Laurence Malcolm: Why Maori don't get their fair share

COMMENT

The debate about race-based allocations in health has overlooked a critical fact. Maori, despite their greater health needs, receive less than 50 per cent of Government spending on primary-care services than well-off Pakeha.

How has it come about? First, how are our primary-care services funded? Is this funding in accordance with need? And what can or should we do about it?

New Zealand, in the main, has a health system of which we can be proud - except in one important respect. We continue to grossly underfund access to critically important primary-care services. Only over the past two years has the Government begun to address this issue.

Certainly, limited adjustments for need have been in place for many years - for example, since 1993 with community services cards. But with certain exceptions, such as children, the average government contribution to the cost of seeing a GP is still only about $15. The remaining average cost of $20 to $30 must be paid by patients, if they can afford it. Many cannot, including disadvantaged Maori.

The cost of seeing a GP is only one aspect of the consultation. In most cases a prescription is issued. Patients must pay the pharmacist a minimum of $3 an item. Some cannot afford this, having already paid the GP. The Government pays an additional $26 on average for prescriptions. Another $7 is paid for laboratory tests and about $3 by ACC for accidents.

GPs, naturally, choose to live and work where patients can afford to pay them. For example, in central Auckland each GP serves 800 to 900 people and sees them more than six times a year.

By contrast, in South Auckland, Tairawhiti (Gisborne district, with 45 per cent Maori population) and the West Coast, the population to each GP is almost twice as high. Patients are seen only about four times a year.

The consequence of this is a serious maldistribution in primary-care spending, including for pharmaceuticals and laboratory services, commonly called referred services. This expenditure for each person is much higher in places such as central Auckland which, despite lesser needs, is about 17 per cent above equity. Tairawhiti is about 24 per cent below equity.

This is an international pattern and is known as the inverse care law, which states that the availability of good medical care tends to vary inversely with the needs of the population served.

There is clear evidence that this inequity has seriously and differentially affected Maori and Pacific Island people. This is partly financial but also cultural. Initiatives during the 1990s from the National Government encouraged the formation of culturally supportive Maori providers of primary-care services.

Examples are the iwi-based Te Oranganui in Wanganui led by Tariana Turia. Another was the urban-based Te Waipareira in West Auckland led by John Tamihere. Many patients suffered from multiple health conditions, but some had rarely seen a GP.

These centres remained seriously underfunded in providing better access to GP services and the flow-on referred services expenditure. Some were subsidised by iwi. Staff received income well below what would be regarded as normal for GPs and practice nurses. In effect, these services subsidised what were otherwise government-funded services.

Over the past two years there has been a beginning, with the Government's primary-care strategy, to address these inequities. The implementation of primary health organisations is now providing, in what is called access funding, special provision for disadvantaged populations, including Maori. But this is only access to GPs and practice nurses. As yet, there is not improved funding for pharmaceutical and laboratory services.

Primary care services hence remain unfairly underfunded on the basis of need. But do Maori have special needs over and above other measures of disadvantage? Should there be an ethnic factor in funding?

Recent studies have shown there are large differences in mortality between Maori and Pakeha, even after allowing for other measures of disadvantage, such as income. High-income Maori have mortality rates 2.25 times higher than non-Maori. For low-income Maori the rates are 3.5 times higher.

The Ministry of Health's Health and Independence Report for 2003 indicates that overall spending per person on Maori and Pacific Island people, relative to their health needs, is less than for other groups.

There is an ethnic weighting in the funding formula of district health boards based on evidence that admission rates to hospital for Maori and Pacific Islanders are higher than other populations. This is a fair compensation to district health boards for the extra costs associated with these services.

Based on this evidence, an ethnic factor has been quite properly introduced into the funding formula for access to primary health organisations. This is to provide extra services that avoid unnecessary hospital admissions for Maori and Pacific Island people. This is a cost all taxpayers bear. It can be avoided through better primary-care services.

Gerry Brownlee has asked for evidence of the effectiveness of this additional funding. This is a quite unrealistic expectation. The additional ethnic funding for hospital services just compensates district health boards for the extra costs associated with these services. It will do little or nothing to improve health outcomes.

The additional small amount of ethnic-based funding for primary health organisations will take years, if not decades, to show evidence of better outcomes.

On the other hand, is there evidence of better outcomes from the above-equity funding received by well-off Pakeha? The answer here is almost certainly no.

Significant resources that might be used to improve health outcomes for Maori and other low-income New Zealanders is tied up in the inefficient and inequitable distribution of referred-services spending.

A committee established by the Minister of Health reported in 2002 on what should be done to address these inequities. Only recently has the ministry, together with district health boards, established a process to implement the report's recommendations.

Achieving a fairer distribution of resources will be difficult. However, without additional resources, redistribution offers the most significant prospect for improving health outcomes. Primary health organisations serving disadvantaged populations could spend the additional funding on stop-smoking programmes, raising immunisation rates, and the better management of chronic diseases such as diabetes.

Most New Zealanders are concerned about fairness, including how our taxes are used. Present distribution favours well-off Pakeha and seriously disadvantages less well-off New Zealanders, including Maori. This is a cost we must all pay in largely avoidable hospital services.

A fairer, more efficient and caring health system is one that targets Maori and other disadvantaged people with more, not less, spending.

* Laurence Malcolm, a professor emeritus at Otago University, is a health consultant.