Review of Māori Child Oral Health Services: Kia Pakiri Mai Ngā Niho

Review of Māori Child Oral Health
Services
Kia pakiri mai ngā niho
December 2004
Acknowledgements
Mauri Ora Associates would like to acknowledge the 16 Māori providers and other
oral health experts interviewed who provided information that contributed to this
review including: Ngati Whatua o Orakei Health Services, Tipu Ora, Te Manu Toroa,
Te Whānau o Waipareira, Te Atiawa Dental Services, Ngati Porou Hauora, Turanga
Health, Hauora Whanui, Kahungunu Executive, Kahungunu Health Services, Te
Kupenga Hauora o Ahuriri, Te Taiwhenua o Heretaunga, Te Kohao Limited, Te
Korowai Hauora o Hauraki, Tuhikaramea Medical Centre and Te Whare Kaitiaki.
We would also like to also acknowledge the Māori Child Oral Health Project Review
Team for their input and guidance throughout the project including Minnie McGibbon,
Edith McNeill, Kay Poananga, Louise Kuraia, Eugene Berryman-Kamp, Charrissa
Makowharemahihi and Kim Smith.
Disclaimer
"This report was prepared under contract to the New Zealand Ministry of Health. The
copyright in this report is owned by the Crown and administered by the Ministry. The
views of the author do not necessarily represent the views or policy of the New
Zealand Ministry of Health. The Ministry makes no warranty, express or implied, nor
assumes any liability or responsibility for use of or reliance on the contents of this
report".
Prepared by Mauri Ora Associates for the Ministry of Health Page 2 of 43

TABLE OF CONTENTS
Executive Summary 5
Introduction 9
Review Methodology 10
Review Responses 11
A description of the Māori child oral health service 11
A description of client demographics and utilisation 15
An assessment of customer satisfaction 16
A description of Māori health providers’ experiences with delivering the
service 16
Costs of establishing and operating a Māori child oral health service 20
Types of relationships with other oral health services, SDS, dentists, WINZ
and schools 21
A description of the relationship and arrangements between the Māori
child oral health service and their District Health Board 23
A description of the types of primary care integrated into the service 24
A description of data collection processes and reporting 25
An analysis of the level of evidence available to demonstrate improved oral
health 25
Māori provider workforce 26
Fluoridation 27
Assess the capacity and capability needs of Māori child oral health
providers 27
Summary and Recommendations 32

Recommendation 1 32
Recommendation 2 33
Recommendation 3 33
Recommendation 4 33
Recommendation 5 34
Recommendation 6 34
Recommendation 7 35
Recommendation 8 35
Recommendation 9 36
Recommendation 10 36
APPENDICES 38
Appendix 1: Māori child oral health providers 38
Appendix 2: Māori child oral health project team 40
Appendix 3: Diagrammatic description of services provided by Māori
providers 41
Appendix 4: Te Manu Toroa service delivery model 42
Abbreviations 43
Glossary 43

References 44

Executive Summary
Unacceptable inequalities exist in the oral health of New Zealand children, especially
among Māori, Pacific and those children from low socioeconomic status (SES) families.
The Public Health Advisory Committee report to the Minister of Health - ‘Improving
Child Oral Health and Reducing Child Oral Health Inequalities’ made a
recommendation that an evaluation of the current Māori oral health initiatives be
undertaken.
A hui of Māori providers, DHB managers and the Ministry of Health recommended a
review process that saw 16 Māori oral health services visited with the objective of
identifying best practice models of Māori Child Oral Health (MCOH) services and to
capture recommendations to develop the MCOH service further, particularly in the
areas of capacity and capability.
Māori providers currently deliver contracts comprising one or more of the components
of the oral health service being enrolment, attendance and treatment. Tamariki ora
nurses deliver many of the stand-alone oral health educators (enrolment) and
adolescent oral health (attendance) contracts by utilising their existing relationships
with whānau, particularly new mothers. Treatment services are typically delivered
through community clinics that primarily support low-income adults as well as some
tamariki and rangatahi.
Most Māori provider contracts are interlinked with mainstream oral health services
such as the School Dental Services (SDS) and dentists. Some have mobile services that
treat tamariki and rangatahi at kohanga reo, kura kaupapa and schools reducing the
need to travel and minimising the common problem of DNA’s (do not attends). In
general, Māori providers over service their DHB contracts, as it is their kaupapa to
treat any member of the whānau that needs to be seen. This flexibility and
commitment to whānau ora places excessive demands on the providers as costs are not
supported by contracted funding. In most cases, funds are found from alternate
sources to ensure that the kaupapa can be maintained. DHB contracts could be better
written to allow Māori providers to provide oral health services in line with whānau
ora.
Many of the barriers faced by Māori in accessing oral health services are systemic, yet
Māori providers overcome these through community and mobile treatment services
and the cooperation and coordination between Māori providers. Several more
community clinics, based on the successful the Te Taiwhenua o Heretaunga model, are
recommended with additional mobile services introduced to reach not only isolated
rural areas but also place the treatment service at the schools tamariki and rangatahi
attend. This report depicts an ideal community model that ensures barriers to Māori
receiving their free oral health treatment are overcome.

In the regions where such a model is not possible, Māori providers should be enlisted
to reduce the barriers to enrolment and attendance through their relationships with
whānau and delivery of other services in an integrated manner. All tamariki ora
nurses should be given the opportunity to enrol tamariki into the community clinic or
SDS.
There are only a few urban Māori providers funded to provide oral health services.
Therefore, it is recommended the Ministry of Health and DHBs with large urban
populations encourage the development of a model that meets the requirements of the
very large number of urban Māori. Such a best practice model may be based on the
community model but practical implementation may see some new issues arise and
overcome that are unique to urban settings. Should further community clinics be
developed, they too will experience some of the issues that the pilot site at Te
Taiwhenua o Heretaunga has overcome. It is therefore considered important that the
Heretaunga programme be further developed as a ‘centre-of-excellence’ for Māori oral
health initiatives combining research and practical experience into sustainable
strategies.
The contract value of the Māori providers oral health contracts are relatively small in
dollar value and do not allow the appointment of a FTE person. Māori providers also
highlight that oral health service contracts do not provide for repairs and maintenance
of critical equipment. Unlike commercial providers, Māori organisations are reliant on
the DHB funding to ensure facilities remain operational. They ask why they are not
considered in the same way as the DHB provider arms that appear to have budgets for
repairs and maintenance as well as capital equipment purchases.
Some Māori providers have difficulty attracting and retaining oral health professionals
appropriate to their services. Some have been unable to deliver much needed services
as positions are or have been vacant. Māori providers with treatment contracts should
be encouraged to develop their own oral health workforce through incentives and
assistance to attracting Māori into the oral health professions.
Te Ao Marama (New Zealand Māori Dental Association) was seen as an important link
for Māori providers as, in some cases, it provided the only contact with the oral health
profession. Conferences allowed those working in regional areas to discuss common
issues and find support in overcoming the issues related to Māori child oral health.
Positive improvements in Māori child oral health is the responsibility of all providers,
not solely the 16 Māori providers included in this review. However, it is important to
identify the contribution made by Māori providers. The limitation of the DHB’s
contract reporting requirements and other data collected makes it difficult to ascertain
the actual improvements in the oral health status of Māori. Reporting aligned to
identifying improvements and analysis of data would allow the anecdotal
improvements to be confirmed providing further support for these initiatives.
In this review, only current contracts were assessed using a systems approach to
service delivery. However, oral health services depend entirely on the wider health
system in which it operates. There were sufficient issues highlighted in this review to
suggest that the current delivery arrangements will only be as effective as the overall
system allows. Further, oral health reviews are recommended into issues like the
relationship between the Ministry of Health oral health policy and DHB
implementation through its funding decisions.
Māori providers will only be as successful at reducing the inequalities in Māori child
oral health as they are able. There are clear examples in this report of how successful
oral health outcomes can be achieved through the delivery of kaupapa Māori services.
Further improvements can be made if the resources are directed in the right areas.
Summary of recommendations
1. Māori providers should have flexible oral health service contracts that are funded
appropriately to ensure that they can provide necessary services to Māori by
adopting a whānau ora approach. More urgently, Māori providers who are
providing services outside of their contracts should be reimbursed for the
additional services.
2. DHBs should consider capitation funding for Māori provider child oral health
contracts so that services can be delivered in the most effective manner.
3. Māori providers recommend increasing the number of oral health community

clinics that are based on the successful service at Te Taiwhenua o Heretaunga.
Such a service adopts whānau ora as its kaupapa and has proven to reduce the
barriers to Māori receiving oral health treatment and therefore reducing
inequalities in Māori oral health.
4. Mobile services are considered an essential part of the ideal community service
model and funding for this should be prioritised by the Ministry of Health and
DHBs in building the capacity of capability of Māori providers.
5. A co-ordinated approach to the delivery of oral health services to Māori is crucial

and the relationship between DHBs, Māori providers, SDS and dentists must be
focused on addressing inequalities in Māori child oral health. Co-ordination
plans should be developed that ensures a partnership approach is adopted and
the key role of the Māori provider recognised in providing the two key
components of any Māori oral health service, being enrolment and attendance.
Many other Māori providers are available to offer these services through their
tamariki ora nurses and therefore the successful models can be easily duplicated.

6. The Te Taiwhenua o Heretaunga oranga niho service should be developed
further into a centre-of-excellence for Māori oral health services. This service
would then act as a development site for new initiatives seeking successful
approaches and outcomes to improve the status of Māori oral health.
7. The Ministry of Health and DHBs with predominantly urban populations should
identify Māori providers who can adapt the community model into a successful
urban service to ensure that the goal of improving child oral health and reducing
child oral health inequalities is achieved.
8. Māori providers should have capital equipment funding made available to them
and repairs and maintenance components included in their contracts. Māori
providers are not private practices and therefore more like the DHB provider
arms than mainstream private practices. DHB contracts should be amended to
reflect this as the lack of operational equipment means that oral health services
can not be delivered.
9. Measures of performance are required to determine the effectiveness of the Māori

child oral health services and to demonstrate how these services are improving
Māori child oral health. A consistent framework that allows the components
influenced by Māori providers should be used to accurately assess the
effectiveness of these services.
10. Māori providers should be encouraged to develop their own oral health
workforce through their relationships with training establishments and the
development of further treatment services where Māori can gain important
community experience and attraction to the oral health professions.
11. Te Ao Marama should be supported by the Ministry of Health and DHBs and be
recognised as an important thread that brings together the Māori oral health
workforce.
12. Further assessment of the wider oral health system should be undertaken to
determine how organisational and systemic issues affecting Māori oral health
providers can be improved.

Introduction
Unacceptable inequalities exist in the oral health of New Zealand children, especially
among Māori and Pacific children and those from low socioeconomic (SES) families.
There is, however, enormous scope to reduce these inequalities, as most dental disease
is preventable.1 The Public Health Advisory Committee’s report ‘Improving Child
Health and Reducing Child Oral Health Inequalities’ describes significant child oral
health inequalities and makes several recommendations including that the Minister of
Health directs the Ministry of Health to fund evaluation of current Māori oral health
initiatives and continue to evaluate and monitor mainstream oral health services for
their impact on Māori oral health.
A review of the Māori Child Oral Health (MCOH) Services is therefore necessary in
order to obtain information about the types of services being delivered, the capacity
and capability needs of the services and to identify preferred models of Māori child
oral health services. The MCOH review would be carried out simultaneously with a
review of the School Dental Services (SDS).
The scope of the review was agreed at a hui of Māori providers, DHB Planning and
Funding Portfolio Managers and the Ministry of Health. The hui recommended a
Māori Child Oral Health Project Team be established to oversee the project and ensure
that the objectives of the review are achieved. All 16 Māori providers 2 were reviewed
to evaluate their operations and experiences in delivering oranga niho services. To
define each of the services in a consistent manner, a ‘systems approach’ 3 was adopted
to assess each of the inter-related elements contributing to successful oral health
outcomes for tamariki and rangatahi.
At the Ministry level, a MCOH Advisory Committee assessed the outcome and
recommendations of the review and combined those with similar initiatives
recommended by the SDS review. Recommendations will be presented to the Minister
of Health for consideration.
1
Report to the Minister of Health from the Public Health Advisory Committee.
2003. Improving Child Oral Health and Reducing Child Oral Health Inequalities.
2
Only 16 of the 200 (plus) Mäori providers nationally have child oral health
service contracts.
3
Minister of Health. 2003. Improving Quality (IQ): A systems approach for the
New Zealand health and disability sector. Ministry of Health.
Review Methodology
Eleven questions formed the basis of the MCOH Review contract scope and
subsequently formed the basis of a qualitative questionnaire that the interviewer used
with the 16 Māori providers.4 The MCOH Project Team5 undertook to approve the
review process including refinement of the questionnaire and project objectives. A key
concern was the efficacy of the review methodology with concern highlighted by
previous oral health reviews not sufficiently considering kaupapa Māori in the process.
A meeting of the MCOH project team adopted a review process to overcome any
barriers Māori providers may have to this type of review and finalised the review
objectives as follows:
Identify best practice Māori models of MCOH services within particular context
and environments.
Capture recommendations from Māori providers for all stakeholders to consider

when developing policies and plans.
Make recommendations on the direction to develop MCOH services further.
Gain a better understanding of the make up of the MCOH workforce (including

ethnicity, age, professional qualifications) and make recommendations
supporting MCOH workforce development.
Provide recommendations to strengthen current service capability and capacity.
To facilitate the review process, an introductory letter was sent to the Māori providers
and relevant DHB Chief Executive Officers’ outlining the aims and objectives of the
review and explaining the contact and interview process planned. Telephone contact
was made with key provider representatives to arrange a meeting date and time.
Upon confirmation, the interview questionnaire was sent to the provider to establish
expectations of the review process. This review methodology ensured that the
interviews were completed as programmed with useful contribution received from all
those interviewed.
Individual provider responses were summarised and returned to Māori providers for
amendment if required. Further analysis involved general themes emerging under
each question group with results reported against each question number. Data such as
workforce composition and access to fluoridation were included as additional
questions prompted by the project team who oversaw the entire process through
regular teleconference meetings.
4
A full list of the Mäori providers is shown at Appendix 1.
5
A full list of members of the MCOH Review Project Team is shown at Appendix 2.
Prepared by Mauri Ora Associates for the Ministry of HealthPage 10 of
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Data analysis involved coding of responses into general themes referenced back to the
original review questionnaire. A systems approach was adopted to evaluate these
themes. A draft report was presented to the Ministry for review by the advisory
committee followed by presentation of the final report.
Review Responses
Interviews were undertaken with the 16 Māori providers nominated in the project
scope as well as the President of the New Zealand Dental Therapist Association and a
dentist who leads a mainstream6 provider in South Auckland with predominantly
Māori and Pacific Island oral health professional staff. Interviewers did not directly
follow the format of the questionnaires but rather used this as a guide only. The
reviewer adopted a conversational approach whereby the information offered was
collected as it arose. The conversations/ questioning therefore continued until such
time as all the required information was gathered or the interviewee felt they had
nothing further to add. The approach ensured a cooperative and collaborative review
process with the interviewer accepting as much or as little as the interviewees were
prepared to contribute. In nearly all cases, the interviews took more time than
planned. However, sufficient time was set aside to ensure no interview was terminated
prematurely or the interviewer was able to enjoy the host’s hospitality.
A description of the Māori child oral health service
By adopting a systems approach to this review, it was found that there are three
general types of contract being completed by the Māori providers covering the areas of
oral health education and enrolment, appointment attendance and delivery of oral
health clinical or treatment services. If placed in a logical flow diagram, (the child oral
health system) the three services can be depicted as follows.
Enrolment Attendance Treatment
Diagram 1: Child oral health service continuum
For the purposes of this report, each of the Māori provider child oral health contracts
has been categorised into one of the three components above. Enrolment and
education contracts are typically carried out by tamariki ora or community nurses who
have undergone oral health promotion training to compliment their core skills. Oral
6
Mainstream in this sense means a health provider that is not specifically
recognised as a Mäori provider through its commitment to a kaupapa Mäori
service.
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health education and enrolment into the School Dental Service is therefore achieved as
providers have an existing relationship with new mothers and their extended whānau.
General oral health information is disseminated and included with other services such
as nutrition advice and Parents as First Teachers. This integrated approach is
considered one of the key strengths of Māori providers and allows young mothers to
be informed of the free oral health services available to tamariki.
Assistance for rangatahi to attend the oral health service is supported by a few small
Adolescent Oral Health contracts (AOHC) that rely on the existing relationships Māori
providers have with whānau encouraging rangatahi to attend their oral health
appointments. In some cases, Māori providers are meeting these contracts by
transporting rangatahi to their appointments, accompanying them through the visit
then transporting them home. With an average value of just $8000, the contracts rely a
great deal on the goodwill of the Māori providers and their willingness to see that
rangatahi receive their treatment.
The most comprehensive contracts include the delivery of oral health treatment. Some
of the providers have fixed site clinics that include services available to pakeke and
kaumatua/kuia in a community clinic. In some cases the service delivery is combined
with a smaller enrolment contract. For the treatment contracts, enrolment and
attendance are aided through the delivery of mobile services in schools, kohanga reo
and kura kaupapa. By taking the services to the tamariki and/or rangatahi, several
barriers are overcome and the entire process facilitated in an efficient manner. All of
the service delivery contracts are performed by qualified oral health professionals,
many of whom are Māori.
Table 1 summarises the oral health contracts currently performed by Māori providers.
Table 1: Summary of contracted Māori child oral health services

Age group Enrolment Attendance Treatment
18 months to 5 years Pre-school School Dental Service
DHB/Ministry of Oral health High risk areas (dental

Health contract types educator/promotion therapist service)
($25,000 –$35,000p.a) Brush-in programme
Special dental benefits
5 years to 12 years At school School Dental Service
DHB/Ministry of High risk areas (dental

Health contract types therapist service)
Brush-in programme
12 years to 18 years Self-enrolment Dentists

43
DHB/Ministry of Adolescent oral Dental benefits scheme
Health contract types health contract Mobile service for high risk
($8000 – (low decile) schools
$9000p.a)
Community clinic (capitation)
Outside of the contracted services, Māori providers typically deliver additional related
services that overcome some of the many barriers experienced with oral health
treatment because it is their kaupapa to deliver services to meet the needs of their
people. Some examples of this include treatment of primary and pre-school tamariki
with DHB and SDS knowledge but without DHB contracts, baby-sitting tamariki
whilst parents take others for treatment, transporting tamariki and rangatahi to their
appointments and providing a triage service to prioritise pre-schoolers for SDS
treatment.
Table 2 depicts the actual services being provided showing how Māori providers are
overcoming some of the barriers to oral health treatment by facilitation of the
enrolment and attendance components of the oral health system. This should be
compared to contracted services in Table 1.
Table 2: Summary of actual Māori child oral services

Age group Enrolment Attendance Treatment
18 months to Pre-school School Dental Service

5 years
Overcoming Tamariki ora Provider “fetch and Māori provider

Barriers nurses enrolling carry” Māori staff
Oral health Provider babysitting Kaupapa Māori service
educators enrolling Whānau ora Cultural competence
Oral health Integrated service
education A familiar face
approach
DHB/Ministry of Health educator/ High risk areas (dental therapist

Health contract promotion service)
types ($25,000 –$35,000 Brush-in programme
p.a) Special dental benefits
5 years to 12 years At school School Dental Service
Overcoming School nurse Whānau ora Community clinic

barriers Fetch and carry Kaupapa Māori service
Mobile clinics Māori staff
Integrated service Cultural competence
Facilitation with SDS A familiar face
DHB/Ministry of High risk areas (dental therapist

Health contract service)
types Brush-in programme
12 years to 18 years Self-enrolment Dentists

43
Overcoming Dentists going to Whānau ora Dental benefits scheme
barriers schools (remove Fetch and carry community clinic
self-enrolment Kaupapa Māori service
option) Mobile clinics
Referrals from Māori staff
Health education
facilitation with Cultural competence
dentists re DNAs A familiar face
Integrated service
approach
DHB/Ministry of Adolescent oral Mobile service for high risk (low

Health contract health contract ($7000 decile) schools
types – 9000p.a) Community clinic (capitation)
A full diagrammatic description of the services being provided by the 16 providers can
be found at Appendix 3. Analysis shows that the enrolment-attendance-service
delivery continuum is best achieved through mobility with just four providers
delivering each of the three steps for both tamariki and rangatahi. 7 The majority of the
Māori provider oral health services just cover one of the three components of the full
service in the continuum.
A common theme from providers is that they provide services beyond their contractual
obligations. If Māori providers only delivered the contractual requirements, they
would not meet the needs of the children the service is designed to support. A key
recommendation from providers is therefore that the DHBs recognise that oral health
contracts need to accept the different steps in delivering a successful service. A
treatment contract alone does not necessarily ensure that the oral health needs of Māori
will be met because there are two prior steps in the process that need to be achieved
before the oral health treatment can be successfully delivered. Mainstream services to
Māori are improved when Māori providers support the enrolment and attendance
components of the wider process. In many cases the work of Māori providers is not
being recognised by the DHB and therefore provided from other scarce Māori provider
resources.
Additionally, several providers felt that the established practice of separating tamariki
and rangatahi services between the SDS and dentists did not support whānau ora.
With exception to Te Whare Kaitiaki and Te Whānau o Waipareira 8, most Māori
providers deliver oral health services outside of their formal DHB contracts, as it is
their kaupapa to support whānau ora. This has an obvious impact on their ability to
maintain services within the budget available.
Each of the service delivery contracts has been established through different routes
including recognition of special needs areas, partnership arrangements between the
7
Te Manu Toroa, Te Whanau o Waipareira, Te Whare Kaitiaki and Hauora Whanui.
8
Te Whanau o Waipareira is the only provider of the 16 providers reviewed, that
have contracts to deliver a full range of services to both tamariki and rangatahi
on site at kohanga reo and kura kaupapa.
43
SDS and Māori providers, long standing arrangements with the School of Dentistry in
Dunedin and the Te Taiwhenua o Heretaunga pilot project in Hastings. Services are
typically managed by the oral health professionals (dentists and dental therapists) with
contract and administration oversight being provided by Māori provider management
teams.
Some services took several months to staff. This highlights the difficulty providers
have in recruiting and retaining oral health professionals appropriate to their services.
Managers, on the other hand, were already established within providers with sufficient
experience and knowledge to support the oral health contracts. For the enrolment and
attendance contracts, execution of the contracts was included in the roles of the existing
workforce, mostly tamariki ora nurses. However, there are examples of dental
therapists (no longer practising) employed in oral health education roles.
A description of client demographics and utilisation
In all cases Māori providers are located near to and support low decile schools and
high deprivation index populations. Many of the DHB contracts specify the particular
schools (typically decile 1) that Māori providers are responsible for as schools are used
as the basis for accessing both tamariki and rangatahi for treatment. Tamariki ora
nurses enrol pre-schoolers into the nearest SDS service or through a mobile service
visiting kohanga reo. Several contracts specifically target high-risk children or areas
where SDS or dentists have difficulty ensuring children are treated.
Providers have good general knowledge of their service coverage area and
demographic characteristics of their whānau. Several providers have detailed
demographic information resulting from local council reviews or population health
studies. In all cases these were not related to the oral health contract. Providers
produced client demographic information for primary and pre-school children through
their reports to the DHB but similar reports were not seen for rangatahi.
Utilisation is therefore predetermined by the contract for primary and secondary

schools with estimated numbers recommended for pre-school tamariki. For the service
delivery contracts, the biggest barrier to utilisation for child oral health service was the
waiting time to see the oral health professional. In several cases this is reduced by the
use of mobile clinics.
A factor affecting pre-school children enrolment was the temporary nature of the SDS
at some primary school clinics, particularly in low decile schools. Oral health
educators described the frustration of trying to encourage young parents to enrol and
attend a clinic that they did not know when would be open. The concern about the

43
reliance on the SDS as the only service provider for tamariki was a general issue
highlighted by several providers who did not offer their own service.
An assessment of customer satisfaction
Only a few providers have formal instruments to capture levels of customer

satisfaction and these were generally part of a wider service assessment under one of
the quality programmes like Te Wana or Quality Health New Zealand. Those with
formal surveys reported over 90–95 percent customer satisfaction. Other providers
referred to anecdotal indicators of satisfaction citing higher levels of comfort within the
clinical environment, improved access achieved by mobility, familiarity with providers
who were part of a close community and more flexible services where all tamariki and
rangatahi in one whānau could be seen at the same time.
In the main, however, providers had few measures of customer satisfaction or

instruments that would allow them to capture this information. They simply know
that the services they are performing are needed and have developed service models to
meet those needs.
A description of Māori health providers’ experiences with delivering the

service
In general, Māori providers offer a kaupapa Māori service that makes Māori more
comfortable in receiving oral health treatment. The relationship between the Māori
providers and whānau allows them to access all members to ensure that all tamariki
and rangatahi are receiving the free oral health services. This relationship forms the
basis of the Adolescent Oral Health Contracts (AOHC) where tamariki ora or
community nurses are asked to assist in ensuring rangatahi attend their oral health
appointments. Provider experiences with the AOHC service include transportation of
rangatahi to their appointments, finding and counselling rangatahi who have missed
dental appointments and unresponsive to further prompting, trying to overcome many
of the known barriers of dental services and generally acting as the advocate between
rangatahi and the dental provider. Obvious strengths are the relationship Māori
providers have with whānau and the main weakness is the small amount of funding
available9 for this kind of service where mobile services attending the high schools
could reach the adolescents at a single point.
Pre-school enrolments are normally provided by tamariki ora or community nurses. In

one or two cases the health education contracts are performed by Māori dental
therapists who are no longer active in clinical practice. Again, the ability of Māori
providers to make use of existing relationships indicates the main strength of them
9
On average, the AOHC contracts are for $8000 per year.
43
providing these services. Added to other services such as midwifery, Parents as First
Teachers, Family Start and tamariki ora, Māori providers know whānau well and can
carry out the oral health education service on a one-on-one basis. Pre-school enrolment
into the SDS is therefore a natural extension to these other whānau ora services. In one
instance where the oral health educator was trained as a dental therapist, a triage
service has been started to prioritise tamariki into the SDS. This service is run out of
the Māori provider’s general practice clinic two mornings per week with the blessing
of the NZDTA and the SDS area co-ordinator.
Weaknesses associated with the oral health education services include:
Oral health education contracts typically cover the salary of less than one full-
time equivalent (FTE) employee and therefore there is no funding available for
oral health promotion materials such as those developed at by Te Whare Kaitiaki
or through ‘brush-in’ programmes.
Where tamariki ora nurses were not fluent in te reo, oral health promotion in
kohanga reo had been difficult with some services being delivered outside of the
classroom in the stauncher kohanga.
In some cases the relationship between the tamariki ora nurses and the SDS is not
amicable meaning contacts to ensure continuity of care do not exist. Several
tamariki ora nurses commented that they assist mothers to complete enrolment
forms and deliver them to the SDS with no further knowledge of whether
appointments have been made and/or kept.
One oral health educator (former SDS dental therapist) explained that she was
initially allowed to review SDS records to ensure tamariki from whānau known
to her were enrolled and had received treatment. The SDS had stopped access to
patient records with privacy being cited as the reason.
In the cases of poor communication between the Māori providers and SDS dental
therapists, there was no coordination to know when school dental clinics would
be in operation and for what hours. Providers commented that it was difficult to
promote the SDS when they did not know when the nearest clinic would be open
to see the tamariki.
Experiences relating to treatment contracts include the breaking down of a number of

barriers to access through the use of mobile vehicles and equipment, by the oral health
professionals being Māori and through the adoption of an understanding that oral
health treatment services present a number of difficulties to Māori and with additional
resources and effort these barriers can be overcome.
One SDS dental therapist explained that in her local area she had access to pre-school,
primary school and high school children within the same area. When she drew names

43
for appointments she drew the whānau name and all tamariki and rangatahi in the
whānau came to the clinic with the eldest child collecting the others on the way. All
were allowed in the clinic at the same time with the youngest treated first to ensure
that others followed suit.
At Te Whare Kaitiaki, tamariki and rangatahi are accompanied by their whānau into
the clinic and allowed to observe and assist where practical. Two words are banned
from this clinic being ‘don’t’ and ‘touch’.
One dentist explained that his place in the surfing community was probably more
important to lowering barriers to oral health services than the fact he was Māori. Many
of the oral health professionals employed by Māori providers were not Māori. The
important strength of the service was the fact that the provider adopted and
demonstrated a kaupapa Māori approach that made both parents and children
comfortable to attend and feel as they were going to be given a measure of respect
despite their poor oral health status. Some said that it was as important to be a
recognised as a member of the close-knit community as being Māori, particularly in
rural and regional areas.
At one service where the relationship between the DHB, SDS and Māori provider was
co-operative and more of a partnership, tamariki enrolled within a network of
providers were seen by a Māori dental therapist who was specifically assigned to
delivering oral health services to them. In this unique model, one larger Māori
provider (also a Māori PHO) held a contract for a number of tamariki located
throughout the rohe. Smaller providers linked to the PHO then utilise their close links
with local whānau to gather tamariki when the dental therapist calls. In this model,
the three steps of enrolment, attendance and treatment service are achieved through
the coordination of smaller providers and a larger provider who holds the oral health
service contract.
As the service is also mobile (chair is moved around the smaller providers) a large
number of tamariki can be seen in environments that they and their parents are
comfortable with and has the flexibility to cope with the inevitable attendance of
additional whānau members who would also like to be seen. As demonstrated by all
Māori providers, everybody is seen.
A diagrammatic representation of this model can be seen at Appendix 4 and represents

several aspects of best practice in the delivery of oral health services to Māori in
regional and rural areas, particularly in lowering the barriers associated with
enrolment and attendance. The same model is used for other health services to access
Māori and others most at risk.
The greatest weakness described by Māori providers is their inability to see more
tamariki and rangatahi. In most cases providers only saw those specified in their
43
contracts so this related directly to schools, kura kaupapa and kohanga reo. Te
Taiwhenua o Heretaunga were contracted to see rangatahi and tamariki who
particularly wished to attend the clinic. They were unable to see all tamariki from local
whānau because they did not have the capacity to do so. The demand for this service
has resulted in up to a thee-month waiting list.
Other weaknesses described by service providers are the lack of funding for repairs
and maintenance of equipment. Most providers had old equipment that had been
either donated or originally sourced from grant funding. As the service contracts did
not cover maintenance, providers had to find money from other areas to maintain their
medical equipment. In one case the lack of a new autoclave would mean the clinic
might have to close until a new one is purchased. In another, where the provider had
independently funded and outfitted mobile vehicles, maintenance and compliance
costs meant that the vehicles were off the road for periods of time.
Te Atiawa Dental Service was no longer operating as it had been established and
operated with the same DHB contracts as other private providers. There were no other
enrolment or attendance DHB contracts. It was found that this funding alone was
insufficient for the work being done particularly as the success of the clinic grew and
attracted more Māori who obviously needed the service. The Māori dentist found that
his private practice was supporting the community work causing a negative impact on
his personal circumstances. It was felt that more support for a community model from
the DHB could have allowed this much needed service to remain in operation.
Although Māori providers predominantly employ Māori oral health professionals,

finding and employing Māori willing to work in remote and regional areas had proved
difficult for some providers. In two cases, the oral health treatment services were not
being provided as suitable oral health professionals could not be sourced. This meant
that those needing to be seen had to go elsewhere or not visit a dental professional at
all.
Common to all Māori providers with fixed clinics was the high number of rangatahi
who failed to attend their appointments in spite of reminder letters and phone calls.
Providers with mobile services who located at high schools were able to overcome this
common problem by calling for other students thereby not wasting valuable treatment
time. In fixed clinics this is not so easily done.
Costs of establishing and operating a Māori child oral health service
The set up and operational costs of the AOHC and oral health education contracts was
much less than treatment contracts. In the main, the oral health promotion and
facilitation contracts were undertaken by existing Māori provider employees or the
tasks were added to those of the tamariki ora nurses. Where the oral health education

43
contracts typically supported less than 1.0 FTE employee, the Māori providers
generally split the role between two or more tamariki ora nurses to gain better
coverage for their pre-school enrolments.
Costs of establishing oral health treatment services were high with most established
through one-off grant funding or the combination of a number of grants. Apart from
Te Whare Kaitiaki, all service delivery contracts required the providers to purchase
equipment, sometimes before the oral health professional arrived.
One service delivery provider held a labour-only contract for tamariki which meant
that all of the ongoing costs were absorbed by the SDS. This allowed the dental
therapist to concentrate on accessing and treating the tamariki and achieving
compliance with the service specification. Other costs like the car and mobile phone
were the responsibility of the Māori provider.
There were equally strong arguments for ongoing costs being provided on a capitation
or fee-for-service basis. One provider described the capitation funding as allowing
them to use the funding in different areas that had the greatest need (eg, resources for
‘brush-in’ programme) and avoided the time consuming form filling and cash-flow
concerns of fee-for service contracts. Alternatively, several of the dentists who also
work in private practice claimed that capitation funding wouldn’t work because the
standard fee per child is too low for Māori who typically need more work and time to
restore their teeth.
Most providers with service contracts were able to split out their ongoing costs with all
again emphasising how the lack of repair and maintenance money threatens the
services they provide. Te Whare Kaitiaki has its costs included in the School of
Dentistry’s budget so would be difficult to split out.
Providers generally felt that the salary costs were the most significant so if funding
formulae were being developed for Māori providers then salary costs should be the
basis rather than the number of patients seen. Some providers attract co-payments
from low-income adults and source emergency and relief of pain money from other
agencies.
A general consensus was that the general benefits scheme amounts were insufficient to
cover the extra needs of rangatahi and therefore this amount could be topped-up by
special purpose funding to target high-needs children.
Some Māori providers were considering a joint commercial/community model citing

an ability to draw additional revenue from some whilst also accessing external agency
funding for low-income adults. Such a model may suit Māori providers in an area
identified as having a constituency with the ability to pay for oral health treatment
then using any excess to support oral health promotion. This approach would require
43
the experience of a dentist who had been in private practice to know how to make such
a model work and therefore was dependent on that individual. This review found
more than one provider considering this option so further investigation on how this
model may best meet the requirements of MCOH services should be undertaken.
All Māori providers spent the budget allocated to their oral health service with one
commenting that they always budgeted for a profit10 but never seemed to achieve it.
Types of relationships with other oral health services, SDS, dentists, WINZ
and schools
All Māori providers commented that it was essential that they have a positive working
relationship with the SDS. This was because the SDS was by far the dominant service
provider for tamariki as it was they who were provided with the resources to treat
tamariki. All of the dental therapists had worked for the SDS at some stage and had
trained in their systems and processes. The oral health educators essentially act as a
conduit for the SDS and therefore were wholly dependent on them to achieve
successful outcomes for their own service. Te Taiwhenua o Heretaunga did not treat
tamariki as a matter of course because their contract did not allow them to provide
sufficient services to treat tamariki in the area as they would have liked. The SDS
remained the primary provider of oral health services to tamariki even where Te
Taiwhenua o Heretaunga offered such a successful service.
Some providers felt that the pre-school enrolment process was not as effective as it
could be due to the structure and delivery model used by the SDS. For example, Māori
providers found it difficult to encourage young mothers to attend a clinic that they did
not know when it would be open. Tamariki ora nurses did not know what happened
to the enrolment forms and whether this resulted in a successful treatment service. In
areas where there was a co-operative arrangement with the SDS, effective service
delivery could be achieved because resources were shared, communication two-way
and a genuine willingness to reach those in greatest need apparent.
The relationship between dentists and Māori providers was of concern, particularly in
regards to differential access. In many of the regions Māori providers held lists from
DHBs, listing the dentists who held General Dental Benefits (GDB) contracts and which
identified which groups of people the dentists choose to see. Some dentists would see
no rangatahi (ie, no DHB contract) whilst other dentists (with GDB contracts) would
only accept rangatahi whose parents were already patients of the dentist. Just why the
DHB would allow dentists to be selective and discriminate in this way was unknown.
Differential access by some dentists11, added another barrier to rangatahi receiving
10
Provider serviced adults and sought a co-payment to help off-set the cost of the
dental treatment.
11
Ministry of Health. 2001. Monitoring Ethnic Inequalities in Health
43
their free oral health treatment. Māori providers should therefore be assisted to
provide services to rangatahi in place of the dentists who were not willing or not able
to see them.
Māori providers worked closely with the SDS to cover areas where dentists did not
provide a GDB service.12 Mobile services located at the high schools appear to be
overcoming these barriers with enrolments rising dramatically13 when the dental
service is taken to the rangatahi. The four Māori providers with service delivery
contracts all treat rangatahi on school sites. As the demand for services increase, these
services need to expand to take in more schools or new providers resourced to meet
the current unmet demand and need. All Māori providers welcomed the opportunity
to expand their services as long as they were funded appropriately to do so. The need
to enrol with a dental service when you commence secondary school was seen as a
systemic barrier that Māori providers considered unnecessary. Māori providers were
well placed to facilitate the continuity of services from the SDS to dental services if
required.
The relationship with WINZ related to low-income adults and therefore was
considered outside the scope of this review. However, it was important to note that all
Māori providers have a relationship with WINZ either as a funder of treatment or as
part of a whānau ora advocacy role advising adults of their entitlements to emergency
dental treatment. In some cases some innovative practices had been developed.
Several Māori providers supported ‘brush-in’ programmes at local schools and

kohanga reo. Providers explained that the school itself was the main conduit to a
successful brush-in programme as the oral health educator or professional only visited
a few times in the year. One provider commented that the SDS was starting to see
improvements in tamariki oral health as a result of the brush in programme but
research to support this was not available. One dentist commented that the state of
pupil’s general health was one criterion assessed during ERO audits and support of a
brush-in programme may be seen positively.
Other relationships with schools related to their willingness to accommodate a mobile

oral health unit in their school including the provision of power and water. In regional
areas this was not considered an issue but at least one urban school principal refused to
allow a Māori provider with a mobile unit to treat rangatahi at his low-decile and high
percentage Māori population school. In regional and rural areas, the mobile vehicles
needed to take account of the roading when considering mobile vehicle characteristics.
12
The one dentist in Wairoa did not hold a GDB or SDB contract so the SDS was
providing a dental therapist service at the high schools with higher needs
children travelling to Napier to see a dentist.
13
Enrolment at one South Auckland secondary school went from 8% to 80%
following the arrival of the Mighty Mouth mobile service.
43
A description of the relationship and arrangements between the Māori child
oral health service and their District Health Board
Like the relationships with other key stakeholders in the provision of health services,
Māori providers saw that a good working relationship with the District Health Boards
as an integral part of delivering successful services. As with all relationships, regular
communication and exchanges of ideas were necessary if the services were to be
effectively implemented and improved.
The oral health educator and AOHC contracts required less oversight by DHBs than
the treatment contracts. Typically, providers made quarterly reports to the DHB and
were in frequent contact with their DHB portfolio manager. The dollar value of the
contracts suggests that this level of contact is sufficient for the oral health promotion
contracts.
The most successful treatment or service delivery contracts were in organisations that
had regular contact with the DHB and met regularly with them as well as other oral
health service providers, such as SDS and hospital dental services, where a combined
strategic view of oral health for the DHB region could be discussed. Providers
commented that this partnership type arrangement allowed some flexibility and
reception of innovative ideas as there was constant communication between the groups
and each knew exactly what areas they were responsible for. These meetings included
input from DHB funding and planning managers who were an important part of the
service delivery equation.
In areas where Māori providers felt that they were in competition with the DHB
provider arm, the services were not as well coordinated and relationships, although
cordial, did not promote a united response to addressing oral health issues within the
DHB region. In these areas meetings between the groups were infrequent with contact
mainly occurring at dental therapist level where more personal working relationships
had formed.
John Broughton (renowned Māori Oral health Advocate and Associate Professor,
University of Otago) described Lois Jackson as the model DHB manager because of the
commitment shown to addressing the oral health needs of Māori and the relationship
formed with Tipu Ora Health Service. This partnership approach had allowed the
services to access pre-school children in a clinic based at the Tunohopu Health Centre
staffed by SDS dental therapists. Additionally, Māori were able access the week-long
clinic of final year dental students from Otago University School of Dentistry with the
assistance of John Broughton. This very successful operation required a great deal of
goodwill and cooperation between the Māori provider, DHB, Otago University and
private practitioners who donated their time to the exercise.

43
A description of the types of primary care integrated into the service
Māori providers combine the oranga niho service into other health services in an
integrated approach that supports whānau ora. In this way, community health
workers can access tamariki and rangatahi that would not otherwise know or be
concerned with their oral health needs. These services include Tamariki Ora, nutrition
education, Family Start, Parents as First Teacher, midwifery, asthma, diabetes,
Smokefree, school nursing, immunisation and general practice services.
For the majority of Māori providers, the oral health treatment continues to rely on the
SDS or private dentist for the final part of the service. This means that they can only
control part of the process without visibility of that final part in some cases. Māori
providers expressed a measure of frustration that they were unable to complete the
process by providing oral health treatment service, as they would have liked. Much of
the success of these services is therefore dependent on the co-ordination and
co-operation between the Māori provider and the mainstream treatment provider as
described above.
Several providers without treatment services expressed a wish to include these into
their range of integrated services thereby adding to their ability to meet the primary
health needs of Māori in ways they believe encourages whānau to seek their assistance.
Providers with treatment services would like to expand as their success is clearly
demonstrated by extensive waiting lists.
A description of data collection processes and reporting
All Māori providers report the data required by them as defined in their oral health
service contract. Most report quarterly and annually and include quantitative data
such as enrolments, ethnicity, completions, DMFT rates (Diseases, Missing, and Filled
Teeth) and access to fluoridation. More details were collected for tamariki than
rangatahi. Several providers included a narrative of their activity to support the
quantitative data including areas of concern and recommendations for improvement.
In all cases the reporting requirement is seen as a compliance issue relating to the
contract rather than any data gathering for further analysis by the Māori provider. All
commented that they had religiously completed their reports but not received any
feedback in terms of consolidated results or analysis that might suggest that service
improvements were required. This was particularly important to the oral health
educators who were interested in the impact their enrolments and advisory services
were having on the data collected by the SDS.
One provider commented that the DMFT figures were only representative of tamariki
seen who utilised the service and did not include those tamariki not seen by the
service. The provider suggested that the DMFT figures needed to be balanced by a
43
completions figure then re-weighted, as they suspected Māori would contribute a good
proportion of those unidentified.
An analysis of the level of evidence available to demonstrate improved oral

health
The overwhelming finding here is that there is no objective information available from
the Māori providers that demonstrate improved oral health of Māori. There were
several anecdotal expressions that SDS is starting to see improvements in the oral
health status of tamariki who have been in a ‘brush-in’ programme but no provider has
a systematic process to analyse their own data to show demonstrable improvements.
One or two providers had research information that described the general oral health
status of tamariki in their area but these were done as part of submissions to the local
council in fluoridation debates and were completed by external parties.
Māori provider workforce
The Māori provider oral health workforce is predominantly Māori. All but three of the
oral health education and AOHC roles are performed by Māori tamariki ora nurses
with one provider being unique having two Pakeha tamariki ora nurses providing the
oral health education and enrolment service. There were five Māori dentists
interviewed as part of this review, one working for a Māori provider, one at the School
of Dentistry and the other three in private practice. Four Māori providers employed
Māori dental therapists or hygienists in clinical roles with two others involved in oral
health promotion. Treatment services employed dental assistants who were all Māori.
Māori providers had experienced difficulty in attracting oral health professionals to

their services for a number of reasons. Geographic isolation meant that some areas of
greatest need had the most trouble finding oral health professionals. There was also an
aspect of professional isolation where dental therapists, in particular, felt that they had
been separated from the SDS who had been their previous employer and the place they
undertook the majority of their training. This highlighted the need for the Māori
providers and the SDS to maintain close relationships so that professional
development could be maintained and the quality of services assured. Professional
oversight by the Principal Dental Officer would be beneficial for all dental therapists
just as it is within the SDS; however, at least one provider was expected to pay for this.
Oral health educators recommended that te reo was important for them to be able to
deliver messages to kohanga reo and kura kaupapa effectively. Although many were
Māori, not all were fluent in te reo which could prove a problem in kohanga that insist
only te reo is spoken inside the school.

43
All Māori providers highlighted the importance of Te Ao Marama,14 particularly the
oral health educators who may not be oral health professionals. All who attend the Te
Ao Marama conferences explained how they updated their knowledge of oral health
education and networked with others in similar roles. For many, this is their only
contact with oral health professionals as they are essentially tamariki ora nurses. Te
Ao Marama is therefore seen as not only the voice of Māori oral health professionals
but an important thread that binds Māori oral health service providers together.
Fluoridation
One of the objectives of this review was to gain an impression of the Māori provider’s
knowledge and activities relating to the access to fluoridated water. There were
essentially three groups who commented on this issue. The first related to the Māori
providers located in areas with 100 percent access to fluoridation. They had an
understanding of the benefits of fluoridation and would only make a comment about it
were there a discussion about removing it from the water supply. In one case, a Māori
dentist canvassed on behalf of Māori to ensure that fluoride continued to be added to
the water in his city.
The second group involved regional providers whose whānau were not generally on a
reticulated water supply. These providers understood that other methods of adding
fluoride could be adopted and this formed part of the oral health promotion message.
In the small towns where reticulated water was available, providers joined wider
community groups to support fluoridation.
The third group of Māori providers had been actively involved in the fluoridation
debate by councils deciding whether to add or remove the fluoride from the water
supply. Māori providers were typically part of a wider community lobby group who
made submissions on behalf of all Māori to the council hearings.
One dental therapist reviewed reports prepared for a DHB that had been referred to
the runanga for comment as part of their consultation process. As a Māori oral health
professional she was able to make recommendations to the runanga that went back to
the DHB citing deficiencies in the report relating specifically to Māori oral health needs
and the use of fluoride in reticulated water supplies.
In general terms, Māori providers have a good understanding of the benefits of

fluoridation but are not confident their input to local government will affect the
decision of whether to add or remove fluoride from the water or even engage in the
debate.
14
Te Ao Marama is the New Zealand Mäori Dental Association.
43
Assess the capacity and capability needs of Māori child oral health providers
There is strong support amongst the Māori providers for the community oral health
service such as that proven successful at Te Taiwhenua o Heretaunga. Many of the
providers would like to duplicate this service as it is proven to be successful in
removing many of the barriers that Māori face in accessing oral health treatment.
Hauora Whanui have probably taken the community concept further with their ability
to add mobile services to their assets removing several of the weaknesses of only
having a fixed clinic service. With both a fixed and mobile service, Hauora Whanui is
able to meet the needs of Māori from 0 years to 100 years delivering mobile services to
schools and remote areas whilst also having a base at Kawakawa that has a visiting
dentist to perform more extensive work. Being collocated with the GP service and
integrated with other public health initiatives means that all of the strengths of Māori
providers described in this report can be found at Hauora Whanui. The issue for them
is that they do not have a DHB contract for the tamariki they see.
One of the key recommendations from providers is that they would like to offer mobile
services as access through transportation is one of the greatest barriers experienced by
Māori. Providers with oral health professionals recommended a fixed clinic base with
mobile outreach services that included oral health education.
Te Manu Toroa has developed their service in a slightly different manner utilising their
network of hauoranga15 to access whānau throughout their region. This emphasises
the point that there may be a base model that is the starting point for a full range of
oral health services but local differences will dictate how the final organisation is set
up.
Diagram 2 represents a proposed ideal service compared to current services can be

seen below.
15
Hauoranga – a collective of Mäori Providers working under Te Manu Toroa
(Tauranga) network
43
Whānau
choice
Current Complimentary
service service
School Dental Service

18 months to
Māori community
12 years
• enrol at pre-school service

• and/or primary
school • Whanau ora
• Central clinic base
• Mobile service for
0 to 100
Enrol with dentist under tamariki, rangatahi,
12 to 18
years
general benefits pakeke and

scheme kaumatua
• Linked to other
health services in
integrated model
User pays
18+ years
• Comprise dentist,
• WINZ
dental therapist,
• Relief of pain dental assistant
Diagram 2: A representation of a proposed ideal community model
All of the current Māori oral health providers have at least one element of the
community model above but no existing Māori providers are contracted to provide the
comprehensive community model identified. For the capacity and capability
development of the Māori providers, it is therefore recommended that those who meet
some initial criteria for a full a range of services be developed to allow them to
implement the missing components of the set above. Such criteria might be the
existence of a GP or related service, high needs and/or rurally isolated population, and
a recognised and influential Māori provider.
The community model appears to work better in regional areas than urban where there
is more a sense of community than in the cities. Just one urban Māori provider was
visited that provided a full range of services and their experiences differed from those
described by iwi based providers. For example, the Te Whānau o Waipareira clinic in
West Auckland saw equal numbers of Māori and Pacific Island patients. Their services
were clearly focused on low SES families regardless of ethnicity. It is expected that the
community model developed in an urban setting may be different to that in a regional
or rural setting. As such a large number of Māori are located in urban centres it is
considered vitally important that a suitable model be developed to provide oranga
niho services to tamariki and rangatahi in the urban centres.

43
For providers who could not sustain the community model above, the oral health
promotion and advocacy roles appear to be the best way they can contribute to further
improving the oral health status of tamariki and rangatahi. These services do,
however, rely on a partnership arrangement with the mainstream clinical providers
such as the SDS and dentists. Without that cooperative and coordinated approach,
Māori providers are only able to influence part of the full process and therefore not as
effective as they could be.
In areas where the SDS were doing an excellent job accessing and treating tamariki and
rangatahi, Māori providers requested better coordination and cooperation so that they
could assist the dental therapists to see tamariki and rangatahi through advocacy,
transportation and oral health promotion. Those with oral health education contracts
would like to expand these services to further outlying areas but expressed concern
that their success in pre-school enrolments may be leading to over-demand of the SDS.
Māori providers appreciate that the SDS has been under some pressure in recent years
with dental therapist numbers reducing, yet the demand for their time has been
growing. It is therefore considered that the work undertaken by Māori providers is
complimentary to the SDS, particularly the treatment services, and any further service
development done is to assist the SDS to cope with increasing demands, particularly
from Māori.
As discussed earlier, Māori providers have had difficulty attracting oral health
professionals to their services due to remote locations and the perceived isolation of
working away from the established dental community. This appears more pronounced
for dental therapists than dentists. For this reason, there is a need for more Māori oral
health professionals at all levels. Māori providers believe there is an aspect of “build it
and they will come” to attracting Māori into the dental professions.
For example, if tamariki or rangatahi never see a Māori dental therapist or dentist then
they may not believe that this is a role Māori can actually perform whereas Māori
providers with Māori oral health professionals have attracted several rangatahi into
dental assistant roles that have seen them go onto the degree courses at Auckland and
Dunedin. Māori oral health professionals may then be more inclined to return to the
Māori provider to work particularly if they have been supported through their studies
by an iwi scholarship.16
16
Personal comment Ngati Porou Hauora.
43
As Te Taiwhenua O Heretaunga has been the flagship for oranga niho services it has
learned a number of lessons in developing its services to overcome barriers and meet
the needs of Māori. Key recommendations above are that a number of other providers
should be contracted to duplicate this service. However, the Ministry of Health and
DHBs must continue to develop Te Taiwhenua o Heretaunga further as there are many
advancements that can be made. For example, in this area Te Taiwhenua o Heretaunga
do not have a contract to treat tamariki although they do not turn away any child that
preferred to attend the clinic with whānau. It may be the ideal location for a DHB to
fund a Māori provider to service all Māori within the area taking over the role of the
SDS and providing an integrated service to all tamariki and rangatahi utilising a
whānau ora approach. Te Taiwhenua o Heretaunga need a mobile service to achieve
this and therefore their capability and capacity enhancement would see them moving
to another level as a pilot project initially and then as the ‘centre-of-excellence’ for
oranga niho services as it is becoming.
To summarise the capability and capacity recommendations for all Māori providers, it
is recommended that each of the current contracts be reviewed against the ideal service
range as set out in the community model. For the providers who meet pre-set criteria,
services should be added until the provider builds up to a point where they can offer a
full range of services from their community clinic. This may include some innovative
thinking about how mobile services can be funded. For providers who do not meet the
criteria at this stage, they could either assist the larger providers with oral health
services (enrolment and attendance) as seen in the Te Manu Toroa model or form
partnership arrangements with the SDS and dentists to ensure that tamariki and
rangatahi are overcoming the barriers preventing them from accessing oral health
services.
A progression framework from oral health education to tamariki treatment then

rangatahi treatment could be established where smaller providers add capability and
capacity sequentially until such time as the resources for a full range of services
became available. A dental therapist could cover all services but support from a
dentist may be a preferable option for professional oversight.

43
Summary and Recommendations
All 16 Māori providers made valuable contributions to this review and looked forward
to positive outcomes from it. Services are being provided that overcome many of the
barriers associated with oral health treatment and there is a sense that tangible gains
are being made in addressing the oral health inequalities experienced by Māori.
Therefore, all providers would like to see their services expanded and funded
appropriately, particularly in the treatment areas where there is significant unmet
demand but insufficient capacity. This is demonstrated by the extensive waiting lists
now evident at some services. In this regard, Māori service providers are more
successful at accessing and treating Māori than they can commercially sustain. In a
commercial practice they could employ more oral health professionals and expand
their services by charging users. For contracted Māori providers, however, services are
constrained by the amount of DHB and external agency funding to ensure the doors
remain open.
Successful service providers need funding to support the desired outcomes. Māori
providers have found successful methods to overcome barriers to Māori accessing oral
health services yet may of these services are outside of their DHB contract. Close and
constant communication with the DHB should ensure that contracts and funding
reflects these essential services. This includes all components of the oral health service;
enrolment, attendance and treatment as in several instances all three are being
delivered but just one or two contracted for. Part of the problem here may be that DHB
contract specifications are not sufficiently flexible to support a whānau ora approach.
If it is difficult to be so specific then perhaps DHBs could consider capitation contracts
that support a certain population group with the amounts taking into account the high
need and risks of Māori.
Recommendation 1
Māori providers should have flexible oral health service contracts that are funded
appropriately to ensure that they can provide necessary services to Māori by adopting a
whānau ora approach. More urgently, Māori providers who are providing services
outside of their contracts should be reimbursed for the additional services.
DHB contract specifications are neither sufficiently flexible nor funded appropriately to
support a whānau ora approach. If it is difficult to be so specific then perhaps DHBs
could consider capitation contracts that support a certain population group with the
amounts taking into account the high need and risks of Māori.

43
Recommendation 2
DHBs should consider capitation funding for Māori provider oral health contracts so that
services can be delivered in the most effective manner.
Māori providers have difficulty with some parts of the oral health service system that
introduce what are considered unnecessary organisational and systemic barriers.
Rangatahi having to re-enrol when they transfer from primary to secondary school is
an unnecessary barrier to receiving free oral health treatment and should therefore be
removed. Rangatahi are also at the discretion of the dentist (with GDB contracts) on
whether or not they can access their services.
Māori providers adopt a whānau ora approach that ensures rangatahi continue to be
seen by a mobile service or a fixed community clinic. DHBs have prioritised oral
health services differently meaning that areas of high need are not being met with
appropriate services. Māori providers have proven capability in meeting those needs
and therefore should be supported to provide services that will directly improve the
oral health status of Māori.
Recommendation 3
Māori providers recommend increasing the number of oral health community clinics that
are based on the successful service at Te Taiwhenua o Heretaunga. Such a service adopts
whānau ora as its kaupapa and has proven to reduce the barriers to Māori receiving oral
health treatment and therefore reducing inequalities in Māori oral health.
Mobile services have been shown to overcome the first two components of oral health
services being enrolment and attendance. Both pre-school and rangatahi enrolments
have improved significantly with the facilitation and treatment by mobile services
offered by Māori providers at kohanga reo, kura kaupapa, primary and secondary
schools.
Recommendation 4
Mobile services are considered an essential part of the ideal community service model and
funding for this service should be prioritised by the Ministry of Health and DHBs in
building the capacity of capability of Māori providers.

43
Where the ideal community models are considered inappropriate or too expensive,
Māori and mainstream providers need to work closely if the services are to meet the
needs of Māori. Several Māori providers are improving access and therefore outcomes
of oral health services to Māori through partnership arrangements with the SDS and
private dentists. DHBs can facilitate this process by providing Māori providers with
oral health service contracts then allowing them to facilitate the services with SDS and
dentists who provide appropriate treatment to Māori and support the provider’s
kaupapa. The models adopted by Te Manu Toroa and Tipu Ora demonstrate that a
coordinated approach between all stakeholders can ensure that the oral health needs of
Māori in regional and rural areas can be met. There is also capacity within other Māori
providers to provide enrolment and attendance support thereby duplicating these
already successful services in other high needs areas.
Recommendation 5
A co-ordinated approach to the delivery of oral health services to Māori is crucial and the
relationship between DHB, Māori providers, SDS and dentists must be focused on
addressing inequalities in Māori child oral health. Co- ordination plans should be
developed that ensures a partnership approach is adopted and the key role of the Māori
provider recognised in providing the two key components of any Māori oral health
service, being enrolment and attendance. Many other Māori providers are available to
offer these services through their tamariki ora nurses and therefore the successful models
can be easily duplicated.
The service at Te Taiwhenua o Heretaunga has proven to address the needs of Māori in
the Hawkes Bay region. Part of the success has been due to the influence of John
Broughton who sits on an overseeing committee and his research into oranga niho
services. Having been in operation now for four years, the operation should be
developed further into a ‘centre-of-excellence’ for Māori oral health services. Such
development could see how the ideal community model can expand through out-reach
services to remote areas, support of other Māori providers in the Hawkes Bay region
and even assisting with addressing the issues in Wairoa. Te Taiwhenua o Heretaunga
could replace the SDS in the area and ensure that all tamariki and rangatahi received
their free oral health treatment through a whānau ora approach. Other DHBs and
larger Māori providers can then adopt the successful practices in their own areas,
adapting and developing them further to suit their own needs.
Recommendation 6
Te Taiwhenua o Heretaunga oranga niho service should be developed further into a

centre-of-excellence for Māori oral health services. This service would then act as a
development site for new initiatives seeking successful approaches and outcomes to
improve the status of Māori oral health.

43
Similarly, there was insufficient data gathered during this review to suggest that the
community model would be as successful in urban settings as it is in the regional
centres. The urban services visited during this review focused on Māori, Pacific Island
and low SES families. Therefore, the oral health community model may need
modification to take into account the larger proportion of non-Māori that are likely to
attend the service. The very large number of Māori living in urban centres means that
this service is vital if oral health inequalities are to be reduced. A service in Auckland
should be developed further to determine whether the community model is
appropriate for urban settings or alternative options sought for high needs groups.
Recommendation 7
The Ministry of Health and DHBs with predominantly urban populations should
identify Māori providers who can adapt the community model into a successful urban
service to ensure that the goal of improving child oral health and reducing child oral
health inequalities is achieved.
Māori providers with treatment contracts highlighted the difficulty of purchasing and
maintaining expensive capital equipment items under the current contract structure
that was limited to services. Several services had been stopped for periods due to the
unavailability of equipment or vehicles. As this equipment ages this issue will only get
worse. Māori providers ask why DHB provider arms can access capital equipment
funding and cover repairs and maintenance when they are limited to service provision
funding only. Māori providers are not private practices and therefore should not be
treated as such.
Recommendation 8
Māori providers should have capital equipment funding made available to them and
repairs and maintenance components included in their contracts. Māori providers are
not private practices and therefore more like the DHB provider arms than mainstream
private practices. DHB contracts should be amended to reflect this as the lack of
operational equipment means that oral health services can not be delivered.
This review found a lack of reliable research or data to determine the effectiveness of
the services being provided. Māori providers commented that DMFT data only
reported tamariki seen and took no account of those not seen. It was expected that
many of those not seen were Māori. Some sought feedback on their regular reports
whilst others were interested in whether the brush-in programmes were starting to
produce results. Reports were considered a compliance issue that reported activity
rather than any measure of performance. Some Māori providers only had a small role

43
in the overall service and therefore dependent on other mainstream providers to show
if their work was having a positive impact. In all, there was little analysed information
making its way back to the providers if such information were available.
Recommendation 9
Measures of performance are required to determine the effectiveness of the Māori child
oral health services and to demonstrate how these services are improving Māori child oral
health. A consistent framework that allows the components influenced by Māori
providers should be used to accurately assess the effectiveness of these services.
Implementation of further Māori provider treatment services will have a positive effect
on the Māori oral health workforce. Already, Māori providers have initially gained the
interest then supported Māori through oral health professional training increasing the
overall number of practitioners. Some Māori providers deliver training programmes
or have relationships with training establishments to increase the number of Māori
moving into the oral health sector. If tamariki and rangatahi experience Māori
providing their oral health treatment then they too may see it as a profession they may
want to join.
Recommendation 10
Māori providers should be encouraged to develop their own oral health workforce through
their relationships with training establishments and the development of further treatment
services where Māori can gain important community experience and attraction to the
oral health professions.
Te Ao Marama acts as an important thread to the Māori oral health workforce as many
are not oral health professionals meaning their attendance at the Te Ao Marama hui is
their only continuing professional education in oranga niho. These hui also provide an
important forum for the discussion of specific oral health issues, relationship building,
ongoing support and coordination between providers.
Recommendation 11
Te Ao Marama should be supported by the Ministry of Health and DHBs and be

recognised as an important thread that brings together the Māori oral health workforce.
This scope of this review was the evaluation of current Māori Child Oral Health service
contracts. A systems approach was used to assess the effectiveness of the operations
and recommendations about how these could be improved. However, Māori child oral

43
health services will only ever be as effective as the wider health system allows, as it is
entirely dependent on the allocation of contracts for various components of the overall
service. Further assessment of the wider health system as it related to oral health
should be undertaken to assess, for example, how Ministry of Health policy on Māori
child oral health is implemented at the DHB level. Other issues, such as the inability of
Māori providers to fund capital equipment, the relationships with the SDS and dentists
and the shortage of Māori oral health professionals are all part of a wider health system
combining to place Māori at a disadvantage in receiving oral health treatment.
Through logical and positive action these issues can be addressed.
Recommendation 12
Further assessment of the wider oral health system should be undertaken to determine
how organisational and systemic issues affecting Māori providers could be improved.

43
APPENDICES
Appendix 1: Māori child oral health providers
Māori provider Postal address Phone number
Ngati Whatua o Orakei Health 128 Apirana Avenue 09 578 0941

Services Ed Glenn Innes
PO Box 42183
Orakei
Auckland
Tipu Ora – Service Tunohopu Health Centre 07 348 9613

Houkotuku Street
Ohinemutu
Rotorua 3201
Te Manu Toroa 15 Garden Place 07 571 2026

Tauranga 07 574 9831(f)
027 254 9060
Te Whānau o Waipareira 13–15 Ratanui Street 09 839 0288

PO Box 21-081 021 958 259
Henderson
Auckland
Te Atiawa Dental Services ‘Taylor Dental’

25 Vivian Street
New Plymouth
Ngati Porou Hauora PO Box 2 06 864 6803

Te Puea Springs
East Coast 3850
Turanga Health 145 Darby Street 06 869 0457

PO Box 41
Gisborne 3815
Hauora Whanui 2–4 Rayner Street 09 404 1551

PO Box 141
Kawakawa
Kahungunu Executive 65 Queen Street 06 838 6835

PO Box 79
Wairoa
Kahungunu Health Services 208 Southampton Street West 06 878 7616

PO Box 901
Hastings
Te Kupenga Hauora o Ahuriri 5 Sale Street 06 835 1840

PO Box 1018
Napier
Taiwhenua o Heretaunga 821 Orchard Road 06 873 0971

Heretaunga Park Complex
PO Box 718
Hastings
Te Kohao Limited – Ed 180 Dey Street 07 856 1211

PO Box 7107
Hamilton
Te Korowai Hauora o Hauraki 201 Richmond Street 07 868 5375

PO Box 605 021 979 350
Thames

43
Māori provider Postal address Phone number
Tuhikaramea Medical Centre 1000 Victoria Street 07 839 5298

Hamilton
Te Whare Kaitiaki Dunedin School of Medicine 03 479 7268

PO Box 913
Dunedin

43
Appendix 2: Māori child oral health project team
Charrissa Makowharemahihi – Māori Health Directorate, Ministry of Health
Eugene Berryman-Kamp – Lakes DHB
Minnie McGibbon – Te Manu Toroa, Bay of Plenty
Edith McNeill – Te Whānau o Waipareira Trust
Louise Kuraia – Te Tai Tokerau MAPO
Kay Poananga – Te Ao Marama
Kim Smith – Oral Health Promotion – Regional Public Health
Tania Hodges – Mauri Ora Associates
Chris Natapu – Mauri Ora Associates

43
Appendix 3: Diagrammatic description of services provided by Māori
providers
Provider Who Enrolment Attendance Service delivery

Ngati Whatua o Orakei Tamariki
Rangatahi
Tipu Ora Tamariki
Rangatahi
Te Manu Toroa Tamariki
Rangatahi Note 1
Te Whānau o Waipareira Tamariki
Rangatahi
Te Atiawa Dental Services Tamariki
Rangatahi
Ngati Porou Hauora Tamariki
Rangatahi
Turanga Health Tamariki
Rangatahi
Hauora Whanui Tamariki
Rangatahi
Kahungunu Executive Tamariki
Rangatahi
Kahungunu Health Services Tamariki
“Choices”
Rangatahi
Te Kupenga Hauora o Ahuriri Tamariki
Rangatahi
Taiwhenua o Heretaunga Tamariki
Rangatahi
Te Kohao Limited Tamariki
Rangatahi
Te Korowai Hauora o Hauraki Tamariki
Rangatahi
Tuhikaramea Medical Centre Tamariki
(Albert Kewene private
Rangatahi
practice)
Te Whare Kaitiaki Tamariki
Rangatahi
Mighty Mouth Tamariki Note 2
Rangatahi
Key
Tamariki contracts Rangatahi contracts
Note 1: Russell Emerson has a contract to provide services to rangatahi with Te Manu Toroa support
Note 2: This contract cancelled in early 2004.

43
Appendix 4: Te Manu Toroa service delivery model
District Health
Board
Small contract Contracted services

Mainstream health
providers
Te Manu Toroa
Hauoranga Hauoranga Hauoranga Barriers
Whānau Whānau Whānau Whānau Whānau Whānau

43
Abbreviations
AOHC Adolescent Oral Health contacts

DHB / DHBs District Health Board / District Health Boards
DMFT Diseased, Missing and Filled Teeth
DNA Did Not Attend
ERO Education Review Office
FTE Full Time Equivalent
GDB General Dental Benefits
MCOH Māori Child Oral Health
NZDTA New Zealand Dental Therapists Association
SDB School Dental Benefits
SDS School Dental Services
SES Socio Economic Status
WINZ Work & Income New Zealand
Glossary
Term Definition
Hauoranga Māori Health Provider Network linked with Te Manu Toroa
Rangatahi Adolescent (in this report, 12 to 18 years)
Tamariki Children (in this report, 18 months to 12 years)
Te Ao Marama New Zealand Māori Dental Association
Whānau Family / Collective family grouping

43
References
Broughton J. 1993. Te niho waiora me te iwi Māori: dental health and the Māori people. New
Zealand Dental Journal 89: 15–18.
Broughton JKP. 1996. Dental Health Service and Māori People. Dunedin: Te Whare Wanaga o
Otago.
Broughton J. 2000. Oranga Niho: Māori oral health services. New Zealand Dental Journal (96):
97–100.
Broughton J. 2003. Report of Te Mahi Oranga Niho for Te Waka o Te Arawa. Dunedin: Te Whare
Wanaga o Otago.
Coggon D, Cooper C. 1999. Fluoridation of Water Supplies. British Medical Journal 319: 269–70.
Ministry of Health. 2001. Monitoring Ethnic Inequalities in Health. Public Health Intelligence
Occasional Bulletin (4). Wellington: Ministry of Health.
Ministry of Health. 2002. Reducing Inequalities in Health. Wellington: Ministry of Health.
Ministry of Health. 2003. School Dental Service Facilities Discussion Document. Wellington:
Ministry of Health.
Public Health Advisory Committee. 2003. Improving Child Oral Health and Reducing Child Oral
Health Inequalities. Wellington: National Health Committee.
Strategic Partners. 2001. Review of Publicly Funded Oral Health Care in New Zealand. Wellington:
Ministry of Health.
Te Ao Marama. 2000. The Journal of Te Ao Marama. Rotorua: Te Ao Marama.

43

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Review of Māori Child Oral Health

Kia pakiri mai ngā niho

Prepared by Mauri Ora Associates for the Ministry of Health Page 2 of 43

Summary and Recommendations 32

Prepared by Mauri Ora Associates for the Ministry of Health Page 3 of 43

Prepared by Mauri Ora Associates for the Ministry of Health Page 4 of 43

Prepared by Mauri Ora Associates for the Ministry of Health Page 5 of 43

3. Māori providers recommend increasing the number of oral health community

5. A co-ordinated approach to the delivery of oral health services to Māori is crucial

Prepared by Mauri Ora Associates for the Ministry of Health Page 7 of 43

9. Measures of performance are required to determine the effectiveness of the Māori

Prepared by Mauri Ora Associates for the Ministry of Health Page 8 of 43

Capture recommendations from Māori providers for all stakeholders to consider

Make recommendations on the direction to develop MCOH services further.

Gain a better understanding of the make up of the MCOH workforce (including

Provide recommendations to strengthen current service capability and capacity.

A description of the Māori child oral health service

Enrolment Attendance Treatment

Diagram 1: Child oral health service continuum

Table 1: Summary of contracted Māori child oral health services

18 months to 5 years Pre-school School Dental Service

DHB/Ministry of Oral health High risk areas (dental

5 years to 12 years At school School Dental Service

DHB/Ministry of High risk areas (dental

12 years to 18 years Self-enrolment Dentists

Prepared by Mauri Ora Associates for the Ministry of HealthPage 12 of

Table 2: Summary of actual Māori child oral services

18 months to Pre-school School Dental Service

Overcoming Tamariki ora Provider “fetch and Māori provider

DHB/Ministry of Health educator/ High risk areas (dental therapist

5 years to 12 years At school School Dental Service

Overcoming School nurse Whānau ora Community clinic

DHB/Ministry of High risk areas (dental therapist

12 years to 18 years Self-enrolment Dentists

Prepared by Mauri Ora Associates for the Ministry of HealthPage 13 of

DHB/Ministry of Adolescent oral Mobile service for high risk (low

A description of client demographics and utilisation

Utilisation is therefore predetermined by the contract for primary and secondary

Prepared by Mauri Ora Associates for the Ministry of HealthPage 15 of

An assessment of customer satisfaction

Only a few providers have formal instruments to capture levels of customer

In the main, however, providers had few measures of customer satisfaction or

A description of Māori health providers’ experiences with delivering the

Pre-school enrolments are normally provided by tamariki ora or community nurses. In

Weaknesses associated with the oral health education services include:

Experiences relating to treatment contracts include the breaking down of a number of

Prepared by Mauri Ora Associates for the Ministry of HealthPage 17 of

A diagrammatic representation of this model can be seen at Appendix 4 and represents

Although Māori providers predominantly employ Māori oral health professionals,

Costs of establishing and operating a Māori child oral health service

Prepared by Mauri Ora Associates for the Ministry of HealthPage 19 of

Some Māori providers were considering a joint commercial/community model citing

Several Māori providers supported ‘brush-in’ programmes at local schools and

Other relationships with schools related to their willingness to accommodate a mobile

Prepared by Mauri Ora Associates for the Ministry of HealthPage 23 of

A description of data collection processes and reporting

An analysis of the level of evidence available to demonstrate improved oral

Māori provider workforce

Māori providers had experienced difficulty in attracting oral health professionals to