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NARRATIVES

7.2 Macro Health Policy

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However, it is formulated; policy has the potential to be either inclusive of multiple perspectives or steadfastly mono-cultural affirming the worldview of one grouping only. Davis and Ashton (2001) suggest even when public consultation processes occur; government control is absolute, regarding their retention of decision-making as to which policy solutions or priorities will be funded. As outlined in chapter three, within the context of Aotearoa, and particularly during the era of colonisation and assimilation, government policy has been used for decades as a powerful mechanism to subjugate Māori.

Labour-Led Coalition Government (1999-2008)

Labour started its life as a party of change – a voice for the working classes who believed that a fairer future was possible. Many of those first involved just wanted the basics – adequate food, clothing and shelter; a job with reasonable conditions and regular wages; support in illness or old age; and a hope for an even brighter future for their children

(Labour Party, n.d.).

The Labour party has gone through various transformations since its formation, the most significant being it is championing of radical free market theories and reforms during the 1980s. The fifth labour-led government (1999-2008) under the leadership of Right Hon. Helen Clark took a more moderate line with an assortment of coalition partners and supply agreements with the Alliance Party, the Progressive Coalition, New Zealand First, the United Future Party and often working with the Green Party. Labour campaigned on a platform of a more planned and community-orientated health system, under revamped health legislative and sector structure. Labour articulated their ideological opposition to a healthcare model, which promoted competitive tendering for contracts (New Zealand Labour Party, 1999).

Their coalition partners’ health policies ranged from commitments to free healthcare, greater investment in public health initiatives, prioritising child health (see Alliance Party, n.d.), investment in the public health system, extending oral health services, endorsement of particular public health initiatives around suicide and alcohol and other drugs (see Progressive Party, n.d.), increased investment in health services and eldercare (see New Zealand First, n.d.) and emphasis on healthy lifestyles choices (see United Futures, n.d.). These competing priorities formed elements of the Labour party’s web of coalition commitments.

Critical to the Labour-led health sector reforms was the development of a number of high-profile sector-wide strategies. These included the New Zealand Health Strategy (NZHS) (A. King, 2000), the New Zealand Disability Strategy (Dalziel, 2001) the Primary Healthcare Strategy (A. King, 2001) and were followed by the Māori health strategy, He Korowai Oranga (A. King & Turia, 2002). Underneath these core strategic documents lay assorted population specific and disease-based strategies, supported by operational level evidence-based toolkits, action plans

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and guidelines to enable policy implementation within the sector (Ministry of Health, 2002d).

Within the following section, I examined NZHS, Achieving Health for All and He Korowai Oranga as the key macro level public health strategy documents.

New Zealand Health Strategy

Behind the statistical comparisons lies the unacceptable reality that some New Zealanders live in unhealthy housing, some have poor nutrition and, in rural areas, some have limited access to clean water and sewerage systems

(A. King, 2000, p. 3).

The NZHS (A. King, 2000) was designed as the foundation document for health and disability service planning. Its overarching goal was to improve the health of the entire population while simultaneously reducing inequalities in health. Then Health Minister, Hon. Annette King, isolated specific areas where she believed the greatest population-level health gain could be achieved to benefit all New Zealanders. The NZHS acknowledged the Royal Commission on Social Policy’s (1988) Treaty principles and the importance of both treaty parties relating to one another in good faith with mutual respect, co-operation and trust.

The NZHS had an explicit commitment to the further development of Māori providers and the continuation of the two-pronged Māori health strategy of mainstream enhancement and the development for Māori and by Māori services.

Māori were positioned within the strategy both as treaty partners and as a community with disproportionately high health needs. The detail of the strategic approach to addressing Māori health was outlined in the then forthcoming document, He Korowai Oranga (A. King & Turia, 2002).

Based on epidemiological analysis and consultation with the public, the NZHS identified a set of key objectives that covered risk factors such as smoking, lack of exercise and prevention of chronic diseases such as diabetes (see Table 11).

Underneath these objectives were detailed performance measures to enable monitoring of progress against the strategy. These priorities then formed the basis of funding agreements with DHBs, who were the primary agents responsible for implementing the strategy. Local and regional needs assessments commissioned by DHBs and assorted advisory committees also helped enable local decision-making and prioritisation processes. In pursuit of greater transparency DHB, performance around implementation has been benchmarked and published.

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Table 11: New Zealand Health Strategy Priorities

Reducing smoking. Improving nutrition. Reducing obesity. Increasing the levels of physical activity.

Minimising harm caused by alcohol and illicit and other drug use.

Reducing the incident and impact of cancer.

Reducing the incident

and impact of

cardiovascular disease.

Reducing the

incident and impact of diabetes.

Improving oral health.

Reducing violence in interpersonal

relationships, families,

schools and

communities.

Improving the health status of people with severe mental illness.

Ensuring access to child health care

services and

immunization.

Note. Adapted from The New Zealand Health Strategy by A. King, 2000, p.13. Wellington, New Zealand: Ministry of Health. Reprinted with permission.

The NZHS operated from the assumption that increased public health activity contributes to the improvement of population health outcomes and the reduction of health inequities. This was reinforced by the inclusion of determinants of health analysis and emphasis on intersectoral activity within the strategy. The influence of generic public health thinking is reflected in many of the key strategic objectives, which relate to behavioural risk factors that both the public and primary healthcare sectors have long wrestled with. The rationale for these priorities and the interventions themselves were primarily generated through epidemiological analysis.

Progress on implementing the NZHS has been regularly published in the Ministry of Health’s Health and Independence Report (Ministry of Health, 2001a, 2002e, 2003b, 2004c, 2005, 2006a, 2007a, 2008b, 2009a, 2010a) alongside the Director-General of Health’s supplemental reporting on the state of public health and implementation of the sector’s quality improvement strategy. These reports illustrate steady improvements in a range of areas including life expectancy and declining smoking rates. In 2007, this reporting on the NZHS was reconfigured by the introduction of core health targets agreed upon between Ministry and DHBs, as a key focus for consolidated attention within a specified year. Under the Labour-led coalition these targets were largely a continuation of priorities lifted from the NZHS, but did lead to restructuring within the Ministry to enable clinical leadership of each target.

He Korowai Oranga

He Korowai Oranga places whānau at the centre of public policy. It challenges us to create environments that are liberating and enable whānau to shape and direct their own lives, to achieve the quality of life Māori are entitled to as tangata whenua in Aotearoa-New Zealand (A. King & Turia, 2002, p. iii).

Launched in 2002, He Korowai Oranga108 is a framework for the public sector to take responsibility for its part in supporting the wellbeing of whānau. Boulton (2005) argues it represents a change of direction in Māori health policy by,

108 He Korowai Oranga translated means the cloak of wellness.

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shifting emphasis from an individualistic approach to health and wellbeing, to one more inclusive of Māori worldviews. Whānau ora became central to Māori health policy, recognising that health and wellbeing is influenced and affected by the circumstances of the collective as well as that of the individual (Ministry of Health, 2002B). Within He Korowai Oranga the authors attempt to address the aspirations of both Māori and the Crown (as depicted in Figure 15), while working with the Royal Commission on Social Policy’s (1988) Treaty principles.

As with the NZHS, the Crown restated its commitment to reducing health inequities between Māori and non-Māori.

Figure 15: He Korowai Oranga

Adapted from He Korowai Oranga: Māori health strategy, by A. King & T. Turia, 2002, p.4.

Wellington, New Zealand: Ministry of Health. Reprinted with permission.

Beyond achieving whānau ora, the purpose of the strategy was twofold, to affirm Māori approaches to service provision and to strengthen Māori health outcomes.

Māori-led initiatives, holistic models and approaches to hauora (health) were emphasised within He Korowai Oranga recognising the desire of Māori for tino rangatiratanga; i.e. to seek Māori solutions and have Māori run and owned health services. The strategy recognised that public policies promoting quality education and employment opportunities and addressing systemic barriers (including institutional racism) were all necessary if whānau ora were to be achieved. The strategy was premised on the need for a reorientation to occur in how health services were planned, funded and delivered.

He Korowai Oranga was implemented through the release of the Whakatātaka109 series of action plans (see Ministry of Health, 2002h, 2006c). These plans specified the roles, responsibilities, performance expectations, measures and initiatives for implementing the strategy. Within the first action plan, Crown officials attempted to achieve change at the level of systems and processes. It emphasised building on the strengths and assets within whānau and Māori communities. The second plan emphasised whānau development and

109 Whakatātaka refers to the weaving of strands, creating a pattern step by step, and eventually forming a taonga such as a korowai.

WHĀNAU ORA

Māori Aspirations Building on Gains Crown Aspirations

Rangatiratanga

Whānau & hapū development Reducing Inequalities

Māori Participation Working across sectors Effective Service Delivery

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led initiatives including strengthening whole-of-government initiatives.

Embedded across the action plans were Māori specific performance indicators and reporting requirements for DHBs.

Achieving Health for All

Promotion of healthy communities and environments will assist in moving the focus from individual risks and behaviour into the nature of the community and the environment in which we live (Ministry of Health, 2003a, p. iii).

Achieving Health for All (Ministry of Health, 2003a) was developed as the public health sector’s response to the NZHS. It affirmed the relevance of the Treaty of Waitangi to public health practice and reinforced both the importance of reducing inequalities and tackling the determinants of health. It highlighted the Ottawa Charter for Health Promotion (World Health Organization, 1986, November) as a framework for public health planning. Emphasis was placed on mobilising the core public health sector as well as territorial local authorities, the wider health sector and other government agencies into engaging in public health activity aligned to the targets of the NZHS. Rather than focus on behavioural change, the strategy highlighted building healthy communities and environments. In order to strengthen the sector the strategy also had components around the utilisation of research and evaluation in public health policy and practice, achieving measurable progress on health outcomes and enhancing public health leadership.

Māori public health action was highlighted across a range of the priority areas to enable the pursuit of whānau ora. Te Pae Mahutonga was identified as an appropriate model from which to develop comprehensive public health programs.

Commitments were made to strengthen Māori public health infrastructure and expand the use of Māori models of health and kaupapa Māori research in the development of policy and practice.

In summary, the fifth Labour-led government created a decade of relative stability in health policy. It could be characterised as having both a strong prevention focus and a commitment to addressing inequalities through improving access to primary care. Official rhetoric was supportive of Māori health development and a whānau ora policy platform was established.

National-Led Coalition Government (2008-Onwards)

The National Party is founded on principles of individual responsibility, private enterprise, and reward for individual effort. These principles are the only sure path to a society of personal freedom and rising standards of living for all (National Party, n.d.).

Under the leadership of the Right Hon. John Key (2008, November 17), the primary policy focus of the National-led government is generating economic growth, to create a globally competitive economy which will deliver prosperity to

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all New Zealanders. The policy platforms to achieve this goal of growth includes support for science, innovation and trade, better regulation and public services, investment in infrastructure, improved educational outcomes and a growth-enhancing tax system (Ministry of Health, 2010g, p. 8). The National Party website110 emphasises the importance of encouraging ambition, valuing families, limited government, competitive enterprise and rewards for achievement as the cornerstones of their conservative political philosophy.

Their coalition parties include the ACT party, the Māori party and United Future.

Their respective health policies focus on having a competitive healthcare environment, investing in innovation and technology (see ACT Party, n.d.), whānau ora, strengthening tobacco control, ending child poverty (see Māori Party, n.d.) and an emphasis on healthy lifestyles (see United Futures, n.d.). Elements of these policies are reflected in the National Party’s respective coalition agreements.

Despite the ideological differences between the Labour-led and National-led governments in relation to health policy, the core structure of the health sector remains defined by the NZPHDA. Core policy documents such as the NZHS, the New Zealand Disability Strategy, the Primary Health Care Strategy and He Korowai Oranga all remain current until the National-led government refreshes or reframes these. Within this section I examined National’s health manifesto Better Sooner and More Convenient (Ryall, 2007), the recent review of the health sector (Ministerial Review Committee, 2009) and new developments in Whānau Ora (Whānau Ora Taskforce, 2009) as core policy documents.

“Better, Sooner, More Convenient”

Our “cultural hard drive” has to alter so that healthy choices are preferred. A successful long-term approach will provide people with the education, skills and desire to make healthy dietary and lifestyle choices and stick to them

(Ryall, 2007, p. 28).

The National Party’s (Ryall, 2007) approach to healthcare is outlined in their discussion document Better, Sooner, More Convenient (see Table 12). Central to the policy platform is the belief that increasing prosperity and opportunity improves health outcomes. This approach aims to halt the growth in health bureaucracy within Crown agencies, to tackle waiting lists and to strengthen workforce capacity (Ministry of Health, 2009d, p. 5). Savings were expected to be generated because of a comprehensive line-by-line review of spending that ensures savings are redirected to front-line health services. Integrated family health centres were to be developed and hospital-based services were to be devolved into a more accessible community-based primary healthcare environment within a climate of greater collaboration between primary and secondary healthcare providers.

110 See http://www.national.org.nz/

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Table 12: Guiding Principles of National’s Health Policy

Putting patients first Patients at the centre of health services and being able to make informed choices.

Care close to home More healthcare services close to home, complex healthcare close to best medical technology.

Integrated care Seamless service delivery as a result of partnerships within the sector and with social and community organisations.

Trusting health professionals Importance of clinical professionalism to secure public trust in the health sector.

Working together for better care Effective use of finite health resources, through shared decisions and innovation.

Healthier lifestyles Access to information to make informed choices, support people chronic illness.

Note. Adapted from Better sooner more convenient: Health discussion paper by T. Ryall, 2007, p.3. Wellington, New Zealand: National Party. Reprinted with permission.

National’s health policy is silent in relation to public health except the over-arching commitment to growing the economy, to raise standards of living (and thereby health) and an emphasis on promoting individual responsibility for lifestyles choices. Better Sooner More Convenient outlines no specific strategy or position on Māori health.

The National-led government health policy is further outlined within the Minister of Health, Hon. Tony Ryall’s (2009, February 19) annual Letter of Expectations to DHBs, the Ministry’s Statement of Intent (2011c) and through refreshed and reconfigured health targets. The 2009 Letter of Expectation had a clear focus on improving hospital-based services including requesting action on improving cancer treatment and emergency department waiting times, increased elective surgery, emphasis on fostering clinical leadership and clinical staff retention.

Devolution of secondary services to integrated family healthcare centres and regional co-ordination across DHBs were also encouraged. Due to the deepening global financial crisis, service reconfigurations were expected to be achieved within existing resources through the reallocation of resources from back-room bureaucratic roles into “front-line” healthcare.

Ministerial Review

New Zealand must strive to get more health service from existing spending by reducing waste and bureaucracy and by lifting productivity (Ryall, 2008).

National Party concerns regarding the relative strength of the health system, the challenges ahead in terms of an aging population and ballooning healthcare expenses, led them to commission a major review of the health sector under the leadership of Murray Horn111 (Ministerial Review Committee, 2009). This substantive report identified two types of recommendations i) those that encouraged changes in culture and processes to enable clinical leadership and improve integration within the health system, and ii) structural change aimed at reducing waste and bureaucracy to enhance quality and financial viability. Central

111 This report is widely known as the Horn Report.

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to the report’s recommendations was the notion of affecting change within existing resources and the current legislative framework.

The Ministerial Review committee (2009, p. 53) identified a number of what they considered key gaps in the current legislative framework. They wanted to see greater clinical-managerial leadership, stronger national and regional decision-making, improved frameworks for rapid development of new models of care and a better rationale for determining access to public funding for new services. If DHBs would commit to the new approach, the committee recommended that more health funding be devolved to them. The committee warned that more fundamental change might well prove necessary if the sector did not respond to the challenges of cost containment and innovation.

Amongst the structural changes proposed was the establishment of a NHB and an associated business unit within the Ministry. As stated previous, the role of the NHB is to “…co-ordinate planning and funding of national services, arbitrate in regional service disputes and undertake national capacity planning and funding for workforce, information technology and capital” (Ministry of Health, 2010g, p. 3).

The NHB also assumes responsibility for monitoring DHBs performance to enable a complete view of health service planning and funding.

Since the release of the Horn Report (July 2009) a variety of actions have been implemented as outlined in the Ministry’s recent Statement of Intent (2010g). The NHB has been appointed and has commenced work on consolidating planning and funding, workforce planning and capital investment. Revised health targets112 and government priorities that reflect both the focus of the Horn Report and Better, Sooner, More Convenient have been established. Significant Ministerial and Ministry Advisory Committees and staffing levels within Crown agencies have been rationalised. A comprehensive line-by-line review and an in-depth spending review to prioritise expenditure from low value to higher value services as of mid 2011 remains active.

As part of the realignment to a new strategic direction, the Ministry of Health has identified two new health and disability system outcomes. First, that New Zealanders live longer, healthier and more independent lives and secondly, that New Zealand’s economic growth is prioritised (Ministry of Health, 2010g, p. 9).

The later reflects a marked change in the ideological orientation of the health sector from the previous Labour-led government. As with Better, Sooner, More Convenient, the Horn Report is predominately silent on both public health and Māori health.

112 These include shorter waiting times for cancer treatment, improved access to elective surgery, shorter stays in emergency departments, increased immunisation, better help for smokers to quit and better diabetes and cardiovascular services (Ministry of Health & National Health Board, 2011).

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The Whānau Ora philosophy... recognises the many variables that have the potential to bring benefits to whānau and is especially concerned with social, economic, cultural and collective benefits. To live comfortably today, and in the years ahead, whānau will be strengthened by a heritage based around whakapapa, distinctive histories, marae and customary resources, as well as by access to societal institutions and opportunities at home and abroad

(Whānau Ora Taskforce, 2010, p. 7).

Parallel to the Ministerial review under the auspices of Whānau Ora, a taskforce was established in June 2009 to work across government to develop an evidence-based framework113 for a preferred approach to interventions with whānau.

Picking up on the initial intent of He Korowai Oranga - to reorientate government funding mechanisms - the proposal developed by the Whānau Ora Taskforce (2009) and their subsequent report (2010) are an attempt to develop a new approach for the design and delivery of government funded services and initiatives to whānau. The framework is about improving collaboration between funders, providers and practitioners to enable whānau to manage their own affairs more effectively, and to contain compliance costs.

As articulated in He Korowai Oranga (A. King & Turia, 2002, p. 1), whānau ora can be defined as Māori families supported “...to achieve their maximum health and wellbeing”. The concept of whānau ora recognises that whānau play a central role in the wellbeing of Māori, individually and collectively, as “...a source of strength, support, security and identity” (Ministry of Health, 2006c, p. 1). Since its coalition negotiations, the National-led government has articulated its hopes to facilitate whānau ora to achieve:

…positive and adaptive relationships within whānau and recognise the interconnectedness of health, education, housing, justice, welfare, employment and lifestyle as elements of whānau wellbeing (Ministry of Health, 2009d, p. 3).

The Whānau Ora Taskforce (2009, 2010) has identified a number of key elements and principles of whānau-centred service delivery (see Figure 16). Central to these elements is recognising the distinct roles of whānau, hapū and iwi and the contrasting responsibilities of government agencies in strengthening whānau ora.

The principle of ngā kaupapa tuku iho is also vital; this refers to how whānau are part of a wider system embedded in Māori epistemology, driven by inter-generational transmission of knowledge, culture, reciprocity and resources. The framework is deliberately strengths-based, requiring innovation, adequate resourcing and a ‘whole of government support’ to succeed.

113 The report was based on relevant literature, developing case studies from the experiences of health and social service agencies, an analysis of oral submissions received at 22 hui and over 100 written submissions from individuals and organisations (Whānau Ora Taskforce, 2010, p. 6).

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Figure 16: Whānau Ora Framework

Reproduced from Whānau Ora: Report of the taskforce on whānau-centred initiatives, by Whānau Ora Taskforce, 2010, p.21. Wellington, New Zealand, Ministry of the Community and Voluntary Sector. Reprinted with permission.

The taskforce reaffirmed the importance of Te Tiriti and the Treaty as a key instrument to guide development, and called for the establishment of an independent trust to administer dedicated government appropriation. Building on existing provider capabilities, the taskforce emphasised a primary focus on whānau outcomes, through integrated and comprehensive delivery. Rather than focussing on what work had been done by agencies, they are interested in what has been achieved with whānau, and how whānau can become stronger and more resilient into the future.

Upon the release of the taskforce’s initial proposal, National Party leadership distanced themselves from the strong by ‘Māori for Māori’ position. Wright (2010, February 15) quoted Right Hon. John Key for TV3 news saying, “Our policy is based on needs, not race, and that’s the way it will be implemented”, he explained, “not all families in need are Maori... and we’re a government that want to provide support to New Zealanders in need”. Consequently the National-led government did not accept all the taskforce’s findings (Small, 2010), and Whānau Ora has shifted from being by Māori for Māori to a program accessible for all New Zealanders. Te Puni Kōkiri was appointed the key government agency responsible for Whānau Ora with key roles also for the Ministry of Health and Ministry of Social Development. National and regional governance arrangements have been confirmed and funding sourced through the reconfiguration of existing Māori funding streams from assorted government departments.114

114Funding is being sourced through the Government’s housing, health, education, justice and social welfare agencies.