Keynote Speech to the Third International Conference on Wellbeing and Public Policy

  • Hon Dr David Clark


It’s my privilege to speak to you as Minister of Health, and discuss a topic that goes to the heart of this Government’s agenda - health and wellbeing.

I’d like to thank the organisers, Victoria University of Wellington, the Treasury/Kaitohutohu Kaupapa Rawa and the International Journal of Wellbeing, for hosting this conference.

Can I start by acknowledging the academics and others who have travelled from overseas, and all of you for being part of this important discussion.

Today I’m going to talk about the opportunity for improving the health of all New Zealanders by focusing on wellbeing.

Wellbeing is integral to our work on improving equity in the areas of primary care, mental health, and child wellbeing.

I’ll talk about how social determinants play a role in improving health, and health’s role in improving the social determinants.

I’ll also explore how this has shaped the thinking behind the child wellbeing strategy, and why this is a keystone policy for this Government.
Health and Wellbeing
When I talk about wellbeing in a health context in New Zealand, I’m drawing on three models.

Sir Mason Durie’s ‘te whare tapa wha’ model, the O-E-C-D Framework for Measuring Wellbeing and Progress and Treasury’s Living Standards Framework.

These models contribute to a way of considering wellbeing which draws on the contributing factors for a good life now, and what’s needed to maintain that into the future.

In New Zealand we have a rich and unique cultural context and we need to acknowledge how that ties into wellbeing.

Te whare tapa wha- the four cornerstones of Hauora or Māori well-being, acknowledges the importance of Taha tinana - the capacity for physical growth and development, Taha wairua - the capacity for faith and wider communication, Taha whānau - the capacity to belong, to care and to share where individuals are part of wider systems and Taha hinengaro - the capacity to communicate, to think and to feel.

Should one of these four cornerstones be missing or harmed, a person or collective may lose their balance and become unwell.

The O-E-C-D model is useful as it describes the indicators of a good life, while the Treasury Living Standards Framework focusses on what’s needed for a good future – natural capital, human capital, social capital and financial and physical capital.

What’s inherent in each of these three frameworks is that wellbeing requires a holistic response.

This Government is committed to putting people’s wellbeing at the heart of its policies – it is woven throughout the Government’s work.

We know if we prioritise wellbeing now, we’re laying the foundations for New Zealanders to have better lives for decades to come.

In New Zealand we have health and disability system that we can be proud of. It has its challenges, but our public health service provides high quality care.

We all deserve and expect support for our health and wellbeing, so we can contribute to our whānau, communities and wider society.

That’s why we are introducing new wellbeing reporting requirements to inform budget decisions, and why we are enhancing our evidence base with measures to support decisions promoting wellbeing.

This important work is being led by my colleagues, the Honourable Grant Robertson, Minister for Finance and the Honourable James Shaw, Minister for Statistics.

In the health sector work, we too are focussed on wellbeing in the work of the health sector, and applying a health lens to cross-cutting issues.

My priorities in health are driven by a concern to promote greater equity of outcomes.

As the first cabs off the rank for reform, I have prioritised change in primary health care, mental health, and child wellbeing. Applying an equity lens to ensure all New Zealanders are receiving the care they need.

The disparities different people currently face are largely preventable, yet they persist across the health and disability system and have done so for decades.

This failing costs us as a country – both in terms of quality of life for individuals and required funding.

The Indian economist and philosopher Amartya Sen once said “I believe that virtually all the problems in the world come from inequality of one kind or another.”

As a Nobel Prize winner for his work on welfare economics; I don’t believe he makes this statement lightly.

I share his view and want New Zealand to have a health system delivering high-quality health outcomes for all people, so they can reach their full potential no matter their ethnicity, socioeconomic status or health status.

Too many New Zealanders are currently being left behind by our health system. 

In the almost two decades since the Public Health and Disability Act made removing inequalities an objective of DHBs only marginal progress has been made.

Many Māori and Pacific New Zealanders, and New Zealanders on lower incomes, still have significantly worse experiences of the health system than the rest of New Zealand. 

They have higher rates of major conditions like diabetes, cancer and poor mental health, have less trust and confidence in the health professionals supporting them, and live shorter lives.

There is a proxy indicator called amenable mortality which captures mortality from a collection of diseases such as diabetes and appendicitis, which can indicate the effectiveness and timeliness of health care.

In 2013 amenable mortality rates in New Zealand were almost three times higher for Māori, and two-and-a-half times higher for Pacific peoples than non-Māori, non-Pacific New Zealanders.

This isn’t something which can be fixed in the short-term, but progress can be made.

Improving outcomes for those communities requires us to work together, to challenge and hold each other to account. 

At the centre of an effective, equitable health system, is improving the access to quality primary health care services.

We know GPs are the first port of call for many when they start to experience mental distress or illness.

They are the front door to our health system, and a referral pathway which unlocks the services you provide in secondary and tertiary settings. 

That front door needs to be open to everyone. 

If someone is unwell they need to be able to see a member of the general practice team. 

They need to be able to get to a clinic and afford to see a health practitioner once they get there.

Unfortunately we’ve seen GP fees going up for some time, which impacts most heavily on the people often facing the greatest level of need.

The first step toward unlocking these doors was the largest single investment in primary health care in recent memory to reduce general practice fees for the New Zealanders least able to afford them. 

The extension of the Very Low Cost Access scheme to Community Services Card holders will benefit around 540,000 New Zealanders. 

This will widen access to low cost fees across the country, and these people will see the cost of primary care visits drop by an average of $20 to $30.

Some will see it drop by as much as $50.

For a lot of New Zealanders this isn’t a cheaper doctor’s visit.

It is a doctor’s visit.

Alongside this, the Free Under 13s primary care scheme will be expanded to Under 14s, benefitting a further 56,000 young people.

Both of these will begin to be put in place from December 1st.

I’ve also asked the Ministry of Health to look at options for the development and implementation of one free annual health check (including an eye check) to Super Gold Card holders with sector input.

Investing in primary health care helps keep people well and reduces the burden on secondary and tertiary services and beyond.

If we invest in care which improves wellbeing now, it will lead to better lives for years to come.
But what we know, and what we regularly hear from practitioners and the general public, is we need to be looking more broadly than the health sector if we are to empower New Zealanders to lead the lives they want to.

Sir Michael Marmot, the acclaimed epidemiologist, has raised an interesting paradox specifically regarding health ministers.

He asks, why is it ‘Ministers of health are the government ministers most concerned with health. Yet their prime responsibility is for health services, not with key determinants of health that lie outside the health care system.’

Delivering on a wellbeing approach, working collaboratively with colleagues in education, housing, social services, finance, statistics, and more is one way we ‘re going to make this change.

We need to be looking to improve wellbeing by improving the health of New Zealanders through the health system, and we also need to improve health by looking at people’s wellbeing holistically.

To make real progress we need to focus on social determinants of health, as well as creating a wellbeing promoting health care service.


That’s why we’re serious about addressing the social determinants of mental health and addiction issues for New Zealanders.

Mental illness and substance use disorders are the leading cause of health loss for our rangitahi, our young people.

The leading contributor to this type of health loss for our young people in 2016 was depressive disorder, followed by anxiety and drug use.

The impact of poor mental health is further seen in other causes of health loss.

Specifically, self-harm was the leading contributor to health lost from injuries for 15-24 year olds.

Unaddressed mental illness which begins in adolescence is much more likely to continue into adult life.

The 2016/17 New Zealand Health Survey indicates that 290,000 adults had experienced psychological distress in the month before taking part in the survey.

That was 7.6 percent of all New Zealanders.

This rate was almost twice as high for Māori women; and higher still for Pacific women at 17.2 percent.

Adults living in the most socioeconomically deprived areas also reported higher rates of psychological distress, at 11.5 percent in the most deprived areas compared to 4.8 percent in the least deprived areas.

We also know Rainbow or L-G-B-T-Q-I-+ New Zealanders are more likely to be over-represented in poor mental health statistics.

For those experiencing the poorest mental health, we know there are complex relationships between poverty, inequity, inequality, housing and other social determinants.

We also know there’s an opportunity to improve the coordination between health services and other services such as services provided by the social or justice systems.

We know many health issues start early in life.

We also know not addressing these issues is only going to create more problems down the line, and create more demand for an already stretched health care service
facing an aging population with serious long-term conditions.

That’s why we are putting more nurses in secondary schools – so that our young people have easier access to support. We’ve extended school based health services to all public secondary schools in deciles 1-4.

And in Canterbury and Kaikoura, where our young people are living with the legacy of earthquakes, we’ve introduced the Mana Ake programme which is putting mental health support in primary and intermediate schools.

The Inquiry into Mental Health and Addiction was also one of the Government’s first priority initiatives in health, launched in our first one hundred days in office.

Due to report back in a few short weeks, the Inquiry will shine a light on what is driving disparities, where we can invest and innovate, and how we can spread that innovation.

It will shine a light on some of the great work we know is happening in many of our communities across Aotearoa, and how we can better support those initiatives.

Although we are hopeful that we can start making important improvements, like improved access to Primary Care, disparities in poor mental health outcomes are not something which can be fixed overnight.

Again, it requires us to work together, to challenge and hold each other to account. 

Together, we’ll take a whole of system and whole of life approach, creating a people centred service designed in partnership with communities to improve mental wellbeing for our people. 

This system approach starts at the beginning of life – with our infants, children and young people.

We need to improve the support we provide to children, young people and their whānau.

A healthy start to life is one of the greatest contributors to good health and wellbeing later in life, but too many children in New Zealand are missing out.

In 2016 a Treasury report estimated that 53,000, or 14.6 percent, of children in New Zealand 5 years old and younger would experience two or more indicators of adversity.

These indicators are things like a finding of abuse or neglect, having spent time in the care of child protection services or having a parent who has received a community or custodial sentence.

As children with these risk factors aged, they became more and more disadvantaged.

They were more likely to leave school without any qualification, and before they turned 21 they’d either be more likely to spend time in jail or receive benefits for over two years.

These experiences, in turn, mean they are more likely to have children who were exposed to these risk factors and associated poor health and wellbeing outcomes from an early age.

If we can address adverse experiences not only would it reduce the problems faced in childhood and adolescence, but it would also improve health outcomes in adulthood.

Reducing adverse childhood experiences has been shown to reduce adverse health behaviours, including smoking, drug use and lack of physical activity, as well as other social outcomes such as poverty and homelessness, mental illness, cardiovascular disease, diabetes and obesity.

This Government has committed to developing the Child Wellbeing Strategy as a keystone policy, with the aim of making New Zealand the best place in the world for children and young people.

There needs to be a comprehensive response to improve wellbeing in all aspects of children’s life.

This Strategy is building on the other guiding wellbeing frameworks by te whare tapa, the O-E-C-D and Treasury to deliver a proposed conception of wellbeing that is relevant to children.

There are five components to the strategy.

• Safety - children are safe and feel safe.

• Security - children enjoy sufficient financial, natural and social resources to thrive.

• Connectedness - children understand who they are, where they belong, and their connection to whānau, culture and community.

• Wellness - children enjoy the best possible physical and mental health.

• And development - children have the skills and knowledge to live good lives and meet aspirations.

This work is being led by the Prime Minister, and Minister for Child Poverty Reduction, Jacinda Ardern, and the Minister for Children, Tracey Martin.

Other Ministers, including me, will lead each of the 16 proposed priority areas identified in the strategy.

To ensure the strategy can increase New Zealanders’ wellbeing, it’s built on a number of concepts including the life course approach, proportionate universalism, and applying a bio-developmental framework.

The life course approach is the focus on what can be done to ensure there is a good start in pregnancy, and people develop well during childhood and adolescence to achieve good outcomes in adulthood.

A number areas in the Strategy focus on supporting children and young people through key stages in development.

We know the importance of the first 1000 days in a child’s life; for the baby, mother and whānau.

We also understand the importance of the 2-6 year age group on social, emotional and learning development – this is a key for not just future learning, but the opportunity to assist in the development of resilience.

If we can support children and young people early in life, they can lead better, more empowered lives.

Proportionate universalism is the resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need.

Services are therefore available to all, not just the most disadvantaged, and are able to respond to the level of presenting need.

This is vital to ensure all people get the services they need and assist in improving equity of outcomes.

That’s why there is a specific focus area on making sure services are accessible to all, so everyone can get the support they need and issues can be resolved early.

The Strategy has a focus on improving the wellbeing of all children and young people, the wellbeing those with greater needs, and the wellbeing of the core populations of interest to Oranga Tamariki – our agency for children in care of the state.

It also aims to reduce child poverty and mitigate the impacts of child poverty and socioeconomic disadvantage experienced by children.

The bio-developmental framework helps us understand the origins of disparities in health, learning and behaviour.

It captures the complex relationship between human genes, the social and physical environments and nutrition, and how this affects outcomes in adulthood.

That’s why we have proposed a strategy that requires the Government to work together to address a broad range of social determinants for health and other issues.

The priority areas capture the need to focus on housing, culture, safety, healthy environments, positive relationships, and many other issues including poverty and inequality.

As an example, one of the focus areas is ‘children and whānau live in affordable, quality housing.’

Supporting affordable and quality housing is beneficial for a number of reasons.

We have a challenge with the state of housing in New Zealand.

Cold, damp, crowded homes can increase the risk of respiratory issues and other preventable health conditions, such as rheumatic fever and skin infections.

A recent Massey University report found an increase of 45 percent in the rates of Kiwi children hospitalised with asthma from 473 per 100,000 in 2002 to 688 per 100,000 in 2016.

There’s strong evidence, both nationally and internationally, that providing warmer and drier homes leads to improved health outcomes.

There’s also the potential to improve social outcomes and quality of life through longer housing tenure, and being closer to school and work.

We’ve made progress through the Healthy Homes Guarantee Act requiring all rental properties to have insulation and heating.

The Healthy Homes Initiative also promotes steps that increase the number of warm and dry homes, through innovative partnerships to provide insulation, education and connecting with other services to improve homes.

Across all areas of the strategy, there will be a focus on mitigating the effects of child poverty and socio-economic disadvantage.

Between 150,000 and 290,000 children are currently living in poverty or hardship, with the number depending on the measure used, and of those, around 80,000 live in severe hardship.

The level of poverty in New Zealand has been increasing since the 1980s.

The presence of sustained child poverty leads to considerably worse health and wellbeing outcomes.

That’s why one of our immediate priorities when we came into government was the introduction of the Families Package which provides targeted assistance to improve incomes for modest-income families with children.

As part of that package we introduced the Best Start payment of $60 a week to every family with a baby born after 1 July 2018. These families will get this payment during the first year of their child’s life – and for some families, Best Start will continue for the first three years.

Best Start and the Families package will lift 64,000 children out of poverty. And relative to 2017 levels, an estimated 384,000 families with children will be made better off by an average of $75 a week in 2020/21 when the Package is fully implemented.

It’s part of the Government’s focus on reducing child poverty, and ensuring children get the best start in life.

Through the Child Wellbeing Strategy we’ll be looking for other opportunities to meet the ambitious target, to reduce the proportion of children in poverty from 15 percent today to a world-leading 5 percent within ten years.

We see health as intrinsic to most of these 16 priority areas, both in terms of the health sector engaging in the response, but also because the benefits are seen in improved health outcomes for children, young people and their whānau.

The strategy will continue to draw on evidence, including the very valuable research and work of New Zealand’s academics, our rich longitudinal studies, and the growing body of data which helps us to understand wellbeing.

We also acknowledge the importance of listening to the voice of the children and young people; hearing their understanding of what wellbeing means to them and what’s important for them.

There will be extensive engagement with children and young people over the next few months to make sure they get a chance to be heard and they know their voice is valued.

Making sure all children can live in a healthy and safe home, are well fed and in school is a responsibility we bear.

We know transformational change requires us to work seamlessly with other providers and agencies, and I’m working with other Ministers across the social sector to make this happen.

But this isn’t only a Government responsibility.

It’s something all New Zealanders need to embrace and take ownership of if we want to make a sustainable change in wellbeing for years to come.

In closing, as I reflect on my ten months as Minister of Health, I think it is important to remember just how well we are served by our public health service. We are fortunate to have outstanding, committed people working in our hospitals and in primary care.

Yes, we face challenges tackling inequality and facing up to the implications of an aging and growing population – but I am optimistic for the future of our health services and the health of New Zealanders.

I hope this conference provides you with the chance share ideas, and drive the wellbeing agenda forward.

I wish you all a fulfilling and productive time while you are here.