Improving health and combating inequality in the Bay of Plenty – Toi Ora

This is a condensed version of an article that appears in the December 2013 Public Sector journal. For the full article please contact:


The Bay of Plenty District Health Board’s Māori health initiative, Toi Ora, has led to significant improvement in Māori health in the Bay of Plenty. The programme was the winner of this year’s IPANZ Gen-i Public Sector Excellence Award for Crown-Māori Relationships.


Toi Ora, optimum health and well-being for Māori, has been a strategic priority for the Bay of Plenty District Health Board (BOPDHB) since the inception of DHBs in 2001. The BOPDHB has as its vision the creation and maintenance of “healthy, thriving communities”, explains CEO Phil Cammish.


“For our Māori population, spread across the whole Bay of Plenty and encompassed by 18 iwi, we have taken a culturally-based approach which has seen a more ready acceptance of the health messages and our input into the well-being of their communities.”


Janet McLeanA number of factors have driven Toi Ora, says Māori Health Planning and Funding Unit General Manager Janet McLean (pictured on left with Rūnanga Chair Punohu McCausland).


“We have the highest number of iwi and the highest number of Māori providers compared with any other DHB. Māori represent 25 per cent of our population, the national average is 15 per cent, and there are a number of health-related inequalities between Māori and non-Māori, so there are some compelling drivers.”


Building Success


There are four main factors key to Toi Ora’s success:


  • A Māori Health Rūnanga, bringing together all 18 iwi in the Bay of Plenty (the highest number of iwi in any DHB), was established to work with the BOPDHB in developing a joint strategy towards Toi Ora.

  • The Māori Health Planning and Funding Unit was established to undertake the planning and funding of Māori health services within the BOPDHB. This includes contracting, monitoring and evaluation of those services, and to contribute to the reduction of health inequalities for Māori in working towards the achievement of Toi Ora. This unit is the only one of its kind in the country.

  • The Māori Health Plan monitoring framework was developed to ensure the DHB delivers services that increase Māori capacity and capability, assess (and increase) the level of Māori involvement and participation and improve the health status of Māori. This provides essential feedback and has been adopted by other DHBs throughout the country.

  • He Pou Oranga Tangata Whenua is a framework developed by the DHB in partnership with the Māori Health Rūnanga to ensure traditional tangata whenua values, knowledge and institutions for all Bay of Plenty iwi are recognised as key indicators of Toi Ora-based services.


Challenges and Lessons


However, getting buy-in has been a challenge.


“Often Māori initiatives can be seen as separatism,” McLean says. “Toi Ora was in fact about working closely with the sector as a whole and emphasising how reducing inequalities for Māori is good for the whole population.”


McLean talks about the proportionate universalism approach where, by focusing solely on the most disadvantaged, we will not reduce health inequalities. Rather, actions need to be taken on a scale and intensity proportionate to the level of need.


“For example, in the case of immunisation, the majority of children will be immunised by their general practice staff, others will be immunised in the hospital environment,” she says. “However, some children and families may need additional support or targeted interventions such as outreach immunisation. The target for two-year-old child immunisation is 95 per cent. This high level is required to stop outbreaks of disease.”


The approach has been a success. In 2009, 54 per cent of Māori two-year-olds in the Bay of Plenty were immunised, compared with 63 per cent non-Māori. In 2012, the Māori percentage had risen to 91 per cent. This means 500 more Māori children have been immunised and, importantly, this has closed the inequality gap.


“Another challenge – throughout the significant period of investment and building capability in the Māori sector – was ensuring Māori were not operating in isolation but connected and working closely with general practitioners, community nurses and local pharmacies,” says McLean.


“It is also essential to remember that in a Māori community a sense of autonomy, self-determination and self-management is very important.”


Looking Ahead


The Toi Ora team is not resting on its laurels, says McLean.


“Now that we are confident in the systems and processes, we want to accelerate the rates of improvement.


“At the moment, a number of our Māori health priorities are trending in the right direction, but we want to close that inequality gap more quickly. For example, the national cervical screening target is 80 per cent. For non-Māori in the Bay of Plenty it is currently tracking at 84 per cent compared with 63 per cent for Māori. We have been trending towards a four per cent improvement over the past two years. We want to accelerate that.”


McLean also talks about placing more emphasis on the Whānau Ora approach and working across agencies to bring about change.


“Current priorities include rheumatic fever, respiratory conditions and skin infections and some of these concerns really lie in the housing area, in terms of poor housing conditions including lack of insulation. We need to ask, how can the health sector work more closely with other agencies in the community?”