Confused about equity, ethnicity and healthcare? The experts got you covered

These descriptions are drawn from our community kōrero about the health system with Lady Tureiti Moxon and Dr Elana Curtis in March 2025. 

Healthcare for Māori should not just be needs-based but also rights-based

Whereas “equitable outcomes” can refer to any two or more groups – not just ethnic groups, and not just Māori – it was Māori who signed Te Tiriti o Waitangi with the Crown – and te Tiriti guarantees tino rangatiratanga to iwi. That is “the right to look after ourselves,” as Lady Moxon puts it – and this includes healthcare.

For Elana, “a Treaty-compliant healthcare system really would put Māori at the centre of everything it does.” Right now, it’s not compliant. “Not surprisingly, it gets really good outcomes for Pākehā. Because it’s designed for them. It’s in their language, it matches their social number profile, it matches their health literacy, it has a workforce that looks like them, it’s focused on what are the big issues in terms of their total population level, therefore it reflects Pākehā reality.

“A treaty-compliant health system would acknowledge Māori indigenous rights, which are here because of us being tangata whenua, and that is reaffirmed by Te Tiriti o Waitangi and He Whakaputanga, and it’s reaffirmed by and expressed through international law, you know, the United Nations Declaration on the Rights of Indigenous Peoples.

“Right now, we have a health system which is centred around Pākehātanga … We already know that Māori can’t get access to it. And then if you do get access to it, it’s of a lower quality. … Every step of the way is not truly compliant for Māori. So every step everywhere needs rethinking, reorientation with Māori needs and rights at the centre.” (See the kōrero report for discussion on Te Aka Whai Ora’s and Whānau Ora’s holistic approaches to health.)

Why “needs-based” must include ethnicity in Aotearoa NZ healthcare

“Equity of outcomes” means the same outcomes for everybody – rather than a “one size fits all” treatment. “Equity for me is about saying that that gap [in outcomes] is unfair and unjust and that that’s wrong,” says Elana. And ethnicity “is a marker of need because of racism, because of patriarchy, because of colonisation, all those things,” says Elana. In other words, it is not primarily about genetics. Instead ethnicity “is the most precise marker of need because of the way in which society is set up to make our needs so much worse.” It is society that “makes ethnicity matter” as a marker of need: ethnicity is “the best precise marker that we have. It’s better than geography, it’s better than socioeconomic status, it’s better than all these other variables.” So “ethnicity-based vs need-based” is a false dichotomy (the life expectancy gap for Māori and non-Māori is seven years).

Side note: Elana side-eyes the use of the phrase “race-based” as “interesting”, given race is “a biological concept which has been debunked and put in there to think that we can divide everyone up into different species of human beings – and there’s no scientific evidence for that.” It’s not a term officially used anymore, even by Crown agencies, and should be rejected.

Privilege: you don’t know what you’ve got, if you’ve always had it

If you go to the shop and the shopkeeper smiles at you, you think this is normal behaviour if you’ve never experienced anything different. You don’t necessarily know that the shopkeeper follows some people around the store to work out what they’re trying to steal.

That’s privilege. And it’s “really really hard” to see your own privilege helping you through life when you have had it all the time. It’s invisible, says Elana. So “one of the first steps to understand privilege is to stop, sit down, have a look at yourself” – and what society might be discriminating about in your favour. “You really have to think about your own identities and what privilege and disadvantages they confer,” says Elana. Elana’s own multiple identities include being Māori, a woman, a doctor. “All these things, they confer either advantage or disadvantage… and you’ve probably got both….. I didn’t earn either the advantage or the disadvantage. ….  I’ve got disadvantage as a Māori, I’ve got disadvantage as a woman, but I’ve got major advantage being a doctor and having a socioeconomic profile that changes that trajectory for me and my whānau.”

And the privilege/advantage and disadvantage is not something that just happened on its own. Lady Moxon: Society “always favours certain groups within itself” and in the main, those who make the rules and make the laws – they write those rules and laws to favour themselves.

At the same time – as if it were a zero-sum game (which it isn’t) – those in power set up environments which make other people unwell – and then blames them for their own unwellness with a “deficit” explanation. Government, says Elana, “puts people in poverty, it doesn’t pay them a living wage, it makes solo mothers jump through hoops to have enough access to money to feed their children. Those are all decisions made at a societal level and that’s where the interventions need to be. It’s not in educating ourselves to behave better so that we don’t [die early]. The top killers are there because society has created an environment for them to be there and to be distributed along the lines of ethnicity in this country.”

So the next step is not just about looking at our own privilege – it’s about assisting others who share our identities to think about their privilege also. Which leads us to…

Cultural safety and cultural competency: not an either/or

Elana is a world-leading expert on cultural safety. “Cultural safety is not actually about you learning about the culture of everyone else around you; [instead it is] learning about yourself, your own culture and what your own identity might mean to a clinical encounter with somebody of a different culture than you. But also [about] the way in which you set up the health care system for people that are of a different culture than you.

“Cultural safety is not learning a waiata, doing a karakia, having a trip to the marae, going on country. Culture safety is the hard work of [identifying] racism and bias and checking yourself and working out what your gaps are and fixing yourself and not allowing yourself to carry on with discrimination and oppression towards people of different identities.

“Notice I’m using the word ‘culture’; I’m not saying it’s just ethnicity or indigeneity, we have different cultural identities so your sexual orientation, your socioeconomic profile, where you’re from, your country of birth, all your identities should really fall under cultural safety. Unfortunately we tend to just put Māori health or indigenous health with cultural safety, but actually the intersectionality of all of those things is really important.

“ ‘Cultural competency’ is another term that’s often used interchangeably with ‘cultural safety’, and cultural competency is about understanding what [things] might mean for somebody who identifies themselves as belonging to a certain cultural group: what their norms are, what their ways of being are – and you would want to have some knowledge of that. You want both cultural safety and cultural competency but it’s for all identities now.

“In our 2019 article … which was like, ‘don’t do cultural competency, do cultural safety,’ I accidentally encouraged everyone to not do any cultural competency, just to do cultural safety, and it was all about Māori health. We’ve just submitted another article because I don’t think it’s helped us. We need to be doing cultural safety for all, cultural competency for all. And [then] Hauora Māori (Māori health) would take on what you do that’s culturally safe for Māori, what’s culturally competent for Māori, and it must be there on its own pou, in its own sort of commitment alongside cultural safety.”