Key Issues for Consideration in Developing Maori Health

• Introduction
• Some Key Issues
• Maori Health: Where are Maori Making a Difference?
• Improvement in Maori Health
• Maori Health Priorities: Alcohol Misuse and Mental Health
• The Coalition Health Agreement and its Proposed Implementation
• New Funding Agency: The THA
• Maori Health Research
• Health Promotion and Health Messages
• Conclusion
• References

Introduction

This paper aims to provide an insight into Maori health issues and to consider the contribution of Maori involvement in the health sector in New Zealand. The paper also addresses common questions being considered by Maori health providers, Maori communities, Maori and non-Maori health decision makers, and politicians.

Some Key Issues

Maori health providers are currently considered some of the most innovative health providers in New Zealand as they are creating change throughout the health sector. However, as Maori providers have had to struggle to be recognised in order to obtain health resources, they have often had to provide a service at a lower cost than other providers.

As Maori are now being recognised as legitimate health providers, as part of the health reforms, there is a need for Maori to define the unique features of Maori service delivery rather than follow the provision of health care model often provided by so-called "mainstream" health providers.

Furthermore, in providing a health service from a kaupapa Maori perspective the full cost of providing such a service now needs to be recognised.

This is an issue which is being grappled with, for example, in the provision of Maori mental health services where an attempt is being made to identify the full costs associated with providing care, reuniting clients with their whanau, involving whanau in client care, and, if appropriate, taking clients home to their tribal area. Undertaking hui, showing of manaakitanga and organising programmes which rebuild and strengthen the cultural identity of Maori clients all carry significant costs.

The setting of appropriate Maori benchmarks for care is important, for if Maori providers continue to be successful, their low cost of service delivery may become the benchmark for "mainstream" providers. This development has occurred to some extent already in early childhood education. The kohanga reo movement, for example, has provided a model of early childhood care and a benchmark for the price for all other forms of early childhood education.

One of the major issues that Maori providers face in the future is whether they can continue to provide sustainable health care in accordance with Maori expectations and accepted Maori and non-Maori standards.

Many Maori providers are providing health services at a great personal cost to themselves and without recognition of the real costs involved including financial, capital, and workforce development costs. Without recognition of the full cost involved, Maori providers and hence health workers face burnout in the near future.  ¹  

Maori Health: Where are Maori Making a Difference?

Maori are making considerable progress in becoming involved in all aspects of health service delivery, especially in the provision of primary and community-based services. However, there has not been a reduction in the inequities in health status between Maori and non-Maori.

Maori providers and Maori health workers are, however, making a difference. Changes in service delivery are increasing Maori access to health care and, in some areas, are changing the patterns of admission and re-admission. As an example, a Maori community-based mental health team established by Auckland Healthcare has reduced Maori re-admissions in the mental health service and this has recently been recognised at an international mental health conference. The issue of Maori mental illness is now increasingly being recognised as the number one health problem facing Maori.  ²  

There are now many Maori mental health providers working in the area of mental health service provision and, alongside other Maori providers, are trying the reverse the current mental health trends, by building self and cultural esteem, supporting whanau development and by promoting the adoption of healthy lifestyles.

Improvement in Maori Health

Making progress in any area of Maori health improvement is not easy. The assistance that Maori providers have received across the country has not been consistent and has varied depending upon the purchasing policy of each regional health authority (RHA), now local divisions of the Transitional Health Authority (THA).

Maori providers’ contracts are influenced by Government policy and depend upon the proportion of resources allocated to crown health enterprises (CHEs), which in turn influences the range of contracts that are offered to other agencies and the funding available.

Because of the process used to implement of the health reforms, Maori providers have to some extent been placed in competition with CHEs and independent practice organisations (IPAs) in contrast to a preferred situation where all providers, individually and collectively, would be encouraged to work together and to report on achievement of defined Maori health gains.

Competition, it seems, has allowed Maori to enter the "market" as providers of health care. However, in the longer term it may do little to improve Maori health. To improve Maori access to, and utilisation of, health services there is a need for health contracts which allow health workers to work across different boundaries, such as along the continuum of public, primary and secondary care, and allow providers to work in collaboration.

Managed care by Maori or Maori health care plans may provide a solution to overcome these obstacles provided that adequate funding is provided to meet Maori health needs as opposed to requests to Maori to ration health services for Maori.  ³  

New Zealand’s health service is becoming increasingly fragmented and services are being centralised in provincial and urban areas. The cost of transport to seek care or to provide support to "sick kin" are real issues that must be considered in relation to Maori.

There is also a need to recognise the health impacts of an ageing Maori population. Maori are likely to have health care needs at an earlier age than non-Maori.

Treatment guidelines, for example, which promote fairness in access to care may, in the future, exacerbate inequities in health care between Maori and non-Maori and may limit or reduce Maori access to dialysis, coronary interventions, hip replacements and so forth.

The recent high profile death of Mr Rau Williams, who was denied dialysis, has brought to Maori attention the effects of rationing and how treatment protocols are being used by clinicians, politicians and the justice system to determine who will receive health care.

What has not been said is that the health condition of Mr Rau Williams is similar to that of many Maori and Pacific Island people who have diabetes and other health problems. Their health condition is a reflection of previous access to health care, current and past socio-economic circumstances and limited access to health information. Rationing of health care is now an every day news item. The full effects on the health and well-being of Maori have not yet been really considered or discussed.

In developing protocols determining access to health care, there is a need to address horizontal and vertical equity issues for Maori as well as the long term health effects of the lack of recognition of Te Tiriti o Waitangi for Maori and the implications this has had and will continue to have in the future. Horizontal equity recognises that people who have the same health conditions should be treated equally. On the other hand, vertical equity recognises that within a population there are different groups whose health status is different and specific resources and solutions are therefore needed to close the health gap.

Maori Health Priorities: Alcohol Misuse and Mental Health

Alcohol and drug abuse is a growing health problem for Maori, underlying many broader health issues, such as family violence, youth suicide, abuse, mental health admissions, and injuries which can result in the need for hospital care and long term rehabilitation. There is currently no national Maori alcohol and drug abuse prevention strategy in place to address alcohol and drug abuse by Maori which is supported across the health sector and by allied agencies such as the Alcohol Liquor Advisory Council.

Recently released information indicates that while the country’s overall level of alcohol consumption has fallen, this is not the case for Maori.  ⁴   Consumption of alcohol by both Maori men and women has risen. Maori patterns of drinking differs from much of the population as it often involves "binge drinking" and drinking in places where the requirement of the alcohol industry to provide host responsibility programmes does not exist, such as in people’s homes and in meeting places where an alcohol licence is not required.

The effects of women’s alcohol abuse on their health are now being noted in trends in Maori women’s health relating to such areas as inpatient admissions in mental health services for either for alcohol and drug abuse, or for drug-induced psychosis. Increased opportunities for the sale of alcohol and the lowering of the legal drinking age from 20 to 18 years will do little to improve Maori health but will likely increase the revenue that both the Government and the alcohol industry will receive from Maori individually and collectively.

Cannabis use is also a growing health problem for Maori and the long term effects of intergenerational use are still not understood. In some areas, for example, it is common to find grandparents, parents and children within a family all smoking cannabis. In many Maori communities, it is also not recognised that long term cannabis use creates health costs and undermines Maori efforts for development and self determination.

Cannabis affects short term memory, encourages lethargy and limits motivation to seek employment and achieve personal goals. The growing of cannabis in isolated rural areas is also a major source of cash income for growers. To make changes will require Maori communities to define the problem from their own perspective and to develop appropriate solutions. Resources, research and information are needed to help Maori communities define the problem and develop their own community-based strategies.

In the medium term, alongside the above issues, gambling addiction is also likely to create many health and social related problems for Maori. Similarly to native Americans, Maori tribal trusts in certain areas, such as Queenstown and Hamilton, are applying for licences with joint venture partners to establish casinos.

Currently, in New Zealand there is a "loophole", giving the two existing casinos the right to expand from their current sites in Christchurch and Auckland after two years of operation provided that the additional sites are 100 km from their present locations. Gambling has provided a vehicle for native American self determination, in that casinos have created employment and huge cash reserves for tribes to use for their own development. The establishment of such casinos are now seen by some Maori groups as the path forward for Maori development.

The Coalition Health Agreement and its Proposed Implementation

For the first time in a number of years Maori health has been identified as an explicit health priority of a new Government. It was announced at the outset that $30 million in additional funding would be made available over the next three years for Maori provider and workforce development. The Coalition Health Agreement proposed changes that were beneficial to Maori, such as free medical care for children under six years, one purchasing authority, the establishment of regional hospital and community services, increased collaboration amongst providers and provision for Maori provider development.

Since these announcements have been made, the Government has also established Maori Health and Education Commissions as part of its commitment to closing the gap in health and education between Maori and non-Maori.

The length of time taken to establish the Maori Health and Education Commissions has also provided an opportunity for the Ministry of Health and the health sector generally to define its areas of responsibilities and to define how such agencies as the Ministry of Maori Development and the new Maori Health Commission will relate to each other and be involved in health developments.

The role of the Ministry of Maori Development (Te Puni Kokiri) is now seen as one of monitoring the Ministry of Health on the delivery of strategic policy advice on Maori health, and of providing policy advice on the relationship between Maori health, Maori development, and the development of Maori providers.

This role is a re-interpretation of the statutory responsibilities of the Ministry of Maori Development which clearly are to facilitate achievement in Maori health and by monitoring and liaison, to ensure the adequacy of mainstream agencies’ services to or for Maori. A recent review by the Ministry of Maori Development of the Ministry of Health has been critical of the lack of progress that the Ministry of Health has achieved in grappling with Maori health policy and leadership issues.  ⁵  

It is interesting to note that, despite the role of the Steering Committee which was established to advise on the implementation of the Coalition Health Agreement, it has not been suggested that new funding for Maori provider and workforce development should reside with the Ministry of Maori Development or with the new Maori Health Commission.  ⁶  

Since the beginning of the health reforms in 1993, the health sector has had every opportunity to advocate and allocate specific funding for Maori providers were this desired. Government policy regarding Maori health has been publicly available through Whai te Ora mo te Iwi 1993 as has advice for health service purchasers through published guidelines.  ⁷  

The role and activities with which the new Maori Health Commission will be involved have not yet been clearly defined. However, it is thought that the Commission will be involved in the development of innovative health projects which will make a difference for Maori health and it will work alongside mainstream health agencies.

The Coalition Health Agreement, when first announced, incorporated "tension" between proposed developments in mainstream health services, such as the move from competition to collaboration, and the allowance for Maori provider development. The tensions inherent in the agreement have recently been visibly played out between political parties and between individuals. For example, there is constant tension around identifying Maori providers, as distinct from CHEs and other mainstream services, who are legitimately entitled to the funding that Government has allocated for Maori workforce development as part of the Coalition Health Agreement.

The real changes which will occur for Maori are yet to be seen. Currently, the health sector is again undergoing a process of change with new bodies renegotiating their roles and what power or influence they will have.

New Funding Agency: The THA

The Coalition Health Agreement signalled a move to one health sector agency responsible for "funding", commissioning and purchasing health services.

This move to a single health authority was seen as creating some consistency across the country in purchasing health services, and as allowing developments in the health sector to be co-ordinated. The need for such a change was highlighted in the Ministerial review of Mental Health Services headed by Judge Ken Mason who was very critical of the accountability and leadership arrangements in place for mental health.  ⁸  

Since the announcement of the establishment of a new funding agency, which will formally take place on 1 July 1998, the old RHAs have not been disbanded but have become divisional offices of the THA. This has added another layer to the health bureaucracy and raises such questions as how many levels of purchasing advice are required to fund a service and what is now the role of the Ministry of Health?

Prior to the new Health Coalition Agreement, the Ministry of Health saw its role in the provision of policy advice directly to Government, acting as the Minister of Health’s agent to negotiate funding and purchasing of health services and monitoring overall health service delivery. These roles are being reviewed again and, as well as the creation of the new funding agencies, there is also a plan to establish new business units to carry out activities that the Ministry of Health has traditionally provided.

Instead of integration, collaboration and a reduced bureaucracy in the health sector, there seems to be even more agencies created, each with their own role. Who is responsible for ensuring that all health care players have the same vision and understand their role and responsibilities in relation to health? Maori know clearly that the whole is far greater than the sum of the parts. Maori constantly advocate an holistic approach to health. This possibility for health is often acknowledged but never truly implemented.

Maori Health Research

The role of research in Maori health development is increasingly being understood and appreciated by Maori. This has largely resulted from the appointment of various Maori leaders to the Health Research Council of New Zealand’s Standing Committee on Maori Health. From the outset, this Committee has had a commitment to meet with Maori on marae to discuss the contribution research can play in development, how different Maori communities may be involved in research and what avenues are available for funding and workforce development.

The Health Research Council has also supported the establishment of two Maori Health Research Centres, Te Pumanawa Hauora (Palmerston North), and the Eru Pomare Research Centre (Wellington). These two centres have now existed for over five years. They have supported Health Research Council initiatives towards developing competent professional Maori health researchers who are able to initiate their own research and be involved in a wide range of research areas. Maori research has also enabled the Health Research Council to support the establishment of Pacific Island Research Centres and new places with an emphasis on Maori research..

It is foreseen that these Maori and Pacific Island centres have already made a difference for they have helped to create a climate where Maori support the idea of research in principle and want to be involved in using research to shape their own future. Maori research is also seen as leading the way for policy development.

Health Promotion and Health Messages

Appropriate health promotion strategies developed by and for Maori are always on the health agenda. Increasingly, it is being recognised by the Minister of Health that Maori are at the cutting edge of change and, through their own energy and commitment, are developing innovative health messages and strategies to address the various health issues.

In the area of alcohol abuse, Maori men, for example, through Brothers Against Drink Driving (BAD), are taking responsibility to develop their own messages to encourage Maori men not to abuse alcohol and not to use violence as a means of expressing their frustration, particularly to their partner or children.

Furthermore, there is growing awareness that the health of Maori men should become a priority. A major pilot project will shortly recruit a wide section of the community, in particular Maori, Pacific Island and Asian men, to be screened to identify their hepatitis B status.

This programme will be piloted in the northern part of the North Island and will give participants the opportunity to determine whether they have had hepatitis B or are carriers of the virus. Participants will have access to information about maintaining good health. Carriers will have access to ongoing surveillance and health care if needed.

Similar to the National Cervical Screening Programme for women, the new hepatitis B programme is expected to raise community awareness of this health issue and give carriers the opportunity to access information about healthy lifestyles, looking at issues like moderate alcohol use, safe sex and so forth.

Conclusion

This paper has been prepared to provide a broad overview of current Maori health issues which are being debated and addressed in many different settings. Maori involvement and participation in the health sector has certainly increased since the early 1980s, however the gap in health status been Maori and non-Maori has not closed but has remained the same.

Maori are now recognised as key stakeholders in health services whose interests must be considered. The new political environment and the coalition established between the National and New Zealand First Parties has also increased awareness of the importance of Maori health and the need to close the health gaps. Looking from the outside into Government and into the health sector generally, Maori are still waiting to see if any real change will occur and, like other groups, may become captured by their own perceived power and influence. There has been a significant increase in the number Maori employed in health management and provision of services since the 1980s. As they are part of the system and the health reform process, they may be placed in a position where they support government direction even though changes in health status for Maori are not occurring significantly.

It is too early, however, to evaluate the success of the current Government and of the new structural changes in the health system in making real changes in Maori health, particularly in terms of health gain.

References