A Provocation for Health Governance
Health inequities affecting Māori, Pacific peoples, and Quintile 5 communities in Aotearoa are well-documented and indisputable. Poverty, colonisation, racism, cultural disconnection, and underinvestment have shaped health outcomes across generations. Boards are rightly held accountable for ensuring systems respond to these realities.
However, a critical governance question now confronts the sector:
At what point does continued system redesign, in the absence of patient engagement, become ineffective, unsafe, and inequitable in itself?
The System Has Moved — But Outcomes Have Not Shifted Enough
Primary care has materially evolved in the past decade. Many services now offer:
Equity-adjusted funding and CSC subsidies
Outreach nursing and whānau-centred models
Extended consultations and flexible access
Transport assistance, recall systems, and proactive follow-up
Cultural competency training and Māori-led service design
These are not theoretical constructs — they are operational realities in many practices.
Yet persistent non-attendance, incomplete investigations, and disengagement remain concentrated in the very populations these investments aim to support.
Governance must therefore confront a difficult truth: system effort alone does not guarantee engagement.
Equity Without Expectation Is Not Equity
Equity has too often been framed as the removal of responsibility from patients in the name of compassion. While well-intentioned, this approach risks producing the opposite effect.
Support without expectation becomes paternalism.
Compassion without accountability risks entrenching harm.
Health care is not something delivered to people; it is something co-produced with them. When engagement is absent despite multiple accessible, culturally appropriate offers of care, continued attribution of responsibility solely to “the system” becomes neither accurate nor clinically safe.
Boards must ask:
How long can services continue to absorb risk, cost, and workforce strain where reciprocal engagement does not occur?
Engagement Is a Clinical Risk Issue, Not a Moral Judgement
This is not an argument for blame, coercion, or withdrawal of care. It is an argument for honesty.
Repeated non-engagement is itself a predictor of poor outcomes and must be recognised as a clinical risk. Ignoring this reality does not advance equity — it obscures it.
From a governance perspective, failure to name disengagement as a risk:
distorts performance metrics
masks the true drivers of unmet need
contributes to staff burnout
misallocates finite resources
disadvantages other high-needs patients who are actively engaging
Trust Is Built Through Participation
The system has a responsibility to be culturally safe and welcoming — but trust cannot be built in the absence of contact. Persistent disengagement limits the system’s ability to establish trust, deliver early intervention, or prevent escalation.
Equity strategies must therefore evolve from access-only frameworks to shared-responsibility frameworks.
The Governance Challenge Ahead
Boards must now move beyond binary narratives of “system failure versus patient blame” and adopt a more mature position:
Systems must remain accountable for removing barriers and resourcing care proportionate to need.
Patients must retain agency — and agency necessarily includes responsibility to engage when support is genuinely accessible.
True equity is not achieved by endlessly lowering expectations.
It is achieved by designing systems that meet people where they are — and being explicit that engagement matters.
No health system, regardless of funding or intent, can sustainably improve outcomes without participation.
The question for governance is no longer whether the system should change — it must.
The question is whether we are willing to acknowledge the limits of system responsibility when engagement does not occur.
That is the uncomfortable conversation equity now requires.
