Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024: further Crown breaches of Te Tiriti o Waitangi.

The Waitangi Tribunal in their Wai 2575 Report recommended the establishment of Te Aka Whai Ora (the Maori Health Authority) to remedy some of the contemporary breaches of Te Tiriti o Waitangi (Te Tiriti). Te Aka Whai Ora was the culmination of decades of Maori advocacy for the establishment of independent Maori health leadership, policymaking and commissioning. Under urgency, the new National-led coalition Government passed the Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024 in February. In this paper we use Critical Tiriti Analysis (CTA), a five-stage process, to review the extent to which the Act is compliant with the five elements of Te Tiriti (the authoritative Maori text), the preamble, the three written articles and the oral article. We found that the Act had very limited Tiriti compliance and the potential to do great harm. We offered practical suggestions how this could have been avoided.

A critical Tiriti analysis of Te Pae Tata: the Interim New Zealand Health Plan.

The current health reforms in Aotearoa New Zealand are being described as "transformational". Political leaders and Crown officials maintain the reforms embed a commitment to Te Tiriti o Waitangi, address racism and promote health equity. These claims are familiar and have been used to socialise previous health sector reforms. This paper interrogates claims of engagement with Te Tiriti by undertaking a desktop critical Tiriti analysis (CTA) of Te Pae Tata: the Interim New Zealand Health Plan. CTA follows five stages from orientation, close reading, determination, strengthening practice, to the Maori final word. The determination was done individually and a consensus was negotiated from the indicators; silent, poor, fair, good, or excellent. Te Pae Tata proactively engaged with Te Tiriti across the entirety of the plan. The authors assessed Te Tiriti elements of the preamble, kawanatanga and tino rangatiratanga as "fair", oritetanga as "good" and wairuatanga as "poor". Engaging more substantively with Te Tiriti requires the Crown to recognise that Maori never ceded sovereignty and treaty principles are not equivalent to the authoritative Maori text. Recommendations of the Waitangi Tribunal WAI 2575 and Haumaru reports need to be explicitly addressed to allow monitoring of progress.

African Hut model of health: a framework for improving African migrant health in Aotearoa/New Zealand.

There is renewed international effort to improve the health and well-being of migrants. For African migrants, theoretical frameworks designed to account for and guide interventions to address the underlying mechanisms that interact to influence health and well-being remain largely underdeveloped. The aim of this study was to address this gap by providing a unique socio-ecological framework with specific entry points for targeted health promotion action aimed at improving the health and well-being of African migrants living in Aotearoa New Zealand. The African Hut model of health was developed through an inductive iterative approach informed by a review of the evidence and semi-structured interviews with key informants. The interviews were conducted in person using one-on-one format and employed to refine initial themes from the literature. A hybrid thematic analysis, involving both inductive and deductive approaches was used to analyse the interview data. The health and well-being of African migrant communities are the outcome of complex interplay of individual, economic, social and structural factors. To protect and promote the health of African communities in Aotearoa requires tailored interventions that centre culture and deliver holistically.

Global food security, self-sufficiency and the cost of bread to Aotearoa.

Nil.

District health board engagement with the living wage movement: evidence from official information requests.

From a public health perspective, there is strong evidence that income is a major modifiable determinant of health. District health boards (DHBs), who were responsible for providing and/or funding regional health services across Aotearoa, are major employers. International literature suggests implementing a living wage strategy can improve health outcomes, contribute until July 2022 to the reduction of ethnic health inequities, and is ethical and socially responsible business practice. In February 2021, official information requests were sent to all DHBs to determine engagement with the living wage movement. This was augmented through a content analysis of publicly available collective employment contracts to benchmark practice. The review found no DHBs were registered living wage employers, nor is it a requirement of those whom they sub-contract. Two out of twenty DHBs are planning to become living wage employers, and several confirmed they were working collectively to improve working conditions of lower paid workers. This paper makes a scholarly argument for DHBs to commit to becoming living wage employers. As significant regional employers this is an opportunity for DHBs to positively contribute to the alleviation of entrenched poverty a modifiable determinant of ethnic health inequities.

A Critical Tiriti Analysis of the Pae Ora (Healthy Futures) Bill.

AIM: The Pae Ora (Healthy Futures) Bill is the framework for a reformed health system intended to embed Te Tiriti o Waitangi and centre equity. The Bill is informed by the Wai 2575 Health Kaupapa Waitangi Tribunal Inquiry and the Health and Disability System Review, both of which established an urgent mandate to transform the health sector. This desktop review explores to what extent the proposed Bill is likely to uphold Te Tiriti. METHODS: This paper uses Critical Tiriti Analysis to review the Pae Ora Bill. The analysis involves five phases: (i) orientation; (ii) close reading; (iii) determination; (iv) strengthening practice and (v) Maori final word. As part of that, a determination is made whether the Bill is silent, poor, fair, good or excellent in relation to the Preamble and the four articles (three written, one verbal) of te Tiriti o Waitangi (Maori text). RESULTS: The desktop analysis showed fair engagement with most of the Te Tiriti elements; but with good commitment to address equity issues. The Bill was silent in relation to wairuatanga (spirituality) and there is no evidence of Maori values informing it. CONCLUSION: The dominant Crown narrative that interprets kawanatanga as the right to govern over all peoples pervades this legislation. There are significant power sharing shifts within this Bill and these are welcomed, but whilst the Crown maintains ultimate power and authority only a partial fulfilment of Te Tiriti will be evident within the health system.

Re-imagining anti-racist theory for the health sector.

Ethnic health inequities between Maori and other New Zealanders continue to manifest systemically across the health sector. They are unjust, unfair, and are a breach of Te Tiriti o Waitangi. Institutional racism is a key modifiable driver of these disparities. Historically, health sector responses to racism could be characterised as ad hoc or in-action. Efforts have included investment in Maori health providers, Maori representation in governance, equity initiatives, kawa whakaruruhau-cultural safety and Te Tiriti training. Most anti-racist interventions have been educational and focused on individual change-especially for operational staff and students, rather than decision-makers. These historic contributions have been insufficient to address entrenched problems of systemic and societal racism.This paper examines three anti-racism initiatives currently occurring across Aotearoa; i) the Matike Mai Constitutional Transformation report/movement, ii) the development of the National Action Plan Against Racism, and iii) Ao Mai Te Ra currently being developed within the health sector.Drawing on long-time involvement in anti-racism praxis and scholarship, the Maori and non-Maori authors of this paper are making the case to re-imagine anti-racism theory. Such re-imagining needs to centre engagement with Te Tiriti. In addition, we argue it needs to involve both tangata whenua and Tauiwi.

A purakau analysis of institutional barriers facing Maori occupational therapy students.

INTRODUCTION: Across Aotearoa (New Zealand), there are chronic shortages of qualified Maori (Indigenous peoples of Aotearoa) health practitioners and systemic ethnic health inequities. This study, focussing on the discipline of occupational therapy, explores Maori graduates' recollections of the institutional barriers that impacted on their study in this field over a 25-year period. METHODS: This qualitative study interviewed seven Maori occupational therapy graduates using purakau-an innovative Maori narrative inquiry method. Purakau (stories) were collected in 2018 via kanohi ki te kanohi (face to face) semi-structured interviews. They were analysed using the kaupapa Maori (Maori philosophical) framework of Pu-Ra-Ka-U which draws on traditional Maori matauranga (knowledge). FINDINGS: The institutional barriers identified were (1) cultural dissonance, (2) cultural (in)competency and (3) the limitations of (Western) pastoral care. CONCLUSION: This study highlighted how racism is embedded within the Western tertiary education system. To create a safe learning environment for Maori students, tertiary education institutions require a planned approach to address racism within policy, procedures, the curriculum, teaching and professional staff.

Learnings on Doing Health Research with Muslim Communities in Aotearoa New Zealand from a Study on Health and Ramadan.

The Muslim community is a vibrant part of New Zealand society. As this community grows, researchers will need to strengthen engagement and collaboration to tailor the delivery of services. Given the paucity of the literature, this conceptual paper drawing on a study on health and Ramadan presents an exemplar for doing research with Muslim communities. This paper proposes several key elements (i) the importance of relationships, (ii) engagement with imams (mosque leaders), (iii) cultural and religious safety, (iv) a gendered approach and (v) utilizing religious festivals. These findings will be of interest to policy makers, practitioners and scholars wishing to engage with this community.

Smashing the patriarchy to address gender health inequities: Past, present and future perspectives from Aotearoa (New Zealand).

The second wave feminist dream of smashing the patriarchy remains a task yet to be completed on a complex to do list. Women, particularly able-bodied cis-gendered white women however do enjoy the privilege of living longer than men. But our longer lives take place within patriarchal-capitalist systems where many women's social and cultural rights continue to be compromised. How do we ensure that all women can exercise our right to health and wellbeing? In this paper, the authors examine, critique, review and re-vision the dynamics of power and patriarchy over three distinct time periods - 1999, 2019 and 2039. We look to the past to track progress; we look to the present to see what we have achieved and look to the future for what might be. This conceptual paper is informed by the authors' expert knowledge, a review of the literature and the novel use of speculative ethnography. The authors conclude that patriarchy remains not only a negative determinant of women's health that needs to be smashed, but is also a threat to all people and to planetary health.

A critical analysis of te Tiriti o Waitangi application in primary health organisations in Aotearoa New Zealand: Findings from a nationwide survey.

Primary health is at the forefront of efforts to address health inequities. Effective primary health care keeps people well and improves longevity and quality of life. The persistence of health inequities, particularly between Indigenous peoples and non-Indigenous peoples globally, suggests that there is a need to strengthen policy and practise. Unique to Aotearoa (New Zealand) is te Tiriti o Waitangi, a treaty negotiated in 1840 between the British Crown and hapu (Maori [Indigenous] subtribes). This treaty is foundational to public policy in Aotearoa and requires the Crown (New Zealand government) to uphold a set of responsibilities around protecting and promoting Maori health. This paper examines to what extent Primary Health Organisations are upholding te Tiriti o Waitangi. The study utilises data from a nationwide telephone survey of public health providers conducted in 2019-2020 recruited from a list on the Ministry of Health website. This paper focuses on data about te Tiriti application from 21 Primary Health Organisations from a sample size of thirty. Critical te Tiriti analysis, an emerging methodology, was used to assess to what extent the participating primary health organisations were te Tiriti compliant. The critical te Tiriti analysis found poor to fair compliance with most elements of te Tiriti but good engagement with equity. Suggestions for strengthening practise included examining relationships with Maori, utilising a planned approach, structural mechanisms, normalising Maori world views and consistency in application. The onus needs to be on non-Maori to contribute to the cultural change and power-sharing required to uphold te Tiriti. Critical te Tiriti analysis is a useful methodology to review te Tiriti compliance and could be used in other contexts to review alignment with Indigenous rights and aspirations.

A Critical Tiriti Analysis of the recruitment and performance review processes of public sector chief executives in Aotearoa.

OBJECTIVE: Breaches of Te Tiriti o Waitangi (Te Tiriti) and evidence of institutional racism have been consistently documented within the public sector for decades. Chief executives across the sector have a critical responsibility to lead the implementation of the Crown's Te Tiriti o Waitangi responsibilities. This paper examines the recruitment and performance review processes of public sector chief executives from 2000 to 2020 to ascertain Te Tiriti compliance. METHODS: Recruitment and performance review templates were obtained via official information requests to Te Kawa Mataaho Public Service Commission. The data were analysed using a five-stage Critical Tiriti Analysis to determine compliance based on indicators developed around the five elements of Te Tiriti. RESULTS: Our study found no explicit evidence of engagement with te Tiriti in any aspect of the recruitment and or performance review processes in the documents released. CONCLUSIONS: This appears to be another contemporary breach of Te Tiriti that urgently needs to be addressed prior to the new round of appointments in the health sector. Implications for public health: With significant senior appointments about to be made within the health sector, this paper is a timely contribution to the wider debate about the implications of the WAI 2575 Waitangi Tribunal report on the health sector.

Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa.

Within Aotearoa (New Zealand) there are systemic health inequities between Maori (the Indigenous people of Aotearoa) and other New Zealanders. These inequities are enabled in part by the failure of the health providers, policy and practitioners to fulfil treaty obligations to Maori as outlined in our foundational document, te Tiriti o Waitangi (te Tiriti). Regulated health professionals have the potential to play a central role in upholding te Tiriti and addressing inequities. Competency documents define health professionals' scope of practice and inform curriculum in health faculties. In this novel study, we critically examine 18 regulated health practitioners' competency documents, which were sourced from the websites of their respective professional bodies. The competencies were reviewed using an adapted criterion from Critical te Tiriti Analysis, a five-phase analysis process, to determine their compliance with te Tiriti. There was considerable variation in the quality of the competency documents reviewed. Most were not te Tiriti compliant. We identified a range of alternative competencies that could strengthen te Tiriti engagement. They focussed on (i) the importance of whanaungatanga (the active making of relationships with Maori), (ii) non-Maori consciously becoming an ally with Maori in the pursuit of racial justice and (iii) actively engaging in decolonisation or power-sharing. In the context of Aotearoa, competency documents need to be te Tiriti compliant to fulfil treaty obligations and policy expectations about health equity. An adapted version of Critical te Tiriti Analysis might be useful for those interested in racial justice who want to review health competencies in other colonial settings.

Women, Patriarchy and Health Inequalities: The Urgent Need to Reorient Our Systems.

This Special Issue is entitled "Women, patriarchy, and health inequalities: an unresolved issue" [...].

The Simpson-led health sector review: a failure to uphold te Tiriti o Waitangi.

The Health and Disability System Review (the 'Simpson Review') was an opportunity for health sector transformation, particularly in light of the recent damning WAI 2575 Waitangi Tribunal report released during the review process. There appears to have been a concerted effort to engage with the sector, an impressive Maori Expert Advisory Group and an extensive body of available scholarship documenting where improvements could be made. In this viewpoint, the authors, tangata whenua (Indigenous people of the land) and tangata Tiriti (people of te Tiriti) and health scholars and leaders undertook a high-level review of the Simpson Review report and analysed it against key elements of te Tiriti o Waitangi. The Simpson Review was an opportunity to share power, commit to Maori health and embed structural mechanisms, such as the proposed Maori health authority, to uphold te Tiriti o Waitangi. It was also an opportunity to recommit to health equity and eliminate institutional racism. We conclude that the Simpson Review did not take up these opportunities, but instead perpetuated further breaches of te Tiriti.

Addressing Structural Racism Through Constitutional Transformation and Decolonization: Insights for the New Zealand Health Sector.

In colonial states and settings, constitutional arrangements are often forged within contexts that serve to maintain structural racism against Indigenous people. In 2013 the New Zealand government initiated national conversations about the constitutional arrangements in Aotearoa. Maori (Indigenous) leadership preceded this, initiating a comprehensive engagement process among Maori in 2010, which resulted in a report by Matike Mai Aotearoa which articulated a collective Maori vision of a written constitution congruent with te Tiriti o Waitangi (the founding document of the colonial state of New Zealand) by 2040.This conceptual article explores the Matike Mai Aotearoa report on constitutional transformation as a novel means to address structural racism within the health system as a key domain within the constitutional sphere. Matike Mai suggests alternative conceptual structural formations through its focus on the kawanatanga (governance), the relational and the tino rangatiratanga (sovereignty) sphere. This framework is informed by a range of Indigenous ethical values such as tikanga (protocol), belonging, and balance that can usefully inform the redesign of the health sector.We assert that constitutional transformation and decolonization are potentially powerful ethical sources of disruption to whiteness and structural racism. We argue that, to eliminate entrenched health disparities, change processes need to be informed by the Indigenous inspirations expressed in the Matike Mai report.

From gorse to ngahere: an emerging allegory for decolonising the New Zealand health system.

Prior to colonisation, Maori had a well-developed holistic health system based on maintaining balance between people, place and spirit. The colonial imposition of British economic, religious, educational, legal, health and governance, through warfare, immigration, legislation and social coercion had a devastating effect on Maori health outcomes. With the release of the WAI 2575 Waitangi Tribunal report exposing the failings of our health system in relation to Maori health, the need to decolonise our health system becomes more pressing. A key difficulty in this work is the poverty of transformative language, concepts and frameworks in our workforce. This paper is the product of an anti-racism think tank that occurred in April 2019. While working through a system change analysis on our colonial health system, Maori and Tauiwi activists and scholars created an allegory-from gorse to ngahere. The allegory depicts the ongoing impact of the colonial health system as represented by gorse, and the possibilities of a decolonised health system represented by ngahere-a self-sustaining and flourishing native forest. Racism has a geographic specificity. The allegory we developed is a mechanism for conceptualising decolonisation for the context of Aotearoa. It serves to reinforce the different roles and responsibilities of the descendants of the colonisers and the colonised in the pursuit of decolonisation.

The Waitangi Tribunal's WAI 2575 Report: Implications for Decolonizing Health Systems.

Te Tiriti o Waitangi, a treaty negotiated between Maori (the Indigenous peoples of Aotearoa) and the British Crown, affirmed Maori sovereignty and guaranteed the protection of hauora (health). The Waitangi Tribunal, established in 1975 to investigate alleged breaches of the agreement, released a major report in 2019 (registered as WAI 2575) about breaches of te Tiriti within the health sector in relation to primary care, legislation, and health policy. This article explores the implications of this report for the New Zealand health sector and the decolonial transformation of health systems. The tribunal found that the Crown has systematically contravened obligations under te Tiriti across the health sector. We complement the tribunal's findings, through critical analysis, to make five substantive recommendations: (1) the adoption of Tiriti-compliant legislation and policy; (2) recognition of extant Maori political authority (tino rangatiratanga); (3) strengthening of accountability mechanisms; (4) investment in Maori health; and (5) embedding equity and anti-racism within the health sector. These recommendations are critical for upholding te Tiriti obligations. We see these requirements as making significant contributions to decolonizing health systems and policy in Aotearoa and thereby contributing to aspirations for health equity as a transformative concept.

The whole and inclusive university: a critical review of health promoting universities from Aotearoa New Zealand.

As well as serving as a critic and conscience for societies, universities are elite sites of privilege which, at a surface level, are unlikely locations for health promotion interventions. This paper provides a critical review of the existing health promoting universities (HPU) approaches which is informed by health promotion values. It explores the silence in the global literature around issues of structural discrimination such as the sexism, homophobia and institutional racism that can thrive within university settings. The existing literature also reveals a very limited engagement about positive mental health or indigeneity. In response, this paper brings together these three factors-structural discrimination, mental health, and indigeneity-all of which the authors consider are criterial to health and its promotion. The authors introduce the New Zealand university landscape, in which there are eight Western universities and three whare wananga (Maori universities), and, drawing on a survey of their Charters and other official statements, offer a moemoea (vision or dream) of an HPU that addresses structural discrimination, is based on holistic conceptions of health, and is centred on indigenous worldviews and concerns.