the pitfalls and promise of transparency in health care a ... · assoc prof bridget robson, eru...
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The pitfalls and promise of transparency in health care
A kaupapa Māori perspective on transparency
Dr Matire HarwoodAssoc Professor University of Auckland/GP Papakura Marae
HQSC Open Forum 10 March 2020
Wellington
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Overview
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Te Pō - Context
Right to:• Equitable health outcomes (via
Crown-funded services)
• Decision making (process)
= Excellence
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Systematic inequalities
• In health outcomes • In exposure to the determinants of health including racism
• In health system responsivenessAssoc Prof Bridget Robson, Eru Pomare
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Te Whei Ao - Tensions
•Equity
•Data sovereignty
•Racism and privilege
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Data Sovereignty
• Data is a living tāonga and is of strategic value to Māori.
• Māori data refers to data produced by Māori or that is about Māori and the environments we have relationships with.
• Māori data is subject to the rights articulated in the Treaty of Waitangi and the UN’s Declaration on the rights of Indigenous Peoples, to which Aotearoa New Zealand is a signatory.
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Please don’t use data to ‘victim-blame’
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Te Ao Marama -Enlightenment
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When transparency ‘worked’• Counties Manukau DHB serves a unique
population of 245,350 people
• Majority are Māori, Pacific people and people living in areas of deprivation
• In 2012, 62,000 of people living in CM were smoking tobacco
• One third were Māori; one third Pacifica
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Stink!
• For Smoking B+C in primary care, CMDHB ranked 20th of 20 DHBs
• CMDHB Board and Leadership endorsed a ‘SmokefreeStrategy’
• Clinical Champions appointed
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What we did1. Collective responsibility (with $$ attached)
2. Call Centre
3. Quality Improvement Hui to share data (some more open than others!)
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Brief Advice and Cessation Support in Primary Care
0
10
20
30
40
50
60
70
80
90
Jan March May
ABCDE
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0
50
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Mortality 1996-99
Rat
e pe
r 10
0,00
0
Māori Pacific Other
0
10
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50
60
CABG Angioplasty
Rat
e pe
r 10
0,00
0
Ajwani et al 2003 Tukuitonga & Bindman 2002
Mortality rates males 1996-1999
Procedure rates males 1990-1999
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We treat everyone the same except…
• When they smoke, are obese, have diabetes
• When they live too far from cardiac centres
• When they refuse
• When we think it won’t make a difference
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Angiography and PCI Maori and non-Maori (2000-4)
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CABG Risk of dying with underlying cause of IHD
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How to achieve equity• Buy in from Cardiologists – excellent data, ‘their own’
• System issue
• Quality Improvement Programme – ethnicity, deprivation, DHB, discrimination are components
• Monitor through regular audits
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“Well I’ll refer to certain doctors. After a while you sort of start to learn the doctors who will follow through on
your referrals and the ones who seem to decide that further
investigation isn’t required. I’m not saying that it doesn’t just happen
for Māori with those doctors. I mean it may be that they are the
same with Pakeha patients, but that certainly hasn’t been my experience.
And so I address my referral letters to certain doctors now.”
- GP J FG2
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Koru - Hope….
Shift the gaze from ‘process’ to ‘outcome’
Build and disseminate evidence
Equity lens Call others up on their
actions…..and inactions
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Key to change
• Indigenous leadership• Systematic monitoring & assessment of equity • Challenging institutional racism • Root causes• Equity-focused quality improvement • Partnerships with Māori
AP Bridget Robson and Dr Rhys Jones
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Haka – the challenge
• Be a Player• Be the Coach• Be the Manager• Be the Ref• Be a Fan
• REFLECT ON YOUR ROLE
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Mā te rongo, ka mōhio
Mā te mōhio, ka mārama
Mā te mārama, ka mātau
Mā te mātau, ka ora