Providing access to the Covid-19 vaccine to everyone in the region was always going to be a challenge for health providers in Northland.
A leading health advocate has now come out saying despite sufficient resources the vaccine rollout wasn't equitable and failed Māori.
Health authorities rejected the notion arguing everyone had worked hard to achieve the best possible outcome for all of Tai Tokerau.
After reaching the 90 per cent hurdle for the first dose among all ethnicities, Northland along with Bay of Plenty and Whanganui is yet to reach the 90 per cent mark for the first dose among the Māori population.
Dr Clair Mills, hauora (health) lead for Tai Tokerau iwi collective Te Kahu O Taonui, says the rollout strategy doesn't fully account for Māori needs despite historic experience with vaccination campaigns.
As the former Northland District Health Board medical officer of health, Mills was one of the drivers behind the 2011 immunisation campaign during the Group C meningococcal disease outbreak.
She said she pushed hard to overcome inequities back then but "unfortunately the DHB didn't learn much".
"We tried a lot of things to ensure that we got an equitable vaccination coverage.
"I pushed for things like having vaccination stations in the shopping centres, having mobile vans and it took a lot of energy.
"It didn't make me popular but we did get there," Mills said.
"We also saw for many communities you have to make it about something that's more holistic and about their health and wellbeing."
A 2018 report by the Ministry of Health found that "persistent disparities in health access, quality of services and outcomes remain" in New Zealand, despite efforts to overcome inequities.
The report also states that differences in health were not only unnecessary and avoidable "but, in addition, are considered unfair and unjust".
The ministry goes on to explain that "uniformity fails to account for the contextual differences between people, such as age, gender, ethnicity, socio-economic status, disability, as well as access to primary health care".
Therefore, equity in health implies resources are distributed and processes are designed in ways most likely to equalise the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts.
Māori have on average the poorest health status of any ethnic group in Aotearoa and are more likely to live in areas of high deprivation than non-Māori.
Living in overcrowded households in remote areas with little access to services, underlying health conditions including diabetes and heart and lung conditions, higher than average smoking rates indicate that Māori have a disproportionate health need.
Mills criticised that despite this prior knowledge, Māori health providers were funded late and the vaccination effort wasn't well coordinated.
"We have the capacity if we want to share our resources around with Māori providers and we have to ensure we engage with our whānau and communities to make sure they feel okay to come in.
"There are lots of things that we can do better. The problem is if you have been doing your best and always get the same results, which is inequitable coverage, it's not very intelligent to keep doing the same thing."
In September last year, the Government reprioritised up to $5 million for the Covid-19 Whānau Recovery Fund to provide immediate relief to vulnerable Māori and communities with the initial focus being Auckland, Te Tai Tokerau, and northern Waikato.
Later that month a funding boost of $36m was set aside to provide additional support for Māori health providers to respond to the Delta outbreak in the same three regions.
Despite the financial support, the Haumaru Covid-19 Priority Report by the Waitangi Tribunal last year slammed the national framework which dictated the vaccination rollout and specifically notes concern for Northland whānau.
"With regard to the vaccine rollout, we heard evidence that the Crown had failed in not prioritising Māori so as to account for the disproportionate risk posed to them," the Haumaru report states.
The Ministry of Health justified its strategy which prioritised border and frontline workers, the elderly, the disabled and those with underlying health conditions without taking ethnic health disparities under consideration.
"We are using age bands because it's simple and easy to understand, we are starting with older people first because they are more at risk if they catch Covid-19," the ministry said in August 2021.
Māori have a younger age structure than the non-Māori population with 77 per cent of the Māori eligible population being under the age of 54 and gaining access to the vaccine later in the rollout.
"The opportunity for significant numbers of the Māori people to be vaccinated will not occur until vaccinations start for this age group," the ministry admitted.
Northland District Health Board chief executive Dr Nick Chamberlain explained that in April 2021 Northland was the first DHB in the country to open vaccination up to whānau Māori over age 12.
"Northland DHB chose to prioritise our over 50 years of age Māori and Pacifica population (and the whānau they lived with) to improve equity and provide as much protection as possible to people who were more vulnerable to Covid-19," Chamberlain said.
"It is therefore incorrect to say that a large population of elderly pākehā in the region were granted access to the vaccine first."
Chamberlain said the DHB was disappointed in Mills' suggestion that the vaccination programme could have been better coordinated.
"Hindsight is wonderful, but so many dedicated healthcare workers who have worked extremely hard on this programme we would prefer to focus on the strengths while continually improving how we all work together.
"Dr Mills has recently returned to New Zealand and, as such, was not in the country for the majority of the vaccination programme roll-out.
Before her position as hauora lead for Te Kahu O Taonui, Mills was the medical director for Médecins Sans Frontières (Doctors Without Borders) in France and had returned to New Zealand in November.
She said she not only followed what was happening in New Zealand while she was away but was also briefed by iwi.
But Chamberlain retorts that providers – including the Māori health providers Mills now works with – from across the region "have worked collectively to coordinate hundreds of clinics that have provided multiple opportunities for people to receive their vaccination".
"This has included fixed clinic sites that have operated seven days a week since March 2021, 79 outreach clinics that travelled into remote Northland, clinics on Marae and mobile clinics that visited suburbs," Chamberlain said.
"All eligible Northlanders have had multiple opportunities to receive the Covid-19 vaccine.
"Northland has received many requests for support whether that be for staff or funding and no request has been declined."
When asked why effective tools such as mobile clinics, were not utilised early on in the rollout, Chamberlain explained:
"In the early days of the vaccination programme cold chain management of the vaccine was very strict and as such, it meant that mobile clinics could not be considered at that time."
The DHB was also working with other constraints in the early days of the vaccination rollout including issues with the national booking system and hold-ups due to vaccine supply.
During Monday's NDHB board meeting, board member Dr Kyle Eggleton enquired about what Māori health providers have asked for and what the DHB hadn't been able to provide to date.
Chamberlain replied: "We have not refused a single request."
Māori health providers had asked for extra staff but there were no people available, especially after losing some of the workforce to the vaccine mandate.
For Geoff Milner, chief executive of the Ngāti Hine Health Trust, Northland's biggest Māori health provider, the discussion about what could have been done differently is not important.
His focus is on "getting the job done".
"These are the challenges of living and developing in Northland.
"Northland was never going to be first to reach a high vaccination coverage.
"Our job is to rise to the challenge. We will get there, just not on anyone else's timetable."
Meanwhile, Martin Kaipo, chief executive of Te Hau Āwhiowhio ō Otangarei Trust who is one of the Māori health providers to drive the vaccination campaign in urban Whangārei, agreed with the notion that coordination between Northland DHB and Māori health providers could be improved.
"We're working in a silo-type of format. Everyone is doing their own stuff. The DHB is not able to streamline communication and we have to chase after information," Kaipo said.
His major concern at this stage of the vaccination campaign, however, were anti-vaxxers who Kaipo labelled "urban terrorists" who intimidate others and damage properties.
Equity and equality – what's the difference?
Equity means that people's needs rather than their social privileges determine the distribution of goods – or this case health services.
Pursuing equity in health means trying to reduce avoidable gaps in health care between groups. It recognises that different people have different privileges and access to different goods and services.
Equality, on the other hand, means everyone is the same and gets the same. Uniform approaches are equal because they provide the same care to every person.
However, this strategy becomes inequitable or unfair as soon as there are differences between groups.