18 Apr 2024

How the coalition plans to replace the quickly scrapped Māori Health Authority

12:30 pm on 18 April 2024
Stylised illustrations of Shane Reti and Hūhana Lyndon along with medicinal herbs, x-ray, medicines, marae, hospital and hands on a heart.

What happens now for Māori healthcare? Photo: RNZ

The end came quickly for Te Aka Whai Ora - the Māori Health Authority.

Health Minister Shane Reti stood in Parliament to introduce the Pae Ora (Disestablishment of Māori Health Authority) Amendment Act, which was rushed through under urgency.

He spoke for six minutes, his head buried in pre-written notes, which he didn't stray from.

"While the particular version of the dream that the Māori Health Authority laid out is coming to an end today, I want to paint a different dream," Reti said.

While it was quick, the bill's passage did not lack fire or emotion.

Green MP Hūhana Lyndon described the disestablishment of the authority - only two years into its existence - as the "recolonisation of hauora Māori".

"There is a strong feeling in our kāinga and within iwi that we've been ripped off by this Government. Disestablishing Te Aka Whai Ora now … we've never got a chance to see the waka grow and reach its full potential. Te Iwi Māori are ripped off. This Government undermines the Waitangi Tribunal. Knowing full well that the urgency is this week, I ask again: where is the justice?"

But throughout the process, Reti maintained scrapping the authority and changing to a different path would improve health outcomes for Māori. He acknowledged the "organisational expertise" of the staff at Te Aka Whai Ora, most of whom will be transferred to Health New Zealand or the Ministry of Health.

"I say to Māori Health Authority staff to please join me, guide me, and help us together to row a different waka towards better health outcomes. This bill enables that."

Te Aka Whai Ora, the result of decades of advocacy from Māori health leaders and Waitangi Tribunal claimants, was effectively gone in under 24 hours.

Now the dust has settled, how do people feel about the changes, and what will happen next?

Healthy and unhealthy lungs

Photo: RNZ

What was Te Aka Whai Ora and where had it got to?

The 2022 establishment of the Māori Health Authority was one of the signature achievements of the previous Labour Government's reforms. After the 2020 Health and Disability System Review, which recommended a reduction in the number of District Health Boards (DHBs), the government announced that all 20 DHBs would be replaced with one national organisation, Te Whatu Ora - Health New Zealand, and that a Māori Health Authority would be created.

Te Aka Whai Ora was to commission Māori health services, achieve equitable outcomes for Māori and monitor the performance of the publicly funded health system.

To help the authority and Te Whatu Ora, three other structures were also established: Iwi-Māori Partnership Boards (IMPBs), localities, and the Hauora Māori Advisory Committee (HMAC). They've all reached different stages and have very different futures under the coalition government.

There are now 15 IMPBs across the motu, each set up to advocate for whānau and communities in their regions. Essentially, IMPBs and their staff were employed to go into communities and gather the voices of whānau. Whether that be by holding a series of interviews, attending hui and wananga at marae, or door knocking people's homes. That whānau voice was collected to inform decision making around health priorities and funding in their rohe.

Chairperson of Te Whanganui-a-Tara-based Āti Awa Toa Hauora IMPB Hikitia Ropata says its six board members meet every six weeks for a full-day.

"We have a range of disciplines of people on that board. People who have worked in the health system, people who have worked in the education system, people who have worked in Social Development, worked in economic development, who've been senior managers across the public sector. And our kaumatua who has been in the health system on a range of different boards, he's the man who keeps us honest."

Under the system Labour established, Health New Zealand was legally required to provide information to IMPBs to support them in achieving their purpose.

Localities had a similar role but there were many more of them planned - between 60 and 80 geographic areas. People representing a locality would tell the government about their community's specific health needs so services and funding could be appropriately allocated. There are 12 'prototype' localities already in place, with the remainder meant to be set up by June - but they're now paused.

Finally, the Hauora Māori Advisory Committee (HMAC) was also established to advise the Minister of Health and ensure the voices of Māori were heard at all levels of the decision making table. Its eight members were expected to ensure there was a Māori voice at the highest level of decision making in the new system.

Stylised illustration of a Hōhipera, hospital and ambulance

Photo: RNZ

Dead, dying or saved - what the coalition changed

Reti's Pae Ora Amendment Bill erases the Māori Health Authority by replacing references to it in law with 'Health New Zealand'. But it also put localities on a pathway to oblivion, changed the appointment process for the HMAC and put the Iwi-Māori partnership boards (IMPBs) on a different trajectory.

It's a mixed picture for IMPBs. On the one hand, they are losing a lot of the statutory power they had to influence policy and funding at a national level. On the other hand, Reti seems keen to give them a much broader remit for the planning and delivery of primary and community services.

Health NZ no longer has to support the boards but instead is required to "take reasonable steps" to support them and "engage" with them when determining priorities for kaupapa Māori investment.

The boards also lose veto power over locality plans and annual reports, because localities are themselves on hold.

Chief Executive of Te Tai Tokerau-based IMPB Te Taumata Hauora Te Kahu O Taonui Boyd Broughton says this reflects the general view of the coalition on partnering with Māori.

"They don't want their legislation to have them beholden to anything Māori. And I think it's safe to say that that's what the change in that language did, it means they no longer have to consult with us, means they can choose who and when they consult with Māori and with Iwi-Māori Partnership boards.

"I think there was this fear that Māori would hold everyone to ransom. But it was just a discussion. And we absolutely recognise that there's a massive population of non-Māori within Aotearoa, who have different needs, and there was no way that we would not sign off on a plan that was going to cater to them as well as to Māori."

Iwi-Māori partnership boards will also no longer be involved in appointing members to the Hauora Māori Advisory Committee (HMAC) - they're all now chosen by the minister.

Jacqui Harema is chief executive of Hapai te Hauora, a Māori public health organisation that advocates for the needs of whānau Māori. She is wary of the idea of ministerial appointments.

"The Iwi-Māori partnership boards have skin in the game, a skin in the communities, they know where things are at. Whereas at a ministerial level, you don't always know what's happening on the ground to be able to make the best decisions of who should be supporting people from the ground.

"They [iwi] know who can adequately represent them. I'm not sure how the minister is going to get that much intel on people that will be suitable to sit at their board and have a say for them."

Stylised illustration of a marae

Photo: RNZ

However, Broughton can see a place for a strong Māori voice in the system, and he remains optimistic.

"We have seen a willingness for them to continue to get real good input from Iwi-Māori Partnership boards. Whether or not they keep our feedback, which reflects our priorities based on what we've been hearing, remains to be seen.

"We don't want to just be an advisory if they've already made funding decisions, we actually want to do the whole gambit from the start."

Reti seems prepared to do something close to exactly that. In early March, he met with IMPBs in Christchurch to discuss his plans for them. He signalled the boards will gain the powers to commission services for their regions, something they don't currently have.

"I want to see IMPBs with the ability to have commissioning authority. I will empower local health decisions and Māori health providers with more autonomy than they have had for some years …You will have a role in planning and delivery of healthcare in your communities. Local input into health services, especially primary and community services, is good for everyone and a priority for this government."

But not all boards are at the same level of development and not all will have the same capacity to provide commissioning services. It is unclear at this stage how much funding will be needed. That's where Iwi-Māori partnership boards are apprehensive.

"We need to make sure we have the same understanding of what our role is in what we expect as commissioners to utilise the monitoring role, etc, over the whole health funding, not just the Māori health fund," says Broughton.

"It's challenging. It's daunting. It's a massive obligation, a huge responsibility to be in the position that we're in now. And it's one we've never had the opportunity to be in. So while we do have some sadness about what's come to pass, we do accept boldly stepping into the spaces that we're being invited to, and trying to step further than we're being asked to."

While the IMPBs survive - and may even thrive - locality planning as Labour had planned it is likely to be dead. The new legislation postpones their final implementation dates from 2024/25 to 2029/30. While this might not seem like a big deal, a Cabinet paper on the Māori Health Authority disestablishment shows that Reti plans to get rid of them.

"With the disestablishment of the Authority I do not intend to progress localities. I have instructed Health New Zealand to stop work on localities pending further legislation."

Broughton says a large part of his job was co-ordinating those localities.

"The idea of the localities was to bring forth: What are their priorities? What do they see as their needs within the region, within their locality? And then say, 'this is the resource we've got that currently caters to that priority, here's the unmet need, Te Aka Whai Ora, you need to find the right resource to invest in this'."

In Te Tai Tokerau there were seven different proposed localities, with one prototype up and running in Te Hiku o te ika, the far north. The funding for the prototype localities will continue until 2025, Broughton understands.

"The frustrating thing was that we just got our localities approved prior to the election and we were really looking forward to being able to get some investments, and we really wanted some quick investment into them. And then everything got paused."

Stylised illustration of Kawakawa leaves

Photo: RNZ

Is anyone mourning the end of Te Aka Whai Ora?

Whilst the legislation to disestablish Te Aka Whai Ora has passed its third and final reading, it doesn't come fully into effect until 30 June. At the end of March, all roles and functions were transferred to Health New Zealand - Te Whatu Ora and the Ministry of Health - Manatū Hauora.

Earlier this month, more than 300 Te Aka Whai ora kaimahi were formally welcomed back into Te Whatu Ora Health NZ, in a pōwhiri at Pipitea marae in Wellington.

Still, Te Aka Whai Ora continues to post promotional content on its social media platforms, as if they are operating as usual.

The content, shared via Instagram, TikTok and Facebook, includes interview style videos with Māori health providers, practitioners and patients, sharing their experiences in the health system. The videos are posted almost daily and seem to be a promotional campaign for Te Aka Whai Ora, even though its demise has been clear for weeks.

Reti has said that it is not "simply a rehoming of the Māori Health Authority within Health New Zealand and the Ministry of Health".

"There will be less funded positions transferred across from unfilled positions especially. These are being covered to date by expensive consultants.

"Across health, we are reprioritising funds from the bureaucracy and into the front line."

Hapai te Hauora chief executive Jacqui Harema says she is concerned that placing Te Aka Whai Ora staff into Te Whatu Ora could stunt progress.

"Te Aka Whai Ora, although it was operating as a government entity, its philosophy that it had underpinning it was very Māori. So, when you take staff that have different worldviews and just plonk them on another mainstream organisation, where at the end of the day, the overall philosophy of that organisation is a non-Māori view, you know, it's really hard to make any real meaningful progress in that type of environment."

Like many Māori health professionals, she thinks Te Aka Whai Ora wasn't given enough time.

"With Te Aka Whai Ora you didn't have to justify your Māori solutions, because they just got it. Whereas if you get absorbed by another government entity, you're going to have to justify 'actually we know this works because…' whereas with Te Aka Whai Ora you didn't have to do that, because they already understood."

While Hikitia Ropata isn't phased by this change specifically she says she is still saddened over the disestablishment of Te Aka Whai Ora.

"There won't be an Iwi-Māori partnership board who did not feel a sense of loss over the disestablishment of Te Aka Whai Ora. That's sad and that's disappointing, it goes without saying for all IMPBs. But we have to move on. The government is the government.

"I don't think structures matter. I think the strength hasn't changed."

Stylised illustration of Shane Reti

Health Minister Shane Reti Photo: RNZ

The coalition's strained relationship with some Māori

For Harema, it's not just the rolling back of Te Aka Whai Ora that will impact Māori health outcomes, it's also some of the Government's other policies, including the repeal of smokefree legislation.

"We're not sure where this Government is coming from. Where are they getting their advice? For us, all the social determinants for Māori … well you've seen our stats, we're at the bottom of nearly all of them. So we're actually bamboozled understanding where they're getting their advice from and some of the decisions that have resulted from that."

Janice Kuka is the chairperson of Turuki Health Care and managing director at Ngā Mataapuna Oranga. Prior to the axing of Te Aka Whai Ora, she and co-claimant Lady Tureiti Moxon filed an urgent claim to the Waitangi Tribunal, citing concerns that the removal of Te Aka Whai Ora would result in prejudice in healthcare.

The claim was set to be heard by the tribunal, but since the amendment act was passed under urgency, the challenge was never heard.

Kuka was also one of the original claimants involved in WAI2575, the Health Services and Outcomes kaupapa inquiry, which recommended the establishment of an independent Māori health authority.

After speaking to Māori health providers, Kuka says people are still grieving.

"At the coalface, I think there's still a bit of confusion, huge disappointment. I think probably more than disappointment. I just felt a sense of disillusion when we were talking to them, like when we thought we had it, now it's gone. Everything we wanted."

Ropata says there is some anxiety about what the future holds.

"Who knows what the minister is thinking. But the minister is party to a coalition agreement and that's got very little to do with us as an IMPB. We have to understand the strategic tactical processes that we might need to build around that but that's fundamentally a political issue. Our eyes remain firmly on our rohe and our iwi and Māori people within our rohe require good services."

She suggests health providers must look past political disagreements and stay focused on much longer term goals.

"The political noise is a distraction from what we need to achieve to get better health for our people. In these times of uncertainty, discomfort and opinion, it is our job as the Ati Awa Toa IMPB to step-up and show leadership. This means using the evidence and information including the voice of our whanau and communities to influence the design and delivery of services that will enable rangatiratanga for our people to get better … We think that is something we can all agree on.

"We've just got to keep marching forward, despite what government sits there, what changes they make. We've been doing that for 200 years anyway. And actually, as an Iwi-Māori partnership board, we have 300 year strategies, not five-year plans."