London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London WC1H 9SH, United Kingdom.
University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
Soc Sci Med. 2023 Feb;319:115315. doi: 10.1016/j.socscimed.2022.115315. Epub 2022 Aug 30.
Despite establishing a so-called universal, taxpayer funded health system from 1938, New Zealand's health system has never delivered equitable health outcomes for its indigenous population, the Māori people. This article, using a case study approach focusing on Māori, documents these historic inequalities and discusses policy attempts to address them from the 1970s when the principles of the Treaty of Waitangi were first introduced in legislation. This period is one of increasing self-determination for Māori, but notwithstanding this, Māori continued to have significantly shorter life expectancy than the population as a whole and suffered poor health at much higher rates. Neo-liberal policies were introduced and expanded during the 1980s and 1990s in New Zealand, including in healthcare from the early 1990s. The introduction of the purchaser-provider split in health services and the focus on devolving responsibility to communities provided an opportunity for Māori health providers to be established. However, the neo-liberal economic and social welfare policies implemented during this time also worked against Māori and adversely affected their health. By analysing attempts to reduce inequity in health outcomes for Māori, we explore why these collective attempts, including by Māori themselves, did not result in overall improved health and increased life expectancy for Māori. There was often a significant gap between government rhetoric and action, and we suggest that a predominantly universal healthcare system did not accommodate cultural and ethnic differences, and this is a potential explanation for the failure to reduce inequities. While this is true for all minority ethnic groups it is even more crucial for Māori as New Zealand's tangata whenua (first people) who had been progressively disadvantaged under colonialism. However, the seeds of ideas around Māori-led healthcare were planted in this period and have become part of the current Labour Government's policy on health reform.
尽管新西兰自 1938 年建立了所谓的全民医保体系，但该体系从未为其土著人口毛利人带来公平的健康结果。本文通过对毛利人的案例研究，记录了这些历史上的不平等，并讨论了自 20 世纪 70 年代《怀唐伊条约》原则首次纳入立法以来，新西兰试图解决这些问题的政策尝试。这一时期是毛利人自治权不断扩大的时期，但尽管如此，毛利人的预期寿命仍明显短于总人口，健康状况也差得多。20 世纪 80 年代和 90 年代，新自由主义政策在新西兰得到引入和扩大，包括 90 年代初的医疗保健。在卫生服务中引入购买者-提供者分离制，并将责任下放给社区，这为毛利人卫生提供者的建立提供了机会。然而，在此期间实施的新自由主义经济和社会福利政策也对毛利人不利，并对他们的健康产生了不利影响。通过分析减少毛利人健康结果不平等的尝试，我们探讨了为什么这些集体尝试，包括毛利人自己的尝试，并没有导致毛利人整体健康状况的改善和预期寿命的延长。政府言论和行动之间往往存在显著差距，我们认为，一个主要的全民医保体系没有考虑到文化和族裔差异，这是未能减少不平等的一个潜在解释。虽然这对所有少数族裔群体都是如此，但对于作为新西兰原住民的毛利人来说更是如此，因为他们在殖民主义下一直处于不利地位。然而，这一时期已经播下了毛利人主导的医疗保健理念的种子，并成为当前工党政府医疗改革政策的一部分。
