The Health and Disability System Review released this week nearly gets it right but it still sets us up to fail, writes consultant and health advocate Gabrielle Baker.

If you like reading long reports about the health and disability system, Tuesday was your day. The long-awaited, highly-anticipated, Health and Disability System Review was finally released and we all got to see what the big deal was. There were numerous big deals of course, but for me, the proposals for a Māori health authority were the biggest deal of all.

The health and disability system’s failings are obvious. There are marked, persistent, inequities between Māori and non-Māori, which are well known and demonstrated in Ministry of Health and District Health Board data. The causes of these unjust differences are complex, for sure, but colonisation, racism, ableism, and a health system that is designed to work for only some of us all play their parts.

The health and disability system review panel has not shied away from the problems of a system that does not meet its Treaty obligations. In fact, much of thinking around Māori health in this report seems to mirror what claimants said to the Waitangi Tribunal in 2018 and the Tribunal’s own findings the following year. But the recommended solution to much of these issues is to create a Māori entity in the Crown’s own image, in a way that looks paternalistic and is probably setting up the Māori health authority to fail.

Would a Māori health authority work?

A Māori health authority could be successful, but not in the way the health and disability review has recommended.

What is recommended in the main part of the review report is really a repackaging of the status quo. A bunch of things that the Ministry of Health already does would be moved to a different agency but not much else changes. I know there is nuance to this, and the DHB recommendations, the introduction of a new Health NZ entity with 50/50 Māori/non-Māori governance and changes to funding formulas might all feel like more than re-packaged status quo. But if the same minister is still in charge with the same ultimate decision making role, I am not sure it is the once-in-a-generation change we were promised.

The other and perhaps more fundamental issue likely to thwart the authority’s success is that it is expected to do one of the hardest jobs in the health sector – combat institutional racism – without being designed in an anti-racist way. And I know the design process wasn’t anti-racist because literally every Māori advisor to the project recommended a different set of functions for the Māori health authority, but these were relegated to being an alternative view, buried in the depths of the report.

The scope of the authority would also be too narrow to make the kind of impact it needs to. Partly this issue stems from the issues faced by all health sector agencies – so much of what drives the inequities in health sit outside the health and disability sector. To be effective, there need to be ways to influence the critical things that keep us well, such as good quality, warm housing, universal basic incomes, education and so on.

However, some of the narrowness comes about because the authority would not actually be able to purchase kaupapa Māori health services. It can only advise and influence the groups with the actual funding. This recommendation, which was not accepted by the majority of the panel but still makes its way to the final report, seems based on the idea that you could not possibly have more than one agency purchasing services because it would create multiple health systems. But that is dangerously romanticising the status quo. Firstly the idea that one-size-fits-all is one that we know doesn’t work. And secondly, there are already multiple arrangements in place in the health and disability sector. ACC is a classic example, where people who need support because of an injury are part of a different system to people who need disability support.

Does it give effect to Te Tiriti o Waitangi obligations at least?

Yeah, nah.

There is a lot of discussion about the Treaty which is, of course, necessary and therefore good to see. But it lacks credibility. For example, there are grounds to worry about the way the report talks about Māori knowledge and inherently Māori concepts.

The report says that the Māori health authority should develop and implement policy on mātauranga Māori and that mātuaranga Māori should be embedded into all health and disability services. But remember, this Māori health authority is a government departmental agency with direct accountability to the Minister of Health. It isn’t a Māori entity. If the idea of the Crown deciding what parts of Māori culture and knowledge are valid and who has access to this knowledge sounds familiar, it’s because it is the basis of colonisation. And while that might sound like drawing a long bow, remember that all the Māori advisors to the review wanted a different set of recommendations and their views were disregarded.

But the decisions haven’t been made yet, so these problems could be fixed, right?

There is clearly still an opportunity to shape final decisions on the health and disability system review, but this has to be done in partnership with Māori and in line with the Waitangi Tribunal’s 2019 Hauora report. And because the health and disability review panel didn’t quite get it right in this regard, there is now heightened expectation on the Crown to act as a good Treaty partner and ensure robust engagement before deciding on system change that, if it goes well, is pro-equity, anti-racist, and gives expression to mana motukahe in health