people into institutions, and the ‘medical model’ approach to disability.¹⁴⁷ Ableism reduces disabled people’s opportunities and access to resources (such as housing and income), which affects their physical and mental health.

Disablism is an inherent belief that disabled people are inferior to people who are not disabled.¹⁴⁸ Disabled people can experience disablism in the form of direct, conscious discriminatory or abusive acts, such as a disability slur, being ignored or being spoken to in a patronising way. In health care, discriminatory assumptions about disabled people can lead to ‘diagnostic overshadowing’. This means that new symptoms are attributed to a known disability instead of being investigated. It can also lead to ‘therapeutic pessimism’, where a disabled person is not offered a treatment because of their underlying disability.¹⁴⁹

Aotearoa New Zealand has adopted the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) social model of disability.¹⁵¹ The social model encompasses a whole-of-life, strengths-based approach, looking at a disabled person’s strengths across their lifetime. While it recognises that individuals have impairments,^vi it sees the disabling elements as being ableist systems, attitudes, and structures, rather than the impairment itself.¹⁴⁵ These ableist systems drive inequities in access to determinants of health for disabled people and also create health system barriers.

Racism, colonisation and ableism are interconnected in New Zealand.¹⁴⁷ Researchers and disability advocates have critiqued the often deficit, Western view of disability. This has failed to consider the ‘…disabling impacts of being disconnected from whakapapa, te reo Māori, tikanga and mātauranga Māori, and inability to access traditional lands, waters or marae.’¹⁵²

[vi] An impairment means a functional limitation that prevents a person carrying out certain tasks and functions in their daily life without support. Common impairments include deafness, blindness or an inability to walk. Disablement occurs when a person with an impairment is not supported to take part on an equal basis with others. The social model places responsibility for this exclusion on systems, attitudes and environments, and not on the person with the impairment.

Discrimination based on sex, gender or sexual orientation

Despite being the first country to give women the vote in 1893, and decades after the ‘second wave’ of feminism in the 1970s,¹⁵³ women in Aotearoa New Zealand continue to face disadvantage in some employment sectors. Women face an ongoing gender pay gap, which is even greater for Māori, Pacific and disabled women.¹⁵⁴

In Aotearoa New Zealand, attitudes towards roles at home and in parenting are generally pro-gender equality. However, in reality women still carry out the majority of household tasks.^155,156 The value of women’s unpaid work and caring is still largely ignored and economically undervalued (as is their paid work).

Single women, disabled women and women who are solo parents experience a higher level of material deprivation and poorer mental health than other women.¹⁵⁷ Women also have much lower retirement savings than men.¹⁵⁸ Many single parent households (most are led by women) report they experience stigma and discrimination.¹⁵⁹

Women are more likely than men to suffer abuse from a partner (this includes repeat victimisation) and sexual violence.^160,161 Women and girls experience disproportionate online harm, sexual harassment and economic harm. Economic harm can involve not having control over financial resources, having access to money withheld or being forbidden to attend school or work.¹⁶⁰ These discriminatory experiences can manifest in poor mental and physical health outcomes.

Experiences of discrimination, harassment and violence based on sexual orientation are also well documented.^123,162 Data from the 2023 Census shows that 1 in 20 adults (4.9%) identify as LGBTQIA+.^143,163 The abbreviation MVPFAFF+ is also used in Aotearoa New Zealand.¹⁴³ It encompasses diverse gender and sexuality expressions and roles across Pacific cultures:

• mahu (Tahiti and Hawaii)
• vakasalewa (Fiji)
• palopa (Papua New Guinea)
• fa‘afafine (Samoa)
• akava‘ine (Cook Islands)
• fakaleiti (leiti) (Tonga)
• fakafifine (Niue).

Experiences of discrimination in employment, housing, higher rates of violence from others and feeling less safe are associated with greater substance use and poorer mental health, especially for trans and non-binary people.¹⁶⁴

Intersecting discriminations

The interaction of different forms of discrimination has increasingly been recognised as having cumulative negative impacts on wellbeing. For example, disabled, Māori or ethnic minorities who are LGBTQIA+ experience the compounding effects of intersecting discriminations.¹⁶⁵ Recent research suggests that trans and non-binary disabled people, are more likely to experience discrimination, be verbally harassed, feel unsafe at school, be treated unfairly by government agencies and have poorer mental health outcomes.^162,166

Our economic system

Our economic system is part of the bedrock – an important influence on multiple determinants of health and how they are distributed in our society.

Land ownership

Access to land is a key resource and source of wealth in Aotearoa New Zealand. In the 19^th century, land owned by Māori substantially reduced, much through illegitimate sales, confiscation and alienation (Figure 4).²⁸ By the 20^th century, most firms and farms were owned by Pākehā families. New Zealand has since developed a market economy, made up of larger corporations and small commercial entities.¹⁶⁷

Figure 4. Māori land loss between 1860 and 1939

Changing economic models and the impact of neoliberalism

In response to economic depression and poverty in the 1930s, the government introduced greater regulation and state ownership of key utilities (such as electricity, telecommunications and public transport), alongside a developing welfare state (state funded health care, education and social benefits). This resulted in a mixed economic model. In the 1970s and 1980s, economic neoliberalism emerged globally. Neoliberalism is characterised by prioritisation of the ‘free’ (unregulated) market, an emphasis on economic competition, individual ‘freedom’ (market choice), and reduced social service provision by the state.^169,170

As a result, rapid structural economic change took place in Aotearoa New Zealand from 1984 into the 1990s. This significantly reduced social housing and social benefits, led to high unemployment for Māori and young people, increased the number of people in casual employment, reduced real incomes for Māori and Pacific households and widened income inequality.¹⁶⁹ These structural changes disproportionately impacted Māori and Pacific peoples and were associated with widening health inequities and plateauing of Māori and Pacific peoples’ life expectancy during the 1990s.¹⁷¹

Liberalising the economy has had ongoing effects that benefit some groups but substantially disadvantage many others. For example, one feature of neoliberalism is deregulation of the labour market, which reduces job security and work safety.

Unemployment is used as a tool to lower inflation, and this also has disproportionate impacts on young people, Māori and Pacific peoples.^172,173 Unemployment is associated with having a lower income, housing insecurity, and poorer health and mental health outcomes.^167,172 Some regions in Aotearoa New Zealand have experienced, and continue to experience, high rates of intergenerational unemployment, with different regions experiencing very different labour market cycles. For example, during labour market contractions, Northland’s unemployment rate typically increases by twice as much as Wellington’s.¹⁷⁴

Income inequality and wealth

During the 1990s, income inequality rose sharply. Although this inequality was partly moderated by progressive taxation policies, the distribution of wealth remains highly skewed.⁶² While our taxation and transfer (social benefits) systems appear progressive and pro-equity when they are measured against taxable income, the Household Economic Surveys from 2015 to 2021 show that the wealthiest 10% of households hold around 50% of the country’s household financial assets. The poorest 20% of households hold only one percent of the country’s household net wealth.

Research by the Treasury and Inland Revenue (IR) shows that our current taxation system results in the wealthiest three hundred families in New Zealand paying an effective tax rate that is less than half the rate that middle-income New Zealanders (such as people who work as plumbers or nurses) pay. IR found that wealthy New Zealanders usually get their income from return on investments; around 80 percent of their economic income is capital gains (which is untaxed in Aotearoa New Zealand).^62,175

The purported benefits of free-market competition (such as lower costs to consumers) have often not materialised. For example, New Zealanders continue to spend a high proportion of their income on housing and food, reflecting our housing market’s failure to provide affordable homes, and the current supermarket duopoly.^176,177 Almost two in five people in Aotearoa New Zealand today find it hard to meet every day costs;¹⁷⁸ two-thirds of New Zealanders do not feel ‘well off’, and one in four sometimes do not have enough to eat.¹⁷⁹

Neoliberalism and healthism

Collective values underlie the rationale for social safety nets and the ‘social contract’ that Aotearoa New Zealand has aspired to. However, neoliberalism values individual agency and personal choice over collective action. It puts less emphasis on reciprocity and collective social obligations.^169,180

Neoliberal views of health (known as ‘healthism’) advocate that individuals have the power and responsibility to manage their own health. Although this is partially true, healthism fails to recognise how structural factors discriminate against some groups, and affect individuals’ behaviour and choices (see below How determinants affect us).^181,182

For example, agricultural and food industries shape our environment and economy in ways that encourage us to consume more affordable but less healthy foods. By focusing on individualism, healthism also ignores evidence that social cohesion has a positive impact on population health and other social wellbeing outcomes (such as, better personal safety and less crime).^183,184

Summary

The bedrock elements which drive the maldistribution of resources in our society today are not random nor fixed. For example, discrimination and colonisation can be addressed through legislation and the social policies the government chooses to implement; our economic system can be modified. To improve our collective health and eliminate health and wellbeing inequities, positive elements in our bedrock need to be enhanced, and the negative influences addressed.

How determinants affect us – individual and collective mechanisms

Social and environmental exposures influence health in many ways. This may be directly – for example, a higher risk of infectious diseases for children living in crowded housing – or indirectly, for example living in an area with a high density of alcohol and fast-food outlets, which influences peoples’ drinking and eating patterns. In this section we summarise what we currently know about the ways in which determinants of health may affect our individual and collective health through biological and physiological mechanisms. We examine some of the mechanisms by which social and environmental exposures ‘get under the skin’.

Epigenetics

Epigenetics refers to how our environment can cause changes that affect the way our genes work.  We inherit more than just DNA from our parents. Genes in the DNA sequence have epigenetic markers that switch our genes ‘on’ or ‘off’.¹⁸⁵ We now know that gene sequences do not translate directly into our physical characteristics (phenotypes), and that changes to genes can occur because of changes in our environment such as stress, air pollution or what we eat. These environmental factors generate changes in genes that can then be transmitted across generations.

These epigenetic changes affect cellular functions, physiology and how our bodies work. Epigenetic changes are reversible – they do not cause genes to mutate (to change the DNA sequence), but they can change how the body ‘reads’ the DNA sequence.¹⁸⁵

Epigenetics change as we develop and age, because we have differential exposure to environmental factors over the course of our lives.²⁶ Pregnancy and early childhood are particularly important periods, because the brain develops rapidly at those times (this is known as ‘neuroplasticity’).¹¹⁰ Our epigenetics continue to change over the course of our lives in response to our changing environmental exposures.²⁶ 

Environmental factors can cause changes in parents’ epigenetic markers that can be passed on to their children. They can also alter gene expression in a foetus after fertilisation and during the infant’s development in utero. Environmental exposures before and during pregnancy are particularly important for the child’s health and subsequent risk of chronic diseases (such as obesity, type 2 diabetes and cardiovascular disease) in later adulthood.^110,188

For example, if a pregnant woman has limited access to healthy food during pregnancy, her unborn child may also experience suboptimal nutrition and consequently have poorer metabolic health as a child.¹⁸⁸ Parental exposure to alcohol, tobacco, or other drugs at the time of conception or during pre-birth development increases the child’s risk of behavioural, physical and mental health issues that may be lifelong. Conversely, ensuring good nutrition and protection from unhealthy exposures during pregnancy has lifelong benefits for children’s health.¹¹⁰ 

Toxic stressors

Developmental research and longitudinal studies, including studies in Aotearoa New Zealand,^107,108 have demonstrated the effects of ‘toxic stress’ on health. Toxic stress describes what happens when our physiological stress-response system is activated excessively or for a prolonged period. Toxic stress is a response to an experience of severe stress, such as witnessing or experiencing neglect or violence (often called an adverse childhood experience (ACE)). This stress reaction can affect many aspects of physiology, including brain development, and the immune, nervous and endocrine (hormone) systems. It is also associated with an increased risk of many chronic diseases in later life.^189,190

We know also that parent or caregiver attachment and bonding, play and interactive reading are important for children to develop ‘executive functions’ – including the ability to learn, exert self-control and show empathy.¹⁹¹ These functions influence children’s subsequent educational achievement, interpersonal relationships, and mental health.

Research has also examined the impact that stressors such as discrimination and racism have on health. While structural discrimination can affect access to health determinants like employment (see Discrimination), an individual’s experience of discrimination is itself a potent biological stressor.^43,66 The links between self-reported racial discrimination and mental and physical health outcomes have been well documented. Research indicates that reported exposure to discrimination is associated with poor mental health, adverse cardiovascular outcomes, excess body weight and high blood pressure.

The evidence about how epigenetics and stressors contribute to health and wellbeing shows that even health issues that we tend to think are due to our DNA or family traits are influenced by wider determinants of health. But toxic stressors can be prevented or removed. And just as epigenetics are changed by negative environmental factors (such as experiencing racism, poverty, pollution or poor diet), they can also respond to positive changes in the environment. Human and animal studies show that epigenetic changes can persist across multiple generations.¹⁰³ Therefore, distributing these positive factors more fairly across society gives us the potential to interrupt multigenerational cycles of ill health.

Socioeconomic patterning

Another way that determinants of health affect the health of communities is through socioeconomic ‘patterning’ of health-damaging factors. For example, in Aotearoa New Zealand, material poverty, ethnic segregation, poor-quality housing and homelessness are often concentrated in the same spaces.^124,192 Communities that experience material deprivation also encounter layers of other health-damaging factors. Compared to wealthier areas, communities experiencing material deprivation have above average numbers of fast-food outlets, alcohol off-licences, and gambling and vaping outlets.^193-197 They also tend to have higher rates of air pollution, poorer public transport and lower access to green space.^194,198,199 This illustrates the cumulative, complex relationships between our environment and our health.²⁰⁰ [See the ‘Healthy Location Index Story Map’ in section 3].

The collective experience

The effect of a negative economic environment on population health outcomes and health equity (the ‘collective’ experience) is also well documented. For example, the collapse of the USSR had an adverse effect on total population mortality and health inequalities in Russia and some East European countries in the 1990s.^201,202 More recently, life expectancy for the least privileged 20% of men in the UK has significantly declined since 2011,⁹⁶ while life expectancy in most European countries has also flattened. These trends are associated with economic austerity, unemployment, rising obesity rates and the COVID-19 pandemic.^96,203 These negative factors have disproportionately affected people who live in Europe’s most socioeconomically deprived communities.²⁰⁴

Aotearoa New Zealand’s collective experience has also been researched. As noted above, the 1980-1990s was a period of rapid structural economic change, when social housing declined, unemployment amongst Māori and young people increased, casual employment increased, the real income of Māori households fell, and income inequality rose.²⁰⁵ Despite life expectancy of the total population increasing between 1980 and 1999, inequities in mortality increased. The gap between Māori and Pacific peoples, and non-Māori, non-Pacific peoples progressively widened.^171,205 For example, the gap between life expectancy at birth for Māori men and that of non-Māori, non-Pacific men increased from 6.3 years in 1980 to 9.9 years by 1999.

During the following decade (2000–2010) incomes and employment improved, and the life expectancy gap reduced. However, large absolute and relative disparities between the health and mortality of Māori and Pacific peoples, and that of non-Māori, non-Pacific peoples, have persisted, particularly related to some cancers and diabetes.²⁰⁶

3. How is Aotearoa New Zealand tracking?

Trends in determinants of health and in health outcomes

In this section we look in more depth at trends in some critical determinants of health and in health status, where possible looking back to the year 2000. The aim of our analysis is to assess progress in these areas, and as importantly, to understand any changes in the absolute or relative differences between population groups for these indicators over the period.^vii

We identified relevant indicators of determinants from wellbeing and health equity monitoring frameworks developed here and internationally.^207-209 We assess differential progress in a selection of these indicators (by ethnic group, age, disability, gender and/or socioeconomic deprivation, where applicable). We then describe trends in inequities in selected health and wellbeing outcomes over the same period.

We acknowledge that these data have important limitations and represent only a part of the rich and complex daily experiences of life for people in Aotearoa New Zealand. It is also important to note the limitation of univariate analysis (that is, analysis of one indicator at a time). As we increasingly understand the interconnectedness and intersectionality of determinants and health outcomes, this likely underestimates the compounding disadvantage experienced by those most affected by inequities.

Data that we have sourced on determinants of health are publicly available from many sources (Appendix 4). The main sources of data are the Census and national surveys. These data have many limitations, including the quality of ethnicity data collection. Over time there have been changes in questions that are asked and the extent of coverage. The various data collections may also define groups differently (e.g. for disability, by total or prioritised ethnicity). These limitations are further discussed in Appendix 4. 

[vii] Absolute inequality reflects the magnitude of difference in an indicator between two subgroups (and retains the same unit of measure as the indicator). Relative inequality measures show the proportional differences for an indicator among subgroups.

Trends in key determinants of health 2000-2024

Income

There is a strong association between income and health status.^210,211 Income provides access to resources like adequate housing and healthy food to support wellbeing.

The stress that can result from a lack of financial security for households is harmful to health. Material poverty in childhood is associated with poorer cognitive, behavioural and health outcomes, and negatively influences opportunities for education, adult income and employment, and health outcomes through the life course.^212,213

In Aotearoa New Zealand, the median individual weekly income increased between 2008 and 2024 for people of all ethnic groups. There was a persistent gap between ethnic groups, with median weekly income from wages and salaries for Europeans $200 higher than for Pacific peoples and $173 higher than for Māori in 2024 (unadjusted for inflation), with no change in this absolute difference between 2008 and 2024 (Figure 5).

Women have lower median hourly earnings than men. The gender pay gap decreased from 16.2% in 1998 to 8.2% in 2024 but varies for different groups of women.²¹⁴ In 2024 the gender pay gap (compared with all men) for wāhine Māori (15%), Pacific peoples (17%), and disabled women (14.2%) was significantly higher than for European women (3.6%).^154,215,216

 Figure 5. Individual weekly median income from wages and salary by total response ethnicity, 2008 to 2024 

Household incomes also increased from 2007-2021, after accounting for inflation. Real incomes increased more in absolute terms for higher income households than low-income ones, but there was a slightly bigger relative increase for low-income households.²¹⁷ This may be explained by increases in hours worked by low-income families, increases in Working for Families Tax credits and the indexation of Superannuation for older people.

For households with low income, housing costs take up a large proportion of income, so it is important to examine income after housing costs (AHC) have been considered. Low-income households with children saw smaller income increases than other low-income households after housing costs were included.²¹⁷

Data on household income by ethnicity is only publicly available from 2020. This recent data available mirrors inequities in individual income data by ethnicity. The annual household incomes for Māori and Pacific peoples remained around 20% lower than for Europeans from 2020 to 2024.²¹⁸ Median income after housing costs for Māori, Pacific, Asian and European households with children showed an approximately 35% real (CPI-adjusted) gain between 2007 and 2023, but with persistent inequities between ethnic groups.²¹⁹

The Household Disability Survey (2023) found higher levels of income inadequacy for disabled people. Just under half (47%) of disabled people lived in households that reported enough or more than enough household income, in contrast to 67% of non-disabled people.¹⁴² 

Income inequality

Greater income inequality at a national level is associated with poorer health and wellbeing outcomes and larger health inequities, although the mechanisms for this are debated.^119,220,221 Life expectancy, infant death rates, child maltreatment, obesity and mental health outcomes have been shown to be poorer in societies with greater income inequality.²²¹ Conversely, reducing income inequality has potential benefits for society as a whole, as well as for those whose material circumstances are improved.^222,223

Aotearoa New Zealand experienced large increases in income inequality in the late 1980s and 1990s, and this inequality has largely persisted.^224,225 The Gini co-efficient is a measure of income inequality (from zero reflecting perfect equality to 1, where all the income would belong to the top income group). Income inequality peaked in 2015, with a Gini co-efficient of 0.41 (after housing costs), then decreased slightly to 0.37 in 2024. However, income inequality remains high compared with the 1980s.

Income inequality is greater when income after housing costs is considered, compared with income before housing costs (Figure 6). As noted above, this is because housing costs generally make up a greater proportion of household income for lower-income households than for higher-income households.

 Figure 6. Gini coefficient before and after housing costs for Aotearoa New Zealand, 1982 to 2024

Child poverty

Child poverty in Aotearoa New Zealand is understood as ‘exclusion from the minimum acceptable way of life (standard of living) in one’s own society because of inadequate resources’.²¹⁹ The Child Poverty Reduction Act (2018) established a framework for measuring and reporting child poverty, which includes a variety of measures. The Ministry of Social Development produces comprehensive reports on child poverty and Stats NZ summarises data with analysis related to the Act’s targets.^219,226 

Material hardship represents the proportion of children living in households who report that they cannot afford 6 or more of 17 basic essential items, such as not having adequate clothing or having to go without fresh fruit or vegetables to keep costs down. Material hardship rates were high in the years after the 2008 Global Financial Crisis, with marked inequities. 47% of Pacific peoples’ children and 36% of tamariki Māori experienced material hardship in 2010-2012, well over double the rates for Asian (16%) and European (18%) children (Figure 7).²¹⁹

Following this, rates of material hardship fell quickly for European and Asian children but more slowly for other ethnic groups. Between 2013 and 2024, rates of material hardship were 2 to 3 times higher for tamariki Māori and 3 to 4 times higher for Pacific children than European children. Thus, although the proportion of children in material hardship has decreased since 2010-2012, and there have been important reductions in absolute inequities, the increase in relative inequity suggests that child poverty initiatives did not have as much impact for tamariki Māori and Pacific children as European children.

Figure 7. Material hardship rates for children by total response ethnicity, for year ended June 2007 to June 2024, in three-year groupings to 2018

In the year ended June 2024, 156,600 children (13.4% of all children) were living in households experiencing material hardship.²²⁶ Although numerically the largest number of children experiencing material hardship are European children, Pacific peoples and Māori children are disproportionately affected. Nearly one in three Pacific children and one in four tamariki Māori experience material hardship, compared to one in ten European children.

One consequence of poverty with clear health impacts is when household food runs out. In the New Zealand Health Survey, this measure of food insecurity for children is assessed by asking households with children if they run out of basics (such as bread, potatoes, etc.) due to insufficient money. Rates of food insecurity have increased in the last two years to very high levels, with data from 2023/24 finding that it impacts over a half of Pacific children, over one third of tamariki Māori and about one in five Asian and European children.²²⁷

Work

Satisfying work provides adequate income, provides for opportunities and skills, and supports whānau and households. Work influences health in other ways, for example through social status, participation in society and workplace safety.²²⁸ Unemployment is strongly associated with poorer mental health, including low self-esteem, anxiety and depression, but also with stress-related conditions like heart disease.^172,229

In the year to December 2024, 71.3% of the working age population were in the labour force. The labour force comprises both employed and unemployed people. Those not in the labour force may be involved in other activities such as studying, caring for children or  other adults, household work, voluntary work, sickness/injury/disability and free-time activities.²³⁰ The definition of ‘unemployed’ by Stats NZ is quite narrow: a person does not have a paid job, has been available in the previous week to start work and has been actively seeking work in the last four weeks, or be due to start a new job in the next four weeks.²³¹ 

Unemployment rate

The unemployment rate is the proportion of unemployed people (as defined above) in the labour force. In the year to December 2024, the unemployment rate was 4.7% (that is, 144,900 people).²³¹ Stats NZ also report an underutilisation rate (11.7%, or 370,500 people in the year to December 2024), which includes people who are unemployed, those who would like to work more hours than they do and people who are potentially available to work but not actively seeking employment.²³² This partly reflects the development of precarious employment in Aotearoa New Zealand over the last decades – work which is temporary, insecure and/or poorly paid.²³³

Peaks of unemployment occurred in the early 1990s associated with the neoliberal economic reforms, and from 2008 following the Global Financial Crisis. Unemployment rates increased slightly with the effect of the COVID-19 pandemic, then fell to their lowest point in several years in 2022, before rising sharply in 2023 – 2024.²³⁴

The unemployment rate varies by age, disability, ethnicity, gender and region. For over three decades, young people have consistently had high unemployment rates, up to six times the rate of other age groups. For people aged 15 to 24 years, the annual unemployment rate to December 2024 was 14.1% (61,700), while it was 2.8% (15,900) for people aged 45 to 54 years.²³¹

Annual unemployment rates to December 2024 for Māori (9.2%) and Pacific peoples (9.6%) were over double those of Asian (4.5%) and European (3.8%). Particularly high rates of unemployment are seen for young Māori and Pacific peoples. Annual unemployment rates to December 2024 for Pacific peoples and Māori aged 15-24 years were 22.5% (10,100) and 19.1% (19,800) respectively.²³¹

Between 2008 and 2024 annual unemployment rates for Māori and Pacific peoples have been approximately two to three times that of European New Zealanders, although there was a slight narrowing of absolute inequities (Figure 8).

 Figure 8. Annual unemployment rate by total response ethnicity, 2008 to 2024

The unemployment rate and the underutilisation rate of disabled people is more than double that of non-disabled people. In the quarter to June 2024, over one in 4 disabled people (26.3%) were either unemployed, wanted to work more hours or were potentially available to work but not actively seeking employment (i.e. the underutilisation rate) compared with 11.3% of non-disabled people.²³⁵

Not in Employment, Education or Training (NEET)

As the unemployment rate considers only those in the labour force, there is a broader measure for young people (15-24 years) who are not in employment, education or training (NEET).²³⁶ In the year to December 2024, 85,500 young people (12.8% of 15-24 year olds) were considered NEET, with Māori (19.5%) and Pacific peoples (18.9%) having higher NEET rates than Asian (10.7%) and Europeans (10.3%). There has been no improvement in the NEET rate in the last 10 years, with an increase seen in the last year (Figure 9). An analysis of NEET in Auckland in 2018 showed rates were highest for those aged 20 to 24 years and slightly higher for females than males.²³⁷

Figure 9. Young people aged 15-24 years who are not in employment, education or training (NEET) by total response ethnicity, 2008 to 2024

Education

Educational attainment is a key determinant of future employment and income, and of health status.²³⁸ Trends in education outcomes since 2000 show persistent differences in educational experience for students of different socioeconomic and ethnic groups. Historically the education system has reflected our colonised society and been a tool for cultural suppression rather than meeting Māori aspirations for education.²³⁹ Attendance and qualification trends for New Zealand students are presented below. More in depth reports, such as those on engagement with school, reasons behind low attendance and experiences of racism, offer further insights into the education system.^133,240,241 The data highlight concerning trends in attendance that have become apparent in the last decade, and particularly in the last four years. 

Early Childhood Education (ECE) participation

Prior participation in Early Childhood Education (ECE) measures the proportion of children starting primary school who have regularly attended early learning in the previous six months. There has been significant investment in ECE since 2000. Figure 10 shows an increase in attendance from 2000 to 2019 with a narrowing of the difference between ethnic groups. However, since that time, attendance has fallen, with widening of the gap between ethnic groups.

Figure 10. Proportion of children attending Early Childhood Education for the 6 months prior to starting school by total response ethnicity, 2000 to 2024

Similarly, participation in ECE for younger children aged 3 and 4 years peaked in 2019 and then fell considerably in 2020-2021. It has remained at lower levels since, with 67% of all children, 56% of Māori, and 53% of Pacific peoples’ children aged 3 participating in ECE for 10 or more hours a week in 2023.²⁴²

School attendance

School attendance is linked to student attainment and wellbeing.^243,244 Regular participation in primary and secondary schools (students who have attended more than 90% of the term) has declined in recent years.²⁴⁵ However, unlike in ECE, where the decreased participation seems to be associated with the COVID-19 pandemic, the decline in regular school attendance started in 2015, with another steeper drop in 2021-2022.²⁴⁵ Regular attendance improved in 2023 and 2024 but is still not at pre-pandemic levels, with 39% of Māori, 41% of Pacific peoples, 66% of Asian and 55% of European students attending school regularly in term 2 of 2024 (Figure 11a).  

There are differences in school attendance between students who have few, moderate and more socioeconomic barriers to achievement, as measured by the School Equity Index (EQI).²⁴⁶ Only 42% students from schools with more barriers to achievement and 68% of students with fewer barriers attended school regularly in 2024. This mirrors trends in attendance seen in previous years using school decile as the variable of analysis.²⁴⁷

Attainment of NCEA

Attainment of Level 2 NCEA or above increased between 2009 and 2020 and then fell for all ethnicities. The latest available data from 2023 shows 58% of Māori and 70% of Pacific school leavers gained at least NCEA Level 2 qualification or equivalent (Figure 11b). For the total population of school leavers, 74% of school leavers gained at least NCEA Level 2 in 2023, which is the lowest it has been since 2013. This reduction in attainment since 2020 is likely to be related to the significant fall in attendance since the COVID-19 pandemic.²⁴⁸

Attainment of a secondary school qualification is associated with future labour force status and income. For example, just under 70% of those with no school qualification, 50% of those with level 1 NCEA and 33% of those with Level 2 NCEA were classified as NEET in their first year after leaving school.²⁴⁹ 

 Figure 11a. Proportion of students attending school 90% or more of the time by total response ethnicity in term 2, 2011 to 2024

Figure 11b. School leavers with Level 2 NCEA or higher by total response ethnicity, 2009 to 2023

On average, school leavers who are male, who are from schools with more barriers to achievement, or who identify as Māori or Pacific peoples, are more likely to leave school without NCEA Level 2 or above. However, Māori students who attend Māori-medium education have similar levels of NCEA Level 2 attainment to non-Māori at English-medium schools and a higher proportion of these students remain at school until at least aged 17 years.²⁵⁰ 

Kaupapa Māori education

The proportion of Māori students attending Māori-medium education (defined as when the curriculum is taught in te reo for more than 50% of the time) has declined since 2004 for ECE but increased for primary and secondary schools (Figure 12).

The proportion of tamariki Māori attending Māori-medium ECE (out of all tamariki Māori that attend ECE) has been steady at around 20% for the last decade, having fallen from 33% in 2004. The proportion of tamariki Māori attending Māori-medium schools is lower than in ECE. However, it increased between 2014 and 2024 from 12% to 15% for primary and 5% to 7% for secondary schools. This corresponded to 25,895 Māori learners in Māori-medium schools in 2024.²⁵¹

Figure 12. Māori attending Māori-medium education out of all Māori attending education, 2004 to 2024 

Homes

Research in Aotearoa New Zealand shows strong evidence for the health and wellbeing benefits of housing security, a warm, dry and safe home, and the importance of appropriate design to meet the intergenerational and cultural needs of whānau.^192,252-256

Insulated, well-designed housing reduces energy costs and household crowding, but also related illnesses from damp and mouldy housing, such as asthma, respiratory infections, rheumatic fever and chronic conditions.^257-259 In this way, the marked inequities in housing measures below correlate strongly with inequities observed in these and other health outcomes.

Home ownership

In Aotearoa New Zealand, home ownership is associated with security of tenure, income and wealth, and affordability. Deposit affordability and mortgage serviceability indicators have decreased markedly since 2004 (by -30% and -15% respectively), with small improvements in 2024.²⁶⁰ Historically, home ownership in Aotearoa peaked in 1991, with 73.8% of households owning their own home, but there were large differences by ethnic group. Home ownership declined to 64.5% in 2018, the lowest level since 1951.²⁶¹

There was a marginal increase in home ownership from 2018 to 2023, with 66% of households owning their own home by 2023, but this gain was not evenly distributed. Housing tenure for Pacific peoples’ households declined from 35.1% in 2018, to 34.2% in 2023. For all other ethnic groups there were small increases in housing tenure in 2023 with 72.2% of European, 60.7% of Asian and 48.6% of Māori households owning their home.²⁶²  

Household crowding

Crowding can affect physical and mental health and is a risk factor for many infectious diseases.^257,259 Household crowding is determined by comparing the number of bedrooms a household needs (based on the occupants’ age, gender and relationship status) and the number of available bedrooms.²⁶³ The number of people living in crowded houses in Aotearoa New Zealand increased from 389,600 (10.0%) in 2006 to 560,637 (12.1%) in 2023, with increases across all ethnic groups (Figure 13).

Since 2006, household crowding rates for Pacific peoples have reduced slightly but they continue to experience the highest rates of crowding. Thirty-eight percent of Pacific peoples lived in crowded households in 2023, over six times the rate for Europeans. Rates of crowding for Māori increased from 20% in 2013 to 23% in 2023, which was 3.7 times that of Europeans (a fall from 4.7 times the rate in 2013). Between 2013 and 2023 rates of crowding increased for Europeans from 4% to 6% and decreased for Asians from 18% to 16%. There is also significant regional variation in household crowding.²⁶⁴ 

Figure 13. Number of people living in crowded households, by total response ethnicity, 2006 to 2023

Identity and Indigeneity

Indigeneity is increasingly conceptualised as a determinant of health, encompassing determinants of health that are specific to indigenous peoples.²⁶⁵ Strong cultural connections are key contributors to a sense of identity and to wellbeing. Shared collective experiences, values and strengths of Indigenous communities, including cultural connectedness, participation, traditional ceremony, and language preservation, can promote health and are protective against some of the negative outcomes of the social determinants of health. ^29,265 There is a strong positive relationship between individual mental wellbeing and whānau wellbeing for Māori.²⁶⁶

Here we have chosen capacity to speak te reo and recognition of iwi affiliation as relevant indicators that are currently available. We recognise these inadequately represent Māori experience, and that broader and more meaningful indicators, and the quality of data collection, need further development. 

Iwi affiliation

The number of Māori recorded as being affiliated to at least one iwi increased by 46% between 2013 and 2023 (Figure 14). In addition to population increases, the redesign of the iwi affiliation question in the 2023 Census enabled whānau Māori to reflect their whakapapa more accurately and appropriately.

Figure 14. Number of Māori affiliated to the ten largest Iwi, 2013 and 2023 

Te reo Māori

Census data indicate an increase in the number of Māori speaking te reo. In 2023, 182,001 Māori said they could have a conversation about everyday things in te reo, an increase of 45% from 2013.¹⁴⁴ This reflects the substantial increase in Māori population between 2013 and 2023, so although the number of Māori who could have a conversation in te reo increased, the proportion decreased slightly, from 21.0% to 20.5% (Figure 15).

Opportunities to learn te reo have become more widely available in Aotearoa New Zealand in recent years. For example, the number of school students in Māori-medium schools and those learning Māori language in English-medium schools increased from 2019 to 2024, while the number of students with no Māori language education decreased over the same time period.²⁵¹

Figure 15. Number and proportion of Māori who speak te reo Māori, 2001 to 2023

Social connections and trust in institutions

There is increasing evidence that high-quality social connections are essential to mental and physical wellbeing, with poor social connection associated with increased risk of cardiovascular disease, hypertension, diabetes, infectious diseases, impaired cognitive function, depression, and anxiety.²⁶⁷ Surveys generally measure self-reported rates of loneliness or connectedness. Likewise, trust in public institutions is an important indicator of social cohesion.

Loneliness

Loneliness was first assessed in the New Zealand Health Survey in 2016/17 and then annually from 2020/21. Loneliness (self-reported feeling of loneliness some, most, or all of the time in the past four weeks) is higher for females than males, for disabled than non-disabled people and for young adults compared with older adults.

There are high rates of loneliness among disabled people, with the New Zealand Health Survey of 2023/24 finding that one in three disabled people experienced loneliness some, most, or all of the time in the previous four weeks.⁷⁶ This was three times the rate of non-disabled people. The rate of experiencing loneliness some, most, or all of the time in the 2023/24 New Zealand Health Survey was also 1.4 times higher for Māori and for Pacific peoples than for non-Māori, after adjusting for age and gender.

Loneliness varies by age, with young people aged 15 to 24 years having the highest rates. For most age groups, there was a marked increase in loneliness from 2016/17 to 2021/22 (Figure 16). One of the contributing factors to loneliness is likely to be the COVID-19 lockdowns, the subsequent decrease in social interactions and increase in online education and remote working. Other reasons for increased loneliness could be related to changes in community and family structures, with more people living alone, and increased use of technology that may provide less meaningful social interactions.

Figure 16. Lonely some, most, or all of the time by age group, 2016/17 and 2020/21 to 2023/24

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Trust in institutions

Levels of trust in Parliament, as measured by the General Social Survey, have been low over the last decade. They fell further between 2021 and 2023, with only 16% of Māori, 27% of Europeans and 34% of Pacific peoples saying that they had high levels of trust in Parliament (scoring 7 to 10 out of 10) in 2023 (Figure 17a).

Figure 17a. Proportion of people with high (7 to 10 out of 10) levels of trust in Parliament, by total response ethnicity, 2014 to 2023 

Figure 17b. Proportion of people with high (7 to 10 out of 10) levels of trust in health institutions, by total response ethnicity, 2014 to 2023 

Levels of trust in health institutions are high compared with trust in Parliament, but there has been a gradual decline in trust in health institutions for people of all ethnic groups from 2014 to 2023 (Figure 17b). Less than half of Māori (43%) and Europeans (49%) rated their trust in health institutions as high in 2023, falling from 57% and 68% respectively in 2014.

The Kiwis Count Survey measures trust in public services each year.²⁶⁸ This covers any public service provided by central government, such as health, education, transport, and social assistance. In 2025 this survey found levels of trust related to the most recent experience of contact with a public service were high (80%), but lower for young people <25 years and disabled people. Levels of trust in public services in general increased significantly for all ethnic groups between 2019 and 2020, fell quite sharply in 2021 and have plateaued at about 50% for Māori and Pacific peoples, 60% for Europeans and 70% for Asian peoples. These levels remain higher than those reported before the COVID-19 pandemic.²⁶⁸ 

Trust within communities

People need to feel a sense of belonging and worth, to participate and be accepted: these things hold communities and societies together and are critical to health and wellbeing.  The General Social Survey results indicate a decline in the trust held for other people since 2014, particularly between 2021 and 2023. In 2014, 55% of Māori and Pacific peoples held high levels of trust (scoring 7 to 10 out of 10) for other people, but this dropped to 40% of Māori and 42% of Pacific peoples by 2023 (Figure 18). The declining levels of trust in recent years are consistent with the findings of a recent report that social cohesion in New Zealand in 2024 was lower than in Australia on every measure.¹⁷⁹

Figure 18. Proportion of the population with high (7 to 10 out of 10) levels of trust for other people by total response ethnicity, 2014 to 2023 

Environment and climate

Our health and wellbeing are intertwined with our physical environment and our sense of connection to place. As well as providing us with a place to live, the taiao shapes our cultural values, practices and sense of identity. While Aotearoa New Zealand has areas of extraordinary beauty and richness, our land, water and air quality are at risk from a range of activities, including intensive farming of dairy cattle, urban developments, high car ownership, and invasive plants and animals.¹⁷ Higher global temperatures are linked to increased frequency and intensity of extreme weather events, putting the environment under further strain. These trends highlight significant risks to the health and wellbeing of our communities. 

Climate change

Human-induced changes in Earth’s ecosphere have important implications for environmental and human health. Changes in temperatures, rising sea levels and increased extreme weather events have impacts on a broad range of health determinants including physical environments, housing, food security, water security and mental health and wellbeing.²⁶⁹

Temperature

Temperatures in Aotearoa New Zealand are expected to increase in line with global warming, with implications for weather patterns, local ecology, agriculture and other human-environmental interactions. 

Figure 19. Aotearoa New Zealand’s annual average temperature anomaly, 1909 to 2022

The 2023 report from the Intergovernmental Panel on Climate Change (IPCC) confirms that greenhouse gas (GHG) emissions are causing global warming, with the global surface temperature now 1.1°C higher than it was in 1850-1900.²⁷¹ Projected GHG emissions to 2030 make it very likely that warming will exceed 1.5°C at some point in the 21st century.²⁷¹ Figure 19 shows the increase in annual temperatures in Aotearoa New Zealand in the last century.

Glaciers

Fluctuations in annual glacier ice volumes are sensitive indicators of climate change. Between 2005 and 2023, the decrease in total volume of glacial ice in New Zealand accelerated, with a 42% reduction (from 52.3 km³ to 30.3 km³>).²⁷² 

Greenhouse Gas Emissions (GHGs)

As part of the Paris Agreement and the United Nations Framework Convention on Climate Change, the Ministry for the Environment reports on New Zealand’s greenhouse gas emissions (GHGs) annually.²⁷³ Aotearoa New Zealand’s gross GHG emissions peaked in 2006, stayed relatively stable until 2019 and declined over the subsequent four years (Figure 20). While heading in the right direction, the gross emissions in 2023 were still 13% higher than in 1990.²⁷³

Figure 20. New Zealand’s gross and net emissions from 1990 to 2023

The key sources of Aotearoa New Zealand’s GHG emissions are our dairy industry, power generation, and road transport. In 2023 almost half (48%) of our GHG emissions were made up of methane, which comes primarily from large populations of livestock. There has been a significant increase in dairy cattle herds in the last 20 years.¹⁷ Farming is also associated with use of synthetic fertiliser which is a major source of nitrous oxide, comprising almost 10% of our GHG emissions.

Power generation and road transport are the main sources of carbon dioxide, which represents over 40% of GHG emissions. Road transport contributes the largest share of carbon dioxide emissions, which also contribute to urban air pollution, and thus directly affect health. Carbon dioxide emissions from road transport increased by 84.5% between 1990 and 2023, peaking in 2008.²⁷³ We have a relatively high rate of vehicle ownership compared with other OECD countries,²⁷⁴ and a relatively old vehicle fleet (the average age of light vehicles was 14.9 years in 2022)²⁷⁵ Electric and petrol hybrid vehicle numbers have increased since 2016 but still made up only 1.6% and 3.8% of the light vehicle fleet respectively in 2022.²⁷⁴

Interconnections in place

Although in this section we have presented trends in individual determinants, we know that within the same community, in the same place, there are important intersections and connections between determinants. This results in multiplying effects on health and wellbeing. 

Figure 21. Socioeconomic deprivation and Healthy Location Index map, Kerikeri

Summary

Several key themes emerge from these data and the trends seen since 2000. Despite absolute gains across many determinants such as income and education, and reductions in some absolute inequalities, there have been limited or no change in the relative differences (privilege or disadvantage) between ethnic and socioeconomic groups for many socioeconomic indicators.

Of concern, housing measures are showing increasing inequities for Pacific peoples, and housing affordability and household crowding measures are not significantly improving for any population group. Although the overall reduction in child poverty and in absolute inequalities up to 2023 is good news, there has been an increase in relative inequities for Māori and Pacific children compared with European children. In some areas, for example school attendance and attainment, social connection and trust in government, climate and environmental measures, the indicators are heading in the wrong direction for all population groups. What we also see are inter-dependencies and intersections between determinants, with some groups of people experiencing multiple disadvantage, and subsequently significantly poorer health outcomes. 

Trends in health indicators 2000-2024

The health of the tōtara branches and fruit, like our health and wellbeing, depends on nourishment from the soil and bedrock. The following section illustrates trends in selected health status indicators since 2000, examining these by ethnic group, and by socio-economic status, disability and gender where available. We look at changes in relative and absolute differences in varied health outcomes between population groups, reflecting the differential access each group has to the resources that support us to flourish. 

Life expectancy and life expectancy gap

Life expectancy is the average number of years a baby born today in a particular population is expected to live, assuming they experience the current age-specific death rates of that population during their life.¹⁵ Life expectancy in Aotearoa New Zealand increased for the whole population between 2001 and 2022, from 81.2 to 84 years for females and 76.7 to 80.5 years for males. Increases were seen for all population groups (defined by sex, geography, ethnicity and socioeconomic status). At the same time, disparities between these groups persisted (Figure 22).¹⁵  

Between 2001-2003 and 2020-2022, life expectancy increased faster for Māori than for Pacific peoples and non-Māori/non-Pacific people, with a 20% reduction in the 8.3 years gap seen in 2001-2003 between Māori and non-Māori/non-Pacific people. However, in 2020-2022 there remained a significant absolute gap in life expectancy of 6.6 years between Māori and non-Māori/non-Pacific people.

Life expectancy for Pacific peoples increased to 77.8 years in 2018-2020 but then dropped slightly to 77.3 years in 2020-2022 (Figure 22). This meant that the life expectancy difference increased between Pacific peoples and non-Māori/non-Pacific people over the period, from the 5.8 years gap in 2001-2003 to 6.1 years in 2020-2022. 

Figure 22. Longitudinal trends in life expectancy by prioritised ethnicity, 2001 to 2022, three-year aggregated estimate

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Life expectancy for people with intellectual disability is considerably lower than for people without intellectual disability. Estimates for 2017-2019 show a gap of 15 years for males and an 18-year gap for females.²⁷⁶ Māori with intellectual disability have the lowest life expectancy across ethnic groups, with a life expectancy of 61.9 years.²⁷⁶

The New Zealand Index of Deprivation (NZDep) is an area-based measure of socioeconomic deprivation.^viii Life expectancy is lower for people living in the most socioeconomically deprived neighbourhoods, compared with more advantaged neighbourhoods, with a gradient effect. Over half of Māori and Pacific peoples live in the most socioeconomically deprived areas (NZDep deciles 8-10). In addition, at any given level of socioeconomic deprivation, Māori and Pacific peoples have a lower life expectancy than non-Māori/non-Pacific people (Figure 23).¹⁵

Figure 23. Life expectancy by New Zealand Index of Deprivation (NZDep) quintile, by prioritised ethnicity Māori and non-Māori/non-Pacific, 2018-2022 

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This difference increases as socioeconomic deprivation increases. In 2018-2022, Māori living in the most socioeconomically deprived areas had a life expectancy of 74.2 years, whereas non-Māori/non-Pacific people living in areas with the same level of deprivation had a life expectancy of 81.6 years, a gap of 7.4 years (Figure 23). This relationship is also seen for Pacific peoples, with a 4- to 5-year difference in life expectancy compared with non-Māori/non-Pacific people across all deprivation quintiles. The greater negative relationship of socioeconomic deprivation and life expectancy for Māori and Pacific peoples may be explained by the relationship operating between coloniality, racism and socio-economic deprivation.^52,115

[viii] The New Zealand Index of Deprivation (NZDep) combines Census data across 8 variables (communication, income, employment, qualifications, home ownership, support, living space and dwelling condition) to give a measure of the socioeconomic deprivation level of an area. A socioeconomic deprivation decile or quintile is calculated for each small area; it does not apply to individuals or households. Each decile contains about 10% of small areas and each quintile contains about 20% of small areas in Aotearoa New Zealand. Decile 1 (and quintile 1) represent the 10 and 20% of areas respectively with the least deprived scores. Decile 10 (and quintile 5) represent the 10 and 20% of areas with the most deprived scores.

Infant and child mortality

Aotearoa New Zealand has relatively high rates of children who die in the first five years of life compared with other OECD countries.²⁷⁷ Infant mortality (defined as the death of a baby between birth and one year of age) decreased in Aotearoa New Zealand in the 1990s, followed by a slowing of that reduction from around 2000.²⁷⁸

There were 300 infant deaths registered in Aotearoa New Zealand in 2022, a rate of 5 deaths per 1,000 live births. These deaths were not evenly distributed. Noting that numbers are small, infant mortality rates have remained higher for Pacific and Māori infants than Asian and non-Māori/non-Pacific/non-Asian (nMnPnA) infants since 1999-2000, as shown in Figure 24.

Figure 24. Infant mortality rates by prioritised ethnicity, 1999-2022

The infant mortality rate for Pacific peoples’ infants decreased from 1999-2000 but only until 2011-12, when it started to rise again. In 2021-22, Pacific peoples had the highest infant death rate at 7.8 per 1,000 births, followed by Māori (6.3 per 1,000 births), Asian (4.7 per 1,000 births) and nMnPnA (4.3 per 1,000 births).

Between 1999-2000 and 2021-2022, the inequity in infant mortality for Māori infants reduced both in absolute and relative terms. In 2021-2022 it was 1.5 times higher than rates for infants of nMnPnA ethnicity, compared with 1.9 times higher in 1999-2000.

In the period 2014-2018, infant mortality rates of infants living in the most deprived areas were over double the rate of those in the least deprived areas.²⁷⁸ The Perinatal and Maternal Mortality Review Committee in 2024 identified considerable preventable mortality, particularly for groups experiencing the most disadvantage. The Committee recommended that different approaches to care are required for different population groups in order to improve infant survival.²⁷⁹

There have also been persistent differences in mortality rates by ethnicity and socio-economic deprivation level for children aged 1 to 14 years. Since 1990-91, death rates in children aged 1 to 14 years have declined for all socio-economic groups, but have consistently been 2 to 4 times higher for those living in the most socioeconomically deprived areas, compared with the least deprived areas.²⁷⁸ 

Deaths from heart disease, stroke and the circulatory system

Mortality rates from heart disease, stroke and diseases of the circulatory system halved from 2000 to 2020. There have been important improvements in absolute inequities, especially between Māori and non-Māori/non-Pacific/non-Asian peoples (nMnPnA).  However, relative inequities persist. Māori and Pacific mortality rates have remained about double those of nMnPnA ethnic groups and are similar to the nMnPnA rates of 25 years ago (Figure 25).

Figure 25. Mortality rates related to diseases of the circulatory system* by prioritised ethnicity, WHO age standardised, 2000-2020

Much of the improvement in cardiovascular mortality is related to reduced smoking rates, monitoring and control of cholesterol and blood pressure, and improved interventions for diagnosis and treatment (such as angioplasty and thrombolysis).²⁸⁰ The reductions in cardiovascular mortality rates have occurred despite rises in the prevalence of excess body weight and diabetes. 

Estimated prevalence of type 1 and type 2 diabetes

The Virtual Diabetes Register estimates the number and proportion of people with type 1 and type 2 diabetes in the Aotearoa New Zealand population at any point in time (prevalence).²⁸¹ We do not currently have a measure of the number of people with type 2 diabetes, but it is a large proportion of the total (international figures suggest around 90%). Onset is usually at an older age than type 1 diabetes.²⁸² 

Figure 26. Estimated prevalence of diabetes (type 1 and type 2) by prioritised ethnicity, WHO age standardised, 2013 to 2023

There has been an increase in age-standardised diabetes prevalence from 36.6 per 1,000 people in 2013 to 44.3 per 1,000 people in 2023. However, diabetes is much more common in some populations: 126 per 1,000 for Pacific peoples, 103 per 1,000 for Indian and 72 per 1,000 for Māori (Figure 26). Diabetes is also more common in populations living in the most deprived neighbourhoods (74 per 1,000 people in 2023) compared with the least deprived (28 per 1,000 people in 2023).²⁸¹

The rising incidence (new cases) and prevalence of diabetes parallels increases in excess body weight (EBW). Aotearoa New Zealand has worrying rates of EBW, with the third highest rate of countries in the OECD.²⁸³ While we acknowledge the limitations of body mass index (BMI) measurement, it provides a pragmatic tool to assess changes in population EBW.²⁸⁴ In 2023/24 one in three (33.8%) adults had a BMI of 30 or over, compared with 17% in 1997.²⁸⁵ In 2023/24, two thirds (66.9%) of adults were considered to have EBW (BMI 25 or more), with this disproportionately affecting those living in the most deprived neighbourhoods (where 78.5% had a BMI ≥25).²²⁷

Psychological distress

Psychological distress has risen in the last 10 years, with a particularly marked increase for young adults. The New Zealand Health Survey reports that the proportion of 15- to 24-year-olds experiencing high or very high psychological distress in the previous four weeks increased more than fourfold between 2011/12 and 2023/24, from one in twenty (5.1%) to more than one in five (22.9%) young people (Figure 27).²²⁷

Rates of psychological distress are higher in women than men (Figure 28) and show an inverse relationship with age (Figure 27). Nearly one third (30%) of women aged 15 to 24 years reported experiencing high or very high psychological distress in the previous four weeks in the 2023/4 New Zealand Health Survey.²²⁷ When people experience high levels of psychological distress, it affects the whole whānau and can have intergenerational impacts.²⁸⁶

Figure 27. Experienced high or very high psychological distress* in the past 4 weeks by age group, 2011/12-2023/24

Reported psychological distress has risen for all ethnic groups since 2019. Approximately 1 in 5 Māori and Pacific peoples, 1 in 11 Asian and 1 in 8 nMnPnA people experienced high or very high psychological distress in the previous four weeks in 2023/24. These data are not standardised for age, so the very high prevalence of psychological distress in Māori and Pacific peoples at least partially reflects the higher proportion of younger people in those populations. Rates of psychological distress are also higher for people living in areas of high socioeconomic deprivation (16.9%), compared with the least deprived areas (10%).

Figure 28. Adults experiencing high or very high psychological distress* in the past 4 weeks by gender 2011/12-2023/24
 

Figure 29. Experienced high or very high psychological distress* in the past 4 weeks by disability, 2018/19-2023/24 

Disabled people have higher rates of psychological distress than non-disabled people, with increasing prevalence in both groups over time (Figure 29). In 2022/23 over a third of disabled people reported experiencing high or very high psychological distress in the previous four weeks. Levels were slightly lower in the most recent survey (2023/24).

Psychological distress is also higher in disabled children with one in three disabled girls (34%) and nearly one in four disabled boys (23%) consulting their GP or nurse about mental health in 2023/24, a much higher rate than non-disabled children (girls 4%, boys 5%).²²⁷

Child oral health

Oral health is important for overall health and wellbeing. Poor oral health is associated with many health conditions such as diabetes, stroke and mental health.²⁸⁷ In this section we focus on child oral health but note that oral disease in Aotearoa New Zealand is also common in adults. There are higher rates in people living in rural and socioeconomically deprived areas, and for Māori and Pacific peoples, with ensuing high social and economic costs.^288,289 A review of potentially preventable hospital admissions for treatment of dental disease notes persistent disparities between Māori and Pacific peoples, and nMnPnA ethnic groups over time.²⁸⁸

In Aotearoa New Zealand, the Community Oral Health Service (COHS) provides free dental care from birth until the end of Year 8 (aged 12-13 years) but service coverage has been declining since 2000. By 2022, COHS coverage was 55% for 5-year-olds and 74% for Year 8 students and varied by geographic location and ethnicity.²⁹⁰ This low coverage limits our analysis of the situation. However, post COVID lockdowns, COHS focused on children at highest risk of dental caries. We do not know the oral health status of those children missing out, and those missing out may disproportionately be from least advantaged populations.

Figure 30. Children aged 5 years with dental decay (caries) at examination with the Community Oral Health Service, by prioritised ethnicity, 2002–2022

For the 5-year-old children seen by COHS between 2000 and 2022 there was a small decrease in rates of dental decay for Māori and non-Māori/non-Pacific and an increase for Pacific peoples’ children (Figure 30). However, rates of dental decay in these populations remain high, affecting nearly two thirds of Māori (61%) and Pacific peoples (66%) children and one third (34%) of non-Māori/non-Pacific children at the COHS 5-year check. For all children aged 5 to 9 years the rates of hospitalisations for dental decay more than doubled between 2000 and 2022, suggesting oral disease is being inadequately prevented and addressed in a timely way in our communities.²⁹⁰ Fluoridation of water supplies is an evidence-based intervention that can help reduce the persistently high and inequitable rates of tooth decay in Aotearoa New Zealand.²⁹¹

Health risk factor: smoking

Smoking increases the risk of many conditions including cardiovascular disease, lung cancer and respiratory conditions. Reductions in death and illness from these conditions are linked to reduced smoking rates.²⁸⁰ The proportion of adults who smoke daily (and have smoked more than 100 cigarettes in their life), as estimated by the New Zealand Health Survey, decreased steadily over the last decade. Rates more than halved in all ethnic groups and there was a large 24.5 percentage point drop for Māori. However, the rate in the last two years has plateaued at 6.9% (2022-24), and there are still inequities in smoking rates (Figure 31). Daily smoking prevalence rates remain well above the 5% goal for Māori (14.7%), Pacific (12.3%), those living in the most socioeconomically deprived areas (13.9%) and for disabled people (10.2%).²⁹²

Figure 31. Daily smokers (have smoked more than 100 cigarettes in lifetime and currently smoke at least once a day) by total response ethnicity, 2006/07 and 2011/12-2023/24

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New Zealand introduced world-leading legislation in 2022 to support reducing daily smoking prevalence in all population groups to under 5%. The legislation included initiatives for a generational smoking ban, reducing the nicotine levels in cigarettes and reducing the number of retail outlets. These initiatives were repealed in 2024, despite concerns that their removal would have impacts on the effectiveness and equity in smoking reduction.^293,294 There is concern that Aotearoa New Zealand’s revised smoking plan lacks measures that make it easier for populations to reach the 5% goal.^292,295 For example, the current plan does not include adequate regulations around retail access and product content (e.g. reduced nicotine levels).²⁹⁶

Health risk factor: vaping

Intended by policymakers as an aid to support smoking cessation, easy access to vaping has had some undesired effects. Although declines in smoking have been positive, there has been an even greater and more rapid increase in vaping, particularly by young people. Over a three-year period (2019/20 to 2022/23), the proportion of adults aged 15-24 years who vaped daily increased from 4.3% to 22.1%.^40,297

The widespread use of vaping is a new phenomenon, and the full extent of the health risks are not yet known. However recent studies have confirmed the association between vaping and significantly increased risk of respiratory problems, with doubling of chronic obstructive pulmonary disease (COPD) and increased rates of high blood pressure in people who vape aged over 30 years.²⁹⁸

Figure 32 shows the proportion of adults who vape by ethnicity (note that the data are not age-standardised so the higher proportion in Māori and Pacific peoples at least partially reflects the higher proportion of younger people in those populations). There was a steep increase in vaping rates from 2019/20, and the rates increased faster for Māori and Pacific people than for Europeans. In 2023/24, the daily vaping rates for adults over 15 years were particularly high for Māori (28.8%), Pacific peoples (21.5%), disabled people (12.5%) and those living in the most socioeconomically deprived areas (19%).

The ASH Year 10 Survey in 2024 of students aged 14-15 years similarly found very low rates of daily smoking but a dramatic increase in daily vaping between 2019 and 2021, when it reached approximately 10%. Daily vaping rates in this age group dropped slightly to 8.7% in 2024.²⁹⁷

Figure 32. Adults who vape daily by total response ethnicity, 2017/18-2023/24

Conclusion

Overall, many health outcomes have improved since 2000 – but more for some people than for others. We live longer, and there have been important reductions in some causes of early death and disability, such as cardiovascular disease and some cancers, along with reductions in absolute inequities. The positive impact of the large reductions in smoking rates and decrease in inequities in smoking across all ethnic groups, are to be celebrated. These reductions have contributed significantly to the reduction in cardiovascular disease, stroke, chronic lung disease, lung cancer and other conditions over the last three decades.

However, relative inequities in many other health indicators are entrenched. Infant and child mortality in Pacific peoples and in more socio-economically deprived communities is very concerning, with no reduction apparent in Pacific infant mortality in the last two decades. Rates of excess body weight have flat-lined or increased. The population prevalence of diabetes is rising, with very unequal impact. There have been increases in absolute inequity for Pacific peoples, and no real change in inequities for Māori and Indian people, compared with all other ethnic groups.

Our mental health is significantly poorer, especially for young people. While there have been some improvements in health-damaging behaviours like smoking and harmful drinking, vaping is at high levels in young people, with marked ethnic inequities.

Overall, there are significant persistent differences in health between population groups, many of which are preventable.^15,70 While there has been improvement on some measures, Māori continue to disproportionately experience poorer health outcomes. And for Pacific peoples, many indicators show no change or even worsening of absolute and relative inequities. These inequities have a huge cost, not just in terms of illness and disability for children and whānau, but also for our future prosperity and wellbeing as a nation.²³

For additional indicators and our overall ‘score card’, see Appendix 4 and online Appendix 7.

4. Looking forward: a threatened forest

Since the NHC published its report on determinants of health in 1998,⁸ the relationships between health and income, employment, education and housing have been further researched and documented, both in Aotearoa New Zealand and overseas. This work has confirmed that these factors – alongside social cohesion, cultural identity and Indigeneity – are vital to our health and wellbeing.^5-7,29,93 In this section, we consider some new and emerging influences that are increasingly shaping our access to resources for health.

The significant influence of commercial actors and processes on health – the ‘commercial determinants’ – has been more widely acknowledged and studied in recent years, with a particular focus on those industries whose activities negatively affect health (for example, alcohol, tobacco products, fossil fuels and ultra-processed foods (UPF)).^170,299

Two ‘megatrends’^16,300 are increasingly recognised as critical to our future health and wellbeing: the climate crisis, and the digital environment, particularly the rapid development of artificial intelligence (AI). These megatrends will increasingly influence patterns of access to other resources for health, such as employment and income, as well as more directly impacting on our health and wellbeing. We briefly examine below the commercial determinants of health and impacts of the climate crisis on health and equity.^301-303 We then explore some of the potential benefits and challenges for population health of AI and changes in the digital environment. 

Commercial determinants of health

A commercial entity is generally defined as one that buys and sells goods or services for profit or a return on investment.³⁰⁴ Our economy includes a range of commercial entities, from small private-sector businesses and NGOs, through to state-owned enterprises and transnational organisations. The ownership, control, purpose and functions of these commercial entities varies widely.

Commercial entities can contribute positively and negatively to human health and equity. The ways that commercial actors influence health and equity are known as the ‘commercial determinants of health’.³⁰⁴ As an example of ‘pro-health’ business, nearly 200 leading financial institutions globally (managing more than US$16 trillion of assets) have pledged to support tobacco-free policies across their lending, investment and insurance portfolios.³⁰⁵ Many businesses in Aotearoa New Zealand, including those in primary industries, also have a strong focus on sustainability, wellbeing of employees and protecting the environment.³⁰⁶

Commercial systems strongly influence other determinants of health such as employment, transport, food systems, and increasingly, health care. The interconnections between our current economic system, some of the more damaging commercial determinants, and negative impacts on the environment (environmental degradation, biodiversity loss, and climate change) have also become very clear.³⁰⁷ 

Products and practices that directly affect health

There is increasing evidence that some commercial entities – particularly large transnational corporations – use practices and promote consumption patterns that are escalating the rate of non-communicable diseases, climate change, and social and health inequity on a global level. The scale of the problem is large. In 2019, the Global Burden of Disease study estimated that four industry sectors (tobacco, ultra-processed foods, fossil fuel and alcohol) account for at least one-third of global deaths.¹⁷⁰

Factors such as occupational exposures (for example, to pesticides, asbestos or dust), shift work and other employment practices are also important components of the impacts commercial determinants have on health. For example, some manufacturing industries have lobbied for less stringent regulatory and enforcement standards, which has contributed to weaker labour and employment practices, environmental damage, and poorer workplace safety both in Aotearoa New Zealand and internationally. Ultimately this has led to workers dying and had health consequences for nearby communities.^170,308

Protecting intellectual property (IP) is another way that commercial interests affect health. For example, while the pharmaceutical industry has made a huge contribution to health by producing lifesaving medicines, it has also restricted access to essential drugs and vaccines to secure high prices, despite massive public investment in developing those products.¹⁷⁰

Compared with other businesses, extractive industries such as mining disproportionately consume or harm natural resources (a form of ‘negative externality’) for the value they generate to shareholders and investors. ³⁰⁹ This imbalance has social and geographical dimensions, since extractive activities often occur in less affluent areas while business owners and investors are more likely to live in wealthy and urban areas.³¹⁰ Turning natural resources into commodities often degrades the environment, for example by affecting water and soil quality.²⁹⁹

Commercial entities – especially in the food, alcohol, tobacco and mining industries –influence policy and political decisions, through lobbying, political donations and misinformation.^304,311 In Aotearoa New Zealand, the tobacco industry successfully lobbied for the repeal of the Smokefree Environments Regulated Products (Smoked Tobacco) Amendment Act 2022 in early 2024. This Act had introduced three evidence-based measures: decreasing tobacco supply, denicotinising tobacco and introducing a smokefree generation policy by progressively increasing the age at which tobacco could be legally sold to someone.^294,312-314

In addition to having the Act repealed, the industry also successfully lobbied for sales of snus, oral nicotine pouches and snuff to be legalised, arguing for customer ‘choice’.²⁹⁴

[ix] ‘Hazardous drinking’ is as an established pattern of drinking that carries a high risk of damage to physical or mental health, or harmful social effects on the drinker or others. It is determined by using the World Health Organization's AUDIT checklist – a score of 8 or more indicates hazardous drinking. 

The climate crisis

Climate change is one of two ‘megatrends’ increasingly recognised as critical to our future health and wellbeing.³⁰⁰ The climate crisis will have significant negative effects on Aotearoa New Zealand in the next 15 years. These effects include increased temperatures, changing rainfall patterns, and increasingly frequent and severe extreme weather events. These effects will cut across most determinants of health, including housing, income, employment, education, transport, infrastructure, food security and water quality.^270,322

We expect the effects of the climate crisis will compound existing inequities, as they will disproportionately affect communities that are already vulnerable. For Māori, this includes potential interruptions to whakapapa and connection to whenua.^303,323-325

Direct effects of the climate crisis on health

The effects of climate change are already bringing new and increasing hazards to Aotearoa New Zealand in the form of flooding, extreme weather events, extreme heat and heatwaves, drought, fire danger, sea-level rise and coastal inundation.^270,303,326

These hazards carry risks that directly affect our health (Figure 33):³⁰³

• Floodwater increases the risk of drowning, injuries, gastrointestinal diseases and illness.
• Flooding and severe weather events damage homes, which can cause multiple health problems (such as mental health issues, respiratory problems from mould, infectious diseases from overcrowding).
• Flooding and severe weather events affect facilities and services that people rely on for their health and wellbeing (such as schools and ECE, primary health care, aged care, marae and urupā).
• Sea-level rise and severe weather events damage infrastructure that people rely on for their health and wellbeing (such as roads, communications, and water, electricity and gas).
• These hazards significantly affect mental health, particularly after repeated adverse events.^327,328 Mental health impacts are disproportionately felt by the most affected communities (for example, Pacific communities in south Auckland, and rural communities in Tairāwhiti and Hawkes Bay affected by Cyclone Gabrielle and severe weather events in 2023).³²⁸

Figure 33. The impact of climate change on health

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Flowchart showing a cycle of:

1. increasing CO2 levels
   1. food supply impacts – malnutrition, diarrheal disease
   2. environmental degradation – forced migration, civil conflict, mental health impacts
2. rising temperatures
   • extreme heat – heat-related illness and death, cardiovascular failure
   • severe weather – injuries, fatalities, mental health impacts
3. more extreme weather
   • air pollution – asthma, cardiovascular disease
   • changes in vector ecology – malaria, dengue, encephalitis, hantavirus, Rift Valley fever, lyme disease, chikungunya, West Nile virus
4. rising sea levels
   • water quality impacts – cholera, cryptosporidiosis, campylobacter, leptospirosis, harmful algal blooms
   • increasing allergens – respiratory allergies, asthma.

Indirect effects of climate change on health

Increasingly other effects of climate change will indirectly affect our health. These effects include poorer air and water quality; drought; introduction of vector-borne diseases, more pollens and allergens; and greater ultraviolet light (UV) exposure. Poorer air quality increases premature mortality from respiratory and cardiovascular diseases; and poorer water quality and reduced availability increases the risk of contracting water-borne diseases (such as giardiasis, cryptosporidiosis and campylobacteriosis) and food-borne diseases (such as salmonellosis).³²⁹ These diseases can cause economic disruption, large outbreaks of illness and even deaths (such as was seen in outbreaks of campylobacter in Havelock North in 2016³³⁰ and of cryptosporidium in Queenstown in 2023).³³¹

Climate change is already disrupting our social and economic systems. Severe weather events are costly – the Treasury estimates Cyclone Gabrielle and the Auckland floods of 2023 together cost between $9.5 and $15.3 billion.^332,333  These events will increasingly impact on our primary industry (what and where we can produce food), our employment and incomes, and our housing and communities (including reactive or managed relocation from areas that will no longer be habitable).³³⁴

Climate change will disproportionately impact communities who live near rivers and the coast – which is most of us. Mean sea level in Aotearoa New Zealand is projected to rise by at least 10 cm by 2040 from 2020.³³⁵ Currently 750,000 people live in areas of Aotearoa New Zealand that are already exposed to extreme flooding.^322,329,334 These areas include major urban centres and 500,000 buildings that collectively are worth more than $145 billion.

It is predicted that ‘insurance retreat’ - where insurers will no longer insure coastal properties at risk of inundation from sea level rise – will soon affect most properties currently within coastal inundation zones that have a current ‘one in a hundred year’ risk of flooding.³³⁵ A partial insurance retreat could be expected within a decade (with less than 10 cm of sea level rise). Modelling predicts a full insurance retreat is likely within 20 to 25 years, with timing dependent on the property’s elevation and distance from the coast. This will not only have implications for relocation of people and the health and cultural impacts of this, but also large effects on the housing market and broader economy.^334,335

Different vulnerability to the effects of climate change

While everyone in Aotearoa New Zealand is affected by climate change, some groups are particularly vulnerable to climate-related hazards. These groups include children, older people, disabled people, people with chronic health conditions, Māori, Pacific peoples, people who live in rural or socioeconomically deprived areas, and people who work in primary industries.^324,329 For today’s children and young people, the psychological and mental health impacts of the climate crisis are already well described.³³⁶

Māori and Pacific peoples are disproportionately at risk of negative climate change impacts, including exacerbation of existing socioeconomic inequities,³²³ because of the industries many are working in (particularly primary production) and current socio-economic circumstances.³²³

Climate change also poses risks to Māori culture, by reducing or restricting people’s access to whenua and taonga species, which will have an enduring effect on whakapapa, kaupapa and tikanga Māori.^323,325 Displacement from whenua that is vulnerable to climate change may also disrupt Māori sharing location-specific mātauranga Māori and tikanga practices, and affect social cohesion and identity.^269,325 Impacts from severe weather events may also have significant spiritual impacts, for example through disruptions to urupā (graveyards), as seen after Cyclone Gabrielle.³³⁷

The effects of the climate crisis on the Pacific region

Accelerating sea rise, ocean warming and acidification are major threats for Pacific nations. Despite accounting for just 0.02% of global emissions, the Pacific islands are uniquely exposed to climate events. Their average elevation is less than two metres above sea level. Ninety percent of the population live within 5 kilometres of the coast and half the infrastructure is within 500 metres of the sea.³³⁸ Climate change impacts include significant threats to cultural wellbeing and mental health, as well as greater risks from vector-borne and water-borne diseases, such as dengue and malaria.^339,340

Aotearoa New Zealand’s close relationship with Pacific Island countries - including the significant populations of Pacific peoples who live here and our legal obligations to Cook Islands, Niue and Tokelau - mean that we need to consider how to support impacted communities, including potential needs for relocation and migration.³⁴¹ 

Strategies to mitigate and adapt to climate change

As Figure 33 illustrates, the effects of climate change pose multiple risks to health outcomes. Therefore, implementing strategies to mitigate climate change (that is, to reduce greenhouse gas emissions, prevent air pollution and reduce global warming) can benefit both the environment and health. However, any strategies we use to mitigate and adapt to climate change must be monitored for equity. These are discussed further in our recommendations (Section 6).

Mitigating and adapting to climate change

• Mitigating climate change involves taking actions that will reduce or prevent greenhouse gas emissions from human activities. These actions include transitioning to renewable forms of energy, using energy more efficiently, adopting regenerative agricultural practices, and restoring forests and critical ecosystems. To effectively mitigate climate change, we need to make structural changes that will reduce emissions and limit global warming to 1.5°C above pre-industrial levels.³⁴²
• Adapting to climate change involves taking actions that make us less vulnerable to the current and expected effects of climate change (such as extreme weather, rising sea levels, biodiversity loss, and food and water insecurity). Measures – many of which need to happen at the local level – include planting more drought-resistant crop varieties, adopting regenerative agricultural practices, improving how we store and use water, managing land better to reduce the risk of wild fires, and building stronger defences against floods and heat waves.³⁴³

AI and other digital determinants of health

Despite the many benefits of the online environment – for work, study, socialising, shopping and entertainment, and information – the negative effects of social media, online marketing and misinformation on our health and wellbeing have become increasingly clear. There are also still important differences in access and digital literacy across our communities.

Online groups have contributed to hate speech, racism and violent extremism, sometimes targeting marginalised individuals.^344,345 For young people, social media is associated with experiences of cyber-bullying, exposure to racism and discrimination, and anxiety.^346,347 Prolonged periods online are associated with reduced physical activity. Online marketing to children of ultra-processed food and alcohol is associated with health harms,^319,348,349 and misinformation on the internet associated with more people refusing vaccinations.^350,351

AI is already widely used in smartphones, facial recognition technology, internet search engines and data analysis tools in business, agriculture and health systems. However, the rapid emergence of generative AI (such as ChatGPT in November 2022) and recent advances in other technologies have significant implications for global economies and societies.^7,16

Given that generative AI is advancing so rapidly, the scale and timing of its impact on the economy, employment, society and the environment – and, therefore, on our health and wellbeing – is uncertain. However, the consensus is that AI will have a major impact.³⁵² Some of its potential benefits and challenges are already evident. A critical issue is how we use AI to enhance societal wellbeing, democracy, health and equity and our economy, while also protecting against its adverse effects.³⁵³

In this section, we consider the impact that current and emerging AI is likely to have on health determinants, and some possible scenarios, risks and challenges.

Effects of AI on economic growth and productivity

If used properly, AI tools have the potential to unlock enormous amounts of data, creating new opportunities to increase economic prosperity and significantly improve lives.³⁵⁴ However, these gains make take years or decades to emerge. More cautious estimates suggest that generative AI could increase growth in labour productivity in Aotearoa New Zealand by just one percentage point a year. By 2038, this would add $76 billion to GDP.³⁵⁵

Aotearoa New Zealand’s economy is based on exports, and 80% of exports are agricultural. To stay competitive and innovative in the global market, AI will be critical to our primary production sector. AI is likely to give us advantages in resource management and monitoring (for example, water, chemicals and pesticides use), land management (for example, livestock, planting and irrigation), soil management and supply chain logistics.³⁵⁶ It has the potential to make primary production more efficient and profitable.

Effects of AI on employment

The impact that AI has on employment will depend on the pace that technology changes, the type of employment affected, and whether AI will help or replace workers. In the US, it is predicted that up to 30% of all hours worked will be ‘replaced’ by AI by 2030.¹⁸

The first industries and occupations to be rapidly affected by AI are likely to be those characterised by repetitive tasks and low complexity. For example, many office tasks can be easily automated by AI. US and European studies suggest 13–14% of current jobs will be replaced by AI in the short term, particularly in banking, finance, administration, secretarial, sales and manufacturing.¹⁸ Based on recent surveys in Aotearoa New Zealand, these sectors are increasingly affected here.³⁵⁷

In 2023, a Datacom survey of 200 large firms in Aotearoa New Zealand found that 48% of businesses were using AI; this had grown to 66% within one year.³⁵⁸ By March 2025, the AI Forum was reporting 82% of firms were using AI tools (a 15% increase in use in six months), along with a small reduction in jobs and some effect on new hiring of staff.³⁵⁷ Most of this increase appears due to incorporating ‘off the shelf’ AI tools like ChatGP and Perplexity into existing operations, rather than developing new AI tools.³⁵⁷

AI may also create new job opportunities, but the transition to these roles may not be easy for everyone, potentially leading to greater social and unemployment inequality.

Within five years, a wide range of tasks across multiple sectors (including the public service, health and social care, engineering and science, and culture and media) are likely to be performed by AI. As some of these sectors have a disproportionate number of female workers, estimates suggest this change is likely to have a greater impact on women.¹⁸ It may also affect younger and older age groups, and disabled people differently.

Risks and challenges of AI

Concerns about AI include its accuracy (for example, ‘AI hallucinations’³⁶¹); algorithmic bias and discrimination;^362,363 increased polarisation of opinions and misinformation;³⁶⁴ surveillance, privacy and IP rights;^365,366 and cybersecurity and safety (for example in health care).^367,368 Globally it also poses societal and environmental risks, such as weaponised AI (for example, the autonomous weapons systems already being used in conflicts today).^16,362

Energy consumption

AI needs good-quality data, large data centres and significant computational power (high performance computing).³⁶⁹ As AI technology advances, the demand for data centres, especially around Auckland, is expected to double.³⁷⁰ Hyperscale data centres consume vast amounts of electricity. Around 40% of power is used for cooling, which also affects local water supplies. This additional energy consumption will increase our carbon footprint and could hinder Aotearoa New Zealand's efforts to meet our climate goals and reduce carbon emissions. It may also affect the local energy system and the cost of energy.³⁷⁰

Algorithmic bias

Algorithmic bias includes racial and other biases in AI tools. AI algorithms and outputs depend on the quality of the data they use. When the data is poor quality or biased, the algorithms will be too.³⁵³ Another problem is that AI models developed outside Aotearoa New Zealand do not reflect our population. This could mean they apply inappropriate or discriminatory logic, such as that seen in predictive policing techniques and in the US ‘technocorrections’ industry.³⁶² There are also concerns in health care that AI tools may replicate existing inequities, rather than reduce them.³⁵³ 

Governance

Governance challenges associated with AI include data privacy, security and ethics. AI systems rely on vast amounts of personal data, which raises concerns about data breaches and unauthorised access. To prevent data being misused, and protect people’s privacy, data protection measures must be robust.³⁶⁵

The lack of transparency in AI algorithms can lead to ‘black box’ scenarios, where it is difficult to understand or explain how decisions are made. This opacity can hinder accountability, which could exacerbate mistrust in the public service.³⁷¹ It also makes it difficult to address errors or biases in AI systems.

Ethics and regulation

It is challenging to design and use AI systems in ways that respect human rights and do not perpetuate discrimination or inequality. The risks this poses in the public sector varies widely. While it may be low in some circumstances (such as using AI to monitor wildlife), it may be very high in others (such as using AI to assess who is eligible for surgery or a social benefit, or to develop policies that could exclude some groups).³⁷² 

Aotearoa New Zealand’s public sector and businesses need a robust regulatory framework to oversee AI and address ethical concerns. Current guidelines, such as the Government Chief Digital Officer’s Responsible AI Guidance for the Public Sector: GenAI, aim to balance the benefits and risks of AI.^371,373 International frameworks are also useful.^374,375 However, these guidelines must be used and monitored consistently, to ensure that AI applications are ethical and do not harm specific communities.

Data sovereignty

The way data is collected, stored and used is important, because it determines how a story is told and who tells the story. It is even more important in the context of AI where the data may be used in ways that are not easy to understand or explain, or may have built-in bias.

In Aotearoa New Zealand there have been increased calls for Māori data sovereignty, in accordance with Te Tiriti o Waitangi and the recognition, by the Waitangi Tribunal, of Māori data as a taonga.^376,377 Māori data sovereignty refers to the inherent interest and rights Māori have in relation to the collection, ownership and use of their own data.³⁷⁸ It recognises that Māori data should be subject to Māori governance and supports tribal sovereignty and the realisation of Māori and iwi aspirations.^378,379 This means that AI models using Māori data should be developed carefully by Māori or in partnership with Māori, and Māori data governance models utilised.

While the potential of AI is recognised and is being explored by Māori,³⁸⁰ Māori also have significant concerns. These include where and how data is stored, leading to calls for Māori-owned and Māori-hosted onshore data storage.³⁷⁸ Generative AI tools such as Chat GPT typically draw on data from the dominant culture and thus risk marginalising Māori and Pacific peoples’ voices. There is also the risk of undermining tikanga and commercial exploitation of taonga, including te reo.^363,378 As a 2024 Treasury paper notes, ‘Related to [AI], Te Tiriti requires extra consideration of Māori rights and interests, as it creates certain obligations on the Crown that will not be provided for if we simply adopt international regulatory standards and systems.’³⁶³

Certain types of Māori data (such as data related to te reo Māori and other taonga) may need to be more actively protected, given their value and the contexts in which they are used.³⁶³ Māori organisations have already developed large language models (LLMs) and are using them to help preserve and revitalise te reo Māori.³⁸¹

Data sovereignty and ethical use of AI is not a concern only for Māori. Pacific, community and public-service leaders PHAC spoke with are concerned about how AI can misinform people and increase inequities. Disquiet was also expressed about AI’s potential impact on shared values, democracy and governance.³⁶⁰

Overall, although there are many uncertainties about the specific impacts of AI on key determinants (including health care), the influence of AI is likely to be large on most aspects of our lives in the next 15 years. Steering and regulating the development of AI tools and their use – and monitoring the outcomes of this in terms of equity and wellbeing – will be critical.

5. What progress has been made?

In this section we summarise the perspectives of community, iwi and public service leaders and young people on the progress we have made since 2000. We also review evidence and evaluations for the effectiveness of policies and programmes in modifying the bedrock and soil of our forest, the fundamental structures and determinants of health. There is reason to be optimistic – although patchy and slow, some progress has been made. But given the stresses on our health and social systems, the economic stress many people in our communities are experiencing, and the enormity of current and future challenges such as the climate crisis, current responses lack sufficient urgency and scale. 

Perspectives of community, iwi and public service leaders

In preparing this report, we spoke with community, iwi and public service leaders and young people about their understandings of health, progress in modifying determinants of health and health equity since 2000, and what they thought needed to be done to address current and future challenges (see Appendix 1 for details). They emphasised that there have been positive changes since 2000. They told us that that overall, local governments and the public service now better understand broader concepts of health and wellbeing, and the contribution of determinants to health and wellbeing. Leaders said that the interconnections between determinants of health, and their biological and physiological effects from early childhood across the lifespan are also now better understood.

The bedrock

We heard from community and iwi leaders that the public now understand more about the impacts that colonisation and racism have on health. There is increasing recognition of the promise and potential that Te Tiriti o Waitangi – the foundational contract for people who live in Aotearoa New Zealand – offers. There is also strong awareness of the inter-relationships between a community’s health and that of their environment.

Investing in communities

We heard a very clear message from community leaders we spoke with. They stressed the importance of mana and self-determination, and developing whānau and community capacity. These factors were seen as fundamental to changing peoples’ lives, improving social cohesion, economic prosperity, and successful wellbeing outcomes. Leaders told us it is essential to devolve resources and decisions to communities and others who are ‘lower down the system’.

Shift power to communities, enabling them to assert more ownership, voice and influence on issues that affect them. The role of community voice, leadership, priority setting, and solution generation have been especially evident [in Healthy Families].

For iwi and hapū, this would represent a shift towards recognising mana and affirming tino rangatiratanga. And for Pacific communities, it would acknowledge that Pacific peoples have the strengths, abilities and resilience to develop relevant, culturally aligned local solutions.

You know, with respect, what happens in Wellington with all the best will in the world, when failure occurs on the ground, what's the impact in town [Wellington]? …. The price is paid in the community and the lives of the individuals and their families. It’s there where capability, resource and power has got to be.

There is robust evidence that programmes to support whānau and community aspirations (such as Healthy Families New Zealand,³⁸⁶ Whānau Ora³⁸⁷ and Ngā Tini Whetū³⁸⁸) are making positive differences to people’s lives.^{84,386,389,390} Many informants spoke of the potential to make greater progress when leaders, workers and communities were focused on improving circumstances for the most vulnerable members of society:

The biggest question is do we have the will to shift things on behalf of the vulnerable? Collectively, as a society, what is our role to shift these outcomes? Because I think…this is a solvable problem. We've demonstrated that by making progress.

Leaders told us that investment in multi-year, Crown–iwi and hapū social programmes are needed to give iwi and hapū greater autonomy, flexibility, and allow for longer-term planning. The programmes need to be sustained and should focus on broad outcomes such as whānau prosperity and wellbeing. They should build on those that have been shown to work and achieve a positive return on investment (such as Whānau Ora commissioning³⁹¹ and Ngā Tini Whetū³⁸⁸).

An enabling approach from government and public services

Leaders support greater investment in place-based and community-led programmes, supporting local solutions that are valued, prioritised and resourced in meaningful and sustained ways. This requires a different approach from government.

Senior public service leaders also recognised the insufficient intersectoral work of government departments and the ineffectiveness of working in silos.

There was critique from in and outside the public service that central government ministries often have little expertise in policy implementation processes – this needs to improve or they need to ‘get out of the way’. While recognising the need to resource communities adequately to empower them to find their own solutions, the public service needs to devolve decision-making and clear any obstacles that get in the way of action.

As a senior public service leader noted:

In line with this, there were calls to strengthen and upskill the public service at local and regional levels, so that decision making, commissioning, and resourcing are better informed by local knowledge.

We heard that the public service urgently needs better analytical tools and skills to design, implement and evaluate policy implementation in ‘real time’. These tools are readily available outside of government.

But communities need to be involved in setting out what is important, and which questions are being asked of data. Local knowledge and the understanding of how each community works (‘practice-based’ evidence) needs to be integrated with data analytics in the context of each community. This will support the design of solutions for successful outcomes.

Public services need to be able – and willing – to take risks. Some informants noted there are often ‘permissions’ (i.e. not real obstructions) and mandates to work collaboratively that are not taken up.

Leadership from government

We heard that every level of society needs flexible, imaginative and reflective leaders, to manage current and future challenges, provide anticipatory, future-looking governance, and ensure our systems are resilient and have the capacity to adapt. 

Overall some progress has been made, but a lack of systemic change

Most leaders pointed to a lack of systemic change and some of the barriers to this. They noted the need to get the fundamentals right, to invest in the conditions that nurture our society as a whole. 

Assessing the evidence for progress

Evidence-based policy implementation

Government policy makers and legislators over the last 25 years have had access to a large body of public health evidence about how modifying determinants of health (such as assuring adequate household incomes, safe and dry homes, healthy food and satisfying work) can improve health and wellbeing. Policies and programmes addressing income support, child poverty, social housing, home ownership and improving housing standards, have well-evidenced positive impacts on health outcomes. There is strong evidence for the effectiveness of investing in early childhood development and family support to improve health and wellbeing outcomes.¹¹⁰ However, the model of intervention and implementation approach are critical in determining the extent to which these interventions reduce inequities in health.^{36,78,88,220,252,393-397}

Public health action using a range of legislative, tax and health promoting interventions on commercial determinants of health such as tobacco and alcohol has contributed significantly to improved health outcomes and absolute reductions in health inequities, such as in SUDI, some cancers, heart disease and stroke.^73,398,399 Public health has also played a key role in advocating for and monitoring safe drinking and recreation water and improving air quality. Improving water and air quality can have strong pro-equity effects, as more disadvantaged parts of the community often benefit most.

We now understand more about the impact determinants of health have on intersecting outcomes. In other words, the determinants not only affect health and wellbeing, but also other desirable outcomes like success in education and employment, social cohesion and crime reduction.¹⁸³ This more holistic understanding of the importance of wellbeing outcomes is reflected in the Treasury’s The Living Standards Framework 2021,²⁰⁸ and in programmes such as Whānau Ora^83,84 and Healthy Families New Zealand.³⁸⁶

A recent review of the way the political economy of a country influences population health (that is, how economic theories work in the real world, and how politics and the economy influence each other and health) concluded that social democratic welfare states, countries that spend more on public services, and countries with lower income inequalities have better self-reported health and lower mortality.²²⁰ Conversely, there is also extensive evidence of the associations between economic recession, unemployment and introduction of neoliberal policies with increased inequities in health and mortality.^96,172 However there are still gaps in the evidence and need for more empirical studies in our context, recognising the challenge of evaluating the effects of interventions in a complex system with multiple interrelationships.

Nourishing the bedrock and soil of our forest

Since 2000 there has been positive progress in addressing some elements of the bedrock and soil.

Te Tiriti o Waitangi: redress and reparation

Before building further on the promise that Te Tiriti o Waitangi holds, the essential steps of recognising the past and ongoing impacts of colonisation – and the need for redress and reparative justice – are required.⁴⁰⁰ After more than a century of resistance and far-sighted leadership by Māori in the face of adverse acts or inaction by the Crown, the Waitangi Tribunal and successive governments have engaged in a process of recognition through the settlements process. In some instances, Crown acknowledgement of, and apologies for, breaches of Te Tiriti o Waitangi have been made.⁴⁰¹

Some recent reparation models have addressed non-financial redress in new and positive ways. For example, the Tūhoe Claims Settlement Act 2014 and Te Urewera Act 2014 include a Crown apology for breaching Te Tiriti o Waitangi, limited financial and cultural redress, and mana motuhake (self-determination) redress through a joint Crown–Tūhoe social service management plan, based on the 40-year vision of Tūhoe.^402-404 Another example is Ruruku Whakatupua (Whanganui River Deed of Settlement) and Te Awa Tupua (Whanganui River Claims Settlement) Act 2017.^405,406 Reaching these settlements has required committed and inspired leadership on both sides, multi-partisan government support, and persistence and compromise by Māori over decades. 

Legislation that enables people to exercise their freedoms and human rights

Legislation is a key element of the bedrock we need to nourish our forest. The New Zealand Bill of Rights Act 1990,⁴⁰⁷ Human Rights Act 1993⁴⁰⁸ and Homosexual Law Reform Act 1986⁴⁰⁹ were milestones in Aotearoa New Zealand’s anti-discrimination law.

Since 2000, the government has also supported the wellbeing of the Rainbow community through the Civil Union Act 2004⁴¹⁰, Marriage (Definition of Marriage) Amendment Act 2013,⁴¹¹ and Conversion Practices Prohibition Legislation Act 2022.⁴¹² 

Aotearoa New Zealand ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2008¹⁵¹ and the United Nations Declaration on the Rights of Indigenous Peoples in 2010.⁴¹³ These are significant milestones. Many of these legislative changes have been agreed through multiparty processes, with leadership from individual politicians. However, our current Human Rights Act needs review, and many pieces of legislation are still not compliant with UNCPRD or UNDRIP, with a lack of substantive progress in realising these international treaties.

The New Zealand government has also maintained reservations in relation to the United Nations Convention on the Rights of the Child (UNCROC), relating to the employment of children, age mixing in prison and differing treatment of children who are not legally resident in Aotearoa New Zealand.⁴¹⁴

Reductions in income inequality and unemployment make a difference

In the forest, the soil represents resources that nourish whānau health and wellbeing – individually and collectively. After rapid increases in income inequality in the 1990s, peaking in 2015, there was a slight reduction in income inequality between 2016-2020, through income transfers and progressive taxes.⁴¹⁵ However, income inequality is again increasing, and a focus on income obscures extreme disparities in wealth.⁶²

Over the same period, unemployment also fell from its peak in the 1990s. This had a positive impact on youth, Māori and Pacific peoples. However, unemployment is on an upward trend again, with these groups again affected significantly more than others.¹⁴⁴

More positively, the Māori economy has grown substantially, from $17 billion in 2018 to $32 billion in 2023, and the rate of Māori asset growth is significantly faster than that of the overall economy (from $69 billion in 2018 to $126 billion in 2023), outstripping predictions.⁵⁹ 

Multi-party support for addressing child poverty

Aotearoa New Zealand achieved significant reductions in child poverty between 2012–14 and 2019–21, with further declines up to 2023 supported by taxation levers and social policies (progressive taxation, Working for Families and ECE subsidies).^416,417 There was initially strong multipartisan support to address the issue, resulting in the introduction of the Child Poverty Reduction Act which established the framework for measuring and reporting on child poverty and agreed long-term targets.

This shows that, with focus and concerted effort, complex problems can be successfully addressed. However there needs to be a stronger focus on reducing the persistent inequities between children of different ethnic groups.⁴¹⁶

Investment in early childhood education

Education is a key determinant of health – and in turn, healthy children and young people attend school more regularly and learn better. Early childhood education (ECE) has received increased government support for ECE attendance since 2000, most recently with ‘Family Boost.’⁴¹⁸

Despite decades of underinvestment in kōhanga reo, and governments failing to adequately sustain kōhanga reo as an environment for transmitting language and whānau development, it has proved to be a resilient movement for Māori aspirations for mokopuna.⁴¹⁹ However, far fewer kōhanga operate now than at their peak of over 800 in 1994.⁴¹⁹ Similar efforts to maintain Pacific languages (for example, through a’oga fa’a Samoa) have survived, but without adequate investment.

Since 2019 the number of licensed ECE services overall has declined by 5%.⁴²⁰ There is robust evidence for the cost-effectiveness of early intervention and quality early education for children in terms of health, education and justice gains. But there is not yet a strategic investment strategy or multi-agency approach to support sustainable, quality ECE and early childhood programmes. 

Changes in secondary education

When young people do well at school, they are more likely to take part in training and employment. Between 2002 and 2004, the government introduced NCEA, replacing the School Certificate and university entrance system that focused on external exams, standardised testing and scaling. NCEA aimed to increase diversity in the curriculum and better recognise individual skills.

Overall, NCEA has produced more successful outcomes for students, but large disparities in educational achievement remain, experienced disproportionately by Māori and Pacific young peoples.⁴²¹ At the same time, students who attend kura kaupapa Māori achieve similar outcomes to non-Māori students in mainstream schools, and better outcomes than Māori students in mainstream education.⁴²²

Quality housing for everyone is possible - but requires sustained political commitment

Ensuring that everyone can access quality housing has been a goal of multiple governments. Despite overwhelming evidence for the health and social benefits, and positive return on investment provided by social housing, achieving this aim has suffered from different ideological approaches and policy swings.^{192,252,256,258,259,423,424}

The increased rate of social homes built between 2017-2024 (accelerating in 2023-2024 with over 8000 new homes built by Kāinga Ora in the two years March 2023-March 2025) shows that it is feasible for social housing to ramp up to meet housing demand.⁴²⁵ The implementation of the Healthy Homes Standards and strengthened tenancy laws also illustrate implementation of evidence-based policy to support low income whānau and households. Other initiatives focused on specific populations, such as the Healthy Homes Initiative⁴²⁶ and Housing First²⁵⁵ (addressing homelessness) have demonstrated important health and social benefits.

However, home ownership rates remain low and there is overwhelming evidence of housing need, with rates of severe housing deprivation increasing over the last three decades.⁴²⁷ There is still a large unmet need for accessible housing and inclusive design standards. The current use of accommodation supplementary benefits transfers large amounts of public money into private property investors; this is not a long-term solution.⁴²⁸ Without more sustained investment in infrastructure, social housing and good-quality affordable homes, our precarious housing market will continue to be an immense challenge for many people and for health equity. 

Imprisonment rates can be reduced

Although public concerns about violent crime often make headlines, the New Zealand Crime and Victims Survey suggests levels of crime have not changed much since the survey began in 2018, with small increases in fraud and vehicle theft.⁴²⁹ The significant positive policy and practice shifts that have occurred in our justice system are less well known. For example, from 2007 to 2021 the rate of incarceration of young Māori men (<25 years) dropped significantly.⁴³⁰ Changes in sentencing policy (such as more community-based, intensive supervision), and the government’s 2017 goal to reduce incarceration by 30% contributed to this, while measures associated with the COVID-19 pandemic had temporary effects.⁴³¹ 

This reduction was also associated with greater recognition in the Courts of the underlying causes of offending, with the development of Alcohol and other Drug Treatment courts,⁴³² and rangatahi and Pasifika youth courts.⁴³³ There is still however insufficient support for the learning impairments, addiction and mental health issues, and disability needs (for example related to fetal alcohol spectrum disorder (FASD), traumatic brain injury or neurodiversity) of many people whom we imprison.

Changes to care for children experiencing neglect or abuse

The Royal Commission of Inquiry into Abuse in Care, examining the period 1950-1999, has highlighted not only decades of abuse, disproportionately experienced by Māori, Pacific peoples and disabled children, but also the cycles of violence this has created.⁴³⁵ Over 200,000 people were systematically abused while in the care of state and faith-based institutions, and there were decades of deliberate cover up. This has contributed to institutional mistrust, intergenerational trauma and significant health impacts. It has been estimated that survivors have an average life expectancy of 46 years (24 years lower than the rest of the community of that age cohort), and are more likely to suffer violent deaths (from self-harm, motor vehicle deaths and assault).⁴³⁶

This abuse also has significant economic costs – not only for the individuals and families concerned. The Inquiry estimated the total economic cost of abuse and neglect in care between 1950 and 2019 at around $200 billion, with lifetime health costs estimated at 7% of total lifetime costs.⁴³⁷ The total cost is over three times the cost of the government's COVID-19 response, and over four times the cost of the Canterbury earthquakes response and recovery.⁴³⁸

The way we care for children experiencing neglect or abuse has started to change, but there is still a long way to go. There is still significant ongoing abuse and neglect of children while in the custody of Oranga Tamariki, disproportionately in secure residences and when children return to their parents’ homes.⁴³⁹

However, from 2014 -2023, the number of Māori and non-Māori children who were subject to a report of concern to Oranga Tamariki fell, with the proportion of Māori remaining at about 50%.⁴⁴⁰ And although the rate of tamariki Māori in care increased between 2014 and 2018, it has fallen significantly since then. This reduction may be associated with recent legislative and policy changes. For example, Section 7AA (since repealed in April 2025) of the Oranga Tamariki Act 1989), and Oranga Tamariki partnerships with iwi are intended to ensure tamariki Māori are in the safe care of their whānau, hapū and iwi.⁴⁴¹

Legislation to reduce harm from tobacco and alcohol works

Taxation and pricing levers have been key to addressing harm from tobacco and alcohol in Aotearoa New Zealand. Overall, the effect of corrective tax policies on health outcomes has been pro-equity. For example, tobacco taxes have contributed to major declines in smoking, with greater impacts on young people and Māori, resulting in fewer smoking-related diseases and deaths. There is evidence of strong public support for greater use of taxation levers, for example in addressing harm from alcohol and sugary drinks.⁴⁴²

Changes in approaches to supporting whānau

In addition to universal social and health services, a range of programmes and projects focus on specific communities or families with more complex support needs. These programmes use varied approaches such as collective impact,⁴⁴³ systems change³⁸⁹ or social investment methodology.⁴⁴⁴ They may have multiple, broad wellbeing aims, or be more tightly focused (for example, focusing on a specific point in life, such as pregnancy or early childhood).

Strengthening Families is a structured, interagency case-conferencing system for coordinating services to whānau that has been operating in Aotearoa New Zealand since 1999.⁴⁴⁵ It aims to intervene early to support families facing challenges and offer prevention or intensive support. It was developed by Oranga Tamariki, the Ministry of Health and Ministry of Education; eight other government departments are signatories.

Outcomes of Strengthening Families have never been formally evaluated. However, in 2019, a review for Oranga Tamariki said that it was dealing with increasingly complex cases, and in many areas, government agencies were engaging poorly in local management groups.⁴⁴⁶

Whānau Ora, established in 2010 collectively by Te Puni Kōkiri, the Ministry of Health and the Ministry of Social Development, supports whānau to determine and achieve their own goals and aspirations. It is a Māori-led and whānau-centred approach. The Whānau Ora commissioning model includes support from kaiārahi (navigators) and flexible funding to ‘[enable] whānau to work together intergenerationally, in culturally aligned kaupapa with financial support.’⁴⁴⁷

Whānau Ora has been extensively evaluated, including analysis of the social return on investment of specific interventions. These evaluations have shown the approach has highly positive wellbeing and economic benefits.^447,448 This evidence shows that specific interventions can create equitable changes for whānau, but these interventions need to be sustained and scaled to the need.^{83,84,391,448,449}

Ngā Tini Whetū was developed in 2019 and is funded by Te Puni Kokiri, Oranga Tamariki and ACC. This programme is delivered through Whānau Ora commissioning agencies. It supports whānau to act autonomously, use their strengths to stay on the path towards mauri oho (energised life force) and to flourish with mana.³⁹¹ Despite having to manoeuvre around ongoing system barriers such as inflexible agency funding and governance mechanisms, the programme has been positively evaluated.³⁹⁰

Since 2015 there has been development of ‘social investment’ approaches by successive governments.⁴⁵⁰ Social investment is characterised by a focus on outcomes (as defined by whānau, communities or government), investment in early intervention, and use of data and evidence to prioritise resources where the impact and value is highest.⁴⁴⁴ Three social investment place-based initiatives were established in 2016 with two – the South Auckland Social Wellbeing Board⁴⁵¹and Manaaki Tairawhiti⁴⁵² – still in operation. The Social Investment Agency, established in 2024, has commissioned three further ‘demonstration initiatives’ as of June 2025.⁴⁵³

Place-based approaches such as the South Auckland Wellbeing Board, the Southern Initiative,⁴⁵⁴ Healthy Families New Zealand³⁸⁶ and the Tāmaki Regeneration programme,⁴⁵⁵while having varying goals and approaches, have similarities in aiming to create and resource community-led solutions. These programmes also aim to use data more effectively, intervene early, respond to local priorities and coordinate government services to work more effectively for communities.

What have we learned? Some progress - but ongoing challenges

Along with the assessment above, the trends in key determinants and health inequities in Aotearoa New Zealand presented in Section ‎3 reflect mixed progress. We demonstrate improvements in some key determinants but show that the uneven distribution of resources and opportunities has largely persisted over 25 years. Regardless of the indicator used, Pākehā are consistently privileged in terms of the determinants of health. Pākehā remain more advantaged in terms of wealth, income and material circumstances, and this is reflected in housing, education, employment and subsequent health outcomes.

There has been little progress on important determinants such as income equality, and home ownership, household crowding and affordability indicators have gone backwards since 2000. Wellbeing outcomes such as social connectedness and mental wellbeing are also going in a negative direction.

Our current economic system does not aim to achieve equity, but neither is it meeting the stated aims of a neoliberal market economy, such as lower prices for consumers. After four decades of neoliberal economics, we have low economic productivity and growth, and evident market failures (such as the housing market and supermarket duopoly).^176,456-458

In the absence of a strong commitment to redistribution (via the tax and benefit system), a focus on economic growth entrenches inequalities and arguably comes at the expense of social cohesion. Any positive benefits of our current economic model are highly unequal. Almost two in five people find it hard to meet everyday costs;¹⁷⁸ two-thirds of New Zealanders do not feel ‘well off’, and one in four sometimes do not have enough to eat.¹⁷⁹ This was the primary concern of young people that were interviewed for this report.

Our social safety net is failing, with benefit levels that are cementing in hardship and again increasing child poverty.^427,428,459 These all have direct effects on physical and mental health.

AI and the digital environment offer huge benefits and potential for good, but also the potential to increase harm from discrimination, the spread of mis- and disinformation, and the exacerbation of inequities. AI tools have developed within the current environment and reflect the global economic system and colonial history.³⁷⁸ The online environment contributes to misinformation, unfiltered discrimination (such as through trolls, and racist or misogynist influencers) and increased access to harmful products. The contribution to endemic social anxiety, cyber bullying and violent extremism is also a public concern.⁴⁶⁰ These harms can be mitigated, if governments take account of the needs and concerns of different communities and ensure these are reflected in appropriate systems of governance and regulation. Importantly, these systems should uphold inclusivity, transparency and human-centred values rather than allowing power over digital environments to be concentrated in the hands of a few.³⁷³

Trust in public services is currently vulnerable, partly fuelled by misinformation and industry lobbying.⁴⁶¹ Social divisions are evident across key issues such as the significance of Te Tiriti o Waitangi,¹⁷⁹ and the extent to which environmental protection should be weighed against business interests.¹⁷ The security of one of our greatest assets – our ‘clean, green environment’ – is threatened by weakening of key regulatory protections.⁴⁶² And, despite recognition of the reality of climate change and evidence of our susceptibility to the impacts of it in Aotearoa New Zealand, our response has been slow and inadequate.

Young people told us about their aspirations for loving relationships, strong family and cultural connections, financial stability, and good jobs. Many spoke about the need to make our places — both physical and digital — more supportive, accessible, and liveable. The links between our environment, mobility (accessible public transport), and mental wellbeing came up often. People want to feel safe and able to move freely. Although many were positive about their own individual future, they were pessimistic about the possibility of system change.

As one leader told us, on a global scale we are now facing a ‘poly-crisis’ – that is, where crises are not just amplifying and accelerating but also appear to be synchronising. The triple planetary crisis of climate change, nature and biodiversity loss, and pollution and waste, is feeding human crises, leading to conflicts for resources, population displacement and widening gaps in health outcomes.¹⁶

We need to recognise the deep uncertainty and complexity this brings. There is, even more than before, a need for evidence rather than misinformation, a focus on intergenerational equity and an acknowledgement of what we don’t know.

6. What needs to change?

PHAC’s recommendations

Invest in and empower communities, the root network of our forest

Wellbeing, social cohesion, economic prosperity, and health start within our whānau and communities. Their mana, aspirations for self-determination, capacity and strengths are fundamentals to build on. Early support for children and their families in our communities is vital to improving health equity and wellbeing across the life course. Our review of evidence and our engagement with community, iwi, and public service leaders suggest that both the siloed way government currently does its business and a lack of innovative approaches ‘get in the way’ of community-led solutions to the challenges we have outlined. Therefore, the actions we propose below are primarily focused on supporting a change in the approach of the public service, in order to support communities to achieve long-term, measurable wellbeing and health equity goals. 

These recommendations align with rangatiratanga for iwi and hapū, supporting Māori to direct their own solutions and achieve their own aims for the future. For Pacific communities, these recommendations acknowledge that Pacific peoples have strengths and abilities to design and deliver culturally aligned, high quality, local solutions. 

Nurture the bedrock

Shared values and respect for human rights are key to a thriving and resilient democracy and a cohesive, healthy society. Democracy relies on agreement on facts, public trust in government and public services, and acknowledgement of our shared history. By 2040, 200 years since Te Tiriti o Waitangi was signed, the Crown and Māori must have a positive and future-focused relationship, built on confidence and mutual respect.⁴⁷⁰

Towards 2040: Te Tiriti o Waitangi and our constitution

As a first step, the Crown must meet its existing commitments under Treaty settlements, and significantly improve how settlements are managed, as recommended in the recent Auditor-General’s report (2025).⁴⁷¹ If the government fails to provide the promised redress, iwi, hapū and whānau will forego significant economic and social opportunities, and the health and wellbeing benefits associated with them.

Failure to meet Crown commitments would further damage the government’s reputation, making it harder for the public sector (including the health sector) to achieve what the settlements intended. It could also create litigation and financial risks for the Crown.⁴⁷¹ It is essential for mana Māori, health and wellbeing that the Crown respect existing obligations under current settlements, and that further progress in processes of reparative justice is made in good faith.

The PHAC supports initiating a broad nationwide discussion in communities about Te Tiriti o Waitangi and our future constitutional arrangements moving towards 2040. The frame and scope of this korero must be agreed by both parties to Te Tiriti o Waitangi and led by respected Māori and Tangata Tiriti leaders. The discussion should cover our constitution, rights and freedoms, recognising the ongoing impact that colonialism has on Māori, and the need for reparative justice. It needs to address common misinterpretations of Te Tiriti o Waitangi and ‘misremembering’ of our history.

The process for this discussion needs to be thoughtful and deliberate, allow for ongoing reparation and healing, and offer communities support. Matike Mai, the kaupapa originally led by Dr Moana Jackson and Margaret Mutu for the National Iwi Chairs forum, could provide a blueprint for starting that discussion. ^473,474 The working group of Matike Mai held over 250 hui throughout New Zealand over three years, and proposed a range of different possible models for constitutional change, with the goal of transformation by 2040.^473,474

The discussion must allow people to express their views safely and hear, and reflect on, other people’s views. Recognising existing power imbalances, it must be adequately resourced and appropriately arranged, so that everyone can take part. Rangatahi voices must have priority and greater weight, as young people have a bigger stake in intergenerational equity.

We can also learn from others’ experiences – for example, the agreements, plans and processes developed between provinces and federal government of Canada and Indigenous (First Nations) peoples since ratifying UNDRIP.^475,476

Commit to human rights and anti-discrimination

For a healthy, equitable and inclusive society, we need to embed existing rights legislation more deeply into our constitutional framework. We can build on the anti-discrimination and inclusion gains made for disability and Rainbow communities.

It is also essential that we continue repairing the discrimination embedded in policies, practices and social norms, as this drives inequality and perpetuates health gaps between Māori and non-Māori. Active anti-racist action must be rooted in our systems.⁸⁶ These actions would uphold Te Tiriti o Waitangi commitments and our international commitments, such as those under UNDRIP. Celebrating Indigeneity as a positive determinant of pae ora – within a non-racist system that does not penalise tangata whenua for being Indigenous – should be our goal. Recognising and healing intergenerational trauma, decolonising and re-Indigenising is important in this process,²⁹ along with tangata o Te Tiriti learning to be an honourable partner.

Aotearoa New Zealand also needs to acknowledge the shared whakapapa of tangata whenua with te tagata o le moana and address the impact that colonisation has had on Pacific nations. An important step in this process is re-examining our identity and re-situating ourselves as a Pacific nation alongside others. This can enlarge and inform our perspectives about how to respond (nationally and regionally) to climate change and environmental challenges, and how to act on inequities that Pacific peoples experience in education, employment, wealth and health in Aotearoa New Zealand.

Modifying the market economy

The goal of a thriving economy and greater wealth should be improved collective wellbeing, rather than a narrow focus on GDP. Our economic system - that results today in one in four of our children growing up in unhealthy, crowded homes, with inadequate material resources and a lack of sufficient food - cannot be seen as a success.

If we are to address the uneven distribution of determinants of health (such as income and wealth) alongside the other challenges we face, we need more discussion and consensus about the values that underlie our economy. 

The World Economic Forum’s The Future of Growth Report 2024 looks at multiple factors to assess balanced growth. It scores Aotearoa New Zealand relatively well on inclusiveness and resilience, less well on innovation and poorly on sustainability.⁴⁷⁷ To improve this score, Aotearoa New Zealand could expand work on wellbeing previously carried out by the Treasury.^208,478,479 Other jurisdictions explicitly consider broader wellbeing and intergenerational outcomes in legislation and budgets, such as in the Welsh Well-being of Future Generations Act (2015).⁴⁸⁰

Wales has developed measurable milestones, such as reductions between social groups in education, employment, mental health and life expectancy differences; a million speakers of Welsh by 2050; and net-zero greenhouse gas emissions by 2050. Scotland is considering a similar Parliamentary Bill as of June 2025, and there are similar discussions in other EU countries. There is advocacy internationally for implementation of similar legislation, including in Australia and Aotearoa New Zealand.^481-483

Outdated economic theory which has failed to deliver equitable outcomes should be challenged. Future-thinking economic theories are now considered mainstream rather than alternative. Examples are the circular economy (based on principles of eliminating pollution and waste, circulating or recycling products and materials, and regeneration);⁴⁸⁵ and the concept of a regenerative economy, also known as the ‘doughnut economy’, that recognises our environmental limits and the value of strong societal foundations.^486,487 This concept has been reinterpreted in Aotearoa New Zealand, sharing Indigenous thinking evident in other global models.⁴⁸⁸ This kind of approach is already evident in economic strategies espoused by some iwi, for example Kai Tahu,⁴⁶⁵ and the Kīngitanga.⁴⁸⁹ 

Reset economic levers

Views differ on how fair and progressive our current economic system is. Wealthier people tend to think it is fairer than those who are less wealthy.¹⁷⁹ But low working incomes and benefit levels today are clearly not enough for people to have a healthy life and fully participate in society.^179,428 Instead, alongside a complex and rather punitive social welfare system, they contribute to entrenched poverty, affecting far too many of our children.⁴²⁸

At the same time, an ageing population, increased demand for health and disability services and challenges like the climate crisis put increased fiscal pressure on our tax system. Current and future governments have choices over how to manage these fiscal pressures. They can do so through spending controls, greater use of private funding mechanisms, or increases in tax as a share of the economy. Each of these have trade-offs in terms of fairness and efficiency.⁴⁹⁰

Tax levers that could be further utilised include larger redistributive income and/or wealth transfers (for example, through capital gains tax (CGT) on property and assets).⁴⁹⁰ These transfers could be reinvested in adequate provision of social and health services accessible to all.

Although Aotearoa New Zealand had made some progress on gender pay equity, this has recently stalled,⁴⁹¹ and even less progress has been made with other important supports for secure and satisfying employment, such as fair pay agreements. A disproportionate number of Māori and Pacific peoples, particularly women, are on the minimum wage or earn less than $25 an hour.^492,493 Lifting the minimum wage to a ‘living wage’ would be a pro-equity step for all.

The government could also consider a universal child benefit in addition to more targeted measures for families. At the other end of the life-course, although our universal superannuation scheme has historically led to low levels of elder poverty, it was premised on high levels of home ownership, which increasingly will not be the case.⁴⁹⁴ Recently, several reports have proposed a universal basic income, or a ‘social floor’ (baseline living standard) for all households. Given the potential impact of AI on employment in future, this may become an urgent need, and the PHAC recommends further investigating this approach.^359,428,493

Confronting the megatrends

Invest in ‘win-win’ solutions that nourish the soil and have compounding benefits for health and other social outcomes

The climate crisis: inserting urgency into our response

Aotearoa New Zealand’s response to the COVID-19 pandemic demonstrates that rapid, dynamic government action, informed by science and evidence, can successfully address major global health threats and save lives.^79,495 Climate change requires a similar focus and urgency but with longer term commitment.

Interventions to mitigate climate change, support transition to clean energy, and reduce emissions, deliver cost savings and avoid the costs and risks that arise from inaction. These include market risks, greater ill health, and the cost of having to make a harsher, more expensive transition in future.^496,497International evidence shows strategies for adapting to and mitigating climate change provide multiple co-benefits (Figure 34).^495,498

Thinking carefully about how we plan our cities and towns and build our homes is an example of action critical to our health and wellbeing. This also has long-term consequences. Health co-benefits of climate mitigation approaches such as improved urban design and active transport include increased access to physical activity, reduced urban air pollution,^499,500 reductions in excess body weight and type 2 diabetes, heart disease, road traffic accidents, cancer and respiratory disease, and improved mental health and wellbeing.²⁶⁹  Active transport initiatives in Aotearoa New Zealand, alongside well-designed urban infrastructure, have been shown to have significant positive effects on physical activity and mental wellbeing, and on household savings through lower car use.^501,502

Some interventions are low cost to implement with a high return on investment. For example, improving car emission standards in Aotearoa New Zealand to European standards has estimated benefits between 35 and 48 times higher than the estimated cost of the policy. Social benefits due to the reduced health effects of air pollution would range from $8,342 million to $1,076 million (in 2019 NZ$ as net present value).⁵⁰⁰ 

Using AI tools with the capacity for analysing large datasets and models has the potential to assist in more rapid design, planning and real-time responses in urban design, and in the energy and agricultural sectors. It is important that these changes are made with, and not to, communities, and that any unintended impacts and outcomes are monitored to ensure the changes are not disproportionately benefiting or disadvantaging certain groups.

There are also major economic and investment opportunities associated with climate change mitigation.⁵¹³ Depending on the mix of policy options adopted, potential co-benefits from emissions reduction and accelerating the transition to clean energy include:

• Increased productivity (as renewable electricity is more efficient and cheaper than fossil fuels).
• Greater energy security and independence.
• Opportunities for innovation to research and develop low emissions solutions, especially in food production.
• Increased resilience – for example through land-use changes that reduce erosion, or by designing electricity and urban networks for emissions reduction. 

Figure 34. Health co-benefits of climate mitigation measures by sector in Aotearoa New Zealand

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Our farms

Emissions from animal and plant production

Mitigation measures that:

• Increase livestock farming efficiency
• Increase sustainable land use and improve water and soil quality
• Increase plant-based food production
• Support local markets, jobs and reduce food transportation
• Optimise AI/technology to improve agricultural practices

Health benefits that arrive from eating more plant-based food

• Improves heart health and diabetes risk
• Eating red meat less than two times a week lowers bowel cancer risk by 20%

Our cities and homes

Emissions associated with building materials, urban planning and heating and cooking

Mitigation measures that:

• Improve access to affordable public transport
• Increase safe walking and cycling infrastructure
• Increase low-carbon building materials
• Incentivise renewable energy sources
• Increase energy efficiency e.g. insultation.

Health benefits that arise from active living and reduced pollution

• Physical activity and healthy weight
• Better respiratory, heart and mental health

Warmer, drier homes

• Decrease of 18.6% in hospitalisations
• Decrease of 5% school absence for children due to illness

Transport

Emissions from cars, trucks, planes, ships and trains

Mitigation measures that:

• Prioritise public transport
• Incentivise use of alternatives to private cars (e-bikes, electric buses and trains)
• Introduce tighter emission standards for vehicles
• Increase active transport e.g. cycling, e-bikes, walking
• Prioritise freight on rail.

In a south Auckland community pilot, 1 in 3 weekly trips were made by e-bike, car trips reduced by 25%.

Health benefits that arise from reduced pollution and increase physical activity

• $6.6 billion of health and social benefits to 2050 if tighter vehicle emission standards introduced.
• Reduction of 116 deaths/year and health costs by $200m/year if cycling replaces 5% of short car trips.

Sustainable environment

Emissions associated with deforestation and ecosystem degradation

Mitigation measures that:

• Increase reforestation and indigenous forest
• Increase urban greening and conservation
• Improve freshwater and marine ecosystems
• Restore land and soil health.

Health benefits that arise from increased greenspace

• 30 mins green space use per week decreases depression and blood pressure
• More urban trees improves mental health and reduces death from heatwaves.

Utilise positive economic levers

Positive economic levers to change behaviours have proved very successful in Aotearoa New Zealand and elsewhere. ^237,422 They include giving people a wider range of choices and incentives to encourage them to shift to clean transport and more sustainable farming measures. These measures include:

• electrifying the car fleet
• public-sharing e-bikes and scooters⁵⁰⁶
• better, cheaper and more accessible public transport
• environmental standards and product traceability.^302,513

The public sector is a large and powerful ‘customer’.⁷ It can use this status to give its suppliers a positive incentive when they take actions that mitigate climate change. Examples include using construction contracts that meet climate-resilient standards for government buildings; and buying healthy locally grown food for public institutions (such as hospitals and schools).⁵¹⁴ This can contribute to better health outcomes, and local economic growth and jobs, while also reducing carbon emissions. 

We need to identify similar levers to incentivise change in other systems that influence health, such as shifting the food system to produce more plant-based foods and high-value dairy products. Learnings from global examples such as Origin Green in Ireland, and from local research, development and innovation could extend existing programmes (such as the voluntary New Zealand Farm Assured Programmes⁵¹⁵) to the whole food system. 

Activities that promote healthy and affordable food in communities can also help us mitigate and adapt to climate change. Community food initiatives (such as māra kai, community gardens and regenerative planting) revitalise cultural knowledge about food production and improve social cohesion and physical and mental health outcomes – while also reducing carbon emissions.⁵¹⁴ Reducing and recycling food waste reduces emissions and improves communities’ food security. When whānau have greater food security and access to healthy foods, they can maintain a healthy body weight and have better oral health. Ensuring children have enough to eat, have good hearing and oral health improves their education outcomes. This will have a long-term impact on their employment and income opportunties.⁵¹⁷

AI and the digital environment

AI is rapidly changing, and in uncertain ways. There is a high risk that societal changes resulting from AI will reinforce existing inequities.³⁶² Given this, the speed of change, and uncertainties, here we focus on actions to address some of the potential challenges to wellbeing.

Government has a key oversight role

The government has a key role to provide and oversee frameworks that enable us to take up the benefits of technological change, protect us against risks, and steer AI and the digital environment towards equity.^371,373 Government and private-sector investments in AI need to recognise the biases in data that AI tools use, particularly when those tools use data from other countries and apply them in Aotearoa New Zealand. When AI tools (such as police facial recognition tools) use existing data and algorithms, they entrench bias, which increases people’s mistrust in government services.

Given that the quality of data has a major impact on the output of AI algorithms, it is crucial to improve the quality of ethnicity data held by the health sector and other government agencies.⁵¹⁸

AI sovereignty refers to a nation’s capability to develop, manage and use AI in ways that align with its own values, regulations and interests. AI sovereignty is increasingly recognised as important, and not only for assuring national security and defence.^{519, 520} Reducing dependence on external AI technology, enhancing our global competitiveness, and fostering innovation and new models, can create high value jobs and retain local talent and expertise.

There are strong ethical arguments for AI sovereignty, for example, in development of public service large language models (LLMs). There is also a strong argument for AI sovereignty related to Te Tiriti o Waitangi obligations. It is a prerequisite that Māori govern and lead how Māori data is used by AI tools. It is therefore a priority to invest in developing AI tools that support innovative economic and social development specific to iwi and hapū.^377,378

Aotearoa New Zealand has infrastructure capacity, innovative companies and a lot of quality data. Given this, we should invest in creating AI tools that are specific to Aotearoa New Zealand, particularly in critical areas like environmental management, primary production and health care. Reducing our dependence on foreign AI technology, fostering innovation and new models, and becoming more globally competitive would create high-value jobs in Aotearoa New Zealand and retain local talent.^18,356,359

Support people whose jobs are affected by AI

Where rapid job losses related to AI are likely to, or do, occur, investment by government and industry in flexible regional and local programmes will be required, to allow people to retrain, upskill and adapt to change. Other countries in our region are already directing young people into short (3-12 months) vocational courses on AI, to provide them with job opportunities in the technology sector and to support businesses transform using AI.⁵²¹

The government must also strengthen the social safety net for those who lose their jobs. If AI reduces the labour share of income, we may need to use other mechanisms to raise tax revenue through capital and introduce a universal basic income approach.³⁵⁹

Plan for the extra energy that AI needs

When the government and private sector are planning investments in clean energy, they must account for the extra energy requirements of AI. AI depends on high-performance compute and large data centres, which escalates its demand for energy and water.

Given Aotearoa New Zealand has the capacity for developing more renewable energy, it has a potential advantage in the global AI market - if there is sufficient investment in new renewable energy sources. AI also has the potential to create an intelligent coordination layer across the generation, transmission, and use of energy, and support a more resilient and adaptive energy system.⁵²²

Use AI to support ‘win win’ solutions

AI tools with the capacity for analysing large datasets and models have the potential to assist in more rapid design, planning and real-time responses in urban and environmental planning, and in the energy and agricultural sectors. It is important that these changes are made with, and not to, communities, and in line with Māori data sovereignty. It is also important that any unintended impacts and outcomes are monitored to ensure the changes are not disproportionately benefiting or disadvantaging particular groups.

Actions for the health system

Finally, we propose key actions for the health system. Although the focus of this report is on the determinants of health outside the health care system, we recognise the important contribution it makes to our health and wellbeing. The health system also has internal and external influence, and levers that it can use to address the ‘megatrends’ and challenges set out in this report. These recommendations align with the three themes above.

Appendix 1. Methods and evidence

1. Literature and evidence reviews

We carried out several literature searches with the support of Ministry of Health librarians. The search strategies were focused on:

• Policy and programmes to improve equity in health outcomes
• Health, equity, and climate change in Aotearoa New Zealand
• The mechanisms (physiological, biological and epigenetic) for how determinants influence physical and mental health
• The commercial determinants of health (and relationship to alcohol harm, excess body weight and other health damaging factors)
• Climate change and health
• AI and predicted effects in Aotearoa New Zealand.

We particularly focused on research and evaluations carried out in Aotearoa New Zealand, including those available in the grey literature, and on the period 2010-2025. We reviewed systematic reviews or ‘reviews of reviews’ of the international literature in these fields. We also accessed key literature recommended by PHAC committee members and public health experts.

2. Key informant interviews

The PHAC aimed to inform this report with learnings from a range of experienced community, iwi and public service leaders. These ‘key informants’ were identified through nomination by PHAC members, by ‘snowballing’ (i.e. referral by other informants) and through identification of lead academics and experts involved in research on key determinants of health, such as housing and transport. We aimed to interview people with knowledge from across a range of areas, from economics to housing, AI and the climate crisis, disability and transport. We also wanted to hear from people with a range of expertise and experience, from research, public service, to programme implementation and ‘practice evidence.’ We based the semi-structured interviews around four main themes/questions. These were:

• the informant’s own concepts of health and understandings of the contribution of determinants of health to wellbeing;
• their assessment of progress made in addressing inequities in determinants of health and in health outcomes since 2000;
• the key challenges they saw looking out to 2040; and
• key actions or solutions they proposed, based on their experience, ‘practice evidence’ or other sources e.g. published research.

The interviews were carried out between December 2024-June 2025, in person or online. The majority of informants were interviewed by Dr Clair Mills (PHAC secretariat), usually accompanied by another secretariat colleague. Interviews were recorded and summary notes taken. Key themes were identified and collated, along with relevant quotes.

3. Engagement with The Hive

The HIVE functioned from 2019 to June 2025 as a collaboration between rangatahi (young people), the Ministry of Youth Development and Curative (a creative change agency), to support youth voice and perspectives into government services. The PHAC secretariat first gathered insights from young people from a broad range of existing sources (see below) and then tasked The HIVE to sense check the relevance of the existing information.  We asked The HIVE to gather further insights with a range of rangatahi from across the motu, through interviews and social media engagement.

Members of The Hive conducted peer interviews with 28 rangatahi from across Aotearoa New Zealand in May 2025. All interviewees were between the ages of 17–25 years. Participants included Māori, Pacific, Pākehā, Asian, Middle Eastern, African, rainbow, gender diverse, urban and rural young people. The findings of these interviews have validated and added to existing youth engagement information on what young people perceive as the most significant determinants of their health and wellbeing. Financial security was identified in these interviews as the most significant influence on young people’s health and wellbeing. This and other findings are summarised into a report (HIVE insights- Determinants of Health). We have used quotes in the PHAC report (in green font) from diverse rangatahi interviewed as part of this engagement.  

4. Review of data and community ‘voice’ from prior community engagement

A diverse range of workshops, hui and talanoa have been conducted in recent years to inform the development of health sector policies and strategies. These include engagements with children and young people, whānau Māori, Pacific communities, disabled communities, and other ethnic communities. The insights gathered reflect the voices and experiences of these groups. PHAC decided not to repeat further community consultation specifically for this report, but to draw on the findings and richness of these existing sources. We reviewed the summaries and had access to some of the raw data. We focused on participants’ understandings of health, the determinants of health and what they viewed as important for the future. 

Children and Young People

• The HIVE. Quarterly newsletters 001-004. Curative NZ and Ministry for Youth Development. News & Updates | The Hive: https://www.thehive.nz/news
• The HIVE. Determinants of Health: Hive - Youth Perspectives. 2025. Insights prepared for the Public Health Advisory Committee. Curative NZ and Ministry for Youth Development.
• Stubbing, J., Gibson, K., Bardsley, A. et al. “We’re living in a world that wasn’t built for us”: A qualitative exploration of young New Zealander’s perspectives on socio-ecological determinants of declining youth mental health. BMC Public Health 25, 1648 (2025). https://doi.org/10.1186/s12889-025-22618-2
• Ministry of Social Development | Te Manatū Whakahiato Ora. 2022. What About Me? The Youth Health and Wellbeing Survey 2021 Overview Report. Link: Youth Health and Wellbeing Survey MSD 2021
• Mana Mokopuna – Children and Young People’s Commission. 2024. “A place to talk peacefully” What helps and what gets in the way. Mokopuna voices on healing from family and sexual violence in Aotearoa New Zealand. ISBN 978-0-473-73046-8 November 2024.  https://www.manamokopuna.org.nz/voices. “A place to talk peacefully: Mokopuna voices on healing from family violence and sexual violence in Aotearoa | Mana Mokopuna
• Mana Mokopuna – Children and Young People’s Commission. 2024. “You need to get in early, as soon as you see people struggling.” Understanding the life-course journey. Mokopuna voices to inform the Child and Youth Wellbeing Strategy Review 2024.ISBN: 978-0-473-73381-0. You need to get in early - voices report | Mana Mokopuna
• Mana Mokopuna Children and Young People’s Commission 2024. Ki te kore te kaikiri ki roto o Aotearoa, kātahi te wāhi pai rawa atu."Without racism Aotearoa would be better": Mokopuna share their experiences of racism and solutions to end it | Mana Mokopuna
• Ministry of Youth Development – Te Manatū Whakahiato Taiohi. Youth Plan Voice, Leadership, Action Strategic Framework. youth-plan-strategic-document-final-.pdf

Whānau Māori

• Iwi Māori Partnership Boards (IMPBs). URL: https://www.tewhatuora.govt.nz/health-services-and-programmes/maori-health/iwi-maori-partnership-boards-impbs Webpage accessed 1 May 2025.
• Whatua - Summary Report: Engagement for the development of Whakamaua: Māori Health Action Plan 2020-2025. Wellington: Ministry of Health. Whatua: Engagement for the development of Whakamaua: Māori Health Action Plan 2020-2025 | Ministry of Health NZ 

Pacific community insights

• Te Mana Ola: The Pacific Health Strategy engagement report –Tagata sa’ilimalo, Pacific women, youth, rural communities, Pasifika Rainbow+ / MVPFAFF+. Lived experience of a mental health condition.
• Health and Disability System Review pacific-persepectives-health-system-review-final-pdf-version.pdf 

Disabled Communities

• Te Whare Whaikaha | Disability Resource Centre. I.Lead conference report cards. 2024.  Accessed via: https://www.ilead.org.nz/
• Minister of Health. 2023. Provisional Health of Disabled People Strategy. Wellington: Ministry of Health. Provisional Health of Disabled People Strategy | Ministry of Health NZ 

Ethnic Communities

• Ministry for Ethnic Communities | Te Tari Mātāwaka. 2021. Engagement on the priorities of the Ministry for Ethnic Communities: What really matters to communities.
• Ministry for Ethnic Communities 2024. Ethnic Evidence report. Wellington, New Zealand. mecethnicevidencereport2024.pdf

Consultations Covering a Diverse Range of Communities

Health and Disability System Review engagements:

• Health and Disability System Review. 2019. Health and Disability System Review - Summary of Submissions. Wellington: HDSR. summary-of-submissions-report-for-the-nz-health-and-disability-system-review.pdf
• Mauriora Associates Limited. New Zealand. 2019. Health and Disability System Review – Summary of the Health and Disability system review Wānanga: Facilitator Report 2019. final-report-from-the-health-and-disability-sector-review-wananga-2019.pdf  

Pae Ora engagements:

• Van Paauwe, P. Cernis, A. Hall, K. Royal, E. Goodwin, E. McArdle, A. 2023. Voices for Change | Diverse lived experience perspectives and opportunities for health equity. Curative & Connect+co for Manatū Hauora | Ministry of Health.
• Ministry of Health. 2023. Pae Ora Health Strategies: Summary of feedback from engagement. Wellington: Ministry of Health. Pae Ora Engagement summary  - Note Ethnic communities, Hauora Māori, Pacific Health, youth, Disability, Rural, rainbow, women.
• Ministry of Health. 2023. Te Mana Ola Engagement Report: What we heard from Pacific peoples. Wellington: Ministry of Health. Te Mana Ola engagement report
• Manatū Hauora. 2023. Ngā Wānanga Pae Ora Summary Report: Engagement for the development of Pae Tū: Hauora Māori Strategy. Wellington: Ministry of Health. Pae Tū Engagement report 

Appendix 2. Case studies

1. Preventing diabetes

To illustrate how we can more effectively prevent diabetes, one of Aotearoa New Zealand’s biggest health challenges, we identify ‘win-win’ solutions: interventions across multiple sectors with health and wellbeing co-benefits. Implementation strategies start with addressing factors in the bedrock and soil.

The challenge

Unhealthy diet and excess body weight are the biggest preventable health risk factors for Type 2 diabetes. One in three adults, nearly 1.5 million of us, were classified as obese (with a BMI of 30 or over) in 2023/24, and rates in children are also increasing.⁷⁶ The more than doubling of excess body weight over only three decades in Aotearoa New Zealand (which is mirrored globally) does not reflect genetic changes, a lack of moral fibre, or individual laziness.⁵²⁴ Rather, these changes parallel the introduction of highly processed foods and sophisticated marketing strategies, along with the impacts of colonisation and a food production system that have removed people from their land and traditional food sources.^492,525-527 At the same time, one in four households are sometimes or often struggling to put food on the table¹⁷⁹ and healthy food is the least affordable, despite our country producing enough food to feed 40 million people.⁵¹⁴

The cost to health, wellbeing, and society

Excess body weight accounts for 17.5% of premature death and disability, and in 2021 drove $2 billion of direct health system costs each year, or 8% of total health expenditure.⁵²⁸ It leads to an estimated total cost to society (through things like loss of productive workforce) of $4-9 billion.⁵²⁸ 

It is predicted there will be a 90% increase in people with diabetes, to more than half a million of us by 2044. Māori, Pacific peoples, and people living in the most deprived neighbourhoods are already disproportionately affected.^2,76 The losses to whānau through ill health, disability and early death will be significant if the current trajectory is not changed – but there will also be enormous associated economic losses and social costs borne by all of us. 

Progress so far…

No country has yet successfully reversed their “obesity epidemic.”⁵²⁹ However there have been areas of improvement internationally and locally that we can learn from and build on. No one policy or intervention will solve the issue, and solutions must be developed and co-designed with people in the most affected communuties.⁵³⁰ 

“Win-win” solutions

A layered combination of approaches is needed for diabetes prevention, aligning with Te Tiriti o Waitangi and recognising the unequal impacts, especially for Pacific peoples. We know that given the powerful commercial influences at play, this challenge cannot be resolved with individual and community-targeted programmes alone, although these are an important element.^514,531 Interventions start with the bedrock and soil, and can build off existing programmes, such as some of the ongoing Healthy Families New Zealand initiatives.^532,533

National settings – the bedrock and soil

• Governments can create the policy settings (e.g. for wages, taxes, food production, welfare and housing) to ensure that low-income households have sufficient disposable income to enable autonomy to make healthy food choices and afford a healthy diet, without relying on grants and food parcels.
• A national food and nutrition strategy could drive and monitor implementation of the policies below.
• Regulatory and taxation levers are key mechanisms in responding to commercial interests that damage our health and wellbeing.^534-536 To note, the food and beverage industries are powerful lobbies with strong political connections, as documented recently in Australia.^537,538

• Evidence-based, cost-effective “whole population” interventions include taxes on sugar-sweetened beverages (SSBs), as already introduced in over 130 jurisdictions globally, including three-quarters of Pacific nations and several US cities.⁵³⁹ Taxes can also be applied to unhealthy ultra-processed foods. These taxes have varied designs, but have been shown to:

  • incentivise industry reformulation to reduce sugar levels in SSBs
  • reduce sugar intake
  • have positive effects on childhood and adult obesity
  • reduce dental caries; and
  • support the health budget through ‘earmarked’ taxes.^443,539

  SSB taxes have had greatest benefits for young people and people on low-incomes.⁵¹⁷

• Other levers include:
  • Mandatory standards for reducing sodium and added sugar in key food categories of processed and ultra-processed foods.
  • Regulating online advertising, sales and sponsorship, especially that aimed at children and young people, and food labelling. These are low cost, effective approaches.⁵³⁵
  • Mandatory nutrition policy for schools and ECE services that ensures foods and drinks provided or sold are healthy and sustainable and that sufficient resources, support and training are allocated for implementation.
  • At least doubling the coverage and funding of Ka Ora, Ka Ako in schools and ECEs.

Regional and local settings

• Support increased physical activity at the local and regional level, by expanding the range of choices people have. For example, shaping urban design through:
  • Walking paths and cycle lanes^540,541
  • Public rental e-bicycles, subsidised e-bikes or other active modes of transport^501,508,511
  • Enhancing accessible public transport.⁵⁴⁰

These interventions, particularly focused in communities with high rates of diabetes, have already demonstrated co-benefits in local settings in Aotearoa New Zealand. These include health outcomes - increased physical activity, improved mental health, weight reduction and reduced illness related to a reduction in polluting emissions, and also household economic benefits.^541-543 

Community settings – supporting the tōtara root network

• Support community-led, co-designed programmes that address food insecurity, food sovereignty, physical activity and broader wellbeing issues.³⁸⁶ These include such examples as:
  • The West Auckland Kai Village kaupapa⁵⁴⁴ – fostering relationships, sharing mātauranga Māori, with a collective approach to local food initiatives
  • The Food Hub Collective (formerly the Papatoetoe Food Hub) – a community-led enterprise, in which surplus food is rescued from being wasted and turned into good affordable food for the community, within a zero-waste approach.⁵⁴⁵
  • Kai Rotorua⁵⁴⁶ – teaching and learning activities around planting, growing and harvesting and storing kumara and healthy kai, and other Māori-led initiatives, such as māra kai and the Kai Atua project.^547,548
  • Revitalising Pacific cultural knowledge systems of growing food, preserving food and adapting to climate change and severe weather events. Pacific churches, as “socio-cultural villages” may play an important role in supporting this transformation.⁵⁴⁹

The overall impact of these multiple interventions at each level of our tōtara forest need to be monitored over time and by population groups, to ensure progress towards equity.

2. Health equity, homes and community design

The importance of home

Home means a place of connectedness and relationships, of identity and security. For Māori, kāinga (or papakāinga) represent the anchoring of tangata to whenua and embody mana (ancestral authority) over surrounding land.⁵⁵⁰ Kāinga are an expression of cultural identity and connection to the whenua.⁵⁵¹ The centrality of ‘home’ to families, for nurturing good relationships and unity are all important aspects of a good home common to Pacific peoples,^492,552 and also for many non-Māori, non-Pacific peoples. Adequate housing is a human right.⁵⁵³ 

Health and wellbeing benefits

The positive benefits for health and wellbeing of warm, dry and safe homes, and the importance of appropriate design to meet the intergenerational and cultural needs of whānau have been well researched in Aotearoa New Zealand. Insulated, well-designed housing reduces energy costs and functional crowding, and related illnesses from damp and mouldy housing, such as asthma, respiratory infections, rheumatic fever and chronic conditions.^{192,252,256,258,259,423,424}

Housing security - that is, secure tenancy or home ownership - is also critical and has multiple impacts on wellbeing of whānau and children. It improves attendance and continuity of education, community connections, household economy, access to employment and a sense of security and safety. Insecure tenancy of housing is associated with increased likelihood of potentially avoidable hospitalisations in young children.⁴²⁴ 

What is the challenge?

Housing affordability is a major issue, especially for families on lower than median incomes.²⁶⁰ In December 2024, the median house price was 7.3 times the median annual household income (down from 10.1 times at the market peak in late 2021), and rents were at a record 28% share of income.⁵⁵⁴ As of March 2025, there were over 19,000 people on the public housing register, with nearly all having high priority needs; it is known that this considerably under-estimates housing need. Nearly half were Māori whānau and 35% Pacific peoples.⁵⁵⁵ 

Nearly one in five young people in the Growing Up in New Zealand (GUiNZ) study have been experiencing the most unstable tenancies or worsening residential stability since birth. These trajectories of experience are associated with material hardship, living in public housing or private rentals, and at worst, homelessness.⁵⁵⁶ Many children in Aotearoa New Zealand still live in inadequately heated homes (one in five in the GUiNZ study).⁵⁵⁶ Homelessness and severe housing deprivation persist at high levels and are associated with very poor health outcomes.⁴²⁷

“Win-win” solutions

A range of housing models and investment is needed to achieve quality affordable housing for all. Experience indicates that funding of housing policy packages is particularly effective when coordinated with community groups, and when there is fair enforcement of housing standards.⁵⁵⁷ There is a need to increase the capacity of iwi, social housing providers and Kāinga Ora as well as negotiating with private developers and investors to assure more affordable housing. Building rural and urban homes which meet the needs of intergenerational whānau, and accessible housing for people with disabilities should be prioritised.

Climate mitigation and multiple social benefits

Developing community and associated infrastructure (including schools and health services) alongside new or retrofitted homes is essential. Building climate-resilient, affordable homes, with urban densification and development of public transport, alongside public green and blue spaces, has multiple benefits - reducing our carbon emissions, providing employment and supporting local economies, and improving health, educational and social outcomes, including social cohesion.⁵⁵⁸

Improving the Building Code, phasing out fossil fuels in commercial buildings and homes, and energy labelling of commercial buildings and homes would, if introduced from 2025, reduce cumulative emissions by 6,100kt by 2030, helping deliver almost a third of the required savings the Climate Change Commission have said are needed. These approaches are widely supported throughout the building industry.⁵⁵⁹

Social housing

The role of government in social rental housing has fluctuated in Aotearoa New Zealand over decades but is relatively small compared with OECD countries like the UK, the Netherlands and France, and below the OECD average of 7% of total housing stock.⁵⁶⁰ Iwi and hapū-led housing projects are playing an important, if still under-resourced, role. The Waitangi Tribunal’s Wai 2750 Kaupapa inquiry into Māori Housing Policy and Services describes the impact of years of insufficient responses to Māori housing issues that have had an intergenerational impact on Māori communities, continuing to be felt today.⁵⁶¹ 

Scaling up things that work

Below we identify existing housing initiatives that could be scaled up to meet current and future housing needs.

• Iwi and Māori-led housing initiatives within the MAIHI Ka Ora – National Māori Housing strategy (2022).⁵⁶² The 2022 Whai Kāinga Whai Oranga funding pool of $731m over four years was the biggest investment in Māori housing and infrastructure in decades, but it remains inadequate in the face of the need and the decades of neglect - and requires long-term cross-party political commitment and scale-up.⁵⁶³
  • Toitū Tairāwhiti, a collaborative of four iwi across Tairāwhiti and eastern Bay of Plenty (Ngāti Porou, Rongowhakaata, Ngai Tamanuhiri and Te Aitanga a Mahaki) has developed a partnership with Te Tūāpapa Kura Kāinga (Ministry of Housing and Urban Development). Having already built 51 new homes for whānau in the region, further investment is supporting 150 more whānau in their rohe into new homes.⁵⁶⁴ Similar agreements are being implemented with others such as Te Pouahi o Taitokerau (Northland hapū and iwi)⁵⁶⁵ and Ka Uruora (a collective iwi charitable trust based in Taranaki).⁵⁶⁶
• Fale mo Aiga – Pacific Housing Strategy 2030 plans home ownership for 500-700 Pacific peoples’ households, by 2030. A ten-fold scale up, as proposed by the Tamaiti ole Moana 2033 report - with the building of 5000 more suitable multigenerational homes for Pacific families through a range of approaches (including Kāinga Ora and community housing provider homes, and underwriting residential development) is a more realistic response to the housing needs of Pacific communities.⁴⁹²
• Scaling up the Warmer Kiwi Homes programme and Healthy Homes Initiative to target 30,000 homes of Pacific families with children for insulation and ventilation upgrades.
• Housing First Originating in Finland in 2007 and introduced in Aotearoa in 2017, Housing First recognises that it is easier for people to deal with complex issues, such as physical ill-health, mental health and addiction needs, if they have a stable place to live. It is targeted towards people who have complex needs and require intensive ongoing support services. Local research shows that after five years of having a home, there were significantly improved outcomes for people in the programme across mental and physical health (measured as reduced hospitalisations, outpatient visits and pharmaceutical use), but also in income levels (+38%) and significantly reduced police offences and criminal charges.²⁵⁵ The ‘Housing First’ approach could be adapted and scaled up to ensure, for example, that all low income whānau with children (or expecting them) can access a home and ‘wrap around’ support.
• Increase the proportion of affordable social housing and Kāinga Ora state-owned units of total housing stock to 7% by 2040.⁵⁶⁷
  • An increase of social housing to 7% of total stock by 2040 would mean building an additional 3,600+ units each year (a similar rate to that in 2023-2024), to reach at least 140,000 dwellings by 2040, requiring a relative increase in building activity and budget required to achieve this. This compares with the funding of only 1500 new social houses announced in the 2024 Budget.
  • As of April 2025, 84% of the over 86,400 social rental housing available was managed by Kāinga Ora, with more than 9800 new Kāinga Ora homes built between June 2023 and April 2025.⁴²⁵ Community Housing Providers (CHPs) provided the remainder, ranging from small charitable trusts and iwi to Councils, with 1670 additional builds in the same period.
  • Providing lower-cost debt facilities to community housing providers (CHPs) via the Community Housing Funding Agency is useful, but CHPs alone are unable to build to the scale required, and leveraging up the capacity of Kāinga Ora is needed. With the current reduction in total new-builds (3000 fewer per month than in August 2023), the waiting list for social housing will continue at 20,000 to 25,000 households and may even increase further if immigration settings exacerbate existing housing shortages.⁵⁶⁷
• Replicate alternative Crown approaches to community housing, such as the Tāmaki Regeneration Programme.⁴⁵⁵

The Tāmaki Regeneration Programme

The Tāmaki Regeneration Programme includes three east Auckland suburbs close to central Auckland - Glen Innes, Panmure, and Point England. It is home to over 20,000 people, many for several generations, with over one-third of residents aged under 25 years. Sixty percent of residents identify as Māori and/or Pacific peoples. Mana whenua of Tāmaki include Ngāti Pāoa, Ngāi Tai ki Tāmaki and Ngāti Whātua Ōrākei. Sixty percent of housing in Tāmaki is social housing, with the first state houses built there in the 1930s, expanding with rapid urban growth after World War Two. The economic reforms of the 1990s had major impacts on the communities in Tāmaki, resulting in very high unemployment, declining household incomes, alcohol and drug issues, and community safety concerns.

Evolving from the 2007 “Tamaki Transformation” project (which was widely distrusted and perceived by the communities as ‘gentrification’ when selling off of state housing was proposed), the Tāmaki Regeneration Company (TRC) was created as a Schedule 4A Company in 2013 under the Public Finance Act (ensuring broader social and regeneration outcomes beyond simple commercial return). It is jointly owned by the Government and Auckland Council. After substantial community and mana whenua engagement, TRC developed an outcomes framework with four key priorities:

• Social (supporting Tāmaki whānau to thrive)
• Housing (building homes and communities)
• Economic (helping the local economy to thrive); and
• Placemaking (supporting local cultural identity and sense of belonging).

In addition to the home building programme, TRC supports a shared home ownership programme, Innovation Hub and Jobs & Skills Hub, and partners with a range of community organisations to support social outcomes.

Appendix 3. A timeline

Key dates and reports: determinants of health and health equity

Key reports are referenced in Yao et al⁵⁶⁸

Appendix 4. Analysis of trends and indicators

In Aotearoa New Zealand there are important and persistent differences in access to the determinants of health and in health outcomes for different population groups. The aim of our analysis was to assess trends in key indicators of determinants and of health status, but more importantly, to understand the absolute and relative changes in the differences between population groups for each of these indicators over the last 25 years. 

Selection of indicators

There are international and local frameworks that provide indicators for monitoring the determinants of health. These include the Sustainable Development Goals,⁵⁷⁴ the World Health Organization’s Operational framework for monitoring social determinants of health equity,²⁰⁹ the Treasury’s Living Standards Framework²⁰⁸ and Stats New Zealand’s Indicators Aotearoa New Zealand – Ngā Tūtohu Aotearoa.²⁰⁷ We reviewed these frameworks to inform our selection of indicators (see Tables 1 and 2).

Given resource and time constraints, our analysis is primarily based on indicators from publicly available datasets (see Tables 3 and 4 for the main sources used). This limited our choices of indicators, as many are not available by the level of disaggregation and/or the timeframe (from 2000) that we sought. Additionally, changes over the last 25 years in the definitions of some indicators (e.g. severe housing deprivation) and the way in which some were measured (e.g. frequency of measurement and size of samples) made assessment of trends over time more challenging.

Disaggregation

We analysed the chosen indicators by multiple variables such as gender, socioeconomic deprivation, ethnicity, disability and age where applicable. The report presents a selection of graphs that demonstrate important differences and/or trends.

We present many indicators by ethnic group. Ethnicity is the ethnic group or groups that people identify with or feel they belong to. It is self-perceived, and people may belong to one or more ethnic groups. In Aotearoa New Zealand, ethnicity is an evidence-based marker of health need.^575,576 At any given level of socio-economic deprivation, Māori and Pacific peoples have poorer health outcomes than other ethnic groups.^15,577,578

Ethnicity Data Protocols for the Health and Disability sector guide the collection, classification, recording and output of ethnicity data.⁵⁷⁹ When people identify with multiple ethnic groups, various methods are used to assign a single ethnic group for the purposes of reporting and analysis.

“Prioritised ethnicity” is used in many health analyses, whereby each respondent is allocated to a single ethnic group using an established prioritisation framework that ensures that ethnic groups of policy importance or of small size are recognised first.⁵⁷⁹ Māori, Pacific peoples and Asian are prioritised as the first three groups. So, for example, if someone identifies as Māori, Pacific and European, they will be assigned prioritised Māori ethnicity.

Stats New Zealand and the New Zealand Health Survey use “total response” ethnicity. “Total response” refers to a method where each person is counted in all of the ethnic groups they identify with; this means the total number of responses is bigger than the number of respondents.

Ideally, the method used for assigning ethnicity should be related to the context and question being asked.^580,581 Prioritised ethnicity is the preferred method to analyse inequities between Māori and non-Māori; total response ethnicity will underestimate inequities between Māori and European ethnic groups because there will be many Māori who are also counted in the comparator European total response group. However, analyses using prioritised ethnicity undercount some ethnic groups, particularly Pacific peoples. Additionally, the assigned ‘prioritised’ ethnicity may not reflect the ethnicity a person most strongly identifies with.

There are well-documented problems related to the completeness and quality of ethnicity data in Aotearoa New Zealand. Post-enumeration surveys indicate the Census has an undercount which is greater for Māori, Pacific and Asian peoples than for Europeans. This leads to inaccurate population estimates, which can have impacts on policy and implementation, especially for those with highest health needs.^582,583 Māori continue to be underrepresented in health data sets compared to official population numbers.⁵⁸⁴

This report draws on a variety of data sources which have different ways of reporting outcomes for populations. Given the time and resource constraints for this report, we were limited to using outputs that were readily available. Consequently, ethnicity groupings are not consistent throughout the report. For determinants of health, total response ethnicity is used and data on four population groups is graphed: Māori, Pacific, Asian and European. We acknowledge that there are groups in the population (such as people of Middle Eastern, Latin American and African ethnicity) that are not included in these graphs.

For health outcomes, prioritised ethnicity is used (except for the New Zealand Health Survey). Some health outcome data are presented as a comparison between Māori and non-Māori/non-Pacific populations, while other health outcome data are presented for four groups: Māori, Pacific, Asian and non-Māori/non-Pacific/non-Asian (nMnPnA). 

Surveys

Some of the data presented come from surveys and therefore represent estimates of that measure within the population. Where sample sizes are small the accuracy of estimates, particularly for sub-populations, are less certain. In our data analysis we have chosen not to include confidence intervals but acknowledge that the confidence intervals could be large when groups are small. We note that data collection for the 2021-22 Household Economic Survey was restricted by both COVID-19 and weather-related events, resulting in a smaller number of households being interviewed.

Selected indicators

Tables 1 and 2 illustrate the complete set of indicators we have selected. Indicators graphed in Section 3 are asterisked. The remainder are appended in the online version of the report. The final two columns of Table 1 show whether the indicator is in the World Health Organization’s Operational framework for monitoring social determinants of health equity²⁰⁹ and/or Stats New Zealand’s Indicators Aotearoa New Zealand – Ngā Tūtohu Aotearoa.²⁰⁷

*Indicators that are included as Figures in Section 3
a. World Health Organization. Operational framework for monitoring social determinants of health equity, 2024.²⁰⁹
b. Stats NZ. Wellbeing data for New Zealanders.²⁰⁷

*Indicators that are included as Figures in Section 3 (where disaggregation is by multiple variables, the disaggregation with the asterisk is shown as a Figure in Section 3)

We have used data from a wide variety of sources, such as the census, national surveys, reports and web tools. Many of these are publicly available and are summarised in the tables below.

*Tools:

• Aotearoa Data Explorer - Stats NZ | Tatauranga Aotearoa. Aotearoa Data Explorer. 2025 (accessed June 11, 2025) https://explore.data.stats.govt.nz/
• Infoshare - Stats NZ | Tatauranga Aotearoa. Infoshare. 2025 (accessed June 11, 2025) https://infoshare.stats.govt.nz/
• Place and ethnicity group summaries - Stats NZ | Tatauranga Aotearoa. Place and ethnic group summaries. 2025 (accessed June 11, 2025) https://tools.summaries.stats.govt.nz/

Table 5: How are we tracking? A scorecard

Determinants	Total population trend	Trends by sub-group	Trends in total population measures, and in absolute and relative inequities by ethnic group, gender, age and disability
Income (individual and household)			Real increase in all household incomes 2007-2021 but no change in income gaps by ethnic groups. Decrease in gender gap overall but large inequities for women by ethnic group.
Income inequality			No substantial change since 2000. Housing costs contribute to increased net income inequality, which impacts differentially on low-income families.
Child poverty			Absolute reductions in measures of child poverty for all ethnic groups from 2007-2009 up to 2022/23 - but increases in relative inequity. Significant increases in material hardship in 2023/24.
Food security (in households with children <15 years)			Food insecurity measures improved from 2012/13 up to 2020/21 but have significantly worsened since 2022/23. Large inequities for Pacific peoples (2.4 times higher than non-Pacific), disabled (1.6 times non-disabled) and children living in the most deprived quintiles compared with least deprived (2.9 times higher).
Unemployment			Total employment fell from 2011/12 to 2022/23 with reductions in absolute and relative inequities. However, there are stark inequities by ethnic group, age and region, which are exacerbated in economic recession.
Not in Employment, Education or Training (NEET)			Little change in overall NEET over last decade; now increasing again. Small reductions in absolute and relative inequities by ethnic group 2010-2020.
ECE attendance			Narrowing of absolute and relative ethnic inequities since 2000, but increasing again since 2020
School attendance			Attendance overall declining since 2015, exacerbated by COVID-19 pandemic. Inequities slightly increasing by ethnic group and School Equity Index.
Attainment NCEA Level 2+			Increased for all ethnic groups up to 2020 but declining for all groups since.
Kaupapa Māori schooling			Increasing numbers of children enrolled after earlier declines.
Household crowding			A small reduction in relative inequities but an overall increase in household crowding for all ethnic groups compared with 2001.
Housing ownership			Declining for all ethnic groups up to 2023, and with increased inequities, especially for Pacific peoples.
Iwi affiliation			Growth in iwi affiliation in Census data.
Te reo speakers			Increases mainly due to population growth.
Loneliness			Worsening indicator up to 2022/2023; marked differences by age group. The measure continued to worsen for young adults 25-34 years in 2023/2024. Disproportionately experienced by disabled people.
Trust			Increasing inequities by ethnic group and by age group (younger people>older) in trust in institutions and in community.
Environmental indicators			Climate and biodiversity measures show declines in most indicators.
Greenhouse Gas Emissions (GHG)			GHG emissions heading in the right direction, but not yet at 1990 levels

Legend

Progress made, inequities reducing

Progress stalled, no change in inequities

Negative trend, increasing inequities

Scorecard: Trends in health indicators and inequities 2000-2024

Health indicator	Total population trend	Trend in sub-groups	Trends in total population measures, and in absolute and relative inequities by ethnic group, gender, age and disability.
Life expectancy			Overall increase in life expectancy (LE). Narrowing of the absolute difference in LE for Māori, but small increase for Pacific peoples compared to nMnP. Gaps also persist by socioeconomic status, disability and region.
Infant mortality and child mortality			Overall reductions in mortality (note small numbers). Some reductions in absolute and relative inequity for Māori compared with non-Māori but worsening for Pacific infants. Still unacceptable differences by socioeconomic status (NZDep quintile) for infants and children.
Heart disease, stroke and circulatory mortality			Halving of total population CVD mortality. Important reduction in absolute inequity between Māori and nMnPnA. Relative inequities persist for Māori and Pacific peoples.
Diabetes prevalence			Total population increase in prevalence. Increase in absolute inequity for Pacific peoples and relative inequities persist for Māori, Pacific and Indian peoples, and by level of socioeconomic deprivation.
Psychological distress			Marked rise for all since 2011/12. Large inequities by age group (young people>>older people), ethnic group, socio-economic status and disability.
Oral health			Poor data; incomplete. Likely no significant overall improvement, and persistent inequities by ethnic group, rurality and socioeconomic status.
Health risk factor: smoking			Significant reduction in smoking rates for all, across all ethnic groups and ages. Relative inequities persist for Māori and Pacific peoples, disabled people and those living in the least advantaged areas.
Health risk factor: vaping			Significant increase in vaping rates for all since 2017. However major inequities by ethnic group, socioeconomic deprivation and age (15-24yrs).

Legend

Progress made, inequities reducing

Progress stalled, no change in inequities

Negative trend, increasing inequities

Appendix 5. AI terminology

Definitions -the language of artificial intelligence

Artificial intelligence

The term ‘AI’ incorporates machine intelligence, machine learning, robotic intelligence, and artificial general intelligence (AGI).

Machine intelligence

Machine intelligence (also called ‘machine learning’) reproduces human ability to detect, describe and analyse patterns in data. It learns from, and acts on, the patterns to refine its capabilities.

Deep learning

Deep learning is a type of machine learning that uses artificial neural networks. These networks mimic how neurons in the human brain signal to one another. Deep learning needs a lot of data but has a powerful predictive capability. It is used in tools like voice recognition, fraud detection, self-driving cars and fintech. AI models built with deep learning can learn shortcuts from the data they’re trained on. This allows them to simulate processes more accurately, and much quicker, than methods that rely on computation.

Artificial general intelligence

AGI (also called ‘full AI’ or ‘human-level AI’) coordinates and integrates AI, so it can operate with a full, or extended, range of human abilities, which aims to match, or surpass, anything human. AGI produces broad and deep data analysis, findings and recommendations, faster – and potentially better – than humans.

Superintelligence

Most machine-learning experts think AGI will quickly and vastly outstrip the combined cognitive capacities of humans. It could become capable of revolutionary technological and economic advances in every sector, much more rapidly than is currently possible.

Source: Adapted from Henderson P. At the cutting edge: How Artificial Intelligence will change our primary sector forever. Auckland, 2023.³⁵⁶

Appendix 6: Te reo glossary

Aotearoa

New Zealand

Hapū

Kinship group, sub-tribe

Hauora

Health, wellbeing

Hui

To gather, assemble; meeting

Iwi

Tribe (In the context of this report ‘iwi’ is sometimes used more broadly to include post settlement entities).

Kai

Food

Kaiārahi

Navigators

Kaitiakitanga

Guardianship

Kāinga

House, home

Kaupapa

Purpose, policy, initiative, theme or topic

Kīngitanga

The King movement

Kōhanga reo

Māori language preschool

Kura kaupapa

Māori school

Mana

Prestige, authority, influence

Mana motuhake

Autonomy, self-government, independence

Māori

Indigenous people of Aotearoa

Marae

The open area in front of the wharenui, where formal greetings and discussions take place. Often also used to include the complex of buildings around the marae.

Mātauranga

Knowledge, wisdom

Mauri oho

Energised life force

Mokopuna

Future generations (grandchild, descendant)

Oranga

Wellbeing

Ōritetanga/Rite tahi

Equity

Pae Ora (Act)

Healthy Futures Act (2022)

Papakāinga

Housing on ancestral land

Pākehā

New Zealander of European descent

Rangatahi

Young person

Taiao

Environment, natural world

Tairāwhiti

Gisborne/East Cape district

Tamariki

Child/children

Tangata Tiriti

Those who do not whakapapa Māori but belong to the land by right of Te Tiriti o Waitangi (coined by Sir Edward Taihakurei Durie in 1989)

Tangata whenua

Indigenous people; people born of the whenua

Taonga

Treasure, property or possession

Te Tai Tokerau

Northland

Te Tiriti o Waitangi

The Treaty of Waitangi

Te reo Māori

Māori language

Tikanga

The customary system of values, laws and practices that have developed over time and are deeply embedded in the social context

Tino rangatiratanga

Sovereignty, self-determination

Tūpuna (or tīpuna)

Ancestors

Wahakura

A woven flax bassinet

Waka

Canoe, vehicle

Wānanga

To talk, discuss

Wāhine

Female, women

Whare wānanga

Place of higher learning, university

Whakapapa

Genealogy, family lineage

Whānau

Extended family, family group

Whenua

Land, country

Appendix 7: Additional data trends 2000–2024

In section 3 of the main report we examine trends in important determinants of health and health outcome indicators. In this annex we provide additional indicators to provide a more comprehensive picture of the important and diverse factors that contribute to our health and wellbeing.

Additional trends in determinants of health 2000–2024

Workplace deaths, injuries and ill health

While unemployment negatively affects wellbeing, being in work is associated with social status, greater income, and may also offer structure and purpose.²²⁸ However, work can also be associated with exposures to health risks, including acute injuries, chronic exposure to hazards such as asbestos, and psychosocial stress.⁵⁸⁵

The rate of work-related acute fatal injuries^x in Aotearoa New Zealand is 1.6 times higher than in Australia and 6.4 times higher than in the UK.⁵⁸⁶ Although the rate of workplace deaths in Aotearoa New Zealand has declined overall in the last 20 years, there have been notable exceptions resulting from the Pike River mine explosion (2010), the Canterbury earthquakes (2011) and the Whakaari/White Island eruption (2019) (see age-standardised rate, 3-year moving average (Figure 35)).

Each year in Aotearoa New Zealand an average of 50 to 60 workers are killed while at work.⁵⁸⁵ Some occupations are at higher risk of adverse physical exposures. From 2011 to 2022, over 50% of fatalities involved a vehicle, and more than 90% of fatalities were among male workers. Forestry and logging had the highest rate of fatalities.⁵⁸⁵

Figure 35. Work-related acute fatalities, number and age-standardised rate, 2002-2021

There were over 400 work-related serious non-fatal injuries^xi annually between 2017 and 2021.⁵⁸⁵The rate of serious injury has decreased since 2002, with a steeper decrease in the rate for Māori than non-Māori. Between 2002-04 and 2019-21, after adjusting for changes in workforce size and age structure, the rate of serious non-fatal injury reduced by 30% for Māori workers and by 19% for non-Māori workers (Figure 36), but the rate of injury remained higher for Māori than non-Māori workers.⁵⁸⁵

Figure 36. Work-related serious non-fatal injuries, age-standardised rate for Māori and non-Māori, 2002-04 to 2019-21

Chronic exposure to hazards at work (such as benzene, solar radiation, crystalline silica, wood dust and asbestos), causes more illness and death than acute injury. Common causes of work-related death and ill health are lung cancer, mesothelioma, chronic obstructive pulmonary disease, ischaemic heart disease, musculoskeletal disorders and mental ill health.⁵⁸⁵ Worksafe’s 2019 analysis estimates that a worker is 15 times more likely to die from a work-related disease than from a workplace accident.⁵⁸⁸ Worksafe estimates that annually there are 750 to 900 work-related health deaths (excluding those caused by injury) and 5,000-6,000 hospitalisations.⁵⁸⁹ 

[x] The Worksafe definition of work-related fatalities includes workers who die from injuries while working and members of the public who die as a result of someone else’s work activity. However, our analysis does not include non-worker fatalities as it is based on work that excluded this group due to inconsistencies in definitions over time.

[xi] Worksafe defines serious non-fatal injuries as injury events in which a patient admitted to hospital is determined to have a probability of death of at least 6.9%

Severe housing deprivation

Severe housing deprivation is the official term for homelessness and is defined by Stats NZ as “a living situation where people with no other options to acquire safe and secure housing are without shelter; in temporary accommodation; sharing accommodation with a household; or living in uninhabitable housing.”⁵⁹⁰ Of these four types of severe housing deprivation, those living in uninhabitable housing^xii form the largest group of people, comprising 61% of the severely housing deprived population in 2023.⁵⁹²

The number and proportion of people who were severely housing deprived increased from 99,462 (2.1% of the population) in 2018 to 112,496 (2.3%) in 2023.⁵⁹² Severe housing deprivation prevalence increased for all ethnic groups between 2018 and 2023 except for Asian people (Figure 37). Estimates of severe housing deprivation from the 2023 census indicate marked inequities by ethnic group, age and disability. Compared with Europeans, Pacific peoples are more than 5 times and Māori more than 3 times as likely to experience homelessness. Disabled people, children, young people (15 to 29 years) and people identifying as LGBTQIA+ also experience higher rates.⁵⁹²

Measures of severe housing deprivation are considered estimates because they are constructed from a combination of variables rather than being counted from a single direct question to individuals in the census. The estimates are likely to undercount the true population experiencing severe housing deprivation. Additionally, uninhabitable housing was not assessed prior to 2018, and so people living in those conditions were not included. Comparison of rates of severe housing deprivation over time requires caution due to the above and other methodological reasons.⁵⁹³ 

Figure 37. Severe housing deprivation by total response ethnicity, 2001-2023

Image

Caption

[xii] Uninhabitable housing is defined as dwellings that lack at least one of six basic amenities (drinkable tap water, electricity, cooking facilities, a kitchen sink, a bath or shower and a toilet). To be included in this category, the residents also have to be assessed as having a low income.⁵⁹¹ 

Experience of racial discrimination

Experience of racism is associated with poorer health and wellbeing measures.⁵⁹⁵ Questions on experience of racial discrimination were asked in the New Zealand Health Surveys of 2011/12, 2016/17 and 2020/21. Māori, Pacific peoples and Asian people report experiences of racism more than European New Zealanders.^123,595

In the 12 months before the 2020/21 survey, 13.8% of Māori, 9.5% of Pacific peoples, 12.3% of Asian and 4.8% of adults identifying as solely of European or other nMnPnA ethnic groups* reported experiencing racial discrimination (Figure 38).⁵⁹⁶ The proportion of Māori who experienced racial discrimination in the past 12 months increased from 10.8% in 2011/12 to 13.8% in 2020/21. In 2020/21 the experience of racial discrimination in the previous 12 months differed by gender, affecting 16.8% of Māori women and 10.7% of Māori men.⁵⁹⁶

Figure 38. Experience of racial discrimination in the past 12 months by ethnic group*, 2011/12, 2016/17 and 2020/21

Digital technologies

There have been rapid changes in digital technologies in the last 25 years, with internet use and the introduction of artificial intelligence being of particular significance. These technologies continue to transform how we engage in and perform activities, including our social relationships, learning, work, and interactions with institutions. This in turn shapes health outcomes, from direct impacts on mental and physical health to the ability to access health and other services using these technologies.^346,597 

Access to the internet

Household access to the internet increased dramatically between 2001 and 2013, then continued to increase gradually through to 2023. While there was a large gap between ethnic groups in access to the internet in 2001, this has closed. In 2023, 94% of Europeans and 91% of Māori had internet access at a household level (Figure 39). People on low incomes and those aged over 75 years have lower access to the internet than the general population.^597,598 Given that many organisations (in health care and other sectors such as social, housing, education and employment) provide information and services online, lack of internet access is a major barrier to accessing these services.

Figure 39. Access to the internet at a household level, by total response ethnicity, 2001-2023

Screen time

We are spending an increasing amount of time on screens (which includes computers, tablets, mobile devices and television). In 2014-15, children aged 11 to 13 years who participated in the New Zealand Kids Cam project used screens on average for over one third of their time after school.⁶⁰⁰ Data from the New Zealand Health Survey on the amount of time children spend engaging with screens is expected in November 2025. The OECD Programme for International Student Assessment (PISA) found that 15-year-olds in Aotearoa New Zealand spent 20 hours a week on the internet in 2012. This had increased to 42 hours per week by 2018.⁶⁰¹

The use of social media by young people has benefits and harms. While it provides a means of social connection, support and information, there are concerns about its potential addictive nature and possible effects on mental health,⁶⁰² cyberbullying,⁶⁰³ exposure to inappropriate content and marketing and managing safety online.^347,460,604

Justice system

People who are or have been in prison generally have poorer health outcomes and higher health needs than the general population.⁶⁰⁵ For example, 62% of prisoners interviewed in 2015 in Aotearoa New Zealand had a diagnosis of a mental health or substance use disorder in the previous 12 months, three times the rate of the general population.⁶⁰⁶ This disparity is seen for other health conditions, including oral health, chronic diseases, and communicable diseases.⁶⁰⁵ Additionally, those who have contact with the prison system have higher mortality rates following release. People released from prison in Aotearoa New Zealand between 1998 and 2016 had more than three times the death rate of the general population.⁶⁰⁷

There is evidence of systemic bias in how the justice system interacts with some populations, including Māori, and disabled people. An Independent Panel commissioned by New Zealand Police | Nga Pirihimana O Aotearoa found evidence of bias at structural, institutional and interpersonal levels.⁶⁰⁸ This research found that all other things being equal, Māori were 11% more likely to be prosecuted by Police than NZ Europeans and experienced higher levels of police apprehensions, use of force incidents and TASER deployment.⁶⁰⁸

In Aotearoa New Zealand, more than half of the people in prison are Māori,⁶⁰⁹ while making up 18% of the total population (2023 Census). In recent years, there has been an increase in the prison population held on remand, and this increase is projected to continue.⁶¹⁰ The reasons behind this include increased use of technology identifying people who do not meet bail conditions and increasingly lengthy court proceedings, which delay trials and sentencing.⁴³¹ These delays have disproportionately affected Māori.⁴³¹

Males make up over 90% of prisoners.⁶⁰⁹ The rates of imprisonment of sentenced Māori males compared with European males under 30 years are shown in Figure 40. There has been a significant decrease in the rate of imprisonment of Māori men under 30 years since 2000.⁶¹¹ However, imprisonment rates for Māori men aged over 30 years have increased.⁶¹¹ This reflects changes in the exposure of different age cohorts to varying policy settings across time. 

Figure 40. Comparisons of European and Māori trends in imprisonment rates for males under 30 years

There has been recent success in reducing incarceration of young people (while inequitable rates between ethnic groups persist). Historically, the high proportion of Māori children entering state care was associated with subsequent high rates of imprisonment of these cohorts.^431,611 Policy settings that reduce the number of children in State care, the incarceration rate of young people, and that prioritise the health and wellbeing of those who come into contact with the Justice system can improve outcomes and health equity for this population. 

Air quality

Air pollution contributes to cardiovascular diseases such as strokes and heart attacks and respiratory diseases such as chronic obstructive pulmonary disease and lung cancer. It exacerbates asthma and bronchitis.⁶¹² In Aotearoa New Zealand the air pollutants that have the biggest impact on health are nitrogen dioxide and fine particulate matter that measures less than 2.5µm (PM_2.5).⁶¹³

We breath in particulate matter, which can settle in our throat and lungs causing respiratory and cardiovascular effects. The very fine particles, called PM_2.5, travel to the lungs, while the larger ones (PM₁₀ – measuring less than 10 µm) reach the nose and throat. Particulate matter mainly comes from domestic fires, but also from other sources such as motor vehicles (brake/tyre wear) and windblown dust from industry and construction. Levels of particulate matter have reduced in recent years, related to interventions to reduce domestic fire emissions. In Aotearoa New Zealand, between 2006 and 2016 there was a decrease of 21% in exposure to human-generated PM_2.5 and an estimated decrease in premature deaths (-9%) and hospitalisations (-11%) from PM_2.5.⁶¹³

Long-term exposure to nitrogen dioxide increases the risk of premature death and respiratory illness, and short-term exposure to high concentrations can trigger asthma attacks. Motor vehicle emissions, particularly diesel vehicles, are the most common source of nitrogen dioxide in Aotearoa New Zealand. Between 2006 and 2016, the modelled average concentration of nitrogen dioxide that people were exposed to increased by 13%, with an estimated 28% increase in premature deaths and 39% increase in hospitalisations related to nitrogen dioxide.⁶¹³ Exposure to nitrogen dioxide is not uniform across population groups: in 2016, 31% of the total population and 55% of Pacific peoples lived in areas with annual average nitrogen dioxide higher than the WHO 2021 guideline.⁶¹⁴

In 2019, it was estimated that human-made air pollution in the form of PM_2.5 and nitrogen dioxide was a factor in 3,239 premature deaths, 13,237 hospitalisations, 12,653 cases of childhood asthma and over 1.771 million restricted activity days.⁶¹⁵

In most monitoring sites there was improvement in levels of particulate matter and nitrogen dioxide between 2016 and 2023.^616,617 However, concentrations continue to exceed the WHO guidelines, especially during winter and in urban areas.^17,616,617

Freshwater

The health of freshwater ecosystems is inseparable from the wellbeing of the environment and communities. Freshwater is a taonga for Māori and has an important place in tikanga, mātauranga and mahinga kai.⁶¹⁸ Despite widespread acknowledgement of the importance of freshwater health (made explicit in the concept of Te Mana o Te Wai in freshwater policies released in 2020), there has been ongoing degradation of some rivers, lakes, wetlands and groundwater.^17,619

The quality of freshwater in Aotearoa New Zealand has been degraded by many things including agriculture, industry, wastewater and storm water.¹⁷  This leads to contamination with bacteria and excess nitrates, which has negative consequences for environmental and human health.^17,620 Between 2019 and 2024, 12% of monitored groundwater sites exceeded maximum acceptable values for nitrates.⁶²¹ Certain regions, such as Canterbury, are particularly affected (with the situation predicted to worsen due to the time it takes for nitrates to move through groundwater sites).⁶²²

The presence of E. Coli in freshwater indicates contamination with animal or human faeces. It is used as a proxy to indicate likely contamination with other pathogens such as campylobacter that cause illness in humans. Between 2001 and 2020, 41% of river monitoring sites were worsening in terms of E. Coli levels and 37% were improving⁶²³ (Figure 41). Contamination of groundwater drinking sources is also a concern. In 2023, 6% of 11, 026 samples from water bores and 33% of samples from springs failed to meet the drinking water standard for E. Coli.⁶²⁴

Figure 41. E. Coli trend direction 2001-2020

Trends in health outcomes 2000-2024

In this section we provide some additional data on trends in health outcomes (child mortality, lung cancer, prevalence of diabetes) and risk factors (excess body weight and alcohol consumption) that complement those described in section 3. We also look at a selection of indicators as proxies for access to health care (including potentially avoidable hospitalisations, enrolment with Lead Maternity Carers and childhood immunisation coverage). 

Child mortality

There have been persistent differences in mortality rates for children aged 1 to 14 years by ethnicity and socio-economic deprivation.²⁷⁸ Since 1990-91, death rates in children aged 1 to 14 years declined for all socio-economic groups, with a substantial reduction in the absolute inequity in mortality rates between children living in the most socioeconomically deprived areas compared with the least deprived areas (Figure 42).

However relative inequity persists, with death rates consistently 2 to 4 times higher for those living in the most socioeconomically deprived areas, compared with the least deprived areas. Mortality rates for children living in the most socioeconomically deprived quintile today are higher than those for children in the most privileged quintile over 30 years ago.²⁷⁸ 

Figure 42. Mortality rates of children aged 1-14 years by New Zealand Index of Deprivation (NZDep) quintile, 1990 to 2018

Deaths from lung cancer

There is a lag time of 20 to 30 years between reductions in population tobacco use and changes in lung cancer mortality.⁶²⁵ Between 2000 and 2020, there was a gradual decline in the mortality rate from lung cancer for all ethnic groups (Figure 43). The mortality rate from lung cancer reduced more for Māori than for other ethnic groups during this time, resulting in a reduction in absolute inequities for Māori compared with non-Māori/non-Pacific/non-Asian (nMnPnA) people. However, relative inequities persist, with rates for Māori remaining 3 times that of nMnPnA people since 2007.

Further substantial reductions in smoking rates for Māori have occurred since 2013/14 (Figure 31, Section 3), which should reduce future lung cancer mortality rates. If a lung cancer screening programme is introduced and successfully implemented, this could further reduce relative and absolute inequities in lung cancer mortality.⁶²⁶

Figure 43. Mortality rates related to malignant cancers of the trachea, bronchus and lung*, by prioritised ethnicity, WHO age-standardised, 2000-2020

Prevalence of diabetes

The Virtual Diabetes Register estimates the number and proportion of people with type 1 and type 2 diabetes in the Aotearoa New Zealand population at any point in time (prevalence). Diabetes is more common in populations living in the most deprived neighbourhoods (74 per 1,000 people in 2023) compared with the least deprived (28 per 1,000 people in 2023) (Figure 44).²⁸¹ The estimated prevalence of diabetes by prioritised ethnicity is shown in Section 3, Figure 26.

Figure 44. Estimated prevalence of diabetes (type 1 and type 2) by New Zealand Index of Deprivation (NZDep), WHO age-standardised, 2013 to 2023

The rising incidence (new cases) and prevalence of diabetes parallels increases in excess body weight (EBW). While we acknowledge the limitations of body mass index (BMI) measurement, particularly its application to different ethnic groups, it provides a pragmatic tool to assess changes in population EBW.²⁸⁴Aotearoa New Zealand has the third highest rate of obesity (BMI 30 or more) of all countries in the OECD.²⁸³ In 2023/24 one in three (34%) adults had a BMI of 30 or more, compared with 17% in 1997.^227,285 

In 2023/24, two thirds (67%) of adults were considered to have EBW (BMI of 25 or more), with it being more common among Pacific peoples (89%) and Māori (77%) (Figure 45). EBW was more common in those living in the most socioeconomically deprived neighbourhoods (where 76% had a BMI of 25 or more) compared with the least deprived (60%).²²⁷

While there was only a small increase in the proportion of the population with BMI of 25 or more between 2013/14 and 2023/24 (65% to 67%), the proportion of the population with BMI of 30 or more increased significantly from 29% to 34%.²²⁷

Figure 45. Population with BMI 25 or over by total response ethnicity, 2006/07 and 2011/12 to 2023/24

Image

Caption

Health risk factor: alcohol

Alcohol consumption can affect all aspects of wellbeing.^{628, 629} In the short-term alcohol intake increases the risk of accidents and injuries (including road traffic accidents), affects decision-making and can lead to aggressive or violent behaviour.⁶²⁸ Long-term health impacts include addiction, increased risk of cancers and stroke, and foetal alcohol spectrum disorder.⁶²⁸ This alcohol-related harm is experienced inequitably amongst population groups.⁶²⁹ Alongside the extensive impacts on whānau, alcohol-related harm has high societal economic costs, estimated to be $9.1 billion annually.⁶³⁰

Consumption of alcohol is a common reason for people attending Emergency Departments. A snapshot survey of 19 Emergency Departments at 2am on a Saturday in 2019 found that one in six patients were receiving treatment for alcohol-related issues.⁶³¹ Alcohol-related presentations to the Christchurch Emergency Department increased from 5.5% in 2013 to 11% in 2022.⁶³² There was also a change in the age profile, with an increased proportion of older people presenting with alcohol-related issues and a decrease in youth aged 25 years and under.⁶³²

Survey data indicate a slight downward trend in reported alcohol consumption in recent years. More people do not drink alcohol at all and the proportion who drink heavily has fallen. In 2023/24, 81% men and 71% women had an alcoholic drink in the previous year, a reduction from 85% and 75% in 2011/12.²²⁷ The proportion of people aged 15 years and older who report drinking heavily (defined as drinking 6 or more standard drinks on one occasion at least weekly) decreased between 2016/17 and 2023/24.²²⁷ This decrease was seen for men and women, and across most age groups, particularly for younger adults.

Heavy drinking rates have also decreased across all ethnic groups. Figure 46 shows that the proportion of adults who report drinking 6 or more standard drinks on one occasion at least weekly decreased for all ethnic groups between 2016/17 and 2023/24. There was a small decrease in the absolute difference between Māori and nMnPnA heavy drinking rates during this time from 5 percentage points to 3.7 percentage points. Heavy drinking rates are higher in men than women for all ethnic groups. For example, 13.6% of nMnPnA men and 4.8% of nMnPnA women drank 6 or more standard drinks at least weekly in 2023/24.²²⁷

The volume of pure alcohol in alcoholic beverages available for consumption (both imported alcoholic drinks and alcohol produced in Aotearoa New Zealand for local consumption) has decreased slightly since 2010.⁶³³ Alcohol available for consumption per person aged 18 and over decreased from 2.2 standard drinks a day in 2010 to 1.77 standard drinks a day in 2024.⁶³³ Measures of the volume of different types of alcoholic drinks available for consumption indicate a decrease in beer and wine consumption since 2006, and an increase in consumption of spirit-based drinks (RTDs), that peaked in 2022.^633,634

Figure 46. People who drank 6 or more alcoholic drinks on one occasion at least weekly by total response ethnicity, 2016/17-2023/24

Access to primary health care

Access to high quality primary health care is an important determinant of health, which can also mitigate the impact of inequities in other determinants of health. A selection of indicators have been chosen, reflecting measures of access to and engagement with primary health care. 

Ambulatory sensitive hospitalisations for people aged 45 to 64 years

Ambulatory sensitive hospitalisations (ASH) are acute hospital admissions for illnesses or conditions that could have been avoided by interventions in primary care or the community, such as vaccination, or timely and effective management of conditions such as asthma in children or heart disease in adults.

From 2001 to 2024 there was a significant 10.9% increase in the total population ASH rate for people aged 45 to 64 years (from 3337 per 100,000 to 3704 per 100,000 people). This total population rate conceals large inequities between groups. Rates for Māori and Pacific peoples were 2 to 3 times higher than for nMnPnA people in each year from 2001 to 2024 (Figure 47). ASH rates were lowest for Asian people, with rates falling between 2001 and 2024.

The relative and absolute inequities in ASH rates for Pacific peoples compared with nMnPnA people increased between 2001 and 2024, and were highest between 2007 and 2019. ASH rates for Pacific peoples increased to a peak in 2011 (8664 per 100,000), declined slowly until 2019 and then fell sharply in 2020-2022. However, they rebounded back to 2019 levels in 2023.

There was a decrease in total population ASH rates between 2020 and 2022, with bigger and more prolonged reductions for Māori and Pacific peoples than for other ethnic groups. During this time, public health measures related to COVID-19 varied in stringency and geographic location. Changes in social connection and behaviours, lower levels of circulating bacteria and viruses, and reductions in access to primary and secondary health services are likely to have contributed to the differing ASH rates experienced by different ethnic groups during this time.^70,635,636 

Figure 47. Ambulatory sensitive hospitalisation rate for people aged 45-64 years (WHO age-standardised) by prioritised ethnicity, 2001-2024

Potentially avoidable hospitalisations in children

Potentially avoidable hospitalisations (PAH) are a broader group of conditions than ASH. PAHs include hospitalisations due to illnesses and injuries that could potentially be prevented by:

• effective primary healthcare services
• public health interventions such as injury prevention (e.g. child car seats) and health promotion and/or
• social policy interventions, such as income support and housing policy.⁶³⁷

PAH are one of the Child Poverty Related Indicators identified under the Child Poverty Act 2018 and are reported annually.⁶³⁸

Figure 48 is based on an analysis of PAH by the New Zealand Child and Youth Epidemiology Service, covering the years 2000 to 2020.²⁷⁸ Figure 49 shows a similar analysis by the Ministry of Health for the years ending June 2020 to June 2024. PAH rates were relatively stable for children aged 0 to 14 years from 2001 to 2019 (Figure 48) but with significant differences between ethnic groups.

PAH rates for Pacific peoples’ children were persistently high at about double the rate for non-Māori/non-Pacific/non-Asian/non-MELAA children. Rates for Asian children were lowest but showed the biggest proportionate increase between 2000 and 2019, increasing by 74%.

Figure 48. Potentially avoidable hospitalisations in children aged 0-14 years by prioritised ethnicity 2000-2020

As seen with ASH in adults (Figure 47), PAH rates for children in all ethnic groups dropped in 2020. This was likely due to public health measures instituted during the COVID-19 response, with decreased transmission of infectious diseases associated with closed borders, decreased community interactions and school closures. PAH rates for children remained low for all ethnicities for 2020/21 and 2021/22 before rising again in 2022/23 (Figure 49). The increase in PAH rate in 2022/23 was particularly marked for Pacific peoples’ children, with an increase in both the relative and absolute inequities between Pacific peoples and nMnPnA children between 2020/21 and 2023/24.

Figure 49. Potentially avoidable hospitalisations in children aged 0-14 years by prioritised ethnicity, year ended June 2020-June 2024

PAH rates differ by socioeconomic status, with those living in more socioeconomically deprived areas having higher rates of PAH. Between 2000 and 2015, children living in the most socioeconomically deprived areas (quintile 5) had much higher PAH rates than other children.

From 2015 to 2019, PAH rates fell for children living in quintile 5, while they increased for those living in quintile 4. From 2019 to 2023/24, the PAH rates for children living in quintiles 4 and 5 have been very similar, and considerably higher than those of children living in less socioeconomically deprived areas (quintiles 1 to 3).^278,639 

Unmet need for General Practice care due to cost

In Aotearoa New Zealand, cost can be a significant barrier to accessing primary health care. GP visits are free for children under 14 years of age, but for everyone else, there is usually a fee, which varies between practices and around the country.  In 2023/24 the New Zealand Health Survey reported that 15.5% of the population 15 years and over said that in the previous 12 months they did not see a GP due to cost, despite having a medical problem.²²⁷ This is the highest rate since 2011/12.

The proportion of the population who do not see a GP due to cost varies by age (Figure 50), disability (Figure 51), gender and ethnicity. In 2024 there were particularly high rates of unmet need for a GP due to cost for women (19%), adults aged 25 to 34 years (25%), disabled people (22%), Pacific peoples (22%) and Māori (20%).²²⁷

Figure 50. Unmet need for a GP in the past 12 months due to cost by age group, 2011/12-2023/24

Figure 51. Unmet need for a GP in the past 12 months due to cost for adults 15 years and older by disability, 2018/19-2023/24

Rates of unmet need for a GP due to cost are much lower for children than adults. In 1996 GP consultations for children under 6 years of age became free, with afterhours visits included from 2011. In July 2015, this was expanded to children under 13 years and then to children under 14 years in 2018.⁶⁴⁰

Figure 52 shows low rates of unmet need for a GP due to cost for children aged 0 to 4 years, and reductions for older children in the years following the policy changes. The policy improved absolute inequities for Māori and Pacific children, for whom rates of unmet need due to cost fell from 7.7% and 6.5% in 2011/12 to 1.9% and 1.5% in 2023/24 respectively, while there was a smaller decrease for Asian and nMnPnA children.²²⁷

Figure 52. Unmet need for GP in the past 12 months due to cost for children aged 0 to 14 years by age group, 2011/12-2023/24

Access to timely care in pregnancy

Early registration and care provided by a Lead Maternity Carer (LMC – usually a midwife, sometimes an obstetrician) in pregnancy allows for access to timely care and support during this critical period. Pregnancy outcomes are poorer for Māori and Pacific peoples than for New Zealand Europeans.²⁷⁹ Mothers and babies who receive care late in pregnancy or after delivery are more likely to experience poorer outcomes.^641,642

In the last 9 years there has been an increase in women accessing care late in pregnancy (Figure 53) or only after birth (postnatally) (Figure 54). Between 2016 and 2023, the proportion of Māori and non-Māori/non-Pacific (nMnP) enrolling with an LMC late in pregnancy doubled, to 11.6% and 4.7% respectively. The proportion of Pacific peoples enrolling late in pregnancy increased to over 10% in 2023.

There were substantial increases in enrolment with an LMC after giving birth for all ethnic groups. In 2023 this rate was 5 times higher than it had been in 2016 for Māori and Pacific and 10 times higher for nMnP. In 2023, 1 in 10 Pacific peoples, 1 in 20 Māori and 1 in 33 nMnP people enrolled with an LMC after giving birth. This implies they did not receive LMC care during pregnancy.

A 2019 review identified six integrated factors that were considered barriers to equitable maternal health outcomes and experiences in Aotearoa New Zealand – physical access, political context, the maternity care system, acceptability, colonialism, and cultural factors.⁶⁴³ The causes for the increase in late access to pregnancy care over the last decade need to be addressed.

The Perinatal and Maternal Mortality Review Committee note that since they started reviewing data in 2007, Māori and Pacific mothers and babies have had poorer outcomes than New Zealand Europeans.²⁷⁹ The proportion of people receiving care late in pregnancy or after birth has increased for all ethnicities, but with rates higher for Māori and Pacific peoples, this is likely to exacerbate inequities (note higher infant mortality rate for Pacific peoples (Figure 24, Section 3)). It is critical that systemic biases are addressed and barriers to accessing care early in pregnancy are removed.²⁷⁹

Figure 53. Registration with a Lead Maternity Carer in the third trimester by prioritised ethnicity 2016, 2019 and 2023

Figure 54. Registration with a Lead Maternity Carer after giving birth, by prioritised ethnicity 2016, 2019 and 2023

Childhood immunisation

Infants and young children can become very unwell and even die from conditions such as whooping cough, meningitis and measles, but these diseases can be prevented by immunisation. High coverage and timely immunisation protect not only the health of a child but also protect the whole community. High coverage prevents infections spreading and therefore protects vulnerable members of the population, such as the very young, the very old, or those with underlying conditions that increase their risk from infectious diseases (i.e. people who are immunocompromised).

Whānau need timely access to health care workers whom they trust and who can provide immunisations.⁶⁴⁴ Figure 55 shows that coverage rates for infants fully immunised at 6 months (according to the National Immunisation Schedule) were lower in the year to December 2024 than they had been in any year since 2009.^645,646 Rates started falling in 2016, with a sharper decline in 2020. In the year to December 2024, 46.4% of Māori and 56.2% of Pacific peoples’ children had their first three series of immunisations on time (by 6 months).⁶⁴⁶

Figure 55. Infants who were fully immunised at 6 months^ by prioritised ethnicity, 2009 to 2024

Between 2013 and 2017 immunisation coverage for children aged 2 years was over 90% for all ethnic groups. From 2016, a gradual decline in coverage occurred, followed by a sharp decrease from 2020, with an ongoing decrease since then (Figure 56). In the year to December 2024, coverage for 2-year olds was 63.6% for Māori, 70.4% for Pacific peoples, 83.4% for Asian and 82.1% for European children.⁶⁴⁶ 

Figure 56. Children who were fully immunised at 24 months^ by prioritised ethnicity, 2009 to 2024

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Lists of figures and tables

Note: If you are in paged view, the links below will take you to the section the figure or table is in, rather than directly to the figure or table.

List of figures

• Figure 1: Tōtara in the forest of Tane
• Figure 2. Tōtara in the forest of Tane
• Figure 3. The persistent relationships between ethnicity and socioeconomic deprivation (NZDep) in Aotearoa New Zealand, 1991-2023
• Figure 4. Māori land loss between 1860 and 1939
• Figure 5. Individual weekly median income from wages and salary by total response ethnicity, 2008 to 2024
• Figure 6. Gini coefficient before and after housing costs for Aotearoa New Zealand, 1982 to 2024
• Figure 7. Material hardship rates for children by total response ethnicity, for year ended June 2007 to June 2024, in three-year groupings to 2018
• Figure 8. Annual unemployment rate by total response ethnicity, 2008 to 2024
• Figure 9. Young people aged 15-24 years who are not in employment, education or training (NEET) by total response ethnicity, 2008 to 2024
• Figure 10. Proportion of children attending Early Childhood Education for the 6 months prior to starting school by total response ethnicity, 2000 to 2024
• Figure 11. a) Proportion of students attending school 90% or more of the time by total response ethnicity in term 2, 2011 to 2024. b) School leavers with Level 2 NCEA or higher by total response ethnicity, 2009 to 2023
• Figure 12. Māori attending Māori-medium education out of all Māori attending education, 2004 to 2024
• Figure 13. Number of people living in crowded households, by total response ethnicity, 2006 to 2023
• Figure 14. Number of Māori affiliated to the ten largest Iwi, 2013 and 2023
• Figure 15. Number and proportion of Māori who speak te reo Māori, 2001 to 2023
• Figure 16. Lonely some, most, or all of the time by age group, 2016/17 and 2020/21 to 2023/24
• Figure 17. Proportion of people with high (7 to 10 out of 10) levels of trust in a) Parliament and b) Health institutions, by total response ethnicity, 2014 to 2023
• Figure 18. Proportion of the population with high (7 to 10 out of 10) levels of trust for other people by total response ethnicity, 2014 to 2023
• Figure 19. Aotearoa New Zealand’s annual average temperature anomaly, 1909 to 2022
• Figure 20. New Zealand’s gross and net emissions from 1990 to 2023
• Figure 21. Socioeconomic deprivation and Healthy Location Index map, Kerikeri
• Figure 22. Longitudinal trends in life expectancy by prioritised ethnicity, 2001 to 2022, three-year aggregated estimate
• Figure 23. Life expectancy by New Zealand Index of Deprivation (NZDep) quintile, by prioritised ethnicity Māori and non-Māori/non-Pacific, 2018-2022
• Figure 24. Infant mortality rates by prioritised ethnicity, 1999-2022
• Figure 25. Mortality rates related to diseases of the circulatory system* by prioritised  ethnicity, WHO age standardised, 2000-2020
• Figure 26. Estimated prevalence of diabetes (type 1 and type 2) by prioritised ethnicity, WHO age standardised, 2013 to 2023
• Figure 27. Experienced high or very high psychological distress* in the past 4 weeks by age group, 2011/12-2023/24
• Figure 28. Adults experiencing high or very high psychological distress* in the past  4 weeks by gender 2011/12-2023/24
• Figure 29. Experienced high or very high psychological distress* in the past 4 weeks by disability, 2018/19-2023/24
• Figure 30. Children aged 5 years with dental decay (caries) at examination with the Community Oral Health Service, by prioritised ethnicity, 2002–2022
• Figure 31. Daily smokers (have smoked more than 100 cigarettes in lifetime and currently smoke at least once a day) by total response ethnicity, 2006/07 and 2011/12-2023/24
• Figure 32. Adults who vape daily by total response ethnicity, 2017/18-2023/24
• Figure 33. The impact of climate change on health
• Figure 34. Health co-benefits of climate mitigation measures by sector in Aotearoa  New Zealand
• Figure 35. Work-related acute fatalities, number and age-standardised rate, 2002-2021
• Figure 36. Work-related serious non-fatal injuries, age-standardised rate for Māori and non-Māori, 2002-04 to 2019-21
• Figure 37. Severe housing deprivation by total response ethnicity, 2001-2023
• Figure 38. Experience of racial discrimination in the past 12 months by ethnic group*, 2011/12, 2016/17 and 2020/21
• Figure 39. Access to the internet at a household level, by total response ethnicity, 2001-2023
• Figure 40. Comparisons of European and Māori trends in imprisonment rates for males under 30 years
• Figure 41. E.Coli trend direction 2001-2020
• Figure 42. Mortality rates of children aged 1-14 years by New Zealand Index of Deprivation (NZDep) quintile, 1990 to 2018
• Figure 43. Mortality rates related to malignant cancers of the trachea, bronchus and lung*, by prioritised ethnicity, WHO age-standardised, 2000-2020
• Figure 44. Estimated prevalence of diabetes (type 1 and type 2) by New Zealand Index of Deprivation (NZDep), WHO age-standardised, 2013 to 2023
• Figure 45. Population with BMI 25 or over by total response ethnicity, 2006/07 and 2011/12 to 2023/24
• Figure 46. People who drank 6 or more alcoholic drinks on one occasion at least weekly by total response ethnicity, 2016/17-2023/24
• Figure 47. Ambulatory sensitive hospitalisation rate for people aged 45-64 years (WHO age-standardised) by prioritised ethnicity, 2001-2024.
• Figure 48. Potentially avoidable hospitalisations in children aged 0-14 years by prioritised ethnicity 2000-2020
• Figure 49. Potentially avoidable hospitalisations in children aged 0-14 years by prioritised ethnicity, year ended June 2020-June 2024
• Figure 50. Unmet need for a GP in the past 12 months due to cost by age group, 2011/12-2023/24
• Figure 51. Unmet need for a GP in the past 12 months due to cost for adults 15 years and older by disability, 2018/19-2023/24
• Figure 52. Unmet need for GP in the past 12 months due to cost for children aged 0 to 14 years by age group, 2011/12-2023/24
• Figure 53. Registration with a Lead Maternity Carer in the third trimester by prioritised ethnicity 2016, 2019 and 2023
• Figure 54. Registration with a Lead Maternity Carer after giving birth, by prioritised ethnicity 2016, 2019 and 2023
• Figure 55. Infants who were fully immunised at 6 months^ by prioritised ethnicity, 2009 to 2024
• Figure 56. Children who were fully immunised at 24 months^ by prioritised ethnicity, 2009 to 2024

List of tables

• Table 1. Indicators: Determinants of health
• Table 2. Indicators: Health outcomes
• Table 3. Publicly available data sources used for determinants of health
• Table 4. Publicly available data sources used for health outcomes
• Table 5: How are we tracking? A scorecard