4. New Zealand today — Aotearoa i tenei rā
In the course of the NZAPHR consultation, the right to health was accorded the highest priority by participants. Many expressed satisfaction with the treatment available publicly, particularly the care available to children. They thought that health services were of a high standard and commented on the dedication of health professionals. Positive remarks were also made about subsidised health services for people on low incomes, the free services for pregnant women, and diabetes testing and vaccination programmes.
While participants recognised that some people were disadvantaged, their views on how to address the problem were polarised, particularly where State intervention was suggested as an option to redress the rights of vulnerable groups. There was a clear division between those who felt that providing special rights for a specific group was discriminatory, and those who felt that it was essential in order to achieve future equality.
Although a number of participants expressed views that were essentially ideological - for example, over the effect of privatisation on the state-funded health system, and a perception of bureaucratisation resulting from the most recent restructuring - the consultation data could be grouped into three themes: access, the cost of services and promotion and education.
Access and equity
Access to health services was a concern for many people. Some commented on the lack of certain services in smaller communities and the closure of hospitals, others criticised the policy of apportioning funding on the grounds of ethnicity (which, they argued discriminated against Pakeha).
The length of waiting lists for elective surgery, the time taken to attend to less acute cases in the public system and the wait at outpatient clinics was mentioned. The length of time that Pharmac took to approve new drugs was also criticised.
Some specific services, including men's health, oncology and antenatal services, were thought to need improvement.
A number of people attributed to the recent restructuring the lack of available funding to pay health professionals or provide the necessary services.
Poverty was identified as the reason that many people did not have the basic necessities of life such as an adequate diet or satisfactory housing. This was seen as contributing to poor health and costing the system more in the long run. A significant number also identified poverty as a reason for people not going to the doctor when they became ill, or picking up prescriptions when they did. The repercussions of this - including overuse of the emergency services and the increased cost of intervention when the illness became more severe - was also commented on. The cost of specialist services such as optometrists and dentists was often raised. A number of participants referred to the cost of health insurance.
Health promotion and education
Many people saw the health system as more than simply the provision of health care, and focused on promotion and prevention. Early intervention was considered important, particularly for parents in relation to children's health. Diet and obesity (and the related discrimination against people by reason of size) were specifically mentioned, together with accident prevention and the low rates of immunisation in New Zealand.
There was a view that people should be able to make choices about their health, not only in terms of how they cared for themselves (comments were made about the importance of healthy eating and the risks of smoking, drinking and drugs), but also in relation to situations over which people felt they had little control, such as fluoridation of water, the use of chemical sprays, genetic modification and aerial spraying.
How specific groups experience the right to health Top
Although clearly all people are affected by the right to health, a number of groups are particularly vulnerable and have a significant stake in how the right is realised. Those identified most consistently in both the consultation exercise and in the relevant literature are people on benefits or low incomes, elderly people, Maori and Pacific peoples and children. The consultation data, in particular, highlighted that people with mental health problems, transgender people, refugees and new migrants could expect to experience difficulties with the health system.
People on benefits or low incomes reported that the money they received was insufficient for them to afford basic necessities such as healthy food or adequate shelter.This group was particularly affected by the inability to access services because of cost. The price of prescriptions was specifically identified.
The United Nations committee reviewing New Zealand 's performance under ICESCR criticised the fact that one in four New Zealanders lived in poverty and that there were no clear indicators to measure the effectiveness of poverty eradication (E/C.12/1/Add.88 para. 17).
Maori and Pacific peoples
Maori and Pacific peoples were identified as having consistently worse health status than other groups across a number of indicators. For example, their children are less likely to receive disability allowances than other children. A study of beneficiary households by the Downtown Community Ministry (submitted to the Commission as part of the consultation exercise) concluded that 'a significant ethnic disparity clearly exists, and the health and welfare and community sectors have a responsibility to do something about it.' Successive reports have also identified the inequalities in health status between Maori and Pacific peoples and other sectors of the population (Blakely & Drew, 2004; Durie et al., 2002; Ministry of Health, 2002b). The poor health of Maori, in particular, was identified by the United Nations Committee on Economic, Social and Cultural Rights (CESCR) as a cause for concern.
Inappropriate health care - including culturally inappropriate care - was an issue for some. Cultural insensitivity was mentioned on a number of occasions, and there were suggestions that more Maori and Pacific health professionals should be trained, and the services that reflect cultural concerns should be better funded. There were a number of requests for free access to rongoa Maori (Maori medicine), a more holistic approach to health and healing, and for health professionals to be trained in alternative medicines.
Children and young people 
There was a general feeling that the needs of children were well catered for, but - despite the fact that considerable planning has already gone into developing a child health strategy (Ministry of Health, 1998a, 1998b) - some people felt further work was necessary. At present, health care for children focuses on ante-natal and intensive post-natal care and well-child checks for children under the age of three, with no corresponding investment in areas such as adolescent mental health.
There was a variety of suggestions for addressing the poor health of children, including extending free health care to children and adolescents, educating parents about the importance of a healthy diet and providing better education and information about the effects of drugs and alcohol. An education campaign to halt the rise in the consumption of alcohol by adolescents was also recommended by the UN Committee reviewing New Zealand 's performance on UNCROC.
The high suicide rate among adolescents, particularly young men (already the subject of an intensive campaign by a number of government agencies) was identified as an issue by both consultation participants and the CESCR in its most recent report on New Zealand 's performance. The CESCR, noting its concern at the 'relatively high suicide rate, especially among young people', requested extra information of a comparative and disaggregated nature in New Zealand 's next report.
Sexual and reproductive health was also a concern, especially the early age of intercourse and pregnancy, and increasing rates of sexually transmissible diseases, notably Chlamydia; abortion; and sexual abuse.
People with mental illness
Mental health services attracted some positive feedback, but other participants identified inadequacies such as poor care following discharge and the need for greater accountability and review of the service provided. The effect of discrimination in accessing other services, lack of choices for consumers (particularly in relation to medication) and the use of compulsion were criticised. Participants considered the use of 'derogatory language' about mental health issues to be a problem and expressed concern about the difficulties resulting from stigmatisation of people with mental health problems.
In 1997, the Ministry of Health set a goal of providing more and better services for the three percent of the population experiencing severe mental disorders at any one time. The Blueprint for Mental Health Services in New Zealand (Mental
Health Commission, 1998) provides detailed guidelines for the resources necessary to meet these objectives and monitor progress. In the most recent report (2004), the Commission reported that progress had declined to 1.6 percent against the national target of three percent, with access levels for children and older people falling well below target. The Government has also moved to fund mental health services for the 17 percent of the population that experiences less severe mental health problems. However, the provision of both mental health and drug and alcohol services remains unsatisfactory. The problems with accessing drug and alcohol services are further compounded by the outdated Alcohol and Drug Addiction Act 1966.
Although these specific points were not raised during the consultations, the Commission has dealt with complaints about the discrimination that people with mental health problems face in obtaining employment,and local authority planning that limits the provision of community housing for people with mental illness.
Refugees and migrants
Both refugees and migrants experienced problems in accessing health services because of language difficulties, inadequate information about how to access services and lack of understanding and appreciation of cultural difference on the part of health professionals - problems that were also identified in an assessment of public health issues facing Asian communities in the Auckland region (Asian
Public Health Project, 2003). The report criticised 'deficiencies in immigration practices and health and social services . for failing to reduce this barrier'.
Refugees - whether they arrive under New Zealand 's UN quota or as asylum seekers - are likely to have high and complex needs, including infectious disease, diabetes, and post-traumatic stress disorder (Solomon,
1997) as well as difficulty in adapting to a foreign culture and environment.
Some refugees claimed that they were denied access to the underlying determinants of health by being placed in the worst housing and were discriminated against in employment. Other migrants also reported that their inability to find work, or the need to accept employment that underutilised their skills, had significant effects on their health, particularly their mental health.
The difficulties of older people in accessing services generally were mentioned, together with certain specific issues such as the provision of adequate care in residential homes, home help and harassment of the elderly. There were suggestions that much of this could be avoided by better needs analysis. In addition, reports by the Law Commission (2001) and, more recently, Age Concern (2003) suggest that the elderly are often subject to financial abuse by family members and to misuse of Enduring Powers of Attorney under the Protection of Personal and Property Rights Act 1988.
These small but highly marginalised populations have major difficulty in obtaining health services that meet their general and specific health needs - partly because there are so few of them, and partly because of stigma. Transgender people called for an amendment to the Human Rights Act to ensure that they could benefit from the protection against discrimination and as a way of questioning health policies that make it difficult for them to access appropriate health services, especially gender reassignment surgery. As a prerequisite for changing policy and practice in the treatment of infants born with indeterminate genitalia, intersex people seek education of health professionals as well as the general public about their condition and their ability to participate fully in society.
The impact of the right to health on disabled people, including the difficulties in accessing a wide range of services, is discussed in detail in Chapter
5: The rights of disabled people.