Decolonization and Health Systems: A Scoping Review

Abstract

Introduction:

Coloniality continues to define knowledge, culture, relationships and health outcomes for Indigenous peoples around the world. Health systems are shaped by coloniality, influencing access to health care and the quality of care. Decolonization, although pluralistic in understanding, provides a theoretical foundation for health system transformation. The aim of this scoping review was to explore what is known about decolonization, Indigenous health, and equity in publicly funded health systems, and to identify gaps in existing literature.

Methods:

This research is grounded in an Indigenous methodology and positioning, providing a critical structural analytical framework. Scoping review methods developed by the Joanna Briggs Institute and PRISMA-ScR were situated within a Kaupapa Māori framework to identify decolonization approaches and characteristics in publicly funded health systems within Aotearoa New Zealand, Australia and Canada. Data sources included four databases and an Aotearoa New Zealand-focused gray literature search.

Results:

Sixteen texts were included with more than three-quarters published between 2019 and 2021. The majority of approaches were at the level of the system or health professional and exploratory in nature. Implementation and outcome measurement were scarce. Characteristics of decolonization in health systems were categorized as Addressing Coloniality, Transformation, Relationships and Indigeneity.

Conclusions:

This review provides a novel synthesis of decolonization in the context of publicly funded health systems, identifying an emergent research area, and disconnect between theory and practice. Decolonization provides a rights-based intersectional framework that is distinct from alternative approaches, unique in its ambition to address power imbalance and see structural transformation. Misalignment between ideological positioning of decolonial theory and governments may limit the opportunity for implementation within publicly funded health systems. Research, implementation and evaluation of decolonization approaches is needed to expand knowledge, influence future public policy and see structural transformation of health systems to support Indigenous well-being and health equity.

Keywords

decolonization health systems Indigenous health health equity

Introduction

The existence of persistent and pervasive adverse health outcomes in Indigenous peoples around the world is well established.¹ The pathways to Indigenous:non-Indigenous health inequities are distinct and context dependent; however, racism and coloniality are common structural determinants resulting in the ongoing oppression and marginalization of Indigenous peoples in society.²

Coloniality encompasses the intersectional hierarchical power structures and practices, resulting from colonialism, that continue to define knowledge, culture, and relationships.³ Coloniality is distinct from, although related to, colonization (the action or process of settling among and establishing control over an Indigenous people) and colonialism (the policy or practice of obtaining political control). While the period of global colonialism is considered to have passed, the legacy of colonial power relations and the exploitation and domination of Indigenous peoples remains.⁴

A manifestation of coloniality is institutional racism, the differential access to material conditions and power by ethnicity.⁵ In health, Indigenous peoples have often been politically marginalized from influencing publicly funded health systems, health organizations and services through differential access to resources, voice and decision-making positions.⁶ As a result, health systems reflect colonial beliefs and ideologies, creating barriers to access and differences in quality of care. While it is important to recognize the significance of environments and social determinants to population health outcomes, timely access to health care and high-quality care are also determinants of health⁷ and inherent rights affirmed in international frameworks.^8,9

Recognizing that health systems are shaped by colonization and coloniality, decolonization provides a theoretical foundation for urgently needed health system transformation. Frequently identified as a process, decolonisation is described as both unmasking the influence of colonialism on the lives of Indigenous peoples and undoing colonialism using indigenous ways of knowing and doing to achieve the vision of equity and social justice.^10,11 Graham Smith describes “conscientization” in this process; that through consciousness raising Indigenous imagination can be reawakened.¹² Similarly, Laenui describes a five-phase process inclusive of rediscovery and recovery, mourning, dreaming, commitment, and action,¹³ emphasizing the significance of dreaming to enable space for exploration and aspiration.

Themes of power, liberation and active resistance are common. Described in 1968’s The Wretched of the Earth, Fanon refers to the reversing of power relations and the attainment of cultural and national liberation through the struggle for power.¹⁴ Liberation is positioned by Freire in Pedagogy of the Oppressed as being central to decolonizing actions, identifying that although the “marks of oppression” are born by both the oppressed and the oppressor, the struggle for liberation must be led by the oppressed.¹⁰ The struggle is articulated by Māori scholar Linda Smith as active resistance, signaling “a need to decolonize our minds, to recover ourselves, to claim a space in which to develop a sense of authentic humanity.”¹⁵ Waziyatawin and Yellow Bird capture these concepts in their description of decolonization:

The intelligent, calculated, and active resistance to forces of colonialism that perpetuate the subjugation of our minds, bodies, and lands, and it is engaged for the ultimate purpose of overturning the colonial structure and realizing indigenous liberation.¹¹

Appreciating the pluralistic and context-specific nature of decolonization and the complexity of health systems, it is necessary and relevant to understand their relationship with regard to Indigenous health and well-being. The aim of this scoping review was to explore what is known about decolonization, Indigenous health, and equity in the context of health systems, and to identify gaps in existing research and literature. Situated within a larger exploratory project, findings provide insight into how decolonization might support the transformation of publicly funded health systems to uphold the rights of Indigenous peoples and achieve healthy people, families, and environments.

Methods

Positioning

This research has been undertaken by a Māori researcher (K.W.) and a Māori research assistant (N.T.) with support and oversight from a senior Kaupapa Māori researcher. Kaupapa Māori provides the theoretical foundation and critical Indigenous positioning where being Māori, Māori knowledge, and Māori ways of doing are valid and legitimate.¹⁶ The struggle for self-determination and upholding of Indigenous rights sits at the heart of Kaupapa Māori approaches, supporting the active examination of privilege and power and resistance to continued colonization.^15,17 As such, research is centered around the experience of Māori, the Indigenous peoples of Aotearoa New Zealand (NZ), and extends to include Indigenous peoples with unique, but similar, colonial histories and health systems.

Study design

Scoping review has been positioned within Kaupapa Māori theory and practice. This supports the mapping of relevant literature, defining concepts, and identification of knowledge gaps^18,19 in a way which centers self-determination and the collective aspirations of Indigenous peoples, recognizing the impact of colonization and coloniality on Māori in NZ and Indigenous peoples around the world.

Research sought to answer the following questions: (i) What are the health system decolonization approaches being described and implemented? (ii) How are health system decolonization approaches and outcomes being measured/monitored? and (iii) How is decolonization being conceptualized in the context of health systems? The study followed the methods for scoping review developed by Joanna Briggs Institute) and the PRISMA-ScR reporting guidelines. A protocol was developed a priori (unpublished, available on request) and the participants, concept, context framework was used to establish the research question and inclusion/exclusion criteria (Table 1). Ethics approval was not required for this study.

Table 1.

Definition of Study Parameters (Population, Concept, and Context)

Study parameter	Definition
Indigenous peoples (population)	Recognizing that Indigenous peoples have unique cultures, languages and systems, the United Nations “working definition” was used to define this parameter. Key characteristics included self-determination as Indigenous, the fundamental importance of ancestral land and territory to collective physical and cultural survival, and “an experience of subjugation, marginalization, dispossession, exclusion, or discrimination because of their different cultures, ways of life or modes of production than the dominant model.”²⁰
Decolonization (concept)	Description of decolonization consistent with at least one of the following: i) Decolonization framed as a response or active resistance to colonization, including restorative processes; ii) Process described is inclusive of Indigenization and transformation to include Indigenous ways of being, knowing, and doing; or iii) Addresses power imbalance between Indigenous and non-Indigenous peoples.
Health system (context)	Health system is defined broadly, consistent with the World Health Organization (WHO).²¹ In the context of this study, this included publicly funded health systems either as a whole or an aspect of that system (e.g., organization, service, program or practitioner within an organization). This included health organization-led programs or activities regarding cultural identity, language, or connection with land/people.
Country (context)	Health systems within NZ, Australia, and Canada were included, countries with unique but comparable colonial experiences. The gray literature search was limited to NZ only, reflecting the research team’s capacity and scope of health system expertise.

Search strategy and study selection

We searched databases [Scopus, Medline (Ovid), PubMed, Web of Science] on 7 December 2022 using the search terms “decolonization,” “health system,” AND “Indigenous peoples” as summarized in Table 2. Databases were selected based on subject area relevance and confirmed following consultation with university library services. No time or language restrictions were applied to the database search.

Table 2.

Primary Search Terms

Search term	Boolean search strings
Decolonization AND	decoloniz* OR decolonis* OR decolonial
Health system AND	health system OR health care system OR health programme OR health organisation OR health organization OR healthcare OR health care OR health service OR primary health care
Indigenous peoples	māori OR inuit OR torres strait islander OR aborigine OR metis OR first nation OR indigen*

We searched google search engine (“govt.co.nz,” ‘health.nz,” “org.nz,” and “teakawhaiora.nz”) on January 24, 2023 using the same search terms. Relevant domains were determined following an exploration of NZ health system-related domains. We also searched texts recommended by key stakeholders and the reference lists of included texts.

Texts were screened by a two-stage process with one researcher (N.T.) screening all texts, and a second researcher (K.W.) providing pilot screening at both stages. Any conflicts were discussed and resolved, with decisions applied across the screening process to support consistency. All included texts were screened by both researchers. We included texts where the concept, process or outcomes of decolonization were discussed in the context of: (i) the health of an Indigenous population and (ii) a publicly funded health system in Australia, Canada or NZ, or an aspect of that system (e.g., health organizations, services, programs or practitioners). We excluded theses/dissertations, blogs and texts in languages other than English at the screening stage due to research scope constraints.

Data collection and analysis

Data were extracted from texts by both authors into an Excel spreadsheet under six predetermined domains: (i) country and Indigenous population, (ii) health system level described, (iii) conceptualization of decolonization, (iv) decolonization approach and stage of implementation, (v) outcomes described, and (vi) measurement and monitoring of outcomes. Domains were selected to answer the research questions, reflecting the Kaupapa Māori approach and decolonial theoretical foundation, which connects “conscientization” to action. Data describing the conceptualization of decolonization were coded and inductive thematic analysis undertaken, informed by Kaupapa Māori principles which center critical structural analysis. Data extracted from texts were coded, then subthemes and themes that characterize decolonization approaches in health systems were identified. Data under the remaining domains were categorized by the research team and are described in the results section. Monitoring included the systematic collection and analysis of outcome data.

Results

The search strategy identified a total of 2,121 texts (741 articles identified through database searches, 427 texts through Google search engine and stakeholder engagement, and 953 from citations of included texts). After removal of duplicates and initial screening, 83 were eligible for full-text review. After full-text review, 16 texts met the study inclusion criteria and were included in our scoping review (Fig. 1). Only one text was excluded during screening based on language (Portuguese).

FIG. 1.

PRISMA Flow diagram of articles selected for inclusion in scoping review.

Characteristics of included texts

Texts were predominantly peer-reviewed journal articles (n = 14). Publication dates ranged from 2005 to 2021, with more than three quarters (n = 12) published between 2019 and 2021. Texts were spread between NZ and Australia somewhat evenly [NZ n = 7, Australia n = 5, and Canada n = 3, all countries (n = 1)], recognizing the addition of two reports from the NZ-specific gray literature search. Indigenous populations described reflected the territories of included countries, specifically Māori, First Nations peoples of Australia and the Torres Straight Islands, Métis, Inuit, and First Nations peoples of Canada (Table 3).

Table 3.

Author, Year, Literature Type, Country, Indigenous Population, Health System Aspect, Stage of Implementation, Outcome(s), and Measuring/Monitoring Approaches for Included Texts

Author	Year	Literature type	Country, Indigenous population	Health system aspect	Stage of implementation	Outcome(s) of decolonization approach	Measuring/monitoring approach
Lang, S.K.W²²	2005	Peer reviewed journal article	NZ, Māori	Organization	Exploratory	Transformation Workforce development	Feedback
Pyett P., et al.²³	2008	Peer reviewed journal article	Australia, First Nation Peoples of Australia	Health professional	Planning	Transformation Workforce development
Dudgeon, P., and Walker, R²⁴	2015	Peer reviewed journal article	Australia, First Nation Peoples of Australia and Torres Strait Islanders	Health professional	Planning	TransformationWorkforce developmentUphold rights
Berghan, G., et al.²⁵	2017	Report	NZ, Māori	Health professional	Planning	TransformationWorkforce developmentAddress inequitiesUphold rights
Jones, R²⁶	2019	Peer-reviewed journal article	NZ, Māori	System	Exploratory	TransformationAddress inequitiesUphold rights
Lawson-Te Aho K., et al.²⁷	2019	Peer-reviewed journal article	NZ, Māori	System	Planning	TransformationAddress inequitiesUphold rights
McGibbon, E²⁸	2019	Peer reviewed journal article	Canada, Métis, Inuit, First Nations Peoples	Health professional	Exploratory	TransformationWorkplace developmentAddress inequitiesUphold rights
Came H., et al.²⁹	2020	Peer-reviewed journal article	NZ, Māori	System	Exploratory	TransformationUphold rights
Cullen P., et al.³⁰	2020	Peer-reviewed journal article	Australia, First Nation Peoples of Australia and Torres Strait Islanders	Organization	Implementation	TransformationWorkforce development	Case study
Gibson, C³¹	2020	Peer-reviewed journal article	Australia, Kamilaroi	Health professional	Planning	TransformationWorkforce developmentAddress inequitiesUphold rights
Pihama L., et al.³²	2020	Report	NZ, Māori	System	Exploratory	TransformationAddressing inequitiesUphold rights
Came, H., Baker, M., & McCreanor, T³³	2021	Peer reviewed journal article	NZ, Māori	System	Exploratory	TransformationWorkforce developmentAddress inequitiesUphold rights
Castle, P³⁴	2021	Peer-reviewed journal article	Australia, First Nation Peoples of Australia	Program	Pilot program	Transformation Workforce development	Case study
Eni R., et al.³⁵	2021	Peer-reviewed journal article	Canada, First Nations Peoples of Canada	System	Exploratory	TransformationWorkforce developmentAddress inequitiesUphold rights
Hunter, C., and Pride, T³⁶	2021	Peer-reviewed journal article	Canada, First Nation Peoples of Canada	Health professional	Exploratory	TransformationWorkforce developmentAddress inequitiesUphold rights
Narasimhan, S., and Chandanabhumma, P³⁷	2021	Peer-reviewed journal article	Australia, NZ and North America, First Nations Peoples of Australia and North America, Māori	Health professional	Exploratory	TransformationWorkforce developmentUphold rights

Health system level, approaches, outcomes and monitoring

The health system level described was categorized into four levels: system (i.e., interconnecting organizations and networks), organization (i.e., an organized group of people including health professional groups and associations), program (i.e., a defined service or set of planned actions), and health professional (i.e., individuals working within a health profession). More than a third referred to a system (n = 6), for example, national level health systems,^29,33 primary health care,³⁵ health promotion,²⁶ or a health issue-related system, such as trauma informed care³² and homelessness.²⁷ Organizations (n = 2) included a counseling association²² and an Indigenous community-controlled health organization.³⁰ Program included a pilot program integrating psychology into remote Indigenous health centers.³⁴ Nearly half referred to health professionals (n = 7), specifically health promoters,^23,25,37 occupational therapists,^31,36 psychologists,²⁴ and health leaders.²⁸

Decolonisation approaches described were categorised as exploratory (i.e., examining foundational ideas), planning (i.e., developing a framework/plan), piloting a program (i.e., testing or trialing a plan/approach), and implementation (i.e., putting a plan/approach into effect). Most texts described the exploratory (n = 9) or planning phases (n = 5). One pilot program described embedding an Indigenous patient-led approach to primary care-based trauma-informed care.³⁴ Implementation included an Indigenous health organization integrating trauma- and violence-informed care.³⁰

Outcomes were categorized as transformation, workforce development, address inequities, and uphold rights. Transformation (i.e., dramatic change) was identified in all texts and included addressing power and resource imbalance^{22,23,25,28–31,33,35–37} and colonial systems/practices,^{26,29,30,33–35} creating Indigenous knowledge,^24,26,35 reclaiming and asserting Indigenous ways,^27,34,36,37 social transformation,^25,29,30,36 effective and high trust relationships,^25,33 and reorientation toward healing.^31,32

Workforce development (n = 12) describes actions to create and sustain a viable and skilled workforce and is comprised of capacity^23,37 (e.g., increasing Indigenous researchers) and capability building^{22–25,28,30,31,33–37} (e.g., practitioner understanding of colonization, Te Tiriti, reflexivity, antiracism, cultural competence, and models of care; decolonizing the practitioner; and developing Indigenous and local practitioners).

Addressing inequities (i.e., avoidable, unfair and unjust differences in health outcomes)³⁸ (n = 9) included addressing social and socioecological determinants of health^{25,26,28,31,32,35,36} and eliminating disparities.^26,27,33 The upholding of Indigenous rights (n = 12) included advancing Indigenous rights, self-determination, and aspirations,^{24–29,31–33,35–37} making use of human rights discourse, frameworks and treaties (e.g., UNDRIP, Te Tiriti o Waitangi).

Measuring/monitoring was identified in a very limited way as feedback (i.e., gathering perceptions and experiences on exploratory concepts)²² and case studies (i.e., a research approach to generate understanding of complex issues in real-life context).^30,34 One text identified the need for robust evaluation to explore the applicability and scalability of the intervention for similar contexts.³⁰

Conceptualization of decolonization in health systems

All included texts provided a description of decolonization. Characteristics of decolonization in health systems were categorized into four themes that are described below and summarized in Table 4.

Table 4.

Themes, Subthemes and Description of Characteristics of Decolonization in Health Systems

Theme	Subtheme	Description
Addressing Coloniality: Identifying and addressing coloniality	Colonization	Identifying and addressing colonization; decolonization as a response to colonization
	Power	Dismantling colonial power structures to achieve Indigenous liberation
	Privilege	Identifying and addressing privilege at all levels
	Racism	Skills-based training and structural transformation to support anti-racism
Transformation: Aspirational and marked change to achieve social justice and equity	Systems	Constitutional and social change to create space for decolonial approaches
	Individuals	Changing beliefs and practice. Regaining positive identities.
Relationships: Connections and the processes surrounding relationships	Whakapapa	Indigenous understandings of connections with people, places and spirituality
	Whakawhanaungatanga	Characteristics to support being in good relation
	Responsibility	Roles and expectations of Indigenous and non-Indigenous peoples; accountability
Indigeneity: Connection of Indigenous peoples with Indigenous lands, knowledge, and ways of doing	Indigenous knowing	Centering Indigenous knowledge and values
	Indigenous ways of doing	Affirming processes, practices, and approaches grounded in Indigenous knowledge and values
	Indigenous rights	Upholding inherent Indigenous rights

Addressing coloniality

Addressing coloniality captures the centrality of recognizing and dismantling the power structures and practices resulting from colonization and colonialism, particularly unequal distribution of power, privilege, and racism. Knowing and understanding the oppressive nature of coloniality is fundamental to healing, followed by action to challenge and dismantle colonial systems. Subthemes are colonization, power, privilege and racism, with each including dimensions of acknowledgment and response.

Colonization was recognized as having historical and ongoing impacts that shape the health and well-being of Indigenous peoples.^26,31 Awareness and understanding of colonization as a concept and process was a requirement of decolonization,²⁴ being inclusive of unlearning colonial history.²⁵ Following on from awareness was active resistance to colonization^24,30,36,37 and colonialism,^24,26 and the unpacking of effects.²⁷ Through this process, decolonization was framed as a response³⁴ and a solution to the colonial legacy,³⁷ dismantling colonialism,²² and addressing oppressive systems.^22,32

Hierarchies of power were identified as inconsistent with Indigenous health and equity,³⁶ recognizing the relationship between power and decision making.²³ As such, power was central to a decolonial lens,²² requiring a substantial shift in power relations.^25,33 Power was identified as a feature distinguishing decolonization from other transformative approaches like cultural safety.²⁸ Shifting power was dependent on recognizing and acknowledging the role of power and power imbalance,^24,28 remedial actions to redistribute power,^23,35 and the dismantling of power structures^22,31 to obtain Indigenous liberation.³⁷

Privilege, the other hidden side of racism, operates at individual, intermediary, and organizational levels and is described by McIntosh as the “invisible knapsack of unearned assets.”³⁹ Approaches described the need to recognize^24,28 and address privilege at all levels to decolonize health care.²⁸ Workshops addressing white privilege and white fragility were an example of an individual-level action.³⁰

Similar to other subthemes, texts described both identifying and addressing racism, understanding this to be “a societal system in which actors are divided into ‘races,’ with power unevenly distributed (or produced) based on these racial classifications.”⁴⁰ Specific actions include skills-based training around antiracism,^28,30 dismantling institutional structures and systems that support racism,²⁶ and integrating antiracism into practice.²⁵

Transformation

Transformation cuts across all other themes but is described as a distinct theme in recognition that ultimately decolonization has a transformative agenda and that decolonization is required for a transformative shift in Indigenous health and well-being.³⁵ Transformation is aspirational and includes marked change in adverse health outcomes,²⁷ social structures, and systems to achieve social justice and health equity.^29,31,37 Subthemes of transformation are systems and individuals.

Systems-level transformation includes constitutional^23,29,33 and social transformation.^25,28,31,37 It is inclusive of transforming colonial systems,^22–24,30 normalizing decolonial action in practice,²⁹ and the creation of safe spaces and places for this practice and approach.³² For one text, decolonization was part of a bigger project of “re-indigenisation.”²⁷

At an individual level, transformation was inclusive of health professionals deconstructing and transforming practice and identity^26,34,36 and working toward critical consciousness.²⁹ The process was described as beginning in the mind,^22,24,32,37 exploring assumptions and beliefs,³⁰ and providing the opportunity to transform learning experiences.³² For Indigenous peoples, the opportunity to regain self-determination and positive identities as individuals, whānau and communities was described.^24,27,31

Relationships

This theme captures connections and the processes or conditions surrounding relationships in a decolonizing approach. Indigenous understandings of relationships underpin this theme, which is conceptualized within Te Ao Māori (Māori worldviews). Subthemes are whakapapa (genealogical connections with people, places, and the gods in the past, present, and future), whakawhanaungatanga (process of establishing relationships and relating well to others), and responsibility.

Whakapapa describes the connections central to a decolonizing approach. Grounded in Indigenous knowledge and understandings of relationships,²³ relationships include Indigenous peoples, communities, organisations,³⁶ and marginalized groups.³⁷ Whakawhanaungatanga describes the characteristics necessary for successful relationships, such as respect and reciprocity.²³

Responsibility describes the roles and expectations articulated in texts, of which there were diverse perspectives. Decolonization was described as both a process for everyone,^{22,24,25,31,35} and one for colonial settlers alone.²⁸ While it was clear that Indigenous peoples must lead indigenization,²⁹ it was also apparent that cultural loading and overburdening must be avoided.²⁸ Non-Indigenous peoples were frequently recognized to have a role, specifically being actively engaged,³³ trusting Indigenous peoples, and providing a safe environment for the restoration of Indigenous practices.²⁹ Related to responsibility is accountability—the consequences and ownership of actions. Accountability was seen as central to decolonization,³⁷ recognizing that decolonizing actions aren’t done and then forgotten.^25,28,34,37

Indigeneity

This theme describes the interconnection of Indigenous peoples with Indigenous lands, knowledge, and ways of doing. Subthemes are Indigenous knowing, Indigenous ways of doing, and Indigenous rights.

Indigenous knowing includes recognition that the affirmation of Indigenous knowledge is fundamental to a decolonizing approach.^26,29,34,37 Indigenous knowledge was defined broadly, being inclusive of Indigenous values^22,23,31,32 and models of health.^34,35 Indigenous ways of doing were grounded in Indigenous values and included processes,^23,30 practices,²⁷ and approaches like Kaupapa Māori^26,27 and family-centered approaches.²⁷ Inherent Indigenous rights were recognized along with the need to uphold treaties.^25,31 Treaties were used as a framework, specifically Te Tiriti o Waitangi in NZ.^22,27,29

Discussion

This scoping review has explored decolonization in the context of health systems and Indigenous health. Research is clearly emergent with publications spanning the 17 years prior to and including 2021. Findings indicate that research over the last two decades has predominantly been exploratory at the level of health system or health professional. Examples of piloted or implemented approaches were limited, with the two identified both involving trauma-informed care. The themes identified are consistent with established decolonial theory,^10,11,13,41 and contextualized within a health system setting. Captured within these themes is the plurality of understanding, including differential perspectives on roles and responsibilities for Indigenous and non-Indigenous peoples.

The characteristics of decolonization in health systems are interconnected and collectively support the upholding of Indigenous rights and well-being. This interconnection is illustrated using the mahau (front porch) of the Māori meeting house (Fig. 2). The key themes are represented by carved pou (post, support) and collectively support the maihi (bargeboards of the meeting house), which represents Indigenous rights and well-being for individuals, families, and the environment. The wharenui (meeting house) is symbolic in the Māori world, being a central site for gathering and connecting with the Māori world, ancestors, relations, and communities. The whare (house) is also significant to Māori health, with a well-known model, Te Whare Tapa Whā, using the house to illustrate holistic understandings of health and well-being.⁴²

FIG. 2.

Interconnected characteristics of decolonisation in health systems illustrated using the mahau (front porch) of the wharenui (Māori meeting house) (figure created by MITA Creative Ltd).

The predominance of exploration and planning infers a disconnect between theory, being pluralistic but well established, and practice, which appears to be significantly limited. Given the study parameters of publicly funded health systems, this is not unexpected. The publicly funded health systems from the countries included (Australia, Canada, and NZ) operate under the direction and priorities of the government of the day. As such, misalignment between the values of the government and decolonial theory is a clear organizational barrier to implementing decolonial health care innovations.⁴³ In this context, decolonization as a framework for transformation in publicly funded sectors has been critiqued, specifically the focus on the colonizer and the faults of the colonized system,⁴⁴ which may lead to defensiveness and resistance. Alternative frameworks to transformation are proposed including equity-based, cultural safety, and indigenization approaches.

Equity-based approaches see achieving fair distribution of health outcomes as the objective and may position equity within social justice.⁴⁵ Although more visibly implemented, capacity to address inequities has been critiqued. Watego argues that equity approaches construct racial categories and see “Whiteness” as a measure of wellness, leading to deficit-based explanations for Indigenous peoples and other marginalized groups.⁴⁶ In addition, although an equity-based approach may consider social determinants of health, basic determinants, such as racism and colonization,^2,47 may go on unaddressed. Indeed, Reid proposes that equity is better viewed as the “yardstick with which Māori may assess governance,” as opposed to the framework for a transformative approach.⁴⁸

Cultural safety, pioneered by Māori nursing educator Irihapeti Ramsden, is grounded in critical theory and requires the unmasking of oppressive ideologies to address the colonial determinants of health inequities.⁴⁹ Curtis et al. identify that cultural safety:

Requires a critical consciousness where health care professionals engage in ongoing self-reflection and hold themselves accountable for culturally safe practice, as defined by patients and their communities, and as measured through progress toward achieving health equity.⁵⁰

Cultural safety, therefore, overlaps with decolonization in that it requires examination of power dynamics, privilege, biases, and structures that lead to health inequities by health practitioners and organizations.⁵¹ However, decolonization more explicitly centers liberation and structural and institutional transformation, creating distinct and significant points of difference. As such, cultural safety has been located within the broader decolonial project in medical education⁵² and as a component of Indigenous health equity guidance for medical practitioners,⁵³ yet, it is recognized that cultural safety in isolation is not the solution to health inequities for Indigenous peoples.⁵⁴

The relationship between indigenization, the normalization of Indigenous knowledge and approaches, and decolonization is a contentious space. Described as “two sides of the same general project,”⁴⁴ divergence is visible concerning the nature of the relationship. For example, indigenization is proposed to lead to decolonization,⁴⁴ decolonization is positioned within the Indigenous experience,⁵⁵ and decolonization viewed as making space for indigenization.¹⁰ This diversity in perspective suggests that in reality the relationship may be something more complex and circular rather than linear, with decolonization envisioning the rebuilding of nations and communities through “restorative indigenous ecologies.”⁵⁶

Decolonization is perhaps best positioned as a rights-based intersectional approach to health system transformation, recognizing that overlapping and relational processes create and maintain health inequities.⁵⁷ In this context, decolonization imagines a health system that can hold and house the values of Indigenous peoples. Such a transformation requires the transfer of power from colonial governments to Indigenous peoples, a distinction which separates decolonization from cultural safety²⁸ and other actions such as Indigenous inclusivity or replacing Indigenous people in positions previously held by non-Indigenous people.^13,44,58 Decolonization requires a fundamental shift in the ideas, knowledge, and values that underpin systems and institutions,⁵⁸ and heeding the warning from Tuck and Yang, must not be used as a metaphor for other social justice actions.⁵⁹

The clear positioning of this scoping review within an Indigenous methodology has centered self-determination and Indigenous rights, supporting findings of relevance to Indigenous peoples. The review was undertaken using rigorous methods and included a range of sources. Project scope introduced some necessary limitations. Restrictions on countries were included to support findings of relevance to the NZ context; hence, findings may be most relevant to those with comparable colonial histories and health systems to NZ. Literature type and language parameters were introduced to manage research scope, and we note that included texts were predominantly from peer-reviewed journal articles, and so, may not capture the true breadth of knowledge. We appreciate that, given the emergent nature of research, theses and dissertations may hold valuable insights. Although language restrictions resulted in the exclusion of only one text, we also recognize the potential for unique insights to be excluded. Importantly, the NZ-targeted gray literature search findings were consistent with those from peer-reviewed literature, suggesting consistency across sources. While non-government funded services were not explored in detail, an identified example was consistent with study findings.⁶⁰ Overall, themes and results are consistent with the theoretical base, providing valuable insight in the context of publicly funded health systems.

Significant research gaps identify future research opportunities and priorities. Program pilots and implementation are scarce and necessary to bridge the gap between theory and practice. Likewise, measurement and monitoring of outcomes are limited and needed to understand impact and support broader policy change to uphold Indigenous rights and the achievement of health equity and well-being.

Conclusions

This review provides a novel and relevant synthesis of what is known about decolonization, Indigenous health and equity in the context of publicly funded health systems. Decolonization is positioned as a rights-based intersectional approach to health system transformation that has unique differences when compared with alternative approaches to addressing health inequities such as equity-based approaches, cultural safety, and indigenization. Misalignment between ideological positionings of decolonial theory and governments is a barrier to overtly implementing decolonization approaches within publicly funded health systems. Understanding key characteristics of decolonization in the context of publicly funded health systems provides insights into approaches that uphold Indigenous rights and support Indigenous health and equity. The identified domains (addressing coloniality, transformation, relationships, and indigeneity) provide a preliminary framework to support aspirational health system change when it is not possible to explicitly identify decolonization as the theoretical foundation.

Authors’ Contributions

Conceptualization and methodology by K.W. Investigation by K.W. and N.T. Writing—original draft by K.W. and N.T. Writing—review and editing by K.W. and N.T. Supervision by K.W.

Footnotes

Acknowledgments

The authors acknowledge and appreciate the contributions of Professor Papaarangi Reid and our governance group, who provided guidance and direction to the broader research project. Ngā mihi nui ki a koutou, e ngā Rangatira.

Author Disclosure Statement

The authors declare that they have no competing interests.

Funding Information

This research was supported by funding from Waipapa Taumata Rau | University of Auckland.

Abbreviation Used

References

1. Anderson

, Robson

, Connolly

, et al. Indigenous and tribal peoples’ health (The Lancet-Lowitja Institute Global Collaboration): A population study. Lancet 2016;388(10040):131–157.

2. Reid

, Cormack

, Paine

S-J

. Colonial histories, racism and health—The experience of Māori and Indigenous peoples. Public Health 2019;172:119–124.

3. Quijano

. Coloniality and modernity/rationality. Cult Stud 2007;21(2–3):168–178.

4. Grosfoguel

. Decolonizing post-colonial studies and paradigms of political-economy: Transmodernity, decolonial thinking, and global coloniality. Transmodernity: journal of Peripheral Cultural Production of the Luso-Hispanic World 2011;1(1).

5. Jones

. Levels of racism: A theoretic framework and a gardener’s tale. Am J Public Health 2000;90(8):1212–1215.

6.Waitangi Tribunal. He Whakaputanga me Te Tiriti: The Declaration and the Treaty. In: Report on stage 1 of the Te Paparahi o Te Raki Inquiry (Wai 1040). Waitangi Tribunal: Wellington; 2014.

7.Institute for Clinical Systems Improvement. Going beyond clinical walls: Solving complex problems. Institute for Clinical Systems Improvement; 2014.

8.UNCHR & AFR. United Nations Declaration on the Rights of Indigenous Peoples 2013. Available from: https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html.

9.United Nations (General Assembly). International Covenant on Economic, Social and Cultural Rights. United Nations; 1966.

10.

10. Freire

. Pedagogy of the oppressed, 30th anniversary ed. The Continuum International Publishing group Inc; 2005.

11.

11. Waziyatawin

, Yellow Bird

. For Indigenous eyes only: A decolonization handbook. School of American Research: Santa Fe. 2005.

12.

12. Smith

. Beyond political literacy: From conscientisation to transformative praxis. Counterpoints 2005;275:29–42.

13.

13. Laenui

. Processes of decolonization. In: Reclaiming Indigenous voice and vision. University of British Columbia Press; 2000; pp. 150–160.

14.

14. Fairchild

. Frantz Fanon’s The Wretched of the Earth in contemporary perspective. J Black Stud 1994;25(2):191–199.

15.

15. Smith

. Decolonizing methodologies: Research and indigenous peoples. Zed Books Ltd; 2013.

16.

16. Smith

. Kaupapa Maori principles and practices: a literature review. International Research Institute for Maori and Indigenous Education; 2000.

17.

17. Mahuika

. Kaupapa Māori theory is critical and anti-colonial. MAI Review 2008;3(4):1–16.

18.

18. Arksey

, O’Malley

. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol 2005;8(1):19–32.

19.

19. Munn

, Peters

, Stern

, et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018;18(1):143–147.

20.

20.Asia Pacific Forum and the Office of the United Nations High Commissioner for Human Rights. The United Nations Declaration on the Rights of Indigenous Peoples: A Manual for National Human Rights Institutions. Asia Pacific Forum and the Office of the United Nations High Commissioner for Human Rights: Geneva; 2013.

21.

21.World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. WHO: Geneva; 2007.

22.

22. Lang

. ‘Decolonialism’and the counselling profession: The Aotearoa/New Zealand experience. Int J Adv Counselling 2005;27(4):557–572.

23.

23. Pyett

, Waples-Crowe

, Van der Sterren

. Challenging our own practices in Indigenous health promotion and research. Health Promot J Austr 2008;19(3):179–183.

24.

24. Dudgeon

, Walker

. Decolonising Australian psychology: Discourses, strategies, and practice. J Soc Polit Psych 2015;3(1):276–297.

25.

25. Berghan

, Came

, Coupe

, et al. Te Tiriti o Waitangi-based practice in health promotion. STIR: Stop Institutional Racism: Auckland, New Zealand; 2017.

26.

26. Jones

. Climate change and Indigenous health promotion. Glob Health Promot 2019;26(3_suppl):73–81.

27.

27. Lawson-Te Aho

, Fariu-Ariki

, Ombler

, et al. A principles framework for taking action on Māori/Indigenous Homelessness in Aotearoa/New Zealand. SSM Popul Health 2019;8:100450.

28.

28. McGibbon

. Truth and reconciliation: Healthcare organizational leadership. In: Healthcare management forum. Sage: Los Angeles, CA; 2019.

29.

29. Came

, Warbrick

, McCreanor

, et al. From gorse to ngahere: An emerging allegory for decolonising the New Zealand health system. New Zealand Medical Journal 2020;133(1524):102–110.

30.

30. Cullen

, Mackean

, Worner

, et al. Trauma and violence informed care through decolonising interagency partnerships: A complexity case study of Waminda’s model of systemic decolonisation. Int J Environ Res Public Health 2020;17(20):7363.

31.

31. Gibson

. When the river runs dry: Leadership, decolonisation and healing in occupational therapy. New Zealand Journal of Occupational Therapy 2020;67(1):11–20.

32.

32. Pihama

, Smith

, Cameron

, et al. He Oranga Ngākau. Te Kotahi Research Institute; 2020.

33.

33. Came

, Baker

, McCreanor

. Addressing structural racism through constitutional transformation and decolonization: Insights for the New Zealand health sector. J Bioeth Inq 2021;18(1):59–70.

34.

34. Castle

. Practice learnings from the Psychologist Integration into Primary Health Care Pilot Program on the Tiwi Islands, Northern territory. Aust Psychol 2021;56(2):137–141.

35.

35. Eni

, Phillips-Beck

, Achan

, et al. Decolonizing health in Canada: A Manitoba first nation perspective. Int J Equity Health 2021;20(1):206–212.

36.

36. Hunter

, Pride

. Critiquing the Canadian model of client-centered enablement (CMCE) for indigenous contexts. Can J Occup Ther 2021;88(4):329–339.

37.

37. Narasimhan

, Chandanabhumma

. A scoping review of decolonization in Indigenous-focused health education and behavior research. Health Educ Behav 2021;48(3):306–319.

38.

38. Whitehead

. The concepts and principles of equity and health. Health Promot Int 1991;6(3):217–228.

39.

39. McIntosh

. White privilege: Unpacking the invisible knapsack. 1990. Available from: https://admin.artsci.washington.edu/sites/adming/files/unpacking-invisible-knapsack.pdf.

40.

40. Paradies

. Defining, conceptualizing and characterizing racism in health research. Crit Public Health 2006;16(2):143–157.

41.

41. Burke

. Frantz Fanon’s” The Wretched of the Earth. Daedalus 1976:127–135.

42.

42. Rochford

. Whare Tapa Wha: A Mäori model of a unified theory of health. The Journal of Primary Prevention 2004;25(1):41–57.

43.

43. Parmar

, Sacrey

, Anderson

, et al. Facilitators, barriers and considerations for the implementation of healthcare innovation: A qualitative rapid systematic review. Health Soc Care Community 2022;30(3):856–868.

44.

44. Hoskins

, Jones

. Indigenous Inclusion and Indigenising the University. New Zealand Journal of Educational Studies 2022;57(2):305–320.

45.

45. Peter

. Health equity and social justice. J Appl Philos 2001;18(2):159–170.

46.

46. Watego

. Sovereign subjects, not equity projects. In: 3rd International Indigenous Health and Wellbeing Conference. Lowitja Institute: Cairns, Australia; 2023.

47.

47. Curtis

, Jones

, Willing

, et al. Indigenous adaptation of a model for understanding the determinants of ethnic health inequities. Discov Soc Sci Health 2023;3(1):10.

48.

48. Reid

. Good governance: the case of health equity. In: Always speaking: The Treaty of Waitangi public policy. ( Tawhai

, Gray-Sharp

., eds.) Huia Publishers; 2011.

49.

49. Ramsden

. Cultural safety and nursing education in Aotearoa and Te Waipounamu. Victoria University of Wellington: Wellington; 2002.

50.

50. Curtis

, Loring

, Jones

, et al. Refining the definitions of cultural safety, cultural competency and Indigenous health: Lessons from Aotearoa New Zealand. Int J Equity Health 2025;24(1):130.

51.

51. Gopal

, Douglass

, Wong

, et al. Reflexivity, Cultural Safety, and improving the health of racially minoritised communities. Lancet 2022;399(10335):1581–1582.

52.

52. Wong

, Gishen

, Lokugamage

. ‘Decolonising the Medical Curriculum‘: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. London Review of Education 2021;19(1).

53.

53.Medical Council of New Zealand. He Ara Hauora Māori: A Pathway to Māori Health Equity. Medical Council of New Zealand; 2019.

54.

54.Council of Medical Colleges, Te ORA. Cultural Safety Training Plan for Vocational Medicine in Aotearoa. Council of Medical Colleges, Te ORA; 2023.

55.

55. Hindmarch

, Hillier

. Reimagining global health: From decolonisation to indigenization. Glob Public Health 2023;18(1):2092183.

56.

56. Denzin

, Lincoln

, Smith

. Introduction: Critical methodologies and indigenous inquiry. In: Handbook of critical and indigenous methodologies. Sage; 2008:1–20.

57.

57. Shannon

, Morgan

, Zeinali

, et al. Intersectional insights into racism and health: Not just a question of identity. Lancet 2022;400(10368):2125–2136.

58.

Mercier

Chapter 2: What is decolonisation? In: Imagining Decolonisation. ( Elkington

, Jackson

, Kiddle

, et al. eds.) Bridget Williams Books: Wellington; 2020, pp. 40–82.

59.

59. Tuck

, Yang

. Decolonization is not a metaphor. Tabula Rasa 2021(38):61–111.

60.

60. Mundel

, Chapman

. A decolonizing approach to health promotion in Canada: The case of the Urban Aboriginal Community Kitchen Garden Project. Health Promot Int 2010;25(2):166–173.