Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. Kia Taupunga te Ngākau Māori Anchoring Māori Health Workforce Potential Annemarie Gillies Ngāti Kahungunu, Ngāti Awa, Te Whānau-a-Apanui, Te Arawa 2006 Kia Taupunga te Ngākau Māori Anchoring Māori Health Workforce Potential A Thesis Presented for the Degree of Doctor of Philosophy Māori Studies Massey University, Palmerston North New Zealand Annemarie Gillies Ngāti Kahungunu, Ngāti Awa, Te Whānau-a-Apanui, Te Arawa December 2006 HE POROPOROĀKĪ E rere nei ko ngā roimata i āku mata, e tētere nei i āku kamo, e tātaka ana i taku kauwae. Pā mai ana ko te matangi ki taku kiri, auwhi ana ko te ngākau e rite nei ki te āhao e whakakoi nei i tāku manawa. Auē, te mamae e papatu nei! Nei ra taku reo karanga e rere, ki āku poutoko manawa, ki āku Manu Aute o te pō, o te Awatea e rērere tonu mai i te poho o Ranginui, whirinaki ana i ōna parirau. Tū mai ra Pukeko, tu mai ra Hokopu ki runga o Putauaki, karawhiua o mata ki Mataatua, tētere rawa i te awa o Rangitaiki, pātata atu ki roto o Poroporo, karawhiua atu ki Wairaka. Rere atu ra ki te tau o to ate e tū mai ana i te maunga o Whanganui– ā– Tara, karawhiua ana ngā mata ki Taupunga whare, ki te marae ātea a Tumatauenga, karawhiu atu ki Te Motu– o– Kura, kia tiketike te titiro, tārewa noa te mamae i ngā mokopuna kua waiho noa. Nei ra te haehae i tāku Manawa. Auē tāku tangi i a koutou e āku manu tioriori, e ngā reikura o tāku manawa. Anō ko te mārama kua ngaro, kua ara anō. Mai i te hiku o te ika, rērere tonu taku rākau ki rō o Waikato awa, ki te manu tīoriori, te rau Pōhutukawa o Tainui waka, nei tana rite ki te kererū i te rangi. Rere tonu atu ki Te Arawa Heke iho ki te puku o te whenua, Taupo – nui – a – Tia, tētere rawa i ngā tapuwae a Tongariro, Ngauruhoe, Ruapehu, ki te awa o Whanganui tae atu ra ki te pane o te motu, whakawhiti atu taku rākau i te moana o Raukawa, ko Te Waipounamu e tau ra! Koutou nā, rere ra i te pō, ki a Hine – nui – te – pō, okioki ra i te Awhireinga. Taukiri e! i HE MIHI ‘E koeko te tūī, e ketekete te kākā, e kūkū te kereru’ ‘Ehara taku toa i te toa takitahi engari he toa takitini’ Nei aku mihi e rere ana ki a koutou katoa i whāngai i ahau ki te kai a te miro. I whakarauikatia ki taku hiahia, koutou i whakaaro nui ki te tohatoha i tā koutou mātauranga hei whāngai i taku hinengaro, e kore aku mihi e pau ki tēna, ki te kore ko koutou, kua kore ko ahau. Ki tēnā, ki tēnā Tēnā tātou katoa. There are many people to thank for their contribution and support for this research, otherwise it would not have been completed. First of all I would like to acknowledge the people and organisations who participated in the study, gave of their time, and shared their knowledge – ngā whānau whānui of Tipu Ora Trust, Vision 2020, Te Rau Puawai, and Māori health protection. Special thanks to Esther Tinirau, and Margaret Forster for being there right to the end, Hine Waitere-Ang my writing buddy –kia kaha e hoa, Jean & Erik Vanags who supported in many ways, Huia Jahnke for continued encouragement and confidence, Sharon Taite for providing motivation, Shirley Barnett for just being so positive about everything, John Waldon and Fiona kia ora korua Rawiri Tinirau and Noreen Mako for their confidence and support, Farah Palmer, Tania Jahnke, Marianne Tremaine, Malcolm Mulholland, and the rest of my Te Au Rangahau colleagues I look forward to celebrating your successes too, my colleagues and friends at Te Pūtahi-ā-Toi, and Pūmanawa Hauora where this all started many thanks for your support and friendship. Many thanks to my colleagues in the department of Management and to the PhD support group Robyn Walker, Colin Higgins, Jo Cheyne, Warren Smith, John Downey for the wonderful discussions and our ventures to interesting writing spots. Special thanks to Tony Vitalis and the department administration team Josie Grace, Brigit Eames, Catherine Toulis, & Janet Toogood. To the team in the Office of the Deputy Vice Chancellor Māori Casey Te Rangi, Marley Jenkins, Kiri Pohe-Thackeray, Karyn Kee and Frances White thank you for the Manaaki, and last to Buck and Deidre arohanui. I would like to make special mention of my brothers and my sister and their children, and all my cousins for keeping up with whānau responsibilities while I have been distracted. Also my love to Nan, a tower of strength and love, I miss you. Finally, my children Hepa and Naha, their partners, and my mokopuna, those I have now, Alexcia and Reremoana Keeri, and those to come, you all make this worthwhile, thank you. Thanks also need to go to the Health Research Council of New Zealand for their initial support and ongoing encouragement. Finally, my supervisor: there is a saying that goes – don’t walk in front of me I may not follow, don’t walk behind me I may not lead, walk beside me and we will go forward together. Thank you Mason for your guidance, encouragement, and for letting me walk beside you for a time, nei anō āku mihi. This thesis is dedicated to my parents Alex and Anne (Keeri), forever in my heart. Nō reira, tēnā koutou katoa. ii ABSTRACT In New Zealand Māori are under-represented in the workforce across multiple sectors. This thesis explores this incongruity with regard to Māori health. A Māori perspective and philosophical foundation formed the basis of the methodological approach, utilising a case study research design to inform the study. This provided the opportunity to explore Māori health workforce development initiatives and their potential to contribute to improvements and gains in Māori health. It was important that this work take into account social and economic factors and their impact on health, as well as the varying political climates of market oriented reform and a fiscal policy focus, because it has not only challenged Māori health development but also provided opportunities for increased Māori involvement and participation in health and New Zealand society. Therefore the thesis, while focused on health takes cognisance of and, coincides with the capacity and capability building efforts that have been a feature of overall Māori development, progress and advancement. In the context of this thesis Māori health workers are seen as leaders within their whānau, hapū, iwi, and Māori communities. Consequently a potential workforce that is strong and powerful can lead to anticipated gains in Māori health alongside other Māori movements for advancement. The potential cannot be under-estimated. This thesis argues that there are critical success factors, specific determinants, influencing Māori health workforce potential, and that these success factors have wider application. Therefore, as this thesis suggests Māori workforce development, especially in relationship to the health workforce, is dependent on effective Māori leadership, the application of Māori values to workplace practices, levels of resourcing that are compatible with training and development, critical mass, and targeted policies and programmes. iii TABLE OF CONTENTS HE POROPOROĀKĪ .................................................................................................................................... i HE MIHI ...................................................................................................................................................... ii ABSTRACT .................................................................................................................................................iii TABLE OF CONTENTS ............................................................................................................................ iv LIST OF TABLES..................................................................................................................................... viii LIST OF FIGURES .................................................................................................................................... ix THESIS DESIGN......................................................................................................................................... x Chapter 1 .......................................................................................................................................................... 1 Introduction .................................................................................................................................................. 1 Colonisation .............................................................................................................................................. 2 Background to Māori health workforce development .............................................................................. 4 Māori doctors ........................................................................................................................................... 8 Māori nurses ........................................................................................................................................... 11 Māori health commissioners and sanitary inspectors ............................................................................. 13 Māori contributions to health ................................................................................................................. 16 Concluding remarks ............................................................................................................................... 33 Chapter 2 ........................................................................................................................................................ 35 Theoretical and Methodological Perspectives ........................................................................................... 35 Introduction ............................................................................................................................................ 35 Knowledge claims .................................................................................................................................. 35 Māori knowledge claims ........................................................................................................................ 44 Strategies of inquiry – quantitative, qualitative, mixed methods ............................................................ 53 Research approach .................................................................................................................................. 57 Case recruitment and selection ............................................................................................................... 59 Research methods ................................................................................................................................... 59 Tono – recruitment and selection processes ........................................................................................ 61 Whakawhānaungatanga ....................................................................................................................... 62 Tirohanga – observations and participation ......................................................................................... 62 Hui – meetings, events, consultation ................................................................................................... 62 Kōrero-a-tahi – communication and interviews ................................................................................... 63 Whāngai Pānui - document review ...................................................................................................... 63 Whāngai Pānui - literature review ........................................................................................................ 64 Whakarongo – listening and recording ................................................................................................ 65 Ngā Taputapu Awhi - technologies and innovations............................................................................ 65 Whakaaro-mai-tanga - qualitative data analysis .................................................................................... 66 Ethical issues .......................................................................................................................................... 68 Māori maintenance issues ....................................................................................................................... 69 The case studies ...................................................................................................................................... 69 Conclusion .............................................................................................................................................. 70 Chapter 3 ........................................................................................................................................................ 71 Contemporary Māori Development............................................................................................................ 71 Introduction ............................................................................................................................................ 71 Background to contemporary Māori development ................................................................................. 71 Urban Māori migration ........................................................................................................................... 73 Devolution .............................................................................................................................................. 73 iv Specific ‘by Māori for Māori’ programmes ........................................................................................... 76 Māori providers ...................................................................................................................................... 83 Māori demographics .............................................................................................................................. 84 Māori economic development ................................................................................................................ 85 Māori cultural development ................................................................................................................... 87 Māori educational development ............................................................................................................. 88 Māori health development ..................................................................................................................... 93 Māori societal development ................................................................................................................... 99 Organisational capacities ..................................................................................................................... 102 Emerging philosophies......................................................................................................................... 104 Māori development frameworks .......................................................................................................... 106 The risks associated with development ................................................................................................ 108 Conclusion ........................................................................................................................................... 111 Chapter 4 ...................................................................................................................................................... 113 Workforce Development .......................................................................................................................... 113 Introduction .......................................................................................................................................... 113 The contours of workforce development ............................................................................................. 113 Demand and supply ......................................................................................................................... 115 Price elasticity of demand ................................................................................................................. 117 Income elasticity of demand ............................................................................................................... 119 Cross elasticity of demand ................................................................................................................ 119 Labour market trends ........................................................................................................................... 119 Workforce incentives ........................................................................................................................... 121 Political philosophies ........................................................................................................................... 123 Workforce constraints .......................................................................................................................... 124 Career development ............................................................................................................................. 126 Professionalism and unionism ............................................................................................................. 128 Shaping a health workforce ................................................................................................................. 129 Training and education agencies .......................................................................................................... 135 The international scene ........................................................................................................................ 137 Conclusion ........................................................................................................................................... 145 Chapter 5 ...................................................................................................................................................... 147 Māori Workforce Responsiveness ........................................................................................................... 147 Introduction .......................................................................................................................................... 147 Concentration of the Māori workforce ................................................................................................. 147 The effects of economic restructuring and rationalisation ................................................................... 148 Community development ..................................................................................................................... 151 Political interest ................................................................................................................................... 153 Māori provider development ................................................................................................................ 153 Māori health service providers ........................................................................................................... 155 Māori health workforce development in research ................................................................................ 160 Māori community health workforce .................................................................................................... 161 Māori demographic profile .................................................................................................................. 161 Influencing factors in legislation and policy ........................................................................................ 163 Māori mental health workforce development programmes ................................................................. 167 Māori health professional organisations .............................................................................................. 168 Current Māori workforce development initiatives ............................................................................... 170 Workforce development experiences in Australia and USA ................................................................ 170 Māori workforce development, a contribution ..................................................................................... 171 Chapter 6 ...................................................................................................................................................... 173 Professional Māori Workforce Development and Environmental Health ............................................ 173 Introduction .......................................................................................................................................... 173 Case I - Professional Māori workforce development: Vision 20/20 .................................................... 173 Case description ............................................................................................................................... 173 Cultural affirmation and supports ........................................................................................................ 176 v Participant revelations ....................................................................................................................... 178 To reach our goal .............................................................................................................................. 181 Why set them up to fail? ................................................................................................................... 183 That’s an unusual choice for a Māori ................................................................................................. 185 It costs a lot of money to run a programme like this .......................................................................... 186 Talking about space .......................................................................................................................... 187 Problems encountered? ..................................................................................................................... 187 Level of Māori involvement in the programme .................................................................................. 190 Measuring programme success .......................................................................................................... 193 What has helped to advance the programme ..................................................................................... 194 Continuous improvement ................................................................................................................. 195 Portability ......................................................................................................................................... 195 Contribution to Māori health development ....................................................................................... 195 Case II - Contemporary health protection environment: Health Protection ......................................... 197 Painting a picture of sameness ........................................................................................................... 197 Regulatory role of health protection .................................................................................................. 199 Working relationships ....................................................................................................................... 201 Māori capacity in health protection ................................................................................................... 203 Māori health protection ..................................................................................................................... 205 Supported, tolerated, joined .............................................................................................................. 211 Māori development ........................................................................................................................... 211 Facilitating policy change .................................................................................................................. 212 Incentives ......................................................................................................................................... 214 Making a difference ........................................................................................................................... 214 Contribution to Māori health development ....................................................................................... 216 Chapter 7 ...................................................................................................................................................... 219 Tipu Ora: Māori Workforce Development and Community Development ............................................ 219 Introduction .......................................................................................................................................... 219 The right message with the right messenger ......................................................................................... 220 Governance along tribal lines ............................................................................................................... 222 Management ......................................................................................................................................... 234 Ngā Kaitiaki – the caregivers ............................................................................................................... 237 Recruitment and selection .................................................................................................................... 239 Kaitiaki employment process ............................................................................................................ 239 Kaitiaki education, training and development .................................................................................... 242 Training facilitators .............................................................................................................................. 245 Tipu Ora’s role in kaitiaki training ....................................................................................................... 246 Specific role of kaitiaki......................................................................................................................... 251 Tipu Ora’s relationship with other iwi/Māori organisations ................................................................. 252 Kaitiaki perceptions of workforce development ................................................................................... 253 Tipu Ora in summary ............................................................................................................................ 256 Chapter 8 ...................................................................................................................................................... 257 Te Rau Puawai: Māori Workforce Development and Community Mental Health .............................. 257 Introduction .......................................................................................................................................... 257 The emergence of a health workforce development support package .................................................. 257 Te Rau Puawai – One hundred blossoms ............................................................................................. 259 A place for Te Rau Puawai ................................................................................................................... 259 Te Kawanatanga o Te Rau Puawai ....................................................................................................... 262 Te hanganga o Te Rau Puawai ............................................................................................................. 264 Te tuituinga o Te Rau Puawai .............................................................................................................. 266 Hei pae āwhina ..................................................................................................................................... 267 Ngā karahipi ......................................................................................................................................... 270 Māori aspects of Te Rau Puawai .......................................................................................................... 271 Destinations of graduates...................................................................................................................... 272 Breakdown of qualifications ................................................................................................................. 273 vi Pass rates .............................................................................................................................................. 276 Workforce contribution ........................................................................................................................ 276 Chapter 9 ...................................................................................................................................................... 279 Māori Approaches to Workforce Development ....................................................................................... 279 Introduction .......................................................................................................................................... 279 Emerging themes ................................................................................................................................. 280 Māori concepts of health .................................................................................................................. 280 Māori leadership potential ................................................................................................................ 282 Funding ............................................................................................................................................ 286 Policy priority ................................................................................................................................... 287 Critical mass ..................................................................................................................................... 289 Whānau concept ............................................................................................................................... 290 Iwi participation ............................................................................................................................... 293 Contribution to health ...................................................................................................................... 294 Critical success factors ......................................................................................................................... 296 Targeted strategies ............................................................................................................................ 296 Critical mass ..................................................................................................................................... 296 Committed funding .......................................................................................................................... 296 Autonomy ........................................................................................................................................ 297 Setting a course for Māori workforce potential ................................................................................... 297 Chapter 10 .................................................................................................................................................... 301 Conclusions .............................................................................................................................................. 301 A Charter for anchoring Māori health workforce development & potential ........................................ 303 Glossary ........................................................................................................................................................ 307 Abbreviations ............................................................................................................................................... 309 Appendix 1 ................................................................................................................................................... 310 Appendix 2 ................................................................................................................................................... 312 Appendix 3 ................................................................................................................................................... 313 Bibliography ................................................................................................................................................ 314 vii