Pharmac should brace for a dose of medicine to perk up its Treaty performance and (all going well) lift Maori health outcomes

Monitoring the Ministers

A raft of appointments has been  announced over the past 24 hours – an ambassador to Turkey, a consul-general to Guangzhou, a chair for KiwiRail, a deputy inspector-general of intelligence and security and an advisory panel for the same outfit. 

Oh – and remember Clare Curran? The former Labour Minister of Broadcasting, Communications and Digital Media has landed a job on the board of a Crown company, Network for Learning (N4L).       

In other announcements, the government joined the disabled community in marking and celebrating the International Day of Persons with Disabilities and Associate Health Minister Ayesha Verrall congratulated Covid testing teams around New Zealand for reaching the five million tests milestone.

Another big health-related statement came from Health Minister Andrew Little, who said care for the sickest New Zealanders is getting a major boost from the government, with plans to spend hundreds of millions of dollars on expanding intensive care-type services.

As the country shifts to the traffic-light system, he said (somewhat ominously)

“… we need to make sure we can cope with the unexpected.”

Cabinet has earmarked $100 million of capital funding from the COVID-19 Response and Recovery Fund to accelerate these intensive care unit projects.  Another $544 million of operational funding is available to fund ongoing costs like staffing.

But Point of Order was drawn to another of Little’s press statements, issued to accompany his release of an interim report by an independent panel reviewing the national pharmaceuticals-buying agency Pharmac.

The review is being chaired by former Consumer New Zealand chief executive Sue Chetwin and the panel is required to make recommendations on two key matters.

The first is how well Pharmac performs against its objectives and whether and how its performance against these could be improved

The second is   

“whether those objectives maximise its potential to improve health outcomes for all New Zealanders (in particular, equitable outcomes for  Māori  and Pacific people) as part of the wider health system, and whether and how these should be changed.”

In the interim report, the panel says it has largely focused on:

  • what it has learned from submissions and stakeholder meetings
  • Pharmac’s role in assessing medicines for public funding
  • whether Pharmac’s current objectives and processes provide for equitable outcomes for Māori and Pacific people and disabled people (of all races, presumably)
  • how and to what extent Pharmac is supporting the Crown in meeting its Te Tiriti o Waitangi obligations

The report says Pharmac has made various commitments to improving equitable outcomes for Māori  and Pacific people and disabled people,

“… but it is a long way from achieving this goal, just as it is a long way from having a fair representation of  Māori  and Pacific people and disabled people within its own ranks, or systems, processes and structures that facilitate equitable outcomes.”

The report provides evidence of what Pharmac might do in terms of staff numbers.

An early indication from numbers provided by Pharmac shows around 4 per cent of clinical advisory group members identify as  Māori , but ethnicity data was not available for all group members.

There has been both a slight decrease in the number of  Māori  staff employed in the past five or so years and a drop in the proportion of staff who identify as  Māori.  At 2.2 per cent it is well short of 16.5 per cent, the Maori share of the total population. 

Whether lifting the proportion of Maori staff to 16.5 per cent would improve Pharmac’s competence and result in  more equitable health outcomes is open to argument.

This is particularly so when the panel has not provided clear evidence of the bad Maori and Pacifika health outcomes that are supposed to be the product of the performance which Pharmac must improve. 

Rather, the panel seems to have been heavily reliant on what people consulted by the panel “sense” has been done by Pharmac:   

Through submissions, we heard equity-related concerns with the way Pharmac made decisions on available funding for pharmaceuticals:

    • A sense that Pharmac was not working to achieve equitable outcomes from the perspective of Māori  and Pacific peoples or other disadvantaged populations.
    • Pharmac looks at medicines in an isolated way and does not consider the shortcomings of the overall health and disability system which have a particular impact on Māori  and Pacific populations and disabled people and those with rare disorders.
    • A sense that despite needs of population groups, including Māori  and Pacific people with significant metabolic disease, pharmaceuticals are not funded quickly enough.

Perhaps reflecting Chetwin’s experience at Consumer NZ, the report contentiously suggests Pharmac should pay more heed to consumers rather than to health experts. 

Submitters also identified that the balance of clinicians and “expert” voices on one hand and consumer voices (particularly  Māori  and Pacific groups and disabled people) was weighted too heavily in favour of health professionals, leading to decisions that did not take the impacts of equity into account sufficiently.

Let’s contrast this with the government’s efforts to persuade us to listen to the experts – and heed the science – in our  response to the Covid pandemic.

Notwithstanding this challenge to the advice of health experts, the panel’s report is political in its thrust and just what the government would like to hear.  This is reflected in its consideration of how and to what extent Pharmac is supporting the Crown’s Treaty of  Waitangi obligations.

Our approach has been to look at guidance to government organisations on building Te Tiriti capability and the findings of the Waitangi Tribunal in stage one of its Kaupapa inquiry into health services and outcomes (specifically Te Tiriti principles as they apply in the context of primary healthcare).

We also examined government strategy documents, published approaches to Te Tiriti analysis and work by  Māori  scholars.

Additionally, we have in places looked at how Pharmac has supported the Crown’s Te Tiriti commitments. In examining questions of equitable access to medicines, for example, we have looked at how Pharmac has put into practice the principles of equity, active protection, and options.

The Crown’s commitments – let’s be clear – means the Ardern government’s commitments. 

Significantly, the report tells us Pharmac’s statutory objective does not explicitly require it to secure equitable health outcomes for all, but rather the best outcomes reasonably achievable within its budget for “eligible people”.

But the report goes on to tell us how the political wisdom of the government of the day influences what happens:

Nonetheless, successive governments have expressed their desire to eliminate the unjustifiable differences that have arisen in health outcomes for  Māori  and Pacific people. Pharmac’s own enabling legislation defines one of the Act’s purposes as “reducing health disparities by improving health outcomes for  Māori  and other population groups”.  Later health legislation refers to “reducing inequalities”. Today, it is called “achieving health equity”.

More critically, “The Crown” (in other words, the Ardern government nowadays)

… has accepted the advice of the Waitangi Tribunal that equity as a Treaty principle should apply throughout the health system.

Accepting that tribunal’s interpretations of the treaty and its requirements fundamentally is a political decision.

An accompanying table in the Chetwin panel’s report shows what the tribunal is prescribing (and hence the implications for our health system) –  

  • “Guarantee of tino rangatiratana – there is Māori  self-determination and mana motuhake in the design, delivery and monitoring of services.
  • Principle of equity – the Crown unequivocally commits to achieving equitable health outcomes for  Māori .
  • Principle of options – the Crown ensures all health services are provided in a culturally appropriate way that recognises and supports the expression of  Māori  models of care. The Crown also supports  Māori  health and disability providers to participate fully in the provision of services.
  • Principle of partnership – the Crown and  Māori  work in partnership in the design, delivery, governance and monitoring of primary healthcare services.

The panel does recognise that assessing health investment is more complicated than people might think, by the way.

But then its report says: 

It is possible to fund services or pharmaceuticals with positive cost-benefit ratios that will improve health for some while at the same time increasing inequity. Bowel cancer screening illustrates this point. Screening is highly cost-effective compared to other healthcare interventions. But since the disease had a relatively lower incidence among  Māori , this could increase inequity by focusing on a disease less common among those with the greatest health needs.

The role of Pharmac in bowel screening is not clear but it does seems the panel leans towards reducing the money spent on bowel screening because not enough Maori benefit.

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