The current environment

19. Maori are playing an increasing role in the planning, purchasing and provision of services. As well as Maori participation in policy development and purchasing there are now over 200 Maori health and disability organisations delivering a growing range of services in primary care, mental health, public health and, more recently, secondary care.

20. Many Maori organisations operate across traditional health sector boundaries to co-ordinate a range of social services and economic development initiatives for their populations, which provides a base for integrated service delivery and opportunities to address some of the wider determinants of health.

21. Maori co-purchasing organisations have been working with funders to improve the delivery of services to Maori. The HFA also has a number of 'Treaty relationship' agreements with iwi organisations that are intended to inform the HFA's decision making about Maori needs and preferences, and to inform Maori communities about health and disability issues (see Annex 1).

22. A recent development has been the emergence of Maori Development Organisations, with specific responsibilities for achieving specified Maori health gain priorities, co-ordinating service delivery, and working with Maori providers to build their capacity to deliver comprehensive high quality services to Maori, and with mainstream providers to increase their responsiveness to Maori.

23. Maori Development Organisations and other Maori health organisations are beginning to identify populations. The next step is for those organisations to negotiate service agreements to take responsibility for arranging a range of services to achieve health gain for those populations.

24. Service contracts with mainstream providers now include Treaty-related clauses requiring them to plan for and meet the needs of Maori consumers, and some have established kaupapa Maori services for more effective delivery to Maori consumers.

25. This increased participation is beginning to show dividends in improving access to services for Maori and more effective service delivery, not only by Maori providers themselves but also by mainstream services. Maintaining momentum through the transitional period and in the new structures is an imperative for Maori and the Government. Maintaining the momentum

26. An important factor allowing the rapid expansion of both Maori provider development and mainstream responsiveness has been the ability of health funders to decide on the most appropriate providers regardless of their ownership. To a lesser degree, support for fledgling Maori providers during their emergent stages (where the Maori Provider Development Scheme played a significant role), and the existence of a coherent strategy and funding pool (currently $50 million a year for services from Maori providers, $10 million a year for Maori provider development), have also been important, as has the move to efficient pricing.

27. Maori provider development is still, however, in its early days, and the proportion of Maori in the health professional workforce is still well below equitable levels.

28. There are a number of potential risks for ongoing Maori provider development in the DHB structure that will need to be managed. These risks include:
    1. internal incentives for the vertically integrated DHBs to provide services through their own facilities where Maori providers would be more effective (particularly where there is overlap between DHB and Maori community based services)
    2. possible incentives to under-fund community based services on the assumption the community can make up the shortfall
    3. loss of direction for Maori provider development if a diversity of approaches develops, as well as dilution of the leverage potential of the Maori services and development funding if it is distributed amongst the 22 DHBs
    4. higher transaction costs for regional Maori organisations, especially those spanning more than one DHB area (for example, Ngai Tahu spans 6 DHBs, Ngati Kahungunu 3 DHBs)
    5. lack of skills in DHBs to manage either an increasingly sophisticated health system or proactive and effective relationships with Maori, especially in some smaller rural boards with high Maori populations and limited budgets, (similar to the problems experienced in the Education sector in the same areas)
    6. the loss of key Maori people and skills from the sector due to an extended period of uncertainty.

29. Any of these risks create a downstream risk of reduced access to and effectiveness of services for Maori, and widening health disparities.

30. There are three main mechanisms available to Government to manage these potential risks to Maori provider development as well as mainstream responsiveness:
    1. Maori representation ("voice")
    2. Regulatory design (the rules under which DHBs will operate)
    3. Accountability (the accountability framework for DHBs, including the New Zealand Health and Disability Strategies).

31. The leadership role that the Government and Ministry of Health play in the sector can also be used to manage uncertainty and concerns, for example through: · clearly signalling in communications with the sector the importance of Maori service and workforce development · encouraging and facilitating marginal boards with insufficient capacity to manage the risks in their areas to either amalgamate or form coalitions to maximise their capacity.

32. The mechanisms are interactive - where one is weak, others need to be correspondingly stronger. The strength of the current separate purchasing function has been increased opportunities for Maori service provision. With DHBs potentially influenced by their ownership of comprehensive facilities, the Maori voice and regulatory measures become more critical. Importantly, these mechanisms are also dynamic in nature - as the DHBs evolve, the balance between them will change.

33. The following options tease out single dimensions of these measures. It is important to note, though, that the health and disability sector has long moved passed uni-dimensional measures relying on a single mechanism such as consultation with Maori and any return to such arrangements would be a backward step. Stronger forms of partnership and participation are now embedded throughout the system. These developments need to be preserved and expanded.