CMPH Journal

Summary

On July 1^st, 2022, the New Zealand government established a new health and disability system, representing the largest overhaul of the current system the country has ever seen. It is expected the new national health system will be simpler and more coordinated, allowing for better and more consistent care, and address equity at all levels. Public health is a particular focus of these reforms with more emphasis on population health and the determinants of health. However, a year on from the establishment of this new health system little has changed with regards to the deep-rooted problems facing public health in New Zealand. The potential to create a public health system that truly delivers on equity can be realized by looking to Māori (Indigenous people of New Zealand) socio-cultural beliefs and practices, which were exemplified by recent localized response to COVID-19. This Viewpoint highlights two important considerations for public health in New Zealand: the lessons from localized Māori responses to COVID-19 and, the creation of a public health framework for New Zealand that is based on a Māori worldview. Looking forward to the future of the public health system in New Zealand, the government must make space for and advocate for Māori ways of public health.

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New Zealand is currently undergoing the largest health reform in the country’s modern history. On 1 July 2022, one national entity, Te Whatu Ora - Health New Zealand (Health NZ) replaced the 20 District Health Boards, becoming responsible for the planning and commissioning of hospital, primary and community health services. Te Aka Whai Ora - the Māori Health Authority (MHA), established alongside Health NZ, is responsible for ensuring the system works well for Māori. [1] A Public Health Agency (PHA) within the Ministry of Health will lead population and public health policy, strategy, regulatory, and knowledge functions across the system [1]. The National Public Health Service (NPHS), within Health NZ, will do the work on the ground, coordinating public health services, and responding to threats such as infectious disease outbreaks. The reforms will see more emphasis on population and public health and the determinants of health. Government agencies and community partners will be expected to work more closely together to strengthen the system to enable New Zealanders to live longer, healthier lives [1]. It is expected the new health system will be simpler and more coordinated, allowing for better and more consistent care.

A year on from the establishment of this new health system little has changed with regards to the deep-rooted problems facing public health in New Zealand. The potential to create a public health system that truly delivers on equity can be realized by looking to Māori socio-cultural beliefs and practices during the recent localized Māori responses to the COVID-19 pandemic.

Māori, the Indigenous People of New Zealand

Māori are the Indigenous peoples of New Zealand and have flourished in Iwi (tribal) and hapū (sub-tribal) based collectives for generations. Traditional Māori society was ordered according to precise tikanga (values and principles) which dictated how individuals within Iwi and hapū interacted with each other, with peoples from other tribes and with their environment. Pre-colonial Māori had an acute understanding of the necessity for healthy communities where tikanga acted in a manner akin to a public health system, regulating and controlling how Māori operated within the environment, with food, waste, illness, and all activities associated with a flourishing society [2]. Māori and the Crown signed Te Tiriti o Waitangi (The Treaty of Waitangi), which in Māori eyes at least, seemed to enshrine Māori rights of selfdetermination, control, and authority over those aspects of Māori culture such as language, mātauranga Māori (Māori knowledge) and rongoā Māori (traditional healing practices). However, the Crown’s actions following the signing of Te Tiriti perpetuated the effects of colonisation, leading to a rapid decline in the health status of Māori [3].

Today, Māori no longer exercise full rangatiratanga (selfdetermination, sovereignty) over the health and well-being of themselves and their whānau (family). However, through our contemporary history, there are examples of Māori relying on their tikanga and pūrākau (ancient legend, myth, story) to respond to public health challenges [4-6]. These responses are grounded in te ao Māori (the Māori worldview) and mātauranga Māori (Māori knowledge).

The COVID-19 Pandemic

With the arrival of COVID-19 to New Zealand in March 2020, public health became a central focus of the Government response. The swift introduction of a countrywide lockdown, closing of international borders, suspension of air travel and the introduction of a four-tier alert system represented unprecedented public health measures to protect the population. These initial public health measures highlighted that the protection of people was also a collective responsibility, where everyone, as stated by Prime Minister Ardern, had an important part to play in the “team of five-million” [7]. Māori responded quickly to the emerging situation through locally based initiatives to keep whānau safe and well. Research on the early COVID-19 response illustrated Māori exercising rangatiratanga. Examples include the establishment of road checkpoints to protect communities; organizing support systems; delivering food and other essentials; and the development of new safety protocols for marae (meeting houses) and tangihanga (funerals) [8]. These initiatives were Māori led, Māori centred public health responses, largely unhampered by Government interference. Furthermore, they were successful in keeping whānau safe from COVID-19, demonstrating the strengths and abilities inherent within Māori communities to quickly and effectively mobilize resources [9].

Unfortunately, the learnings from these examples of successful Māori-led public health responses were not translated into the evolving COVID-19 Protection Framework, which saw New Zealand move from elimination to mitigation. From the outset the government’s vaccination rollout disadvantaged Māori population through, for example, failure to communicate and work in partnership with Māori leaders; a sequencing framework which failed to prioritize ethnicity and therefore equity; employing an age-banding structure which did not take into account Māori demographics and co-morbidities; and giving inadequate consideration to vaccination delivery. These implementation failures led to 83.4% of Māori completing their primary vaccination course compared to 90·1% of total eligible non-Māori population, and 56·0% of all eligible Māori having received a booster compared with 73·0% of the total eligible non-Māori population at the end of 2022 [10]. Moreover at the end of 2022, Māori made up 19·0% of all COVID-19 related hospitalizations and 21·0% of cases requiring ICU care, despite only representing 17·1% of the national population [11]. The myriad implementation failures were further compounded by the Crown ignoring advice offered by Māori health experts, resulting in the New Zealand Māori Council bringing a claim against the government to the Waitangi Tribunal; a claim which was upheld [12]. The design of “one-size fits all” public health approach to COVID-19 was seen by the Tribunal as a failure of the Crown to engage meaningfully with Māori throughout the course of the pandemic [13].

Health in te ao Māori

While the Crown has described Māori models of care during the pandemic as innovative and creative, for Māori these models represent normal practice [13]. The Māori response to the pandemic has always been guided by the holistic, collaborative and relationship-centred principles of te ao Māori (Māori worldview).

The Māori worldview encapsulates some of the core ideas of public health. For Māori, similar to other Indigenous peoples, health is not simply the absence of disease. From a Māori perspective, health has always been all embracing – encompassing the physical, spiritual, the mental and emotional. In a Māori worldview, our health and wellbeing are also determined by our connections - not just to people, or to our environment but to all things, animate and inanimate. Health and wellbeing recognize the interconnectedness between all the elements that make up our world. This is captured in the well-known whakatuaki (proverb) from Whanganui, “E rere kau mai te awa nui mai i te Kahui Maunga ki Tangaroa, ko au te awa, ko te awa ko au” (The great river flows from the mountain to the sea, I am the River, and the River is me) [14]. The saying speaks about the people of the river and their connection to it. It talks about the river as an indivisible and living whole from its source in the mountains all the way to the sea, including its tributaries and all its physical and spiritual elements. It speaks of the inseparable connection that we have as Māori, and all people, to the lifeforce that comes from water but also from land and from each other.

In the New Zealand context, public health has been described as having five core functions: 1) health needs assessment and surveillance, 2) public health capability & capacity development 3) health promotion, 4) health protection and, 5) preventative interventions [15]. This western framework has an obvious omission of a function that covers community development and mobilization [16]. The new public health organizations established as part of the reforms have used this framework to develop their organizational structure and work programs [17,18.] In the COVID-19 response local Māori illustrated an approach which was based upon a Māori worldview, one that not only captured these public health functions and activated community voices, but went above and beyond. This illustrates that viewing health through a Māori lens of interrelated and connected parts results in tangible and positive outcomes for Māori. This is not to say that the described core public health functions are inappropriate for New Zealand, but rather, a Māori worldview adds a depth and connectedness that is not captured by traditionally western public health ways of thinking.

Harnessing the Lessons of COVID-19

New Zealand has undergone significant change during the last three years. The COVID-19 pandemic has created vast and serious challenges for a health system, which was already under pressure. Critical analysis of the health system, including the New Zealand Health and Disability System Review and the Wai 2575 Treaty of Waitangi Health Claim highlighted the shortcomings of the health system long before COVID-19 hit the shores of New Zealand [19,20]. The issues highlighted by these inquiries, around inequity of health outcomes for segments of our population, most notably Māori, have been played out not just within the public health response to COVID-19, but within the ongoing high rates of Māori being affected by the COVID-19 virus. However, concurrently there have also been positive developments that have grown organically out of Māori communities facing COVID-19 on their own terms, despite limited resourcing. The readiness of communities to respond to the threat of COVID-19 has been highlighted throughout this viewpoint. This, coupled with the Government’s initiatives to reform an under-performing health system through the establishment of new channels of commissioning, delivery, and accountability, means that we are at a time where all these existing levers can, and must, come together to affect real change.

There are opportunities right now to harness the learnings from the last two years of the pandemic, and the way in which Māori have been able to mobilize and apply real public health initiatives that have worked from the ground up. Within the ongoing re-shuffling of the health system the Government is ideally situated to work towards a Māori-centered, Māori-led public health system. Amongst the reforms, public health appears to sit somewhat off to the side with no obvious pathway or leadership on establishing how public health could become a powerful mechanism for addressing the equity issue that the Government is trying to solve. Public health leadership (such as the proposed Public Health Advisory Committee) sits within a Crown structure yet is postulated to be informed by and reflect Māori perspectives [17]. This is counter-intuitive. Additionally, there is no sector-wide public health strategy or overarching framework that is relevant for this new system or that takes into account Māori models of care and the unique context of New Zealand.

The Future of Public Health in New Zealand

The future of a Tiriti-based Māori public health approach would signify real – rather than superficial- change within the health system.

We therefore recommend that the New Zealand Government should:

• Ensure that the future of Māori public health sits within Māori leadership, Māori decision making and Māori structures, outside the Crown.
• Develop a Tiriti-based Māori public health strategy and resource it in such a way that Iwi and communities can tie their actions to it while exercising local control over local issues and full rangatiratanga.
• Ensure public health staff recognize they cannot speak on behalf of Māori. The Crown must appropriately fund public health capability and Māori models of public health outside of the Crown structures.

The future of Māori public health needs to sit within Māori decision-making structures, and the Māori worldview must be acknowledged as a valid public health framework. Looking forward to the future New Zealand public health system, the Crown must make space for and advocate for Māori ways of public health. By recognizing the richness that this worldview brings to public health approaches, the Crown can deepen its understanding of Māori communities. Culturally informed policymaking is necessary to reinforce that the systems environment and social infrastructure must collectively progress to help create healthy people, places and futures.

References

1. Department of Prime Minister and Cabinet (2021) Our health and disability system: building a stronger health and disability system that delivers for all New Zealanders. New Zealand Government.
2. Durie M (1998) Whaiora: Māori health development. Oxford University Press.
3. Durie MH (2012) Indigenous health: New Zealand experience. Med J Aust 197: 10-11.
4. Mead HM (2016) Tikanga Māori (revised edition): Living by Māori values. Huia publishers.
5. Pihama L, Lipsham M (2020) Noho Haumaru: Reflecting on Māori approaches to staying safe during COVID-19 in Aotearoa New Zealand. JISD 9: 92-101.
6. King M (1977) Te Puea: a biography. Hodder and Stoughton.
7. Beattie A, Priestley R. Fighting COVID-19 with the team of 5 million: Aotearoa New Zealand government communication during the 2020 lockdown. Soc Sci Humanit Open 4: 100209.
8. McMeeking S, Savage C (2020) Māori Responses to COVID-19. Policy Quarterly 16.
9. Boulton A, Devine T, McMennamin K, Walsh-Tapiata W (2022) Te Ranga Tupua: An Iwi (Tribal) Response to COVID-19 in Aotearoa New Zealand. International Journal of Indigenous Health 17.
10. Ministry of Health (2021) COVID-19 Vaccine Data. Wellington.
11. Ministry of Health (2021) COVID-19 Case demographics. Wellington: Ministry of Health.
12. Rātana L (2021) How the vaccination rollout failed to deliver for Māori. The Spinoff.
13. Waitangi Tribunal (2021) Haumaru: the COVID-19 Priority Report.
14. Ministry of Justice. Te Awa Tupua (Whanganui River Claims Settlement) Act 2017.
15. Williams D, Garbutt B, Peters J (2015) Core public health functions for New Zealand. NZ Med J 128: 16-26.
16. Public Health National Center for Innovations. The 10 Essential Public Health Services.
17. Ministry of Health. The Public Health Agency. New Zealand Government.
18. Te Whatu Ora Health New Zealand. National Public Health Service. New Zealand Government.
19. Waitangi Tribunal (2019) Hauora Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry. WAI 2575. Lower Hutt: Legislation Direct.