GUEST BLOG: Ian Powell – Pae Ora Act amendments and Māori healthcare

It is difficult to characterise the bill in the name of Minister of Health Simeon Brown which is going through the parliamentary process. It seeks to several varying amendments to the Pae Ora (Healthy Futures) Act.

The Act came into force on 1 July 2022 under the former Labour government. Currently in its select committee phase, the amending bill is required to be reported back to Parliament by 24 November.

Government seeks to detrimentally amend Pae Ora Act

These amendments include:

• legislating for arbitrary ‘health targets’ (which only cover part of what the health system actually does and focus on both what can be counted and what is politically convenient to count); and
• negatively removing the requirement to have a charter based on valuing and constructively engaging with the health workforce.

In part, these amendments are petty and immature. In part, they reflect a reductionist approach to a health system that of necessity is characterised by complexity. In greater part, they are based on simplistic and misplaced ideology.

The narrow mindset that sits behind the amendments also involves a negative attitude towards addressing Māori healthcare needs.

Simplistically this is implicit in seeking to change the name of the Act from ‘Pae Ora (Healthy Futures)’ to ‘Healthy Futures (Pae Ora)’.

Reversing the order seems more consistent with a spiteful negative narrative towards Māori healthcare than any other logic. Pettiness is the kindest descriptor.

Māori Health Authority precursor

The coalition government’s negative attitude towards a focus on Māori healthcare came to the fore during the 2023 general election campaign.

This accelerated once in government with its decision to use parliamentary urgency to disestablish the Māori Health Authority (Te Aka Whai Ora) which had been a major feature of the 2022 Act.

When the former Labour government moved to establish the Authority I welcomed it in an article published in BusinessDesk (12 June 2022): A good call but not a magic bullet.

Back then I observed that:

When the Pae Ora (Healthy Futures) Act takes force on July 1, the Māori Health Authority will have the power to:

• Co-commission and plan Māori healthcare services with the new Health New Zealand structure which replaces the district health boards
• Commission kaupapa Māori services.
• Monitor the performance of the system for Māori.

This makes the authority a potentially influential organisation to help turn around the largely accepted health inequities Māori face. Recognising kaupapa alone is significant, given that it comprises principles and ideas which act as a base or foundation for action. This could be powerful for ensuring that Māori access to quality community healthcare is improved, which also improves access to hospital diagnosis and treatment. 

However, I also warned against the hyping up of expectations over what it might achieve simply by establishing the new structure. This hype ignored powerful external constraints on the new organisation which were beyond its control.

Primarily these were the impact of social determinants of health as the biggest driver of health demand and inequities and the wider ‘command and control’ leadership culture of the health system brought about vertical centralisation (replacing district health boards with Health New Zealand – Te Whatu Ora).

Shane Reti supported abolishing the Māori Health Authority but not its functions

Then Health Minister Shane Reti argued forcefully in Parliament for the disestablishment of the Māori Health Authority because he wanted to put function before structure.

In other words, while the structure of the Authority was being abolished, its functions were not.

Instead, Reti advocated, they would be transferred to both Health New Zealand and empowered Iwi Māori Partnership Boards (IMPBs) which were being established under the Pae Ora Act.

There was logic behind Reti’s position. Excluding political leadership and business consultants, putting function before structure is well-established health system wisdom.

However, in this case there were two key factors which undermined Reti’s argument. First, the Authority never had a chance to prove itself barely lasting two years. It deserved to have that chance.

Second, contrary to his more respectful position, the dominant narrative for abolishing the Authority was not only false; it was negatively destructive.

Christopher Luxon at the forefront of negative separatism narrative

Essentially, with Prime Minister Christopher Luxon at the forefront, this narrative claimed that the Authority signified separatism in the health system.

Complete nonsense but why should the truth be allowed to get in the way of negative ideology!

From changing structure to changing functions

The amendments proposed by Dr Reti’s successor, however, are about undermining the functions that had been transferred from the disestablished Authority.

Whereas Reti focussed on changing the structure but retaining the function, Brown has gone in the opposite direction in respect of function.

NZ Doctor’s Alan Perrott drills down into undermining of Māori healthcare functions

This is discussed by NZ Doctor journalist Alan Perrott in a recent paywalled article (15 September): Reducing IMPBs functions.

Perrott draws on the insights of Rakihia Tau, Chair of the Te Tauraki IMPB covering much of the South Island (plus the Chatham Islands).

Tau describes the amendments as silencing a “powerful voice” for the very communities experiencing the greatest health inequities. He calls the means of achieving this objective “disruptive reform”.

Perrott also covers the national response to the amendments by the 15 IMPBs in a collective submission. They dismiss the proposed changes because they “…are not simply technical or administrative; they will directly harm Māori communities.”

As reported by Perrott they say that:

The repeal of sections requiring engagement, cultural responsiveness, and ongoing monitoring of Māori health outcomes, according to the submission, will result in more Māori disengaging from health services, inequities going unreported, and a return to one-size-fits-all policies that fail to meet the needs of Māori.

The effective change in function is seeking to reduce IMPBs from being “genuine partners in health system design to mere advisory voices…”

Māori healthcare deserves much more than soundbites

Te Puna Ora o Mataatua is a charitable trust based in Whakatane which works to support whānau to achieve better long-term health and wellbeing.

It delivers a range of homebase, community, medical and social services across the Eastern Bay of Plenty region.

As reported in the above-mentioned NZ Doctor article, its chief executive Dr Chris Tooley is forthright:

There is nothing at all for Māori here. Even when you think about their core role of producing community plans, there is no funding for research, nothing for modelling, nothing for co-design and nothing for engagement.

Simeon Brown needs to respect IMPB function

Simeon Brown needs to listen to and act on this concern. His argument for reducing the function of the Iwi Māori Partnership Boards amounts to little more than simplistic soundbites.

Māori healthcare deserves much better than this. So does the whole Aotearoa New Zealand health system.

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion