Changes in the New Zealand Health System and Potential for Child and Youth Health

The opinions expressed are those of the author and should not be taken as representing those of his employer or other organisations with which he is associated.

The New Zealand health system has shifted since the early 1990s from a structure based on a Department of Health, area health boards and hospitals through to the purchaser-provider split environment. Subsequent changes in that structure have included replacement of regional health authorities as the health purchaser with a Health Funding Authority and the conversion of Crown Health Enterprises, which had replaced public hospitals, to Hospital and Health Services.

Unplanned side effects of this planned and imposed evolution in the health system have included, in particular, an increase in private health insurance with the government paying "less and less for more and more".

In addition, the changes imposed on the health system have not occurred in isolation. A number of other changes occurring simultaneously have also had tremendous impact on the New Zealand health sector, including increasing complexity of the health system and increased numbers of new health care provider groups.

The most recent shift has been a system based on District Health Boards (DHBs), hospitals and other health providers. This change has been accompanied by a strategic rethink in a number of health care delivery areas, a good example of which is the Primary Health Care Strategy.

Concerns related to the DHB-based system include an apparently top heavy management system and a contracting and funding system that significantly restricts the ability to assess the requirements for and provide specific services at a local level.

The Ministry of Health, not the DHBs, will hold funds for the period November 2000 to November 2001. During that time, the keys for clinicians to effectively work within the system will be to:


•   know the Ministry people
•   identify key board members
•   identify key board subcommittees
•   become involved in the election process
•   become involved in regional analysis.

Despite the changes and the associated expansion of the Ministry of Health, New Zealand still lacks a service in the Ministry of Health that is specific to children. In addition, children are not clearly represented in some other key ministries. Poverty and the poor health of certain ethnic groups contribute to child health issues. These circumstances should be, but often are not, taken into consideration within the health system structure.

Achieving effective health services for children requires identification of who and where children are, what is happening for children, who is responsible for children, and how adequate and what quality of service is available.

This requires defining, enrolling and monitoring the entire population of children with respect to health activities, health improvement, and quality of services and it is not clear how the recently released Primary Health Care Strategy will do this.

In fact the Primary Health Care Strategy fails to focus on children and youth as a distinct group although it addresses other groups, by factors including culture (eg, Maori, Pacific), special interest or dependency (eg, disability) and vulnerability (eg, mental health).

Other concerns with the Primary Health Care Strategy relate to enrolment and an apparent "demonising" of anything that is not the "new" model, without recognising current naturally evolving models.

Whilst the Primary Health Care Strategy has worthy goals and proposes using population enrolment with primary care providers to reach these goals, the voluntary nature of enrolment is likely to lead to failure. Certainly the groups at most risk are the groups least likely to enroll in a voluntary primary care system.

At both the DHB level, and using the Primary Care Strategy as a specific example, there is a sense that worthy goals and sensible principles are being hamstrung in the details of their implementation.