A scheme that gave free nappies and food vouchers to Māori families to encourage them to have their children vaccinated has been abandoned after a review concluded the barrier to immunisation is an "inherently racist, failing and culturally incompetent" health system.
Counties Manukau DHB has determined the year-long "incentives" pilot hadn't made a clear difference. Instead, its evaluation report recommended health workers get training to counter "cultural microaggressions, white privilege, stereotyping and prejudice".
The extraordinary findings come amidst growing concern about falling rates of young children getting immunised against life-threatening diseases.
In Counties Manukau, on-time immunisation coverage for Māori 8-month-olds was just 68 per cent in May, the latest figures available show - down from 85 per cent a year earlier, and well below the national target to have 95 per cent of kids protected.
Nationally, there's been an overall decline in coverage, and among other ethnicities including Pacific and NZ European.
"We are very worried. Measles is way more infectious than Covid. It would be very easy for measles to come back," Dr Nikki Turner, director of the Immunisation Advisory Centre, told the Herald.
More resourcing for "very stretched" childhood immunisation services was urgently needed, she said, to avoid the sort of measles outbreak seen in 2019, which put children in intensive care before spreading to Samoa and taking 83 lives.
"Childhood vaccination rates are diving in many countries which are disrupted by Covid. If we drop our immunisation coverage we are at high risk of measles when we ease up on the border restrictions."
How to reach families who are not getting their children vaccinated has been a long-running problem. Outreach immunisation services (OIS) follow up with children who are overdue for jabs, including by going to homes to administer them.
Counties Manukau DHB trialled a scheme that gave "incentives" - nappies and a $20 petrol or grocery voucher - to Māori families in contact with outreach services.
The pilot ran to May 2020. An evaluation, released to the Herald under the Official Information Act, found no strong evidence the gifts made a difference.
The scheme "takes the onus from a failing and culturally incompetent system, viewing Māori as outputs or objects of the health system, rather than acknowledging the whānau as a system, with its own objectives, autonomy and health indicators", the report stated.
Interviews with 14 families "revealed criticisms of racism in General Practice, as well as the OIS Plunket service". Most described immunisation experiences at GPs that left them feeling uncomfortable, unwanted and uninformed.
Other reasons for not going included a lack of choice, including because some practices had full enrolments or weren't within walking distance.
"Whānau were in a constant state of stress forced to engage in a system that is inherently racist. Implicit and explicit biases, as forms of racism were present in both whānau and staff interviews," the report stated.
One vaccinator told reviewers: "We don't want to give them a voucher that the family would be tempted to go and buy booze or something ... I'm just saying, like there's smokers in the household."
The report was produced by Ko Awatea, the DHB's centre for "innovation and improvement". Its recommendations included to "recognise and challenge ethnic biases among staff, and in the processes of the OIS system", and set-up a "framework for institutional cultural change".
"This should aim to decolonise dominant discourse and biases," the report explained. "Understanding of the journey from historical trauma to the manifestation of Māori health status today is integral for staff to increase cultural competency and responsiveness."
Māori needed to be represented in the leadership of the service, the review recommended, with Kaupapa Māori practices introduced.
About half of the families interviewed only knew of the incentives when they were given them at their first home visit. They were grateful, but most indicated the gifts wouldn't influence their decision to immunise. One mother proposed using the money on widening the service's reach.
The six OIS workers interviewed were generally sceptical about the scheme, the report noted. They already regularly gave free nappies "and were unconvinced a twenty-dollar voucher could influence a historically hard to reach population to engage and develop positive immunisation attitudes and behaviours".
Many felt uncomfortable giving what they believed could be seen as a bribe. "I know my team hated the incentive programme," one said. A lack of health literacy and the power of the anti-vaxx movement were identified by staff as major problems.
Counties Manukau DHB has now ordered a wide-ranging review into childhood immunisation, and is taking control of OIS from contracted provider Plunket.
The DHB's chief executive Fepulea'i Margie Apa said the evaluation would help "inform the development of approaches that are culturally safe and responsive to the needs of whānau Māori".
Counties would also "work with existing providers to address the evaluation findings regarding cultural safety within the service with a view to immediate improvements", Apa said. "Opportunities to make more substantive changes will also be explored and we are planning on working closely with Māori providers to explore alternative options."
Amanda Malu, chief executive of Whānau Āwhina Plunket, told the Herald the organisation acknowledged the findings of the evaluation review, which "provide important insights", and align with work already happening to improve services for Māori.
Counties took over the OIS contract in order to better integrate it with Covid and MMR vaccinations, Malu said.
By year end, all Plunket staff are expected to have completed "being a better Treaty partner" training, which covers the impacts of colonisation, implicit bias, racism and privilege.
"We are absolutely committed to addressing unconscious attitudes and uninformed beliefs among our staff," Malu said. "We are changing how we work with whānau Māori to acknowledge the inequities, bias and racism Māori have experienced right across the health system. Like most organisations we know we still have a lot to do."
Dr Rawiri McKree Jansen, the clinical director of the National Hauora Coalition, said taking OIS off Plunket was the right thing to do.
"The evaluation is one of the strongest-worded reports I've ever seen ... I don't think it's totally saying incentives don't work. But it is clearly saying, 'incentives in the hands of this service provider did not work'."
The National Hauora Coalition is a clinical network of 57 practices, serving more than 230,000 patients. McKree Jansen said childhood immunisation rates among their families hadn't dropped by nearly as much after Covid-19 disruption, and he invited Counties Manukau DHB to work with the coalition.
Turner, of the Immunisation Advisory Centre, said coverage rates, particularly timeliness of vaccination, had fallen dramatically after Covid-19 struck, in many areas. They improved for a time, but fell again this year.
There were many factors behind the drop-off, Turner said, including badly stretched health services, the need for more cultural sensitivity, and increasing poverty and stress on families, who move more because of the housing crisis.