Māori issues

Disputes over powers of proposed Māori Health Authority

Analysis: In a rare instance of public disagreement on a major review panel, the authors of the Health and Disability System Review could not come to a consensus on the powers of the proposed Māori Health Authority, Marc Daalder reports

A public battle is brewing over what powers a proposed new Māori Health Authority should be granted.

The Heather Simpson-chaired Health and Disability System Review, released on Tuesday morning, calls for an overhaul of the health sector, culling or merging of District Health Boards and the formation of two new health agencies: Health NZ, to oversee the rest of the system, and a Māori Health Authority. 

The Māori agency was one of the key recommendations of a June 2019 report from Wai 2575, the Waitangi Tribunal's inquiry into Māori health outcomes. Details on the proposed authority were limited, but Wai 2575 was considered as part of the Simpson review's examination of Māori health.

Now, Simpson's review has recommended the creation of a Māori Health Authority (MHA), but Simpson and two other panel members dissented from a four-member majority of the panel and the entirety of the Māori Expert Advisory Group (MEAG) in opposing granting the agency commissioning powers.

Internal ructions over commissioning

The debate over commissioning, as one of the only issues the panel could not reach consensus on, will likely characterise much of the discussion as the Government moves to implement the review's findings after the election.

"There was no consensus on the extent to which the Māori Health Authority should control the funding and commissioning of services for Māori," the review states.

In essence, the MHA, as recommended by the review, would be responsible for monitoring Māori health outcomes, managing Māori workforce initiatives, controlling Māori-specific innovation funds and advising Health NZ, the Ministry of Health and the Minister of Health on how to redress inequities in the system.

What the majority of the main panel and the MEAG members called for in an "alternative view" section of the review was a much stronger agency. Their MHA would be in charge of funding, contracting and overseeing health services provided to Māori.

"The equity challenges that Māori face demand more than a clearer mandate for Māori policy development, more than the simple identification of strategy execution failures, and more than the identification of the systematic disadvantaging of Māori and Kaupapa providers by contracting arrangements," the alternative view authors wrote.

"Similarly, the equity challenges demand more than a partnership role for Māori in the commissioning process because, in the worst-case scenario, this would mean that Māori have little more than an advisory role."

Authority and autonomy

Sharon Shea, the chair of the MEAG, says a commissioning MHA would embody rangatiratanga and mana motuhake - Māori authority and Māori autonomy.

"There is a significant global and local evidence to say that universal systems don't suit indigenous people well and persistent inequities in our system, which is predominately a universal system, have contributed to that body of evidence," she said.

"We need to do something differently. We don't need a policy that talks about prioritising Māori and then we don't have structures and systems and leaders in place to actually enable us to effect that change."

Without commissioning powers, the MHA could easily be sidelined into a noisy-but-ignored panel, Shea worries.

"That is a real risk and it's one we felt we needed to point out," she said.

Rhys Jones, a public health physician and senior lecturer in Māori health at the University of Auckland, was even more scathing.

"The NZ health & disability system is racist to the core and complicit in (re)producing health inequities," he said in a statement provided through the Science Media Centre.

"Establishing a new Crown agency, reducing the number of DHBs, and creating a Māori health authority with limited powers is not going to change that. So it seems the review's recommendations will fail to realise the transformation that's needed to achieve equity in our health and disability system. This represents a failure to honour Te Tiriti and give full expression to Indigenous rights."

Simpson defended her position, telling Stuff on Tuesday, "We were reviewing the whole system with an equity lens on it, we were not doing a study simply in Māori health."

Health Minister David Clark said the Government would give both sides a fair hearing as officials worked to implement the report's recommendations. Peeni Henare, the Associate Minister for Health in charge of Māori health, and the Minister for Whānau Ora, told Newsroom that Whānau Ora showed the efficacy of Māori commissioning and that he was eager to ensure the alternative view was considered.

Māori health outcomes deeply inequitable

Both the Waitangi report and an earlier interim report from the Simpson review found massive failings in addressing health inequities between Māori and the general population.

The Tribunal found that, in underfunding primary healthcare for Māori, the Crown had breached the principles of the Treaty of Waitangi.

"The Crown’s failure adequately to amend or replace these funding arrangements for over a decade, in the face of both consistent advice to do so and persisting Māori health inequity, is inconsistent with the duty of good faith and is a breach of the Treaty principles," the Tribunal wrote.

Both reports noted that Māori as a population experience far worse health outcomes than Pākehā.

"More than 80 years after the establishment of our public health system, the health and wellbeing outcomes for Māori are still significantly poorer than for non-Māori New Zealanders," the interim Simpson report stated.

"As a population group, Māori have on average the poorest health status of any ethnic group in New Zealand," the Waitangi Tribunal wrote.

Māori health overhaul called for

In addition to the MHA, the review called for other widespread changes to the way the health system handles Māori.

Alongside the creation of the health authority, the review recommends an update of provisions relating to the Te Tiriti o Waitangi/Treaty of Waitangi in health-related legislation. As it stands, the legislation does not explicitly mandate that te Tiriti principles be applied throughout the entire health system.

DHBs would also be specifically mandated to improve "equity of Māori health outcomes". All Tier 1 service plans would need to incorporate consideration for kaupapa Māori services and the funding formulas for most services would take into account the Māori population "to better reflect unmet needs".

The MHA would also oversee a second major plank of the Māori health reforms - the embedding of mātauranga Māori services within the health sector.

"The Review supports mātauranga Māori being embedded in the health and disability system and that it should recognise the holistic approach to mātauranga Māori towards health and wellness as being more than just a cultural option; it should be an integral part of the system."

This means enhanced funding for the provision of mātauranga Māori and that tikanga Māori applied as a norm in health services and settings for Māori patients, whānau and communities. Such development would be governed by the health authority but also take a bottom-up approach for Tier 1 services, so that specific iwi and hapū could ensure their local system meets their own specific tikanga needs.

Māori-led and -owned health services would also need greater investment in the new system, the review recommends.

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