Abstract
Pacific people migrated to New Zealand in search of a better life. However, despite making important social, sports, cultural, and economic contributions in New Zealand, they continue to face challenges in other areas such as health, education, employment, housing, and the justice system. The level of health inequalities between Pacific and non-Pacific people had become a major
concern by the late 1990s and became a policy focus of the incoming Labour-led Government in 2000. The ambitious health reforms led by this government meant a significant change in tide for the entire health sector.
The principal purpose of this thesis is to analyse the Pacific health sector experience during the 2000 health reforms, which established District Health Boards (DHBs) and required, for the first time, an explicit focus on improving Pacific health and reducing health inequalities, but built on earlier strategies and policies. It is a qualitative piece of research undertaken by an ‘insider’, which aims to capture the stories and experiences, voices and viewpoints of those trying to paddle the popao (canoe) to improve Pacific health and reduce health inequalities during this period of intensive reform.
It is an exploratory study about how DHB model was working (2000-2005) with a view to develop further to ensure there is a strong focus on Pacific health issues and appropriate service delivery for Pacific peoples.
The goal and aims of this thesis:
To identify the factors that support, and the factors that provide barriers to progress, in the early stages of the DHB model, with respect to improving Pacific Health and further developing services to more appropriately meet the needs of Pacific peoples.
Aims:
• To describe the structures and processes established by DHBs in respect of Pacific Health.
• To describe the experiences of Pacific and non-Pacific senior staff and Pacific providers during the health reforms with respect to those structures and processes.
• To provide recommendations to inform future work on the impact of implementing policies to reduce health inequalities.
A combination of Pacific and Tongan frameworks, metaphors, and proverbs are used to frame the study, as well as inform analysis and presentation of ideas. The three data collections approaches were: (1) Talanoa (sharing or telling stories) – face-to-face interviews; (2) Lalanga (weaving) – textual analysis of strategic documents; and (3) Siofi (observation) – participant observation. Three-week placements were carried out with four DHBs and with three Pacific providers funded by those DHBs. The four DHBs studied were chosen because of their large Pacific populations, and also to provide a range of geographical perspectives. Overall, participants were overwhelmingly generous with their time. This willingness to engage highlighted the effectiveness of the talanoa (sharing stories) method, as it provided an open space for sharing experiences and eliciting the rich views of the participants.
Factors that enabled and acted as barriers to implementing policies related to Pacific health are discussed in detail in this thesis. In particular, the study found that having Pacific people participating in decision making at the governance level was critical to pushing the reducing inequalities agenda forward in institutions that were not ready for change. Participants strongly advocated for more inclusion of Pacific cultural values at all levels of decision making within the health sector. In addition, health workers being fakatoukatea, or able to operate in both Pacific and non-Pacific worlds, was seen to be a vital enabling factor. This research documents the complexities of working in a DHB environment where there are many tides and currents operating. The local needs, community demands, organisational requirements and agendas of DHBs, and broader political currents and influences did not necessarily flow in the same direction. In addition, the study describes a complex, but important relationship between Māori and Pacific communities.
The popao (canoe) was developed as the interpretive and analytical framework to describe the existing organisational structure of the DHB, acknowledging the desirability of moving to a kalia, a more stable double-hulled canoe. This thesis argues that health inequalities will continue until there is a renewed emphasis on social and economic determinants and DHB structures and processes move beyond the popao and develop the structural support of a kalia, where Pacific values are given enough space to co-exist, and Pacific people have real input into navigation. The study uses the popao and kalia as guiding metaphors to analyse the existing organisational structure of the DHB and possibilities for the future. In addition, the study utilised the Pacific Policy Framework ‘Alamo’ui: Pathways to Pacific Health and Wellbeing (MOH, 2014) to guide and to elaborate the discussion of results and findings. Effectively improving the health of Pacific peoples and reducing inequalities in this context of competing demands is challenging. This study provides an insider account of those at the forefront of paddling the popao for change in a complex environment.