Kerri Nuku, Kaiwhakahaere
NZNO Tōpūtanga Tapuhi Kaitiaki o Aotearoa

In my previous blog post I discussed the context that gave us Te Tiriti o Waitangi (Te Tiriti) and how dishonouring it has led to the marginalisation and politicisation of Māori health. Since my last blog we have seen the introduction of the HPCA Act Review, the slashing of the Pay Equity process and the Equal Pay Act, and the insidious Regulatory Standards Bill. Changes to these pieces of legislation remain relevant to our work as nurses, midwives, healthcare workers and tauira; as well as for our Pākehā, Tauiwi and non-Māori members.

It remains clear that honouring Te Tiriti will enable Māori to take control of their own decisions and futures. But how can we identify when Māori are not considered in the decisions made for us? In March the NERF Committee invited Dr Heather Came to deliver a workshop on Strengthening Engagement with Te Tiriti o Waitangi. Dr Came is an activist and anti-racist scholar and her research focuses on institutional racism within the New Zealand public health system.

Dr Came has developed a Critical Tiriti Analysis framework that enables policymakers and practitioners such as yourself to evaluate whether policies and processes are consistent with Te Tiriti, and helps develop solutions that honour Te Tiriti. The framework allows you to examine a policy through the preamble and four articles of Te Tiriti o Waitangi to determine whether Te Tiriti is upheld throughout the delivery of healthcare policies. Because the New Zealand public healthcare system has been imported from Britain, we can assume that there are many policies that do not uphold Te Tiriti. Findings from the 2019 WAI 2572 Health Services and Outcomes Inquiry found that the ongoing resistance of the Crown in honouring Te Tiriti places the burden on Māori to assert their needs, which continues to harm Māori.

Critical Tiriti Analysis teaches us to look and ask for evidence that Māori values and decision making have influenced the policy design; that the policy ensures equitable participation and leadership; that wairua is acknowledged as more than physical health, and that Te Tiriti is central to the policy design process.

Hospital visitor and carer policies are a good example for this analysis. Hospital visitor policies restrict the number, frequency and age of visitors who come to the hospital to support the patient. For Māori, ‘whānau’ goes beyond the immediate family and includes those who secure a person’s wellbeing and safety. This may include parents and siblings, aunts, uncles and cousins, and the neighbour that checks in on you. Whangai children may be raised by grandparents, great grandparents, or caregivers. All these people secure a person’s wellbeing and safety, and all may be considered whānau. In comparison, many hospitals visitor policies centre on the Pākehā ‘nuclear family’ unit that includes parents and sibling, spouses and children. The Pākehā conceptualisation of ‘family’ focuses on the immediate kinship group.

By following Dr Came’s the analysis framework we can identify that:

1. Preamble: The policy does not preserve Māori interests because it does not allow for the conceptualisation of ‘whānau’.
2. Kāwanatanga: Because Māori interests have not been preserved it is clear that Māori thought leadership did not contribute to the development of this policy – the policy embeds a Western conceptualisation of ‘family’ into our healthcare system.
3. Tino Rangatiratanga: “the right for Māori to make decisions for Māori”, is not allowed for in this policy, because it does not allow for an interpretation that recognises ‘whānau’.
4. Ōritetanga: The rights and privileges of the citizens of Aotearoa should be equal, including access to healthcare and the factors that ensure wellbeing, such as access to whānau. The policy excludes access to whānau when you are a patient. 
5. Wairuatanga: this policy diminishes the mana of the patient as they are denied access to their whānau and support network.
6. Now that we can identify where the hospital and carer visitor policy breaches Te Tiriti, it is our responsibility to suggest improvements that ensure the service we provide is meeting the needs of your patient and their community. This needs to involve consultation with Māori to ensure the policy honours the five sections of Te Tiriti and ensures the patient and their whānau are informed enough to make their own healthcare decisions. This may include expanding the number of visitors, changing the ‘requirements’ for visitors, training for healthcare professionals or the building of hospitals that centre wairuatanga in healthcare strategies.

Once you understand the Critical Tiriti Analysis framework, you may start to see other policies that can be improved, such as the ability to provide professional care for whānau, patient advocacy, bereavement leave, case management, and pathways for students and graduates.

Critical Tiriti Analysis requires long and robust efforts to improve our healthcare system, but it will create culturally informed and mana-enhancing engagement and informed by racial justice. When Te Tiriti is honoured, we will have a public healthcare system that authentically engages with the aspirations of Māori citizens and grounded in equitable healthcare outcomes. And we will all be healthier for it.