Mäori Public Health Action Plan

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1 Mäori Public Health Action Plan Public Health Directorate Ministry of Health

2 Printed in December 2003 by the Ministry of Health PO Box 5013, Wellington, New Zealand This document is available from Maori Public Health Public Health Directorate HP 3739 Private Bag , Wellesley Street, Auckland Design: Marion Bawdon/Paradigm Associates

3 Table of contents Commitment to the Treaty of Waitangi 4 Introduction 5 Purpose of this document 5 Mäori Public Health Action 5 Background 6 How was this plan developed? 6 How this Action Plan links to Achieving Health For All People 6 How this Action Plan links to He Korowai Oranga 7 Inequalities framework 7 Mäori Public Health Actions 8 Action Area One: Contribute to the Framework For Public Health Action 8 Action Area Two: Implement He Korowai Oranga 9 Action Area Three: Strengthen Mäori Public Health Infrastructure 10 Action Area Four: Develop and Implement Mäori Public Health Priorities 11 Action Area Five: Measure Progress on Outcomes for Mäori Public Health 11 Appendix One: Achieving Health For All People: A Summary 12 Appendix Two: He Korowai Oranga: A Summary 14 Appendix Three: Mäori Health and Disability Priorities 16 Appendix Four: Summary of Three Mäori Models of Health 17 Appendix Five: Summary of Inequalities Framework 21 References 23

4 4 Mäori Public Health Action Commitment to the Treaty of Waitangi The Crown recognises the Treaty of Waitangi as the founding document of New Zealand, and is committed to fulfilling its obligations as a Treaty partner. The special relationship between the Crown and Mäori is ongoing and is based on the underlying premise that Mäori are Tangata Whenua. Tangata Whenua have a long history of maintaining the health of populations through concepts and practices such as tapu, noa, and rähui that protect water supplies, food sources and safety of whänau. To date, the relationship between Mäori and the Crown in the health and disability sector has been based on three key principles: Partnership Working together with iwi, hapü, whänau and Mäori communities to develop strategies for Mäori health gain and appropriate health and disability services. Participation Involving Mäori at all levels of the sector, in decision-making, planning, development and delivery of health and disability services. Protection Working to ensure Mäori have at least the same level of health as non-mäori and safeguarding Mäori cultural concepts, values and practices. Central to the Treaty relationship and implementation of the Treaty of Waitangi principles is a common understanding that Mäori will have an important role in implementing health strategies for Mäori and that the Crown and Mäori will relate to each other in good faith with mutual respect, co-operation and trust. Not only is it important to improve Mäori health status, but other goals based on concepts of equity, partnership and economic and cultural security must also be achieved.

5 Mäori Public Health Action Introduction Purpose of this document Improving Mäori health through public health action requires commitment and action from the public health sector and agencies that influence health status. The Mäori Public Health Action Plan for 2003/2004 has been developed to guide the work of the Public Health Directorate of the Ministry of Health for the next twelve to fifteen months. Mäori Public Health Action Public health action has been defined as action which improves the health of whole populations. During consultation to develop Whakatutuki Te Oranga Hauora Mö Ngä Tangata Katoa (Achieving Health For All People) the concept of Mäori public health was discussed. The Ministry of Health was advised by the hui attendees that Mäori define public health action for themselves at a hapü level 1. However each hui during the consultation phase offered various concepts, with the common theme being that, Mäori public health is founded in hauora, and, for Mäori, hauora is a reflection of the well-being of whänau, hapü and iwi. There are contemporary models of Mäori health which incorporate that theme and they include the models of Te Pae Mahutonga, Te Whare Tapa Whä, and Te Wheke. A summary of these models can be found in Appendix Four. 1 Refer to Development of Mäori Public Health Action Consultation Report (September 2002) Ministry of Health for definitions offered at each hui.

6 6 Mäori Public Health Action Background Developing the Mäori public health action plan has resulted in a two-phase approach. The first phase is this plan, which represents the actions that will be undertaken by the Public Health Directorate of the Ministry of Health to lead the development of Mäori public health over the next twelve- to fifteen-month period. The second phase is the completion of a Mäori Public Health Implementation Plan which will provide guidance on how to implement the Mäori public health actions set out in Achieving Health For All People, the strategic framework for public health. The Implementation Plan will be designed for use by whänau, hapü, iwi Mäori, the health sector 2 and those agencies that influence Mäori population health status. The Implementation Plan will be developed once the strategic framework for public health Achieving Health For All People is finalised in late How was this plan developed? This plan was developed by members of Te Totara (the Mäori staff network) within the Public Health Directorate in consultation with Te Kete Hauora (TKH), the Mäori Health Directorate. How this Action Plan links to Achieving Health For All People This plan provides an initial guide to implementing the strategic directions for Mäori public health action until Achieving Health For All People is finalised. Achieving Health For All People identifies objectives and action areas for improving Mäori public health. They are largely focused on processes or approaches to improving Mäori involvement and participation in the public health sector. A summary of this strategic document can be found in Appendix One of this plan. 2 The health sector in this instance includes consumers, communities, health providers, policy makers, District Health Boards, Primary Healthcare Organisations (PHO), planners, funders, evaluators, and researchers.

7 Mäori Public Health Action How this Action Plan links to He Korowai Oranga The Mäori Public Health Action Plan will support the objectives of He Korowai Oranga. While this is a public health plan of action to improve and protect Mäori health, there will be many instances where this plan will work alongside Whakatätaka 3, the Mäori Health Action Plan to achieve the same broad objectives. A summary of He Korowai Oranga can be found in Appendix Two of this plan. Inequalities framework Reducing inequalities requires a systematic and sustained effort by the health sector. The Ministry of Health has developed a framework that provides policy analysts, service planners, funders, and service providers with the tools to assist them to achieve the Government s aim of reducing inequalities. A fuller discussion of the framework can be found in Appendix Five. Development of this plan has been done within the context of the inequalities framework, with a focus on improving Mäori population health. 3 Whakatätaka was developed alongside He Korowai Oranga to implement the strategic directions set out in He Korowai Oranga.

8 8 Mäori Public Health Action Mäori Public Health Actions Action Areas Five action areas have been developed to assist the work of the Public Health Directorate to make progress on improving population health for Mäori. It is acknowledged that shared decision-making with District Health Boards (DHB) is a key element in the work of the Public Health Directorate. Each action area identifies the action, who is responsible to lead the action area and the milestones/outcomes for each of the actions. Action Area One: Contribute to the Framework For Public Health Action; Achieving Health For All People Action area Further develop objectives to guide Mäori public health action in Achieving Health For All People Lead Role Public Health Directorate with input from the Mäori Public Health team Milestone/Outcome Mäori public health priorities and actions are clearly identified in Achieving Health For All People by December 2003 Develop Mäori public health implementation plan with steps to carry out the key objectives and actions for Mäori public health in Achieving Health For All People ensuring that the following Mäori public health priorities are addressed: Reducing tobacco consumption in Mäori Reducing Mäori suicides Addressing physical activity, better nutrition and reducing obesity for Mäori Improving the rates of Mäori access to immunisation Reducing interpersonal violence Public Health Directorate Implementation plan consulted on with key stakeholders and completed by July 2004

9 Mäori Public Health Action Action Area Two: Implement He Korowai Oranga Action area Foster whänau/hapü led responses to achieving better health gain for Mäori Lead Role Public Health Directorate Milestone/Outcome Increased participation of whänau/hapü and Mäori communities in the health sector Develop a partnership model between the Ministry of Health and whänau Public Health Directorate Whänau/hapü and Mäori ownership of their development Implement He Korowai Oranga through services targeted at whänau/hapü development Public Health Directorate Whänau/hapü and Mäori aspirations for Mäori control of services, by and for Mäori are realised Improved access for Mäori to public health services Monitor Public Health Directorate s contributions to the pathways in He Korowai Oranga Public Health Directorate Links to He Korowai Oranga illustrated in Achieving Health For All People and the implementation plan by June 2004 Planning and activities across the directorate will be consistent with the pathways of He Korowai Oranga by June 2004

10 10 Mäori Public Health Action Mäori Public Health Actions Action Area Three: Strengthen Mäori public health infrastructure Action area Promote and implement Mäori leadership programmes Lead Role Public Health Directorate Milestone/Outcome Mäori community leaders identified and supported to contribute to improving the health status of Mäori Establish and maintain relationships with Te Kete Hauora, DHBs and PHOs and work collaboratively to strengthen Mäori providers Public Health Directorate Mäori public health providers are providing an effective service Strengthen the relationships between Mäori providers who have an interest in health gains for Mäori and a commitment to Mäori development on a wider scale Scope and develop Mäori public health infrastructure initiatives as part of the public health workforce development plan: Scope Mäori public health workforce sector to identify areas to be resourced and developed Develop strategies to address Mäori workforce development issues Public Health Directorate Public Health Directorate workforce development workstream with input from Mäori public health team Whänau/hapü and Mäori communities are working together to achieve better health for Mäori Mäori workforce needs are identified and a strategy to address those needs completed by June 2004 Mäori public health infrastructure initiatives identified in public health workforce development plan by June 2004 Areas scoped by December 2003 Strategies developed by June 2004

11 Mäori Public Health Action Action Area Four: Develop and implement Mäori public health priorities 4 Action area Identify and agree Mäori public health priorities for the next three to five years. Lead Role Strategic Management team with input from the Mäori public health team and Te Tötara Milestone/Outcome Public Health Directorate annual business plans, work programmes and funding allocations clearly address Mäori public health priorities by June 2004 Plan, fund and implement public health action to address Mäori public health priorities Operational Management Team Action Area Five: Measure progress on outcomes for Mäori public health Action area Develop indicators to measure progress on improving Mäori public health Lead Role Public Health Intelligence and Public Health Policy with input from the Mäori public health team. Milestone/Outcome Indicators against which progress on improving Mäori public health will be measured developed by June 2004 Monitor progress on improving Mäori public health against indicators Public Health Intelligence Progress reports completed and submitted to DDG on an annual basis 4 Refer to Appendix Three for a copy of the current Maori health priorities identified in He Korowai Oranga

12 12 Mäori Public Health Action Appendix One: Achieving Health For All People: A Summary 5 Our vision for public health is Achieving Health For All People, Whakatutuki Te Oranga Hauora Mö Ngä Tangata Katoa. Our mission is To reduce health inequalities and improve overall health status through population and public health activities, and the organised efforts of the whole of society. There are three over-arching goals Improve the overall health status of the population Improve the health status of Mäori Reduce inequalities in health Objectives and areas for action To achieve the goals, five objectives have been identified. Each objective is supported by areas for action. Objective 1: Build strong public health leadership at all levels and across all sectors. Areas for action Strengthen leadership for public health action across government agencies, District Health Boards, public health and other providers, local government and other sectors, and communities. Strengthen whänau, hapü, iwi and Mäori so that Mäori can provide leadership for Mäori public health action. 5 Source Achieving Health For All People, Whakatutuki Te Oranga Hauora Mö Ngä Tangata Katoa Ministry of Health (November 2002)

13 Mäori Public Health Action Objective 2: Encourage effective public health action across the whole of the health sector. Areas for action Establish and maintain clear roles and responsibilities in public health action. Strengthen and maintain effective public health practices. Promote the use of a population health approach within the primary, secondary and tertiary care sectors. Strengthen and maintain effective Mäori public health infrastructure. Strengthen the use of Mäori models of health in the development of Mäori public health policy and practice. Strengthen and maintain effective Pacific public health action. Objective 3: Promote healthy communities and healthy environments. Areas for action Promote increased use of community development and action. Promote intersectoral collaboration and action at all levels. Contribute to development of social and physical environments which improve, promote and protect public health, whänau, hapü, iwi, and Mäori public health. Promote the development of whänau, iwi and Mäori capability to enable active engagement in community development and promotion of healthy environments. Promote the development and use of Mäori models of community development. Objective 4: Make better use of research and evaluation in developing public health policy and practice. Areas for action Strengthen the degree to which policy and practice are evidence-based while encouraging innovation where evidence is not strong. Strengthen the utilisation of evaluation and develop public health practitioners skills in evaluation. Strengthen the utilisation of kaupapa Mäori research in the development of Mäori public health policy and practice. Strengthen the capabilities of the Mäori public health workforce in evaluation and research skills. Objective 5: Achieve measurable progress on public health outcomes. Areas for action Measure progress on public health outcomes against key health indicators. Develop indicators to measure progress on improving Mäori health.

14 14 Mäori Public Health Action Appendix Two: He Korowai Oranga: A Summary 6 The overall aim of He Korowai Oranga is whänau ora: healthy Mäori families supported to achieve their maximum health and well-being, and able to participate to the fullest possible extent in every aspect of New Zealand society including te ao Mäori. He Korowai Oranga recognises that both Mäori and the Government have aspirations for Mäori health and critical roles in achieving the desired whänau outcomes, and that realising those aspirations requires putting into action the Treaty of Waitangi principles of partnership, protection and participation. Three key threads woven throughout the strategy are: Acknowledging Mäori aspirations for rangatiratanga or control over their own lives Maintaining and building on the gains already made in Mäori health Reducing the inequalities which currently exist between the health and well-being of Mäori and other population groups. Whänau ora will be achieved through actions along four pathways: Development of whänau, hapü, iwi and Mäori communities Mäori participation throughout the health and disability sector Effective health and disability services Working across sectors. 6 Source: Whakatataka: Maori Health Action Plan , Ministry of Health (November 2002)

15 Mäori Public Health Action He Korowai Oranga Overall aim Whänau Ora Broad directions Mäori aspirations and contributions Crown aspirations and contributions Key threads Rangatiratanga Building on the gains Reducing inequalities Pathways Whänau Hapü Iwi development Mäori participation Effective service delivery Working across sectors Outcome and Performance Measures Resource Allocation Monitoring, Research and Evaluation Treaty Principles: Partnership, Participation and Protection

16 16 Mäori Public Health Action Appendix Three: Mäori Health and Disability Priorities 7 There are a number of Mäori health priorities which DHBs and the Ministry of Health will progress. These include: The eight Mäori health-gain priority areas which have been incorporated in purchasing for Mäori health gain for the past two to three years The 13 population health objectives from the New Zealand Health Strategy which were chosen from areas where there is a significant burden of disease for New Zealanders and real potential to reduce Mäori health disparities, among other things Disability support from the New Zealand Disability Strategy The Government Mäori health priorities (as identified in He Pütahitanga Hou). Mäori Health and Disability Priorities Reduce Violence Wellchild Immunisation Cardiovascular Injury Reduce Cancer Prevention Hearing Reduce Smoking Asthma Smoking Reduce Diabetes Diabetes Improve Mental Health Mental Health Whänau Ora Improve Oral Health Oral Health Population Health Approaches DSS Improve Nutrition Rangatahi Health Sexual & Reproductive Health Reduce Obesity Alcohol & Drug Use Population Health Objectives Mäori Health Objectives Physical Activity Reduce Alcohol & Drug Use Reduce Suicide Needs Assessment and Community/Treaty Partner Consultation He Korowai Oranga 7 Source: Appendix Three, He Korowai Oranga (November 2002)

17 Mäori Public Health Action Appendix Four: Summary of Three Mäori Models of Health Te Pae Mahutonga Te Pae Mahutonga (Southern Cross star constellation) brings together elements of modern health promotion. The model is presented in the shape of the Southern Cross. The four central stars represent four key tasks of health promotion; Mauriora: Waiora, Toiora and Te Oranga. The two pointers represent Ngä Manukura and Te Mana Whakahaere (Durie,1999). The table below illustrates the model used in mental health promotion. A summary of the elements of Te Pae Mahutonga in relation to mental health promotion 8 Determinants Promotion Activity Determinants Promotion Activity Te Oranga Affordable housing Waiora Clean environment (Participation in society) Favourable work conditions (Physical environment) Sustainable natural resources Quality education Toiora (Healthy lifestyles) Foster healthy child development Encourage development of mental health protective factors Mauriora (Cultural identity) The Crown s obligation to the Treaty of Waitangi met All groups supported to participate in society Cultural diversity is valued Ngä Manukura Explore macro Te Mana Whakahaere Support for (Community policy responses to (Autonomy) providers and their leadership) reduce health inequalities development to deliver health Promote public and solutions for Mäori primary approaches to mental health promotion Develop self-sufficiency Develop supportive communities 8 Source: Building on Strengths, Ministry of Health (December 2002)

18 18 Mäori Public Health Action Te Whare Tapa Whä For Mäori, the concepts of health and well-being go beyond physical well-being. Good health is recognised as being dependent on a balance of factors. Mason Durie s Whare Tapa Whä model of health (1994) describes four components which represent the four walls of a house and the idea that if one of these walls fails, the house will fall. Reflecting a Mäori perspective of health, whare tapa whä includes consideration of: Te taha wairua Te taha tinana spiritual health, including the practice of tikanga Mäori in general. the physical aspects of health. Te taha hinengaro the emotional and psychological well-being of the whänau and of each individual within it. Te taha whänau the social environment in which individuals live the whänau of family, the communities in which whänau live and act. Te Whare Tapa Whä model 9 Dimensions Taha Wairua Taha Hinengaro Taha Tinana Taha Whänau Focus Spiritual Mental Physical Extended Family Key aspects The capacity The capacity to The capacity for The capacity to for faith and wider communicate, to physical growth belong, to care communion think and to feel and development and to share Themes Health is related Mind and body Good physical Individuals are to unseen and are inseparable health is required a part of wider unspoken energies for optimal social systems development 9 Refer to Mason Durie s discussion of this model in M. Durie (1994), Whaiora Mäori: Health development, Oxford University Press

19 Mäori Public Health Action In public health, there are two other perspectives which are seen as particularly important: Te ao turoa the environment: the relationship between Mäori and te ao turoa is one of tiakitanga (stewardship). It is the continuous flow of life source. Without the natural environment, the people cease to exist as Mäori. Te reo rangatira expresses the values and beliefs of people and is a focus of identity. The root of all cultures is the language, and te reo is a vital expression of rangatiratanga (Health For All People, He Oranga Mö Te Katoa, Ministry of Health, March 2002). Te Wheke Rose Pere 10 provides us with the concept of Te Wheke, the octopus, to define family health. Pere describes the head of the octopus as te whänau, the eyes of the octopus as waiora (total well-being for the individual and family) and each of the eight tentacles as representing a specific dimension of health. The dimensions of health are as follows: wairuatanga (spirituality), taha tinana (physical wellbeing), hinengaro (the mind), the whänaungatanga (the extended family), mana ake (the uniqueness of each individual and family), mauri (life force), ha a koro ma a kui ma (the breath of life from our forbears) and whatumanawa (the open and healthy expression of emotion). The tentacles are interwoven and this represents the close relationship of each of these dimensions. 10 Refer to Rose Pere s discussion of this model in R.R.Pere, (1984) Te Oranga o Te Whänau: the Health of the family in hui Whakaoranga Mäori Health planning workshop, Hoani Waititi Marae March 1984.

20 20 Mäori Public Health Action Pictorial development of Te Whare Tapa Whä E tohua ana e te wharenui te whariki mö te hauora Mäori The wharenui provides the foundations for Mäori health Mana Kotahitanga Tangata Whenua Tangata Whenua Manaakitanga Whakamana Kaupapa Mäori Wairuatanga Rangatiratanga Whanaungatanga Taurahere Position on the wharenui Ätea Whänau/hapü Family, extended family unit Amo Tangata whenua Local people, tribal members Taurahere Those who whakpapa to other areas Maihi Manaakitanga Value, respect, accept, support, guide motivate, deliver and host Whakamana Rangatiratanga Whanaungatanga Enable, empower, build confidence and understanding Lead with confidence and integrity Partnering, networking,info sharing, service co-ordination and shared kaupapa Pouporuru Kaupapa Mäori Tikanga, Mäori values, Mäori for Mäori Wairuatanga Cosmic principles and spirituality Tekoteko Mana Transparency, integrity and professionalism Tähuhu Kotahitanga Working together, holistic in nature, shared kaupapa, unified approaches Wisdom and knowledge of the tupuna lies in this part of the marae

21 Mäori Public Health Action Appendix Five: Summary of Inequalities Framework 11 In New Zealand as elsewhere, inequalities in health exist among socio-economic groups, ethnic groups, people living in different geographic areas, and males and females. These inequalities are not random: in all countries more socially disadvantaged groups have poorer health, greater exposure to health risks and poorer access to health services. In countries with a colonial past, such as New Zealand, indigenous peoples have poorer health, even when socio-economic position is taken into account. Mäori not only have poorer health due to a low overall socioeconomic status, but also through institutionalised racism, in access to resources and means to improve wider social outcomes. Inequalities in the distribution of, and access to, the social determinants income, education, employment and housing are the primary cause of health inequalities. Differential access to health care services and differences in treatment for those receiving services also have a considerable impact on health status and mortality. Woven in with social and economic determinants of health is the impact of ethnic identity. Mäori at all educational, occupational and income levels have poorer health status than non-mäori. These ethnic inequalities suggest that there are other, pervasive characteristics of New Zealand society that cause poor health in Mäori; these characteristics are thought to include institutionalised racism. Addressing these socio-economic, ethnic, gender and geographical inequalities requires a population health approach that takes account of all the influences on health and how they can be tackled to improve health. This approach requires both intersectoral action that addresses the unequal distribution of the social and economic determinants of health, and action within health and disability services themselves to address differential access and treatment. 11 Source: Teresa Wall, Manager Maori Health Policy, Te Kete Hauora.

22 22 Mäori Public Health Action The Ministry publication Reducing Inequalities in Health proposes principles that should be applied to whatever activities are undertaken in the health sector to ensure that those activities help to reduce health inequalities. The proposed framework for intervention entails developing and implementing comprehensive strategies at four levels. Structural tackling the root causes of health inequalities, that is, the unequal distribution of the social, economic, cultural and historical factors that fundamentally determine health Intermediary pathways targeting material, psychosocial and behavioural factors that mediate the impact of structural factors on health Health and disability services undertaking specific actions within health and disability services Impact minimizing the impact of disability and illness on socio-economic position. Policy-makers, funders and providers should undertake intervention at these four levels nationally, regionally and locally. Actions to address Mäori health inequalities must also recognise the Treaty of Waitangi obligations of the Crown. Mäori public health action needs to focus on ensuring that action to address health inequalities will reduce health inequalities for Mäori, and that the concerns and cultural aspects important for Mäori are appropriately incorporated.

23 Mäori Public Health Action References M. Durie Whaiora: Mäori Health Development. Auckland. Oxford University Press M. Durie Te Pae Mahutonga: A model for Mäori health promotion. Unpublished paper. Palmerston North. School of Mäori Studies, Massey University. R. R. Pere Te Oranga o Te Whänau: the Health of the family, in hui Whakaoranga Mäori Health planning workshop proceedings, Hoani Waititi Marae March 1984 Ministry of Health. December Building on Strengths. Wellington. Ministry of Health Ministry of Health. March Health For all People: Te Pai Me Te Oranga O Ngä Iwi. Wellington. Ministry of Health Ministry of Health. November Achieving Health For all People: Whakatutuki Te Oranga Hauora Mö Ngä Tangata Katoa. Wellington. Ministry of Health Ministry of Health. November He Korowai Oranga: Mäori Health Strategy. Wellington. Ministry of Health Ministry of Health. November Whakatataka: Mäori Public Health Action Plan Wellington. Ministry of Health

24 24 Mäori Public Health Action Notes

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