A new plan for mental health for the next decade makes for welcome reading. But important questions await, writes community mental health expert Dr Kaaren Mathias.

This week Kia Manawanui was unveiled: a new 10-year plan for mental health. Kia manawanui means to be resolute, steadfast and committed and this “action plan” tries to respond to the 40 or so recommendations for better mental health in Aotearoa, as set out in He Ara Oranga (Pathways to Wellness), almost three years ago. As someone who has been advocating and working for mental health in communities for decades, here are some beacons and some black holes I can see in this action plan.

What’s to like

First, the goals for mental health promise to be grounded in te Tiriti o Waitangi and equity. There is space to engage with the upcoming Māori Health Authority and the new structures in the health system reform. This is core.

Second, it moves from a focus on specialist mental health services to upstream causes of mental ill-health. This will be the only way to increase equity in outcomes. For example, a person who is Māori is likely to experience racism that limits their access to care and if they also have mental health problems and a physical disability they will have more challenges in accessing care and poorer mental health outcomes. We cannot improve mental health without addressing structures of inequity like health messaging that people with disabilities can’t access. Building on this, Kia Manawanui underlines the value of inter-sectoral collaboration, which is central when we know that 80% of health outcomes are determined outside the control of mental health and addiction services. It is great to see policy and practice edging towards mental wellbeing in all policies with an intersectoral approach

Third, the mental wellbeing system is a great concept – it recognises that rugby clubs, knit-and-natter circles at public libraries, community gardens in maraes, churches and mosques that are active in communities – and even Covid-19 vaccination centres – all contribute to mental wellbeing in New Zealand.

Fourth, I am glad that there will be structures in place that may increase accountability of mental health services, with establishment of the Mental Health and Wellbeing Commission as well as the Suicide Prevention Office. 

Fifth, it is great to see an acceptance that some social determinants of wellbeing are much more accessible to people to address for themselves. I am glad to see the reference to the “five ways to wellbeing” as an evidenced based way to feel good and function well. Almost everyone can do something to give, connect, take notice, learn and be active every day. We also can do much more, through health promotion and community development initiatives to support people to be experts in their own wellbeing and how to nurture it.

In effect, this is already the practice in many kaupapa Māori providers. For example, Turanga Health in Tairawhiti provide mental health support and their kaiāwhina  build relationships over many years to provide practical and social support. They will take a client to the supermarket, for a walk on the beach or pick up their relatives from the airport. They help clients move house, sort photos and use Zoom to talk to distant family with Mauri ora as their meta-objective.

What is yet to be answered

Among the questions I will watch for in the coming months and years are these:

Where is mental health promotion and public health in this all?

It’s good to see reference to mental wellbeing promotion and literacy as crucial but it is very worrying to see the small print which implies health promotion is about “programmes” and “educating the population”. This language indicates a very limited understanding of best practice health promotion, which begins with a conversation about meaning and purpose (“What matters to you?”), not a lecture about “what is the matter with you?” (Your alcohol consumption, gambling, etc.)

One of the government’s largest investment in population based mental health promotions in recent years has been the All Right?/Getting Through Together campaign. This has always been funded through disaster/psychosocial funding, yet there are strong arguments for investing long term to build the emotional literacy of all people in Aotearoa. Good emotional literacy is a resource which can protect wellbeing across the lifespan.

A broader shortcoming in the document is that the workforce development focus does not engage with mental health promotion. There is a huge opportunity for the soon-to-be-restructured public health services to engage mental health promotion. The lack of connection to public health in this document is evident elsewhere: we only found one reference to public health, around changing alcohol legislation. Public health is much bigger and much more important to mental health in New Zealand than this.

What are the structures of accountability to the community?

People in communities are best placed to ensure that mental health services are relevant and acceptable. When communities co-produce knowledge, it is more appropriate, responsive and effective in generating change. With engaged and non-hierarchical discussions, community members with lived experience can assess relevance of services or if the funding is used appropriately. We need to develop processes that make us stop and listen to communities and recognise their expertise. How will this new era of mental health ensure that people with lived experience participate in governance, service delivery and evaluation? Without their local knowledge we all fail. Good examples of governance and accountability where service users are front and centre in Aotearoa are found in service user led groups like Balance and MHAPs.

Where is the detail on implementation?

The actions supporting the big-picture objectives are sparse in detail. The risk of this is that measures are not defined and we are walking towards a misty mirage in the distance. Using enablers such as leadership, information, technology and workforce, there are broad actions proposed in the short (2021-23), medium (2023 -27) and long term (2027-31). However, Kia Manawanui actions are broad and hard to measure. For example, a medium term objective is to “to amplify the voices and leadership of Māori with lived experience, whānau and populations with specific cultures and needs”, with the linked action as: “Increase the transparency of collaborative ways of working through reporting and sharing of best practice.” These actions are not Specific, Measurable, Achievable, Relevant or Time-Bound. The bigger question is how will all of us across the motu know whether Kia Manawanui is delivering transformation? 

Is this action plan bold enough for genuine transformation?

This document aligns with recommendations from the new health reforms. It is too broad, however, to tell us how services practically shift their perspective from being a benevolent service-provider with a focus on care to supporting to promoting agency for people with mental health problems. Community development approaches working with peer supporter have been shown to increase agency, recovery and flourishing yet this document does not give sufficient detail about where and how peer support will work. The Mental Health Advocacy and Peer Support network in Ōtautahi Christchurch achieves this through mutual respect and curiosity that is peer-to-peer. Learning is two-way and a peer support worker asks ‘what does this person want or need? how do I support them to live well?’.

Kia Manawanui offers a lot to be optimistic about, and I’d encourage everyone to check it out. I am delighted to say there are many indications that the perspectives of mental health service users and providers have been included. As always, however, the proof will be in the pudding. If we are to take the important steps required to improved and more equitable mental health and wellbeing over the next decade, here’s hoping that Kia Manawanui proves true to its name. 

Dr Kaaren Mathias is senior lecturer in the School of Health Sciences at the University of Canterbury