Our Country: Our Choice

New Zealand Health Futures

George Salmond*

So far the 1990s have been years of turmoil for health services in New Zealand and internationally. Ageing populations, new technologies, rising costs and increasing public expectations are placing enormous pressure on publicly funded health systems. Fundamental questions are being asked in all countries about how health systems are organised and services financed and rationed. What are the roles and functions of a health system? What care should be publicly funded and accessible to all as a right of citizenship? To what extent should those who can afford to pay be required to finance their own health care? How should publicly funded services be rationed and targeted to those in greatest need? How can costs be contained and resources distributed more equitably and used more efficiently? How can health be promoted as well as health services? These are dilemmas with which all countries must grapple.

The New Zealand reforms

New Zealand has for most of the last decade been at the international forefront of health sector reform. In keeping with the structural adjustments made to the economy generally, the health sector changes have been radical and continuing. The changes foreshadowed by the incoming National Government in December 1990 and introduced in July 1993 were not initially so much about health as they were about the financing of health services. The prime objective was to reduce government spending in the health sector. The aim was to create a health system largely based on a social insurance model with competitive purchasing and provision of services. Those who could afford to pay more for care would be required to do so. Those who could not, after means testing, would have their basic needs met by the state.

In keeping with the political style of the last decade the changes were introduced quickly with little open-minded consultation with either service providers or the wider public. Key components in the design such as health care plans and explicit definition of core services proved to be unworkable. Other elements, such as the separate purchasing of public health services, were modified significantly along the way. The arrangements now in place are not what the architects of the reforms originally envisioned.

Despite the high social and financial costs, the health sector reforms have not advanced many of their stated objectives. In some areas there may have been significant gains in productivity. Whether or not these are due to the reforms or would have been achieved without them is debatable. There may have been some gains in the equitable allocation of resources, particularly to Maori. These have, however, been overshadowed by the health effects of increasing poverty in some communities. There are now signs of increasing inequity in health status and in health service use between the relatively affluent and the relatively poor in New Zealand society. For those with the education and discretionary income necessary to purchase the services they need and want, prospects are bright. For those of lesser means, and that is most New Zealanders, the rising personal cost of care is cause for concern. For the poor, obtaining ready access to good quality health care is a source of real worry. This in itself is damaging to health. Is this the sort of society we want in this country? Is this the sort of future we want for public health and for the provision of health services?

Public opinion on the reforms is divided. Those who favour a health system based on a universal entitlement of all citizens to publicly planned, funded and provided health care are particularly critical of the changes. At the other end of the spectrum are those who believe that the full benefits of moving to a more market driven health system will not be achieved until the scheme, as envisioned by the architects of the reforms in 1991, is fully implemented. In the middle ground most people are weary of the changes, tired of the endless political debates and 'bad news stories' in the media, and hope for less combative and more co-operative approaches to the provision of more accessible, culturally appropriate and consumer-sensitive health care.

In all of this little attention has been given to the social values which underlie community attitudes towards health and health service delivery. Apart from involvement in occasional needs assessments and associated consultation, communities have had little tangible and ongoing encouragement to become involved in health promotion and health service delivery. Communities have not been directly and actively engaged as integral parts of the health system. Nor has much weight been placed on the values and sense of vocational commitment that many if not most health professionals bring to their work. At all levels the changes seem to have divided and demoralised people rather than enhanced social cohesion and unity of purpose.

Perhaps it is time to fundamentally rethink our health future?

Health Futures

Health futures provide a set of tools to allow more effective exploration of what might happen in the health sector. They help us clarify what we want to happen, what we want to create. The present trends are not inevitable. The future is not fixed, something we can do nothing about. Such passive thinking leads to apathy, to feelings of incompetence and lack of control. What is needed at this time is a much clearer sense of a shared vision as to what health is all about in our society and what we want from, and are prepared to contribute to, health services. What we need is a vision which embodies not only the practicalities of what the health technologies have to offer and resource limitations but also the values and the aspirations we as New Zealanders have for our own health, the health of our families, our communities, our society as a whole, even our planet. Without a guiding vision the divisions and problems presently evident in our health system seem certain to continue.

For a start it is important to distinguish between health futurism - the future for health - and medical futurism - the future for medical services. The future for health concerns itself with the future state of our health and well-being and the factors that will influence our future state of health. Key health determinants include social, environmental, economic and political forces together with biophysiological and genetic or human biology factors. These factors largely both determine our future state of health and influence the future shape of health services.

The factors that will affect the future of health services are going to be dominated primarily by technological, professional and fiscal forces and by our state of health. How healthy we are and what health aspirations we have will determine what use we make of, and what demands we create individually and as a society, for health and health services. Both futures will be very much influenced by our values.

In the past medical considerations have tended to dominate our thinking and discussion of health futures. While forecasts and visions for the health professions and health care delivery are essential, it is important not to lose sight of 'health' as the primary objective and become preoccupied with the future for medical services. Health care in the future must reflect societal values and be determined by societal futures, not the other way round. The medical tail must not be allowed to wag the health dog.

There are a wide range of approaches to looking into health futures. Broadly speaking these can be grouped into trends, scenarios, visions and strategies. Trends record, for discrete topics, changing patterns over time. Important health trends include disease prevalence, therapeutic advances and health care costs. A wide array of quantitative and qualitative methods can be used to develop health trends.

Trends can and often do move in conflicting directions. Scenarios are compilations of trends into different images of the future. These images enable us to consider a broad range of future possibilities given different trends and sets of assumptions. Scenarios invite us to think about our relative preferences. In any set the scenario considered most likely may not be considered the most desirable. Typically in developing and studying scenarios we tend to focus most attention on the threats and opportunities associated with what is perceived as the most probable future. Much more time should be spent in thinking about what ought to be, or what could be, a vision for the future.

Whereas scenarios are 'futures for the head,' visions are 'futures for the heart.' To be effective, visions must touch and move us. Scenarios provide flexibility in the face of uncertainty. Visions inspire us, commit us and give us energy and something to work for. For a vision to be effective two conditions must be met. First, it must be developed with and owned by the principal stakeholders. They must be willing to stretch themselves and their organisations to make the vision happen. Second, those involved must believe that, by their own efforts, they can make it happen; a shared vision can become a palpable force for change when people truly believe that they can shape the future.

A Health Vision for New Zealand

The New Zealand health sector currently lacks a clear health focus. In a strategic sense it has lost the main plot. Economic rationalism has been the driving force behind efforts to achieve greater efficiency in the production of medical outcomes. The focus has been on medical rather than health futures. Regularly there is talk of the need for more of a public health approach. Public opinion when tested regularly favours such an approach. But, despite the talk, there has been little concerted action for public health.

Lack of a broadly based national health planning forum, or some other organised entity, to assist the government to set a strategic direction for the sector is a serious problem. Working from a health futures perspective, such an entity should be charged with the tasks of identifying and studying the relevant trends, of building and analysing the relevant scenarios, of publicising and encouraging wide and open debate on those scenarios, of involving and facilitating the principal stakeholders to reach consensus on a shared vision for the system and of creating the means where by that vision is captured in a national health strategy for promoting health and for purchasing and providing health services.

The nearest thing that New Zealand currently has to such a planning forum is the National Advisory Committee on Health and Disability. This committee started life in 1992 as the National Advisory Committee on Core Health and Disability Services. The Committee's prime task was to advise the Government "on what health and disability support services the Government should ensure are purchased, with due respect to limited fiscal means, in order that people have access to effective services in fair terms." The Committee's early endeavours were therefore directed to trying to define core personal health services. When this proved impracticable the Committee turned its attention to the development of guidelines for the provision of personal health and disability services. In 1995 the Committee was renamed the National Advisory Committee on Health and Disability and had its terms of reference broadened to include public health services. Given these terms of reference and the associated key tasks, the Committee appeared to have the necessary mandate from the Government to address those more fundamental issues which bore directly upon New Zealand's health future. At this point two questions are important. The status and purpose of the Committee subsequent to the 1996 election has yet to be clarified.

An Early Health Futures Initiative

If the health leadership role does fall to the National Advisory Committee on Health and Disability, and if it decides to use a health futures methodology, it need not start from scratch. The first New Zealand work on health futures was done nearly ten years ago by the Department of Health. In June 1987 a futures health scenario project was initiated to: "explore and integrate the range of possible trends and events (national and international) which will impact upon the future of health services in New Zealand to the year 2000, and to present these using scenarios.'

Four task forces were established, each comprising a diversity of members from across the health services and also from outside of the health sector. More than forty people were involved.

In total the task forces generated 16 scenarios. Each represented a plausible New Zealand future and reflected the likely shape and nature of health services within that society. Scenarios were developed to take account of the country's health status profile, economic performance, political philosophy, level and nature of state involvement in health and health services, value systems in relation to biculturalism and equity in the allocation and use of health resources.

Debate and reflection by the task forces on and around the scenarios were used to produce a vision statement for New Zealand's health services to the year 2000. Unfortunately this work was not formally published but a decade later the process and conclusions remain interesting.

Many of the scenarios were visionary in nature, setting out a perceived ideal state for health services for the future. Two of the strongest common themes were first, the need to see 'health' as a much wider concept than the absence of disease and for health sector activities to reflect that broad philosophy. Second, was the desire to see a truly indigenous health system for New Zealand. We should seek out our own solutions to our own problems, and not uncritically adopt models and practices from overseas. In developing its health vision for the future the task forces identified five guiding principles for an ideal health service in New Zealand. These were:

1. Holism

'Holism' to the task forces was about recognising linkages and connections between: · The spiritual (wairua), mental (hinengaro), physical (tinana) and family (whanau) dimensions of health · Social and economic circumstances such as unemployment, poverty and health · The members of teams of caregivers from different disciplines · Public policy areas such as education, housing, welfare, justice, the environment and health

 2. Empowerment of individuals and communities

Empowerment is about enabling individuals to become more fully involved in, and responsible for, their own health. This applies not only to personal health promotion and treatment services but also to the advancement of health and the provision of services in community settings.

3. Cultural and social self determination

This implies that cultural and social groups in New Zealand will be given greater freedom and greater access to the public resources needed to meet their own needs in their own way.

4. Equity of access to care

Within the resources publicly available, all New Zealanders should have equal access according to need. No New Zealander should be deprived of basic health care because of cultural insensitivity or inability to pay.

5. Devolution

Decision-making about the allocation and use of health resources should be moved away from the large health institutions and towards those who purchase and provide care in community settings.

The task forces went on to describe how they saw these principles being applied in the development of national and regional services, balancing the provision of primary and secondary care, planning and developing the health workforce, women's health, Maori health, the care of people with disabilities and in environmental health. They further reflected on how the vision and the five guiding principles might impact upon the behaviour of New Zealanders - the way we see ourselves and the way we are seen by, and relate to, others. New Zealanders, it was suggested, have a strong sense of collective responsibility in matters of health and education. We show concern for the socially disadvantaged and for minority groups. Discrimination, it was suggested, fades as we increasingly accept and value diversity in life styles and attitudes.

In exploring alternative pathways towards its preferred health future the scenario project group identified three broad options:

Option 1. Public funding and private provision Option 2. Private funding and private provision Option 3. Public funding and public provision

After a careful exploration of each of these options, and in the light of its two key themes and its five guiding principles, the group reached the following conclusions.

"The direction in which New Zealand is currently headed is towards option 1: public funding (but with a private insurance component) and private provision. The favoured alternative is the establishment of regional health authorities. This pathway allows the five guiding principles to be met. Many of the participants in the scenario project favoured this approach provided all the funding was public. However, it may be that once provision was fully privatised, funding would gradually follow suit leading eventually to option 2: complete privatisation. This option is less likely to promote the five principles, particularly equity. Although the other principles may be met for some consumers, this option is unlikely to ensure that they are all met.

Option 3: a completely public health service, is most likely to guarantee the philosophy of universal care, with which most participants in the scenario project were sympathetic. It could also potentially allow the four other principles to be met, although this would depend upon government policy at the time. The system would need to be very carefully and imaginatively managed."

These conclusions are particularly interesting in the light of the health sector changes which have taken place since 1987.

Future Prospects

This early New Zealand work on health futures was, at the time, quite innovative. Most of what is now an extensive and rapidly growing international literature on health futures has been produced in the last five years. An important health futures milestone was reached internationally when in July 1993 the World Health Organisation held and reported on an international consultation on health futures - 'Health Futures in Support of Health for All.'

Did those who participated in the 1987 project get it wrong? Were the vision and the five guiding principles they developed significantly out of step with how New Zealanders saw health and what they wanted their health services to be? Have the attitudes and aspirations of those interested and involved in the health sector changed significantly since 1987?

History shows that the scenario project group correctly identified the direction in which the health sector was moving at the time and correctly identified the consequences, particularly the equity consequence of that movement. In finally opting for a publicly funded and provided health system as the approach most likely to meet the requirements of the shared vision the group probably reflected the view of most serious health sector thinkers at the time. What the group did not record, and probably did not know, was that, at the same time, there was another group of government advisers who had quite a different vision for the future of the health sector. In the event it was advice from this group that was to influence government policy for the next decade.

It is clearly time to reactivate the debate on possible health futures. In terms of the existing health sector structures the National Advisory Committee on Health and Disability appears to be best placed to lead the way. The methods available to study health futures have developed enormously in the last five years and are in use in Australia. This time it would be good if an open, widely publicised and reasonably well resourced health futures project could be mounted. It would also be good if all of the principal stakeholders were involved in the process and included in the decision making.

*This paper has been edited to fit the format of Our Country: Our Choices and all references supplied by the author have been removed. The author used material from the report 'Health Futures in support of health for all' edited by Ann Taket and published by WHO in 1995 - in particular material contributed by Clement Bezold and Trevor Hancock.

*George Salmond

Professor George Salmond is an Otago medical graduate, trained as an internal physician, research worker and specialist in public health medicine. For more than a decade he directed the health services research and planning activities of the Department of Health. In 1986 Dr Salmond was appointed as Director-General of Health, a position he held for five years. In 1993 he was appointed to head a Health Research Council of New Zealandfunded Health Services Research Centre which is a joint venture by the Victoria University of Wellington and the Wellington School of Medicine.