L-R David Tipene-Leach, Rawiri Jansen, Janice Kuka, Matire Harwood, Donna Cormack. Illustration: Gabrielle Baker

How to get the most from Māori health providers

What lies beyond the new Labour government’s ‘first 100 days’ for health policy and outcomes for Māori? In part five of our series on the future of Māori health, former Ministry of Health advisor and policy analyst Gabrielle Baker looks at what we should expect from Māori health providers and how to get them where they need to be.

I was asked in a meeting once why Māori health providers are funded if they haven’t fixed inequalities. I wish I could say this was tongue and cheek, or that I haven’t been asked any other version of this question. But I have lost count of the times I’ve been asked why Māori providers aren’t meeting higher standards than we expect of mainstream providers. Because of this I didn’t want to talk about Māori or kaupapa services too early in this series — I wanted to leave it until we had looked at other parts of the health system.

The other reason I left the discussion on Māori providers until now is figuring out how to better support Māori providers naturally raises questions about the environment in which Māori providers operate. For Māori providers to really thrive the underlying Crown-Māori relationship also needs to be thriving, and the health of this relationship often benefits from public scrutiny around Waitangi Day.

Let’s go back to March ‘94…

Recently I reached true policy nerd status, spending time at the Alexander Turnbull Library in Wellington reading Te Ara Ahu Whakamua, the proceedings of the Māori Health Decade Hui of March 1994. This is a time capsule of presentations and discussions from when a different government was bringing in health reforms. It was evidently a time when there was optimism about developing the relationship between Māori and the Crown and what the next 25 years would bring.

The then-government was focused on individual responsibility and commercialising health, and minister of health Jenny Shipley said outlandish things about the need for Māori to take responsibility for their side of the partnership because “the Crown will deliver”. But in spite of this there are still lessons for today.

When it came to Māori providers delivering health services there was plenty of advice about how they could better seize opportunities. Among all of the advice to Māori providers one of the interesting transcripts came from John Tamihere, who was presenting for Te Whānau o Waipareira Trust. “We are very good service providers and we can provide services in the most competitive, cost efficient and effective manner. Procedural fairness that valued order over justice meant that there wasn’t an even playing field and there needed to be will to have equality of opportunity in the first place.”

Some of the language of 1994, particularly around equality of opportunity, is dated but what John Tamihere said resonates.

Getting the conditions right for Māori health providers

Donna Cormack talked about this with me recently. “Kaupapa services are put into an existing system and expected to fix its problems. They do a lot, but the systems constrain them and don’t allow them to fully realise their ambitions. Fixing this means a genuine commitment to disrupting the colonial system that maintains inequity.” This will also mean more investment so that Māori providers can make the kind of difference the health sector needs.

Investment is a sore point though. Ministry of Health figures, available here show funding to Māori health providers increased by $14.4 million between 2011/12 and 2015/16. Which sounds like a lot. But when you put it in the context of the total amount of government health funding, funding to Māori health providers has failed to keep pace with other increases.

Janice Kuka of Ngā Mataapuna Oranga, a health provider and Primary Health Organisation in Tauranga, told me providers are disillusioned by how funders, like district health boards and the Ministry of Health, have been treating them over the past five years. What Janice described sounded eerily like a return to 1994. “Funders are starting to pull back roles that we got in the 80s and are starting to make decisions for providers again” – signalling that some of the gains that were made in the late 90s and early 2000 to invest in provider capacity and capability haven’t been sustained. Janice, like Donna, sees this as linking back to Māori health providers operating in a health system that is still driven by a Pākehā world view, where providers are seen as being the sum total of their contracts not as a critical partner and contributor to the health system.

But you still want providers to perform though, surely?

No one is arguing Māori health providers should be funded indefinitely if they don’t meet performance requirements.

Matire Harwood put it this way: “Māori providers are not there by right to get a service contract. To me this is confusing the different roles we play. No provider should just get money without demonstrating that they’re doing what they should be. But Māori providers should be an option for people. To make this happen, funders like DHBs and the Ministry of Health need to be supporting them to provide quality services.”

This need is not just driven by the fact Māori providers have resources we want to use, or that Māori want more culturally appropriate services (although both statements are true). Part of what drives the need to foster Māori providers is the health sector’s guiding legislation, which tells us Parliament expects there to be Māori involved in service delivery in order to give effect to the principles of the Treaty of Waitangi. Without strong Māori health providers, holding decent service contracts, it’s difficult to see how a DHB chief executive could put their hand on their heart and say they are meeting this obligation.

Taking immediate steps to support Māori health providers

Something that the government could do in the short term is strengthen the Ministry of Health’s Māori provider development scheme. It may also be a relic of the 1990s but it is still needed, in some form, today. To anticipate the concerns I have heard in the past, we can’t let devotion to procedural fairness trick us into thinking that this kind of fund is a product of (non-existent) Māori privilege when the way the system operates is already exceedingly fair to mainstream providers. Strengthening the scheme might include more money, and it will definitely include taking a more strategic look at how the health system can work with Māori health providers to get better outcomes.

Funding Māori programmes that have been shown to work is also a way the government can act immediately. When I sent a previous week’s article to David Tipene-Leach, Chair of Te Ohu Rata o Aotearoa (the organisation that represents Māori medical students and doctors) and member of the recently established Ministerial Advisory Group on the Health System, he reminded me that as well as change at system level there needs to be support for programmes that demonstrate success. There are examples for funders and providers that show equitable outcomes can indeed be achieved. There are programmes like Te Kūwatawata in Tairawhiti, which is a response to mental health and addiction distress grounded in mātauranga māori, that show promise and should get more support. “With such examples one would want to inculcate the thinking that inequitable outcomes are simply unacceptable.”

There are a bunch of examples here, like the health literacy and medications management programme Leanne Te Karu talked about last week, but they usually struggle to find sustainable funding.

Māori providers will also be stronger if funders like DHBs become better at their business too. Some of this the new government could control by setting parameters for contracts, increasing the amount of funding for services in line with community need, and setting expectations that DHBs include Māori health providers in district-wide annual planning. But the real change that’s needed is to the relationship between providers and funders. A better relationship will require Māori involvement in DHB decision making at every level, funding decisions to be based on a commitment to equity for Māori, and for funders to leave behind their biases for maintenance of the status quo (and their fear of rocking the boat too much).

Maintaining the status quo will never get us there

To get to a better relationship between Māori health providers and their current funders the health system needs to shift to something new. And there are a range of ideas about how the shift can happen. From where I stand, these suggestions seem underpinned by a view that the Crown-Māori relationship needs to evolve. One way it might evolve is for the government to hand over power and resources to establish a Māori health commission.

This suggestion has come up in the context of Waitangi Tribunal claims before, and something like it was discussed in 1994 too, so it is not new. But there is renewed enthusiasm for it. I spoke with Rawiri Jansen, an Auckland based GP and clinical director, about what a commission might do. While a commission could follow the model of being a watchdog (for example the health and disability commissioner) or the model of purchasing services – like the Whānau Ora Commissioning agencies – Rawiri saw it as doing something more.

“Think of something more fundamental, like ACC or PHARMAC. These are the kinds models we should be looking at. How did they start off? In the case of ACC it was a response to a big problem that led to a Royal Commission looking into workers compensation. Today the failure of the health system for Māori is also a big problem. An agency that has responsibility for purchasing all health services for Māori — including hospital level services — sounds like the beginning of an answer worth exploring”.

You might think this is a separate health system and therefore messy and unmanageable. But Donna Cormack pointed out to me that we already have separate health systems. Around a third of New Zealand adults have private health insurance, and the health system has been able to keep doing its business. Why would another system not be able to operate too?

The biggest challenge a Māori health commission brings is not how it would work on a day to day basis — as hard as it will be, we know how to buy services, set eligibility criteria and build hospitals — but how its establishment would reflect an evolved Crown-Māori relationship.

The signal the government sends by having a Crown and Māori relationship portfolio separate from the Treaty negotiations portfolio is that they are ready for the evolution. The new portfolio looks to distinguish the redress of past wrongs from the opportunity to improve how the business of government is done to better reflect the Treaty and its principles.

Doing better will mean having broader conversation with Māori about how the relationship will work to advance health outcomes and services. For Māori, there is an opportunity to celebrate and share what Professor Sir Mason Durie talked about at the 1994 hui – diverse Māori realities. Iwi will be involved (unquestionably) but you’d expect to see others here too (more Māori women and young people for example).

For the Crown it is an opportunity to look beyond the Office of Treaty Settlements. And it is a challenge for the Crown too, who will face criticism if it does anything too ‘disruptive’. Papaarangi Reid in 1994 questioned whether, even if the Crown wanted to be a better Treaty partner, there would be “political will to tempt the white backlash that might arise if it were to meet its obligations”. I have those same questions now. But I am cautiously optimistic after Waiting Day that this government is ready to be bolder than its predecessor.

The first step for the evolved relationship isn’t immediately obvious to me, but I don’t think that is a bad thing. A relationship’s parameters aren’t decided by one party alone – they’re worked out together. And I know I said this three weeks ago, but the Waitangi Tribunal’s Kaupapa Inquiry into health could provide the push that we need to start moving.

Next week: I will bring together the various threads we have covered in the past month or so. In particular I will revisit the question of what a pro-equity, anti-racist health system would look like, because when it comes down to it spending weeks talking to Māori health experts has led me to see this as the fundamental question for the Minister of Health and the associate health Ministers.

Read the rest of this series here.

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