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Public health and the reforms: the New Zealand experience
Health Policy 29 (1994) 127-141
Public health and the reforms: the New Zealand experience Don Bandaranayake* Department of Atblic Health, Wellington School of Medicine, PO Box New Zealand
7343, Wellington South,
(Accepted 13 April 1994)
Abstract The main aim of a national public health service is to conserve and improve the population’s health. The health service reforms introduced in 1992 proposed the establishment of a Public Health Commission, which was to be responsible for health monitoring, public health policy advice and the purchase of public health services. These reforms, implemented in 1993, while emphasising a purchaser-provider separation also earmarked a budget for public health activities to be administered by the Commission. Such protection of funding is unusual. Public health activities span a wide range of measures to protect and promote health as well as to prevent disease. Many of these measures have been, and will continue to be, carried out at a local level. The results of some of these measures are not usually seen in the short term. Improvement of the population’s health also requires proactive measures which are outside the traditional health service. The demonstration af quantifiable benefits to the public’s health from such measures may require an even longer term. It is mainly in this area of activity, however, that the achievements of the Commission will be judged. Beginning with a short summary of the history of public health services in New Zealand, this paper looks briefly at the events that led to the establishment of the Public Health Commission, before moving on to describe its achievements to date, the challenges it faces and its impact on public health service provision. Based on such observations and an analysis of the strengths and weaknesses of the Commission, the paper attempts an appraisal of the public health function in the reformed health service, a
* Corresponding author. 0168-8510/94/$06.00 0 1994 Elsevier Science Ireland Ltd. AU rights reserved. SSDZ 0168-8510(93)00651-T
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function that will almost certainly be observed with interest in other countries. Certain ways of improving the public health function are outlined in the conclusions. Key words: Public health function; Health reforms; New Zealand
1. Introduction Public health is most commonly defined as ‘the science and art of preventing disease, prolonging life and promoting health through organised efforts of society’ [l]. A more utilitarian definition states that public health is ‘the organised application of resources to achieve the greatest health for the greatest number’ (Sir John Brotherston, former Chief Medical Officer of Scotland, unpublished speech, 1978). A recent report in the United States by the Committee for the Study of the Future of Public Health stated that ‘public health is what we, as a society, do to assure the conditions for people to be healthy, and requires that continuing and emerging threats to the health of the public be successfully countered’ [2]. Whichever definition is preferred by the reader, there is general agreement that public health services are those concerned with populations rather than individuals or families. The provision of public health services in New Zealand, as in other countries, has always been overshadowed by the necessity of providing acute care services, which are mainly hospital-based. The traditional public health services, especially health protection, are safeguarded by legislation. The Medical Officer of Health has been, and to a certain extent still is, the statutory officer who has the power to oversee the public health function at district level and to advise local authorities on health issues as necessary. The advent of the ‘new’ public health, the increasing importance of resource management and ecological issues and diminished administrative requirements have modified the role and functions of the Medical Officer of Health. There is currently some doubt about the precise role of this officer in the reformed health service. A major revision of the public health legislation, which should clarify this issue, is long overdue. It is necessary to trace the evolution of public health services in New Zealand to comprehend current developments fully. One of the key features of the 1992 health reforms has been the establishment of the Public Health Commission. Its main functions are to monitor the public health, advise the Minister of Health on public health policy and purchase public health services, both nationally and regionally. In attempting to define goals as part of its policy advice role and subsequently to evaluate services, it was essential at the outset to monitor and analyze the state of the public health.
2. History of public health in New Zealand In New Zealand, as in several other countries, the earliest measures to protect the health of the public were those taken to control infectious disease. Most of the early legislative initiatives to protect the public’s health were taken in the middle of
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the nineteenth century with quarantine and vaccination [3]. The legal and administrative developments followed the British pattern as to the content and scope of public health legislation and were based on the great sanitary movement in Europe. Beaglehole [4] acknowledges the response of health services to the danger of the spread of infectious disease but is critical of initiatives taken to abate the modern epidemic of chronic disease. He indicates that the response to epidemics of cardiovascular disease and cancer was late by some thirty years. The modern era of public health in New Zealand began in 19.56, when the current Health Act was passed. During the 30-year period 1950-1980 much was achieved in public health in New Zealand. This included health protection and disease prevention activities covering food, water, air and occupational and communicable disease control. A major development was the establishment of health promotion programmes in the 1980s with the appointment of a separate workforce at central and district levels. From the mid-1980s the influence of the Ottawa Charter and the recognition of the so-called ‘new’ public health led to the restructuring of district health offices as health development units and later public health units within the restructured health care system, briefly described below. The prospect of rationalising the health sector administration and integrating public sector health care delivery had been the policy of successive governments since 1974, but it was not until 1989 that the network of 14 Area Health Boards was finally established. The Area Health Boards Act (1983) enabled the boards to merge the public health services of district health offices and the hospital and related services of hospital boards. Each board was responsible for the health and health care of a defined population through the provision of both clinical and public health services. The population-based public health services included health protection, disease prevention and health promotion activities, and were administered mainly through Health Development Units in each board. These were the former district offices of the Department of Health. There was an emphasis on health promotion initiatives in line with the ‘new’ public health function. Fig. 1 illustrates these arrangements. The contractual arrangement between each board and the Minister of Health was to provide a comprehensive range of services, curative and preventive, with a focus on the health status of their resident populations. These concepts were subsequently cemented by the establishment of a New Zealand Health Charter and quantified national health goals [51. In more recent times there has also been a major shift of emphasis in public health thinking throughout the world. To the emergence of the new public health alongside the initiatives in primary health care in the eighties have now been added another focus brought on by a greater recognition of dangers to the planet, and possibly to the very existence of humankind. Even while the imminent danger of another global war has receded, issues of climate change, overpopulation, unemployment, poverty and a proliferation of local conflicts have taken centre stage. The end of the twentieth century sees a period of rebuilding and protecting thie planet with a move away from concerns for humans alone. Ironically, the threat of indiscriminate use of nuclear energy for hostile purposes may also have increased with the break-up of the Soviet Union and the end of the cold war. Public health
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“cn.UNTARY PRCIWDERS
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Fig. 1. Organisation of the New Zealand health care system (1992).
services at both national and local level face a challenge in coping with these new requirements. 3. The establishment of the Public Health Commission In 1990 the National government, faced with a large budget deficit, decided to cut public spending and benefit payments. The health care sector was earmarked for reforms and a task force established for this purpose. The composition of this task force was heavily weighted with economists and treasury officials. Arising out of the work of the task force was the Green and White Paper on the proposed health service reforms released in mid-1991 [6]. From a public health perspective a major proposal in these reforms was the separation of public health from personal health activities. Combined with the overarching philosophy of the purchaser-provider separation, which influenced the whole reform process, there were major consequences for future public health service provision. A defined budget was to be made available to a new organisation named the Public Health Commission to advise the government on the best policies necessary for the maintenance and improvement of public health. The Commission was to be located within the Department (now Ministry) of Health as an independent unit ‘to allow for sharing of information and to achieve economies of administration.’ The Green and White Paper proposed the establishment of a Public Health Agency with three regional offices for the main purpose of public health service provision. It was also proposed that this agency would
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Private and Voluntary Providers I
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Fig. 2. Proposed public health system.
administer public health legislation and advise the Regional Health Authorities and local authorities. It was to maintain a capacity to respond to public health emergencies and to manage food and drug recalls. These vital health protection functions were to be managed through contracts with the Public Health Commission. The Commission was not to be involved in carrying out public health programmes. These proposed structural relationships are shown in Fig. 2. The main reasons given for this change were, first, to boost the public health functions and, second, to counter the tendency there had been for Area Health Boards to divert, or attempt to divert, money earmarked for the provision of pubhc health services to clinical services. A Public Health Commission Implementation Group, established soon after the Green and White Paper was released, undertook, together with public health professionals and potential service providers, a comprehensive consultation process on the proposed reforms. It found some
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evidence of diversion of public health funds to individual health care by boards but little hard evidence of any major misallocation of public health resources by the boards, even if a general neglect of traditional public health service provision at this level was apparent. The decision to abandon the proposal to establish a Public Health Agency was taken by the implementation group with little consultation of public or health professional organisations. This was one of two major recommendations of the Task Force that was abandoned. The other was the decision to site the Public Health Commission as a Crown (i.e. state government) entity with a board outside the Ministry of Health. The main reasons given for this decision were that difficult choices between competing claims would be avoided if accountability of the Commission was to a board, and that public perception of the commitment of the government to public health would be increased. The task of public health service provision, along with most of the other functions of the proposed Public Health Agency, was placed under Crown Health Enterprises. This was done by moving all board staff who had not previously reported directly to the general manager to the Crown Health Enterprise on 1 June 1993. The relationship between the Public Health Commission and the health sector is shown in Fig. 3. A major change announced in the Green and White Paper was the separation of the funding and management of population-based strategies from personal health care services. The separation of the purchasing and provider functions for public health services and the establishment of contestable contracting arrangements to provide national public health services were also detailed, as was the requirement to establish contestable sub-contracting arrangements for specific regional services. These changes were designed to provide incentives for efficiency, improved service provision and accountability.
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/ Health Policy 29 (1994) 127-141
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The reforms, having abolished Area Health Boards, established four Regional Health Authorities as the main purchasers of all government-funded personal health services and some public health services. Populations served by the Regional Health Authorities range from almost 700000 to a million in each region. The main providers are the Crown Health Enterprises, the more-or-less direct descendants of the boards but increased in number from 14 to 23. Two other groups of providers i.e. Community Trusts (particularly in the rural areas) and the independent general practitioners were to compete for contracts negotiated through the Regional Health Authorities. The major change at the centre was the establishment of the Public Health Commission, with a clear separation of the purchasing of population-based public health from that of personal care services. These reforms were contained in the Health and Disability Services Act (1993). The Act also gave effect to the government decision that regulatory public health services should be a Ministry of Health responsibility, attained through the designation of statutory officers (such as Medical Officers of Health and health protection officers) by the Director-General of Health. The shadow Public Health Commission was appointed in 1992, although the reforms did not take effect until July 1993. A budget for public health, less than 2% of the total health vote, was identified. The Commission’s main concern was to be with population-based programmes on specific issues such as nutrition, tobacco and alcohol consumption and unintentional injury and more general issues such as environmental health and the prevention and control of infectious disease. Its focus also includes the public health needs of special groups such as the Mao& Pacific Islanders, children and the elderly. The Commission’s purchasing functiom for regional services was to be carried out by using the Regional Health Authorities as its agents. National services were to be directly contracted by the Commission through independent providers. Most public health service provision at regional level would be by the Crown Health Enterprises (as the inheritors of the area health board public health services) and non-governmental agencies. Currently over 90 per cent of the Commission’s total budget is allocated to the purchasing function, and approximately two-thirds of this is for the purchase of regional public health services to be provided mainly by the Crown Health Enterprises. The Public Health Commission, which was formally established in July 1993, is accountable, through its board, to the Minister of Health. This relationship is based on the funding agreement each financial year between the Crown and the Commission, and related policy guidelines, a statement of intent and purchasing plans. Through these the Crown agrees to provide funds in return for the Commission monitoring and analyzing health status, providing policy advice and purchasing public health services. The mandate for the Commission as agreed by the Cabinet also states that the Commission’s policy advice role could extend to the issue of public health regulations, but that the Ministry would have the role of providing overarching advice on health policy. The 1994/95 policy guidelines to the Commission from the Minister 171clearly indicate that the Commission and the Ministry of Health should be committed to a co-operative relationship that recognises the negotiating and monitoring functions of the Ministry in relation to the funding agreement. Currently these consultative
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links remain ill-defined, leading to lengthy discussions on defining boundaries of responsibility. There is continuing difficulties with respect to several issues on the current placement of the regulatory services within the Ministry; the precise dimensions of public health; the level at which the Commission could and should act; and the relative roles and relationships of the Ministry of Health as opposed to the Commission. The relationship between the Commission and the Regional Health Authorities has also been specified in the policy guidelines, which state that these organisations should co-operate ‘as far as practicable’ to co-ordinate the purchase of public and personal health services to produce the best and ‘most cost-effective’ outcomes for the people of New Zealand. This is now considered a key function of the Commission. The guidelines specifically stress the importance of such collaboration in the area of Maori health. The Commission is obliged to consider the cost implications for Regional Health Authorities when providing advice affecting personal health services. The Commission is not obliged to utilise the services of regional authorities, just as these authorities can opt out of purchasing services on behalf of the Commission. These guidelines do help to clarify the process of service purchasing and relationships among the main players, but much confusion remains. 4. Achievements of the Public Health Commission During its first year, the Commission, after wide public and professional consultation, identified six public health goals for the nation, although this was done without the benefit of a formal health status review. The discussion document published by the Commission proposed specific disease-related goals. However, submissions received from individuals and organisations suggested that these could be improved. The goals that were finally decided include a broad aim of promoting a social and physical environment that improves and protects the public health. Other key areas are Maori health and the health of children, young and older people. Maori health is regarded as a key issue, with much emphasis on the Treaty of Waitangi and the vital issues of equity in general. More details about quantified targets and a set of guidelines emphasising quality issues in public health service provision for distribution to potential service providers have recently been published [Sl. These have specified the services the Commission wishes to purchase and have also put in place formal contracts for these services. This publication indicates that detailed planning at national and regional levels is under way to determine how best to achieve national goals and specify targets. Timelines for these have now been set. Regional Health Authorities, public health service providers and other groups are to be encouraged to develop further the objectives and targets to achieve goals in response to particular identified public health needs. It is also suggested that an intersectoral strategy be developed to promote health. In a post-election briefing paper prepared for the Minister of Health [9], the Commission identifies the need for an intersectoral strategy for improving the public health and states the intention of the Commission to work closely with other national organisations to reduce injuries. Pursuing this intersectoral strategy and in
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response to a major toxic shellfish outbreak in 1992, the Commission has actively participated in establishing a marine biotoxin monitoring board. It also organised the launch of the national haemophilus influenzae B immunisation programme in early 1994. The Commission’s major publication in 1993 has been the end product of information-gathering on the nation’s health. Titled ‘Our Health, Our Future,’ this 260-page report identifies areas of major concern and provides a yardstick against which future improvements can be measured [lo]. 5. Discussion The separation of funding of personal care services from public health services is a unique feature in the New Zealand public health care reforms. There is some merit in maintaining protected funding, provided it can be protected through the contracting chain. Some public health activities provide for health as a ‘public good’ and require different funding arrangements from personal health service interventions, which are more appropriately considered as ‘private goods’. If these public goods are to be provided within society they must inevitably be publicly funded, as the market would otherwise fail to provide them, or provide them at a less than optimal level. Unprotected funding might also result in some diversion of resources from public health to clinical services. On the other hand, on the negative side of the equation the separation of public from personal health service provision can be somewhat artificial. It is often impossible to separate these services at the point of delivery, as many personal health care providers will continue to play a key role in meeting public health goals. The Regional Health Authorities, for example, are responsible for purchasing immunisation and screening services, which are seen as individual health care interventions, and are now in the process of contracting for these with private provider agencies. The reverse is also true, as many public health staff provide personal services in areas with difficulties in service access. Consequently the division between personal and public health services ignores the basic principles of public health service planning and delivery, which emphasise the importance of integration and co-operation. With the demise of the Area Health Boards, the machinery essential for community involvement has disappeared and it is most unlikely that either the Regional Health Authorities or the Crown Health Enterprises will ever be able to fill this vacuum. The Area Health Boards were, at least in part, elected and therefore accountable locally. This accountability has to a large extent disappeared under the new structure, which is primarily geared to cost-cutting and devolving responsibility away from the centre. Contrary to what was envisaged in the reforms, there is no guarantee of a clearly identifiable public health budget beyond the regional tier. Ring-fencing of such funds at the periphery is difficult, particularly when clear service specifications far public health purchasing have not been laid down. Contractual arrangements far public health outcomes or even outputs are more difficult to quantify than most outputs for clinical services. Crown Health Enterprises will predictably consider public health as an insignificant area of involvement, with little opportunity for
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‘profit’, with the added perceived problem of high risk, particularly in the health protection area. They would gladly see this function centralised. There is more support for health promotion activities, but largely as public relations exercises. These have the potential for raising institutional profile and improving the image of these organisations. Conversely, health protection activities may be seen as a ‘police’ regulatory role, which may damage their public image. During the first post-reform year, the Crown Health Enterprises were directed by the Minister to ‘roll-over’ existing service provision, including public health services. Now these bodies can legitimately discard public health activities without having to justify such action. Some Crown Health Enterprises are interested in public health service provision, and have publicly stated so. Others are not. Wherever Crown Health Enterprises opt out of providing public health services, the Regional Health Authority or the Public Health Commission will have to enter into contractual agreements with a variety of other service providers. Such variation in the reorganisation does not enhance the prospects for a well co-ordinated and integrated public health service. The Commission, through its board, is required to give independent advice to the government on public health issues and potential strategies to address them. Although in the interests of improving the health status of all New Zealanders this must remain the key function, it is not perceived as such in the 1994/95 policy guidelines, where the purchasing function alone has been emphasised. The Commission has a unique role in presenting accurate information to the public for debate and discussion and finding acceptable solutions. An independent role, however, cannot be maintained if the Commission also gets too closely involved with the machinery of government. A satisfactory solution to this situation, which has the potential for conflict, has to be found. The Commission will also continue to come into conflict with major commercial groups, who argue issues of healthy public policy solely on economic grounds, and vested interests. As indicated below, this has occurred in the recent past. In order that appropriate and timely advice can be given by the Commission to the Minister, it is essential that a suitable information system be available. Arising from the health care reforms and other recent legislation, such as the Privacy Act (19931, there are difficulties and demands placed on providers of information and on the uses to which the information is put. In the briefing paper to the new Minister, in late 1993, the Commission has indicated that ‘the separation of the policy, purchase and provision functions has led to some differences in needs and uses of information as well as raising ownership and control measures’ [9]. While acknowledging the importance of information from outside the health sector, the paper also indicates that the information strategy adopted by the Ministry of Health in 1991 is inadequate for public health purposes. The reforms were based on the idea of better-managed care, mainly in treatment services but also in the public health sector. Improved efficiency and protected public health funding alongside better public awareness were expected to enhance more informed community participation in public health activities. The improved efficiency so generated was to allow for new and different public health programmes to be implemented. The existing domination of special interest groups in
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1.17
getting at the health care budget was to be diminished through a more transparent process of decision-making and funding. Clearer roles and responsibilities would improve services and allow ‘voice’ to a wider variety of groups. Healthy public policy was to be the responsibility of the Public Health Commission. The rhetoric is there, but what real power does the Commission have to deliver? In the few months leading up to the 1993 general election the Commission came under increasing pressure from commercial groups who disagreed with the advice given to the Minister in the draft policy document on alcohol sales and consumption [ll]. The alcohol lobby group also stated that the Commission had not taken heed of the due process of consultation. The policy document was withdrawn and is currently being revised with the aim of tightening up the basis of its main proposals on epidemiological grounds. The strained relationship with the Ministry of Health is another major issue. Currently the situation is unsatisfactory, with a lack of integration of advice on personal and public health matters. There is continuing debate about the current placement of the regulatory services within the Ministry. While the regulatory public health services have been retained within the Ministry, the boundaries between the regulatory and non-regulatory services remain somewhat blurred. In addition there is fragmentation of the regulatory services, with the licensing of facilities and medicines control, which has reverted to direct control by the Ministry. Other public health regulatory functions are based in the Crown Health Enterprises’ public health administration contracts. Other than the requirement that enforcement powers remain as close to the Crown as possible, there appears to be no good reason for the separation of regulatory from non-regulatory service,s. The Commission in discharging its functions to prevent disease, prolong life and promote health must necessarily purchase some services that are under regulation. The Commission, for example, purchases food safety services related to administration of legislation on behalf of the Ministry. This separation has created some confusion within the public health workforce. Two issues arise for debate from this: firstly, whether or not the purchaser/provider separation can be applied comfortably to public health service provision, and secondly, given this difficulty, whether it is sensible to distinguish between regulatory and non-regulatory services. The establishment of a suitable infrastructure at the regional level and below with a guarantee of maintenance of existing services is also an important issue. The mere existence of at least 23 Crown Health Enterprises, as opposed to only 14 Boards in the previous structure, has also resulted in a reduction in the critical mass of public health personnel available at the periphery. The reforms paid scant attention to such matters, and there are no guidelines established for the Regional Health Authorities in this respect. Some Crown Health Enterprises have already indicated that they do not see public health as core business, having considered that there is little advantage in such services for these organisations and some conflict of interest with what they perceive as their main functions. There is some evidence of fragmentation of public health services (for example health promotion being aligned with public relations), which has resulted in further loss of morale within the workforce.
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During recent years there has not been sufficient effort directed towards developing and maintaining a viable public health workforce in New Zealand. The reforms have done nothing to improve this situation. With the disestablishment of the national network of Health Development Units, there has been considerable disillusionment within a workforce that genuinely believed they were doing the best possible job under the circumstances. Indeed this was true in many of the smaller units, which were closer to the people and able to foster public health activity. Many are of the opinion that the health development strategy was not given a chance to work before the boards were abolished. With the dismantling of the public health structure and unclear signals from the Commission about the new arrangements at the coal face, the morale of public health staff is now at an all-time low. There is anecdotal evidence of asset-stripping activities from the former public health units now within the Crown Health Enterprises. Unless urgent action is taken nationally, both the skilled workforce and morale will continue to drop and wither away. 6. Conclusions Leaving aside the rest of the reforms, the public health arrangements per se have so far not gone well. There has been official acknowledgement of this fact by both the Commission and the Ministry in their respective briefings to the new Minister of Health following the recent elections [9,12]. The involvement of the Commission either directly or indirectly in purchasing public health services seems at odds with its vital functions of health monitoring and policy advice. The original recommendation of the task force to establish a Public Health Agency to be the main service provider should not have been abandoned. Such an agency would have a better chance of organising the provision of services at a regional level and beyond, while establishing precise contractual agreements built on appropriate area-specific service specifications. The Commission has become too involved in the minutiae while remaining at a distance from the action. Consideration should now be given to establishing an agency. Overall the Commission is in a strong position to bring key health issues to the notice of the public. As long as this is done in a professional rhanner, with irrefutable scientific evidence to back up its policy advice, vested interests will have little room for argument. The anti-smoking initiatives that have been carried on from the pre-Commission days are a good example of this line of action, Arousing the antagonism of vested interests by showing sufficient independence to speak out when necessary is itself an achievement. The Commission, if it is able to continue to produce policy that affects major industries and other commercial interests whose products have a detrimental effect on health, will be able to play a major role in improving those conditions that affect health. The Commission’s purchasing role, other than for those nationally co-ordinated services, remains an anomaly and should be discarded. This would enable the Commission to establish closer links with the Core Services Committee as a common body for policy advice to the Minister. An amalgamation at the centre of the personal and public health services at a policy development and planning stage
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is essential. An alternative to the Public Health Commission’s role in purchasing regional services must be found. The Regional Health Authorities are, in theory at least, well placed to purchase all services. The mix of services purchased should reflect the overall health and health care needs of the population they serve. At the coal face, the current tenuous, even strained, links between some local and health authorities need to be strengthened. The Healthy Cities/Communities movement which began in New Zealand in the mid-eighties has made relatively little progress. This is due partly to the restructuring that has taken place in local government as well as the health sector. There is a need to promote this initiative much more actively in the country as a whole, with emphasis on intersectoral collaboration at the periphery as well as at the centre. One Crown Health Enterprise is attempting to collaborate fully with the Regional Council by es+ tablishing a more co-ordinated service with a joint budget for the provision of public health services. Although negotiations have only recently begun, a provisio+ nal joint public health service plan is the expected outcome. Such examples are unfortunately rare in the current scene. There is a need to build on those that do exist. The health sector and local government have a common interest in matters of the health and safety of the community they serve. Regional and local government bodies have shown a greater interest in ecological aspects of health and sustainability than the health authorities and have a very significant public health role under recent revamps of resource management and buildings legislation. The Resource Management Act (1991) has made a laudable start along these lines. While efforts initiated by the Department of Health in the early eighties and geared towards greater collaboration and joint health planning between regional councils and the health sector were largely unsuccessful [13], the Public Health Commission must now signal similar intentions to regional and local government. A mutually supportive partnership between health agencies and local government in the combined interests of health gain and ecological sustainability is required. The time is now opportune to invite local and regional authorities to play a larger role in building a new public health infrastructure. Core public health legislation, based on the Health Act (1956), is now almost completely outdated. New and more appropriate legislation embracing the overarching principles of the Resource Management Act is urgently needed. Public health professionals continue to be hampered in their duties by some of the archaic requirements of the traditional regulatory approaches. A collaborative approach linking the several health professionals with distinctive expertise in various fields is now required to tackle adequately the complex issues arising in environmental health. There is a need for a statutory role for the regional public health medicine specialist in New Zealand. There ought to be a requirement for the Regional Health Authorities or Crown Health Enterprises to report on the population’s health status. The Public Health Commission, which intends to produce an annual report, is not well placed to consult communities and identify local health needs. New Zealand might benefit from studying the situation in the United Kingdom, where the Director of Public Health, a senior member of the management team at
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district level, heads the department of public health, comprising several specialists. The Director advises the management on key public health issues and is expected by statute to analyze the health status of the population and report annually on the state of the public health. Finally, more attention must be paid to public health vocational training and education. A recent study conducted in one academic department showed clearly that there was a demand for such action [14]. Either the Commission or the Ministry of Health must act on this front, given the relative scarcity of expertise at the centre and at district level. Collaborative arrangements with academic departments of public health and environmental science should be developed. Joint appointments at a senior level between such departments and the Public Health Commission and the Ministry of Health need also to be considered. Similar joint appointments should be possible between the Commission and other agencies, such as the Ministry for the Environment and the Occupational Safety and Health Unit of the Ministry of Labour. Such initiatives would also enhance the potential for an independent voice on major public health issues. The public health function in the reformed health service has been changed to a remarkable degree. It is too early to state whether or not these changes will improve the health of New Zealanders. As indicated, many areas of uncertainty and confusion remain, and some structural changes may still be necessary. Currently several countries are in the process of restructuring their national health systems or have already done so. In all these countries the public health system is an integral part of the total health care structure. The New Zealand experience, with separate and protected funding for the public health function, will almost certainly be observed with interest in these countries. Acknowledgements The author is indebted to the following for their valuable input and advice. Dr Phil Shoemack, Medical Officer of Health, Tauranga, Lady Keith, Head, Department of Public Health, Wellington School of Medicine and Professor George Salmond, Director, Health Services Research Centre, Wellington. The views presented, however, are those of the author. References 1 Department of Health and Social Services, Public Health in England: Report of the Committee of Inquiry into the Future Development of the Public Health Function [the Acheson Report] (Cm 2891, HMSO, London, 1988. 2 Committee for the Study of the Future of Public Health in the USA, The Future of Public Health, Washington, 1988. 3 McLean, F.S., A Challenge for Health: a history of Public Health in New Zealand, Government Printer, Wellington, 1964. 4 Beaglehole, R., Prospects for public health in New Zealand, New Zealand Medical Journal, 105 (1992) 29-31. 5 New Zealand health goals and targets, health charter and contract for Area Health Boards. In Department of Health, New Relationships, Government Printer, Wellington, 1989. 6 Upton, S., Your Health and the Public Health: a Statement of Government Health Policy, Department of Health, Wellington, 1991.
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Shipley, S., Minister of Health, Policy Guidelines for the Public Health Commission, 1994/1995, 1994. Public Health Commission, A Strategic Direction to Improve and Protect the Public Health, Public Health Commission, 1993. Post-election briefing to the incoming Minister of Health from the Public Health Commission, 1993. Public Health Commission, Our Health, Our Future: the State of the Public Health in New Zealand, 1993, Public Health Commission, 1993. Public Health Commission, Towards Healthy Lives for New Zealanders: Action Plans for Heath, 1994/95, Draft paper - Alcohol, Public Health Commission, 1993. Post-election briefing to the incoming Minister of Health from the Ministry of Health, 1993. Brunton, W., The health services and regional planning, New Zealand Health Review, 1 (1981) 7-g. Malcolm. L., Fougere, G., Bandaranayake, D., Keith, J., Taylor, R. and Newell, J., Need and Demand for Education and Training in Public Health, Department of Community Health, Wellington School of Medicine, Wellington, 1992.
Public health and the reforms: the New Zealand experience Don Bandaranayake* Department of Atblic Health, Wellington School of Medicine, PO Box New Zealand
7343, Wellington South,
(Accepted 13 April 1994)
Abstract The main aim of a national public health service is to conserve and improve the population’s health. The health service reforms introduced in 1992 proposed the establishment of a Public Health Commission, which was to be responsible for health monitoring, public health policy advice and the purchase of public health services. These reforms, implemented in 1993, while emphasising a purchaser-provider separation also earmarked a budget for public health activities to be administered by the Commission. Such protection of funding is unusual. Public health activities span a wide range of measures to protect and promote health as well as to prevent disease. Many of these measures have been, and will continue to be, carried out at a local level. The results of some of these measures are not usually seen in the short term. Improvement of the population’s health also requires proactive measures which are outside the traditional health service. The demonstration af quantifiable benefits to the public’s health from such measures may require an even longer term. It is mainly in this area of activity, however, that the achievements of the Commission will be judged. Beginning with a short summary of the history of public health services in New Zealand, this paper looks briefly at the events that led to the establishment of the Public Health Commission, before moving on to describe its achievements to date, the challenges it faces and its impact on public health service provision. Based on such observations and an analysis of the strengths and weaknesses of the Commission, the paper attempts an appraisal of the public health function in the reformed health service, a
* Corresponding author. 0168-8510/94/$06.00 0 1994 Elsevier Science Ireland Ltd. AU rights reserved. SSDZ 0168-8510(93)00651-T
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function that will almost certainly be observed with interest in other countries. Certain ways of improving the public health function are outlined in the conclusions. Key words: Public health function; Health reforms; New Zealand
1. Introduction Public health is most commonly defined as ‘the science and art of preventing disease, prolonging life and promoting health through organised efforts of society’ [l]. A more utilitarian definition states that public health is ‘the organised application of resources to achieve the greatest health for the greatest number’ (Sir John Brotherston, former Chief Medical Officer of Scotland, unpublished speech, 1978). A recent report in the United States by the Committee for the Study of the Future of Public Health stated that ‘public health is what we, as a society, do to assure the conditions for people to be healthy, and requires that continuing and emerging threats to the health of the public be successfully countered’ [2]. Whichever definition is preferred by the reader, there is general agreement that public health services are those concerned with populations rather than individuals or families. The provision of public health services in New Zealand, as in other countries, has always been overshadowed by the necessity of providing acute care services, which are mainly hospital-based. The traditional public health services, especially health protection, are safeguarded by legislation. The Medical Officer of Health has been, and to a certain extent still is, the statutory officer who has the power to oversee the public health function at district level and to advise local authorities on health issues as necessary. The advent of the ‘new’ public health, the increasing importance of resource management and ecological issues and diminished administrative requirements have modified the role and functions of the Medical Officer of Health. There is currently some doubt about the precise role of this officer in the reformed health service. A major revision of the public health legislation, which should clarify this issue, is long overdue. It is necessary to trace the evolution of public health services in New Zealand to comprehend current developments fully. One of the key features of the 1992 health reforms has been the establishment of the Public Health Commission. Its main functions are to monitor the public health, advise the Minister of Health on public health policy and purchase public health services, both nationally and regionally. In attempting to define goals as part of its policy advice role and subsequently to evaluate services, it was essential at the outset to monitor and analyze the state of the public health.
2. History of public health in New Zealand In New Zealand, as in several other countries, the earliest measures to protect the health of the public were those taken to control infectious disease. Most of the early legislative initiatives to protect the public’s health were taken in the middle of
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the nineteenth century with quarantine and vaccination [3]. The legal and administrative developments followed the British pattern as to the content and scope of public health legislation and were based on the great sanitary movement in Europe. Beaglehole [4] acknowledges the response of health services to the danger of the spread of infectious disease but is critical of initiatives taken to abate the modern epidemic of chronic disease. He indicates that the response to epidemics of cardiovascular disease and cancer was late by some thirty years. The modern era of public health in New Zealand began in 19.56, when the current Health Act was passed. During the 30-year period 1950-1980 much was achieved in public health in New Zealand. This included health protection and disease prevention activities covering food, water, air and occupational and communicable disease control. A major development was the establishment of health promotion programmes in the 1980s with the appointment of a separate workforce at central and district levels. From the mid-1980s the influence of the Ottawa Charter and the recognition of the so-called ‘new’ public health led to the restructuring of district health offices as health development units and later public health units within the restructured health care system, briefly described below. The prospect of rationalising the health sector administration and integrating public sector health care delivery had been the policy of successive governments since 1974, but it was not until 1989 that the network of 14 Area Health Boards was finally established. The Area Health Boards Act (1983) enabled the boards to merge the public health services of district health offices and the hospital and related services of hospital boards. Each board was responsible for the health and health care of a defined population through the provision of both clinical and public health services. The population-based public health services included health protection, disease prevention and health promotion activities, and were administered mainly through Health Development Units in each board. These were the former district offices of the Department of Health. There was an emphasis on health promotion initiatives in line with the ‘new’ public health function. Fig. 1 illustrates these arrangements. The contractual arrangement between each board and the Minister of Health was to provide a comprehensive range of services, curative and preventive, with a focus on the health status of their resident populations. These concepts were subsequently cemented by the establishment of a New Zealand Health Charter and quantified national health goals [51. In more recent times there has also been a major shift of emphasis in public health thinking throughout the world. To the emergence of the new public health alongside the initiatives in primary health care in the eighties have now been added another focus brought on by a greater recognition of dangers to the planet, and possibly to the very existence of humankind. Even while the imminent danger of another global war has receded, issues of climate change, overpopulation, unemployment, poverty and a proliferation of local conflicts have taken centre stage. The end of the twentieth century sees a period of rebuilding and protecting thie planet with a move away from concerns for humans alone. Ironically, the threat of indiscriminate use of nuclear energy for hostile purposes may also have increased with the break-up of the Soviet Union and the end of the cold war. Public health
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“cn.UNTARY PRCIWDERS
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Fig. 1. Organisation of the New Zealand health care system (1992).
services at both national and local level face a challenge in coping with these new requirements. 3. The establishment of the Public Health Commission In 1990 the National government, faced with a large budget deficit, decided to cut public spending and benefit payments. The health care sector was earmarked for reforms and a task force established for this purpose. The composition of this task force was heavily weighted with economists and treasury officials. Arising out of the work of the task force was the Green and White Paper on the proposed health service reforms released in mid-1991 [6]. From a public health perspective a major proposal in these reforms was the separation of public health from personal health activities. Combined with the overarching philosophy of the purchaser-provider separation, which influenced the whole reform process, there were major consequences for future public health service provision. A defined budget was to be made available to a new organisation named the Public Health Commission to advise the government on the best policies necessary for the maintenance and improvement of public health. The Commission was to be located within the Department (now Ministry) of Health as an independent unit ‘to allow for sharing of information and to achieve economies of administration.’ The Green and White Paper proposed the establishment of a Public Health Agency with three regional offices for the main purpose of public health service provision. It was also proposed that this agency would
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Private and Voluntary Providers I
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Fig. 2. Proposed public health system.
administer public health legislation and advise the Regional Health Authorities and local authorities. It was to maintain a capacity to respond to public health emergencies and to manage food and drug recalls. These vital health protection functions were to be managed through contracts with the Public Health Commission. The Commission was not to be involved in carrying out public health programmes. These proposed structural relationships are shown in Fig. 2. The main reasons given for this change were, first, to boost the public health functions and, second, to counter the tendency there had been for Area Health Boards to divert, or attempt to divert, money earmarked for the provision of pubhc health services to clinical services. A Public Health Commission Implementation Group, established soon after the Green and White Paper was released, undertook, together with public health professionals and potential service providers, a comprehensive consultation process on the proposed reforms. It found some
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evidence of diversion of public health funds to individual health care by boards but little hard evidence of any major misallocation of public health resources by the boards, even if a general neglect of traditional public health service provision at this level was apparent. The decision to abandon the proposal to establish a Public Health Agency was taken by the implementation group with little consultation of public or health professional organisations. This was one of two major recommendations of the Task Force that was abandoned. The other was the decision to site the Public Health Commission as a Crown (i.e. state government) entity with a board outside the Ministry of Health. The main reasons given for this decision were that difficult choices between competing claims would be avoided if accountability of the Commission was to a board, and that public perception of the commitment of the government to public health would be increased. The task of public health service provision, along with most of the other functions of the proposed Public Health Agency, was placed under Crown Health Enterprises. This was done by moving all board staff who had not previously reported directly to the general manager to the Crown Health Enterprise on 1 June 1993. The relationship between the Public Health Commission and the health sector is shown in Fig. 3. A major change announced in the Green and White Paper was the separation of the funding and management of population-based strategies from personal health care services. The separation of the purchasing and provider functions for public health services and the establishment of contestable contracting arrangements to provide national public health services were also detailed, as was the requirement to establish contestable sub-contracting arrangements for specific regional services. These changes were designed to provide incentives for efficiency, improved service provision and accountability.
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/ Health Policy 29 (1994) 127-141
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The reforms, having abolished Area Health Boards, established four Regional Health Authorities as the main purchasers of all government-funded personal health services and some public health services. Populations served by the Regional Health Authorities range from almost 700000 to a million in each region. The main providers are the Crown Health Enterprises, the more-or-less direct descendants of the boards but increased in number from 14 to 23. Two other groups of providers i.e. Community Trusts (particularly in the rural areas) and the independent general practitioners were to compete for contracts negotiated through the Regional Health Authorities. The major change at the centre was the establishment of the Public Health Commission, with a clear separation of the purchasing of population-based public health from that of personal care services. These reforms were contained in the Health and Disability Services Act (1993). The Act also gave effect to the government decision that regulatory public health services should be a Ministry of Health responsibility, attained through the designation of statutory officers (such as Medical Officers of Health and health protection officers) by the Director-General of Health. The shadow Public Health Commission was appointed in 1992, although the reforms did not take effect until July 1993. A budget for public health, less than 2% of the total health vote, was identified. The Commission’s main concern was to be with population-based programmes on specific issues such as nutrition, tobacco and alcohol consumption and unintentional injury and more general issues such as environmental health and the prevention and control of infectious disease. Its focus also includes the public health needs of special groups such as the Mao& Pacific Islanders, children and the elderly. The Commission’s purchasing functiom for regional services was to be carried out by using the Regional Health Authorities as its agents. National services were to be directly contracted by the Commission through independent providers. Most public health service provision at regional level would be by the Crown Health Enterprises (as the inheritors of the area health board public health services) and non-governmental agencies. Currently over 90 per cent of the Commission’s total budget is allocated to the purchasing function, and approximately two-thirds of this is for the purchase of regional public health services to be provided mainly by the Crown Health Enterprises. The Public Health Commission, which was formally established in July 1993, is accountable, through its board, to the Minister of Health. This relationship is based on the funding agreement each financial year between the Crown and the Commission, and related policy guidelines, a statement of intent and purchasing plans. Through these the Crown agrees to provide funds in return for the Commission monitoring and analyzing health status, providing policy advice and purchasing public health services. The mandate for the Commission as agreed by the Cabinet also states that the Commission’s policy advice role could extend to the issue of public health regulations, but that the Ministry would have the role of providing overarching advice on health policy. The 1994/95 policy guidelines to the Commission from the Minister 171clearly indicate that the Commission and the Ministry of Health should be committed to a co-operative relationship that recognises the negotiating and monitoring functions of the Ministry in relation to the funding agreement. Currently these consultative
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links remain ill-defined, leading to lengthy discussions on defining boundaries of responsibility. There is continuing difficulties with respect to several issues on the current placement of the regulatory services within the Ministry; the precise dimensions of public health; the level at which the Commission could and should act; and the relative roles and relationships of the Ministry of Health as opposed to the Commission. The relationship between the Commission and the Regional Health Authorities has also been specified in the policy guidelines, which state that these organisations should co-operate ‘as far as practicable’ to co-ordinate the purchase of public and personal health services to produce the best and ‘most cost-effective’ outcomes for the people of New Zealand. This is now considered a key function of the Commission. The guidelines specifically stress the importance of such collaboration in the area of Maori health. The Commission is obliged to consider the cost implications for Regional Health Authorities when providing advice affecting personal health services. The Commission is not obliged to utilise the services of regional authorities, just as these authorities can opt out of purchasing services on behalf of the Commission. These guidelines do help to clarify the process of service purchasing and relationships among the main players, but much confusion remains. 4. Achievements of the Public Health Commission During its first year, the Commission, after wide public and professional consultation, identified six public health goals for the nation, although this was done without the benefit of a formal health status review. The discussion document published by the Commission proposed specific disease-related goals. However, submissions received from individuals and organisations suggested that these could be improved. The goals that were finally decided include a broad aim of promoting a social and physical environment that improves and protects the public health. Other key areas are Maori health and the health of children, young and older people. Maori health is regarded as a key issue, with much emphasis on the Treaty of Waitangi and the vital issues of equity in general. More details about quantified targets and a set of guidelines emphasising quality issues in public health service provision for distribution to potential service providers have recently been published [Sl. These have specified the services the Commission wishes to purchase and have also put in place formal contracts for these services. This publication indicates that detailed planning at national and regional levels is under way to determine how best to achieve national goals and specify targets. Timelines for these have now been set. Regional Health Authorities, public health service providers and other groups are to be encouraged to develop further the objectives and targets to achieve goals in response to particular identified public health needs. It is also suggested that an intersectoral strategy be developed to promote health. In a post-election briefing paper prepared for the Minister of Health [9], the Commission identifies the need for an intersectoral strategy for improving the public health and states the intention of the Commission to work closely with other national organisations to reduce injuries. Pursuing this intersectoral strategy and in
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response to a major toxic shellfish outbreak in 1992, the Commission has actively participated in establishing a marine biotoxin monitoring board. It also organised the launch of the national haemophilus influenzae B immunisation programme in early 1994. The Commission’s major publication in 1993 has been the end product of information-gathering on the nation’s health. Titled ‘Our Health, Our Future,’ this 260-page report identifies areas of major concern and provides a yardstick against which future improvements can be measured [lo]. 5. Discussion The separation of funding of personal care services from public health services is a unique feature in the New Zealand public health care reforms. There is some merit in maintaining protected funding, provided it can be protected through the contracting chain. Some public health activities provide for health as a ‘public good’ and require different funding arrangements from personal health service interventions, which are more appropriately considered as ‘private goods’. If these public goods are to be provided within society they must inevitably be publicly funded, as the market would otherwise fail to provide them, or provide them at a less than optimal level. Unprotected funding might also result in some diversion of resources from public health to clinical services. On the other hand, on the negative side of the equation the separation of public from personal health service provision can be somewhat artificial. It is often impossible to separate these services at the point of delivery, as many personal health care providers will continue to play a key role in meeting public health goals. The Regional Health Authorities, for example, are responsible for purchasing immunisation and screening services, which are seen as individual health care interventions, and are now in the process of contracting for these with private provider agencies. The reverse is also true, as many public health staff provide personal services in areas with difficulties in service access. Consequently the division between personal and public health services ignores the basic principles of public health service planning and delivery, which emphasise the importance of integration and co-operation. With the demise of the Area Health Boards, the machinery essential for community involvement has disappeared and it is most unlikely that either the Regional Health Authorities or the Crown Health Enterprises will ever be able to fill this vacuum. The Area Health Boards were, at least in part, elected and therefore accountable locally. This accountability has to a large extent disappeared under the new structure, which is primarily geared to cost-cutting and devolving responsibility away from the centre. Contrary to what was envisaged in the reforms, there is no guarantee of a clearly identifiable public health budget beyond the regional tier. Ring-fencing of such funds at the periphery is difficult, particularly when clear service specifications far public health purchasing have not been laid down. Contractual arrangements far public health outcomes or even outputs are more difficult to quantify than most outputs for clinical services. Crown Health Enterprises will predictably consider public health as an insignificant area of involvement, with little opportunity for
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‘profit’, with the added perceived problem of high risk, particularly in the health protection area. They would gladly see this function centralised. There is more support for health promotion activities, but largely as public relations exercises. These have the potential for raising institutional profile and improving the image of these organisations. Conversely, health protection activities may be seen as a ‘police’ regulatory role, which may damage their public image. During the first post-reform year, the Crown Health Enterprises were directed by the Minister to ‘roll-over’ existing service provision, including public health services. Now these bodies can legitimately discard public health activities without having to justify such action. Some Crown Health Enterprises are interested in public health service provision, and have publicly stated so. Others are not. Wherever Crown Health Enterprises opt out of providing public health services, the Regional Health Authority or the Public Health Commission will have to enter into contractual agreements with a variety of other service providers. Such variation in the reorganisation does not enhance the prospects for a well co-ordinated and integrated public health service. The Commission, through its board, is required to give independent advice to the government on public health issues and potential strategies to address them. Although in the interests of improving the health status of all New Zealanders this must remain the key function, it is not perceived as such in the 1994/95 policy guidelines, where the purchasing function alone has been emphasised. The Commission has a unique role in presenting accurate information to the public for debate and discussion and finding acceptable solutions. An independent role, however, cannot be maintained if the Commission also gets too closely involved with the machinery of government. A satisfactory solution to this situation, which has the potential for conflict, has to be found. The Commission will also continue to come into conflict with major commercial groups, who argue issues of healthy public policy solely on economic grounds, and vested interests. As indicated below, this has occurred in the recent past. In order that appropriate and timely advice can be given by the Commission to the Minister, it is essential that a suitable information system be available. Arising from the health care reforms and other recent legislation, such as the Privacy Act (19931, there are difficulties and demands placed on providers of information and on the uses to which the information is put. In the briefing paper to the new Minister, in late 1993, the Commission has indicated that ‘the separation of the policy, purchase and provision functions has led to some differences in needs and uses of information as well as raising ownership and control measures’ [9]. While acknowledging the importance of information from outside the health sector, the paper also indicates that the information strategy adopted by the Ministry of Health in 1991 is inadequate for public health purposes. The reforms were based on the idea of better-managed care, mainly in treatment services but also in the public health sector. Improved efficiency and protected public health funding alongside better public awareness were expected to enhance more informed community participation in public health activities. The improved efficiency so generated was to allow for new and different public health programmes to be implemented. The existing domination of special interest groups in
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1.17
getting at the health care budget was to be diminished through a more transparent process of decision-making and funding. Clearer roles and responsibilities would improve services and allow ‘voice’ to a wider variety of groups. Healthy public policy was to be the responsibility of the Public Health Commission. The rhetoric is there, but what real power does the Commission have to deliver? In the few months leading up to the 1993 general election the Commission came under increasing pressure from commercial groups who disagreed with the advice given to the Minister in the draft policy document on alcohol sales and consumption [ll]. The alcohol lobby group also stated that the Commission had not taken heed of the due process of consultation. The policy document was withdrawn and is currently being revised with the aim of tightening up the basis of its main proposals on epidemiological grounds. The strained relationship with the Ministry of Health is another major issue. Currently the situation is unsatisfactory, with a lack of integration of advice on personal and public health matters. There is continuing debate about the current placement of the regulatory services within the Ministry. While the regulatory public health services have been retained within the Ministry, the boundaries between the regulatory and non-regulatory services remain somewhat blurred. In addition there is fragmentation of the regulatory services, with the licensing of facilities and medicines control, which has reverted to direct control by the Ministry. Other public health regulatory functions are based in the Crown Health Enterprises’ public health administration contracts. Other than the requirement that enforcement powers remain as close to the Crown as possible, there appears to be no good reason for the separation of regulatory from non-regulatory service,s. The Commission in discharging its functions to prevent disease, prolong life and promote health must necessarily purchase some services that are under regulation. The Commission, for example, purchases food safety services related to administration of legislation on behalf of the Ministry. This separation has created some confusion within the public health workforce. Two issues arise for debate from this: firstly, whether or not the purchaser/provider separation can be applied comfortably to public health service provision, and secondly, given this difficulty, whether it is sensible to distinguish between regulatory and non-regulatory services. The establishment of a suitable infrastructure at the regional level and below with a guarantee of maintenance of existing services is also an important issue. The mere existence of at least 23 Crown Health Enterprises, as opposed to only 14 Boards in the previous structure, has also resulted in a reduction in the critical mass of public health personnel available at the periphery. The reforms paid scant attention to such matters, and there are no guidelines established for the Regional Health Authorities in this respect. Some Crown Health Enterprises have already indicated that they do not see public health as core business, having considered that there is little advantage in such services for these organisations and some conflict of interest with what they perceive as their main functions. There is some evidence of fragmentation of public health services (for example health promotion being aligned with public relations), which has resulted in further loss of morale within the workforce.
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During recent years there has not been sufficient effort directed towards developing and maintaining a viable public health workforce in New Zealand. The reforms have done nothing to improve this situation. With the disestablishment of the national network of Health Development Units, there has been considerable disillusionment within a workforce that genuinely believed they were doing the best possible job under the circumstances. Indeed this was true in many of the smaller units, which were closer to the people and able to foster public health activity. Many are of the opinion that the health development strategy was not given a chance to work before the boards were abolished. With the dismantling of the public health structure and unclear signals from the Commission about the new arrangements at the coal face, the morale of public health staff is now at an all-time low. There is anecdotal evidence of asset-stripping activities from the former public health units now within the Crown Health Enterprises. Unless urgent action is taken nationally, both the skilled workforce and morale will continue to drop and wither away. 6. Conclusions Leaving aside the rest of the reforms, the public health arrangements per se have so far not gone well. There has been official acknowledgement of this fact by both the Commission and the Ministry in their respective briefings to the new Minister of Health following the recent elections [9,12]. The involvement of the Commission either directly or indirectly in purchasing public health services seems at odds with its vital functions of health monitoring and policy advice. The original recommendation of the task force to establish a Public Health Agency to be the main service provider should not have been abandoned. Such an agency would have a better chance of organising the provision of services at a regional level and beyond, while establishing precise contractual agreements built on appropriate area-specific service specifications. The Commission has become too involved in the minutiae while remaining at a distance from the action. Consideration should now be given to establishing an agency. Overall the Commission is in a strong position to bring key health issues to the notice of the public. As long as this is done in a professional rhanner, with irrefutable scientific evidence to back up its policy advice, vested interests will have little room for argument. The anti-smoking initiatives that have been carried on from the pre-Commission days are a good example of this line of action, Arousing the antagonism of vested interests by showing sufficient independence to speak out when necessary is itself an achievement. The Commission, if it is able to continue to produce policy that affects major industries and other commercial interests whose products have a detrimental effect on health, will be able to play a major role in improving those conditions that affect health. The Commission’s purchasing role, other than for those nationally co-ordinated services, remains an anomaly and should be discarded. This would enable the Commission to establish closer links with the Core Services Committee as a common body for policy advice to the Minister. An amalgamation at the centre of the personal and public health services at a policy development and planning stage
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is essential. An alternative to the Public Health Commission’s role in purchasing regional services must be found. The Regional Health Authorities are, in theory at least, well placed to purchase all services. The mix of services purchased should reflect the overall health and health care needs of the population they serve. At the coal face, the current tenuous, even strained, links between some local and health authorities need to be strengthened. The Healthy Cities/Communities movement which began in New Zealand in the mid-eighties has made relatively little progress. This is due partly to the restructuring that has taken place in local government as well as the health sector. There is a need to promote this initiative much more actively in the country as a whole, with emphasis on intersectoral collaboration at the periphery as well as at the centre. One Crown Health Enterprise is attempting to collaborate fully with the Regional Council by es+ tablishing a more co-ordinated service with a joint budget for the provision of public health services. Although negotiations have only recently begun, a provisio+ nal joint public health service plan is the expected outcome. Such examples are unfortunately rare in the current scene. There is a need to build on those that do exist. The health sector and local government have a common interest in matters of the health and safety of the community they serve. Regional and local government bodies have shown a greater interest in ecological aspects of health and sustainability than the health authorities and have a very significant public health role under recent revamps of resource management and buildings legislation. The Resource Management Act (1991) has made a laudable start along these lines. While efforts initiated by the Department of Health in the early eighties and geared towards greater collaboration and joint health planning between regional councils and the health sector were largely unsuccessful [13], the Public Health Commission must now signal similar intentions to regional and local government. A mutually supportive partnership between health agencies and local government in the combined interests of health gain and ecological sustainability is required. The time is now opportune to invite local and regional authorities to play a larger role in building a new public health infrastructure. Core public health legislation, based on the Health Act (1956), is now almost completely outdated. New and more appropriate legislation embracing the overarching principles of the Resource Management Act is urgently needed. Public health professionals continue to be hampered in their duties by some of the archaic requirements of the traditional regulatory approaches. A collaborative approach linking the several health professionals with distinctive expertise in various fields is now required to tackle adequately the complex issues arising in environmental health. There is a need for a statutory role for the regional public health medicine specialist in New Zealand. There ought to be a requirement for the Regional Health Authorities or Crown Health Enterprises to report on the population’s health status. The Public Health Commission, which intends to produce an annual report, is not well placed to consult communities and identify local health needs. New Zealand might benefit from studying the situation in the United Kingdom, where the Director of Public Health, a senior member of the management team at
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district level, heads the department of public health, comprising several specialists. The Director advises the management on key public health issues and is expected by statute to analyze the health status of the population and report annually on the state of the public health. Finally, more attention must be paid to public health vocational training and education. A recent study conducted in one academic department showed clearly that there was a demand for such action [14]. Either the Commission or the Ministry of Health must act on this front, given the relative scarcity of expertise at the centre and at district level. Collaborative arrangements with academic departments of public health and environmental science should be developed. Joint appointments at a senior level between such departments and the Public Health Commission and the Ministry of Health need also to be considered. Similar joint appointments should be possible between the Commission and other agencies, such as the Ministry for the Environment and the Occupational Safety and Health Unit of the Ministry of Labour. Such initiatives would also enhance the potential for an independent voice on major public health issues. The public health function in the reformed health service has been changed to a remarkable degree. It is too early to state whether or not these changes will improve the health of New Zealanders. As indicated, many areas of uncertainty and confusion remain, and some structural changes may still be necessary. Currently several countries are in the process of restructuring their national health systems or have already done so. In all these countries the public health system is an integral part of the total health care structure. The New Zealand experience, with separate and protected funding for the public health function, will almost certainly be observed with interest in these countries. Acknowledgements The author is indebted to the following for their valuable input and advice. Dr Phil Shoemack, Medical Officer of Health, Tauranga, Lady Keith, Head, Department of Public Health, Wellington School of Medicine and Professor George Salmond, Director, Health Services Research Centre, Wellington. The views presented, however, are those of the author. References 1 Department of Health and Social Services, Public Health in England: Report of the Committee of Inquiry into the Future Development of the Public Health Function [the Acheson Report] (Cm 2891, HMSO, London, 1988. 2 Committee for the Study of the Future of Public Health in the USA, The Future of Public Health, Washington, 1988. 3 McLean, F.S., A Challenge for Health: a history of Public Health in New Zealand, Government Printer, Wellington, 1964. 4 Beaglehole, R., Prospects for public health in New Zealand, New Zealand Medical Journal, 105 (1992) 29-31. 5 New Zealand health goals and targets, health charter and contract for Area Health Boards. In Department of Health, New Relationships, Government Printer, Wellington, 1989. 6 Upton, S., Your Health and the Public Health: a Statement of Government Health Policy, Department of Health, Wellington, 1991.
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Shipley, S., Minister of Health, Policy Guidelines for the Public Health Commission, 1994/1995, 1994. Public Health Commission, A Strategic Direction to Improve and Protect the Public Health, Public Health Commission, 1993. Post-election briefing to the incoming Minister of Health from the Public Health Commission, 1993. Public Health Commission, Our Health, Our Future: the State of the Public Health in New Zealand, 1993, Public Health Commission, 1993. Public Health Commission, Towards Healthy Lives for New Zealanders: Action Plans for Heath, 1994/95, Draft paper - Alcohol, Public Health Commission, 1993. Post-election briefing to the incoming Minister of Health from the Ministry of Health, 1993. Brunton, W., The health services and regional planning, New Zealand Health Review, 1 (1981) 7-g. Malcolm. L., Fougere, G., Bandaranayake, D., Keith, J., Taylor, R. and Newell, J., Need and Demand for Education and Training in Public Health, Department of Community Health, Wellington School of Medicine, Wellington, 1992.