Māngere Integrated Community Health

Many issues in our work in Māngere are relevant across Aotearoa New Zealand. They are:

Who owns health?

Who owns health?

Health service delivery is often controlled by business interests (eg private health providers and drug companies). There are many services but in the way they are designed and delivered they do not seem to be about us. The government should lessen its grip on the way health services operate in communities. Then our communities must step up to fill the gap.

A real challenge is whether we can get a community perspective into the way services are designed and delivered. The issue is how to work with the many different groups that make up communities in ways that respect our uniquely different starting points. People need to be able to express their health and wellness aspirations in ways that do justice to their needs as Tangata Whenua and Tangata Tiriti communities.

We believe that community aspirations are the key to understanding how communities wish to own their health. These aspirations can guide the way services are designed and delivered in support of those aspirations. This will benefit everyone who provides and receives health services.

Across the Māngere community we believe that taking responsibility for our own health and that of our families means taking direct responsibility for the management of the following areas:

  • emotional
  • spiritual
  • physical
  • psychological

When a person arrives at a general practice or an agency office/NGO, they need support so that the discussion and the whole experience works well for them. They may be on their own or with whānau. This support is needed because many of our people find themselves in a powerless position. This position only changes when the more powerful participant (the professional, for example) reduces their power. When this happens, engagement is possible. So too is a relationship and a practical working together. We have drawn up some ideas for how this can be done in our

Specifications for developing facilities

Owning our health implies that our primary focus will be on prevention rather than cure. As we progressively manage this throughout Māngere, with support, there will be two main benefits:

  1. Improved effectiveness of those services that need to be offered once they have been integrated and further developed
  2. Improved effectiveness in the overall health spend in Māngere.

One group in our community expressed its view on connectedness and on what owning health means like this: “What you eat, so you think. What you think you become”. Another view from a Tongan group expressed the same sentiment in a different way:

A healthy family is a happy family. I need to be happy first and then I can be healthy. There is a strong emphasis on owning solutions. If I don’t own them they won’t work for me. If I do own them I take responsibility for action and demonstrate that I can do it in practice.

Tangata Whenua and Tangata Tiriti

We own our health in terms of our identities as people. Our collective view of our common life in Aotearoa New Zealand is also informed by who we are. Our identity is highly specific to us as the people of Aotearoa New Zealand. We never were and will not be seen as anonymous health consumers who just happen to live in this country.

Some of our communities are Mana Whenua and Tangata Whenua in Aotearoa New Zealand. As Mana Whenua we have a long history of being connected with the land of this area. We understand that our responsibilities to own our health include the health of the land and all the people of Aotearoa New Zealand.

We are also Tangata Tiriti and come with proud cultural traditions that are important to state and to preserve in the way we own our health.

We value our worldviews as an important part of our identities as people. As we own our health we will lead from the perspective of who we are – Tangata Whenua and Tangata Tiriti together in this place we call home.

Tiriti/Treaty Page

Interest in health

The community has the greatest interest in health

When a community takes a lead role in developing its aspirations for health and wellness, the next steps must remain under the control of the community.

The community needs to direct the shape of service provision and to be accountable for health and wellness gain.

Community leadership thus understood is primarily accountable to its various parts and collectively to the whole.

When the approach to owning our health and working together to create our wellness begins with the community, not with health providers or other agencies, this acknowledges that communities have the greatest interest, and investment in the way health is organised.

Continued expectation that the community will passively receive health services needs to cease. When the opposite occurs, the conditions for community engagement become a reality. Getting there needs the support of providers and other agencies.

Communities can lead the way

Here are some of our key directions in Māngere:

  1. We will participate in decision-making about the development and delivery of health services and wellness initiatives. We have a whole-of-community perspective based on our framework of inclusive relationships.
  2. We insist that those who take actions that affect the lives of our people do so in a more holistic fashion in support of our aspirations.We will grow our knowledge and confidence to care for each other and collaborate with others to work on wellness into the future.
  3. We will become informed about the health and wellness of our people and communities.
  4. We will advocate for strategic leadership initiatives that promote the integrated care of our people. We will mobilise our people to take action on those initiatives, in particular on issues relating to service design and delivery.
  5. We will champion the importance of relationships and relationship development in the design and delivery of our heath and other services.
  6. We will challenge the segmentation of our common life as a strategic health issue. We will promote integration in ways that make space for different tikanga across the community.
  7. We will set standards that lay out an inclusive approach to the achievement of the common good.
  8. We will encourage the setting up of development structures that suit the way different communities wish to work.
  9. Clearly these points imply change and change in key concepts such as ‘quality’. We believe the term has become consumerist and the system is stressed along with the people in it.

This is a social movement that will involve a renegotiation of power relationships from a community leadership perspective. We believe that will be good for us all.

Community ideas on health & wellness

Approaches to health

The relationships approach to care

A relationships approach is quite different from those based on cause and effect and empirical evidence. In the standard cause and effect empirical model, risks are managed on the ‘we know better than you do’ premise rather than working it out together.

Some major points:

  • ‘We, me – not they!’ – changing responsibility for the direction of individual and whānau health.
  • Relationships drive, services follow – working through people

The relationships approach

The vital role of culture in health

Integration of health services is a cultural issue not a management or service delivery issue. Our experience is that the issue of culture is effectively sidelined when it is treated as just another process consideration.

This is why the cultural lead is important to the development of primary care in Māngere. All cultures participating in Māngere have stressed the importance of not segmenting the physical, mental and spiritual dimensions of health. As we aspire to live in a more integrated way, so too we require our services to operate in ways that are consistent with this interconnectedness.

Therefore we say that service providers must acknowledge and respectfully work with cultural differences in any future development that seeks to integrate services and enhance service delivery.

When we state that we wish to focus on wellness and not sickness, we are articulating a highly integrated concept that relates to who we are, how we see the world and how we would like our health services to engage us. This is why the cultural lead is important to the development of primary care in Māngere.

We know that time spent to establish good relationships with significant others including professionals, community agencies and other support is an important part of asking for help or giving advice. Developing good relationships between patients and doctors and between doctors and patients is the practical mechanism where culture can lead. There can be an outlet for the important values of welcome, hospitality and respect.

These fundamental values operate throughout the communities of Aotearoa New Zealand and can be worked on in a coherent way in terms of a Tiriti/Treaty of Waitangi relationships framework. The values and the variety of practices that give them life need to become part of the normal operating environment in all general practices and in the work of service providers, NGOs and government agencies. Then service delivery will to focus on the patient and their family as those with the greatest interest in their health.

Therefore it is important to state that there is a difference between a relationships approach and a transactional approach to the delivery of health care and service delivery from related agencies.

The transactional approach starts with the service needed to solve a problem while the relationships approach starts with the person and their whānau. The first step is to recognise the person in relation to their identity and culture. This happens before working with them.

Working with a relationships perspective in our various roles in health and wellness

A relationships approach to working with the communities of Māngere essentially revolves around cultural difference. Health providers must know how to form and maintain relationships across culture gaps. Our experience is that agencies will need to review their ways of doing things and learn new ones for this to be achieved. Some key areas of community concern are:

Handling gender issues

Handling gender issues

There are issues relating to gender matching that are important to our community.

In many communities within Māngere, female patients don’t want to consult male doctors and male patients don’t want to consult female doctors. The issue relates to privacy and the importance of preserving male and female roles in the cultures where this is important. There are logistical issues concerning how to work with the reality of too few male or female doctors and other staff. However this challenge presents a practical opportunity to explore the value of male and female roles in health and how gender separation can strengthen the mana of males and females in relation to wellness.

The role of doctors and other professionals

The role of doctors and other professionals

There needs to be a shift to a more supportive, collaborative relationship between doctors and patients. There will be a change in the role of doctor from being an ‘expert dispenser’ to an ‘expert supporter’. We believe it is worth both parties working at this. It is important that doctors are confident in their role and just as important that patients have faith in the doctor.

When doctors are confident and act as expert supporter then, at the psychological level, the usefulness of their advice is increased in the eyes of the patient. We found that people in Māngere do not want to be the doctor. Their desire for change springs from the general view that they want the health services to be focused on them and their health. We feel that health services at the moment are driven by system requirements, current aspirations, funding and measurement regimes and their future development.

Clinicians to the people

Clinicians to the people

The idea of ‘clinicians to the people’ arose in our Māngere discussions. This expression summarises our view that, while it is important to have a range of facilities within easy proximity to each other, health facilities do not drive development from a community perspective. It is worth considering taking services to where people are once there is a relationship to support them. This might help solve the problem of there being not enough clinics to cover the need for primary care services. There are also the ongoing issues of overcrowded surgeries and long queues.

Community ideas for health and wellness

Community ideas for health and wellness

Communities have ideas for developing and maintaining health and wellness. These ideas are an important expression of the power of community leadership. This does not mean an increase in agency programmes where the communities are simply passive recipients. The aim is for communities and service providers to work together on community ideas and community-led initiatives.

These are some of the ideas from Māngere communities:

  • Positive parenting programmes for migrant groups within the wider community.
  • Support groups for solo mums, general parenting and reflecting on the issues of drugs and alcohol in such groups.
  • Endorse and encourage the healthy activities that Māngere people currently do – walking, bowls, exercise classes, swimming and the gym. Greater enjoyment from learning to develop healthy eating.
  • Interest in body ‘warrants of fitness’ at different stages throughout life.
  • Developing a greater first aid ability in the community and the confidence to apply it.
  • Liaison with acupuncture, physiotherapy and chiropractor services coordinated in the general practice setting.

When these and other community-led initiatives are worked through with our communities, communities will grow in confidence and will be able to take the lead.

Ongoing learning and capability development for communities

Ongoing learning and capability development for communities

Community education assumes a base of respect for people. People usually resist being told things and prefer to work them out together with others.

If the starting point regarding health and wellness is the community, rather than health professionals and other agencies, it follows that the way awareness, knowledge and skill acquisition needs to be approached should also reflect the lead of the community.

Communities have raised a number of issues relating to areas where they need to know more or to become more skilled. They also raised areas where health professionals and agency staff need to develop knowledge and skill in order to be effective.

What communities may want to know

What communities may want to know

  • Learning related to the health system itself, e.g. the role of the family doctor as coordinator or expert supporter.
  • Alcohol abuse.
  • Dementia, especially the detection of early onset dementia.
  • Targeted understanding of the risk factors for different diseases across all cultural groups together with community-driven strategies for addressing these matters.
  • Getting a greater understanding of what people can do themselves and when they need others to help.
  • Knowledge of and ability to work with people’s ethnicity in an engaged manner from their perspective.
  • Acknowledging that people have a right to health information relating to services but need to get it differently so they actually understand it.
What health and other professionals may want to know

What health and other professionals may want to know

  • Developing more targeted and useful ways to provide information relating to the questions people are asking.
  • Changing focus to help increase the community’s ownership of health and wellness. Help to improve the community’s skill and confidence to act effectively.

The training of health professionals from a community perspective needs to be focused on the diversity of our communities of Aotearoa New Zealand. For us that means training at community level in Māngere. Professionals must understand the cultural and religious dimensions to the various cultural groups. They should know how to respect and engage people who belong to those groups.

How will health and service providers know that this approach is effective? One indicator is that communities would take more part in productive and mutually beneficial relationships about health and wellness.

There is probably a need for some ongoing cultural advice for health professionals and agencies. This would logically come from the various communities. It would need some central coordination to keep things alive, relevant and moving forward.

Useful ways to realign health towards community ownership

Useful ways to realign health towards community ownership

There are many examples of useful tools and practices that would assist with the process of realigning health towards greater community ownership:

  • Helplines
  • Providing electronic tools for people to use interactively
  • Advice centres
  • Having health and community workers join community meetings to discuss health issues as part of a community agenda
  • Getting onto the agendas of church committees, marae committees and other community gatherings where people like to meet
  • Using internet tools like social networking, blogs and websites.

If there were fewer programmes and more places and people to visit to seek advice, this would begin the practical realignment towards acknowledging community ownership of health.

Models of medicine

Traditional medicine vs. the western medical model

Across Aotearoa New Zealand we don’t all think in the same way about the world, about our problems and therefore about solutions.

The western philosophical paradigm is committed to the segmentation of the world in order to understand how everything works. This is a relatively recent idea. Now it is time to review how modern specialised knowledge has obscured our need to connect the various parts of our life.

Interconnectedness

In cultural terms the interconnection of everything that exists, living and not living, has a direct relationship to the health of people and communities. A Tangata Whenua worldview values interconnection. So too does a Hindu worldview. Interconnectedness is a reality for many Pasifika cultures as well. In cultural terms the interconnection of everything that exists, living and not living, has a direct relationship to the health of people and communities. The implications of this are that the mind:body separation is not relevant to many in our community.

Within our communities there are a range of traditional approaches to health and wellness that work. These need to be recognised by healthcare providers. At the moment rongoā Māori, for example, is acknowledged within secondary care on the basis of risk. This means that the patient must provide a list of rongoā and the hospital assesses whether these will have an adverse effect on western treatments. The hospital often decides what is acceptable and what needs to be stopped. In effect the western treatment becomes the norm and traditional medicines are ‘other’. This powerful approach is a long way from patient ownership of health.

Across our communities today there are examples where the first preferred route is traditional medicine and at a later stage a doctor will be considered. Many Pasifika people use a range of options such as prayer for healing within the family and prayer with the pastor or elders of the church (particularly in serious cases) and anointing with oil. Traditional fofō involves the use of selected plant leaves to massage the body. People also drink the juice from selected leaves, when available, to cleanse the body and promote healing.

Taken overall, our reflection on traditional practice is that it is not about who is right and who is wrong. We’re interested in what could be done well or better together if health service provision was informed and guided by a different kind of relationship between the various parties

Facilities that feel like home

Facilities that feel like home

Some people in Māngere said that when visiting a doctor they needed to go to a place where they felt comfortable. Sometimes they would travel considerable distances to achieve that. The issue related to the relationship with the doctor and was often described in terms of trust. Others articulated the need for health facilities to have a look and feel of ‘home’. The concept of home or being at home is connected with the acknowledgement of the person in the context of an engaged relationship.

There are also issues related to colour schemes in surgeries and agency offices. Many Pasifika people are used to seeing more colour than is to be found in the ‘corporate office’ colour schemes of many general practices, for example.

There are issues relating to the hours of work for clinics. There is also a need for more flexible hours of work. People find it hard to take time off to go with family members to the doctor for language or cultural reasons or for more general support (say for children).

Cultural practices about food and cleanliness

Cultural practices about food and cleanliness

A Muslim value around cleanliness relates primarily to ablutions and to food. Toilet facilities need to be designed in such a way that there is easy access to clean water for washing within the toilet cubicle. The design needed is similar to a disabled toilet.

Halāl restrictions on food and the need for medicines to be free of alcohol and animal ingredients suggest that Halāl and its place in the health of people needs to be better understood.

Tongan groups in Māngere suggested it would be good to have shared discussions with health professionals and agencies about the strengths and weaknesses of traditional foods. Everyone would benefit from such discussions.

Services that meet different cultural needs

Services that meet different cultural needs

There are implications of waiting to consult a doctor (often at a hospital) for Muslim people, given their prayer schedule. People need to pray 4 to 5 times a day at particular times. For this to occur there must be a place to pray together, with a place to wash as part of the prayer process.

There is also a need to provide for particular religious requirements (for Muslim communities) at gyms and swimming pools. Men and women must be able to participate separately or they can’t participate at all.

The spiritual aspect of health and wellness

The spiritual aspect of health and wellness

We place a central importance on a practical acknowledgement of our spiritual dimension. We know that the provision of health services needs to address this aspect of our identity in order to be relevant and useful to us. We express our spirituality in a variety of different ways and we expect those who provide services to know these things and to work with us accordingly. We bring our spirituality with us when we seek the support of health professionals and other related agencies. We do not leave it at the door.

We further state that as our children and their children grow and become part of our communities as adults and parents themselves that they will retain their cultural identity. This needs to be acknowledged and respected when health professionals and other related agencies work with us. When cultural acknowledgement occurs in practice it enables us to have a positive faith in both the healing process and the relationship we can have with health professionals and others.

When such an acknowledgement is absent there is a danger, well known to us, of mental health problems arising from assimilation. This happens when a person loses contact with their base and becomes ‘not from here,’ ‘not from there,’ in fact ‘not from anywhere’.

Time means different things to different people

Time means different things to different people

Some members of our community have expressed the need for greater understanding of time from their perspective. When a person feels they can take the time that they need, they are more likely to open up to share the issues. This means they’re more likely to get help that is relevant.

Time slots often work counterproductively for patients and this needs to change.

Language

Language and communication

Culture and language are so intertwined that when people can speak their own language, they feel more confidence to manage their own health. We wish to have the fear of visiting a doctor removed because our people cannot communicate with the doctor nor the doctor with them.

Culture and language are so intertwined that when people can speak their own language, they feel more confidence to manage their own health. This level of language difficulty applies in some parts of our community more than others. In parts of the Tongan and Samoan communities this difficulty is extreme for some elders because they cannot speak English. For others it is the feeling of disconnection with the culture of the service and style of service delivery. They do not find it acceptable to ask questions. It is not their way.

The disconnection doesn’t stop the professional dispensing of health. However it does continue to disempower people and reduces their confidence in owning their health.

Many community members have a strong preference to communicate with health professionals and related staff in their own language. This is an issue of empowerment. We acknowledge that it presents a number of challenges, some of which are logistical.

The feeling from a number of different communities is that when professionals use a person’s own language when working with them, it makes a strong signal about the intent and direction of interpersonal engagement. It can be an encouraging signal to the person and usually invites a positive response. This can be a key starting point for relationship development.

Health outcomes

Who owns health outcomes?

When the government owns health outcomes, the desired outcomes might be things like shorter waiting lists. But when the community owns the outcomes, there’s a greater focus on the wellness of men, women and children and the family group. Health providers, NGOs, schools and government agencies are in a supporting role.

  • Community aspirations are agency priorities – ‘We see what you see.’
  • Agencies work cooperatively with each other to get collective results.
  • Health services support the community’s health and wellness aspirations.
  • Empowerment through access to shared knowledge leading to improved confidence – ‘You own your health – we’ll work with you.’
  • Services are delivered in ways that relate specifically to individual patient and family/whānau preferences, needs, cultures and values.
  • New or enhanced services will be designed and delivered in ways that are integrated from a patient and family/whānau perspective.

The following health outcomes are a guide to what we are aiming for:

  • The health status of all New Zealanders is measurably improved
  • People know about how to manage their own health and support the health and wellness of others
  • Everyone knows what services are available and how to access them.

We believe that professionals must understand that their role is to support communities as they work for health and wellness. When they can do this, the benefits of community leadership of primary care in Aotearoa New Zealand will be obvious.

Health budget

Health spend vs. sickness spend

Healthy is normal.

Health is a lifestyle choice for the community and a challenge to professionals – ‘We in the community are ready when you are.’

Owning our health implies that our primary focus will be on prevention rather than cure. As we progressively manage this across Aotearoa New Zealand, with support, there will be two main benefits:

  1. Improved effectiveness of those services that need to be offered once they have been integrated and further developed
  2. Improved effectiveness in the overall health spend in Aotearoa New Zealand.

Costs

In some communities there are real problems with the cost of medical services. Some Pasifika communities pool costs for some individuals to receive medication. Cost may be a factor when people leave the decision to seek help until too late or when a condition has become very serious.

Over the past 20 years political parties have tried to drive down the cost of the health system. But their strategies do not seem to have had any empowering effect for communities to manage health more effectively.

When economic drivers dominate, the systems act powerfully on people’s confidence to take control of their own situation. This is why in some communities the priority for things other than health is in evidence. However from a relationships perspective in some Samoan communities, placing a priority on funding basic needs, the church, weddings and funerals makes sense from the perspective of remaining integrated. The alternative is to engage in a health and related agency system from which people feel disconnected.

An interesting question arises from a relationships perspective. If people were acknowledged, engaged and supported within the professional and agency network for who they are, would the view of funding priorities change?

For more information about the work of MICH, please contact us