For South Auckland's frontline Māori health providers, Covid is a head-shaking reminder of the gulf between bureaucracy and reality
It is difficult delivering health services to very vulnerable communities in South Auckland during so-called "normal" times for any practitioner, let alone for patients requiring more than a standard 15-minute consultation. The past 18 months have seen a radical shift in how health can be delivered, and what works best. The pandemic has given Māori health organisations the opportunity to work with their communities in ways unimaginable two years ago.
Four Māori health providers stand like pou (pillars) in South Auckland. Combined, their influence stretches across the western side of the Manukau region, from Māngere in the north to Franklin in the south. They are led by a formidable collective of urban Māori health leaders. Together, they deliver healthcare to this youthful, culturally diverse region. They are proud about what has been achieved so far, while acknowledging that much more has to be done.
/cloudfront-ap-southeast-2.images.arcpublishing.com/nzme/X732TA4D7QIKU2NXHABW577WMU.jpg)
Turuki Healthcare, Manurewa Marae, Papakura Marae and Huakina Development Trust serve the people of South Auckland.
Te Puea Winiata ((Ngāi Tamarāwaho, Ngāti Ranginui, Ngāiterangi), chief executive of Turuki for 12 years, is based in Māngere. Influenced by her parents and her grandfather, a matakite (visionary) and tohunga (healer), she has always worked in the sector, initially as an addiction counsellor and later a care and protection social worker.
Winiata reflects that as she gets older, she can see the pathway of her journey a lot clearer. It keeps unfolding as history repeats itself but with different people in the role. For Winiata, who was named after Te Puea Hērangi, her role at Turuki aligns with Princess Te Puea's aspirations for her people. There are significant intergenerational connections between Winiata's family and Tainui that are not there by accident. Those networks continue to be strengthened with Winiata as a health provider in an important Māori network.
Manurewa Marae, built by local families in the 1980s, sits on land gifted by the former Manukau City Council. Takutai Moana Natasha Kemp (Ngā Rauru, Ngāti Tūwharetoa me nga iwi o Mōkai Pātea ki Taihape), chief executive of Manurewa Marae, was barely six months into her role when Covid struck. Kemp, from an army family, was raised by her grandparents and immersed in tikanga Māori. Her grandfather was a tohunga.
She has a long history working in health, being mentored by Syd Jackson when he was establishing Turuki Healthcare in the late 1990s.
Advertisement
Advertise with NZME.For Kemp, it is about people. "People are paramount, look after the people and everything will follow. It is always about whānau. Turuki was formed on the principle that if you looked after the māmā, then the pēpē [baby] will thrive."
Papakura Marae, lying on Ngāti Tamaoho/council land, straddles industrial and residential communities. It is surrounded by new housing estates and redeveloped parcels of land. Tony Kake (Ngāti Hau [Ngā Puhi], Ngāti Mahuta, Ngāti Whawhakia [Waikato Tainui]), born and raised in Papakura, the marae's chief executive for 11 years, knows the business inside out, having worked for central and local government, including the Counties Manukau District Health Board.
Kake is essentially on secondment from his hapū and ultimately will return to Whangārei, where his father is buried. He learnt a lot from his parents. "My father was a fisherman. We'd go fishing together. We might say only 10 words all day, but it was enough. My dad taught me patience, humility and to never give up."
/cloudfront-ap-southeast-2.images.arcpublishing.com/nzme/NL3UWRLT7ABNC3GS2KI4OFPMTY.jpg)
Kake doesn't like the term "provider", because it has connotations of being subservient in the funder-provider relationship. He often says there are only two ships that will survive in a storm: partnerships and relationships. Both are based on trust and respect.
Further south, in Pukekohe, is Huakina Healthcare. Maria Clarke (Ngāti Kapumanawawhiti, Ngāti Raukawa ki te Tonga) has been Huakina's tumuaki for four years.
The Huakina Development Trust, originally established to advocate on environmental issues affecting the Waikato River and the Manukau Harbour, soon also became involved in addressing social and health issues. The medical clinics have grown from addressing those concerns.
Huakina's vision, Ka tū Rangatira ai hei oranga tātou (standing up for our survival), starts with whānau, just as Clarke credits her upbringing for her values. "Our grandmother loved every grandchild. You don't forget that. People need to belong. For our little cousins, being part of a marae, learning to set tables, wash dishes, clean toilets, and make beds all adds up to caring for all who visit."
Clarke would rather Māori health providers be called kaupapa organisations that deliver services to their people and everyone else who asks for support. "Whanaungatanga is us knowing our relationships and organising ourselves around what we need to do to manaaki whānau (care and respect). The phrase 'Māori providers' is to differentiate us from other ethnicities; it doesn't explain what we do. We serve everyone, not just Māori."
Advertisement
Advertise with NZME.Building trust
All four kaupapa organisations work as a collective for South Auckland. They are a tight team who trust each other implicitly, knowing how each other will respond in any given situation.
Winiata is clear that it is their right to deliver services that are most appropriate for Māori. She knows from experience that things can go wrong in the predominant culture's services. "We work in a system that doesn't get it. People are employed to be this bit and that bit, and there is huge difficulty in joining everything up.
"You have to see the whole person, not just the diabetes or the broken arm. Working in a kaupapa Māori space, you need to consider the medical issues plus whether this person has kai on the table, a roof over their head or their wairua [spirit] is being impacted on."
All providers agree that building trust with Māori is paramount. Winiata says there are issues in building trust with whānau after multiple generations have received care that is not appropriate for them. "Whatever a kaupapa organisation does, it has to be about building a relationship and working to the aspirations of what a person wants, not what we want for them."
/cloudfront-ap-southeast-2.images.arcpublishing.com/nzme/4GB3WYAZFQQM3A3LCLHHWK3FMY.jpg)
Clarke agrees. "Māori do not trust the health system, full stop. And they don't trust us [if we deliver along European lines]." She reiterates the gulf between non-Māori and Māori health practices: "If you are whānau-centred, you aren't going to deliver health in silos."
Manurewa Marae's Kemp knows that health services for Māori, by Māori will prioritise their needs as Māori so they are at the top of the ladder, not at the bottom.
Kake is emphatic that it is about whānau. "It is about bringing decision-making as close to whānau as possible. We have a kahupapa [layering] role where we spread the korowai [cloak] around the whānau to support them until they are strong and confident in themselves to fly."
Delivering the vaccine
When the Covid-19 vaccination delivery scheme was rolled out, these kaupapa organisations chalked up a series of national firsts: the first marae to vaccinate residents; the first marae to have a drive-through; the first health provider nationally contracted to immunise staff at MIQ centres.
All four know that marae around the country are used to working during crises. It has been the same during Covid. Kake is proud that while others shut up shop, they expanded their services. "Our staff are tired. They need a break. But not right now. To them, it is all about the collective, not the individual. It is about manaakitanga values – making people feel welcome, kindness, respect, humility and honesty. We ask people when we employ them, 'Will you love our whānau as if they were your own?' I don't care how many letters someone has after their name; if they can't love our whānau like they are one of their own, they will not cut it on our marae."
Kake continues: "The real story here is in the combined Māori effort, which goes far beyond vaccinations. It's the combined package: a do-what-it-takes attitude. Vaccinations, Covid testing, noho tapu – self-isolation support, providing kai, vouchers, social services, mental health, family-violence counselling, medical centres operating through adversity and challenges (high risk) and anything else whānau need. I say this because the vaccination effort is absolutely admirable, but the manaaki over and above has been extraordinary – and unequalled anywhere else in the country when you consider the demographic and whānau challenges we all face in Tāmaki ki te Tonga [South Auckland]."
All the organisations have flexed and changed to accommodate the evolving community needs. Before Manurewa Marae became a vaccination centre, the marae board had a long kōrero about it. They concluded it was a safe space, and should be open to everyone as a community urban marae. They covered the floor of the wharenui to protect it – as, usually, all visitors remove their shoes when they enter as a mark of respect. Then they began vaccinating the community.
/cloudfront-ap-southeast-2.images.arcpublishing.com/nzme/ZBXGP3NXSS3MN6WPMGAMEI66GY.jpg)
At Papakura Marae, Dr Rawiri Jansen asked Kake to do the drive-through vaccines. The marae was set up in 72 hours, with Fulton Hogan laying tarseal so the cars could drive through. The rationale is simple and convenient: people can stay in their car with whānau, listen to music and relax.
For Clarke, things have changed since Covid hit her community. "Before Covid, our suggestions on how best to care for our people fell on deaf ears. Now, everyone wants to understand this kaupapa."
At the start of vaccinating people on the marae, the booking procedures were not synchronised into existing provider systems and people were turned away. It was an intensely frustrating time for all involved.
Kemp found herself at the sharp end of advocating for a different booking system. "It was tough at the beginning. The system was never designed for us [Māori]. There were five providers working on the vaccination bookings, but the marae didn't have access to that list. Our people don't book; we [Māori providers] all know that stuff. We were fighting and scrapping all the time about that at the beginning."
Clarke agrees it was a confusing and challenging time. "In the early days, from time to time, we had reports of people being told via the 0800 number not to come to us for a vaccination. They were told to go somewhere else miles away. That was very controlling."
The providers have now taken control of their own vaccination-booking process. There are no bookings required at Manurewa Marae. Despite their desire to see Māori and Pasifika people prioritised for vaccinations, it didn't happen. Although all providers acknowledge that planning and executing the vaccination programme was a huge logistical challenge, what they were asked to do didn't fit their communities.
They knew their strengths and wanted to use them. After vaccinating the MIQ staff, Winiata knew Turuki could do mobile Covid vaccinations. "We had already had a year delivering mobile flu and measles vaccinations, and checks in lockdown, so we felt a certain amount of autonomy. Despite our experience in mobile clinics, we were not being contracted, because the model at that point was not in the plan. If we were given more capacity to reach Māori whānau and communities in a personal and targeted way in the early stages, we wouldn't be playing catch-up."
However, getting mobile units operational wasn't easy. "There was a lot of red tape to navigate to get site accreditation. We had to go through the accreditation process multiple times even though in some cases we had more on-the-ground experience than those accrediting us."
They all know that mainstream providers can't do what they do. They hold their vaccination events based on community intelligence. Kemp knows her community: "Pasifika go to events; for Māori, it needs to be street by street. When they turn up, people say, 'It's awesome you came here to us.'"
Racism, overt and hidden
All four providers frequently face racist attitudes. Years of patronising attitudes and insults have affected Māori. The quartet know that if they can feel racism in the system, then those receiving healthcare can as well. None of them are surprised that Māori were slow to get vaccinated. Their view is, if you are not part of the system, if it doesn't meet your needs and there is little trust, often on both sides, then you hang back, suspicious and uncertain. There has to be trust in the system and the providers for it to be successful.
/cloudfront-ap-southeast-2.images.arcpublishing.com/nzme/Y4DJ4VJUQBDGMSLWTHTQCPT3AU.jpg)
Kemp is pragmatic about getting people to a vaccination centre. "If it takes a food parcel to get people vaccinated, so be it. We are talking about some of the most marginalised people in the country here. And I mean marginalised in every sense of the word."
Kake calls it out. "Racism sits there under the surface. It's about the slights, the attitudes you encounter. I question partnerships when the real view is that you are subservient. People call it a 'partnership', but it's not. Trust, true representation and equity issues have to be addressed. It is about respect, which, of course, is earned by actions; policies do not automatically earn respect. It has to be generated through actions. Strategies without resourcing are a hallucination.'
Clarke talks from first-hand experience about racism in her community. "It is hard to rent or lease a building here if Māori are the tenant. We had real estate agents looking everywhere for us before we finally found this place. We also had a testing drive-through sorted on council land. All parties agreed to it until a local bureaucrat pulled the plug. Why? We weren't even using a council facility, just the carpark. Would they do that to a Pākehā organisation?'
For all the kaupapa providers, attitudes and approaches have to change.
Kemp noted the irony of the Manurewa Marae being good enough for Prime Minister Jacinda Ardern to have her first Covid injection, but still she senses a lack of trust from some bureaucrats. She knows she constantly has to prove herself and the work done at the marae.
"Recently, we were offered 300 food vouchers by the Northern Region Health Co-ordination Centre [NRHCC] if we could vaccinate 300 whānau in a weekend. We were vaccinating only on the Saturday, so I suggested to them that we vaccinate the 300 over the following week, instead. The NRHCC agreed.
"My husband and I went to collect the vouchers. The staff counted the vouchers out one by one in front of us – I had to kick my husband under the table; he was so affronted. Then they asked how we were going to account for the vouchers. For me, the message was that they could not trust me, that I was going to steal the vouchers. I replied that as they got my statistics every week, and had done since we started vaccinating people, they would easily know when we'd reached the 300-voucher target."
Winiata adds: "Racism has many guises in the health sector, and Māori providers have seen them all. We have seen preferential contracting of DHBs to do work that, in our view, should be delivered by Māori providers; the disparity of pay scales and operational costs between government health agencies and Māori providers, and preferential access for non-Māori to services and specialist healthcare over many years."
Backing themselves
All four welcome the establishment of a Māori Health Authority. They want it to be fully funded, and to have autonomy and influence over systems and processes that will make it better for Māori who are part of non-Māori services.
Essentially, they are backing themselves, their experience and expertise for the future of Māori health. They know they have made a difference and there is no going back. In the words of Sir James Hēnare, "Tawhiti rawa i tō tatou haerenga atu te kore haere tonu/We have come too far not to go further, we have done too much not to do more", they have clear messages for those in positions of influence.
Winiata believes kaupapa organisations need to be driven less by what DHBs or the Ministry of Social Development want. "Money has to be used to effect change in whānau. It has to be better for them and they, in turn, will make it better for others. The situation in South Auckland changes daily, organisations need to be flexible, professional and able to pivot at a moment's notice.
"We have demonstrated that we have the capacity and capability to reach out to community and respond to need. How could we not keep doing that?"
All the kaupapa organisations are concerned about the repetitive reporting they have to adhere to. Kake and Clarke manage 45 and 25 contracts respectively. They would like to see a streamlined system for reporting against the contracts and an end to duplicating information to satisfy multiple government agencies.
Kemp feels strongly that more accountability and risk-management reports are put on a Māori provider than on others. "It is insulting. You have to work 100 times harder and share more of our mahi to prove what we can do. This must change."
Adds Winiata: "Many Māori providers are still without secure contract arrangements. The lag in receiving payments remains. Transparency over funding streams remains a mystery, and Māori providers still manage a No 8 wire approach to caring for all people, not just whānau."
Kake sees the current funding arrangements as underscoring a lack of trust and confidence in kaupapa organisations. "To me, multiple contracts mean they don't trust us. Politicians love us. They come here all the time. It is the bureaucrats who find us difficult. Why is it that we still have one-year contracts when I know another organisation down the road providing the same service has a five-year contract? That's stink!
"Our message to them is, 'Understand us before you judge us.' Our challenge is, 'Join us, hop on the waka, you may enjoy the experience.'" l
- Colleen Brown (Ngāi Tahu) lives in South Auckland and serves on the Counties Manukau District Health Board and chairs Disability Connect.
