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THE WHARE HAUORA ONGATI POROU

THE COMMUNITY DESIGN STUDIO, UNIVERSITY OF AUCKLAND 2001

©2009

Tony WardTo download this and other free PDFs visit:

www.TonyWardEdu.com.

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CRITICAL HEALTH PRAXIS

The state of health of most of the people in the world is appalling. That ofindigenous peoples is the most appalling of all. Statistically, thoseindigenous peoples living in previously colonised countries like the UnitedStates, Australia, New Zealand, , Canada, etc. have the worst incidences ofunemployment, incarceration, alcohol and drug abuse, suicide, mentalillness, diabetes, asthma, heart failure and so on. In New Zealand thepicture is very much the same. 150 years of subordination anddiscrimination has left the Maori at the very bottom of the health statistics.No amount of increased revenue to the Health budget has succeeded inclosing the disparity in health between Maori and non-Maori. In recenttimes, Maori have begun to claim the right to determine their own healthtreatments, and to control the budgets of the treatments they receive. Thistino rangatiratanga of self-determination model has been adopted in Health,Education, and to some extent Justice systems. This is the story of oneexample of Maori self-determination in Health. It is the story of Ngati PorouHauora, and their small regional hospital at Te Puia Springs on the EastCoast of the North Island.

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NGATI POROUNgati Porou are a tribal group ofNorth Island Maori who occupy theremote East Coast of New Zealand‘sNorth Island. They were the firstnative inhabitants of Aotearoa toencounter Captain James Cook in hisvoyage on the Endeavour on 8thOctober1769 at what is nowGisborne. Since that time, Maori havelost much of their productive capacityand been reduced to conditions ofeconomic servitude by theincreasingly predominant Britishculture. By the 1950s, the Maorilanguage had all but disappeared,save in remote areas like the EastCape. Children were punished forspeaking their native tongue at Schooland parents, fearful for their well-being, insisted on speaking English athome.

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MAORI HEALTH STATISTICS

As their culture suffered under colonialassimilationist policies, so also did theirhealth. Increasingly, introduced Europeandiseases took their toll upon the indigenouspeople, most significantly in the ‘fluepidemic of 1918. Maori also sufferedenormously from the two world wars withsome tribes - like Ngati Porou - losing alarge proportion of the adult malepopulation. Gradually, they, along withother Maori were absorbed into treatmentunder the State Health System. But it was asystem that failed to heal or help them to alarge degree. Maori life expectancy andinfant mortality rates are both significantlyworse than that of non-Maori (right). Andalthough there has been an improvement inthe health of Maori, the disparity continues.

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EAST COAST HEALTHFor most of the last 100 years, thepredominantly Maori population of theEast Coast has been served by twohospitals. The Gisborne Hospital and thesmall and remote Te Puia SpringsHospital. The latter served the scatteredrural population of the East Coast, whileGisborne served mainly its own Cityresidents - except for services that thesmaller hospital could not deliver. It was asmall, autonomous hospital, employingdozens of locals in its gardens, orchards,maintenance staff and laundry - as well asthe numerous medical staff in its employ.Most of the people on the Coast were bornthere. Its one major resource is the naturalthermal springs that initiated its existence.

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BUILDING NEGLECT

With the inauguration of the DistrictHealth Boards (DHBs), togetherwith Bulk Funding regimesestablished in the 1980s - part of aGovernment move to increaseefficiency, cut costs and duplicationof services, Te Puia SpringsHospital was absorbed into thelarger new Tairawhiti Health Boardlocated in Gisborne, some two hoursdrive away. Thus began a gradualprocess of cutting services (laundry,elective surgery, maintenance etc.)to the satellite hospital. Deferredmaintenance was not done, andgradually the state and condition ofthe physical plant and equipmentdeclined.

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CERVICAL CANCER CRISIS

• Since the bulk of the non Maori population served by Tairawhiti HealthBoard (composed of mainly non-Maori members) lived in or close toGisborne, it was the majority Maori population of the Coast that sufferedmost from the cuts. This issue came to a head in the 1990s. Between 1990and 1996, Dr. Michael Bottrill the cytologist responsible for checkingcervical smears for severe abnormalities, failed to detect 129 out of 157such cases (68%) out of a total diagnosis of 22,000 slides. He was sued byone of his patients in 1994, It is not known how many of his patients wereMåori women, but that same year, Ngati Porou formed a working party towrest control of Coast health care from Tairawhiti Health. In 1997, Dr.Bottrill was found to be guilty of negligence by the Medical PractitionersDisciplinary Committee, and in 1999, the Government contracted NgatiPorou Haouora to be the primary Health provider to the East Coast, andtransferred ownership of all Coast health assets (including the now-dilapidated Te Puia Springs Hospital) to the Hauora.

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A DEVELOPMENT PROPOSAL

That same year, the CEO of the Hauora, approached the School ofArchitecture at the University of Auckland seeking help in developingrefurbishment proposals for Te Puia Springs Hospital. It was the Hauora’saim to transform the seriously under-maintained institution into a model forMaori Health provision. Clearly, the State health system had not servedMaori well, and the Hauora had decided that Maori Health could only beimproved if it was administered by Maori, for Maori, in a mannerconsistent with Maori cultural beliefs and tikanga. This kaupapa fitted indirectly with many of the previous projects carried out in the CommunityDesign Studio in support of Maori sovereignty. An initial visit in the firstweek of the new millennium led to an agreement for the CommunityDesign Studio to develop a design proposal for the Hospital, and inpreparation of the study a survey of the site was carried out and a secondvisit was made in February

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COMMUNICATIONS MEDIUMThe project commenced with a joint team ofArchitecture and Planning students building a3 dimensional model of the existing facility(bottom left) from on-site and aerialphotographs. (top right). This allowed for avery direct medium of communication withboth staff and members of the communityabout necessary changes to the existingbuildings.

A series of hui (meetings) were thenorganised in different locations throughoutthe Coast to consult with communitygroups about what needed to be done,using the model as a means ofcommunication and demonstration. Thishad the advantage of circumventingprofessional jargon and madecommunication user-centred.

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MAINTENANCE AUDIT

Simultaneously, two members ofthe Architecture Faculty, Drs.David Leifer and Tony Wardcompleted a maintenance audit ofthe facility. This noted the sorrystate to which the facilities hadbeen allowed to deteriorate byTairawhiti Health and maderecommendations for a graduatedmaintenance programme to becarried out alongside any majorchanges to the physical plant. Itwas clear that significantupgrading was necessary forseismic and sustainability issues.

The heavily corroded and neglectednatural spa pool

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DESIGN PROJECT

Over the next two semesters, a total of 24architecture students, three staff and oneconsultant worked with the Hauora and thecommunity to develop design proposals for TePuia Springs Hospital. They began by developinga design brief, consulting continuously with staffand community groups. From this a series ofdesign proposals were formulated and presented atregular intervals to the Ngati Porou Hauora Boardfor their consideration. These proposals weresupported by statistical and anecdotal data culledfrom the community meetings.

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BUILDING A BRIEF

From all of this, a design brief slowly emerged. The Brief presumed a holiisticmodel of health based upon prevention rather than cure, - the normative model of ill-health-treatment. This involved a consideration of the different issues that affectedthe health of individuals in the community:• cultural health• physical health• emotional health• spiritual health• intellectual health• economic health• social health• environmental health

All of these were seen to be necessary components of the parametersdriving the design. It was understood, for instance, that any design of thefacilities must have as a main consideration the creation of employmentopportunities for the Coast community. What follows is a synopsis of themajor findings and design considerations produced by the students.

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Te Whare Hauora o Ngati Porou

Pool

Community Design Studio, School of Architecture, University of AucklandWith Ngati Porou Hauora Whanau

Comprehensive Development Plan 2001

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EXISTING SITE PLAN

Main Entrance

Pool

Physio

Wards

Doctors

Accommodation

Reremoanaaccommodation

WorkshopsMortuary

Te Ao MaramaAccommodation

Main

hig

hway

Admin

StaffTawhiti

A&ERadiology

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KAUPAPA

When Ngati Porou Hauora took possession of Te Puia SpringsHospital from Tairawhiti Health Board, the facility was dilapidatedand close unsustainable. It had suffered years of neglect and poormaintenance and offered services which did not adequately servethe health needs of the East Coast community. It suffered:

• Structurally unsafe Buildings• Impossible maintenance needs• High running costs• Economic unsustainability• Environmental unsustainability• Poor water quality• Tikanga (cultural practices) difficulties• Staffing difficulties• Local Health Care difficulties• Regional health care difficulties

There was a need to solve ALL these problems

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STATUS QUO 2000

Neglect, poor maintenance and planning

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THE VISION

To make Te Whare Hauora o Ngati Poroua model of excellence in:

• Local Health Care• Regional Health Care• Preventative Health Care• Holistic Health Care• Maori Health Care• Sustainability

• Socially• Culturally• Environmentally• Economically

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THE HOLISTIC HEALTH MODEL

HEALTH

Physical

Spiritual

MentalEconomic

Social

Cultural

Environmental

Health is a multi-faceted, interactive phenomenon

Intellectual

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AIMS

• There is a need for the Whare Hauora to confrontALL facets of Health to better to address :• cultural health• physical health• emotional health• spiritual health• intellectual health• economic health• social health• environmental health

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OBJECTIVES

Rehabilitate and expand the facilities and services to:• Model Good Health practices

• Embody Tikanga Maori in design and practice

• Improve in-patient care

• Improve out-patient care

• Develop as a Regional Administrative Hub

• Improve and expand Regional Health Care

• Expand to provide cradle to grave support

• Improve and expand local and emergency services

• Attract and retain premium staff

• Create employment opportunities in community

• Provide quality accommodation for staff and patients

• Provide educational and training opportunities

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DESIGN DEVELOPMENT PROGRAMME

1. Assess Maintenance Issues2. Assess Seismic Issues3. Assess Tikanga Issues4. Assess Social Issues5. Community Survey6. Assess economic sustainability7. Conduct an Environmental Audit8. Assess natural resources9. Assess market potentials10. Long-term environmental strategy11. Comprehensive Design Brief12. Building Plans and Design Report13. Te Whare Hauora - He Ao Maori14. Phased Development Programme15. Fundraise Phase1

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ECONOMIC SUSTAINABILITY

• Improved Accounting Practices• Infrastructure Economies• Centralised Administration• Outreach Clinics• Internalise Economy• Use Physical Resources• Maximise Natural Resources

• Thermal water• Natural gas• Solar heat• Horticulture / farmland

• Use human resources• Use cultural resources• Training and Education

Develop economic self-sufficiency by:

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ECONOMIC HEALTH & EMPLOYMENT

• New laundry service• Cleaning service• Construction and maintenance contracts• Residential construction programme• Vehicle fleet maintenance programme• Catering services• Nutrition training programmes• Organic horticulture & market gardening• Landscaping design/build programme• Rongoa nursery development• Cultural tourism ventures• Health tourism ventures• Community Education programmes• Trade Training programmes• Health Training & Education programmes

Promote job-creation opportunities through:

Initiate Possible Joint Ventures

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ENVIRONMENTAL SUSTAINABILITY

• A potable water system• Rehabilitating the Lagoon• Sustainable waste disposal• Passive solar heating• Building insulation• Natural gas for heating• Commercial thermal spring• Native Planting• Organic produce planting• Rehabilitate fruit trees• Develop neglected areas first• Outdoor spaces to face North

Create a model of sustainability by

The Lagoon where treated effluent isdischarged

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HE AO MAORIDevelop the Whare Hauora as a truly Maori world by:

• Acknowledging Hikurangi Te Maunga• Expressing Tikanga Maori in design• Supporting Te Reo Maori in practice• Articulating Tapu/Noa in design• Developing Main Entrance / Waharoa• Incorporating a Marae Atea• Integrate whakairo and raranga• Native planting programme• Rongoa nursery programme• Developing Kaumatua Housing• Developing connection of communities• Incorporating Kohanga Reo / Creche• Acknowledging Life Cycles• Incorporating Whanau Support Facilities• Developing Active And Passive Healing

Heal the environment to heal the people

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DESIGN ISSUES 1• Confusing Entrance

• Inaccessible Receptionist

• Accessible Administration

• Confusing A&E

• Poor ambulance parking

• Difficult manakitanga

• Inadequate Kitchen / Staff Room

Staff Room

Main Entrance

Reception?Ambulance Parking

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DESIGN ISSUES 2

• Inaccessible Outpatient Clinic• Lack of privacy for Mental Health• Dilapidated Mortuary & Chapel• Mortuary/Workshop conflict• Small cluttered Workshops• Surplus disused equipment

Mortuary/Chapel

Outpatients/A&E

Workshops

Workshops & Mortuary

Mortuary/Chapel

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DESIGN ISSUES 3

• Serious seismic damage• Dilapidated Thermal Pool• Small Physiotherapy space• Expensive off site Laundry• Small maternity unit• Poor staff accommodation• Poor long-term wards• Lack of storage

Reremoana Long-term wards

Maternity wing

Former Laundry

ReremoanaThermal Pool

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DESIGN ISSUES 4

• No Library Resource• No staff or patient childcare• No Whanau (family) facilities• Ad hoc/piecemeal development• Incoherent planning• Jumbled building shapes• High heating costs• Lack of outdoor North access• Poor mobile lab parking• Neglected landscaping

Jumbled Buildings

Ad hoc development

North FaceLab parking at Entrance No outdoor access

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ENTRANCE DESIGN

• Prominently visible Entrance• Welcoming Entrance• Highly visible Reception• One Receptionist

New Main Entrance

Existing Entrance

Out Patient Care

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ACCESSIBLE ADMINISTRATION

• One visible Receptionist for all enquiries• Administration centralised• Improved security• Private Administration (1st Floor above Entrance)• Good separation of public and private domains

Entrance

Reception

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MEDICAL• Residential Care expanded with:

• Improved accommodation• Good indoor/outdoor access

• Accessible Accident and Emergency• Improved ambulance parking • Expanded Maternity suite• Outpatients more accessible • Separate Mental Health environment• Central whanau support facilities

Mobile Services

Men. Health Residential

Outpatients

Whanau

Maternity

Residential

Gymnasium

RongoaMirimiri

OutpatiensEntrance

Mental Health

Outpatients

A&EAmbulances

Residential

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THERMAL POOLS

• Public/ Private Spa• Different Pool Experiences• Physiotherapy• Rongoa• Mirimiri• Gymnasium• Refreshments• Views of Hikurangi

MaternityGymnasium

RongoaMirimiri

Residential

Residential

Rongoa

Mirimiri

Public Entrance

HIKURANGI

Private Pool

Kai

Office

Rongoa Mirimiri

Rongoa

Gynasium

Changing

Maternity

Long Term Care

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WORKSHOP / LAUNDRY

• Remove disused diesel tanks• Reinstate Laundry• Heat exchange boilers• Gas powered dryers • Redevelop Workshops• Install insulation• New and separate:

• Vehicle bays• Carpentry shop• Metalwork shop• Storage sheds

• Fleet garaging• Relocate mortuary• Replace with memorial garden

Existing

Proposed

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KITCHEN / STAFF ROOM

• Centralised Kitchen • Direct Access to Wards• Kitchen serves:

• Staff Café • Residents • Separate Public

• Private realm for Staff• Staff close to Creche• Staff Changing

Basement Plan Staff Cafe

Central Atrium

North facing atrium

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SUPPORT AREAS

• Whanau Room with: Privacy Cooking & bathing facilities Creche Public CaféViews of Hikurangi Library

Creche below

Whanau aboveCreche below

Library

Kitchen

Library

Whanau

Kitchen

Mental Health

Mental Health

A&E

Maternity

Central Atrium

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BASEMENT PLAN

atrium

kitchen

Staff cafe

changing

Creche

Public lift

Service Lift

Stair

Hikurangi

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GROUND FLOOR PLAN

atrium

MainEntrance

Reception

A&Eentrance

Hot springs

workshops

Long Term CareMental Health

Maternity Outpatients

Whanau Room

Library

Cafe

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FIRST FLOOR PLAN

administration

atrium

administration

Administration above Entrance for Access and Privacy

Entry below

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ROOF PLANIntegrating and Reconciling Existing Roof Forms

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ATRIUM

ReceptionMain Entrance

North Side of Atrium

Atrium Internal

Doctors Consulting

Mental Health

Café Seating

Whanau Room

Atrium View Thru to Hikurangi

Whanau Room

StaffKitchen

Cafe

Administration

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PROPOSED OVERALL PLAN

MainEntrance

Adminover

Mental

A&EEntrance

Wards

Workshops

Hot Springs

Reremoana Accommodation

Mai

n H

ighw

ay

Maternity Doctors

Public EntranceTo Springs

Mortuary

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COMPREHENSIVE DEVELOPMENT PLAN

• Clinical Services• Staff Residential• Kaumatua (Elder) Housing• Health Education• Staff Training• Health Tourism

In addition to the actual Hospital design, it was also important todevelop proposals for the wider contextual issues

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Clinical Services• New satellite health Clinics were opened at Kaiti (Gisborne), Ruatoria,

Tokomaru Bay, Te Araroa)

Staff Residential• Plans were completed to remodel one of the existing houses into a 7 bed

nursing hostel

Kaumatua (Elder) Housing• Space was allocated around the Lagoon for the inclusions of Kaumatua

Housing

Health Education and Staff Training• Proposals were developed to rehabilitate Reremoana

Health Tourism• Proposals were developed to purchase the nearby Te Puia Springs Hotel

with its own thermal spring to separate the Hospital and Tourismfunctions of the existing pool. These were never carried through

COMPREHENSIVE DEVELOPMENTPLAN

In addition, new Gisborne premises were leased to house Research projects,Mental Health Advocate, a Rehabilitation programme, Problem GamblingCounsellor and the Tairawhiti Innovative Nursing Team.

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FINAL REPORT AND ANIMATION

Finally, the design was completed and a 250 pageComprehensive Design Report was developed todocument the proposal. This included:• Phased Development Plan• Complete “Pattern Language” of design principles• Full cost estimates• Phased economic sustainability plan

This was accompanied by a computer simulated fly-through developed to:• Make the proposals more comprehensible to the

wider community• Use as a basis for fund-raising