In Aotearoa, Māori, Pacific peoples, and those living in Quintile 5 communities face the greatest burden of illness and the steepest barriers to health care. For years, the dominant narrative has been clear: poor outcomes are the result of system failure, not individual behaviour. This framing has been necessary, corrective, and overdue. But it is no longer sufficient on its own.
At some point, equity conversations must evolve beyond where responsibility sits and begin grappling honestly with how responsibility is shared.
The health system has failed Māori, Pacific, and high-deprivation communities in very real and measurable ways. Poverty, transport barriers, housing instability, inflexible employment, cultural disconnection, racism, and distrust have all contributed to lower engagement and worse outcomes. These are not abstract issues — they shape daily decisions about whether attending an appointment, collecting medication, or completing investigations is even possible.
But acknowledging systemic failure does not mean pretending agency does not exist.
Systems Can Open Doors — They Cannot Walk Through Them
Modern primary care has changed. Outreach nursing, free or low-cost visits, CSC subsidies, equity funding, transport assistance, text recalls, whānau-centred models, extended consultations, culturally competent clinicians — these are no longer aspirational ideas. In many practices, they are already in place.
And yet, non-attendance persists.
Investigations go incomplete.
Medications remain uncollected.
Care plans stall.
At a certain point, it becomes intellectually dishonest — and clinically unsafe — to argue that every instance of non-engagement is solely the system’s fault.
Support without expectation risks becoming paternalism.
Compassion without accountability risks reinforcing harm.
Engagement Is Not Blame — It Is Partnership
Requiring engagement is not about punishment or judgement. It is about recognising that health care is not something that can be done to people — it must be done with them.
Equity does not mean removing responsibility; it means adjusting the starting line, not eliminating the race.
When a patient repeatedly declines contact, ignores recalls, or disengages from care despite multiple culturally appropriate, flexible, and accessible offers of support, the question must shift:
How long do we continue to redesign systems around non-engagement before we name disengagement itself as a clinical risk?
The uncomfortable truth is that health outcomes cannot improve without some degree of reciprocal effort. Systems can lower barriers, but they cannot replace participation. At some point, continuing to blame “the system” alone becomes a way of avoiding harder conversations about readiness, motivation, fear, mistrust — and choice.
Trust Cuts Both Ways
Trust is rightly discussed as something the system must earn. But trust is also something that grows through repeated interaction. If patients disengage entirely, the opportunity to build trust never materialises.
This does not mean withdrawing care.
It does mean being honest about limits.
Health services cannot indefinitely chase, persuade, and absorb risk without engagement — not without burning out staff, misallocating scarce resources, and unintentionally disadvantaging other patients who are ready and willing to engage.
A More Honest Equity Conversation
The next phase of equity work must hold two truths at once:
Systems must remain accountable for removing barriers, embedding cultural safety, and resourcing care proportionate to need.
Patients must retain agency — and with agency comes responsibility to engage when support is genuinely accessible.
Real equity is not achieved by endlessly lowering expectations. It is achieved by walking alongside people, offering support that fits their realities — and being clear that engagement matters.
Because the hardest truth is this:
No system, no matter how well designed, can improve the health of someone who will not engage with it at all.
And pretending otherwise helps no one.
