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Public Health Policy Framework in New Zealand

Thursday, July 1st, 1999
Dr Gillian Durham, Director of Public Health and Deputy Director-General, Safety and Regulation, Ministry of Health, New Zealand



Introduction

Public health is defined in New Zealand legislation  1   as the health of all of the people of New Zealand or a community or section of such people. Public health strategies incorporate health promotion, health protection and disease prevention. In the 1990s, successive New Zealand ministers of health have emphasised the importance of public health,  2   improvements in health status,  3   achieving action on health and independence,  4   and a greater emphasis on population health approaches.  5   How has this political commitment been translated into a policy framework for public health? What factors have contributed to or detracted from effective implementation of the framework? How does New Zealand’s public health policy framework compare with that of other jurisdictions, such as Australia? What lessons can be learnt for future directions?




Health Status in New Zealand

Trends in Health Status
Progress on a range of health status indicators has been mixed.  6   Over the last five years for which data are available, a number of indicators show progress to improved health. Health indicators have shown improvement in areas such as oral health, sudden infant death syndrome, drownings, child abuse, road traffic injuries, HIV/AIDS, alcohol related health outcomes, ischaemic heart disease and cervical cancer. Progress towards reduction in the prevalence of tobacco smoking in the adult population has not changed greatly between 1994 and 1998, declining from a prevalence of 27 percent to 25 percent.  7   Rates of breast-feeding, sexually transmitted diseases and alcohol consumption are static.  6   Indicators for rheumatic fever, diabetes, youth suicide  6   and use of cannabis and other illicit drugs  8   are showing a deterioration in health. Of particular concern is the increase in obesity from 11 percent to 17 percent of the population between 1989 and 1997. In 1997, an additional 35 percent of the population were considered overweight.  9   It is thus not surprising, given the wealth of evidence that indicates that obesity is a risk factor for diabetes,  10   that diabetes is an increasing health problem in New Zealand with 3.7% reporting that they had been diagnosed with this disease in the 1996/97 New Zealand Health Survey compared with 2 percent in the 1992/93 Health Survey.  11  

Inequalities in Health
Inequalities in health status between those in lower socioeconomic groups and those higher up the socioeconomic scale, are a feature of many contemporary societies. New Zealand is no exception. In the 1996/97 New Zealand Health Survey, people in lower socioeconomic groups were more likely to be smokers, to have high blood pressure, and to have been diagnosed with diabetes  11   There are also inequalities in health status between Mäori and non-Mäori,  6   and between Pacific Island people and the general population.  12   In 1996, life expectancy of Mäori at birth was approximately eight years less than non-Mäori, for both males and females.  13   Given the increased risk of sickness, hospitalisation and death amongst children from relatively disadvantaged communities and households, the increase in income disparity in New Zealand families with children between 1981 and 1991 is of particular concern.  14   In 1996, 23 percent of children aged 0–14 years did not have a parent participating in the labour force, and 23 percent of children lived in one-parent families.

In the 1997 National Nutrition Survey, 13 percent of New Zealanders reported that their household ‘can afford to eat properly’ only sometimes. Fourteen percent reported that in their household ‘food runs out due to lack of money’ ‘sometimes’ (12 percent) or ‘often’ (2 percent). A similar percentage ‘sometimes’ or ‘often’ ‘eat less because of lack of money’ and were ‘stressed because of not having enough money for food’. Seven percent of the population reported that their households ‘sometimes’ or often ‘rely on others for food, and/or money for food’, and the households of four percent of the population ‘sometimes’ used foodbanks or grants in the previous year. These problems with food security were most marked for young women, Mäori and Pacific Island people in the lowest socioeconomic quartile.  9  

International Comparisons
New Zealanders’ life expectancy and the mortality rate for those under 5 years old (UFMR) have slipped relative to other OECD countries. Between 1960 and 1995, New Zealand’s ranking for life expectancy has dropped from 8th out of 27 countries to 19th out of 28 countries for females and from 6th to 13th for males. For UFMR in the same time period, the slippage in OECD ranking has been from 6th to 15th.  13  

These trends in some health status measures, health inequalities, and international comparisons show action is required over the state of the public health in New Zealand and fully justify the political commitment of health ministers over the past decade, as previously discussed.  2  ,   3  ,   4  ,   5  




Policy Framework for Public Health

In the last decade, New Zealand has taken a strategic approach to public health. The initial approach was prioritised around 10 health goals.  15   These goals dealt with risk factors (tobacco smoking, alcohol misuse, nutrition and high blood pressure), diseases (ischaemic heart disease, stroke, cervical cancer, and melanoma) and unintentional injuries.

In 1994, after a review of the health of the nation  16   and widespread consultation, the Public Health Commission released A Strategic Direction to Improve and Protect the Public Health.  17   The strategy was set at three levels of detail: goals, objectives and targets. In 1997, the strategic direction was reviewed following consultation, as was the stated intent in the recommendations of the 1994 Strategic Direction.  17   Minor adjustments were made to the goals, objectives and targets, but these were set within the context of a vision of where New Zealand is trying to go and of values to guide the process. Four cross-cutting themes for strengthening public health action were identified: focussing on the determinants of health; building strategic alliances; implementing comprehensive programmes; and strengthening the public health infrastructure. A set of criteria was also developed for prioritising the goals, objectives and targets for whatever unit of activity was relevant for those applying the criteria – for example, within regions, providers, or local communities.  18  ,   19  These criteria include current and future health impact, effectiveness of available interventions, potential to reduce inequalities in health status, value for money, sustainability and public and intersectoral support.

Seven public health goals are supported by 41 objectives and 100 targets. The goals are general aims for which to strive, and include:

  • to ensure a social and physical environment which improves, promotes and protects public health and whänau public health
  • to improve, promote and protect Mäori health status so that in the future Mäori will have the opportunity to enjoy at least the same level of health as non-Mäori
  • to improve, promote and protect the health of Pacific Island people
  • to improve, promote and protect the health of children/tamariki
  • to improve, promote and protect the health of young people/rangatahi
  • to improve, promote and protect the health of adults/pakeke/matua
  • to improve, promote and protect the health of older people/kaumätua.

The objectives are the end results a programme seeks to achieve. They relate to environmental determinants, behavioural risk or protective factors, or specific diseases or injuries. They were selected according to the criteria for prioritisation described above.

Since the Public Health Commission first released its Strategic Direction, 31 issue-based policy advice papers have been prepared, each covering one or more of the objectives.  20   Each paper reviews the issues related to the objective, the policy, programme, research and information strategies required to achieve the objective, and sets outcome targets as milestones along the way. Widespread consultation has been undertaken in the development of each of the papers.

The analysis in the papers has contributed to the development of specific strategies, such as the National Immunisation Strategy,  21   the National Drug Policy,  22   and Strategies for the Prevention and Control of Diabetes in New Zealand.  10   The programmes have guided the purchasing by the Public Health Commission, the regional health authorities, and more recently the Health Funding Authority. Examples include the establishment of community injury prevention pilots, a destigmatisation programme to address negative community attitudes to mental illness, and community nutrition pilot programmes. The information issues have been addressed through a periodic survey programme. Examples of surveys that are part of this programme include the New Zealand Health Survey,  11   the National Nutrition Survey  9  , the National Survey on Drugs in New Zealand,  23   and anonymous, unlinked seroprevalence surveys of sentinel populations (ie, specific populations in which relatively high disease rates may precede the occurrence of higher rates in the general population) for HIV prevalence.  6  

The 100 targets for the 41 objectives and seven goals have been set following analysis of historical baseline and trend data and of the likely impact of existing, augmented and new public health programmes. The targets are aspirational and are not part of the accountability arrangements in the health sector. One reason for this is that many sectors contribute to achievement of the targets. The intersectoral nature of public health has been recognised particularly in the implementation of the National Drug Policy  22   and the National Youth Suicide Prevention Strategy.  24   The implementation of each of these strategies is led by a Ministerial Committee, chaired by the Minister of Health and including ministers from the relevant portfolios (eg, for the National Drug Policy, Corrections, Customs, Justice, Police, Mäori Affairs, Youth Affairs, Transport and Education). The two Ministerial Committees are each supported by an officials group (one for the National Drug Policy and one for the National Youth Suicide Prevention Strategy), again each chaired by an official from the Ministry of Health, but with representatives of all relevant departments.

Expert judgement and widespread consultation have been used to set the targets at an achievable, but challenging level. Progress against the targets is reported on annually.  6   The annual reporting function is a statutory responsibility (under a 1995 amendment to the Health Act 1956) placed on the Director-General of Health who is required to table his or her report in parliament.

Nationwide health goals and targets have the potential to influence national health policy, resource allocation, and re-orientation of the health sector to achieve population health outcomes.  25   If they are set at an overly ambitious level, there is the risk that the health sector will be set up for failure, and this can be associated with a loss of morale and withdrawal of effort.  19   There can be a number of reasons for not achieving targets. The targets may have been set at the wrong level in the first place, in terms of magnitude of change expected and timescale. This may have been because of insufficient historical trend data, or inadequate analysis of the effectiveness of existing and/or new programmes. Public health programmes may have been inadequately implemented, or may have been displaced by emerging issues considered to have a higher priority. Factors outside the health sector may have had a greater influence than anticipated, such as macroeconomic performance.  6   For these reasons, the annual review of progress includes an assessment of whether there is any justification for revising the target.

A key feature of the New Zealand public health framework is its inclusiveness at the national level. The framework is supported by a set of criteria that each stakeholder can use to set priorities within the overarching national framework but which are appropriate to the needs of local communities, the available resources, and the context within which they work.  19   The New Zealand approach has empirical support from the evaluation of the UK Health of the Nation policy.  26   This evaluation recommended as one of many pointers for a new public health strategy, a requirement for the development of local strategies and targets. Unfortunately, there is little information that suggests that New Zealand stakeholders have taken this opportunity to set targets for their work within the enabling public health framework.




Implementation of the Public Health Policy Framework

Factors Contributing to the Implementation of the Framework
Implementation of the framework has been facilitated by a well-developed commitment to focus on the determinants of health, established co-operative working relationships, and a history of comprehensive programmes. The Government’s Strengthening Families strategy builds on these strengths and aims to improve the life outcomes of children in families with multiple social and economic disadvantages by improving services through effective interagency collaboration between health, education and social welfare at all levels, together with prototype intensive home visiting programmes.  27   Further information on this strategy can be found at http://www.strengtheningfamilies.govt.nz. The implementation of the National Drug Policy  22   and the National Youth Suicide Prevention Strategy  24   are further examples of programmes that focus on the determinants of health, build strategic alliances and seek to implement comprehensive programmes. One of the best examples of implementation of the framework through a comprehensive programme is New Zealand’s tobacco control programme, consisting of legislation, taxation, education and smoking cessation services.  28   As a result of this programme, smoking prevalence in adults (aged 15+ years) in New Zealand has declined by almost one-third between 1976 and 1998.

There has also been an emphasis on building the evidence base for the public health function through the 31 issue-based policy advice papers, the national strategies, and the dissemination of the evidence through guidelines to public health professionals and services.  20   The public health legislative framework has been reviewed,  29   and efforts have been made to improve public health information and research.  6  ,   9  ,   11  In the last four years, public health funding has grown and kept pace with the rest of Vote Health.  30   This recent growth in funding contrasts with reductions in public health funding under area health boards in the early nineties, and slower rates of growth compared with the rest of the Vote during the years that the Public Health Commission was in place (1993–1995). Funding for public health still only amounts to less than 2 percent of the Vote. The funding is ring fenced but there is risk of seepage out of the ring fence within providers whose funding comes from within more than one ring fence.  30  

Factors Detracting from Implementation of the Framework
Despite recognition that a crucial ingredient for effective public health is a well-trained workforce,  19   less effort has been focussed on developing the workforce in a systematic way. Ad hoc training has been provided in response to perceived gaps or to improve response to emerging issues. One of the reasons for the lack of a systematic approach to workforce development has been uncertainty about the competencies required for the future as a result of review of the public health legislation. In addition, the health sector does not have a common view of the varying responsibilities of the Ministry of Health, the Health Funding Authority and of providers in relation to workforce development.

The public health framework has had little influence on the personal health sector. This lack of influence is demonstrated by the probable decline in immunisation rates recently, despite immunisation being one of the most cost-effective and successful health strategies available.  6  ,   21  An attempt to overcome this lack of influence, and to achieve a population perspective in the health sector, was initiated at the Action for Health and Independence Conference, convened by the Ministry of Health, in late 1998.  31   This conference considered strategies to change the culture of the health sector, to develop information for action, to engage the community, and for integration. Conference participants also identified incentives for action.

Although the need to address inequalities in health is implicit in the framework, the framework tends to favour “downstream” interventions with narrower impacts, such as healthy behaviours, rather than “upstream” interventions which impact closer to the point of causation, such as improving food security.  32   The health sector is increasingly seen to have a role in contributing to the development and implementation of policies to address poverty,  33   even if only to adopt a supportive role in relation to those policies.  34   The complex relationships between social capital,  35  ,   36  community capacity  37   and health are becoming clearer as a result of improvements in the quantity and quality of research undertaken on these issues. These developments should lead to the implementation of a more balanced set of interventions to address inequalities in health, incorporating both “upstream” and “downstream” interventions.




Comparison with Other Jurisdictions – Australia

Australia has taken a broadly similar stance to New Zealand, in terms of a strategic approach to public health and an emphasis on development of the infrastructure. A federal system introduces complexities in policy development and implementation. The robust debate on policy issues that occurs between the Australian States and Territories and the Commonwealth may serve to focus and improve the quality of policy analysis or alternatively, compromises may dilute its impact. To ensure this dilution does not occur, Australian Health Ministers agreed in October 1996 to establish the National Public Health Partnership. The overall purpose of the Partnership is to enhance national efforts in public health, concentrating on matters where concerted national effort, collaboration and consistency among jurisdictions are considered important.  38  

Australians have a higher life expectancy than New Zealanders do,  39   but greater inequalities in health. Indigenous Australians have death rates about three times higher than other Australians do and their average life expectancy is 20 years lower.  40   Australia has prioritised at the national level and has established six national health priority areas – cardiovascular health, diabetes, injury, mental health, cancer and asthma.  41   It has also used national public health strategies as a key mechanism to respond to public health issues over the last 20 years. There are currently over 20 such strategies at different stages of development and implementation.  42   Health status is reviewed biannually.  39   In addition, there is a reporting framework for the National Health Priority Areas. In Australia, public health expenditure is probably about 2–3 percent of total health expenditure.  43   International comparisons of the proportion of health funding allocated to public health are compromised by varying definitions of “public health”. The Australian definition includes some clinical services.

Whereas New Zealand’s national public health framework is inclusive, Australia has applied priorities more rigorously at the national level; but alongside these national priorities are a large number of strategies developed in response to a particular issue. New Zealand has succeeded in achieving cohesiveness, but at the expense of rigorous prioritisation. New Zealand is focussing on co-ordination of public health interventions within the health sector and between sectors,  22  ,   24  ,   27  whereas the focus in Australia is co-ordination within the health sector between the States, Territories and the Commonwealth. Intersectoral co-ordination and collaboration facilitates the implementation of comprehensive programmes. Both countries are seeking to improve their infrastructure, focussing on legislative frameworks, information and the development and dissemination of evidence that underpins public health strategies.  20  ,   38  

Australia is taking a more systematic approach than New Zealand to developing the public health workforce.  38   Much can be learned from the National Health Priorities Initiative in respect of the public health framework influencing the personal health sector, particularly if the approach moves from a passive monitoring and reporting function to a focus on action and results.  41   New Zealand is more advanced than Australia in seeking to develop a more balanced set of interventions to address inequalities in health, incorporating “upstream” and “downstream” interventions, with some evidence of success.  44  




Lessons for the Future

The philosopher Soren Kierkegaard once said “Life can only be understood backwards, but it must be lived forwards.” There is no doubt that, given the pressing health problems facing New Zealand, the political commitment to public health, outlined in the introduction to this paper, is well placed. It appears that if New Zealanders are to be successful in improving the health of the nation, and reducing inequalities in health, we must build on the strengths of our cohesive national public health framework, but achieve a balanced approach – a balance between central control and local autonomy in terms of the level at which prioritisation occurs, and balance between “upstream” and “downstream” interventions to reduce inequalities. Finally, we need to take a systematic approach to developing a flexible workforce that readily builds evidence into practice, communicates well and can cope with complexity, uncertainty and ambiguity.



Acknowledgements

I would like to thank Helen Wyn for her comments on an earlier draft of this paper. This paper is published with the permission of the Director-General of Health. The opinions expressed are those of the author and do not necessarily represent those of the Ministry of Health.



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