5. Conclusions — Ngā whakamutunga

The following conclusions about the realisation of the right to health in New Zealand are based on a combination of the information obtained in the consultation process and data that is generally available (including material from the Ministry of Health, academic references and discussion papers commissioned specifically for the NZAPHR process).

In addition, a 'whole-of-government' approach is necessary to adequately address the right to health as it is understood internationally. This need for an intersectoral approach - recognised by the Ministry of Health in 1998 in the Determinants Report and in subsequent health strategies - means that the following comments must be referenced to other chapters in this report.

Availability

Sufficient functioning health services, facilities and programmes are available

There is now substantial recognition that, over the next few years, overall health gains will be achieved by focusing on improving the health of the most disadvantaged groups in New Zealand society. This can best be achieved by improving the availability of effective primary health care services to ethnic and socioeconomic subgroups with poorer health status, and intersectoral initiatives to address the social, cultural and economic determinants that shape or constrain the lifestyle choices so important to health at the individual level (Ministry of Health, 1999).

The 2001 reforms attempt to do this by requiring DHBs to plan services for the whole population of each district based on assessment of health needs, and to promote the integration and coordination of services to meet those needs. Structural reform is complemented by the Primary Care Strategy, which is designed to reduce inequalities by improving the availability and accessibility of primary health care services. The strategy is centred on the establishment of primary healthcare organisations (PHO) to provide a wide range of low-cost services and incorporate conventional general practice with community outreach and health promotion. In its early stages, the strategy is focused primarily on improving the availability of services for the most needy population groups - children, older people, Maori and Pacific populations and people of low socio-economic status - but intends over time to fund PHO coverage for the whole population.

At the same time, Achieving Health for All People 2003 provides a strategic framework to address the wider determinants through traditional public health services and improved population health approaches to the 13 health priorities identified in the NZHS. Public health units attached to DHBs provide traditional public health services (including environmental health, communicable disease control and emergency planning), working in collaboration with a range of other agencies, including territorial and local authorities, and the Food Safety Authority. A wide range of DHB, PHO and NGO providers are funded to address each of the NZHS priorities, particularly those amenable to health promotion strategies, such as smoking, alcohol and other drug use, obesity and domestic violence.

The need to work across sectors to reduce inequalities is recognised, and promoted through changes to the Local Government Act that encourage wider scope of action and longer frames of planning. The Ministry of Social Development is developing a broad strategic overview - Opportunities for All - which includes health and a range of determinants such as income support, employment and housing. A programme of action for Sustainable Development for New Zealand (Department of Prime Minister & Cabinet, 2003) has also been launched. The purpose of the programme is to apply to decision-making across the public sector a set of guiding principles that take into consideration the long-term implications of decisions affecting significant determinants of health. The programme prioritises water quality and allocation, energy, sustainable cities and child and youth development.

The Ministry of Health is developing an Intersectoral Community Action for Health programme (ICAH) to encourage collaborative action among health services, local authorities and community agencies. Examples include Health Promoting Schools, Healthy Cities, Community Action on Youth and Drugs, Safer Community Councils and Strengthening Families.

While the Government has developed strategies to address the availability of public health and healthcare services and programmes, there remain some constraints on its ability to deliver. Many of the improvements in the determinants of health can take considerable time - often a generation - to produce a measurable difference. It is still too early to judge the success of new systems such as the PHOs in improving primary health care and, in the meantime, secondary services (hospitals) continue to cope with a high burden of avoidable illness. Waiting lists for elective surgery and some non-elective treatments (such as cancer) continue to be a major stress on the health system. While nationally consistent referral and assessment tools have been developed for primary and secondary services, together with a framework to aid consistent and transparent decision-making, the number of people waiting for treatment is still unacceptable.

The CESCR recommended that New Zealand improve the availability of health services in rural and remote areas. Rural primary healthcare, in particular, has been identified as a critical factor in improving the health access of Maori (Ministry of Health, 2000a).

“Bring in fences at the top rather than an ambulance at the bottom”
Workshop participant

While there is a commitment on the part of the Government to improving the health status of people with severe mental illness, services for children and young people are inadequately funded (Ministry of Health/Mental Health Commission, 2003). The UNCROC Committee recommended that New Zealand should strengthen mental health and counselling services, ensuring they are accessible to, and appropriate for, all adolescents (including Maori children and those in rural areas and residential institutions: para. 38(d)). Mental health services for children and youth are inadequate. In addition, the 3 percent benchmark for acute illness has still not been achieved, and there are few services for the 17 percent with moderate illness.

Refugees have complex needs for which existing services are not always suitable. Asylum seekers, in particular, are disadvantaged as they are only accorded the minimum necessary to satisfy the requirements of the Refugee Convention. Other countries, most notably some of the EU countries that have significantly greater numbers of refugees than New Zealand provide them with the same level of access to health services as guaranteed to their citizens. New Zealand , with its small number of asylum seekers, could do the same.

Workforce shortages account for a significant part of the problem. Recent comparatively rapid decline in numbers of medical practitioners, especially in general practice and nursing, threatens the viability of strategies such as the Primary Health Care strategy, not only in rural areas, but also in high deprivation areas such as South Auckland. In the context of a world-wide shortage, and in competition with larger economies, New Zealand 's ability to recruit and retain health professionals is constantly under challenge.

Accessibility

Services and facilities are available to everyone on a non-discriminatory basis, are physically accessible and affordable, and the public are aware of them.

Non-discriminatory access to health services in New Zealand is protected by the terms of the HRA, the Code of Health and Disability Consumers' Rights , and the PHDA. Health services can contribute to reducing inequalities if they ensure equity of access by distributing resources in relation to need and remove barriers, however defined, that inhibit the effective use of services for all ethnic and social groups (Benzeval et al., 1995). This may require special measures or targeted programmes to redress the inequalities currently experienced by some groups.

The Population-Based Funding Formula (PBFF) determines the share of funding to be allocated to each DHB, based on the population living in each district. The aim of the PBFF is to distribute fairly the funding available according to the relative needs of populations and the cost of providing the necessary services in those areas.

To remove cost barriers to accessing primary care, the formula for subsidising PHOs covers children, older people, and residents of high-deprivation areas, with additional weighting on the basis of the number of Maori and Pacific enrolments. Funding is targeted to these population groups on the basis of identified need; the PHDA makes it clear that the Act does not entitle anyone to preferential treatment on the basis of race.

Accessibility is also affected by acceptability, as people may often suffer in silence rather than use a service where they feel unwelcome or uncomfortable, or if the service is culturally inappropriate. Maori and Pacific peoples have rates of avoidable hospitalisations approximately 60 percent higher than European/Other New Zealanders (Ministry of Health, 1999). This is at least partly because they feel uncomfortable with the available primary care services. Where cultural appropriateness is a significant barrier to access, Government is increasingly contracting organisations that provide culturally appropriate services on the basis of ethnicity, gender or other status.

For many disabled people, physical accessibility to buildings remains an often unrecognised barrier to some health services.

Acceptability

Services respect medical ethics, are culturally appropriate, and respect confidentiality.

As explained above, many health services target the prevalence of health problems in different population groups on the basis of characteristics such as age, gender or ethnicity, and may be delivered by services that are culturally appropriate for the population served. This includes 'by Maori, for Maori' and 'by Pacific peoples, for Pacific peoples' health service providers, and other non-government organisations, such as the Family Planning Association (primarily targeting women), Plunket (targeting children) and the Asian Health Network.

Ensuring culturally appropriate care has also led to measures to improve the representation of Maori and Pacific peoples in the health workforce (Director General's Annual Report, 2003). Strategies to increase the numbers of such employees have resulted in complaints about the way in which positions in the health sector have been advertised, or placements at medical schools decided. Attempts to diversify the healthcare workforce need to comply with the provisions of the HRA.

Better understanding of the health outcomes sought by Maori - particularly the importance of balancing the four factors that make up the Maori concept of health: te taha wairua (spiritual health); te taha tinana (physical health); te taha hinengaro (emotional well-being of the whanau and the individuals within it) and te taha whanau (the social environment) (Durie et al., 2002) - might also alleviate some of the criticism of the initiatives introduced to address the poor health status of Maori people.

Empowering communities to identify their own needs and priorities, and take more control over their lives, is a recognised strategy for reducing inequalities in health (Benzeval et al., 1995). The 2001 health reforms are designed, among other things, to promote more effective collaboration between communities and consumers of health and disability services. Requirements for the election of some of the board members to DHBs, and for PHOs to involve communities in their governance, to have public consultation over strategic plans, and to hold meetings open to the public are all methods of encouraging consultation and collaboration.

The HDC Act and the accompanying Code ensure an ethical approach to the delivery of health services and research, and respect for informed consent. The Privacy Act and the Health Information Privacy Code address the issue of confidentiality. There is also a national and regional framework of health and disability ethics committees that is designed to safeguard the rights of consumers and participants in health research.

Quality

Services are scientifically and medically appropriate and of good quality.

The Government is committed to assessing the efficacy of health sector activities so as to ensure a 'fair and functional' health system. This involves provision for accountability and evaluation as the basis for improvements in the sector (Ministry of Health, 2003a).

New Zealand has an extensive system designed to ensure that health facilities, services, and goods are scientifically and medically appropriate and of good quality. For example, the Ministry of Health has units to monitor and regulate the safety and quality of food (Food Safety Authority), medicines and medical devices (Medsafe) and pharmaceuticals (PHARMAC). A number of independent agencies accredit health services for quality standards, and the Ministry of Health is currently developing a quality improvement strategy for public hospitals.

There are also systems to require transparent planning and accountability from health services and from the Ministry itself. The Ministry is required to produce an annual Statement of Intent, setting out its strategic priorities over a three- to five-year period, to which Government and the public can hold it accountable. The current Statement of Intent focuses on enhancing performance measures (how progress may be tracked and how well the Ministry is doing). The Statement of Intent has been informed by international models of health performance and the outcomes, as well as the values and principles contained within New Zealand 's key strategies for the health sector.

The DHB Funding and Performance Directorate of the Ministry monitors the performance of the DHBs and other Crown entities in implementing the NZHS. This involves planning supervision and support, enforcement of relevant legislation, and other support systems such as workforce development through the Clinical Training Agency.

The Ministry also monitors, and reports against, a wide range of indicators in a number of publications, such as The Health and Independence Report and Implementing the New Zealand Health Strategy , which are tabled annually in Parliament and are sources of current information on issues and achieved outcomes. The Public Health Intelligence group monitors the health of New Zealanders and provides evidence for population health policy and decision-making. The work of this group is complemented by the New Zealand Guidelines Group, which sets the standard for an evidence-based approach to the delivery of health and disability services. Each of the population health priorities identified in the NZHS has an evidence-based national strategy and implementation plan to support local planning, funding and delivery of services.

The National Health Committee advises the Minister of Health on the kinds of public health services, personal health services and disability services - and their relative priorities - that it believes should be publicly funded. This includes consideration of emerging issues such as improving processes for identification, assessment and diffusion of new health technologies, provision of genetic services, a quality assurance framework and health impact assessment.

Nevertheless, the percentage of adverse events - one in eight hospital admissions, of which it is estimated that half are preventable - in New Zealand hospitals is high compared with the UK and the US - although not as high as in Australia. Equally seriously, the cost of avoidable adverse events amounts to 20 percent of public hospital expenditure (Davis et al., 2001).

Where New Zealand does well — Ngā mahi pai e oti nei i Aotearoa

For a small country, with corresponding budgetary limitations, New Zealand performs fairly well.

• The Ministry of Health provides well-researched strategic plans to address significant health issues, and a comprehensive system of performance monitoring and accountability. Strategic and operational plans are regularly reviewed.
• Public participation is encouraged through election of members to DHBs, the requirement for community representation in the governance of PHOs, consultation on Ministry of Health strategies, and funding of NGO service providers. This enables a wide range of community interests, including Maori, Pacific and Asian people, to participate in the management and delivery of health services.
• Health service funders generally recognise the need for, and fund, services that address the issues of accessibility and acceptability and are non-discriminatory (although the rationale for this needs to be better understood by the public - see below).
• There is a range of processes to acknowledge health service consumers' rights and resolve complaints.
• There are well-established systems for ensuring scientifically and medically appropriate services of good quality.
• As consultation with the public for this report demonstrates, New Zealanders generally feel well served by their health services, and health service professionals are held in high regard.

Where we need to do better — Kia piki ake te pai i roto i enei wahanga

Although New Zealand rates quite well according to a number of measures of quality of care and health outcomes, there is room for improvement in some areas.

• With less than two percent of the total expenditure on health available for public health services (such as environmental health, communicable disease control and health promotion) the potential to improve health, and protect against preventable diseases, is severely limited.
• Of particular importance are the gaps associated with ethnicity and socioeconomic status. Maori life expectancy at birth is nine years lower than non-Maori for females and eight years lower for males. There are similar gaps in terms of socioeconomic status and disability.
• Although there has been a drop in New Zealand 's infant mortality rate, this is not reflected among Maori[19]. The overall infant death rate is still unacceptably high in comparison to other OECD countries, and the rate at which children are hospitalised is increasing.
• Maori are less likely to access health services. When they do, they are less likely to receive high-technology interventions.
• Poverty plays an integral part in the right to health. Consideration should be given to the suggestion by the UN Committee on Economic Social and Cultural Rights (2002) that New Zealand adopt a national plan of action for the eradication of poverty, with clear indicators to assess the impact of poverty on disadvantaged and marginalised groups.
• Inadequate housing is a significant contributor to poor health, especially of children.
• Specific population groups for whom services are inadequate are Pacific peoples, people with early signs of mental illness (especially children and young people), and refugees with high and complex needs.
• New Zealanders also face some ongoing health challenges, such as clean air and safe water, as well as new ones through the re-emergence of familiar diseases associated with poverty and overcrowding
• Issues that need to be addressed include the training and retention of the workforce, and some aspects of the quality of health care (notably the level of adverse events in hospitals).
• Despite the recent rounds of restructuring, services are still poorly integrated. Lines of accountability remain unclear.
• ICESCR requires that rights be provided on a non-discriminatory basis. It also provides that, where resources are limited, the available resources should be targeted to the groups that are most vulnerable. This provides a mechanism for reconciling a needs-based approach with a human-rights approach. A discourse that not only promotes an understanding of the right to health and the responsibilities of individuals and society, but clarifies the shared nature of obligations arising from a human-rights approach, would allow the most transparent way of distributing health resources to be identified.

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