Pae Ora (Disestablishment of Māori 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 Māori 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 Māori advocacy for the establishment of independent Māori health leadership, policymaking and commissioning. Under urgency, the new National-led coalition Government passed the Pae Ora (Disestablishment of Māori 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 Māori 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 Māori 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, kāwanatanga and tino rangatiratanga as "fair", ōritetanga as "good" and wairuatanga as "poor". Engaging more substantively with Te Tiriti requires the Crown to recognise that Māori never ceded sovereignty and treaty principles are not equivalent to the authoritative Māori 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.

Using vignettes about racism from health practice in Aotearoa to generate anti-racism interventions

Racism is a key modifiable determinant of health that contributes to health inequities in Aotearoa and elsewhere. Experiences of racism occur within the health sector for workers, patients and their whānau (extended family) every day. This paper uses stories of racism from nurses - reworked into vignettes - to examine the dynamics of racism to generate possible micro, meso and macro anti-racism interventions. A critical qualitative design was utilised, informed by kaupapa Māori approaches. The five vignettes in this paper were sourced from a pair of caucused focus groups with nine senior Māori (Indigenous peoples of Aotearoa) and Tauiwi (non-Māori) nurses held in Auckland Aotearoa in 2019. The vignettes were lightly edited and then critically analysed by both authors to identify sites of racism and generate ideas for anti-racism interventions. The vignettes illustrate five key themes in relation to racism. These include (i) mono-cultural practice, (ii) everyday micro-aggressions; (iii) complexity and the costs of racism, (iv) Pākehā (white settler) privilege and (v) employment discrimination. From analysing these themes, a range of evidence-based micro, meso and macro-level anti-racism interventions were derived. These ranged from engaging in reflective practice, education initiatives, monitoring, through to collective advocacy. Vignettes are a novel way to reveal sites of racism to create teachable moments and spark reflective practice and more active engagement in anti-racism interventions. When systematically analysed vignettes can be utilised to inform and refine anti-racist interventions. Being able to identify racism is essential to being able to effectively counter racism.

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.

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

Nil.

Diabetes podiatry services for Māori in Aotearoa: a step in the right direction?

Māori with diabetes are at a 65% greater risk of amputation compared to non-Māori with diabetes. Despite evidence to support the role of podiatrists in reducing diabetes-related lower limb amputations; the effectiveness of diabetes podiatry services at the community and secondary level to achieve this for Māori is largely unknown. Diabetes podiatry services need to be reorientated and be culturally applicable to Indigenous communities. Transforming diabetes podiatry services and practice may reduce Indigenous amputation rates and improve quality of life for an unserved community.

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.

Re-imagining anti-racist theory for the health sector

Ethnic health inequities between Māori 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 Māori health providers, Māori 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 Rā currently being developed within the health sector.Drawing on long-time involvement in anti-racism praxis and scholarship, the Māori and non-Māori 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 pūrākau analysis of institutional barriers facing Māori occupational therapy students

Introduction

Across Aotearoa (New Zealand), there are chronic shortages of qualified Māori (Indigenous peoples of Aotearoa) health practitioners and systemic ethnic health inequities. This study, focussing on the discipline of occupational therapy, explores Māori 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 Māori occupational therapy graduates using pūrākau—an innovative Māori narrative inquiry method. Pūrākau (stories) were collected in 2018 via kanohi ki te kanohi (face to face) semi‐structured interviews. They were analysed using the kaupapa Māori (Māori philosophical) framework of Pū‐Rā‐Ka‐Ū which draws on traditional Māori mātauranga (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 Māori students, tertiary education institutions require a planned approach to address racism within policy, procedures, the curriculum, teaching and professional staff.

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) Māori 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 (Māori 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 Māori values informing it.

CONCLUSION

The dominant Crown narrative that interprets kāwanatanga 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.

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 hapū (Māori [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 Māori 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 Māori, utilising a planned approach, structural mechanisms, normalising Māori world views and consistency in application. The onus needs to be on non-Māori 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.

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.

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

Within Aotearoa (New Zealand) there are systemic health inequities between Māori (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 Māori 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 Māori), (ii) non-Māori consciously becoming an ally with Māori 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.

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 Māori 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 Māori health and embed structural mechanisms, such as the proposed Māori 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. Māori (Indigenous) leadership preceded this, initiating a comprehensive engagement process among Māori in 2010, which resulted in a report by Matike Mai Aotearoa which articulated a collective Māori 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 kāwanatanga (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, Māori 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 Māori health outcomes. With the release of the WAI 2575 Waitangi Tribunal report exposing the failings of our health system in relation to Māori 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, Māori 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.

Introducing Critical Tiriti Policy Analysis: A new tool for anti-racism from Aotearoa New Zealand

Issue/problem

Te Tiriti o Waitangi (te Tiriti) was negotiated between the British Crown and Indigenous Māori in 1840. Māori understood the agreement as an affirmation of political authority and a guarantee of British protection. The Crown understood it as a cession of sovereignty. Te Tiriti places a mandatory obligation on the Crown to protect and promote Māori health that has not been upheld.

Description of the problem

Ethnic inequities in health outcomes have been allowed to flourish in Aotearoa. We explored to what extend te Tiriti could be a anti-racism tool that health policy could be usefully evaluated against?

Results

We introduce Critical Tiriti Analysis (CTA) a new form of critical policy analysis. CTA involves reviewing policy documents against the Preamble and the Articles of the Māori text of te Tiriti o Waitangi. The review process has five defined phases: i) orientation; ii) close reading; iii) determination; iv) strengthening practice; and v) Māori final word. We present a working example of CTA using the New Zealand Government’s Primary Health Care Strategy. This policy analysis found poor alignment with te Tiriti overall and the indicators of its implementation that we propose.

Lessons

This paper provides direction to public health practitioners wanting to improve Māori health outcomes and ensure Indigenous engagement, leadership and substantive authority in the policy process. It offers an approach to analysing policy that is simple to use and, inherently, a tool for advancing social justice.

Key messages

CTA is an anti-racism tool for holding the Crown accountable for Māori health. CTA could be adapted and applied in other colonial contexts to advance Indigenous health.

Re-imagining anti-racism in the health sector in Aotearoa New Zealand

Background

Racism and dishonouring of te Tiriti o Waitangi are significant contributors to ethnic health inequities in Aotearoa. It is unclear how health professionals can contribute to the disruption of racism.

Methods

This multi-disciplinary study draws on systems change tools, evidence from the health kaupapa Waitangi Tribunal claim (WAI 2575), a review of professional competencies documents, and focus groups with Māori and non-Māori health practitioners to identify how to strengthen anti-racism praxis in health services. The preliminary data collected in 2019 has undergone a thematic analysis and is being synthesised collaboratively with stakeholders to generate a complex continuum of anti-racism praxis. This will be applied via two site-specific action research projects.

Results

The pilot study has been completed but data collection is still underway on the main study. The initial cut of a continuum of practice grouped behaviours into i) problematic, ii) variable to iii) proactive. Problematic behaviors included examples of cultural and institutional racism, Variable behavior included engagement with Te Reo me ona tikanga (Māori language and protocols), and professional development and compliance. The proactive grouping included Māori leadership and workforce, responding to Māori realities, reflective practice and critical consciousness.

Conclusions

Initial findings suggest anti-racism continuum of practice may be useful to strengthen competency documents, curricula, policy and discipline-specific professional development planning.

Key messages

With the persistence of institutional racism in colonial settings like Aotearoa we need to imagine new ways to pursue anti-racism. Mapping anti-racism praxis is a useful way to identify variations in practice with a view to strengthening curriculum, competencies and ultimately practice.

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

Te Tiriti o Waitangi, a treaty negotiated between Māori (the Indigenous peoples of Aotearoa) and the British Crown, affirmed Māori 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 Māori political authority (tino rangatiratanga); (3) strengthening of accountability mechanisms; (4) investment in Māori 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.

Shades of competence? A critical analysis of the cultural competencies of the regulated-health workforce in Aotearoa New Zealand

OBJECTIVE

To critically examine, within the New Zealand context, the regulated-health practitioners' cultural competencies, their readiness to deliver culturally responsive health services to Māori (Indigenous peoples) and identify areas for development.

DESIGN

A mixed methods critical analysis of the regulatory bodies' cultural competency standards for health practitioners from their websites.

SETTING

The New Zealand regulated-health workforce, legislated by the Health Practitioners' Competency Assurance Act 2003 and the Medical Practitioners Act 2007, requires practitioners to regularly demonstrate cultural competence.

PARTICIPANTS

The information provided on the websites of the 16 professional bodies for regulated-health practitioners.

MAIN OUTCOME MEASURE(S)

These standards were analysed against indicators of the knowledge-action-integration (KAI) framework for culturally responsive practice, and scored according to these being explicit, not explicit, or not evident.

RESULTS

Competency standards aligned to the 'knowledge' component were more likely to be explicit requirements. This included indicators related to understanding personal cultural values, beliefs, practices, assumptions, stereotypes and biases and the influence these have on practice. However, the 'action' and 'integration' components were less likely to be explicit. Five regulatory bodies provided no definitions of cultural competence. There was mixed engagement with te Tiriti o Waitangi or the Treaty of Waitangi.

CONCLUSIONS

Variation in clarity surrounding requirements for cultural competence/responsiveness exists across most health regulatory bodies. Notably, the measurability of many standards tended to lack precision. Universal cultural competence standards could support health practitioners to deliver an improved healthcare experience for Māori, emphasizing cultural competence as a quality and safety issue.

Resisting ethnic inequities in advanced breast cancer: a call to action

Māori women with advanced breast cancer are less than half as likely as their Pākehā counterparts to reach the five-year survival mark. We argue that this inequity is unacceptable. We trace the inequity back to i) inadequate screening and risk assessment, ii) lack of support for patient navigation, iii) failure to offer accessible state-of-the-art treatments, and iv) delays in receiving life-prolonging care. We posit that each of these factors is a site of institutional racism and privilege as they cause Māori women to experience significantly worse outcomes than non-Māori. In the active pursuit of justice, cancer survivors, women living with cancer and their supporters across the country have been engaging in passionate advocacy to address inequities. As the Ministry of Health develops a new cancer control plan, in this viewpoint opinion piece, we seek to amplify these distressing inequities and offer evidence-based recommendations to improve the quality of care and ultimately survival rates. Breast cancer inequities are modifiable. We recommend prioritising breast cancer screening and risk assessments for Māori women, reducing treatment delays, providing Māori-centered patient navigation, increasing funding for treatments and drugs to align with the OECD standard of care, and holding health providers accountable for ethnic inequities. We call on policy makers drafting the new cancer control strategy, and those working across the cancer continuum, to take action to improve breast cancer outcomes so Māori women will gain valuable life-years.

Upholding Te Tiriti, ending institutional racism and Crown inaction on health equity

Upholding te Tiriti o Waitangi should eliminate institutional racism against Māori and contribute to the achievement of health equity. Given the Waitangi Tribunal is investigating health-related breaches of te Tiriti o Waitangi, we argue institutional racism, a key determinant of health inequalities, needs to be acknowledged and addressed within the health sector. Historically the Crown response can be characterised by denial and inaction. The Crown has the power and resources to take action through mechanisms such as those they are currently applying to child poverty and gender pay inequity. Anti-racism literature recommends planned, systems-based approaches to eradicate the problem. We need the government to uphold our Tiriti responsibilities and we require a plan to end racism in the New Zealand health system.

The shame of fat shaming in public health: moving past racism to embrace indigenous solutions

OBJECTIVES

The aim of this article is to explore perceptions of weight and racism towards Māori, as an indigenous group, and the association between the two. We then propose indigenous solutions as pathways out of fat shaming.

STUDY DESIGN

This is a conceptual article supported by a review of literature in the fields of weight stigma, racism and indigenous (Māori) health.

METHODS

This article is taken from the perspective of three researchers involved in Māori health research, studies on institutional and societal racism and critical research on weight stigma and the weight loss industry. Indigenous peoples in developed nations are more likely to be overweight, obese and disproportionately affected by the comorbidities and physical disorders associated with weight when compared with their counterparts. Beyond the physical ailments are a variety of psychological, emotional and social issues, which are associated with being 'fat' and/or overweight and/or from subsequent stigmatisation.

RESULTS

Long before this world's populations reached the current alarming level of obesity, indigenous peoples in colonised countries were stigmatised because of the colour of their skin, their beliefs and their culture. Stigma is nothing new to indigenous peoples, and so when Māori, or any other indigenous groups are told they are fat and less productive (or moral) because of 'fatness', there is no surprise because they have been told the same thing (albeit for a different reason) for generations. Considering the relatively high proportion of indigenous people in New Zealand, North America and beyond who do not fit the 'recommended weight range', the justification for racist sentiment is seemingly strengthened.

CONCLUSIONS

A weight loss-centred approach to health has not improved the health of indigenous people. Initiatives that draw on, or are underpinned by local, traditional knowledge are more relevant for indigenous peoples and could lead to better health outcomes for these groups.

Treaty of Waitangi in New Zealand public health strategies and plans 2006-2016

AIM

This study examines how public health policy in New Zealand has represented the Treaty of Waitangi (the English version) and te Tiriti o Waitangi (the Māori text) between 2006 to 2016.

METHOD

A dataset of 49 public health strategies and plans, published between 2006 and 2016, were secured from the New Zealand Ministry of Health database. A thematic analysis using Braun and Clarke's process was undertaken and then the findings were reviewed against the Māori text of te Tiriti.

RESULTS

Twelve documents referred to either te Tiriti or the Treaty. Crown discourses were characterised as i) rhetorical, ii aspirational, iii) practical and/or iv) substantive. We present a matrix of Crown health strategy and plan discourses and analyse their relationship to te Tiriti.

DISCUSSION

Public health strategies and plans rarely address Treaty of Waitangi or te Tiriti o Waitangi obligations. This silence is inconsistent with legislative requirements to engage with the Treaty and health equity and is likely to inform health-related Waitangi Tribunal claims [WAI 2575]. Further work needs to be done to strengthen alignment of health policy to fulfil Crown obligations under te Tiriti.

Unravelling the whāriki of Crown Māori health infrastructure

New Zealand's central government, and more specifically the Ministry of Health, consistently acknowledges their special relationship with Māori and the strategic importance of Māori health, and certainly, strengthening Māori health is critical to addressing systemic health inequities. This paper, framed in terms of the Crown principles attributed to the Treaty of Waitangi, ie, participation, protection and partnership, examines three structural decisions that threaten to unravel the whāriki (foundational mat) of Crown Māori health policy infrastructure. These include the disestablishment of the Ministry of Health's policy team, Te Kete Hauora, revoking mandatory district health boards' (DHB) Māori health plans and reporting, and downscaling the requirements of DHBs to consult. These actions appear to breach the Articles of te Tiriti o Waitangi and may be cited as such in the forthcoming WAI 2575 kaupapa health hearing before the Waitangi Tribunal. The authors call for the Ministry of Health to embrace its Treaty obligations, and to protect and reinstate the whāriki of Māori health infrastructure.

Tackling racism as a "wicked" public health problem: Enabling allies in anti-racism praxis

Racism is a "wicked" public health problem that fuels systemic health inequities between population groups in New Zealand, the United States and elsewhere. While literature has examined racism and its effects on health, the work describing how to intervene to address racism in public health is less developed. While the notion of raising awareness of racism through socio-political education is not new, given the way racism has morphed into new narratives in health institutional settings, it has become critical to support allies to make informing efforts to address racism as a fundamental cause of health inequities. In this paper, we make the case for anti-racism praxis as a tool to address inequities in public health, and focus on describing an anti-racism praxis framework to inform the training and support of allies. The limited work on anti-racism rarely articulates the unique challenges or needs of allies or targets of racism, but we seek to help fill that gap. Our anti-racism praxis for allies includes five core elements: reflexive relational praxis, structural power analysis, socio-political education, monitoring and evaluation and systems change approaches. We recognize that racism is a modifiable determinant of health and racial inequities can be eliminated with the necessary political will and a planned system change approach. Anti-racism praxis provides the tools to examine the interconnection and interdependence of cultural and institutional factors as a foundation for examining where and how to intervene to address racism.

The New Zealand Health Strategy 2016: whither health equity?

New Zealand's core health policy document-the New Zealand Health Strategy (NZHS)-was released in its final form in April 2016. This paper provides a critique of the strategy in particular, as it relates to health equity particularly for Māori. We introduce the five NZHS themes of-people powered, closer to home, value and high performance, one team and smart system-to focus on the aspirational goal of eliminating health inequities. Our critical framework is informed by Te Tiriti o Waitangi. We identified that the NZHS relies on the isolated efforts of committed individuals and organisations to achieve health equity and Te Tiriti engagement, rather than through a planned systems viewpoint. Evidence on health equity and Te Tiriti application suggests efforts need to be sustained, systematic and multi-levelled to be successful, rather than ad hoc and piecemeal.