The canary in the coal mine: inequitable healthcare for those living with multimorbidity in Aotearoa New Zealand

Primary healthcare, a component of the wider healthcare system, has long been established as a key driver of a population’s health status. The World Health Organization has recently defined primary healthcare as a mechanism to provide equity and optimum health outcomes through a whole-of-society approach. This is achieved by addressing individuals’ needs early in the continuum of care.¹ Those living with a long-term condition or multiple long-term conditions make up a considerable proportion of those receiving primary healthcare as they seek regular health support, require repeat prescriptions or medication reviews and require help with health exacerbations.² Aotearoa New Zealand is considered to have a strong primary healthcare system, with health indicators among the highest in Organisation for Economic Co-operation and Development (OECD) countries.³ Despite this, health inequities persist, particularly for Māori and those most likely to have multiple long-term conditions.⁴

The 2001 Primary Health Care Strategy (PHCS) was considered innovative and inspiring when it was released. It had a key goal of achieving equity in health outcomes for all New Zealanders and included a significant change in how primary healthcare was organised and funded.⁵ Strong government leadership at the time meant significant reforms in how primary healthcare was delivered and this led to an early commitment to equity approaches.⁶ Along with the goal of improving equity through a population health approach, the PHCS introduced capitation payments, rather than a fee for service, to encourage general practices to adopt a systems-based health approach and incorporate new ways of working with a focus on preventative health strategies.

Primary healthcare in 2026—how far have we come?

In 2026 it is clear that the PHCS has not achieved many of its goals, particularly that of ensuring equity of outcomes. According to the inverse care law, in health systems influenced by market forces, individuals with the greatest health needs are often those with the least access to appropriate care.⁷ In Aotearoa New Zealand, those for whom the system was originally designed—primarily the socio-economically advantaged and culturally dominant groups—continue to experience the most favourable health outcomes.^5,8 Since the inception of the PHCS, limited funding has been spent on developing the primary care system to account for the social determinants of health and the increasing diversity in Aotearoa New Zealand society. This has meant many of the programmes established to reduce inequities have not achieved their aims.⁹ The original (2002) capitation funding formula meant that general practices received a set amount of funding per enrolled patient each year. This was based on sex and age as determinants of health. In 2026, this will be updated to include multimorbidity, rurality and socio-economic deprivation,¹⁰ but continues to exclude ethnicity as a health determinant. This means Māori and Pacific health providers will continue to be disadvantaged, despite Māori and Pacific peoples having a recognised higher burden of disease.⁹

Equity in primary healthcare

Despite the absence of ethnicity-based capitation funding, the PHCS has consistently emphasised equity, particularly for Māori. Repeated analyses of the New Zealand Health Survey indicate that this focus has yielded only marginal improvements in health outcomes for Māori and Pacific peoples, who continue to experience the poorest health indicators in Aotearoa New Zealand.¹¹ While recent life expectancy data show a relatively greater increase for Māori compared with other ethnic groups, overall disparities persist.¹² Māori, Pacific peoples, individuals with disabilities and rural communities continue to face disproportionately high rates of morbidity and mortality.^13–15

Impact on Māori

An extensive review of the Aotearoa New Zealand health and disability system in 2020 found entrenched inequities and a fragmented health system, which impacted vulnerable groups.¹⁶ This had already been noted in the 2019 Waitangi Tribunal report, which suggested that the PHCS had failed to meet the Crown’s obligations under Te Tiriti o Waitangi.^17–19 Reidy et al. found that entrenched ways of working and embedded structures constrained reforms in primary care, which could have improved access to primary healthcare.⁹ Crengle et al. suggests that Māori are more likely than non-Māori to live rurally or remotely and are more likely to live with socio-economic deprivation.⁸ Moreover, Māori people live shorter lives, and with higher morbidity than their urban counterparts. Significantly, Māori have 60% higher rates of ambulatory-sensitive hospitalisations, which is an indicator of poor access to primary healthcare.^8,11

Models of care for long-term conditions

The PHCS also encouraged the development of different models of care to reduce inequity. To facilitate different models of long-term conditions management, the funding model Care Plus was established in 2004 to provide extra funding for long-term conditions care in general practice. There was a quick uptake, and by 2006 80% of general practices were accessing Care Plus funding.²⁰ Almost 20 years later, primary health networks (PHNs) were encouraged to use Care Plus funding in more innovative ways to explicitly address inequity of outcomes for Māori.^21,22 Historically, robust evaluation of innovations derived from funding streams has been limited, therefore evidence of their ability to reduce inequities in health outcomes is scarce; however, in relation to client-led integrated care (CLIC) this was able to be undertaken (see Box 1).

View Box 1.

Implications and future directions

There is appeal in implementing alternative models of care, such as CLIC, to support people with long-term conditions to self-manage their health and thus lessen the need for expensive interventions at the secondary care level. CLIC’s implementation, though well intentioned, did not achieve its intended outcomes.

Addressing the enduring consequences of the inverse care law

The inverse care law persists, as do the inequities (social injustices) that are the outcome of a health system that fails to address these inequities.^5,7,8 The CLIC model was based on a Western model of health focussed on the individual, and did not consider Te Ao Māori (a Māori worldview). Neither did it encompass Pacific models of health or the challenges for those with a disability. The geographic consequences of rurality were also unaccounted for in the support and referral systems for those living with health and social complexity.²³ This meant CLIC did not engage those most affected by multiple long-term conditions and their consequences.

Achieving equity

The literature is clear that to achieve equity, people require personalised and different approaches as well as distinct resources to achieve equitable health outcomes.^17,24 There is no “one size fits all” of care, particularly for those with multiple long-term conditions. Graham and Masters-Awatere²⁵ suggest that new models of health can result in alternate ways of achieving health. For example, in Aotearoa New Zealand, health may be understood through the lens of whānau (family) rather than individualised care. Prioritising whakawhanaungatanga, the building of relationships, and continuity of care are important considerations of successful long-term conditions care. In Aotearoa New Zealand, the consideration of Te Ao Māori, mātauranga Māori (Māori knowledge) and tikanga (correct protocol) are also important and are an important foundation of culturally appropriate care models. The Public Health Advisory Committee (PHAC) released their report in August 2025, which acknowledges that equitable health outcomes are essential for a strong, cohesive community and economy and suggests that in Aotearoa New Zealand these should be guided by Te Tiriti o Waitangi. This report outlines a solid blueprint for the future, focussing on adjusting exisiting economic structures to provide equitable access to health resources so all New Zealanders may have access to a healthy life and future as mandated in the Pae Ora (Healthy Futures) Act (2022).²⁶

Changing existing structure to support new models of care

The evaluation of CLIC found that participating general practices knew different ways of working with their population were required due to widening diversity and cultural, social and political needs, but they felt ill prepared and underfunded to cater for this complexity. They were also aware of the inequities inherent in the system structure, but had few resources or the required workforce to address these effectively. General practice participants in the CLIC evaluation had wanted, through CLIC, to provide a structured and more holistic model of care that was team based. They also sought to provide better support for people to self-manage their health conditions so people felt more in control, as well as reducing reliance on healthcare, and they wanted to deliver a more sustainable primary healthcare system.²³

Rural and Kaupapa Māori services provide examples of innovation

The CLIC study included a rural general practice, which had a legacy of successful long-term conditions programmes. They further developed CLIC to suit their practice population and subsequently experienced a high level of commitment to the programme with those who were already engaged with the practice.²³ This showed CLIC, if tailored to suit the needs of a community and with patient and practice engagement, could be a successful care model.

Although no Kaupapa Māori services were included in the sample of CLIC practices, we know that Kaupapa Māori organisations proved in the pandemic years that they are connected with their communities and can provide accessible and acceptable care to some of the most vulnerable and disenfranchised people in our communities.²⁴ There are many other interventions and models of care developed from a Te Ao Māori worldview and Indigenous knowledge around Aotearoa New Zealand. These services have been designed or co-designed with Māori, are delivered by Māori and have proven to be mana enhancing—empowering people’s self-care and improving wellbeing.^14,27,28 Rolleston et al.¹⁴ suggests that there is a disconnect between evidence of effectiveness for Kaupapa Māori programmes and the funding and support that should follow these successful models. This has meant that these programmes have not been sustainable. Significant structural change in how primary healthcare is delivered could be extended to provide more equitable care and models of care not only for Māori but for those living rurally, Pacific peoples and those with disabilities.

Flexibility in funding for multimorbidity care

One of the key motivations for establishing CLIC was the unequal distribution of Care Plus funding across the district. Care Plus funding was used extensively by some practices, usually the larger general practices, to support those with long-term conditions. The PHN found that this funding was utilised minimally or not at all by other general practices. The evaluation of CLIC revealed that unfortunately this inequitable funding distribution continued under CLIC. Due to greater resources and therefore an increased ability to implement and resource CLIC, some large and well-resourced general practices were able to enrol large numbers of people. Smaller practices were slow to incorporate CLIC into their clinical work with existing staff resources and as a result enrolled fewer numbers and subsequently received less funding.²³ The more recently introduced “Journey to Wellbeing Huarahi Ora” model from Health New Zealand – Te Whatu Ora may be successful in providing a set of guiding principles for health providers and communities to design long-term conditions programmes that aspire to be culturally safe, meaningful, accessible and sustainable.²¹ It is hoped this will avoid past experience where innovative long-term conditions programmes incorporating interprofessional teams have not been sustainable due to poor or short-term funding and/or have not been audited for consistency or evaluated, particularly around their ability to produce equitable outcomes.

An inherent barrier to equity is the fee for service co-payment, which has steadily risen as general practices struggle to manage costs with static public funding. The capitation funding model has not led to sustainable innovation in primary healthcare due to the entrenched structures and limitations inherent in the system.⁹ Reidy et al. suggest this is because primary healthcare in Aotearoa New Zealand has retained an episodic care mindset, even though capitation as a funding model was meant to encourage planned care, particularly for long-term conditions care.⁹

Conclusion

A strong and well-funded Te Tiriti o Waitangi–led primary health system could reduce inequity and result in better population health, lower rates of avoidable hospitalisations and less healthcare spending. While the PHCS was grounded in the intention to improve equity through population health funding delivered via PHNs, structural limitations, inconsistent funding and lack of cultural alignment have hindered the vision. The evaluation of CLIC, an innovative long-term conditions programme, identified key equity barriers, namely funding allocation, structural constraints limiting innovation and suboptimally applied programmes, particularly for Māori, Pacific peoples, rural populations and those living with disabilities. These factors warrant targeted attention in the future development of long-term condition frameworks and highlight the limitations of applying universalised models in a diverse and complex Aotearoa New Zealand context.

To advance equity in primary healthcare, models must be explicitly grounded in Te Tiriti o Waitangi, recognise the realities of the social determinants of health and embed Te Ao Māori, mātauranga Māori and tikanga as foundational principles. Equitable care requires deliberate redistribution of resources to fill service delivery gaps in rural and remote settings, co-design with communities and representation of diverse groups and the dismantling of entrenched power structures that exclude marginalised voices from policy development. These are all strategies suggested by the PHAC report, Determining our Future (2025).²⁶

A future-focussed system must resist a homogenised approach and instead support a diverse, team-based and community-embedded approach to primary healthcare. Authentic commitment has meant that this has been achieved in other parts of the world. Sustained and meaningful investment in primary care, as a frontline of intervention for health and wellbeing, is essential for achieving health equity in Aotearoa New Zealand. Only through honouring Te Tiriti and centring whānau and people, not the system, can we realise a truly just and inclusive health future.