Submission on:

August 2001

Introduction
The College of Nurses Aotearoa welcomes the opportunity to respond to the Ministry of Health draft Mäori Health Strategy - He Korowai Oranga. We acknowledge the intention of this government to address the growing health and socio-economic disparities between Mäori and other New Zealanders in health, education and social policy, a feature that has been lacking in previous times.
The College of Nurses Aotearoa fully supports the development and implementation of a Mäori health strategy that is adopted by all stakeholders in the health sector. The College recognises that Mäori health is everyone's responsibility and that both Mäori and Pakeha Treaty partners have a role to play.
This later point is all to frequently lost by decision-makers unaccustomed to models of health and service delivery that are different from the norm or by an uninformed majority who perpetuate barriers to Mäori health development.

General comments
Simplifying the model He Korowai Oranga brings together a range of strategies that have been recommended as a way forward for Mäori health for the last two decades. While it is important to retain these ideas, it is also important that the key messages for decision-makers and service providers responsible for implementing this strategy are clearly understood.
The model as it is currently proposed is comprehensive, however there is a risk that mainstream service providers who deliver the majority of health care to Mäori may find the model difficult to interpret and subsequently apply in practice. A simplification of the model and more detail on the relationships required to make the model operational are recommended.

Directions and endorsements
The directions and endorsements in He Korowai Oranga could be more effectively described as the key planning assumptions and principles for the strategy and Mäori health improvement . These assumptions would then provide the basis for decision-making and planning for the sector. These assumptions include:

* Mäori desire control over the direction and shape of health services for Mäori i.e. rangatiratanga, leadership, Mäori participation in planning and service delivery.

* Mäori health development is part of a larger goal of Mäori development i.e. whänau ora.

* Government aspirations are to reduce the health disparities between Mäori and other New Zealanders i.e. commitment to population health approach and accountability/performance.

* Maintaining and building on past (and future gains) i.e. investing in Mäori solutions and best-practice models, maintaining stability in the sector and relationship development.

These directions and endorsements are in essence reflective of the Treaty of Waitangi. It would be useful for the model to make this connection more explicit so that District Health Boards and health providers are able to utilise this strategy as a Treaty-based framework for health service planning and delivery. Again, a simplification of the model to minimise duplication and maintain clear and consistent messages is warranted.

Treaty of Waitangi
The principles of the Treaty of Waitangi are sited in all ministerial policy and strategic intentions. What is missing are any clear guidelines, competencies, policy, or protocol that provide Crown agents (including District Health Board directors) with an understanding about their delegated Treaty responsibilities.
It could be argued that if Crown agents were better informed about these responsibilities, then significant Mäori health improvement could be achieved more efficiently and effectively.

Monitoring and Evaluation
The objectives described in He Korowai Oranga are not new nor are the issues regarding how health outcomes and health provider performance will be measured. The development of health indicators and performance measures that are both reliable and valid, is long overdue. These measures should be inclusive of:

* Mäori health outcomes eg. quantity and quality of life indicators

* Populations health objectives eg. mobidity and mortality rates.

* Clinical and quality indicators eg. Comparable treatment/intervention rates, access measures, Mäori consumer satisfaction.

* Mainstream responsiveness eg. Mäori workforce participation rates, performance measures, resource allocation for Mäori health
.
* Relationship development eg. Governance, operational and service delivery relationship initiatives.

Standardised measures and data collection processes will:

* Provide an evidence-base for monitoring trends and responses to interventions over time.

* Identify service needs and priorities and subsequent planning requirements.

* Support more accurate comparisons or bench-marking between District Health Boards.

* Ensure District Health Board accountability and public confidence

These measures should be integrated into all contractual service agreements between the Ministry of Health and District Health Boards.
Performance against these measures should also include incentives that reward good performance on Mäori health objectives and disincentives for poor performance.
Mäori should be included in the development of these measures, data collection processes and data analysis and interpretation to support the validity of the findings.

Timeframe for implementation
The timeframe for developing and implementing this strategy is too long. The strategy does not align with this year's annual planning processes for District Health Boards (DHB) or purchasing intention plans.
It could be argued that with the pressure on District Health Boards to manage projected deficits, build completed national strategies into service and annuals plans and hold District Health Board elections, He Korowai Oranga strategies will not feature in District Health Board service provision until 2002-2003 unless new monies are specifically provided.

Question 1:
The draft strategy proposes one overall aim of whänau ora: healthy Mäori families supported to achieve their maximum health and wellbeing.
The College agrees with 'whänau ora' as the vision or goal for this strategy. The role of whänau in promoting health practices and advancing health gain, is acknowledged and the need for public health policy directed at whänau is supported . Being part of a whänau is the common ground that people share.
The strategy needs to be inclusive of traditional and contemporary whänau structures. whänau are now included in pan-tribal urban authorities, kohanga reo, kura kaupapa and other organisations where Mäori may not have whakapapa links. These contemporary whänau groups also provide social support for Mäori whänau based on the values of whänaungatanga and manaakitanga and should be supported.
The outcomes stated for whänau ora in the draft strategy are visionary, but open to interpretation. The outcomes (rather than outputs) that the health sector should be working towards need to be explicit and measurable to identify the desired change and response to interventions.
It is an assumption that a shared understanding of the concepts of 'whänau' and 'hauora' exist between Mäori and other New Zealanders. Education for the majority of health service providers on Mäori health concepts and application in service planning remains ad hoc.

Question 2:
Four pathways are outlined in the strategy. These are designed to improve whänau health and wellbeing. Do you think the pathways are useful or appropriate?
The four pathways or strategic directions for He Korowai Oranga are useful and appropriate. The area that is under-developed in the model is Mäori health research and development of best practice service and clinical guidelines.
Information and data included under Pathway 3 refers to Mäori health information for monitoring population health status. More research to evaluate interventions that contribute to improved Mäori health outcomes is warranted. Examples of research opportunities could include the impact of Mäori nurse practitioners in primary health care for Mäori patients and their whänau.
The objectives and tables under each pathway are a good starting point for developing 'Mäori health action plans'. With more refinement these plans could be integrated directly into District Health Board and health service provider contracts and service plans. Suggested amendments include timeframes and indicative resource allocation. The outcome would be standardised Mäori health objectives and monitoring and evaluation methodology to measure Mäori health outcomes.

Question 3:
The first pathway focuses on fostering the conditions that encourage health and wellbeing as well as preventing or treating disease. Is this a useful approach?
Pathway 1 attempts to identify the conditions or pre-requisites required to support Mäori health development. These pre-requisites are inclusive of some of the determinants of health that encompass cultural identity and community / whänau development principles.
More attention to these pre-requisites or conditions to meet the objective of fostering whänau development and health is necessary to make this pathway more pragmatic for District Health Boards and health providers. Current policy and processes for this pathway are limited as are the next steps for both the Ministry and District Health Boards. A more effectively framework for identifying these conditions and expanding on this pathway is suggested below.

Back to Top
All rights reserved © College of Nurses Aotearoa (NZ) Inc.