|Implemented in this survey?|
New Zealand?s publicly financed health system was restructured and 21 locally-elected District Health Boards were established. Funded on a population basis, DHBs are responsible for providing or purchasing health services for people living in their district. In November 2003, a university-based research team reported on early findings from a formative evaluation of the development of DHBs. The evaluation focused on governance, strategic decision-making, accountability and purchasing.
In 2001, the New Zealand public health system was restructured and 21 District Health Boards (DHBs) were established. Members of their governing boards are locally-elected but the Minister of
Health may appoint up to 4 additional members to improve the mix of skills or ethnic representation on the board.
Funded on a population basis, the DHBs are responsible for assessing the health needs of their populations, and for providing or purchasing health services according to these assessed needs. Although decision-making appears to have been decentralised, the decisions and activities of DHBs must be in line with the vision of the central government as set out in the New Zealand Health Strategy, plus the annual and strategic plans of DHBs must be agreed with the Minister of Health.
In November 2003, a university-based research team reported on some early findings from a formative evaluation of the development of DHBs. The evaluation focused primarily on governance, strategic decision-making, accountability and purchasing.
Objectives of the restructuringThe main objectives of the restructuring were:
The District Health Boards are required to provide (or purchase) their services within a fixed annual budget. This encourages them to examine their priorities with respect to service provision, and where possible, to keep expenditure within their capped budgets.
Elected board members have an incentive to represent the preferences of their constituencies if they wish to be re-elected. However under the legislation their accountability is in the first instance to the Minister of Health (who provides their funding) rather than to their constituents (who use the services).
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
This policy was driven largely by political ideology - especially a belief that the community should have the opportunity to participate in health sector decision-making - rather than by any clear
evidence that this structure is likely to be either more equitable or more efficient that the previous arrangements. The structure depends on guidance and control rather than upon any in-built
A key difference between this and previous reforms has been a willingness on the part of the government to undertake some evaluation of the reform process. While this is unlikely to lead to any major redirection or reorganisation of the system overall, it may result in some fine-tuning of current arrangements.
The District Health Board structure was introduced soon after the election of a Labour-led coalition government in 1999. The restructuring was stimulated by the Labour party's opposition to the previous market-oriented system in which the roles of purchaser and provider were split, and health services were purchased via contracts. The stated concerns of the Labour party (and the reasons for the restructuring) were that the existing arrangements:
|Implemented in this survey?|
The DHB structure in many ways mirrors the organisational arrangements that were in place in New Zealand prior to 1993 and which were supported by the Labour Government at that time. Common features between the pre-1993 and post 2000 systems are:
The approach of the idea is described as:
Since the early 1990s the publicly financed health care system in New Zealand has gone through a series of major changes. These changes have caused major disruptions for many people working within
the system. Yet another round of restructuring was therefore not welcomed by many health professionals and others within the sector. However the focus of this opposition was primarily against further
major changes of any kind, rather than against the specific structure.
Since the restructuring, political parties in opposition have continued to challenge some of the details of the new structure. There does however now appear to be a general recognition that, in the interests of maintaining stability, no further major changes should be made. The focus now is therefore on fine-tuning some aspects of the system and building the capacity and capability within the DHBs.
The new structure was enacted under the New Zealand Public Health and Disability Act 2000. This legislation sets out the roles and responsibilities of the Minister, the District Health Boards and other related government health agencies.
A research project is evaluating various dimensions of the new structure in the first 3 years (2001 - 2004). An interim report has been published, and feedback is being provided to the government,
the District Health Boards, and other key players within the system. The objectives are to identify strengths and weaknesses or problems with the new structure as early as possible and, if
appropriate, to make any changes that are deemed desirable by the government.
Key findings of the interim report of the evaluation team included:
The restructuring has been seen by some to fragment the critical mass of expertise that had been formed under the previous arrangements, leaving some DHBs with a shortage of capacity to undertake some tasks.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
An overview of the DHB structure is described in:
Devlin, N., Maynard, A., & Mays, N. (2001). New Zealand's new health sector reforms: back to the future? British Medical Journal 322, 1171-1174.
The interim report of the research team is at: www.sog.vuw.ac.nz/vuw/fca/sog/files/Interim%20Report%20on%20Health%20Reforms%202001.pdf
Toni Ashton, Jackie Cumming