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- Key Issues for Te Hau Ora o te Tai Tokerau in Providing Best Care for Maori
- Areas of Successful Progress in Maori Health
- Barriers to Progress in Maori Health
- Priority Areas in Maori Health
- Maori Health Services Under the Coalition Health Policy
- Key Issues for Te Hau Ora o te Tai Tokerau Working Alongside Mainstream Services
- Relationships Between Maori Provider Groups
- Integration of Maori Health Services
- Key Issues with Respect to Maori Participation in the Health Sector
- Goals in Maori Health
- The Shift to the Transitional Health Authority (THA)
- The Role of Maori Health Research Centres
- References
Key Issues for Te Hau Ora o te Tai Tokerau in Providing Best Care for Maori
Te Hau Ora o te Tai Tokerau faces a number of key issues in providing best care for Maori.
Issues which relate directly to Te Hau Ora o te Tai Tokerau as a service provider include the need to establish a kaupapa or philosophy upon which to base service provision.
In addition, Te Hau Ora o te Tai Tokerau needs to secure a mandate from iwi/hapu to deliver services and to provide governance opportunities for iwi/hapu stakeholders of the Maori community in Tai Tokerau.
Other key issues for Te Hau Ora o te Tai Tokerau as a service provider involve:
- ensuring the competency of the administration base
- providing strong leadership
- securing and successfully delivering on contracts
- identifying parameters of service provision
- undertaking high quality strategic planning
- providing "best care practices" to improve Maori health as determined by Maori and monitor and evaluate results in order to constantly improve
- accessing high quality professional advice to assist in our development
- scoping future health trends and developing an organisation that can respond quickly to those trends.
Certain issues facing Te Hau Ora o te Tai Tokerau relate to relationships with other providers. Te Hau Ora o te Tai Tokerau operates in competition with the crown health enterprise (CHE) and other Maori service providers. As such they must work to build up a client constituency within this competitive marketplace.
However, against this competitive background Te Hau Ora o te Tai Tokerau must also work co-operatively with other groups, developing and maintaining relationships with other providers in the area, both Maori and non-Maori.
This involves managing strategic alliances, joint ventures and mergers as vehicles to minimise the adverse effects of competition in the region.
A further issue relates to the need for Te Hau Ora o te Tai Tokerau to develop relationships with funding agencies without compromising the integrity of the organisation’s philosophical position.
Workforce issues centre around the lack of Maori with skills to deliver services. There is a need for planning for future Maori health workforce development for Tai Tokerau. Te Hau Ora o te Tai Tokerau must also work to attract staff who are committed and motivated to improve Maori health status and who are prepared to go that little bit further.
Finally, a number of issues relate to awareness and education and include the need for Te Hau Ora o te Tai Tokerau to:
- promote Maori ownership of Maori health at both a personal and collective level
- teach children to take greater responsibility for their health than has been the case with Maori to date
- assist understanding the paradox of "by Maori for Maori" service delivery. The "by Maori for Maori" approach is limiting both in terms of actual service provision, but more importantly also in terms of thinking
- try not to contribute to the dysfunction that exists amongst Maori in Tai Tokerau.
Areas of Successful Progress in Maori Health
The burgeoning of Maori health service providers over the past five years is one of several signs of good progress in Maori health. In addition, increased attention is being paid to Maori health workforce development.
There has also been a gradual increase in awareness of health issues amongst the Maori community directly as a result of an increase in the numbers of Maori health workers working in Maori communities. Maori now have a greater say in the allocation of resources for example the Maori Co-Purchasing Organisation (MAPO) model at North Health.
The MAPO model allows Maori to co-purchase health services in conjunction with North health. The model consists of three Maori co-purchasing bodies (Tainui MAPO, Tihi Ora MAPO (on behalf of Ngati Whatua) and Tai Tokerau MAPO (on behalf of Tai Tokerau)). Any purchasing by North Health that impacts on Maori health status must be done in conjunction with the appropriate MAPO body.
Other signs of progress include:
- more focussed research on Maori health initiatives
- better understanding by mainstream organisations of the particular needs of Maori clientele
- an increase in Maori public health service provision in Northland.
With respect to specific issues in Tai Tokerau, anecdotal feedback to Te Hau Ora o te Tai Tokerau, suggests that good progress has been made in the following areas:
- smokefree programmes
- nutrition
- exercise
- Maori male violence prevention
- home support and attendant care services to Maori
- whanau well-being
- the development of a Maori health infrastructure in Tai Tokerau
- identification and activation of local Maori community networks
- Maori youth suicide prevention programmes
- Maori employment and training initiatives
- greater Maori involvement in disability and support services.
Key features common to the more successful initiatives include:
- good relationships with constituent client groups
- mandate from iwi and hapu to operate in the area
- stakeholder involvement in design and implementation of service
- shared values between organisations and their workers
- high quality strategic planning
- appropriate structure
- systems to support the structure
- style reflective of the culture of the organisation
- staff who are motivated and committed to the kaupapa
- appropriate skills
- competent leadership
- adequate funding
- good relationships with funder organisations
- vision
- ability to work in with competitors including mainstream organisations.
Barriers to Progress in Maori Health
Several issues act as barriers to progress in Maori health. Key issues which make progress difficult can be grouped under the following headings:
Funding and Policy Issues
These include issues such as "getting past" gatekeepers of health funding and keeping track of changing Government policy and the implications it has for service providers.
Issues Around Service Provision
A number of issues relating to service delivery impact on progress in Maori health. These include:
- finding qualified staff to deliver health service contracts;
- determining who should provide which services in a given area;
- securing contracts;
- maintaining effective relationships with CHEs; CHEs and Te Hau Ora o te Tai Tokerau seem to operate from a different philosophical basis with the CHE highly focussed on achieving profit, and Te Hau Ora o te Tai Tokerau on meeting the needs of people.
Education and Awareness Issues
There is a need to promote the notion of "by Maori for Maori" to overcome barriers created by a lack of understanding of the need for such services.
There is also a need to educate Maori to take responsibility for their health.
There are a number of issues relating to the need to be aware of and to manage any potential conflict between Maori cultural values and business expectations. Examples include the need to reconcile whanaungatanga values with hard-nosed competition, and to respect tribal boundaries in pursuit of market opportunities.
In addition there is a need to reconcile the tension between Maori aspirations as seen by the powerless and the powerful.
The aspirations in terms of improving Maori health status of those in positions of power, and those who are not, are often not the same. For example, there is a desire on the part of many Maori groups to become involved in some aspects of Maori health service provision. However, the policy of North Health is to establish a small number, three or four, Maori health service providers, and let others fall.
Priority Areas in Maori Health
The following health areas are seen as a priority:
- Maori mental health
- Maori whanau well-being
- change in smoking habits and/or smoking cessation
- nutrition
- exercise.
In addition there needs to be focus on the following processes to achieve the health gains required:
- processes that teach or allow Maori to take responsibility for their own health
- te reo Maori me ona tikanga (Maori language and customs)
- Maori Public Health activities, including health promotion and health protection services.
Maori Health Services Under the Coalition Health Policy
The Coalition Agreement is regarded to be tenuous and subject to change. The Steering Group Report on implementing the Coalition Agreement on Health outlined a dual strategy to provide appropriate services for Maori. This strategy which involved service provision through culturally effective mainstream services and services from not-for-profit Maori providers is appropriate with the exception that Maori providers should be able to make a profit. 1
Key Issues for Te Hau Ora o te Tai Tokerau Working Alongside Mainstream Services
As a Maori health provider, Te Hau Ora o te Tai Tokerau must work alongside mainstream healthcare providers. The following are regarded as important to promote good working relationships with mainstream providers:
- establishing and maintaining good communication
- managing power differentials
- understanding and accepting that providers may come from different philosophical approaches and acknowledging that, despite those differences, all have a role to play
- being clear about the differences and similarities in value bases
- clarifying roles and responsibilities in order to minimise duplication of services and wasting of resources
- identifying areas of overlap where groups can support and collaborate with each other
- moving beyond grievance mode into a spirit of co-operation
- accepting that there may be times when it is more appropriate for a mainstream organisation, rather than Te Hau Ora o te Tai Tokerau, to deliver a service to a Maori client.
Relationships Between Maori Provider Groups
The extent of dysfunction between and amongst Maori groups in Tai Tokerau is significant. This is particularly evident at the iwi and hapu political level but is also apparent at the whanau and individual level.
In responding to Maori community development needs, including Maori health needs, all players need to ensure that they do not contribute to or exacerbate the dysfunction that currently exists.
Maori are relatively new players in the health provider arena. Managing relationships (particularly Maori relationships) against the backdrop of a competitive marketplace is fraught with difficulty.
Funder organisations need to exercise particular care that they do not take advantage of the vulnerable position of Maori in pursuit of their own agendas.
Successful relationships with other providers demand that groups are focussed on the needs of others. There needs to be a collaborative approach to working to improve Maori health status in Tai Tokerau.
Maori health service providers in Tai Tokerau need to develop relationship protocols that describe the relationships between themselves and ensure:
- an understanding of who will deliver what to whom
- non-duplication of resources
- sharing of resources and skills where appropriate
- political leverage on issues associated with Tai Tokerau
- providers are not played off against each other on the open market
- Te Hau Ora o te Tai Tokerau is able to maximise its impact at a regional level to improve Maori health status in Tai Tokerau
- Te Hau Ora o te Tai Tokerau achieves maximum health funding for the region
- the approach to Maori health care in Tai Tokerau is co-ordinated.
Groups with whom Te Hau Ora o te Tai Tokerau has working relationships are:
- Hauora Whanui/Ngati Hine Health Trust
- Te Hiku o te Ika
- Hokianga Health Trust
- Te Roopu Whakapiringa
- Tihi Ora (Ngati Whatua MAPO)
- Tai Tokerau MAPO
- Ngati Wai Trust Board
- Whaingaroa Health Trust.
Integration of Maori Health Services
From the outset, Te Hau Ora o te Tai Tokerau has sought to develop an operational framework that reflects an integration of health service provision to Maori in Tai Tokerau. Not only was this in keeping with the group’s holistic view of Maori health, it also reflected the need to look beyond the confines of generic health service provision. There are a number of reasons for this:
- the small Maori population in Northland (36,000)
- competition between providers
- limitation of contractual opportunities within generic health services
- limited co-ordination/integration of health services to Maori in Tai Tokerau in the past, mainly because there were no Maori providers and most services were CHE driven, or driven by area health boards with few or no Maori members
- greater expectation on the part of the Maori community for Maori ownership and control of Maori initiatives.
An integrated Maori service could sit alongside an integrated mainstream service without difficulty so long as boundaries and relationship issues were clarified.
Key Issues with Respect to Maori Participation in the Health Sector
Factors crucial to effective Maori participation in the health sector include:
- Maori ownership and control of Maori health initiatives
- greater responsibility by Maori for their health care needs at the individual level
- promotion and recognition of Maori models of health care and the holistic Maori view of health
- adequate funding for Maori health initiatives
- allowance for adequate capital establishment costs for Maori health providers
- planning and co-ordination of the development of the Maori health infrastructure in Tai Tokerau
- competent administration bases
- Maori health workforce development.
With respect to workforce development, contracts need to recognise the ongoing training and developmental needs of staff. There is also a need to promote health sector employment opportunities through career guidance services to Maori students and to provide scholarship opportunities for Maori students.
Other issues which impact on Maori participation in the health sector include:
- Government policy
- gate-keeping by funding agencies
- the current state of dysfunction of the Tai Tokerau Maori community.
Goals in Maori Health
Equality of health status is a reasonable goal, given the relative position of Maori health compared to Pakeha health. However, Maori ought to have the opportunity to develop health goals that are appropriate to them, even where this may be at variance with the health status levels achieved by Pakeha.
The Shift to the Transitional Health Authority (THA)
The transition to a central purchaser will undoubtedly affect activities relating to Maori health although the extent and impact of change is uncertain.
Some likely positive outcomes of the shift to centralised purchasing include standardisation of services although this can also have disadvantages.
Centralised purchasing also offers the advantage of central decision making processes although again there could be difficulties inherent in this.
It is hoped that the shift to the THA will mean faster implementation of Government policy and better coordination of Maori health policy and implementation.
Like all things, the success of the shift will pivot on the quality of the people involved and their determination to improve Maori health status.
The new funding situation may demand a different approach to the advocacy of individual Maori health service providers, given potentially less access to the funder and more competition between providers.
Potential disadvantages of the shift to the THA include the risks associated with standardisation and central decision making processes as mentioned above.
Centralised purchasing may also enhance gate-keeping potential and may focus greater power into fewer hands. Associated with this is the risk that centralised purchasing will be more easily manipulated by politicians.
There is a perception that the THA will be further away from Northland in time, distance and understanding.
A final concern is that centralised purchasing will reduce opportunities for creativity in health service provision.
It is not possible to determine whether centralised purchasing will be preferable for Maori without first experiencing life under the THA.
Maori health service providers need to make the most of whatever opportunities arise, regardless of the purchasing structure. This approach requires that service providers be focussed on what it is they are doing, be able to adjust or adapt quickly to changing conditions, and maximise their ability to improve Maori health status.
The Role of Maori Health Research Centres
Maori health research centres such as Te Pumanawa Hauora at Massey University and the Wellington School of Medicine have a critical role to play in the development of Maori health, and in developing Maori health researchers.
There would be value in developing a funding mechanism that would allow an organisation like Te Hau Ora o te Tai Tokerau to be able to access the research centres as and when the need arose.
As Maori take greater responsibility and control over their health, there will be increased pressure on existing Maori health research centres. There is a need now for an Auckland/Northland based Maori health research centre.
References
- Poutasi K, et al. Implementing the Coalition Agreement on health: the report of the steering group to oversee health and disability changes to the Minister of Health and the Associate Minister of Health. Wellington: Ministry of Health, 1997.
