Introducing the Hauora Māori Equity Toolkit for Specialist Healthcare Services (HMET-SHS)

This viewpoint article introduces the rationale and design of the Hauora Māori Equity Toolkit for Specialist Healthcare Services (HMET-SHS), a systematic tool designed to address health inequities within specialist healthcare services. The HMET-SHS is a framework for service evaluation, providing specific, achievable and measurable goals to guide comprehensive service-wide transformation in addressing health inequities.

Health systems in Aotearoa New Zealand struggle to grapple with a colonial history that has led to health inequities between Māori and non-Māori. In the current health system, non-Māori enjoy health privilege, including greater access to best-practice healthcare and effective healthcare interventions, along with better outcomes despite a lower disease burden.^1,2 Despite strategic changes and efforts to improve healthcare access and quality for Māori communities, the aspirational wording of these high-level strategies have not translated into meaningful improvements for health equity in Aotearoa New Zealand.^1,3,4

Addressing racism within health systems is critical for achieving health equity. Quality assurance must actively identify and address racism, challenge mono-cultural frameworks and embed culturally responsive interventions.^3,4,5,6 Effective interventions involve tackling systemic and organisational barriers to healthcare access, such as incomplete patient registration, access and scheduling issues, along with prohibitive service costs, which disproportionately affect Māori.⁷

In 2020, an implementation plan for Aotearoa New Zealand’s Health Strategy was introduced, entitled Whakamaua: Māori Health Action Plan 2020–2025.⁸ Whakamaua identified a range of actions to be taken to achieve strategic gains for Māori health, including an intention that the health system delivers equitable outcomes for Māori, addressing racism in the health sector and supporting Māori communities to exercise self-determination to improve their health and wellbeing.

The HMET-SHS empowers communities of practice to monitor the Crown’s efforts in addressing persistent health inequities. It is designed to uphold rangatiratanga (self-determination) of Māori, to exercise their rights under Te Tiriti o Waitangi and the United Nations Declaration on the Rights of Indigenous Peoples. Central to its purpose is ensuring the attainment of the highest possible standard of physical and mental health for Māori.⁹

Rationale for the HMET-SHS

Implementation tools, including equity evaluation toolkits, have been developed to assess potential impacts of policies on Māori and reduce inequities.¹⁰ However, the application of these tools has been largely limited to regional or national policies; progress in enacting these plans at local levels has been slow. The goal of the HMET-SHS is to embed Hauora Māori approaches in order to drive systemic changes and, ultimately, achieve equitable outcomes for service users. It is only through systemic changes that systemic inequities can be addressed.¹¹

The HMET-SHS offers a practical framework for health services to implement and review recommendations aimed at improving Māori health outcomes. It emphasises incorporating Māori perspectives and adopting a strategic approach to embed structural mechanisms of change within health systems.

Integrating health equity research evidence into the HMET-SHS

The initial development phase of the HMET-SHS involved an in-depth review of existing literature and health equity frameworks to identify key markers of health inequity across the health sector. This process also highlighted recommendations for improving service provision. The review uncovered numerous factors contributing to health inequities, particularly within the domains of quality and safety, spanning both administrative and clinical pathways.

Building on these findings, the HMET-SHS incorporates specific, evidence-based tasks designed to address known barriers to equitable health outcomes within services, as identified by existing health research.^12,13

The Whakamaua action plan emphasises the importance of routinely monitoring quality and safety improvement initiatives to reduce variation in health services that contribute to inequities.⁹ Similarly, key reviews on equity for Māori within the health system have highlighted the use of locally adapted equity tools, co-designed and implemented in partnership with Māori, to address issues within the quality and safety domain.^3,14 These tools are particularly effective when they actively engage participants in developing action plans, fostering motivation for change and ensuring consistent application across services.¹⁵ The HMET-SHS draws on insights from three key barriers to equity, which are summarised below.

Access to appointments

Māori patients experience significantly higher rates of non-attendance at health appointments,¹⁶ which are linked to poorer health outcomes. Poor communication between health services and patients has been identified as a major contributing factor, particularly for Māori. To address this, implementing culturally aligned communication, clear booking confirmation and follow-up protocols for missed appointments are essential.¹² Additionally, ensuring timely access to Māori health workers and community services play a crucial role in improving equitable access.

Racism and discrimination

Negative experiences, such as cultural alienation, are a key driver of higher non-attendance rates among whānau Māori.^13,14 Discrimination with the health system is strongly linked to poorer health outcomes for Māori and reflects institutional racism that continues to hinder health equity.^13,17 Achieving equity requires an anti-racist and decolonial approach, with health services collectively taking responsibility for supporting Māori communities.^17–19 This includes rejecting narratives that impart blame upon Māori or label them as non-compliant.

Workforce

Barriers to consistent, high-quality healthcare for Māori remain a persistent issue across health systems.²⁰ A significant challenge lies in workforce development: both the under-representation of Māori in the health workforce and insufficient investment in cultural competency and safety training for existing staff. Building and sustaining a strong Māori health workforce is a critical enabler of improved health outcomes. This includes deliberate recruitment of staff with Hauora Māori expertise and prioritising professional development to foster cultural safety.²¹ This allows integration of such supportive practices to become “business as usual” within teams.

Development of the HMET-SHS

The HMET-SHS was co-developed by Māori and non-Māori experts with extensive clinical, research and medical education experience in Hauora Māori. It aligns with key Māori health initiatives like Whakamaua,⁸ the Meihana Model²² and the Hui Process.²³ The Meihana Model explicitly incorporates the ongoing impacts of colonisation and systemic racism as critical determinants of health outcomes. Similarly, HMET-SHS supports health services in creating culturally competent and responsive systems, promoting collective responsibility for addressing systemic health disparities and advancing the broader goal of health equity in Aotearoa New Zealand.

The Periodic Service Review format

The HMET-SHS operates as a Periodic Service Review (PSR), a structured approach to service improvement, that involves setting standards, implementing interventions and regularly monitoring progress towards those standards.²⁴ Drawing on evidence of key drivers of behavioural change, PSRs focus on establishing specific, actionable goals and encourage self-monitoring. This process begins with establishing baseline measurements of agreed reference points, followed by the implementation of interventions and monitoring to assess progress over time. Unlike audits, which review markers and goals retrospectively, PSRs track and evaluate change over time, using tools from behavioural analysis and organisational behaviour management to drive meaningful, lasting change. In the context of the HMET-SHS, this involves understanding the drivers of behaviour change within healthcare settings and designing interventions to promote more equitable practices.

Equity tools that utilise a PSR framework are well-suited to empower health services to drive change, measure outcomes and proactively address the known drivers of health inequities. This rationale led to the decision to adopt a PSR framework for the HMET-SHS, offering a theoretically grounded, ecological and comprehensive approach to systematically transforming health systems.

Tasks and structure of HMET-SHS

The full HMET-SHS is presented in Table 1. The HMET-SHS contains 29 equity-focussed tasks spread across four domains:

Domain 1: Service Manager

Domain 2: Senior Medical Officer

Domain 3: Clinician

Domain 4: Administrator

The HMET-SHS enables regular monitoring of progress towards actionable goals in each domain, integrating continuous feedback and fostering shared responsibility. The specific tasks within the HMET-SHS were designed to address known barriers to equitable health outcomes, drawing on both existing health research and the clinical experience of the Hauora Māori health professionals in the HMET-SHS team.

The tool promotes shared responsibility across the healthcare team, empowering members to set realistic, actionable goals and implement a service-wide monitoring system. By distributing tasks across domains, the HMET-SHS encourages collective responsibility and engages the entire service team in achieving common objectives, focussing on overall service performance rather than individual team contributions.²⁴

View Table 1.

Domain-specific accountabilities

The HMET-SHS assigns specific tasks across four domains: administration staff, service managers, clinicians and senior medical officers (SMOs). These accountabilities engage all members of the healthcare team, ensuring each role contributes to the shared goal of improving service-wide health outcomes.

Domain 1: Service Manager

The Service Manager domain involves the largest set of tasks, focussing on embedding responsive systems and protocols. Service Managers are responsible for implementing anti-racism strategies to counter institutional and interpersonal racism. This includes ensuring culturally safe and competent booking and communication protocols, and maintaining consistent referral protocols.

A critical responsibility for Service Managers is to ensure effective data collection and management systems, enabling the review and monitoring of equitable health outcomes. This includes confirming the patient databases are accurate and in accordance with the Ministry of Health protocols, to monitor Māori patients and track progress towards health equity.²⁵ Inadequate IT systems can hinder the accurate collection of ethnicity data, making it impossible to monitor health inequities effectively. Therefore, ensuring correct gathering and analysis of ethnicity data is a priority for health services.²⁶ Service Managers are also tasked with ensuring the physical environment is inclusive of Hauora Māori, facilitating professional development for team members in Hauora Māori and promoting awareness of protocols to manage discriminatory behaviour.

Domain 2: Senior Medical Officer (SMO)

In the HMET-SHS framework, SMOs play a crucial role in identifying conditions significant to Māori patients through data analysis and in implementing evaluation and quality improvement programmes. They are responsible for establishing best practice pathways for patient care and for ensuring these pathways are culturally competent, safe and responsive. SMOs are also tasked with ensuring quality improvement initiatives are in place to address health inequities identified through these pathways. They must implement clear reporting systems to monitor outcomes for Māori patients based on these pathways.

Domain 3: Clinician domain (non-SMO clinical staff)

Clinicians share responsibility for the consistent implementation of HMET-SHS tasks within their departments. They are tasked with ensuring there are clear referral pathways to Hauora Māori providers in the community, and have access to a dedicated Health Pathways page that provides details of Hauora Māori services, including Māori social services that address the social determinants of health.

Clinicians must confirm outpatient appointments before patient discharge, ensuring that appointment times are convenient and accessible for Māori patients. It is crucial to regularly record and monitor referral and appointment data to track progress and ensure consistency across services.

Domain 4: Administrator

Healthcare administrators, often the first point of contact for patients, play a critical but under-researched role in the healthcare system.²⁷ Within the HMET-SHS framework, administrators are responsible for developing cultural safety and competency skills, particularly focussing on the correct pronunciation of Māori names and fostering respectful, patient-led te reo Māori communication.

Administrators also implement booking and confirmation protocols aligned with Kaupapa Māori clinical models, which support effective communication and access for Māori patients. These protocols are based on work conducted on the West Coast (oral communication between author MP and Kylie Parkin, Ngāpuhi/Ngāti Whātua/Te Roroa, Interim General Manager Hauora Māori, West Coast District Health Board , February 2021), and aim to reduce barriers to appointment access, including addressing issues like transportation.

Administrators must also facilitate professional development opportunities to support culturally safe communication with Māori patients, challenge discriminatory narratives and ensure that Māori patients are not subjected to explicit and implicit racism. Administrators play an essential role in recognising and combating victim-blaming stereotypes and narratives that overlook the impact of social determinants of health and colonisation.²⁸

Shared tasks: professional development

To facilitate the integration of Hauora Māori principles across all aspects of healthcare service provision, the HMET-SHS requires every staff member within a service to be enrolled in the service’s Hauora Māori professional development programme. To provide culturally safe and competent care, healthcare services must address racism in the workplace, as well as intersecting forms of discrimination. HMET-SHS emphasises the need for reform to deliver clinically and culturally appropriate care in order to reduce health inequities. Achieving this requires leadership to take concrete actions in addressing both structural and interpersonal racism. The HMET-SHS revealed a need for increased Hauora Māori knowledge and skills within the workforce. The subsequent implementation of a dedicated professional development package saw considerable uptake and engagement, suggesting a positive shift towards a more culturally responsive and equitable service.

Monitoring progress and embedding accountability

The success of the HMET-SHS depends on regular monitoring of progress towards health equity. To implement the HMET-SHS effectively, services create systems of interlocking accountability, with oversight from high-level management and multiple people. While it is important to clearly designate who is ultimately accountable for implementing specific tasks, the process should be collaborative, fostering collective responsibility across the team.

We recommend that monitoring and oversight be carried out by a Clinical Director, Service Manager, Administrative Manager and Quality Assurance Officer, each reporting on their respective domains. For example, Administrative Managers are well placed to oversee the implementation of booking and communication protocols, while Service Managers can track staff participation in professional development programmes.

Data monitoring should occur at regular intervals throughout the year, ideally in a quarterly cycle. These reviews should involve SMOs analysing data to track progress in addressing inequities in clinical pathways, as well as scoring the HMET-SHS across all domains to assess that standards are being maintained and improved.

The HMET-SHS uses a scoring system with a maximum of 29 points (equivalent to 100%) spread across the four domains. This distribution of tasks ensures that Hauora Māori equity principles are integrated into every aspect of the healthcare service and promotes shared responsibility across the entire team. Departmental presentations of such data in a supportive environment with all members of the team present provides visible motivation to support these changes.

To enhance monitoring and accountability, the HMET-SHS development team recommends creating a visual dashboard to track outcomes for Māori patients throughout the implementation period.²⁹ Dashboards provide services with constant access to relevant data, improving adherence to quality guidelines and ultimately leading to better patient outcomes. Research shows that using multiple forms of feedback such as visual aids, along with explicit targets and action plans,³⁰ fosters positive behaviour change and motivates teams to consistently implement interventions.

Conclusions: charting a course forward

Potential next steps are the mandatory adoption of health equity assessment tools across the healthcare sector. Additionally, there is a need to design interoperable IT systems with Māori data experts to support real-time equity monitoring, enhance compliance with national health strategy and address systemic failures to uphold Te Tiriti o Waitangi. Grounded in Hauora Māori principles and informed by research in health equity and organisational improvement, the HMET-SHS offers a powerful framework for driving tangible, sustainable improvements in healthcare outcomes for Māori.

The HMET-SHS is a robust tool with broad applicability. Early pilots in Waitaha/Canterbury have demonstrated its potential to identify and address health inequities, improving specialist healthcare delivery for Māori communities. Given the ongoing and widespread nature of health inequities across the national health system, expanding the HMET-SHS framework to a broader healthcare context is essential. This should include specialist health and hospital services, where the pervasive issue of non-Māori privilege in healthcare access and outcomes, particularly in mental health, remains a critical barrier to achieving equity.^1,20,31–33