Te Tiriti o Waitangi (Māori text) and the Treaty of Waitangi (English version) and the understandings that surround them constitute and codify the relationship between Māori and the Crown. Under international law the Māori text of te Tiriti, the text which reaffirms Māori sovereignty—absolute territorial authority—is the sole legitimate version of this founding document of the colonial state.1 In 2014 the Waitangi Tribunal2 ruled that Ngāpuhi (and by extension other Māori) did not cede sovereignty by signing te Tiriti, sparking renewed debate about its place in policy. This has been heightened in the health sector with preparations for WAI 2575, the health-related Waitangi Tribunal claims.

The relevance of te Tiriti to health is well-established, particularly in the work of Māori scholars, including Durie,3 Ramsden,4 Reid and Robson.5 This relationship is also established in law through the New Zealand Public Health and Disability Act (NZPHDA) 2000, which requires the health sector to work towards eliminating entrenched health inequities between Māori and other New Zealanders. It expects the sector to engage with Treaty principles of partnership, protection and participation that were developed by the Royal Commission on Social Policy.6 As public health researchers we are proud that the discipline has led this progressive approach, and eager to see the realisation of its potential and real impact on inequalities.

In this paper we assay the development of policy in public health as an indicator of how the sector has attempted to build from the NZPHDA. We are aware that the community engagement that is vital to public health effectiveness means that it will be among the most sensitive disciplines in the domain of health; few other areas will be more active and progressive in working with te Tiriti.

However, the NZPHDA (and indeed health policy during the period of this study) omits any mention of te Tiriti, referring instead to the Treaty principles and the English text. Nevertheless, Boulton and Simonsen7 have argued that the inclusion of Treaty clauses in NZPHDA was a significant step towards its incorporation into the administration of the health sector.

Conservative elements of New Zealand society have vigorously opposed legislative protections of Treaty rights. In the health arena, such pressure resulted in senior management within the Ministry of Health, instructing staff to remove all references to the Treaty from health policy. Such incidents confirm that policy remains a contested site of colonial power, and that decolonisation as represented by te Tiriti promises, and the guarantee of Māori sovereignty, remain distant goals. Meanwhile even achievable aims such as the elimination of health disparities between Māori and non-Māori are underserved by this failure of acknowledgement. In this paper, we review how public health policy (from 2006–2016) representations and particularly their failure to engage with te Tiriti and/or the Treaty, have become a roadblock in progress towards health equity.

Method

Public health policies from 2006 to 2016 were collected from the Ministry of Health’s website under publications: strategies and plans. During this time period there were 121 strategies and plans uploaded onto the Ministry’s website. In this selection we were guided by Winslow’s9 definition of public health as: “...the science and art of preventing disease, prolonging life and promoting health through the organised efforts of and informed choices of society, organisations, public and private, communities and individuals”.

All generic health policy with a focus on treatment, data management, medicines, collation of submissions, progress reports, geographically specific and case studies of organisations were excluded. Workforce planning documents were omitted as they did not cover public health staff. We included strategy and planning documents that were future focused and had a prevention rather than clinical focus. The selected documents targeted keeping the New Zealand population or a particular ethnic group healthy. The selected documents were then assessed with reference to their level of engagement with te Tiriti and/or the Treaty.

Documents that referred to the Treaty were analysed using Braun and Clarke’s well-respected phase method of thematic analysis.10 First, a search for the term “Waitangi” across the policies was made and one author (RC) familiarised herself with this corpus to get a sense of key ideas, actions and intentions. This was followed by a second reading to generate initial codes and allocate data excerpts to codes. Next, these working divisions were named and shaped into draft themes. These were then reviewed by a second author (HC) to ensure themes reflected the coded extracts. Finally, the team engaged in a collaborative analysis to refine the specifics of each theme and these were mapped into a hierarchy of engagement against te Tiriti articles.

Results

We found that between 2006 and 2016, 49 public health policy and strategy documents fitted our criteria. None of the documents referred to the Māori text and 37 (75%) contained no reference to the English version.

Table 1 lists the 12 documents that drew upon the Treaty. Five of these documents were specific to Māori, one targeted a particular population group, one was the core health strategy document and the remainder were issue-specific strategies. Those public health policy documents that did not mention the Treaty covered mental health, addiction, disability, child health and Pacific health plans and strategies.

Table 1: Public health policy and/or strategy documents that reference Treaty of Waitangi.

1.  Minister of Health and Associate Minister of Health. (2006). Whakatātaka Tuarua: Māori Health Action Plan 2006–2011. Wellington, New Zealand: Ministry of Health.11

2.  Ministry of Health. (2006). Ngā kāwai: Implementing whakatātaka 2002–2005. Wellington, New Zealand: Author.12

3.  Thornley L, Waa A, Ball J. (2007). Comprehensive plan to inform the design of a national breastfeeding promotion campaign. Wellington, New Zealand: Ministry of Health.13

4.  Ministry of Health. (2008). Te Puāwaiwhero - The second Māori mental health and addiction national strategic framework 2008–2015. Wellington. New Zealand: Author.14

5.  National Breastfeeding Committee. (2009). National strategic plan of action for breastfeeding 2008–2012. Wellington, New Zealand: Ministry of Health.15

6.  Ministry of Health. (2009). Public health (wellbeing) in New Zealand: Interface with local government. Wellington, New Zealand: Author.16

7.  Ministry of Health. (2010). Preventing and minimising gambling harm: Six-year strategic plan 2010/11–2015/16. Wellington, New Zealand: Author.17

8.  Ministry of Health. (2012). Whāia te ao mārama: The Māori disability action plan for disability support services 2012 to 2017. Wellington, New Zealand: Author.18

9.  Ministry of Health. (2014). The guide to he korowai oranga: Māori health strategy. Wellington, New Zealand: Author.19

10. Associate Minister of Health. (2016). Healthy Ageing Strategy. Wellington: Ministry of Health. Wellington, New Zealand: Ministry of Health.20

11. Ministry of Health. (2016). Strategy to prevent and minimise gambling harm 2016/17 to 2018/19. Wellington, New Zealand: Author.21

12. Ministry of Health. (2016a). New Zealand health strategy: Future direction. Wellington, New Zealand: Author.22 

The documents that did discuss the Treaty engaged with it in different ways (see Table 2). There was a rhetorical level where policy named Treaty principles. Others promoted practical actions towards implementing the Treaty. Some offered high-level aspirational statements around health inequities and articulated a commitment to Māori health outcomes. Some policies addressed substantive issues of relationships, Treaty obligations, Māori involvement in decision-making and service delivery.

Table 2: Crown Treaty of Waitangi health policy matrix.

Rhetoric

 

Treaty principles

(see 1,2,4,5,7–12)

 

Practical implementation

Monitor, audit and/or review effectiveness

(see 1–3,6)

Tikanga and/or Treaty of Waitangi training and/or policy

(see 2,5)

Holistic Māori health models

(see 2,3)

Aspirational statements

 

Health inequities, inequalities and/or disparities

(see 5,6,11,12)

Improve Māori health outcomes

(see 2,4–10)

Substantive

Treaty obligations

(see 6)

Treaty partnership and/or relationship
(see 5,9–12)

Māori decision-making and service delivery

(see 3,4,6,7,8–10)

Note: the numbers here refer to the policy documents named and numbered in Table 1. 

Rhetoric

Most of the policy documents included specific references to the Royal Commission on Social Policy’s6 Treaty principles of partnership, protection and participation. Other Crown-defined treaty principles23 were not named. These Treaty references were sparse and seemed rhetorical in that there were no actions assigned to them. Some documents provided interpretations of the Treaty principles.

Practical implementation

Perhaps reflecting a more authentic engagement, some policies included specific actions. The Whakatātaka implementation plan, for example, committed agencies to engage in developing cultural and political competencies through tikanga best practice and Treaty of Waitangi training for staff. Several documents required developing action plans and/or policies about implementing the Treaty and undertaking stocktakes. Two policies mentioned Māori models of health and holistic approaches to health alongside Treaty references. Practical actions around auditing and reviewing activities to monitor their effectiveness in relation to Māori health were identified. The He Ritenga Health Audit Framework24 was named as a tool in policy documents, as was the Whānau Ora Impact Assessment Tool.25

Aspirational statements

Several policies included aspirational statements around addressing health inequities between Māori and other New Zealanders and made specific commitments around improving Māori health outcomes. One policy explained “Māori have the right to enjoy a health status that is at least the same as that enjoyed by non-Māori”.13 Another notes “The Ministry also intends to identify factors that contribute to gambling harm-related inequities for Māori, and to develop, pilot, evaluate and implement one or more initiatives specifically focused on reducing these inequities”.17

Substantive actions

Several policy documents named the strategic, special nature of the relationship between Māori and the Crown and acknowledged the obligations this placed on the Crown. One policy explained “Māori can be seen as having a right to determine the nature of Māori focused breastfeeding interventions”.13 Another indicated that it provided “… mechanisms for Māori to contribute to decision-making on, and participate in, the delivery of services at all levels of the health and disability sector”.14 Another stated an aim to “… improve Māori health and recognise the Treaty of Waitangi obligations of the Crown”.17 Several policy documents recognised the need for Māori to be involved in decision-making within the health sector and the need for effective service delivery to Māori.

Discussion

Te Tiriti o Waitangi establishes a partnership that recognises Māori as indigenous people and guarantees their sovereignty.2 Article One granted the British the right to govern their people, Article Two reaffirmed Māori sovereignty enshrined by He Wakaputanga, Article Three guaranteed Māori the same rights and privileges as British subjects and Article Four, the oral article, recognised the right of religious freedom.

Working within Article One involves sharing power and establishing structural and other mechanisms to ensure Māori representation and involvement in decision-making throughout the health sector.30 In our analysis of the policy documents, this relates most closely with the domain of substantive action. Health policy more widely has rarely ventured explicitly into this area under a treaty banner. For instance there are only fleeting references in the core health policy documents—He Korowai Oranga19 and the New Zealand Health Strategy22 to Māori involvement in decision-making.

Article Two requires that Māori are able to exercise tino rangatiratanga (sovereignty)—being in control of individual and collective destiny. Complimenting this work has been the removal of barriers and obstacles to Māori success, which involves challenging institutional and other forms of racism. This article aligns across the domains of substantive action, aspirational statements and practical implementation. Inclusion of mechanisms such as policy auditing and monitoring are ways of ensuring policy is accountable to Māori for outcomes. Berghan et al26 argue that Māori providers and/or Māori health promotion have been common expressions of tino rangatiratanga.

Article Three is about embracing ethical decision-making that reduces health inequities and addresses the wider determinants of health.26 This most closely aligns with aspirational statements and practical application. Of the policy documents that included treaty references this was a major focus of their Treaty responsiveness.

Working with Article Four involves normalising wairuatanga, te reo me ono tikanga (Māori language and cultural protocols).26 There is little in the policy documents that addressed this element beyond parts of practical application that recognised holistic models of health.

Conclusion

This study shows that health policy substantively ignores Māori rights as laid down in te Tiriti, in that 75% of our sample is silent in this regard. This marginalisation can be viewed as a breach of the governments te Tiriti obligations and is likely to inform [WAI 2575] health-related Waitangi Tribunal claims. Where there have been efforts at engagement with te Tiriti as a foundational policy framework, we see weak, fragmented work that relates piecemeal to some articles and no comprehensive whole of te Tiriti response. Little is happening in terms of kāwanatanga and tino rangatiratanga, there is some engagement with ōritetanga and limited progress in relation to wairuatanga. Although one can look at te Tiriti in its component parts, it is more useful to look at is as one coherent framework. It seems logical that a multi-level systems approach including strong engagement with kāwanatanga responsibilities and tino rangatiratanga would strengthen Māori health outcomes. Further work is needed to strengthen alignment of health policy to Crown obligations under te Tiriti.