34. Maori voice options span a continuum from relatively 'soft' forms such as consultation with Maori or Maori advisory committees, through to 'stronger' forms such as participation in decision-making. This section considers consultation and advisory mechanisms, and membership on DHB boards. Additional ways of structuring the partnership between Maori and the Crown are considered in paragraphs 46-65.

35. A given is that DHBs will consult with the Maori consumers, whanau, hapü and iwi in their areas, just as they will with other populations for whom they are responsible, but this is unlikely to achieve the desired outcomes of partnership on its own.

36. There will be occasions when the DHB will want to formally seek the advice of Maori on specific issues, and they should be able to set up ad hoc Maori advisory committees, or other means of getting Maori advice, when required.

37. Standing Maori advisory committees are not, however, recommended. Experience shows such committees can be easily sidelined and rapidly become marginalised and irrelevant. Rather, Maori (both iwi and non-iwi) should be well represented on the two major DHB committees, the Primary Care Advisory Committee and the Hospitals Committee, to ensure their advice is integral to the work of those committees.

38. The Government has agreed there should be equitable representation of Maori or tangata whenua on DHBs and their committees. [CAB (00) M2/4]. The concept of equitable representation requires a number of issues to be worked through, such as what equitable representation means, processes for selecting Maori members (election and/or appointment), the roles of any Maori members including their relationship with the local Maori community compared to the Board as a whole, their relationship with any other DHB 'Treaty partners', and their training and support needs. These issues will be included in the 31 March report to Ministers.

39. The structural design of the DHB provides a potentially powerful tool to mitigate some of the risks to Maori provider development. Provisions could include:
    1. minimising incentives for DHBs to favour their own services over Maori providers where Maori provision would be more effective; this would be assisted by:
       putting hospital assets at arms-length within DHBs

       ensuring internal and external providers face similar terms and conditions such as finance and monitoring regimes

       requiring DHBs to go through certain procedures before exiting from Maori services (similar to the Change Protocols that HHSs must go through now when exiting from services)

    2. maximising the likelihood that incumbent Maori health and disability providers will be able to continue to develop and that new providers will be able to commence providing; this would be assisted by:
       ensuring DHBs pay sustainable prices to both mainstream and Maori providers that reflect the long term cost of providing those services (i.e. eliminating hidden subsidies for publicly owned mainstream services that would disadvantage Maori-owned providers)

       ensuring that service agreement length is of sufficient duration for providers to make adequate arrangements for service planning and asset structure

       ensuring that service agreements allow clinical, financial and service risks to be shared between DHBs and Maori health organisations.

Ensuring Results: Accountability Options

40. DHBs will operate within an accountability framework consisting of the primary legislation and secondary regulatory instruments, including the NZ Health and Disability strategies, and any agreements established between DHBs and the Minister's expectations with regard to funding and performance. The accountability framework can be used to mitigate some of the risks to Maori provider development and mainstream responsiveness.

41. Provisions could include strengthening incentives on DHBs to encourage Maori service development and mainstream responsiveness, where appropriate, by:
    • giving DHBs explicit objectives relating to Maori health gain, meeting Maori preferences, and Maori capacity building
    • requiring DHBs to establish relationships with local iwi and Maori
    • requiring DHBs to report on their spending on Maori health, progress towards Maori health goals and targets and other agreed performance measures (the Government has already adopted a policy of increasing accountability for Maori spending (GAP (00) M 1/1&2 REV 1)
    • maximising the transparency of DHB decisions, especially needs assessment, strategic planning, prioritisation and provider selection processes, reporting and monitoring (e.g. through public meetings, consultation requirements, annual reports, published benchmarks or scorecards)
    • using the Minister's suggested powers to reduce DHB autonomy where necessary should DHBs fail to meet their responsibilities relating to Maori health (see Roles paper).

42. Another option could be to ring-fence some aspects of Maori spending. This is a matter to be considered in the 30 June 2000 report on funding for DHBs.

43. As with mainstream services, Maori service provision could also be protected by encouraging economies of scale and lower transaction costs for Maori by allowing some Maori development functions and service provision to be funded at a regional level (e.g. the emerging Maori Development Organisations), or national level (e.g. some Maori public health services, or the Maori Provider Development Scheme). Major advantages would be more co-ordinated service delivery to Maori consumers and facilitation of integrated service planning and delivery with other sectors.

44. There may also be a need for the Ministry of Health to manage some Maori contracts until the fledgling DHBs can demonstrate they have built the capacity to effectively manage their Maori responsibilities. Such 'evolutionary devolution' is in line with the recommendations in the accompanying paper on the role of DHBs.

45. Some aspects of these recommendations would be included in the legislation, while others would belong more appropriately in the New Zealand Health Strategy or the accountability documents that give effect to both. Decisions on where to locate provisions need to be worked through in the next phase of development.

MOVING FORWARD: OPTIONS FOR EFFECTIVE PARTNERSHIP

46. Options for configuring other forms of Maori participation in decision-making over and above the Voice options in paragraphs 34-38 include:
    1. a sector-wide model of participation at all levels (a generic partnership model). A variation would see iwi or other appropriate Maori organisations mandated the right to be consulted on certain decisions or to nominate representatives
    2. a 'delegated' model, where some functions would be formally delegated to appropriate Maori organisations
    3. sub-purchasing models, which would allow Maori to control decisions over a narrower, specified range of services for a defined population.

47. The following sections describe each option in more detail, including assessing some of their advantages and disadvantages. None of the models are mutually exclusive (although running both the generic partnership and delegated models together could be complex and costly).

48. A generic model for facilitating Maori participation at all levels of the health and disability sector is illustrated in Figure 1. Details are included in Annex 2.

49. Partnership relationships with Maori would be established at each level of the health sector from the centre to DHB operational levels. The DHB board would establish Treaty-based relationship agreements with local iwi to work together to establish strategic priorities for their Maori populations.

50. Maori capacity building organisations would work with the Boards' operational levels to arrange services to achieve the agreed strategic priorities. This would include working with Maori providers, mainstream providers, and other sectors to co-ordinate services and foster the delivery of high quality, effective services for Maori.
51. A national forum would provide opportunities for Maori to discuss issues of national strategic importance for Maori with Ministers and the Ministry of Health.

52. The arrangements would be flexible, taking different forms in different areas according to the characteristics and desires of local Maori and DHBs. They would also evolve over time, with the suggested Maori capacity building organisations perhaps taking on responsibilities for a Maori population.

53. The foundations for the arrangements are already in place, with a number of Treaty relationship agreements already operating between the HFA and iwi, and Maori Development Organisations carrying out Maori capacity building functions (see Annex 1).

NB It is likely that one Maori partner may have relationships with several DHBs where boundaries are inconsistent