Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024: further Crown breaches of Te Tiriti o Waitangi.

The Waitangi Tribunal in their Wai 2575 Report recommended the establishment of Te Aka Whai Ora (the Maori Health Authority) to remedy some of the contemporary breaches of Te Tiriti o Waitangi (Te Tiriti). Te Aka Whai Ora was the culmination of decades of Maori advocacy for the establishment of independent Maori health leadership, policymaking and commissioning. Under urgency, the new National-led coalition Government passed the Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024 in February. In this paper we use Critical Tiriti Analysis (CTA), a five-stage process, to review the extent to which the Act is compliant with the five elements of Te Tiriti (the authoritative Maori text), the preamble, the three written articles and the oral article. We found that the Act had very limited Tiriti compliance and the potential to do great harm. We offered practical suggestions how this could have been avoided.

A Critical Tiriti Analysis of the Pae Ora (Healthy Futures) Bill.

AIM: The Pae Ora (Healthy Futures) Bill is the framework for a reformed health system intended to embed Te Tiriti o Waitangi and centre equity. The Bill is informed by the Wai 2575 Health Kaupapa Waitangi Tribunal Inquiry and the Health and Disability System Review, both of which established an urgent mandate to transform the health sector. This desktop review explores to what extent the proposed Bill is likely to uphold Te Tiriti. METHODS: This paper uses Critical Tiriti Analysis to review the Pae Ora Bill. The analysis involves five phases: (i) orientation; (ii) close reading; (iii) determination; (iv) strengthening practice and (v) Maori final word. As part of that, a determination is made whether the Bill is silent, poor, fair, good or excellent in relation to the Preamble and the four articles (three written, one verbal) of te Tiriti o Waitangi (Maori text). RESULTS: The desktop analysis showed fair engagement with most of the Te Tiriti elements; but with good commitment to address equity issues. The Bill was silent in relation to wairuatanga (spirituality) and there is no evidence of Maori values informing it. CONCLUSION: The dominant Crown narrative that interprets kawanatanga as the right to govern over all peoples pervades this legislation. There are significant power sharing shifts within this Bill and these are welcomed, but whilst the Crown maintains ultimate power and authority only a partial fulfilment of Te Tiriti will be evident within the health system.

Re-imagining anti-racist theory for the health sector.

Ethnic health inequities between Maori and other New Zealanders continue to manifest systemically across the health sector. They are unjust, unfair, and are a breach of Te Tiriti o Waitangi. Institutional racism is a key modifiable driver of these disparities. Historically, health sector responses to racism could be characterised as ad hoc or in-action. Efforts have included investment in Maori health providers, Maori representation in governance, equity initiatives, kawa whakaruruhau-cultural safety and Te Tiriti training. Most anti-racist interventions have been educational and focused on individual change-especially for operational staff and students, rather than decision-makers. These historic contributions have been insufficient to address entrenched problems of systemic and societal racism.This paper examines three anti-racism initiatives currently occurring across Aotearoa; i) the Matike Mai Constitutional Transformation report/movement, ii) the development of the National Action Plan Against Racism, and iii) Ao Mai Te Ra currently being developed within the health sector.Drawing on long-time involvement in anti-racism praxis and scholarship, the Maori and non-Maori authors of this paper are making the case to re-imagine anti-racism theory. Such re-imagining needs to centre engagement with Te Tiriti. In addition, we argue it needs to involve both tangata whenua and Tauiwi.

Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa.

Within Aotearoa (New Zealand) there are systemic health inequities between Maori (the Indigenous people of Aotearoa) and other New Zealanders. These inequities are enabled in part by the failure of the health providers, policy and practitioners to fulfil treaty obligations to Maori as outlined in our foundational document, te Tiriti o Waitangi (te Tiriti). Regulated health professionals have the potential to play a central role in upholding te Tiriti and addressing inequities. Competency documents define health professionals' scope of practice and inform curriculum in health faculties. In this novel study, we critically examine 18 regulated health practitioners' competency documents, which were sourced from the websites of their respective professional bodies. The competencies were reviewed using an adapted criterion from Critical te Tiriti Analysis, a five-phase analysis process, to determine their compliance with te Tiriti. There was considerable variation in the quality of the competency documents reviewed. Most were not te Tiriti compliant. We identified a range of alternative competencies that could strengthen te Tiriti engagement. They focussed on (i) the importance of whanaungatanga (the active making of relationships with Maori), (ii) non-Maori consciously becoming an ally with Maori in the pursuit of racial justice and (iii) actively engaging in decolonisation or power-sharing. In the context of Aotearoa, competency documents need to be te Tiriti compliant to fulfil treaty obligations and policy expectations about health equity. An adapted version of Critical te Tiriti Analysis might be useful for those interested in racial justice who want to review health competencies in other colonial settings.

The Simpson-led health sector review: a failure to uphold te Tiriti o Waitangi.

The Health and Disability System Review (the 'Simpson Review') was an opportunity for health sector transformation, particularly in light of the recent damning WAI 2575 Waitangi Tribunal report released during the review process. There appears to have been a concerted effort to engage with the sector, an impressive Maori Expert Advisory Group and an extensive body of available scholarship documenting where improvements could be made. In this viewpoint, the authors, tangata whenua (Indigenous people of the land) and tangata Tiriti (people of te Tiriti) and health scholars and leaders undertook a high-level review of the Simpson Review report and analysed it against key elements of te Tiriti o Waitangi. The Simpson Review was an opportunity to share power, commit to Maori health and embed structural mechanisms, such as the proposed Maori health authority, to uphold te Tiriti o Waitangi. It was also an opportunity to recommit to health equity and eliminate institutional racism. We conclude that the Simpson Review did not take up these opportunities, but instead perpetuated further breaches of te Tiriti.

Addressing Structural Racism Through Constitutional Transformation and Decolonization: Insights for the New Zealand Health Sector.

In colonial states and settings, constitutional arrangements are often forged within contexts that serve to maintain structural racism against Indigenous people. In 2013 the New Zealand government initiated national conversations about the constitutional arrangements in Aotearoa. Maori (Indigenous) leadership preceded this, initiating a comprehensive engagement process among Maori in 2010, which resulted in a report by Matike Mai Aotearoa which articulated a collective Maori vision of a written constitution congruent with te Tiriti o Waitangi (the founding document of the colonial state of New Zealand) by 2040.This conceptual article explores the Matike Mai Aotearoa report on constitutional transformation as a novel means to address structural racism within the health system as a key domain within the constitutional sphere. Matike Mai suggests alternative conceptual structural formations through its focus on the kawanatanga (governance), the relational and the tino rangatiratanga (sovereignty) sphere. This framework is informed by a range of Indigenous ethical values such as tikanga (protocol), belonging, and balance that can usefully inform the redesign of the health sector.We assert that constitutional transformation and decolonization are potentially powerful ethical sources of disruption to whiteness and structural racism. We argue that, to eliminate entrenched health disparities, change processes need to be informed by the Indigenous inspirations expressed in the Matike Mai report.

From gorse to ngahere: an emerging allegory for decolonising the New Zealand health system.

Prior to colonisation, Maori had a well-developed holistic health system based on maintaining balance between people, place and spirit. The colonial imposition of British economic, religious, educational, legal, health and governance, through warfare, immigration, legislation and social coercion had a devastating effect on Maori health outcomes. With the release of the WAI 2575 Waitangi Tribunal report exposing the failings of our health system in relation to Maori health, the need to decolonise our health system becomes more pressing. A key difficulty in this work is the poverty of transformative language, concepts and frameworks in our workforce. This paper is the product of an anti-racism think tank that occurred in April 2019. While working through a system change analysis on our colonial health system, Maori and Tauiwi activists and scholars created an allegory-from gorse to ngahere. The allegory depicts the ongoing impact of the colonial health system as represented by gorse, and the possibilities of a decolonised health system represented by ngahere-a self-sustaining and flourishing native forest. Racism has a geographic specificity. The allegory we developed is a mechanism for conceptualising decolonisation for the context of Aotearoa. It serves to reinforce the different roles and responsibilities of the descendants of the colonisers and the colonised in the pursuit of decolonisation.

Noho Taiao: reclaiming Maori science with young people.

Connections and belonging to ancestral lands are strongly and consistently argued as fundamental to Maori education, health and wellbeing. When our connections with and access to health-promoting places of belonging are damaged, we lose more than component parts of wellbeing. An entire cultural infrastructure integral to identity, community, spirituality, sustainability and even material sustenance is eroded, compromising health, wellbeing and vitality. Young people in rural areas are often seen as missing out on the amenities and attractions available in cities, but are assumed to have compensatory access to and positive relationships with 'nature'. For multiple reasons, many arising from colonial legacies, this is often not so for young Maori and there are initiatives underway that seek to reconnect them with customary environments. Place-based learning approaches that use local environments and ecosystems as living laboratories, reimagining the way students engage with knowledge, science and understandings of the natural world can be valuable in this respect. Te Rarawa Noho Taiao projects in the Far North of Aotearoa have been operating for nearly a decade, using indigenous pedagogy that promotes Maori science, science leadership, and learning, applying them in ways that produce a range of health and wellbeing benefits. These include enhanced educational engagement, strengthened capabilities, increased participation/belonging, stronger connections, constructive peer processes and positive intergenerational interactions, all based in Maori values and praxis. Such elements are widely recognised in health-promoting frameworks as highly implicated in the creation and maintenance of health and wellbeing for individuals, communities and populations. In this paper, we use interviews with organisers and teachers of these Noho Taiao and a survey of student participants, to explore the educational and health promotion effects.

Upholding Te Tiriti, ending institutional racism and Crown inaction on health equity.

Upholding te Tiriti o Waitangi should eliminate institutional racism against Maori and contribute to the achievement of health equity. Given the Waitangi Tribunal is investigating health-related breaches of te Tiriti o Waitangi, we argue institutional racism, a key determinant of health inequalities, needs to be acknowledged and addressed within the health sector. Historically the Crown response can be characterised by denial and inaction. The Crown has the power and resources to take action through mechanisms such as those they are currently applying to child poverty and gender pay inequity. Anti-racism literature recommends planned, systems-based approaches to eradicate the problem. We need the government to uphold our Tiriti responsibilities and we require a plan to end racism in the New Zealand health system.

Treaty of Waitangi in New Zealand public health strategies and plans 2006-2016.

AIM: This study examines how public health policy in New Zealand has represented the Treaty of Waitangi (the English version) and te Tiriti o Waitangi (the Maori text) between 2006 to 2016. METHOD: A dataset of 49 public health strategies and plans, published between 2006 and 2016, were secured from the New Zealand Ministry of Health database. A thematic analysis using Braun and Clarke's process was undertaken and then the findings were reviewed against the Maori text of te Tiriti. RESULTS: Twelve documents referred to either te Tiriti or the Treaty. Crown discourses were characterised as i) rhetorical, ii aspirational, iii) practical and/or iv) substantive. We present a matrix of Crown health strategy and plan discourses and analyse their relationship to te Tiriti. DISCUSSION: Public health strategies and plans rarely address Treaty of Waitangi or te Tiriti o Waitangi obligations. This silence is inconsistent with legislative requirements to engage with the Treaty and health equity and is likely to inform health-related Waitangi Tribunal claims [WAI 2575]. Further work needs to be done to strengthen alignment of health policy to fulfil Crown obligations under te Tiriti.

The New Zealand Health Strategy 2016: whither health equity?

New Zealand's core health policy document-the New Zealand Health Strategy (NZHS)-was released in its final form in April 2016. This paper provides a critique of the strategy in particular, as it relates to health equity particularly for Maori. We introduce the five NZHS themes of-people powered, closer to home, value and high performance, one team and smart system-to focus on the aspirational goal of eliminating health inequities. Our critical framework is informed by Te Tiriti o Waitangi. We identified that the NZHS relies on the isolated efforts of committed individuals and organisations to achieve health equity and Te Tiriti engagement, rather than through a planned systems viewpoint. Evidence on health equity and Te Tiriti application suggests efforts need to be sustained, systematic and multi-levelled to be successful, rather than ad hoc and piecemeal.

Ko Tangonge Te Wai: Indigenous and Technical Data Come Together in Restoration Efforts.

In Aotearoa New Zealand, Maori aspirations around land and water conflict with settler interests. As indigenous people, Maori struggle to enact agency over resources, despite Treaty (Treaty of Waitangi/Te Tiriti o Waitangi is an 1840 agreement between Maori and the crown) settlement processes returning some lands. Returns are complex since changes wrought by dispossession may be extreme, requiring multiple stakeholder engagements. Tangonge, a heavily modified wetland, in northern Aotearoa New Zealand has been the subject of iwi (tribe or tribes) claims since the 1890s. Reparation processes have returned significant areas surrounding Tangonge to key iwi, Te Rarawa and Ngai Takoto, who formed the Tangonge Restoration Group to plan management and restoration. The vision of the iwi is to restore Tangonge as a wetland to rekindle usage by manawhenua (people with demonstrated authority and tribal links to the area in question) and local communities. However, perceived Maori privilege, distrust in Maori praxis and fear of alienation of stakeholders mean the situation presents challenges as well as opportunities. Understanding that various parties view knowledge in particular ways, the Restoration Group sought to juxtapose technical data and manawhenua knowledge about Tangonge. Hydrology findings and local aspirations were aligned to produce ideas for actions that encompassed the broad concerns. This integration of knowledge provides strategic steps for working with administrative authorities who have historical and ongoing interests.

Social networking and young adults' drinking practices: innovative qualitative methods for health behavior research.

OBJECTIVES: Understandings of health behaviors can be enriched by using innovative qualitative research designs. We illustrate this with a project that used multiple qualitative methods to explore the confluence of young adults' drinking behaviors and social networking practices in Aotearoa, New Zealand. METHOD: Participants were 18-25 year old males and females from diverse ethnic, class, and occupational backgrounds. In Stage 1, 34 friendship focus group discussions were video-recorded with 141 young adults who talked about their drinking and social networking practices. In Stage 2, 23 individual interviews were conducted using screen-capture software and video to record participants showing and discussing their Facebook pages. In Stage 3, a database of Web-based material regarding drinking and alcohol was developed and analyzed. RESULTS: In friendship group data, young adults co-constructed accounts of drinking practices and networking about drinking via Facebook as intensely social and pleasurable. However, this pleasure was less prominent in individual interviews, where there was greater explication of unpleasant or problematic experiences and practices. The pleasure derived from drinking and social networking practices was also differentiated by ethnicity, gender, and social class. Juxtaposing the Web-based data with participants' talk about their drinking and social media use showed the deep penetration of online alcohol marketing into young people's social worlds. CONCLUSIONS: Multiple qualitative methods, generating multimodal datasets, allowed valuable nuanced insights into young adults' drinking practices and social networking behaviors. This knowledge can usefully inform health policy, health promotion strategies, and targeted health interventions.

"Aren't labels for pickle jars, not people?" Negotiating identity and community in talk about 'being gay'.

Understanding how people in any given population think about and experience their sexuality is fundamental to developing and implementing good health policy, research, and practice. Yet despite several decades of focus on sexual identity and HIV risk within health research, gay men as a category are often treated in an uncomplicated way. This article reports on focus group discussions held with 45 gay and other men who have sex with men in New Zealand to identify how they talked about issues of gay identity and gay community/ies. The men negotiated and renegotiated their gay identity and being gay was reported as just one part of most men's lives. Many men did not like to be labeled as gay and downplayed aspects of their gay identity. Only a few men proclaimed being gay. Men reported very mixed experiences with the gay community/ies. Understanding how men experience being gay, provides information vital to enhancing policy, research and practice responses to gay men's health issues. A major challenge for health service provision to appropriately engage with men who have sex with other men but resist being labeled as gay was identified.

HIV/AIDS, beersellers and critical community health psychology in Cambodia: a case study.

This case study illustrates a participatory framework for confronting critical community health issues using 'grass-roots' research-guided community-defined interventions. Ongoing work in Cambodia has culturally adapted research, theory and practice for particular, local health-promotion responses to HIV/AIDS, alcohol abuse and other challenges in the community of Siem Reap. For resource-poor communities in Cambodia, we recycle such 'older' concepts as 'empowerment' and 'action research'. We re-imagine community health psychology, when confronted with 'critical', life-and-death issues, as adjusting its research and practices to local, particular ontological and epistemological urgencies of trauma, morbidity and mortality.

Gay men's explanations of health and how to improve it.

Little is known about the health views of gay men. In this article we report on how gay men explained health and the ways they discussed how health for gay men can be improved. We conducted a thematic analysis of data collected from 45 gay men in 11 focus groups and identified that health was mainly explained in individual terms, as were the ways to improve health (personal health care services and health promotion). The second way health was explained drew on social and community factors, with the societal acceptance of gay men being reported as essential for health improvements. These individual and social/community approaches were in tension; overall, the individualized approaches dominated. In line with other theorizing in health, we argue that appropriate policy and service provision to meet the health needs of gay men require greater acknowledgment of the social and community explanations of health and ways of improving health.

Gay men talking about health: are sexuality and health interlinked?

Defining and describing health has traditionally been the role of medical experts. Although a rich literature has recently established the importance of lay accounts of health, one important gap relates to gay men's accounts of health. Data from 11 focus groups involving 45 gay men were thematically analyzed to investigate gay men's views of health. Two contrasting positions on a possible relationship between sexuality and health-there is no link or there is a definite link-were identified. In addition, five key ways gay men talked about health were identified: health is the absence of disease, is functional ability, is fitness and exercise, is psychological, and is multifaceted. Although there are similarities in the ways gay and other men talk about health, important differences exist, which suggest that issues of sexuality need to be considered by health policy and service planners so that responsive health services can be provided.

Narratives of deprivation: Women's life stories around Maori sudden infant death syndrome.

Maori babies in Aotearoa/New Zealand die of Sudden Infant Death Syndrome (SIDS) at over five times the rate of their non-Maori peers. Research and health promotion around modifiable risk factors has produced only a small improvement in this situation since the mid-1990s. This paper reports on life story interviews, conducted between 2002 and 2004, with nineteen mothers of Maori infants who have died of SIDS. Potential participants were identified and accessed with the support of the national Maori SIDS Prevention Programme care-workers, in both urban and rural locations throughout both main islands of New Zealand. The paper articulates, in a thematic fashion, the bereaved mothers' experiences of alienation, marginalisation and exclusion, as a testimony of lives lived under conditions of serious deprivation in an affluent society. Constructing these experiences as non-modifiable risk factors hinders the development of policy and health promotion interventions that could improve the conditions in which Maori mothers live and raise their babies. It is argued that new approaches that target those whose lives are described here and build on the WHO Social Determinants of Health framework are vital to the efforts of New Zealanders to attain health equity and stem the tide of devastating and preventable loss of Maori babies to SIDS.

Survival disparities in Indigenous and non-Indigenous New Zealanders with colon cancer: the role of patient comorbidity, treatment and health service factors.

BACKGROUND: Ethnic disparities in cancer survival have been documented in many populations and cancer types. The causes of these inequalities are not well understood but may include disease and patient characteristics, treatment differences and health service factors. Survival was compared in a cohort of Maori (Indigenous) and non-Maori New Zealanders with colon cancer, and the contribution of demographics, disease characteristics, patient comorbidity, treatment and healthcare factors to survival disparities was assessed. METHODS: Maori patients diagnosed as having colon cancer between 1996 and 2003 were identified from the New Zealand Cancer Registry and compared with a randomly selected sample of non-Maori patients. Clinical and outcome data were obtained from medical records, pathology reports and the national mortality database. Cancer-specific survival was examined using Kaplan-Meier survival curves and Cox hazards modelling with multivariable adjustment. RESULTS: 301 Maori and 328 non-Maori patients with colon cancer were compared. Maori had a significantly poorer cancer survival than non-Maori (hazard ratio (HR)=1.33, 95% CI 1.03 to 1.71) that was not explained by demographic or disease characteristics. The most important factors contributing to poorer survival in Maori were patient comorbidity and markers of healthcare access, each of which accounted for around a third of the survival disparity. The final model accounted for almost all the survival disparity between Maori and non-Maori patients (HR=1.07, 95% CI 0.77 to 1.47). CONCLUSION: Higher patient comorbidity and poorer access and quality of cancer care are both important explanations for worse survival in Maori compared with non-Maori New Zealanders with colon cancer.

Kaupapa Maori Action Research to improve heart disease services in Aotearoa, New Zealand.

Action Research can be a powerful tool for change and improvement in health services for indigenous people when utilised within an appropriate framework. The project Maori Utilisation & Experience of Ischaemic Heart Disease Management illustrates this convergence in its use of Kaupapa Maori Action Research methods in its efforts to improve the health and well-being of Maori within the northern region of Aotearoa/New Zealand. We outline the research processes and outcomes obtained through the application of 'by Maori for Maori' approaches to understanding Maori pathways and barriers to care for ischaemic heart disease. Maori understandings of their illness and experiences of treatment, and healthcare providers' perspectives on care of Maori with ischaemic heart disease, were combined into Maori-led actions to improve service provision. The paper examines critical factors in an action research approach to health service innovations and implications for efforts to reduce entrenched health disparities.