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7.3 Meso Health Planning

Often measures are recorded not because they are important, or useful, but simply because they are easy or convenient to record

(Boulton, 2005, p. 53).

Within the realm of public policy, there are often hierarchies of documents guiding the purchasing and ultimately the provision of services. Within the health sector, macro-level policy and strategic direction are usually initiated and led by the Minister of Health. The core documents for public health policy since 2000, despite the change of government, remain the NZHS (A. King, 2000) and He Korowai Oranga (A. King & Turia, 2002). Underneath this macro, policy lays a range of issue-specific strategic and operational level planning led by senior Crown officials. This meso level planning is frequently web-like with complex interconnections across strategies and plans, with references to earlier, and at times forthcoming, strategic documents.

Smith (1994) in his analysis of excellence in public sector management argues there needs to be clear link between macro and meso level policy and planning.

Planning logic, he contends needs to flow into contracted activities and organisational practices. There are currently two key planning approaches being promoted within the health sector; i) program logic outcome based planning (Ministry of Health, 2007b; Steering Group Managing for Outcomes, 2002); and ii) results based accountability planning (Friedman, 2005). The effective and inclusive utilisation of both approaches requires a range of competencies including technical knowledge of planning and epidemiology, understanding of Māori worldviews and the aspirations and circumstances of communities.

Wren (2007, p. 2) asserts program logic outcome based planning is a management tool to facilitate accountability, direct change, enables the prioritisation of resources and highlights areas requiring further attention. It is a mechanism to define and track changes in health status and health determinants and inequities, resource and service utilisation and programs responsiveness to a target population. Emphasis is placed on selecting a few outcomes to monitor, that are attributable to a program of work, that are timely, show the cost-benefits of an intervention and that are robust enough to withstand public scrutiny.

Results based accountability frameworks championed by Friedman (2005) allows communities and agencies to identify what they want to attain and then tracks

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back how this could be achieved. It involves assessing the current base-line data around the issue being targeted and developing performance measures and indicators to monitor progress. At an operational level it involves identifying how much has been done, how well that was done and what impact has occurred.

Central Government Public Health Plans and Strategies The Ministry of Health and at times other central government agencies has been involved in the development of an extensive collection of strategies and plans (see Table 13) to enable the vision of the NZHS. During the Labour-led coalition the Minister of Health and or senior Ministry of Health officials has led out most of this work. Others strategic documents were developed through the Minister of ACC, the Minister of Social Services and Employment and some were overseen by various Ministerial committees.

Table 13: Core Public Health Strategic Plans

Note: This table shows a range of core public strategic plans including those produced by the Minister for ACC, Minister for Social Services and Employment, the Ministerial Committee on Drug Policy and a range of Ministry of Health publications. The shaded plans were developed under the Labour-led coalition government the blank ones under the National-led coalition government.

The plans, frameworks and strategies take many forms. The National Drug Policy (Ministerial Committee on Drug Policy, 2007) for instance is a high-level plan, which acts as an umbrella for alcohol, tobacco control, methamphetamine, and other illicit drug strategic planning. The recently developed Influenza Pandemic Plan (Ministry of Health, 2010e) in contrast is a highly technical plan to co-ordinate a whole of government response to the human, social and economic threat of a pandemic.

The bulk of meso level planning currently undertaken to implement the NZHS, reflects generic public health traditions and is dominated with bio-medical understandings around disease prevention. Māori public health traditions are not represented in the selection of issue areas for policy development. Central to

NZ Influenza

Pandemic Plan Immunisation in NZ:

Strategic Directions National Drug Policy National Alcohol Policy

Clearing the Smoke:

A five year plan for Tobacco Control

NZ Cancer Control Strategy

Healthy Eating Healthy Action:

Strategic Framwork

Breastfeeding: A Guide to Action

NZ Suicide Prevention Action


Good Oral Health For Life: The Strategic Vision for

Oral Health

Like Minds Like Mine National Plan

Building on Strengths: Mental Heatlh Promotion

HIV/AIDS Action Plan

Sexual and Reproductive Health


NZ Injury Prevention Strategy

Te Uru Kahikatea:

The Public Health Workforce Development Plan

Preventing and Minimising Gambling

Related Harm

An Integrated approach to Infections Diseases:

Priorities for Action

Te Rito :NZ Family Violence Prevention


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Ministry of Health planning is a strong emphasis on quantitative population level data and epidemiological analysis of disease and injury patterns. Improving population level surveillance and strategic use of research and evaluation findings are highlighted areas for further action across many of the plans. Frequently a literature review is undertaken as part of the planning process, which is sometimes published as a companion document.

Most plans and strategies115 are developed with input from a sector and/or an expert reference group with a small to large-scale consultation process, depending on the significance and priority of the strategy or plan. The HIV/AIDS Action Plan (Ministry of Health, 2003d) is an exception to this process, as the New Zealand AIDS Foundation, who are also contracted to deliver services in that area, led it.

Māori are consistently represented within reference groups but remain a minority within these forums.

The most frequently cited framework across this planning, mentioned in over half the plans and strategies is the Ottawa Charter for Health Promotion (World Health Organization, 1986, November). The five core strands of the Charter are often identified as action areas within plans and form the structural basis of others (Ministry of Health, 2002b, 2003c). Subsequent WHO health promotion declarations and or charters such as the Jakarta Declaration on Leading Health Promotion into the 21st Century116 (1997, July), the Bangkok Charter for Health Promotion in a Globalized World (2005, August)117 do not enjoy the same level of attention. Māori models of health such as Te Wheke (Pere, 1991), Te Whare Tapa Whā (Durie, 1994b) and Te Pae Mahutonga (Durie, 1999) are periodically mentioned but have not been utilised as the organising framework for planning documents.

A common theme across several of the plans and strategies is achieving compliance with various United Nations agreements, WHO and International Labour Organisation guidelines that the New Zealand governments have endorsed. Domestic legislation and government regulation also pre-determine elements of public health responses and actions within the areas of tobacco control, drug policy and pandemic planning.

115 The process used to develop the breastfeeding, immunisation and gambling plans is not described within the documents.

116 The Jakarta Declaration (World Health Organization, 1997, July) reiterated the importance of the Ottawa Charter (World Health Organization, 1986, November) and introduced new priorities for health promotion in the 21st century. These included promoting social responsibilities for health, increased investment in health development, consolidating and expanding partnerships for health, increase community capacity and empowerment of individual and strengthen infrastructure for health promotion.

117 The Bangkok Charter (World Health Organization, 2005, August) pledges action to address the determinants of health in a globalised world. It emphasises the importance of building alliances, investment in sustainable policies, building capacity for policy development, regulating, legislating and advocating for health.

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Many of the plans from the early 2000s make specific mention of the Treaty of Waitangi. More specifically, they name the Royal Commission on Social Policy’s Treaty principles of participation, protection and partnership as part of their

‘setting the scene’ sections. Since the mid 2000s, post the Brash (2004, January) Orewa speech118, terminology has changed, with the removal of Treaty references in favour of acknowledgement of the special status of Māori as tāngata whenua (see Ministry of Health, 2008e, 2010e) or more recently references to whānau ora (see 2006b; Ministry of Health, 2010f). Many strategies and plans emphasise the need to develop targeted approaches to engaging with Māori communities, without detailing how this might be achieved.

In summary central government meso-level, strategic planning has a strong epidemiological base and a population wide analysis. The Ottawa Charter is the most widely used framework within the plans/strategies, with the increasing use of outcomes and results based frameworks. Various commitments to Māori health are articulated across most of the plans. Under the National-led coalition government there has been only two meso-level public health planning projects undertaken (gambling and pandemic), which restricts the usefulness of a comparative analysis across the coalition governments at this time. The National-led coalition has however demonstrated low-level interest in public health and decreased regard for consultation.

District Health Board Planning

DHBs are charged with identifying health needs within their respective districts and developing plans to address those health needs, aligned to central government priorities. They are required to develop a Health Needs Assessment (HNA) and a DSP, from which DAPs are generated. Many DHBs also produce a range of lower level plans to support the implementation of their DSP. Although each of the twenty DHBs across Aotearoa has unique health needs and population profiles, there are many commonalities across much of this planning. These commonalities occur due to the prescriptive frameworks that documents must comply with in order to be endorsed by the Minister of Health. The following section profiles the planning processes of Northland DHB as an example of DHB level planning.

Northland DHB Strategic Plans

Northland DHB provides health services for over one hundred and fifty thousand people, covering the Far North, Whangarei and the Kaipara districts. Thirty percent of the population are Māori. Thirty eight percent of Māori living in Te Tai Tokerau are under fifteen years of age. The primary Northern tribes are Ngāti Whātua, Ngāti Wai, Ngā Puhi, Ngāti Hine, Ngāti Kahu, Whaingaroa, Ngāi Takoto, Ngāti Kurī, Te Rarawa, and Te Aupōuri (Northland DHB, 2005b). Both Te Tiriti and He Whakaputanga o Te Rangatiratanga o Nu Turei hold particularly

118 The Orewa speech advocated for the removal of affirmative action programs and references to the Treaty of Waitangi in legislation. It was widely accused of fuelling racist sentiment against Māori.

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meaning in Northland, as it was here that they were signed. Te Tai Tokerau has a relatively deprived and scattered population with high rates of chronic disease and poor oral health (Northland DHB, 2005b).

Historically inherited from the local RHA, North Health, the Northland DHB (2005b, 2009b) until 2010 had a treaty-based relationship with both Te Tai Tokerau MAPO Trust119 and Tihi Ora MAPO.120 These relationships operated at both governance and operational level, as co-funding partnerships. Te Tai Tokerau MAPO Trust had a written partnership agreement with Northland DHB and were active in relation to, prioritisation and funding decision-making, strategic and service planning, consultation and communication with Māori, health providers and other stakeholders, contract negotiations, management and monitoring and Māori provider and workforce development (Northland DHB, 2005b, pp. 54-55).

The evidence base for most DHB-led health planning within Te Tai Tokerau is their HNA (2005a). This information forms the foundation of the DSP (Northland DHB, 2005b), under this lies population specific (See Northland DHB, 2007b;

2008, 2009a), and issue-specific health plans (see Northland DHB, 2007a, 2007c, 2007d; 2006a, 2006b) that provide the content for the DAP (Northland DHB, 2009b). Figure 17 Te Kahukura Oranga o Te Tai Tokerau shows how the Northland DHB authored and/or endorsed plans engage with Dahlgren and Whitehead’s (1991) model of the determinants of health. This foundation is then overlaid with Durie’s (1999) Te Pae Mahutonga and Te Tiriti o Waitangi, to represent Māori aspirations and paradigms (used in both the Te Tai Tokerau Strategic Māori Health and Public Health Plans see below).

119 Te Tai Tokerau MAPO Trust governance structure consists of representatives drawn from Ngā Puhi, Ngatiwai and the five Muri Whenua Iwi of the Far North, this agreement covers the Whangarei and Far North districts.

120 Tihi Ora MAPO is governed by Te Runanga o Ngati Whātua and represented the interests of Ngati Whātua in Te Tai Tokerau, as they related to the Kaipara region.

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Figure 17: Te Kahukura Oranga o Te Tai Tokerau

From Te Tai Tokerau strategic Māori health plan 2008-2013, Te Rōpū Kai Hapai o Hauora o Te Tai Tokerau, 2008, p.18. Whangarei, New Zealand: Northland DHB. Reprinted with permission.

The HNA (2001, 2005a) outlines the current demographic profile of the population of Northland and through epidemiological analysis quantifies trends in morbidity and mortality. This information informs operational planning around the provision of both treatment and public health services. The HNA benchmarks disease and injury rates of Northland residents with other DHB areas, and hence identifies areas requiring greater attention. Sub-regional analysis reveals inequities across Northland residents, most notably life expectancy gaps between Māori and non-Māori. Within the HNA, these inequities are located within a wider context of restricted access to the social and economic determinants of health for many residents and the recognition that poor lifestyle choices continue to contribute to the growing prevalence of diabetes, obesity, cardiovascular disease and cancer.

HNA analysis is both strongly quantitative and bio-medical in its perspective.

This pattern is adopted consistently by DHBs across the country, to enable funders to quickly identify the major (illness) priorities they might invest in (Northland DHB, 2005a, p. 3). The HNA authors concede there are considerable information gaps within their analysis and note the difficulty and expense in addressing these gaps, as at times data does not exist or cannot be usefully broken down to a local level. Kaupapa Māori measures and indicators to track health status are not currently included within the HNA.

A companion document of the HNA, the DSP (Northland DHB, 2005b) describes the high-level intentions of how Northland DHB intends to address the health needs of its residents over a five-year period. In accordance with the NZPHDA, intricate to its development is a consultation process of public meetings, supplemented by a written submission process to enable community and provider engagement. Key frameworks utilised within the plan include the Ministry’s reducing inequalities framework (2002g) and leading for outcomes models (Ministry of Health, 2007b) and a locally adapted prioritisation framework.

Northland DHB has identified both a set of strategic priorities (diabetes, cardiovascular disease, cancer, oral health and elective services) and several population subgroups with high health needs (Māori, Pacific peoples, children and youth and older people) as the focus of their DSP. Particular reference is made within the DSP of the importance of promoting healthy eating and physical activity as a vehicle for preventing and managing chronic disease. The importance of healthy lifestyles and reducing inequalities is highlighted throughout the plan with no further detail provided on how this might be achieved. Healthy public policy is mentioned in the context of oral health, but the remainder of the plan is largely silent in regards to public health.

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The DSP reiterates the commitment of Northland DHB to Te Tiriti and the Treaty and to fulfilling its statutory responsibilities to Māori. To achieve these ends the Northland DHB identified a variety of strategies to improve Māori health aligned to He Korowai Oranga (A. King & Turia, 2002) and the Whakatātaka series of action plans (Ministry of Health, 2002h, 2006c). These strategies aim to significantly reduce the life expectancy gap between Māori and non-Māori by 2015 and involve including Māori in health system planning and delivery at all levels. They aim for equitable resource allocation for kaupapa Māori programmes and for any new or expanded initiative and tracking health status and service use by ethnicity to enable effective monitoring.

Within Northland’s hierarchy of plans underneath the DSP are the Te Tai Tokerau Strategic Māori Health and Public Health Plans (Te Rōpū Kai Hapai o Hauora o Te Tai Tokerau, 2008; Te Tai Tokerau MAPO Trust & Northland DHB, 2008).

The first was written collaboratively by the Māori health leadership group Te Rōpū Kai Hapai o Hauora o Te Tai Tokerau121 and the second was co-authored with Te Tai Tokerau MAPO Trust. Both affirm Māori public health traditions and represent Māori aspirations in relation to health. A review of Northland DHB board minutes (from Sept 2008 to Sept 2011) and responses to OIR (Roach, 2011, August 11, 2011, September 12) provided no verifiable confirmation that either plans has yet been substantively implemented.

Building on previous planning undertaken by the Te Tai Tokerau Strategic Māori Health Alliance, the Māori Health Plan (Te Rōpū Kai Hapai o Hauora o Te Tai Tokerau, 2008) originates from a Māori worldview122 and is infused with public health thinking. This plan was developed collaboratively through a series of workshops and extensive debate amongst the local Māori health leadership. Te Tiriti forms the heart of the plan, with strong emphasis on the importance of partnership between the Crown and Māori. Te Rōpū Kai Hapai, as the Māori health leadership forum within Te Tai Tokerau strongly asserts they should be involved in the determination of funding and other decisions made in respect of Māori health in the region.

Within the Māori health plan, Te Rōpū Kai Hapai expressed concerns (2008, p. 2) regarding health inequities and called for a new approach based on the realities of the circumstances in which many Māori in Te Tai Tokerau live. Central to this proposed approach (2008, p. viii) was a focus on “...addressing the social and economic determinants of Māori health – poverty, employment, education,

121 Te Rōpū Kai Hapai o Hauora o Te Tai Tokerau is made up of membership consists of the chief executives of Te Tai Tokerau Māori Health Strategic Alliance, Te Tai Tokerau MAPO Trust, Northland DHB and local Primary Health Organisations.

122 The principles of Māori health plan are enmeshed in tikanga Māori, they include the concepts of tika (that which is just, fair and proper), pono (truth and sincerity), aroha (love and respect), kotahitanga (collaboration or working together), whakapiki ake (building capacity) and ngā tūmanako me ngā whakapaunga kaha a te Kāwanatanga ( a commitment to reduce health disparities) (Te Rōpū Kai Hapai o Hauora o Te Tai Tokerau, 2008, pp. 1-2).

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housing, the natural environment and Māori leadership, without distracting from the provision of effective health and disability services”. The premise being that improving the conditions of daily life, by tackling inequitable distribution of power, money and resources is likely to improve health status in its broadest sense.

The plan is a matrix that links the contributions of existing local, regional and national strategies back to Māori health goals. One axis relates to the building blocks of hauora, the other covers a series of crosscutting themes and action areas.

The themes include kotahitanga, he tangata in this context referring to leadership, workforce and capacity building, he rangahau hauora (research) and he putea related to equitable resource distribution. Across the plan child, health also has prominence, with many of the recommendations from the Child Poverty Action Group’s (St John & Wynd, 2008) report, Left Behind: How Social and Income Inequalities Damage New Zealand Children incorporated into the plan. Another key proposed action is the development of a Māori Hauora Index, as an authoritative compendium of a range of Māori data to inform future health policy and planning. The plan also specifically named addressing institutional racism as an action area.

The central framework for the public health plan (Te Tai Tokerau MAPO Trust &

Northland DHB, 2008) is Durie’s (1999) Te Pae Mahutonga. The plan was initially informed by interviews and focus groups with Māori stakeholders and a review of Māori health literature. Later a representative reference group was established and written submission process was instigated targeting those working within the sector. The plan introduced a Te Tai Tokerau approach to public health (see Figure 18) which takes into account both epidemiological and kaupapa Māori evidence and analysis and community aspirations within plan. Central to the approach is recognising the realities of the circumstances in which many Northlanders live. The plan has two key platforms, i) strengthening action on the building blocks of hauora; ii) improving public health workforce capacity.

Figure 18: Te Tai Tokerau Approach to Public Health

Adapted from Te Tai Tokerau strategic public health plan 2008-2011, by Te Tai Tokerau MAPO Trust & Northland DHB, 2008, p.7. Whangarei, New Zealand: Northland DHB. Reprinted with permission.


Community Aspirations Kaupapa


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The building blocks of health are about ensuring individuals and whānau have access to the essentials of life (food, shelter, clean water, sanitation, peace etc) health and determining what the health sector can contribute to ensuring this access. Other elements of the plan emphasises strengthening collective leadership around advocacy, embedding a regional approach to Ministry defined public health issue areas, hapū and community development, a commitment to environmental health and communicating and engaging effectively with Māori.

Significant to this research the plan (Te Tai Tokerau MAPO Trust & Northland DHB, 2008, pp. 20-21) names both personally mediated and institutional racism as action areas needing to be addressed.

Northland DHB also has a range of additional operational/strategic plans with some relevance to public health (see Table 14). Given the sequence of their development, these plans are not yet all aligned to the strategic direction outlined in the Māori health and public health plans. As these plans are renewed, the intention is their alignment will be strengthened. Key actions from these strategies/plans are lifted out annually to populate the DAP which delineates the operational purchasing and work-plan for that year.

Table 14: Core Northland DHB Strategies and Plans

Note. This table includes a range of public health related strategic plans produced by the Northland DHB.

The standard DHB planning process involves a review of relevant national strategies, local epidemiological and/or demographic data, followed by a stock take and gap analysis with various levels of sector engagement. Usually an advisory/reference/planning group is established, predominately made up of DHB staff from both the funding and provider arms, alongside representation from external stakeholders including Māori providers. Reference lists of cited material are frequently omitted making it difficult to identify what if any literature has been reviewed beyond Ministry documents. When peer review is undertaken, the pattern is to utilise staff from other DHBs and/or the Ministry (Northland DHB, 2007b, 2007d). Formal sign-off of the plan/strategies occurs at Board level, which includes both locally elected representatives and Minister of Health appointees.

With the exception of the oral health strategy (Northland DHB, 2007d) all strategies/plans reviewed included standard setting the scene statements about

Northland Diabetes

Strategy Oral Health for all

Northlanders Cardiovascular

Disease Strategic Plan

Northland Cancer Control Strategic

Action Plan

Child and Youth Health

Strategy Health of Older People

Strategic Action Plan Disability Strategy and Implementation Plan

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Crown-defined Treaty principles and the importance of whānau ora as defined within He Korowai Oranga (A. King & Turia, 2002). These Treaty statements emphasise the importance of Māori involvement at all levels and stages of health system planning and delivery. The Northland Diabetes Strategy (Northland DHB, 2006b, p. 2) goes further however, stating a commitment to equitably resource kaupapa Māori programmes on any new and or expanded initiatives. Māori health models are not named or used as frameworks in any of the reviewed plans.

The plans/strategies fit into two primary categories: those focused on sub-populations, and those concentrating on chronic disease management and prevention. The population specific plans emphasise the importance of accessible services and addressing the particular health needs of that population. Consumer input was deliberately sought in the development of both the disability and older people strategies. The particular health needs of Māori are mentioned variously within the plans but limited Māori specific actions are identified to address those stated needs. In the Health of Older People Strategy Action Plan (Northland DHB, 2008) for instance the only planned Māori specific activity for the term of the strategy is undertaking a small-scale research project to define need further.

The reviewed plans/strategies have a strong clinical base, which is reflected in how the health “problems” are defined, through to the selection of membership of the reference groups and planned activity. The life-course approach to chronic disease management is a useful framework to strengthen the interface between primary and secondary services (Halfon & Hochstein, 2002). Discourse around reducing inequalities is present within all reviewed Northland DHB plans and strategies. The mechanics of how the Ministry’s inequalities framework (2002g) and the HEAT tool (Ministry of Health, 2004d) have been applied in decision-making around action areas is not transparent.