Health Minister Shane Reti responsible for review of ‘affirmative action’ scheme he graduated from in 1980s

A long-standing admissions programme for Māori and Pasifika medical students is "racial discrimination", says ACT Party leader David Seymour, who is behind a pending government-led review. But the scheme is effective and the review is pointless, its supporters say.

Dr Simone Watkins has always enjoyed interacting with tamariki. Having grown up in Tāmaki Makaurau, her summer holidays as a teenager often included the odd job working at school holiday programmes, fostering her love for children.

"Children just have this immense kind of joy for life. And it's just that child outlook on life which I just really loved being around when I was younger."

Paired with her affinity for the sciences, Watkins decided at just 18 years old to pursue a career in paediatric medicine.

"It all sounds a bit cliche," she laughs.

However, the journey to becoming a doctor in New Zealand is no walk in the park, it's more like an intense marathon. With a limited number of spots in medical school and a line of eager candidates, getting in requires more than just acing exams. The competition is fierce, demanding stellar grades and a resume that shouts commitment to healthcare, community service and cultural awareness.

Watkins navigated med school through the Māori and Pacific Admissions Scheme (MAPAS) run by the University of Auckland. Of both Samoan and Palagi whakapapa, with her father originating from the village of Mo'ototua in Samoa, she applied and got in.

Established in 1972, MAPAS allocates about 30 percent of entries into the Faculty of Medical and Health Sciences to Māori and Pasifika students. MAPAS is not only an admissions pathway but also provides ongoing support to students throughout their studies, including noho marae stays, camps, whakawhānauatanga, and additional tutorials.

Watkins fondly remembers the supportive learning environment MAPAS provided for her and her fellow students.

"There were lots of different social events where MAPAS students had a chance to gather around and meet and one of them was the camps. I have a really fond memory of sitting around a campfire just laughing with new friends. And at that time, not really knowing the influence and impact that a lot of them will have through my career.

"It helped us to build a community of students, and have support also from those who have gone before. Building those networks of support is quite unique."

So when the new National and ACT coalition agreement announced it would be reviewing MAPAS and its Otago equivalent 'Mirror on Society', Watkins' phone blew up with messages from her Pasifika colleagues, all concerned for the future of the schemes.

"I immediately thought, I need to stand up for something that was integral in my career and in making me who I am now," says Watkins.

What is MAPAS?

MAPAS is certainly not a new initiative. An affirmative action admissions pathway for Māori and Pacific students was created in 1972 just four years after the University of Auckland's School of Medicine first opened its doors in 1968. The aim was to create greater diversity within the health system and reflect the needs that exist across New Zealand.

The first year only three places were allocated for Māori and Pacific students out of the total intake of 60 students. By 1979, there were 32 applicants and four admissions, so the university increased the number of places from six per annum to nine. It grew even more in the 1990s, with 12 entrants in 1990 rising to 23 in 1999. Now, 30 percent of places at the University of Auckland go specifically to Māori and Pacific students.

MAPAS students are generally admitted with a lower grade point average (GPA), come from higher deprivation and are more likely to be the first in their family to attend university, compared to their non-MAPAS counterparts. However, all students must meet the same requirements and standards in order to graduate.

MAPAS is also not the only 'affirmative action' pathway into medical school at the University of Auckland. Out of the 287 available places for domestic students for 2024, there are 115 places for MAPAS students, 65 places for rural and regional students, two spots for students with disabilities, six places for students from low socio-economic backgrounds, and one place for a student from a refugee background. If there are unfilled places in any of these groups of students, the places go to applicants in the general group.

Its Otago equivalent, established in 2012 and formerly known as the Mirror on Society policy, now Te Kauae Parāoa, is an admissions scheme for domestic students which is aimed at facilitating equity for students from the underrepresented groups; Māori, Pacific, rural, low-socioeconomic, and refugee background.

Watkins, who graduated from her medical studies with distinction in 2011, says MAPAS made her and her colleagues feel they had a voice.

"It gives us a pathway, a support network. It gives us the tools of the trade. And it's given me, I would say in my situation, also being empowered to stand up and speak up when I feel like justice or social justice, or inequality issues have arisen."

Reviewing the scheme, she says, threatens the steps forward it has already made.

"I can name on two hands, how many Māori and Pacific paediatricians I know. And that's not enough.

"There are a lot of us out there who continue to work in this space to bring good and better health outcomes for our people. So hopefully, they [the government] can divert their resources elsewhere, not review a program that has clear success, in my opinion."

What the ACT Party - and the coalition government - want

The review has come about as a result of the ACT Party's coalition agreement with National. Whilst it was not something the party specifically campaigned on, examining the scheme fits within its critique of 'race-based policies.'

Party leader David Seymour, of Ngāpuhi and European descent, says a review of MAPAS and its Otago equivalent is a "perfectly sensible" thing to do.

"MAPAS is a scheme that openly practises racial discrimination, that treats people differently based on their ethnic background. That's something we generally don't tolerate in our society, unless it is done to achieve a particular objective, in this case, to improve health outcomes for Māori and Pacific patients.

"I think it is well worth asking the question, has the intervention worked? Does it justify the racial discrimination inherent in the policy? And if not, should changes be made?"

Seymour says 'blanket racial discrimination' should not be allowed if it's not achieving a public goal, as it creates resentment amongst students. He outlines the criteria he believes the scheme should meet in order to continue.

"If we find that it is getting more Māori and Pasifika into medicine, that they are staying in medicine in such a way that they treat more Māori and Pacific patients and that the presence of Māori and Pacific medical graduates is more effective at helping those Māori and Pacific patients than doctors or nurses from other ethnicities, then sure, I think it should continue.

"That may involve using data that the healthcare system has to evaluate health outcomes, it might involve evaluating the destinations of people who graduate from the scheme, or it might be some combination of the two," Seymour says.

Responsibility for the review will fall to Minister of Health Shane Reti, who happens to be a graduate of the scheme. Reti's perspective on the scheme, the reason it exists, and the point of the review seem a little different to Seymour's.

Having gone through MAPAS in the '80s, he says he has good memories of his time on it.

"What was good about it was the whakawhānaungatanga from the other people, other colleagues in the scheme. There was a special bonding with those of us who were on the MAPAS scheme that I found really useful."

While Reti would not rule out the possibility of scrapping the scheme completely, he was more keen to talk about ways to potentially improve it.

"If the review finds that the objectives … are not being met, what do I need to do to help them be met? Think about it in that way," he says.

The review should be underway within the government's first year in office, he says.

More generally, Reti says having a representative healthcare workforce is a priority for the new government and there may be other ways of doing it.

"There are scholarship and support options that might be explored. There's a range of things that we could look at how we best have the health workforce graduate, that mostly looks and represents the general New Zealand society. So those are discussions we'll have across our portfolios, actually."

Prior to his career in politics, Reti practised family medicine and dermatology in Whangārei for 16 years and served on the Northland District Health Board for three terms.

"My own 30 years of clinical experience, and I think a wide body of evidence, says that if you're treated in a culturally competent context, you get a better outcome. I absolutely believe that," he says.

But for Seymour "the number one priority" is effective health care for all patients.

"Whether or not the people in the industry are from the 'correct' demographic is secondary to that. And it's only a priority to the extent that it helps with the primary goal of better outcomes for patients."

Why does MAPAS exist?

According to the Medical Council's 2023 workforce report, the current proportion of registered Māori doctors is 4.7 percent, with registered Pasifika doctors at 2.3 percent. That remains well short of matching the population as a whole - Māori are about 16.5 percent of the total population and just over eight percent of New Zealanders identify as Pasifika.

If the medical workforce was representative of our population, there would be 3193 Māori doctors and 1567 Pasifika doctors. But there are currently only 909 Māori doctors and 445 Pasifika doctors.

The council's report cites progress being driven by the medical schools. Nearly a fifth (17 percent) of students beginning medical school between 2019 and 2022 identified as Māori. And one in 10 (9.8 percent) identified as Pasifika.

The numbers are similar for graduates from Otago and Auckland universities in 2022.

For Dr Warwick Bagg, this is all evidence that the scheme works and the review is "a waste of time".

Bagg is the Acting Dean for the Faculty of Medical and Health Sciences at the University of Auckland.

"When I see the number of Māori and Pacific doctors who are now specialists, and the leadership roles they are playing and the influence they are having on our system, not only for individual patient outcomes, but for system outcomes. Of course it works. There's no question that it works."

Bagg recently published research which showed Māori and Pacific medical students continue to remain underrepresented in Aotearoa. The study also found poverty is a barrier to studying medicine across all demographic groups, and rural-background students are underrepresented in medicine.

"So if you go to a high decile school or you're well off socio-economically, you're much more likely to get into medical school than not. And there's a strong relationship between socio economic deprivation and being Māori and Pacific. And so those two factors do go together."

The research, which was conducted over several years, is timely and shows the need for the MAPAS scheme, Bagg says.

"Selecting students and ensuring that we provide pathways is really, really important if we're ever going to try to match the population demographic, mirror the society that we are serving and address health inequities."

Why is having a representative healthcare workforce important?

The health inequities for Māori and Pasifika are stark.

On average, Māori die seven years younger than non-Māori. Māori are twice as likely to have type 2 diabetes compared to non-Māori. Māori wāhine are 33 percent more likely to die of breast cancer within 10 years than Pākehā. And it's not just breast cancer, the total cancer mortality rate among Māori is more than 1.5 times higher than non-Māori, according to statistics from the Ministry of Health.

Pasifika people have high rates of dying early from long-term health conditions such as heart disease, diabetes, kidney failure, stroke and lung disease.

Bagg says Māori and Pacific peoples are not the problem but in fact the solution to improving health outcomes for their people.

"There is unconscious bias active in the system at the moment, which results in people not receiving equal treatment.

"There's no question about it, that when you have cultural concordance between your provider and your patient, then you're much more likely to get a better health outcome. And so that's why this focus on the MAPAS selection system is simply baffling to me."

If affirmative action is such a concern, why focus solely on the MAPAS only scheme, he asks.

"I am interested that they've targeted Māori and Pacific affirmative action, but they haven't looked at our other admission pathways for rural and regional people, for people with disabilities or refugees. So I am really left questioning why one particular affirmative pathway has been chosen to be investigated."

The controversy that's come before

Every few years debate over the schemes resurface and Māori and Pacific medical students are once again asked to justify their places in medical school.

In August 2020, there was anger over a University of Otago proposal to set a cap on the number of medical school admissions for Māori and Pasifika students through its Māori and Pacific Entry Pathways. The pathway previously had no limit.

A discussion document presented to the university's medical admissions committee suggested capping the Māori entry to 56 students and the Pacific Entry Pathway to 20. After a backlash, the university apologised for the distress the document had caused.

Shortly after, in October 2020, a parent took the University of Otago to court over its medical school selection process. The North Island man, whose name was suppressed by the High Court, alleged in a civil case against the university the 'Mirror on Society' admissions scheme was "misleading and deceptive", and acted against the Education Act.

He filed the case after his child, who did not fit a special category, was denied entry to its medical programme, despite his high academic achievement. The court case was eventually dropped and the university accepted the proceedings highlighted the "desirability of increased clarity and transparency" in its admissions process.

Dr Mataroria Lyndon is a senior lecturer in Medical Education at the University of Auckland, Tend Health Co-founder, MAPAS and Harvard Graduate. Lyndon says often MAPAS is the scheme that is singled out, rather than the other admissions pathways for students from rural areas or low socio economic backgrounds.

"There's a greater purpose of, especially publicly funded medical schools, to be obliged to think beyond individuals to serve the nation. And so it's part of a broader strategy or plan in terms of contributing to better health outcomes for Aotearoa."

He says sometimes MAPAS students are seen as lesser doctors, even though the same requirements need to be met to graduate.

"There can be a perception of somehow not having the same academic standards or grades, when actually we all sit the same exams, and we all graduate having passed and achieved those standards as well."

MAPAS levels the playing field so students from different backgrounds with fewer opportunities get a chance, he says.

"Sometimes people might think it's a privilege for Māori and Pasifika students, when actually you're looking at the inequities that Māori and Pacific face, but also the under-representation among many generations of Māori and Pacific who haven't had a chance to be able to go into health."

Who owns MAPAS?

If the upcoming review did lead to calls for major changes - or even scrapping the scheme - could the government actually enforce that?

Dr Warwick Bagg has his doubts.

"We have, under the Education Act, the ability to select for people who are underrepresented. We have a legal framework through the Education Act. We have Te Tiriti, which we believe is really important in holding our obligations under Te Tiriti. And we have a social contract with New Zealand to deliver a health care workforce that meets the needs of all New Zealanders."

But ultimately Bagg says the bigger issue is getting more spaces on the courses.

"Every person who gets a place in medical school deserves their place. Let's be absolutely clear. Whatever your ethnicity, you deserve your place. But what we need is to have more places so that we can train more doctors, because we have no shortage of interest.

"The fundamental issue here is not, again, the MAPAS system being a problem. The problem is that we don't have enough places."

The Tertiary Education Commission tightly controls the funding for medical schools and determines how many places they can offer to students, says Bagg.

Currently the University of Auckland is allowed to admit 287 students per year to medicine.

"Because the cost of training medical students is very expensive for the taxpayer, the taxpayer picks up about two thirds of the cost of training each medical student."

He says in its pre-election promises the National Party suggested it would give them additional places.

"We've yet to hear whether they're going to deliver on those."

Whatever the government decides to do, Dr Simone Watkins says she's ready to stand up for the scheme.

"I will speak up about the importance of it, the integral nature of it in producing future health professionals who are of Māori and Pacific background and culture, who understand those traversing through the healthcare system."