Keeping it in the whanau

Malachi McCall gets a massage from his mother Jonelle main at Te Tohu O Te Ora O Ngati Awa. Photo / Alan Gibson

What is Whanau Ora?

"A new approach for the design and delivery of government-funded services and initiatives to whanau - one that places whanau at the centre and builds on the strengths and capabilities already present in whanau."

- Whanau Ora Discussion Paper

As Tariana Turia sees it, "Whanau Ora" is an opportunity for "transformational change" in Maori society.

"I believe our greatest hope lies in Whanau Ora - in strategies and policies which place whanau at the centre," she said in notes for a speech on the East Coast this week.

At her party conference last month, she said: "If I can achieve Whanau Ora, so [whanau] can stand on their own two feet, I'll be happy if I don't achieve anything else."

At first sight, it's an extraordinary load to place on a purely structural change in the way state services are delivered to Maori, bundling multiple contracts for healthcare, education, housing, justice and social services into some kind of super-contract for "family wellbeing" (whanau ora).

But to many Maori, this is finally a chance to achieve significant self-determination, lifting Maori at last out of what the late John Rangihau's report on the social welfare system 21 years ago called "a state of dependency-mokai [slavery] in their own land". It may sound like a dream, but what it could mean in practice is now starting to emerge.

A discussion paper published last month by a taskforce led by Massey University professor Mason Durie proposes a "Whanau Ora fund, derived from those sectors that have current obligations to Maori consistent with the Whanau Ora objectives".

Contracts would be granted from the fund, not for detailed "outputs" such as treating a dozen alcoholics or 20 young delinquents, but for "outcomes".

"Two sets of indicators will be used to measure the success of Whanau Ora interventions," the discussion paper says. "Individual indicators, such as health status or employment, will provide measures relevant to individual whanau members. But in addition, outcome indicators associated with the whanau as a whole will be employed.

"While whanau satisfaction will be an important indicator of provider effectiveness, there will be greater reliance on indicators that are capable of measuring increases in whanau strengths such as a capacity to care for each other, to transmit knowledge and values, to model healthy lifestyles, provide access to society and to te ao Maori [the Maori world], and to transfer language, culture and ethics between generations."

Put like that, clearly the structural change is intended to release a much deeper cultural change - a shift from outside agencies fixing Maori "deficits" to enabling Maori families to look after themselves and others.

Turia again, in an interview this week: "Whanau Ora is about the opportunity to re-empower families to take back responsibility for their lives."

She stands in a long tradition of Maori pressure for self-governance. Auckland law professor David Williams points to education initiatives such as kohanga reo and kura kaupapa Maori in the 1980s, a 1990 law that would have devolved funding to iwi but was scrapped a year later, and the blossoming since then of what are now 270 Maori health providers.

Ngati Kahungunu lawyer Moana Jackson says the philosophy of working with whanau, not just individuals, is "as old and as long as our people have been in this land".

"We have a saying, Kaore te kahikatea e tu mokemoke ai, the kahikatea never stands alone," he says. "You can't see an unwell person or a young person in jail or whatever in isolation from everything else."

Modern research backs him up. Medical Association general practice head Mark Peterson says socioeconomic factors such as education, employment and housing "are actually more important health determinants than how many times you see the doctor".

Whanau Ora meshes happily with National Party policies to cut costs and end what Health Minister Tony Ryall has called the syndrome of "five cars up the driveway", all from different agencies dealing with the same family.

In September, Social Development Minister Paula Bennett unveiled a "high trust model" combining multiple contracts with different parts of her ministry into single contracts.

In the same month, the Health Ministry called for expressions of interest for new primary healthcare contracts for a wider range of services, shifting some services from hospitals to what Ryall calls "integrated family health centres". It asked specifically for "Whanau Ora approaches where appropriate".

One of nine consortiums chosen last week to develop more detailed plans was a coalition of 11 Maori-led primary health organisations (PHOs) led by Simon Royal, chief executive until recently of Waitakere's Waiora Healthcare.

"Ours focused around mothers and babies and children, and management of long-term conditions, and development of Whanau Ora centres - building high-performing Maori providers up and down the country," Royal says.

The business cases are due by February 15, two weeks after Durie's taskforce is due to submit its final report to Turia on how Whanau Ora should work. Public submissions on the taskforce report close on November 30.

The Cabinet will then decide whether Whanau Ora will go ahead and, if so, how. Questions it will need to consider include:

1. How much money will Whanau Ora get?

Turia says the Maori workshop at February's Job Summit suggested devolving "maybe 2 per cent of the total budget", or $1.2 billion out of total state spending of $62 billion a year. "We're not going to get $1.2 billion this year," she concedes. The Cabinet is likely to start cautiously, perhaps giving providers the option of moving multiple contracts into single contracts for the same total money they get now. Even in the long term, ministers are likely to insist money going into Whanau Ora will have to come from existing budgets for health, education and so on.

2. Who will allocate the money?

Royal says the funding agency should be run by Maori "in the same way as the National Kohanga Reo Trust or the Maori Fisheries Commission - with a high degree of independence from Government, although they have to report back to ministers."

3. Who will get the money?

Durie's discussion paper says Whanau Ora providers will need "skills and experience across a range of sectors". Many providers already cover the range, such as Waitakere's Te Whanau O Waipareira which has 74 contracts spanning healthcare, education and training, youth justice and social services. In other cases the taskforce expects providers will need to work together to provide integrated services.

4. How will they be accountable?

Whanau Ora providers will be accountable for "outcomes", not "outputs". Royal suggests "the ultimate" measures could be lifting Maori life expectancy and reducing the numbers of Maori infants dying before their first birthday (currently 6.3 out of every 1000 Maori babies, compared with the national average of 4.6). Short-term measures could include surveys asking people whether their families have got better or worse on key indicators such as health. Durie says indicators could be negotiated by each provider on a case by case basis. Consultants are working with the taskforce on this.

5. Will it be population-based?

Family doctors, and the PHOs they belong to, are now funded on the basis of enrolled populations. It is relatively easy to see how outcome measures could be developed for their populations. But Ngaire Whata of Nga Ngaru Hauora o Aotearoa, representing 129 Maori health providers, says most of her members do not have family doctors or enrolled members, but simply serve anybody who comes in the door. "We have made it known to Tariana we are not happy with her enrolled population structure," she says. Durie appears to be aware of this when he describes Whanau Ora as an option that might be taken up by only a few families. "Most whanau don't need services of any sort," he says. "They get on with it, do it their own way and have no trouble negotiating whatever they need. I think that will continue. This [Whanau Ora] won't be targeted, it will be available widely. But in practice the uptake will be for people who are not as well equipped to deal with it [ life's problems."

6. Will it be only for Maori?

Durie says the scheme is for Maori whanau, not for providers. "I expect it will be for a whanau, there will be some Maori in it," he says. "I think it could emerge as a good model for the rest of New Zealand, but that is not our immediate aim." But virtually every Maori whanau includes non-Maori individuals, and virtually every Maori health provider serves people of all ethnicities. Says Whata: "Being professionals, as we were, our code of ethics always said that, although we work in a kaupapa Maori way, we work for everyone." Or, in Royal's words: "While this is Maori-led and owned and driven, it's not an initiative that is exclusively for use by Maori. It is open to all New Zealanders."

Taskforce report: www.msd.govt.nz

COMMUNITY SERVICES

When Jonnelle Main came to a class for massaging her baby on Thursday, the last thing on her mind was where the funding came from.

The mirimiri (baby massage) class at Te Tohu o Te Ora O Ngati Awa (Ngati Awa Social and Health Services) at Whakatane was actually a joint effort.

Lynne Cooper, Te Tohu's primary contact person with Main and her 7-month-old baby Malachi, first met the family when she was teaching Main's older boy Liam, now 4, in Te Tohu's early childhood centre, funded then by the Education Ministry. Now she works as a kaiawhina (support worker) for the Social Development Ministry's Family Start programme, which provides intensive home-based support for 128 local families.

In the same room with Main and other mothers and babies on Thursday were kaiawhina paid through a Health Ministry contract for Tamariki Ora, the Maori equivalent of Plunket, who visit 300 local mothers every month.

Main has also had help from services outside Te Tohu, such as the midwife who delivered Malachi, but says there are some things she would never ask anyone except Te Tohu.

"They can give more personal advice than a midwife can," she says. "Quite often I text Lynne and she will come and see me. We just moved house and she helped me find my house and organised for someone to move me out of my old house."

Cooper also helped her register with Work and Income and has given budget tips.

"We've had to tighten our belts," Main says. "We've got a garden now. I can go home and cook something different for tea that we've learned at Cooking on a Budget."

Te Tohu is one of two agencies piloting a new "high trust" contract merging seven of its eight Social Development Ministry contracts into one - a kind of halfway step towards what may eventually be a single "Whanau Ora" contract spanning health and education as well. But asked how Whanau Ora will affect the agency, general manager Enid Ratahi Pryor says: "We are already doing it."

The mirimiri class, merging staff from several contracts, is one example. There are others.

"Nine out of 10 of the people getting budgeting are also the people getting counselling and emergency housing," she says. "You don't have to be a rocket scientist to figure out that emergency housing and budgeting go together, but the funders don't."

However, Te Tohu also illustrates a problem for Whanau Ora, because its 14 health contracts cover services such as addictions, asthma and diabetes - but not general practitioners (GPs).

"We made a decision some time back that the provision of GP services was a specialist area that for us to get into we would want Maori GPs," says Ratahi Pryor. "Because Maori GPs are like hen's teeth, the chances of a continuity of Maori doctors is just not possible."

Many families come to Te Tohu independently of GPs, get the help they need, and move on. "Whanau Ora is not about the money, that's what drives the population-based GP system," Ratahi Pryor says. "The Whanau Ora system isn't driven by the dollars."