Racism is a modifiable determinant of health outcomes that, particularly at the institutional level, impacts the quality and availability of health services, thereby fuelling health inequities.[[1]] It is the lived experience of Māori that Tauiwi—mainly Pākehā—have unjustly established in this country:

Everyday racism [that] attacks our rangatiratanga and prevents us from living our lives in the ways we want to, both as individuals and as groups.[[2]]

In a reciprocal manner, racism is also the mechanism by which Pākehā actively and passively benefit from the established social order. Racism in the health sector has been linked to increased health risk factors, poorer mental and physical health outcomes, increased co-morbidities and premature death.[[3]] The existence of institutional racism within the health sector is a breach of Te Tiriti o Waitangi[[4]] the Declaration on the Rights of Indigenous Peoples[[5]] and the Convention on the Elimination of All Forms of Racial Discrimination.[[6]]

The landmark report Pūao Te Ata Tū[[7]] brought institutional racism to the attention of the public sector. The report inspired bicultural reforms, such as incorporating Māori values into policy and attempting to address cultural and historic racism by the transfer of resources to Māori. However, the neo-liberal ideologies that transformed Aotearoa into a market economy from the mid-1980s[[8]] ignored the recommendations of Pūao Te Ata Tū, claiming deregulation would resolve inequities. This hands-off approach has allowed institutional racism to flourish, with measurable negative impacts on health inequities.[[9]] It is literally a matter of Māori life and death.

While there is a growing acknowledgement of racism and some improvement in individual practice in Aotearoa, few initiatives have attempted to enact change at an institutional or societal level.[[10]] For example, there have been decades of kawa whakaruruhau and Te Tiriti training in the health sector.[[11,12]] Health workers are encouraged and even required, for a number of professions, to undertake competency training to be culturally safe practitioners.[[13,14]] There have also been various efforts to decolonise and indigenise health curricula, but they have not had adequate financial or political support to ensure their sustainability.[[15]] There have also been social marketing and education-orientated anti-racism interventions targeting civil society.[[16]]

While all these initiatives have had beneficial impacts, there is little evidence that existing anti-racism interventions have led to a reduction in institutional racism or improved Māori health outcomes.[[17]] Crown witnesses in the Wai 2575 hearings conceded that institutional racism and subsequent health inequities continue to be a significant problem.[[4]]

Despite the lack of success in disrupting racism to date, there is currently unprecedented interest in anti-racism work. The Ministry of Justice and the Human Rights Commission are currently developing a National Action Plan on Racism, the Ministry of Health have commissioned major work, and the Teaching Council is also undertaking a significant programme of work. In addition, scholars from Auckland University of Technology, and the universities of Waikato and Otago have all secured major research grants to work in this area, and we are also aware of ongoing unfunded or non-funded community-led initiatives.

Meanwhile, Matike Mai Aotearoa[[18]] released a landmark report on constitutional transformation, as a pathway to just and sustainable futures for Aotearoa. Led by Margaret Mutu and Moana Jackson, this engagement process involved expansive discussions through hundreds of hui (gatherings), with thousands of participants. Hui were complemented by written submissions, focus groups and interviews that were gathered throughout the motu (land). From this deeply grounded process came a set of values and the suggestions for new constitutional arrangements that could honour Indigenous and treaty rights.

This paper provides an overview of i) the Matike Mai Constitutional Transformation movement, ii) examines the proposed National Action Plan Against Racism, and iii) Ao Mai Te Rā, the major health sector project. Finally, we outline contributions we hope our Marsden study, ‘Re-imagining anti-racism for the health sector’ can offer.

Matike Mai—Constitutional Transformation

Matike Mai incorporates understandings of the independence of hapū (sub-tribes) alongside their interdependence through whakapapa (genealogy), within the wider Māori polity, as the basis for constitutional authority. It proposes a dynamic relationship between Māori and the Crown, where just constitutional relations require independence for hapū to make decisions while acknowledging interdependence embedded in Te Tiriti. Matike Mai proposes distinct but interconnected spheres or domains:

We call those spheres of influence the “rangatiratanga [Māori unfettered authority] sphere”, where Māori make decisions for Māori and the “kāwanatanga [governance] sphere” where the Crown will make decisions for its people. The sphere where they will work together as equals we call the “relational sphere” because it is where the Tiriti relationship will operate.[[18]]

The Matike Mai vision requires authentic engagement, collaboration and commitment that recognises the realities and tensions of colonial history, its unresolved injustices and inequities. As experts, knowledge-holders and leaders within the rangatiratanga sphere, as well as drawing on intergenerational lived experiences of racism, Māori are able to guide and advise Tauiwi in theories, approaches and interventions to eliminate it. Within the kāwanatanga sphere, the Crown needs to be able to match the radical generosity Māori frequently bring to the table, with a mighty commitment to addressing racism and transforming monocultural practice. It is here that Tauiwi must prepare themselves to work respectfully in upholding Te Tiriti and halting racism. It is important to reiterate that the kāwanatanga sphere is inhabited by Tauiwi but Māori also occupy this sphere with rights and responsibilities, both within and outside the Crown.[[19]]

Matike Mai provides a useful mechanism for challenging structural racism that could help the health sector re-focus and transform the unjust Crown structures and practices that featured so prominently in the Wai 2575 Waitangi Tribunal report.[[4]] The forthcoming establishment of the Māori Health Authority may address some of the aspirations of Matike Mai, but it remains to be seen whether their scope of practice and investment levels will enable the full expression of tino rangatiratanga.[[20]]

National Action Plan Against Racism

Across the globe, countries have developed national action plans on racism as part of their active implementation of the Convention on the Elimination of All Forms of Racial Discrimination.[[6]] Our government has been slow to commence work after it appeared as a recommendation from a United Nations Human Rights Committee,[[22]] and the next reporting round was due December 2021.

The Ministry of Justice is leading the whole-of-Government engagement and the Human Rights Commission are leading civil society engagement. At the time of writing, there was limited information available in the public domain about how the plan will be developed and what it might address. We understand the Human Rights Commission have established an advisory think tank to inform its work made up of 50% Māori and 50% ethnic communities—focusing on those with lived experience of racism. This proposed national plan it is of enormous importance to both those targeted by racism and those working in anti-racism.

In response to the lack of progress on the proposed plan in March 2021, a gathering of anti-racism practitioners (approximately 75 from around the country) was called to collectively articulate what we wanted to see in a national action plan on racism. A unique comprehensive briefing paper[[23]] was developed and signed off by the group which presented the views of tangata whenua, tangata Tiriti—Pākehā (white settlers)—and tangata Tiriti—Tauiwi of colour. The briefing paper centred on Māori aspirations and values, and articulated what Te Tiriti-based anti-racism praxis looks like currently in Aotearoa. It emphasised the need for constitutional transformation, Te Tiriti compliance, and decolonisation of narratives and spaces. It advocated for the establishment of an anti-racism clearing house to strengthen the evidence base, co-ordinate anti-racism work and build an anti-racism workforce. It concluded with distinctive priorities from each caucus.

The briefing paper showed diverse viewpoints of the dynamics of racism and idiosyncratic framing about what is anti-racism. The briefing paper[[23]] defined anti-racism as:

… the art and science of naming, reducing, disrupting, preventing, dismantling and eliminating racism. It takes a multiplicity of forms but centres around solidarity with those targeted by racism, an analysis of power and a commitment to reflective, transformative practice (p.9).

In the context of Aotearoa, this also involves tino rangatiratanga, decolonisation and upholding Te Tiriti.

Ao Mai Te Rā—health sector

The Wai 2575 Waitangi Tribunal[[4]] stage one report was damning of the normalisation of racism within the health sector. The evidence presented to the Tribunal exposed racism within legislation, policy, funding and contracting practices; within governance structures; and critically in the quality and accessibility of care provided. Politically, it was impossible for the Ministry of Health to not respond as they engage in stages two and three of the hearings.

In July 2020, the Ministry of Health[[24]] released Whakamaua, their new Māori health action plan, which was buttressed in August 2020 by a new Te Tiriti framework.[[25]] Whakamaua identifies that addressing racism and discrimination is one of four high level priorities over the next five years. This positioning of racism has the (unintended) result of reinforcing the idea that the responsibility to address racism sits with Māori. Our experience, and analysis, is that eliminating racism is the responsibility of the Crown and Pākehā in alliance with Māori and Tauiwi of colour who wish to work in this space.

With little consultation with long-standing anti-racism groups, the Ministry has initiated Ao Mai Te Rā, an anti-racism programme which aims to support the health sector with insights and tools to understand and address racism. The brief is to address racism against Māori, Pacific and other ethnic minorities as the groups most impacted by racism. During the initial stage of the project, the contracted Māori and Pacific research team are undertaking a review of international literature to determine best practice, and a local environmental scan. The project leads are planning on engaging widely with the sector to build collective ownership, and they are working towards developing an anti-racism maturity model[[26]] to determine where to invest.

The authors respectfully suggest that as well as the approach outlined above it is critical to address racism at its source. Pākehā are the main instigators (and beneficiaries) of racism within the health sector, and as the party most in need of change it would therefore be useful to involve Pākehā in identifying solutions. Pākehā have cultural insider insights into racism and Te Tiriti responsibilities within the kāwanatanga sphere, and need to be responsible for working constructively with their people, in alliance with Māori, to eliminate racism.

Racism has a geographic specificity[[27]] so solutions imported from other countries may not have relevance or effectiveness in the context of this land. There is no magic bullet to anti-racism rather it is an iterative art and science of having a go, reflecting, and having another go. Most anti-racism work that has occurred in this country has been unfunded and remains unpublished. Much of the mātauranga (knowledge) around anti-racist praxis lies with elders of the Māori sovereignty and anti-racism movements rather than in books and academic papers. It has always been relational work.

Re-imagining anti-racism

Racism and anti-racism are multifaceted and complex phenomena that require an innovative and actively transformative approach to produce meaningful changes in the health sector. The health system, with its ideological denial of racism, is profoundly resistant to change from without, which has contributed to a lack of cohesion and sustainability among the approaches highlighted in the introduction. We have embarked on a project, funded by a Marsden grant, to develop an action-focused theory of anti-racism that is relevant to all levels of the health sector, from education to policy and practice.

Drawing particularly on the work of Matike Mai, our focus is on the nexus of Māori and Tauiwi health aspirations and knowledges that, if fully articulated, can inspire individual and systems change. We see the tricameral nature of Matike Mai as the overarching organising structure for our study. This includes the organisation of the project (eg constitution of the research team, recruitment of participants, choice of methods etc), and also the understanding of the project aims. Here, we conceptualise the health sector as a relational sphere in which Māori and Tauiwi could work together as equals. At present this is not a reality in the health sector, although the forthcoming health reforms have the potential to realise greater equity.

The project incorporates the development of a draft theory using wānanga with health professionals engaged in anti-racism or Te Tiriti honouring practices. The draft theory will be tested in the healthcare sector, with attention to ensuring its practical application and capacity for drawing together the anti-racism initiatives being developed across the disciplinary and population boundaries in Aotearoa. Inquiries about the project can be directed to the corresponding author.

Conclusion

Active resistance, inaction and ad hoc approaches mean anti-racism initiatives have not significantly disrupted racism within our health system. Matike Mai offers an articulate vision for Te Tiriti—honouring decision-making processes which embrace tino rangatiratanga and create a setting to produce respectful relational engagement between tangata whenua and tangata Tiriti. To successfully address racism we need a planned, systemic approach that is congruent with the holistic, relational constitutional transformations envisaged by Matike Mai. This paper has introduced a research project that aims to develop and test such an approach.