Improving health equity among the African ethnic minority through health system strengthening: a narrative review of the New Zealand healthcare system

As the growth of migrant communities continues to raise globally, creating unique health challenges at a scale that has never been seen, there is renewed interest in and momentum for strengthening health systems [1, 2]. There is mounting evidence that health systems that deliver services equitably and efficiently achieve health for all [3]. Health system strengthening is therefore both critical and timely as it comes in the wake of the 2030 Agenda for Sustainable Development call to “leave no one behind”, where State governments are encouraged to integrate the health needs of migrants into national plans, policies, and strategies across sectors [4]. The G20 also recently reaffirmed the importance of continuing to strengthen global health systems as health systems have neither been responsive enough to the migrant influx, nor to the moral requirement to attend to migrants with dignity [5]. Table 1 pre- 79 T1 sents the aims and desirable attributes of each building 80 block.

In light of above, there is growing recognition that the health of New Zealand citizens is inextricably related to the health of the estimated 1.2 million migrants residing in a community of 4.4 million [6]. Economic, human rights, and public health imperatives all point to the need to ensure that migrant populations have access to equitable, efficient and quality health services critical for achieving improved health status [7, 8], in order to have an impact on the health outcome for the entire community [3]. The Migration Integration Policy Index – a government sourced document report the New Zealand government to have taken official measures to build responsive health systems which are culturally competent and committed to properly treating patients of diverse cultural backgrounds by use of the Pacific and Māori health models which have been adapted to serve immigrant communities [9]. However, independent research in New Zealand show inequities remain high [10, 11]. There are substantial challenges to attaining health equity for migrants, in particular ethnic minority groups. The African com- 78 munity is one such migrant minority group.

These ethnic minorities often have reduced entitlements in receiving societies. Not only do they have reduced ac- 117 cess to health care for a number of political, administrative 118 and cultural reasons which are not necessarily present for 119 the native population [10, 24], they are exposed to poor 120 working and living conditions and or resource-poor 121 neighbourhoods [6, 25‐27], which leads to poor health 122 outcomes. New Zealand comprises of many ethnic groups with the dominant groups being European ethnic group which makes up the majority of the population (74%), with Māori - the Tangata Whenua - of Indigenous people, being the largest minority (15%), followed by Asian (12%) and Pacific (7%) [12]. Resultantly, the current trends in health equity studies have been heavily focused on Māori [13‐15], the Pacific [16] and to a lesser extent the Asian community [17, 18]. The Treaty of Waitangi of Biculturalism and the principles of protection, participation and partnership of the Māori indigenous of New Zealand, has therefore widely informed the health policies priorities and services in New Zealand [19]. The migrants from the Western Pacific regions came to New Zealand under the special arrangements between Pacific governments after attaining colonial independence; temporary seasonal work schemes and the family reunion and international/humanitarian streams in immigration policy; and more recently, the New Zealand’s special quota systems for Samoa and the New Zealand’s ‘Pacific Access Category’, which awards entree to a set number of migrants from Tonga, Kiribati and Tuvalu each year [20]. Therefore, the New Zealand health policies and services are informed by historical migration and within the protection of its indigenous Māori minorities. For that reason, it is of no surprise, that resources dedicated for migrants coming later in the early 1990s like African communities [21] have been lacking. The health and well-being of ethnic minority populations has therefore been historically and consistently underrepresented in New Zealand, yet New Zealand is a culturally diverse nation, which requires a set refugee and migrant health policies and strategies that respond to the health needs of migrants.

This article adopts the definition of ethnic minority to be an immigrant or racial groups or immediate descendant thereof [22], regarded by those claiming to speak for the cultural majority as distinct and unable to adapt and adjust with ease into the New Zealand society due to differences in cultures and traditions [23]. The definition is ‘migrant oriented’ and aligns well with this article as ethnic minority grouping generally becomes noticeable due to migration, whether forced or voluntary and may only attain the position of an ethnic association as a result of migration [22, 23]. This paper set out to undertake a situational analysis of the New Zealand health system in improving health and health equity amongst African ethnic minority using the World Health Organisation (WHO) framework on health system strengthening.

WHO developed two of these frameworks. The first framework recognised fundamental goals of the health systems (health status, financial risk protection, and responsiveness) and four functions of health systems that determine how inputs affect health systems performance (resource generation, financing, service provision, and stewardship) [28]. In this framework, Musgrove and colleagues [28], defined health systems as including all actors, institutions, and resources whose primary intention were to promote, maintain, or restore health. The other WHO framework [3] built upon Musgrove’s framework by organizing health systems into six building blocks: service delivery, health workforce, information, medical products and technologies, financing, and governance and leadership. Since its launch in 2007, this framework has been used worldwide as it has been seen as the most comprehensive and it provides specific guiding blocks strengthening health system in many countries [3, 29]. This article, therefore adopted it to assess the New Zealand health system capacity to manage ethnic minorities with specific reference to the African community.

In this article, gaps and key constraints are critically reviewed for each building block where literature exists. Subsequently, recommendations are provided to government, stakeholders and health and social services professionals, which enables the management and the collaborations of the building blocks in ways that ensure the equitable and sustained improvement of health services and health outcomes for the African population.

A critical narrative literature review was applied in this article. This was the preferred method in favour of the systematic review for its ability to cover current and a wide a comprehensive range of issues within a given topic [30, 31]. However, some features of systematic review methodology were used to reduce selection bias [32] by applying the Preferred Reporting Items for Systematic reviews and Meta-Analyses, which follows a protocol with clear methods that demonstrate [34] how many publications were identified and screened for eligibility, how many publications were excluded and why. The aim of the review was to identify literature on theoretical issues and evidence around the attainment of health equity of African minority within the New Zealand health delivery system. See Fig. 1. The electronic search included four databases, CINAHL, PubMed, Scopus, and Google Scholar published from 2010 onwards. Due to the drastic change in nature and growth of ethnic minority communities over the last two decades years, the authors believed that literature published before 2010 may have not provide the true picture of the current trend of health equity of African minority within the New Zealand health delivery system. Search terms used to select relevant articles are presented in Table 2.

The above key words were combined with derivations of the terms `equity’ OR `inequity’ (i.e. equity/equitable/equitably/equities/equitability, with the same derivations for inequity). Papers were excluded if they did not meet the following criteria: (i) studies that included New Zealand; (ii) have a focus on equity that influenced ethnic minority health outcomes in the delivering of healthcare; and (iii) articles for which full text was not available. Key details of the papers were summarised to include the name of the study and author, year title, study design and main result in respect to the building blocks. See Table 3.

After an initial reading, the first author [BK] grouped the articles into five areas of the six WHO criteria for the six building blocks of health system strengthening concepts: 1) service delivery; 2) health workforce; 3) health information system; 4) health financing system; and 6) leadership and governance. Only one paper briefly mentioned the 5th criteria: equitable access to essential medical products, vaccines and technologies, which also fell under the theme service delivery. All authors agreed on these grouping themes.

The search retrieved 390 articles. After applying the criteria, 11 journal articles were included in the final analysis. Similar studies [34‐36] with limited and or complex evidence, showed prescribed procedural search strategies to have failed to identify important literature. We therefore used informal approaches to retrieve grey literature using the same terms listed earlier, including international and New Zealand government websites and web archives known to specialise in ethnic minority health and which may provide important detail on the health system strengthening. The process also involved manually selecting relevant publications that were cited in the articles retrieved during the first search. The search found an additional 7 government documents on organisational websites: Auckland and Waitemata District Health Boards; Ministry of Business, Innovation and Development; and Ministry of Health and four from international websites. An additional included grey literature from media (three), and three from reference tracking brought the total number of articles included in the review to 27. Eight were qualitative studies, four were quantitative studies, two used a mixed methodology strategy, and nine studies were literature reviews. Four studies did not mention the methodology used. Of these 27, only nine explicitly mentioned the African community in New Zealand.

The review shows a severe dearth of studies specifically related to the African ethnic minority population’s health needs and challenges residing in New Zealand, within the WHO concept of health systems strengthening [3]; which incorporates six inter-related health system building blocks: 1) service delivery; 2) health workforce; 3) information; 4) medical products/vaccines/technologies; 5) financing; and 6) leadership and governance. In general, huge disparities exists across different building blocks of health systems addressing the health needs and rights of ethnic minorities, including those in African communities.

Historically, New Zealand health policies and services for ethnic minorities, has been more responsive to the needs of indigenous Māori ethnic group, than other ethnic minorities who came as migrant and refugees New Zealand. Therefore, the accounts offered in this review in regards to the building block – service delivery, describe governmental policies and programmes not to address factors hindering access to healthcare of ethnic minorities as they do with the Pacific and Asian community [17, 56]. Acknowledged is the lack of culturally sensitive and responsive health service delivery, which unfortunately manifests as a top-down and ‘one size fits all’ service. Consequently, the healthcare delivery system has not been culturally adapted and made sensitive for Africans alongside populations from Middle East and Latin American grouped as MELAA categorisation which in itself is problematic when used to inform, plan, and monitor services [56] as many health differences are masked. This promotes the invisibility of African health inequity within all the other building blocks especially the health information system and health financing system.

Accordingly, the New Zealand health information system has not been able to adequately capture the ethnic dimension of African communities. This may be attributed to the continuous use of an inaccurate description of an African migrant without any critical reflection on the inherent discrepancies it creates by underestimating the actual African population in New Zealand. Callister [58] notes the process and politics of ethnic enumeration to inform New Zealand policy formulation and resource allocation. Inaccurate numerical presentation of African migrant communities and subsequently inaccurate representation of their needs may explain to some extent the underfunding or lack of funding of migrant health services like interpretation services. It is therefore not surprising New Zealand amongst other countries which has migration inflows, has a publicly funded healthcare system which is correlated with out-of-pocket private health spending and not with public health expenditure. Further, targeted District Health Board funding outside of mainstream funding is limited due to the equity focus on Māori and Pacific health outcomes at present.

For a multi-cultural society like New Zealand, ones would assume that a major feature of the country’s health workforce would be a diversified workforce. Poynter et al., [59] viewed it as an implicit bias in the way services are set up, where a health workforce from English-speaking countries are prefered, yet they are the least likely to stay, compared to overseas trained doctors from Africa, Middle East and Asia [49]. Although having health professionals of African backgrounds does not guarantee improvement of health services for African communities, yet when such professionals are available, awarding shorter contracts, or lack of African trained health professionals may be hindrance to the effectiveness healthcare service delivery to the African community. At the same time, the lack of African cultural understanding and African culturally appropriate education by the health service providers, have been noted to affect the confidence of African communities to approach services [25, 50]. African migrants have shown preferences for their own cultural context of care in their hospital encounters, an example of which includes traditional confinement practises for the mothers post natally [60], which are often contested within the western healthcare model [37].

Leadership and the governance of the New Zealand health systems for improving health outcomes for the poor often coincide with ethnic minority status. At the national level, uncertainty and incongruity on the inclusion of migrant health in the public health system, continue to be pose challenges to health equity. For example, Auckland (the largest city in New Zealand) has the highest number of immigrants, with 40% of its population being born overseas and almost half of the total African population, live, study and work in Auckland [6]. Ironically, the identified health needs of the migrants within the Auckland region were not catered for in the Auckland Regional Strategic Plan 2005–2010 as they were not recognised as a priority group in national health policy or in reducing inequalities. Each District Health Board use discretion on what and how they allocate the population-based funding to their populations based on the equity needs of the Māori and Pacific community.

The New Zealand health delivery system continues to perform reasonably well, but inequities remain high for visible ethnic minority migrants like Africans who have limited or no access to healthcare. There is a need to strengthen the health system derived from a well-informed funding allocation relevant for health services needed by the African communities. Furthermore, there should be strategic discussions followed by action to address structural and institutional racism and white privilege in order to explicitly address root causes of inadequate access and care processes for ethnic minorities.

The health information system must be strengthened to include employing context relevant household surveys or other means to gather specific demographic and health baseline data from African migrant communities. This would need to include a categorisation label for Africans in the health information system to allow for monitoring and timely dissemination of information. Such an initiative would in turn then assist in resource allocation and adjusting of some building blocks to meet the needs of this population. The New Zealand government should also start conducting time series reports that provide trends in health outcomes and utilisation of health services by the African minority group to allow for a more valid and comprehensive picture of their health in New Zealand.

Workforce development is a key for ensuring improved health outcomes for Africans. It includes relevant training and the provision for a health workforce which works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances; that is; there are enough numbers and ethnic mix of staff, fairly distributed; they are competent, responsive and productive. African health professionals already residents of New Zealand should receive equal opportunities for practicing in keeping with other professions from different ethnic backgrounds. Such engaged professionals would also be much less likely to have a racial bias which would have major implications on how services are delivered and acceptance by the African healthcare user.

There is generally a need for more research and political will to strengthen the WHO building blocks within the current New Zealand health system service deliveries to be more responsive to the health needs and rights of African minority and other ethnic minorities. Whilst, this review acknowledges the lack of quantitative research, it appraises qualitative research to be best suited to answer the questions of ‘why’ and ‘how’. Such knowledge is needed to design interventions and take affirmative action. Nonetheless, the use of both qualitative and quantitative analysis is recommended to measure health equity within the health system for African minorities. Intrinsic to such research is a strong engagement with African minorities and the use of a multi-pronged data collection approach, and a reliance on an all-encompassing use of a cultural element to maximise the trustworthiness of findings.