Abstract
The Aotearoa New Zealand (Aotearoa) health system requires transformational change to promote health equity and meet the needs of Māori populations under Te Tiriti o Waitangi. Evidence-based approaches are required to assist the health system in putting health equity at the centre of planning and decision-making to translate the principle of equity into routine practice. Internationally, health equity tools have been proposed to support the health sector in operationalising equity. The Ministry of Health (Ministry) 2008 Health Equity Assessment Tool (HEAT) is one such planning tool that was designed to assist the health sector in Aotearoa to promote health equity. Despite being published by the Ministry, application of the HEAT tool has never been evaluated.
This study conducted the first known formal evaluation of the HEAT tool to explore its contribution to the consideration of health equity in health service and programme planning in Aotearoa. A national review was conducted focusing on Ministry policy on guiding the health sector to use health equity tools, such as HEAT, and the accountability mechanisms it put in place over time. Data was collected from an Official Information Act request to the Ministry, retrieved through publicly available records and analysed to provide a national picture of the guidance, accountability, and action on HEAT since its development. A case study of the HEAT tool in practice was examined. A process and impact evaluation was undertaken on Taranaki District Health Board’s Health Equity Assessment (HEA) to examine how HEAT has been applied to review existing health services and programmes with a critical health equity lens and identify what changed as a result. Employing an embedded single case study design by an ‘insider’ researcher, data was collected through key informant interviews, a stakeholder workshop and document analysis.
The national review found that the Ministry gave minimal guidance to District Health Boards and Public Health Units on the use of HEAT and other equity tools between 2004 and 2022. It concluded that the lack of Ministry leadership in the health sector on the use of equity planning tools, such as HEAT, was a missed opportunity to strengthen equity and Tiriti compliance in health service and programme planning. The case study evaluation showed that HEA positively impacted the planning, decision-making and prioritisation of health resources to promote health equity. HEA encouraged participants to reinterpret the health issue from an equity perspective, increased equity-focused dialogue, planning and decision-making, improved stakeholder relationships and strengthened individuals’ focus on health equity which had positive effects on other areas of planning. Significantly, HEA resulted in the reprioritisation of health resources to promote health equity (investment and divestment).
This study suggests that HEAT can improve the consideration of health equity in service planning and decision-making by providing a practical framework for operationalising the principle of health equity. It may support equity-focused reprioritisation of health resources, although this is not guaranteed, and recommendations require time to be implemented. By focusing on the social determinants of health, HEAT can promote consideration of the structural causes of inequities and highlight these as sites for intervention. It may encourage the development of critical consciousness about health inequities and assist efforts to challenge institutionalised racism and privilege in the health system by interrogating and interrupting ‘white business as usual’ approaches that sustain inequities for Māori. To promote meaningful change, the tool requires organisational and government leadership and commitment, accountability, resourcing, capacity building and evaluation.
Represented symbolically as a large adze capable of shaping an even surface, he toki aronui haratua kia papa, the Health Equity Assessment Tool, has the potential to strengthen health equity and Tiriti compliance in health service and programme planning. Increased Government leadership and investment in the HEAT tool is recommended. As part of the Government’s broader effort to eliminate persistent health inequities in Aotearoa, a legislated Ministry directive to the health sector requiring the mandatory use of health equity tools such as HEAT in routine planning is recommended. This research provides insights about equity planning and evaluation that may be of value to other jurisdictions, particularly those with colonial histories.