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Putting an end to the ‘post-code lottery’ in healthcare requires a systemic overhaul, rather than just technical solutions.


In the face of multiple environmental and social crises, the long-term solution to achieving fairer and healthier societies on a livable planet will not be a technical solution. It will be a fundamental change in the way communities work.

Although we are more connected virtually than ever, where we live continues to determine many aspects of our lives. This includes food security, the quality of service, the state of essential infrastructure, working conditions, access to information and the ability to participate in democracy and governance.

Inequality is not just an outcome. It’s a process that implies an entire system of raw material extraction, with consequences for all of us through the depletion of those resources and the polarization of social groups due to growing inequality.

For some communities, especially those that already have less money, less ability to make decisions and a poorer connection to wider society, the effects are worse.

For the health sector in particular, the global evidence shows a strong and enduring relationship between health outcomes and geographieswhere people in poorer regions live shorter lives than people in richer regions.

It is no surprise that New Zealanders have a “zip code lotteryin health. But the causes of health inequality extend beyond the influence of the now dismantled District Health Boards (DHBs).

Read more: NZ’s health system has been under strain for decades. Reforms need to think big and long-term to be effective

Inequality is a policy and governance choice

The sum of policy efforts to reduce inequality – from taxation and regulation to health care and welfare – has so far come nowhere close to stopping the flow of resources away from local communities.

I have often heard from people working for social change in socioeconomically disadvantaged communities about the lack of improvement, or even worsening, despite significant financial investments.

Do not get me wrong. Money is needed, and more of it. But it must be brought differently and accompanied by better ways of organizing and working. Our current policy systems favor blunt, isolated, detached approaches that hinder learning and adaptation over time. They prevent some communities from meeting basic needs, let alone being able to transform.

Social complexity has increased. Growing populations and their interaction, enabled by technologies such as social media, have created ‘communities’ of people who are geographically far apart. This distance has increased the challenge for our policy systems to achieve health and social goals.

The demise of DHBs shows our long-standing problem with implementation. This also applies to primary health care organizations, which were founded in 2002. The latter were intended to transform local health systems, but are not yet improved equitable accesslet alone spread innovative practices.

Instead, Māori, Pacific and other community organizations continue to close the gaps in the local health system despite uncertain and short-term funding and the challenging community needs to which they respond.

Read more: New authority could change Māori health, but only if it’s a leader, not a partner

Where health care funding has not extended to broader socio-economic determinants such as poverty, these organizations have incurred costs to cover basic needs such as food and transportation. Where contracts do not allow for long-term planning, they have ensured continuity despite uncertainty.

Where an isolated policy focus discourages local cooperation, they have pooled their resources. Where adaptation is not supported and local information has no roads, they have gathered their own evidence and used creative ways to reach the population.

A paradigm shift to acting within complexity

There are currently a number of better options for organizing ourselves. These promote regenerative action and greater local focus through more sophisticated connections and system-wide targets.

International, reduced models of Donut economics and versions of the movement after growth have guided governments to prevent their activities from crossing planetary boundaries. These and other ways to focus on enrichment and preserve value within local communities have also blossomed.

These approaches are on the way to Aotearoa but we already have our own policy lessons for strengthening local relationships to improve health and well-being, including:

  • building and connecting leadership

  • implementing high-trust contracts between government and communities

  • learn how to use scientific evidence for local action

  • develop insights about what works to make collaboration and partnerships effective

  • building local communication capacity

  • recognition of the value and refinement of local social and environmental practices

  • and creating ways to learn from action and develop what is going well.

But these new approaches are still marginalized by the current hierarchical, technocratic and historical paradigms of organizing for health. However, we have the opportunity to understand something about this innovation.

New service and community networks within the current one health reformsknown as “locals”, can be transformational if set up as learning systems.

Rather than being driven by data and technology, “human learning systems” support timely reflection on successes and failures, sharing expert and local knowledge. They are better able to respond to changing needs and provide a way for all communities authority and a vote.

Properly implemented, these new services can become central, adaptive cogs within the health system, turning information and resources into evidence-based changes for better health and well-being. The co-benefits include strengthening social cohesion and an edge for all communities to respond to threats such as pandemics, natural disasters and climate change.

How we organize the health system is critical. We need to think longer term and short circuit the perpetual cycles of inequality that capitalism has created. Investing energy in how we organize ourselves locally can be that circuit breaker.

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