SUMMARY OF POSITION
1. The state of Māori health, and the inequities between Māori and non-Māori is both a travesty and an emergency. We are at a crisis point; and arguably have been here for some time.
2. The Crown, in the current Waitangi Tribunal’s Health Services and Outcomes Kaupapa Inquiry, has accepted that the status of Māori health is “unacceptable”, it is a “crisis situation” and “it requires a very significant response”. The current status quo is a clear breach of the Crown’s responsibilities pursuant to Te Tiriti o Waitangi – the Treaty of Waitangi.
3. In addition to the inequities in health outcomes between Māori and non-Māori, there is racism within the current Health and Disability System.
4. Urgent and transformative action and change is required to address the status quo. No further time should be provided for the Crown to act; the time is now. The current Government set up an Interim Climate Change Committee (in advance of a Commission) in a matter of months which illustrates the speed at which Governments can move in time of immediate need. The urgency haste is needed for transformational reform in the Health and Disability Sector.
5. Māori must now have more control in all forms of health care for Māori. He Korowai Oranga must be revised, funded appropriately and operationalized through the entire health sector. Well-being must be well-being through a holistic and whanau centered lens.
6. The Crown must acknowledge the overarching system redesign principles that still need to be recognised and provided for:
(a) all components of healthcare system and all service delivery components;
(b) the fundamental question of what is assigned to be part of an integrated approach; and what is assigned to be an area of targeted kaupapa Māori service delivery and;
(c) the State Services Commission and either the Māori-Crown Relations Office or Te Puni Kōkiri commissioning a whole-of-government equity strategy led by Māori (that includes the whole equity-chain).
7. Te Puna Ora o Mataatua (TPOOM) is an interested party in the Waitangi Tribunal’s current Health Services and Outcomes Kaupapa inquiry and is of the view that the Tribunal’s findings will assist the Government to consider the issues it needs to address with respect to the inequities in the Health and Disability system. It will be filing a Statement of Claim shortly, specifically relating to inequities across the Homebased Support Services Sector. TPOOM recommends that the Inquiry, alongside the submissions it receives in this process and through the korero it will hear, examines previous Waitangi Tribunal reports that have examined the state of Māori health and made findings in relation to Crown breaches. In addition to the claims that have been heard, the Inquiry should also review the material that has been filed relatively recently in the current Waitangi Tribunal’s Health Services and Outcomes Kaupapa Inquiry including closing submissions for Stage One.
8. TPOOM supports the Select Committee Inquiry into health inequities for Māori (announced March 2019). It should require the Health and Disability System Review to report to it on its findings and recommendations relating to Māori inequality. It should also require that it consult specifically with Māori before finalising their recommendations in early 2020.
9. There is a need to both act quickly and ensure that the reform that will likely result from the Review is coordinated and cognizant of the directive and helpful material that has previously been undertaken and that is currently before the Waitangi Tribunal on this important kaupapa.
10. TPOOM is a kaupapa Māori health and social service provider based in Whakatane, Eastern Bay of Plenty (in the Mataatua tribal region). Established in 1991 by iwi leaders of nine Mataatua tribes TPOOM actively promotes health and wellbeing for all Māori and non-Māori living and working in the Eastern Bay of Plenty.
11. TPOOM has a staff of 34 FTE and over 400 support workers across the Bay of Plenty. TPOOM services include Primary Healthcare Medical GP Clinic, Homebased Support and ACC services, Social Housing, Whānau Ora Kaiārahi, Children’s Team Lead Professionals, Māmā and Pēpe, Kaumātua Services and Health Promotion. TPOOM also has a Driving Academy and the Health and Population Research Institute. More information on TPOOM is available at our website at www.tpoom.co.nz.
12. TPOOM is interested in the Inquiry at a range of levels but primarily given TPOOM’s role as a kaupapa Māori health and social service provider.
THE STATUS QUO
13. The Crown has recently, in the current Waitangi Tribunal’s Health Services and Outcomes Kaupapa Inquiry, accepted that the status of Māori health is “unacceptable”, it is a “crisis situation” and “it requires a very significant response”. The Crown has also accepted that the primary health care system is not working well for Māori.
14. The following is now also common ground between the Crown and Māori:
(a) Māori continue to experience significantly worse health status at a population level than non-Māori.
(b) At a population level Māori are disproportionately represented in nearly all negative health statistics and low socio-economic factors.
(c) The nature and extent of inequities between Māori and non-Māori is widespread.
(d) Māori have higher levels of unmet need for primary health care.
15. He Korowai Oranga continues to be the Māori Strategy. The current strategy has no associated action plans, and accordingly there is no current action plan for implementing He Korowai Oranga.
16. He Korowai Oranga is the only part of the policy framework that incorporates tikanga Māori and promotes a more holistic approach consonant with the Māori concept of “hauora”. However, without an action plan, He Korowai Oranga struggles to fulfill its potential. It has also failed to support kaupapa Māori models of care that take the very holistic approach that the strategy is intended to promote.
17. Whānau Ora has potential to continue to improve outcomes, including health outcomes in a holistic sense for Māori. However, Whānau Ora is not always viewed as a directly applicable approach in health. This attitude needs to change. Whānau Ora provides both an approach and a lens through which reform of the Health and Disability Sector can be viewed.
THE HEALTH AND SYSTEM DISABILITY REVIEW
18. The Health and Disability System Review Panel has been established to identify opportunities to improve the performance, structure and sustainability of the system in the future, with a key focus on equity. The Panel’s direction that focuses on improving health and wellness outcomes for all New Zealanders and addressing the inequities, particularly for Māori and Pacific peoples low income communities.
We note there is no Māori representation on the Expert Review Panel.
20. The Review is wide-ranging and has the potential to be wide-reaching. TPOOM recommends that this Inquiry require the Review to:
(a) Give effect to the current recommendations of the Waitangi Tribunal in Stage One of the Health Services and Outcomes Kaupapa Inquiry.
(b) Give effect to the recommendations of Māori Affairs Select Committee Inquiry.
21. TPOOM makes the following submission in advance of the finalisation of the report:
(a) Any recommendations in the Review must recognise and provide for the Treaty of Waitangi and its principles.
(b) The principles of the Treaty must guide all aspects of re-design.
(c) Māori must have mana motuhake in the primary health care system.
(d) Whānau Ora is directly relevant to this Review. Whānau Ora must be incorporated into any recommendations and used as a lens, alongside the Treaty principles, for any recommendations.
(e) Hauora (being holistic wellbeing) is intrinsic to Māori health and the Māori primary health system.
(f) The current Māori health strategy, He Korowai, should be operationalized and enabled to work rather than the current situation which sees He Korowai underfunded and without a current action plan. This will require both funding and partnership with Māori to revise the strategy, develop the policy to sit around the strategy and develop the action plans.
(g) Kaupapa Māori models of care must be recognized and valued.
(h) Funding for kaupapa Māori providers must be increased as one practical way to enable mana motuhake for Māori primary health care.
(i) Financial barriers to access primary health care must be removed for Māori.
22. TPOOM agrees with some current commentary, and claimants in the Waitangi Tribunal inquiry, that an independent statutory Hauora Authority is required to ensure that Māori health care is integrated across the entire health system.
KEY OVERARCHING SYSTEM REDESIGN PRINCIPLES
23. Māori must be included in all components of healthcare redesign, including but not limited to:
(a) hospital-based care;
(b) health of older people;
(c) mental health services;
(d) general practices;
(e) service lab testing;
(f) pharmacy; and
(g) general community care.
Language within current inquiries, reviews and tribunal hearings often generalise these sectors, but nevertheless they still commenting on all these service delivery components.
24. The above components are how the BOPDHB divided spend by service for FY18. Language may very between DHBs across the country. Overall, the BOPDHB spends 3.55% of funding on targeted kaupapa Māori contracts.
25. The diagram below illustrates the investment percentage per service area.
26. TPOOM supports the Waitangi Tribunals finding in Stage One of its Inquiry for an independent Health Authority to be established. Māori are and remain entitled to the rights of self-determination and self-development across well-being and healthcare services. For TPOOM, this is set out in our Te Potokomanawa o Te Puna Ora Framework.
Key decisions will shortly need to be made about what parts of our healthcare system need to remain integrated and what parts need to be assigned to a targeted kaupapa Māori service delivery system. For example, we will not be able to duplicate hospital services in a fiscally constrained environment and this needs to be a case of integrated delivery between mainstream and kaupapa Māori. But whatever is assigned between integrated and targeted delivery frameworks, and how Māori and/or the independent Health Authority is involved in each one, needs to be decided amongst Māori.
TPOOM recommends that State Services Commission and either the Māori-Crown Relations Office or Te Puni Kōkiri commission the development of an equity framework, led by Māori, that can be implemented across the whole-of-government. There is often an assumption that equity concerns matters relating to access only; however the whole equity-chain needs to be considered.
Equity components include, but not limited to:
(a) Co-design of policy;
(b) Co-design of funding formulas;
(c) Co-design of service delivery;
(d) Procurement procedures;
(e) Co-design of monitoring, reporting and auditing requirements;
(f) Research and evaluation.
Further to 29(c) above, an equity framework relating to operational service delivery should entrench the following markers (over and above cultural and Treaty matters).
(g) Clinical/Well-being complexity;
(h) Deprivation; and
29. When we consider any government agency, there should be a kaupapa Māori pathway through each internal department or division, to give effect to the principles of the Treaty of Waitangi. This is time sensitive as there are a number of merges across the PHO sector, particularly across the BOPDHB, with Māori providers/whānau been absorbed within non-kaupapa Māori frameworks. This will only be exacerbated as the national conversation around merging DHBs across the country advances.
TPOOM intends to submit a Statement of Claim in Stage 2 of the Waitangi Tribunal Health Services and Outcomes Kaupapa Inquiry.
32. There is a need to both act quickly and ensure that all the Inquiries, Reviews and Tribunal Hearings contribute to a collective and integrated response to Māori healthcare.