MASSEY UNIVERSITYDEPARTMENT OF MAORI STUDIES

TE PUMANAWA HAUORA

EFFECTIVE HEALTH POLICY FOR MAORI0

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

I

JSTACKWA300[QI

CON1997

/ Te Piamanawa Hamm

Effective Health PolicyFor MAori

0 0 0 0 S S • • S •

Advice to Te Kete Hauora on a StrategicFrameworkfor the Development ofMaoriHealth Policy

CW Cunningham and S Taite May 1997

Inkmiation CentreInformation ManagernenMinistiy 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 8He Anga K7iakamana - A framework for the delivery of disability support servicesfor Maori 12The CHI audit model - culturally appropriate Public Health Services15Guidelines for purchasing personal mental health services for Maori17

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 Information23

Future work 29

Appendix 1:

POLICY OUTCOME SUPPORTS MAORI HEALTH GAINS 30

RECOGNISESAND ADDRESSES THE DETERMINANTS OFMAORI HEALTHSTATUS 30ENABLES MAORI WORKFORCE DEVELOPMENT 31ADDRESSES THE GOVERNMENT'S HEALTH PRIORITIES 32IS CONSISTENT WITH THE GOVERNMENT 'SMAORI DEVELOPMENTANDTREATY OF WAITANGI POLICIES 33ADDRESSES HEALTH PRIORITIES OFMAORI 34PROMOTES MAORI WISHES TO TAKE RESPONSIBILITY FOR THEIR 0 WHEALTH 35USES A VA ILA BLE NATIONAL STANDARDSAND MEETS GOVERNMENTOBLIGATIONS 35

3

REQUIRES QUALJTYMAORI SOL UTIONSAND SPECIFICALLY SUPPORTSOUTCOMES SPECIFIED IN RELEVANT, EXISTING WISDOM 36REQUIRES COMPETENT, SAFE AND EFFICACIOUS SERVICES37ENABLES MEANINGFUL DATA TO BE COLLECTED 37PROMOTES GOALS WHICH RELATE TO MEASURABLE OUTCOMES38

POLICY OUTCOME RESPONSIVE TO MAORI 39

IDENTIFIES MAORIASA RELEVANT TARGET GROUP 39PROMOTES CHOICE FOR MAORI 40RESPONDS TO DIVERSE MAORI REALITIES 40RECOGNISESAND ADDRESSES MAORI DEVELOPMENT PRIORITIES 41PROMOTES SEAMLESSNESS (OF SERVICESAND BETWEEN HEALTHANDDEVELOPMENT) 42PROMOTES CULTURAL AFFIRMATION FOR MAORI 42IMPROVESACCESSIBILITY FOR IvL4ORI BYADDRESSING KNOWNBARRIERS TO ACCESS 43PROMOTESAND SUPPORTS INFORMED CHOICE 44PROMOTES IMPROVED COMMUNICATION WITH MA0RI 44SUPPORTS MAORI PREFERENCES FOR SERVICE PROVIDERS (INCLUDINGSERVICES PROVIDED BYMAORI) 44PROMOTES APPROPRIA TE. USE OF TE REO MAORI 45PROMOTES LINKAGES TO MAORI INSTITUTIONS 45

POLICY DEVELOPMENT PROCESS RESPONSIVE TO MAORI 46

RESPECTS MAORI INTELLECTUAL PROPER TY RIGHTS 46ACTIVELY INVOL VESMAORI IN POLICY DEVELOPMENT 46A CTI VELYINVOL VESMAORI IN DECISION MA KING 47CONSULTSMEANINGFULLY WITH MAORI 47AFFIRMS MAORI CULTURAL VIEWPOINTS/IS CULTURALLY SAFE/USES TEREO MAORI CORRECTLY 48ACKNOWLEDGES THE RIGHTS/SPECIAL NEEDS OF TANGA TA WHENUA 48IDENTIFIES THE IMPACT ON CR0 WN/TANGA TA WHENUA REM TIONSHIP49RESPECTS MAORIAND IN TURN DEVELOPS TRUST 49

POLICY DEVELOPMENT PROCESS IS ANALYTICALLY SOUND50

IS BASED ONA RIGOROUS POLICY DEVELOPMENTMODEL50IS CLEARLY BASED ONA FRAMEWORK CONSISTENT WITH MAORI VIE W550CLEARLY PROVIDES FOR A MONITORING PROCESS 50MEANINGFULLY USES MAORI SPECIFIC DATA 51IDENTIFIES MAORIASA RELEVANT TARGET GROUP 51

BIBLIOGRAPHY 52

Executive Summary

Effective Health Policy for Mãon

The Ministry of Health's policy analysts all contribute to the achievement of healthgains 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 theGovernment and Mori it is useful to consider that:

• all policy developed within the Ministry of Health impacts on Maori in someway - it is not an issue of whether there is an impact but rather how much of animpact there is and how that is managed; yet there are priorities for Maorihealth;

• a Maori analysis is as fundamental to the development of policy within theMinistry as an economic analysis is or at least it should be if the Ministry is torealistically address it's commitment to Maori and, to advance Maori health asit is required to do.

A framework for informing the policy development process, in order that more effectivehealth policy for Maori is achieved, has been developed. The framework has threeprincipal first order criteria (elements) based on reasonable expectations of effectivehealth policy for Maori.

Effective health policy should:

• support health gains for Maori (policy outcomes);

• be responsive to Maori needs and expectations (policy outcomes and policydevelopment process); and,

be analytically sound (policy development process).

A checklist for policy analysts and supporting information are presented. The primarychecklist, which appears on the following page (and page 23), interprets the meaning ofthe 'first order criteria' identified above. A more comprehensive checklist (page 24-29)is intended to assist analysts by identifying the information needed by them andrecommending the types of measures which may be incorporated into the specific policy.Finally, the bibliography (Appendix 1) references statements drawn from the backgroundliterature in support of the elements of the checklist.

4

"5

Effective Health Policy For Maori--------- ------------V.

policy outcome supports Mãori policy outcome is responsivehealth gains to MAori

• recognises and addresses the determinants of• identifies Maori as a relevant target groupMaori 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 Mãoripriorities

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 meetsknown 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 providerswisdom (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 isanalytically 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 developmentHauoralMaori Advisors (audit trail))

• actively involves Maori in decision making• is clearly based on a framework consistent with• consults meaningfully with MaoriMãori views (Treaty of Waitangi, Whare Tapa• affirms Maori cultural viewpointsWha)• is culturally safe; uses te reo Maori correctly• clearly provides for a monitoring process• acknowledges the rights/special needs of tangata• meaningfully uses Maori specific data

whenua• identifies Maori as a relevant target group• 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 anissue of whether there is an impact but rather how much of an impact there is and how well we manage thatimpact;

• a Maori analysis is as fundamental as an economic analysis to the development of policy within the Ministry ifwe are to realistically address our commitment to Maori and, to advance Maori health as we are required to do.

Mental Health Services Ic Ptirnanawa Hauora forthe i.Ministry ot I kahh

introduction

AdYice sought by Te Kete Hauora

A number of frameworks have recently been proposed to describe effective healthservices for Maori. These frameworks are listed in Table 1, and include He TauraTieke: Measuring Effective Health Services for Maori' which was produced by theMinistry of Health in 1995/62.

Table]: Frameworks - Health Services for Maori.

Senice Area•-- : Framework .- Author ..

Personal Healthisf-Ic Taura Tieke: Population HealthMeasuring Effective Health Services. Ministry Services for MoriHealth

The advice sought from Te Pumanawa Hauora was the reconciliation of theseframeworks and the development of a central framework for the development ofstrategic Mori health policy which takes the same approach to policy development thatthese frameworks take to service delivery. Importantly, many of these frameworks takethe approach of enabling service providers themselves to analyse and improve their owndelivery by encouraging self audit. The frameworks also provide information based onexpectations of Maori as service consumers.

Population Health Services Section (1995), He Taura Treke - Measuring Effective HealthServices 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 AngaWhakamana - A frameworkfor the delivery of disability support services for Maori,NACCJ-IDSS, Wellington.

4 M Dune, A Gillies, TeK Kingi, MM Ratima, JA Waldon, PS Morrison, GR Allan, Guidelinesfor Purchasing Personal Mental Health Services for Maori, Te Pamanawa Hauora, PalmerstonNorth.

MR Dune (1993), The CHIAudit Model - A culturally appropriate auditing model for PublicHealth Services, Public Health Commission, Wellington.

This report is based upon a thematic analysis of the frameworks above in order toproduce a 'strategic' framework which proposes criteria for effective health policy forMaori.

Effective Health Policy for Mãon

There have already been a number of attempts to develop and implement Maori policyframeworks within the Department and Ministry of Health.

An older example is the Hauora Maori Checklist6 which was developed in 1990 by TeWahanga 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 theImpact Checklist' and Decision Tree 8 tools.

Of note is a discussion document on 'A Maori Policy Analysis Framework' producedin 1995. This discussion document attempted to summarise the varied materialproduced on responsiveness and Maori policy analysis models throughout the publicsector. The work also analysed generic policy analysis models and collected datathrough interviews with staff from the Ministry of Health. The resulting discussiondocument proposed to 'culturise' the policy produced within the Ministry by Maori andnon-Maori staff alike.

The draft framework is... shaped by the requirements, constraints andculture of the Ministry of Health rather than strictly Maori

II methodologies.10

The discussion document also made a number of assumptions, two of which areparticularly relevant:

• all policy developed within the Ministry of Health will impact on Maori insome way therefore it is not an issue of whether there is an impact but ratherhow much of an impact there is and how that is managed;

• a Maori analysis is as fundamental to the development of policy within theMinistry as an economic analysis is or at least it should be if the Ministry is torealistically address it's commitment to Maori and, to advance Maori health asit is required to do.

Before advancing the advice on Effective Health Policy for Maori it is worthwhile alsoexamining the frameworks which have recently been proposed for health servicedelivery 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 - DiscussionDocument, Ministry of Health, Wellington.

10 ibid.

Existing frameworks - effective health services for MâonFour service-focussed frameworks have provided the basis for this analysis. Thedevelopment of each framework has taken a slightly different approach, and, thevariation in the use of language between and among the frameworks can makeinterpretation more difficult. It is worthwhile looking at each piece of work in moredetail.

He Taura fleke - Measuring Effective Health Services for MãoriProduced by the Population Health Services Section of the Ministry of Health, He TauraTreke proposed an approach for measuring effectiveness of health services for Maoribased on the expectations of Maori consumers themselves.

The report sought to identify 'key attributes' of effective health services for Maoriconsumers. It was proposed that by meeting the needs and expectations of Maori, healthservice providers would improve access to health services used by Maori, supportindependence and improve Maori health.

He Taura Tieke identified those key health service attributes that were thought effectivefor Maori consumers and presented them in a checklist framework. In compiling thedocument the authors addressed the following questions:

• what are Maori expectations of effective health services?

• what attributes of effective health services are highly rated by Maoriconsumers?

• what features of care and service contribute most to Maori consumersatisfaction?

The clear and major expectation ofMãori is that their health will beimproved as an automatic consequence of using a health service. Webelieve that improved outcomes for Maori will result through greaterunderstanding ofMaori expectations, refocusing services to better meetthese expectations and measuring progress towards meetingexpectations11.

The framework in He Taura Tieke is composed of elements and attributes. For each ofthe attributes 'expectations' are given together with a list of questions designed to assistthe provider in developing more appropriate service responses.

In summary, the authors found that the attributes of effective services valued by Maoriare:

' 1 see references in He Taura Tieke.

9

I

Structural and Systemic • Maori developmentResponsiveness--

Maori workiorce development

• preferred providcrs

The document describes each of the attributes in greater detail and then proposes severalchecklists for service providers to use.

Of importance is the approach taken within the checklists where standards ofperformance are identified together with informative questions designed to promptservice providers into identifying the most appropriate responses given the particularservice and community served.

The generic checklists are reproduced here. The reader is referred to the document forthe complete set.

Co M P E T.E N CE STRUCTURAL & SYSTEMIC

!Côeteiic1ëMoñitrrin.ifSà1ety=

- Mãon consumersProviders are pfotduitdconsumers know

- -from harm orhealth servionI firther haim toare meding ........h

.ei bodies, theirgoals andmmtal andobjectives (they

well-may also medspiritual -being and theirbroader aimsculture; treatmtait ----valUed byMaori)produces desired - -Outcome- - -

RESPONSIVENESSMR- MA1--fér1cdFicwDièIopmen

.______ ..WThe philosophicdHealth isMãori arcThe goneralbase or-addressed aslone -employed andprefermee offramework fromcomponait ofdeveloped as staff Mâori consumaswhidithe ...sevce -broad Miori ......t all levels by thefor servicesis structured anddeveiopmont inservice as one ..delivcnd bydeliverd iswhidi social,-specific way ofMion is aecqsted

.consitent with. -political, culturalcontributingtoand praaisedañdmaysuppoit,andeconomic:: --Maori-- - - - --Muon consumersfactors are also - develojimait- --- --viewsfhealthaddressedto - --•r: - -

baiefitthe--- --consumer -•- - - - - -

Doesthebuilding H6 -d --- -- llow4oyouactivctyh.weyouHowdoyouensureHowdoyoumakeinSet building safety ..guliriv valuateaim to achim'ed lopcd your-MAori staff arefemale staff

- codes .an ..allo your seivice?equity (ofaccess,rdrlionship with the - employod at allavailable for-access for those -use and outcome)MSim comnmnitv - -- - levels of yourwãhine?with disabilities? -- How dii 'nu keepfor 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 assistI tow do you monitor How do you addrccrHave you consideredIs ...tranng-staff to ensure theysnd tespund to ---- and act on MAonestablishing a MIor, -- csiupu[sorv?are personally andchmgmg needs of social culiui-al andunit within your

-- professionally safe9your 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 theHealth and Disabilities Sector, Department of Health, Wellington.

"Minister of Health, (1995), 1995196 Policy Guidelines to Regional Health Authorities, Ministry of Health,Wellington.

... 11

CONSUMER SATISFACTION

AcessIformatiIi= IWforrned MTNO Sãiii1essnessGhoice= Resp-ec -

ProvidersMãori coitsUthersMaori consumers - In addition to•communtcate ........................mor fee1respecedbeingapartofthescessfliIlywithdsoicb':-and infurnfnisi - - rsrv1ce workforce.Mäon by giving-.being givm - --thëprovid- -Mãori areclear informationoptions snrsitivewho..-=. T rnvolved inabout the serviceto their needs- .niaintains their-: -- managemait

S•receivingusefiul- nyacyan - --decisions and mayinformation frominformation from-- confidmtialityhave a stake mMãoricxassumerstheproviderto- providestheowning health

-: smsitive '

l: keepassist them in -ossib carese-best plers Ices-confidmtialct\.making daoices-= available- able to be olionti•useinformation.== .p--- - __- -

-concens- -_sassitnel to _Iciltural and -- -......- -- = ---- boneflttheMãon-:=-lifestyle -- - --:

-5- : consumer - -- S

...

- - -

I

How dO uHow How dyoudsoose and uexplain all-respeil Maoriappropriate mediatreatmeiat options -. healing processesand formats forclearly? -(e g, karakiainformation(e.g.- :==-rongoa) and - -plain How do youmsureihefrl -Maon/Enghshknow youravailability aslanguage, fhmiliar - patimts --. - -- sufriers wish?Maoriconcqsts)?understand?--

IHowdo you makeHow do you me.How do you -- ±How do youHow do youHow do youMãdri staff availableconsumerclearly explain - iiiölude-include Mãori inhandle disdiarge

oustiut theconfidontiabty and the risks andpatieiit's whanauthe planning,planning? -rservicle7- pnvacy guidelinesoutcomes of thein the service?:delivering and

-- :—:o- -(eg.Privacytreat . .iñoitoringof -options? :_yourservice? -

- Ow. : do youBow do yu -eijsure datamake .consumers

- colledion isaware ofseissitive to MSoriconsumerconsumer needsadsocacv(e g not makingservies?- -insmsthve, value- - --basedassumptions)? - --

How do von helpHow do you takeMacli to Like careadvantage of - ........

..:oftheir os1iroutine-health' appointmmtsto-

provide healthHow do oucx.lucation? - --monitor \lãoriconsumersatisfadion?

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 disabilitysupport services for MoriProduced by Te Pamanawa Hauora, Massey University, He Anga Whakamana wasadvice produced for the (then) National Advisory Committee on Core Health andDisability Support Services [Core Services Committee].

In commissioning the report, the Core Services Committee was particularly interestedin:

• the philosophy of a disability support service that would be acceptable forMaori people;

• the characteristics that distinguish the development and delivery of disabilitysupport services (dss) in a way that will be of maximum benefit to Maoripeople; and,

• the ways in which quality can be assessed to ensure services are appropriate andbeneficial to Maori.

The report proposed a culturally appropriate philosophy for dss for Maori and aframework 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 disabilityitself, and does not necessarily suggest differences between Maori and non-Maoriclients. The focus of the second level is on cultural factors relevant to MAon people withdisabilities.

Consistent with the philosophy is He Anga Whakamana, a framework for the deliveryof 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 areassociated with measurable indicators.

The indicators provide guidelines as to appropriate measures for use inmonitoring services, though the actual indicators and measures are bestnegotiated between purchasers, providers and clients. 15

The authors proposed 'service implications' stemming from each of the principles, andfurther described indicators as 'guidelines' to measures which the provider wouldnegotiate with clients and the purchasers when developing.

13

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4.:m rIIsIv : s vice op ionser

15 NM Ratima, TvlH Dune, etal.., (1995), HeAnga Whakamana - A fran:eworkfor the delivery of disabilitysupport 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, whichdefinitions for Maori are used, whether collection is purposeful and consistent,and whether issues of confidentiality and guardianship are considered in themanagement 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 intomonitoring and review processes?

• caregiver/case manager participation, including whether there is assessmentof Maori institutions on behalf of the client, whether there is understanding ofMaori perspectives and values by the caregiver/case manager. Also, askinghow the caregiver is involved in programme development, planning,implementation and review?

• whAnau participation, including whether there is involvement of whflnau inservices, the recording of interactions, the purpose and meaningfulness ofparticipation, the interaction of the client and whanau beyond the service, andthe availability of facilities for whanau including accommodation.

• appropriate use of the MAori language, including what is the extent of use ofMaori language within the service, are Maori speaking staff available, iswritten information provided in both Maori and English?

• links with Mãori institutions, including whether links exist, the extent oflinkages and the participation of Mori organisations in the service.

• consistency, including whether the service is available 24-hours a day, whetherpolicies for Maori exist, whether there are explicit contact points for clients andtheir whanau, and whether outreach services are available?

• workforce composition and sensitivity, including whether professionally andculturally qualified staff are actively being recruited, how many Maori staff arethere, are Maori jobs designated, is bicultural training and integral aspect ofstaff development.

• assessment procedures, including assessing how cultural factors are includedin client assessments, how the client and their whanau participate inassessments, and whether assessments include a formal cultural profile.

• consultation, including whether Maori are involved in the overall developmentand planning of services, the extent of the consultation, who was consulted,whether there was agreement among those consulted and whether there arearrangements for continued Maori input.

• MAori specific factors, including whether there is a process for referral toMaori specific services, especially Maori traditional healers.

The CHI audit model - culturally appropriate Public Health ServicesProduced by Te Pamanawa Hauora for the former Public Health Commission, the CHIaudit model recommended both the attributes which any cultural audit model shouldattain, 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 tomonitor and assess health and Maori policies and programmes'. These public sectormodels 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 andaccountability (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 ofWomen's Affairs, Wellington.

19 Te Puni KOkiri, (1993), Te Raranga Kete - A Process for Reviewing Government Services, Ministry ofMaori Development, Wellington.

20 Treaty-based framework made up of provisions and principles was first used in a report prepared forNorth 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, betweenthe 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 endorsementby the purchaser, and the project is then audited according to those measurements.

Guidelines for purchasing personal mental health services for MãoriProduced for the Mental Health Services Section of the Ministry of Health by TePamanawa Hauora, the report sought to develop purchasing guidelines for personalmental health services for Maori. In particular, the development of:

• a framework through which culturally effective services can be identified andassessed;

• a cultural effectiveness scale for the measurement of mental health services interms of their capacity to meet the mental health needs of Maori.

The framework produced consisted of two interacting dimensions labeled 'purchasingoptions' 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 usealongside other frameworks to ensure that key issues relating to personal metal healthservices 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 theauthors. The Cultural Effectiveness Scale has three dimensions with 3 sub-scales. Thefinal 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 healthneeds in an effective and culturally appropriate way.

MH

Table 3: Cultural Effectiveness Measures

.I)meñsionsHCOthpolleIti fsPossi'b1eJWeasuref.

i\'1ori Affirmation•cultural inputs % time allocated to culturalactivities

(MA) • Maori expertisedegree of appropriateness

JI haical 1nputsasseihent -Lreatrnentiir protocols completed______rehailatationäctivitie-

Health Outcomes• level ofeUnessSF-36

(HO) Whare Tapa Wha

22 The SF-36TM is a self-assessed health status tool, trademarked to the New England Medical Centre.

Rationalisation of the frameworksClearly one of the difficulties in rationalising the various frameworks is that, while theyeach identify criteria for cultural effectiveness (in different service settings), the criteriaare sometimes presented as having a different 'order' across the frameworks. That is,the same criterion may be represented, for example, as an overarching principle, atheme or an indicator.

Another complication for users of the frameworks is that the taxonomy which applies tothese 'orders' has, by and large, reflected the preferred language of the authors ratherthan some standard nomenclature. There are 'cornerstones', 'principles', 'serviceimplications' 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 astandard, if unimaginative, nomenclature - 'first order', 'second order' and so on.Based on the frameworks analysed we can summarise the orderings as follows.

First order criteriaThese tend to be 'overarching' in the sense that they are fundamental to the philosophyof the particular framework.

Second order criteriaThese tend to be 'thematic' in the sense that they represent significant aggregations ofideas 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 anindividual 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 aservice operating at a 'high level of performance ' 23 . These standards are set in orderthat 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 beuseful in reinforcing the contribution of the groups of second-order criteria to theoutcomes desired.

Among the four frameworks we are able to identify a number of consistent themes whichassists us in specifying the standards which effective health policy for Maori needs toachieve.

19

23 oha Hams, personal communication.

ChecklistElements of framework - Effective Health Policy for Mâon

One of the problems policy analysts have in interpreting current frameworks forresponsive policy is that these frameworks frequently mix process and contentindicators.

The framework developed in this report seeks to be much clearer in differentiatingbetween the process of policy development and the outcome of the particular policywhich is being developed.

The framework has three principal first order criteria based on reasonable expectationsof 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 policydevelopment process)

• be analytically sound (policy development process)

Within each first order criterion are a number of second order criteria which form thebasis of the checklists:

20

• recognises and addresses the detcrminants of Maori• policy outcome- health statussupports Maori • enables Maori workforce developmenthealth gains• addresses the Governments health priorities

- • is consistent with the Government s Mlori

•respects .aor i ntellectual propohcv development..• actively involves Mori in polv'• •cvc•o..process isresponsive• actively involves Maori in dcc ision niaingMaori• 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

21

.22

Effective Health Policy For Maori.......................

MPoiiyMeei uhpolicy outcome supports Mãori policy outcome is responsive

health gains to Mãori

• recognises and addresses the determinants of• identifies Maori as a relevant target groupMaori 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 Maoripriorities

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 meetsknown 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 providerswisdom (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 isanalytically 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 developmentHauora/MAori Advisors (audit trail))

• actively involves Maori in decision making• is clearly based on a framework consistent with• consults meaningfully with MãoriMaori views (Treaty of Waitangi, Whare TapaWha) • affirms Maori cultural viewpoints

• is culturally safe; uses te reo Maori correctly• clearly provides for a monitoring process• acknowledges the rights/special needs of tangata• meaningfully uses MAori specific data

whenua• identifies Maori as a relevant target group• 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 anissue of whether there is an impact but rather how much of an impact there is and how well we manage thatimpact;

• a Maori analysis is as fundamental as an economic analysis to the development of policy within the Ministry ifwe 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 beenextended, in the third column, to include an identification of the information which is requiredfor analysts, who may be competent analysts but relatively uninformed in a Maori health sense, sothat they can better undertake their tasks. The fourth column identifies measures which could beincluded in the specific policy. These are measures of the effect of the policy rather thanmeasures of the written policy itself. If a set of (relatively) standard measures could is embeddedwithin 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

F_ffceiit' IltaliliPoiks br \ln

policy outcome• supports Mori

• health gains

Means (policyRiq U ires (nut\ I ca surcs andshould) necessarily Ironiindicators (to be built

I ku)ifllt polici)

0 enables Maoristatement of Maori0/) Mflori workforec inworkforcc healthworkforcepriority areas; number ofdevelopmentdevelopment prioritiesMori staff represented in

professional ranks

measurement of Maori

...asacon with workforcedevelopment methods

addresses theclear articulationofmeasurement of change inGovernment'sspecific Maori healthhealth and disability statushealth nrioriiics .rnrilics for cxarnnlcindicainrs

cldde ao

is consistent withknowledge of measurement of outcomesGovernment'sGovernment's Maoriagainst M3oriMaori Development Development and Treaty DcvclopmcnL and Treaty ofand Treaty ofof Waitangi policyWaitangi policiesWaitangi policies

addresses healthknowledge of prioritiesmeasurement of changes inprioritiesof Maoribased bah ealth andhealth and disability status

disability status analysis cators

knowledge of articulatedhealth and disability statusMaori views on priorities mcasurcsinclude Maori

view of health

24

Expectations of

Means (policyRequires (not

Measures andEffective Health should)necessarily fromindicators (to be builtPolicy for MAori

TKH)

into policy)

promotes Mäonknowledge of approaches measurement of success ofwish to takewhich enable Maori to•::policyin;terms ofresponsibility forsuccessfully takepromoting Maontheir own healthresponsibility responsibility

uses availablenational minimum : .......monitoriiiofoutpütsandnational standardsstandards (e .g. serviceoutcomes, perhaps byand meets,. , . obligations) ............Ministry ofHealth'sGovernment ....... .. Performance Managementobligations Unit

requires quality. quality Maori indicatorsinclusion of measurementsMaori solutions and (eg. RHAoiitT eti: 'as identified within body ofspecificallyschedules) available advicesupports outcomesspeci&d in .analysts have access to

... relevant, existingthe bodyofavailable ..,•wisdom'wisdom'/advice

requires competent; operating standards formeasurement againstsafe and efficacious performance of healthMaori expectations (see Heservices ..,and disability services..TauraTreke)

enables meaningful : standards for Maori datameaningful data collectiondata to be collectedare set and clearlyfor use in monitoring theto contribute toarticulated policy outcomesmomtonngoutcomes

promotes goals.......'knowledge of tools :,measurement of success ofivhichreiàte toavailable for "measuring of outcomesmeasurablemeaiiingfully'measutingoutcomes outcomes for Maori (e g

SF36?) .

policy Outcome isresponsive toMâori

identifies Maori asknowledge of how tomeasurement of extent toa relevant targetassess relevancewhich relevance isgroup satisfactory to Maori

measurement of relativeimprovement in Maorihealth status

promotes choice for knowledge of range andmeasurement of MaoriMaori type of choices satisfaction with choices

appropriate for Maori;made availableMaori expectations (seeHe Taura Ticke)

..25

.26

Expectations ofMeans (policyRequires (not

Measures andEffective Health should)necessarily fromindicators (to be builtPolicy for Mori- TKII)

into policy)

promotes improved knowledge of effectivemeasurement of Maoricommunicationcommunication methods H. satisfaction withwith Maorifor Maori communication methods

knowledge of prerredmeasurement of Maorimodes for informationsatisfaction with provisioncarriage of information

supports MaoriI knowledge of Maorimeasurement of Maoripreference forpreferences satisfaction with policychoice of services outcome(including servicesknowledge of Maori

: provided by Maori)providers

promote knowledge of legal status measurement of Moriappropriate use ofof te reo Maori satisfaction with policytc rco Maori outcome in respect of te rco

Maori.

promote linkages toknowledge of benefits ofmeasurement of existenceMori institutionslinkages to Maoriof linkslas an effectiveinstitutionsstrategy for 11 measurement ofmainstreamknowledge of Maoriparticipation andproviders].• models and Maorisatisfaction of Mori

institutions to link toorganisations

policy... ..respects Maori. knowledge of Maorimeasurement of Maoridevelopmentintellectual propethattitudes to intellectualsatisfaction . ith treatment

process rights propert (includingof their intellectualkiiov ing hat counts'as :'aspropert

responsive to Maori intdkctualMoii propulI)

activelv . involvcs ... knowledge ôfmostmeasurementof MaoriinMari polico appropnate methods forsatisfaction with methods

dc . elopmentinoh.ing Maoriuscd

know lcdgc of suitablemeasurement ol nature ofM'tori forin ol ementMaori i n ol cmnt(c g Maori with rele antincludint appropriateness

.skills and expertiscand iLislictionh result

acLi%cl inokcsknowledge of mostmeasurement of MaoriMaori in decisionappropnatc methods forsatisfaction siLh methodsmaking involving Maoriused

know ledgL of suitabkmeasurement of nature ofMaori for inolcincntMaori inohcmcnt'. g Maori with rLk% ant ...ig .1ppp

skills and expertiseand satisfactiôii with result

I

acknowledges therights/special needsof tangata shenua --

measurement ofsatisfaction of tangatawhenua

.27

consults knowledge c measurement of extent andmeaningfully withof effective nature of Maori

is culturally safe:knowledge of relevantmeasurement of Maoriuses te reo Moricultural safety issuessatisfaction with culturalcorrectly safety: appropriate use of

me reo Maon

I, ....tat.

measurement (IIknowledge of Crownsatisfaction of(.ro%nposition with respect tolangata w henua

till thL nm leJi.e ,l .' r'wii andmcasurcment ol1fl1UL Oil tHCM,ri

position satisfaction ol ..gCrown/tangatacharacteristics ofwhcnuawhenua relationshiprelationship measurenient of

satisfaction of crown

respects Maori andhonest and 'pen processmeasurement of extent toin turn develops'rs"""' .h,.h t.4n.. fo.,1 thns

mist of rocecs by

SIAIJI.L...fl LKL ..........................................................................

28

Lpectitions ofMeans (policyRequires (notMeasures andTffec1i e Healthshould)iiecess rily fromindic flors (to be builtPolicy for N, I5ori TKII) itito policy)

is based on inowle4ge of i ngoroussidLnct of use of inrigorous policipolicy modU (Nliriistrsappropriate modLi

rocess de\LloprnenI modclo}Iealth polic\ an.itStsconsultation (audit iriti)P (ins mi inementManual)anal\ ticall y sound sion

consultation ssitlife KeteHauoralMaonAds isors (audittrail),

be clearly based ona framework whichis consistent XvithMon \ie\ s (ofhealth and N1toridevelopment e.g.ToW, \Vliare Tapa

cicark' provide for amonitoflng processboth for the policy'sdes elopinent and itsdesired outconics

ineani ng1till useMori specific data

identification ofMori as a relevanttarget group

knoss ledge of aailablcfrarnessorks and theirrcle\000e (C g Treart ofWaitangi: \Vhaia te oramo (c issi. Whare TapaWha: Ottawa Charter)

knowledge of methodsfor mom lonng processand outcomes

knossledge of the short-comings of availabledata (e g biases)

actiN , clv support thecollection of accuratedata as a polie\ outcome('or the policy

knowled ge of policyhis1or. for N11ort

es deuce of consistenc\with appropriate1raniesork

evidence of nionitori rigprocess as part of policoutput

evidence of appropriate useof data

evidence of impros ementin available data as a result id01 policy efforts

evidence of improvedpolicN , des etopmenl processand policy outcome

EIIIIIIIRIM

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 ofthe checklists.

Future work

There are a number of pieces of information which need to be collated and made available to ALLpolicy analysts to support the development of effective health policy for Maori:

• the description of various 'models' of the Maori view of health (Whare TapaWha, 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. morbidityand 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.

Appendix 1:Background Literature

The following listing provides detail from the base material used in the analysis for thisproject, and has been organised under each of the primary and secondary criteriaproposed in the framework. The listing is provided in order to give analysts specificdetail 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 MAORIHEALTH STATUS• Factors which determine the health status of Maori include: geographic,

expectational and cultural issues, and socio-economic status. When looking atMaori health statistics it is important to assess the quality of the informationavailable and the data collection process used.

• "Socioeconomic factors such as health, income, employment, housing and educationare strongly related to health" (Pomare, E., etal., 1995:145). However whilesocioeconomic elements are significant they are not necessarily accurate "indicatorsof health status" (Pomare, B., etal., 1995:147).

From consultation undertaken by the Public Health Commission in 1994 a numberof factors were named as affecting the public health status of Maori. Those whowere part of the consultation process suggested "a need for Maori-specific policy toaddress the essential problem which is that the major determinants of public healthstatus are social and economic" (Public Health Commission, 1995a: 16). Factorsnamed include: employment, household income, income support, cost of services,poverty, land loss, urbanisation, housing, isolation, health literacy, language,education, socialisation, information, identity, pollution, other environmentalissues, religion, wairua, legislation, whanau breakdown, racism, ethnicity, inequity,monocultural health system, colonisation, and political status (Public HealthCommission, 1995a: 16).

• "Inequitable access to utilisation of primary health care services is a significantfactor 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, andreflects the low utilisation by Maori, particularly of primary health care(Malcolm, L., 1996:358).

• To improve the health status of Maori (and other disadvantaged NewZealanders), Malcolm (1996:356) recommends a review of issues concerningfinances and access.

• Both poor access and a lack of utilisation of primary care services are elementswhich result in the high use of hospital inpatients services. (Malcolm, L., 1996:3 56)

.30

• If patients do not have regular checkups, and discontinue any proposedtreatment, the health problems which may arise are likely to be "multiple andcomplex". (Malcolm, L., 1996:358)

• Access issues are likely to be a significant cause in low Maori health status anda lack of improvement in Mori health status. (Malcolm, L., 1996356)

• Malcolm (1996:358) has found that poor populations may experience a lack ofaccess 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 leadto a need for hospital admission when unresolved health problems have becomeworse or exacerbated. Hospital inpatient utilisation can therefore be directlyrelated to access barriers to primary medical health services. (Malcolm,L.,1996:358)

• In Policy Guidelines 1996197, (Shipley, J., 1996:12), the policy goal associatedwith equity is: to improve equity of access for New Zealanders to health anddisability 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 allpopulations including Maori. Care targeted at a determined population and basedon funding provides a means to remove the balance of "care from secondary toprimary" (Malcolm L.,1996:358).

• Managed care is "the process by which, within an agreed budget, comprehensiveprimary and a range of secondary care services are provided which are fullycoordinated from the primary care level" (Te Puni Kokin, 1994:8).

• Kilgour and Keefe (1992) have indicated a lack of compatibility in the collection ofethnic data.

• Problems occur when data used may originate from a number of sources whohave constructed different definitions of "Maori" and "ethnicity". (Pomare, E.,et al., 1995:43). As well, it is difficult to present an accurate analysis if presentdata systems are unable to be compared with earlier data.

• The Maori Disability Framework (Potaka, U.K., et al., 1994) is a useful modelwhich 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 alllevels as a specific means of contributing to Maori development (Population HealthServices Section, 1995). The greater participation of Maori working at all levels ofthe health sector should be encouraged.

• Maori are under-represented in professional ranks involving planning, policy anddecision-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 ofprofessional and culturally qualified staff, by designating specific positions withinthe service for Maori, and by incorporating a bicultural component into stafftraining (Ratima, M.M., et al., 1995:46).

It is crucial that employers acknowledge that the active employment of Maori in thehealth 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 theparticipation and involvement of Maori personnel across the purchasing andprovider functions".

• For mainstream health services, active consideration will need to be given totraining 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 andmedical schools and for Maori to become qualified health professionals.

• In the short-term, employment opportunities for Maori in liaison or advisorypositions 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 ofhealth as non-Maori" (Department of Health and Te Puni Kokiri, 1993:13).

The development of purchasing strategies for all health service areas are instructedby Government's Maori health policy directions. They are: greater participation ofMaori at all levels of the health sector; resource allocation priorities which takeaccount of Maori health needs and perspectives; and the development of culturallyappropriate 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 in1996/97 i.e. child health, mental health, physical environmental health and Maorihealth. (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 systemswhich are responsive to Maori needs; integrated and cost-effective systemsresponsive to diverse Maori realities; access to information; improving thecollecting of health statistics; the implementation, monitoring and ademonstration of progress to improve Maori health; the incorporation of HeMatariki; and a focus on the health of the whanau.

• A commitment to Child Health can improve health gain by: reducing mortalityand morbidity; increasing the length and quality of life; and by strengtheningfamilies. Policy Guidelines 1996197 (Shipley, J., 1996:14) proposes a numberof key issues which include: well-child/tamariki ora services; the role of parents

and caregivers; pregnancy; preschool children; 'at-risk' families; recognisingthe correlations in ethnicity, lower socio-economic status and lower healthstatus; improving co-ordination, integration and access to services acrosssettings for at-risk school children, adolescents and their families inconsultation with schools and other relevant agencies.

In the area of Mental Health the intention is to lessen the prevalence of mentalillness and to decrease the impact of mental disorders on consumers, theirfamilies, caregivers, and the community. Key issues include: health promotion;promotion of mental health; early identification of mental health problems andpositive help-seeking behaviour; the purchase of mental health services;understanding services' contribution to outcomes; consultation and liaisonservices; improving access; the development of specialised mental healthservices; the development of the workforce; and the deinstitutionalisationprocess (Shipley, J., 1996:14-15).

• The aim in regards to Physical Environmental Health is to effect anenvironment which "improves and protects the public health" (Shipley, J.,1996:15). Health gains can be attained by focusing on areas which "reducemortality, 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-Maorimust be addressed as well as an acknowledgement of the Crown's partnershipresponsibility to tangata whenua. (Shipley, J., 1996:14)

Context, identified as a key area in A Maori Policy Analysis Framework for theMinistry of Health (Te Aho Associates, 1995:7) refers to the "environment withinwhich the policy is being developed". This comprises the "organisational focus" ofthe Ministry of Health together with the Ministry's commitment to advancing MaoriHealth, and also includes the impact which social issues may have on policydevelopment activities (Te Aho Associates, 1995:7).

IS CONSISTENT WITH THE GOVERNMENT'S MAORI DEVELOPMENTAND TREATY OF WAITANGI POLICIES

Ka Awatea (1991) states that positive Maori Development is key to addressingMaori social, cultural and economic well-being, and reducing disparities betweenMaori and non-Maori.

In Whaia te ora mo te iwi (Department of Health, 1992:22) the "Governmentregards the Treaty of Waitangi as the founding document of New Zealand" andacknowledges that the government must "meet the health needs of Maori and helpaddress the improvement of their health status". This is reinforced in PolicyGuidelines for Mdori Health 1996197 (Shipley, 1., 1996:16) which states, "theGovernment affirms that the Treaty of Waitangi is the Nation's foundingdocument" and that "the particular relationship of Maori, as tangata whenua, withthe Crown, under the Treaty of Waitangi" must be acknowledged by RHAs.

The Dual Focus Framework, "a combination of Treaty provisions and principles canbe 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 HauoraChecklist) come closest to operationalising the Treaty so that it can be usefullyincluded as part of an audit mechanism" (Dune, M.H., 1993a: 13). "The DFFprovides a ... template for ... assessing development strategies that will achievegains in Maori health" (Dune, M.H., 1993a:10)

33

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 toexercise authority of their own affairs, and ontetanga (article 3) "guaranteesequality and equity between Maori individuals and other New Zealanders" (Dune,M.H., 1993a:10, note: "A Treaty framework made up of provisions and principleswas first used in a report prepared for North Health by G Doherty and MH Dune inJune 1993")

• "A number of Treaty principles have been proposed over the past two decadesthough for different purposes" (Dune. M.H., 1993a:10) The Royal Commissionon Social Policy (1988:47-69) provided three principles relevant to social policiesincluding health: Partnership, Participation, Active Protection.

• The principle of partnership acknowledges the relationship "between theCrown or its agencies and iwi" (Dune, M.H., 1993a: 11)

•Participation comprises at least 3 levels, namely participation by Maoriindividuals, by iwi or hapu, and by invitation. Participation "emphasisespositive 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 activelyprotect Maori interests and is "about health promotion and preventativestrategies and implies that the State will adopt pro-active approaches and seekopportunities for the enhancement of Maori health" (Dune, M.H., 1993a: 11)

• As stated in Mdori Poll cyAnalysis Framework (Te Aho Associates, 1995:7), theTreaty of Waitangi is a "fundamental part of the development of policy that impactson 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. childhealth, mental health, physical environmental health and Maori health.

• To meet the special needs of Maori, the Government requires purchasers to enlistand support health services and initiatives which "promote positive health forMaori" (Department of Health and Te Puni Kokiri, 1993:13).

The themes in Ka Awatea are reproduced in the Maori health policy provisions ofthe Coalition Agreement. Included are:

• the development of Maori providers and the Maori health professionalworkforce

• 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 healthpriority 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 ofservice, in response to the diverse realities in which Maori live a move towardswhanau development and a "focus on ordinary Maori households" was suggested.

.34

In

• 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, andwhanau development will become a significant step in that direction".

The Ministry of Health (1995b) release, Effective Services for Young People: TeTotora o Toku Whanaketanga, has been designed as a guide for RHAs andproviders to develop services which improve the accessibility of youth to a moreresponsive health care system.

Also see Diverse Maori Realities.

PROMOTES MAORI WISHES TO TAKE RESPONSIBILITY FOR THEIROWN 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-sufficiencywith reduced reliance on the state and the development of services managed byMaori" (Steering Group, 1997:55).

• Three consumer driven themes related to the operation of funding and disabilitysupport services were prominent at a Core Services Committee consensusdevelopment conference: the desire for autonomy and self-determination, the desireto be in control of our services, and a move away from charity to a rights basedapproach. (Core Services Committee, 1993a:6).

• The Ottawa Charter states that "people cannot achieve their fullest health potentialunless 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 bea priority, that opportunities for Maori to take responsibility for their own health aremade available, that Maori are empowered through training and education, and thatservice provision by Maori is advocated.

• Bicultural issues and the treaty need to be addressed to allow Maori to takeresponsibility for their own health (Core Services Committee, 1993b).

• Iwi, Maori groups and organisations need assistance to enable them to beresponsible for their own health. Maori should be encouraged to participate asproviders (Ministry of Health, 1995a).

• "Good health is an active process and empowering communities to deal with theirown health issues, whenever possible, reinforces the notion of greater control andself direction" (Dune, M.H., 1993a:14).

• Maori health initiatives should be developed and maintained to empower Maori tobecome responsible for their own health (Dune, M.H., 1993a).

USES AVAILABLE NATIONAL STANDARDS AND MEETSGOVERNMENT OBLIGATIONS

.35

"Central Government ... has a role to playas protector of the populations health.respect of Maori people that role carries with it some responsibility for proactivestrategies so that all policies, across the range of social and economic interests, wbe consistent with good health" (Durie, M.H., 1993a:15).

• Government objectives for Maori health show a commitment by government toimprove Maori health and to reduce the disparities between Maori and non-Maorihealth status (Department of Health and Te Puni Kokiri, 1993:13). Healthprogrammes must have regard for "disparities in health standards and seek toreduce them" (Dune, M.H., 1993a:15)

• To provide a safe and competent service, professional organisations, providersand 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 aboutsystems which are responsive by adhering to "policy guidelines, contractualarrangements, 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 needsare fulfilled by "matching service provision to Maori expectations" (PopulationHealth Services Section, 1995:11 also see checklist).

Included in the service obligations for Maori health, as shown in Policy Guidelines1996197, (Shipley, J., 1996:16), it is suggested that RHAs and their providersshould incorporate the Government's response to Maori issues as stated in Whaia teora nio te iwi (Department of Health, 1992). This is essential to improving Maorihealth status in a manner appropriate to meeting Maori needs and aspirations andupholding the relationship between Maori as tangata whenua, and the Crown.

REQUIRES QUALITY MAORI SOLUTIONS AND SPECIFICALLYSUPPORTS OUTCOMES SPECIFIED IN RELEVANT, EXISTING WISDOM

The incorporation of a Maori framework/s together with monitoring and assessmentprocedures (including evaluations and standard setting) will assist in producingquality Maori solutions.

• In He Anga Whakamana (Ratima, M.M., et al., 1995:44-47) relevant indicatorsand measures provided are: quality information collection, client participation,caregiver/case manager participation, appropriate use of the Maori language, linkswith Maori institutions, consistency, workforce composition and sensitivity,assessment procedures, consultation, and M specific factors.

• Quality solutions for Maori may include cultural safety measures, staff trainingand Maori consumer awareness practices.

• In explaining the principle of Quality, Guidelines for Purchasing Personal MentalHealth Services for Mãori, (Dune, M.H., 1995:18) states that "in any service highstandards of care and treatment are necessary and this should be reflected inoutcomes".

• The RHAs "require providers to participate in quality improvement processes whichare effective across all cultures" (Shipley, J., 1996:20). Quality improvementobjectives given include: responding to the special needs of Maori, using bestpractice guidelines, and appropriately matching the skills of staff with the needs ofthe client group (Shipley, J., 1996:20).

• A representative workforce who "have a sound knowledge and ... understanding of tikangaMaori and Te Reo Maori" is vital to meeting Maori needs (Ratima, M.M., et al., 1995:41).

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• 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 institutionand 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, theinter-disciplinary application of knowledge) should provide something quantifiablewhich 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 policyhas come from, earlier policies, the effects which led to a changed environment andtherefore perhaps changes in government policy).

• Knowledge of and access to, policies from other areas and the influences which thesehave or may have on new policy need to be considered.

• The National Advisory Committee on Core Health and Disability Support Services hasrecommended 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 HuiWhakapumau. Dune (1994b:167) has said that "the gains made in earlier years shouldnot 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 byMaori" (Ministry of Health, 1995, see checklist).

• A service is competent and safe when "Maori consumers are protected from harmor further harm to their bodies, their mental and spiritual well-being and theirculture; when treatment produces the desired outcome (Population Health ServicesSection, 1995, see checklist).

• The framework upon which the service is shaped and delivered should ensure thatMaori views of health are acknowledged (Population Health Services Section, 1995,see checklist).

• Measures should be pursued to "protect consumers and the public from avoidablephysical and non-physical harm". Systems should be implemented to identify keyrisk areas so that risks can be eliminated, reduced or isolated (Shipley, J., 1996:13).

• "Services should only be purchased from those providers who comply withrelevant legislation" (Shipley, J., 1996:13).

• Effective systems and responses to reduce risks of avoidable harm shouldeliminate 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 beenfound by Kilgour and Keefe (1992). They recommend the development of an ethnicstatistical system.

• The Maori Disability Information Framework (MDI) (U.K. Potaka, et al., 1994), auseful model which provides minimum standards for the collection of information,has 3 major categories: Princi ples, Maori Specific Data, and The Generation andTransfer 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 beutilised 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 theclassification of ethnicity becomes a requirement for all health and disabilityservice purchasers and providers".-

• The information collection process should be sensitive to Maori and theinformation 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 itscomponents: data and technology, cultural safety, methods of collection, anddata processing. (U.K. Potaka, etal., 1994:27)

• In He Anga Whakamana (Ratima, M.M., etal., 1995:44) Quality InformationCollection is given as an indicator which can be measured by the type of datacollected, how "Maori" is defined in the data, whether the information collected ispurposeful and consistent, and whether confidentiality and guardianship have beenconsidered 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 thatproviders should become more proficient "in collecting appropriate data as part of aservice 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, etal., 1995:31).

• The Maori view of health is holistic (Durie, M.H., etal., 1995:3 1). Al Te HuiWhakaoranga 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 healthstate is being used increasingly as a health status/outcome measure (J. Sceats,1995).

•The SF-36 allows for an integrated approach to measuring health. Theapplication of SF-36 implies that health outcome measures can be reconciledwithin frameworks which are practicable and relevant to health services(Durie, M.H., etal., 1995:3 1).

• It is suggested by Midland Health (1995) that the testing of SF-36 particularlyby Mori might subsequently result in a Maori version of the SF-36 beingproduced (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 rolelimitations, emotional role limitations, vitality, and bodily pain) have"implications" for the four dimensions of Whare Tapa Wha. In Guidelines ForPurchasing Personal Mental Health Services for Maori, the use of both SF36 andWhare Tapa Wha is recommended. Both are measurements of outcome whichencompass a Maori view of health (Dune, MR, et a!, 1995:32).

• The four dimensions to health (taha wairua, taha hinengaro, taha tinana, and tahawhanau) suggested in the Whare Tai,a Wha model inter-relate to effect an "overallpicture 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 goodhealth and that health services will seek "good outcomes for health and not simply aremoval of symptoms" (Dune, M.H., etal., 1995:32).

• Indicators of Maori health can include: "the level of employment among Maori; theresponsiveness of society to the Treaty of Waitangi; use of te reo Mori and tikanga;the progress of Maori children through Kohanga Reo; improved networks andcommunication; and the use of traditional Maori health measures" (Public HealthCommission, 1995a: 17).

• During Te Ara Ahu Whakamua (March 1994) it was felt that Maori health couldbe "measured best in terms of the number of Maori in positions of influence; thevalue of resources in ownership; life expectancy; reduced crime rates; increasededucational and business achievement; and usage of te reo" (Public HealthCommission, 1995a: 19).

• Specific health policies be developed at a community level, and these should bedeveloped with the five challenges identified by delegates at the Hui Ara AlmWhakamua (Durie, M.H., 1995:210), these were a greater emphasis onwhakawhanaungatanga, equality of Maori women, whanau development (with theelimination 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 importantpart of the process and this needs to be identified". In the later stages of thedevelopment process relevance can also be based on the extent of Maori satisfaction.

• Policy Guidelines 1996197 (Shipley, J., 1996:12) states that "effectiveness focuseson ensuring services result in better health outcomes" To be effective, services musttarget people's needs. Therefore a key aspect given is that the targeting of healthand disability support services should be based on the needs of populations,individuals, and their family/whanau/caregivers (Shipley, J., 1996:13).

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"Effective services are those where treatment is likely to provide a significant nethealth benefit. Services known to have no significant beneficial effect on people'shealth 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 forMaori 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 ofservices 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 ofMaori.

• Accordingly Policy Guidelines for Maori Health 1996197 (Shipley, J., 1996:25)states that "the Government supports innovation and variety so that people will havea choice" and that therefore the R}iAs should support "the development of a rangeof service models suitable for different groups and situations".

• Providers should be encouraged to provide services which respond to Whaia te oramo 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 andDisability Support Services advised that RHAs "may purchase aspects of Maoritraditional healing" where this would be seen to assist in increasing the utilisationof health services by Maori and improve health status (Shipley, J., 1996:17).

• To effect culturally effective services. Maori preference for a choice of servicesincluding services provided by Maori for Maori must be acknowledged, togetherwith 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 beenable to provide a satisfactory service for Maori. As Ramsden (1994:121) states,"the commonality is Maori service and contract design and the willingness ofemployees to work in a different way".

• Options, identified as a key area in A Maori Policy Analysis Framework (Te AhoAssociates, 1995:7) suggests that there should be an emphasis "on the considerationof 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".

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According to Dune (1994c:214) "Maori live in diverse cultural worlds. There is noone reality nor is there any longer a single definition which will encompass therange of Maori lifestyles".

To reduce the disparities between Maori and non-Maori health status, it is crucialthat Maori health is addressed "from a broadly based perspective" which allows forMaori diversity (Dune, M.H., 1993a:4). That "policies for Maori health and theprovision of health services for Maori should take cognisance of the diverse socialand 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 (KornitiWhakahaere, ed. 1984)

• encouraging Maori to manage their own health and encourage the developmentof Maori as service providers

• improving the ability of mainstream services to respond to Maori

• encouraging systems and services which empower Maori individuals, whanauand caregivers, (Ministry of Health and Te Puni Kokiri, 1995:15).

A broad range of health services is required. Health services provided b y Maoriand non-Maori should be culturally effective (Shipley, J., 1996:17).

The principle of Acceptability, given in Policy Guidelines for Maori Health1996197 (Shipley, J., 1996:13) emphasises the respect, empowerment, autonomy,and participation of people. A key aspect of this principles includes: improving theresponsiveness of services to people's diverse needs, preferences and cultures. Thepurchase of services should be "responsive to the cultural diversity of communitiesand populations" (Shipley, J., 1996:13).

• Delegates present at Te Hui Ma Ahu Whakamua (March, 1994) "were in fullagreement with the conference theme that Maori had a right to health, though itwas recognised that there was a need for a range of approaches to meet diverseMaori needs" (Dune, 1994c:210).

RECOGNISES AND ADDRESSES MAORI DEVELOPMENT PRIORITIESThe significance of linking Maori health and Maori development is acknowledgedin 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 beconsolidated and Maori participation in the health and disability sectoraccelerated".

• To improve Maori health status "health initiatives must incorporate a holisticdefinition and approach and be part of a developmental strategy to improve theoverall 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 isa guiding principle for Maori health policies as proposed by Dutie. The principle oftino rangatiratanga should ultimately "underlie the development of future policiesfor Maori health" (Dune, M.H., 1994a:129).

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I

PROMOTES SEAMLESSNESS (OF SERVICES AND BETWEEN HEALTHAND 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 integratedapproach to service delivery was preferred". Health services need to establish linkswith Maori institutions so that clients are able to participate in the community.

• An information paper produced by Midland Health (April 1997) though directed atMental Health service provision, makes a number of points with regards tointegrated health services which are relevant to wider health issues.

Integration provides a framework whereby health providers are able to "focus on thesame outcomes, and work closely together to achieve them" (Midland Health,1997).

It is proposed that effective networks are created to improve relationships andcommunication between health workers. Services should not exist in isolationof other health services. Without strong links between service providersconsumers may "slip through the gaps" and/or they may not have access or anawareness 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 heavilyon information-sharing strategies which give parties equal access".

• Health care should be "comprehensive, integrated and continuous" (Ministry ofHealth. 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 theprovision of culturally effective services, including the affirmation of Maoripractices 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 thereforepromote cultural affirmation within health. Although the report focuses on mentalhealth the points made are appropriate for all health areas and include: culturalassessment; whanau participation; use of Maori language; tikanga Maori; Maorileisure pursuits; karakia; rongoa; involvement of tohunga/traditional healers; aMaori workforce.

Cultural Assessment "refers to the process through which the relevance ofculture to mental health is ascertained" (Dune, M.H., et al., 1995:20).Assessments are considered necessary, to "plan treatment and... programmeswhich are relevant and motivating" (Dune, M.H., et al., 1995:20). [This hasbeen taken a step further with a practitioner becoming aware of the potential formisdiagnosis of Maori as diagnoses are being re-evaluated when Maori clientsare 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 theinitial diagnostician. 12.5

• Whanau Participation can "occur at several levels" although a balance needs tobe found between a personal need (i.e. a Maori consumer's need) for

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25 R Chaplow, (personal communication).

independence and the involvement of whanau. Throughwhakawhanaungatanga, 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 tounderstanding the thoughts and feelings of Maori clients." However the use ofMaori "presumes staff competence in ... Maori language". As well, beinggiven the opportunity to learn te reo may assist in helping individuals to learnand acknowledge who they are (identity). Indicated therefore is a need to"have a degree of expertise in Maori language and the service itself may beexpected to provide opportunities for language development as part and parcelof 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 areconducted, group decision making processes, opportunities for consensusdevelopment, reciprocity and sharing resources" (Dune, M.H., et al., 1995:22).

• "The Core Services Committee (1995) has acknowledged the importance ofculture to health care and the potential value of traditional healing in providingspiritual and cultural sustenance as well as physical and emotionalrehabilitation, encouraging whanau participation and enabling the use of Maorilanguage for discussions of health" (Dune, M.H., etal., 1995:24).

IMPROVES ACCESSIBILITY FOR MAORI BY ADDRESSING KNOWNBARRIERS TO ACCESS

In Policy Guidelines 1996197, (Shipley, J., 1996:11) Barriers to Access for Maorito Health and Disability Support Services include:

• ineffective communication about what services are available, or how to accessthem

• unresponsive staff and services that do not meet Maori health needs andcultural 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 intellectualproperty 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 orwithin the community; by offering a culturally acceptable service; and by addressingconsumers' 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 andacknowledge Maori understandings and values (Ratima, M.M., etal., 1995:34).

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• 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 "slipthrough the gaps" (Midland Health, 1997).

• More Maori in the health profession will allow for effective culturally appropriateservices 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, seechecklist)

• The need to "ensure access to useful service information for Maori" was identifiedin Maori Policy Gui delinesfor Maori Health 199411995, (Ministry Of Health andTe Puni Kokiri, 1994:15),

• When seeking appropriate methods for informing Maori the medium (e.g. themedia), the content (e.g. the inclusion of familiar Maori concepts) and the language(plain Maori/English language used) must be taken into account (PopulationHealth Services Section, 1995, see checklist).

• The Steering Group (1997:57) supports communication between organisations andtheir communities. This will assist Maori to "judge the performance of theorganisations" 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 theutilisation 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., etal. 1995:36)

• A professional and culturally qualified workforce is suggested as an effective meansto improve communication and the flow of information (Ratima, M.M., et al.1995:36).

• Improvement in communication methods can assist to reduce access barriers tohealth 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 Maorisupport made available (Population Health Services Section, 1995, see checklist).

• As well as supporting generic service provision by Maori, the establishment ofa "range of kaupapa Maori services" is also required. Kaupapa Maori servicesmay involve traditional healing and other services based on a Maoriphilosophical 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 informalnetworks 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 thecontextual framework of the RHAs three-year strategic plans. Progress in thisdirection should support the integration and co-ordination of service delivery inconjunction with other service providers" (Shipley, J., 1996:17)

• Services which are based upon Maori cultural philosophies" are "seen as anessential 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 andcultural preferences (Dune, M.H., 1993a:17).

• Training "in tikanga and kaupapa Maori and Treaty issues" should be included instaff development programmes (Population Health Services Section, 1995, seechecklist).

• "RHAs are to encourage the development of organisations that provide integratedand coordinated services suitable for Maori" (Shipley, J., 1996:17).

• "RHAs should seek to increase the involvement of Maori in their activities andencourage 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 availableto 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 ofMaori language in both written and oral forms can be crucial to understanding thethoughts and feelings of Maori clients". Many Maori find it "easier to expressthemselves 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 andplanning" 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 theseassociations" (Ratima, M.M., et al., 1995:46).

• The Ottawa Charter (World Health Organisation. 1986) proposes that "coordinatedaction" will effect policies which encourage "greater equity". Furthermore, "jointaction contributes to ensuring safer and healthier goals and services, healthierpublic services, and cleaner, more enjoyable environments".

• To ensure a "health care system" which will improve the health status ofMaori, further points made within the Ottawa Charter (World HealthOrganisation, 1986) advocate that health services can be promoted if"individuals, community groups, health professionals, health serviceinstitutions and gOvernments" work together.

• The Charter (World Health Organisation, 1986) recommends that healthservices "embrace an expanded mandate which is sensitive and respectscultural 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; theneed to appreciate both collective and individual ownership; and the need to respectculturally significant items.

• The information process should not be demeaning to Maori. Permission should besought 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 inappropriateprocedures (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 ofthe health sector.

• The effective inclusion of Maori within the policy development process can be basedon the extent of Maori involvement and genuine consultation.

• In Whala te ora mote iwi (Department of Health andTe Pum Kokiri, 1993:13) itis recommended to "encourage the greater participation of Maori in order to develophealth solutions which are effective, affordable, accessible and culturallyappropriate".

• "Maori and iwi groups" should be included in the "development, implementationand 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 toappreciate Maori needs, and as stated in He Anga Whakamana (Ratima, M.M., etal., 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 nominatetheir 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

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needs of Maori, the Government has "specific duties to consult with Maori in thedevelopment 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 "greaterparticipation of Maori at all levels of the health sector".

• "RHAs should provide evidence of Maori involvement in their planning, purchasingand decision-making processes. They should also encourage the same level ofparticipation at the provider level" (Shipley, J., 1996:18).

• For Maori, becoming qualified in the health field should lead to a higher Maoriprofile within all health disciplines and ideally give Maori an opportunity to seekkey 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 ofconsultation" (Department of Health and Te Puni Kokiri, 1993:16).

• "R}{As are obliged to encourage providers to: work sensitively with MAoriliwithrough 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 theTreaty 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 mostaffected

• "Consultation in isolation is not enough to satisfy the requirements of a Treatypartner. The Crown has to genuinely consider and where appropriate incorporatethe concerns and perspectives of Maori in the policy. The Crown must consult at ameaningful time in the process. As a general rule this will mean as early on in theprocess as possible. Consultation only once the policy has been developed isentirely inadequate" (in Mdori Policy Analysts and the Treaty of Waitangi, 1994).

• Consultation should occur at appropriate times throughout the development of thepolicy, so as to make the consultation effective and meaningful (in Maori PolicyAnalysts and the Treaty of Waitangi, 1994).

• Consideration of Maori consultation processes (i.e. hui), and the involvement ofMaori in the policy development process is essential (Te Aho Associates, 1995:6).Importantly, "consultation is a key process in the analysis and development of

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Maori health policy however consultation for the sake of consultation isinsufficient" (Te Aho Associates, 1995:24).

• In He Anga Whakamana (Ratima, M.M., et al., 1995:46) several questions aregiven 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 CULTURALLYSAFE/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 thatculturally appropriate practices and procedures are an integral requirement in thepurchase and provision of health services" (Public Health Commission, 1993:22).

• Service providers should have sufficient knowledge and cultural awareness to avoidprocedures 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 intoaccount Maori health perspectives. Cultural factors will be acknowledged withinservice provision (Dune, M.H., 1993a:12).

• Mainstream services must incorporate "Maori perspectives and understandings".The "increased participation of Maori as health workers" would significantlyimprove the "responsiveness" of mainstream services to Maori needs (Ratima,M.M., et al., 1995: 48).

ACKNOWLEDGES THE RIGHTS/SPECIAL NEEDS OF TANGATAWHENUA• 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 iwiand Maori have perceptions of health "often linked to their history" (Ministry ofHealth and Te Puni Kokini, 1994b:42).

• In Whaia te ora nzo te iwi (Department of Health and Te Puni Kokiri, 1993:13) it issuggested that RHAs and the PHC acknowledge Maori, structures "such as thosebased 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 ofMaori" must be met and the relationship between the Crown and tangata whenuamust be acknowledged by:

• "being aware of and responding to the diverse needs and expectations of Maoriwho may best receive their services in a Maori and/on mainstream setting

• working sensitively with Maori through high quality consultation

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• recognising the tikanga and mana of iwi in their region

• encouraging greater participation of Maori in service, planning, delivery andmonitoring

• coordinating and linking health services which strengthen the integrateddelivery of health services to Maori

• considering how the health needs of Maori who are outside of their tangatawhenua area will be met

• being aware that Maori and iwi have their own vision of health often linked totheir history

• recognising and responding to the particular employment requirements ofMori staff' (Shipley, J., 1996:3 1).

• In He Matariki (Public Health Commission, 1995a: 13) it says the Treaty ofWaitangi is "a living document which recognises the special tangata whenua(indigenous people) status of Maori and establishes an ongoing relationship betweenMaori and the Crown".

IDENTIFIES THE IMPACT ON CROWNITANGATA WHENUARELATIONSHIP• 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 theTreaty of Waitangi".

• The State's domination of "Maori policy formulation" has resulted in a situationwhereby 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 policieswhich have already been decided. This type of process maintains the State'sauthority, and ignores the Crownfrangata Whenua relationship, preventing avenuesfor Maori input and participation. As well the consultation process may besomewhat restricted if only one partner in the relationship chooses who they shouldconsult (Dune, E., 1994:18).

RESPECTS MAORI AND IN TURN DEVELOPS TRUSTOne of six principles for purchasing decisions stated in Policy Guidelines 1996197(Shipley, J., 1996:13) is Acceptability, which "focuses on respect for andempowerment of people and on their autonomy and participation". People andcommunities should be involved, informed and consulted. With regards tocommunities, including hapu/iwi, "proper and due consultation" should take place,together with "adequate information on the issues" and "provision of feedback atthe end of the consultation process".

• Maori health policies must acknowledge the diverse realities of Maori people. AsDune (1994a: 11) states, "in formulating Maori health policy all Maori peopleshould come first".

• To ensure that Maori are respected throughout the policy process, "high qualityconsultation" should occur, with the participation of Maori in "service, planning,delivery and monitoring" advocated (Shipley, J., 1996:31).

• 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 ofData.

Also see Existing Wisdom, and Framework Consistent with Maori Views of Healthand Maori Development.

IS CLEARLY BASED ON A FRAMEWORK CONSISTENT WITH MAORIVIEWS

Maori development focuses on the links between health and other social, cultural,economic and environmental issues. For Maori, health cannot be considered as aseparate 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 physicaldimensions must be acknowledged (Ministry of Health, 1995:2 1). Also see Goalswhich 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-beingof Maori will not necessarily improve without progress being made in a number ofareas which impact Maori health. Health cannot be "seriously considered inisolation from other key factors which play a part in determining the Maoriposition" (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 integratedapproach to Maori development, whereby Maori might be able to enjoy the samelevel of health as non-Maori (Dune M.H., 1993b: 15).

• A broad knowledge of available frameworks which encompass Maori perspectivesof health and development is required. The Treaty of Waitangi, the Dual FocusedFramework, Whaia te Ora mo te Iwi, Whare Tape Wha and the Ottawa Charter areexamples 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 consumersatisfaction (Dune, M.H., 1993a: 12).

• Cultural safety is an important factor "to be used in monitoring the quality of carefor Maori" (Durie, M.H.. 1993a:12).

• "Purchasers should indicate how they will take account of Maori cultural values andpractices in the services being purchased and the appropriate means of monitoringthese services" (Department of Health and Te Puni Kokini, 1993:15).

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• "The participation of Maori in the development of service practices and proceduresand their performance measures will be essential" (Department of Health and TePuniKokiri, 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 areneeded. As well, the information process should include a place for culturalidentification, Maori values, be consistent with tikanga Maori, and acknowledgethe diverse reality of Maori.

• Kilgour and Keefe (1992) have suggested that an ethnic statistical system beimplemented.

• As given in the Maori Disability Information Framework elements which relate tothe collection of Maori Specific Data include Ethnicity, Cultural, Circumstancesand Disability Data (Potaka, U.K., etal., 1994:26).

• Guidelines for Ethnicity include: the Maori Affairs Amendment Act 1974definition; Descent and self-identification; Census Questions 1991 (Potaka,U.K., etal., 1994:26).

• Guidelines for Cultural components are: Hapu and iwi; Maori networks; Maoriaffirmation (Potaka, U.K., etal., 1994:26).

• Circumstances include: Whanau support; Economic position; Other socialindicators (Potaka, U.K., et al., 1994:26).

• Requirements for Disability Data are: Same as mainstream; Correlation ofdisability (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, itshould be established from the outset whether there is a "need" by Mori for thispolicy, 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 toprevent/mitigate this disadvantage? (in Maori Policy Analysts & The Treaty ofWaitangi, 1994).

• An acknowledgement of policy history means that "past trends may be identifiedand duplication avoided" (Te Aho Associates, 1995:25).

• Also see Maori as a relevant target group.

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