Rifling through Cabinet papers for clues on Māori health policy

It seems inevitable there will be pressure throughout this, explicit or otherwise, on IMPBs to bow to government priorities

You may be surprised to learn who described: “the gains in Māori health outcomes include increased Māori representation in the workforce, reducing health cost barriers, strengthened Māori leadership and governance at all levels of the system, increased investment into the hauora Māori sector, and strengthened monitoring and accountability arrangements” as a legacy that “provides a strong foundation to accelerate change”.

It was health minister Shane Reti, to Cabinet, in June.

For someone whose ministerial focus for the first 100 days was disestablishing Te Aka Whai Ora, the Māori health authority, and whose Government Policy Statement doesn’t mention Te Tiriti o Waitangi even once, the inclusion of improved participation in health sector leadership and decision-making by Māori as a health outcome seems incongruous. However, notwithstanding my need to see receipts on the alleged reduced cost barriers, this statement does make me think that so much of what this (and any) new government wants to do is rebrand as much as it can from the previous administration to present a causal relationship between an election win and any kind of gain.

The June Cabinet paper from Dr Reti was part of a proactively released bundle of Cabinet papers, talking points, aide-mémoire notes and briefings uploaded on the Ministry of Health website in mid-August about the next steps for Māori health. Although it is tempting to go through it line by line, including to theorise about what might be in the many pages of redacted “talking points” for the minister from the ministry, I’ll instead focus on four main points from what Dr Reti has said he will focus on over the next 12 months.

Currently, there is the interim Pae Tū: Hauora Māori Strategy 2023; He Korowai Oranga: Māori Health Strategy – the long-standing strategy which is still sort of in the mix; and Whakamaua: Māori Health Action Plan 2020– 2025. It’s too much, too confusing, or, as the Cabinet paper puts it, “it has become increasingly complex and difficult to navigate”.

The solution is a new strategy that consolidates these documents. It will be presented to Cabinet by December for release in early 2025.

Consolidating these documents makes sense, and it would have happened under any government, frankly. But the Cabinet paper states this strategy will “align with the new Government Policy Statement on Health”. But that’s not what the GPS is meant to do exactly. The GPS is meant to guide the New Zealand Health Plan over the next three years, with the strategies taking a longer-term view. And this subtle inference (that the GPS might guide the Māori health strategy) is only consequential given the GPS doesn’t mention Te Tiriti o Waitangi. Earlier in August, a health official was asked about the lack of te Tiriti references in the GPS during cross-examination in the Waitangi Tribunal and they pointed to the strategies having those references. But, it seems, this may not be true in December.

The health sector targets and priorities from the GPS will be the focus of monitoring system performance. This is arguably too narrow to cover what truly matters most to whānau Māori or even Māori understandings of hauora rather than clinical health services.

However, in March this year, the ministry opened its brief to Dr Reti by saying: “You have set a clear vision for Māori health that includes lifting every health metric to the same level as non-Māori.”

In other words, the health sector is only performing if it is getting the same outcomes for Māori and non-Māori. This, in itself, is not equity, but it is a bar the health system currently does not meet. Thus, it will require everyone in the system to do better than they are now.

There are many pages of detail around iwi Māori partnership boards. A lot of this is reshuffling and restating the current role of IMPBs. But the headline is really around the IMPB commissioning role.

For background, IMPBs were not set up to be commissioners of health services under the Pae Ora (Healthy Futures) Act 2022. And in their previous iterations under DHBs, their functions varied so much it is hard to say exactly what they did – but it generally did not include commissioning in any real sense.

In a speech from March, Dr Reti said: “I want to see IMPBs with the ability to have commissioning authority. I will empower local health decisions and Māori health providers with more autonomy than they have had for some years.”

So, drumroll…the new functions for IMPBs will include “strategic commissioning”.

This is essentially the same as what IMPBs do now, but perhaps with more explicit obligations on Te Whatu Ora. IMPBs will have input into understanding the needs of their local population (the first step in most commissioning cycles) and participate in monitoring (the end of the commissioning cycle). But the decision from Dr Reti and Cabinet “stops short of operational responsibility for procurement, contract management, or budget holding”.

In order to operationalise this “new” strategic commissioning role, Te Whatu Ora will test its approach with a small number of IMPBs who meet some minimum requirements, including having plans in place and priorities that align with those of the Government.

It seems inevitable there will be pressure throughout this, explicit or otherwise, on IMPBs to bow to government priorities in order to be included in opportunities for commissioning in early 2025. However, I’m not sure IMPBs will agree to priorities that are not reflected in what they have gathered on whānau voice and local health need. So hopefully the risks here are never realised.

The last of the key points made by Dr Reti in his Cabinet paper is that the health sector will progress, and test locally led initiatives to lift preventive, whānau-centred and community healthcare within the current policy settings. This sounds good, but detail on what it means is light. I guess we can watch this space.

All in all, the Cabinet paper sets out some tentative “next steps” for Māori health. But they do not reveal a comprehensive picture of what will replace Te Aka Whai Ora, as seems to be the inference from the ministry releasing this information on its website under the heading: “Disestablishment of the Māori Health Authority – Next Steps on Māori health”. Instead, it repackages a lot of what is already in progress or already required by legislation.

Notably, the consequential next steps outlined in the paper are around developing a Māori Health Strategy and the IMPB commissioning role. There does not appear to be much opportunity for widespread consultation on either of these – the paper talks about targeted engagement on the strategy being with other health entities, the Hauora Māori Advisory Committee and IMPBs – as if whānau and communities wouldn’t have anything to add.

How the ministry overcomes this serious shortcoming over the next few months will be important to keep our eyes on.

Gabrielle Baker (Ngāpuhi, Ngāti Kuri) is an independent health policy consultant