Are we there yet? The road to the Women’s Health Strategy for Aotearoa New Zealand

Speakers

Angela Meyer, Professor Bev Lawton (ONZM) (Ngāti Porou), Orna McGinn, Erin

Angela Meyer: And welcome everybody. It's lovely to see so many people online. It is my very great pleasure today to be chairing this important discussion. And I just wanted to speak a little bit about the context of this discussion. So in this Are we there yet? series, it connects with the exhibition called Kurawaka, reaching into the red clay, shaping gender justice in Aotearoa, which is on currently at the National Library.

And this exhibition tells how people in Aotearoa, New Zealand have come together to push for gender equity and health. Meanwhile, the fight for gender equity still continues. We've got gender norms, roles, and relations, and gender inequality and inequity. And that is affecting how our health system is run.

We've had the unfortunate experiment at the National Women's health, National Women's Hospital to the postcode lottery around free contraception. And women's health has long been an issue of concern in Aotearoa New Zealand. In July this year, the government will share its first ever women's health strategy for Aotearoa New Zealand. Look, it has taken over 20 years many, many hours of unpaid women's labour. There's been Health Select committees, new legislation, and the deaths of many women to get to this point. But will this really deliver what women need to live healthy lives?

So today on our panel we are going to examine the long road to the Women's Health strategy and what our hopes for the future are. With me on the panel is Dr Orna McGinn who is a GP with an interest in women's health. She's also the chair of Women in Medicine, and she's a university lecturer. We also have Professor Bev Lawton who is a women's health researcher. She's the director of Te Tātai Hauora o Hine, the centre of women's health research in Aotearoa. And Erin Jackson who is one of my colleagues at Project Gender and an incredible campaigner. Welcome you amazing woman. I'm very excited to start our kōrero.

What is a Women’s health strategy?

So Orna, I'd like to begin by asking you. First off, what is a women's health strategy?

Orna McGinn: Kia ora, Angela, it's lovely to be here. I suppose we should say that what a strategy isn't is actually an action plan. So there's a difference between those two things. A strategy is a high level vision for services an aspirational plan, let's just say. So I imagine we'll get into that more as the discussion goes on. But I think we may have to manage our expectations for what is being released in July, because that is when the strategy is being released.

But I think if we are expecting specific commitments to specific outcomes as regards women's health we may be a little underwhelmed. But it is certainly a momentous start. And as you say, it's taken a huge amount of effort to get here because it was not originally part of the Pae Ora legislation.

Looking at the updated health system, there was always a plan for a specific strategy, multi-health strategy, and Disability Strategy. And only after an awful lot of advocacy was there included a women's health, and a rural health strategy. But the Women's Health strategy was not part of the original plan. So we wouldn't be sitting here now if it wasn't for advocacy by the part of people like Erin, and yourself, and health care workers, and women in general.

Why is a women's health strategy important?

Angela Meyer: Thank you. Bev, why is a women's health strategy important?

Bev Lawton: Oh, that's a good question to ask me. Tēnā koutou katoa. Ko Beverly Lawton ahau. Thank you for inviting me, and thank you for all the work you've done to date. I'm a practical person. I'm only saying things that are drivers to change. And the place of a woman's health strategy may be a pathway, and may be something that has actions offered. It may be a blueprint for a driver to change. But it's the first step. And it's a first step. And you put this blueprint that we all agree on it, and then we have to somehow have the will to drive it to change. And I think that's where I see it. I'm not a great one on strategies. I'm more on actionable issues. It can be a simple issue and I make a strategy to achieve it.

So if you look at it the other way as a driver to change then the strategy has got to be an important component-- an important component. But it might just sit on the shelf but I'd be interested to see what other people think.

Activism and advocacy

Angela Meyer: Yeah. Let's hope it doesn't sit on the shelf. Erin, just I'm asking these questions as I suppose part of the kete and for the rest of our discussion. But you have been involved in the activism and the advocacy, and getting this into the legislation. As Orna mentioned, it wasn't going to be part of the Pae Ora legislation. But you've done a lot of work to make this happen. And I was really keen to ask you, how did you go about that advocacy? And why did project gender get involved in the first place?

Erin Jackson: Absolutely. Ko Erin toku ingoa. When you say sit on a shelf, those words just chill my heart. Yes. And I think that's exactly what we don't want to see. And I think, Ange, to your question. I think the first important piece of this is that there's been a huge amount of advocacy over the years. And I want to acknowledge and tautoko the work that has come before us.

Because all of us stand here today on this many people that have campaigned and advocated for women's health over the years. And I particularly refer to-- there were documents put forward that we found, Ange, and back end 2014 in terms of a case for women's health. And the problem fundamentally being we know that woman—wāhine, trans, nonbinary, and intersex people have disproportionately worse health outcomes than their male counterparts.

And so acknowledging that, looking at the Ministry of Health's review of 2020 that comes out loud and clearly. Where we got involved in the work, and I guess where my journey to this piece came from is when we got involved with the 2020 election. And we went out and we said to a woman wāhine trans, non-binary, intersex people, what do you want and need to thrive across the motu?

And the thing that came out in our top 10 recommendations from respondents, over 3,500 people responded. Three of those issues related to health care, in terms of access, in terms of challenges that people were facing. And so I guess from our perspective that was where the conversation was like, well, we started to look around and comparative countries, and who we rank ourselves against and we said, well, hold on a second, what's missing.

And I guess that's really where this piece of advocacy started from, was actually back in 2020. And as I say, building on all of the other work that had come in over the years. But actually saying, well, if we are going to genuinely transform and improve our health care system, surely there's an opportunity to do better. But as Orna says, this women's health strategy wasn't initially included and that's what led to years worth of advocacy, and lobbying and requests for that to be included, and to have it included within the Pae Ora legislation.

Health strategies in other countries

Angela Meyer: Right. Well, thank you. Orna, you talked about-- you've talked about the need for a National Women's health strategy. I'm really interested. And one of the conversations we had at the very start of this process was other countries have a women's health strategy. And I'm really keen to know what are some of the broad things that are included within those strategies in other countries.

Orna McGinn: It's really interesting. And when you look at what has been done abroad, because there is far more than that unites us than divides us, essentially. New Zealand has a tendency to exceptionalism, which can sometimes be really unhelpful. Because we're small. Don't have an awful lot of money or resources to reinvent the wheel.

So when you look abroad at what is contained in other strategies, let's say the Australian, UK, Irish, Canadian, EU, women's health strategies, the themes are nigh on identical. So that says to me that a lot of issues for women, wāhine, trans, and non-binary, and intersex individuals are universal. So we can save some time and energy by looking at what has already been done. So that's one issue. The other really interesting thing looking at the development of a strategy, thinking about what Erin was saying about the length of time it's taken to get here.

Initially, something that a number of us have been working for many years. And initially that was sad, demoralising, depressing, seeing inquiries come and go, and recommendations be listed, and never taken up. But I can actually see now that the conversation over the years has become a lot wider. So that's an advantage. So it's actually less focused just on health and the conversation across all these other strategies in other countries. And now, I hope, in New Zealand is beginning to recognise that the health of women is completely intersected by all the social determinants of health that we know about-- housing, poverty, incarceration, all sorts of things.

And so because the conversation has got wider, I imagine the strategy will be wider because that's certainly what is included abroad. A commitment to prevention. A commitment to addressing the social determinants of health. And those are very, very relevant for New Zealand. I mean, I can talk in a broad-- brush about some of the medical themes if you like as well. Yeah.

Angela Meyer: If you like, yeah.

Maternity care

Orna McGinn: So I mean the things which come up again and again in all the strategies, and they've come up in numerous inquiries in New Zealand. So really we are overdue. These being addressed are maternity, maternity care. Pelvic pain and endometriosis. Mental health. I mean, if we look at some of these things. A lot of these require population health approaches. And they are the absolute baseline for the health of the nation essentially.

I mean our maternity system at the moment is not fit for purpose. We know that. We have a very distressingly high rate of maternal suicide. It's the higher-- it's the biggest cause of death in the antenatal, postnatal period. If you're a Māori wāhine, you're almost three times more likely to die of suicide around the time of pregnancy. This is unacceptable. Rate of perinatal mortality hasn't moved in 15 years.

There is such-- everything is interconnected. So if you address some of these big picture things we will make an enormous difference. And I think the level of discourse up until now has been a little bit limited. I would say a bit disappointing. So I hope that the publication of this strategy leads to a bigger conversation.

Equity for Māori and Pacific womenAngela Meyer: Bev, I'd love to bring you in here. What are you-- do you have anything to add today in terms of the need for this strategy, the current state?

Bev Lawton: Well, I think we need the will to it. I think we're all convinced on the Zoom. But the people with the money, and the people with the will is part of our problem. And obviously the things we're not talking about is the mark in equities, particularly for Māori and Pacific within all of these areas. And unless we tackle them we're not going to have the right result.

I mean, we have had a good result recently. We've got maternal birth injuries on ACC. I mean, you can get good results for wāhine and people that might need it. So we can do single issue, things in that respect. But what you're talking about here is a concerted effort for the well health of wāhine and others that is appropriate to have.

I mean, that's big. That vision is big. But I don't know how much we want to wait around to get some action. And we're going back to the action. What do we think? What do we think? When are we going to get some action on some of these very real issues? We've got 60,000 women having babies every year and there's preventable injury, harm, death for the woman and the babies, and protected from [Māori and Pacific. So there is preventable harm that we need some safe. We need to change the language to-- our system is unsafe others.

Three top priorities for strategy?

Angela Meyer: Bev, just to pick up on that. You talk about being a really practical action-based person, which I absolutely love. Are there like three top priorities that you would really want to see addressed in this strategy that we're going to see in July?

Bev Lawton: Oh, I think I want pick on some of them. But I mean, the obvious thing. Not that I'm vocal on this at the moment is cervical cancer is sitting up there. Let's just get there. That's a low hanging fruit. It's preventable. Why don't we just put a little bit more money. It's cost effective. Let's make that happen. And screening is not funded. Mammography is currently funded, bowel screening is funded. And yet cervical screening isn't. And yet we can prevent cervical cancer through vaccination and testing. So that's obviously one of our focus in our research, a big focus.

And the other one is maternity, preventable harm, and death, and materity for our babies and for our mums. Those are the things that are really important. And the other one that I think is really—a win for women]. And I think I'd like to hear your views. It's more like uterine cancer is on the move. So how do we approach that whole approach of us having that tino rangatira about our-- feeling about our bodies. That manaenhancing feeling. That we have that ability to know that something's gone wrong. And to say that it's all right to go and talk to someone about it.

It's all right to know that that's wrong, and then to get the right service that's mana enhancing, they feel better. So there are some things about us that our bodies that we need to head there-- we need to be able to be encouraged to be able to be supported. That this is well health. And there's some things that we need to be able to be supported. So those are the things apart from that and the access to contraception, of course, which all of those are all about that.

That ability to be able to control your reproductive health. And when something is abnormal and not to have early death. Do you think I should add some more?

Angela Meyer: Yeah. Look, we can--

Orna McGinn: Bev, we could be here all day. I mean--

Bev Lawton: . But the mental health was what Orna mentioned is really important. And I think that's probably under emphasised, isn’t't it?

Policy failure and obesity

Orna McGinn: I completely agree. I mean, Bev, I never disagree with anything you say. But I think what you've articulated there is basically what we are-- what our system is focused on at the moment is actually addressing recurrent policy failures. The whole system is picking up the pieces from policy failure. And this-- so everything needs a reset. A lot of the things that Bev has mentioned there, you can take a whole system approach to it.

Like Bev, you have mentioned endometrial cancer. We have an epidemic of endometrial cancer. I mean, the growth has been exponential over the last 20 years. And that's directly related to obesity. So you pull that back. And you say on a population level, how can the government support healthy living. How can we stop people becoming obese in the first place, which then means you have less endometrial cancer. You have better maternal outcomes.

Because again, a lot of poor maternal outcomes are related to obesity in pregnancy. And we know that women living with obesity give birth to babies who are genetically programmed to be obese. And so we have this cycle that continues. So we really need to-- really-- be a little bit cleverer in the long term in our thinking. So obesity is a massive issue.

Screening. Again, these are low cost, which save money in the long term. The status quo is really expensive. And that's what we're doing. We're focusing on picking up the pieces. So I mean, I'm still gobsmacked that women have to pay for cervical screening. And it's one of the things I vocalised quite early in my career here in New Zealand. And people looked at me like I was crazy, because that's the way it is here.

But I'm sorry, if you lived abroad having to pay for your own cervix to be scraped, I'm sorry, who's going to go along and volunteer $50 for that? Nobody. So this is nonsense and that should be-- and there still is no-- even when the new HPV screening comes in in July, there still is no funding in primary care for that. We have been told to pass the cost to the consumer. This is an absolute disgrace. And it's the same with early—

Structural factors and obesity

Bev Lawton: I'm going to stop, just because it's really important. Sign the petition for free screening by the way. But I'd just like to change your language a little bit. The obesity stuff is very blaming. It's really, really blaming. I think we've got to talk about other structural things that are related to obesity. And money, and being able to buy the right foods, being able to--

Orna McGinn: Totally. That's what I mean by a population health approach. We have to enable people to be able to eat healthily. That's where the policy factors come in.

Bev Lawton: And to be able to have you-- have your heavy bleeding treated. You have access--

Orna McGinn: Totally.

Bev Lawton: --to prevent the uterine cancer. So we've got to get down onto the-- the woman as always in the centre. And the woman is good. This gets in the house mana enhancing say, what can we do? I mean, how can we unravel some why we got here. And because we've got here, because of generations of not having a woman's health strategy. We need a strategy to prevent enable a woman to prevent some of these issues. And then—

Campaigning for a Women’s Health Strategy – system challenges

Angela Meyer: Yeah. I want to pick up on that Bev, because-- and bring Erin into the conversation here. So Erin, as part of the advocacy work that we did as project gender, we heard from a lot of women sharing their story. And just to pick up on that sense of shame or like feeling really anxious about even engaging with the health system, did you want to kind of add anything on that space?

Erin Jackson: I mean, many things. I think--

Angela Mayer: So much.

Erin Jackson: Yeah. So much. We could all be here all day. This is the-- this is the best part. And I think what's really interesting is that the year that we really kicked this piece of mahi off from this piece of advocacy, I think there were 14 different single issue petitions presented to Parliament that same year on female health issues. So it wasn't not just that. But in terms of single issues.

And I think what that really highlighted for us, is we were trying to go out, and we had this petition-- to sign a petition for the strategy. And strategies are not sexy. You say to people, oh, sign this petition. And they are like, all right. OK, cool. And explaining to them what it was actually going to do, Bev, to your point, what's it actually going to do?

And I think the interesting thing-- well, my hope personally is that what it would mean is that we start to look at the life cycles of people differently that is mana enhancing and it helps to build trust within a system. Because what we've heard, time and time, and time again. When you look at all of the studies, and it all stacks up. But what we just heard from was from women, wāhine trans, nonbinary, intersex people who had been let down. Who had been stigmatised, who got shame, who had been misdiagnosed. Just issue after issue.

And because we also know, and I'm careful here, because Orna and Bev are the experts in the space. I am very much not. But what we also know is that issues are related in terms of because I went to the doctor with this issue. And then that didn't happen, and then I couldn't go back there. And I'm the carer for my family. There's this systematic challenges that overlay for people.

And so when we went out and we said tell us about your experience with the health system a couple of years ago. We were overwhelmed. And I mean, we sent 112 pages, I think, in one submission to parliament. And most of those are from stories from people that shared their experiences of the health system with us. And it is-- to be honest, and Ange you've read them. Everyone has read them. They're just galling.

And I know that Bev and Orna you'll hear these every day as well. But I think that for me really highlights just the challenges that we face when we try and go single issue, single issue. And so the opportunity, if we're casting-- I'm an optimist by nature. But if we're saying what we could do with the strategy is to actually say how do we help to systemically create change across the health system. And that's better for everybody.

I just-- and I think when you start to delve into those stories, and start to think about all of the issues, or the challenges that each individual person has faced when they-- for the one thing that they're sharing but actually it was their birth injury that they couldn't get treated, or it was that-- and they lived with it for two years or it just-- all of this-- and what that means for them.

And I think the other interesting thing, Ange, as well is that the other piece of it is this is not just the health care issue as Orna alluded to earlier. This actually then also comes down to how they live their lives, and how they go about their lives, whether it's caring for their whānau. Whether it's working, whether it's-- whatever sense, we are drastically failing women, wāhine], trans, non-binary people at the moment. And we need to do better. So I think that's my hope that we could use this. But—

How do we get there?

Angela Meyer: Yeah. The other thing here is it's sounds like if we're answering the question are we there yet? It certainly sounds like we are not there. But I'm really interested, Bev, actually, what do you think there is?Just--

Bev Lawton: Oh, wow. This took me a minute. Gosh, what does that mean? We would get there. I suppose it's a woman is in her space. She feels secure in herself and her body. She has her well health maximised. She's able to get the care that's appropriate. She's able to get control of her sexual reproductive health if she wishes like all that we're saying about contraception, Can she get the services she needs, and that she's safe. That she's safe. I mean that's part of being healthy too-- to be safe. I missed something. Did I miss something, Orna?

Closing the gap

Orna McGinn: No. I would probably also say one of the things we really need to aim for is trying to close the gap between different populations of women. So one of the reasons I've been told why there was a bit of resistance to having a women's health strategy is that women live longer than men. So why would we need one.

Unfortunately, this is what I about the level of discourse and understanding. Even at the quite high level, maybe even within the Ministry in Te Whatu Ora it's very disappointing, because that is actually where those comments came from. Yes, women live longer than men. They live longer in ill health and disability.

And the other thing to understand is that there is a marked disparity in life expectancy between Māori and Pacific women, and non-Māori, and non-Pacific women. And these are largely due to preventable diseases such as Bev has mentioned-- cervical cancer, also lung cancer, endometrial cancer, preventable diseases. So we really, really need to do better. It's really appalling. As I said, the status quo is expensive.

The other thing we really need to do, and this goes back to what Erin was talking about with advocacy-- is we need to listen better. I'm not sure that the engagement to date on the strategy has really caught the essence of what is going on for women. I mean, the majority of healthcare workers are women as well in this country. So we've seen it on both sides. We've been patient and carer.

So we do try and raise our voices from within the system, because we know that sometimes we have to advocate for our patients because it's very difficult for them to advocate themselves. Other countries have gone through this strategy process have had what they've called radical listening exercises. I'm not sure we've had any radical listening. I'm not sure we've really captured the voices of women.

Radical listening I find a really interesting concept. It's what they used in Ireland. I mean, it's used in conflict resolution situations. It's really digging down into what's being unsaid as well as what is being said. What are the real issues behind the speech. And this is proper research into what's going on. And it's not-- it's not happened. So that does make me a little concerned as to what the strategy will look like.

Because if you don't go looking for problems you probably won't find them.

Accessibility

Angela Meyer: Erin.

Erin Jackson: Sorry you can sense me. And I think-- and I think, absolutely agree, Orna. And I think it's also the thing that we are very worried about is also just meeting communities where they are. And I think-- and I think that's just one of the things that it's very easy for government consultation to become a-- but with the best of intentions, but to become a bit of a tick box exercise, which is a case of-- and I think, we working both in real life and in the online space, you can easily see how you can be accessible to some, but then exclude others. And so you need to then go and sit-in person, and sit and have a kōrero.

There's different ways to doing that. And I think it also takes time. And I know that-- I know that there are challenges in terms of time frames, and budget cycles, and all of those pieces. But I agree. I think that we need-- because it concerns me when we say, well, we were able to re-share the stories in terms of they were on the public record, and say, this is what we can go. But there's more out there that we need to be hearing across the motu about what's happening. Yeah, I agree.

Working with Māori communities

Angela Meyer: Bev, you have done a lot of work in this space, especially working with Māoricommunities. Is there anything that you would like to add to that?

Bev Lawton: I'm thinking about that before. Are we there yet? And I think that well health. And for me as a medical model it's quite hard because you have to challenge yourself out of that negative model, which is a mental health model. One of our pou is to eliminate preventable harm and death. But it's very much like almost like a negative. But we're talking about the opportunities to having well health and to have recognition of yourself as a cultural group, the self of what you want to do. Mātauranga Māori, those all contribute to what health.

And then there's the structural determinants of health, which are really integral to this. And I just had a thought before, probably not the right thought. I've been having those comments from the Ministry-- from ministers actually about men living less-- usually male ministers. And so why are we looking-- actually they say, why are we looking at women's health when men live less. I've had those comments for 30 years.

And we really-- if we can change that, I think that would be very helpful. The part that doesn't recognise woman's other different problems, and we're not going to talk about prostate. So are our barriers, and are actually sincerely are our barriers men, or our barriers to well health women. I mean, what is holding us back?

The power is and the money is with men. Or am I saying the wrong thing here? What structurally is holding us back is there's a lot more women, a lot more Māori in parliament, and yet we can't even get free cervical screening.

What are the complexities of advancing women’s health?

Angela Meyer: It's a really, really good question, Bev. I think we also know, and you know this probably best of all, is that there's so little money and resource put into researching women's health, which again I think makes it very difficult for people to-- everything has to be based on a business case, which actually is kind of counter sometimes to actually a really people-centred health system.

Orna McGinn: It's also the short-termism, Ange. I think New Zealand has a really short election cycle. People have barely warmed the sit before they are preparing for the next election. And when you look at how long it takes anyone in a new role to get to grips with complexity, this is a massive issue. There is a lack of institutional knowledge then that results with a quick turnover.

Health is never a quick win. These are long-term entrenched inequities that we're talking about trying to overcome. And that requires long-term thinking. It also requires complex thinking like the understanding that nothing is isolated. I've drawn a Venn diagram of the different ministries which intersect to affect and empower women's health, and that's-- it's not just the Ministry of Health. It's the Ministry of Justice, Ministry of Social Development, and the mysterious Ministry for Women which-- and I call it mysterious, because I'd like to think that it champions women. But it doesn't appear to champion women's health.

And you would imagine that was part of its remit. Interestingly, I discovered recently that Ireland has a minister for women's health. So they've actually recognised that that's an important policy area which needs its own minister. In our ministry of health, we don't even have a department for women's health.

There's a fragmented approach with people who hold the pen as the term-- hold the pen on different bits of policy which affect women like cervical screening is not looked after by the same team who look after contraception. Not the same teams that look after maternity. Not the same team that look after abortion. Because there's not an integrated and joined up approach. It's no wonder policy sinks like a stone.

Angela Meyer: Erin, I want to ask you about the-- just to go back to the engagement piece, and the advocacy piece. What are your senses around the appetite for a minister for women's health?

Erin Jackson: My optimism doesn't extend that far. I mean, I'd love to see it but I'm actually-- I mean, I'm interested just in saying one of the questions that has come through in terms of the-- which touches on the appetite question. And I think to be honest, I think the appetite for this has been frustrating over the last few years.

And I think we have-- Bev said before in terms of the number of Māori, the number of women, the number of champions that we should have in Parliament at the moment. And there's been a handful to be honest, it is. When the rubber hits the road, it has only been-- there's been a handful of MPs that have been really real champions of this mahi. Obviously, got through in terms of the power to legislation, which was great.

But I remain concerned that we don't have enough people really advocating for this. And I think that extends to a range of other issues that affect women across the motu, not just health. Even though health is obviously-- affects so many different elements. I think, Ange-- I think we-- I mean, there's a whole dismantling the patriarchy question here. So we can set that aside for a second.

But I think that one of the challenges is also is starting to-- is telling this, again, it's us doing the work, which is frustrating. But it's also-- when we talk, for example, about maternity care, it's interesting because when people go through that phase of their life now, it's all of a sudden, it doesn't just become a woman's issue. Because if you have a two-partnered household, the other partner also sees and experiences that as well.

And I think there's power in that storytelling and advocacy in terms of how do we actually help more men, and other people across the community to help champion these issues. And I think there's an opportunity there. And I think I'm personally, I think we've started to see some of that, which Orna, in terms of your comment before about the changing tides, there has been a lot of work of this over the years.

But we are starting to see more understanding that if we are in ill-health we are not at our best and a range of centres. So I think there's more-- there's more to do. And I think there's a comment here around-- the strategy is obviously is due. But I think that there are also layers that sit underneath them. So this is going to be a long-term. I'm going to say fight for us to continue advocating for. And yes, we need more champions. I mean it’s an election. Come on.

Do we need a minister for women’s health?

Angela Meyer: Yeah. Well, let's make an election issue. Erin, also just thinking about the conversation. When we're working on this and working hard to make sure it was part of the Pae Ora legislation, we met with the then minister of health, Minister Little. And I recall him saying something along the lines of-- because I don't have the exact quote. But it's a no brainer. Why wouldn't we have a National Women's health strategy. And it at the time surprised me because he seemed surprised that there wasn't already a women's health strategy.

Erin Jackson: And I think that maybe Ange, that also speaks to what we do is we also have these conversations. And it was literally, as soon as we got Minister Little as the health minister, his support. Then all of a sudden it did feel like the tide really turned, and actually in some ways on reflection of that all that advocacy work. Should we have really got in front of him sooner and said, well, we could have saved ourselves some more, some work.

But I think actually that goes to the point of actually this is an all-of-community conversation. And we need to make it there. And I think sometimes it's easy to say, oh, we'll have this feminist chats over on the side. But actually this is about everyone's health and well-being. So let's bring everyone into the conversation.

Advocacy - Unpaid women’s labour?

Angela Meyer: Just to also think about that advocacy piece a little bit more. And this is a question for all of you. One of the things that I did before this conversation-- asked the Ministry to provide a bit of an update. And the update is that over 700 submissions have been received, engagement with over 51,000 people. I suppose one of the questions that I have is, or I suppose it's a conversation starter really-- is that a lot of this work is done on unpaid women's labour. And I'm really interested in your thoughts about how that might change. Start up a team. Anyone. Anyone.

Orna McGinn: I can tell you why it should change. But I--

Angela Meyer: Tell us why, let us in on it.

Orna McGinn: That's not-- that's not the same as how or if it will. Yeah. Angela, I completely agree with you. This entire body of work has been precipitated by the enthusiasm, energy, and activism of people who are not paid to do it. The submission document that women in medicine submitted we had, including Bev, there were 20 medical experts who in their own time wrote this extensive document. And basically handed it on a plate but all in our own time.

We're all just-- and it's because we feel really strongly about it. And even when we've asked directly would members of expert advisory groups be remunerated for their time. Very hard to get a straight answer. The only answer we're usually given is that well, when we engage we expect that people will be engaging within their usual work roles. Their usual paid work roles.

And so I think that doesn't suggest that they are necessarily looking for different voices who aren't already within the system, which sometimes can be an echo chamber. Because obviously you-- it is more valuable to actually go out and seek voices from people who are underrepresented. But those people are not generally on the payroll of Te Whatu Ora or on the Ministry of Health. So those are my thoughts. Bev, what about you?

Bev Lawton: Paid, unpaid work. They do pay for advisor groups generally. I think that's-- I want to-- I think we should put that top of your list actually, Angy. That there actually needs to be some recognition of the value of the expertise of women to contribute to this. I mean, it's-- I don't know. Advocacy or get action. I'm under the action phase. We're going to get the strategy, and then we're going to do some action. And that's going to cost money. Any change requires resources. If it's individual unpaid, it's still a resource or paid resource. There's still a cost to it though.

Angela Meyer: Yeah. And Erin, any thoughts on that topic?

Erin Jackson: Yeah. Me. Me. And I believe it's about addressing barriers in the sense of actually saying, well, who do we need to hear from, and also what are the barriers that they might not be consulting with us at the moment. And how-- and I said before about meeting communities where they are. Sometimes it's financial. Sometimes it's childcare. Sometimes it's being in person versus like-- it looks different for different communities.

But that does, one, require resources to be willing to understand that. And two, so it might just be a cup of tea and a biscuit. But we're having tamariki being able to play on the floor, and be there in the room and as part of the conversation. And I know, Ange, thinking about other pieces of work that we've done particularly around single mother. That was the game changer for many people being able to participate was that they could bring their little ones along with them.

So I think it is about recognising effort and contribution. And I do believe we should pay for that and pay for expertise, and people are the experts of their own lives. So I do believe, yes, we should contribute in support for that knowledge. And I love to be able to support everyone who'd given us their information, and shared their stories with us. I would love to be able to support them financially, and to recognise their efforts.

And that's the other thing. Is that when these stories have been shared with us, and we know this because we build relationships with these people. They sit down and they write their story about their birth trauma or the time when they had prolapse, or and the shame, and the stigma, and the battles that they had. They relive that trauma. They sit and write it.

Then they have a conversation with me or whoever's at the other end of the social media platform in terms of it. Then they ask follow up. They are engaging in their process. And they're committed to that. And I think that we should-- particularly when we put this in the context of the Women's Health strategy or any strategy, to be fair, we should be actually recognising that level of effort and commitment because they're ultimately doing it so that no one else has to go through what they went through. And I think we should honour that more and more effectively.

Angela Meyer: Yeah. And I think to just sort of summarise in terms of Orna, and Bev, all of our points, really. Is that if we do want to hear from other people we do need to break down those barriers and make it as accessible as possible. And I think also acknowledging that a lot of people do this-- a lot of experts do it for free. But actually if it was any other organisation-- any other I suppose professional capacity you would be charging your hourly rate to be able to provide that expertise. So that's something for the government. We'll just add that to do list. Pay professionals for their time, and also make it accessible.

Making Women’s Health Strategy sustainable

Angela Meyer: The other thing I really wanted to ask about is thinking broadly about one of the things we've heard around the development of the strategy. And this is really for you. ‘Action Bev’, as I like to call you. Is how do we make sure that this Women's Health strategy is sustainable and adaptable over time, and to those changing circumstances that might happen. What hot tips would you have for that space, Bev?

Bev Lawton: Well, you are talking about it being a blueprint. I'm into action. I'm not into strategy. So it should be an action plan. I think it has to have actions associated with the timelines, and it has to be regularly reviewed. It doesn't sit on the shelf gathering dust, which all our guidelines seem to do for our medicine and various things.

So usually when you have a guideline it has to be reviewed every two to three years. So it has a finite renewal period. I think that would be a good suggestion. And then it has to have a score sheet. Just what do we do? How do we achieve it? And somebody needs to be monitoring that. As almost an outsider, how would you recommend that? Almost like they need an independent monitoring on a six-monthly basis.

So I think that's where our target should be almost six monthly, and a three-yearly review sounds not unreasonable. But that has to be funded. And it might be a half review and then a full review at five years.

Angela Meyer: Yeah. Orna, I'm just thinking about in terms of what your expectations for the strategy at this-- that we're hopefully going to see-- well, we are going to see in July. And picking up on Bev’s point about what-- for want of a better word, KPIs, would you like to see in there-- key performance indicators.

Orna McGinn: Well, I think having KPIs is essential. And again, I don't think we're going to have them in this initial strategy because it is going to be really high level. But when an action plan does come out following the strategy at some point you need KPIs in order to build accountability into the process. Because without that it's just more pointless paper that will end up on a shelf.

What they've done a broad when they develop strategies, they've actually specifically ring-fenced funding to address some of the priority areas. I would say that's one of the first things you'd have to do. And the first cabs off the rank would have to be the very, very basic things like fully funding cervical screening. I would say fully funding contraception. They've even done that in Ireland now. This is Ireland where it was even illegal to get contraception within my lifetime. So they fully fund contraception and fully fund your maternity care.

And a lot of doctors still don't know that women have to pay a surcharge for their scans in pregnancy. This is a huge surprise to women when they become pregnant. That there is a surcharge for scans. And the reason for this is that the funding for radiology providers has not increased in 30 years. So it's not greedy radiology providers. It's the fact that the amount of funding has not kept up with the cost and the complexity of scanning.

But all of those things I've mentioned are things which save money to the health service. If you have women being able to do their self-screening for HPV. If you have women who can make their own choices to use effective contraception, if that's what they want without a cost barrier. If you can make sure that women can access maternity care without a cost barrier, you you're going to go a long way towards having a healthier population.

So I would really be very keen to have those built in KPIs. And I'd actually say that they are just basic human rights.

Erin Jackson: I was going to say it doesn't feel like we're reaching for the stars there. [LAUGHTER}

Orna McGinn: I'm afraid-- I'm afraid I agree with you, Erin. I mean, [INAUDIBLE] people going, wow, those things not free? No. So we're setting the bar pretty low I would say.

Angela Meyer: That's the Ministry calling you now saying, OK, we've got the KPI.

Orna McGinn: OK, yeah, no worries we'll get on to that.

[LAUGHTER]

So yeah. I would say, yeah, those are the things that I would go for.

Transparency

Angela Meyer: And in our comments, Judy has said a data and digital dashboard should be available that reveals the KPIs locally, regionally, and nationally. The KPIs need to be transparent and demonstrate accountability to women living in the community. I think that's-- I totally think that's a brilliant idea, Judy. I'm with you on it.

Orna McGinn: Judy, I'm with you as well. Because I would say actually, we know that being accountable to the Ministry doesn't do anything. I've seen the way-- seen the way that figures get massaged or sometimes alternative facts can be presented such that they do not upset people. But if you are accountable to the population that you serve that is more meaningful, I would say.

So that's about transparency, isn't it? And that's about-- that's about women being able to take charge of their own health. If they can see that in their area these important targets are not being met, well, then they can raise their voice. Or I'd like to think that there was an opportunity to do that.

Erin Jackson: I think it also touches beautifully, both the comment, and your remarks, on what we haven't probably gone into as much as we do know is a massive problem, which is the rural-urban divide. And I think that that's just in terms of health care and access. I think that's something that you actually don't realise exists in this country until you know what, I think. And I think that's one of the things that we heard very, very strongly about, just access.

And so to say we're not reaching for the stars, but actually just in terms of access to health care in some cases is prohibitive for women, and particularly when we talk about sexual and reproductive health. Or when they go through the maternity experience, I'll call it-- into navigating health care there. And so I think that that's I love the idea of being accountable locally because actually then it would also empower communities to ask those questions because that's-- I mean, how good would that be as you say, in terms of them holding people to account. Fantastic.

Angela Meyer: Yeah. I’m into it.

Maternity care

Bev Lawton: It's really important. I'd just like to mention that there are some good examples like in WairoaIt was 240k return trip to get a scan. I mean, that's enormous that they've got kids at home from school and various things, very expensive. And until recently, they've now established a scanning service. I mean, just how long did that take? It took a lot of effort.

Now for a lot of people. Now, the British the UK have done a very good example for their maternity service. And we think we should have those transformational goals for mum and pēpē here. And if I could read it out. The maternity care providers came together four years ago. This is what we submitted some of our-- what we wanted to do for the Women's Health strategy. They came together to make maternity care safer by setting a transformational program. And they set targets to halve the rates of stillbirths, neonatal mortality, and maternal mortality, and brain injury by 2025.

They resourced the areas to sit down around the table and make it happen. And they are having progress. As Orna said, we are getting nowhere.

Orna McGinn: Nowhere.

Bev Lawton: Nowhere. 12 years of perinatal mortality, and reported no change. And yet they've done that. They've done that just by sitting-- sitting together, making it well for the top and all the way down. And getting their champions. [INAUDIBLE]

Orna McGinn: I would say by picking up from what you just said about say, champions. What I think is really, really necessary is having some visible strong leadership in this area. Again, what they've done in other countries, they have a very obvious lead for women's health or for the Women's Health strategy. The UK have an ambassador for health who is Dame Lesley Reagan who used to be the chair of the Royal College of obstetricians and gynaecologist.

You just feel that there is a non-partisan person who is the face of this mahi. And I think that's what we don't have here, which leads to this clutching at folk feeling. When you try and speak to somebody who might be accountable or be able to take someone up-- take something up the chain to someone who is accountable, it's very difficult to identify or locate those people.

So I think that would be a very important part of the strategy to have clear and visible leadership which is both clinical and non-clinical. I think clinical leadership is really important. People who are within the system. And then I think people who sit outside the system, having women's voices is really obviously vital as well.

Angela Meyer: One of the things that and asking the Ministry for a bit of an update, they say the strategy will describe a 10 year vision for women's health and well-being, and the system shifts required to get there. So I mean, that's some pretty bold statement. So perhaps maybe in this strategy that we're going to see in July, we will have a level of accountability, and some pretty decent KPIs in there that talk about exactly what those system shifts need to be potentially.

Whole-of-system changes

Orna McGinn: And it is a system. It's actually a whole of system shift. One of the questions that came in was about-- how do we make sure that international medical graduates for instance know our landscape, our health landscape, our cultural landscape. And I'm still on that journey myself. I've only been in New Zealand for 12 years. And New Zealand is very complex and unique. And 42% of our workforce qualified overseas.

So I agree that there needs to be a really strong program of integration so that new doctors really understand Te Tiriti, they really understand the cultural landscape, the inequities and how they've resulted from New Zealand's long and complex history. I mean, in some areas 60% of the doctors working are international medical graduates. That is an issue. And we can't assume therefore that number one, they understand the landscape.

Number two, they've had the education and training in women's health, which is necessary to understand then how to deal with the needs of these women. This is an area which both Bev and I are involved in teaching, and education, and training. And we're still at a stage here where we don't even have a national training system to enable doctors and nurses to fit IUDs.

I mean, again, this is something that I was trying to do 20 years ago in the UK. And we still have an attitude here of number 8 wire and see one, do one, teach one. And it's very hard to get over-- to get over that thinking. Sometimes so the transformational whole of system shift, I think, needs to go right back to how our health workers are educated, and trained as well. So that workforce part is vital to.

Angela Meyer: Bev, do you in the work that you do, and in the research that you do, do you also work with the health workforce?

Bev Lawton: Yes. We do. Obviously, at the moment we're running for the trials. And those clinical trials are through like implementation. And so the health workforce, particularly for HPV, we're talking with cervical screening. We work with the workforce and train them how to do it. And they are the champions of the change, and that informs the new program coming along.

We'd like to say we've got all we want from the new program, but no I should say that we are. It's very hard to change business as usual, and to change a program to be-- to take the opportunities. And we should talk about not the challenges. I've been trying not to talk about challenges, but what are our opportunities. And maybe that's the way to turn the conversation here. The opportunities are to eradicate cervical cancer. The opportunities are a better training system for our clinicians, and that has the same safe training for all.

And I think there are some people who are actually managing that within various parts. And I think [INAUDIBLE] have a really rigorous training that's equal. But there's a lot of areas we need in that. But also we need to have-- take the opportunities because we do know the best practice for many things. We do know that we can do better. So maybe what are our top opportunities of the strategy. I'll get you to answer that , Angie.

What do women want from a health system?

Angela Meyer: Well, look, as not a health care professional at all. But as a user of the services, I would say I think you're right. I think it is a really interesting way to think about it. What if we totally flipped it around and actually did say, OK. Well, here you are as a young woman. A woman intersex non-binary person. And what would be the best way that you could receive health care? What is it that you want? And I think-- I suppose part of this is thinking about that in terms of the engagement strategy. I'm not sure that those questions have been asked. I think it has been from a deficit-based questioning in terms of what has been not good in the health system.

And absolutely, you can get a really good sense of things that need to change. But it is a really great way of framing it, Bev, well what else do you need. Erin, did we-- did you see-- obviously knowing that women are the experts of their own lives. What were some of the things that came through in terms of the pieces from women about what they needed and wanted from a health system?

Erin Jackson: Yeah. Maybe potentially a little bit representative of our age groups that we particularly engaged with. So we'll just put a disclaimer there. I feel like [INAUDIBLE] will be listening. And she'll be on me otherwise, in terms of our communities that we spoke to. But we heard a lot, Orna, reflecting your comments around contraception, sexual reproductive health. It was a hugely challenging for a number of people, and particularly around issues like endo, ] like access to IUDs issues, et cetera. So that was a huge theme there.

Maternity will surprise nobody in terms of all encompassing. And I think what was interesting in terms of literally and I've just seen a couple of comments in there and in the chat as well. And you know right from first trimester challenges whether access to scans, support, midwifery issues, et cetera. Through to then birth injuries and treatment for that.

And I think it's important also to note that for a lot of stories that were shared with us, it was a really long tail to a lot of the issues that people brought out with us. Whether it was endo or a birth injury. In terms of the impact was in the scale of years rather than weeks, and months. And quite a lot around access-- sorry-- awareness and access to support around menopause was something else that came up quite a lot as well.

And so again, I've said before about the life stages. And we very neatly heard clustered around those three key stages. We heard a lot. But then there was also just-- there was a real theme, I think, as well. And this is hard a challenge to address in a strategy. But I think, Bev, thinking about the opportunities. And it was the fear and the distrust that we heard a lot of. Or the feeling of being let down. And that came through a lot in the conversation and in the stories.

And I think that the opportunity there is to think about how we mana enhancing how we empower and support women, wāhine to show up, and to be able to access the health care they need. But then also to be able to get the solutions that they need to their own health as well. So I think that was another key element that we heard.

Angela Meyer: Yeah. And I think there's something about-- I think there's something also about doing that vision setting piece, and maybe this is what we will see in the strategy of maybe the vision might be. Something like New Zealand is the best place to receive the best health care for women, wāhine, trans, intersex, and non-binary in the world.

I mean, if you start it from there then you're going to have to really pull your socks up in lots of different areas. And there'd be lots of funding for you, Bev, for all your research. And Orna, in terms of contraception and women's health. And efficacy would also be funded. Imagine. I want to open it up to some questions. And this is for all of our listeners. People who are watching our kōrero.

Questions and answers

The rise of women’s sports

And one of the questions that has come through in the chat is-- do you think the rise in women's sports, especially at a higher elite level will help acknowledge women's health issues, and hopefully gain more traction? Erin, Orna, do you want to go?

Orna McGill: I was going to say it ties in neatly with what Bev was talking about, which is coming from a health perspective rather than a deficit perspective. It gives seeing some of those amazing sportswomen like Ruby Tui being very visible shows what it's like to live with health. So from that point of view that is, I think, really, really valuable.

Erin Jackson: I think particularly, yes, absolutely, the likes of-- the likes of Ruby Tui. But I think there's also some really powerful conversations happening around disability as well. And particularly women's sport. But then we've also got the rise of some really incredible disability advocates who have been talking about their experiences with the health care system and access.

And I think that's really phenomenal as well because taking a very intersectional approach we know that-- I think it's 25% of New Zealanders have a disability or live with a disability every day. So I think there's a whole piece of the conversation which is-- we're starting to talk more and more about. And I just think that's so powerful. So yes, more of this.

Action plan?

Angela Meyer: One of the other questions is the-- this is from-- sorry. A little concerned that the strategy is nearly written and will go through Parliament soon in order to be finalised by July. What are you expecting? And as an action plan alongside the strategy. I mean, we have talked about that. But I am really interested in what we really-- what are we expecting?

Orna McGill: I might just briefly speak to that. So what I'm expecting is to say something really high level. What I'd really like to see is the acknowledgment that the focus on single modular elements of health is really not how anyone, let alone women live their lives. So we've got a rise. Certainly I'm speaking as a primary care doctor here in complex multi-morbid patients. So that's why the focus that we've had until now on single illnesses is again not very helpful, and it's quite outdated.

And it's one of the reasons, actually, that the Ministry of Health have begun to look at how the proposed strategies intersect, which is a much better way to look at it. To look at Māori health as separate from women's health as is separate from disabled persons health. It's not as useful as looking as Pae Ora overall, and where they intersect.

So I think looking at it, how we address health to prevent people being unwell. How we then acknowledge and look after people who are unwell in lots of different ways is really important. And then I think the other thing that you mentioned earlier, Ange,, well, what do we actually want to see. What does success look like? I think it looks like people being able to access what they need easily, which means not having to see multiple health care workers in multiple places to deal with the issue.

Certainly for a woman if she's able to go to a one stop shop and deal with-- get her smear done and maybe also see her midwife, or maybe her baby's unwell, to bring the baby in as well because there's also a baby's health clinic. So being able to create more opportunities for integrated medicine in the community is a huge opportunity. Because we do have this-- a rural population who cannot travel 200 kilometres to get to secondary care. So we need to enable that as part of the new system as well. And that needs to be worked into all the strategies.

Is health an election issue or humanitarian issue?

Angela Meyer: My other question is-- one of the other questions here is-- I know it's easy to say let's make health an election issue, but is it? Is it an election issue or is it a humanitarian issue? And Erin, I'm going to throw that one to you.

Erin Jackson: I think it's both. I mean, I think-- and that's the thing. We fundamentally-- this is, of course it's a humanitarian issue. And it boggles all of our minds that we sit here, and we're having these conversations around it. But in order to achieve change, we need to make it an election issue. And I think that's where the reality is. Because unfortunately, the machinery of government was made up by lots of really well-meaning well-intentioned people.

We need the leadership from the top to actually drive this change. And I think we have an opportunity, I think, personally, at the moment to really to still make this an election issue. Because we've seen the reforms. And now it's a case of saying what comes next, and where are we going from here. And I'd love to see our MPs really jump on board at this with enthusiasm, and show some leadership, and show some guts to actually commit to this. I mean, I'm optimistic. But come on, tackle health care it's not at all [INAUDIBLE].

Angela Meyer: Yeah, and I mean, and also you could just say there's actually more women than men in this country. There's more women that are equivalent to the city the size of Tauranga. So if it was nothing else, if you put it to any MP's watching or listening. If you actually put women's health at the top of your priority list chances are you're going to win some votes. It's just me being very clinical-- not clinical, just like actually do it.

Has the situation declines in the last decade?

Angela Meyer: The other thing-- we've had a question here from someone who has been working in Australia for the last 10 years. And working in the Health Research sector, and is about to return to New Zealand. And is shocked by the conversation we've been having today on the current situation. But the question is has the situation declined in the last decade? And Bev, to someone who's been working in the system for a few years--

Bev Lawton: Put it that way [LAUGHTER]

Angela Meyer: At least Here in Aotearoa. I'm really interested in hearing your thoughts actually.

Bev Lawton: I think we have very lively conversations more, which is lovely. And we've definitely been single issue. And I think it's really important that when we're talking about what we're still talking about pēpē. We're still talking about whānau, because it's very much a big relationship. And I feel that the wāhine is definitely a cornerstone for all that. It comes around us on the whānau.

So I think things got worse. Well, I know that our perinatal---. I think people would say that our expectation is that our perinatal mortality would have improved, then maybe it has got worse. But others would say that maybe we're holding our own, and that's a good thing. I think we're tending to-- I think we've tended to start to focus on the things that really matter, and we're not othering people. As Māori we get othered the lot. I'd much rather other non-Māori. I'd much rather change the stats to make a strategy totally helpful for Māori, and then everybody else will benefit.

So if we get it right for Māori, then we're changing our access to resources. So I mean, I think our attitudes are getting better. I think there's more openness about that, and people aren't feeling so threatened that we want to improve the health and well-being particularly of Māori the treaty partner. And realize that makes a social and economic benefit to the country. I'm not too sure that answers the question. But I say what I want to say.

Concluding comments

Angela Meyer: Yes. And actually just we've got like two minutes before we wrap up. So I want to give Erin any last request, like a milky bar. But any last request or anything you'd like to say before we wrap up.

Erin Jackson: Yes. I think the success of the strategy. And it's easy to feel like this is just going to be another document. But I think the success of this in getting it to where it's got to, but also where it goes next will actually be everyone continuing to champion and advocate for it, because they feel like that's actually how we've got to the stage. And I believe that for all of the Pae Ora strategies to be fair, not just this one. But in this context.

And I think that takes everybody asking the question of what comes next? Where is the action plan? How are we holding accountable? And continually challenging and questioning where we are with health care because actually I think that's the piece that makes a real difference. That's how we've got to the stage. So my request-- echoing, Bev's. Please sign all of the petitions including the free cervical screening. But as also to make sure that we continue to ask and champion and hold our decision-makers to account because we need to do better. So that's our opportunity and keep questioning

Angela Meyer: Thank you. Orna, one minute. What do you want people-- anything else?

Orna McGill: I think it's good to be tenacious. So I would echo what Erin has said. I think approaching all of-- in this election year, approaching all the leaders of the parties and saying, what are you going to be doing to enhance the health of women in the next Parliament? And if they don’t know that will be a little unfortunate. But I would say we need to keep questioning the leaders and not letting this go.

Angela Meyer: Thank you. And just on that, we didn't even get into breast cancer and breast cancer screening. But the breast Cancer Society have actually developed a really good cheat sheet that sees which party is supportive of what they're asking for as well. So you can check that out as well. I just want to thank everybody so much for your time, via unpaid labor. Thank you very much. I think it's really exciting.

We do have an amazing opportunity here. And I echo everybody's, I suppose, comments here around the need to keep a watchful eye on our decision-makers, on our elected members. And support, but also hold the Ministry of Health in Te Whatu Ora to account to make sure that New Zealand is the country that does have the best health care in the world for women, wāhine], trans, intersex, and non-binary. And frankly, I'm here for that, and I'm pretty sure everyone else is here too. I would love.

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