Te Tiriti o Waitangi policy

Te Tono ꟷ Pledge

As a health entity guided by the health sector principles in Pae Ora (Healthy Futures) Act 2022 (the Act), Pharmac acknowledges the Crown intention to give effect to the principles of Te Tiriti o Waitangi[1]. Through our work on behalf of Aotearoa New Zealand, we strive to improve health outcomes for all New Zealanders, particularly for Māori and other population groups with high health needs.

He Aronga ꟷ Purpose

Pharmac’s te Tiriti o Waitangi policy expresses our unequivocal commitment to upholding the mana of te Tiriti o Waitangi (te Tiriti) and supports us to strive for excellence in enacting te Tiriti partnership in everything we say and do, both within our organisation and in our external relationships.[2]

This policy sets out the expectations and requirements for Pharmac Te Pātaka Whaioranga to uphold te Tiriti through our work in line with the requirements set out in the Act and the Government Policy Statement on Health 2024-2027 (GPS) to improve health outcomes for all New Zealanders, including those with the highest need. This includes priorities for the population groups consistent with the Act health strategies: Māori, Pacific peoples, disabled people, women, and people living in rural communities. Pharmac is also guided by section 7(1) Health Sector Principles of the Act.

This includes creating and maintaining effective relationships with Māori as part of wider engagement work and partnership obligations, enabling strong Māori leadership and involvement, cultural competence and capability across the organisation, and changes to core business.[3]

Our goals under this policy supports the wider Government commitments to improving the health and wellbeing of Māori by continuing to implement Pae Tū: Hauora Māori Strategy, and Whakamaua: Māori Health Action Plan 2020–2025 in a pathway to consolidating and further focusing Māori health outcomes[4].

It also recognises that Māori have worse health outcomes than non-Māori across most measures of health, including those related to non-communicable diseases and key modifiable risk factors.[5]

Whakapiki ake te Tiriti ꟷ Our commitment to te Tiriti o Waitangi

He Whakaputanga o te Rangatiratanga o Niu Tīreni

This policy recognises the critical importance of He Whakaputanga o te Rangatiratanga o Niu Tireni 1835 ꟷ known in English as the Declaration of Independence of the United Tribes of New Zealand. This assertion of sovereignty by Māori underpinned the drafting and adoption of Te Tiriti o Waitangi some five years later. Te Tiriti established the terms and conditions of British settlement and reaffirmed Māori sovereignty already articulated through He Whakaputanga.

Te Tiriti o Waitangi

The text of te Tiriti, including the preamble and the three articles, along with the Ritenga Māori declaration[6] are the enduring foundation of the Tiriti partnership and our approach. The preamble and key articles are summarised below:

Preamble: The preamble sets the tone for the Tiriti relationship between the Crown and Māori. The Māori text emphasised that the Queen's main promises to Māori were to secure tribal rangatiratanga and secure Māori land ownership. To avoid ambiguity, it is important to consider the text:

kia tohungia ki a ratou o ratou rangatiratanga me to ratou Wenua… na te mea hoki he tokomaha ke nga tangata o tona Iwi kua noho ki tenei wenua, a, e haere mai nei.

[To preserve their independence and their land…because there are many of her subjects already living on this land, and others yet to come.]

The preamble is also about the importance and recognition of whakawhanaungatanga – the active process of building relationships through shared experiences, connections and a commitment to authentic engagement.

Article One: Kawanatanga – Rangatira (chiefs) exercised full authority (‘mana’) over land and resources on behalf of the wider community while the Crown gains the right to govern. At the same time Māori retain sovereignty.

Article Two: Tino Rangatiratanga – the Crown promises that Māori will have the right to self-manage resources and taonga (including health and mātauranga) they wish to retain. The words Tino Rangatiratanga emphasise status and authority.

Article Three: Ōritetanga – the Crown promised to Māori the benefits of royal protection and full citizenship. This text emphasises the right to equity for Māori alongside all other people.

Te Tiriti must be considered ‘as a whole’ ꟷ the applicability of all articles and the relationship each has to others need to be considered in any situation. When kawanatanga and tino rangatiratanga are in balance ōritetanga will be achieved.

Pharmac’s commitment to upholding the mana of te Tiriti is primarily driven by our desire to achieve excellence as a Tiriti partner through authentic, respectful, and mutually advantageous relationships.

It is also integral to achieving our statutory obligations to improve health outcomes for all New Zealanders, including those with the highest need. This includes priorities for the population groups consistent with the Act and related health strategies (ie: Māori, Pacific peoples and others).

Our commitment aligns with the Act and the GPS and aims to improve health outcomes underpinned by robust data and evidence, in accordance with our statutory responsibilities (as part of serving all New Zealanders based on actual need not background as a proxy of need) and aligns with the Associate Minister of Health ‘s Letter of Expectations to the Chair of Pharmac, together with relevant sections of Pharmac’s equity policy[7].

Hāpaitia te Tiriti o Waitangi ꟷ Giving effect to our commitment to te Tiriti o Waitangi

The importance of the Tiriti partnership in relation to improving health outcomes for those with the highest health needs is similarly reflected in our:

• Statement of Intent 2023/24-2026/27 as a tool for ensuring health equity is applied to all strategic priorities, and
• Statement of Performance Expectations 2024/25 which includes a reference to contributing to health equity and giving effect to the Equity policy.

Language matters ꟷ what we mean by health and health equity

In implementing this policy we must be clear about the use of terms in everyday use in Pharmac.

Health/Hauora

Health and Hauora are often used interchangeably. Hauora however, has a more holistic scope than the narrow traditional western constructs of health that have dominated mainstream health service provision. It is about health and wellbeing rather than the absence of illness or disease. The most well-known model of Māori health is Sir Mason Durie’s Te Whare Tapa Wha[8],  which identifies four inextricably connected, interdependent and equally important foundations for health and wellbeing: taha tinana (physical health, taha wairua (spiritual health), taha whānau (family health) and taha hinengaro (mental health). Going forward, and consistent with more contemporary understandings of health even within western paradigms, Pharmac Te Pātaka Whaioranga will understand health to align with hauora with respect to all the people it serves – not only Māori.

Health Equity

Te Pātaka Whaioranga Pharmac embraces the Ministry of Health definition of health equity:

“In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes”.[9]

Māori health inequity is understood as arising from adverse impacts of colonisation on the wider social and economic determinants of health, for example, education, poverty, discrimination, quality of housing.[10]

Alignment with our Equity policy 

Our Equity policy outlines how Pharmac will ensure our processes, policies and resources are directed towards equitable access to and responsible use of pharmaceuticals/medical devices.

It also notes Pharmac will proactively address the needs of the population groups furthest behind and those with the highest health needs and acknowledges Pharmac will support the health sector to be equitable which includes ensuring Māori and other population groups have access to services, in proportion to their needs.

Our specific commitments

We have committed to always having a Māori responsiveness strategy to give effect to our te Tiriti commitments. Our current strategy, Te Rautaki o Te Whaioranga (Te Whaioranga), provides a framework for meeting our te Tiriti responsibilities and for achieving ōritetanga (equity) – equitable health outcomes for Māori. This framework will be further assessed in coming months pending the review of Pae Tū by the Ministry of Health (likely October 2024).

To give further effect to our te Tiriti policy Te Pātaka Whaioranga Pharmac will:

• ensure all policies are informed by, and consistent with, this te Tiriti policy
• strive to carry out all its business, including implementation of this te Tiriti policy, in a way that exemplifies strong te Tiriti partnership
• ensure that implementation of this te Tiriti policy is planned, prioritised and appropriately resourced
• document explicit expectations, processes and measures that provide clear guidance and tools to all managers and staff
• build accountability for implementing our te Tiriti policy into all role descriptions and performance agreements
• ensure our performance against this policy is monitored and evaluated robustly and transparently in ways consistent with te Tiriti partnership
• regularly update the policy, and Te Whaioranga, to maintain alignment with rapidly evolving best practice for effective te Tiriti partnership and achieving equitable health outcomes for Māori.

The section below sets out further requirements and expectations with respect to implementation of this te Tiriti policy, which fully embrace the five principles for implementing te Tiriti (as outlined above).

Key Requirements and Expectations

Ōritetanga – equitable health outcomes for Māori

Our policies and decision-making processes are intentionally designed to be pro-equity, enabling equitable Māori health outcomes to be achieved – as required by the principle of whakamaru (active protection).

• Our commitment to te Tiriti and equitable health outcomes for Māori, are embedded in our purpose and all policies, principles and procedural documents.
• Māori are routinely involved in all key areas of our business (pātuitanga).
• Mātauranga Māori is valued as a knowledge system, and demonstrably influences decision-making (kōwhiringa).
• We access, grow and build into our processes Māori scholarship and expertise in assessing applications to fund new medicines and medical devices.
• Prioritisation and decision-making processes are explicitly designed to align with our Equity policy.
• We extend our perspective beyond the limitation of ethnicity as a “risk factor”. When analysing and drawing conclusions from data, disseminating results, or monitoring and measuring outcomes we will consider the wider context of underlying health determinants, and the existent and continuing impact of colonisation on Māori health outcomes.
• Research and analysis are prioritised to generate insights that help to improve health outcomes for Māori. We will respect Māori data sovereignty in our collection, use and dissemination of data and information.

We have strong relationships with Health New Zealand, to ensure that our work is aligned with the broader health system goals for Māori, and that we are learning, contributing and using our influence to accelerate progress.

Whakawhanaungatanga ꟷ Relationships with our te Tiriti partners and whānau Māori

We nurture respectful, strong, enduring, mutually beneficial relationships with our te Tiriti partners and whānau Māori (pātuitanga).

• We apply the Te Arawhiti Māori Crown Engagement Framework to determine who we should engage with and how on issues of interest to Māori; including by engaging early, working inclusively and involving Māori in co-design, co-management or leadership roles to ensure partnership is at the right level from a Māori perspective.[11]
• We support through action the development and honouring of mātauranga Māori within our work with and for Māori in culturally appropriate ways that value and support the expression of mātauranga Māori (kōwhiringa). This is upheld by recognising the sanctity and interconnectedness of hauora to mātauranga Māori, whenua, wairuatanga and the mauri of all things.
• We use Māori models in our work, and in monitoring and evaluating our progress.
• We provide by, with, of and for Māori mechanisms for developing and communicating Māori perspectives, and ensuring they are reflected transparently in our work (kōwhiringa).

Hikitia te mana Māori ꟷ Strong Māori leadership and involvement

Strong Māori leadership and involvement is central to achieving tino rangatiratanga and mana motuhake.

• Tino rangatiratanga and mātauranga Māori are instrumental in determining Māori health priorities, ensuring there is sufficient time and space for Māori to develop their aspirations and mātauranga.
• Māori staff will be kept safe – managers and staff are required and supported to ensure a culturally safe working environment is maintained where Māori are comfortable operating and able to contribute fully to the organisation’s mahi.
• We recognise the critical importance of Māori directors, leaders, staff and Māori expert advisors in supporting us to achieve excellence in te Tiriti partnership and systematically engage with them across all key work areas.
• We set clear targets and implement effective approaches for increasing recruitment, retention and advancement of Māori staff across the organisation.

Māori are well-represented across the organisation, including in governance, leadership, and management decision-making roles and its advisory committees, and are supported to give effect to te Tiriti in those roles.

Ahurea Māori ꟷ Cultural safety, competence and capability

It is critical that managers and staff understand how their role at Pharmac Te Pātaka Whaioranga relates to te Tiriti and are well-supported to give effect to this policy in their day-to-day work. We work in the knowledge that cultural safety precedes competence. An essential component of cultural safety is critical consciousness. This involves examining the interplay of power, privilege and authority and is honoured in open and creative forms of relationship ꟷ whanaungatanga, grounded in accountability to whānau and communities.

Building the capability of our workforce to operate effectively in te ao Māori, including through development of te reo and tikanga Māori, will be integral to the culture of Te Pātaka Whaioranga and how we operate on a day-to-day basis.

• We recognise that systemic racism is a key determinant of health outcomes for Māori, and systematically review, identify and address systemic racism across our work.
• We take active steps to develop critical consciousness through reflection and on-going examination of our beliefs, and audits of practice, to recognise and address racism and bias.
• All staff will participate in training that includes Aotearoa New Zealand’s history and impacts of colonisation, the wider determinants of health, racism and unexamined bias.
• We use Critical Tiriti Analysis routinely across our work to build our capability and ensure that te Tiriti is upheld.
• We apply the Te Arawhiti Māori Crown Relations Capability Framework for the Public Service, which includes organisational capability and individual capability components and a self-assessment tool.[12]
• All staff are expected to build and extend their cultural safety practices, cultural capability and competence as part of their professional development plans and are supported by the organisation to do so.
• Board, leadership and staff role descriptions and performance agreements include key performance indicators related to giving effect to te Tiriti, cultural safety practices, cultural capability and competence, which they are held accountable against.

Mana motuhake o ngā raraunga Māori ꟷ Māori data sovereignty

• We undertake accurate and consistent collection of ethnicity data, and the use of ethnicity data to assess and improve our work in achieving Māori health equity.
• We actively support Māori data sovereignty in the context of our work.
• We will seek out and use empirical tools explicitly designed for, with, and by Māori to inform and improve our work.

He piki hāerenga ꟷ Ensuring we make good progress

To enact the Tiriti partnership and improve Māori health outcomes there will need to be changes to how we carry out many aspects of our core business. We will work together to clarify what this means for each part of our work, and to support each other to implement agreed changes.

All our planning, monitoring and evaluation will include a te Ao Māori lens, employing processes that exemplify good te Tiriti partnership. This includes asking Māori to evaluate our performance in ways that are meaningful for them, and that we are open to learning from that feedback and making required changes. Te Tiriti measures will be developed to routinely monitor and evaluate our effectiveness as a Tiriti partner.

A detailed implementation plan is required to drive change in priority areas and provide guidance on how to effect the transformation necessary to implement our te Tiriti policy across our business.

Progress against the plan will be routinely monitored and reported against as part of our day-to-day business processes and as part of our role in the broader health system.

We recognise that this policy expresses aspirational goals, and we have much to do to achieve them, but we are committed to working together to achieve rapid and sustained progress.

Footnotes

[1]    s.6 of the Act

[2]    For the avoidance of doubt this policy applies to Pharmac and its expert advisory networks.

[3]    The meanings of Māori words and concepts in this document are set out in a variety of landmark reports that Te Pātaka Whaioranga Pharmac staff should be familiar with, such as Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry, which provides a brief glossary (p xxi). Retrieved from https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_195476216/Hauora%202023%20W.pdf(external link) 4 April 2022.

[4]    GPS p.9

[5]    GPS p.16

[6]    The Ritenga Māori declaration (often referred to as the ‘fourth article’) was drafted in te reo Māori and read out during discussions with rangatira concerning te Tiriti o Waitangi. The Ritenga Māori declaration provides for the protection of religious freedom and the protection of traditional spirituality and knowledge. Te Puni Kōkiri (2001), A Guide to the Principles of the Treaty of Waitangi as expressed by the Courts and the Waitangi Tribunal. Wellington: Te Puni Kōkiri. pp.40-41.

[7]    Further direction and guidance are provided in te Tiriti o Waitangi/Treaty of Waitangi Guidance provided in Cabinet circular (CO (19) 5), the Waitangi Tribunal Report Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry Hauora Report (Hauora Report), and Te Arawhiti advice and resources.

[8]    For further information see Māori health models – Te Whare Tapa Whā | Ministry of Health NZ(external link)

[9]    This definition of equity was signed-off by Director-General of Health, Dr Ashley Bloomfield. In March 2019.

[10]    What are health inequalities? | The King's Fund (kingsfund.org.uk)(external link) accessed 22 July 2022

[11]     The Te Arawhiti Māori Crown Engagement Framework for the Public Service, accessed from https://www.tearawhiti.govt.nz/assets/Maori-Crown-Relations-Roopu/451100e49c/Engagement-Framework-1-Oct-18.pdf(external link), retrieved 11 Aril 2022

[12]     The Te Arawhiti Māori Crown Relations Capability Framework for the Public Service, accessed from https://www.tearawhiti.govt.nz/tools-and-resources/public-sector-maori-crown-relations-capability/(external link) retrieved 7 Aril 2022