The Pathway Forward - Directions For Māori Health: Views of the Hui. Te Ara Ahu Whakamua - Māori Health Decade Hui, Rotorua, 22-25 March 1994
Lorna Dyall,
Manager, Health Portfolio
Susan Wauchop,
Senior Policy Analyst, Te Puni Kokiri
At the edge of Lake Rotorua, looking out across the water to the sacred island of Mokoia which was once its home, sits Tamatekapua – the ancestral meeting house of the Te Arawa people. For four late summer days in March, Tamatekapua and its guardians, the Ngati Whakaue, watched over and inspired those who came to Rotorua to "find the way forward" for Māori health.
Planned to coincide with the tenth anniversary of the last major Māori health hui – Hui Whakaoranga held in Auckland in March 1984 – Te Ara Ahu Whakamua provided an opportunity to review progress in Māori health over the past decade and to set directions through to the year 2000 and beyond.
Participating in the discussions over the four days of the hui were more than 600 people – Māori and non-Māori – from grassroots health programmes and private practice, from the boards of the Regional Health Authorities, from Crown Health Enterprises, from the health media and from central government policy agencies.
Within the broad theme of the hui, "Māori have a right to be healthy", speakers and delegates were invited to address five key questions:
- What constitutes a healthy Māori?
- What indicators might be developed to measure Māori health?
- What role should Government agencies play in promoting Māori health
- What policies should be put in place to promote Māori health?
- What strategic objectives should be set for the year 2000?
What follows below is the distillation of Māori views, as expressed in the formal presentations, workshops and several open forums. As responses to the questions and the emerging themes illustrate, "health" for Māori is considerably broader than the conventional concept with its narrow focus on the treatment of sickness and injury. For Māori, health is a total state of wellbeing – a product of the social, cultural, economic and physical environment.
Responses to the key questions
"What constitutes a healthy Māori?"
"Self-esteem" and a "clear sense of identity" were most frequently mentioned. Equally important was "control over one's own destiny" and "a voice that is heard". Alongside "intellectual alertness, physical fitness and spiritual awareness", "readiness to accept personal responsibility for one's own health" featured highly.
The security of a caring, supportive and violence-free whānau was considered by delegates to be a prerequisite of personal health. Issues surrounding violence in the family, seldom raised in earlier forums, were addressed by a number of participants. Knowledge of whakapapa , te reo and tikanga was regarded by delegates as an important constituent of good health. Employment, economic stability, and the absence of poverty was perceived to be the other key ingredients of personal health.
"What indicators might be developed to measure Māori health?"
This question invited delegates to propose some measures more appropriate to the Māori concept of health than the present narrow measures of morbidity and mortality.
Again, the desire among Māori for greater power and influence in the community was reflected in delegates' proposals that the "number of Māori in positions of influence" be a key indicator of Māori health. The "value of resources in Māori ownership", the "rate of business success", and "an increase in the number of Māori employed" reflect the significance of Māori health of economic security. Reversal of negative statistics such as a "drop in the crime rate" and a "drop in the rate of psychiatric illness" were also proposed as key indicators of improvements in Māori health.
"What role should Government and its agencies play in promoting
Māori health?"
"Handing resources over to Māori" is the greatest contribution Government agencies can make to promoting Māori health, according to the conference. "Listening to Māori", "involving Māori" (particularly Māori women) and "keeping Māori well-informed" rank next.
Delegates also delivered a clear message that they would like to see a greater degree of co-operation between agencies working in the area of Māori health. They want mainstream agencies to be accountable for the effectiveness of services and programmes provided to Māori.
"What policies should be put in place to achieve healthy Māori?"
Delegates advocated policies that are developed by Māori for Māori, that empower whānau, hapu and iwi, that raise the status of te reo and tikanga Māori, that ensure access on an equal basis, and that promote the unique qualities and talents of Māori. Specifically, in the health service, there was a desire to see more resources directed into primary health care; an increase in the length of funding cycles; recognition of rongoa Māori , and free health care for preschool children.
In education, delegates advocated a greater level of support for second chance education, full funding for kura kaupapa Māori , and a reassessment of criteria for entry to universities. A greater focus on management training for Māori was also called for.
Another policy area to come under scrutiny was broadcasting, where delegates were keen to see greater access for Māori; fewer violent programmes; and greater media responsibility in things Māori.
Delegates wanted to see the number of Māori seats in Parliament related to the number of Māori identified in the Census, and they wanted to see an accommodation of Māori processes in the justice system.
"What strategic objectives should be set for the year 2000?"
Greater empowerment of Māori, with Māori controlling a larger part of their own destiny, is one of the key objectives identified by the hui participants for the year 2000. Prerequisite to effective use of greater empowerment, however, are strong Māori structures. Delegates want to see well-resourced, accessible and accountable Māori organisations – whether they be iwi , or wananga , or health clinics. There was considerable support for the establishment of a Māori Health Authority.
Greater political influence is an objective related to that of empowerment. In addition to a greater representation of Māori in Parliament, delegates wanted to see more Māori at the policy-making level in Government.
Māori as the "leanest, healthiest" New Zealanders is a strongly supported objective. A number of specific health objectives for the year 2000 were proposed, including 100 per cent immunisation of Māori children and a smokefree generation of young Māori.
Predominantly positive images of Maori in the media, and "everyone wanting to learn te reo" were perceived as important objectives on the way to a "truly bicultural" society. "Employment for all" was the ultimate objective.
Emerging themes
The need to listen to Māori women
The relative invisibility of Māori women at policy making levels struck a number of speakers as ironic, given, as one speaker noted, women's pivotal role at the centre of whānau. There was a strong call for Māori women to be "substantially involved in the policy development and decision making processes – at local, regional and national levels". As one speaker pointed out, Māori women "disproportionately bear the burden of all responsibilities, yet it is Māori men who represent us, and … it is largely Māori men with whom (mainly) government men consult."
The absence of women's voices at negotiating tables and in the boardrooms of the country suggested to some that Māori women might see few of the benefits from the realisation of the commercial benefits of Māori assets.
Donna Awatere's dream of an Aotearoa where it would be safe to be born a Māori girl, where she would have equal opportunity to survive and flourish and enjoy the benefits of being tangata whenua was recalled. Speakers reflected that family violence, abuse and the continuation of oppressive protocols continued to threaten the realisation of this dream. "Let us listen to the women", said a prominent kaumatua .
The importance of strengthening the whānau
Delegates agreed that a greater commitment was needed to ensure the strength of the core institutions of Māoridom – particularly the whānau. It was within the whānau that health status was determined and mana born, yet there was insufficient commitment and action to reinforce it, in the view of the hui. "There is too much rhetoric about whānau. We cannot continue to romanticise the concept of whānau and bury our heads in the sand of reality," said one speaker.
As a number of delegates observed, much of the burden of raising the next generation of Māori was falling on Māori women, often in extremely limited economic situations. With 50 per cent of Māori households headed by a sole adult, 90 per cent of whom were women, that burden was too great. As Hekia Parata said, "Māori women cannot be the sole providers… at least not endlessly so. The whānau is, or should be, a system of mutual benefit. Today it is mostly about male benefit. It is my view that Māori women must be more demanding of their men."
Delegates agreed that, having focused on iwi development over the past decade, attention must now move more decisively towards whānau development whānaungatanga (family cohesion). It could not be assumed that developments at an iwi or even a hapu level would have any impact on whānau in, say, Auckland, who may be living some distance away from tribal areas. Fresh approaches which focused on ordinary Māori households were called for.
The need to address violence in the family
An issue that had barely been acknowledged in previous forums was frankly conceded by many speakers to be a major threat to the functionality of the whānau. Family violence and abuse must be tackled as a mater of priority, the conference agreed.
Domestic violence, child molestation, sexual abuse, incest, substance abuse and denigration of the role of women, were perpetrated and often perpetuated because of a "conspiracy of silence to protect the so-called whānau", according to one speaker. Others observed that violence was being modelled and passed on. As one prominent general practitioner observed, "if we Māori men can get ourselves together and take responsibility for our emotions, feelings, attitudes and behaviours, we could potentially prevent a considerable amount of hurt, damage and distress that we are currently inflicting on each other, our partners and whānau."
The need to take greater personal responsibility for health outcomes
Preparedness to take greater personal responsibility for health was urged upon the conference by a number of speakers and was reflected in delegates' contributions in the workshop sessions. Whether a product of what Professor Mason Durie observed as New Zealand's steady move towards a libertarian philosophy, or whether a reflection of frustration at the lack of any strong commitment to Māori health on behalf of successive governments, the call for Māori to take greater control of their own lives was constantly repeated.
This control meant taking personal steps like quitting smoking and addressing family violence in the whānau, and learning non-violent and non-threatening ways of dealing with children and sorting out differences in opinion.
While there was much in the world Māori could not influence or control, there was much that they could, it was observed. "While it is the right of Māori to be healthy, and it is the government that must provide services within negotiated parameters, ultimately it is the obligation of individuals to take responsibility for their personal health."
This was no less true in respect of Māori language. Professor Timoti Karetu was blunt: "Every person who wishes the Māori language to survive must be committed to that proposition." That meant speaking the language at "every Māori function, and at all times, everywhere."
"Tatau Tatau" – The need for collective responsibility
The calls for acceptance of a greater level of personal responsibility for health were balanced by an equally strong emphasis on the importance of collective responsibility in the development of healthy public policies.
While acknowledging that personal responsibility for health could not be ignored, nor disregard for personal health condoned, Professor Mason Durie pointed out that individual obligations must be balanced with collective responsibility if there was to be significant improvement in Māori health status: "Gains in health are related to all socio-economic policies. Co-ordination and co-operation between all sectors are important, particularly in addressing mental health issues." It was a futile exercise, for example, to attempt to convince young men that alcohol was a health hazard if there was no public policy to discourage alcohol use.
Some concern was also expressed that an exclusive focus on individual responsibility without examining concurrent public policies would disadvantage the disadvantaged. Threatening to withhold social welfare payments from mothers who did not have their children immunised, or refusing surgery to heavy smokers, would simply add to existing burdens and would not address the fundamental problems.
Concern at the consequences for Māori health of the current competitive regime was expressed by a number of speakers. The prospect of iwi competing with one another for resources and for business, alarmed one speaker who saw tribalism "rearing its head again". "The manaaki of our people should not be limited or constrained between tribal boundaries for it is that intrinsic manaakitanga that distinguishes our culture from other distinct groups."
Lack of Government action on social policy issues
Consecutive governments' slowness and/or reluctance to address social inequality between Māori and non-Māori was discussed in a number of sessions.
Some considered that greater constitutional clarity was needed. Lawyer Annette Sykes was adamant in asserting that "Māori's sovereign status as tangata whenua must be respected and provided for in the management philosophy and regimes of the modern New Zealand state." She was equally clear in her view that "the crucial issue that remains unaddressed but requires attention, and urgently, is the need for constitutional adjustments to occur which reflects these intrinsic rights."
Professor Mason Durie observed that it appeared easier for the Crown to recognise Treaty of Waitangi rights when land, forest and fisheries were under consideration, but in social policy areas "there was little evidence that Māori were perceived as anything other than a disadvantaged minority." He considered that a constitutional review based on the application of the Treaty was imperative before any structural change – like a move to republican status – was unilaterally introduced.
Some speakers, however, were of the view that it was a lack of will rather than the lack of a constitution that was constraining Māori aspirations for equality of opportunity. In Paparangi Reid's words, "Our Treaty partner has amnesia". And even if it regained its memory, she did not believe that there was the "political will to tempt the white backlash that might arise."
The reason for lack of action may not simply lie with Government, however. It was hardly fair, said Hekia Parata, to expect policy makers to design policy to fit Māori requirements if Māori themselves were unclear about what they needed, or were ambiguous in their articulation of it. It was not enough, she said, to say "it is our right" or that "it says so in the Treaty", or that "it is the Māori way". Clarity and explicitness in the expression of Māori's requirements was required.
The need to acknowledge the diversity of Māori
Health policy makers were encouraged by the hui to "get to know" their Māori clients. As Professor Durie reminded the conference, Māori live in "diverse realities". He said that it could no longer be assumed that most Māori were linked to conservative structures of hapu or iwi, or that kohanga reo would be accessed by all Māori children, or that the marae would continue to be the favoured meeting place for all Māori. Different strategies, he said, would be needed if all Māori were to be reached.
Health service providers in the audience received the same message: Māori do not necessarily patronise a health service simply because it is run by Māori. Like any other consumer; Māori consumers sought services that were of high quality and that met their needs.
"Less talk, more action"
Calls to act more and talk less were applauded by the conference. Delegates were urged to "seize the moment" by a number of speakers who saw the health reforms as "full of opportunities" for Māori. Iwi were exhorted to develop plans of action to achieve Māori health goals. Māori had to challenge and break the mindsets that had mesmerised them into believing that they could only ever be service recipients. Māori had demonstrated they could be competitive, cost-efficient and effective service providers.
According to Tipene O'Regan, "too many of Māoridom's best and brightest brains were caught up in the bureaucracies negotiating the distribution of wealth and assets, instead of being out generating wealth and generating new opportunities. A driving determination to fund our own social growth and wealth is the only thing that is going to give me any dreams that will ever have healthy Māori", he said.
Researcher Paparangi Reid cautioned against expending too much energy and resources gathering and perfecting the collection of information, before getting on with addressing the challenges the information demonstrated. She believed that there was a danger of "paralysis by analysis" in, for example, the current debate over the accuracy of Māori health data.
If you pay the piper you can select the tune….
Māori's best hope of obtaining the health services that they wanted was by buying them themselves. Only by having control of the purse strings would Māori have real choice in the market place. This was the conclusion reached by a number of speakers, albeit for different reasons.
In Tipene O'Regan's view, a democracy was not capable of delivering to a minority, therefore the minority would have to have control of its own assets, and be able to generate the capital to buy the services that it required. Others observed that governments do not necessarily make the best decisions on the taxpayers' behalf.
Need for a greater focus on outcomes
Greater emphasis needed to be placed on monitoring the effectiveness of programmes and services delivered to Māori, in the view of a number of key speakers. The fact that services existed did not necessarily guarantee an improvement in health. The outcome of these services needed to be regularly evaluated.
Whetu Tirakatene-Sullivan proposed amending the Public Finance Act to require departments that had received funding for Māori programmes as a result of "mainstreaming" to report to Parliament on the outcomes of their service delivery. As she pointed out, the Public Finance Act currently requires departments to report only on outputs, not outcomes. If mainstream departments were demonstrably not delivering to Maori, then Maori could legitimately ask for the funding to be returned to Maori agencies.
Conclusion
The themes and views extracted above convey only a portion of the flavour of a conference that included over 30 formal addresses, 24 workshops and a number of informal discussions. For those who are interested in the wider debate, full proceedings of the Hui Te Ara Ahu Whakamua can be obtained by writing to Lorna Dyall, Te Puni Kokiri, P O Box 3943, Wellington.
In his concluding remarks to the hui, Te Puni Kokiri's chief executive Wira Gardiner said that impact of the hui would in the end be measured by the difference it made to the health of Māori people. If the dreams, desires and hopes of the delegates were to be translated into reality, a plan of action would be needed.
That plan of action has been drafted. Over the next few months, every person and every agency with an interest in Māori health will, we hope, be joined in the process of realising the hui's aspirations.
"Tatau, tatau – working together we will achieve our dreams."
