Providing health services to indigenous peoplesBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7412.408 (Published 21 August 2003) Cite this as: BMJ 2003;327:408
- Mason Durie, professor of Maori research and development ()
A combination of conventional services and indigenous programmes is needed
Although indigenous health is influenced by many factors outside the formal health sector, access to quality health services is none the less an important determinant of good health.1 In New Zealand, efforts to improve Maori health have resulted in substantial shifts across the entire health sector. The primary driver for reorienting health services is linked to health gains and a reduction in disparities between Maori and non-Maori. However, the position of Maori as indigenous people adds another dimension, reflected in section 8 of the New Zealand Public Health and Disability Act (2000), requiring health services to recognise the principles of the Treaty of Waitangi, an 1840 agreement that saw sovereignty exchanged for Crown protection. Because of the treaty, Maori occupy a position that is not afforded other non-indigenous ethnic minority groups, even where comparable standards of health exist.
The New Zealand health strategy
Of the several approaches to improving health services for indigenous health two broad directions can be identified: increasing the responsiveness of conventional services and establishing dedicated indigenous programmes. Both approaches are endorsed in legislation and government health policy. The New Zealand health strategy, for example, sets out the government's broad health goals and major priorities for the development of the health service.2
The New Zealand health strategy is broad in its reach. It aims to influence macro policies such as labour market policies, population approaches to health, and personal health services. In this respect it is consistent with the Maori holistic approach to health and the intersectoral determinants of health.3 Yet it is difficult to predict the effect the strategy will have on the status of Maori health. For each objective there are clear measures so that within two to three years it should be possible at least to assess progress. However, because the strategies are so broad, progress will not come from the health sector alone but from a range of policy areas. Unlike non-Maori mortality rates, Maori rates have not declined over the period 1980-99, and the widening disparity coincides with major economic and structural changes in New Zealand during that period.4
Less clear in the strategy is how funding will match the goals, objectives, and service priorities. Without a realistic level of funding no amount of goodwill will lead to significant changes. Furthermore, funding to reduce the other socioeconomic gaps (such as housing, education, and employment) must accompany health funding. Although an emphasis is placed on intersectoral gains, there is no clear methodology for achieving the necessary level of collaboration across sectors.
Much work is also needed to develop appropriate progress measures. Simple indicators such as hospital admissions, death rates, and average life expectancies are useful but are not capable of capturing more subtle changes. In moving from input and output measures to measures of outcome, as signalled in the strategy, there is a corresponding need to frame indicators around Maori perspectives of health.5 Comparisons with non-Maori may be less helpful than comparisons between Maori groups or other indigenous peoples.
The strategy recognises the broad approaches to Maori health taken over the past two decades. Improved responsiveness requires health services to recognise the significance of culture to health6 and to adopt methods that actively engage patients–through appropriate language, respect for custom, the use of culturally validated assessment protocols and outcome measures, and the employment of indigenous health workers.
Indigenous health services
Indigenous health services provide a range of healing methods, including conventional professional services and traditional healing. Probably their most significant contribution is improved access to health services for indigenous people, enabling earlier intervention, energetic outreach, higher levels of compliance, and a greater sense of community participation and ownership. Indigenous services tend to be built around indigenous philosophies, aspirations, social networks, and economic realities.
As noted in the New Zealand health strategy, development of the workforce is a common theme in the development of indigenous health. Maori make up around 14% of the total population but only 5% of the national health workforce.7 On equity grounds, indigenous participation in the professional health workforce should match community demographic profiles and may challenge health educators to review admission criteria and the content of curriculums. Indigenous health workers are often employed as cultural or community aids bringing first hand knowledge of the community and a capacity to engage reluctant patients. However, they should also be well enough versed in health issues to make informed decisions about patients' referral and management. Otherwise there is potential for professional and cultural interventions to diverge.
While there is some debate about which approach is likely to produce the best results, in practice conventional services and indigenous services can exist comfortably together. More pertinent is the type of service that is going to be most beneficial to meet a particular need. In general, indigenous health services are more convincing at the level of primary health care. Higher rates of childhood immunisation, for example, sem to be possible with services that are closely linked to indigenous networks, and early intervention is embraced with greater enthusiasm when offered by indigenous providers.8
Conventional health services and indigenous services need, however, to work together within a collaborative framework.9 Clinical acumen will be sharpened by cultural knowledge, and community endeavours will be strengthened by access to professional expertise. It makes sense to build health networks that encourage synergies between agencies, even when philosophies differ.
Because indigenous services are well placed to foster greater awareness of health issues, sponsor a stronger sense of self management, and promote healthy lifestyles, they represent innovative and important components of the health care system, complementing other initiatives.
Competing interests None declared.
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