Strengthening Māori participation in the New Zealand health and disability workforce

Substantial progress has been made in Māori health and disability workforce development in the past 15 years. This is reflected in the range of current interventions, as well as increasing numbers of Māori health professionals. However, wide and sustained disparities in Māori health workforce participation persist.

Māori and the New Zealand Government agree that proactive measures are required to continue to address health workforce participation disparities. The success of interventions to date provides direction for future action.

In the 1996 and 2001 censuses, Māori made up about 15% of the New Zealand population, but less than 10% of the workforce employed in health and community service.1 According to the Health Workforce Advisory Committee 2002 stocktake of the New Zealand health and disability workforce,2 the proportion of Māori within the health and disability workforce groups is below 7% (with the exception of social workers at 18%). In many health occupational groups or specialist areas, Māori are either not represented or are vastly under-represented. Further, Māori tend to be clustered in areas that require lower levels of formal qualifications, such as health field service workers (13.2% of service workers are Māori). Māori account for nearly 13.8% of the health “technicians and associate professionals” occupational groups, and about 5.7% of the health “professional” occupational groups, with levels of 2% or lower in about half of the “professional” groups. In terms of retention in the workforce, where workforce data enable measurement, it appears that there are generally moderate levels of Māori retention (60%–80%) across health professions.3

Māori medical practitioners provide an example of progress. In the 2001 census, Māori medical practitioners accounted for 2.6% of the medical workforce (consistent with findings of the New Zealand Health Information Service workforce survey 2001–02). More recent statistics show that the number of registered Māori medical practitioners has increased; however, the proportion of the workforce remained stable through to 2004. Māori are under-represented in all medical practitioner employment categories, particularly for specialists (1.9% in 2004–05) and medical officers (1.6% in 2004–05). Examination of data on active Māori doctors by employment type (eg, anaesthesia, dermatology, pathology) showed many areas in which no Māori were reported as working or where there were fewer than four Māori.

The number of Māori students completing medical studies during 2001–2003 remained stable, but enrolments over the period increased by about 20%. Nevertheless, substantial additional growth in Māori student enrolments and completions is required to facilitate representative participation of Māori.3

Progress across occupational categories is varied, and this may reflect differences in the level of commitment to Māori health workforce development across professions, including training institutions and professional bodies. Nevertheless, Māori enrolments are increasing in some health courses, especially medicine, which indicates that activities to increase Māori participation in the health workforce are having a positive effect.

Five areas that contribute to workforce development provide a useful framework: workforce development infrastructure; organisational development of health care providers; training and development; workforce information, research and intervention evaluation; and recruitment and retention. This article focuses on recruitment and retention interventions. However, it is important to keep the overall framework in mind, as successful Māori health workforce recruitment and retention will require activities to be carried out simultaneously across each of the five areas. It should be noted that the interventions described in this article have generally had strong Māori leadership in development and delivery.

Te Rau Puawai is a New Zealand Ministry of Health and Massey University joint venture, with the goal of accelerating the development of the Māori mental health workforce.4 The initiative is located at the university’s Palmerston North campus in the central North Island. As of 2005, Te Rau Puawai has contributed 146 graduates to the Māori mental health workforce.5

The program provides comprehensive support to Māori students seeking university qualifications in mental health fields. Support includes scholarships, academic mentoring, learning and personal support (including telephone team learning support), course planning assistance, facilitation of access to Māori and student networks, support visits to distant bursars, a website containing program information, student gatherings, dedicated facilities, and job-seeking assistance.

Program evaluation indicates that key factors underpinning the success of the intervention are:

• it is integrated within the university environment;

• it is Māori focused with strong leadership;

• it has a high standard of program coordination;

• it includes provision of financial assistance;

• it allows access to Māori mentoring and peer support; and

• it provides comprehensive support.4

Te Rau Matatini is a national Māori mental health workforce development organisation funded by the Ministry of Health.6 Te Rau Matatini contributes to Māori mental health workforce policy development, increasing the capacity and capability of the Māori mental health workforce, and promoting career opportunities in mental health among Māori.

Te Rau Matatini projects have included developing clinical placement guidelines for Māori tertiary students7 and working with educational providers to better ensure that programs align with the needs of the Māori mental health workforce.8 The key strength of Te Rau Matatini is that, although it focuses on Māori mental health workforce development, it has a broad mandate in the sense that it operates at a number of levels (eg, structural, systems, organisational) and with a range of stakeholders.

Vision 20:209 is a University of Auckland Faculty of Medical and Health Sciences initiative to increase the number of Māori health professionals (some aspects of the program also target Pacific students). The program has three components: the Māori and Pacific Admissions Scheme (MAPAS); Hikitia Te Ora (Certificate in Health Sciences); and the Whakapiki Ake Project.

MAPAS was established to increase the number of Māori and Pacific students enrolled within the faculty’s health programs and graduating as health professionals. Eligible Māori and Pacific candidates undergo an interview process, including cultural components and opportunities for extended family input, to determine their most appropriate academic pathway within the faculty. The following support is offered to students who choose the MAPAS entry pathway:

• a support team;

• mentoring;

• additional tutorials as required;

• pre-exam study weekends;

• peer and extended family support through regular shared lunches;

• a camp and marae (Māori community centre) cultural experience;

• scholarships information;

• support to apply to faculty programs;

• support to access the Student Learning Centre;

• summer studentship research opportunities;

• access to Māori and Pacific medical and research staff; and

• a supportive environment to learn Māori or Pacific languages.

Hikitia te Ora is a 1-year foundation program that is designed to enable Māori and Pacific school leavers or alternative entry applicants to make a supported transition from secondary school or their community or workplace to university. The certificate course supports development of study skills. Successful students receive a university entrance equivalent qualification and are encouraged to apply for entry into a range of tertiary health field programs.

The Whakapiki Ake Project, which began in July 2003, facilitates secondary school student entry into Hikitia Te Ora, and aims to recruit 100 Māori students per year, half of whom would be channelled into the School of Medicine at the completion of the course, with the other half moving into various health programs. Generally, students gain access to the project through 31 schools with which formal relationships have been developed. The project provides information on health careers, facilitates opportunities for health field work experience, provides assistance with applications and course costs, and ensures access to learning and other support throughout the students’ study. Since the project was initiated, the number of Māori enrolling in Hikitia Te Ora has grown rapidly, with 24 students enrolled in 2003, and 49 enrolments in 2006.

Strengths of the Vision 20:20 program include:

• enhanced admissions processes that take account of broad competencies;

• use of Māori role models and mentors;

• measures to enhance the learning environment for Māori;

• efforts to assist students to access financial assistance;

• endorsement of Māori values and cultural development opportunities and support for a culture of success;

• a supported transition into tertiary health field education;

• a focus on secondary school students and the establishment of formal relationships with secondary schools;

• outreach to schools and extended family;

• practical learning opportunities; and

• ongoing learning support for the duration of health-field programs.

The Hauora Māori Scholarship program10 is administered by the Ministry of Health. The program provides financial assistance to Māori students to support Māori health workforce development. It has been successful in facilitating Māori student entry into and completion of tertiary health-related studies, and in making a substantial contribution to the capacity and capability of the Māori workforce. Success factors include a history of governance-level champions, a clear intervention logic, targeting of Māori and an evidence-based rationale, consistency with government policy, an interdisciplinary and multilevel focus, and provision of financial support to address the barrier of affordability of tertiary education.

The Health Research Council invests in Māori career development awards at the postgraduate and postdoctoral levels through a contestable annual funding process. The purpose of the program is to foster Māori health research workforce development, and its success is indicated in the growing number of PhD qualified Māori health researchers who are past recipients of the awards and who are now actively pursuing research careers.11 Key program success factors include a long-term strategy, consistent funding, strong Māori leadership, the provision of financial assistance, opportunities for broad training with a variety of research institutions and across disciplines, and a robust selection process.

Hauora.com Trust is a Māori-led National Māori Workforce Development Organisation formed in 2000. The functions of the organisation include national leadership and strategy, advocacy with government agencies, facilitating training opportunities, and providing support and strategic and management advice for stakeholders. Key strengths of Hauora.com are that it was established by Māori health professionals and is Māori led, is independent, has close relationships with Māori professional bodies and networks, takes an inter- and intra-sectoral approach, and operates across the workforce development pathway.

Professional bodies have been set up to support Māori health professionals. As an example, Te Ohu Rata o Aotearoa/the Māori Medical Practitioners Association of Aotearoa New Zealand (Te ORA) represents the interests of Māori medical students and doctors. The functions of Te ORA include promotion of the recruitment and retention of Māori medical students, provision of advice to stakeholders regarding increasing Māori entry into medical education and expansion and strengthening of the workforce, the provision of peer support and collegial relationships for Māori doctors, and support for members to enhance their competencies. Professional bodies are important sources of support for Māori health professionals, and provide advocacy for workforce development.

Both the Royal New Zealand College of General Practitioners and the Australasian Faculty of Public Health Medicine employ a Director of Māori Training. Both positions are funded by the Clinical Training Agency. The directors provide a Māori workforce development focus within influential mainstream organisations that would not otherwise have access to a regular source of internal Māori workforce development expertise. The role facilitates more consistent action to address Māori training needs.

Official statistics indicate that Māori health workforce recruitment and retention interventions are having a positive effect. There is much to be learnt from the key strengths and success factors of these interventions, and there are opportunities both to consolidate progress to date, and to build on it as a foundation for ongoing action to increase Māori participation in the health workforce. The initiatives described provide models for intervention that may be applied more widely, in particular Te Rau Puawai, Te Rau Matatini, and Vision 20:20.

Key success factors of the interventions have included:

• Māori led, focused and targeted interventions;

• consistent investment over a prolonged period;

• emphasis on the development of dual cultural and clinical competencies;

• integration of student support programs within a university environment;

• provision of comprehensive support to tertiary students, including financial assistance, access to Māori mentors and peer support, and inclusion in communities of learning;

• congruence with industry needs;

• supported transitions into and between study and work;

• attention to the broader determinants of Māori health workforce participation; and

• action across the workforce development pipeline (including secondary schools).

The lessons learned from Māori health workforce development activities provide a strong basis for ongoing action to address inequities in Māori health workforce participation, and are likely to be relevant to health workforce development approaches for other indigenous peoples.