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- Introduction
- Producing Health or Health Care?
- Major Influences on the Future Health and Disability Sector
- Outcomes and Goals That Will Contribute to Health and Independence in 2010
- Conclusion
- References
Introduction
This paper discusses trends that are expected to impact on the health and disability sector in New Zealand. It is intended to stimulate debate between end-users and researchers about investment in health research that will meet the future knowledge needs of the health sector.
The Ministry of Health was one of many health sector organisations and groups that participated in the Ministry of Research, Science and Technology’s (MoRST) Foresight Project. This project uses future-based scenarios to aid thinking about future knowledge needs and knowledge goals for New Zealand.
Foresight is a process for discovering a route to a desirable future. It involves imagining a desirable future and developing strategies for creating that future. The Foresight process deliberately focusses on the long term future. It establishes a coherent picture of trends, drivers and uncertainties, and helps to bring into focus a desirable position within that future.
The Foresight project has two aims:
1. Overarching
To provide leadership for New Zealanders in developing a more comprehensive understanding of the future bases of our social, economic and environmental well-being.
2. Specific
To assist the Government in deciding on priorities for future investment in research, science and technology (RS&T).
This paper covers some of the points made in a submission to MoRST prepared by the Ministry of Health and the Health Research Council (HRC) 1 . The submission was developed following contributions from a large number of people both within and beyond the health sector.
The deadline for submitting sector Foresight submissions to MoRST was 31 October 1998. MoRST asked sectors to describe a vision for their sector, outline key outcomes for achieving that vision and determine what new knowledge would be needed to achieve the vision (MoRST 1998). In November 1998, MoRST hosted a conference to determine the final knowledge outcomes to guide the purchase of RS&T. By March 1999, MoRST will provide Government with final advice on the set of proposed knowledge outcomes in RS&T. On 1 July 2000 investment decisions based on those knowledge outcomes will start to take effect.
Producing Health or Health Care?
The ultimate goal of health and disability services is to improve health and independence of the community. A central issue in the health sector is the extent to which the health sector is producing health or health care.
The activity of the health sector is largely related to ‘curing’ and ‘caring’. Health care makes a vital but relatively minor contribution to overall health outcomes and is often seen as an end in itself. However, health care does improve quality of life and is desirable for this reason alone. Health care consumes considerable resources – seven percent of New Zealand’s GDP (Ministry of Health, 1998). The US spends 14 percent of GDP and scores similarly, or worse, on key health status indicators. More investment in health care does not necessarily lead to better health.
The tremendous achievements of scientific modes of inquiry in the 20th century have seen the health sector become the main repository of knowledge relating to improvement in health status. As a result, there is a growing gap between our understanding of the determinants of health and the current primary focus of health policy on improving health care services 2 .
Government has an interest in improving, promoting and protecting the health and independence of the population rather than merely funding a system to deliver health and disability support services. Therefore, it is necessary to rethink approaches to investigation and generation of new knowledge about the links between the determinants of health and health outcomes and how existing knowledge can be applied in new and innovative ways. It follows, then, that investment in health research must contribute to health outcomes.
The Foresight framework focussed primarily on ensuring that RS&T investment contributes to economic outcomes. Within this framework, health care and having a healthy population does contribute to economic outcomes. It is important, however, to ensure that within RS&T investment there is also a health outcomes focus to complement the economic focus.
Major Influences on the Future Health and Disability Sector
The drivers that will have the most impact on shaping the health and disability sector are not unique to New Zealand, but operate in most OECD countries. As Krieble and Middleton 3 outlined in Health Futures: 2020 Visions (1997) the main drivers or pressures for change are:
- demographic and social trends
- information and technology
- public expectation and consumer demand
- affordability and rationing
- epidemiological trends
- research and development.
The first three will have a major influence on the health sector of the future. Elements of these trends are discussed in further detail below.
Major population changes since the end of last century continue
Specifically, New Zealand has:
- an ageing population, although younger elderly still predominate
- population peristalsis (“baby blip” around 1990, blip echo effects around 2015)
- geographical redistribution (Auckland growth, urban overspill, sunbelt migration, “drift north” slowing or stopped)
- ethnic changes with an increasing proportion of Maori and Pacific Islands populations and changing dependency ratios (Maori and Pacific Islands populations are growing at a faster rate) 4
- changes in family dynamics, for example, one-parent households.
A number of implications for research investment arise from these factors, for example, Maori and Pacific Islands populations’ health will be a priority and is only likely to be undertaken in New Zealand.
The proportion of people with disabilities continues to grow
This is partly as a result of the improved life expectancy of people with disabilities. Currently, disability research receives a very small percentage of health research funding, but disability services account for 25 percent of Vote:Health expenditure. An increase in the level of investment in disability research can therefore be expected.
The benefit of technological advances will be immense.
Pharmaceuticals, immunology, equipment, techniques, information technology, telemedicine, human genetics, biotechnology and robotics will have an impact on the health of New Zealanders. Ensuring that the overall benefits and impact of the technology are clear will require a robust technology assessment framework and careful attention to equity and ethical considerations.
In future, health research experience and an understanding of ethics must be applied to ensure that the impact of technology used by the health sector is well understood.
Access to health information from the Internet and greater awareness of individual rights will mean better informed and aware people.
People will increasingly expect that services will reflect the diversity of their communities and will involve them in decisions about their own care and treatment. They will look for information that will help them evaluate options and better manage their own health. They will, therefore, interested in participating in decisions about what services will be publicly funded.
There will be a constant tension between meeting people’s expectations regarding the services provided by the health and disability sector and the level of public funding available.
The increasing demand for health care comes from changes in the distribution and nature of disease, demography and social patterns and, most importantly, increases in new technology and consumer expectations. The mix of funding available for health care will change over time, with more collaboration and joint ventures likely between public and private investors.
Health services research will play an important role in addressing issues related to access to health care, the type and mix of services and meeting consumer demands.
New patterns of disease and changing patterns of existing diseases continue to shape the health sector.
Particularly important is the incidence of: some infectious diseases as a result of emergence/re-emergence, antibiotic resistance and low socio-economic status, for example tuberculosis and HIV/AIDS; ageing-related neurodegenerative and musculoskeletal diseases; growing numbers of disabled people with high needs because of better survival rates (which may be offset by lower incidence and slower progression of these conditions); mental illness; diabetes; and some cancers.
The burden of preventable disease from the 20th century continues to impact on health services.
The leading causes of death and disability in New Zealand in 2020 are expected to be much as they are now. Thus, stroke and heart disease are predicted to be among the leading cause of death and disability. 5
This view is supported by Murray and Lopez 6 in their work for the World Health Organisation. The diagram below shows that the top 10 causes of years of life lost to some degree of disability (disability life adjusted year or “DALY”) will remain about the same for the next 20 years.
(Murray and Lopez 1996 6 )
These ranked diseases or injuries are, in the majority of cases, influenced by lifestyle factors. Therefore, we can expect research portfolios of the future to include a range of research ranging from biomedical through to social science research.
The effects of increasing globalisation – travel, trade, technology, communication – will be both positive and negative.
The positive aspects will include innovations such as international telemedicine. The negative impacts may include antibiotic resistance and the safety and integrity of the food supply and confidence in the food supply, because of the possible influence of the state of the environment and genetic engineering on food.
Assessing the impact and possible effects of globalisation will require collaborative research efforts between health and other sectors.
Collaboration across sectors will contribute to health outcomes.
Improvements in health care will come from advances in technology and an increased understanding on the part of those working in the health sector about the needs and expectations of those using the services.
The health and disability sector’s key alliances for achieving improved health outcomes will be with education, environment, welfare, labour, justice, housing, food, information technology, social sciences, biotechnology, Maori communities and Pacific Islands people. Having clear ethical frameworks and a strong cultural context will help with setting priorities.
Links to other sectors, including the RS&T sector, will be key to achieving success.
For example, in the areas of social and economic determinants, biotechnology, food and nutrition and Maori development.
Outcomes and Goals That Will Contribute to Health and Independence in 2010
The success of New Zealand’s health and disability sector will depend on its ability to respond to pressures for change and on how well it responds to opportunities to deliver services in new ways.
The key objective is an improvement in the health, well-being and independence of New Zealanders. The goals generated through Foresight to achieve that objective are:
Goal 1: Healthy and independent individuals and populations
Prevention of death, disease and disability; effective promotion, protection, restoration and maintenance of New Zealanders’ health and independence.
Goal 2: Effective health care
Effective delivery of health care and technology assessment based on rigorous, culturally safe and ethical research.
Goal 3: Equitable health outcomes
Contributing to well-being, equity and inclusiveness for all New Zealanders, with a particular focus on vulnerable populations.
Goal 4: Maori development
Recognising the value of building on existing support and momentum of Maori to address Maori health concerns as expressed by Maori.
Goal 5: Intersectoral action goal
Strong collaboration within and across sectors and communities, and between health funders, health providers, policy-makers and researchers to address the social, cultural and economic determinants of health and well-being.
Goal 6: Health’s contribution to society and economy
To recognise people’s health as critical to future social and economic prosperity.
Goal 7: Healthy environments
Enhancing and protecting New Zealand’s environment and natural resources and creating communities and workplaces which enhance health and independence.
Goal 8: Innovation and technology
Development and application of new technologies relevant to health, within appropriate ethical and regulatory frameworks.
Strong co-operative efforts and intersectoral collaboration will be needed to underpin the achievement of these goals. The first three goals – healthy and independent people, effective health care and equitable health outcomes – cover the areas traditionally seen as the responsibility of the health sector. Nonetheless, their achievement will also require strong convergence between health and other sectors.
Conclusion
Successful change requires sustainability, flexibility, responsiveness and innovation. Sharing knowledge and skills both within the health and disability sector and across sectors will be key to ensuring that successful change takes place.
The individuals and organisations in the health and disability sector will have to understand the role they play in contributing to the improved health, wellness and independence of New Zealanders. Even more importantly, they will have to know more than at present about all the other factors outside the health sector which also contribute to health gain. With an increasing understanding of their role, and of that of other sectors which improve health and independence, comes a responsibility to contribute to decisions about what research would be beneficial.
Within the health sector the following features are expected:
These features are likely because of an increasing need to ensure that investment in health care is well utilised, particularly in response to new technologies and consumer demand for treatment and care that reflects best practice. The health and disability sector must take the leading role in ensuring that other sectors which influence health gain understand the ways in which, together, the sectors can work to improve health. Therefore, expect more collaboration, co-ordination and innovation across sectors. And hopefully as a result, health gain. References Further Reading
There must be ongoing debate across the health sector about how to achieve the eight Foresight goals outlined above. The balance between the resources allocated to health services and specific items of technology or pharmaceuticals and those allocated to public health or Maori development initiatives, for example. There will be more pressure to ensure the services and treatment offered by health providers do offer tangible benefits to patients.
The relationship between researchers and end-users of the research must be strong to ensure that the research being undertaken can be applied and that the strategies used to disseminate the results of the research are effective. In particular, there must be dialogue to determine:
