… the exercise of guardianship by the tangata whenua of an area in accordance with tikanga Māori in relation to natural and physical resources, and include the ethic of stewardship (section 2 RMA)

A web of obligations: to the taonga, to the atua and to ourselves and our uri. Kaitiaki have a responsibility to provide for everyone and ensure everyone benefits Independent of ‘ownership’ in a European sense. As on land, kaitiaki responsibilities are independent of other who hold ‘ownership’ or use rights under the la. For example, although as kaitiaki, iwi/hapū may ‘own’ only a percentage of the total marine farming space in a region under existing law, they still hold kaitiaki responsibilities over the whole area in accordance with tikanga

Enabled through rangatiratanga, which includes the authority that is needed to control access to and use of resources, and to determine how the benefits will be shared. This means that it can be expressed in part through the concepts of ‘ownership’, ‘property’, ‘title’ or ‘stewardship’ – however it is much wider than any of these.

It incorporates a nexus of beliefs that permeates the spiritual, environmental and human spheres: rangatiratanga, mana whenua ‘customary authority over, and of, land’, tapu, rahui, hihiri and mauri ‘life principle’ (Marsden and Henare 1992). Kaitiakitanga also embraces social protocols associated with hospitality, reciprocity and obligation (manaaki, tuku and utu). These beliefs are moulded with, and by, each generation for they have an important role in maintaining the social fabric of the kin group. Moreover, kaitiakitanga is a fundamental means by which survival is ensured—survival in spiritual, economic and political terms. Since Maori society is a tribal society with respect to relationships with environmental resources, their actual management is itself a constituent element in the tribal kinship system.

kaitiakitanga is equally about the past and managing sets of relationships that transcend time and space: between atua ‘gods, spiritual beings’ and ancestors on one hand, and their living kaitiaki on the other.

As a tool, kaitiakitanga is used by Maori to promote their unique status as tangata whenua, while also affirming certain rights guaranteed by Article Two of the 1840 Treaty of Waitangi.

Such trends seemed indicative of the increasing costs of care and the impacts of restructuring then being felt in the wider economy.

The introduction of the Community Service Card (CSC) in 1992 had the potential to increase access by targeting increased levels of benefits according to income. However, the research from the 1990s indicates that the positive impacts of the introduction of the CSC were less than expected (Davis et al. 1994). Barnett and Kearns (1996), for example, in a study of the utilisation of two Auckland accident and medical centres, found that almost one-third of their respondents visited GPs less often than in previous years. This reduced use was largely attributed to changed financial circumstances arising from the effects of economic and welfare restructuring. Most of those reporting financial difficulties were of Māori or Pacific Island origin and 60% of this group, compared with only 24% of Pakeha respondents, mentioned that their changed economic circumstances had restricted their GP visits.

Economic Barriers to Primary Health Care in New Zealand

Much attention in New Zealand has been focused on integrated care within primary care services (‘horizontal’ integration); and between primary and secondary care services (‘vertical’ integration); public health and curative services; health and support services (e.g. personal support services for people with disabilities or for older people); and health and social welfare services (e.g. welfare, housing, and employment services) (‘inter-sectoral’ integration).

Third, a lack of information sharing and liaison between providers were seen to result in poorly co-ordinated care: service users could slip through gaps in the system or be seen by multiple providers for the same condition, information might not be shared or could go missing, tests might be duplicated, harm could occur from the use of incompatible medications, and service users might receive different health advice from different health providers [3, 4, 6, 16, 17]. The overall impacts of these arrangements were seen to be poor quality of care and a waste of scarce health resources.

An integrated system would rely on: collaboration across services; a focus on health promotion and prevention of disease, avoidable complications, and disability; consumer support services for people managing their own health; effective information and management systems; a focus on evidence-based practice; partnerships between service users and professionals; and achieving improved health and cost-effective service delivery

in the upper left is the world of community, formally represented by the trustees of the hospital, informally by those people who volunteer their efforts to it. They are neither directly connected to the hospital's operation nor personally beholden to its hierarchy—they, in other words, are both up and out.

Persistent challenges to a robust, responsive health care and public health system in the United States include health disparities, access to care, quality of care, and health care costs.

Unfortunately, CHWs have yet to be fully integrated into the US health care system and face many workforce challenges. This lack of integration prevents CHWs from realizing their maximum effectiveness to improve the health of individuals, families, and communities. Additional barriers that CHWs face are lack of sustainable funding for their work and lack of a standard core curriculum for professional training and certification.

Community health officer are the most promising form of delivering health services to resource-constrained areas. They are seen as secondary health services in most low-income countries are available as a service to the community.