Time to take health inequities seriously

For the money New Zealand spends on health care, the country has a world-class health system. In the main it works well for the majority of New Zealanders, but not for Māori, Pacific and rural residents. Inequities exist across all reported health conditions which is unfair and unjust, and entirely preventable.

Type 2 diabetes mellitus (T2DM) is a good illustration of this inequality. T2DM is extremely common among Pacific and Māori people. Approximately 10 percent of Pacific New Zealanders have this disease and a further 10 percent have impaired glucose tolerance, a pre-diabetes condition. This means T2DM is approximately three to four times more common among Pacific people compared with other New Zealanders.

It is generally accepted rising levels of T2DM and other non-communicable diseases (NCDs) among Pacific populations reflect the community’s high prevalence of obesity, changing diets and reduced physical activity levels. But consideration must also be given to the considerable variation in the quality of care received by Pacific and Māori, including access to effective medicines.

The NZ Health Quality and Safety Commission (NZHQSC) has produced the Atlas of Health Care Variation for common conditions in Aotearoa New Zealand. The Atlas shows considerable variation in the prevalence and complications from T2DM between district health boards (DHBs) and in the quality of care provided to people with the disease.

Further to this disparity, T2DM remains under-diagnosed in Aotearoa New Zealand, which is of particular concern among Pacific and Māori communities. A recent study of more than 4700 people found higher rates of undiagnosed diabetes in Pacific peoples (6.4 percent), compared with Māori (2.2 percent) and New Zealand European and others (1.5 percent).

But unfortunately, even when people are diagnosed, a significant proportion do not receive high quality care. Pacific people, in particular, are more likely to be under treated for their condition and, as a result, show high rates of serious complications such as renal failure, heart disease, blindness and microvascular diseases.

A recent study found Pacific and Māori peoples are 6.48 times more likely to develop end-stage renal disease due to T2DM compared with other New Zealanders. More than two-thirds of Pacific end stage disease is due to diabetes compared with just more than one-third in New Zealand Europeans.

The graph below shows the number of people on kidney dialysis by prioritised ethnic group at Counties Manukau DHB as at the end of August 2020. More than half of all dialysis patients are Pacific people. The demand for dialysis at CMDHB continues to grow in an unsustainable manner.

Improving the quality of care for Pacific and Māori people will reduce the overall cost of health care to Aotearoa New Zealand and reduce inequities. Access to modern safe and effective medicines is an important priority in achieving this goal.

Pharmac is currently considering funding two additional classes of medicines for treating T2DM. These are:

Empagliflozin (Jardiance) and empagliflozin with metformin (Jardiamet).

Dulaglutide (Trulicity) with funding to start as soon as practicable following Medsafe approval.

These drugs were registered in the US and EU in 2014 and found to be safe and effective with improved heart and kidney outcomes for people with T2DM. It is encouraging that Pharmac is considering funding for these medicines but, given the prevalence of T2DM and the effectiveness of these drugs, one wonders why it has taken so long.

If funding is approved, it would significantly improve the options available to doctors treating people with type 2 diabetes. It will improve the quality of their care, especially Pacific and Māori who are disproportionately affected with poor outcomes. A decision to fund will be a huge step in improving patient care in Aotearoa New Zealand and will reduce at least one aspect of the chronic health inequities that have existed for too long.