Aotearoa New Zealand is an island nation in the South Pacific. Originally discovered by Māori, the indigenous people, between 1250 and 1300, the country was colonised by the British, and sovereignty was proclaimed in the signing of the Treaty of Waitangi in 1840 [1]. This founding document is as significant today as it was nearly 200 years ago and features prominently in the 2022 health reforms. A defining characteristic of the Treaty is that the British, the Crown, signed an English version and a translated (by British representatives) te reo Māori version was signed by Māori chiefs, known in te reo as te Tiriti o Waitangi. While the English version referred to Māori giving British sovereignty, the Māori version refers instead to kāwanatanga, Māori giving the Crown the right to govern, not ceding sovereignty [2].

As the founding document, Te Tiriti o Waitangi makes Aotearoa New Zealand unique with respect to the relationship with its colonial past, and claims can be made with respect to whether the Crown (the New Zealand Government) are honouring the Treaty. In 1975 the Waitangi Tribunal was established to hear historic and contemporary claims of breaches by the Crown [3]. In 2016 the Tribunal initiated the Waitangi Tribunal Health Services and Outcomes Inquiry (Wai 2575). Numerous claims have been heard and the first report in 2019 [4] found that the Crown systematically contravened its obligations under te Tiriti across the health sector [5], and these breaches contributed to the pervasive and persistently poor health outcomes of Māori [6]. At a similar time, the then Labour Government (in coalition with New Zealand First) instigated the New Zealand Health and Disability System Review, which reviewed the state of publicly funded health and disability services [7]. The Health and Disability System Review produced proposals to reform the health and disability system in Aotearoa New Zealand to ensure the delivery of equitable health outcomes for all New Zealanders. Moreover, the review suggested transitioning from a deficit-based framework that focuses on treating illness and disease, to be more strengths-based and focus on health and wellbeing, and do so effectively, fairly and sustainably.

On 1 July 2022, the Pae Ora (Healthy Futures) Act [8] came into effect, a once-in-a-generation reform of Aotearoa New Zealand’s public healthcare system. For a ‘young’ nation, Aotearoa New Zealand is not unfamiliar with health reforms [9, 10]:

  • The 1980s was a period of decentralisation, funding and service management was controlled by 14 area health boards;

  • A purchaser–provider split occurred in the 1990s with four regional health authorities purchasing care from 23 Crown health enterprises (reconfigured health boards);

  • In the late 1990s the regional health authorities were amalgamated into one central authority, the health funding authority;

  • A new Labour-led government in 1999 disbanded the purchaser–provider split and created district health boards and later primary health organisations.

Three terms of a National Government from 2008 to 2017 left the healthcare system largely untouched reforms wise (apart from specifying health targets to improve district health board efficiency), yet significantly underfunded [11]; note the downward decline in Fig. 1. This under-investment, together with structural and systematic racism across a range of social institutions, has created and exacerbated health inequalities [12].

Fig. 1
figure 1

Source: https://flo.uri.sh/visualisation/11752412/embed, Te Tai Ōhanga/The Treasury; Graphic: Murray Jones

Crown spending on health by year and annual change.

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Māori account for 17.4% of Aotearoa New Zealand’s population of 5 million people [13]. On average, Māori live 7 years less than non-Māori non-Pacific people, and 4.4–5.0 years of these are potentially avoidable (Fig. 2) [14]. Māori have higher rates of cardiovascular disease mortality (200.8 per 100,000 population, compared with 99.5 per 100,000 for non-Māori non-Pacific), higher rates of cancer mortality (200.9 per 100,000 population, versus 113.9 per 100,000 for non-Māori non-Pacific), and higher infant mortality rates (4.7 per 1000 live births, versus 3.3 per 1000 live births for non-Māori non-Pacific people) [7]. Inequitable health outcomes are exacerbated by inequitable access to health services, with Māori more likely than non-Māori to cite cost as a barrier to accessing care and less likely to access medicines [15, 16]. The Pasifika population (there are over 40 different Pacific Island ethnic groups in Aotearoa New Zealand) accounts for approximately 8% of the 2018 population in Aotearoa New Zealand [17], and they too experience inequitable health outcomes: living 6 years less than non-Māori non-Pacific people [7]. This is due to a high chronic disease burden, for example the prevalence of diabetes in Pasifika people is more than double that of other ethnic groups [18]. These inequities, recently described as ‘an international embarrassment’ [19], are driven by the same determinants affecting Māori described above. Pasifika health has been a health system priority since the publication of the first Pacific Health and Disability Action Plan [20], and there are a number of Pasifika-led health providers employing models of health based on indigenous Pasifika concepts, knowledge, values and practices [21].

Fig. 2
figure 2

Source: Walsh and Gray [14]

Percentage of death that were potentially avoidable by ethnicity and total, 2013–2015.

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There is much promise (and hope) that a reformed health and disability system will address these inequities [22]. A key element of the reform is abolishing the district health boards and centralising the management of hospital and specialist services and primary and community care to Te Whatu Ora (Health New Zealand). Te Whatu Ora, largely modelled on the UK’s National Health Service, has four regions: Northern, Te Manawa Taki, Central and Te Waipounamu. Underpinned by a nationally planned approach which is regionally delivered and locally tailored, the reforms centre on an individual’s health needs, rather than where they live. The development of localities for place-based service planning is another feature of the reforms, where a geographical area with specific health needs will provide advice to Te Whatu Ora (and Te Aka Whai Ora, see below) as to their needs [23]. Localities have 2 years (as part of the interim New Zealand Health Plan [24]) to develop; there are currently 12 areas testing and piloting new models and ways of working. The geographic extent of each locality is different, with catchment populations ranging from 8000 to nearly 100,000 people. The ethnic composition of each locality also varies, with the West Coast locality in the South Island | Te Waipounamu having a population comprising of 11% Māori and 1% Pasifika people, and the Otara/Papatoetoe Ward in Auckland | Tāmaki Makaurau having a population which is 15% Māori and 42% Pasifika people [25]. The heterogeneity of localities and place-based planning may challenge the equity focus of the reforms.

Another new initiative grounded in the need to address te Tiriti obligations is Te Aka Whai Ora (the Māori Health Authority). Te Tiriti o Waitangi guaranteed Māori self-determination, tino rangatiratanga. Te Aka Whai Ora is a by Māori for Māori health agency, tasked with championing Māori hauora | health and wellbeing, and commissioning healthcare (hauora providers have been established for decades [26]), and they will work in partnership with Te Whatu Ora to address the health and wellbeing needs of whānau Māori. Te Aka Whai Ora will also work with the Ministry of Health | Manatū Hauora to monitor outcomes, ensuring healthcare is delivered for Māori with a Te Tiriti lens [27]. Te Aka Whai Ora is tasked with indigenising the healthcare system, including growing the Māori workforce, preserving, protecting and supporting rongoā Māori (traditional healing grounded in te ao Māori), creating Iwi-Māori partnership boards to enable Māori governance in the determination of health priorities for iwi (tribes) and Māori across localities, amongst other objectives. The challenge is immense and involves a paradigm shift in how healthcare is organised, delivered and commissioned for the indigenous population of Aotearoa New Zealand. While more services are often a welcome output of reform, in the context of Māori health more of the same will not be enough; for example Russell et al. [28] reports that the medically dominated, general practice-centric, business-oriented primary health care system is ‘programmatic’, ‘transactional’, ‘broken’, ‘flawed’, ‘deficit-focused’, ‘reactive’ and ‘racist’, and the authors call for self-determined health and well-being solutions informed by indigenous knowledge. Such a significant change needs to be adequately funded. While some argue Māori hauora and Te Aka Whai Ora should have at least a proportional share of the budget in line with the proportion of the population that are Māori [29], we contend that these entities should have a budget proportional to the health needs of Māori. Te Aka Whai Ora’s budget is modest, and while the health reforms agenda has been supported by $14.9 billion of new funding, time will tell whether this is enough to support such fundamental change [23, 30].

Much of the funding is to support the centralisation of healthcare with the disestablishment of district health boards and their merger into Te Whatu Ora. This focus on the secondary care system has researchers questioning whether the underinvestment in primary care will be explicitly addressed [31]. Māori health providers have been under-funded since their inception [4], although the majority of Māori (and Pasifika) patients are enrolled in ‘traditional’ (GP-led and owned) practices [32], and the under-funded nature extends across the primary healthcare sector. This underfunding is particularly evident for those providers that care for high-needs populations (which includes Māori and Pasifika patients) [32,33,34]. Evidence has been submitted to Wai 2575 to quantify the direct under-funding so to inform compensation discussions and the cost of the inequality caused by lack of access to primary care services for Māori [35]. Conservative estimates of the economic cost of the inequities between Māori and non-Māori suggest significant direct ($39.9 million) and indirect ($823.4 million) costs [36].

Funding, more specifically the allocation mechanism, is key to a successful reform. While there is a move to multi-year budgets that offer greater certainty for commissioners, the efficient and equitable allocation of funds to different agencies, and for different population needs, remains unresolved. Elsewhere researchers have elicited evidence on the public’s aversion to health inequities [37, 38] and explored the use of payment mechanisms to incentivise the delivery of care to disadvantaged populations [39]. Aotearoa New Zealand’s health reform provides an opportunity to explore innovations in (a) the way health care is commissioned to deliver not just health improvement, but improvements in the distribution of health outcomes, and (b) social procurement to address the climate crisis and consider the distributional equity concerns of future generations. Achieving equity through value-based payments [40] and whether pay-for-performance can reduce health disparities [41] has been discussed in the literature. The role of social procurement is somewhat more novel [42, 43], but potentially achievable in a country with pragmatism; described by Allen [42] as policy bricolage, but also known as the “No. 8 wire” mentality, Kiwi ingenuity, resourcefulness and a can-do attitude [44]. The reform is Aotearoa New Zealand’s most opportune moment to explore alternative funding models and be a global leader in using health care commissioning to deliver equitable and sustainable health improvements for all.

Outwith the health reform, Pharmac, Aotearoa New Zealand’s health technology assessment agency, has also been subject to an independent review [45]. Pharmac is globally known for being a staunch negotiator and for controlling costs within its budget [46]. The review found that this has been at the expense of equitable access to medicines. It reported that there was lower per capita expenditure for priority populations (Māori and Pasifika), in part due to barriers to accessing medicine and accessing care more generally, but also due to Pharmac not including equity considerations in their decision making. Similarly, investment in cancer medicines was found to favour non-Māori non-Pacific populations at the expense of other treatments, that is the opportunity cost of new cancer medicines is health improvements for Māori and Pasifika. The transparency of decision making within the agency was also called into question, although other research has shown that Pharmac is transparent in its processes and its values, but that work is required with respect to accountability and participation [47], which aligns with the review findings. The review made 33 recommendations and Pharmac have recently responded that the agency will improve its assessment methods, engage and partner with Māori, strengthen their focus on equity, incorporate the consumer voice, and share information [48]. This is an opportune time for Pharmac to take a global lead in health technology assessment methods. For example, it could embrace the new methodological innovations in distributional cost-effectiveness analysis [49], and investigate whether employing a societal perspective may address the recommendations for change [50]. Exploring how health-related quality of life is measured and valued, and whether a country that is embracing decolonisation and indigeneity needs new instruments, is also imperative [51].

Ask any New Zealanders and they will wax lyrical about the uniqueness of Aotearoa New Zealand (the steepest street, the longest placename, the team of 5 million), but in a global context, our persistent socio-economic and ethnic inequities are not unique, nor our multiple health reforms to market and back [52, 53]. What is unique is Te Tiriti, the partnership between Māori and the Crown, the contractual requirement to honour the Treaty and address health inequities. While other countries can only hope that the social justice movement will effect change in health policies to reduce health inequalities [54], Aotearoa New Zealand has more than just hope: to which we say “Kia kaha!”.Footnote 1