Academic journal article Social Policy Journal of New Zealand

Primary Health Care in New Zealand: Problems and Policy Approaches

Academic journal article Social Policy Journal of New Zealand

Primary Health Care in New Zealand: Problems and Policy Approaches

Article excerpt

Abstract

Primary health care in New Zealand has been funded by a partial fee-for-service payment from the state for consultations and pharmaceuticals, supplemented by substantial co-payments from patients. Despite some targeting according to income and high need, there have been inequalities in access, with poorer people and Maori often using services at rates less than might be expected given their high levels of need. New policies are directed towards changing both the funding and organisational arrangements through which primary health care is delivered. New primary health organisations will be formed by provider groups, including general practitioners, and will have high levels of community governance. The new organisations will be funded through capitation, with funding levels dependent on the level of deprivation of the area within which individuals reside. The problems of funding on this basis are discussed. The paper concludes that this fundamental shift in strategy has the potential to improve access, but that the risks inherent in the new systems will require careful monitoring.

INTRODUCTION

After more than a decade of neoliberalism, which saw social and economic inequality substantially widen in New Zealand (Mowbray 2001, Howden-Chapman et al. 2000), there are now government initiatives to address the social consequences of past policies. Such initiatives parallel similar moves elsewhere in the developed world where the social costs of neoliberalism are also apparent (Coburn 2000). This has been particularly true in the health sector, where the growing socio-economic costs of inequality are becoming more fully understood (Wilkinson 1996, Macintyre 1997, Acheson 1998, Ministry of Health 2000b, 2002c). The policy context of health has changed dramatically, with governments now fostering co-operative over competitive models of service provision and seeing an increased focus on primary care as the key to overall improvements in service delivery and health (Moon and North 2000, National Health Committee 2000).

Within New Zealand, the New Zealand Health Strategy (Minister of Health 2001b) and the Primary Health Care Strategy (Minister of Health 2001c) are evidence of attempts to develop more equitable policies. The New Zealand Health Strategy, for example, anticipated new institutional arrangements and elected district health boards (DHBs) to implement these policies. Within the framework of DHBs the more recent Primary Health Care Strategy proposes new organisational structures, known as primary health organisations (PHOs), to address problems of access to services and a lack of coordination between providers. While DHBs are now fully established and the process of setting up PHOs well advanced, there is some uncertainty about how their equity goals are to be achieved.

This paper examines problems of access to primary care in New Zealand and discusses whether changes in the institutional and funding environment are likely to lead to greater equity in access to services. Following Starfield (1998), we define equity in terms of "equal treatment for equal need", such that systematic disparities in health and in the use of health services are reduced between more and less advantaged social groups. We primarily view differences in access as arising from socio-economic differences in wealth and pay less attention to geographic variations in access, which, undoubtedly, are also important (Joseph and Phillips 1984). In adopting such an approach, the paper has three specific objectives: (i) to determine the extent to which economic barriers to the use of primary health care services persist in New Zealand; (ii) to outline briefly current policy developments, in particular the development of primary health organisations (PHOs); and (iii) to assess how likely these are to address barriers to access within the wider context of health inequalities.

ECONOMIC BARRIERS TO PRIMARY HEALTH CARE IN NEW ZEALAND

In New Zealand, as in many other developed countries, economic restructuring and the unravelling of the welfare state have contributed to a substantial increase in the incidence of poverty (Waldegrave et al. …

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