Part 5: Reducing health disparities for Māori

5.1
In this Part, we discuss the requirement for DHBs to improve the health of Māori and reduce health disparities for Māori, and how DHBs monitor and report this.

5.2
In our view, the combination of lack of information in the annual reports on Māori health needs and on targets to reduce disparities makes it hard to gauge DHBs' progress.

Requirement to reduce health disparities for Māori

5.3
Under section 22(1)(e) and (f) of the New Zealand Public Health and Disability Act 2000 (the Act), DHBs have a statutory objective to reduce (with a view to eliminating) health outcome disparities "by improving health outcomes for Māori and other population groups". DHBs are expected to prepare and put into effect services and programmes to do so.

5.4
Under the Act, DHBs must also establish and maintain processes enabling Māori take part in, and contribute to, strategies for improving the health of Māori. He Korowai Oranga is the Government's strategy for improving Māori health and reducing health inequalities for Māori.

5.5
In 2009, a Ministry assessment of DHBs' Māori health plans²⁹ found that all DHBs had such plans (seven of which were jointly prepared by the DHB in partnership with Māori and 12 of the others by the DHB), and that almost all of the plans were in line with the DHBs' district annual plans and He Korowai Oranga.³⁰ Although most plans had a strategic focus, only some included actions, and the duration of the DHBs' Māori health plans varied (three-, five-, or ten-year plans). There tended to be a lack of clarity in the plans about who would monitor and evaluate the plan's effect and when and how they would do it.

5.6
In 2011/12, the Ministry required every DHB to produce an annual Māori health plan describing how the health of Māori in its district will be improved and inequalities reduced.³¹ The Māori health plan should be in line with the DHB's annual planning document and He Korowai Oranga. The Ministry expects there to be governance-level (usually partnership) relationships (what the Ministry calls a Māori relationship board) with local Māori communities, which would help assess achievements against the Māori health plan.

5.7
As a result of the lack of clarity noted in its 2009 assessment, the Ministry introduced a template for the plans and now requires DHBs to report against a set of 15 indicators in nine health issue areas. Seven of these (access to care, maternal health, cardiovascular disease, diabetes, cancer, smoking, and immunisation) relate to services, while two (workforce and data quality) relate to organisational capability. DHBs can consider regional and district priorities in the plans by including additional indicators. The Ministry also requires DHBs with high rates of rheumatic fever and/or sudden infant death syndrome to include them in their local indicator set.

5.8
DHBs are expected to internally assess their own progress on the Māori health plans. The Ministry will monitor DHBs to ensure that DHBs evaluate and review progress to achieve the desired outcomes. In doing so, the Ministry has certain expectations, central among them that:

• there are targets, milestones, and actions that can be measured; and
• the DHB makes changes if indicator targets are not being achieved.

5.9
The new structure for Māori health plans introduced for 2011/12 is intended to provide a more effective planning mechanism for reducing inequalities and improving the health of the Māori population.

Our review

5.10
We do not audit the Māori health plans. However, we do have a strong interest in the accountability of public entities. Each year we audit DHBs' performance reporting (the statement of service performance in the annual report).

5.11
We expect that each DHB in whose district the health status of Māori differs significantly from the population in general will, in its accountability documents, report meaningfully on what the disparities are and how it has improved the health of, and reduced disparities for, Māori.

5.12
For 2010/11, we decided to review each DHB annual report to assess whether the DHB reported there on:

• the extent of the district's health disparities for Māori;
• initiatives, with measures and targets, that the DHB is taking to reduce disparities and to respond if it fails to achieve its targets for Māori; and
• the effect of those initiatives on Māori health (that is, whether measures, targets, and trends for effects are reported, and to what extent).

5.13
We also noted whether the DHB had in place processes for Māori to contribute to strategies for improving the health of Māori in their community.

The extent of health disparities for Māori

5.14
We expected DHBs to identify in the annual report any particular health disparities for its Māori population, to give an idea of the extent of the disparities (in terms of severity and areas of disparity), and to use this as the basis for its planning of services to meet the needs of Māori.

5.15
DHBs are also expected to have this information in their Māori health plans. Acknowledging this, we still expect that if Māori health disparities are a priority for a DHB, this will be clear in the annual report by the DHB, as it is held to account through this document.

What we found

5.16
DHBs' stated general intent to achieve health equity is not usually accompanied by any detailed information about disparity in the district or the size of the disparity for Māori.

5.17
Four DHBs did not describe in their annual report the district's health disparities for Māori (that is, they either mentioned only the statutory requirement about addressing disparities or did not mention or quantify district-specific Māori health disparities).

5.18
The other DHBs typically made a general statement that Māori health is a priority, described the nature of the partnership arrangements in the district, and described initiatives for improving staff capability and capacity. They did not, generally, describe the particular health disparities between Māori and other groups in the district, or the relative importance of the issue for the district.

5.19
It is possible that DHBs expect people to read the Māori health plans to get this information. The Ministry's 2009 assessment found that all DHBs had such plans and that most DHBs provided information in the Māori health plans on the needs and priorities of Māori within their district.

5.20
We found it difficult to locate the Māori health plans of four of the DHBs. We question whether an interested reader of the DHB's annual report would have gone to the lengths we did to find the Māori health plans of those DHBs.

5.21
Some Māori health plans were easier to access. Counties Manukau DHB's Whaanau Ora Plan 2006–2011, for example, was available on the DHB's website.³²

5.22
Māori health plans, being plans and not reports, do not give the kind of information needed to hold the DHB to account for reducing disparities for Māori. However, if these plans were linked to statements of intent and statements of service performance, it would be possible to provide this information.

5.23
Counties Manukau DHB's Whaanau Ora Plan 2006–2011 has measures³³ but no report (because it is a plan) of progress toward those outcomes during the five years for which the plan was in place. However, Counties Manukau DHB reported on a comprehensive range of Māori-specific performance indicators in its 2010/11 statement of service performance, with some close matches between the Whaanau Ora Plan 2006–2011 measures and the performance results. Among these were avoidable hospitalisations: in the plan the aim was to "reduce potentially avoidable hospitalisations 0-14 years and 15+ years", and the reported result (on page 74 of the Annual Report as at 30 June 2011) was set out for the age groups 0-4, 45-64, and 0-74 years. Also, in the plan was the aim to "increase the number of children who are fully immunised at 2 years of age", and this was reported on page 71 of the Annual Report as at 30 June 2011.

5.24
In our view, this linking of plans to performance reporting is a necessary step in reducing disparities for Māori. Unless information about the actual district Māori health disparities and initiatives taken by the DHB is available in the statement of service performance, there is no formal mechanism to hold the DHB to account. We expect the DHB's accountability documents to identify any significant Māori health disparities and the annual report to detail progress to reduce disparities.

Specific initiatives to improve Māori health

5.25
In the preamble to their annual report, 14 of the 20 DHBs mentioned initiatives that they were taking to address disparities for Māori. However, descriptions were usually general rather than specific, and usually involved workforce, governance, or process initiatives (such as training support for providers of services for Māori), not health service initiatives. Lakes DHB's annual report is an exception in its descriptions of both governance and health service initiatives for Māori.

5.26
Again, the Māori health plans might outline specific initiatives. We found that the Counties Manukau Whaanau Ora Plan 2006–2011 has a section on "service development strategies" (page 36). However, these tend to be inputs and processes (such as "risk management") rather than health service initiatives.

Measuring how effective initiatives are in reducing health disparities for Māori

Indicators of progress

5.27
Although all DHBs had indicators that measured achievements for Māori, the number of such indicators varied widely, with half having five or fewer in their statement of service performance.

5.28
It was not clear why some DHBs that said they had high disparities for Māori had few indicators for those disparities.

5.29
The Ministry's reporting requirements for the Māori health plans (introduced in 2011/12) include national and regional indicators, with the DHB expected to establish district-specific indicators as appropriate. The Ministry also expects DHBs to report data for Māori against 15 indicators (including 13 service performance indicators) quarterly, six-monthly, or annually to the Ministry. We see this as a positive move.

Targets and trends

5.30
The result that New Zealanders want is for differences in health between Māori and non-Māori to be as small as possible or, better still, none at all. Setting targets helps the DHB to see the results of the work it is doing to reduce disparities.

5.31
Where the disparity in health status for Māori is significant, we expect to see measures and targets for Māori, with trend data, in the annual report of the DHB.

5.32
The national Māori health plan indicators reflect National Health Targets for immunisation, smoking, cardiovascular disease, cancer, and diabetes, as well as maternal health and access to care (percentage of Māori enrolled in PHOs, and avoidable hospitalisations).³⁴

5.33
Most of the National Health Targets are set very high and are being met, so it is unlikely that disparities for Māori would be evident. If there are still disparities for Māori in these health areas, we expect to see measures and targets for Māori in the annual reports of the DHB.

5.34
Where DHBs had indicator measures for Māori in their annual report, all had specific targets. In some instances, targets were set at the same level as for other population groups. In others, targets for Māori were lower, even considerably lower. There was usually little trend data to show progress toward the target, or toward reduced disparity. Most DHBs showed only baseline data for the indicator, not the trend.

5.35
In some DHBs (for example Bay of Plenty DHB), the same targets were set for all population groups (an "aspirational" target), and the Ministry has taken this approach through the Māori health plan template. "Aspirational" targets, coupled with trend data to guide specific action plans year by year toward the target, may be more effective than setting low targets with no specific initiatives.

5.36
In our view, more work needs to be done on the effect of the level of the target on the likelihood, and time taken, to reduce significant disparities for Māori.

5.37
Public reporting (for example, in annual reports) could also be helpful in achieving change. Māori and Pacific peoples' immunisation rates have improved,³⁵ arguably as a result of setting the targets at the same levels for these groups as for others and publicly reporting the results.

5.38
We were unable to form a view about how well DHBs use information about Māori health status to focus on their next steps, because DHBs tended to be vague about what they intended to do. For example, one DHB said that "A range of initiatives are being undertaken to meet this target which is expected to lead to improved results."

District health boards' partnership arrangements

5.39
Some DHBs, such as Lakes DHB, clearly state partnership arrangements in accountability documents. In Lakes DHB, the Māori partners have the status of a governance body, signing off the DHB's statement of intent and annual plan.

5.40
This is not so for all DHBs. In six of the DHBs' annual reports, it was not clear what processes were in place to allow Māori to take part in, and contribute to, strategies for improving Māori health. Again, the DHBs concerned might have expected readers of their annual reports to access this information through the Māori health plan or their website.

Our focus for 2011/12

5.41
As one aspect of our audit focus on service performance reporting for 2011/12, we intend to pay attention to the quality of DHBs' reporting of their efforts to reduce health disparities for Māori.

5.42
We consider that there are clear and sensible reporting requirements (in the form of the Ministry's Māori health plan template for 2011/12). In our view, better information about the disparities and about trends for the main indicators of those disparities would help DHBs to shape their health initiatives. Reporting against the Ministry's health indicators in the annual report would be helpful. We will discuss the monitoring and reporting of DHBs' Māori health initiatives with the Ministry.

5.43
We are considering, for our audit work in 2012/13, whether to focus on child health initiatives throughout the public sector in the medium to long term, and how well those initiatives address the future needs of New Zealanders. An important aspect of this would be the effectiveness of DHBs' initiatives to reduce disparities for Māori.

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29: Information provided by the Ministry of Health, 12 January 2012.

30: The annual plan and regional plans have replaced district annual plans and district strategic plans.

31: The Operational Policy Framework empowers Ministry requirements for Māori health plans. Clause 21.5 of SOC Min (10) 15/2 states that annual plans of DHBs are to include Māori health plans.

32: Available at www.cmdhb.org.nz/About_CMDHB/Planning/Maori-Health-Plan/WhanauOraPlan.pdf.

33: It has sections outlining medium-term priorities, outcomes, and measures (pages 20-21 and 26-29).

34: There is flexibility for the regional and district indicators to reflect regional and district health needs. However, priorities for affected DHBs include indicators for rheumatic fever and sudden infant death syndrome.

35: Information provided by the Ministry of Health, 2 February 2012.

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