Ambiente de control

For Māori, the existing health policies and practices prior to the 1990s had clearly failed and significant disparities persisted. Public health and health promotion approaches, arguably a little better understood by government post Ottawa Charter, offered some potential to improve Māori health status and reduce ethnic inequalities in health. However, the focus remained largely on individual health (Lovell and Neuwelt 2011) and further concerns were raised over the lack of effective programmes and evidence for Māori (Moewaka Barnes 2000). As a result there was mounting pressure from Māori to be given at least some ownership of their own health and health programmes within their communities (Moewaka Barnes 2000). The addition of external programme evaluation allowed Governments to risk funding short-term (generally three years and less) Māori health promotion initiatives and the era of the Māori health promotion programme pilots (and evaluation) began.

In 1991, changes to health funding arrangements provided an opportunity for a wider range of organisations to become involved in service delivery, including health

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promotion – “Māori health providers increased from 13 in 1993 to 240 in 2004” (Ellison-Loschmann and Pearce 2006:8). Many of the health promotion projects were influenced by the “by Māori, for Māori” approaches (Moewaka Barnes 2000) and by Māori models of health that were beginning to rise to prominence, e.g. Te Whare Tapa Wha (Durie 1994). Kaupapa Māori theory, introduced in education in the 1990s (Smith 1997, 1999) became the theoretical foundation for many of the initiatives and their evaluations. Premised on Māori rights under the Treaty of Waitangi, Kaupapa Māori theory laid a theoretical foundation from which Māori could springboard political action towards self-determination. Kaupapa Māori theory is a theory of praxis, and as it gained momentum, the result was Kaupapa Māori and other by Māori, for Māori-based programmes and initiatives in the 1990s (Moewaka Barnes 1999, 2000, Moewaka Barnes et al. 1998) and a proliferation of these initiatives into the 21st century.

For the early Māori health promotion pilot programmes, many of the people involved were new to health promotion approaches. The external evaluators were often the ones who had the greatest knowledge of what officially constituted health promotion and of the accepted research evidence on effectiveness. APHRU’s three part formative, process and impact approach to evaluation became widely used, and evaluators, also with particular expertise in the field of health promotion, contributed their knowledge to programme planning and implementation. Formative evaluation allowed input into programme design and implementation (Casswell and Duignan 1989, Duignan and Casswell 1990, Duignan 1997, Waa et al. 1998) and created the space for evaluators to work together with Māori communities to help further Māori aspirations. Within the context of small community-based Māori health promotion initiatives, formative evaluation soon became linked with Māori community development. The fit seemed

natural, given evaluator knowledge of what constituted health promotion and health promotion’s goal of strengthening community action (WHO 1986).

In Aotearoa New Zealand, formative evaluation incorporated more than the timely feedback of results for developmental purposes, which was the internationally accepted definition (Dehar et al. 1993, Scriven 1991) – it included a strong focus on developing community and provider relationships and allowed for considerable input into the design and planning of programmes (Moewaka Barnes 2000). In some ways its approach was in sympathy with elements of what Patton (Patton 2011) has now characterised as developmental evaluation – evaluation which works at the very early stages of programme development with stakeholders to help formulate the problem as well as possible interventions. As well as taking a broad approach in relation to formative evaluation, health promotion evaluation in general was developing a stronger emphasis on relationships with a wide range of stakeholders and, in particular, the engagement of Māori and Māori worldviews. As programmes based on Māori health models within Māori worldviews were increasingly trialled in Māori communities, the overall evaluation question was extended to include “Is this the best thing to be doing in this context?” For Māori, this meant evaluation needed to step outside the dominant paradigm and examine Māori experiences and understandings. It became imperative to describe the context and to document the processes involved in delivering pilots in different contexts, in order to understand the wider processes that impacted on programme design, implementation and effectiveness (Moewaka Barnes 2000).

However, evaluation capacity was an issue across the board and this was particularly so for Māori. Although Māori were increasingly calling for Māori led initiatives to be

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evaluated by Māori, a scarcity of Māori evaluators and lack of understanding of the importance of Māori involvement in evaluation meant that non-Māori evaluated many Māori initiatives, requiring consideration of a number of issues (Moewaka Barnes 2003). For non-Māori who saw the importance of Māori involvement, one approach was to develop relationships with Māori that valued the range of skills and experiences that all parties had to offer. Alongside Māori controlled evaluation, partnership approaches based on the Treaty of Waitangi were explored, with varying success. Partnerships were one way of Māori and non-Māori attempting to work toward a Treaty-based model of practice and they continue to be an important option.