Proposed Pharmac changes to diabetes medicines are facing growing criticism from Māori health leaders and clinicians, who warn that removing ethnicity-based access criteria could deepen already entrenched health inequities for Māori and Pacific communities.
Pharmac has opened consultation on proposed changes to the Special Authority criteria for several type 2 diabetes medicines, including empagliflozin, liraglutide and dulaglutide.
Under the proposal, the cardiovascular risk threshold required to access the medicines would be lowered from a five-year risk of 15 per cent to 10 per cent.
The proposal, however, would also remove the current eligibility pathway allowing Māori and Pacific patients to access the medicines without needing to demonstrate specific cardiovascular or renal complications.
Associate Health Minister David Seymour and Health Minister Simeon Brown say the proposal would widen access and ensure treatment is based on “clinical need, rather than ethnicity”.
“Ethnicity shouldn’t decide what funded options you can access to manage type 2 diabetes,” Seymour said.
“If approved, Pharmac estimates that around 10,000 more people could benefit in the first year, increasing to around 23,000 people after five years.”
But Māori health organisations, pharmacists and diabetes experts say the changes risk dismantling one of the few targeted equity measures introduced to address longstanding disparities in chronic disease outcomes for Māori and Pacific peoples.
Te Tiratū, one of the country’s largest Iwi Māori Partnership Boards representing more than 121,000 Māori, says the proposal could reverse years of progress aimed at improving access to life-saving medicines.
Te Tiratū co-chair, Glen Tupuhi, said Māori continue to experience significantly higher rates of diabetes, cardiovascular disease and chronic kidney disease, while also facing persistent barriers to accessing treatment.
“These medicines save lives and prevent devastating complications for whānau,” Tupuhi said.
“Māori are diagnosed younger, become sicker earlier, and die sooner from preventable chronic illnesses.
“Equity pathways exist because the health system has not delivered equitable outcomes for Māori.” he said.
‘You just have to look in our urupā to see the impact’
Associate Professor Dr Ryan Paul, clinician and expert technical advisor to Te Tiratū, said he was “really gutted” by the proposal, particularly given the success of the current pathway.
“We fought to get it across the line, how welcomed it was by all the medical community and more importantly how successful it’s actually shown to be,” Paul said.
Paul said the ethnicity criterion was one of five pathways enabling access to the medicines, but unlike the others, it helped overcome systemic barriers Māori and Pacific patients often faced within the health system.
“The other criteria require other tests to be done and frequent visits. We know how hard that can be for our Māori, but also just within the health system, that’s not done for Māori as much as done for non-Māori,” he said.
“So all of a sudden, what the ethnicity criteria did is it overcame those systemic barriers to accessing medications, which is likely why the ethnicity criterion was so successful [in] eliminating disparities in access to care.”
The current ethnicity-based criteria were introduced in 2021 following advocacy from Māori clinicians and researchers who argued Māori and Pacific patients were significantly less likely to receive newer diabetes medicines despite carrying a higher burden of disease.
Dr Paul said Māori and Pacific peoples were two to three times more likely to develop type 2 diabetes, suffer complications and die from the condition.
“We actually showed from our research that it reduced mortality in high-risk Māori and Pacific by fourfold,” he said.
“That’s why we need to be fighting this because it was actually one of the most successful interventions we’ve ever done for equitable care in Aotearoa.”
Diabetes Foundation Aotearoa chair Dr John Baker described the proposal as “a great leap backwards”, arguing the changes would make it harder for the communities most affected by diabetes to access treatment.
Research following the introduction of the equity pathway in South Auckland showed a significant increase in prescriptions for Pacific patients after the criteria were eased.
“It worked. And now they’re reversing it,” Baker said.
“The likely outcome of this is that the European worried well who go to the doctor most often and complain the most will continue to get the medicines, and those who don’t go to the doctors and who are really sick don’t get it.”
Paul said while wider access to the medicines was welcome, the proposed replacement criteria could still create barriers for Māori and Pacific communities.
“For those people to have a high cardiovascular risk over 10 per cent, often it may actually be too late to prevent loss of health or from a complication burden from their diabetes,” he said.
“But more importantly, we know that Māori and Pacific people do not have as many cardiovascular risk assessments as non-Māori. So as a result, once again introducing a barrier to care, which we know will cause inequity in outcomes.”
Te Tiratū and Māori pharmacists are also raising concerns about whether the proposal aligns with Pharmac’s Te Tiriti o Waitangi obligations.
Associate Professor Leanne Te Karu, a claimant in the Waitangi Tribunal Health Services and Outcomes Inquiry, said restricting equitable access risks worsening what has previously been described as “prescription inequity” within the health system.
Her research references the “missing million prescriptions” analysis, which highlighted the scale of inequitable prescribing experienced by Māori relative to health need.
“Restricting equitable access to SGLT2 inhibitors and GLP-1 medicines risks widening the very inequities the health system has acknowledged for years,” Te Karu said.
Meanwhile, Ngā Kaitiaki o te Puna Rongoā o Aotearoa, the Māori Pharmacists’ Association, says equity measures should not be removed before equitable outcomes are achieved.
Tumuaki Mariana Hudson said universal thresholds may appear fair on paper, but Māori do not experience the health system in the same way as other populations.
“I would strongly encourage Pharmac to undertake and publicly share robust Māori-specific equity impact analysis before progressing these changes,” Hudson said.
‘Need over race’ - Seymour
“People should be getting medicines based on their need rather than their race,” Seymour told Te Ao Māori News when asked about Māori health leaders concerns.
“No matter what your ethnic background, if you have the markers of need, then you will get access.”
Seymour said decisions should focus on the underlying risk factors.
“Sometimes you will find, for example, that because the Māori population is younger there’ll be greater need for a disease that hits people when they’re younger,” he said.
“However, the right way to do that is just give it to all young people, then you’ll catch Māori too.” Seymour said.
The consultation closes on May 28.
