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

Nā te hiahia kia titiro, ā, ka kite ai tātou te mutunga

You must understand the beginning if you wish to see the end

Under te Tiriti o Waitangi, the founding document of the colonial state of New Zealand, health is recognised as a taonga (treasure) that should be protected. Te Tiriti also reaffirmed Māori tino rangatiratanga and promised ōritetanga (equity) with British subjects. Through the WAI 2575 kaupapa inquiry, the Waitangi Tribunal is currently investigating alleged health-related breaches of te Tiriti and over 200 deeds of claim have been lodged covering diverse aspects of the performance of the health system.

Historical practices of colonisation and forced assimilation enacted by the Crown were profoundly racist.1 The policies that flowed from colonisation were informed by assumptions about the superiority of Pākehā people and institutions, and therefore the entitlement of Pākehā to resources and power. Colonisation has resulted in severe damage to iwi and tino rangatiratanga, with major losses of people, language, whenua and culture. This has resulted in many Māori living in conditions that put their health at risk and has entrenched preventable health disparities.

Compelling evidence suggests racism against Māori, in all its forms, has become a normalised part of New Zealand society.2–5 This has occurred despite the relational, contractual obligations and protections of te Tiriti, the Declaration on the Rights of Indigenous Peoples and the Convention on the Elimination of All Forms of Racial Discrimination (CERD) and other international human rights instruments.

Racism has been theorised by Jones6 as a multi-layered phenomenon encompassing personal, interpersonal and institutional levels. Many studies have documented critical influences of racism within the New Zealand health system7–9 which in our paper refers particularly to state-funded services along with legislation, policy and infrastructures that support them. This research spans a spectrum from health policy-making and contracting, through to the behaviour of health professionals, managers and receptionists.

In this article (i) institutional racism will be defined, examined and its links to health equity elucidated, then (ii) anti-racism praxis will be described and explored as a solution to institutional racism in the health system, and finally (iii) the Crown’s response to institutional racism in their administration of the health system will be outlined and critically examined in light of the ‘anti-racism’ systems-change strategy described below.

Institutional racism

Institutional racism is a pattern of differential access to material resources, cultural capital, social legitimation and political power that disadvantages one group while advantaging another.7 Power can be exercised through the entrenchment of institutions, the creation of legislation, framing of policy, decision-making, agenda setting, withholding information, prioritisation and imposing worldviews.10 It also manifests in the political, social and personal narratives that a nation reproduces around identity, culture and social justice, in the public sphere, in the mass media and in everyday lives.11

In New Zealand, institutional racism works through:

“…the outcomes of mono-cultural institutions which simply ignore and freeze out the cultures of those who do not belong to the majority. National structures are evolved which are rooted in the values, systems and viewpoints of one culture only.”12

Institutional racism does not involve the intention of those within the system,13 rather it turns on the structures, policies and practices of that system and the ways in which they reflect and maintain cultural dominance. Systemic inequities in social, educational and health outcomes are an indication of the effects of institutional racism that can also be seen in policies, practices and the racial climate within an organisation.

Pakeha often find racism can be difficult to detect because it becomes ‘naturalised’ in the routine, mundane doings and beings of established social orders.14 Detection requires vigilance in terms of examining the past and present practices of organisations and can also involve both action and inaction in the face of need. The focus of this paper is the Crown’s inaction in relation to the health needs of Māori.

Health inequities

Ethnic inequities are a defining feature of the health profile of this country.15 Health equity, defined as the absence of systematic disparities16 can be utilised as an indicator of the existence of racism in health systems. Blas et al17 argued there are at least three distinct pathways for States to eliminate health disparities i) as provider/guarantor of equitable, rights-based health services, ii) as driver of transformational equity policy frameworks, iii) as monitor of progress toward health equity. These features are absent or deficient in the current New Zealand health system, highlighting Crown inaction.

The United Nations CERD committee,18 responding to the evidence presented by health NGOs, noted concerns about structural biases in the New Zealand health system. They recommended that service provision to Māori be improved and encouraged the strengthening of Māori input into planning, service delivery and evaluation.

Anti-racism

Honouring te Tiriti o Waitangi is a strong platform from which to eliminate institutional racism in health. However, the Ministry of Health19 issued a memo banning mention of the Treaty of Waitangi in health documents and indicating that over time, all contracts, service specifications would be realigned to this edict. A subsequent review of Crown public health policy documents by Came et al20 from the Ministry of Health website identified 49 documents of which only 12 mentioned either te Tiriti o Waitangi [Māori text] or the Treaty of Waitangi [the English version]. This determined silence in relation to te Tiriti and the Treaty is incompatible with a meaningful commitment to uphold te Tiriti responsibilities.

Institutional racism is a complex problem, difficult and highly resistant to change. Most anti-racism interventions are poorly funded, weakly supported and focus on addressing personally-mediated racism. They are often educational and concentrate on strengthening cultural competencies of individuals.21 Addressing institutional racism effectively requires both policy and practice interventions. Education alone cannot address structural elements of racism.

A systems-change approach is well-suited to problems such as institutional racism that require holistic thinking, flexibility, engaged stakeholders and a long-term focus.22 Systems-change is an iterative process that involves cycles of defining and expressing the problem, investigating its causes and developing, revising, implementing and evaluating interventions. This cycle is led by a change team and supported by socio-political education and ideally political will.

Came et al23 argued New Zealand needs a coordinated national action plan to end racism. Such a plan would have four pathways: i) honouring te Tiriti o Waitangi and resolving the legacy of historic racism, ii) improving racial climate through public education and conscientisation, iii) transforming public institutions through systems-change, and iv) mobilising civil society. To this we would explicitly add the imperative to engage in constitutional transformation24 because without this underpinning, systems-change is harder to achieve.

Crown responses to institutional racism

Ramsden25 has argued power-sharing is critical to addressing racism, noting those in power rarely willingly relinquish that power. Spoonley26 maintained it is useful to investigate who benefits from the normalisation of racism. The Crown’s response to institutional racism within the health sector has been a mixture of silence, inaction, denial and resistance.

Few Ministry policy documents available through their website have identified institutional racism as a barrier and/or as a structural determinant of health.27,28 Mentions are fleeting and offer no direction, plan, suggestions or guidance about how to identify, monitor or prevent institutional racism. The Whakatātaka Series, designed to operationalise He Korowai Oranga (the core Māori health strategy), contains no detail around addressing racism.

NgāKawai29 mentions a series of eight workshops on tackling inequalities, held in 2002/03 with senior staff from Crown agencies. The evaluation report30 described these workshops as “…limited but valuable”. The workshops used institutional racism as a case study, participants wrote personalised action plans and recommendations were developed to address inequalities, but it is unclear whether these were implemented.

The New Zealand Health Strategy31 as the core health policy document makes no mention of racism or anti-racism nor does the core health quality framework.32 This silence is widespread across policy documents and reflects inaction by the Crown in addressing institutional racism. Policy sometimes mentions reducing inequalities but rarely racism. Given the systems-change orientation to the New Zealand quality assurance system it could be a critical platform to address institutional racism.

Puao te Ata Tu12 remains a landmark report documenting institutional racism within the social welfare sector. It provided useful recommendations for the public sector. Table 1 summarises some of its key recommendations and the Crown’s response in health.

Table 1: Key recommendations from Puao te Ata Tu and Crown health sector responses.

Recommendations

Crown response in health sector

A commitment to end all forms of racism

Acknowledgement of racism in He Korowai Oranga.

Incorporating Māori values and beliefs into policy

Some inclusion in Māori-specific policies.

Ensuring Māori have an equitable share of resources

Māori providers receive 1.86% of Vote Health.33

Sharing power and authority over resources with Māori                                            

There is no independent body that ensures the Crown shares power and resources with Māori.

Te Kete Hauora the internal Māori team within the Ministry of Health was disestablished.34

Enhanced accountability to Māori communities

Unclear.

Change recruitment and promotion practices

Still concerns at the low numbers Māori health professionals.

Strengthen cultural competencies

Cultural competencies a requirement for the regulated health workforce under the Health Practitioners Competency Assurance Act 2003. Regulatory authorities oversee competencies but there are no core standard cultural competencies across the regulated workforce. Some benchmarks are low.

Take a whole-of-government approach to systemic social problems

This occurs in healthy housing initiatives.

Refresh relevant legislation

New Zealand Public Health and Disability Act 2000 mentions Treaty of Waitangi principles and equity.

From a review of key policy documents and an analysis of the response to the Puao te Ata Tu recommendations, little coordinated action has occurred. Progress seems weak, fragmented and unsystematic.

Evidence of racism within the health system continues to be produced and debated. Table 2 shows a small selection of media articles about racism. This indicative analysis shows a pattern of silence and denial from the Crown.

Table 2: Crown responses to media articles about racism in health system.

Racism

Crown spokesperson

Harris S. (13/7/2017). Māori voice on decline in health NZ Herald.

Disestablishment of Te Kete Hauora and revoking of requirement for Māori health plans

Staff re-deployed and planning requirement embedded in core annual planning.

Biddle D-L. (18 November 2015). Poor health a big risk for Maori. Waikato Times.

Institutional racism contributes to ‘being Māori’ being the biggest risk factor for poor health outcomes.

“there are persistent inequalities that need to be addressed.”

Kelsey F. (10 July 2013). ‘Racism’ a factor in avoidable illnesses, more Maori hospitalised. Manawatu Standard.

Racism and cultural insensitivity among health practitioners contributes to high Māori levels of ambulatory avoidable hospitalisations.

“the disparity here is the second-best in the country.”

Humphreys L. (1 July 2009) Racism probe call for TDHB, Taranaki Daily News.

Evidence of disparities concerning racism within DHB.

“our team are certainly working hard to ensure that there is this element of equality.”

A notable exception to this analysis of silence, denial and inaction is Dame Tariana Turia, whose experience of leadership in Māori health puts her in a unique position of oversight. Turia has consistently called out institutional racism within the health sector before, during and after she was an Associate Minister of Health. Dame Tariana35 on leaving parliament confirmed her biggest regret was “…the failure of any government to address the systematic damage incurred by decades of institutional racism”.

The international community through CERD has recognised what Dame Tariana has been long been saying about institutional racism within the New Zealand health system. The CERD committee19 shared their concern about the absence of a national action plan in their report on New Zealand’s poor performance in eliminating racism.

Conclusion

Racism is a breach of the Crown’s responsibilities under te Tiriti o Waitangi. Rather than denial and inaction, the health sector needs the Crown to develop a systems-change strategy and plan to eradicate institutional racism. Furthermore, the detection, prevention and eradication of racism should be incorporated into the quality assurance practices of the health system at all levels.