Evaluating Indigenous health workforce development interventions for Māori and Indigenous Pacific tertiary students: success at Waipapa Taumata Rau | The University of Auckland (2016–2023)

A key goal of health systems is to develop a workforce that reflects the communities they serve.^1–3 Aotearoa faces major health workforce gaps due to systemic under-investment and fragmented approaches, which have disproportionately impacted recruitment and retention of Māori and Pacific health professionals.^1,4 In addition to equity arguments, there are Crown obligations deriving from Te Tiriti o Waitangi to address inequities in the Māori health workforce.⁴

Notwithstanding recent increases, only 5.1% of registered medical practitioners in Aotearoa are Māori and 2.4% are Pacific peoples.⁵ Seven percent of registered nurses are Māori and 4% Pacific peoples;⁶ the proportions of Māori and Pacific pharmacists and other health professionals are even lower. Despite these significant and persistent disparities, pro-equity initiatives to increase the Māori and Pacific health workforce are currently facing scrutiny.

To produce an optimal health workforce, health professional programmes should recruit those with the most potential to contribute to the health and wellbeing of patients in Aotearoa, particularly members of under-served communities. Recruitment of students into health professional training programmes has relied predominantly on prior academic achievement as it is a predictor of tertiary academic success. However, prior secondary school and early tertiary achievement is highly patterned by socio-economic privilege and ethnicity in Aotearoa, and is not the best (nor only) predictor of health professional excellence and retention.^7,8 The education system in Aotearoa systematically advantages Pākehā students and fails to meet the educational aspirations of Māori and Pacific students.^9–11 Institutionalised privilege and discrimination (including streaming practices in schools, inequitable access to educational resources, lack of culturally responsive teaching and learning, experiencing racism, and socio-economic inequities impacting on learning) result in inequitable secondary education outcomes by ethnicity.^9,10 This experience is mirrored internationally in other Indigenous and marginalised communities.^11,12

Universities in Aotearoa have long-standing policies aiming to improve equity and diversity in their health professional programmes.^2,11 Given the entrenched socio-economic and ethnic inequities produced by the education system, attaining this goal requires comprehensive strategies to support the recruitment and retention of students.^12–14 The COVID-19 pandemic exposed and exacerbated existing educational inequities for Māori and Pacific students,¹⁰ further heightening the need for supportive interventions.

The Faculty of Medical and Health Sciences (FMHS) at Waipapa Taumata Rau | The University of Auckland (UoA) offers clinical programmes in medicine, nursing, pharmacy, optometry and medical imaging, along with degrees in health sciences. Vision 20:20 is the Indigenous-led strategy within FMHS delivering evidence-based interventions to support the recruitment, admission, foundation education, retention and graduation of Māori and Indigenous Pacific students (Figure 1).^15,16 The Māori and Pacific Admission Scheme (MAPAS) and Hikitia Te Ora | Certificate in Health Sciences bridging/foundation programme are two Vision 20:20 interventions and are the focus of this evaluation. Interconnected interventions outside of the scope of this study include the Whakapiki Ake and Pacific Health Wayfinders programmes, which support secondary school recruitment and admission into tertiary health study.¹⁶

View Figure 1, Table 1–4.

Overview of selected Vision 20:20 interventions for Hikitia Te Ora and MAPAS students

Admission

Students with Māori or Indigenous Pacific ancestry are eligible to apply for MAPAS. Comprehensive entry interviews are undertaken to assess aspirations, academic preparation and whānau supports in addition to academic literacy and numeracy testing. Following the review of prior academic results, students are recommended their best starting point for success: either direct entry to degree-level study, bridging/foundation study in Hikitia Te Ora or additional foundational study outside of FMHS.¹⁷

Foundation education

Hikitia Te Ora is a 1-year, Level 4 bridging/foundation education certificate offered to selected MAPAS applicants. Hikitia Te Ora applies Indigenous pedagogy and supports the development of academic and science literacy, with comprehensive academic, cultural and pastoral support provided across multiple levels to prepare students for success in first-year bachelor’s degree study and subsequent clinical programmes.¹⁸

Retention and graduation

Following enrolment into the first-year Bachelor of Health Science or Biomedical Science (either directly from interview or in the year following Hikitia Te Ora), MAPAS continues to provide academic, cultural and pastoral support for students across their entire health degree. The interventions provided across the tertiary health study pipeline are comprehensive and evidence based.¹¹ Particular strengths (in addition to supporting academic success) include the provision of culturally safe spaces and the strengthening of students’ Indigenous identities, confidence and leadership skills to prepare them for entry into and success within the health workforce.^15,19

The aim of this study was to evaluate the impact of selected Vision 20:20 interventions on course pass rates, retention rates and graduation rates by comparing outcomes for Hikitia Te Ora and MAPAS students against routinely published results for all Māori and Pacific students at UoA using standard educational performance indicators developed by the Tertiary Education Commission (TEC).^20,21

Methods

Positionality

This evaluation was undertaken by Māori and tauiwi researchers within Te Kupenga Hauora Māori at UoA. We acknowledge the Indigenous rights of Māori, reaffirmed in Te Tiriti o Waitangi. These rights have been, and continue to be, systematically breached by the Crown. We use a critical structural framing that recognises health and social inequities by ethnicity as outcomes of historical and contemporary processes of colonisation, racism and privilege,²² and acknowledge the fundamental role of the education system in colonisation.²³ We also recognise the diverse cultures and histories of Pacific communities, who experience unacceptable health and social inequities in Aotearoa due to systemic discrimination and exclusion.²⁴ This study aims to support institutional change towards culturally safe²⁵ educational systems that uphold Te Tiriti o Waitangi and enable Māori and Pacific student success.

Data sources

A de-identified dataset of students who attended MAPAS interviews and were studying in their first year of Hikitia Te Ora or health bachelor’s degree was extracted from the MAPAS programme database, with relevant socio-demographic details and academic records for each available year following enrolment. Data for first-year MAPAS and Hikitia Te Ora students were extracted from 2015 to 2023 to allow for calculation of indicator results for the reporting period 2016–2023. Aggregated indicator results for equivalent total Māori and Pacific student cohorts at UoA were recorded from the TEC website using relevant year, ethnicity and cohort filters.²⁰

Socio-demographic variables

Ethnic categories in MAPAS data use whakapapa (ancestry), while TEC data use up to three self-identified ethnicities. We grouped ethnic categories by total response, meaning students with both Māori and Pacific identity are counted in both groups. Pacific MAPAS students all have Indigenous Pacific ancestry, while the total UoA Pacific category includes non-Indigenous Pacific groups such as Fijian Indian.

For MAPAS students, secondary school quintiles (based on census data for households with students residing within a school catchment area) were used as a proxy for socio-economic position (quintile 5 schools are those in the highest 20% of socio-economic privilege, equivalent to deciles 9–10).

Educational performance indicators

We measured MAPAS performance using three TEC educational performance indicators: course pass rates, retention rates and graduation rates (Table 1).²¹ Two MAPAS analytical cohorts were created based on previous methods.¹⁷ The “Hikitia Te Ora cohort” included all foundation Hikitia Te Ora students, and the “Bachelor cohort” included all students in first-year health bachelor’s degrees, including students who had studied Hikitia Te Ora in the prior year. Indicators were calculated from subsets of each cohort using relevant starting year cohorts to align with TEC reporting years. Course pass and retention rates were reported from 2016 to 2023; graduation rates were reported for shorter periods due to the availability of MAPAS starting cohorts.

Analysis

Each indicator was calculated as a proportion for each MAPAS cohort as a whole and by total response ethnic categories. Hikitia Te Ora and MAPAS results for each ethnic category were compared with equivalent results for total UoA Māori and Pacific students by calculating differences in proportions. The Hikitia Te Ora cohort was compared to UoA certificate and diploma (Level 4–7 non-degree) results, and the Bachelor cohort was compared with UoA Bachelor (Level 7 degree) results by calculating differences in proportions. To estimate the effect of MAPAS interventions on graduation rates we calculated the difference from observed graduation numbers that would have occurred if MAPAS students had graduated at the same rate as all UoA Māori and Pacific students.

Ethics

Ethics approval was obtained from The University of Auckland Human Participants Ethics Committee (UAHPEC27023).

Results

Socio-demographic profile of total first-year Hikitia Te Ora and MAPAS students, 2015–2023

From 2015 to 2023 there were data available for 609 Hikitia Te Ora students (73% female, n=446) and 829 bachelor’s students (70% female, n=582). Three hundred and twenty-three (39%) of the Bachelor cohort had undertaken Hikitia Te Ora study in the previous year. Twelve percent of the Hikitia Te Ora students and 8% of the Bachelor students had both Māori and Pacific ancestry. Approximately 15% of Hikitia Te Ora students and 20% of Bachelor students had attended schools with the highest socio-economic privilege (quintile 5) (Table 2).

MAPAS educational performance indicators, 2016–2023

From 2016 to 2023, the Hikitia Te Ora cohort made up approximately 35% of total Māori and 20% of the total Pacific certificate and undergraduate diploma students at UoA. The MAPAS Bachelor cohort made up approximately 9% of total Māori and 6% of the total Pacific students studying bachelor’s degrees at UoA (Appendix Table 1). Hikitia Te Ora and MAPAS student numbers grew by 34% between 2016 and 2023, with 652 undergraduates supported in 2023.

Indicator results for each MAPAS cohort are detailed in Table 3. In the Hikitia Te Ora cohort, 94% of enrolled courses were passed, 79% of students graduated and 75% of students were retained into a second year of study, with the majority (n=401/407) entering bachelor’s degree study. The Bachelor cohort course pass rate and first-year retention rate were both 89%, and the 6-year graduation rate was 66%. Of these graduates (n=232), 50% completed a clinical programme (n=82 medical, n=35 other clinical specialties), 28% (n=65) graduated with a Bachelor of Health Science (including conjoint degrees) and 22% (n=50) graduated with a degree outside of FMHS. An additional 15 students (including 10 in clinical programmes) graduated in 7 or more years.

Comparison of MAPAS and UoA total Māori and Pacific cohorts

The MAPAS programme out-performed total UoA Māori and Pacific student outcomes across all indicators (Table 4). Hikitia Te Ora course pass and graduation rates were between 15 and 23 percentage points higher compared with those of total UoA Māori and Pacific certificate and undergraduate diploma students. MAPAS bachelor’s course pass, retention and graduation rates were between 8 and 18 percentage points higher than total UoA Māori and Pacific bachelor’s degree students.

Estimating the effect of MAPAS support on bachelor’s graduation outcomes

In the 2020–2023 reporting period, 140/202 (69%) Māori MAPAS bachelor’s students and 117/186 (63%) Pacific MAPAS bachelor’s students graduated within 6 years, with half graduating from clinical programmes. During this time, the total UoA 6-year bachelor’s graduation rate was 54% for Māori students and 46% for Pacific students. Applying UoA graduation rates to the MAPAS cohorts would have resulted in approximately 31 fewer Māori and 31 fewer Pacific graduates in this period, equivalent to approximately 16 fewer total graduates (including eight fewer clinical professionals) per year.

Discussion

MAPAS and Hikitia Te Ora interventions are supporting student success in foundation study, retention and graduation of Māori and Pacific health professionals, reflecting Vision 20:20 commitments to develop evidence-based initiatives to improve student outcomes.^11,17,18 Hikitia Te Ora and MAPAS student numbers grew by a third between 2016 and 2023, in contrast to declines in total numbers of Māori and Pacific students at the UoA.²⁶ Measured against standardised educational performance indicators, MAPAS and Hikitia Te Ora have achieved excellent results for Māori and Pacific health students, with achievement consistently above UoA Māori and Pacific averages.^20,26 MAPAS and Hikitia Te Ora performance is also similar to or higher than national tertiary and UoA 2023 results for non-Māori, non-Pacific students²⁰ and exceeded UoA 2023 targets for course completion and first-year retention for all ethnicities,²⁶ confirmation that Vision 20:20 plays a significant role in increasing equity of academic achievement. Notably, the Hikitia Te Ora foundation course achieved nearly equal course pass and graduation rates for Pacific as for Māori students, narrowing inequities observed across tertiary educational outcomes between Pacific and Māori student achievement²⁰ and further demonstrating the strengths of a culturally safe and responsive learning environment.

This success is even more notable when considering entrenched socio-economic and ethnic inequities within the education system. Fifty-eight percent of all university entrants in Aotearoa come from the most privileged (deciles 8–10) schools.¹⁰ Recent studies have shown this extreme skew towards socio-economic privilege is even more marked in tertiary health programmes, with less than 5% of enrolled students coming from the least privileged (decile 1 and 2) schools.^2,27 In contrast, 10% of Māori and 23% of Pacific MAPAS bachelor’s students came from decile 1 and 2 schools, with even higher proportions enrolled in the Hikitia Te Ora foundation course. Students attending less socio-economically privileged schools face multiple barriers to entering tertiary study, including cost.¹⁰ They are also less likely to be offered the full range of science subjects at school, and more likely to have lower NCEA grades and a range of literacy, numeracy and learning needs as a result of systemic school failure to identify and support these needs.¹⁰ Vision 20:20, particularly via Hikitia Te Ora, provides a successful example of culturally responsive interventions specifically designed to address these secondary education gaps. However, addressing and eliminating the barriers that lead to inequitable educational opportunities for students attending less privileged secondary schools will require much broader systemic transformation.

Tertiary institutions in Aotearoa perpetuate many of the same biases and culturally unsafe environments that are seen in the secondary school system, evidenced by persistent ethnic inequities in retention, course completion and qualification rates.²⁰ The holistic approach of Vision 20:20 that works across the whole student pipeline from recruitment to graduation is therefore critical to the success of students, and is reconfirmed by our evaluation results. Recruitment of Indigenous students in the absence of holistic support is unethical, ineffective and ignores the continuing system bias that labels unequal outcomes as student failure.^12,15 While Vision 20:20 provides a comprehensive set of initiatives to support successful academic outcomes and cultural safety for Māori and Pacific students within FMHS, it does not relieve the wider education system from its duty to protect the rights of all students from racial abuse and discrimination, and to continue to reform culturally unsafe learning environments.

The benefits of successful pro-equity programmes such as MAPAS are substantial and extend far beyond the indicators measured in our evaluation.^11,15 Students strengthen their cultural identity and enter professions that provide socio-economic security and opportunity, which can positively impact their whānau and future generations. The health workforce benefits as medical graduates from Aotearoa are retained at significantly higher rates than international graduates, with Māori and Pacific medical doctors’ 10-year retention consistently as high or higher than Pākehā graduates.⁵

Māori and Pacific peoples experience racism and discrimination when accessing healthcare, and robust evidence demonstrates that culturally safe practitioners who understand Māori and Pacific experience and acknowledge and respect Indigenous identity are highly valued.^28,29 As more Māori and Pacific health practitioners, researchers and leaders emerge, there is a “re-presenting” effect that may counter perceptions of Māori and Pacific peoples solely as passive recipients of care in a Pākehā-dominated health system.¹¹ A critical mass of Māori and Pacific health professionals in leadership, policy and decision-making roles can contribute to transforming the health system towards the elimination of Māori and Pacific health inequities.^25,30 However, recent research reveals Māori doctors experience high levels of racism and discrimination in their work and training environments, which negatively affects their health, career decisions and desire to remain in their profession.³¹ Therefore, greater numbers and representation alone will not necessarily lead to a safe environment for staff or patients—institutionalised racism and power imbalances must also be addressed.²⁵

Strengths and limitations

Strengths of this study include the critical framing of systems of power and privilege as drivers of ethnic inequities in secondary and tertiary education outcomes. The use of standardised indicators to evaluate MAPAS performance allows for evaluation of the programme along the whole undergraduate student pathway and has allowed comparison with publicly available and routinely reported results that can be monitored over time.

The use of aggregated TEC data was a limitation of this study as the comparator group included MAPAS students; therefore we were unable to test for statistical differences between groups or perform any more comprehensive analyses. Using TEC data was a pragmatic choice as we did not have access to disaggregated student data for non-MAPAS Māori and Pacific UoA students. Furthermore, comparison with total Māori and Pacific UoA students in equivalent courses was appropriate as most Māori and Pacific undergraduate students at FMHS are supported by MAPAS, so there was not an adequately sized comparator group within FMHS. On balance, our choice meant we were able to undertake simple comparisons to estimate the impact of the Vision 20:20 initiatives, although our results should be interpreted with the following considerations. We expect reported differences will be underestimates as UoA averages will be higher due to the inclusion of Vision 20:20 students, particularly for the Hikitia Te Ora cohort who make up a large proportion of total UoA certificate and diploma students. Similarly, the effect on MAPAS bachelor’s graduation rates was a crude counterfactual calculation that will underestimate the true result as it does not account for the wider effects of MAPAS and Vision 20:20 on recruitment and baseline admission rates. Some selection bias is likely in our results due to the different definitions of ethnic category, particularly for the Pacific category where TEC data include non-Indigenous Pacific students. We were also unable to control for confounding by prior academic achievement, which is a predictor of tertiary success.¹⁷ FMHS programmes have high academic requirements for entry, which could overestimate the MAPAS differences if FMHS students are at baseline more likely to succeed than students in other faculties. Acknowledging these limitations, the size and consistency of differences across all indicators for the MAPAS interventions compared with UoA averages suggest a true positive effect. Future research could confirm our results and address these limitations by obtaining a dataset of all Māori and Pacific UoA students to measure indicators that would allow for more comprehensive statistical analysis, including adjustment for potential confounders.

Conclusion

Realising a sustainable health workforce that reflects our society now and in the future is a significant challenge. In Aotearoa today, 25% of people under 25 years are Māori and 14% are Pacific peoples,³² and population growth and ageing are placing increased demands on an already under-resourced health system. Pro-equity health workforce programmes are part of the solution to the health workforce challenge and need greater investment and consistent support; political and legal attacks may have long-term negative impacts.³³ Given current under-representation and future demographic trends, we recommend universities aspire for at least 30% Māori and 15% Pacific graduates in health professional programmes. In parallel, wider institutional strategies to reform entrenched racialised and culturally unsafe learning and working environments are critical to uphold Te Tiriti o Waitangi and protect the rights of all students and health professionals.

View Appendix.