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Illustration: Gabrielle Baker
Illustration: Gabrielle Baker

ĀteaFebruary 4, 2018

Summer health series: more funding or wiser spending?

Guest writer
Illustration: Gabrielle Baker
Illustration: Gabrielle Baker

In part four of our series on the future of Māori health, former Ministry of Health advisor and policy analyst Gabrielle Baker looks at where social investment and health intersect and asks if we’re spending money on the right services.

In previous weeks I’ve talked about equity, inequality and Māori involvement in decision making. These are important foundations for the health system. But for most of us it isn’t what we judge the government’s performance in health by. We want reliable health services that we trust, when we need them. We want health services that work for us.

Minister of health David Clark will be under pressure to trust in health services and professionals to do what they do best. Yet these same services haven’t figured out how to consistently deliver for Māori. So something needs to change.

How are health services doing now?

One indicator health officials use to keep an eye on system performance is ambulatory sensitive hospitalisations. The language is unnecessarily complicated, but it covers a situation where someone wouldn’t have been hospitalised if other health services (like the kind you get from your GP) had worked. The reasons behind going to hospital are varied — there might not have been services available when they were needed, the services may have been inaccessible or unaffordable. Or the quality of the care may have been inadequate.

Whatever the exact causes, we know that for lots of people the system works okay. But time and time again the same population groups are disproportionately hospitalised where it might have been avoided. Mostly it is Māori and Pacific people. Often it is kids with conditions like asthma that should have been better managed in primary care.

Isn’t this about people needing to take better care of themselves? (Spoiler – no it isn’t)

To make sure people are able to get the services they need (so bigger consequences, like being hospitalised, are avoided) we need to look beyond this being the result of individual choice. There are myths like “people choose not to use services that would keep them well”. But we need to challenge this because evidence doesn’t support it. I spoke with Matire Harwood, a South Auckland based GP, researcher and senior lecturer at Auckland University about this in the context of immunisation – the kind of health intervention that can prevent kids from getting sick.

“There is a discourse around Māori refusing to have immunisations which is just not true. When you look at the data you see that Māori kids have their first immunisations. So we are okay with immunisation itself. It’s after three months when the rates drop off, which is when parents go back to work. So you need to think about whether there are problems with the accessibility of services for working parents, for example.”


Maybe it is about having more money for health services?

Labour Party policy is to invest $8 billion in health over the next four years. Primary care, cancer treatment, mental health (particularly community services) and rebuilding Dunedin hospital are all poised to benefit from this cash injection. But just picking areas for investment without understanding how it relates to the overall objectives of the government – that stuff about reducing inequalities – seems unlikely to deliver on what’s been promised.

So it is not surprising the people I spoke to weren’t strong advocates for more funding so much as they were advocating for pro-equity, anti-racist use of health sector resources.

Leanne Te Karu, a prescribing pharmacist who works primarily in Turangi and Papakura, wasn’t wholly convinced that more funding is needed. “What I see is perpetuation of a model that is not premised on equity and hence is an unwise spend.”

Many services aren’t working for Māori but are funded because that’s what we’ve always done. In contrast, programmes that focus specifically on improving the health of Māori might – at best – be able to secure one-off funding.

“I led a project, funded by the Ministry of Health. The funding was to develop and test an approach centred on Māori to build the health literacy of whānau to improve clinical management, especially around medications. The project was very successful. Feedback was that people had never felt so empowered as when they were able to direct their doctor about their condition and medication. The whole community benefits when people are this empowered. Sadly, finding ongoing funding for this type of model has not been possible.”

Matire Harwood also talked about wastage created by services that aren’t working for Māori and the need for accountability. “There needs to be better use of the kinds of levers the health system has.”

I spoke with Sir Matiu Rei a few weeks ago in Porirua. Sir Matiu is the executive director of Ngāti Toa Rangatira, which also runs Ora Toa (one of the country’s four Māori owned Primary Health Organisations). He said something similar:

“Parts of the health sector know they are underperforming – they have the data to show it – but they seem happy for it to stay unknown. [They] don’t want to let it be known how badly the system’s been treating Māori.”

So what would pro-equity, anti-racist investment in services look like? When I asked people what services they would spend money on there were no quick fixes.

We can start by shifting the power to the community

Something you could do immediately is involve Māori in service design. Leanne talked about this too: “How about we ask the community what they want and how it should be delivered? How about we truly engage?”

Some things are already in place and are showing promise. Matire used Whānau Ora as an example of giving people a say in how money is spent to support their needs. “Good examples are coming through from Te Pou Matakana and the Whānau Direct fund where people get to say what their aspirations are. They commit to these aspirations and get creative about how to achieve them. Funding might then be available to help. It could mean buying an exercycle to help a person get fitter and healthier. And it can work.”

Other things are in place too, but the jury is out on how effective they are. A term that has attracted a lot of government interest in the past couple of years is co-design and there is a proliferation of design laboratories and use of experts across the health system.

Co-design seems to cover a range of activity, from stakeholders providing information or stories as part of a design process to help make a service fit for purpose to supportive and sustained partnerships with whānau and communities to effectively address the issues. Or it could mean something in between.

There is room for cynicism. Paula King, a public health physician and clinical research fellow at Otago University, has been looking at co-design in health services and equity for Māori children and young people and their whānau.

“The ‘co’ part of the word co-design is key, Paula says. She points out that it is problematic if a Crown agency gets to set the boundaries unilaterally or control how the information is used, while still calling it co-design.

Paula also notes the irony of the way co-design is evolving. “The very word laboratory sits awkwardly with community. There are significant ethical issues if Crown agencies with a history of structural violence against Māori children and young people (for example abuse of children and people with disabilities in state care) establish laboratories with a focus on children and young people”.

So the uneasy conclusion is there isn’t evidence yet that the haven’t yet got a way for co-design to deliver on equity aims.

The answers aren’t all in the health sector

Leanne Te Karu sees that the answers don’t all lie in health services. “There is no way that I’m fixing people by sitting in a clinic without collaboratively working with other professionals – you can’t just patch people up knowing they are going back to garages as their housing”.

Rhys Jones, a public health physician, senior lecturer and advocate for action that aligns health, environmental and equity goals, sees potential for government to push agencies and sectors to work together to have a bigger impact. “We should be incorporating health and health equity in all policies. I think we’d see a fundamental shift, with agencies working towards the same overarching aim instead of having policy objectives that compete with each other. A good example is the transport sector. If we include considerations about the health and health equity impacts of transport decisions, we’d see funding allocations and transport outcomes looking radically different. We would rapidly move away from our existing system that promotes chronic disease, injuries, climate pollution and inequity, replacing it with healthy, sustainable transport that facilitates equitable access to society’s resources.”

Social investment has been touted as a way to break down the silos between agencies on the basis of data that tells us where to spend. According to Treasury, social investment means using information to better understand the people who need public services and what works for them. But the new minister for social development Carmel Sepuloni has shared concerns about social investment: “We don’t agree with New Zealanders being deemed potential liabilities for the state. With that negative stigma put on New Zealand citizens, with them being deemed potential risks and predictive risk modelling used to assess risk.”

This concern was echoed by Donna Cormack, who splits her time between Auckland and Otago Universities, “We are over-surveilling particular groups of people, to the point we make it look like being Māori predicts risk. Interrogating the data government agencies hold isn’t going to tell us anything we don’t already know at a high level. It doesn’t change our beliefs of who we think deserves our support.”

And this takes us back to the idea that the health system needs to be clear on its values before it can get the services and investment decisions right.

So what does our minister of health need to do?

The health portfolio is huge and David Clark has a task ahead of him in getting services to work more equitably. But luckily, advice is at hand.

More Reading

    David, if you’re reading, here’s what I think you most need to know:

    • The health system is expensive to run, and needs investment, but there is also wastage and money is spent on services that don’t deliver for Māori.
    • Set expectations of equity. Services should be getting the same results for Māori as they are for all other groups.
    • Monitor services, and report on performance by ethnicity. Services that don’t perform for Māori need consequences, including public scrutiny. You also need to be bold and disinvest in mainstream services that aren’t working for Māori – this is what a commitment to equity looks like.
    • Use the mental health inquiry and your focus on improving access to primary care services to showcase meaningful involvement of Māori in service design. Imagine the inroads that would make to a pro-equity, anti-racist system!
    • Look beyond clinical health services and seek out cross-sectoral ‘wins’ – work with your colleagues on health equity in all policies because you will find ways to deliver on the Government’s big statements around “reducing inequalities” if you do.

    The way Māori are treated in the health sector hasn’t happened by accident. Nor are inequitable outcomes the result of individuals choosing to make it hard for the health system. To be honest, I think this point is just that you need to stay woke.

    Maybe the answer is also in investing more in services that are run by Māori owned organisations? Next week I’ll explore this – and its links with the Crown – Māori relationship, so it will be one for David Clark and Kelvin Davis to both keep an eye out for.

    Keep going!
    Image: Auckland Council
    Image: Auckland Council

    ĀteaFebruary 2, 2018

    Why aren’t people listening? Māori scientists on why rāhui are important

    Image: Auckland Council
    Image: Auckland Council

    Why are people ignoring the rāhui on the Waitakere Ranges? Māori researchers Melanie Mark-Shadbolt and Dr James Ataria spoke to a number of kaumatua and kaitiaki around the North Island to discuss what can be done to protect our taonga.

    In a desperate effort to stop the spread of kauri dieback in their forests, local iwi Te Kawarau-a-Maki have placed a rāhui on the Waitakere Forest (Te Wao Nui a Tiriwa). The rāhui, while supported by Māori throughout Aotearoa, much of the Waitakere community, the Tree Council, Forest & Bird, the Independent Māori Statutory Board (IMSB) and Te Tira Whakamātaki The Māori Biosecurity Network, has not received support from the Auckland Council. The council’s Environment and Community Committee chose to reject the rāhui request made by Te Kawarau-a-Maki, deciding instead to close only high-risk and medium-risk tracks.

    So why did the Auckland Council reject the request by Te Kawarau-a-Maki to close the park? Was it because they did not fully understand the concept of a rāhui, or was it because they did not, and do not understand their Treaty obligations?

    In late January we spoke to a number of kaumatua and kaitiaki around the North Island and asked them two questions: what is a rāhui? And, in their opinion, why they thought the rāhui wasn’t supported by the Auckland Council.

    What is a rāhui?

    A rāhui is a form of Māori environmental management utilised by rangatira to modify human behaviour and engagement for the purpose of protecting people and taonga.

    A rāhui encompasses both the physical and metaphysical realms and is often designated as esoteric by Western culture. According to the Māori worldview, people and the environment co-exist, and all things (biotic and abiotic) are part of an interconnected system which harmonises tapu and mana to create ‘balance’. When this system comes under stress or pressure a shift occurs, resulting in nature and/or people moving towards a state of disease and disharmony. Rangatira exercising their right as mana whenua and kaitiaki consider the impacts and employ appropriate measures, like rāhui, to restrict human behaviour and activity. This restriction allows nature time to re-establish balance, or its natural or desired state.

    A rāhui may be placed on forests, gardens, food gathering areas, rivers, lakes or the sea, and may be placed for a variety of reasons such as claiming ownership, respecting the site of a recent death, the need to replenish food stocks or resources in an area, or to prevent the risk or spread of disease. For example, a rāhui was placed on the taking of seafood in areas that may have been contaminated by oil spilled from the Rena.

    The power of a rāhui comes from the mana of the person or group that impose it. For that reason, rāhui can only exist under the mantle of the mana whenua, whose cultural authority as rangatira and kaitiaki affords them power over place and people, and the authority to restrict access in the protection of people, place and nature, until such time that balance is reached or the risks have been mitigated. Pre-colonisation, the infringement of a rāhui could be considered sufficient enough to give rise to war between tribes, or was punishable by death.

    We met with Kuia Moana Nui Aukiwa Wood (Ngātirua) in Kaeo and she told us: “Rāhui should be seen as a traditional ‘management system’ for managing the environment. Because rāhui considers physical and metaphysical, or spiritual realms, our systems are often viewed as ‘hocus pocus’ ceremonies that are of little use or importance in protecting our environment.”

    However evidence supports the practice of rāhui as a method for controlling human behaviour and allowing nature time to recover. Te Rarawa chair Haami Piripi said that “we have personally seen the evidence for this in Ahipara” where a rāhui was placed to protect marine food stocks. He noted that monitoring has revealed “explosive growth” in paua stocks. Similarly, a rāhui in Karekare in Waitakere in 1993 saw the shellfish recover completely. He also said the power of a rāhui comes from its tapu (sacred) nature and the fear of the consequences for breaching it.

    Why wasn’t the rāhui supported by Auckland Council?

    The decision to oppose the rāhui is well documented, commercial interests and an inability to monitor and enforce compliance being some of the reasons given. However, in the minds of some Māori, the decision seems more likely to be one of cultural arrogance than practicality. The fact that Māori are both tangata whenua and New Zealand citizens is often not recognised or appreciated when it comes to the management of our natural resources. The decision to not support the rāhui can be viewed as evidence that Māori practices of environmental management are not seen as equal to those that come from non-Māori New Zealanders.

    Additionally the decision goes against several pieces of legislation, including the RMA, which require local government to take into account the principles of the Treaty of Waitangi, and to recognise and provide for the particular role of iwi as kaitiaki or guardians of their natural resources. That means the council as a Treaty partner is expected to protect not only the kauri forests, but also Te Kawarau a Maki as the kaitiaki of those forests. Here the council has failed to recognise and meet its obligations under the Treaty, and legislation, by not supporting the rāhui or the decision made by Te Kawarau a Maki.

    This now-deleted tweet shows that people are choosing to ignore the mana of the rāhui. Some businesses such as bike tours also continue to operate in Waitakere forest.

    Furthermore the decision to not enforce the rāhui, despite the council’s website saying it supports the principles of the rāhui, has not only frustrated Māori but confused visitors to the ranges, and once again revealed the true state of the relationship between Māori people, and those that have assumed authority over our land and people (in this case Auckland Council).

    In our own land, Māori leadership with its limited social and political authority, has now being displaced through the ignorant erosion of our cultural authority. The lack of public outcry exposes the apathy prevalent in the community to Māori culture and authority – an attitude that was summarised nicely by a couple quoted in the NZ Herald: “We are Europeans, so we will listen and respect the final word of those who have the power to shut or leave the tracks open.” Te Kawarau-a-Maki, as the council’s partner, do have the power to shut the tracks and have done so.

    In a country that exalts and promotes its bicultural roots with its indigenous peoples and the rhetoric of ‘partnership,’ Māori can only marvel at the ignorance and inherent racism exhibited by Auckland Council members and their inability or desire to give effect to their Treaty of Waitangi obligations.

    So while the action taken by the council has drawn attention to the meaning of rāhui, the focus on the rāhui itself is overshadowed by a much more ominous realisation: that in this millennium, Māori culture is still not understood, not valued and not recognised. And for that reason we most likely will see the extinction of kauri within our lifetime.

    Ātea