The Waitangi Tribunal will dissect over 200 claims of inequality and system failure.

The perilous state of Māori health has been described as a humanitarian crisis. It's now under investigation by the Waitangi Tribunal, with more than 200 claimants accusing the Crown of operating a sick, racist system that fails Māori. Carmen Parahi reports.

New Zealanders find it hard to believe not everyone is treated the same in the health care system.

After all, practitioners are ruled by professional codes of ethics and the system was set up and administered by the government.

But when this scenario is put before some of the Māori health claimants they have a different story to tell.

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"It's a myth. Māori are not treated equally," says claimant Simon Royal, chief executive of the National Hauora Coalition, the largest Māori primary health organisation in the country.

"New Zealand does not have a handle on the deep unconscious bias being experienced by Māori."

The WAI 2575 Health Services and Outcomes hearings start on Monday at Tūrangawaewae marae, Ngaruawahia.

The panel will hear from claimants Māori die earlier and suffer the worst health outcomes. One claimant, Huntly kaumātua and former Māori health executive Taitimu Maipi says in his evidence it's a by-product of entrenched institutional racism.

Another claimant, New Zealand Nurses Organisation Kaiwhakahaere Kerri Nuku says the system isn't culturally safe for Māori as a worker or user, who may experience prejudice from a health professional or suffer from systemic bias.

In the Ministry of Health's Māori health chart book 2015, it shows the self-reported experience of unfair treatment by a health professional on the basis of race was three times higher for Māori than non-Māori.

Nuku says a nurse was once told by her non-Māori colleagues: "Māori don't give organs so they shouldn't be the first to get them."

It's just one of many incidents she claims Māori nurses deal with behind closed doors.

"Institutional racism within the health sector is a wicked problem, that is, it is complex, difficult and highly resistant to solutions."

A HISTORY OF INEQUALITY

Since the signing of the Treaty of Waitangi in 1840, Māori have sought equality with the Crown as treaty partners.

Māori sold or donated land to the Crown for hospitals but few were ever built. Introduced diseases such as influenza wiped out thousands, and by the turn of the 20th Century, the Māori population was decimated.

Although Māori health has improved, compared to other ethnic groups they suffer worse outcomes across all conditions.

It has taken a long time for the Crown to acknowledge its role over Māori health disparities.

"The Crown's response to institutional racism within the health sector has been a mixture of silence, inaction, denial and resistance," says Nuku.

Māori concerns were largely ignored until the Crown's own evidence started to pile up.

ALDEN WILLIAMS/STUFF Dr Rawiri Jansen at Papakura Marae hauora or health clinic. He says health services must include the social issues affecting patients not just the illness.

CROWN OPEN TO CHANGE, ACCEPTS NO BLAME

Since 2000, implicit in government legislation, official health reports and policies are details of racism, inequity in care and poor health outcomes for Māori.

"The evidence for inequities is unimpeachable right now," says Dr Rawiri Jansen.

Jansen is representing Māori practitioners at the inquiry. He believes equity is possible within a generation and cites a recent example, 15.5 per cent of graduating doctors being Māori, proportional to the Māori population.

He says the tribunal's non-binding recommendations need to be strong and the government willing to act on them.

In the New Zealand Public Health and Disability Act 2000 it states, '... must reduce health disparities by improving the health outcomes of Māori and other population groups.'

The Crown's tribunal evidence does not deny inequity and agrees it's unacceptable but doesn't go so far to accept any blame.

It's evidence details a long list of active steps it's taken over time to address the issue.

ALDEN WILLIAMS/STUFF Simon Royal says New Zealand does not have a handle on the deep unconscious bias being experienced by Māori.

Surprising claimants, the Crown has taken a non-adversarial stance for the inquiry and wants to hear what solutions Māori may have.

The Ministry of Health's Alison Thom, Māori Leadership says this is an important inquiry and wants it to be successful.

"We hope it will assist and inform decision-making and policy development for health services and improved outcomes for Māori, and supports increased Māori participation in the health and disability sector," says Thom.

"Ministry sets the direction for Māori health and is committed to guiding the sector as we work to increase access, achieve equity and improve outcomes for Māori."

Māori and the Crown are finally on the same page about Māori disparity but at odds on how the innumerable problems should be fixed.

This is where the Waitangi Tribunal comes in.

DISSECTION OF A SICK SYSTEM

Māori health grievances have been documented by the tribunal in different claims since it was established in 1975.

In 2011, the tribunal identified Māori were undergoing a serious health crisis.

This investigation is the third of 11 kaupapa inquiries, set up to look at a single theme of national significance such as health, the military, constitutional issues, justice etc.

The tribunal has wrestled with the sheer volume and scope of this inquiry. There is no closing date for lodging a claim, and 205 have already been received so far but more are expected.

It will investigate the claims in three stages - stage one, which starts on Monday, is a targeted inquiry into the legislative and policy framework of the primary healthcare system.

The tribunal focused the stage one hearings to two claims from Māori primary health organisations and providers in Wai 1315 and the National Hauora Coalition in Wai 2687. Both groups lodged their claims over 10 years ago.

In stage one, other claimants can only appear as interested parties, their evidence to form part of the tribunal's considerations.

Late in 2019, the tribunal will start stage two looking at Māori mental health, disability, alcohol and substance abuse. The parameters of the final stage are yet to be announced.

The diversity of the claims, from nannies helping meth junkies to dentists to personal grievances to a claim against the Counties Manukau DHB means claimants are all competing, demanding attention from the tribunal.

Some claimants have been critical of others but despite their differences say they're united by one kaupapa or purpose, improving Māori health.

The entire inquiry including submissions, hearings and recommendations for the three stages could take up to five years.

Alden Williams Papakura Marae Pharmacy in South Auckland, one of many services offered by the Māori hauora or health clinic.

AN UNEVEN PLAYING FIELD

Claimant Simon Royal says the health system has failed Māori, "this ought to be considered a humanitarian crisis".

In the Ministry of Health's Māori health chart book 2015, life expectancy at birth was 73.0 years for Māori males and 80.3 years for non-Māori males. For Māori females it is 77.1 years compared to 83.9 for non-Māori females.

A range of heart conditions clearly demonstrates disparities between Māori and non-Māori. For instance, the cardiovascular disease and heart failure mortality rates are twice as high. Stroke mortality is one and a half times higher and rheumatic heart disease deaths five times higher.

Total cancer mortality is more than one and a half times higher for Māori than non-Māori. For many cancers the registration rates were less than or similar to non-Māori yet the mortality rates are higher suggesting Māori have a higher risk of dying.

For example, the mortality rate for cervical cancer is two and a half times higher for Māori women and the disparity for lung cancer is four times higher.

In Māori males, lung and liver cancer rates was nearly three to three and a half times higher than non-Māori men.

The Waitangi Tribunal's list of Māori health issues is eye-wateringly extensive but sums it all up in just one sentence.

"Many of these illnesses and problems are practically at epidemic levels," says the tribunal.

But it's not just health outcomes under scrutiny, so is the system.

In 2000, the government reformed the health system introducing a new health, primary healthcare and disability strategy.

A public private model it set up 20 health systems or district health boards (DHBs) across New Zealand. Each DHB has many functions including to govern, fund and approve primary health organisations (PHOs) and service providers in their regions. A model Royal argues has limited Māori ambitions to address inequity and improve outcomes for Māori. He's the chief executive of the largest Māori PHO in the country, the National Hauora Coalition (NHC). The trust has over 130,000 patients and is chaired by former Associate Minister of Health Tariana Turia. Royal claims Māori organisations including his own have been hamstrung by DHBs. He calls it racist and a breach of treaty rights. He says there was enormous resistance to rolling out a successful Auckland rheumatic fever programme in the Bay of Plenty and Northland. "We cracked the code to make it work," he says. "To not then have it available to other parts of New Zealand is reprehensible and speaks to the structural issues." The Crown concedes in its tribunal evidence when it created the model there was an uneven playing field, which meant some organisations were able to thrive in the new regime while others struggled especially startup Māori, Pacific and refugee outfits. Maihi says in his claim: "I believe Māori PHOs and providers have been set up to fail". Māori health providers received less than 2 per cent of the overall health budget from the Ministry of Health and the DHBs between 2011 and 2016.

She says the intent to improve access for everyone meant funding was not based on ethnicity and deprivation, it disadvantaged high needs providers including Māori.

"On reflection we now see this funding proved insufficient to service these high needs populations," says Brooking.

MAKING MONEY OFF SICK MĀORI

Royal says the health system is an economic system, people are profiteering off the sick.

"Our concern is Māori ill health is perversely an incentive or sits as a way of incentivising the system to stay the way it is."

He says the government hasn't got a handle on how different health organisations charge the public for medical care and receive taxpayer funding.

It's one of the concerns raised by Brooking in her evidence.

She says there has been an increase in the power and scope of general practice organisations who've benefited the most from the strategy.

"If you didn't have unwell Māori how big would your business be? We're like an input to an economic machine," says Royal.

Stuff asked Royal if his PHO was trying to profit off sick Māori too.

"Our agenda is equity. We have one kaupapa. Add value to the lives of whānau through the health system."

A NEW, MĀORI SYSTEM

During the hearings, over 50 witnesses will testify - but they will have just 15 minutes to state their case with a few exceptions. All will argue the system needs Māori values to fix inequity and improve Māori health. Any service for Māori needs to factor in the social determinants impacting on a patient too such as poverty, poor housing, family dynamics etc.

Maipi will demand a new system based on an overseas indigenous model.

Royal plans to push for either a national Māori DHB or a standalone Māori hauora or health system based on matauranga or Māori knowledge.

"Those solutions need to be Māori led, adequately resourced, supported by government," says Royal.

But the new director general of health Ashley Bloomfield, who will appear before the tribunal, has already stated his preferred position.

He will not back a new Māori model but does want to fix the current system.

In his evidence Bloomfield says the system already has a Māori strategy in place called, He Korowai Oranga and includes the claimants aspirations.

"The wider health care system should not be discharged of responsibility to be responsive to Māori and to improve equity for Māori," says Bloomfield.

He says currently Māori receive their health services mainly from mainstream services, not from Māori providers and the choice should remain.

"I anticipate a stronger Māori provider sector will lead to more Māori accessing services from Māori providers and that this would be a positive outcome.

"I want to be part of this success story and am looking for ways to strengthen Māori providers."

Royal says the Crown has had its turn and failed.

"All we are hearing is more of the same just give us one more go.

"Māori tolerance now for government failure in the system is at an all time low."

Significantly, the tribunal's inquiry recommendations will be included in the government's own Health and Disability Service Review due in August 2020.

"There doesn't need to be more new money pumped into the system just a smarter use of existing money," Royal says.

"The government in many respects needs to get out of the way of Māori - allow us to develop solutions for ourselves rather than making decisions based on what they think is in our best interests."

Stage one of the Health Services and Outcomes Kaupapa Inquiry starts on Monday at at Tūrangawaewae marae in Ngaruawahia, and will run over three weeks.

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