Equity, regulation and Te Tiriti o Waitangi: a rapid review of Putting Patients First

New Zealand’s health system continues the legacies of colonisation, intergenerational trauma and sustained breaches of Te Tiriti o Waitangi. Normalised institutional racism produces inequitable health outcomes. Health practitioners—regulated and unregulated—are pivotal to addressing these inequities. Their collective clinical, community and cultural expertise significantly shape health outcomes.

The Waitangi Tribunal is unequivocal. Its Hauora² and Haumaru COVID-19³ inquiries condemned successive governments for chronic under-investment in Māori health, neglecting equity and disregarding tino rangatiratanga in policy and service design. WAI 2575 concluded that the entire Ministry of Health – Manatū Hauora policy corpus was non-compliant with Te Tiriti o Waitangi.

From November 2023, the National-led Coalition intensified this neglect. In a blitzkrieg of reforms, it dismantled Te Aka Whai Ora – Māori Health Authority,⁴ introduced the divisive Treaty Principles and Regulatory Standards Bills and advanced Cabinet Circular CO(24)5,⁵ which imposed a “needs not race” framing across government. Came et al.⁶ argued this framing mischaracterises equality as sameness, displaces Indigenous rights and entrenches inequities. By treating ethnicity as irrelevant, it denies structural racism underpinning disparities in health, education and social outcomes. So-called “needs-based” approaches cloak neoliberal ideology in language of neutrality, eroding Māori self-determination.

In this hostile policy environment, the Coalition released Putting Patients First: Modernising health workforce regulation (PPF).¹ We apply rapid Tiriti review—a critical tool responding quickly in the current environment—assessing the implications of PPF for equity, Tiriti justice, the future of health workforce regulation and cultural responsiveness to health and wellbeing of everyone living in New Zealand.

Method

A rapid Tiriti review is adapted from critical Tiriti analysis (CTA),⁷ a desk-based method designed to monitor Crown performance against the five elements of Te Tiriti o Waitangi, expressed in the authoritative Māori text. CTA contributes to critical policy scholarship aimed at addressing systemic inequities and follows five stages: i) orienting how policies engage with Te Ao Māori, Te Tiriti and equity; ii) close analysis of alignment with the preamble, three written articles and an oral article; iii) independent and collective ratings; iv) constructive recommendations; and v) he whakaaro Māori—a final determination by Māori authors.

A rapid Tiriti review retains these five steps but streamlines them, merging orientation and close reading, offering holistic assessment of engagement with the preamble and oral and written articles, guided by adapted prompting questions.⁸ As with CTA, suggestions to strengthen practice are central, as is he whakaaro Māori.

Crucially, substantive Māori involvement and leadership is essential; without these, it is not a rapid Tiriti review. As a desktop exercise, it analyses only written text, not author intent or context, while acknowledging the challenging environment faced by Crown policy writers.

The authors of this paper are: HC, a Pākehā activist scholar; CA (Ngāti Maru, Ngāti Whanaunga, Ngāti Tamaterā), a researcher focussed on Māori health, HIV, Indigenous wellbeing and equity; AB, a Pākehā researcher working with a Kaupapa Māori health and social sector workforce development organisation; and MB (Ngāpuhi, Te Rarawa), a Kaupapa Māori researcher specialising in Māori health, equity and Tiriti-based practice.

Findings: PPF

PPF¹ proposed reforms addressing health workforce shortages, inefficiencies and barriers to timely care, outlining four themes: patient-centred regulation, streamlined processes, right-sized frameworks and future-proofed approaches. Patient-centred reforms include stronger public input, more diverse regulator boards, greater attention to choice and access, streamlining aims to cut duplication across regulatory authorities through shared systems or potential mergers and seeking a more efficient, equitable regulatory framework.

Preamble: what relationships does this policy describe with Māori, Māori organisations and/or hapū or whānau?

PPF proposals fail to acknowledge important Tiriti relationships between hapū and the Crown, breaching the expressed Tiriti preamble intention of good faith and mutual benefit. This is starkly evident on page 1 where Māori are not listed among groups the Crown wishes to hear from.¹ Allowing submissions only through the Ministry of Health – Manatū Hauora’s website limits abilities of communities to engage kanohi ki te kanohi, rangatira ki te rangatira (face to face, leader to leader).

The Waitangi Tribunal, legal jurisprudence and public policy affirm that health is a taonga protected by Te Tiriti, obliging the Crown to promote and protect Hauora Māori. PPF is silent on this duty, ignoring systemic inequities and complex whānau needs. By treating Kaupapa Māori services as optional, it sidelines effective, evidence-based workforces. Models such as Te Whare Tapa Whā, Te Wheke and Rongoā Māori are not alternatives but proven systems delivering better outcomes for Māori and non-Māori alike.⁹

Article 1: how were Māori involved in kāwanatanga decision making about PPF?

We note (page 3) Crown officials engaging with unnamed Māori professional associations in forming PPF.¹ Feedback from Māori groups is invisible in the document, so it is unclear whether they supported PPF. We welcome the practice of publishing consultation feedback and encourage ethnic analysis making Māori aspirations transparent in relation to particular kaupapa. Neglecting this is another “downgrade” of equity expertise in the workforce, signalling a retreat from measurable, enforceable commitments to Māori health equity. Such changes hinder progress tracking, holding institutions accountable or addressing systemic racism in health.¹⁰

By assuming unitary parliamentary sovereignty in 1852, the Crown accepted responsibilities for providing health and disability services for all New Zealanders. Under international human rights conventions and declarations, all citizens have rights to healthcare and freedom from discrimination.¹¹ Indigenous peoples have additional rights and protections, in acknowledgement of the global harm of colonisation.^12,13 The Crown must therefore address the needs of “everybody”, and specifically Māori, under Te Tiriti and international human rights instruments. These Māori whānau needs are not addressed in PPF in any way approaching Te Tiriti compliance.

Article 2: how does PPF acknowledge or foster tino rangatiratanga and/or advance Māori aspirations?

PPF demonstrates no consideration of tino rangatiratanga as expressed in He Whakaputanga o te Rangatiratanga o Nu Tireni or Te Tiriti. Instead, emphasis is placed exclusively on clinical safety rather than on both competencies, which are fundamental to holistic health outcomes. The submission questions about this, presented on page 5, are blatantly biased and misleading.¹

“Do you agree that regulators should focus on factors beyond clinical safety, for example mandating cultural requirements, or solely on ensuring that the most qualified professionals provide care for patients?”¹

Obviously Māori need both culturally and clinically safe care, enjoying the same quality and quantity of life as other New Zealanders. This needs to be foremost and central in workforce reform.

We recommend at least 50% Māori membership on all health regulatory boards. To honour Te Tiriti and address whānau health needs, boards require expertise in cultural safety, Te Tiriti, antiracism and Te Ao Māori. We support Māori oversight of Māori practitioners, professional peer regulation and autonomous, resourced Māori leadership. A dedicated Māori Health Authority is essential to uphold tino rangatiratanga, ensure equity and deliver culturally grounded care.

Article 3: how will PPF achieve ōritetanga—equitable health outcomes for Māori?

The executive summary on page 2 fails to acknowledge the long-standing ethnic health inequities that harm economic, social and ethical vitality.¹ Our health system is not delivering equally well to all New Zealanders.¹⁴ PPF statements presented are withholding key information and are therefore misleading. Nowhere in the PPF are issues of racism, privilege, equity and inequities addressed.

We note institutional racism remains widespread within the colonial health system.¹⁵ There is overwhelming evidence that Māori experience racism through the public system, receiving less quality and quantity of care, resulting in poorer health outcomes. These inequities need to be addressed within health workforce regulations. Addressing health inequities will result in considerable direct and indirect cost savings to the health sector.¹⁶

PPF proposals increase austerity and rationing, further exacerbating existing interpersonal racism. All practitioners working in this country (whether from Australia, Asia, the United Kingdom or Africa) need to be both clinically and culturally safe regardless of where they trained. Quality holistic health care involves more than clinical excellence. Any clinician unable to pronounce your name, breaching tikanga and/or being racist contributes to poorer health outcomes. Māori have a fundamental right to clinically and culturally safe practitioners that should not be compromised because of the Crown’s aspiration for less regulation.

Oral article: how is tikanga normalised within PPF?

In PPF, tikanga is noted by some regulators but dismissed in favour of clinical requirements. The document fails to recognise that health is culturally constructed, and Māori models differ from Western ones.¹⁷ Mason Durie¹⁸ emphasises wairua and hinengaro as fundamental to hauora.

Discussion

PPF promises more efficient, patient-centred regulation but fails to honour the Tiriti relationships that must underpin health governance. Māori are omitted from the preamble’s stakeholders, consultation is limited to online submissions and the Crown’s duty to protect Hauora Māori as a taonga is absent. PPF provides no clear account of Māori involvement in decision making, sidelines Kaupapa Māori services and falsely positions cultural safety as competing with clinical competence. By ignoring racism, long-standing inequities and tino rangatiratanga, it risks deepening rather than reducing harm. A Tiriti-aligned system requires meaningful engagement with Māori, at least 50% Māori representation on regulatory boards, mandated cultural safety and antiracism competencies and recognition of tikanga and Kaupapa Māori as essential to safe, effective practice. Without this, PPF cannot deliver equitable or culturally grounded workforce reform.

PPF implies that policy reforms are driven by patient-centred approaches to care and support within the health system, a concept gaining currency recently but which health professionals struggle to implement.¹ If reforms proposed by PPF serve the entire population of New Zealand, they must give due recognition to its diversity, acknowledging levels of need varying across population groups. Truly patient-centred approaches to health reform potentially address disparate needs of population groups, particularly those that traditionally experience disadvantage caused by inequitable access to services.¹⁹

Our rapid Tiriti review provides substantial evidence that PPF is unlikely to overcome barriers to equitable health provision or address the challenges of health professionals who for decades have struggled to apply genuine patient-centred care. We assert healthcare is a public good and right, not a commercial enterprise. The system is not “bloated” (page 12) but chronically underfunded, with austerity hitting Māori providers hardest.¹ The proposed changes deepen non-compliance with Te Tiriti, further undermine culturally safe practice and fail to address entrenched systemic racism.²⁰

The importance of culture in healthcare is well established.²¹ In 2021, Came et al.²² reviewed all regulatory health competency documents in response to ethnic health inequities and the legal requirement for cultural competency. Using the knowledge-action-integration (KAI) framework,²³ they found significant variation across disciplines. Knowledge components, such as addressing stereotypes and bias, were most explicit, while action and integration were less evident. Five regulatory bodies provided no definition of cultural competency or safety, and confusion persisted between Te Tiriti and the Treaty.

Came et al.²² found poor Te Tiriti compliance in regulatory competency documents, and therefore proposed strengthening political, cultural and equity competencies. Political competencies include knowledge of local hapū/iwi, recognising existing white privilege and practising whakawhanaungatanga. Kāwanatanga requires familiarity with Te Tiriti and He Whakaputanga, reflective practice and support for Māori leadership. Tino rangatiratanga emphasises Māori health aspirations, Kaupapa Māori approaches and advocacy. Ōritetanga calls for equity analysis and awareness of determinants and intergenerational trauma, while wairuatanga highlights te reo, tikanga, Māori models, whakapapa, humility and embodying manaakitanga, aroha, tika and pono.

We recommend that changes to the consultation requirements of regulatory authorities specifically include expectations about engagement with Māori organisations and whānau. Establishing a ministerial review and occupational tribunal increases rather than decreases bureaucracy. This tribunal could include mandatory expertise in Te Tiriti, equity and Kaupapa Māori health practices benefitting public health,¹⁶ essential for culturally safe, antiracist and effective health services.

We call for greater investment in Māori public health to improve whānau outcomes. Public health is cost effective, prevents illness and lifts population wellbeing, yet PPF overlooks its potential. While patient safety matters, collective safety is equally vital. Regulatory bodies should be mandated to work with Māori organisations to identify ethnic inequities and take corrective action.

We believe whānau can only receive appropriate care as equal citizens when changes to health workforce regulation explicitly address Te Tiriti, cultural safety and antiracism. We recommend the introduction of standard Te Tiriti, cultural safety and antiracism competencies across all regulated professions developed with Māori input. This would create useful synergies in terms of regulation, training and monitoring and would strengthen multidisciplinary collaboration. Practitioners need at least a base-level understanding of te reo me ōna tikanga to provide appropriate care for whānau, regardless of training background.

He whakaaro Māori

The Māori co-authors of this paper see deliberate and unrelenting condemnation of all things Māori by the National-led C oalition Government, which we describe as political cancel culture. The immediate and overt cancelling out of Māori—by silencing Māori voices, excluding Māori contributions and ignoring Māori perspectives—is attempting to render Māori invisible and less influential in our own country. This political movement alienates Te Tiriti o Waitangi and the obligations of the Crown that were established in partnership with Māori. It is a movement eradicating the distinct tangata whenua status of Māori through the Government’s fierce attempts to marginalise Māori via dominant colonial powers.

Our analysis of PPF provides confirmation that current inequities will become progressively entrenched and further disadvantage Māori. A genuinely patient-centred approach to policy reform must acknowledge disparities and set out Tiriti-based strategies to address and overcome them. Such an approach will go some way towards achieving equitable health and social outcomes for Māori, as promised by article three of Te Tiriti, while ensuring social justice for everybody living in New Zealand.

View Appendix.