Background

Māori, the indigenous population of New Zealand (NZ) continue to suffer from the effects of colonisation, both historical and contemporary as evidenced through longstanding inequities in health outcomes and access to gold-standard health interventions.1 Institutional racism is considered the legacy of colonisation as it has created systems that disproportionately disadvantage Māori. The recognition and remediation of the trauma experienced by Indigenous peoples remains a global challenge as indigenous populations around the world encounter less access to the socioeconomic determinants of health.2 3 In NZ, the signing of the Treaty of Waitangi (English version) and Te Tiriti o Waitangi (Māori text) reaffirmed Māori rights to self-determination, sovereignty (Tino Rangatiratanga) and equal rights with British subjects.4 Despite this, the Treaty has been continuously disputed and challenged as to its place as the founding cornerstone of NZ society.5 Synonymous with indigenous peoples worldwide, significant health inequities exist for Māori who experience poorer quality of healthcare, access to healthcare and health outcomes.2 The Institute for Health Improvement (IHI), Boston, often considered a paragon for quality improvement in modern healthcare, recognises the importance of equitable care yet does not provide an adequate solution for reducing ethnic disparities.6 Te Tiriti o Waitangi lays the groundwork in a national-legislative capacity to help reduce ethnic inequities and to reaffirm Māori leadership as a foundation for providing equitable healthcare for all NZs.7 8

Te Tiriti o Waitangi, Rangatiratanga, and Health Equity

Te Tiriti o Waitangi and the Treaty of Waitangi constitute and codify the relationship between Māori and the British Crown.4 Under international law of contra proferentem - precedence is given to treaty agreements written in the language of the indigenous population and not the drafter.9 In this light Te Tiriti o Waitangi reaffirms Māori sovereignty or absolute territorial authority, which was not clearly acknowledged in the English version, the Treaty of Waitangi.4 9 Te Tiriti o Waitangi contains three written articles and was sought to establish a partnership with the British Crown that ratified Māori as tangata whenua (people of the land), reaffirming and recognising Māori sovereignty over their lands and people.10 The relevance of Te Tiriti to health is also legislatively established through the NZ and Public Health and Disability Act 2000, which requires the health sector to ‘work towards eliminating entrenched health inequities between Māori and non-Māori’.11

The NZ Ministry of Health recognises three actions in its framework to provide healthcare for Māori: leadership, knowledge and commitment.12 Engaging and involving Māori in health initiatives remains an important challenge for the healthcare system, perhaps best served by adopting the methodology of shared, or distributive leadership. The shared leadership model begets a culture of collaboration, allowing for a shared mental model and mutual understanding of the attitudes and barriers towards health improvement and health equity.13 This model can be used as the basis of developing allegiance and shared vision with indigenous populations, generating an allegiance through collectivism, cogovernance and coleadership.14 15

Precolonial Māori leadership, Rangatiratanga, embodied centralised-transformational leadership approaches of chieftainship and chiefly authority.7 Rangatiratanga has been extensively discussed in relation to Te Tiriti; the word ‘Rangatiratanga’ appears in article 2 encompassing sovereignty, chieftainship, leadership and self-determination.16 In the late 19th and early 20th century, Rangatiratanga evolved into a more dynamic leadership role that promoted the collective well-being of Māori, mirroring the contemporary approaches of ethical and servant leadership within a distributive leadership model.7 15 Rangatiratanga guides the philosophy of bringing people together, learning from one another, sharing wisdom and building mana (prestige and mutual influence).15 17 Māori leadership embraces collectivism, nurturing relationships, reciprocity and a system of interdependent leadership that merits the common goals of all peoples.15 17 Rangatiratanga provides a contemporary basis for engagement with Iwi (tribes) and Hapū (subtribes) and is a culturally authentic and self-affirming model of health leadership.15 17 It is proposed that leadership systems are influenced by the social and political context within which they dwell and that traditional professional hierarchy in healthcare can limit the development of collectivist, collaborative leadership systems.18 Where traditional western professional hierarchy centralises leadership, rangatiratanga acts as a suitable rebuff for this barrier in the modern NZ and health environment.

Western and Indigenous Epistemologies

The IHI proposes that leadership regarding health initiatives should be multidisciplinary, and advocates for leadership systems that foster a ‘culture of accessibility, open communication and advocacy’.19 The IHI White Paper series proposes four key components of leadership as; guarding the learning system, creating psychological safety, fostering trust and ensuring alignment of values.6 These principles also underpin Mātauranga Māori (Māori knowledge and ways of ‘knowing’) where responsibilities are intricately connected and shared among communities through tikanga Māori (Māori custom).16 17 19 The NZ Health Quality and Safety Commission (HQSC) builds on the IHI principles and proposes that leadership roles must develop actions and set examples for other to follow.20

Internationally, the IHI is recognised in the strive for the Triple Aim for quality improvement, yet further endeavours are necessary to allow for equitable leadership that is appropriate for indigenous health structures. The HQSC acknowledges the Triple Aim and, using Te Tiriti o Waitangi as a critical tool to help guide public policy, has made efforts to improve health and equity for all populations.21 HQSC recognises the inequity in health access, inequity in health outcomes, net health loss, and resource allocation inefficiencies for Māori compared with non-Māori.20 21 However, despite the echoes of Kaupapa Māori and Mātauranga Māori within the IHI framework, the engagement, empowerment and inclusion of Māori in health quality and safety are yet to feature in HQSC’s abstractions. It is argued that the inclusion of indigenous epistemologies within health policy, process and structure is paramount in undoing the effects of colonisation: allowing for self-sovereignty, cogovernance and the alignment of a population’s values22 23

Incorporating Māori knowledge systems into health leadership will help foster a safe, equitable learning culture.17 Generally, shifting health leadership to adopt integrative, collectivist and future-focussed models has been associated with improved organisational processes and improved team outcomes.24 Mātauranga Māori and tikanga Māori have largely been suppressed through colonisation despite ethical and leadership principles rooted in social justice, reciprocity and community.15 16 25 Māori jurisdiction over the usage and application of mātauranga Māori in contemporary health settings is necessary to ensure the appropriate protections and processes are in place to protect Māori epistemologies.26 Mātauranga Māori is led by Māori and should be at the centre of any service delivered to Māori. In this light, Kaupapa Māori research (KMR) methodology advocates for ethical cogovernance and leadership ‘by Māori, for Māori,’ as western-centric initiatives have not been suitable to address the inequities in Māori health.27 KMR has grown exponentially and the work of Māori scholars has seen it evolve into a space of renaissance within academia.28 Traditional western research paradigms are privileged and upheld as ‘all knowing,’ leading to criticisms of KMR being of limited focus and unsuitable in quality improvement, despite it providing greater health quality and health outcomes for Māori.28 29

Rangatiratanga, Servant Leadership, and Ethical Leadership

Flattening leadership hierarchies is encouraged when developing quality health initiatives, allowing for leadership to develop at all levels.19 Two such leadership theories that exemplify this approach are servant and ethical leadership. Servant leadership is generated from and acts in turn to empower its followership, the people that are led, embodying humility and stewardship but not necessarily based on ethical and moral values.30 31 Ethical leadership in turn demonstrates morality and ethics as its core focus and in this paradigm, leaders act to shepherd behaviours deemed moral or ethical and admonish actions which are not.30 31 Linking the two theories further allows for the development of an adaptation of the shared and distributive leadership model that incorporates indigenous epistemologies.23 Shared and distributive leadership in this sense is neither prescriptive nor rigid and allows for close examination and revision to adopt to internal and external organisational factors of a given social and political context.

Leadership extends beyond the command and direction of followers by any one individual or group of individuals, and is instead acknowledged as an inclusive system sharing a common context or goal.32 The shared leadership model, characterised as a dynamic process, has been noted to promote better and more meaningful connections with Māori.33 Leaders and team members engage in a reciprocal relationship informed by tikanga Māori (Māori customs) through principles of utu (reciprocity) and manaakitanga (nurturing relationships).16 17 24 Shared leadership, or collective leadership, is an emergent and self-perpetuating model, where reciprocal influence and dynamic interpersonal relationships lead groups or organisations towards achieving their common purpose and goals.33 This leadership model better aligns with Indigenous Māori leadership which is informed by holistic and collectivist methodologies.15 25 Leaders participating in the shared leadership model act as moderators rather than the ‘heroes’ epitomised in models of vertical leadership.34–36 This moderator of shared leadership resembles the integrator of the Triple Aim model, an entity bringing together the three arms of the triple aim to provide equitable quality of care.37

Māori epistemologies privilege and prioritise a healthy and reciprocal relationship between tangata (people) and whenua (land), synonymous with ethical and servant leadership models.15 17 25 Developing a positive leadership approach for the shared leadership climate also allows a servant leadership model to develop from within, with the idea that a leadership system acts to nurture and develop its participants to strengthen the quality of its service outcomes.25 Māori as a tribal peoples are not altogether homogeneous with one another and the deliberate destruction of Māori history, epistemologies and paradigms has marked the struggle for Māori self-determination.17 Ideas and practices related to tikanga Māori and mātauranga Māori may differ among Iwi (Māori tribes) and so the advent of ethical and servant leadership models support Māori rangatiratanga to develop health solutions that are ‘Te Tiriti’ focused, equitable and antiracist.15 16 25 A ‘one-size fits all’ approach to rangatiratanga and leadership for Māori is not feasible however, Kaupapa Māori methodology informed by mātauranga Māori can be applied concomitantly with the ethical and servant leadership approaches to support and promote Māori self-determination.17

Contemporary NZ has shown a strong response to a servant leadership style in healthcare, as evidenced by a strong public support for empathetic public figures such as Mike King, awarded NZ of the Year for his services to mental health and suicide prevention, as well as Hon Jacinda Ardern and Dr Ashley Bloomfield for their response to the COVID-19 pandemic.38 39 Furthermore, several holistic Māori health models are commonly utilised within NZ healthcare services and reflect the values of ethical and servant leadership models.40 The servant leader is aware of their followers’ values, are teachers as well as listeners and act to foster a community of safety and awareness.17 25 33 This approach may also coalesce vertical and shared leadership frameworks, allowing easier adaptation to healthcare settings where leadership as a concrete entity is more readily accepted than leadership as an abstract system.33 34

Positionality statement

This article seeks to improve the challenge of leading health quality initiatives that include, engage and benefit indigenous populations. The three authors reside in Aotearoa, NZ, and are all currently working in the surgical field. DSP is a surgical resident with an interest in clinical governance, health systems, and an is an advocate for vulnerable patient populations. J-LR is also a surgical resident and an expert in the field of Māori health and KMR. JK is a highly accomplished general surgeon and clinical Associate Professor of Surgery at the University of Auckland. He is also a leader in the field of Māori health, KMR and surgical care.