The district health board (DHB) system is New Zealand's present structure for the governance and delivery of publicly-funded health care. An aim of the DHB system is to democratise health care governance, and a key element of DHBs is elected membership of their governing boards. This article focuses on the electoral component of DHBs. It reports on the first DHB elections of 2001 and recent 2004 elections. The article presents and discusses data regarding candidates, the electoral process, voter behaviour and election results. It suggests that the extent to which the DHB elections are contributing to aims of democratisation is questionable.
Aust Health Rev 2005: 29(3): 345-352
HEALTH CARE IS THE LARGEST public expenditure category in New Zealand, accounting for almost 20% of all government expenditure. This is equivalent to 6.8% of gross domestic product (total health expenditure is 8.7%).1 Reflecting the size and importance of the sector (and political preferences), the governance and organisational arrangements for publicly funded health care in New Zealand have been restructured several times since the late 1980s.2,3 The most recent set of arrangements were announced by a new Labour-led coalition government following the 1999 general election. Commonly known as the "district health board" (DHB) system, this features 21 regionally based DHBs. A primary motivation for creating the DHB system was to democratise health care governance, particularly in terms of increasing opportunities for public participation in health care planning and decision-making processes. Thus, DHBs feature various mechanisms for engaging with the public, one of which is elected membership of their governing boards. This article reports on the DHB elections of 2001 and 2004. First, it overviews the DHB system including the rationale, the regulatory framework and governance structures. Next, it considers the organisation and results of the 2001 and 2004 elections. Finally, the article reflects on the extent to which the elections have delivered on aims of democratising health care governance.
The DHB system
The DHB system was implemented on the tail of a decade (the 1990s) of health system restructuring in New Zealand. As with prior restructures, the plans for the DHB system were unveiled following a general election and change of government. The health systems in place through most of the 1990s were based on a competitive business model, with health services treated as commodities, with contracting and tendering at the heart of funding and cost setting, and service governance concerned primarily with price and quality issues and accountable only to central government. This said, toward the latter part of the decade, both government policy and the health system had begun to embrace other concepts including community involvement, greater transparency in decision-making, reducing health inequalities, and improving primary care and collaboration between service providers.4,5 Immediately preceding DHBs, the system consisted of a single national purchasing body, the Health Funding Authority, that maintained local presence in a number of regional offices, as well as 23 hospitals and Health Services which were clusters of public hospitals governed by appointed boards. Primary medical care was provided by private independent general practitioners (receiving government subsidies), many of whom were grouped into formal practitioner associations.6
Despite the policy evolution through the 1990s, the Labour Party, which had earmarked health system change in pre-election campaigning, viewed the health system governance structures as lacking local presence and failing to facilitate adequate public participation. Labour argued that this lack of presence and participation were the source of low levels of public confidence found in an international health-system study.7 Creation of the DHB system was no small undertaking, involving dissolution of the Health Funding Authority and splitting its purchasing functions. …