The interim recommendations of the Waitangi Tribunal’s Hauora report identified multiple Treaty breaches in how the primary health care system has failed Māori. It called for structural reform that genuinely empowers tino rangatiratanga.
Now, in their final Stage One recommendations, released last week, the report’s authors say that the government’s decision to establish a Māori Health Authority is a welcome development.
In fact, they say, it goes further than they envisaged.
However, they’re disappointed that no agreement has been reached on a way to calculate the underfunding of Māori primary health providers over the last 20 years. They’re especially disappointed that this is largely due to the Crown not engaging with the claimants on this issue.
And the longer this crucial work is delayed, they write, the more the prejudice Māori have already suffered as a result of ongoing health inequities is exacerbated.
We’ve extracted and condensed parts of the Tribunal’s report here to provide this summary of their findings, in their own words.
The Māori Health Authority’s stated mandate and functions will require it to discharge what is arguably the hardest job of any of the central health agencies.
It will be expected to advocate for the equity agenda when the other central health agencies have dropped the ball.
It will be expected to intervene in the worst-performing services of the health system, and improve them, including services offered by so-called ‘mainstream’ providers.
It will also, as an agent of tino rangatiratanga and of iwi, hapū, and whānau health needs and aspirations, feel the enormous pressure of the communities it serves.
The Crown has been advised many times — both in our inquiry and previous Tribunal inquiries — that, if it is going to delegate significant responsibilities to Māori-controlled bodies, it must provide them with enough resources to ensure that they do not fail, and are able to discharge those responsibilities in a way that benefits the whānau, hapū, and iwi they serve.
. . .
The indisputable fact that the Crown funds the primary health care system inadequately is a key reason for the extent of inequity that Māori continue to suffer.
While the health system cannot be accountable for all of the social determinants of health, it has available to it some of the strongest levers to effect change.
Our recommendation that the parties agree on an underfunding methodology was expressed as an interim one because we considered the seriousness of the Crown’s Treaty breaches, and the significant prejudice they wrought, needed to be addressed fairly and accurately.
We were determined that the Crown’s actions to address that prejudice would account adequately for the impact of its past actions and omissions.
We also wanted to ensure the Crown would not repeat its mistakes, nor sanction a system in which inequitable Māori health outcomes were likely to continue, including by funding the system inadequately.
We acknowledge that coming up with an estimate of over 20 years of underfunding in primary care is multifaceted. But so is designing a new health system. The parties have, to an extent, worked together to inform the latter. We remain confident that they can achieve the former.
During our hearings, we were told that a fit-for-purpose primary health system — one where general practices and other service providers successfully identify and treat problems before they become serious enough to warrant hospital treatment — required much more significant upfront costs than were then being spent.
However, we were assured these costs would be far outweighed by the long-term costs of dealing with undetected or inadequately treated health conditions.
The Sapere report’s analysis bears this out. It clearly indicates the severe, and unsustainable, economic cost to all New Zealanders of an inequitable health system.
It also makes it clear that coming up with a credible methodology to estimate underfunding is possible and provides a clearer pathway forward to complete that work.
To meet its Treaty obligations, the Crown must fund a Treaty-compliant health system; one that prioritises equity and empowers tino rangatiratanga of hauora Māori.
Our interim recommendation was thus intended both to allow an estimate of the amount of compensation due to Māori primary health organisations and providers to be developed, and to stimulate work that would help the parties come up with the funding regime for the new primary health system.
We reiterate our disappointment that these intentions have been only partly realised.
In finalising our interim recommendation, we can therefore only reiterate it with even greater urgency.
We recommend that the Crown and claimants work together to agree upon a methodology for the assessment of the extent of underfunding of Māori primary health organisations and providers.
The methodology should include a means of assessing initial establishment and ongoing resource underfunding since the commencement of the New Zealand Public Health and Disability Act 2000.
We expect the Crown to engage with greater commitment than it appears to have done to date and that as a result parties can complete this work urgently.
We now turn to what should happen once an underfunding methodology is agreed.
We recommend that, once the parties have agreed on an underfunding methodology, the Crown fully compensate for the underfunding determined by that methodology.
The full compensation should be calculated as the total underfunding incurred between the enactment of the New Zealand Public Health and Disability Act 2000, and the date on which parties agree on the underfunding methodology.
As part of our interim recommendation, we said our initial thinking is that the compensation could be paid first to Māori primary health organisations and providers still in existence. We remain of this view.
We recommend that, at the very least, the full compensation should be paid to those Māori primary health organisations and providers that suffered from this underfunding and are still in existence, or to their successor entities.
Once the full compensation amount has been calculated, the parties should negotiate as to how it should be paid out: whether as a lump sum, in reparative instalments, or a combination of both.
. . .
The broader reforms of the health system present a real opportunity.
We remain optimistic that the Crown is committed to acting on the claimants’ concerns and to remedying the undeniably appalling Māori health statistics that still confront us in 2021.
We hope that the progress made to date will give momentum to partnership processes right across the health sector, and that these reflect the Treaty partnership and the duty of good faith that should guide the conduct of the Treaty partners.
But the momentum must be maintained. The Crown’s responsibility to uphold its Treaty obligations in respect of our interim recommendations remains, even though we have made them final.
Having said this, the gravity of the issues before us means that we cannot be satisfied with a merely “satisfactory” process.
We are confident that the ways and means can be found to give effect to a truly equitable health care system, because a truly equitable health system is the only Treaty-consistent pathway forward.
Through its reforms, the Crown has promised it will finally give effect to tino rangatiratanga and, with that, the Treaty partnership. Its enduring obligation now is to live up to its promises.
As Taitimu Maipi put it on our first day of hearings, the Crown and Māori must now “breathe life into what . . . tino rangatiratanga looks like”.
This is extracted from Chapter 10 of the Hauora Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry, released last week and available in full here.
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