I
MASSEY UNIVERSITY DEPARTMENT OF MAORI STUDIES TE PUMANAWA HAUORA
EFFECTIVE HEALTH POLICY FOR MAORI
0
A Strategic Framework for the Development of Mãori Health Policy
A report prepared for Te Kete Hauora
by
CW Cunningham and SH Taite
May 1997 JSTACK
WA 300 [QI CON 1997 / Te Piamanawa Hamm
Effective Health Policy For MAori
0 0 0 0 S S • • S •
Advice to Te Kete Hauora on a Strategic Frameworkfor the Development ofMaori Health Policy
CW Cunningham and S Taite May 1997
Inkmiation Centre Information Managernen Ministiy of Health Table of Contents
Executive Summary
Effective Health Policy for Mãori 4 Introduction
Advice sought by Te Kete Hauora 6
Effective Health Policy for Mãori 7
Existing frameworks - effective health services for Mäori 8
He Taura T(eke - Measuring Effective Health Services for Maori 8 He Anga K7iakamana - A framework for the delivery of disability support services for Maori 12 The CHI audit model - culturally appropriate Public Health Services 15 Guidelines for purchasing personal mental health services for Maori 17
Rationalisation of the frameworks 19
First order criteria 19
Second order criteria 19
Third order criteria 19 Checklist
Elements of framework - Effective Health Policy for Mãori 20
Checklist: Effective Health Policy for MAori - Supporting Information 23
Future work 29 Appendix 1:
POLICY OUTCOME SUPPORTS MAORI HEALTH GAINS 30
RECOGNISESAND ADDRESSES THE DETERMINANTS OFMAORI HEALTH STATUS 30 ENABLES MAORI WORKFORCE DEVELOPMENT 31 ADDRESSES THE GOVERNMENT S HEALTH PRIORITIES 32 IS CONSISTENT WITH THE GOVERNMENT SMAORI DEVELOPMENTAND TREATY OF WAITANGI POLICIES 33 ADDRESSES HEALTH PRIORITIES OFMAORI 34 PROMOTES MAORI WISHES TO TAKE RESPONSIBILITY FOR THEIR 0 W HEALTH 35 USES A VA ILA BLE NATIONAL STANDARDSAND MEETS GOVERNMENT OBLIGATIONS 35 3
REQUIRES QUALJTYMAORI SOL UTIONSAND SPECIFICALLY SUPPORTS OUTCOMES SPECIFIED IN RELEVANT, EXISTING WISDOM 36 REQUIRES COMPETENT, SAFE AND EFFICACIOUS SERVICES 37 ENABLES MEANINGFUL DATA TO BE COLLECTED 37 PROMOTES GOALS WHICH RELATE TO MEASURABLE OUTCOMES 38
POLICY OUTCOME RESPONSIVE TO MAORI 39
IDENTIFIES MAORIASA RELEVANT TARGET GROUP 39 PROMOTES CHOICE FOR MAORI 40 RESPONDS TO DIVERSE MAORI REALITIES 40 RECOGNISESAND ADDRESSES MAORI DEVELOPMENT PRIORITIES 41 PROMOTES SEAMLESSNESS (OF SERVICESAND BETWEEN HEALTHAND DEVELOPMENT) 42 PROMOTES CULTURAL AFFIRMATION FOR MAORI 42 IMPROVESACCESSIBILITY FOR IvL4ORI BYADDRESSING KNOWN BARRIERS TO ACCESS 43 PROMOTESAND SUPPORTS INFORMED CHOICE 44 PROMOTES IMPROVED COMMUNICATION WITH MA0RI 44 SUPPORTS MAORI PREFERENCES FOR SERVICE PROVIDERS (INCLUDING SERVICES PROVIDED BYMAORI) 44 PROMOTES APPROPRIA TE. USE OF TE REO MAORI 45 PROMOTES LINKAGES TO MAORI INSTITUTIONS 45
POLICY DEVELOPMENT PROCESS RESPONSIVE TO MAORI 46
RESPECTS MAORI INTELLECTUAL PROPER TY RIGHTS 46 ACTIVELY INVOL VESMAORI IN POLICY DEVELOPMENT 46 A CTI VELYINVOL VESMAORI IN DECISION MA KING 47 CONSULTSMEANINGFULLY WITH MAORI 47 AFFIRMS MAORI CULTURAL VIEWPOINTS/IS CULTURALLY SAFE/USES TE REO MAORI CORRECTLY 48 ACKNOWLEDGES THE RIGHTS/SPECIAL NEEDS OF TANGA TA WHENUA 48 IDENTIFIES THE IMPACT ON CR0 WN/TANGA TA WHENUA REM TIONSHIP49 RESPECTS MAORIAND IN TURN DEVELOPS TRUST 49
POLICY DEVELOPMENT PROCESS IS ANALYTICALLY SOUND 50
IS BASED ONA RIGOROUS POLICY DEVELOPMENTMODEL 50 IS CLEARLY BASED ONA FRAMEWORK CONSISTENT WITH MAORI VIE W550 CLEARLY PROVIDES FOR A MONITORING PROCESS 50 MEANINGFULLY USES MAORI SPECIFIC DATA 51 IDENTIFIES MAORIASA RELEVANT TARGET GROUP 51
BIBLIOGRAPHY 52 4
Executive Summary
Effective Health Policy for Mãon
The Ministry of Health s policy analysts all contribute to the achievement of health gains for Maori through the high quality performance of their craft of policy analysis. In order that the Ministry of Health can better meet its responsibilities to the Government and Mori it is useful to consider that:
• all policy developed within the Ministry of Health impacts on Maori in some way - it is not an issue of whether there is an impact but rather how much of an impact there is and how that is managed; yet there are priorities for Maori health;
• a Maori analysis is as fundamental to the development of policy within the Ministry as an economic analysis is or at least it should be if the Ministry is to realistically address it s commitment to Maori and, to advance Maori health as it is required to do. A framework for informing the policy development process, in order that more effective health policy for Maori is achieved, has been developed. The framework has three principal first order criteria (elements) based on reasonable expectations of effective health policy for Maori. Effective health policy should:
• support health gains for Maori (policy outcomes);
• be responsive to Maori needs and expectations (policy outcomes and policy development process); and,
be analytically sound (policy development process). A checklist for policy analysts and supporting information are presented. The primary checklist, which appears on the following page (and page 23), interprets the meaning of the first order criteria identified above. A more comprehensive checklist (page 24-29) is intended to assist analysts by identifying the information needed by them and recommending the types of measures which may be incorporated into the specific policy. Finally, the bibliography (Appendix 1) references statements drawn from the background literature in support of the elements of the checklist. "5
Effective Health------Policy For Maori V.
policy outcome supports Mãori policy outcome is responsive health gains to MAori • recognises and addresses the determinants of • identifies Maori as a relevant target group Maori health • promotes choice for Maori • enables Mãon workforce development • responds to diverse Maori realities • addresses the Government s health priorities • recognises and addresses Maori development • is consistent with the Government s Mãori priorities Development and Treaty policies • promotes seamlessness (of services, and, • addresses health priorities of Maori between health and development) • promotes Mäori wishes to take responsibility for • promotes cultural affirmation for Mãori their own health • improves accessibility for Maori by addressing • uses available national standards and meets known barriers to access Government obligations • promotes and supports informed choice • requires quality Maori solutions and specifically • promotes improved communication with Maori supports outcomes specified in relevant, existing • supports Maori preferences for service providers wisdom (including services provided by Maori) • requires competent, safe and efficacious services • promotes appropriate use of te reo Mori • enables meaningful data to be collected • promotes linkages to MAori institutions • promotes goals which relate to measurable outcomes
policy development process is policy development process is analytically sound responsive to Mãori is based on a rigorous policy development model • respects Maori intellectual property rights (management sign-off, consultation with Te Kete • actively involves Maori in policy development HauoralMaori Advisors (audit trail)) • actively involves Maori in decision making • is clearly based on a framework consistent with Mãori views (Treaty of Waitangi, Whare Tapa • consults meaningfully with Maori Wha) • affirms Maori cultural viewpoints • clearly provides for a monitoring process • is culturally safe; uses te reo Maori correctly • meaningfully uses Maori specific data • acknowledges the rights/special needs of tangata • identifies Maori as a relevant target group whenua • identifies the impact on Crown/tangata whenua relationship • respects Maori and in turn develops trust
• all policy developed within the Ministry of Health will impact on Maori in some way therefore it is not an issue of whether there is an impact but rather how much of an impact there is and how well we manage that impact; • a Maori analysis is as fundamental as an economic analysis to the development of policy within the Ministry if we are to realistically address our commitment to Maori and, to advance Maori health as we are required to do. introduction
AdYice sought by Te Kete Hauora
A number of frameworks have recently been proposed to describe effective health services for Maori. These frameworks are listed in Table 1, and include He Taura Tieke: Measuring Effective Health Services for Maori which was produced by the Ministry of Health in 1995/62.
Table]: Frameworks - Health Services for Maori.
Senice Area• - - : Framework . - Author ..
Personal Health is f-Ic Taura Tieke: Population Health Measuring Effective Health Services. Ministry Services for Mori Health
Mental Health Services Ic Ptirnanawa Hauora for thei.Ministry ot I kahh
The advice sought from Te Pumanawa Hauora was the reconciliation of these frameworks and the development of a central framework for the development of strategic Mori health policy which takes the same approach to policy development that these frameworks take to service delivery. Importantly, many of these frameworks take the approach of enabling service providers themselves to analyse and improve their own delivery by encouraging self audit. The frameworks also provide information based on expectations of Maori as service consumers.
Population Health Services Section (1995), He Taura Treke - Measuring Effective Health Services for Mabri, Ministry of Health, Wellington.
2 11e Taura Tieke is currently being evaluated by Te Pumanawa Hauora.
3 M Ratima, MR Dune, GR Allan, PS Morrison, A Gillies and JA Waldon (1995), He Anga Whakamana - A frameworkfor the delivery of disability support services for Maori, NACCJ-IDSS, Wellington.
4M Dune, A Gillies, TeK Kingi, MM Ratima, JA Waldon, PS Morrison, GR Allan, Guidelines for Purchasing Personal Mental Health Services for Maori, Te Pamanawa Hauora, Palmerston North.
MR Dune (1993), The CHIAudit Model - A culturally appropriate auditing model for Public Health Services, Public Health Commission, Wellington. This report is based upon a thematic analysis of the frameworks above in order to produce a strategic framework which proposes criteria for effective health policy for Maori.
Effective Health Policy for Mãon
There have already been a number of attempts to develop and implement Maori policy frameworks within the Department and Ministry of Health.
An older example is the Hauora Maori Checklist6 which was developed in 1990 by Te Wahanga Hauora Maori - the Mori Policy Section of the former Department of Health. More recent examples have been attempted by Te Kete Hauora and included in the Impact Checklist and Decision Tree8 tools.
Of note is a discussion document on A Maori Policy Analysis Framework produced in 1995. This discussion document attempted to summarise the varied material produced on responsiveness and Maori policy analysis models throughout the public sector. The work also analysed generic policy analysis models and collected data through interviews with staff from the Ministry of Health. The resulting discussion document proposed to culturise the policy produced within the Ministry by Maori and non-Maori staff alike.
The draft framework is... shaped by the requirements, constraints and culture of the Ministry of Health rather than strictly Maori II methodologies.10 The discussion document also made a number of assumptions, two of which are particularly relevant:
• all policy developed within the Ministry of Health will impact on Maori in some way therefore it is not an issue of whether there is an impact but rather how much of an impact there is and how that is managed;
• a Maori analysis is as fundamental to the development of policy within the Ministry as an economic analysis is or at least it should be if the Ministry is to realistically address it s commitment to Maori and, to advance Maori health as it is required to do.
Before advancing the advice on Effective Health Policy for Maori it is worthwhile also examining the frameworks which have recently been proposed for health service delivery and planning within the reformed health sector.
6 Department of Health, (1990), Hauora Maori Checklist, Department of Health, Wellington.
" Te Kete Hauora, (1993), Decision Tree, Ministry of Health, Wellington.
8 Te Kete Hauora, (1993), Impact Checklist, Ministry of Health, Wellington.
Te Aho Associates, (1995), A Maori Policy Analysis Frameworkfor the Ministry ofHealth - Discussion Document, Ministry of Health, Wellington.
10 ibid. Existing frameworks - effective health services for Mâon
Four service-focussed frameworks have provided the basis for this analysis. The development of each framework has taken a slightly different approach, and, the variation in the use of language between and among the frameworks can make interpretation more difficult. It is worthwhile looking at each piece of work in more detail.
He Taura fleke - Measuring Effective Health Services for Mãori Produced by the Population Health Services Section of the Ministry of Health, He Taura Treke proposed an approach for measuring effectiveness of health services for Maori based on the expectations of Maori consumers themselves.
The report sought to identify key attributes of effective health services for Maori consumers. It was proposed that by meeting the needs and expectations of Maori, health service providers would improve access to health services used by Maori, support independence and improve Maori health.
He Taura Tieke identified those key health service attributes that were thought effective for Maori consumers and presented them in a checklist framework. In compiling the document the authors addressed the following questions:
• what are Maori expectations of effective health services?
• what attributes of effective health services are highly rated by Maori consumers?
• what features of care and service contribute most to Maori consumer satisfaction?
The clear and major expectation ofMãori is that their health will be improved as an automatic consequence of using a health service. We believe that improved outcomes for Maori will result through greater understanding ofMaori expectations, refocusing services to better meet these expectations and measuring progress towards meeting expectations11.
The framework in He Taura Tieke is composed of elements and attributes. For each of the attributes expectations are given together with a list of questions designed to assist the provider in developing more appropriate service responses.
In summary, the authors found that the attributes of effective services valued by Maori are:
1see references in He Taura Tieke. I 9
Structural and Systemic • Maori development Responsiveness - - Maori workiorce development
• preferred providcrs
The document describes each of the attributes in greater detail and then proposes several checklists for service providers to use.
Of importance is the approach taken within the checklists where standards of performance are identified together with informative questions designed to prompt service providers into identifying the most appropriate responses given the particular service and community served.
The generic checklists are reproduced here. The reader is referred to the document for the complete set. Co M P E T.E N CE STRUCTURAL & SYSTEMIC RESPONSIVENESS !Côeteiic1ë Moñitrrin. MR- MA1-- fér1cd ifSà1ety= FicwDièIopmen ..W.______- Mãon consumers Providers The philosophicd Health is Mãori arc The goneral are pfotduitd consumers know base or - addressed aslone -employed and prefermee of - -from harm or health servion framework from componait of developed as staff Mâori consumas I firther haim to are meding ...... h whidithe ...sevce - broad Miori t ...... all levels by the for services ei. bodies, their goals and is structured and deveiopmont in service as one delivcnd.. by mmtal and objectives (they deliverd is whidi social, - specific way of Mion is aecqsted spiritual well- may also med - .consitent with. - political, cultural contributingto and praaised being and their broader aims añdmaysuppoit, andeconomic:: -- Maori ------culture; treatmtait ----valUed byMaori) Muon consumers factors are also - develojimait------produces desired - - viewsfhealth addressedto - - -•r: - - -- Outcome - - - baiefitthe - - - consumer -•------
Doesthebuilding H6 -d --- - - llow4oyouactivcty h.weyou Howdoyouensure Howdoyoumake inSet building safety guliriv.. valuate aim to achim e d lopcd your - MAori staff are female staff - codes an. allo.. your seivice? equity (ofaccess, rdrlionship with the - employod at all available for - access for those - use and outcome) MSim comnmnitv - -- - levels of your wãhine? with disabilities? -- How dii nu keep for Maori? - - you seive? - service? How do you make MIon ware that : - -- -. e.g. pailnerships - peer staff available. youz service is ------e.g. as peer ctingitsgoals? - - - •-----educators?-
:J-low do you assist I tow do you monitor How do you addrccr Have you considered Is tranng ... -staff to ensure they snd tespund to ---- and act on MAon establishing a MIor, -- csiupu[sorv? are personally and chmgmg needs of social culiui-al and unit within your -- professionally safe9 your Miori fsctoo. to -- seivice? - communiiy? ------benefit Maon -- -- - : - - -
Howdovouensure --- - r - _Howdoyou - - - - the intervention ...... - - - - specifically develop - meets safety ------Mica stalt? standards and/or - - bestfitsctice - - - - -r -- - guidelines? ------
"MH Dune, (1994), Whaiora: Maori Health Development, Oxford University Press.
Minister of Health, (1992), Whaia te ora mo te iwi, The Government s Response to Maori Issues in the Health and Disabilities Sector, Department of Health, Wellington.
"Minister of Health, (1995), 1995196 Policy Guidelines to Regional Health Authorities, Ministry of Health, Wellington. I ... 11
CONSUMER SATISFACTION
Acess IformatiIi= IWforrned MT NO Sãiii1essness Ghoice= Resp-ec - Providers Mãori coitsUthers Maori consumers - In addition to •communtcate mor...... fee1respeced beingapartofthe scessfliIlywith dsoicb :- and infurnfnisi - - rsrv1ce workforce. Mäon by giving -.being givm - --thëprovid- - Mãori are clear information options snrsitive who.. -=. T rnvolved in about the service to their needs - .niaintains their-: -- managemait S •receivingusefiul- nyacyan - -- decisions and may information from information from-- confidmtiality have a stake m Mãoricxassumers theproviderto - providesthe owning health -: smsitivel: keep assist them in - - best pleossib care sers Ices -confidmtialct\. making daoices- = available - able to be olionti .== •useinformation p---. - __- - -concens- - _sassitnel to _Iciltural and - - -...... - -- = - --- boneflttheMãon -: =- lifestyle -- - - -: ... -5- : consumer - - - S - - -
How dO u How How dyou dsoose and u explain all - respeil Maori appropriate media treatmeiat options -. healing processes and formats for clearly? - (e g, karakia information(e.g. - :== - rongoa) and - - plain How do you msureihefrl - Maon/Enghsh know your availability as language, fhmiliar - patimts - -. - - - sufriers wish? Maoriconcqsts)? understand? --
IHowdo you make How do you me. How do you -- ±How do you How do you How do you Mãdri staff available consumer clearly explain - iiiölude - include Mãori in handle disdiarge oustiut the confidontiabty and the risks and patieiit s whanau the planning, planning? - rservicle7 - pnvacy guidelines outcomes of the in the service?: delivering and - - :—:o- -(eg.Privacy treat . iñoitoringof. - options? :_ yourservice? -
- Ow.:do you Bow do yu - How do von help How do you take eijsure data make consumers. Macli to Like care advantage of - ...... - colledion is aware of ..:oftheir os1i routine seissitive to MSori consumer -health appointmmtsto- consumer needs adsocacv provide health (e g not making servies?- - How do oucx.lucation? - -- insmsthve, value- - -- monitor \lãori based consumer assumptions)? - -- satisfadion?
How doiou onsure - = _- - How do you - that those who are - - - aioourage Maori - - - - - ... targetedareatually ...... ------toparticipateas - -. - usingthe service? ------providers? He Anga Whakamana - A framework for the delivery of disability support services for Mori Produced by Te Pamanawa Hauora, Massey University, He Anga Whakamana was advice produced for the (then) National Advisory Committee on Core Health and Disability Support Services [Core Services Committee].
In commissioning the report, the Core Services Committee was particularly interested in:
• the philosophy of a disability support service that would be acceptable for Maori people;
• the characteristics that distinguish the development and delivery of disability support services (dss) in a way that will be of maximum benefit to Maori people; and,
• the ways in which quality can be assessed to ensure services are appropriate and beneficial to Maori.
The report proposed a culturally appropriate philosophy for dss for Maori and a framework based upon principles, service implications and indicators.
The three cornerstones which underlie the philosophy are:
Ic HA o te Tangata - Respect for Clients
• Te Herenga Tangata - A Community Focussed Approach
• Whakapakari MAori - Workforce Profiles.
Each cornerstone contains two levels of focus. The first level focuses on the disability itself, and does not necessarily suggest differences between Maori and non-Maori clients. The focus of the second level is on cultural factors relevant to MAon people with disabilities.
Consistent with the philosophy is He Anga Whakamana, a framework for the delivery of dss for Maori.
The six principles are:
• Whakapiki - enablement
• Whai wAhi - participation
• Whakaruruhau -safety
• TUtika - effectiveness
• Putanga - accessibility
• WhakawhAnaungatanga - integration
The authors stated that the principles translate to service implications which are associated with measurable indicators. 13
The indicators provide guidelines as to appropriate measures for use in monitoring services, though the actual indicators and measures are best negotiated between purchasers, providers and clients. 15
The authors proposed service implications stemming from each of the principles, and further described indicators as guidelines to measures which the provider would negotiate with clients and the purchasers when developing.
akm
P.
4. :m rIIsIv : ser vice op ions
15 NM Ratima, TvlH Dune, etal.., (1995), HeAnga Whakamana - A fran:eworkfor the delivery of disability support services for Maori, NACCFIDSS, Wellington. A number of indicators are then proposed as guidelines to the development of measures. These indicators and measures include:
• quality information collection, included asking how data is collected, which definitions for Maori are used, whether collection is purposeful and consistent, and whether issues of confidentiality and guardianship are considered in the management of data and information?
• client participation, including whether there are clear process for client input, whether there is choice for Maori clients, and whether there is input into monitoring and review processes?
• caregiver/case manager participation, including whether there is assessment of Maori institutions on behalf of the client, whether there is understanding of Maori perspectives and values by the caregiver/case manager. Also, asking how the caregiver is involved in programme development, planning, implementation and review?
• whAnau participation, including whether there is involvement of whflnau in services, the recording of interactions, the purpose and meaningfulness of participation, the interaction of the client and whanau beyond the service, and the availability of facilities for whanau including accommodation.
• appropriate use of the MAori language, including what is the extent of use of Maori language within the service, are Maori speaking staff available, is written information provided in both Maori and English?
• links with Mãori institutions, including whether links exist, the extent of linkages and the participation of Mori organisations in the service.
• consistency, including whether the service is available 24-hours a day, whether policies for Maori exist, whether there are explicit contact points for clients and their whanau, and whether outreach services are available?
• workforce composition and sensitivity, including whether professionally and culturally qualified staff are actively being recruited, how many Maori staff are there, are Maori jobs designated, is bicultural training and integral aspect of staff development.
• assessment procedures, including assessing how cultural factors are included in client assessments, how the client and their whanau participate in assessments, and whether assessments include a formal cultural profile.
• consultation, including whether Maori are involved in the overall development and planning of services, the extent of the consultation, who was consulted, whether there was agreement among those consulted and whether there are arrangements for continued Maori input.
• MAori specific factors, including whether there is a process for referral to Maori specific services, especially Maori traditional healers. The CHI audit model - culturally appropriate Public Health Services Produced by Te Pamanawa Hauora for the former Public Health Commission, the CHI audit model recommended both the attributes which any cultural audit model should attain, as well as a specific model for providers of public health services for Maori.
The proposed model was usefully based on initiatives developed over the past decade to monitor and assess health and Maori policies and programmes . These public sector models included:
• Department of Health Performance Indicators 16
• Hauora Maori Checklist
• Ministry of Women s Affairs - Responsiveness to Maori Plan s
• Te Raranga Kete from Te Puni KOkiri19
• The Dual Focussed Framework20
• The Royal Commission on Social Policy21
Dune s analysis of these various models resulted in the identification of a framework, the CHI audit model which is composed of
• three key features;
• seven themes grouped into goal categories;
• around 29 indicators, associated with the themes.
The three key features are consolidation, holism and integration, hence CHI.
There were seven themes proposed, grouped into three goal categories:
• themes consistent with Mãori development goals:
• the Treaty of Waitangi
• empowerment
• themes associated with gains in MAori health:
16 Coopers and Lybrand, (1990), Performance Monitoring System, Improved direction, performance and accountability (Maori Health), Department of Health, Wellington.
17 Department of Health, (1990), Hauora Maori Check List, Department of Health, Wellington.
18 Maori Caucus, (1993), He Kaupapa ... He Hanga Tikanga: A Foundation ... Shaping a Way, Ministry of Women s Affairs, Wellington.
19 Te Puni KOkiri, (1993), Te Raranga Kete - A Process for Reviewing Government Services, Ministry of Maori Development, Wellington.
20 Treaty-based framework made up of provisions and principles was first used in a report prepared for North Health by G Doherty and MIT Dune in June 1993.
21 Royal Commission on Social Policy, (1988), The April Report, Vol. ii, pp. 47-69. • national standards and Government obligations,
data and information,
• active involvement
• themes which take account of Mäori cultural values and beliefs:
• cultural safety,
• intellectual property rights.
Appropriate indicators for each theme would need to be negotiated, in this case, between the Public Health Purchaser and the service provider.
Indicators could include
• kawanatanga • tino rangatiratanga • oritetanga • partnership • participation • active protection • extent of Maori involvement in planning, delivery and monitoring • opportunity for Maori ownership • Maori community involvement • Links to positive Maori development • Relevance to Government objectives for Maori health • Recognised Maori health priority • Links to Public Health Goals • Arrangements for obtaining ethnic data • level of accuracy of ethnic data • reasons for seeking ethnic data • method of transfer of technology to Mori • level of programme priority for Maori • % Maori workforce • numbers of Maori likely to be targeted in the programme • circumstances of Maori targeted in the programme • consultation with appropriate tangata whenua • identification of areas where cultural factors will be significant • strategy to satisfy cultural needs • involvement of Maori in planning and implementing cultural safety strategies • sources of cultural information acknowledged • permission obtained to use cultural knowledge • cultural material given due respect • efforts made to retain an appropriate context when using cultural information or practices.
Providers are invited to develop there own set of measurements, subject to endorsement by the purchaser, and the project is then audited according to those measurements. MH
Guidelines for purchasing personal mental health services for Mãori Produced for the Mental Health Services Section of the Ministry of Health by Te Pamanawa Hauora, the report sought to develop purchasing guidelines for personal mental health services for Maori. In particular, the development of:
• a framework through which culturally effective services can be identified and assessed;
• a cultural effectiveness scale for the measurement of mental health services in terms of their capacity to meet the mental health needs of Maori.
The framework produced consisted of two interacting dimensions labeled purchasing options and purchasing principles .
Table 2: The Culturally Effective Purchasing Framework.
The framework is not a checklist; rather its potential value was thought to lie in its use alongside other frameworks to ensure that key issues relating to personal metal health services for Maori can be considered in relationship to each other.
Essentially the framework was intended to clarify for purchasers the balance between:
• cultural and clinical parameters
• mainstream and Maori services
• narrow and broad outcome measures
• short term and long term benefits
• health sector development and Maori development.
Following from the first framework, a cultural effectiveness scale was developed by the authors. The Cultural Effectiveness Scale has three dimensions with 3 sub-scales. The final product of all three sub-scale scores would constitute a cultural effectiveness index (CEI), a short hand measure of the capacity of a service to meet Maori mental health needs in an effective and culturally appropriate way. Table 3: Cultural Effectiveness Measures
.I)meñsionsH COthpolleIti fsPossi b1eJWeasuref.
i\ 1ori Affirmation • cultural inputs % time allocated to cultural activities (MA) • Maori expertise degree of appropriateness
JI haical 1nputs asseihent -Lreatrnentiir protocols completed______rehailatationäctivitie -
Health Outcomes • level ofeUness SF-36
(HO) Whare Tapa Wha
22 The SF-36TM is a self-assessed health status tool, trademarked to the New England Medical Centre. 19
Rationalisation of the frameworks
Clearly one of the difficulties in rationalising the various frameworks is that, while they each identify criteria for cultural effectiveness (in different service settings), the criteria are sometimes presented as having a different order across the frameworks. That is, the same criterion may be represented, for example, as an overarching principle, a theme or an indicator.
Another complication for users of the frameworks is that the taxonomy which applies to these orders has, by and large, reflected the preferred language of the authors rather than some standard nomenclature. There are cornerstones , principles , service implications and indicators ; attributes and elements ; features , themes and goal categories ; dimensions , "components and measures
In rationalising the frameworks, and to simplify the analysis, we have initially adopted a standard, if unimaginative, nomenclature - first order , second order and so on. Based on the frameworks analysed we can summarise the orderings as follows.
First order criteria These tend to be overarching in the sense that they are fundamental to the philosophy of the particular framework.
Second order criteria These tend to be thematic in the sense that they represent significant aggregations of ideas constructed in a way to assist the reader by modeling some ideal.
Third order criteria I These tend to be at the level of specific measures or indicators, usually related to an individual second-order criterion or more generically to the set of second-order criteria.
The frameworks also contain a number of useful devices, designed to assist the reader, which are worthy of mention (and modeling).
He Taura Tieke gives standards for its second-order attributes which describe a service operating at a high level of performance 23. These standards are set in order that the service might better meet the expectation of the Maori consumers.
He Anga Whakamana introduces a fourth level of criteria with goal categories , apparently between the first and second-order criteria. These goal categories may be useful in reinforcing the contribution of the groups of second-order criteria to the outcomes desired.
Among the four frameworks we are able to identify a number of consistent themes which assists us in specifying the standards which effective health policy for Maori needs to achieve.
23 oha Hams, personal communication. 20 Checklist
Elements of framework - Effective Health Policy for Mâon
One of the problems policy analysts have in interpreting current frameworks for responsive policy is that these frameworks frequently mix process and content indicators.
The framework developed in this report seeks to be much clearer in differentiating between the process of policy development and the outcome of the particular policy which is being developed.
The framework has three principal first order criteria based on reasonable expectations of health policy for Maori. Effective health policy should:
• support health gains for Maori (policy outcomes)
• be responsive to Maori needs and expectations (policy outcomes and policy development process)
• be analytically sound (policy development process)
Within each first order criterion are a number of second order criteria which form the basis of the checklists: 21
• recognises and addresses the detcrminants of Maori • policy outcome - health status supports Maori • enables Maori workforce development health gains • addresses the Governments health priorities - • is consistent with the Government s Mlori
• respects aor i ntellectual pro pohcv development . . . • actively involves Mori in polv • •cvc•o.. process is responsive • actively involves Maori in dcc ision niaing Maori• consults meininfullv with Maori • affirms \1ri cultural viewp)Ints • is culturalls site • acknowlcdgc th eghts/special , -, needs of taligata whcnua • identifies ti ....o /tangata whenua relationshir • respects Maon and in turn develops trust .22 Effective Health Policy For Maori ...... MPoiiyMeei uh
policy outcome supports Mãori policy outcome is responsive health gains to Mãori • recognises and addresses the determinants of • identifies Maori as a relevant target group Maori health • promotes choice for Maori • enables Maori workforce development • responds to diverse Maori realities • addresses the Government s health priorities • recognises and addresses Maori development • is consistent with the Government s Maori priorities Development and Treaty policies • promotes seamlessness (of services, and, • addresses health priorities of MAori between health and development) • promotes Maori wishes to take responsibility for • promotes cultural affirmation for Maori their own health • improves accessibility for Mori by addressing • uses available national standards and meets known barriers to access Government obligations • promotes and supports informed choice • requires quality Maori solutions and specifically • promotes improved communication with MAori supports outcomes specified in relevant, existing • supports Maori preferences for service providers wisdom (including services provided by Maori) • requires competent, safe and efficacious services • promotes appropriate use of te reo MAori • enables meaningful data to be collected • promotes linkages to Maori institutions • promotes goals which relate to measurable outcomes
policy development process is policy development process is analytically sound responsive to Miori is based on a rigorous policy development model • respects Maori intellectual property rights (management sign-off, consultation with Te Kete • actively involves Maori in policy development Hauora/MAori Advisors (audit trail)) • actively involves Maori in decision making • is clearly based on a framework consistent with Maori views (Treaty of Waitangi, Whare Tapa • consults meaningfully with Mãori Wha) • affirms Maori cultural viewpoints • clearly provides for a monitoring process • is culturally safe; uses te reo Maori correctly • meaningfully uses MAori specific data • acknowledges the rights/special needs of tangata • identifies Maori as a relevant target group whenua • identifies the impact on Crown/tangata whenua relationship • respects Maori and in turn develops trust
all policy developed within the Ministry of Health will impact on Maori in some way therefore it is not an issue of whether there is an impact but rather how much of an impact there is and how well we manage that impact;
• a Maori analysis is as fundamental as an economic analysis to the development of policy within the Ministry if we are to realistically address our commitment to Maori and, to advance Maori health as we are required to do. .23
The following table has been designed as a supplement to the checklist. The criteria have been extended, in the third column, to include an identification of the information which is required for analysts, who may be competent analysts but relatively uninformed in a Maori health sense, so that they can better undertake their tasks. The fourth column identifies measures which could be included in the specific policy. These are measures of the effect of the policy rather than measures of the written policy itself. If a set of (relatively) standard measures could is embedded within policies it may be possible in the future to measure the effect of such policies in supporting, or otherwise, Maori health gains.
LxPecta I iuflS 01 Means (policy Riq U ires (nut \ I ca surcs and F_ffceiit Iltalili should) necessarily Ironi indicators (to be built Poiks br \ln I ku)ifllt polici)
policy outcome • supports Mori • health gains
enables Maori statement of Maori 0/) Mflori workforec in workforcc healthworkforce priority areas; number of development development priorities Mori staff represented in professional ranks
measurement of Maori asacon with workforce ... 0 development methods
addresses the clear articulationof measurement of change in Government s specific Maori health health and disability status health nrioriiics rnrilics for cxarnnlc indicainrs .
cldde ao
is consistent withknowledge of measurement of outcomes Government s Government s Maori against M3ori Maori Development Development and Treaty DcvclopmcnL and Treaty of and Treaty of of Waitangi policy Waitangi policies Waitangi policies
addresses health knowledge of priorities measurement of changes in prioritiesof Maori based bah ealth and health and disability status disability status analysis cators
knowledge of articulated health and disability status Maori views on priorities mcasurcsinclude Maori view of health 24
Expectations of Means (policy Requires (not Measures and Effective Health should) necessarily from indicators (to be built Policy for MAori TKH) into policy)
promotes Mäon knowledge of approaches measurement of success of wish to take which enable Maori to •::policyin;terms of responsibility for successfully take promoting Maon their own health responsibility responsibility
uses available national minimum : ...... monitoriiiofoutpütsand national standards standards (e.g. service outcomes, perhaps by and meets, . , . obligations) ...... Ministry ofHealth s Government ...... Performance Management obligations Unit
requires quality . quality Maori indicators inclusion of measurements Maori solutions and (eg. RHAoiitT eti: as identified within body of specifically schedules) available advice supports outcomes speci&d in . analysts have access to
... relevant, existing the bodyofavailable . . ,• wisdom wisdom /advice
requires competent; operating standards for measurement against safe and efficacious performance of health Maori expectations (see He services . .,and disability services ..TauraTreke)
enables meaningful : standards for Maori data meaningful data collection data to be collected are set and clearly for use in monitoring the to contribute to articulated policy outcomes momtonng outcomes
promotes goals...... knowledge of tools :, measurement of success of ivhichreiàte to available for "measuring of outcomes measurable meaiiingfully measuting outcomes outcomes for Maori (e g SF36?) .
policy Outcome is identifies Maori as knowledge of how to measurement of extent to responsive to a relevant target assess relevance which relevance is Mâori group satisfactory to Maori measurement of relative improvement in Maori health status
promotes choice for knowledge of range and measurement of Maori Maori type of choices satisfaction with choices appropriate for Maori; made available Maori expectations (see He Taura Ticke) ..25 I .26
Expectations of Means (policy Requires (not Measures and Effective Health should) necessarily from indicators (to be built Policy for Mori - TKII) into policy)
promotes improved knowledge of effective measurement of Maori communication communication methods H. satisfaction with with Maori for Maori communication methods
knowledge of prerred measurement of Maori modes for information satisfaction with provision carriage of information
supports Maori I knowledge of Maori measurement of Maori preference for preferences satisfaction with policy choice of services outcome (including services knowledge of Maori : provided by Maori) providers
promote knowledge of legal status measurement of Mori appropriate use of of te reo Maori satisfaction with policy tc rco Maori outcome in respect of te rco Maori.
promote linkages to knowledge of benefits of measurement of existence Mori institutions linkages to Maori of links las an effective institutions strategy for 11 measurement of mainstream knowledge of Maori participation and providers] .• models and Maori satisfaction of Mori institutions to link to organisations
policy ... .. respects Maori . knowledge of Maori measurement of Maori development intellectual propeth attitudes to intellectual satisfaction . ith treatment rights propert (including of their intellectual process kiiov ing hat counts asas : propert responsive to Maori intdkctual Moii propulI)
activelv . involvcs ... knowledge ôfmost measurementof Maori Mario inpolic appropnate methods for satisfaction with methods dc .elopment inoh.ing Maori uscd
know lcdgc of suitable measurement ol nature of M tori forin ol ement Maori i n ol cmnt (c g Maori with rele ant includint appropriateness . skills and expertisc and iLisliction h result
acLi%cl inokcs knowledge of most measurement of Maori Maori in decision appropnatc methods for satisfaction siLh methods making involving Maori used
know ledgL of suitabk measurement of nature of Maori for inolcincnt Maori inohcmcnt . g Maori with rLk% ant ig... ppp.1 skills and expertise and satisfactiôii with result
.27
consults knowledge c measurement of extent and
meaningfully with of effective nature of Maori
is culturally safe: knowledge of relevant measurement of Maori uses te reo Mori cultural safety issues satisfaction with cultural correctly safety: appropriate use of me reo Maon
acknowledges the measurement of rights/special needs satisfaction of tangata of tangata shenua -- whenua I, ....tat. measurement (II knowledge of Crown satisfaction of(.ro%n position with respect to langata w henua
till th L nm leJi.e ,l . r wii and mcasurcment ol 1fl1UL Oil tHC M,ri position g satisfaction ol .. Crown/tangata characteristics of whcnua whenua relationship relationship measurenient of satisfaction of crown
respects Maori and honest and pen process measurement of extent to in turn develops rs""" .h,.h t.4n.. fo.,1 thns mist of rocecs by
SIAIJI.L...fl LKL ...... 28
Lpectitions of Means (policy Requires (not Measures and Tffec1i e Health should) iiecess rily from indic flors (to be built Policy for N, I5ori TKII) itito policy)
is based on inowle4ge of i ngorous sidLnct of use of in rigorous polici policy modU (Nliriistrs appropriate modLi P rocess de\LloprnenI modcl o}Iealth polic\ an.itSts consultation (audit iriti) (ins mi inement Manual) anal\ ticall y sound sion consultation ssitli fe Kete HauoralMaon EIIIIIII RIM Ads isors (audit trail),
be clearly based on knoss ledge of aailablc es deuce of consistenc\ a framework which frarnessorks and their with appropriate is consistent Xvith rcle\000e (C g Treart of 1raniesork Mon \ie\ s (of Waitangi: \Vhaia te ora health and N1tori mo (c issi. Whare Tapa development e.g. Wha: Ottawa Charter) ToW, \Vliare Tapa
cicark provide for a knowledge of methods evidence of nionitori rig monitoflng process for mom lonng process process as part of polic both for the policy s and outcomes output des elopinent and its desired outconics
ineani ng1till use knossledge of the short- evidence of appropriate use Mori specific data comings of available of data data (e g biases) evidence of impros ement actiN,clv support the in available data as a result id collection of accurate 01 policy efforts data as a polie\ outcome ( or the policy
identification of knowled ge of policy evidence of improved Mori as a relevant his1or. for N11ort policN, des etopmenl process target group and policy outcome
Successful implementation of the checklists will be dependant on a number of issues:
• ownership of the checklist by the Ministry;
• high level organisational endorsement (Director-General, General Managers);
• training of analysts;
monitoring of use of checklists/outcome of use of checklists;
on-going revision/review of checklists; and, .29
the supply of additional resource information, most likely by Te Kete Hauora.
It is this last point where additional work must be undertaken to support the use of the checklists.
Future work
There are a number of pieces of information which need to be collated and made available to ALL policy analysts to support the development of effective health policy for Maori:
• the description of various models of the Maori view of health (Whare Tapa Wha, Wheke, Whaiora);
• the collation of the results of research on determinants of health (for Maori)24;
• the articulation of workforce development priorities;
• the clear articulation of Maori Development and Treaty of Waitangi Policies (Coalition Agreement);
• the clear articulation of priorities for Maori (e.g. analysis of hui proceeding etc);
• examples of effective Maori health services/interventions;
• health priorities for Maori based on an analysis of health status (e.g. morbidity and mortality statistics; SF-36);
• an anthology of current wisdom in Maori health; and,
• standards for information promulgation and data collection.
24 The National Health Committee is currently undertaking a project to collate the material on Social, Cultural and Economic Determinants of Health. .30 Appendix 1:
Background Literature
The following listing provides detail from the base material used in the analysis for this project, and has been organised under each of the primary and secondary criteria proposed in the framework. The listing is provided in order to give analysts specific detail to assist in developing their policy proposals.
A bibliography is given at the end of this appendix.
POLICY OUTCOME SUPPORTS MAORI HEALTH GAINS
RECOGNISES AND ADDRESSES THE DETERMINANTS OF MAORI HEALTH STATUS • Factors which determine the health status of Maori include: geographic, expectational and cultural issues, and socio-economic status. When looking at Maori health statistics it is important to assess the quality of the information available and the data collection process used.
• "Socioeconomic factors such as health, income, employment, housing and education are strongly related to health" (Pomare, E., etal., 1995:145). However while socioeconomic elements are significant they are not necessarily accurate "indicators of health status" (Pomare, B., etal., 1995:147).
From consultation undertaken by the Public Health Commission in 1994 a number of factors were named as affecting the public health status of Maori. Those who were part of the consultation process suggested "a need for Maori-specific policy to address the essential problem which is that the major determinants of public health status are social and economic" (Public Health Commission, 1995a: 16). Factors named include: employment, household income, income support, cost of services, poverty, land loss, urbanisation, housing, isolation, health literacy, language, education, socialisation, information, identity, pollution, other environmental issues, religion, wairua, legislation, whanau breakdown, racism, ethnicity, inequity, monocultural health system, colonisation, and political status (Public Health Commission, 1995a: 16).
• "Inequitable access to utilisation of primary health care services is a significant factor contributing to the inequities in health status between Mori and non-Maori" (Te Puni Kokin, 1994:9).
• Lack of finances is a barrier which limits Maori access to health services, and reflects the low utilisation by Maori, particularly of primary health care (Malcolm, L., 1996:358).
• To improve the health status of Maori (and other disadvantaged New Zealanders), Malcolm (1996:356) recommends a review of issues concerning finances and access.
• Both poor access and a lack of utilisation of primary care services are elements which result in the high use of hospital inpatients services. (Malcolm, L., 1996:3 56) • If patients do not have regular checkups, and discontinue any proposed treatment, the health problems which may arise are likely to be "multiple and complex". (Malcolm, L., 1996:358)
• Access issues are likely to be a significant cause in low Maori health status and a lack of improvement in Mori health status. (Malcolm, L., 1996356)
• Malcolm (1996:358) has found that poor populations may experience a lack of access to public transport and may live in a rural area with isolated populations.
Maori generally do not see the advantage in using primary health care. Treatment may be avoided for cultural and other reasons. This can eventually lead to a need for hospital admission when unresolved health problems have become worse or exacerbated. Hospital inpatient utilisation can therefore be directly related to access barriers to primary medical health services. (Malcolm, L.,1996:358)
• In Policy Guidelines 1996197, (Shipley, J., 1996:12), the policy goal associated with equity is: to improve equity of access for New Zealanders to health and disability services in terms of waiting times, geographical access and affordability.
• Importantly, health services are only one means to improve health status. (Malcolm. L., 1996: 356)
• Malcolm (1996:358) suggests a long term answer may be "managed care" for all populations including Maori. Care targeted at a determined population and based on funding provides a means to remove the balance of "care from secondary to primary" (Malcolm L.,1996:358).
• Managed care is "the process by which, within an agreed budget, comprehensive primary and a range of secondary care services are provided which are fully coordinated from the primary care level" (Te Puni Kokin, 1994:8).
• Kilgour and Keefe (1992) have indicated a lack of compatibility in the collection of ethnic data.
• Problems occur when data used may originate from a number of sources who have constructed different definitions of "Maori" and "ethnicity". (Pomare, E., et al., 1995:43). As well, it is difficult to present an accurate analysis if present data systems are unable to be compared with earlier data.
• The Maori Disability Framework (Potaka, U.K., et al., 1994) is a useful model which provides minimum standards for the collection of information.
See also Collection of Data.
ENABLES MAORI WORKFORCE DEVELOPMENT • A representative and competent workforce, with an understanding of Maori perspectives allows for a workforce which can promote cultural understandings. (Ratima, MM, etal., 1995: 41)
• It is an expectation of Maori that Maori are employed and developed as staff at all levels as a specific means of contributing to Maori development (Population Health Services Section, 1995). The greater participation of Maori working at all levels of the health sector should be encouraged.
• Maori are under-represented in professional ranks involving planning, policy and decision-making (Durie, M.H., 1993a: 16). 32
"Good Employer Personnel Policies should seek to address the:
(a) aims and aspirations of Maori people; (b) training and developmental needs of Maori employees; (c) need for greater involvement of Maori employees of the employers" (Department of Health and Te Puni Kokiri, 1993:15)
• An effective workforce can be arrived at through: the active recruitment of professional and culturally qualified staff, by designating specific positions within the service for Maori, and by incorporating a bicultural component into staff training (Ratima, M.M., et al., 1995:46).
It is crucial that employers acknowledge that the active employment of Maori in the health workforce is directly related to Mori health outcomes. (Dune, M.H., 1993a:12). Policy Guidelines for Maori Health 1996197 (Shipley, J., 1996:17) states "there is an extricable link between health improvements for Maori and the participation and involvement of Maori personnel across the purchasing and provider functions".
• For mainstream health services, active consideration will need to be given to training and employment strategies (Dune, M.H., 1993b:21).
• Maori professional participation within health should be a goal (Dune, M.H., 1993b:21). There is a need to ensure that Maori quotas are filled in universities and medical schools and for Maori to become qualified health professionals.
• In the short-term, employment opportunities for Maori in liaison or advisory positions to work with other professionals need to be made available (Dune, M.H., 1993b:21).
ADDRESSES THE GOVERNMENT S HEALTH PRIORITIES • The Crown s objective for Maori health is "to improve Maori health status so in the future Maori will have the same opportunity to enjoy at least the same level of health as non-Maori" (Department of Health and Te Puni Kokiri, 1993:13).
The development of purchasing strategies for all health service areas are instructed by Government s Maori health policy directions. They are: greater participation of Maori at all levels of the health sector; resource allocation priorities which take account of Maori health needs and perspectives; and the development of culturally appropriate practices and procedures" (Department of Health and Te Puni Kokiri, 1993:14).
• The four health gain priority areas identified in 1994/95 continue to apply in 1996/97 i.e. child health, mental health, physical environmental health and Maori health. (Shipley, J., 1996:14).
Key issues for Maori health as shown in the Policy Guidelines, 199617 (Shipley, J., 1996:14) include: service delivery and decision-making systems which are responsive to Maori needs; integrated and cost-effective systems responsive to diverse Maori realities; access to information; improving the collecting of health statistics; the implementation, monitoring and a demonstration of progress to improve Maori health; the incorporation of He Matariki; and a focus on the health of the whanau.
• A commitment to Child Health can improve health gain by: reducing mortality and morbidity; increasing the length and quality of life; and by strengthening families. Policy Guidelines 1996197 (Shipley, J., 1996:14) proposes a number of key issues which include: well-child/tamariki ora services; the role of parents 33
and caregivers; pregnancy; preschool children; at-risk families; recognising the correlations in ethnicity, lower socio-economic status and lower health status; improving co-ordination, integration and access to services across settings for at-risk school children, adolescents and their families in consultation with schools and other relevant agencies.
In the area of Mental Health the intention is to lessen the prevalence of mental illness and to decrease the impact of mental disorders on consumers, their families, caregivers, and the community. Key issues include: health promotion; promotion of mental health; early identification of mental health problems and positive help-seeking behaviour; the purchase of mental health services; understanding services contribution to outcomes; consultation and liaison services; improving access; the development of specialised mental health services; the development of the workforce; and the deinstitutionalisation process (Shipley, J., 1996:14-15).
• The aim in regards to Physical Environmental Health is to effect an environment which "improves and protects the public health" (Shipley, J., 1996:15). Health gains can be attained by focusing on areas which "reduce mortality, disease, injury and disability, and increase length and quality of life" (Shipley, J., 1996:15). A number of key issues are given in Policy Guidelines.
• To achieve health gains for Maori the disparities between Maori and non-Maori must be addressed as well as an acknowledgement of the Crown s partnership responsibility to tangata whenua. (Shipley, J., 1996:14)
Context, identified as a key area in A Maori Policy Analysis Framework for the Ministry of Health (Te Aho Associates, 1995:7) refers to the "environment within which the policy is being developed". This comprises the "organisational focus" of the Ministry of Health together with the Ministry s commitment to advancing Maori Health, and also includes the impact which social issues may have on policy development activities (Te Aho Associates, 1995:7).
IS CONSISTENT WITH THE GOVERNMENT S MAORI DEVELOPMENT AND TREATY OF WAITANGI POLICIES Ka Awatea (1991) states that positive Maori Development is key to addressing Maori social, cultural and economic well-being, and reducing disparities between Maori and non-Maori.
In Whaia te ora mo te iwi (Department of Health, 1992:22) the "Government regards the Treaty of Waitangi as the founding document of New Zealand" and acknowledges that the government must "meet the health needs of Maori and help address the improvement of their health status". This is reinforced in Policy Guidelines for Mdori Health 1996197 (Shipley, 1., 1996:16) which states, "the Government affirms that the Treaty of Waitangi is the Nation s founding document" and that "the particular relationship of Maori, as tangata whenua, with the Crown, under the Treaty of Waitangi" must be acknowledged by RHAs.
The Dual Focus Framework, "a combination of Treaty provisions and principles can be used as a basis for a framework in which Maori health objectives can be" achieved. (Dune, M.H., 1993a: 10). "The Dual Focused Framework (and the Hauora Checklist) come closest to operationalising the Treaty so that it can be usefully included as part of an audit mechanism" (Dune, M.H., 1993a: 13). "The DFF provides a ... template for ... assessing development strategies that will achieve gains in Maori health" (Dune, M.H., 1993a:10) .34
The 3 key Treaty provisions are kawanatanga, tino rangatiratanga and oritetanga. Kawanatanga (from article one) "is a provision for the Government to govern" (Dune, M.H., 1993a: 10). Tino rangatiratanga (article 2) provides for tribes to exercise authority of their own affairs, and ontetanga (article 3) "guarantees equality and equity between Maori individuals and other New Zealanders" (Dune, M.H., 1993a:10, note: "A Treaty framework made up of provisions and principles was first used in a report prepared for North Health by G Doherty and MH Dune in June 1993")
• "A number of Treaty principles have been proposed over the past two decades though for different purposes" (Dune. M.H., 1993a:10) The Royal Commission on Social Policy (1988:47-69) provided three principles relevant to social policies including health: Partnership, Participation, Active Protection.
• The principle of partnership acknowledges the relationship "between the Crown or its agencies and iwi" (Dune, M.H., 1993a: 11)
• Participation comprises at least 3 levels, namely participation by Maori individuals, by iwi or hapu, and by invitation. Participation "emphasises positive Maori involvement in all aspects of New Zealand society" (Dune, M.H., 1993a:11)
• The principle of Active Protection refers to the Crown s obligation to actively protect Maori interests and is "about health promotion and preventative strategies and implies that the State will adopt pro-active approaches and seek opportunities for the enhancement of Maori health" (Dune, M.H., 1993a: 11)
• As stated in Mdori Poll cyAnalysis Framework (Te Aho Associates, 1995:7), the Treaty of Waitangi is a "fundamental part of the development of policy that impacts on Maori".
ADDRESSES HEALTH PRIORITIES OF MAORI • The four health gain priority areas named in Policy Guidelines for Regional Health Authorities 199411995 still apply in 1996/97 (Shipley, J., 1996:14), i.e. child health, mental health, physical environmental health and Maori health.
• To meet the special needs of Maori, the Government requires purchasers to enlist and support health services and initiatives which "promote positive health for Maori" (Department of Health and Te Puni Kokiri, 1993:13).
The themes in Ka Awatea are reproduced in the Maori health policy provisions of the Coalition Agreement. Included are:
• the development of Maori providers and the Maori health professional workforce • increased resources for Maori health • a focus on health gains and outcomes • continued improvements in the effectiveness of Crown-owned providers (Steering Group: 1997:54).
• Maori Youth and Whanau Development have been named by Maori as two health priority areas (Dutie, M.H., etal., 1995:33-37).
• At Te Hui Whakaoranga (1984) the need for iwi health services was emphasised. By 1994 however, while Dune (1994a: 128) acknowledged the need for this type of service, in response to the diverse realities in which Maori live a move towards whanau development and a "focus on ordinary Maori households" was suggested. .35
• Later in 1994 at Te Hui Whakapuniau (the Maori Development Conference, August 1994), a number of speakers reinforced this proposal by advocating that "whanau development become a priority". As Professor Dune (1994b: 170) states "the challenge will be to respond to Maori, regardless of socio-cultural position, and whanau development will become a significant step in that direction".
The Ministry of Health (1995b) release, Effective Services for Young People: Te Totora o Toku Whanaketanga, has been designed as a guide for RHAs and providers to develop services which improve the accessibility of youth to a more responsive health care system.
Also see Diverse Maori Realities.
PROMOTES MAORI WISHES TO TAKE RESPONSIBILITY FOR THEIR OWN HEALTH • Maori expect to be able to exercise authority over their own health affairs (Ministry of Health, 1995a, see checklist).
• The Steering Group s report to the Minister of Health, states that the concept of - "rangatiratanga" "recognises Maori aspirations for autonomy and self-sufficiency with reduced reliance on the state and the development of services managed by Maori" (Steering Group, 1997:55).
• Three consumer driven themes related to the operation of funding and disability support services were prominent at a Core Services Committee consensus development conference: the desire for autonomy and self-determination, the desire to be in control of our services, and a move away from charity to a rights based approach. (Core Services Committee, 1993a:6).
• The Ottawa Charter states that "people cannot achieve their fullest health potential unless they are able to take control of those things which determine their health". The strategies proposed within the Ottawa Charter infer that Maori health should be a priority, that opportunities for Maori to take responsibility for their own health are made available, that Maori are empowered through training and education, and that service provision by Maori is advocated.
• Bicultural issues and the treaty need to be addressed to allow Maori to take responsibility for their own health (Core Services Committee, 1993b).
• Iwi, Maori groups and organisations need assistance to enable them to be responsible for their own health. Maori should be encouraged to participate as providers (Ministry of Health, 1995a).
• "Good health is an active process and empowering communities to deal with their own health issues, whenever possible, reinforces the notion of greater control and self direction" (Dune, M.H., 1993a:14).
• Maori health initiatives should be developed and maintained to empower Maori to become responsible for their own health (Dune, M.H., 1993a).
USES AVAILABLE NATIONAL STANDARDS AND MEETS GOVERNMENT OBLIGATIONS "Central Government ... has a role to playas protector of the populations health. In respect of Maori people that role carries with it some responsibility for proactive strategies so that all policies, across the range of social and economic interests, w be consistent with good health" (Durie, M.H., 1993a:15). 36
• Government objectives for Maori health show a commitment by government to improve Maori health and to reduce the disparities between Maori and non-Maori health status (Department of Health and Te Puni Kokiri, 1993:13). Health programmes must have regard for "disparities in health standards and seek to reduce them" (Dune, M.H., 1993a:15)
• To provide a safe and competent service, professional organisations, providers and the Ministry of Health must conform with "legislation, regulations, standards and best practice guidelines" (Population Health Services Section, 1995:9 also see checklist).
• The Ministry of Health and the Regional Health Authorities can bring about systems which are responsive by adhering to "policy guidelines, contractual arrangements, and monitoring procedures" (Population Health Services Section, 1995:10 also see checklist).
• It is the duty of service providers and the RHIAs to ensure that consumer needs are fulfilled by "matching service provision to Maori expectations" (Population Health Services Section, 1995:11 also see checklist).
Included in the service obligations for Maori health, as shown in Policy Guidelines 1996197, (Shipley, J., 1996:16), it is suggested that RHAs and their providers should incorporate the Government s response to Maori issues as stated in Whaia te ora nio te iwi (Department of Health, 1992). This is essential to improving Maori health status in a manner appropriate to meeting Maori needs and aspirations and upholding the relationship between Maori as tangata whenua, and the Crown.
REQUIRES QUALITY MAORI SOLUTIONS AND SPECIFICALLY SUPPORTS OUTCOMES SPECIFIED IN RELEVANT, EXISTING WISDOM The incorporation of a Maori framework/s together with monitoring and assessment procedures (including evaluations and standard setting) will assist in producing quality Maori solutions.
• In He Anga Whakamana (Ratima, M.M., et al., 1995:44-47) relevant indicators and measures provided are: quality information collection, client participation, caregiver/case manager participation, appropriate use of the Maori language, links with Maori institutions, consistency, workforce composition and sensitivity, assessment procedures, consultation, and M specific factors.
• Quality solutions for Maori may include cultural safety measures, staff training and Maori consumer awareness practices.
• In explaining the principle of Quality, Guidelines for Purchasing Personal Mental Health Services for Mãori, (Dune, M.H., 1995:18) states that "in any service high standards of care and treatment are necessary and this should be reflected in outcomes".
• The RHAs "require providers to participate in quality improvement processes which are effective across all cultures" (Shipley, J., 1996:20). Quality improvement objectives given include: responding to the special needs of Maori, using best practice guidelines, and appropriately matching the skills of staff with the needs of the client group (Shipley, J., 1996:20).
• A representative workforce who "have a sound knowledge and ... understanding of tikanga Maori and Te Reo Maori" is vital to meeting Maori needs (Ratima, M.M., et al., 1995:41). ..37
• Included in submissions to the Public Health Commission in 1994, was a strong desire for a "restoration" of Maori health status. A focus on "strengthening the whanau as an institution and as a pivotal vehicle in which to promote sound interventionist policies and programmes" was encouraged (Public Health Commission, 1995a: 17).
• The utilisation of existing wisdom (for example, mythology, common sense, the inter-disciplinary application of knowledge) should provide something quantifiable which can be used to either prove or disprove a particular theory or idea.
• Knowledge is required of the background or history of the policy (i.e. where the policy has come from, earlier policies, the effects which led to a changed environment and therefore perhaps changes in government policy).
• Knowledge of and access to, policies from other areas and the influences which these have or may have on new policy need to be considered.
• The National Advisory Committee on Core Health and Disability Support Services has recommended that best practice guidelines should be evidence-based (1993a).
. Guidelines should be safe and culturally appropriate.
• Previous contributions and past achievements should be acknowledged.
• To "Build on gains already made - Haere tonu" was a theme which emerged at Te Hui Whakapumau. Dune (1994b:167) has said that "the gains made in earlier years should not be forgotten nor the lesson learned, ignored".
REQUIRES COMPETENT, SAFE AND EFFICACIOUS SERVICES • It is an expectation of Maori that "providers and consumers know health services are meeting their goals and objectives and may also meet broader aims valued by Maori" (Ministry of Health, 1995, see checklist).
• A service is competent and safe when "Maori consumers are protected from harm or further harm to their bodies, their mental and spiritual well-being and their culture; when treatment produces the desired outcome (Population Health Services Section, 1995, see checklist).
• The framework upon which the service is shaped and delivered should ensure that Maori views of health are acknowledged (Population Health Services Section, 1995, see checklist).
• Measures should be pursued to "protect consumers and the public from avoidable physical and non-physical harm". Systems should be implemented to identify key risk areas so that risks can be eliminated, reduced or isolated (Shipley, J., 1996:13).
• "Services should only be purchased from those providers who comply with relevant legislation" (Shipley, J., 1996:13).
• Effective systems and responses to reduce risks of avoidable harm should eliminate culturally inappropriate practices (Shipley, J., 1996:16).
ENABLES MEANINGFUL DATA TO BE COLLECTED • The Core Services Committee (1992) has emphasised the scarcity of information in certain areas, especially primary health care. • Inconsistencies in the collection of ethnic data and a lack of useful data have been found by Kilgour and Keefe (1992). They recommend the development of an ethnic statistical system.
• The Maori Disability Information Framework (MDI) (U.K. Potaka, et al., 1994), a useful model which provides minimum standards for the collection of information, has 3 major categories: Principles, Maori Specific Data, and The Generation and Transfer of Data.
• The Principles in the MDI Framework are the Treaty of Waitangi, Confidentiality and Guardianship, and Purposefulness and Consistency (U.K. Potaka, etal., 1994:25). The MDI report recommends that these principles be utilised to guide the data collection process (U.K. Potaka, et al., 1994:28).
• Components relevant to the collection of Maori S pecific Data are Ethnicity, Cultural, Circumstances, and Disability Data (U.K. Potaka, et al., 1994:26).
• In Hauora III (Pomare, E., etal., 1995:168) it is recommended "that the classification of ethnicity becomes a requirement for all health and disability service purchasers and providers". -
• The information collection process should be sensitive to Maori and the information should not be used without permission. "Information is a taonga" (Te Puni Kokiri, 1993).
• The Generation and Transfer of Data is the third category, and has as its components: data and technology, cultural safety, methods of collection, and data processing. (U.K. Potaka, etal., 1994:27)
• In He Anga Whakamana (Ratima, M.M., etal., 1995:44) Quality Information Collection is given as an indicator which can be measured by the type of data collected, how "Maori" is defined in the data, whether the information collected is purposeful and consistent, and whether confidentiality and guardianship have been considered in the management of that information.
• Without reliable data it is difficult to calculate the efficiency of a service (Dune, M.H., 1993a:17). The CHI Audit Model (Dune, M.H., 1993a:17) suggests that providers should become more proficient "in collecting appropriate data as part of a service delivery function".
PROMOTES GOALS WHICH RELATE TO MEASURABLE OUTCOMES • Imperfect measuring tools and a lack of conformity as to what should be measured creates problems when measuring both health gains and outcomes (Durie, MR, et al., 1995:31).
• The Maori view of health is holistic (Durie, M.H., etal., 1995:3 1). Al Te Hui Whakaoranga a holistic approach to health was recommended for future action (Maori Health Planning Workshop, 1984:26).
• The SF-36 health survey questionnaire with its 8 dimensions of perceived health state is being used increasingly as a health status/outcome measure (J. Sceats, 1995).
• The SF-36 allows for an integrated approach to measuring health. The application of SF-36 implies that health outcome measures can be reconciled within frameworks which are practicable and relevant to health services (Durie, M.H., etal., 1995:3 1). 39
• It is suggested by Midland Health (1995) that the testing of SF-36 particularly by Mori might subsequently result in a Maori version of the SF-36 being produced (J. Kokaua, etal., 1995:10).
The 8 dimensions within SF-36 comprising a number of health measures (i.e. general health, mental health, physical functioning, social functioning, physical role limitations, emotional role limitations, vitality, and bodily pain) have "implications" for the four dimensions of Whare Tapa Wha. In Guidelines For Purchasing Personal Mental Health Services for Maori, the use of both SF36 and Whare Tapa Wha is recommended. Both are measurements of outcome which encompass a Maori view of health (Dune, MR, et a!, 1995:32).
• The four dimensions to health (taha wairua, taha hinengaro, taha tinana, and taha whanau) suggested in the Whare Tai,a Wha model inter-relate to effect an "overall picture of health" (Dune, M.H., et al., 1995:32). These four components "encapsulate" Maori health. (J. Kokaua, etal., 1995:1).
• Maori expect that outcome measures will comprise extensive measures of good health and that health services will seek "good outcomes for health and not simply a removal of symptoms" (Dune, M.H., etal., 1995:32).
• Indicators of Maori health can include: "the level of employment among Maori; the responsiveness of society to the Treaty of Waitangi; use of te reo Mori and tikanga; the progress of Maori children through Kohanga Reo; improved networks and communication; and the use of traditional Maori health measures" (Public Health Commission, 1995a: 17).
• During Te Ara Ahu Whakamua (March 1994) it was felt that Maori health could be "measured best in terms of the number of Maori in positions of influence; the value of resources in ownership; life expectancy; reduced crime rates; increased educational and business achievement; and usage of te reo" (Public Health Commission, 1995a: 19).
• Specific health policies be developed at a community level, and these should be developed with the five challenges identified by delegates at the Hui Ara Alm Whakamua (Durie, M.H., 1995:210), these were a greater emphasis on whakawhanaungatanga, equality of Maori women, whanau development (with the elimination of household violence and abuse), deliberate planning for older Maori, and mental health in an integrated and coherent national policy.
POLICY OUTCOME RESPONSIVE TO MAORI
IDENTIFIES MAORI AS A RELEVANT TARGET GROUP • It must be determined in the early stages if the policy is "relevant" to Maori. Te Aho (1995:7) states that the "means by which relevance is assessed is an important part of the process and this needs to be identified". In the later stages of the development process relevance can also be based on the extent of Maori satisfaction.
• Policy Guidelines 1996197 (Shipley, J., 1996:12) states that "effectiveness focuses on ensuring services result in better health outcomes" To be effective, services must target people s needs. Therefore a key aspect given is that the targeting of health and disability support services should be based on the needs of populations, individuals, and their family/whanau/caregivers (Shipley, J., 1996:13). .40
"Effective services are those where treatment is likely to provide a significant net health benefit. Services known to have no significant beneficial effect on people s health should not be purchased." (Shipley, J., 1996:13).
• The means by which the impact of policy on Maori is "computed" and "determined" is important. Steps which prevent any adverse effects of policy for Maori must be employed (Te Aho Associates, 1995:9).
See also Maori as a relevant target group
PROMOTES CHOICE FOR MAORI • The provision of options sensitive to Maori needs is necessary to adequately satisfy Maori expectations (Population Health Services Section, 1995a). A range of services is required so that options for different types of services are made available (Dune, M.H., et al., 1995:18). Heath services must reflect the diverse realities of Maori.
• Accordingly Policy Guidelines for Maori Health 1996197 (Shipley, J., 1996:25) states that "the Government supports innovation and variety so that people will have a choice" and that therefore the R}iAs should support "the development of a range of service models suitable for different groups and situations".
• Providers should be encouraged to provide services which respond to Whaia te ora mo te iwi.
• Health services should be culturally effective and appropriate to Maori needs (Shipley, J., 1996).
• In their 1995 Report, the National Advisory Committee on Core Health and Disability Support Services advised that RHAs "may purchase aspects of Maori traditional healing" where this would be seen to assist in increasing the utilisation of health services by Maori and improve health status (Shipley, J., 1996:17).
• To effect culturally effective services. Maori preference for a choice of services including services provided by Maori for Maori must be acknowledged, together with Maori preference for community or marae-based services (Shipley, J., 1996:31).
• Mainstream services should be culturally sale (Ratima, M.M., et al., 1995:36). They should be "affordable, accessible, appropriate and acceptable" (Pomare, E., etal., 1995:168).
• Several health clinics who have a number of non-Maori employees, have been able to provide a satisfactory service for Maori. As Ramsden (1994:121) states, "the commonality is Maori service and contract design and the willingness of employees to work in a different way".
• Options, identified as a key area in A Maori Policy Analysis Framework (Te Aho Associates, 1995:7) suggests that there should be an emphasis "on the consideration of alternative methods and models for addressing policy problems".
RESPONDS TO DIVERSE MAORI REALITIES • As stated in Policy Guidelines 1996197 (Shipley, J., 1996:17) "Maori are not a homogeneous population group". .41
According to Dune (1994c:214) "Maori live in diverse cultural worlds. There is no one reality nor is there any longer a single definition which will encompass the range of Maori lifestyles".
To reduce the disparities between Maori and non-Maori health status, it is crucial that Maori health is addressed "from a broadly based perspective" which allows for Maori diversity (Dune, M.H., 1993a:4). That "policies for Maori health and the provision of health services for Maori should take cognisance of the diverse social and cultural realities within which Maori live" is stated in Aga Matatini Maori, Diverse Maori Realities (Dune, M.H.,1995:15)
. A response to diverse Maori realities can be achieved by:
• acknowledging traditional Maori healing and health practices (Korniti Whakahaere, ed. 1984)
• encouraging Maori to manage their own health and encourage the development of Maori as service providers
• improving the ability of mainstream services to respond to Maori
• encouraging systems and services which empower Maori individuals, whanau and caregivers, (Ministry of Health and Te Puni Kokiri, 1995:15).
A broad range of health services is required. Health services provided b y Maori and non-Maori should be culturally effective (Shipley, J., 1996:17).
The principle of Acceptability, given in Policy Guidelines for Maori Health 1996197 (Shipley, J., 1996:13) emphasises the respect, empowerment, autonomy, and participation of people. A key aspect of this principles includes: improving the responsiveness of services to people s diverse needs, preferences and cultures. The purchase of services should be "responsive to the cultural diversity of communities and populations" (Shipley, J., 1996:13).
• Delegates present at Te Hui Ma Ahu Whakamua (March, 1994) "were in full agreement with the conference theme that Maori had a right to health, though it was recognised that there was a need for a range of approaches to meet diverse Maori needs" (Dune, 1994c:210).
RECOGNISES AND ADDRESSES MAORI DEVELOPMENT PRIORITIES The significance of linking Maori health and Maori development is acknowledged in Implementing the Coalition Agreement on Health (Steering Group, 1997:55).
• In the Report of the Steering Group to oversee Health and Disability Changes (1997:56) it is recommended that "gains made in Maori health development be consolidated and Maori participation in the health and disability sector accelerated".
• To improve Maori health status "health initiatives must incorporate a holistic definition and approach and be part of a developmental strategy to improve the overall status and well-being of a Maori community, tribal or family group" (Durie, M.H., 1994c:78).
• Policies should reflect Maori rights to development and sell-determination. This is a guiding principle for Maori health policies as proposed by Dutie. The principle of tino rangatiratanga should ultimately "underlie the development of future policies for Maori health" (Dune, M.H., 1994a:129). I .42
PROMOTES SEAMLESSNESS (OF SERVICES AND BETWEEN HEALTH AND DEVELOPMENT) • In He Anga Whakamana , A framework for the delivery of disability support services for Maori, (Ratima, M.M., et al., 1995:37) it was found that "an integrated approach to service delivery was preferred". Health services need to establish links with Maori institutions so that clients are able to participate in the community.
• An information paper produced by Midland Health (April 1997) though directed at Mental Health service provision, makes a number of points with regards to integrated health services which are relevant to wider health issues.
Integration provides a framework whereby health providers are able to "focus on the same outcomes, and work closely together to achieve them" (Midland Health, 1997).
It is proposed that effective networks are created to improve relationships and communication between health workers. Services should not exist in isolation of other health services. Without strong links between service providers consumers may "slip through the gaps" and/or they may not have access or an awareness of "the full range of support services or expertise available" (Midland Health, 1997).
• As the Steering Group (1997:56) states "intrasectoral co-ordination will rely heavily on information-sharing strategies which give parties equal access".
• Health care should be "comprehensive, integrated and continuous" (Ministry of Health. 1995a).
PROMOTES CULTURAL AFFIRMATION FOR MAORI • Policy Guidelines 1996197 (Shipley, 1996:33) advises that RHAs must acknowledge the "particular health needs and expectations of Maori for the provision of culturally effective services, including the affirmation of Maori practices and beliefs".
Guidelines for Purchasing Personal Mental Health Services (Dune, MR, et al., 1995:19) suggests a number of means to introduce Cultural In puts and therefore promote cultural affirmation within health. Although the report focuses on mental health the points made are appropriate for all health areas and include: cultural assessment; whanau participation; use of Maori language; tikanga Maori; Maori leisure pursuits; karakia; rongoa; involvement of tohunga/traditional healers; a Maori workforce.
Cultural Assessment "refers to the process through which the relevance of culture to mental health is ascertained" (Dune, M.H., et al., 1995:20). Assessments are considered necessary, to "plan treatment and... programmes which are relevant and motivating" (Dune, M.H., et al., 1995:20). [This has been taken a step further with a practitioner becoming aware of the potential for misdiagnosis of Maori as diagnoses are being re-evaluated when Maori clients are admitted with symptoms that do not appear to fit the initial diagnosis, suggesting the taha Maori of the client was not originally considered b y the initial diagnostician. 12.5
• Whanau Participation can "occur at several levels" although a balance needs to be found between a personal need (i.e. a Maori consumer s need) for
25 R Chaplow, (personal communication). .43
independence and the involvement of whanau. Through whakawhanaungatanga, relationships and networks may be "strengthened" (Dune, M.H., et al., 1995:21).
"The use of Maori language in both written and oral forms can be crucial to understanding the thoughts and feelings of Maori clients." However the use of Maori "presumes staff competence in ... Maori language". As well, being given the opportunity to learn te reo may assist in helping individuals to learn and acknowledge who they are (identity). Indicated therefore is a need to "have a degree of expertise in Maori language and the service itself may be expected to provide opportunities for language development as part and parcel of an integrated approach" (Dune, MR, et al., 1995:22).
• The use of Tikanga Maori in health settings can include a number of practices "such as the manner in which visitors are received, the way meetings are conducted, group decision making processes, opportunities for consensus development, reciprocity and sharing resources" (Dune, M.H., et al., 1995:22).
• "The Core Services Committee (1995) has acknowledged the importance of culture to health care and the potential value of traditional healing in providing spiritual and cultural sustenance as well as physical and emotional rehabilitation, encouraging whanau participation and enabling the use of Maori language for discussions of health" (Dune, M.H., etal., 1995:24).
IMPROVES ACCESSIBILITY FOR MAORI BY ADDRESSING KNOWN BARRIERS TO ACCESS In Policy Guidelines 1996197, (Shipley, J., 1996:11) Barriers to Access for Maori to Health and Disability Support Services include:
• ineffective communication about what services are available, or how to access them
• unresponsive staff and services that do not meet Maori health needs and cultural expectations
• transport to and the cost of services, including indirect associated service costs
• distance and lack of access to transport
• lack of co-ordination and integration of services, privacy and intellectual property issues.
"Maori who are alienated from both mainstream New Zealand and Maori society" are most "likely to face the greatest barriers to access" (Ratima, M.M., et al., 1995:35)
• Barriers to access for Maori can be removed by making services available locally or within the community; by offering a culturally acceptable service; and by addressing consumers financial concerns (Ministry of Health, 1995a, see checklist).
• To effect a service environment appropriate to Maori, it must be "spiritually, culturally and physically safe". Physical safety includes building access (Ratima, M.M., etal., 1995:34).
• Staff should be culturally aware (Ratima, M.M., et al., 1995:30).
• Policy development must include Maori participation and consultation and acknowledge Maori understandings and values (Ratima, M.M., etal., 1995:34). • To provide for Maori users of mainstream services "those services must be safe, equitable, culturally effective and appropriate" (Steering Group, 1997:55).
• Effective networks are required among health workers to facilitate information flow. A lack of strong links between service providers means that consumers may "slip through the gaps" (Midland Health, 1997).
• More Maori in the health profession will allow for effective culturally appropriate services which may be seen as more accessible.
PROMOTES AND SUPPORTS INFORMED CHOICE • Maori consumers are able to make informed choices when clear and helpful information is made available (Population Health Services Section, 1995, see checklist)
• The need to "ensure access to useful service information for Maori" was identified in Maori Policy Gui delinesfor Maori Health 199411995, (Ministry Of Health and Te Puni Kokiri, 1994:15),
• When seeking appropriate methods for informing Maori the medium (e.g. the media), the content (e.g. the inclusion of familiar Maori concepts) and the language (plain Maori/English language used) must be taken into account (Population Health Services Section, 1995, see checklist).
• The Steering Group (1997:57) supports communication between organisations and their communities. This will assist Maori to "judge the performance of the organisations" and "make informed choices about their own care".
PROMOTES IMPROVED COMMUNICATION WITH MAORI • Information should be "up-to-date and presented in the medium of the client s choice (e.g. Braille, Maori language)" (Ratima, M.M., et al., 1995:33).
• Poor communication methods has been highlighted as a major barrier to the utilisation of disability support services. Because of this a service may be used only "in times of extreme need, if at all, rather than at an early stage" (Ratima, M.M., et al. 1995:36)
• A professional and culturally qualified workforce is suggested as an effective means to improve communication and the flow of information (Ratima, M.M., et al. 1995:36).
• Improvement in communication methods can assist to reduce access barriers to health services.
Also see Promote Informed Choice for Maori Consumers
SUPPORTS MAORI PREFERENCES FOR SERVICE PROVIDERS (INCLUDING SERVICES PROVIDED BY MAORI) • Maori expect that their preference "for services delivered by Maori is accepted and practiced" To achieve this the recruitment of Maori as staff is required, or Maori support made available (Population Health Services Section, 1995, see checklist).
• As well as supporting generic service provision by Maori, the establishment of a "range of kaupapa Maori services" is also required. Kaupapa Maori services may involve traditional healing and other services based on a Maori philosophical base (Steering Group, 1997:55). • Services provided by Maori are inclined to be seen by Maori as "user friendly", and as having "strong links with Maori institutions, have access to informal networks and be conversant in tikanga Maori and Te Reo Maori". Importantly, "such services provide choice" (Ratima, M.M., et al., 1995:48).
• The growth and development of new Maori providers should be seen within the contextual framework of the RHAs three-year strategic plans. Progress in this direction should support the integration and co-ordination of service delivery in conjunction with other service providers" (Shipley, J., 1996:17)
• Services which are based upon Maori cultural philosophies" are "seen as an essential complement to mainstream services" (Ratima, M.M., et al., 1995:34).
• To provide a culturally safe service there must be an awareness of cultural risk and cultural preferences (Dune, M.H., 1993a:17).
• Training "in tikanga and kaupapa Maori and Treaty issues" should be included in staff development programmes (Population Health Services Section, 1995, see checklist).
• "RHAs are to encourage the development of organisations that provide integrated and coordinated services suitable for Maori" (Shipley, J., 1996:17).
• "RHAs should seek to increase the involvement of Maori in their activities and encourage a similar approach by all providers who deliver a service to Maori" (Shipley, J., 1996:17).
PROMOTES APPROPRIATE. USE OF TE REO MAORI • The legal status of Te Reo Maori must be acknowledged, "Maori is an official language of New Zealand" (Ratima, M.M., etal., 1995:22).
• Health services should endeavour to ensure that Maori speaking staff are available to clients (Ratima, M.M., etal., 1995:45).
• Written information should be provided in both English and Maori (Ratima, M.M., etal., 1995:45).
• As stated in He Anga Whakamana (Ratima, M.M., et al., 1995:22), "the use of Maori language in both written and oral forms can be crucial to understanding the thoughts and feelings of Maori clients". Many Maori find it "easier to express themselves in Maori" (Ratima, M.M., etal., 1995:22).
PROMOTES LINKAGES TO MAORI INSTITUTIONS • It is important to "develop and maintain links with Maori institutions" to provide avenues for Maori to "participate within these institutions" (Ratima, M.M., et al., 1995:41).
• Maori institutions should be involved in "overall service development and planning" if the service is to be effective (Ratima, M.M., et al., 1995:46).
• Good links with Maori institutions can be based on the "extent of these associations" (Ratima, M.M., et al., 1995:46).
• The Ottawa Charter (World Health Organisation. 1986) proposes that "coordinated action" will effect policies which encourage "greater equity". Furthermore, "joint action contributes to ensuring safer and healthier goals and services, healthier public services, and cleaner, more enjoyable environments". .46
• To ensure a "health care system" which will improve the health status of Maori, further points made within the Ottawa Charter (World Health Organisation, 1986) advocate that health services can be promoted if "individuals, community groups, health professionals, health service institutions and gOvernments" work together.
• The Charter (World Health Organisation, 1986) recommends that health services "embrace an expanded mandate which is sensitive and respects cultural needs".
• Also see Seamlessness
POLICY DEVELOPMENT PROCESS RESPONSIVE TO MAORI
RESPECTS MAORI INTELLECTUAL PROPERTY RIGHTS • The Mataatua Declaration (1993) emphasises a number of statements appropriate for Maori. The Declaration recommends a code of ethics for external users; the need to appreciate both collective and individual ownership; and the need to respect culturally significant items.
• The information process should not be demeaning to Maori. Permission should be sought before information is used (Dune, M.H., 1993a: 19).
• Cultural material should be respected (Dune, M.H., 1993a:24).
• Active Maori participation within the process will lessen the possibility of inappropriate procedures (Dune, M.H., 1993a:18)
ACTIVELY INVOLVES MAORI IN POLICY DEVELOPMENT • In the Royal Commission on Social Policy report (1988, Vol. IV) "a participatory health service was favoured".
• In 1992, the Department of Health recommended Maori participation at all levels of the health sector.
• The effective inclusion of Maori within the policy development process can be based on the extent of Maori involvement and genuine consultation.
• In Whala te ora mote iwi (Department of Health andTe Pum Kokiri, 1993:13) it is recommended to "encourage the greater participation of Maori in order to develop health solutions which are effective, affordable, accessible and culturally appropriate".
• "Maori and iwi groups" should be included in the "development, implementation and review of purchasing plans" (Department of Health and Te Puni Kokiri, 1993:16).
• By actively involving Maori in the policy process, services will be better equipped to appreciate Maori needs, and as stated in He Anga Whakamana (Ratima, M.M., et al., 1995:39) "client preferences should be evident in all aspects of services".
• "Iwi must be afforded the opportunity to define themselves as well as to nominate their own spokespeople" (Clark, 1993: 20).
• "The Treaty contains within it specific obligations which require the Government, as Treaty partner, to address the inequitable position of Maori". To meet the health .47
needs of Maori, the Government has "specific duties to consult with Maori in the development of government policies and programmes" (Public Health Commission, 1995a: 13).
ACTIVELY INVOLVES MAORI IN DECISION MAKING • The Government s Maori health policy directions as stated in Whaia te ora mo te iwi (Department of Health and Te Puni Kokin, 1993:14) propose "greater participation of Maori at all levels of the health sector".
• "RHAs should provide evidence of Maori involvement in their planning, purchasing and decision-making processes. They should also encourage the same level of participation at the provider level" (Shipley, J., 1996:18).
• For Maori, becoming qualified in the health field should lead to a higher Maori profile within all health disciplines and ideally give Maori an opportunity to seek key roles, especially in the decision-making process.
CONSULTS MEANINGFULLY WITH MAORI • Whaia te ora no te iwi (Department of Health and Te Puni Kokin. 1993:16) recommends that consultation with Maori be carried out to establish the particular "needs of Maori communities and consumer groups".
• "Performance measures" should "be used to monitor and evaluate the process of consultation" (Department of Health and Te Puni Kokiri, 1993:16).
• "R}{As are obliged to encourage providers to: work sensitively with MAoriliwi through high quality consultation" (Ministry of Health and Te Puni Kokiri, 1994b:42).
• Consultation strategies implemented should:
• "identify the relevant communities and other parties;
• consider Maori interests taking account of the Crown s obligations under the Treaty of Waitangi;
• consider the results of consultation carefully
• and inform participants of the outcome." (Shipley, J., 1996:19)
• The consultation process should be accommodated to include those who are most affected
• "Consultation in isolation is not enough to satisfy the requirements of a Treaty partner. The Crown has to genuinely consider and where appropriate incorporate the concerns and perspectives of Maori in the policy. The Crown must consult at a meaningful time in the process. As a general rule this will mean as early on in the process as possible. Consultation only once the policy has been developed is entirely inadequate" (in Mdori Policy Analysts and the Treaty of Waitangi, 1994).
• Consultation should occur at appropriate times throughout the development of the policy, so as to make the consultation effective and meaningful (in Maori Policy Analysts and the Treaty of Waitangi, 1994).
• Consideration of Maori consultation processes (i.e. hui), and the involvement of Maori in the policy development process is essential (Te Aho Associates, 1995:6). Importantly, "consultation is a key process in the analysis and development of ..48
Maori health policy however consultation for the sake of consultation is insufficient" (Te Aho Associates, 1995:24).
• In He Anga Whakamana (Ratima, M.M., et al., 1995:46) several questions are given in relation to consultation.
• Importantly, Judge Dune (1994:18) states that "consultation, or the calling of hui, cannot be called upon to validate state-driven directions".
• Also see Impact on Crown/Tangata Whenua Relationship
AFFIRMS MAORI CULTURAL VIEWPOINTS/IS CULTURALLY SAFE/USES TE REO MAORI CORRECTLY • In 1993 the Public Health Commission in order to develop public health services for Maori had as one of its key objectives the development of "systems to ensure that culturally appropriate practices and procedures are an integral requirement in the purchase and provision of health services" (Public Health Commission, 1993:22).
• Service providers should have sufficient knowledge and cultural awareness to avoid procedures which are insensitive to Maori (Dune, M.H., 1993a: 17).
• Maori cultural values and practices should be employed wherever possible (Dune, M.H., etal., 1995).
• A culturally sale service will use Maori language appropriately and take into account Maori health perspectives. Cultural factors will be acknowledged within service provision (Dune, M.H., 1993a:12).
• Mainstream services must incorporate "Maori perspectives and understandings". The "increased participation of Maori as health workers" would significantly improve the "responsiveness" of mainstream services to Maori needs (Ratima, M.M., et al., 1995: 48).
ACKNOWLEDGES THE RIGHTS/SPECIAL NEEDS OF TANGATA WHENUA • The Health and Disability Services Act requires RHAs to take into consideration the special needs of Maori.
• To address the needs of Maori, RHAs should impel providers to be aware that iwi and Maori have perceptions of health "often linked to their history" (Ministry of Health and Te Puni Kokini, 1994b:42).
• In Whaia te ora nzo te iwi (Department of Health and Te Puni Kokiri, 1993:13) it is suggested that RHAs and the PHC acknowledge Maori, structures "such as those based around whanau, hapu and iwi".
• The "tikanga and mana of each Iwi group in their region" should be appreciated (Ministry of Health and Te Pum Kokiri, 1994b:42).
• In seeking to improve Maori health status, the "health needs and expectations of Maori" must be met and the relationship between the Crown and tangata whenua must be acknowledged by:
• "being aware of and responding to the diverse needs and expectations of Maori who may best receive their services in a Maori and/on mainstream setting
• working sensitively with Maori through high quality consultation ".49
• recognising the tikanga and mana of iwi in their region
• encouraging greater participation of Maori in service, planning, delivery and monitoring
• coordinating and linking health services which strengthen the integrated delivery of health services to Maori
• considering how the health needs of Maori who are outside of their tangata whenua area will be met
• being aware that Maori and iwi have their own vision of health often linked to their history
• recognising and responding to the particular employment requirements of Mori staff (Shipley, J., 1996:3 1).
• In He Matariki (Public Health Commission, 1995a: 13) it says the Treaty of Waitangi is "a living document which recognises the special tangata whenua (indigenous people) status of Maori and establishes an ongoing relationship between Maori and the Crown".
IDENTIFIES THE IMPACT ON CROWNITANGATA WHENUA RELATIONSHIP • A key issue identified by the Steering Group (1997:54) is "the need to continue to acknowledge the special relationship between Maori and the Crown under the Treaty of Waitangi".
• The State s domination of "Maori policy formulation" has resulted in a situation whereby Maori organisations within districts are compelled to contest for funding, for the benefits of Treaty settlements and for the right to be consulted (Dune, B, 1994:17).
Consultation is inadequate if the aim is only to confirm measures and policies which have already been decided. This type of process maintains the State s authority, and ignores the Crownfrangata Whenua relationship, preventing avenues for Maori input and participation. As well the consultation process may be somewhat restricted if only one partner in the relationship chooses who they should consult (Dune, E., 1994:18).
RESPECTS MAORI AND IN TURN DEVELOPS TRUST One of six principles for purchasing decisions stated in Policy Guidelines 1996197 (Shipley, J., 1996:13) is Acceptability, which "focuses on respect for and empowerment of people and on their autonomy and participation". People and communities should be involved, informed and consulted. With regards to communities, including hapu/iwi, "proper and due consultation" should take place, together with "adequate information on the issues" and "provision of feedback at the end of the consultation process".
• Maori health policies must acknowledge the diverse realities of Maori people. As Dune (1994a: 11) states, "in formulating Maori health policy all Maori people should come first".
• To ensure that Maori are respected throughout the policy process, "high quality consultation" should occur, with the participation of Maori in "service, planning, delivery and monitoring" advocated (Shipley, J., 1996:31). ..50
• To be culturally sale, Maori health perspectives must be acknowledged (Dune. M.H., 1993a: 12). Inappropriate practices must be avoided
POLICY DEVELOPMENT PROCESS IS ANALYTICALLY SOUND
IS BASED ON A RIGOROUS POLICY DEVELOPMENT MODEL • Policy must be based on accurate evidence and the development model needs to be methodologically sound.
• Throughout analysis there should be an awareness of bias and the limitations of Data.
Also see Existing Wisdom, and Framework Consistent with Maori Views of Health and Maori Development.
IS CLEARLY BASED ON A FRAMEWORK CONSISTENT WITH MAORI VIEWS Maori development focuses on the links between health and other social, cultural, economic and environmental issues. For Maori, health cannot be considered as a separate issue. (Public Health Commission, 1995:54).
• An holistic approach to health is required. Health for Maori places emphasis on the "four cornerstones of health". The spiritual, mental, family and physical dimensions must be acknowledged (Ministry of Health, 1995:2 1). Also see Goals which relate to Measurable Outcomes
To cater for the needs of Maori, improvements in areas such as education, housing, and employment need to be looked at as a total package. The health and well-being of Maori will not necessarily improve without progress being made in a number of areas which impact Maori health. Health cannot be "seriously considered in isolation from other key factors which play a part in determining the Maori position" (Dune, 1993b:6).
• Maori aspire for "integrated development over longer time frames" (Dune, 1994a: 12). Policy planning over a longer time period would allow for an integrated approach to Maori development, whereby Maori might be able to enjoy the same level of health as non-Maori (Dune M.H., 1993b: 15).
• A broad knowledge of available frameworks which encompass Maori perspectives of health and development is required. The Treaty of Waitangi, the Dual Focused Framework, Whaia te Ora mo te Iwi, Whare Tape Wha and the Ottawa Charter are examples which have been mentioned earlier in this report.
CLEARLY PROVIDES FOR A MONITORING PROCESS • An effective system for gathering information is required to monitor health status.
• The monitoring process should include components to measure consumer satisfaction (Dune, M.H., 1993a: 12).
• Cultural safety is an important factor "to be used in monitoring the quality of care for Maori" (Durie, M.H.. 1993a:12).
• "Purchasers should indicate how they will take account of Maori cultural values and practices in the services being purchased and the appropriate means of monitoring these services" (Department of Health and Te Puni Kokini, 1993:15). 51
• "The participation of Maori in the development of service practices and procedures and their performance measures will be essential" (Department of Health and Te PuniKokiri, 1993:16).
MEANINGFULLY USES MAORI SPECIFIC DATA • To effect accurate, comparable data with regards to Maori health a uniform definition of Maori is required. Clear consistent definitions across the sectors are needed. As well, the information process should include a place for cultural identification, Maori values, be consistent with tikanga Maori, and acknowledge the diverse reality of Maori.
• Kilgour and Keefe (1992) have suggested that an ethnic statistical system be implemented.
• As given in the Maori Disability Information Framework elements which relate to the collection of Maori Specific Data include Ethnicity, Cultural, Circumstances and Disability Data (Potaka, U.K., etal., 1994:26).
• Guidelines for Ethnicity include: the Maori Affairs Amendment Act 1974 definition; Descent and self-identification; Census Questions 1991 (Potaka, U.K., etal., 1994:26).
• Guidelines for Cultural components are: Hapu and iwi; Maori networks; Maori affirmation (Potaka, U.K., etal., 1994:26).
• Circumstances include: Whanau support; Economic position; Other social indicators (Potaka, U.K., et al., 1994:26).
• Requirements for Disability Data are: Same as mainstream; Correlation of disability (multiple disabilities) (Potaka, U.K., etal., 1994:26).
Also see Collection of Data
IDENTIFIES MAORI AS A RELEVANT TARGET GROUP • An assessment is required to determine whether the policy will actually improve the health of Maori (Dune, M.H., 1993a:9). To ensure that the process is sound, it should be established from the outset whether there is a "need" by Mori for this policy, i.e. is this policy relevant to Maori?
• Questions which might be used to identify if Maori are a relevant target group are:
• "How will this policy affect Maori?
• To what degree will this policy affect Maori over and above the population?
• What specific Maori society are affected (is any) by this policy?
• What past involvement have Maori had with the policy/legislative area?
• Will this policy be a disadvantage to Maori, and if so what needs to be done to prevent/mitigate this disadvantage? (in Maori Policy Analysts & The Treaty of Waitangi, 1994).
• An acknowledgement of policy history means that "past trends may be identified and duplication avoided" (Te Aho Associates, 1995:25).
• Also see Maori as a relevant target group. .52
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