Health and Public Policy in New Zealand
ed Peter Davis and Toni Ashton
Oxford University Press, $55.00,
This thoughtful and stimulating book, edited by two of New Zealand’s foremost scholars of health policy, deserves a wide audience both in New Zealand and internationally. Although primarily directed to students and practitioners of health policy, it will be of great interest to people, professional and lay, who are keen to understand the New Zealand policy experiments of the last two decades. There has been a rather unfortunate tendency to accept the far-reaching New Zealand policy reforms that began in the mid-1980s as successful examples of the application of neo-liberalism. Clearly, the reality is different, as this book so clearly describes.
The book concentrates on the health sector reforms, especially those introduced in the early 1990s under the leadership of Simon Upton. Given the central importance of health services to our sense of well-being and security, and the large amount of public resources spent on health care, the evidence presented in this book is relevant to all of us as the health reforms continue unabated.
The purpose of the book is twofold. First, to direct scholarly analysis to the health sector reforms and, secondly, to use this experience to reflect upon the health policy making process more generally, with a view to improving future policy making both in the health sector and else-where. The first of its three parts addresses the theory of the policy making process. The second part explores the key influences on the recent development and implementation of health policy in New Zealand. The third part is devoted to five case studies – three on the organisation of health services (mental health, primary health care and public hospitals) and two covering alcohol and tobacco control policies. The final chapter summarises the lessons learnt and their application to the future of health policy making.
The general introduction by the editors sets the scene nicely, and newcomers to the field of public policy analysis will especially welcome it. This chapter also summarises the health status of New Zealanders, the funding and organisation of health services in New Zealand and the 1990s reforms. It perhaps says something about the practice of health policy in New Zealand that the book does not return to the extremely disappointing, almost shameful, state of our health as a nation, except in a couple of the case studies. After all, it might be reasonable to expect the overarching purpose of health policy to be to improve the health status of all New Zealanders. There remains a tremendous burden of preventable premature mortality and sickness in New Zealand, the alleviation of which should, in my epidemiological view, be the first goal of our health policy.
The most interesting chapter is by Martin and Salmond, who have both long had a direct experience of the policy making process from their years spent at high level within the Department of Health. The title of their chapter “Policy making: the messy reality” gets closer to the truth than more theoretical approaches to the process. The question now must be how we can make the process less messy. Can we envisage a New Zealand health service that responds in an equitable and efficient manner to most of our health needs without consuming too many of our limited national resources? Specifying the dimensions of such a service is not too difficult; the real problem is in implementation, especially now after the long period of re(dis)organisation of our health services.
There are important lessons to be learnt from the case studies, especially on tobacco and alcohol control policies. The products of the tobacco industry are probably the most readily preventable cause of death and disease in New Zealand. For readers not up to date with the chilling statistics: half of all current tobacco users will die from diseases caused by tobacco; one half of these deaths will occur before the age of 69, and, on average, smokers who die in their middle years will lose over 20 years of life. So this is a serious health problem and, as Thomson and Wilson point out, considerable progress in reducing the harm caused by tobacco was made in the late 1980s and early 1990s. Since then, however, progress has been painfully slow. We have not been able to convert the huge amount of scientific evidence into health-promoting policies. And if we can’t do this with a relatively straightforward and uncontentious scientific issue such as smoking, the industry notwithstanding, what chance do we have for better health policy more generally?
In the last chapter, the editors draw out the lessons from the previous chapters and attempt to answer the question of how best to develop health policy in New Zealand. The book went to press just as the next round of reforms were being introduced and although the editors describe these, it was too early to comment on their likely effectiveness. However, the editors stress the need for the health service to have clear and explicit objectives since only then will it be possible to evaluate the effect of any changes.
What is clear from this book and the last two decades of reform, is that health services are of great public concern. Confidence in the quality of the service has been undermined by lack of ongoing evaluation – for example, of the screening services and some hospital services. The time for radical change has probably passed. The evolution of service will need to proceed slowly and with much public participation. We can also be sure that increasing resources will need to be devoted to health, especially from taxation, and the public will probably support this. We also need to be reminded that, in the long run, the state of health of New Zealanders depends more on sectors outside the formal health sector than it does on hospitals and doctors. It really is time to build the public health side of our health service. Greater effort directed towards preventing disease and promoting health should be a key feature of health policy in New Zealand.
Robert Beaglehole is on leave from his position as Professor of Community Health at the University of Auckland and working at the World Health Organization in Geneva.