Lynne Chepulis, Associate Professor, Health Sciences, University of Waikato, Sara Mustafa, Research Fellow in Health Science, University of Waikato
For the tens of thousands of New Zealanders who live with type 2 diabetes, managing the chronic condition can start to feel like keeping score.
A patient is given a list of numbers by their doctor. Blood sugar, blood pressure and cholesterol levels are tracked closely, with targets designed to reduce the risk of complications such as heart attacks, kidney failure, blindness and early death.
In theory, those targets apply equally to everyone. In practice, they are far harder to reach for some New Zealanders than others.
Using health records from more than 57,000 adults with type 2 diabetes, our newly published study found Maori and Pacific people are much less likely than New Zealand Europeans to meet key clinical targets, even when they are seeing a doctor regularly.
The same pattern holds for people living in more deprived neighbourhoods and for many rural patients.
Consider HbA1c (glycated haemoglobin) tests. These measure average blood sugar levels over the past three months. A lower result is better. But fewer than half of all people in the study hit the recommended targets for HbA1c.
Among Maori, just 43% met the targets. Among Pacific people, the rate was lower still, at 36%. By contrast, around one in two Asian and New Zealand European patients were at target. We also found the proportion of people not meeting targets also rises dramatically relative to social deprivation.
These disparities can come with dire consequences. Over time, high blood sugar damages blood vessels and nerves, driving up the risk of amputations.
Maori and Pacific people face these complications earlier and more often than other New Zealanders, often due to being diagnosed much earlier in life. The same pattern shows up for blood pressure and cholesterol, key predictors of strokes and heart attacks.
Clear targets, unequal outcomes
At first glance, they can look like the result of individual choices. A common refrain is that people are simply not trying hard enough. But that explanation doesn’t hold up. It assumes a level playing field, which does not exist.
Most health targets are set as if everyone has easy access to care: a regular doctor, reliable transport and enough income to support healthier choices. But managing diabetes demands more than willpower. It involves regular appointments, blood tests, adjusting medications and building long-term relationships with clinicians.
That may be easy to write into a guideline, but it is much harder if a patient lives far away, can’t get time off work or is juggling transport, childcare and tight budgets.
For patients in rural areas, a routine appointment can mean taking half a day off work and spending hours on the road, along with the cost of fuel. Specialist services are often even further away. With ongoing workforce shortages, continuity of care can be difficult to maintain.
Many patients end up seeing a different doctor or nurse each visit, which makes it hard to build any kind of relationship with the person managing their care. For Maori and Pacific patients, this lack of continuity can compound care that already feels rushed or culturally unsafe.
When people do not feel heard, it becomes harder to stay engaged. Missed appointments are often labelled as “disengagement”, when they are more accurately a reasonable response to a system that does not fit people’s lives.
Newer diabetes medicines that protect the heart and kidneys are now available, but access is not always straightforward. Although these drugs are funded in New Zealand, tight eligibility rules and follow-up requirements mean many people who qualify never receive them.
Others stop taking them because of side effects, cost, or uncertainty about how the medicines are meant to help.
Cost matters, too. Even in a publicly funded system, people still face co-payments for GP visits, prescriptions and transport. For families already stretched by housing and food costs, diabetes care must compete with everything else.
Accordingly, people living in more deprived areas face greater challenges keeping glucose at optimal levels, regardless of motivation.
What the targets are really telling us
Over time, these small frictions accumulate. Blood sugar creeps up, blood pressure stays high, and targets are missed. The system records a “failure”, but that failure is not evenly distributed.
Clinical targets developed under ideal conditions are not neutral when applied universally. They remain useful, but only if there is honesty about what they capture. In practice, they often reflect how well the health system is working.
More equitable diabetes care would look different: seeing patients closer to home, longer appointments and support that includes whanau as well as individuals. It would mean removing cost barriers, ensuring continuity and investing in rural and kaupapa Maori services alongside urban hospitals.
Read this way, diabetes targets become indicators of system performance. Right now, they show where care is accessible and effective – and where inequity persists. Ignoring these signals risks embedding inequity for another generation.
Lynne Chepulis receives funding from the Health Research Council of New Zealand
Sara Mustafa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
