• ethnicity
• Māori
• quality of care

L ife expectancy for indigenous people in colonised countries is shorter than it should be. In New Zealand, Māori die on average 10 years younger than people of Anglo-European descent.¹ The usual suspects of poverty and poor socioeconomic opportunities contribute to inequity, but failures in service organisation and delivery are part of the picture. New Zealand is not the only colonised nation where higher rates of illness and premature mortality exist, but it is a country making concerted efforts to address the disparity.

The starting point in identifying inequality in health outcomes is ensuring accuracy of data. New Zealand is a diverse country; the 2001 census indicates that 14.1% of the population are Māori, 6.2% are Pacific people, and 6.4% are Asian.² Each of these groups is actually growing at a faster rate than pakeha (the white descendants of colonial settlers). However, until recently, documentation of ethnic origin in relation to health was not routinely collected. Even when ethnicity was recorded, it tended to be based on health workers’ assessment of the appearance of the service user. Addressing health needs and planning appropriate levels of service clearly requires a more accurate and sensible approach. Self-identification of ethnicity is now established as “best practice” in New Zealand¹ and, as a result, knowledge about health and the incidence and prevalence of certain conditions is improving.

A second step in enhancing responsiveness to cultural needs of patients is “cultural safety” introduced by Irihapeti Ramsden.³ Cultural safety goes further than learning factual information regarding dietary or religious needs of different ethnic groups. Rather, it means engaging with the sociopolitical context of beliefs about whanau (family) and of what is tapu (forbidden) in a range of healthcare practice, from washing someone through to physical examination or handling of biological specimens. It is increasingly understood that failure to take such things into consideration may well lead to interventions that fail in the short term and that build suspicion in the longer term as people lose their trust in healthcare providers. While cultural safety began as a movement within nursing, it is now being introduced within the other undergraduate curricula and professional development programmes.

Difficulties in accessing services have been identified for Māori and other ethnic groups in New Zealand.¹ Resultant delays in initiating treatment may well contribute to the significantly worse outcomes found in patients with stroke, cancer, cardiovascular disease, diabetes, and mental illness.^4–6 While services that use the principles of cultural safety can reduce barriers and encourage access, a number of culturally specific services have been successfully introduced. Among developments are GP services based within marae (local meeting houses), specialist outreach clinics for young people with mental health problems, and culturally specific health education programmes.¹ Making decisions about where and when “culturally specific services” versus “culturally safe generic services” are most appropriate is difficult and complex. It is likely that each is required if high quality services are to be provided across the country.

Developing appropriate and responsive services requires dialogue and partnership between health service organisers and community leaders. Partnership is a core component of the Treaty of Waitangi, the original agreement intended to protect the interests of both the original inhabitants and the incomers. The Treaty has not always been honoured by the New Zealand government or pakeha, and examples of institutional and personal racism are well documented.⁷ Over the last few decades the responsibilities of leadership have been challenged and many steps taken towards redressing the lack demonstrated throughout the 19th and 20th centuries. Experience from other countries suggests that, without the Treaty, New Zealand may well not have tackled much of the implicit and explicit discriminatory practice. Things are by no means perfect and, without continued effort, those improvements made so far may well be transitory. However, healthcare policy, clinical practice and research processes are now all influenced by the Treaty, and attention to the impact of ethnicity on health is growing.

The final issue highlighted here concerns how service effectiveness is evaluated. Most measures of process and outcome are based largely on Eurocentric or US perspectives.⁸ While there is a place for such approaches, they may well fail to address issues which matter most to people of different ethnic origin. A recent model which explicitly addresses a Māori perspective of health and wellbeing is the Whare Tapa Wha model developed by Durie, visualised as a “four sided house” where each construct is required for health (table 1).⁹ Durie suggests that the link between these four components is fundamental: “A person’s synergy relies on these foundations being secure. Move one of these, however slightly, and the person may become unwell.”⁹

Although expert derived, this model is quite different from many others used in health care in being very definitely owned by the community. It makes the interconnectedness between different aspects of life and wellbeing explicit, has been the basis of new services, and underpins an outcome measure now used in mental health.¹⁰

Life expectancy and poorer outcomes in association with ethnicity remain important issues for many countries, including New Zealand. National and local developments such as those described here are making a difference, but ongoing and expanding effort is required if significant improvements in health are to occur.