1. In this paper, we propose options for strengthening the Crown's partnership with Maori at the District Health Board (DHB) and other levels in the funding and provision of services. These options build on gains already made and include:
   1. establishment of partnership arrangements with Maori throughout the sector
   2. regulatory and accountability arrangements for DHBs that ensure they achieve Maori health gain and Maori provider development

2. This paper is one of a suite of papers on policy settings for the new health sector, including the Public Health Services Bill. It provides the Government with options for effective partnership arrangements with Maori that will contribute to Maori health gain and improve relationships with Maori under the Treaty of Waitangi.

3. Partnership can take many forms in the context of DHBs. The Treaty of Waitangi is the basis for partnership between Maori and the Crown. The working group will report back to Ministers by 31 March on issues around including the Treaty in legislation.

4. Maori capacity building and participation throughout the sector are integral to an effective partnership. Considerable gains have been made in Maori service delivery, and there are already a range of Treaty-based partnership arrangements with Maori operating in the sector. The paper identifies some risks that the present momentum could be lost. It recommends three mechanisms to protect the gains already made:
   • Maori representation: forums for Maori voice throughout the sector
   • regulatory design: DHB operating rules that ensure fair opportunities for Maori health and disability organisations
   • accountability mechanisms that create incentives for DHBs to achieve Maori health gain and effective partnerships with Maori.

5. Options are also proposed for building forward from the current position. The starting point for an effective partnership between Maori and the Crown would be to build on existing partnership arrangements to extend Maori participation throughout the sector, including a national Maori forum, Treaty relationships at DHB Board level and Maori capacity building organisations at DHB operational level. The paper proposes further work on options for transferring some functions or responsibilities to Maori health and disability organisations.

6. On 31 January 2000 Cabinet directed the Ministry of Health to report to the Ad Hoc Ministerial Committee by 29 February 2000 on options for appropriate partnership arrangements with Maori at the DHB level in the funding and provision of services (CAB (00) M 2/4 (gg)(vi) refers).

7. Other reports due on the same date cover the role of DHBs and the division of functions between DHBs and the Ministry of Health, preferred options for the organisational form of DHBs and its committees, and the communication strategy.

8. These options were developed by an inter-agency working group led by Te Kete Hauora in the Ministry of Health, and including Te Puni Kökiri, the Maori Health Operating Group from the Health Funding Authority, the Ministry of Justice and CCMAU (in consultation with the State Services Commission and Treasury)

9. The working group consulted on 18 February with a focus group of about 40 representatives from the Maori health and disability sector (see Health Report 845, 23 February 2000). That hui considered the Treaty of Waitangi was the starting point for partnership, and that the Treaty should be reflected in health legislation. It expressed a strong preference for Maori control over health and disability services, as part of wider whanau, hapü, iwi and Maori development.

COMMENT

The nature of partnership and its relationship to the Treaty of Waitangi

10. Partnership can take many forms in the context of DHBs. Whatever the form, partnership implies that parties have an ongoing relationship. While the status of the parties may differ, there is a common understanding that they will share decision-making in some way, and, relate to each other in good faith, with reasonable co-operation, and mutual support.

11. The outcomes of an effective partnership would include:
    • improved access and service effectiveness for Maori (both Maori-provided and mainstream)
    • corresponding reductions in avoidable illness and decreased Maori health disparities
    • reduced marginalisation of Maori and greater trust and improved relationships between Maori and Government
    • greater sector cohesiveness.

12. Any discussion of partnership between Maori and a Crown entity has to start with the Treaty of Waitangi. The Government has accepted the Treaty of Waitangi as New Zealand's founding document and as the basis of constitutional government in this country. It has also acknowledged that a special constitutional relationship is ongoing between Maori and the Crown under the Treaty of Waitangi - the relationship between Maori and the Crown will not end when health disparities between Maori and other New Zealanders are addressed. The relationship between Maori and the Crown is based on the underlying premise of the Treaty itself, that Maori could continue to live in Aotearoa as Maori.

13. To date, the relationship between Maori and the Crown in the health and disability sector has formed around three key strategies:
    • ˇ participation at all levels (including policy, purchasing, service delivery and workforce)
    • partnership (including explicit Treaty relationship agreements between the funders and iwi)
    • ˇ protection (including strategies for Maori health gain).

14. These strategies are interlinked. Maori health gain is critical given that Maori on average have the poorest health status of any group in New Zealand. Maori providers understand and meet the needs of Maori consumers in ways not easily achievable by non-Maori providers. They are able to provide services that are appreciated and understood by Maori and reflect Maori beliefs, values and practices. Mainstream services will continue to hold most of the more specialised medical skills and facilities required by Maori. Both need to work together if the needs of Maori consumers are to be met and health disparities reduced.

15. Work is underway in the wider public sector to clarify the contemporary application of the Treaty of Waitangi in the government sector. This work will not be completed in time to guide decisions on new health sector legislation, however, so the advice in this paper working group is based on existing approaches to the Treaty in Health.

16. A critical issue not addressed in this paper is whether or not the Treaty of Waitangi should be included in the proposed Public Health Services Bill. While there is clear support for this option in the Ad Hoc Ministerial Committee and Maori health leaders, there are a number of issues still to be worked through (including any legal risks). It is proposed that officials report back to Ministers on this issue by 31 March 2000.

17. Building on existing strategies, the main criteria for assessing options for partnership between Maori and the DHBs are the extent to which they:
    • ˇ continue to build Maori capacity for participating in the health and disability sector, and allow Maori communities to provide for their own health needs
    • ˇ encourage effective relationships between DHBs and Maori (including good information, communication in good faith and opportunities for dialogue)
    • ˇ create incentives to improve Maori health outcomes and reduce health disparities between Maori and other New Zealanders (including mainstream responsiveness to Maori and intersectoral linkages to address wider determinants of health).

18. Other principles include:
    • Building forward from the base already established
    • ˇ Flexibility: recognition of diverse Maori realities, and allowing both different organisational forms in different areas according to the wishes of local Maori and their circumstances, and change over time
    • ˇ Integration with social and economic services: Maori health gain requires collaboration with other sectors to address wider determinants of health; Maori consumers and whanau benefit from services provided more holistically
    • ˇ Clear accountabilities for achieving Maori health objectives
    • ˇ Cost effectiveness: options should achieve the objectives cost-effectively.