Population health in New Zealand 2000-2013: Targets disrupt service integration from addressing health determinants

Abstract

Introduction: Health system restructuring has emphasized a shift from medical care to population health and primary health care in an attempt to reduce social exclusion and disparities in health. Broad notions of integrated care emphasize connections between health and social services. A population health approach demands operational commitment to reducing inequalities. The health system is recognized as a determinant of health interacting with other social determinants including, income, education, employment, housing and neighborhoods, and discrimination. In New Zealand, the Treaty of Waitangi signed in 1840 guarantees the rights of Māori (as indigenous peoples) and clearly implies equity of health outcomes.Description of policy, objectives and targeted population: In New Zealand, since the year 2000, health system restructuring has resulted in decentralization to regional District Health Boards and Primary Health Organizations. There was a strong initial focus on population health and an imperative to contain health-care spending strongly influenced by neo-liberal economics and politics. Internationally, other important drivers of health reform include a desire to shift services from institutions to primary health care, greater community participation in decision-making, a lack of integration between health and social services, and the ineffectiveness of medical interventions.The research presented here explores whether the values reflected in the original intentions of a population health approach have altered in over a decade of major restructuring.We interviewed managers, clinicians, government policy advisors and academics in 2007 and 2008 and reviewed major government health policies from 2009 to 2013 to establish which notions of population health were reflected.Key findings: Over the decade from 2000, population health shifted from a broad notion of health determinants to population health as the ‘sum of the health of individuals’ – where health was narrowly defined in terms of clinical conditions or need for health services. Participants recognized the impact of determinants on health, but most prioritized the work of health systems as clinical services.New Zealand was caught up in the international concern about safety, quality and variation in health service provision. An emphasis on ‘quality and safety’ impeded population health activities due to a focus on a small number of quantifiable health targets driven by financial incentives. District Health Board programs to identify high risk individuals diverted attention from broader population health outcomes. Boards were not held accountable for integrating a population health approach in service planning and did not initiate or lead intersectoral work. Participants reflected with disappointment that Boards appeared unable to break free of the constraints of national policy, even when narrowly focused on targets. Community consultation was limited. Primary Health Organizations mandated to address population health nevertheless aligned with the small-business model of general practice impeding service integration. ‘Population health’ dropped from favor in the mid-2000s, although many documents outside the health sector carried forward these values.Highlights: The ability of targets to focus provider attention appears so powerful as to eclipse attention to anything else. We know of no other health system with such a small number of targets. The narrowed focus on 6 targets limited attempts to integrate health services and completely undermined any understanding of integrated care as linking health and social services.The small-business model of primary care provision remains a perennial challenge to service integration. This model is readily compatible with a view of population health as the sum of individuals, who can be stratified and targeted, and for whom services can be counted and contracted.An emphasis on population health, followed by an emphasis on individual health, is a cycle repeated across decades.Conclusion: A progressively narrower focus on a small number of targets disrupted service integration, which in turn disrupted attention to determinants of health. Achieving integrated care that links health and social services is one pragmatic orientation that can support delivering population health care.