Ngā Pou o Ngārongo. Beyond Symbolic Inclusion: Power, Tokenism, and Indigenous Health Policy Across Four Settler States

Indigenous health inequities remain entrenched across the United States, Canada, Australia, and Aotearoa New Zealand despite decades of reform framed as partnership, participation, and equity. This thesis argues that the persistence of these inequities reflects not a lack of policy activity, but a recurring governance pattern in which Indigenous inclusion is made visible while substantive authority remains elsewhere. Across settler-colonial health systems, Indigenous peoples have recently been invited into consultation, advisory, and co-design processes, yet decision rights, resource control, accountability, and institutional durability remain largely retained by the state. This thesis conceptualises that pattern as tokenism: inclusion without sufficient power to shape policy design, implementation, or accountability in ways that materially alter outcomes. Using a comparative, document-based case study design, this thesis examines selected Indigenous health policy episodes across four settler states. It develops and applies a ten-domain Tokenism-to-Power rubric to assess the extent to which policy arrangements move beyond symbolic participation towards substantive authority. The analysis draws on legislation, policy and budget documents, audit and inquiry reports, Indigenous-authored scholarship, and equity relevant indicators, including measures related to primary care access and avoidable harm. The findings show that tokenism is systematically reproduced through policy architectures that signal recognition while preserving central control. Across cases, this occurs through advisory participation without mandate, equity commitments without protected resourcing, monitoring without enforceable consequences, and reforms vulnerable to political or administrative reversal. In contrast, the strongest departures from tokenism occur where Indigenous communities exercise meaningful authority through service ownership, commissioning influence, Indigenous-defined priorities, control over evaluation, and community-accountable governance. These findings are synthesised into Ngā Pou o Ngārongo, a kaupapa Māori anti-tokenism framework identifying the structural conditions required for meaningful authority-sharing: defined decision rights, protected and needs-based resourcing, Indigenous authority over priorities and evaluation, investment in Indigenous capability, and institutional durability beyond political and funding cycles. The central contribution of this thesis is to shift the focus of Indigenous health reform from participation as presence to power as institutional reality. It argues that improving the trajectory of Indigenous health requires more than inclusion within existing systems. It requires Indigenous communities to be equipped with the authority, resources, capability, infrastructure, and institutional protections necessary to determine and sustain responses to their own priorities. The central contribution of this thesis is to shift the debate from participation as presence to power as institutional reality. Meaningful reform is measured not by inclusion, but by whether it leaves Indigenous communities stronger, better resourced, and more able to exercise rangatiratanga over the conditions that influence and improve their health.